Medi Flashcards
(184 cards)
1
Q
Chronic Disease Model of Care - Health System
A
- Create a culture, organization, and mechanisms that promote safe, high quality care
- Visibly support improvement at all levels of the organization, beginning w/ the senior leader
- Promote effective improvement strategies aimed at comprehensive system change
- Encourage open and sytematic handling of errors and quality problems to improve care
- Provide incentives based on quality of care
- Develop agreements that facilitate care coordination w/in and across organizations
2
Q
Chronic Disease Model of Care - Self-Management Support
A
- Empower and prepare patients to manage their health and healthcare
- Emphasize the patient’s central role in managing their health
- Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up
- Organize internal and community resources to provide ongoing self-management support to patients
- All patients w/ chronic illness make decisions and engage in behaviors that affect their health (self-management)
- Disease control and outcomes depend to a significant degree on the effectiveness of self-management
3
Q
Chronic Disease Model of Care - Delivery System Design
A
- Assure the delivery of effective, efficient clinical care and self-management support
- Define roles and distribute tasks among team members
- Use planned interaction to support evidence-based care
- Provide clinical case management services for complex patients
- Ensure regular follow-up by the care team
- Give care that patients understand and that fits w/ their cultural background
4
Q
Chronic Disease Model of Care - Decision Support
A
- Promote clinical care that is consistent w/ scientific evidence and patient preferences
- Embed evidence-based guidelines into daily clinical practice
- Share evidence-based guidelines and information w/ patients to encourage their participation
- Use proven provider education methods
- Integrate specialist expertise and primary care
5
Q
Chronic Disease Model of Care - Clinical Information Systems
A
- Organize patient and population data to facilitate efficient and effective care
- Provide timely reminders for providers and patients
- Identify relevant subpopulations for proactive care
- Facilitate individual patient care planning
- Share information w/ patients and providers to coordinate care
- Monitor performance of practice team and care system
6
Q
Chronic Disease Model of Care - The Community
A
- Mobilize community resources to meet needs of patients
- Encourage patients to participate in effective community programs
- Form partnerships w/ community organizations to support and develop interventions that fill gaps in needed services
- Advocate for policies to improve patient care
7
Q
Criteria for Screening
A
- Burden of suffering caused by the condition (prevalence and severity)
- Effectiveness, Safety, and Cost of the preventative intervention or treatment
- Performance of Screening Test
8
Q
Screening for HTN
A
- Adults aged 18 years or older
- Recommended to obtain measurments outside of the clinical setting for diagnostic confirmation before starting treatment
9
Q
Tobacco Screening
A
- Screen ALL Patients
- Ask
- Advise them to stop using
- Provide behavioral interventions
10
Q
Screening for AAA
A
- Men 65-75 who have ever smoked should be screened one time w/ abdominal ultrasonography
- Recommends against screening for AAA in women who have never smoked
11
Q
Screening for Carotid Artery Stenosis
A
- Recommends against screening in asymptomatic adult population
12
Q
Screening for Diabetes
A
- Screen individuals 40-70 years old who are overweight or obese
- BMI 25 or greater
13
Q
American Diabetes Association Criteria for Diagnosis
A
- HbA1c level of 6.5% or higher
- Fasting plasma glucose level of 126 mg/dL or higher
- 2-Hour plasma glucose level of 200 mg/dL or higher during a 75-g oral glucose tolerance test
- Random plasma glucose of 200 mg/dL or higher in a patient w/ classic symptoms of hyperglycemia
- Polyuria, Polydipsia, Polyphagia, Weight Loss, or Hyperglycemic Crisis
- Recommends repeating same test for confirmation, since there will be a greater likelihood of occurrence
- Diagnosis also confirmed if the results of 2 different tests are above diagnostic thresholds
14
Q
Screening for Lung Cancers
A
- Lung cancer is the leading cause of cancer-related death
- Promoting smoking cessation is likely to have far greater impact on lung cancer mortality than screening
- Plain chest x-ray is ineffective for lung cancer screening
- Annual screening w/ low-dose computed tomography
- In adults aged 55-80 years old
- Who have a 30 pack-year smoking history and are currently smoking or have quit w/in the past 15 years
- Screening discontinued when:
- Person has not smoked for 15 years
- Develops health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
15
Q
Screening for Breast Cancer
A
- USPSTF
- Mammogram every 2 years for women 50-74
- Women w/ parent, sibling, or child w/ breast cancer are at higher risk and may benefit from earlier screening in 40s
- Not recommended screening >75
- ACS
- 40-44 should have choice to start annual breast cancer screening w/ mammograms
- 45-54 yearly mammograms
- 55 and older can switch to every 2 years or continue yearly screening
- ACS At High Risk
- MRI and Mammogram yearly
- Based on Evidence
- BRCA Mutation
- First-degree relative of BRCA carrier, but untested
- Lifetime Risk 20-25% or greater
- As defined by BRCAPRO or other models
16
Q
Presentations of Interstitial Lung Disease
A
- Progressive exertional dyspnea
- Persistent nonproductive cough that does not resolve
- Hemoptysis
- Wheezing
- Chest Pains
- Incidental findings of interstitial opacities on a CXR
17
Q
Most Common ILDz of Unknown Etiology
A
- Sarcoidosis
- Idiopathic Pulmonary Fibrosis
- Pulmonary Firbrosis due to Connective Tissue Diseases
18
Q
Most Common ILDz of Known Etiology
A
- ILDz due to occupational and inhalational exposures
19
Q
Granulomatous Disorders
A
- Known Cause
- Hypersensitivity Pneumonitis (Organic Dusts)
- Inorganic Dusts (Beryllium, Silica)
- Unknown Cause
- Sarcoidosis (MOST COMMON)
- Granulmatosis w/ Polyangitis
- Allergic Granulomatosis of Churg-Strauss
- Bronchocentric Granulomatosis
- Lymphomatoid Granulomatosis
20
Q
Idiopathic Interstitial Pneumonias
A
- Idiopathic Pulmonary Fibrosis (Usually Interstitial Pneumonia) MOST COMMON
- Acute Interstitial Pneumonia
- Cryptogenic Organizing Pneumonia
- Nonspecific Interstitial Pneumonia
- Respiratory Bronchiolitis-Associated ILD
- Desquamative Interstitial Pneumonia
21
Q
Connective Tissue Related ILD
A
- SLE
- Rheumatoid Arthritis
- Sjogren’s
- Polymyositis
- Dermatomyositis
22
Q
Drug Induced ILDz
A
- Meds
- Abx
- Nitrofurantoin
- Amiodarone
- Gold
- Chemo Drugs (Bleomycin and Methotrexate
- Illicit Drugs
- Cocaine
23
Q
Pulmonary Vasculitic Disorders
A
- Diffuse Alveolar Hemorrhage
- Granulmatosis w/ Polyangiitis
- Microscopic Polyangiitis
- Churg-Strauss Syndrome
24
Q
Diagnosis of ILDz
A
- High Resolution CT Scans
- Sometimes accurate enough to eliminate the need for tissue Bx
- May be diagnostic in cases of:
- Idiopathic Pulmonary Fibrosis
- Sarcoidosis
- Hypersensitivity Pneumonitis
- Absestosis
- Lymphangitic Carcinoma
- May also serve as a sugical guide for optimal areas to biopsy for thoracoscopic or open lung biopsy procedure
- Tissue Biopsy
- Often by open lung biopsy (thoracotomy) or by thorascopic means (less invasive)
25
History in ILDz
* Duration of Ilness
* Acute (Days to Weeks)
* AIP, Hypersensitivity Pneumonitis, Allergic
* Subacute (Weeks to Months)
* Sarcoid, SLE, Drug Induced, COP/BOOP
* Chronic (Months to Years)
* IPF, Eosinophilic Granuloma
* Episodic
* Hypersensitivity, Pulmonary Hemorrhage Syndromes
* Age
* Most hereditary present in ages 20-40
* IPF patients are usually 60 years or older
* Gender
* Exclusive to Females
* LAM and Pulmonary Tuberous Sclerosis
* More Frequent w/ Females
* Hermansky-Pudlak and Most CTDz
* More Common in Men
* RA Lung Involvement
* IPF
* Pneumonconiosis
* Family Hx
* Familial Lung Fibrosis
* Associated w/ 3 Gene Mutations
* Associated w/ Interstitial Pneumonia Patterns
* Risk Factors
* Older Age
* Male Sex
* Hx of Smoking
* Smoking
* 66-75% of IPF and FLF pts have smoking hx
* SMOKING MAKES ALL PULMONARY DISEASE PROCESSES WORSE!!
* Occupational and Environmental Exposure
* Obtain detailed chronological work/occupational hx
* Ask about exposures to chemicals, dust, gas, animal products
* Ask if symptoms worse when at or away from work
* Ask about hobbies and pastimes, especially related to dust exposures, animal products, etc
* Travel Hx
* Ask about recent/past travel
* Always consider hx of previous infections including parasites
* Ask about social hx relating to HIV
* Many of these dz present in more rapid and serious forms in immuno-suppressed
26
Signs and Symptoms of ILDz
* Dyspnea (Common)
* Wheezing (Uncommon in Most)
* Chest Pain (Uncommon)
* Sudden Sub-Sternal Pain (Common in Sarcoidosis)
* Sudden Worsening of Dyspnea
* Associated w/ Spontaneous Pneumothorax
* Frank Hemoptysis (Rare in Most)
* Blood Tinged Sputum (Rare in Most)
* Fatigue (Very Common)
* Weight Loss (Very Common)
27
Physical Exam Findings in ILDz
* Tachypnea
* Bibasilar End-Inspiratory Dry Rales or Crackles
* (Both More Common in Inflammatory rather than Granulomatous Dz)
* Scattered Late Inspiratory High Pitched Rhonchi
* Called "inspiratory squeaks"
* Seen in bronchiolitis
* Middle to Late Stages Frequently Manifest Signs of Cor Pulmonale or Pulmonary HTN
* Cyanosis and Clubbing may present in Advanced Dz
28
Lab and Studies in ILDz
* Presence of Autoimmune Antibodies
* Elevated LDH is Common Nonspecific Finding
* Elevated ACE Level is Common in Sarcoidosis
* Anti-Neutrophil Cytoplasmic Antibodies and Antibasement Membrane Antibodies in Vasculitis Syndromes
* EKG normal until later dz
* Echo may show RVH or RV dilation
29
Chest Imaging in ILDz
* Common CXR Findings
* Bibasilar Reticular Pattern
* Increased Reticular Markings
* Certain ILDz exhibit nodular densities w/ predisposition for the upper zones of the lung
* Sarcoid
* Silicosis
* Berylliosis
* Ankylosing Spondylitis
* RA (Necorbiotic Form)
* PLCH (Pulm. Langerhans Histocytosis)
* CXR do not correlate well w/ clinical or histo-pathologic stage of dz present
* When honeycombing changes are evident on CXR this goes along w/ poorer prognosis
* Not Specific Enough to Make a Diagnosis
30
Cervical Cancer Screening
* Methods
* Conventional Slides
* Liquid Based
* HPV Testing
* USPSTF
* Screening for Women 21-65 by cytology (pap smear) every 3 years (Grade A)
* Women 30-65 who want to lengthen the screening interval w/ combo of cytology and HPV testing every 5 years (Grade A)
* Against screening \>65 or those w/ hysterectomy w/ removal of cervix
* Against screening w/ HPV alone or in combo w/ cytology in women \<30
31
Colon Cancer Screening
* 3rd Most Common Cancer, 2nd Leading Cause of Death from Cancer
* USPSTF
* Recommends screening starting at 50-75
* 76-85 Individualized
* \>85 Not Recommended
* Flex Sig = Every 5 Years
* Colonoscopy = Every 10 Years
* Double-Contrast Barium Enema = Every 5 Years
* CT Colonography (Virtual Colonoscopy) = Every 5 Years
* Tests That Detect Cancer
* gFOBT - Annually
* iFOBT (FIT) - Annually
* sDNA
* ACG
* Colonoscopy preferred screening/prevention test
* FIT as preferred screening/detection test for patients who decline cancer prevention tests
* Initiation of screening at 45 for African Americans
* Increased Risk (First Degree Relative w/ CRC at age \<60 years, or 2 FDR at Any Age)
* Colonoscopy strating at 40 or 10 years younger than the earliest diagnosis in their family
* Colonoscopy should be repeated every 5 years
32
Prostate Cancer Screening
* USPSTF
* Recommends against PSA-based screening
* ACS
* Recommends men have chance to make an informed decision
* Discussion should take place at:
* Age 50 for men at average risk
* Age 45 for men at high risk (African Americans and those w/ FDR diagnosed \<65)
* Age 40 for men at even higher risk (Those w/ more than one FDR who had prostate cancer at an early age)
* Men who want screening should be tested w/ **PSA Blood Test**
* Digital Rectal Exam may also be done as part of screening
33
Osteoporosis Screening
* USPSTF
* Women 65 and older be screened routinely
* Or \<65 at increased risk equivalent to or greater than a 65 yo woman
* Does not recommend screening for men
* DXA/DEXA Scan
* Repeat in 3-5 Years
34
HIV Screening
* USPSTF
* Screen adolescents and adults ages 15-65
* Younger or older if at increased risk
* Screen all pregnant women for HIV
35
Chlamydia/Gonorrhea
* USPSTF
* Screen all sexually active, non-pregnant young women 24 and younger and in older non-pregnant women who are at increased risk (Grade A)
* Screen all pregnant women 24 and younger in older pregnant women who are at increased risk (Grade B)
36
Acute Cough
* Most commonly due to upper respiratory infection
* Common Cold
* Acute Bacterial Sinusitis
* Pertussis - Reportable dz
* May also be presenting symptom of
* Pneumonia
* Pulmonary Embolism
* Acute Exacerbation of Heart Failure
37
Subacute and Chronic Cough
* Most Common Causes
* Post Nasal Drip
* Asthma
* GERD
* Also Consider
* Post-Infectious Cough
* Pulmonary Disease
* ACE Inhibitor Use
* Etiology is found in 75-90% of pts
38
Post Nasal Drip
* Most common cause of subacute and chronic cough
* Symptoms
* Frequent Nasal Discharge
* Sensation in the Back of the Throat
* Frequent Throat Clearing
* Etiology
* Allergic
* Non Allergic Seasonal
* Vasomotor Rhinitis
* Diagnosis confirmed by response to treatment
39
Asthma
* Second most common cause of subacute and chronic cough
* Most common in children
* Wheeze or cough variant asthma
* Non Asthmatic Eosinophilic Bronchitis
* Atopic pts w/ idiopathic cough and sputum eosinophilia
40
GERD
* Third most common cause of subacute/chronic cough
* Symptoms absent in up to 40% of pts
* Cause of cough
* Stimulation of upper airway receptors
* Aspiration of gastric acid
* Esophageal receptor activation
* May contribute to development of asthma
* Laryngopharyngeal Reflux (LPR)
* 35% of pts report heartburn
* Dysphonia/hoarseness, chronic cough, non productive throat clearing, mild dysphagia
* Upper esophageal sphincter - occurs while upright
41
Medications to Quickly Relieve Asthma
* Short Acting Beta-2 Agonists
* Albuterol
* Levalbuterols
* R-enantiomer of albuterol
42
Long-Term Control of Asthma
* Taken daily over a long period of time
* Reduce inflammation, relax airway muscles, and improve symptoms and pulmonary function
* Inhaled corticosteroids: most important
* Long-acting beta 2 agonists (In Combination)
* Leukotriene Modifiers
* Biologics
43
Classification of Asthma Severity - Intermittent
* Symptoms
* \< or = 2 days/week
* Nighttime Awakenings
* \< or = 2x/month
* Short-Acting Beta 2 Use
* \< or = 2 days/week
* Interference w/ Normal Activity
* None
* Lung Function
* Normal FEV1
* FEV1 \>80%
* FEV1/FVC Normal
44
Classification of Asthma Severity - Persistent Mild
* Symptoms
* \> 2 days/week but not daily
* Nighttime Awakenings
* 3-4x/month
* Short-Acting Beta 2 Use
* \>2 days/week but not \>1x/day
* Interference w/ Normal Activity
* Minor Limitation
* Lung Function
* FEV1 \> or = 80%
* FEV1/FVC Normal
45
Classification of Asthma Severity - Persistent Severe
* Symptoms
* Throughout Day
* Nighttime Awakenings
* Often 7x/week
* Short-Acting Beta 2 Use
* Several Times Per Day
* Interference w/ Normal Activity
* Extreme Limitation
* Lung Function
* FEV1 \< 60% predicted
* FEV1/FVC Reduced \>5%
46
Classification of Asthma Severity - Persistent Moderate
* Symptoms
* Daily
* Nighttime Awakenings
* \>1x/week bjut not nightly
* Short-Acting Beta 2 Use
* Daily
* Interference w/ Normal Activity
* Some Limitation
* Lung Function
* FEV1 \> 60% but \<80% predicted
* FEV1/FVC Reduced 5%
47
Pleural Effusion
* Normally a very thin layer of fluid b/t visceral and parietal pleura
* .25 ml/kg of low protein fluid
* Originates from systemic capillaries in the parietal pleura
* Rate of .6 ml/hr
* Development
* Increased rates of production
* Increased permeability (protein rich), hydrostatic pressure of systemic/pulmonary venous system
* Decreased pleural pressure (atelectasias), plasma oncotic pressure (hypoalbuminemia)
* Decreased rates of absorption
* Speculate related to pleura lymphatics
* Intrinsic Factors
* Inflammation, radiation, drugs, cancer, anatomic
* Extrinsic Factors
* Decreased respiration, compression or blockage of lymphatics, increased systemic venous pressure
48
Approach to Patient w/ Pleural Effusion
* History and Physical
* Most important step
* Imaging
* Pleural Fluid Analysis
* Thoracentesis
* First episode deserves diagnostic eval
* Okay to follow clinically if pt has uncomplicated hf or viral pleurisy
* If severe symptoms develop = therapeutic thoracentesis
49
Imaging Pleural Effusions
* Plain Film - INITIAL IMAGING CHOICE
* Fluid usually follows gravity
* Subpulmonic location can hold 75cc before spill over into costophrenic angle
* Front and lateral views most commonly used
* Oblique and lateral can be used as well
* Can be loculated secondary to adhesions
* CT
* Provides good detail of pleural fluid
* Can detect as little as 2 ml in pleural space
* Ability to measure fluid density
* Ability to measure pleural thickness
* Possibly identify other causes of an effusion
* Ultrasound
* Can identify free and loculated fluid collections
* Solid masses from effusion
* Lung movement w/in the effusion
* Measurement of distances
* Aid in thoracentesis
* Echogenicity of pleural effusion (Compare to liver)
* Usually anechoic (black), hypoechoic
* Hemothorax and empyema may be isoechoic to the liver
* Presence of air
* MRI
* Good to determine age of hemothorax
* Define anatomy of the pleural space
* Image tumors associated w/ the pleural spaces
50
Pleural Fluid Analysis
* Transudate
* Systemic factors
* Imbalance of hydrostatic and oncontic pressure
* Movement of fluid from peritoneal or retroperitoneal space
* Iatrogenic
* Exudate
* Local factors
* More extensive differential
51
Pale Yellow Pleural Fluid
Transudate, some exudates
52
Red (Bloody) Pleural Fluid
Malignancy
Benign Asbestos Pleural Effusion
Postcardiac Injury Syndrome
Pulmonary Infarction in Absence of Trauma
53
Light's Diagnostic Criteria Pleural Effusion
* Measure serum and pleural fluid protein and LDH
* Protein/Serum Protein \>0.5
* LDH/Serum LDH \>0.6
* LDH greater than 2/3 upper limits of normal serum LDH
* At least one of three = almost always exudate
54
Pleural Effusion Protein
* Most transudates have absolute concentrations below 3 g/dl
* Acute diuresis can raise this
* TB
* Usually \>4.0 g/dl
* \>7.0-8.0
* Must consider
* Waldenstroms Macroglobulinemia
* Multiple Myeloma
55
Chemical Analysis of Pleural Fluid
* LDH
* \>1000 IU/L characteristic of:
* Empyema
* Rheumatoid Pleurisy
* Pleural Paragonimiasis
* Occasionally malignancy will also have LDH \> 1000
* Glucose
* Low Concnetrations
* Rheumatoid Pleurisy
* Parapneumonic/Empyema
* Malignant
* TB
* Lupus
* Esophageal Rupture
* pH
* Normal = 7.6
* \< 7.3 - Pleural cells and bacteria
* Transudates - 7.4-7.55
* Exudates - 7.3-7.45
* Amylase
* Acute Pancreatitis
* Chronic Pancreatitis
* Esophageal Rupture
* Malignancy
56
Differential Diagnosis of VTE
* Muscle injury
* Cellulitis
* Can occur concomitantly
* Valvular Insufficiency
* Popliteal Cyst
* Drug Induced Edema
57
Diagnostic Eval of VTE
* Ultrasound
* Most reliable
* Limitations
* Unable to see pelvic and very high femoral lesions
* Limited to pts w/ exposed skin
* Impedence Plethysmography
* Looking for volume changes
* Sens and Spec for Proximal DVT
* May have false positives in pts w/ venous insufficiency or elevated right sided pressures
* Venography
* GOLD STANDARD
* Invasive
* Complications
* DVT
* Renal Failure (Contrast Material)
* Lab Studies
* D-Dimer
* Normal usually = NO VTE
* CT
* MRI
58
Treatment of VTE
* LMWH
* Fondaparinux
* Anti-Xa, once daily injection
* Heparin
* PTT 1.5-2.0 x Normal
* Need to monitor platelet counts
* Warfarin
* INR 2.0-3.0
* Vit K Antagonist
* Inhibits formation of active factors II, VII, IX, X and Protein C & S
* Need to bridge w/ LMWH or Heparin until INR gaps
* Fibrinolysis
* tPa
* Risk = bleeding (especially head)
* Thrombectomy
* IVC Filters (Greenfield Filter)
* Rivaroxaban (Xarelto)
* Oral Factor Xa Inhibitor
* Dabigatran
* Oral Direct Thrombin Inhibitor
* Approved in Europe for DVT Proph
59
Duration of Treatment
* First DVT w/ Associated Time Limited or Reversible Risk Factor
* Min. of 3 Months
* First Idiopathic DVT
* 6 Months to 1 Year
* Recurrent DVT
* Possibly Indefinitely
* Associated Inherited Coagulopathy
* Possibly Indefinitely
* Compression Stockings w/in 1 Month of Dx and Continue for 1 Year
60
Pulmonary Embolism
* Highest Risk in Pts w/ Proximal and Pelvic Vein DVT
* Physiology
* Hypoxemia (Decreased PaO2)
* V/Q Mismatch
* Increase in Anatomic Dead Space
* Increase in Physiologic Dead Space
* Increased Pulmonary Vascular Resistance
* Alveolar Hyperventilation (Respiratory Alkalosis)
* Increased Airway Resistance
* Decreased Pulmonary Compliance
* R Ventricular Dysfunction
61
Presentation of Pulmonary Embolism
* May be asymptomatic
* Dyspnea
* Cough
* Hemoptysis
* Pleuritic Chest Pain
* Massive PE
* Systemic Arterial Hypotension
* Symptoms of DVT
62
Differential Dx of Pulmonary Embolism
* Pneumonia
* Asthma
* COPD
* Heart Failure
* Pericarditis
* Rib Fracture
* Pneumothorax
* Acute Coronary Syndrome
* Anxiety
63
Diagnosis of Pulmonary Embolism
* Non-Imaging Testing
* D-Dimer
* Cardiac Biomarker
* EKG
* S1Q3T3
* Non-Invasive Imaging
* CXR
* Usually Normal
* Contrast CT
* Imaging modality of choice
* V/Q Scanning
* Now second line
* MRI
64
Treatment of Pulmonary Embolism
* Similar to DVT
* Same Drugs, Same Doses
* Target INR for Coumadin (2.0-3.0)
* Fibrinolysis
* Embolectomy
65
DVT Prophylaxis
* Who
* Surgical Pts
* Medical Pts
* How
* Low Dose Sub Q Heparin
* 5000 Units every 8-12 Hours
* Cheap
* LMWH
* Less risk of heparin induced thrombocytopenia
* Warfarin
* Needs to be bridged w/ others until INR 2.0-3.0
* Intermittent Compression Stockings
* Cheap
* Easy
* Reserved for Low Risk Pts
* Duration
* While hospitalized
* While immobilized
* Joint Replacement
* Knee 7-10 Days
* Hip 28-35 Days
* Hip Fracture
* Typically 3 Months
* At least until mobile
66
Pneumoconioses
* Associated w/ inhalation of various dust particles, frequently occupation associated
* Inorganic
* Chronic diseases that usually progress to fibrosis
* Silicosis, asbestosis, berylliosis, coal dust, etc
* May be mixed exposures depending on occupation
* These diseases are incurable
* Bronchioalveolar lavage has little effect on removal of these particles
* Scarring leads to pulmonary fibrosis, which causes worsening right heart failure (cor pulmonale) and eventual death
* Organic
* Allergy/hypersensitivity mediated diseases from spores, fibers, etc exposure
* Type I - IgE mediated, asthma, atopy
* Type III - Immune complex mediated such as vasculitis syndromes
* Type IV - Cell mediated, granulomatous disease
* Usually reversible w/ treatment but get worse w/ recurrent bouts of disease
67
Progressive Massive Fibrosis
* Defined as complication of environmental lung disease that results in the formation of many lung nodules 1 cm in diameter or larger and/or the development of 1 or more large circumscribed areas of dense black scar tissue
* Large circumscribed lesions usually occur in an upper lobe
* PMF is progressive and lethal
* NO Treatment
68
Coal Workers Pneumoconiosis (CWP)
* Mixed pneumoconiosis w/ multiple lesions
* Coal dust lesions
* Silicotic lesions/nodules
* Lesion from con-comittant
* Cigarette smoking
* Tuberculosis (rare)
* Autoimmune Dz (Caplans syndrome)
* Air Pollution
* Progressive Massive Fibrosis (Black Lung) - only in the worst cases
* Coal dust accumulates to form coal macules
* By themselves cause little or no respiratory symptoms unless accompanied by smoking or other con-committant lung dz
* Do not grow or progress after exposure stops
69
Silicosis
* Deadly pneumoconiosis, common in workers in:
* Sandblasting
* Mining
* Tunneling
* Gun Flint Industry
* Sandstone Industry
* Granite Industry
* Pottery Industry
* Metal Grinding
* Abrasive Soap Industry
* Silica Dust Deposition Causes:
* Pleural Adhesions
* Silicotic Nodules
* Eggshell Calcification in Lungs and Lymph Nodes
* Massively expanding lymph nodes in mediastinum can pinch off or occlude the pulmonary artery
* At risk for mycobacterium kansasii
* Variants of Disease
* Acute Silicosis
* Large dose of silica particles enter the lung
* Lung becomes flooded w/ proteinaceous fluid, surfactant, and pulmonary macrophages, usually fatal in a few days
* Silicotuberculosis
* Silicosis w/ TB disease
* Anthrosilicosis
* Silicosis plus coal workers pneumoconiosis
* Siderosilicosis
* Silicosis plus iron oxide exposure
* Caplans Syndrome
* Inorganic pneumoconiosis plus autoimmune disease
70
Asbestosis
* Usually occurs after acute heavy, or prolonged exposue (often greater than 10 years) to asbestos containing dusts
* Disease tends to progress even after exposure has ceased
* Numerous industries and occupations historically are linked to abestos exposure
* Shipyard Workers
* Insulation
* Fireproofing
* Cement
* Water Mains
* Brake Linings
* Linoleum
* Ironing Boards
* Fire-Resistant Clothing
* Whitewash
* Long slender needle-like asbestos fibers travel through the lung towards the pleural surface
* Cause interstitial pulmonary fibrosis
* Causes a diffuse pattern rather than the nodular pattern seen w/ silicosis
* Pulmonary fibrosis occurs first on pleural surfaces then progresses to the lung parenchyma
* May lead to chronic bleeding from these pleural surfaces
* Pulmonary fibrosis is made worse w/ concurrent smoking
* Cancer risk involved w/ asbestos exposure
* MOST COMMON MALIGNANCY - Bronchogenic carcinoma
* Known risk factor for developing Mesothelioma
* Asbestos also increases risk of
* Laryngeal Cancer
* GI Associated Cancers
* Malignant Lymphomas
71
Berylliosis
* Due to inhaled beryllium dust
* Most historical now, associated w/ past exposure in workers who worked w/ rockets and fluorescent light bulbs
* Causes interstitial fibrosis and granulomas
* May also show areas of necrosis
* Not all exposed to the beryllium dust were "sensitive", some were exposed w/ little consequence
* Non-necrotizing granulomas can be found in skin of workers who may have scratched themselves w/ broken fluorescent bulbs
72
Farmers Lung
* Hypersensitivity pneumonitis
* Farmers become sensitive to fungal and allergenic bacterial spores in moldy hay
* Present w/:
* Asthma symptoms (early in disease) - IgE mediated, causes resp symptoms such as broncho-spasms and wheezing
* Late symptoms develop from an IgG mediated, immune complex, Type III sort of hypersensitivity
* Creates vasculitis which can result in granulomas, necrosis, and pulmonary fibrosis
* Bagassosis - farmers lung due to moldy sugar cane plants
73
Spirometric Changes in Hypersensitivity Pneumonitis
* Acute Phases
* Restrictive physiology w/ preserved airflow is seen but can sometimes present as obstruction (asthma like symptoms)
* Chronic Phases
* Patients develop severe restriction and or mixed restrictive/obstructive disease
* DLCO is reduced in _all stages of disease_
* May have reduced SaO2 at rest, usually drops w/ exertion/exercise
74
Byssinosis
* Cotton Dust Lung Disease
* "Monday Chest Tightness" or "Monday Fever"
* Symptoms worse on monday after a weekend off and diminish through the week w/ repeated exposure
* Acute dz is asthma like (PFT show obstructive changes acutely)
* Acute Tx
* Avoidance of exposure
* Beta agonsists and other asthma drugs
* Chronic airway disease is only seen after decades of exposure
* Only about 1/3 of those exposed get sick
* Tends to get worse w/ repeated episodes
* Does not require a previous exposure to "sensitize" the lungs
* Non-allergic reaction, thus persons exposed to cotton dust for the first time may react
75
Mycobacterium Tuberculosis
* Acid Fast Staining
* Rod-Shaped
* Non-Spore Forming
* Aerobic
* 4-8 Weeks for Visible Growth on Solid Medium
* Grows in parallel groups called cords
76
Persons at Increased Risk of Tuberculosis Infection
* Persons Infected w/ HIV
* Children Younger than 5
* Those recently infected w/in past 2 years
* Hx of untreated or inadequately treated TB dz
* Those receiving immunosuppressive therapy
* Those w/ silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
* Those who have had a gastrectomy or jejunoileal bypass
* Persons less than 90% of their ideal body weight
* Cigarette smokers and persons who abuse drugs and/or alcohol
* Populations defined locally as having an increased incidence of disease due to M. tuberculosis
77
TST Interpretation
* 5-mm Induration is Postive In:
* Immunocompromised
* Close contacts to infectious TB case
* Persons w/ chest radiographs consistent w/ prior untreated TB
* 10-mm Induration is Positive In:
* Everything in b/t
* 15-mm Induration is Postive In:
* Persons w/ no known risk factors
78
Signs and Symptoms of Tuberculosis
* Chronic Cough (\>3wks)
* Night Sweats
* Weight Loss
* Fever/Chills
* Hemoptysis or Rust-Tinged Sputum
* Same as lung cancer...
79
Diagnosis of Tuberculosis
* CT Scan - Helpful
* Sputum Culture
* Sputum AFB Smear
* Acid-Fast (Can be challenging to get)
* Sputum DNA PCR
80
Workup For Cough
* First
* Nasal Antihistamine-Decongestant Combo
* Partial Relief
* Add Nasal Steroid or Anticholinergic
* If NO Relief
* Spirometry w/ methacholine challenge should be considered
* If positive, treatment w/ bronchodilators
* Consider sputum for eosinophils
* Lastly
* Empiric Tx w/ PPI for GERD w/ lifestyle and dietary changes
81
Main Causes of Dyspnea
* Chronic
* Asthma
* COPD
* Interstitial Lung Dz
* Myocardial Dysfunction
* Obesity or Deconditioning
* Complex interaction of efferent and afferent processing in the brain
* Increased work of breathing
* Feeling of air hunger because of increased ventilation
* Acute Anxiety
82
Evaluation of Dyspnea
* Hx
* Have patient describe the sensation they feel
* Exacerbating
* Body Position Changes
* Activity Level
* Associated Symptoms
* Risk Factors
* Occupational
* Family Hx
* Chronic Illnesses
* PE
* Vital Signs
* Look for evidence of increased work of breathing
* Accessory Muscles
* Retractions
* Signs of Fatigue
* Examine Chest Wall Mechanics
* Auscultate of the heart and lung fields
* Look for signs of anemia, fluid overload, or muscle wasting
* Watch the patient walk if they complain of exertional dyspnea
* Studies
* Chest Radiograph
* Plain Film and CT
* Pulmonary Function Test
* EKG
* Echocardiogram
* Labs
* ABG
* CBC
* Electrolytes
* Markers of Kidney and Liver Function
* BNP
* Cardiac Stress Test
83
When do you supplement w/ oxygen?
* O2 Sat below 90%
* SpO2 below 60
84
Criteria for Normal Post-Bronchodilator Spirometry
* FEV1: \> or = 80%
* FVC: \> or = 80%
* FEV1/FVC: \>0.7
85
Obstructive Disorder Spirometry
* Decreased:
* FEV1
* FEF25-75
* FEV1/FVC \<0.7
* Increased or Normal TLC
86
In Bronchodilator Reversibility Testing, what is diagnostic for asthma?
FEV1 that is both greater than 200 ml and 12% above the pre-bronchodilator FEV1
87
Restrictive Lung Dz Spirometry
* Decreased
* TLC
* FVC
* Normal or Increased
* FEV1/FVC
88
Criteria for Restrictive Dz
* FEV1 \< 80%
* FVC \< 80%
* FEV1/FVC \> 0.7
89
What medications should be withheld before performoing spirometry?
* SABA for 6 Hours
* LABA for 12 Hours
* SAMA for 6 Hours
* LAMA for 24 Hours
* Subjects should also avoid caffeine and smoking for 30 minutes before
90
GOLD 1 COPD
Mild
FEV1 \> or = 80%
91
GOLD 2 COPD
Moderate
FEV1 50-80%
92
GOLD 3
Severe
FEV1 30-50%
93
GOLD 4 COPD
Very Severe
FEV1 \< 30%
94
GOLD Group C
* 2 or more exacerbations
* Or 1 or more leading to hospitalization
* mMRC 0-1
* CAT \< 10
95
GOLD Group A
* 0-1 Exacerbations (Not leading to hospitilization)
* mMRC 0-1
* CAT \< 10
96
GOLD Group B
* 0-1 Exacerbation Hx
* mMRC \> or = 2
* CAT \> or = 10
97
GOLD Group D
* 2 or more exacerbation Hx
* Or 1 or more leading to hospitalization
* mMRC \> or = 2
* CAT \> or = 10
98
What therapies can influence the progression of COPD?
1. Smoking Cessation
2. Oxygen Therapy - If Hypoxic
3. Lung Volume Reduction Surgery
99
What is the only pharmacologic therapy demonstrated to unequivocally decrease mortality rates in pts w/ COPD?
Supplemental O2
100
Indications for Supplemental Oxygen
* Resting SpO2 of 88% or Less
* Resting SpO2 of 90% or Less IF Pulmonary Hypertension or R Heart Failure
* Nocturnal Oximetry 88% or Less for more that 5 minutes
* Desaturation seen w/ exercise that recovers w/ supplemental oxygen
101
Indications for Pulmonary Rehabilitation
* Symptomatic Patients
* FEV1 \< 50% Predicted
* Must have had spirometry w/in the last two weeks of ordering therapy
102
Indications of Lung Volume Reduction Surgery
* Upper lobe-predominant Emphysema
* Low Post-Rehab Exercise Capacity
103
Type 1 AECOPD
* Increased Dyspnea
* Increased Sputum Volume
* Increased Sputum Purulence
104
Type 2 AECOPD
* Increased Sputum Volume
* Increased Sputum Purulence
105
Type 3 AECOPD
* One of:
* Increased dyspnea
* Increased sputum volume
* Increased sputum purulence
* AND
* Cough, Wheeze, or Symptoms of URI
106
Who benefits most from non-invasive ventilation?
Hypercapnic Patients
PaCO2 \> 6.0 kPa, 45 mmHg
107
Discharge Criteria for Pts w/ AECOPD
* Inhaled Beta-2 agonist therapy required no more frequently then q4
* If previously ambulatory, able to walk across room
* Able to eat and sleep w/o frequent awakening by dyspnea
* Clinically stable for 12-24 hours
* ABG stable for 12-24 hours
* Full understanding of correct use of medications
* Follow-up and home care arrangements complete
* Patient, family, and physician are confident patient can manage successfully at home
108
Hypoxic Hypoxia
* Low arterial pO2 when oxygen carrying capacity of blood and rate of blood flow to tissues are normal or elevated
* Characterized by:
* Low arterial pO2
* Low arterial O2 content
* Low arterial % O2 saturation of hemoglobin
* Low A-V pO2 difference
* Causes
* Low pO2 of inspired air
* Decreased pulmonary ventilation
* Defect in exchange of gases
* Venous arterial shunts
109
Hypemic (Anemic) Hypoxia
* Arterial pO2 is normal but the amount of hemoglobin available to carry oxygen is reduced
* Characterized by:
* Normal arterial pO2
* Arterial O2 content moderately reduced
* A-V pO2 difference is normal
* Causes
* Anemia
* Hemorrhage
* Dysfunctional Hemoglobin
* Sickle Cell
* Carbon Monoxide
* Conversion of Hemoglobin to Some Abnormal Form
* Methemoglobinemia
110
Circulational/Stagnant/Ischemic Hypoxia
* Blood flow to the tissue is so low that adequate oxygen is not delivered to them despite normal arterial pO2 and hemoglobin concentration
* Characterized by:
* Normal Arterial pO2
* Normal arterial O2 content
* Normal arterial % O2 saturation of hemoglobin
* A-V difference more than normal
* Causes
* Circulatory Failure
* Hemorrhage via Baroreceptors leading to Reflex Vasoconstriction
111
Histotoxic Hypoxia
* Amount of oxygen delivered to the tissues is adequate but because of the action of toxic agents the tissues cannot make use of the oxygen supplied to them
* Characterized by:
* Normal pO2
* No difference in O2 content of arterial and venous blood
* A-V pO2 difference is less than normal
* Causes
* Cyanide Poisoning causing damage to enzyme cytochrome oxidase
112
What clinical feature is seen in all types of hypoxia except anemic hypoxia?
* Hyperventilation
* Increase in HR and Systemic Blood Pressure
113
Clinical Features of Hypoxia
* Hyperventilation is seen in all types EXCEPT anemic
* Drowsiness, Depression/Excitement, Emotional Outburst
* O2 Sat of hemoglobin falls below 60%, unconsciousness w/in 20 seconds, causing death in 4-5 minutes
* Severe hypoxia causes increase in HR and Systemic BP EXCEPT in anemic hypoxia
* Associated Symptoms
* Nausea
* Vomiting
* Anorexia
114
Effects of Hypoxia
* Conversion from aerobic to anaerobic metabolism
* Lactic acid build up
* Cellular respiration eventually slows down, ceases, and cell death occurs
115
Treatments of Hypoxia
* Acclimatization to high altitude
* Continuous O2 Therapy
* CPAP/BiPAP
* Invasive/Mechanical Ventilation for Acute Hypoxia due to severe sepsis, etc
* Tx of Underlying Cause
* Fix Pneumothorax, Treat CO Poisoning, Increase Blood Flow to Affected Area, etc
116
Purpose of ABG Monitoring
* pH of Blood
* Partial Pressures of O2 and CO2
* How well body delivers O2 and removes CO2 to and from tissues
* Bicarbonate
* O2 Saturation
* Measures what percentage of hemoglobin molecules are carrying oxygen
117
Clinical Reasons for ABG
* Evaluation of Severity of Lung Dz
* Monitoring Effectiveness of Pulmonary Treatments
* Monitoring and Making Adjustments to Mechanical Ventilation Therapy
* Titration of O2 Therapy
* Measurement of Acid-Base Status of Patients
* CHF, Renal Failure, DKA, Sepsis, Sleep Disordered Breathing, Toxic Ingestions/Overdoses
118
ABG Analysis
1. pH
2. Primary Disorder Present
3. Appropriate Compensation?
4. Acute or Chronic?
5. Anion Gap?
6. If yes, check delta gap
7. Differential for Clinical Process
119
Normal ABG pH Values?
7.35-7.45
120
Normal ABG pCO2 Values?
35-45
121
Normal ABG Bicarbonate Values?
22-26
122
Normal ABG Anion Gap Values?
10-14
123
Normal ABG Albumin Values?
4
124
Acute Compensation Respiratory Acidosis
Every 10 Increase in pCO2, HCO3 Increases by 1
Decrease of 0.08 in pH
125
Chronic Compensation Respiratory Acidosis
Every 10 Increase in pCO2, HCO3 Increases by 4
Decrease of 0.03 in pH
126
Chronic Compensation Respiratory Alkalosis
Every 10 Decrease in pCO2, HCO3 Decreases by 5
Increase of 0.03 in pH
127
Acute Compensation Respiratory Alkalosis
Every 10 Decrease in pCO2, HCO3 Decreases by 2
Increase of 0.08 in pH
128
Compensation Metabolic Acidosis
* Winter's Formula
* pCO2 = 1.5[HCO3] + 8 +/- 2
* If serum pCO2 is greater than expected pCO2 = Additional Respiratory Acidosis
129
Compensation Metabolic Alkalosis
Every 10 Increase in HCO3, pCO2 Increases 6
130
Anion Gap
* = Na - (Cl + HCO3)
* \< 12 - loss of bicarb, renal tubular acidosis, eatrly kidney failure
* \> 15 - presence of accumulating organic acids or advanced renal failure
* Low albumin level can cause major decrease in anion gap
131
Delta Gap
* = (actual Anion Gap - 12) + HCO3
* If \> 30 = Additional Metabolic Alkalosis
* If \< 18 = Additional Non-Gap Metabolic Acidosis
* If 18-30 = No Additional Metabolic Disorders
132
Differential for Anion Gap Metabolic Acidosis
MUDPILERS
* Methanol
* Uremia
* DKA, Starvation Ketoacidosis, EtOH Ketoacidosis
* Paraldehyde
* INH, Iron Toxicity
* Lactic Acidosis
* Ethylene Glycol
* Rhabdomyolysis
* Salicylates
133
Narcolepsy
* Classic Triad
* Excessive Daytime Sleepiness (\>3 Months)
* Cataplexy (Brief/Sudden Loss of Muscle Tone)
* Hallucinations (Not Always)
* Hypnagogic Hallucinations
* Hypnopompic Hallucinations
* Sleep Paralysis
* Dx
* Polysomnogram (R/O other sleep disorders)
* Multiple Sleep Latency Test
* Average Sleep Latency \<8 min and/or At Least 2 REMs at onset of sleep
* Tx
* Stimulants
* Sleep Regulation
134
Insomnia
* Consider if
* Repeated difficultu w/ sleep initiation, maintenance, or quality
* Occurs despite adequate time and opportunity for sleep
* Results in some form of _daytime impairment_
* Dx
* Clinical Dx
* Sleep Hx
* Tx
* Behavioral and Pharmocological
* Sleep Hygiene
135
Obesity Hypoventilation Syndrome
* Common cause of hypoventilation
* Defined as combo of:
* Obesity - BMI \>= 30
* Awake Chronic Hypercapnia (PaCO2 \> 45 mmHg
* And Sleep-Disordered Breathing
* 90% also have OSA
* Worse during REM than non-REM
* Tx
* Weight Loss
136
Apnea Hypopnea Index
* Mild OSA = 5-15 Events/hr
* Moderate OSA = 15-30 Events/hr
* Severe OSA = \> 30 Events/hr
137
Central Sleep Apnea
* Brain fails to signal respiratory muscle
* Oxygen levels drop abruptly
* **Cheyne-Stokes Breathing**
* Cyclic crescendo-decrescendo respiratory effort and airflow during wakefulness or sleep, _w/o upper airway obstruction_
* When is accompanied by apnea during sleep, it is considered a type of CSAS
138
Obstructive Sleep Apnea
* Most common type of Sleep Disorder Breathing
* Estimated that \>25% of adults are at high risk of OSA
* Risk Factors
* Obesity
* Etc
139
Signs and Symptoms of Sleep Apnea
* Snoring
* Sleepiness
* Irritability/Depression
* Morning Headaches
* Dry Mouth in AMs
* Periods of Silence Terminated Loud Snoring
* Poor Concentration
140
Complications/Adverse Outcomes of Sleep Apnea
* 3-6 Fold Increased Risk of All-Cause Mortality
* Cardiovascular Complications
* Systemic HTN
* Pulmonary HTN
* MI
* Cardiac Arrhythmias
* Night-Time Cardiac Death
* Stroke
* Excessive Daytime Sleepiness
* Inattention, and Fatigue, Impaired Daily Function
* Accidents/MVAs (2-3x Risk)
* Greater Risk for Perioperative Complications
* Due to intubation difficulty or impaired arousal from sedatives
* Metabolic Syndrome/Type II DM
141
Diagnosis of Sleep Apnea
* Clinical Suspicion\*\*\* - Epworth Sleepiness Scale
* Polysomnography (Sleep Study) - GOLD STANDARD
* AHI or RDI \>= 15 Events/hr
* AHI or RDI 5-14 events/hr w/ documented symptoms of excessive daytime sleepiness (EDS); impaired cognition; mood disorder; insomnia; or documented HTN, ischemic heart disease, or hx of stroke
* Home Sleep Apnea Testing (HSAT)
* May be used as an alternative to PSG in patients w/ high pre-test probability of moderate to severe OSA
142
Cystic Fibrosis
* Most Common lethal inherited dz affecting Caucasians
* Autosomal Recessive
* CFTR 7q
* Encodes an ATP-gated Cl- channel that secretes Cl- in lungs and GI tract, and reabsorbs Cl- in sweat glands
* F508 accounts fo 70% or mutations
143
Pathophysiology of Cystic Fibrosis
1. Misfolded protein
2. Protein retained in RER and not transported to cell membrane
3. Decreased Cl (and H2O) secretion
4. Increase intracellular Cl
5. Increase Na absorption via epithelial Na channels
6. Increases H2O reabsorption
7. Abnormal thick mucus secreted into lungs and GI tract
8. Increase in Na reabsorption
9. Negative trans-epithelial potential difference
144
Diagnosis of Cystic Fibrosis
* Step 1
* Presence of one or more characteristic phenotypic features
* Chronic Recurrent Sino-pulmonary dz
* Nutritional deficiencies
* GI abnormalities
* Male urogenital abnormalities
* Salt depletion syndromes
* Hx of CF in sibling
* Positive newborn screening test
* Step 2
* Sweat Chloride Testing
* Abnormal or Intermediate
* 23-Panel ACMG DNA Testing
* If positive for _2 CF mutations_ = CF Diagnosis
* If inconclusive
* Repeat sweat chloride
* Expanded DNA Testing Panel
145
Complications of Cystic Fibrosis
* Recurrent Infection
* S. aureus - early infancy
* P. aeruginosa - adolescence
* Chronic bronchitis and bronchiectasis - reticulonodular pattern on CXR
* Pancreatic Insufficiency
* Infertility in Men
* Meconium Ileus in Newborns
* Subfertility in Women
* **_Nasal Polyps and Clubbing of Nails_**
146
Treatment of Cystic Fibrosis
* Chest Physiotherapy
* Aerosolized dornase alfa (DNAse)
* Hypertonic Saline Facilitated Mucus Clearance
* Pancreatic Enzymes
147
Colonies of Mucoid Pseudomonas in Lungs
Cystic Fibrosis
148
Finger Clubbing and Nasal Polyps
Cystic Fibrosis
149
Most common cause of death in cystic fibrosis?
Pulmonary Infections
150
SMART-COP
* Systolic BP Low
* Multilobar CXR Involvement
* Albumin Level Low
* Respiratory Rate High
* Tachycardia
* Confusion
* Oxygenation Poor
* pH - low arterial
SOP = 2 Points Each
Score of 3 or greater = Intensive Support Needed
151
CURB-65
* Confusion
* Urea \> 7mmol/L
* RR 30 or greater
* BP S less than 90 D less than 60
* Age 65 or older
* Scores
* 0 treated outside hospital
* 2 should be admitted to hospital
* 3 or greater may require ICU
152
What toxin is associated w/ necrotizing pneumonia, abscesses, and empyemas in MRSA?
Panton-Valentine leukocidin
153
Healthcare Associated Pneumonia
* Pts who have been hospitalized in acute care for 2+ days w/in 90 days of infection
* Resident of nursing home/long-term care facility
* Received recent antibiotic therapy, chemotherapy, or wound care w/in 30 days of infection
* Attended a hemodialysis or wound clinic
* Receive home infusion therapy
* Have a family member w/ multi-drug resistant infection
154
Hospital Acquired Pneumonia
* VAP occurs more than 48-72 hrs after endotracheal intubation
* HAP occurs 48 hrs or more after admission to hospital
155
Empiric Therapy for Early Onset HAP
* Ceftriaxone
* Respiratory Fluoroquinolone
* Ampicillin/sulbactam
* Ertapenem
156
Empiric Therapy for Late Onset HAP
* Cefepime/ceftazidime OR imipenem OR piperacillin/tazobactam
* PLUS
* Ciprofloxacin/Levofloxacin OR Aminoglycoside
* PLUS
* Linezolid OR Vancomycin
157
Outpatient CAP Therapy
* Health NO Risk Factors
* Macrolide OR Doxycycline
* Comorbidities OR Prior Antimicrobial Use (Past 3 Months)
* Respiratory Fluoroquinolone OR Beta-Lactam PLUS Macrolide
158
Duration of Antiobiotic Therapy Pneumonia
* Minimum of 5 Days
* Pt should be afebrile for 48-72 hours
* Should have no more than 1 sign of clinical instability
* Temp \< 37.8
* HR \< 100
* RR \< 24
* SBP \> 90
* SpO2 \> 90%
* Able to maintain oral intake
* Normal mental status
* Longer if resistant to initial therapy
* Longer if complicated by extrapulmonary infection
* Longer if P. aeruginosa or Acinetobacter
159
Prevention of Pneumonia
* Avoid/Minimize Duration of Mechanical Ventilation
* Non-Invasive
* Spontaneous Breathing Trials
* Elevating Head of Bed to \> 30º
* Prevent micro-aspiration
* Avoid excessive transportations
* Aggressive Oral Care
* Chlorohexidine
160
Bronchitis/Bronchiolitis
* Self-limited inflammation of bronchi
* Cough \> 5 days, sputum production
* Usually caused by viral infections
* Bacterial bronchitis rare in the absence of tracheostomy, intubation, or exacerbations of chronic bronchitis
161
Influenza Bronchitis
* Cough, purulent sputum, fever
* Myalgias, headache
* Can be diagnoses w/ rapid antigen test of nasal washings
* Treatable w/ neuroaminidase inhibitors
* If given w/in 48 hours of symptoms
162
Bacterial Bronchitis
* Mycoplasma
* Pharyngitis, persistant cough
* Chlaymydophila
* Pharyngitis, laryngitis, hoarseness, low grade fever
* Bordetella pertussis
* Prolonged duration cough
* Treat w/ macrolide antibiotic
163
Empyema
* Manifestations of long-standing anaerobic pulmonary infection
* Foul-smelling sputum
* Pleuritic chest pain
* Chest wall tenderness
* Air-fluid level seen on CXR
* Pocket of pus w/in pleural cavity
* **_Drainage Required_**
164
Legionella
* Aerobic gram negative bacilli
* Non-productive cough
* Occasionally streaked w/ blood
* Fever
* Relative bradycardia
* Chest pain
* Hyponatremia
* No organisms seen on gram stain
* Multilobar involvement
165
Bordetella Pertussis
* 1-2 Weeks of Catarrhal Phase
* Coryza, Lacrimation, Mild Cough
* Low-Grade Fever, Malaise
* 2-4 Weeks of Paroxysmal Phase
* Frequent, spasmodic cough
* Post-tussive vomitting, fatigue
* 1-3 Months of Convalescent Phase
* Gradual resolution of coughing episodes
* Viral infections/URI may cause recurrence of paroxysmal cough
* Pneumonia develops most commonly in infants and adults \> 50
* In adolescents usually due to a secondary infection w/ encapsulated organisms
* Dx
* Culture of nasopharyngeal secretions
* PCR
* Tx
* Erythro/Clarithro/Azithro
* TMP-SMX
* Pts placed in _droplet isolation_
* Vaccinations
* 3-dose primary w/ boosters at 18 mos, 4-6 yrs, and after age 11
* Adult formulations now recommended as well - pregnant women at 27-36 weeks gest
166
Tularemia
* Dx
* Agglutination test to confirm diagnosis
* Single titer 1:160 or greater is considered to be +
* Tx
* Gentamycin is drug of choice
* IM Streptomycin is effective
* Susceptibility testing can't be done
167
Pneumonic Plague
* Sputum production
* Water, frothy, blood-tinged
* Rapid onset fever
* Single lobe involvement early w/ rapid spread
* Dx
* Blood cultures/smear
* Lymph node aspirations
* Sputum samples
* Pharyngeal swab
* Lower respiratory secretions
* DFA, ELISA, and PCR
* Tx
* Streptomycin = DRUG OF CHOICE
* Gentamycin
* Doxy
* Chloramphenicol
168
Nocardia
* Think immunocompromised
* Subacute presentation
* Productive cough, fever, anorexia, malaise, dyspnea, rarely hemoptysis
* CXR - nodules or cavitations
* Empyema in 1/3 of case
* Dx
* Sputum culture shows branching, beaded gram-positive filaments
* May take up to 2 weeks to appear
* Blood cultures
* Tx
* 6-12 months
* TMP-SMX
* Minocycline
* Linezolid
* Amikacin (IV)
* Cefs (IV)
169
Actinomyces
* Growth results in formation of sulfur granules
* Chest pain, fever, and weight loss
* Cough variably productive
* CXR - pneumonia or mass
* \> 50% show pleural thickening, effusion or empyema on CT
* May cross fissures or pleura, extend into mediastinum, bone or chest wall and may form sinus tract
* Dx
* Often unrecognized until seen by pathologist
* Sulfur granules
* Sputum identification of little significance unless sulfur granules seen
* Tx
* Requires prolonged treatment
* 2-6 weeks of IV Penicillin followed by
* 6-12 months of Oral Amoxicillin
170
Psittacosis
* Chlamydophila psittaci - obligate intracellular bacteria
* Starts abruptly
* Shaking, chills, fevers (105°F)
* Headache
* Dry hacking cough
* Epistaxis
* Pericarditis (rare)
* Myalgias
* Pharyngitis
* Occasional endocarditis
* Dx
* CXR - nonspecific infiltrates
* WBCs normal or decreased initially
* Transient proteinuria common
* Confirmed w/
* Isolation of organism (blood or sputum)
* Rising titers of complement fixation Ab
* Treat
* Tetracyclines
171
Treatment of Histoplasmosis
Amph__otericin B w/ Itraconazole
172
Treatment of Coccidiomycosis
Fluconazole or Itraconazole or Amphotericin B
173
Treatment of Blastomycosis
Itraconazole or Amphotericin B (immunocompromised)
174
Treatment of Cryptococcus
Fluconazole for 3-6 Months
Lifetime treatment w/ AIDS pts
175
Aspergillosis
* A. fumigatus - most common
* Grow on compost
* Invasive Pulmonary Aspergillosis
* Develops over a month (acute) or 1-3 mos (subacute)
* May be asymptomatic, fever, cough, chest discomfort, hemoptysis, SOB
* Chronic Pulmonary Aspergillosis
* 1+ pulm cavities arising over mos - yrs w/ assoc fatigue and weight loss
* If untreated → upper lobe fibrosis
* Aspergilloma
* Minor s/s - cough, hemoptysis, fatigue
* 10% remain stable, others are features of CPA
* Allergic Bronchopulmonary Aspergillosis
* Hypersensitivity Rxn
* Mucous plugs, expectorate thick sputum casts
* Eosinophilia, inc IgE, positive skin-prick test to A. fumigatus, or detection of Aspergillus-specific IgE and IgG Abs
* Tx
* Voriconazole
* Itraconazole
* IV Preferred for Acute Invasive dz
* May need to treat up to 3 mos
* Chronic cavitary forms probably require lifelong tx
* Surgical important in single aspergillomas
176
Diagnosis of asthma if pt has obvious symptoms, but spirometry fails to detect asthma?
Methacholine Challenge (Gold Standard)
Positive of methacholine produces 20% fall in FEV1
177
Exhaled Nitric Oxide
* Indication of eosinophilic inflammation and poor/no asthma control
* Can be used to tritrate dose of inhaled corticosteroids
178
Indications for Omalizumab Use
* Corticosteroid-dependent asthma
* Poor response to corticosteroids
* Elevated IgE level
179
Treatment for Culture-Positive TB Patients
1. Place patient on initial phase-regimen - RIPE for 2 Months
2. Culture positive at end of 2 months of initial phase?
1. No - Give continuation phase treatment of (RI) daily for twice weekly for 4 months
2. Yes
1. Cavitation on initial CXR?
1. Yes - continuation phase treatment (RI) daily or twice weekly for 7 months
2. No
1. Patient HIV positive?
1. Yes - Continuation phase treatment (RI) daily for 7 months
2. No - Continuation phase treatment (RI) daily or twice weekly for 4 months
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Workup of Lung Nodule
1. CXR
2. CT Scan = new nodule identified
3. Benign calcification or stability for 2 yrs?
1. Yes = No further testing
2. No = does probability of cancer warrant further investigation?
1. No = Risk Factor Surgery
2. Yes
1. Low probability of cancer
1. 3, 6, 12, and 24 month CTs
2. Moderate probability of cancer
1. Additional Tests: PET if nodule \> 1 cm, FNA, CECT, Bronchoscopy
1. If positive = surgery
2. If negative = 3, 6, 12, and 24 month CTs
181
Nonsmall Cell Lung Cancer Staging
* Stage I-IV
* Stage I - contained to lung parenchyma
* Stage II - spread to local lymph nodes or chest wall
* Stage IIIa - spread to mediastinal lymph nodes
* Stage IIIb - spread to mediastinal structures or lymph nodes around clavicle or to pleural tissue
* Stage IV - distant metastisis to bone, brain, liver, etc
182
Small Cell Lung Cancer Staging
* Limited or Extensive
* Limited - in one lung and its local lymph nodes
* Extensive - extends to both lungs, more distant lymph nodes or other organs
183
Hypercalcemia of Malignancy
* Paraneoplastic syndrome
* Due to release of PTH related peptide causing increased bone resorption
* Common in NSCLCA
* Rarely occurs w/ SCLCA
* 23% of Squamous Cell
184
Eaton-Lambert Syndrome
* Paraneoplastic Syndrome
* Especially in SCLCA
* Autoimmune rxn that reduces neurotransmitter levels at nerve/muscle synapses causing weakness, numbness, and other neurological symptoms
* Tends get better w/ continued exercise
* As opposed to myasthenia gravis which gets worse
