Pulmonary Uworld
Goal of FiO2
55-80mmHg (88-95% sat)
Tidal volume on mechanical assist
6mL/kg
Normal pleural fluid pH
7.6 Transudative: 7.4-7.55 Exudative: 7.3-7.45
Solitary pulmonary nodule
>0.8cm bx/excise (might be malignant) based on hx (smoking, age, sex, location of nodule, appearance--regular vs. irregular borders, famhx)
Small cell paraneoplastic
ACTH production (Cushing syndrome) SIADH Lambert-eaton syndrome Central lesion 10-15%
Bronchiectasis
Abnormal bronchial widening in the setting of recurrent infection and inflammation (irreversible dilation and destruction of bronchi) Similar to chronic bronchitis, but sputum production is more prominent Xray reveals dilated airways FVC low (<80%) due to airway destruction Dx: High resolution CT (initial diagnosis, shows bronchial wall thickening), immunoglobin testing, CF/sputum testing, PFT Tx: Chest physiotherapy
Lung abscess imaging
Air-fluid levels, NOT fungus balls
Exercise-induced bronchoconstriction tx
Albuterol 10-20 minutes before exercise Or an anti-leukotriene agent 10-20 minutes before (montelukast, if they cannot tolerate beta agonist)
Epinepherine
Alpha-1 and beta-2, so vasoconstriction and bronchodilation (good for anaphylaxis)
Theophylline
Alternative for ICS + LABA (step 3) of asthma
New pulmonary nodules
Always use CT to test (especially if bigger than 0.8cm with smooth borders -- low risk) and then follow-up if not malignant
Inhaled bronchodilators
Anti-muscarinics (ipratropium, tiatropium) used in COPD and asthma
PE tx
Anticoag should be given prior to CT IF there are no contraindications
Mucus plugging
Atelectasis
Sarcoidosis
Bilateral hilar adenopathy Renal involvement may occur: Interstitial nephritis/nephrolithiasis
Dead space ventilation
Blood isn't getting to a certain area (e.g., PE)
Asbestosis cancer risk
Bronchogenic carcinoma (more common, esp with smokers and has pleural plaques) Pleural mesothelioma (rarer, and presents with unilateral pleural abnormality with large pleural effusion)
Severe renal insufficiency anticoag
CANNOT use enoxaparin, fondaparinux, or rivaroxaban Use unfractionated heparin Bad renal: <30mL GFR
Cor pulmonale etiologies
COPD Interstitial lung disease Pulmonary vascular disease Obstructive sleep apnea
Pulmonary contusion
CT/CXR of patchy, alveolar infiltrate not restricted by anatomical borders Tx: Pain control, pulmonary hygiene, supplemental O2 and ventilatory support Blunt trauma and occurs within <24 hours
TB sxs
Calcified hilar lymph nodes
CREST syndrome
Calcinosis, Raynaud's, esophageal dysmotility with reflux, Sclerodactyly, Telangiectasia Associated with limited cutaneous systemic sclerosis => pulmonary HTN (increases in african americans). Anticentromere antibodies
Mitral stenosis effects
Can cause elevation of left mainstem bronchus (from LA dilation)
Supplemental O2 caution
Can reduce CO2 expiration - Loss of compensatory vasoconstriction and poorly ventilated areas (worsen V/Q mismatch) - Increase in oxyhemoglobin reduces uptake of CO2 due to Haldane effect - Decreased respiratory drive (people don't blow off as much CO2)
Alveolar hypoventilation
Can result from narcotics, anesthetics, sedatives COPD, obstructive sleep apnea, obesity, scoliosis Myasthenia gravis, lambert-eaton, guillan-barre Brainsteam lesion, stroke, infection A-a gradient is normal (is elevated in V/Q mismatch) + respiratory acidosis
Pulmonary TB imaging
Cavitary lesion
Lung abscess xray
Cavity with air/fluid levels
Subcutaneous emphysema next step
Chest xray to rule out pneumothorax
CF pulmonary features
Chronic sinopulmonary infections Nasal polyps Bronchiectasis Digital clubbing Upper lopes (characteristic of bronchiectasis due to CF) Poor growth can be seen as a feature of pancreatic insufficiency
Persistent pulmonary HTN
Clear lungs with decreased pulmonary vascularity (in term/post-term neonates)
Smoking and wrist pain
Concern for hypertrophic osteoarthropathy (may be lung malignancy or TB)
Transient tachypnea of the newborn
Condition of rapid respirations caused by inadequate absorption of fetal lung fluid Risk: Prematurity, c-section Sx: Tachypnea, clear breath sounds, xray: fluid in fissues, hyperinflation Tx: Supportive, resolution in 1-3 days
COPD and sputum
Consider giving abx to COPD (might be what caused acute exacerbation) Also give abx to COPD that requires mechanical ventilation
Refractory anaphylaxis treatment
Continue giving IM epi
Acute exacerbation of COPD
Cough severity or frequency Volume or character of sputum production Level of dyspnea URI may predispose
PEEP with hypovolemic shock
Could collapse the cardiac system by reducing preload (causes increased intrathoracic pressure that squeezes shut the vessels to the right heart)
Nebulized racemic epinephrine
Croup therapy
Pleural effusions sounds
DECREASED tactile fremitus (insulation from lungs) Decreased breath sounds Dullness to percussion
Compensatory metabolic alkalosis process
Decrease Cl- to increase HCO3- (exchanger in kidney)
Bronchiolitis concerns (RSV)
Development of apnea Recurrent wheezing through childhood Use pavilizumab
Cor pulmonale sys
Dilated pulmonary arteries with no congestion Exertional symptoms Loud P2 Tricuspid regurg Elevated JVD Peripheral edema Hepatomegaly Ascites Distant heart sounds (due to hyperinflated lungs)
Empyema tx
Drainage by chesttube and prolonged abx
Consolidation
Dull percussion Increased fremitus and egophony Increased intensity of breath sounds
Tracheobronchial tear sx
Dyspnea Hemoptysis Subcutaneous emphysema Hamman sign (audible crepitus on cardiac auscultation) Sternal tenderness
pneumocystis pneumonia
Dyspnea Nonproductive cough Fever (Usually) Bilateral, diffuse, interstitial infiltrates on chest imaging
CMV pneumonitis
Dyspnea Nonproductive cough Low-grade fever Imaging CT: Patchy or diffuse ground-glass opacities
Nonseminomatous germ cell tumors
Elevated B-HCG and alpha-fetoprotein Usually occur in males and are locally invasive Almost all germ cell tumors in anterior mediastinum are primary rather than metastatic Benign teratomas do not produce markers
Unstable pneumothorax
Emergent needle thorcotomy (do not need to do xray)
Light criteria
Exudative effusion if 1 of following: 1. (Pleural fluid protein) / (serum protein) = >.5 2. (Pleural fluid LDH) / (Serum LDH) = >.6 3. Pleural fluid LDH > 2/3 normal serum LDH
Galactosemia
Failure to thrive in neonatal period Jaundice Vomiting Hepatomegaly Congenital cataracts
Aspiration pneumonia sxs
Fever Leukocytosis Cough Lobar infiltrate May also present with pleuritic chest pain and exudative pleural effusion (but need fever!)
CHF vs COPD
Findings of hypoxia, hypocapnia, and respiratory alkalosis COPD would have respiratory acidosis and hypoxia
Asthma dx
First use PFTs (spirometry) with methacholine challenge
Bleeding in lungs treatment (>600mL/24hr)
First: Bronchoscopy (with treatment, balloon tamponade, cautery) If not: Thoracotomy
Fixed upper airway obstruction
Flattened inspiration and expiration volume loop Could you laryngeal edema (from an allergic reaction to food; use epi, corticosteroids, and antihistamines)
Wells criteria
For pre-test probability of PE 3 points: Clinical signs of DVT, alternate diagnosis less likely than DVT 1.5 points: Previous DVT or PE, heart rate >100, recent surgery or immobilization 1 point: Hemoptysis, cancer >4 PE likely, otherwise unlikely Normal D-dimer but high wells still might mean PE (D-dimer only excludes if low probability)
Histoplasma
Fungi in lung Associated with caves Granulomas Narrow-budding yeast Mid-western US
Acute respiratory distress syndrome (ARDS)
Gas exchange impaired by V/Q mismatch Lung compliance decreased (loss of surfactant and recoil because of edematous lungs) Pulmonary arterial pressure increased (hypoxic vasoconstriction, destruction of lung parenchyma, compression of vascular structures from PEEP)
Drug-induced lupus medications
Hydralazine Procainamide Isoniazid
Squamous cell
Hyperca Central lesion (hilar mass) Smoking history Necrosis and cavitation 20-25%
Hypercapnia on brain
Hypercapnia increases cerebral vasodilation => seizures
Beta-2 agonist side effects
Hypokalemia (drive K+ into cells) => muscle weakness, EKG changes, arrhythmias Tremor, headache, palpitations
Massive PE sxs
Hypotension Acute RH strain
PEEP side effects
Hypotension Alveolar damage Pneumothorax
Atelectasis ABG
Hypoxemia Hypocapnia Respiratory alkalosis
Pulmonary embolism ABG
Hypoxemia Respiratory alkalosis Widened A-a gradient
Severe, persistent asthma tx
IV mag
Hodgkin lymphoma complications
If <30, can develop secondary malignancies due to chemoradiation
Aspirin-exacerbated respiratory disease (AERD)
In patients with asthma and chronic rhinosinitus (sudden worsening of symptoms after ingestion of aspirin) Pseudoallergic reaction (pro-inflammatory leukotrienes and reducation of anti-inflammatory prostaglandins) Tx: Leukotriene antagonists may help (montelukast, zileuton)
Best postoperative prevention of pneumonia
Incentive spirometry
Ventilation
Increase respiratory rate and increase tidal volume Increased tidal volume can cause barotrauma
Consolidation sounds
Increased tactile fremitus Increased breath sounds Dullness to percussion
Pneumointis
Inflammation from gastric acid Presents HOURS after aspiration event (vs. days with pneumonia) Tx: Supportive (no abx)
Restrictive lung disease
Interstitial lung disease (Pneumoconiosis, Pulmonary fibrosis) Sarcoidosis Asbestosis (pleural plaques) HF Low DLCO, normal FEV1/FVC Reduced pulmonary compliance Increased A-a (esp in interstitial lung disease)
Anaphylaxis tx
Intramuscular epi Airway management and volume resuscitation Adjunctive therapy (antihistamines, glucocorticoids)
Obesity hypoventilation syndrome
Just due to alveolar hypoventilation (NOT neuromuscular)
Pulmonary edema markings
Kerley B lines Bilateral infiltrates
Chylothorax
Leak of chyle (from thoracic duct): T-lymphocytes, immunoglobins, lipid-transporting chylomicrons with TGs tx: thoracentesis/chest tube placement, limitation of dietary fat, possible thoracic duct ligation
Survival in COPD
Long term home oxygen (if <88% O2 sat, or <89% O2 sat with cor pulmonale or hematocrit >55%)
Obstructive lung disease
Low DLCO: Emphysema Normal: Chronic bronchitis, asthma High: Asthma
ankylosing spondylitis
Low back pain (<40yo) Hip and buttock pain Limited chest expansion and spinal mobility Enthesitis (inflammation at site of tendon to bone insertion) Systemic symptoms (chills, fever, etc.) Can develop: Acute anterior uveitus, IBD, cardiac, aortic regurg Restrictive lung disease (low FVC, normal FEV/FVC) Improvement of pain with activity Elevated ESR Pain at night HLA-B27
Loculated (complicated paraneumonic) pleural effusion
Low glucose Low pH High protein Tx: Drainage and abx
Transudative pleural effusion
Low protein Normal glucose/pH
Clubbing reasons
Lung malignancies CF Right-to-left cardiac shunts COPD does not cause it
Flail chest treatment
Mechanical positive pressure ventilation (replaces negative with positive, so forces all segments to move outward during inspiration)
Croup tx
Mild: Corticosteroids + humidified air Worse: Corticosteroids + nebulized racemic epi
Nonallergic rhinitis treatment
Mild: intranasal antihistamines or glucocorticoids Moderate - Severe: Combination therapy Boggy, erythematous nasal mucosa but no other atopic sxs Dx: Clinical, do not need any testing
Tuberculous effusion
Moderate lymphocytes Elevated protein Elevated LDH Low pleural pH Low glucose Usually right-sided
Diaphragmatic rupture
More common on the left because right is protected by the liver Xray: May show NG tube in chest cavity
Acetylcysteine
Mucolytic agent Acetaminophen overdose
Panic attack breathing volume loop
Normal
Bad signs for acute asthma exacerbation
Normal PCO2 (usually is decreased in acute because person is breathing so fast, so normalizing means the person can't breathe anymore -- is getting tired) Hypoxemia -- >60mmHg O2 is good for asthma. Anything less is concern for another underlying pathology.
Community acquired pneumonia tx
O/P: Macrolide or doxy (healthy); fluoroquinolone OR beta-lactam + macrolide (comorbidities) Inpatient (non-ICU): IV Fluroquinolone OR IV macrolide + beta-lactam Inaptient (ICU): IV fluoroquinolone + beta-lactam OR IV macrolide + beta-lactam
Alveolar blebs
Occur with smoking (chronic destruction of alveoli) Can rupture and leak air into the pleural space Causes pneumothorax (COPD risk!) Tx: Supportive (with O2) to thoracotomy (dependent on size)
Right-to-left intrapulmonary shunting
Occurs in alveolar consolidation (worsens when lying on the side that is affected) Refers to passage of blood from right side to left side without actually getting oxygenated
Invasive Pulmonary Aspergillosis
Occurs in severe immunosuppression - Prolonged neutropenia - Glucocorticoid therapy - Hematopoietic stem cell transplant - Advanced AIDS (CD4 < 50) - Solid organ transplants - Chronic granulomatous disease Sx: triad of fever, pleuritic chest pain, hemoptysis CT: Nodules and surrounding ground-glass opacities (halo sign) Dx: Biomarkers for cell wall components (galactomannan assay) and sputum stain/culture Tx: 1-2 weeks of voriconazole + echinocandin (caspofungin)
Albuterol
Only beta-2 agonist, relieves airway obstruction
D-dimer testing
Only used in patients with low probability of PE (cannot rule out PE in high-risk--use CT)
Post-natal drip tx
Oral first-generation antihistamines (chlorpheniramine) Combined antihistamine-decongestant (brompheniramine, pseudoephedrine)
Oxygenation
PEEP and FiO2 (use PEEP to keep alveoli open) FiO2 usually wants to be weaned to <60% asap
Small effusions
Paraneumonic effusions that are small without much symptoms can be followed with oral abx and close outpatient follow-up
Meconium aspiration xray
Patchy infiltrates Coarse streaking of both lung fields Flattening of the diaphragm
Mechanical ventilation pressures
Peak airway pressure = Airway resistance + plateau pressure Plateau pressure = Elastic pressure + PEEP Calculated by the end-inspiratory hold maneuver
SIADH
People with HIV are prone to SIADH NS can worsen hyponatremia
Large cell carcinoma
Peripheral Gynecomastia, galactorrhea 5-10%
Adenocarcinoma
Peripheral lesion Hypertrophic pulmonary osteoarthropathy Clubbing Most common (40-50%) In both smokers/nonsmokers, but predominant in nonsmokers
Mesothelioma imaging
Pleural thickening and effusion
Theophylline toxicity
Predisposes if taking a CYP450 deactivator (e.g., fluroquinolones), infection, or diet. Has a narrow therapeutic index. Sx: CNS stimulation (headache, insomnia, seizures) GI disturbances (n/v) Cardiac toxicity (cardiac arrhythmia, multi-focal atrial tachy, supraventricular tachy, ventricular arrythmia) Dx: Serum theophylline levels
Predisposition to respiratory distress syndrome
Prematurity Male sex Perinatal aphysxia Maternal diabetes (delays maturation of surfactant; maternal hyperglycemia => fetal hyperglycemia => fetal hyperinsulinemia => prevent steroids from maturing lungs) C-section without labor Decrease risk: Intrauterine growth restriction, maternal HTN, prolonged rupture of membranes (stress is supposed to help with surfactant maturation)
Alpha-1-antitrypsin deficiency
Presents in 30 for smokers, and 40s in nonsmokers Causes emphysema Basilar-predominant May not have wheezing/other sounds. May have mucoid sputum Dx: Serum AAT and PFTs Tx: IV supplementation with pooled human AAT
Inhaled cromolyn
Prevention of acute bronchoconstriction Long-term management of asthma
Kartagener syndrome
Primary ciliary dyskinesia, bad mucus clearance => recurrent bronchopulmonary infections Triad: Situs inversus, recurrent sinusitis, bronchiectasis CF differences: No dextrocardia, there is pancreatic insufficiency
Chronic bronchitis
Productive cough for >= 3 months over 2 consecutive years Normal DLCO Xray reveals prominent bronchovascular markings and flattened diaphragm May demonstrate more hypoxemia than emphysema
PE risk factors
Prolonged immobilization Central venous catheters Surgery Obesity Advancing age Conditions that increase blood clotting History of thromboembolism
Severe combined immunodeficiency
Recurrent severe infections Poor growth Chronic diarrhea If does not have hematopoietic stem cell transplant, will die by 1 YO
COPD
Reduced inspiratory/expiratory flow rates Increased compliance/distensibility (reduced elasticity) Increased work of breathing (alveoli collapse) Increased TLC, FRC, residual volume, diaphragmatic flattening
Interstitial lung disease sounds
Resonant to percussion Breath sounds are normal/decreased intensity Fine crackles heard at end of inspiration
Congenital Diaphragmatic Hernia (CDH)
Right heart sounds (bowel push heart to right) Polyhydramnios (compression of esophagus) Pulmonary hypoplasia/HTN Bowel may cause concave abdomen/barrel-shaped chest Absent breath sounds on one side (left) of the chest Tx: Endotracheal tube immediately
Chronic pulmonary aspergiollosis
Risk factor: Cavitary TB Sx: Cavitary lesion (fungus ball) Positive asperigillus IgG Tx: Resect, azole meds (Voricanazole), embolize (if severe hemopytsis)
CURB-65
Risk-stratify for pneumonia Confusion Urea > 20 Respirations >30 Blood pressure (<90sys, <60dia) Age >=65 0 = low mortality 1-2 = middle risk 3-5 = high risk (ICU admission if >4) Moxifloxicin is a respiratory fluoroquinolone
Euvolemic hyponatremia
SIADH Tx: Fluid restriction initially, demecylcline (reduces effects of ADH, but nephrotoxic so only use if fluid restriction/salt tablets does not work) Correlated with small cell lung cancer (smoking) Hypertonic solution as tx should only be used if symptomatic hyponatremia, because of risk of overcorrecting
Limited cutaneous systemic sclerosis
Scleroderma on head and distal UE Prominent vascular manifestations - Raynaud phenomenon - Pulmonary HTN (no infiltrates on xray) - Cutaneous telangectasia CREST syndrome Anti-centromere antibodies Better prognosis
Diffuse cutaneous systemic sclerosis
Scleroderma on trunk and UE Prominent internal organ involvement - Scleroderma renal crisis - Myocardial ischemia and fibrosis - Interstitial lung disease Anti-Scl-70 (topoisomerase) Anti-RNA polymerase III antibodies Worse prognosis
Bronchogenic cyst
Seen on AP chest xray, but dx best with CT Located in middle mediastinum Benign Other mediastinal masses: tracheal tumors, pericardial cysts, lymphona, lymph node enlargement, aortic aneurysms of the arch Anterior mediastinum: retrosternal thyroid, teratoma, lymphoma, thymoma. Pts may have chest discomfort and heaviness; hoarseness/Horner's syndrome may occur if tumors invade locally Posterior mediastinum: Neurogenic tumors: meningocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, aortic aneurysms. Use MRI to dx.
Idiopathic pulmonary fibrosis
Slow deterioration of lung function (progressive dyspnea on exertion) Restrictive profile Presents 50-70YO End-inspiratory crackles/squeaks Digital clubbing Abnormal S2 (loud P2, fixed split S2) due to pulmonary HTN Exposure to navy => asbestos => possible fibrosis
Small pneumothorax
Small (<2cm): Supportive with supplemental O2 Large and stable: Needle thoracostomy or chest tube
PE effusions
Small pleural EXUDATIVE effusions (high neutrophil)
Granulomatosis with polyangiitis (Wegener)
Small-medium vasculitis that involves Nose (saddle-nose deformity), lungs, renal, skin (livedo reticularis, nonhealing ulcer) Xray: Tracheal narrowing with ulceration, multiple lung nodules with cavitation with alveolar opacities Dx: ANCA, bx Tx: Corticosteroids, immunomodulators (MTX, cyclophosphamide)
Centracinar emphysema
Smoking-related COPD
GERD
Sore throat Morning hoarseness Worsening cough only at night Increased need for her albuterol inhaler after meals Can exacerbate asthma
Acute pulmonary edema sx
Sudden onset chest pain with rapid progression to orthopnea and dyspnea Bilateral crackles Third heart sound
Pancoast tumor
Superior pulmonary sulcus tumor Tumor compression of brachial plexus - radiating arm pain and parasthesias Horner syndrome due to invasion of sympathetic trunk Hoarseness due to recurrent laryngeal involvement Superior vena cava syndrome Weight loss
COPD exacerbation tx
Supplemental O2 Short-acting bronchodilators (B2 agonist/anticholinergic) Systemic glucocorticoids Abx (in certain pts)
Respiratory distress syndrome
Surfactant deficiency Diffuse reticular (ground-glass) appearance, air bronchograms, low lung volumes Tx: Glucocorticoids, and continuous positive air ventilation
Complement deficiency
Susceptibility to encapsulated organisms
PE findings
Tachypnea, tachycardia, low-grade fever ECG: S1Q3T3 Imaging: Hampton hump, Westermark sign Correlation: Afib, perhaps JVD
Oral corticosteroids side effect
Thrush
Sodium bicarbonate
Treatment for severe acute metabolic acidosis (<7.2)
Hypersensitivity pneumonitis
Tx: Avoidance of antigen causing problem Complications: Pulmonary fibrosis, clubbing, weight loss, honeycombing of lung Imaging: Noncaseating granulomas; xray shows reticular, nodular, or alveolar opacities (NO cavitation)
Moderate or large effusions tx
U/S and drainage (chest tube, video-assisted thorascopic surgery)
Coccidiomycosis
Unilateral infiltrate with ipsilateral hilar LAD Bx has spherules with endospores Western US (including Arizona)
Obstructive sleep apnea
Upper airway collapse
Recurrent pneumonia
Use CT to figure out what's going on (and rule out malignancy) Internal bronchial obstruction (foreign body, bronchiectasis, bronchial stenosis, endobronchial carcinoid) External bronchial compression (lymphadenopathy, tumor, vascular anamoly) Afterwards, may want to do bronchoscopy for bx
COPD exacerbation tx
Use a trial of noninvasive positive-pressure ventilation first. If fails, then intubate.
Pleural effusion
Use thoracentesis to diagnose (need to know if it's malignant or not, exudative vs. transudative) Malignant: Lung and breast carcinomas, lymphoma
Eosinophilic granulomatosis with polyangiitis (Churg- Strauss)
Usually dxed in adulthood Sx: Chronic rhinosinutis (nasal polyps), asthma, eosinophilia
Burn victim
Usually intubate (low threshold) because can be progressively harder with airway edema in the future
PE CT
Wedge-shaped pleural-based opacification Contrast-enhanced CT will show a pulmonary artery filling defect
Esophageal rupture xray
With subcutaneuous crepitus appears as a pneumomediastinum (widened top and air under the heart)
Pneumonia dx
Xray first! Then treat. Need to confirm
Diaphragmatic rupture
Xray may show, but use CT to confirm Children may present without problems in the beginning, but then worsen with time (can take up to months)
Goodpasture's disease
Young adult males Nephritis-range proteinuria Acute renal failure Urinary sediment with dysmorphic RBCs and red cell casts Pulmonary: Shortness of breath, cough, hemoptysis caused by pulmonary hemorrhage Systemic symptoms Patchy bilateral pulmonary infiltrates Path: Antibodies to alpha-3 chain of collagen IV in basement membranes (glomerular and alveolar) Dx: Renal bx shows linear IgG deposition
Panacinar emphysema
alpha 1 antitrypsin deficiency
Fluticasone
inhaled glucocorticoid for asthma (not COPD)
Roflumilast
phosphodiesterase-4 inhibitor with anti-inflammatory properties (can be used in COPD for maintenance and asthma (?))