Pulmonology Flashcards

Question

SABAs

Answer 1

Short acting beta-2 agonists * albuterol * levalbuterol * metaproterenol * Terbutaline

Answer 2

SABA: MDI and neb * _dosing_: 2puffs Q4-6hours (90mcg/puff) * stimulates beta-2 receptors = bronchial muscle relaxation * _SEs_: **_HypoK_** especially during continuous neb * beta-2 stimulation causes cellular uptake of K+ = decreased srum K+ * also **tachycardia** (because not very selective and will stimulate beta-1 receptors)

Answer 3

SABA: MDI and neb * steroisomer of albuterol, but higher affinity for beta-2 so less sysstemic sympathetic effects = b/c less binding to beta-1 * _SEs_: **_HypoK_**

Answer 4

SABA: PO * _SEs_: palpitations * tachycardia * **hypoK** * tremor * HA, nausea, nervousness

Answer 5

SABA: PO or pareneteral (SQ injection) * often used for acute attack (**0.25mg SubQ**) * _SEs:_ * SABA * tocolytic * **not approved for children \<6yo**

Answer 6

long acting beta-2 agonists * salmeterol DPI (Serevent Diskus) * Formoterol DPI (Foradil) * Arformoterol (Brovana) * not for kids * Indacaterol (Arcapta) * not for kids * Olodaterol (striverdi Respimat) * (**Some Fish Are Inherently Odorous)**

Answer 7

LABA **do not use as monotherapy** * partial agonist

Answer 8

LABA * helpful for nighttime sxs * full agonist * onset = to that of albutero but DO NOT USE FOR ACUTE BRONCHOSPASM * _SEs:_ **paradoxical bronchospasm**

Answer 9

LABA: neb * used for **COPD only!!** * 2x more potent than formoterol * _SEs:_ * __**paradoxical bronchospasm** * palpitation/tachy/tremor * lightheadedness/nervousness/HA/nausea * **NOT APPROVED FOR CHILDREN**

Answer 10

LABA: DPI * for COPD * _SEs_: * **paradoxical bronchospasms** * palpitations/tachy/tremor * nervousness/lightheadedness/HA/nausea * **NOT APPROVED IN CHILDREN**

Answer 11

LABA: inhaler * **Long half life!!** t_1/2 = 45hours * *2C9 substrate =* increased side SEs * plus Same SEs as other LABAs

Answer 12

MOA: inhibit inflammatory cells (mast cell, eosinophils, neutrophils) and cytokines (histamine, leukotriens) **\*\*Flat dose response curve = double the dose adds limited additional effect \*\*** **BID Dosing is better (need more in smokers)** * Beclomethasone HFA (QVAR) * Budesonide DPI (Pulmicort) * Ciclesonide (Alvesco) * Fluticasone HFA (Flovent) * Fluticasone DPI (Flovent Diskus) * Flunisolide (Aerobid) * Mometasone DPI (Asmanex) * _SEs_: * oral candidiasis * cough * Dysphonia * Adrenal Suppression (at high dose)

Answer 13

monoclono- **anti-IgE antibody** * stops release of inflammatory mediatorys * used for moderate to severe asthma * **significantly reduces ICS use** * SQ injection * _SEs:_ * injection site rxn, bruising, redness, pain, stinging, itching etc * anaphylaxis (rare) * monitor 2 hours after injection for 3 months then 30 min thereafter

Answer 14

* Fluticasone/Salmeterol (Advair) DPI * Fluticasone/Vilanterol (Breo Ellipta) * +3A4 inhibitors (both advair and breo) = increased LABAs = **QT prolongation** * Budesonide/Formoterol HFA (Symbicort) * Mometasone/Formoterol (Dulera) * _SEs_: Thrush * dysphonia * pharyngitis * HA * nausea * tremor

Answer 15

for COPD * Gold 1: FEV₁ \>80% * mild * Gold 2: FEV₁ 50-79% * moderate * Gold 3: FEV₁ 30-49% * severe * Gold 4: FEV₁ \<30% * very severe

Answer 16

* First Line: * SABA prn or SAMA prn (bronchodilators) * Second Line: * LAMA or LABA or SABA + SAMA

Answer 17

* First line: * LAMA or LABA (long acting bronchodilators) * Second Line: * LAMA + LABA

Answer 18

* First line: * ICS + LABA or **LAMA** * Second Line: * LAMA + LABA * LAMA + PDE4i * LABA + PDE4i

Answer 19

* First Line: * ICS + LABA and/or LAMA * Second Line: * ICS + LABA and LAMA * ICS + LABA and PDE4i * LAMA + LABA * LAMA + PDE4i

Answer 20

inhibit breakdown of cAMP = reduction of inflammation **Roflumilast (Dalirespt)** * for prevention of COPD * _SEs_: * diarrhea, decreased appetite, weight loss, abdominal pain * headache, insomnia * anxiety and depression * DDI: CYP 1A2 and 3A4 * inducers: butalbital, phenytoin, rifampin, carbamazepine (avoid use) * inhibitors: amiodarone, clarithromycin, cimetidine, ketoconazole (use with caution)

Answer 21

* Mild: * strep pneumo, H.flu, Moraxella * Severe: * E.coli, Klebsiella, enterobacter, pseudomonas

Answer 22

1. 4 or more courses of abx over the past year 2. recent hospitalization (2+ days in past 90) 3. isolation of pseudomonas during a previous hospital visit 4. severe underlying COPD 1. FEV₁\<50

Answer 23

monoclondal antibody that **targets** **IL-5** * IL-5 stimulates matural and release of eosinophils in bone more = inflammation * Indication: maintenance tx of severe asthma **age \>/=12 yo** * _SEs_: * anaphylaxis, angioedema, bronchospasm, hypotension, urticaria, rash * herpes zoster has occurred: IZ if appropriate prior to starting therapy

Answer 24

monoclonal antibody **against IL-5** * _indications_: add on maintenance tx with severe asthma for **\>/= 18 yo** and an eosinophilic phenotype * IV infusion only * _SEs_: * **anaphylaxis, malignancy** * CPK electation = adverse muscle related rxns * oropharyngeal pain

Answer 25

**theophylline** inhibit phosphodiesterase = bronchodilation * less effective than ICS * narrow therapeutic index 5-15mcg/mL * metabolized by CYP 1A2 and 3A4 * DDI: inducers: carbamazeine, phenytin, rifampin, ST. John Wort * inhibitors: clarithromycin, telithromycin, ketoconazole, itraconazole, voriconazoe, grape fruit juice * _SEs_:cardiac arrhythmias, seizures

Answer 26

long acting muscarinic antagonists * Tiotroprium * alcidinium * glycopyrrolate * Umeclidinium

Answer 27

* Albuterol/Ipratroprium (Combivent Respimat) * Duoneb * _SEs_: paradoxical bronchospasm * palpitations/tremor/tachy * **CONTRAINDICATION: soy or peanut allergy** * NOT for Children

Answer 28

only for asthma (LTRA) * montelukast (Singulair) * Zileuton (Zyflo) * SEs: **hepatotoxicity** * DDIs: * **inducers**: rifampin, carbamazepine, St. John's wort * **inhibitors**: fluconazole, amiodarone, fluvoxamine, metronidazole, voriconazole

Answer 29

immunomodulator (**anti-IgE antibody**) * inhibits biding of IgE onto mast cells and basophils = stops release of inflammatory mediators mainly used in COPD, but also for moderate-severe asthma * SQ injects Q2-4 weeks **in clinic**, must be observed 2 hours after injection x 3months, then 30 min thereafter. * significantly reduces use of ICS

Answer 30

Mild, no abx needed cardinal sxs: increased dyspnea, sputum volume, or purulence

Answer 31

macrolide 2nd and 3rd gen ceph doxy Septra (TMP/Sulfamethoxazole)

Answer 32

respiratory FQs (moxi/levo/gemi) Amoxicillin/Clavulanate (Augmentin)

Answer 33

FQ (levo PO or IV) Cephalosporins (Cefepime IV or Ceftazidime IV) Zosyn IV (piperacillin + tazobactam)

Answer 34

FQ (levo or Moxi) Cephalosporins (ceftriaxone or cefotaxime)

Answer 35

FEV₁\<50% age \>65 \>/= 3 exacerbations/year cardiac disease

Answer 36

ssRNA Hemagglutinin spikes→ allow virus to bind to host(targeted by IZs) , neuraminidase→ allow virus to bud (targeted by meds) * S/sxs: **sudden onset** high fever, chills, malaise, sore throat, headache, and coryza, **myalgias** (especially legs and lumbosacral), non-productive cough * **_classic triad: FEVER, DRY COUGH, MYALGIAS_** * PE: ill appearance, mild pharyngeal edema, cervical adenopathy +/-, serous nasal drainage * Dx: **rapid antigen test**, serology = more accurate, WBC does not correlate well with severity → often normal or low (if \>15K → suggests secondary bacterial) * Tx: mild disease & healthy? → supportive tx (acetaminophen, fluids, and rest) * hospitalized or at-risk? → neuraminidase inhibitors (Oseltamivir or Zanamivir (Dr. Oz txs the flu)) → need to be initiated within 48 hours of onset * empiric antiviral tx: children \<2, pregnant, 65+, women up to 2 weeks post-partum, chronic or immunosuppressed

Answer 37

aka Whooping Cough → causative agent **bordetella pertussis** → gram -, coccobacillus common in children \<2 yrs, respiratory droplet transmission * S/sxs: consider in adults with cough \> 2weeks * _catarrhal stage_: cold like sxs, poor feeding and sleeping * _paroxysmal stage_: high-pitched **inspiratory whoop** *between coughing fits* → post-tussive emesis is highly indicative of this infx * _convalescent stage_: residual cough (up to 100 days) * Dx: nasopharyngeal swab for cx and PCR * Tx: supportive care +/- steroids/SBAS * **Macrolides** (clarithromycin, azithromycin) * DTaP, TDap Izs * Complications: **PNA**, encephalopathy, otitis media, sinusitis, seizures

Answer 38

Causative Agents: **S. Pneumo (rusty color sputum**, common in after splenectomy), **S. aureus (salmon colored sputum**, lobar, after influenza), Hflu, **Klebsiella (alcohol abuse; currant jelly sputu**m, aspiration); atypicals → **mycoplasma (young ppl living in dorms**, (+) cold agglutination), **chlamydia (college kids**, sore throat), **legionella (air conditioning**, low Na⁺, GI sxs and high fever) * S/sxs: tachycardia, tachypnea, **fever**, pleuritic chest pain, dyspnea +/- rigors (associated with strep pneumo) * PE: CXR: **infiltrate/consolidation** * Typical: percussion → dull, increased tactile fremitus, egophony and crackles * atypical: pulmonary exam is often normal (may have crackles) * Dx: CXR, **blood cxs x 2** , sputum gram stain * Tx: outpt → **doxycycline, macrolides (500mg 1st day, then 250mg for days 2-5)** * CURB-65: Confusion, uremia (BUN \>19), RR \>30, BP \<90/\<60, age 65+ * inpatient tx: * **ceftriaxone + azithromycin, respiratory fluoroquinolones** (Moxi, levo)

Answer 39

\*\*\*most common cause of lower respiratory tract infx in children world wide\*\*\* leading cause of pna and bronchiolitis * S/sxs: rhinorrhea, **wheezing/coughing**, persists for months, low grade fever, nasal flaring/ retractions, often prodomal sxs for 1-2 days before **respiratory distress** * PE: visible retractions * Dx: nasal washing, **RSV antigen test** * CXR can show diffuse infiltrates * Tx: oxygen \<95-96% → hospitalize, same with tachypnea, difficulty feeding * supportive tx * should resolve in 5-7 days * albuterol via neb, humidified O₂

Answer 40

1-2% of lung cancers → carcinoid syndrome tumors that arise from **neuroendocrine cells** → lead to excess secretion of _serotonin_, bradykinin, and histamine * \*\*\*often start at appendix, mesastasize to liver then travel via blood stream to the **lungs**\*\*\* * S/sxs: flushing, diarrhea, wheezing, and low blood pressure * vasodilation and flushing = increased histamine and bradykinin * PE: heart valve dysfunction → tricuspid regurge due to _increased serotonin_ that causes **collagen fiber thickening, fibrosis** * Dx: **CT-scan**, **_octreoscan_** (radiolabeled somatostatin analog binds to receptors on tumor cells) * urinalysis: shows increased **5-hydroxyindoleacetic acid (5-HIAA)** = main metabolite of serotonin * **pellagra** (vitamin B3 deficiency/ niacin) * Tx: **surgical excision** * octreotide: somatostatin analog binds to somatostatin receptors and **decreases the serotonin being secreted** by the tumor * niacin supplement

Answer 41

non-small cell lung cancer **characterized by _keratin_ production** * S/sxs: cough, weight loss, night sweats, hemoptysis (superficial squamous cells burst in lungs), chestpain/back pain, SOB * **located in bronchial tubes (where it starts**) * paraneoplastic syndrome → **hypercalcemia** of malignancy = think stones, bones, and psychiatric overtones * → mediated by **PTHrP** (parathyroid hormone related peptide) * Tx: stage I and II: surgery * Stage IIIa: surgery +chemo * Advanced disease (IIIB and IV): * treat the driver mutation * if PDL1 is expressed by tumor → **pembrolizumab** (PDL1 inhibitor) * if PDL1 expression \<50% → **tradition chemo + PDL1 inhibitor** * _Pancoast Tumor_: should pain, horner's syndrome, brachial plexus compression * _Horner's Syndrome_: unilateral miosis, ptosis, and anhydrosis

Answer 42

non-small cell cancer most common type of lung cancer, and _most common type of lung cancer to occur in never smokers_ * **begins in periphery of lungs** * also associated with smoking and asbestos exposure * paraneoplastic syndrome: _thrombophlebitis_ * tx:

Answer 43

non-small cell cancer most common type of lung cancer, and _most common type of lung cancer to occur in never smokers_ * **begins in periphery of lungs** * PATHOLOGY: * neoplastic gland formation * also associated with smoking and asbestos exposure * paraneoplastic syndrome: _thrombophlebitis_ * tx:Tx: stage I and II: surgery * Stage IIIa: surgery +chemo * Advanced disease (IIIB and IV): * treat the driver mutation * if PDL1 is expressed by tumor → **pembrolizumab** (PDL1 inhibitor) * if PDL1 expression \<50% → **tradition chemo + PDL1 inhibitor**

Answer 44

non-small cell carcinoma very fast doubling time but causes sxs late * rare: only 5% * usually begins on the outer edges of the lungs * _paraneoplastic syndrome_: **gynecomastia** * Tx: stage I and II: surgery * Stage IIIa: surgery +chemo * Advanced disease (IIIB and IV): * treat the driver mutation * if PDL1 is expressed by tumor → **pembrolizumab** (PDL1 inhibitor) * if PDL1 expression \<50% → **tradition chemo + PDL1 inhibitor**

Answer 45

“All of the Ss" * grow very quickly → 54-132 day doubling rate * (if faster growth than this = decreased risk of malignancy) * **aggressive and metastic** * All the Ss: * Smoking, Sentrally located, Super Aggressive, SVC syndrome, Sitting to Standing (Lambert-Eaton Myasthenic Syndrome), Sodium/SIADH→ leads to low sodium through SIADH * **TX: surgical excision is NOT an option** * _limited stage disease_ → chemo and radiation * _extensive stage disease_ → chemo + immunotherapy * _Superior Vena Cava Syndrome_: cancer pushes on superior vena cava and traps blood in upper body * _Lambert-Eaton Myasthenic Syndrome_: similar to myasthenia gravis → *proximal muscle weakness* * _Syndrome of Inappropriate Secretion of ADH_ (SIADH): * euvolemic hyponatremia → retaining too much water * _Cushing Syndrome_: too much cortisol * central obesity, purple striae, hyperglycemia * * _Carcinoid syndrome_: flushing, diarrhea, telangiectasia

Answer 46

pts 50-80 yo; with \>50 year pack hx of smoking, with either current smoking or having quit \<15 years ago

Answer 47

nodule \<3cm (coin lesion), mass \>3cm * smooth, well defined edges → most likely benign * **ill-defined, lobular, spiculated edges** → most likely cancer * when found as incidental finding: * _Fleischner society pulmonary nodule recommendation_ * when found as part of cancer screening: * **Lung-RADS**

Answer 48

excess fluid in the pleural space * S/sxs: dyspnea, discomfort or sharp pain that worsens with inspiration * PE: _dullness to percussion_ * **decreased** tactile fremitus, **decreased** breath sounds * may have a pleural friction rub * CXR: **blunting of costophrenic angles** + _meniscus sign_ * lateral decubitus film (pt lying on their side) = best to detect smaller effusions * differentiates b/w loculations and empyema from new effusions and scarring * Tx: * **_thoracocentesis_ is both diagnostic and therapeutic** * if _empyema_ (pleural fluid pH \<7.2, glucose \<40mg/dL, or positive gram stain of pleural fluid) → can inject **streptokinase** to break up loculations * chronic effisions or recurrent and causing sxs: * **pleurodesis** (pleural space is artificially obliterated) or by intermittent drainage with an indwelling catheter

Answer 49

**the compartmentalization of a fluid-filled cavity into smaller spaces** (locules) by fibrous septa

Answer 50

collapse lung caused by an accumulation of air in the pleural space * **Primary**: occurs in absence of underlying disease (tall, thin males age 10-30) * **secondary**: in presence of underlying disease (COPD, asthma, CF, interstitial lung disease) * **Tension Pneumothorax**: penetrating injury → air into pleural space increased and unable to escape * S/sxs: **acute onset** ipsilateral chest pain and **dyspnea** * non-exertional, sudden * PE: decreased tactile fremitus, deviated trachea, hyperresonance, diminished breath sounds * _tension pneumo_: **mediastinal shift** to the contralateral side and impaired ventilation, **increased JVP, systemic hypotension** * Dx: * CXR: pleural air * ABG: shows hypoxemia * Tx: depends on size * \<15% (small)= will resolve **spontaneously** * **can also do high flow 100% oxygen** * \>15% (large) and symptomatic = **chest tube placement** * need to do **serial CXR every 24 hours** until resolved * _tension pneumo_: * MEDICAL EMERGENCY!!! large bore needle to allow air of the chest + chest tube for decompression * Pt Education: * avoid pressure changes 2+ weeks

Answer 51

Right Ventricular enlargement → eventually leads to R heart failure secondary to a lung disorder that causes pulmonary HTN * Etiology: * COPD (most common), pulmonary embolism, vasculitis, asthma, ARDS * S/sxs: * worsening dyspnea, purulent sputum production, inspiratory crackles, ventricular gallop * PE: lower extremity edema, JVD distention, hepatomegaly, parasternal lift * tricuspid/pulmonic insufficiency **loud S2** * EKG: **S1Q3T3** * \*\*\*\*occurs after pulmonary HTN\*\*\*\*\* * Dx: tx the underlying condition b4 the cardiac structure change becomes irreversible * **diuretics are not helpful and MAY BE HARMFUL!**

Answer 52

obstruction of pulmonary blood flow due to a blood clot (usually thrombosed from a DVT) * Risk Factors: **Virchow's Triad:** 1. Damage (trauma, infx, inflammation) 2. Stasis: immobilization, surgery, prolonged sitting \> 4 hours 3. hypercoagulability: protein C or S deficiency, factor V leiden mutation, Oral contraceptive pills, malignancy, pregnancy, smoking * S/sxs: Classic Triad: * **dyspnea, pleuritic chest pain,** hemoptysis (classic but rare), cough * PE: Tachypnea (most common sign), tachycardia, low-grade fever, lung exam = normal * if large PE = syncope, hypotension, pulseless electrical activity * Dx: **helical (spiral) CT angiography** * _pulmonary angiography_ = GOLD STANDARD (may order if high suspicion and negative CT or VQ scan) * D-Dimer or ABG = respiratory alkalosis secondary to hyperventilation * _Westermark sign_: avascular markings distal to PE * _Hampton hump_: wedge-shaped infiltrate due to infarction * **atelectasis** = most common abnormal finding * Tx: **Heparin** and **oral direct thrombin inhibitors** (_dabigatran_)

Answer 53

blood pressure in lungs is usually **very low** (15/5) pulmonary HTN → \>25mmHg usually caused by underlying disorder: constrictive pericarditis, mitral stenosis, L ventricular failure * Risk Factors: middle-aged or young women (mean age = 50), **BPMR2 gene defect** → usually inhibits pulmonary vessel smooth muscle growth and vasoconstriction * S/sxs: * dyspnea on exertion, fatigue, chest pain, edema * PE: **loud pulmonic component of S2 due to prominent P2,** may have a fixed or paradoxically split P2 * signs of R heart failure: * JVD, ascites, hepatojugular reflux * lower limb edema * pulmonary regurg, R ventricular heave, systolic ejection click * Dx: **R heart catheterization** = _GOLD STANDARD_ * CXR: enlarged pulmonary arteries, lung fields may not be clear, depends on underlying cause * **Echocardiogram**: increased pressure in pulmonary arteries, Right ventricles→ dilated pulmonary artery, dilation/hypertrophy of R atrium/ventricle * **ECG**: right heart strain pattern: T-wave inversion in R precordial leads (V1-4), and inferior leads (II, III, aVF) **cor pulmonale** * Tx: * identify and tx underlying cause * heart-lung transplant = definitive

Answer 54

scarring of the lungs due to unknown cause \*\*\*most common in men \>40, smokers\*\*\* * S/sxs: Worsening dyspnea, non-productive (dry) cough * PE: fine, dry, bibasilar inspiratory crackles * clubbing of fingers * Dx: * CXR: **basal predominant reticular opacities _(honeycombing)_** * Chest CT: Preferred imaging\*\*\*\* **reticular honeycombing, focal ground-glass opacifications**, bronchiectasis * PFTs: **demonstrate a restrictive pattern** (opposite of asthma) * → decreased lung volume with a normal or increased FEV₁/FVC * Tx: lung transplant → only cure

Answer 55

lung disease caused by asbestos Occupation: insulation, demolition, construction, shipworker * S/sxs: dyspnea **on exertion**, cough * PE: bibasilar crackles * **restrictive lung pattern**: normal or increased FEV₁/FVC, normal or decreased FVC, decreased lung volume (shifted to the R on loop) * Dx: * CXR: * reticular **linear pattern** with **basilar predominance, opacities**, and **honey combing** * “**shaggy heart sign**” ground glass obscures the heart * Biopsy: may show **linear asbestos bodies** * Tx: no therapy → bronchodilators, O₂, corticosteroids, +/- lung transplant * \*\*\*can progress to bronchogenic carcinoma or mesothelioma\*\*\*

Answer 56

aka black lung disease occurs when coal dust is inhaled and leads to scarring in the lungs * S/sxs: dyspnea, cough, fine crackles * **caplan syndrome**: coal worker pneumoconiosis + RA (serologically positive) * PE: bibasilar crackles * **restrictive lung pattern**: normal or increased FEV₁/FVC, normal or decreased FVC, decreased lung volumes * Dx: * CXR: **small nodules** especially in the **upper lung fields** with hyperinflation of the lower lobes in an obstructive pattern (looks like emphysema) * _Lung Biopsy_: show dark “black” lungs (not needed for diagnosis) * Tx: supportive care

Answer 57

inhalation of silicone dioxide Risk factors: quarry work with **granite, slate, quartz**, pottery, sandblasting, glass, etc * s/sxs: * acute: dyspnea, cough, weight loss, fatigue * chronic: often asymptomatic, dyspnea on exertion, non-productive cough, crackles * Dx: many small (\<10mm) round nodular opacities (**miliary papttern**) mostly in the upper lobes * **_eggshell calcification_** of hilar and mediastinal nodes * bilateral nodular densities that progress * Tx: removal from exposure= MAINSTAY * nonspecific management: corticosteroids, O₂, rehab

Answer 58

granulomatous pulmonary disease caused by exposure to beryllium used for aerospace material→ high risk: ceramics, tool and dye manufacturing, jewelry making, fluorescent light bulbs * S/sxs: dyspnea, cough, joint pain, fever weight loss * Dx: * CXR: hilar lymphadenopathy, and increased interstitial lung markings (looks like sarcoidosis) → diffuse infiltrates * tx: chronic corticosteroid use * oxygen * methotrexate if corticosteroids do not work * **associated with risk of lung, stomach, and colon cancer**

Answer 59

unknown cause, chronic multisystem inflammatory **granulomatous disease** (exaggerated T-cell response to antigens or self-antigens that leads to central immune system activation, granuloma formation, and peripheral immune depression) Risk factors: female, African American, N. Europeans, age 20-40 * S/Sxs: dry cough, dyspnea, chest pain, and crackles * affects lymph nodes as well * may have abnormal masses or nodules (granulomas) * PE: * **erythema nodosum (**classic), **lupus pernio**, maculopapular rash, anterior uveitis, restrictive cardiomyopathy, arrhythmias, heart block * Dx: serum blood tests show: **hypercalcemia** and **ACE levels x4 normal** * ESR = elevated * CXR: Bilateral hilar lymphadenopathy * _Diagnosis_: biopsy of peripheral lesion or fiber-optic bronchoscopy for central pulmonary lesion * PFTS: **restrictive pattern** * Tx: * Symptomatic pts: CORTICOSTEROIDS (1mg/kg **prednisone)** **methotrexate** and other immunosuppressive meds * **ACE inhibitors** for periodic HTN * → leading cause of death = pulmonary fibrosis

Answer 60

intermittent obstructive airflow → results in periods of apnea at night Risk factors: OBESITY!!! structural abnormalities of the upper airway, family hx, alcohol/sedatives/opiates, hypothyroidism * S/sxs: * SNORING and **daytime sleepiness**! caused by disrupted nocturnal sleep * personality changes: poor mood and mental dysfunction * **morning headaches**, polycythemia * can lead to systemic and pulmonary HTN and **Afib** * Diagnosis: * **Polysomnography = GOLD STANDARD** * can also do home sleep apnea testing but rarely covered by insurance * _Obesity-Hypoventilation Syndrome_: -obesity (\>30BMI), -awake alveolar hypoventilation PaCO₂\>45mmHg, -alternative causes of hypercapnia and hypoventilation ruled out * Tx: * WEIGHT LOSS, exercise, avoiding alcohol/sedatives, and not sleeping supine * **oral appliances** → mild to moderate * → **BiPAP** or **CPAP** * **Uvulopalatopharyngoplasty (UPPP) →** remove extra tissue from oropharynx * **tracheostomy**

Answer 61

type of **respiratory failure** that is **fluid collection in the lungs** and prevents exhange of O₂ * usually occurs in **critically ill** or someone with **significant injuries** * S/sxs; **rapid onset** of _sever dyspnea_ occurring 12-24 hours after a precipitating event * PE: tachycardia, **pink, frothy sputum**, diffuse crackles * Dx: sxs develop within 1 week, bilateral diffuse infiltrates on CXR (not explained by congestive heart failure) * CXR: shows **air bronchograms & bilateral fluffy infiltrate** * tx: * identify and tx underlying cause * tracheal intubation

Answer 62

ssRNA hemagluttinin and neuraminidase tx: neuraminidase inhibitors vaccines: target hemagluttinin Type A = most common Type B= humans only Type C = nonsymptomatic, little medical concern SHIFT vs DRIFT

Answer 63

* Histoplasma * S**ystemic fungi and mold → yeast at 37C** * inhalation from bats/ birds: CAVES and TREE REMOVAL * acute pneumonia sometimes developes * infect Macrophages * bone marrow disruption * apical pulmonary lesions resembling cavitary TB * tx: **itraconazole**

Answer 64

* **yeast** that can end up in the brain but is inhaled! * \*\***Defining opportunistic infection in aids patients**\*\* * skin lesions that look similar to acne, molloscum contagiosum, or basal cell carcinoma * CNS: low grade fever, ocular or facial palseys, headache * Lungs: pneumonia, AIDS (severe dyspnea) tx: **Fluconazole for non CNS, CNS: amphotericin B**

Answer 65

* yeast: pneumocystis jirovecii * \*\*only issue for immunocompromised people\*\* * aerosolized: fever, dyspnea and DRY cough tx: **Bactrim (sulfamethoxazole/trimethoprim )** high risk for HIV pts with CD4 counts \<200/mcL

Answer 66

* gram + diplococci, ENCAPSULATED * causes pneumonia: * rusty mucus * productive cough * fever * malaise * sudden onset chills and rigors (violent shaking) * causes: bacteremia and meningitis * tx: **Ceftriaxone**

Answer 67

most common cause in adults: **Influenza;** most common cause in children **RSV, Parainfluenza virus** * S/sxs: **persistent** sxs of sore throat, HA, myalgias, malaise for **more than 3-5 days** then **_new respiratory sxs_** _-→_ dyspnea, cyanosis * Dx: CXR: **bilateral lung involvement with interstitial infiltrate** * Rapid antigen test for influenza * _RSV_ nasal swab * _cold agglutinin titer_ to r/o Mycoplasma (should be negative with this) * Tx: flu → oseltamivir, zanamivir * RSV → **Ribavirin**

Answer 68

**reversible** chronic, inflammatory airway disease → recurrent attacks of breathlessness and wheezing that affects the trachea to the terminal bronchioles * caused by **mast cell mediators** * diminished FEV₁ that is improved with inhaler * s/sxs: dyspnea, wheezing, cough, chest tightness (NOT PAIN) * worse at night * increased mucus production * PE: wheezing, prolonged expiratory phase * Diagnosis: * **GOLD STANDARD**: FEV₁/FVC \< 75-80% in adults, below 85% in children * \>12% increase in FEV₁ after bronchodilator * exhaled nitric oxide = can be used to measure eosinophilic airway inflammation * if pt \<5 yo = RAD, not asthma * GINA guidelines

Answer 69

**_Autosomal Recessive Disorder_** mutation in the CFTR gene → abnormal production of mucus by most exocrine glands → pulm infx most common cause of death (staph and HIB acute, chronic = pseudomonas) * lungs normal at birth then begin to develop pulmonary disease often during infancy or childhood * _infancy_: **meconium ileus**, failure to thrive (FTT), diarrhea from malabsorption (can lead to rectal prolapse) * _pulmonary:_: CF = **most common cause of bronchiectasis in the US** (dilation and destruction of the bronchi due to chronic infx and inflammation * PE: rhonchi and crackles * CXR may show hyperinflation, mucus pluggung and focal atelectasis * Dx: elevated sweat chloride test on **two different days** * use pilocarpine → NaCL \>60mEq/L * Tx: **CFTR genotyping** to see if they are approved for CFTR modulator therapy * hypertonic saline and chest physiotherapy → clears the secretions from the airways * tx infections * replacement of pancreatic enzymes: **supplement fat-soluble enzymes (A, D, E, K)**

Answer 70

usually lodges in the larynx or trachea can lead to chronic, recurrent infx if left for a while→ PNA, ARDS, asphyxia * Risk factors: \>85 yo, \<2 yo, poor dentition, alcohol use, sedative use, institutionalization * S/sxs: Inspiratory stridor * Dx: CXR first * tx: rigid bronchoscopy = preferred for children * soft or rigid bronchoscopy for adults * surgical removal * Cxs if PNA is suspected

Answer 71

aka Hyaline membrane disease * affects **preterm infants** when they have not produced enough **surfactant** → poor lung compliance and atelectasis * \*\*\*most common cause of respiratory distress in pre-term infants\*\*\* * Risk factors: caucasion, male, multiple births, maternal diabetes * S/sxs: * respiratory distress at birth (tachypnea \>60 /min, tachycardia, chest wall retractions, grunting, nasal flaring, cyanosis) * Dx: CXR: diffuse bilateral atelectasis that cause a **ground glass appearance** and air bronchograms * Tx: * antenatal steroids within 24-48 hours of birth → **betamethasone IM x 2** * **artificial surfactant** via ET tube * mechanical ventilation with positive pressure

Answer 72

chronic widening or enlargement of the bronchi and their branches → increased risk of infection

Answer 73

most common cause in adults: **Influenza;** most common cause in children **RSV, Parainfluenza virus** * S/sxs: **persistent** sxs of sore throat, HA, myalgias, malaise for **more than 3-5 days** then **_new respiratory sxs_** _-→_ dyspnea, cyanosis * Dx: CXR: **bilateral lung involvement with interstitial infiltrate** * Rapid antigen test for influenza * _RSV_ nasal swab * _cold agglutinin titer_ to r/o Mycoplasma (should be negative with this) * Tx: flu → oseltamivir, zanamivir * RSV → **Ribavirin**

Pulmonology Flashcards

(98 cards)