1
Q
Acute Bronchitis defined as:
A
a cough that persists for MORE THAN 5 DAYS
2
Q
Sx of acute bronchitis
A
one-week history of cough productive of whitish sputum. This was preceded one week prior by a URI. She denies chills, night sweats, shortness of breath, or wheeze. Temperature is 99.9°F (37.7°C)
Fever is unusual → if fever present consider pnuemonia
3
Q
Bacterial causes of acute bronchitis
A
- M. Catarrhalis (the common bacterial cause of acute bronchitis)
- H. influenzae
- S. Pneumoniae
4
Q
Dx for acute bronchitis
A
Chest X-Ray if the diagnosis is uncertain or symptoms have persisted despite conservative treatment
5
Q
Tx for acute bronchitis
A
- Supportive measures include hydration, expectorants, analgesics, β2-agonists, and cough suppressants as needed (not recommended for children)
- For patients who desire medication for cough offer over-the-counter medications such as dextromethorphan or guaifenesin rather than other medications
- Reserve use of inhaled beta-agonists, such as albuterol, for patients with wheezing and underlying pulmonary disease
6
Q
When are abx indicated in acute bronchitis?
A
- Antibiotics are indicated for the following: elderly patients, those with underlying cardiopulmonary diseases and cough for more than 7 to 10 days, and any patient who is immunocompromised
7
Q
Presentation: Most often young patients present with wheezing and dyspnea often associated with illness, exercise, and allergic triggers
A
Asthma
8
Q
Airway inflammation, hyperresponsiveness, and reversible airflow obstruction
A
Asthma
9
Q
Dx of asthma
A
Diagnosis and monitor with peak flow. PFT’s: Greater than 12% increase in FEV1 after bronchodilator therapy
- FEV1 to FVC ratio < 80% (You would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
- In asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
10
Q
Tx for mild intermittent asthma
A
Less than 2 times per week or 3-night symptoms per month
- Step 1: Short-acting beta2 agonist (SABA) PRN
11
Q
Tx for mild persistant asthma
A
Mild Persistent: More than 2 times per week or 3-4 night symptoms per month
- Step 2: Low-Dose inhaled corticosteroids (ICS) daily
12
Q
Tx for moderate persistant asthma
A
Moderate Persistent: Daily symptoms or more than 1 nightly episode per week
- Step 3: Low-Dose ICS + Long-acting beta2 agonist (LABA) daily
- Step 4: Medium-Dose ICS +LABA daily
13
Q
Tx of severe persistent asthma
A
Severe Persistent: Symptoms several times per day and nightly
- Step 5: High-Dose ICS +LABA daily
- Step 6: High-Dose ICS +LABA +oral steroids daily
14
Q
Acute tx of asthma
A
Acute treatment: Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
15
Q
A condition in which the lungs’ airways become dilated and damaged, leading to inadequate clearance of mucus in airways
A
Bronchiectasis
16
Q
- Mucus builds up and breeds bacteria, causing frequent infections
- A common endpoint of disorders that cause chronic airway inflammation (CF, immune defects, recurrent pneumonia, aspiration, tumor)
- ½ of cases are due to cystic fibrosis
A
Bronchiectasis
17
Q
MCC Bronchiectasis
A
½ cases are from Cystic fibrosis
18
Q
Sx of Bronchiectasis
A
Daily cough that occurs over months or years and production of copious foul-smelling sputum, frequent respiratory infection
19
Q
Dx of Bronchiectasis
A
CXR = linear “tram track” lung markings, dilated and thickened airways – “plate-like” atelectasis; CT chest = gold standard
- Crackles, wheezes, purulent sputum
20
Q
Tx of bronchiectasis
A
TX: ambulatory oxygen, aggressive antibiotics for acute exacerbations, CPT (chest physiotherapy = bang on the back); eventual lung transplant
21
Q
What is a carcinoid tumor
A
A tumor arising from neuroendocrine cells → leading to excess secretion of serotonin, histamine, and bradykinin
22
Q
Common primary sites of carcinoid tumor
A
Common primary sites include GI (small and large intestines, stomach, pancreas, liver), lungs, ovaries, and thymus
- The most common site of a neuroendocrine (carcinoid) tumor to metastasize to is the liver
- Carcinoid tumor of the appendix is the most common cause. The appendiceal cancer travels from the appendix then to the liver where it metastasizes to the lungs
23
Q
Carcinoid syndrome
A
- Carcinoid syndrome (the hallmark sign) = Cutaneous flushing, diarrhea, wheezing and low blood pressure is actually quite rare and occurs in ~ 5% of carcinoid tumors and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation.
- The syndrome includes flushing, ↑ intestinal motility (diarrhea), itching and less frequently, heart failure, vomiting, bronchoconstriction, asthma, and wheezing
24
Q
Sx of increase serotonin d/t carcinoid tumor
A
- ↑ Serotonin leads to collagen fiber thickening, fibrosis = heart valve dysfunction → tricuspid regurgitation, pulmonary stenosis/bronchoconstriction, and wheezing
- ↑ Histamine and bradykinin = vasodilation and flushing
- ↑ serotonin synthesis → ↓ tryptophan → ↓ niacin/B3 synthesis = pellagra
25
Dx of carcinoid tumor
**CT-Scan** to locate the tumors
* **Octreoscan** → radiolabeled somatostatin analog (octreotide) binds to somatostatin receptors on tumor cells
* Urinalysis → elevated **5-hydroxyindoleacetic acid (5-HIAA) →** is the main **metabolite of serotonin** and is used to determine **serotonin** levels in the body
* **Pellagra (niacin/B3 deficiency)** - ↑ serotonin synthesis → ↓ tryptophan → ↓ niacin/B3 synthesis
* **Chest X-Ray** shows low-grade CA seen as **pedunculated sessile growth in the central bronchi**
* Bronchoscopy- pink/purple central lesion, well-vascularized
26
Tx of carcinoid tumor
* The lesions are resistant to radiation therapy and chemotherapy
* **Octreotide -** a somatostatin analog that binds the somatostatin receptors and **decreases the secretion of serotonin** by the tumor
* Niacin supplementation
27
Defined as a **chronic cough** that is **productive of phlegm** occurring **on most days for 3 months of the year for 2 or more consecutive years** without an otherwise-defined acute cause
Chronic bronchitis
28
Sx of chronic bronchitis
Common in **Smokers (80% of COPD patients)**
* **Frequent cough** and expectoration are typical (compared to emphysema)
* **Stocky, overweight**. Occasionally a barrel chest. (compared to emphysema)
29
Dx of chronic bronchitis
* **PFT's: FEV1/FVC ratio of less than 0.7**
* Chest radiograph: peribronchial and **perivascular markings**
* **↑ HGB** and HCT are common because of the chronic hypoxic state
* Auscultation of chest: **crackles and wheezes**
* Percussion of chest: **Normal**
30
Tx of chronic bronchitis
* Short-acting bronchodilators for **mild disease**
* long-acting bronchodilators +/- inhaled corticosteroids for **moderate to severe disease**
* **Ipratropium bromide** is the inhaler of choice for COPD
* Smoking cessation and supplemental O2 (**O2 is the single most important medication** in the long term)
* **Antibiotics** for acute exacerbations
* **Flu and pneumococcal vaccines** are a must
31
* The body's natural **response to ↓ lung function** is **chronic hyperventilation** **;**
* CO2 Retainers - the body must increase ventilation to blow off CO2
Emphysema
32
Sx of emphysema
**Minimal cough** (compared to chronic bronchitis), **quite lungs, thin, barrel chest**
## Footnote
**Minimal sputum** (compared to chronic bronchitis)
**Thin, underweight,** and **barrel chest**
33
Dx of emphysema
* ***hest X-ray*** reveals **loss of lung markings** and **hyperinflation, a flattened diaphragm,** small thin appearing heart
* parenchymal bullae ***(subpleural blebs*****)** are pathognomonic
* Normal hematocrit (HCT)
* Auscultation of chest: **Diminished breath sounds**. Prolonged expirations. **Diminished heart sounds**
* Percussion of chest: **hyperresonance**
34
Tx of emphysema
* Ipratropium (also albuterol inhaler)
* O2
* Oral Prednisone 40mg x 5days
* Antibiotics
* Azithromycin 500 mg x 3 days or Z-pack x 5 days
* Cefuroxime 500 mg BID x 10 days
* Doxycycline 100 mg BID x 10 days
35
Tx of COPD exacerbation
* **COPD exacerbations** are managed with **systemic glucocorticoids**, **antibiotics** (tailored to the likelihood of specific pathogens), **antiviral therapy** when influenza is suspected
* Glucocorticoids: **prednisone 40 mg per day for five days**
* Antibiotics (examples):
* Azithromycin 500 mg x 3 days or Z-pack x 5 days
* Cefuroxime 500 mg BID x 10 days
* Doxycycline 100 mg BID x 10 days
36
Dx of chronic bronchitis aka COPD
**Lung biopsy → Gold Standard**
**Chest radiographs in** chronic bronchitis demonstrate **increased** [**interstitial markings**](https://smartypance.com/wp-content/uploads/2018/02/Chronic-Bronchits.jpg), particularly at the **bases** and thickening of the bronchial walls. Unlike in emphysema **diaphragms are NOT flattened**
37
What would be expected of the Hbg + Hct in COPD pt?
Labs: **↑ HGB** and **HCT** common because of the **chronic hypoxic state**
38
What is the PFT in chronic bronchitis?
**PFTs** in chronic bronchitis:
**FEV1/FVC ratio of less than 0.7**
39
In which pt do you see air trapping with
Emphysema
40
**right ventricular enlargement** and eventually **failure** **secondary to a lung disorder** that **causes pulmonary artery hypertension**
Cor Pulmonale
41
MCC of Cor pulmonale
* **Lung disorders** such as PE, vasculitis, ARDS, **COPD (most common)**, asthma, and ILD causes pulmonary artery hypertension
* Pulmonary artery hypertension then leads to **right ventricular failure**
42
PE findings of Cor Pulmonle
Peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift
43
Tx of Cor Pulmonale
Tx underlying pulmonary dz
\*Diuretics may be harmful NOT helpful
44
**Obesity hypoventilation syndrome (OHS)**, also known as **Pickwickian syndrome**
* a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels.
* s/s: sluggish/sleepy during day
* **Sequelae: pulmonary hypertension, cor pulmonale, secondary erythrocytosis**
45
Type of lung disease that results in **scarring (fibrosis)** of the lungs for an unknown reason
**Idiopathic pulmonary fibrosis (IPF)**
46
MC of all interstitial lung dz
Idiopathic pulmonary fibrosis
47
Common non-idiopathic causes of pulmonary fibrosis that must be r/o to dx as idiopathic
* Cigarette smoking
* Certain viral infections
* Exposure to environmental pollutants, including silica and hard metal dusts, bacteria and animal proteins, and gases and fumes
* The use of certain medicines (**methotrexate**, **amiodarone**, nitrofurantoin, rituximab, bleomycin, and cyclophosphamide)
* Genetics
* Radiation treatment
* Gastroesophageal reflux disease (GERD)
48
Dx of Idiopathic pulmonary fibrosis
**CXR** shows [**fibrosis**](https://smartypance.com/wp-content/uploads/2018/08/Pulmonary-Fibrosis.jpg)
**CT chest: diffuse patchy fibrosis** with pleural **_based**_ [_**honeycombing_**](https://smartypance.com/wp-content/uploads/2015/11/honeycombing-on-pulmonary-fibrosis.jpg)
**PFTs will demonstrate a restrictive pattern** - opposite of what you would see with asthma:
Decreased lung volume with a normal to increased FEV1/FVC ratio
49
Tx of idiopathic pulmonary fibrosis
Treatment includes the judicial use of **corticosteroids, O2,** and **eventually lung transplant**
50
How does coal workers pneumoconiosis present?
Coal mining; complication = progressive massive fibrosis
* CXR: small nodular opacities in upper lung fields
51
How does silicosis pneumoconiosis present?
* **Silicosis:** mining, sandblasting, stone, quarry work; increased risk TB and progression to massive fibrosis
* CXR: small rounded opacities throughout the lung, hilar lymph nodes may be calcified - **"eggshell" calcifications**
52
How does asbestos pneumoconiosis present?
* **Asbestos:** insulation, demolition, **shipbuilding**, construction; complication = **mesothelioma**
* CXR: interstitial fibrosis, thickened pleura, **calcified plaques appear on diaphragms or lateral chest wall**
53
How does Berylliosis pneumoconiosis present?
* **Berylliosis:** high tech field, nuclear power, ceramics, aerospace, electrical plants, foundries; requires chronic steroids
* **CXR: diffuse infiltrates and hilar adenopathy**
54
MCC of Viral pneumonia
**Viral:** adults ⇒ flu = MC cause; kids ⇒ RSV; comes on fast
55
Dx of viral pneumonia
Dx: CXR = bilateral interstitial infiltrates; rapid antigen testing for flu, RSV nasal swab, cold agglutinin titer negative
56
Tx of viral pneumonia
Tx: flu with Tamiflu (A and B) if sx began \<48 hrs; symptomatic tx = beta 2 agonists, fluids, rest
57
Sx of Viral pneumonia
**Persistent cough, sore throat, headache, myalgia, and malaise for more than three to five days**.
The symptoms may worsen with time, and new respiratory signs and symptoms, such as dyspnea and cyanosis, appear.
58
MCC of viral pneumonia in adults
Influenza virus
59
Viral pneumonia sx in kids
[**_RSV_**](https://smartypance.com/lessons/infectious-disorders/respiratory-syncytial-virus-infection-reeldx044/), 1st episode of wheezing
* Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection in infants and children and the second most common viral cause of pneumonia in adults
* Patients with RSV pneumonia typically present with **fever, nonproductive cough, otalgia, anorexia, and dyspnea. Wheezes, rales, and rhonchi are common physical findings.**
60
MC bug in bacterial pneumonia, causing rust colored sputum
**S. Pneumoniae -** Rust-colored sputum - common in patients with splenectomy
61
MC bug in bacterial pneumonia, causing salmon colored sputum?
Salmon colored sputum - MRSA treat with vancomycin
62
MC bug in bacterial pneumonia on ventilator pts
**Pseudomonas -** Ventilators, patients become sick fast - treat with 2 antibiotics
63
MC bug in bacterial pneumonia + diarrhea
**Legionella -** low NA+ (hyponatremia), GI symptoms (diarrhea), and high fever
64
MC bug in bacterial pneumonia for patients living in dorms?
**Mycoplasma -** Young people living in dorms, (+) cold agglutinins, bullous myringitis
65
MC bug in bacterial pneumonia, causing currant jelly sputum?
**Klebsiella -** currant jelly sputum, drinkers, aspiration
66
Dx of pneumonia
**Chest radiography** usually demonstrates **bilateral** **lung involvement**, but none of the viral etiologies of pneumonia result in pathognomonic findings with CXR
* Rapid antigen testing for **influenza**
* **RSV** nasal swab
* **Cold agglutinin titer** that is **negativ**
67
Tx of bacterial pneumonia
Tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs
68
Tx of viral pneumonia
Tx: flu with Tamiflu (A and B) if sx began \<48 hrs; symptomatic tx = beta 2 agonists, fluids, rest
69
Patient with non-remitting cough/bronchitis non-responsive to conventional treatments.
**Coccidioides (valley fever)**
70
Dx of fungal pneumonia
Serologic tests using enzyme-linked immunoassays (EIA) for IgM and IgG should be ordered first, if possible. If the EIA is positive, a confirmatory immunodiffusion test should be performed.
71
Tx of fungal pneumonia
Treatment: **fluconazole or itraconazole**
72
[**Histoplasma capsulatum**](https://smartypance.com/lessons/fungal-disease/histoplasmosis/) **sx**
pulmonary lesions that are apical and resemble cavitary TB; **worsening cough and dyspnea, progression to disabling respiratory dysfunction; no dissemination**
Bird or bat droppings (caves, zoo, bird); Mississippi ohio river valley
Signs: mediastinal or hilar LAD (**looks like sarcoid**)
Tx: amp B
73
What type of fungal pneumonia is seen in **Mississippi** and **Ohio River Valleys**
[**Histoplasma capsulatum**](https://smartypance.com/lessons/fungal-disease/histoplasmosis/)
**opportunistic fungus** that is known to cause systemic disease in HIV patients that involves **low-grade fevers, cough, hepatosplenomegaly,** and **tongue ulceration**
74
[**Histoplasma capsulatum**](https://smartypance.com/lessons/fungal-disease/histoplasmosis/) **dx**
**Culture is the gold standard for diagnosis** but requires a lengthy incubation period
75
Tx of Histoplasma capsulatum
Treat with **itraconazole** orally for weeks to months or **Amphotericin B** if severe or failed Itraconazole
76
Budding yeast found in soil contaminated with **pigeon/bird droppings**
[**Cryptococcus**](https://smartypance.com/lessons/fungal-disease/cryptococcosis/)**:** Caused by the fungus Cryptococcus neoformans, common in **AIDS** and immunocompromised states, is considered an **AIDS-defining illness**
77
Dx of cryptococcus
Found in soil; can disseminate and ⇒ meningitis
Lumbar puncture for meningitis
78
Tx of cryptococcus
* Treat with **Amphotericin B + Flucytosine for 2 weeks** followed by **Fluconazole for 10 weeks**
* Prophylaxis **if CD4 with Fluconazole**
79
Who is at risk for pulmonary aspergillosis
The majority of cases occur in people with underlying illnesses such as tuberculosis or chronic obstructive pulmonary disease (COPD), but **with otherwise healthy immune systems**
80
Tx of pulmonary aspergillosis
Treatment: **fluconazole or itraconazole**
81
Common in HIV-infected patients with a low **CD4 count of less than 200, which fungal pneumonia**
[**Pneumocystis Jiroveci**](https://smartypance.com/lessons/fungal-disease/pneumocystis/)(formerly PCP Pneumonia now called PJP)
82
[**Pneumocystis Jiroveci**](https://smartypance.com/lessons/fungal-disease/pneumocystis/)**tx**
**Trimethoprim-sulfamethoxazole (BACTRIM)** and steroids
* Prophylaxis for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.
83
Dx for HIV related pneumonia aka **Pneumocystis jiroveci**
**CXR** is the cornerstone of diagnosis. The radiograph shows **diffuse interstitial or bilateral perihilar infiltrates**
* **Bronchoalveolar lavage (PCR)**, labs, and an HIV test
* Will often have **very low O2 saturation despite supplemental O2**
84
What is the lights criteria for transudative pleural effusion?
Protein \< 0.5
LDH \<0.6
Common Causes: Hypoalbuminema (cirrhosis, nephrotic syndrome), CHF, Constrictive pericarditis
85
What is the lights criteria for exudative pleural effusion?
Protein \>0.5
LDH \> 0.6
MCC: Autoimmune dz, esophageal rupture, infection, malignancy, pancreatitis, post-CABG, PE
86
Presents with Acute onset **ipsilateral chest pain** and **dyspnea** with **decreased tactile fremitus**, **deviated trachea**, h**yperresonance, diminished breath sounds**
Pneumothorax
87
2 types of pneumothorax
Can be **spontaneous** or **traumatic**
* **Primary:** occurs in **absence of underlying disease** (tall, thin males age 10-30 at greatest risk)
* **Secondary:** in **presence of underlying disease** (COPD, asthma, cystic fibrosis, interstitial lung disease)
88
What is a tension pneumothorax
[**Tension pneumothorax**](https://smartypance.com/wp-content/uploads/2019/12/Pneumothora-comparison.jpg) → penetrating injury → **air in pleural space increasing** and **unable to escape**
* **A mediastinal shift** to the **contralateral side** and impaired ventilation
* [**CXR = pleural air**](https://smartypance.com/wp-content/uploads/2019/12/Tension-Pneumothorax.jpg); ABG shows hypoxemia
EOR - Internal Med
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