Hy Kaplan Pulm

7/28/2019 Hy Kaplan Pulm

1/9

Kaplan Pulmonology Video Notes

Diagnostic Tests

1. Pulmonary Function Testsa. Differentiate types of lung processes

i. Restrictive vs. Obstructive1. Obstructive: Asthma, COPD2. Restrictive: Occupational exposure, pulm. fibrosis

2. Lung Volumesa. Lung volumes measured under static conditions (not dynamic)b. Only allows diagnosis of restrictive lung disease

i. Helps confirm volume in restrictive diseaseii. Obstructive disease may have lung volumes

c.i. Expel air out of lung: left w/ RV.

ii. > 80% predicted = Normal

d.i. Measured against time (dynamic conditions)

e. FEV1/FVC is the best measure

f.i. Graph 2: Obstructive disease


2/9

1. Slope of curve: 25-75% predicted (part of FVC)ii. Restrictive disease: FEV1 and FVC decrease equally (ratio)

g. 2 ways to measure obstructive diseases:i. FEV1/FVC

ii. Slope of curve between 25-75

h.3. DLCO

a.b. Measure of oxygen diffusing capacity

c.d. DLCO with alveolar hemorrhage: Goodpastures, SLE

4. Other Testsa. Methacholine challenge tests

i. Use when considering diagnosis of asthmaii. Asthmatic patient will have a mini asthma attack

HY PULMONOLOGY

1. COPD: Chronic bronchitis vs Emphysemaa. Airflow obstruction secondary to emphysema &/or chronic bronchitisb. Etiology

i. Tobacco smoking (destroys elastin fibers)ii. Alpha-1 antitrypsin deficiency


3/9

c. Presentationi. SOB worsened by exertion

ii. Intermittent exacerbations w/ cough, sputum, SOB (due to infection)iii. Barrel chest from air trappingiv. Muscle wasting & cachexia

d. Diagnosisi. Best initial test: X-ray

1. Increased anterior-posterior diameter (AP)2. Air trapping and flattened diaphragms

ii. Most accurate diagnostic test: PFT1. FEV1, FVC, FEV1/FVC ration < 70%2. TLC due to RV3. DLCO emphysema4. Incomplete improvement w/ albuterol (unlike asthma)5. Little or no worsening with methacholine.

iii. Arterial blood gas1. Acute exacerbations of COPD -- Pco2 & HYPOXIA

a. Respiratory acidosis (bicarb will be elevated to compensate)iv. EKG

1. Right atrial hypertrophy & right ventricular hypertrophy2. A-fib or multifocal atrial tachycartia (MAT)

v. ECHO1. Pulm HTN2. Right atrial & ventricular hypertrophy

e. Treatment thatimproves mortality in COPDi. Smoking cessation

ii. O2 therapy for hypoxia

1.f. Treatment thatimproves symptoms in COPD

i. Short acting beta agonists:Albuterolii. Inhaled Anticholinergic agents

1. Tiotropium (long acting)2. Ipratropium (short acting)

iii. Long-acting beta agonists:Salmeteroliv. Theophylline

1. PDE4 inhibitor2. Narrow therapeutic index3. Interacts w/ cimetidine, phenytoin4. Toxicity by: erythromycin, cimetidine, fluoroquinolones (Cipro)

g. No benefiti. Cromolyn

ii. Leukotriene modifiersh. Treatment of Acute exacerbations: Steroids + Antibiotics

i. Combo of bronchodilator & systemic steroidii. Antibiotics (moderate severe)


4/9


5/9

iii. Sputum culturee. Treatment/Management

i. Chest physiotherapy (cupping & clapping + postural drainage)ii. Treat each episode of infection

1. Abx same as COPD exacerbation2. Inhaled antibiotics may be helpful

iii. Surgical Resection3. Allergic Bronchopulmonary Aspergillosis

a. Hypersensitivity to fungal Ag that colonizes resp tractb. Found w/ asthma & atopic disordersc. Look for:

i. Asthmatic w/ recurrent episodes of brown-flecked sputum & transient infiltrates on X-rayd. Clinical: cough, wheezing, hemoptysise. Diagnosis:

i. Peripheral eosinophiliaii. Skin test reactivity to aspergillus

iii. IgEiv. Pulm infiltrate on CXR or chest CT

f. Treatment:i. Acute flare prednisone

ii. Itraconazole or voriconazole orally4. Cystic fibrosis

a. Autosomal recessive mutation, codes for chloride transporti. CFTR mutation, chromosome 17

b.


6/9

c.d. Lungs:

i. Damaged mucous clearance decreases ability to get rid of inhaled bacteria

Solitary Pulmonary Nodule & Interstitial Lung disease

1. Solitary Pulm Nodule:a. Benign: < 30 yrs old, no change in size, nonsmoker, smooth border, < 1 cm, no adenopathy, normal

PET, dense CENTRAL calcification

i. Often represent SCAR from infectionii. Immigrant TB

iii. SW US Coocidioidomycosisiv.

Ohio, River Valley

HISTOPLASMOSIS

b. Malignant:i. Remove lesion

ii. Sputum cytology, needle biopsy, PETc. Intermediate probability lesion:

i. Age 30-40 yearsii. Size > 1 cm, < 2 cm

iii. Sputum cytology is the best next stepiv. Bronchoscopy or Transthoracic needle biopsy (peripheral lesions)

d. PET cani. 85-95% sensitivity

e. VATS: Video assisted thoracic surgeryi. More sensitive & more specific

2. Interstitial Lung diseasea. Disease characterized by inflammation of interalveolar septumb. Fibrosis causes

i. Impaired gas exchangeii. Increased lung stiffness

iii. &iv. Decreased lung compliance & expansion


7/9

c.d. Types of Pneumoconioses

i. Coal exposureCoal workers pneumoconiosisii. Sandblasting, rock mining, tunneling Silicosis

iii. Shipyard worker, insulator Asbestosisiv. Cotton Byssinosisv. Electronic Berylliosis

1. Biopsy: Granulomase. Presentation of Pulm Fibrosis

i. Dyspnea worsening on exertionii. Hypoxia worsening on exertion

iii. Fine rales or crackles on examiv. Loud P2 (pulm HTN)v. Clubbed fingers

f. Diagnosisi.

Best initial test: CXRii. Most accurate test: Lung biopsy

1. Inflammation, fibrosisiii. PFT: Restrictive lung disease

1. FEV1, FVC, TLC & RV , but FEV1/FV C ration normaliv. DLCO:

g. Treatmenti. Berylliosis is most likely to respond to steroids.

3. Hypersensitivity Pneumonitisa. Presentation:

i. ACUTE:1. Fever, dyspnea, severe cough2. 4-6 hours after exposure

ii. CHRONIC:1. Progressive dyspnea2. Rales

b. Most common Antigent:i. Feathers: Bird fanciers lung

ii. MAI: hot tub lungiii. Spores of actinomyces: Farmers lung/Air conditioner lung


8/9

c. Treatment:i. Corticosteroids

ii. Avoid exposureSARCOIDOSIS

1. Most common in African American women2. Infiltration of NONCASEATING granulomas3. Presentation:

a. SOB on exertion, fine rales, NO wheezingb. Erythema nodosum, Lymphadenopathy

i. Bilateral, hilar lymphadenopathyc. Fever, malaise, weight lossd. Arthritise. Parotid gland enlargementf. Facial palsyg. Heart blockh. Iritis, uveitis

4.

Diagnosis:a. CXR best initial test

i. Hilar lymphadenopathyii. Parenchymal involvement

b. Lymph node biopsymost accurate testc. ACE level (60%)d. Hypercalciuriae. Hypercalcemia

i. Granulomas in sarcoidosis make Vitamin Df. PFTs: restrictive lung disease

5. Treatment:a. Prednisone

THROMBOEMBOLIC DISEASE

1. Etiologya. Virchows Triad:

i.b. Presentation:

i. Sudden onset of SOB, normal CXRii. Other findings:

1. Tachypnea, tachycardia, cough, hemoptysis2. Leg pain from DVT


9/9

3. Pleuritic chest pain 2/2 lung infarct4. Fever 2/2 clot or hematoma

c. Diagnosis:i. CXR typically normal or atelectasis

1. Hampton hump 2. Westermark sign oligemia of one lobe

ii. EKG1. Nonspecific ST-T wave changes2. 5% will have new RBBB or RV hypertrophy

iii. ABG1. Hypoxia & respiratory alkalosi

a. pH, pCO2

Documents

Hy Kaplan Pulm