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Pulm Flashcards

1
Q

What are main causes of acute asthma exacerbations

A 
Allergens
Infection, Cold air
Exercise
Aspirin, NSAIDs, BBs
GERD
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2
Q

Extrinsic vs Intrinsic Asthma severity

A

Extrinsic is better (ie. has precipitants)

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3
Q

Most likely associations w/ Asthma

A 
Sx worse at night
Nasal polyps and sensitivity to aspirin
Pulsus paradoxus
Eczema or atopic dermatitis
Increased length of expiratory phase
Increased use of accessory muscles
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4
Q

Best initial test for acute exacerbation of asthma

A

Peak expiratory flow or ABG

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5
Q

Why do CXR in asthma

A

Exclude PN or other chest etiology for sx

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6
Q

Most accurate Dx test in asthma

A

PFTs

  • ↓FEV1/FVC
  • ↓FEV1, ↓FVC
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7
Q

Most accurate test in asymptomatic asthma

A

20% decrease in FEV1 w/ use of methacholine or histamine

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8
Q

PFTs in asthma

A

↓ FEV1/FVC
↓ FEV1, ↓ FVC
↑ FEV1 of >20% and 200ml w/ use of albuterol
↓ FEV1 of >20% w/ use of methacholine or histamine

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9
Q

Additional tests in asthma

A

CBC - increased eosinophils
Skin test for allergens
IgE for allergic etiology

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10
Q

Protocol for chronic asthma management

A
  1. SABA
    • ICS
    • LABA or Increase ICS dose
  4. Increase ICS dose to max
    • Omalizumab
    • Oral steroids
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11
Q

Drug that works best in childhood and exercise-induced PPx

A

Cromolyn and Nedocromil

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12
Q

Drug used to help pts ween off steroids

A

Montelukast
Zafirlukast
Zileuton

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13
Q

Steroid AEs

A 
Osteoporosis
Cataracts
Adrenal suppression and fat distribution
Hyperlipidemia, hyperglycemia, acne, hirsuitism
Thinning of skin, striae, easy bruising
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14
Q

Vaccines for all asthmatics

A

Influenxae

Pneumococcal

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15
Q

Best indicator for severity of disease in asthma

A

Respiratory rate (severe SOB = 34)

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16
Q

Quantification of severe SOB

A

Decreased PEF

ABG w/ increased A-a

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17
Q

Rx acute asthma exacerbation

A

O2
Albuterol
Steroids

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18
Q

Best initial therapy for acute asthma exacerbation

A

O2 w/ SABA

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19
Q

Drug of last resort in acute asthma exacerbation

A

Epi

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20
Q

What to do if there is no response to therapy in acute asthma exacerbation

A

Intubation in ICU

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21
Q

What is NOT effective in acute asthma exacerbation

A 
Theophylline
Cromolyn, Nedocromil
LT modifiers
Omalizumab
Salmeterol
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22
Q

What is Mg good for in acute asthma exacerbation

A

Non-responsive to albuterol while waiting for steroids to start working

Relieve bronchospasm

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23
Q

What is COPD

A

SOB from lung destruction due to loss of elastic recoil

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24
Q

Why are steroids ineffective in chronic COPD

A

Non-inflammatory

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25
Major PFT findings in COPD
↓ FEV1, FVC | ↑ TLC
26
MCC COPD
Tobacco smoking
27
When to suspect A1AT def causing COPD
Young Non smoker Transaminitis
28
Common presentation of COPD
SOB Barrel chest Cachexia (emphysema)
29
Best initial test for COPD
CXR
30
CXR findings in COPD
Increased AP diameter | Flattened diaphragm
31
Most accurate test for COPD
PFTs
32
PFTs in COPD
``` ↓ FEV1, FVC, FEV1/FVC ↑ TLC ↓ DLCO (emphysema) Incomplete improvement w/ albuterol Not much effect after methacholine ```
33
Response to bronchodilators in COPD
Little to full reversibility
34
What is full reversibility in COPD
>12% increase and 200mL increase in FEV1
35
ABG findings in acute exacerbation of COPD
Increased pO2 Hypoxia Respiratory acidosis if no compensation
36
What increases survival in COPD
Smoking cessation | O2 (when pO2
37
When to give O2 in COPD when they also have pulm HTN, high HCT or cardiomyopathy
pO2
38
Symptomatic rx in COPD
``` SABA Anticholinergics Steroids (good in acute) LABA Pulm rehab ```
39
When to give theophylline in COPD
When all else fails
40
Rx when all medical therapy is insufficient for COPD
Transplantation
41
Rx acute exacerbation of chronic bronchitis
Same as acute asthma exacerbations | Plus ABX
42
What do ABX need to cover in AECB
Strep pneumo, H. flu, M. catarrhalis
43
What ABX are given in AECB
Macrolides Cepalosporins Augmentin Quinolones
44
What is bronchiectasis
Chronic dilation of large bronchi | Permanent anatomic abnormality
45
MCC bronchiectasis
CF
46
Other causes of bronchiectasis
``` Infection Panhypogammaglobulinemia Foreign body/tumors Aspergillosis Collagen vascular disease ```
47
Pathognomonic w/ bronchiectasis
Purulent foul smelling cough/sputum
48
PE and lab findings in bronchiectasis
``` Hemoptysis Wt loss AOCD Crackles Dyskinetic cilia ```
49
Best initial test in bronchiectasis
CXR showing dilated thickened bronchi
50
Most accurate test in bronchiectasis
High resolution CT
51
Only way to determine specific bacterial etiology of bronchiectasis
Sputum Cx
52
Rx bronchiectasis
Chest physio and postural drainage Treat each infection episode Rotate ABX 1 weekly each month Surgical resection
53
Who gets allergic bronchopulmonary aspergillosis (ABPA)
Asthma | Hx atopic disorders
54
What to look for in ABPA
Asthmatic w/ recurrent brown-flecked sputum | Transient infiltrates on CXR
55
Dx tests for ABPA
``` Peripheral eosinophilia Skin test reactivity Aspergillus Abs Elevated IgE Infiltrates on CXR, CT ```
56
Rx ABPA
Oral prednisone | Itraconazole if reccurent
57
What is CF
AR mutation in chloride transport gene (CFTR)
58
MCC death in CF
Lung disease
59
What to look for in CF
Young adult Chronic lung disease Recurrent infections Sinus pain and polyps
60
GI features of CF
``` Meconium ileus Pancreatic insufficiency - steatorrhea, vit ADEK malabsorption Recurrent pancreatitis Distal intestinal obstruction Biliary cirrhosis ```
61
GU features of CF
Men - Azoospermia, missing vas deferens | Women - Infertile 2/2 thickening of cervical mucus
62
Most accurate test for CF
Sweat chloride test
63
ABG in CF
Hypoxemia | Resp acidosis
64
Which cells in the pancreas are spared in CF
Beta
65
Sputum Cx in CF may show
H. flu Pseudomonas S. aureus Burkholderia
66
Rx CF
``` Routine ABX (same ones as bronchiectasis) Recombinant human deoxyribonuclease Inhaled bronchodilators Pneumococcal and flu vax Lung transplant in severe disease ```
67
What is CAP
PN before or within 48hrs of hospitalization
68
MCC CAP
Strep pneumo - REGARDLESS of comorbidities
69
CAP association w/ COPD
H. flu
70
CAP association w/ recent viral illness
S. aureus
71
CAP association w/ alcoholism/DM
Klebsiella
72
CAP association w/ poor dentition or aspiration
Anaerobes
73
CAP association w/ young healthy pts
Mycoplasma pneumoniae
74
CAP association w/ hoarseness
Chlamydophila
75
CAP association w/ contaminated water sources, AC, ventilation
Legionella
76
CAP association w/ birds
Chlamydia psittaci
77
CAP association w/ animals at time of birth, vets, farmers
Coxiella
78
Common findings in all PN
Fever Cough Dyspnea Dullness to percussion if effusion
79
Features of severe PN
Tachy Hypotension Tachypnea
80
Signs of bacteremia
Chills and Rigors
81
Unique presentation of klebsiella PN
Current jelly sputum
82
Unique presentation of Anaerobe PN
Rotten egg smelling sputum
83
Unique presentation of mycoplasma PN
Dry cough, rarely severe, bullous myringitis
84
Unique presentation of Legionella PN
GI or CNS sx
85
Unique presentation of pneumocystis PN
AIDS w/ CD4
86
Infections w/ dry cough
``` Mycoplasma Viruses Coxiella Pneumocystis Chlamydia ```
87
Best initial test for all resp infections
CXR
88
Most accurate test for resp infections
Sputum stain and Cx | Much of the time this is negative
89
Characteristic CXR finding in bacterial PN
Right middle lobe infiltrate
90
Organisms causing B/L infiltrate in CXR
``` Mycoplasma Viruses Coxiella PCP Chlamydia Legionella ```
91
How do you know sputum gram stain is adequate
> 25 WBCs and
92
Tests done in severe disease w/ unclear etiology
Thoracocentesis Empyema analysis Bronchoscopy only in ICU and worsening
93
Dx test to confirm mycoplasma
PCR Cold agglutinin Serology Special cx media
94
Dx test to confirm chlamydophila
Rising serology titres
95
Dx test to confirm legionella
Urine Ag | Cx on charcoal-yeast extract
96
Dx test to confirm chlamydia psittaci
Rising serology titres
97
Dx test to confirm coxiella
Rising serology titres
98
Dx test to confirm PCP
BAL
99
Empiric Rx outpatient if previously healthy
Macrolide or Doxy
100
Empiric Rx outpatient if comorbidities or ABX in last 3 mos
Resp fluoroquinolone
101
Empiric Rx inpatient
Resp fluoroquinolone or (Ceftriaxone and Azithromycin)
102
Reasons to hospitalize for PN
``` Hypotension Hypoxia Elevated BUN or Hyponatremia Tachy, Confusion Fever > 65 ```
103
Management of Empyema
Drain it
104
CURB65 (2 or more = admission)
``` Confusion Uremia Resp distress BP low > 65 ```
105
Features of empyema (Exudate)
pH 60% of serum or Protein >50% of serum
106
What causes exudate
Infection | Cancer
107
Reasons to give pneumococcal vaccine
``` >65 Chronic heart, liver, kidney, lung disease Functional or anatomic asplenia Blood cancer Immunosuppression CSF leak or cochlear implant ```
108
What is HAP
PN >48hrs after admission or after hospitalization within the last 90 days
109
What are the main bugs in HAP
E. coli | Pseudomonas
110
What is given for HAP
``` Antipseudomonal cephalosporins - Cefepime - Ceftazidine Antipseudomonal PCNs Carbapenems ```
111
What to look for to suggest VAP
Fever with rising white count New infiltrate Purulent secretions
112
Dx tests for VAP
``` Tracheal aspirate BAL Protected brush specimen VAT Open lung Bx ```
113
Rx VAP
``` Antipseudomonal beta lactam PLUS Aminoglycoside or fluoroquinolone PLUS MRSA agent ```
114
Imipenem AE
Seizures 2/2 renal failure
115
How does large volume aspiration occur
``` Stroke w/ loss of gag Seizures Intoxication ET tube Bad teeth ```
116
When to suspect lung abscess
Pt w/ risk factors and weeks of sx | Large volume foul smelling sputum
117
Best initial test for lung abscess
CXR
118
Most accurate test for lung abscess
Bx - gives microbe
119
Best empiric rx for lung abscess
Clindamycin or PCN
120
Presentation of PCP
Dry cough and fever in AIDs pt w/ CD4
121
Best initial test for PCP
CXR w/ B/L infiltrates | ABG w/ hypoxia and increased A-a
122
Most accurate test in PCP
BAL
123
LDH in PCP
ALWAYS elevated
124
Next best step w/ negative sputum
BAL
125
Best initial therapy for PPx and Rx
TMP/SMX | Add steroids if severe
126
TMP/SMX AE
``` #1 Rash #2 BM suppression ```
127
What is severe PCP
pO2 35
128
Rx PCP w/ TMP/SMX tox
Clinda and primaquin OR Pentamidine
129
PCP PPX w/ TMP/SMX tox
Atovaquone or dapsone
130
When is dapsone contraindicated
G6PD def
131
RFs TB
``` Immigrant, homeless Prisoners HIV Healthcare Alcoholics ```
132
Common features of TB
RFs | Fever, weight loss, night sweats, cough, hemoptysis
133
Best initial test for TB
CXR
134
Sputum protocol in TB
Stain and Cx 3 times
135
Most accurate test for TB
Pleural Bx
136
Pt w/ TB RFs and +CXR w/ apical infiltrate
Sputum stain and Cx
137
Pt w/ TB positive sputum stain and cx
Empiric therapy
138
Initial therapy for TB
Rifampin Isoniazid Pyrazinamide Ethambutol
139
Rx protocol in TB
RIPE for 2 months | Rifampin and INH for another 4
140
When do you extend TB Rx to 9 months
Osteo Milliary Meningitis Pregnancy (and any other time pyrazinamide is contraindicated)
141
All TB meds can cause
Hepatotoxicity
142
Rifampin AE
Red coloured body secretions
143
INH AE
Peripheral neuropathy | Pyridoxine to prevent
144
Pyrazinamide AE
Hyperuricemia
145
Ethambutol AE
Optic neuritis/Colour vision | Decrease dose in renal failure
146
When to give steroids in TB
Reduce risk of constrictive pericarditis and meningitis
147
When to do PPD
Asymptomatic pts in RISK GROUPS ONLY | Must have neg CXR
148
When is 5mm induration pertinent
``` HIV Steroid users Close contact to TB person Abnormal calcifications on CXR Organ transplant recipients ```
149
When is 10mm induration pertinent
``` Immigrant Prisoner Healthcare worker Close contact to TB person Blood cancer, alcoholics, DM ```
150
When is 15mm induration pertinent
People with no RFs
151
First time PPD protocol
2nd test 1-2 weeks later if 1st is negative
152
Reactive PPD next step
CXR
153
BCG role in PPD testing
Doesn't matter
154
Pt w/ +PPD and -CXR next step
INH for 9 months
155
Qualities of benign pulmonary nodule
156
Qualities of malignant pulmonary nodule
``` >40 Enlarging Smoker Spikes >2cm Atelectasis Sparse, eccentric calcification Abnormal PET ```
157
Best initial test for all lung lesions
Compare to old CXRs
158
Best next step for features of malignant lesions
Resect
159
Cytology is positive in pulm nodule, next best step
Resect
160
Intermediate probability lesions next best step
Central - bronchoscopy | Peripheral - transthoracic Bx
161
MC AE transthoracic bx
PTX
162
When is a PET most accurate
>1cm
163
Most sensitive and specific test for pulm nodule
VATS
164
What is interstitial lung disease
Thickening of interstitial septum of lung between arterial space and alveolus
165
Specific causes of pulmonary fibrosis
``` Idiopathic Radiation Drugs Vasculitis Eosinophilic PN ```
166
Drugs that can cause pulm fibrosis
``` Bleomycin Amiodarone Methylsergide Nitrofurantoin Cyclophosphamide ```
167
Pneumoconiosis in exposure to coal
Coal worker's lung
168
Pneumoconiosis in exposure to sandblasting, rock mining, tunneling
Silicosis
169
Pneumoconiosis in exposure to shipyards, pipe fitting, insulators
Asbestosis
170
Pneumoconiosis in exposure to cotton
Byssinosis
171
Pneumoconiosis in exposure to electronic manufacturing
Beryliosis (also aerospace)
172
Pneumoconiosis in exposure to moldy sugar cane
Bagassosis
173
Features of coal worker's lung
``` Upper ↑ IgA, G ↓ C3 ANA+ Can have RA ```
174
Features of silicosis
Upper | Egg-shell calcification of LNs
175
Features of Asbestosis
Lower | Dumbbell shaped
176
Features of all pulm fibrosis
Dyspnea worse on exertion Rales Loud P2 Clubbing
177
Best initial test for pulm fibrosis
CXR
178
Most accurate test for pulm fibrosis
Lung Bx
179
What does echo show in pulm fibrosis
RVH | Pulm HTN
180
CXR pattern in pulm fibrosis
Diffuse reticulonodular pattern | Honeycombing
181
What does Bx show in berylliosis
Granulomas
182
When are PFTs used in pulm fibrosis
Response to therapy
183
PFTs in pulm fibrosis
Decreased everything | Decreased DLCO
184
When can you rx interstitial lung disease
``` Bx shows WBC infiltration Use Prednisone (berylliosis responds best) ```
185
Who gets sarcoidosis
Young AA woman
186
Presentation of sarcoidosis
SOB on exertion | Erythema nodosum and lymphadenopathy
187
Misc findings in sarcoidosis
``` Parotid gland enlargement Facial palsy Heart block and restrictive cardiomyopathy CNS sx Iritis, Uveitis ```
188
Best initial test in sarcoidosis
CXR
189
Most accurate test in sarcoidosis
LN Bx | Shows noncaseating granulomas
190
Drug of choice in sarcoidosis
Prednisone
191
Where do PEs derive from
DVT in leg - 70% | DVT in pelvic vein - 30%
192
Causes of DVTs
``` Immobility Surgery Trauma Joint replacement Thrombophilia Malignancy Pregnancy ```
193
Inherited thrombophilia causing DVT
Factor V Leiden
194
Aquired thrombophilias
Lupus anticoagulant Nephrotic syndrome OCPs esp in smokers
195
How does nephrotic syndrome cause DVTs
Loss of albumin and Anti-thrombin III | Leads to renal vascular thrombosis
196
Most common findings in PE
Sudden SOB w/ clear lungs and normal CXR
197
Best initial tests for PE
CXR EKG ABG
198
Most accurate test for PE
Angiography
199
Mortality rate in angiography
0.5%
200
MC finding on CXR for PE
Atelectasis
201
Other findings on CXR for PE
Wedge infarction Pleural lesion Westermark sign
202
MC abnormality on EKG for PE
Nonspecific ST-T changes
203
ABG findings in PE
Hypoxia and resp alkalosis w/ NL CXR
204
Suspect PE what is next best step
Start therapy | Do NOT wait for confirmatory testing (Spiral CT or V/Q)
205
MC confirmatory test for PE
Spiral CT
206
When to use V/Q as confirmatory test for PE
``` Pregnancy (Use as 1st test) CXR NL (but spiral CT is still better) ```
207
When is D-dimer the answer for PE test
Pretest probability for PE is low
208
LE doppler positive in PE pt, what is the next step
No more testing | Heparin then warfarin for 6mos
209
-CT, -V/Q, -LE doppler, now what
Stop heparin
210
Angiography AE
Allergy Renal tox Death
211
Best initial therapy for PE or DVT
Heparin (warfarin started at same time)
212
When is IVC filter the rx for PE/DVT
Contraindication to anticoagulants Recurrent emboli while on heparin or therapeutic warfarin RV dysfunction
213
When are thrombolytics the rx for PE/DVT
Hemodynamically unstable | Acute RV dysfinction
214
When are direct acting thrombin inhibitors the rx for PE/DVT
HIT
215
When is aspirin the rx for PE/DVT
Never
216
What is pulm HTN
SBP>25 | DBP>8
217
Causes of pulm HTN
Idiopathic Chronic lung disease - COPD - Fibrosis
218
Presentation of pulm HTN
Dyspnea and fatigue Syncope CP Wide splitting S2, Loud P2
219
Best initial test for pulm HTN
CXR and CT
220
Most accurate test for pulm HTN
Swan Ganz catheter
221
Rx pulm HTN
Treat underlying cause
222
When is idiopathic pulm HTN treated
Vascular reactivity
223
Rx idiopathic pulm HTN
``` Prostacyclin analogues - Epoprostenol - Trepostinil - Iloprost - Beraprost Endothelin antagonists - Bosentan Phosphodiesterase inhibitors - Sidenafil ```
224
Role of O2 in pulm HTN
Slowes progression
225
Only cure for pulm HTN
Lung transplant
226
MCC OSA
Obesity
227
Most accurate test for OSA
Sleep study
228
How does OSA have increased bicarb
Hypoventilation → Hypoxia, hypercapnea, ↓O2 sat → chronic resp acidosis → compensate w/ increased bicarb
229
Rx OSA
``` Lose weight No alcohol CPAP Keep tongue out of the way Uvuloplatopharyngoplasty (LAST RESORT) ```
230
Picture of ARDS
Pt in ICU doing better then rapidly deteriorates w/ a pulmonary edema picture
231
Problem in ARDS
Loss of surfactant leading to leaky alveoli that fills w/ fluid
232
Causes of ARDS
``` Sepsis/aspiration Contusion/trauma Near-drowning Burns or pancreatitis DIC ```
233
MCC ARDS
G- sepsis by pseudomonas
234
CXR in ARDS
B/L infiltrates | White-out
235
pO2/FIO2 ratio in ARDS
236
pO2 in ARDS
237
FIO2 in ARDS
238
Wedge pressure in ARDS
NL
239
Does anything reverse ARDS
No
240
Best support for ARDS
Low tidal volume mechanical ventilation | 6mL/kg
241
What is used to decrease FIO2
PEEP | Maintain plateau pressure of

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