IM pulm

• Misc: 60+, CA, prior DVT/PE, 
• Hereditary: hypercoag states (factor V Leiden, prot C&S defic, ~thromb III defic)
• Cond: Card dz (CHF), obese, nephrotic syndr
• Major: surg, trauma
• Estrogen: preg, OCC

dysp, tachyp, pleuritic CP, rales, cough, DVT s/sx, tachyc, S4, /P2, shock, LG F, BS, dull on percuss

• US: venous duplex of LE (+) hep, (-)?
• V/Q: nl r/o PE, hi-prob hep, /clin suspicion - PA
• CT: helical chest - good s/s
• Pulm angio: gold std - invasive
• D-dimer: nl & clin susp low - likely not PE (also / MI, CHF, PNA, post-op
• Modified Wells criteria: .

• PE likelihood
• 3: clin s/sx DVT; alt dx less likely
• 1.5: HR>100, immob/surg<4wk, prior DVT/PE
• 1: hemop, CA last 6mo
• Clinical probability
• Low: <2 (<=10%)
• Med: 2-6(<=30%)
• High: >6(>=705)
• 4: D-dimer assay, if abnl do spiral CT
• 5+: Spiral CT scan

• O2: correct hypoxia
• A ~coag tx: UFH/LMWH -> PTT 1.5-2.5x 80ug/kg bolus, 18ug/kg/hr for 5-10 days
• Warfarin: LT tx, start day1->INR 2-3 for 3-6mo
• Throbolytic tx: tPA - massive PE, unstable, R HF
• IVC: CI to ~throm, fail, low pulm reserve
• Embolectomy: surg/cath - CI tPA/fail
• Prophyl: hep 5000uSC every 8-12hr; enoxaparin 30mgSC BID or 40mg SC daily. SCD

• Typical: S. pneumo, H. flu, aerobic Gram- rods (klebsiella [EtOH], enterobacteriacae), Staph aureus
• Atypical: M. pneumo, chlamydia, coxiella burnetii, legionella, viruses (flu, adenovius, parainfluenza, RSV)

• Typical:Atypical
• Acute:Insideous
• Prod cough:dry cough
• Purulent sputum:no sputum
• F w/shaking chills:F w/no chill
• Tachypnea/tachycardia:pulse/temp dissociation
• late insp crackles, bronch BS, ^fremitus, dullness on percuss
• wheeze,ronchi,crackles

• Typical: lobar consolidat'n; multi-lobar=serious
• Atypical: diff reticulonod'r infiltr's; ~consolidat'n

• CXR (PA/Lat), Chgs lag 6 wks
• Pre-tx sputum Gram stain/cx
• Urinary antigen assay (legionella, S. pneumo)
• Blood cx
• CBC

• CAP: in community or 1st 72 hrs hosp
• H(C)AP: after 72 hrs hospitalization

• G(-) rods (E. coli, Psuedomonas)
• Staph aureus

• G- rods
• Cephalosporins w/pseudomonal coverage:
• - Ceftazidime, cefepime
• - Carbapenems (imipedem)
• - Piperacillin/tazobactam (Zosyn)
• NOT macrolides (azith, clarith, eryth)

• Right <3 border   - RML
• Left <3 border     - lingula
• R hemidiaphr       - RLL
• L hemidiaphr       - LLL
• Descending aorta - LUL

• C bronchitis: clin dx - c cough+sputum x3mo/yr for 2 yrs. /mucus->inflam&scar, /glands, sm muscle hyperplasia
• Emphysema: pat dx - alveoli destruct; <-smoke
• Coexist; /obstruction

Smoke, α-antitrypsin defic, 2nd-hand smoke, POC,     c asthma

• Any combo: cough, sputum, /dyspnea
• DOE: limit activity
• /FET: prolonged forced expiratory time >=6sec
• Auscult: end-forced-expir wheezes, breath sounds, inspiratory crackles
• Misc: tachyp, tachyc, cyanosis, accessory, hyperresonance, signs cor pulmonale

• Emphysema > C Bronchitis
• Thin, lean fwd, barrel chest, tachyp w/pursed lips, distressed, uses accessory musc (straps)

• C Bronchitis > Emphysema
• Overweight, cyanotic, c cough w/sputum, signs of cor pulmonale, RR nl-slight/, NAD

• PFT (spirometry) - definitive test
• FEV1: 70% mild, 70-50 mod, 50- severe
• FEV1/FVC: < 0.70 obstruction
• /TLC, RV, FRV: .
• peak exp flow rate: <350L/min do PFT
• FEF50%: 0.5 = obstruction
• CXR: HInflat'n, flat diaph, /retrosternal space, vasc markings, r/o PNA/pnuemothorax
• α-antitrypsin lvl: fam hx <= 50
• ABG: c pCO2 retention, O2 -> c resp acidosis + metabolic acidosis to compensate

• X smoke: sx improve by 1 year
• O2 tx: lowers mortality (18 hr/day P-HTN) - PaO2 55, O2sat<88, PaO2 55-59 = polycythemia or cor pulmonale
• i B2-agon: (lev)albuterol - bronchodilators. Long-acting salmeterol, formoterol
• i ~cholinergic: ipratropium bromide, tiotropium (slower than B2 but last longer); combo
• i corticosteroids: budesonide, fluticsone, ~inflam - minimal FEV1 decrease
• Misc: pulm rehab, vaccinations, abx, surg

• Mild-mod: bronchodilator MDI, LD i glucocorticoids, ?theophylline
• Severe: Meds + continuous O2 tx, pulm rehab, triple inhaler tx.

• s/sx: persistent /dysp not relieved by dilators, /sputum, cough
• complic: acute resp failure
• organisms: S. pneumo, H flu, M. catarrhalis, V

• Bronchodil: (B-agonist) alone w/anticholinergics
• Syst corticosteroids: hosp IV methylprednisone, taper w/ oral prednisone (NOT inhaled!)
• Abx: azith, levo, TMP/SMX, amox, doxy
• O2: >90%
• NPPV: non-invasive +-pressure vent BIPP CPAP
• Hosp: or not?
• CXR: .

• acute exacerbations: infect, non-comply, HD
• 2ndary polycythemia: HCT>55M/47F
• Pulm HTN & cor pulmonale: severe, long-standing
• RV hypertrophy: <- c bronchitis

• Def: c systemic granulomatous dz char by noncaseating granulomas, mult organ sys incl lungs
• Occur: >AA, W, 75%<40yo, 50% incidental CXR

• Dyspnea
• CP
• HCa
• Ocular
• CNS
• Cardiac involvement
• Progressive pulmonary dz

• CXR: B hilar adenop, 50%
• /ACE: 50-80%
• HCaUria/emia: common
• LFT: abnlities
• Bx: transbronchial - definitive; see noncase gran
• PFT: lung vol (VC, TLC), DLco, FEV1/FVC
• Galium scan: panda sign

• I: B hilar adenopathy w/out parench infiltrates
• II: hilar adenopathy with parenchymal infiltrates
• III: diffuse parench infiltrates w/o hilar adenop
• IV: pulmonary fibrosis w/ honeycombing and fibrocystic parencymal changes

• Most resolve in 2 yrs
• Systemic corticosteroids x 6 wks, 2-3mo taper
• Methotrexate if refractory to corticosteroids