Pulm Flashcards
1
Q
4 types of CT
A
- Conventional CT
- High resolution CT
- Helical CT
- Electron Beam CT
2
Q
Conventional CT for
A
Look at anatomy
Not really for lungs
3
Q
High resolution CT for
A
Lung parenchyma at high resolution
ILD
Bronchiectasis
4
Q
Does high resolution need contrast?
A
No
NOT to look at vessels
5
Q
Use what CT to guide biopsies?
A
HRCT
6
Q
Two types of helical CT
A
Single section CT
Multidetector CT
7
Q
Does helical CT need contrast
A
Yes, IV contrast
8
Q
Multidetector CT best way for
A
Performing CT pulmonary angio
9
Q
Helical/MDCT 3 advantages
A
- Scan large section on single breath
- Collect image precisely when flow of contrast is in the system you are concerned about
- Narrowing of collimation thru chest so lung & hilar images are “High resolution”
10
Q
Electron beam CT
A
Lower radiation than hCT
But more $$$$$
Initially for heart
11
Q
Diagnose ILD or bronchiectasis with
A
HRCT
12
Q
Work up solitary pulm nodule
A
hCT or HRCT
13
Q
Diagnose PE
A
CTPA via hCT or MDCT
14
Q
MRI
A
Tumor near blood vessel or nerves
Determining what is tumor and what is not
Rarely venous thrombosis
15
Q
3 methods for lung biopsy
A
- Transbronchial
- Open lung
- VATS
16
Q
Before lung biopsy use
A
Chest x-ray & HRCT
17
Q
Lung biopsy to get diagnosis of
A
Interstitial lung dz Lymphangitic spread of CA Eosinophilic pneumonia Vasculitis Certain infections
18
Q
HRCT over lung biopsy usually enough for diagnosis for
A
ILD & IPF
Except in atypical cases
19
Q
Gold standard for dx PE
A
Pulmonary angiogram
But rarely used because CT PA is very reliable
20
Q
PET scan
A
Benign vs malignant pulm nodule
Infectious or inflammatory conditions
21
Q
BAL normal findings
A
< 16% lymphocytes
No eosinophils
22
Q
BAL: increased neutrophils
A
IPF Collagen Vasc Dz Asbestosis Suppurative infections Granulomatosis with polyangitis ARDS
23
Q
BAL: Increased lymphocytes
A
Hypersensitivity pneumonitis
Sarcoidosis
24
Q
BAL: increased eosinophils
A
Acute & chronic eosinophilic PNA ARDS Churg Strauss Loffler Syndrome Tropical Eosinophilia Parasites (ascariasis) TB Collagen Vasc dz Malignancy Drug reactions
25
BAL to diagnose PNA
PJP in AIDS
CMV pna--inclusion body
Disseminated TB or fungal infection
Dx PNA in ARDS
26
BAL: turbid PAS +
Alveolar proteinosis
27
BAL: Langerhans cells
Eosinophilic granulomatosis (histiocytosis x)
28
BAL: bloody with large amt of hemosiderin in alveolar macrophages
Diffuse Alveolar Hemorrhage
29
BAL: hyperplastic & atypical type 2 pneumocytes
Cytotoxic lung Injury
30
BAL: foamy changes with lamellar inclusion
Amiodarone induced disease
31
6 Causes of hypoxemia
1. V/Q mismatch
2. R-> L shunt
3. Decreased alveolar ventilation
4. Decreased diffusion
5. High altitude
6. Low mixed venous 02
32
V/Q mismatch as a cause of hypoxemia
Means?
Airspace inadequately perfused or perfused areas inadequately ventilated
Responds to oxygen!!!
33
Examples of V/Q mismatch
(Chronic lung diseases)
```
Asthma
COPD
Pneumonia, interstitial dz, pulm Vasc dz
Pulmonary HTN
PE
```
34
Right to left shunting as cause of hypoxemia.
Examples?
Hypoxemia due to perfusion of non ventilated alveoli.
ARDS
Intra-alveolar filling: PNA, pulm edema
Intracardiac shunt
Vascular shunt
Does NOT respond to oxygen
35
Decreased alveolar ventilation as a cause of hypoxemia
Seen with decreased TV or low RRs
High pCO2
Normal Aa Gradient
Drug overdose
Neuromuscular dz
CNS disorder
36
Decreased diffusion as accuse of hypoxemia
Examples
Low DLCO
ILD
Emphysema
37
Hypoxemia association with DLCO
DLCO < or = 30% of predicted
At Higher DLCO if rapid HR
38
Increased DLCO
Alveolar hemorrhage
39
What cause of hypoxemia improves with oxygen? Which does not?
V/Q mismatch: improves with 02
| R-->L shunt: does not improved with 02
40
Aa gradient
Difference between the partial pressure of oxygen in alveoli and arterial blood
41
Normal Aa gradient
5-15
42
Aa gradient increases with
Age
| Abnormal lung disease
43
Aa gradient in hypo ventilation and high altitude
Normal Aa gradient!
44
Aa gradient really only helpful when
Patient is breathing on room air
Because Aa gradient will increase as Fio2 increases
45
Formula for Aa gradient
Aa gradient:
149 - [PaO2 + (1.25 x PaCO2)]
46
Oxygen transport to tissues dependent on:
Cardiac output
Hemoglobin level
Hemoglobin saturation (Sa02)
47
PaO2 of 60mmhg results in Sa02 of?
>90%
48
Oxygen saturation of hemoglobin is dependent on
Temperature
2,3 DPG
pH
49
High phosphorous affects 2,3 DPG
High phos --> High 2,3 DPG
50
What does it mean to "RIGHT" shift oxyhb dissociation curve?
RIGHT shift
Decreased hb affinity for oxygen
(So at same PaO2 you carry less O2)
51
What RIGHT shifts the curve?
TAP
Increased Temperature
increased Acidosis
Increased 2,3 dPg
52
CO does what to ODC
Left shifts curve
High affinity of CO for hemoglobin
Pulse ox does not distinguish between oxy and carboxyhb :(
53
What is methemoglobin?
Iron is oxidized from ferrous (fe2+) to ferric (fe3+)
So can't hold onto o2 or co2 & curve LEFT shifted
54
What two things left shift ODC
CO
| MetHB
55
Clinical effects of metHbemia
Perioral & peripheral cyanosis
Fatigue & dyspraxia
Coma & death
56
Treatment of metHbemia
100% 02 & methylene blue
57
Treatment of chronic hereditary metHbemia
1-2 grams daily vit c
58
Normal oximetry is inaccurate with?
CO
MetHb
59
Decreased affinity for hb and oxygen (or right shifting curve) means
Release of oxygen to TISSUe
60
DLCO is decreased by
Anything that interrupts the gas-blood 02 exchange
61
DLCO decrease implies
Loss of effective capillary alveolus interface
62
Causes of low DLCO
Emphysema
Interstitial lung disease
Pulmonary vascular disease
Anemia
63
What is the first parameter to decrease in interstitial lung disease?
DLCO
64
Follow DLCO when prescribing
Dangerous meds like
Amiodarone or
Lung toxic chemo
65
how do you determine emphysema from chronic bronchitis & asthma?
DLCO
Low: emphysema
Normal: asthma & bronchitis
66
Normal DLCO in asthma & chronic bronchitis because?
Even though there is bronchi construction there is NO alveolar disease
67
Increased DLCO in
Problems that increase effective blood flow lung
CHF
Diffuse Alveolar Hemorrhage
Pulmonary infarct
Idiopathic pulm fibrosis
68
Things you can check on spirometry (in office)
Lung volume capacity
Exp flow
Flow vol loops
Bronchodilator response
69
Need pulm function in lab for additional
TLC
DLCO
Methacholine challenge
70
What is an abnormal lung volume?
>120%
| <80%
71
TLC assesses
Interstitial lung disease
72
Exploratory flow rate assess
| FEV1/FVC
Obstructive lung disease
| <70%
73
Four basic functional volumes of which lung is made
RV: residual volume
ERV: expiratory reserve volume
TV: tidal volume
IRV: inspiratory reserve volume
74
RV is
Unused space
75
ERV is
Expiratory Reserve Volume
From full non forced end-expiration to full forced end-expiration
76
TV is
Tidal Volume
Used in normal unforced ventilation
77
IRV is
Inspiratory reserve volume
From normal unforced end-inspiration to full-forced end inspiration
78
What is a capacity?
2 more more of the basic volumes and more functional significance
79
Vital capacity is
The volume you have available for breathing
80
Formula for VC
VC= IRV + TV + ERV
81
TLC formula
TLC = VC + RV
82
COPD lung volumes
TLC normal or increased
VC decreased
Increased RV (barrel chest)
83
Restrictive disease
TLC decreased
Decreased VC
Decreased RV
84
FEV1/FVC ratios
Normal
Obstructive
Restrictive
FEV1/FVC
Normal: 0.8
Restrictive > 0.8
Obstructive: <0.8
85
Asthma can have what sort of FEV1/FVC
Normal
Or
Less 0.8 if acute attack
And it is reversible!!
86
Flow diagram for obstructive disease
Decreased expiratory flow
(Bc of increased airway resistance)
Scooping
87
Causes of obstructive lung disease
Asthma
Bronchiectasis
COPD
Cystic fibrosis
88
Flow diagram for restrictive lung disease
Similar to normal curve but offset right and smaller
No scooping
89
Restrictive dz and RV
Intrathoracic dz: ILD, parenchymal LOW RV
Extrathoracic dz: obese, kyphosis
NORMAL RV
90
2 reasons to do bronchodilator response
Determine of obstruction is responsive to beta agonist
Test current regimen efficacy
91
If testing PFT with bronchodilator for responsiveness
Withhold beta 2 agonist for 8 hours & theophylline for 12-24 hours before testing
92
Work up if chronic cough can include
Methacholine or bronchoprovocation challenge
93
First step in evaluation possible asthmatic
PFTs
94
If normal PFT in suspected asthmatic next step is
Bronchoprovocation
95
Asthmatics vs non asthmatics in bronchoprovocation test
Asthmatics bronchoconstrict at a VERY low dose if the irritant while non asthmatics do not
96
Are PFTs indicated in routine pre op exam?
NO
97
PFT & ABG indicated preop when:
1. If surgery close to diaphragm (gb)
2. If pt has mod or worse lung dz
3. For lung ca or lung resection presurg eval
98
What indicates higher risk postoperative pulm complications in a patient with moderate or worse lung dz?
FEV1 <1L
| Elevated pCO2
99
High risk of post op pulm complications for pt with lung cancer or lung resection pre surgical if PFTs?
FEV1 < 0.8L after surgery
100
Emphysema exp flow volume
Decreased expiratory flow volume
101
Emphysema expiratory flow volume tracing
Concave
102
Emphysema response to beta 2 agonist
<200mL improvement in FEV1 or FVC
103
Emphysema TLC and VC
Emphysema
Increased TLC
Reduced VC (hyperinflation with trapped air)
104
Emphysema DLCO
Decreased DLCO
105
Chronic bronchitis Exp flow volume
Chronic bronchitis decreased expiratory flow volume
106
Chronic bronchitis response to beta 2 agonist
Minimal response to beta 2 agonist
<200 mL improvement in FEV1 or FVC
107
Chronic bronchitis TLC & VC
Chronic bronchitis TLC slight increase
Normal or slight increase VC
108
Chronic bronchitis DLCO
Chronic bronchitis DLCO normal to slightly decreased
109
Asthma PFT
Normal if no active disease
| Or decreased exp flow
110
Asthma exp flow vol loop tracing
Asthma exp flow vol loop tracing
| Concave
111
Asthma response to beta 2 agonist
Asthma response to beta 2 agonist
Significant
112
Asthma TLC and VC
Asthma TLC normal or increased
| VC normal or reduced
113
Asthma DLCO
Asthma DLCO normal
114
Interstitial lung dz FEV1/FVC
Normal to increased FEV1/FVC
115
Interstitial lung dz exp flow vol loop
Interstitial lung dz exp flow vol loop
Straight or slightly convex
116
Interstitial lung dz lung volumes
Interstitial lung dz volumes proportional all decreased
117
Interstitial lung dz DLCO
Interstitial lung dz DLCO reduced
118
Asthma triad
"Samter's triad"
ASA sensitivity
Asthma
Nasal polyposis
119
Treat allergic rhinitis with
Intranasal glucocorticoids
120
Asthma is exacerbated by what comorbid conditions
Allergic bronchopulmonary aspergillosis
OSA
Stress
121
What is the strongest identifiable predisposing factor for IgE mediated asthma?
Atopy
122
Severity of airflow obstruction in asthma is classified how?
Intermittent or persistent
| Persistent: mild, moderate, or severe
123
Initial work up tests for asthma
FEV in 6 seconds
FVC
FEV1/FVC before and after bronchodilator
124
What is a response to a bronchodilator?
Increase in FEV1 of > or = 12%
and
an increase of at least 200mL
125
Do bronchoprovocation test in patient with normal spirometry if they also have one of following:
Chronic cough
Intermittent symptoms of cough/wheeze
Exertion all dyspnea of unknown cause
126
3 types of challenge used to confirm diagnosis of asthma?
Methacholine challenge
Histamine challenge
Thermal (cold air) challenge
127
Diagnosis if asthma in respect to challenge
Patient must both tighten up with the challenge and loosen up with subsequent bronchodilators
128
How do you diagnose exercise induced bronchospasm?
Decrease in FEV1 of >/= 10% after graded exercise on treadmill or stationary bike
129
The most effective treatment for most asthma
Stop exposure to any environmental agents that act as triggers
Or can take extra bronchodilator inhalation a before exposure
130
Guidelines for management for what in patients with difficult to control asthma
Empirically manage GERD and allergic rhinitis
131
GERD management in co-existent asthma
About intake of foods that lessen LES tone (etoh, caffeine, nicotine, peppermint)
No eating within 3 hours of bed
Elevate head if bed
PPIs
132
Treat rhinitis with
Intranasal steroids
133
Monitor peak expiratory flow (PEF) in what sort of asthmatics?
Moderate-severe asthma
Or
Patients who can't reliably describe symptoms of exacerbation
134
Symptom based monitoring is as effective as PEF in all asthmatics except
moderate to severe asthmatics or poor historian
135
Quick relief meds for AE asthma (mild or intermittent)
SABA
Systemic corticosteroids
Anticholinergics
136
Long term control meds for asthma
```
ICS-most potent & most effective
LABA
Mast cell stabilizers
Leukotriene modifiers
Methylxanthines
Immunomodulators
```
137
1st choice for rescue treatment of AE asthma
Inhaled SABA- albuterol
EVEN if patient routinely uses them at home
138
What indicates poor control of asthma?
SABA use >2 days/week
139
When are OCS indicated for AE asthma?
Peak flow <80% after 3 treatments of rescue SABA
140
What drug has been shown to decrease the frequency if return visits to ER for asthma?
Oral CS
141
When do you use oral vs IV steroids?
Oral = IV = IM bioavailability
Only use IV: respiratory failure or vomiting
142
Types of anticholinergics for asthma treatment
Ipratropium- asthma
| Tiotropium- copd
143
Short vs long acting anticholinergics
Short acting: ipratropriun (for asthma)
Long acting: tiotroprium (for copd)
144
How do anticholinergics work?
Decrease cGMP that relaxes contractions of bronchial smooth muscle
145
Use ipratroprium for
Moderate to severe exacerbation of acute asthma
With SABA!!
146
Anticholinergics are not used for treatment of
Chronic treatment if asthma
147
Goal for Oxygen for AE Asthma?
Pa02 of at least 60mmhg
or
02 sat >/= 90%
148
Preferred drug for treatment of persist asthma when not controlled with SABA?
ICS
BID = QID
149
Benefit of spacer use for steroids
Decreases amount of drug deposited in oropharynx
Increased amount of drug reaching the lungs
150
Preferred inhaled steroid during pregnancy
Budesonide
151
SE of ICS
Easy bruising
| Higher dose: oral thrush & dysphonia & recurrent pulmonary infxn
152
Examples of LABA
Salmeterol
| Formeterol
153
How do LABA work?
Increase cAMP causing relaxation if bronchial smooth muscles
154
Only use LABA after
ICS
155
LABA is indicated for treatment of
Moderate to severe persistent asthma
(After treatment with ICS & SABA)
(Not for acute or mild asthma)
156
Never use what asthma med as monotherapy?
LABA
Otherwise increases exacerbation & mortality
157
Treatment options for exercise induced bronchospasm
LABA (not for daily use)
Albuterol
Cromolyn
158
Examples of mast cell stabilizers
Cromolyn sodium
| Nedocromil
159
How to mast cell stabilizers work
Inhibit degradation of mast cells
| Mild antiinflamatory effects from decreasing release of inflammatory mediators
160
Drugs for daily control of exercise induced bronchoconstriction
Inhaled albuterol
| Inhaled cromolyn
161
What do leukotrienes do?
```
Contract smooth muscles
Promote mucus production
Cause airway edema
Vasoconstrict
Stimulate arachidonic acid rease
```
162
What releases leukotrienes?
Mast cell
Basophils
Eosinophils
163
Examples of leukotrienes modifiers
Montelukast
Zafirlukast
Zileutin
164
How does montelukast & zafirlukast work?
Leukotriene receptor antagonist
165
How does zileuton work?
5-lipooxygenase pathway inhibitor
166
Leukotriene modifiers may have side effect of
Eosinophilic vasculitis (churg strauss)
Never preferred treatment for adults more often used for kids
Less potent than ICS & less effective than LABA
167
Example & mechanism of methylxanthine
Theophylline
Bronchodilator
Mild antiinflamatory by inhibiting PDE
168
When do you use theophylline?
Adjunct to ICS for difficult to control asthmatics
For chronic use
NOT FOR ACUTE treatment
Inferior overall
169
Therapeutic range if theophylline
5-15
170
Signs if theophylline toxicity
N & V
HA
Tremulousness
Palpitations
Seizure
Hypotension
Cardiac arrhythmia
171
What drugs increase theophylline levels?
```
Cipro
Clarithromycin
Zileuton
Allopurinol
Mtx
Estrogen
Propranolol
Verapamil
```
172
What drugs decrease theophylline levels?
AEDs
Rifampin
SJ wort
Smoking
(Can cause AE asthma)
173
What drugs when given with theophylline can decrease the level of coadminstered drug?
Phenytoin
| Lithium
174
What immunomodulators are available for asthma
Omalizumab
Anti IgE mab blocking the receptors on mast cells and basophils
175
When is omalizumab indicated?
Allergies & severe uncontrolled persistent asthma on high doses of an ICS & LABA
176
Classification of asthma types based on FEV1/PEF
>/= 80%: intermittent or mild persistent
60-80%: moderate persistent
<60%: severe persistent
177
Night time awakenings to classify asthma
1nt a week but not daily: moderate
| Often 7nt/wk: severe persistent
178
Diagnose COPD when
Large airway symptoms: dyspnea, cough, sputum
Irreversible airway obstruction
FEV1/FVC <0.70
179
Smoking damages
Big airways
Little airways
Alveoli
180
Large airway damage from smoking
"Bronchitis"
Cough & mucus production
181
Small airway damage from smoking
Airflow obstruction with hyperinflation
182
Smokers bronchioles are affected how?
Centriacinar
Upper lungs
183
Alpha antitrypsin deficiency and effects on lungs?
Panacinar
Lower lungs
184
Spirometry and COPD
FEV1/FVC: <0.70
Elevated RV
Elevated TLC
Decreased VC
Emphysema: low DLCO
185
Definition of chronic bronchitis
Cough with sputum production for at least 3 consecutive months for at least 2 consecutive years
186
If you see clubbing
Look for other lung pathology
| I.e. IPF or lung cancer
187
GOLD classification for COPD based on
FEV1
188
GOLD classification into:
Mild: FEV1> or = 80%
Moderate: FEV1 50-80%
Severe: FEV1 30-49%
Very Severe: FEV1 <30%
189
Update on GOLD criteria 2011 also now includes
1. GOLD spirometry
2. Severity of symptoms
3. Risk of exacerbations
4. Comorbidities
190
A-D COPD classification
A: fewer symptoms, low risk exacerbations
B: more symptoms, low risk
C: fewer symptoms, high risk
D: more symptoms, high risk
191
BODE index for COPD
B: BMI
O: airway Obstruction
D: Dyspnea
E: Exercise capacity
E = 6 min walk test
Higher BODE = increasing risk of death
192
COPD pathology results in
Airway obstruction
Hyperinflation
Problems with gas exchange
193
Best prognostic indicator in COPD
FEV1
194
Best predictor of FEV1
Pack years of smoking
Normal age related decrease in FEV1 is 15-30mL/yr
COPD: 60-120mL/yr of lung function
195
Smoking cessation & lungs best when?
Younger age before any loss of pulm function
196
PaO2 in COPD falls when?
Late in disease
When FEV1 <50%
197
Chronic retention of CO in COPD doesn't occur until when?
Very late in disease
FEV1< 25%
198
Cor pulmonale occurs only when in COPD?
After prolonged, marked reduction in FEV1 < 25% with severe, chronic hypoxemia
199
Hypoxemia in COPD is due to?
V/Q mismatch
Responsive to O2
200
Treatment for COPD
stop smoking!
| SABA --> LABA --> ICS --> roflumilast
201
In COPD never use what alone?
Do not use ICS alone
| Always ICS and LABA
202
Combo LABA & ICS has increased risk of
PNA
203
When so you use roflumilast & how does it work?
GOLD 3 & 4
PDE 4 inhibitor
204
When do you use theophylline in COPD?
COPD patients on max therapy
Adds slight bronchodilator effect to salmeterol
205
What vaccines do COPD patients need?
Pneumococcal
| Influenza
206
When is Oxygen appropriate for COPD?
Resting PaO2 55%
207
Oxygen therapy in COPD endpoint level is?
90%
208
When using O2 in COPD how long?
Continuous x 24hr
Minimal at least 15hr/day
Re-eval patients places on oxygen 2 months after they are on a stable regimen of drug therapy
209
Pulmonary rehab benefits in COPD
Improves symptoms
Improves quality of life
Reduces hospitalizations & days in hospital
Survival is improved
210
When do patients need lung volume reduction surgery (LVR)?
Emphysematous patients with upper lobe disease & low exercise capacity
211
What interventions affect COPD outcomes long term?
Oxygen
Smoking cessation
LVR surgery
Lung transplant
212
In COPD bronchodilator refers to
Anticholinergics
Or
Beta agonist
213
Treatment for group A COPD
Short acting bronchodilator
214
Treatment for group B COPD
Long acting bronchodilator
215
Treatment for group C COPD
ICS & long acting bronchodilator
If cant afford:
SA bronchodilator & theophylline
Also: roflumilast
216
Treatment for group D COPD
ICS & long acting bronchodilator
| Roflumilast
217
How do you assess for AE COPD
CXR
EKG: PE
ABG
Don't use spirometry or peak flows
218
Signs of PE on EkG
S1Q3T3
New RBBB
RAD
219
Treatment of AE COPD
SABA & anticholinergics
Systemic corticosteroids
If mod/severe ill with purulent sputum antibiotics
NPPV
220
Organisms associated with AE COPD
Moraxella
Pneumococcus
H. Influenza
Pseudomonas: in GOLD 3&4
221
When do you think about alpha antitrypsin deficiency
Rare
Young smokers with bullous COPD at lung bases
FH of liver & lung disease
222
Gene for AAT
Pi locus
PiZZ - low low levels of AAT
Variable dz
Smoking worsens lung dz!
223
How do you diagnose AAT?
Serum level of AAT
| Genetic testing of Pi locus
224
Treatment of AAT
```
Weekly IV AAT
Stop smoking
Treat as COPD
Liver & lung transplant if needed
Vaccinations
```
225
Selection criteria for AAT treatment
PiZZ
AAT < 11
Abnormal CT or spirometry
Non smoker or ex smoker
226
What is bronchiectasis?
Persistent pathologic dilatation of bronchi caused by infection mediated inflammation and destruction of airway walls
Bronchi fill with mucus & pus and then become fibrotic
227
Specific causes of bronchiectasis
```
Infection
Focal lung obstruction
Systemic diseases reducing mucociliary clearance or preventing adequate immune response
Inhaling toxin
ABPA
AAT deficiency
```
228
Specific infections causing bronchiectasis
```
Virus: adeno or influenza
Poorly treated staph or gram neg PNA
Bordetella pertussis
TB
MAC
```
229
What sort if focal lung obstructions cause bronchiectasis?
Endobronchial tumor a
Lymph nodes
Foreign bodies
230
Systemic disease causing bronchiectasis
Decrease mucociliary clearance or prevent adequate immune response
(Thus allow colonization of bacteria)
CF
Ciliary dyskinesia
HIV/AIDS
Immunoglobulin deficiency
231
How do you diagnose bronchiectasis?
HRCT
232
How do you treat bronchiectasis?
10-14 days antibiotics
Driven by sputum data
Chronic prophylaxis only causes resistance
Surgical resection if massive hemoptysis or in resolving infxn
233
Empiric abx for CF bronchiectasis
Oral ciprofloxacin or aminoglycoside
Plus parenteral antipseudomonal pcn
234
What gene mutation causes CF?
CFTR gene on chromosome 7
| CF transmembrane conductance regulator protein
235
CFTR gene mutation causes what problems
Decrease Na absorption
Decreased Cl secretion
Lung mucus dehydrated & sticky & low in o2 ~> bacterial superinfxn
236
Consider CF with what symptoms
Recurrent sinusitis
Nasal polyps
Weight loss
Chronic prod cough- thick purulent sputum
Recurrent exacerbations of febrile respiratory infxns requiring abx
Infertile
Clubbing & cor pulmonale
237
Organisms in CF
```
GNR
Staph
H. Influenza
Pseudomonas
Enteric GNR; proteus, E. coli & klebsiella
Wierd: burkholderia
Aspergillus
Non TB mycobacteria
```
238
Spirometry for CF
Reduction in FVC & FVC1
Reversible until late disease
239
How do you screen for CF
Elevated chloride in sweat
240
Confirmatory test for CF
Nasal potential difference test
| Genetic analysis
241
How do you manage CF
```
Aggressive pulm toilet
Pancreatic enzymes
Vitamins A, D, E, K
Culture guided antibiotics for exacerbations
Recombinant DNAase
Inhaled hypertonic saline
```
242
How does DNAase work for CF?
Degrades accumulated DNA in airways & better airflow
243
How does hypertonic saline work for CF?
Improve airway clearance
244
What abx are commonly used for CF prophylaxis?
Inhaled aminoglycosides
Aztreonam
Oral azithromycin
245
Complications of CF
```
Respiratory failure
Pulm HTN
Cor Pulmonale
PTX
Hemoptysis
```
246
Antibiotics for AE COPD
Amox/clavulanate
Azithromycin
Respiratory quinolones
Pseudomonas coverage for GOLD 3&4
247
Clinical presentation of ILD
```
Dyspnea
Diffuse dz on CXR
Restrictive PFT
Decreased DLCO
Elevated Aa gradient
```
248
3 types of ILD
Occupational & environmental
Idiopathic interstitial pneumonia
Others
249
3 groups of occupational/ environmental ILD
1) occupational & environmental
2) organic dust induced (byssinosis)
3) inorganic dust induced
250
Hypersensitivity pneumonitis mechanism
Immune-mediated granulomatous reaction to organic antigens
Poorly formed granulomas are typical
251
Types of hypersensitivity pneumonitis
```
Moldy hay = "farmers lungs"
Pet birds = "bird fancier or breeder"
Grain dust - workers ingrain elevator
Isocyanates
Air conditioning systems
Crack cocaine
```
252
Hypersensitivity pneumonitis presentation of symptoms
Acute
Subacute
Chronic forms
Insidious onset
Recurrent or persistent pneumonia
Exposure
253
How do you diagnose hypersensitivity pneumonitis
By history!!
| CXR: fleeting (infiltrates)
254
Differential diagnosis for hypersensitivity pneumonitis
Eosinophilic pneumonia
Cryptigenic organizing pneumonia (COP)
Sarcoidosis
255
How do you differentiate sarcoidosis & hypersensitivity pneumonitis?
BAL: both increased lymphocytes
Hypersensitivity pneumonitis: helper/suppressor ratio 4:1
256
Treatment for hypersensitivity pneumonitis
Remove offending agents
| Corticosteroids in acute dz
257
Cause of organic dust ILD
Byssinosis
258
Exposure to what cases byssinosis?
Cotton
Flax
Hemp dust
259
Symptoms of byssinosis
Monday chest tightness
Early stage: occ chest tightness
Late stage: regular chest tightness toward end of 1st day of workweek
(Monday blues)
260
Types of inorganic dusts causing ILD
"C As Be S"
Coal worker pneumoconiosis
Asbetos
Berylliosis
Silicosis
261
4 types of asbestos associated dz
Benign pleural plaques
BAPE: being asbestos pleural effusion
Malignant mesothelioma
Asbestosis
263
Being pleural plaques of asbestos
Asbestos exposure
Bilateral mid thoracic pleural thickening plaques & calcifications
Spares costophrenic angle & apex
BENIGN
Not manifestation of asbestosis
264
BAPE
MC manifestation of asbestos exposure in first 10 yrs
Eosinophils in pleural fluid
Effusion: serous or bloody
265
Malignant mesothelioma
Merely exposure!
Tumor of mesothelial cell of pleura
Latency >40 years
Rapidly fatal
Not associated with smoking
266
Asbestosis
The pulmonary disease
Parenchymal fibrosis & resultant impairment
At the BASES
Smoking is synergistic :(
267
Asbestosis can lead to what?
Squamous & adeno Ca
268
What cancers are associated with asbestos?
Malignant mesothelioma (just exposure)
Squamous
AdenoCA
269
Toes of silicosis disease
Simple nodular
Complicated nodular
Silicoproteinosis
270
Silica and macrophage relationship
Silica integrated by alveolar macrophages renders them ineffective
271
Anytime you see +PPD in pt with silicosis
Treat like Latent TB
| +PPD makes diagnosis of latent TB
272
All patients with silicosis have increased risk for?
TB & malignancy
273
What is simple nodular silicosis
Fibrocalcified small nodules
Upper lung
Hilar nodules "eggshell calcification"
Carcinogen!
274
Things affecting upper lung
Silicosis
Coal workers pneumoconiosis
Berylliosis
TB
275
If symptoms of silicosis rapidly worsen think
TB
276
What is complicated nodular silicosis?
Big nodules >1cm
Progressive, massive fibrosis
277
What is silicoproteinosis
Overwhelming exposure causes it within 5 years
Alveoli fill with eosinophilic material (like PAP)
278
Treatment for silicosis
Acute: steroids
Severe: lung transplant
279
Types of coal worker pneumoconiosis
Simple
Complicated Progressive
Caplan syndrome
280
Simple CWP progression correlates with
Amount of coal dust deposited in lungs
281
Complicated CWP
Progressive massive fibrosis nodules >2cm
No hilar involvement
Not based on amt of coal deposited
282
CWP treatment
None
| Smoking accelerated dysfunction
283
Calplan syndrome
Seropositive RA & massive CWP
Heralded by peripheral lung nodules in addition to upper field nodules
284
Exposure to what causes silicosis
```
Mining
Glasswork
Ceramics
Sandblasting
Brickyards
Foundaries
```
Latency 20-30 years
