Adult Med

Front 1

What is a Pulmonary embolism?

Back 1

Majority usually begin as a DVT. (in lower extremity)

Front 2

How many deaths result every year due to PE?
What % are recognized Post Mortem?

Back 2

50,000

90%

Front 3

What are the risk factors for PE?

Back 3

Virchow's Triad
Venous stasis (usually from bed rest or during a major operation)
Injury (to the intima of the vein, usually smooth)
A Hypercoagulable state.

Front 4

PE Predispositions;

Back 4

BC pills + >35 + smoking.

Front 5

PE Classic Triad;

Back 5

Hemoptysis
Pleuritic CP
Dyspnea
Triad occurs in <20% of cases.

Front 6

Are embolic events instantly fatal?

Back 6

Yes

Front 7

PE Physical Exam;

Back 7

Not necessarily helpful in dx of PE. Increased resp. rate, Rales on ausculation, Increased 2nd heart sound (common), Increased HR, (sometimes) elevated temp., Px evidence of phlebitis, Cardiac gallop, Diaphoresis, Edema, Cardiac murmur, Cyanosis.

Front 8

What is the most profound evidence for PE in a Px Exam?

Back 8

Profound Hypoxia in the absence of underlying lung dz w/a normal CXR.

Front 9

What labs should be ran for a suspected PE?

Back 9

D Dimer (degradation product of fibrin) Elisa is 95% sensitive (if - then definetly - PE) & 45% Specific (if positive not necessarily PE) Latex agglutination not helpful.

Front 10

What can a EKG look like for a pt w/PE?

Back 10

Non specific changes, usually sinius tach.
S in I, q in III, inverted T in III classic but rarely seen.

Front 11

What is Hemoptysis?

Back 11

The expectoration of blood that arises from the larynx, trachea, bronchi, or lungs.

Front 12

What is phlebitis?

Back 12

Inflammation of a vein.

Front 13

What is the test of choice (gold standard)to dx PE?
And when should it be ran?

Back 13

Pulmonary Angiogram
Other screening studies are inconclusive.
Stron suspicion of PE exists.
Dx must be made w/certainty.

Front 14

What findings might be on an CXR on a pt w/PE?

Back 14

Atelectasis (lower lobe) & Parenchymal densities (seen in anyone), Hampton's Hump, Westermarks's Sign, Diaphragm may be elevated, Blunting of the left costophrenic angle.

Front 15

What is Hampton's Hump?

Back 15

Pleural based poacities w/convex medial margins, may be an indication of lung infarction.

Front 16

What does a elevated diphragm reflect?

Back 16

Volume loss in the affected lung.

Front 17

What is a Pleural effusion?

Back 17

Fluid in the thoracic cavity between the visceral and parietal pleura. It may be seen on a chest radiograph if it exceeds 300 ml.

Front 18

Are pleural effusions common in pt's with a PE?

Back 18

Yes, & are most often unilateral despite the fact that most clots are bilateral. They are almost always small, <15% of a hemithorax & rarely increase in size p 3days (a increase p 3-4days should raise suspician of a pulmonary infection of re-embolization).

Front 19

What is a Westermark's sign?

Back 19

(on CXR) A peripheral wedge-shaped density, which is a area of decreased vascularity & perfusion accompainied by an enlarged pulmonary artery on the affected side

Front 20

Ventilation Perfusion Scan/PE;

Back 20

Not used very much anymore (pulmonary arteriography used now) R/O dx of PE, or gives results of High, Inermediate, or Low Probability.

Front 21

Ventilation Perfusion Scan/High Probability;

Back 21

Detect areas of lung that are ventilated but do not perfuse
(as occurs in PE)results are reported as low, intermediate, or high probability of PE based on patterns of V/Q mismatch. A completely normal scan essentially excludes PE with nearly 100% accuracy, but a low-probability scan still carries a 15% likelihood of PE.

Front 22

Helical CT Scan/PE;

Back 22

Initial diagnostic study of choice, Faster, less contrast used. Less sensitive than perfusion scans (60% vs > 99%)Less specific than pulmonary arteriograms (90% vs > 95%)

Front 23

Diagnostic work up of suspected PE;

Back 23

D dimer(if low & low clinical probability no further work up needed) If elevated, helical chest CT(if neg US LE for DVT)If + tx(If US neg F/U clinically)if _ tx.

Front 24

What is the primary anticoagulant used to acutely treat DVT & PE?

Back 24

Heparin, loading dose of 5,000u then 1,000u q hr (keep PTT at 1.5-2 X control).
When risk of PE is highest bolus dose of 10,000-15,000u for pulmonary embolism may increase chance pt remain theraputic in 1st 24hrs.

Front 25

What is Heparin?

Back 25

A mixture of glycosaminoglycans that bind to & activate antithrombin III to inhibit further clot formation.

Front 26

What is low molecular weight heparin?

Back 26

Lovenox(enoxaprin) can be used in place of unfractionated heparin when there is a small PE, or diagnostic studies are inconclusive, but suspicion is high, also useful in DVT w/out PE (easier to administer).

Front 27

What is warfarin?

Back 27

(Coumadin) A compound that competes w/vit K & depletes vit K-dependent clotting factors (II,VII,IX, & X)Which inhibits clot formation. Advantage is that it can be taken orally.

Front 28

When should warfarin therapy start if pt is on heparin therapy?

Back 28

It can begin on day 1 of heparin therapy, & is monitored using the PT & a INR of 2.0-3.0 is sonsidered therapeutic.(several days of overlap of warfarin & heparin are usually required because of warfarin's mode of action)

Front 29

Warfarin clotting factor production?

Back 29

Because warfarin inhibits clotting factor production, the PT does not elevate until the preexisting clotting factors are consumed or degraded.

Front 30

PE Management & Tx Thrombolytics;

Back 30

Urokinase, Streptokinase & Tissue plaminogen activator (TPA) act by increasing existing clot lysis, they do not inhibit new clot formation.

Front 31

Regarding PE, When should thrombolytics be used?

Back 31

In studies comparing heparin & thrombolytics there is no survival advantage of thrombolytic therapy over heparin, current recomendations support the use of thrombolytics if the pt is in shock.

Front 32

What other methods can be used for Management & Tx of PE?

Back 32

Pressure stockings, Early ambultaion after sugery, Use of sequential compression during surgery, Small filtration devices can be placed w/in the lumen of the Vena Cava to prevent migration of the pulmonary emboli.

Front 33

What is Cor Pulmonale?

Back 33

Right ventricular enlargement secondary to a lung disorder that produces pulmonary artery hypertension. Uaually chronic but may be acute & reversible.

Front 34

What is the cause of acute Cor Pulmonale?

Back 34

Massive pulmonary emboli.

Front 35

What is the cause of chronic Cor Pulmonale?

Back 35

COPD, chronic pulmonary emoli, pneumoconiosis, pulmonary fibrosis, primary pulmonary hypertension & other conditions.

Front 36

Cor Pulmonale Pathophysiology;

Back 36

Directly caused by alterations in pulmonary circulation that lead to pulmonary arterial hypertension, thereby increasint the mechanical load on the right ventricle emptying.

Front 37

Cor Pulmonale Symtoms;

Back 37

Dyspnea on exertion (most common), syncope or easy fatigue w/exertion, chronic productive cough, wheezing respirations, RUQ pain (liver backs up), dependent edema (more difficult for extremeties to drain).

Front 38

Cor Pulmonale Signs;

Back 38

Cyanosis, clubbing, distended neck veins, right ventricular heave, tricuspid insufficiency or pulmonic insufficiency mumurs, s4,s3 gallop, prominent lower sternal epigastric pulsations, enlarged & tender liver, edema.

Front 39

Cor Pulmonale Lab studies;

Back 39

Polycythemia often present due to COPD.
Arterial O@ sat <85%, PCO2 may or may not be elevated.

Front 40

Cor Pulmonale EKG;

Back 40

Big prominent P waves, RAD, Low voltage, Supraventricular arrhythmias, right ventricular hypertrophy (uncommon)

Front 41

Cor Pulmonale Chest X-ray;

Back 41

Presence of parenchymal dz
Prominent right ventricle (may show)
Enlarged pulmonary artery (may show)

Front 42

Cor Pulmonale Echo;

Back 42

Normal LV & RV dilation.

Front 43

What is the most specific test for pulmonary emboli?

Back 43

Pulmonary angiography

Front 44

Cor Pulmonale Right heart cath;

Back 44

Will give difinitive dx but usually used to exclude LV failure.

Front 45

In the early stages what usually diagnoses Cor Pulmonale?

Back 45

Radiologic, Echocardiographic or EKG evidence.

Front 46

Cor Pulmonale complications;

Back 46

Right ventricular heart failure.
Atril fib

Front 47

Cor Pulmonale Management;

Back 47

Tx is directed at pulmonary process responsible for tight heart failure;
O2, fluid restriction, salt restriction, & diuretics are the mainstays for tx.

Front 48

Cor Pulmonale Prognosis;

Back 48

Same as underlying pulmonary dx.
Life expectancy is 2-5yrs p signs of CHF appear.
It is significantly longer when uncomplicated emphysema is the underlying cause.

Front 49

Name some types of Interstitial Lung Disease;

Back 49

Pulmonary fibrosis, Pneumoconiosis (coal workers lung dz), Asbestosis, Silicosis, Beryliosis, Sarcoidosis.

Front 50

What is Interstitial Lung Disease?

Back 50

The end result of several nininfectious & nonmalignant processes. May present acutely, intermittently, subacutely or chronically (often).

Front 51

What are the 2 primary pathways of Interstitial Lung Disease?

Back 51

Granulomatous
Inflammation & fibrosis.

Front 52

What is Granulomatous Interstitial Lung Disease?

Back 52

Accumulation of T-lymphocytes, macrophages, & epitheloid cells into discrete structures (gramulomas) in the primary parenchma. Can progress to fibrosis but usually mild symptoms that respond to tx.

Front 53

What is the usual cause of Granulomatous Interstitial Lung Disease?

Back 53

Sarcoid or a hypersensitivity pneumonitis.

Front 54

What is Inflammation & fibrosis, Interstitial Lung Disease?

Back 54

Initial injury to epithelium & alveolar walls. Chronic inflammation can spread to adjacent tissues & cause interstital fibrosis. Irreversible scarring (fibrosis) of alveolar walls, airways or vasculature is worst outcome (progressive & leads to significant physiologic impairment, poor gas exchange).

Front 55

Interstitial Lung Disease S/Sx;

Back 55

Progressive extertional dyspnea, Persistent non-productive cough, Fatigue & wt loss, (rarely wheezing, CP, or hemoptysis).

Front 56

Interstitial Lung Disease PE;

Back 56

Usually non-specific, Tachypnea, Bi-basilar inspiratory dry crackles, Rarely rhonchi, (Late in dz may have signs of Cor Pulmonale).

Front 57

Interstitial Lung Disease Labs;

Back 57

ANA
RE
LDH increased in most

Front 58

Interstitial Lung Disease EKG;

Back 58

RAD
Right heart strain
Cor Pulmonale

Front 59

Interstitial Lung Disease Echo;

Back 59

Right Vent Dilation
RVH
Pulm HTN

Front 60

Interstitial Lung Disease CSR;

Back 60

Bibasilar reticular (lace like) pattern, Nodular pattern, Poor correlation to actual clinical dz progression, Small cystic spaces/honeycombing indicates progressive fibrosis (poor prognosis), Generally non-specific (usually read as interstitial pattern).

Front 61

Interstitial Lung Disease CT;

Back 61

Very useful to stage progression & plan biopsy.

Front 62

Interstitial Lung Disease Spiromentry;

Back 62

Measures extent of lung involvement (reduced total lung capacity, FEV% normal)

Front 63

Interstitial Lung Disease ABG;

Back 63

Shows hypoxemia
End stage elevated PCO2

Front 64

Interstitial Lung Disease Biopsy;

Back 64

Can find etiology & help w/tx.

Front 65

Interstitial Lung Disease Cardiac Stress Testing;

Back 65

Documents difference between resting & exertional hypoxia & is useful to follow dz progression & response to tx.

Front 66

Interstitial Lung Disease Tx;

Back 66

Course is variable, Progression is insidious, Can't reverse fibrosis so goal is to limit scarring & inflammation, O2 if hypoxic, Glucocorticoids mainstay (but not real helpful), Cyclophosphamide & & azathioprine occasionally tried, Methotrexate & other immune modulating drugs occasionally used, Lung transplant (for end stage).

Front 67

(Interstitial Lung Disease) Idiopathic Pulmonary Fibrosis Differentiate;

Back 67

Important to differentiate from other causes of fibrosis.

Front 68

(Interstitial Lung Disease) Idiopathic Pulmonary Fibrosis S/Sx;

Back 68

Exertional dyspnea, nonproduvtive cough, inspiratory crackles (may have clubbing)

Front 69

(Interstitial Lung Disease) Idiopathic Pulmonary Fibrosis Tests;

Back 69

CT:patchy basilar, subpleural reticular opacities.
PFT:restrictive pattern
Poor exercise tolerance

Front 70

(Interstitial Lung Disease) Idiopathic Pulmonary Fibrosis Clinical course;

Back 70

Varies
5yr survival rate 40%

Front 71

(Interstitial Lung Disease) Idiopathic Pulmonary Fibrosis Tx;

Back 71

Immune modulating drugs used but no evidence that they improve survival or quality of life.
Lung transplant for end stage (several criteria for transplant pts)

Front 72

(Interstitial Lung Disease)Pneumoconiosis describe?

Back 72

Inflammation of the lungs leading to fibrosis caused by inhalation of dust related to various occupations. (Coal dust is common cause, additive effects w/smoking; rapidly advancing COPD)

Front 73

(Interstitial Lung Disease) CXR simple coal miners pneumoconiosis;

Back 73

Early: small, irregular ipacities (reticular)
Later: small, rounded, regular opacities 1-5mm in diameter (nodular)
Calcifications unusual

Front 74

(Interstitial Lung Disease) Pneumoconiosis complicated dz CXR findings;

Back 74

Nodules from 1cm to entire lobe (usually in superior 1/2 of lung)
Significantly reduced diffusing capacity.

Front 75

(Interstitial Lung Disease)Pneumoconiosis Tx;

Back 75

(complicated dz has poor prognosis)
Same as for other causes of pulmonary fibrosis.
Mild dz treated as COPD
More severe will involve use in immune modulating drugs.

Front 76

(Interstitial Lung Disease)What is Asbestosis?

Back 76

A generic term for several different forms of mineral silicate fibers. Used extensively in 1940's to 1970's

Front 77

(Interstitial Lung Disease)What are the major dzs caused by asbestos?

Back 77

Pulmonary fibrosis & CA of the respiratory tract & pleura.

Front 78

(Interstitial Lung Disease)
What is asbestosis?

Back 78

Diffuse interstitial fibrosing dz of the lung that is directly related to the intensity & duration of exposure. (clinically resembles other forms of diffuse interstitial fibrosis)

Front 79

(Interstitial Lung Disease) What are the risk factors of asbestosis?

Back 79

Usually moderate to severe exposure that has taken place for at least 10yrs prior to sx appearance.

Front 80

(Interstitial Lung Disease)
Asbestosis Spirometry;

Back 80

Reveals restrictivie pattern w/decrease in lung volumes.
(flow rates are not impacted as much as would be predicted by the volume restriction)

Front 81

(Interstitial Lung Disease)
Asbestosis CXR findings;

Back 81

Pleural plaques, thickening or calcification along parietal pleura, lower lung fields or cardiac border. (indicate past exposure not impairment) may have effusions. Irregular or linear opacities 1st noted in the lower field & spreading cephalad as the asbestosis progresses (occasionally indistinct hrt boarder or ground glass appearance)

Front 82

(Interstitial Lung Disease)
Asbestosis Lung Cancer (squamous cell carcinoma or adenocarcinoma);

Back 82

15-19 yrs from exposure to onset.
Marked increase in smokers

Front 83

(Interstitial Lung Disease)
Asbestosis Lung CA (Mesothelioma);

Back 83

80% of cases have some relation of asbestos exposure. Plural & Peritonea, no association w/smoking Short term exposure 1-2yrs can present in 20-25yrs, Peak incidence 30-35yrs p exposure. 50% metastasize but death usually due to local invasion. (Effusions common).

Front 84

(Interstitial Lung Disease)
Asbestosis Tx;

Back 84

No specific therapy, Must stop smoking, Supportive care as in other causes of pulmonary fibrosis, CA tx is type specific.

Front 85

(Interstitial Lung Disease)
What is Silicosis?

Back 85

Free silica (SiO2) or crystalline quartz inhalation. 1.2-3million persons in USA. Progressive pulmonary fibrosis occurs after many years of exposure in a dose response pattern

Front 86

(Interstitial Lung Disease)
Silicosis Risk Factors;

Back 86

Acute silicosis can develop 10mos of intense exposure to silicates. Mining, stone cutting, foundry work, granite quarry, sandblasting in confined spaces, tunneling through rock w/a high quartz content, manufacture of abrasive soaps, (fine dust).

Front 87

(Interstitial Lung Disease)
Silicosis Prognosis;

Back 87

Rapidly fatal in < 2yrs.

Front 88

(Interstitial Lung Disease)
Silicosis Acute CXR findings;

Back 88

Profuse miliary infiltration or consolidation.

Front 89

(Interstitial Lung Disease)
Silicosis Chronic (after 15-20yrs) CXR findings;

Back 89

Small rounded opacities in the upper lobes, Retraction & hilar adenopathy, Calcification of hilar nodes (classic eggshell pattern) Reticular pattern of irregular densities uniformly present in the upper lobes.

Front 90

(Interstitial Lung Disease)
Silicosis Progressive CXR findings;

Back 90

Coalescence of nodules & formation of irregular masses >1cm, can become very large.

Front 91

(Interstitial Lung Disease)
Silicosis Spirometry findings;

Back 91

Significant impairment, Restrictive & Obstructive, Late ventilatory failure.

Front 92

(Interstitial Lung Disease)
Silicosis Complications;

Back 92

Increased risk of acquiring TB & other atypical mycobacterial infections.

Front 93

(Interstitial Lung Disease)
Silicosis Tx;

Back 93

Same as for any other Interstitial Lung dz.

Front 94

(Granulomatous Lung Dz)
Berylliosis Etiology;

Back 94

Beryllium may produce a acute pneumonitis or chronic granulomatous dz (more common). 2-15yrs of exposure to manifest dz.

Front 95

What is Beryllium?

Back 95

Used in manufacture of alloys, ceramics, high-tech electronics, & early fluorescent lights (1950's)

Front 96

(Granulomatous Lung Dz)
Berylliosis PE;

Back 96

PFT usually shows restrictive dz.
Clinical picture very similar to sarcoidosis but beryllium levels are elevated.

Front 97

(Granulomatous Lung Dz)
Sarcoidosis Patho?

Back 97

A chronic multi-system disorder of unknown etiology. Characterized by accumulation of T-lymphocytes & mononuclear phagocytes, epitheliod granulomas & derangement of normal tissue architecture. Exaggerated T-helper 1 lymphocyte immune process.

Front 98

(Granulomatous Lung Dz)
Sarcoidosis dz course;

Back 98

Can involve any part of the body, but most commonly the lung. Maybe acute or subacute, but is commonly chronic, waxing & waning over many years. Environmental trigger of exaggerated immune respones suspected but antigen not identified.

Front 99

(Granulomatous Lung Dz)
Sarcoidosis Epidemaology?

Back 99

10-40 per 100k, 10:1 black to white in USA, but overall evenly distributed worldwide. Favors non-smokers, presents between age 20-40.

Front 100

(Granulomatous Lung Dz)
Sarcoidosis S/Sx;

Back 100

Onset over weeks (20-40%) or months (40-70%).

Front 101

(Granulomatous Lung Dz)
Sarcoidosis S/Sx of dz onset over weeks;

Back 101

Fever, Fatigue, Anorexia, Wt loss, Cough, Dyspnea, Vague retrosternal discomford, Polyarthritis, Erythema Nodosum (same type of rash as coxicidial mycosis)

Front 102

(Granulomatous Lung Dz)
Sarcoidosis S/Sx of dz onset over months;

Back 102

Respiratory complaints w/out constitutional Sx, Dyspnea on exertion & dry cough, Dry rales.
This type develops chronic sarcoid w/permanent damage to lung & in 10% other organs (hrt, eye, CNS)

Front 103

(Granulomatous Lung Dz)
Sarcoidosis CXR findings;

Back 103

90% will have a abnorman CXR. Bilateral hilar adenopathy is hallmark, Diffuse parenchymal changes consistent w/interstitial lung dz, Occasionally eggshell calcification of hilar nodes, May see granulomas.

Front 104

(Granulomatous Lung Dz)
Sarcoidosis Lab Findings;

Back 104

Angiotensin converting enzyme elevated in 66% of pts, Hypercalcemia occasionally, Eosinophilla, Increased ESR, Biopsy via fiberoptic brochoscope; Noncaseating granulomas, increased # of Th1 subset of CD4 T-lymphocytes.

Front 105

(Granulomatous Lung Dz)
Sarcoidosis PFT findings;

Back 105

Normal to increased FEV1/FVC ratio, Decreased total lung volume, Decreased diffusing capacity.

Front 106

(Granulomatous Lung Dz)
Sarcoidosis ABG findings;

Back 106

Mild hypoxemia
Mild, compensated hypocarbia

Front 107

(Granulomatous Lung Dz)
Sarcoidosis Tx;

Back 107

Main delemma is when to tx; Clears spontaneously 50%, Usually observe 2-3mos tx if not better.
Mainstay glucorticoids (Prednisone 1mg/kg x 6wks, then taper over 3mos)
2nd line Methotrexate

Front 108

(Granulomatous Lung Dz)
Sarcoidosis Prognosis;

Back 108

Overall good; 50% resolve spontaneously. 50% have mild permanent organ dysfunction, usually; mild, stable & rarely progresses. 15-20% will have active dz or recur intermittantly. 10% will die from dz.

Front 109

What is influenza?

Back 109

Acute respiratory infection w/influenza, a virus causing fever, coryza, cough, H/A, malaise, & inflamed respiratory mucous membranes.

Front 110

What is coryza?

Back 110

An acute inflammation of the nasal mucosa accompanied by profuse nasal discharge.

Front 111

Influenza strains?

Back 111

A, B, or C. Only 1 strain of influenza B is recognzed. 'A' strains are recognized by hemagglutinin & neurominidase (determines how virus spreads & replicates) Mutations of HA & NA result in antigenic drift.

Front 112

What is antigenic drift?

Back 112

A minor change in the protein marker or antigen on an organism. Small changes in the antigenic surface markers of some microorganisms (such as the influenza virus) occur from year to year. Vaccinations against the virus are adapted annually to combat these changes and prevent epidemic infection.

Front 113

Influenza Epidemiology?

Back 113

Widespread sparadic respiratory illness during fall & winter q year. Epidemica q 2-3yrs. B strains usually less virulent than A strains. Highest in school aged children their contacts, & chronic illness.

Front 114

How is influenza spread?

Back 114

Airborne droples, person to person or contact w/contaminated items.

Front 115

Influenza risk factors?

Back 115

COPD, Valvular hrt dz, Pulmonary edema, Women in 3rd trimester, Elderly, Very young, Bedridden.

Front 116

Influenza S/Sx;

Back 116

48hr incubation w/abrupt onset, chills, fever (102-103)sudden onset, prostration & generalized aches & pain (back of legs), H/A w/photophobia, scratchy sore throat, substernal burning, nonproductive cough, coryza.

Front 117

What is prostration?

Back 117

Absolute exhaustion.

Front 118

What is coryza?

Back 118

An acute inflammation of the nasal mucosa accompanied by profuse nasal discharge.

Front 119

Severe Influenza S/Sx;

Back 119

Bloody sputum, warm & flushed, Reddened mm in mouth (no exudate), Eyes burn & watering (no exudate), Nausea & vomiting in Peds, Weakness, Sweating, & fatigue may persist for several days to weeks.

Front 120

Influenza when do acute S/Sx usually subside?

Back 120

2-3 days.

Front 121

Influenza Complications;

Back 121

Hemorrhagic bronchitis & Pneumonia, Death in severe cases of pneumonia, 2ndary bacterial infection of the lungs. (Encephalitis, myocarditis & myoglobinuria are infrequent complications)

Front 122

What microbes are responsible for secondary bacterial infection of the lungs in influenza?

Back 122

Pneumococcal or Staphylococcal.

Front 123

Influenza diagnostic tests & lab findings;

Back 123

Dx is clinical, no routine testing are recomended or used. Uncomplicated Influenza leukocytes are normal. Fever & severe constitution sx differentiate the flu from common cold, X-ray may be normal.

Front 124

Influenza D/Dx;

Back 124

Parinfluenza
RSV
Rhinoviruses
Echoviruses

Front 125

Influenza Prognosis;

Back 125

Healthy pts demonstrate lingering effects for weeks p the acute illness. Severe illness may require hospitalization especially if pt is high risk (very young or very old w/comorbidities, compromised immune system) Mortality from pneumonia & Influenza 1 of the 10 leading causes of death in US (>20,000 q yr)

Front 126

Influenza Prophylaxis;

Back 126

Vaccinate in the fall, Immunity in 2 wks,

Front 127

What types of Influenza vaccines are available?

Back 127

Traditional IM vaccine (fluzone) not live.
Attenuated virus given intranasally (Flumist) Live Virus.

Front 128

Who should get the Influenza vaccine?

Back 128

All adults >65
Anyone w/high risk.
Women who will be in their 3rd trimester durning winter mos.
People who provide medical & nursing care.

Front 129

What are the condrindications to the IM Influenza vaccine?

Back 129

Allergy to eggs.
Acute neurologic disorder.

Front 130

What are the condrindications to the intranasal influenza vaccine?

Back 130

(live virus)
Active infection, allergy to eggs, hx of Guillain-Barre syndrome, asthma, bronchospasm, pregnancy, DM, & renal dysfunction.

Front 131

What antiviral drugs are available for influenza?

Back 131

Amantadine & Rimantadine (will shorten the course & lessen the effects)
Effective against A strain,
Adult dose 100mg BID
Elderly 100mg qd
Can be used in children.

Front 132

What is the tx for influenza?

Back 132

Symptomatic;
Rest, Hydration, Influenza antiviarals, antipyretics, analgesics, nasal decongestant, steam inhalation.

Front 133

What is a antipyretic?

Back 133

An agent that reduces fever.

Front 134

What is Respiratory Syncytial Virus?

Back 134

RSV, lower respiratory tract viral illness (including bronchiolitis & pneumonia) in infants & young children.

Front 135

What are Respiratory Syncytial Virus risk factors?

Back 135

Premature infants (can be fatal) Less severe manifestation in older children & adults. (one of the most important causes of lower respiratory tract illness) Thought to be the cause of SIDS w/resp dz.

Front 136

Respiratory Syncytial Virus Etiology;

Back 136

RNA virus (resembles influenza & parainfluenza viruses) Outbreaks in winter or early spring. Increases morbidity from bronchitis & pneumonia. Poor protective effect of serum antibody (severe infections)

Front 137

Respiratory Syncytial Virus S/Sx;

Back 137

Vary w/age, previous exposure & underlying dz.
Dyspnea, Cough, Wheezing appearing several days p upper resp signs including fever, Apnea, Bronchopneumonia & bronchiolitis on X-ray.

Front 138

Respiratory Syncytial Virus lab findings;

Back 138

Leukocyte ct normal, may have elevated granulocytes.

Front 139

Respiratory Syncytial Virus S/Sx in older children & adults;

Back 139

(accounts for 15% of hospitalizations for exacerbation of chronic bronchitis)
Afebrile
URI
Influenza

Front 140

Respiratory Syncytial Virus D/Dx;

Back 140

Isolated from respiratory secretion, enzyme linked immunosorbent assay to detect RSV antigens is convenient & timely.

Front 141

Respiratory Syncytial Virus Tx;

Back 141

Mild infections resolve spontaneously.
Severe dx in infants & children; Hospitalization, ABGs, O2 tx, Respiratory support.
Ribavirin (reduces shedding & accelerates recovery) Aerosolized tx 3-5 days.

Front 142

What is Acute Laryngotracheobronchitis?

Back 142

Croup
Acute viral inflammation of the upper & lower respiratory tracts.

Front 143

What are the characteristics of Acute Laryngotracheobronchitis?

Back 143

Inspiratory stridor
Subglottic swelling
Respiratory distress that is most pronounced on inspiration.

Front 144

What age group is Acute Laryngotracheobronchitis most prevalent in?

Back 144

Children 6mos to 3yrs

Front 145

What are the major pathogens that cause Acute Laryngotracheobronchitis?

Back 145

RSV
Influenza B
Adenovirus

Front 146

When are outbreaks of Acute Laryngotracheobronchitis most common?

Back 146

Seasonal outbreaks;
Parinfluenza fall
RSV & influenza in winter & spring

Front 147

How is Acute Laryngotracheobronchitis spread?

Back 147

Airborne route or contact

Front 148

Acute Laryngotracheobronchitis etiology;

Back 148

Croup produces inflammation of laryx, trachea, bronchi, bronchioles, & lung parenchyma (subglottic structures). Swelling & inflammatory exudate most pronounced in subglottic region, this leads to; Dyspnea & possibley hypercapnia, & Atelectasis.

Front 149

What is hypercapnia?

Back 149

An increase in the partial pressure of carbon dioxide in the blood. (cerebral vasodilation can occur)

Front 150

What is Atelectasis?

Back 150

A collapsed or airless condition of the lung.

Front 151

What are possible secondary conditions to Acute Laryngotracheobronchitis?

Back 151

Parenchymal pulmonary infection

Front 152

What is parenchyma?

Back 152

The essential parts of an organ that are concerned with its function in contradistinction to its framework.

Front 153

Acute Laryngotracheobronchitis S/Sx;

Back 153

Preceded by URI, Barking, spasmodic cough, hoarseness, Tachypnea, Tachycardia, retractions, Harsh inspiratory stridor, prolonged inspiration & stridor w/ some expiratory rhonchi & wheezes, breath sounds may be dimished (atelectasis) Fever (50%), imporvement in AM worsens PM.

Front 154

What lab findings would you expect w/Acute Laryngotracheobronchitis ?

Back 154

Marked leukocytosis w/increased PMNs.
ABGs; Hypoxemia +/-hypercapnia.

Front 155

Acute Laryngotracheobronchitis D/Dx;

Back 155

Epiglottis (pt appears toxic)
Bacterial tracheitis
Foreign body
Diphtheria
Retropharyngeal abscess

Front 156

Acute Laryngotracheobronchitis Tx;

Back 156

Most can be tx at home. Well hydrated, Rest, Humidification (cold), Tylenol or motrin. Increasing resp distress, tachycardia, fatigue, cyanosis or dehydration need hospitaliaztion.

Front 157

Acute Laryngotracheobronchitis Tx of hopitalized pt?

Back 157

ABGs, humidified O2 (to loosen secretion & support O2) Intubated (hypercapnia, fatigue), Nebulized racemic epi (effects transient) Dexamthasone, ABX are rarely indicated.

Front 158

What is Bronchiolitis?

Back 158

Acute viral infection of the lower resp tract affecting infants & young children.

Front 159

What are the charastics of Bronchiolitis?

Back 159

Respiratory distress, expiratory obstruction, wheezing & crackles.

Front 160

Bronchiolitis epidemiology;

Back 160

Occurs in epidemics in children <18mos, Peak incidence in infants <6mos. Annual incidence in 1st year of life, 11:100 children.

Front 161

What Virus' usually cause Bronchiolitis?

Back 161

RSV, parainfluenza 3 virus, Influenza A & B, Parinfluenza, Adenovirus.

Front 162

What is the action of the virus in Bronchiolitis?

Back 162

Virus spreads from upper resp tract to med & sm bronchi & bronchioles→Epithelial necrosis.

Front 163

What causes obstruction in Bronchiolitis?

Back 163

Edema & exudate.
Expiration→air trapping in alveoli→atelectasis.

Front 164

Bronchiolitis S/Sx;

Back 164

Preceding URI, Rapid onset of resp distress, tachypnea, tachycardia, hacking cough, ↑ distress w/circumoral cyanosis, deepening retractions & wheezing, lethargy, +-Fever, Dehydration, resp acidosis, hyperresonant chest on precussion, prolonged expriation, crackles.

Front 165

What is circumoral cyanosis?

Back 165

Central cyanosis
central cyanosis-A bluish discoloration of the mucous membranes in the mouth, indicating hypoxemia and respiratory failure.

Front 166

What would you expect to find on a CXR of a pt w/Bronchiolitis?

Back 166

Hyperinflated lungs, Depressed diaphragm, Prominent hilar markings, Infiltrates.

Front 167

What lab findings would be expected for Bronchiolitis?

Back 167

2/3 have WBC 10,000-15000/ul
BUN & electrolytes may reflect dehydration.
ABGs show hypoxemia.
Viral isolation (immunoflourescence & enzyme linked immunosorbent assay for RSV)

Front 168

Bronchiolitis D/Dx;

Back 168

Asthma (more likely in children >18mos w/previous hx of sx.
GERD
Foreign body aspiration.

Front 169

Bronchiolitis Prognosis;

Back 169

Recovery in 2-5days, Mortality rate is <1% w/adequate medical care.

Front 170

What are the indications to hospitalize a pt w/Bronchiolitis?

Back 170

Increasing resp distress, cyanosis, fatigue & dehydration.
Co-morbidities that put a child at risk requires more diligent f/u & possible hospitalization.

Front 171

Bronchiolitis tx;

Back 171

Most pts can be tx at home.
Nebulization, ribavirin & ABX (if secondary infection is present)

Front 172

What tx are contraindicated or have no benefit for a pt w/Bronchiolitis?

Back 172

Corticosteroids (no benefit)
Sedatives (contraindicated)
Bronchodilators (usually ineffective)

Front 173

What is ribavirin?

Back 173

An antiviral agent used to treat respiratory syncytial viral infection and hepatitis C.

Front 174

What is the tx of a pt admitted for Bronchiolitis?

Back 174

Recognize & tx hypoxemia. ABGs, PaO2<60mmHg tent face mask w/30-40% O2, Intubation (if indicated), Postural drainage, Trachal suctioning, Humidified O2, Nubulization, Hydration (PO or IV)

Front 175

What is Postural drainage?

Back 175

A passive airway clearance technique in which patients are positioned so that gravity will assist the removal of secretions from specific lobes of the lung, bronchi, or lung cavities.

Front 176

What is Pertussis?

Back 176

Whooping Cough, Acute highly communicable bacterial dz, caused by bordetella pertusis.

Front 177

What are the characteristics of Pertussis?

Back 177

Paroxysmal or spasmodic cough that usually ends in a prolonged high pitched, crowing inspiration (The Whoop).

Front 178

What is a Paroxysmal cough?

Back 178

A persistent cough occurring with a sudden onset.

Front 179

What is Paroxysmal?

Back 179

Occurring repeatedly and without warning.

Front 180

Pertussis Epidemiology;

Back 180

Endimic throughout the world, occurs at all ages, 38% occur in infants <6mos, 71% occur in peds <5yrs

Front 181

Pertussis Etiology;

Back 181

Nonmotile, gram-negative coccobacillus, Sprayed in the air w/coughing, Contact w/contaminated articles is rare, 1 attack does not confer natural immunity.

Front 182

Pertussis S/Sx;

Back 182

Incubation 7-14 days
Invades mucose of nasopharynx, trachea, bronchi & bronchioles ↑ the section of mucus, which is initally thin, then becomes very tenacious.

Front 183

What are the different stages of Pertussis?

Back 183

Catarrhal
Paroxysmal
Cnovalescent

Front 184

Describe the S/Sx of Catarrhal stage of pertussis;

Back 184

Insidious, Sneezing, Lacrimation, Coryza, Anorexia, Listlessnes, Hacking nocturnal cought & becomes diurnal, fever is rare.

Front 185

What is Insidious?

Back 185

Of gradual, subtle, or indistinct onset; said of some slowly developing diseases.

Front 186

What is diurnal?

Back 186

Happening in the daytime or pert. to it.

Front 187

Describe the S/Sx of the Paroxysmal stage of pertussis;

Back 187

P 10-14days, 5-15 more rapidly consecutive forceful coughs during a single expiration followed by a whoop, a hurried deep inspiration, Normal breaths than another episode of coughing ending w/a whoop, Viscid mucus, vomiting p coughing d/t viscid mucus, Choking infants d/t viscid mucus.

Front 188

Describe the S/Sx of the Convalescent Stage of pertussis;

Back 188

Withing 4wks, Paroxysma not as frequent or severe, other sx decreased, pt looks & feels better, duration 7wks, Paroxysmal coughing may recur for months especially when induced by irritation from a URI.

Front 189

What are the complications of pertussis?

Back 189

Asphyxia in infants, Bronchopneumonia (may be fatal), Interstitial & subQ emphsema & pneumothorax (uncommon) from ↑ intrathoracic pressure, Convulsions in infants, Hemorrhage into the brain, skin, MM, Cerebral hemorrhage or edema (→Mental retardation or spastic paralysis)

Front 190

What tests should be ran & what results are expected for pertussis?

Back 190

Cultures of nasopharyngeal secretions (especially in catarrhal & early paroxysmal stages). Special collection w/cotton swab on zinc coated wire, Bordet-Gengou or charcoal agar medium to inhibit overgrowth by other flora, Fluorescent antibody testing, Parapertussis differentiated by culture or flourescent antibody technique.

Front 191

Pertussis Prognosis;

Back 191

<2yr mortality 1-2%, Most deaths are from bronchopneumonia or cerebral complication, Elderly & very young have a higher risk for complications.

Front 192

Pertussis Tx of choice;

Back 192

Erythromycin estolate 12.5mg/kg PO q6hrs (starting during the incubation to diminish infectivity to others & aborting infection in contacts.

Front 193

Pertussis Tx;

Back 193

Hospitalization for serious infection (especially infants) Sm freq meals, IV hydration, Suction, O2, Minimize stimulation in infants, Expectorants, cough suppressant & mild sedation are questionable. Theophylline, albuterol & corticosteroids (controversial tx)

Front 194

Pertussis ABX Tx;

Back 194

Catarrhal stage may avert dz, p paroxysmal stage started ABX have no discernible effect, but recommended to limit spread, Erythromycin 40-50mg/kg q 5hrs X 14days.

Front 195

What is Tuberculosis?

Back 195

A chronic, recurrent infection, most commonly in the lungs.

Front 196

Tuberculosis Etiology;

Back 196

Caused by Mycobacterium Tuberculosis, M bovis or M aficanum. Inhalation of organism (droplet) Can float in the air for several hours.

Front 197

Tuberculosis Epidemiology;

Back 197

In the US is prevalent in; people >70, 2:1 blacks to whites, Immigrants, HIV, IV drug users.

Front 198

Tuberculosis Initial Stage Pathogenisis;

Back 198

Active at any age, Clinical TB can occur in any organ, most often Apical areas of the lungs, occurs q 1-2yrs p initial infection, May activate p onset of DM, Stress, corticosteroids, HIV. Simon foci(scars in apical areas)

Front 199

Tuberculosis Latent or Dormant Stage Pathogenisis;

Back 199

Typically occurs in Apex of lungs, Illness may manifest itself when some other dx facilitates its reactivation of infection.

Front 200

Tuberculosis S/Sx;

Back 200

Asymptomatic & Vague, Fever, Cough, Mucus on rising, Dyspnea, Wt loss, Hempotysis (late in dz).

Front 201

Tuberculosis regarding the elderly;

Back 201

They are easily overlooked.
Spread to others quickly (SNF)

Front 202

Tuberculosis regarding HIV pts;

Back 202

Common & rapid

Front 203

Pleural TB Patho;

Back 203

Pleural pulmonary lesion ruptures→effusion of infected material, may seed ther organs.

Front 204

What are some of the reasons for the difference of dz course w/Tuberculosis?

Back 204

Inoculum, Virulence of organism, Competence of host, presence of other dz, Rapid among blacks & American indians, Whites more chronic dz without serious illness.

Front 205

What is Inoculum?

Back 205

A substance introduced by inoculation

Front 206

Tuberculosis CXR findings;

Back 206

Multinodular infiltrate above or behind the clavicle-recrudescence (reactivation of a latent or dormant site of old TB infection.
Younger pts w/new infection between middle & lower lobe.

Front 207

What tests could be ran to Dx tuberculosis?

Back 207

AFB (acid fast bacilli on smear) Bronchoscopy w/biopsy, Throacentesis of pleural fluid, WBC, pH, histologic eval & culture. PPD.

Front 208

Define prophylaxis;

Back 208

Observance of rules necessary to prevent disease.

Front 209

Tuberculosis PPD describe;

Back 209

0.1ml intradermal injection, Induration of >10mm usually +, Does not indicate activity of infection, May be - in HIV or elderly pts (don't have strong enough immune sys to present +)

Front 210

What should be done for a pt w/a + PPD?

Back 210

If no active dz start prophylaxis tx.
If test + & symptoms of active dz are presesnt (x-ray changes) treat w/combination therapy.

Front 211

Describe the 2 step test;

Back 211

If 1st test is - repeat 1-3wks later, if + it is a booster reaction (prevents from providing unnecessary meds next time pt tests + for PPD)

Front 212

What is BCG?

Back 212

Vaccine made from attenuated strain of M. bovis, used in developing countries w/high rate of TB, May cause a + PPD. (recommendation is to tx these pt w/+ PPD like they are + for TB)

Front 213

What is the prophylaxis tx for a tuberculosis pt?

Back 213

Isoniazid (INH)300mg/day for 6-9mos
Children 10mg/kg/day
Usually noninfectious w/in 10-14 days of tx
(usually don't isolate from family, damage is already done)

Front 214

Who should recieve prophylaxis tx?

Back 214

Pts whose PPD converted from - to +w/in the previous 2yrs, Elderly >15mm & not a booster reaction. Small peds, HIV 10mm, IDDM, anyone who has recently converted & is at risk for complications.

Front 215

Tuberculosis tx;

Back 215

Goal: cure dz & limit dz spread, Have to take the full course, Single med is used when clinical dz is absent, Pts w/+ smears & extrapulmonary TB uses at least 2 drugs (INH & rifampin) for 9mos.

Front 216

(Tuberculosis Tx)
What is Isoniazid?

Back 216

(INH) single most useful & least expensive med for TB, Very effective when given w/rifampin, Safe during pregnancy.

Front 217

What is agranulocytosis?

Back 217

An acute disease marked by a deficit or absolute lack of granulocytic white blood cells (neutrophils, basophils, and eosinophils).

Front 218

What are the adverse reaction of Isoniazid (INH)

Back 218

Allergy; rash, drug fever, anemia & agranulocytosis. (liver injury rare but ↑w/age)
Anorexis, nausea, vomiting, jaundice, Peripheral neuropathy (tx w/vit B), Decrease dilantin dose.

Front 219

What are reasons to stop Isoniazid (INH)?

Back 219

Jaundice is a sign of Hep toxicity d/c med.
If transaminase (AST)is >500 d/c med (may restart at a smaller dose & see if pt tolerates)

Front 220

(Tuberculosis Tx)
What is Rifampin?

Back 220

(mircle drug) 600mg qd (adult)
Safe w/pregnancy, Accelerates metabolism of many other drugs, BCP, coumadin, digoxin, DM meds. VitD levels may drop (supplement)

Front 221

(Tuberculosis Tx)
Strepomycin;

Back 221

CSF penetration poor, Injections 5days/wk, Contraindicated in pregnancy.

Front 222

(Tuberculosis Tx)
What are the toxic effects of Rifampin?

Back 222

Cholestatic jaundice (rare), fever, thrombocytopenia & renal failure.

Front 223

(Tuberculosis Tx)
What are the toxic effects of Strepomycin?

Back 223

Renal tubular damage
Vestibular damage
Ototoxicity

Front 224

(Tuberculosis Tx)
Prazinamide;

Back 224

Used in combination w/other TB meds
Shortens course to 6mos
Not advisable >60y/o
Toxic effect-hyperuricemia

Front 225

What is hyperuricemia?

Back 225

An excessive amount of uric acid in the blood.

Front 226

(Tuberculosis Tx)
Ethambutol;

Back 226

Deters resistance to bactericidal drugs
Toxic effects-optic nerve, inability to tell blue from green, impaired VA (both reversible early on if med is d/cd).

Front 227

(Tuberculosis Tx)
What are the recommended drug combinations?

Back 227

RMP & INH daily for 9mos or daily for 1mo & then twice weekly for 8mos (600mg RMP & 900mg INH)
RMP, INH, EMB & PZA for 2wk DOT, then RMP, INH, EMB & PZA 2X/wk for 6 mos.

Front 228

(Tuberculosis Tx)
What are the CDC recommendations for drug combination therapy?

Back 228

RMPH & INH qd for 6 mos w/PZA for the 1st 2 mos.

Front 229

What is Pneumonia?

Back 229

Acut infection of lung parenchyma including alveolar spaces & interstitial tissue.

Front 230

What are the common microbes responsible for bacterial pneumonia?

Back 230

S. pneumoniae (most common cause of community-acquired bacterial pneumonia.
H. influenzae
K. pneumoniae

Front 231

What are the uncommon microbes responsible for bacterial pneumonia?

Back 231

S. aureus
S. pyogenes
P. aeruginosa
N. meningitidis

Front 232

Bacterial Pneumonia Etiology;

Back 232

Usually acquired by bronchogenic spread of the pathogen, Suprainfection in pts previously infected by an upper or lower resp viral infection. Incidence of infection ↑w/age, most pts are >50 & have underlying COPD, cardiovascular or other chronic dz.

Front 233

Streptococcus pheumoniae epidemiology;

Back 233

Affects children & adults worldwide, Leading cause of illness in young peds, Causes illness & death among the elderly & pts w/underlying med conditions, 40,000 deaths annually in US, 1/2 could be prevented through use of vaccine, Fatality rate is 15-20% among adults.

Front 234

Where does Streptococcus pheumoniae colonize?

Back 234

Organism colonizes the upper resp tract

Front 235

What types of illness can Streptococcus pheumoniae cause?

Back 235

Disseminated invasive infections including; bacteremia & meningitis, Pneumonia & other lower resp tract infections, Upper resp tract infections including; otitis media & sinusitis.

Front 236

Each year in the US, pneumococcal dz accounts for;

Back 236

3,000 cases of meningitis
50,000 cases of bacteremia
500,000 cases of pneumonia
7 million cases of OM

Front 237

Severe pneumococcal infections result from;

Back 237

Dissemination of bacteria to the bloodstream & the CNS.

Front 238

Define
disseminated;

Back 238

Scattered or distributed over a considerable area, esp. applied to disease organisms; scattered throughout an organ or the body.

Front 239

In adults what % of pneumococcal bacteremia is associated w/pneumonia?

Back 239

60-87%

Front 240

What are the risks for acquiring bacteremia amoung the racial groups?

Back 240

Lower in whites than other races.
Black adulet 3-5 X higher than whites.
Invasive pneumococcal dz are exceptionally high among Alaskan natives, & Native Americans.

Front 241

In what pts are H influenzae & K pneumoniae more commonly seen in?

Back 241

COPD
Alcoholics
Elderly

Front 242

What manifestations are common in a pt w/H influenza Bacterial Pneumonia?

Back 242

Pleural effusion, Bacteremia, & other infections such as; Otitis, Sinusitis, Meningitis, Epiglottis, & Facial infection.

Front 243

What is Bacteremia?

Back 243

Bacteria in the blood.

Front 244

What pts are at risk for K. pneumoniae?

Back 244

Alchol abusers
COPD
Neonates

Front 245

What are the manifestations of K. pneumoniae?

Back 245

(lg gram - rod w/capsule)
"Currant jelly" sputum
Bulging fissure
Lung necrosis

Front 246

What pts are at risk for S. aureus pneumonia?

Back 246

IV drug users
Elderly
Pts w/recent influenza virus infection
Pts w/cystic fibrosis

Front 247

What are the mainifestions of S. aureus pneumonia?

Back 247

(gram + cocci in clusters)
Pleuritic CP
Multiple thin walled abscesses (pneumatoceles)
Cardiac murmurs

Front 248

What other infections should be checked for in a pt w/S. aureus pneumonia?

Back 248

Endocarditis
Abscesses
Skin furuncles
(from desemination)
Most common is bacteremia.

Front 249

What pts are most at risk for P. aeruginosa Pneumonia?

Back 249

Pts w/cystic fibrosis
Severly compromised resp defenses
Pts on respirators (P. aeruginosa usual cause)

Front 250

What are the manifestations of P.Aeruginosa Pneumonia?

Back 250

Gram - rod (encapsulated in pts w/cystic fibrosis)
Green sputum, fulminant course, Necrotizing w/multiple sm & lg abscesses.

Front 251

Define fulminant;

Back 251

Having a rapid and severe onset.

Front 252

In a pt w/P. aeruginosa pneumonia what other infections should you look for?

Back 252

Skin lesions ecthyma gangrenosum.

Front 253

What bacterial cause of pneumonia is not very common now due to ABX used to tx URI?

Back 253

S. pyogenes pneumonia

Front 254

What bacterial cause of pneumonia is occasionally seen in epidemics in military recruits?

Back 254

N. meningitidis

Front 255

What bacterial pneumonia is due to environmental exposure to a infected rat population?

Back 255

Y. pestis

Front 256

What bacterial pneumonia is due to exposure w/contaminated soil in southeast asia?

Back 256

B. pseudomallei

Front 257

What are the S/Sx of bacterial pneumonia?

Back 257

Malaise, high fever, dyspnea, chest discomfort, pleuritic pain, chest splinting, cough productive of purulent or blood-tinged sputum, tachypnea, tachycardia, cyanosis, confusion.

Front 258

What chest sounds would you expect to hear in a pt w/early onset of bacterial pneumonia?

Back 258

fine crepitant rales over the involved portion of the lung(s).

Front 259

What chest sounds result from lobar consolidation (a sx of bacterial pneumonia)?

Back 259

Dullness to percussion, vocal fremitus, whispered pectoriloquy, bronchial breathing.

Front 260

Bacterial Pneumonia PE;

Back 260

Lobar consolidation
Pleural effusions (pleural friction rub, dullness to percussion, ↓Breath sounds) Egophony, Lower lobe involvement may cause referred pain to abdominal area d/t diaphragmatic inflammation.

Front 261

What is Egophony?

Back 261

An abnormal change in tone, somewhat like the bleat of a goat, heard in auscultation of the chest when the subject speaks normally.

Front 262

What is the most useful lab test for the initial dx of bacterial pneumonia?

Back 262

Gram stain examinatio of sputum.

Front 263

(Bacterial pneumonia)
Why can culturing sputum be misleading?

Back 263

Because normal oropharyngeal flora may contaminate specimen during passage through the upper airways.

Front 264

(Bacterial pneumonia)
Where should specimens be taken from?

Back 264

Normally sterile sites; Blood cultures in septic pts, Pleural fluid from empyema, Special culture techniques, special stains serologic assays.

Front 265

(Bacterial pneumonia)
Lung biopsies to identify?

Back 265

Mycobacteria (may be TB), Mycoplasmas, Anaerobic bacteria, Chlamydiae, Viruses.

Front 266

What is the classic radiologic feature of bacterial pneumonia?

Back 266

Dense lobar consolidation, consolidations may involve one or more lobes, unilateral or bilateral. A pleural effusion may exist.

Front 267

(Bacterial Pneumonia)
What X-ray findings would you expect for Klebsiella pneumoniae infection?

Back 267

"Bulging fissure" sign, Upper lobar consolidation w/a bowing fissure.

Front 268

(Bacterial Pneumonia)
What X-ray findings would you expect for Staphylococcus aureus infection?

Back 268

Multiple bilateral nodular inflitrates w/central cavitation. In whildren one can seel ill-defined, thin walled cavities ("pneumatoceles), bronchopleural fistulas, & empyema.

Front 269

(Bacterial Pneumonia)
What X-ray findings would you expect for Pseudomonas aeruginosa infection?

Back 269

microabscesses which may coalesce into large abscesses.

Front 270

(Bacterial Pneumonia)
If you see lung necrosis on a X-ray what microbes would you suspect?

Back 270

Gram-negative rod infections;
Klebsiella
Proteus
E. coli.

Front 271

Bacterial Pneumonia D/Dx;

Back 271

Viral pneumonia, Atypical Pneumonia (Coxie), TB, Influenza, Lung CA.

Front 272

Bacterial Pneumonia Management & Tx;

Back 272

Resp support, O2, ABX, Hospitalization, Antipyretics, Hydration.

Front 273

How are ABX selected for Bacterial Pneumonia?

Back 273

Gram stain results, If gram stain is not performed or does not establish a dx, ABX are selected on the basis of probabilities according to pts age, epidemiology, host risk factors & severity of illness.

Front 274

Which baterias can cause Atypical Pneumonia?

Back 274

Mycoplasma pneumoniae (most common), Legionella sp (Legionnaire's dz), Francisella Tularesis (Tularemia), Bacillus anthracis (anthrax), Bortadella pertussis (Whooping cough), Chlamydia psittaci (psittacosis), Chlamydia trachomatis, Chlamydia pneumoniae, Coxiella burnetii, Q fever.

Front 275

Which viruses can cause Atypical Pneumonia?

Back 275

Influenza
Parainfluenza *
Respiratory syncytial virus *
Adenovirus

Front 276

Which fungi can cause Atypical Pneumonia?

Back 276

Histoplasma capsulatum (histoplasmosis)
Coccidioides immitis (occidiodomycosis)
Pneumocystis carinii/jiroveci (Pneumocystosis)*
Aspergillus fumigatus (Aspergillosis)*

Front 277

Which atypical pneumonia ranks second only to S. pneumoniae among all pneumonias due to infectious dx?

Back 277

Mycoplasma pneumonia, cause of pneumonia in 20-25% of all age groups & to persist in certain persons for weeks to mos, resulting in prolonged reduced pulmonary clearance & airway hyper-responsiveness.

Front 278

Mycoplasma pneumonia etioloby;

Back 278

Aka; Atypical, Walking or Eaton agent pneumonia. Outbreaks occur year round. Tends to >in adolescents & young adults, Males > Females. Transmission person to person.

Front 279

What is the incubation period of Mycoplasma pneumonia?

Back 279

10-21 days

Front 280

Mycoplasma pneumonia pathophysiology;

Back 280

Destroys ciliated epithelial cells of the respiratory tract mucosa, causes interstitial pneumonitis, bronchitis & bronchiolitis. Peribronchial areas are infiltrated w/plasma cells & sm lymphocytes, w/in the bronchial lumina are neutrophils, macrophages, fibrin strands & epithelial cell debris.

Front 281

What are the initial S/Sx of Mycoplasma pneumonia?

Back 281

Resemble influenza; Malaise, Sore throat, Dry cough ↑ in severity as the dz progresses, productive sputum that is mucoid, mucopurulent or blood-streaked.

Front 282

How does Mycoplasma pneumonia progress?

Back 282

Gradually

Front 283

How long does Mycoplasma Pneumonia usually last?

Back 283

Acute symptoms for 1-2wk followed by gradual recovery, pts may continue to have symptoms w/fatigue & malise for several wks, spontaneous recovery is the rule.

Front 284

What can what can severe Mycoplasma Pneumonia develop into?

Back 284

Adult Respiratory Distress Syndrome

Front 285

Pts who have Mycoplasma Pneumonia can have what derm sx?

Back 285

Maculopapular rashes (10-20%)
Erythema Multiform
Stevens-Johnson Syndrome

Front 286

Mycoplasma Pneumonia PE;

Back 286

PE tends to be unimpressive in contrast w/the pts complaints & X-ray changes.

Front 287

Mycoplasma Pneumonia Lab findings;

Back 287

Gram stain of sputum shows; sparse bacteria, mixture of PMNs & mononuclear cells, & clumps of desquamated resp epithelial cells. WBC ct is normal-modestly elevated.

Front 288

Mycoplasma Pneumonia Culture;

Back 288

Difficult to culture & requires 7-21 days to grow; successful in 40-90% of cases.

Front 289

Mycoplasma Pneumonia Cold Agglutinin;

Back 289

Is considered + if there is a fourfold ↑ in titer w/sequential specimens or a single tieter >=1:64

Front 290

What is the most practical method of confirming a Mycoplasma Pneumonia dx?

Back 290

The use of serologic assays. Most often, a single elevated IgM or a fourfold rise in titer w/a peak titer >=1:64 at 2 to 4 wk p the onset of sx.

Front 291

What other labs can be ran to dx Mycoplasma Pneumonia?

Back 291

Complement fixation test, IgM by latex agglutination or ELISA, Cold agglutinins***, Indirect Flourescent Antibody test to detect Mycoplasma Pneumonia antibodies.

Front 292

Mycoplasma Pneumonia D/Dx;

Back 292

Chlamydia pneumonia, Legionella pneumonia, Chlamydia psittaci, Chlamydia trachomatis, Coxiella burnetii (Q fever)

Front 293

Mycoplasma Pneumonia Tx;

Back 293

Most pt's recover w/out tx, Mycoplasmas do not respond to ABX that interfere w/cell wall structure (including beta-lactam ABX), Meds of choice tetracycline or erythromycin (A 500mg q6h, P<8yr 30-50mg/kg/day)

Front 294

Chlamydia pneumonia causes what % of community acquired pneumonia?

Back 294

10%

Front 295

Chlamydia pneumonia Etiology;

Back 295

C. pneumoniae
C. trachomatis
C. psittaci

Front 296

Chlamydia pneumonia S/Sx;

Back 296

Pharyngitis, Bronchitis, Pneumonitis, Persistent cough, fever, sputum production (but are not seriously ill), S/Sx resemble M. Pneumonia, primarily in older children & young adults.

Front 297

Chlamydia Trachomatis is a common cause of pneumonia in?

Back 297

Infants aged 3-8wk.

Front 298

Chlamydia Pneumoniae is distinguishable from psittacosis & not epidemiologically linked w/?

Back 298

Birds

Front 299

What is Chlamydia Psittacosis?

Back 299

An infectious atypical pneumonia caused by Chlamydia Psittaci & transmitted to humans by certain birds.

Front 300

Which birds transmit Chlamydia Psittacosis?

Back 300

Parrots, Parakeets, Lovebirds, Poultry, Pigeons, Canaries, Snowy egrets, Herring gulls, Petrels, Fumars

Front 301

Chlamydia Psittacosis etiology;

Back 301

Usually caused by inhaling dust from feathers or excreta of infected birds, or by the bite of a infected bire, sometimes by inhaling cough droplets of infected pts or venereally, Human to Human transmission is associated w/highly virulent avian strains.

Front 302

Define venereal;

Back 302

Pert. to or resulting from sexual intercourse.

Front 303

How long is the incubation period for Chlamydia Psittacosis?

Back 303

1-3 weeks

Front 304

Chlamydia Psittacosis S/Sx;

Back 304

Onset insidious or abrupt, temperature gradually rises, chills, malaise, anorexia, cough develops (initally dry but at times mucopurulent), Pneumonia & frank consolidation may occur w/2ndary purulent lung infection, temp is elevated for 2-3wks then falls slowly.

Front 305

What determines the severiry of Chlamydia Psittacosis Pneumonia?

Back 305

Pt's age & extent of the pneumonia.

Front 306

Chlamydia Psittacosis prognisis;

Back 306

A progressive, pronounced increase in pulse & resp rate is a ominous sign, Mortality may reach 30% in severe untx cases, (higher rates are reported w/virulent strains) A gradual convalescence may be prolonged, especially in severe cases.

Front 307

Chlamydia Psittacosis D/Dx;

Back 307

Influenza, Typhoid fever, Mycoplasmal pneumonia, Legionnaires' dz, Q fever.

Front 308

Chlamydia Psittacosis Tx;

Back 308

Avoid infected sick birds, especially dust from feathers & cage contents, Tetracycline 1-2g/day po in divided doses q6hr or doxycycline 100mg bid (tx for at least 10days), Strict bed rest, O2 when needed, & cough control.

Front 309

What is Legionnaires' Dz?

Back 309

>30 species, 19 have been implicated as caustice agents of pneumonia.
These organisms are morphologically dimilar, share biochemical characteristics & cause simular dzs.

Front 310

Name some of the species of Legionnaires' that cause Legionnaires' Pneumonia?

Back 310

Legionnaires' pneumophila (most causative agent)
Legionnaires' micdadei (most causative cause)
L. bozemanii & L. dumoffi

Front 311

What is the spectrum of Legionnaires' dz?

Back 311

Asymptomatic seroconversion, A self-limited, flu-like illness w/out pneumonia, "pontiac fever", Pneumonia, Rare localized soft tissue infections.

Front 312

Legionnaires' Dz risk factors;

Back 312

Occur at any age,> in middle aged men, Smoking, EOTH abuse, Immunosuppression, especially corticosteroids,

Front 313

Legionnaires' Dz epidemology;

Back 313

1-8% of community acquired pneumonias resulting in hospitalization, 4% of lethal nosocomial pneumonias. Occurs sporadically, predilection for late summer & early fall. Person-to-person transmission has not benn demonstrated. Outbreaks tend to occur in hospitals & hotels. w/contaminated H2O supply, organisms spread from evaporative condensers of air conditioning systems or contaminated showerheads.

Front 314

What is the incubation period of Legionnaire's Dz?

Back 314

2-10 days

Front 315

Legionnaire's Dz S/Sx
Prodromal phase;

Back 315

Malaise, Fever, H/A, Myalgias

Front 316

Define Prodromal;

Back 316

Pert. to the initial stage of a disease; the interval between the earliest symptoms and the appearance of a rash or fever.

Front 317

Define Myalgia;

Back 317

Tenderness or pain in the muscles; muscular rheumatism.

Front 318

Legionnaire's Dz S/Sx;

Back 318

Initial cough nonproductive w/subsequent production of mucoid sputum, High fever.
Sometimes; bradycardia, Diarrhea, Altered mental status.

Front 319

Legionnaires' Dz Lab findings;

Back 319

Leukocytosis; WBC 10,000-15,000/ul, CSF studies are normal, Stool is neg for blood & WBCs
Legionella sp. is stained w/Dieterle silver stain & direct fluorescent antibody staining, Urine test for Legionella antigen, Culture.

Front 320

Legionnaire's Dz CXR findings;

Back 320

Unilateral, patchy segmental or lobar slveolar infiltrate(Early on), (later in dz) many pts develop bilateral involvement & pleural effusions, occasionally lung abscesses & multiple rounded densities suggesting septic emboli.

Front 321

Legionnaire's Dz Tx;

Back 321

Erythromycin (drug of choice) 1g IV q 6hr, less severe 500mg po qid, Seriously ill erythromycin w/rifampin 300mg bid po or IV, Tx should be for >=3wk.
Cipro 750mg po bid
Azithromycin 500mg (initial dose) 250mg qd

Front 322

Which viruses can cause Atypical pneumonia?

Back 322

Resp Syncytial, Parainfluenzsa, Influenza A & B, Cytomegalovirus (CMV), Adenovirus, Varicella-Zoster, Epstein-Barr, Coxsackie, Hanta.

Front 323

Atypical pneumonia Viruses Eitology;

Back 323

Viruses invade the bronchiolar epitheliam, causing bronchiolitis, infection extends to the pulmonary interstitium & alveoli, causing pneumonia.

Front 324

How do the affected areas respond to viral atypical pneumonia?

Back 324

Congested, +/-hemorrhagic, Display inflammatory reaction composed of mononuclear cells.

Front 325

With viral atypical pneumonia what do the alveoli contain?

Back 325

Fibrin, mononuclear cells, +/-neutophils, +/-hyaline membranes.

Front 326

In viral atypical pneumonia what viral inclusions may occur?

Back 326

Adenovirus, CMV, Respiratory syncytial virus, Varicella-zoster.

Front 327

Viral atypical pneumonia S/Sx;

Back 327

H/A, Fever, Myalgia, Cough(produces scant sputum).

Front 328

Viral atypical pneumonia lab findings;

Back 328

Sparse bacteria & a dominance of monocytes on smears of sputum, +throat washings or tissue, ID of typical inclusions in cytopathology or biopsy speciments, serologyic assays, viral culture (if available)

Front 329

Viral atypical pneumonia X-ray findings;

Back 329

(most common) Interstitial pneumonia or peribronchial thickening. Lobar consolidation & pleural effusions are not common but may occur w/bacterial superinfection.

Front 330

Viral atypical pneumonia Tx;

Back 330

Acyclovir 5-10mg/kg q 8hr (adults) or 250-500mg/m2 BSA q 8hr (peds)
CMV pneumonia may be tx w/ganciclovir 5mg/kg IV bid & immune globulin (IV immune globulin or CMV immune globulin)

Front 331

Viral atypical pneumonia complications;

Back 331

Superimposed bacterial infections by: Streptococcus pneumoniae, Staphylococcus aureus, HiB, Group A hemolytic streptococci, Neisseria meningitidis.

Front 332

(Atypical Pneumonias Fungal)
Histoplasmosis Definition;

Back 332

Dz caused by histoplasma capsulatum, causing primary pulmonary lesions & hematogenous dissemination.

Front 333

(Atypical Pneumonias Fungal)
Histoplasmosis Risk factors;

Back 333

(Severe dz more common p heavy, prolonged exposure)
Men
Infants
Compromised T-cell-mediated immunity.

Front 334

(Atypical Pneumonias Fungal)
What are the endemic areas of Histoplasmosis?

Back 334

Ohio-Missippi river valleys extending into parts of northern Maryland, Southern Pennsylvania, Central New York, California & Texas

Front 335

(Atypical Pneumonias Fungal)
Histoplasmosis Patho;

Back 335

H. capsulatum grows in soil & material contaminated w/bat or bird droppings, spores become airborne when contaminated soil is disturbed, breathing the spores causes the infection. The dz is not transmitted person to person.

Front 336

(Atypical Pneumonias Fungal)
Acute primary Histoplasmosis S/Sx;

Back 336

Usually asymptomatic.
Sometimes; Non specific sx, Fever, Cough, Malaise of varying severity, Acute pneumonia (sometimes evident on PE or CXR)

Front 337

(Atypical Pneumonias Fungal)
Progressive Disseminated Histoplasmosis S/Sx;

Back 337

Hematogenous Spread from the lungs (what isn't controlled by normal cell-mediated host defense mechanisms); Hepatosplenomegaly, Lymphadenopathy, Bone marrow involvement, Oral or GI ulcers. Severe manifestations occur in infants & immunocompromised pts.

Front 338

(Atypical Pneumonias Fungal)
Progressive Disseminated Histoplasmosis in AIDS pts;

Back 338

One of the defining opportunistic infections. AIDS pts may develop severe acute pneumonia w/hypoxia suggestive of Pneumocystis carinii infection & hypotension, mental status changes, coagulopathy or rhabdomyolysis.

Front 339

(Atypical Pneumonias Fungal)
Chronic cavitary histoplasmosis S/Sx;

Back 339

Atypical pulmonary lesions (resemble cavitary TB), worsening manifestations cough & dyspnea, progresses to disabling resp dysfunction. Dissemination does not occur.

Front 340

(Atypical Pneumonias Fungal)
Histoplasmosis Labs Smears & Cultures Findings;

Back 340

Tissue specimens;
characteristic clusters of small, oval yeast cells w/in macrophages, blood monocytes or neutrophils. Intracellular yeasts may be seen in Wright's or Giemsa.

Front 341

(Atypical Pneumonias Fungal)
Histoplasmosis Serology Testing Culture;

Back 341

Sputum, lymph nodes, bone marrow, liver biopsy, blood, urine.

Front 342

(Atypical Pneumonias Fungal)
Histoplasmosis Serology Testing Findings;

Back 342

Antigen can be detected in serum, urine, CSF or bronchoalveolar lavage samples by enzymatic assay or radioimmunoassay.

Front 343

(Atypical Pneumonias Fungal)
Acute primary Histoplasmosis Tx;

Back 343

Usually self-limited (rare fatalities p massive infections have been reported)

Front 344

(Atypical Pneumonias Fungal)
Progressive Disseminated Histoplasmosis Tx;

Back 344

Itraconozole for less severe cases.
Amphotericin B (IV) for more severe disseminated cases.

Front 345

(Atypical Pneumonias Fungal)
Progressive Disseminated prognosis;

Back 345

(untx) has a fatality rate >90%

Front 346

(Atypical Pneumonias Fungal)
Chronic cavitary histoplasmosis prognosis;

Back 346

Can cause death from severe resp insufficiency.

Front 347

Define Coccidioides immitis;

Back 347

Dz caused by fungus C. immitis, usually occurs as a acute benign asymptomatic or self-limited resp inf, occasionally disseminating to cause focal lesions in skin, subQ tissues, lymph nodes, bones, liver, kidneys, meninges, brain or other tissues.

Front 348

Where is Coccidioidomycosis endemic?

Back 348

Southwestern USA; Including the central valley of California

Front 349

How are Coccidioidomycosis infections aquired?

Back 349

Inhalation of spore-laden dust.

Front 350

Coccidioidomycosis Patho;

Back 350

C. immitis conidia (spores) convert at 98.6 degrees to form lg tissue-invasive spherules, they rupture, each releases multiple sm endospores that may form new spherules.

Front 351

Primary Coccidioidomycosis Eitology;

Back 351

Usually asymptomatic, but nonspecific resp sx resembling influenza or acute bronchitis sometimes occur, less often acute pneumonia or pleural effusion.

Front 352

Primary Coccidioidomycosis S/Sx;

Back 352

Fever, Cough, CP, Chills, Sputum production, Sore throat, Hemoptysis, Scattered rales w/or w/out areas of dullness to percussion over lung fields. Usually leukocytosis & sometimes eosinophillia.

Front 353

Progressive Coccidioidomycosis S/Sx;

Back 353

Low grade fever, anorexia, wt loss, weakness. Extensive pulmonary envolvement may cause progressive cyanosis, dyspnea, & discharge of mucopurulent or bloody sputum. Extrapulmonary lesions are usually focal, involving one or more tissue sites in bones, joints, skin, subQ tissues, viscera, brain or meninges

Front 354

Progressive Coccidioidomycosis Eitology;

Back 354

May develop in weeks to years after primary infection. Men > Women.

Front 355

What labs should be ordered for a pt with Coccidioidomycosis?

Back 355

Complement fixation for IgG anticoccidioidal antibodies (most useful test) Titers >/= 1:4 in serum are consistant w/current or recent infection. Higher tiers >/=1:32 signify an increased likelihood of extrapulmonary dissemination.

Front 356

Progressive Coccidioidomycosis Tx;

Back 356

IV amphotericin B is preferable for severely ill pts. AIDS pts require maintence therapy to prevent relapse. Tx for meningeal coccidioidomycosis must be continued for mos to life long. Surgical removal of involved bone may be necessary. Untreated disseminated coccidiomycosis is usually fatal. Mortality of HIV pts exceeds 70% in 1st month of dx.

Front 357

Tx for mild to moderate Coccidioidomycosis

Back 357

=/> Fluconazole 400mg/day or Itraconazole 400mg/day.

Front 358

What is Pneumocystosis?

Back 358

P. Carinii in rats, P. jiroveci affects humans, Rare in immune competent pts, Occurs in 80% of AIDS pts w/high mortality.

Front 359

Pneumocystosis Diagnostics;

Back 359

DXR; diffuse interstitial pattern.
Can't culture; need organism to dx.

Front 360

Pneumocystosis Tx;

Back 360

Bactrim/Septra

Front 361

What is Aspergillosis?

Back 361

Clinical illness occurs w/tissue invasion or aberrant immunologic response (severe asthma excerbations) In immune compent pts causes chronic sinusitis. Invasive dz in HIV/AIDS pts, Necrotizing pneumonia w/dissemination of organism throughout body.

Front 362

What is ARDS?

Back 362

Adult respiratory distress syndrome, resp failure caused by various acute pulm injuries & characterized by noncardiogenic pulmonary edema, resp distress, & hypoxemia.

Front 363

Adult respiratory distress Etiology;

Back 363

Always caused by something else, Occurance >30% w/sepsis. Plasma & blood leak into interstitial & intra-alveolar spaces; atelectasis, inflammation in 2-3days, severe interstitial fibrosis 2-3wks, → stiff lungs, ↓ functional capacity (lungs to full of stuff), V/Q mismatch, hypoxemia, pulm HTN.

Front 364

Adult respiratory distress S/Sx;

Back 364

Dyspnea progressing to resp failure, lung sounds; normal>rales>wheezes, hypoxemia that doesn't resolve w/O2 (incl intubation w/100% FI02)

Front 365

Adult respiratory distress D/Dx;

Back 365

Heart failure
PE
PCP

Front 366

Adult respiratory distress Tx;

Back 366

O2 therapy (inc vent), TPN, hydration, swan ganz, ABGs, tx underlying cause, inhaled nitric oxide, suppress tumor necrosing factor (TNF) w/ketoconazole, aerosolized surfactant.

Front 367

Adult respiratory distress Labs;

Back 367

ABG; acute resp alkalosis, low PO2, norm or low PCO2.

Front 368

Adult respiratory distress CXR;

Back 368

Diffuse bilateral alveolar infiltrates, cardiac silhouette normal.

Front 369

What is asthma?

Back 369

Pulmonary dz characterized by; reversivle airway obstruction, airway inflammation, ↑ airway responsiveness to a variety of stimuli.

Front 370

What is the leading cause of hospitalization for peds?

Back 370

Asthma

Front 371

Asthma Patho;

Back 371

Bronchospasm, Hyper-responsive/Hyper-reactive airways, Inflammatory mediators, cholinergic reflex bronchoconstrictions.

Front 372

Asthma Bronchoconstricion Patho;

Back 372

Smooth muscle contracion, used to be the only patho acknowledged tx in asthma.

Front 373

Asthma Hyperresponsiveness Patho;

Back 373

Exaggerated bronchoconstrictior response to different stimuli, degree of hyperresponsiveness is linked to the extent of inflammation, cause unknown, struction changes in airways may contribute.

Front 374

Asthma What results from desquamation of epithelium;

Back 374

loss of relaxing factor & of prostaglandin E2 (both reduce contractile response to mediators.

Front 375

Asthma What is the result from epithelium damage;

Back 375

Decreased 'Neutral Endopeptidases', these are normally responsibe for metabolizing bronchchoconstricting mediators, Airway remodeling causes slightly thicker airways.

Front 376

In Asthma what are released &/or formed as a consequence of allergic reaction in the lungs?

Back 376

Inflammatory mediators; Histamines & Products of arachidonic acid metabolism transietly increase airway hyperresponsiveness (leukotrienes (LTC4 & LTD$ & Thromboxane)

Front 377

In Asthma what inflammatory mediators are the key activatiors?

Back 377

T-cell, they produce cytokines, perpetuate airway inflammation (Interleukin (IL4) is necessary for IgE production & Interleukin (IL5) attracts eosinophils) T-cells promote growth, differentiation, activation & migration of inflammatory cells to airways.

Front 378

In Asthma what is cholinergic reflex bronchoconstriction?

Back 378

Response to inhalation of irritant. Neuropeptides cause; Vascular permeability, Mucus secretion, Bronchoconstriction, Bronchial vasodilation (Neuokinin A, Calcitonin peptide) → obstrucion & ventilation that is not uniform (V/Q mismatch)

Front 379

Asthma Acute attack S/Sx;

Back 379

Tachypnea, Tachycardia, Sit upright, lean forward, accessory muscle use, anxious, Prolonged expiratory phase w/high pitched wheezes, hyperinflated chest, choarse rhonchi, fatigue, cyanosis, confusion, quiet chest.

Front 380

What are the life threatening signs in a Acute attack of asthma?

Back 380

Dyspnea at rest, inability to speak, cyanosis, pulus paradoxus (9.20-30mmHg), use of accessory muscles.

Front 381

Asthma labs;

Back 381

ABG; pH, blood gasses.
Eosinophil ct; >250-400 present regardless of allergic factors involvement in attack.
Sputum; Tenacious, Rubbery, Whitish, Charcot-Leyden crystal present, PMN & bacteria rarely present.

Front 382

Asthma PFT;

Back 382

Useless during acute attack, degree of airway obstruction, measure response to inhaled allergens & chemicals, before & p bronchodilatior, Static lung capacities, Dynamic lung capacities.

Front 383

Asthma CXR;

Back 383

Vary depending on severity of dx;
Hyperinflation
Atelectasis

Front 384

Asthma Dx;

Back 384

Consider anyone who wheezes, persistent cough, catagorize severity to direct tx.

Front 385

Asthma D/Dx;

Back 385

Foreign body, URI, Epiglottitis, RSV, COPD, CHF, other bronchial obstructions.

Front 386

Asthma Rx What is a Agonist?

Back 386

Adrenergic drugs, relax bronchial smooth muscle & modulate mediator release;
Epinephrine & selective Beta 2 agonists.

Front 387

Asthma Rx Beta 2 agonist for acute attack?

Back 387

Albuerol, Proventil, Ventolin, Maxair (Pirbuterol), Xopenex (Levabuterol) active for 6-8hrs. (some cardiac adverse R);P inhalation rapid onset in mins, active for 4-6h

Front 388

Asthma Rx Beta 2 agonist for maintence;

Back 388

Salmetorol or Foradil; long-acting (↑12hrs) Helps control nocturnal sx, combined w/a inhaled corticosteroid is Advair.

Front 389

Asthma Rx Methylxanthine;

Back 389

Theophylline; relaxes bronchial smooth muscle & has some modest anti-inflammatory activity, ↓ microvascular leakage into the airway mucosa, inhibit late allergen response, ↓ infiltration of eosinophils into bronchial mucosa, ↓ T lymphocytes into epithelium, ↑ myocardial & diaphragmatic contractility, extended release useful for nocternal asthma, narrow therapeutic index,

Front 390

Asthma Rx anticholinergic drugs;

Back 390

Atrophine & ipratropium bromide; Inhibits muscarinic cholinergic receptors that cause airway obstruction, block reflex bronchoconstriction due to irritants or to reflux esophagitis.

Front 391

Asthma Rx Corticosteroids;

Back 391

Inhibit the attraction of inflammatory cells & inhibits their activation, Blocks leukotriene synthesis, inhibits cytokine production & adhesion protein activation, block the late response to allergens, w/long-term use, bronchial hyperresponsiveness gradually decreases, use systemic (5-7days) to kick start. Pts still need albuterol for acute attacks.

Front 392

Asthma Rx Mast Cell stabilizers;

Back 392

Cromolyn & nedocromil (Intal);(safest antiasthmatic meds)Inhalation prophylactically, inhibit mediator release from inflammatory cells. Reduce airway hyperresponsiveness, block early & late responses to allergens.

Front 393

Asthma Rx Leukotriene modifiers;

Back 393

Montelukast (Singular) & Zafirlukast (Accolate); Selective competitive inhibitors of LTD4 & LTE4 receptors & sileuton, a 5 lipoxygenase inhibitor.

Front 394

What are the stages of asthma attacks?

Back 394

I-Mild
II- Moderate
III-Severe
IV- Respiratory failure

Front 395

What tx should be administered for a pt w/Asthma in Stage I?

Back 395

Bronchodilatior Inhaler/Nebulizer, Albuterol (MR X3)
Epi (MR X1-2 in 20-30min)or Terbutaline SQ (<CV affects)

Front 396

What tx should be administered for a pt w/Asthma in Stage II?

Back 396

Stage I Tx + Corticosteroid 120-180mg po in 3 divided doses for 48 hr then ↓ dose, Peds 1mg/kg/day max 60mg.
ABGs

Front 397

What tx should be administered for a pt w/Asthma in Stage III?

Back 397

ABG immediately, albuterol neb sol 5mg/ml tx, (10-15mg/hr Adults, Peds 0.5mg/kg/h max 15mg/h) O2 tx. Methyleprednisolone IV, Admit if failure to improve, worsening fatigue, relapse p repeated agonist & aminophyilie tx, sig↓ in PaO2 or ↑ in PaCO2.

Front 398

What tx should be administered for a pt w/Asthma in Stage IV?

Back 398

Beta agonist, Theophyiline, Methyleprednisolone 1-2mg/kg IV q 4-6h,if no response to aggressive 2agonist & corticosteroid tx, & have fatigue & progressive deterioration in ABGs & Ph should be considered for intubation.

Front 399

Why is sedative use in a non-intubated asthma pt dangerous?

Back 399

It can knock out their resp drive.

Front 400

Why is volume-cycled ventilation used in a Asthma pt?

Back 400

If pt has resp acidosis it is a mechanical problem that must be relieved, VC ventilation can provide reasonably constant alveolar ventilation when airway resistance in high & changing.

Front 401

What is Bronchiectasis?

Back 401

Congenital or caquired disorder of the lg bronchi characterized by permanent abnormal dilation & edstruction of bronchial walls.

Front 402

Bronchiectasis Etiology;

Back 402

Recurrent inflammation or infection, Cystic fibrosis (causes 50% of all cases), TB, Fungal infections, Lung abscess, Pneumonia, Rheumatic dz, Congenital & acquired immunodeficiencies (drugs).

Front 403

Bronchiectasis S/Sx;

Back 403

Chronic cough, Production of copious purulent sputum, Hemoptysis, Recurrent pneumonia, Wt loss, Anemia, Crackeles @ bases, Clubbing, Copious foul smelling purulent sputum, Obstructive pulm dys w/hypoxemia, Crowded bronchial markings, cystic spaces @ bases, fibrosis.

Front 404

Bronchiectasis Acute Exacerbation Tx;

Back 404

ABX (amoxicillin or augmentin)
Daily chest physiotherpay w/posteral drainage.
Inhaled bronchodilators.

Front 405

Bronchiectasis Prophylaxis;

Back 405

Inhaled aminoglycosides (helps prevent infections)

Front 406

Bronchiectasis Complications;

Back 406

Hemoptysis (become anemic), Cor pulmonale, Amyloidosis, Veseral Abscess.

Front 407

Bronchiectasis Dx;

Back 407

Bronchoscopy
Srugical resection

Front 408

What is chronic bronchitis?

Back 408

Presence of a mucus-producing cough, most days of the month, 3 months a year, for 2 successive years w/out other underlying dz to explain the cough.

Front 409

Chronic Bronchitis risk factors;

Back 409

Females>males, >45yrs, Smokers, Sx worsen when air pollutants↑ (especially smokers), Occupational exposure to dust & irritating fumes.

Front 410

Chronic bronchitis Etiology;

Back 410

(pts are more at risk for infection) The lining of the bronchial tubes become inflamed, when the bronchi are inflamed &/or infected, less air is able to flow to & from the lungs & heavy mucus or phlegm is coughed up.

Front 411

What is emphysema?

Back 411

The breakdown of the walls of the alveoli. The damaged alveoli cannot exchange O2 & CO2, the bronchioles lose elasticity & collapse on exhalation, trapping air in the lungs, the trapped air keeps sufficient levels of O2 from entering the lungs.

Front 412

What is COPD?

Back 412

A general term used for chronic bronchitis, emphysema, & chronic asthma (most pts have chronic bronchitis & emphysema) COPD worsens gradually, causing limited airflow in & out of the lungs.

Front 413

COPD Epidemiology;

Back 413

Emphysema & chronic brochitis affect about 16milllion people in the US, close to 11% of the population.

Front 414

COPD Risk factors;

Back 414

#1 Smoking
Alpha1-antitrypsin (AAT) deficiency-deficiency of alpha1-protease inhibitor, Elastase (enzyme that breaks down elastin) is no inhibited resulting in elastin degradation (onset by middle age)

Front 415

What is the most common sx of COPD?

Back 415

Dyspnea, gradual onset 1st noticed during px exertion or during acute exerbations, pts >60, closely associated w/lung function decline & is not always associated w/decreaased O2 in the blood.

Front 416

COPD S/Sx cough;

Back 416

Begins as a AM cough & slowly progresses to an all-day cough, produces small amts of sputum, clear or whitish but may be discolored, sputum production ↓ when one quits smoking, the progression of the cough is very slow (any change in chronic cough should be throughly investigated)

Front 417

COPD S/Sx hemoptysis;

Back 417

Common cause of hemoptysis, usually during acute exacerbation, w/productive cough w/purulent sputum (may be a sign of Lung CA)

Front 418

COPD S/Sx Pink Puffer;

Back 418

Emphysema type predominate; Airflow out is limited & exhalation takes longer, alveoli lose elasticity, pt forcefull exhales, ↑ calorie burn for breathing, pts are SOB & it is harder to eat.

Front 419

COPD S/Sx Blue bloater;

Back 419

Chronic bronchitis predominate type; Poor O2 supply pt appears cyanotic, PE reveals a bluish tinge to skin, lips & nail beds.

Front 420

COPD S/Sx Barrel Chest;

Back 420

Chest wall is enlarged, accessory breathing muscles become less efficient (contributes to SOB), When lungs become enlarged, the diaphragm is displaced downward & is unable to contract efficiently, dyspnea occurs when arms are raised, tripod position.

Front 421

COPD S/Sx Lower extremity edema;

Back 421

Pulmonary artery pressures ↑, Right ventricular failure, which leads to lower extremity edema.

Front 422

COPD labs;

Back 422

EKG Check hrt function & R/O hrt dz, HXR for lung changes, PFT for lung volume & air flow, Pulse ox for O2 sat, ABGs check amt of O2 & CO2 in blood, Exercise test to check O2 level w/exertion.

Front 423

COPD EKG;

Back 423

Cor pulmonale, R wave lg or lger than S wave in V1, Right axis deviation >110 degree w/out RT bundle branch block.

Front 424

COPD X-RAY;

Back 424

Low flat diaphragn in frontal view (overdistenion of lungs), In lateral view, wedening of the retrosternal sirspace & ↑ in angle formed by the sternum & diaphragm form acute to >=90degree. Hrt shadow is long & narrow, lungs are hyperlucent.

Front 425

COPD Emphysema X-Ray;

Back 425

Bullae >1cm

Front 426

COPD Lab sputum;

Back 426

In stable chronic bronchitis is mucoid, During exacerbation, purulent w/influx of neutrophils gram stain may show; Strep Pneumoniae, HiB, Moraxella catarrhalis, Gram neg rods, staphylococcus.

Front 427

COPD PFT;

Back 427

The FEV1 & FEV1/FVC fall progressively as severity ↑, FEV1 is less variable & can be predicted more accurately from age, sex & ht.

Front 428

(COPD PFT) Can PFT distinguish between chronic bronitis & emphysema?

Back 428

No

Front 429

COPD Arterial blood gases;

Back 429

ABGs measurements detect hypoxemia & hypercapnia & determine their severity(During early stages they are mild), As dz progresses, hypoxemia becomes more severe & hypercapnia predominates. Hypercapnia occurs as the FEV1 falls below 1L. Abnormalties worsen during acute exacergations & excerise & sleep. Functional residual capacity & residual volume are ↑, vital capacity is ↓.

Front 430

COPD D/Dx;

Back 430

TB & CA

Front 431

COPD TX;

Back 431

Fluvax annually, Pneumovax, Smoking cessation, Bronchodialtor drugs, Anticholinergic drugs, Theophylline, Corticosteroids, ABX prn, Good hydration (thin secretions), O2 tx, Energy conservation for ADLs, Nutrition ED, Lung transplant, Lunvolume reduction surg, Pulm rehab programs, Tx of alpha-antitrypsin deficiency w/purified human 1-antitrypsin (very expensive)

Front 432

What is a pleural effusion?

Back 432

Abnormal accumulation of fluid in the pleural space.