Flashcards in Pulmonology Deck (117):
A pt presents with shortness of breath with expiratory wheezing, use of accessory muscles and possibly inability to speak in complete sentences most likely suffers from ...
What are five important features of severe asthma exacerbation?
1. hyperventilation/ increased respiratory rate
2. decrease in peak flow
4. respiratory acidosis
5. possible absence of wheezing (omnious sign bc means no airflow)
What is the diagnostic test for suspected active asthma?
pulmonary function tests (PFTs) before & after bronchodilators (increase in FEV1 > 12%)
What is the diagnostic test for suspected asthma in an asymptomatic pt with history of asthmatic symptoms?
methacholine stimulating testing (decrease in FEV1 in response to metacholine)
What is the best initial treatment for a pt with acute asthma exacerbation?
1. inhaled bronchodilators (albuterol)
2. bolus of methylprednisone (needs 4-6 hours)
3. inhaled ipratropium
When should a pt presenting with asthma exacerbation be placed in ICU?
if have respiratory acidosis with CO2 retention (persistence indicates need for intubation and mechanical ventilation)
What are the 4 things that should be performed for all patients with shortness of breath presentation?
2. continous oximeter
3. chest x-ray
4. arterial blood gas
What is the best initial therapy for nonacute asthma?
inhaled bronchodilator (albuterol)
What is the next best step in management of a nonacute asthma not controlled by inhaled bronchodilator?
add inhaled steroid (chronic controller medication)
What is the next best step in management of nonacute asthma not controlled by inhaled bronchodilator and inhaled steroid?
add long acting inhaled beta agonist (salmeterol or formeterol)
What is the last resort for managing nonacute asthma not controlled by other medications?
What is a treatment that is specific for asthma associated with extrinsic allergies (such as hay fever)?
cromolyn or nedocromil
What is a treatment that is specific for asthma associated with atopic disease?
What is a treatment that is specific for asthma exacerbation associated with COPD?
tiotropium or ipratropium (inhaled anti-muscarinic)
What is a treatment that is specific for asthma associated with high IgE levels and not controlled with cromolyn?
omalizumab (IgG that is anti-IgE)
What is the best treatment for exercise-induced asthma?
inhaled bronchodilator prior to exercise
A long-term smoker presents with increasing shortness of breath and decreased exercise tolerance most likely suffers from ...
Chronic Obstructive Pulmonary Disease (COPD)
What six things should be performed at the initial presentation of COPD exacerbation?
2. arterial blood gas (assess for CO2 retention)
3. inhaled albuterol
4. inhaled ipratropium
5. bolus of methylprednisone
6. chest X-ray (to assess for possible pneumonia)
What should be added to treatment if fever, sputum and/or new infiltrate on chest X-ray are present in a COPD exacerbation?
ceftriaxone and azithromyocin
What is the best treatment for mild respiratory acidosis in a COPD exacerbation?
CPAP or BiPAP
When should a COPD exacerbation pt be intubated?
if worsening drop in pH (indicative of worsening respiratory acidosis)
What are the pulmonary function testing results associated with COPD? (6)
1. decrease FEV1
2. decrease FVC (loss of elastic recoil)
3. decrease FEV1/FVC ratio
4. increase total lung capacity
5. increase residual volume
6. decrease in DLCO (diffusion capacity of lung carbon monoxide)
What is included in chronic medical therapy of COPD?
1. tiotropium/ ipratropium inhaler
2. albuterol inhaler
3. pneumococcal vaccine
4. influenza vaccine
5. smoking cessation
6. long term home oxygen (if indicated)
When is long term home oxygen indicated for COPD treatment?
What are the two treatments in the chronic medical therapy of COPD that lowers mortality?
1. smoking cessation
2. home oxygen therapy
A non-smoking pt
Alpha-1 antitrypsin deficiency
What is the treatment for alpha-1 antitrypsin deficiency?
alpha-1 antitrypsin infusion
What are diagnostic tests for alpha-1 antitrypsin deficiency? (4)
1. chest x-ray (bullae, barrel chest, flat diaphragm)
2. low albumin and elevated prothrombin time (due to cirrhosis)
3. low alpha-1 antitrypsin level
4. genetic testing
A pt presents with chronic resolving and recurring episodes of lung infection with very high sputum volume, hemoptysis and fever most likely suffers from ...
Bronchiectasis (profound dilation of bronchi)
What is the best initial test for suspected Bronchiectasis?
shows tram tracking (parallel lines) and dilated bronchi
What is the most accurate test for suspected Bronchiectasis?
high resolution chest CT
What is the best supportive therapy treatments for bronchiectasis?
1. chest PT with cupping and clapping (dislodge secretions)
2. rotating antibiotics as infections occur
A pt presents with shortness of breath with dry, nonproductive cough, chronic hypoxia, episodes of bronchitis/ pneumonia, dry velcro rales, loud P2 (sign of pulmonary hypertension) and clubbing most likely suffers from ...
Interstitial Lung Disease (ILD)
(if no known etiology, then idiopathic pulmonary fibrosis)
A pt with signs and symptoms of interstitial lung disease with exposure to abestos (old building,etc) most likely suffers from..
A glass worker/ miner/ sanblaster/ brickyard worker presents with signs and symptoms of interstitial lung disease most likely suffers from...
A coal worker presenting with signs and symptoms of interstitial lung disease most likely suffers from...
Coal worker's pneumoconiosis
A cotton worker presenting with signs and symptoms of interstitial lung disease most likely suffers from ....
An electronic/ ceramics/ fluorescent light bulb worker presenting with signs and symptoms of interstitial lung disease most likely suffers from ...
(responds to steroids; granulomatous)
A pt exposed to mercury presenting with signs and symptoms of interstitial lung disease most likely suffers from ...
What are the pulmonary function test results associated with interstitial lung disease (ILD/ pulmonary fibrosis)?
1. decreased FEV1
2. decreased FVC
3. normal FEV1/FVC ratio
4. decreased total lung capacity
5. decreased residual volume
6. deceased DLCO
When is a trial of steroids indicated as treatment for interstitial lung disease?
biopsy shows inflammatory infiltrate (berylliosis responds to steroids as a granulomatous disease)
What medications are associated with development of interstitial lung disease? (2)
1. trimethoprim-sulfamethizole (Bactrim)
A pt presents with actue development of cough, rales, shortness of breath with fever, malaise and myalgias and without any occupational exposure most likely suffers from ...
Bronchiolitis obliterans organizing pneumonia (BOOP)/ cryptogenic oragnizing pneumonia (COP)
What is the most accurate diagnostic test for suspected BOOP/COP?
open lung biopsy
(Chest X-ray shows bilateral patchy infiltrates; chest CT shows interstitial disease and alveolitis)
What is the treatment for BOOP/COP?
An african american female
What are extrapulmonary findings associated with sarcoidosis? (7)
1. uveitis (eye)
2. 7th cranial nerve palsy
3. lupus pernio (purlpish lesion on face)
4. erythema nodosum
5. restrictive cardiomyopathy/ cardiac conduction defects
6. hypercalcemia (via vitamin D production)
7. elevated ACE levels
What is the best initial test for suspected sarcoidosis?
Chest X-ray (enlarged lymph nodes with possible interstitial lung disease)
What is the most accurate test for suspected sarcoidosis?
lung/lymph node biopsy (noncaseating granulomas)
(bronchoalveolar lavage shows numerous helper cells)
What is the best treatment for sarcoidosis?
A female pt presents with shortness of breath, loud P2, tricuspid regurgitation murmur, right ventricular heave and raynaud's phenomenon most likely suffers from...
pulmonary hypertension (due to overgrowth & obliteration of pulmonary vasculature)
What is the most accurate test for pulmonary hypertension?
right heart catheterization (increased pulmonary artery pressure)
What are initial diagnostic tests and their associated findings for pulmonary hypertension?
1. transthoracic ECHO (RV hypertrophy & enlarged RA)
2. EKG (RV hypertrophy, enlarged RA, right axis deviation)
What are the four possible treatments for pulmonary hypertension?
1. bosentan (endothelin inhibitor)
2. epoprostenol/ treprostinil (prostacyclin analogs --> pulmonary vasodilators)
3. calcium channel blockers
A pt with history of immobility/cancer/ trauma/ surgery/ thrombophilia who presents with sudden onset shortness of breath, clear lung exam, chest X-ray is normal/ atelectasi,, EKG shows sinus tachycardia, and ABG shows hypoxia with increased A-a gradient and mild respiratory alkalosis most likely suffers from ...
What is the best step in management of a clear case of pulmonary embolus with sudden onset shortness breath, clear lung and a risk factor after obtaining chest X-ray and blood gas?
What is the best initial test for suspected pulmonary embolus if chest x-ray is abnormal?
CT angiogram (can miss embolus if small or in periphery)
What is the best initial test for ruling out pulmonary embolus in a pt with a low probability of having disease?
d-dimer (sensitive but non-specific)
What is the most accurate test for pulmonary embolism?
angiography (invasive with significant risk of death)
(less accurate tests: CT angiogram, V/Q scan, lower extremity doppler, d-dimer)
What is the best treatment for a pt with pulmonary embolism in which there is a contraindication for heparin use (anticoagulation)?
Inferior vena cava filter (IVC filter)
What is the best treatment for a pt with pulmonary embolism and hemodynamically unstable (hypotension)?
What is routine treatment for pt with pulmonary embolism?
heparin and oxygen followed by warfarin for at least 6 months
What is the best initial test for suspected pleural effusion?
Chest X-ray (AP and decubitus to assess if free flowing)
(Chest CT gives a lil more detail)
What is the most accurate test for suspected pleural effusion?
What 8 tests should be ordered on pleural fluid in cases of pleural effusion?
1. gram stain and culture
2. acid fast stain
3. total protein (and serum protein)
4. LDH (and serum LDH)
6. cell count with diff
What findings suggest that a pleural effusion is due to cancer or infection (exudative)?
1. protein high (> 50% of serum level)
2. LDH high (> 60% of serum level)
What is the best treatment for a large plerual effusion?
chest tube for drainage (especially if empyema-infection)
What is the best treatment for a large, recurrent pleural effusion?
pleurodesis (infuse bleomycin/ talcum powder to irritate and inflame pleura --> fibrosis to eliminate pleural space)
What is the next best treatment for a large, recurrent pleural effusion that is not corrected by pleurodesis?
decortication (strip pleura off lung to cause it to stick to chest wall)
An obese pt presents with daytime somnolence, a history of severe snoring, hypertension, headache, erectile dysfunction and fat neck most likely suffers from...
(obstructive- fatty tissue blocking breathing; central- decreased respiratory drive)
What is the diagnostic test for sleep apnea?
polysomnography (sleep study assessing periods of apnea lasting >10 seconds and oxygen saturation)
What are the definitions of mild sleep apnea and severe sleep apnea?
mild: 5-20 apneic periods/hour
severe: >30 apneic periods/hour
What is the best initial treatment for obstructive sleep apnea?
weight loss and CPAP/ BiPAP
(if not sucessful, surgically remove uvula, palate, pharynx)
What is the treatment options for central sleep apnea?
1. avoiding alcohol and sedatives
2. acetazolamide (leads to metabolic acidosis to increase respiratory drive)
3. medroxyprogesterone (central respiratory stimulant)
An asthmatic pt presents with worsening asthma symptoms, brownish mucous plugs, recurrent infiltrates, peripheral eosinophilia, elevated IgE and central bronchiesctasis most likely suffers from...
Allergic Bronchopulmonary Aspergilliosis (ABPA)
What is the treatment for allergic broncopulmonary aspergillosis?
corticosteroids (add itraconazole if refractory)
What are the diagnostic tests that are used for suspected allergic bronchopulmonary aspergillosis?
1. aspergillus skin testing
2. IgE levels (elevated)
3. circulating precipitins
4. A. fumigatus specific antibodies
A pt with history of sepsis/ gastric aspiration/ shock/ infection/ lung contusion/ trauma/ toxic inhalation/ near drowning/ pancreatitis/ burns who develop sudden, severe respiratory failure, have diffuse patchy infiltrates that become confluent on chest X-ray and pO2/FIO2 ratio
acute respiratory distress syndrome (ARDS due to diffuse lung injury secondary to overwhelming systemic injury)
What is the treatment for acute respiratory distress syndrome (ARDS)? (5)
1. transfer to ICU
2. ventilatory support with low tidal volume (6 ml/kg)
3. positive end expiratory pressure (PEEP to open aveoli)
4. possibly diuretics and positive inotropes (dobutamine)
5. prone positioning
What are the Swan-Ganz/ pulmonary artery catheterization results associated with hypovolemia? (3)
1. low cardiac output
2. low wedge pressure
3. high systemic vascular resistance
What are the Swan-Ganz/ pulmonary artery catheterization results associated with cardiogenic shock? (3)
1. low cardiac output
2. high wedge pressure
3. high systemic vascular resistance
What are the Swan-Ganz/ pulmonary artery catheterization results associated with septic shock? (3)
1. high cardiac output
2. low wedge pressure
3. low systemic vascular resistance
What is the most common organism that causes community acquired pneumonia?
What is the most common organism that causes hospital-acquired pneumonia?
gram- negative bacilli
What is the strongest indicator for hospital admission for pt presenting with pneumonia (fever, cough, sputum with possible shortness of breath)?
(CURB 65: confusion, urea/BUN >7 mmol/l, respiratory rate >30, BP
What is the best initial test and the most accurate test for pneumonia?
Chest X-ray; sputum gram stain and culture
What tests should be ordered initially in all respiratory distress (fever, cough, sputum) cases?
Chest X-ray and oximeter
What should be ordered along with chest x-ray and oximeter in respiratory distress cases with shortness of breath or hypoxia?
What should be ordered along with chest x-ray and oximeter in respiratory distress cases with hypoxia?
What is the outpatient treatment for pneumonia?
1. macrolide(azithromycin, doxycyline, clarithromycin)
2.respiratory fluroquinolone (levofloxacin, moxifloxacin)
What is the inpatient treatment for pneumonia?
1. ceftriaxone and azithromycin
What is the treatment for ventilator associated pneumonia (fever, hypoxia, new infiltrate, increasing secretions)?
1. imipenem/ meropenem/ tazobactam/cefepime
2. with gentamicin
3. with vancomycin/ linezolid
An alcoholic presenting with pneumonia most likely is infected with ...
A pt with a history of a recent viral syndrome and presenting with pneumonia most likely is infected with..
An elderly pt with GI symptoms, confusion and pneumonia most likely is infected with ...
A young healthy pt with pneumonia most likely is infected with ...
A pt with a history of being present at an animal birth who presents with pneumonia most likely is infected with ...
An arizona construction worker presenting with pneumonia most likely infected with...
A HIV pt with CD4 count less than 200 presenting with pneumonia is most likely infected with ...
What is the most accurate test in suspected pneumocystis (PCP)?
What is the best treatment for pneumocystis (PCP)?
bactrim (trimethoprim/ sulfamethoxazole)
What are the indications that steroids should be added to the treatment of pneumocytis (PCP) along with bactrim?
1. pO2 35
A immigrant/HIV positive/ homeless/ prisoner/ alcoholic pt presents with fever, cough, sputum/ hemoptysis, weight loss and night sweats most likely suffers from ...
What is the best initial test for tuberculosis (TB)?
What is the confirmatory test for tuberculosis (TB)?
sputum acid fast stain and culture
What is the standard treatment for a patient with newly diagnosed tuberculosis (TB)? (4)
1. Isoniazid (INH for 6 months)
2. rifampin (for 6 months)
3. pyrazinamide (for first 2 months)
4. ethambutol (for first 2 months)
What is an indication to stop tuberculosis (TB) treatment earlier?
liver toxicity (if transaminases > 5x upper limit of normal)
What is a major side effect of isoniazid (INH)?
peripheral neuropathy (along with liver toxicity)
What is a major side effect of rifampin?
red/orange colored bodily secretions (along with liver toxicity)
What is a major side effect of pyrazinamide?
hyperuricemia (along with liver toxicity)
What is a major side effect of ethambutol?
optic neuritis (along with liver toxicity)
What are the five conditions in which tuberculosis should be treated for longer than 6 months?
1. osteomyelitis with TB
2. TB meningitis
3. miliary TB
4. cavitary TB
What is considered a positive PPD test for TB?
5 mm: close contact of person w/ TB, steroid user, HIV
10mm: at risk group (homeless, alcoholics, immigrants, health care workers, prisoners)
15 mm: not at increased risk
What is routine screening guideline for latent tuberculosis for pts who have never been tested before or it has been several years since the last test?
2-stage testing (if initial PPD is negative, perform second one 1-2 weeks later)
What is the next best step in management of an asymptomatic pt with a positive PPD test?
Chest X-ray (if abnormal conduct sputum staining for TB and if positive start 4 drug treatment)
What is the next best step in management of an asymptomatic pt with a positive PPD test but a negative chest X-ray?
treat with isoniazid (INH) for 9 months (to reduce lifetime risk of developing TB)