PULMONOLOGY TIKI TAKA _______________________
. BRONCHIAL ASTHMA: ___________________ ___________________
. SHORTNESS OF BREATH (SOB) + EXPIRATORY WHEEZES.
. Severe asthma -> Use of accessory muscles & inability of speaking complete se ntence.
. SEVERE ASTHMA EXACERBATION manifestations: _____________________________________________ -> ++ RR = Hyperventillation.
-> -- in peak flow. -> -- O2 = Hypoxia.
-> -- pH = Respiratory acidosis.
-> Possible absence of wheezes (To wheeze, one must have air flow!). . Dx -> Pt with SOB & unclear if the cause is BA:
__________________________________________________
-> Do "PULMONARY FUNCTION TESTS" (PFTs) before & after INHALED BRONCHODILATORS: -> ++ in FEV1 > 12 % -> Confirmed BA.
. Dx -> Asymptomatic pt now i.e. H/O of intermittent SOB episodes but now he is normal:
________________________________________________________________________________ ________
-> Do "METACHOLINE STIMULATION TEST":
-> -- in FEV1 in response to synthetic acetylcholine (if the pt has BA). . Tx -> ACUTE ASTHMA:
______________________
-> INHALED BRONCHODILATORS (SABA) -> ALBUTEROL.
-> BOLUS "Not inhaled" of steroids (Methyl prednisone). -> INHALED IPRATROPIUM.
-> OXYGEN. -> Magnesium.
. N.B. Any BA pt. with RESPIRATORY ACIDOSIS & CO2 RETENTION sh'd be placed in t he ICU.
-> Persistent resp. acidosis is an indication of INTUBATION & MECHANICAL VENTIL LATION.
. The following therapies have "NO BENIFIT" in acute asthma exacerbation:
-> Theophylline - Cromolyn - Montelukast - INHALED steroids - LABA "Salmeterol" .
. NON-ACUTE BA: ________________
-> Best initial -> INHALED BRONCHODILATORs (ALBUTEROL). -> Not controlled -> ADD + INHALED STEROIDs.
-> Not controlled -> ADD + INHALED LABA (SALMETEROL).
. Extrinsic allergies (HAY FEVER) -> Cromolyn or nedocromil. . High Ig E levels not controlled with Cromolyn -> Omalizumab. . Atopic disease -> Montelukast.
. N.B. VVVVVVVVVVVVVV. imp. GERD can exacerbate airflow obstruction in asthmati cs:
________________________________________________________________________________ ___
. Due to ++ vagal tone & micro-aspiration of gastric contents into the upper ai rway.
. Risk factors: Obesity, supine position after meals, laryngitis.
. Manifestations: Change in voice & NOCTURNAL COUGH. (ACE Is lead to day & nigh t cough!).
. Anti-GERD life style modification.
. Give a trial of a proton pump inhibitor (Esomeprazole).
. GERD is present in 75% of asthma pts & may be the trigger of many cases. . Adult onset asthma with GERD (Worsening syms after meals or with lying down). . Obesity, hoarsness, pharyngitis & laryngitis tend towards GERD.
. A trial of proton pump inhibitors (Omeprazole) can be both diagnostic & thera peutic.
. N.B. Efficacy of BETA blockers for mortality in cases of MI & CHF is more imp ortant than its adverse effects e.g. Asthma & COPD.
. N.B. Exercise induced asthma -> Tx with INHALED BRONCHODILARORS prior to exer cise.
. N.B. All pts with SOB sh'd 've -> O2 - pulse oximeter - CXR & ABG.
. TREATMENT OF BRONCHIAL ASTHMA DEPENDS ON ITS SEVERITY: _________________________________________________________
* INTERMITTENT -> CONTINUE CURRENT REGIMEN SABA (B-agonists: ALBUTEROL): _________________________________________________________________________ . Day time syms < 2 /week.
. Night time awakenings < 2 / month. . B-agnists < 2 / week.
. Normal PFTs.
. No limitations on daily activities.
* MILD PERSISTENT -> ADD INHALED CORTICOSTEROIDS: __________________________________________________ . Day time syms > 2 /week.
. Night time awakenings 3-4 / month. . Normal PFTs.
. MINOR limitations on daily activities.
* MODERATE PERSISTENT -> ADD INHALED LABA (SALMETEROL): ________________________________________________________ . Daily symptoms.
. Weekly Night time awakenings. . FEV1 <60 - 80 % of predicted.
. Moderate limitations on daily activities. * SEVERE PERSISTENT -> ADD ORAL PREDNISONE: ____________________________________________ . Symptoms through out the day.
. Frequent night time awakenings. . FEV1 < 60 % of predicted.
. IMPORTANT DRUG SIDE EFFECTS: ______________________________ ______________________________
. N.B. The most common adverse effect of INHALED CORTICOSTEROIDS is OROPHARYNGE AL THRUSH.
. N.B. The most common adverse effect of "IV" CORTICOSTEROIDS is -- WBCs "NEUTR OPHILIA".
. Glucocorticoids ++ bone marrow release of of neutrophils. . Glucocorticoids mobilize the marginated neutrophilic pool. . Eosinophils & lymphocytes are decreased.
. N.B. High doses of B2 agonists may develop HYPOKALEMIA !
. Hypokalemia may present as ms weakness, arrhythmia & EKG abnormalities. . N.B. Theophylline toxicity:
. CNS stimulation (Headache, insomnia & seizures). . GIT disturbances (Nausea & vomiting).
. Cardiac toxicity (Arrhythmia - Multifocal atrial tachycardia & premature beat ).
. Dx -> Measure serum theophylline levels. . INDICATORS OF SEVERE ASTHMATIC ATTACK: ________________________________________
. NORMAL or INCREASED CO2 is the worst sign indicating acute severe attack. . CO2 retention is due to severe airway obstruction (air trapping) & respirat. ms fatigue . Speech difficulties. . Diaphoresis. . Altered sensorium. . Cyanosis. . SILENT lungs.
. ACUTE EPISODES of SOB MANAGEMENT: ___________________________________ -> Oxygen & ABG.
-> CXR.
-> SABA "ALBUTERL" INHALED. -> IPRATROPIUM INHALED.
-> BOLUS of steroids (Methyl prednisone).---> VVVVVVVVVVV. imp. -> Chest, heart, extremity & nerological exam.
-> If fever, sputum & or new infiltrate is present on CXR:
ADD CEFTRIAXONE & AZITHROMYCIN for community acquired pneumonia.
. N.B. In pts with acute asthma exacerbation, an ELEVATED or even NORMAL PCO2 = RF.
. Respiratory failure due to -- respiratory drive due to respiratory muscle fat igue.
. ENDO-TRACEAL INTUBATION & MECHANICAL VENTILLATION is MANDATORY.
. Add inhaled SABA (Albeterol) & inhaled ipratropium & systemic corticosteroids .
. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD): _______________________________________________ _______________________________________________
. Barrel shaped chest. . Clubbing of fingers.
. ++ A-P diameter of the chest.
. Loud P2 heart sound (Sign of pulmonary hypertension). . Edema (Sign of -- Rt ventricular out put).
. EKG -> Rt. axis deviation - Rt atrial & ventricular hypertrophy.
. CXR -> Elongated heart - Flattenning of the diaphragm due to hyperinflated lu ngs.
. N.B. FLATTENING OF THE DIAPHRAGM ++ The WORK OF BREATHING.
. CBC -> ++ Hematocrit & reactive microcytic eryhthrocytosis due to chronic hyp oxia.
. ABG -> ++ pCO2 & -- pO2 & -- pH (Respiratory acidosis).
. Chemistry -> ++ serum bicarbonate as metabolic compensation for respiratory a cidosis.
. N.B. (1):
. ABG is critical in acute SOB due to COPD (No other way to assess for CO2 rete ntion !).
. N.B. (2):
. ABG is important to assess for CO2 retention.
. ABG is important to assess for the need for chronic home oxygen based on pO2. . N.B. (3):
. In moderate & severe cases of COPD, pts may become members of the 50/50 club !!
. Both pO2 & pCO2 are around 50s !
. Ex -> pH. 7.35 - pCO2 49 - pO2 52 - HCO3 32.
. PULMONARY FUNCTION TESTS in COPD -> OBSTRUCTIVE PATTERN: ___________________________________________________________ -> -- FEV1.
-> -- FVC (Loss of elastic recoil of the lung). -> -- FEV1/FVC ratio.
-> ++ Total Lung Capacity (++ TLC due to air trapping .. VVVVVVVVVVVV.imp.). -> ++ Residual Volume.
-> -- Diffusion capacity lung CO (-- DLCO due to destruction of lung interstiti um).
-> INCOMPLETE IMPROVEMENT WITH ALBUTEROL (# Asthma). -> LITTLE OR NO IMPROVEMENT WITH METACHOLINE (# Asthma).
. N.B. A bronchodilator response test to differentiate COPD from BA: ____________________________________________________________________
. Measuring FEV1 before & after adminstration of bronchodilator (B2 agonist). . Significant improvement in FEV1 (> 15%) after bronchodilator -> Reversibility = Asthma.
. Little or no improvement in FEV1 after bronchodilator -> Irreversibility = CO PD.
. N.B. Chronic hypercapneic respiratory failure due to COPD: ____________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD. . But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acid osis.
. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++ bicarbonate retention.
. CHRONIC MEDICAL THERAPY of COPD: ___________________________________
. IPRATROPIUM or TIOTROPIUM INHALED (Most effective therapy to reduce syms in C OPD).
. SABA ALBUTEROL INHALED.
. Pneumococcal vaccine -> Hepatavalent vaccine (Pneumovax). . Influenza vaccine yearly.
. Long term home oxygen therapy (If pO2 < 55 or SO2 < 88%).
. N.B. Long term O2 therapy in a pulmonary hypertension pt or HCT > 55% -> PaO2 < 60 mmHg.
. N.B. Both smoking cessation & home oxygen therapy & vaccines lower mortality i n COPD.
. N.B. SABA (Albuterol), Anticholinergic (Anti-muscarinic ipratropium),LABA & ST EROIDS:
improve symptoms only without -- mortality rate.
. N.B. INHALED ANTI-CHOLINERGICS = INHALED MUSCARINIC ANTAGONISTS - INHALED IPRA TROPIUM
are the most effective in COPD.
. N.B. Cromolyn & Montelukast have no benefit in COPD. . ACUTE EXACERBATION OF COPD TTT:
_________________________________
. Acute worsening of symptoms in a pt. with COPD. . Caused by upper respiratory tract infection. . May be preceided by cough & fever.
. Exam -> Bilateral wheezes.
. ABG -> Respiratory acidosis & hypoxia.
. Inhaled bronchodilators (B2 agonists = Albuterol). . Inhaled anti-cholinergics (Ipratropium).
. Broad spectrum antibiotics.
. INHALED CORTICOSTEROIDS for 2 weeks then tapered gradually. . Smoking cessation.
. Oxygen (If pO2 < 55 mmHg or SO2 < 88%).
. N.B. Pts with acute on chronic respiratory failure ttt with high flow supplem ental O2,
. are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS,
. due to a combination of reduced alveolar ventillation & ++ dead space ventill ation,
. causing ventillation perfusion mis-match & -- Hb affinity for CO2.
. The goal oxy-hemoglobin saturation in these pts is 90 - 94 % (Not > 95%)! . NON INVASIVE POSITIVE PRESSURE VENTILLATION (NIPPV):
_______________________________________________________
. Used in acute exacerbations of COPD REFRACTORY to ttt with B-agonist & inhaed steroids.
. Used before intubation to avoid its side effects e.g. infection.
. Recommended in pt e' respiratory distress with a pH<7.35 or pCO2>45mmHg or RR >25/min.
. It is contraindicated in septic, hypotensive or dysrhythmic pts. . NIPPV will provide more O2 & wash out excess CO2.
. If the pt. is refractory to NIPPV -> Intubate with mechanical ventillation ! . SPONTANEOUS PNEUMOTHORAX (A complication of COPD):
____________________________________________________
. COPD pt presenting with catastrophic worsening of respiratory symptoms. . Cigarette smoking markedly ++ risk of pneumothorax.
. It leads to chronic airway inflammation & respiratory bronchiolitis.
. The chronic destruction of the alveolar sacs -> Formation of large alveolar b lebs.
. which can rupture & leak air into the pleural space.
. presents with acute onset of chest pain & shortness of breath.
. Breath sounds are markedly reduced & hyperresonance to percussion on affected side.
. VVVVVVVVV. IMP. TWO PRIMARY SUB-TYPES OF COPD: CHRONIC BRONCHITIS & EMPHYSEMA: ________________________________________________________________________________ _
{A} . COPD with EMPHYSEMA pre-dominance -> (-- DLCO): ______________________________________________________ . Thin pts with severe dyspnea, hyperinflated chest. . DECREASED vascular markings.
. SEVERE flattening of diaphragm.
. DECREASED DLCO -> due to alveolar destruction.
{B} . COPD with CHRONIC BRONCHITIS pre-dominance -> (NORMAL DLCO): ___________________________________________________________________ . Chronic productive cough for > 3months over 2 consecutive years.
. Due to hypersecretion of mucus & structural changes in the tracheo-bronchial tree.
. PROMINENT vascular markings. . MILD flattening of diaphragm. . NORMAL DLCO.
. EXACERBATION OF CONGESTIVE HEART FAILURE: ___________________________________________
. H/O of coronary artery disease -> Lt ventricular dysfunction -> Heart failure .
. Un-controlled hypertension & smoking H/O are risk factors for coronary vascul ar disease
. LVF -> Tachypnea -> fluid pooling in the lungs -> pleural effusion -> Hypoven tillation.
. Hypoventillation -> Hypoxemia.
. Tachypnea -> Hypocapnia & respiratory alkalosis.
. Signs of fluid overload - S3 & S4 gallops & cardiomegaly. . Lung exam -> Bi-basilar crackles.
. Lung exam -> -- breath sounds at lung bases due to pleural effusion from CHF. . Wheezing can occasionally be present (Cardiac asthma).
. ABG -> HYPOXIA - HYPOCAPNIA - RESPIRATORY ALKALOSIS (COPD -> Respiratoy ACIDO SIS).
. Dx -> BNP & PCWP.
. ALPHA 1 ANTI-TRYPSIN DEFECIENCY: __________________________________ __________________________________ . Genetic disorder.
. Liver cirrhosis + COPD. . NON-smoker.
. Dx -> CXR -> Findings of COPD (Bullae - Barrel chest - Flat diaphragm). . Dx -> Blood test -> -- ALBUMIN & ++ PT (Cirrhosis).
. Dx -> -- Alpha-1 antitrypsin level. . Tx -> Alpha-1 antitrypsin infusion ! . BRONCHIECTASIS:
_________________ _________________
. Cough - mucopurulent sputum - hemoptysis. . Profound dilatation of the bronchi.
. due to anatomic defect in the lungs mostly due to infection in childhood. . Episodes of lung infection with high volume of sputum.
. Hemoptysis & fever may occur.
. Dx -> CXR -> Dilated bronchi (TRMA TRACKING). . Dx -> CT Chest -> Most accurate test.
. Tx -> No curative therapy.
. Just ttt the infectious episodes with rotating antibiotics to avoid resistanc e.
. CYSTIC FIBROSIS: __________________ __________________ . Young pt.
. Mutation in the Chloride transporter protein CFTR. . Abnormally thick secretions.
. Affect the respiratory tract - sinuses - pancreas - intestines & reproductive systems.
. Respiratory tract -> Chronic cough e' frequent exacerbations & superimposed i nfections.
. Most pts develop BRONCHIECTASIS leading to HEMOPTYSIS.
. Pancreas -> Fat malabsorption with bloating & greasy, floating stools. . Dx -> CT -> Atrophic pancreas with calcifications.
. INTERSTITISAL LUNG DISEASES (ILD): ____________________________________ ____________________________________
. Pulmonary fibrosis 2ry to environmental or occupational exposure (Pneumoconio sis).
. Also caused by medications (NITROFURANTOIN & TMP-SMX "BACTRIM"). . If the etiology is unknown (IDIOPATHIC PULMONARY FIBROSIS).
. ASBESTOSIS -> Shipyard - Mining - Construction workers - Pipe fitters). . SILICOSIS -> Glass workers - Mining - Sandblasting & Brickyards.
. COAL WORKER's PNEUMONIA -> Coal worker ! . BYSSINOSIS -> COTTON.
. BERYLLIOSIS -> Electronics - Ceramics - Fluorescent & Light bulbs. . PULMONARY FIBROSIS -> Mercury.
. Shortness of breath.
. "DRY" = NON productive cough & chronic hypoxia. . Dry rales - Bi-basilar end-inspiratory crackles. . Loud P2 (Sign of pulmonary hypertension).
. Digital clubbing.
. NOOOO FEVER - NOOOO systemic findings.
. Dx -> CXR -> Interstitial fibrosis & Honeycombing.
. Dx -> CXR -> Pulmonary vascular congestion at the hilum.
. Dx -> CT -> PLEURAL PLAQES ARE PATHOGNOMONIC (Pneumoconiosis)! . Dx -> Lung biopsy.
. Dx -> PFTs -> ALL MEASURES ARE DECREASED but PROPORTIONATELY. . PULMONARY FUNCTION TESTS in ILD -> RESTRICTIVE PATTERN:
__________________________________________________________ -> -- FEV1.
-> -- FVC.
-> NORMAL FEV1/FVC ratio. -> -- TLC.
-> -- RV.
-> -- DLCO (VVVVVVVVVV. imp.).
-> VVVVVVVVVV. imp. -> ILF -> +++ A-a gradient !
. Tx -> No specific therapy to reverse any of ILD forms.
. If the lung biopsy shows an inflammatory infiltrate, a trial of steroids is u sed.
. The only form of ILD that responds to steroids is BERYLLIOSIS (Granulomatous disease).
. N.B. The most common type of cancer in ASBESTOSIS is LUNG CANCER not mesothel ioma.
. N.B. ILD may be complicated by COR PULMONALE:
-> peripheral edema - Hepatojugular reflex - Jugular venous distension - Rt ven tr. heave.
. COMPARISON BETWEEN PFTs in COPD & ILD: ________________________________________
. COPD -> OBSTRUCTIVE PATTERN & ILD -> RESTRICTIVE PATTERN: ___________________________________________________________ . PFTs ___________ COPD __________ ILD . FEV1 ___________ __________ . FVC ___________ __________ . FEV1/FVC _______ -- __________ NORMAL . TLC ____________ ++ __________ . RV _____________ ++ __________ . DLCO ___________ -- __________ --
. BRONCHILOTIS OBLITERANS ORGANIZING PNEUMONIA BOOP / CRYPTOGENIC ORGANZING PNEU MONIA COP:
________________________________________________________________________________ __________
________________________________________________________________________________ __________
. Inflammation of the small airways with a chronic alveolitis of an unkown orig in !
. Associated with Rheumatoid arthritis.
. Resembles ILD but more acute presentation (Over weeks to months). . (SOB - Cough - rales) + FEVER + MALAISE + MYALGIA.
. No occupational exposure in history ! . CXR -> Bilateral PATCHY infiltrates. . CT -> Inerstitial disease & alveolitis. . Most accurate -> OPEN LUNG BIOPSY !
. Tx -> Steroids (No response to antibiotics).
____________________________________
. BOOP/COP _______________________________ . ILD
. Fever- myalgia - malaise _______________ . NO.
. Presents over days to weeks ____________ . 6 months or more of symptoms. . PATCHY infiltrates _____________________ . INTERSTITIAL infiltrates.
. STEROIDs EFFECTIVE _____________________ . Only BERYLLIOSIS may respond to st eroids.
. SARCOIDOSIS: ______________
. AFRICAN AMERICAN WOMEN. . Age < 40s.
. SOB - Cough & fatigue over a few weeks to months. . Lung - > Rales.
. Eye -> ANTERIOR UVEITIS (Sight threatening). . Neural -> Facial palsy (7th cranial nerve). . Skin -> ERYTHEMA NODOSUM.
. Joint -> Polyarthralgia.
. Heart -> RESTRICTIVE CARDIOMYOPATHY.
. HYPERCALCEMIA (2ry to Vit.D production by the granulomas). . Dx -> Best initial test -> CXR.
. CXR -> BILATERAL HILAR LYMPHADENOPATHY & diffuse interstitial infiltrates. . Dx -> Most accurate test -> LUNG or LN biopsy -> NON-CASEATING GRANULOMA. . Dx -> ++ Ca & ++ ACE levels
. Dx -> BAL -> ++ helper cells. . Tx -> STEROIDs.
. SYSTEMIC SCLEROSIS: _____________________
. Pulmonary symptoms (Due to interstitial fibrosis). . Dysphagia. . Raynaud's phenomenon. . Hypertension. . Telangiectasia. . PULMONARY HYPERTENSION: _________________________
. Mean pulmonary arterial blood pressure > 25 mmHg.
. Overgrowth & obliteration of pulmonary vasculature -> -- outflow of the Rt ve ntricle.
. SOB more often in young women.
. May be 2ry to (MS - COPD - PCV - ILD & chronic pulmonary emboli). . Physical findings (Loud P2 - TR - RV heave).
. Dx -> TRANS-THORACIC ECHOCARDIOGRAM (TTE) -> Rt atrial & ventricular hypertro phy.
. Dx -> EKG -> Rt axis deviation.
. Dx -> CXR -> Pulmonary arteries enlarg. & RVE & tapering of distal vessels (P runing).
. Most accurate -> RIGHT HEART SWAN GANZ CATHETERIZATION -> ++ PULMONARY ARTERY pressure.
. Tx -> BOSENTAN -> Endothelial inhibitor.
. May be complicated by RVF (Rt ventricular heave JVD Tender hepatomegaly Ascites).
. COR PULMONALE: ________________
. Rt sided heart failure due to pulmonary disease. . Jugular venous distension.
. Right sided S3 gallop. . Right ventricular heave. . Hepatomegaly.
. Ascites.
. Dependent LL edema.
. Most commonly caused by COPD (Flattened diaphragm - prominent pulmonary vesse ls on CXR)
. CXR -> Prominent right ventricle & pulmonary artery. . PULMONARY EMBOLISM:
_____________________ _____________________
. PERFUSION DEFECT & NO VENTILLATION DEFECT. . ++++++++++++++++++++++++++++ A-a gradient. . SUDDEN onset SOB + CLEAR LUNGs.
. Risk factors of DVT (Immobility - Malignancy - Trauma - Surgery - Thrombophil ia).
. H/O of recent orthopedic surgery followed by bed rest. . No specific physical finding for PE.
. MODIFIED WELL'S CRITERIA for PRE-TEST PROPABILITY of PE: ___________________________________________________________ -> Score + 3 points (Clinical signs of DVT).
-> Score + 1.5 points (Prev PE/DVT - HR>100 - Recent surgery <4wks - Immobiliza tion>3ds)
-> Score + 1 point (Hemoptysis - cancer).
-> Total score for clinical propability (< 4 -> PE UN-likely .. > 4 -> PE likel y).
. . Clinical assessment for pulmonary embolism .____________________________________________ .< Modified Well's criteria>
.____________________________ | .________________________________ .| .| . PE UN-likely . PE likely .______________ .___________ .| .| . D-dimer assay .| ._______________ .| .| .| .___________________ .| .| .| .(< 500 ng/ml) .(> 500 ng/ml)-->. CT PULMONARY ANGIOGRAPHY .| .____________________________ . PE EXCLUDED .|
.(-ve = PE EXCLUDED BUT +ve = PE CONFI RMED)
. CONFIRMATORY TESTS -> Spiral CT - V/Q scan - LL Doppler - D-Dimer.
. MOST ACCURATE TEST -> PULMONARY ANGIOGRAPHY = CHEST CT ANGIOGRAPHY with IV CO NTRAST.
. 1 . CXR: ___________
. Most common result -> NORMAL.
. Most common abnormailty -> Atelectasis.
. Wedge shaped infarction & pleural humps are rare. . 2 . EKG:
___________
. Most common showing -> SINUS TACHYCARDIA.
. Most common abnormality -> NON-SPECIFIC ST-T WAVE CHANGES. . Right axis deviation & Rt BBB are rare.
. 3 . ABG: ___________
. HYPOXIA -> ++ A-a gradient. . Mild respiratory alkalosis.
. 4 . SPIRAL CT -> TEST OF CHOICE if the CXR is ABNORMAL: __________________________________________________________ . Standard to confirm the presence of a pulmonary embolus. . Excellent if +ve being specific.
. Not specific as it can miss some emboli if they are small & in the periphery. . Chest CT showing a WEDGE SHAPED infarction is PATHOGNOMONIC for pulmonary emb olism.
. 5 . VENTILLATION PERFUSION V/Q SCAN -> TEST OF CHOICE if the CXR is NORMAL: ______________________________________________________________________________ . PERFUSION DEFECT with NO VENTILLATION DEFECT.
. NORMAL V/Q scan excludes pulmonary embolism. . 6 . LOWER EXTREMITY DOPPLER:
_______________________________
. If +ve -> No further tests are needed to confirm PE.
. The problem is that 30 % of PEs originate in pelvic veins, so the LL Doppler is NORMAL.
. So it has low sensitivity i.e. can't exclude PE. . 7 . D-DIMER TESTING = FIBRIN SPLIT PRODUCTS TESTING: _______________________________________________________ . SINGLE TEST TO EXCLUDE PE.
. Very sensitive test with poor specificity. . D-DIMER -> NEGATIVE -> NO PULMONARY EMBOLISM. . D-DIMER -> Not specific -> May be other causes.
. The best use of D-DIMER test is in a pt with LOW propability of PE, . & u want a single test to exclude PE !!
. 8 . ANGIOGRAPHY -> SINGLE MOST ACCURATE TEST FOR PE: ______________________________________________________
. ANGIOGRAPHY = CHEST CT ANGIOGRAPHY WITH INTRAVENOUS CONTRAST (VVVVVV. imp.). . INVASIVE with risk of death (0.5%).
. MANAGEMENT of PULMONARY EMBOLISM: ___________________________________
{1} HEPARIN & OXYGEN -> Standard of care.
{2} Warfarin -> Sh'd be used at least for 6 months after Heparin.
.
{4} Thrombolytics -> used in pts who r hemodynamically UN-stable (e.g. hypotens ion).
{5} Embolectomy is rarely done (High risk of death).
. N.B. When the case so clearly suggests a pulmonary embolism,
. i.e. Pt presenting with sudden onset of SOB & clear lungs with H/O of major s urgery,
. the 1st thing to do is CXR & ABG followed by HEPARIN.
. Don't wait the results of V/Q scan or spiral CT to start heparin !! . When there is a contraindication to anticoagulation e.g. hematoma, . Don't use heparin ! Place an IVC filter.
. For anticoagulation, "Un-fractionated" heparin is preferred in pts with -- GF R !
. LMW heparin (Enoxaparin) can't be given as it causes severe renal insuffecien cy.
. Warfarin can be thrombogenic without heparin as a bridge !
. It sh'd be given after initiating heparin with PTT goal 1.5-2 times of normal .
. Warfarin takes up to 5-6 days to reach its therapeutic level.
. After reaching therapeutic INR level (2-3), heparin can be stopped.
. VVVVVV. imp. N.B. A PROGRESSING CLOT in a pt with sub-therapeutic INR (ex. 1. 2),
. requires BRIDGING HEPARIN until the INR is therapeutic (2-3), . Example .. A pt recently hospitalized for LL DVT then discharged,
. After 5 days, U$ reveals popliteal vein thrombosis extending into the deep fe moral vein
. So .. U sh'd START INTRAVENOUS UNFRACTIONATED HEPARIN & CONTINUE WARFARIN. . The proximal deep leg veins are the most common source of symptomatic pulmonar y embolism
. Less common sources of emboli include calf, pelvic & upper evtremity veins & R t heart.
. "Factor V Leiden" is the most common genetic disorder causing hypercoagulabili ty & DVT.
. N.B. Acute massive pulmonary embolism can present initially with syncope & sho ck.
. e.g. sudden loss of consciousness at work, BP:80/40 & HR:120/min with cold cla mmy skin.
. Rt heart catheterization -> ++ Right atrial & pulmonary artery pressures. . Normal PCWP Pulmonary artery capillary wedge pressure.
. N.B. Massive pulmonary embolism usually presents with signs of low arterial pe rfusion,
. Hypotension, acute dyspnea, pleuritic chest pain, tachycardia & syncope. . The thrombus ++ pulmonary vascular resistance & Rt ventricular pressure, . causing Rt ventricular hypokinesis -> Rt ventricular dilatation.
. APPROACH TO MANAGEMENT OF PATIENT WITH SUSPECTED PULMONARY EMBOLISM: ______________________________________________________________________ ______________________________________________________________________
._________________________________________ .| . CONTRAINDICATIONS to Anticoagulate ? ._____________________________________ .| ._______________________________________________ .| .| . YES = Diagnostic tests to evaluate for PE . NO = MODIFIED WELL's C RITERIA .__________________________________________ ._______________________ ________ .| .| ._____________________ .______________ _ .| .| .| .|
. +ve PE . -ve PE . PE Un-likely . PE likely
.________ .________ .______________ .___ ________
.| .| .| .|
. IVC FILTER . No further tests .| . START antic oagulation .| .____________ __________ .| .| . D-DIMER TESTING fo r PE .___________________ _____ .| .__________________________________________________________________ ___ .| .| . +ve . -ve
. Start or continue anticoagulation, . STOP antico agulation
. consider surgery or thrombolysis if indicated.
. PLEURAL EFFUSION: ___________________ ___________________
. Best initial test -> CXR.
. Decubitus films (Pt lying on one side) sh'd be done next to assess the fluid mobility.
. Most accurate test -> THORAC-CENTESIS.
. Un-diagnosed pleural effusion is best evaluated with THORACOCENTESIS, . To detect whether it is a transudate or an exudate.
. Except in pts with clear-cut evidence of congestive heart failure, . Associated fluid overgain, pedal edema & bilateral lung base crackles. . Diuretics & echo sh'd be done not thoracocentesis.
. COMPARISON BETWEEN EXUDATE & TRANSUDATE (VVVVVVVVVVV. imp.): _______________________________________________________________
. EXUDATE PLEURAL EFFUSION ______________________ . TRANSUDATE PLEURAL EFFUSION . Cancer & infection & Pulmonary embolism _______ . Congestive heart failure & cirrhosis.
. High ptn level > 50 % of serum level __________ . Low ptn level < 50 % of ser um level.
. High LDH level > 60 % of serum level __________ . Low LDH level < 60 % of ser um level.
. LDH > 2/3 upper limit of normal serum LDH (250) . < 2/3 !
. pH > 7.3 (Normal 7.6) ______________________ . pH < 7.3 (++ acid prod. by bac teria).
. NO CHANGE IN GLUCOSE OR AMYLASE LEVELS IN BOTH TYPES ! . Tx -> Small pleural effusions don't need therapy !
. Diuretics can be used for those caused by congestive heart failure. . Larger effusions esp. those caused by empyema -> Drain by CHEST TUBE. . Large recurrent effusion from an un-correctable cause -> PLEURODESIS. . If pleurodesis failed -> Decortication.
. N.B. 1 -> EXUDATE -> MALIGNANCY OR INFECTION -> ++ Capillary permeability. . N.B. 2 -> TRANSUDATE -> CONGESTIVE HEART FAILURE -> ++ HYDROSTATIC PRESSURE. . N.B. 3 -> TRANSUDATE -> CIRRHOTIC LIVER FAILURE -> -- PLASMA ONCOTIC PRESSURE .
. COMPLICATED PARA-PNEUMONIC EFFUSION CRITERIA: ________________________________________________ . Exudative pleural effusion.
. Pleural fluid acidosis.
. Low pleural fluid glucose < 60 mg/dl(High metabolic activity of leukocytes or bacteria)
. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION: ________________________________________________________________________ 1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.
. EMPYEMA = INFECTION OF THE PLEURAL SPACE: ___________________________________________
. Due to untreated pneumonia cased by bacterial invasion of a pleural effusion. . or contamination of the pleural space by rupture of a lung abscess.
. Others: Bronchopleural fistula - penetrating trauma - thoracotomy or ruptured viscus.
. May complicate hemothorax, the residual blood is an excellent medium for bact eria.
. A mixed aerobic & anaerobic bacterial infection (Strept. - Staph. - Klebsilel la).
. Low grade fever. . Dx -> CT scan.
. Tx -> Drainage & antibiotics.
. Tx -> SURGERY (If localized - complex or having thick rim). . SLEEP APNEA:
______________
. The pt's partener will report severe snoring.
. Hypertension - Headache - Erectile dysfunction & fat neck.
. Obstructive sleep apnea from fatty tissues of the neck blocking breathing. . Central sleep apnea due to -- respiratory drive from the CNS.
. Dx -> NOCTURNAL POLYSOMNOGRAPHY (GOLD STANDARD OF DIAGNOSIS). . Mild sleep apnea -> 5 - 20 apneic periods per hour.
. Severe sleep apnea -> > 30 apneic periods per hour.
. Tx of obstructive sleep apnea -> Weight loss & CPAP:Continous positive airway pressure
. If not effective -> Uvulo-palato-pharyngo-plasty.
. Tx of central sleep apnea -> Avoid alcohol & sedatives. . Medroxyprogesterone -> Central respiratory stimulant.
. OBESITY HYPOVENTILLATION $YNDROME (OH$) = PICKWICKIAN $YNDROME: _________________________________________________________________
. Severe obesity (Greater then 150% of ideal body weight -> BMI = 55!). . Thin neck & hypersomnolence.
. Obesity -> Distant heart sounds & Low voltage QRS complexes on EKG. . Alveolar hypoventillation during WAKEFULLNESS !
. Polycythemia secondary to alveolar hypoventillation. . ABG -> Hypoxemia & Hypercapnia & Respiratory acidosis.
. Due to DECREASED LUNG & CHEST WALL COMPLIANCE ! (Not resp. ms weakness xxx). . Tx -> Weight loss - Ventilator support - Oxygen - Avoid supine posture during sleep.
. COMPLICATIONS of long-standing OSA or OH$: ____________________________________________ . Pulmonary hypertension with cor pulmonale. . Secondary erythrocytosis.
. Hypoxia, chronic hypercapnea & respiratory acidosis (Due to chronic hypoventi llation).
. N.B. Chronic hypercapneic respiratory failure due to OH$: ___________________________________________________________
. Marked acidosis should be the result of respiratory failure in OH$. . But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acid osis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead ! . HOW TO DIFFERENTIATE BETWEEN OBSTRUCTIVE SLEEP APNEA & OBESITY HYPOVENTILLATIO N $:
________________________________________________________________________________ ____
________________________________________________________________________________ ____
.{1}. OBSTRUCTIVE SLEEP APNEA: _______________________________
. Air flow is impeded by AIRWAY OBSTRUCTION, . due to POOR ORO-PHARYNGEAL TONE.
. NORMAL ABG !
__________________________________
. Air flow is impeded by diminished expansion of chest & abdominal wall due to obesity.
. ABG -> HYPO-ventillation -> Chronic hyoxia & hypercapnia. . ALLERGIC BRONCHO-PUMONARY ASPERGILLOSIS (ABPA):
_________________________________________________ . Asthmatic pt with worsening asthma symptoms.
. Coughing of brownish mucous plugs with recurrent infiltrates. . Peripheral eosinophilia.
. ++ Ig E levels.
. Central bronchiectasis may be seen.
. Tx -> ORAL (Not inhaled) corticosteroids. . PULMONARY EDEMA:
__________________
. Hypoxia - SOB - Tachypnea.
. CXR -> Diffuse alveolar infiltrates.
. May be cardiogenic (LVF) or non cardiogenic (ARD$).
. Differentiate bet. the two types using pulmonary capillary wedge pressue (PCW P).
. PCWP > 18 -> Cardiogenic pulmonary edema. . PCWP < 18 -> Non cardiogenic = ARD$.
. ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$) = NON-CARDIOGENIC PULMONARY EDEMA: _______________________________________________________________________________ . Sudden severe respiratory failure resulting from diffuse lung injury,
. secondary to a number of overwheming systemic injuries e.g.
. Sepsis - Aspiration of gastric contents - shock - severe infections,
. Lung contusion - trauma - toxic inhalation - drowning - pancrestitis - burns. . CXR -> Diffuse patchy infiltrates.
. NORMAL wedge pressure -> i.e. < 18. . pO2/FiO2 ratio < 200.
. Tx -> Ventilatory support with low tidal volume of 6 ml/kg. . PEEP to keep the alveoli open. (Sh'd reach 15 cm H2O). . ++ FiO2 (Never exceed 60 %).
. Prone positioning of the pt's body.
. Possible use of diuretics & +ve inotropes such as dobutamine. . Transfer the pt to the ICU if not already there !
. STEROIDS ARE NOTTTTTTT EFFECIVE ! . ARD$ pts on MECHANICAL VENTILLATION: _______________________________________
. Mechanical ventillation includes two components FiO2 & PEEP. . FiO2 = Fraction of inspired oxygen.
. PEEP = Positive end expiratory pressure. . ++ FiO2 -> Improves oxygenation.
. PEEP -> Prevent alveolar collapse.
. Arterial pO2 is influenced by FiO2 & PEEP. . Arterial pCO2 is influenced by RR & TV.
. When you find a given ABF with pO2 55 mmHg = Low oxygenation. & FiO2 = 70% . So .. You should add PEEP 1st to improve oxygenation.
. Don't decrease the FiO2 before adding PEEP or you will worsen the condition ! . When you find a given ABG with pO2 105 mmHg = TOXIC OXYGEN LEVEL.
0% !
. PEEP may be ++ as needed to maintain adequate oxygenation but avoid tension p neumothx.
. When you are given an ABG with respiratory alkalosis (pH > 7.4) & hypocapnia (--CO2),
. With appropriate tidal volume < 6 ml/kg (pt. 70 kg -> 420 ml). . With appropriate FiO2 (Ex. 40 %),
. With appropriate PEEP (Ex. 5 cm H2O),
. Look at the respiratory rate (If it is high e.g. 18),
. This respiratory alkalosis will be due to HYPER-ventillation.
. So .. Decreasing the respiratory rate is the most appropriate step. . Ventillation = RR x TV.
. Respiratory alkalosis results from hyperventillation. . The RR sh'd be lowered.
. -- in TV can trigger ++ in RR -> worsening the condition. . POSITIVE END-EXPIRATORY PRESSURE (PEEP):
__________________________________________
. Used in cases of hypoxemic respiratory failue e.g. ARD$ & cardiogenic edema. . Helps to maintain air way pressure above atmospheric pressure at the end of e xpiration.
. Complications -> Alveolar damage - tension pneumothorax & hypotension.
. Sudden SOB - --BP & ++ HR - tracheal deviation & unilateral absence of breath sounds.
. SWAN-GANZ (PULMONARY ARTERY) CATHETERIZATION: _______________________________________________ -> Hypovolemic shock -> -- COP & -- CPWP & ++ TPR. -> Cardiogenic shock -> -- COP & ++ CPWP & ++ TPR. -> SEPTIC SHOCK ---> ++ COP & -- CPWP & -- TPR. . COP -> LOW except in septic shock (High).
. PCWP -> LOW except in cardiogenic shock (High). . TPR -> HIGH except in septic shock (Low).
. PCWP is NORMAL in ARD$. (VVVVVVVVVV. imp.). . PCWP is NORMAL in PE. (VVVVVVVVVVVV. imp.). . PNEUMONIA:
____________
. Fever, cough & sputum. . Severe illness -> SOB.
. COMMUNITY ACQUIRED PNEUMONIA (CAP) -> PNEUMOCOCCUS. . HOSPITAL ACQUIRED PNEUMONIA (HAP) -> Gram -ve bacilli. . PPI ++ the risk of hospital acquired pneumonia.
. Pts > 65ys with chronic dis. of lungs or liver are more prone to respiratory failure.
. DM - HIV - Steroid use - Asplenia -> Worse prognosis.
. ELDERLY HYPOXIC PT WITH OR WITHOUT FEVER SHOUL BE ADMITTED ! . Dx -> Best initial test -> CXR.
. Dx -> Most accurate test -> Sputum gram stain & culture.
. N.B. All pts with suspected pneumonia sh'd have a CXR done as the 1st step. . Antibiotics sh'd be adminstered ASAP without waiting for sputum gram stain or
culture.
. Tx -> OUT-PATIENT PNEUMONIA: _______________________________
-> Macrolide (Azithromycin - Doxycycline - Clarithromycin). -> Respiratory fluoroquinolone (Levofloxacin - Moxifloxacin). . Tx -> IN-PATIENT PNEUMONIA:
______________________________ -> Ceftriaxone & Azithromycin.
-> Fluoroquinolone as a single agent.
. REASONS TO HOSPITALIZE pts with pneumonia: _____________________________________________ . Hypotension -> SBP < 90 mmHg.
. Tachycardia -> HR > 125/min. . Temperature -> T -> 104 F.
. Respiratory rate -> RR > 30/min. . PO2 < 60 mmHg. . pH < 7.35 . BUN > 30 mg/dl. . Na < 130. . Glucose > 250. . Confusion. . Age > 65 ys or older.
. Co-morbidities eg. cancer, COPD, CHF & RF or liver disease.
. HYPOXIA & HYPOTENSION as single factors are a reason to hospitalize ! . Tx -> VENTILLATOR ASSOCIATED PNEUMONIA (VAP):
________________________________________________
. VAP -> Fever - Hypoxia - New infiltrate & ++ secretions. -> Imipenim - Cefepime or Piperacillin/Tazobactam.
-> Gentamycin & Vancomycin.
. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION: ________________________________________________________________________ 1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl. . SPECIFIC ASSOCIATIONS: _________________________
* Recent viral infection -> Staphylococcus. * Alcoholics -> Klebsiella.
* GIT syms & confusion -> Legionella. * Young healthy pts -> Mycoplasma. * Animal contact -> Coxiella Burnetii.
* Arizona construction workers -> Coccidioidmycosis. * HIV with < 200 CD4 cells -> Pneumocystis carinii PCP. . MYCOPLASMA PNEUMONIAE:
________________________
. Most common cause of atypical pneumonia. . Non productive i.e. dry cough.
. Many extra-pulmonary symptoms (Headache - sore throat - skin rash).
. ERYTHEMA MULTIFORME -> Dusky red TARGET shaped skin lesions on extremities. . CXR -> Lower lobe interstitial infiltrates.
. No cell wall (Only polymorphnuclear cells will appear on gram stain). . MYCOBACTERIAL PNEUMONIA:
__________________________
. HIV pts have a higher risk of reactivation of tuberculosis.
. Non specific symptoms (Cough - Weight loss - Fatigue - Low grade fever & Nigh t sweats).
. CXR -> UPPER LOBE INFILTRATES WITH CAVITATION. . ASPIRATION PNEUMONIA = ANAEROBIC PNEUMONIA: _____________________________________________
. Impaired swallowing due to IMPAIRED EPIGLOTTIC REFLEX is the most imp. predis p. factor.
. Aspiration of oro-pharyngeal secretions. . May be a complication of upper GI endoscopy.
. Usually caused by ANAEROBES & Streptococcal viridans.
. Advanced age, poor dentition, dementia, alcohol addiction are predisposing fa ctors.
. Pt presents with systemic syms e.g. fever & malaise & FOUL SMELLING SPUTUM. . Tx -> CLINDAMYCIN.
. KLEBSIELLA PNEUMONIA = FRIEDLANDER's PNEUMONIA: _________________________________________________ . Gram -ve bacilli.
. More associated with ALCOHOLICS & immunocomprized pts with neutropenia.
. Mechanism -> Colonization in the oropharynx followed by microaspiration of se cretions.
. Mostly affect the UPPER lobes. . produce CURRANT JELLY sputum.
. Sputum culture -> Mucoid colonies. . PNEUMOCYSTIS CARINII PNEUMONIA (PCP): _______________________________________
. Almost exclusively in AIDS pts with CD4 count < 200. . The HIV pt is usually not on prophylaxis for PCP! . Immunocompromized pt due to chemotherapy.
. Dyspnea on exertion, dry cough & fever.
. Dx -> Best initial test -> CXR -> Bilateral interstitial infiltrates (CHARACT ERISTIC).
. Dx -> ABG -> Hypoxia & ++ A-a gradient. (VVVVVVV imp.). . Dx -> ++ LDH level (Normal LDH level excludes PCP).
. Dx -> Most accurate test -> BRONCHO-ALVEOLAR LAVAGE. (VVVVVVVVV. imp.). . Dx -> Sputum stain -> if +ve -> Confirm PCP & if -ve -> Bronchoscopy. . Tx -> Best initial therapy for treatment & prophylaxis -> TMP-SMX.
. If PCP is severe (pO2 < 70 or A-a gradient > 35) -> Add STEROIDS to -- mortal ity.
. If there is toxicity from TMP-SMX (Rash - BM depression) -> PENTAMIDINE or Pr imaquine.
. If the pt is African American with G6PD (Bite cells on smear) -> Don't give P rimaquine.
. For PCP prophylaxis -> TMP-SMX .. if there is a rash or neutropenia -> Atovaq uone.
. If CD4 count is ++ & maintained above 200 for several months -> Stop prophyla xis.
. But, NEVER to stop the anti-retroviral medications against HIV ! . LEGIONNAIRE's DISEASE:
________________________
. H/O of recent TRAVEL or trip (BAHAMAS).
. Linked to cruise ship & hotel water supplies. . HIGH GRADE FEVER > 39 c.
. GIT symptoms (Nausea & vomiting & loose stools). . Mild ++ LFTs.
. HYPONATREMIA (PATHOGNOMONIC for LEGIONELLA). . CXR -> Focal lobular consolidation.
. Gram -ve stain rod & stains poorly (Intracellular organism).
. So.. Gram stain will show many neutrophils but no organisms is chracteristic. . Most accurate test -> Urine antigen test.
. Tx -> AZITHROMYCIN or Levofloxacin.
. N.B. ACUTE PNEUMONIA WITH CONSOLIDATION & PHYSILOGIC SHUNT: ______________________________________________________________ . -- Breath sounds, ++ Tactile vocal fremitus.
. Alveoli of the affected lung become filled with exudative fluid & cellular de bris.
. These alveoli may have persistent blood flow to areas with impaired ventillat ion.
. Leading to a physiologic intra-pulmonary shunt & arterial hypoxemia.
. Positioning of the pt. with the affected lung in dependent position can worse n the case
. i.e. his SO2 will drop for example from 94% when lying on one side to 84% on other side
. RECURRENT PNEUMONIA: ______________________
. {A} INVOLVING SAME REGION OF THE LUNG: _________________________________________ .1. Local anatomic obstruction:
________________________________ .. Bronchial compression (Neoplasm).
.. Bronchial obstruction (Bronchiectasis - Retained FB). .2. Recurrent aspiration:
__________________________ .. Seizures.
.. Ethanol or drug use. .. GERD.
. {B} INVOLVING DIFFERENT REGION OF THE LUNG: ______________________________________________ . Sino-pulmonary disease (Cystic fibrosis). . Non-infectious (BOOP).
. Immunodefeciency (HIV - Leukemia - --immunoglobulins).
. BRONCHOGENIC CARCINOMA is the most common cause of recurrent pneumonia in same region.
. Associated H/O of old age & prolonged smoking H/O . Dx -> CT chest. (If CT is -ve -> Bronchoscopy). . HYPERSENSITIVITY PNEUMONITIS (HP):
____________________________________
. Inflammation of the lung parenchyma caused by antigen exposure. . Ex: Fancier's lung -> Inhalation of aerosolized bird droppings. . Ex: Farmer's lung -> Inhalation of molds associated with farming.
. Acute episodes of cough, breathlessness, fever & malaise within 4-6 hs of Ag exposure.
. Chronic exposue may lead to weight loss, clubbing & honey-combing of the lung .
. The cornerstone of HP management is AVOIDANCE OF THE RESPONSIBLE ANTIGEN ! . TUBERCULOSIS (T.B):
_____________________
. Immigrants - HIV - Homeless - Prisoners & Alcoholics.
. Most important epidemiologic factor is FOREIGN BORN INDIVIDUAL (Not US born: MEXICO!).
. Fever - cough - sputum - weight loss & night sweats.
. Dx -> CXR & Sputum acid fast stain & culture to confirm TB.
. If culture is +ve -> Start 6 months course of ANTI-TUBERCULOUS THERAPY.
. ISONIAZID 6 m - RIFAMPIN 6m - PYRAZINAMIDE & ETHAMBUTOL stop after 2 months. . All of them can lead to liver toxicity.
. TB medications sh'd be stopped if the transaminases raised up to 5 times of n ormal.
. Isoniazid -> Peripheral neuropathy (Give Vit.B6). . Rifampin -> Red colored bodily secretions.
. Pyrazinamide -> Hyperuricemia. . Ethambutol -> Optic neuritis.
. Conditions need ttt > 6ms: Osteomyelitis, Meningitis, Miliary - cavitary TB & pregnancy
. LATENT T.B. _____________
. PPD -> PURIFIED PROTEIN DERIVATIVE TEST: ___________________________________________ . PPD is a screening test for high risk groups. . POSITIVE TEST IF:
-> 5 mm -> Close contacts, steroid users, HIV +ve.
-> 10 mm -> Homeless - Immigrants - Alcoholics - Health care workers & prisoner s.
-> 15 mm -> Those without any risks. . If PPD is +ve -> Proceed as follows: ______________________________________
. CXR -> to make sure that occult active disease hasn't been detected. . If CXR is abnormal -> Sputum staining for TB is done.
. If sputum staining is +ve -> Give full dose 4 drug therapy. . ISONIAZID alone is used for 9 months to treat a +ve PPD. . It -- the risk of developing TB from 99% to 1%.
. Once a PPD is +ve, the test sh'd never be repeated. . RHINITIS:
___________
{A} ALLERGIC RHINITIS: _______________________
. Watery rhinorrhea & sneezing with more prominent eye symptoms. . Early age of onset.
. Identifiable trigger (animals - environmental exposure).
. Usually seasonal symptoms but can be persistent throughout year. . Nasal mucosa can be normal, pale blue or pale on exam.
. Associated with allergic disorders e.g. eczema & asthma. . Tx -> Allergen avoidance.
. Tx -> Topical intra-nasal glucocorticoids. {B} NON-ALLERGIC RHINITIS = VASOMOTOR RHINITIS: ________________________________________________
gh).
. Late age of onset > 20 ys. . Can't identify clear trigger !
. Symptoms throughout the year but sometimes worse with seasons change. . Nasal mucosa may be normal or erythematous.
. Less commonly associated with allergic disorders e.g. asthma or eczema. . Routine allergy testing isn't necessary prior to initiating empiric ttt. . May respond to 1st generation oral H1 antihistaminics (Chloramphenicol), . Never ever responds to antihistaminics without anticholinergic properties (Lo ratidine)!
. Tx -> TOPICAL INTRANASAL GLUCOCORTICOIDS.
. The 3 most common causes of CHRONIC COUGH (> 8 weeks): ________________________________________________________ . UPPER AIRWAY COUGH $YNDROME (Post-nasal drip).
. BRONCHIAL ASTHMA. . GERD.
. UPPER AIRWAY COUGH $YNDROME = POST-NASAL DRIP: _________________________________________________ . NON-smoker.
. Caused by rhino-sinusitis conditions.
. Dry cough is most likely due to post-nasal drip associated with allergic rhin itis.
. Dx -> Confirmed by improvement of the nasal discharge & cough with H1 Anti-hi staminics.
. Chlorpheniramine is an H1 receptor blocker that decreases the allergic respon se.
. Decrease in NASAL SECRETIONS is most likely to significally improve symptoms. . ANAPHYLAXIS = ANAPHYLACTIC SHOCK:
___________________________________ . Type 1 hypersensitivity reaction.
. Pts usually have prior exposure to the offending substance.
. Pts have preformed Ig E -> Histamine mediated peripheral vasodilatation. . Bee stings - food & medications are the most common allergens.
. Acute onset of hypotension & tachycardia.
. Dangerous allergic reaction may progress to respiratory failure & circulatory collapse.
. Allergen exposure -> Sudden onset of symptoms in more than one system, . Cutaneous (hives - flushing - pruritis).
. GIT ( Lip / tongue swelling - vomiting).
. Respiratory (Dyspnea - wheezing - stridor - hypoxia). . Cardiovascular (Hypotension).
. It is a medical emergency.
. Tx -> INTRA-MUSCULAR EPINEPHRINE into the THIGH. . ASPIRIN SENSITIVITY $YNDROME:
_______________________________
. Aspirin ingestion - persistent nasal blockage - Episodes of bronchoconstricti on.
. Pathogenesis -> Psudo-allergic reaction. . Aspirin -> PGs/LKs imbalance.
. Tx -> Avoid NSAIDs & Leukotriene recptor antagonists (Drug of choice).
. MEDIASTINAL TUMORS: _____________________ _____________________ . Dx -> Helical CT CHEST.
. ANTERIOR mediastinum --> THYMOMA & GERM CELL TUMORS. . MIDDLE mediastinum ----> BRONCHOGENIC CYST.
. POSTERIOR mediastinum -> Neurogenic tumors e.g. Meningocele. . GERM CELL TUMORS:
___________________ . Affect young adults.
. Present as large ANTERIOR mediastinal mass.
. Two types of germ cell tumors (Seminomatous & Non-seminomatous). . Both types produce B-HCG (B-Human chorionic gonadotropin).
. ONLY "NON"-seminomatous type produces Alpha-feto protein (AFP). . CHORIOCARCINOMA:
__________________
. Metastatic form of gestational trophoblastic disease. . It may occur after molar pregnancy or normal gestation. . The lungs are the most frequent site of metastatic spread.
. Any postpartum woman e' pulmonary sympotms & multiple nodules on CXR = CHORIO CARCINOMA.
. Dx -> ++++++ B-HCG levels.
. INCIDENTALLY DISCOVERED SOLITARY PULMONARY NODULE: ____________________________________________________ . May be BENIGN -> Infectious granuloma or hamartoma. . May be MALIGNANT -> Bronchogenic carcinoma & metastasis.
. BIOPSY is the only way to definitively detect whether a nodule is benign or m alignant.
. Clinical characteristics favoring malignancy:
. Age > 50 - H/O of smoking - Weight loss - Previous malignancy. . Radiographic characteristics of malignancy:
. Large size - Low density - Spiculated borders - Absence of calcifications. . Rate of lesion growth is an important parameter:
. Malignant nodules tend to double in size bet. one month & one year.
. OBTAINING PREVIOUS X-RAY if possible is the FIRST BEST STEP in management. . If a previous x-ray demonstrates that the lesion has been stable in size > 2 ys,
. Malignancy is effectively ruled out & no further testing is necessary. . LOW propability nodules are followed by serial high resolution CT CHEST. . INTERMEDIATE propability nodules are followed by PET SCAN or BIOPSY. . HIGH propability nodules are removed surgically.
. PULMONARY - RENAL ASSOCIATIONS: _________________________________
.1. WEGENER's GRANULOMATOSIS WITH POLYANGIITIS: ________________________________________________
. SYSTEMIC VASCULITIS + UPPER & LOWER RESPIRATORY TRACT INFECTION + GLOMERULONE PHRITIS.
. Age around 40s.
. URT symptoms (Bloody or purulent nasal discharge - oral ulcers - sinusitis). . LRT symptoms (Dyspnea - cough - Hemoptysis).
. Renal symptoms (Microscopic hematuria - RBC casts).
. Granulomatous inflammation of nasopharynx (Epistaxis - Rhinorrhea - Otitis - sinusitis)
. Saddle nose deformity due to destruction of the nasal cartilage.
. Cutaneous manifestations (Painful SC nodules - palpable purpura - pyoderma ga ngrenosum)
. BEST INITIAL TEST -> +ve C-ANCA = serum anti-neutrophilic cytoplasmic antibod y.
. CXR -> Bilateral multiple nodular opacities.
. Urinalysis -> RBCs casts - proteinuria & sterile pyuria. . Tx -> CYCLOPHOSPHAMIDE & High dose corticosteroids. .2. GOODPASTURE's DISEASE:
___________________________
. Due to renal basement membrane antibodies ! . Young male.
. Lungs (cough - dyspnes - hemoptysis).
. Kidneys (Nephritic proteinuria - ARF - Dysmorphic RBCs & red cell casts on ur inalysis).
. Systemic symptoms are un common.
. Dx -> Renal biopsy -> LINEAR IgG antibodies along the glomerular basement mem brane.
. EFFECTS OF ARTERIAL OXYGENATION & VENTILATION IN VARIOUS ENVIRONMENTS: ________________________________________________________________________
_____________________________ Example ________ A-a gradient ____ Pa CO2 ___ Corr ects e' O2
. -- inspired O2 tension = HIGH ALTITUDE: _________________________________________ . A-a gradient -> Normal.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES. . Hypoventillation = CNS DEPRESSION: ____________________________________ . A-a gradient -> Normal.
. Pa CO2 -> +++++.
. Corrects with supplemental O2 -> YES.
. Diffusion limitation = INTERSTITIAL LUNG DISEASES: ______________________________________________________ . A-a gradient -> +++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.
. Shunt = Intracardiac shunt or extensive ARD$: _______________________________________________ . A-a gradient -> +++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> NOOOOOO.
. V/Q mis-match = Obstructive diseases, atelectasis, pulmonary edema & pneumonia :
________________________________________________________________________________ _
. A-a gradient -> ++++++. . Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES. . Low lung compliance.
________________________________________________ . ACUTE ONSET dyspnea & difficulty swallowing. . Agitation & gasping of breath.
. Excessive accessory respiratory muscle use.
. Retraction of the subclavicular fossae during inspiration. . H/O of previous food allergy.
. Identifiable precipitating event e.g. peanut ingestion.
. Physical exam. may reveal stridor & harsh respiratory sounds from trachea. . Wheezing is generally absent on lung auscultation.
. A fixed upper airway obstruction will -- air flowrate in all inspiration & ex piration.
* NORMAL LUNG EXAMINATION: __________________________ . Percussion -> Resonant.
. Auscultation -> Vesicular breathing. * LUNG CONSOLIDATION EXAM:
__________________________ . Percussion -> Dullness.
. Auscultation -> LOUDER vesicular breathing if airways are patent (Faint if bl ocked).
. Bronchial breathing with full expiratory phase. . ++ TVF.
. Bronchophony.
. Egophony (Ask the pt to say "E", it will sounds like "A"). . Widespread pectoriloquy.
* PLEURAL EFFUSION EXAM: ________________________
. Inspection -> -- movements of ipsilateral chest. . Percussion -> Dullness.
. Auscultation -> Decreased breath sounds. . -- TVF.
* PNEUMOTHORAX EXAM: ____________________
. Percussion -> Hyper-resonance.
. Auscultation -> Decreased breath sounds (Will be absent entirely if large pne umothorax)
. -- TVF.
. JVD, Hypotension & Tracheal deviation to the opposite side. * EMPHYSEMA EXAM:
_________________
. Percussion -> bilateral resonance.
. Auscultation -> Vesicuar breathing with fine crackles at inspiration.
. N.B. Recurrent bacterial infections in an adult may indicate a HUMORAL IMMUNIT Y defect.
. Recurrent sino-pulmonary & gastro-intestinal infections.
. Dx -> Quantitative measurment of serum immunoglobulin "G" levels -> DECREASED. . Cystic fibrosis may have similar presentation BUT (Earlier in life & e'out GIT infects).
. ACE INHIBITORS & DRY COUGH: _____________________________
. Always consider ACE Is as a potential cause of chronic cough. . Pathogenesis -> Accumulation of bradykinins & prostaglandins.
. Simple discontinuation of the drug sh'd precede any diagnostic tests !
. SINGLE PULMONARY NODULE APPROACH: ___________________________________
. SOLITARY PULMONARY NODULE = Lesion < 3 cm completely surrounded by pulmonary p arenchyma ._______________________________________________________________________________ __________ .| ._______________________________________________ .| .| .|
. HIGH MALIGNANCY RISK . INTERMEDIATE RISK . LOW MALIGNANCY RISK ._____________________ .___________________ ._____________________ .| .| .|
. Surgical excision. . NODULE SIZE ? . SERIAL CT SCANS . < 1cm: Serial CTs.
. > 1cm: PET scan.
* FUNGAL INFECTIONS OF THE LUNG: ________________________________ .1. HISTOPLASMOSIS:
___________________
. Asymptomatic pulmonary nodule.
. Residence in suburban Mississippi or o"H"io river valleys ! . Absence of any complaints.
. Absence of significant past H/O. . Absence of any cavitary lesions.
. Calcified nodes in the lung may be seen.
. It is a dimorphic fungus found in soil with high concentration of bird or bat droppings
. Infection through inhalation of the spores of Histoplasma capsulatum fungus. .2. BLASTOMYCOSIS -> ULCERATED SKIN LESIONS & LYTIC BONE LESIONS:
_________________________________________________________________ . Fungal infection of the lung..
. Residence in great lakes, Mississippi, Ohio river & Wisconsin. . Pulmonary symptoms resembling T.B. & Histoplasmosis.
. ULCERATED SKIN LESIONS & LYTIC BONE LESIONS (Characteristic!).
. Skin lesions -> Multiple well circuscribed verrucus crusted lesions. . Bone lesions -> Lytic lesions in the anterior ribs.
. Dx -> Sputum culture -> BROAD BASED BUDDING YEAST. . Tx -> ITRACONAZOLE or Amphotericin B.
.3. COCCIDIOIDOMYCOSIS: _______________________
. Fungal infection of the lung. . Residence in Southwestern US. . Fever, cough & night sweats.
. Extra-pulmonary -> skin, meninges & skeleton.
.4. ASPERGILLOSIS = A MOBILE LUNG CAVITARY MASS + INTERMITTENT HEMOPTYSIS: __________________________________________________________________________ . Fungal infection of the lung.
. Coarse fragmented septae. . Hyphae are typically seen.
. Cavitary lesion may form due to destruction of the underlying pulmonary paren chyma.
. Debris & hyphae may coalese forming a FUNGUS BALL.
. The ball lies freely in the cavity & moves around with position change. . A MOBILE CAVITARY MASS + INTERMITTENT HEMOPTYSIS = ASPERGILLOMA.
. SUPERIOR SULCUS TUMOR: ________________________
. Apical lung tumor causing compression effects. . Superior vena cava -> SVC $yndrome.
. Sympathetic trunk -> Horner $yndrome.
. Brachial plexus -> Pancoast $yndrome (Pain - paresthesia - weakness of arm). . Rt recurrent laryngeal nerve -> Hoarsness of voice.
. PANCOAST $YNDROME: ____________________
. Apical lung tumor at the thoracic inlet.
. Compress the inferior portion of the brachial plexus. . Shoulder pain radiating in an ulnar distribution. . SUPERIOR VENA CAVA $YNDROME (SVC):
____________________________________
. Obstruction of SVC impedes venous return from the head, neck, face & arms to the heart.
. Dyspnea - Venous congestion & swelling of the head, neck & arms.
. Malignancy is the most common cause of obstruction (Lung cancer - Hodgkin's l ymphoma).
. H/O of chronic heavy smoker with recent un-intentional weight loss -> Lung ca ncer.
. Best initial test -> CXR -> If abnormal -> Follow up with Ct chest. . HYPERTROPHIC OSTEOARTHROPATHY:
________________________________
. Development of clubbing & sudden onset joint arthropathy in a chronic smoker. . Bilateral wrist tendrness, thickening of distal fingers & convex nail beds. . Associated with lung cancer.
. CXR is mandatory to rule out malignancy. . FINGER CLUBBING:
__________________
. Thickening of the nail bed that causes a devrease in the angle bet the nail b ed & fold.
. In severe cluccing, the terminal parts of the fingers appear swollen like dru msticks.
. It is NOT a feature of simple COPD.
. NEW CLUBBING in COPD pts indicates the development of lung cancer or occult m alignancy. . GOLDEN SCHEME: ________________ ________________ . . SPIROMETRY .____________ .| .____________________________________________________ .| .|
. LOW FEV1/FVC . NORMAL OR HIGH FEV1/FVC .______________ .________________________ _
.| .|
. OBSTRUCTIVE DISEASE . RESTRICTIVE DISEASE ._____________________ ._____________________ .| .|
. BRONCHO-DILATOR CHALLENGE . DLCO ____________________________ .______ .| .| ._________ .________________ .| .| .| .| . ++ FEV1 . No ++ in FEV1 . NORMAL . -- DLCO ._________ ._______________ ._______ .________ _
. ASTHMA. . COPD. . CHEST WALL WEAKNESS . ILD. .|
. DLCO
._____________________ .| .|
. (--) -> Emphysema . (++) -> Chronic bronchitis.
. N.B. RIGHT MAIN STEM BRONCHUS INTUBATION: ___________________________________________
. Relative complication of endotracheal intubation.
. It causes asymmetric chest expansion during inspiration.
. Markedly decreased or absent breath sounds on the left side on auscultation. . Solve the problem by repositioning of the tube,
. Tx -> Pull it back slightly, this will move its tip between the carina & voca l cords.
. N.B. 2ry MALIGNANCY AFTER CHEMOTHERAPY ! __________________________________________
. Up to 4% of pts with HODGKIN's disease wil develop a 2ry malignancy (Lung - b reast)
. After being treated with chemotherapy & radiation ! . N.B. POST-ICTAL STATE ABG:
____________________________ . Repiratory ACIDOSIS. . Acisosis (-- pH). . Hypercarbia (++ CO2). . Normal or ++ HCO3 !
. HYPO-ventillation is a major cause of respiratory acidosis. . N.B. MOST COMMON CAUSE OF HEMOPTYSIS is -> CHRONIC BRONCHITIS: ________________________________________________________________
. Chronic productive cough for 3 months in 2 successive years with ciagarette sm oking.
. Other important causes -> BRONCHOGENIC CARCINOMA & BRONCHIECTASIS. . CXR is mandatory to exclude malignancy.
. N.B. Acute bronchitis is a common cause of blood-tinged sputum. . It is usually viral in etiology.
. In an "A"FEBRILE pt with NEW-ONSET BLOOD TINGED SPUTUM e'OUT significant seri ous signs,
. OBSERVATION & CLOSE CLINICAL FOLLOW UP is the best ttt strategy. . MITRAL STENOSIS:
__________________
. Pt. 40 - 50ys.
. presents with gradual & progressively worsening dyspnea on exertion. . Orthopnea & hemoptysis due to pulmonary edema.
. Auscultation -> Loud S1 & Opening snap after S2 at apex.
. Low pitched diastolic rumble at apex (When pt lies on left side with breath h olding).
. Atrial fibrillation is a common complication.
. Af causes rapid decompensation in a previously asymptomatic pt.
. Long-standing MS can cause Left atrial enlargement -> Elevation of left main bronchus.
. ACE inhibitors side effect -> Dry cough: __________________________________________
. Pathophysiology -> Accumulation of KININs due to activation of arachidonic ac id pathway
. N.B. ACID-BASE BALANCE in two different situations: _____________________________________________________ _____________________________________________________
. 1 . Chronic hypercapneic respiratory failure due to COPD: ___________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD. . But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acid osis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead ! . BOTTOM LINE -> The body compensates for chronic hypercapnea by ++ bicarbonate retention.
. 2 . Mechanically vetillated pt following head trauma: _______________________________________________________
. Hyper-ventillation (Due to ++ TV or RR) -> Excessive CO2 loss & Respiratory A lkalosis.
. Hypo-ventillation (Due to -- TV or RR) -> Excess CO2 Retention & Respiratory Acidosis.
. Respiratory alkalosis: -> ++ pH (N = 7.4).
-> -- PCO2 (N = 40 mmHg).
-> -- HCO3 (N= 24) -> DECREASED due to attempted renal compensation for resp. a lkalosis.
-> The kidneys retain increased amounts of Hydrogen H (protons)
-> & excrete ++ amounts of bicarbonate (HCO3) in attempt to normalize serum pH. -> The ++ amount of HCO3 in urine ALKALIZES the urine.
Dr. Wael Tawfic Mohamed __________________________
