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Flashcards in Pulmonary Deck (56):
1

Systemic Sarcoidosis

-multi-system dx of unknown etiology with NONCASEATING GRANULOMAS
- often found in African-American females and North European Caucasians
- often arises in 3rd or 4th decade of life

2

Systemic Sarcoidosis: Hx and PE

can present with fever, cough, malaise, weight loss, dyspnea, and arthritis

3

Systemic Sarcoidosis: Dx

CXR/CT: lymphadenopathy and nodules used to stage disease
Biopsy: lymph node biopsy or T-VATS lung biopsy shows noncaseating granulomas
PFTS: show restrictive/obstructive patter and decr. diffused capacity
- increased serum ACE levels, hypercalcemia, increased alk phos, lymphopneia, CN defcitic, arrhythmias

4

Systemic Sarcoidosis: Tx

Systemic corticosteroids indicared for deteriorating respiratory fxn, constitutional sx, hypercalcemia, or extrathoracic organ involvement

5

Obstructive Lung Disease

- characteried by airway narrowing
- OLD restricts aire movement and cause air trapping

6

Etiology of Obstructive Lung Disease

ABCT
Asthma
Bronchiectasis
Cystic fibrosis/ COPD
Tracheal or bronchial obstruction

7

Asthma

- reversible airway obstruction secondary to bronchial hyperactivity, airway inflammation, mucous plugging and smooth muscle hypertrophy

8

Asthma: Hx and PE

- persists with cough, episodic wheezing, dyspnea and/or chest tightness
- exam shows wheezing, prolonged expiratory duration (decr. I/E ration), accessory muscle use
- decreased breath sounds and decreased SpO2 are late signs

9

Asthma: Dx

- ABGs: mild hypoxia and respiratory alkalosis
- Spirometry: decreased FEV1/FVC
- increased residual volume and total lung capacity
- CBC: possible eosinophilia
- CXR: hyperinflation

10

Methacholine challenged

- tests for bronchial hyperresponsive
- useful when PFTs are normal but still suspect asthma

11

Asthma: Tx

Avoid triggers (allergens, URIs, cold air, exercise, drugs, and stress)

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Tx of acute asthma

- Oxygen
- Bronchodilating agents (inhaled B2 agonists - first line therapy)
- Ipatropium (never used alone for asthma)
- Systemic corticosteroids, magnesium for severe exacerbations

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Tx for chronic asthma

- administer long acting bronchodilators and/or inhaled corticosteroids
- can also use systemic corticosteroids, cromolyn or rarely theophylline
- Montelukas and other leukotriene antagonist s are oral adjuncts to inhalant therapy

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B-2 agonists

albuterol or salmeterol

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Albuterol

- short acting B-2 agonists
-relaxes bronchial smooth muscle (B 2 adrenoreceptors)

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Salmeterol

- long acting B-2 agonist for prophylaxis

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Inhaled corticosteroids

- first line treatment for long term control of asthma

18

Beclomethasone, prednisone

inhibit synthesis of virtually all cytokines

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Muscarinic antagonists

(e.g. ipratroprium)
- competitively blocks muscarinic receptors, preventing bronchospasm

20

Methylxanthines

(e.g. theophylline)
- likely causes bronchodilation by inhibiting phosphodiesterae, thereby decreasing cAMP hydrolysis and increasing cAMP levels
- limited use b/c of narrow therapeutic-toxic index (cardiotoxcity, neurotoxicity)

21

Cromolyn

- prevents release of vasoactive mediators from mast cells
- useful for exercise induced bronchospasm
- EFFECTIVE FOR PROPHYLAXIS OF ASTHMA
- not effective during acute asthma attack

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Antileukotrienes

(e.g. zileuton, monteleukast, zafirlukast)

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Zileuton

5- lipoxygenase pathway inhibitor. Blocks conversion of arachodonic acid to leukotriens

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Monteleukast, zafirleukast

- block leukotriene receptors

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Meds for ASTHMA exacerbation

ASTHMA
Albuterol
Salmeterol
Theophylline (rare)
Humidified oxygen
Magnesium (for severe exacerbations)
Anticholingerics

26

10 yr old with hx of asthma on daily fluticasone has been using an albuterol inhaler once a day for several weeks. What changes should be made to current regimen?

Moderate persistent asthma w/ daily symptoms
- may benefit from long acting B-2 agonist (salmeterol) for prevention of symptoms

27

Mild intermittent asthma

< 2 days/ week
< 2 nights/month
FEV > 80%
- no daily meds
- prn short acting bronchodilator (albuterol)

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Mild persistent asthma

> 2 / weeks but < 1/ day
> 2 nights/ month
FEV > 80 %
- daily low dose inhaled corticosteroids
- prn short acting B2 agonist

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Moderate persistent asthma

Daily
> 1 night/ week
FEV 60 - 80%
low to medium dose inhaled corticosteroids + long acting inhaled B2 agonist
prn short-acting bronchodilator

30

Severe persistent asthma

Continual, frequent
FEV < 60 %
High dose inhaled corticosteroids + long acting B2 agonists
- possible PO corticosteroids
PRN short-acting bronchodilator

31

Bronchiectasis

- disease caused by cycles of infection and inflammation in the bronchi/bronchioles that lead to fibrosis, remodeling and PERMANENT DILATION OF BRONCHI

32

Bronchiectasis: Hx and PE

- presents with chronic cough accompanied by frequent bouts of yellow or green sputum production, dyspnea, and possible hemoptysis and halitosis
- exam reveals rales, wheezes, rhonchi, purulent mucous and occasional hemoptysis

33

Conditions associated with bronchiectasis

- Pulmonary infxns
- Hypersensitivity
- Cystic fibrosis
- Immunodeficiency
- Localized airway obstruction

34

Bronchiectasis: Dx

CXR: shows increased bronchovascular marking and tram lines (parallel lines outlinting dilating bronchi )
CT: Dilated airways and balloon cysts are seen at end of bronchus (mostly lower lobes)

35

Bronchiectasis: Tx

- Abx for bacterial infections
- maintain bronchopulmonary hygiene (cough control, postural drainage)
- consider lobectomy for localized disease or lung transplantation

36

Chronic Obstructive Pulmonary Disease (COPD)

- disease with decreased lung fxn associated with airflow obstruction
- secondary to chronic bronchitis or emphysema

37

Chronic Bronchitis

- productive cough for > 3 months per year for 2 consecutive years

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Emphysema

terminal airway destruction and destruction that may be secondary to smoking (centrilobular) or to alpha-1 antitrypsin deficient (panlobular)

39

Emphysema: Hx and PE

"Pink puffer": dyspnea, pursed lips, minimal cough, decreased breath sounds
- late hypercarbia/hypoxia
- tend to have thin wasted apperance
- few exacerbations in between episodes

40

Chronic bronchitis

"Blue bloater": Cyanosis with mild dyspnea, productive cough
- often overweight with peripheral edema, rhonchi and early signs of hypercarbia/hypoxia

41

COPD: Dx

CXR: Hyperinflated lungs: decreased lung markings with flat diaphragms and thin heart/mediastiunum
- parenchymal bullae or subpleural blebs
ABGS: hypoxemia with acute or chronic respiratory acidosis
- consider gram stain or sputum culture if pt has fecer or productive cough

42

COPD: PFTs

Decreased FEV1/FVC
- normal or decreased FVC
- increased TLC (emphysema, asthma)
- decreased DLco (emphysema)

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Acute COPD exacerbation Treatment

- Oxygen
- Inhaled B2 agonists
- Anticholingerics (ipatropium, tiotroprium)
- IV and/or inhaled corticosteroids
- Abx
** Severe cases may need BiPap**

44

Chronic COPD exacerbation treatment

- Smoking cessation, inhaled B2 agonists, anticholingerics (tiotroprium), systemic/inhaled corticosteroids
- Supplemental oxygen if resting PaO2 < 55 mm Hg or SaO2 < 80% or has cor pulmonale, pulm HTN, or hematocrit < 35%
- Give pneumococcal and flu vaccines

45

COPD Treatment

COPD
Corticosteroids
Oxygen
Prevention (stop smoking/ flu + pneumoccocal vaccines)
Dilators (B2 agonists, anticholinergic)

46

Restrictive Lung Disease

- loss of lung compliance
- result in increased lung stffness and decreased lung expansion

47

Causes of atypical pneumonia

- Mycoplasma
- Legionella
- Chlamydia

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Causes of nosocomial pneumonia

- GNRs
- Staphylcoccus
- Anaerobes

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Causes of immunocompromised pneumonia

- Staphylcoccocus
- Gram positive rods
- Fungi (e.g. aspergillous)
- P. jiroveci (esp with HIV)
- Mycobacteria

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Causes of aspiration pneumonia

Anaerobes

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Causes of pneumonia in alcoholics/IV drug users

S. pneumoniae
Klebsuella
Staphylococcus

52

Causes of cystic fibrosis pneumonia

Pseudomonas
Burkholderia
S. aureus
Mycobacteria

53

Causes of pneumonia in COPD

H. influenzae
Moraxella catarrhalis
S. pneumoniae

54

Causes of post-viral pneumonia

S. pneumonoia
Staphylococcus
H. influenzae

55

Causes of pneumonia in neonates

Group B Strep
E. coli

56

Causes of recurrent pneumnoa

Obstruction
Bronchogenic carcinoma
Lymphoma
Wegener's granulomatosis
Immunodeficiency
Unusual organisms (e.g. Nocardia, Coxiella burnetti, Aspergillus, Pseudomona