PULMONARY TIDBITS

 

COUGH

  1. PNDS, asthma, GERD, chronic bronchitis, bronchiectasis, ACEI, post-infectious account for 98% of chronic cough
  2. In GERD cough, 75% have no GI sxs

 

HEMOPTYSIS

  1. Causes:
    1. ALL: bronchitis 37%, ca 19%, TB 7%, pneumonia 5%, bronchiectasis 1%
    2. >200cc/d: ca 36%, bronchiectasis/bronchitis 28%, CF 7%, anticoagulation 7%, TB 5%
    3. HIV: pneumonia 70%, KS 12%, bronchiectasis 5%, PE 5%, bronchitis 3%, endocarditis 3%, ca 3%
    4. >600cc/d: ca, TB, bronchiectasis, abcess/infection
  2. Bronchial arteries cause >90%
  3. TA fistula rare before 48h, 72% occur in first 21d
  4. FOB dxs site of bleeding 93% if performed in first 24h, 51% after
  5. Angiography dxs site 90-93% but only 4% with negative FOB
  6. Surgery: any pt for whom surg is definitive rx or bleeds >1L/d despite conservative rx.

 

DYSPNEA

  1. Chronic- 75% respiratory, 2/3 explained by 4 causes: COPD, asthma, ILD, CMP
  2. Helpful tests:

Test

Dx

NPV%

methacholine

asthma

100

spirometry

COPD

100

DLCO

ILD

95

CXR

all

91

 

ALTITUDE

  1. 8000ft: PIO2=118
    1. Regression eq: PaO2alt = .453 PaO2sea + .386(FEV1 %pred + 2.44)
    2. Measure in lab, if <50 give suppl O2
  2. Acute Mountain Sickness-
    1. HA, malaise, N/V, anorexia, dyspnea, insomnia;
    2. >7000-15000ft
    3. Px: acetazolamide 1-2d prior and 48h after ascent
    4. Rx: dexamethasone, descent, O2
  3. High Altititude Pulmonary Edema
    1. 2-4d post ascent
    2. Dyspnea, cough, fatigue, delta MS
    3. 60% recurrence
    4. Px: nifedipine
    5. Rx: O2, descent
  4. High Altitude Cerebral Edema
    1. Rx: O2, descent, ?dexamethasone

 

ACUTE CHEST SYNDROME

  1. Leading cause of death in sickle cell disease
  2. Causes: fat embolism, microvascular occlusion, pneumonia (chlamydia, mycoplasma, viral), thoracic bone infarction
  3. Rx: pain control, hydration, O2, abx, PRBC, incentive spirometry

 

RADIATION

  1. Dose dependent- <30Gy well tolerated, >50Gy nearly always causes symptomatic lung injury
  2. Radiation pneumonitis- latent period up to 6mos, Rx: steroids
  3. Radiation fibrosis- presents 6mos-2yrs post rx

 

WEGNER’S GRANULOMATOSUS

  1. Pulm manifestations: BOOP, DAH/capillaritis, eosinophilic infiltrates
  2. Dx criteria (88% sens, 92% spec): nasal/oral inflammation, abn CXR, abn Ur sed, hempotysis OR granulomas on bx
  3. cANCA- 81% sens, 98% specific
  4. Rx: steroids + cytoxan (>90% remission)
  5. Px: Bactrim (160/800 QD) decreases relapse rate 40% à 18%

 

CHURG-STRAUSS

  1. >4 of: 1) asthma, 2) eos >10%, 3) mono/polyneuropathy, 4) non-fixed pulm infiltrates, 5) paranasal sinus abn, 6) extravascular eos (85% sens, 100% spec)

 

LUNG TRANSPLANT

  1. Disease-specific criteria
    1. COPD: FEV1 <25% or PCO2 >55 or cor pulmonale- *no survival benefit
    2. IPF: symptoms not responding to rx or VC <60-70% or DL <50-60% or desaturation
    3. CF: FEV1 <30% or PO2 <55 or PCO2>50
    4. PPH: NYHA III or IV, or PAmean >55 or CI <2 or RA >15

 

NON-TUBERCULOUS MYCOBACTERIA

1.                  Most common isolates: 1) MAC, 2) kansasii, 3) fortuitum et al

2.                  Patterns of disease: 1) upper lobe (mimics MTB), 2) bronchiectasis, 3) Lady Windermere’s syndrome

3.                  Criteria for dx: infiltrate, nodules, or cavitary dz PLUS:

a.      3 cxs OR 2 cxs and 1 smear

b.      1 cx with 2-4+ growth OR 4+ smear

c.      1 cx PLUS consistent pathology (granulomas or AFB)