Pulm/HEENT Anki
if Q=0 it means?
" dead space" no blood supply for the lungs ex: PE
atypical pneumonia is commonly referred to as?
"walking pneumonia"; transmitted by respiratory droplets has 2-3 weeks incubation period
What do the different generation of Cephalosporins cover for?
*1st Generation:* mostly gram + coverage *2nd Generation:* gram + (cocci), some gram - *3rd Generation:* more gram - coverage & less gram + coverage than 2nd generation *4th Generation:* very broad spectrum
How long should otic drops be allowed to sit in the ear?
*20 Minutes*
How long should you treat a patient with CAP who is NOT admitted to the hospital?
*7-10 days for most treatments* *Exceptions:* 5 days for Azithromycin & Levaquin (750mg)
What are the systemic corticosteroids that are used for Burst Therapy? How long does Burst therapy usually last?
*Burst Therapy:* 3-10 days average -Prednisone (sterepred) -Methylprednisolone (medrol) -Dexamethasone (decadron)
What are the contraindications and important SE of beta blockers used for POAG? What is a way to minimize these SE's?
*Contraindications:* -Reactive Airway Disease, CHF, 2nd or 3rd degree heart blocks *Side Effects:* -Systemic: ↓ HR & BP, negative inotropic effects (CHF), bronchospasm *Nasal Lacrimal Oclusion technique may reduce side effects*
What is the MoA for Beta-2 Adrenergic Agonists?
*Direct stimulation of B2 receptor leading to... -Airway smooth muscle relaxation *(Bronchodilator)* -↑ mucociliary clearance -Mast cell stabilization
What is the treatment strategy for Primary Open Angle Glaucoma?
*First-Line Agents:* -*Prostaglandin Analogs* (-prost) -*Beta Blockers* (-olol) -Alpha 2 Agonists Other Options: -cholinergic agonists -carbonic anhydrase inhibitors -miotics Last Line Treatments: -laser therapy -Surgery
What form of the Influenza vaccine uses the inactivated virus and what form uses the live attenuated virus? What ages can get each form?
*Inactivated Virus:* IM injection -age > 6 months *Live Attenuated Virus:* Nasal Spray -age 5-49, non pregnant
*RR X Vt= ??*
*MV*
What is the MoA for Alpha-2 Agonists used in POAG? What are some of the big SE's to be aware of?
*MoA:* -decreases rate of aqueous humor production *Side Effects:* -Use cautiously in pts with CV disease, renal impairment, & DM
What severe complication is possible in immunocompromised patients with Otitis Externa and how is it managaed?
*Necrotizing or Malignant Otitis Externa* Management: antibiotics against pseudomonas -ciprofloxacin
How quick is onset and what is the duration of LABA's?
*Onset:* 20-30 minutes *Duration:* up to 12 hours
How quick is onset and the duration of SABA's?
*Onset:* < 5 minutes *Duration:* 4-6 hours
What symptomatic treatment may be done with patients with acute otitis media? What should not be used?
*Pain Relievers* -acetaminophen -ibuprofen -antipyrine/benzocaine (analgesic ear drops) *Decongestants and/or antihistamines NOT recommended*
What is the most common pathogen associated with Acute Otitis Media (AOM)?
*Strep Pneumoniae (25-50%)* -generally requires antibiotics to treat other two most common if you want to know... -H. Influenza -Moraxella Catarrhalis (Both of these generally spontaneously resolve in 24-48 hours)
What is the treatment strategy for Viral Rhinitis (common cold)?
*Treatment (Supportive)* -Rest -Decongestants -Expectorants -Analgesics -Cough suppressant (If interfering with rest)
What antibiotics are used for bacterial sinusitis?
*Uncomplicated sinusitis* Amoxicillin (double dose) Clarithromycin Azithromycin *2nd Line Agents* Amoxicillin/clavulante (Augmentin) Cefuroxime (Ceftin) Cefixime (Suprax) *USE FOR 10-14 DAYS*
What are the most common causes of Sinusitis?
*Viral most common* -Bacterial: Strep pneumoniae, H. influenza, M. catarrhalis -Allergic
diffusion is _____ limited
*distance*
*_____ precedes (and drives) hypoxemia*
*hypercapnia*
pressure = ???/???
*pressure = Force/Area*
reactivity/ bronchodilator response is defined as...?
+ 200 cc, and 12% by ATS guidelines
how do you manage bronchiolitis?
- ADMIT to hospital! - humidifed O2 - nasal suctioning * steroids controversial and bronchodilators are commonly used by are not useful
what drugs could act as triggers for asthma?
- ASA - beta blockers
what are the 2 different surveys we can give to pts to assess their GOLD group?
- CAT (COPD Assessment test) - mMRC (modified medical research council dyspnea scale)
what are labs you want to order for a suspected ILD patient?
- CBC, CMP, TSH - BNP: check for heart failure - HIV - ANA and RF (rheumatoid factor) - ANCA - angiotensin converting enzyme (ACE)
what are the 3 most common causes for transudate effusions?
- CHF - nephrosis - hepatic hydrothorax: seen with end stage liver dz
what are examples of obstructive diseases?
- COPD - asthma - bronchiectasis - cystic fibrosis - bronchiolitis
how do you treat vocal cord dysfunction?
- CPAP - heliox (helium o2) long term: - speech therapy - psych eval depending on cause
how is hyaline membrane disease (infant respiratory distress syndrome) managed?
- CPAP; keep alveoli open - supplemental o2 for sat >90% - intubation might be needed - consider exogenous surfactant (expensive)
list predisposing factors for aspiration pneumonia (x7)
- Etoh/drugs - seizures - impaired LOC - recent anesthesia - swallowing disorders - poor oral care - GERD
describe the MCT procedure
- FEV 1 at baseline - pt inhales concentrations of methacholine while you measure FEV1 - if a 20% response is shown, give an inhaled bronchodilator - take 6 measurements and if 20% decrease is not achieved the test is negative
how do you treat CAP (outpatient) in a healthy adult that had recent abx use or has comorbidities?
- FQs (moxifloxacin. gemifloxacin, levofloxacin) OR beta lactam PLUS macrolide for 5 days
what are important values in spirometry?
- FVC - FEV 1 - Ratio
list contraindications for thrombolytic therapy?
- Hx of CVA in the past 6 months - any prior hx of hemorrhagic stroke - CNS stroke - Hx of GI bleed in the past month - any known risks of bleeding - trauma or surgery in the past 3 weeks
when treating status asthmaticus, in addition to continuous neb. beta 2 agents, what else should be added?
- IV steroid like solumedrol - consider adding short acting muscarinic antagonist like atrovent
how do symptoms of histoplasmosis present?
- MC presentation is asymptomatic - subacute pulmonary infection for weeks to months (mild). - sore throat is uncommon.
what are risk factors for spontaneous pneumothorax
- Male - 20-40 y/o - smoking - family hx - recurrence
how do you treat status asthamticus?
- O2 - IV steroids - inhaled beta agonists neb with/without atrovent - mucolytic therapy - eval. for MV * antiobiotics if signs or infection
what are 3 causes for acute Cor Pulmonale?
- PE - Withdrawal of pHTN meds - ARDS * patients with pHTN are usually on vasodialtors. disconnecting them will cause acute constriction leading to higher pressures and failure of the right ventricle.
what can decrease DLCO?
- PE: lack of blood flow - emphysema - lung resection - less surface area - pulmonary fibrosis (sarcoidosis, lupus, pneumonia) - anemia - increase level of carboxyhemoglobin - scledroderma
what are diagnostic tests for asthma?
- PFTs - FeNO (Exhaled nitric oxide) - Methacholine challenge study
TB diagnosis workup
- PPD - CXR - sputum AFB ( x 3 times on separate days): stain for bacilli - sputum cultures ( 6 weeks to come back) * cultures might guide your treatment choice
what are 4 causes for typical bacterial PNA?
- S. pneumoniae - H. influenze - S. aureus - Klebsiella pneumoniae
how do you treat severe exacerbations?
- SABA - ipratripium - IV corticosteroids - Mg sulfate IV (severe cases) - monitor sats - ABG CXR if needed
how does acute bronchitis present?
- URI symptoms initially (congestion, nasal drip, facial pressure) - *develop cough that persists >5 days*, usually 10-20 days - sputum production 50% of pt - no fever usually
severity of PAH is based on?
- WHO functional class - exercise capacity/ 6MW - echo - labs/ hemodynamics
risk factors for multi drug resistant pathogens
- abx therapy in last 90 days - current hospitalization >5 days - high freq, abx resistance in community - risk factors for HCAP
what are the 3 categories of pulmonary embolism?
- acute PE - submassive PE - massive PE
how do you manage CF?
- airway clearance - abx - corticosteroids- controversial - dornase alfa: mucolytic not often used - hypertonic saline - CFTR modulator therapies
upper airway cough syndrome can be caused by (4x)?
- allergies - rhinitis - sinusitis - acute nasopharyngitis
what 2 drugs are controversial in their role for the treatment of status asthmaticus?
- aminophylline - magnesium sulfate
what can cause a decrease in DLCO?
- architectural destruction of the lungs - lack of taking in DEEP breaths like with some restrictive patterns: scoliosis and obesity - methotrexate, PHTN, emphysema, fibrosis
what are CF prenatal tests?
- assessment of immunoreactive trypsinogen (IRT) - confirmation of positive IRT by CF gene mutation analysis - confirmation of results with sweat test
what is the asthma triad?
- asthma - nasal polyposis - ASA allergy
Allergic bronchopulmonary aspergillosis
- asthma resistant to bronchidiallator - central airway bronchiectasis - hyperimmune response * part of bronchiectasis etiology
what is the asthma triad?
- atopy - nasal polyposis - ASA allergy
list the causes for DVT?
- autoimmune - pregnancy - cancer - surgery - trauma - exogenous hormone use - genetic deficiencies
where do histoplasmosis spores typically grow? what questions should you ask if you suspect it?
- bird or bat droppings: spores grow in soil. areas like chicken coops, farm buildings and caves are common locations. - ask pt if they are a farmer (raising chickens), recent cave dives? or travel to the midwest
epiglottitis workup
- blood cultures: 70% of Hib in kids - throat cultres are negative - epiglottic cultures can help - direct visualization! with fiberoptic laryngoscopy - CBC - Lateral neck x-ray
what can cause elevated DLCO?
- blood in alveoli - pulm hemorrhage
phlegmasia cerulea dolens is?
- blue leg (ischemic) progression from white leg. - caused by blockage of multiple major veins in the leg - most pts have DM or cancer - common in elderly - can become gangrenous
what is the asthma presentation triad?
- bronchospasm - mucus production - airway inflammation
How is diffusing capacity measured?
- carbon monoxide diffused into lung - measures amount of CO binding to RBC - pt takes a deep breath and holds it for 10 sec - it measures the surface area of the lungs * help differentiate diagnosis of restrictive lung dz; the lungs could be completely find like in obesity, an extrinsic pattern
what are indications for IVC filter?
- caval DVT - if pt has contraindications to anticouagulants - if pt clots even when on therapy
what are 2 types of emphysema?
- centrilobular: involves bronchioles - panacinar: alpha 1 antitrypsin deficiency
what occupations are at risk for berylliosis?
- ceramics - machining - rod and wire making - automotive - computers - aerospace - jewelry making
CV blood flow is mediated by (4x)?
- chamber contraction - valves - pressure gradients - vessel compliance
how do you manage patients with bronchiectasis who suffer from frequent pseudomonas?
- chronic abx: change abx every month or two to avoid resistance.
list some common COPD symptoms
- chronic, productive cough (can be dry) especially in the morning - wheezing - chest tightness/heaviness - recurrent acute bronchitis - air hunger/increase WOB * remember that symptoms can happen late, after 50% of lung function is lost!
milky pleural fluid indicates?
- chylothorax - cholesterol effusion
treatment for aspiration pneumonia?
- clindamycin - carbapenem - beta lactam/ beta lactamase inhibitor
Caplan's syndrome can be seen in patients with what conditions?
- coal worker pneumoconiosis - silicosis - asbestosis
what are the 3 D's of epiglotitis?
- dysphagia - drooling - distress
how does histoplasmosis present on CXR?
- enlarged hilar or mediastinal lymph nodes with focal infiltrates
treatment for bordetella pertussis (whooping cough)
- erythromycin x 14 days - zithromax (z-pak) - clarithryomycin - bactrim DS
most common antigens to cause hypersensetivity pneumonitis are:
- farming/ moldy hay ("farmer's lung") - poultry workers lung - exposure to ventilation systems and water reservoirs ("humidifier lung") - gran and flour processing/molds - lumber milling, construction, bark stripping - textiles
what are symptoms of pneumocystis jirovecii pneumonia (PJP)?
- fever - *NON* productive cough - difficulty breathing
to diagnose ventilator aquired pneumonia pt needs to have a new infiltrate on CXR plus 2 of the following....
- fever - elevated WBCs - purulent trach secretions
how does active TB present?
- fever, night sweats, wt loss, fatigue, dyspnea - cough, hemoptysis - lasts >3 weeks * may be fever alone for weeks - immunocompotent people get over it and stay with latent TB, 10% of people will have a reactivation at a random time. might never have symptoms with initial infection
69 y/o female presents with fever, chills, productive cough and aches. states started 24hrs ago. denies recent hospital visits or abx in the past 6 months. PE: RR: 32, HR:110 spo2: 89% crackles RLL. - what is the first step? - should you admit? what treatment should you give? - what is the most likely organism
- first get CXR - admit because meets criteria. give levolfoxacin x 5 days. if you would rather give azithromycin make sure to add cephlosporin. - strep pneumo: most common for CAP and symptoms occur within first 24hrs
how often should histoplasmosis patients be followed up?
- follow for 5 years * CXR every 6 months
predictive values for PFTs are generated by the software based on?
- height - age - gender - race
what are the 4 types of exudative pleural effusions?
- hemothroax - chylous - parapneumonic/complex - empyema
once the lung is full, the pressure inside the lung is ______
- high, in this case once the lung is full the pressure inside is high and the volume is high. * note: In order to get air in the lung in the first place a pressure gradient must exists; meaning pressure in the lung must be lower while pressure outside must be higher. However, once the lung is full of air the pressure inside the lung is high. like a balloon that is already inflated with air.
other than immunocompromised individuals who are at higher risk for TB, what general populations are at increased risk for TB?
- homeless shelters - nursing homes - prisons - immigrants - alcoholism
what are risk factors for Healthcare-associated pneumonia (HCAP)?
- hosp. > 2 in past 90 days - home infusion therapy - chronic dialysis - home wound care - family member with MDR pathogen - immunosupressive dz/therapy
GOLD scores are based on what 3 things?
- hx of exacerbations - FEV 1 - how it effects activities of daily living
asthma diagnosis MUST include?
- hx/ presence of respiratory symptoms that are consistent with asthma AND variable expiratory airflow obstruction via spiro.
when would you need to order a CXR on an acute bronchitis pt?
- if abnormal vitals - rales on chest exam - advanced age >75 - has underlying pulm. dz * if pt is healthy CXR not needed even if small amt. of wheezing present
what is the treatment for coccidiodomycosis?
- if healthy without severe infection antifungal not needed - if severe or pt at risk: treat with: fluconazole or itraconazole if mild for severe: treat with amphotericin B for 3-6 months * follow up for 2 years
what are characteristics of pneumonia caused by Pseudomonas aeruginosa?
- increased risk with HAP and immunocompromised pts - pts with recent abx use - green foul smelling sputum - CXR variable can be focal or diffuse infiltrates - seen with bronchiectasis, CF, and COPD
if lung cancer pt experiences rapid re accumulation 1 month after thoracentesis, what should be the next step?
- indwelling pleural catheter - pleuradesis
what is the definition of acute bronchitis?
- inflammation of the bronchi due to upper airway infection - cough lasting > 5 days - usually 1-3 weeks - usually with sputum production
what are causes of pleuritis?
- inflammation/ autoimmune dz - infection (viral/bacterial) - radiation - PE - pneumothorax - trauma
list physical exam findings with pneumonia
- inspection: conversational dyspnea, use of accessory muscles, mediastinal shift - vitals: increase HR, RR - lymphadenopathy - dullness to percussion - crackles, rales, egophany (E -> A)
what are 3 diffusion disorders?
- interstitial lung disease - alveolar disease - pulmonary vascular disease * there are plenty more but not needed for now
intrapleural pressure is always negative, what happens to this pressure when you inhale?
- it becomes more negative (goes down). it drags alveolar pressure with it. - during expiration intrapleural pressure becomes less negative (but never positive unless disease/trauma).
what role does bronchoscopy play in bronchiectasis?
- it helps to identify the obstruction if its foreign body, tumor, deformity, etc... - bronchoalveolar lavage can localize bleeding
how can right heart cath help us with the diagnosis of PAH?
- it is required to confirm PAH - evaluate the severity of PAH - exclude left sided heart disease - assess vasodilator response - assess hemodynamics
in order to inhale, what must happen to alveolar pressure?
- it must go down! when you exhale it will go back up - in order to get air into the lung we have to decrease the alveolar pressure by expanding the chest wall
what anatomical features make peds different than adults (airway wise)?
- large head, small neck - large posteriorly placed tongue - high glottic opening - small airways - enlarged tonsils
list common findings seen with emphysema on CT
- lungs look much bigger than the heart - lungs are hyperinflated - AP diameter 1:1 barrel chest - lots of black= air, not much white lung tissue (destruction of alveoli) - Bullae- air trapped pockets concerning finding high risk for pneumothorax
how do you treat CAP (outpatient) in healthy adults that were not on abx in the past 3 months
- macrolide (azithromycin, clarithromycin, erythromycin) OR doxycycline for 5 days
what factors influence vital capacity?
- male vs. female - age - respiratory muscle strength - posture - pregnancy
red/blood pleural fluid indicates?
- malignant - asbestos - exudative
what 3 criteria must be met to diagnose PAH?
- mean PAP > 25 mmHg - PAWP < 15 mmHg - PVR (pulmonary vascular resistance) > Wood units
how do you read a PPD?
- measure induration, not erythema - do not use a band aid - 20% of adults with active TB do not respond to PPD - remember that a person that has been exposed to TB at any point in their lifetime might have a positive test
how do you treat histoplasmosis?
- most cases are self limited - severe or immunocompromised should be treated with itraconazole - if severe; amphotericin B
what tests are used to diagnose bordatella pertussis?
- nasopharyngeal culture - PCR - serology (antibody titers) * do not wait for tests results to start treatment
what might you find on CT with blastomycosis?
- nodules, consolidation, "tree in bud opacities" (a nonspecific imaging finding that implies impaction within bronchioles)
what are supportive treatment options for pHTN?
- o2: to reduce vasoconstriction - diuretics: decrease RV wall stress and RHF symptoms - digoxin: control A fib - dobutamine/nitric oxide: consider in decompensated PAH - anticoagulation
normal DLCO with reduced TLC and VC= what conditions?
- obesity - pleural effusions - neuromuscular weakness - kyphoscoliosis
to diagnose bordatella pertussis, pt must have a cough lasting 2 weeks without cause + one of?
- paroxysmal coughing - inspiratory whoop - posttussive emesis
what is the pathophys behind histoplasmosis?
- particles inhaled and cause acute pneumonia. macrophages ingest but cannot kill it. in a healthy individual this will not cause illness, cell immunity occurs within 2 weeks. however, if pt is immunocompromised symptoms will occur.
what are extrapulmonary symptoms for histoplasmosis?
- pericarditis - rheumatological - skin: * erythema nodosum or erythema multiforme*
if your pneumonia patient is at risk for pseudomonas what are your abx options?
- piperacillin- tazobactam, cefepime, imipenem or meropenem. PLUS cirprofloxacin or levofloxacin
give examples of direct lung injury that can result in ARDS
- pneumonia - aspiration of gastric contents - pulmonary contusion - near drowning - toxic inhalation injury
what are 2 common serious complications of influenza?
- pneumonia - ARDS * can also have CNS and cardiac involvement
what are the 4 major respiratory control centers?
- pneumotaxic (pons) - apneustic (pons) - ventral respiratory group (medulla) - dorsal respiratory group (medulla)
what can increase DLCO?
- polycythemia - left of right shunts - pulmonary hemorrhage - exercise
what 3 things modify stroke volume?
- preload - inotropy - afterload
what are risk factors for hyaline membrane disease (infant respiratory distress syndrome)?
- preterm infants - down syndrome - mothers w/ gestational diabetes
how can hyaline membrane disease (infant respiratory distress syndrome) be prevented?
- prevent preterm birth - prenatal glucocorticoids therapy (speeds up development of lungs)
what are the general treatment goals for pHTN?
- prevent/ reverse vasoactive imbalance and vascular remodeling - prevent RV failure (decrease wall stress, and manage diastolic BP) - treat and manage reversible and underlying causes of pulmonary HTN
what are some standard ICU strategies for ARDS?
- protect the lungs using ARDSnet - deep sedation (normally dont want to do this but with ARDS keep pt fully sedeated) - diuresis (dry out pt a little bit, prevents fluids overload) - paralyze (normally, dont paralyze people on the vent, with ARDS you want full control)
what are extra pulmonary features with mycoplasma pneumonia?
- rash: can be from mild to SJS and raynaud's - CNS: peripheral neuropathy, meningitis, ataxia - cardiac: CHF, myocarditis
how does bronchilitis present?
- recent URI - gradual onset of respiratory distress with increased WOB - expiratory wheezing - extreme tachypnea described by parents as child "breathing funny"
a 10mm induration will be concidered positive PPD in what type of patients?
- recent arrivals (<5yrs) from high prevalence countries - IV drug users - employees of prisons, hospitals, nursing homes - lab personnel - DM, steroids treatment, leukemia, renal dz - kids under 4
what can interfere with PFT?
- recent bronchodilator use - respiratory infections - pt effort/ inability to maintain seal - exercise (increased CO) - polycythemia interfere with DLCO - increased levels of COHb in smokers. - anemia decreases DLCO
what occupations are at risk for asbestosis?
- roofing - insulation work - pipe fitters - plumbing - construction - shipbuilding - breaks
low DLCO with reduced TLC and VC = what conditions?
- sarcoidosis - chest irradiation - pulm toxicity from drugs - rheumatoid dz
what are examples of restrictive diseases?
- scoliosis/ kyphosis (easier to breath when you can sit up) - phrenic nerve paralysis - fibrosis - obesity - ALS - pulmonary edema - extrinsic VS. intrinsic causes
give examples of indirect lung injury that can result in ARDS
- sepsis - severe trauma - multiple transfusions - drug overdose - pancreatitis - cardiopulmonary bipass
what 3 symptoms that occur together should make you think of ARDS?
- severe hypoxemia - absence of cardiac failure - diffuse bilateral infiltrates on CXR
what are the classifications for silicosis?
- simple silicosis - complicated silicosis - acute silicosis - caplan's syndrome
what is the pathophys behind TB?
- small TB particles enter the peripheral subpleural space - a macrophage picks them up and presents them to local lymph nodes - a granuloma forms in the subpeural space. - you also develop granuloma in the mediastinal lymph node
general guidelines for all ILD patients
- smoking cessation - refer to pulm. rehab - think about lung transplant early before things become worse - check for HIV and latent TB - make sure vaccines are up to date! - discuss code status
what 3 properties are tested with PFTs?
- spirometry - lung volumes - diffusion capacity (alveolar health)
what types of bacteria colonize children with CF?
- staph a. - MRSA - non typable H. flu - pseudomonas aeruginosa - burkholderia cepacia also: - candida - aspergilus fumigatus - nontuberculous mycobacteria
what are treatment options for costochondritis?
- stretching - heat - NSAIDs/tylenol - 1% diclofenac hel/ cyclobenziprin
why are functional tests important as part of the diagnostic workup for pHTN, give 2 examples of tests?
- the 6 MWT is a good baseline test. so at the time of diagnosis we get a baseline and we can compare this baseline as pt progresses with treatment - CPET (Cardiopulmonary Exercise Testing): measuring the amount of oxygen your body is using, the amount of carbon dioxide it is producing, your breathing pattern, and electrocardiogram (EKG) while you are riding a stationary bicycle.
what are contraindications of PFTs?
- there are no absolute contraidications, but consider your patient: - elderly - weak - too dyspnic - dementia: cant follow directions - hemoptysis/ pneumothorax
the berlin definition for ARDS is?
- timing: within 1 week of known clinical insult or woresning respiratory symptoms - chest imaging: bilateral opacities no explained by other etiology like effusions or nodules - origin of edema: not explaned by fluid overload or cardiac reasons - PF ratio grading
what are examples of 'fixed' airway types of obstruction?
- tracheal stenosis/ post intubation - goiter - endotracheal mass * hamburger sign on graph
what are examples of intrathoracic obsturction?
- trachemoalacia - airway tumor
what can cause chylous effusions?
- trauma - tumor invading thoracic duct - complications from surgery
how do you treat bronchiectasis?
- treat underlying disease if possible, at least prevent further damage - Fluroquinolones for 10-14 days for infections - IV abx for pseudomonas like FQs, aminoglycosides, azactams, or broad spectrum PCN
how do you treat pneumocystis jirovecii pneumonia (PJP)?
- trimethoprim/sulfamethoxazole * treat for 21 days in HIV pts, 14 days in others * steroids in severe cases
what are the 3 types of parapneumonic effusions?
- uncomplicated - complicated - empyemea
what are physical exam findings for ILD?
- usually non specific - "velcro rales" / crackles at the lung bases in the posterior axillary line on inspiration - finger clubbing - extra pulmonary findings gives clue to systemic disease - signs of cor pulmonale (peripheral edema, JVD, heaves, accentuated second heart sound)
what are examples of extrathoracic types of obstruction?
- vocal cord paralysis or constriction - laryngeal edema - OSA with upper airway narrowing
what are ways to prevent pts from getting ventilator acquired pneumonia
- wash hands - elevate head of the bed 30-40 degrees - orogastric rather than nasogastric feeding tube - oral care - maintain ETT cuff > 20 cmH2O - GI ppx - DVT ppx - Daily spontaneous breathing trial
what are common CXR findings with COPD?
- widened rib spaces - flattened diaphragms - elongated heart - can have basilar crowding of vessels due to apical bullae (seen w/ emphysema)
what are the 3 west zones?
- zone 1: no blood flow, has more air, it is on top - zone 2: moderate blood flow, moderate air; arterial pressure> alveolar pressure> venous pressure. the only zone with V/Q matching. the other zones are at mismatch - zone 3: greatest blood flow, least amount of air
What antibiotics drops/ointments may be used for treatment of a corneal abrasion?
-*Erythromycin* or sulfacetamide ointment -Bacitracin/polymixin B ointment (Polysporin®) -ciprofloxacin(Ciloxan®) -ofloxacin(Ocuflox®)
What is the treatment for allergic rhinitis?
-*Nasal glucocorticoids* -Allergen avoidance -Antihistamines -Decongestants -Mast cell stabilizers -Topical anticholinergics
How do corticosteroids help in asthma?
-*decrease airway inflammation* and edema -decrease mucus production -increase response to B2 agonists
What is the treatment for *early onset* or *low risk of multidrug resistant* infection HAP, HCAP or VAP?
-3rd Gen. Cephalosporin (ceftriaxone) -Respiratory Fluoroquinolones (moxifloxacin, gemifloxacin and levofloxacin)
Who is indicated to get the Pneumococcal Vaccines?
-Adults > 65 -Any patient > 6 years old with... chronic health conditions or conidtions that lower immune response (including medications) -Alaskan native & certain Native American Populations
What medication types are known to commonly cause acute angle closure glaucoma?
-Anticholinergics -Sympathomimetics
What are the AE's of anticholinergics?
-Blurred vision -Dry mouth -Urinary retention -Constipation *not as common when used in inhaled form*
What is the treatment for Keratoconjunctivitis Sicca (dry eyes)?
-D/C causative medication (if possible) -Ocular Lubricants /Mucomimetics -Cyclosporine (Restasis): *Chronic keratoconjunctivitis sicca* -Oral Cholinergic Agonists: Pilocarpine, Cevimeline (Evoxac®) -Refer for silicone plugging in canaliculi *if severe & unresponsive*
What is the MoA for Beta Blockers used for POAG?
-Decrease production of aqueous humor by the ciliary body
What are some AE's of *systemic* corticosteroids?
-Endocrine: HPA suppression & growth retardation, osteoporosis, hyperglycemia, truncal obesity -Psychiatric disturbance -Fluid/Electrolyte Abnormalities -Immunosuppression, impaired wound healing -Ophthalmic: glaucoma, cataracts -Thinning of skin
What group of people are highly recommended to get the influenza vaccine?
-Extreme Ages (>50, 6-23 months) -residents of LTC -Chronic Illness -Women who will be pregnant during flu season -anyone who is in close contact with any of the above populations
What is the MoA for Prostaglandin Analogs used in POAG? What is the one contraindication for them?
-Increases uveoscleral & trabecular outflow -Reduce IOP 25-35% *Contraindication:* inflammatory eye disorders (uveitis)
What is the MoA of anticholinergics?
-Inhibit the effects of acetylcholine on muscarinic receptors in the airway
What antibiotics are used in *uncomplicated exacerbations of COPD?*
-Macrolide OR -2nd/3rd Gen Cephalosporin OR -Doxycycline
What are some of the cautions with Theophyilline?
-Narrow therapeutic index, requires monitoring -lots of drug/drug interactions -AE's: headache, irritability, n/v, arrhythmias, seizures
When can you refer a child with serous otitis media for tympanostomy tube placement?
-Need to observe and have effusion >3 months prior to referral
What medication drops are used most commonly for Otitis Externa?
-Oflaxacin (Floxin Otic) -Ciprofloaxacin and Hydrocortisone (Cipro HC Otic) -Tobramycin and Dexamethasone (Tobradex) -Neomycin/Polymyxin B/Hydrocortisone (Cortisporin Otic) (difficult because it requires the most drops per day)
What are some potential AE's to ICS?
-Oral candidiasis -Dysphonia/Hoarseness *Typically due to oropharyngeal deposition* -can be reduced by rinsing mouth after use or by using a spacer
What are the most common organisms responsible for Otitis Externa?
-P. aeruginosa -S. aureus
Why are quinolones not usually used in pediatrics?
-Possible bone/joint problems
What things are preventaitive for AOM in children?
-breastfeeding during first 6 months -reduction of pacifier use during the second 6 months of life -eliminating exposure to passive tobacco smoke
When are mast cell stabalizers used in asthma and what is important to know about their dosing?
-mild persistent asthma and prophylacticly for allergen-induced asthma *takes up to 4-6 weeks for full effect*
pnemothorax will occur when transpulmonary preassure reaches?
0 and up
what 3 things can cause PE?
1) DVT 2) fat embolus 3) air embolus
what 2 guidelines you should follow to categorize asthma severity?
1) GINA guidelines- evidence medicine based on asthma control 2) NIH/ATS guidelines
what are the top 2 most common clinical symptoms with ILD?
1) SOB 2) persistent non productive cough * typically pts do well at rest. when they get up and try to go places its when they start coughing, no medication has helped them in a long period of time
urine antigens could detect what pneumonia?
1) Strep. pneumonia: sensitivity 50-80% and specificity > 90% 2) Legionella: sensitivity 70-90% and specificity 99%
What is the treatment strategy for Acute Angle Closure Glucoma?
1) Systemic Carbonic Anhydrase Inhibitor -acetazolamide IM injection 2) Topical medictions (usually a beta-blocker) 3) Iridectomy
*what are the 3 rules of respiration?*
1) air in/out; blood round & round 2) diffusion depends on surface area, distance, and pressure difference 3) O2- diffusion/Co2- ventilation
What is 1st line therapy for COPD?
1) anticholinergic 2) beta 2 agonist 3) glucocorticosteroid/methylxanthines
what makes up the pediatric assessment triangle?
1) appearance: tone, gaze, cry 2) work of breathing: falring, gasping, grunting, breath sounds 3) circulation: pulse, BP, skin
what are the 4 pulmonary pressures?
1) atmospheric pressure 2) transpulmonary pressure 3) intraplueral pressure 4) intra-alveolar pressure
what are 4 ways TB can present?
1) atypical 2) pleurisy 3) direct progression from primary TB to upper lobe involvement 4) systemic dissemination: children/ HIV pts
noncaseating granulomas on lung bx can be seen in what 2 conditions?
1) berylliosis 2) sarcoidosis
what are 3 major contributing factors to oxygen delivery
1) cardiac output (SV x HR) 2) Hb (more Hb more O2 binding) 3) SaO2 (how saturated with o2 Hb molecules are)
what are the 3 stages of bordetella pertussis?
1) catarrhal phase 2) paroxysmal phase 3) convalescent phase
restrictive defects can be due to 2 main reasons, what are they?
1) chest wall disease like rib fracture, kyphoscoliosis, or neuro muscular disease 2) interstitial lung disease: pneumonitis, fibrosis, pneumoconioses, granulomatosis, edema, sarcoidosis
what is the sequence (order) of pressure and air in the lung?
1) chest wall expands 2) intrapleural pressure goes down 3) alveolar pressure goes down 4) lots of air flows inside the lungs 5) once lots of air entered the lung, pressure INSIDE the lung goes UP
what are the 4 general types of pneumonia?
1) community acquired 2) health care associated 3) hospital acquired 4) ventilator associated
what are 2 ways for us to prevent RV failure?
1) decrease wall stress (decrease PVR, pulm arterial pressures and RV diameter) 2) ensure adequate systemic diastolic BP
what are 2 causes for hypoventilation?
1) drop in minute ventilation 2) increase in dead space
what are the 3 kinds of exudate effusions?
1) empyema ("pus" thorax) 2) hemorrhagic/hemothroax 3) chylous
list the 4 phases of ARDS
1) exudative 2) transition 3) proliferative 4) fibrotic * 3 and 4 sometimes combined called Fibroproliferative phase
what are the two final phases of ARDS?
1) fibrotic phase: patients are not going to recover from 2) recovery phase: lungs slowly going back to normal
During excercise we need more of zone 2. lungs can achive more zone 2 in two ways, what are they?
1) increase CO; more blood to zone 1 2) increase tidal vol; more air to zone 3
during physiological stress like aerobic workout, we can increase minute ventilation by?
1) increase tidal volume 2) dipping into IRV 3) dipping into ERV
what are 2 factors that lead to bronchiectasis?
1) infectious insult 2) host defense defect, impaired draining, airway obstruction * the point is that bronchiectasis does not present by it self, it is caused by something and you must treat that cause
what are 4 cateogories of asthma? what are they based on?
1) intermittent 2) mild persistent 3) moderate persistent 4) severe persistent * based on the most severe element
what are 3 types of shunts?
1) intracardiac shunt: R to L ventricle without going to lungs 2) alveolar shunt: ARDS 3) vascular shunt: AV malformations
what are 2 medications that appear to slow the dz progression in pt with mild to modreate IPF (idiopathic pulmonary fibrosis)
1) nintedanib (ofev)- tyrosine kinase inhibitor; causes diarrhea 2) pirfenidone (esbriet)- anti fibrotic agent; causes nausea and rash
what are 3 classifications for coal worker's pneumoconiosis?
1) simple coal worker's pneumoconiosis 2) complicated coal worker's pneumoconiosis 3) caplan's syndrome
what are 4 types of pneumothorax?
1) spontaneous/ primary 2) traumatic / iatrogenic 3) tension 4) secondary
what are the 3 types of PE?
1) stable 2) submassive PE 3) massive PE
what are the 3 types of histoplasmosis?
1) subacute pulmonary infection: may never get treated, typically resolves 2) acute diffuse pulmonary histoplasmosis: heavily contaminated soil, acute symptoms within 1 week 3) chronic pulmonary histoplasmosis: similar to reactivation TB
diffusion depends on 3 things what are they?
1) surface area: more area, more diffusion 2) pressure/ concentration difference 3) distance: more distance between 2 compartments decreases diffusion.
what are 6 things that are proven to help ARDS patients?
1) use lung protective strategies (ARDSnet) 2) deepen sedation 3) diuresis if able 4) paralyze 5) prone positioning 6) ECO
what makes up Virchow's triad?
1) venous stasis 2) endothelial damage 3) hypercoagulability
What is the standard duration for antimicrobial treatment of Acute Otitis Media?
10 Days
with asthma, FVC or FEV1 improves by at least ___ % and ____ cc after BD use or with 1 month of ICS use
12% and 200 cc
usually hospital acquired pneumonia is treated for 7 days, however if Pseudomonas is suspected treat for ____ days
14 days
FEV 1 >= 80% is GOLD grade ___?
1; Mild
When do you give antibiotics in COPD?
2 or more of the following symptoms: ↑dyspnea ↑sputum volume ↑sputum purulence
what are the general strategies behind ARDSnet?
2 parts: 1) low tidal vol, 6-8 kg/body wt 2) higher PEEP corresponding to FIO2 * can use ARDsnet to prevent ARDS * giving tidal volume based on pts "ideal body wt" not actual weight.
50% <= FEV 1 < 80% is GOLD grade ____ ?
2; Moderate
latency period between initial beryllium exposure and onset of symptoms varies from _____ to ____
3 months to 30 years
croup symptoms usually last for?
3-7 days; more common in males
subacute cough lasts?
3-8 weeks
30% <= FEV 1 <50% is GOLD grade ____ ?
3; Severe
ABX treatment for epiglottitis?
3rd gen ceph: ceftriaxone or cefotaxime in addition to antistaph like vanc (if MRSA). treat for 7-10 days. * steroids not recommended * epi not recommended
how long can a 'dry' cough last after acute infection subsides?
4-6 days of a persistent cough. pt is not infectious anymore just has left over sensitive airways. * you may give albuterol (sometimes corticosteroids) to a pt presenting with this.
you should assess the asthma pt every hour, if there is no significant improvement within ____ hours, admit
4-6 hours
0-30% FEV 1 meets what GOLD grade?
4/4 or respiratory failure with elevated pCO2
hospital acquired pneumonia occurs within ___ hours or more AFTER admission
48 hours
How quickly should you see improvement to pneumonia symptoms once treatment begins?
48-72 hours
FEV1 < 30% is GOLD grade ___ ?
4; Very severe
a 5mm induration will be concidered positive PPD in what type of patients?
5 mm is the minimum needed for a PPD to be positive, so the people in highest risk will be positive with only 5 mm induration - HIV - recent exposure to TB - CXR with old healed TB - immunocompromised: organ transplants or chemo
for hemothorax, the Hct of plueral fluid is =/> _____ % of Hct of peripheral blood
50%
when giving O2 in COPD exacerbations, give enough to get PaO2 above ____ mmHg
60, this minimizes risk of respiratory acidosis due to CO2 retention
how long do you keep pts with health care acquired and ventilator acquired pneumonia on abx?
7 days
normal PAP is?
8-20 mmHg
acute cough lasts?
< 3 weeks
chronic cough lasts?
> 8 weeks
how is chronic cough defined?
>3 months coughing in two consecutive years. it doesnt have to be 3 months in a row, just 3 months out of 2 years.
What is caseous necrosis?
A form of coagulative necrosis in which a thick, yellowish, cheesy substance forms. you get this from bx a granuloma
parapneumonic effusion means?
A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis.
- low pressure - low resistance - high compliance (low elastance) ^ the above describe: A. pulmonary circulation OR B. systemic circulation
A. pulmonary circulation
#1 thing to manage in epiglottitis
AIRWAY! get experts ENT+ anesthesia+ critical care
how can ARDS and west zones be related?
ARDS fills up bottom first with a lot of proteins and other junk. this decreases perfusion by a large amount since west zone 3, the bottom one is the main site of perfusion.
What is the treatment for hyperacute bacterial conjuctivitis?
Abrupt onset, copious purulent discharge, rapidly progressing Prompt Treatment: -Fluroquinolones (-floxacin's) + ceftriaxone (rocephin)
What are Brimonidine and Apraclonidine and what are they used for?
Alpha-2 Agonists used for POAG!
how do you treat blastomycosis?
Amphotericin B * if mild to moderate azoles can be used, itraconazole is the MC
What is the MoA for Leukotriene modifiers?
Antagonize leukotriene D4
what is the most useful test for chronic pulmonary histoplasmosis?
Antigen detection (urine and blood): high sensitivity! * Cultures: takes 6 weeks to grow, has low sensitivity and need multiple sputum and bronch cultures
How long should you treat a patient with CAP who is admitted to the hospital?
Antimicrobials x 7-10 days unless blood cultures are positive, then continue antimicrobials for 14 days after blood cultures are negative
name 3 things that differentiate asthma and COPD
Asthma: nocturnal symptoms, bronchodialator response on spiro. and strong steroid response COPD: early AM symptoms, partial to none BD response, and weak steroid response
58 y/o presents with persistent dyspnea and wheezing for several week. on PE expiratory wheezes noted. what would be the next appropriate step in making the diagnosis? A. ABG B. PFTs C. CT scan chest D. Methacholine challenge study
B. PFTs
- high pressure - high resistance - low compliance (high elastance) ^ the above describe: A. pulmonary circulation OR B. systemic circulation
B. systemic circulation
if you want to bronchodialate smooth muscle in the lungs, what receptors you need to modify?
B2; adrenergic stimulation, bronchodialate lungs remember that B1 controls the heart
What are the ICS medications?
BBFMT! -*B*udesonide -*B*eclomethasone -*F*luticasone -*M*ometasone -*T*riamcinolone
PPD test might be false positive in pts who received what vaccine?
BCG; Bacillus Calmette-Guérin vaccine is a vaccine primarily used against tuberculosis. In countries where tuberculosis or leprosy is common,
how can you exclude cardiogenic pulmonary edema in a pt you suspect has ARDS?
BNP and Echo
pulsus paradoxus means?
BP drop on inspiration by 10 mmHg * a physical exam finding in asthma
What is the IL-5 receptor blocker?
Benralizumab (SQ injection)
What is the treatment for late onset or high risk of multidrug resistant HAP, HCAP, or VAP?
Beta-Lactam *or* Carbapenem *or* Respiratory Fluoroquinolone *AND* Aminoglycoside (gentamicin, neomycin, etc.) *If MRSA is suspected:* -add Vancomycin or Linezolid
What is the one selective Beta Blocker?
Betaxolol (betoptic)
What are some potential AE's of nasal corticosteroids?
Burning/stinging, epistaxis, URI, bad taste
ABG was done in the ER on a pt with severe asthma attack. which of the following ABGs would give you the most concern for impending respiratory failure? A. 7.36/40/60 B. 7.49/28/55 C. 7.31/55/60 D. 7.51/27/73
C. 7.31/55/60 notice the pH is acidic with high CO2
pneumonia that *starts abruptly*; presents with fever, chills, SOB, N/V/D with CXR findings of lobar pneumonia (dense consolidation) is what type of pneumonia?
CAP; strep. pneumoniae * pts at risk should get a vaccine
how does a sweat test work for cystic fibrosis?
CF pts cannot reabsorb NaCl making their sweat saltier
bronchiectasis will present very similarly to ____ oh physical exam
COPD. you might find crackles, rhonchi, wheezing or clubbing
ratio (FEV1/ FVC) <70% and decreased in DLCO indicates?
COPD/ emphysema
what is the study of choice to diagnose PE?
CT angiography
what must be excluded in every case of PAH?
CTEPH (chronic thromboembolic pulmonary hypertension): at least one segemental or larger mismatched ventilation - perfusion defects are present
what is the gold standard for CAP diagnosis?
CXR- infiltrates (there are different types)
A patient with Glaucoma and sulfa allergies should probably not get what type of medication?
Carbonic Anhydrase Inhibitors
What precautions should you be aware of when prescribing antihistamines?
Careful in sinusitis or LRI due to thickening effect of mucus Cautions • Sedation • Closed angle glaucoma • Urinary tract obstruction • Anticholinergic SE (esp in elderly) • Cardiac or thyroid disease
What is the anticholinergic/B2 agonist combination med used in COPD?
Combivent
right ventricular dysfucntion/failure as a result of pulmonary disease is known as?
Cor Pulmonale * aka "heart lung disease"
What are the Mast Cell Stabalizer medications used for asthma?
Cromolyn Nedocromil
cold the progresses to hoarseness and cough. with fever and night time increased edema. Pts present with stridor, "seal bark" cough and cyanosis at times is known as?
Croup
most common fatal inherited disorder in caucasians is?
Cystic fibrosis
most common cause for bronchiectasis?
Cystic fibrosis * caused by a mutation to chromosome 7
How does guaifensin (mucinex) work?
Decreases mucus viscosity (thins the mucus) by ↑ respiratory secretions -take with plenty of water
What is the IL-4/IL-13 inhibitor?
Dupilumab (SQ injection)
27 yo female presents having an asthma attack. she has used her inhaler 10x in the 2 hours with little relief. all of the following are appropriate except: A. start neb treatment B. give solumedrol IV C. CXR D. ABG E. start terbutaline gtts
E. terbutaline isnt recommended for exacerbation in adults
unlike granulomatosis with polyangiitis, goodpasture's dz does not have what type of symptoms?
ENT symptoms
How is early onset defined for patients with HAP, HCAP or VAP?
Early onset = 5 days or less
this type of parapneumonic effusion results in PUS or + gram stain and increase in fibrin.
Empyema: consider fibrolytics - TPA; treat with chest tube/ VATS and 4-6 week abx. Community acquired: flagyl or ceph Hospital acquired: must cover MRSA/ pseudomonas
What is the MoA for Carbonic Anhydrase Inhibitors and when should you use the topical or systemic formulations?
End in -amide *MoA:* Decreases ciliary body aqueous humor production *Topical:* 2nd-line POAG *Systemic:* 1st-line for Acute Angle Closure Glaucoma (given IM) -*Acetazolamide (Diamox)*
What is Light's criteria?
Exudate effusion has one or more of the following: - ratio of pleural to serum protein is >0.5 - ratio of pleural to serum LDH is >0.6 - pleural fluid LDH is more than 2/3 the upper normal limit of serum LDH
true or false: pulmonary vasodilators may be stopped on a pHTN pt
FALSE! NEVER stop pulmonary vasodilators on a pHTN pt.
true or false: intubation should be one of the initial interventions for cor pulmonale patients
FALSE! it is the absolutely last resort for the management of cor pulmonale * breathing in negative pressures draws blood into the chest improving RV preload, decreases RV afterload and makes cardiac output better. intubating a pt and introducing positive pressure will make everything much worse. * high flow nasal cannula is a great alternative to intubation in these patients
true or false: *all that wheezes is asthma*
FALSE! pulmonary edema, allergies, pneumonia, foreign body aspirations, COPD, acute bronchitis and GERD can all wheeze
flow (or speed) of air coming out of the lung during the middle portion of a *forced* expiration is known as?
FEF: forced expiratory flow; pt needs to exhale as hard and as fast as they can
this value of the PFT determines the severity of the obstruction
FEV 1
this value in the PFT is used to determine obstructive vs. restrictive disease
FEV 1/ FVC ratio
this value in the PFT shows how much air a pt can blow out in one second comapred to how much air they can blow out, total.
FEV 1/FVC (ratio)
forced expiratory vol. in the first second of the FVC maneuver is known as?
FEV 1; mesure of air flow in the first second, large airways (the straw).
if order to diagnose COPD you must have this PFT value
FEV1/FVC ratio
GOLD stage is based on?
FEV1; air flow limitation
what 2 settings track oxidation on the vent?
FIO2 and PEEP (more PEEP more we opening up alveoli)
what is the CAP inpatient treatment for an adult that is not in the ICU?
FQs (moxifloxacin, hemifloxacin, levofloxacin) OR beta lactam (amoxicillin- clavulante, ceftriaxone, cefprodoxime) PLUS macrolide for 5 days
the maximal amount of air that can be exhaled forcibly and completely after maximal inspiration is known as?
FVC: forced vital capacity. we want pt to exhale over 6 full seconds >80% = normal range
What medication(s) are standardly used with Acute Otitis Media?
First Line: *High Dose Amoxicillin* -80-90 mg/kg/day PO BID -effective against pneumococci bacteria Second Line: *Amoxicillin/Clavulanate (augmentin)* -90mg/kg/day PO BID
What are the ICS/LABA combination medications?
Fluticasone/Salmeterol Bedesonide/Formeterol Mometasone/Fometerol etc.
What medication might be used to treat AOM if the patient has a penicillin allergy?
For Type 1 allergy: -Azithromycin (zithromax) For non-type 1 allergy: -Cefdinir (omnicef) Others: -Ceftriaxone (rocephin)
pt has FEV1 / FVC of 60% with predicted FEV 1 of 40%. Pt had 2 exacerbations that led to hospitalization in the past year. CAT score was 10. Patient belong to what GOLD grade? what ABCD group?
GOLD grade 3, group D
triple threat therapy is used for what GOLD group? what does it include?
GOLD group D; includes LAMA (anticholinergic) + LABA + ICS
pulmonary arterial hypertension belong to what WHO group?
Group 1: This is a primary problem with pulmonary arterial vasoconstriction
What are the most common pathogens associated with COPD?
H. Influenza M. Catarrhalis S. Pneumoniae
Emedastine (elestat) and Ketotifen are what type of medication?
H1 Blocker + Mast Cell Stabalizer + Eosinophil Action
Azelastine (optivar), Olopatadine (patanol) and Nedocromil (alocril) are what type of medication?
H1 Blocker + Mast Cell Stablizer -used in allergic conjuctivitis
what does PERC criteria include?
HADCLOTS! Hemoptysis Age > 50 DVT/ PE hx Contraceptive use Leg swelling unilateral O2 sats below 94% Tachycardia Surgery or trauma <4 weeks ago * if the answer is yes to 3 or more get a CT!
patients suffering from what chronic disease have a higher incidence of COPD?
HIV
Epiglottitis is caused by?
Haemophilus influenza
What is cyclosporine (restasis) used for, when should it not be used, and what is it's MoA?
Indication: chronic Keratoconjunctivitis Sicca (dry eyes) Contraindication: ocular infection MoA: Immunosuppressant • Inhibits activation of T cells • T cells cause inflammation & disruption of lacrimal gland function
What are common complications of Acute Otitis Media?
Intracranial complications, meningitis, *mastoiditis*, brain abscesses
What are the anticholinergic medications used in asthma and copd?
Ipratropium Tiotropium
what physical exam finding can help you get an idea of the patient's central venous pressure?
JVP
What is the treatment for Keratitis?
Keratitis: infection of the cornea Topical Antibiotics: Fluroquinolones -moxifloxacin -gatifloxacin may also use topical corticosteroids but they may cause local immunosuppression.
elevated eosinophils may predict increased risk of A/E rates in patients on _______ ?
LABA and not on ICS
in 90% of pts with pneumocystis jirovecii pneumonia (PJP), _____ is elevated
LDH
type of tuberculosis in which the person carries the disease but does not show symptoms and cannot infect others.
Latent TB infection; you get TB and that Ghon focus that is formed might contain dead TB or dormant TB. it is safer to call it latent TB infection since you dont know if the pathogen is dead or not
How is theophylline dosed initially?
Loading dose for quick effect, then based of serum levels
What is the general treatment for previously healthy adults with *community acquired pneumonia?*
Macrolide ((Azithromcyin, Clarithromycin, Erythromycin) OR Doxcycline
Cromolyn Sodium, Lodaxamide, and Pemirolast are what type of medication? How do they work?
Mast Cell Stabalizers! -MoA: They block mast cell degranulation, stabilizing the cell and thereby preventing the release of histamine and related mediators.
once this pressure is high we know we have pHTN, what pressure is that?
Mean PAP (pulmonary artery pressure) > 25 mmHg. we dont know what type yet, just pulmonary pressure is high
What are the IL-5 inhibitors?
Mepolizumab (sq injection) Reslizumab (IV)
what is the main muscle of expiration?
NONE! its a passive process driven by elasin, rib cage, and pressure gradients. accessory muscles are active during distress
Talcosis
Occurs among people who work in industries that manufacture paint, ceramics, roofing materials, cosmetics, and rubber goods. get fibrosis, pneumonitis: more chronic than ARDS
What is the medication that *selectively binds to human IgE?*
Omalizumab; used in poorly controlled asthma w/conventional therapy
what can cause the RV afterload to go up very suddenly?
PE
Hampton's hump on CXR should make you think of what diagnosis?
PE, lung already started to necroes
pt comes in with a fever + chest pain with hx of recent surgery, you should immediately suspect?
PE.......
Westermark's Sign should make you think of?
PE; collapsed vessel distal to the PE. pt will show signs of hypoxemia
most helpful diagnostic test for vocal cord dysfunction?
PFTs; normal spirometry
What antibiotics are used for strep pharyngitis?
Penicillin/Amoxicillin or Cephalosporin Penicillin allergy: Macrolide, Erythromycin, or Clindamycin
Bordatella pertussis is known as?
Pertussis (whooping cough)
What AE can occur when dextromethorophan is taken at an amount that exceeds anti-tussive recommendations?
Potential for *CNS depression* at doses exceeding anti-tussive recommendations
What is the Centor criteria?
Presence of the following symptoms in Adults is suggestive of Strep Pharyngitis! -tonsillar exudates -tender anterior cervical adenopathy -absence of cough -history of fever
What are some possible SE of ocular lubricants?
Preservatives may cause keratitis or conjunctivitis. • If problematic, change to preservative-free preparation
What medication type may cause changes in iris pigmentation and cause the eyelashes to grow and darken?
Prostaglandin Analogs -end in -prost -used in glaucoma management
PROVe It is a mnemonic for? what does it mean?
Pulmonary stenosis Right ventricular hypertrophy Overriding aorta Ventricular septal defect
airway disease caused by exposure to inhaled chemicals/irritants/gasses that is often misdiagnosed as asthma is known as?
RADS (reactive airway dysfunction syndrome)
active TB treatment?
RIPE - rifampin: 6 months - isoniazid: 6 months, with vit B6 - pyrazinamide: 2 months - ethambutol: 2 months
How long should you treat a patient with HAP, HCAP or VAP?
Ranges from 10-21 days
what 2 settings track ventilation on the vent?
Rate (F) and tidal volume (VT)
What is the general treatment for adults with comorbidities who contract *community acquired pneumonia?*
Respiratory Fluoroquinolone (-floxacin) OR Macrolide + Beta Lactam (amoxicillin or augmentin) *macrolide contraindication:* use doxycicline *amoxicillin/augmentin contraindication:* ceftriaxone or cefuroxime
What antibiotics are used in *complicated exacerbations of COPD?*
Respiratory fluoroquinolone (levofloxacin, moxifloxacin, gatifloxacin)
most common cause of bronchiolitis?
Respiratory syncytial virus (RSV); most kids will stop at URI but some will progress to broncholitis
What COPD medication causes weight loss and psychiatric problems?
Roflumilast; phosphodiesterase inhibitor
What is the phosphodiesterase inhibitor and what disease is it used in?
Roflumilast; used in COPD
most specific abnormal EKG finding for DVT/PE?
S1 Q3 T3 sign of R heart strain
for severe acute cases you should give asthma patients
SABA +/- ipratropium
What medication classes are considered Bronchodilators?
SABA's *AND* Anticholinergics
What is the criteria for each of the Asthma Catagories?
SEE PICTURE Intermittent Mild Persistent Moderate Persistent Severe Persistent
What are the recommendations of observation or antimicrobial treatment for children <6 months, 6 months - 2 years, and >2 years old with Acute Otitis Media?
See picture!
Every catagory of asthma treatment includes what medication?
Short-actuing B2 Agonist (SABA)
What is the black box warning for LABA use in asthma?
Should *NOT* be used in monotherapy! -increased mortality with monotherapy. *not a problem with COPD*
explain the pathophys of ARDS
Some insult occurs first that leads to immune response. activated macrophages activate T cells that further activate inflammatory mediators (interleukins and TNF). As the signaling gets amplified, endothelium damage occurs. Type 1 cells are destroyed leading allowing more fluids to flood the alveoli space. the lungs try to compensate by differentiating type 2 cells into type 1.
What is the treatment strategy for Allergic Conjunctivitis?
Step approach: 1) Artificial tears 2) Topical Antihistamines 3) Mast cell stabilizers 4) Topical NSAIDs 5) Ocular Steroids (short term) Option 2 and 3 are often combined: *Olopatadine (patanol)*
What is the treatment strategy for Viral Conjunctivitis?
Supportive: -cool compresses -usually lasts for about 10 days -may consider topical antibiotics to prevent secondary bacterial infection
How should you manage viral sinusitis?
Symptomatic Treatment: -Humidifier/Vaporizer -Warm Compresses -Hydration Medications: -Decongestants PO: phenylephrine or *pseudoephedrine* (Sudafed) Topical: Oxymetazoline (Afrin®) for ONLY 72 hrs!!! -Intranasal corticosteroids (flonase, nasocort, nasonex, etc.)
What is Pott's disease?
TB of the vertebral column; TB can cause extrapulmonary symptoms
Silicosis puts patients in increased risk for what diseases?
TB, lung cancer, and scleroderma
What adverse effect should you be aware of with Cortisporin Otic?
The neomycin in it can cause contact dermatitis if the patient has a neosporin allergy!
What is the methylxanthine used for asthma and COPD?
Theophylline
What are the SABA medications?
Think LAPT! If you don't use your SABA before exercise you're going to get LAPT by the competition! *L*evalbuterol: R isomer only, should have less AE's *A*lbuterol: 50/50 R and S isomers, S more likelty to cause AE *P*irbuterol *T*erbutaline: (oral only)
What are the LABA medications?
Think salamanders, forceps, Indian dinosaurs and dogs! And dinosaurs lived a long time ago so these must be LABA's! Salmeterol (salamander) Formoterol (forceps) Indacterol (Indian dinosaurs) Arfomoterol (dogs)
the amt. of air we breath during quiet, comfortable breathing is known as?
Tidal Volume (Vt)
What topical drops can be given for pain associated with corneal abrasion? What is the potential downside?
Topical NSAID's • Diclofenac • Ketorolac • Bromfenac Caution: • may delay wound healing • Caution in patients with bleeding disorders
VC+ RV = ?
Total lung capacity (TLC) *remember that capacity refers to 2 or more volumes
what is the gold standard diagnostic test for pleural effusion?
US guided thoracentesis
What is the treatment for Bacterial Conjunctivitis?
Untreated: Usually self-limited 10-14 days Treated: usually clears in 2-3 days -erythromycin -fluroquinolones (-floxacin's)
what is the preferred scan for chronic thromboembolic pulmonary hypertension (CTEPH)?
V/Q scan; pt inhales a tracer for ventilation and there is a dye for perfusion. these images are compared for "mismatch"
what is the most common cause for hypoxemia?
VQ mismatch
hypoxemia in hyaline membrane disease (infant respiratory distress syndrome) comes from?
VQ mismatchl V<<<<<<< Q
if you are concerned about MRSA with your pneumonia pt what are your abx options?
Vancomycin or linezolid
How do differentiate viral from bacterial sinusitis?
Viral: -fewer than 10 days of symptoms -absence of high fever Bacterial: -greater than 10 days but less than 30 without improvement -nasal discharge -daytime cough
what are causes for chronic Cor Pulmonale?
WHO GROUPS: 1) PAH 2) left sided heart failure 3) chronic lung disease: COPD, LID, OSA, CF 4) CTEPH 5) sarcoid, vasculitis, etc...
PHTN due to left sided heart failure belong to what WHO group?
WHO II
PHTN due to lung disease or hypoxemia belong to what WHO group?
WHO III
PHTN due to chronic pulmonary embolisms belong to what WHO group?
WHO IV
PHTN due to a grab bag of causes to include sarcoidosis, tumors, or vasculitis belong to what WHO group?
WHO V
What are the Leukotriene Modifiers?
Zifurlukast (accolate) Montelukast (singulair)
What is the Leukotriene Formation Inhibitor?
Zileuton (zyflow) uncommon due to AE's: hepatoxicity, cyp 450 inhibition
interstitial lung disease
a group of almost 200 disorders that cause inflammation and scarring of the alveoli and their supporting structures
normal larynx: true vocal cords _______with inspiration and _____ with expiration
abduct, adduct
primary progressive TB is known as?
active TB * both reactivation/ progressive secondary TB and primary progressive TB are active
patient present ill appearing, with shortness of breath, AMS, and chest pain. these are subjective findings with what type of cor pulmonale?
acute
a clot with no RV strain, with a hemodynamically stable pt describes what category of PE?
acute PE
self limiting inflammation of the bronchi, caused by upper airway inflammation is known as?
acute bronchitis * most are viral
pt with any of WHO group pulmonary hypertension who develop a PE, ARDS, or severe hypoxemia can fall into what category of Cor Pulmonale?
acute on chornic * acute: no time to adapt to RV dilation
this type of silicosis is seen more in the lower lobes. in addition on CXR can see air bronchograms (consolidations around the airway that keep the airway patent)
acute silicosis
tachycardia, tachypnea, hypoxia, hypotension and cool skin, are objective findings with what type of cor pulmonale?
acute; patients look very ill * like chronic cor pulmonale, JVD can be seen here too.
What are the Interleukin medications used for (IL-5, IL-4, IL-13)?
add-on maintenance tx of severe asthma in *patients with eosinophilic phenotype*
with vocal cord dysfunction; true vocal cords _____ with inspiration, expiration or both
adduct; associated with psych (stress), exercise, neuro dmg, GERD, and irritants. * often misdiagnosed as asthma
cytology is more accurate with what type of lung cancer?
adenocarcinoma
the force the ventricle must pump against is known as?
afterload (peripheral resistance)
if intra alveolar pressure is negative, where will air flow?
air will from high to low pressure, into the lungs.
what is steeple sign?
airway narrowing, seen with croup!
PFT measures all of the following except? - patency of airways (large and small) - parenchyma (interstitial/alveoli) - pulmonary vasculature - diaphragm/ chest wall movement - neural control of ventilation (brain) - A/a gradient
all except A/a gradient
what is an important genetic factor to consider on younger COPD patients?
alpha 1 antitrypsin deficiency ;consider on younger patients with obstruction that is out of proportion to their smoking hx
what kind of shunt does acute respiratory distress syndrome (ARDS) causes?
alveolar shunt, it is a full shunt meaning that the amount of o2 in the lungs doesn't matter because gas exchange cannot occur.
what pathogens could sputum cultures detect?
always "true pathogens" (have the ability to inflict disease or infect in healthy individual with fully functional immune system): - Legoionella - Mycobacterium tuberulosis - M pneumonia - C pneumonia - Chlamydia psittaci
by breathing in a rapid and shallow manner pt creates what type of dead space?
anatomic dead space * remember both types of dead space are ventilated but not perfused
what is the reversal agent for xarelto (rivaroxaban)?
annexa
localized outbreaks of the flu are referred to as?
antigenic drifts * remember that shifts are more global
major changes in influenza that result in epidemics are known as?
antigenic shifts. * remember that drifts are more localized * influenza A has high propensity for changes like H1, H2, H3, N1, N2..... influenza B only H changes
what is the CAP inpatient treatment for an adult that is in the ICU?
antipneumococcal beta lactam (cefotaxime, cefriaxone OR ampicillin sulbactam) PLUS macrolide OR respiratory FQs (moxifloxacin, gemifloxacin, levofloxacin) PLUS aztreonam (for PCN allergy)
this respiratory center delivers pro inspiratory signals to the medulla that cause us to take a breath
apneustic control center; without this pt will not be able to take a breath without the assistance of a ventilator
diaphragmatic pleural plaques are pathognomonic for??
asbestos related pleural disease; may also be seen on the posterior and lateral surfaces of parietal pleura adjacent to ribs * calcified 80% of the time. * slow growing, often 20-30 year latent period
ferrunginous bodies are histological findings with?
asbestosis * macrophages attempt to engulf asbestos fibers
unilateral wheeze on a pediatric patient should make you think of?
aspiration, foreign body can cause atelectasis like in this CXR * especially if afebrile child presents with sudden onset of respiratory distress, coughing, stridor or wheeze
what is the #2 cause of chronic cough?
asthma (MCC in children)
most common serious medical illness with pregnancy is?
asthma... * remember that it is SAFER for pregnant women with asthma to be treated with asthma meds than for them to have persistent asthma symptoms and exacerbations; it can cause low birth weight, preeclampsia, and preterm birth
ratio (FEV1/ FVC) <70% with increased or normal DLCO indicates?
asthma; intrathoracic pressure negative, more blood into heart > into lungs which will increase # RBC in circulation, bind with CO
if a pt can pant during an exacerbation we know that pt does not have ________
asthma; it is a sign of vocal cord dysfunction!
all pressures are relative to _______?
atmospheric pressure of 760mmHg or 1 atm
fever, nonproductive cough, unilateral lower lobe patchy infiltrates or hillar adenopathy. these describe what type of TB presentation?
atypical; classic
pt presents with GI upet, diarrhea, hemoptysis, and cavitation on imaging. this describes what type of pneumonia?
atypical; legionella; can cause hyponatremia/ elevated LFTs and acute kidney injury
cystic fibrosis is caused by?
autosomal recessive genetic dz; deletion of phenylalanine 508 on chromosome 7
why do the WHO groups matter so much?
because each group is treated differently. understanding the groups alone can help providers target their treatment plan to the right type of pHTN.
why is transpulmonary pressure important clinically?
because it correlates with the elastic power of the lung
why the role of steroids is controversial in pneumonia?
because it decreases inflammatory response, however, it also decreases immune system function with other side effects.
why do we care about sleep tests (PSG) as part of the diagnostic workup for PHTN?
because sleep apnea can cause left ventricular dysfunction. * if a pt just has sleep apnea they dont get screened for pHTN, but if they have pHTN they do get screened for sleep apnea
why do we give IV fluids to status asthmaticus pts?
because they are losing a ton of water by increased effort of breathing
why should mechanical ventilation setting allow for long expiratory times in severe asthmatic pts?
because they have obstruction, must allow time for them to breath out the trapped air
PF ratio needs to be below _____ to diagnose ARDS
below 300, there are different criteria as well according to the berlin definition
granumlomatous lung dz caused by exposure to beryllium is known as?
berylliosis
imaging for goodpasture's dz (pulmonary hemorrhage)
bilateral nodular opacities, ground glass. this CXR shows pulmonary hemorrhage
what is a biomarker used to evalute exacerbations risk?
blood eosinophils * it can also predict effect on ICS on exacerbations prevention
first line therapy for DVT?
blood thinners like warfarin, heparin, lovenox (low molecular weight heparin) or any factor Xa inhibitors like xorelto
what causes inflammation/consolidation in pneumonia?
body response with WBCs to microorganisms that are inhaled to the alveoli causes acute infection of the pulmonary parenchyma
- inspiratory whoop - paraxysmal cough (abrupt severe cough) - posttussive emesis the above are hallmark for?
bordatella pertussis (whooping cough) * cough can be so bad that it might cause patients to vomit
pt presents with a cough lasting > 2 weeks with inspiratory whoop, brocnchospastic coughing bouts, and some vomiting. Cough gets really severe at night. this is likely?
bordetella pertussis (whooping cough)
Tube 1 has a pressure of 100mmHg in point A and 75 mmHg in point B. Tube 2 has a pressure of 40 mmHg in point A and 15mmHg in point B. which tube will have more flow?
both have equal flow! flow follows pressure gradient not absolute pressure. both tubes have absolute pressure of 25mmHg (delta= 25) equal flow.
on HRCT you notice airway dialation, tram lines, and lack of tapering airways towards periphery in addition to broncial wall thickening. this describes?
bronchiectasis * can also see "tree in bud" linear markings or ballooned cysts at the end of the bronchus * in the image note the scarring and how thick the airways are all the way down to the periphery
on CXR you note dialated thickened airways with tram/parallel lines and ring shadows. this is most likley?
bronchiectasis. on a normal CXR you shouldnt be able to see the small airways so well
what procedure can confirm ciliary dyskinesia?
bronchoalveolar lavage through a bronchoscopy
what procedure can confirm mycobacterium avian infection (MAI)?
bronchoalveolar lavage through a bronchoscopy
what condition presents with extreme tachypnea with recent hx of URI and is described by parents as "breathing funny"
broncholitis
tertiary bronchi (segmental) serves?
bronchopulmonary segments 'wedges'. remember that each segment has its own vessels, in some cases of cancer, a wedge can be taken out instead of a whole lobe
how do pt with chronically high PA pressures compensate?
by remodeling the RV; making the RV larger and constrict blood vessels
How are vasculitides defined?
by the presence of inflammatory leukocytes in vessel walls with reactive damage to mural structures.
rare condition seen in coal workers with rheumatoid arthritis. 0.5-5 cm nodules, multiple bilateral and usually peripheral. is known as?
caplan's syndrome; can also be seen in pts with silicosis and asbestosis. * may cavitate or calcify typically develops rapidly over a period of weeks
abx are most effective in what phase of bordatella pertussis?
catarrhal phase; the problem is that this phase is early and patients present like a normal URI, most of the time abx are not given to these patients because they are misdiagnosed
this type of emphysema involves the bronchioles, exclusively found in smokers and is upper lobe predominant
centrilobularl; distal alveoli are normal. * because of upper lobe involvement lung volume reduction surgery where the apex of the lung is removed can help
what is the treatment for a PTX of 4 CM in a stable pt?
chest tube * chest tube used in unstable PTX pts and if it is a recurrence regardless of size
pneumonia is most common and most dangerous to what age groups?
children and adults >65
typically what age groups get Respiratory syncytial virus (RSV)?
children under 2 years old. 80% are under 1 years old
pt is 40 y/o has the following findings: - mild dyspnea - persistent cough and sputum production - obese, no wt loss - percussion normal - no increase in AP diamater - wheezing on auscultation - CXR: increased lung markings - ABG: hypoxemia, hypercampnia. resp. acidosis - PFT: normal DLCO and RV/TLC
chronic bronchitis
chronic cough and sputum production for at least 3 months of the year for at least 2 years in the absence of any other dz indicates?
chronic bronchitis; caused by hypertrophy and hyperplasia of mucus secreting glands
patient presents with shortness of breath, *cough*, *fatigue*, *peripheral edema*, *anorexia*, *GI distress* and *weight gain*. these are subjective findings with what type of cor pulmonale?
chronic cor pulmonale. * much more subtle, when compared to acute.
what does bronchiectasis mean?
chronic dilation of a bronchus secondary to infection * recurrent infections leads to further scarring
asthma that doesnt get treated for a long time, and doesnt show reversibility on spiro. is known as?
chronic obstructive asthma, resembles COPD in the way it presents
Ascites, sternal heave, hepato/splenomegaly are objective findings with what type of cor pulmonale?
chronic; subtle findings that mimic other disease. * can also find JVD, seen in acute cor pulmonale as well.
thoracentesis with triglycerides >110 means?
chylothorax
this effusion results from disruption of the thoracic duct causing lymph in the pleural space to accumulate
chylous effusion - triglycerides > 110 mg/mil - milky white color
what are risk factors for idiopathic pulmonary fibrosis?
cigarette smoking, possibly acid reflux and aspiration
inhilation of silica- free coal dust particles is known as?
coal worker pneumoconiosis * alveolar macrophages engulf the black coal dust= "dust macules"
Asbestosis CXR findings
coarse irregular linear opacities, predominance for lower lobes
what happens if the pleural cavity is not negative like it normally should be?
collapsed lung (pneumothorax most commonly)
___________ refers to the amt of pressure required to inflate or deflate the lungs
compliance
how easily the lung can stretch is known as?
compliance (distensibility), it is the inverse of elastance. * C= V/P
formation of large conglomerate masses in the upper lobes, called "progressive massive fibrosis" describes what type of coal worker pneumoconiosis ?
complicated CWP
what type of silicosis can have "angel wing" apperance on CXR? what does that mean?
complicated silicosis - it means that conglomerate masses migrated towards the hilar regions with sharp peripheral and poorly marginated medial margins this looks like "angel wings" on CXR * after 10 yrs, 20-30% of pts with simple disease progress to this stage also called "progressive massive fibrosis"
hilar and mediastinal lymphadenopathy with "eggshell" calcifications are seen with what type of silicosis?
complicated silicosis * also occurs in 1% of pts with CWP and may be seen with sarcoidosis
this type of parapneumonic effusion is caused by bacterial invasion of the pleural space, has high neutrophil count with LDH >1000
complicated- requires chest tube drainage/ VATS
supplemental oxygen may delay onset of ______ in patients with IPF (idiopathic pulmonary fibrosis)
cor pulmonale
if pt does not respond to SABA, prescribe _____
corticosteroids
pain/inflammation of the costosternal joints is known as?
costochondritis; worse with deep breaths, reproducible pain to palpation
what makes bronchitis more severe than a typical URI?
cough lasting > 5 days
what type of drug should influenza patients avoid?
cough suppressants
how do you diagnose blastomycosis?
cultures: - sputum 75-86% yield - bronch: 92% wet prep: - low yield but quick
what is the gold standard diagnostic test for bordetella pertussis (whooping cough)?
cultures; dont wait for cultures to start treating! * nasopharynheal swab/aspirate culture and PCR
gold standard diagnosis for TB?
cultures; takes 3-6 weeks to grow. * PPD is okay, but it is false negative in 20-25% of patients
6 y/o presents with cough, fever, dyspnea, and digital clubbing hx: hospitalized 7z for pneumonia since birth (first at 1 month) - frequent diarrhea - always coughing this is likely?
cystic fibrosis
the goal of expiration is to _____ intrathoracic vol.
decrease
most restrictive diseases will _____ compliance, therefore _____ elastance
decrease compliance, therefore increase elastance. * becomes more restricted, harder to inspire super easy to breath out. * pressure goes up much easier relative to how much vol. got in
tactile fremitus with PTX will be?
decreased
PaCO2 is ______ with asthma attacks because pts are hyperventilating
decreased * if the PaCO2 is normal/elevated it means bad!
interferon gamma release assay aka quantiferon- GOLD
detect latent TB. same indication PPD. more specific, no false positive with BCG infection/immunization. * positive same as PPD, cannot differentiate reactivation and primary TB
hyaline membrane disease (infant respiratory distress syndrome) leads to?
diffuse, bilateral atelectasis; infants cant generate enough inspiratory force to keep alveoli open
what rule does interstitial lung disease violate?
diffusion; diffusion is distance limited. normally endothelial cells are 2 cell layer. however, in interstitial lung disease there is inflammation and proteins separating capillaries from alveolus making gas exchange take much harder. when these patients exert themselves blood doesnt have enough time to do gas exchange because it is so much slower now that the distance is very long
this control center mainly controls inspiration. it is the terminal sensor for vagus/glossopharyngeal nerves (chemoreceptors, baroreceptors, lung receptors).
dorsal respiratory group (medulla); responsible for inspiratory "ramp". allows us to break in a slow controlled manner and does not allow us to hold our breath in for too long
why is the intrapleural pressure always negative?
due to lymphatics constantly pumping out fluids, it keeps the membranes approximated; (like beer on a coaster) keeps the visceral and parietal pleura stuck together.
with pleural effusion pt will have _______ to percussion and ______ tactile fremitus
dullness, decrease
pathology of asthma
edema of the mucosa with mast cells, eosinophils and lymphocytes that promote the synthesis of IgE * in severe cases the mucosa thickens causing airway obstruction
what do you need to remember about effusions and TB?
effusions may hide TB on a CXR. pt could have gotten a pneumonia and the effusion that can be pericardial or pleural is hiding TB ghon complex
how does pneumocystis jirovecii pneumonia (PJP) gets diagnosed?
either sputum sample or bronchoscopy
how easily can the lung collapse is known as?
elastance (collapsibility), it is the inverse of compliance * E= P/V
diffusely deceased breath sounds are seen with what type of COPD?
emphysema
pt is 52 y/o. has the following findings: - dyspnea, constant - dry cough - AP diameter increased - percussion hyperresonant - diminished lung sounds - on CXR: bulla, blebs, hyperinflation - labs: ABG normal - PFT: increased RV, TLC and decreased diffusion is this COPD or emphysema?
emphysema: pt is most likely thin with cachexia.
enlargement of airspaces distal to conducting airways is characteristic of?
emphysema; bronchioles and alveoli walls are weakened, lysis of elastin and structural proteins occurs
pus appearing pleural fluid indicates?
empyema
low pH on thoracentesis is associated with?
empyema and malignancy - low pH with malignancy -> shorter life expectancy
thoracentesis with over 1000 LDH means?
empyema; thick fluid within the pleural space, hard to pull out * could be seen with rheumatoid and malignancy
pts who have asthma that responds better to inhaled corticosteroids have higher ________ components
eosinophilic; as eosinophilic levels come down we can titrate down the steroids
on lateral x-ray you notice "thumb print sign" this is most likely due to?
epiglottitis
pt presents with dysphagia, drooling, distress, sudden fever, "hot potato voice" without a cough. this is most likely?
epiglottitis * adults will have rapidly developing sore throat or odynophagia that is out of proportion to clinical findings note: on physical exam pt will have stridor and oropharynx will be benign
elevated amylase on thoracentesis means?
esophageal rupture, acute or chronic pancreatitis, and malignancy
what TB med has ocular toxicity as side effect?
ethambutol; visual acuity as baseline
a pt with asthma who uses a peak flow meter (PEFR) at home notices a 20% deviation from baseline while having SOB, this means?
exacerbation * 50% from baseline = severe attack
what is a sniff test?
exam that checks how the diaphragm moves when you breathe normally and when you inhale quickly
majority of young asthmatics experience what type of asthma?
exercise induced asthma/ bronchospasm
as the degree to which transpulmonary pressure increases, the degree to which the lung wants to _______ goes up
exhale
if your transpulmonary pressure goes up, your lung wants to_____
exhale
maximal amount of air forcefully exhaled after normal inspiration and expiration is known as?
expiratory reserve volume
how much air we are able to breath out at the end of a tidal expiration is known as?
expiratory reserve volume (ERV)
______ obstruction seen on inhalation
extrathoracic
- scoliosis - ankylosing spondylitis - pleural effusions - pregnancy - obesity - pleurisy - tumors - ascites all of the above are ______ restrictive defects
extrinsic; * remember that just because you see restrictive dz it doesnt mean that the problem are the lungs, neuromuscular dz like ALS, myasthenia gravis, and even malnutrition can cause it
this type of effusions is caused by lung/pleural inflammation (results in increased capillary and pleural membrane permeability) OR lymph drainage into pleural spaces
exudate effusion
what type of effusion can appear loculated ("walled off") on CXR or US
exudate effusion
what type of effusion has higher protein concentration?
exudate effusion
what type of effusion is deeper color, turbid?
exudate effusion
what phase of ARDS is gravity dependent, meaning that position change will have an impact on how the dz looks on imaging
exudative phase. * as dz progresses it becomes less and less gravity dependent as fibrosis occurs.
true or false: fever is a hallmark sign of bordatella pertussis
false!
true or false: inhaled corticosteroids are better than IV steroids in asthma exacerbations
false!
true or false: lower respiratory tract infections begin in the larynx
false!
true or false: prednisone is recommended as standard treatment for IPF (idiopathic pulmonary fibrosis)
false!
true or false: serology is helpful in the diagnosis of blastomycosis
false!
true or false: wheezing alone can diagnose asthma
false!
true or false: methacholine challenge study is diagnostic for vocal cord dysfunction
false! * CXR and ABG- WNL
true or false: imaging abnormalities with ILD are usually unilateral
false! bilateral
true or false: tactile fremitus is increase with asthma
false! diminished!
true or false: diagnosis for berylliosis can be made from imaging alone
false! hilar denopathy, nodular, reticular, and/ or ground glass opacities can be seen with other conditions
true or false: acid fast bacilli (AFB) is a specific stain for TB
false! it can confirm clinical suspicion. any myobacterium is positive for AFB.
true or false: vital capacity is decreased in restriction but increased in obstruction
false! it can decrease in both restriction or obstruction
true or false: PaO2 is a good measure of hypoxia
false! it is only a small number in the oxygen delivery equation. SaO2 (SATURATION) is a better measurement
true or false: inhaled abx are better than PO for bronchiectasis
false! no added benefit, in fact they can increase bronchospasm
true or false: leukotriene are a great choice in a pt with asthma exacerbations
false! not studied enough to determine if there is any benefit during exacerbations!
true or false: productive cough is a classic presentation of pneumocystis jirovecii pneumonia (PJP)
false! pts with PJP have a NON productive cough
true or false: all coughs are from pulmonary reasons
false! some can be from mechanical receptors like touch or displacement of cough receptors
true or false: cough supressants are effective in treating bordatella pertussis
false! they are ineffective but we still give them to patients
true or false: kids have low o2 demand than adults
false! they breath faster and their heart beats faster. they have lower ability to store energy and use more O2
true or false: pretty much all of the WHO groups can fall within the acute Cor Pulmonale umbrella
false! within the chronic cor pulmonale * chronic: there is time for the RV to adapt. RV hyperthrophy with or without dilation
Fibroproliferative phase leads to?
fibrosis and cystic changes. pro fibrotic factors are released further worsening fibrosis. occurs when inflammatory response has not resolved at earlier stages or the process ultimately severe fibrosis leads to lung remodeling marked by significant fibrosis and honeycombing
the first step in managing bronchiectasis is?
find out the cause!
Tracheobronchomalacia
flaccidity of the tracheal support cartilage which leads to tracheal collapse. This condition can also affect the bronchi * seen with bronchiectasis. does not allow mucus to leave the lower airways
if pressure builds up in a given 'compartment' of the circulation, flow ______, blood backs up, and pressures will build up ______ to that compartment
flow decrease, proximal to. * remember that blood flows from an area of high pressure to an area of lower pressure. this means that if pressure becomes too high flow will decrease to that area.
what happens during the exudative phase of ARDS?
fluid from the plasma leaks into the alveolus leading to pulmonary edema. gas exchange starts being blocked by fluid
what cause of hypoxemia you cannot fix with 100% O2
full shunt. the problem is that blood bipasses the lungs completely so it doesnt matter how much o2 you have in the lungs blood doesnt even get there.
ERV + RV = ?
functional residual capacity (FRC) *remember that capacity refers to 2 or more volumes
the granulma in the periphery + the granuloma in the mediastinum lymph node are together known as?
ghon complex
a granuloma that forms in the subpleural space where the TB particles were initially picked up by macrophages is known as?
ghon focus
how do you manage a stable PE?
give blood thinners and can discharge. no major signs or symptoms
first line therapy for pulmonary sarcoidosis?
glucocorticoids
treatment for COPD is based on?
gold GROUPS
what dz is characterized by anti glomerular basement membrane antibodies disrupt the collagen in the basement membranes of the lung and kidney
goodpasture's dz * pts present with both pulmonary hemorrhage and glomerulonephritis
80-100% FEV 1 meets what GOLD grade?
grade 1/4
50-80% FEV 1 meets what GOLD grade?
grade 2/4
30-50% FEV 1 meets what GOLD grade?
grade 3/4
in the GOLD guidelines: Grade 1-4 is based on ___ Group A-D is based on__
grade is based on FEV1 group is based on s/sx and risk of exacerbations/hx of exacerbations
granulomatous inflammation of the respiratory tract and kidneys is known as?
granulomatosis with polyangiitis (GPA) * ANCA (anti neutrophil cytoplasmic antibodies)
what disease effects kidneys, lung, and EENT with +ANCA?
granulomatosis with polyngiitis (GPA) * 90% of pts have nasal, sinus, or ear complaints
ANA connective tissue dz causes pHTN that falls in what WHO group?
group 1 PAHTN
portal hypertension causes pHTN in what WHO group?
group 1 PAHTN
abnormal PFTs puts pHTN pts in what WHO group?
group 3, they have lung disease like COPD
low density gas that diffuses to small airways even if they are completely obstructed is known as?
heliox
- ground glass opacities - bronchiectasis - honeycombing the above are best seen with what imaging test?
high res. CT * has better sensitivity and specificity than CXR. * if suspected nodules or masses, get regular CT high res can miss big things
what are mediators that are responsible for asthma attacks?
histamin, leukotrienes, and acetylcholine
you have performed PFT, MCT and both were negative for asthma, however you are still suspicious pt might have asthma. what is the next test you should order?
histamine test
most common endemic mycosis is?
histoplasmosis
infant respiratory distress syndrome is also known as?
hyaline membrane disease
what is the hallmark finding of the proliferative phase of ARDS?
hyaline membrane formed from protein rich fluid and dead cell debris accumulation.
starting on the arterial end of the capillary, ________ forces INSIDE the vessels are very high
hydrostatic forces; this directs fluid out of the capillary and into the interstitial space
what percussion note would you find with PTX?
hyper resonance
what percussion sound would you expect in a pt having an asthma attack?
hyper resonance
what percussion sound would you expect to hear on a COPD pt?
hyper resonance; air trapping
mosaic attenuation on CT commonly seen with?
hypersensitivity pneumonitis
inhalation exposure to *organic* materials that causes an immunologic reaction within the lungs parenchyma is known as?
hypersensitivity pneumonitis (HP); "extrinsic allergic alveloitis" * there are over 300 antigens that have been reported to cause HP
decreased O2 content (CaO2) of the blood is known as?
hypoxEMIA * remember that hypoxia is a condition of low O2 at the cellular level often caused by hypoxemia
asthma patient with PaO2 <60 mmHg or o2 sats < 90% has? its a sign of?
hypoxemia, sign that patient is heading towards severe complications!
a state of low oxygen delivery (DO2) to oxygen consumption (VO2) is known as? DO2< VO2
hypoxia
condition of low O2 at the cellular level is known as?
hypoxia * remember that hypoxemia is decreased O2 content of the blood that often causes hypoxia
UIP pattern on HRCT chest is associated with?
idiopathic pulmonary fibrosis * UIP= subpleural, bibasilar predominance of reticular markings
elderly male with SOB with nonproductive cough. CT shows fibrosis, this should make you think of what dz?
idiopathic pulmonary fibrosis * gradual onset of dyspnea with exertion and non productive cough for several months
most common type of idiopathic interstitial pneumonia
idiopathic pulmonary fibrosis (IPF)
when should glucocorticoids be considered in pneumonia?
if pt has severe sepsis/ respiratory failure plus one of the following: - metabolic acidosis - lactic acid > 4 - CRP > 150
what is the treatment for granulomatosis with polyangiitis?
immunosupressive therapy +/- plasma exchange
with ILD, crackles or "velcro rales" best heard at the lung bases in the ____________ on inspiration or expiration?
in the posterior axillary line on inspiration
the goal of inspiration is to ______ intrathoracic vol.
increase
many obstructive diseases will _____ compliance, therefore _____ elastance
increase compliance, decrease elastance. * easy to inspire, difficult to breath out * takes much larger vol. to increase pressure.
reversibility of asthma is defined as?
increase if FEV1 of >= 12% from baseline or >200 ml
what Echo results will support a diagnosis of PAHTN?
increase tricuspid regurgitation links to elevated right ventricular systolic pressure * could have normal right artia and ventricle because in a slow progression of dz acute enlargement wont occur until later stages. once it gets bad tho you can have flattening of the intervenrticular septum which will cause the RV to push on the LV
if we know that PAWP is elevated we can attribute that to ...?
increased pressure in the left side of the heart
where can you find stratified squamous epithelium within the respiratory tract?
inferior portion of the pharynx; it protects the epithelium from abrasions and chemicals
how can you differentiate influenza from pneumonia based on pt hx?
influenza progresses much faster, more abrupt
Pt presents with abrupt onset fever with headache, myalgias, malaise. Pt has a cough, sore throat and nasal discharge all started quickly. you note cervical lymphadenopathy and that pt is hot to the touch. this most likely describes
influenza usually improves after 2-5 days. * residual symptoms can last for weeks
how often should TB pts who are being treated have their LFTs checked?
initially, and every month, all of the drugs below cause hepatotoxicity rifampin isoniazid pyrazinamide
the strength of ventricular squeeze is known as?
inotropy
maximal amount of air forcefully inhaled after normal inhalation is known as?
inspiratory reserve vol.
how much air we are able to breath in at the end of a tidal inspiration is known as?
inspiratory reserve volume (IRV)
what asthma category is described: - pt has 2 or less days with symptoms per week - no more than 2 times per month of nighttime awakenings - has to use inhaler on 2 days per week - has no interference with normal activity - FEV1> 80% predicted and normal between exacerbations
intermittent
the pressure of air inside the alveoli is known as?
intra alveolar pressure.
_______ obstruction seen on exhalation
intrathoracic
- sarcoidosis - TB - pneumonia - pneumonectomy ^ all of the above are ______ restrictive defects
intrinsic
Young's syndrome
is a rare condition that encompasses a combination of syndromes such as bronchiectasis, rhinosinusitis and obstructive azoospermia
how does mechanical ventilation makes ARDS worse?
it adds to the worsening of fibrosis by adding shear forces that further injure the lung and promote more fibroproliferation
how can procalcitonin help with a bronchitis pt?
it can help distinguish bacterial from vital. it does take 1-2 days to get back so you wont get results immediately. in the hospital setting it can help find pneumonia but the role of this test is still mostly unclear.
what is CURB 65? when should you use it?
it is a scale to determine when to admit a pneumonia pt to the hospital C- confusion U- urea (BUN) R- RR ( >30) B- BP (diastolic <60, systolic <90) Age: > 65 each category = 1 point. 0-1 points are low risk while 2-5 points are high risk -> hospitalize
mcconnell's sign on echo means?
it is a very specific sign for PE, if you see this it is PE until proven otherwise. with this sign the apex of the heart is normal while the base of the RV is failing. you will see RV dilatation with a normal apex.
what is the purpose of the Murray score?
it is used to evaluate if an ARDS pt requires ECMO
in an RV strain in what direction does the septum of the heart move?
it moves right to left, normally should be left to right.
should you give a pt suffering from acute bronchitis short acting beta agonists?
it wont help much, but it wont hurt, might make pt happy that they got something since giving them ABX is worse.
what age group could not be asthma 'catagorized'?
kids 5-11 y/o
kids under what age are difficult to diagnose/ treat?
kids <5 y/o
pt presents with currant jelly sputum, what bacteria causes this presentation?
klebsiella pneumoniae * seen with pts with Etoh abuse, COPD, and DM
what diagnostic tool confirms diagnosis of vocal cord dysfunction?
laryngoscopy
post capillary pulmonary HTN caused by?
left sided heart failure after lung capillary
most common cause for chronic cor pulmonale?
left sided heart failure, WHO group 2
concentric fibers, thick wall, and low compliance describes what ventricle?
left ventricle
elevated right sided pressures reduces _____ cardiac output
left ventricle. as the RV dilates it smushes the LV. as the LV gets smaller, cardiac output drops
where can you find cuboidal epithelium within the respiratory tract?
lining the finer bronchioles
secondary bronchi (lobar) serves?
lobes; 3 R 2 L
- formoterol (foradil) - arformoterol (brovana) the above belong to what class of inhalers?
long acting beta agonists
how can CBC be a helpful diagnostic test in asthma?
looking for eosinophils/ IgE levels
the only cure for IPF(idiopathic pulmonary fibrosis) is?
lung transplant, no med seem to cure it
primary bronchus serves?
lungs
what are sites of TB reactivation in the body?
lungs, kidneys, bones, and meninges; initially our immune system is winning but then the bacilli travels throughout the body
pneumocystis jirovecii pneumonia (PJP) is seen in patients with?
mainly HIV but can also present in pts undergoing cancer treatment or pts that use meds that suppress their immune system
chronic balstomycosis may mimic what respiratory disorders?
malignancy or TB * cough for balstomycosis starts nonproductive and becomes more productive as disease progresses
A pt presents with a PE. systole blood pressure below 90. this describes what type of PE?
massive PE
a clot with RV strain, with a hemodynamically unstable pt describes what type of PE?
massive PE. * remember that the size of the clot doesnt matter, a pt can have a massive PE with a tiny clot and an acute PE with a big clot. the grading scale for PE comes from the effects of the clot of the right ventricle
should you give a cor pulmonale pt fluids?
maybe, you can try a small fluid bolus if you have to. however, the right side of the heart is already overwhelmed with fluids, giving a large bolus will cause the RV even more stress. pts might present with low BP but the hypotension is because of a weak LV not because of hypovolemia.
what does it mean when the pt "splints" during inspiration
means that pt cant take deep breaths because of pain; typically seen with pleuritis
what does FeNO measure?
measures eosinophilic airway inflammation; used as a biomarker in inflammatory airway dz * exhaled nitric oxide comes from low airways of the lungs. it is higher in pts with eosinophilic airway inflammation associated with asthma
what can cause decreased PVR (pulmonary vascular resistance)?
medications: Ca+ ch. blockers, O2 delivery, etc..
which test is the overall best test to exclude asthma if normal?
methacholine challenge test
second line treatment for pulmonary sarcoidosis?
methotrexate, then azathioprine or leflunomide * methotrexate and leflunomide are anti metabolite with both immunosuppressive and anti inflammatory properties * azathioprine affects synthesis of RNA and DNA, thus inhibiting lymphocyte proliferation
where in the US can most patients suffering from histoplasmosis be found ?
midwest: ohio and mississippi river valleys. * important to ask about travel hx to these areas if you suspect histoplasmosis
croup with no stridor, presents with a barking cough is what severity? how is it managed?
mild croup; reassurance and moist, cool air, cool mist or hot steam will help
what asthma category is described: - pt has symptoms on more than 2 days of the week - has no more than 4 nighttime awakenings per month - has to use inhaler more than 2 days per week, not daily - minor limitations with everyday activity - FEV1 >80% predicted
mild persistent
a subset of TB that occurs in 1-3 % of pts. presents as tiny lesions in various areas like the liver, spleen, bones, and joints is known as?
miliary TB; can either be with primary infection or reactivation, it can also either be acute (very sick) or subacute/chronic. * looks like millet seeds
what asthma category is described: - pt has symptoms every day - has nighttime awakening more than once per week, not every night - has to use inhaler daily - has some (more than minor) limitations to normal activity - FEV 1 60-80% predicted
moderate persistent
what type of wheezes are more suggestive of asthma?
monophonic wheezes
what is a left shift on a saturation curve?
more relaxed; increased affinity for O2. hold on to more O2 * at the lungs*
what is a right shift on a saturation curve?
more tense; decreased affinity for O2. when *tissue* needs more O2, easier to offload O2 * causes for right shift can be remembered by "CADET": - CO2 - Acid - 2-3 DPG - Exercise - Temperature
this pneumonia has a gradual onset, pts complain of HA, malaise, chills and low grade fever
mycoplasma pneumonia; PE has scattered rales/wheezes, and sinus tenderness
the pressure inside the intrapleural space is always ________
negative!
if V=0 it means?
no air enters the alveoli, unoxygenated blood continues to the systemic circulation ex: pnemonia, atelectasis
fEV 1/ FVC ratio > 70% indicates?
no obstruction! possible restriction
what are imaging results for granulomatosis with polyangiitis?
nodular opacities (wax and wanes), ground glass, cavities, and fibrotic changes
most of the time CXR in asthma patients is?
normal
DLCO is usually ____ in chronic bronchitis
normal as long as there is no destruction of the alveoli
what is the treatment for a PTX of <2-3 CM in a stable pt?
observation and oxygenation * O2 increases rate of re-absorption of the air in the plueral space
FEV 1/ FVC ratio < 70% indicates?
obstruction
FEV1/FVC ratio less than 70% means?
obstruction
smaller airways = more ____
obstruction
Low FEF% suggests?
obstruction in the smaller airways
total lung capacity is increased with?
obstruction; can be normal or increased with hyperinflation/ emphysema
Pulmonary Parynchymal dz like emphysema is obstructive or restrictive?
obstructive
bronchitis, bronchiectasis, CF and asthma are all obstructive or restrictive?
obstructive
upper airway dz like: - tumors - edema - infections - foreign body - collapsed airway and stenosis all of the above are obstructive or restrictive defects?
obstructive
what kind of impairment on PFT is most common with bronchiectasis?
obstructive, you can see restrictive as well tho PFT will test for it, but its not specific
Haemophilus influenza (H.flu) is seen with what population group?
older adults with chornic pulm dz like bronchiectasis, CF, COPD, and HIV * green sputum
what is the definition of tension PTX?
one way valve develops where air can enter pleural space but can not exit
the concentration of proteins, cells, and other large molecules goes up as fluid reaches the venous end of the capillary. this increases ______ pressure
osmotic (oncotic) pressure; now fluids wants to go back in, and 98% of the fluid will re enter the capillary. * the remainder of the fluid (~2%) will enter lymph
what neuroaminidase inhibitor is most commonly used to treat influenza?
osteltamivir (tamiflu) * baloxavir (xofluza) is a new drug on the market that is still being in studied in hospitalized patients
oxygen is dependent on _____ while Co2 is dependent on______
oxygen depends on diffusion, Co2 depends on ventilation * Co2 always moves into the lung and we must exhale it to get rid of it. if we hold our breath Co2 keeps building up in the blood, to the point where our brain detects it and forces us to breath or we pass out.
hypoxemic respiratory failure, is a failure of?
oxygenation
What is Homan's sign?
pain on passive dorsiflexion of ankle only 10% accurate....
this type of emphysema is related to alpha 1 antitrypsin deficiency it is exacerbated by smoking and is lower lobe predominant
panacinar emphysema; pt have severe disease when compared to age/ pack hx
fluid formation in the pleural space from bacterial pneumonia is known as?
parapneumonic effusion
what are 2 important views on Echo that are important for PAH?
parasternal view and apical 4- chamber view
how can you educate your patients about recognizing acute exacerbations?
pay attention to: - changes in sputum color - increase in SOB - increase in amount of sputum * also look for signs of infection like fever, chills, hemoptysis, crackles/rales
a 15mm induration will be concidered positive PPD in what type of patients?
people with not known risk factors, these that wont be automatically screened
acording to the CDC, what is the only indication for antibiotics in acute bronchitis?
pertussis (whooping cough)
this condition is considered to be the worst type of DVT; pt will present with a white leg. often pt has cancer or is pregnant
phlegmasia alba dolens; non ischemic * caused by compression of the iliac vein by the uterus in the third trimester in pregnant patients.
what type of dead space is created by problems w/ the pulmonary artery or pulmonary capillaries like PE?
physiologic dead space; ALWAYS pathalogic! * remember both types of dead spaces are ventilated but not perfused
treatment for goodpasture's dz
plasmapheresis + immunosuppressive meds
what should you recommend to pts if their PTX is reoccurring?
pleuradesis
in the lungs, in addition to osmotic and hydrostatic pressures we also have _____ and ____ pressures
pleural and alveolar pressures
collection of fluid in the pleural cavity between the parietal and visceral pleura is known as?
pleural effusion
pain caused by inflammation of the pleura, irritation of the parietal pleura is known as?
pleuristic pain; localized chest pain worsens with cough/inspiration, movement, deep breaths, and sneezing
effusion, PPD positive, fever, cough, pleuritic chest pain, dyspnea. this describes what type of TB presentation?
pleurisy
procedure performed to obliterate the pleural space to prevent recurrent pleural effusion or pneumothorax or to a treat persistent pneumothora is known as
pleurodesis
inhalation exposures to *inorganic* particles such as mineral dust is known as?
pneumoconioses
pt comes in with signs of bronchitis, on labs you notice brandemia, what must you rule out now?
pneumonia * with acute bronchitis WBC, CXR, and sputum culture should be WNL
acute blastomycosis most often mimics what other respiratory infection?
pneumonia. * often diagnosis is delayed over a month because of this, pt keeps getting different types of antibiotics and doesnt get better.
most common cause "shunt" V<Q
pneumonia; these patients cant ventilate, but perfusion is fine
this control center controls both depth and rate of breathing, it acts as an "off switch" for inspiratory ramp (stretch)
pneumotaxic center (pons); when we take a full breath in, this allows us to gulp few more cc's of air.
air in the plueral space is known as?
pneumothorax
a low V/Q ratio suggests?
poor ventilation; lack of O2 supply. pt has more perfusion than ventilation - ex: chronic bronchitis, asthma, acute pulmonary edema
how do you diagnose berylliosis?
positive berylliun lymphocyte proliferation test * lung biopsy: noncaseating granulomas
all atypical pneumonias can be caused by (3x)?
post flu, prior abx, and pulm commodities
end diastolic blood vol. is known as?
preload
how is a pulmonary capillary wedge measured?
pressure is measured when the balloon at the tip of the catheter occludes the pulmonary artery. it measures the pressures distal to it while occluding all pressures proximal to it. It measures the pressures that effect the left atrium.
on CXR you note: - homogeneous infiltrates - hilar/ paratracheal lymph node enlargement - cavitations with progressive disease this is most likely?
primary TB
serum biomarker to determine bacterial infection vs others is known as?
procalcitonin; best used to guide EARLY abx discontinuation in pts with CAP
TB that got reactivated from latent stage is known as?
progressive secondary TB aka reactivation disease
murray score >3 means?
pt needs to be on ecmo!
what type of patients usually get influenza specific pharmacological meds?
pts suffering from lung disease, the elderly, NH residents, the immunosuppresed and pregnant pts.
what test is more specific than CT for catching PEs?
pulmonary angiography; dye injected in the vasculature and visualized with fluroscopy. it is more invasive than CT angiography so it has been replaced by CT because CT is safer ,faster and almost as good
increased pressure in the left side of the heart rules out what type of pHTN?
pulmonary arterial hypertension
elevated PAP with normal wedge means?
pulmonary arterial hypertension * this makes sense because with pAHTN we have a problem with the right side of the heart, high wedge means that the problem is on the left side
on CXR, how can you tell pulmonary HTN (with enlarged pulmonary arteries) from lymphadenopahy. both of these are located really close to one another
pulmonary arteries have a smooth border while lymphadenopathy has irregular borders
what pressure do we need to measure to diagnose pulmonary hypertension?
pulmonary artery pressure.
- low pressure - low resistance - high compliance these describe what type of circulation?
pulmonary circulation. * high compliance low elastnace
most common cause of "dead space" V>Q
pulmonary embolism; these patients ventilate fine, but can perfuse
noncaseating granulomas on pathology means?
pulmonary sarcoidosis
what disorders can cause increased PVR?
pulmonary vascular dz, PE, vasculitis
the net flow of fluid wants to be in the pleural space how does the body prevents this?
pumping out lots of fluids down the lymph channels (this keeps pleura negative), the rest leaves alveolus via water vapor when we exhale
if too much fluids is being drawn too fast during a thoracentesis what complication can occur?
re expansion pulmonary edema
cavitary apical posterior segments involved on CXR is classic with?
reactivation TB
cavitary lung disease is more common in _______ type of TB. it has the highest risk of transmission
reactivation type; because when it is reactivated there are a bunch of bacilli hanging out in the cavity ready to infect your friends!
classification of ILD slide
red ones are most important!
amount of air left in the lungs after maximal exhalation is known s?
residual volume
how much air is stuck in our lungs after we breath out all of our ERV is known as?
residual volume (RV); you can never get rid of this unless you give your self bilateral pneumothoracies
what is pseudostratified columnar epithelium, where can it be found?
respiratory mucosa with mucous cells, lines the nasal cavity, superior portion of the pharynx, and the conducting portion of the lower respiratory tract
small lung size = more ____
restriction
low RV is consistent with _____
restriction; RV decreases in diseases that occlude alveoli
total lung capacity is decreased in ______ ventilatory defect
restrictive - edema - atelectasis - neoplasm - pneumothorax - thoracic restriction
with PFT, transpulmonary pressure can help you diagnose?
restrictive vs. obstructive lung disease
ILD is restrictive or obstructive?
restrictive!
most common CXR findings with mycoplasma pneumonia?
reticulonodular pattern, uni or bi lateral, airspace consolidation in lower lobes
the rapid antigen test for influenza has been traditionally used to identify inflenza A and B. it is not very sensitive but it is very specific! what test is replacing it these days because it is more sensitive and specific?
reverse transcriptase PCR. takes 2 days to get results. * the test results dont really matter because you would treat the symptoms anyway
the definition of asthma is obstruction *with* ______
reversibility
pulmonary arterial hypertension causes pressures to rise in the _____ atrium and ventricle
right
what is the gold standard for diagnosis of PAH?
right heart cath
pre capillary pulmonary arterial HTN caused by?
right side of the heart before lung capillary bed
verticle fibers, thin wall, and high compliance describe what ventricle?
right ventricle * the right ventricle is like a spring collapsing on itself. if pressures go up it does not have the contraction force the left ventricle has so it fails. However, it is very compliant and if can extend to great sizes when it is filled with fluids- like a balloon.
an emboli located where the left and right pulmonary artery branches divide is known as?
saddle PE; almost always fetal! * only definitive treatment is thrombectomy or thrombolytics
latent TB treatment?
same as active but you give isoniazid for 9 months.
mycoplasma pneumonia has high infection rates in what institutions?
schools and military
pt initially had flu symptoms for a few days, these got better. however, pt suddenly gets worse this is characteristic of ?
secondary bacterial pneumonia. the hallmark of this condition is worsened fevers and symptoms after initial improvement * caused by S. pneumoniae, H.Flu, staph A and CA-MRSA
what is the pathophys of croup?
seeds in nasopharynx spread down to respiratory epithelium. ultimately laryngeal, tracheal edema leads to airflow obstruction
what are the most common reasons for death associated with ARDS?
sepsis and pneumonia
croup with stridor, with increased work of breathing and retractions is what severity? how is it managed?
severe croup; humidified high concentration o2 with nebulized racemic epi * consider steroids although controversial
what asthma category is described: - pt has symptoms throughout the day - nightly nighttime awakenings - has to use inhaler several times per day - extreme interference with normal activity - FEV 1 less than 60^ predicted
severe persistent
how do you treat bronchiectasis exacerbations?
short course of systemic steroids, careful because of increase risk for infection with these patients.
what is the most widespread pneumoconiosis in the US?
silicosis
inhalation of crystalline silica (quartz, granite, sandstone) typically seen in pts who worked in mining, quarrying, drilling, and sandblasting is known as?
silicosis * increased risk for TB, lung cancer and scleroderma
small round nodular opacities <1cm in diameter that have a preference for the upper lobe describe what type of coal worker pneumoconiosis ?
simple CWP
innumerable bilateral small round nodular opacities with distinct margins, predominately upper lobes. this fits into what classification of silicosis?
simple silicosis * may be calcified
what type of epithelium lines the gas exchange surfaces of the lung?
simple squamous epithelium
type 1 cell of alveoli means?
simple squamous, very thin for maximal gas exchange
most common abnormal EKG finding with DVT/PE is?
sinus tachycardia.............
what are extrapulmonary symptoms of blastomycosis?
skin: verrucous lesions (irregular borders; grey- violet, looks like squamous cell) bone: osteomyelitits GU: prostatitis
what increases the risk of asbestosis progression and lung cancer (adenocarcinoma MC)?
smoking
Coccidioidomycosis is mostly seen in what part of the US?
southwest: arizona/cali (valley fever) * 3-5 microns spores under the desert soil that remain suspended for a long time
pathogenesis for coccidioidmycosis
spores enlarge to 70 microns inside the lungs!
pleuritic chest pain is described as?
stabbing and sharp
bilateral hilar lymphadenopathy, right paratracheal lymphadenopathy is what stage of pulmonary sarcoidosis?
stage 1; granulomas are only in lymph nodes * staging is done by CXR
Bilateral hilar lymphadenopathy and reticular opacities, usually in upper lobes is what stage of pulmonary sarcoidosis?
stage 2; sarcoidosis is present in the lymph nodes and lung tissue
reticular opacities predominately in the upper lobes is what stage of pulmonary sarcoidosis?
stage 3; granulomas are only present in the lung tissue
reticular opacities, extensive calcification, volume loss in upper lobes, masses, cavitary lesions, and cysts. these all describe what stage of pulmonary sarcoidosis?
stage 4; scarring in the tissues of the lungs, indicating irreversible damage.
this pathogen causes necrosis of the lungs
staph, specifically MRSA
asthma that doesnt respond to B2 agonism is known as?
status asthmaticus
severe prolonged asthma attack with FEV1 <40% even after treatment is known as?
status asthmaticus; severe attack
pt is 18 y/o female, RR>30 HR >120, you note use of accessory muscles and conversational dyspnea. FEV1 <40% after treatment. most likely diagnosis?
status asthmaticus; severe attack * always admit!
what is second line therapy for DVT (severe cases)?
steptokinase (a thrombolytic medication and enzyme) or TPA * can also do thrombectomy
what is the goal for asthma treatment?
stop inflammatory changes, relieve acute bronchoconstriction/ improve QOL
pneumonia caused by what bacteria will have a greater rise in procalcitonin?
strep pneumo, H.Flu, and PJP
________ account for 2/3 of all positive pneumonia blood cultures
strep pneumoniae
most common CAP in the US is?
strep. pneumoniae aka pneumococcus
a clot with RV strain, with a hemodynamically stable describes what type of PE?
submassive PE
A pt presents with a PE. Systole > 90, EKG changes present with RV dilation and elevated pro BNP. pt has what type of PE? what would you do?
submassive PE, send pt to the ICU
what is Usual interstitial pneumonia (UIP) pattern on HRCT chest?
subpleural, bibasilar predominance of reticular markings
most wheezing from COPD, asthma, etc.. come from what area of the lower respiratory tract?
subsegemental bronchi (bronchioles)
there is always some amt. of water in the lung, elastin + the surface area of water are trying to collapse the lung, what stops these forces from collapsing the lung?
surfactant breaks the surface tension of water, so it can no longer collapse the alveoli.
if foregin body is visible, you should?
sweep out (never blind) * if not; infant 5 back blows/ 5 chest thrusts and for a child abdominal thrusts
- high pressure - high resistance - low compliance these describe what type of circulation?
systemic circulation * low compliance high elastnace
patient with____ shouldnt be getting bronchodilator for PFTs
tachycardia
sweat chloride test is used for?
testing for CF
pt is 1 y/o with central cynosis when crying. grade 4 SEM present with sternal heave. digital clubbing noted. on chest X ray you notice a "boot shaped heart" this is most likely?
tetrology of fallot * "boot shaped heart" is pathognomonic for this condition
what is the physiology behind cystic fibrosis?
the CFTR gene controls Cl- ch. on apical epithelial cells. with genetic abnormalitis there is no NaCl + entry of water into the airways, making secretions super dry and thick. * also occurs in the pancreas/biliary ducts, and sweat glands.
PAWP estimates the pressure of?
the LV at the end of diastole
how can dilation of the RV cause reduces perfusion/circulation to the heart muscle?
the RCA comes off the aorta. blood flows from high to low pressures, blood flows from the aorta to the RV. as the right ventricle increases in size and squishes the left side the pressures in the aorta become low. this decreases the coronary blood flow, decreasing perfusion of heart muscle
normal A-a gradient means?
the ability to transfer gas from lung to vessel is fine. * O2 content in artery matches that in alveolus, how ever much O2 lungs are able to give the artery will take. so in high altitude, lungs give the artery as much O2 as they can, its just that there isnt enough in the first place. high altitude hypoxia is not due to lung damage but its due to a lack of O2 in the atm.
high A-a gradient means?
the ability to transfer gas from lung to vessel is impaired. * lots of O2 in alveolus, not a lot in artery. Even if there is plenty of O2 in the lungs they cant give it to arteries.
FeNO is used to determine?
the etiology of respiratory symptoms; it helps determine if there is an allergic component of asthma and how to best utilize systemic/inhaled steroids * it helps to identify eosinophilic asthma phenotypes
hydrostatic pressure
the fluid pressure within a blood vessel that tends to push water out of the vessel
bronchiectasis workup slide
the goal is to find out why they are having bronchiectasis
you have a pt on the vent, and you see that his transpulmonary pressure is very high, it tells you that?
the vol. you are giving the pt is way too high and trauma will happen to the lung.
Starling's law of the heart states that
the volume of blood that enters the heart during diastole directly affects the force of contraction at systole. to put it more simply, the heart pumps more blood when more blood returns
infants breath primarily through?
their nose!
what leads to thicker secretions and recurrent infections in Cystic fibrosis?
there are changes in electrolytes in the respiratory epithelium. reduction of Na leads to thicker secretions that cannot be coughed up, this leads to infections because bacteria can stay in the lungs longer and reproduce
why is residual volume usually high in emphysema pts?
these pts lose elasticity in their alveoli, this causes air to stay trapped inside the alveoli. this means that every breath they take in some amount of air stays inside their lungs making it harder to take the next breath.
what should you think about when you see a pt with PNA caused by anaerobes?
think aspiration, eval swallowing
rare syndrome that develops abruptly. characterized by swelling at the rib cartilage junction that can last for months
tietze syndrome; usually affects 2nd and 3rd ribs
why do we order CXR in COPD excerbations?
to rule out pneumonia
what is barium swallow used for with kids who are suspected to have asthma?
to rule out reflux
vital capacity + residual volume = ?
total lung capacity
when looking at lung volumes, the top 3 most important aspects to look are?
total lung capacity, vital capacity, and residual volume
give examples of anatomic dead space
trachea and non respiratory bronchi/ bronchioles. * it is being ventilated, but not perfused by the pulmonary capillaries
if we reduce the intra- alveolar pressure from the intra- pleural pressure we get what type of pressure?
trans- pulmonary pressure (TTP) * intra alveolar pressure - intra pleural pressure = TTP
pressure difference inside a given tube vs outside of the tube is known as?
transmural pressure
what type of effusion is most common?
transudate
this effusion is caused by increase in pulmonary venous pressure or hypoproteinemia (imabalance of hydrostatic and oncotic pressures in the chest)
transudate effusion
what type of effusion is typically clear, yellow/straw colored?
transudate effusion
protein <3.0 g/100ml is seen with what type of effusion?
transudate; total protein may be elevated in pts who have been given diuretics "pseudoexudative"
pale yellow/ straw colored pleural fluid indicates?
transudative
most common cause for pneumothorax is?
traumatic/ iatrogenic (caused by medical procedure)
if after 2 months of treatment sputum cultures are still positive, how long should TB treatment last?
treat for 9 months! * monthly cultures * if cultures cleared at 2 month continue treatment until 6 months have passed do not stop
true or false: inhaled corticosteroids cannot be used as solo therapy
true!
true or false: residual volume is reversible with bronchodialator in asthma but it is permanent in emphysema
true!
true or false: the lung parenchyma has no nerve fibers, all the nerves are located on the pleura- therefore any inflammation is VERY painful!
true!
true or false: you should consider a trial of PPI for poorly controlled asthma
true!
true or false: it is not critical to distinguish acute bronchitis from viral URI
true! * it is critical to distinguish acute bronchitis from pneumonia
true or false: glucocorticoids are not helpful for chronic hypersensitivity pneumonitis
true! chronic progresses to fibrosis which is irreversible. * glucosteroids can be helpful with acute HP
true or false: reactivation of TB is the cause of most active cases
true! it is the 2nd leading infectious cause of mortality for adults worldwide
true or false: ARDS CXR will have absence of pleural effusions
true! it will have diffuse bilateral infiltrates
true or false: both reactivation and primary TB have active disease
true! only latent/dormant TB is not considered "active disease"
true or false: ventilation increases before paCO2 goes up during exercise
true! paCO2 actually drops at the start of exercise
true or false: you can diagnose emphysema on CT/ CXR
true! you cannot diagnose COPD on imaging tho! must have spirometry
true or false: croup is caused by a virus most of the time
true!; caused by parainfluenza 1 and 2 MC
true or false: CXR can be relatively normal even in severe respiratory distress in patients with pneumocystis jirovecii pneumonia (PJP)
true!; typically CXR will show diffuse bilateral interstitial infiltrates
total protein >4 on thoracentesis means?
tuberculous pleurisy
what is last resort treatment for pulmonary sarcoidosis?
tumor necrosis factor alpha antagonists (TNFa) * lung transplantation for select patients with stage 4 dz
what cell type in the alveoli secretes surfactant?
type 2. - surfactant decreases surface tension; prevents alveolar collapse
what patients are at high risk for healthcare associated pnemonia?
typically its patients with high risk of multidrug resistant organism pneumonia. examples: - nursing home pts - dialysis pts - hospitalized within 3 months - immunocompromised
what is the test of choice for a DVT?
ultrasound can confirm the diagnosis and the severity * D-dimer is often false positive
this type of parapneumonic effusions has neutrophil predominance and resolves with treatment for pneumonia
uncomplicated parapneumonic effusion
what causes secondary PTX?
underlying dz like: - COPD - CF - sacrcoidosis - TB - AIDS- PCP
how can you tell CHF and ARDS apart of a CXR?
unlike CHF, ARDS is not peripheral sparing. * remember that although you can see differences between cardiogenic and noncardiogenic disease on CXR it is not a reliable way to distinguish them apart must have more testing. you can have a pt who developed ARDS from pneumonia but that pt has CHF as well
what is the #1 cause of chronic cough?
upper airway cough syndrome (aka post nasal drip)
how would a CXR of a pt with acute bronchitis would typically show?
usually normal
if there is an area of the lung that isnt receiving enough o2, what would the blood vessels in that area do?
vasoconstrict, this is the opposite of what vessels in systemic circulation would have done. the reason behind the vasocnstirciton is for the lungs to combat V/Q mismatch. if an area of the lung was getting a lot of o2 the lung would have vasodialated this area.
when lungs are exposed to less o2, what do the pulmonary capillaries do?
vasoconstriction; fluid goes out of the capillaries and into the alveoli causes pulmonary edema.
What is VV ECMO
veno- venous: lung bypass: taking blood out of the vein, oxygenating it, and running it back to a vein. this is what is used in ARDS often
what is VA ECMO
venous arterial: bypass heart and lungs, reserved to really bad cases of ARDS
hypercapnic respiratory failure, is a failure of?
ventilation build up of CO2
a high V/Q ratio suggests?
ventilation exceeds perfusion. - unable to oxygenate any blood like with COPD
V/Q ratio is?
ventilation/perfusion ratio
this respiratory control center is inactive during normal, quiet respiration. it kicks in when respiratory drive is high to control accessory muscles in expiration
ventral respiratory group (medulla); can control both inspiration and expiration. active during pathology but also stress and exercise
this type of penumonia has interstitial infiltrates on CXR without dense consolidations; has high fever, dyspnea, and hypoxemia
viral pneumonia
maximum amount of air that can be exhaled after maximal inhalation is known as?
vital capacity
ERV+ Vt+ IRV= ?
vital capacity (VC) *remember that capacity refers to 2 or more volumes
flow volume loop that is flattened on inspiration or "saw tooth pattern" with inspiration indicates?
vocal cord dysfunction
mycoplasma pneumoniae is aka?
walking pneumonia * severe URI symptoms for 4-6 weeks (cough, pharyngitis)
what are 2 grading scores for PE?
well score and PERC criteria * PERC is better overall because if it is completely negative it is certain that PT is PE free
what are pulmonary complaints pts have with granulomatosis with polyangiitis ?
wheezing, stridor, coughing up blood
when a baby who suffers from tetrology of fallot cries, what happens to pressure in the lungs? how does it effect systemic circulation?
when a baby cries pressure in the lungs goes way up. this causes blood in the right ventricle to bipass the lungs and go straight into the left ventricle through a ventricular defect. this blood gets pumped to systemic flow and causes cyanosis
what is a check valve obstruction?
when air can get in but cant get out; thats why make sure to get inspiratory and expiratory chest films
how does placing the pt in a prone position improves ARDS?
when pt is prone it helps to take fluid out of zone 3 by gravity. in addition the weight of the heart is not on the lungs its on the sternum, helps lungs recover faster. * prone for 16 hours while having pt on paralytics and keeping all lines and tubes attached. reasses PF ratios until they are better
when would you use a methacholine challenge test (MCT)?
when pulmonary function testing was normal in a pt you suspect of having some hypersensetivity * a positive test is >20% decrease in FEV 1 from baseline
when is the only time antiobiotics should be used with influenza patients?
when secondary bacterial pneumonia is expected
when should you use a methacholine challenge test, what is it?
when you are convinced pt has asthma due to hypersensetivity but spirometry is normal. in this test we are trying to induce a mild asthma sympotms in a controlled environment. usually takes 6 measurements and 20% decrease in FEV1 is needed for positive result
when would you use a V/Q scan over CT with a suspected PE?
when you cant do a CT scan in patients with shellfish allergy, dye allergy, claustrophobic, or with kidney failure. * low probability <20% chance for PE * intermediate probability: 20-80% chance PE * high probability: <80% chance PE
what does 'diastolic step up' mean?
when you move the pulmonary artery catheter into the pulmonary artery you get this diastolic step up because the pulmonary valve closes, preventing pressures from equalizing into the right ventricle.
what does 'systolic step up' mean?
when you move the pulmonary artery catheter into the right ventricle you get a 'systolic step up' because the RV contracts during systole
when should you get an ABG on an asthmatic pt?
with acute exacerbation; pO2 < 50 mmHg is seen with severe obstruction
how may patients with berylliosis present?
with dry cough, SOB, night sweats, fever, fatigue, and wt loss. * can occur 3 months to 30 years from exposure to beryllium
how can legionella be diagnosed?
with urine antigen
pt has primary PTX, he is stable with 100% SpO2 on room air, should you give high flow O2 to this pt?
yes, O2 increases reabsorption of air in the pleural space
should you give bordatella pertussis patients abx in later stages like after 4 weeks of symptoms?
yes, they wont help much in reducing the duration of the disease at this point but abx are given to all family members as well to reduce spread of disease.
what is the first thing to remember about ARDS treatment?
you must treat the underlying cause, it is the reason they got ARDS in the first place
What is the MoA of Phenylephrine?
• Alpha-adrenergic stimulation: vasoconstriction of arterioles of nasal mucosa • Weak Beta-adrenergic stimulation
What is the MoA for pseudoephedrine?
• Alpha-adrenergic stimulation: vasoconstriction of respiratory mucosa • Beta stimulation: ↑ rate/contractility of heart, bronchorelaxation
What are some of the possible side effects of Pseudoephedrine?
• Cardiovascular: *tachycardia*, palpitations, arrhythmia, ↑BP • CNS: dizziness, headache, *insomnia*, nervousness, CNS stimulation • GI: N/V • GU: dysuria
What are some potential side effects of Phenylephrine?
• Cardiovascular: hypertension • CNS: HA, dizziness, anxiety, restlessness
How would you treat rebound congestion from topical nasal decongestants that have been used too long?
• Cessation of spray *• Nasal corticosteroids*
What antibiotics should be used to cover for pseudomonas for contact wearers with corneal abrasion or bacterial conjunctivitis?
• Gentamicin (Gentak®) • Fluoroquinolones: Ciprofloxacin (Ciloxan®), Ofloxacin (Ocuflox®)
What are the SE of topical steroid use for ophthalmic conditions?
• Mask infection • Affect wound healing • Increase IOP, worsen glaucoma • Contribute to cataract formation