Pulmonology

Question 1

peak expiratory flow and pulmonary function tests

Answer 1

• if <350L/min, perform PFTs to screen for obstruction
• PFT:
  
  • FEV1: amount of air that can be forced out of the lungs in 1 second
    
    • Airway obstruction dx by: normal/increased TLC w/ decreased FEV1 (FEV1/FVC <0.7)
  • Tiffeneau index (FEV1/FVC x 100): % of FVC expired in 1 second
  • FET = forced expiratory time
• Obstructive vs restrictive: BASED ON TLC, NOT VITAL CAPACITY

Question 2

obstructive vs restrictive dz

Answer 2

Question 3

Tidal volume, residual volume, insp reserve, exp reserve, vital capacity, total lung capacity, insp capacity, funcitonal residual capacity

Answer 3

Question 4

DLCO

Answer 4

• diffusing capacity of the lung for carbon monoxide
• DLCO = CO into lungs - CO out of lungs
• use carbon monoxide bc we can maximize diffusion bc of the affinitiy of Hgb for it - Volume = area/thickness x (P1 - P2) x constant
• In emphysema, tissue is destroyed, reducing surface area for diffusion - decreased surface area causes volume to decrease
• In sarcoidosis and fibrosis, lung thickness increases, also driving volume to decrease

Question 5

Acute/Chronic bronchitis

Answer 5

• etiology: viruses (most), cannot distinguish acute bronchitis from URTI in first few days
• sxs: cough >5d (+/- sputum), lasts 2-3wks
  
  • chest discomfort
  • SOB
  • +/- fever
• dx: labs not indicated, unless pneumonia suspected (HR >100, RR >24, T >38C, rales, hypoxemia, mental confusion, or systemic illness)
  
  • CXR
• Tx: abx not recommended since most viral
• sxs based tx: NSAIDs, ASA, tylenol, and/or ipratropium
  
  • abx and cough suppressants not indicated
    
    • cough suppressants: codeine-containing cough meds
    • bronchodilators (albuterol)

Question 6

Asthma

Answer 6

• characteristics: airway inflammation, airway hyperresponsiveness, reversible airflow obstruction, may begin at any age, dyspnea common when rapid changes in temp or humidity
• extrinsic: Atopic: produce IgE dt enviro triggers (eczema, hay fever), become asthmatic young
• intrinsic: not related to atopy of enviro factors
• want to see increased FEV1 >12% with albuterol
• can also see decrease in FEV1 >20% with methacholine or histamine challenge
• increase in diffusion capacity of lung for DLCO

Question 7

Asthma characteristics, signs, sxs

Answer 7

• Triggers: pollens, house dust, molds, cockroaches, cats, dogs, cold air, viral infxns, tobacco smoke, meds (BB, ASA), exercise
• sxs: SOB, wheezing, chest tightness, cough (occurs in 30 mins to exposure to triggers, sxs worse at night)
• signs: wheezing (inspiration and expiration) is the MC finding

Question 8

Asthma dx and tx

Answer 8

• Dx: CXR for first time wheezers, PFTs required to dx, spirometry before and after bronchodilators - increase in FEV1 ro FVC by 12%
• Tx 1:
  
  • SABA for acute attacks (onset 2-5 min, lasts 4-6h
  • LABA (salmeterol) for nighttime asthma and exercise induced
  • ICS: moderate to severe asthma, use reg to decrease airway hyperresp.
• Tx 2:
  
  • Montekukast: proph for mild exercised induced and control of mild-moderate, allows for reduction in steroid and B2
  • Cromolyn sodium: proph before exercise
  • Avoid BB in asthmatics

Question 9

Acute asthma exacerbation

Answer 9

• sxs: sweating, wheezing, speaking incomplete sentences, tachypnea, paradoxical mvmt of abdomen, use of accessory mm.
• dx: PEFR: low, severe <60
  
  • ABG: increased A-a gradient
  • CXR: ro pneumonia, pneumothorax
• tx 1: nebulizer (SABA) or MDI, IV or oral steroids, IV magnesium (prevent bronchospasm)
• complications:
  
  • status asthmaticus: doesnt respond to standard meds
  • ARDS: resp mm fatigue
  • pneumothorax, atelectasis, pneumomediastinum

Question 10

Asthma classification

Answer 10

• Intermittent, mild persistent, moderate persistent, severe persistent

Question 11

COPD

Answer 11

• 4th leading cause of death in the United States
• Coexisting bronchitis and emphysema, rarely one or the other by itself
• Leads to chronic respiratoyr acidosis with metabolic alkalosis as compensation
• risk factors and causes:
  
  • Smoking (tobacco), alpha antitrypsin deficiency, enviro factors (second hand smoke), chronic asthma
• MCC acute exacerbation: infxn, noncompliance, cardiac dz
• secondary polycythemia (response to chronic hypoxemia

Question 12

Chronic Bronchitis

Answer 12

• excess mucous narrows airways (productive cough), scarring and inflamm -> enlarged glands -> smooth m hyperplasia = obstruction
• sxs: cough, sputum, dyspnea (on exert or rest)
• signs: prolonged forced exp time, exp wheezes, dec. breath sounds, insp crackles, tachypnea, tachycardia, cyanosis, accessory mm use, hyperresonance, signs of cor pulmonale
• dx: chronic cough and sputum >3 mo, at least 2 consec years
  
  • CXR, alpha antitryp levels, ABG

Question 13

emphysema etiology and types

Answer 13

• elastase (protease) excess and overinflation (elastase released from WBCs ingesting lung tissue, normally inhib by alpha antitryp.; tobacco smoke increases WBCs, inhibits antitryp, increases oxidative stress)
• types:
  
  • centrilobular: MC, smokers, destruction of bronchioles in upper lungs
  • Panlobular: pts with alpha antityrp def.; destruction of prox and distal acini (lung bases)

Question 14

emphysema sxs, dx

Answer 14

• sxs: productive cough or chest tightness, worse in morning, clear to white sputum, 50yo typical
  
  • dyspnea MC presents at 60yo, wheezing
• signs: tachypnea, DOE, cyanosis, JVD, atrophy of limb musculature, peripheral edema, Barrel chest (2:1 A:P), diffuse or focal wheezing, diminished breath sounds, hyperresonance
• dx: permanent enlargement of airspaces distal to terminal bronchioles dt destruction . of alveolar walls
  
  • decreased DLCO
  • PFTs (spirometry): FEV1/FVC <0.75, FEV1 decreased, TLC, residual volume, FRC increased
  • Vital capacity decreased: extra air coming in is not useful - becomes dead space
  • CXR

Question 15

chronic bronchitis tx

Answer 15

• smoking cessation (most important)
• albuterol (long term salmeterol for requent use of SABA)
• anticholinergics (ipratropium)
• combo of B agonist and anticholinergics
• Inhaled corticosteroids (O2 tx): long term hypoxemia leads to HTN and cor pulmonale
• pulmonary rehab: improves exercise tolerance
• IMZ: flue and strep q1y pneumo q5-6y
• surgery: lung resection vs transplant

Question 16

emphysema tx

Answer 16

• smoking cessation and home O2 are the only interventions shown to lower mortality
• steroids and abx for acute exacerbations: increased sputum produciton or change in character or worsening SOB
  
  • not responsive to bronchodilators, IV methylprednisolone if hosp., azithro or levo, O2>90% nasal cannula, NPPV (BiPAP or CPAP), can lead to ARDS
• Criteria for O2: PaO2 55mm Hg, O2 sat <88% (pulse ox) at rest or exercise, PaO2 55-59 + polycythemia or cor pulmonale
• look for nocturnal hypoxemia, give CPAP or O2 as needed

Question 17

COPD staging

Answer 17

Question 18

Community acquired PNA

Answer 18

• occurs when there is a defect in pulm defense mech (cough reflex, mucociliary clearance, immune response)
• urinary Ag for Strep pneumo helpful screening tool in pts w/ leukopenia, asplenia, alcohol use, chronic liver dz, pleural effusion, ICU
• urinary Ag for Legionella helpful in pts with alc use, travel previous 2 wks, pleural effusion, ICU
• broad spectrum B-lactamase species: enterobacter, klebsiella pneumo, e. coli

Question 19

community acquired PNA (pneumo PNA) in immunocompetent: etiology, RF, sxs

Answer 19

• MCC: s. pneumo, H flu, Myco PNA, S aureus, N meningitidis, M catarrhalis, K PNA, other GNR
• viruses: influenza, RSV, adeno, parainfluenza
• Occurs outside hosp or within 48hr of hosp admission
• RF: old, alcoholic, smoker, asthma, COPD
• MCC pulm dz in HIV pts
• sxs: fever, cough (with or without sputum), SOB, sweats, chills, rigors, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, HA< abd pain
• signs: fever or hypotherm, tachypnea, tachycardia, O2 desat, insp crackles and bronchial breath sounds, dullness to percussion

Question 20

CAP in immunocompetent: dx

Answer 20

• dx:
  
  • imaging:
    
    • CXR (patchy airspace opacities to lobar consolidation with air bronchograms) - not necessary in outpt bc empiric tx is effective, recommended if unusual presentation, hx, or inpt, clearing of opacities can take 6 wk or longer
    • CT: more sensitive and specific
  • Labs: sputum gram stain (not sensitive or specific for strep pneumo), urinary Ag test for strep pneumo and legionella, rapid Ag test for flu, pre-antibiotic sputum and blood cultures, CBC, CMP, LFTs, bilirubin, ABG in hypoxemic pts, HIV testing, procalcitonin-released by bact toxins and inhibited by viral infxn

Question 21

community acquire PNA in immunocompromised pts

Answer 21

• etiology: HIV (ANC <1000), current or recent exposure to myelo or immunosuppressive medications, or pts taking chronic steroids
• dx: sputum induction, BAL (r/o PCP PNA)

Question 22

Nosocomial PNA

Answer 22

• Pathogens: s. aureus, K. PNA, E. coli, pseudomonas aeruginosa
• sxs: at >/= 2 of the following: fever, leukcytosis, purulent sputum
• dx: CXR, blood cultures x2, CBC and CMP, sputum culture and gram stain (not sensitive or specific), ABG, thoracentesis if effusion, procalcitonin

Question 23

pneumocystis pneumonia

Answer 23

• pneumocystis jirovecii - caused by fungus found in lungs of mammals
• MC opportunistic infxn in HIV/AIDS
• sxs: fever, SOB, nonproductive cough, exam findings disproportionate to imaging showing diffuse interstitial infiltraties, fatigue, weakness, weight loss
• dx: CXR (definitive): diffuse or perihilar infiltrates, reticular interstitial PNA or airspace dz that mimics pulm edema (5-10%) normal CXR, absent pleural effusions)
  
  • sputum wright-giemsa stain or DFA (direct fluorescence Ab) - definitive in 50-80%
  • BAL - definitive in 95%
  • CD4 <200 - if AIDS
  • ABG; hypoxia, hypocapnia, reduced DLCO
  • increased LDH but nonsepcific, serum B-glucan is more sensitive and specific, WBC low
• tx: Bactrim, add steroids if PaO2 <79 or A-a gradient >35 if given in 72h, dapson if sulfa allergy, all pts with CD4 <200 should undergo proph

Question 24

PNA tx: outpatient, smokers, and inpatient (non-ICU)

Answer 24

• Outpt: 5 djays minimum or until pt afebrile x48-72h
  
  • pathogens: S pnemo, M pneumo, C pneumo, flu virus
  • Previously healthy, no recent abx: macrolide (clarithro or azithro x4d), doxy
  • At risk for drug resistance (old, comorbid, immunosuppress, exposure to child in daycare): respiratory FQ (moxiflox), macrolide plus B lactam
• Smokers: Cefdinir
• Inpt, non-ICU:
  
  • Pathogens: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas
  • First line: Resp FQ (IV levo), or IV cipro
  • If at risk for pseudomonas: IV macrolide plus IV B lactam (HD ampicillin or Ceoftaxime or ceftriaxone)

Question 25

PNA tx: hospitalized or ICU pts

Answer 25

* Duration: 5d minimum or until pt afebrile x48-72h * ICU: S pneumo, Legionella, H flu, Enterobact, S aureus, Pseudomonas * Previously healthy: Azithro or resp FQ (moxi or **levo**) plus **cefotaxime**, ceftriaxone, or UNASYN * if B lactam allergy: FQ plus Aztreonam * pts at risk for drug resistance: Antipneumococcal and antipseudomonal B lactam: **Zosyn,** cefepime, imipenem or meropenem _PLUS:_ * cipro or **levo**, _OR_, antipneumo B-lactam (cefotaxime, ceftriaxone, UNASYN) _PLUS_ Aminoglyc (gent, tobra, amikacin) _PLUS_ Azithro or resp FQ * If at risk for MRSA: add vanco or linezolid

Question 26

PNA tx: nosocomial PNA

Answer 26

* previously healthy: ceftriaxone, moxi, levo, cipro, UNASYN, Zosyn, or ertapenem * at risk for drug resistance: one agent from each: * Antipseudomonal * Cefepime, Impenem, Zosyn, or aztreonam (if PCN allergy) * Second antipseudomonal * Levo, cipro, gent, tobra, or amikacin * MRSA coverage * vanco or linezolid

Question 27

When to admit for PNA

Answer 27

* CURB-65 Score * 1. confusion * 2. uremia * 3. resp rate * 4. blood pressure * 5. age \>65 * \<1 = no hosp * 1-2 = hosp (maybe ICU) * 3+ = definite ICU admit

Question 28

Tuberculosis

Answer 28

* can present as acute or latent infxn * **only active TB is contagious (cough, sneezing), PRIMARY TB IS NOT CONTAGIOUS** * difficult to dx in HIV, PPD will be neg, atypical CXR findings, sputum likely neg, granuloma may not be present * RF: HIV, immigrants, prisoners, health care workers, close contact, alcoholics, DM, steroids, blood malig, IVDU * MC: **mycobacterium tuberculosis**, slow growing * Transmission: inhalation of **aerosolized droplets** * sxs: fatigue, weight loss, fever, night sweats, productive cough * dx: sputum stain (acid fast bacilli), sputume culture + for M. tuberculosis, PPD, CXR (caseating granuloma formation (pulm opacitis, most often atypical) * tx: RIPE tx, dc tx if transaminases \>3-5x ULN, can spread to vertebral column

Question 29

Primary, Secondary, and Extrapulmonary TB

Answer 29

* Primary: bacilli inhaled and deposited into lung - ingested by alveolar macrophages * surviving orgs multiply and disseminate via lymphatics and blood * **granulomas** form and "wall off" mycobacteria - remains dormant * insults on immune syst reactivates (5-10%) * **Asymptomatic:** pleural effusion, can be progressive with pulm and constitutional sxs, usually clinically and radiographically silent * Secondary: Host's immunity weakened (HIV, malignancy, steroids, substance abuse, poor nutrition), gastrectomy, silicosis, DM) * most oxygenated parts of lung: **apical/posterior segments** * **Symptomatic:** fever, night sweats, weight loss, malaise, **chronic cough, progressive** (dry to purulent, **blood streaked)** * signs: chronically ill appearing, malnourished, posttussive apical rales * Extrapulmonary TB: impaired immunity cannot contain bacteria - disseminates (HIV) * any organ * Miliary TB: hematogenous spread - can be due to reactivation or new infxn, HIV pts, organomegaly, reticulonodular infiltrates, choroidal tubercles in eye

Question 30

TB diagnostics

Answer 30

* high index of suspicion depending on RF and presentation * **CXR -** unilateral **apical infiltrates with cavitations,** hilar and paratracheal lymph node enlargement, pleural effusions, Ghon complex, Ranke complex * HIV may show lower lung zone, diffuse, or miliary infiltrates * **Sputum studies:** definitive dx by **sputum culture**, obtain 3 morning sputum speciments, takes 4-8wks, PCR can detect specifics * **PPD (Mantoux test)**: screening to detect previous TB exposure, not for active TB dx; if + use CXR to r/o active TB * if sxatic or abnl CXR, order AFB * \>15mm if no risk factors; \>10 if high risk (homeless, imigrants, health care workers, DM); \>5 if very high risk (HIV, organ transplant, contact with active TB) * **Interferon gamma release assay:** measures interferon gamma release in response to MTB antigens, helps exclude false + TST * blood cultures * NAAT-R

Question 31

signs of healed primary TB:

Answer 31

* **Ghon complex**: calcified focus with associated lymph node * Ranke complex: Ghon complex undergoes fibrosis and calcification * CXR: fibrocavitary apical dz, discrete nodules, pneumonic infiltrates usually in apical or posterior segments of upper lobes or in superior segments of lower lobes

Question 32

TB treatment: active TB, Pregnant women, Latent TB, Immunnocompetent, HIV pos

Answer 32

* Active TB: droplet precautions; isolation until sputum neg for AFB * **2 months of tx with 4 drug RIPE, then 4 months with INH and Rifampin** * once isolate determined to be isoniazid sensitive, ethambutold can be DCed; if susceptible to isoniazid and rif, may continue on 2-drug regimens * tx \>/= 3 mos past neg cxs for MTB * Pregnant: DONT TAKE PYRAZINAMIDE: RIE x 2mo, then isoniazid and rif for 7 mo; B6 (pyridoxine) daily to prevent periph neuropathy; breastfeeding NOT contraindicated * Latent (+ PPD): 9mo INH AFTER active TB excluded via CXR, sputum, or both; NOT infxous, no active dz * Immunocompetent: INH x9mo; adverse effect = drug induced hepatitis * HIV pos: **9mo INH** _OR_ 2mo rif and pyrazinamide _OR_ rif x 4mo * Other: 9 mo tx when miliary, meninegal or bone/jnt dz; surgical drainage and debridement of necrotic bone in skeletal dz; steroid tx to prevent constrictive pericarditis and neuro complications

Question 33

Pulmonary neoplasm

Answer 33

* Risk factors: **cigarette smoking** (\>85%) increased risk with increasing pack yrs * *Adenocarcinoma = lowest association of smoking* * Asbestos * Radon * COPD * Metastatic dz: **brain, bone, adrenal glands, liver**

Question 34

Small cell lung cancer

Answer 34

* 25% * Sxs: **recurrent PNA, anorexia, weight loss, weakness, cough** * Associated sxs: **superior vena cava syndrome** (facial fullness, edema, dilated veins over ant chest, arms, face, JVD, phrenic nerve palsy, recurrent laryngeal nerve palsy (hoarseness), **Horner syndrome** (unilateral facial anihdrosis, ptosis, miosis), malignant pleural effusion, **Eaton-Lambert syndrome** (similar to myasthenia gravis) * Dx: **CXR** (not for screening), **CT chest** (staging), **bx** (histologic type), cytologic exam of sputum (central tumors), fiberoptic bronchoscope (central dz), PET scan, transthoracic bx (peripheral dz), mediastinoscopy (advanced dz) * Tx: **chemo and radiation** * if dz is extensive, **chemo only** and then radiation if it is responsive to chemo * Prognosis: * Limited: **10-13% 5y survival** * Exstensive: 1-3% 5y survival * Staging: limited = confined to CHEST and supraclavicular nodes (not cervical or axillary); extensive = outside chest and supraclavicular nodes

Question 35

Non-small cell lung cancer

Answer 35

* Etiology: **SCC**, adeno, large cell, bronchoalveolar cell * sxs: cough, hemoptysis, obstruction, wheezing, **pancoast syndrome** (superior sulcus tumor - shoulder pain, radiates down arm, pain and upper extremity weakness dt brachial plexus invasion, horner syndrome) * associated sxs: paraneoplastic syndromes (SIADH, ectopic ACTH, PTH-like secretion, hypertrophic pulm osteoarthropathy) * dx: CXR (pleural effusion) - always perform bx for intrathoracic lymphadenopathy * tx: surgery = best option (if met outside chest, not candidate; may recur after surgery) * Radiation: important adjunct, chemotherapy has an uncertain benefit * staging: primary TNM staging

Question 36

lung cancer screening

Answer 36

* annual screening for lung cancer with low-dose CT 55-80yo w/ 30 pack/yr hx and currently smoke or quit within past 15yrs * discontinue screening once person stops for 15yrs or develops health prob that substantially limits life expectancy

Question 37

Obestiy hypoventilation (pickwickian) syndorme

Answer 37

* severely overweight ppl fail to breathe rapidly or deeply enough resulting in low blood O2 and high CO2 levels * may result in OSA, eventual heart failure sxs (leg swelling0 * clinical features: **obestiy (BMI \>30)** * tx: **weight loss, cpap**

Question 38

Obstructive sleep apnea etiology, RF, sxs

Answer 38

* etiology: loss of pharyngeal m tone * RF: micrognathia, macroglossia, obesity, tonsillar hypertrophy, hypothyroid, smoking, ingestion of ETOH or sedatives before sleep, nasal obstruction (flu) * sxs: hx of loud snoring, apnea (cessation of breathing), excessive daytime sleepiness, fatigue, personality changes, poor judgment, memory impairment, depression, HTN, HA worse in AM, impotence * Signs: appears sleepy, narrow oropharynx, large tonsils, large tongue, deviated septum, "bull neck" appearance

Question 39

OSA dx and tx

Answer 39

* Dx: **polysomnography (definitive): 5+ episodes** of apnea, hypopnea or resp related arousals per hour during sleep * erythrocytosis, CO2 \>45 * Tx: **weight loss**, avoid hypnotics, CPAP, if O2 \<90% switch to BiPAP (higher inspiration, lower expiration pressures), add O2 if both previous txs dont work, UPPP, **tracheostomy** = definitive tx

Question 40

therapies for smoking cessation

Answer 40

* Bupropion (norepinephrine/dopamine reuptake inhibitor); taken PO, works in 1-2wks * CI: hx seizure, eating disorder, ubrupt discontinuation of ETOH or sedatives, use of MAOIs within 14d, linezolid or IV methylene blue * AE: insomnia, HA, dry mouth, const, N/V, weight loss * Nicotine gum (nicotinic cholinergic receptor agonist) * AE: mouth soreness or ulcers, dyspepsia, HA, excess salivation, sore jaw * Nicotine patch (nicotine agonist) transdermal * AE: insomnia, skin irritation) * Varenicline (chantix - partial cholinergic receptor agonist) * CI: cardiovasc dz, mood disorders * AE: N/V, HA, vivid dreams, constipation * Second line tx: * Clonidine (alpha agonist) * CI: rebound HTN if dced too quick * AE: dry mouth, drowsiness, dizziness, **HoTN**, **Sedation**, HA * Nortryptyline (TCA - inhib reuptake of NE more than serotonin) * CI: risk arrhythmia, dont use in acute recovery of MI * AE: sedation, dry mouth, const, increased appetite, blurred vision, tinnitus