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236 Cards in this Set
- Front
- Back
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Presentation of asthma?
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Wheezing with the acute onset of shortness of breath, cough, and chest tightness
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Symptoms or findings that are commonly associated with asthma?
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Worse at night, nasal polyps and aspirin sensitivity, eczema or atopic dermatitis, increased length of expiratory phase, increased use of accessory respiratory muscles (e.g., intercostals)
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Best initial test in acute exacerbation of asthma?
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Peak expiratory flow (PEF) or arterial blood gas (ABG); peak flow can be used by the patient to determine function
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The most accurate test for asthma?
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PFTs; spirometry will show a decrease in the ratio of FEV1 to FVC; the FEV1 decreases more than the FVC
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CXR findings in asthma?
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Most often normal; may show hyperinflation
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What is the use of CXR in asthma?
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Exclude pneumonia or other diseases such as pneumothorax or CHF
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Most accurate test for asthma in an asymptomatic patient?
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>20% decrease in FEV1 with use of methacholine or histamine; ABG and PEF are only useful during acute exacerbations
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What will PFTs show in asthma?
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Decreased FEV1 and FVC, with a decreased ratio; increase in FEV1 of >12% and 12mL with albuterol; decrease in FEV1 of >20% with the use of methacholine or histamine; increase in the diffusion capacity of the lung for carbon monoxide (DLCO)
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How does histamine and acetylcholine decrease FEV1?
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By provoking bronchoconstriction and increasing bronchial secretions
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What is methacholine?
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Artificial acetylcholine used in diagnostic testing
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Other tests to consider in asthma?
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CBC (increased eosinophil count), skin testing (allergens), increased IgE levels suggest an ellergic etiology and may help guide therapy such as the use of anti-IgE medication omalizumab
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Increased IgE levels may also be associated with?
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Churg-Strauss and allergic bronchopulmonary aspergillosis
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General principle of asthma therapy
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Manage in a stepwise fashion of progressively adding more types of treatment if there is no response
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Step 1 in asthma management
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Inhaled short-acting beta agonist (SABA) as needed, such as albuterol, pirbutol, and levalbuterol
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Step 2 in asthma management
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Add a long-term control to a SABA. Low-dose inhaled corticosteroids (ICS) are the best initial long-term agent
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Examples of ICS?
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Beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone
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Adverse effects of inhaled steroids
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Dysphonia and oral candidiasis
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Best initial long-term control agent for asthma?
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Inhaled corticosteroids (ICS)
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Alternate long-term agents in asthma
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Cromolyn and nedocromil, theophylline, or leukotriene modulators
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Step 3 in asthma management
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Add a long-acting beta agonist (LABA) to a SABA and ICS, or increase the dose of the ICS
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LABA medications
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Salmeterol or formoterol
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Step 4 in asthma management
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Increase the dose of ICS to the maximum in addition to the LABA and SABA
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If increased levels of IgE in asthma, what is the treatment?
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Add omalizumab to the SABA, ICS, and LABA
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Last resort if no other therapies are enough to control the asthma?
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Oral corticosteroids such as prednisone
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Adverse effects of systemic steroids
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Osteoporosis, cataracts, adrenal suppression and fat redistribution, hyperlipidemia, hyperglycemia, acne, and hirsutism, thinning of skin, striae, and easy bruising
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Role of anticholinergics in asthma?
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Not clear; these agents will dilate bronchi and decrease secretions; very effective in COPD
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Vaccines that should be given to all asthma patients?
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Pneumococcal and influenza
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Best indication of severity of asthma?
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Respiratory rate
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How is the severity of asthma quantified?
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Decreased PEF and ABG with an increased A-a gradient
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Cause of wheezing in extremely severe asthma?
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Loss of air movement
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How long do corticosteroids need to begin to work?
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4-6 hours
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Drugs that are not effective at all in acute exacerbations of asthma?
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Theophylline, cromolyn and nedocromil, leukotriene modifiers, omalizumab, and salmeterol
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If the patient does not respond to oxygen, albuterol, and steroids, or develops respiratory acidosis (increased pCO2), the patient needs
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to undergo endotracheal intubation for mechanical ventilation; place these patients in the ICU
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Etiology of most COPD?
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Tobacco smoking; tobacco destroys elastin fibers
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If the case describes a patient who is young and a non-smoker with symptoms of COPD, what is the most likely diagnosis?
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alpha-1 antitrypsin deficiency
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Presentation of COPD?
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Shortness of breath worse with exertion, intermittent exacerbations with increased cough, sputum, and SOB brought on by infectin, "barrel chest" from increased air trapping, and muscle wasting and cachexia
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Best initial test in COPD?
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CXR; Increased anterior-posterior diameter, and air trapping and flattened diaphragms
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Most accurate testing for COPD?
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PFTs; Decreased FEV1, FVC, and ratio below 70%; increased TLC because of increased residual volume, decreased DLCO, incomplete improvement with albuterol, little or no worsening with methacholine
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Full reversibility to bronchodilators is defined as?
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Greater than 12% increase and 200mL increase in FEV1
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ABGsin acute exacerbations of COPD?
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Increaesd pCO2 and hypoxia; respiratory acidosis may be present if there is insufficient metabolic compensation and bicarbonate will increase to compensate
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CBC in COPD?
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May have an increased hematocrit from chronic hypoxia
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ECG in COPD?
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RA and RV hypertrophy; atrial fibrillation or multifocal atrial tachycardia (MAT)
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COPD treatment that improves mortality and delays progression of the disease?
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Smoking cessation, oxygen therapy for those with pO2 <55 or saturation <88%; mortality benefit is directly proportional to the number of hours that the oxygen is used; influenza and pneumococcal vaccines
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COPD treatment that definitely improves symptoms, but does not decrase disease progression or mortality?
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SABAs (e.g., albuterol), anticholinergics (ipratropium, tiotropium), steroids, LABAs (e.g., salmeterol), and pulmonary rehabilitation
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Treatment for COPD when not controlled with albuterol?
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Anticholinergics (e.g., tiotropium) --> inhaled steroid
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COPD treatments that possibly improves symptoms?
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Theohylline and lung volume reduction surgery
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COPD treatment options that has no benefit?
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Cromolyn and leukotriene modifiers
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When all medical therapy in COPD is insufficient, what is the next step?
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Transplant
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Management of acute episodes of increased shortness of breath
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Bronchodilators and corticosteroids combined with antibiotics
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Why are antibiotics often used in acute exacerbations of chronic bronchitis?
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Because infection is the most commonly identified cause
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Antibiotic coverage in chronic bronchitis?
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Coverage against H.influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis
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First-line antibiotics for chronic bronchitis?
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Cefurozime, cefixime, cefaclor, ceftibuten; amoxicillin/clavulanic acid; levofloxacin, moxifloxacin, gemifloxacin; azithromycin, clarithromycin
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Second-line agents in chronic bronchitis?
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Doxycycline and TMP-SMZ
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Criteria for use of oxygen in COPD
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pO2 below 55 or oxygen saturation below 88%; if there are signs of right-sided HF or elevated Hct: pO2 <60 or saturation <90%
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Single most common cause of bronchiectasis?
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Cystic fibrosis, which accounts for half of all cases
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Other causes of bronchiectasis
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Infections (TB, pneumonia), immune deficiency, foreign body or tumors, allergic bronchopulmonary aspergillosis (ABPA), and collagen-vascular disease such as rheumatoid arthritis
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Key finding to the suggestion of bronchoectasis?
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Recurrent episodes of very high volume purulent sputum production
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Presentation of bronchiectasis?
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High volume purulent sputum, hemoptysis, dyspnea and wheezing; weight loss, ACD, crackles, clubbing, and dyskinetic cilia syndrome
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Best initial test in bronchiectasis?
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CXR that shows dilated, thickened bronchi, sometimes with "tram-tracks" which is the thickening of bronchi.
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Most accurate test for bronchiectasis?
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High-resolution chest CT
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Treatment of bronchiectasis?
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Chest physiotherapy ("cupping and clapping") and postural drainage; treat infections; rotate antibiotics, 1 weekly each month; surgical resection of focal lesions
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What is allergic bronchopulmonary aspergillosis (ABPA)?
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Hypersensitivity of the lungs to fungal antigens that colonize the bronchial tree; ABPA occurs almost exclusively in patients with asthma and a history of atopic disorders
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When is ABPA the most likely diagnosis?
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Asthmatic patient with recurrent episodes of brown-flecked sputum and transient infiltrates on CXR; cough, wheezing, hemoptysis, and sometimes bronchiectasis occur
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Diagnostic tests for ABPA?
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Peripheral eosinophilia, skin test reactivity to aspergillus, precipitating antibodies to aspergillus on blood test, elevated IgE, pulmonary infiltrates on CXR or CT
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Treatment of ABPA?
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Oral steroids (prednisone) for severe case; inhaled steroids are not effective; itraconazole orally for recurrent episodes
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Why are inhaled steroids not effective in ABPA?
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Inhalers cannot deliver a high enough dose of steroids
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Features that make the diagnosis of sarcoidosis very likely?
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Young black woman with shortness of breath on exertion and occasional fine rales on lung exam, but without the wheezing of asthma; erythema nodosum and lymphadenopathy
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Sarcoidosis may also present with what?
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Parotid gland enlargement, facial palsy, heart block and restrictive cardiomyopathy, CNS involvement, iritis and uveitis
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Answer sarcoidosis when CXR or CT shows
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hilar adenopathy in a generally healthy black woman
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Best initial test for sarcoidosis?
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CXR; hilar adenopathy is present in more than 95% of patients; parenchymal involvement is also present in combination with lymphadenopathy
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Most accurate test for sarcoidosis?
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Lymph node biopsy
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Treatment of sarcoidosis?
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Prednisone is the drug of choice; few patients fail to respond; asymptomatic hilar adenopathy does not need to be treated
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Other diagnostic findings in sarcoidosis?
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Elevated ACE levels, hypercalciuria, hypercalcemia, and evidence of restrictive lung disease on PFTs
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Bronchoalveolar lavage will show what in sarcoidosis?
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Elevated level of helper cells
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How are neutrophils involved in cystic fibrosis?
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They dump tons of DNA into airway secretions, clogging them up
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Presentation of CF
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Chronic lung disease (cough, sputum, hemoptysis, bronchiectasis, wheezing and dyspnea) and recurrent episodes of infection; sinus pain and nasal polyps are common
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GI involvement in cystic fibrosis
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Meconium ileus in infants, pancreatic insufficiency (in 90%), recurrent pancreatitis, distal intestinal obstruction, biliary cirrhosis
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What is the genitourinary involvement in CF?
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Men are often infertile; 95% have azoospermia, with the vas deferens missing in 20%; women are infertile because chronic lung disease alters the menstrual cycle and thick cervical mucus blocks sperm entry
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What is the most accurate test for cystic fibrosis?
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Increased sweat chloride test; chloride levels in sweat above 60 mEq/L on repeated testing establishes the diagnosis
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Which drug is used in sweat chloride testing?
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Pilocarpine increases acetylcholine levels, which increases sweat production
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Why is genotyping not the most accurate test for cystic fibrosis?
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Because there are so many different types of mutations leading to CF
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PFTs in cystic fibrosis
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Obstructive and restrictive patterns; decrease in FVC and TLC; and decreased DLCO
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Sputum culture in cystic fibrosis
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Nontypable H.influenzae, Pseudomonas aeruginosa, Staphylococcus aureus, Burkholderia cepacia
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Treatment of cystic fibrosis
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Antibiotics (esp. inhaled aminoglycosides), inhaled recombinant human DNase, bronchodilators, pneumococcal and influenza vaccine, lung transplant in advanced disease
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Definition of community-acquired pneumonia (CAP)
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Pneumonia occurring before hospitalization or within 48 hours of hospital admission; CAP is the most common infectious cause of death in the US
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Most common cause of community-acquired pneumonia (CAP)?
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Streptococcus pneumoniae; neither the environmental reservoir nor its method of acquisition is known
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H. influenzae in CAP is associated with?
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COPD
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S.aureus in CAP is associated with?
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Recent viral infection (influenza)
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Klebsiella pneumonia in CAP is associated with?
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Alcoholism and diabetes
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Anaerobes in CAP is associated with?
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Poor dentition and aspiration
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M.pnneumoniae in CAP is associated with?
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Young, healthy patients
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Chlammydohilia pneumonia in CAP is associated with?
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Hoarseness
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Legionella in CAP is associated with?
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Contaminated water sources, air conditioning, ventilation systems
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Chlamydia psittaci in CAP is associated with?
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Birds
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Coxiella burnetii in CAP is associated with?
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Animals at the time of giving birth, veterinarians, and farmers
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Presentation of pneumonia?
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Fever and cough, chest pain is often pleuritic (changes with respiration), and dyspnea. Cough may be associated with hemoptysis and dullness to percussion if there is an effusion
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Reason for bronchial breath sounds and egophony in pneumonia?
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Consolidation of air spaces
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Severe pneumonia is distinguished by?
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Abnormalities of vital signs (tachycardia, tachypnea, and hypotension) or mental status
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Chills or "rigors" in the setting of pneumonia is a sign of what?
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Bacteremia
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Main way to distinguish pneumonia from bronchitis?
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Dyspnea, high fever, and abnormal CXR
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Klebsiella pneumonia presents with what?
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Hemoptysis from necrotizing disease, "currant jelly" sputum
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Anaerobic pneumonia presents with what?
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Foul-smelling sputum, "rotten eggs"
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Mycoplasma pneumoniae pneumonia presents with what?
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Dry cough, rarely severe, bullous myringitis (inflammation of the tympanic membrane)
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Legionella pneumonia presents with what?
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GI symptoms (abdominal pain, diarrhea) or CNS symptoms such as headache and confusion
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Pneumocystis pneumonia presents with what?
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AIDS with <100 CD4 cells
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Organisms that cause a "dry" or non-productive cough?
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Mycoplasma, viruses, Coxiellla, Pneumocystis, and Chlamydia
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Why do some infections often cause a dry cough?
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Because they preferentially involve the interstitial space and more often leave leave the air spaces of the alveoli empty; specific sputum colours are useless in detemrining etiology
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Best initial test for all respiratory infections?
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CXR; however, it cannot determine etiology
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Best ways to try and determine specific microbial etiology for respiratory infections?
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Sputum Gram stain and sputum culture
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What does the term atypical pneumonia refer to?
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An organism not visible on Gram stain and not culturable on standard blood agar
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False negative rate of first CXR in pneumonia?
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10% to 20%
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Bilateral interstitial infiltrates on CXR are seen with which infections?
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Mycoplasma, viruses, Coxiella, Pneumocystis, Chlamydia
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When is sputum Gram stain "adequate"?
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If there are more than 25 WBCs and fewer than 10 epithelial cells
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How often are blood cultures positive in CAP?
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5% to 15%, particularly with S.pneumoniae
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Which tests are done in severe cases of pneumonia with an unclear etiology, or those who do not respond to treatment?
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Thoracentesis, check for empyema (LDH 60% above serum levels and protein 50% above), and bronchoscopy (rarely done)
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When is bronchoscopy needed in CAP?
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If there is severe disease such as someone needing placement in an ICU when initial testing such as sputum stain and culture and blood cultures do not yield an organism
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Specific diagnostic test for Mycoplasma pneumoniae?
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PCR, cold agglutins, serology, special culture media
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Specific diagnostic test for Chlamydophila pneumoniae?
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Rising serologic titers
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Specific diagnostic test for Legionella?
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Urine antigen, culture on charcoal-yeast extract
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Specific diagnostic test for Chlamydia psittaci?
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Rising serologic titers
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Specific diagnostic test for Coxiella burnetii?
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Rising serologic titers
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Specific diagnostic test for Pneumocystis jirovecci (PCP)?
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Bronchoalveolar lavage (BAL)
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What drives the initial therapy of pneumonia?
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Severity of the disease
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Common criteria for hospital admission for pneumonia?
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CURB65; Confusion, Uremia, Respiratory distress, BP low, Age >65; 0-1 point - home, 2 or more - admit
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Severe pneumonia is defined as
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Hypotension (SBP <90), respiratory distress (pO2 <60, pH <7.35, RR >30), elevated BUN >30, Na <130, glucose >250, pulse >125, confusion, temperature >40 (104F), age 65 or other comorbidities such as cancer, COPD, CHF, renal failure, or liver disease
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Empyema is best treated with
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Drainage by chest tube or thoracostomy; a large effusion acts like an abscess and is hard to sterilize
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Which findings suggest empyema?
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Pleural effusion with pH <7.2
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Who should be vaccinated with the pneumococcal vaccine?
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Everyone above 65, and those with chronic heart, liver, kidney or lung disease should be vaccinated regardless of age
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Other reasons to be vaccinated with the pneumococcal vaccine?
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Asplenia, hematologic malignancy, immunosuppression, or CSF leak and cochlear implant recipients
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Outpatient treatment of CAP?
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Previously healthy or no antibiotics in the past 3 months and mild symptoms: macrolide or doxycycline; comorbidities or antibiotics in the past 3 months: respiratory fluoroqionolone or ceftriaxone and azithromycin
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Respiratory fluoroquinolones
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Levofloxacin and moxifloxacin
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What percentage of patients with pneumonia can be safely treated on an outpatient basis?
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80%
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Definition of hospital-acquired pneumonia (HAP)
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Pneumonia occurring more than 48 hours after admission or after hospitalization in the last 90 days; these patients are usually infected by Gram-negative bacilli such as E.coli and Pseudomonas
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Main difference between HAP and CAP in terms of treatment?
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Macrolides (azithromycin and clarithromycin) are not acceptable as empiric therapy in HAP
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Treatment of HAP is centered around
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Antipseudomonal cephalosporins such as cefepime and ceftazidime or antipseudomonal penicillins (piperacillin/tazobactam) or carbapenems (imipenem, meropenem, or doripenem)
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Why is ventilator use associated with pneumonia?
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Positive pressure is tremendously damaging to the normal ability to clear colonization and it interferes with normal mucociliay clearance of the respiratory tract; VAP has an incidence of 5% per day in the first few days on a ventilator
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When is ventilator-associated pneumonia a likely diagnosis?
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Look for fever and/or rising WBC count, new infiltrate on CXR, and purulent secretions coming from the endotracheal tube
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The diagnosis of a specific etiology in VAP is extremely difficult. Which tests are given in order from the least accurate but easiest to do, to do the most accurate but most dangerous?
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Tracheal aspirate, bronchoalveolar lavage, protected brush specimen, video-assisted thoracoscopy (VAT), and open lung biopsy
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How is tracheal aspirate done?
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A suction catheter is placed into the ET and aspirates the contents below the trachea when the catheter is past the end of the ET tube
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How is bronchoalveolar lavage (BAL) performed?
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A bronchoscope is placed deeper into the lungs where there are not supposed to be any organisms; can be contaminated on its way through the nasopharynx
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How is a protected brush specimen taken?
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The tip of the bronchoscope is covered when passed through the nasopharynx, then uncovered only inside the lungs
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How is video-assisted thoracoscopy (VAT) performed?
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A scope is placed through the chest wall, and a sample of the lung is biopsied; this allows a large piece of lung to be taken without the need for cutting the chest open (thoracostomy)
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Treatment of VAP
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Combination of three drugs: antipseudomonal beta-lactam, a second antipseudomonal agent (aminoglycoside or fluoroqionolone), plus a methicillin-resistant antistaphylococcal agent (vancomycin or linezolid)
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Antipseudomnal beta-lactams used in VAP
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Cephalosporin (ceftazidime or cefepime), penicillin (piperacillin/tazobactam), and carbapenem (imipenem, meropenem, or doripenem)
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Aminoglycosides used in VAP
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Gentamicin or tobramycin or amikacin
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Fluoroquinolones used in VAP
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Ciprofloxacin or levofloxacin
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In which patients does lung abscesses occur?
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Patients with large-volume aspirations or oral/pharyngeal contents, usually with poor dentition, who is not adequately treated
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Risk factors for large-volume aspirations
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Stroke with loss of gag reflex, seizures, intoxication, and ET
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When lying flat, in which lung lobe does the aspirate usually end up in?
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Upper
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When is lung abscess the most likely diagnosis?
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Look for a patient with risk factors for aspirations,presenting a chronic infection developing over several weeks with large-volume sputum that is foul smelling from the anaerobes; weight loss is also common
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Best initial test for lung abscess?
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CXR; will show a cavity, possibly with an air-fluid level: CT is more accurate but still cannot tell the etiology
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Best treatment to cover lung abscess
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Clindamycin or penicillin
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Most accurate test for establishing the etiology of a lung abscess
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Ling biopsy
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When is pneumocystis pneumonia the most likely diagnosis?
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AIDS patient presenting with dyspnea on exertion, dry cough, and a fever; the question will often suggest or directly say that the CD4 count is below 200 and that the patient is not on prophylaxis
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Best initial test for pneumocystis pneumonia
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CXR showing bilateral infiltrates or an ABG with hypoxia or an increased A-a gradient; LDH levels are always elevated and you cannot answer PCP as the most likely diagnosis if LDH levels are normal
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Most accurate test for pneumocystis pneumonia?
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BAL; sputum stain is quite specific if it is positive and there is no need for further testing if positive
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Best initial therapy for PCP?
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TMP-SMX; add steroids to decrease mrotality if the disease is severe (pO2 <70, or an A-a gradient >35)
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If the PCP is mild, what's an alternative drug?
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Atovaquone
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If there is toxicity from the main treatment for PCP, what should you switch to?
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Clindamycin and priomaquine or pentamidine
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If the patient develops side effects from TMP-SMZ prophylaxis for PCP, what should you do?
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Switch to atovoquoone or dapsone (contraindicated in those with G6PD defificency); choose therapy based first on efficacy not side effects
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Most accurate test for TB
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Pleural biopsy
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Presentation of TB
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Established risk factor, fever, cough, sputum, weight loss, hemoptysis, and night sweats
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Risk factors for TB
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Health care worker, teroid use, DM, alcoholics, hematologic malignancies, HIV positive, recent immigrants, prisoners, close contacts of someone with TB
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Best initial test for TB
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CXR; sputum stain and culture specifically for acid-fast bacilli (mycobacteria) must be done 3 times to fully exclude TB
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Treatment of TB
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When the smear is positive: Rifampin, Isoniazid, Pyrazinamide, and Ethambutol; Ethambutol is given as part of a 4-drug empiric treatment prior to knowing sensitivity; after RIPE for the first 2 months, stop PE and continue with rifampin and isoniazid for 4 months
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In which cases should TB treatment be extended to 9 months?
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Osteomyelitis, miliary tuberculosis, meningitis, and pregnancy or any other time pyrazinamide is not used
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All of the TB medications cause hepatotoxicity. When should you stop therapy?
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If transaminases rise to 3 to 5 times the upper limit of normal
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Main toxicity and management of rifampin?
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Red colour to body secretions; no management necessary
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Main toxicity and management of isoniazid?
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Peripheral neuropathy; use pyridoxine to prevent
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Main toxicity and management of pyrazinamide?
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Hyperuricemia; no treatment unless symptomatic
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Main toxicity and management of ethambutol?
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Optic neuritis/colour vision; decrease dose in renal failure
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Use of steroids in TB management?
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DEcrease the risk of constrictive pericarditis in those with pericardial involvement; they also decrease neurologic complication in TB meningitis
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In which groups of patients is an induration of PPD test larger than 5, but smaller than 10mm considered a positive test?
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HIV-positive patients, steroid users, close contacts with those with active TB, abnormal calcifications on CXR, and organ transplant recipients
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In which groups of patients is an induration of PPD test larger than 10mm considered a positive test?
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Recent immigrants (5 years), prisoners, healthcare workers, close contacts of someone with TB, hematologic malignancy, alcoholics, DM
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In which groups of patients is an induration of PPD test larger than 15mm considered a positive test?
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Those with no risk factors
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Who should have a CXR after a positive PPD test?
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Everyone, even if they have been vaccinated with BCG
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Explain two-stage PPD testing
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If the patient has never had a PPD skin test before, a second one is indicated within 1 to 2 weeks if the first is negative; if the second is negative, the patient is truly negative. If the first is positive, there is no need for a second test.
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What is an alternative testing method for TB?
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Interferon gamma release assay (IGRA) is a blood test equal in significance to PPD to exclude TB exposure; there is no cross-reaction with BCG
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What is the standard treatment for a positive PPD or IGRA?
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Exclude TB with a CXR, then the patient should receive isoniazid for 9 months. A positive PPD test confers a 10% lifetime risk of tuberculosis; isoniazid reduces this by 90% and the lifetime risk goes down to 1%. The PPD test should not be repeated once it is positive.
Those at high risk should have a PPD done every year (e.g., healthcare workers) |
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What is the best initial step in all lung lesions?
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Compare the size with old x-rays
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What is the right thing to do if a solitary lung lesion has many malignant features?
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Resect the lesion; sputum cytology, needle biopsy, and PET scan should not be done because a negative test is likely a false negative
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What is the most appropriate next step in management if the sputum cytology is positive?
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This is highly specific and resection of the lesion is the best next step; a negative cytology does not exclude malignancy
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When is bronchoscopy or transthoracic needle biopsy the most appropriate next step?
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In patients with intermediate probability of malignancy (e.g., between age 30 and 40, lesion between 1 and 2 cm); bronchoscopy - central lesions, transthoracic biopsy for peripheral
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What is the most common adverse effect of transthoracic biopsy?
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Pneumothorax
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Coal exposure leads to what type of pneumoconiosis?
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Coal worker's pneumoconiosis
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Sandblasting, rock mining, and tunneling exposure lead to what type of pneumoconiosis?
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Silicosis
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Shipyard workers, pipe fitting, and insulator exposure lead to what type of pneumoconiosis?
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Asbestosis
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Cotton exposure leads to what type of pneumoconiosis?
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Byssinosis
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Electronic manufacture exposure leads to what type of pneumoconiosis?
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Beryllosis
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Moldy sugar cane exposure leads to what type of pneumoconiosis?
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Bagassosis
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How does pulmonary fibrosis present?
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Dyspnea that worsens on exertion, fine rales or "crackles" on examination, loud P2 heart sound, and clubbing of the fingers
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What is the best initial test for pulmonary fibrosis? Most accurate?
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CXR; high resolution CT is more accurate (honeycombing), but the most accurate is a lung biopsy; echo will often show pulmonary HTN and possibly RV hypertrophy
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What will the PFTs show in pulmonary fibrosis?
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Decrease of everything proportionately, which means the FEV1/FVC ratio will be normal; DLCO will decrease in proportion to the severity of the thickening of the alveolar septum
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Treatment of pulmonary fibrosis?
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Most are untreatable; if there is white cells or inflammatory infiltrate, prednisone should be used; berylliosis is the most likely to respond to steroids
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Most common etiologies of DVTs?
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Stasis, thrombophilia such as factor V Leiden mutation and antiphospholipid syndrome, and malignancy of any kind
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Presentation of thromboembolic disease?
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Sudden onset shortness of breath with clear lungs on examination and normal CXR; tachypnea, tachycardia, cough, and hemoptysis, pleuritic chest pain, fever, hypotension
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What are the best initial tests in suspected pulmonary embolism?
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CXR, EKG, and ABGs; angiography is the most accurate test, but can be fatal in 0.5% of cases
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Findings on CXR with pulmonary embolism?
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Usually normal; the most common abnormality is atelectasis; wedge-shaped infarction, pleuural-based lesion (Hampton hump), and oligemia of one lobe (Westermark sign) are much less common
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Findings on ECG with pulmonary embolism?
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Sinus tachycardia; the most common abnormality is nonspecific ST-T wave changes; only 5% will show right axis deviation, RV hypertrophy or right bundle branch block; the most common WRONG answer is to choose S1, Q3, T3 as the most common abnormality that will be found on ECG
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What will ABGs look like with pulmonary embolism?
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Hypoxia and respiratory alkalosis (high pH and low pCO2) with a normal CXR
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Standard of care in terms of diagnostic testing to confirm the presence of a PE after the CXR, ECG, and ABG?
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Spiral CT scan, also called a CT angiogram; specificity is >95% and sensitivity for clinically significant clots varies from 95% to 98%
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When is D-dimer the answer?
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When the pretest probability of a PE is low and you need a simple, noninvasive test to exclude thromboembolic disease
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Features of V/Q scans
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High probability scans have no clot (FP) in 15%; low-probability scans have a clot (FN) in 15%; a completely normal scan essentially excludes a clot; V/Q scans are first only in pregnancy
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Features of D-dimer testing
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Very sensitive test (better than 97% NPV) but the specificity is poor since any cause of clot or increased bleeding can elevate D-dimers; a negative test excludes a clot, but a positive test means nothing
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What criteria must be fulfilled for a V/Q scan to have any degree of accuracy?
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CXR must be normal; do a spiral CT if the CXR is abnormal
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If the V/Q and spiral CT do not give a clear diagnosis, what is the next step?
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LE Doppler; if positive no further testing is needed. Only 70% originate in the legs, so it will miss the 30% originating in the pelvic veins
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Adverse effects of angiography?
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Allergy, renal toxicity, and death
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Best initial therapy of pulmonary embolism?
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Heparin; Warfarin should be started at the same time and continued for 6 months
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When is IVC filter the right answer?
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Contraindications to the use of anticoagulants, recurrent emboli while on heparin, RV dysfunction with enlarged RV on echo
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When are thrombolytics the right answer with pulmonary embolism?
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Hemodynamically unstable patients (e.g., hypotension [SBP <90] and tachycardia) and acute RV dysfunction
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When are direct-acing thrombin inhibitors (argatroban, lepirudin) the answer with pulmonary embolism?
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Heparin-induced thrombocytopenia (HIT)
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When is aspirin the right answer with pulmonary embolism?
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Never
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Alternative drug to heparin
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Fondaparinux
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Time limit for use of thrombolytics with pulmonary embolism?
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There isn't one
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Definition of pulmonary hypertension?
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Systolic BP >25 mm Hg, diastolic BP >8 mm Hg; any chronic lung disease leads to back pressure into the pulmonary artery, obstructing flow out of the right side of the heart
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Etiology of primary pulmonary hypertension
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It is, by definition, idiopathic
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Pathogenesis of pulmonary hypertension
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Hypoxemia causes vasoconstriction of the pulmonary circulation as a normal reflex to shunt blood away from areas of the lung it considers to have poor oxygenation. This is why hypoxia leads o pulmonary hypertension, and pulmonary hypertension results in more hypoxemia
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Presentation of pulmonary hypertension
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Dyspnea and fatigue, syncope, chest pain, wide splitting of S2 from pulmonary hypertension with a loud P2 or tricuspid and pulmonary valve insufficiency
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Best initial test for pulmonary hypertension?
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CXR; shows dilation of the proximal pulmonary arteries with narrowing or "pruning" of distal vessels
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What is the most accurate test for pulmonary hypertension?
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Right heart or Swan-Ganz catheter is the most accurate and most precise method to measure pressures by vascular reactivity
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What will the ECG show in pulmonary hypertension?
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Right axis deviation, right atrial and ventricular hypertrophy
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Findings on echocardiography in ulmonary hypertension?
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RA and RV hypertrophy; Doppler estimates pulmonary artery (PA) pressure
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CBC in pulmonary hypertension is likely to show?
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Polycythemia fro mchronic hypoxia
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Treatment of pulmonary hypertension?
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Treat underlying cause first; idiopathic disease is treated with prostacyclin analogues, endothelin antagonists (bosentan), and phosphodiesterase inhibitors (sildenafil); oxygen slows progression, particularly with COPD
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Most common cause of obstructive sleep apnea?
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Obesity
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Common presenting symptoms of sleep apnea?
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Daytime somnolence and a history of loud snoring; headache, impaired memory, depression, hypertension, ED, and "bull neck"
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Most accurate test for sleep apnea?
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Polysomnography which shows multiple episodes of apnea
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Treatment of sleep apnea
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Weight loss and alcohol avoidance, CPAP, surgical widening of the airway (uvulopalatopharyngoplasty) if this fails, avoid use of sedatives, and oral appliances to keep the tongue out of the way
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Sleep apnea + increased bicarbonate is what?
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Obesity/hypoventilation syndrome
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What is acute respiratory distress syndrome (ARDS)?
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Respiratory failure from overwhelming lung injury or systemic disease leading to severe hypoxia with a CXR suggestive of CHF but normal cardiac hemodynamic measurements; ARDS decreases surfactant and makes the lung cells "leaky" so that the alveoli fill up with fluid
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Etiology of ARDS
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Idiopathic; a large number of illnesses and injuries are assocaited with alveolar epithelial cell and capillary endothelial cell damage
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Give some examples of illnesses and injuries associated with the development of ARDS
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Sepsis or aspiration, lung contusion/trauma, near-drowning, burns and pancreatitis
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Typical CXR in ARDS?
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Bilateral infiltrates that quickly become confluent ("white out"); air bronchograms are common
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Definition of ARDS
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pO2/FIO2 ratio below 300; <200 - moderately severe, <100 - severe; e.g., ABG measures 70 while on 50% oxygen - 70/0.5=140 = moderately severe ARDS
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Treatment of ARDS
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Low tidal-volume mechanical ventilation is the best support; use 6mL / kg tidal volume; steroids are not clearly beneficial
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When is positive end-expiratory pressure used in ARDS?
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When the patient is undergoing mechanical ventilation to try to decrease the FIO2; levels of FIO2 above 50% are toxic to the lungs; maintain the plateau pressure of less than 30cm of water (measured on the ventilator)
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