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179 Cards in this Set
- Front
- Back
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FEV1/FVC in obstructive pulmonary disease
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less than normal (.75-.8)
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FEV1/FVC in restrictive pulmonary disease
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often normal
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what should CO2 be in a patient with acute asthma?
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low because patient should be hyperventilating
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when should you think about intubation?
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any patient whose CO2>50 or whose O2<50
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what should you do if a patient has a solitary pulmonary nodule on CXR?
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compare with old films; if hasn't changed in 2-3 years it is likely benign
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solitary pulmonary nodule in an immigrant?
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TB; do skin test
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solitary pulmonary nodule in Southwest US exposure?
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coccidiodes immitis
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solitary pulmonary nodule in a cave explorer/exposure to bird droppings/Ohio/Mississippi river valless?
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histoplasmosis
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solitary pulmonary nodule in a smoker over age 50?
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lung cancer; order bronchoscopy and biopsy
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solitary pulmonary nodule in a person under 40 with no risk factors?
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hamartoma
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in what pre-op patients is CXR standard?
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over 60 or known pulmonary or CV disease
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what is the best way to reduce post-op pulmonary complications?
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stop smoking preoperatively
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most common cause of post-op fever in first 24 hours?
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atelectasis
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what does ARDS cause?
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noncardiogenic pulmonary edema, respiratory distress, hypoxemia
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what are common causes for ARDS?
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sepsis, major trauma, pancreatitis, shock, near-drowning, drug overdose
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during what time frame after the initial insult does ARDS develop?
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within 24-48 hours
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mottled skin, intercostal retractions, rales/rhonchi, no improvement of hypoxia with O2 administration
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ARDS
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how do you treat ARDS?
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intubation, mechanical ventilation with high percentage O2, PEEP (while addressing underlying cause)
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choice of antibiotics in typical pneumonia?
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ceftriaxone, broad-spectrum
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choice of antibiotic in atypical pneumonia
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azithromycin, fluoroquiniolone (e.g. levofloxacin)
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college student with PNA?
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mycoplasma or chlamydia
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alcoholic with PNA
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klebsiella, s. aureus, other enterics
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patient with cystic fibrosis and PNA
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pseudomonas or staph aureus
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immigrant with PNA
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TB
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COPD patient with PNA
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H flu, moraxella
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patient with known TB with pulmonary cavitation with PNA
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aspergillus
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PNA and silicosis (metal, granite, pottery worksers)
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think TB
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PNA in patient with exposure to AC or aerosolized water
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legionella
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PNA in HIV/AIDS
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PCP or CMV
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PNA in patient with exposure to bird droppings
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chlamydia psittaci or histoplasmosis
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PNA in child less than one year
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RSV
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PNA in child 2-5 years old
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parainfluenza
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foreign body is most likely to go down which bronchus?
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right
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child with recurrent pneumonias in the same location?
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foreign body aspiration (esp if right middle or lower lobe)
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if a pneumonia doesn't clear within 4-6 weeks, what is the classic culprit?
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malignancy - specifically bronchoalveolar carcinoma (subtype of adenocarcinoma)
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what causes infant respiratory distress syndrome?
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atelectsis froma deficiency of surfactant
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in what infants does respiratory distress syndrome occur?
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premies and infants of diabetic mothers
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what does ABG show in infant respiratory distress syndrome
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hypoxemia and hypercarbia
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what does CXR show in infant RDS?
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diffuse, granular infiltrates (atelectasis)
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how do you treat infant RDS?
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O2, surfactant, and intubate if necessary
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what are complications of acute or chronic mechanical ventilation in kids?
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intraventricular hemorrhage and pneumothorax or bronchopulmonary dysplasia
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what in the amniotic fluid indicates fetal lung maturity?
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lecithin-to-sphingomyelin ratio greateer than 2:1 or the presence of phosphatidylglycerol
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what is the preferred test for fetal lung maturity in diabetic mothers?
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phosphatidylglycerol
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what can be seen on CXR in diaphragmatic hernia?
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herniated bowel
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on what side are 90% or diaphragmatic hernias located?
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left
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how does diaphragmatic hernia present? what can it cause?
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respiratory difficulty; lung hypoplasia
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scaphoid abdomen and bowel sounds in chest
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diaphragmatic hernia
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what is the most common type of TE fistula
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esophagus with blind pouch proximally and fistula between bronchus/carina and the distal esophagus
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neonate with excessive oral secretions, coughing or cyanosis with attempted feedings, abdominal distention and aspiration pneumonia
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TE fistula
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how is the diagnosis of TE fistula maade?
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inability to pass NG tube; or injection of air via NG under fluoro shows only proximal esophagus
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treatment for TE fistula
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early surgical correction
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rectal prolapse, meconium ileus, esophageal varices
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cystic fibrosis
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salty tasting infant
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cystic fibrosis
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what percent of males with CF are infertile? females?
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98%/50%
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how is CF diagnosed?
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sweat test or DNA test
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protein level in infected pleural fluid?
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high
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glucose level with infected pleural fluid?
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low
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what tests do you order if you are trying to determine if a pleural effusion is a transudate or an exudate?
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albumin, lactate dehydrogenase
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causes of interstitial lung disease
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idiopathic pulmonary fibrosis, collagen vascular disease, granulomatous disorders, pneumoconiosis
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are lung volumes higher or lower than normal in obstructive lung disease? in restrictive?
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higher in obstructive
lower in restrictive |
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CXR showing reticular pattern that is more pronounced at the bases; honeycomb pattern in severe disease
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interstitial lung disease
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what type of lung disease presents with shallow, rapid breathing; dyspnea with exercise; non-productive cough?
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interstitial lung disease (restrictive)
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non-caseating granulomas
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sarcoid
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in what patients is sarcoidosis typically seen? when does it present?
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black females and Norwegians; most often arises in third/fourth decade
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drugs associaed with interstitial lung disease?
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busulfan, nitrofurantoin, amiodarone, bleomycin, radiation, long-term high O2 concentratin (ventilators)
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treatment for sarcoidosis?
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systemic corticosteriods
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features of sarcoid?
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GREULING
Granulomas Rheumatoid arthritis Uveitis Erythema nodosum Lymphadenopathy Interstitial fibrosis Negative TB test Gammaglobulinemia |
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antigen in farmer's lung?
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spores of actinomycetes from moldy hay
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antigen in bird fancier's lung
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antigens from feathers, poop, serum
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antigen in mushroom worker's lung?
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spores of actinomycetes from compost
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antigen in malt worker's lung?
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spores of aspergillus clavatus
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antigen in grain handler's lung
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grain weevil dust
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antigen in bagassosis
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spores of actinomycetes from surgarcane
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antigen in air conditioner lung
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spores of actinomycetes from AC
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what happens in hypersensitivity pneumonitis?
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environmental exposure to antigens -> alveolar thickening and granulomas
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CXR in hypersensitivity pneumonitis?
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normal or shows miliary nodular infiltrate (acute); fibrosis in upper lobes (chronic)
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treatment for hypersensitivity pneumonitis?
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avoid ongoing exposure; give steroids to decrease inflammation
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complications of asbestosis?
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increased risck of mesothelioma and lung CA (worse in smokers)
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work involving manufacture of tile or brake linings, insulation, construction, demolition, or building maintenance
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asbestosis
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biopsy findings in asbestosis
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asbestos bodies
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CXR in asbestosis
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linear opacities at lung bases and pleural plaques
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complications of coal mine disease
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progressive masssive fibrosis
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CxR in coal mine disease
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small nodular opacities (<1 cm) in upper lung zones
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spirometry in coal mine disease and silicosis is consistent with what?
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restrictive disease
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work in mines or quarries or with glass or pottery
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silicosis
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classic finding on CXR in silicosis
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eggshell calcifications; also see small nodular opacities in upper lobes
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what are patients with silicosis at an increased risk for?
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TB; need annual skin test
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work in high-technology fields such as aerospace, nuclear and electronics plants; ceramics industries; foundries; plating facilities; dental materal sites; dye manufacturing
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berylliosis
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CXR findings in berylliosis
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diffuse infiltrates; hilar adenopathy
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treatment for berylliosis
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chronic steroids
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causes of obstructive pulmonary disease
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ABCT
asthma bronchiectasis cystic fibrosis tracheal or bronchial obstruction |
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define asthma
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reversible airway obstruction secondary to bronchial hyperreactivity, airway inflammation, mucous plugging, and smooth muscle hypertrophy
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ABG in asthma eacerbation
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mild hypoxia and respiratory allkalosis
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CXR findings in asthma
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hyperinflation
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what is a methacholine challenge?
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tests for bronchial hyperrespnsiveness; allows definitive dx of asthma
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when should a methacholine challenge be performed?
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at least 3 months after an acute episode
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continual day asthma sx; frequent night sx
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severe persistent asthma
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daily sx; 1 night/wk sx
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moderate persistent asthma
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2x/wk but <1/day & >2 nights/month
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mild persistent asthma
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less than 2 days/wk; less than 2 nights/month
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mild intermittent
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meds for mild intermittent asthma
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none daily; PRN short-acting bronchodilator
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meds for mild persistent asthma
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low dose inhaled corticosteroids; PRN short-acting bronchodilator
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meds for moderate persistent asthma
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low-medium dose inhaled corticosteroids + long-acting inhaled beta2 agonists; PRN short acting bronchodilator
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meds for severe persistent asthma
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high-dose inhaled corticosteriods + long-acting B2 agonists; possible PO steroids; PRN short-acting bronchodilator
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disease caused by cycles fo infection and inflammation in the bronchi/bronchioles that leads to permanent fibrosis, remodeling, and dilatation of bronchi
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bronchiectasis
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how does bronchiectasis present?
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frequent bouts of green sputum accompanied by cough, dyspnea, and possible hemoptysis and halitosis
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exam in bronchiectasis?
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rales, wheezes, rhonchi, purulent mucus, occasional hemoptysis
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tram lines on CXR
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parallel lines outlining dilated bronchi as a result of peribronchial inflammation and fibrosis
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CXR findings in bronchiectasis
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tram lines and honeycombing
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CT showing dilated airways and ballooned cysts at the end of the broncus (mostly lower lobes)
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bronchiectasis
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define chronic bronchitis
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productive cough less than/equal to three months per year for two consecutive years
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define emphysema
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terminal airway destruction that may be due to smoking or to alpha-1 antitrypsin deficiency
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centrilobular emphysema
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smoking
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panlobular emphysema
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a1 antitrypsin deficiency
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dyspnea, pursed lips, minimal cough, decreased breath sounds
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emphysema (pink puffer)
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productive cough, cyanosis wiht mild dyspnea; overweight with edema, rhonchi, end-expiratory wheezing; JVD, barrel chest
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chronic bronchitis (blue bloater)
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CXR findings in COPD
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hyperinflated and hyperlucent lungs, flat diaphragms, increased AP diameter, narrow mediastinum, large upper bullae
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ABG in COPD
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hypoxemia with acute respiratory acidosis (increased PCO2)
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treatment of acute COPD exacerbation
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O2, inhaled B-agonists, anticholinergics (ipratropium), IV steriods, antibiotics
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what vaccines should be given to patients with COPD
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pneumococcal and flu vaccines
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if patient on ventilator is hypoxic what do you do?
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increase O2 saturation by increasing FiO2; increase PEEP or increase I/E ratio
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for patients on ventilator who are hypercapnic
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increase minute ventilation (by increasing tidal volume or increasing respiratory rate)
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pathogenisis of ARDS?
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endothelial injury
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criteria for ARDS diagnosis?
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ARDS
Acute onset Ratio (PaO2/FiO2)<200 Diffuse infiltration Swan-Ganz wedge pressure <18 (no evidence of cardiac origin) |
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treatment for ARDS
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treat underlying disease and maintain adequate perfusion and O2 delivery to organs (use mechanical ventilation with PEEEP and low tidal volumes because of decreased lung compliance)
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Definition of pulmnonary HTN
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mean PA pressure greater than 25 (normal is <15)
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loud, palpable S2 (often split), SEM, S4 or parasternal heave
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pulmonary HTN
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Virchow's triad
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stasis, endothelial injury, hypercoagulable states
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ABG in PE
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respiratory alkalosis (hyperventilation) with PO2 <80
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classic EKG triad in PE
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S1Q3T3 - S wave in lead I, Q wave in III, inverted T wave in III (acute right heart strain)
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risk factors for sleep apnea
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male, obesity, sedative use for sleep, nasal obstruction, hypothyroidism, macroglossia, acromegaly
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PFTS in sleep apnea?
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normal
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in what types of patients is central sleep apnea seen?
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CHF, CNS disease
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in children, what are most cases of sleep apnea due to?
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tonsillar/adenoidal hypertrophy
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main locations for lung cancer mets
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bone, liver, adrenals, brain
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type of lung CA highly correlated with cigarette smoke
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small cell lung CA
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where are small cell lung cancers typically located and what is their origin?
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central; neuroendocrine origin
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what is the most common type of lung cancer and where is it typically located?
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adenocarcinoma; peripherally
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lung cancer associated with multiple nodules, interstitial infiltration, and prolific sputum production
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bronchoalveolar carcinoma
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central location; 98% seen in smokers
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squamous cell lung CA
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least common lung CAs; associated with poor prognosis
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large cell/neuroendocrine carcinomas
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treatment for SCLC
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not resectable; often responds to XRT and chemo but always recurs
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NSCLC treatment
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surgical resection in early stages; palliation for symptomatic but unresectable disease
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in whom is primary spontaneuos pneumothorax typically seen
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tall, thin young males
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what is primary spontaneuos pneumothorax due to?
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rupture of subpleural apical blebs
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what are some causes of secondary pneumothorax?
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COPD, TB, trauma, PCP, iatrogenic factors
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Presentation of pneumothorax
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P-THORAX
pleuritic pain tracheal deviation hyperresonance onset sudden reduced breath sounds (and dyspnea) absent fremitus x-ray shows collapse |
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what should you suspect in the presence of respiratory distress, falling O2 sat, hypotension, distended neck veins, and tracheal deviation
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tension pneumothorax
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treatment for tension pneumothorax
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immediate needle decompression followed by chest tube
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where do you do needle decompression?
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second intercostal space at mid-clavicular line
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postpartum female with SOB and hemoptysis
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choriocarcinoma
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tests to order for suspected choriocarcinoma
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BHCG, CXR, pelvic exam
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how does PEEP affect CO?
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decreases it
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what do you use in an acute COPD exacerbation?
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bronchodilators and steriods
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lung mass in which biopsy shows cartilage
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hamartoma - benign
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what is the most common inherited disorder that causes hypercoagulability?
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factor V leiden - predisposes to DVT
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how do you treat aspirin sensitivity syndrome?
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leukotriene receptor antagonists
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what is aspirin sensitivity syndrome?
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persistent nasal blockage adn episodes of bronchoconstriction (pseudo-allergic reaction)
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characteristics of allergic bronchopulmonary aspergillus?
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asthma-like symptoms, increased Ige, increased eosinophil count, central bronchiectasis
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next steps after PNA doesn't heal after 2 wks of appropriate treatment?
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CT chest then bronchoscopy to ensure that bronchus isn't blocked and there is no abscess
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upper and lower respiratory tract involvement plus glomerulonephritis
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Wegener's
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test to order in suspected Wegener's
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C-ANCA
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symptoms of theophylline toxicity
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headache, palpitations, vomiting (stimulation of epinephrine release)
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crepitus over neck and chest in severe asthmatic
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subcutaneous emphysema
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what do you order when you suspect subcutaneous emphysema?
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CXR to rule out pneumothorax
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allergic rhinitis, asthma, and prominent peripheral blood eosinophilia
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Churg-Strauss
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what is seen in up to 75% of patients with Churg Strauss?
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peripheral neuropathy
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what class of drugs can cause Churg Strauss?
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leukotriene antagonists
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what is the most serious complication of bronchiectasis?
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hemoptysis
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mucoid colonies, gram-negative bacilli in upper lobe PNA?
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Klebsiella
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pneumonia, hyponatremia, diarrhea
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Legionella
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treatment for Legionella?
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erythromycin
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pleural plaques on CXR
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asbestosis
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what happens to the A-a gradient in idiopathic pulmonary fibrosis?
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increased due to poor oxygenation
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what is the most common lung CA associated with asbestosis?
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bronchogenic carcinoma
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work-up for suspected PE
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CXR, ABG, then EKG and V/Q scan
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what is the most common cause of constrictive pericarditis in immigrants?
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TB
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drug of choice for community-aquired pneumonia in inpatients? outpatients?
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levofloxacin; doxycycline or azithromycin
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what is the only thing known to prolong survival in COPD?
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home O2
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