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Internal Medicine > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Causes of acute exacerbations of asthma

A 
Allergens
Exercise/Stress
Infection/cold air
Catamenial
ASA, NSAIDS, Beta-blocker, His
GERD
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2
Q

Common associations with Asthma

A 
Worse at night
Nasal polyps
Eczema/Atopic dermatitis
Increased expiratory phase of respiration
Increased use of accessory resp muscles
Exclusively as a cough
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3
Q

Best initial test for acute asthma exacerbation

A

FEV1 (peak expiratory flow<350) or ABG (increased A-a gradient)

CXR to rule out pneumonia/pneumothorax

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4
Q

Most accurate diagnostic test for asthma during exacerbation

A

FEV1 (Decrease FEV1/FVC ratio)

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5
Q

Most accurate diagnostic test for asymptomatic asthma

A

Methacholine challenge test (20% decrease in FEV1)

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6
Q

PFTs in Asthma

A
  • Decrease FEV1/FVC ratio
  • Increase in FEV1 by 12% after use of albuterol
  • Decrease in FEV1 of 20% after use of methacholine
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7
Q

CBC, Skin testing and Antibody levels of Asthma

A

CBC: increased eosinophilic count
Skin testing: specific allergen for bronchoconstriction
Antibody: may suggest high IgE (also in allergic bronchopulmonary aspergillosis)

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8
Q

Stepwise management of asthma

A
  1. SABA
  2. low dose ICS
  3. LABA
  4. increase dose of ICS
  5. oral corticosteroids
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9
Q

Examples of inhaled short acting beta agonists

A

Albuterol
Pirbuterol
Levalbuterol

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10
Q

Examples of low dose ICS

A 
Beclomethasone
Budesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone
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11
Q

Preferred pharm agent for: extrinsic allergies

A

Cromolyn/Nedocromil (mast cell inhibitor/eosinophil recruitment)

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12
Q

Preferred pharm agent for: atopic allergies

A

Leukotriene modifiers (montelukast, zafirleukast, zileuton)

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13
Q

Adverse effects of inhaled steroids

A

Oral candidiasis
Dysphonia

Use spacer with MDIs and rinse mouth after to minimize side effects.

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14
Q

Adverse effects of zafirleukast

A

Hepatotoxic

Associated with Churg-Strauss syndrome

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15
Q

Examples of inhaled long acting beta agonist

A

Salmeterol

Formoterol

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16
Q

Preferred pharm agent for: IgE-elevated allergies

A

Omalizumab (if no control with cromolyn)

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17
Q

Adverse effects of systemic corticosteroids

A

Cataracts
Thinning of skin, striae, easy bruising, acne, hirsutism
Osteoporosis
Adrenal suppression and fat redistribution
Hyperlipidemia, hyperglycemia

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18
Q

Role of ipratropium and tiotropium in asthma

A

Not clear. Anticholinergics to dilate bronchi and decrease secretions.

Very effective in COPD

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19
Q

What should be given to all patients with asthma?

A

Influenza and pneumococcal vaccines

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20
Q

Treatment of acute asthma exacerbation?

A

Oxygen
Albuterol (SABA)
Steroids

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21
Q

Acute asthma exacerbation not responding to several rounds to albuterol?

A

Mg (relieves bronchospasm).
Not as effective as albuterol, ipratropium or steroids.

Epinephrine is rarely used and as drug of last resort

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22
Q

Acute asthma exacerbation developing respiratory acidosis?

A

Endotracheal intubation and place in ICU.

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23
Q

Complications of asthma

A

Status asthmaticus (not respond to standard meds)
Acute respiratory failure 2/2 muscle fatigue
Pneumothorax, atelectasis, pneumomediastinum

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24
Q

History of SOB and nasal polyps

A

Aspirin-sensitive asthma

Avoid ASA/NSAIDs

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25
Q

Presentation of COPD

A

SOB worsened by exertion
“Barrel chest” with increased air trapping, clubbing of fingers
Muscle wasting and cachexia
Loud P2 (pulmonary hypertension); edema 2/2 reduced RV output

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26
Q

Best initial test for COPD

A

CXR: increased AP diameter, flattened diaphragms

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27
Q

Most accurate test for COPD

A

PFTs

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28
Q

PFTs for COPD:

  • FEV1
  • FEV1/FVC
  • TLC
  • RV
  • DLCO
  • response to albuterol and methacholine
A
  • low FEV1
  • decreased FEV1/FVC < 0.75
  • high TLC
  • high RV
  • low DLCO (emphysema, not chronic bronchitis)
  • incomplete to albuterol (<12%) and not respond to methacholine
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29
Q

Young, non-smoker with COPD-like picture

A

Alpha-1 antitrypsin deficiency

Panlobular emphysema

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30
Q

Diagnosis and Treatment of A1 antitrypsin deficiency

A

Dx: genetic testing, low albumin/high PT (cirrhosis), low antitrypsin

Tx: antitrypsin infusion

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31
Q

COPD presentation:

CBC, Chem, EKG, Echo

A

CBC: high hematocrit from hypoxia
Chem: high bicarb
EKG: right atrial/ventricular hypertrophy; afib or MAT
Echo: RA/V hypertrophy, pulmonary hypertension

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32
Q

COPD tx that improves mortality

A 
Smoking cessation (most important)
O2 therapy (pO2<88%)
Influenza and pneumococcal vaccines
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33
Q

COPD tx that improves symptoms (but not mortality)

A

SABA (albuterol)
Anticholinergics (tiotropium, ipratropium) - most effective
LABA (salmeterol)
Pulmonary rehab

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34
Q

COPD tx if medical therapy fails

A

Refer for transplant

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35
Q

Complications of COPD

A

Acute exacerbations (often 2/2 infections, not using meds)
2nd polycythemia
Pulmonary HTN, cor pulmonale

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36
Q

What bacteria should you cover in a COPD exacerbation?

A

S. pneumo
H. influenza
M. catarrhalis

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37
Q

Tx of acute COPD exacerbation (Antibiotics)

A

Macrolides: azithromycin, clarithromycin
Cephalosporins: cefuroxime, cefixime, cefaclor, ceftibuten
Amoxicillin/clavulanic acid
Quinolones: levofloxacin, moxifloxacin, gemifloxacin

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38
Q

Criteria for O2 use in COPD

A

pO2< 88%
or pO2<90 if there are signs of RH disease or elevated Hct

Use as much O2 necessary to raise pO2 above 90% sat

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39
Q

Bronchiectasis: pathophysiology and common causes

A

Permanent chronic dilation of large bronchi
50% from cystic fibrosis. can also occur from infections (TB, PNA, abscess), panhypogammaglobulinemia/immune deficiency, foreign body/tumors, ABPA, collagen vascular disease

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40
Q

Recurrent high volume purulent sputum with possible hemotypsis, dyspnea and wheezing

A

Bronchiectasis

Can also present with weight loss, anemia of chronic dx, crackles, dyskinetic cilia syndrome

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41
Q

Best initial test for bronchiectasis

A

CXR: dilated, thickened bronchi with tram-tracks

42
Q

Most accurate test for bronchiectasis

A

high-res CT

43
Q

Treatment for bronchiectasis

A
  1. Chest physiotherapy and postural drainage
  2. Use same antibiotics for exacerbations of COPD
  3. Rotate antibiotics, 1 weekly each month
  4. Surgery may be indicated for focal lesions
44
Q

Asthmatic patient with recurrent episodes of brown-flecked sputum and transient infiltrates on CXR. Most likely diagnosis?

A

Allergic bronchopulmonary aspergillosis (ABPA)

45
Q

Diagnostic tests for ABPA

A 
Peripheral eosinophilia
Skin reactivity to aspergillus antigens
Precipitating antibodies to aspergillus on blood test
Elevated IgE levels
Pulmonary infiltrates on CXR or CT
46
Q

Treatment for ABPA

A 
Oral steroids (inhaled are not effective)
Itraconazole for recurrent episodes
47
Q

Cystic fibrosis: pathophysiology

A

Autosomal recessive mutation of CFTR (chloride transport) gene results in thick mucus

48
Q

Young adult with chronic lung disease (cough, sputum, hemotypsis, bronchiectasis, wheezing, dyspnea), recurrent infection, sinus pain and polyps.

A

Cystic fibrosis

49
Q

GI involvement of CF

A
  1. meconium ileus (infants)
  2. pancreatic insufficiency (steatorrhea/ADEK vitamin deficiency)
  3. recurrent pancreatitis
  4. distal intestinal obstruction
  5. biliary cirrhosis

Islets are spared. Beta cell function is normal until much later in life.

50
Q

GU involvement of CF

A
  1. men: azoospermia with missing vas deferens

2. women: altered menstrual cycle from chronic lung disease, thick cervical mucus blocks sperm entry

51
Q

Most accurate diagnostic test for CF

A

Sweat chloride test
Genotyping is not as accurate (many different mutations)

Additional tests to confirm include CXR/CT, ABG, PFTs

52
Q

Treatment for CF

A
  1. Antibiotics
  2. Inhaled recombinant human deoxyribonuclease (rhDNase)
  3. Inhaled bronchodilators (albuterol)
  4. Pneumococcal/influenza vaccines
  5. Lung transplant for advanced disease
53
Q

Most common cause of CAP

A

S. pneumo

54
Q

Most likely PNA pathogen: COPD

A

Haemophilus influenzae

55
Q

Most likely PNA pathogen: Recent viral infection (influenza)

A

Staphylococcus aureus

56
Q

Most likely PNA pathogen: Alcoholism, diabetes

A

Klebsiella pneumoniae

57
Q

Most likely PNA pathogen: Poor dentition, aspiration

A

Anaerobes

58
Q

Most likely PNA pathogen: Young, healthy patients

A

Mycoplasma pneumoniae

59
Q

Most likely PNA pathogen: Hoarseness

A

Chlamydophila pneumoniae

60
Q

Most likely PNA pathogen: Contaminated water sources, air conditioning, ventilation systems

A

Legionella

61
Q

Most likely PNA pathogen: Birds

A

Chlamydia psittaci

62
Q

Most likely PNA pathogen: Animals at time of giving birth, vets, farmers

A

Coxiella burnetii

63
Q

Characteristic of PNA chest pain

A

Pleuritic, changing with respiration

64
Q

Pneumonia vs Bronchitis

A

Dyspnea, high fever, abnormal CXR

65
Q

Most likely PNA pathogen: Hemoptysis from necrotizing disease, “currant jelly” sputum

A

Klebsiella

66
Q

Most likely PNA pathogen: Foul-smelling sputum, “rotten eggs”

A

Anaerobes

67
Q

Most likely PNA pathogen: Dry cough, rarely severe, bullous myringitis

A

Mycoplasma pneumonia

68
Q

Most likely PNA pathogen: GI symptoms or CNS symptoms (hx, confusion)

A

Legionella

69
Q

Most likely PNA pathogen: AIDS<200 CD4

A

Pneumocystis

70
Q

Infections with dry/non-productive cough

A 
Viruses
Mycoplasma
Coxiella
Pneumocystis
Chlamydia
71
Q

Best initial test for respiratory infections

A

CXR

72
Q

What defines an “adequate” sputum gram stain?

A

> 25 WBC, < 10 epithelial cells

73
Q

Empyema: LDH, protein, WBC and pH levels

A

LDH>60% serum
Protein>50% serum
WBC>1000/ul
pH<7.2

74
Q

PNA diagnostic test for: Mycoplasma

A

PCR, cold agglutins, serology, special culture media

75
Q

PNA diagnostic test for: Chlamydia pneumoniae

A

Serologic titer

76
Q

PNA diagnostic test for: Legionella

A

Urine antigen, culture on charcoal-yeast

77
Q

PNA diagnostic test for: Coxiella burnetii

A

Serologic titer

78
Q

PNA diagnostic test for: PCP

A

Bronchoalveolar lavage (BAL)

79
Q

Outpatient treatment for PNA

A

Healthy or no antibiotics in past 3 months:
Macrolide (Azithromycin or clarithromycin) or
Doxycycline

Otherwise: respiratory fluoroquinolones (levofloxacin or moxifloxacin)

80
Q

Inpatient treatment for PNA

A

Fluoroquinolone (Levo or moxifloxacin)

Ceftriaxone and azithromycin

81
Q

When to hospitalize for PNA

A
  1. Hypotension (30 or pO230, Na250
  2. HR>125
  3. Confusion
  4. T>104
  5. Age 65+, comorbidities

“CURB65” - Confusion, Uremia, Resp distress, BP low, age 65+ (>2=admission)
CXR does not guide admission - cannot tell severity of hypoxia.

82
Q

Most appropriate management of infected pleural effusion/empyema

A

Drainage by chest tube or thoracostomy

83
Q

Who should receive pneumococcal vaccination?

A
  1. All 65+
  2. Chronic heart, liver, kidney, lung disease
  3. Functional/anatomic asplenia
  4. Hematologic malignancy (leukemia, lymphoma)
  5. Immunosuppression (DM, EtOH, steroid use, AIDs/HIV+)
  6. CSF leak/cochlear implantation

Health workers do NOT need the vaccine

84
Q

What is HAP and how is treatment different than CAP?

A

PNA > 48h of admission or after hospitalization in the last 90 days.

Macrolides are not empiric (more gram negatives: ecoli, pseudomonas). Need gram-negative therapy.

85
Q

Antibiotics for HAP

A

Antipseudomonal cephalosporins: cefepime, ceftazidime
Antipseudomonal penicillin: piperacillin/tazobactam (Zosyn)
Carbapenems: imipenem, meropenem, doripenem.

86
Q

Fever, new infiltrate on CXR and purulent secretions from endotracheal tube

A

Ventilator-associated PNA

87
Q

Diagnostic test for VAP

A

Sputum culture is worthless because of contamination!

Tracheal aspirate, BAL, protected brush specimen, VAT, open lung biopsy

88
Q

Treatment for VAP

A

Combine 3 antibiotics:

  1. Antipseudomonal beta-lactam
  2. 2nd antipseudomonal agent (aminoglycoside or fluoroquiolone)
  3. MRSA (Vancomycin or linezolid)
89
Q

Which antibiotic can cause seizures in renal failure?

A

Imipenem

90
Q

Who are at risk for large volume aspiration?

A
  1. Stroke with loss of gag reflex
  2. Seizures
  3. Intoxication
  4. Endotracheal intubation
91
Q

Patient with risk factor for aspiration and foul-smelling sputum

A

Lung abscess

92
Q

Best initial test for lung abscess

A

CXR: cavity with air fluid level

Culture is the wrong answer

93
Q

Initial treatment for lung abscess

A

Clindamycin or penicillin

94
Q

AIDS patient (CD4<200 or not on prophylaxis) with dyspnea on exertion, dry cough and fever

A

PCP

95
Q

Best initial test for PCP

A

CXR: bilateral interstitial infiltrates
ABG with increased A-a gradient
High LDH level (Do not answer PCP if LDH is normal)

96
Q

Most accurate test for PCP

A

Bronchoalveolar lavage

97
Q

Treatment for PCP

A

Bactrim
Add steroid if severe (pO235)

Atovoquone can be used as alternative if PCP is mild

98
Q

Treatment for PCP but cannot tolerate bactrim

A

Clindamycin and primaquine or

Pentamidine

99
Q

AA patient developed rash/neutropenia/bite cells after on bactrim for PCP. Next step in therapy.

A

IV Pentamidine

Clindamycine and Primaquine is another second line for PCP, but primaquine is contraindicated in G6PD

100
Q

PCP Prophylaxis

A

CD count < 200
Bactrim
if contraindicated - atovaquone or dapsone (not for G6PD)

Internal Medicine (1 decks)

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