Step Up to Med - Pulmonary Flashcards
two types of chronic obstructive pulmonary disease
chronic bronchitis
emphysema
clinical diagnosis of chronic bronchitis
chronic cough productive of sputum for at least 3 months per year for at least 2 consecutive years
permanent enlargement of air spaces distal to the terminal bronchioles due to destruction of alveolar walls
emphysema
fourth leading cause of death in the US
COPD
two main risk factors for emphysema
tobacco smoke
alpha 1 antitrypsin deficiency
excess mucus production narrowing the airways with productive cough inflammation and scarring occurs with enlargement in mucous glands and smooth muscle hyperplasia leading to obstruction
chronic bronchitis
destruction of alveolar walls due to relative excess in proteases or relative deficiency of antiproteases in the lungs
emphysema
tobacco smoke and
number of activated PMNs and macrophages
alpha 1 antitrypsin
oxidative stress
increase
decrease
increase
definitive diagnostic test in COPD
pulmonary function testing (spirometry)
what are the critical spirometry findings in COPD
decrease FEV1/FVC ratio
increase TLC residual volume and FRC
GOLD staging is based on
FEV1
GOLD staging and FEV1
> 80% pred - mild
50-80 mod
30-50 sev
<30 very sev
CXR changes in COPD
hyperinflation
flattened diaphragm
enlarged retrosternal space
in what conditions is CXR useful in COPD
during acute exacerbation to R/O pulmonary causes such as PNA or PTX`
should be measured in patients with a personal or family historyt of premature emphysema less that 50 y.o
alpha 1 antitrypsin
the most important intervention for COPD’ers
smoking cessation
what is the effect of quitting smoking on the rate of decling of FEV1
decreases the RATE of decline to that of a normal person but WILL NOT reverse it
what are the three medications commonly employed in the treatment for COPD
ipratropium bromide
albuterol
corticosteroids
dhown to improve survival and QOL in patients with COPD AND chronic hypoxemia
oxygen therapy
requirements for home O2 (2)
PaO2 <55mHg on ABG
OR
O2 sat <88%
what two vaccinations are necessary for COPD’er
strep pneumo every 5-6 years, patients with severe disease before 65
anually get the flu vaccination
.increased dyspnea spuitum production and or cough in a patient with known COPD
acute exacerbation
where is the o2 saturation goal for a chronic COPD patient
90-93#
what type of steroids should be used for an acute COPD exacerbation
IV methylprednisone with prednisone taper once clinical improved
3 most common causes for acute exacerbations
infection
noncompliance
cardiac disease
what is one of the main long term complications of COPD
pulmonary HTN and cor pulmonale (long standing hypoxia in the pulmonary vasculature
airway inflammation
airway hyperresponsiveness
reversible airflow obstruction
asthma
T/F asthma can begin at any age
T
what is the typical clinical picture with extrinsic asthma
atopic, hay fever and eczema
asthma symptoms are typically worse at what time of the day
night
Sob wheezing tightness and cough
asthma
what testing is required for diagnosis of asthma
PFTs
what must be done in PFTs to confirm the diagnosis of asthma
administer PFTs before and after the administration of bronchodilators in order to show reversibility
increase of what magnitude following bronchodilators in PFTs regarding asthma diagnosis is considered reversible
12%
useful meassurement of airflow obstruction in asthma
peak flow
useful when asthma is suspected but PFTs are nondiagnostic
bronchoprovocation
what kind of medication is methacholine and what is it used for?
muscarinic agonist
bronchoprovocation in asthma
when is CXR helpful in asthma
severe cases to r/o other causes PNA PTX etc
when should ABGs be considered in a patient with asthma
severe respiratory distress
increasing levels of what on ABG are highly concerning for impending respiratory failure in an asthmatic
normal or elevated PaCO2
if PaCO2 is normal or increased in asthmatic
admit and consider intubation
acute asthma exacerbation first step
inhaled broncho dilators typically nebulized or MDI
monitor peak flows and clinically for improvement
what should be done in acute asthma exacerbation following trial on inhaled albuterol through nebulizer
IV steroids
third line agent in acute asthma exacerbation in the hospital
IV magnesium
reduces bronchospasm
what are the 3 adjunct therapies to consider on top of albuterol steroids and mag in an acute asthmatic
oxygen therapy
ABX
intubation if all else fails
permanent abnormal dilation and destruction of bronchial walls with chronic inflammation airway collapse and ciliary loss dysfunction leading to impaired clearance of secretions
bronchiectasis
airway obstruction
immunodeficiency
allergic bronchopulmonary aspergillosis
mycobacterium infections recurrent should raise concern for
bronchiectasis
most common cause for bronchiectasis
CF
rare congenital cause for bronchiectasis
kartagener syndrome
chronic cough with large amounts of mucopurulent foul smelling sputum
dyspnea
hemoptysis
recurrent or persistent PNA
bronchiectasis
diagnostic study of choice in bronchiectasis
high resolution CT
acute exacerbation of bronchiectasis requires what initial treatment
ABX
bronchial hygeine steps in bronchiectasis
hydration
bronchodilators
chest physiotherapy
excessively thick viscous secretions in the respiratory tract, exocrine pancreas, sweat glands, intestines, genitourinary tract
CF
treatment for CF
pancreatic enzyme replacement fat soluble vitamin supplements chest physical therapy vaccinations treatment of infections inhaled rhDNase (breaks down the DNA in respiratory mucus that clogs the airways)
most common lung cancer
Nonsmall cell lung cancers
biggest risk for lung CA
smoking
lowest association with smoking of all the lung cancers
adenocarcinoma
common in shipbuilding and construction industry, car mechanics, painting
increasing lung CA risk
asbestos
high levels found in basements
increase riskl for lung CA
radon
cough hemoptysis obstruction wheezing dyspnea recurrent PNA
most associated with what lung CA
squamous cell CA
anorexia
weight loss
weakness
associated prognosis with lung CA
bad (progressive at this point)
SVC synbdrome most commonly occurs in what type of lung CA
SCLC
facial fullness
facial and arm edema
dilated veins over anterior chest arms and face
JVD
SVC syndrome
nerve that courses through the mediastinum and can be injured by lung cancer if destructive
phrenic nerve
hoarseness secondary to lung cancer
recurrent laryngeal nerve injury
Apical tumor involved C8 and T1-T2 nerve roots
causing shoulder pain radiating down the arm
superior sulcus tumors
superior sulcus tumors almost always of what type
squamous cell
what syndrome can be involved with superior sulcus tumors
horners syndrome
why is the prognosis so poor associated with malignant pleural effusion
equivalent to distant metastasis
SIADH occurs with what pulmonary cancers
small cell lung cancer
ectopic ACTH secretion occurs with what lung cancers
small cell lung cancers
PTH like hormone secreting lung cancer
squamous cell carcinoma
hypertrophic pulmonary osteoarthropathy occurs in what two types of lung cancer
adenocarcinoma and squamous cell
proximal muscle weakness fatigability diminished deep tendon reflexes paresthesias in lung cancer setting
lambert eaten syndrome
loss of normal angle between the fingernail and nail bed due to thickening of subungual soft tissue
digital clubbing
digital clubbing usually iindicates
lung ca
most important radiologic study for the diagnosis of lung cancer
CXR
CXR criteria associated with benign lung tumor
stable over a 2 year period
useful test for staging of lung carcinoma
CT scan
cytologic exam of sputum in lung cancer useful for what type
central tumors
useful for diagnosing central visualized tumors but not peripheral lesions
fiberoptic bronchoscopy
best management for NSCLC
Surgery
treatment used as an adjunct following surgery for NSCLC
radiation
what is the treatment for management for SCLC
radiation and chemotherapy
50% chance of malignancy for solitary nodule if the patient is over the age of ____
50
T/F smoking has no effect on the chance of malignancy of a solitary pulmonary nodule
F (smoking definitely increases malignancy chance)
cutoff for large malignancy of pulmonary nodule
2cm
borders indicative of malignancy
irregular
type of calcifcation that indicates malignancyu in solitary pulmonary nodule
asymmetric calcification
dense calcification suggests
benign pulm nodule
enlarging pulmonary nodule suggests
malignancy
follow up of pulm nodule on xray with no old xray or new nodule
CT
low probability nodules management in pulmonary nodules
serial CT scan
intermediate probability nodule 1 cm or larger
PET scan
PET scan positive in pulmonary nodule
biopsy
high probability nodule follow up
biopsy
most common cause of mediastinal mass in older patients
metastatic cancer
most common cause of anterior mediastinum
FOUR T's thymoma teratoma thymoma terrible lymphoma
middle mediastinum most common causes (5)
lung cancer lymphoma aneurysm cysts morgagni hernia
posterior mediastinum most common causes (5)
neurogenic tumors esophageal masses enteric cysts aneurysms bochdalek hernia
most common symptoms of mediastinal structures
compressive symptoms
what kind of pneumonia is common with mediastinal structure
postobstructive PNA
what are the three neuronal type injuries associated with mediastinal masses
hoarseness with recurrent laryngeal nerve injury
horner syndrome from sympathetic ganglia
diaphragmatic paralysis 2/2 phrenic nerve injury
what is the test of choice with mediastinal masses
CT scan
lights criteria (3)
Protein (pleural)/Protein (serum) >0.5\
LDH (p)/LDH(s) >0.6
LDH> two thirds the upper limit of normal serum LDH
most common cause of pleural effusion
CHF
most common malignancy leading to pleural effusion
lung
Dullness to percussion
decreased breath sounds over the effusion
decreased tactile fremitus
pleural effusion
blunting of costophrenic angle
sign of what on CXR
pleural effusion
at least what volume of fluid can accumulate before pleural effusion can be detected
250ml
when is thoracentesis useful in pleural effusion
not obvious etiology
what is the complication associated with thoracentesis
PTX
treatment for transudative effusions
diuretics and sodium restriction
therapeutic thoracentesis
what is the treatment for exudative pleural effusions
treat underlying disease
uncomplicated parapneumonic effusions
ABX alone
complicated effusions parapneumonic
chest tube
intrapleural injection of thrombolytics if loculated
potential surgical lysis of adhesions
