Clinical Medicine Exam 4

Hypersensitivity Pneumonitis

"Extrinsic allergic alveolitis" Pulmonary disease that occurs due to inhalational exposure to a variety of antigens leading to an inflammatory response of the alveoli and small airways "Nonatopic, nonasthmatic inflammatory pulmonary disease" Generally caused by the inhalation of organic dusts. This results in a T cell mediated hypersensitivity alveolitis. Acute phase prodrome - often resolves when exposure is eliminated.

FEV1

( Forced Expiratory Volume in One Second) The volume of air forcefully exhaled in One second from a maximal inhalation.

FVC

(Forced Vital Capacity) This is when a pt takes a full inhalation and then forcefully exhales all the volume of air they can get out.

FRC

(Functional Residual Capacity) This is the volume of air in the lungs at the end of a normal exhalation.

RV

(Residual Volume) At the end of a maximum exhalation this is the volume left over.

Itraconazole

(Sporanox®) highly effective, good for outpatient Tx. Cure rates as high as 81%. Drug levels monitored at two weeks. What med is this for histoplasmosis treatment?

TLC

(Total Lung Capacity) This is the volume that the lungs can hold at a maximum inhalation

Varenicline

0.5 mg po once/day for 3 days, then 0.5 mg bid for 4 days, then 1 mg bid 12-24 weeks of treatment Most commonly nausea and sleep disturbances, also possible serious neuropsychiatric symptoms* What med is this for smoking?

Needle decompression

14 Gauge or large bore needle Administer oxygen 12 L/min Locate the 2nd intercostal space in the midclavicular line Clean area with antiseptic. Re-identify 2nd intercostal space in the midclavicular line. Insert needle over the top of the rib into the pleural space avoids blood vessels and nerves which run under the bottom of the rib. Listen for a decompression (hissing) from the needle Leave the catheter in place and apply bandage Observe and prepare for a chest-tube insertion if necessary What is this for?

Bupropion SR 150mg

150 mg every morning for 3 days (beginning 1-2 week before quitting), then 150 mg twice/day 7-12 week initially (may continue up to 6 months) SE: Insomnia, dry mouth and possible serious neuropsychiatric symptoms* What med is this for smoking?

Moderate persistent ICS and LABA or moderate dose ICS

16 y/o female presents with episodes of SOA, cough, wheezing and chest tightness daily for 2-4 weeks now. She states that she has had to use her rescue inhaler daily and that she has had to limit her activities because of the severity of each episode. What is her Classification? What therapy should you add to her regimen?

Needle Decompression

18 gauge In 2nd ICS on affected side -gas escape will be immediate and tension relieved Leave it there until thoracostomy tube is in place What management is this with tension pneumothorax?

2nd ICS

18 gauge In what area on affected side with tension pneumothorax?

Primary spontaneous

19 yr old with normal lungs What pneumothorax is this?

Small cell carcinoma (AKA oat cell)

20-25% of all Bronchogenic Carcinomas Strong Smoker association - very rare in non-smokers Tend to be the MOST malignant and metastasize fast. Tumors usually occur centrally

Nicotine Patch

21 mg/24 h for 6 week, then 14 mg/24 h for 2 week, then 7 mg/24 h for 2 week If smoking> 10 cigarettes/day: 21 mg as starting dose If smoking<10 cigarettes/day: 14 mg as starting dose 10 week treatment What med is this for smoking?

Squamous cell

25-30% of lung cancers The original most common lung malignancy - now replaced by adenocarcinoma Described as keratin producing tumor cells Predominantly arises in the proximal aspects if the bronchial tree. Generally metastasizes early and aggressively to lymph nodes-dyspnea and mass in neck-pancostumor Micrometastasis is assumed upon diagnosis. found in epithelial lining. Proximal Bronchial Tree. Bad news!! What is this?

Intermittent persistent SABA

36 y/o female presents to the office as a new pt. Pt states that she has asthma and uses an inhaler for her symptoms. She states her attacks are no more than a couple times a week and seem to last only a few hours. She states that she has no symptoms between attacks and her inhaler helps during the attacks. What is her classification? What med would she most likely be on?

Glucocorticosteroids

40 mg oral prednisone per day for 10 days Or 10 mg. on a 6-6-5-5-4-4-3-3-2-2-1-1 (42 tabs)

Mycoplasma Pneumoniae

5-10% of atypical CAP Spread by inhalation of respiratory droplets Common in young adults Increased incidence in the winter Incubation period of 3 weeks Mycoplasma grows slowly and require at least 1 week to form a visible colony Disease resolves spontaneously in 10-14 days Clinical Presentation Onset is gradual and begins with nonproductive cough, sore throat, or earache Small amounts of white non-bloody sputum Constitutional symptoms of fever, HA, malaise, myalgia's are significant Exam: paucity of findings on chest examination Lab diagnosis Serologic testing is the mainstay of diagnosis. A cold-agglutinin titer of 1:128 or higher is indicative of recent infection Cold agglutinins are IgM autoantibodies against type O red blood cells that agglutinate these cells at 4°C but not at 37°C However, only half of patients with Mycoplasma pneumonia will be positive for cold agglutinins CXR Diffuse reticulonodular infiltrates or interstitial infiltrates

25 pack years Emphysema 50% lung function gone Spirometry FEV/FVC ratio decreased FEV decreased TLC increased

50 year old who has smoked 1PPD for 25 years presents with a cough that is worsening but has been present for over a year and dyspnea on exertion. What diagnostic test or test should be done and what do you expect the results of those tests to be?

Traumatic (iatrogenic)

50 yr old s/p thoracentesis What pneumothorax is this?

Traumatic

50 yr old with broken ribs from MVC What pneumothorax is this?

False (90%)

50% of COPD is attributed to smoking-T or F?

Moderate CPAP, lifestyle modification, postural changes Raise bed, roll over on side

56 y/o male presents to the office with his wife, who is complaining that he snores loudly in his sleep. She states that he has snored for several years now, but she has also noticed over the last several months that he seems to stop breathing at times, which is concerning to her. Pt reports that he is tired all the time and tends to fall asleep easily during the day and has a very hard time concentrating on his work. He states that he does wake up several times a night gasping for breath and tends to wake up with HA's. He states he has never been diagnosed with OSA. Vitals: BP 142/90, HR 85, RR 16, T 98.6, O2sat 96%, BMI 39.2 PE: obese male, who appears fatigued and irritable, no acute distress, Mallampati classification IV, normal S1/S2, no murmurs rubs or gallops, RRR, Lungs clear to auscultation, no wheezes, rales or rhonchi. PMH/PFH: none Meds: none His AHI is 20. What is the classification of his OSA? How are you going to treat him? How and what are you going to counsel him on?

Sleep study to pulmonologist (overnight study)

56 y/o male presents to the office with his wife, who is complaining that he snores loudly in his sleep. She states that he has snored for several years now, but she has also noticed over the last several months that he seems to stop breathing at times, which is concerning to her. Pt reports that he is tired all the time and tends to fall asleep easily during the day and has a very hard time concentrating on his work. He states that he does wake up several times a night gasping for breath and tends to wake up with HA's. He states he has never been diagnosed with OSA. Vitals: BP 142/90, HR 85, RR 16, T 98.6, O2sat 96%, BMI 39.2 PE: obese male, who appears fatigued and irritable, no acute distress, Mallampati classification IV, normal S1/S2, no murmurs rubs or gallops, RRR, Lungs clear to auscultation, no wheezes, rales or rhonchi. PMH/PFH: none Meds: none What is the next step in diagnosing this pt?

Cardiopulmonary Exercise Testing

6 minute walk test May reveal exercise hypoxia and tachypnea Serial rest and exercise gas exchange measures is an excellent method for following disease activity and responsiveness to treatment

Mild persistent ICS

6 y/o male presents to your office with his mother. Mother reports that he was recently diagnosed of asthma by his previous provider. Her son has episodes of breathlessness, cough, and wheezing about 3 times a week and states that he has the same symptoms at night about 4 times a month. Mother states that when these symptoms occur he has to set down until they resolve, that the symptoms seem to be severe enough to keep him from activities. Mother states that when he has these episodes, she gives him an albuterol treatment which seems to help somewhat, but not completely. What is his Classification? What would be the next line therapy?

Secondary spontaneous

68 yr old with COPD What pneumothorax is this?

Age over 65 Based on CURB-65 no (He should probably have an overnight stay though bc of his comorbidities)

70 y/o male with PMH of DM, HTN, hyperlipidemia and COPD presents to the office with progressive SOA x 5 days. He reports that he is using his inhaler's more but they are not helping. He reports high fever of 101 degrees F on multiple occasions, chills and body aches with it. He states that he has been taking Tylenol for fever and pain. He reports that cough is productive. He denies any hemoptysis. He reports fatigue more than normal and states that he has been wanting to do no more than lay on the couch. He reports pain in his chest with inspiration. He denies, CP, palpitations, abdominal pain, N/V, any abnormal bowel/urinary symptoms, dizziness, syncope. Vitals: BP 100/60, O2sat 90% on RA, RR 27, Temp 101.2 F PE: Pleasant older gentleman brought in by wheelchair today, ill appearing, MMM, tachycardia with regular rhythm, no murmurs rubs or gallops. Tachypnea with use of accessory muscles, decreased breath sounds throughout but crackles heard in bilateral lower lobes. No confusion, AMTS is WNL CBC: WBC of 12,000 cells/mcL CXR: showed bilateral Lower lobe consolidation concerning for pneumonia BMP: BUN 6 mg/dL ***Use the CURB 65 criteria to asses whether this patient needs to be admitted.

FEV6

80% of lung volume should be exhaled within the first 6 seconds of an FVC maneuver in normal lungs

COPD

90% From Cigarette smoking Dose and duration dependent 10 %: Second or third hand smoke Occupational (dust, chemicals, cooking/heating fuel) Air pollution Allergy (airway hyperresponsiveness) Familial or Genetic α1-antitrypsin deficiency Emphysema What etiology is this for?

Needs to be admitted (not responding to treatment, hospitalizations, so many meds not helping)

A 13 y/o female with PMH of allergic rhinitis and asthma presents to your office with 3 days of progressive SOA. Her father with her states that they had been outside more this weekend and he thinks that's what triggered it. She has been hospitalized twice in the last year for asthma and went to the ER for an asthma exacerbation last month. She has been having to use her rescue inhaler more often and her other meds don't seem to be helping. Nothing has makes her symptoms better. Pt reports SOA at rest, and chest tightness all of which are getting worse, despite her current regimen. Pt reports cough which is nonproductive. She reports nasal congestion, sneezing, itchy/watery eyes, but has forgot to take her Claritin for the past couple of weeks. She denies Fever/chills, N/V. Vitals: 118/78, RR: 24, P: 115, O2sat: 93% T: 98.7 Meds: Claritin, Flonase, Proair, Symbicort and Singulair PE: Pt is setting on the edge of the bed. well developed, well nourished, but in moderate respiratory distress. Tachycardic rate, regular rhythm, Normal S1 and S2, with no murmurs, rubs or gallops. Inspiratory and expiratory wheezing in all lobes. Using accessory muscles for breathing with nasal flaring, and unable to speak in complete sentences. No signs of cyanosis. Pt is given Duoneb treatment in office and assessed afterwards: Pt's symptoms improves minimally What is your next step in treatment? Does she need to be admitted?

B

A 27-year-old who is 27 weeks pregnant presents with complaints of a cough and cold. Two days ago she developed a cough, runny nose and temp of 99.0 °F. Over the past 24 hours she notes increasing dyspnea and SOB, finding it difficult to climb the stairs. Her cough is non-productive and she notes difficulty taking a deep breath due to pain. Her BP-128/72, T- 98.7 °F, pulse 118, and RR 40 and shallow. Pulse oximetry is 88 %. Her lungs are clear bilaterally. What is the best test for this patient? A. Ultrasound B. Computed tomography (CT) C. Arterial blood gases D. Chest x-ray E. Magnetic resonance imaging (MRI)

B

A 58-year-old female with a known history of rheumatoid arthritis presents with a complaint of difficulty breathing and feeling short of breath. She also complains of chest pain that increases with inspiration and expiration. On physical exam you note decreased breath sounds and dullness to percussion over the right lower lobe. What is the most likely diagnosis? A. Pleuritis B. Pleural effusion C. Spontaneous pneumothorax D. Tension pneumothorax

C

A 62-year-old male comes in with a history of increasing dyspnea and mild temperature elevation. Examination of the chest shows: Dullness on percussion of the left posterior chest up to the level of the sixth intercostal (IC) space, distant bronchovesicular breath sounds in the same area, increased whispered voice sounds in the same area, a tympanic percussive note immediately above the sixth IC space, spoken voice sounds markedly diminished below the sixth IC space and increased above it, and fine rales above the sixth IC space. What is the most likely diagnosis? A. Consolidation of the lung and a plugged bronchus B. Marked elevation of the diaphragm C. Pleural effusion D. Pulmonary fibrosis

Pleural effusion

A 62-year-old male presents with increasing dyspnea and mild temperature elevation. Chest exam shows: Dullness on percussion of the left posterior chest up to the sixth IC space, distant breath sounds in the same area, increased whispered voice sounds in the same area, spoken voice sounds diminished below the sixth IC space and increased above it, and fine rales above the sixth IC space. What is the most likely diagnosis? Pleurisy Pulmonary Embolism Pneumothorax Pleural Effusion Lung Cancer

D

A 71-year-old male with a prior hx of DVT presents with sudden onset of dyspnea and chest pain with inspiration. On exam- BP128/84, pulse 118, respiratory rate of 28, and T-100.2° F. The chest x-ray is unremarkable, and the electrocardiogram (ECG) reveals sinus tachycardia at 120, but is otherwise normal. There are slight crackles present in the right base. Which of the following is the most likely diagnosis? A. Pneumonia B. Chronic obstructive pulmonary disease (COPD) C. Myocardial infarction (MI) D. Pulmonary embolism

True

A Majority of PE's are not detected until autopsy-true or false?

True

A Spiral CT is the diagnostic test of choice for a PE-true or false?

Pleural Effusion

A detailed history helps establish the etiology. Chronic hepatitis, Alcoholism, or pancreatitis. Trauma or surgery to the spine- CSF leak. Cancer- malignant pleural effusion, hemoptysis Asbestos exposure- mesothelioma CHF -edema, orthopnea, and PND TB- Night sweats, fever, hemoptysis, and weight loss Pneumonia- Fever, purulent sputum, and pleuritic CP. What clinical history is this for?

Circulatory stasis

A fib Left ventricular dysfunction Immobility or paralysis Venous insufficiency or varicose veins Venous obstruction from tumor, obesity, or prego Bed-rest or Long-distance travel Recent cast or external fixator CHF, Obesity, Pregnancy What part of virchow's triad is this?

FVC (Forced Vital Capacity)

A full inhalation is forcefully exhaled Measures the volume of air exhaled

FEV1(Forced Expiratory Volume in One Second)

A full inhalation is forcefully exhaled Measures the volume of air exhaled in One second

Staphylococcus Aureus

A gram-positive cocci that is able to cause a multitude of diseases ranging in severity One of the most common causes of hospital acquired PNA, septicemia and wound infections Rapidly progressive infection that can lead to pulmonary necrosis, shock and neutropenia Three species of staphylococci are human pathogens S. aureus, S. epidermidis, and S. saprophyticus Pneumonia is among the most prominent, accounting for an estimated 50,000 staphylococcal infections per year in the United States alone Over half of S. aureus isolates are currently classified as methicillin-resistant S. aureus (MRSA), harboring genes that render these isolates insensitive to a once potent class of antimicrobial agents S. aureus is distinguished from the others primarily by coagulase production Usually seen in older adults and younger patients with or recovering from influenza Influenza-induced increase in S. aureus-specific adhesion throughout the respiratory tract and S. aureus-specific proteases may increase influenza viral replication Synergistic relationship Strains of influenza A virus decrease phagocytic killing of S. aureus, leading to increased host susceptibility to bacterial superinfection No other respiratory virus appears to share with influenza such a prominent role in predisposing to and increasing the severity of S. aureus pneumonia

Exhaled Nitric Oxide

A noninvasive test to measure eosinophilic airway inflammation Used to test for compliance for meds (Inhaled Corticosteroids) and useful in demonstrating insufficient anti-inflammatory therapy What test is this with asthma?

This patient does not have a pulmonary embolism and a different diagnosis should be entertained

A patient with a low pretest probability of PE receives a normal V-Q scan. What is the next step in the work-up of this patient? This patient should undergo pulmonary angiography to exclude the diagnosis of pulmonary embolism This patient should undergo helical computed tomography (CT) of the chest exclude the diagnosis of pulmonary embolism This patient has a pulmonary embolism, and no further diagnostic imaging is necessary to confirm the diagnosis This patient does not have a pulmonary embolism and a different diagnosis should be entertained What is it?

COPD

A preventable and treatable disease with significant extrapulmonary effects contributing to its severity. What is this?

Hematologic Studies

ABG Mild asthma may be normal Respiratory alkalosis common Total IgE and specific IgE to inhaled allergens may be measured in some patients Radioallergosorbent test (RAST) Scaled 0-6 based on response What are these with asthma?

Severe Obstructive Sleep Apnea

AHI ˃ 30 respiratory events per hour of sleep and/or an oxyhemoglobin saturation ˂ 90% for more than 20% of total sleep time Often have severe daytime sleepiness that interferes with daily activities Often fall asleep during the day in a sitting posture and are at risk from accidental injury from sleepiness Cardiopulmonary failure, nocturnal angina, polycythemia and/or cor pulmonale may result from hypoxemia These pts benefit from prompt therapeutic intervention

Type I

AKA G542X This mutation results in the complete absence of the CFTR gene. Thereby making it the most lethal of the mutations. What CFTR mutation is this?

Type III

AKA G551D CFTR produced normally but does not get activated in the cell. What CFTR mutation is this?

Type IV

AKA R117H CFTR is produced and expressed on the apical membrane of the cell but chloride passage is reduced. What CFTR mutation is this?

Type II

AKA ΔF508 This mutation forms the CFTR complex but is mutated in such a way that it cannot get out of the endoplasmic reticulum once formed. This is the second most lethal mutation in CF. What CFTR mutation is this?

Lung cancer

Accounts for about 15 to 20% of tobacco-related deaths Tobacco is the most common cause of lung cancer in North America and Europe Inhaled carcinogens are directly exposed to lung tissue

Coronary Artery Disease

Accounts for about 30 to 40% of all tobacco-related deaths Risk of MI is increased by probably > 200% if smoking < 1 pack/day and risk of cardiovascular mortality is increased by > 50% over a 35-yr period Mechanisms may include endothelial cell damage, transient increases in BP and heart rate, induction of a prothrombotic state, and adverse effects on serum lipids

COPD

Accounts for roughly 20% of tobacco-related deaths Smoking impairs local respiratory tract defense mechanisms and, particularly in genetically susceptible people, tends to accelerate decline in pulmonary functions Coughing and dyspnea on exertion are common symptoms

Granulomatous

Accumulation of T lymphocytes, macrophages, and epitheliod cells into organized structures called granulomas May lead to fibrosis Many remain symptom-free or, with symptoms, respond to treatment Main differential is sarcoidosis and hypersensitivity pneumonitis What type of ILD is it?

Community Acquired Pneumonia

Acquired in the home or nonhospital environment Bacteria are the most common cause Typical pathogens Streptococcus pneumonia* Haemophilus influenza Staphylococcus aureus (MRSA) Klebsiella pneumonia Pseudomonas aeruginosa Atypical pathogens Mycoplasma pneumonia* Chlamydia pneumonia Legionella sp. Viral species (type A & B and adenoviruses) Viruses include: RSV*, influenza virus, adenovirus and parainfluenza virus

Well's Criteria

Active cancer (w/in 6 months) Paralysis, paresis, or immobilization Bedridden for greater than 3 days bc of surgery (w/in 4 wks) Tenderness on deep palpation of veins Unilat calf swelling over 3 cm Unilat pitting edema Superficial veins Alternative diagnosis as likely as DVT (-2 pts) Everything else 1 pt Over 3 high risk for DVT 1-2 moderate Less than 1 low risk What is this?

PE

Acute MI Pneumothorax Pneumonia Rib Fracture Asthma Pericarditis Musculoskeletal Pain Pulmonary Edema These are differential diagnosis for what?

Lung cancer

Adenocarcima leads to what?

TB

Adenosine Deaminase elevated indicates what with pleural effusion?

Pneumonia

Adults with no Previous Pneumococcal Vaccinations The Advisory Committee on Immunization Practices (ACIP) recommends that all adults 65 years of age or older receive a dose of PCV13 followed by a dose of PPSV23 6 to 12 months later Adults with Previous Pneumococcal Polysaccharide Vaccinations (PPSV23) Adults 65 years of age or older who have not previously received PCV13 and who have previously received one or more doses of PPSV23 should receive a dose of PCV13 All adults 65 years of age or older should receive a dose of PPSV23, regardless of previous history of vaccination with pneumococcal vaccine The dose of PCV13 should be given around 1 year after receipt of the most recent PPSV23 dose What is this prevention for?

Pediatrics special populations

Affects 1-10% of children (most mild, outgrow) Consequences of untreated OSA include failure to thrive, enuresis, attention-deficit disorder, behavior problems, poor academic performance, and cardiopulmonary disease Most common etiology is adenotonsillar hypertrophy Adenotonsillectomy is curative in most patients What is this for?

Pneumonia

Age Alcoholism Malnutrition Chronic pulmonary disease Immunosuppression Tobacco use Recent travel Renal Insufficiency Diabetes Mellitus Cognitive Impairment Prior hospitalization Close quarters Recent Viral Illness Living arrangements What history is this for?

PERC

Age less than 50 Pulse less than 100 SaO2 over 95% No hemoptysis No exogenous estrogen use No prior VT No surgery or trauma No unilat leg swelling All 8 are met, PE can be excluded what is criteria is this?

ILD

Age: Age 20-40: Sarcoidosis and connective tissue disorders Age >60: Inflammatory Pulmonary Fibrosis Gender: Women: Connective tissue disorders, Hermansky-Pudlak syndrome, Lymphagnegioleiomyomatosis Men: Idiopathic Pulmonary Fibrosis, Rheumatoid arthritis Smoking history: 75% of patients with idiopathic pulmonary fibrosis have history of smoking Family history of inherited disorders? Niemann Pick, Gaucher disease, Tuberous Sclerosis Family history of other disorders? Sarcoidosis, familial lung fibrosis from surfactant mutations Personal medical history Lupus-rash, RA, Sjogren's-dry eyes and dry mouth-swelling of glands-severe fatigue and dehydration, polymyositis, other connective tissue disorders Occupational / Environmental exposures? (DUST) Birding, farmer's lung, mining, stone cutting, asbestos exposure, radiation exposure Symptoms may diminish or disappear after the patient leaves the site of exposure for several days, reappear with return to exposure Travel history: Parasitic infections Medication use Rx, OTC, topical, herbal, remedies What is this history for?

Pneumothorax

Air in the pleural cavity resulting in lung collapse The space between the two pleura is under negative pressure. Disrupting this pressure may result lung collapse

PE

Air- central venous catheters, diving, and surgery Amniotic fluid- labor Fat- long bone fractures Parasite eggs Septic emboli- endocarditis Tumor cells- carcinoma (renal) Foreign bodies- Ex. talcum powder (IV drug users use) These can cause what?

Airway Inflammation

Airway mucosa infiltrated with activated eosinophils and T lymphocytes Activation of mucosal mast cells Thickening of the basement membrane due to subepithelial collagen deposition (Remodeling) Epithelium is often shed or friable Airway wall itself may be thickened and edematous, (fatal asthma) Mucosal plugs found in severe/fatal asthma (related to glycoproteins secreted from Goblet cells What pathophys is this with asthma?

Nebulized

Albuterol Levalbuterol (Xopenex®) Albuterol/Ipratroprium Bromide Budesonide (steroid—Pulmicort) Antibiotics and Other drugs can be what as well but the above are the most common?

Early Phase Reaction

Allergen inhalation by a sensitized individual leads to bronchoconstriction Release of mast cell mediators Mediators: histamine, prostaglandin D2, and cysteinyl leukotrienes (LTC4, D4, and E4) Mediators contact airway smooth muscle directly May also stimulate reflex neural pathways What phase reaction pathophys is this with asthma?

Asthma

Allergic rhinitis COPD Bronchiolitis Tracheal narrowing Laryngotracheal mass Bronchiectasis Foreign body aspiration GERD Vocal cord dysfunction CHF ("cardiac wheezing") CF Airway edema Pneumonia What differential diagnosis is this for?

Peak Flow Meters

Allows patient to assess status of his/her asthma People with moderate or severe asthma should take readings Every morning Every evening After an exacerbation Before inhaling certain medications

Needle decompression

Almost exclusively for Primary, Spontaneous Pneumothorax What management is this?

Meconium ileus

Almost ¼ will present with a what during their first 24 hours after birth with CF?

Supraglottic airways

Also known as the laryngeal mask airway (LMA) Tubular oropharyngeal airway that is shorter than an ETT Has a laryngeal mask that inflates and provides a seal around the larynx Does not reach the esophagus or trachea Placed only in apneic, unconscious adults What esophageal an layngeal airway is this?

Pleural Effusion

Altered pleural membrane permeability Due to inflammation, malignancy, PE... Reduced vascular oncotic pressure Due to hypoalbuminemia, cirrhosis ... Increased capillary permeability Due to trauma, malignancy, infection, uremia, pancreatitis... Increased capillary hydrostatic pressure Due to CHF, superior vena cava syndrome... Reduced pressure in the pleural space Due to atelectasis, mesothelioma... Decreased lymphatic drainage Due to malignancy, trauma What do these cause?

Exudative

Alveolar capillary endothelial and epithelial cells are injured Leads to loss of alveolar barrier to fluid and macromolecules Edema accumulates in the interstitial and alveolar spaces Inflammatory process begins, leading to leukocyte deposition into the pulmonary interstitium and alveoli Surfactant becomes dysfunctional and forms hyaline membrane whorls Pulmonary vascular injury occurs, and vascular obliteration begins What phase is this with ARDS?

True

Amniotic Fluid is a potential source of a PE-true or false?

Esophageal rupture

Amylase elevated with pleural effusion indicates what?

Pleural Effusion

An excess of fluid in the pleural space resulting from : excess production decreased absorption The most common pleural disease Always due to underlying disease What is this?

15

An induration of what or more millimeters is considered positive in any person, including persons with no known risk factors for TB on the skin test?

Staging

An intentionally vague 2 stage system is utilized. Limited stage - Tumor spread is limited to single hemithorax, mediastinum, and contralateral hilar or supraclavicular nodes Extensive stage - Any spread beyond the limited stage, including malignant pleural effusion. What is this?

Obstructive sleep apnea

Anatomical Deviations Micrognathia (small jaw) Macroglossia (large tongue) Tonsillar hypertrophy Anatomical Changes Upper airway obstruction (tongue) Loss of normal pharyngeal muscle tone Pharynx collapses passively during inspiration External factors Common colds Ingestion of sedatives/ alcohol Smoking Medical conditions Hypothyroidism Obesity Tonsillar hypertrophy Nasal obstruction What pathophys is this for?

Warfarin

Anticoagulant Coumadin Interferes with Vit-K dependent factors: II, VII, IX, and X, and protein C & S Causes temporary hypercoagulable state Patient must be anticoagulated with heparin before initiating Warfarin Target INR is 2.0 - 3.0 What PE treatment is this?

ILD

Antinuclear antibodies (ANA) and anti-immunoglobulin antibodies (rheumatoid factors) tend to be positive, even in the absence of a defined CTD Elevation of the serum level of angiotensin-converting enzyme is common in ILDs, especially sarcoidosis Antineutrophil cytoplasmic or anti-basement membrane antibodies are useful if vasculitis is suspected EKG and ECHO is usually normal unless pulmonary hypertension is present Right-axis deviation Right ventricular hypertrophy Right atrial enlargement or hypertrophy What lab findings are these?

Reactivation TB

Apical infiltrates Hilar adenopathy Pleural effusions Solitary nodules Often present even with no respiratory complaints What is this on radiograph?

Bronchoscopy

Appropriate for *centrally* located tumors. Allows direct visualization of bronchial tree and tumor. Can obtain specimen by biopsy, lavage, or brushings. What invasive testing is this with lung cancer?

Yes

Are steroids effective short term therapy for sarcoidosis?

Fondaparinux

Arixtra Synthetic heparin Catalyzes factor Xa inactivation without inhibiting thrombin Contraindicated in: Renal Insufficiency Creatinine Cl < 30 mL/min What PE treatment is this for PE?

TB

As a general rule, lab studies are normal. Late disease may demonstrate anemia (of chronic disease) leukocytosis, rarely monocytosis. Thrombocytosis Elevated erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) Hyponatremia secondary to SIADH What lab is this for?

Inflammatory ILD

Asbestosis Fumes, gases Drugs Radiation Aspiration ARDS-acute respiratory distress syndrome Smoking Idiopathic Interstitial Pneumonias Connective tissue diseases-marfan's syndrome Pulmonary Hemorrhage syndromes-Goodpasture's Pulmonary alveolar proteinosis Lymphocytic infiltrative Disorders Eosinophilic pneumonias Amyloidosis Inherited Disorders GI diseases Graft vs. Host Disease What are these etiologies for?

ILD

Asbestosis Sarcoidosis Idiopathic Pulmonary Fibrosis Interstitial lung disease with connective tissue diseases Hypersensitivity pneumonitis Silicosis Pneumoconiosis These are common diseases in the US of what?

Obstructive and mixed sleep apneas (more common)

Associated with life-threatening cardiac arrhythmias Severe hypoxemia during sleep Daytime somnolence (hyperactivity in children) Pulmonary hypertension Systemic hypertension

Cystic Fibrosis

Autosomal Recessive Trait (Clinical disease requires mutation on both copies of the CFTR gene) Mutation or Deletion of the CFTR CF transmembrane conductance regulatory gene (CFTR) Found on chromosome 7 This gene codes for a glycoprotein which is common to epithelial cells that function in various locations throughout the human body CFTR is an ion channel that regulates the flow of Na + and Cl - into the epithelial cell layers As a result of the malfunctioning gene Cl - is not secreted into the epithelial layer and Na is absorbed to much

Low Dose CT

B" Recommendation given by US Preventative Services Task Force (USPSTF) Medicare and Medicaid WILL cover cost for pt's at high risk. Criteria Age 55 to 77 Who have NO symptoms of lung cancer Have 30 pack year smoking history If they have quit within the last 15 years What lab imaging will be done?

Pyrazinamide

Bactericidal - GI upset is common - Hepatotoxicity and Hyperuricemia. What TB med is this?

Ethambutol

Bacteriostatic - easily tolerated - Optic neuritis at high doses What TB med is this?

Acute pneumothorax

Be prepared for possible tension pneumothorax Emergency ! For stable pneumothorax, consult Pulmonology Cardiothoracic Surgery Emergency Medicine What management is this for?

Embolectomy

Before clot busters this was the treatment for PE 40% operative mortality Considered when pt. presentation is very severe This is a procedure where a suction tip catheter is placed in contact with the thrombus under fluoroscopy and sucked out while catheter is withdrawn What PE treatment is this?

BiPAP

Bi-Level Positive Airway Pressure This device gives you a pressure on inspiration and a different pressure on expiration. IPAP = Determines ventilation and controls volume. EPAP = Stabalizes alveoli and improves oxygenation To prevent airway collapse. Limitation see CPAP they are the same. 2 pressures-keep inspiration and expiration open-better for perfusion Sleep studies done to see if BiPAP or CPAP should be used-most efficient and tolerated

Pneumococci

Bloody or rust colored sputum means what bacteria?

Pleural Effusion

Blunt costophrenic angle Elevated diaphragm Opacification ground-glass effect Lateral decubitus view Demonstrates as little as 150 cc of effusion; while 300 cc may be missed on a PA view! What does this CXR indicate?

Mucolytics

Breakdown mucous properties lowering their viscosity and allowing for easier mucous clearance. Acetylcysteine (Mucomyst) Dornase Alpha

Cheyne-Stokes Respirations

Breathing pattern marked by a period of apnea lasting 10-60 seconds followed by a gradually increase in depth and rate of respirations. Brain Damage, CHF, Respiratory Depression

Airway Responsiveness Testing

Bronchial Provocation Testing Can be used in the differential diagnosis of chronic cough and when the diagnosis is in doubt in the setting of normal pulmonary function tests Measured by using methacholine or histamine Positive test: reduced FEV1 by 20% or more with exposure to a concentration of 16mg/ml or less Not recommended if FEV1 is <65% of predicted Exercise testing may demonstrate the post exercise bronchoconstriction if there is a predominant history of exercise induced asthma What is this with asthma?

Sarcoidosis

Bronchiolar lavage may demonstrate higher than normal CD4/CD8 helper T cell ratios which is indicative of Sarcoidosis. Bronchial mucosal biopsy may show non-caseating granulomas. Triad of CD4 to CD8 ratio greater than 3.5:1, a lymphocyte percentage greater than or equal to 16%, and a transbronchial biopsy demonstrating noncaseating granulomas What is this?

Theophylline in COPD treatment

Bronchodilator Third-line agent after anticholinergics, B2-agonists, and combined inhaled corticosteroid therapy Improves FEV1, FVC & gas exchange, dec. dyspnea, improves exercise performance Not used much because of its narrow therapeutic window & TOXICITY

Manage acute exacerbations

Bronchodilators: Increase dose and/or frequency of existing therapy Add anticholinergics until symptoms improve Glucocorticosteroids: 40 mg oral prednisone per day for 10 days Or 10 mg. on a 6-6-5-5-4-4-3-3-2-2-1-1 (42 tabs) Antibiotics: If dyspnea and cough are severe and sputum is purulent and increased in volume Macrolide, Fleuroquinalone, Augmentin, Doxycycline, others! What management of COPD is this?

Emphysema

Bullae, parenchymal markings, or lucency Increased lung volume Flattening of the diaphragm (hyper-inflation) What radiographic finding is this?

Pulmonary HTN

CBC Polycythemia Pulse Oximetry Low oxygen levels EKG P Pulmonale Right Ventricular Hypertrophy Right Axis Deviation What lab and EKG finding is this for?

Sarcoidosis

CBC may show anemia (of chronic disease), leukopenia, eosinophilia ESR is elevated Hypercalciuria is more commonly observed than hypercalcemia Positive rheumatoid factor can be present Elevation in serum alkaline phosphatase concentration implies diffuse granulomatous hepatic involvement Serum ACE: Elevated in 75% of untreated patients with sarcoidosis Limited use secondary to false positives What is this?

Mucus

CF this is made up of different debris that lacks hydration. Most healthy this is made up of mucin however CF this contains very little mucin at all. CF this contains substances from neutrophil degradation, which includes filamentous actin and polymerized DNA. What is this for CF?

Pleural Effusion

CHF- Peripheral edema, distended neck veins, and S 3 gallop Edema -nephrotic syndrome; pericardial disease. Liver disease: Ascites Malignancy: Lymphadenopathy or palpable mass These physical exam findings are done for what?

Severe hypoxemia

CNS AMS, headache, somnolence Hypoxic brain injury Cardiovascular Tachycardia, hypertension Bradycardia, hypotension Pulmonary hypertension Renal Sodium retention Proteinuria What are these effects from?

Reversibility

COPD has Limited what after bronchodilators because of the irreversible lung damage?

True

COPD is preventable-T or F?

False

COPD is reversible-T or F?

Refer to pulmonologist

COPD onset before age 40 >2 exacerbations a year despite treatment Severe or rapidly progressive COPD Symptoms disproportionate to obstruction severity Need for long-term oxygen therapy Severe comorbid illnesses(heart failure, lung cancer...) What should be done?

Moraxella catarrhalis Haemophilus influenza

COPD or other chronic lung diseases is associated with what bacteria with pneumonia?

Secondary spontaneous peumothorax

COPD, Emphysema Tuberculosis Pneumonia Cystic fibrosis Connective tissue disease Sarcoidosis Idiopathic pulmonary fibrosis Inhalational and IV drug use Asthma Lung Abscess HIV/AIDS with Pneumocystis jiroveci Metastatic lung cancer Interstitial lung diseases Acute respiratory distress syndrome (ARDS) Severe acute respiratory syndrome (SARS) What risk factor is this for?

Iatrogenic

CPR Thoracentesis Pleural biopsy Tracheostomy Subclavian central lines Abdominal Paracentesis Positive pressure mechanical ventilation What pneumothorax is this?

Pleural Effusion

CXR First Choice due to availability, accuracy, and low cost US Guides needle for thoracentesis & chest tube placement CT (Spiral) Use if etiology is unknown to identify malignancy Additional testing guided by the suspected etiology. Echocardiography if CHF or pericardial effusion is suspected Contrast -study for Esophageal perforation What imagings are these done for?

Yes

Can a patient with P.E. have a normal SaO2?

Mechanical ventilation

Can aggravate lung injury secondary to repeated alveolar over distention and recurrent alveolar collapse Positive end-expiration Pressure (PEEP) is set high to minimize FiO2(Inspired O2 percentage) Usually 12-15 mmHg in ARDS 5 mm Hg normal What treatment is this with ARDS?

Bronchial Provocation Testing

Can be used in the differential diagnosis of chronic cough and when the diagnosis is in doubt in the setting of normal pulmonary function tests Measured by using methacholine or histamine Positive test: reduced FEV1 by 20% or more with exposure to a concentration of 16mg/ml or less Not recommended if FEV1 is <65% of predicted What airway responsiveness test is this for asthma?

Exudative

Cancer Infection (pneumonia, TB, abscess etc.) Trauma PE Esophageal Perforation Pancreatitis Diaphragmatic hernia Collagen vascular disease Chylothorax/ Hemothorax Post. CABG or MI Asbestos Sarcoidosis/lupus Uremia Drugs /Radiation What pleural effusion is this?

Staging

Cancers are given a baseline name, and then renamed with progression dependent on tumor type, node involvement, and metastasis What is this?

Secondary spontaneous

Caused by Underlying lung Disease What pneumothorax type is this?

Iatrogenic

Caused by a surgical procedure (Usually thoracentesis) What type of pneumothorax is this?

Traumatic

Caused by blunt or penetrating injury What pneumothorax type is this?

Health Care-Associated Pneumonia

Caused by organisms that colonize ill patients, staff, and equipment IV therapy, wound care, IV chemo within prior 30 days Residence in long term care facility Hospitalization in acute care hospital for 2 or more days in the prior 90 days Attendance at hospital or dialysis clinic in prior 30 days Most common organisms Staphylococcus Aureus and gram negative bacilli Pseudomonas Aeruginosa Klebsiella sp., E. coli, and Enterobacter sp. The second most common cause of hospital acquired infection Produces clinical infection more than 48 hours after admission to the hospital Higher risk: ICU patients & patients on mechanical ventilation Clinical features are similar to those with CAP Dx is clinical and supportive Lab testing Gram stain and sputum culture Blood cultures CXR may help to support the dx

Hypercapnea

Causes: Hypoventilation Ventilation/perfusion inequality Effects: CNS Effects Vasodilation Increased ICP Headache Restlessness/tremor Slurred speech AMS What are these for?

TB

Cell mediated immune response develops 2-6 weeks after the initial infection, suppressing the infection (making it inactive). In the event the host is unable to mount such a response, the bacilli erode through the alveoli (thereby becoming contagious) and the result is an 80% mortality rate. What is this?

Interstitial Lung Disease

Characterized by a large number of conditions that involve the parenchyma of lung Now more commonly called Diffuse Parenchymal Lung Disease Associated symptoms include: Dyspnea Persistent cough, nonproductive vs. productive Wheezing Chest pain

Long term pneumothorax

Chemical Pleuridesis (alternative to surgery) Tetracycline, silver nitrate, erythromycin, fluorouracil, interferon, cisplatin. Irritation inflammation pleural surfaces adhere Surgical Pleuridesis with Thorascopy Preferred to chemical Allows for inspection and resection of blebs What management is this for?

IPF

Chest Radiograph: Confluent small reticular opacities with small lung volumes CT: Patchy, basilar, sub-pleural opacities Traction bronchiectasis and honeycombing Atypical findings that should suggest an alternative diagnosis include extensive ground-glass abnormality, nodular opacities, upper or midzone predominance, and prominent hilar or mediastinal lymphadenopathy. What radiographic findings is this for?

Pulmonary HTN

Chest Xray and CT Dilation of the pulmonary arteries and right side of heart Echocardiogram- abnormal heart valves and right ventricular enlargement can estimate pulmonary artery pressures Right atrial catheterization-(BEST TEST) 100% accurate measurement of the pressure What imaging is this for?

Pleural Effusion

Chest pain Sharp or stabbing Worse with inspiration Refers to shoulder Dyspnea Cough But...may have NO symptoms Depending on severity and cause, symptoms vary greatly. What symptoms are these for?

COPD

Cigarette smoke or other trigger Inflamed Bronchial cells Narrowed Airway Edema Excess mucus Ciliary function declines What pathophys is this for?

Tendinitis and tendon rupture Risk of CVD death

Cipro and levo quinolones warning for COPD is what?

TB

Classified as pulmonary, extrapulmonary, or both Only 1/3 of patients develop pulmonary symptoms. Only 25% of patients develop additional symptoms Chest pain -- Cough Pleuritic chest pain -- Arthralgia Fatigue -- pharyngitis Weight loss -- night sweats Dyspnea -- Hemoptysis The most common symptom is fever that can last 14-21 days. What clinical manifestation is this?

Pneumonia Severity Index

Classifies the severity of pneumonia and determines whether a patient can be treated as outpatient or inpatient

Well's Criteria

Clinical signs and symptoms compatible with DVT (3) PE judged to be most likely diagnosis (3) Surgery or bedridden (1.5) Previous DVT or PE (1.5) HR over 100 (1.5) Hemopytsis (1) Active cancer (1) 6 pts is high 4.5-6 moderate Less than 4 low What criteria is this for PE?

Cystic Fibrosis

Clinical symptoms in at least one organ. Evidence of CFTR dysfuntion. Elevated sweat chloride > 60mmol/L (2 times) Mututations on each parental allele with CFTR mutation Abnormal nasal potential difference PFT's Decreased RV and TLC Decreased FVC and FEV1 Test for Carrier Screening CXR Early findings are those of Hyperinflation Late findings are those of Bronchial Cuffing and Bronchiectasis What are these evaluations for?

Thrombolytic Agents

Clot Busters Dissolve clots Alteplase, Streptokinase, Urokinase, Lanoteplase, Tenecteplase... Dose: 100MG IV over 2 h. Monitor aPTT Resume Heparin when aPTT normal What PE treatment is this?

Surgical resection

Comes with risks Limited to stage IIIA and better Limited to unilateral disease Must have healthy enough lung reserve to compensate for surgical changes What treatment is this with lung cancer?

PE

Common Deadly Often Missed Found only on autopsy What epidemiology is this for?

Pseudomonas aeruginosa

Common cause of gram-negative HCAP Most patients have an identifiable risk factor for disease A compromised immune system Recent prior antibiotic use Cirrhosis of the liver Structural lung abnormalities such as cystic fibrosis or bronchiectasis Repeated exacerbations of chronic obstructive pulmonary disease requiring frequent glucocorticoid and/or antibiotic use Patients with P. aeruginosa sepsis have a mortality rate of greater than 50% It is an important cause of endocarditis in IV drug users Acute P. aeruginosa pneumonia is usually characterized by cough productive of purulent sputum, dyspnea, fever, chills, confusion, and severe systemic toxicity

Histoplasmosis

Common sites associated with exposure to H. capsulatum include: Chicken coops Farm buildings with accumulations of chicken droppings Abandoned buildings Bird roost sites Caves Wood lots Farmers Activities commonly associated with exposure include Excavation Construction Demolition Remodeling Wood cutting/gathering Cave Exploration Camping where guano is readily seen What could they have?

Pleural effusion

Common: transudates, HF, exudates, cancer: primary or metastatic, bacterial peumonia, PE, either transudatesor exudates-transudates after diuretic therapy Less Common: cirrhosis w/ascites, peritoneal dialysis, nephrotic syndrome, viral, fungal, mycobacterial, or parasitic infection, systemic rheumatologic disorders like lupus and RA, uremia, pancreatitis, postcardiac surgery, drug-related amiodarone What differential diagnosis is this for?

Pneumoconiosis

Complicated CWP is manifested by the appearance on the chest radiograph of nodules ≥1 cm in diameter generally confined to the upper half of the lungs This condition can progress to PMF that is accompanied by severe lung function deficits and associated with premature mortality Cases of PMF still occur in the United States at a disturbing rate What condition is this?

CT scan

Confirm findings of CXR Assist in staging, (include upper abdomen)-TMN system-tumor, metastasis, lymph nodes-prognosis for it Used to determine intracranial involvement What lab imaging is this for lung cancer?

Transudative

Congestive Heart Failure Left ventricular failure Pulmonary embolism Pericardial Disease Obstruction of SVC Cirrhosis Nephrotic Syndrome Hypoalbuminemia Think (Liver, Kidney, Heart) What pleural effusion is this?

Connective Tissue Associated ILDs

Connective tissue disorders predispose patients to ILDs Clinical findings suggestive of Connective Tissue Disease (CTD) such as musculoskeletal pain, weakness, fatigue, fever, joint pain, Raynaud phenomenon, dry eyes/mouth, etc. should be sought in any patient with ILD What is this?

Strep pneumoniae

Consolidation of the alveoli begins in the peripheral airspaces Usually causes a lobar or segmental pattern This infection has a tendency to involve the pleura Parapneumonic effusions are common in pneumococcal pneumonia A patchy bronchopneumonic pattern involving the lower lobes is seen in the elderly What radiograph findings is this for?

CPAP

Continuous Positive Airway Pressure Used to prevent airway collapse. OSA Snoring HTN Excessive daytime fatigue Noninvasive Limitations Noncompliance Dry Airways Pressure Irritation Epistaxis-keep air open all the time have to breathe against Leaks One pressure setting

Wheezes

Continuous musical sound caused by narrowing of airways. Can be on expiration or inspiration or both.

Controller Medications

Corticosteroids Long acting bronchodilators Beta adrenergic agonists Mediator inhibitors Anticholinergics Phosphodiesterase inhibitors Leukotriene modifiers Anti IgE Immunotherapy Immunomodulators What meds are these for with asthma?

Pleurisy

Costochondritis pain on palpation Herpes zoster Pain on a dermatome Rib fracture History of trauma What differential diagnosis is this for?

Central tumor squamous Chest radiograph

Cough Dyspnea Atelectesis Post-obstructive pneumonia Wheezing (localized) Hemoptysis - tumors are often highly vascular, but friable. What is this history for? Also what followup should you ALWAYS get??

Peripheral tumors (adenocarcinoma or large cell carcinoma)

Cough Dyspsnea Pleural effusion Pleural pain secondary to invasion parietal pleura Extra-pulmonary findings secondary to mets. What history is this for?

Chronic bronchitis

Cough and Sputum >3 months ,2 years in a row Exclude other causes of chronic cough What type of COPD is this?

3 months

Cough and Sputum greater than what ,2 years in a row is chronic bronchitis?

Pulmonary Complaints

Cough-deep, sputum, rattle, color, sticky, smell Fever Night Sweats Mucous Production Sputum color Shortness of Breath Dyspnea Orthopnea Wheezing-inspiration or expiration-expiration okay but not inspiration Weight Loss-lung cancer Sharp chest pain-pleuirsy Associated swelling anywhere on body? Cor pulmonale Hemoptysis-cough up blood clot Is it worse over time? How long? Is it exertional? Immunization UTD Seasonal Are you on ACE? Does cold air bring it on? Asthmatics Is it worse at night? Is it worse when you lay down? What is your job? Contributing to problem-allergic to something around Fever, color, production, and cough can tell if infection or not Asthma at night-children cough more at night What history is this?

Pulmonary symptoms for CF

Cough-thick and can't move it-in there Recurrent Pulmonary Infiltrates Chronic Sinusitis Rhinnorhea Nasal Obstruction Nasal Polyps-kids should not have this Lung Infections Bronchiolitis Pneumothorax Hemoptysis Digital Clubbing/Cor Pulmonale What presentation is this?

Klebsiella and Pneumococci

Currant jelly sputum means what bacteria?

Pseudomonas aeruginosa

Cystic fibrosis is associated with what bacteria with pneumonia?

ILD

DMARDs (with and without glucocorticoids) Cyclophosphamide Azathioprine Methotrexate Cyclosporine Mycophenolate All of these agents that have been tried with variable success The role of these medications remains to be determined Lung transplantation may be the only treatment for survival of end stage ILDs What other available therapies are these for?

Heparin

DVT pts are started on what med first?

Moderate

Daily symptoms Over 1X/wk but not nightly-nighttime awakenings Daily-short acting B agonist Some limitation FEV1 over 60% but less than 80% predicted FEV1/FVC reduced 5% What severity is this with asthma?

Hypoxemia

Decreased O2 concentration in the blood

Obstructive sleep apnea

Definite: Obesity- best documented risk factor Craniofacial abnormalities/ upper airway soft tissue abnormalities (per previous slide) Potential: Heredity-NOT due to a single gene mutation or protein action; only ¼ of the prevalence has a genetic basis Smoking-current smokers (but not past smokers) are nearly 3x more likely to have OSA than never smokers Nasal congestion (any chronic cause) Diabetes It is important to note that while these factors may be associated with OSA, their elimination is not necessarily curative of OSA Weight loss or correction of craniofacial abnormality may resolve OSA but: Smoking cessation and management of nasal congestion or septal deviation have not been shown to have a high yield as a primary therapy What are these risk factors for?

Chest physiotherapy

Dependent airway clearance device. Effective way to mobilization secretions to help reduce exacerbations. Combined with Postural Drainage VERY TIME CONSUMING AND REQUIRES ASSISTANCE. 2-3 times daily Cup hands sounds like horse galloping-vibrate every section of lung-takes 20 mins-cover every area of the lung in different positions What airway clearance device and technique is this?

Hypercapnia

Depressed central resp drive, structural CNS disease, brainstem lesions, drug depression of resp center: opioids, sedatives, anesthetics, endogenous toxins: tetanus, thoracic cage disorders, kyphoscoliosis, morbid obesity, neuromuscular impairment, neuromuscular disease and toxin, intrinsic lung disease, COPD, upper airway obstruction What is this differential for?

Oral devices

Designed to protrude mandible forward or hold the tongue in a more anterior position Either design holds the soft tissues of the oropharynx away from the posterior pharyngeal wall They decrease frequency of respiratory events, may improve daytime symptoms but effect on mortality unknown What OSA specific therapy is this?

Emphysema

Destruction of alveoli Enlarged airspaces No fibrosis What type of COPD is this?

TEE

Diagnosing of early right ventricular strain is important because it is a strong predictor of subsequent death Important to recommend echocardiogram with your admitting internist if a pattern of right heart strain is suggested by EKG. Studies have documented that lives are saved with early fibrinolysis is considered in these patients. What lab test is this?

PFT/Spirometry

Diagnosis is confirmed by what for COPD and is the most helpful diagnostic test?

IPF

Diagnosis of what can be made 90% confidence in patients: Over age 65 with idiopathic disease by history and who demonstrate inspiratory crackles on PE Restrictive physiology on pulmonary function testing Characteristic radiographic evidence of progressive fibrosis over several years Diffuse, patchy fibrosis with pleural based honeycombing on high resolution CT scan

Thoracentesis

Diagnostic and Therapeutic Bedside procedure Sterile technique Enter at superior border of 5th rib to avoid nerves 10-20cc (diagnostic) Up to 1 L (therapeutic) What is this for with pleural effusion?

Pneumothorax

Diaphoresis Holding chest wall (to relieve pain) Cyanotic Tachypnia Tachycardia (most common finding) Hypotension (with tension pneumothorax) Asymmetric lung expansion Tracheal shift to the contralateral side Distant or absent breath sounds Hyperresonance on percussion Decreased tactile and vocal fremitus Jugular venous distension (tension pneumothorax) What PE is this for?

Transpleural Pressure

Difference between intrapleural and intrapulmonary pressures

Pre and Post Spirometry Tests

Differentiates Asthma from COPD & Determines the efficacy of β Adrenergic Bronchodilators Test before and after bronchodilator and compare Asthma- Improved FEV1 or FEV1/FVC ratio by >10% Bronchitis or Emphysema only mild improvement

Pulmonary HTN

Difficult to diagnose Symptoms are often due to the underlying cause Identify the cause Dyspnea on exertion or at rest (severe cases) CP- Dull, retrosternal Fatigue Cough Syncope Peripheral Edema What symptoms are these for?

DLCO

Diffusion Capacity of the Lung for Carbon Monoxide Used to evaluate for Parenchymal Lung Disease The test is done by inhaling to vital capacity then holding the breath for 10 seconds before exhaling completely. Abnormal Hemoglobin levels can affect the DLCO

Westermark's sign

Dilation of pulmonary vessels proximal to the embolism and collapse or "cut-off" of distal vessels What sign is this on a CXR for PE?

ARDS

Direct Lung Injury: pneumonia, aspiration of gastric contents, pulmonary contusion, near-drowning (swallow pond water and are fine then in a few hours develop ARDS-cause inflammation of the lung from not coughing the water all the way up and bacteria gets in there and causes inflammation and pleural effusion), toxic inhalation injury Indirect lung injury: sepsis, severe trauma-multiple bone fractures, flail chest, head trauma, burns, multiple transfusions, drug overdose, pancreatitis, postcardiopulmonary bypass What clinical disorders is this associated with?

Yes

Do COPD pts cough both day and night?

Inhaled bronchodilators for COPD

Do not alter decline in lung function but do improve symptoms & activity tolerance Therapeutic mainstay for COPD Match to the severity of symptoms using GOLD If no symptomatic improvement, bronchodilators should be discontinued

LMW Heparin

Dose: 1 mg/kg Sub Q bolus Q 12 hours Available formulations: ENOXAPARIN (Lovenox) preferred in pregnant patients TINZAPARIN (Innohep) DALTEPARIN (Fragmin) ARDEPARIN (Normiflo) REVIPARIN (Heparin) No antidote Follow renal function What PE treatment is this?

CHF

Drainage of transudates is limited to what?

Prophylaxis; PE

Due to risk in all hospitalized patients, VTE what is mandatory for all bed bound patients in most hospitals? Patients with what are more likely to suffer recurrence than patients with DVT?

Sarcoidosis

Due to the multi-organ involvement, patients often present initially to a variety of specialties. Presentation ranges from asymptomatic to those with organ failure. Most commonly present with respiratory complaints Cough/Dyspnea Chest Pain Often 2-4 week history Symptoms related to cutaneous and ocular disease is next most common complaints Nonspecific constitutional symptoms may include fever, fatigue, weight loss, exercise intolerance, and night sweats. Constitutional symptoms are more common in the African American population. Often is an overlooked differential of Fever of Unknown Origin. What clinical presentation is this for?

Respiratory Distress

Dyspnea A "Work" issue Hypoxemia A "Perfusion" issue Hypercapnia A "Retention" issue Wheezing A "structure" issue Cough An "irritant" issue Hiccups An "annoying" issue Cyanosis A number of issues Pleural effusion A "fluid" issue What are these signs of?

Sarcoidosis

Dyspnea Dry cough Chest pain (retrosternal - often described as a vague tightness) Hemoptysis (rare)-also TB and good pasture's with kidney disease and blood in urine Clubbing of the digits (rare) Lung crackles (rare) What clinical presentation is this for?

ILD

Dyspnea Non productive cough Wheezing, hemoptysis, and chest pain is not common Chest discomfort or pleuritic chest pain Pneumothorax Acute presentation with dyspnea and chest pain associated with pulmonary Langerhans cell histiocytosis (PLCH) Fatigue and weight loss is common What clinical presentation is this?

COPD

Dyspnea (emphysema) On exertion (or rest if severe) Ask: effort when catching a breath activity level reduction due to breathing Chronic cough Define quality, quantity, and timing Sputum (bronchitis) Define quantity and timing Wheeze What signs and symptoms is this for?

Emphysema

Dyspnea-CC Uncomfortable at rest Chest-quiet No peripheral edema Presents age 20-50 Thin What are these symptoms of?

Pulmonary HTN

Elevated pressure in pulmonary arteries Caused by constriction and thickening The right side of the heart works harder to overcome the pressure The right side of the heart weakens and eventually fails this is known as Cor Pulmonale What is this?

angiotensin-converting enzyme

Elevation of the serum level of what is common in ILDs, especially sarcoidosis

False (chronic bronchitis)

Emphysema is the more common of the two types of COPD-T or F?

3 years

Environmental/occupational Exposure >what. OR Recurrent respiratory infection > what one yr. w/COPD?

Asthma

Episodic wheezing Dyspnea Chest tightness Cough Excess sputum production What are these common symptoms for?

Pneumothorax

Esophageal Spasm Myocardial Ischemia Acute Pericarditis Pleurodynia Pulmonary Embolism What differential diagnosis is this for?

Respiratory Distress

Evaluation of respiratory function includes assessment of patient position (sitting), rate, work of breathing (recruitment), skin and mucous membranes color, and mental status Sounds may include stridor and grunting Respiratory rate alone is an insensitive means of evaluating for respiratory distress Varies greatly with: Age Anxiety Excitement Fever Tachypnea and bradypnea may be a manifestation of respiratory distress, but can also vary with underlying illness What is this?

Ventilator

Every pneumothorax gets a what with management?

Tension pneumothorax

Exam: Hypotension Absent/decreased breath sounds Hyperresonance to percussion Tracheal deviation (away from affected side) Diagnostics: If you wait for the CXR YOU'RE TOO LATE!!! What is this for?

Anti IgE

Example: Omalizumab (Xolair) Neutralized circulating IgE without binding to cell-bound IgE to inhibit IgE-mediated reactions Shown to reduce number of exacerbations in patients with severe asthma and may improve asthma control Reserved for severe asthma who are not controlled on maximal doses of inhaler therapy & have circulating IgE within a specific range SubQ injection q 2-4 weeks What med is this for asthma?

Inhaled Corticosteroids

Examples: Beclomethasone HFA (Qvar), Budesonide (Pulmicort), fluticasone (Flovent) Lung function improves over several days & further prevents irreversible changes to the airway function that occur with chronic asthma Maximal improvement may take several months of therapy Effective in preventing asthma symptoms (i.e. EIA, nocturnal exacerbations, and severe exacerbations) What meds are these with asthma?

Mediator Inhibitors

Examples: Cromolyn sodium, nedocromil sodium Appear to inhibit mast cells and eosinophil recruitment and inhibit early and late asthma responses to allergen and EIA Short duration of action Require frequent dosing to be effective (QID) What meds are these with asthma?

Antileukotrienes

Examples: Montelukast (Singulair), zafirlukast (Accolate) Useful as adjunct medication for patient not well controlled with low dose ICS Orally daily or BID Block cys-LT-receptors (inflammatory mediator produced by mast cells and eosinophils) What meds are these with asthma?

Immunomodulators

Examples: methotrexate, cyclosporin A, Azathioprine, Gold, IV gamma globulin Used in severe asthma Reduce the requirement of oral corticosteroids in patients with serious side effects with this therapy What med is this for asthma?

Asthma

Exhaustion Dehydration-increase histamine production-in lungs cause spasm of bronchioles-conserve moisture Airway Infection Tussive syncope Pneumothorax Acute hypercapnic and hypoxemic respiratory failure What are these complications of?

Asthma

Exposure to "trigger" Mast cell activation and release of mediators (i.e. histamine, bradykinin, leukotrienes, cytokines, prostaglandins) Inflammatory cell infiltration within bronchial lining (i.e. eosinophils, neutrophils, lymphocytes) Goblet cell hyperplasia and plugging of small airways with thick mucus Collagen deposits under basement membranes Hypertrophy of bronchial smooth muscle Airway edema Stripping of airway epithelium What pathophys is this?

Allergens

Exposure to house dust mites in early childhood Domestic pets (i.e. cats) associated with allergic sensitization Early exposure to cats in the home may be protective through the induction of tolerance People who are allergic to pets should not have them in the house At a minimum, do not allow pets in the bedroom

Flu vaccine Short acting bronchodilator 1 or more long-acting bronchodilator Add rehab Inhaled glucocorticosteroids if repeated exacerbations

FEV1/FVC less than 0.70 FEV1 greater than 30% or less than 50% predicted What is the gold criteria treatment for severe?

Flu vaccine Short-acting bronchodilator 1 or more long-acting bronchodilators Add rehab

FEV1/FVC less than 0.70 FEV1 greater than 50% less than 80% predicted What is the gold criteria treatment for moderate?

Flu vaccine Short acting bronchodilator 1 or more long-acting bronchodilator Add rehab Inhaled glucocorticosteroids if repeated exacerbations Long term oxygen Consider surgery

FEV1/FVC less than 0.70 FEV1 less than 30% predicted or FEV1 less than 50% predicted plus chronic resp failure What is the gold criteria treatment for severe?

Flu vaccine Short-acting bronchodilator

FEV1/FVC less than 0.70 and FEV1 greater than 80% predicted What is the gold criteria treatment for mild?

Normal

FEV1/FVC ratio is usually what with PFT spirometry with ILD?

III

FEV1/FVC ratio<70% FEV1 <30% Severe Symptoms Severity-severe Symptoms - Symptoms are severe What stage is this?

IV

FEV1/FVC ratio<70% FEV1 <30% or <50% with resp. failure Very Severe Symptoms, affecting quality of life Severity- very severe Symptoms - Symptoms are life impairing What stage is this?

II

FEV1/FVC ratio<70% FEV1 <50% Mild symptoms Severity- moderate Symptoms -Chronic cough, dyspnea, or sputum What stage is this?

1

FEV1/FVC ratio<70% FEV1 >80% May or may not have symptoms Severity- mild Symptoms -Mild cough, dyspnea, or sputum What stage is this?

COPD

FEVI-Decreased FEVI/FVC Ratio-decreased RV-Increased FVC- Normal (differentiates from mixed disease) TLC- Increased DLCO- Decreased FRC- Increased What are these results for on spirometry?

Asthma and PFT

FVC -Normal TLC-Normal FEV1-Decreased RV-Normal FEV1/FVC Ratio-decreased FRC- Normal DLCO Normal What condition is this?

Restrictive Lung Diseases and PFT

FVC -decreased TLC-Decreased FEV1-Decreased RV-Decreased FEV1/FVC Ratio-Normal or Increased FRC-Decreased DLCO Decreased What condition is this?

COPD and PFT

FVC-normal or decreased TLC -Increased FEV1-Decreased RV-Increased FEV1/FVC Ratio-Decreased FRC Increased DLCO Decreased What condition is this?

GI symptoms for CF

Failure to thrive Meconium Ileus Abdominal distention Consipation Greasy Stools Protein Malabsorption Fat Malabsorption CF induced Diabetes Pancreatic insufficiency What presentation is this?

D-dimer

Fibrin degradation product Circulates for 4-6 hours Good sensitivity but poor specificity Good Negative predictive value May waste time? Basically, the assay is enzyme-linked monoclonal antibody test used to identify the protein itself is a unique degradation product that is produced by a plasmin mediated breakdown of cross-linked fibrin Good test with respect to its negative predictive value. The drawbacks are some of the false positives that we commonly see in the ER. There is no clear answer to the question/debate. It's confusing test to order. What lab test is this?

Histoplasmosis

Fibrosing mediastinitis Broncholithiasis-stones in the lungs-calcification in bronchioles itself-decrease movement of air in that section Mediastinal Granuloma Pericarditis Rheumatologic manifestations What complications is this for?

Long term

First PE/ with risk factors: Warfarin for 6 months First PE/ with no risk factors: Warfarin for 3 months Recurrent PE or DVT: Indefinite Warfarin (Coumadin) therapy Prevents VTE but risks major hemorrhage What PE treatment is this?

aPTT and heparin

For UFH what should be tested-anticoag for DVT every 6 hours until therapeutic range reached?

CT guided biopsy

For tumors that can not be reached by bronchoscopy, but are close to the chest wall. What invasive testing is this with lung cancer?

Over 2

For warfarin/heparin overlap give until INR over what for 24 hrs then discontinue heparin for 5 days?

Anaerobic organisms

Foul smelling sputum means what bacteria?

Histoplasmosis

Fungal culture remains the gold standard diagnostic test Culture results may not be known for 1 month Cultures are often negative in less severe cases Pathology - granuloma formation especially with giant cells. Histology stains highlight fungi. Antigen detection - urine, blood, or BAL - false positives in blatomycosis, coccidiomycosis, penicillinosis, paracocciomycosis, and aspergillosis. Serology - immunodiffusion test - decrease sensitivity in immunosuppressed population What is this the diagnosis for?His

Paraneoplastic syndrome

Generalized associations to all cancers in general. Anemia DIC Eosinophilia Thrombocytosis Acanthosis Nigrans What is this associated with?

Endogenous

Genetic predisposition Atopy Early Viral infections Gender Ethnicity Obesity What risk factors are these for asthma?

Lung cancer

Genetics There is an established familial risk that suggests genetic involvement. Dietary factors Antioxidants, cruciferous vegetables, phytoestrogens - suggested to decrease the risk of CA, but not well demonstrated in clinical trials. These risk lead to what?

TB

Goals: Prevent morbidity and death by curing this while preventing emergence of drug resistance Interrupt transmission by rendering patients noninfectious Due to Multi-Drug Resistance , current chemotherapy recommendations, for active disease, involves 4 different polypharmacy recommendations. English - there are 4 current drug combination recommendations. These recommendations come from the Infectious Disease Society of America and the U.S. Public health Service. What is this treatment for?

Polysomnography

Gold standard for diagnosis of OSA Overnight test performed at a sleep lab May reveal: Apneic episodes lasting as long as 60 seconds Very low oxygen saturation levels Bradydysrhythmias: Sinus bradycardia, sinus arrest, AV block PSVT may occur Multi-parametric test Electroencephalogram - four "exploring" electrodes, two "reference" electrodes Electrocardiogram - two - three leads rather than 12 Electrooculogram - helps determine when sleep actually occurs; electrodes will pick up the activity of the eyes in virtue of the electropotential difference between the cornea and the retina; helps determine when REM sleep occurs Electromyogram - helps to detect limb movement disorders Pulse oximetry - measures oxygen saturation levels Nasal/ oral airflow - helps measure rate of respiration and pick up apneic episodes

Pulmonary Function Testing: Spirometry

Good for establishing a baseline and for monitoring progression of disease Generally reveal restrictive disease Reduced TLC, functional residual capacity, residual volume FEV1/FVC ratio is usually normal Pulmonary function studies have been proved to have prognostic value in patients with idiopathic interstitial pneumonias, particularly IPF and nonspecific interstitial pneumonia (NSIP) What test is this?

Pulmonary rehab in COPD

Graded aerobic physical exercise Prevents COPD progression Improves exercise tolerance & ADLs Train inspiratory muscles by inspiring against progressively larger resistance Reduces dyspnea Improves exercise tolerance & ADLs Improves respiratory muscle strength

Klebsiella Pneumoniae

Gram negative rod that can colonize the GI tract, GU tract and pulmonary circulation Targets the debilitated elderly with chronic disease (DM) Commonly associated with alcoholism in the US Can have high mortality rate, especially if bacteremic Presentation Acute onset of high fever, chills, flu-like symptoms, blood tinged (currant jelly) sputum Klebsiella, Enterobacter, and Serratia are closely related normal intestinal flora that rarely cause disease in normal hosts Of the three organisms K. pneumoniae is most likely to be a primary, non-opportunistic pathogen Carried in the respiratory tract of about 10% of healthy people, who are prone to pneumonia if host defenses are lowered

Sarcoidosis

Granuloma formation is the pathologic hallmark of sarcoidosis Formation of granulomas in the connective tissue of the bronchioles and alveolar interstitium Blood vessels are often involved There is local accumulation of inflammatory cells Granulomas consist of phagocytes, T-lymphocytes and inflammatory mediators such as TNF, interferon and interleukins. These either resolve or lead to fibrosis and sometimes hyalinization of the tissue. What pathology is this for?

Low risk Less symptoms (Group A)

Greater than 50% predicted with post bronchodilator FEV1 Exacerbated less than 2 years Moderate symptoms What is this on the combined COPD assessment scale?

Low risk More symptoms (Group B)

Greater than 50% predicted with post bronchodilator FEV1 Exacerbated less than 2 years Severe symptoms What is this on the combined COPD assessment scale?

Pseudomonas, Haemophilus, Pneumococci

Green colored sputum means what bacteria?

Aspiration Pneumonia

Gross Impaired state of consciousness Post-surgical Intoxicated Neurologic injury Anatomic incompetence Inadequate glottis closure Body position Micro-aspiration Essentially "constant" throughout the day/night Smaller inoculum

Sarcomatoid Carcinoma

Group of non-small cell carcinomas with Sarcoma like elements. Pleomorphic - used if greater than 10 percent of a heterogeneous tumor is composed of giant or spindle cells Spindle cell - comprised of entirely spindle cells Giant Cell - Large bizarre cells that do not fit any other categories that are found in squamous or adenocarcinoma tumors Carcinosarcoma - squamous or adenocarcinoam tumors that display sarcoma like elements (bone, cartilage, muscle cells) Pulomary blastoma - highly malignant tumors that are adenocarcinoma with the appearance of fetal adenocarcinoma and Wilm's tumor.

Pneumocystis, Histoplasma, Cryptococcus, MAC, TB

HIV is associated with what bacterias with pneumonia?

Computed Tomography (CT)

HRCT is superior to the plain chest x-ray for early detection and confirmation of suspected ILD Allows better assessment of the extent and distribution of disease Allows investigation of patients with a normal chest radiograph Coexisting disease is often best recognized on HRCT scanning, e.g., mediastinal adenopathy, carcinoma, or emphysema HRCT may be sufficiently characteristic to preclude the need for lung biopsy in IPF, sarcoidosis, hypersensitivity pneumonitis, asbestosis, lymphangitic carcinoma, and PLCH When a lung biopsy is required, HRCT scanning is useful for determining the most appropriate area from which biopsy samples should be taken What diagnostic is this for ILD?

Stridor

Harsh, wheeze resembling sound, ON INSPIRATION. This indicates an obstruction of the airway and demands immediate attention. Epiglottis

Bronchitis

Hb elevated ABG (resp acidosis)-PaO2 reduced, PaCO2 elevated Chest x-ray-increased vascular markings What lab studies is this for?

Emphysema

Hb usually normal ABG-PaO2 and PaCO2 normal/slightly reduced Chest x-ray-hyperinflation, flat diaphragms, diminished vascular markings What lab studies is this for?

Lung cancer

Head and Neck Supraclavicular adenopathy Horner syndrome - ptosis, miosis, anhidrosis SVC syndrome - edema of head, neck and upper extremities. Respiratory Central lesions - may cause collapse of the entire lung - no breath sounds on that side Peripheral lesions - may cause collapse of peripheral lung segments - decreased breath sounds or dullness to percussion Pleural effusions may result in decreased breath sounds and dullness to percussion Cardiovascular No findings unless secondary to pericardial effusion. Friction rub Tamponade-fast HR, low BP Gastrointestinal Most common finding is hepatomegaly and hepatic tenderness secondary to metastatic spread Musculoskeletal Tenderness to palpation of bony extremities or spine (secondary to metastasis) CNS findings Non-specific - based on metastatic spread. Full neuro exam is necessary. What PE findings are these associated with?

NSAIDS

Help treat musculoskeletal symptoms and erythema nodosum. Watch with steroid use-causes GI bleeding Treatment for sarcoidosis

Peak Expiratory Fow

Helps confirm diagnosis Improves asthma control Quantifies asthma severity What test is this?

Methotrexate

Helps suppress the disease, especially in combination of steroids, but not to cure it Symptoms usually return if it is discontinued Risk for drug induced interstitial pneumonitis. Cytotoxic agents Treatment for sarcoidosis

Military

Hematogenous spread of the bacilli develops into what tuberculosis-outside the lungs.

TB

Hemoptysis Small amount Pneumothorax ~1% of hospitalized patients Result of rupture of peripheral cavity or subpleural caseous focus with liquefaction into the pleural space Can lead to fistula, tube drain likely required Bronchiectasis Extensive pulmonary destruction Septic Shock Associated with patients with: Lower BMI Lower mean WBC count HIV Malignancy Chronic pulmonary aspergillosis What complication is this for?

Long term Warfarin (Coumadin)

Heparin is given for a minimum of 5 days and INR should be within therapeutic range for 24 hours before starting coumadin. Initial dose 5 mg qd for 2 days then adjust according to INR Target INR: 2.0-3.0 Measure INR q 1-2 days until stable then q1-2 weeks, subsequent monitoring is 2-4 wks. What PE treatment is this?

Acute Severe Asthma

High concentration of O2 by face mask to achieve O2 sat >90% High dose SABA by nebulizer or MDI Albuterol 2.5-5 mg every 20 minutes for 3 doses by nebulizer, or 4-8 puffs from MDI Inhaled anticholinergic may also be used if not responsive to B2 agonist alone Systemic Glucocorticoids Methylprednisolone 60-125 mg IV In patients who are refractory to inhaled therapies, a slow infusion of aminophylline may be effective Monitor blood levels Magnesium sulfate: 2 grams IV over 20 minutes for life threatening exacerbations or lasting more than 1 hour despite aggressive therapies Bronchodilation effect, believed to inhibit Ca+2 influx into airway smooth muscle cells Prophylactic intubation may be indicated: Impending respiratory failure When the PCO2 is normal or rises For patients with respiratory failure, it is necessary to intubate and institute ventilation These patients may benefit from an anesthetic such as halothane if they have not responded to conventional bronchodilators Sedatives should never be given because they may depress ventilation Antibiotics should not be used routinely unless there are signs of pneumonia What is this treatment for?

V/Q scan

High probability Treat for PE Only 50% of PE patients have this type of scan Normal /Negative Eliminates PE diagnosis-unless had high Well's score Vague Additional Testing Required nondiagnostic (most common) What lab test results is this?

False (for all pts especially bed ridden)

High risk pts. are put on VTE prophylaxis when hospitalized-true or false?

Simple Diffusion

Higher concentration of O2 in the blood than the tissue cells Higher concentration of CO2 in the tissue cells than the blood

Posaconazole (Noxafil)

Highly active against H. capsulatum in vitro. Reserved as salvage therapy for failed regimens What med is this with histoplasmosis?

Acute TB

Hilar adenopathy (65 %) is most common CXR finding Usually resolve slowly, up to 1 year Other findings include pleural effusions, pulmonary infiltrates, most findings are in the RML. What is this?

Pre-invasive (hyperplasia) and invasive

Histology specimens will be classified as what?

IPF

Histology usually required to make a diagnosis. Open surgical biopsy required Transbronchial biopsy usually not satisfactory What diagnosis is this for?

Sputum cultures

How is diagnosis made with TB?

Skin testing (PPD)

How is screening for TB exposure done?

10-14 days

How long should you give antibiotics for COPD?

10 pack years

How many pack years almost always have emphysema need to be screened with spirometry every year?

Pneumonia

Hx: 1-10 days of progressive productive cough with purulent sputum, dyspnea, pleuritic CP, fever and chills/rigors. Headache, malaise, N/V, diarrhea, anorexia and abdominal pain are also possible Symptoms are nonspecific and do not reliably differentiate the various causes of pneumonia Knowledge of the most common etiologic organisms is crucial in determining rational empiric antibiotic regimens PE: fever, tachycardia, tachypnea, adventurous breath sounds (wheezes, rhonchi, rales, crackles), decreased breath sounds, dullness to percussion with effusion, bronchial breath sounds over consolidation, accessory muscle use Lab findings Stain or sputum culture CXR: lobar or segmental infiltrates, air bronchograms and pleural effusion CBC: leukocytosis What clinical feature is this for?

Hypertonic saline

Hydrating the airways to aid in mucus expectoration. Drawback = bronchospasm (recommendations it be given with a bronchodilator) What mucoactive agent is this?

Antimalarials

Hydroxychloroquine - less retinal injury than chloroquine, and may be beneficial for diabetics as it suppresses gluconeogenesis. Treatment for sarcoidosis

Sqaumous cell associated syndromes (with paraneoplastic syndromes)

Hypercalcemia (parathyroid like hormone) Is associated with what lung cancer?

Granulomatous ILD

Hypersensitiviy pneumonitis (organic dusts) Inorganic dusts Sarcoidosis Langerhan's Granulomatous Vasculitides Wegner's, Churg-Strauss Bronchocentric Lymphatoid What are these etiologies for?

CPAP

Hypoventilation Nausea-wait 2 hours after eating Facial Trauma Untreated pneumothorax-making it worse Elevated ICP What are these contraindications for?

Hypoxemia

Hypoventilation Neuromuscular Neurogenic Pulmonary Diseases COPD Asthma VQ mismatches Pneumonia Atelectasis-alveoli not expanding-not taking deep breath-stays collapsed Venous to Arterial Cardiac Shunts Anemias Abnormal Hemaglobins Ex: Sickle Cell Anemia Vascular Disease What are these mechanisms of?

Episodic

ILD Eosinophilic pneumonia, hypersensitivity pneumonitis, COP, Churg-Strauss syndrome

Acute (days to weeks)

ILD Unusual, but occurs with allery, acute interstitial pneiumonia, eosinophilic pneumonia, and hypersensitivity pneumonitis

True

Ideal INR for anticoagulant therapy is >2-true or false?

Pulmonary HTN

Idiopathic No identifiable cardio respiratory cause Secondary has an identifiable cause Chronic Lung Disease COPD, Asthma, Cystic Fibrosis... Pulmonary Embolism Polycythemia (increased red cell count) Pericarditis Aortic or Mitral Valve Disease Left Ventricular Failure Medications (Phen-Phen) Liver Disease (Cirrhosis) What do these cause?

Antibiotics

If dyspnea and cough are severe and sputum is purulent and increased in volume Macrolide, Fleuroquinalone, Augmentin, Doxycycline, others!

Sarcoidosis CD4/CD8 ratio

If get a bronchial washing and culture and is negative what could they have? And what test should you do next?

Pneumonia, malignancy, TB, RA, hemothorax, Churg-Strauss

If glucose less than 60 for pleural effusions what conditions is this?

DNA sequencing test

If immunoreactive trypsin level and sweat chloride test positive what test should be done next?

Pneumonia, esophageal rupture, RA, TB, malignancy, lupus

If pH less than 7.2 with lab results with pleural effusion what conditions is this?

Pleurisy

If there is no effusion or parenchymal abnormality, the differential is narrowed: Viral Pleuritis PE Collagen Vascular Disease Abdominal process Pericardial disease What diagnosis is this for?

Pneumothorax observation

If this is small, limited symptoms 100% O2 by facemask (to reabsorb pleural air) Repeat CXR (4 to 24 hrs) Most minor asymptomatic pneumothoracies resolve spontaneously in 1 - 2 weeks What is this for?

Alpha 1 antitrypsin deficiency

If young, use what test for COPD?

Heparin

Immediate thrombin inhibition Prevents further clots Does not dissolve or shrink a clot Will not work in patients with antithrombin deficiency Few absolute contraindications Available Unfractionated or LMW What anticoag treatment is this for PE?

PE

Immobilization (long air travel) Surgery in the last 3 months Stroke/Paralysis Hx. VTE Single most important risk factor Malignancy Central Venous Instrument in last 3 mo. Heart disease/Hypertension Obesity Uses >25 cigarettes a day Genetics: Factor V Leiden or Prothrombin gene mutation Taking oral contraceptives or postmenopausal Pregnant/post partum Trauma COPD Antiphospholipid Antibody Syndrome What risk factors are these for?

C

In a hospitalized patient at risk for the development of venous thromboembolism after surgery, which of the following would be the best choice for prevention in terms of safety, efficacy, and cost-effectiveness? A. Aspirin B. Warfarin C. Low-molecular-weight heparin D. Unfractionated heparin

Fiberoptic Bronchoscopy and Bronchoalveolar Lavage

In selected diseases (e.g., sarcoidosis, hypersensitivity pneumonitis, DAH syndrome, cancer, pulmonary alveolar proteinosis), cellular analysis of BAL fluid may be useful in narrowing the differential diagnostic possibilities among various types of ILD The role of BAL in defining the stage of disease and assessment of disease progression or response to therapy remains poorly understood

Neuromuscular blockade

In severe ARDS, sedation alone can be inadequate for the patient-ventilator synchrony required for lung-protective ventilation In severe ARDS, early neuromuscular blockade increased the rate of survival and ventilator-free days without increasing ICU-acquired paresis What treatment is this with ARDS?

Symptom free

In the acute phase, a healthy individual, with minimal inhalation exposure, usually remains what with histoplasmosis?

Atelectasis; Pneumonia

Incentive Spirometer works to keep alveoli inflated and prevent what which then prevents what?

Bronchodilators

Increase dose and/or frequency of existing therapy Add anticholinergics until symptoms improve

Chronic

Increased Monocytes on WBC differential-acute or chronic?

Acute

Increased PMN on WBC differential-acute or chronic?

Sjogren's syndrome

Increased risk of pathology secondary to dryness of the airway Pathology required to make final diagnosis What CT is this associated with ILD?

Respiratory Distress

Increased work of breathing is evidenced by: Nasal flaring-trying to open airway as much as can to get air in Retractions: Suprasternal Intercostal Subcostal retractions Accessory muscle use Auscultation may give a clue to the underlying pathology, and may reveal: Wheezing/stridor Rales Decreased breath sounds may be present Cyanosis, when present, represents severe distress and is best seen on mucous membranes of the mouth and nail beds Peripheral cyanosis is more likely due to circulatory failure than a primary pulmonary source Inability to speak-document how they speak-in btw breathes or really fast and then breath which is anxiety Mental status changes and agitation What PE is this for?

Positive Expiratory Pressure

Independent Airway Clearance Device Easy for children and adults Patient's will take in a deep breath and then begin to breathe into a device which offers resistance to their exhalation. This causes mobilization of secretions. Most cost effective Put in purses and work with these Flutter valve and acapella-can turn acapella What airway clearance device is this?

High Frequency Chest Wall Oscillation

Independent airway clearance device. The Vest Vibrations and shaking motions to mimic CPT. Breathe to TLC, turn on the vest, and then forcefully exhale. A study by Darbee, Kanga, and Ohtake showed that the FEV1 improved with high frequency chest wall oscillation, and that the weight of mucus production was higher than PD, Percussion, or Vibration. Downside there can be a drop in SpO2. Cost $10,000 Can do self if can afford it Lay in different positions Can get mucus plug What airway clearance device is this?

BPAP and CPAP (CPAP for less severe pts and BPAP for more ill but absolute contraindication is altered mental status-intubate)

Indications: Exacerbations of chronic obstructive pulmonary disease (COPD) that are complicated by hypercapnic acidosis (arterial carbon dioxide tension [PaCO2] >45 mmHg or pH <7.30) Cardiogenic pulmonary edema Acute hypoxemic respiratory failure Contraindications: Cardiac or respiratory arrest *Inability to cooperate, protect the airway, or clear secretions-intubate altered mental status* Severely impaired consciousness Nonrespiratory organ failure that is acutely life threatening Facial surgery, trauma, or deformity High aspiration risk Prolonged duration of mechanical ventilation anticipated Recent esophageal anastomosis What noninvasive positive pressure ventilation is this?

Environmental

Indoor/Outdoor Allergens Occupational sensitizers Smoking/Second hand smoke Respiratory infections Diet What risk factors are these for asthma?

Pneumonia

Infection and inflammation in the alveoli or interstitium of the lung caused by microorganisms Two types Health Care-Associated Pneumonia (HCAP) Community Acquired Pneumonia (CAP) Primary cause of mortality from infectious disease Severity depends on the extent of the pneumonia Increasing incidence of multidrug resistant strains Widespread use of potent antibiotics Earlier transfer of patients out of acute care setting Outpatient IV antibiotic use General aging of the population

Tuberculosis

Infection due primarily to Mycobacterium tuberculosis. Other etiologies include: Mycobacterium bovis, Mycobacterium africanum, Mycobacterium caprae, and Mycobacterium microti, Mycobacterium pinnipedii Acid fast bacillus due to the organisms; high content of mycolic acid, long-chain fatty acids, and other cell-wall lipids

Asthma

Inflammation and narrowing of the airways leading to increased mucous production Causes symptoms of airway obstruction (i.e. dyspnea, wheezing, chest tightness, cough) Multifactorial Chronic lung disease Allergic and inflammatory dz Inherited tendency (i.e. atopy) Certain respiratory infections or exposure to allergens during early development of immune system

Asthma

Inflammation from trachea to terminal bronchioles Predominance in the bronchi Airway inflammation is associated with airway hyperresponsiveness Increased contractibility of surrounding smooth muscles Narrowing of the airways Intermittent airflow obstruction What etiology is this?

Bronchitis

Inflammation of the airways of the lungs Lower respiratory tract infection No evidence of pneumonia Occurs in the absence of COPD Typically occurs in the setting of a URI

Peurisy

Inflammation of the pleural lining Leads to (sharp) inspiratory chest pain Develops lung inflammation or infection: Pneumonia (viral or bacterial) TB Asbestos-related disease Certain cancers Chest trauma Pulmonary embolus What is this?

Anti-TNF agents

Infliximab significantly improves lung function when given to a patient with chronic disease already on cytotoxic drugs and steroids MOA: Monoclonal antibody against TNF, also binds to TNF on the surface of some cells that release TNF Treatment for sarcoidosis

Leukotriene Receptor Antagonists

Inhibit bronchoconstriction by working as a competitive receptor antagonist. Montelukast (Singulair)

Mast Cell Stabilizers

Inhibits histamine release from mast cells by stabilizing the mast cell membranes. Found in tissues throughout the body and mediate inflammatory responses. Cromolyn Sodium

Lung cancer

Initial findings are usually on plain chest radiograph Initial screening imaging study. *** If a tumor is visible, serial CXR can be used to monitor progression. What non-invasive diagnosis is this for?

False (Heparin)

Initial treatment of VTE is Coumadin-T or F?

Sarcoidosis

Initially presents with one or more of the following abnormalities: *Bilateral hilar adenopathy-big area of thickened hilum on the chest* Pulmonary reticular opacities Skin, joint, and/or eye lesions What is this?

Mast Cells

Initiates the acute bronchoconstriction responses to allergens and several other indirectly acting stimuli (i.e. exercise) Activated mucosal this are found at the airway surface in asthma patients and also in the airway smooth-muscle layer Not seen in normal subjects or patients with eosinophilic bronchitis These are activated by allergens through an IgE-dependent mechanism Binding of specific IgE to mast cells renders them more sensitive to activation by physical stimuli What pathophys is this with asthma?

Immunotherapy

Injected extracts of specific allergens May cause anaphylaxis What med is this for asthma?

Asthma

Inspiratory and expiratory wheezes and rhonchi Use of accessory muscles Tachypnea Tachycardia Allergic Rhinitis Eczema What physical exam is this for?

Pneumonia

Intrinsic Aspiration Hematogenous spread Contiguous extension from infected area Extrinsic Exposure to agent Exposure to pulmonary irritant Direct pulmonary injury Normal pulmonary defense mechanisms (cough reflex, mucocillary transport and pulmonary macrophages) usually defend against infection Susceptible hosts: defenses are suppressed or overwhelmed by invading organism Invading organism multiples and release damaging toxins causing inflammation and edema in lung parenchyma, resulting in accumulation and of cellular debris and exudates Lung tissue fills with exudates and fluid Goes from an airless state to a consolidated state Clinical PNA syndrome Triggered by the lower respiratory tract's inflammatory response to the pathogens Release of inflammatory mediators results in fever Chemokines stimulate the release of neutrophils, leading to peripheral leukocytosis and increased secretions Inflammatory mediators create a localized alveolar capillary leak Erythrocytes can cross the alveolar capillary membrane resulting in hemoptysis Radiographic infiltrate Rales on auscultation Hypoxemia from alveolar filling All of these findings together cause dyspnea Increased respiratory drive --- respiratory alkalosis What pathophys is this for?

Mediastinoscopy

Invasive method of sampling lymph nodes of the mediastinum. Useful in determining the need for surgical resection. What invasive testing is this with lung cancer?

UPPP

Involves resection of the uvula, redundant retrolingual soft tissue and palatine tonsillar tissue UPPP appears to achieve a surgical cure (defined as AHI ˂ 5 events per hour of sleep) in only a minority of patients and may compromise CPAP therapy by promoting mouth leaking and reducing the amount of pressure tolerated by patients

Asbestosis

Irregular or linear opacities that usually are first noted in the lower lung fields are the chest radiographic hallmark of what?

Chronic Obstructive Pulmonary Disease

Irreversible (not asthma) Progressive Obstruction of airflow Elevated inflammatory response Systemic manifestations This definition does not use the terms chronic bronchitis and emphysema and excludes asthma (reversible airflow limitation). May be partially reversible if caught early and treated aggressively. What is this?

Yes

Is TB reportable to the health department?

Tuberculosis

Is a bacillus with no cell envelope Is transmitted by droplets (coughing, sneezing, spitting), which dry rapidly and stay suspended in the air for several hours Single bacterium can transmit the infection. If not defeated by host immunity, invades macrophages within the alveolar interstitium. This results in cell death and the subsequent release of inflammatory markers (cytokines and chemokines) Exogenous factors Latent is walled off

MRI

Is most useful when evaluating for spinal pathology. More sensitive than CT in defining intracranial pathology. What lab imaging is this with lung cancer?

Yes

Is there a genetic predisposition with asthma?

Latent TB

Isoniazid 9 months, daily use Preferred treatment for patients with HIV, children 2-11, and pregnant females Isoniazid and Rifapentine 3 months, once weekly Patients older than 12 years NOT for Younger than age 2 years HIV positive taking antiretroviral treatment Presumed infection with INH or RIF-resistant M. tuberculosis Pregnant women Rifampin 4 months, daily use What is this treatment for?

Sleep hygiene

Keep sleep times consistent Darken room Use bedroom for sleep only Limit electronics in bedroom Maximize daytime activities Limit late-day caffeine, alcohol and nicotine intake What is this?

Additional therapy

LABAs should only be used as what for patients with asthma who are currently taking but are not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid.

Pneumothorax

Laboratory ABG's- hypoxemia Imaging CXR (confirms pneumothorax) Absence of lung markings Presence of a pleural stripe. A linear shadow of visceral pleura Mediastinal shift toward the contralateral lung. Small pleural effusion US -also reliable for diagnosis, may be quicker if bedside What testing is this for?

Pleurisy

Labored Breathing Cough Pleural friction rub Decreased Oxygen Saturation Cyanosis Dullness to percussion Fever (depending on cause) What PE is this for?

PE

Labored Breathing Shortness of Breath Cough Fever Hemoptysis Wheezing or crackles Tachycardia Cyanosis 3rd or 4th heart sound Pleural friction rub Leg Swelling/tenderness/+Homan's sign What possible symptoms are these for?

Histoplasmosis

Large inoculum exposure, or immuno-suppresed individuals develop a severe and potentially fatal pulmonary disease What is this with?

OSA (other surgical procedures)

Laser assisted and radiofrequency ablation are less invasive variants of UPPP Septoplasty, rhinoplasty, nasal turbinate reduction, nasal polypectomy, palatal advancement pharyngoplasty, tonsillectomy, adenoidectomy, tongue reduction etc, etc To the point: Clinical trials have failed to consistently demonstrate benefit from surgical therapy So surgery reserved for select pts only with the exception of the pt with an easily corrected obstructing lesion where surgery is the first-line therapy What is this used for?

DVT

Leg Unilateral swelling >1.5 cm difference Tender + Homan's Sign Calf Pain on dorsiflexion Red Warm Palpable venous cord Fever Risk factors are a better predictor than physical exam! What symptoms is this for?

Intermittent

Less than 2 days/week symptoms Less than 2x/month nighttime awakening Less than 2 days/wk short-acting B agonist No interference with normal activity Norm FEV1 btw excerbations FEV1 over 80% FEV1/FVC normal What severity is this with asthma?

Histoplasmosis

Less than 5 % develop symptomatic disease Prodromal symptoms - fever, cough, headache, malaise, myalgias, anorexia, and chest pain. These usually develop at 2-4 weeks. Chest pain is usually induced by respirations and often a 'pleuritic' pain. Coryza-snotty nose and pharyngitis should raise the suspicion of an alternative diagnosis What clinical findings is this for?

High risk Less symptoms (Group C)

Less than 50% predicted with post bronchodilator FEV1 Exacerbated more than 2 years Moderate symptoms What is this on the combined COPD assessment scale?

High risk More symptoms (Group D)

Less than 50% predicted with post bronchodilator FEV1 Exacerbated more than 2 years Severe symptoms What is this on the combined COPD assessment scale?

Tension pneumothorax

Life threatening EMERGENCY Rapid Rise in + pleural pressure Pressure in chest cavity > lung Pressure compresses the mediastinum, decreasing venous return to the heart Cardiac output drops, reducing venous return Hypoxemia SHOCK, DEATH What is this?

Tension

Life-threatening, Caused by a worsening pneumothorax What type of pneumothorax is this?

Lung cancer

Little has changed in the treatment of small cell carcinoma over the last two decades. 5 year Survival is virtually unchanged. Chemotherapy research is aimed at angiogenesis blockade. Not for curing for symptom control What treatment is this associated with?

Gram negative organisms

Long term care residents with pneumonia have what bacteria?

Pulmonary Complaints

Look first: Any chest wall deformaties Retractions ↑WOB-work of breathing Respiratory pattern Cyanosis Tracheal Deviation? Auscultation Adventitious Sounds-wheezes, rales, ronchi Percussion Resonant Hyperresonant-COPD Dull Palpation Tactile Fremitus (vibration) What is this physical exam?

Silhouette Sign

Loss of a normal lung/soft tissue interface or "silhouette" caused by any pathology which either replaces or displaces normal air filled lung (mass or fluid) Commonly applied to heart, mediastinum, chest wall and diaphragm Right lower lobe consolidation may obliterate part or all of the right hemidiaphragm, but the right cardiac border would still be clearly defined due to normal aeration of the adjacent middle lobe.

Venturi Mask

Lots of Pieces Mixes 100% O2 with Room Air (21% O2) Different entrainment pieces allow different FiO2's Delivers between 24-50% FiO2 Different flow rates are needed for different entrainment devices.

Rhonchi

Low pitched breath sound that has a snoring quality to it.

Transudate

Low protein & LDH All tests within a normal range What pleural fluid is this?

DLCO

Lung Diffusion Capacity for Carbon Monoxide Evaluates for Parenchymal Lung Disease Patient inhales to vital capacity, then holds their breath for 10 seconds before exhaling completely Abnormal Hemoglobin levels affect this?

Lung Biopsy

Lung biopsy is the most effective method for confirming the diagnosis and assessing disease activity Biopsy should be obtained before the initiation of treatment Avoids confusion and anxiety later in the clinical course if the patient does not respond to therapy or experiences serious side effects from it Fiberoptic bronchoscopy with multiple transbronchial lung biopsies (4-8 biopsy samples) is the initial procedure of choice

Asbestosis

Lung cancer 15-19 years between first exposure and development of disease Risk of disease is higher in those that work with the product, not those that manufacture the product Commonly associated with smoking Mesothelioma Tumors associated with both pleural and peritoneal areas Does not appear to be associated with smoking Remote short-term exposures have been associated with this What complications are these with?

Systemic Lupus Erythematosus

Lung disease is common pathology in what. Especially pleuritis, with or without effusion. What CT is this associated with ILD?

Histoplasmosis

Lungs are the primary source of infection The conidia (fungal fragments) are inhaled. Induce a local, patchy, disease if the fungus invades the lung defenses. What is this?

Chylous Pleural Effusion

Lymph in the pleural space Etiology: Injury to the thoracic duct by laceration, obstruction (tumor) Lab: + Triglycerides Tx. Chest Tube NPO, TPN What is this?

Dornase Alfa

MOA decrease adhesiveness and viscosity of the mucus through reduction of airway inflammation by neutrophils, and reducing the size of DNA Synergistic effect with Tobramycin Large portions of polymerized DNA in the mucus of CF patients binds to the Tobramycin and prevents it from effectively reaching the bacteria, however with the co administration Dornase Alfa the polymerized DNA is now smaller and less binding to the Tobramycin. What mucoactive agent is this?

N-acetylcysteine (NAC)

MOA decrease the viscous and elastic nature of mucus in the airways. NAC works to break down MUCIN Cannot be co administered with Tobramycin-used with pseudomonas Always give with bronchodilator What mucoactive agent is this?

Denufosol

MOA it is an ion-transport modifiers. Works on the luminal surface of the airways. Inhibits absorption of sodium as well as stimulates the secretion of chloride out of the epithelial cell layers. Drawback is cough and bronchospasm. What mucoactive agent is this?

CPAP

Machine with hose attached to mask, nasal pillow Pressure used is determined during sleep study Pressures are measured in centimeters of water and can range from *3 - 20cm* (Most require 6 - 12cm) Airflow acts as a pneumatic splint that keeps the pharyngeal airway open In general, heavier patients with short, thick necks and severe apnea require higher pressures *Not curative* Must be used whenever sleeping Nocturnally Naptime This usage should be monitored objectively to help assure utilization (these machines contain meters that record use) *Self reported use does not correlate with actual use and is therefore unreliable* Initial this follow-up is recommended yearly or as needed to address: Mask Machine Usage issues Many patients have difficulty tolerating therapy Even one night without this may mitigate the benefits of the therapy Complaints: "I feel a rush of air when I exhale" "It feels like too much pressure" "The mask bothers me" What device is this?

Histoplasmosis

Macrophages ingest the fungal elements and disseminate throughout the immune system. Patients usually remain asymptomatic during the 10-14 days it takes to develop immunity, unless immuno-suppression exists. T-lymphocytes activate the macrophages to kill the fungi and the infection is controlled Both TNF and Interferon -gamma are thought to play large roles in defending against H. capsulatum. Illness progresses in the patients that do not develop cellular immunity. What is this?

Fluid management

Maintaining a low left atrial filling pressure minimizes pulmonary edema and prevents further decrements in arterial oxygenation and lung compliance Improves pulmonary mechanics Shortens ICU stay and the duration of mechanical ventilation Aggressive attempts to reduce left atrial filling pressures with fluid restriction and diuretics should be an important aspect of ARDS management What treatment is this with ARDS?

Pancreatic enzyme insufficiency in CF

Malabsorption of fat soluble vitamins E and K especially Beta Cells functionality decrease with aging Insulin Resistance Hyperglycemia What presentation is this?

GU symptoms of CF

Male Sterility due to Absent Vas Deferens or Azoospermic Not all males but around 90% Females can carry viable pregnancies but thick tenacious mucus sometimes makes conceiving difficult What presentation is this?

Hypercoagulable state

Malignancy Prego Oestrogen therapy TRauma or surgery IBD Nephrotic syndrome Sepsis Thrombophilia What part of Virchow's triad is this?

Non small cell carcinoid tumors

Malignant neuroendocrine glandular tumors. Grow slowly-also prostate, heart cancer Rarely metsastisize Difficult to classify DIPNECH - Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia TYPICAL ATYPICAL LARGE

Admit

Marked increase in intensity of symptoms New onset of cyanosis, edema, arrythmia, hypoxemia, hypercapnia, change in mental status, or other symptoms No treatment response Inadequate home care, or inability to maintain nutrition/hydration High-risk comorbid conditions Uncertain diagnosis Old Age What should you do?

B

Marked tachycardia and hypotension are most suggestive of which pulmonary disorder? A. Spontaneous pneumothorax B. Tension pneumothorax C. Traumatic pneumothorax D. Pleural effusion

Pure, central sleep apnea (is uncommon)

May be an isolated finding May occur in patients with primary alveolar hypoventilation from stroke What sleep apnea is this?

Lung cancer

May complains of: *Cough (tussis) (50-75%)* Fatigue (malaise) Weight loss (cachexia) Appetite loss (anorexia) *Shortness of breath (Dyspnea) (25%)* *Coughing blood (Hemoptysis) (25-50%)* Hoarseness (dysphonia) Bone pain (ostealgia) Difficulty swallowing (Dysphagia) RUQ pain Neurological complaints *Chest pain (pleurisy, angina, pectalgia) (20%)* 1/2 pack in lifetime 50% increase for aortic anureysm What history is this for?

Subacute (Weeks to months)

May occur in all ILDs, but more common in sarcoidosis, drug-induced ILD, alveolar hemorrhage, cryptogenic organizing pneumonia (COP), and in SLE related pneumonia

Corticosteroid treatment for COPD

May reduce the frequency of exacerbations and increase functional status Inhaled Glucocorticoids - fluticasone (FLOVENT), budesonide No effect on decline in lung function or mortality Not first line therapy in stable patients Oral corticosteriods used in exacerbations

Incentive Spirometer

Measures Inspiratory Volume Commonly used Post Op Commonly used in Pneumonia Commonly used in bedbound patient Works to keep alveoli inflated and prevent atelectasis,****and to prevent the complications of atelectasis. Prevents pneumonia Reminds them to breathe deep to prevent atelectasis and pneumonia Wake up breathe with it Before go to sleep breathe with it

Spirometry

Measures airflow in: volume vs. time Inexpensive Easy to do What is this for?

Tension pneumothorax

Mechanical ventilation The pressure used to deliver breaths 'pops' parenchyma Then forces air into the pleural space Preexisting pneumothorax Classic Patient: Pt. in ICU on ventilation What risk factor is this for?

Expectorants

Medication that promotes clearance of mucous. It increases fluid in the pulmonary tract and therefore reduces the viscosity of secretions. Guafenesin

Decongestants

Medications that reduce congestion and swelling. Pseudoephedrine Phenylephrine Oxymetazoline

Antitussives

Medications uses to suppress coughs. Codeine Dectromethorphan Robitussin Benzonatate (tessalon Perles)

Short-acting bronchodilators

Metered dose inhalers Get laminar flow-2 finger tips from device to mouth then breathe it in Proventil, ventoin, proair HFA, maxair, combivent, xopenex

Pontiac Fever

Mild form of Legionella infection Symptoms: fever, malaise, chills, fatigue, headache, and no respiratory complaints Chest radiograph is unrevealing Mean incubation period is 36 hours Much shorter than the 2 to 10 days for Legionnaires' disease Usually self-limited and does not require treatment

Antimicrobials

Minocycline is useful for cutaneous sarcoidosis Treatment for sarcoidosis

Rheumatoid Arthritis

More common in men Pleurisy is most common respiratory finding. ILD in approx. 20% of RA population Rare - upper airway obstruction secondary to crico- arytenoid arthritis. What CT is this w/ILD?

False (women have smaller chest and lungs-smoking impacts them more)

More men have COPD than women-T or F

False (asymptomatic)

Most PE patients have SOB and CP-true or false?

Pulmonary angiogram

Most Sensitive and specific Low morbidity and mortality Performed in a Cath Lab Contrast via femoral vein Positive result Cut-off of flow intraluminal filling defect Negative test excludes PE What lab test is this?

Dyspnea

Most common causes: obstructive airway disease, asthma, COPD, HF/cardiogenic pulmonary edema, IHD, unstable angina and MI, pneumonia, psychogenic Most immediately life-threatening: Upper airway obstruction: foreign body, angioedema, hemorrhage, tension pneumothorax, PE, neuromuscular weakness: myasthenia gravis, Gullian-Barre syndrome, botulism, fat embolism What differential diagnosis is this for?

Idiopathic Pulmonary Fibrosis

Most common form of Idiopathic Interstitial Pneumonia Very poor outcome, does not respond well to treatment Clinical presentation: Exertional Dyspnea Non-productive cough Inspiratory crackles +/- Digital clubbing

Streptococcus Pneumoniae

Most common pathogen in CAP Aerobic, gram positive diplococci Colonizes the nasopharynx and is aspirated Presentation Rapid onset of shaking chills (rigors) with productive cough and fever Pt will have rust-colored sputum Presentation may be subacute in the elderly or immunocompromised 1 in 4 patients with pneumonia will be bacteremic Complications empyema, sepsis, meningitis 15-20% of isolates are intermediately resistant to Penicillin (PCN); 2-5% of isolates are highly resistant Regional resistance patterns for penicillin and macrolides should be considered for empiric therapy PCN sensitive strain--beta lactam antibiotics (PCN, PCN derivative, or second generation cephalosporins)

Adenocarcinoma

Most common type of lung cancer 35-40% of cases. *Common in non-smoker cancers **** Usually a peripheral tumor that metastasizes to distant organs. The liver most commonly Usually glandular in origin or produces Mucin Adenosquamous carcinoma Mixed tumor of squamous and glandular cells Bronchoalveolar carcinoma Demonstrate a lepedic growth pattern. (growth along the intact alveoli) Mucinous adenocarcinoma - non BAC type Low association with cigarette smoking Production of mucin (glandular) Papillary Classified separately because of poor prognosis in association with branching papillae. Fetal Rare asymptomatic tumors - originally described based on their similarity in appearance to the fetal lung. Better prognosis than typical

Obstructive sleep apnea

Most commonly patients are obese Nasal obstruction, deviated septum Oropharynx frequently narrowed by excessive soft tissue folds, large tonsils Thick, "bull neck" Often fatigued, irritable What physical exam findings is this for?

Histoplasmosis

Most infections are self-limiting and require no treatment. Amphotericin B - reserved for severe or refractory disease due to its potential toxicity. Itraconazole - (Sporanox®) highly effective, good for outpatient Tx. Cure rates as high as 81%. Drug levels monitored at two weeks. Fluconazole (Diflucan) - Not active against H. capsulatum invitro, poor outcomes in clinical setting, and may increase resistance. Posaconazole (Noxafil) - Highly active against H. capsulatum in vitro. Reserved as salvage therapy for failed regimens Voriconazole (Vfend) - reserved for serious refractory disease. What is this the treatment for?

Normal

Most patients with PE have a what pulse oximetry Most patients with an abnormal pulse oximetry do not have a PE?

PE

Most- the lower extremities Deep calf veins (10-20%) Iliofemoral (70-80%) May also originate in: Heart Pelvis Kidney Upper extremity If venous catheter Paget-Schrotter Syndrome (DVT in young athletes) Thoracic Outlet Syndrome What origin is this for?

Airway Remodeling

Mucous gland hyperplasia Smooth Muscle hypertrophy Fibrosis Goblet cell formation Angiogenesis What pathophys is this with asthma?

Atypical CAP

Mycoplasma pneumoniae is the most common cause Gradual Onset (days-weeks) Clinical Features: nonproductive cough, myalgia, fatigue, low grade fever, mild pulmonary sx's which are self limited and occurring in young otherwise healthy adult Lab Testing: stain or sputum culture, cbc (WBC usually normal), CXR (segmental unilateral lower lung infiltrates or diffuse infiltrates)

Tobramycin (used for pseudomonas)

N-acetylcysteine (NAC) cannot be co administered with what?

CPAP

Nasal symptoms (most common complaint) Dryness Congestion Rhinorrhea Air leakage from mask Claustrophobia Skin abrasions Conjunctivitis What device causes these minor complications?

Sarcoidosis

Nervous system effects: CN effects, seizures, cognitive changes Palpable peripheral lymphadenopathy Cervical, epitrochlear, axillary and inguinal Splenomegaly and bone marrow changes Cardiac: Arrhythmias and CHF Skin lesions (erythema nodosum, maculopapular lesions, hyper and hypopigmented lesions, keloid formation, and lupus pernio) Swollen painful joints (Myalgias) Uveitis on retinal exam-painful spasm of eye Change in liver function Parotid gland enlargement (mimics mumps) Renal disease: Hyercalcemia/hypercalciuria, nephritis What clinical presentation is this for?

Pseudomonas, Staph aureus, Aspergillus

Neutropenia is assciated with what bacteria with pneumonia?

Primary spontaneous

No lung Disease, sudden, no inciting event What pneumothorax type is this?

Primary spontaneous Pneumothorax

No underlying lung disease No trauma Age 20's Healthy Tall Thin Male 90% are smokers Classic PSP Patient: Tall, thin, 21 yr old, male smoker What presentation is this?

Interstitial Lung Disease

Non malignant, non infectious, pathology of the interstitium that results in fibrosis of the affected tissue. Does NOT affect the proximal airways.

Smoking

Noncardiac vascular diseases Stroke Aortic aneurysm Other cancers Bladder Cervical Esophageal, kidney Laryngeal Oropharyngeal Pancreatic Stomach Throat Acute myelocytic leukemia Pneumonia Risk factor for other conditions URIs Cataracts Infertility Premature menopause Peptic ulcer disease Osteoporosis Periodontitis What are these less common serious disorders from?

Large cell carcinoma

Nonsquamous, non glandular malignancies of epithelial tissue (by light microscopy). Electron microscopy may demonstrate squamous, glandular or neuroendocrine differentiation. Diagnosis of exclusion (Does not fall into any other category) Presents as large peripheral mass with necrosis. Grows in and cells die Metastasizes early. Tumor on stomach hurts to eat and don't eat as much

Fluconazole (Diflucan)

Not active against H. capsulatum invitro, poor outcomes in clinical setting, and may increase resistance. What med is this with histoplasmosis?

Open surgical biopsy

Not as prevalent with aforementioned modalities. Biopsy of ectopic sites Lymph nodes, liver, pleura, pericardium, etc.) What invasive test is this with lung cancer?

Mannitol

Not specifically approved to treat CF patients. MOA is that it creates an osmotic gradient in the airway which allows for hydration. It also appears to have a double affect on expectoration of mucus by causing the mediators of cilia in the airway to beat at a higher frequency than they normally would causing an increase in their secretion. Drawback it can cause growth in bacteria in the airway due to Carbon in its make up. What mucoactive agent is this?

Bone scintigraphy

Nuclear bone scan Reveal metastatic lesions Useful with bone pain or elevated calcium and or alkaline phosphatase levels. What lab test is this with lung cancer?

Obstructive sleep apnea

Obese, middle-aged men ?????? Systemic hypertension very common Patients complain of: Snoring and daytime sleepiness are most common Waking with a sensation of choking, gasping or smothering Nocturnal angina Cognitive impairment Headaches (often AM) Weight gain Impotence Thick neck greater than 19 in men and 17 in women Partners complain of: Loud cyclical snoring Breath cessation Witnessed apneas Restlessness Thrashing movements of the extremities Personality changes Poor judgment Depression Intellectual impairment Work-related problems Angina-not getting enough oxygen What clinical manifestation is this?

Chlamydia Pneumoniae

Obligate Intracellular Bacteria: Gram (-) Rod Common in elderly Patients Reinfection Possible Usually asymptomatic-mildly symptomatic Gradual Onset of Symptoms Causes Pharyngitis/Laryngitis/Sinusitis Airway Hypereactivity C. pneumoniae infect primarily epithelial cells of the mucous membranes or the lungs They rarely cause invasive, disseminated infections C. pneumoniae causes upper and lower respiratory tract infections, especially bronchitis and pneumonia, in young adults Infection with C. pneumoniae usually presents with a normal white blood cell count, and the chest radiograph typically shows one patchy area of sub segmental infiltration

PE

Occlusion of pulmonary arteries by thrombi, air, fat or other particle

Sarcoidosis

Occupational and environmental exposures Kveim Siltzbach reagent Infectious etiology - Mycobacterium Major histocompatibility component (MHC)-presents antigens to the body and other genes T cell abnormalities/receptor abnormalities What possible etiologies are these for?

Coal Worker's Pneumoconiosis

Occupational exposure to coal dust can lead to CWP Simple radiographically identified CWP is seen in ~10% of all coal miners and in as many as 50% of anthracite miners with more than 20 years of work on the coal face With prolonged exposure to coal dust (i.e., 15-20 years), small, rounded opacities similar to those of silicosis may develop As in silicosis, the presence of these nodules usually is not associated with pulmonary impairment Coal dust can also cause chronic bronchitis and COPD The effects of coal dust are additive to those of cigarette smoking What condition is this?

Paraneoplastic syndrome

Occurs in 15-20% of lung cancers Most common in small cell cancers Secondary pathology resulting from the mere presence of cancer cells. These cells often excrete hormones or inflammatory markers that result in an autoimmune response against the tumor. Endocrine function outside normal loop What is this?

Silicosis

Often at greater risk of acquiring Mycobacterium tuberculosis, atypical mycobacteria, and fungi secondary to cytotoxic effect of silica on alveolar macrophages Another potential clinical complication of silicosis is autoimmune connective tissue disorders such as rheumatoid arthritis and scleroderma Considered a probable lung carcinogen What complication is this for?

Hypersensitivity Pneumonitis

Often relates to history Chest radiograph: Nonspecific: Normal to ill defined micronodular opacities or ground glass opacities Findings will resolve with removal of the offending agent Computed tomography: Not routinely done with acute phase Ground glass airspace opacities are characteristic in subacute Bronchiectasis can be seen in chronic HP Honeycombing may be seen in subpleural space, but bases are typically spared What diagnosis is this for?

Pleural Effusion

On average, > 150 ml must be present for a pleural effusion to be detected on an erect chest X-ray Smaller volumes ( > 75 ml) may be detected on a decubitus view, with the patient lying on the side of the suspected effusion

New black box warning for long acting B agonists in asthma

Once asthma control is achieved and maintained, patients should be assessed at regular intervals and step down therapy should begin (e.g., discontinue LABA), if possible without loss of asthma control, and the patient should continue to be treated with a long-term asthma control medication, such as an inhaled corticosteroid. Pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid should use a combination product containing both an inhaled corticosteroid and a LABA, to ensure adherence with both medications. What is this?

Asthma

Onset to early-life .Symptoms vary, day to day.Worse at night & exercise or trigger.Allergy and/or eczema also present.Family history of asthma.Reversible What is this?

COPD

Onset to mid-life Symptoms slowly progress Smoking history Worse with exercise Irreversible What is this?

Air Pollution

Outdoor/indoor pollution May trigger asthma symptoms i.e. Nitrogen oxide from cooking stoves, vehicle exhaust, exposure to passive cigarette smoke Maternal smoking increases asthma risk May relate to increased risk of respiratory infections

Mild

Over 2 days/wk but not daily-symptoms 3-4X a month-nighttime awakenings Over 2 days/wk but not daily and not more than 1X on any day-short-acting B agonist Minor limitation FEV1 over 80% predicted FEV1/FVC norm What severity is this with asthma?

IV 55 88%

Oxygen Used in what stage COPD Or when PaO2 <what mmHg. Or hemoglobin oxygen saturation (SaO2) < what on room air at rest.?

Oxygen therapy for COPD

Oxygen is the only treatment documented to improve the natural history of COPD! - longer survival - reduced hospitalization - better quality of life Survival is proportionate to the number of hours per day oxygen is administered Used in Stage IV COPD Or when PaO2 <55 mmHg. Or hemoglobin oxygen saturation (SaO2) < 88% on room air at rest.

New treatment options

PDE-4 inhibitors- Phosphodiesterase 4 inhibitors (Cilomilast, roflomislast) Promote airway smooth muscle relaxation For COPD with hx of exacerbations Benefit modest, still being studied

Spiral (Helical) Chest CT

PE: Filling defects Vessel occlusion Segmental avascularity Prolonged arterial filling Tortuous tapering peripheral vessels Sensitivity: 83% of pts. With PE have a positive CT Specificity: 96% of pts. Without PE have a negative CT Add venous imaging sensitivity- 90%/specificity- 97% What lab test is this?

Acute Bronchitis

PE: variable (i.e. wheezing, rhonchi, normal exam) Differential: pneumonia, asthma, influenza, sinusitis, pharyngitis, COPD, alpha-1 antitrypsin deficiency, GERD, CHF, PE, ACE use What condition is this?

Acute Severe Asthma

PEF <40% predicted indicates severe obstruction Severe hypoxia (Ox saturation <=95% despite high flow O2 treatment by nonrebreather mask) portends imminent respiratory arrest Arterial Blood Gas (ABG) Hypoxemia PCO2 low secondary to hyperventilation If rising, this is an indication of impending respiratory failure CXR Pneumonia or pneumothorax If diagnosis is in doubt High risk patients IV drug abusers, immunosuppressed, chronic pulmonary disease, CHF What assessment is this for?

Asbestosis

PFT testing reveals RESTRICTIVE pattern Treatment is mainly supportive Is a known precursor or primary risk factor for primary pulmonary neoplasm What treatment is this for?

Restrictive

PFT testing reveals what pattern with asbestosis?

restrictive

PFTs characteristically reveal a what pattern associated with a reduction in the DLCO and reduced 6 mile walk test with sarcoidosis?

Pulse Oximetry

PaO2 measurement requires an arterial puncture, but SpO2 measurement is given by pulse oximetry an only requires a clip onto a pt's finger to measure the O2 saturation Measures the absorption of light by two different wavelengths in hemaglobin-hands ice cold-have to have circulation. How and when is it used? Noninvasive For pt's that require frequent monitoring. When an ABG sample would not be appropriate. LIMITATIONS Can give you false readings!!!! Low Cardiac Output Vasoconstriction Hypothermia Carbon Monoxide Poisoning (where cherry red can be dead)-binds stronger to hemoglobin-100% SpO2 not O2 is carbon monoxide Methemaglobin-meth cases-child got into chemicals-chocolate milk blood and SpO2 is 100%

Pack years

Pack year is 20 cigs (1pack) daily for 1 year. Number of packs per day x number of years smoked Or Number of cigs per day/20 x years What calculation is this?

Endobronchial TB

Pathognomic chest x-ray demonstrates upper lobe infiltrate and CAVITY. There may be ipsilateral spread to the lower lobe and contralateral spread to the lower lobe. demonstrates atelectasis. Usually right middle lobe.

ILD

Patients with connective tissue disorders and pulmonary diseases that do not improve with 'traditional treatment' need evaluation for what or other non-infectious pathology?

Hospitalization

Peak flow <40% of predicted Patients with peak flow 40-70% predicted, new onset asthma, multiple prior hospitalizations/ED visits for asthma, use of oral glucocorticoids at time of presentation with acute deterioration, or complicating psychosocial difficulties Patients with PEF above 70% of normal can typically continue their care at home What does this indicate?

Traumatic

Penetrating chest injury Blunt chest injury What pneumothorax is this?

FEV1/FVC Ratio

Percentage of forced vital capacity and forced expiratory volume in one second

FEV6

Percentage of lung capacity exhaled in 6 seconds 80% of volume should be exhaled within 6 seconds

CXR

Performed with the VQ scan Most are nonspecific and insensitive for PE What PE ancillary test is this for?

TB

Physical Examination Findings may be absent, but include: Rales/rhonchi Decreased Tactile Fremitus-increased is consolidation Increased whispered pectoriloquy Clubbing Dermatologic manifestations. What is this?

Histoplasmosis

Physical exam - usually non-specific CXR - hilar and mediastinal adenopathy Patchy or nodular infiltrates Usually not cavitary Infiltrates may be diffuse Occasional pleural effusions are present. What are the clinical findings for this?

Thoracentesis

Pleural effusion aspirate may contain tumor cells. Looking for malignant pleural effusion. This is a bad prognostic indicator. What invasive lab testing is this with lung cancer?

Pleurisy

Pleuritic CP. "It hurts when I breathe" Worse with breathing, cough, or movement. Possibly referred to the shoulder. Coughing Shortness of breath Tachypnea What symptoms is this for?

Asthma deaths

Poorly controlled disease with frequent use of bronchodilator inhaler Lack of or poor compliance with ICS therapy Previous admissions to hospital with near-fatal asthma What do these major risk factors cause?

Legionella

Poorly staining gram negative rod Facultatively intracellular Likes water Typical candidate for Legionnaries' disease An older man who smokes and consumes substantial amounts of alcohol Patients with AIDS, cancer, or transplants (especially renal transplants) or patients being treated with corticosteroids are predisposed to Legionella pneumonia Indicates that cell-mediated immunity is the most important defense mechanism Despite airborne transmission of the organism, person-to-person spread does not occur, as shown by the failure of secondary cases to occur in close contacts of patients Clinical picture: Variable From a mild influenza-like illness to a severe pneumonia accompanied by fever, HA, mental confusion, non bloody diarrhea, proteinuria, and microscopic hematuria Often look for urinary antigen in dx Although cough is a prominent symptom, sputum is frequently scanty and nonpurulent Hyponatremia (serum sodium ≤ 130 mEq/L) is an important laboratory finding that occurs more often in Legionella pneumonia than in pneumonia caused by other bacteria Most cases resolve spontaneously in 7 to 10 days, but in older or immunocompromised patients, the infection can be fatal

5mm

Positive at what and greater if: HIV + Recent contact with TB patient Organ transplant recipient Fibrolytic lesions consistent with old TB on XR Immunosuppressed patients High risk pulmonary disease Dialysis On TB skin test?

Inhaled corticosteroids

Potent anti-inflammatory. Inhibits inflammatory cells and release of inflammatory mediators (histamine, eicosanoids, cytokines). Beclomethasone - QVAR Budesonide - Pulmicort Ciclesonide - Alvesco Fluticasone - Flovent Mometasone - asmanex Salmeterol/Fluticasone - Advair combo LABA and Corticosteroid Budesonide/Formoterol - Symbicort Combo Mometasone/Formoterol - Dulera Combo

Unfractionated Heparin

Preferred in: Hypotension Increased bleed risk (short acting, easy to reverse) If thrombolysis is being considered Obese Renal failure Continuous IV infusion 80 units/kg bolus followed by 18 units/kg/hour. Titrate q 4-6 hours to goal aPTT (50-70) Monitor aPTT, hematocrit, platelet count Until INR is 2.0 Antidote *protamine sulfate* What treatment is this with PE?

Step 5

Preferred-High dose ICS + LABA nd consider omalizumab for pts who have allergies What step is this for asthma?

Step 6

Preferred-high dose ICS + LABA + oral corticosteroid And Consider omalizumab for pts who have allergies What step is this?

Step 2

Preferred-low dose inhaled corticosteroids Alternative-cromolyn, LTRA, edocromil, or theophylline What step is this for asthma?

Step 3

Preferred-low dose inhaled corticosteroids + Long acting BA or medium-dose ICS Alternative-low dose ICS + either LTRA, theophylline, or zileuton What step is this for asthma?

Step 4

Preferred-medium dose inhaled cortiocosteroids+ LABA Alternative-low dose ICS + either LTRA, theophylline, or zileuton What step is this for asthma?

False positives

Pregnant or postpartum Patients Malignancy Advanced age > 80 years Hemorrhage AMI Hepatic Impairment Recent Surgery Sepsis CVA Collagen Vascular Disease This indicates what on a D-dimer?

Acute Severe Asthma/Status Asthmaticus

Presentation Increased chest tightness, wheezing, and dyspnea that are not relieved by their usual reliever inhaler Physical examination Increased ventilation, hyperinflation, and tachycardia Use of accessory muscles Brief, fragmented speech Cyanosis Inability to lie supine Profound diaphoresis Agitation

Hypersensitivity Pneumonitis

Presentation: Sudden onset of malaise and fatigue Fever/chills Cough Dyspnea Nausea with acute presentation Physical Examination: Bibasilar crackles Tachypnea/tachycardia Cyanosis Clubbing of digits with chronic presentation What condition is this?

Oxygen and hemostasis-give anticoag-do Well's criteria and PERC score to see PE risk Do spiral CT

Presentation: Hypotension and Right Ventricular failure To spite emergency care, pt. died in 2 hours Diagnosis did not occur until the following was found on autopsy= PE in lungs What could have been done to prevent death in this patient?

Intrapulmonary Pressure

Pressure in the (lungs) alveoli 760mmHg When this pressure falls below 760mmHg we have inspiration Boyles P1V1=P2V2

Intrapleural pressure

Pressure in the pleural cavity - 4mmHg (- negative pressure) This is always a negative pressure. It helps prevent collapse of the lungs.

D-dimer (pos-perform emergency bedside ultrasound for DVT-negative repeat 5-7 days and positive give anticoag and if d-dimer was neg then DVT excluded)

Pretest probability for DVT and low risk then what test should be ordered?

Emergency bedside ultrasound for DVT (neg obtain d-dimer and if neg DVT excluded, pos-repeat ultrasound 5-7 days or obtain confirmatory study) (If positive then give anticoag)

Pretest probability for DVT and moderate to high risk perform what?

COPD

Prevent progression Relieve symptoms Improve exercise tolerance Improve health status Prevent and treat complications/exacerbations Prevent or minimize side effects from treatment Reduce mortality What are these the goals for management?

VTE

Preventable Causes: IV Drug Abuse Smoking Obesity OCP's Diseases: MI Sepsis Malignancy Ulcerative Colitis Lupus Polycythemia Vera Myeloproliferative Disorder What acquired etiology is this for?

IVC Filter

Prevents emboli from getting to the lungs Complications Bleeding/Thrombosis Filter misplacement or erosion Perforation of the IVC wall Indicated for PE or prophylaxis if: Pt. has absolute contraindication to anticoagulation Recurrent PE despite therapy Severe bleeding from anticoagulation What PE treatment is this?

Oral Airway (J tube)

Prevents the tongue from occluding the hypopharynx or as a bite block during or after orotracheal intubation Only used in patients without a gag reflex What oxygen delivery airway adjunct is this?

Klebsiella pneumoniae

Produces lobar PNA similar to streptococcus Patchy bronchopneumonia and dense lobar consolidations Predilection for involvement of the posterior segment of the RUL Tendency to form an early abscess, empyema, cavitations What radiograph is this for?

Xanthines

Promotes bronchial smooth muscle relaxation. May play a role in inflammatory regulation. Theophylline

VTE

Protein C and S Deficiency Antithrombin Deficiency Antiphospholipid Syndrome Prothrombin 20210A Dysfibrinogenemia Factor XIII 34val Factor V Leiden What inherited etiology is this for?

Doxycycline, macrolides, fluoroquinolones, cephalosporins

Pt who is healthy and in no respiratory distress with no complications can be treated as outpatient with oral abx and supportive care What are the meds for pneumonia?

Hypersensitivity Pneumonitis

Pulmonary Function Tests: Either restrictive or obstructive can be present The pattern of PFT change is not useful in establishing the diagnosis of HP Obtaining PFTs is of use in characterizing the physiologic impairment of an individual patient and in gauging the response to antigen avoidance and/or corticosteroid therapy Treatment: Antigen avoidance Pharmacologic therapy not generally necessary Corticosteroids for 1-2 weeks with a 6 week taper What diagnosis and treatment is this for?

Caseating

Pulmonary TB: post-primary disease produces what pneumonia?

Pneumothorax

Pulmonary scarring Pulmonary edema Lung infarction Subcutaneous emphysema Hemopneumothorax Infection Hypoxemic respiratory failure Respiratory or cardiac arrest Bronchopulmonary fistula What complications is this for?

Respiratory Distress

Pulse oximetry should be used in order to disclose undetected oxygen desaturation states Noninvasive Reasonably accurate Readings may be difficult to obtain in patients with poor perfusion or cold sites of placement In selected patients, especially those with significant tachypnea or work of breathing, pulse oximetry may underestimate degree of distress, and it provides no indication as to the adequacy of ventilation In such patients, it may be necessary to obtain arterial blood gas levels to help measure the severity and nature of the ventilation or oxygenation disturbance Take fingernail polish off What PE is this for?

Empymic Pleural Effusion

Pus in the pleural space Etiology: Pneumonia, lung abscess Fluid PH is <7.2 Tx. Chest Tube & Abx. What is this?

Radiotherapy

Radical radiotherapy - High intensity for the purposes of 'curing.' CHART - continuous hyperfractionated accelerated radiotherapy High doses in short time periods Brachytherapy (localized) - given directly inside the airway to target obstructing lesions-in prostate cancer-put chemo capsules in there to diminish cancer cells that did not clean out-good for slow growing cancers What is this?

Pseudomonas aeruginosa

Radiographic findings of this pneumonia are variable and no single finding is predictive or characteristic Diffuse bilateral infiltrates, with or without pleural effusion, may be present Multifocal airspace consolidation Nodular infiltrates, tree-in-bud opacities, and necrosis What radiograph finding is this?

Silicosis

Radiography often shows profuse miliary-all about infiltration or consolidation, and there is characteristic on CT called "Crazy paving." What is this for?

Crazy paving

Radiography often shows profuse miliary-all about infiltration or consolidation, and there is characteristic on CT called what for silicosis?

Regular Nasal Cannula

Ranges from 1 L/M to 6 L/M Room Air 21% O2 Each 1 L increase gives an approx. 3% increase of FiO2 Roughly 1 = 24% 2 = 28% 3 = 32% 4 = 36% 5 = 40% 6 = 44%

High Flow Nasal Cannula

Ranges from 6,8,10,12, and 15 L/M FiO2 from mid 50% to 75% Highly Variable Keep your pt comfortable and place humidity on these

Nicotine and Carbon Monoxide

Rapidly effects the cardiovascular system Nicotine raises blood pressure and heart rate Nicotine causes spasms in blood vessels Carbon monoxide interferes with oxygen delivery to cardiac (and other) tissues Also damages endothelium of blood vessels. Increases blood viscosity

Apical infiltrates

Reactivation TB has what on radiograph?

TB

Recent infection (<1 year) Fibrotic lesions Comorbidities and iatrogenic effects HIV, Silicosis, Renal failure with hemodialysis, Diabetes, IV drug use, Immunosuppressive treatments, Gastrectomy Tobacco smoking Malnutrition/severe underweight This are risk factors for active what?

Late Phase Reaction

Recruitment of inflammatory and immune cells (i.e. eosinophils, basophils, neutrophils, and helper, memory T cells) to sites of allergen exposure Recruitment of dendritic cells to inflammatory sites likely play important roles in mediating or modulating the response to allergen exposure Mediators released by these cells causes airway smooth muscle contraction Smooth muscle contraction largely reversible with Beta 2 agonists What phase reaction is this with pathophys with asthma?

Oral corticosteroids

Reduce and control inflammation in the airways. Use lowest possible dose for shortest time. Dexamethasone Methylprednisolone Prednisone Prednisolone

Simple spirometry

Reduced Forced Expiratory Volume (FEV1), Forced vital Capacity (FVC), FEV1/Forced Vital Capacity (FVC) ratio before and after inhaled short acting bronchodilator >10% increase in FEV1 after bronchodilator therapy is supportive of dx Reversibility is defined by a >12% and 200 mL increase in FEV1 or FVC 15 after an inhaled short acting Beta 2 agonist or in some patients by a 2-4 week trial of oral corticosteroids What test is this?

Secondary TB (post-primary disease)

Referred to as reactivation or what May result from endogenous reactivation of distant LTBI or recent infection (primary infection or reinfection). Usually localized to the apical and posterior segments of the upper lobes, where the substantially higher mean oxygen tension favors mycobacterial growth The superior segments of the lower lobes are also more frequently involved With cavity formation, liquefied necrotic contents are ultimately discharged into the airways and may undergo bronchogenic spread, resulting in satellite lesions within the lungs that may in turn undergo cavitation Produces caseating pneumonia

Occupational Exposures

Relatively common and may affect up to 10% of young adults Over 300 sensitizing agents have been identified Suspect occupational asthma when symptoms improve during weekends and holidays

Histoplasmosis

Relatively common mycotic infection. Caused by Histoplasma capsulatum Found worldwide, but most common in Central and North America, especially along the Mississippi and Ohio valleys Fungi lives in warm, moist, and acidic soil. Especially with contamination of bird or bat droppings / guano. Exposure is related to disturbance of the droppings / soil especially in an enclosed environment.......

Cyclophosphamide

Reserved for patients with severe refractory disease as it is significantly more toxic Decreases lymphocytes and reduces inflammation. Treatment for sarcoidosis

Thoracoscopy

Reserved for tumors that can not be appropriately evaluated in any other method. Especially for pleural disease. What testing is this for with lung cancer?

Factor that affect diffusion

Respiratory membrane thickness-fibrosis Surface area-emphysema Diffusion coefficient of the gas-O2 or CO2 Pressure differences on both sides of the membrane. Difference between the partial pressure of the gas on the alveoli and the partial pressure of the gas in the capillary bed.

Inflammatory

Results as an injury to the epithelial surface causing inflammation in the air spaces and alveolar walls Inflammation may spread to adjacent structures and lead to interstitial fibrosis The development of irreversible scarring may occur What type of ILD is it?

Exudate

Rich in protein or LDH Exudate meets one of the following criteria: Pleural protein/serum protein ratio > 0.5 Pleural LDH/serum LDH ratio > 0.6 Pleural LDH >2/3 that of normal serum LDH What pleural fluid is this?

Lung cancer

Risk declines after smoking cessation. After 15 years the risk is 2 times that of a non-smoker but is much lower Radiation therapy - Treatment of a primary malignancy with radiation, increases the risk of a second primary malignancy of the lung. Especially breast cancer and Hodgkins Lymphoma. Thyroid The risk is improving with advanced RT techniques that limit radiation to malignant tissue. Environmental Toxins Second hand smoke, asbestos, radon, arsenic, chromium, nickel, aromatic hydrocarbons, AIR POLLUTION. Pulmonary fibrosis Increases the risk 7 times This risk is independent of smoking Adenocarcima (primary type of risk here) HIV - increases the risk vs non-infected patients What risk factor is this for?

TB

Risk of developing disease depends largely on endogenous factors, such as the individual's innate immunologic and nonimmunologic defenses and level of function of cell mediated immunity Clinical illness that is directly after infection is classified as primary Dormant bacilli may persist for years, and reactivate to produce secondary Primary got single bacteria and breathed it in from resp droplets-now producing in sputum-treatment for 9 months to 1 year-walled off and better-high risk lifestyle and symptoms again-secondary different strand more than likely What is this?

Pleural fluid

Routine Studies Cell Count & differential pH Glucose Protein LDH Culture Special studies / Cytology adenosine deaminase Acid Fast Bacterial smear/culture fungal smear/culture Gram stain What analysis is this for?

Chronic (Months to years)

Sarcoidosis, pneumoconiosis, pulmonary Langerhans cell histiocytosis (PLCH)

Screen and diagnose

Screen for risk factors prior to symptoms Spirometry for risk factors for greater than 10 pack years, 3 lung infections, 3 years or more occupational risk What is this management for COPD?

Haemophilus Influenzae

Second leading cause of CAP in adults Common cause of PNA in adult smokers and those with COPD Anaerobic gram-negative coccobacillus Colonization of the nasopharynx Causes bronchitis, pneumonia, otitis media, sinusitis Blood cultures are usually negative 25% of strains produce beta-lactamases

Bag-valve Mask (Ambu Bag)

Self inflating bag connected to a non-rebreathing valve that can be attached to a facemask May connect to O2 or left open to room air The mask can be removed to allow the bag to connect to the endotracheal tube What oxygen delivery airway adjunct is this?

Long-acting bronchodilators

Serevent Foradil DPI dry powder inhalers-push side button to pop it open-put in mouth and suck in dry powder

Black box warning regarding LABA

Serevent Diskus (salmeterol) Foradil (formoterol) Advair Diskus (fluticasone/salmeterol) Advair HFA Symbicort (budesonide/formoterol) Brovana (arformoterol) Perforomist (formoterol) Dulera (mometasone/formoterol) What drugs are these for?

Partial Rebreather

Set around 8-10 L/M Delivers 50-70% FiO2 Do not let the reservoir bag deflate when the patient inhales There is a problem if on this No rubber valve stopper

Nonrebreather

Set around 8-10 L/M Delivers 70-100% FiO2 Do not let the reservoir bag deflate when the patient inhales There is a problem if on this Has rubber valve stopper placed

Pregnancy special populations

Several case reports have associated intrauterine growth restriction in fetuses of pregnant women with untreated OSAS Rate of preeclampsia is higher in snoring women with signs/ symptoms of OSAS Pregnant women should be referred for evaluation IF snoring is associated with other symptoms of OSAS What is this for?

Chest Radiograph

Severe patient's may show hyperinflated lungs Others: bronchial wall thickening, diminished peripheral lung vascular shadows Exacerbations may cause complications (i.e. pneumothorax) What imaging is this for asthma?

B-2 Agonists

Short Acting (SABA) or Long Acting (LABA) Activate B2-adrenergic receptors Relax smooth muscle cells of all airways Other nonbronchodilator effects: decreasing mucous release SABA Albuterol (Proair, Proventil, Ventolin) Levalbuterol (Xopenex) Pirbuterol (Maxair) Alformeterol (Brovana) LABA: salmeterol & formoterol

Step 1

Short acting BA What step is this for asthma?

Bronchodilators, the short and long

Short acting beta agonists- albuteral, levalbuterol, pributeral Short acting anti-cholinergics - ipratropium, formoteral Long acting beta agonists - salmeterol, formoterol, arformoterol (ADVAIR or SYMBICORT) Long acting anticholinergics - tiotropium (SPIRIVA)

Anticholinergics

Short acting: Ipratroprium (Atrovent) Long acting: tiotropium (Spiriva) Muscarinic receptor antagonists Reverse vagally mediated bronchospasm May decreased mucous gland hypersecretion Used only as an additional bronchodilator in patients with asthma not controlled by other inhaled medications Reduces rate of admission when added to short acting beta 2 agonists in mod-severe asthma Drug of choice in patients with intolerance to beta 2 agonist or with bronchospasm due to beta blocker meds What med is this?

Yes

Should Coryza-snotty nose and pharyngitis raise the suspicion of an alternative diagnosis with Histoplasmosis?

Azathioprine

Shown to be beneficial in suppressing chronic disease, with or without steroids Acts by inhibiting DNA and RNA synthesis. Cytotoxic agent Treatment for sarcoidosis

Pleurisy

Similar to Causes of Exudative Effusion Neoplasm Infection Pulmonary Embolus Pancreatitis Intra-abdominal abscess Diaphragmatic hernia Collagen vascular disease Myocardial infarction Pneumonia Asbestos Sarcoidosis Uremia Drugs Radiation pneumonitis Hemothorax Chylothorax Iatrogenic injury Pneumothorax What do these cause?

EKG

Sinus Tachycardia-most common Nonspecific ST/T-changes RBBB S1-Q3-T3 Right axis deviation P Pulmonale Right ventricular hypertrophy Not diagnostic Rules out MI /other cardiac causes! What lab test is this for PE?

Latent TB

Skin test reaction should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will need to be retested The reaction should be measured in millimeters of the induration Do not measure erythema The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis). What diagnosis is this for?

Paraneoplastic syndrome

Small cell associated syndromes Cushing's (ectopic ACTH) SIADH Peripheral Neuropathy Myasthenia-muscle weakness Cerebellar degeneration-balance issues What syndromes is this for?

Neuroendocrine

Small cell carcinoma are classifed as what tumors meaning they secrete what hormones. Give rise to paraneoplastic syndromes Often are heterogeneous tumors Difficult to evaluate histologically because of associated necrosis.

10 mm

Smaller size of induration could also be positive at what on TB skin test if: Recent immigrants (< 5 years) from high-prevalence countries -IV drug users -Residents and employees of high-risk congregate settings -Mycobacteriology laboratory personnel -Persons with clinical conditions that place them at high risk -Children < 4 years of age - Infants, children, and adolescents exposed to adults in high-risk categories

Second Hand Smoke

Smoke inhaled involuntarily by nonsmokers Studies as early as the 1980s have demonstrated SHS causes lung cancer. Surgeon General Warning of 2006 leaves no doubt that SHS is dangerous. Arguments: Sidestream smoke loses is toxicity as it dissipates in the air Mainstream smoke has very low levels of toxicity as it has already been inhaled. What is this?

Emphysema

Smoking Inflamed airspaces Elastolytic proteinase release Alveoli& bronchial cells are destroyed Alveoli burst & coalesce Loss of surface area What pathophys is this?

Chronic Bronchitis

Smoking Mucous glands Enlarge & Goblet cells increase Cough & Mucus production Bronchi undergo squamous metaplasia Reduced mucociliary clearance What pathophys is this?

Primary spontaenous pneumothorax

Smoking Tall, thin stature Pregnant Genetic disease Marfan syndrome Homocystinuria Birt-Hogg-Dube syndrome Familial tendency Autosomal dominant inheritance 10% have a positive family history What risk factors are these for?

Reduce risk factors

Smoking cessation Avoid all 2nd and 3rd hand smoke Avoid occupational exposure What is this management for COPD?

O2 or Ventilation

Some patients have no obvious symptoms-COPD Tachypnea, Dyspnea, ↑WOB, Bradypnea Retractions Cyanosis (peripheral or central-blue on lips) Clubbing Abnormal Breath Sounds Low O2 Saturation Lethargy Confusion Abnormal ABG's Anemia What presentation is this?

Manage and monitor

Spirometry annually Treat per GOLD criteria guidelines start with 6 week trial of med. then F/U every 3-6 months Baseline Labs AFTER initial diagnosis CXR ABG Alpha-1 antitrypsin deficiency (New guidelines ALL COPD) Pulmonary Rehab (Resp. Therapist Referral) Vaccines Flu annually Pneumonia- once as an adult then again at age 65 What is this management for COPD?

0

Spirometry normal but at risk or symptomatic with normal spirometry Test every 6months Severity- only at risk Symptoms usually none Spirometry - normal What stage is this?

Encapsulated organisms (S. pneumoniae, H. influenzae)

Splenectomy pts/immunoglobulin def is associated with what bacteria with pneumonia?

Pulmonary HTN

Split second heart sound Heart murmur Peripheral Edema JVD & Ascites- if they have liver disease What physical exam finding is this for?

Bronchitis

Sputum-CC Comfortable at rest Chest-noisy-rhonchi/wheeze Peripheral edema Presents in 50s Overweight What are these symptoms of?

Paraneoplastic syndrome

Squamous cell associated syndromes Hypercalcemia (parathyroid like hormone) Adenocarcinoma associated syndromes Thrombophlebitis-clotting blood clot in the veins These are associated with what?

Surgical resection

Stage I and II non-small cell carcinoma treatment is what?

Chemo

Stage IIIA and B and IV non-small cell carcinoma treatment is what?

Pneumonia

Start antibiotics empirically Narrow coverage once microbiological data available (C&S) Pt who is healthy and in no respiratory distress with no complications can be treated as outpatient with oral abx and supportive care Doxycycline, macrolides, fluoroquinolones, cephalosporins Consider hospitalization: neutropenia, multilobular, poor host resistance and >50 y/o with comorbidities Coverage for Streptococcus pneumoniae and Legionella sp. Cephalosporin and macrolide or fluoroquinolone Vancomycin Piperacillin/Tazobactam (Zosyn) Linezolid (Zyvox) Empiric Therapy Long term care residents Gram negative organisms Alcoholics Oral anaerobes, Klebsiella COPD or other chronic lung disease Moraxella catarrhalis, Haemophilus influenza Cystic fibrosis Pseudomonas aeruginosa Occupation Construction (fungal exposures) Pets or animal exposure Bird handlers (Chlamydia psittaci) What is this treatment for?

Sarcoidosis

Steroid dosing: Generally 20-40 mg/day initial dose, tapered to 5-10 mg/day over the course of 12 months. Shorter for mild disease and longer for significant disease, or neurological involvement. Toxicity often develops, and leads to steroid sparing therapies Start on non steroid methotrex before stop steroids What is this treatment for?

Primary spontaneous pneumothorax

Stress & smoking causes apical blebs Sheer forces are higher in the apices Spontaneous rupture occurs Air enters pleural space and Boom! Pulmonary blebs are small subpleural thin walled air containing spaces, not larger than 1-2 cm in diameter. ... If they rupture, they allow air to escape into pleural space resulting in a spontaneous pneumothorax. What etiology is this for?

Pneumothorax

Sudden chest pain Severe / stabbing Radiates to shoulder Increases with inspiration (pleuritic) Sudden shortness of breath Anxiety Cough Dyspnea (worse with SSP) What history and symptoms is this for?

Hygiene Hypothesis

Suggests that lower level of infections may be a factor in affluent societies that increase the risk of asthma Suggests that lack of infections in early childhood preserves the T2 cell bias at birth, whereas exposure to infections and endotoxin result in a shift toward a predominant protective T1 immune response Exposure to high level of endotoxin decreases risk of allergic sensitization Intestinal parasites may also reduce risk of asthma

Small cell carcinoma

Surgery plays little to no role except very early stage-Surgery takes too long to heal and would have to wait to do chemo-not good Combination of chemotherapy agents in early stage - 4-6 cycles Limited stage combination chemotherapy (platinum agent) and thoracic radiation. If successful, then prophylactic cranial radiation (can reduce the risk of brain mets as much as 25-30%) Extensive stage is still considered incurable Treated with combination chemotherapy What treatment is this for?

Acute Bronchitis

Sx: Moderate to severe cough with or without sputum production (for at least 5 days) , dyspnea, fatigue, myalgias, fever relatively uncommon (usually indicative of influenza/pneumonia), concurrent URI (rhinorrhea, nasal congestion, HA and pharyngitis) Cough will resolve in 1-3 weeks This causes what condition?

Lung cancer

Symptoms due to local or regional spread SVC syndrome -pitting edema of head and neck-big head and neck-blood pools up there Paralysis of Recurrent Laryngeal Nerve Phrenic Nerve Palsy Horner's Syndrome-one eye dilates other dose not-nerve is compressed-miosis, pitosis, and dishydrosis Dysphagia-difficulty swallowing Pericardial effusion Pancoast tumors with radiculopathy.-radiation of pain-C5 to T1-Apex tumor pushing on brachial plexus causing a radiculopathy. What clinical findings is this for?

Respiratory Distress

Symptoms range from dyspnea to a patient with impending respiratory arrest Relates to the balance between work of breathing and the capacity of the respiratory muscles to generate pressure As stated in previous discussions, hypoxia, and possibly hypercapnia, can impair sensations of respiratory load Diaphragm is skeletal muscle-will fatigue overtime if breathing quickly then have respiratory arrest What is this?

Primary spontaneous pneumothorax

Symptoms: Acute pleuritic chest pain Dyspnea Cough Physical Exam: ↓breath sounds Tactile fremitus Hyperresonant percussion CXR: Confirms Dx. loss of lung markings visceral pleural line is visible What is this for?

Severe

T/out the day-symptoms Often 7X/wk-nighttime awakenings Several times per day-short acting B agonist Extreme limitation FEV1 less than 60% predicted FEV1/FVC reduced over 5% What severity is this with asthma?

Small cell carcinoma

TNM method of staging has failed to show any prognostic value in what?

PE

Tachypnea ~55% Tachycardia~50% Abnormal Lung Sounds~50% Leg Swelling~25% Circulatory Collapse~25% These possible physical exam findings are for what?

Right Ventricular Hypertrophy

Tall R waves in V1, V2 What is this on EKG for PE?

Away from affected side (all others are to affected side)

Tension pneumothorax tracheal deviation is how?

True

The CC in chronic bronchitis is sputum production-T or F?

+ Homans' sign

The Classic Triad of patients presenting to the ED with PE includes all of the following except: Hemoptysis Dyspnea + Homans' sign Pleuritic Pain What?

Spiral (Helical) Chest CT

The Most Useful diagnostic test for PE Uses contrast Advantages Noninvasive Rapid Finds Alternative Diagnoses Disadvantages Expensive Renal Risk! Misses small PEs What test is this?

FRC (Functional Residual Capacity)

The air left in the lungs after exhalation

Lung parenchyma

The alveoli and alveolar epithelium The capillary endothelium The perivascular and perilymphatic tissues The spaces between theses structures

False (spirometery)

The best diagnostic test for COPD is a CXR-T or F?

False (Doppler ultrasound)

The best diagnostic test for a DVT is a D-Dimer-T or F?

Perfusion

The circulation of blood through tissues.

Sarcoidosis

The diagnosis of what requires three elements: Compatible clinical and radiographic manifestations Exclusion of other diseases that may present similarly-TB skin test, HIV test Histopathologic detection of noncaseating granulomas

ILD

The findings are usually not specific Tachypnea Bibasilar end-inspiratory dry crackles Crackles may be present Scattered late inspiratory high-pitched rhonchi (AKA inspiratory squeaks) are heard in patients with bronchiolitis The cardiac examination is usually normal except in the middle or late stages of the disease Pulmonary hypertension Cor pulmonale Cyanosis and clubbing of the digits occur in some patients with advanced disease What physical exam is this?

Nodular granulomatous

The inflammatory markers attract cellular immune response (monocytes, other macrophages and neutrophils) and develop a what structure with TB where the bacteria enter the lymphs and leads to lymphadenopathy?

Sarcoidosis

The initial lesion within the pulmonary system is a CD4+ T cell alveolitis, followed by the development of noncaseating granulomata The sarcoid granuloma can resolve without sequelae or undergo obliterative fibrosis, with the resultant development of interstitial fibrosis The presence of granulomatous inflammation is thought to result from an exaggerated cell-mediated immune response to one or more unidentified antigens What is this the pathophys for?

Noncaseating granulomata

The initial lesion within the pulmonary system is a CD4+ T cell alveolitis, followed by the development of what with sarcoidosis?

Rifabutin

The main aim in the management of HIV-associated TB is to initiate anti-TB treatment and to immediately consider initiating or continuing HAART Replace rifampin with what, as rifampin can lead to adverse drug effects (lowers serum levels of HIV protease inhibitors) Sanford Guide recommends INH + Rifampin (or Rifabutin) + Pyrazinamide for 2 months

ILD

The major goals of treatment are permanent removal of the offending agent, when known, and early identification and aggressive suppression of the acute and chronic inflammatory process, thereby reducing further lung damage Hypoxemia is treated with supplemental oxygen Glucocorticoids are the mainstay of prescription treatment. The optimal dose and duration is not currently known Common starting dose is 0.5-1 mg/kg Prednisone daily for 4-12 weeks, followed by a taper over the next 4-12 weeks Success rate is low Many cases of ILD are chronic and irreversible despite therapy What treatment is this for?

Ventilation

The movement of air into and out of the lungs. The movement of O2 into to lungs and release of CO2 out of the lungs but remember there are other gasses involved. Can you get it in and out?

VTE

The platelet glycoprotein (Gp) IIb/IIIa (alpha Iib beta 3) complex is the most abundant receptor on the platelet surface; platelet activation converts the normally inactive Gp IIb/IIIa receptor into an active receptor, enabling binding to fibrinogen and vWF; because the surface of each platelet has ~ 50,000 Gp IIb/IIIa fibrinogen binding sites, numerous activated platelets recruited to the site of vascular injury can rapidly form an occlusive aggregate by means of a dense network of intercellular fibrinogen bridges; since this receptor is the key mediator of platelet aggregation, it has become an effective target for antiplatelet therapy What pathophys is this for forming a fibrin mesh?

Pleurisy

The pleura become and filled with fluid Pleura become inflamed resulting in dyspnea Pleura rub together with each breath, A rough, grating "friction rub." Like walking on Snow Hold breath, if the rub is still there it is cardiac What pathology is this for?

Oxygen Consumption

The rate that oxygen is used by the tissues. Normal approx. 250ml/minute AKA = VO2 max Use Fick Principle VO2 max = Q (CaO2-CvO2) Q = Cardiac Output CaO2 = Arterial Oxygen Content CvO2 = Venous Oxygen Content

Tar

The residue from burning tobacco Condenses in smoker's lungs Provides flavor and "joy" for smokers Damages cilia Inflames the respiratory tract lining Causes infection, chronic lung disease, and cancer

Arterial Blood Gas

The resting arterial blood gas may be normal or reveal hypoxemia (secondary to a mismatching of ventilation to perfusion) and respiratory alkalosis A normal arterial O2 at rest does not rule out significant hypoxemia during exercise or sleep Carbon dioxide (CO2) retention is rare and is usually a manifestation of end-stage disease.

Stage II Flu vaccine, short acting and long acting bronchodilator maybe rehab

The results on the above patients test was: Fev1/FVC ratio 68% FEV1 50% What is the gold stage of COPD? What is the appropriate treatment?

BAL

The role of what in defining the stage of disease and assessment of disease progression or response to therapy remains poorly understood

TLC (Total Lung Capacity)

The total inhaled volume that the lungs can hold

RV (Residual Volume)

The volume left in the lungs at the end of a maximum/forced exhalation

Phosphodiesterase Inhibitors

Theophylline Mild bronchodilator, anti-inflammatory properties, enhances mucocilary clearance Serum levels need to be monitored Therapeutic doses often leads to side effects Insomnia, urination difficulties in men with BPH, dyspepsia/reflux Dose related toxicity N/V, arrhythmias, HA, seizures, hyperglycemia, hypokalemia What meds are these with asthma?

Histoplasmosis

Therapy should be reserved for patients with symptoms greater than 4 weeks, unless improving. Indicated without delay in patients with moderately severe or severe disease. Amphotericin B for the severe and or hospitalized patients. Itraconazole for those that need treatment without hospitalization. What treatment is this for?

IPF

There is no effective therapy for what Thalidomide appears to improve cough in patients with what Treat gastroesophageal reflux disease Patients with IPF and coexisting emphysema are more likely to require long-term oxygen therapy Refer to pulmonology for early lung transplant Poor prognosis: Deterioration due to infections, pulmonary embolism, pneumothorax, heart failure, ischemic heart disease What treatment is this with?

Pleural Friction Rub

This is a crackling type of sound. Heard during inspiration and expiration. Due to inflammation of the pleural surfaces and the rubbing of them together on inspiration and expiration.

Spirometry

This is a test that measures the amount of airflow from the lungs in a volume VS time format. Inexpensive Easy to do in Primary Care Setting Great Screening Test When you suspect pulmonary disease of some form. To evaluate progression of a pulmonary or neuromuscular disease To evaluate the efficacy of tx (bronchodilator therapy) Pre op surgical clearance Disability

Inspiration

This is an active process. Drawing air into the lungs Musculature involved: External intercostals Diaphragm Levatores Costarum Pectoralis Minor Scaleni Serratus Posterior Superior Sternocleidomastoid

Expiration

This is normally a passive process unless one forces air out. Brought about by the elasticity of the lung Weight or recoil of chest wall and relaxation of intercostals. Ascention of the diaphragm. This is a 2:1 process of inspiration to expiration in normal lung function

Pre and Post Spirometry

This is the main test you will order so that you can determine the efficacy of β Adrenergic Bronchodilators (Albuterol). Any increase in FEV1 or FEV1/FVC ratio of 10-15% shows a benefit to the patient with the medication.

SCLC

This method of staging is utilized for radiation purposes. Limited stage can generally be treated through single radiation port and chemotherapy Extensive stage is treated with chemotherapy alone What staging is this?

Proliferative

This phase of ARDS usually lasts from day 7 to day 21 Most patients recover rapidly and are liberated from mechanical ventilation during this phase Despite this improvement, many patients still experience dyspnea, tachypnea, and hypoxemia Some patients develop progressive lung injury and early changes of pulmonary fibrosis during the proliferative phase Lung repair often begins in this phase Synthesis of new pulmonary surfactant Pulmonary infiltrates more from neutrophilic to lymphocytic What phase is this?

Staph aureus

This pneumonia PNA usually begins in the peripheral airways Patchy bronchopneumonia is more common and often bilateral, though lobar consolidation may be seen Late development of abscesses is relatively common When staphylococcal pneumonia occurs as a complication of influenza, it is usually rapidly progressive with extensive bilateral pneumonia that resembles pulmonary edema What radiograph is this for?

H influenza

This pneumonia is indistinguishable from pneumococcal pneumonia Patchy bronchopneumonic pattern, but segmental and lobar consolidation may be seen Pleural effusion is a common finding Usually show a multilobar infiltrate and pleural effusions in 50% of cases Resolution is usually slow What radiograph is this for?

Skin Tests

To assess sensitivity to environmental allergens What test is this with asthma?

Oxygen Toxicity

To much O2 at high concentration (breathing high partial O2 pressures). Use 100%< 24 hrs. Decrease to 70% in 2 days and 50% by 5 days. Issue in the CNS, Lungs, and Occular System Tracheobronchitis Diffuse Alveolar Damage ARDS Premature Babies Eyes (Retinopathy of Prematurity) Seizure Activity Twitching Confusion Nausea Vertigo Tinnitis Fatigue

Vascular wall injury

Trauma or surgery Venepuncture Chemical irritation Heart valve disease or replacement Atherosclerosis Indwelling catheters What part of Virchow's triad is this?

Lung cancer

Treat secondary pathologies-small cell carcinoma Medication side affects Especially nausea Ondansetron (Zofran) Granisetron (Kytril) Dolasetron (Anzemet) Palonosetron (Aloxi) Dexamethasone (Decadron) Secondary infections Paraneoplastic syndromes Anemia, hypercalcemia, etc. What treatment is this for?

ARDS

Treatment centers on: Recognition and treatment of underlying medical and surgical disorders (e.g., sepsis, aspiration, trauma) Minimization of procedures and their complications Prophylaxis against venous thromboembolism, gastrointestinal bleeding, aspiration, excessive sedation, and central venous catheter infections Prompt recognition of nosocomial infections Provision of adequate nutrition There have been studies of multiple other therapies, including steroid use, hyperventilation techniques, and surfactant replacement, but none of these therapies were beneficial, and currently not recommended What treatment is this for?

Pleurisy

Treatment depends on the etiology! Treatment goals: Remove the fluid, air, or blood from the pleural space Relieve symptoms Treat the underlying condition Antibiotics Chemotherapy Diuretics Etc... What treatment is this for?

Air Bronchogram

Tubular outline of an airway made visible by filling of surrounding alveoli When the alveoli no longer contain air and opacify, the air-filled bronchi passing through the same area may be visible as branching linear lucencies, or air bronchograms May be seen in atelectasis, lung consolidation, pulmonary edema, severe interstitial disease, neoplasm, normal expiration

Histological

Tumors are classified by their what findings?

Acute Bronchitis

Tx: Supportive-- hydration, rest, analgesics, antipyretics, nasal decongestants, cough suppressant/expectorants, bronchodilators What is this the treatment for?

Asbestosis

Type of Inflammatory ILD resulting from inhalation of asbestos fibers Directly related to the intensity and duration of exposure Resembles other forms of diffuse interstitial fibrosis Shipbuilders, pipe fitters, boilermakers The mechanisms by which asbestos fibers induce lung fibrosis are not completely understood Past exposure to asbestos is specifically indicated by pleural plaques on chest radiographs, characterized by either thickening or calcification along the parietal pleura Irregular or linear opacities that usually are first noted in the lower lung fields are the chest radiographic hallmark of asbestosis

Secondary Pneumothorax

Underlying lung disease COPD common Age 60's Multiple illnesses Classic Patient : A 65 yr old ill man with COPD What presentation is this for?

Biot's Respirations

Unpredictable and Irregular Breathing. Usually small quick breaths followed by apneic periods. Seen in brain damage.

Wheezing

Upper airway (more likely to be stridor, may have element of wheezing), angioedema: allergic, ACEI, idiopathic, foreign body, infection: coup, epiglottis, tracheitis Lower airway, asthma, transient airway, broncholitis, COPD, foreign body, cariovascular, PE What differential is this for?

Contraindicated

Use of a LABA alone without use of a long-term asthma control medication, such as an inhaled corticosteroid, is what (absolutely advised against) in the treatment of asthma. LABAs should not be used in patients whose asthma is adequately controlled on low or medium dose inhaled corticosteroids.

Systemic Corticosteroids

Used primarily in acute, mod-severe asthma exacerbations Oral or IV used Recent studies show oral steroids are easier to administer and just as effective Usually prednisone or prednisolone 30-45 mg once daily for 5-10 days is effective, no taper needed 1% of asthmatics require maintenance treatment with oral steroids Lowest dose necessary to maintain control needs to be determined Monitor bone density in these patients What meds are these with asthma?

Nasal Airway (Nasal Trumpet)

Used to maintain patency of the nares May be used on patients with intact gag reflex What oxygen delivery airway adjunct is this?

Esophageal airways

Used when endotracheal intubation is not a viable option Placed without visualization of the vocal chords Placed only in apneic, unconscious adults What esophageal and laryngeal airway is this?

Partial Rebreather

Used with oxygen delivery at 10-15 L/minute Provides O2 at 70-90% What airway management technique is this?

Non-rebreather

Used with oxygen delivery at 12-15 L/minute Provides O2 at 80-100% What airway management technique is this?

Nasal cannula

Used with oxygen delivery at 2-6 L/minute Provides O2 at 24-44% What airway management technique is this?

Venturi Mask

Used with oxygen delivery at 3-15 L/minute Provides O2 at 24-50% What airway management technique is this?

Simple Mask

Used with oxygen delivery at 5-8 L/minute Provides O2 at 40-60% What is this airway management technique is this?

Tube Thoracostomy

Useful in ... SSP Tension What management is this for with pneumothorax management?

PET

Useful in staging (especially mediastinal disease) Detects things undetected by CT Reveals the 'nature' of the pathology Looking for hyperactivity What lab imaging is this with lung cancer?

CURB-65

Uses five prognostic variables Confusion (based upon a specific mental test or disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) Respiratory rate >30 breaths/minute Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) Age >65 years (Sanford Guide, 44th Ed. Page 39) Each criteria is assigned 1 point each 0-1: Treat as an outpatient 2: Consider a short stay in hospital or watch very closely as an outpatient 3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit What is this?

Cystic Fibrosis

Usual presentation is within One year after birth with ongoing respiratory tract infections However 7% ARE DX AS ADULTS Present with diabetes, infertility, and GI symptoms Almost ¼ will present with a meconium ileus during their first 24 hours after birth. What presentation is this?

Venous thromboembolism

VTE Venous Blood Clot Two kinds... DVT =in deep veins of the legs PE =in the lungs What is this?

Type V

Variations 5T, 7T, and 9T These are inappropriate splicing of the CFTR gene and in turn decrease its function. What CFTR mutation is this?

Pulmonary Function Testing

Ventilation / Perfusion (V/Q) studies Demonstrate a 'mismatch' secondary to destruction of alveolar capillaries Lung regions with reduced compliance due to either fibrosis or cellular infiltration may be poorly ventilated but may still maintain adequate blood flow

V/Q scan

Ventilation/Perfusion Scan If Spiral CT is unavailable this is the initial test of choice Preferred test in pregnant patients What lab test is this?

Kussma's Respirations

Very deep breathing. Can be fast, normal or slow Occurs in diabetic acidosis and coma patients

Acute Bronchitis

Viral (most common etiology) Influenza A &B Parainfluenza Coronavirus Rhinovirus RSV Bacterial Mycoplasma pneumonia Chlamydia pneumonia Bordetella pertussis These cause what condition?

Pleural surfaces

Visceral Adheres to lung lobes Blood from bronchial art. Limited lymphatic drainage No innervation (no pain) Parietal adheres to chest wall Blood from systemic cap. Lymphatic drainage Innervated (pain) Both make fluid The two do not communicate Drainage occurs primarily through the parietal pleura Pleural fluid decreases friction the pleural surfaces Pleural fluid is constantly being formed -100ml/hr Hydrostatic and oncotic forces favor leakage from both surfaces Pleural Fluid is Constantly being drained- 100ml/hr What is this?

Respiratory Pressure Concepts

Volume changes lead to pressure changes which lead to the flow of gases to equalize the pressure

PE

WBC Poor sensitivity and nonspecific but Can be high in some patients Hgb/Hct +/- Polycythemia, a risk factor for PE ESR Shows inflammation but not specific High What lab analysis is this for?

acute diseases have more PMNs, chronic ones have Monos

WBC differential for pleural effusion indicates what?

Lung cancer

Wedge resection - part of lobe Segmentectomy Lobectomy Bilobectomy Pneumonectomy What treatment is this for?

Hampton's Hump

Wedge shaped pleural infiltrate/consolidation adjacent to the hilum What finding is this on a CXR for PE?

ABG and oximety

What 2 things are not sensitive for diagnosis with COPD? Sometimes used in the evaluation of pts with a COPD exacerbation that warrants hospitalization

Simple spirometry Peak Expiratory Flow

What 2 things are used with the pulmonary function test?

PERC criteria Wells criteria Geneva score

What 3 criterias are used for predicting PE?

Macrolide Fluoroquinolone Augmentin Doxycycline

What 4 antibiotics are used to manage acute exacerbations with COPD?

D-dimer

What PE diagnostic lab analysis is done more often?

Chest Radiograph

What Will often be the initial suspicion of ILD?

CXR EKG Pulse Oximetry

What ancillary testing is done for PE diagnostic testing?

Macrolide

What antibiotic is the last choice with COPD acute exacerbation?

Inflammatory Granulomatous

What are 2 types of ILD?

Asthma Bronchiectasis Cystic fibrosis Bronchopulmonary mycosis

What are 4 differential diagnosis for COPD?

Recent MI Unstable Angina Thoracic aneurysms Pneumothorax Any form of thoracic or abdominal surgery

What are contraindications to spirometry?

Salmeterol Formoterol

What are long acting B-2 agonists for asthma?

Squamous cell adenocarcinoma large cell

What are non-small cell carcinomas with lung cancer?

Albuterol (Proair, Proventil, Ventolin) Levalbuterol (Xopenex) Pirbuterol (Maxair) Alformeterol (Brovana)

What are short acting B-2 agonists for asthma?

IC+FRC IRV+VT+ERV+RV

What are the 2 equations for TLC?

Transudative Exudative

What are the 2 types of pleural effusion?

Heparin: (Three Choices) (LMWH, fondaparinux, or unfractionated heparin (UFH)) Add Warfarin ((Coumadin) on day 2 5 mg PO daily) Overlap Warfarin/Heparin therapy (until INR is >2 for 24 hours Usually about 5 days)

What are the 3 anticoag treatment for DVT?

Bronchodilators Glucocorticosteroids Antibiotics

What are the 3 manage acute exacerbations meds?

No symptoms (secondary lifestyle) Respiratory symptoms (effecting quality of life, dyspnea on exertion, gray sputum cough) Acute exacerbation (wheeze, cough, dyspnea)

What are the 3 ways COPD presents?

Screen and Diagnose Early. Reduce Risk Factors Manage and Monitor Manage Acute Exacerbations

What are the 4 components of COPD management?

Isoniazid Rifampin Pyrazinamide Ethambutol

What are the 4 first line drugs used for TB?

Screen Diagnose Determine severity Monitor progression

What are the 4 functions of spirometry in COPD?

Gum Logenze Inhaler Nasal spray

What are the 4 nicotine replacement treatments?

Nasal cannula Simple Mask Partial Rebreather Non-rebreather Venturi Mask

What are the 5 airway management techniques?

Pseudomonas Aeruginosa Staphylococcus Aureus Hemophilus Influenzae Burkholderia Aspergillus

What are the 5 pulmonary pathogens in CF?

Duplex US D-dimer

What are the DVT diagnostic tests?

Recent MI Unstable Angina Thoracic aneurysms Pneumothorax Thoracic or abdominal surgery

What are the absolute contraindications to spirometry?

Tobramycin TOBI Bramitob Azithromycin Colistin Cayston (Aztreonam)

What are the antibiotic treatment in CF pathogens?

Dyspnea Persistent cough, nonproductive vs. productive Wheezing Chest pain

What are the associated symptoms with interstitial lung disease?

Mycoplasma Pneumoniae Chlamydia Pneumoniae Legionella

What are the atypical pathogens of CAP?

Hypoventilation Diffusion Shunting Ventilation/perfusion inequality (underinflated llung with atelectasis)

What are the causes of hypoxemia?

CBC and differential LFTs Renal function Glucose Electrolytes Serum calcium Urinalysis (Other tests to consider: HIV Erythrocyte sedimentation rate and c-reactive protein Serum angiotensin converting enzyme (ACE) level)

What are the diagnostic components for sarcoidosis?

CXR CBC Blood/sputum (culture only if suspected bacterial infection) Flu test

What are the diagnostic tests for acute bronchitis?

CBC diff and manual smear Renal function Electrolytes LFTs Serum LDH Serum alkaline phosphatase Bone marrow aspirate if CBC abnormal.

What are the lab diagnosis for lung cancer?

Glucocorticoids

What are the mainstay of prescription treatment for ILD?

Coronary artery disease Lung cancer COPD

What are the major chronic conditions from chronic smoking?

Brain Bone Adrenals Contralateral lung Liver Pericardium Kidneys (Brain, bone, kidney, and liver most common places)

What are the most common sites of metastasis?

I, II, III

What are the most lethal CF type mutations?

Thoracentesis Pleural fluid analysis CXR or other imaging

What are the pleural effusion labs to differentiate btw transudative and exudative?

FVC Normal or Reduced FEV1 Reduced FEV1/FVC ratio Reduced

What are the results of FVC and FEV1 and the ratio for obstructive asthma?

FVC reduced FEV1 reduced Ratio Norm/High

What are the results of FVC and FEV1 and the ratio for restrictive asthma?

CHF Pneumonia Malignancy PE

What are the top 4 cases causing pleural effusion?

Behavioral modifications Weight loss OSA-specific therapies Oral appliances Positive airway pressure Surgery

What are the treatments for obstructive sleep apnea?

Emphysema Chronic bronchitis

What are the two types of COPD?

Streptococcus Pneumoniae H Influenzae Staph aureus Klebsiella Pneumoniae Pseudomonas

What are the typical pathogens of CAP?

Blue bloater

What bloater is bronchitis prominent COPD? is a person where the primary underlying lung pathology is chronic bronchitis. Chronic bronchitis is caused by excessive mucus production with airway obstruction resulting from hyperplasia of mucus-producing glands, goblet cell metaplasia, and chronic inflammation around bronchi. Unlike emphysema, the pulmonary capillary bed is undamaged. Instead, the body responds to the increased obstruction by decreasing ventilation and increasing cardiac output. There is a dreadful ventilation to perfusion mismatch leading to hypoxemia and polycythemia. In addition, they also have increased carbon dioxide retention (hypercapnia). Because of increasing obstruction, their residual lung volume gradually increases (the "bloating" part). They are hypoxemic/cyanotic because they actually have worse hypoxemia than pink puffers and this manifests as bluish lips and faces.

DKA Renal failure

What conditions lead to metabolic acidosis?

Prolonged vomiting NG tube suction

What conditions lead to metabolic alkalosis?

Fever Anxiety Mechanical ventilation

What conditions lead to respiratory alkalosis?

Well's Criteria

What criteria is used for DVT diagnosis?

Imaging Pulmonary Function Test Airway responsiveness Hematologic tests Skin tests Exhaled nitric oxide

What diagnostic evaluations should be done for asthma?

Hemoglobin Thyroid function studies (hypothyroidism) Nocturnal oximetry Polysomnography (gold standard)

What diagnostic testing should be done with obstructive sleep apnea?

Heart Obstruction Reactive Infection Death (PE or pneumothorax)

What does HORID mean when evaluation pulmonary complaints for breathing or respiratory issues?

Emphysema Hepatic cirrhosis Carcinoma

What does alpha 1 antitrypsin deficiency lead to with chronic illnesses?

Confusion (based upon a specific mental test or disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) (>7 mmol/L) (20 mg/dL) Respiratory rate (>30 breaths/minute) Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) Age >65 years

What does the CURB-65 mean?

Trauma Hypercoaguable state Recreational drugs Old age >40 Malignancy Birth control Obesity Surgery/smoke Immobilization Sickness

What does the mnemonic thrombosis mean with VTE risk factors?

CT

What has greater sensitivity and specificity than CXR with COPD?

Transudate

What has low protein and LDH-exudate or transudate for pleural effusion?

Chest CT (spiral)

What imaging is done first for PE diagnostic testing?

BODE

What index addresses this criticism by including Body Mass Index, Airflow Obstruction, Dyspnea and Exercise capacity in the calculation

VO2 max = Q (CaO2-CvO2)

What is Fick's equation?

Venous stasis Hypercoaguability Vascular injury (2 of the 3 must be present for clot to form)

What is Virchow's triad 3 components?

Neuropsychiatric events (suicidal thoughts-agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor.)

What is a bad side effect of singulair?

Acute Respiratory Distress Syndrome (ARDS)

What is a clinical syndrome of severe dyspnea of rapid onset, hypoxemia, and diffuse pulmonary infiltrates leading to respiratory failure Caused by diffuse lung injury from underlying medical and/or surgical disorders The lung injury is classified as either direct lung injury or indirect Further classified based on the degrees of hypoxemia Mild Moderate Severe Associated with mortality risk and with the duration of mechanical ventilation needs

Lung infections

What is a frequent infection that is a hallmark of COPD?

Excessive salty tasting sweat

What is a hallmark symptom presentation of CF?

Allergy

What is a mini warning with augmentin with COPD?

Honeycombing

What is a poor prognosis and late finding for ILD and will not go away?

Sarcoidosis

What is characterized by the accumulation of T lymphocytes, mononuclear phagocytes, and noncaseating granulomas in involved tissues The lungs are affected in approximately 90 percent of patients, and pulmonary disease accounts for the majority of the morbidity and mortality associated with this disease Requires presence of 2 or more organs affected to make the diagnosis Other tissues commonly involved include the skin, eyes, and lymph node?

Thoracentesis

What is diagnostic and therapeutic for pleural effusion?

Theophylline

What is not used much because of its narrow therpeutic window and toxicity with COPD?

Trapped lung

What is one of the outcomes of fibrinous or granulomatous pleuritis and is a cause of chronic, benign, unilateral pleural effusion. It is characterized by inability of the lung to expand and fill the thoracic cavity due to a restricting fibrous visceral pleural peel.?

All of the above (Pleuritis better term)

What is pleurisy? A. An antiquated term B. Inflammation of the pleura C. Synonym for 'pleuritis' D. Infection of the Pleura

Exudate

What is rich in protein or LDH-Exudate or Transudate for pleural fluid?

HRCT

What is superior to the plain chest x-ray for early detection and confirmation of suspected ILD ?

Chest CT (Spiral) then VQ scan then US using TEE then MRI or Pulmonary Angiogram

What is the Harrison's algorithm for PE work up labs?

Asthma Allergic rhinitis Atopic dermatitis (eczema)

What is the atopic triad for asthma?

Weight loss (May only need to lose 10-20% Only a small percentage of dieters lose weight permanently) Exercise (may improve OSA even w/out wt loss) Avoidance of alcohol, hypnotic meds (Relaxes tongue and pharyngeal muscles Causes CNS depression ETOH use increases risk of weight gain) Positional therapy (Raise head of bed moves tongue forward Avoid supine position Side lying sleep moves tongue to side)

What is the behavior modification treatment of OSA?

Lateral Decubitus view

What is the best CXR view to order when trying to determine if there is fluid in the lungs? Lateral Decubitus View Anterior Posterior View Standard View Posterior Anterior View Upright View

Right atrial catheterization

What is the best test for pulmonary HTN? (but Chest XRAY and CT and Echo is normally good enough)

P = Pericarditis A= AMI P=PE P= Pneumothorax A= Aneurysm

What is the chest pain mnemonic PAPPA mean?

Hemoptysis Dyspnea Pleuritic Pain (uncommon and usually vague)

What is the classic triad for PE?

ERV+RV

What is the equation for FRC?

IRV+VT

What is the equation for IC?

CXR

What is the first choice imaging for pleural effusion due to availability, accuracy, and low cost?

start with 6 week trial of med. then F/U every 3-6 months

What is the gold criteria guidelines for manage and monitor with COPD?

Polysomnography

What is the gold standard diagnosis of obstructive sleep apnea?

Sweat Chloride Test (Fail initial test have to have gold standard test-sweat chloride test-2 weeks old certain weight-is collecting sweat with pilocarpine iontophoresis and chemical determination of the chloride concentration. (apply pilocarpine to skin and apply a small collection system for the sweat and cover with plastic wrap) ( 6 months or less <29 mmol/L Unlikely 30-59 mmol/L Intermediate >60 mmol/L Likely >6 months <39 unlikely, 40-59 intermediate, >60 likely)

What is the gold standard for CF?

Chest Physiotherapy

What is the gold standard for airway clearance devices and techniques?

Stabilize (Oxygen Hemodynamic support 500ml NS bolus +Vasopressor) Anticoag (Risk of mortality(30%) outweighs risk of major bleed (3%) Heparin followed by Warfarin)

What is the initial phase of treatment for PE?

Immunoreactive Trypsin Level (IRT)

What is the initial screening test for newborns with CF?

Isoniazid (INH-10 mg/kg/day for 8-10 weeks) Repeat TST If neg test stop INH If TST positive or age less than 6 months continue INH for 3 more months

What is the initial therapy for TB exposure

tiotropium (Spiriva)

What is the long acting anticholinergic for asthma?

Observation Needle Decompression Tube Thoracostomy (chest tube) VAT (video-assisted thoracoscopy) (Open thoracotomy) (Choice depends on severity)

What is the management for pneumothorax?

Hilar adenopathy

What is the most common CXR finding with TB Usually resolve slowly, up to 1 year

Sinus tachy

What is the most common ECG finding in patients with PE? Right axis deviation RBBB S1-Q3-T3 Tall peaked T-waves in lead II (P pulmonale) Sinus tachycardia What is it?

Sinus Tachycardia

What is the most common finding on an EKG with PE?

Pseudomonas Aeruginosa

What is the most common pulmonary pathogen in CF?

Uvulopalatopharyngoplasty (UPPP)

What is the most common surgical procedure that is performed with OSA?

Type II F508

What is the most common type of CF mutation?

Cough/Dyspnea Chest pain

What is the most commonly present respiratory complaints?

Endotracheal Intubation (ETT)

What is the most reliable way to ensure a patent airway, provide oxygenation and ventilation, and prevent aspiration It consists of placing a cuffed tube either in the mouth or nose through the vocal cords and into the trachea above the carina Orotracheal intubation is the most common method is used for a variety of reasons, most commonly it is used to correct hypoxia or hypercarbia, prevention of impending hypoventilation, to ensure maintenance of a patent airway and to deliver general endotracheal anesthesia

Clear color pH less than 7.60-7.64 Protein less than 2% WBC less than 1000 Glucose matches that of the plasma LDH less than 50% Na, K, and Ca similar to interstitial fluid

What is the normal pleural fluid values with color, pH, protein, WBC, glucose, LDH, and Na/K/Ca?

Headache (give non rebreather to compete with CO2)

What is the number one symptom with hypoxemia?

Oxygen

What is the only treatment documented to improve the natural history of COPD?!

Granuloma formation

What is the pathologic hallmark of sarcoidosis?

Labs: CBC CMP Chest X-ray ECG CT Diagnostic Thoracentesis

What is the pleurisy diagnostic testings?

Influenza (Annually > 6 Months Different Types) PCV-Pneumococcal conjugate vaccine (Prevnar) (4 dose series age 6 weeks-15 months) PPV-Polyvalent Pneumococcal vaccine (Pneumovax) (Contains antigens of 23 common stains of the pneumococcus) PPSV-Pneumococcal polysaccharide vaccine (Pneumovax) (Aged 2-5 years who have not been previously immunized >65 years old or any person with chronic illness that increases risk Booster shots needs q 6 years)

What is the prevention for pneumonia?

Ipratroprium (Atrovent)

What is the short acting anticholinergic for asthma?

Smoking cessation

What is the single most effective intervention slow the progression of COPD?

Inhaled bronchodilators

What is the therapeutic mainstay for COPD?

2nd or 3rd generation cephalosporin (beta lactamase producing) or amoxicillin (non-beta lactamase producing)

What is the treatment for H influenzae?

Erythromycin (mycoplasma pneumonia and legionella infection) Tetracycline (chlamydia infection)

What is the treatment for bacterial atypical CAP?

doxycycline (100 mg orally twice daily) (for 10 to 14 days)

What is the treatment for chlamydia Pneumoniae?

cefepime (Maxipime), Piperacillin/Tazobactam (Zosyn), meropenem (Merrem)

What is the treatment for health care-associated pneumonia?

Long term oral anticoag (Coumadin) Supplemental Oxygen (Initially may be reversed with O2) Diuretics CCB Sildenafil (Vasodilator)

What is the treatment for idiopathic pulmonary HTN?

Carbapenems: Imipenem or Meropenem If resistant, add colisti

What is the treatment for klebsiella pneumonia?

6-12 months of Isoniazid (INH), or Rifampin if susceptibility is likely. (Treatment must be continuous Get Baseline hepatic panel before starting treatment)

What is the treatment for latent TB?

Azithromycin

What is the treatment for legionella?

Macrolide (erythromycin or azithromycin) Tetracycline (doxycycline) (Can shorten the duration of symptoms)

What is the treatment for mycoplasma pneumoniae?

Piperacillin-tazobactam (Zosyn) plus Tobramycin Tobramycin: Aminoglycosides are generally used in combination with a beta-lactam

What is the treatment for pseudomonas?

MSSA: Nafcillin, Oxacillin, or Flucloxacillin MRSA: Vancomycin

What is the treatment for staph aureus?

Penicillin Augmentin Amoxicillin Clarithromycin Azithromycin Erythromycin (The majority of patients with CAP are treated empirically with a regimen that includes coverage against pneumococcus Empiric therapy differs pending age, comorbid disease, and treatment setting)

What is the treatment for strep pneumoniae?

Education Counseling Pharmacotherapy

What is the treatment for the chronic disease tobacco abuse?

Treat underlying cause Oxygen (For 15+ hours per day-slows progression) Anticoag Vasodilators (CCB, hydralizine, nitro) Therapeutic phlebotomy (for those with Polycythemia) Refer to a pulmonologist

What is the treatment of secondary pulmonary HTN?

QT interval prolongation

What is the warning for azithro with COPD?

CBC, ESR, Hgb/Hct, D-Dimer ABG's

What lab analysis should you get for PE diagnostic testing?

V/Q scan

What lab test for PE is the preferred test in prego pts?

Bronchoscopy/biopsy

What may be necessary tests if tests for histoplasmosis are inconclusive?

Lung transplantation

What may be the only treatment for survival of end stage ILDs?

Itraconazole

What med should you give for those that need treatment w/out hospitalization with histoplasmosis?

Amphotericin B

What med should you use for the severe and or hospitalized pts with histoplasmosis?

Beta adrenergic agonists Corticosteriods Anticholinergics

What meds are quick relief with asthma?

Oral corticosteroids

What meds are used in exacerbation with COPD?

Dornase Alfa

What mucoactive agent can be given with tobramycin?

PE

What must be thought about with every patient with CP or SOB?

Empyema (some malignnt effusions)

What needs a chest tube with exudative?

Primary pulmonary TB

What occurs soon after the initial infection with tubercle bacilli It may be asymptomatic or may present with fever and occasionally pleuritic chest pain Because most inspired air is distributed to the middle and lower lung zones, these areas are most commonly involved in primary TB The lesion forming after initial infection (Ghon focus) is usually peripheral and accompanied by transient hilar or paratracheal lymphadenopathy The Ghon focus, with or without overlying pleural reaction, thickening, and regional lymphadenopathy, is referred to as the Ghon complex Some patients develop erythema nodosum on the legs or conjunctivitis In the majority of cases, the lesion heals spontaneously and becomes evident only as a small calcified nodule

50 (The rule of 50s)

What of COPD pts are undiagnosed COPD is evident by the age of what years? At the time of diagnosis, FEV1 is less than what predicted What is a 5-year survival?

Chest percussion (help increase mobilization of secretions) Alpha 1-antitrypsin replacement therapy Surgery (lung transplant, lung volume reduction surgery, or bullectomy)

What other treatment is done for COPD?

Pink puffer

What puffer is emphysema prominent COPD? emphysema is the primary underlying pathology. Emphysema results from destruction of the airways distal to the terminal bronchiole--which also includes the gradual destruction of the pulmonary capillary bed and thus decreased inability to oxygenate the blood. So, not only is there less surface area for gas exchange, there is also less vascular bed for gas exchange--but less ventilation-perfusion mismatch than blue bloaters. The body then has to compensate by hyperventilation (the "puffer" part). Their arterial blood gases (ABGs) actually are relatively normal because of this compensatory hyperventilation. Eventually, because of the low cardiac output, people afflicted with this disease develop muscle wasting and weight loss. They actually have less hypoxemia (compared to blue bloaters) and appear to have a "pink" complexion and hence "pink puffer". Some of the pink appearance may also be due to the work (use of neck and chest muscles) these folks put into just drawing a breath.

COPD Asthma CHF Pneumonia

What pulmonary conditions lead to respiratory acidosis?

Fungal culture

What remains the gold standard diagnostic for Histoplasmosis?

Fluoroquinolones

What second line therapy med is used with TB treatment?

PE

What should always be on your radar and reflect that you thought about/ruled it out with specific medical decision-making criteria and pertinent neg?

Histoplasmosis

What should be considered in: Known exposure Mediastinal obstructive syndromes Sarcoidosis Pulmonary disease with arthralgias Pulmonary malignancy Pneumonia with hilar / mediastinal adenopathy Cavitary lung disease Pericarditis with adenopathy

Platelets

What should be monitored in all heparin pts? D/C heparin if platelet count less than 75,000 Heparin induced thrombocytopenia is UGLY!

TB skin test Posteroanterior chest radiograph and high resolution computed tomography PFT ECG Opthalmologic exam

What should you evaluate with sarcoidosis?

Bronchial washing and culture Positive means presence of histoplasmosis

What should you get to differentiate btw histoplasmosis and sarcoidosis and what does a positive test mean?

Sputum

What sign and symptom is most common with bronchitis?

Dyspnea

What sign and symptom is most common with emphysema?

Extrapulmonary TB

What sites most commonly involved in TB include: Lymph nodes Painless swelling of posterior cervical and supraclavicular sites-pulmonary or GI cancer Pleura with empyema or pleural effusions (dullness to percussion) Genitourinary tract: Urinary symptoms, renal/GU damage Bones and joints: Typically weight bearing areas CNS: Meningitis, Tuberculoma (space occupying lesion) Peritoneum: Commonly terminal ileum and cecum Pericardium: Symptoms of pericarditis vs. tamponade Extrapulmonary TB is seen more commonly today than in the past in settings of high HIV prevalence

Inflammatory ILD

What spreads to surrounding interstitial tissue causing disruption of the tissue, loss of alveoli function, and resulting in fibrosis and scarring of the functional tissue. Progressive irreversible fibrosis (scarring) leads to loss of pulmonary elasticity and gas exchange.

Gold

What staging system has been criticized for excluding extra-pulmonary COPD manifestations in predicting outcome The BODE index addresses this criticism by including Body Mass Index, Airflow Obstruction, Dyspnea and Exercise capacity in the calculation

Pulmonary angiogram

What test is the most sensitive and specific for PE?

Lateral decubitus view

What view should you get on a CXR for pleural effusion?

hilar and mediastinal adenopathy

What will be seen on a chest radiograph with histoplasmosis?

Normal

What's the most common finding on CXR in PE?

COPD

Wheezing Barrel chest (Increased AP diameter) Decreased breath sounds Crackles at lung bases Depressed diaphragm Pursed lip breathing Prolonged expiratory time Use of accessory muscles Digital Clubbing (+/-) Peripheral edema What physical exam is this for?

False (higher)

When COPD symptoms begin, the patient has already lost 25% of lung function-T or F

HRCT

When a lung biopsy is required, What scanning is useful for determining the most appropriate area from which biopsy samples should be taken?

Crackles

When air passes over retained airway secretions. Or the opening of collapsed airways. Fine = soft very short and high pitched (pulm fibrosis and pulm edema) Coarse = Loud long and low pitched (excess secretions) Discontinuous in sound.

Severity (but is debatable)

When is it necessary to prescribe an antibiotic for COPD exacerbation?

Radiograph

When patients present with fever, chills, or cough, pneumonia is suggested on the basis of focal or diffuse opacities The vast majority of opacities appear within 12 hours When patients are referred from the community to the radiologist, adequate time has usually lapsed for its detection In immunosuppressed patients, especially those with coexistent neutropenia, diabetes, alcoholism, or uremia, the appearance of infiltrates may be delayed Other findings that suggest the presence of pneumonia Air bronchograms Silhouette sign Parapneumonic effusions Complications of pneumonia, such as lung abscesses, and atelectasis Bilateral pleural effusion and multilobar pneumonia have been associated with an increased mortality Bacterial pneumonias usually tend to be unilobar and have cavitary lesions and effusions Atypical pathogens can cause multilobar involvement with nodular or reticular infiltrates, lobar or segmental collapse, or perihilar adenopathy What lab imaging is this?

D

Which of the following characteristics of aspirated pleural fluid is diagnostic of an exudative pleural effusion? A. Fewer than 1000 white blood cells/mcL with a predominance of mononuclear cells B. Ratio of pleural fluid protein to serum protein less than 0.5 C. Pleural fluid creatinine greater than serum creatinine D. Ratio of pleural fluid lactate dehydrogenase (LDH) to serum LDH greater than 0.6 E. Pleural fluid glucose equal to serum glucose

D

Which of the following is not a part of virchows triad? a. Hypercoagulability b. Stasis to flow c. Vessel injury d. History of previous DVT

C, D (B-for asthma, E-helpful for bronchitis, F-has to be less than 50 like 30)

Which of the following statements about the diagnosis and treatment of COPD is true? A. ABG's are necessary for diagnosis. B. Inhaled corticosteroids are first line treatment for stage I COPD. C. Oxygen treatment is the only therapy that changes the natural history of the disease. D. A ½ PPD smoker age 35 who has been diagnosed with COPD should be tested for alpha I antitrypsin deficiency. E. Chest percussion is particularly helpful for patients with emphysema type COPD. F. If the baseline FEV1 is 50% predicted during a acute exacerbation, oral prednisone 10 mg a day should be added to the chronic regimen.

C

Which of the following studies is the most specific for a pulmonary embolism? A. Arterial blood gas B. Chest x-ray C. Computed tomography (CT) angiogram of the chest D. Peak expiratory flow rate E. Venous Doppler study of the lower extremities

Inflammatory

Which one is irreversible, inflammatory or graulomatous?

Small cells

Which one is less common and worse to get-virulent with lung cancer: small cell or non-small cell?

Supraclavicular

Which one is worse supraclavicular or subcostal retractions?

Exudative

Which ones need a chest tube? Bacterial infections -Empyema Some malignant effusions What about the rest? Treat the underlying cause If effusion is large, patient needs a thoracentesis What if it doesn't resolve Chronic exudate leads to fibrosis, 'trapped' lung What is this treatment for with pleural effusion?

Transudative

Which ones need a chest tube? None Treat underlying cause Transudates do not cause fibrosis What about LARGE transudates? Thoracentesis for relief (ex. CHF ) What is this treatment for with pleural effusion?

ARDS

While many medical and surgical illnesses have been associated with the development of what, most cases (>80%) are caused by a relatively small number of clinical disorders Severe sepsis syndrome and/or bacterial pneumonia (~40-50%) Trauma Multiple transfusions Aspiration of gastric contents Drug overdose The risks of developing what are increased in patients with more than one predisposing medical or surgical condition. Several other clinical variables have been associated with the development of what Older age Chronic alcohol abuse Metabolic acidosis Severity of critical illness

Fibrotic

While many patients with ARDS recover lung function 3-4 weeks after the initial pulmonary injury, some enter a fibrotic phase that may require long-term support on mechanical ventilators and/or supplemental oxygen The alveolar edema and inflammatory exudates of earlier phases are now converted to extensive alveolar-duct and interstitial fibrosis Emphysema-like changes occur Formation of large bullae Increased risk of pneumothorax Reductions in lung compliance Increased pulmonary dead space causes progressive vascular occlusion and pulmonary hypertension What phase is this?

Chest radiograph

Will often be the initial suspicion of ILD Reveals a bibasilar reticular pattern The radiographic finding of honeycombing usually is associated with a poor prognosis Typically, the chest radiograph is nonspecific and usually does not allow a specific diagnosis Always compare to previous films for baseline and progression of disease What diagnostic is this for ILD?

Needle decompression and chest tube insertion

You are called to the bedside of a 52 y/o man in the ICU. He is being treated for sepsis. He has become acutely tachycardic, hypotensive, and his oxygen requirement has increased. A left subclavian line was placed 20 minutes ago. The trachea is deviated to the right. What is your immediate plan of action? Needle decompression and chest tube insertion. CXR and thoracentesis. ECG CBC and CMP CT

(Most likely has emphysema) Flattened diaphragm Middle blebs

Your patient was hospitalized for pneumonia, but complains of chronic breathing problems. On examination you observe a thin male in his 50's with barrel chest and pursed lip breathing who speaks in short jerky sentences. Lungs have decreased breath sounds and are hyperresonant to percussion throughout. An x-ray was taken to assure that the pneumonia was cleared. What other finding do you expect to see on the chest x-ray and why?

Mixed

an apnea that begins as a central apnea and ends as an obstructive apnea

AHI (apnea/hypopnea index)

assesses severity by measuring the number per hour of sleep (>5 diagnostic for OSA; >30 equals severe OSA)

Isoniazid

bactericidal - inexpensive - easily tolerated - hepatotoxicity What TB med is this?

Rifampin

bateriocidal - easily tolerated - less hepatotoxicity - Competes with multiple medications (OCP, steroids, warfarin, retrovirals, and methadone). Excreted as a 'red dye' through body fluids. What TB med is this?

IRV

breathe in as much as possible is what on lung volumes and capacities?

CT

can find lesions too small for plain CXR Test of choice to evaluate early bronchogenic spread May better define cavitary lesions, nodules or branching linear densities. What test is this with TB?

Silicosis

caused by inhalation of crystalline quartz dust Seen in miners, sandblasting, stone cutting, sand blasting, granite quarrying, glass manufacturing and others Pulmonary fibrosis due to what exposure occurs in a dose-response fashion after many years of exposure. May be progressive despite discontinuation of exposure May benefit from 'whole lung' lavage-wash out

Squamous

central tumors are usually what with lung cancer?

Central apnea

cessation of airflow because the brain stops sending signals to the muscles of respiration

Obstructive

cessation of airflow during sleep with persistent respiratory effort - most common

Moderate Obstructive Sleep Apnea

classified as those with an AHI between 15-30 respiratory events per hour of sleep These pts are typically aware of daytime sleepiness and take steps to avoid falling asleep at inappropriate times (ie: take naps) They are able to continue daily activities but at decreased levels; may have more MVA's etc Systemic HTN may exist but cor pulmonale usually absent Responds to positive airway pressure with some improvement in symptoms

Mild obstructive sleep apnea

classified as those with an AHI between 5-15 respiratory events per hour of sleep These pts may be relatively asymptomatic or report sedentary waketime sleepiness. The daytime sleepiness often does not impair daily life Sometimes daytime sleepiness may become apparent to the patient only after it improves due to wt loss, ETOH abstinence or treatment of OSA Sleep stages generally well preserved and HTN, cor pulmonale and polycythemia are generally absent

Pleural effusion

decreased breath sounds decreased chest expansion on affected side dullness to percussion decreased tactile fremitus Egophony- changes above fluid level Pleural Friction Rub Vitals vary Hypotensive vs. Hypertensive Fever vs. Afebrile What physical exam is this for?

Pleurisy

describes a benign, self-limited process

Light's

diagnostically differentiates between a transudative and exudative pleural effusion; Pleural fluid protein/serum protein ratio greater than 0.5 Pleural fluid LDH/serum LDH ratio greater than 0.6 Pleural fluid greater than ⅔ upper limit of normal serum LDH Exudate if any 1 of the above criteria is met, otherwise usually transudate What criteria is this?

ABG

do not confirm or rule out PE Results may reveal Hypoxea Hypocapnea Respiratory Alkalosis (pH >7.5, Serum bicarbonate and paCO2 decreased) What lab analysis for PE is this?

Pleuritis

emphasizes the inflammatory basis of the complaint, and spurs a search for the cause

ERV

end of normal expiration blow rest of air out is what on lung volumes and capacities?

Brachytherapy

given directly inside the airway to target obstructing lesions-in prostate cancer-put chemo capsules in there to diminish cancer cells that did not clean out-good for slow growing cancers What is this?

Electrooculogram

helps determine when sleep actually occurs; electrodes will pick up the activity of the eyes in virtue of the electropotential difference between the cornea and the retina; helps determine when REM sleep occurs

Electromyogram

helps to detect limb movement disorders

Eosinophils

infiltration is a characteristic feature of asthmatic airways Allergen inhalation results in a marked increase in activated eosinophils in the airways at the time of the late reaction These are linked to the development of airway hyperresponsiveness through the release of basic proteins and oxygen-derived free radicals This recruitment involves adhesion of eosinophils to vascular endothelial cells in the airway circulation What pathophys is this with asthma?

Obstructive sleep apnea

is a common chronic disorder of repetitive collapse of the upper airway during sleep that often requires lifelong care (complete cessation of breathing), hypopneas (partial obstruction), or respiratory effort related arousals Daytime symptoms attributed to disrupted sleep such as sleepiness, fatigue or poor concentration Signs of disturbed sleep such as snoring, restlessness or resuscitative snorts

Sleep apnea

is a disorder in which you have one or more pauses in breathing or shallow breaths while you sleep

Alpha 1 antitrypsin deficiency

is a naturally occurring enzyme that protects from lung damage Some are born with a gene variant that results in a deficiency of alpha-1 antitrypsin Consider family history Emphysema begins in 3rd decade Hepatic cirrhosis and carcinoma risk develop emphysema in Teens/20s They MUST quit smoking!!! People with this deficiency who don't smoke may never develop symptoms Treatment - Alpha 1 AT augmentation.... Weekly IV infusion You must not smoke to be eligible!

Obstructive sleep apnea

is an important disorder because patients are at increased risk for poor neurocognitive performance and medical disorders due to repeated arousals and/or hypoxemia during sleep over months to years There is a 3-6 fold increased risk of all-cause mortality in patients with untreated severe OSA vs those without OSA

Chronic bronchitis

nonspecific bronchial or vascular marking what radiographic finding is this?

Diffusion

occurs when there is gas exchange between the alveolar air and the pulmonary blood circulation through "respiratory membranes"(air-blood barrier) Gases have diffusion coefficients. It is of note that CO2 has a diffusion coefficient that is 20x that of O2.

HRCT

of the chest is typically obtained to evaluate abnormalities seen on a chest radiograph or to evaluate unexplained dyspnea or cough in a patient with a clear chest radiograph Hilar and mediastinal lymphadenopathy Beaded or irregular thickening of the bronchovascular bundles Nodules along bronchi, vessels, and subpleural regions Bronchial wall thickening Ground glass opacification Parenchymal masses or nodular consolidation, occasionally with cavitation Parenchymal bands Cysts Fibrosis with distortion of the lung architecture and traction bronchiectasis scanning typically reveals a mid-to-upper zone predominance of the lung parenchymal changes.

Infection (Staph-MRSA?)

pH 6.8, glucose 4 mg/dl, gram+ cocci on gs What underlying cause is this with exudative effusion?

Pneumonia

pH 7.0, glucose 5 mg/dl, gs/cx negative; pt has pneumococcal pneumonia What is the underlying cause of these exudative effusions?

TB

pH 7.3, glucose 40 mg/dl, Adenosine Deaminase Elevated What is the underlying cause of these exudative effusions?

Acidosis Respiratory Uncompensated

pH 7.33 PaCO2 52 HCO3 24 PaO2 65 Acidosis or Alkalosis? Respiratory or Metabolic? Is this compensated or uncompensated?

Transudative (low protein and LDH)

pH 7.4, glucose 90, protein 0.04 mg/dl, LDH Transudative or Exudative?

Exudative (protein over 0.5 and LDH over 0.6)

pH 7.4, glucose 90, protein 8 mg/dl, LDH 220 Transudative or Exudative?

Alkalosis Metabolic Uncompensated

pH 7.48 PaCO2 40 HCO3 28 PaO2 90 Acidosis or Alkalosis? Respiratory or Metabolic? Is it compensated?

Hering-Breuer reflex

protective reflex initiated by extreme overinflation of the lungs; initiates expiration

Simple Mask

ran between 5-8 L/M DO NOT RUN BELOW 5 L/M The less flow is not enough to flush CO2 from the mask. Delivers 30-55% FiO2 Great for patients that are mouth breathers

Voriconazole (Vfend)

reserved for serious refractory disease. What med is this for histoplasmosis?

Amphotericin B

reserved for severe or refractory disease due to its potential toxicity. What med is this for histoplasmosis treatment?

Medullary Respiratory Centers

responsible for respiratory rhythm nerve impulses travel along the phrenic and intercostal nerves to excite the diaphragm and external intercostal muscles respectively

Positive airway pressure

splints the upper airway open and is generally considered first-line therapy for OSA CPAP (continuous positive airway pressure) Delivers pos. airway pressure at a constant level It is used most often b/c it's the simplest, most studied and associated with the most clinical experience *Only about 75% of patients continue to use CPAP regularly > 1 year* Supplemental oxygen may be added for severe desaturations, but may lengthen apnea

Pneumotaxic Center (pons)

take deep breath and then stops it exerts inhibitory effects on the medulla

Right Axis Deviation

tall R waves in the right precordial leads (V1-V3), and deep S waves in the left precordials (V4-V6) What is this on EKG for PE?

P pulmonale

tall, narrow, peaked P waves usually in leads II, III and AVF What is this on EKG for PE

Surgery

treatment appears to be most effective in patients who have OSA due to severe, surgically correctable, obstructing lesion (i.e.: tonsillar hypertrophy) There is no consensus regarding the role of surgery in the absence of such a lesion Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure that is performed in this context

Bronchodilator Therapy

β Adrenergic agonists Albuterol short acting Salmeterol long acting Albuterol decreases the amount of damage occurring to the mucosal layer of the lungs. There is a significant amount of bronchodilation However, there is not significant evidence to show improvement long term in the FVC or FEV1 Both improve mucus transport in the lungs.