Exam 2 (S6 UE3)

Overview of the different types of Obstructive lung disease

(Chronic Bronchiolitis is sometimes referred to 'small airway disease,' and may be seen in any type of obstructive disease, and has a restrictive counterpart) COPD: I. Emphysema: alveolar wall destruction, overinflation -small airway disease that affects the acinus lvl -morphological diagnosis II. Chronic Bronchitis: productive cough -airway inflammation -clinical diagnosis Asthma: reversible obstruction -bronchial hyperresponsiveness triggered by allergens, infections, etc.

Comparison of UFH and LMWH and adverse effects

(Protamine sulfate used to reverse heparin) Adverse: -hemorrhage -immune-mediated thrombocytopenia (HIT) -osteoporosis w/ long-term use

**Describe the Effect of Exercise on Arterial Blood Gases in Interstitial Disease

**Causes increased V/Q mismatching! Characteristic drop in PO2 and O2 saturation w/ exercise in ILD

Pyrazinamide common SE's, monitoring, drug interactions

**Hepatotoxicity hyperuricemia (gout)

Bacterial tracheitis most common cause, pathogenesis, presentation

**Most commonly due to Staph Aureus bacterial infection of the subglottic airway causing an obstruction as a result of subglottic edema and copious mucopurulent secretions. -secretions become inspissated and form casts of the bronchopulmonary tree -may mimic foreign body aspiration more common than epiglottitis but much less common than LTB. Presentation: -insidious onset of URI prior to the onset of stridor -high fever -respiratory distress -barky/brassy cough -toxic appearing -sudden onset resp. distress w/ obstruction that may be repetitive -retractions

Isoniazide Side Effects, interactions, monitoring

**Peripheral neuropathy Hepatotoxicity Rash

Unilateral sinusitis indicates what possible etiologies?

**RED FLAG!! Consider inverting papilloma, Squamous cell carcinoma, lymphoma, angiofibroma.

Small cell carcinoma of the lung

**metastasizes VERY EARLY (liver, bone, CNS, adrenal glands) appears submucosal **Central location- star burst picture Histo: -Kulchitsky-type cells of neuroectodermal origin -diffuse sheets of small cells Most rapidly growing lung cancer Ectopic hormone production (ACTH, calcitonin (hypercalcemia), ADH(hyponatremia)) Highly Associated w/ smoking **Therapy= chemo for all stages

Preseptal vs orbital cellulitis

*Preseptal*-> mild infection eyelid anterior to the orbital septum - outpatient oral antibiotics *Orbital* -> serious infection posterior orbital septum, *pain extraocular movt, diplopia, opthalmoplegia* (dangerous complications: blind + intracranial infection) - in patient IV antibiotics **Most feared complication= cavernous sinus thrombosis hard to tell w/ just physical exam

List some Chronic Comorbid conditions associated w/ asthma

- Allergic bronchopulmonary aspergillosis (ABPA) - Obesity - Gastroesophageal reflux disease (GERD) - Rhinitis/sinusitis - Obstructive sleep apnea (OSA) - Stress/depression Treating comorbid conditions may improve overall control of asthma and lessen requirements for asthma medications.

What pathogens commonly cause acute bacterial sinusitis?

- Haemophilus influenzae - Moraxella catarrhalis - Streptococcus pneumoniae - Anaerobic organisms

What is the standard dose of epinephrine IM?

.01mg/kg

What is the maximum dose of epinephrine?

.3mg/kg

American Thoracic Society Classification of Pulmonary TB

0 - No tuberculosis exposure (no exposure history, PPD neg) I - Tuberculosis exposure, no evidence of infection (history of exposure, PPD neg) II - Tuberculosis infection without disease (positive PPD, negative chest x-ray and microbiologic evaluation III -Tuberculosis: infected with disease (positive PPD with x- ray and microbiologic evidence of active infection)

Asthma is characterized by?

1. A syndrome - not a single disease 2. Usually characterized by chronic airway inflammation 3. Variable/reversible airway obstruction 4. Airway hyperresponsiveness

Asthma risk factors

1. Allergy history, a family history of asthma (the strongest) 2. Respiratory viral infection (especially in childhood) 3. "Hygiene Hypothesis" a reduction in bacterial exposure in childhood (↓TH1(IgG) resulting in ↑TH2 (IgE)) 4. Air pollution 5. Obesity 6. Occupational exposure: Work-related asthma (WRA)

What are the two Asthma Cellular Endotypes (based on Sputum Cytology)

1. Eosinophilic (Th2 high) 2. Noneosinophilic (Th2 low): -adult onset -poor response to glucocorticoids

List the 4 Cellular Classifications of Asthma Based on Sputum Cytology

1. Eosinophilic (classic atopic asthma) 2. Neutrophilic (acute and chronic infection, obesity, smoking) 3. Mixed eosinophilic and neutrophilic (refractory asthma) 4. Paucigranulocytic asthma: no observable inflammatory cells

Silicosis increases the risk of?

1. Lung cancer 2. M. Tuberculosis and Atypical Mycobacterium 3. Rheumatoid Arthritis and Systemic Sclerosis

What are the 2 types of Asbestos fibers?

1. Serpentine (chrysotile): -Curly stranded curved structures -95% of all asbestos used commercially -low malignancy risk 2. Amphibole (crocidolite, amosite, and tremolite): -straight, rod-like fibers -high malignancy risk

Tumors of Mixed Histology

10% of lung cancers are mixed histology diagnosis of exclusion Image: basophilic cells of signet-ring cell adenocarcinoma (more on left) mixed with larger, eosinophilic cells of squamous cell carcinoma (more on right)

Figure out the dose of epinephrine for a 10kg patient

10kg x 0.01mg/kg = .1mg Remember 1:1,000 epi, which is the strength used for IM administration, we have to use 1mg/1cc SO.. 0.1mg = .1cc of 1:1000 IM

Epistaxis management

1st attempt squeezing nose shut for 10 minutes Vasoconstrictors (Afrin Spray) if conservative measures fail Chemical cautery (Silver Nitrate) -first apply topical lidocaine Electric cautery (if Afrin and Silver nitrate unsuccessful) Then try packing -anterior packing: vaseline gauze left in for 3-4 days- MUST be put on antibiotic prophylaxis -posterior pack (if ant. fails or posterior bleed known): requires IV sedation for placement, and Abx monitored in hospital Surgery if all else fails: -septoplasty -maxillary A. ligation (in pterygopalatine fossa) -Ethmoidal A's ligation for posterior bleeds (optic N at risk for damage) -Sphenopalatine A ligation -angiography/embolization

Describe the evaluation and treament sequence of a respiratory patient

1st: Evaluate the thoracic spine and treat any significant somatic dysfunctions. 2ng: check for and treat structural rib dysfunctions. 3rd:. treat any remaining respiratory rib dysfunctions. 4th: Address and balance the autonomic nervous system. -sympathetic NS via T2-T7 -parasympathetic NS via vagus N -chapmans point (sympathetic)

ABCD Assessment tool of COPD

1st: spirometry confirms diagnosis 2nd: Places patient in a Gold category based on an assessment of airflow limitation 3rd: then placed into category A-D based on an assessment of symptoms/risk of exacerbations

Tonsillectomy complications

2% post-operative hemorrhage -Most common 5-10 days after surgery Dehydration POPE—Post-obstructive pulmonary edema. Velopharyngeal insufficiency.

Massive hemothorax

2000-4000 cc blood loss Signs/symptoms: -absent breath sounds ipsilaterally -dull to percussion -hypotensive Tx: **must treat shock first -once shock controlled- then insert a chest tube -definitive care= open thoracotomy

Be able to convert weight b/w kg/lbs

22lbs 2.2lbs per kilogram (22lbs= 2.2lbs/kg) 22lbs x 1kg / 2.2lbs = 10kg

Asthma exacerbations are more common during what trimester of pregnancy?

2nd trimester

Embryology of nasal cavity

3 major structures: -brain -nasal cavity -oral cavity came from same starting place As hard palate develops, it separates nasal cavity from oral cavity Nasal bones derived from Neural crest cells

List some Reasons to Refer sinusitis to Otolaryngology

3-4 infections per year An infection that does not respond to two three-week courses of antibiotics Nasal polyps A complication of sinusitis

What is the initial tx of choice for TB? (initial phase- 1st 2 months)

4 drug regimen comprised of: -isoniazid -rifampin -pyrazinamide -ethambutol or streptomycin Once the TB isolate is known to be fully susceptible, ethambutol (or streptomycin) can be discontinued After 2 months of treatment, pyrazinamide can be stopped Sputum analysis for TB should be done weekly until conversion is documented

What would be the correct dose to give a 44lb child?

44/2.2= 20kg 20kg x 0.01mg/kg= .2cc SO correctly written as: Epinephrine 1:1000 0.2cc (or mg) IM

Croup Tx

5-10% require admission -persistent stridor at rest, exhaustion, toxicity, respiratory distress, hypoxia, dehydration, unreliable caregivers 1-6% require intubation -need for intubation is established by clinical examination revealing severe respiratory distress manifested by tachycardia, tachypnea, chest retraction, cyanosis, exhaustion, agitation, or confusion. Oxygen should be delivered to all pts if hypoxic Mist treatment Racemic epinephrine: -may be watched in the emergency department for several hours and then safely discharged if their condition remains stable Heliox: -decreases work of breathing in more severe cases -changes laminar flow properties of gas- lighter than O2- helps O2 flow in Dexamethasone (steroids)

Normal pediatric respiratory rate

50-60 breaths per minute (When counting respiratory rate, in infants and young children you should count for a full minute as they often will have a somewhat erratic breathing pattern)

Where is a chest tube placed?

5th intercostal space at the anterior or midaxillary line. just over the top of the rib

What is the target tidal volume for mechanical ventilation in ARDS patients?

6 ml/kg IBW tidal volume

How do most pulmonary emboli present?

60-80% are clinically silent -relatively small, and become incorporated/organized into the vascular wall

How is the continuation phase tx of TB different in pregnancy?

7 months long instead of 4 months Same 2 drug regimen: -Isoniazid -Rifampin

Most foreign body aspiration occur in what pts?

80% occur in children <3

What is the most common type and location of oral cancer?

90% are squamous cell carcinoma -lips- usually lower lip -tongue basal cell carcinoma if present is more common on upper lip

Presentation of Amniotic Fluid Embolism

A defect in membranes that allows amniotic fluid to enter maternal circulation Signs/symptoms: -Severe and sudden dyspnea -Frequent association with shock, massive hemorrhage -DIC in 50% of patients over ensuing hours Accounts for 7-10% of all maternal deaths Unpredictable and unpreventable - Process is more similar to anaphylaxis than embolism

Asbestosis

A diffuse parenchymal lung disease/ILD due to asbestos exposure Requires much higher dose of asbestos than the minimum necessary to cause mesothelioma and benign pleural disease long latent period Increased incidence of lung cancer with 60% increase in smokers Pathology: -Asbestos fibers penetrate macrophage and pulmonary epithelial cells around respiratory bronchioles causing an inflammatory response that progresses to peribronchiolar fibrosis

What is the function of Alpha-1 antitrypsin and how does it relate to emphysema?

A glycoprotein - The major inhibitor of serum proteases, including neutrophil elastase Degradation of interstitial elastin fibers by elastase is central in the development of emphysema The threshold point for increased risk of emphysema is an Alpha1-Antitrypsin level of about 80 mg/dL or less which is about 30% of normal

Hypersensitivity Pneumonitis (HP) (Extrinsic Allergic Alveolitis)

A group of diffuse parenchymal lung diseases caused by inhalation of organic or inorganic antigens I. Fungi → Farmer's lung wood pulp Worker's lung II. Animal protein - Bird Fancier's disease III. Bacteria (thermophilic actinomycetes - Farmer's lung) IV. Chemicals - Isocyanate HP, Amiodarone Pathology: -Immunologic disease involving T lymphocytes -Localize to the alveoli and distant bronchioles -Type IV hypersensitivity (granuloma formation) and Type III Antibody-antigen immune complex Clinical Features: -Variable: Depends on the stage of the disease -Acute: Abrupt onset chills, fever, arthralgias, myalgias, SOB, dry cough, chest tightness, bibasilar crackles -Subacute and Chronic: Progressive SOB, productive cough, weight loss, fatigue

What is Interstitial Lung Disease (ILD)

A group of disorders characterized by distinct cellular infiltrates and extracellular matrix deposition within the MSUC regions of the lung distal to the terminal bronchiole, i.e., the acinus

Cavitary TB

A large amount of organisms Upper lobes Infectious state High incidence of dissemination - Reinfect other lung segments - Erode blood vessels with lymph hematogenous spread - Adjacent nonpulmonary edges (larynx, ears, GI tract) Other complications - Superinfection (aspergilli, atypical mycobacterium) - Underlying carcinoma

Idarucizumab

A monoclonal antibody fragment shown to completely and almost immediately reverse serious bleeding in patients taking dabigatran First antidote for oral anticoagulant other than warfarin

Combitube

A multi-lumen airway device that consists of a single tube with two lumens, two balloons, and two ventilation ports an alternative airway device if endotracheal intubation is not possible or has failed

What must be done before a diagnosis of TB can be made?

A positive bacteriologic culture for M. tuberculosis is essential to confirm the diagnosis of tuberculosis

What is Non-Invasive Positive Pressure Ventilation (NIV/NIPPV)?

A pressure is delivered either in a continuous fashion, CPAP or split between inspiration and expiration (BiPAP) The patient generates a tidal volume depending on their respiratory mechanics Can be used in acute or chronic respiratory failure Modes of NIV • Conventional oxygen therapy (COT) - Nasal oronasal full facemask • Continuous positive airway pressure (CPAP) • Bi-level positive pressure (BiPAP) • High-frequency nasal cannula (HFNC) for acute respiratory failure • Helmet ventilation

malignant pleural mesothelioma

A rare malignant tumor of the parietal pleura or peritoneum resulting from asbestos exposure Smoking NOT a risk factor Not related to asbestos DOSE Long latency period (+40 years)

What is a positive TB skin test (Mantoux test)

A reaction of ≥ 5mm is positive in: • Close contacts to patients with infectious tuberculosis • Persons with HIV infection • Persons who have chest radiographs with fibrotic lesions A reaction of ≥ 10mm is positive in: • Persons with medical risk factors that increase the risk of tuberculosis once the infection has occurred • Foreign-born persons from high prevalence countries • Low-income populations, including high-risk minorities • Intravenous drug users • Residents of long-term care facilities, such as correctional institutions and nursing homes • Other high-risk populations identified locally e.g., health care workers in some areas A reaction of ≥ 15mm is positive in: • Persons with no additional risk factors for tuberculosis

ExtraCorporeal Membrane Oxygenation (ECMO)

A technique for pulmonary bypass in which deoxygenated blood is removed, passed through a circuit that oxygenates the blood, and then returned. Used for selected newborn and pediatric patients in respiratory failure with an otherwise good prognosis

Sellick maneuver

A technique that is used with intubation in which pressure is applied on either side of the cricoid cartilage to prevent gastric distention and aspiration and allow better visualization of vocal cords; also called cricoid pressure.

AMPLE mnemonic for History in trauma patient

A- allergies M- medications P- past illnesses L- last meal E- events preceding

ABCDEFG Primary survey

A= airway maintenance w/ C-spine control B= breathing -assess for pneumonothorax -assess for large flail chest w/ contusion C= circulation w/ hemorrhage control -pulses, capillary blanch -direct compression, topical clotting agents D= disability: neurological status -a= alert -v= responds to verbal stimuli -p= responds to painful stimuli -u= unresponsive E= expose: completely undress the pt F= fetal heart tone G= RhoGAM if pregnant and Rh-

Goodpasture syndrome

Ab's against basement membrane (anti-GBM antibodies) -specifically the a3 subunit of type IV collagen Damage to lungs and kidney -lungs effected b4 kidneys Usually Males 20-40's Signs/symptoms: -pulmonary hemorrhage, recurrent hemoptysis -rapidly progressive glomerulonephritis (RPGN) - can lead to uremia and death Tx: Apheresis -vascular system hooked up to machine -blood leaves pt, gets centrifuged, splits into red cell, white cell, and plasma layers -plasma layer is removed and filtered to remove auto-Ab's -blood then pumped back into pt

Mycobacterium Leprae General Properties

Acid fast, slightly curved bacillus Metachromatic granule near pole or center Contains mycolic acids (as other mycobacteria) Large amounts specific phenolic glycolipid Loss of acid fastness by pyridine extraction Characteristic slow growth curve in footpads of mice Ability to oxidize dihydrooxyphenylalanine (DOPA) Tendency to infect peripheral nerves of humans

Describe the pulmonary pathology in ILD.

Acute Injury -> Propagation -> Chronic Fibrosis

When should Invasive Mechanical Ventilation be used?

Acute Respiratory Failure is the major indication for mechanical ventilation Two basic causes: I. Hypoxic Respiratory Failure: Failure to adequately oxygenate - ineffective gas exchange 1. V/Q mismatch 2. Shunt 3. Decreased FRC II. Hypercapnic Respiratory Failure- Failure to adequately ventilate: 1. Reduced respiratory drive 2. Respiratory muscle fatigue 3. Decreased compliance: Chest wall, lung parenchyma

Histoplasmosis clinical manifestations

Acute pulmonary histoplasmosis • Fever, chills, fatigue, myalgia, dyspnea, non- productive cough • Chest x-ray - Patchy infiltrates - Multilobar, nodular infiltrates with hilar and mediastinal nodes Granulomatous mediastinitus • Large mediastinal, hilar nodes, necrotic • Impinge on adjacent structures • Dysphagia, chest pain, cough • Tracheoesophageal fistula Chronic cavitary pulmonary histoplasmosis • Fever, fatigue, anorexia, weight loss, productive cough, hemoptysis • Chest x-ray • Mimmics tuberculosis • Cavitary upper lobe infiltrate Fibrosing mediastinitus • Young women • Excessive fibrotic response in mediastinum • Entrapment of great vessels and bronchus • Dyspnea, cough, wheezing, hemoptysis • Superior vena cava syndrome, heart failure, pulmonary emboli Disseminated Infection: -immunocompromised pts (AIDS, transplants, TNF inhibitors, steroids) -symptoms: chills, fever, malaise, anorexia, weight loss, dyspnea, hypotenison, ARDS, sepsis, DIC Labs: pancytopenia, elevated alkaline phosphatase

Inhaled SABAs (Short acting beta agonists) should be used for?

Acute relief

Peritonsillar Abscess

Adolescents/young adults w/ preceding history of tonsillitis treated partially or untreated Presentation: -unilateral throat pain -severe dysphagia -trismus -drooling PE: -tonsils pushed down medially toward midline, displacing uvula Tx: -Incision & Drainage -Abx -may require hospital admission

List some consequences of Septic Shock

Adrenal gland necrosis due to DIC (Waterhouse-Friderichson Syndrome) Cardiovascular collapse Increased vascular permeability and endothelial injury lead to lung failure and acute respiratory distress syndrome Anuria can develop due to acute tubular necrosis and renal failure Multiorgan failure involving liver, adrenals, etc. can result

Advantages/Disadvantages of SQ/IM Medications (Epinephrine, Terbutaline, Methylprednisolone)

Advantages: -Does not require pt cooperation -fast onset Disadvantages: -require shot (not good for children) -more side effects than aerosol

Advantages/Disadvantages of Inhaled Medications (Albuterol)

Advantages: -Easiest to use if cooperative -Can be administered w/ or w/o oxygen -Heliox changes laminar flow properties- oxygen and meds float w/ it -Forane for severe attacks- usually given in ICU not ED Disadvantages: -slightly longer onset -used by mask in a young child (may freak out) -racemic epinephrine often commits to admit -forane always used in ICU

Advantages/Disadvantages of IV medications (Epinephrine, Theophylline (rarely), Isopreterenol(last ditch)

Advantages: -fastest onset after IV started -dosage can be titrated Disadvantages: -requires IV site -more side effects because 100% absorbed -Isoproterenol and Propofol commit you to an ICU bed for admit. Again these are only used very rarely for the very severe patient

Advantages/Disadvantages of oral medications (albuterol, steroids(prednisone), Theophylline, Terbutaline)

Advantages: -no needles -can help tide pt over Disadvantages: -other than steroids, oral rarely used for bronchodilation -slower onset- not used for acute attacks -more for chronic conditions

Mycobacterium Tuberculosis characteristics

Aerobic, non-spore-forming, non-motile bacillus A mycolic acid cell wall Slow generation time Acid-fast positive with Ziehl Neelsen stain UCO Fluoreses positive with auramine fluorochrome stain Lacks pigment Produces niacin and heat sensitive catalase Reduces nitrates Sensitive to INH

Allergic Rhinitis

Afebrile, clear nasal drainage, may have polyps Allergy tests positive IgE positive Family History Positive Seasonal symptoms. - Pollen • Bluegrass, Timothy, Ragweed Perennial symptoms: - Household allergens • Dust mites, molds, feathers, animal dander

Vasomotor Rhinitis

Afebrile, clear nasal drainage. Allergy tests negative. IgE negative Family history negative. Pathophysiology: rhinitis secondary to overactive parasympathetic activity from a wide variety of triggers. - Environmental triggers: humidity and temperature changes, dust, smoke, and pollution - Endocrine and metabolic: pregnancy, oral contraceptives (estrogen inhibits anticholinesterases) Other triggers: -Medications: antihypertensives, antipsychotics, cocaine -Psychotropic: anxiety, stress, exercise

How does the presentation of Stage IV Sarcoidosis present differently in Caucasians vs African americans?

African Americans more commonly present with: -honeycomb scar -restrictive Disease Caucasians more commonly present w/: -Bronchovascular distortion -obstructive disease

At what point is an emergent surgical airway needed?

After 3 failed airway attempts of intubation emergent- cricothyroidotmy non-emergent- tracheostomy

Otitis media with effusion(OME):

After the acute phase passes, sterile fluid remains which will either clear in about 90 days of may become re-infected. Concern for malignancy in adults -Thorough exam of head and neck to include the larynx and nasopharynx.

Large cell lung cancer

Aggressive large cell carcinoma bulky, peripheral or central invade pleura, adjacent lung anaplastic type metastasis can cavitate Histo: numerous large cells -NO glands

What causes asthma?

Airway Inflammation is a result of complex interaction between multiple T-cells and chemical mediators Inflammatory cells derived from the circulation (eosinophils, lymphocytes, mast cells, and macrophages) Structural cells (epithelial and endothelial cells, fibroblasts and smooth muscle cells) Results in structural changes called "airway remodeling"

Oropharyngeal airway

Airway adjunct inserted into the mouth of an unresponsive patient to keep the tongue from blocking the upper airway and to facilitate suctioning the airway, if necessary. NEVER use in concious pt or patient with gag reflex

How does pregnancy effect the Upper Respiratory Tract?

Airway mucosal changes • Hyperemia, hypersecretions, mucosal edema Consequences • Nasal obstruction • Epistaxis • Sneezing spells • Changes in voice • Polyposis of the nasal sinus mucosa

What cartilage allows you to flare your nostrils?

Alar cartilages

Indications for use of Non-Invasive Positive Pressure Ventilation (NIV/NIPPV)

Alert/cooperative Able to protect airway (in tact gag reflex) - PaO2/FiO2 > 200 mmHg - Hypercapnia: PaCO2 > 45 and 7.3 < pH < 7.35 - Severe dyspnea: ↑ WOB - Tachypnea: RR > 24 breaths/min Primarily used in acute respiratory failure due to: - Acute exacerbation of COPD - Acute CHF/pulmonary edema

Orbital cellulitis tx

All pts must be admitted IV Abx ENT and Optho consult Recurrent exams: vision, pupil response May need decompression surgery or abscess drainage

Non pharmacological management of COPD pts

All stages of disease - Smoking cessation - Avoidance of indoor and outdoor occupational exposures Vaccinations - Influenza - Pneumococcal - limited documented evidence Optimizing nutrition • Pulmonary rehabilitation • Address depression/anxiety • Address end-of-life measures palliative care, hospice As indicated: -Surgery: LVRS, lung transplantation -Bronchoscopy: Endobronchial valves, coils -Home O2

Clinical uses of Antihistamines

Allergic rhinitis and conjunctivitis Pruritis Urticaria Angioedema Motion sickness - dimenhydrinate (Dramamine) Insomnia, anxiety - diphenhydramine Drug-induced parkinsonism - diphenhydramine

What is the purpose of the Eustachian tube?

Allows equalization of air pressure so the tympanic membrane does not rupture. Children: -short and straight -more susceptible to ear infection (from nasopharyngeal infection) Adults: -angled up and to the side

What labs are used for Dx of COPD?

Alpha 1 Antitrypsin level (by ATS/ERS in all patients diagnosed with COPD) Arterial blood gases (helpful to have a baseline)

Two blood tests for COPD endotypes are:

Alpha1 antitrypsin Blood eosinophil count -may be responsive to corticosteroid inhaler

Streptomycin common SE's, monitoring, drug interactions

Aminoglycoside: binds 30S ribosome and causes misreading of genetic code **CNVIII damage Nephrotoxicity

Histoplasma Tx

Amphotericin B Azoles/triazoles in milder cases

Coccidioidomycosis Tx

Amphotericin B= 1st choice in severe/immunocompromised Fluconazole/itraconazole in mild/moderate infection

Candidiasis Tx

Amphotericin B= mainstay Flucytosine of benefit if added to Amphotericin B Echinocandins (Capsofungin)= alternative

Why is a saturation of 90% significant?

An SaO2 (arterial oxygen saturation) value below 90% causes hypoxia below 90% sat. it rapidly drops to 0%

Open pneumothorax

An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound; also referred to as a sucking chest wound. Management: -sterile occlusive dressings fixed on 3 sides (flutter valve effect- some air can exit but not enter as well) -chest tube -may need definitive surgery

Allergic Fungal Rhinosinusitis (AKA: Intrinsic rhinitis, Hyperplastic rhinitis, Eosinophilic nonallergic rhinitis)

Analogous to Allergic Bronchopulmonary Aspergillosis (ABPA) 5-10% of chronic rhinosinusitis -Allergic rhinitis seen in 67% of these patients -Asthma seen in 50% of these patients Early symptoms: nasal airway obstruction Late symptoms: extensive nasal polyposis -Pain is uncommon (pain suggests a bacterial infection) Dx: -Afebrile, clear nasal drainage, intranasal polyps -IgE positive -eMBP antigen (Eosinophil Major Basic Protein) -Alt-1 antigen (Alternaria)

Andexanet (AndexXa)

Andexanet (coagulation factor Xa (recombinant) - inactivated -xhzo- is FDA- approved as a reversal agent for life- threatening hemorrhage caused by apixiban and rivaroxaban.

Perennial Allergic Rhinitis tx

Animals outside No smoking in house Molds are found in: - Houseplants - Basements - Showers - Humidifiers (also increases house mites) Minimize use of rugs To get rid of mites: -wash bed linen in 140 degree water -plastic pillow liner and water bed Electric HEPA air filters

Describe the lymphatic drainage for the oral (anterior 2/3) and pharyngeal (posterior 1/3) portions of the tongue.

Anterior 2/3: -submandibular nodes -> deep cervical nodes -submental nodes -> deep cervical nodes Posterior 1/3: -jugulodigastric -deep cervical nerves Hard and soft palate: -retropharyngeal nodes -> deep cervical nodes

Ethmoidal sinuses drainage, innervation, blood supply, venous drainage, lymph drainage

Anterior and middle cells drain to middle nasal meatus Posterior cells drain to superior meatus • Close proximity to optic n. Innervation • Nasocilliary n. (branch of V1) Blood supply • Anterior ethmoidal aa. from ophthalmic a. • Sphenopalatine a. Venous drainage • Corresponding veins Lymph drainage • Submandibular nodes • Retropharyngeal nodes

Describe the location of the anterior and posterior chapmans points that relate to the respiratory system

Anterior points (diagnostic): -Upper lung: on either side at the 3rd intercostal space just lateral to the sternum -Lower lung: on either side at the 4th intercostal space just lateral to the sternum Posterior points (therapeutic): -Upper lung: on either side of the spinous process of T3 -Lower lung: on either side of the spinous process of T4

Describe the lymphatic drainage of the anterior and posterior nose.

Anterior portion: -submental -submandibular Posterior -deep cervical nodes -> retropharyngeal/jugulodigastric nodes

how does the antigen load in TB effect the presentation of disease?

Antigen load low - tissue hypersensitivity high - Granuloma Antigen load and tissue hypersensitivity high - Caseous necrosis

Seasonal Allergic Rhinitis tx

Antihistamines Decongestants Nasal Steroids (Fluconase, Nasonex, Nasocort AQ, Rhinocort Aqua) Singulair (montelukast) -selectively binds to cystenyl leukotriene receptors Allergy desensitization

Apnea vs Hypoapnea

Apnea: -cessation of thermal sensor airflow by >90% of baseline for more than 10 seconds Hypoapnea: -a 50% or greater decrease in airflow or less than 50% airflow associated w/ arousals

Which races tend to be slow vs fast acetylators?

Approximately 50 percent of African Americans and Caucasians are "slow acetylaters" -Slow acetylation may lead to higher blood levels of the drug and thus, to an increase in toxic reactions. The rest are "rapid acetylaters" -Majority of Eskimos and Asians are "rapid acetylaters."

Larynx anatomy

Aretynoid cartilage: -attach to vocal cords -tense or relax cords

Specify the major blood supply and venous drainage of the larynx.

Artery supply: I. External carotid artery: • Superior thyroid a. • Superior laryngeal a. II. Subclavian artery: • Inferior thyroid a. • Inferior laryngeal a. Venous drainage: I. Superior thyroid v. • Superior laryngeal v. • Inferior laryngeal v. II. Middle thyroid v. III. Inferior thyroid v.

Fulminant Fungal Sinusitis/mucormycosis most common pathogen

Aspergillus most common as well as the Saprophytics (no idea what this guys is trying to say... he said aspergillus is the most common cause of mucormycosis even though thats a separate fungus itself so........)

Adverse Side Effects & Complications of NIPPV

Aspiration pneumonia Pneumothorax

Mendelson's Syndrome

Aspiration pneumonia associated with delivery Declining due to its awareness of the problem leading to improved obstetric care Factors that predispose to aspiration during labor and delivery: -Raised intragastric pressure due to the gravid uterus -Relaxed gastroesophageal sphincter tone (progesterone effect) -Delayed gastric emptying that accompanies pregnancy -Vigorous abdominal palpation examination -Reduced consciousness due to anesthesia and analgesia

List some drugs/substances that can Precipitate Asthma

Aspirin NSAIDs Tartrazine dye (yellow) Metabisulfites (used as preservatives) Beta-adrenergic antagonists Cholinesterase inhibitors-e.g. pyridostigmine Methacholine Ozone, sulfur dioxide

Nasal polyps are associated w/?

Associated w/ Allergies and Cystic Fibrosis tx: steroids may help Histo: -outgrowth of normal mucosa -Mixed inflammation with abundant neutrophils, eosinophils, and plasma cells would be seen, and this mix is typical for an allergic process.

Nasopharyngeal Carcinoma

Associated w/ EBV #1 malignancy in parts of Africa in southern China and Southeast Asian islands, the most/one of the most common cancers in ADULTS Risk factors: -diets high in nitrosamines, like fermented and salt-cured foods; smoke byproducts; chemicals in common use, etc Histo: -resembles an undifferentiated carcinoma, and consists of vaguely epithelioid, larger tumor cells with pale cytoplasm. -Mixed in are abundant smaller lymphocytes, and sometimes the lymphocytes will be so numerous the tumor may resemble lymphoma. Keratinizing type: -produce keratin, scant lymphocytes -poor 5-year survival rate Non-keratinizing type: -scant lymphocytes w/ no keratin -good 5-year survival rate

Squamous Cell Carcinoma (SCC)

Associated w/ SMOKING Gross: -lesions centrally located w/ cavitation and obstruction/compression of vital structures Micro: **keratin pearl formation and intercellular bridges

How can Mechanical ventilation cause organ injury?

Associated with numerous complications: Infections: Ventilator-Associated Pneumonia (VAP) from bypassing host defense mechanism Neurologic: Cognitive Decline, Delirium Respiratory: Ventilator Induced Lung Injury (VILI) Musculoskeletal: Critical Care Myopathy

Definition of asthma

Asthma is a chronic inflammatory disease of the airways in which many inflammatory cell types play a role, in particular mast cells, eosinophils, T-lymphocytes, neutrophils, and epithelial cells In susceptible individuals, the inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough—particularly at night and/or in the early morning These symptoms are usually associated with widespread but variable airflow obstruction that is at least partly reversible either spontaneously or with treatment This inflammation also causes an associated increase in airway responsiveness to a variety of stimuli

What is meant by "Airway hyperresponsiveness" in asthmatic patients?

Asthmatic airway resistance will increase far more than in normals, for a given degree of smooth muscle shortening Airway wall thickening in asthma may account for a large part of airway hyperresponsiveness

When should you ventilate in ARDS?

At all levels of PaO2/FiO2 mechanical ventilation is always an option PaO2/FiO2 between 200-300 w/ PEEP= Non-Invasive PPV PaO2/FiO2 between 100-200 w/ PEEP= Mechanical Ventilation PaO2/FiO2<100mmHg w/ PEEP= Mechanical ventilation PLUS prone positioning, ECMO

Idiopathic Pulmonary Hemosiderosis

Autoimmune disease- unkown etiology Young children (2-10) Females Triad of: -hemoptysis -parenchymal infiltrates on chest radiograph -iron-deficiency anemia Characteristic histology: -alveolar capillary hemorrhage and accumulation of hemosiderin (rare disease characterized by repeated episodes of bleeding into the lungs, which can cause anemia and lung disease. The body is able to remove most of the blood from the lungs, but a large amount of iron is left behind.)

How does invasion into the pleura affect tumor staging?

Automatically upstages tumor to at least a T2 (out of T4)

Explain how you avoid Atelectrauma and Volutrauma on mechanical ventilation

Avoid Atelectotrauma (collapsed lung/alveoli): add PEEP Avoid Volutrauma: decreased tidal volume

What antibiotic may be beneficial in current nonsmokers who continue to have exacerbations on maximal inhaled therapy

Azithromycin (induces antiviral state in bronchial epithelial cells)

Pertussis treatment

Azithromycin Sulfa as an alternative if>2 months **MUST start Abx WITHIN 2 weeks or will NOT shorten course BUT still given b/c it might decrease shedding of bacteria

Menier's disease symptoms and triggers

Believed to be caused by changes in the fluid in tubes of the inner ear (endolymph) Symptoms: -fluctuating hearing -tinnitus -aural fullness -vertigo Triggers: (The no CATS approach.) •Caffeine •Alcohol, Aspirin products •Tobacco •Sodium

Specify the location of the retropharyngeal space and describe its clinical significance.

Between the pre-vertebral fascia (posterior) and Buccopharyngeal fascia (anterior) in the cervical region if infected, allows for spread from oral cavity to thoracic cavity

Specify the major innervation, blood supply and venous drainage of the pharynx.

Blood supply: -Facial arteries (from carotid) -branches of the external carotid artery: Ascending pharyngeal artery. Venous drainage: -facial vein -internal jugular vein Innervation: -glossopharyngeal (CN IX)- sensory to pharynx and motor to sylopharyngeus -vagus (CN X): motor innervation to pharyngeal constrictor muscles

Describe the Clinical Approach to the ILD Patient

Blood tests, serologies, etc. Pulmonary functions test Chest radiograph High-resolution computed tomography (HRCT) Bronchoscopic procedures as indicated Endobronchial and transbronchial biopsies Bronchoalveolar lavage (BAL) Surgical biopsy video-assisted thorascopic surgery (VATS) if needed to establish a diagnosis

What are the possible risks of taking Heparin during pregnancy?

Bone loss of pregnancy accelerated with heparin (osteoporosis related fx may be as high as 2- 3%) HIT (Heparin Induced Thrombocytopenia) Bleeding All risks appear reduced with LMWH

Fractures of the larynx are indicated by the following triad

Bony crepitus (a dry, crackling sound or sensation) Subcutaneous emphysema Hoarseness

What is the most common pediatric congenital neck mass?

Brachial cleft cysts -2nd brachial cleft most common (between the hyoid and thyroid cartilages, just anterior to the sternocleidomastoid m.)

Blood supply of the nose

Branches of maxillary branch of external carotid artery: - Sphenopalatine - Pharyngeal - Descending palatine - Posterior nasal Branches of the internal carotid artery: - Anterior ethmoid - Posterior ethmoid

Innervation of the Larynx

Branches of the Vagus N. (CN X) Superior Laryngeal Nerve branches: I. Internal branch (from the epiglottis to vocal cords) II. External branch (cricothyroid muscle) III. Recurrent laryngeal N. -sensory innervation to larynx and trachea (below lvl of vocal fold) -motor innervation to intrinsic muscles of the larynx **Superior laryngeal N. can be injured during Cricothyrotomy** Effects of damage: -internal laryngeal/ external laryngeal: weak voice, with decreased pitch -recurrent laryngeal: hoarseness

Rifampin MOA

Broad spectrum-inhibits growth of most gram + and gram - bacteria MOA: Inhibits DNA-dependent RNA polymerase -Prevents the bacillus from synthesizing mRNA and protein. unique antibacterial properties against dormant bacilli that are no longer in the active phase of replication. PCK: -Excreted via the biliary tract ( up to 65%). -part of drug is excreted in unmetabolized form and reabsorbed in intestine, increasing serum lvls of drug -75-80% bound to plasma proteins

Adenocarcinoma of the lung

Bronchealveolar epithelium peripheral, small, confined to one lobe prior lung injury may predispose females NOT assx w/ smoking Invades pleura and lymph nodes Histo: glandular

Definitive dx of endobronchial lesions

Bronchoscopy

Indoor air pollution is caused by?

Burning Biomass Fuels: -Wood, charcoal, crop residues, dung More than 50% of premature deaths due to pneumonia among children under 5 caused by particulate matter More common in developing countries: -Africa -India -Asia

What is the most common cause of Pleural effusion?

CHF (transudative) Followed by pneumonia (exudative)

Describe the relationship between CN IX and the retropharyngeal space.

CN IX lies in the palatine tonsil erosion through the fascia and superior constrictor muscle puts pathogens into the lateral pharyngeal space -> retropharyngeal space -> superior mediastinum (most often affected by tonsillitis)

List the most common causes of Dyspnea

COPD CHF/Pulmonary Edema Ischemic heart diseases including unstable angina and MI Arrhythmias Pneumonia Psychogenic

What is the best tx for OSA?

CPAP

If imaging is done for sinusitis what is the preferred method?

CT (not necessary to dx sinusitis)

Cangrelor (Kengreal)

Cangrelor is a nonthienopyridine ATP analog which binds reversibly to P2Y12 ADP receptors to prevent platelet activation It is given IV with a Tmax of 2 minutes and a half-life of 3-6 minutes. It is approved for use in PCI in patients who have not been pretreated with a P2Y12 inhibitor and are not receiving a glycoprotein IIb/IIIa inhibitor

Löfgren Syndrome

Caused by sarcoidosis Classic Triad of: - Erythema nodosum - Hilar lymphadenopathy - Arthralgias (ankle)/arthritis Another Feature: - Fever (often)

Vasomotor Rhinitis tx

Chemical cautery Anticholinergic nasal sprays (ipratopium bromide) - Atrovent Nasal 2 sprays each nostril tid/qid Azelastine (Astelin) Nasal Spray - 2 sprays each nostril bid **Oral antihistamines and nasal steroids DO NOT give symptomatic relief in most patients. Surgical Management: - Surface turbinate cautery • Electrocautery, chemical cautery, cryotherapy - Septoplasty removes mechanical points of irritation - Partial Turbinectomy - Division of parasympathetic fibers

COPD clinical features

Chest Exam • Increased AP Diameter • Decreased intensity of breaths and/or heart sounds • Wheezing and prolonged expiratory time • Pursed-lip breather and use of accessory respiratory muscles • Hoover's sign - the inward movement of the rib cage during inspiration Other Clinical Features • Fatigue • Depression/Anxiety • Weight loss/Muscle wasting • Anorexia • Osteoporosis vertebral collapse rib fracture from coughing • Ankle swelling

Mesothelioma Clinical features

Chest pain (usually dull), slowly progressive shortness of breath, weight loss, fatigue Paraneoplastic syndromes can occur: DIL, hemolytic anemia, hypoglycemia, hypercalcemia Pleural effusion in 60% of patients CXR: Irregular or lobulated pleural thickening Diagnosis: Pleural disease Very poor prognosis no really good treatment option

Chest X-rays of a Patient with Advanced Emphysema

Chest x-ray - not useful in diagnosing COPD but, helps rule out other diseases - Typical COPD findings: increased airspace (barrel chest), radiolucency, flat diaphragm, + increased retrosternal airspace.

Interstitial lung disease Dx

Chest x-ray: -10% or more of pts with ILD have normal chest X-ray **High resolution computed tomography (HRCT)

What are the 2 types of COPD?

Chonic bronchitis: -production of sputum most days for at least 3 months -2 consecutive years -all other causes of chronic cough excluded Emphysema: -abnormal, permanent enlargement of the distal air spaces, distal to the terminal bronchioles -accompanied by destruction of their walls and without obvious fibrosis.

Silicosis X-ray findings

Chronic disease: 1 °involves UPPER lung zones ***Progressive Massive Fibrosis (PMF) **May see "egg shell calcification" in hilar lymph nodes

Pseudochylous & Chyliform Effusions

Chylomicrons & fat globules are absent Pseudochylous - Lipid mainly comprises cholesterol crystals Chyliform - Lipid may be lecithin-globulin complexes Both seen in chromic pleural effusions from many causes (TB, Ca, RA, etc.

Otitis externa tx

Clean the canal Topical antibiotic therapy to cover Gram + and -, especially pseudomonads* - Aminoglycosides (avoid Neomycin due to rxns) - Fluoroquinolones - Systemic antibiotics generally not required for uncomplicated cases Suitable pain management

Criteria for use of Non-Invasive Positive Pressure Ventilation (NIV/NIPPV)

Clinical criteria • Alert • Cooperative • Able to protect airway • Demonstrate: moderate to severe respiratory distress • Increased dyspnea • Tachypnea • Use of accessory muscle • Paradoxical breathing pattern Blood gas criteria • PaCO2 > 45 mmHg (> 6.0 kPa) and pH < 7.35, or PaO2/FiO2 > 200

Crytococcus clinical manifestations

Clinical manifestations - Asymptomatic - Fever, nonproductive cough, chest pain, weight loss - Acute respiratory failure - Immunocompromised have associated CNS involvement

What are some Common Parameters that should be Monitored During Mechanical Ventilation

Clinical: Physical exam - Vital signs - Patient's WOB - EKG Ventilator - RR, VT (tidal volume), VE (minute ventilation) - Airway pressure, especially the plateau (goal <30), peak waveforms - Compliance (static/dynamic) Pulse oximetry/ABG

Criteria for dx of Sarcoidosis

Clinicoradiographic findings Histologic evidence of noncaseating granuloma Exclusion of known causes of granulomatous disease Evidence of disease in at least two organs

Clopidogrel

Clopidogrel is a thienopyridine prodrug that irreversibly blocks the Gi-coupled platelet ADP (P2Y12) receptor and thus inhibits platelet aggregation. Equivalent to aspirin in secondary prevention of stroke Adverse: -GI bleeding -diarrhea, rash

Sphenoid Sinuses drainage, innervation, blood supply, venous drainage, lymph drainage

Close to optic canal, optic chiasm, pituitary gland, cavernous sinus, ICA Drain to sphenoethmoidal recess (superior meatus) Innervation • Nasocilliary n. (branch of V1) Blood supply • Anterior ethmoidal aa. from ophthalmic a. Venous drainage • Corresponding veins Lymph drainage • Retropharyngeal nodes

Tetanus

Clostridium tetani (gram (+) anaerobic bacilli) -produces toxin called tetanospasmin Hx of incomplete immunization and trivial injury Incubation of 3-21 days Presentation: -risus sardonicus (facial paralysis) -trismus -glottic/laryngeal spasm Tx: -admit to ICU -Tetanus immune globulin (TIG) -Metronidazole or Penicillin -wound debridement -paralysis/sedation may be needed to stop spasms -complete immunization series

What presentation of Adult Epiglottitis indicates the pt requires emergent airway management?

Combination of: Dyspnea Stridor Drooling

How does vitamin D excess effect PTH?

Compensatory Decrease

Antihistamine moa

Competitive antagonists (?) of histamine at histamine1 receptors on effector sites. (INVERSE AGONISTS) Inhibit histamine-induced vascular permeability, bronchial constriction, pruritis and erythematous flare Reverse but do not prevent responses mediated by histamine alone First-generation drugs have muscarinic antagonist properties

Montelukast (Singulair)

Competitive antagonists of leukotrienes Prevent but not reverse bronchoconstriction Effective for exercise and ASA-induced bronchoconstriction Generally less effective than inhaled corticosteroids FDA-required Black Box: neuropsychiatric events

Complications of pertussis

Complication more common in adults = pneumonia More common in unvaccinated children: -seizures -encephalopathy -death

Before "stepping down" treatment of asthma once control is maintained a patient must be?

Consider stepping down once control is maintained, to identify the lowest treatment step required to maintain control. Before stepping down must be stable on current controller for ≥ 3 months

Signs/symptoms of Hypercalcemia

Constipation Hyporeflexia Lethargy Somnolence/coma in severe hypercalcemia (Since calcium blocks sodium channels and inhibits depolarization of nerve and muscle fibers, increased calcium raises the threshold for depolarization)

Sarcoidosis signs/symptoms

Constitutional - Low-grade fever - Night sweats - Weight loss - Depression - Cranial nerve palsy - Erythema nodosum Pulmonary - Cough present in 90% of patients with acute pulmonary disease doesn't correlate with spirometry or chest x-ray - Dyspnea - Wheeze - Chest pain/pleurisy Some Common Findings in Sarcoidosis: • Lymphadenopathy • Mucocutaneous discoloration, granulomas • Uveitis • Hepatomegaly • Splenomegaly • Enlarged parotid salivary glands • Lupus pernio

Uncontrolled maternal asthma during pregnancy is associated w/ what fetal outcomes?

Control of asthma is essential to avoid fetal hypoxia Associated with - Increased perinatal and neonatal deaths - Increased prematurity (gestation < 37 weeks) - Low birth weight infants (wt < 2.5g) - Preclampsia - Congenital malformation A range of maternal and placental complications - Gestational diabetes - Placenta previa - Cesarean section

Fluticasone (Flovent)

Corticosteroid (inhaled) MOA: up-regulate beta-adrenergic receptors Other effects: -Decrease vascular permeability -Decrease leukotriene synthesis -Decrease late-phase inflammatory response -Inhibit transcription factors involved in asthmatic inflammation (nuclear kappa B) -Redistribution of monos, eos, and lymphs Use: -Asthma, COPD

What techniques can be used to treat the ParaSympathetic NS from a respiratory perspective?

Cranium and Cervical Spine Occipitomastoid suture release CV4 Condylar decompression Suboccipital muscle release C0-C1 (OA) C1-C2 (AA)

Air embolism most commonly occurs due to?

Decompression sickness -results when individuals experience a sudden decrease in atmospheric pressure (more than 100 cc (ml) of air is needed to have a clinical effect on pulmonary circulation,) Pathology: -air breathed in at higher pressures causes more of the gas (particularly nitrogen) to be in solution in the blood and tissues. -W/ a sudden decrease in pressure, the nitrogen comes out of solution and returns to a gaseous state, thereby causing air embolism. Signs/symptoms: -bends: gas bubbles in the skeletal muscle causing joint pain -chokes: respiratory distress caused by pulmonary gas emboli w/ edema, hemorrhage, focal atelectasis or emphyseyma

What pts are at higher risk of Cryptococcal infection?

Deficiencies in cell-mediated immunity (intracellular) Th1 response: -production of TNF, IFN, IL2

Blastomycosis dx, tx

Definitive dx= culture -Yeasts are large, thick-walled, and buds single and broad based -Stain with methenamine silver or PAS Serology -Ab tests not sensitive or specific -urine Ag available Tx- dont need to know: -amphotericin B -Azoles

Paraneoplastic syndromes in lung cancer

Digital clubbing - reactive periosteal changes in underlying -pulmonary arthropathy Periostitis: -Tibial pain due to periostial hyperactivity Hypercalcemia due to ectopic PTH like hormone Hyponatremia (ADH)- (sorry had this as hyper before) Cushing's syndrome: ectopic ACTH secretion Pancytopenia Acanthosis nigricans

Coccidiomycosis epidemiology/characteristics

Dimorphic fungus -arthroconidia (spores) -spherule w/ endospores (tissues) Southwestern USA, San Joaquin Valley, Arizona, Mexico Soil organism, dispersed in air Pathogenesis: -arthroconidia inhaled -> ingested by pulmonary macrophages -> convert to spherule w/ hundreds of endospores -> spherules rupture -> disseminate hematogenously -host control via cell-mediated immunity

Crytococcus dx, tx

Direct exam of specimens from bronchoscopy • Round encapsulated yeast cells (5 - 20 mm) Culture • No hyphae or pseudohyphae • Urease positive Histopathology • Pulmonary nodules, Bronchealveolar lavage, lung tissue • Gomoris methenamine silver stain, PAS stain, Fontana- Masson silver stain Serology not always useful- may be negative in immunocompetent -cryptococcal Ab may be false + in blastomycosis, histoplasmosis Tx- dont need to know -fluconazole, itraconazole, amphotericin B -severe immunocompromised: amphotericin B plus flucytosine for 2 weeks then fluconazole for 10 weeks

What is the gold standard for dx of TB?

Direct sputum microscopy X-ray showing Pulmonary opacities, most often apical

Direct vs Indirect insults in ARDS

Direct: -alveolar lumen -Pulmonary injury affecting lung epithelium Common: - Pneumonia (viral and bacterial) - Aspiration of gastric contents - Mechanical ventilation Indirect: -interstitium -Indirect Lung injury affecting the vascular endothelium Common: - Sepsis - Severe non-thoracic trauma with shock and multiple transfusion

If isolated isoniazid resistance is documented, what do you do?

Discontinue isoniazid and continue treatment with: -rifampin -pyrazinamide -ethambutol PLUS quinolone antibiotic (levofloxacin) For entire 6 months

Coal Worker's Pneumoconiosis (CWP) (Black Lung)

Disease resulting from chronic exposure to coal and dust Coal macules (small nodules) favor UPPER lung zones The severity of CWP corresponds to levels of coal and dust exposure and carbon content (highest: anthracite coal) Dx: better defined by HRCT compared to CXR Pathogenesis: -Coal dust engulfed by macrophage → inflammation → fibrosis -primary lesion is coal macule in upper lobes: consists of aggregates of dust-laden macrophages and fibroblasts in the respiratory bronchioles and alveoli -weakens bronchioles and causes focal emphysema

What is ARDS characterized by?

Disruption of alveolar-capillary membrane with increased permeability to intravascular fluid Alveoli fill with fluid Dyspnea, hypoxemia refractory to supplemental oxygen Decreased lung compliance and pulmonary infiltrates The hallmark of ARDS is a proteinaceous pulmonary edema that results from increased capillary permeability

When is Non-Invasive Positive Pressure Ventilation Contraindicated?

Do not use in patient who would be more safely managed invasively. For example: • Overt respiratory distress • Cardiac/respiratory arrest • Shock • Smoke inhalation (risk of airway edema) • Severe facial trauma or deformity • Glasgow coma scale score <10 • Gastrointestinal bleed Don't use if uncooperative or agitated Don't use if unable to protect airway

Stages in the Evolution of a Parapneumonic effusion

Do not want it to get past exudative stage

Frontal sinuses drainage, innervation, blood supply, venous drainage, lymph drainage

Drain to middle nasal meatus via frontonasal duct into semilunar hiatus Innervation • Supraorbital n. (branch of V1) Blood supply • Anterior ethmoidal aa. from ophthalmic a. Venous drainage • Supraorbital v. to ophthalmic v. Lymph drainage • Submandibular nodes

Pathogenesis of Mycobacterium Tuberculosis

Droplet nuclei inhaled and deposited lower lobes of lung (airflow greatest) Unstimulated macrophages ingest organisms - proliferate intracellularly Infected macrophages to regional nodes (hilar, mediastinal) T lymphocytes activated by macrophages -> replication -> cytokines -> activate macrophages (Epitheloid cells, Langerhans giant cells) -> granuloma formation Lymph hematogenous dissemination -Extrapulmonary (CNS, kidney, bone, etc.) -Secondary pulmonary (apical posterior lung) Factors influencing the fate of infection • Age of patient • Underlying immunocompromised states

List some drugs that have increased serum concentrations when co-administered with azoles

Drugs that are metabolized by CYP450 system: • Alprazolam • Carbamazepine • Cyclosporine • Digoxin • Fexofenadine • Imatinib • Lovastatin • Omeprazole • Tacrolimus • Warfarin

***Mycobacterium Avium Complex (MAC) dx and tx

Dx: -Sputums • Normal colonization • Pathogen if underlying cavities infiltrates - Blood Cultures - Lymph nodes, bone marrow, liver biopsies - Methods • AFB smear • Cultures • DNA probe • PCR Tx: -very resistant, requires multiple drugs I. Disseminated disease: -clarithromycin or azithromycin -ethambutol -rifampin II. Prophylaxis: -clarithromycin -azithromycin

Coccidiomycosis dx, tx

Dx: -definitive dx = culture -methenamine silver, PAS: spherules w/ endospores ELISA, IgG, IgM (sensitive and specific) Complement fixation: - 1:16 or > worsening disease Tx-dont need to know: -Amphotericin B -azoles -echinocandinds

Histoplasmosis dx, tx

Dx: -growth on tissue/fluid sample definitive for dx: uniform appearing 2-4um oval budding yeast Stains: -methamine silver or PAS -bone marrow, liver, lymph nodes, ulcers Urine antigen: -for disseminated infx Antibody tests: -Useful for chronic disseminated or chronic pulmonary histoplasmosis Tx- dont need to know: -amphoterisin B -azoles -echinocandins

Invasive Sinopulmonary Aspergillosis dx, tx

Dx: I. CT: ground glass attenuation surrounding a pulmonary nodule "halo sign", multiple nodules, lobar infiltrates to pleura II. Cultures: positive culture interpreted w/ risk factors: hematologic malignancies, neutropenia, HSCT III. Histology: dichotomous acute-angle branching hyphae, septate IV. Serology: galactomannan assay Tx- dont need to know -amphotericine B -azoles -echinocandins (capsofungin)

Myocardial Contusion

Dx: EKG, cardiac enzymes, history Risk is cardiac arrhythmias= sinus tachycardia Tx: admit and monitor for 48 hours

Epiglottitis Dx & Tx

Dx: do not do oropharyngeal exam -dx in surgery room under anesthesia Tx: -all pts admitted to ICU, intubated, oxygenated -Antibiotics that cover H. influenza (amoxicillin/clavulonate, ceftriaxone) -Prophylaxis w/ Rifampin

Adverse Effects of Inhaled Corticosteroids (Fluticasone)

Dysphonia Candidiasis (thrush) Growth retardation in children—but catch up Cataracts

ARDS clinical presentation

Dyspnea Tachypnea Hypoxemia Cyanosis Use of accessory respiratory muscles CXR: bilateral lung opacity ("white out")

Review the proteins that high risk HPV posesses

E6: -degrades p53 -loss of cell-cycle arrest/apoptosis -simulates expression of TERT (telomerase)- facilitating immortalization E7: -binds RB protein- promotes progression through cell cycle -inactivates CDK inhibitors p21 and p27B -activates cyclins E and A

Hairy leukoplakia is associated w/

EBV cannot be scraped off (candidiasis can be) When seen in immunosuppression, may indicate a more severe disease course or that current anti-viral therapies are waning in effectiveness

Acute suppurative otitis media appearance during each phase

Early TM appearance: still transparent, bulging Middle phase: suppurative (purulent fluid behind TM) Late phase: weeping and possible rupture

Early vs late stage laryngeal cancer tx

Early stage: -radiation therapy or surgery along -CO2 laser used most commonly Late stage: -laryngectomy

Give examples of drugs that decrease azole concentrations when co-administered:

Either CYP450 inducers or effect gastric absorption: • Antacids • Didanosine • Efavirenz • Nevrapine • Proton pump inhibitors • Phenytoin • Rifampin • Ritonovir

Two COPD types identified on CT imaging are:

Emphysema Bronchitis

ARDS pathophysiology

Endothelial cells and/or alveolar macrophages become injured and/or activated, and begin to release immune-promoting mediators, procoagulant proteins, cytokines of all types, etc. pulmonary and systemic immune rxns begin to occur Neutrophils migrate into pulmonary parenchyma from capillaries -> degranulate -> amplify immune response Vessels become leaky -> abundant fluid leaks into alveolar spaces formation of hyaline membranes -> diffuse alveolar damage

How does pregnancy effect the Lower Respiratory Tract?

Enlarging uterus leads to • Increased elevation in level of the diaphragm • Increase in the AP and transverse diameter of chest Function of the diaphragm and chest wall musculature is unimpaired and because tidal breathing is larger, excursions are increased

Epiglottitis presentation

Epiglottis lies at C2-C3 in infants rapid onset of respiratory distress w/ illness less than 24 hours high fever, a toxic appearance, and obvious respiratory distress with inspiratory stridor, if not overt respiratory failure. child will prefer to sit with the head extended and will drool rather than swallow saliva because of the severe pain with swallowing and may have a muffled or guttural voice. may have croupy cough Complications: -sudden respiratory arrest -accidental extubation -abnormal CXR -secondary foci of infection

Anaphylaxis treatment

Epinephrine Antihistamines only effective in treating cutaneous symptoms such as pruritis and urticaria

What is used acutely for rapid tx of Asthma?

Epinephrine Parenteral-subcutaneous, intramuscular or iv Onset -rapid; duration up to 4 hours

How would you write the dose for a 10kg pt given standard epi dose?

Epinephrine 1:1000 0.1mg IM (could also say 0.1cc IM) **ALWAYS put a zero before a decimal **NEVER put a zero after a decimal

Asthma clinical features

Episodes of cough, wheeze, dyspnea and chest tightness Large number of patients may not have classic symptoms and hence go undiagnosed. Need to consider in: - Recurrent bronchitis - Dyspnea with exercise - Unexplained chronic cough

Resuscitation components

Establish and maintain an adequate airway and ventilation IV therapy -fluids EKG monitoring Initiate shock management Catheters - NG and urinary if not contraindicated

ARDS pathophysiology

Evolves Around Gas Exchange: • Shunting and V/Q mismatch → Hypoxemia • Alterations to surfactant production and effectiveness • Lung mechanics reflect heterogeneous disease involvement • Decreased pulmonary compliance • Decreased FRC (Functional Residual Capacity) • Increased pulmonary vascular resistance • VO2 (oxygen consumption) to DO2 (delivery) markedly abnormal

Usual Presenting Symptoms in Interstitial Lung Diseases (ILD)

Exceptions • Acute onset of dyspnea, fever, malaise, headache and fatigue - Hypersensitivity pneumonias - Some drug-induced ILD's - Infection in immunocompromised host - Toxic gas inhalation Pulmonary involvement in collagen vascular disease - Scleroderma - Rheumatoid arthritis - Dermatomyositis

Exhalation ribs vs inhalation ribs

Exhalation Ribs: -restriction in inhalation -during inspiration one or more ribs cease rising entirely -top of rib group is key -intercostal muscle tightness and tenderness to palpation noted below key rib Inhalation Rib: -restricted in exhalation -during exhalation one or more ribs stop falling early -bottom rib of group is key -intercostal muscle tightness and tenderness to palpation noted above the key rib

Foreign body aspiration dx

Exhalation radiographs -affected lung will be hyper-inflated during exhalation Bronchoscopy

Full lepromatous leprosy

Extensive bilateral, symmetrical erythematous macules, papules or nodules Advanced skin thickening of face, nose, ears (classic leonine facies) Destruction nasal-maxillary structures Nerve involvement patchy less severe

Keratosis Obturans

External auditory canal cholesteatoma caused by blockage of the external auditory canal permitting accumulation of epithelial debris

Innervation of the Tympanic membrane:

External surface of TM & External Acoustic meatus - auriculotemporal nerve (CN V3) Internal surface - glossopharyngeal (IX) Small amount by X

What changes in lung function occur in pregnancy?

FRC decreased by 18% ((↓ ERV and ↓ RV) ↓lung volume due to elevation of diaphram, only partially offset by an increase in chest wall diameter Increased resp. drive and Minute Ventilation due to ↑ serum progesterone Primary respiratory alkalosis w/ renal bicarb wasting as compensation 30-35% increase in tidal volume -> ↑ minute ventilation (VE) -in excess of CO2 production Respiratory rate changes minimally early and rises only about 10% late in pregnancy Oxygen consumption (VO2) increases to 20-33% to increased maternal and fetal metabolic demands

Submandibular gland parasympathetic innervation

Facial Nerve (CN VII - via Chorda Tympani & Lingual Nerve)

List some indications for intubation

Failure of airway maintenance or protection Failure of ventilation or oxygenation Clinical condition is expected to deteriorate To manage other clinical problems

Describe the condition of cleft palate.

Failure of the mesoderm from the lateral Palatine processes to fuse at the midline (incisive foramen) Usually occurs from week 6-9

Differentiate b/w features that indicate a primary lung malignancy vs a metastasis

Features favoring a primary lung malignancy: -central desmoplasia -lepidic growth or irregular growth at the periphery of the mass (left image) -immunohistochemistry indicative of pulmonary origin (for TTF-1, napsin, etc.) -single lesions Features favoring a metastasis: -multiple masses, particularly located at the lung periphery; multiple masses that radiographically are round and uniform ('cannonball lesions') -lesions that microscopically look 'plopped' into the lung parenchyma (right image) -immunohistochemistry indicative of another location (ER/PR positivity for breast carcinoma, etc.)

Nonspecific Interstitial Pneumonia (NSIP)

Female smokers >60 Cough for several months w/o other features of ILD **NSIP pt's get BETTER w/ Corticosteroids (UIP pts may get worse)

What is Pneumoconiosis- list the types

Fibrotic lung diseases following inhalation of inorganic dust 3 types: -Silicosis -Coal Worker's Pneumoconiosis -Asbestosis and other asbestos related lung disease

What is the gold standard dx for an unknown neck mass?

Fine needle aspiration biopsy CT helpful to determine extent of lesion MRI better for upper neck and skull US used to determine cystic vs solid -helps to guide FNA (Any asymmetric neck mass in the adult must be considered malignant until proven otherwise.)

Cryptococcus Tx

Fluconazole= mild cases Amphotericin B= severe/immunocompromised Flucytosine may help when combined w/ amphotericin B in pts w/ disseminated disease

Describe the clinical importance of the piriform recesses and vallecula.

Food/medication may get stuck in the piriform recess: -pockets b/w the aryepiglottic folds (medial) and thyroid cartilage (lateral) Vallecula: -space b/w root of tongue and epiglottis -also may trap particles, pills, food, saliva

Sarcoidosis Tx

For patients with advanced pulmonary fibrosis from sarcoidosis, lung transplantation remains the only hope for long-term survival. Other patients: Corticosteroids Hydroxychloroquine can be used for cutaneous manifestations

M. Scrofulaceum

Frequently contaminates specimens, reagents, standing water Colonize respiratory secretions of well individuals Clinical: • Lymphadenitis, submandibular area • Children age 1-3 years • Enlarge slowly over weeks • May rupture with draining sinus Differential • M. Tuberculosis • PPD (-) Therapy • Surgical removal

List some Comorbidities Associated With IPF

GERD COPD Pulmonary hypertension Lung cancer Obstructive sleep apnea Venous thromboembolism

How does GFR change w/ pregnancy?

GFR increases 40-50% in pregnancy

Mycobacterium Avium Complex (MAC) clinical presentation

Gastrointestinal • Nausea, vomiting, diarrhea, abdominal pain, colitis, ileal and duodenal involvement Hematologic • Anemia, neutropenia Systemic • Fever, chills, night sweats, wasting syndrome, liver involvement (alkaline phosphatase) Pulmonary • Unusual site -cough, sputum production

Glycoprotein IIb/IIIa Inhibitors (Abciximab (Reopro), Eptifibatide (Integrilin), Tirofiban (Aggrastat)

Glycoprotein IIb/IIIa is a platelet-surface integrin that is a receptor for fibrinogen and von Willebrand factor. It anchors platelets to foreign surfaces and to each other, thus mediating platelet aggregation Activated by thrombin, collagen or thromboxane A2 Abciximab: -Fab fragment of a humanized monoclonal antibody directed against the IIb/IIIa receptor Epifibatide: ---a cyclopeptide derived from rattlesnake venom --reversible; may need dose reduction if poor renal function Tirofiban --a peptidomimetic inhibitor --reversible; may require dose reduction if poor renal function

obstructive sleep apnea (OSA) dx

Gold standard= polysomnography Epworth Sleepiness scale usually >16 (upper limit of normal=9) witnessed snoring/apneas have a high predictive value (64%)

List some Good vs Poor Prognostic variables of Sarcoidosis

Good Prognostic Variables: - Acute onset - Erythema nodosum - Acute iritis - Radiographic Stage I - Lofgren syndrome - Paucity of extrathoracic disease Poor Prognostic Variables: - Insidious onset - Radiographic Stage III - Bone involvement - Lupus pernio - Chronic uveitis - Upper respiratory tract involvement - African-American - Age >40 - Pulmonary hypertension - ↑ FIO2 requirement

Medical Risk Factors which Increase the Risk of Developing Tuberculosis Once Infection Has Occurred

HIV infection Silicosis Abnormal chest radiograph showing fibrotic lesions Diabetes mellitus Prolonged corticosteroid therapy Immunosuppressive therapy Hematologic and reticuloendothelial diseases e.g., leukemia and Hodgkin's disease) End-stage renal disease Intestinal bypass Post-gastrectomy Chronic malabsorption syndromes Carcinomas of the oropharynx and upper gastrointestinal tract Ten percent or more below ideal body weight

Who is at high risk of developing TB?

HIV pts Close contacts of known infectious TB Medical risk factors that increase risk of TB once infection has occurred Foreign-born persons from prevalence countries Medically underserved/low-income populations including minorities (African American, Hispanic, Native American) Residents of long-term care facilities such as correctional institutions and nursing homes

Who should be screened for TB?

HIV pts Close contacts of known infectious TB cases Pts with risk factors Foreign-born Underserved Alcoholics/IV Drug users Residents of long-term care facilities Health care workers

Theophylline adverse effects

Headaches - PDE4 inhibition Nausea and vomiting -PDE4 inhibition Gastric discomfort - PDE4 inhibition Tachycardia and arrhythmias - PDE3 inhibition and A1 receptor antagonism Diuresis - A1 receptor antagonism Insomnia and irritability - ?? Seizures - A1 receptor antagonism

How does the time it takes to desaturate differ in the following patients; (<90% sat.) -healthy adult -obese -pregnant -pediatric

Healthy, pre-oxygenated adult: >90% sat. for about 8 minutes Obese: desaturates in <3 minutes pregnant women to term: desaturation in <3 minutes pediatric patient: desaturates in <4 minutes

what system plays a role in susceptibility to carcinogens?

Heme-containing cytochrome P-450 oxidase system has many proteins, and polymorphisms in these proteins (CYP1A1, etc.) may allow for increased conversion of inhaled pro-carcinogens into active carcinogens

What anticoagulants are safe for use in pregnancy?

Heparin doesnt cross placenta -Low-Molecular-Weight heparin preferred over unfractionated heparin Contraindicated: -Warfarin does cross-> DO NOT USE -Thrombolytic therapy -direct oral anticoagulants cross placenta

Isoniazide adverse effects and follow up tests

Hepatotoxicity peripheral neuropathy Hypersensitivity Follow up: -pyridoxine -liver fxn tests

Ramsay Hunt Syndrome

Herpes zoster on external ear with a facial nerve palsy Pathophysiology: primary infection or reactivation of HSV

Asthma is highest in which populations?

Highest in vulnerable population: children, people living below the poverty level, specific minority groups; Blacks, Puerto Ricans Children > adults

Risk Factors for Asthma Exacerbations

History of severe asthma Inadequate prenatal care Obesity Lack of appropriate treatment with inhaled corticosteroids

laryngeal cancer presentation

Hoarseness Dysphagia All patients with hoarseness of more than two weeks duration should have flexible fiberoptic laryngoscopy

Croup presentation

Hx of URI for previous 2-3 days sudden development of hoarse, barky cough w/ inspiratory stridor in middle of the night may have sternal and chest wall retractions Exam: -mild respiratory distress -normal-appearing pharynx -lungs generally clear

Hypercalcemia Tx

Hydration, mobilization Avoid Thiazide diuretics (cause Hypercalcemia) Glucocorticoids in pts w/ sarcoidosis -decrease the synthesis of calcitriol -improve disease process -counteract effects of Vitamin D on GI tract (Vitamin D intoxication, sarcoidosis)

Ethambutol adverse and follow up

Hypersensitivity Optic neuritis Follow up: -visual acuity

Aspergillosis can cause?

I. Allergic - Extrinsic allergic alveolitis - Extrinsic asthma - Allergic bronchopulmonary aspergillosis - Allergic aspergillus sinusitis II. Saprophytic - Pulmonary aspergilloma III. Invasive - Bronchopneumonia - Necrotizing tracheobronchitis - Invasive sinusitis - Chronic necrotizing aspergillosis

List some triggers for DIC

I. Bacterial infection: -endotoxins can inhibit the endothelial expression of thrombomodulin directly or indirectly by stimulating immune cells to make TNF -Endotoxins can also activate factor XII II. Antigen-Ab complexes: -can activate classical complement cascade causing complement fragments and activation of platelets/granulocytes III. Massive trauma, surgery, severe burns: -tissue factor released in abundance IV. Obstetric complications: -procoagulants from placenta, dead/retained fetus, amniotic fluid may enter circulation V. Acute promyelocitic leukemia/adenocarcinoma: -tumor-related DIC

3 stages of pertussis

I. Catarrhal (rhinorrhea and mild cough) II. Paroxysmal (increased cough severity) -coughing spells, inspiratory whoop -post-tussive vomiting III. Convalescent (decreasing coughing spells) lasts for 100 days total

Tx guidelines If less than 35 - 40 years old without diabetes or heart trouble:

I. Epinephrine 1:1000 IM every 20 minutes x 3. II. Aerosol of choice. III. Steroids - i.e. Solu-Medrol (methylprednisolone) 125 mg IV. IV. Depending on Theophylline history, may want to give IV loading dose or obtain a level and then treat accordingly - (coming back into style on occasion). V. Magnesium sulfate, 1-2 gm IV, over 5-10 min. -can relax bronchial smooth muscle Monitor speech, peak flow, use of accessory muscles, and skin color.

Phases of ARDS

I. Exudative phase, <7-10 days • release of inflammatory mediators, proteases, and oxidants • Injury to alveolar epithelium and alveolar-capillary endothelium • Increase permeability -> edema (proteinaceous) → stiff lung • Decreased surfactant production and function → alveoli collapse resulting in shunt-like gas exchange • Hyaline membrane formation II. Proliferative phase, > 7-14 days (approximately) • Hypertrophic type II alveolar epithelial cells replicate to replace lost type I cells • Inflammation and fibroblast proliferation in the interstitium • Fibroblasts invade the alveolar space • Hyaline membranes disappear • Intra-alveolar plugs of proliferative fibroblast III. Fibrotic phase, after 2 weeks • Regions of intense fibrosis • Obstruction and/or destruction of the pulmonary vascular bed

What is the "triple response" (of Lewis) to histamine intradermal injection

I. Localized redness in few seconds -histamine induced vasodilation II. Red flare: -histamine-induced nerve ending irritation causes reflex vasodilation III. Wheal (localized edema): -reflects increased vascular permeability

What are the 2 main complications of Coal Workers' Pneumoconiosis

I. Mycobacterium tuberculosis and atypical mycobacteria -but less frequently than in silicosis II. Caplan Syndrome: -Association of CWP with seropositive rheumatoid arthritis -Large pulmonary rheumatoid nodules associated with CWP -Nodules may be multiple and may cavitate

Stages of Shock

I. Nonprogressive stage: -reflex neurohumoral compensation mechanisms are activated (catecholamines, ADH, renin-angiotensin axis, etc.) -produces tachycardia, peripheral vasoconstriction, and renal conservation of fluid. -Perfusion of vital organs can therefore be maintained. II. Progressive stage: -hypoxemia leads to anaerobic glycolysis, lactic acid generation, decreased tissue pH -vasodilation, peripheral pooling, decreased CO, tissue hypoxia III. Irreversible stage: -re-perfusion will not correct the death spiral -ischemic bowel may lead to superimposed bacteremia/septic shock, renal failure, tubular necrosis, anuria

obstructive vs. restrictive lung disease - high or low FEV1/FVC ratio?

I. Obstructive - Increase in resistance to air flow anywhere from the trachea to the bronchioles • FEV1/FVC < 0.7 II. Restrictive - Decreased total lung capacity from reduced expansion of the lung parenchyma • FEV1/FVC usually normal, because all lung capabilities decrease Occurs in one of two pathologic categories: -Chest wall disorders (that usually limit expansion) -Interstitial and infiltrative diseases (that usually reduce lung plasticity)

When are Tympanostomy tubes used?

I. Otitis media w/ E ffusion> 3months (Consider adenoidectomy if over age 4 or second set of tympanostomy tubes) II. 6 or more months of effusions in the previous 12 months III. Recurrent episodes of otalgia or AOM (> 3 episodes/6 months or > 4 episodes/12 months) IV. Persisting or recurrent ear discharge V. Retraction of the TM or pars flaccida, negative middle ear pressure, or TM perforation > 3months VI. OM with imminent air travel or barotrauma (injury following pressure changes) following air travel VII. Craniofacial anomalies that predispose to middle ear dysfunction (eg, cleft palate, Down's syndrome)

Review how to differentiate b/w the causes of hypercalcemia: -sarcoidosis -Hyperparathyroidism -malignancy -excess ingestion of vitamin D

I. Sarcoidosis: -high calcium -PTH decreased -increased calcitriol (1,25(OH)2D) -normal PTHrP II. Hyperparathyroidism: -PTH high -Ca++ high III. Malignancy: -increased PTH related protein (PTHrP) IV. Excess ingestion of Vitamin D: -high 25(OH)D lvls -decreased PTH

List the 3 non life threatening chest injuries

I. Simple Pneumothorax -no deviation of trachea II. Simple Hemothorax -if 1500cc blood loss, surgery needed III. Rib Fractures -fx of ribs 1 and 2 are more serious -middle rib fractures more common

List the neurovasculature that travels through the sphenopalatine foramen and the greater palatine foramen.

I. Sphenopalatine foramen: -sphenopalatine A. (from maxillary A.) -nasopalatine N. (CN V2)- innervates hard palate -posterior superior lateral nasal nerve (sphenopalatine N)- supply nasal mucosa II. Greater palatine Foramen: -greater palantine A. (Maxillary A.) -greater palantine N. (Maxillary N.-CN V2)- innervates hard palate

Review Virchows triad and how it relates specifically to pregnancy

I. Stasis of blood flow: -progesterone-induced vasodilation -pelvic compression by a gravid uterus -rt. Iliac artery causing pulsatile compression on iliac vein II. Endothelial injury: -Vascular damage during vaginal delivery or caesarian section III. Hypercoagulability: -occurs in pregnancy -increase in clotting factors, fibrinogen, VWF -decrease in coagulation inhibitors (decreased protein S, increased resistance to Protein C) -impaired fibrinolysis (increase in plasminogen activator inhibitors) -D-dimer lvls increase w/ gestational age -protein C and antithrombin lvls do not change

Types of Pulmonary HTN

I. Systemic, essential HTN: -usually mild effects on pulmonary system II. Idiopathic Pulmonary HTN: -uncommon -isolated HTN affecting pulmonary vessels w/ genetic basis of inheritance -women ages 20-40 w/ dyspnea, fatigue, cyanosis III. As part of Cardio or Pulmonary structural disease: -ILD -obstructive lung disease -chronic hypoxia -Left Heart failure -autoimmune disease -valcular disease/cardiomyopathies

Tx guidelines If greater than 35 - 40 years old or if history of heart trouble/diabetes:

I. Terbutaline (beta agonist) 0.25 cc subcutaneously every 30 to 40 minutes x 2. II. Aerosol of choice. III. Steroids - i.e. Solu-Medrol (methylprednisolone) 125 mg IV. IV. Depending on Theophylline history, may want to give IV loading dose or obtain a level and then treat accordingly. - (coming back in to style on occasion). V. Magnesium sulfate, 1-2 gm IV, over 5-10 min. Monitor speech, peak flow, use of accessory muscles, and skin color. Order an EKG. (same thing except use Terbutaline instead of Epinephrine)

**Complicated vs Uncomplicated parapneumonic effusions

I. Uncomplicated results in free-flowing effusion that resolves w/ Abx II. Complicated results in loculated effusion that requires pleural space drainage and eventually empyema

Phases of swallowing

I: Oral Phase (oral preparatory phase and oral propulsion phase) -food in oral cavity II: Pharyngeal Phase: -past lingual tonsil -soft palate rises and closes off nasopharynx -epiglottis begins to close of airway (folds backwards) -larynx elevates/closes off III: Esophageal Phase: -superior portion= skeletal muscle -inferior portion= smooth muscle

List the broad classification categories of interstitial lung disease.

Idiopathic Interstitial Pneumonias Connective tissue disease/collagen vascular disorders Occupational and Environmental exposures -organic -inorganic Granulomatous Diseases Treatment related: -drug rx -radiation pneumonitis -immunosuppression Infection Interstitial pneumonia w/ autoimmune features Primary (unclassified) ILD -Immunosuppresion/transplant

Rhinosinusitis Treatment

If no allergic symptoms- antihistamines may or may not be used If allergic- nasal steroids can be used Adjunctive tx for recurrent and chronic sinusitis: -moisturizers such as saline nasal spray -decongestants (**BE CAREFUL w/ hypertensive pts)

Differentiate b/w pleural effusion vs hemothorax

If the pleural fluid is bloody, a pleural fluid hematocrit should be obtained HCT > 50% of peripheral blood = hemothorax HCT < 1% - no clinical significance HCT 1-20% - consider: » Malignant pleural disease » Pulmonary embolism » Traumatically induced

Foreign body removal guidelines

If you do not know what the object is, DO NOT IRRIGATE. Also, you do not always know the status of the tympanic membrane. -Plant materials or insects will swell. Use an operating otoscope or a microscope to remove the foreign body in conjunction with a Hartman forceps or an alligator forceps.

How is Coronavirus ARDS different from classic ARDS?

In Coronavirus ARDS there is more inflammation earlier on and injury to the alveoli during the ACUTE phase increased thrombotic mediators decreased expression of interferons higher neutrophil count decreased lymphocytes increase in inflammatory biomarkers greater monocyte and lymphocyte activation more damage to alveolar interstitial capillary unit

How are Arterial blood gases effected by restrictive (ILD) vs obstructive lung diseases?

In ILD pts generally breathe faster and breath off more CO2?

Describe the differences between the pediatric and adult external ear canal and how this impacts otoscopic examination

In adult eustachian tube is at more of an angle to the external ear canal -this is why you pull the ear up and back to get it more in line In child pull ear straight back

Definitive care components

In-depth management Fracture stabilization and splinting Necessary operative intervention May need to stabilize and transport to facility that can provide the appropriate care

Heparin MOA

Inactivates Factor Xa and inhibits conversion of prothrombin to thrombin

how does the cardiovascular system change during pregnancy

Increase in CO begin during 8th week and is 30-50% above normal near term (↑HR, ↑SV, ↓PVR) Extracellular water increase by 1-2 liters SV increases HR increases BP decreases SVR decreases

How does the immune system change during pregnancy?

Increased sex hormones leads to decreased cell mediated immunity: -CD4+ T cells -CD8+ T cells -B cells -NK cells -Cytotoxicity and Increased: -Monocytes/phagocytes -dendritic cells -Neutrophils (PMN's) -a-Defensins -Regulatory T cells

What are some conditions that predispose to ARDs

Infections - Shock, sepsis, aspiration, diffuse infectious pneumonia Trauma or other physical, chemical, radiation injury Drug reactions - ASA, barbiturates, paraquat Hematologic disease - Disseminated intravascular coagulation (DIC), transfusion

What infectious disease process may lead to septic shock, ARDS OR DIC?

Infectious pneumonia → bacteremia → septicemia → septic shock Infectious pneumonia → ARDS Infectious pneumonia → DIC Infectious pneumonia → septic shock → DIC → ARDS

Specify where the following structures open into the nasal cavity: frontal sinus, anterior, middle and posterior ethmoid air cells, sphenoid sinus, maxillary sinus, nasolacrimal duct.

Inferior Meatus: -Nasolacrimal duct: Semilunar hiatus (In Middle Meatus): -maxillary sinus -middle ethmoidal air cells -anterior ethmoidal air cells -frontal sinus (via frontonasal duct) Spheno-ethmoidal recess (in Superior Meatus): -sphenoid sinus -Posterior ethmoidal air cells

Neck mass management

Inflammed lymph nodes: -broad-spectrum antibiotics and reassessment in 2 weeks Thyroid/salivary gland nodules: -fine-needle aspiration and biopsy Contrast-enhanced CT is best imaging for neck mass -should be used whenever the diagnosis is unclear Recent chest radiograph to exclude metabolic disorders/uncommon causes

Patients with higher eosinophil counts (>300 cells/mcl) or asthma are most likely to benefit from an?

Inhaled corticosteroid

Treatment of Intermittent Asthma -symptoms no more than 2x per week -no interference w/ normal activity -exacerbations brief -no nighttime symptoms more than 2x per month -normal lung function

Inhaled short-acting B2 agonist as needed (albuterol)

Azole MOA

Inhibit lanosterol 14a-demethylase- the enzyme required to convert lanosterol into ergosterol

Enoxaparin moa

Inhibits Factor Xa and thrombin (Factor IIa) frequent monitoring NOT needed

Isoniazid MOA, PCK

Inhibits mycolic acid synthesis -diffuses into mycoplasma where it is "activated" by KatG to nicotinoyl radical -nicotinoyl radical reacts w/ NAD+ to inhibit enzymes in cell wall synthesis -also reacts w/ NADP+ to produce inhibitor of nucleic acid synthesis Isoniazid has the strongest antibactericidal action PCK: -prodrug activated by TB catalase-peroxidase enzyme KatG -metabolized in liver Resistance: -mutations of KatG enzymes that lead to decreased activity of isoniazid (prodrug cant be converted to active metabolite) -point mutation

Pulmonary contusion

Injury or bruising of lung tissue that results in hemorrhage. often does not show up on CXR but may show up on CT tx varies often requires intubation and mechanical ventilation

List the three subdivisions of the ear and describe the function of each.

Inner: (cochlea, semicircular canals, vestibule): -changes sound waves to electrical signals (nerve impulses). This allows the brain to hear and understand sounds. -The inner ear is also important for balance Middle: (eardrum, ossicles) -offset the decrease in acoustic energy that would occur if the low impedance ear canal air directly contacted the high-impedance cochlear fluid. Outer: (pinna) -catch sound waves, amplify them slightly, and funnel them down the ear canal to the tympanic membrane

Pneumoconioses are considered what type of lung disease?

Interstitial Lung disease induced by inhaled organic or nonorganic particulates, chemical fumes and vapors, usually acquired in a workplace setting. the offending agent is small in size (1-5um) and reach terminal airways Includes: -coal workers pneumoconiosis -silicosis -asbestosis Involves Pulmonary macrophages: -IL-1 and TNF released when particles are taken up by macrophages -promotes collagen deposition and fibrosis

If a pt arrives in SEVERE respiratory distress what should be done?

Intubate Draw ABG's Start 3 pronged attack: -IV (steroids) -aerosol -SQ/IM (terbutaline)

galactomannan enzyme immunoassay is used for detection of?

Invasive Aspergillosis specificity of 97.5% and sensitivity, 92%.

Invasive Sinopulmonary Aspergillosis presentation

Invasive sinus disease • Headache, stuffiness, fever, epistaxis • Proptosis, cranial nerve palsies Invasive pulmonary disease • Fever, cough, pleuritic pain, hemoptysis

Mycobacterium Avium Complex (MAC) epidemiology, risk factors

Isolated sources • Soil, natural, municipal water, food, host dust, domestic, wild animals • Inhalation of aerosols • No person-to-person spread Risk Factors • Chronic lung disease • Gastrectomy • T-cell deficiency (<100) • Lung disease seen in "normal people"

What drug regiment should be used in the continuation phase of TB (next 4 months)

Isoniazid Rifampin

What is the tx of initial phase TB in pregnancy?

Isoniazid Rifampin Ethambutol Pyrazinamide not used- side effects

Blastomycosis Tx

Itraconazole= 1st choice for mild infection Amphotericin B in severe/immunocompromised

Renal Consequences of Hypercalcemia

Kidney stones **Polyuria, Polydipsia, Nocturia, Dehydration Nephrocalcinosis Kidney Failure

Identify the common locations for epistaxis in the nasal cavity

Kiesselbach area (anterior nose)= common area for nose bleeds -a lot of anastomosis in these areas Woodruff's Plexus (posterior nose) -mostly sphenopalantine A. -harder to control bleeding, packing may be needed

What is the most common location of anterior epistaxis?

Kiesselbach's Plexus (Little's Area) - Area of the nasal septum where branches of sphenopalatine, anterior ethmoid, superior labial, and greater palatine arteries anastamose. **Most pediatric epistaxis is related to picking the nose in this area.

Hair cell anatomy

Kinocilium: - right most stereocilia -basal body intracellular organ Stereocilia: -actin filaments w/in a tubular membrane directional sensitivity (morphological polarization) I. Movement towards Kinocilium opens ion channels causing depolarization II. Movement away from Kinocilium closes ion channels causing hyperpolarization

Massive hemothorax xray

L lung

LEMON pneumonic for predicting difficult intubation

L- look externally E- evaluate 3-3-2 -can pt put 3 fingers b/w incisors -is mandible 3 fingers length from mentum to hyoid bone (tip of jaw and beginning of neck) -2 fingers distance from hyoid to thyroid (thyroid notch and floor of mandible) M- Mallampati score- degree to which the posterior pharynx is visible -class 1: can see whole posterior oropharynx (easy intubation) -class 4: can only see portion of soft palate, no posterior oropharynx O - Obstruction N - Neck mobility

Full tuberculoid leprosy

Large erythematous plaques with sharply demarcated raised outer edges Area is anesthetic May have damaged few peripheral nerves

Leukoplakia vs Erythroplakia

Leukoplakia: • Whitish plaque that cannot be scraped off • 5-20% malignant potential • Microscopy: hyperkeratosis and atypia Erythroplakia • Red patch or macule with soft, velvety texture • 60-90% malignant potential • Treatment is surgical excision

Provide an example of how oral health is linked to respiratory health.

Link b/w oral health and pneumonia -Oral bacteria in oropharynx and from oral biofilms (dental plaque) aspirated into lower respiratory tract Inflammatory products from peritoneal disease may also be aspirated Increased risk of developing lung infection

Mucormycosis Tx

Lipid Amphotericin B Posaconazol= 2nd line Resistant to azoles Echinocandins (Caspofungin)= salvage therapy

Treatment of Moderate Persistent asthma: -daily symptoms -daily use of inhaled short-acting B2 agonist -some limitations w/ normal activity -exacerbations at least 2x per week; may last days -nighttime symptoms more than 1x per week but not nightly -FEV1>60% but <80% predicted -FEV1/FVC reduced by 5%

Low dose inhaled corticosteroid PLUS long-acting B2 agonist (formterol) OR Medium-dose inhaled corticosteroid

What is the goal FiO2 in mechanical ventilation?

Lowest possible FiO2 that maintains O2 sat ≥ 88% target FiO2 of < 0.6 (60%)

List some causes of a large pleural effusion w/ the ABSENCE of a contralateral mediastinal shift

Lung cancer causing atelectasis on the side of the effusion Fixed mediastinum Malignant mesothelioma Parenchymal tumor invasion Mucus plug

List some things that cause difficult bag/mask ventilation

M - Mask Seal -Bushy beards, crusted blood on the face, disruption of lower facial anatomy O - Obesity/Obstruction Includes Third trimester pregnancy A - Age > 55 N - No teeth difficult seal - mask tends to cave in S - Stiff Patients with stiff lungs

Benzonatate moa, use, side effects

MOA: -local anesthetic that, taken orally, can anesthetize stretch receptors in respiratory passages, lungs and pleura. use: may reduce the cough reflex at its source. Side Effects: -dizziness -dysphagia -Metabolized to PABA which may trigger allergic rxn in sensitive pts

Montelukast

MOA: A cysteinyl leukotriene antagonist Use: Approved for treatment of seasonal allergic rhinitis in adults and children >2 y -Efficacy less than intranasal corticosteroids

Dupilumab: Dupixent

MOA: A monoclonal antibody inhibits interleukin-4 and interleukin-13 signaling, appears especially good for severe asthma

Pharmacological Effects and Clinical uses of Decongestants (Phenylephrine (Neo-Synephrine), Pseudoephedrine (Sudafed, Novafed) , Oxymetazoline (Afrin))

MOA: Alpha1 adrenergic agonists -Vasoconstriction -Increased blood pressure -Decongestant effect -Increased heart rate -CNS stimulation Clinical uses: -symptomatic relief of nasal congestion -obstructed eustachian ostia as in serous otitis or barotitis (pseudoephedrine must be requested from pharmacist b/c it can be used in synthesis of methamphetamine)

Mepolizumab: Nucala

MOA: Monoclonal antibody Blocks IL5 a key cytokine responsible for eosinophil maturation and recruitment

Omalizumab: Xolair

MOA: Monoclonal antibody Blocks the interaction of IgE with mast cells and basophils

Reslizumab: Cinqair

MOA: Monoclonal antibody Prevents IL5 from binding to the alpha chain of the IL5 receptor (IL5 stimulates the production, activation, and maturation of eosinophils)

Amantadine and Rimantadine

MOA: act on M2 proton selective ion channel and prevent uncoating of influenza A particles Resistance is an increasing problem and not currently recommended.

Amphotericin B MOA

MOA: binds ergosterol in fungal membrane = causes pore formation and cell lysis Administered IV for systemic fungal infections Side effects: -nephrotoxicity: monitor creatinine, BUN, CBC, liver fxn, serum electrolytes -infusion related rxns: premedicate w/ antipyretics, antihistamines, antimetics to reduce fever, chills, nausea -Amph B deoxycholate, commonly known as conventional AmB (C-AmB), is associated with a high incidence of toxicities.

Ethambutol MOA

MOA: decrease carbohydrate polymerization of the mycobacterium cell wall by blocking arabinosyltransferase -inhibits cell wall synthesis PCK: -80% of drug is not metabolized at all and renally excreted (in renal failure should be lower dose and given only 3 times weekly instead of daily)

Omalizumab (Xolair)

MOA: humanized monoclonal antibody directed against IgE. -binds to circulating free IgE. -Free IgE concentrations decrease by >95%. -This leads to decreased expression of high-affinity IgE receptors on the surface of mast cells. -also blocks the binding of IgE to low-affinity receptors on other inflammatory cells. Administered sc every 2 or 4 weeks Use: moderate to severe persistent asthma in patients with reactions to allergens and not controlled with inhaled corticosteroids Adverse: Anaphylaxis (high cost)

Echinocandins (Micafungin, Anidulafungin, Capsofungin) MOA

MOA: inhibition of the synthesis of beta- (1,3) glucan synthase, an important component of fungal cell walls, resulting in osmotic instability and cell death. available IV only. Side effects: -infusion-related rxn such as rash, headache, fever, chills -decreased WBC, hemoglobin/hematocrit counts

Triazole antifungals MOA, adverse (fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole)

MOA: interference with CYP450 leading to inhibition of lanosterol • Causes a decrease in ergosterol synthesis and inhibition of cell-membrane development. ***metabolized by liver: drug-drug interactions through CYP450 system Side effects: • GI disturbances • Hepatotoxicity • Headache • Rash

Benralizumab: Fasenra

MOA: monoclonal antibody IL5 cytolytic antibody, leads to apoptosis of eosinophils and basophils through antibody-dependant cell-mediated cytotoxicity

Flucytosine MOA, side effects

MOA: pyrimidine analogue- converted to 5-FU by the fungal enzyme cytosine deaminase -active against yeast infections -5-FC -> 5-FU -> FUTP: inhibits protein synthesis by replacing Uridylic Acid in RNA ALSO 5-FU conversion to 5FdUMP, which inhibits DNA synthesis by inhibiting thymidylate synthase Side Effects: **Hepatotoxicity **Bone marrow suppression: leukopenia, thrombocytopenia, pancytopenia

Mepolizumab (Nucala)

MOA: sc injected humanized interleukin-5 antagonist monoclonal antibody Use: maintenance tx of severe asthma in patients >12 yo who have an eosinophilic phenotype

Roflumilast (Daliresp)

MOA: selective PDE4 inhibitor -reduces inflammation by increasing cAMP levels. Use: approved to reduce the risk of exacerbations in adults with severe COPD associated with chronic bronchitis Adverse: -Nausea, vomiting, weight loss and psychiatric symptoms are common **reserved for pts not responding to other therapies- do not use as an add-on.

Pyrazinamide MOA

MOA: synthetic pyrazine analog of nicotinamide -activated by acidic conditions -inhibits cell membrane synthesis and trans-translation PCK: -oral availability 90% -GI absorption separates pts into two groups (fast absorbers and slow absorbers) -metabolized in liver, excreted by kidneys (clearance reduced in renal failure) **hemodialysis removes pyrazinamide; therefore drug needs to be redosed after each session of hemodialysis

Squamous cell carcinoma of the lung

Male smokers bronchial epithelium centrally located- commonly cavitate locally invasive 50% of Pancoast tumors **produce PTH: hypercalcemia Histo: **keratin pearls

Mucormycosis Diagnosis and Tx

Manifest almost exclusively in an immunocompromised host. -DKA, HIV, chemotherapy, bone marrow transplant Dx: -Necrotic, black turbinates -Biopsy and culture -Cranial nerve involvement -MRI best: enhancement in T2: weighted images from fungal elements Tx: -Aggressive and urgent surgical debridement and long-term amphotericin B, maximal medical management of underlying derangements.

Rifampin Side effects, monitoring, drug interactions

Many drug interactions Hepatitis Nephrotoxicity temporary discoloration (yellow, reddish-orange, or brown color) of your skin, teeth, saliva, urine, stool, sweat, and tears)

Specify the blood supply and venous drainage of the oral cavity and dentition.

Maxillary A (from External carotid) -inferior alveolar A. (mandibular foramen) -infraorbital A. (gives off superior alveolar A's) Venous drainage: -Superior to ophthalmic veins -Inferior to facial veins -from sphenopalatine vein to pterygoid plexus to pterygoid plexus to maxillary vein to the jugular vein

What bones/cartilage are altered in a deviated septum?

Maxillary crest Vomer bone Perpendicular plate of Ethmoid bone Nasal cartilages bones and cartilage or just cartilage can be deviated

Benign positional vertigo

Mechanism: -otoliths dislodge from hair cells and enter semicircular canal (usually posterior canal) -otoliths drag endolymph even when head has stopped moving -brain thinks head is stll moving Episodes of dizziness and a sensation of spinning with certain head movements. Check for nystagmus w/ Dix-Hallpike maneuver -vertigo lasts <1 minute -brought on by positional changes -fatigues w/ repeated testing

Treatment of Severe Persistent asthma: -continual symptoms -extremely limited w/ normal activity -frequent exacerbations -nighttime symptoms often nightly -FEV1 <60% predicted -FEV1/FVC reduced >5%

Medium- or High-dose inhaled corticosteroid plus long-acting B2 agonist Consider short course of oral corticosteroid

Describe the relationship of the following structures to the tympanic (middle ear) cavity: middle cranial fossa, nasopharynx, chorda tympani, and mastoid antrum/air cells.

Middle cranial fossa: -sits above petrous portion of the temporal bone which houses inner ear Nasopharynx: -connected to middle ear via eustachian tube Chorda tympani: (branch of facial nerve) -goes through internal acoustic meatus to the internal ear -descends through mastoid air cells to nasal cavity -if things taste funny may indicate the involvement of chorda tympani Mastoid air cells: -surround the middle and inner ear -connects to the middle ear via the Aditus -if infection of middle ear- can infect mastoid air cells (poor blood flow)

Oropharyngeal candidiasis treatment

Mild forms: topical nystatin Mild chronic: nystatin + clotrimazole Refractory/immunocompromised w/o systemic involvement: nystatin + oral fluconazole Systemic involvement: Amphotericin B

Histoplasmosis epidemiology/pathogenesis

Mississippi and Ohio River Valley (indianapolis) large flocks of birds, cave explorers (spelunking), bats Microconidia is infectious form-ingulfed by macrophages yeast phase exist intracellularly in macrphages- spread to hilar/mediastinal lymph nodes and hematogenous to RES latent infection-reactivates in immunocompromised

Decongestant drug-drug interactions

Monoamine oxidase inhibitors: -decrease breakdown of Norepinephrine, accentuate effects of decongestants Levothyroxine: -sensitizes catecholamine receptors to effects of decongestants Tricyclic antidepressants: -block reuptake of NE, accentuate effects of decongestants

Traumatic Diaphragmatic Hernia

More likely to be diagnosed on L side b/c of appearance of bowel or nasogastric tube on L side of chest R side may be delayed in dx b/c it takes a while for bowel to get into chest

Codeine moa, side effects

Morphine-3-methylether -converted to morphine by CYP2D6 MOA: depresses medullary cough center Side effects: -dizziness, nausea, constipation

most common causes of lesions of the oral cavity

Most Likely: Aphthous ulcer, HSV, Trauma, Malignancy Less Likely: Varicella Zoster, Autoimmune disease, Fungal infection, Malnourishment Must Rule Out: Malignancy, Immunosuppresion, Bacterial/Fungal disease, Some of the autoimmune diseases

How does albumin affect calcium levels?

Most calcium is bound to albumin If albumin decreased by 1g, total calcium decreases by ~.8g **low albumin would cause pts with sarcoidosis to have a FALSELY LOW calcium lvl- so make sure to check albumin AND total calcium lvls **always confirm Ca++ lvls by checking free ionized lvls

Tocolytic-Induced pulmonary edema

Most common cause of Pulmonary Edema in pregnancy Associated w/ Beta-adrenergic agents- primarily Terbutaline With the discontinuation of the tocolytic, the vasodilated vessels return to normal tone. During delivery, uterine contractions lead to autotransfusion. The increased venous tone and the increased blood volume can then lead to pulmonary edema, usually in the postpartum period. Nonspecific clinical findings occurs during or <24 hours after exposure Prompt response to the cessation of meds, support, diuresis

Diffuse ("swimmers ear") Otitis externa

Most common form of bacterial AOE Optimally managed with ototopical agents

Respiratory Bronchiolitis-Associated Interstitial Lung Disease (RBILD)

Most common pathologic finding in smokers peribronchiolar fibrosis with chronic inflammation Smokers macrophages may be found in and around the bronchioles, adjacent vessels, or otherwise in the peribronchiolar spaces DIP areas may be seen in some alveolar spaces

Presentation of foreign body aspiration in larynx vs trachea vs bronchus

Most common symptom= cough Larynx: -hoarseness -aphonia -drooling -stridor -complete airway obstruction Trachea: -cough -stridor -hemoptysis -wheezing -dyspnea -complete airway obstruction If in bronchus may have unilateral symptoms

Retropharyngeal Abscess

Most commonly caused by Group A Strep rare, deep neck infection, which extends from the anterior border of the cervical vertebrae to the posterior wall of the esophagus Children and adults Presentation: -cervical adenopathy w/ meningismus hallmarks -toxic appearance Dx: -lateral neck radiograph shows thickening of soft tissue to anterior to cervical bodies (usually at C2) Tx: -admitted -IV abx -may need intubation (not always) -may need surgical drainage of abscess (not always) Complications: mediastinitis w/ high mortality rate

Bronchial injury most commonly occurs where along the respiratory tree?

Most follow blunt trauma and occur within one inch of the carina. Half of the deaths from this injury occur within one hour. Signs/symptoms: -hemoptysis -tension pneumothorax -Subcutaneous air Suspect if Tension pneumothorax w/ persistent air leak despite chest tube suggests major bronchial injury Dx: bronchoscopy

Silicosis

Most prevalent chronic occupational disease worldwide A diffuse parenchymal lung disease due to exposure to silica (quartz) Pathology: cytotoxic effect of silica on alveolar macrophage Hallmark lesion silicotic nodule (small) I. Chronic (10-20 yrs after exposure): -silicotic nodule -lower dust concentration -PMF progressive massive fibrosis II. Accelerated (<10 years after exposure): -changes similar to chronic but more intense III. Acute (weeks to 4-5 yrs): -example= sandblasting

List some neoplastic diseases of the salivary glands that are malignant

Mucoepidermoid carcinoma: -most common Malignant mixed tumors • Adenocarcinoma -nodal metastasis can occur Adenoid cystic carcinoma: -most common malignant tumor of submandibular/sublingual glands Accinic Cell Carcinoma: -amyloid as pathologic hallmark Squamous cell carcinoma: -men of older age

Is inspiratory stridor a good predictor of severity of obstruction?

NO pt with full obstruction will have no stridor pt will mild obstruction will have severe stridor

Is ACE testing used for dx of Sarcoidosis?

NO- too many false positives -not specific for sarcoidosis But it does reflect the total granuloma burden in sarcoidosis ACE is Produced by the epithelial cell of the sarcoid granuloma -ACE elevated in 50 - 80% of patients • Usually highest in untreated with active disease • Falls toward normal during remission

Samter's Triad

Nasal Polyposis ASA intolerance Asthma

List the three subdivisions of the pharynx and specify the openings through which they communicate with the nasal cavity, oral cavity, and larynx.

Nasopharynx: -Nasal cavity divided from nasopharynx by choana Oropharynx: -separated from oral cavity by two arches (palatoglossa, palatopharyngeal) Laryngopharynx

Types of Non-invasive ventilation

Negative pressure via: - Iron lung (tank) - Cuirass (turtle) - Poncho (pneumosuit) Positive pressure via: - Face mask - Nasal masks - High Flow Nasal Cannula (HFNC) - Helmet - Mouthpiece/sip ventilation

What are the most common causes of malignant pleural effusions?

Neoplasms of the lung, breast, ovary, and lymphoma causes exudative (cell and protein rich) effusion

What pts are at higher risk of infection w/ Aspergillosis?

Neutropenic pts

Who is at higher risk for Blastomycosis infection?

Neutrophils deficiencies Cell-mediated immunity deficiencies with T cells, macrophages More severe disease in immunocompromised

Normal respiratory rates by age

Newborns: 40-50bpm 1 year: 30-35bpm 4 years: 20-25 bpm 8-10 years: 12-15bpm Tachypnea is an early sign of respiratory distress and generally correlates fairly well with the severity of the disease.

What is the "Gold standard" therapy in acute hypercapnic exacerbation of COPD?

Non-Invasive Positive Pressure Ventilation Has a failure rate of around 20% in acute hypercapnic respiratory failure

Stages of sleep

Non-REM: -Step 1: the beginning of sleep -Step 2: sleep is easily awakened -Step 3: deep sleep, slow-wave sleep, dreaming is more common, but not as common as in REM sleep. parasomnias most commonly occur during this stage REM: -burst of rapid eye movement -decreased skeletal muscle tone, almost complete paralysis -heart, diaphragm, eye muscles, smooth muscles continue to fx -episodes longer as night progresses -Pons crucial for REM sleep -when most dreams occur

Dextromethorphan moa, side effects

Non-narcotic Not analgesic or sedative MOA: Blocks NMDA receptors at high doses Presently popular with adolescents and young adults to get a 'high' - 'Skittles' in cold tablets and combine with alcohol -converted to active metabolite dextrorphan which is antagonist at NMDA receptors at high doses -euphoria, paranoria, disorientation, tactile visual, auditory hallucinations Few side effects when used as cough suppressant- occasional nausea

Most common types of lung cancer

Non-small cell carcinomas dominate: (75%) I. Adenocarcinoma (35%) II. Squamous cell carcinoma (30%) III. Large cell carcinoma (10%) Small Cell Carcinomas (20%) Other (5%)

How does COPD present on Pulmonary function testing?

OBSTRUCTIVE Spirometry (Pre and Post Bronchodilator) -decreased FEV1, Normal/decreased FVC • decreased POST-bronchodilator FEV1/FVC < 0.70 establishes the presence of PERSISTENT airflow obstruction Lung Volumes: • Hyperinflation TLC> 120% predicted or FRC >120% • Air trapping RV > 120% and/or RV/TLC ratio ↑ DLCO will be decreased in emphysema DLCO will be normal/slightly decreased in chronic bronchitis

How does asthma present on Spirometry?

OBSTRUCTIVE DISEASE Normal: FVC, FEV1 and FEV1/FVC Attack: ↓'s in FVC, FEV1 and FEV1/FVC DLCO is normal/high (high w/ hyperinflation) Decline **responds to bronchodilators e.g., reversible airway obstruction

Necrotizing Otitis Externa

Occurs in diabetic and other immunocompromised patients Can be fatal Requires urgent referral to a specialist Tx: oral cipro, or IV tx

Specify the function of the olfactory nerve and describe its anatomical relationship with the cribriform plate and nasal cavity walls

Olfactory bulb sits on ethmoidal bone -sends nerves down through cribriform plate into the superior nasal conchae

Ethambutol SE's, monitoring, drug interactions

Optic neuritis Changes in Red-Green color vision

Hypersensitivity Pneumonitis (HP) tx

Oral corticosteroids are the first-line treatment used for all In patient with progressive fibrotic HP lung transplantation should be considered

Rifampin adverse and follow up

Orange discoloration of secretions Hepatitis Reaction with other drugs (Warfarin, Quinidine) Follow-Up: -LFT's

Cryptogenic Organizing Pneumonia (COP)

Organizing pneumonia w/ INTRAalveolar fibrosis (not interstitial) develops in pts w/: -known viral or bacterial pneumonia -rxns to toxins, drugs -connective tissue diseases -graft vs host disease in bone marrow transplant pts Characteristics: -plugs of connective tissue called Masson bodies -body can remove or resolve fibrosis- many pts recover spontaneously or recover completely w/ corticosteroids

Acute Otitis Media (AOM) treatment

Ototopical antibiotics alone are appropriate therapy in uncomplicated cases - Fluoroquinolones Adjunctive systemic antibiotics may be used if needed

Blastomycosis clinical manifestations

Overwhelming severe infection • ARDS Acute pneumonia • Atypical presentation without response to antibiotics Sub acute, chronic pneumonia • Fever, night sweats, fatigue, productive cough, dyspnea **Cutaneous lesions • Well circumscribed, nonpainful papules, nodules, plaques • May be verrucous with microabscess • May ulcerate • May be confused with squamous cell cancer, atypical pyoderma gangrenosum or nontuberculous mycobacterial lesions Genitourinary- Prostate Septic arthritis Osteomyelitis

Silo Filler's Disease

Oxides of nitrogen (primarily NO2) releases as a byproduct of decomposing silage, typically corn or alfalfa Low solubility of oxides of nitrogen = Lower respiratory tract at risk 15-25 ppm: Acute mucous membrane irritation eyes and throat 25-100 ppm: Toxic pneumonitis and bronchiolitis often with smothering sensation and dyspnea >150 ppm: Often fatal obstructive bronchiolitis, chemical pneumonitis, and pulmonary edema

What is Saddle Embolus?

PE that straddles the pulmonary artery and is in the lumen of both the right and left pulmonary arteries

List some strategies that are used to lower FiO2

PEEP Maximize O2 delivery/maximize PvO2 Lower VO2 to maximize PvO2 Prone positioning if PaO2/FiO2 < 150

PEEP (Positive End Expiratory Pressure)

PEEP is the maintenance of positive pressure (above atmospheric) at the airway opening at the end of expiration. PEEP acts to distend distal alveoli, assuming there is no airway obstruction. Improves airflow → improves oxygenation Prevents atelectasis at end expiration Helps to recruit collapsed alveoli Helps to lower FiO2 need thereby minimizes risk of oxygen toxicity

Lights Criteria for Separating Transudates from exudates

PF/Serum protein ratio >0.5 PF/Serum LDH ratio >0.6 PF LDH >0.67 of upper limits normal of serum If any is positive, it is an EXUDATE

Hypersensitivity Pneumonitis (HP) clinical features

PFT: Restriction Labs: leukocytosis not eosinophilia -non-specific serum markers of inflammation CRP, ESR, LDH, ACE Imaging: HRCT most sensitive: -may demonstrate ground-glass opacities, centrilobular nodules, mosaic attenuation, reticulation, honeycombing

Typical maternal arterial blood gasses

PO2 higher A-a gradient increased Compensated respiratory alkalosis w/ pH 7.40 to 7.45 Slightly Hypocapnic HCO3 decreased to compensate

List the lymphatic tissues that form "Waldeyer's Ring" and specify their locations.

Palatine tonsil: -b/w palatoglossal and palatopharyngeal arches, lie on the tonsillar bed against the fascia Lingual tonsil: -base of the tongue Pharyngeal tonsil (Adenoid tonsil): -superior nasopharynx Tubal tonsil: -opening of the eustachian tube (All tonsils are considered GALT which is a subset of MALT)

Croup in the fall and winter is almost always caused by?

Parainfluenza type 1

What is the most common cause of an exudative pleural effusion in the US?

Parapneumonic effusions (assx w/ pneumonia)

Which Type of Pulmonary Sarcoidosis is more favorable?

Parenchymal Pulmonary Sarcoidosis • Outcomes less favorable compared to lymph node limited disease • Relapsing disease more common • Can progress to pulmonary fibrosis Lymph Node Limited Disease • More favorable outcomes compared to parenchymal pulmonary sarcoidosis

Discuss the pulmonary pathophysiology as it relates to gas exchange in ILD.

Parenchymal inflammation and fibrosis leads to: I. Decreased compliance/Decreased lung volumes II. Obliteration of small pulmonary vessels III. Diffusion Impairment IV. V/Q mismatch V. Hypoxemia VI. Pulmonary HTN

List the three pairs of salivary glands; indicate the anatomical location of each and the location in the oral cavity where each drains.

Parotid gland: -in front of ear -drains into mouth near secondary maxillary molar Sublingual gland: -deep under mucosa of tongue -drains into inferior tongue through many ducts Submandibular gland -right under mandible -drains right under tongue

What pathogens commonly cause Chronic Invasive Fungal Sinusitis? Dx? Tx?

Pathogens: Aspergillus, Mucor, Rhizopus, Absidia Diagnosis: biopsy and culture, MRI (best) and CT of paranasal sinuses Treatment: surgical debridement and long-term amphotericin B and itraconazole.

coal worker's pneumoconiosis (CWP)

Pathology ranges from anthracosis (carbon deposited in lung macrophages and lymphatics) to progressive massive fibrosis. fibrosis primarily in UPPER zones of lungs then progresses

List some of the functional differences of the airway in pediatric vs adult patients

Pediatric airway: 1. Head and tongue are relatively large 2. Neck is naturally flexed 3. Nasal airway is relatively narrow **4. The epiglottis is more elongated or omega-shaped, and sits at the level of C2/3 in the pediatric patient whereas it is typically in the C5/6 region in the adult and not visible on a typical oral exam in the adult, whereas it is often seen in the oropharyngeal exam in the pediatric patient.

Reactive Airways Dysfunction Syndrome

Persistence of airway hyperresponsiveness/reactivity Following acute exposure to a respiratory irritant • Onset within 24 hours of exposure and persistence for at least 3 weeks • Non-immunologic (irritant induced) • No latency • Symptoms consistent with asthma (cough, wheeze, dyspnea) • Non-smoker

Asthma diagnosis

Personal history: Family history of asthma, history of atopy, pets, etc. Work history: Occupation, airborne irritants, symptoms improve away from work Physical exam: Expiratory wheeze, prolonged expiration -hyperexpansion of thorax -nasal polyps -edematous nasal turbinates -atopic dermatitis Note: Should not have cyanosis or clubbing of the nails **Cardinal Symptoms: -cough -wheezing -breathlessness (dyspnea) PFT: Spirometry, ± provocative challenges -Exhaled Nitric Oxide (FeNO) Radiographic imaging studies Biomarkers: IgE, peripheral eosinophils, FeNO, Periostin Sputum Eosinophils **Demonstrate Reversibility of Obstruction/Symptoms w/ tx

Much of the ear is located within what bone?

Petrous portion of the temporal bone -inner ear and middle ear Tympanic part of the temporal bone -external ear canal

Describe the lymphatic drainage of the pharynx and larynx.

Pharynx: -superior deep cervical= jugulodiagastric nodes -drains to retropharyngeal nodes and deep cervical nodes Larynx: -above vocal cords: deep cervical nodes -below vocal cords: pretracheal nodes

List some neoplastic salivary gland diseases that are BENIGN

Pleomorphic adenoma: -most common, parotid gland Monomorphic adenoma Warthin's tumor: -men>women Oncocytoma -rare

Asbestos exposure most commonly presents as?

Pleural Plaque formation: -dense collagen plaques that develop on parietal pleura and over domes of diaphragm -most common pathologic finding (Plaques are not the same as having asbestosis, and aren't known to increase the risk for asbestos-induced neoplasia.)

What is the most common cause of non-obstetric infection in pregnant patients?

Pneumonia -Strep. pneumo -H. influenza -viral pneumonia- assume greater virulence -atypical pneumonia: mycoplasma, chlamydia A serious complication of pregnancy: - Increased maternal mortality - Premature labor - Fetal loss

Describe the venous drainage of the nasal cavity

Posterior nasal cavity -> maxillary vein -> sphenopalatine vein -> pterygoid plexus -> cavernous sinus -important in infection Superior conchae -> ophthalmic veins -> orbit -> cavernous sinus -important in infection Inferior Conchae -> Facial Veins

Prasugrel

Prasugrel is a thienopyridine prodrug but does not require CYP2C19 for activation. Like clopidogrel, it binds irreversibly to P2Y12 ADP receptors.

What is the BODE index used for?

Predicts the outcomes of COPD B: Body mass index O: degree of airflow Obstruction (FEV1) D: Dyspnea E: Exercise capacity Higher score= worse outcome

Parapharyngeal Abscess

Presentation: -marked trismus -fever -painful swallowing -altered voice -stiff neck PE: -parapharyngeal swelling w/ displacement of tonsils -external swelling may be present in the parotid region Tx: -I&D -Abx -may require hospital admission

Spasmodic croup

Presentation: -sudden onset, middle of the night -barky cough, inspiratory stridor -rarely associated w/ URI -afebrile w/ normal exam -effects inspiratory and expiratory parts of the flow-volume loop May recur Dx: -endoscopically subglottic tissues are pale and watery (ie-like allergic) Tx: -humidification -cool air -reassurance -Does NOT respond to racemic epinephrine

COPD definition

Preventable and treatable chronic lung disease Heterogeneous group of small airway diseases Airflow limitation is not fully reversible Abnormal inflammatory response to noxious particles of gases Usually progressive A complex systemic disease syndrome

**What causes Hypoxemia in ILD?

Primarily due to abnormal matching ventilation/perfusion "Diffusion Block" also occurs

Usual interstitial pneumonia (UIP)/Idiopathic pulmonary fibrosis (IPF)

Progressive pulmonary fibrosis and respiratory failure Unknown etiology Dx of exclusion Males>females usually >60y.o. Smokers Initial symptoms= dyspnea on exertion and dry cough Median survival= 3 years, tx not curative (not responsive to corticosteroids) Pathogenesis: -repeated cycles of epithelial activation & injury by an unknown agent resulting in abnormal repair and fibrosis **TGF-β may be an important mediator in UIP because it is fibrogenic Characteristic appearance: -patchy interstitial fibrosis in lower lobes/subpleural region -temporal heterogeneity (some areas look older/younger than others) -fibroblastic foci (early plugs of connective tissue that get remodeled into permanent fibrosis) -honeycomb fibrosis

What are the 3 natural anticoagulants?

Protein C, S, antithrombin III A deficiency in protein C or S increases the risk of a DVT or PE 2-11X A deficiency in antithrombin carries a 50% risk of DVT or PE

Specify the function of the trigeminal nerve in the nasal cavity and describe how the ophthalmic and maxillary divisions innervate the nasal cavity.

Provides innervation to nasal mucosa and sinuses V1: -superior conchae -anterior nose/nasal cavity V2: -middle conchae -inferior conchae -posterior nasal cavity

Forms of oral candidiasis

Pseudomembranous (thrush) • Most common form • Whitish plaque which can be scraped off to reveal a beefy red base Atrophic candidiasis • Typically on lateral tongue • Erythematous patch Angular cheilitis - Infection affects oral commissure - Causes: poor oral closure, poor fitting dentures

What is the most common cause of maternal deaths?

Pulmonary embolism most common cause of death DVT three to fourfold more common than PE in pregnancy: -DVT more likely to develop in L leg -Increased risk of isolated pelvic vein thrombosis- 64% at lvl of iliofemoral vein (more common during pregnancy) highest risk during 2nd trimester: - 1st trimester 24% - 2nd trimester 47% - 3rd trimester 29%

List some indications for tx of Sarcoidosis

Pulmonary: • Deteriorating FVC, DLCO, and worsening imaging studies • Hemoptysis Hypercalcemia Sight threatening ocular sarcoidosis Neurosarcoidosis Cardiac sarcoidosis

Review the 4 types of Physiologic Rib Motions

Pump handle: -all ribs, primarily ribs 1-5 -scalenes, pecs Bucket handle: -all ribs, primarily ribs 6-10 -serratus anterior Caliper: -ribs 11, 12 -quadratus lumborum Torsion: -typical ribs only -accompanies rotation of thoracic vertebrae

Pericardiocentesis

Puncture the skin 1 to 2 cm inferior to the left of the xiphochondral junction at a 45 degree angle (to the skin). advance the needle cephalad and aim toward the tip of the left scapula. -If the needle is advanced too far (into the ventricular muscle), an injury pattern (e.g., extreme ST-T wave changes, or widened and enlarged QRS complex) will appear on the ECG monitor. A full 12-Lead ECG should also be done upon completion of this procedure.

Review a pulmonary function test report of a pt with ILD

RESTRICTIVE FVC decreased FEV1 decreased FEV1/FVC ratio normal (sorry i had this wrong the first time) TLC reduced Diffusion capacity reduced Does NOT get better after therapy

Describe some changes that occur with interstitial lung disease (in relation to pulmonary function)

RESTRICTIVE PROCESS Increased Work of breathing FEV1/FVC ratio normal ↓ Lung volumes ↓ Diffusion capacity ↓ PO2 ↓ Abnormal CXR/HRCT

Dix-Hallpike maneuver

Rapidly moving the pt from a sitting position to the supine position with the head turned 45 degrees to the Right. and head off table in 20 degrees of extension After waiting for apx. 20-30 sec, the pt is returned to the sitting position. If no Nystagmus is observed, the procedure is then repeated on the Left side. Positive test= rotational nystagmus -fast phase of nystagmus is towards the affected ear (side closes to ground)

Typical fetal maternal arterial blood gases

Received via umbilical vein PO2 of 26-32 mmHg Saturation 80-90% PCO2 of 28-42 mmHg pH of 7.30 to 7.3

Differential Dx of Neck mass

Recent travel, trauma to the head and neck, insect bites, or exposure to pets or farm animals suggests an inflammatory or infectious cause for a neck mass. -Staphylococcus and Streptococcus A history of smoking, heavy alcohol use, or previous radiation treatment increases the likelihood of malignancy. The otologic examination may show a sinus or fistula associated with a branchial anomaly. -Lateral Neck. Branchial anomalies are the most common congenital masses in the lateral neck. Central Neck. The thyroglossal duct cyst is the most common congenital anomaly of the central portion of the neck Evidence of chronic sinusitis or pharyngitis suggests reactive adenopathy as the most likely cause of a neck mass. Cervical adenitis is probably the most common cause of an inflammatory mass in the neck. This condition is characterized by painful enlargement of normal lymph nodes in response to infection or inflammation. Cat-scratch disease (Bartonella henselae): -In general, only one lymph node is enlarged, and the node returns to normal size without treatment. Infectious mononucleosis usually presents with acute pharyngitis, cervical adenopathy, and an elevated Epstein-Barr virus titer. Pseudoaneurysm or an arteriovenous fistula of a major arterial vessel in the neck due to blunt force trauma Benign Masses. Lipomas, hemangiomas, neuromas, and fibromas Malignant Masses. Thyroid cancer, salivary gland cancer, lymphomas, and sarcomas are examples of primary malignancies.

Benefits of oxygen therapy

Relieves hypoxia Proposed additional beneficial effects - Lowers TNF Alpha • ? Less wasting - Reduces sympathetic activity - Less skeletal muscle dysfunction - Lowers pulmonary vascular resistance

Branchial (cleft) cyst

Remnant of the second branchial arch embryologically Usually occur in the lateral, upper neck along the sternocleidomastoid muscle cysts that are lined by stratified squamous or pseudostratified columnar epithelium

What treatments can be used to remove restrictions to lymphatic flow/enhance lymphatic drainage?

Remove restrictions to lymphatic flow. • Thoracic inlet release • Thoracoabdominal diaphragm release Enhance lymphatic drainage. • Thoracic pump • Pedal pump

Streptomycin adverse and follow up

Renal toxicity Vestibular damage Follow up: -creatinine

Upper airway resistance syndrome

Repeated arousals secondary to increased upper airway resistance (crescendo snoring) Apnea/Hypoapnea Index/Respiratory Disturbance Index normal no significant oxygen desaturation episodes

Coccidiomycosis clinical manifestations

Resembles CAP or influenza - Fever, cough, pulmonary infiltrates • Most resolve spontaneously Special conditions: - Rheumatologic syndromes » Erythema nodosum, erythema multiforme Coccidioidoma: -benign mass-like lesion Progressive/persistent pneumonia: -immunocompromised -infiltrates present over 2 months w/ cavitation Chronic pulmonary coccidiomycosis • 5% of patients • Smoldering over years • Nodules may cavitate and fibrosis • Destroy lungs progressively • May need resection Disseminated disease • All regions of the body except GI • Mortality high CNS: -life long therapy

Who qualifies for supplemental oxygen?

Resting PaO2 < 55 mmHg • With exercise O2 saturation < 88% Resting PaO2 < 59 and one or more of the following conditions are present: - Peripheral edema/cor pulmonale - HCT > 55% - EKG evidence of P. pulmonale

Characteristics of Interstitial lung disease

Restrictive process Fibrosis collects in interstitium distance b/w alveolar space increases and will eventually make adequate oxygen diffusion impossible End-stage fibrotic changes may lead to honeycomb lungs -airspaces destroyed

What techniques can be used to treat the Sympathetic NS from a respiratory perspective?

Rib raising Paraspinal stretch Paraspinal inhibition Assess for Chapman's points Thoracic somatic dysfunctions

Invasive Squamous Cell Carcinoma (SCC) Risk factors

Risk factors: -alcohol -tobacco -Betel leaf/betel quid/paan consumption -radiation **HPV infection is implicated in ~70% of SCC in the oropharynx (tonsils, base of tongue, soft palate)

Maxillary Sinuses drainage, innervation, blood supply, venous drainage, lymph drainage

Roof is floor of orbit Drain to semilunar hiatus (middle meatus) Superior drainage opening • Can be difficult to drain when upright Innervation • Infraorbital n. (V2) Blood supply: -facial, infraorbital, greater palantine aa. Venous drainage: -corresponding veins Lymph drainage: -submandibular nodes (related to tooth pain)

Cochlea anatomy

Round window: -below oval window -not in contact w/ stapes- transmits sound Oval window: -in contact w/ stapes -As the stapes footplate moves into the oval window, the round window membrane moves out, and this allows movement of the fluid within the cochlea, leading to movement of the cochlear inner hair cells and thus hearing. Scala vestibuli and Scala tympani filled w/ perilymph: -similar ionic composition as extracellular fluid found elsewhere in the body Scala media has endolymph: -unique composition not found elsewhere in the body (higher specific gravity)

List the atypical mycobacterium

Runyon Group I: -M. kansasii -M. marinum -M. simiae Runyon Group II: -M. scrofulaceum -M. szulgai -M. gordonae -M. flavescens Runyon Group III: -M. avium-intracellulare -M. xenopi -M. ulcerans -M. gastri -M. terrae -M. triviale Runyon Group IV: -M. fortuitum -M. chelonae -M. smegmatis

SHORT mnemonic of Difficult Cricothyroidotomy

S- Surgery -hx of neck surgery, presence of surgical scar H- hematoma O- Obesity R- radiation: -hx or evidence of radiation therapy T- trauma: -direct laryngeal trauma w/ disrupted landmarks

What is the gold standard for allergy testing

SET (Skin End Point Titration) -Uncomfortable, cannot be on beta-blockers. Beta blockers are contraindicated b/c they may: 1) worsen anaphylaxis severity 2) make treatment of anaphylaxis more difficult 3) increase the incidence of anaphylaxis itself.

Squamous cell carcinoma of larynx

SMOKING symptoms include hoarseness, dysphagia, and dysphonia. lesions can progress from hyperplasia to dysplasia to neoplasia, -typically ulcerated HPV association not as common as in oropharyngeal SCC

Risk factors for COPD

SMOKING - Number one risk factor - single most important • Cigarette >> pipe and cigars • Passive/second hand smoke • Only minority of smokers develop COPD Non-Smoking - • Occupational exposures • Genetic susceptibility • Air pollution ▪ Outdoors ▪ Indoor/biomass

Smoker's Rhinitis

STOP SMOKING Chronic rhinitis Resistant to medications and surgery Hypertonic saline rinses help **Smoking cessation may transiently worsen symptoms if goblet cell activity and secretions recover without recovery in cilliary clearance.

Sedative vs Nonsedative antihistamines

Sedative antihistamines (lipid-soluble and cross BBB) - diphenhydramine HCl - chlorpheniramine maleate - hydroxyzine - promethazine Nonsedative antihistamines - loratadine (Claritin) - fexofenadine (Allegra) - cetirizine (active metabolite of hydroxyzine) Zyrtec)

Albuterol, Salmeterol/Formoterol, Levalbuterol

Selective Beta 2 agonists Albuterol: -onset= 5 min -peak 30-60 min -duration: 4-6 hrs Salmeterol, Formoterol= long-acting -onset: 15-20 min -peak 3-4 hours -duration: 12 hours Stimulate Gs -> Increased cAMP -> simulate PKA -> inhibit myosin light chain kinase + decreased intracellular [Ca++] -> relaxation

Pts recieving pyrazinamide should undergo baseline and periodic assessments of?

Serum uric acid (can cause gout)

Asbestosis

Signs/symptoms: wheezing, coughing, SOB, chest pain, etc long-term inflammation and scarring of the lungs due to asbestos fibers. restrictive disease I. Asbestos bodies: -iron-containing proteinaceous material surrounding asbestos fibers II. Ferruginous bodies: -same material surrounding other inorganic particles

Most common causes of preseptal cellulitis and orbital cellulitis

Sinusitis most commonly the Ethmoid sinuses

Hypovolemic shock

Situation in which there is insufficient blood flow to provide adequate cellular oxygenation causing anaerobic metabolism to ensue. -not defined by the blood pressure value

What particles will deposit where in the respiratory tree based on size? Solubility?

Size: ->10um= upper respiratory tree -5-10um= trachea/bronchi -<5um= lower respiratory tree: can reach the terminal bronchioles and alveoli Solubility: -High soluble gases: trapped in moist lining of upper airway -Low soluble gases: can reach lower lung parenchyma down to the alveoli

B2 Agonist (Albuterol, Salmeterol/Formoterol, Levalbuterol) adverse effects

Skeletal muscle tremor-direct B2 effect on skm Restlessness Tachycardia-direct on atrial B2R and reflex due to vascular B2 vasodilation Hypokalemia-direct B2 effect of skm uptake of K+ Hypoxemia-increased VQ mismatch due to reversal of hypoxic vasoconstriction Metabolic effects-increased FFA, glucose, lactate, and pyruvate

Borderline borderline Leprosy

Skin manifestations more numerous Raised satellite lesions present Anesthesia less marked (skin lesions similar to those of tuberculoid leprosy, but they are more numerous and may be accompanied by satellite lesions around large lesions.)

Risk factors for Idiopathic Pulmonary Fibrosis

Smoking history especially ≥ 20 packs/year • Gastroesophageal reflux disease (GERD) a very common finding Male predominance Age: > 50 years; median age 65-70 years Infection Genetic factors (familial IPF) Environmental exposures

Specify the cranial nerves involved in the innervation of the soft palate and pharynx and describe how they are tested clinically.

Soft palate: -There are five muscles which give the actions of the soft palate. They are all innervated by the pharyngeal branch of the vagus nerve (CN X) - apart from Tensor veli palatini - which is innervated by the medial pterygoid nerve (a branch of CN V3). Pharynx: -mucosa of pharynx innervated by the glossopharyngeal nerve (CN IX) -All the muscles of the pharynx are innervated by the vagus nerve (CN X), except for the stylopharyngeus, which is innervated by the glossopharyngeal nerve (CN IX)

Croup Dx

Soft tissue neck radiographs -demonstrate "steeple sign" of subglottic narrowing -epiglottis should be normal (A significant percentage of patients with subglottic narrowing and croup will have normal radiographs.)

Blastomycosis Epidemiology

South Central and North Central USA • Wisconsin, Minnesota, Southern Ontario, Manitoba, Alberta Soil, decaying wood- large outbreak in beaver ponds seen in outdoorsmen Inhalation of mold -> alveoli -change to yeast form in lungs

***Rapid Growing Mycobacterium

Species - M. Chelonei - M. Abscessus - M. Fortuitum Requires 2 to 30 days for growth Isolated from water, contaminated biologicals, domestic animals Clinical Syndromes **cause post-surgical infections and infection of surgical equipment** - Infections of skin and soft tissue - Cardiac surgery, augmentation mammoplasty, peritoneal dialysis, arthroplasty - Bronchopulmonary infections • May colonize respiratory secretions without disease - Other diseases • Lymphadenitis, keratitis, osteomyelitis, meningitis - Disseminated Disease • Majority immunodeficie

Paranasal sinuses

Sphenoid, maxillary, frontal, ethmoidal Function: -bones lighter -voice resonance -filter/moisten air

Peritonsillar abscess

Spread of infection outside of the tonsillar capsule into the peritonsillar space. Signs and symptoms: - Unilateral otalgia - Uvular deviation - Odynophagia Treatment: urgent incision and drainage

***M. Marinum

Spread via Trauma to skin • Swimming pools, aquariums, natural bodies of water • Fish spines, nips of crustaceans Local SKIN Infection • Papule ulcer • Sporotrichoid type spread Therapy • Rifampin + Ethambutol • Tetracyclines • Trimethoprim - sulfamethoxazole

Sarcoidosis staging

Stage I and II most common

Specify the functions of the stapedius and tensor tympani muscles in hearing and specify their motor innervation.

Stapedius- stabilizes stapes in oval window, tilts it posteriorly -innervation: stapedial branch of the facial nerve (CN VII) Tensor tympani: -function: dampens loud sounds, such as those produced from chewing, shouting, or thunder. -innervation: tensor tympani N. (branch of mandibular (V3) branch of CN V)

Furunculosis Otitis Externa

Staph aureus most common cause Abscess in lateral portion of external auditory canal May require systemic antibiotic therapy

Explain the universal numbering system for teeth.

Start at 1 with Right maxillary molar then go all the way to the left, down and over to the right 1-16 on top 17-32 on bottom

How does expiratory/inspiratory stridor help to locate the area of the respiratory system effected?

Stridor on inspiration indicates obstruction at or above the larynx biphasic stridor during inhalation as well as expiration places the obstruction in the trachea expiratory stridor alone means obstruction below the carina, and this is much more difficult to evaluate.

Lymphatic drainage of the ear

Superficial regions of ear: -progress through parotid nodes or jugulodigastric nodes before going into ipsilateral cervical trunk/nodes Middle ear: -parotid nodes or retropharyngeal nodes (very deep-problematic) Inner ear: -superficial cervical nodes

Nasal conchae on CT

Superior nasal concha not well developed in children

Allergic Fungal Rhinosinusitis tx

Surgical Debridement of obstructed sinuses to remove fungal debris. Itraconazole - 200 mg po bid (studies have used 400 mg bid, but this is above the recommend max of 600 mg/day) Antifungal nasal washes Intranasal steroids

Esophageal Trauma

Suspect in patient w/: I. left pneumothorax or hemothorax without a rib fracture, who has received a severe blow to the lower sternum or epigastrium and is in pain or shock out of proportion to the apparent injury II. whenever particulate matter appears in chest tube drainage after blood begins to clear III. chest tube bubbles continuously during inspiration and expiration- suggests connection b/w esophagus and pleural space Dx: mediastinal air/emphysema usually on L side Tx= surgical

Dx of PE in pregnant patient

Suspected PE Leg symptoms present: -Compression ultrasound -if positive-> treat NO leg symptoms: -Chest X ray I. If abnormal CXR -> order CT Pulmonary Angiogram: -if positive -> treat -if insufficient evidence -> Compression ultrasound and repeat CTPA -if negative -> NO treatment II. If NORMAL CXR-> V/Q studies: -if positive-> treat -if normal/negative -> NO treatment ****Remember if you use a D- dimer in the work-up to adjust the upper limit of normal to account for a normal increase sometimes seen in pregnancy.****

Reactive nodules/polyps

Symptoms include hoarseness and change in vocal qualities. Mechanical/repetitive stress causes injury and trauma of the vocal cords, changing vocal cord mass and vibratory qualities bilateral nodules= classic "singer's" nodules females>males

Asbestosis Clinical presentation and tx

Symptoms: -Insidious onset of dyspnea, non-productive cough, bibasilar crackles, clubbing in 40% of cases CXR: -Reticulonodular pattern LOWER lobes of lung -Pleural plaques and/or thickening may progress to honeycombing HRCT: Ground-glass opacities and above PFT: Restrictive pattern= FVC↓, FEV1/FVC Normal, TLC ↓, DLCO ↓ Tx is supportive (smoking cessation) (picture= asbestos body)

What is sarcoidosis?

Systemic disease characterized by noncaseating granulomas in multiple organs (lung and hilar lymph nodes) leads to restrictive lung disease African American females Unknown etiology; likely d/t to CD4 helper Th1 Cell response to unknown antigen Most common in USA Granulomas most commonly involve the hilar lymph nodes and lung (characteristic stellate inclusions - steriod bodies - seen within giant cells of granulomas) Other commonly involved tissues: -uvea (uveitis) -skin (cutaneous nodules or erythema nodosum) -salivary and lacrimal glands (mimics Sjogren syndrome) -almost any tissue can be involved

What other conditions must you rule out before dx of Sarcoidosis?

TB Aspergillosis/Fungal Infection Hypersensitivity Pneumonitis Lymphoma

HIV infected pregnant women are at higher risk of mortality due to what infection?

TB Clinical manifestations - Cough 74% - Weight loss 41% - Fever 30% - Malaise and fatigue 30% - Hemoptysis 19% - No significant symptoms 20%

What genetic factors cause marked individual susceptibility to development of (COPD) emphysema?

TGF-β (play a central role in wound healing and in tissue repair): -with certain polymorphisms, mesenchymal cell response to TGF-β is reduced resulting in inadequate repair of elastin injury Matrix metalloproteinases polymorphisms can result in higher levels of MMP-9 and MMP-12, which are found increasingly in emphysema patients -contribute to tissue breakdown

Interstitial Lung Diseases (ILD) Physical findings

Tachypnea Inspiratory crackles/rales "Clubbed" fingers occurs in 25-50% of IPF cases Cyanosis (late) Extrapulmonary -Adenopathy -Arthritis -Systemic sclerosis -Rash Signs of severe PHT (pulmonary hypertension) - Elevated JVD - Leg edema (late)

Antibiotics to avoid during pregnancy include

Tetracycline Aminoglycosides Sulfonamides Quinolones

Specify the blood supply of the nasal cavity and distinguish the locations of arterial plexuses in the nasal cavity that result in epistaxis.

The Sphenopalantine foramen on posterior wall next to middle nasal conchae transmits the: -sphenopalantine A (end artery of Maxillary A. which came from External Carotid A.) and the -nasopalantine N. (V2 branch) Sphenopalantine A.: -supplies lateral wall, conchae, ethmoid sinuses, and nasal septum Anterior/Posterior Ethmoidal A's (from opthlamic A.- from internal carotid artery through optic canal to nasal cavity)

BURP maneuver

The backward, upward, rightward (patient's right) pressure used during intubation to improve the laryngoscopic view of the glottic opening and vocal cords; also called external laryngeal manipulation

hygeine hypothesis

The immune system of the newborn infant is skewed toward Th2 cells and needs timely and appropriate environmental stimuli to create a balanced immune response.

How does Sarcoidosis most commonly present on Pulmonary Function Tests?

The most common abnormality is a restrictive ventilator impairment with an abnormal diffusion capacity (DLCO) Some patients can demonstrate: - Small and/or large airways obstruction - Methacholine hypersensitivity - Exercise desaturation

What muscle does the phrenic nerve travel along?

The phrenic nerve is found in the middle mediastinum and travels along the anterior scalene muscle DEEP to the carotid sheath.

Neuroendocrine proliferations/Low Grade Neuroendocrine carcinoma

These cells play a role in hypoxia detection, receive neural inputs, and subsequently release hormones that regulate blood blow, regulate bronchial wall tone, etc. Neuroendocrine cells are not well visualized on H&E stains. Stained w/ chromogranin

nasopharyngeal trumpet

This artificial means to keeping an open upper airway can be used in patients who are semiconscious-awake and have a gag reflex

Tx of Pleural Effusion

Thoracentesis and tube thoracostomy preferred as first- line approaches to PPE - If fluid >10 mm in thickness on decubitus - For nonloculated PPEs, may provide adequate drainage - For multiloculated, viscous PPEs, this may be inadequate Fibrinolytic therapy - If the fluid is loculated, install chest tube and instill fibrinolytics with DNase daily VATS and surgery are highly effective and definitive but associated with - Bleeding - Infection - Postoperative pain - Anesthesia risks

What is the second most common type of congenital pediatric neck mass.

Thyroglossal duct cysts most commonly occur in the midline and elevate with swallowing. Occasionally, they will swell after an upper respiratory infection, bringing them to clinical attention. must remove cyst and middle portion of hyoid bone (otherwise may recurr)

External ligaments of Larynx

Thyrohyoid membrane: transmits: -internal branch of superior laryngeal N. (innervates laryngeal mucosa) -superior laryngeal A. Cricothyroid membrane and Median Cricothyroid ligament -important in cricothyrotomy that is done when someone is choking

Specify the locations of the palpable laryngeal cartilages and indicate which one is a landmark for finding the carotid pulse and which one for the superior extent of the trachea

Thyroid cartilage Cricoid cartilage: -feel pulse of common carotid a. at this lvl -use to find superior extent of trachea Thyroid gland Tracheal rings

Describe the developmental basis, anatomical locations, and clinical manifestations of thyroglossal duct cysts.

Thyroid gland descends from foramen cecum to below cricothyroid cartilage usually obliterates remnants of thyroglossal ducts can occur (cyst) thyroglossal duct cysts generally occur at base of tongue, hyoid bone, or thyroid cartilage

Ticagrelor

Ticagrelor is a cyclopentyltriazolopyrimidine which binds reversibly to P2Y12 ADP receptors. -It has a more rapid and consistent onset of action than clopidogrel and also a faster offset of action more effective, higher risk of hemorrhage -dyspnea **contraindicated in pts w/ history of intracranial hemorrhage

Side Effects of Decongestants (Phenylephrine (Neo-Synephrine), Pseudoephedrine (Sudafed, Novafed) , Oxymetazoline (Afrin))

Topical Side effects: • Nasal stinging, dryness, irritation • Rebound congestion • Tachyphylaxis • Rhinitis medicamentosa Sytemic Adverse Effect: • Tachycardia • Arrhythmias • Hypertension • Nervousness • CNS stimulation • Insomnia • Dizziness • Nausea

What is the most widely used marker of anaphylaxis?

Total serum tryptase -usually elevated plasma histamine lvls only transiently elevated

Tension pneumothorax signs/symptoms

Tracheal deviation contralaterally Hypotension Absent breath sounds ipsilaterally Neck vein distention Cyanosis Hyperresonant to percussion Tx: I. Initial: needle decompression -2nd intercostal space midclavicular line of effective lung-converts to simple pneumothorax II. Definitive: chest tube -4th/5th ICS midaxillary line, permanently expands lung

Most common cause of Transudative (hypocellular and protein poor) vs Exudative Pleural Effusions?

Transudative: -Congestive Heart Failure (>90%) Exudative: -pneumonia -Malignancy

Review the 3 types of ribs

True ribs (1-7) -attach directly to the sternum False ribs (8-10) -attach to the 7th costal cartilage Floating ribs (11-12) -no anterior attachment

tuberculoid vs lepromatous leprosy

Tuberculoid • Histology similar to sarcoid granulomas • Nerve bundles that are grossly swollen and infiltrated with mononuclear cells • Acid-fast bacilli few to absent • Able to manifest delayed-type hypersensitivity to skin tests -limited disease and relatively few bacteria in the skin and nerves Signs/symptoms: -severe pain, muscle weakness -enlarged nerves -red patches on skin Lepromatous • Predominant cell is macrophage • Langhan type giant cells, lymphocytes are few • Granulomas not developed • Numerous acid-fast bacilli • Profoundly anergic Signs/symptoms: -leonine faces -peripheral neuropathy -extensor surface nodules

Treatment of TB

Tuberculosis should always be treated with at least two drugs After the initial phase of daily therapy, twice weekly therapy may be instituted The preferred 6 month treatment regimen includes: 2 months Isoniazid + Rifampin + Pyrazinamide followed by 4 months Isoniazid + Rifampin An acceptable alternative 9-month regimen includes: 9 months INH + RIF

Secondary survey components

Tubes and fingers in every orifice Entire body examined Complete neurological exam X-ray, labs, peritoneal lavage

Superior vena cava syndrome

Tumor can compress SVC and cause swelling of face, JVD, and visible chest veins Signs/symptoms: -confusion -facial swelling -prominent chest wall veins

Occupational Airway Disease

Two types: I. Occupational Asthma: -New onset of variable airflow limitation and/or bronchial hyperresponsiveness due to workplace environment exposure in an individual with no prior history of asthma II. Work-related asthma: -Exacerbation of pre-existing asthma Dx is difficult: -history: temporal association of symptoms w/ work, decreased when away from work -peak flow monitoring before/after work -PFT -wheezing on exam -allergy testing -bronchoprovocation test Tx: 1. Remove or limit the patient from the irritating agent in the workplace environment 2. Pharmacologic medications

What are the Two subphenotypes of ARDS

Type 1: Hypo-inflammatory -More responsive to lower PEEP -Required less days of mechanical ventilation Type 2: Hyper-inflammatory -Approximately 1/3 of ARDS patients characterized by high inflammatory biomarkers -Higher prevalence of sepsis -Fewer ventilator-free days -More metabolic acidosis -Required high levels of PEEP -Higher mortality

What immune cells are involved in Asthma?

Type 2 immune responses - central immunologic abnormality -Mediated by the CD4+/Th2 cells and IgE The CD4+ cell prominence → think asthma

Dx of DVT in pregnant patient

Ultrasound of proximal veins If high suspicion of isolated Iliac DVT- do MRI

List some of the most immediate life threatening causes of dyspnea

Upper airway obstruction by foreign body angioedema or hemorrhage tension pneumothorax pulmonary embolism COPD - acute exacerbation status asthmaticus.

Describe which cancer is associated w/ inflammation of each lymph node

Upper jugular chain/jugulodigastric area: -metastasis from nasopharynx Posterior triangle: -nasopharynx, posterior scalp, ear, temporal bone, skull base Lower jugular chain area (supraclavicular nodes): -thyroid, pyriform sinuses, upper esophagus, primary tumor below clavicle Submandibular Triangle: -oral cavity -anterior 2/3 of tongue, floor of mouth, gums, mucosa of cheek Submental Triangle: -rarely involved early, except in cancer of lip Midjugular chain area (deep lateral cervical nodes): -any portion of oral cavity, pharynx, or larynx (especially from Waldeyer's tonsillar ring)

Urticaria vs Angioedema

Urticaria: -localized, non-pitting edema -involves ONLY superficial dermis -primary cell= cutaneous mast cell that release histamine Tx: anti-histamines. may add H2 blocker (cimetidine) and short-term oral corticosteroids Angioedema: -life-threatening -covers larger surface area and involves the dermis and SubQ tissue Dx: C2, C4, C1 esterase inhibitor lvls to rule out HAE. Tx: antihistamines/corticosteroids. if airway compromise, use epinephrine, antihistamines and corticosteroids

Asthma Pathogenesis/Characteristics

Usually Atopic etiology: -IgE mediated (Type I hypersensitivity rxn) Non-atopic etiology due to respiratory viruses, pollutants, drug rxn Hallmarks: -Intermittent & REVERSIBLE airway obstruction -Chronic bronchial inflammation with eosinophils -Bronchial smooth muscle cell hypertrophy & hyperreactivity -Increased mucus production -Lung over-inflation Microscopically: -mucus plugging w/ many eosinophils -increased submucosal glands w/ goblet cell hyperplasia -hypertrophy/hyperplasia of smooth muscle -airway remodeling

Herpes Oral infection

Usually HSV-1 Most pts asymptomatic May present w/: -numerous herpetic oral vesicles -fever -lymphadenopathy -acute herpetic gingivostomatitis -herpes labialis (start as small vesicles then burst and produce ulcers on "wet" mucosa or crusty blisters on "dry" surfaces" Histology: -intranuclear inclusions or fusion of cells into multinucleated giant cell Can remain dormant in local ganglion cells and recur

Other surgeries for OSA

Uvulectomy Nasal reconstruction Permanent tracheotomy: -100% curative -indicated for severe apnea assx w/ life-threatening cardiac arrhythmias uvulopalatopharyngoplasty: -surgical repair of the uvula, palate, and pharynx **severity of disease is NOT prognostic indicator of success

Distinguish the functions of the following cranial nerves in the oral cavity and tongue: V2, V3, VII, IX, X, XII and specify how each of these nerves is assessed clinically.

V2 (maxillary N.) -innervates hard palate -innervates maxillary teeth V3 (mandibular N.) I. Inferior alveolar N. (through mandibular foramen) innervates mandibular teeth II. Mental N. (from inf. alveolar N going through the mental foramen) innervates chin and lower lip III. Buccal Branch: sensory info to mucosa of oral cavity IV. Lingual nerve: sensory to anterior 2/3 of tongue CN VII: -submandibular gland -sublingual gland -Chorda tympani: TASTE to anterior 2/3 of tongue CN IX: -parotid gland -palatine tonsil -posterior oropharynx (afferent limb of gag reflex) -TASTE to posterior 1/3 of tongue CN X: -palatoglossus muscle -pharynx motor innervation -efferent limb of gag reflex CN XII: -tongue muscles (except palatoglossus)

Varicella zoster most commonly effects what dermatome?

V3

Mnemonic for developing a differential diagnosis around a patient presenting symptom or constellation of symptoms

VITAMINS A,C, D and E • Vascular • Infectious • Trauma • Autoimmune • Metabolic and Masses • Inflammatory • Neoplastic • Sickle Cell • AIDS • Coagulopathy • Developmental/Degenerative • Endocrine

What are some Pathophysiological Features Associated With Asthma

Variable airflow obstruction Airway hyperreactivity

Effects of Histamine

Vasodilation leading to decreased BP-H1,2 Bronchoconstriction-H1R Itching and pain-H1R Increased gastric secretion-H2R Sleep, cognition, obesity-H3R

Internal larynx anatomy

Vestibule Ventricle Glottis Infraglottic space Aryepiglottic fold Vocal ligament (true vocal cord/fold) Vestibular fold (false vocal cord)

Fat and Marrow emboli most commonly occur in what clinical scenarios?

Vigorous cardiopulmonary resuscitation - likely no clinical consequence Fracture of long bones - seen in 90% of individuals with severe skeletal injury, but less than 10% of these patients experience overt symptoms Soft tissue trauma Burn patients Signs/symptoms of Fat Emboli Syndrome: -pulmonary insufficiency -neurologic symptoms -anemia -thrombocytopenia -diffuse petechial rash -may be fatal

Epiglottis innervation

Visceral component= superior laryngeal nerve (branch of vagus nerve) -provides sensory and motor input -palpate anterior to cervical transverse process w/in deep cervical fascia Mucosal Sensory component= internal laryngeal N (branch of superior laryngeal N) The remaining branches (recurrent, external laryngeal) are both motor and sensory

Blood supply of visceral vs parietal pleura

Visceral: -bronchial arteries -no pain fibers -drains into the bronchopulmonary lymph nodes Parietal: -capillaries from intercostal arteries -pain fibers -anterior parietal pleura drains to the internal intercostal lymph nodes -posterior parietal pleura drains to the lymph nodes located along the internal thoracic artery.

Review the process of activation and breakdown of Vitamin D

Vitamin D3 synthesized in Skin or consumed D2 derived from plant sterols The liver converts D2 and D3 into 25 (OH) D In kidney: I. 1-hydroxylase (stimulated by increased PTH or decreased PO4) forms active Vitamin D (1,25 (OH)2D-Calcitrol) II. 24-hydroxylase (stimulated by decreased PTH, increased PO4, FGF23) breaks down active vitamin D -1,25(OH)2D -> 24,25 (OH)2D (inactive)

Vorapaxar (Zontivity)

Vorapaxar is an oral protease-activated receptor-1 (PAR-1) antagonist. It is approved for use with aspirin and/or clopidogrel in patients with peripheral arterial disease or a history of MI It has a half-life of 8 days and is metabolized by CYP3A4. high risk of serious hemorrhage.

Aspergillosis Tx

Voriconazole= invasive aspergillosis Lipid formulations of Amphotericin B Posaconazole= 2nd line agent Echinocandins (Capsofungin)= 2nd line therapy in tx of invasive aspergillus infx unresponsive to amphotericin B

M. Kansasii general, high risk patients, clinical presentation, tx

Water is a natural reservoir Southwest, Midwest Men > Women - 5th decade High risk • Pneumoconiosis • COPD • Immunodeficient Pulmonary infection • Mild chronic symptoms • Physical exam minimal • Chest x-ray (may be similar to TB) • Sputums - Repeatedly positive without other cause - May coexist with TB Clinical Disease: - Lymphadenitis - Syndrome resembling sporotrichosis - Cellulitis - Osteomyelitis - Hypersensitivity syndrome (E. nodosum) - Dissemination • Immunocompromised • Pancytopenic Therapy - INH, RMP, EMB

What are some comorbiditis of COPD?

Weight loss with decreased fat- free mass Muscle wasting and weakness Other systemic effects: - osteoporosis - anemia - depression May be related to Systemic Inflammation

Review the relationship b/w plasma calcium and PTH

When calcium is high it binds to Ca++ receptors and inhibits PTH secretion

How does the color of Pleural effusion help to determine cause?

White milky color suggests chylothorax Reddish tinge indicates blood Brownish color suggests rupture of an amebic liver abscess into the pleural space Black discoloration suggests aspergillus infection

Chylothorax

White, odorless, and milky pleural fluid Triglyceride levels > 110 mg/dl Caused by disruptions of the thoracic duct > 50% 2 ° to tumor invading the thoracic lymph duct (**lymphoma responsible for 75%) Trauma is the 2nd leading cause (25% of cases) Rare cause - pulmonary lymphangiomyomatosis

Consequences of DIC

Widespread deposition of fibrin leading to: -ischemia -microangiopathic hemolytic anemia: produces RBC fragments (schistocytes) as RBC's try to squeeze through narrowed vasculature -hemorrhagic diathesis: end result as clotting factors, platelets consumed (bleeding tissue)

What is the most common site of posterior epistaxis?

Woodruff's Plexus - Sphenopalatine Artery mostly Dx: -Observe the posterior pharynx for constant dripping of blood that may signify a posterior rather than an anterior bleed. Usually older pts

Gold standard dx of Pleural Effusion

X-ray: -PA and lateral -Bilateral decubitus CXR CT: -empyema vs. peripheral lung abscess -evaluation of lung parenchyma in undiagnosed exudative effusions Ultrasound -used during thoracentesis

Alpha1-Antitrypsin Deficiency Phenotypes and Emphysema Risk

ZZ and Null = high risk

Pulseless Electrical Activity (PEA)

a condition in which the heart's electrical rhythm remains relatively normal, yet the mechanical pumping activity fails to follow the electrical activity, causing cardiac arrest electrical activity present w/ no pulse Causes: Most common cause= Hypoxia due to respiratory failure: tx w/ 100% O2, intubation **Hypovolemia: tx w/ fluid bolus -tension pneumothorax: tx w/ needle decompression -Cardiac tamponade: tx w/ pericardiocentesis -Massive pulmonary embolus: tx w/ TPA -Severe hypercarbia: tx w/ intubation and hyperventilation -Acidosis: measure pH, give bicarb if pH <7 -Massive myocardial dysfunction: tx reversible cause

Is pulse oximetry reliable?

a quick bedside tool, but it lags 1-2 minutes behind actual clinical physiology -looks better than it is on the downward trend of respiratory failure -looks worse than it is on the upward correction of respiratory failure Cannot read on cold extremities or vasoocclusive digits, and finger polish may obscure reading tells you nothing about the ventilatory status of the patient

Anaphylactic shock

a rarer cause with systemic vasodilation and increased vascular permeability (IgE-mediated hypersensitivity) Increased HR Decreased CO Normal/decreased central venous pressure Decreased precapillary wedge pressure Decreased systemic vascular resistance

If a patient has 1-2 word dyspnea, is using accessory muscles and appears pale and in acute distress the essential hx to obtain is?

a. Medication and allergies b. What will work? c. Are you or have you ever been on steroids? d. What have you used at home? e. Have you been compliant with meds at home? f. Have you ever been on a ventilator? If yes, when? g. Do you want us to use a ventilator if we can not fix this any other way or your body tires out and just can't keep up?

Cardiac tamponade

acute compression of the heart caused by fluid accumulation in the pericardial cavity Etiology: -penetrating trauma -blunt trauma Beck's Triad: -increased CVP (distended neck veins) -hypotension -muffled HEART sounds (breath sounds present) Management: -patent airway -IV therapy **pericardiocentesis -open thoracotomy w/ repair

Distal acinar (paraseptal) emphysema (often called bullous emphysema)

adjacent to pleura, lobular connective tissue septae Bullae formation Risk of spontaneous pneumothorax in young adults

Bacterial tracheitis Tx

admit to ICU intubate FIRST then perform Physical Exam -intubation does not solve the entire problem b/c endotracheal tube may obstruct secondary to secretions Tracheostomy may be preferred (easier to keep clean) Abx that cover S. aureus as well as broad-spectrum to cover Strep species, Hemophilus, Klebsiella, and Pseudomonas.

Adenocarcinoma genetics

alterations in the tyrosine kinase receptor signal transduction pathway KRAS, EGFR

What should immediately be done for a pt in acute respiratory distress?

always place on high flow oxygen, cardiac monitor and start an IV. If at all possible, get a room air oximetry and peak flow at the beginning so you can monitor therapy. ABG's generally reserved for severe cases that aren't getting better or those in extremis on arrival.

how does Mucormycosis present in the upper airway?

angioinvasive- nasal tissue necrosis and local invasion into areas such as periorbital tissues and cranial vault Histo: Broad, non-septated hyphae with right-angle branching (arrow) are characteristic.

Treatment of Mild persistent asthma: -symptoms > 2x per week but <once per day -minor limitation w/ normal activity -nighttime symptoms 3-4 times per month -normal lung function

anti-inflammatory therapy (inhaled corticosteroid-Fluticasone) Inhaled short-acting B2 agonist as needed Alternative: sustained-release theophylline, leukotriene modifier or cromoglycate

Large Cell Carcinoma (LCC)

appears to be a mutationally-progressing, undifferentiated common pathway for both adenocarcinoma and squamous cell carcinoma. when you cannot define a lesion as adenocarcinoma or SCC but small cell carcinoma can be ruled out = LCC dx of exclusion

Wartharin Tumor (Papillary cystadenoma lymphomatosum)

arises ONLY in the parotid gland 10% are bilateral, and 70% of all bilateral salivary tumors are Warthin tumors Smokers, males Characteristics: -Dense lymphocyte infiltrate -papillary-like proliferation **abundant lymphoid germinal centers form usually benign, rarely may undergo malignant change into lymphoma or carcinoma

Low grade Neuroendocrine Carcinoma

arises from neuroendocrine cells AKA: carcinoid tumor (or slightly higher grade atypical carcinoid tumor) <40, non-smokers Grow intraluminally and endobronchially Can produce carcinoid syndrome (flushing, diarrhea, cyanosis)

Tonsil/lateral pharyngeal wall cancer usually presents?

as widespread neck disease at time of dx very aggressive

COPD vs Asthma

asthma not considered COPD

Persons with suspected pulmonary or laryngeal tuberculosis should initially have?

at least 3 sputum specimens examined by smear and culture Additional methods to obtain sputum specimens: - Gastric aspiration - Sputum induction - Bronchoscopy

gold COPD assessment

based on FEV1 Gold 1: FEV >80% Gold 2: FEV1 50-79% Gold 3: FEV1 30-49% Gold 4: FEV1 <30%

What monitoring should be done when using RIPE therapy?

baseline and periodic liver enzymes complete blood cell (CBC) count serum creatinine

Modiolus

bony core of cochlea

Verrucous oral cancer is most commonly found where?

buccal mucosa

How does sarcoidosis cause hypercalcemia?

by increasing the conversion of 25-OH-D to 1,25-OH-D (calcitriol) by granulomatous tissue -leads to increased absorption of Ca++ and PO4+ How?: -activated pulmonary alveolar macrophages increase expression of 1a-hydroxylase in response to inflammatory cytokines (activates Vitamin D to calcitriol)

How does Sarcoidosis effect TB skin testing? What is the preferred method?

can be falsely negative during active disease (anergy) Preferred method of TB dx w/ Sarcoidosis: -Interferon Gamma Release Assay (IGRA): Quantiferon TB Gold (QFT) or T-Spot are Unaffected by sarcoidosis activity

Hypersensitivity Pneumonitis

can develop when inhaled, organic antigens cause a predominately interstitial allergic response Restrictive lung disease Types: I. Farmer's lung - spores of actinomycetes in warm, humid hay II. Pigeon breeder's lung (bird fancier's disease) - several types of bird-derived material III. Bagassosis - exposure to bagasse (byproduct of sugarcane) Characteristics: -interstitial pneumonitis and granulomas common -UIP-like fibrosis w/ fibroblastic foci -honeycombing -Type IV rxn w/ granuloma formation -Type III rxn w/ complement and immunoglobulins in vessel wall

Epiglottitis most common cause

caused almost exclusively by Hemophilus influenza type B nearly eliminated by vaccination (HIB vaccine)

Diptheria

caused by Corynebacterium diphtheriae, a club-shaped gram-positive bacillus 50% also have Strep This organism causes a severe illness involving the respiratory tract, including the appearance of pseudomembranous pharyngitis and possible airway obstruction. -sore throat -dysphagia -headache -low-grade temp Tx: -antitoxins + Penicillin or Erythromycin IV -may need intubation or surgical airway

Allergic Angioneurotic edema

caused by allergic rxn classically caused by ACE inhibitors

Smoking-Related Interstitial Diseases (Desquamative Interstitial Pneumonia (DIP)

characterized by large collections of macrophages filling the alveolar spaces (not desquamative or interstitial.......) Macrophages contain faint/dusty brown pigment (smoker's macrophages) interstitium remains relatively preserved

Caisson disease

chronic condition of decompression seen in underwater bridge workers where the persistence of gas emboli in the skeletal system leads to multiple foci of ischemic necrosis of the femoral heads, tibia, and humeri

Idiopathic Pulmonary Fibrosis (IPF)

chronic progressive lung disorder characterized by increasing scarring, which ultimately reduces the capacity of the lungs; etiology unknown Accounts for about 28% of all ILD's A diagnosis of exclusion Pathology: -injury/inflammation leads to recruitment of inflammatory cells -cytokine production -release of proteases, oxidant radicals -> degradation of connective tissue matrix -recruitment of fibroblasts -fibrosis Symptoms: • Dyspnea on exertion (progressive) • Dry cough • Bibasilar crackles (sounds like velcro being pulled apart) • Finger clubbing: Occurs in 25-50% of patients

Risk factors for head and neck cancer (oral cavity, larynx, pharynx)

chronic sun exposure, tobacco and alcohol use, poor dentition, industrial or environmental exposures, and family history.

Hamartoma (AKA: pulmonary hamartoma, chondroid hamartoma)

classic 'coin lesion' - a round, well-defined radio-opaque lesion on chest film Micro: -mix of smooth muscle cells, bronchial epithelium, connective tissue/collagen, cartilage

Normal composition of pleural fluid

clear and colorless w/ protein concentration of <1.5g/dL monocytes and mononuclear cells predominate volume generally .1-.2mL/kg of body weight

Specify the location of the deep cervical lymph nodes.

contained in the carotid space in the neck, close to the internal jugular vein.

How does shock effect the adrenals?

cortical cell lipid depletion as stored lipids are used for the synthesis of steroids.

Charcot-Leyden crystals

crystalline aggregates of eosinophils with eosinophil protein called galactin-10 can aggregate that show up in the mucus of asthmatics Can occur in any medical condition with abundant eosinophils (not just asthma).

How does FRC change in a pregnant women in the supine position?

decreases 10-25% in supine position w/ possible atelectasis due to enlarged uterus

Pulmonary Alveolar Proteinosis (PAP)

defects in granulocyte-macrophage colony stimulating factor (GM-CSF) or macrophage function results in the accumulation of surfactant in alveolar spaces Presentation: cough that is productive of abundant, mucoid/gelatinous material Tx= pulmonary lavage

Basal membrane

deformed by a traveling wave Considered "Topotonical": -each portion of the basal membrane is sensitive to a different sound frequencies -due to Variation in the width of the basilar membrane

Thymoma

develops from 3rd and 4th pharyngeal pouches impingement on mediastinal or neck structures **associated w/ Myasthenia Gravis Micro: -abundant non-neoplastic T lymphocytes (thymocytes) -also has eosinophilic neoplastic epithelial cell clusters (minority)

How does shock effect the lungs?

diffuse alveolar damage can be seen w/ SEPSIS or TRAUMA -hyaline membranes line alveolar spaces w/ associated interstitial inflammation and pneumocyte proliferation NOT usually seen w/ pure hypovolemic shock

Atypical Adenomatous Hyperplasia (AAH)

earliest lesion of the adenocarcinoma sequence. < or = to 0.5cm pneumocyte hyperplasia w/ mild dysplasia, slight fibrosis in interalveolar septae

How do you evaluate work of breathing?

evaluate speech diction: -if pt can only speak 1-2 words at a time they are in serious trouble using accessory muscles? listen to lungs look at skin color

Pyogenic Granuloma

exaggerations of granulation tissue, and as such, can grow rapidly, can regress or can organize/mature into a fibrotic nodule Children, young adults, and pregnant women ("tumor of pregnancy") gingival location most common

Fibroma

exaggerations of wound healing due to chronic irritation or trauma Histo: stroma and new collagen seen usually occur along gingiva or on buccal mucosa along the bite line Surgical excision is curative

Emphysema histology

expanded/destroyed alveoli

How does shock effect the Kidneys?

extensive tubular ischemic injury (acute tubular necrosis) causes oliguria, anuria, and electrolyte disturbances histopathology shows swollen, vacuolated tubular cells in association with tubular cell necrosis and tubular casts (early cast at arrow).

Which gender is more effected by COPD?

females Prevalence of COPD among women significantly higher than among men. Since 2000 more women than men have died from COPD Increased risk of women developing lung cancer as compared to men as FEV1 declines.

How long should treatment for MDR-TB be continued?

for 18-24 months after sputum culture conversion all pts should be closely observed for 2 years after completion of treatment

Curshmann Spiral

found in sputum or lavage fluid of asthmatics. papanicolaou stain gives red core with fuzzy margin to which many cells are attached. Composed of mucosubstance. mucus plugs can be extruded from submucosal gland ducts or bronchi

Flail chest

fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment Treatment: -adequate ventilation -humidified oxygen -internal fixation w/ intubation -analgesics

Parotid gland parasympathetic innervation

glossopharyngeal nerve

Pertussis

gram negative coccobacillis causes whooping cough ("100 day cough") only vaccine-preventable disease that is on the rise Most cases occur in <1 years or 10-19 years old -all age groups

Otosclerosis

hardening of the bony tissue of the middle ear can result in conductive hearing loss (most common) or sensorineural hearing loss sounds reach TM but are incompletely transferred via ossicular chain in middle hear, and partly fail to reach inner ear (cochlea) Tx: -hearing aids -laser stapedotomy w/ placement of a piston prosthesis

Angioedema without urticaria should raise suspicion for ?

hereditary angioedema (HAE) C2, C4, C1 esterase inhibitor lvls to rule out C4 concentration is almost always decreased during attacks and is usually low between attacks

Describe the anatomical basis of sublingual drug administration.

highly vascularized Rapid (<1min) systemic absorption into deep lingual and sublingual vv. Drain directly into Internal Jugular Vein

Who is at higher risk of Coccidiomycosis infx?

host control via cell-mediated immunity Occupation with soil exposure Immunocompromised patients • AIDS • Transplants • TNF antagonists • Pregnancy Persons of Filipino or African-American descent

Squamous papilloma

hyperplastic squamous cell proliferation arranged in fingerlike projections with central fibrovascular cores (papillomatous hyperplasia) caused by low-risk HPV (typically serotypes 6 and 11)

Restlessness and agitation in a child may indicate?

hypoxemia rather than anxiety

Tachycardia out of proportion to the fever is a reflection of the?

hypoxic status of the patient

Adult Epiglottitis (supraglottits) tx

if acute onset- admit to ICU for intubation/tracheostomy broad spectrum Abx consider fungal organisms steroids unproven

What is the value of pre-oxygenation for 2-3 minutes w/ 100% oxygen to the pt? What advantage does it serve you as the person performing the intubation?

increases the FRC oxygen store and delays the onset of arterial desaturation and hypoxemia during the apneic period following induction of anesthesia and muscle relaxation.

When are antiplatelet drugs indicated

indicated primarily for diseases on the arterial side of the circulation: -myocardial infarction -stroke They are essential in the acute phase and in long-term follow-up to prevent recurrent events. Used primarily for acute coronary syndrome which includes: - Unstable angina/non-ST-elevation MI (NSTEMI) - ST-elevation MI (STEMI) - Percutaneous coronary intervention

Preseptal cellulitis tx

infants must be admitted adults can be followed/recheck cover staph, MRSA, strep -duration of therapy= 7-10

What is the most common cause of TM perforation?

infection

Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia)

is an AD condition characterized by the prescence of telangectasias in the skin as well as mucus membranes (lips, GI tract, respiratory tract and urinary tract). These telangiectasias can rupture and cause epistaxis, GI bleed, and hematuria Causes arterial- venous fistulas on mucosal surfaces 90% present with epistaxis

How is obstructive sleep apnea (OSA) damaging

leads to Oxidative stress disorders -Ischemia - Reperfusion Non-Cardiovascular Effects: • Sleepiness- Crashes • Depression • Insulin resistance/Type 2 DM Cardiovascular Effects: • Systemic hypertension • Pulmonary hypertension • Congestive heart failure • Coronary artery disease • Nocturnal arrhythmias • Stroke • Atherosclerosis

Adenocarcinoma in-situ/Minimally invasive adenocarcinoma

lepidic growth pattern (along alveolar lining) 3cm or less NO lymphovascular or pleural invasion 5 year survival rate near 10%

The maximum goal ICS inhaler use per week should be?

less than 2 days a week (not including prevention)

Expectorants (Guaifenesin) moa, use

liquify respiratory secretions so that they are more easily dislodged during coughing episodes

Hypovolemic shock

low cardiac output due to extensive hemorrhage and/or fluid loss (burns, trauma, vomiting, diarrhea) Decreased Cardiac Output Decreased Precapillary Wedge pressure (RA pressure) Increased Systemic Vascular resistance (compensatory)

Cardiogenic shock

low cardiac output due to outflow obstruction (PE) or myocardial pump failure (myocardial infarction, arrhythmia, or pericardial tamponade) Decreased Cardiac Output Increased Precapillary Wedge Pressure (RA pressure) Increased central venous pressure Increased systemic pressure

Septic shock

low cardiac output due to vasodilation and peripheral blood pooling caused by overwhelming microbial infection and associated immune response DIC results in up to 50% of patients mortality rate of 20% #1 cause of death in intensive care units most common following infection with gram positive bacteria, gram-negative bacteria and fungi. Normal pump function Decreased Systemic vascular resistance (massive vasodilation) Decreased Precapillary wedge pressure (RA pressure)

Persistent symptoms should be treated with?

low daily doses of Inhaled corticosteroids If symptomatic despite good adherence and technique, add a Long-acting Beta Agonist

How do you avoid barotrauma on mechanical ventilation?

low tidal volume avoid hyperventilation by using slight hypoventilation: -may cause high CO2

Panacinar emphysema

lower lung zones alpha-1-antitrypsin deficiency (antiprotease) effects the alveoli

Sinonasal papilloma types

males>>females two types: I. Exophytic: -low-risk HPV -nasal septum II. Inverted: -low AND high-risk HPV -lateral nasal walls or sinuses -may extend/push into adjacent tissues in a locally aggressive manner -high recurrence rate -10% chance of transforming into malignancy **Koilocytic change suggests HPV atypical

What is the greatest concern in a pt with a neck mass?

malignancy

When pleural LDH suggests an Exudative effusion & protein suggests a transudative effusion what causes should be suspected?

malignant effusions pneumocystis jiroveccii (PCP) effusions

Choana

marks the transition from the nasal cavity to nasopharynx posteriorly

Esophageal foreign body may cause what complication

may cause posterior tracheal compression often complain of dysphagia chest radiograph and barium swallow may be necessary

How many mg epinephrine medication in 1:1000 solution?

means 1 gram of epinephrine in 1,000ml of solution 1gram= 1,000mg SO 1000mg/1000ml so the amount per unit of volume is 1 mg/mL

How many mg epinephrine medication in 1:10,000 solution?

means 1 gram of epinephrine in 10,000mL of solution 1 gram = 1000mg so 1000mg/10000mL = 1mg/10ml = 0.1mg/mL = more dilute

Obesity- Hypoventilation Syndrome (OHS) "pickwickian syndrome"

morbid obesity & chronic hypoventilation w/ daytime hypercapnia (PaCO2 >45mmHg) OSA present in the majority of pts

Cancer at the base of the tongue has higher rate of?

more aggressive higher rate of cervical metastasis (60%)

Mucoepidermoid carcinoma

most common MALIGNANT salivary tumor more likely in parotid gland BUT accounts for high proportion of minor salivary gland tumors Histo: -tricellular (squamous, mucin, intermediate cells)

Pleomorphic Adenoma (benign mixed tumor)

most common tumor of salivary glands Composed of epithelial and myoepithelial tumor cells -may have collagen, myxoid, cartilage or bone material Parotid gland >>submandibular Painless, slow-growing, movable increased risk of malignant transformation to adenocarcinoma or carcinoma ex pleomorphic adenoma

Adenocarcinoma

most common type of pulmonary malignancy female, non-smokers young males Fatigue, cough, weight loss, dyspnea, chest pain, hemoptysis Peripheral mass arise from normal cells of bronchi, bronchioles or alveoli (may produce mucins) Grossly: -white-tan-yellow solid, peripheral mass Micro: -most show prominent central desmoplasia w/ lepidic growth at periphery

Net pressures across the parietal and visceral pleura favor?

movement into pleural space

Erythroplakia

much more likely (90% of cases) to show squamous cell dysplasia, particularly of the high grade/severe/CIS type.

Bronchealveolar carcinoma of the lung

multinodular VERY malignant hard to distinguish from metastasis assx w/ prior lung disease NO smoking hx Histo: glandular, multinodular

How do you confirm tube placements?

must have 2 of the following: -physical exam -exhaled CO2 -capnography -chest x-ray -ultrasound -esophageal detector devices

Describe the importance of the relationship between the maxillary sinuses and the maxillary dentition.

nasal infections can spread to any of the sinuses dental abscess can infect maxillary sinuses

All specimens for testing of pertussis must be from the?

nasopharynx

Theophylline

naturally occurring methylxanthine differing from caffeine by one methyl group. MOA: phosphodiesterase inhibitor, blocks adenosine receptors I. competitively inhibits type III and type IV phosphodiesterase (PDE), which increases cAMP and promotes smooth muscle relaxation II. Adenosine antagonism: -adenosine modulates histamine release: decreased histamine leads to bronchodilation -also results in norephinephrine release Adverse: ****NARROW therapeutic index complicated by drug-drug and disease-drug interaction Use: COPD (little used now)

Paraganglioma (AKA: carotid body tumor)

neural crest-derived cells arranged in a highly vascular matrix Slow growing, painless mass Micro: Classic appearance showing small nests of uniform cells (called the zellballen pattern) typical of neuroendocrine tumors. -can be stained w/ chromogranin (Paraganglioma= tumors that arise in neuroendocrine cells that are in close association with the sympathetic or parasympathetic nervous system.- most common paraganglioma= pheochromocytoma)

Signs/symptoms of hypocarbia due to hyperventilation

numb around the mouth and the fingers and toes go numb. Then the patient will develop carpopedal spasm and their hands and feet will cramp up like claws and they will be worried they are having a stroke.

Pediatric patients are referred to as ____ breathers.

obligate nasal breathers

Mucocele (mucous retention cyst)

obstructed salivary duct/tube/vessel, etc → abnormal luminal expansion → 1) cyst formation (more likely acutely) or 2) corkscrew dilation of the duct/tube (more likely chronically) child/young adults inner surfaces of the lower lip, buccal mucosa, or floor of mouth (ranula) mucosal mass w/ bluish hue

Grunting indicates?

occurs during exhalation when the glottis is partially closed causing a delay and then forceful noisy expiration, which is the grunt localizes a respiratory disease to the lower respiratory tract

Patient Induced Self Lung Injury (P-SILI)

occurs secondary to Increased Respiratory Drive mechanical ventilation is used to avoid this

Bronchiectasis

occurs when a chronic and often necrotizing infection causes permanent dilation of bronchi and bronchioles. any disease that predisposes to airway obstruction increases the likelihood of bronchiectasis occurring -asthma, chronic bronchitis, emphysema -CF, kartagener syndrome, autoimmune diseases the eventual inflammatory-mediated destruction of smooth muscle and elastin that supports and surrounds the airways eventually leading to irregular dilation of airway and mucus plugging

Traumatic aortic rupture

often occurs at site of the ligamentum arteriosum fatal 90% of time high index of suspicion in deceleration injuries CXR- obliteration of aortic knob -loss of space b/w pulmonary artery and aorta -widening of mediastinum -deviation of esophagus/trachea Dx: aortogram Tx: surgical

What is the purpose of nasal flaring?

outward and upward flaring of the nares on inspiration, more often seen in children felt to probably be an attempt to decrease the airway resistance at the nares, which is high in young infants.

How does Granulomatosis with polyangiitis (Wegener granulomatosis) present in the upper airway?

p-ANCA positive saddle-nose deformity: -granulomatous inflammation and necrosis of the nasal cavity -destroys the nasal cavity and destroys the nasal septum causing the collapse of the nasal bridge

Wheezing indicates what?

pathology of main bronchus just distal to carina

Epley maneuver procedure

patient begins upright w/ legs fully extened, head rotated 45 degrees towards effected side lie pt down w/ 30 degrees neck extension observe "primary stage" nystagmus remain in position for 1-2 minutes then turn pts head 90 degrees in the opposite direction, maintain 30 deg. extension remain for 1-2 minutes have pt roll onto shoulder rotating head another 90 degrees in the direction they are facing- now looking down at 45-degree angle observe "secondary stage" nystagmus -should beat in the same direction as primary stage nystagmus remain for 1-2 minutes bring pt back up slowly w/ head still at 45 deg. rotation The patient holds sitting position for up to 30 seconds.

Central sleep apnea (CSA)

patient makes no respiratory effort during the apnea less common then OSA most commonly during NREM sleep (OSA occurs during REM) Signs/symptoms: -daytime sleepiness, witnessed apneas -snoring NOT a prominent finding -any body habitus (not just obese) Risk factors: -CHF -Neurological disease -Ascent to high altitudes

Chronic Bronchitis pathogenesis

persistent cough with sputum production for at least 3 months in at least 2 consecutive years. 20-25% of men aged 40-65 overlaps and co-exists with emphysema, exacerbating decreased lung function. Smokers, urban dwellers in smoggy cities Pathology: -mucus hypersecretion in large airways (originally protective)-> general inflammation -> atypical metaplasia/dysplasia Micro: mucous gland hyperplasia

What are the adenoids

pharyngeal tonsils enlarge during childhood, regress during puberty

White leukoplakia

plaque-like lesion Dysplasia is assumed to be present (only 10-25% of cases), until disproven by biopsy A minority of cases will evolve into invasive SCC biopsy becomes crucial for treatment purposes.

Systemic sclerosis may mimic which ILD?

presents as diffuse interstitial fibrosis (NSIP-like or UIP-like patterns)

Aspirin pharmacology

prevents formation of thromboxane A1 by IRREVERSIBLY inhibiting COX2 last 7-10 days (lifespan of platelet) Also inhibits synthesis of PGI2 (antiaggregant) but this effect is reversible in 2-6 hrs Adverse: -GI bleeding

Silicosis

production of fibrotic silica nodules that eventually form collagenous scars typically UPPER lobes

obstructive sleep apnea (OSA)

pt continues to make respiratory efforts against obstruction events more prominent during REM sleep due to hypotonia of upper airway musculature Characterized by repetitive narrowing or collapse of the pharyngeal airway during sleep that can produce severe disabilities Signs/symptoms: • Excessive daytime sleepiness • Waking up unrefreshed/tired after sleeping • Complain of morning headaches • Irritability/personality changes/depression • Cognitive impairment • Decreased libido • Morning dry mouth • Nocturia/enuresis may also be seen

Cyanosis does not present until?

pt has at least 5 grams of hemoglobin unsaturated blow 85% saturation

What pts are at higher risk of histoplasmosis

pts w/ cell mediated immunodeficiencies (intracellular)

Echinacea

purple coneflower plant typically used for prevention and tx of colds Side effects: -unpleasant taste -allergic rxns (anaphylaxis, asthma exacerbation, angioedema, rash) ('There is no convincing evidence that echinacea decreases the severity or shortens the duration of an upper respiratory tract infection')

Tiotropium (Spiriva)

quaternary muscarinic cholinergic antagonist, particularly at M3 receptors, with 24h duration Administered as a dry powder in a HandiHaler daily Use: -Approved for the treatment of COPD Side Effects: -Dry mouth is most common side effect

Malignant Mesothelioma

rare asbestos exposure **Associated w/ certain occupations: -railyard workers -brickmasons -electricians -plumbers -firefighters -miners -longshoreman -teachers Arises from visceral or parietal mesothelial cells Typically arises several decades after exposure Incidence not significantly higher in smokers (in contrast to asbestos-induced lung carcinoma)

Hereditary Angioedema (HAE)

rare autosomal dominant C1 esterase inhibitor deficiency (if C1 is normal, due to Factor XII gene mutation) Most common areas of the body to develop swelling are the limbs, face, intestinal tract, and airway Consider HAE in individuals with: -Recurrent angioedema without urticaria -Laryngeal edema -Recurrent episodes of abdominal pain and vomiting -A positive family history Dx= Low C1 inhibitor lvls, Low C4 levels Tx: C1 inhibitor concentrate

Neurogenic shock

rarer cause with loss of sympathetic vascular tone and peripheral pooling (anesthetic accident, spinal cord injury) Bradycardia Decreased Cardiac Output DECREASED peripheral vascular resistance (venous & arterial vasodilation) Decreased precapillary wedge pressure (RA pressure) Normal/decreased central venous pressure

Apthous Ulcer

reoccurring, very painful ulcers of unknown etiology Tend to be located on 'soft' mucosa (such as the buccal mucosa, floor of the mouth, inside of lips) Can be seen in the mucosa of many organ systems Various triggers can recur during flares of autoimmune disease

ARDS clinical presentation

respiratory distress CXR lags behind clinical picture Respiratory symptoms other than dyspnea uncommon PE: increased HR, increased RR, increased WOB • Dyspnea, tachypnea • Rales / crackles • ↓P02, normal or ↓PC02, ↑ Aa gradient • Severe hypoxemia refractory to oxygen therapy (Pa02/FI02 < 300) • Normal pulmonary vascular pressure PCW<18mmHg • Diminished compliance (<40 mL/cmH20) Radiography- Bilateral interstitial and alveolar edema

Shock pathophysiology

results from either reduced CO or reduced effective circulating lung volume leads to hypotension followed by impaired tissue perfusion and cellular hypoxia

Adult Epiglottitis (supraglottits)

severe sore throat w/ painful dysphagia normal oropharyngeal exam and the throat pain will be out of proportion to what you see on the physical exam. half the patients with adult epiglottitis will have respiratory difficulty, a muffled voice, and gradual onset of the disease acute onset indicates sicker pt- may require intubation Cause: -25% caused by Hemophilus influenza -75% are caused by a variety of organisms. Complications: -epiglottic abscesses (will have normal AP view in epiglottis)

Ipratroprium (Atrovent)

shorter-acting inhaled muscarinic antagonist. It is combined with albuterol as Combivent.

What is the most common reason to perform a tonsillectomy?

sleep apnea 97% curative for OSA in pediatric pt

Risk factors for oral cancer

smoking alcohol use EBV

How does smoking cessation benefit lungs of COPD pts?

smoking cessation slows the rate of lung function loss

The physical exam sign common to all UPPER respiratory tract obstructions is

stridor

Triangles of the neck

subdivided into two large triangles by sternocleidomastoid

What is the ONLY therapy that has ever been shown to prolong life in COPD patients?

supplemental Oxygen It should be used in all patients with hypoxemia after their condition becomes stable with maximum conventional therapy

What is the biological clock?

suprachiasmatic nucleus

Retropharyngeal swelling causes, and possible complications

swelling of soft tissue anterior to C2 may be caused by C-spine fractures leading to hematoma and retropharyngeal edema that compresses the airway Complications: -penetrating trauma may injure the airway -vocal cord paralysis may result from shearing of recurrent laryngeal nerves in the neck

Sarcoidosis

systemic, autoimmune disease of unknown etiology that causes granulomatous pulmonary changes Black women in 30's-40's Immune abnormalities: -anergy to skin antigens (TB, candida) -Polyclonal hypergammaglobulinemia -Accumulations of CD4+ TH1 cells -Angiotensin converting enzyme (ACE) levels may be elevated, as ACE is produced by epithelioid macrophages Characteristic Noncaseating Granulomata -any organ of the body -diffuse scattered granulomas -lymph node involvement causing hilar and mediastinal adenopathy

Needle thoracentesis

tension pneumothorax 2nd ICS in midclavicular line **make sure to go over top of 3rd rib to avoid neruovasclar bundle (not below 2nd)

Describe the anatomical basis of the relationship between pharyngitis, otitis media, and mastoiditis

the Mastoid air cells connect to middle ear -if infection of middle ear- can infect mastoid air cells (poor blood flow) -may then spread superiorly into middle cranial fossa and infect meninges if left untreated The nasal cavity connects to the middle ear via the eustachian tube

Laryngeal cancer most commonly affects what region?

the true vocal cords (75% of the time)

Small Cell Carcinoma (SCLC, High Grade Neuroendocrine Carcinoma)

there isn't a well-established pre-invasive phase (ie., low grade NE carcinoma doesn't evolve into SCC). STRONGLY associated w/ cigarette smoking commonly involves hilar/mediastinal nodes or distant mets MANY paraneoplastic syndromes: -Cushings (ectopic ACTH) -SIADH (ectopic ADH) -autoantibodies (Lamber-Eaton myasthenic syndrome) Micro: -small blue cells w/ little cytoplasm -"salt and pepper" chromatin -distorting cell bodies and nuclei, so-called nuclear molding; high mitotic activity

Leading cause of lung cancer

tobacco smoke

Describe the pathophysiology of emphysema

tobacco smoke -> ROS -> oxidative stress -> inflammatory response protease-antiprotease imbalance -promotes tissue breakdown -neutrophils & macrophages produce elastase in response to tobacco, leading to the inactivation of antiproteases -MMP's from neutrophils also promote tissue breakdown Protease-antiprotease and oxidant-antioxidant imbalances cause self-perpetuating inflammation that persists even after the smoking has ceased, leading to continued tissue destruction.

Laryngeal cancer risk factors

tobacco, alcohol

What is the most common cause of airway obstruction in unconcious pt?

tongue can use chin lift/jaw

Transudate vs Exudate

transudate is hypocellular and protein poor exudate is cellular and protein-rich

Centriacinar emphysema

upper lobes apical region most common in tobacco smokers effects respiratory bronchioles

What is the "LEFT" rule?

used to assess three variables to predict the likelihood of a DVT 1. (L) Calf circumference (≥ 2 cm greater than rt.) 2. (E) Edema 3. (FT) First trimester presentation

Common pathogens associated with preseptal and orbital cellulitis

usually MRSA or Strep pneumo

Isoniazid drug interactions

usually involves CYP3A

Guidelines for tx of respiratory issues in children.

usually tx w/ aerosolized medications via mask or nebulizer medication depends on pt start w/ aerosols if not in acute distress if moderately severe on arrival add IM epinephrine (can repeat every 20 min for 3 doses)

Dipyridamole

vasodilator and inhibitor of platelet aggregation MOA: inhibits phosphodiesterase and adenosine uptake by cells. used in combo with low dose ASA For secondary prevention of stroke, more effective than ASA alone, but less effective vs clopidogrel and caused more major hemorrhages.

60% of the time the cause of acute pharyngitis is?

viral

The most common cause of Acute Rhinitis is..

viral

Pts recieving long-term ethambutol therapy should undergo baseline and periodic assessment of?

visual acuity and red-green color perception testing (can cause optic neuritis)

Before you pass an endotracheal tube into the trachea during orotracheal intubation you must make sure to?

visualize the vocal cords

Volume targeted ventilation vs Pressure targeted ventilation

volume control favors the control of ventilation pressure control favors the control of oxygenation

If a patient has a pyramidal thyroid lobe where will it be located?

will sit over cricoid cartilage (anterior to cricothyroid ligament)

Does losing one hour a sleep per night effect the body?

yes these add up to form a "sleep debt"

Asthma triggers

• Allergen exposure • Air pollution • Cigarette smoke • Respiratory infections • Strong expressions of • Household products ST emotion (laughing, crying) • Drugs • Vigorous exercise • Pets • Cold air • Dust

Chronic Pulmonary TB characteristics

• Begins as patch of pneumonitis apical posterior UPPER lobe - Mild disease - Atypical fibrous scar Extensive disease: - Caseous necrosis - Reinfection of other lung segments - Cavitary disease - Rupture blood vessels with lymph hematogenous spread Lower lobe disease

What organ systems should be included in the H&P for developing a differential dx

• Derm • Endocrine • Neurologic • Musculoskeletal • Cardiac • Pulmonary • GI • GU • Heme • Reproductive

Tonsillectomy and adenoidectomy complications

• Immediate and delayed hemorrhage • Anesthetic complications • Dehydration • Pulmonary edema: Caused by sudden relief of airway obstruction • Velopharyngeal insufficiency • Velopharyngeal stenosis.

Pathophysiology of COPD

• Increased airway inflammatory response • Protease - anti-protease imbalance • Oxidant/antioxidant imbalance and oxidative stress • Alveolar loss through apoptosis and Vascular Endothelial Growth Factor (VEGF) decrease • Genetic factors Chronic Airflow limitation (Flow) caused by: -loss of elastic recoil (pressure) -airway narrowing (resistance)