Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
196 Cards in this Set
- Front
- Back
|
What is the result of a conservative fluid goal in sepsis treatment?
|
More ICU and ventilator-free days
|
|
|
What is involved in the maintenance phase of sepsis treatment?
|
Don't kill the patient:
Prevent nosocomial infection Avoid new infection Minimize blood transfusions Get off the ventilator early (wake up & breath) |
|
|
What is the most common cause of acute infectious rhinitis?
|
Viruses!
|
|
|
What are causes of chronic infectious rhinitis?
|
Bacterial, fungal
|
|
|
What is idiopathic perennial non-allergic rhinitis?
|
Vasomotor rhinitis
|
|
|
What are the key players in allergic response?
|
TH2 cells & IgE
|
|
|
What mediates the early phase allergic response?
|
Histamine
Itchy, water eyes, hives |
|
|
What mediates the late phase allergic response?
|
Nasal congestion
|
|
|
What is priming?
|
Continuous exposure to allergens results in reaction to lower doses of allergen overtime
|
|
|
What is hyper-reactivity?
|
hypersensitive allergic response that reacts to nonspecific allergens
|
|
|
What is the appearance of allergic rhinitis?
|
Pale bluish hue of nasal mucosa w/edema of turbinates, lymphoid hyperplasia of posterior pharynx (cobblestoning)
|
|
|
What is the appearance of non-allergic rhinitis?
|
Boggy & erythematous
|
|
|
What is the most effective single therapy for allergic rhinitis?
|
Inhaled glucocorticoids
|
|
|
What is sinusitis?
|
Inflammation of 1 or more of the paranasal sinuses
|
|
|
What is the definition of chronic sinusitis?
|
Symptoms longer than 8 weeks
|
|
|
What differentiates a viral rhinosinusitis from an acute bacterial sinusitis?
|
Viral has low grade fever & run-down feeling
Bacterial has pain in sinuses & teeth, purulent nasal production, higher fever (101.5), re-sickening |
|
|
When do you suspect acute bacterial sinusitis?
|
Lasts longer than 10-14 days
Acute facial pain Erythema or swelling of face High fever |
|
|
What calls for an emergent evaluation of a possible acute bacterial sinusitis?
|
Abnormal vision
Altered mental status Periorbital edema |
|
|
What are the most common pathogens of acute bacterial sinusitis?
|
S. pneumoniae
M. catarrhalis H. influenzae |
|
|
What is a common empiral antibiotic for uncomplicated acute bacterial sinusitis?
|
Amoxicillin
|
|
|
What the pathogens that may be found in chronic sinusitis, in addition to the ones from acute sinusitis?
|
S. aurues
Enteric gram negatives (aeruginosa) Anaerobes (prevotella) Fungi |
|
|
What are symptoms of nasal polyps?
|
Hypo- or anosmia
Rhinorrhea Nasal congestion |
|
|
What do nasal polyps look like on exam?
|
Swollen, pearly white or blue gray
Do not bleed Insensate Arise from middle meatus or along middle or superior turbinates Do not decrease in size w/application of topical decongestant |
|
|
What should you think if you see nasal polyps in a child?
|
CF
|
|
|
What is Samter's triad?
|
Nasal polyps
ASthma Aspirin sensitivity |
|
|
How are nasal polyps treated?
|
Surgery if really needed
Oral corticosteroids Inhaled steroids for maintenance |
|
|
What is angioedema?
|
Self-limited localized swelling of skin & mucosa due to extravasation of fluid into interstitial spaces due to increased vascular permeability
|
|
|
What mediates angioedema?
|
90% is mast cell mediated (allergy)
10% is kinin mediated (C1 inhibitor deficiency) |
|
|
When does hoarseness need ENT evaluation?
|
Greater than 2 weeks
|
|
|
What is included in the ddx of hoarseness?
|
Laryngitis
Vocal cord polyps Vocal cord nodules VCD Vocal cord paralysis Laryngeal cancer |
|
|
What kind of cancer is found in laryngeal cancer?
|
squamous cell carcinoma
|
|
|
What is involved in the work up of a possible asthmatic?
|
Spirometry always
CXR or ABGs if really bad Peak flow if older patients |
|
|
What is ipratropium?
|
Atrovent
Anticholinergic sometimes used in treatment of acute asthma |
|
|
When do you put a patient with an acute asthma exacerbation in the ICU?
|
albuterol needed more than q1h
signs of impending respiratory failure |
|
|
What are the side effects of inhaled steroids?
|
Thrush
Dysphonia Temporary growth velocity decrease |
|
|
What are the rare, serious side effcts of inhaled steroids?
|
Bone demineralization
Adrenal suppression Cataracts |
|
|
How do you use long-acting beta agonists in asthma treatment?
|
NEVER alone
In combination with inhaled corticosteroids |
|
|
What is the problem with epinephrine in the treatment of asthma?
|
Activates all beta 1 AND beta 2 receptors
This causes tachycardia |
|
|
What is the problem with isoproterenol in the treatment of asthma?
|
Activates all beta 1 AND beta 2 receptors but beta 2 more than beta 1
Still not selective enough |
|
|
What are the very selective beta-2 agonists for inhalation?
|
albuterol
terbutaline formoterol bitolterol pirbuterol levalbuterol |
|
|
What are the long-acting beta-2 agonists?
|
formoterol
arformoterol salmeterol |
|
|
What is metaproterenol?
|
Less selective beta 2 agonist for inhalation
|
|
|
What is isoetharine?
|
less selective beta-2 agonist
|
|
|
What are the S/E of beta-2 agonists?
|
Tremor
Tachycardia Palpitations |
|
|
What are the anticholinergics used in asthma treatment?
|
ipratropium
tiotropium |
|
|
What is a contraindication for anticholinergic use?
|
narrow angle glaucoma
|
|
|
What is thiophylline?
|
Phosphodiesterase inhibitor
Long duration of action Inhibits breakdown of cAMP in muscle cells |
|
|
What is thiophylline related to?
|
Caffeine-->methylxanthine
|
|
|
What are the side effects of thiophylline?
|
CNS stimulation
Cardiac stimulation GI upset Diuretic Low therapeutic index Metabolized by cytP450 |
|
|
What are the mast cell inhibitors?
|
cromolyn sodium
nedocromil |
|
|
What are the side effects of the mast cell inhibitors?
|
throat irritation, cough, bad taste
|
|
|
What is ciclesonide?
|
Glucocorticoid prodrug converted to active form in the lung
|
|
|
What are the effects of glucocorticoids that help prevent asthma?
|
Decrease leukotriene synthesis
Apoptosis of immune cells Increased numbers of beta receptors Decreased edema & mucus production |
|
|
What are the side effects of omalizumab?
|
Possible anaphylaxis b/c 10% rabbit anitbody
|
|
|
What is zileuton?
|
Inhibitor of 5-lipoxygenase
|
|
|
What are the side effects of zileuton?
|
Liver inflammation (inhib. of P450)
|
|
|
What are the leukotriene receptor blockers?
|
Montelukast sodium
Zafirlukast |
|
|
What are the side effects of montelukast?
|
CNS stimulation
|
|
|
What is the gold standard for diagnosis of EIB?
|
Eucapnic Voluntary Hyperventilation
|
|
|
What methods of diagnosis for EIB?
|
Methacholine challenge
Exercise spirometry EVH |
|
|
How is VCD diagnosed?
|
videolaryngostroboscopy (VLS)
|
|
|
How do you treat VCD?
|
relaxation
|
|
|
How is EIB prevented?
|
2 puffs albuterol 15 minutes before exercise
Leukotriene 2 hours before exercsie Warmup period |
|
|
What are the lab features of an exudate?
|
LDH>0.6
Protein>0.5 |
|
|
What is indicated by increased glucose in an exudate?
|
Malignancy
Bacterial infection Rheumatoid pleuritis |
|
|
What is indicated by a transudative effusion?
|
CHF, nephrosis, cirrhosis
|
|
|
What is indicated by increased lipids in a pleural effusion?
|
chylothorax
|
|
|
What is indicated by increased lymphocytes in a pleural effusion?
|
Inflammatory process
|
|
|
What is Meigs syndrome?
|
Ascites
Ovarian fibroma R sided hydrothorax (transudate) |
|
|
What is the chemistry of a malignant effusion?
|
Bloody
Lymphocytes +/- decreased glucose & pH |
|
|
What is a primary pneumothorax?
|
Rupture of subpleural bleb
|
|
|
What is a secondary pneumothorax?
|
Secondary to underlying lung disease
|
|
|
Define (clinically) chronic bronchitis.
|
chronic productive cough for at least 3 months for at least 2 years
|
|
|
Define (clinically) emphysema.
|
progressive DOE
|
|
|
What is seen pathologically in chronic bronchitis?
|
Smooth muscle hypertrophy, enlarged mucus glands, bronchiolar inflammation, squamous metaplasia
|
|
|
What is seen pathologically in emphysema?
|
alveolar wall destruction & airspace enlargement
|
|
|
What is the clinical presentation of COPD?
|
20 pack year hx of smoking
50s+ DOE Productive cough |
|
|
What is found on PE of a person with COPD?
|
Mild-can be normal or have wheezing or prolonged expiratory phase
Moderate/Severe-barrel chested, hyperinflation, increased RR, pursed lips, elevated neck veins, peripheral edema, hyperresonance, accessory muscle use |
|
|
What is the best way to assess severity of COPD?
|
% of normal FEV1
|
|
|
What is the gold standard in diagnosis of COPD?
|
spirometry
|
|
|
What are the indications for supplemental oxygen in COPD?
|
PO2<55mmHg or
PO2<59mmHg & evidence of PH |
|
|
What are the guidelines for lung transplant for COPD patients?
|
FEV1<25% predicted
Resting PaO2<60mmHg Hypercapnia Secondary PH Rapid deterioration |
|
|
What are the results of lung resection surgery for patients w/COPD?
|
Increased elastic recoil
Decreased hyperinflation Improved V/Q matching |
|
|
What is an alternative to lung resection to treat COPD surgically?
|
One way valve inserted into bronchiole to create a resection w/osurgery
|
|
|
What is the BODE index?
|
Index indicating the prognosis for COPD patients.
B=body mass index O=obstruction D=dyspnea E=exercise |
|
|
What are the systemic manifestations of pneumonia?
|
Fever
Chills Myalgias Malaise |
|
|
What are common pathogens in community-acquired pneumonia?
|
S. pneumoniae
H. influenzae Chlamydia pneumoniae Legionella pneumophila M. pneumoniae |
|
|
What are common pathogens in hospital-acquired pneumonia?
|
Enteric gram-negatives
Pseudomonas S. aureus |
|
|
What are signs of pulmonary consolidation?
|
Egophony
Dullness Increased fremitus Bronchial breath sounds Wet crackles |
|
|
A Giemsa stain is particularly good for what pathogen causing lung infection?
|
Pneumocystis
|
|
|
Acid-fast stains what bacteria?
|
Mycobacteria
Nocardia (need modified acid-fast stain) |
|
|
Evidence of Legionella pneumoniae infection can be found where?
|
Urine antigen
|
|
|
Antibody titers can be found for what diseases?
|
CMV, Mycoplasma pneumoniae, Chlamydia
|
|
|
What is used in the outpatient setting to treat community-acquired pneumonia?
|
Macrolides
Fluoroquinolines (-floxacins) |
|
|
What is used in the inpatient setting to treat hospital-acquired pneumonia?
|
anti-pseudomonal cephalosporin, carbapenem or penicllin + aminoglycoside or fluoroquionlone + vanco or linezolid
|
|
|
What is used in the ICU setting for community-acquired pneumonia?
|
beta-lactamase resistant penicllin + macrolide
|
|
|
What is used in the general inpatient setting for community-acquired pneumonia?
|
Fluoroquinolone OR beta-lactamase resistant penicillin + macrolide
|
|
|
What can cause bronchiectasis?
|
Ciliary dyskinesia
Immunoglobulin deficiency CF Mycobacterial infection Recurrent bacterial infections |
|
|
Describe primary TB.
|
Mid-lower lung fields
Hilar lymphadenopathy Often heals into calcified lesion spontaneously Affects children |
|
|
Describe post-primary TB.
|
Occurs in adults.
Affects apical & posterior upper lobes most frequently. Varies from small infiltrates to extensive cavitary disease |
|
|
What is the diagnostic course of TB?
|
Chest radiography
AFB microscopy Mycobacterial culture PPD skin test Drug susceptibility testing |
|
|
What is the treatment regiment for TB?
|
1st 2 months: rifampin, isoniazid, pyrazinamide, ethambutol
2nd 4 months: isoniazid & rifampin |
|
|
What is the treatment for chronic necrotizing aspergillosis?
|
Antifungals
|
|
|
What is the treatment for aspergilloma?
|
Surgery
|
|
|
What is the treatment for angioinvasive aspergillus?
|
Antifungals
|
|
|
What is the treatment for ABPA?
|
Steroids
|
|
|
What is the disease associated with Histoplasma capsulatum?
|
Frequent cuase of pulmonary nodules
Mild pneumonitis & lymphadenopathy |
|
|
What is the presentation of coccidiomycosis?
|
Desert SW
Mild-flu-like illness or asymptomatic |
|
|
What are possible complications of influenza infectin?
|
Viral pneumonia
Secondary bacterial pneumonia (s. aureus, s. pneumoniae, h. influenzae) COPD/asthma exacerbtion Respiratory failure |
|
|
What antivirals work for influenza A?
|
Rimantidine
Amantidine |
|
|
What antivirals fork for influenza B?
|
Oseltamivir
Zanamivir |
|
|
What antivirals work for H1N1?
|
Oseltamivir
Zanamivir |
|
|
What viruses commonly cause laryngotracheitis in children?
|
Parainfluenza 1,2,3
|
|
|
What is respiratory virus found in children in the summer?
|
Parainfluenza 3
Adenovirus (any time of year) |
|
|
What viruses cause bronchiolitis in children?
|
RSV
Metapneumovirus Both winter/spring |
|
|
What virus causes bronchitis in children?
|
Influenza A, B
Winter, spring |
|
|
What illnesses can adenoviruses cause in children?
|
Any respiratory illness
|
|
|
What bacteria cause mostly pneumonias in children?
|
S. pyogenes
S. aureus S. pneumoniae |
|
|
What bacteria can cause bronchitis or pneumonia in children?
|
M. pneumoniae
|
|
|
What bacteria causes solely bronchitis?
|
Bordetella pertussis
|
|
|
Rapid antigen assays are available for which viruses?
|
RSV, influenza
|
|
|
When does a diaphragmatic hernia develop?
|
6 weeks of fetal age
|
|
|
What else is a concern in an infant with diaphragmatic hernia?
|
Congenital heart disease or other congenital defect
|
|
|
What is a tracheoesophageal fistula?
|
Separation of trachea & esophagus during development
Esophagus becomes blind pouch |
|
|
When does a tracheoesophageal fistula develop?
|
4-6 weeks post conception
|
|
|
What are possible complications of a tracheoesophageal fistual after surgical correctino?
|
gastroesophageal reflux
Persistent fistulas Recurrent esophageal strictures |
|
|
What are possible methods of accidental injury to the pediatric respiratory tract?
|
Foreign body aspiration
Food/gastric content aspiration Drowning/near drowning |
|
|
What is the most common cause of hospitalization of school age kids?
|
Asthma
|
|
|
What pediatric illnesses are likely to present with stridor (inspiratory)?
|
Chronic aspiration syndrome
Tumor/growth in airway Croup (laryngotracheobronchitis) Could be foreign body aspiration |
|
|
What pediatric illnesses are likely to present with wheezing (expiratory)?
|
Asthma
EIB Could be foreign body aspiration |
|
|
List 3 respiratory infections that can be prevented by vaccination.
|
Pertussis
Pneumococcus Hemophilus influenzae |
|
|
A child has recurrent pneumonia, a chronic cough, recurrent stridor and Mom says he was always a "noisy breather". What is he likely to have? How would you diagnose him?
|
Chronic aspiration syndrome
Could treat or do video-swallow study |
|
|
List the causes of hemoptysis in children.
|
Respiratory infection (TB, histo)
Foreign body aspiration Bronchiectasis |
|
|
How do you treat hemoptysis in children?
|
Ice saline, topical epinephrine, fibrin/thrombin mix, selective occlusion
Might us embolization |
|
|
List the common causes of chronic cough in childhood.
|
Asthma
Post-nasal drip Gastroesophageal reflux (habit cough) |
|
|
List the common causes of SOB during exercise in children.
|
EIB
VCD Deconditioning |
|
|
What is bronchiectasis?
|
Permanently scarred, misshapen medium-sized airways due to pooling of secretions & inflammation
|
|
|
What are some causes of bronchiectasis?
|
Infection
Impaired host defense Toxins Hyperactive immune response (ABPA) Alpha-1-antitrypsin def. Yellow nail syndrome |
|
|
Yellow nail syndrome is mentioned in what context?
|
Causes bronchiectasis.
Hypoplastic lymphatics, lymphedema, pleural effusions, yellow nails |
|
|
What are signs & symptoms of bronchiectasis?
|
Chronic/recurrent productive cough w/purulent sputum
Hemoptysis Crackles, rhonchi, wheeze on breathing |
|
|
What are major complications of bronchiectasis?
|
Cor pulmonale (right heart failure)
Hemoptysis |
|
|
Bronchiectasis located primarily in the upper lobe might be what?
|
TB
ABPA |
|
|
What is the mutation associated with CF?
|
Mutation in cystic fibrosis transmembrane regulator (CFTR) on chromosome 7
|
|
|
What are common secondary lung infections in CF patients
|
Pseudomonas
S. aureus |
|
|
What is needed for a diagnosis of CF?
|
Typical symptoms and/or positive family Hx of CF
AND Positive sweat Cl test OR 2 identifiable CFTR abnormalities |
|
|
What is checked on the newborn screen that is important for this exam?
|
IRT (immunoreactive trypsinogen)
High IRT-->check for CFTR alleles Sweat Cl test-->early diagnosis of CF |
|
|
How often does the typical CF patient have routine hospital visits?
|
Every 2-3 months
|
|
|
What is the regimen for CF patients?
|
Twice daily chest therapy
High calorie diet Water-soluble vitamins Enzyme replacement Inhaled albuteral, mucolytic, tobramycin, hypertonic saline |
|
|
How is an exacerbation of CF treated on an outpatient basis?
|
10-21 days of antibiotics based on sputum culture
|
|
|
How is an exacerbation of CF treated on an inpatient basis?
|
Clean out
Severe problems or failure to response to exacerbation care IV abx Thrice daily chest therapy PIC line |
|
|
What is end stage care for CF?
|
Lung transplant (new lung will not have CF)
Palliative |
|
|
What are common complications of CF?
|
Hemoptysis
Pneumothorax Distal intestinal obstruction syndrome Diabetes ABPA Osteoporosis Depression Death due to respiratory insufficiency |
|
|
Where does DIOS occur?
|
Distal ileum & colon in CF patients
|
|
|
How is DIOS treated?
|
Miralax, go-lytely, gastrografin enemas, surgery
|
|
|
What are the two types of hemoptysis seen in CF patients?
|
"little h": streaks of blood in sputum, non-emergent-->treat exacerbation
"big H": >1 cupblood/day of bleeding due to overgrown bronchial arteries. Treat with embolization |
|
|
What is a particularly sudden onset complication in older CF patients?
|
Big H hemoptysis
|
|
|
What are the three most common causes of chronic cough in adults?
|
Upper airway cough syndrome (UACS)
Asthma GERD |
|
|
What is in the DDx for a subacute cough?
|
#1=postviral airway inflammation
UACS Asthma GERD |
|
|
How is postviral airway inflammation-caused subacute cough treated?
|
Inhalaed ipratropium
Inhaled corticosteroids |
|
|
Post-cough vomiting in a young person is particularly related to what?
|
PERTUSSIS
|
|
|
How is pertussis infection treated?
|
Macrolide abx
|
|
|
What is included in empiric therapy for a cough though to be due to UACS?
|
Antihistamines (oral!!!)
Nasal steroids Oral leukotriene inhibitors Nasal ipratropium |
|
|
When do you use a methacholine challenge in the workup of a chronic cough?
|
If bronchodilator challenge isn't sufficient for diagnosis.
Methacholine unreactive-->no asthma Methacholine reactive-->could be asthma, try treating for asthma |
|
|
What is NAEB?
|
Non-asthmatic eosinophilic bronchitis
|
|
|
What is seen in NAEB?
|
Normal CXR & spirometry
No airway hyperresponsivemess MARKED airway eosinophilia |
|
|
How is NAEB treated?
|
Inhaled corticosteroids
|
|
|
How can GERD cause cough?
|
Aspiration into airways
Reflux laryngitis Esophageal-bronchial cough reflex |
|
|
What is a mainstay of treatment for GERD?
|
PPIs
|
|
|
What are the most common causes of chronic dyspnea?
|
COPD
Asthma Heart failure Interstitial lung disease |
|
|
What are the most common causes of acute dyspnea?
|
Acute ischemia
Heart failure Bronchospasm Pulmonary embolism |
|
|
When is BNP measured?
|
Evaluation of acute dyspnea.
High BNP can indicate heart failure |
|
|
What is involved in the work up of acute dyspnea?
|
CXR
CBC Pulse oximetry and/or ABG EKG BNP |
|
|
What is involved in the workup of chronic dyspnea?
|
CBC
Metabolic profile Spirometry CXR EKG Oximetry |
|
|
What are obstructive lung diseases?
|
Asthma
Chronic bronchitis Emphysema Bronchiectasis Bronchiolitis obliterans |
|
|
What lung diseases are indicated by restricted PFTs?
|
Interstitial lung disease
Alveolar filling processes Chest wall impairment Respiratory muscle weakness |
|
|
What questions can be answered by a pulmonary exercise study?
|
1. Is px impaired?
2. Is impairment cardiac? 3. Is impairment pulmonary? 4. Did px desaturate? |
|
|
How is tracheostenosis diagnosed?
|
Bronchoscopy
|
|
|
How is larygnospasm diagnosed?
|
pH probe
|
|
|
What are the parts of dyspnea treatment?
|
1. Reduce metabolic load: exercise
2. Alter afferent information-->make patient less aware of dyspnea 3. Improve CO2 elimination 4. Reduce ventilatory impedance (reduce hyperinflation & airway resistance) 5. Improve inspiratory muscle strength 6. Alter central perception (anxiolytics, etc.) |
|
|
How would you improve CO2 elimination?
|
Reduce carbohydrate intake
Increase fat intake |
|
|
What can't I forget about in the evaluation of chronic dyspnea?
|
Cardiopulmonary exercise test!
|
|
|
Dry crackles indicate what?
|
Pulmonary fibrosis
|
|
|
Wet crackles indicate what?
|
Consolidation or edema
|
|
|
Rhonchi are what and what do they indicate?
|
"coarse wheeze"
pneumonia or bronchitis |
|
|
What does stridor indicate?
|
Upper airway obstruction
|
|
|
What does wheeze indicate?
|
Lower airway obstruction
|
|
|
What can egophony indicate?
|
Consolidation
|
|
|
IRV+TV+ERV=?
|
VC
|
|
|
TLC-RV=?
|
VC
|
|
|
What is a non-pulmonary cause of decreased DLCO?
|
anemia
|
|
|
What are causes of increased DLCO?
|
Asthma
Polycythemia Mild CHF Alveolar hemorrhage |
|
|
What causes increased DPG?
|
Chronic lung disease
Living at high altitude |
|
|
What causes a right shift of the oxyhemoglobin dissociation curve?
|
Acidosis
Fever High pCO2 Increased DPG |
|
|
What causes a left shift of the oxyhemoglobin dissociation curve?
|
Alkalosis
Hypothermia Low pCO2 Decreased DPG Carbon monoxide |
|
|
What is signified by a right shift in the oxyhemoglobin dissociation curve?
|
Reduced oxygen affinity for HgB
More O2 unloading in the capillaires for a given pO2 |
|
|
What is signified by a left shift in the oxyhemoglobin dissociation curve?
|
Oxygen affinity for HgB increased
Less O2 unloading in capillaries for a given pO2 |
