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457 Cards in this Set
- Front
- Back
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What is Asthma?
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Asthma is Reactive Airway Disease, Abnormal Bronchoconstriction of airway, Reversible (COPD is Irreversible)
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What is Asthma etiology asso?
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Asthma etiology asso with 1 Atopic Disorders and 2 Obesity
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Asthma Acute Exacerbations of symptoms cause?
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Asthma Acute Exacerbations of symptoms cause - 1 Allergens (Pollen, Dust mites, Cockroaches, Cat dander), 2 Infection and Cold air, 3 Emotional Stress or Exercise, 4 Catamenial (related to menstrual cycle), 5 Aspirin, NSAIDs, Beta Blockers, HIstamine, any Nebulized med, Tobacco smoke, 6 GERD
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Asthma Px?
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Asthma Px - 1 Wheezing with Acute onset of Shortness of breath, 2 Cough, 3 Chest Tightness, 4 Increased sputum production
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1 Wheezing with Acute onset of Shortness of breath, 2 Cough, 3 Chest Tightness - Dx?
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Asthma Px - 1 Wheezing with Acute onset of Shortness of breath, 2 Cough, 3 Chest Tightness, 4 Increased sputum production
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What is Stridor?
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Stridor is loud Inspiratory sound
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What is Wheezing?
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Wheezing is loud Expiratory sound
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What is Asso with Asthma?
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Asthma asso - 1 Symptoms Worse at Night, 2 Nasal Polyps (Allergic Rhinitis), 3 Eczema or Atopic Dermatitis, 4 Increased Length of Expiratory phase of respiration (Wheezing), 5 Accessory Respiratory muscle use (Severe)
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Asthma Acute Exacerbation Lx?
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Asthma Acute Exacerbation Lx - Initial - ABG or Peak Expiratory Flow (PEF). CXR is Normal in Asthma (may have Hyperinflation), Exclude Pneumonia as a cause of exacerbation, Exclude other Diseases (Pneumothorax or CHF). MA - Pulmonary Function Testing (PFT). Spirometr shows Decrease in ratio of Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC).
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PFT results for Asthma vs COPD vs Restrictive Lung Disease?
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PFT results - FEV1 over FVC - Asthma (Decrease, Reversible with Albuterol) vs COPD (Decrease, Irreversibel) vs Restrictive Lung Disease (Normal)
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15 yo boy with Occasional Shortness of Breath every few weeks. Currently feeling well. Most Accurate Lx?
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15 yo boy with Occasional Shortness of Breath every few weeks. Currently feeling well. Most Accurate Lx - Asymptomatic pt - 20 Perc Decrease in FEV1 with use of Methacholine or Histamine
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When to use Flow-Volume Loop on Spirometry?
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Flow-Volume Loop on Spirometry can be used for fixed Obstructions (Tracheal Lesions or COPD)
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What are PFT tests in Asthma? Test results?
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PFT tests in Asthma are RAID - 1 Decreased FEV1 per FVC (Acute), 2 FEV1 Increase more than 12 perc with Albuterol (Reversible), 3 FEV1 Decrease more than 20 perc with Methacholine or Histamine (Induction), 4 Increase in DLCO (Diffusion).
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What is the DLCO in Asthma? Emphysema?
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DLCO in Asthma - Increase. Emphysema - Decrease
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What is Methacholine? When to use?
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Methacholine is Artificial form of Acetylcholine used in Lx. Acetylcholine and Histamine Provoke Bronchoconstriction and Increase in Bronchial Secretion. Methacholine is Most Accurate Lx for Asthma.
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What CBC finding maybe positive in Asthma?
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CBC finding maybe positive in Asthma - 1 Increased Eosinophil count, 2 Increased IgE levels for Allergic cause (Skin Testing for Specific Allergens that Provoke Bronchoconstriction). IgE level may help guide therapy (Anti-IgE med Omalizumab. Increase IgE levels asso with Allergic Bronchopulmonary Aspergillosis.
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What is Omalizumab? When to use?
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Omalizumab is Anti-IgE med. It is used to Tx Asthma with Increased IgE levels.
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What are classes of Chronic Asthma? Class definition? Tx?
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Chronic Asthma classes - Tx - 1 Mild Intermittent, 2 Mild Persistent, 3 Moderate Persistent, 4 Severe Persistent. Symptom during Day and Night - 1 Mild Intermittent (D Less than 2/wk, N Less than 2/month), 2 Mild Persistent (D More or Equal 2/Wk, N More or Equal 2/Month), 3 Moderate Persistent (D more than 1/day, N more than 1/Wk), 4 Severe Persistent (D more than 1/day, N more than 1/day). Tx - 1 Mild Intermittent (Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol), 2 Mild Persistent (Add Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone), 3 Moderate Persistent (Add Long Acting Beta Agonist - Salmeterol, Formoterol), 4 Severe Persistent (Add Oral or IV Corticosteroid - Prednisone).
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Chronic Asthma classes - Mild Intermittent – Definition? Tx?
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Chronic Asthma classes - Mild Intermittent – Definition - Mild Intermittent (D Less than 2/wk, N Less than 2/month). Tx - Mild Intermittent (Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol)
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Chronic Asthma classes - Mild Persistent – Definition? Tx?
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Chronic Asthma classes - Mild Persistent – Definition - Mild Persistent (D More or Equal 2/Wk, N More or Equal 2/Month). Tx - Mild Persistent (Add Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone)
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Chronic Asthma classes - Moderate Persistent – Definition? Tx?
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Chronic Asthma classes - Moderate Persistent – Definition - Moderate Persistent (D more than 1/day, N more than 1/Wk). Tx - Moderate Persistent (Add Long Acting Beta Agonist - Salmeterol, Formoterol)
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Chronic Asthma classes - Severe Persistent – Definition? Tx?
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Chronic Asthma classes - Severe Persistent – Definition - Severe Persistent (D more than 1/day, N more than 1/day). Tx - Severe Persistent (Add Oral or IV Corticosteroid - Prednisone)
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Chronic Asthma classes - D Less than 2/wk, N Less than 2/month. What class? Tx?
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Chronic Asthma classes - Mild Intermittent – Definition - Mild Intermittent (D Less than 2/wk, N Less than 2/month). Tx - Mild Intermittent (Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol)
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Chronic Asthma classes - D More or Equal 2/Wk, N More or Equal 2/Month. What class? Tx?
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Chronic Asthma classes - Mild Persistent – Definition - Mild Persistent (D More or Equal 2/Wk, N More or Equal 2/Month). Tx - Mild Persistent (Add Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone)
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Chronic Asthma classes - D more than 1/day, N more than 1/Wk. What class? Tx?
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Chronic Asthma classes - Moderate Persistent – Definition - Moderate Persistent (D more than 1/day, N more than 1/Wk). Tx - Moderate Persistent (Add Long Acting Beta Agonist - Salmeterol, Formoterol)
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Chronic Asthma classes - D more than 1/day, N more than 1/day. What class? Tx?
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Chronic Asthma classes - Severe Persistent – Definition - Severe Persistent (D more than 1/day, N more than 1/day). Tx - Severe Persistent (Add Oral or IV Corticosteroid - Prednisone)
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Short Acting Beta Agonist SABA?
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Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol
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Low Dose Inhale Corticosteroid ICS?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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Long Acting Beta Agonist?
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Long Acting Beta Agonist - Salmeterol, Formoterol
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Oral or IV Corticosteroid?
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Oral or IV Corticosteroid - Prednisone
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What med class is Albuterol?
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Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol
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What med class is Pirbuterol?
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Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol
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What med class is Levalbuterol?
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Short Acting Beta Agonist SABA - Albuterol, Pirbuterol, Levalbuterol
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What med class is Beclomethasone?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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What med class is Budesonide?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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What med class is Flunisolide?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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What med class is Fluticasone?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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What med class is mometasone?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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What med class is Triamcinolone?
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Low Dose Inhale Corticosteroid ICS - Beclomethasone, Budesonide, Flunisolide, Fluticasone, mometasone, Triamcinolone
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What med class is Salmeterol?
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Long Acting Beta Agonist - Salmeterol, Formoterol
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What med class is Formoterol?
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Long Acting Beta Agonist - Salmeterol, Formoterol
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What med class is Prednisone?
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Oral or IV Corticosteroid - Prednisone
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What are Asthma Alternative Long Term control agents?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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Inhibit Mast Cell Mediator release and Eosinophil Recruitment med?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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Leukotriene Modifiers med?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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What med class is Cromolyn? Use for?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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What med class is Nedocromil? Use for?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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What med class is Theophylline? Use for?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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What med class is Montelukast? Use for?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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What med class is Zafirleukast? Use for?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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What med class is Zileuton? Use for?
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Asthma Alternative Long Term control agents - 1 Inhibit Mast Cell Mediator release and Eosinophil Recruitment (Cromolyn and Nedocromil), 2 Theophylline, 3 Leukotriene Modifiers (Montelukast, Zafirleukast, or Zileuton best for Atopic pt)
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Inhaled Steroids AE?
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Inhaled Steroids AE - 1 Dysphonia, 2 Oral Candidiasis
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Zafirleukast AE?
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Zafirleukast AE - Hepatotoxic, Associated with Churg-Strauss Syndrome
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Systemic Corticosteroids AE?
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Systemic Corticosteroids AE - FLASH OCG - 1 Fat Redistribution, 2 hyperLipidemia, 3 Acne and Adrenal suppression, 4 Striae, Skin bruise and thining, 5 Hirsutism, 6 Osteoporosis, 7 Cataracts, 8 hyperGlycemia
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What are Anticholinergics med? use for?
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Anticholinergic (AntiMuscarinic) med are 1 Ipratropium, 2 Tiotropium. Anticholinergic agents will Dilate Bronchi and Decrease Secretions. They are Very effective in COPD.
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What is Ipratropium med class? use for?
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Anticholinergic (AntiMuscarinic) med are 1 Ipratropium, 2 Tiotropium. They are Very effective in COPD
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What is Tiotropium med class? use for?
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Anticholinergic (AntiMuscarinic) med are 1 Ipratropium, 2 Tiotropium. They are Very effective in COPD
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47 yo man, hx of Asthma in ER, Several days of Increasing Shortness of Breath, Cough, and Sputum Production. Respiratory Rate is 34 per minute. Diffuse Expiratory Wheezing and a Prolonged Expiratory phase. Best Indication of Severity of his Asthma?
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47 yo man, hx of Asthma in ER, Several days of Increasing Shortness of Breath, Cough, and Sputum Production. Respiratory Rate is 34 per minute. Diffuse Expiratory Wheezing and a Prolonged Expiratory phase. Best Indication of Severity of his Asthma - Respiratory Rate (NL 10-16 per minute)
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Acute Asthma Exacerbation Severity Lx?
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Acute Asthma Exacerbation Severity Lx - 1 Decrease PEF (Peak Expiratory Flow), 2 ABG with Increased A-a Gradient. PEF is approx of FVC. Compare PEF of pt while acute and stable.
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What does Asthma Predispose to?
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Asthma Predispose to Pneumothorax complication
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What is Acute Asthma Exacerbation Tx?
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Acute Asthma Exacerbation Tx - 1 Albuterol and Oxygen, 2 Steroids, 3 Endotracheal Intubation, 4 Place in ICU
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Acute Severe Asthma Exacerbation, not responsive to several rounds of Albuterol, while waiting for Steroids to take effect. Next Step?
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Acute Severe Asthma Exacerbation, not responsive to several rounds of Albuterol, while waiting for Steroids to take effect. Next Step - Magnesium - Helps Bronchospasm.
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Magnesium use in Asthma?
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Acute Severe Asthma Exacerbation, not responsive to several rounds of Albuterol, while waiting for Steroids to take effect. Next Step - Magnesium - Helps Bronchospasm.
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Asthma Bronchospasm Tx?
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Acute Severe Asthma Exacerbation, not responsive to several rounds of Albuterol, while waiting for Steroids to take effect. Next Step - Magnesium - Helps Bronchospasm.
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Acute Asthma Exacerbation Non Effective Tx?
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Acute Asthma Exacerbation Non Effective Tx - 1 Theophylline, 2 Cromolyn and Nedocromil, 3 Leukotriene modifiers, 4 Omalizumab, 5 Salmeterol
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Asthma Not respond to Oxygen, Albuterol, and Steroids, or Develops Respiratory Acidosis. Next Step?
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Asthma Not respond to Oxygen, Albuterol, and Steroids, or Develops Respiratory Acidosis (Increased pCO2). Next Step - Endotracheal Intubation for Mechanical Ventilation. They should be placed in ICU
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Chronic Asthma vs Acute Exacerbation Lx? Tx?
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Lx Chronic Asthma (Init - ABG or PEF, MA - PFT - FEV1 per FVC Decrease. Decrease More than 20 perc in FEV1 with Methacholine). vs Acute Exacerbation (Decrease PEF, ABG with Increase A-a Gradient). Tx Chronic Asthma (classes based on Symptom - Mild Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent. 1 SABA - Albuterol, 2 ICS - Budesonide, 3 LABA - Salmeterol, 4 Oral Corticosteroid). vs Acute Exacerbation (1 Albuterold and Oxygen, 2 Steroids, 3 Endotracheal Intubation and ICU)
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What is COPD diseases?
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COPD diseases - 1 Emphysema, 2 Chronic Bronchitis
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What is COPD pathophysiology?
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COPD pathophysiology - Lung Destruction Decreasing Elastic Recoil, Loss in Exhalation (Decrease in FEV1 per FVC, Increase in Total Lung Capacity TLC - Residual Volume Increase). Smoking Destroys Elastin Fibers - major cause.
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Young, NonSmoker, COPD. Dx? What type of disease?
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Young, NonSmoker, COPD. Dx - Alpha1 AntiTrypsin Deficiency. This is PanAcinar Emphysema (Cigarette - CentriAcinar Emphysema)
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Shotness of Breath Worsen by Exertion, Barrel Chest. Dx? Lx? Tx?
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Shotness of Breath Worsen by Exertion, Barrel Chest. Dx - COPD. Lx - Initial - CXR - 1 Increased Anterior-Posterior (AP) Diameter, 2 Flattened Diaphragms (COPD sign). Lx - MA - PFT - 1 Decreased FEV1, FVC, FEV1 per FVC ratio (Under 70 perc), 2 Increased TLC (Increase in Residual Volume, 3 Decreased DLCO, 4 Incomplete improvement with Albuterol, Little or No Worsening with Methacholine). Tx - 1 Improve Mortality and Delay Progression of Disease - Smoking Cessation, Oxygen Therapy for Hypoxic pt, Vaccinations(Influenza and Pneumococcal). 2 Definitely Improves Symptoms - aaa SABA (Albuterol), bbb AntiCholinergic (AntiMuscarinic) AGENTS (Tiotropium, Ipratropium), ccc Inhaled Steroids, ddd LABA, eee Pulmonary Rehabilitation
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CXR shows Flattened Diaphragms. Dx?
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CXR shows Flattened Diaphragms. Dx - COPD
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What is Full Reversibility in Response to Bronchodilators?
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Full Reversibility in Response to Bronchodilators - 1. FEV1 Greater than 12 perc Increase and 2. FEV1 Increase by 200 mL.
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COPD Increased TLC. Why? How to see it?
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COPD Increased TLC because Increase in Residual Volume. Plethysmography will show an Increase in Residual Volume.
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What Lx to see change in Residual Volume?
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Lx to see change in Residual Volume - Plethysmography.
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What Lx to measure pulmonary function and various volumes?
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Lx to measure pulmonary function and various volumes - 1 Spirometry can measure everything, except Residual Volume and TLC. 2 Plethysmography can measure Residual Volume. (Pithy left over)
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What is COPD complication?
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COPD complication - Right Atrial and Right Ventricular Hypertrophy
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For COPD, What can be seen ABG? CBC? EKG? Echocardiography?
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For COPD, ABG - Acute Exacerbations show Increased pCO2 and Hypoxia. Respiratory Acidosis if there is Insufficient Metabolic Compensation and Bicarbonate level Elevated to compensate. CBC - Increase in Hematocrit from Chronic Hypoxia. EKG - Right Atrial Hypertrophy and Right Ventricular Hypertrophy (Cor Pulmonale), Atrial Fibrillation or Multifocal Atrial Tachycardia (MAT). Echocardiography - Right Atrial and Right Ventricular Hypertrophy, Pulmonary Hypertension.
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Multifocal Atrial Tachycardia Tx?
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Multifocal Atrial Tachycardia Tx - Pulmonary problem therapy - COPD - Give Oxygen
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Increased AP Diameter. Dx?
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Increased AP Diameter. Dx - COPD
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What is COPD Lx? Finding?
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COPD. Lx - 1 CXR, 2 PFT, 3 ABG, 4 CBC, 5 EKG, 6 Echocardiography. Lx - Initial - CXR - 1 Increased Anterior-Posterior (AP) Diameter, 2 Flattened Diaphragms (COPD sign). Lx - MA - PFT - 1 Decreased FEV1, FVC, FEV1 per FVC ratio (Under 70 perc), 2 Increased TLC (Increase in Residual Volume, 3 Decreased DLCO, 4 Incomplete improvement with Albuterol, Little or No Worsening with Methacholine). Tx - 1 Improve Mortality and Delay Progression of Disease - Smoking Cessation, Oxygen Therapy for Hypoxic pt, Vaccinations(Influenza and Pneumococcal). 2 Definitely Improves Symptoms - aaa SABA (Albuterol), bbb AntiCholinergic (AntiMuscarinic) AGENTS (Tiotropium, Ipratropium), ccc Inhaled Steroids, ddd LABA, eee Pulmonary Rehabilitation
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What are Inhaled AntiCholinergic med? What disease is Inhaled AntiCholinergic Most Effective?
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Inhaled AntiCholinergic med - Ipratropium, Tiotropium. Disease is Inhaled AntiCholinergic Most Effective - COPD
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Medical Tx - Asthma vs COPD?
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Medical Tx - Asthma (Albuterol -- Inhaled Steroid) vs COPD (Albuterol -- AntiCholinergic -- Inhaled Steroid)
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For COPD, When all medical therapy is insufficient, Tx?
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For COPD, When all medical therapy is insufficient, Tx - Refer for Transplantation
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Acute Exacerbation of Chronic Bronchitis Tx?
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Acute Exacerbation of Chronic Bronchitis Tx - similar to Tx for Acute Asthma Exacerbation - 1 SABA (bronchodilators), 2 Corticosteroid, 3 Antibiotics (infections most commonly identified cause). Cover 1 Strep Pneumoniae, 2 H Influenzae, 3 Moraxella Catarrhalis. Antibiotic Tx - 111 Macrolides (Azithromycin, Clarithromycin), 2 Cephalosporins (Cefuroxime, Cefixime, Cefaclor, Ceftibuten 2g), 3 Amoxicillin_Clavulanic acid, 444 Quinolones (Levofloxacin, Moxifloxacin, Gemifloxacin)
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Criteria for Oxygen use in COPD?
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Criteria for Oxygen use in COPD - 1 pO2 Below 55 mm Hg (NL 75-100), or Oxygen Saturation Below 88 perc (O2 Sat - NL 95-100), or 2 Signs of Right-sided Heart Disease_Failure (Cor Pulmonale) or an Elevated Hematocrit - pO2 Less than 60 or Oxygen Saturation Below 90 perc.
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NL pO2?
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pO2 - NL 75-100
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NL O2 Sat?
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Oxygen Saturation - NL 95-100
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What is Bronchiectasis? Most Common Cause?
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Bronchiectasis - uncommon disease from Chronic Dilation of Large Bronchi, Permanent Anatomic Abnormality, Irreversible. Infections of lung lead to Weakening of Bronchial walls. Most common cause - Cystic Fibrosis (50 perc). Other cause - 1 Infections (Tb, Pneumonia, Abscess), 2 Panhypogammaglobulinemia and Immune deficiency, 3 Foreign body or tumors, 4 Allergic Bronchopulmonary Aspergillosis (ABPA), 5 Collagen-Vascular disease (Rheumatoid Arthritis)
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Recurrent High Volume Purulent Sputum production, Hemoptysis. Dx?
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Recurrent 1 High Volume 2 Purulent Sputum production, 3 Hemoptysis. Dx - Bronchiectasis.
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Bronchiectasis Px?
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Recurrent 1 High Volume 2 Purulent Sputum production, 3 Hemoptysis. Dx - Bronchiectasis. Other finding - 1 Dyspnea and wheezing, 2 weight loss, 3 Anemia of chronic disease, 4 Crackles on lung exam, 5 Clubbing is uncommon
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Bronchiectasis Lx?
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Bronchiectasis Lx - initial - CXR - Dilated, Thickened Bronchi, sometimes with Tram-Tracks(thickening of Bronchi). MA Lx - High-Resolution CT. Sputum Culture - Specific Bacterial Etiology.
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Bronchiectasis Tx?
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Bronchiectasis Tx - 1 Chest Physiotherapy (Cupping and Clapping) and Postural Drainage to Dislodging plugged-up bronchi, 2 Infection - Same antibiotics as Exacerbations of COPD. Antibiotic Tx - 111 Macrolides (Azithromycin, Clarithromycin), 2 Cephalosporins (Cefuroxime, Cefixime, Cefaclor, Ceftibuten 2g), 3 Amoxicillin_Clavulanic acid, 444 Quinolones (Levofloxacin, Moxifloxacin, Gemifloxacin). Inhaled Antibiotics have some Efficacy. MAI can be found. 3 Surgical Resection of focal lesions may be indicated.
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What is ABPA? Px? Lx? Tx?
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ABPA (Allergic Bronchopulmonary Aspergillosis is Hypersensitivity of lung to Fungal Antigens in Bronchial tree. Mainly in Asthma and hx of Atopic Disorders. Px - 1 Asthmatic, 2 Recurrent, Brown-Flecked Sputum, 3 Transient Infiltrates on CXR. Cough, Wheezing, Hemoptysis, and sometiems Bronchiectasis occur. Lx - 111 Peripheral Eosinophilia, 2 Skin test Reactivity to Aspergillus Antigens, 3 Precipitating Antibodies to Aspergillus on Blood test, 444 Elevated Serum IgE levels, 555 Pulmonary Infiltrates or Fungal ball (Mycetoma) on CXR or CT. Tx - 1 Oral Steroids (Prednisone) for Severe cases, 2 Itraconazole Orally for Recurrent Episodes. Inhaled steroids cannot deliver High enough dose to be effective for ABPA.
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Cystic Fibrosis Etiology?
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Cystic Fibrosis - 1 Autosomal Recessive, 2 Mutation in Gene code for 3 Chloride Transport (Cystic Fibrosis Transmembrane Conductance Regulator CFTR). 4 Damage Chloride and Water Transport Across Apical Surface of Epithelial Cells in Exocrine Glands, 5 Abnormal Thick Mucus (Lungs, Pancreas, Liver, Sinuses, Intestines, Genitourinary tract). 6 Clog Up. 7 Damaged Mucus Clearance - Decrease inhaled bacteria Clearance.
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Cystic Fibrosis Px?
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Cystic Fibrosis Px - 1 Young Adult, 2 Chronic Lung Disease (Cough, Sputum, Hemoptysis, Bronchiectasis, Wheezing, Dyspnea) and 3 Recurrent Episodes of Infection, 4 Sinus Pain and Polyps are common.
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Cystic Fibrosis GI involvement?
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Cystic Fibrosis GI involvement - 1 Meconium Ileus in Infants with Abdominal Distention, 2 Pancreatic Insufficiency (in 90 perc) with Steatorrhea and Vitamin KADE malabsorption, 3 Recurrent Pancreatitis, 4 Distal Intestinal Obstruction, 5 Biliary Cirrhosis.
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Cystic Fibrosis GU involvement?
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Cystic Fibrosis GU involvement - 1 Men are Often Infertile (95 perc have Azoospermia, 20 perc have Vas Deferens Missing). 2 Women are Infertile -Chronic Lung Disease Alters Menstrual Cycle and Thick Cervical Mucus Blocks Sperm Entry.
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In Cystic Fibrosis, why is lung infection?
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In Cystic Fibrosis, lung infection - Neutrophils Dumps Tons of DNA into Airway secretions, Clogging them up.
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What is major cause of Death in Cystic Fibrosis?
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Major cause of Death in Cystic Fibrosis - Lung disease account for 95 perc of deaths
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In Cystic Fibrosis, what is spared until later in life?
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In Cystic Fibrosis, Spared until later in life - Islets - Beta Cell Normal until much later in life
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Cystic Fibrosis Lx?
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Cystic Fibrosis Lx - MA - Increased Sweat Chloride Test (Pilocarpine Increases Acetylcholine levels -- Increases Sweat Production -- Chloride Levels in Sweat Above 60 meq per L on Repeated testing.) Genotyping is not accurate (many different mutations). Additional Lx - 1 CXR and CT - Bronchiectasis, Pneumothorax, Scarring, Atelectasis, Hyperinflation, 2 Arterial Blood Gas (Hypoxemia. Advanced disease - Respiratory Acidosis), 3 PFT (Mixed Obstructive and Restrictive Patterns, Decreased FVC and TLC, Decreased DLCO), 4 Sputum Culture (Pseudomonas Aeruginosa, Nontypable H Influenzae, S Aureus, Burkholderia Cepacia)
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Cystic Fibrosis Tx?
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Cystic Fibrosis Tx - 1 Antibiotics are Routine (same as Bronchiectasis - Antibiotic Tx - 111 Macrolides (Azithromycin, Clarithromycin), 2 Cephalosporins (Cefuroxime, Cefixime, Cefaclor, Ceftibuten 2g), 3 Amoxicillin_Clavulanic acid, 444 Quinolones (Levofloxacin, Moxifloxacin, Gemifloxacin)). Culture to guide Tx. Inhaled Aminoglycosides (cover Pseudomonas) is exclusively limited to CF. 2 Inhaled Recombinant Human Deoxyribonuclease (rhDNase) - breakdown massive amounts of DNA in respiratory mucus. 3 Inhaled Bronchodilators (Albuterol), 4 Pneumococcal and Influenza Vaccination, 5 Lung Transplantation in Advanced disease not responsive to Tx.
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CXR of Typical vs Atypical Pneumonia?
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CXR of Typical (Consolidation) vs Atypical (Diffuse Infiltrate) Pneumonia
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What is Community Acquired Pneumonia?
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Community Acquired Pneumonia CAP - occurring Before Hospitalization or Within 48 hours of admission. The only infectious disease among Top 10 cause of death.
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Community Acquired Pneumonia Etiology?
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Community Acquired Pneumonia Etiology - S Pneumoniae.
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Community Acquired Pneumonia CAP – COPD, asso pathogen?
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Community Acquired Pneumonia CAP – COPD, asso pathogen – H Influenzae
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Community Acquired Pneumonia CAP – Recent Viral infection, asso pathogen?
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Community Acquired Pneumonia CAP – Recent Viral infection, asso pathogen – S Aureus
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Community Acquired Pneumonia CAP - Alcoholism, asso pathogen?
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Community Acquired Pneumonia CAP - Alcoholism, asso pathogen – Klebsiella Pneumoniae
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Community Acquired Pneumonia CAP - Diabetes, asso pathogen?
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Community Acquired Pneumonia CAP - Diabetes, asso pathogen – Klebsiella Pneumoniae
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Community Acquired Pneumonia CAP – Poor Dentition, asso pathogen?
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Community Acquired Pneumonia CAP – Poor Dentition, asso pathogen - Anaerobes
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Community Acquired Pneumonia CAP - Aspiration, asso pathogen?
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Community Acquired Pneumonia CAP - Aspiration, asso pathogen - Anaerobes
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Community Acquired Pneumonia CAP – Young Healthy pt, asso pathogen?
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Community Acquired Pneumonia CAP – Young Healthy pt, asso pathogen – Mycoplasma Pneumoniae
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Community Acquired Pneumonia CAP - Hoarseness, asso pathogen?
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Community Acquired Pneumonia CAP - Hoarseness, asso pathogen – Chlamydophila Pneumoniae
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Community Acquired Pneumonia CAP – Contaminated Water Sources, asso pathogen?
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Community Acquired Pneumonia CAP – Contaminated Water Sources, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – Air Conditioning, asso pathogen?
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Community Acquired Pneumonia CAP – Air Conditioning, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – Ventilation Systems, asso pathogen?
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Community Acquired Pneumonia CAP – Ventilation Systems, asso pathogen - Legionella
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Community Acquired Pneumonia CAP - Birds, asso pathogen?
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Community Acquired Pneumonia CAP - Birds, asso pathogen – Chlamydia Psittaci
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Community Acquired Pneumonia CAP – Animals at Time of Giving Birth, asso pathogen?
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Community Acquired Pneumonia CAP – Animals at Time of Giving Birth, asso pathogen - Coxiella Burnetii
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Community Acquired Pneumonia CAP - Veterinarians, asso pathogen?
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Community Acquired Pneumonia CAP - Veterinarians, asso pathogen - Coxiella Burnetii
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Community Acquired Pneumonia CAP - Farmers, asso pathogen?
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Community Acquired Pneumonia CAP - Farmers, asso pathogen - Coxiella Burnetii
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How is Chest Pain from Pneumonia different from MI?
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Chest Pain from Pneumonia (Pleuritic - Changing with Respiration) different from MI
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Difference between Acute Bronchitis and Pneumonia?
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Difference between Acute Bronchitis (CXR NL, Low Fever) and Pneumonia (CXR abnormal, High Fever, Dyspnea)
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What is Pneumonia Px? Symptom for Severe?
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Pneumonia Px - 1 Fever or Hypothermia, 2 Cough. Symptom for Severe - 1 Dyspnea, 2 Vital Signs Abnormalities (Tachycardia, Hypotension, Tachypnea), 3 Mental Status (Confusion).
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What does Pneumonia with Abdominal pain means? Chest pain means?
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Pneumonia with Abdominal pain or Diarrhea means - Infection in Lower Lobes Irritating Intestines through Diaphragm. Chest pain means - Inflammation of Pleura.
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What does Pneumonia with Diarrhea means? Chest pain means?
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Pneumonia with Abdominal pain or Diarrhea means - Infection in Lower Lobes Irritating Intestines through Diaphragm. Chest pain means - Inflammation of Pleura.
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Lung exam. What does Dullness to Percussion means?
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Lung exam. Dullness to Percussion means - Effusion
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Lung exam. What does Egophony means?
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Lung exam. Egophony means - say E and hear A - Consolidation of air spaces.
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In Pneumonia, How does Effusion present on Physical exam?
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In Pneumonia, Effusion present on Physical exam - Dullness to Percussion.
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In Pneumonia, How does Consolidation present on Physical exam?
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In Pneumonia, Consolidation present on Physical exam - Bronchial or Vesicular Breath sound, and Egophony (say E, hear A)
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Lung exam. What does Rales, Rhonchi, Crepitations mean?
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Lung exam. Rales, Rhonchi, Crepitations mean - auscultor findings from any form of lung infection.
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In Pneumonia, How does Lower Lobes infection present on Physical exam?
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In Pneumonia, Lower Lobes infection present on Physical exam - Irritating intestines through diaphragm - have Abdominal Pain and Diarrhea.
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In Pneumonia, What does Chills or Rigors mean?
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In Pneumonia, Chills or Rigors mean - Bacteremia, often with Bacterial Pathogens.
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In Pneumonia, How does Pleural iniflammation present on Physical exam?
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In Pneumonia, Pleural iniflammation present on Physical exam - Chest Pain with Respiration
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Contrast Acute Bronchitis vs Pneumonia?
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Contrast Acute Bronchitis (Low Fever, CXR NL) vs Pneumonia (High Fever, CXR Abnormal, Dypnea)
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Community Acquired Pneumonia CAP – Hemoptysis from Necrotizing disease, asso pathogen ?
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Community Acquired Pneumonia CAP – Hemoptysis from Necrotizing disease, asso pathogen – Klebsiella Pneumoniae
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Community Acquired Pneumonia CAP – Currant Jelly Sputum, asso pathogen ?
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Community Acquired Pneumonia CAP – Currant Jelly Sputum, asso pathogen – Klebsiella Pneumoniae
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Community Acquired Pneumonia CAP – Foul Smelling Sputum, asso pathogen ?
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Community Acquired Pneumonia CAP – Foul Smelling Sputum, asso pathogen - Anaerobes
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Community Acquired Pneumonia CAP – Rotten Eggs smell, asso pathogen ?
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Community Acquired Pneumonia CAP – Rotten Eggs smell, asso pathogen - Anaerobes
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Community Acquired Pneumonia CAP – Dry Cough, Rarely Severe, asso pathogen ?
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Community Acquired Pneumonia CAP – Dry Cough, Rarely Severe, asso pathogen – Mycoplasma Pneumoniae
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Community Acquired Pneumonia CAP – Bullous Myringitis, asso pathogen ?
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Community Acquired Pneumonia CAP – Bullous Myringitis, asso pathogen – Mycoplasma Pneumoniae
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Community Acquired Pneumonia CAP – Gastrointestinal symptoms, asso pathogen ?
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Community Acquired Pneumonia CAP – Gastrointestinal symptoms, asso pathogen – Legionella
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Community Acquired Pneumonia CAP – Abdominal Pain, asso pathogen ?
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Community Acquired Pneumonia CAP – Abdominal Pain, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – Diarrhea, asso pathogen ?
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Community Acquired Pneumonia CAP – Diarrhea, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – CNS symptoms, asso pathogen ?
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Community Acquired Pneumonia CAP – CNS symptoms, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – Headache, asso pathogen ?
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Community Acquired Pneumonia CAP – Headache, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – Confusion, asso pathogen ?
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Community Acquired Pneumonia CAP – Confusion, asso pathogen - Legionella
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Community Acquired Pneumonia CAP – AIDS with CD4 Less than 200 , asso pathogen ?
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Community Acquired Pneumonia CAP – AIDS with CD4 Less than 200 - Pneumocystis
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What is Myringitis?
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Myringitis is Inflammation of Tympanic Membrane
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Atypical Pneumonia Organisms?
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Atypical Pneumonia Organisms - 1 Mycoplasma, 2 Virus, 3 Coxiella, 4 Pneumocystis, 5 Chlamydia, 6 Chlamydophila, 7 Legionella. They involve Interstitial Space and often Leave Air Spaces of Alveoli Empty (Less Sputum). Atypical Pneumonia accounts for 30 to 50 perc of CAP. They are Not Visible on Gram Stain
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Difference between Atypical and Typical Pneumonia?
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Difference between Atypical (CXR Abnormal Bilateral, Air spaces presence, Dry cough) and Typical (CXR Consolidation Unilateral, Alveoli Involve - all white in a section, Productive cough) Pneumonia
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How to know Sputum Gram Stain is Adequate?
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Sputum Gram Stain is Adequate - 1 More than 25 WBC, and 2 Less than 10 Epithelial cells
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How to Rule Out Interstitial Lung Disease?
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Rule Out Interstitial Lung Disease - Normal CXR does Not Rule Out Interstitial lung disease, High Resolution CT Does Rule Out
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Severe Pneumonia, Unclear Etiology, or Not Responding to Tx. Next Step?
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Severe Pneumonia, Unclear Etiology, or Not Responding to Tx. Next Step - 1 Thoracentesis (look for large efusion and empyema), 2 Empyema (LDH More than 60 perc, Protein More than 50 perc of serum leve, WBC Above 1000 per uL), 3 Bronchoscopy (in ICU pt, Sputum stain_culture, blood culture show No organism, Pt Worsening despite Empiric Tx - except PCP because nonInvasive rarely reveals a dx).
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What is Empyema? Requirement? Tx?
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Empyema - Infected Pleural Effusion, Acts like an Abscess, Will improve more Rapidly if Drained with Chest Tube. Requirement - LDH Above 60 perc of serum level, Protein above 50 perc, WBC above 1000 per uL - suggest investion.
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New, Large Effusions Secondary to Pneumonia. Next Step?
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New, Large Effusions Secondary to Pneumonia. Next Step - Tapped
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Pleural Effusion. Lx? What kind?
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Pleural Effusion. Lx - Initial - CXR Decubitus, Chest CT. Lx - MA - Thoracentesis. Exudative and Transudative. Exudative - 1 Cancer, 2 Infection (TB, Pneumonia), 3 PE. Transudative - 1 CHF, 2 Nephrotic (Edema, Hydrostatic), 3 Cirrhosis (Edema - Oncotic), 4 PE. PE can be both Exudative or Transudative. Exudative - Protein Above 50 perc serum level, LDH above 60 perc, LDH above 200, pH below 7.3 (Parapneumonic Effusion pH below 7.2). Transudative - Protein below 50 perc, LDH below 60 perc, pH is 7.35 (neutral).
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Parapneumonic Effusion pH?
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Parapneumonic Effusion pH below 7.2
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Exudative Effusion. Requirement? Causes?
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Exudative Effusion. Requirement - Exudative - Protein Above 50 perc serum level, LDH above 60 perc, LDH above 200, pH below 7.3 (Parapneumonic Effusion pH below 7.2). Transudative - Protein below 50 perc, LDH below 60 perc, pH is 7.35 (neutral). Causes - Exudative - 1 Cancer, 2 Infection (TB, Pneumonia), 3 PE. Transudative - 1 CHF, 2 Nephrotic (Edema, Hydrostatic), 3 Cirrhosis (Edema - Oncotic), 4 PE. PE can be both Exudative or Transudative.
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Transudative Effusion. Requirement? Causes?
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Exudative Effusion. Requirement - Exudative - Protein Above 50 perc serum level, LDH above 60 perc, LDH above 200, pH below 7.3 (Parapneumonic Effusion pH below 7.2). Transudative - Protein below 50 perc, LDH below 60 perc, pH is 7.35 (neutral). Causes - Exudative - 1 Cancer, 2 Infection (TB, Pneumonia), 3 PE. Transudative - 1 CHF, 2 Nephrotic (Edema, Hydrostatic), 3 Cirrhosis (Edema - Oncotic), 4 PE. PE can be both Exudative or Transudative.
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Cancer – Exudative or Transudative Effusion?
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Cancer – Exudative or Transudative Effusion? – Exudative
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Infection – Exudative or Transudative Effusion?
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Infection – Exudative or Transudative Effusion? – Exudative
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TB – Exudative or Transudative Effusion?
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TB – Exudative or Transudative Effusion? – Exudative
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Pneumonia – Exudative or Transudative Effusion?
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Pneumonia – Exudative or Transudative Effusion? – Exudative
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PE – Exudative or Transudative Effusion?
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PE – Exudative or Transudative Effusion? – can be either
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CHF - Exudative or Transudative Effusion?
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CHF - Exudative or Transudative Effusion? – Transudative
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Nephrotic - Exudative or Transudative Effusion?
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Nephrotic - Exudative or Transudative Effusion? – Transudative, Edema - Hydrostatic
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Cirrhosis – Exudative or Transudative Effusion?
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Cirrhosis – Exudative or Transudative Effusion? – Transudative, Edema - Oncotic
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Specific Lx by Organism – Mycoplasma Pneumoniae – Lx?
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Specific Lx by Organism – Mycoplasma Pneumoniae – PCR, Cold Agglutins, Serology, Special Culture Media
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Specific Lx by Organism – Cold Agglutins - Orginism ?
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Specific Lx by Organism – Mycoplasma Pneumoniae – PCR, Cold Agglutins, Serology, Special Culture Media
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Specific Lx by Organism – Chlamydophila Pneumoniae – Lx ?
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Specific Lx by Organism – Chlamydophila Pneumoniae – Rising Serologic Titers
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Specific Lx by Organism – Legionella – Lx ?
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Specific Lx by Organism – Legionella – Urine Antigen, Culture on Charcoal-Yeast Extract
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Specific Lx by Organism – Urine Antigen - Organism ?
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Specific Lx by Organism – Legionella – Urine Antigen, Culture on Charcoal-Yeast Extract
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Specific Lx by Organism – Culture on Charcoal-Yeast Extract - Organism ?
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Specific Lx by Organism – Legionella – Urine Antigen, Culture on Charcoal-Yeast Extract
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Specific Lx by Organism – Chlamydia Psittaci - Lx?
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Specific Lx by Organism – Chlamydia Psittaci – Rising Serologic Titers
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Specific Lx by Organism – Coxiella Burnetii – Lx?
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Specific Lx by Organism – Coxiella Burnetii – Rising Serologic Titers
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Specific Lx by Organism – Pneumocystis Jiroveci (PCP) – Lx ?
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Specific Lx by Organism – Pneumocystis Jiroveci (PCP) – Bronchoalveolar Lavage
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Specific Lx by Organism – Bronchoalveolar Lavage - Organism ?
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Specific Lx by Organism – Pneumocystis Jiroveci (PCP) – Bronchoalveolar Lavage
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Specific Lx by Organism – Rising Serologic Titers - Organism ?
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Specific Lx by Organism – Mycoplasma Pneumoniae , Chlamydophila Pneumoniae , Chlamydia Psittaci, Coxiella Burnetii – Rising Serologic Titers
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What Atypical Pneumonia are Tx Empirically and Rarely Confirmed?
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Atypical Pneumonia are Tx Empirically and Rarely Confirmed - Mycoplasma and Chlamydophila
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What is Most Important Step in Initial Management of Pneumonia?
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Most Important Step in Initial Management of Pneumonia - Determining Severeity of Disease for Location to place pt
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Pneumonia, Outpatient Criteria? Tx?
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Pneumonia, Outpatient Criteria - 1 Healthy, No Antibiotics Last 3 Months, Mild Symptoms (Macrolide - Azithromycin or Clarithromycin, Or Doxycycline). 2 Comorbidities, or Antibiotics Last 3 Months (Respiratory Fluoroquinolone - Levofloxacin, Moxifloxacin).
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Pneumonia, Inpatient Criteria? Tx?
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Pneumonia, Inpatient Criteria - CURB 65 - 1 Confusion, Comorbidities (Cancer, COPD, CHF, Renal Failure, Liver Disease, Diabetes - Glucose above 250), 2 Uremia (BUN above 30, Sodium below 130 - SIADH), 3 Respiration (Respiratory rate above 30, or pO2 below 60, pH below 7.35), 4 BP (Hypotension - Sytolic below 90), 5 Age Aboe 65. Hypoxia and Hypotension are reason to Hospitalize. Tx - Respiratory Fluoroquinolone (Levofloxacin or Moxifloxacin), Or Ceftriaxone and Azithromycin.
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Pneumonia, Reasons to Hospitalize? Tx?
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Pneumonia, Reasons to Hospitalize - CURB 65 - 1 Confusion, Comorbidities (Cancer, COPD, CHF, Renal Failure, Liver Disease, Diabetes - Glucose above 250), 2 Uremia (BUN above 30, Sodium below 130 - SIADH), 3 Respiration (Respiratory rate above 30, or pO2 below 60, pH below 7.35), 4 BP (Hypotension - Sytolic below 90), 5 Age Aboe 65. Hypoxia and Hypotension are reason to Hospitalize. Tx - Respiratory Fluoroquinolone (Levofloxacin or Moxifloxacin), Or Ceftriaxone and Azithromycin.
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Most important reason to Hospitalize Pneumonia pt?
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Most important reason to Hospitalize Pneumonia pt - 1 Hypoxia, 2 Hypotension.
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What is Hypoxia?
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Hypoxia for Pneumonia pt - pO2 below 60 (NL 75-100), Respiratory rate above 30 per minute
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Large Empyema. Next Step?
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Large Empyema. Next Step - Drainage by Chest Tube or Thoracostomy
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Minimal Inhibitory Concentration MIC to Penicillin less than 0.1 ug per mL. Interpretation?
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Minimal Inhibitory Concentration MIC to Penicillin less than 0.1 ug per mL. Interpretation - Low MIC to Penicillin - Organism Sensitive to Penicillin
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Who should get Pneumococcal Vaccination? When? How many Times?
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Pneumococcal Vaccination should be given - 1 Age above 65, 2 Chronic disease (Chronic Heart, Liver, Kidney, or Lung disease, Asthma), 3 Functional or Anatomic Asplenia (sickle cell), Hematologic Malignancy (Leukemia, Lymphoma), Immunosuppression (Diabetes Mellitus, Alcoholics, Corticosteroid users, AIDS or HIV positive, CSF leak and Cochlear implantation recipients. Healthy pt should get A Single Dose at 65. For pt with Chronic disease, if First Vaccination was given before age 65, give a Second dose 5 years after first dose.
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Pneumococcal Vaccination group, other than Age over 65, and Chronic Disease?
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Pneumococcal Vaccination group, other than Age over 65, and Chronic Disease - 1 Functional or Anatomic Asplenia (Sickle cell), 2 Hematologic Malignancy (Leukemia, Lymphoma), 3 Immunosuppression (Diabetes Mellitus, Alcoholics, Corticosteroid users, AIDS or HIV positive), 4 CSF Leak and Cochlear Implantation recipients
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Do Health Care worker need Pneumococcal Vaccine?
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Do Health Care worker need Pneumococcal Vaccine? No
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What is Healthcare Associated Pneumonia? Cause? Tx?
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Healthcare Associated Pneumonia (Hospital Acquuired Pneumonia) - Developing More than 48 Hours after Admission. Cause - Higher incidence of Gram Negative Bacilli - E Coli or Pseudomonas. Tx (Gram Negative Bacilli) - 1 Antipseudomonal Cephalosporins (Cefepime or Ceftazidime), or 2 Antipseudomonal Penicillin (Piperacillin_Tazobactam), or 3 Carbapenems (Imipenem, Meropenem, or Doripenem).
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What is Ventilator Associated Pneumonia Etiology?
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Ventilator Associated Pneumonia Etiology - Mechanical Ventilation Interferes with Normal Mucociliary Clearance of Respiratory Tract (ability to Cough). Positive Pressure Damage normal ability to clear Colonization. As high at 5 perc per day in First few days on ventilator. Pt has multiple concurrent illnesses, so difficult to establish.
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Contrast CHF vs VAP?
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Contrast CHF (Clear Secretion) vs Ventilator Associated Pneumonia VAP (Fever, Increase WBC, New Infiltrate, Endotracheal Tube Purulent Secretion)
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VAP Lx?
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VAP Lx (Start with Least Accurate, but Easiest to do) - 1 Tracheal Aspirate - Least Accurate - aspirate below the end of ET tube, 2 Bronchoalveolar Lavage BAL - deeper into lungs where there are Not supposed to be any Organism, 3 Protected Brush Specimen - tip Uncovered Only inside lungs, 4 Video Assisted Thoracoscopy VAT - Placed through Chest Wall, 5 Open Lung Biopsy - Most Accurate - Greater Morbidity and Potential Complication due to Thoracotomy.
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VAP Tx?
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VAP Tx - Combine 3 drugs - 1 Antipseudomonal Beta Lactam - aaa Cephalosporin (Ceftazidime or Cefepime), or bbb Penicillin (Piperacillin_Tazobactam), or ccc Carbapenem (Imipenem, Meropenem, or Doripenem), Plus 2 Second Antipseudomonal agent - aaa Aminoglycoside (Gentamicin or Tobramycin or Amikacin), or bbb Fluoroquinolone (Ciprofloxacin or Levofloxacin), Plus 3 MRSA agent - aaa Vancomycin or Linezolid
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What are AntiPseudomonal Tx?
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AntiPseudomonal Tx - 1 Penicillins (Piperacillin_Tazobactam, Ticarcillin_Clavulanate), 2 Cefalosporin (Ceftazidime, Cefepime), 3 Carbapenem (Imipenem, Meropenem, NO Ertapenem), 4 Aztreonem, 5 Aminoglycoside (Gentamicin, Tobramycin, Amikacin), 6 Fluoroquinolone (Levofloxacin, Gatifloxacin, Moxifloxacin)
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Imipenem AE?
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Imipenem AE - Seizure (Renal Clearance), CNS problem
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Which broncus is Vertical? Horizontal?
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Broncus is Vertical - Right. Horizontal - Left (Heart pushing lung up)
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Where is Aspiration Pneumonia when pt Lying Flat?
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Aspiration Pneumonia when pt Lying Flat - Upper Lobe
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How do Large Volume Aspiration occur?
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Large Volume Aspiration occur - 1 Stroke (with Loss of Gag Reflex), 2 Seizures, 3 Intoxication (Alcoholics), 4 Endotracheal Intubation
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Lung Abscess Px?
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Lung Abscess Px - 1 Large Volume Aspiration (Oral Pharyngeal Contents), 2 Poor Dentition, 3 Aspiration Not Adequately Treated. Most Aspiration are Treated, so Lung Abscess is Rare.
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Chronic infection developing Over several weeks, Large Volume Sputum, Foul Smelling. Dx?
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Chronic infection developing Over several weeks, Large Volume Sputum (Anaerobes), Foul Smelling. Risk Factors for Aspiration - 1 Stroke (with Loss of Gag Reflex), 2 Seizures, 3 Intoxication (Alcoholics), 4 Endotracheal Intubation. Weight Loss is Common. Dx - Abscess
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Abscess. Lx? Tx?
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Abscess. Lx - Initial - CXR - Cavity (Air Fluid level). Chest CT is More Accurate than CXR. Lx - MA - Lung Biopsy. Sputum Culture is Wrong Answer because everyone has Anaerobes from mouth flora. Tx - 1 Clindamycin, or 2 Penicillin - Best to cover lung abscess..
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HIV, CD4 Below 200. Dyspnea on Exertion, Dry Cought, Fever. Dx? Lx? Tx?
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HIV, CD4 Below 200. Dyspnea on Exertion, Dry Cought, Fever. Dx - PCP. Lx - Initial - 1 CXR shows Bilateral Interstitial Infiltrates, or 2 Arterial Blood Gas shows Hypoxia, or 3 A-a Gradient Increased (More than 20). LDH Levels Elevated. Lx - MA - Bronchoalveolar Lavage BAL - Sputum Stain - 1 Toluidine Blue, 2 Silver Stain, or 3 Periodic Acid Schiff - Shows Ping-Pong Ball - Cysts. Negative BAL - Lx - Best - Bronchoscopy. Tx - TMP_SMX (Tx and Prophylaxis). Severe - pO2 Below 70, or A-a Gradient Above 35 - Tx - Add Steroids. Rash to TMP_SMX - Mild (Mild Hypoxia) PCP - Atovoquone. Toxicity to TMP_SMX - Switch to 1 Clindamycin and Primaquine, or 2 IV Pentamidine.
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What is A-a Gradient? Normal A-a Gridient?
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A-a Gradient is Oxygen in A(Aveolar) minus a(arterial). Remember the path of Oxygen from Alveolar to arterial. Normal A-a Gradient is 20.
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What is Normal pO2?
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Normal pO2 is 70-100.
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Sputum Stain with Toluidine Blue shows cells. Dx?
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Sputum Stain with Toluidine Blue shows cells. Lx - MA - Bronchoalveolar Lavage BAL - Sputum Stain - 1 Toluidine Blue, 2 Silver Stain, or 3 Periodic Acid Schiff - Shows Ping-Pong Ball - Cysts. Dx - PCP
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Sputum Stain with Silver Stain shows cells. Dx?
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Sputum Stain with Silver Stain shows cells. Lx - MA - Bronchoalveolar Lavage BAL - Sputum Stain - 1 Toluidine Blue, 2 Silver Stain, or 3 Periodic Acid Schiff - Shows Ping-Pong Ball - Cysts. Dx - PCP
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Sputum Stain with Periodic Acid Schiff shows cells. Dx?
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Sputum Stain with Periodic Acid Schiff cells. Lx - MA - Bronchoalveolar Lavage BAL - Sputum Stain - 1 Toluidine Blue, 2 Silver Stain, or 3 Periodic Acid Schiff - Shows Ping-Pong Ball - Cysts. Dx - PCP
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PCP. Lx - MA?
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PCP. Lx - MA - Bronchoalveolar Lavage BAL - Sputum Stain - 1 Toluidine Blue, 2 Silver Stain, or 3 Periodic Acid Schiff - Shows Ping-Pong Ball - Cysts.
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PCP. Toxicity to TMP_SMX. Tx?
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PCP. Toxicity to TMP_SMX. Tx - Switch to 1 Clindamycin and Primaquine, or 2 IV Pentamidine
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G6PD. What Tx is Contraindicated in PCP?
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G6PD. Tx Contraindicated in PCP - Primaquine, Dapsone, TMP_SMX
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African American, Anemia, Bite Cell in smear. Dx?
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African American, Anemia, Bite Cell in smear. Dx - G6PD
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Why is AntiRetrovirals Relatively Contraindicated in Acute Opportunistic Infections?
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Why is AntiRetrovirals Relatively Contraindicated in Acute Opportunistic Infections - Immune Reconstitution Syndrome
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If Answers have 2 Correct Tx, what to do?
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If Answers have 2 Correct Tx, what to do - Look for a Contraindication to One
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When to do PCP Prophylaxis? Tx? What kind of AE? What to Switch Tx to?
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When to do PCP Prophylaxis - CD4 Below 200. Tx - TMP_SMX. What kind of AE - 1 Rash, or 2 Neutropenia. What to Switch Tx to - 1 Atovoquone, or 2 Dapsone.
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TB Risk Factors?
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TB Risk Factors - 1 Recent Immigrants (In Past 5 ys), 2 Prisoners, 3 HIV Positive, 4 Healthcare Workers, 5 Close Contacts of someone with TB, 6 Steroid use, 7 Hematologic Malignancy, 8 Alcoholics, 9 Diabetes Mellitus
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What is Required to Diagnose TB?
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Requirement to Diagnose TB - 1 Risk Factor, 2 CXR - Cavity, or 2 Smear Positive
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Immigrant. Fever, Cough, Sputum, Weight Loss, Hemoptysis, Night Sweat. Dx?
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Immigrant. Fever, Cough, Sputum, Weight Loss, Hemoptysis, Night Sweat. Dx - TB. Only Lymphoma does Not have Hemoptysis
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TB Lx steps?
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TB Lx Steps - 1 PPD (Asymptomatic, Risk Factor), 2 CXR (Symptomatic), 3 Sputum Stain and Culture, 4 Pleural Biopsy - MA Lx. 1 PPD Positive - Prophylaxis with INH 9 months, 2 CXR Positive - Tx - RIPE 2 months, RI 4 months, 3 Sputum Stain and Culture Positive - Tx - RIPE 2 months, RI 4 months. Tx - 9 months - Pregnancy, Osteomyelitis Pott TB Spine, Meningitis TB, Disseminated_Miliary TB. Tx - HIV with TB - 6 month.
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What TB situation needs Special 9 months Tx?
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TB situation needs Special 9 months Tx - 1 Pregnancy, 2 Osteomyelitis - Potts TB Spine, 3 TB Meningitis, 4 Disseminated_Miliary TB. HIV TB is Normal Tx of 6 month
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TB Prophylaxis Tx?
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TB Prophylaxis Tx - 1 PPD Positive - Prophylaxis with INH 9 months
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TB Tx?
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TB Tx - 1 CXR Positive, or 2 Sputum Stain and Culture Positive - Tx - 1 Rifampin, 2 INH, 3 Pyrazinamide, 4 Ethambutol (RIPE) 2 months, and 1 Rifampin, 2 INH (RI) 4 months. Special Tx - 9 months - Pregnancy, Pott TB Spine, Meningitis TB, Disseminated_Miliary TB. Tx - HIV with TB - 6 month. Add Steroids - Heart (Pericarditis), Brain (Meningitis)
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What is TB med AE?
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TB med AE - Hepatotoxicity. Do Not stop unless Transaminases Rise to 3 to 5 Times Upper Limit of Normal. Rifampin AE - Red Color Body Secretions - Management - None because Benign. Isoniazid AE - Peripheral Neuropathy - Management - Use Pyridoxine B6. Pyrazinamide AE - Hyperuricemia (Gout) - Management - No Tx Unless Symptomatic. Ethambutol AE - Eye - Optic Neuritis (Pain) or Color Vision - Management - Decrease Dose in renal Failure.
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Rifampin AE? Management?
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TB med AE - Hepatotoxicity. Do Not stop unless Transaminases Rise to 3 to 5 Times Upper Limit of Normal. Rifampin AE - Red Color Body Secretions - Management - None because Benign. Isoniazid AE - Peripheral Neuropathy - Management - Use Pyridoxine B6. Pyrazinamide AE - Hyperuricemia (Gout) - Management - No Tx Unless Symptomatic. Ethambutol AE - Eye - Optic Neuritis (Pain) or Color Vision - Management - Decrease Dose in renal Failure.
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Isoniazid AE? Managment?
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TB med AE - Hepatotoxicity. Do Not stop unless Transaminases Rise to 3 to 5 Times Upper Limit of Normal. Rifampin AE - Red Color Body Secretions - Management - None because Benign. Isoniazid AE - Peripheral Neuropathy - Management - Use Pyridoxine B6. Pyrazinamide AE - Hyperuricemia (Gout) - Management - No Tx Unless Symptomatic. Ethambutol AE - Eye - Optic Neuritis (Pain) or Color Vision - Management - Decrease Dose in renal Failure.
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Pyrazinamide AE? Management?
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TB med AE - Hepatotoxicity. Do Not stop unless Transaminases Rise to 3 to 5 Times Upper Limit of Normal. Rifampin AE - Red Color Body Secretions - Management - None because Benign. Isoniazid AE - Peripheral Neuropathy - Management - Use Pyridoxine B6. Pyrazinamide AE - Hyperuricemia (Gout) - Management - No Tx Unless Symptomatic. Ethambutol AE - Eye - Optic Neuritis (Pain) or Color Vision - Management - Decrease Dose in renal Failure.
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Ethambutol AE? Management?
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TB med AE - Hepatotoxicity. Do Not stop unless Transaminases Rise to 3 to 5 Times Upper Limit of Normal. Rifampin AE - Red Color Body Secretions - Management - None because Benign. Isoniazid AE - Peripheral Neuropathy - Management - Use Pyridoxine B6. Pyrazinamide AE - Hyperuricemia (Gout) - Management - No Tx Unless Symptomatic. Ethambutol AE - Eye - Optic Neuritis (Pain) or Color Vision - Management - Decrease Dose in renal Failure.
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TB med Contraindicated in Pregnancy?
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TB med Contraindicated in Pregnancy - Pyrazinamide, Streptomycin
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What is Positive TB test?
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Positive TB test is Induration for each group. Induration Above 5 mm (Immune Compromised) - 1 HIV, 2 Glucocorticoids use, 3 Close Contacts of Those with Active TB, 4 Abnormal Calcifications on CXR, 5 Organ Transplant recipients (Zero immune system). Induration Above 10 mm (Profession and Location) - 1 Recent Immigrants (Past 5 y), 2 Prisoners, 3 Healthcare workers, 4 Close Contacts of someone wtih TB, 5 Hematologic Malignancy, Alcoholics, Diabetes Mellitus. Induration Above 15 mm - Those with No Risk Factors.
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HIV. PPD test size for TB positive?
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HIV. PPD test size for TB positive? Induration Above 5 mm
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Glucocorticoids use. PPD test size for TB positive?
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Glucocorticoids use. PPD test size for TB positive? Induration Above 5 mm
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Close Contacts of Those with Active TB . PPD test size for TB positive?
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Close Contacts of Those with Active TB . PPD test size for TB positive? Induration Above 5 mm
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Abnormal Calcifications on CXR. PPD test size for TB positive?
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Abnormal Calcifications on CXR. PPD test size for TB positive? Induration Above 5 mm
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Organ Transplant recipients. PPD test size for TB positive?
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Organ Transplant recipients. PPD test size for TB positive? Induration Above 5 mm
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Recent Immigrants (Past 5 y) . PPD test size for TB positive?
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Recent Immigrants (Past 5 y) . PPD test size for TB positive? Induration Above 10 mm
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Prisoners . PPD test size for TB positive?
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Prisoners . PPD test size for TB positive? Induration Above 10 mm
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Healthcare workers . PPD test size for TB positive?
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Healthcare workers . PPD test size for TB positive? Induration Above 10 mm
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Close Contacts of someone wtih TB . PPD test size for TB positive?
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Close Contacts of someone wtih TB . PPD test size for TB positive? Induration Above 10 mm
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Hematologic Malignancy . PPD test size for TB positive?
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Hematologic Malignancy . PPD test size for TB positive? Induration Above 10 mm
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Alcoholics . PPD test size for TB positive?
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Alcoholics . PPD test size for TB positive? Induration Above 10 mm
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Diabetes Mellitus . PPD test size for TB positive?
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Diabetes Mellitus . PPD test size for TB positive? Induration Above 10 mm
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No Risk Factors . PPD test size for TB positive?
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No Risk Factors . PPD test size for TB positive? Induration Above 15 mm
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Younger than 30 yo, Benign or Malignant Nodule?
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Younger than 30 yo, Benign or Malignant Nodule? - Benign Nodule
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No Change in Size, Benign or Malignant Nodule?
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No Change in Size, Benign or Malignant Nodule? - Benign Nodule
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NonSmoker, Benign or Malignant Nodule?
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NonSmoker, Benign or Malignant Nodule? - Benign Nodule
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Smooth Border, Benign or Malignant Nodule?
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Smooth Border, Benign or Malignant Nodule? - Benign Nodule
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Small, Less than 1 cm, Benign or Malignant Nodule?
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Small, Less than 1 cm, Benign or Malignant Nodule? - Benign Nodule
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Normal Lung, Benign or Malignant Nodule?
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Normal Lung, Benign or Malignant Nodule? - Benign Nodule
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No Adenopathy, Benign or Malignant Nodule?
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No Adenopathy, Benign or Malignant Nodule? - Benign Nodule
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Dense, Central Calcification, Benign or Malignant Nodule?
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Dense, Central Calcification, Benign or Malignant Nodule? - Benign Nodule
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Pop Corn Ball Calcification, Benign or Malignant Nodule?
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Pop Corn Ball Calcification, Benign or Malignant Nodule? - Benign Nodule
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Normal PET scan, Benign or Malignant Nodule?
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Normal PET scan, Benign or Malignant Nodule? - Benign Nodule
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Older than 40 yo, Benign or Malignant Nodule?
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Older than 40 yo, Benign or Malignant Nodule? - Malignant Nodule
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Enlarging, Benign or Malignant Nodule?
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Enlarging, Benign or Malignant Nodule? - Malignant Nodule
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Smoker, Benign or Malignant Nodule?
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Smoker, Benign or Malignant Nodule? - Malignant Nodule
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Spiculated, Benign or Malignant Nodule?
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Spiculated, Benign or Malignant Nodule? - Malignant Nodule
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Spikes, Benign or Malignant Nodule?
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Spikes, Benign or Malignant Nodule? - Malignant Nodule
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Large, Greater than 2 cm, Benign or Malignant Nodule?
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Large, Greater than 2 cm, Benign or Malignant Nodule? - Malignant Nodule
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Atelectasis, Benign or Malignant Nodule?
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Atelectasis, Benign or Malignant Nodule? - Malignant Nodule
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Yes Adenopathy, Benign or Malignant Nodule?
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Yes Adenopathy, Benign or Malignant Nodule? - Malignant Nodule
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Sparse, Eccentric Calcification, Benign or Malignant Nodule?
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Sparse, Eccentric Calcification, Benign or Malignant Nodule? - Malignant Nodule
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Stipple Calcification, Benign or Malignant Nodule?
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Stipple Calcification, Benign or Malignant Nodule? - Malignant Nodule
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Abnormal PET scan, Benign or Malignant Nodule?
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Abnormal PET scan, Benign or Malignant Nodule? - Malignant Nodule
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Solitary Pulmonary Nodule. Lx?
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Solitary Pulmonary Nodule. Lx - 1 CXR (compare to Old), 2a Benign - Serial CT (every 3 months for 2 years), 2b Indeterminant or Suspicious for Malignancy - CT (for Location), 3b Bx or PET scan
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Solitary Pulmonary Nodule. What is High Probability Lesion? Lx?
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Solitary Pulmonary Nodule. High Probability Lesion - 1 Age Above 40, 2 Smoker, 3 Size Above 1-2cm (CXR). Lx - 1 CT (for Location) - 2 Open Lung Bx and Resection.
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Solitary Pulmonary Nodule. What is Intermediate Probability Lesion? Lx?
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Solitary Pulmonary Nodule. Intermediate Probability Lesion - Size 1-2 cm (CXR). Lx - 1 CT - 2 Sputum Cytology (Positive - Resection), or 3 PET, or 4 Bronchoscopy (Central lesion), or 5 Transthoracic Needle Biopsy (Peripheral lesion), or 6 VAT (may Convert to Open Thoracoscopy and Lobectomy if Malignancy is found).
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Solitary Pulmonary Nodule. What is Low Probability Lesion? Lx?
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Solitary Pulmonary Nodule. Low Probability Lesion - 1 Age Below 30, 2 NonSmoker, 3 Size Below 1 cm. Lx - 1 CT - 2 Serial CT or CXR (every 3 month for 2 year)
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Solitary Pulmonary Nodule. Central Lesion. Lx?
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Solitary Pulmonary Nodule. Central Lesion. Lx - Do 1 CT (Location) before doing 2 Bronchoscopy
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Solitary Pulmonary Nodule. Peripheral Lesion. Lx?
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Solitary Pulmonary Nodule. Peripheral Lesion. Lx - Do 1 CT (Location) before doing 2 Transthoracic Needle Bx
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Solitary Pulmonary Nodule. When to use Bronchoscopy?
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Solitary Pulmonary Nodule. Central Lesion. Lx - Do 1 CT (Location) before doing 2 Bronchoscopy
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Solitary Pulmonary Nodule. When to use Transthoracic Needle Bx?
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Solitary Pulmonary Nodule. Peripheral Lesion. Lx - Do 1 CT (Location) before doing 2 Transthoracic Needle Bx
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What is Complication of Transthoracic Needle Bx?
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Complication of Transthoracic Needle Bx - Pneumothorax
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What is Complication of Interstitial Lung Disease?
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Complication of Interstitial Lung Disease - Cor Pulmonale - R Ventricle Hypertrophy
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What is Pulmonary Fibrosis?
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Pulmonary Fibrosis - Thickening of Interstitial Septum of lung between Arteriolar space and Alveolus. Fibrosis interferes with Gas Exchange in both direction
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Cause of Pulmonary Fibrosis?
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Cause of Pulmonary Fibrosis - 1 Idiopathic (Interstitial Pulmonary Fibrosis), 2 Secondary to Inflammatory Conditions, 3 Radiation, 4 Drugs (Bleomycin, Busulfan, Amiodarone, Methylsergide, Nitrofurantoin, Cyclophosphamide), or from 5 Inhalatin of Toxins. They Thicken Septum. Idiopathic Fibrosing Interstitial Pneumonia.
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What med causes Pulmonary Fibrosis?
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Pulmonary Fibrosis causing Drugs - 1Bleomycin, 2 Busulfan, 3 Amiodarone, 4 Methylsergide, 5 Nitrofurantoin, 6 Cyclophosphamide
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Exposure to Coal. What Lung Disease?Tx? -
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Exposure to Coal. What Lung Disease?Tx? - Coal Worker's Pneumoconiosis
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Exposure to Sandblasting. What Lung Disease?Tx? -
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Exposure to Sandblasting. What Lung Disease?Tx? - Silicosis (Ceiling - Upper Lobe, Asso TB). Tx - Stop Smoking
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Exposure to Rock Mining. What Lung Disease?Tx? -
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Exposure to Rock Mining. What Lung Disease?Tx? - Silicosis (Ceiling - Upper Lobe, Asso TB). Tx - Stop Smoking
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Exposure to Tunneling. What Lung Disease?Tx? -
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Exposure to Tunneling. What Lung Disease?Tx? - Silicosis (Ceiling - Upper Lobe, Asso TB). Tx - Stop Smoking
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Exposure of Shipyard workers. What Lung Disease?Tx? -
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Exposure of Shipyard workers. What Lung Disease?Tx? - Asbestosis (Lower Lobe, Mesotheoloma)
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Exposure to Pipe Fitting. What Lung Disease?Tx? -
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Exposure to Pipe Fitting. What Lung Disease?Tx? - Asbestosis (Lower Lobe, Mesotheoloma)
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Exposure to Insulators. What Lung Disease?Tx? -
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Exposure to Insulators. What Lung Disease?Tx? - Asbestosis (Lower Lobe, Mesotheoloma)
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Exposure to Cotton. What Lung Disease?Tx? -
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Exposure to Cotton. What Lung Disease?Tx? - Byssinosis
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Exposure of Electronic Manufacture. What Lung Disease?Tx? -
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Exposure of Electronic Manufacture. What Lung Disease?Tx? - Berylliosis (Blackberry). Tx - Steroids
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Exposure to Moldy Sugar Cane. What Lung Disease?Tx? -
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Exposure to Moldy Sugar Cane. What Lung Disease?Tx? - Bagassosis
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Contrast Inflammatory Infiltration with White Cells vs Fibrosis?
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Contrast Inflammatory Infiltration (Treatable) with White Cells vs Fibrosis (Irreversible)
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Pulmonary Fibrosis. Px?
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Pulmonary Fibrosis. Px - 1 Dyspnea, Worsening on Exertion, 2 Fine Rales or Crackles on Exam, 3 Loud P2 Heart Sound (Pulmonary HTN), 4 Clubbing of Fingers
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What auscultatory finding for Pulmonary Hypertention?
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Auscultatory finding for Pulmonary Hypertention - Loud P2 Heart Sound
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Dyspnea, Worsening on Exertion, Fine Rales or Crackles on Exam, Loud P2 Heart Sound, Clubbing of Fingers. Dx? Lx? Tx?
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Dyspnea, Worsening on Exertion, Fine Rales or Crackles on Exam, Loud P2 Heart Sound, Clubbing of Fingers. Dx - Pulmonary Fibrosis (Interstitial Lung Disease). Lx - Best Initial - CXR (High Resolution CT more accurate - Honey Combing of lungs). Lx - MA - Lung Biopsy. Echnocardiography - show Pulmonary Hypertension and maybe Right Ventricular Hypertrophy. PFT - FEV1, FVC< TLC, Residual Volume Decreased proportionately. FEV1 per FVC is Normal. DLCO is Decreased due to Thickening of Alveolar Septum. Tx - Only Berylliosis (Electronic manufacturing) - Granulomas - Sign of inflammation with Steroids. If Biopsy shows White cell or Inflammatory Infiltrate - Prednisone.
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What Pneumoconionsis has Granulomas?
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Pneumoconionsis has Granulomas - Berylliosis - Tx - Steroids
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Types of Pneumoconionsis?
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Types of Pneumoconionsis - 1 Coal Worker Pneumoconiosis, 2 Silicosis, 3 Asbestosis, 4 Byssinosis, 5 Berylliosis, 6 Bagassosis
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What causes Mesotheoloma?
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Mesotheoloma - Asbestosis
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African American, Shortness of Breath on Exertion, Erythema Nodosum, Lymphadenopathy. Dx? Asso Px? Lx? Tx?
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African American, Shortness of Breath on Exertion, Erythema Nodosum, Lymphadenopathy. Dx - Sarcoidosis. Asso Px - 1 Parotid Gland Enlargement, 2 Facial Palsy, 3 Heart Bloack and Restrictive Cardiomyopathy, 4 CNS involvement, 5 Iritis and Uveitis. Lx - Best Initial - CXR - Hilar Adenopathy. Lx - MA - Lymph Node Biopsy - NonCaseating Granulomas. 1 ACE Level Elevated, 2 hypercalciuria, 3 Hypercalcemia (Granulomas in Sarcoidosis makes Vitamin D), 4 PFT - Restrictive lung disease (FEV1, FVC, TLC Decrease. FEV1 per FVC Normal). BAL shows Elevated level of Helper cells. Tx - Prednisone (Steroids - Sarcoidosis). Asymptomatic Hilar Adenopathy Does Not need Tx.
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Disease with Granuloma? Type of Granuloma?
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Disease with Granuloma - 1 Sarcoidosis - NonCaseating, 2 TB - Caseating.
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What is Sarcoidosis?
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Sarcoidosis is Idiopathic Inflammatory Disorder mainly in Lung, but can affect most of the body. More common in African American Women.
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Sarcoidosis Px?
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Sarcoidosis Px - 1 African American Women, 2 Idiopathic Inflammatory Disorder (mainly Lungs, but affect any part of body), 3 Erythema Nodosum and Lymphadenopathy (Physical exam or CXR). Other Px - 1 Parotid Gland Enlargement, 2 Facial Palsy, 333 Heart Block and Restrictive Cardiomyopathy, 4 CNS involvement, 555 Iritis and Uveitis.
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Generally Healthy African American Woman, CXR or CT shows Hilar Adenopathy. Dx?
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Generally Healthy African American Woman, CXR or CT shows Hilar Adenopathy. Dx - Sarcoidosis
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Sarcoidosis Lx?
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Sarcoidosis Lx - Best Initial - CXR - Hilar Adenopathy. Lx - MA - Lymph Node Biopsy - NonCaseating Granulomas. 1 ACE Level Elevated, 2 hypercalciuria, 3 Hypercalcemia (Granulomas in Sarcoidosis makes Vitamin D), 4 PFT - Restrictive lung disease (FEV1, FVC, TLC Decrease. FEV1 per FVC Normal). BAL shows Elevated level of Helper cells.
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Sarcoidosis Tx?
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Sarcoidosis Tx - Prednisone (Steroids - Sarcoidosis). Asymptomatic Hilar Adenopathy Does Not need Tx.
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Elevated ACE level. Dx?
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Elevated ACE level. Dx - suggest Sarcoidosis
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What is PE? What is Etiology of PE? Px? Lx? Tx?
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PE and DVT are treated as a Spectrum of same disease. PE derives from DVT of Large Vessels of Legs (Proximal) in 70 perc and Pelvic Veins in 30 perc, but Risks and Tx are the same. Etiology of PE - DVT arise due to - 1 Stasis from Immobility, Surgery (Hip Replacement), Trauma, Joint Replacement, or Thrombophilia (Factor V Leiden Mutation). 2 Malignancy (Cancer of any kind). Px - 1 Sudden Onset of Shortness of Breath, 2 with Clear Lungs on Exam and a Normal CXR. Other Px - 1 Tachypnea, Tachycardia, Cough, and Hemoptysis, 2 Leg Pain from DVT, 3 Pleuritic Chest Pain from Lung Infarction, 4 Fever (can Arise from Any Cause of Clot or Hematoma), 5 Extremely Severe Emboli will Produce Hypotension. Lx - Initial - CXR, EKG, ABG. Lx - MA - Angiography (Can be Fatal in 0.5 perc). 1 CXR - Usually Normal. Most Common Abnormality - Atelectasis. Wedge-shaped Infarction, Pleural-based lesion (Hampton Hump), and Oligemia of one lobe (Westermark Sign) are Much Less Common than Atelectasis. 2 EKG - Usually Sinus Tachycardia. Most Common Abnormality is NonSpecific ST-T Wave Changes. Only 5 perc show Right Axis Deviation, RV Hypertrophy, or Right Bundle Branch Block. S1 Q3 T3 - uncommon. 3 ABG - Hypoxia and Respiratory Alkalosis (High pH and Low pCO2) with Normal CXR is Extremely Suggestive of PE. 4. Spiral CT Scan (aka CT Angiogram) - Std of Care to Confirm PE after CXR, EKG, and ABG are done (ContraIndicated in Pregnancy -- do V_Q Scan). 5 Ventilation_Perfusion V_Q Scan - Completely Normal Scan Essentially Excludes a Clot. 6. D-Dimer - Very Sensitive, but Specificity is Poor (any cause of Clot or Increased Bleeding can Elevate D-Dimer) - Negative Test Excludes a Clot, but a Positive Test Does Not mean Anything (Pretest Probability of PE is Low and Simple NonInvasive Test to Exclude Thromboembolic Disease). 7. Lower Extremity Doppler Study - LE Doppler is Positive, No Further Testing is Needed. (will miss 30 perc of cases not from Leg). Do Not need Spiral CT or V_Q scan to Confirm - need Heparin and 6 months of Warfarin. 8 Angiography - MA - but 0.5 perc Mortality. Angiograph AE - Allergy, Renal Toxicity, and Death. Tx - Best Initial - Heparin (Warfarin should be started at the same time as Heparin in order to achieve a therapeutic INR of 2 to 3 times normal as quickly as possible). Tx - Inferior Vena Cava IVC filter - Resistant or RV dysfunction (1. Contraindication to use of Anticoagulants (ex Melena, CNS Bleeding), 2. Recurrent Emboli (while on Heparin, or Fully THerapeutic Warfarin with INR 2-3), 3. Right Ventricular Dysfunction with Enlarged RV on Echo - disease is So Severe - next small emoblus could be fatal.) Tx - Thrombolytics - 1 Hemodynamically Unstable Pts (eg Hypotension and Tachycardia), 2 Acute RV Dysfunction. Tx - Direct-Acting Thrombin Inhibitors (Argatroban, Lepirudin) - 1 Heparin-Induced Thrombocytopenia (Heparin CI). Aspirin is Never the answer.
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What is PE?
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PE and DVT are treated as a Spectrum of same disease. PE derives from DVT of Large Vessels of Legs (Proximal) in 70 perc and Pelvic Veins in 30 perc, but Risks and Tx are the same.
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What is Etiology of PE?
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Etiology of PE - DVT arise due to - 1 Stasis from Immobility, Surgery (Hip Replacement), Trauma, Joint Replacement, or Thrombophilia (Factor V Leiden Mutation). 2 Malignancy (Cancer of any kind).
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What is PE Px?
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PE Px - 1 Sudden Onset of Shortness of Breath, 2 with Clear Lungs on Exam and a Normal CXR. Other Px - 1 Tachypnea, Tachycardia, Cough, and Hemoptysis, 2 Leg Pain from DVT, 3 Pleuritic Chest Pain from Lung Infarction, 4 Fever (can Arise from Any Cause of Clot or Hematoma), 5 Extremely Severe Emboli will Produce Hypotension.
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What is PE Lx?
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PE Lx - Initial - CXR, EKG, ABG. Lx - MA - Angiography (Can be Fatal in 0.5 perc). 1 CXR - Usually Normal. Most Common Abnormality - Atelectasis. Wedge-shaped Infarction, Pleural-based lesion (Hampton Hump), and Oligemia of one lobe (Westermark Sign) are Much Less Common than Atelectasis. 2 EKG - Usually Sinus Tachycardia. Most Common Abnormality is NonSpecific ST-T Wave Changes. Only 5 perc show Right Axis Deviation, RV Hypertrophy, or Right Bundle Branch Block. S1 Q3 T3 - uncommon. 3 ABG - Hypoxia and Respiratory Alkalosis (High pH and Low pCO2) with Normal CXR is Extremely Suggestive of PE. 4. Spiral CT Scan (aka CT Angiogram) - Std of Care to Confirm PE after CXR, EKG, and ABG are done (ContraIndicated in Pregnancy -- do V_Q Scan). 5 Ventilation_Perfusion V_Q Scan - Completely Normal Scan Essentially Excludes a Clot. 6. D-Dimer - Very Sensitive, but Specificity is Poor (any cause of Clot or Increased Bleeding can Elevate D-Dimer) - Negative Test Excludes a Clot, but a Positive Test Does Not mean Anything (Pretest Probability of PE is Low and Simple NonInvasive Test to Exclude Thromboembolic Disease). 7. Lower Extremity Doppler Study - LE Doppler is Positive, No Further Testing is Needed. (will miss 30 perc of cases not from Leg). Do Not need Spiral CT or V_Q scan to Confirm - need Heparin and 6 months of Warfarin. 8 Angiography - MA - but 0.5 perc Mortality. Angiograph AE - Allergy, Renal Toxicity, and Death. Most Common Abnormality Lx - CXR - Atelectasis, EKG - NonSpecific ST-T Changes, ABG - Hypoxia and Respiratory Alkalosis.
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What is PE Tx?
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PE Tx - Best Initial - Heparin (Warfarin - 6 months Tx - should be started at the same time as Heparin in order to achieve a therapeutic INR of 2 to 3 times normal as quickly as possible). Tx - Inferior Vena Cava IVC filter - Resistant or RV dysfunction (1. Contraindication to use of Anticoagulants (ex Melena, CNS Bleeding), 2. Recurrent Emboli (while on Heparin, or Fully THerapeutic Warfarin with INR 2-3), 3. Right Ventricular Dysfunction with Enlarged RV on Echo - disease is So Severe - next small emoblus could be fatal.) Tx - Thrombolytics - 1 Hemodynamically Unstable Pts (eg Hypotension and Tachycardia), 2 Acute RV Dysfunction. Tx - Direct-Acting Thrombin Inhibitors (Argatroban, Lepirudin) - 1 Heparin-Induced Thrombocytopenia (Heparin CI). Aspirin is Never the answer.
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What class of med is Heparin?
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Heparin and Warfarin are AntiThrombolytic for PE
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What class of med is Warfarin?
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Heparin and Warfarin are AntiThrombolytic for PE
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What class of med is Aspirin?
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Aspirin is AntiPlatelet.
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PE Pretest Probability - Low, Moderate, High? Lx?
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PE Pretest Probability and Lx - Low (Young, Not Immobile - D-Dimer), Moderate (Smoker, Not Immobile - CT Scan), High (Old, Immobile, Hip Surgery - CT Scan).
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PE Lx with High Sensitivity and Low Specificity? Function?
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PE Lx with High Sensitivity and Low Specificity - D-Dimer. Negative test Excludes a Clot, but a Positive test Does Not Mean anything. Similar to BNP in CHF - Neg BNP means No CHF.
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PE Lx in Pregnancy?
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PE Lx in Pregnancy - CT Contrast is ContraIndicated, Use V_Q Scan
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What is rare EKG abnormality in PE?
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Rare EKG abnormality in PE - SQT 133 - S1, Q3, T3.
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What PE Lx is abnormal in COPD?
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PE Lx abnormal in COPD - V_Q Scan
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For PE, what Lx should be done based on CXR result?
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For PE, Lx should be done based on CXR result. CXR Normal - Do V_Q Scan. CXR Abnormal - Do Spiral CT.
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For PE, what Lx should be done if V_Q Scan and Spiral CT Do Not Give a Clear result?
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For PE, Lx should be done if V_Q Scan and Spiral CT Do Not Give a Clear result - Lower Extremity Doppler.
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What is Angiography AE?
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Angiography AE - Allergy, Renal Toxicity, and Death.
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PE, Hemodynamically Stable, Can tolerate Thrombolytic. Next Step?
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PE, Hemodynamically Stable, Can tolerate Thrombolytic. Next Step - Heparin 5 days and Warfarin for 6 months.
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PE, Hemodynamically UnStable, Can tolerate Thrombolytic. Next Step?
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PE, Hemodynamically UnStable, Can tolerate Thrombolytic. Next Step - Heparin 5 days and Warfarin for 6 months.
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PE, Hemodynamically Stable, ContraIndication to Thrombolytic. Next Step?
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PE, Hemodynamically Stable, ContraIndication to Thrombolytic (or Recurrent PE, or RV Dysfunction). Next Step - IVC Filter.
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PE, Hemodynamically UnStable, ContraIndication to Thrombolytic. Next Step?
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PE, Hemodynamically UnStable, ContraIndication to Thrombolytic. Next Step - Thrombolectomy, or IVC Filter
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What is the Time Limit to use Thrombolytics in PE?
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Time Limit to use Thrombolytics in PE - 24 hours. Stroke Time Limit - 3 Hours. MI Time Limit - 12 Hours.
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What is the Time Limit to use Thrombolytics in Stroke?
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Time Limit to use Thrombolytics in PE - 24 hours. Stroke Time Limit - 3 Hours. MI Time Limit - 12 Hours.
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What is the Time Limit to use Thrombolytics in MI?
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Time Limit to use Thrombolytics in PE - 24 hours. Stroke Time Limit - 3 Hours. MI Time Limit - 12 Hours.
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In PE, what medication should maintain INR? What INR?
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In PE, medication should maintain INR - Warfarin. INR of 2-3.
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In PE, when is Inferior Vena Cava Filter used?
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In PE, when is Inferior Vena Cava Filter used - 1 ContrIndication to Use of AntiCoagulants (Melena, CNS Bleeding), 2 Recurrent Emboli (On Heparin or Therapeutic Warfarin with INR 2-3), 3 Right Ventricular Dysfunction (Enlarged RV on Echo - Disease is So Severe - Next small embolus could be fatal).
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In PE, when is Thrombolytics used?
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In PE, when is Thrombolytics used - 1 Hemodynamically Unstable Pt (Hypotension and Tachycardia), 2 Acute RV Dysfunction.
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What is Direct Acting Thrombin Inhibitors med?
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Direct Acting Thrombin Inhibitors med - 1 Argatroban, 2 Lepirudin. They are used when Heparin CI due to Heparin-Induced Thrombocytopenia.
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What med class is Argatroban?
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Direct Acting Thrombin Inhibitors med - 1 Argatroban, 2 Lepirudin.
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What med class is Lepirudin?
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Direct Acting Thrombin Inhibitors med - 1 Argatroban, 2 Lepirudin.
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When is Aspirin used in PE?
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Aspirin used in PE - Never
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What is Warfarin function?
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Warfarin is 6 month Thrombolytic in PE (INR 2-3). Warfarin Inhibit Factor 7 in Extrinsic (2, 7, 9, 10). Warfarin CI in Pregnancy.
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What is Heparin function?
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Heparin is 5 days Thrombolytic in PE. Heparin Inhibit Factor 2.
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What is the pressure of Pulmonary circulation?
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Pressure of Pulmonary Circulation is Low (Systolic 25 mmHg, Diastolic 8 mmHg). Any Chronic Lung Disease leads to Back Pressure into Pulmonary Artery - Obstructing Flow Out of Right Side of Heart
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Dyspnea and Fatigue, Syncope, Chest pain, Wide Splitting of S2 with a Loud P2, or Tricuspid and Pulmonary Valve Insufficiency. Dx? Etiology? Lx? Tx?
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Dyspnea and Fatigue, Syncope, Chest pain, Wide Splitting of S2 with a Loud P2, or Tricuspid and Pulmonary Valve Insufficiency. Dx - Pulmonary Hypertension. Etiology - Primary Pulmonary Hypertension (Idiopathic), Secondary - Chronic Lung Disease (COPD, Fibrosis - Elevate Pulmonary Artery Pressure). Hypoxemia Causes Vasoconstriction of Pulmonary Circulation (Normal Reflex in Lungs to Shunt Blood away from areas of lung with Poor Oxygenation). Hypoxia leads to Pulmonary Hypertension, and Pulmonary Hypertension Results in More Hypoxia (Negative Feedback). Lx - Best Initial - 1 CXR and CT - Dilation of Proximal Pulmonary Arteries with Narrowing (Pruning) of Distal Vessels. Lx - MA - 2 Right Heart or Swan-Ganz Catheter - Measure Pressure. 3 EKG - Right Axis Deviation, Right Atrial and Ventricular Hypertrophy. 4 Echocardiography - RA and RV Hypertrophy - Doppler (Estimates Pulmonary Artery Pressure. 5 V_Q Scanning - Identifies Chronic PE as the Cause of Pulmonary Hypertension. CBC - Polycythemia from Chronic Hypoxia. Tx - 1 Correct Underlying Cause when Known, 2 Idiopathic Disease (aaa Prostacyclin Analogues - PA Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost. bbb Endothelin Antagonists - Bosentan. ccc Phosphodiesterase Inhibitors - Sildenafil) - they are Better than CCB, Hydralazine, and Nitroglycerin. 3 Oxygen Slows Progression, Particularly with COPD. Only Lung Transplantation is Curative for Idiopathic Pulmonary Hypertension.
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What is Curative Tx for Idiopathic Pulmonary Hypertension?
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Curative Tx for Idiopathic Pulmonary Hypertension - Lung Transplantation
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Pulmonary Hypertension - Etiology? Lx? Tx?
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Pulmonary Hypertension - Etiology? - Primary Pulmonary Hypertension (Idiopathic), Secondary - Chronic Lung Disease (COPD, Fibrosis - Elevate Pulmonary Artery Pressure). Hypoxemia Causes Vasoconstriction of Pulmonary Circulation (Normal Reflex in Lungs to Shunt Blood away from areas of lung with Poor Oxygenation). Hypoxia leads to Pulmonary Hypertension, and Pulmonary Hypertension Results in More Hypoxia (Negative Feedback). Lx - Best Initial - 1 CXR and CT - Dilation of Proximal Pulmonary Arteries with Narrowing (Pruning) of Distal Vessels. Lx - MA - 2 Right Heart or Swan-Ganz Catheter - Measure Pressure. 3 EKG - Right Axis Deviation, Right Atrial and Ventricular Hypertrophy. 4 Echocardiography - RA and RV Hypertrophy - Doppler (Estimates Pulmonary Artery Pressure. 5 V_Q Scanning - Identifies Chronic PE as the Cause of Pulmonary Hypertension. CBC - Polycythemia from Chronic Hypoxia. Tx - 1 Correct Underlying Cause when Known, 2 Idiopathic Disease (aaa Prostacyclin Analogues - PA Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost. bbb Endothelin Antagonists - Bosentan. ccc Phosphodiesterase Inhibitors - Sildenafil) - they are Better than CCB, Hydralazine, and Nitroglycerin. 3 Oxygen Slows Progression, Particularly with COPD. Only Lung Transplantation is Curative for Idiopathic Pulmonary Hypertension.
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Pulmonary Hypertension - Etiology?
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Pulmonary Hypertension - Etiology? - Primar Pulmonary Hypertension (Idiopathic), Secondary - Chronic Lung Disease (COPD, Fibrosis - Elevate Pulmonary Artery Pressure). Hypoxemia Causes Vasoconstriction of Pulmonary Circulation (Normal Reflex in Lungs to Shunt Blood away from areas of lung with Poor Oxygenation). Hypoxia leads to Pulmonary Hypertension, and Pulmonary Hypertension Results in More Hypoxia (Negative Feedback).
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What does Chronic Lung Disease Cause?
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What does Chronic Lung Disease Cause (COPD, Fibrosis)? - Elevate Pulmonary Artery Pressure. Hypoxemia Causes Vasoconstriction of Pulmonary Circulation (Normal Reflex in Lungs to Shunt Blood away from areas of lung with Poor Oxygenation). Hypoxia leads to Pulmonary Hypertension, and Pulmonary Hypertension Results in More Hypoxia (Negative Feedback).
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Pulmonary Hypertension Lx?
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Pulmonary Hypertension Lx? - Best Initial - 1 CXR and CT - Dilation of Proximal Pulmonary Arteries with Narrowing (Pruning) of Distal Vessels. Lx - MA - 2 Right Heart or Swan-Ganz Catheter - Measure Pressure. 3 EKG - Right Axis Deviation, Right Atrial and Ventricular Hypertrophy. 4 Echocardiography - RA and RV Hypertrophy - Doppler (Estimates Pulmonary Artery Pressure. 5 V_Q Scanning - Identifies Chronic PE as the Cause of Pulmonary Hypertension. 6 CBC - Polycythemia from Chronic Hypoxia.
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Pulmonary Hypertension Tx?
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Pulmonary Hypertension Tx - 1 Correct Underlying Cause when Known, 2 Idiopathic Disease (aaa Prostacyclin Analogues - PA Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost. bbb Endothelin Antagonists - Bosentan. ccc Phosphodiesterase Inhibitors - Sildenafil) - they are Better than CCB, Hydralazine, and Nitroglycerin. 3 Oxygen Slows Progression, Particularly with COPD. Only Lung Transplantation is Curative for Idiopathic Pulmonary Hypertension.
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Pulmonary Hypertension due to Idiopathic Disease Tx?
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Pulmonary Hypertension due to Idiopathic Disease Tx? (aaa Prostacyclin Analogues - PA Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost. bbb Endothelin Antagonists - Bosentan. ccc Phosphodiesterase Inhibitors - Sildenafil) - they are Better than CCB, Hydralazine, and Nitroglycerin.
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Pulmonary Hypertension CXR and CT finding?
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Pulmonary Hypertension CXR and CT finding? - Dilation of Proximal Pulmonary Arteries with Narrowing (Pruning) of Distal Vessels.
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What is Swan-Ganz Catheter?
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What is Swan-Ganz Catheter? Swan-Ganz Catheter - Measure Pressure in Right Ventricle. Swan-Ganz Catheter is Lx MA for Pulmonary Hypertension.
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What is Prostacyclin Analogues meds? What do they do? What do they Tx?
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What is Prostacyclin Analogues meds? What do they do? What do they Tx? - Pulmonary Artery Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost. They Tx Pulmonary Hypertension due to Idiopathic Disease
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What is Endothelin Antagonists meds? What do they do? What do they Tx?
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What is Endothelin Antagonists meds? What do they do? What do they Tx? Endothelin Antagonists - Bosentan. They Tx Idiopathic Pulmonary Hypertension.
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What is Phosphodiesterase Inhibitors meds? What do they do? What do they Tx?
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What is Phosphodiesterase Inhibitors meds? What do they do? What do they Tx? Phosphodiesterase Inhibitors - Sildenafil. They can Tx Idiopathic Pulmonary Hypertension
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Epoprostenol. What med class? -
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Epoprostenol. What med class? - Prostacyclin Analogues – Pulmonary Artery Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost.
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Treprostinil. What med class? -
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Treprostinil. What med class? - Prostacyclin Analogues – Pulmonary Artery Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost.
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Iloprost. What med class? -
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Iloprost. What med class? - Prostacyclin Analogues – Pulmonary Artery Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost.
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Beraprost. What med class? -
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Beraprost. What med class? - Prostacyclin Analogues – Pulmonary Artery Vasodilators - Epoprostenol, Treprostinil, Iloprost, Beraprost.
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Bosentan. What med class? -
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Bosentan. What med class? - Endothelin Antagonists - Bosentan.
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Sildenafil. What med class? -
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Sildenafil. What med class? - Phosphodiesterase Inhibitors – Sildenafil
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What does Wide Splitting of S2 with a Loud P2 means?
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Wide Splitting of S2 with a Loud P2 means - Pulmonary Valve Insufficiency or Delay. It is seen in Pulmonary Hypertension. Tricuspid and Pulmonary Valve Insufficiency due to back flow of Blood. S2 has A2 and P2
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What is Normal Pulmonary Artery Mean Pressure?
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Normal Pulmonary Artery Mean Pressure is Less than 20.
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What is Normal Pulmonary Capillary Wedge Pressure?
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Normal Pulmonary Capillary Wedge Pressure is Less than 12. PCWP More than 12 is Cardiogenic Shock and Failure
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Idiopathic Pulmonary Hypertension Curative Tx?
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Idiopathic Pulmonary Hypertension Curative Tx - Lung Transplantation
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What does Hypoxia cause in Lung?
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Hypoxia causes Vasoconstriction in Pulmonary Circulation as a Normal Reflex in Lungs to Shunt Blood Away from areas of lung it considers to have Poor Oxygenation. Hypoxia leads to Pulmonary Hypertension, and Pulmonary Hypertension results in more Hypoxemia.
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Day time Somnolence, Loud Snoring, Hypertension. Dx? Lx? Tx?
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Day time Somnolence, Loud Snoring, Hypertension (Bull Neck, Headache, Impaired Memory and Judgement). Dx - Obstructive Sleep Apnea. Etiology - Obesity is Most Common identified cause. Lx - MA - Polysomnography (aka Sleep Study) - shows multiple episodes of apnea. Arrythmias and Erythrocytosis are common. Tx - 1 Weight Loss and Avoid Alcohol, 2 Nasal CPAP, 3 Uvuloplatopharyngoplasty (Surgical Widening of Airway), 4 Avoid use of Sedatives.
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ARDS definition? Etiology? Lx? Tx?
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ARDS definition - Respiratory Failure from 1 Overwhelming Lung Injury, or 2 Systemic Disease leading to Severe Hypoxia with CXR whiteout, but Cardiac Hemodynamic normal. ARDS Decreases Surfactant and makes Lung cells Leaky, so Alveoli Fill Up with Fluid. Etiology - Idiopathic. Many illnesses asso with Alveolar Epithelial Cell and Capillary Endothelial Cell Damage. Risk of ARDS - SAD CT BP (Sepsis, Aspiration, Drowning, Contusion, Trauma, Burns, Pancreatitis) - 1 Sepsis or Aspiration, 2 Lung Contusion or Trauma, 3 Near-Drowning, 4 Burns or Pancreatitis. Lx - CXR - Bilateral Infiltrates - Quickly becomes confluent (White Out). Air Bronchograms are Common. ARDS defines as pO2 over FIO2 ratio Below 200. Wedge Pressure is Normal (Cardiogenic Shock has INcrease Wedge Pressure). Ex pO2(105 in ABG) over FIO2(.21 - 21 perc oxygen) is 500. Tx - Low Tidal volume Mechanical Ventilation (6 mL per Kg of Tidal Volume) is Best Support while waiting to see if lungs will recover. Steriods are Not clearly beneficial. PEEP is used when Mechanical ventilation to try to Decrease FIO2. FIO2 Above 50 perc is Toxic to Lungs. Maintain Plateau Pressure of Less than 30 cm of Water.
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ARDS definition?
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ARDS definition - Respiratory Failure from 1 Overwhelming Lung Injury, or 2 Systemic Disease leading to Severe Hypoxia with CXR whiteout, but Cardiac Hemodynamic normal. ARDS Decreases Surfactant and makes Lung cells Leaky, so Alveoli Fill Up with Fluid.
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ARDS Etiology?
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ARDS Etiology - Idiopathic. Many illnesses asso with Alveolar Epithelial Cell and Capillary Endothelial Cell Damage. Risk of ARDS - SAD CT BP (Sepsis, Aspiration, Drowning, Contusion, Trauma, Burns, Pancreatitis) - 1 Sepsis or Aspiration, 2 Lung Contusion or Trauma, 3 Near-Drowning, 4 Burns or Pancreatitis.
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ARDS Risk Factors?
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ARDS Risk factors - SAD CT BP (Sepsis, Aspiration, Drowning, Contusion, Trauma, Burns, Pancreatitis) - 1 Sepsis or Aspiration, 2 Lung Contusion or Trauma, 3 Near-Drowning, 4 Burns or Pancreatitis.
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ARDS Lx and Lx Definition?
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ARDS Lx - CXR - Bilateral Infiltrates - Quickly becomes confluent (White Out). Air Bronchograms are Common. ARDS Lx defines as pO2 over FIO2 ratio Below 200. Wedge Pressure is Normal (Cardiogenic Shock has INcrease Wedge Pressure). Ex pO2(105 in ABG) over FIO2(.21 - 21 perc oxygen) is 500.
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ARDS Tx?
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ARDS Tx - Low Tidal volume Mechanical Ventilation (6 mL per Kg of Tidal Volume) is Best Support while waiting to see if lungs will recover. Steriods are Not clearly beneficial. PEEP is used when Mechanical ventilation to try to Decrease FIO2. FIO2 Above 50 perc is Toxic to Lungs. Maintain Plateau Pressure of Less than 30 cm of Water.
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Where to get pO2? Normal pO2?
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Get pO2 from ABG. Normal pO2 is 75 to 100.
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What is FIO2? Normal FIO2?
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FIO2 is Fraction of Inspired Oxygen in Ventilator Setting. Room Air is 21 perc. Normal FIO2 is 21 to 50 Perc. FIO2 More than 50 perc is toxic
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What is PEEP? Normal PEEP?
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PEEP is Positive End Expiratory Pressure on Ventilator setting. Normal PEEP is 5 to 15.
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Where to get pCO2? What is Normal pCO2?
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Get pCO2 from ABG. Normal pCO2 is 35 to 45.
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What is Normal Respiratory Rate?
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Normal Respiratory Rate is 12 to 20.
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What is Normal Tidal Volume?
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Normal Tidal Volume is 6 cc per Kg.
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ARDS ventilator management?
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ARDS Ventilator Management - look at pO2 to see whether it is Abnormal, then look at pCO2 for Abnormality. If pO2 is Abnormal (pO2 Normal 75-100), Adjust (OP) - 1 FIO2, 2 PEEP. If pCO2 is Abnormal (pCO2 Normal is 35-45), Adjust (COuRT) - 1 Respiratory Rate, 2 Tidal Volume.
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ARDS, RR-14, PEEP? Tv (70Kg) - 420, FiO2 - 70 perc, pO2 Decrease.
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ARDS, RR-14, PEEP? Tv (70Kg) - 420, FiO2 - 70 perc, pO2 Decrease. - Increase PEEP
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ARDS, PEEP-5 mmHg, RR-8, pO2-80, pCO2-50, Management?
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ARDS, PEEP-5 mmHg, RR-8, pO2-80, pCO2-50, Management - RR Increase (will Increase O2)
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ARDS, PEEP-8, RR-14, pO2-102, FIO2-80 perc, pCO2-37, Management?
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ARDS, PEEP-8, RR-14, pO2-102, FIO2-80 perc, pCO2-37, Management - Decrease FIO2 (pCO2 - Normal - Do Not Change RR)
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ARDS, PEEP-8, RR-14, pO2-102, FIO2-40 perc, pCO2-27, Management?
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ARDS, PEEP-8, RR-14, pO2-102, FIO2-40 perc, pCO2-27, Management - Decrease RR
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What are Categories of Hypoxemia? Factors to look for in Differentiating these Categories?
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Categories of Hypoxemia - 1 HypoVentilation (High PaCO2), 2 Decreased in Inspired Oxygen (Normal A-a gradient and Normal PaCO2), 3 Shunting (Blockage in Alveoli - Does Not Correct with 100 perc Oxygen), 4 V_Q Mismatch (Blockage in pulmonary arterial - Correct with 100 perc Oxygen). High A-a Gradient (More than 30) are 3 Shunting, 4 V_Q Mismatch. Ex of Shunting - 1 Pulmonary Edema, 2 Pneumonia, 3 Vascular Shunt. Ex of V_Q Mismatch - 1 PE, 2 Exacerbation of Asthma. Factors to look for in Differentiating these Categories - A-a Gradient, and PaCO2.
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What is High A-a Gradient? Which one has High A-a Gradient?
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High A-a Gradient (More than 30) are 3 Shunting, 4 V_Q Mismatch. Ex of Shunting - 1 Pulmonary Edema, 2 Pneumonia, 3 Vascular Shunt. Ex of V_Q Mismatch - 1 PE, 2 Exacerbation of Asthma.
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What is NIPPV? When to use NIPPV? CI?
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Non-Invasive Positive Pressure Ventilation NIPPV ahead of intubation. NIPPV is an excellent option for pts with COPD exacerbation. It should be tried before Intubation and Mechancial Ventilation in COPD pt with CO2 retention. NIPPV - Decrease Complications that are a hallmark of Intubation, which includes Infections. NIPPV is recommended in a pt of respiratory distress with a pH Less than 7.35 or PaCO2 More than 45 or Respiratory Rate More than 25. NIPPV CI in Septic, Hypotensive, or Dysrhythmic pts.
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Most Common Cause of Pulmonary Complications in Systemic Sclerosis?
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Most common cause of pulmonary complications in pts with Systemic Sclerosis is Interstitial Fibrosis.
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What is Hypersensitivity Pneumonitis?
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Hypersensitivity Pneumonitis HP is Inflammation of Lung Parenchyma caused by Antigen Exposure. Acute episodes present with Cough, Breathlessness, Fever, and Malaise that occur within 4-6 hours of antigenic exposure. Chronic Exposure may cause Weight Loss, Clubbing, and Honey Combing of Lung. Chronic exposure may develop Pulmonary Fibrosis and Restrictive Pattern on Lung Spirometry. Classic radiographic findings - Ground Glass Opacity, or Haziness of Lower Lung Fields. The Cornerstone of HP management is Avoidance of Responsible Antigen.
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ARDS managment?
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Acute Pancreatitis can cause ARDS in up to 15 perc of pts. First step in Initial Ventilator management of ARDS is usually to Decrease FiO2 to relatively non-toxic values (Less than 60 perc). PEEP may be increased as needed to maintain adequate oxygenation after FiO2 is lowered. Goal of paO2 is Greater 60.
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CHF exacerbation Px? Lx?
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CHF exacerbation can cause Tachypnea as Left Ventricular Dysfunction allows Fluid to Pool in lungs, causing a Pleural Effusion and Hypoxemia due to Reduced Ventilation. Tachypnea causes Hypocapnia and Respiratory Alkalosis. Exam typically shows signs of fluid overload, S3 and S4 Gallops, Cardiomegaly, and Bibasilar Crackles in lungs. CHF - ABG - Hypoxia, HypoCapnia, and Respiratory Alkalosis (COPD - Hypoxia, HyperCapnia, Respiratory Acidosis). CHF - BNP Elevated, PCWP_LA Elevated.
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What lab abnormality does Glucocorticoids cause?
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Glucocorticoids cause Neutrophilia by Increasing the bone marrow release and mobilizing the marginated neutrophil pool. Eosinophils and Lymphocytes are Decreased.
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What is ACEI AE? What is the cause?
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ACEI AE is cough due to accumulation of Inflammatory or Proinflammatory mediators Bradykinin, Substance P, Thromboxanes, and Prostaglandins.
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In pleural effusion, what is considered Low Glucose level? What is the cause?
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In pleural effusion, Low Glucose concentration is Less than 30 (empyema or rheumatic effusion). Low Glucose concentration is due to High White blood cell content.
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What is Obesity Hypoventilation Syndrome? What is the problem?
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Obesity Hypoventilation Syndrome is Long term consequence of Severe Obesity and Untreated Obstructive Sleep Apnea. It causes 1 Chronic HyperCapnia and Hypoxic Respiratory Failure, 2 Respiratory Acidosis (Compensated by Increase Bicarb and Decrease Chloride), 3 Secondary Erythrocytosis, 4 Pulmonary Hypertension, and 5 Cor Pulmonale. In order to maintain a normal pH, kidney Increases Bicarbonate Retention and Decreases Chloride Reabsorption.
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COPD pt, home oxygen treatment requirement? Reason for lower Requirement and Requirement?
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COPD pt, home oxygen treatment - 1 PaO2 Less than 55, or SaO2 Less than 88 perc on room air. Reason to Lower Requirement - 2 Heart affected (Cor Pulmonale, Evidence of Pulmonary Hypertension, or Hematocrit Greater than 55 perc) when PaO2 is Less than 60 with SaO2 Less than 90 perc. 3 Resting Awake PaO2 Greater than 60 with SaO2 Greater than 90 perc if Hypoxic during Exercise or Sleep (Nocturnal Hypoxia).
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What is Cor Pulmonale? What is cause? Px?
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Cor Pulmonale is Right-sided Heart Failure Most Commonly due to Pulmonary Disease. Other causes - 1 Pneumoconiosis, 2 Pulmonary Fibrosis, 3 Kyphoscoliosis, 4 Primary Pulmonary Hypertension, and 5 Repeated Episodes of Pulmonary Embolism. Signs of Right-Sided Heart Failure - 1 Jugular Venous Distension (NL Less than 4cm), 2 Right-sided S3, 3 Right Ventricular Heave, 4 Hepatomegaly (NL Liver span 6 to 12 cm), 5 Ascites, and 6 Dependent Edema.
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What is Cardiac Tamponade? What is classic signs?
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Cardiac Tamponade is a Life-Threatening condition in which Pericardial Effusion develops rapidly or becomes so large that it compresses the heart. The classical features - 1 Jugular Venous Distension (JVP More than 4 cm), 2 Hypotension, 3 Distant Heart Sounds, and 4 Pulsus Paradoxus.
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Dusky red, target shaped skin lesions over all four extremities. What is it? What disease?
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Dusky red, target shaped skin lesions over all four extremities - Erythema Multiforme. Found in Mycoplama Pneumoniae.
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Aspiration Pneumonia Px? Risk factors?
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Aspiration Pneumonia Px - 1 Foul-Smelling sputum, Right Lower Lobe pneumonia. Risk factors (DANS) - 1 Altered Consciousness (Seizure, Alcoholism, Drug Overdose, CVA, etc), 2 Dysphagia (Esophageal Reflux, Diverticula, Obstruction, etc), 3 Neurologic Disorder (Advanced Dementia, Parkinsonism, Myasthenia, etc), 4 Sedation to Procedures (Bronchoscopy, Intubation, Endoscopy, etc).
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Hypoxia, High A-a Gradient, 100 perc Oxygen Correct the problem. Dx?
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Hypoxia, High A-a Gradient, 100 perc Oxygen Correct the problem - V_Q Mismatch - 1 PE or 2 Exacerbation of Asthma
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Hypoxia, High A-a Gradient, 100 perc Oxygen Does Not Correct the problem. Dx?
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Hypoxia, High A-a Gradient, 100 perc Oxygen Does Not Correct the problem - Shunting - 1 Pulmonary Edema, 2 Pneumonia, 3 Vascular Shunt.
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Hypoxia, High A-a Gradient. Dx?
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Hypoxia, High A-a Gradient. Dx - 1 Shunting (100 perc O2 Does Not Correct), 2 V_Q Mismatch (100 perc O2 Correct)
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ABG - PaO2 - 60, pH - 7.46, PaCO2 - 37, HCO3 - 22. How to Calculate A-a Gradient?
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ABG - PaO2 - 60, pH - 7.46, PaCO2 - 37, HCO3 - 22. How to Calculate A-a Gradient? A-a Gradient is PAO2 - PaO2. PAO2 = FiO2 (760-47) - PaCO2 / 0.8. PAO2 = (0.21 x 713) - (37 / 0.8) = 150 (Room Air) - 46 = 104. A-a Gradient = PAO2 - PaO2 = 104 - 60 = 44. Normal A-a Gradient Less than 30.
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Risk factors for Pulmonary edema?
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Risk factors for Pulmonary Edema - 1 MI, 2 Decreased Left Ventricular function (Hypertension, Diabetes, CAD, Recent Blood Loss or Surgery).
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What is Obesity Hypoventilation Syndrome? Px? Lx? Tx?
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Obesity Hypoventilation Syndrome is Severe Obesity (Greater than 150 perc of Ideal Body Weight - Normal between 18.5 and 25 BMI) and Alveolar Hypoventilation during Wakefulness. Px - 1 Distant Heart Sounds, 2 Low Voltage QRS complexes on EKG, and 3 Poor Quality CXR. Lx - ABG - 1 HyperCapnia, 2 Hypoxemia, 3 Respiratory Acidosis due to Decreased Lung Compliance. Tx - 1 Weight Loss, 2 Ventilator Support, 3 Oxygen Therapy, and 4 Progestins (Respiratory Stimulant).
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What is Progestins? Tx what disease?
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Progestins is Respiratory Stimulant. Tx - Obesity Hypoventilation syndrome.
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How is Complicated Pleural Effusion defined? Complication? Tx?
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Complicated Pleural Effusions - 1 pH Less than 7.2, 2 Glucose Less than 60, 3 Positive Gram Stain, 4 Positive Culture. Complication - Progress to Empyema (Frank Pus in Pleural Space). Tx - Chest Tube Drainage.
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What is ARDS? Etiology? Tx? Complications?
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ARDS is a form of Non-Cardiogenic Pulmonary Edema caused by Leaky Alveolar Capillaries. Etiology - 1 Sepsis, 2 Severe Infection, 3 Severe Bleeding, 4 Toxic Ingestions, 5 Burns. Tx - Mechanical Ventilation with Low Tidal Volumes and PEEP can improve Oxygenation. Potential Complications of PEEP - 1 Barotrauma and 2 Tension Pneumothorax.
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Describe Flow-Volume Loop diagram components. Normal, Obstructive, and Restrictive lung Disease, and Laryngeal Edema.
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Flow-Volume Loop Diagram Components - 1 Horizontal Axis (TLC - Left, RV - Right), 2 Vertical (Expiration - Above, Inspiration - Below). Normal - Equal side right triangle on Half Circle (Diameter of Circle - TLC to RV). Obstructive - Bomer Ring (scoop out) on Half Circle (Diameter is Bigger than TLC to RV). Restrictive - Tall Triangle on Half Circle (Diameter of Circle is Smaller than TLC to RV). Laryngeal Edema - Donut shape (Flatten).
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What does Flow-Volume Loop Diagram show for Fixed Upper Airway Obstruction? Tx?
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Fixed Upper Airway Obstruction (Laryngeal Edema) - Decrease Airflow Rate During 1 Inspiration (Below Horizontal line), 2 Active Expiration, 3 Passive Expiration (Above Horizontal Line). Tx - 1 Epinephrine, 2 Sytemic Corticosteroids, 3 AntiHistamine.
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What is complication of Bronchiectasis?
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Complication of Bronchiectasis is Hemoptysis.
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Obesity Chest Wall Compliance? COPD Chest Wall Compliance?
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Obesity Chest Wall Compliance (Expansion) - Decreased. COPD Chest Wall Compliance - Increased
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Alpha-Adrenergic Blockers Tx for?
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Alpha-Adrenergic Blockers Tx for Benign PRostatic Hypertrophy and Hypertension.
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HIV, fever, night sweats, weight loss, fatigue, cough for 2 months, Arizona. Dx? Lx?
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HIV, fever, night sweats, weight loss, fatigue, chronic cough, cough for 2 months, hemoptysis, Arizona. Dx - TB (HIV pt has 10 perc per year risk of Reactivation). Lx - CXR (Apical Cavitary lesion - Reactivation, Mediastinal_Hilar Lymphadenopathy. Primary site of infection - Ghon Focus - remains Calcified Granuloma)
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What disease has highest risk of reactivation of TB?
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Disease with highest risk of reactivation of TB - HIV - 10 perc per year risk.
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Most Common Causes of Chronic Cough?
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Most Common Causes of Chronic Cough - 1 Bronchial Asthma (Wheezing), 2 GERD (Post Prandial, Recumbent - lying down), and 3 Post-Nasal Drip (Cobblestoning of Nasal Mucosa, Complain of Nasal Congestion).
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Sudden onset Shortness of Breath, Difficulty Swallowing, Gasping for Breath, Excessive Accessory Respiratory Muscle use, Retraction of Subclavicular Fossae during Inspiration, Scattered Urticaria, Food Intolerance, Skin Allergies. Dx?
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Sudden onset Shortness of Breath, Difficulty Swallowing, Gasping for Breath, Excessive Accessory Respiratory Muscle use, Retraction of Subclavicular Fossae during Inspiration, Scattered Urticaria, Food Intolerance, Skin Allergies. Dx - Upper Airway Obstruction - Laryngeal Edema due to Food allergy (Precipitating Event - Peanut). Stridor and Harsh Respiratory Sounds from Trachea.
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Several days of Shortness of breath, Gradual onset, Diffuse wheezes, Fine Inspiratory crackles, Peripheral Eosinophia. Dx?
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Several days of Shortness of breath, Gradual onset, Diffuse wheezes, Fine Inspiratory crackles, (Asthma-like symptoms ongoing for several days), Peripheral Eosinophia. Dx - Eosinophilic Pneumonia.
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What is general DVT Tx? Explain?
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General DVT Tx - 1 Acute AntiCoagulation and Clot Stabilization, 2 Chronic AntiCoagulation, and 3 Tx of DVT-related Complications. 111 Initial Clot Stabilization with Heparin. Heparin Retards Further Thrombus Formation by Binding to AntiThrombin 3 and Enhancing its activity. 222 Long-Term AntiCoagulation with Warfarin is Necessary. Warfarin Inhibits Activation of Vitamin K-Dependent Clotting factors (2, 7, 9, 10), but it Takes at least 4-5 days for Warfanin to become Therapeutic (INR 2-3), so need Bridging Heparin. 333 New DVT should wear Compression Stockings to Decrease the Risk of developing Post-Phlebitic Syndrome, a Potentially devastating complication. Inferior Vena Cava filters used in pt with lower extremity DVT with AntiCoagulation ContraIndicated.
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Heparin function?
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Initial Clot Stabilization of DVT with Heparin. Heparin Retards Further Thrombus Formation by Binding to AntiThrombin 3 and Enhancing its activity.
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Warfarin function?
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Long-Term AntiCoagulation with Warfarin is Necessary for DVT. Warfarin Inhibits Activation of Vitamin K-Dependent Clotting factors (2, 7, 9, 10), but it Takes at least 4-5 days for Warfanin to become Therapeutic (INR 2-3), so need Bridging Heparin.
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What is Post-Phlebitic Syndrome?
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Post-Phlebitic Syndrome (Post Thrombotic Syndrome - Pain, Swelling, Varicose Vein) is a Potentially devastating complication of DVT.
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What is Phlebitis?
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Phlebitis is Inflammation of Veins.
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How is Hypoxia defined?
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Hypoxia defined by 1 ABG (PaO2 Less than 55), 2 Pulse Oximetry (SaO2 Less than 88 perc), 3 Erythrocyt osis (Hematocrit More than 55 perc), 4 Evidence of Cor Pulmonale.
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What is another name for Superior Sulcus Tumor? Px?
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Superior Sulcus Tumor is same as Pancoast Tumor - an apical lung tumor. Apical lung tumor Px - 1 Compression of Sympathetic Trunk (Horner Syndrome), 2 Brachial Plexus ((Pancoast syndrome - Shoulder Pain Radiating into arm in an Ulnar Distribution and is caused Tumor invasion of Eight Cervical and First Throacic nerves) - Pain, Paresthesias, Weakness of Ipsi-Arm), 3 Right Recurrent Laryngeal Nerve (Hoarse Voice), and 4 Superior Vena Cava (SVC syndrome).
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Horner Syndrome px?
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Compression of Sympathetic Trunk
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Pancoast syndrome px? problem?
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Pancoast syndrome Px and Problem - Shoulder Pain Radiating into arm in an Ulnar Distribution and is caused Tumor invasion of Eight Cervical and First Throacic nerves. Compression of Brachial Plexus - Pain, Paresthesias, Weakness of Ipsi-Arm
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Brachial Plexus compression Px?
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Brachial Plexus compression Px - Pancoast syndrome - Shoulder Pain Radiating into arm in an Ulnar Distribution and is caused Tumor invasion of Eight Cervical and First Throacic nerves) - Pain, Paresthesias, Weakness of Ipsi-Arm
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Cause of Hoarse Voice in Apical Lung tumor?
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Cause of Hoarse Voice in Apical Lung tumor - Right Recurrent Laryngeal Nerve compression
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Right Recurrent Laryngeal Nerve compression Px?
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Right Recurrent Laryngeal Nerve compression Px - Hoarse Voice
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Superior Vena Cava syndrome Px?
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Superior Vena Cava syndrome Px - 1 Dyspnea, 2 Facial Edema (in Morning), 3 Upper Limb Edema. Common Cause - Bronchogenic Carcinoma
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Aspergiloma Px?
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Aspergilloma Px - 1 Hemoptysis, Fever, Weight Loss, Chronic Cough, 2 CXR - Crescent Radiolucy - Mass Mobile and Moves with position, 3 Hyphae
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Carcinoid Tumor Px?
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Carcinoid Tumor Px - Centrally Located (Bronchoscope visible), Cought and Recurrent Hemptysis, Slow Growing and Best prognosis lung cancer.
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Histoplasmosis px?
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Histoplasmosis px - 1 Mississippi and Ohio River Valleys and Central America, 2 Found in Soil with high Concentration of Bird or Bat Guano dropping. Disseminated Histoplasmosis in Immunocompromised adults and young children. CXR - Patch lobar or multinodular lobar infiltrates. Chronic Cavitary Pulmonary Histo is Progressive Fatal form in Older COPD.
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Diffuse ST-segment Elevation on EKG. Dx?
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Diffuse ST-segment Elevation on EKG. Dx - Acute Pericarditis, and in some MI
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Define Pulmonary Hypertension? Px? Lx? Complication?
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Pulmonary Hypertension Defined - mean Pulmonary Arterial Pressure Greater than 25 (at Rest), or 30 (with Exercise). Px - Dyspnea, Weakness, and Fatigue, Chest Pain, Hemoptysis, Syncope, Hoarseness. Right Ventricular failure late - Right Ventricular Heave, JVD, Tender Hepatomegaly, Ascites, Edema. Lx - Enlargement of Pulmonary Arteries with Rapid Tapering of Distal Vessels (Pruning) and Enlargement of Right Ventricle. EKG - Right Axis deviation (Right Ventricular Strain and Hypertrophy). Complication of Pulmonary Hypertension - Cor Pulmonale.
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65 yo female, 6 months of worsening Dyspnea and Dry cough, Breathless after Walking just a few steps, Hydrochlorothiazide for Hypertension, blood pressure is 140 over 86, Late Inspiratory Crackles and Finger Clubbing. Dx? PFT? CXR?
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65 yo female, 6 months of worsening Dyspnea and Dry cough, Breathless after Walking just a few steps, Hydrochlorothiazide for Hypertension, blood pressure is 140 over 86, Late Inspiratory Crackles and Finger Clubbing. Dx - Idiopathic Pulmonary Fibrosis (IPF) - a Restrictive Lung Disease - Chronic Inflammation of Alveolar Walls causes Progressive Widespread Fibrosis and Destruction of Normal Lung Architecture. Restrictive Lung Disease pattern on PFT result - 1 Decreased TLC, Functional Residual Capacity and Residual Volume. Diffusing Capacity Progressively Reduced, Largely due to Ventilation-Perfusion Mismatch, Resulting in Increased A-a Gradient. CXR - Decreased Lung Volumes, Airway Fibrosis giving HoneyComb pattern, and Pulmonary Vascular Congestion Most Evident in Hilum.
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Restrictive Lung Disease PFT result?
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Restrictive Lung Disease PFT result - 1 Decreased TLC, Functional Residual Capacity and Residual Volume, 2 Normal FEV1 over FVC.
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Contrast IPF and CHF.
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IPF (Idiopathic Pulmonary Fibrosis) - Dyspnea, Dry Cough, Inspiratory Crackles, Finger Clubbing, V_Q Mismatch. CHF - Dyspnea, Paroxysmal Nocturnal Dyspnea, Left Heart Failure (Orthopnea = Pulmonary Edema = Crackles), Right Heart Failure (1 JVD, 2 Hepatomegaly, 3 Ascites, 4 Peripheral Edema)
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Left Heart Failure Px?
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Left Heart Failure Px - Orthopnea = Pulmonary Edema = Crackles
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Right Heart Failure Px?
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Right Heart Failure Px - 1 JVD, 2 Hepatomegaly, 3 Ascites, 4 Peripheral Edema
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What is consider High PEEP? Complications of High PEEP?
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High PEEP is Greater than 15. High PEEP complications - 1 Alveolar Damage, 2 Tension Pneumothorax, and 3 Hypotension.
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Tension Pneumothorax Px?
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Tension Pneumothorax Px - 1 Sudden-Onset Shortness of Breath, 2 Hypotension (compression of Mediastinum and Impaired Right Ventricular filling), 3 Tachycardia, 4 Tracheal Deviation, and 5 Unilateral Absence of Breath Sounds.
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Sudden-Onset Shortness of Breath, Hypotension, Tachycardia, Tracheal Deviation, and Unilateral Absence of Breath Sounds. Dx?
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Sudden-Onset Shortness of Breath, Hypotension, Tachycardia, Tracheal Deviation, and Unilateral Absence of Breath Sound - Tension Pneumothorax
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In Chronic Respiratory Acidosis, what is the ratio of HCO3- to pCO2 Increase?
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In Chronic Respiratory Acidosis, the ratio of HCO3- to pCO2 Increase is Increase of 3.5 HCO3 to 10 pCO2.
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What is the reason for Aspiration Pneumonia?
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The reason for Aspiration Pneumonia in Impaired Consciousness, Advanced Dementia, and other Neurologic Disorders are Predisposed due to Impaired Epiglottic Function.
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23 yo Caucasian female, 6 month of nasal breathing difficulty and sneezing, Clear Rhinorrhea and Slightly Hyperemic Anterior Nasal Mucosa. Next Step?
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23 yo Caucasian female, 6 month of nasal breathing difficulty and sneezing, Clear Rhinorrhea and Slightly Hyperemic Anterior Nasal Mucosa. Next Step - Nasal Smear and Cytology - infectious (Neutrophils), Allergic Rhinitis (Eosinophils), Perennial Non-Allergic Rhinitis (Vasomotor Rhinitis) - Absent Eosinophil. Allergic Rhinitis - Nasal Polyposis (Include Aspirin Sensitivity), Non-Allergic Rhinitis with Eosinophilia.
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72 yo whie male, Hypertension, Hypohyroidism, CAD. Fever, Mailaise, Non-Productive Cough, and Shortness of Breath. 101F, CXR show Patchy Righ Lower Lobe Infiltrate, sent home on Oral Amoxicillin. Two days later in ER, Fever, Headache, Pleuritic Chest Pain, Abdominal Pain, Some Loose Stools. Confused. 102F, Right Lower Lobe Consolidation. Sodium 126, Potassium 3.9, Creatinine 1.1, AST 102, ALT 113, Alkaline Phosphatase 98. Dx?
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72 yo whie male, Hypertension, Hypohyroidism, CAD. Fever, Mailaise, Non-Productive Cough, and Shortness of Breath. 101F, CXR show Patchy Righ Lower Lobe Infiltrate, sent home on Oral Amoxicillin. Two days later in ER, Fever, Headache, Pleuritic Chest Pain, Abdominal Pain, Some Loose Stools. Confused. 102F, Right Lower Lobe Consolidation. Sodium 126, Potassium 3.9, Creatinine 1.1, AST 102, ALT 113, Alkaline Phosphatase 98. Dx - Legionella - GI symptoms, HypoNatremia, LFT Abnormalities.
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Pneumonia, Abdominal pain, Loose Stools, Sodium 126, Potassium 3.9, Creatinine 1.1, AST 102, ALT 113, Alkaline Phosphatase 98. Dx? Lx? Tx?
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Pneumonia, Abdominal pain, Loose Stools, Sodium 126, Potassium 3.9, Creatinine 1.1, AST 102, ALT 113, Alkaline Phosphatase 98. Dx - Legionella. Lx - Urinary Antigen Test. Tx - Quinolone or Macrolide.
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19 yo woman, occasional wheezing and breathlessness following aerobic exercise. Allergic Rhinitis and Acne. Dx? Tx?
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19 yo woman, occasional wheezing and breathlessness following aerobic exercise. Allergic Rhinitis and Acne. Dx - Exercise-induced Asthma - exposure to various triggers (cold air, dry air cause mast cell degranulation). Tx - SABA 20 minutes before Exercise, Mast cell stabilizers, LABA (beta adrenergic agonist) - athletic activities throughout the day.
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Pulmonary Tuberculosis Keywords?
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Pulmonary Tuberculosis Keywords - 1 Endemic, 2 Productive Cough, 3 Hemoptysis, 4 Recurrent Fever, 5 Weight Loss, 6 Upper Lobe Cavitary lesion on CXR, 7 Chronic Pulmonary complaints
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Bronchiectasis Keywords?
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Bronchiectasis Keywords - 1 Bronchial Dilation, 2 Cyst Formation, 3 Poor Mucus Clearance, 4 Secretion Pooling (result from Severe Repeated Airway Inflammation), 4 CT Bronchial Thickening.
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ABPA Keywords?
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Allergic Bronchopulmonary Aspergillosis ABPA Keywords - 1 Hypersensitivity to Aspergillus colonization of Bronchi, 2 Asthma or Cystic Fibrosis, 3 Fever, 4 Malaise, 5 Productive Cough, 6 Eosinophilia, 7 Hemoptysis
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Sarcoidosis Keywords?
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Sarcoidosis Keywords - 1 Systemic Granulomatous disease most common affect Lungs, 2 Perihilar Lymphadenopathy, 3 may develop Interstitial Lung disease and pulmonary Fibrosis.
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What should Endotracheal tube end?
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Endotracheal tube should end between Vocal Cord and Carina.
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Intubated, Left side breath sound markedly Decreased. Dx? Tx?
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Intubated, Left side breath sound markedly Decreased. Dx - Right Mainstem Bronchus Intubation - Relatively common complication of endotracheal intubation. Tx - Withdrawal of tube.
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When to do Needle Thoracostomy?
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Needle Thoracostomy used in Life-Threatening Tension Pneumothorax.
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When to do Pericardiocentesis?
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Pericardiocentesis used in Cardiac Tamponade and other Symptomatic Pericardial Effusions.
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What does it mean when pleural effusion glucose < 60?
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Pleural effusion glucose < 60 - exudate or empyema
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Compare Parapneumonic effusion vs Pleural effusion.
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Compare Parapneumonic effusion vs pleural effusion. parapneumonic - a type of pleural effusion (uncomplicated, complicated, empyema) - pH < 7.2
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Contrast Emphysema and Chronic Bronchitis.
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Contrast Emphysema and Chronic Bronchitis - Empysema (FEV1 over FVC Decreased, DLCO Decreased), Chronic Bronchitis (FEV1 over FVC Decreased, DLCO Normal)
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