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Flashcards in Pulm Deck (172):
1

Risk factors for DVT

Stasis, endothelial injury, hypercoagulability - Virchow's triad

2

Criteria for exudative effusion

Pleural/serum protein >0.5
Pleural/serum LDH>0.6
PLeural fluid LDH >2/3 upper limit of nromal serum LDH

3

Causes exudative effusion

Leaky capillaries
-Malignancy, TB, bacterial or viral infection, PE with infarct, pancreatitis

THink inflammation

4

Causes transudative effusion

Intact capillaries
-CHF, liver or kidney disease, protein losing enteropathy

think changes in hydrostatic and oncotic P

5

Normalizing PCO2 in pt having an asthma exacerbation may indicate

Fatigue and impending respiratory failure

6

Sarcoidosis

Dyspnea
Lateral hilar LNopathy on CXR
noncaseating granulomas
Inc ACE
Hypercalcemia

7

PFT obstructive disease

Dec FEV1/FVC (<80)

8

PFT restrictive disease

Inc FEV1/FVC, dec TLC (>110)

9

Honeycomb on CXR
Tx

Diffuse interstitial pulm fibrosis
Supportive care and steroids

10

Tx SVC syndrome

Rads

11

Tx mild persistent asthma

Inhaled beta agonists and inhaled corticosteroids

12

Tx COPD exacerbation

O2, bronchoD, abx, corticosteroids with taper, smoking cessation

13

Tx chronic COPD

Smoking cessation, home O2, Beta agonist, antichol, systemic or inhaled corticosteroids, flu and pneumo vaccines

14

Acid base disorder in PE

Resp alkalosis with hypoxia and hypocarbia

15

Non Small cel lung cancer associated with hypercalcemia

SCC

16

Lung cancer w/ SIADH

Small cell lung cancer

17

Lung cancer related to cigarette

Small cell lung cancer

18

Tall caucasion man witha cute SOB
Dx
Tx

Spontaneous pneumothorax
Spontaneous regression, supplemental O2 may help

19

Tx tension pneumo

Immediate needle thoracostaomy

20

Characteristics favoring carcinoma in isolated pulm nodule

Age >45-50
Lesions new ot larger compared to old films
Absence calcification or irregular calcification
Size >2 cm
Irregular margins

21

ARDS

Hypoxemia and pulm edema with normal PCWP
Resp alkalosis

22

Sequelae asbestos exposure

Pulmonary fibrosis-->pleural plaques-->bronchogenic carcinoma (mass in lung field)-->mesothelioma (pleural mass

23

Inc risk of what infection with silicosis

TB

24

Causes hypoxemia

Right to left shunt
Hypoventilation
Low inspired O2
Diffusion defect
V/Q mismatch

25

Classic CXR findings for pulm edema

Cardiomegaly, prominent pulm vessels, Kerley B lines, bat's wing appearance of hilar shadows, perivascular and peribronchial cuffing

26

Westermark's sign and Hamptom's hump

CXR findings suggesting PE

27

Etiologies of obstructive disease

ABCT
Asthma
Bronchiectasis
CF/COPD
Tracheal or bronchial obstruction

28

Reversible airway obstruction 2/2 bronchial hyperreactivity, airway inflammation, mucous plugging, smooth mm hypertrophy

Asthma

29

pH imbalance asthma

Resp alkalosis with mild hypoxia

30

Dx asthma

Dec FEV1/FVC
Methacholine challenge- tests for bronchial hyper responsiveness

31

Meds for asthma exacerbations

ASTHMA
Albuterol
Steroids
Theophylline
Humidified O2
Magnesium - severe
Antichol

32

Example long and short acting beta 2 agonist

albuterol - short
Salmeterol- long

33

Function corticosteroids in asthma

Inhibit cytokine synthesis - beclomethasone/prednisone

34

Fcn muscarinic antagonist in asthma

block muscarinic receptors = prevent bronchoC
Ipratroprium

35

Fcn methylxanthines asthma

BronchoD by inhibiting PDE = inc cAMP levels
Theophylline- narrow therapeutic window (Cardio and neurotoxic)

36

Cromlyn fcn

Prevents release vasoactive mediators from mast cell
Use exercise induced bronchospasm = only good for prophy

37

AntiLT fcn

Zileuton: 5-lipoxygenase pathway inhibitor, blocks conversion of arachnidonic aci to LT
Montelukast, Zafirlukast: block LT receptors

38

Mild intermittent asthma
Howo often
Fev1
Tx

=80%
PRN short acting bronchoD

39

Mild persistent asthma
How often
FEV1
Tx

>2/wk but 2 night/month
>=80%
Daily low dose corticosteroid, PRN short acting bronchoD

40

Moderate persistent asthma
How often
FEV1
Tx

Daily
>1 night/wk
60-80%
Low to medium dose corticosteroid + long acting beta 2 and PRN short bronchoD

41

Severe persistent
How often
FEV1
Tx

Continual, frequent
<=60
High dose inhaled corticosteroid _ long acting beta 2; PO corticosteroid; PRN short acting bronchoD

42

Permanent dilation of bronchii 2/2 cycles of infection and inflammation
Chronic cough, yellow/green sputum, dysponea, hemoptysis, halitosis
CXR: inc bronchovascular marking and TRAM LINES (outline dilated bronchi)
CT: dilated airway and ballooned cyst
Spiro: dec FEV1/FVC

Bronchiectasis

43

If chronic hypercapnea, what can O2 do?

Suppress hypoxic respiratory drive

44

Chronic bronchitis - time criteria

productive cough >3 months in 2 consecutive yrs

45

Terminal airway destruction and dilation

Emphysema

46

Emphysema vs bronchitis S?S

E: pink puffer - dyspnea, pursed lips, minimal cough; thin appearance, late hypercarbia/hypoxia
B: blue bloater - cyanosis with mild dyspnea, productive cough, overweight, edema, rhonchi, early signs hypoxia

47

CXR of COPD

Hyperinflated lung, flat diaphragm, thin heart and mediastinum; bullae or blebs

48

pH status COPD

acute or chronic resp acidosis (inc pCO2) with hypoxemia

49

TX COPD

COPD
Corticosteroids
Oxygen if PaO2 <=89%
Prevention - smoking, pneumo and flu vaccines
Dilators: Beta 2 ag and antichol

50

Inflammation or fibrosis of interalveolar septum
Honey combing
Shallow rapid breathing, DOE, nonproductive cough, fine crackles, RHF

Interstitial lung disease

51

PFT for interstitial lung dis

Dec TLC, FCV, DLCO
normal FEV1/FVC

52

Meds cause interstitial lung disease

AMIODARONE
BLM
busulfan
Nitrofurantoin
Rads

53

Sarcoid S/S

GRUELING
Granulomas
aRthritis
Uveitis
Erythema nodosum
LNopathy
Interstitial fibrosis
Negative TB
Gammaglobulinemia

Labs: Inc ACE, hyperCa, hypercalciuria, inc ALP

54

Sarcoid most common in

Afr Am females

55

Alveolar thickening and granulomas 2/2 environmental exposure

Acute within 4-6 hrs
Chronic - progressive dyspnea and rales

Hypersensitivity pneumonitis

56

Inhalation small inorganic dust particles

Pneumoconiosis

57

Manufacture tile or brake linings, insulation, construction, demolition, shipbuilding
Can see fibers on pleural biopsy
15-20 yrs after initial exposure
CXR shows/multinodular opacities and interstitial fibrosis; calcified pleural plaques, CT shows linear fibrosis
Complications?

Asbestosis

Complication: inc risk mesothelioma and other lung cancers

58

Coal mines
CXR small nodular opacities in upper lung
Spiro shows restrictive dis
Complicationn?

Coal miners disease

Progressive massive fibrosis

59

Work in mines or quarries with glass, pottery or silica, sandblasting, cutting granite
CXR: small nodular opacities in upper lung zones, EGGSHELL CALCIFICATIONS, hilar adenopathy
Spiro: restrictive disease
Complication?

Silicosis

Increased risk TB, need annual TB test; progressive massive fibrosis

60

Work in high technology fields = aerospace, nuclear, electronic plants
Ceramics, foundries, plating facilities, dental material sites, dye manufacturing
CXR: diffuse infiltrates and BILATERAL hilar adenoathy, granulomas

Complications

Berylliosis

Requires chronic corticosteroids

61

Diverse group w/ eosinophilic pulm infiltrate and eosinophilia

Eosinophilic pulmonary syndromes

62

Decreased PO2

Hypoxemia

63

Tx hypercapnic pts

Inc ventilation to inc CO2 exchange

64

How to increase oxygenation on mechanical ventilator

Inc FiO2 or PEEP

65

How to increase ventilationon mechanical ventilator

Inc RR or Inc TV

66

Dx ARDS

Acute onset
Ratio PaO2/FiO2 <18

Hypoxemia, dec lung compliance, pulm edema

67

4 phases ARDS

1. acute injury - normal PE and possible resp alkalosis
2. 6-48 hrs: hyperventilation, hypocapnia, widening A-a gradient
3. ARF, tachypnea, dyspnea, dec lung compliance, scattered rales, diffuse chest opacity on CXR
4. Severe hypoxemia unresponsive to Tx, inc intrapulm shunting, metabolic and resp acidosis

68

Goal oxygenation ARDS

PaO2 > 60
SaO2>90% on FiO2 <=0.6

69

Mean pulm arterial P > 25 (normal 15)
5 classifications
1. Arterial pulm Htn
2. inc pulm venous P from L sided heart disease
3. Hypoxic vasoconstriction 2/2 chronic lung dis
4. chronic thromboembolic dis
5. Pulm Htn with unclear multifactorial etiology

Pulm HTN/Cor pulmonale

70

Causes pulm HTn

LHF
MV disease
Inc resistance pulm VV

71

S/S pulm HTN

DOE
Fatigue
Letharfy
Syncope with exertion
CP
RHF (edema, abdominal distention, JVD)'
Loud palpable S2, S4, parasternal heave

72

Sudden onset dyspnea, pleuritic CP, low grade fever, cough, tachypnea, tachycardia, resp alkalosis, loud P2, RHF

Pulmonary thromboembolism

73

Most common cause PE

from DVT

74

Dx of PE

CXR: normal, possble Hapmtoms hump (wedge shaped infarct) or Westermarks sign (oligemia in affected lung zone)
EKG: sinus tach or S1Q3T3
Ct pulm ang with IV contrast - spiral CT
VQ scan- mismatch
D dimer: sensitive not specific
LE venous US: clot

75

Lung nodules on CXR
-Recent immigrant
-SW US
-Ohio River Vally

-TB
-Cocci
-Histoplasmosis

76

Benign vs malignant
-age
-smoking
-films
-appearance
-margins
-size

/ 2cm

77

Highly correlated with cigarette exposure, central location, neuroendocrine origin, paraneoplastic, mets on presentation (brain, liver, bone)

Small cell lung cancer

78

3 types nonsmall cell lung ca

AdenoCA
SCC
Large cell/neuroendocrine

79

Most common lung CA, peripheral location, broncheoalveolar carcinoma (single nodules, interstitial infiltration, prolific sputum), pleural effusion have increased hyaluronidase NOT ASSOCIATED WITH SMOKING

AdenoCA

80

central location, 98% smokers

SCC

81

least common, poor prognosis, peripheral location, early cavitation

Large cell/neuroendocrine CA

82

Lung cancer mets

LABB
Liver
Adrenals
Brain
Bone

83

Horners
Associated tumor

Miosis, ptosis, anhidrosis
Pancoast tumor at apex

84

Facial swelling and lung Ca

SVC syndrome - supraclavicular engorgement and facial swelling

85

Hoarseness and lung CA

recurrent laryngeal n involvement

86

Examples paraneoplastic syndromes of lung CA

-Endocrine/metabolic
--Cushing - SCLC
--SIADH--SCLC
--Hypercalcemia--SCC
--Gynecomastia--Large cell
-Skeletal
--Hypertrophic pulmoary osteoarthyopatyh- non small
--Digital clubbing - non small
-Neuromuscular
--Peripheral neuropathy, subacute cerebellar degen, MG (Lambert-Eaton) - SCLC
--Dermatomyositis- All
-CV
--Thrombophlebitis or nonbacterial venous endocarditis - Adeno
-Heme
--Anemia, DIC, eosinophilia, thrombocytosis-All
--Hypercoagulability- Adeno
-Cutaneous- acanthosis nigircans -All

87

Tx SCLC

Unresectable, rads and chemo- low survival rate b/c returns

88

Tx NSCLC

Surgical resection, rads or chemo

89

Dyspnea, pleuritic CP, cough, dullness to percussion, dec breast sounds, possible rub

Pleural effusion

90

Tx pleural effusion

Thoracentesis

91

Acute onset unilat pleuritic CP and dyspnea; tachypnea, diminished or absent breat sounds, hyper resonance, dec tactile fremitus, JCD, decreased chest wall movement

Pneumothorax

Tension pneumo: tracheal deviation and hemodynamic instability

92

Primary vs secondary pneumothorax

Primary: 2/2 rupture subpleural apical blebs - tall thin young adulte males
Secondary: COPD, trauma, infectious, iatrogenic

93

1 way air valve causing air trapping in pleural space

Tension pneumothorax

94

Presentation of pneumothorax

P-THORAX
Pleuritic pain
Tracheal deviation
Hyperresonance
Onset sudden
Reduced breast sounds and dyspnea
Absent fremitus (asymmetric chest wall)
Xray shows collapse

95

What does DLCO stand for

Diffusing capacity of lungs - ability to transfer gases from alveoli to pulm capillaries

96

Inspiratory V during normal respiration

TV

97

Air V beyond normal tidal V that is filled during maximal inspiration

IRV

98

Total inspiratory air volume considering both TV and IRV

IC

99

Air V beyond TV that can be expired during normal respiration

ERV

100

Remaining air V left in lungs following max expiration

RV

101

RV + ERV = air remaining after expiration of TV

FRC

102

Max air volume that can be expired and inspired IC + ERV

FVC

103

Total air volume of lungs FVC + RV

TLC

104

2 PFT decreased in obstructive, all others are increased

FVC and FEV1

105

Normal A-a gradient

5-15 mmHg

Inc: PE, pulm edema, r-l shunt
False normal: may be seen in causes of hypoventilation or at high altitudes

106

PAO2-PaO2 gradient

713 x 0.21 -(PaCO2/0.8)-PaO2

0.21 = FiO2 fraction of O2 in inspired air
PAo2: alveolar O2 content
PaO2 - arterial O2 (90-100)

107

Nasal and throat irritation, sneezing, rhinorrhea, nonproductive cough, fever, no exudative or productive coug

Viral rhinitis/common cold

108

Sore throat, LNopathy, fever, red swollen pharynx, tonsillar exudates
Causes?

Pharyngitis

Cause: GABS or common cold virus

109

Tx GABS

Penicillin, amoxicillin, etc

110

Complications GABS pharyngitis

PSGN- high antistreptolysin O
Rheumatic fever
Rheumatic heart disease

111

Cause of tonsillar infections

Strep pharyngitis

112

Arthralgias, myalgias, sore throat, nasal congestion, nonproductive cough, N/V, diarrhea, high fever, LNopathy

Rx to shorten course

Viral influenza

Oseltamivir

113

Major complication of sinusitis

Meningitis

114

Causes acute sinusitis

Strep pneumo
H flu
Moraxella catarrhalis

115

Cause chronic sinusitis

Anaerobic

116

DM and sinusitis

Mucormycosis

117

Which sinuses usually affected in sinusitis

Maxillary

118

Rx sinusitis

Amoxicillin

119

Productive cough, sore throat, fever, wheezing tight breath sounds
Usual cause

Acute bronchitis

Viral
If inc risk bacterial infection give fluoroquinolones, tetracycline, erythromycin

120

Infection broncheolaveolar tree by nasopharyngeal bugs--> prod or nonprod cough, dyspnea, chills, night sweats, pleuritic CP, decreased breast sound, dullness to percussion egophony, tachypnea
Labs: Inc WBC, positive sputum
CXR: lobar consolidation

Pneumonia

Bacterial or fungal- broad spectrum abx until cultures return

121

Cough, hemoptysis, dyspnea, weight loss, night sweats, fever, rales

Dx?

TB

TB is screening for exposure

Acid fast stain, culture, bronchoscopy

122

CXR reactived vs primary

Primary- lower lobe

Reactivated - apical

Also Ghon complexes- calcified granulomas/LN

123

Most common pneumo in kids

Viral

124

Most common pneumo adults

Strep pneumo - higher risk in pts w/ sickle cell

PRODUCTIVE COUGH

Tx: beta lactams and macrolides

125

Pneumo common in COPD, slower onset than classic pneumo

H flu

Tx: Beta lactams or TMP-SNX

126

Nosocomical pneumoa common in immunocompromised pts
Forms abscess

Staph auresu

Beta lactams

127

Pneumo in alcoholics with high risk aspiration, currant jelly sputum

Kleb pneumo

Cephalosporin, aminoglycosides (gentamicin)

128

Chronically ill and immunocompromised, CF, rapid onset pneumo

Pseudomonas

Tx: Fluroquinolones, aminoglycosides, 3rd gen cephalopsoring,

129

Neonates and infants pneumo

GBS

Beta lactams

130

Nosomical and elderly pts

Enterobacter
TMP SMX

131

3 types atypical pneumo

Mycoplasma- young adults (college), positive cold agglutinin (macrolides)
Legionella: aerosolized water (macrolides, fluoroquinolones)
Chalmydophila - young and old (doxycyline and macrolides)

132

Pneumo
Midwest and south central america

Blastomycosis

KOH prep
Verrucous or ulcerated skin lesions
Itraconazole

133

Pneumo caves

Histoplasmosis

134

Immunocompromised Pneumo + GI

PCP - inc LDH (or CMV if koilocytosis)
TMP SMX

135

Paired gram + cocci pneumo

Strep pneumo

136

PPD test positive at 5 mm

HIV, close contacts with TB, signs TB on CXR

137

PPD test positive 10 mm

Homeless, immigrants, IVDU, health care, recent incarceration

138

PPD test positive 15 mm

Always positive

139

Causes ARDS

A- aspiration, acute pancreatitis, air or amniotic embolism
R - radiation
D- drug OD, diffuse lung disease, DIC, drowning
S -shock, sepsis, smoke inhalation

140

Proonged, nonresponsive asthma attack that can be fatal
Tx

Status asthmaticus

Agressive bronchoD, corticosteroids, O2, possibly intubation

141

Emphysema vs chronic bronchitis:

DLCO
Normal in bronchitis
Dec in ephysema (also asbestosis)

142

Alpha 1 antitrypsin def induced emphysema vs not

Alpha 1: panlobular
Not: centrilobular

143

Hoarseness worsens with time, dysphagia, hemoptysis, assocaited tob and alcohol

Laryngeal CA
Tx - remove lesions, rads with surg

144

> 50 yrs, inflammatory lung disease, restrictive, inc PMN on lavage, CXT with honeycomb and CT ground glass

Idiopathic pulm fibrosis

Tx: steroids + azothioprine/cyclophosphamide

145

Progressive AI disease of lungs and kidneys 2/2 antiglomerular basement membrane Ab (anit-GBM)
S/S: hemoptysis, dyspnea, resp infection
Labs: restrictive PFT, UA proteinuria and granular casts, renal biopsy crescenteric GMN and IgG in glomerular capillaries
Tx?

Goodpasture

Plasmapheresis, steroid and immunosuppressive Rx

146

Granulomatous inflammation and necrosis of lung and other organs 2/2 systemic vasculitis affecting lung and kidneys - noncaseeating granulomas and destruction of lung parenchyma
S/S: ulceration of nasopharynx, CNS Sx
Lab: + cytoplasmic antineutrophil Ab (c-ANCA)
Tx

Granulomatosis with polyangitis -Wegner

Cytotoxic Tx - cyclophosphamide and steroids

147

Risk factors PE

7H
Hereditary hypercoagulability
History- prior DVT or PE
Hypomobility
Hypovolemia- heydration
Hypercoagulability
Hormones
Hyperhomocysteinemia

148

Time line to anticoagulate after PE

3-6 months

149

3 types pneumothorax

Closed - chest wall intact (COPD, spontaneous, TB, blunt trauma)

Open- air through opening in chest wall (penetrating trauma, iatrogenic)

Tension- air enters but does not leave (trauma)

150

Dyspnea, pleuritic CP, weakness, decreased BS, dullness to percussion, decreased tactile fremitus

Hemothorax

151

Tumor on visceral pleura or peritoneum with poor prognosis
Asbestos (20 yrs later)

Mesothelioma

Extrapleural pneumonectomy w/ chemo and rads - Tx

152

Tx central sleep apnea

respiratory stimulants
phrenic n pacemaking

153

Localized alveolar collapse, common after surgery and anesthesia, also asthmatics/FB aspiration/ mass effect
CXR: fluffy infiltrates and lobar collapse
Preventive Tx?

Atelectasis

Incentive spiro, ambulate, PT

154

How to check proper placement of ET tube?

end tidal CO2 - rise following expiration

155

What can be adjusted with mechanical ventilation?

TV
RR
FiO2
inspirator P

PEEP prevent alveolar collapse

156

Predictors of weaning success

Max ins P < 30 cm H2O
VC > 10mL/Kg
minute vent 200
frequency: TV ratio <100 breaths/min/L

157

Determines and automatically delivers set TV and rate
Pt provides no effort

CMV

158

Determines and automatically devliers set TV and rate
Pt can breathe spontaneously between mechanical breaths

IMV

159

Machines tries to synch rate with pt initiated breaths, automatically delivers TC and rate
Pt can breathe spontaneously between mechanical breaths

SIMV

160

Machines senses pt's attempt to breathe and delivers full preset TV, backup rate if no spont breathing
Pt driven unless no attempts to breath

AC

161

Acute inflammation of larynx, 3 mo - 5 yrs, barking cough, inspiratory stridor, subglottic narrowing/steeple sign
Causes?

Croup
Parainfluenza 1 and 2 (RSV, influenza, rubeola, adenovirus, Myco pneumo)

162

Cause epiglottitis
Major S/S

HiB, strep or the H flu
Dysphagia, drooling, muffled voice, high fever, lean forward to breath, THUMBPRINT SIGN (opacified epiglottis obscures airways)

163

Cause bronchiolitis

RSV or parainfluenza 3 (not common)

S/S - wheezing and resp distress
CXR - hyperinflation lungs

Tx- monitor airway

164

Caused by surfactant def; presents within 2 d of birth, inc RR, ABG shows inc CO2, dec O2, ground glass on CXR

RDS of newborn

Increased risk of developing asthma

165

complication meconium aspiration

pulm HTN

166

Tx CF

DNase - decrease viscosity of phlegm
NSAIDS
BRonchD
abx

167

Common pulm infection

Pseudomonas
Staph

168

Top 3 causes cough in outpt

Asthma
GERD
postnasal drip

169

Pneumo in TB and pulm cavitation

Aspergillus

170

Popcorn calcifcations

Granulomas - bening

171

NBulls eye calcifications

Hamartomas- benign

172

Gold standard PE

pulm angiography