4. Pulmonology Flashcards
(92 cards)
1
Q
What are the classic types of chronic obstructive pulmonary disease (COPD) ?
A
chronic bronchitis and emphysema.
2
Q
Chronic bronchitis is ?
A
A clinical diagnosis: chronic cough productive of sputum
for at least 3 months per year for at least 2 consecutive years.
3
Q
Emphysema is ?
A
A pathologic diagnosis: permanent enlargement of air spaces
distal to terminal bronchioles due to destruction of alveolar walls.
4
Q
Risk factors of COPD ?
A
A. Tobacco smoke (indicated in almost 90% of COPD cases)
B. α1-Antitrypsin deficiency—risk is even worse in combination with smoking
C. Environmental factors (e.g., second-hand smoke)
D. Chronic asthma—speculated by some to be an independent risk factor
5
Q
Pathogenesis of chronic bronchitis ?
A
- Excess mucus production narrows the airways, patient often have a productive cough.
- Inflammation and scarring in Airways, enlargement in mucous glands, and smooth muscle hyperplasia lead to obstruction
6
Q
Pathogenesis of Emphysema ?
A
- Destruction of alveolar walls is due to relative excess in protease (elastase) activity, OR relative deficiency of antiprotease (alpha-antitrypsin) activity.
7
Q
Respiratory function test results in COPD ?
A
- The FEV1/FVC ratio is <0.70. (decreassed)
- FEV1 is decreased.
- TLC is increased.
- Residual volume is increased.
- Functional reserve capacity is increased.
8
Q
Predominant Chronic Bronchitis (“Blue Bloaters”) features ?
A
- Patients tend to be overweight and cyanotic.
- Chronic cough and sputum production are characteristic.
9
Q
Predominant Emphysema (“pink puffers”) features ?
A
- Patients tend to be thin due to increased energy expenditure during breathing.
- When sitting, patients tend to lean forward.
- Patients have a barrel chest (increased AP diameter of chest).
- Patient is distressed and uses accessory muscles (esp. strap muscles in neck).
10
Q
Diagnosis of COPD ?
A
- Pulmonary function testing (spirometry):
- This is the definitive diagnosis test. - CXR:
- only severe, advanced emphysema will show the typical changes. - Measure alpha-antitrypsin levels. (in pts with hx of premature emphysema <50 yrs).
- ABG.
11
Q
How to stage COPD and what are the stages ?
A
- Staging is based on FEV1:
- Mild disease: FEV1 >80% of predicated value.
- Moderate disease: 50-80% of predicated value.
- Severe disease: 30-50% of predicated value.
- Very severe disease: <30% of predicated value.
12
Q
What are the interventions that lowers mortality in COPD?
A
Smoking cessation and home oxygen.
13
Q
Treatment of Mild to moderate COPD ?
A
- Begin with a bronchodilator in a metered-does inhaler (MDI) formulations: Anticholinergic drugs and/or β-agonists are first-line agents.
- Inhaled glucocorticoids may be used as well. (low dose)
- Theophylline may considered if above not adequately control.
14
Q
Treatment of Severe COPD ?
A
- Triple inhaler therapy ( long acting B-agonist plus a long-acting anticholinergic plus an inhaled glucocorticoid) is an option for severe disease.
- Continous oxygen therapy (if pts is hypoxemic).
- Pulmonary Rehabilitation.
15
Q
Management of acute COPD exacerbation ?
A
- Def: increased dyspnea, sputum production and/or cough.
- order CXR.
1. Bronchodilators (β2-agonist) alone or in combination with anticholinergics are first-line therapy.
- systemic corticosteroids are used for patients requiring hospitalization (IV methylprednisolone is a common choice).
- Antibiotics (azithromycin, levofloxacin, doxycycline).
- Supplemental oxygen is used to keep saturation 90% to 93%.
- NPPV if needed.
16
Q
Complication of COPD?
A
- Acute exacerbations.
- 2ndary polycythemia.
- Pulmonary HTN and cor pulmonale
17
Q
Asthma triad ?
A
- Airway inflammation.
- Airway hyperresponsivness.
- Reversible airflow obstruction.
18
Q
Clinical features of asthma ?
A
- SOB, wheezing, chest tightness, and cough.
- Symptoms are typically worse at night.
- Wheezing is the most common finding on PE.
19
Q
Diagnosis of Asthma ?
A
- PFTs are required for diagnosis. (show obstructive pattern).
- Spirometry before and after bronchodilators can confirm diagnosis by proving reversible airway obstruction. (FEV1 increase 12%: albuterol)
- methacholine test (FEV1 decrease 20%)
- —–
* 4. Peak flow. (in acute settings ED when patient is SOB, peak flow measurements is quickest method of diagnosis).
20
Q
If inhalation of a bronchodilator (b2-agonist) result in an increase in FEV1 or FVC by at least (…..?….), airway obstruction os considered reversible ?
A
12%
21
Q
Management of Asthma ?
A
- STEP1: ICS + SABA.
- STEP2: LABA (salmeterol or formoterol) + (or increase ICS does)
- STEP3: Antimuscarinic (tiotropium).
- STEP4: Omalizumab
- Step5: Oral CS.
22
Q
Management of acute severe exacerbation of Asthma ?
A
• Oxygen. • Albuterol. (SABA) • Steroids (orally) • Ipratropium - IV magnesium (not responsive to several rounds of albuterol while waiting for steroids to take effect).
23
Q
Adverse Effects of Systemic Corticosteroids ?
A
- Osteoporosis.
- Cataracts.
- Adrenal suppression and fat redistribution.
- Hyperlipidemia, hyperglycemia, acne, and hirsutism (particularly in women) Thinning of skin, striae, and easy bruising
24
Q
Bronchiectasis?
A
- There is permanent, abnormal dilation and destruction of bronchial walls with chronic inflammation, airway collapse, and ciliary loss/dysfunction leading to impaired clearance of secretions.
25
Bronchiectasis causes ?
1. Recurrent infections.
2. Cystic fibrosis. (is the most common cause).
3. Primary ciliary dyskinesia (eg, kartagener syndrome)
4. Autoimmune disease.
5. Hormonal immunodeficiency.
26
Clinical features of Bronchiectasis ?
1. Chronic cough with large amount of mucopulent, foul-smellin sputum.
2. Dyspnea.
3. Hemoptysis.
4. Recurrent or persistent pneumonia.
27
Diagnosis of Bronchiectasis ?
1. High-resolution CT is the diagnostic study of choice.
2. PFTs reveal an obstructive pattern.
3. CXR is abnormal in most cases, but findings are nonspecific.
4. Bronchoscopy applies in certain cases.
28
TTT of Bronchiectasis ?
1. Antibiotics for acute exacerbations.
| 2. Bronchial hygiene is very important (hydration, chest physiotherapy, inhaled bronchdilators)
29
Cystic Fibrosis ?
- Autosomal recessive.
- Defect in chloride channel protein causes impaired chloride and water transport, which leads to excessively thick, viscous secretions in respiratory tract, exocrine pancreas, sweat glands, intestines, and GI.
30
Risk factors for lung cancer ?
```
A. smoking.
B. Second-hand smoke.
C. Asbestos.
D. Radon.
E. COPD.
```
31
Which type of lung cancer has the lowest association with smoking of all lung cancers.?
Adenocarcinoma.
* also its only one gives false negative with PET CT
32
Staging of lung cancer ?
1. NSCLC is staged via the primary TNM system.
2. SCLC is staged differently:
a. Limited.
b. Extensive.
33
Clinical features of lung cancer ?
1. Local manifestations:
- cough, hemoptysis, obstruction, wheezing, dyspnea.
2. Constitutional symptoms:
- Anorexia, weight loss, weakness.
3. Local invasion:
- SVC syndrome (5%).
- Phrenic nerve palsy.
- Recuurent laryngeal nerve palsy.
- Horner syndrome.
- Pancoast tumor.
34
Horner syndrome ?
- Due to invasion of cervical sympathetic chain by an apical
tumor.
- Symptoms: unilateral facial anhidrosis (no sweating), ptosis, and miosis.
35
Diagnosis of lung cancer ?
1. CXR. (most important)
2. CT scan. (very useful for staging)
3. Tissue biopsy.
36
Pleural effusion caused by one of the following mechanisms ?
- Increased drainage of fluid into pleural space.
- Increased production of fluid by cells in the pleural space.
- Decreased drainage of fluid from the pleural space.
37
Symptoms of pleural effusion ?
- Often asymptomatic.
- Progressively worsening SOB (due to limited expansion of the lung)/
- Pleuritic chest pain. (sharp pain that worsens with INSPIRATION due to irritation of somatically innervated parietal pleura)
* may look for associated symptoms to clue u to the etiology:
- fever, chills and productive cough -> pneumonia.
- unintentional weight loss and loss of appetite -> malignancy.
- Night sweats, travel to endemic area and hemoptysis -> TB.
- Othopnea & paroxysmal nocturnal dyspnea -> CHF.
- occupational exposure to asbestos -> mesothelioma.
- Joint pain or rash -> Autoimmune disease.
38
Signs of pleural effusion ?
- Dullness to percussion.
- Decreased breath sound over the effusion.
- Decreased tactile fremitus.
39
Diagnosis of pleural effusion ?
1. CXR.
- Blunting of costophrenic angle.
- at least 250 ml of fluid to be detected.
- Two types to detect trans or exu ( u can also use USG)
2. Thoracentesis.
- useful if euiology is not obvoius.
- Therapeutic "drainage provides relief for large effusions".
40
Treatment of pleural effusion ?
1. Transudative effusions:
- Diuretics and sodium restriction.
- Therapeutic thoracentesis—only if massive effusion is causing dyspnea.
2. Exudative effusions: treat underlying disease.
41
Pneumothorax ?
- Defined as air in the normally airless pleural space.
- Two major categories: spontaneous and traumatic pneumothoraces.
- CXR for diagnosis.
42
Symptoms of Pneumothorax ?
a. Ipsilateral chest pain, usually sudden in onset.
b. Dyspnea
c. Cough
43
Signs of Pneumothorax ?
a. Decreased breath sounds over the affected side
b. Hyperresonance over the chest
c. Decreased or absent tactile fremitus on affected side.
d. Mediastinal shift toward side of pneumothorax.
44
Tension Pneumothorax ?
- Accumulation of air within the pleural space such that tissues surrounding the opening into the pleural cavity act as valves, allowing air to enter but not to escape.
- The accumulation of air under (positive) pressure in the pleural space collapses the ipsilateral lung and shifts the mediastinum away from the side of the pneumothorax.
45
Clinical features of Tension Pneumothorax ?
1. Hypotension.
2. Distended neck veins.
3. Shift of trachea away from side of pneumothorax on CXR.
4. Decreased breath sounds on affected side.
5. Hyperresonance to percussion on side of pneumothorax.
46
Interstitial Lung Disease?
- ILD Is defined as an inflammatory process involving the alveolar wall that can lead to irreversible fibrosis, distortion of lung architecture, and impaired gas exchange
47
Signs of ILD ?
A. Rales at the bases are common
B. Digital clubbing is common.
C. Signs of pulmonary HTN and cyanosis in advanced disease.
48
Diagnosis of ILD ?
1. CXR.
2. CT.
3. PFT.
4. Tissue biopsy.
49
" Honeycomb lung" referes to ?
- A scarred shrunken lung and is an end-stage finding with poor prognosis.
- Air spaces are dilated, and there are fibrous scars in the interstitium.
- It can arise from many different types of ILD.
50
Sarcoidosis ?
- A chronic systemic granulomatous disease characterized by noncaseating granulomas, often involving multiple organ systems. Lungs are almost always involved. Etiology unknown.
51
Clinical features of Sarcoidosis ?
```
A. Constitutional symptoms:
- Malaise, fever, anorexia, weight loss.
B. Lungs: dry cough, dyspnea.
C. Skin: erytherma nodosum.
D. Eyes: Ant. uveitis.
```
52
when u see erythema nodosum, make sure its not a complication of sarcoidosis, WHY ?
coz its because of sarcoidosis then u shouldn’t give steriods “most cases”
53
What is the most common cause of death in patient with sarcoidosis ?
Cardiac disease, although it is not a common finding.
54
Diagnosis of sarcoidosis ?
* Diagnosis is based on clinical, radiographic, and histologic findings.
1. CXR—Bilateral hilar adenopathy is the hallmark of this disease.
2. biopsy is the most accurate test. The granulomas are noncaseating.
3. Elevated ACE level: 60%
Hypercalciuria: 20%
Hypercalcemia: 5%
4. PFT: restrictive pattern. ((it shows obstructive actually!!!))
55
General criteria used to define acute respiratory failure ?
A. Hypoxia (PaO2 < 60 mm Hg).
| B. Hypercapnia (PCO2 > 50 mm Hg).
56
What is the most commonly identified cause of obstructive sleep apnea ?
Obesity.
57
Obstructive sleep apnea symptoms ?
- Patients present with daytime somnolence and a history of loud snoring
- Other symptoms include:
• Headache
• Impaired memory and judgement
• Depression
• Hypertension
• Erectile dysfunction
• “Bull neck”
58
What is the most accurate test for obstructive sleep apnea ?
Polysomnography (sleep study).
- which shows multiple episodes of apnea.
- Arrhythmias and erythrocytosis are common.
59
TTT of Obstructive sleep apnea symptoms ?
1. Weight loss and avoidance of alcohol
2. Continuous positive airway pressure (CPAP)
3. Surgical widening of the airway, if this fails Avoid use of sedatives.
4. Oral appliances to keep the tongue out of the way.
60
Community-Acquired Pneumonia (CAP) ?
- defined as pneumonia occurring before hospitalization or within 72 hours of hospital admission.
- Can be typical or atypical.
61
What is the most common cause of CAP?
Streptococcus pneumoniae. (60%)
- H. influenza (15%)
62
Classic CAP presents with ?
Sudden chill followed by fever, pleuritic pain and productive cough.
63
The atypical pneumonia ?
- Associated with Mycoplasma (most common) or Chlamydia infection.
- Often begins with a sore throat and headache, followed by a nonproductive cough and dyspnea.
64
Hospital-acquired pneumonia (HAP) or Nosocomial pneumonia ?
- Occurs during hospitalization after 1st 72 hrs.
65
What is the most common cause of HAP?
_ Gran-negative rods (E.coli, Pseudomonas) and S. aureus.
66
What is the difference between typical and atypical pneumonia in CXR ?
* Typical:
- Lobar consolidation.
- Multilobar consolidation indicates very serious illness.
* Atypical:
- Diffuse reticulonodular infiltrates.
- Absent or minimal consolidation.
67
Atypical pneumonia refers to ?
Organisms NOT visible on Gram stain and not culturable on standard blood agar.
68
Diagnosis of pneumonia ?
- CXR to confirm.
| - sputum culture.
69
False-negative chest radiographs in pneumonia occur with ?
- Neutropenia
- Dehydration.
- Infection with PCP (Pneumocystis carinii pneumonia).
- Early disease (<24 hrs).
70
What is the most important step in the initial management of pneumonia ?
* is determining the severity of disease in order to determine the location in which to place the patient.
```
* using CRUB65:
• Confusion
• Uremia
• Respiratory distress
• BP low
• Age >65
```
71
Outpatient treatment of CAP?
* ppl younger than 60 yrs ->
- 1st line: Macrolides (azithromycin or clarithromycin) or doxycycline.
- 2nd line: fluoroquinolones.
* older patients with comorbidities ->
- 1st line: fluoroquinolones (levofloxacin, moxifloxacin)
72
Inpatient treatment of CAP ?
- 1st line: fluoroquinolones (levofloxacin, moxifloxacin)
OR
Ceftriaxone and azithromycin
73
treatment of HAP?
1. Cephalosporins with peudomonal coverage: ceftazidime or cefepime.
2. Carbapenems: imipenem.
3. Piperacillin/tazobactam.
74
Where does secondary TB usually manifests ?
In the most oxygenated portions of the lungs:
| - The apical/posterior segments.
75
Risk factors for TB?
- HIV-positive.
- Recent immigrants (within the past five years).
- Prisoners.
- Healthcare workers.
- Close contact with someone with TB.
- Alcoholics.
- Diabetes.
- Glucocorticoid use.
- Hematologic malignancy.
- Injections drug users.
76
2ndary TB clinical features ?
1. Constitutional symptoms: Fever, night sweats, weight loss, and malaise are common.
2. Cough progresses from dry cough to purulent sputum. Hemoptysis suggests advanced TB.
3. Apical rales may be present on examination.
77
Radiographic Findings in Primary TB ?
- Ghon complex: calcified primary focus with an associated lymph node.
- Ranke complex: When Ghon complex undergoes fibrosis and calcification.
78
Diagnosis of TB ?
1. CXR.
- Classic findings are upper lobe infiltrates with cavitations.
2. Sputum studies (sputum acid-fast testing).
- Definitive diagnosis is made by sputum culture: growth of M. tuberculosis (4-8 wks)
3. PPD test.
- Tuberculin skin test is a screening test to detect those who may have been exposed to TB.
79
PPD test ?
- Tuberculin skin test is a screening test to detect those who may have been exposed to TB.
- It is not for a diagnosis of active TB, but rather of latent (primary) TB (If positive, a chest x-ray is years to diagnose active TB).
- PPD is not a screening test for everyone, only patients with one or more of the risk factors should have this test.
- If patient is symptomatic or has abnormal chest x-ray, order a sputum acid-fast test, not a PPD.
80
If PPD Is positive, which is x-ray is needed to rule out active disease. Once active disease is excluded ?
9 months of isoniazid treatment is indicated.
- A patient with positive PPD has a 10% lifetime risk of TB, and this risk is reduced to 1% after 9 months.
81
Diagnosis of TB Is challenging in HIV patients because?
- PPD skin test result is negative.
- Patient have "atypical" CXR findings.
- Sputum smears are more likely to be negative.
- Granuloma formation may not be present in the late stages.
82
Isoniazid, most common side effect and how to prevent?
- Peripheral neuropathy.
| - Use Pyridoxine (vit. B6)
83
Treatment of active TB ?
* Initial 2 months phase:
1. Isoniazid.
2. Rifampin.
3. Pyrazinamide.
4. Ethambutol.
* Continuation 4 months phase:
1. Isoniazid.
2. Rifampin.
84
Pulmonary Hypertension ?
- Defined as a mean pulmonary arterial pressure greater than 25 mm Hg at rest.
85
Symptoms of Pulmonary Hypertension ?
A. Dyspnea on exertion.
B. Fatigue.
C. Chest pain "exertional".
- Syncope "exertional" (with severe disease)
86
Cough duration def ?
- Acute (infection),<3 weeks
- Subacute 3-8 weeks
- Chronic (COPD) >8weeks
87
Absolute contraindication for spirometry ?
Myocardial infarction within the previous month
88
Degree of severity in spirometry based on FEV1 % ?
- Mild: >70
- Moderate: 60-69.
- Moderately severe: 50-59.
- Severe: 35-49
- Very severe: <35
89
Pleural effusions are caused in 75% by 4 disorders ?
1. Malignant neoplasms (33%)
2. TB (16-21%)
3. Pneumonia (16-20%)
4. Pulmonary thromboemolism (12%)
* they all cause EXUDATES
90
Chylothorax ?
A milky or chylous pleural effusion- is caused by traumatic or neoplastic ( most often a lymphoma) injury to the thoracic duct.The lipid content of the fluid ( neutral fat and fatty acids) is high; sudanophilic fat droplets ( presence of chylomicrons) are often seen microscopically; cholesterol content is low.
91
Hypoxemic respiratory failure ?
* pO2 < 60 mmHg with normal or low pCO2 and normal or high pH
* Most common form of respiratory failure.
* Ventilation is maintained but lung diseases is severe to interfere with pulmonary oxygen exchange.
* Caused by a disorder of heart, blood or lung.
92
Hypercapnic respiratory failure ?
- pCO2 > 50 mmHg.
- Hypoxemia is always present.
- pH depends on level of HCO3.
- HCO3 depends on duration of hypercapnia.
- Renal response occurs over days to weeks.
