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Flashcards in Pulm Deck (53)
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Order of asthma management

Start with inhaled SABA
Next add low-dose inhaled corticosteroid, alternates include cromolyn, LK modifiers: montelukast
Next add LABA to the SABA and ICS or increase the dose of ICS
Then increase the dose of the ICS to maximum in addition to the LABA and SABA
May add Omalizumab if increased IgE
Finally, oral corticosteroids when all others have failed


The severity of an asthma exacerbation is quantified by?

Decreased peak expiratory flow – an approximation of the FVC
Also ABG with an increased A-a gradient


Treatment of an asthma exacerbation

Oxygen, albuterol, steroids, iPratropium may help, magnesium only an acute, severe asthma not responsive to several rounds of albuterol


COPD diagnosis

best initial: CXR
most accurate: PFT (will have decreased FEV1/FVC less than 70% decreased DLCO) (not reversible -i.e. less than 12% / 200 mL improvement in FEV1)
ABG in acute exacerbations will have increased pCO2 and hypoxia, elevated bicarb to compensate


what improves mortality in COPDers?

smoking cessation
O2 if pO2 less than 55 or sat lass than 88% (or 60, 90% if RHF or elevated HCT or pulm HTN)
influenza/pneumo vaccines


effective meds in COPD

anticholinergics are most effective**
SABAs, steroids, LABAs, pulm rehab
in contrast to asthmatics, COPD not controlled with albuterol>anticholinergic>ICS


management of AECB

bronchodilators, steroids, antibiotics: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line


high volume purulent sputum, +/- hemoptysis, wheezing, dyspnea, crackles, dilated, thickened bronchi ("tram-tracks") on CXR, think? best diagnostic tool?

most accurate test is high-resolution CT (get CXR first)
sputum culture to determine specific bacteria


bronchiectasis tx

"cup and clap" - physiotherapy (associated with CF)
tx infection, rotate abx
sx resection


brown sputum, ^IgE, eospinophilia, think?



sinus pain and polyps are common in ?

biliary cirrhosis, intestinal obstruction, pancreatitis (islets are spared)


best diagnostic test for CF
what bugs on sputum cx

sweat chloride (above 60) after pilocarpine tx (^Ach>^Cl-)
genotyping not accurate, too many diff genes
H. flu (nontype), pseudomonas, S. aureus, Burkholderia


CF tx

abx: macrolides, cephas, augmentin, FQs, doxy or bactrim 2nd line
inhaled rhDNase, inhaled bronchodilators (albuterol), pneumo/influenza vaccination, lung transplant if refractory
Ivacaftor ^CFTR activity


main ways to distinguish pneumonia from bronchitis

abnormal CXR, high fevers, dyspnea?


CAP orgs not visible on gram stain

Mycoplasma, Chlamydia, Legionella, Coxiella, viruses


sputum gram stain is adequate if ?

more than 25 WBCs and fewer than 10 epithelial cells


pleural effusion with:
WBC above 1000, pH less than 7.2?
LDH above 60% and protein above 50% of serum level?



bronchoscopy in pneumonia?

rarely needed, only when stain/cx do not yield org and need for ICU placement
exception: PCP
other uses: foreign bodies, cytology for lung masses


Outpatient treatment of pneumonia

If previously healthy: macrolide or doxycycline
If comorbidities or antibiotics in the past three months: floor quinolones – not Cipro


Inpatient treatment of pneumonia

Flora quinolone – not Cipro or ceftriaxone and azithromycin


Reasons to hospitalize people with pneumonia

Hypotension, respiratory rate above 30 or PO to lesson 60, pH below 7.35, B1 above 30, sodium lesson 130, glucose about 250, possible of 125, confusion, temperature above 104, 65 or older or comorbidities such as cancer COPD CHF renal failure liver disease


Curb 65 criteria for pneumonia and mission

Confusion, uremia, respiratory distress, BP low, age over 65
With 0 to 1.: Home
If 2+ points: admission


How to manage infected profusion or empyema in addition to antibiotics?

Drainage for a chest tube or thoracostomy, each of the chest can accommodate 2 to 3 L of fluid, a large effusion ask like an abscess and is hard to sterilize


Who gets the pneumococcal vaccine

Everyone at 65: first 13 then the 23
Once underlying condition is discovered in those with heart, liver, kidney, lung disease or immunocompromise or cancer
Second those should be given five years after the first dose


Difference with HAP

Higher incidence of Graham negatives: E. coli or Pseudomonas, macrolides are not acceptable
Need anti pseudomonal cephalosporins or antipseudomonal PCN, (Zosyn) or carbapenem


Diagnostic test for VAP from least accurate but easiest to most accurate but most dangerous

Trick your aspirin, BAL, protected brush specimen, VAT, open lung biopsy – thoracotomy


Therapy for VAP

Combine three different drugs:
Anti-pseudomonal beta-lactam: cephalosporin, penicillin, or carbapenem
PLUS SecondAnti-pseudomonal agent: aminoglycoside or floor quinolone
PLUS MRSA agent: vancomycin or linezolid no daptomycin! Inactivated by surfactant


Best for covering long abscesses

Penicillin or clindamycin
CXR is the best initial test, CT is more accurate, only a long biopsy can establish the etiology, sputum culture is wrong


Alternative to Bactrim in PCP

Atovaquone if mild, if that Jim toxicity switch to clindamycin and primaquine or pentamadine


Diagnosing TB

Best initial test: CXR
Sputum stayed in culture,
Most accurate test: plural biopsy