Internal Med- Pulmonology Flashcards
What is the main difference between Asthma and COPD?
Asthma is a reversible bronchoconstriction
What are the 2 most common associations with Asthma?
Atopic disorders and obesity
What clinical presentation would make Asthma the most likely diagnosis?
The clear presence of wheezing with the acute onset of shortness of breath,
cough, and chest tightness
What are some of the associations / findings in a Pt with Asthma?
- Symptoms worse at night
- Nasal polyps and sensitivity to aspirin
- Eczema or atopic dermatitis on physical examination
- Increased length of expiratory phase of respiration
- Increased use of accessory respiratory muscles (e.g., intercostals)
What is the best initial test in an acute exacerbation of asthma?
What is the most accurate diagnostic test?
The best initial test is based on the severity of presentation.
Peak expiratory flow (PEF) or
arterial blood gas (ABG).
Pulmonary function test (PFT) [Spirometry]
FEV1/FVC => The FEV1 decreases more than the FVC.
If asymptomatic on presentation=> methacholine challenge or histamine
A 15-year-old boy comes to the office because of occasional shortness of breath every few weeks. Currently he feels well. He uses no medications and denies any other medical problems. Physical examination reveals a pulse of 70 and a respiratory rate of 12 per minute. Chest examination is normal.
Which of the following is the single most accurate diagnostic test at this time?
a. Peak expiratory flow.
b. Increase in FEV1 with albuterol.
c. Diffusion capacity of carbon monoxide.
d. >20% decrease in FEV1 with use of methacholine.
e. Increased alveolar-arterial oxygen difference (A-a gradient).
f. Increase in FVC with albuterol.
g. Flow-volume loop on spirometry.
h. Chest CT scan.
i. Increased pCO2 on ABG.
*D.
When a patient is currently asymptomatic, it is less likely to find an increase in FEV1 with the use of short-acting bronchodilators like albuterol.
When the patient is asymptomatic, the most accurate test of reactive airway disease is a 20% decrease in FEV1 with the use of methacholine or histamine.
Chest CT, like an x-ray, shows either nothing or hyperinflation. The ABG and PEF are useful during an acute exacerbation. Flow-volume loops are best for fixed obstructions such as tracheal lesions or COPD.
When diagnosing Asthma with a PFT, what do we expect to see with the FEV1 with either Albuterol or Methacholine?
FEV1 ↑ (>12%): albuterol
FEV1 ↓ (>20%): methacholine
When diagnosing Asthma what can the CBC show?
CBC may show an increased eosinophil count
What immunologic test can be done in an Asthma Pt?
IgE levels. Increased levels suggest an allergic etiology.
What medication in relation to increased IgE in an Asthma Pt can be given?
Anti-IgE medication=> omalizumab
Apart from Asthma what other disease is associated with increased IgE levels?
allergic bronchopulmonary aspergillosis
How would you Mgx a Pt with Asthma?
Asthma is managed in a stepwise fashion of progressively adding more types of treatment if there is no response.
Step 1. inhaled short-acting beta agonist (SABA):
Albuterol, Levalbuterol
Step 2. Add a long-term control agent to a SABA. Low-dose inhaled corticosteroids (ICS): fluticasone, budesonide
Step 3. Add a long-acting beta agonist (LABA) [salmeterol or formoterol] to a SABA and ICS, or increase the dose of the ICS.
Step 4. Increase the dose of the ICS to maximum in addition to the LABA and
SABA. Add tiotropium, an antimuscarinic agent.
*Oral corticosteroids such as prednisone are added when all the other therapies are not sufficient to control symptoms.
What are some of the adverse effects of inhaled steroids?
Dysphonia and oral candidiasis?
What are some of the alternative long-term control agents?
Cromolyn inhibits mast cell mediator release and eosinophil recruitment
Theophylline
Leukotriene modifiers: montelukast (best with
atopic patients)
What are some of the adverse effects of systemic steroids?
Osteoporosis
Cataracts
Hyperlipidemia, hyperglycemia, acne, and hirsutism (particularly in women)
Thinning of skin, striae, and easy bruising
Which vaccines are mandatory in all asthma Pt?
Influenza and pneumococcal vaccine
A 47-year-old man with a history of asthma comes to the emergency department with several days of increasing shortness of breath, cough, and sputum production. On physical examination his respiratory rate is 34 per minute. He has diffuse expiratory wheezing and a prolonged expiratory phase.
Which of the following would you use as the best indication of the severity of his asthma?
a. Respiratory rate.
b. Use of accessory muscles.
c. Pulse oximetry.
d. Pulmonary function testing.
e. Pulse rate.
*A.
A normal respiratory rate is 10 to 16 per minute. By itself, a respiratory rate of 34 indicates severe shortness of breath. Accessory muscle use is hard to assess and is subjective.
Pulse oximetry will not show hypoxia until the patient is nearly at the point of imminent respiratory failure. Oxygen saturation can be maintained above 90% by hyperventilating. Pulmonary function testing cannot be done when a patient is acutely short of breath.
How can the severity of an asthma exacerbation be quantified?
- Decreased peak expiratory flow (PEF)
- ABG with an increased A-a gradient
How would you manage an acute exacerbation of Asthma?
The best initial therapy is oxygen combined with inhaled short-acting beta agonists such as albuterol and a bolus of steroids. Corticosteroids need 4 to 6 hours to begin to work, so give them right away.
When can Magnesium be used in Asthma?
Magnesium is used only in an acute, severe asthma exacerbation not responsive to several rounds of albuterol while waiting for steroids to take effect.
If a Pt with Asthma does not respond to oxygen, albuterol, and steroids OR develops respiratory acidosis (increased pCO2), what is the next best step?
The Pt may have to endotracheal intubation for mechanical ventilation.
These patients should be placed in the intensive care unit.
Why is Tobacco smoking associated with COPD?
Tobacco destroys elastin fibers
If a Pt presents with a clinical picture like COPD but is young and a nonsmoker, what is the most likely cause?
Alpha-1 antitrypsin deficiency
What are some of the clinical features of a COPD Pt?
- Shortness of breath worsened by exertion
- Intermittent exacerbations with increased cough, sputum, and shortness of breath often brought on by infection
- “Barrel chest” from increased air trapping
- Muscle wasting and cachexia
What is the best initial test in COPD? What are the features?
Chest x-ray:
- Increased anterior-posterior (AP) diameter
- Air trapping and flattened diaphragms
What is the accurate diagnostic test in COPD? What are the features?
PFT:
- Decreased FEV1, decreased FVC, decreased FEV1/FVC ratio (under 70%)
- Increased TLC because of an increase in residual volume
- Decreased DLCO (emphysema, not chronic bronchitis)
- Incomplete improvement with albuterol
- Little or no worsening with methacholine
In COPD, what are the chances of reversibility with Inhaled Bronchodilators and what quantitative figure defines fines reversibility?
About 50% will have some degree of response.
About 50% will have some degree of response.
Full reversibility in response to bronchodilators is defined as greater than 12% or 200 mL increase in FEV1.
What changes do you expect to see with the ABG in a Pt with an acute exacerbation of COPD?
Increased pCO2 and hypoxia. Respiratory alkalosis but acidosis may be present if there is insufficient metabolic compensation
What changes may be present on the CBC in a Pt with COPD?
May have an increase in hematocrit from chronic hypoxia
What ECG findings may be consistent with a Pt with COPD?
- Right atrial hypertrophy and right ventricular hypertrophy (Corplumonale)
- Atrial fibrillation or multifocal atrial tachycardia (MAT)
What Echocardiography findings do you expect to find in a Pt with COPD?
- Right atrial and right ventricular hypertrophy
- Pulmonary hypertension
What is the best initial treatment of COPD?
*Smoking cessation
O2 therapy=>
pO2 below 55 mm Hg or oxygen saturation below 88%
OR
If there are signs of right-sided heart disease/failure or an elevated hematocrit:
pO2 less than 60 mm Hg or oxygen saturation below 90%
Anticholinergic agents: tiotropium, ipratropium
Which vaccines are mandatory in COPD?
Influenza and pneumococcal vaccinations
What medication/therapy can improve symptoms but not decrease disease progression or mortality?
- Short-acting beta agonists (e.g., albuterol)
- Anticholinergic agents: tiotropium, ipratropium
- Steroids
- Long-acting beta agonists (e.g., salmeterol, formoterol)
- Pulmonary rehabilitation
How would you Tx Acute Exacerbations of Chronic Bronchitis?
Bronchodilators (Ipratropium) and
corticosteroid therapy is combined with antibiotics
Why are antibiotics used in Acute Exacerbations of Chronic Bronchitis?
Which antibitics can be used in Acute Exacerbations of Chronic Bronchitis?
Because infection is by far the most commonly identified cause of Acute Exacerbations of Chronic Bronchitis.
- Macrolides: azithromycin, clarithromycin
- Cephalosporins: cefuroxime, cefixime
- Amoxicillin/clavulanic acid (Amoxiclav)
- Quinolones: levofloxacin, moxifloxacin
What are some of the causes of Bronchiectasis?
The single most common cause of bronchiectasis is cystic fibrosis, which accounts for half of cases. Other causes are:
- Infections: tuberculosis, pneumonia, abscess
- Immune deficiency
- Foreign body or tumors
- Allergic bronchopulmonary aspergillosis (ABPA)
- Collagen-vascular disease such as rheumatoid arthritis
What clinical presentation would make Bronchiectasis the most likely diagnosis?
Recurrent episodes of very high volume purulent sputum production is the key to the suggestion of the diagnosis. Hemoptysis can occur. Dyspnea and wheezing are present in 75% of cases. Other findings are:
- Weight loss
- Anemia of chronic disease
- Crackles on lung exam
- Dyskinetic cilia syndrome
What is the best initial test to diagnose Bronchiectasis?
What is the most accurate test?
A chest x-ray:
Will show dilated, thickened bronchi,
sometimes with “tram-tracks,” which is the thickening of the bronchi
CT scan is the most accurate test
How would you Mgx Bronchiectasis?
Chest physiotherapy and postural drainage are essential for dislodging plugged-up bronchi.
Rotate antibiotics, 1 weekly each month.
What is Allergic Bronchopulmonary Aspergillosis (ABPA)?
Its a hypersensitivity of the lungs to fungal antigens that colonize the bronchial tree. ABPA occurs almost exclusively in patients with asthma and a history of atopic disorders.
What clinical presentation would make Allergic Bronchopulmonary Aspergillosis (ABPA) the most likely diagnosis?
An asthmatic patient with recurrent episodes of brown-flecked sputum
and transient infiltrates on chest x-ray.
What are some of the test that can be used to Dx Allergic Bronchopulmonary Aspergillosis (ABPA)?
- Peripheral eosinophilia
- Skin test reactivity to aspergillus antigens
- Precipitating antibodies to aspergillus on blood test
- Elevated serum IgE levels
- Pulmonary infiltrates on chest x-ray or CT
How would you Mgx Allergic Bronchopulmonary Aspergillosis (ABPA)?
Oral steroids (prednisone) for severe cases because inhaled steroids are not effective for ABPA
Itraconazole orally for recurrent episodes.
What is the pathophysiologic definition of Cystic fibrosis (CF)?
is an autosomal recessive disorder caused by a mutation
in the genes that code for chloride transport, the cystic fibrosis transmembrane regulator (CFTR). This leads to abnormally thick mucus in the lungs, as well as damage to the pancreas, liver, sinuses, intestines, and genitourinary tract. Neutrophils also dump tons of DNA into airway secretions, clogging them up.
What are the possible forms of clinical presentations consistent with Gastrointestinal Involvement in Cystic fibrosis (CF)?
- Meconium ileus in infants with abdominal distention
- Pancreatic insufficiency (in 90%) with steatorrhea and vitamin A, D, E, and K malabsorption
- Recurrent pancreatitis
- Distal intestinal obstruction
- Biliary cirrhosis
Can Cystic fibrosis (CF) result in Diabetes Mellitus?
Not really because islets are spared. Beta cell function is normal until much later in life.
What are the possible forms of clinical presentations consistent with Genitourinary Involvement in Cystic fibrosis (CF)?
Men are often infertile; 95% have azoospermia, with the vas deferens missing in 20%.
Women are infertile because chronic lung disease alters the menstrual cycle and thick cervical mucus blocks sperm entry
What is the most accurate test to Dx Cystic fibrosis (CF)?
Increased sweat chloride test.
Pilocarpine increases acetylcholine levels which increases sweat production. Chloride levels in sweat above 60 meq/L on repeated testing establishes the diagnosis.
Why is genotyping with CFTR not the most accurate test to Dx Cystic fibrosis (CF)?
Because there are so many different types of mutations that can lead to CF.
What will PFT’s show in Cystic fibrosis (CF)?
Show mixed obstructive and restrictive patterns; decrease in FVC and total lung capacity; and decreased diffusing capacity for carbon monoxide.
How would you Mgx Cystic fibrosis (CF)?
- Antibiotics are routine (Inhaled aminoglycosides)
- Inhaled recombinant human deoxyribonuclease (rhDNase). This breaks down the massive amounts of DNA in respiratory mucus that clogs up the airways.
- Inhaled bronchodilators such as albuterol
- Ivacaftor increases the activity of CFTR in the 5% of patients who have a specific mutation
Which vaccines are mandatory in Cystic fibrosis (CF)?
Pneumococcal and influenza vaccinations
What is Community-Acquired Pneumonia?
CAP is defined as pneumonia occurring
before hospitalization or within 48 hours of hospital admission.
Which pathogen is the most common cause of Community-Acquired Pneumonia (CAP)?
Streptococcus pneumoniae
Name (8) common pathogens in Community-Acquired Pneumonia (CAP) and their associations
- Haemophilus
influenzae- COPD - Staphylococcus aureus- Recent viral infection (influenza)
- Klebsiella pneumoniae- Alcoholism, diabetes
- Anaerobes- Poor dentition, aspiration
- Mycoplasma
pneumoniae- Young, healthy patients - Legionella- Contaminated water sources, air conditioning, ventilation systems
- Chlamydia psittaci- Birds
- Coxiella burnetii- Animals at the time of giving birth, veterinarians, farmers
What are some of the clinical features of Community-Acquired Pneumonia (CAP)?
- All forms of pneumonia present with fever and cough.
- Cough, from any etiology, may be associated with hemoptysis.
- Dullness to percussion is found if there is an effusion.
- “Bronchial” breath sounds and egophony occur from consolidation of air spaces.
- Rales, rhonchi, and crepitations are auscultatory findings from virtually any form of lung infection.
- Abdominal pain or diarrhea can occur with infection in the lower lobes irritating the intestines through the diaphragm.
- Chills or “rigors” are a sign of bacteremia often with bacterial pathogens.
- Chest pain from pneumonia is often pleuritic, changing with respiration.
- Hypothermia is just as bad as a fever in terms of pathologic significance.
How do you distinguish severe infections in Community-Acquired Pneumonia (CAP)?
Severe infections are distinguished by abnormalities of vital signs (tachycardia, hypotension, tachypnea) or mental status.
What are the main ways to distinguish pneumonia from bronchitis?
Dyspnea, high fever, and an abnormal chest x-ray
What are the associations on presentation of the following pathogens: 1. Klebsiella pneumoniae 2. Anaerobes 3. Mycoplasma pneumoniae 4. Legionella 5. Pneumocystis
- Hemoptysis from necrotizing disease, “currant jelly” sputum
- Foul-smelling sputum, “rotten eggs”
- Dry cough, rarely severe, bullous myringitis
- Gastrointestinal symptoms (abdominal pain, diarrhea) or CNS
symptoms such as headache and confusion - AIDS with <200 CD4 cells
Which organisms causing Community-Acquired Pneumonia (CAP) are often accompanied by a dry cough and why?
Viruses Mycoplasma Coxiella Pneumocystis Chlamydia
These infections preferentially involve the interstitial space and more often leave the air spaces of the alveoli empty. That is why there is less sputum production.
What is the best initial test to Dx Community-Acquired Pneumonia (CAP)?
The best initial test for all respiratory infections is a chest x-ray
What are the 2 best ways to first try determine a specific microbial etiology in pneumonia?
Sputum Gram stain and sputum culture.
What does the term atypical pneumonia mean?
It refers to an organism not visible on Gram stain and not culturable on standard blood agar.
In Pneumonia, why is the use of sputum stain and culture is somewhat controversial?
Even after thorough sputum examination, no etiology is found in at least 50% of cases. This is because Mycoplasma, Chlamydophila, Legionella, Coxiella, and viruses are not visible on Gram stain yet they’re not atypical pneumonia causing organisms but CAP.
Which organisms present with bilateral interstitial infiltrates on chest X-ray?
The same organisms that typically present with a nonproductive cough. Viruses Mycoplasma Coxiella Pneumocystis Chlamydia
What are the chances of the first X-ray being falsely negative in pneumonia?
at least 10% to 20% of cases.
What are the chances of blood cultures being positive in pneumonia?
<15% of cases of CAP
When is Thoracentesis indicated in Pneumonia?
When the diagnosis is unclear and to exclude an empyema.
What is an empyema? How is it managed?
It is an infected pleural effusion.
Empyema acts like an abscess and will improve more rapidly if it is drained with a chest tube.
