Pulm step2

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gm1147
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166153
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Pulm step2
Updated:
2012-09-13 10:17:36
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Pulm pulmonology step2
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kaplan
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  1. 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
  2. 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
  3. Oral steroids sides
    • Osteoporosis
    • Cataracts
    • Adrenal suppresion
    • fat redistribution
    • Hyperlipidemia
    • Hyperglycemia
    • Acne
    • Hirsutism
    • Striae
  4. 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
  5. COPD tx
    • Improves mortality: stop smoking, O2, flu and pneumococcal vaccines
    • Symptoms: SABA, Anticholinergics (tiotropium, ipratropium), ICS, LABA, rehab
    • Possible: theophylline, lung reduction
  6. O2 use in COPD
    • pO2<55 or O2 sat <88%
    • If right heart failure or inc in hematocrit, pO2<60 or O2 sat <90%
  7. Bronchiectasis causes
    • Cystic fibrosis
    • Infections - TB, PNA, abcess
    • Panhypogammaglobulinemia
    • Foreign body
    • tumor
    • Allergic bronchopulmonary aspergillosis
    • Rheumatoid arthritis
  8. Bronchiectasis tests
    • initial: CXR - tram tracks
    • Accurate: high res CT
    • Sputum cx
  9. 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
  10. Cystic fibrosis PFTs, bugs
    • mixed - dec FVC and TLV, dec DLCM
    • H flu, Pseudomonas, Staph, Burkholderia
  11. Cystic fibrosis tx
    • Abx, inhaled aminoglycosides
    • Inhaled recombinant human DNase
    • Inhaled bronchodilators
    • Pneumococcal and flu vaccines
    • Lung transplant
  12. 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
  13. Dry PNA
    • mycoplasma
    • viral
    • coxiella
    • PCP
    • Chlamydia
  14. Adequate sputum gram stain
    • >25 WBC
    • <10 epithelial cells
  15. Empyema labs
    • LDH >60% serum
    • protein >50% serum
    • WBC >1000
  16. Dx test for mycoplsma
    • PCR
    • cold agglutins
    • serology
    • special media
  17. Dx test for chlamydia or coxiella pna
    Rising serologic titers
  18. Dx test for legionella
    • urine antigen
    • Cx on charcoal yeast
  19. Dx test for PCP
    BAL
  20. 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)
  21. Inpatient tx of PNA
    • Fluoroquinolone (levofloxacin or moxifloxacin)
    • Or
    • Ceftriaxone + azithromycin
  22. 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
  23. Hospital acq pna bugs and tx
    • Ecoli and pseudomonas
    • Cefepime or ceftrazidime
    • or
    • Piperacillin/tazobactam
    • or
    • Imipenem, meropenem, doripenem
  24. 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
  25. Linezolid met and sides
    • renal
    • sz
  26. Lung abscess tx
    Clindamycin or pen
  27. PCP tests
    • CD4<200
    • Initial: CXR or ABG
    • LDH inc
    • Accurate: BAL
    • Sputum stain has only PPV
  28. PCP tx
    • bactrim
    • Steroids if severe (pO2<70, Aa>35)
    • If mild, alternative is atovoquone
    • If toxic to bactrim, clinda+primaquine or pentamidine
  29. Bactrim sides
    • most common is rash
    • 2nd is bone marrow suppression
  30. PCP ppx
    • when <200
    • bactrim
    • alternative is atovoquone or dapsone
  31. TB risk factors
    • Immigrant
    • Prisoner
    • HIV
    • Healthcare
    • Close contact
    • Steroids
    • Hematologic malignancy
    • Alcoholic
    • DM
  32. TB tests
    • Intial: CXR
    • Sputum stain and cx x 3
    • Accurate: pleural bx
  33. 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
  34. 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
  35. 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
  36. Latent TB tx
    • 9mo INH
    • 10 to 1% lifetime risk of TB
  37. Signs of malignany of a pulm nodule
    • spicules
    • >2cm
    • atelectasis
    • adenopathy
    • sparse, eccentric Ca
    • abnormal PET
  38. Intermediate probability lung nodules
    signs
    work up
    • 1-2 cm, 30-40 yo
    • Sputum cytology has PPV
    • bronchoscopy or transthoracic bx
    • PET
    • VATs
  39. Drugs causing pulm fibrosis
    • Bleomycin
    • Busulfan
    • Amiodarone
    • Methysergide
    • Nitrofurantoin
    • Cyclophosphamide
  40. Risks for:
    silicosis,
    asbestosis,
    byssinosis,
    berylliosis,
    bagassosis
    • sandblasting, mining, tunneling
    • shipyard, pipe, insulators,
    • cotton
    • electronics
    • moldy sugar cane
  41. Interstitial lung disease tx
    prednisone if WBC/inflammatory. best for berylliosis (granulomas)
  42. Sarcoid dx
    • intial: CXR
    • accurate: LN bx with noncaseating granulomas
    • inc ACE
    • HyperCa in urine and serum
    • PFTs
  43. PE tests
    • Initial: CXR, EKG, ABG
    • Accurate: Angiography
    • DDimer - NPV so only for low prob
    • Follow CT with V/Q or dopplers
  44. PE CXR
    • Normal
    • Atelectasis
    • Wedge infarct
    • Plearal based lesion=Hamptom hump
    • Oligemia of one lobe=Westermark sign
  45. PE EKG
    • Sinus tach
    • nonspecific ST-T wave chenages
    • R axis
    • RV hypertrophy
    • RBBB
    • S1 Q3 T3
  46. PE ABG
    • Hypoxia
    • Resp alkalosis
  47. IVC filter indications
    • Melena
    • CNS bleeding
    • Recurrent emboli
    • RV dysfunction
  48. Pulm htn tests
    • Intitial: CXR
    • Accurate: Swan-Ganz
    • EKG - R axis, RAH, RVH
    • Echo
  49. Idiopathic pulm htn tx
    • Prostacyclin analogues: epoprostenol, treprdostinil, iloprost, beraprost
    • Endothelin antagonists: bosentan
    • Phosphodiesterase inh: sildenafil
    • O2 to slow progression
    • Transplant
  50. ARDS risks
    • Sepsis
    • aspiration
    • lung contusion
    • near drowning
    • burns
    • pancreatitis
  51. ARDS dx
    • CXR: white out, air bronchograms
    • pO2/FIO2 <200 (room air is 0.21 FIO2)
    • Normal wedge pressure
  52. 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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