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Emergency Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

The acute onset of fever, cough, and bloody sputum may indicate _____ or _____.

A

Pneumonia or Bronchitis

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2
Q

Dyspnea and pleuritic chest pain are indicators of ______.

A

Pulmonary embolism

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3
Q

Patients typically complain of sudden onset of pleuritic chest pain associated with dyspnea, tachypnea, tachycardia, or hypoxemia in cases of ______.

A

Pulmonary embolism

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4
Q

The BREATHS of P.E. (PERC Criteria)

A
  • Blood in sputum
  • Room air sat <95%
  • Estrogen or OCP use
  • Age > 50y/o
  • Thrombosis (in past or current suspicion of DVT)
  • Heart rate >100 documented at ANY time
  • Surgery in last 4 weeks
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5
Q

Treatment for P.E. is:

A
  1. Regular PE (vitals stable, no elevation in cardiac enzymes or BNP)- lovenox or heparin drip and admit
  2. Submassive PE (vitals stable with elevation in CEs or BNP, right heart strain on echo)- lovenox, strongly consider ICU admit for thrombolytics
  3. Massive PE (unstable vitals, systolic BP less than 90 at any time)- thrombolytics and ICU admit
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6
Q

If someone has a moderate or high probability for a P.E. you should perform a _____.

A

CT pulmonary angiogram (CTPA)

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7
Q

In a diagnosis of ______ patients may complain of positional or pleuritic chest pain, dyspnea, and palpitations. Physical exam will show tachycardia, hypotension, JVD, and distant heart sounds. If CV collapse is imminent, emergent pericardiocentesis is indicated

A

Pericardial tamponade

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8
Q

Sx of ______ include: cough (with or without sputum), dyspnea, fever, sore throat, headache, myalgias, substernal discomfort, and expiratory rhonchi or wheezes

A

Acute bronchitis

  • More than 90% of cases are caused by viruses including rhinovirus, coronavirus, and RSV
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9
Q

Treatment of acute bronchitis includes:

A

o Supportive measures → hydration, expectorants, analgesics, β2-agonists, and cough suppressants

o If pertussis is strongly suggested, give azithromycin

o Antibiotics are indicated for the following → elderly patients, those with underlying cardiopulmonary diseases and a cough for more than 7-10 days, and any patient who is immunocompromised

o For acute exacerbations in otherwise healthy adults, no empiric treatment is needed

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10
Q

______ is the most frequent lower respiratory infection in the first 2 years of life. It is caused by RSV.

A

Acute bronchiolitis

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11
Q

Sx of bronchiolitis include:

A

-Fever, wheezing, tachypnea, cough, rales, use of accessory muscles, nasal flaring

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12
Q

ED care for bronchiolitis involves:

A

o Supportive!
o Nasal suctioning and saline drops
o Oxygen to maintain sats 90-92%
o Nebulized albuterol
•If no response, racemic epinephrine
o Heliox
o No corticosteroids
o May need IV fluids and rehydration
o Ribavirin has been used successfully for severe cases
o Palivizumab prophylaxis for children < 2 years old with chronic lung disease, premature infants (<32 weeks), or significant congenital heart disease

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13
Q

______ is responsible for most cases of stridor after the neonatal period. Usually a benign and self-limited disease.

A

Viral croup

  • MC in males 6 months- 3 years
  • *MC caused by parainfluenza
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14
Q

Sx of croup are:

A

o Inspiratory stridor (intermittent at first but increases as obstruction increases)
o Hoarseness
o “Barking seal” cough x 3-4 days
o Prodrome of low-grade fever and rhinorrhea 12-24 hours prior to the onset of stridor
o Symptoms usually worse at night and children prefer to sit up. Also aggravated by agitation and crying
• Symptoms peak around day 3-4

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15
Q

“Steeple sign” on xray is associated with:

A

Croup

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16
Q

Treatment of croup includes:

A
  • Cool mist humidification of the environmental air
  • Heliox
  • Inhaled racemic epinephrine for more severe airway compromise
  • IM or PO steroids (dexamethasone)
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17
Q

Complications of the flu are common in the elderly and chronically ill. Necrosis of respiratory epithelium results in secondary bacterial infection (Staphylococcus, Streptococcus, or Haemophilus sp.), acute sinusitis, otitis media, and purulent bronchitis

A

:(

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18
Q

Reye’s can be associated with the flu. Some more about Reye’s…

A

o Fatty liver with encephalopathy

o Rapidly progressive, has a 30% fatality rate, and may develop 2-3 weeks after onset of influenza A or varicella infection, especially if aspirin is ingested. Peak age is 5-14 years – rare in patients over 18 years

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19
Q

_______ is recommended for patients with influenza requiring hospitalization or in those with high risk of morbidity and mortality.

A

Oseltamivir (Tamiflu)

  • Contraindicated in patients younger than 12
  • *Flu season= October-March
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20
Q

______ is also known as “whooping cough”

A

Pertussis

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21
Q

Clinical disease of pertussis has 3 stages that last ~8 weeks. These are:

A
  1. Catarrhal Stage → low grade fever, cough, coryza
    • Follows a 7-10 day incubation period and lasts 1-2 weeks
  2. Paroxysmal Stage → cough with inspirational “whoop.” Posttussive emesis is common. Facial petechiae and scleral hemorrhages can develop due to forceful cough
    • Lasts 2-6 weeks
  3. Convalescent Stage → gradual symptom resolution
    • Cough may persist 2-8 weeks
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22
Q

How is pertussis diagnosed?

A

Culture, PCR, fluorescent antibody staining

Labs & Imaging:
-Increased WBC with lymphocytosis

-CXR = segmental atelectasis, perihilar infiltrates

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23
Q

Treatment of pertussis involves…

A

Macrolides- Azithromycin in neonates can shorten duration if given early enough in catarrhal phase.

  • After coughing paroxysms begin, antibiotics cannot affect course of illness but are still recommended to decrease the period of infectivity
  • *14-day course of erythromycin or 5-day course of azithromycin
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24
Q

The MC cause of Community Acquired Pneumonia is?

A

Strep pneumoniae

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25
Q

Cavitary lesions shown on a CXR is associated with what culprit of PNA?

A

Klebsiella

  • Common in ETOHics
  • *Usually R upper lobe
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26
Q

____ (lobe of lung) is the MC site of aspiration PNA

A

Right lower lobe (think anaerobes)

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27
Q

Immunocompromised (ex HIV) are more prone to PNA caused by what organism?

A

Pseudomonas

*Common culprit of hospital-acquired PNA

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28
Q

____ is the MC cause of viral PNA in infants/small kids.

A

RSV/Parainfluenza

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29
Q

____is the MC cause of viral PNA in adults.

A

Influenza

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30
Q

Some examples of fungal PNA include:

A
  1. Pneumocystis jirovecii- think compromised host with pleuritic CP
  2. Histoplasma- Mississippi and Ohio River Valleys, soil contaminated with bird and bat droppings
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31
Q

Abx guidelines for CAP, OUTpatient…

A

1st line= Macrolide of Doxycycline

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32
Q

Abx guidelines for CAP, INpatient…

A

B lactam + Macrolide (or Doxy) OR broad spectrum FQ

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33
Q

Abx guidelines for hospital-acquired PNA…

A

Anti-PSEUDOMONAL B lactam and and-PSEUDOMONAL AG or FQ (p.109)

  • Add Vanc if MRSA suspected
  • *Add Levofloxacin or Azithromycin if Legionella suspected
  • **Add Bactrim if PCP suspected
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34
Q

Those ≥65 y and those ≥2-64 with chronic dz (such as HIV) should be vaccinated against PNA

A

Single revaccination if ≥5 y since last dose

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35
Q

p 109-112 for pictures of PNA

A

fyi

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36
Q

_______ is the MC cause of bronchiolitis in kids < 1y

A

RSV

*Most infxns go away on their own in a week or two. Manage symptoms with fluids and fever reduces as needed and recommended

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37
Q

A drug called palivizumab is available to prevent severe ____ illness in certain infants and children who are at high risk. The drug can help prevent development of serious disease

A

RSV

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38
Q

Samter’s Triad (associated with atopic dermatitis) includes what 3 elements?

A
  1. Asthma
  2. Nasal polyps
  3. ASA/NSAID allergy
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39
Q

____ (Intrinsic/Extrinsic) causes of asthma are most common in children/adolescents while _____ (intrinsic/extrinsic) causes are MC <3y & >30y.

A
  1. Extrinsic (Allergic) MC in kids
  2. Intrinsic (Nonallergic) MC in other age group- includes viral URI, medications (beta blockers, ASA, NSAIDs, ACEI), occupational, exercise, emotional, and cold air
40
Q

PE findings for asthma include:

A

Prolonged expiration with wheezing, hyperresonance to percussion, decreased breath sounds, tachycardia, tachypnea, and use of accessory muscles

41
Q

The gold standard test for asthma is _____.

A

Pulmonary Function Test

42
Q

______ is the best and most objective way to assess asthma exacerbation severity & patient response in the ED.

A

Peak Expiratory Flow Rate (PEFR)

43
Q

To discharge from ED PEFR needs to be >70% predicted, PEFR> 15% initial, subjective improvement, clear lungs with good air movement, adequate followup within 24-72h, response sustained 1 hour after treatment.

A

fyi

44
Q

Rescue drugs for an ACUTE exacerbation include:

A
  1. Short acting beta agonists (SABA)- Albuterol; bronchodilator
    • check for tachycardia/arrhythmias, muscle tremors, CNS stimulation, hypokalemia
  2. Anticholinergics- Ipratropium (Atrovent)
  3. Corticosteroids- Prednisone, Solumedrol; these are anti-inflammatory
    • All but the mildest exacerbations should be discharged on a short course of oral corticosteroids because they decrease relapse :)
45
Q

For chronic maintenance of asthma….

A
  1. Inhaled corticosteroid!
  2. LABA- added to steroids ONLY if persistent asthma is not controlled with ICS alone (once asthma control maintained > 3 months, step down off LABA is recommended
  3. Leukotriene modifiers/receptor antagonists (LTRA)- Singulair (Montelukast) for example. Useful in asthmatics with allergic rhinitis/ASA-induced asthma
46
Q

_____ may be used as an adjunctive therapy in cases of severe asthma exacerbation.

A

IV magnesium- bronchodilator that decreases calcium mediated smooth muscle contraction

*Omalizumab is an anti-IgE antibody that is used in severe, uncontrolled asthma

47
Q

See chart p. 83!!

A

Drugs…

  • SABA- Albuterol
  • Anticholinergic- Ipratropium (Atrovent)
  • Corticosteroids- Prednisone, Methylprednisolone (Solumedrol), Prednisolone.
  • ICS- Beclomethasone
  • LABA- Salmeterol
  • ICS + LABA= Symbicort (Budenoside/Formoterol), Advair
  • LTRA- Montelukast (Singulair), Zafirlukast
48
Q

High risk populations for TB include:

A
  1. High risk exposure- close contacts in pts with TB, health care workers
  2. High risk of TB infxn- immigrants from high-prevalence areas, homeless
  3. High risk active TB once infected- immunodeficient (HIV, DM, IVDA, ETOHics, malignancy)
    * Mycobacterium is the culprit!!
49
Q

Types of TB infections:

A
  1. Primary TB- outcome of initial infxn (usually self-limiting)
    • Primary Rapidly Progressive TB- active initial infxn with clinical progression; contagious!!
  2. Chronic (Latent) Infxn- 90% control initial primary infxn via GRANULOMA formation. They may become CASEATING (central necrosis, acidic with low oxygen, making it hostile for TB to grow)–> NOT CONTAGIOUS
  3. Secondary (Reactivation) TB- reactivation of latent TB with waning immune defenses (elderly, HIV, steroid use, malignancy)
    - MC localized in apex/upper lobes with CAVITARY lesions–> CONTAGIOUS
50
Q

Clinical manifestations of TB include:

A
  1. Pumonary TB- pulmonary sx such a CP (often pleuritic) and hemoptysis if advanced.
    - Fever, night sweats, fatigue, anorexia, weight loss
  2. Extra-pulmonary TB- can affect any organ- vertebrae, lymph nodes, pericarditis, peritonitis, joints, kidney, etc.
51
Q

TB screening for infection…

A

PPD

SIZE NEEDED FOR POSITIVE READING-

  1. ≥5mm: positive test for those with HIV, immunocompromised
  2. ≥10mm: All other high risk populations this is considered a positive test
  3. ≥15mm: Everyone else (no known risk factors for TB)
52
Q

Diagnostic studies for suspected TB:

A
  1. Acid-fast Smear & Sputum Culture x 3 days. TB ruled out after 3 negative smears. AFB cultures GOLD STANDARD
  2. CXR- Used as yearly screening to r/o active TB in patients with known positive PPD
    a. Reactivation- apical (upper lobe) fibrocavitary dz
    b. Primary TB- middle/lower lobe consolidation
    c. Miliary TB- CXR shows small millet-seed like
    nodular lesions
  3. Interferon Gamma Release Assay
53
Q

Treatment of active TB infxn:

A

Initial 4 DRUG REGIMEN for 6 months (for active TB)

  1. Rifampin
  2. INH- Isoniazid
  3. PZA- Pyrazinamide
  4. EMB- Ethambutol
    * Not considered infectious 2 weeks after initiation of therapy!

**p.114 for table of meds and ADRs and p.115 for CXRs

54
Q

____ is defined as life threatening acute hypoxemic respiratory failure (organ failure from prolonged hypoxemia).

A

ARDS

*MC in critically ill patients

55
Q

Causes of ARDS include:

A

Sepsis (MC), Severe trauma, Aspiration of gastric contents

56
Q

3 main components of ARDS are:

A
  1. Severe refractory hypoxemia
  2. Bilateral pulmonary infiltrates on CXR–> white out pattern (spares costophrenic angles!)
  3. Absence of cardiogenic pulmonary edema/CHF
    * ARDS v. Cardiogenic pulmonary edema- check the pulmonary capillary wedge pressure (if < 18mmHg then you have ARDS)
57
Q

Management of ARDS involves…

A

Noninvasive or mechanical ventilation and treating the underlying cause

58
Q

AMS, Alcoholism, Impaired cough/swallowing reflex, and dementia are all RFs for ______ (dangerous pulmonary event).

A

Foreign body aspiration

59
Q

Foreign body aspiration is MC on the ____ (right/left) side of the lung.

A

Right- due to wider, more vertical, shorter main bronchus

60
Q

Foreign body aspiration is diagnosed and treated by:

A

Bronchoscopy- provides direct visualization of and removal of the foreign object

*on CXR- see regional hyperinflation

61
Q

_____ cancer is common in patients with a smoking history and presents with a central mass, hilar adenopathy, and mediastinal widening

A

Squamous cell lung cancer

62
Q

Cavitation is seen with a _____ or primary TB.

A

Lung abscess

63
Q

____ (type of lung cancer) is associated with the poorest prognosis.

A

Small cell lung cancer is the most common type of lung cancer that is metastatic at the time of discovery, and therefore has the poorest prognosis

64
Q

A PE exam finding of DECREASED tactile fremitus and dullness to percussion would suggest ______.

A

Pleural effusion (PNA has increased tactile fremitus!)

65
Q

_____ is the MC of cancer deaths in men and women 50-60 y

A

Lung cancer

*Cigarette smoking is MC

66
Q

The primary sites of METS w/ lung cancer are:

A

brain, bone, liver, lymph nodes, and adrenals

67
Q

MC type of lung cancer is _______.

A

A non-small cell carcinoma (85%)

68
Q

What are the 3 types of non-small cell carcinoma?

A
  1. Adenocarcinoma
  2. Squamous cell
  3. Large cell (anaplastic) carcinoma
69
Q

_____ is the most common type of non-small cell carcinoma in women.

A

Adenocarcinoma

*Bronchioalveolar is a rare low-grade subtype that has the best prognosis. Presents with voluminous sputum and an interstitial pattern on CXR.

70
Q

______ (type of lung cancer) is typically centrally located and associated with cavitary lesions, HYPERcalcemia, and pancoast syndrome (Think CCCP).

A

Squamous cell

71
Q

_______ (type of lung cancer) is VERY AGGRESSIVE.

A

Large Cell (Anaplastic)

72
Q

Describe small cell carcinoma…

A

Typically METS early–> surgery usually not a treatment option

73
Q

What are the Signs and Symptoms of Small Cell lung cancer?

A
  • dilated neck veins, prominent chest veins
  • SIADH/hyponatremia
  • Cushing’s syndrome
  • Lambert-Eaton syndrome- weakness (improves with movement)
74
Q

What is pancoast syndrome?

A

Associated with squamous cell carcinoma. Atrophy of hand/arm muscles, tumors at superior sulcus, shoulder pain, Horner’s syndrome (miosis, ptosis, anhydrosis)

75
Q

How is lung cancer diagnosed?

A

Found on CXR; CT for staging

76
Q

How is Non small cell cancer treated? How is small cell treated?

A

Non small cell- surgery

Small cell- chemo

77
Q

Name 4 classifications of pleural effusion:

A
  1. Empyema- grossly purulent due to direct infxn of pleural space
  2. Parapneumonic- noninfected secondary to bacterial PNA
  3. Hemothorax- gross blood (think chest trauma and malignancy)
  4. Chylothorax- increased lymph involvement
78
Q

What is transudate and what causes it?

A

Transudate- circulatory system fluid due to increased hydrostatic pressure and/or decreased oncotic pressure

Etiologies- CHF is the MC cause (also nephrotic syndrome and cirrhosis)

79
Q

What is exudate and what causes it?

A

Exudate occurs when local factors increase vascular permeability (INFECTION, INFLAMMATION)
-contains plasma proteins, WBCs, platelets, RBCs

80
Q

What is Light’s Criteria?

A

Exclusive to EXUDATES. Presence of any 3 of the following= exudative.

  1. Pleural fluid protein
  2. Pleural fluid LDH
  3. Pleural fluid LDH (diff parameters than above, see study guide)
81
Q

What are the Signs and Symptoms of pleural effusion?

A

Usually asymptomatic. May complain of “pleuritic” chest pain, cough, dyspnea

82
Q

PE findings of Pleural Effusion-

A

DECREASED TACTILE FREMITUS

DECREASED BREATH SOUNDS

DULLNESS TO PERCUSSION

83
Q

How is a pleural effusion diagnosed?

A

CXR: PA/Lateral
-blunting of costophrenic angles

*LATERAL DECUBITUS films are the best

**Thoracentesis is the test of choice!!

84
Q

How do you treat a pleural effusion?

A
  1. Treat underlying condition- diuretics, sodium restriction
  2. Thoracentesis: gold standard! DON’T remove more than 1.5L during any one procedure
  3. Chest tube pleural fluid drainage: if empyema may inject with streptokinase to facilitate drainage
85
Q

What is the primary cause of a pulmonary embolism?

A

95% originate from DVTs in the LE above the knee or pelvis

*other= fat emboli from long bone fracture and air emboli from central lines

86
Q

What are the Signs and Symptoms of a PE?

A

Dyspnea MC symptom
Tachypnea MC sign

(Remember BREATHS acronym from podcast)

87
Q

What is the classic triad of a pulmonary embolism?

A

Dyspnea, pleuritic chest pain, hemoptysis

88
Q

What is the classic presentation of a pulmonary embolism?

A

Post-op patient with sudden tachypnea, tachycardia, +/- cough, hemoptysis

*Factor V Leiden in the MC predisposing condition

89
Q

How is a pulmonary embolism diagnosed?

A

Helical CT scan best initial test!

(pulmonary angiography is gold standard)

CXR: Westermarks sign, Hampton’s hump
ECG: sinus tach

90
Q

How is a pulmonary embolism managed?

A
  1. Anticoagulation with Heparin
    - Then warfarin x 3mos or
    - Dabigitran or edoxaban
  2. IVC filter: if pt CI for anticoagulate
  3. Thrombolysis: if massive PE and hemodynamically unstable
  4. Thrombectomy/Embolectomy: if thrombolysis is CI
91
Q

Prophylactic options for PE?

A

Early ambulation, elastic stockings/SCDs, LMWH

92
Q

Name and describe the different types of PTX…

A
  1. Spontaneous
    - Atraumatic & idiopathic. Due to bleb rupture.
    a. Primary- NO underlying lung dz, mainly affects tall and thin men 20-40y, smokers, ppl w/ family hx of PTX
    b. Secondary- + underlying lung dz w/o trauma (COPD, asthma)
  2. Traumatic
    - Iatrogenic- during CPR, thoracentesis, PEEP, subclavian line placement, accidents (MVAs)
  3. Tension
    - Any type of PTX in which the positive air pressure pushes lungs, trachea, great vessels & heart to the CONTRALATERAL SIDE. Immediately life threatening! MC seen during TRAUMA, mechanical ventilation, resuscitation efforts
    - Have increased JVP, pulsus paradoxus, hypotension
93
Q

Describing chest pain and PE findings with PTX…

A

Chest pain usually pleuritic, unilateral, non exertional, and sudden onset, dyspnea

  • Hyperresonance to percussion, decreased fremitus, decreased breath sounds
  • Unequal respiratory expansion, tachycardia, tachypnea
94
Q

How is a PTX diagnosed?

A

CXR with EXPIRATORY VIEW

*may see companion lines

95
Q

How is a PTX treated?

A
  1. Observation in primary spontaneous if small (often resolves within 10 days on its own)
  2. Chest tube placement (thoracostomy) if large or severe symptoms
  3. Needle Aspiration: if tension PTX followed by chest tube placement. Needle placed in 2nd intercostal space at midclavicular line of the affected side.
96
Q

What is Mendelson’s syndrome?

A

Chemical pneumonitis secondary to aspiration of stomach contents.

Emergency Medicine (11 decks)

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