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117 Cards in this Set

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pulmonary function tests
spirometry (mechanical ventilation)
Dlco (gas exchange)
methacholine challenge test (bronchial hyperreactivity)
TLC
restrictive pattern
FEV1/FVC > 80%
obstructive pattern
FEV1/FVC < 80%
seen in emphysema, chronic bronchitis, asthma, bronchiectasis
↓DLco
if FEV1/FVC < 80% suggests emphysema
if FEV1/FVC > 80% suggests interstitial lung disease or mild left heart failure
↑DLco
suggests hemorrhage such as in Goodpasture
methacholine test
bronchoprovocation in patients with cough or wheezing who have normal pulmonary function tests, for possible asthma
do basal and postprovocation spirometry
postitive test if baseline FEV1 decreased >20%
A-a gradient formula
150 - (1.25 x PaCO2) - PaO2 normal: 5-15mmHg; increases with age and all forms of hypoxemia except hypoventilation and high altitude
solitary pulmonary nodule
1/3 are malignant
first step in management is looking for previous image study
if none available then consider if patient is high or low risk for cancer
low risk nonsmoker <35 --> x-ray every 3 months for 2 years, if no growth stop follow-up
high risk smoker >50 --> open-lung biopsy and removal due to cancer risk
transudative pleural effusion
↓hydrostatic pressure or ↓oncotic pressure; usually bilateral and equal
low LDH and proteins in fluid and serum (200, 0.6, 0.5)
need all three values for diagnosis, else exudate
exudative pleural effusion
due to local process; usually unilateral; need further investigation; high LDH and proteins in fluid and serum (200, 0.6, 0.5); don't need all three values high to make diagnosis
transudative causes of pleural effusion
heart failure
nephrotic syndrome
liver disease
pulmonary embolism
atelectasis
exudative causes of pleural effusion
pneumonia
cancer (lung, breast or lymphoma)
pulmonary embolism
drug-induced
pancreatitis
TB
RA
SLE
transudative pleural effusion with no apparent cause
consider pulmonary embolism which can be either transudative or exudative
indications of thoracocentesis
any new and unexplained pleural effusion --> rule out empyema
decubitus x-ray --> <1cm free-flowing fluid --> minimal risk
if non-free fluid need ultrasound guidance
malignant pleural effusions
due mostly to breast cancer, lung cancer and lymphoma
send thoracocentesis fluid for cytologic exam also
hemorrhagic pleural effusion
seen in mesothelioma, metastatic lung or breast cancer, pulmonary embolism with infarction and trauma
lymphocytic-predominant pleural effusions
suggests TB due to tuberculin hypersensitivity
check ↑adenosine deaminase and postivie PCR for TB
acid-fast and culture of fluid are only positive in 30%
respiratory compromise and distress
presents with shortness of breath, dyspnea, tachypnea (>30) and associated symptoms such as agitation, confusion or ↓consciousness
evaluation of respiratory distress
ensure patent airway
focus on quickness of onset and associated symptoms
most important lab test is arterial blood gases then B-natriuretic peptide and chest x-ray
acute respiratory distress with fever, cough or sputum
suggests infectious etiology
acute respiratory distress without systemic symptoms
suggests airway obstruction, cardiac disease or thromboembolism
chronic respiratory distress
suggests interstitial lung disease or COPD
common lung physical exam findings
diffuse wheezing --> asthma
localized wheezing --> foreign object
rales --> pneumonia, interstitial disease, heart failure
dull percusion --> pneumonia or atelectasis
normal exam --> pneumocystis jirovecci, central respiratory problems
B-natriuretic peptide in acute dyspnea
elevation is sensitive for heart failure but can also be elevated in cor pulmonale and acute right ventricular failure (thromboembolism)
chest x-ray without parenchymal infiltrates in acute dyspnea
suggests thromboembolism
central respiratory depression
neuromuscular disease
upper airway obstruction
chest x-ray hyperinflation in acute dyspnea
suggests asthma and COPD
chest x-ray with focal infiltrates in acute dyspnea
suggests bacterial, viral or fungal pneumonia, aspiration or pulmonary hemorrhage
chest x-ray with diffuse edema in acute dyspnea
suggests heart failure or ARDS
ICU indications in respiratory failure
persistent hypoxemia --> hospitalization

ICU indications -->
need for mechanical ventilation
close monitoring
increasing oxygen demand
continuous nursing
indications for intubation and/or mechanical ventilation
respiratory acidosis and hypercapnia in asthmatic patient
upper airway injury (burns, laryngeal edema, trauma)
neurologic airway depression (often with loss of gag and cough reflexes)
respiratory distress in hospitalized patients
inpatient who develops dyspnea, tachypnea and/or hypoxemia should raise possiblity of pulmonary embolism or aspiration
types of asthma
intrinsic (50%) is secondary to nonimmunologic stimuli (infections, irritating inhalants, cold air and emotional); extrinsic (20%) due to allergens
asthma stimuli
infections (RSV, rhinovirus), drugs (aspirin/NSAIDs, coloring agents, betablockers), allergens, cold air, emotions
asthma presentation
tachypnea, tachycardia, diffuse wheezing, use of accesory muscles, diminished breath sounds, hyperresonance, intercostal retractions
asthma poor prognosis factors
fatigue
diaphoresis
pulsus paradoxus
inaudible breath sounds
decreased wheezing
cyanosis
bradycardia
asthma diagnosis
initial tests for acute attacks --> ↓PaCO2, ↑pH, normal or ↓PaO2
severe attack -->↓PaO2, ↑PaCO2, ↓pH
chest x-ray to rule out infection as cause
spirometry --> obstructive pattern that reverses with beta agonist (FEV1 reverses by 12%)
methacholine test --> ↓FEV1/FVC of 20%
acute asthma management
O2
metered inhaled beta agonists --> albuterol/salbutamol, terbutaline
salmeterol is long-lasting for nocturnal variant
catecholamines may be used but not routinely
aminophylline and theophyline have modest potency and are not routine
anticholinergics (ipratropium) if heart disease (slow onset, medium potency)
chronic asthma management
acute exacerbations: systemic prednisone 10-14 days along with inhaled albuterol; inhaled corticosteroids are first line maintenance; cromolyn is first line maintenance in children and prophylaxis in adults; zileuton, zafirlukast, mmonteleukast for severe asthma resistant to maximum doses of inhaled steroids
mild asthma definition and treatment
symptoms ~2 days/week and rare night symptoms
FEV1 is normal
no long-term control needed only inhaled beta agonists for attacks
moderate asthma definition and treatment
symptoms on most days and at least 5 nights/month with FEV1 60-80%
treat with daily inhaled steroids (also cromolyn specially in children)
maybe also salmeterol
severe asthma definition and treatment
daily symptoms, frequent night symptoms and hospital emergencies with FEV1 <60%; daily inhaled steroids, daily inhaled salmeterol along with antileukotriene drug and possibly low-dose oral steroid
physical exam in emphysema
distant breath sounds
pink skin
thin
barrel chest
accesory muscles
symptoms of right heart failure and clubbing
physical exam in chronic bronchitis
rhonchi and wheezes
signs of cyanosis
weight gain
symptoms of right heart failure and clubbing
chest x-ray findings in COPD
chronic bronchitis --> increased pulmonary markings
emphysema --> bilateral hyperinflantion, diaphragm flattening, small heart size, increase in retrosternal space
COPD diagnosis and work-up
↓FEV1/FVC
FEF 25-75
↑RV and TLC
emphysema has ↓DLco and chronic bronchitis has normal DLco
FEV1/FVC after bronchodilation will stay the same

also order -->
EKG --> right axis deviation and hypertrophy
CXR
CBC --> increased hematocrit
electrolytes --> increased bicarbonate
ABG --> assess need of home O2 if CO2 retention
COPD complications
hypoxemia with nocturnal desaturation
secondary erythrocytosis
cor pulmonale
chronic ventilatory failure
CO2 retention
maintenance treatment for COPD
first-line --> ipratropium via metered inhaler;
inhaled albuterol inhaled
pneumococcal vaccine
yearly influenza vaccine
smoking cessation
if PO2 < 55 or SaO2 < 88% --> home O2

corticosteroids are not used in COPD
if above fails --> theophylline (watch for cytochrome inhibitors and inducers)
only treatment that reduces mortality in COPD
home O2 supplementation and smoking cessation
home oxygen for hypoxemia (PaO2<55mmHg or saturation <88%)
pneumococcal vaccine every 5 years, influenza vaccine yearly and haemophilus vaccine if unvaccinated
COPD exacerbation general management
1) measure O2 saturation (pulse oximetry)
2) arterial blood gases
3) chest x-ray
4) check theophylline levels
5) CBC and ECG
6) hospital admission if significant hypercapnia or hypoxemia
7) intubation and mechanical ventilation if pH drops (not CO2 retention)
8) specific treament
spirometry is NOT done or useful in exacerbation
COPD exacerbation specific treatment
1) O2 supplementation
2) inhaled albuterol and ipratropium concomitantly
3) IV (bolus) or oral methyl prednisolone for 2 weeks
4) antibiotics despite normal x-ray (ceftriaxone + azithromycin
5) council on smoking cessation
6) teach optimal use of MDI
no benefit in IV theophylline and avoid opiates and sedatives
bronchiectasis etiology
secondary to recurrent pneumonias, TB, fungal or abscess
cystic fibrosis, immotile cilia syndrome (50% Kartagener)
bronchiectasis presentation
suspect in anyone with
chronic cough
foul-smelling sputum
hemoptysis
recurrent pulmonary infections
sinusitis
immune deficiencies

presents with purulent copious sputum, wheezes, crackles and history of recurrent pneumonias (specially gram- and pseudomonas)
bronchiectasis diagnosis
early chest x-ray may be normal or severe cases show 1-2cm cysts and crowding of bronchi; chest CT is best noninvasive test
bronchiectasis treatment
bronchodilators, chest physical therapy, postural drainage, rotating gram- antibiotics
surgery in cases of localized bronchiectasis or massive hemoptysis
yearly influenza vaccine and pneumococcal vaccine with booster at 5 years
bronchiectasis complications
massive hemoptysis, amyloidosis, cor pulmonale, visceral abscesses
interstitial lung disease general presentation
exertional dyspnea
nonproductive cough
crackles
pulmonary hypertension
clubbing
restrictive pattern
interstitial lung diseases
idiopathic pulmonary fibrosis
sarcoidosis
pneumoconiosis --> asbestosis, silicosis, coal pneumoconiosis
idiopathic pulmonary fibrosis presentation
exercise intolerance, dyspnea, coarse crackles
idiopathic pulmonary fibrosis diagnosis
reticular or reticulonodular pattern on chest x-ray
high res CT
restrictive pattern on PFTs
increased macrophages on bronchoalveolar lavage (nonspecific)
lung biopsy
idiopathic pulmonary fibrosis treatment
steroids with or without azathioprine works in 20%; the rest develop fatal lung disease
idiopathic pulmonary fibrosis prognosis
20-40% 5-year survival; best prognostic factor is response to steroids as evidenced in PFTs
sarcoidosis presentation
"GRAIN"
gammaglubilinemia
rheumatoid arthritis
ACE increase
interstitial fibrosis
non-casseating granuloma
hilar and left paratracheal adenopathy
hypercalcemia due to vitamin activation by macrophages
uveitis/conjunctivitis in >25%
chest x-ray findings
restrictive or normal PFTs
chest x-ray findings in sarcoidosis
four stages found (not progressive)
bilateral hilar adenopathy
hilar adenopathy with reticulonodular parenchyma
reticulonodular parenchyma alone
honeycombing of bilateral lung fields with fibrosis
sarcoidosis diagnosis
biopsy of affected tissue showing noncasseating granulomas; all patients should have ophthalmologic exam
sarcoidosis prognosis
80% remain stable or spontaseoulsy resolves; 20% progress to organ compromise
sarcoidosis treatment
no treatment is effective
if organ compromise may use trial of high-dose steroids
if uveitis, CNS involvement or hypercalcemia --> steroids are mandatory
pneumoconiosis general presentation
dyspnea, shortness of breath, cough, sputum, cor pulmonale, clubbing, restrictive pattern, ↓DLco, hypoxemia with ↑A-a
ocupations associated with asbestosis
mining, milling, foundry work, shipyards, pipes, break linings, insulation, boilers; history of exposure necessary for Dx
asbestosis x-ray findings
diffuse or local pleural thickening, pleural plaques, calcifications near diaphragm, pleural effusions, lower lobe interstitial infiltrate
asbestosis associated cancers
lung adenocarcinoma or SCC
pleural mesothelioma is less common
asbestosis diagnosis
history of exposure + lung biopsy showing barbell-shaped asbestos fibers
asbestosis treatment
no effective treatment; must stop smoking due 75x increased risk of cancer
ocupations associated with silicosis
mining, quarrying, tunneling, glass and pottery making, sandblasting
silicosis x-ray findings
1-10mm nodules throughout the lungs, most prominent in upper lobes
in progressive massive fibrosis nodules are >10mm and coalesce
silicosis diagnosis
history of exposure + lung biopsy showing silica particles
pathologic lesion is the hyaline nodule
silicosis treatment
no effective treatment; should have yearly PPD test and if >10mm --> INH prophylaxis for 9 months
Lofgren syndrome
acute sarcoidosis presentation with erythema nodosum, arthritis, hilar adenopathy
Heefordt-Waldenstrom syndrome
acute sarcoidosis presentation with fever, parotid enlargement, uveitis and facial palsy
Caplan syndrome
rheumatoid nodules in periphery of lung, rheumatoid arthritis and coesxisting pneumoconiosis (usually CWP)
coal worker's pneumoconiosis x-ray findings
small round parenchymal densities
usually in upper half of lungs
progressive massive fibrosis has 1cm densities in whole lung
coal worker's pneumoconiosis immunologic findings
↑IgA, ↑IgG, ↑C3, ANA and rheumatoid factor
pulmonary embolus site of origin
most are from above-the-knee deep veins which result from distal deep vein thrombosis; in patients with catheters it can originate from upper limb, subclavian and internal jugular veins
criteria for high-risk pulmonary embolism patients
immobilized patients
oral contraceptives
pregnancy
recent surgery (specially orthopedic, knee replacement has 70% risk)
cancer history (prostate, breast, pelvic, abdominal)
acquired thrombophilia (lupus anticoagulant, nephrotic syndrome)
inherited thrombophilia (factor V Leiden, protein C/S deficiency, antithrombin III deficiency)

need 1 risk factor and consistent signs and symptoms for high-risk label
signs and symptoms consistent with pulmonary embolism
sudden onset of dyspnea, tachypnea, thigh/calf swelling, pleuritic chest pain, hemoptysis, tachycardia, ↑P2
when to consider pulmonary embolism
all patients with dyspnea and normal chest x-ray
nonspecific routine tests for dyspnea; may suggest PE
arterial blood gases show hypoxemia with ↑A-a
chest x-ray (normal in PE)
ECG (to exclude others) shows S1, Q3, T3, tachycardia
specific tests for pulmonary embolism
best initial test is spiral CT scan; V/Q scan (if normal excludes PE); angiogram is gold standard
deep venous thrombosis specific tests
best intial test is compression or duplex ultrasound; venogram is rarely done; MRI
tests for DVT and PE
D-dimer is most sensitive; can only exclude thromboembolism if normal levels
may also be high in surgery, infection, trauma, pregnancy and DIC
normal D-dimer and CT scan rule out thromboembolism in 98% of low-risk patients
tests results that exclude pulmonary embolism
normal CT + normal D-dimer in low-risk patients
normal CT + normal doppler in low-risk patients
V/Q scan is completely normal
generalities of pulmonary embolism diagnosis
all patients should be on heparin during diagnosis and imaging; if PE is suspected start CT scan right after chest x-ray; if all tests are negative but it's high-risk patient --> angiogram; normal CT + normal D-dimer or doppler excludes PE in low-risk patients
pulmonary embolism treatment
1) O2
2) start heparin before confirmation and during work-up
3) concomitant warfarin
4) if hemodynamically unstable or massive PE --> thrombolytics (tPa, streptokinase)
heparin considerations in pulmonary embolism
if LMWH then no need to follow PTT and less chance of heparin-induced thrombocytopenia
HIT is associated with more thrombotic events, not bleeding diathesis, and is treated with new anticoagulants (argatroban, lepirudin)
start heparin immediately
warfarin considerations in pulmonary embolism
monitor PT
titrate to INR of 2-3
skin necrosis can occur if protein C deficiency already present
contraindicated in pregnancy (use LMWH 6 months instead)
contraindications of anticoagulation therapy in PE
contraindicated in patients with recent neurosurgery or eye surgery; use inferior vena cava filter instead
post thrombotic syndrome
pain
edema
hyperpigmentation
skin ulceration in 2/3 of PE patients
compression stockings can prevent it
fat embolism
acute dyspnea, petechiae in neck or axilla, confusion, 3 days after long bone fracture or after CPR; no anticoagulation necessary
ARDS etiology
sepsis
trauma
DIC
Goodpasture
SLE
drug overdose
toxin inhalation
drowning
ARDS presentation
dyspnea, tachypnea, diffuse rales and ronchi
ARDS diagnosis
chest x-ray --> diffuse interstitial or alveolar infiltrates
ABGs --> ↓PaO2, ↑PaCO2
Swan-Ganz --> normal cardiac output and capillary wedge pressure but ↑pulmonary artery pressure
ARDS treatment
treat underlying cause; mechanical ventialtion with positive end-expiratory pressure
ARDS prognosis
70% mortality
sleep apnea
cessation of airflow >10s at least 10-15/hour of sleep + daytime somnolence
confirm with polysomnography
treat obstructive with weight loss and nasal continuous positive airway pressure (CPAP)
treat central with acetazolamide, progesterone and O2
lung cancer etiology
90% of cases are directly related to cigarette smoke; nonsmokers develop adenocarcinoma; all lung cancers are associated with smoking; active smokers have 10x greater risk; 40 pack-year history increases risk 60-70x; asbestos increases risk 75x
types of lung cancer
most common is adenocarcinoma (40%); squamous cell carcinoma, small cell and large cell
centrally located lung cancers
squamous cell and small cell
peripheral located lung cancers
adenocarcinoma and large cell
lung cancer paraneoplastic syndromes
SCC --> hypercalcemia (PTH-like peptide)
small cell --> SIADH and Eaton-Lambert
lung cancer metastasis
SCC --> direct extension to hilar node and mediastinum
small cell and adenocarcinoma --> liver, adrenals, brain, bones
lung cancer presentation
cough
weight loss
dyspnea
hemoptysis
chest pain
recurrent pneumonic processes
hoarseness
lung cancer diagnosis
sputum cytology (specially SCC)
bronchoscopy for centrally located lessions
needle aspiration biopsy if highly suspicious and nonspecific bronchoscopy findings or peripheral lession
symptoms of unresectable lung cancer
weight loss >10%
bone pain
extrathoracic metastasis
CNS symptoms
SVC syndrome
hoarseness
contralateral mediastinal adenopathy
lung cancer treatment
resectable small cell --> VP16 (etoposide, platinum); resectable non-small --> CAP (cyclo, adriamycin, platinum) and radio
lung cancer prognosis
5-8% 5-year survival
after resection of SCC --> 30-35%
after resection of large-cell and adeno --> 25%
atelectasis etiology
most common is postsurgery; also mucuous plug, foreign body or tumor
atelectasis presentation
tachycardia, dyspnea, fever, hypoxemia
atelectasis diagnosis
ipsilateral trachea deviation --> upper lobe
mediastinal deviation --> massive atelectasis
elevation of hemidiaphragm --> lower lobe
atelectatic lobe looks denser, consolidated and smaller than normal contralateral lobe