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Emergency Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

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1
Q

Acute Bronchiolitis

eti, sxs, dx

A

MCC RSV - fall and winter months

Infants and young children

Sxs:

  • tachypnea
  • respiratory distress
  • wheezing

Dx:

  • nasal washing for RSV culture antigen assay
  • CXR - normal
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2
Q

Acute Bronchiolitis

Tx

A

Hospitalization if

  • O2 Sat < 95-96%
  • < 3mos old
  • RR > 70
  • nasal flaring
  • retractions
  • atelectasis on CXR

Supportive Tx —>

  • humidified O2,
  • antipyretics,
  • B agonist (albuterol),
  • neb racemic epinephrine, and
  • steroids

O2 is only tx to improve

Ribavirin for severe lung or heart dz in IMC pts

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3
Q

Acute Bronchitis

eti, sxs

A

Cough > 5 days; lasts 1-3 wks

MC viral, Bacterial - M catarrhalis

Chronic Lung pt - H influ, S pneumo, M. catarrhales

Sxs:

  • Cough NO fever ( if + then consider PNA)
  • constitutional symptoms less severe than PNA
  • normal VS,
  • no Rales or egophony
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4
Q

Acute Bronchitis

dx, tx

A

CXR if uncertain or persistent symptoms

Tx:

  • Supportive - h2, analgesics, B agonist, cough suppressants
  • Acute exacerbation of chronic bronchitis - more likely to be bacterial
    • empiric 1st line- 2nd gen cephalosporin,
    • 2nd gen macrolide or Bactrim
      • eldery
      • underlying cardiopulmonary dz w/ cough >7-10 d
      • pts who is IMC
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5
Q

Acute Epiglottitis

eti, sxs

A

EMERGENCY - Supraglottic inflammation

airway obstruction d/t H. influenzas type B (Hib)

MC unvaccinated children

Sxs: 3 Ds of epiglottis

  • Dysphagia
  • Drooling
  • Respiratory Distress
  • tripoding
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6
Q

Acute Epiglottitis

dx, tx

A

X ray lateral film - Thumbprint sign

Secure airway - get cultures for H influ

Tx:

  • intubation
  • supportive care
  • Ceftriaxone* Tx as outpatient if stable
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7
Q

Acute Respiratory Distress Syndrome

eti

A

ARDS - respiratory failure characterized by fluid collecting in lungs = no O2

incr permeability of alveolar-capillary membrane -> development of protein rich pulp edema (non cariogenic pulm edema)

can also be d/t critically ill pts or those with significant injuries I.e. sepsis, severe trauma, aspiration of gastric contents, near drowning

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8
Q

ARDS

sxs

A
  • Severe SOB - unable to breath independently w/o ventilator
  • rapid onset of profound dyspnea occurring w/in 12-24 hrs after precipitating event
  • Tachypnea
  • pink frothy sputum crackles
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9
Q

ARDS

dx

A

ABG PaO2 and FIO2 ratio - not responsive to 100% O2

  • mild 200-300
  • mod 100-200
  • severe <100

CXR

  • bilateral infiltrates => white out pattern
  • spares CP angles

Cardiacs Cath of plum artery

  • Pulm cap wedge pressure (PCWP) < 18 mmHg = ARDS
  • if > 18 mmHg - Cardiopulm edema
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10
Q

ARDS

tx

A

Tx underlying cause

PEEP lowest setting to maintain PaO2 > 60 mmHg and keep O2 sat > 90%

often fatal

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11
Q

Asthma eti

A

Chronic, reversible inflammatory airway disease w/ recurrent attacks of breathlessness and wheezing

Sxs:

  • Samter’s triad
    • asthma nasal
    • polyps
    • ASA/NSAID allergy
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12
Q

Asthma sxs

A

SXS: triad of dyspnea, wheezing, cough chest tightness

PE

  • prolonged expiration with wheezing
  • hyperresonance to percussion
  • tachycardia
  • tachypnea
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13
Q

Asthma dx

A
  • PFT - dec FEV1, decr FEV1/FVC ratio
  • Methacholine challenge test >/= 20% dec in FEV1 Bronchodilator test >= 12% incr in FEV1
  • Peak Expiratory Flow Rate used in ED (nl is 400-600) PEFR >15% from initial attempt = response to tx
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14
Q

Asthma tx

A

Categorization

Mild intermittent - (<2x/wk or < 2n/mo) -

  • SABA PRN

Mild Persistent (>2x/wk or 3-4 n/mo)

  • low dose ICS daily

Mod Persistent - (Daily sx or > 1n/wk)

  • Low dose ICS + LABA Daily Med dose ICS + LABA daily

Severe Persistent (sx sev x / d and nightly)

  • High dose ICS + LABA qd High dose ICS + LABA + PO steroids

Acute exacerbations O2 Neb SABA Ipatropium bromide PO steroids (5-7 days)

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15
Q

Croup

A

Eti:

  • Infection of upper airway - obstructs breathing causing barking cough
  • MCC - parainfluenza virus
  • Children 6mos-3yo, fall - early winter mos

sxs

  • barking cough
  • stridor

dx

  • Steeple sign on PA CXR

tx

  • supportive - air humidifier
  • antipyretics
  • Severe - IV Fluids, neb racemic epi, steroids (Dexamethasone)
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16
Q

Foreign Body Aspiration

A

MC in mainstem or lobar bronchus R>L and d/t food

RFs - institutionalization, advanced age, poor dentition, etoh, sedative use

Sxs: Presentation depends on location of obstruction

  • Inspiratory stridor - high in airway
  • wheezing and decr breath sounds - low in airway

Dx

  • Expiratory CXR - hyperinflation to affected side
  • ABG - eval ventilation

Tx

  • Remove foreign body with bronchoscope
  • Rigid bronchoscopy in children
  • Flexible is diagnostic and therapeutic in adults
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17
Q

Hemoptysis

eti, sxs

A

Coughing up blood - airway bleeding

MCC

  • Bronchitis - hemoptysis, dry cough, cough with phlegm
  • Tumor mass - hemoptysis, chest pain, rib pain, tobacco hx, wt loss, clubbing
  • Tuberculosis - hemptysis, chest pain, sweating

Sxs:

  • blood stained mucus or blood from bronchi, larynx, trachea, or lungs
  • Bronchial capillaries rupture d/t acute infx (viral/bacterial bronchitis, bronchiectasis, cig smoking)
  • Tiny blood vessles broken
  • Vascular engorgement w/ erosions in Pulm HTN or masses
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18
Q

Hemoptysis

dx, tx

A

Dx

  • Cytology
  • Sputum/expectorant examination
  • Fiberoptic bronch - for CA tissue
    • biopsy
    • bronchial lavage
    • brushing
  • Rigid bronch - massive bleeding - better suctioning and airway maintenance capabilities
  • High Res CT - pathophys

Tx

  • massive hemoptysis - aggressive early consult with pulmnologist
  • ABCs - airway maintenance is vital - primary COD d/t aspyhixation
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19
Q

Influenza

A

Viral respiratory infx by orthomyxovirus (three strains A, B, C)

sxs

  • fever, coryza, cough, headache, malaise

Dx

  • rapid antigen test in clinic
  • rapid serology more accurate
  • CXR - bilateral diffuse infiltrates

Tx

  • symptomatic for most
  • antivirals w/in < 48-72 hrs
    • Tamiflu/Oseltamivir or Zanamivir/Relenza for influ A & B
    • hospitalized pts
    • outpt with severe progressive illness
    • high complications risk
      • IMC
      • chronic med conditions
      • >65yo
      • pregnant or 2 wks pp
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20
Q

Lung Cancer

subtypes

A

Two major categories

  1. Small Cell Lung Cancer (SCLC) - 15% and poor prognosis
  2. Non-Small Cell Lung Cancer (NSCLC) - 85%
  • adenocarcinoma​
  • squamous cell carcinoma
  • large cell carcinoma
  • carcinoid tumor

Dx

  • CXR to screen
  • Bronchscopy and biopsy or FNA - gold standard
  • Squamous Cell or SCLC - central mass
  • Adenocarcinoma - peripheral mass
  • LC and Carcinoid - throughout lungs
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21
Q

Lung Cancer - Adenocarcinoma

Study These Flashcards
A

35-40% of cases

MC type of bronchogenic carcinoma

non-smoker w/ incidental finding and small peripheral lesion

22
Q

Lung Cancer - Squamous Cell Carcinoma

Study These Flashcards
A

25-35% of cases

Bronchial in origin and centrally located mass

MC in smokers

likely to have hemoptysis, central bronchus solitary tumor

23
Q

Lung Cancer - Large Cell

Study These Flashcards
A

rare 5%

rapid doubling time

rarely response to surgery

24
Q

Lung Cancer - Carinoid

Study These Flashcards
A

1-2%

tumor that produces excess serotonin (niacin B3 deficiency)

Pink purple leasion in the central airway

resistant to chemo/radiation

surgical excision

25
Lung Cancer - SCLC
15% Highly aggressive always occurs in smokers rapidly growing, mets by dx **_cannot be tx with sx, needs chemo/XRT_** a/w * ACTH and ADH - hyponatremia and hypercalcemia * Lambert-Eaton myasthenic syndrome - muscle weakness of limbs d/t ACTH/ADH * SVC syndrome * Horner syndrome
26
Horner's Syndrome (Lungs CA)
Cervical sympathetic chain 1. unilateral facial anhidrosis (no sweating) 2. ptosis 3. miosis
27
Pancoast Syndrome
A/w Squamous Cell Carcinoma tumor at lung apex crushes brachial plexus + cervical sympathetic chain * Shoulder pain * UE weakness * Horner's syndrome
28
SVC Syndrome
a/w SCLC obstruction of SVC by tumor resulting in * facial fullness * JVD * dilated veins in anterior chest *
29
Screening for Lung Cancer
USPSTF * annual Lung CA screenign with low dose CT * 55-80 yo * 30 pack year hx * current smokers or * quit within last 15 years Incidental finding on CXR * send for CT * if suspicious - need bx * Ill defined borders, lobular or spiculated = cancer * If not suspicious \< 1cm * monitor q 3mos, 6 mos, yearly for two years * calcifications, smooth, well defined edges = benign
30
Lung Cancer Treatment
_NSCLC_ Stage 1-2 = sx Stage 3 = chemo then surgery Stage 4 = palliative _SCLC_ chemo only can't be tx with sx
31
Pertussis eti, sxs
Whooping cough - severe hacking cough followed by high pitched intake of breath (sounds like whoop) Gram neg bacteria = **Bordetalla pertusis** Consider in **adults with cough \> 2 wks**, patients \< 2yo 1. catarrhal stage - cold like sxs, poor feeding, sleeping 2. Paroxysmla stage - high pitched **inspiratory whoop** 3. Convalescent stage - residual cough (100 days)
32
Pertussis dx, tx
Nasopharyngeal swab of secretions and culture Tx - with **_Macrolide (clarithomycin/azithromycin)_** supportive care w/ steroids + B2 agonists vaccinations * 5 doses - 2, 4, 6, 15-18mos, 4-6 yrs (DTap) * 11-18 yo = 1 dose Tday * Expectant mothers Tdap each pregnancy at 27-36 wks
33
Pleural Effusion
Accumulation of excess fluids in pleura space Sxs * dyspnea * vague discomfort or sharp pain that worsens during inspiration Dx Determine whether pleurocentesis * **exudative** (infection, malignancy, immune) or * **transudative** (transient changes in hydrostatic pressure - cirrhosis, CHF, nephrotic syndrome, ascites, hypoalbuminemia Lateral decubitis CXR * Isolated L Pleural effusion = exudative * R sided = transudative Chest CT US **Thoracentesis - gold std and tx**
34
Light's Criteria
Pleurocentesis to determine if Pleural fluid is exudative: 1. Pleural fluid protein / serum protein \>0.5 2. Pleural fluid LDH / Serum LDH \>0.6 3. Pleural fluid LDH \> 2/3 Exudative - infection, malignancy, immune, MCC - pna, CA, PE, TB
35
Pleuritic Chest Pain
Inflammation of tissues that line lungs and chest cavity (pleura) sudden, intensely sharp , stabing, burning pain in chest when inhaling and exhaling exacerbated by deep breathing, coughing, sneezing, or laughing **MCC - PNA, pericarditis, pericardial effusion, pancreatitis**
36
Pneumonia - Bacterial
**S pneumo** Sxs * fever, dyspnea, cough * tachycardia, tachypnea * +/- sputum Dx * Patchy, segmental lobar, multilobar **_consolidation_** * Blood cultures x 2 * Sputum gram stain tx * outpatient - doxy, macrolides * inpt - ceftriaxone + azithromycin/resp FQs
37
PNA - Viral
Adults - Flu MC Kids - RSV quick onset Dx * CXR - bilateral interstitial infiltrates * rapid antigen testing for flu * RSV nasal swab * cold agglutinin titer negative Tx * Flu with Tamiflu (A & B) if sxs \< 48hrs onset * symptomatic tx = B2 agonists, fluids, rest
38
PNA - Fungal
Common in IMC pts (AIDS, steroid use, organ transplant) _Coccidiodes_ (valley fever) * non remitting cough/bronchitis non responsive to conventional tx * Fungal inhalation in Western States * Dx with ELISA for IgM and IgG * Tx with **fluconazole/itraconazole** _Pulmonary aspergillosis_ - health immune systems * **fluconazole/itraconazole** _Cryptococcus_ - soil, disseminate and a menintitis * LP for meningitis * Tx with **amp B** _Histoplasmosis_ - apical pulmonary lesions resembling cavitary TB, worsening cough and dyspnea, progression to disabling respiratory dysfx * bird or bat droppings - Mississippi Ohio River Valley * Signs - mediastinal or hilar LAD (sarcoid) * tx with **amp B** _HIV - PJP (Pneumocystis jiroveci)_ Common in HIV pts with CD4 count \< 200 * CXR - diffuse interstitial or bilateral perihilar infiltrates * dx - bronchoalveolar lavage PCR, labs, HIV tests, low O2 despite supplemental oxygen * Tx with **bactrim** and steroids
39
Curb-65 Score
Hospitalization for Pneumonia Severity * Confusion * Urea \> 7 * RR \> 30 * BP \< 90/60 * Age \> 65yo 0-1 = low risk 2 = probable admission vs close outpt mgmt 3-5 = admission & manage as severe
40
Pneumothorax
Collapsed lung caused by accumulation of air in pleural space _Spontaneous vs traumatic_ * primary - abs of underlying dz (tall, thin, male age 10-30 at greater risk) * Secondary - presence of underlying dz (COPD, asthma, CF, ILD) SXS: * Acute onset ipsilateral chest pain and dyspnea - **decreased tactile fremitus** * deviated trachea * **hyperresonance** * Diminished breath sounds Tx - depends on size * **small \< 15%** of diameter of hemithorax - resolves spontaneously w/o chest tube placement * **large \> 15%** diameter & symptomatic - chest tube placement * Serial CXR q 24 hrs until resolve
41
Tension PTX
penetrating injury -\> air in pleural space increasing and unable to escape Mediastinal shift to contralateral side and impaired ventilation CXR = pleural air ABG = hypoxemia medical emergency - large bore needles to allow air out of chest Chest tube for decompression
42
Pulmonary Embolism eti, sxs
blockage in one of pulmonary arteries in lungs MCC - deep veins of LEs RF: * Virchow's Triad * Hypercoagulable state (sx, CA, OCP, preg, smoking, long bone fracture) * Venous stasis * Epithelial injury Sxs * Dyspnea MC * pleuritic chest pain * Tachycardia --\> EKG with **S1Q3T3, non spec ST waves** * Tachypnea
43
Well's Criteria
44
Pulmonary Embolism dx
Dx - Well's score assess probability of PE * **Spiral CT - best initial test** * **Pulm angiography - gold standard** * CXR - Westermark sign or Hampton Hump (Triangular or rounded pleural base ) BUT NORMAL VQ scans - old school ABG = **respiratory alkalosis** 2/2 hyperventilation =\> **resp acidosis** D-Dimer only if LOW suspicion - RULE OUT
45
Pulmonary Embolism tx
**Hemodynamically stable** 1. Anticoags * **Warfarin** - 3 mos bridge with heparin 3-5 days * INR range 2-3 * **Heparin** - acute phase with followed by factor Xa inhibitors **Rivaroxaban or** PO Direct Thrombin Inhibitors **Dabigatran** * Minimal antigoag for 3 mos w/ reversible RFs * if unprovoked - 6 mos then reeval * If two eps unprovoked - long term anticoag 1. **IVC filter -** stable pt who can't take anticoags or unsuccessful UNSTABLE 1. **Thrombolectomy** - if unstable or massive PE
46
Respiratory Syncytial Virus
MCC LRTI in children - get by age 3 leading cause of PNA and bronchiolitis sxs * Rhinorrhea * wheezing/coughing that persists for months * low grade fever * nasal flaring/retractions * nail bed cyanosis Tx * hospitalization if * tachypnea w/ feeding difficulties * visible retractions * O2 Sat \<95% * Supportive care * albuterol via neb * antipyretics * humidified O2 * Steroids (controversial) * Resolves in 5-7 days Vaccines for children with lung issues or premature --\> **synagis prophylaxis (palivizumab)** 1x/m for 5 mos in Nov
47
Tuberculosis eti, sxs
**Mycobacterium tuberculosis** RF - endemic area, IMC (HIV), recent immigrants (\<5yo), prisoners, health care workers transmission - inhalation of aerosolized droplets Sxs: * fatigue, productive cough, bloody sputum * night sweats, wt loss, post tussive rales
48
Tuberculosis Screening
PPD - Tb skin test Mantoux Test Rules - tests positive if * \>5mm at high risk, fibrotic changes on CXR, IMC HIV/Drugs, steroids/TNF antagonist daily, or close contact w/ infectious TB * \> 10mm in pts \< 4yo, and risk factors = health care facilities, IVD, recent immigrants with high prevalence, renal insufficiency, prison, homeless shelter, bypass surgery * \> 15mm if no other risk factor
49
Tuberculosis Dx
* **Sputum for AFB smears** - have to be 3 AFB negatives * NAAT - quicker dx * CXR - cavitary lesions, infiltrates, ghon complexes in **apex of lungs** * **Bx - caseating granulomas** * miliary TB = spread outside lungs =\> vertebral column (Pott disease)
50
Tuberculosis tx
_Empiric tx_ PPD + & CXR negative - latent TB =\> Isoniazid 9 mos +B6 for neuropathy PPD + & CXR positive - active TB =\> quad therapy (RIPE) * **Rifampin** - red orange urine, hepatitis * **Isoniazid** - perip neuropathy (B6 pyridoxine 25-50mg/day) * **Pyrazinamide** - hyperuricemia (gout) * **Ethambutol** - optic neuritis (eye changes), red green blindedness Need two negative AFB smears and cultures to stop therapy Prophy isoniazid for household members - for 1 year dc therapy if transaminases \> 3-5 x ULN
51
Shortness of Breath
RR \> 25 or \< 10 O2 Sat \< 92% usu in older adults weak respiratory effort Hypercapnia - elevated CO2 on ABG DDx * Asthma * COPD * CHF Tx * HFNC or rebreathing mask 100% O2 * Albuterol for asthma and COPD * Lasix for CHF * BiPAP for respiratory difficulty and low O2 sat * Intubation for severe cases
52
SOB Pearls
VS addressed first SOB - initial tx is O2 R/o Pulm and cardio etis CXRs, CBC, CMP, BNP, Trop, EKG on all patients ABGs - resp is functioning

Emergency Medicine (13 decks)

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