Pulmonology

Upper Respiratory Infection (URI)

Acute bronchitis

Allergic Bronchopulmonary Aspergillosis (ABPA)

• Dx:
  • – Aspergillus skin testing
    
  • – Measurement of IgE levels, circulating precipitins, and A. fumigatus-specific antibodies.
• Tx:
  • corticosteroids and, in
  • patients with refractory disease: itraconazole.

ARDS

• Dx:
  • – CXR: This shows diffuse patchy infiltrates that become confluent. May suggest CHF.
    
  • – Normal wedge pressure
    
  • – pO2/FIO2 ratio < 200, with the FIO2 expressed as a decimal (e.g., room air is 0.21). For example, if the pO2 is 100/0.21, the ratio is 476.
• Tx:
  • – Ventilatory support with low tidal volume of 6 mL/kg
  • – PEEP to keep the alveoli open
  • – Prone positioning of the patient’s body
  • – Possible use of diuretics and positive inotropes, such as dobutamine
  • – Transfer the patient to the ICU if not already there
  • – Steroids are NOT effective in cases of ARDS.

Asthma

• Path:
  • 1. chronic airway inflammation
    
  • 2. mucus hypersecretion
    
  • 3. intermittent and reversible airway obstruction from smooth muscle contraction (physical obstruction of bronchiole)
    
  • 4. bronchial hyperresponsiveness (more responsive to triggers, allergins, smoke)
• Triggers:
  • URI
    
  • exercise
    
  • weather (cold)
    
  • stress
    
  • irritant exposures (smoke, pet, mold)
    
  • meds (BB, ASA, NSAIDs)
• Classification:
  • intermittent – symptoms < 2/wk; @night <2/mo, asymptomatic and normal PEF blw excerbations
  • mild persistent – symptoms > 2/wk, but < 1/day; @ night > 2/mo
  • mod persistent – need daily SABA; @night >1/wk, acute exacerbation > 2/wk
  • severe persistent – continual symptoms that limit physical activity; @ night – frequent
• Dx:
  • Spirometry:
    • FEV1 < 80%
      
    • FEV1/FVC normal or decreased relative to predicted values (70-85%) (usually decreased)
      
    • reversibility of 12% or more (8% or more in young kids) in FEV1 with bronchodilator
• Treatment:
  • Step 1 – intermittent: select SABA PRN
    
    • Albuterol, ( Provent, ProAir )
    • Levalbuterol (Xopenex) or Pirbuterol (Maxamir)
  • Step 2 – mild persistent: + low dose inhaled corticosteroid
    • fluticasone, budesonide
      
    • Ciclesonide (MDI (ALVESCO)
      
    • Beclomethasone dipropionate
  • Step 3 – moderate-persistent: +High dose inhaled corticosteroid + LABA 
    
    • Salmeterol, Formoterol, or Arformoterol
    • Fluticasone/ Salmeterol: Advair
      
    • Budesonide/ Formoterol: Symbicort
  • Step 4 – Severe persistant: 

Bronchiectasis

• Dx:
  • Initial: CXR – shows dilated bronchi with “tram tracking,” which are parallel lines consistent with dilated bronchi.
  • Most accurate: high-resolution CT scan of the chest
• Tx:
  • There is no curative therapy. Treat the infectious episodes as they occur.

COPD

• Lowers Mortality:
  • 1 – Smoking cessation
    
  • 2 – Home oxygen therapy (continuous)
• Chronic Therapy:
  • – Tiotropium or ipratropium inhaler
  • – Albuterol inhaler
  • – Pneumococcal vaccine: Heptavalent vaccine, Pneumovax
  • – Influenza vaccine: Yearly. Inactivated injections only.
  • – Smoking cessation (IMPROVES SURVIVAL)
  • – Long-term home oxygen if the pO2 < 55 or the oxygen saturation is < 88 % (IMPROVES SURVIVAL)
  • – Pulm rehab: improves the quality of life but NOT a survival
  • – consider roflumilast (PDE-4 inhibitor) for severe COPD NOT responding to 1st line Rx

DVT/PE

• Risk Factors:
  • – Immobility
    
  • – Malignancy
    
  • – Trauma
    
  • – Surgery, especially joint replacement
    
  • – Thrombophilia, such a factor V mutation, lupus anticoagulant, or protein C and S deficiency
    
  • There are no specific physical findings for PE.
• Dx:
  • Wells Score for DVT and PE:
    • – low risk < 2pts
      
    • – intermediate 2 to 6 pts
      
    • – high risk > 6pts
      ————————————-
      
    • – PE unlikely 0-4pts
      
    • – PE likely > 4pts
  • After calculating pretest probability (using Wells) of “low probability”, next step:
    • Order D-dimer (stop evaluation if negative for VTE diseases i.e. DVT, PE)
      
    • The best use of D-dimer testing is in a patient with a low probability of PE in whom you want a single test to exclude PE.
    • (D-dimers = Plasmin chopped up fresh clot)
  • After calculating pretest probability (using Wells) of “intermediate probability”, next step:
    • PE –> CT angio (stop evaluation if normal)
      
    • DVT –> duplex doppler (stop evaluation if normal)
  • After calculating pretest probability (using Wells) of “high probability”, next step:
    • PE –> begin empiric Rx, order CT (if neg –> duplex)
      
    • DVT –> begin empiric Rx, confirm Dx w/ doppler on legs
  • Notes:
    • – Normal SpO2 or PaO2 DOES NOT r/o PE
      
    • – Normal D-dimer DOES NOT exclude DVT or PE in a Pt w/ high pretest probability of DVT or PE:
  • If the CXR is ABnormal in a pt with suspected PE, what is next best test to do:
    • The CT angiogram is clearly the test of choice if the x-ray is abnormal.
  • For a V/Q scan to be accurate, the chest x-ray must be Normal
    • The less normal the x-ray, the less accurate the V/Q scan.
    • This is still a good test for PE. The problem is that only a truly normal scan excludes a PE.
• Types of VTE therapy and their indications/contraindications:
  • – SQ LMWH –> AVOID in severe renal failure
  • – SQ Fondaparinus –> AVOID in severe renal failure
  • – IV UFN (2nd line): most useful in hemodynamically UNstable pts; pts w/ renal failure
  • – New oral anticoagulants (NOAC) monoRX (e.g. rivaroxaban or apixaban) –> AVOID BMI > 40, eGFR < 30ml/min/1.7 m2
  • – warfarin–> INR of 2-3; overlap 4-5 days w/ parenteral anticoagulants; 2 therapeutic INR measurements 24 apart
  • – LMWH for 2° prevention of VTE in Pts w/ cancer
  • – IV or catheter-directed thrombolysis for massive iliofemoral DVT and risk of limb loss
  • – IV thrombolytic Rx for PE: shock or cardiac arrest; PE assoc. w/ ↓BP and no contraindications
  • – embolectomy: massive PE and shock when anticoagulant or thrombolytic Rx is unsuccessful or contraindicated
  • – IVC filter: unstable PE and strong contraindications to anticoagulation.

Influenza

Pertussis

Pleuritis

Pleural Effusion

• Dx:
  • Initial:
    • Chest x-ray.
      
    • Decubitus films with the patient lying on one side should be done next to see if the fluid is freely flowing.
      
    • Chest CT may add a little more detail to a chest x-ray.
  • Most Accurate: Thoracentesis
    • Order the following tests on pleural fluid:
      • — Gram stain and culture
        
      • — Acid-fast stain
        
      • — Total pleural protein
        
      • — serum protein
        
      • — pleural LDH
        
      • — serum LDH
        
      • — Glucose
        
      • — Cell count w/differential
        
      • — Triglycerides
        
      • — pH
    • EXUDATE:
      • Features:
        • – Quality: cloudy/serosanquinous
          
        • – Protein level HIGH (> 50% of serum level; >3g/dl)
          
        • – LDH level HIGH (> 60% of serum level; >200 IU/L; ratio > 0.6)
          
        • – pH < 7.2
          
        • – glucose < 60 mg/dl
          
        • – WBC/diff: > 1000/ml (thoracocentesis); >50% lymph-TB
          
        • – clotting: present
      • 3 important parameters for EXUDATE pleural effusion fluid:
        • pleural fluid protein/serum protein ratio > 0.5
          
        • pleural fluid LDH > 200 IU/L or 2/3rds ULN
          
        • pleural fluid LDH/serum LDH ration > 0.6
    • TRANSUDATE:
      • Etiology of TRANSUDATE pleural effusion fluid:
        • ↑ hydrostatic pressure (HF, constrictive pericarditis, SVC obstruction)
          
        • ↓ Oncotic pressure (hypoalbuminemia, nephrotic synd, cirrhosis, malnutrition)
      • Features:
        • – Quality: serous
          
        • – Protein level LOW (< 50% of serum level; <3g/dl)
          
        • – LDH level LOW (< 60% of serum level; <200 IU/L; ratio < 0.6)
          
        • – pH > 7.2
          
        • – glucose –> equal to serum
          
        • – WBC/diff: < 200/uL (thoracocentesis); mononuclear
          
        • – clotting: none
    • Effusions that DO NOT NEED to be aspirated:
      • Small effusions (<1 cm) assoc. w/ HF, pneumonia, or heart surgery
• DDx of pleural effusion:
  • Transudate
    
    • – CHF (MCC)
      
    • – liver cirrhosis
      
    • – nephrotic syndrome
      
  • Exudate
    
    • – TB
      
    • – malignancy (the yield for + cytology is max after 2 thoracocentesis)
      
    • – PE
      
    • – parapneumonic (pneumonia, lung abscess, bronchoectasis)
• Tx:
  • – Small pleural effusions: do not need therapy. Diuretics can be used, especially for those caused by CHF.
  • – For larger effusions: especially those caused by infection (empyema), a chest tube for drainage is placed.
  • – If the effusion is large and recurrent from a cause that cannot be corrected, pleurodesis is performed.

Pneumonia

Ventilator-associated pneumonia (VAP)

• Px:
  • •• Fever
    
  • •• Hypoxia
    
  • •• New infiltrate
    
  • •• Increasing secretions
• Tx:
  • – Imipenem or meropenem, piperacillin/tazobactam or cefepime;
    
  • – Gentamicin; and
    
  • – Vancomycin or linezolid

Pulmonary HTN

• Dx:
  • Initial:
    • TTE – Shows RV hypertrophy and enlarged RA
      
    • EKG: Shows the same findings as well as right axis deviation
  • Most Accurate:
    • Right heart catheterization (Swan-Ganz catheterization) with increased pulmonary artery pressure

Sarcoidosis

• Px:
  • African-American woman < 40 with cough, SOB, and fatigue over a few weeks to months. P/E shows rales. Although sarcoidosis can involve many organs, the vast majority of cases present with lung findings only.
• Dx:
  • Initial: CXR – which always shows enlarged lymph nodes (bilateral hilar adenopathy, reticular opacities). There may be interstitial lung disease in addition to the nodal involvement.
  • Most accurate: Lung or LN Bx showing noncaseating granulomas
  • Other tests:
    • – Ca++ and ACE levels may be elevated, but these are not specific enough to lead to a specific diagnosis.
      
    • – BAL shows increased numbers of helper cells.
• Tx:
  • Steroids are the undisputed best therapy

Sleep Apnea

• Types:
  • 1- The majority (95%) of cases are obstructive sleep apnea (OSA) from fatty tissues of the neck blocking breathing.
  • 2 – A small number of patients will have CENTRAL sleep apnea, which is ↓ a respiratory drive from the central nervous system.
    
  • Severe sleep apnea is defined as > 30 apneic periods an hour.
• Tx:
  • OSA
    • – weight loss and CPAP or BiPAP.
    • – If this is not effective, surgical resection of the uvula, palate, and pharynx can be performed.
  • Central SA
    • – avoiding alcohol and sedatives.
    • – may respond to acetazolamide, which causes metabolic acidosis. This may help drive respiration.
    • – Some patients respond to medroxyprogesterone, which is also a central respiratory stimulant.

Tuberculosis

• Px:
  • Active TB:
    
    • (+) fever
    • cough > 3 weeks
    • hemoptysis
    • night sweats
    • weight loss
    • fatigue
• Path:
  • Mycoplasma
  • tuberculosis
• Dx:
  • PPD
  • CXR
  • Acid-fast stain
  • Interferon-gamma release assay (IGRA) (Quantiferon):
    • IGRA is an in-vitro blood test that is used for the detection of latent TB.
    • The indication for an IGRA is the same as for a PPD.
    • The main difference is that the IGRA is more specific than a PPD.
    • There are no false positives on an IGRA with previous BCG infection.
    • IGRAs have a 90 percent sensitivity for previous TB exposure.
    • A positive test is treated with INH alone.
    • A positive IGRA does not mean active infection.
    • As with a PPD, a positive IGRA confers only a 10% lifetime risk of TB.
• Tx:
  • Once the acid-fast stain is +, Rx with 4 anti-TB Rx should be started.
  • Six months of therapy is the standard of care. “RIPE”
    
    • 1. Rifampin: 6 months
      
    • 2. Isoniazid (INH): 6 months
      
    • 3. Pyrazinamide: Stop after 2 months
      
    • 4. Ethambutol: Stop after 2 months
• Specific toxicities of anti-TB drugs:
  • – Rifampin: Red/orange-colored bodily secretions
    
  • – Isoniazid: Peripheral neuropathy
    
  • – Pyrazinamide: Hyperuricemia
    
  • – Ethambutol: Optic neuritis
    
  • All of these meds can lead to liver toxicity. TB medications should be stopped if the transaminases reach 5x the UL of normal.
• Require anti-TB Rx > 6 months:
  • ·· Osteomyelitis
    
  • ·· Meningitis
    
  • ·· Miliary tuberculosis
    
  • ·· Cavitary tuberculosis
    
  • ·· Pregnancy