Pulmonology 7

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  1. Stratifies patients into high and low risk for pneumonia mortality
    PORT scoring system
  2. Prediction rule focuses on recognizing low risk patients and not overestimating severity of illness
    PORT scoring system
  3. Included primarily patients presenting through emergency departments rather than those evaluated in physicians offices and sent home
    PORT scoring system
  4. Has been extrapolated for use in defining need for hospitalization
    PORT scoring system
  5. Expectorated; Induced (aerosolized NaCl induces cough)
  6. Suctioned from tracheostomy tube
  7. Bronchial washings/aspirates; BAL (Bronchoalveolar lavage); Bronchial brush or biopsy
    Bronchoscopy specimens
  8. is normally sterile if directly sampled
    Lower Respiratory Tract
  9. Used to evaluate quality of specimen for bacterial culture
    Gram Stain:
  10. Acceptable sputum spec:
    <10 squamous epithelial cells/low power field
  11. Induced specimens, BAL & Bronchial brushings or biopsy
    do not require “screening” Gram stain
  12. Indicative of oral mucosal contamination
    Squamous epithelial cells
  13. Absence not predictive if pt is immunocompromised (or neutropenic)
  14. numerous WBC’s =
  15. Activated phagocytic cells common in fungal, acid-fast & some atypical bacterial infections
  16. Indicative of allergic reaction or parasitic infection
  17. Mucus secreted to mechanically cleanse respiratory pathway & directly attacks inhaled bacteria via antibodies (primarily IgA) & lysosomes
    Mucus Strands:
  18. Distinguish normal flora from pathogens
    Bacteria & Yeast:
  19. Lancet shaped gram positive cocci in pairs
    Streptococcus pneumoniae with several neutrophils
  20. Gram negative diplococci…..
    Moraxella catarrhalis
  21. can cause pneumonia, especially in patients with alcoholism or chronic obstructive lung disease.
    Moraxella catarrhalis
  22. meningococci and Haemophilus influenzae, Moraxella catarrhalis are
    often visible within the cytoplasm of neutrophils.
  23. Sputum Gram Stain with Mucus strands…
    Haemophilus influenzae
  24. with infection caused by gram negative bacilli or staphylococci is probably the major type of hospital acquired pneumonia, followed by pneumococcal disease.
    Aspiration pneumonia
  25. from a pulmonary abscess….think hospital acquired pneumonia in a ventilator pt or if outpatient, also consider EtOH/substance abuser with aspiration
    Klebsiella pneumoniae
  26. Anaerobic (aspiration) pneumonia
    Prevotella or Bacteroides species
  27. Inflammation of tracheo-bronchial tree (Acute vs Chronic)
  28. clinical diagnosis - xs bronchial mucus production & daily productive cough for >3 months in 2 consecutive yrs; Predominantly viral (both acute & chronic); Culture never indicated
    Chronic Bronchitis
  29. Inflammation of lower resp. tract usually due to an infection
  30. Standard bacterial culture which isolates most common pathogens (Strep pneumo, H. flu, etc)
    Routine Culture:
  31. treatment takes into consideration lack of anaerobic culture
    Aspiration pneumonia
  32. not always pathognomonic
    CXR findings
  33. Requires specific fungal culture order
    Respiratory Cultures Fungi
  34. Important in immunocompromised, immunosuppressed or post antibiotic pts
    Respiratory Cultures Fungi
  35. Candida albicans, Aspergillus, Histoplasmosis, Blastomycosis, Coccidiosis, Zygomycosis
    Respiratory Cultures Fungi
  36. Cultures incubated several weeks before culture results are finalized
    Respiratory Cultures Fungi
  37. Collect serial early AM sputum cultures x 3, (Acid Fast Bacilli)
    Mycobacterium tuberculosis:
  38. if positive, presumptively treat for TB in appropriate clinical picture (as low as 20% sensitive)
    Acid Fast Stain:
  39. always reported by micro lab to state health dept for contact evaluation
    + TB
  40. Causative agent of TB
    Mycobacterium tuberculosis complex
  41. spread person to person via respiratory droplets in air (cough)
    TB infection
  42. Administer 5 units (0.1 ml) of PPD (purified protein derivative) intracutaneous (volar aspect of forearm) to best detect infection
    Mantoux test:
  43. Requires 2-12 weeks to develop an immune response to TB; delayed type hypersensitivity mediated by T cells
    TB Skin Testing
  44. not erythema is measured @ 48 -72 hours
  45. determined by underlying risk
    Zone Size”
  46. Children < 4yrs old, or infants, children & adolescents exposed to adults @ high risk for active TB:
    zone size >10mm (Positive PPD Zone Sizes)
  47. if pt has no risk factors
    > 15 mm (Positive PPD Zone Sizes)
  48. if pt has co-morbid risk factors (Diabetes, chronic renal failure, cancer, IVDA, congregate setting (hospital, prison, shelter), foreign born/immigrant <5yrs from endemic area (Asia, Africa, Latin America), Mycobacteriology lab tech, gastrectomy\
    > 10 mm (Positive PPD Zone Sizes)
  49. if HIV+, contact of TB + person, organ transplant/immunosuppressed, pts with fibrotic CXR (indicates healed TB infection) or pts on >15mg prednisone/day or on TNF alpha inhibitor
    > 5mm (Positive PPD Zone Sizes)
  50. is tested to determine if the individual's immune system is functioning well; a normal immune system demonstrates a positive reaction.
    Candida antigen
  51. the inability to react to skin tests because of a weakened immune system (e.g. advanced HIV infection, malignancy)
  52. develop TB rxn > 10mm within 8 to 12 wks following vaccination (although zone size does not correlate with vaccine protection)
    Most BCG recipients
  53. Difficult to distinguish between TB + rxn & BCG rxn therefore: Prior BCG vaccination is not a valid basis for dismissing + rxns so recommend using
    interferon gamma release assays
  54. usually elicits a positive PPD reaction
    BCG (Bacille Calmette-Guérin) vaccine:
  55. may also elicit positive PPD
    Latent TB
  56. Pt with + PPD for first time
  57. Pt who previously had documented neg PPD who now tests +
  58. Pt with latent TB may have neg PPD if tested years after infection
  59. Place 1st PPD…if neg, retest in 2 to 3 weeks to access for a delayed “memory” response
    Two Step Testing: TB Skin Testing
  60. indicates Latent TB or prior BCG vaccine & should be classified as reactors, not converters.
    If 2nd test is positive,
  61. If 2nd test neg
    pt probably not infected
  62. more specific test for LTBI & can help exclude BCG or Mycobacterium not TB rxns.
    Interferon Gamma Release Assay
  63. Ex vivo T cell based assay…T cells of pts previously infected with M. tuberculosis will produce high levels of interferon-gamma. As antigens used in test are not shared by BCG or other Mycobacterium, low cross reactivity
    Interferon Gamma Release Assay
  64. ELISA methodology
    TB Skin Testing
  65. x 3 (early AM specs) to evaluate for active dz
    Obtain AFB cultures & AFB smears
  66. honey combing, suggest pulmonary fibrosis
  67. movement of air in and out of the lungs
  68. negative pressure
  69. passive process; Result of natural recoil/elasticity
  70. between the alveoli and pulmonary capillaries
    Gas exchange
  71. normal Gas exchange
    6 liters of air per minute
  72. Gas exchange during heavy exercise
    can increase to 75 liters per minute
  73. Inflammatory/allergic condition, can be childhood or adult onset, may be concurrent with allergies
  74. Cough, wheezing, chest tightness, triggers, exertional, night sxs
  75. Asthma, COPD, Chronic Bronchitis, Emphysema
    Obstructive Lung Diseases
  76. most often seen in smokers, chronic cough/dyspnea with increased sputum production
    Chronic Bronchitis
  77. chronic dyspnea with destruction of alveoli
  78. Chronic Bronchitis, Emphysema
    COPD – Chronic Obstructive Pulmonary Disease
  79. disorders of the chest wall or pleura; Includes obesity, pleural effusion
    Extrinsic Disorders
  80. Interstitial Lung Disease, Acute pneumonitis
    Intrinsic Lung Disease
  81. inflammation/scarring of the lung tissue
    Interstitial Lung Disease
  82. airspaces filled with exudate or debris (often due to irritant exposure)
    Acute pneumonitis
  83. Chronic persistent cough, wheezing, dyspnea, exertional cough or chest discomfort, fatigue
    Indications for Pulmonary Function Testing
  84. Objective assessment of bronchodilator therapy; Evaluation of occupational exposures
    Indications for Pulmonary Function Testing
  85. Pre-operative risk assessment; Objective assessment of impairment or disability
    Indications for Pulmonary Function Testing
  86. Chest or abdominal pain of any cause; Oral or facial pain exacerbated by a mouthpiece; Stress incontinence; Dementia or confusional state
    Contraindications for PFTs
  87. measures the amount & rate of air a person breathes in order to diagnose illness or determine progress in treatment
  88. amount of air that can be exhaled with a maximal effort after a maximal inhalation.
    FVC – Forced vital capacity
  89. Forced expiratory volume in 1 second
  90. proportion of the FVC that can be expelled in the first second of forced exhalation
    FEV1/FVC ratio
  91. average flow rate over the middle 50% of expired volume during a maximal forced expiratory maneuver
    FEF 25-75%
  92. Spirometry Interpretation: low FEV1 compared to FVC. In late stages can also see low FVC as well.
  93. Spirometry Interpretation: low volume seen on FVC
  94. Decline in lung function more rapid than expected from aging alone.
    Spirometry Interpretation: INDICATOR OF AN ADVERSE EFFECT
  95. approximately 30cc/year – less than 1%/yr
    Spirometry Interpretation: Expected rate of decline
  96. Normal variability between results of spirometry sessions
    5% changes in FEV1
  97. comparison of 5 years or less – 10% to 14% decline or 275 - 400ml/yr decline
    possibly significant
  98. comparison of 5 years or less – 15% or more decline or 400 ml or more decline
  99. comparison of over 5 years – between 2-3% per year decline or 55-80 ml/year decline
    possibly significant
  100. comparison of over 5 years - 3 % per year or more decline or 80 ml/year or more decline
  101. Uses spectometry to measure oxygen saturation peripherally
    Pulse Oximetry
  102. Normal > 95%; < 88% at rest required for O2 therapy
    Pulse Oximetry
  103. Not accurate in using to titrate O2 therapy in advanced COPD
    Pulse Oximetry
  104. Measures oxygen saturation of hemoglobin in arterial blood - which is a measure of the average amount of oxygen bound to each hemoglobin molecule
    Pulse Oximetry
  105. DLCO
    Diffusing Capacity for Carbon Monoxide
  106. Most commonly “single breath method”; 3% CO and 10% helium; Uptake of CO measured at exhalation; Two tests, mean value reported; Threshold values have not been standardized – use reference ranges given by facility
    Diffusing Capacity of Carbon Monoxide
  107. Polycythemia; Severe obesity; Asthma
    Increased DLCO
  108. Pulmonary hemorrhage; Left-to-right intracardiac shunting; Mild left heart failure; Exercise just prior to the test
    Increased DLCO
  109. Anemia – mild decrease; Pulmonary vascular disease; Early interstitial lung disease
    Low DLCO with normal spirometry
  110. Emphysema; Cystic fibrosis; Bronchiolitis
    Low DLCO with obstruction
  111. Interstitial lung disease & Pneumonitis
    Low DLCO with restriction
  112. Anemia
    reduces DLCO
  113. Carboxyhemoglobin
    reduces DLCO
  114. Altitude
    increases DLCO
  115. Used to monitor respiratory function in asthma
    Peak Flow
  116. Based on each patient’s personal best – compare this to standardized reference ranges based on age, height, and sex
    Peak Flow
  117. Safer to make diagnosis of asthma than using methacholine challenge. Assists patients in therapeutic decisions
    Peak Flow
  118. Asthma Action Plan -Green zone, Yellow zone, Red zone; Essentially multiple checks of FEV1.
    Peak Flow
  119. Measures ECG along with pulmonary gas exchange and pulse oximetry.
    Cardiopulmonary Stress Testing
  120. Evaluation of dyspnea or shortness of breath; Functional status determination in congestive heart failure
    Cardiopulmonary Stress Testing
  121. occur in cycles 90-120 minutes each – REM vs. Non-REM sleep
    Sleep stages
  122. active, awake EEG pattern; atonic EMG; presence of rapid eye movements
    REM sleep
  123. 3 stages
    NREM sleep
  124. lightest, 2-5% of sleep, transition stage
    Stage 1
  125. intermediate, 40-50%, slowing of EEG
    Stage 2
  126. deep/slow wave, 20%
    Stages 3&4
  127. wakefulness to Stage 1, then to stages 2, 3, and 4. Stages 3 and 2 reappear, then REM.
    First ½ of night
  128. stage 2 and REM alternate
    Second ½ of the night
  129. Excessive daytime fatigue; Excessive snoring, Witnessed apnea, Obesity/HTN/heart disease, Active/Violent nighttime behaviors, Parasomnias, Insomnia
    Indications for Polysomnography
  130. test records body functions during sleep, including brain activity, eye movement, o2 & co2 blood levels, HR and rhythm, breathing rate and rhythm, the flow of air through your mouth and nose, snoring, body muscle movements, and chest and belly movement.
  131. Sleep time, stages of sleep (NREM and REM), and awake time are normal. No abnormal brain activity (such as a seizure) is noted.
    Brain activity (electroencephalogram, or EEG):
  132. Slow eye movements are present at the start of sleep and change to rapid eye movements during REM sleep.
    Eye movement (electrooculogram, or EOG):
  133. No leg jerking or other abnormal muscle movement is present.
    Muscle movement (electromyogram, or EMG):
  134. Blood O2 level is greater than 90%.
    Blood oxygen (O2) level:
  135. Heart rate and rhythm are normal. No heart rate changes (arrhythmias)-such as an abnormally slow or fast heart rate-are noted.
    Heart rate and rhythm (EKG, ECG):
  136. Reduced air flow (hypopnea) or no air flow (apnea) to the lungs occurs fewer than 5 times in 1 hour.
    Breathing effort (respiratory disturbance index, or RDI):
  137. chest and abdomen move normally throughout the study.
    Chest and abdominal movements
  138. Sleep is restful and not disturbed. Night terrors, sleepwalking, and sleep talking do not occur.
    Audio and video recordings:
  139. Excessive snoring or abnormal snoring patterns are not present.
    Snoring monitor:
  140. Airflow through the mouth and nose is not blocked.
    Airflow monitors:
  141. Objective measure of daytime sleepiness
    Sleep Studies – Multiple sleep latency test (MSLT)
  142. Patient given 4-5 opportunities to nap at 2 hour intervals during the day; Each time, patient is asked to lie down and nap in appropriate environment – measurements taken – EEG, eye movements, muscle tone.
    Sleep Studies – Multiple sleep latency test (MSLT)
  143. Time from wakefulness to sleep onset is measured to determine
    “sleep latency”.
  144. REM sleep presence during > 2 of the naps is consistent with
  145. Taking 10 to 20 minutes to fall asleep in MSLT
    is normal.
  146. 5 minutes or less is to fall asleep in MSLT
    severe daytime sleepiness.
  147. Patients recline in quiet, darkened room. Try to stay awake as long as possible. Variant of MSLT
    Maintenance of wakefulness test (MWT)
  148. Likely to be performed in the primary care/prenatal setting
    Risk assessment for common conditions
  149. Increasingly performed in primary care/prenatal setting
    Screening and testing for genetic conditions
  150. Most carrier test are for
    autosomal recessive conditions (some X-linked)
  151. Typically carriers of autosomal recessive conditions
    do not have symptoms of the condition
  152. Particular genetic carrier tests offered to everyone in the general population
    Population-based screening
  153. Carrier screening limited to particular groups of people determined to be at higher risk for specific genetic disorders; e.g. ethnicity-based screening
    Targeted population based screening
  154. Purpose: To detect couples at risk for prenatally diagnosable genetic disease
    Ethnic-Based Genetic Carrier Screening
  155. Type of testing offered based on clients’ ethnic background
    Ethnic-Based Genetic Carrier Screening
  156. Offered to all individuals of that ethnic background (targeted population screening)
    Ethnic-Based Genetic Carrier Screening
  157. Should be offered to patients: Seeking preconception counseling, OR Seeking infertility care, OR During the first or early second trimester of pregnancy
    Principles of Carrier Screening
  158. Depends on gestational age; If early in pregnancy, can do sequential screening; Concurrent testing is an options later in pregnancy
    Screening during pregnancy:
  159. Counseling before screening should include
    Informed Consent
  160. Patients brochures about CF and other ethnicity- based genetic screening available from multiple sources
    Utilize patient resource materials
  161. informed consent discussion and patient’s decision
  162. Carrier Screening is
  163. Patient education/informed decision-making is
  164. Most tests detect a majority, but
    not all carriers
  165. is available and advised for carriers and carrier/carrier couples
    Genetic counseling
  166. Chronic lung disease with GI malabsorption
    Cystic Fibrosis
  167. Incidence in 1 in 2500 – 1 in 3300 in Caucasian and Ashkenazi Jewish Population
    Cystic Fibrosis
  168. Age of onset typically early childhood. Variable symptoms: Life expectancy 20 -35 years. Non-classical forms exist.
    Cystic Fibrosis
  169. Treatment: daily respiratory therapy, digestive enzymes, medication to promote lung function
    Cystic Fibrosis
  170. encodes a protein called the transmembrane conductance regulator; Autosomal recessive; >1000 genes identified
    CFTR gene
  171. CF Located on q arm of
    chromosome 7
  172. most common mutation in Caucasian population in CF
    Delta F508 gene
  173. As of 2010, all states are required by legislation to include CF screening on the newborn screening panel
    Typically done by Immunoreactive Trypsinogen (IRT) levels.
  174. as a mild manifestation of CF
    Congenital absence of the vas deferens (CAVD)
  175. The risk of the fetus having CF if both are carriers is
  176. to determine the status of the fetus
  177. The risk of the fetus having CF if one is a carrier and the other has a negative screen is
    1/824 (may vary by lab)
  178. The risk of the fetus having CF if both have negative screen results is
    1/170,000 (may vary by lab)
  179. Major manifestations: Chronic bronchopulmonary infection; Malabsorption; High sweat chloride; Infertility
  180. Autosomal recessive disorder, CF Gene is located on long arm of
    chromosome 7
  181. is most common mutation in CF
    Delta F 508
  182. cystic fibrosis transmembrane conductance regulator (CFTR) . CFTR also may regulate activity of other Cl and Na channels, so In airways, hyperabsorption of Na, and decreased Cl secretion
    Defect in c-Amp mediated chloride channel:
  183. Hydrate epithelial surfaces; Bind and clear bacteria; Detoxify and clear particulates
    Functions of Normal Airway Mucus and Mucociliary Clearance
  184. Protect against oxidants and proteases; Important element of the Innate Immune System in the lungs
    Functions of Normal Airway Mucus and Mucociliary Clearance
  185. Is a Key Component of Normal
    • Lung Defense, Depends on Adequate Surface Liquid Volume, and Is Defective in Cystic Fibrosis
    • Mucus Clearance
  186. Albuterol
    ProAir HFA, Proventil HFA, Ventolin HFA
  187. Levalbuterol
    Xopenex HFA
  188. Formoterol
  189. Salmeterol
  190. Ipratropium
    Atrovent HFA
  191. Tiotropium
  192. Albuterol/ipratropium
  193. Cromolyn sodium
  194. Beclomethasone
    Beconase AQ, QVAR
  195. Budesonide
    Rhinocort Aqua, Pulmicort Respules
  196. Flunisolide
  197. Fluticasone
    Flovent HFA, Veramyst
  198. Mometasone
    Nasonex, Asmanex
  199. Triamcinolone
    Nasacort AQ
  200. Fluticasone - Salmeterol
    Advair Diskus
  201. Budesonide - Formoterol
  202. Theophylline
    Uniphyl (oral)
  203. Montelukast
    Singulair (oral)
  204. Zafirlukast
    Accolate (oral)
  205. Zileuton
    Zyflo (oral)
  206. Isoproterenol
    Isuprel (injection)
  207. Omalizumab
    Xolair (injection)
  208. Class: Albuterol
  209. Class: Levalbuterol
  210. Class: Formoterol
  211. Class: Salmeterol
  212. Class: Ipratropium
    Anticholinergic, SHORT acting
  213. Class: Tiotropium
    Anticholinergic, LONG acting
  214. Class: Albuterol/ipratropium
    β-2 agonist-Anticholinergic
  215. Class: Cromolyn sodium
    Mast-cell stabilizer
  216. Class: Beclomethasone
  217. Class: Budesonide
  218. Class: Flunisolide
  219. Class: Fluticasone
  220. Class: Mometasone
  221. Class: Triamcinolone
  222. Class: Fluticasone - Salmeterol
    LABA / Corticosteroid
  223. Class: Budesonide - Formoterol
    LABA / Corticosteroid
  224. Class: Theophylline
    Methylxanthine (oral)
  225. Class: Montelukast
    Leukotriene modifier (oral)
  226. Class: Zafirlukast
    Leukotriene modifier (oral)
  227. Class: Zileuton
    Leukotriene modifier (oral)
  228. Class: Isoproterenol
    SABA (injection)
  229. Class: Omalizumab
    Immunomodulator (injection)
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Pulmonology 7
Pulmonology flashcards made by previous students.
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