Pulmonology 6

  1. have cartilage, smooth muscle, mucus glands
    Proximal generations
  2. are membranous and held open by tethering forces
    Distal generations
  3. 23 branched tube structure; Proximal generations have cartilage, smooth muscle, mucus glands; Distal generations are membranous and held open by tethering forces
    Normal airway
  4. Inflammation narrows airways (asthma, bronchitis), reducing airflow
    Obstructive airway diseases:
  5. More distal involvement can also create alveolar destruction (emphysema)
    Obstructive airway diseases:
  6. normal spirogram
    normal VC, normal FEV1 AND normal FEV1/VC ratio
  7. Obstruction defined
    by low FEV1/VC ratio
  8. rough rule below 70%
  9. severity graded by
    FEV1 % predicted
  10. Restriction defined by
    low VC, low FEV1 BUT normal FEV1/VC ratio
  11. wheezing/SOB; reduced FEV1/FVC and increased RV (during exacerbations or methacholine)
  12. include environment, allergies, GERD, infection, sinuses, stress
    episodic asthma triggers
  13. Methacholine challenge
  14. (<2/wk, near nl PFT)
    Intermittent Asthma
  15. (<1/d, near nl PFT)
    Mild persistent Asthma
  16. (daily, mild/mod PFT)
    Moderate persistent Asthma
  17. (daily/nocturnal, mod/sev PFT)
    Severe persistent Asthma
  18. mucus gland hypertrophy (cough/sputum); reduced respiratory drive; airway hyper-reactivity
    COPD: Proximal predominant (large airways)
  19. dyspnea - active respiratory drive; reduced DLCO
    COPD: Distal predominant (small airways/alveoli)
  20. mucus gland hypertrophy (cough/sputum)
    COPD: Proximal predominant (large airways)
  21. reduced respiratory drive
    COPD: Proximal predominant (large airways)
  22. airway hyper-reactivity
    COPD: Proximal predominant (large airways)
  23. dyspnea - active respiratory drive reduced DLCO
    COPD: Distal predominant (small airways/alveoli)
  24. reduced DLCO
    COPD: Distal predominant (small airways/alveoli)
  25. middle age/ elderly, cough, phlegm, wheeze, rhonchi, hyperinflation, cor pulmonale, LoPO2/HiPCO2 chronically
    Chronic bronchitis
  26. blue bloater
    chronic bronchitis
  27. middle age/elderly, dyspnea, distant breath sounds, hyperinflation, cor pulmonale late, near normal until late
  28. pink puffer
  29. minute ventilation
  30. MVV
    maximal voluntary ventilation
  31. Hyper-reactive airways from: allergies - IgE dust mite, cockroach droppings; induced: occupational exposures - RADS, viruses, environment/inhaled toxins, other (familial) Cellular elements: mast cells, eosinophils, CD4 lymphs
    Asthma - etiology
  32. Inhaled toxins: tobacco, others; Anti-protease deficiencies; Airway “remodelling” in persistent asthma
    COPD - etiology
  33. dissipates as immune system “grows up”
    Childhood allergic asthma
  34. waxes/wanes depending on inducing causes; persistent reactivity predisposes to COPD (airway remodelling)
    Acquired asthma in adults
  35. depends on tobacco exposure/sensitivity
    COPD natural history
  36. Low delivery means must load with more drug; Tidal breathing, long time
  37. Delivery to 40%; Pt coordination required; Spacer for coord, velocity
    MDI: metered dose inhaler
  38. Delivery to 40%; Easier coordination
    DPI: dry powder inhaler
  39. Tobacco cessation; Pharmacologic therapy; Oxygen, Rehabilitation; Surgery
    COPD management
  40. Education: [chronic & acute management], Exercise: [deconditioning common; may need bronchodilators/O2]; Psycho-social support
    Pulmonary rehabilitation
  41. removes overdistended regions to allow more normal regions to re-expand; puts diaphragm at better rest point; being evaluated in large trial (NETT)
    Lung volume reduction surgery
  42. Endobronchial valves; Biologically mediated scar formation; New collateral channels for ventilation
    Less Invasive Approaches to LVRS
  43. LVRS
    Lung volume reduction surgery
  44. put needle in & shoot, pop a bubble; & leave a stent
    Bronchial Fenestration
  45. Infections (viral); Acute exposures to allergens; Exercise (cold air); ?Stress; Anaphylactic like reaction (“sudden death”)
    Asthma exacerbations triggers
  46. Usually infectious trigger; Must rule out: PE, CHF, pneumothorax, other
  47. Bronchodilators, Steroids, Oxygen, Antibiotics, NPPV
    AECOPD management
  48. increase beta agonist if on inhaled steroid, double dose
    mild asthma (> 80)
  49. increase beta agonist, add/increase oral steroid
    moderate asthma (50-80%)
  50. increase beta agonist, add/increase oral steroid, proceed to ED
    severe asthma (<50%)
  51. Advanced pigment changes of ________ are characterized by red oozing skin (worse on the left anterior leg) with some scaling on the ankle.
    Stasis dermatitis:
  52. Longstanding edema in this patient with chronic venous insufficiency led to moderately advanced pigment changes on the medial and lateral ankles, which extend onto the dorsum of the foot.
    Skin changes of chronic edema:
  53. Large venous ulcer on the medial ankle in a patient with chronic venous stasis. The ulcer is shallow and red-based with irregular borders.
    Venous stasis ulcer:
  54. Progression of Chronic Venous Insufficiency
    Stasis dermatitis: Skin changes of chronic edema: Venous stasis ulcer:
  55. Which of the following causes the most deaths in the United States every year? A. Breast cancer; B. Pulmonary embolism, C. Highway fatalities, D. AIDS
    Pulmonary embolism
  56. Virchow’s Triad:
    Stasis, Venous injury, Hypercoagulability
  57. VTE Risk Stratification: Patient Factors: Clinical
    Reduced mobility
  58. interferes with the function of the calf muscles in pumping blood upstream through the veins.
  59. confers a higher risk than other positions.
    Immobilization in a sitting position
  60. Pain, tenderness, swelling, warmth / erythema; Sensation of muscle cramping (“I pulled a muscle”); May be acute or develop over days or longer
    Deep Venous Thrombosis: Symptoms and Signs
  61. Deep venous thrombosis; Postphlebitic syndrome, Cellulitis, Trauma / hematoma, Muscle cramp, Baker’s cyst
    • Acute Deep Venous Thrombosis:
    • The Differential Diagnosis
  62. Lab Tests: D-dimer
    Acute Deep Venous Thrombosis
  63. Diagnostic Imaging Tests for Suspected Acute DVT
    Ultrasound, Contrast venography, Magnetic resonance imaging, CT
  64. Diagnostic Imaging Tests for Suspected Acute DVT: most common / practical
  65. Diagnostic Imaging Tests for Suspected Acute DVT: gold standard, rarely done
    Contrast venography
  66. Diagnostic Imaging Tests for Suspected Acute DVT: also accurate
  67. Diagnostic Imaging Tests for Suspected Acute DVT: very accurate
    Magnetic resonance imaging
  68. 72 yo. college professor with CHF and acute proximal DVT. How would you treat?
    Unfractionated heparin; LMWH
  69. For patients with a high clinical suspicion of DVT or PE, we recommend treatment with
    anticoagulants while awaiting the outcome of diagnostic tests (Grade 1C)
  70. Arterial blood gas; D-dimer; Troponin; BNP
    Lab Tests: Pulmonary Embolism
  71. Lab Tests: Pulmonary Embolism: hypoxemia
    Arterial blood gas
  72. Lab Tests: Pulmonary Embolism: Sensitive, not specific
  73. Lab Tests: Pulmonary Embolism: + with RV damage
  74. Lab Tests: Pulmonary Embolism: increases with LV or RV dilation
  75. may be present in PE but not diagnostic!
    S1 Q3 T3
  76. Diagnostic Imaging Tests for Suspected Acute PE: most common test
    Spiral (helical) CT
  77. Diagnostic Imaging Tests for Suspected Acute PE
    Pulmonary arteriogram; Ventilation-perfusion scan, Spiral (helical) CT; Compression ultrasound; MRI
  78. PIOPED
    Prospective Investigation of Pulmonary Embolism Diagnosis
  79. When the VQ scan is normal, PE is not present; When the VQ scan is high probability, and clinical suspicion is high, PE is considered present; When the VQ scan is nondiagnostic (low prob or intermediate prob), more studies are needed.
  80. CTA sensitivity = 83%, CTA + CTV sensitivity = >90%
  81. an established technique for the diagnosis of PE.
    Pulmonary angiography (PA)
  82. Increased bioavailability compared with UFH; Once or twice daily subcutaneous delivery; Monitoring not generally required; Outpatient therapy facilitated; Lower rate of HIT
  83. for the Initial Treatment of DVT
  84. In patients with acute DVT and severe renal failure, we suggest
    UFH over LMWH (Grade 2C).
  85. In patients with acute DVT treated with LMWH, we recommend against routine monitoring with
    anti-factor Xa level measurements (Grade 1A)
  86. For acute nonmassive PE, we recommend initial treatment with
    LMWH over IV UFH (Grade 1A).
  87. For massive PE, in situations where there is concern about SC absorption, or when thrombolytic therapy is being considered or planned, we suggest
    IV UFH over SC LMWH, SC fondaparinux, or SC UFH (Grade 2C).
  88. For acute PE treated with LMWH, we recommend against routine monitoring with
    anti-factor Xa level measurements (Grade 1A).
  89. In patients with acute PE and severe renal failure, we suggest
    UFH over LMWH (Grade 2C).
  90. for Initial Treatment of PE
    IVC Filters
  91. In patients with acute PE, if anticoagulant therapy is not possible because of risk of bleeding, we recommend placement of an
    IVC filter (Grade 1C).
  92. For patients with acute PE who have an IVC filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of
    anticoagulant therapy if their risk of bleeding resolves (Grade 1C).
  93. Indication: contraindication to anticoagulation
  94. be used primarily in patients at high risk for bleeding (Grade 1A), or possibly as an adjunct to anticoagulant-based prophylaxis (Grade 2A).
    mechanical methods of thromboprophylaxis
  95. With leg pain / swelling
    think DVT.
  96. With sudden onset dyspnea or CP
    think PE.
  97. Look for risk factors if you are considering
  98. Consider starting _______________ before diagnosis is confirmed if your suspicion is high.
  99. For massive PE, consider
    thrombolytic therapy.
  100. With proven DVT or PE, and contraindication to anticoagulation, or with recurrence on therapy
    IVCF should be placed.
  101. It is indicated in nearly all hospitalized patients.
    Use prophylaxis
  102. Mean pulmonary artery pressure of > 25 mmHg at rest; (Right-heart catheterization)
    Pulmonary Hypertension:
  103. Increased in Pulmonary Arteries of Patients with IPAH
    ET-1 Expression
  104. Idiopathic PAH; Familial PAH; Associated with PAH
    Pulmonary arterial hypertension
  105. Connective tissue disease
    Pulmonary arterial hypertension
  106. Congenital systemic-to-pulmonary shunts
    Pulmonary arterial hypertension
  107. Portal hypertension
    Pulmonary arterial hypertension
  108. HIV infection; Drugs and toxins; Other; Associated w/ significant venous /capillary involvement (PVOD, PCH); Persistent PH of the newborn
    Pulmonary arterial hypertension
  109. Left-sided atrial or ventricular heart disease
    Pulmonary hypertension with left-heart disease
  110. Left-sided valvular heart disease
    Pulmonary hypertension with left-heart disease
  111. COPD & Interstitial lung disease
    Pulmonary hypertension associated with lung disease or hypoxemia
  112. Sleep-disordered breathing & Alveolar hypoventilation disorders
    Pulmonary hypertension associated with lung disease or hypoxemia
  113. Chronic exposure to high altitude & Developmental abnormalities
    Pulmonary hypertension associated with lung disease or hypoxemia
  114. Thromboembolic obstruction of proximal & distal PAs
    Pulmonary hypertension due to chronic thrombotic and /or embolic disease
  115. Non-thrombotic PE (tumor, parasites, foreign material)
    Pulmonary hypertension due to chronic thrombotic and /or embolic disease
  116. dry crackles
    pulmonary fibrosis
  117. due to congenital heart disease or pulm fibrosis or sarcoidosis.
  118. is the most common presenting symptom.
  119. Altered temp, rigors, sweats, cough, sputum, dyspnea, chest pain; Fatigue, myalgias, abdominal pain, anorexia, headache; Lack sensitivity and specificity
    Pneumonia: Symptoms of acute infection
  120. the largest epithelial surface in the body (70 m2 alveolar surface)
  121. Epiglottis; Cough reflex; Mucociliary clearance
    Pulmonary defenses: Mechanical
  122. Humoral (lysozyme, lactoferrin, IgA, collectins, e.g. surfactant proteins A and D); Cellular (alveolar macrophage, pattern recognition receptors)
    Pulmonary defenses: Innate immune system
  123. is the ~8th leading cause of death in the US and the #1 cause of death from infectious disease
  124. Most lethal infection; Outpatient mortality <1%; 12% of those hospitalized die; 40% ICU mortality
  125. patient in the ambulatory setting
    Community acquired pneumonia (CAP)
  126. patient in extended care, on home infusion therapy, long term hemodialysis within past 30 days, home wound care, exposure to family members with resistant pathogens, or hospitalized more than 2 days within the past 90 days
    Health care associated pneumonia (HCAP)
  127. Pneumonia onset >48 hours after hospital admission
    Hospital acquired pneumonia (HAP)
  128. Pneumonia onset >48 hours after initiation of intubation and mechanical ventilation
    Ventilator associated pneumonia (VAP)
  129. colonizes 5-10% of healthy adults
  130. most common etiology of CAP, and a likely etiology in much ‘culture negative’ CAP
    Pneumococcal pneumonia
  131. complications include bacteremia, meningitis, otitis media, sinusitis
    Pneumococcal pneumonia
  132. higher mortality post-splenectomy
    Pneumococcal pneumonia
  133. pneumococcal vaccination (23 serotypes)
    Pneumococcal pneumonia
  134. Serotype b and nontypeable cause most pneumonias
    Haemophilus influenzae
  135. Hib vaccination has decreased carriage rates; More common in smokers; Most empiric regimens cover H. flu adequately
    Haemophilus influenzae
  136. The original ‘atypical’ organism, described in 1944 when atypical meant non-pneumococcal
    Mycoplasma pneumoniae
  137. Occurs in up to 1/3 of CAP in outpatients when serologic testing performed
    Mycoplasma pneumoniae
  138. May have associated non-respiratory syndromes (CNS, immune hemolytic anemia)
    Mycoplasma pneumoniae
  139. Bullous myringitis is classic but uncommon and nonspecific
    Mycoplasma pneumoniae
  140. ‘Discovered’ in 1976 during an outbreak of pneumonia; Found in aquatic environments
    Legionella pneumophila
  141. Urinary antigen is diagnostic, but only detects serogroup 1; DFA is presumptive
    Legionella pneumophila
  142. 50% of 20 year olds have serologic evidence of past infection
    Chlamydia pneumoniae
  143. TWAR; Diagnosis is difficult so true incidence is unknown; Organism is associated with chronic inflammatory diseases (atherosclerosis)
    Chlamydia pneumoniae
  144. Uncommon in outpatients, but occurs in ~10% of patients with CAP admitted to hospitals (highest in patients requiring ICU admission)
    Gram negative pneumonia
  145. Patients with medical co-morbidities or recent antibiotic therapy at increased risk (enteric gram negatives, P. aeruginosa)
    Gram negative pneumonia
  146. May cavitate or produce empyema
    Gram negative pneumonia
  147. Uncommon in CAP; Relatively common complication post-influenza; Reports of community acquired MRSA pneumonia have been increasing
    Staphylococcal pneumonia
  148. May cause necrotizing infiltrates or (in children) pneumatoceles
    Staphylococcal pneumonia
  149. After inhalation of oropharyngeal or gastric contents and correlates with volume of aspirated material
    Aspiration pneumonia
  150. Risk factors include: neurologic dysphagia, anatomic or functional abnormalities of upper GI tract, nursing home residency, drug overdose, general anesthesia, loss of consciousness
    Aspiration pneumonia
  151. Radiographic changes in dependent lung segments; Both enteric gram negative organisms and anaerobes isolated
    Aspiration pneumonia
  152. May lead to necrotizing pneumonia, empyema, or lung abscess
    Aspiration pneumonia
  153. Lab evaluation of patients with pneumonia
    If hospitalized: CBC, BUN, glucose, electrolytes, LFTs, O2 sat, HIV (15-54 yo)
  154. Chest X-ray; Tests for an etiologic agent For outpatients: none considered standard; For hospitalized patients: 2 pretreatment blood cultures and expectorated sputum Gram stain and culture; Serologic tests usually not helpful
    Lab evaluation of patients with pneumonia
  155. deep-cough specimen before antibiotic treatment, transported and processed within a few hours of collection
    The sputum sample
  156. sputum sample culture contingent on cytologic examination, except for
    Mycobacteria and Legionella
  157. induced sputum for detection of
    Mycobacterium tuberculosis and Pneumocystis carinii
  158. urinary antigen tests for serogroup 1 only
  159. Standard methods for pneumococcal diagnosis are
    blood culture and sputum for GS and culture
Card Set
Pulmonology 6
Pulmonology flashcards made by previous students.