-
Asthma tests
- Acute: ABG and peak flow
- Accurate: PFTs- dec FEV1/FVC, inc FEV1 >12% with albuterol, dec FEV1 >20% with methacholine or histamine, inc DLCO
-
Asthma tx
- 1 - SABA
- 2- low dose ICS (beclomethasone, budesonide, fluticasone, mometasone - dysphonia and candidiasis)
- Cromolyn and nedocromil to inh mast cells
- theophylline
- leukotriene modifiers - montelukast, zarifleukast (hepatotoxic and churg strauss), zileuton. best for atopic
- 3. Inc ICS or add LABA
- 4. Inc ICS to max
- 5. Omalizumab if inc IgE
- 6. oral steroids
- Flu and pneumococcal vaccines
-
Oral steroids sides
- Osteoporosis
- Cataracts
- Adrenal suppresion
- fat redistribution
- Hyperlipidemia
- Hyperglycemia
- Acne
- Hirsutism
- Striae
-
COPD tests
- Initial: CXR
- Accurate: PFTs - FEV1/FVC <70%, inc TLC, dec DLCO, no change with albuterol or methacholine
- ABG: inc pCO2, hypoxia, resp acidosis
- CBC: inc hematocrit
- EKG: RAH, RVH, Afib, MAT
- Echo: RAH, RVH, pulm htn
-
COPD tx
- Improves mortality: stop smoking, O2, flu and pneumococcal vaccines
- Symptoms: SABA, Anticholinergics (tiotropium, ipratropium), ICS, LABA, rehab
- Possible: theophylline, lung reduction
-
O2 use in COPD
- pO2<55 or O2 sat <88%
- If right heart failure or inc in hematocrit, pO2<60 or O2 sat <90%
-
Bronchiectasis causes
- Cystic fibrosis
- Infections - TB, PNA, abcess
- Panhypogammaglobulinemia
- Foreign body
- tumor
- Allergic bronchopulmonary aspergillosis
- Rheumatoid arthritis
-
Bronchiectasis tests
- initial: CXR - tram tracks
- Accurate: high res CT
- Sputum cx
-
Allergic bronchopulmonary aspergillosis (ABPA): presentation, dx, tx
- In pts with asthma or atopic
- Brown flecked sputum and transient infiltrates
- Eosinophilia, skin test, Ab, IgE, CXR, CT
- oral steroids, itraconazole for recurrent
-
Cystic fibrosis PFTs, bugs
- mixed - dec FVC and TLV, dec DLCM
- H flu, Pseudomonas, Staph, Burkholderia
-
Cystic fibrosis tx
- Abx, inhaled aminoglycosides
- Inhaled recombinant human DNase
- Inhaled bronchodilators
- Pneumococcal and flu vaccines
- Lung transplant
-
Assocation of PNA caused by:
Hflu,
Staph,
Klebsiella,
Anaerobes
Mycoplasma,
Chlamydia,
Legionella,
Chlamydia psittaci,
Coxiella burnetii
- COPD
- Recent flu
- Alcoholism, DM
- Aspiration, poor dentition
- Young and health
- Hoarseness
- Contaminated water sources
- Birds
- Animals
-
Dry PNA
- mycoplasma
- viral
- coxiella
- PCP
- Chlamydia
-
Adequate sputum gram stain
- >25 WBC
- <10 epithelial cells
-
Empyema labs
- LDH >60% serum
- protein >50% serum
- WBC >1000
-
Dx test for mycoplsma
- PCR
- cold agglutins
- serology
- special media
-
Dx test for chlamydia or coxiella pna
Rising serologic titers
-
Dx test for legionella
- urine antigen
- Cx on charcoal yeast
-
-
Outpt tx of PNA
- Previously healthy, no Abx in past 3 mo, mild sx: Macrolide (azithromycin clarithromycin) or doxy
- Comorbidities or Abx in past 3 mo: fluoroquinolone (levofloxacin or moxifloxacin)
-
Inpatient tx of PNA
- Fluoroquinolone (levofloxacin or moxifloxacin)
- Or
- Ceftriaxone + azithromycin
-
Reason to hospitalize pna
- Hypotension
- RR>30 or pO2<60 or pH<7.35
- BUN>30, Na<130, or glc>250
- HR >125
- Confusion
- Temp >104
- 65+
- Comorbid cancer, COPD, CHF, renal failure, liver disease
-
Hospital acq pna bugs and tx
- Ecoli and pseudomonas
- Cefepime or ceftrazidime
- or
- Piperacillin/tazobactam
- or
- Imipenem, meropenem, doripenem
-
Ventilator associated pna incidence, dx, tx
- 5% per day for first days
- Least accurate to most: tracheal aspirate, BAL, protected bursh specimen, video assisted thorascopy, open bx
- Cephalosporin or Piperacillin/tazobactam or carbapenem + aminoglycoside or fluoroquinolone + vanc or linezolid
-
-
Lung abscess tx
Clindamycin or pen
-
PCP tests
- CD4<200
- Initial: CXR or ABG
- LDH inc
- Accurate: BAL
- Sputum stain has only PPV
-
PCP tx
- bactrim
- Steroids if severe (pO2<70, Aa>35)
- If mild, alternative is atovoquone
- If toxic to bactrim, clinda+primaquine or pentamidine
-
Bactrim sides
- most common is rash
- 2nd is bone marrow suppression
-
PCP ppx
- when <200
- bactrim
- alternative is atovoquone or dapsone
-
TB risk factors
- Immigrant
- Prisoner
- HIV
- Healthcare
- Close contact
- Steroids
- Hematologic malignancy
- Alcoholic
- DM
-
TB tests
- Intial: CXR
- Sputum stain and cx x 3
- Accurate: pleural bx
-
TB tx
- + smear: Rifampin, isoniazid, pyrazinamide, and ethambutol x 2 mo. Rifampin and INH for 4 mo.
- 9mo for osteomyelitis, miliary, meningitis, pregnancy or other cause of not using pyrazinamide
- Add steroids if pericardial or meningeal involvement
-
TB tx toxicity
- All hepatoxic. Dont stop unless 3-5x upper limit of normal
- Rifampin: red secretions, benign
- INH: peripheral neuropathy, give pyridoxine
- Pyrazinamide: teratogen, hyperuricemia
- Ethambutol: color vision, optic neuritis. dec dose if renal failure
-
PPD positive
- Induration 5mm: HIV, steroids, close contacts of active, transplant
- 10mm: immigrants, prisoner, healthcare, close contacts, heme malignancy, alcoholic, DM
- 15mm: no risk factors
- If PPD neg, repeat within 1-2weeks
-
Latent TB tx
- 9mo INH
- 10 to 1% lifetime risk of TB
-
Signs of malignany of a pulm nodule
- spicules
- >2cm
- atelectasis
- adenopathy
- sparse, eccentric Ca
- abnormal PET
-
Intermediate probability lung nodules
signs
work up
- 1-2 cm, 30-40 yo
- Sputum cytology has PPV
- bronchoscopy or transthoracic bx
- PET
- VATs
-
Drugs causing pulm fibrosis
- Bleomycin
- Busulfan
- Amiodarone
- Methysergide
- Nitrofurantoin
- Cyclophosphamide
-
Risks for:
silicosis,
asbestosis,
byssinosis,
berylliosis,
bagassosis
- sandblasting, mining, tunneling
- shipyard, pipe, insulators,
- cotton
- electronics
- moldy sugar cane
-
Interstitial lung disease tx
prednisone if WBC/inflammatory. best for berylliosis (granulomas)
-
Sarcoid dx
- intial: CXR
- accurate: LN bx with noncaseating granulomas
- inc ACE
- HyperCa in urine and serum
- PFTs
-
PE tests
- Initial: CXR, EKG, ABG
- Accurate: Angiography
- DDimer - NPV so only for low prob
- Follow CT with V/Q or dopplers
-
PE CXR
- Normal
- Atelectasis
- Wedge infarct
- Plearal based lesion=Hamptom hump
- Oligemia of one lobe=Westermark sign
-
PE EKG
- Sinus tach
- nonspecific ST-T wave chenages
- R axis
- RV hypertrophy
- RBBB
- S1 Q3 T3
-
-
IVC filter indications
- Melena
- CNS bleeding
- Recurrent emboli
- RV dysfunction
-
Pulm htn tests
- Intitial: CXR
- Accurate: Swan-Ganz
- EKG - R axis, RAH, RVH
- Echo
-
Idiopathic pulm htn tx
- Prostacyclin analogues: epoprostenol, treprdostinil, iloprost, beraprost
- Endothelin antagonists: bosentan
- Phosphodiesterase inh: sildenafil
- O2 to slow progression
- Transplant
-
ARDS risks
- Sepsis
- aspiration
- lung contusion
- near drowning
- burns
- pancreatitis
-
ARDS dx
- CXR: white out, air bronchograms
- pO2/FIO2 <200 (room air is 0.21 FIO2)
- Normal wedge pressure
-
ARDS tx:
- Underlying cause
- Low tidal volume ventilation - 6ml per kg of tidal volume
- Late steroids
- PEEP to dec FIO2 - above 50% is toxic
- Plateau pressure of less than 30cm of water
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