Pulmonary (copy)

Acute Bronchiolitis

Acute Bronchiolitis

-Inflammation of the bronchioles, usu. occurs in children <2yrs.

Etiology:

• RSV = Most common cause

• Infants 2 months - 2 yrs = MOST at risk.

Clinical manifestations:

• Viral prodrome (URI) for 1-2days followed by resp. distress. (Wheezing, tachypnea, nasal flaring, cyanosis)

• Signs of severity: Hypoxemia, apnea, resp. failure.

Dx: Clinical.

• CXR nonspecific, Pulse oximetry = single best predictor.

Management:

• Supportive measures = mainstay of treatment. (Humidified O2, IV fluids)

• Mech. ventilation may be indicated

• Corticosteroids NOT indicated unless hx of underlying reactive airway.

Prevention:

• Palivizumab

• Handwashing

Acute/Chronic Bronchitis

Acute: Cough >5 days; can last 1-3wks.

• Sx: Fever is unusual. MC is viral

  • Bacterial → M. catarrhalis

• Dx: CXR

• Tx: symptomatic/supportive

  • Hydration, B2 agonist, expectorant

• abx → elderly, underlying dz, cough >7-10 days

Chronic:

• Results from enlargement of mucus glands and goblet cell hypertrophy in large airway (>3 months!)

• Tx:

  • Acute exacerbation: O2, beta-agonist, steroids

  • Chronic: Smoking cessation = best

Asthma

-Chronic inflammatory disease of the airways characterized by persistent variable symptoms that include dyspnea, cough, and wheezing.

-Most common chronic lung disease in the US. (COPD most common in the world)

-More common in women and children and poor

-Environmental factors and genetic factors.

Pathophysiology:

1. Bronchospasm (Hyperreactivity)

2. Bronchial wall edema (bronchoconstriction)

3. Increased mucus secretion (inflammation)

-T2-High → allergic (Allergens)

-T2-Low → non-allergic (meds, stress, exercise, GERD)

Risk factors:

• Atopy = Strongest risk factor

• Samter’s triad: (Aspirin-exacerbated resp. disease)

  • Asthma + Chronic rhinosinusitis w/ nasal polyps + Sensitivity to Aspirin/NSAIDs

• Atopic Triad: Asthma, Atopic disease, Allergies

Clinical Manifestations of Asthma

Symptoms:

• Classic Triad (Esp. @ night)

  • Dyspnea, Cough, wheezing

-PE: Prolonged expiration w/ wheezing, hyperresonance to percussion.

• Severe asthma & Status asthmatics: inability to speak in full sentences, “tripod” positioning. Silent chest.

• Altered mental status = ominous.

Dx: Made in office

• Pulmonary Function test → Methacholine challenge (>20% decrease in FEV1) followed by bronchodilator (increase of FEV1 by 12%)

Dx Criteria of Asthma severity

Components:

• Daytime symptoms > 2x week

• Nighttime awakenings due to asthma

• Interference with normal activity

• Reliever meds needed >2x per week

-Apparently mild Asthma (well controlled) → meets none of the above.

-Moderate Asthma (Partly-controlled) → 1-2 components within the last 4 weeks

-Severe Asthma (Not controlled) → 3-4 components within the last 4 weeks.

-Life-threatening →

• Exhausted

• Cyanotic

• Pulse ox. < 90% (severe under 94%)

• Absent breath sounds

• Accessory muscle use/tripod position

General Line of Treatment for Asthma

1.) Long-term controller

• Reduce airway inflammation, symptoms, and risk of exacerbation

• Inhaled corticosteroids (foundation of treatment)

2.) Reliever

• Used PRN to relieve breakthrough symptoms

• SABAs (albuterol)

• Low-dose ICS-formoterol (LABA)

3.) Add-on therapies

• For severe asthma

• Systemic corticosteroids

• Anticholinergics

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Max doses:

Budesonide-formoterol (Symbicort)→ 12 for adults, 8 for children.

Beclometasone-formoterol (Fostair)→ 8 for everyone.

Steps 1-2

-Symptoms less than 4-5 days a week

-Take 1 puff low dose ICS-formoterol PRN

+rescue inhaler

Step 3

-Symptoms most days, or waking with asthma once a week or more.

-Take 1 puff low dose maintenance ICS-formoterol 2x/day + 1 puff inhalation PRN

+rescue inhaler (low dose ICS-formoterol)

Step 4

-Daily symptoms, or waking with asthma once a week or more, AND low lung function.

-Take 2 puffs 2x daily + 1 puff PRN

+Rescue inhaler (low dose ICS-formoterol PRN)

Step 5

Step 4 +

• Add-on LAMA

• Refer for assessment of phenotype

• Consider High dose maintenance ICS-formoterol + antibodies

Cystic Fibrosis

-Autosomal Recessive trait → abnormal mucus production → obstruction of glands and ducts

Patho:

• CTFR gene mutation → abnormal chloride & water transport → thick, viscous secretions.

Clinical Manifestations

• Infancy: Meconium ileus, failure to thrive, diarrhea from malabsorption.

• Pulmonary: Most common cause of Bronchiectasis.

• GI: Malabsorption → fatty stools, foul smelling.

Dx:

• Elevated Tripsinogen in neonatal screening = Red flag.

• Elevated Sweat chloride = Test of Choice (most accurate)

  • NaCL 60mmol/L or greater on 2 occasions after Pilocarpine administration.

  • Pulmonary function test → obstructive pattern. (irreversible)

Cystic Fibrosis Management

Management:

• Abx are often needed: Macrolides, Cephalosporins….(all broad spectrum)

• Airway clearance treatment

• Supportive (Pancreatic enzymes, fat-soluble vits., vaccinations.)

General measures:

• Mean survival is 47yrs

• First few years of life → resp infx from staph and H. flu

  • P. aeruginosa = major cause of infection after first years of life.

Foreign Body Aspiration

-Peanuts are MC FB aspirated in children

• MC age is 2yrs, MC cause of death is hypoxic brain injury.

-Most common on the right side (position may influence locations:

• Supine → MC in sup. segment of right lower lobe

• Sitting/standing: MC in posterobasal of RLL

• Lying on right side → MC in right/middle lobe or Post. seg. of RUL.

Clinical Manifestations:

• Sudden onset of choking, cough, and dyspnea.

• Wheezing or asymmetric breath sounds.

  • Inspiratory stridor if FB is high in airway

  • Wheezing & decreased breath sounds if in low airway.

Dx: CXR or CT (air trapping MC finding)

• Right bronchoscopy = definitive dx. (also therapeutic)

Management:

• Rigid Bronchoscopy → removal of FB

  • Thoracotomy if refractory

• Emergency → Heimlich maneuver

  • Tracheostomy if unsuccessful

Hyaline Membrane Disease

(Resp. distress syndrome)

-Atelectasis & pulm. perfusion w/o ventilation d/t insufficiency of surfactant production by an immature lung.

Patho:

• Lack of surfactant production (if born before 35wks = very high risk)

  • Airways collapse => struggle to breath until MOD and death

• MC single cause of death in 1st month of life.

Risk factors:

• Caucasians, Males, Multiple births, maternal diabetes.

Clinical Manifestations: Present @ birth (tachypnea, chest wall retractions, expiratory grunting, nasal flaring, cyanosis.

Dx: CXR → bilateral reticular atelectassi (ground glass appearance) + air ronchograms

• ABG → hypoxia

Management:

• Exogenous surfactant via endotracheal tube + Mechanical Vent (CPAP)

  • This opens up the alveoli

Prevention:

• Antanatal glucocorticoids given to mature lungs if premature birth suspected (24-36 wks.)

Croup (Laryngotracheitis)

Etiology: MCC = parainfluenza type 1, RSV, Adenovirus, and Rhinovirus

• MC between 6months-6 years, esp in fall/winter

Clinical Manifestation:

• Upper airway involvement: Harsh “seal-like barking cough” = Hallmark of disease

  • Inspiratory stridor, hoarseness in older children.

• URI symptoms

Dx: Clinical diagnosis (once epiglottitis & FB aspiration are excluded)

• Frontal cervical radiograph: Steeple sign (subglottic narrowing of the airway)

Management:

• Mild (no stridor @ rest, no resp. distress)

  • Supportive care (cool humidified air), Dexamethasone/Prednisone

• Moderate (Stridor @ rest, mild/mod retractions)

  • Dexamethasone or PRednisone

  • nebulized epi (racemic epi)

• Severe (Stridor @ rest, marked retractions)

  • Dexamethasone + nebulized epi and Hospitalization

Hemoptysis

MC causes:

• Bronchitis (50%)

  • Hemoptysis, dry cough, cough w/ phlegm

• Tumor mass (20%)

  • Hemoptysis, chest pain, rib pain, smoking hx, wt. loss, clubbing

• TB (8%)

  • Hemoptysis, chest pain, sweating

• Other

Pulmonary Nodules

<3cm = Nodule, >3cm = Mass

-Typically incidental findings, if found get CT (best imaging)

• Suspicious → biposy

• Not suspicious → monitor @ 3mo, 6mo, then yearly.

  • smooth, calcifications, not in upper lobe

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Carcinoid tumors:

• Most pt. have a centrally located tumor that are symptomatic (wheezing, cough, hemoptysis…)

• Carcinoid syndrome:

  • Diarrhea (Serotonin release), flushing, tachy, wheezing, hypotension.

• DX: Chest CT and bronchoscopy (pink/purple well vasc. central tumor)

• TX:

  • Surgicla = definitive

  • Octreotide = symptom management.

Pleural Effusion

Pathologic accumulation of fluid

Transudate effusions: (CHF (MC), nephrotic syndrome, Cirrhosis)

• Increased hydrostatic pressure

• Decreased oncotic pressure

Exudate effusions: (increased capillary perm.)

• any condition assoc. w/ Infection or inflammation.

Clinical presentation:

• Dullness to percussion, decreased fremitus, decreased breath sounds

Dx:

• Xray → inital test of choice (lateral decubitus = best postion)

  • Blunting of costophrenic angles (Menisci sign)

• Thoracentesis = dx standard

  • Light’s criteria: exudate present if any of three are present

    • Pleural fluid protein (>0.5)

    • Pleural fluid LDH (>0.6)

    • Pleural fluid LDH >2/3 normal limit.

• CT scan or U/S = mrore accurate than lateral decubitus.

Tx:

• Treat underlying disease = mainstay

• Chest tube fluid drainage if empyema

Pneumothorax

-Accumulation of air in the pleural space, leading to lung collapse from the positive pressure.

Types:

• Primary spontaneous → atraumatic and idiopathy

• Secondary spont. → underlying disease (COPD/Asthma)

• Tension → Any type in which positive air pressure pushes the trachea, great vessels, &/or heart to the contralateral side.

Sx: sudden onset dyspnea & chest pain (usu. pleuritic, ipsilateral, unilateral, non-exertional.

PE:

• Air: Hyperresonant, decreased fremitus and breath sounds.

• Tension: Increased JVP, systemic hypotension, pulsus paradoxus.

Dx: Chest XR → initial test of choice (expiratory upright)

Management:

• Small PSP (<3cm from chest wall):

  • Small & first episode: Obsv. for 4-6hrs if pt. is reliable

• Large PSP:

  • Needle aspiration (chest tube if fails)

• Stable, Secondary PT:

  • Chest tube placement (tube thoracostomy) and hospitalization.

• Tension PT:

  • Needle aspiration followed by chest tube thoracostomy

    • VATS if a persistent leak or no regression

Pt. Ed: Avoid pressure changes for a minimum of 2 weeks.

Pulmonary Embolism

-70% arise from DVT

-Virhcow’s triad

Clinical Manifestations:

• Sudden onset dyspnea (MC) followed by pleuritic chest pain and cough (sometimes hemoptysis)

Dx:

• CXR: Westermark sign (sharp cut-off of pulm. vessels, Hampton’s hump (wedge-shaped, pleural-based opacity at periphery of lung)

• ECG: S1Q3T3 pattern not common but most specific for PE.

• D-Dimer, ABG, Well’s criteria

• Pulmonary angiography = Gold standard

Tx: (anticoag should continue for at least 3 months.)

• Anticoagulation = mainstay of treatment.

  • IV heparin then switch to oral after 5 days.

  • Oral monotherapy (Rivaroxaban or Apixaban) (preferred to warfarin for prophylaxis)

  • IV heparin “bridged” to warfarin.

• IVC filter

  • For those who fail anticoagulation or it is contraindicated in.

• Unstable → Thrombolytic therapy or embolectomy

• Pregnant/malignancy → LMWH

RSV

MCC of lower resp. tract infection in children. MCC of pneumonia and bronchiolitis.

• Sx of viral infection

Dx: RSV test or CXR shows diffuse bilateral infiltrates.

Tx: Supportive (should resolve in 5-7 days)

• Hospitalize → Tachypnea w/ feeding, Visible retractions, decreased O2

• Vaccine for children w/ lung issues or premature/immunocom.

TB

Sx: Fever, night sweats, wt. loss

Dx:

• >5mm: + for high risk pts.

  • CXR w/ evident findings, HIV, steroids daily, contact w/ infectious pt.

• >10mm: Some risk factors

  • IVDU, recent immigrants, renal dz, prison/homeless, diabetes, head/neck cancer, GI bypass surgery.

• >15mm: no risk factors

Tx:

• PPD+ and CXR negative = latent → Isonazide x9mo

• PPD+ and CXR+ = Active. → quad therapy

  • RIPE x8 wks, RI x 16wks

  • Rifampin: Orange body fluids, hepatitis

  • Isoniazid: Peripheral neuropathy (B6 to help)

  • Pyrazinamide: Gout (hyperuricemia)

  • Ethambutol: Optic neuritis, red-grn color blindness.