Pulmonology

Question 1

peak expiratory flow and pulmonary function tests

Answer 1

• if <350L/min, perform PFTs to screen for obstruction
• PFT:
  
  • FEV1: amount of air that can be forced out of the lungs in 1 second
    
    • Airway obstruction dx by: normal/increased TLC w/ decreased FEV1 (FEV1/FVC <0.7)
  • Tiffeneau index (FEV1/FVC x 100): % of FVC expired in 1 second
  • FET = forced expiratory time
• Obstructive vs restrictive: BASED ON TLC, NOT VITAL CAPACITY

Question 2

obstructive vs restrictive dz

Answer 2

Question 3

Tidal volume, residual volume, insp reserve, exp reserve, vital capacity, total lung capacity, insp capacity, funcitonal residual capacity

Answer 3

Question 4

DLCO

Answer 4

• diffusing capacity of the lung for carbon monoxide
• DLCO = CO into lungs - CO out of lungs
• use carbon monoxide bc we can maximize diffusion bc of the affinitiy of Hgb for it - Volume = area/thickness x (P1 - P2) x constant
• In emphysema, tissue is destroyed, reducing surface area for diffusion - decreased surface area causes volume to decrease
• In sarcoidosis and fibrosis, lung thickness increases, also driving volume to decrease

Question 5

Acute/Chronic bronchitis

Answer 5

• etiology: viruses (most), cannot distinguish acute bronchitis from URTI in first few days
• sxs: cough >5d (+/- sputum), lasts 2-3wks
  
  • chest discomfort
  • SOB
  • +/- fever
• dx: labs not indicated, unless pneumonia suspected (HR >100, RR >24, T >38C, rales, hypoxemia, mental confusion, or systemic illness)
  
  • CXR
• Tx: abx not recommended since most viral
• sxs based tx: NSAIDs, ASA, tylenol, and/or ipratropium
  
  • abx and cough suppressants not indicated
    
    • cough suppressants: codeine-containing cough meds
    • bronchodilators (albuterol)

Question 6

Asthma

Answer 6

• characteristics: airway inflammation, airway hyperresponsiveness, reversible airflow obstruction, may begin at any age, dyspnea common when rapid changes in temp or humidity
• extrinsic: Atopic: produce IgE dt enviro triggers (eczema, hay fever), become asthmatic young
• intrinsic: not related to atopy of enviro factors
• want to see increased FEV1 >12% with albuterol
• can also see decrease in FEV1 >20% with methacholine or histamine challenge
• increase in diffusion capacity of lung for DLCO

Question 7

Asthma characteristics, signs, sxs

Answer 7

• Triggers: pollens, house dust, molds, cockroaches, cats, dogs, cold air, viral infxns, tobacco smoke, meds (BB, ASA), exercise
• sxs: SOB, wheezing, chest tightness, cough (occurs in 30 mins to exposure to triggers, sxs worse at night)
• signs: wheezing (inspiration and expiration) is the MC finding

Question 8

Asthma dx and tx

Answer 8

• Dx: CXR for first time wheezers, PFTs required to dx, spirometry before and after bronchodilators - increase in FEV1 ro FVC by 12%
• Tx 1:
  
  • SABA for acute attacks (onset 2-5 min, lasts 4-6h
  • LABA (salmeterol) for nighttime asthma and exercise induced
  • ICS: moderate to severe asthma, use reg to decrease airway hyperresp.
• Tx 2:
  
  • Montekukast: proph for mild exercised induced and control of mild-moderate, allows for reduction in steroid and B2
  • Cromolyn sodium: proph before exercise
  • Avoid BB in asthmatics

Question 9

Acute asthma exacerbation

Answer 9

• sxs: sweating, wheezing, speaking incomplete sentences, tachypnea, paradoxical mvmt of abdomen, use of accessory mm.
• dx: PEFR: low, severe <60
  
  • ABG: increased A-a gradient
  • CXR: ro pneumonia, pneumothorax
• tx 1: nebulizer (SABA) or MDI, IV or oral steroids, IV magnesium (prevent bronchospasm)
• complications:
  
  • status asthmaticus: doesnt respond to standard meds
  • ARDS: resp mm fatigue
  • pneumothorax, atelectasis, pneumomediastinum

Question 10

Asthma classification

Answer 10

• Intermittent, mild persistent, moderate persistent, severe persistent

Question 11

COPD

Answer 11

• 4th leading cause of death in the United States
• Coexisting bronchitis and emphysema, rarely one or the other by itself
• Leads to chronic respiratoyr acidosis with metabolic alkalosis as compensation
• risk factors and causes:
  
  • Smoking (tobacco), alpha antitrypsin deficiency, enviro factors (second hand smoke), chronic asthma
• MCC acute exacerbation: infxn, noncompliance, cardiac dz
• secondary polycythemia (response to chronic hypoxemia

Question 12

Chronic Bronchitis

Answer 12

• excess mucous narrows airways (productive cough), scarring and inflamm -> enlarged glands -> smooth m hyperplasia = obstruction
• sxs: cough, sputum, dyspnea (on exert or rest)
• signs: prolonged forced exp time, exp wheezes, dec. breath sounds, insp crackles, tachypnea, tachycardia, cyanosis, accessory mm use, hyperresonance, signs of cor pulmonale
• dx: chronic cough and sputum >3 mo, at least 2 consec years
  
  • CXR, alpha antitryp levels, ABG

Question 13

emphysema etiology and types

Answer 13

• elastase (protease) excess and overinflation (elastase released from WBCs ingesting lung tissue, normally inhib by alpha antitryp.; tobacco smoke increases WBCs, inhibits antitryp, increases oxidative stress)
• types:
  
  • centrilobular: MC, smokers, destruction of bronchioles in upper lungs
  • Panlobular: pts with alpha antityrp def.; destruction of prox and distal acini (lung bases)

Question 14

emphysema sxs, dx

Answer 14

• sxs: productive cough or chest tightness, worse in morning, clear to white sputum, 50yo typical
  
  • dyspnea MC presents at 60yo, wheezing
• signs: tachypnea, DOE, cyanosis, JVD, atrophy of limb musculature, peripheral edema, Barrel chest (2:1 A:P), diffuse or focal wheezing, diminished breath sounds, hyperresonance
• dx: permanent enlargement of airspaces distal to terminal bronchioles dt destruction . of alveolar walls
  
  • decreased DLCO
  • PFTs (spirometry): FEV1/FVC <0.75, FEV1 decreased, TLC, residual volume, FRC increased
  • Vital capacity decreased: extra air coming in is not useful - becomes dead space
  • CXR

Question 15

chronic bronchitis tx

Answer 15

• smoking cessation (most important)
• albuterol (long term salmeterol for requent use of SABA)
• anticholinergics (ipratropium)
• combo of B agonist and anticholinergics
• Inhaled corticosteroids (O2 tx): long term hypoxemia leads to HTN and cor pulmonale
• pulmonary rehab: improves exercise tolerance
• IMZ: flue and strep q1y pneumo q5-6y
• surgery: lung resection vs transplant

Question 16

emphysema tx

Answer 16

• smoking cessation and home O2 are the only interventions shown to lower mortality
• steroids and abx for acute exacerbations: increased sputum produciton or change in character or worsening SOB
  
  • not responsive to bronchodilators, IV methylprednisolone if hosp., azithro or levo, O2>90% nasal cannula, NPPV (BiPAP or CPAP), can lead to ARDS
• Criteria for O2: PaO2 55mm Hg, O2 sat <88% (pulse ox) at rest or exercise, PaO2 55-59 + polycythemia or cor pulmonale
• look for nocturnal hypoxemia, give CPAP or O2 as needed

Question 17

COPD staging

Answer 17

Question 18

Community acquired PNA

Answer 18

• occurs when there is a defect in pulm defense mech (cough reflex, mucociliary clearance, immune response)
• urinary Ag for Strep pneumo helpful screening tool in pts w/ leukopenia, asplenia, alcohol use, chronic liver dz, pleural effusion, ICU
• urinary Ag for Legionella helpful in pts with alc use, travel previous 2 wks, pleural effusion, ICU
• broad spectrum B-lactamase species: enterobacter, klebsiella pneumo, e. coli

Question 19

community acquired PNA (pneumo PNA) in immunocompetent: etiology, RF, sxs

Answer 19

• MCC: s. pneumo, H flu, Myco PNA, S aureus, N meningitidis, M catarrhalis, K PNA, other GNR
• viruses: influenza, RSV, adeno, parainfluenza
• Occurs outside hosp or within 48hr of hosp admission
• RF: old, alcoholic, smoker, asthma, COPD
• MCC pulm dz in HIV pts
• sxs: fever, cough (with or without sputum), SOB, sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, HA< abd pain
• signs: fever or hypotherm, tachypnea, tachycardia, O2 desat, insp crackles and bronchial breath sounds, dullness to percussion

Question 20

CAP in immunocompetent: dx

Answer 20

• dx:
  
  • imaging:
    
    • CXR (patchy airspace opacities to lobar consolidation with air bronchograms) - not necessary in outpt bc empiric tx is effective, recommended if unusual presentation, hx, or inpt, clearing of opacities can take 6 wk or longer
    • CT: more sensitive and specific
  • Labs: sputum gram stain (not sensitive or specific for strep pneumo), urinary Ag test for strep pneumo and legionella, rapid Ag test for flu, pre-antibiotic sputum and blood cultures, CBC, CMP, LFTs, bilirubin, ABG in hypoxemic pts, HIV testing, procalcitonin-released by bact toxins and inhibited by viral infxn

Question 21

community acquire PNA in immunocompromised pts

Answer 21

• etiology: HIV (ANC <1000), current or recent exposure to myelo or immunosuppressive medications, or pts taking chronic steroids
• dx: sputum induction, BAL (r/o PCP PNA)

Question 22

Nosocomial PNA

Answer 22

• Pathogens: s. aureus, K. PNA, E. coli, pseudomonas aeruginosa
• sxs: at >/= 2 of the following: fever, leukcytosis, purulent sputum
• dx: CXR, blood cultures x2, CBC and CMP, sputum culture and gram stain (not sensitive or specific), ABG, thoracentesis if effusion, procalcitonin

Question 23

pneumocystis pneumonia

Answer 23

• pneumocystis jirovecii - caused by fungus found in lungs of mammals
• MC opportunistic infxn in HIV/AIDS
• sxs: fever, SOB, nonproductive cough, exam findings disproportionate to imaging showing diffuse interstitial infiltraties, fatigue, weakness, weight loss
• dx: CXR (definitive): diffuse or perihilar infiltrates, reticular interstitial PNA or airspace dz that mimics pulm edema (5-10%) normal CXR, absent pleural effusions)
  
  • sputum wright-giemsa stain or DFA (direct fluorescence Ab) - definitive in 50-80%
  • BAL - definitive in 95%
  • CD4 <200 - if AIDS
  • ABG; hypoxia, hypocapnia, reduced DLCO
  • increased LDH but nonsepcific, serum B-glucan is more sensitive and specific, WBC low
• tx: Bactrim, add steroids if PaO2 <79 or A-a gradient >35 if given in 72h, dapson if sulfa allergy, all pts with CD4 <200 should undergo proph

Question 24

PNA tx: outpatient, smokers, and inpatient (non-ICU)

Answer 24

• Outpt: 5 djays minimum or until pt afebrile x48-72h
  
  • pathogens: S pnemo, M pneumo, C pneumo, flu virus
  • Previously healthy, no recent abx: macrolide (clarithro or azithro x4d), doxy
  • At risk for drug resistance (old, comorbid, immunosuppress, exposure to child in daycare): respiratory FQ (moxiflox), macrolide plus B lactam
• Smokers: Cefdinir
• Inpt, non-ICU:
  
  • Pathogens: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
  • First line: Resp FQ (IV levo), or IV cipro
  • If at risk for pseudomonas: IV macrolide plus IV B lactam (HD ampicillin or Ceoftaxime or ceftriaxone)

Question 25

PNA tx: hospitalized or ICU pts

Answer 25

• Duration: 5d minimum or until pt afebrile x48-72h
• ICU: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
• Previously healthy: Azithro or resp FQ (moxi or levo) plus cefotaxime, ceftriaxone, or UNASYN
  
  • if B lactam allergy: FQ plus Aztreonam
• pts at risk for drug resistance: Antipneumococcal and antipseudomonal B lactam: Zosyn, cefepime, imipenem or meropenem PLUS:
  
  • cipro or levo, OR, antipneumo B-lactam (cefotaxime, ceftriaxone, UNASYN) PLUS Aminoglyc (gent, tobra, amikacin) PLUS Azithro or resp FQ
  • If at risk for MRSA: add vanco or linezolid

Question 26

PNA tx: nosocomial PNA

Answer 26

• previously healthy: ceftriaxone, moxi, levo, cipro, UNASYN, Zosyn, or ertapenem
• at risk for drug resistance: one agent from each:
  
  • Antipseudomonal
    
    • Cefepime, Impenem, Zosyn, or aztreonam (if PCN allergy)
  • Second antipseudomonal
    
    • Levo, cipro, gent, tobra, or amikacin
  • MRSA coverage
    
    • vanco or linezolid

Question 27

When to admit for PNA

Answer 27

• CURB-65 Score
  
  • 1. confusion
  • 2. uremia
  • 3. resp rate
  • 4. blood pressure
  • 5. age >65
• <1 = no hosp
• 1-2 = hosp (maybe ICU)
• 3+ = definite ICU admit

Question 28

Tuberculosis

Answer 28

• can present as acute or latent infxn
• only active TB is contagious (cough, sneezing), PRIMARY TB IS NOT CONTAGIOUS
• difficult to dx in HIV, PPD will be neg, atypical CXR findings, sputum likely neg, granuloma may not be present
• RF: HIV, immigrants, prisoners, health care workers, close contact, alcoholics, DM, steroids, blood malig, IVDU
• MC: mycobacterium tuberculosis, slow growing
• Transmission: inhalation of aerosolized droplets
• sxs: fatigue, weight loss, fever, night sweats, productive cough
• dx: sputum stain (acid fast bacilli), sputume culture + for M. tuberculosis, PPD, CXR (caseating granuloma formation (pulm opacitis, most often atypical)
• tx: RIPE tx, dc tx if transaminases >3-5x ULN, can spread to vertebral column

Question 29

Primary, Secondary, and Extrapulmonary TB

Answer 29

• Primary: bacilli inhaled and deposited into lung - ingested by alveolar macrophages
  
  • surviving orgs multiply and disseminate via lymphatics and blood
  • granulomas form and “wall off” mycobacteria - remains dormant
  • insults on immune syst reactivates (5-10%)
  • Asymptomatic: pleural effusion, can be progressive with pulm and constitutional sxs, usually clinically and radiographically silent
• Secondary: Host’s immunity weakened (HIV, malignancy, steroids, substance abuse, poor nutrition), gastrectomy, silicosis, DM)
  
  • most oxygenated parts of lung: apical/posterior segments
  • Symptomatic: fever, night sweats, weight loss, malaise, chronic cough, progressive (dry to purulent, blood streaked)
    
    • signs: chronically ill appearing, malnourished, posttussive apical rales
• Extrapulmonary TB: impaired immunity cannot contain bacteria - disseminates (HIV)
  
  • any organ
  • Miliary TB: hematogenous spread - can be due to reactivation or new infxn, HIV pts, organomegaly, reticulonodular infiltrates, choroidal tubercles in eye

Question 30

TB diagnostics

Answer 30

• high index of suspicion depending on RF and presentation
• CXR - unilateral apical infiltrates with cavitations, hilar and paratracheal lymph node enlargement, pleural effusions, Ghon complex, Ranke complex
  
  • HIV may show lower lung zone, diffuse, or miliary infiltrates
• Sputum studies: definitive dx by sputum culture, obtain 3 morning sputum speciments, takes 4-8wks, PCR can detect specifics
• PPD (Mantoux test): screening to detect previous TB exposure, not for active TB dx; if + use CXR to r/o active TB
  
  • if sxatic or abnl CXR, order AFB
  • >15mm if no risk factors; >10 if high risk (homeless, imigrants, health care workers, DM); >5 if very high risk (HIV, organ transplant, contact with active TB)
• Interferon gamma release assay: measures interferon gamma release in response to MTB antigens, helps exclude false + TST
• blood cultures
• NAAT-R

Question 31

signs of healed primary TB:

Answer 31

• Ghon complex: calcified focus with associated lymph node
• Ranke complex: Ghon complex undergoes fibrosis and calcification
• CXR: fibrocavitary apical dz, discrete nodules, pneumonic infiltrates usually in apical or posterior segments of upper lobes or in superior segments of lower lobes

Question 32

TB treatment: active TB, Pregnant women, Latent TB, Immunnocompetent, HIV pos

Answer 32

• Active TB: droplet precautions; isolation until sputum neg for AFB
  
  • 2 months of tx with 4 drug RIPE, then 4 months with INH and Rifampin
  • once isolate determined to be isoniazid sensitive, ethambutold can be DCed; if susceptible to isoniazid and rif, may continue on 2-drug regimens
  • tx >/= 3 mos past neg cxs for MTB
• Pregnant: DONT TAKE PYRAZINAMIDE: RIE x 2mo, then isoniazid and rif for 7 mo; B6 (pyridoxine) daily to prevent periph neuropathy; breastfeeding NOT contraindicated
• Latent (+ PPD): 9mo INH AFTER active TB excluded via CXR, sputum, or both; NOT infxous, no active dz
• Immunocompetent: INH x9mo; adverse effect = drug induced hepatitis
• HIV pos: 9mo INH OR 2mo rif and pyrazinamide OR rif x 4mo
• Other: 9 mo tx when miliary, meninegal or bone/jnt dz; surgical drainage and debridement of necrotic bone in skeletal dz; steroid tx to prevent constrictive pericarditis and neuro complications

Question 33

Pulmonary neoplasm

Answer 33

• Risk factors: cigarette smoking (>85%) increased risk with increasing pack yrs
  
  • Adenocarcinoma = lowest association of smoking
  • Asbestos
  • Radon
  • COPD
• Metastatic dz: brain, bone, adrenal glands, liver

Question 34

Small cell lung cancer

Answer 34

• 25%
• Sxs: recurrent PNA, anorexia, weight loss, weakness, cough
• Associated sxs: superior vena cava syndrome (facial fullness, edema, dilated veins over ant chest, arms, face, JVD, phrenic nerve palsy, recurrent laryngeal nerve palsy (hoarseness), Horner syndrome (unilateral facial anihdrosis, ptosis, miosis), malignant pleural effusion, Eaton-Lambert syndrome (similar to myasthenia gravis)
• Dx: CXR (not for screening), CT chest (staging), bx (histologic type), cytologic exam of sputum (central tumors), fiberoptic bronchoscope (central dz), PET scan, transthoracic bx (peripheral dz), mediastinoscopy (advanced dz)
• Tx: chemo and radiation
  
  • if dz is extensive, chemo only and then radiation if it is responsive to chemo
• Prognosis:
  
  • Limited: 10-13% 5y survival
  • Exstensive: 1-3% 5y survival
• Staging: limited = confined to CHEST and supraclavicular nodes (not cervical or axillary); extensive = outside chest and supraclavicular nodes

Question 35

Non-small cell lung cancer

Answer 35

• Etiology: SCC, adeno, large cell, bronchoalveolar cell
• sxs: cough, hemoptysis, obstruction, wheezing, pancoast syndrome (superior sulcus tumor - shoulder pain, radiates down arm, pain and upper extremity weakness dt brachial plexus invasion, horner syndrome)
• associated sxs: paraneoplastic syndromes (SIADH, ectopic ACTH, PTH-like secretion, hypertrophic pulm osteoarthropathy)
• dx: CXR (pleural effusion) - always perform bx for intrathoracic lymphadenopathy
• tx: surgery = best option (if met outside chest, not candidate; may recur after surgery)
  
  • Radiation: important adjunct, chemotherapy has an uncertain benefit
• staging: primary TNM staging

Question 36

lung cancer screening

Answer 36

• annual screening for lung cancer with low-dose CT 55-80yo w/ 30 pack/yr hx and currently smoke or quit within past 15yrs
• discontinue screening once person stops for 15yrs or develops health prob that substantially limits life expectancy

Question 37

Obestiy hypoventilation (pickwickian) syndorme

Answer 37

• severely overweight ppl fail to breathe rapidly or deeply enough resulting in low blood O2 and high CO2 levels
  
  • may result in OSA, eventual heart failure sxs (leg swelling0
• clinical features: obestiy (BMI >30)
• tx: weight loss, cpap

Question 38

Obstructive sleep apnea etiology, RF, sxs

Answer 38

• etiology: loss of pharyngeal m tone
• RF: micrognathia, macroglossia, obesity, tonsillar hypertrophy, hypothyroid, smoking, ingestion of ETOH or sedatives before sleep, nasal obstruction (flu)
• sxs: hx of loud snoring, apnea (cessation of breathing), excessive daytime sleepiness, fatigue, personality changes, poor judgment, memory impairment, depression, HTN, HA worse in AM, impotence
• Signs: appears sleepy, narrow oropharynx, large tonsils, large tongue, deviated septum, “bull neck” appearance

Question 39

OSA dx and tx

Answer 39

• Dx: polysomnography (definitive): 5+ episodes of apnea, hypopnea or resp related arousals per hour during sleep
  
  • erythrocytosis, CO2 >45
• Tx: weight loss, avoid hypnotics, CPAP, if O2 <90% switch to BiPAP (higher inspiration, lower expiration pressures), add O2 if both previous txs dont work, UPPP, tracheostomy = definitive tx

Question 40

therapies for smoking cessation

Answer 40

• Bupropion (norepinephrine/dopamine reuptake inhibitor); taken PO, works in 1-2wks
  
  • CI: hx seizure, eating disorder, ubrupt discontinuation of ETOH or sedatives, use of MAOIs within 14d, linezolid or IV methylene blue
  • AE: insomnia, HA, dry mouth, const, N/V, weight loss
• Nicotine gum (nicotinic cholinergic receptor agonist)
  
  • AE: mouth soreness or ulcers, dyspepsia, HA, excess salivation, sore jaw
• Nicotine patch (nicotine agonist) transdermal
  
  • AE: insomnia, skin irritation)
• Varenicline (chantix - partial cholinergic receptor agonist)
  
  • CI: cardiovasc dz, mood disorders
  • AE: N/V, HA, vivid dreams, constipation
• Second line tx:
  
  • Clonidine (alpha agonist)
    
    • CI: rebound HTN if dced too quick
    • AE: dry mouth, drowsiness, dizziness, HoTN, Sedation, HA
  • Nortryptyline (TCA - inhib reuptake of NE more than serotonin)
    
    • CI: risk arrhythmia, dont use in acute recovery of MI
    • AE: sedation, dry mouth, const, increased appetite, blurred vision, tinnitus