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pulm Flashcards

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1
Q

Asthma MOA

A

Reversible bronchoconstriction of airways

Mucosal inflammation

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2
Q

ASA Induced Asthma

A 
ASA insensitivity
Nasal polyps
Starts w/perennial vasomotor rhinitis
asthma w/minimal ingestion
desensitization possible
Chronic over-secretion of LKE = activate mast cells
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3
Q

Findings in patients with Asthma

A
  • Sx’s worse at night
  • Nasal Polyps
  • Increased expiratory phase length
  • Eczema or atopic dermatitis
  • Use of accessory muscles
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4
Q

Best Initial Test - Asthma

What does CXR show?

A

ABG
Peak Expiratory Flow
CXR = Normal

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5
Q

Most Accurate Test - Asthma

A

Pulmonary Function Tests (PFTs)
Decrease ratio of FEV1/FEVC
FEV1 decreases MORE than FEV during exacerbation

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6
Q

PFTs in Asthma
Albuterol effect
Methacholine effect

A

Decrease ratio of FEV1/FVC (FEV1 decreases MORE than FVC during exacerbation)
Increase in DLCO
Increase in FEV1 >12% w/Albuterol
Decrease in FEV1 >20% w/Methacholine or histamine

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7
Q

What is DLCO?

A

measures the alveolar membrane permeability

measures gas exchange

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8
Q

When is DLCO decreased?

A 
Alveolar walls are destroyed and pulmonary capillaries obliterated 
- Emphysema = Obstructive
Alveolar-capillary membrane thickened
- Edema, Consolidation
- Fibrosis = Interstitial Lung Dz
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9
Q

Asthma Treatment

A
  1. Inhaled SABA
  2. Low does ICS
  3. Inhaled LABA
  4. Increase dose of ICS
  5. Omalizumab for increased IgE
  6. Oral Steroid - Prednisone
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10
Q

Budesonide

What is it?

A

Low dose inhaled corticosteroid (ICS)

Category B = Pregnancy

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11
Q

Cromolyn and Nedocromil
MOA
Use?

A

Inhibit mast cell mediator release and eosinophil recruitment
Used in Peds asthma, never in adults

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12
Q

Theophylline
MOA
AE’s

A

Methylxanthine

AEs: N/V, palpitations, tremulousness, death by cardiac arrythmia

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13
Q

Theophylline increased toxicity with what drugs?

A 
FQ's
Clarithromycin
H2 blockers (rantidine, cimetidine)
some Beta blockers
CCBs
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14
Q

Theophylline decreased toxicity with what drugs?

A

Rifampin
Phenobarbs
smoking

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15
Q

Zafirlukast: MOA
AE
Ass’d with?

A

LKE receptor antagonist
Hepatotoxic
Ass’d with Churg-Strauss

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16
Q

Adverse effects of inhaled steroids?

A

Dysphonia

Oral candidiasis

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17
Q

Adverse effects of systemic steroids?

A 
Osteoperosis
Cataracts
Adrenal suppression - fat redistribution
Hyperlipidemia, hyperglycemia, acne, hirsutism
Thinning of skin, striae, easy bruising
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18
Q

What vaccines given to all asthma patients?

A

Influenza

Pneumococcal

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19
Q

Best indication for severity of asthma?

A

Increased Respiratory Rate

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20
Q

Severity of asthma exacerbation measured by?

A

Decreased PEF

ABG with increased A-a gradient

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21
Q

Tx for Asthma Exacerbation

A

Oxygen
Albuterol
Steroids - need 4-6 hrs to work

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22
Q

Are epinephrines used for asthma exacerbation?

A

Rarely - steroids used instead b/c less AE’s and same efficacy

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23
Q

Magnesium in asthma exacerbation?

A

Acute, severe exacerbation unresponsive to several rounds of Albuterol when waiting for steroids to work

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24
Q

When to do endotracheal intubation in asthmatic?

A 
Unresponsive to Oxygen, Albuterol, and steroids OR
Respiratory Acidosis (increased pCO2)
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25
What happens to elastic recoil in emphysema?
Decreases b/c of abnormal permanent dilatation of air spaces distal to terminal bronchioles w/destruction of air space walls
26
What is lost in COPD?
Ability to exhale from elastic fibers (tobacco destroys elastin fibers)
27
COPD presentation
SOB worse w/exertion cough, sputum, Barrel chest from air trapping Muscle wasting/cachexia
28
When do we see alveolar Hypoventilation?
Obstructive Lung Dz Obesity hypoventilation syndrome These cause hypoxia secondary to alveolar hypoventilation
29
Best initial test for COPD?
CXR Increased A-P diameter Flattened diaphragm (increases work of breathing) and air trapping
30
Most accurate test for COPD?
PFT - Decreased FEV1/FVC < 70% (both values decreased) - Increased TLC - increased RV - Decreased DLCO
31
How do we differentiate emphysema from Chronic Bronchitis?
``` Emphysema = decreased DLCO CB = Normal DLCO ```
32
Does COPD reverse with bronchodilators?
Not always - broad range. | This differentiates it from Asthma, where there is always reversal
33
What can be seen on EKG for COPD?
Right Atrial Hypertrophy Right Ventricular Hypertrophy A Fib Multifocal Atrial Tachycardia
34
What is seen on Echo for COPD?
RA and RV Hypertrophy | Pulmonary Hypertension
35
What is the treatment for COPD that improves mortality and delays progression?
Smoking Cessation - Bupropion has increased SI risk Home Oxygen for pts with hypoxia Influenza and Pneumococcal vaccines
36
When do COPD patients get oxygen?
Hypoxemia | - pO2 is < 90%
37
What is tx for COPD?
Inhaled anticholinergic - most effective in COPD: tiotropium, ipratropium Short acting beta agonist Inhaled steroids Long acting beta agonists
38
When do we refer COPD for transplantation?
When all medical therapy is insufficient?
39
What are causes of acute bronchitis and presentation?
Viral - MC | Blood tinged sputum, lack of other serious si/sx's
40
What is the tx for acute exacerbation of chronic bronchitis (ACEB)?
``` ABx: First Line: Macrolides: Azithromycin Cephalosporins: Cefuroxime, Cefixime, Cefaclor, Ceftibuten Amoxicillin/Clavulanic Acid Quinolones: Levofloxacin, Moxifloxacin, Gemifloxacin Second Line: Doxycycline Trimethoprim/sulfamethaxazole ```
41
Macrolides: Use
URIs, Pneumonia STDs - Gram + coci Atypical Pneumonia - Mycoplasma, Legionella, Chlamydia, Neisseria
42
What ABx Prolongs QT?
Azithromycin
43
What is the best indicator of survival in COPD patient?
FEV1
44
What is the pathophysiology of bronchiecstasis?
Chronic dilatation of large bronchi
45
MCC of bronchiecstasis
MCC = Cystic Fibrosis
46
What Infxn gives poor prognosis in CF?
Burkholdoria cepacia Infxn: Can't get lung transplant
47
What is the presentation of bronchiecstasis?
Recurrent episodes of high volume sputum
48
Best initial test for Bronchiecstasis?
CXR
49
Most Accurate test for Bronchiecstasis?
High - resolution CT
50
Preventive vaccinations for Bronchiecstasis?
Influenza
51
Treatment for Bronchiecstasis?
Chest physiotherapy and postural drainage
52
What is Allergic Bronchopulmonary Aspergillosis (ABPA)?
Hypersensitivity of lungs to fungal Ags that colonize bronchial tree
53
Asthmatic patient w/ recurrent episodes of brown-flecked sputum?
ABPA
54
Presentation of ABPA?
cough, wheezing, hemoptysis, bronchiecstasis
55
Testing for ABPA?
Peripheral eosinophilia
56
Tx for ABPA?
Oral steroids = Prednisone
57
What is the pathophys of Cystic Fibrosis?
AR; mutation for chloride transport; CFTR
58
What is the presentation of CF?
Young adult with chronic lung dz and recurrent infxn
59
GI involvement in infants w CF? | General?
Meconium ileus - infants w/abdominal distension | Chronic, frequent diarrhea
60
What cell is responsible for dumping DNA into airway secretions in CF?
Neutrophils
61
Which pancreatic cell is spared until later in life in CF?
Islet cells - beta cell function
62
What are GU sx's in CF?
Infertility
63
Most accurate test for CF?
Increased Sweat chloride test
64
What does Pilocarpine do?
Increases Ach Levels = increases sweat production
65
Is genotyping in CF testing accurate?
No, not as accurate as sweat chloride
66
What are PFTs of CF?
Mixed restrictive and obstructive
67
What bugs seen in CF on sputum culture?
Nontypable Haemophilus influenzae
68
Tx for CF?
``` Respiratory therapy Bronchodilators Steroids DNA-ase ABX Pancreatic enzymes ```
69
Vaccines in CF?
Influenza
70
What is Community Acquired Pneumonia (CAP)?
Pneumonia before hospitalization
71
Presentation of CAP?
Fever, cough, dyspnea
72
When are bronchial breath sounds heard and egophony?
Consolidation of air spaces in CAP
73
What auscultory findings heard in CAP?
Rales - crackles, velcro being pulled apart
74
When is abdominal pain seen in CAP?
Infection of lower lobes that irritate intestines through diaphragm
75
When are chills or rigors seen?
Bacteremia
76
When is chest pain seen in CAP?
Inflammation of pleura causing pleuritic pain - changes w/respiration
77
Dyspnea, high fever, abnormal CXR Dx?
Pneumonia
78
CAP in COPD/smokers pathogen?
Haemophilus influenzae
79
CAP with hoarseness?
Chlamidophila pneumoniae
80
CAP with contaminated water sources, AC, Ventilation systems?
Legionella
81
CAP epidemic infx with older smokers, GI and CNS involvement?
Legionella
82
Dry cough, rarely severe, bullous myringitis Pathogen?
Mycoplasma pneumoniae
83
Which pneumonia is seen w Infxn of alveolar space?
Lobar pneumonia w/parapneumonic pleural effusion:
84
Which area of lung do Infxn w/dry cough or non-productive prefer?
Prefer interstitial space - leave alveolar air spaces empty
85
Best initial test for CAP?
CXR - best initial for ALL respiratory infxn
86
What is seen on CXR for Atypical Pneumonia?
Bilateral interstitial infiltrates
87
When do we do Thoracocentesis?
Tapping
88
How do we classify empyema?
LDH >60% serum level
89
When do we do bronchoscopy?
- Severe dz when initial testing of sputum stain and culture don't show pathogen
90
Test for Mycoplasma Pneumoiae?
PCR
91
Test for Chlamidophilia pneumoniae?
Rising serologic titers
92
Test for Legionella?
Urine Antigen
93
Test for PCP CAP?
Bronchoalveolar Lavage (BAL)
94
What is the inpatient Tx for CAP?
Respiratory Fluroquinolones (Levo, Moxi)
95
What is the Tx for CAP in pts w/severe PCN allergy?
IV Vanco
96
When to hospitalize for CAP?
Hypotension (SBP <90mmHg)
97
When to hospitalize for CAP mneumonic?
CURB-65
98
When do we do thoracostomy?
Drainage by chest tube
99
What is seen on CXR of pleural effusion?
Meniscus sign
100
Who gets a pneumococcal vaccine?
Everyone above 65 - 23 polyvalent vaccine
101
When to give a pneumococcal vaccine?
Healthy get single dose at 65
102
Do healthcare workers need pneumococcal vaccine?
No
103
What is Hospital Acquired Pneumonia (HAP)?
Pneumonia after 48 hrs of admission
104
Causes of HAP?
Gram -
105
Tx for HAP?
Antipseudomonal Cephalsoprins: Cefepime or ceftazidime
106
When is Ventilator Associated Pneumonia seen?
Seen in mechanical ventilation, like positive pressure - damages normal ability to clear colonization
107
Fever +/- rising WBC count, new infiltrate on CXR, and purulent secretions from endotracheal tube?
VAP
108
When is Aspiration Pneumonia seen?
Recurrence
109
Which part of lung does Aspiration Pneumonia affect?
Same anatomic region repeatedly
110
Risk factors for Aspiration Pneumonia?
Altered consciousness
111
What is a BAL?
Bronchoscope placed deeper into lung where there are not supposed to be organisms
112
Open lung Bx?
Most accurate test for VAP, BUT greater morbidity
113
TX for VAP?
3 drugs
114
AE of Imipenem
Causes seizures
115
Causes of large volume aspiration
Stroke with loss of gag reflex
116
When do pts get Aspiration pneumonia? What part of lung affected?
Lying flat
117
When does lung abscess occur?
Pt with large volume aspiration of oral/pharyngeal contents
118
Foul smelling sputum and weight loss?
Lung Abscess
119
Best initial test for Lung Abscess
CXR
120
What test to determine tx for Lung Abscess?
Lung Bx
121
Tx for Lung Abscess
Clindamycin
122
Best initial test for PCP?
CXR
123
Most Accurate test for PCP?
BAL
124
What is elevated in PCP?
LDH
125
Tx for PCP?
Trimethoprim-sulfmethoxole
126
AE's of Trimethoprim-sulfmethaxole?
1. Rash - MC
127
PCP PPX?
1. Trimethoprim-sulfmethaxole
128
What drugs are CI in G6PD?
1. Sulfas
129
Risk factors for TB
Immigrant (past 5 yrs)
130
Best initial test for TB?
CXR
131
Most accurate test for TB?
Pleural Bx
132
Sputum stain req's for TB?
3 times for acid-fast to exclude TB
133
Tx for TB?
Positive smear:
134
When to tx TB for 9 mo's?
Osteomyelitis
135
Which TB drugs CI in pregnancy?
Pyranzinamide
136
When to tx TB for 12 mo's?
Meningitis
137
Which TB drugs are hepatotoxic?
All of them
138
TB drug with hyperuricemia?
Pyranzinamide
139
What AE does Ethambutol cause?
Optic neuritis/color vision
140
When do we decrease dose of ethambutol?
In renal failure
141
When do we use steroids in TB?
Meningitis, Pericarditis
142
Who is screened for TB?
Those with risk factors
143
What is a positive PPD test?
Induration > 5mm
144
Who gets a CXR in TB testing?
Everyone with reactive PPD
145
If first test is +, do we do second in 2-stage test?
No
146
Tx for positive PPD
1. CXR to r/o active TB
147
Actinomyces
Gram + filamentous
148
Nocardiosis
Gram + partially acid fast filamentous
149
What is the Tx for Nocardiosis?
TMP-SMX
150
What is the Tx for Actinomyces?
PEN G
151
Best initial step in lung lesions?
Compare size with old CXR
152
Most common adverse effect of transthoracic Bx?
Pneumothorax
153
What is a PET scan done and when is it done?
To assess content of lesion - malignant v benign - w/out bx.
154
What is the next step in an enlarging lung lesion?
Bx.
155
What is pathophys of pulmonary fibrosis?
Thickening of interstitial septum of lung b/t arteriolar space and alveolus
156
What is the A-a gradient of pulmonary fibrosis?
Increased
157
Drugs that cause pulmonary fibrosis?
Bleomycin
158
Pneumoconiosis ass'd with sandblasting, rock mining and tunneling?
Silicosis
159
Pneumoconiosis ass'd with shipyard workers, pipe fitting, insulation?
Asbestosis
160
Pneumoconiosis ass'd with cotton?
Byssinosis
161
Pneumoconiosis ass'd with electronic manufacture and ceramic alloys?
Berylliosis
162
Pneumoconiosis ass'd with moldy sugar cane?
Bagassosis
163
What lung dz is increased in asbestosis exposure?
Bronchogenic cancer
164
Bronchogenic cancer presentation
Progressive dyspnea
165
Bronchogenic cancer CXR?
Bibasilar Reticulonodular infiltrates
166
Presentation of pulmonary fibrosis?
Dyspnea, worse on exertion
167
Best initial test pulmonary fibrosis?
CXR
168
Most accurate test pulmonary fibrosis?
Lung Bx
169
Echo findings on pulmonary fibrosis?
Pulmonary HTN
170
PFT's in Pulmonary fibrosis?
Restrictive lung dz findings: decreased everything in proportion
171
Tx of pulmonary fibrosis
If Bx shows WBCs or inflammation ->Prednisone
172
Sarcoidosis Presentation
African American
173
Skin finding in Sarcoidosis
Erythema nodosum - inflammation of fat cells under the skin
174
CXR/CT with hilar adenopathy in healthy African American female?
Sarcoidosis
175
Best initial test for Sarcoidosis?
CXR - Hilar LA; parenchymal involvement common
176
What is the most accurate test for Sarcoidosis?
Lymph Node Bx.
177
Lab findings in Sarcoidosis?
Elevated ACE
178
PFT's in Sarcoidosis?
Restrictive lung dz
179
Bronchoalveloar lavage findings in Sarcoidosis?
Elevated level of helper cells
180
Tx for sarcoidosis?
Prednisone if symptomatic
181
What happens if you tx asymptomatic sarcoid pt?
Increased remission
182
Most common vessel in DVT?
Large vessels of legs (70%)
183
Etiology of DVT?
Stasis from:
184
Presentation of PE/DVT?
Sudden onset SOB
185
Best initial test in PE
CXR
186
Most accurate test in PE
Angiography
187
Most common abnormality with PE
CXR - usually normal
188
EKG findings in PE?
Sinus tachycardia
189
ABG of PE?
Hypoxia
190
If hx and initial labs suggest PE, what is the most appropriate next step?
Start IV unfractionated heparin
191
After CXR, EKG and ABG, what is the next best test?
Spiral CT = CTA = CT Angiogram
192
When do we do V/Q scan for PE?
Pts with:
193
What test is used to rule out PE?
D-Dimer
194
When is LE Doppler done?
If V/Q and Spiral CT do not give clear Dx.
195
What are the adverse effects of angiography?
Allergy
196
What is the tx for PE?
Best initial = heparin. Start warfarin @ same time to get INR 2-3
197
When is IVC filter answer in PE?
CI to anticoagulation - melena, CNS bleeds
198
When do we use thrombolytics in PE?
Hemodynamically unstable pt
199
When are direct acting thrombin inhibitors tx in PE?
HIT
200
When is ASA answer in PE?
Never.
201
Normal pulmonary pressure?
Systolic 25mmHg
202
What causes Pulmonary HTN?
Chronic lung dz, fibrosis - elevate PA pressure
203
Presentation of pulm HTN?
dyspnea/fatigue
204
Best initial test Pulm HTN?
CXR - dilation of proximal PAs, narrowing of distal vessels
205
What is the most accurate test in pulm HTN?
Right heart/Swan-Ganz catheter
206
EKG/ECHO findings in pulm HTN?
EKG: Right Axis deviation, RA and RV Hypertrophy
207
Curative tx for Pulm HTN?
Lung transplant
208
Tx for Pulm HTN?
Prostacyclin analogues - PA vasodilators - "prosts"
209
Sx's of Obstructive Sleep Apnea
Obesity
210
When does OSA most commonly occur?
In REM = muscle atonia - loss of voluntary control of diaphragm, eyes, spinchter
211
Most accurate test for OSA?
Polysomnography
212
Tx for OSA?
Weight loss
213
ARDS - pathophys?
Hypoxia -> Respiratory failure
214
CXR in ARDS?
Congestive failure, normal cardiac hemodynamics
215
Causes of ARDS?
Sepsis - MCC
216
When does ARDS occur (time frame)
Within 5 days of inciting event
217
Si's/Sx's of ARDS?
Dyspnea, Increased respiratory rate, diffuse rales and rhonchi
218
What does CXR show of ARDS?
Bilateral infiltrates - white out/confluent
219
pO2/FIO2 in ARDS?
pO2/FIO2 ratio < 200
220
Tx for ARDS
Low tidal-volume mechanical ventilation
221
Blastomycoces dermatitis
Midwest, Mississippi Valley
222
Skin findings seen with Blastomycoces dermatitis
Heaped up, verrucuous, nodular lesions w/violet hue ->evolve into microabscess
223
What is Pickwickian syndrome?
Obesity Hypoventilation Syndrome (OHS)
224
Mediators in asthma?
Histamine Bradykinin Leukotrienes C, D, E PGE2, F2, D2

Pulmonary (2 decks)

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