FunMed Pulmonary Flashcards by Patrick Nelson

Adult ICU CAP treatment

ICU: B-lactam + macrolide OR B-lactam + fluoroquinolone
broaden antibiotics with Pseudomonas coverage, i.e., B-lactam
Consider further testing if not improving (eg CT of chest); thoracentesis if pleural fluid is present
Outpatient: macrolide +/- B-lactam; doxycycline
Inpatient: B-lactam + macrolide OR a respiratory fluoroquinolone

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Supportive care
Limit the number of paroxysms
Observe the severity of cough and provide assistance when necessary; Elevate head
Maximize nutrition, rest, and recovery
Azithromycin is the treatment of choice for all patients.
Trimethoprim-sulfamethoxazole if a hypersensitivity to macrolides
Prophylaxis for exposed/susceptible persons is also azithromycin for 5 days

Treatment of Pertussis

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paramyxovirus
annual outbreaks, winter, mid-October - January
A leading cause of hospitalization in US children
Can also cause upper and lower respiratory tract infection in adults
increasingly recognized severity in those with comorbid conditions

Respiratory Syncytial Virus (RSV)

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Use these for diagnosis of what?

Radiographically presents with nodular, irregular, pleural thickening, poss pleural effusion, and pleural plaquing
CXR
CT
Thoracentesis
Surgical biopsy
Usually necessary for diagnosis
Difficult to diagnose
PET
Helpful in ?malignancy; staging; poss surgical candidate

Mesothelioma

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•2-5mm radio-opaque nodules on CXR

Dust particles in the alveoli are ingested by macrophages which then become “coal macules”

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HIV testing
Interferon-gamma release assay (IGRA)
Acid-fast bacilli (AFB) smear and culture with drug susceptibility

Using sputum from the patient collected in the early morning on how many consecutive days?

Diagnostic Tests for TB

3 consecutive days

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Complications include
Respiratory failure for a minority of patients
Malignancy
Bronchogenic adenocarcinoma
Malignant Mesothelioma (cancer arising from the mesothelial surface of the pleural cavity)
Concomitant tobacco use increases risk of malignancy even more
Treatment is supportive and preventative

Pneumoconiosis – Asbestosis

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PCR assay is faster and more sensitive, but Nasopharyngeal swab is criterion standard for diagnosis

CBC will show leukocytosis with absolute lymphocytosis

Positive tests must be reported to state and local public health authorities

Diagnosis of Pertussis

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•Alveolar ventilation (⩒A) ultimately determines the

PaCO2

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Recurrent, alveolar hemorrhage
Children or young adults
Iron deficiency
Celiac disease.
Treatment of acute episodes of hemorrhage with corticosteroids. Recurrent episodes of pulmonary hemorrhage may result in interstitial fibrosis and pulmonary failure.

Alveolar Hemorrhage Syndrome: Idiopathic pulmonary hemosiderosis:

Renal involvement and anti-glomerular basement membrane antibodies are absent, in contrast to Goodpasture Syndrome

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Symptoms last 5-7 days
Edema and obstruction of these upper airways.
Viral infection of the larynx, trachea, and the upper bronchial tree
Most common between 7 and 36 months of age
Lungs are typically clear to auscultation

Acute Laryngotracheitis / Croup

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Slowly progressive constitutional symptoms
Malaise
Anorexia
Weight loss
Fever
Night sweats
Chronic cough, productive with blood streaked sputum

Presentation of TB

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Patients typically present decades after relevant exposure with:
Wait for it…
Slowly progressive dyspnea, dry cough, and inspiratory crackles on exam…

Restrictive Lung Diseases Interstitial Lung Disease/Diffuse Parenchymal Lung Disease

Occupational Lung Diseases

Pneumoconiosis – Asbestosis

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Pediatric Pneumonia, drug of choice for each age group?

<4 weeks:
4-12 weeks:
3mo-5 yrs:
>5yrs:

<4 weeks: ampicillin and gentamicin or cefotaxime
4-12 weeks: IV ampicillin
3mo-5yrs: oral amoxicillin (if outpatient)
>5 yrs: oral amoxicillin +/- a macrolide if an atypical organism is likely

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Virchow triad?

(1) venous stasis
(2) activation of blood coagulation
(3) vein damage

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2-5mm radio-opaque nodules on CXR
Nodular opacities occur primarily in the upper lung fields in simple version
May become more widespread and then confluent with progression to large opacities in complicated version with progressive massive fibrosis

Pneumoconiosis – Coal Worker’s Lung

simple coal workers pneumoconiosis

complicated coal workers pneumoconiosis

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Which Alveolar Hemorrhage Syndrome?

Idiopathic, recurrent alveolar hemorrhage
Glomerulonephritis - rapidly progressive
Occurs in men 30-40 yo
Hemoptysis usual presenting symptom
Dyspnea, cough, hypoxemia, diffuse bilateral alveolar infiltrates
Iron deficiency anemia and microscopic hematuria (glomerulonephritis)

Goodpasture syndrome

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Abrupt onset (w/in 4-6 hrs) of fever, chills, malaise, nausea, cough, chest tightness, dyspnea.
Exam: basilar crackles and tachypnea.
CXR frequently normal
Potentially confused with a viral or bacterial infection and given antibiotics
Treatment: remove from environment
Symptoms subside within 12hrs to several days.

Disease may recur with reexposure

ACUTE Hypersensitivity Pneumonitis

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Transmitted via respiratory droplets
Attacks ciliated epithelium
Produces toxins —> inflammation and necrosis —> airway plugs, bronchopneumonia, and hypoxemia.

Pertussis

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Nasopharyngeal swab for culture is the Criterion standard for diagnosis but Takes a long time to get results and Must be cultured during catarrhal or paroxysmal phases
PCR assays and antigen detection has Rapid results and More sensitivity and Can use later in the disease course
CBC will show leukocytosis with absolute lymphocytosis
Positive tests must be reported to state and local public health authorities

Diagnosis of Pertussis

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Since cause is most often viral, antibiotics not necessary.
Avoid cough suppressants (try not to mess with the mucociliary clearance!)
Okay to use at night if patient needs sleep

Treatment of Acute Bronchitis

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Adult CAP Treatment

•Always cover _______?

Generally cover________?

Outpatient:
Inpatient:
ICU:

S. pneumoniae

Atypicals

macrolide +/- B-lactam OR doxycycline

B-lactam + macrolide OR a respiratory fluoroquinolone

B-lactam + macrolide OR B-lactam + fluoroquinolone

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Most cases caused by RSV
Edema and cellular debris cause obstruction of small airways.
most often in infants and young children.
Most commonly in first 2 years of life.
Peak age is 6 months.
Leading cause of infant hospitalization.

Acute Bronchiolitis

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OSA: treatment (children)

●Much more likely to be treated surgically ○Good outcomes data in otherwise healthy children with adenotonsillar hypertrophy ●Other surgeries can be done for children with craniofacial abnormalities; case-by-case evaluation ●CPAP if no surgical option, especially in obese children ○Need frequent re-evaluation of mask fit ●Other lifestyle interventions ○Healthy diet, exercise, weight management ○Management of allergy/nasal congestion if present ○Orthodontia if needed otherwise

Adult CAP: diagnostic testing: 1. CBC with differential and chemistries to? 2. WBC differential can (sometimes) assist with differentiating? 3. Must be true sputum rather than saliva. Criteria per high powered field? 4. Blood cultures for high-risk patients or those suspected of? 5. Nasopharyngeal swab for? 6. Urine antigen testing for?

1. Help assess the severity of illness 2. Viral from bacterial etiology 3. \>25 WBCs and \<10 squamous epithelial cells per HPF 4. Sepsis 5. PCR looking for viral infection and some atypicals 6. Legionella and S. pneumoniae.

no current or recent hospitalization or stay in a long-term care facility no antibiotic therapy in the past 3 months not on chronic dialysis or home infusion therapy no home wound care no household contact with a multi-drug resistant organism

community-acquired pneumonia

* Identification of _________ and ferruginous bodies on pathology aid diagnosis (though usually unnecessary) * Respiratory failure for a minority of patients * Bronchogenic adenocarcinoma * Malignant \_\_\_\_\_\_\_\_\_? Concomitant tobacco use increases risk of malignancy even more

asbestos fibers Pneumoconiosis -- Asbestosis Mesothelioma (cancer arising from the mesothelial surface of the pleural cavity)

An Immunologic reaction to an inhaled organic antigen

Hypersensitivity Pneumonitis

* Reticular and small nodular opacities bilaterally in the lower lung fields * Calcified pleural plaques, also typically in the lower lungs * Pleural effusions

Pneumoconiosis -- Asbestosis

* Most patients recover in 3 days * Malaise may persist for weeks Rapid Diagnostic Testing takes about 15 minutes for results. RT-PCR assay testing can take 4 to 8 hours; Some tests can differentiate between A&B, some can specify the strain of A; complex lab test and $$$ Viral Culture takes 10-14 days.

Influenza

* Chronic * Simple version: * Appears as innumerable, small, rounded opacities (\<10mm) in the dorsal, upper lung fields. * HRCT is helpful in evaluation

Pneumoconiosis -- Silicosis

* It is VERY important to establish clearing of? * A common presentation of lung tumor is post-obstructive? * A follow-up CXR should always be done in ______ to document return to normalcy * After hospitalization, follow up within ______ prevents re-admission

pneumonia pneumonia 6-8 weeks 5 days

Dyspnea- tachypnea- chest pain may be your only clues for?

A normal A-a gradient is less than?

Patient's age divided by 4 + 4

* Characteristic linear **IgG deposits** detected by immunofluorescence in glomeruli or alveoli is diagnostic * Combinations of **immunosuppressive drugs and plasmapheresis** work well for treatment

Diagnosis and treatment for the Alveolar Hemorrhage Syndrome, **Goodpasture syndrome**

What disease?

A representative anteroposterior chest x-ray in the exudative phase of ARDS •Pressure-volume relationship in the lungs of a patient with acute respiratory distress syndrome (ARDS)

* Low grade malignant neoplasms * Most common in GI tract * Well-differentiated neuroendocrine tumors * Central vs. peripheral pulmonary

Carcinoid/Bronchial gland tumors, aka: bronchial adenomas

★A leading cause of hospitalization in young children ★Nasopharyngeal swab for RSV rapid viral antigen test ★Treat with oxygenation, hydration, bronchodilators, suctioning

★Bronchiolitis/RSV

A chronic, immunologically mediated, granulomatous disease ## Footnote •Inhalation causes lung pathology. However, skin contact can cause cutaneous nodules as well

Pneumoconiosis -- Berylliosis

* Occurs most commonly in children \<2 or 9 - 15 yrs * Cough may or may not be productive Labs and Chest X-ray are usually not necessary unless patient appears to be more acutely ill or fever is very high. Physical Exam shows: * Wheezing * Rhonchi * Fever

Acute Bronchitis

* Symptoms: Gradual/insidious onset of: productive cough, dyspnea, fatigue, anorexia and weight loss. * Exam: tachypnea, diffuse crackles. * PFTs: restrictive, decreased DLCO. * CXR: normal to micronodular or reticular opacities. * HRCT: diffuse micronodules * BAL: marked lymphocytosis * Tissue pathology: noncaseating granulomas * Treatment: remove exposure. glucocorticoids may be required. Improvement in symptoms and function takes longer than with acute HP, weeks to months.

SUBACUTE Hypersensitivity Pneumonitis

•CURB-65: for what?

* Confusion * Urea (BUN) \>19 * Respiratory rate \>30 * Blood pressure: systolic \<90, diastolic \<60 * 65 years of age or older Adult CAP

The most common cause of death from ARDS is? severe irreversible hypoxemia accounts for only?

multi-organ failure secondary to sepsis 9% to 19% of deaths

* Typical lesion is a **granuloma with central caseation necrosis**. * Bacilli proliferate locally and spread through the lymphatics to a hilar node, forming the **Ghon complex**.

Pathophysiology of TB

Symptoms: URI symptoms, Wheezing, Cough, Dyspnea, Irritability, Poor feeding, Low grade fever, Apnea Exam Findings Tachypnea (can be up to 60-80 breaths per minute!), Nasal flaring, Use of accessory muscles for respiration, Diffuse wheezing •Fine rales, Tachycardia, Fever (but not always), Hypoxia

Presentation of Bronchiolitis

Carcinoid Syndrome Rare (\<10%) Name four Symptoms?

* Flushing * Diarrhea * Wheezing Bronchospasm * Hypotension

Avoid triggers Treat allergic rhinitis causing PND, treat GERD QUIT SMOKING!!!!!!!!! Allergy Desensitization if indicated Vaccination: Pneumococcal and influenza

Asthma - prevention/treatment

★Supportive care, cool mist humidifier, bronchodilators as needed ★Antibiotics are NOT needed! This is most likely a viral infection ★Most common in the first 2 years of life

★Bronchiolitis/RSV

Pediatric pneumonia •Transmitted upper airway noise is difficult to differentiate from lower respiratory abnormalities

•Listen to the chest, then hold your stethoscope up to the cheek

The mechanisms of lung parenchyma damage and role of airway changes following smoke inhalation injury. This is looking at what happens when thermal injury and chemical injury occur.

Cast formation!

Names of the three types of Mesothelioma? 1st. Most common, \>50%? 2nd. Worst prognosis and resistant? 3rd. ? All progress rapidly and are painful.

1st. Epithelial 2nd. Sarcomatoid 3rd. Biphasic

What type of Non-Squamous Cell Carcinoma? * Can grow anywhere in the lungs, ie.e, central or peripheral * Is heterogeneous, i.e., undifferentiated * Rapid doubling time * Metastasize early

Large Cell

* Prognosis: * Course is variable and if disease responds to glucocorticoids then may live with it chronically. * If fail glucocorticoids then may try Methotrexate or other immunosuppressive agents but no clear evidence showing efficacy * Some patients experience progressive deterioration of lung function and development of pulmonary fibrosis * No increased risk of cancer

Pneumoconiosis -- Berylliosis

the minimum age for flu vaccine?

6 months

Xray shows normal or hyper-inflation More done to rule out pneumonia or Other complications

Chest x-ray in Asthma

★A self-limiting cough lasting more than 5 days and up to 3-4 weeks ★Most commonly caused by a virus (Rhinovirus, adenovirus,...) ★Occurs most frequently in children ★Virus disrupts the mucociliary clearance in the airways ★Causes cough and wheezing ★Supportive care, cool mist humidifier, bronchodilators as needed ★Antibiotics are NOT needed! This is most likely a viral infection

★Acute Bronchitis Pearls

•reticular opacities are more often in the middle and upper lung fields as opposed to the bases. Also see hilar adenopathy.

Sarcoidosis

Pleurodesis (though rare)

to seal lung to pleura using talc

○OSA is diagnosed when

there are 5 events (apnea, hypopnea, desaturation) per hour in a patient with typical symptoms; or 15 events per hour regardless of symptoms

_Presentation of Mesothelioma_ Bi or unilateral? chest pain pleuritic or non-pleuritic? usually present with?

Unilateral - 60% right sided, 5% bilateral Non-pleuritic chest pain pleural effusion

Tracheobronchomalacia- uncommon disease of the central airways resulting from softening or damage of the cartilaginous structures of the airway ## Footnote Tracheal Stenosis - narrowing of the trachea Chronic cough GERD

DD for Asthama

Complication of Influenza? * Associated with aspirin use in the management of viral infections * Occurs in young children * Consists of rapidly progressive hepatic failure and encephalopathy * 30% mortality rate.

Reye syndrome

1. What disease? _CXR usually diagnostic with these common patterns_: 2. Patchy...? 3. Lobar...? 4. Diffuse...? 5. Pleural...? 6. Patterns can be suggestive of but not...?

1. Adult CAP 2. patchy airspace opacities 3. lobar consolidation with air bronchograms 4. diffuse alveolar or interstitial opacities 5. pleural effusion 6. diagnostic for specific etiologies

fever, fatigue and **productive cough** between 5 days and 3-4 weeks * 90% viral * inflammation of trachea, bronchi, and bronchioles. * self-limiting

Acute Bronchitis

Prevention of what disease? * **DTaP vaccine**: Recommended at the ages of ________ and __ - __ months and at age __ - __ years; it is not recommended for children aged 7 years or older * **Tdap vaccine**: Recommended for children aged __ -\_\_ years who are not fully vaccinated; as a single dose for adolescents 11-18 years of age; for any adult 19 years of age or older; and for pregnant woman regardless of vaccination history, including repeat vaccinations in subsequent pregnancies

Prevention of Pertussis 2, 4, 6, and 15-18 months 4-6 years 7-10

A multisystem granulomatous disorder of unknown etiology

Sarcoidosis

These are risks for? * Age \<3 months * Low birth weight * Gestational age of \<29 weeks * Low socioeconomic group * Crowded living conditions * Parental smoking * Chronic lung diseases * Neurologic diseases * Congenital Heart disease with pulmonary hypertension * Immunodeficiencies * Airway anomalies

Acute Bronchiolitis

Adult Inpatient CAP ## Footnote •Inpatients can be converted to oral antibiotics when: 1. 2. 3.

1. Hemodynamically stable 2. Able to ingest and absorb oral medications 3. Clinically improving

Respiratory Failure * Type I = * Type II = * Type III = * Type IV =

hypoxemia hypercapnia Perioperative (atelectasis) Shock (Hypoperfusion)

recurrent episodes of apnea lasting at least 10 seconds, associated with oxygen desaturation in the blood; or hypopnea, defined as decreased airflow and drop in saturation of at least 4%

Obstructive sleep apnea: definition

A 6-month-old boy presents to the ER with his parents with acute onset of rhinorrhea, cough, and wheezing. The symptoms have quickly progressed and the patient now has dyspnea and irritability. The mother states that her child was born at 34 weeks gestation with a small patent foramen ovale that they are hoping will close with age. On examination, the child’s temperature is 38oC or 100.4oF. There are rhonchi heard in all lung lobes. His respiratory rate is 50 breaths per minute, and he exhibits flaring of nares and use of accessory muscles of respiration resulting in intercostal and supraclavicular retractions. Widespread fine rales are heard at the end of inspiration and in early expiration. The expiratory phase is prolonged and wheezing is audible throughout the lung fields. What is the most likely diagnosis? What test or tests should be performed? Chest X-ray (?), Treatment in this child will include what? Is there a vaccine that this child missed? Would this child have qualified for Synagis?

Acute Bronchiolitis RSV rapid viral antigen nasal swab Hospitalization, Humidified oxygen, nebulized bronchodilators, nebulized ribavirin, IV hydration, nasopharyngeal suctioning. No vaccine for RSV. Yes, premature and small congenital heart defect. Should have been started on Synagis at the beginning of the RSV season.

_Adult CAP Treatment_ ## Footnote * Traditional duration of treatment is \_\_\_\_\_\_\_\_, but when using a respiratory fluoroquinolone\_\_\_\_\_\_\_\_ is sufficient IF uncomplicated * Patient should be improving and afebrile ________ to stop ABx

10-14 days 5 days 48-72 h

* May have Fatigue, Malaise, Fever or Weight Loss * Skin lesions * Cervical Lymphadenopathy * Visual changes, dry eyes * Dry mouth, parotid swelling * Palpitations, syncope * Joint pain or swelling * Muscle weakness * Hepatomegaly and tenderness

Sarcoidosis: Extrapulmonary findings

Symptoms include: Malaise, Fever, Night Sweats, Weight loss, Productive cough, Blood-streaked sputum; Exam: Cervical lymphadenopathy and apical rales.

Tuberculosis

★Virus disrupts the mucociliary clearance in the airways. What disease?

★Acute Bronchitis Pearls

Airway Edema + Accumulation of cellular debris in small airways ----\> obstruction ----\> V/Q mismatch = wasted perfusion, a right-to-left shunt, and hypoxemia early in the course of the disease

Pathophysiology of Acute Bronchiolitis

Sarcoidosis

Chronic, immunologically mediated, granulomatous disease

Pneumoconiosis -- Berylliosis

REMEMBER IT THIS WAY: Eosinophils, think Granuloma, think Angiitis, think

asthma nodules in lungs vasculitis of arteries

* pO2 \< 60 mmHg and/or * pCO2 \> 50 mmHg

Respiratory Failure

Pleural effusion ## Footnote * Transudative = * Exudative = * If moderate or greater, should be\_\_\_\_\_\_\_\_\_?

(clear) fluid is an inflammatory reaction (purulent) fluid = empyema tapped and evaluated

moderate to severe acute exacerbation of COPD 2 or more of the following get what? increased sputm, dyspnea or sputum purulence

ABs

* Symptoms: * #1 Weight loss/anorexia/asthenia * #2 A cough * Dyspnea * Chest pain * Symptoms more likely if prior COPD dx * Exam: * Lymphadenopathy * Hepatomegaly * Clubbing fingers

NSCLC CT of Non-Small Cell Squamous Cell Carcinoma

Pathologic condition in which alveoli are perfused with blood, but not ventilated.

Pulmonary Shunting

ECG is typically normal except in advanced disease, where right ventricular hypertrophy (right axis deviation, incomplete right bundle branch block) and right atrial enlargement (peaked P wave in the inferior and right-sided leads)

Pulmonary Hypertension

People with AIDS are 20-40 times more likely than immunocompetent persons to develop * HIV infection * Intravenous drug abuse * Incareration * Household contacts with TB * Homelessness/Shelter living * Travel to an endemic area * Alcoholism * Diabetes mellitus * Silicosis * Immunosuppressive therapy * Tumor necrosis factor–alpha antagonists * Cancer of the head and neck * Hematologic malignancies * End-stage renal disease * Intestinal bypass surgery or gastrectomy * Chronic malabsorption syndromes * Low body weight * Smoking - Smokers who develop TB should be encouraged to stop smoking to decrease the risk of relapse * Age below 5 years

Risk Factors for TB TB is the leading cause of death in HIV positive people.

This treatment for which neoplastic lung disease? * Surgery (Only Stage I), Mediastinal Staging always indicated preop, Always followed by chemo * Smoking Cessation * Systemic Chemotherapy +/- radiation * Good initial response but often recurrence * Pain management * Palliative care referral usually indicated

Small Cell

Inpatient treatment: * Oxygen * Racemic epinephrine via NEB * Corticosteroids * Intubation/ventilation Most patients can be treated at home: * Cool, humidified air * **Corticosteroids** * **Single dose dexamethasone** * **Single dose racemic epi**

Treatment for Croup

Exam Findings * Fever * Tachycardia * Flushed face * Conjunctival erythema * Pharyngeal injection

Influenza

Board buzz words for? Egophony Pleural friction rub Dullness to percussion Other symptoms to expect?

pleural effusion ## Footnote * Dyspnea * Cough * Chest pain * Absent or diminished breath sounds over the effusion * Bronchial breath sounds * Tracheal shift (large effusion)

Nebulized Ribavirin

= a broad-spectrum antiviral agent used in severe cases of RSV ●High cost Lack of demonstrated benefit in decreasing hospitalization or mortality

* Imaging: * CXR: * Basilar predominance of Reticular opacities indicative of Idiopathic Pulmonary Fibrosis

Most patients can be treated at home: * Cool, humidified air * Corticosteroids * Single dose dexamethasone IM * Single dose of racemic epinephrine

Treatment of Croup

* organisms are transmitted via respiratory droplets * Attack ciliated epithelium in airways * Produce toxins, resulting in inflammation and necrosis of the walls of small airways * Leads to plugging of airways, bronchopneumonia, and hypoxemia.

Pathogenesis and Presentation of Pertussis

* Primary tumor arising from the pleural lining of lung or thorax * can be either parietal or visceral * 75% are diffuse/malignant * Men:Women ratio? * 60-80% have h/o? 20 - 40 year? Is tobacco a risk?

Mesothelioma 3:1 ratio h/o Asbestos exposure latent period no

Pneumoconiosis -- Berylliosis

most common and quintessential histologic form of **Idiopathic Pulmonary Fibrosis**

Usual Interstitial Pneumonia ## Footnote * Epidemiology: * Men\>Women * 55-60 yo * Signs & Symptoms: * Insidious onset dry, hacking cough and SOB * Inspiratory crackles on exam

Functional Classification of Pulmonary Hypertension Class I: Class II: Class III: Class IV:

without limitation slight limitation marked limitation inability to perform any physical activity

1. CXR findings in Hyaline Membrane Disease 2. Why do we care about this disease in the pre-term infant?

1. **Diffuse bilateral atelectasis**, which has the appearance of “ground-glass”, patchy alveolar opacities, or “whiteout”, all representing **diffuse confluent alveolar filling**. 2. Most common cause of respiratory distress in the preterm infant

●Most commonly used is the STOP-Bang mnemonic ○Do you **Snore** loudly (can be heard through closed doors?) ○Are you **Tired**, fatigued, or sleepy during the day? ○Has anyone **Observed** that you stop breathing during sleep? ○Do you have high blood **Pressure**? ○**Body** mass index over 35 ○**Age** over 50 ○**Neck** circumference \>16” female, \>17” male ○**Gender** = male? ●Scoring: ○0-2 = low risk, 3-4 = moderate risk, 5-8 = high risk

OSA: screening tools

* Latent - No active disease; cannot transmit the organism to others. * Contained but not eradicated * Viable organisms may lie dormant within granulomas for years. * Reactivation of disease may occur if the host’s immune defenses become impaired.

Pathophysiology of TB

* Overall presentation is similar to Sarcoidosis...BUT!.... * There’s a specific test! * Blood test, low sensitivity. High specificity. Repeat negative or borderline tests. Two negative tests is a ‘negative’ * Tissue pathology shows noncaseating granulomas

Berylliosis •BeLPT - Beryllium Lymphocyte Proliferation Test

* Bed Rest * Hydration * Oxygenation * Antipyretics/Analgesics * Prescription antiviral drugs: Neuraminidase inhibitors, Oseltamivir (Tamiflu, oral), Zanamivir (Relenza, inhaled), Peramivir (Rapivab, IV) * Must be administered within 24-48 hours of symptom onset.

Treatment of Influenza

* Palivizumab (Synagis) is available in the United States for prevention of * Decreases hospitalization rates * Decision to use this drug is based on: * The age of the child at the onset of RSV season * The child’s medical history

RSV disease in high-risk infants.

Surface proteins on Influenza A include (i.e., H1N1)

hemagglutinin and neuraminidase These proteins are critical for virulence and are major targets for the neutralizing antibodies of acquired immunity to influenza. Used to identify Influenza A subtypes

The two types of Non-Squamous Cell Carcinoma?

* Adenocarcinoma * **P****eripheral**, i.e., starts in the cells that line the alveoli of the lungs * Large cell carcinoma * **Central or peripheral**, i.e., can grow anywhere in the lungs

Alteration in the **_structure and function_** of the right ventricle (RV) of the heart caused by pulmonary hypertension associated with diseases outside the heart.

Cor pulmonale (“pulmonary heart disease”)

* Imaging shows * Reticular and small nodular opacities bilaterally in the lower lung fields * Calcified pleural plaques, also typically in the lower lungs * Pleural effusions

Pneumoconiosis -- Asbestosis

Chest X-ray: may show hyperinflation with scattered consolidation or lobar consolidation from a secondary infection

Acute Bronchiolitis

* obstructive, asthma-like * caused by inhalation of cotton fibers. * chest tightness, cough, wheezing and dyspnea * worse on Mondays or first day back * May progress to chronic bronchitis/COPD.

Byssinosis

Empyema should always be drained by\_\_\_\_\_\_\_\_to clear infection?

tube thoracostomy

Asthma Differential Diagnosis: Vocal fold dysfunction syndrome

- adduction of the true vocal cords on inspiration and abduction on expiration - causes inspiratory airway obstruction and stridor that is often mistaken for asthma - more common among women aged 20 to 40 - associated with anxiety, depression, posttraumatic stress disorder, and personality disorders - Symptoms are usually inspiratory stridor and less often expiratory wheezing, hoarseness, throat tightness, a choking sensation, and cough - Diagnosis is made by observing inspiratory closure of the vocal cords with direct laryngoscopy. Often not suspected until pt fails to improve on asthma treatment. - Treatment :counseling from a speech therapist on special breathing techniques,

* Chest X-ray or CT scan * Caseating granuloma in the apical lung * Miliary granulomas * Hilar and paratracheal lymphadenopathy * Calcified granuloma + associated lymph node = Ghon Complex * Segmental atelectasis * Pleural effusion Radiograph shows right apical thick-walled cavity and surrounding lung consolidation

Diagnostic Tests for TB The radiograph shows a classic posterior segment right upper lobe density consistent with active tuberculosis.

Infected end organs typically have **high regional oxygen tension.** Mediastinal, retroperitoneal, and cervical lymph nodes Vertebral bodies Adrenals Meninges GI tract

Pathophysiology of TB

What stain? IGRA •Interferon-gamma release assay with antigens specific for Mycobacterium tuberculosis (blood test) - more specificity AFB •Acid-fast bacilli smear and culture with drug susceptibility - Use sputum from patient collected early morning on 3 consecutive days •HIV testing

Ziehl-Neelsen stain Diagnostic Tests for TB

* Diagnosis: * Based on H&P (absence of historical features indicative of other similar presenting disorders) and imaging findings but must also have tissue for path * Must demonstrate noncaseating granulomas * TB test to rule out TB (a caseating granulomatous disease) * CBC to rule out lymphomas * Treatment: * Glucocorticoids (Prednisone) * Immunosuppressive therapy if ineffective (Methotrexate)

Sarcoidosis

Pathophysiology: 3 different **types** of inhalation injury?

1. Thermal injury 2. Chemical irritation 3. Systemic toxicity/impaired tissue oxygenation (fire releases poisons)

Symptoms * Sudden onset of symptoms * Fever/chills * Sore throat * Myalgias * Frontal or retro-orbital headache * Nasal discharge * Weakness and severe fatigue * Nonproductive cough and other respiratory symptoms * Red, watery eyes * Nausea, vomiting, diarrhea (children)

Influenza

Physical Exam in what disease? * **_Jugular venous distention_** * Accentuated pulmonary valve component of the second heart sound * Right-sided third heart sound * Tricuspid regurgitation murmur * Hepatomegaly * **_Lower extremity edema_** * Cyanosis can occur in patients with an open patent foramen ovale and right-to-left shunt due to increased right atrial pressure

Pulmonary Hypertension

Parainfluenza viruses are the most common agents, along with adenovirus, respiratory syncytial virus (RSV), and (rarely) Mycoplasma pneumoniae. * 5% of children will have during their second year of life. * Symptoms last for 5-7 days * Inspiratory stridor Chest X-ray shows “Steeple sign” =

Acute Laryngotracheitis / Croup •A viral infection of the larynx, trachea, and the upper bronchial tree subglottic narrowing in the neck; lungs usually appear normal

* African Americans\>Caucasians * Female slightly \> male * Presents between 20-30 years of age (though can present into the 60s) * Another Idiopathic Disease * Multisystem inflammatory disorder characterized by noncaseating granuloma formation

Sarcoidosis

Samter’s triad:

aspirin sensitivity, asthma, nasal polyps

* Chronic * Complicated version (Progressive Massive Fibrosis) * The small nodules of Simple version progress and coalesce into larger nodules (\>1cm) that evolve into conglomerate masses * Looks similar to malignancies

Pneumoconiosis -- Silicosis

catarrhal, paroxysmal, and convalescent stages

Pertussis 2 weeks each, 6 total

3 Determinants of Ventilation?

1. Tidal volume (Vt ) 2. Dead space volume (Vd) 3. Respiratory frequency ( f )

* **Supportive care** * Limit the number of paroxysms * Observe the severity of cough and provide assistance when necessary; Elevate head * Maximize nutrition, rest, and recovery * **Azithromycin** is the treatment of choice for all patients. * **Trimethoprim-sulfamethoxazole** if a hypersensitivity to macrolides * Prophylaxis for exposed, susceptible persons is also azithromycin for 5 days

Treatment of Pertussis

If HIV negative: **6 to 9 mo regimen** 2 months Isoniazid, Rifampin, Pyrazinamide, and Ethambutol. If I-sensitive, stop E •If I and R sensitive, drop P and continue I and R 4 months more \*Treatment must extend 3 months beyond documentation of negative sputum

Treatment of Active TB

Hyaline Membrane Disease? Most common cause of? Results in?

Deficiency of surfactant production respiratory distress in the preterm infant poor lung compliance and atelectasis

•Injury and damage occurs to the alveolar epithelial or capillary endothelial cells leading to inflammation (alveolitis) and eventually fibrosis

All Interstitial Lung Diseases: shared pathophysiology

A 70-year-old white female presents to the urgent care complaining of muscle aches, a severe headache, a non-productive cough, and chills. She states she woke up that morning feeling miserable. She also complains of a sore throat and a runny nose. She states she is so tired her husband had to drive her to the urgent care. She is relatively healthy but does take Toprol for hypertension. She had been out shopping with her daughter the last two days and felt fine. On exam, her temperature is 103oF, pulse is 95 bpm, respirations are 28 breaths per minute, pulse ox is 90%, and BP is 135/88. The patient appears acutely ill and diaphoretic. You hear scattered rhonchi and fine rales bilaterally in the lungs. Pharynx is erythematous and conjunctiva are injected. What is the most likely diagnosis? What test or tests should be performed? Treatment in this patient will include what? Hospitalization (?), Why does this patient qualify for a neuraminidase inhibitor? Is there a vaccine that this patient may have missed?

What is the most likely diagnosis? Influenza What test or tests should be performed? Chest X-ray, Rapid Influenza diagnostic test, Influenza RT-PCR and culture Treatment in this patient will include what? Hospitalization (?), Humidified oxygen, IV hydration, Analgesics/Anti-pyretics, Neuraminidase inhibitor (Oseltamivir = Tamiflu, oral) Why does this patient qualify for a neuraminidase inhibitor? Less than 24 hours since onset of symptoms. Is there a vaccine that this patient may have missed? Flu vaccine.

* A paramyxovirus * An orthomyxovirus (single stranded RNA virus) that if not neutralized by secretory antibodies, invades airway and respiratory tract cells.

Respiratory Syncytial Virus (RSV) Influenza

Case Study * 57 yo male with 30 pack/year history presents with new bothersome productive cough x 3 days with fever 101F. No other symptoms. No pertinent medical history. PE wnl * What do you order??? * Diagnosis??? * Treatment???

CXR Classic RML Pneumonia * Outpatient: macrolide +/- B-lactam; doxycycline * Inpatient: B-lactam + macrolide OR a respiratory fluoroquinolone * ICU: B-lactam + macrolide OR B-lactam + fluoroquinolone

Dead Space Volume ## Footnote * Anatomical = * Alveolar = * Physiological =

volume of air in conducting airways gas volume in unperfused alveoli anatomical + alveolar

What is one of the most important prognostic factors for pulmonary hypertension?

Right ventricular function

•A 6-week disease divided into catarrhal, paroxysmal, and convalescent stages, each lasting 1-2 weeks.

Pathogenesis and Presentation of Pertussis

What may be used to collect pleural fluid for culture or other testing, or can be therapeutic if the amount of fluid is large and causing lung compression? What disease?

Thoracentesis Adult CAP

Mendelson’s Syndrome? CXR?

Acute Aspiration of Gastric Contents (One of the most common causes of ARDS) Patchy alveolar opacities in dependent lung zones

What disease? Electrocardiogram demonstrating the changes of __________________ (long arrow) with strain in a patient with \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Right axis deviation (short arrow), increased P-wave amplitude in lead II (black arrowhead), and incomplete right bundle branch block (white arrowhead) are highly specific but lack sensitivity for the detection of right ventricular hypertrophy.

Electrocardiogram demonstrating the changes of right ventricular hypertrophy (long arrow) with strain in a patient with primary pulmonary hypertension. Right axis deviation (short arrow), increased P-wave amplitude in lead II (black arrowhead), and incomplete right bundle branch block (white arrowhead) are highly specific but lack sensitivity for the detection of right ventricular hypertrophy

What disease? ★Chest X-ray typically shows \_\_\_\_\_\_\_\_\_\_\_\_; and Ghon complex, which is?

Tuberculosis apical caseating granuloma in the lung a calcified focus of infection and associated lymph node

●Snoring: usually bothersome to partner, loud enough to be heard through a closed door (in adults). Snoring more than 3 times per week (in children)

OSA: history and symptoms

Normal pulmonary artery systolic pressure at rest is \_\_\_\_\_\_\_\_\_\_\_\_, with a mean pressure of \_\_\_\_\_\_\_\_\_\_? Pulmonary hypertension reached at pressures of?

15–30 mmHg 10-18 mmHg \>30 mmHg systolic or mean pressure \>20 mm Hg.

* 6 to 9 month regimens (HIV negative) * 2 months of daily isoniazid, rifampin, pyrazinamide, and ethambutol. * Once the isolate is determined to be isoniazid-sensitive, ethambutol may be discontinued. * If the isolate is susceptible to isoniazid and rifampin, the second phase of therapy consists of isoniazid and rifampin for a minimum of 4 additional months, with treatment to extend at least 3 months beyond documentation of negative sputum cultures.

Treatment of Active TB

S P H E R E of Lung CA complications?

* SVC syndrome * Pancoast Tumor * Horner Syndrome: miosis, partial ptosis, anhidrosis * Endocrine * Recurrent Laryngeal Nerve * Effusions

40 - 80% of exudative pleural effusions are?

malignant \>90% of malignant pleural effusions are exudative. Most commonly, **lung** cancer (1/3) and **breast** cancer.

•Only one with a specific test and what is it? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_which is a blood test with low sensitivity and high specificity. Must repeat negative or borderline tests. Two negative tests is a ‘negative’ * Also perform test on BAL effluent * No increased risk of cancer

•BeLPT - Beryllium Lymphocyte Proliferation Test for Berylliosis

Alveolar inflammation leads to?

recruitment of inflammatory cells

Pathogens different depending on age of \<4 weeks: perinatally acquired Group B strep (first 24 hours); Gram negatives, Chlamydia pneumoniae (2-4 weeks) 4-12 weeks: more typical respiratory pathogens: S pneumo, S aureus, H influenzae, RSV 3 months - 5 years: 90% are viral. RSV commonest especially winter and early spring; influenza, parainfluenza, rhinovirus, enterovirus. Bacteria are typical respiratory bacteria: S pneumo, S aureus, H influenzae •School-age - adolescent: Mycoplasma pneumoniae is commonest (atypical); influenza, typical respiratory bacteria also occur.

•Primary screening method for TB infection (active or latent) A positive test cannot determine between active and latent infections.

•Mantoux tuberculin skin test with purified protein derivative (PPD)

TREATMENT: * Bed Rest * Hydration * Oxygenation * Antipyretics/Analgesics * Neuraminidase inhibitors O-amivir Z-amivir P-amivir •Must be administered within _________ of symptom onset?

Treatment of Influenza * **Oseltamivir** (Tamiflu, oral) * **Zanamivir** (Relenza, inhaled) * **Peramivir** (Rapivab, IV) 24-48 hours

**Optimal** **duration of anticoagulation therapy for venous thromboembolism is unknown.** **Generally, though...** After first episode when there is a reversible risk factor? After first episode of idiopathic thrombosis? In patients with nonreversible risk factors or recurrent disease?

6 months 12 months 6–12 months

Antigenic drift = Antigenic shift =

Mutation: drift = inaccurate viral RNA polymerase frequently produces point mutations in certain error-prone regions in the genes. Gene sharing: shift = influenza genes between 2 strains are reassorted, presumably during coinfection of a single host.

Palivizumab (Synagis) ## Footnote * Decreases hospitalization rates * Decision to use this drug is based on age of child at ______ and medical history

Prevention of Acute Bronchiolitis/RSV Not a vaccine. Monthly shots of a prophylactic monoclonal antibody.

fibrous magnesium silicate

asbestos fibers

* Most commonly caused by respiratory syncytial virus (RSV). * Edema and accumulated cellular debris cause obstruction of small airways. * Occurs most often in infants and young children. * Most commonly in the first 2 years of life. * Peak age is ~6 months. * Leading cause of infant hospitalization.

Acute Bronchiolitis

* Diagnosis: * Can be made on H&P and imaging alone as long as all features are present. Otherwise may require tissue for pathology via Bronchoalveolar Lavage or Transbronchial Biopsy or Surgical Lung biopsy * Treatment and Prognosis: * No medical management\*\*\* * Lung transplant is definitive treatment * 5yr survival after transplant: ~50%

Idiopathic Pulmonary Fibrosis (Usual Interstitial Pneumonia) Must be truly idiopathic: must rule out other Interstitial Diseases

* Dormant tubercle bacilli are reactivated * Mycobacteria are released into the surrounding tissue and bloodstream causes a vigorous, nonspecific immune response * Host becomes symptomatic and highly contagious

•Secondary Tuberculosis

Most common causes of transudatie and exudative Pleural Effusions?

Transudative: **Heart failure** (\> 90% of cases) Exudative: **Pneumonia** (parapneumonic effusion) and **Cancer**

_Alveolar Hemorrhage Syndromes_ **Autoimmune causes** Anti-basement membrane antibody disease...aka? and **Nonimmune causes** Children or young adults Anti-glomerular basement membrane antibodies are absent

Goodpasture syndrome Idiopathic pulmonary hemosiderosis

Croup Inspiratory or Expiratory stridor?

Inspiratory stridor

●cyanide disrupts cellular function by inhibiting \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, which prevents cellular oxygen utilization.

cytochrome oxidase ## Footnote ●Classic signs ●There may be a faint “bitter almond” smell noted on the patient’s breath or in vomitus ●This is a “classic sign,” but is not a reliable indicator

COPD chest X-ray findings

Hyaline Membrane Disease treatment antenatally?

Corticosteroids to the mother to accelerate lung maturation

Asthma Differential Diagnosis: Vocal fold paralysis

* May be unilateral (more common) or bilateral * Etiology: ⅓ cancer, ⅓ trauma; ⅓ idiopathic * Symptoms: unilateral paralysis, the voice may be hoarse and breadth bilateral paralysis, voice is of good quality but of limited intensity and pitch; may have stridor and dyspnea * Diagnosis: laryngoscopy, but identification of the cause typically requires imaging (eg, MRI) * Treatment: unilateral paralysis, surgical procedures to move cords closer together * For bilateral paralysis, surgical procedures and measures to maintain airway foreign body aspiration laryngotracheal masses tracheal narrowing airway edema (eg, angioedema or inhalation injury) •

* Diffusion Impairment * Alveolar hypoventilation (normal A-aDO2) * High altitude

Causes of Hypoxemia i.e., Ventilation/Perfusion (V/Q) Mismatch

* Imaging on CXR is more variable than the other disorders but does tend more to the upper lung fields. Can appear as nodular, ground glass, or linear opacities * Hilar and mediastinal lymph node enlargement is common * The cutaneous nodules are on the exposed areas of skin (generally fingers and forearms) and smaller than those in Sarcoidosis

Berylliosis

•Historically was known as “Consumption” 85% of patients present with pulmonary complaints.

Tuberculosis (TB)

* Incubation period 1–4 days. * Aerosol transmission may occur 1 day before onset of symptoms. * Viral shedding continues for 5-10 days.

Influenza

1. Presence of **Amylase** in Pleural effusion suggests? 2. Presence of **LOW Glucose** in Pleural effusion suggests? 3. Presence of **Protein** in Pleural effusion suggests?

1. **pancreatitis**, pancreatic tumor, adenocarcinoma of the lung or pancreas, or esophageal rupture. 2. if MUCH less than serum, then consider **empyema** (glucose consumed by bacteria) 3. high in **TB**

Orthomyxovirus single- or double-stranded RNA virus? What are used to distinguish the 3 types? \_\_\_\_\_\_\_\_\_\_\_ is most common type in humans and is genetically labile, with mutation rates as high as 300 times that of other microbes?

Influenza Virus Single-stranded Core nucleoproteins: A, B, and C. Influenza A

Adult HCAP: treatment ## Footnote * Broader antibiotic coverage from 3 categories: * Duration of antibiotics _______ days depending on need for Pseudomonas coverage

* A **first** **antipseudomonal** agent (which also covers typical respiratory pathogens); e.g. imipenem, piperacillin-tazobactam * A **second antipseudomonal** agent; usually a fluoroquinolone * **Coverage for MRSA**; vancomycin or linezolid 8-15 days

* Fever * Tachycardia * Flushed face * Conjunctival erythema * Pharyngeal injection

Presentation of Influenza

Treatment of pulmonary vasculitis usually requires? ## Footnote Given until complete remission is obtained and then is slowly tapered, and often replaced with ___________ or _________ for maintenance therapy.

corticosteroids and cyclophosphamide methotrexate or azathioprine

Pediatric pneumonia •All young infants (\<12 weeks) should be

hospitalized •Children over 5 rarely require hospitalization

* An obstructive, asthma-like, disorder caused by inhalation of cotton fibers. * Presents with chest tightness, cough, wheezing and dyspnea * Usually worse on Mondays or first day back after a break/vacation * If left untreated and without job change, could lead to chronic bronchitis/COPD.

Byssinosis

CXR in Interstitial Lung Disease showing: * Reticular and nodular opacities * Pattern and distribution of opacities on CXR can help differentiate which form it is.

Nebulized Ribavirin =

a broad-spectrum antiviral agent used in severe cases of RSV ●High cost ●Lack of demonstrated benefit in decreasing hospitalization or mortality

* Most common type of lung CA in US * Most common histology in NON-SMOKERS * Starts in the cells that line the alveoli of the lungs/peripheral * Metastasizes to distant organs * Often brain * Common path of colon CA

Non-Squamous Cell Carcinoma: i.e., **Adenocarcinoma**

What disease? \_\_\_\_\_\_\_\_ingested by macrophages which then become macules: 2-5mm radio-opaque nodules on CXR Nodular opacities occur primarily in the upper lung fields May become more widespread and then confluent with progression to large opacities

Pneumoconiosis -- Coal Worker’s Lung

Clinical Course of?

ARDS * The exudative phase is the acute, early phase * A proliferative phase ensues within 7 days – prominent interstitial inflammation and early fibrotic changes * Most patients recover approximately 21 days after the initial pulmonary injury; however, some enter the fibrotic phase (substantial fibrosis and bullae formation)

* Central vs. peripheral pulmonary * Men=Women * Usually younger; \<60 yo * Usually asymptomatic * No known exposure/risk factors

Carcinoid Bronchial gland tumors, aka, bronchial adenomas Adenoma is a benign tumor of glandular tissue

* Carries a poor prognosis in that it progresses and frequently results in respiratory failure * Survival after onset of symptoms is typically less than 4 years.

•Acute Silicosis

Complications of what cancer? * Pain * Superior vena cava syndrome * Hoarseness (recurrent laryngeal nerve, vagus nerve) * Horner Syndrome * Arrhythmias * Dysphagia * Multiple Paraneoplastic Syndromes * Weakness and weight loss (due to aggressiveness of cancer)

Mesothelioma

CXR for what disease shows “Steeple sign” and what is it?

Croup = subglottic narrowing in the neck; lungs usually appear normal

Solitary Pulmonary Nodule * Size? * Etiology? * Risk Factors/History? * Symptoms? * Imaging? * Treatment? * Biopsy? * Risks?

* \<3 cm (if \>3cm, lesion is not called nodule anymore, it's called a called mass) * \>2cm \<3cm = 80 % malignancy rate * Cancer/Malignancy, Granuloma, Fungal infection, TB, Benign Tumor, Foreign body (rare) * Environmental, Occupational, Smoking, Infections, Cancers * Almost always asymptomatic/incidental finding * CXR, CT, PET, review old imaging * PET detects increased glucose metabolism * High sensitivity and specificity * what's their risk? * low - serial imaging every 3 for 12 then 6 till 24 * after 24, considered benign * intermediate - PET scan, biopsy * high - surgical referral for diagnosis/treatment * •CT guided lung biopsy/transthoracic needle aspiration (TTNA) * Biggest risk are bleeding and pneumothorax

Interstitial Lung Disease, general findings * Imaging: HRCT - High Res CT * Reticular pattern * Honeycombing * Traction bronchiectasis

* Often in patients with poor dentition or periodontal disease * Cough produces foul-smelling sputum * Pneumonia and abscess usually in the dependent lung zones What disease? Treat with?

Adult pneumonia: anaerobic infection penicillin or clindamycin

* Usually bronchial origin; central * Often narrows bronchus * More likely to have metastasis at presentation * Rapid doubling time * High growth fraction * Early metastases

Small Cell

heparin followed by 3-6 months of oral warfarin results in an 80–90% reduction in the risk of

both recurrent venous thrombosis and death from PE.

* Radiologic findings in which disease? * **Focal lucencies** scattered in lungs consistent with pathologic changes * Often predominates in **upper zones of each lobe.** * May reveal **large bullae or blebs** * Loss of vasculature in affected areas * Mostly ordered to assess for **which form?** * and to **rule out?**

chest CT in COPD emphysema bronchiectasis

* A bacterial infection that affects airways lined with ciliated epithelium. * Most common in the unimmunized. * Highly contagious * Half of all cases occur before 2. * Adults and adolescents are reservoirs of infection.

Pertussis (Whooping Cough)

Essentials of Diagnosis for what? (must know) Dyspnea, fatigue, chest pain, and syncope on exertion. Electrocardiographic evidence of right ventricular strain or hypertrophy and right atrial enlargement. Enlarged central pulmonary arteries on chest radiograph. Elevated right ventricular systolic pressure on two-dimensional echocardiography with Doppler flow studies.

Pulmonary Hypertension

* A group of chronic fibrotic lung diseases * Result from inhalation of inorganic dusts typically associated with specific occupations * Symptomatology and onset can vary * Chest radiographs generally show diffuse nodular opacities * Prognosis varies * Treatment is supportive

Pneumoconiosis

★A self-limiting cough lasting more than 5 days and up to 3-4 weeks What disease?

★Acute Bronchitis

* Insidious onset of cough, dyspnea, fatigue, weight loss. * Differentiation from IPF may be difficult, imaging is very similar. * BAL: Low CD4 to CD8 ratio. * There are HP antibody panels that include the most frequent antigens that can aid in diagnosis * Tissue pathology: noncaseating granulomas, destruction of alveoli, bronchiolitis obliterans * Treatment: chronic glucocorticoids. * Removal from exposure still necessary but doesn’t help as much.

Chronic Hypersensitivity Pneumonitis

•palivizumab

prophylactic monthly monoclonal antibody shots against RSV * Effective in high-risk infants (congenital heart and lung diseases, Down syndrome) * No proven efficacy among adults with RSV

★Symptoms include: Malaise, Fever, Night Sweats, Weight loss, Productive cough, Blood-streaked sputum; Exam: Cervical lymphadenopathy and apical rales.

Tuberculosis

Four stages of what? 1) Cancer only in pleura, lateral, only one side 2) ipsilateral, spread within lung or LN on the same side 3) Spread to contralateral side, anywhere in chest wall, pericardium or ABD cavity 4) Widespread disease

Mesothelioma

* Usually unexpected/incidental * Almost always asymptomatic/incidental finding * Otherwise can have similar symptoms as will discuss in malignancy/compression symptoms if large

* “coin lesion” * isolated * \<3 cm•\>3cm ---\> MASS

Toxic lung injury due to Nitrogen dioxide inhalation * Leads to **increased tissue permeability → pulmonary edema** * Presents with dyspnea, cough, crackles on exam, occasionally wheezing as well * Treatment is with **glucocorticoids ASAP to prevent progression to bronchiolitis obliterans**, a common late complication.

Silo-filler’s Disease

Rapid viral antigen testing (nasopharyngeal swab) for?

RSV//Acute Bronchiolitis

Exam finding of what disease? * Post-tussive apical rales * Malnourished appearance * Painless, **Cervical and S****upraclavicular****Lymphadenopathy** * Exam findings dependent on other involved organs

Exam finding of TB

PE gets?

Admitted HR/Helical CT Angio Anticoagulation

Vaccine not recommended if \< 6 months?

Influenza vaccine

Adenoma is? Carcinoid is?

a benign tumor formed from glandular structures in epithelial tissue. a tumor of a type occurring in the glands of the intestine (especially the appendix) or in the bronchi, and abnormally secreting hormones.

* More important to try to identify the causative organism * Empiric therapy less likely to be effective * Sputum evaluation, urine antigen testing, bronchoalveolar lavage may be done * Thorascopic lung biopsy may be needed * Imaging (CXR, chest CT) usually nonspecific, but should be done to assess for pulmonary emboli and to define the pattern/distribution of infiltrate * These patients require specialty care from a team including Pulmonary, Infectious Disease, Oncology if applicable

Adult pneumonia: immunocompromised host

Treatment of ARDS?

* Mechanical ventilation = cornerstone of treatment * •use low tidal volumes to prevent barotrauma * Treat the underlying condition * Supportive care * Hemodynamic monitoring * Oxygenation * Fluid management * Infection prevention * DVT and GI prophylaxis * Nutritional support

○Diffuse, patchy, interstitial infiltrate in

atypical pneumonia

Venous admixture =?

* amount of mixed venous blood required to mix with pulmonary capillary blood to produce observed A-aDO2 * The result of mixing of shunted non-reoxygenated blood with reoxygenated blood distal to the alveoli Venous Admixture explains why the pO2 decreases from the heart to the systemic arteries.

Occupational Lung Disease secondary to inhalation of Inorganic Dusts

Pneumoconiosis

•Often years after cessation of job associated with exposure

Pneumoconiosis -- Silicosis

* Supportive Care * Antipyretics * Bronchodilators * Steroids (if severe coughing with wheezing) * Cool mist humidifier * Encourage immunizations (specifically for diphtheria, pertussis, and influenza) * Since cause is most often viral, antibiotics are usually not necessary. * Avoid use of cough suppressants (try not to mess with the mucociliary clearance!) * Okay to use at night if patient needs sleep

Treatment of Acute Bronchitis

Pulmonary Embolism 1. Treatment of choice? 2. Thrombolytic therapy 3. Inferior vena cava filter 4. Pulmonary embolectomy

1. Anticoagulation: not definitive therapy but a form of secondary prevention. It slows additional thrombus formation, allowing endogenous fibrinolytic mechanisms to lyse existing clot. **Heparin followed by 3-6 months of oral warfarin** results in an 80–90% reduction in the risk of both recurrent venous thrombosis and death from PE 2. Accelerates resolution of emboli within the first 24 hours compared with standard heparin therapy. **No difference in outcome or improved mortality compared with heparin and warfarin.** Thrombolytic therapy is for patients at high risk for death where rapid resolution of thrombus may be lifesaving. 3. For recurrent thromboembolism despite adequate anticoagulation. Temporary placement/not long-term (ie pre-surgery if high risk) 4. **Emergency** **procedure of last resort** with a very high mortality rate. It is performed only in a few specialized centers. Catheter devices are used to fragment and extract thrombus through a transvenous approach

Farmers and bird lovers get this. ## Footnote Exam with **basilar crackles and tachypnea**. Acute form has an abrupt onset (w/in 4-6 hrs) of fever, chills, malaise, nausea, cough, chest tightness, dyspnea. **Chronic has Low CD4 to CD8 ratio** CXR frequently normal Potentially confused with a viral or bacterial infection and given antibiotics Treatment is removal from environment where exposure occurred and not return. Symptoms subside within 12hrs to several days. Disease may recur with reexposure Tissue Pathology shows noncaseating granulomas

Hypersensitivity Pneumonitis

★Acute Bronchitis Pearls

The virus infects the respiratory epithelial cells of the small airways, leading to necrosis, inflammation, edema and mucus secretion. The combination of cellular destruction and inflammation leads to obstruction of the small airways. The physiologic and clinical results consist of hyperinflation, atelectasis, and wheezing. In severe cases, interstitial inflammation and alveolar infiltrates also develop. Regrowth of the epithelial cell layer does not occur until approximately 2 weeks after infection, with compete recovery requiring 4 to 8 weeks. Edema and accumulation of cellular debris in small airways leads to obstruction causing a ventilation-perfusion mismatch with wasted perfusion, a right-to-left shunt, and hypoxemia early in the course of the disease.

Etiology of Bronchiolitis

Sarcoidosis

Directly observed therapy (DOT) =

a healthcare worker physically observes the patient ingest antituberculous medications in the home, clinic, hospital, or elsewhere; improves adherence to treatment. Multi-drug resistant TB may require up to two years of treatment.

* Should be suspected in: * Adults with snoring, daytime fatigue, headaches, hypertension * Children with adenotonsillar hypertrophy, snoring, fatigue * Adults and kids with observed apneic episodes \>10 seconds * Adults and kids with craniofacial abnormalities * Exam and labs usually nonspecific, done to rule out other contributing factors * Office questionnaires helpful, sometimes required for pre-op evaluation * Gold standard for diagnosis is overnight polysomnography * CPAP and weight loss most effective treatments in adults * Adenotonsillectomy most effective treatment in (otherwise healthy) children

Obstructive sleep apnea: summary

* A bacterial infection that affects airways lined with ciliated epithelium. * Most common in unimmunized infants and adults. * Highly contagious * Adults and adolescents are reservoirs of infection.

Bordetella pertussis aka Whooping Cough

DTaP and Tdap vaccinations for what? But?

Prevention of Pertussis ## Footnote ★Neither immunization nor disease confers lasting immunity

●Standard/most effective treatments are nocturnal CPAP and weight loss ●Surgical ○Commonest procedure is uvulopalatoplasty to remove redundant tissue

OSA: treatment (adult)

What disease? Symptoms: URI-like, Wheezing, Cough, Dyspnea, Irritability, **Poor feeding,** Low grade fever, **Apnea** Exam: Tachypnea, Nasal flaring, Accessory muscles use, Diffuse wheezing, Fine rales, Tachycardia, Fever (but not always), Hypoxia

Bronchiolitis

* Age \<3 months * Low birth weight * Gestational age of \<29 weeks * Low socioeconomic group * Crowded living conditions * Parental smoking * Chronic lung diseases * Neurologic diseases * Congenital Heart disease with pulmonary hypertension * Immunodeficiencies * Airway anomalies

Risk Factors for Acute Bronchiolitis

* Cough lasting \> 5 days and up to 3-4 weeks * Symptoms include: fever, fatigue, and a productive cough. * 90% are viral in origin, and 10% are bacterial. * Infection leads to inflammation of the trachea, bronchi, and bronchioles. * Usually self-limiting and resolves over time.

Acute Bronchitis

GOLD III SEVERE COPD FEV1 =?

30% - 50% predicted

GOLD I MILD COPD FEV1 = ?

\>80% predicted

GOLD IV VERY SEVERE (end stage) COPD FEV1 = Or FEV1 =

\<30% predicted OR \<50% WITH chronic resp failure

GOLD II MODERATE COPD FEV1 =

50% - 80% predicted

type II pneumocytes

5% of alveolar area 60% of cells Secrete 'surfactant'

FunMed Pulmonary Flashcards

(235 cards)