What is acute bronchitis?
cough > 5 days with or without sputum production, lasts 2-3 weeks
- chest discomfort
- shortness of breath
- +/- fever
What is the etiology of acute bronchitis?
viruses (most common)
-cannot distinguish acute bronchitis from URTI in the first few days
What are the labs for acute bronchitis?
labs not indicated, unless pneumonia suspected (HR>100, RR >24, T>38, rales, hypoxemia, mental confusion, or systemic illness) - CXR
What is the tx for acute bronchitis?
antibiotic not recommended - mostly viral
- symptomatic-based treatment NSAIDs, ASA, Tylenol, and/or ipratropium
- cough suppressants - codeine-containing cough meds
- bronchodilators (albuterol)
What is the presentation of asthma?
most often young patients present with wheezing and dyspnea often associated with illness, exercise and allergic triggers
-airway inflammation, hyperresponsiveness, and reversible airflow obstruction
How do you diagnosis with asthma?
diagnosis and monitor with peak flow
- PFT’s: greater than 12% increase in FEV1 after bronchodilator therapy
- FEV1 to FVC ratio <80% (you would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
- in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio
What is the tx for mild intermittent asthma?
less than 2 times per week or 3-night symptoms per month
-step 1: short acting beta2 agonist (SABA) prn
What is the tx for mild persistent asthma?
more than 2 times per week or 3-4 night symptoms per month
-step 2: low-dose inhaled corticosteroids (ICS) daily
What is the tx for moderate persistent asthma?
daily symptoms or more than 1 nightly episode per week
- step 3: low dose ICS + long acting beta2 agonist (LABA) daily
- step 4: medium-dose ICS + LABA daily
What is the tx for severe persistent asthma?
symptoms several times per day and nightly
- step 5: high-dose ICS + LABA daily
- step 6: high-dose ICS + LABA + oral steroids daily
What is acute treatment for asthma?
oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
What is forced vital capacity?
- forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath
- the amount of air exhaled may be measured during the first (FEV1), second (FEV2), and/or third seconds (FEV3) of the forced breath
- forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
- you would expect the amount of air exhaled during the first second to be the greatest amount
- in asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a decreased FEV1 to FVC ratio
What is bronchiectasis?
a condition in which the lungs’ airways become dilated and damaged, leading to inadequate clearance of mucus in airways
- mucus builds up and breeds bacteria, causing frequent infections
- a common endpoint of disorders that cause chronic airway inflammation (CF, immune defects, recurrent pneumonia, aspiration, tumor)
- 1/2 of cases are due to cystic fibrosis
What are the symptoms of bronchiectasis?
include a daily cough that occurs over months or years and production of copious foul-smelling sputum, frequent respiratory infections
How is bronchiectasis dx?
CXR=linear “tram track” lung markings, dilated and thickened airways - “plate-like” atelectasis; CT chest = gold standard
-crackles, wheezes, purulent sputum
What is the tx for bronchiectasis?
ambulatory oxygen, aggressive antibiotics for acute exacerbations, CPT (chest physiotherapy = bang on the back); eventual lung transplant
What is a carcinoid tumor?
a tumor arising from neuroendocrine cells = leading to excess secretions of serotonin, histamine, and bradykinin
What are the characteristics of carcinoid tumor?
- common primary sites include GI (small and large intestines, stomach, pancreas, liver), lungs, ovaries, and thymus
- carcinoid syndrome (the hallmark sign) is actually quite rare and occurs in approximately 5% of carcinoid tumors and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation
- carcinoid syndrome = diarrhea, shortness of breath, flushing, itching
How is carcinoid tumor dx?
octreotide scan, urine for 5-hydroxyindoleacetic acid (5-HIAA), serum niacin, CT scan to locate tumor
What is the tx for carcinoid tumor?
is by surgical excision and carries a good prognosis
- the lesions are resistant to radiation therapy and chemotherapy
- octreotide - a somatostatin analog which binds the somatostatin receptors and decreases the secretion of serotonin by the tumor
- niacin supplementation
What is chronic obstructive pulmonary disease?
a chronic inflammatory lung disease that causes obstructed airflow from the lungs due to loss of elastic recoil and increasing airways resistance
What are the characteristics of chronic obstructive pulmonary disease?
- includes emphysema and chronic bronchitis = both usually coexist with one being more dominant
- damage to the lungs from COPD can’t be reversed
- 30 pack-year history = low dose chest CT
What are the risk factors of chronic obstructive pulmonary disease?
- cigarette smoking/exposure is the most important risk
- alpha 1 antitrypsin deficiency = genetic and linked to COPD in patients <40 y/o (protects elastin in lungs from damage by WBCs)
What is emphysema?
- exposure to irritants (eg cigarette smoke) - degrades elastin in alveoli, airways - lose elasticity - low pressure during expiration pulls walls of alveoli inward - collapse - air-trapping distal to collapse - septa breaks down - neighboring alveoli coalesce into larger air spaces - decreased surface area available for gas exchange
- loss of elastin - lungs more compliant (lungs expand, hold air)
- alveolar air sacs permanently enlarge, lose elasticity - exhaling is difficult
- DOE = hallmark symptom
- hyperinflation of lungs + hyperresonance to percussion, decreased/absent breath sounds, decreased fremitus, barrel chest (increased AP diameter), quiet chest, pursed-lip breathing
- individuals are able to oxygenate blood (pink) but they have to purse their lips to do so (puffers) = Pink Puffers
- pursing lip increases pressure in airway - keeps the airway from collapsing - weight loss
- barrel chest due to air trapping and hyperinflation of lungs
- CXR reveals loss of lung markings, hyperinflation, increased anterior-posterior diameter
- PETs show FVC decreases (esp. FEV1) + increased TLC (due to air trapping)
- ABG/labs: respiratory alkalosis, mild hypoxemia, normal CO2
- cachectic with pursed-lip breathing - “pink puffers”
What is chronic bronchitis?
defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause
- exposure to irritants (e.g cigarette smoke) - hypertrophy/hyperplasia of bronchial mucous glands, goblet cells in bronchioles, cilia less mobile - increased mucus production, less movement - mucus plugs - obstruction in bronchioles - air trapping - productive cough
- rales (crackles), rhonchi, wheezing, signs of cor pulmonale (peripheral edema, cyanosis)
- ABGs: respiratory acidosis (arterial PCO2>45 mmHg, bicarbonate >30 mEq/L)
- PET’s: FEV1/FVC ratio less than 0.7
- increased TLC (air trapping)
- chest radiography: peribronchial and perivascular markings
- increased HGB and HCT are common because of the chronic hypoxic state
- pulmonary HTN with RVH, distended neck veins, hepatomegaly
- obese and cyanotic = blue bloaters
What are the diagnostic studies for chronic obstructive pulmonary disease?
- PFTs/spirometry = gold standard diagnosis COPD
- FEV1 = important factor of prognosis and mortality (<1 L = increased mortality)
- obstruction: decreased FEV1, decreased FVC, decreased FEV1/FVC
- hyperinflation: increased lung volumes: increased RV, TLC, RV/TLC, increased FRC (functional residual capacity)
- CXR/CT scan
- emphysema: hyperinflation: flat diaphragm, increased AP diameter, increased vascular markings, enlarged right heart border
- ECG: cor pulmonale: RVH, RAE, RAD, r-sided heart failure (due to longstanding pulmonary hypertension), MAT, hypertension
What are the clinical therapeutics for chronic obstructive pulmonary disease?
-smoking cessation = single most important step
-bronchodilators: combo therapy (Beta2 agonist + anticholinergic = greater response than used alone - tx of choice in stable COPD with resp. symptoms
-short acting (SAMA) or long-acting (LAMA) muscarinic agent (also known as an anticholinergic agent): tiotropium (spiriva) inhaled long-acting; ipratropium (atrovent)
-ipratropium preferred over short-acting B2 agonist in COPD
s/e: dry mouth, thirst, blurred vision, urinary retention, difficulty swallowing, mydriasis
-contraindications: glaucoma, BPH
-short acting (SABA) or long-acting (LABA) beta 2 agonist: albuterol, terbutaline, salmeterol (long-acting)
-s/e: B1 cross-reactivity, tachycardia/arrhythmias, muscle tremor, CNS stimulation
-contraindications: severe CAD; caution in pt. with DM (hyperglycemia), hyperthyroid)
-theophylline: only used in refractory cases bc narrow therapautic index - monitor serum levels to prevent nausea, palpitations, arrhythmias, seizures from toxic levels; higher doses needed in smokers and coffee drinkers - don’t initiate in acute exacerbation
-+/- inhaled glucocorticoids: inhaled corticosteroids not considered monotherapy
-s/e: osteoporosis, thrush
-oxygen: only medical therapy proven to decrease mortality (decreases pulmonary hypertension/cor pulmonale by decreasing hypoxia-mediated pulmonary vasoconstriction)
-long-term oxygen therapy in all patients with COPD who have chronic hypoxemia defined as resting PaO2 <55 mmHg or SaO2 <89
What is the tx for stage I for chronic obstructive pulmonary disease?
mild
- FEV1 >80%
- bronchodilators prn short-acting/decrease risk factors
What is the tx for stage 2 for chronic obstructive pulmonary disease?
moderate
- FEV1 50-80%
- above + long-acting dilator
What is the tx for stage 3 for chronic obstructive pulmonary disease?
severe
- FEV1 30-50%
- above + pulm rehab; inhaled steroids if increased exacerbations
What is the tx for stage 4 for chronic obstructive pulmonary disease?
very severe
- cor pulmonale, right heart failure, resp failure, FEV1 <30%
- above + O2 therapy
What is the health maintenance for chronic obstructive pulmonary disease?
- control triggers: pollutants, bronchospasm, cardiopulmonary disease, meds (decongestants, B blockers, sedative)
- infections: bronchitis and pneumonia
- prevention of exacerbations: SMOKING CESSATION
- vaccinations: pneumococcal and influenza every fall
- pulmonary rehab: improves the quality of life, dyspnea, and exercise intolerance
- surgery: lung reduction surgery - improves dyspnea by removing damaged lung; lung transplant
- azithromycin has anti-inflammatory properties in the lung
What is cor pulmonale?
right ventricular enlargement and eventually failure secondary to lung disorder that causes pulmonary artery HTN
What is the etiology of cor pulmonale?
COPD (most common), pulmonary embolism, vasculitis, asthma, ILD, acute respiratory distress syndrome
What is the physical exam of cor pulmonale?
lower extremity edema, neck vein distention, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2
How is cor pulmonale dx?
- the diagnosis of cor pulmonale is usually made with an echocardiogram that shows evidence of increased pressure in the pulmonary arteries and right ventricle
- follow up tests can be done to identify the underlying cause, for example, spirometry can be done to look for chronic lung disease
- the gold standard diagnostic test to directly measure pulmonary pressures and assess for response to vasodilating medications is a right heart catheterization
What is the tx for cor pulmonale?
diagnose and treat the underlying condition before cardiac structure change becomes irreversible
-diuretics not helpful, may be harmful
What is hypoventilation syndrome?
may be secondary to several mechanisms, including central respiratory drive depression (drugs - narcotics, benzodiazepines, neurologic disorders - multiple sclerosis, etc.), neuromuscular disorders (ALS, myasthenia gravis, etc.), chest wall abnormalities, obesity hypoventilation, and COPD
What are the characteristics of hypoventilation syndrome?
- obesity hypoventilation syndrome (OHS), also known as Pickwickian syndrome, is a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels
- s/s: sluggish/sleepy during day
- sequalae: pulmonary hypertension, cor pulmonale, secondary erythrocytosis
How is hypoventilation syndrome dx?
PFTs, sleep studies, CXR, arterial blood gas, serum bicarb
What is the treatment of hypoventilation syndrome?
lifestyle, healthy weight, physical activity, CPAP, tracheostomy
-sleep apnea fails into this category
What is idiopathic pulmonary fibrosis?
a type of lung disease that results in scarring (fibrosis) of the lungs for an unknown reason
What are the characteristics of idiopathic pulmonary fibrosis?
- over time, the scarring gets worse and it becomes hard to take in a deep breath and the lungs cannot take in enough oxygen
- etiology unknown: MC of all interstitial lung diseases
- in order to be considered “idiopathic”, you must rule out other common causes such as drugs (amiodarone), and environmental or occupational exposures
- non-idiopathic: smoking, viral infections, environmental (silica, hard metal dust), medications, genetics, XRT, GERD
- physical exam: inspiratory crackles
How is idiopathic pulmonary fibrosis dx?
CXR shows fibrosis
- CT chest: diffuse patchy fibrosis with pleural based honeycombing
- PFTs = restrictive (decreased lung volume, normal/increased FEV1/FVC ratio)
How is idiopathic pulmonary fibrosis tx?
few effective treatment options other than a lung transplant
-corticosteroids, O2
What is pneumoconiosis?
any fibrosis of the lung tissues with a known cause - usually from prolonged environmental or occupational contact
What is Coal Worker’s?
coal mining; complication = progressive massive fibrosis
-CXR: small nodular opacities in upper lung fields
What is Silicosis?
mining, sandblasting, stone, quarry work; increased risk TB and progression to massive fibrosis
-CXR: small rounded opacities throughout the lung, hilar lymph nodes may be calcified - “eggshell” calcifications
What is Asbestos?
insulation, demolition, shipbuilding, construction; complication = mesothelioma
-CXR: interstitial fibrosis, thicken pleura, calcified plaques appear on diaphragms or lateral chest wall
What is Berylliosis?
high tech field, nuclear power, ceramics, aerospace, electrical plants, foundries; requires chronic steroids
-CXR: diffuse infiltrates and hilar adenopathy
What are the s/sx of pneumoconiosis?
SOB + nonproductive cough + chronic hypoxia, cor pulmonale
How is pneumoconiosis dx?
CXR: interstitial fibrosis
-PFTs = reduced lung volume - restrictive dysfunction and reduced diffusing capacity
What is the tx for pneumoconiosis?
primarily supportive = oxygen, vaccinations (pneumococcal, flu) and rehab
- steroids to relieve chronic alveolitis
- smoking cessation = synergistically linked to lung cancer
What is viral pneumonia?
adults = flu = MC cause; kids = RSV; comes on fast
- Dx: CXR = bilateral interstitial infiltrates; rapid antigen testing for flu, RSV nasal swab, cold agglutinin titer negative
- Tx: flu with Tamiflu (A and B) if sx began <48 hrs; symptomatic tx = beta 2 agonists, fluids, rest
What is bacterial pneumonia?
fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum
- dx: patchy, segmental lobar, multilobar consolidation; blood cultures x2, sputum gram stain
- tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs
What is fungal pneumonia?
common in immunocompromised pt (AIDs, steroid use, organ transplant)
What is coccidiodes (valley fever)?
non-remitting cough/bronchitis non-responsive to conventional tx
- fungal inhalation in western states; test with EIA or IgM and IgG
- tx: fluconazole/itraconazole
What is pulmonary aspergillosis?
usually those with healthy immune systems
-tx: fluconazole/itraconazole
What is cryptococcus?
found in soil; can disseminate and = meningitis
- lumbar puncture for meningitis
- tx: amphotericin B
What is histoplasma capsulatum?
pulmonary lesions that are apical and resemble cavitary TB; worsening cough and dyspnea, progression to disabling respiratory dysfunction; no dissemination
- bird or bat droppings (caves, zoo, bird); Mississippi ohio river valley
- signs: mediastinal or hilar LAD (looks like sarcoid)
- Tx: amp B
What is PJP (pneumocystis jiroveci)?
- common in HIV patients with CD4 count <200
- XR: diffuse interstitial or bilateral perihilar infiltrates
How is PJP dx?
bronchoalveolar lavage PCR, labs, HIV test; low O2 sat despite supplemental oxygen
What is the tx of PJP?
bactrim and steroids; pentamidine for allergy
-prophylaxis for high risk pt with Cd4 <200 = daily bactrium
What is CURB65?
estimates mortality of community-acquired pneumonia to help determine inpatient vs outpatient treatment
- confusion, urea >7, RR >30, SBP <90 OR DBP <60, age >65
- 0-1 = low risk, consider home tx
- 2 = probable admission vs close outpatient management
- 3-5 admission, manage as severe
What is pulmonary hypertension?
blood pressure in the lugs is usually very low 15/5
-in pulmonary hypertension, the pressure increases > 25 mmHg at rest
What are the characteristics of pulmonary hypertension?
- usually caused by an underlying disorder (constrictive pericarditis, mitral stenosis = MC, LV failure, mediastinal disease compression pulmonary veins)
- mitral stenosis: mitral valve = tight so blood can’t pass into left ventricle = pressure backs up to lungs
- when the right heart can’t pump against vascular resistance = right heart failure = cor pulmonale
What is the presentation and physical exam of pulmonary hypertension?
- presentation: dyspnea on exertion, fatigue, chest pain, edema
- physical exam: loud pulmonic component of second heart sound (P2); jugular venous distention; ascites; hepatojugular reflux; lower limb edema
How do you dx pulmonary hypertension?
a right heart catheterization (gold standard) - most accurate measure of pressures
- CXR:
- enlarged pulmonary arteries
- lung fields may or may not be clear, dependent on the underlying cause
- Echocardiogram:
- increased pressure in pulmonary arteries, right ventricles - dilated pulmonary artery
- dilation/hypertrophy of right atrium, right ventricle
- large right ventricle - bulging septum
- ECG - right heart strain pattern: T wave inversion in right precordial (V1-V4), and inferior leads (II, III, aVF)
What is the tx for pulmonary hypertension?
identify and treat the underlying cause
- pulmonary hypertension secondary to left ventricular failure - optimize left ventricular function
- diuretics (cautiously - individuals may be preload dependent)
- digoxin
- anticoagulants
- cardiogenic pulmonary arterial hypertension
- relax smooth muscle (promote vasodilation), reduce vascular remodeling, improve exercise capacity with prostanoids, phosphodiesterase inhibitors, endothelin antagonists
- pulmonary arterial hypertension
- endothelin receptor antagonists
- prostanoids
What are the two major categories of lung cancer?
- small cell lung cancer (SCLC), about 15% of cases (poor prognosis)
- non-small cell lung cancer (NSCLC), about 85% of cases, four subtypes include adenocarcinoma, squamous cell carcinoma, large cell carcinoma and carcinoid tumor
What is small cell lung cancer?
(15% of cases) - 99% smokers, does not respond to surgery and metastases at presentation
- location: (central mass), very aggressive
- treatment: combination chemotherapy needed
- paraneoplastic syndrome: Cushing’s, SIADH
What is non-small cell?
(85% lung cancer cases)
- adenocarcinoma
- squamous cell (central mass)
- large cell
- carcinoid tumor
What is adenocarcinoma?
most common (peripheral mass), 35-40% of cases of lung cancer
- most common
- associated with smoking and asbestos exposure
- location: periphery
- paraneoplastic syndrome: thrombophlebitis
What is squamous cell?
(central mass) with hemoptysis, 25-35% of lung cancer cases
- location: central
- may cause hemoptysis
- pareneoplastic syndrome: hypercalcemia
- elevated PTHrp
What is large cell?
fast doubling rates - responds to surgery rare (only 5%)
- location: periphery 60%
- paraneoplastic syndrome: gynecomastia
What is carcinoid tumor (1-2%?
lack glandular and squamous differentiation
- a tumor arising from neuroendocrine cells - leading to excess secretion of serotonin, histamine, and bradykinin
- GI tract carcinoid tumor may metastasize to lung (CA of appendix = MC; appendix - liver - lung)
- presentation: hemoptysis, cough, focal wheezing, recurrent pneumonia
- carcinoid syndrome = cutaneous flushing, diarrhea, wheezing, hypotension (telltale sign)
- adenoma = MC type (slow-growing, rare)
What is the tx for non-small cell?
can be treated with surgery
- treatment depends on staging:
- stage 1-2 surgery
- stage 3 Chemo then surgery
- stage 4 palliative
- carcinoid tumors are treated with surgery
What is the tx for small cell?
CAN NOT be treated with surgery will need chemotherapy
- associated manifestations:
- superior vena cava syndrome (facial/arm edema and swollen chest wall veins)
- pancoast tumor (shoulder pain, Horner’s syndrome, brachial plexus compression)
- Horner’s syndrome (unilateral miosis, ptosis, and anhidrosis)
- Carcinoid syndrome (flushing, diarrhea, and telangiectasia)
What is sarcoidosis?
chronic autoimmune inflammatory disease in which small nodules (granulomas) develop in lungs, lymph nodes, and other organs, increased ACE levels + bilateral hilar adenopathy
-pulmonary manifestations (most common); skin = 2nd most; skin and lymph = mot common areas
What are the symptoms of sarcoidosis?
- symptoms vary, depending on the organs affected - fever, weight loss, arthralgias, erythema nodosum = initial presenting sx
- Lupus pernio (chronic, violaceous, raise plaques and nodules commonly found on cheeks, nose, eyes) = pathognomonic for sarcoid and most specific physical exam finding
How is sarcoidosis dx?
chest radiograph: bilateral hilar lymphadenopathy, reticular infiltrates
- hypercalcemia; ACE levels 4x normal, elevated ESR
- biopsy of peripheral lesions or fiber optic bronchoscopy for central pulmonary lesions
- biopsy = non-caseating granulomas
What is the tx for sarcoidosis?
steroids = 90% respond to steroid
- methotrexate, other immunosuppressive meds
- serial PFTs to assess disease progression/guide treatment
- ACE-I for periodic HTN
prognosis depends on disease severity; spontaneous improvement common
-pulmonary fibrosis = leading cause of death
What is pulmonary nodules?
< 3 cm = nodules, >3 cm = mass
- found on CXR = get CT
- if suspicious = biopsy (ill-defined lobular or spiculated suggests cancer)
- not suspicious = < 1 cm monitor at 3 cm, 6 mo, yearly for 2 yr (calcification, smooth well defined edges = benign
What are the radiographic characteristics that help to define the malignant potential of solitary pulmonary nodules?
- growth rate determined by comparison of previous CXR or CT
- the lesion that hasn’t grown in >2 yr = benign
- double from 21-40 days = malignant
- small (< 1 cm) monitor at 3, 6 mo then yearly for 2 yr
- calcification suggests benign especially if central, concentric, popcorn
- margins that are spiculated or irregular = CA
- diameter <1.5 cm strongly suggests benign; diameter >5.3 cm strongly suggests CA
What is the tx for pulmonary nodules?
management depends on radiographic findings
-if malignant = biopsy
