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Year 2 - Pulmonary and HTN

Terms in this set (303)

Asthma - risk factors?
-Atopy (eczema, allergic rhinitis) = strongest predictor
-Male children
-Female adults
-Blacks (highest mortality)
Asthma - pathophysiology?
-Airway inflammation (narrow lumen)
-Goblet cell hyperplasia (thick mucus)
-Bronchial smooth muscle hypertrophy
-Collagen deposit beneath basement membrane
-Denuding of airway epithelium
Intermittent Asthma:
-Symptoms
-Nighttime awakenings
-SABA use
-Interference with normal activity
-FEV1
-FEV1/FVC
-Treatment Step
-Symptoms: 2 or fewer days per week
-Nighttime awakenings: 2 or fewer times per month
-SABA use: 2 or fewer times per week
-Interference with normal activity: None
-FEV1: >80% predicted
-FEV1/FVC: normal (>80%)
-Treatment: Step 1
Mild Persistent Asthma:
-Symptoms
-Nighttime awakenings
-SABA use
-Interference with normal activity
-FEV1
-FEV1/FVC
-Treatment Step
-Symptoms: 3-6 days per week
-Nighttime awakenings: 3-4 times per month
-SABA use: 3-6 days per week (not more than once daily)
-Interference with normal activity: Minor
-FEV1: >80% predicted
-FEV1/FVC: normal (>80%)
-Treatment: Step 2 (or step up 1 from current)
Moderate Persistent Asthma:
-Symptoms
-Nighttime awakenings
-SABA use
-Interference with normal activity
-FEV1
-FEV1/FVC
-Treatment Step
-Symptoms: 1 per day
-Nighttime awakenings: 2-6 times per week
-SABA use: 1 per day
-Interference with normal activity: Some
-FEV1: 60-80%
-FEV1/FVC: reduced 5% (75-80%)
-Treatment: Step 3 (or step up 1-2 from current)
Severe Persistent Asthma:
-Symptoms
-Nighttime awakenings
-SABA use
-Interference with normal activity
-FEV1
-FEV1/FVC
-Treatment Step
-Symptoms: >1 per day
-Nighttime awakenings: every night
-SABA use: >1 per day
-Interference with normal activity: Extreme
-FEV1: <60%
-FEV1/FVC: reduced >5% (<75%)
-Treatment: Step 4 or 5 (o step up 2 from current)
Asthma - symptoms?
-Resonant to percussion
-Cough
-Chest tightness
-Wheezing
-Abnormal I:E (short inspiration, prolonged expiration)
-NO clubbing
-NO peripheral edema
At what time of day are asthma exacerbations most likely to occur?
3-4 am
Mild Asthma Exacerbation:
-Breathlessness
-Talks in...
-Alertnesss
-RR
-Body position
-Accessory muscle use/Retractions
-Wheezing
-Pulse
-PEF or FEV1
-SaO2
-pH
-Breathlessness: while walking
-Talks in: sentences
-Alertnesss: slight agitation
-RR: increased
-Body position: can lie down
-Accessory muscle use/Retractions: none
-Wheezing: moderate at end of expiration
-Pulse: <100
-PEF or FEV1: >70%
-SaO2: >95%
-pH: respiratory alkalosis
Moderate Asthma Exacerbation:
-Breathlessness
-Talks in...
-Alertnesss
-RR
-Body position
-Accessory muscle use/Retractions
-Wheezing
-Pulse
-PEF or FEV1
-SaO2
-pH
-Breathlessness: at rest
-Talks in: phrases
-Alertnesss: agitation
-RR: increased
-Body position: prefers sitting
-Accessory muscle use/Retractions: sometimes
-Wheezing: loud throughout expiration
-Pulse: 100-120
-PEF or FEV1: 40-70%
-SaO2: 90-95%
-pH: respiratory alkalosis
Severe Asthma Exacerbation:
-Breathlessness
-Talks in...
-Alertnesss
-RR
-Body position
-Accessory muscle use/Retractions
-Wheezing
-Pulse
-PEF or FEV1
-SaO2
-pH
-Breathlessness: at rest
-Talks in: word (gasps between words)
-Alertnesss: agitation
-RR: >30
-Body position: sits upright
-Accessory muscle use/Retractions: usually
-Wheezing: loud throughout inspiration and expiration
-Pulse: >120
-PEF or FEV1: 25-40%
-SaO2: <90%
-pH: respiratory acidosis
Respiratory Arrest Imminent Asthma Exacerbation:
-Breathlessness
-Talks in...
-Alertnesss
-RR
-Body position
-Accessory muscle use/Retractions
-Wheezing
-Pulse
-PEF or FEV1
-SaO2
-pH
-Breathlessness: at rest
-Talks in: silent/mute
-Alertnesss: drowsy/confused
-RR: >30
-Body position: tripod
-Accessory muscle use/Retractions: paradoxical thoracoabdominal movement
-Wheezing: none
-Pulse: Bradycardia
-PEF or FEV1: <25%
-SaO2: <90%
-pH: respiratory acidosis
Asthma - labs?
-FEV1 (forced expiratory flow in 1 second)
-FVC (forced vital capacity)
-Bronchial provocation testing (inhaled methacholine)
-PEF (peak expiratory flow)
-CXR
NAEPP 3 Guidelines for Asthma treatment?
1. Assess and monitor severity and control
2. Patient education (written asthma action plan)
3. Control environmental factors and comorbid conditions (GERD, obesity)
4. Pharmacologic agents
What are the 6 steps of pharmacologic management of asthma?
1 = SABA prn
2 = Low-dose ICS + SABA prn
3 = Low-dose ICS + LABA + SABA prn OR medium-dose ICS + SABA prn
4 = Medium-dose ICS + LABA + SABA prn
5 = High-dose ICS + LABA + SABA prn (consider omalizumab in pts with allergies)
6 = High-dose ICS + LABA + oral steroid + SABA prn (consider omalizumab in pts with allergies)

Consult with asthma specialist if Step 4 or higher
Management of a patient with well-controlled asthma?
-Maintain current step
-Follow-up in 1-6 months
-Step down 1 step if well controlled > 3 months
Management of patient with not well-controlled asthma?
-Step up one (after checking adherence, environment, and comorbid conditions)
-Follow-up in 2-6 weeks
Management of patient with very poorly controlled asthma?
-Short-term oral steroids
-Step up 1-2
-Follow-up in 2 weeks
What are the long-term medications for asthma control?
1. Inhaled corticosteroids (beclomethasone, budesonide, flunisolide, fluticasone)
2. Systemic corticosteroids (prednisone, methylprednisolone)
3. Mast cell stabilizers (cromolyn, nedocromil)
4. LABA (salmeterol, formoterol)
5. Inhaled Anticholinergics (tiotropium)
6. Phosphodiesterase inhibitors (theophylline)
7. Leukotriene modifiers (montelukast, zafirlukast, zileuton)
8. Immunomodulators (omalizumab)
What are quick relief medications for asthma?
1. SABA (albuterol, levalbuterol, terbutaline)
2. Anticholinergics (ipratropium)
3. Systemic corticosteroids (prednisone, methylprednisolone)
Treatment for a mild asthma attack?
-SABA every 3-4 hours for 24-48 hours
-Repeat assessment in 60-90 minutes
-Discharge if no distress and FEV1 or PEF > 60%and no respiratory acidosis
Treatment for moderate asthma attack?
-SABA every 20 minutes for 1 hour
-Oral corticosteroid
-Oxygen to get SaO2 > 90%
-Repeat assessment in 60-90 minutes
-Discharge if no distress and FEV1 or PEF > 60%and no respiratory acidosis
Treatment for severe asthma attack?
-Immediate oxygen to get SaO2 > 90%
-High-dose SABA + ipratropium (continuously)
-Oral corticosteroid
-IV magnesium sulfate
-Repeat assessment in 60-90 minutes
-Discharge if no distress and FEV1 or PEF > 60%and no respiratory acidosis
Treatment of asthma attack with impending respiratory arrest?
-Intubation with mechanical ventilation with 100% O2
-High dose SABA+ Ipratropium (continuously)
-IV corticosteroid
-Admit to hospital
When to refer an asthma patient?
-Complicating comorbid conditions
-Suboptimal response to therapy
-Not meeting goals after 3-6 months therapy
-Requires high dose inhaled corticosteroid
-More than 2 doses oral prednisone in a year
-Required hospitalization in past year
Chronic Bronchitis (COPD Type B) - pathophysiology?
-Excessive secretion of bronchial mucus
Chronic Bronchitis (COPD Type B) - clinical diagnosis?
-Daily productive cough over 3 month period for at least 2 consecutive years
Emphysema (COPD Type A) - pathophysiology
-Abnormal permanent enlargement of air spaces distal to terminal bronchiole
-Destruction of walls of bronchioles and alveoli
-No fibrosis
Most common cause of COPD?
smoking
COPD - risk factors?
-Smoking
-30s-40s (bronchitis) or 50s (emphysema)
-Occupational risks (welders, migrant workers)
-Genetics
Chronic Bronchitis (COPD Type B) - symptoms?
-Chronic productive cough for years
-Excessive sputum
-Dyspnea on exertion (or at rest if severe)
-Frequent chest infections
-Overweight
-Cyanosis
-Peripheral edema
-Wheezing and rhonci
-Prolonged expiration
-Nail clubbing
Chronic Bronchitis (COPD Type B) - lab findings?
-Total lung capacity = normal or increased
-FEV1 = decreased
-FEV1/FVC = decreased
-CBC = erythrocytosis (increased RBCs)
-PaCO2 = increased (if severe)
-CXR = enlarged heart, increased markings at bases
Emphysema (COPD Type A) - symptoms?
-Dyspnea on exertion
-Cachexia (thinness)
-Barrel chest
-Nail clubbing
-Prolonged expiration
-Hyperresonance on percussion
-Quiet chest (decreased breath sounds)
Emphysema (COPD Type A) - lab findings?
-Total lung capacity = increased
-FEV1 = decreased
-FEV1/FVC = decreased
-CBC = normal
-PaCO2 = increased (if severe)
-CXR = hyperinflation, flat diaphgrams, tear-drop heart, diminished markings at apices
Early emphysema is due to...
Genetics (alpha-1-antritrypsin deficiency)
COPD - complications?
-Pulmonary hypertension
-Cor pulmonale
-Pneumothorax (in emphysema)
COPD - treatment?
-Quit smoking (most important intervention)
-Influenza and Pneumococcal vaccines
-Pulmonary rehab exercises
-Abx during acute exacerbations
-Home oxygen therapy (if SaO2 < 88% or PaO2 < 55 mmhg)
-Bronchodilators (for symptomatic relief) = ipratropium bromide +/- albuterol
-LABA (salmeterol)
-Long-acting anticholinergics (tiotropium)
-Inhaled corticosteroids (when combined with previous drugs)
-Theophylline (if previous therapies don't work)
-AVOID cough suppressants and sedatives
When to refer COPD patient?
-Onset < 40 years old
-2 or more exacerbations per year
-Need for oxygen therapy
-Comorbid illness (heart failure, lung cancer)
Bronchiectasis - pathophysiology?
-Obstructive and restrictive disease
-Dilated bronchi
-Thin/destroyed bronchi walls
-Mucopurulent exudate obstructions
Bronchiectasis - causes?
-Cystic fibrosis (MC)
-Recurrent infections (e.g., due to COPD)
-Local obstruction (tumor)
-Immunodeficiency
Bronchiectasis - symptoms?
-Chronic cough with copious amounts of purulent, foul-smelling sputum (> 10 mL per day)
-Hemoptysis (flecks of blood in sputum)
-Dyspnea
-Wheeing
-Pleuritic chest pain
-Weight loss
-Anemia
-Crackles at lung bases
Bronchiectasis - lab findings?
-CT = diagnostic study of choice
-CXR = dilated thick bronchi appearing as "Tram tracks" or rings, scattered opacities
-Sputum culture = H. flu MC (psueodomonas is worst prognosis
-Sputum divides into 3 layers
Bronchiectasis - tx?
Acute exacerbations:
-Abx (augmentin)
-Daily chest physiotherapy (percussion, drainage) or flutter valve devices
-Inhaled bronchodilators

Surgical tx:
-Resection of localized bronchiectasis
-Lung transplant
What is the most common cause of severe chronic lung disease in young adults?
Cystic Fibrosis
What is the most common fatal hereditary disorder of whites in the US?
Cystic Fibrosis
Cystic Fibrosis - pathophysiology?
-Autosomal recessive disorder
-Mutation of CFTR membrane chloride channel
-All exocrine glands produce thick mucous
Cystic Fibrosis - symptoms?
-Cough with sputum
-Decreased exercise tolerance
-Hemoptysis
-Steatorrhea and diarrhea
-Malnourishment
-Meconium ileus (thick clogged stool)
-Recurrent lung infections (especially bronchiectasis)
-Digital clubbing
-Barrel chest
-Hyperresonance to percusion
-Apical crackles
-Purulent nasal secretions
Cystic Fibrosis - complications?
-Recurrent lung and sinus infections
-Infertility
-Biliary disease
-Gallstones
-Pancreatitis
-Cancer in GI tract
-Osteopenia
Cystic Fibrosis - lab findings?
-Respiratory acidsosis
-Reduced FVC
-Air trapping
-CXR = hyperinfation, peribronchial cuffing, atelectasis, ring shadows, increased interstitial markings
How do you diagnose cystic fibrosis?
Two separates tests of Pilocarpine iontophoresis sweat test shows >60 sodium and chloride
Cystic Fibrosis - tx?
-Screen family members
-Genetic counseling
-Flu and Pneumococcal vaccine
-Refer to cystic fibrosis center
-Pancreatic enzyme replacement
-Abx (azithromycin 3x a week)
-Nutritional support
-Clearance of lung secretions (chest percussion, flutter valve)
-Inhaled bronchodilators
-Ivacaftor (drug aimed at CFTR channel)
-Lung transplant (only definitive tx)
Bronchiolitis - causes?
-RSV (MC)
-Adenovirus
What is the most common acute respiratory illness in infants and young children?
Bronchiolitis
Bronchiolitis - symptoms?
-Cough
-Tachypnea
-Respiratory distress
-Crackles/wheezes
-Fever (1-2 days)
-Rhinorrhea
Bronchiolitis - tx?
-Frequent suctioning
-Hydration
Acute Bronchitis - symptoms?
-Productive cough (1-3 weeks)
-Hemoptysis
-Fever
-Wheezing
-Rhonci
-Prolonged expiration
Acute Bronchitis - tx?
-Protussive therapy (during day to encourage cough)
-Bronchodilators if wheezing
-NO abx
RSV - pathophysiology?
-Paramyxovirus
-Causes proliferation and necrosis of bronchiolar epithelium, producing obstruction and increased mucus
What is the leading cause of hospitalization in US children?
RSV infection
RSV infection - risk factors?
-October to January
-Prematurity
-Low birth weight
-Young age (< 6 months)
-Congenital heart disease
-Bronchopulmonary dysplasia
-Day care use
-Later birth order
RSV infection - symptoms?
-Fever (low)
-Tachypnea
-Wheezes
-Apnea
-Hyperinflated lungs
-Increased work on breathing
RSV infection - labs?
-Viral antigen identification of nasal washings
-Culture or nasopharyngeal secretions (standard for dx)
RSV infection - tx?
-Hydrations
-Humidification
-Ribavirin (if high risk patient)

Palivizumab prophylaxis recommended for:
-Infants with chronic lung disease of prematurity
-Infants with bronchopulmonary dysplasia
-Infants with congenital heart disease
How do penicillins work?
Destroy bacterial cell walls
What is the drug of choice for Treponema Pallidum (syphilis)?
Penicillin
Augmentin, Unasyn, Timentin, and Zosyn are useful in treating which organisms?
-Strep
-Staph aureus
-H flu
-Moraxella catarrhalis
Cephalexin (Keflex) and Cefazolin (Ancef) are which generation? What are they useful in treating?
1st generation cephalosporin

-Gram positive cocci (Strep and Staph)
-Soft tissue infections (cellulitis)
Cefoxitin, Cefuroxime, and Cefotetan are which generation? What are they useful in treating?
2nd generation cephalosporin

-H flu
-Pneumococci
-Less gram positive activity than first generation
Cefotaxime and Ceftriaxone are which generation? What are they useful in treating?
3rd generation cephalosporin

-H flu
-Pneumococci
-Gram negatives
-Penetrates CSF in meningitis
-Gonorrhea
-Less active against staph than first generation
Cefepime is which generation? What is it useful in treating?
4th generation cephalosporin

-Pseudomonas
Ceftaroline (Teflaro) is which generation? What is it useful in treating?
5th generation cephalosporin

-MRSA
-Community acquired pneumonia
How do macrolides work?
Inhibit protein synthesis of 50s
What are macrolides good for?
-Mycoplasma
-Legionella
-Chlamydia
-H flu (except erythromycin)
How are newer macrolides better than older macrolides (erythromycin)?
-More active against h flu
-Longer half life
-Better tissue penetration
-Less GI side effects
How do tetracyclines work?
-Bacteriostatic
-Inhibit protein synthesis of 30s
What are tetracyclines good for?
-Strep pneumoniae
-H flu
-Chlamydiae
-Mycoplasma
-STDs
How do fluoroquinolones work?
Inhibit bacterial DNA synthesis
What are fluoroquinolones good for?
Older agents (norfloxacin, cipro):
-UTIs

Newer agents (levofloxacin, moxifloxicin)
-Broad spectrum pneumonia
What are the routes of the bacterial inoculation of the lungs in pneumonia?
-Aspiration of oropharyngeal secretions
-Inhalation of airborn pathogens
-Bacteremia (directly seeded from blood)
-Direct extension into lungs
What are the host defense mechanisms against pneumonia?
-Epiglotic reflex (gagging, coughing)
-Ciliary escalator (stops in smokers)
-Mucosal blanket in bronchiole tubes has Ig
-Surfactant (prevents attachment of bacteria)
-PMNs attracted to bacteria
When is a sputum specimen rejected by the lab?
10 or more squamous cells
How can you identify organisms in pneumonia?
-Expectorated sputum gram stain
-Expectorated sputum culture
-Urinary antigen test (for strep and legionella)
-Transtracheal aspiration
-Bronchoalveolar lavage
-Pleuraccentesis
-Blood cultures
-CXR
Pneumococcal pneumonia - causative organism?
Strep pneumoniae (gram +)
Pneumococcal pneumonia - symptoms?
-Preceded by URI
-Abrupt onset and rapid progression (24 hours)
-High fever (104)
-Chills
-Cough (rust colored sputum)
-Chest pain
-Tachypnea
-Dullness to percussion
-Decreased breath sounds
-Rales/crackles
Most common bacterial pneumonia?
Strep pneumoniae
Pneumococcal pneumonia - labs and CXR?
-Increased WBCs with left shift
-Gram + displococci on gram strain
-Blood cultures + (in 25% of pts)

CXR:
-Lower lobe consolidation
Staph pneumonia - risk factors?
-Residence in chronic care facility
-Influenza
-Injection drug use
-Cystic fibrosis
Staph pneumonia - symptoms?
-Abrupt onset of fever
-Dyspnea
-Cough with Purulent sputum
-Crackles
-Diminished lung sounds
Staph pneumonia - labs and CXR?
-Increased WBCs

CXR:
-Abscess
-Pneumatocele (honeycombing)
H flu pneumonia - risk factors?
-COPD
-Smokers
-Immunocompromised
-Recent URI
H flu pneumonia - symptoms?
-Fever
-Cough
-Tachypnea
-Crackles
-Dullness to percussion
H flu pneumonia - labs and CXR?
CXR:
-Bilateral, multi-lobar consolidation
H flu pneumonia - prevention?
Hib vaccine
H flu pneumonia - tx?
-Cetriaxone
-Cefotaxime

(2nd or 3rd gen cephalosporin)
Pneumococcal pneumonia - complications?
-Lung abscess (air fluid line on CXR)
-Septic arthritis
-Intravascular coagulopathy
-Endocarditis
-Pericarditis
Pneumococcal pneumonia - tx?
-Penicillin
-Cephalosporins
-Erythromycin
Indications for the pneumococcal vaccine?
PCV 13:
-Older than 65
-Functional or anatomic asplenia
-Sickle cell
-HIV
-Chronic renal failure
-Malignancy
-ORgant transplant

PPSV 23 (Same as PCV 13 plus):
-Heart disease
-Lung disease
-Liver disease
-DM
-Alcoholic
-Smoker
Indications for the influenza vaccine?
> 6 months old

Get it in September (since it takes 3-4 weeks to develop immunity)
When is the peak influenza month?
February
Mycoplasma Pneumoniae - risk factors?
-5-20 yrs old
-Summer and fall
Mycoplasma Pneumoniae - symptoms?
-Slow onset
-Mild fever
-Paroxysmal non-productive hacking cough
-Myalgia
-Malaise
-Fine rales or normal lung sounds
Mycoplasma Pneumoniae - labs and CXR?
-Gram stain = nothing
-WBCs = normal or slight increase
-Cold agglutinin titer > 1:32
-Complement fixation levels = high

CXR:
-Marked patchy infiltrate at base of lungs
Mycoplasma Pneumoniae - complications?
-Pleural effusion
-Erythema multiforme
-SJS
-Bullous myringitis
-Cold agglutinin hemolytic anemia
Legionella Pneumoniae - risk factors?
-Exposure to contaminated water source (air conditioner, construction site)
-Summer
-Males > 40
-Smokers
-Alcoholics
-Immunosuppressed
Legionella Pneumoniae - symptoms?
-Cough (starts dry then progresses to productive)
-Sore throat
-Fever
-Diarrhea
-CNS symptoms (headaches, seizures, hallucination)
-Liver, lungs, kidneys, GI, CNS issues
Legionella Pneumoniae - labs and CXR?
-High WBC with left shift
-LFTs = high
-Hematuria
-High BUN and creatinine

CXR:
-Patchy infiltrate to consolidation
Legionella Pneumoniae - tx?
Macrolide
Pneumocystis Pneumoniae - causative organism?
Peumocystis jiroveci (fungus with protozoan like properties)
Pneumocystis Pneumoniae - risk factors?
-Immunocompromised (CD4 < 200)
Pneumocystis Pneumoniae - symptoms?
-Fever
-Tachypnea
-Dyspnea
-Non-productive cough
-Normal auscultation
Pneumocystis Pneumoniae - labs and CXR?
-Hypoxemia (PaO2 < 80)
-LDH (lactic dehydrogenase) increased
-Leukopenia
-Anemia
-Methanamine silver and Giemsa stains of sputum

CXR:
-Bilateral diffuse interstitial infiltrate
-Ground glass opacification
Pneumocystis Pneumoniae - tx?
-Bactrim
-Pentamidine
Chlamydophila pnieumoniae - symptoms?
-Nonproductive cough
-Sore throat
-Hoarseness
-Wheezing
Chlamydophila pnieumoniae - labs and CXR?
-Complement fixation
-Immunofloruoescent
-PCR
-Cell culture
Chlamydophila pnieumoniae - tx?
-Tetracycline
-Macrolide
Klebsiella pneumoniae - risk factors?
-Alcoholic
-DM
Klebsiella pneumoniae - symptoms?
-Abrupt onset
-Fever
-Current jelly sputum
-Productive cough
-Tachypnea
-Decreased breath sounds
-Dullness to percussion
Klebsiella pneumoniae - labs and CXR?
CXR:
-Consolidation in upper lobes
-Bulging fissures
What is the most deadly infectious disease in the US?
Community Acquired Pneumonia
Most common organisms in community acquired pneumonia?
-Strep pneumoniae
-Myoplasma plneumoniae
-H flu
-Chlamydiae pneumoniae
-Respiratory viruses
How should you treat community acquired pneumoniae outpatient?
If no abx in last 3 months:
-Macrolide
-Doxycyline

If comorbid condition or abx use in last 3 months:
-Respiratory fluoroquinolone
-Beta-lactam (amoxicillin, cephalosporin) + Macrolide
Who should receive a revaccination of the pneumococcal vaccine?
-Immunocompromised 6 years after initial vaccination
-Age > 65 but last vaccination was > 6 years ago when they were younger than 65
What measures are used to determine if you should admit a patient for pneumonia?
-Pneumoniae Severity Index (PSI)
-CURB-65 (hospitalize if 1-2; ICU if 3 or more)

CURB-65:
-Confusion
-Uremia (>20)
-Respiratory rate (>30)
-Blood pressure (<90/60)
-Age > 65
How should you treat community acquired pneumoniae inpatient?
-Respiratory fluoroquinolone
-Beta-lactam (amoxicillin, cephalosporin) + Macrolide
Definition of Hospital Acquired Pneumonia (HAP)?
Pneumonia in patients who have been in hospital or long-term facility > 48 hours
Definition of Healthcare Associated Pneumonia (HCAP)?
Pneumonia in health workers exposed to HAP
Definition of Ventilator Associated Pneumonia (VAP)?
Pneumonia in patients who have been ventilated for > 48 hours via endotracheal tube
What is the 2nd most common cause of infection among hospital patients?
Hospital Acquired Pneumonia (HAP)
What is the leading cause of death due to infection among hospital patients?
Hospital Acquired Pneumonia (HAP)?
Hospital Acquired Pneumonia (HAP) - risk factors?
-Malnutrition
-Advanced age
-Altered consciousness
-Swallowing disorders
-Underlying pulmonary disease
-Underlying systemic disease
Healthcare Associated Pneumonia (HCAP) - risk factors?
-Abx use within 90 days
-Hospitalization > 48 hours within 90 days
-Residence in nursing home
-Home infusion therapy (chemo) within 30 days
-Long-term dialysis within 30 days
-Home wound care
-Family member with drug resistant infection
-Immunosuppression
What organisms are common in nosocomial pneumonias?
-Strep pneumonia (often drug resistant)
-Staph aureus
-MRSA
-Gram negative rods
-Klebsiella
-E. coli
-Enterobacter
-Pseudomonas
-Acinetobacter
Nosocomial pneumonia - symptoms?
-New or progressive infiltrate on CXR
-Fever
-Leukocytosis
-Purulent sputum
Nosocomial pneumonia - labs?
-Blood cultures rom 2 different sites
-Thoracentesis
-Cultures of sputum
-Bronchoscopy
-CXR
Nosocomial pneumonia - tx when low risk for multiple drug resistant pathogens?
One of the following:
-Ceftriaxone
-Fluroquinolone
-Augmentin
-Pip-Tazo
-Ertapenem
Nosocomial pneumonia - tx when high risk of multiple drug resistant pathogens?
One from each category
1. Antipseudomonas:
-Cefipime
-Pip-Tazo
-Imipenem
2. Another antipseudomonas:
-Fluoroquinolone
-Aminoglycoside
3. MRSA coverage
-Vancomycin
-Linezolid
Anaerobic pneumonia - cause? risk factors?
Aspiration

-Alcohol intoxication
-Seizures
-General anesthesia
-Tracheal or NG tube
-Neurologic disorders
-Periodontal disease
Anaerobic pneumonia - symptoms?
-High fever
-Weight loss
-Cough with foul smelling purulent sputum
-Localized dullness to percussion
Anaerobic pneumonia - CXR findings?
-Lung abscess = thick walled, solitary cavity with air-fluid level surrounded by consolidation
-Necrosis = multiple areas of cavitation in an area of consolidation
-Empyema = purulent pleural fluid with cavitation
Anaerobic pneumonia - tx?
-Clindamycin
-Augmentin
Can patients with latent TB transmit the disease to others?
No
Definition of Drug Resistant TB?
-Resistant to one first line drug (Isoniazid or Rifampin)
Definition of Multi-drug Resistant TB?
-Resistant to both Isoniazid and Rifampin
Definition of Extensively Drug Resistant TB?
-Resistant to Isoniazid, Rifampin, fluoroquinolones and aminoglycosides
TB - symptoms?
Slow progression of:
-Malaise
-Anorexia
-Weight loss
-Fever
-Night sweats
-Chronic cough (dry at first, then purulent, then blood streaked)
TB - labs?
-Sputum Culture or DNA/RNA amplification (needed for definitive dx)
-Acid fast bacilli (could be any mycobacteria)
-Tuberculin skin test (does not distinguish between latent and active)
TB - CXR?
Primary TB:
-Small unilateral infiltrates
-Hilar adenopathy
-Segmental atelectssis
-Pleural effusion

Reactivation TB:
-Discrete nodules in apices

Resolved TB:
-Upper lobe scarring
-Nodules in pulmonary hila
-Ghon focus (calcified focus)
-Ranke comples (ghon + hilar lymphadenopathy)
Mantoux test - positive results?
> 5 mm:
-Immunosuppressed (organ transplant, HIV)
-Recent contact with active TB
-Fibrotic changes on CXR

>10 mm:
-Recent immigrants from countries of high TB rates
-IV drug user
-Residents and employees of prisons, nursing homes, hospitals, homeless shelters
-Children < 4
-Children > 4 exposed to adults at high risk
-Malignancy
-DM
-Kidney disease
-Mycobacteriology lab personnel

>15 mm:
-Everyone else
Tx for Active TB?
-Report to state public health
-Hospitalize if likely to expose to new pts or won't take care of self
-2 months of Isoniazid, Rifampin, Pyrazinamide, Ethambutol
-4 more months of Isoniazid, Rifampin
-Monthly follow-up

If drug resistant:
-6 months of Rifampin, Pyrazinamide, Ethambutol or Streptomycin
Side effects of TB drugs?
1. Isoniazid - Hepatitis, peripheral neuropathy
2. Rifampin - Hepatitis, GI upset, bleeding, kidney failure
3. Pyrazinamide - Hyperuricemia, hepatitis, GI upset
4. Ethambutol - Optic neuritis
5. Streptomycin - Acoustic nerve damage, Nephrotoxicity
Tx fo Latent TB?
One of the following:
-Isoniazid for 9 months (preferred)
-Rifampin+ Pyrazinamide for 2 months
-Rifampin for 4 months
Solitary Pulmonary Nodule - CXR?
-Isolated, round opacity < 3 cm

No infiltrate, atelectasis, or adenopathy
What factors increase the probability that a solitary pulmonary nodule is malignant?
-Age > 30
-Smoking
-Previous malignant
-Doubling time between 30-465 days (<30 = infection; >465 = benign)
-Increased size
-Edge is not smooth or well-defined
-Spiculated margins
-Peripheral halo on CT
-Less calcification that is not central or laminated pattern
Solitary pulmonary nodule - tx?
If low probability (<5%):
-Watchful waiting with serial CT scans

If intermediate probability (5-60%):
-Biopsy via needle aspiration or broncoscopy
-PET scan
-Sputum cytology

If high probability (>60%):
-Resection and staging
Carcinoid tumors - risk factors?
-Age < 60 yrs old
Carcinoid tumors - symptoms?
-Hemoptysis
-Cough
-Focal wheezing
-Recurrent pnuemonia
-Carcinoid syndrome = flushing, diarrhea, wheezing, hypotension
Carcinoid tumors - labs?
-Fiberoptic bronchoscopy = pink/purple, very vascularizedm mass in central airway
Carcinoid tumors - tx?
-Surgical excision if symptomatic
-Rarely metasticizes but can bleed or obstruct airway
What is the leading cause of cancer deaths?
Lung cancer
Lung cancer - risk factors?
-Smoking (including 2nd hand exposure)
-Radon gas (miners)
-Asbestos
-Metals (arsenic, nick, chromium)
-Family hx
-Pulmonary fibrosis
-COPD
-Sarcoidosis
-Age > 40
Rank types of lung cancer in order of prevalence?
-Adenocarcinoma (35-40%)
-Squamous cell (20%)
-Small cell (10-15%)
-Large cell (3-5%)
-Bronchioalveolar cell (2%)
Hemoptysis is most common in which type of lung cancer?
Squamous cell
Squamous cell carcinoma - CXR?
-Centrally located, intraluminal mass
-Hiar adenopathy
-Mediastinal widening
Squamous cell carcinoma - arises from?
Bronchial epithelium
Adenocarcinoma - arises from?
Mucous glands
Adenocarcinoma- CXR?
-Solitary, peripheral nodule with variable margins
Large cell carcinoma - CXR?
-Large mass > 3cm with quick doubling time
-Pleural effusion
Small cell carcinoma - CXR?
-Hilar abnormalities
-Mediastinal abnormalities
Lung cancer - symptoms?
-Anorexia
-Weight loss
-Weakness
-New cough
-Hemoptysis
-Pain in the bones
-Clubbing
Complications of lung cancer?
-Horner syndrome
-Superior vena cava syndrome (supraclavicular venous engorgement)
-SIADH (in small cell carcinoma)
Lung cancer - labs?
-Sputum cytology
-Thoracentesis
-Thoracoscopy
-Fiberoptic bronchoscopy
TNM staging for lung cancer?
-T = size and location of tumor
-N = nodal metastisis
-M = distance metastisis
Small cell lung cancer - tx?
-Cisplatin
-Etoposide
What is the most common diagnosis among patients with interstitial lung disease?
Idiopathic interstitial pneumonia
Idiopathic Interstitial Pneumonia - symptoms and signs?
-Insidious dry cough
-Dyspnea (months to years)
-Clubbing
-Late inspiratory crackles
-Restrictive disease on PFTs
-Pleural-based honeycombins on CT
Idiopathic Interstitial Pneumonia - diagnostic techqniues?
-Bronchoalveolar lavage
-Transbronchial biopsy
-Surgical lung biopsy
Idiopathic Interstitial Pneumonia - tx?
-None
-Lung transplant is only option
-50% 5-year mortality
Sarcoidosis - risk factors?
-Black women < 40 yrs old
Sarcoidosis - symptoms?
Slow onset:
-Malaise
-Fever
-Dyspnea
-Erythema nodosum
-Peripheral neuropathy
-Iritis
-Arthritis
-Hepatosplenomegaly
-Lymphadenopathy
Sarcoidosis - labs and CXR?
-Tissue biopsy (for dx)
-Elevated ESR
-Leukopenia
-Elevated ACE
-Restrictive PFTs (decreased lung volume)

CXR:
-Bilateral hilar adenopathy + parenchymal reticular infiltrates
Sarcoidosis - tx?
-Corticosteroids
What are pneumoconioses?
Chronic fibrotic lung diseases caused by inhalation of inorganic dusts

-Coal worker's pneumoconiosis
-Silicosis
-Asbestosis
Coal Worker's Pneumoconiosis - complications?
Caplan Syndrome:
-Rheumatoid nodules in lung periphery
-Rheumatoid arthritis
Coal Worker's Pneumoconiosis - CXR?
-Diffuse opacities in upper lungs
Silicosis - risk factors?
-Rock minning
-Quarrying
-Stone cutting
-Tunneling
-Sand blasting
-Pottery
Silicosis - CXR?
-Diffuse, small round opacities throughout lung
-Eggshell calcification (calcified hilar lymph nodes)
Silicosis - complications?
-TB
Asbestosis - risk factors?
-Mining
-Insulation
-Construction
-Ship building
-Pipe fitting
Asbestosis - CXR?
-Linear streaking at lung bases
-Honeycombing
-Various opacities
-Pleural calcification
Tx for pneumoconioses?
Purely supportive
How much fluid is in normal pleural space?
5-15 mL
4 types of pleural effusion?
1. Transudative = increased hydrostatic pressure or decreased oncotic pressure
2. Exudative = Abnormal capillary permeability or decreased lymphatic clearance
3. Empyema = infection in pleural space
4. Hemothorax = bleeding in pleural space
Causes of transudative pleural effusion?
-CHF (MC = 90%)
-Cirrhosis with ascites
-Nephrotic syndrome
-Peritoneal dialysis
-Myxedema
-Atelectasis
-Constrictive pericarditis
-Superior vena cava syndrome
-Pulmonary embolism
Causes of exudative pleural effusion?
-Pneumonia (or any infection)
-Cancer (usually lung or breast)
-Pulmonary embolism
-Tb
-Connective tissue disease
-Asbestos
-Pancreatic disease
-Uremia
-Sarcoidosis
-Drug reaction
-Post-MI syndrome
Pleural effusion - symptoms?
-Dyspnea
-Dry cough
-Chest pain with breathing
-Dullness to percussion (shifting with change in position)
Lab findings of exudative pleural effusion?
1. Ratio of pleural fluid protein to serum protein > .5
2. Ration of pleural fluid LD to serum LD > .6
Lab findings of transudative pleural effusion?
1. Pleural glucose = serum glucose
2. pH between 7.4-7.55
3. < 1 x 10^9 WBCs per Liter
How much fluid is needed before you can see a pleural effusion on CXR?
-75-100 mL for lateral CXR
-175-200 mL for PA CXR
Empyema - tx?
Always drain via tube thoracostomy
Types of Pneumothorax?
1. Primary spontaneous = no underlying lung disease
2. Secondary spontaneous = complication of pre-existing pulmonary disease
3. Traumatic = from penetrating or blunt trauma
4. Iatrogenic = from thoracentesis, biopsy, catheter, bronchoscopy, positive-pressure ventiltion
5. Tension = air enters pleural space on inspiration but doesn't leave on expiration
Spontaneous pneumothorax - risk factors?
-Tall thin boys
-Family hx
-Smoking
-COPD
-Asthma
-CF
-Tb
-Menstruation
-Pneumocystis pneumonia
Pneumothorax - symptoms?
-Chest pain
-Dypnea
-Diminished breath sounds (if large)
-Decreased tactile fremitus (if large)

If tension:
-Tachycardia
-Hypotension
-Mediastinal or tracheal shift (towards the good side)
Pneumothorax - tx?
If small (<15%) and stable:
-nothing

If primary spontaneous and large:
-small bore catheter

If severe, secondary, or tension:
-chest tube (tube thoracostomy)
What is ARDS?
-Acute hypoxemia respiratory failure following a systemic or pulmonary insult
-NO evidence of heart failure
What is the most severe form of acute lung injury?
ARDS
What are the four characteristics of ARDS?
1. Acute onset within 1 week of known clinical insult
2. Bilateral radiographic pulmonary infiltrates
3. Respiratory failure not explained by heart failure or volume overload
4. PaO2 to FIO2 ratio < 300
ARDS - risk factors?
-Sepsis (33% of cases)
-Aspiration of gastric contents
-Shock
-Infection
-Trauma
-Toxic inhalation
-Near drowning
-Multiple blood transfusions
ARDS - pathophysiology?
-Capillary endothelial cell damage
-Alveolar epithelial cell damage
-Increased vascular permeability
-Decreased production of surfactant
-Pulmonary edema and alveolar collapse
ARDS - symptoms? CXR?
-Profound dyspnea (12-48 hours after initial cause)
-Intercostal retraction
-Crackles
-Diffuse bilateral infiltrates (not in costophrenic angles)
-Air bronchograms
-Hypoxemia that does not respond to O2
-NORMAL heart size
-NO pleural effusions
ARDS - tx?
-Tx underlying cause
-Tracheal intubation
-Positive End Pressure (PEEP) to get PaO2 > 55 and SaO2 > 88%
-Avoid excess fluids
What is the third leading cause of death among hospitalized patients?
PE
What percentage of patients with DVT will develop PE?
50-60%
What is Virchow's triad?
-Venous stasis
-Injury to vessel wall
-Hypercoagulability
What are the risk factors for PE?
-Bed rest
-Obesity
-Stroke
-Polycythemia
-Low cardiac output
-Pregnancy
-Trauma
-Oral contraceptives
-Malignancy
-Lupus
-Factor V Leiden
What is the most common inherited cause in Whites of hypercoagulability?
factor V Leiden (resistance to activated protein C)
PE - symptoms?
-Dyspnea
-Tachypnea
-Pain on inspiriation
-Hemoptysis
-Leg pain
-Cough
-Tachycardia
PE - labs and imaging?
-ECG = non-specific ST and T wave changes
-Respiratory alkalosis
-Hypoxia
-Widened alveolar-arterial PO2
-D-dimer > 300-500
-CXR = westermark sign (prominent pulmonary artery) and hampton hump (increased opacity in pleura)
What is used as the initial diagnostic study in the US for suspected PE?
Helical CT pulmonary angiography
What is the Well's Criteria for PE?
-Signs of DVT = 3
-Alternative diagnosis less likely than PE = 3
-Tachycardia = 1.5
-Immobilization > 3 days = 1.5
-Previous PE or DVT = 1.5
-Hemoptysis = 1
-Cancer = 1

PE likely if > 4
PE unlikely if < or = 4
PE - tx?
-Heparin
-Warfarin for 3 months (if 1st PE) or 6-12 months (if recurrent episode)
-Thrombolytic therapy (e.g., streptokinase) if high risk of death
-Inferior vena cava filter (possible)
Pulmonary Hypertension - definition?
Elevated pulmonary arterial pressure.
-Systolic pressure > 30
-Mean pressure > 20
Pulmonary Hypertension - 5 group WHO classification?
-Group 1 = pulmonary arterial hypertension due to pulmonary vasculopathy
-Group 2 = PH due to left heart failure
-Group 3 = PH due to lung disease/hypoxemia (e.g. COPD)
-Group 4 = PH due to thromboembolic disease
-Group 5 = PH due to hematologic, systemic, metabolic, or miscellaneous causes
Pulmonary Hypertension - NYHA 4 classes?
-Class 1 = no symptoms, normal activity
-Class 2 = symptoms with ordinary activity, slight limitation of activity
-Class 3 = symptoms with less than ordinary activity, marked limitation of activity
-Class 4 = symptoms at rest, inability to perform basic activity
Pulmonary Hypertension - symptoms?
-Dyspnea with exertion
-Chest pain
-Nonproductive cough
-Fatigue
-JVD
-Split S2
-S3
-Tricuspid regurg murmur
-Hepatomegaly
-Edema
Pulmonary Hypertension - labs and imaging?
-EKG = right arterial and ventricular hypertrophy (if advanced)
-CT = enlarged pulmonary arteries
-Cardiac catheterization (gold standard)
What is the gold standard for diagnosis of pulmonary hypertension?
-Right-sided cardiac catheterization
Pulmonary Hypertension - tx?
-CCBs (first line therapy)
-Endothelin receptor antagonists
-Phosphodiesterase inhibitors
-Prostanoid Eprprostenol inusion
What is the most important prognostic factor in assessing pulmonary hypertension?
Right ventricular function (cor pulmonale = poor survival)
Cor Pulmonale - causes?
-COPD (most common)
-Pulmonary fibrosis
-Pulmonary HTN
Cor Pulmonale - symptoms?
-Pitting Edema
-Dyspnea on exertion
-Hepatomegaly
-Abdominal distention
-Chronic productive cough
-Hepatojugular reflux (> 1 cm)
-Ascites
-S3
-RV parasternal lift
Cor Pulmonale - labs and imaging?
-EKG = right axis deviation, peaked p-waves
-CXR = enlarged pulmonary vessels and enlarged right heart
Cor Pulmonale - tx?
-O2
-Salt and fluid restriction
-Diuretics
Croup - risk factors?
-Age 6 months - 5 years old
-Fall/early winter
Croup - organisms?
-Parainfluenza (MC)
-RSV
-Coronavirus
-Rhinovirus
-Influenza
Croup - symptoms?
-Prodrome of URI
-Stridor
-Barking cough
-NO drooling
Croup - CXR?
-Steeple sign (subglottic narrowing)
Croup - tx?
-Hydration
-Racemic EPI (if stridor at rest)
-Dexamethasone glucocorticoids
-Inhaled budesonide
-Admit to hospital if not better within 3 hours of tx
Epiglottitis - organisms?
-H flu (in unimmunized pts)
-Strep
-Neisseria meningitides
Epiglottitis - symptoms?
-Acute onset of high fever
-Dysphagia
-Drooling
-Muffled voice
-Inspiratory retractions
-Stridor
-Cyanosis
-Sniffing dog position (neck hyperextended)
Epiglottits - CXR?
-Thumbprint sign (swollen epiglottis)
Epiglottitis - tx?
-Endoctracheal intubation
-Ceftriaxone
Most common cause of bacterial tracheitis (pseudomembranous croup)?
-Staph aureus
Pertussis - orgnaism?
Bordetella pertussis
Pertussis - symptoms?
Catarrhal stage (first 3 weeks):
-Rhinitis
-Sneezing
-Mild cough
-No fever or mild fever

Paroxysmal cough stage (weeks 3-7):
-10-30 coughs ending with loud inspiration (whoop)
-Vomiting
-Cyanosis
-Sweating
-Fatigue
Pertussis - labs and CXR?
-Lymphocytosis
-Nasopharyngeal swab culture or PCR (proves dx)
-CXR = "shaggy" heart border and thickened bronchi
Pertussis - complications?
-Bronchopneumonia (MC)
-Atelectasis
-Recurrent URIs
-Otitis media
-Epistaxis
-Subconjunctival hemorrhage
Pertussis - prevention?
-DTaP
-Booster with Tdap
-Prophylaxis with azithromycin for family members
Pertussis - tx?
-Azythromycin
-Corticosteroids (possibly)
-Albuterol (possibly)
Foreign body aspiration - risk factors?
-Age 6 months - 4 years
-Older siblings feeding children
Foreign body aspiration - symptoms?
-Choking
-Inability to vocalize or cough (if complete obstruction)
-Drooling
-Stridor
Foreign body aspiration - gold standard for dx?
Rigid bronchoscopy
Foreign body aspiration - tx?
-Less than 1 years old and conscious = back blows alternating with chest thrusts
-Older than 1 and conscious = heimlich maneuver
-If unconscious = CPR
-Rigid bronchoscopy
Hyaline Membrane Disease - cause?
Deficiency of surfactant causing alveoli to collapse
What is the most common cause of respiratory distress in the preterm infant?
Hyaline membrane disease
Hyaline Membrane Disease - symptoms?
-Nasal flaring
-Grunting
-Retractions
-Cyanosis
-Tachypnea
-Decreased air movement on auscultation
Hyaline Membrane Disease - CXR?
-CXR = atelectasis, ground glass appearance, air bronchograms
Hyaline Membrane Disease - tx?
-O2 and CPAP
-Surfactant
Hyaline Membrane Disease - prevention?
Surfactant for any baby delivered < 27 weeks
JNC-8 blood pressure goals?
-CKD = <140/90
-DM = <140/90
-Age<60 = <140/90

-Age>60 without CKD or DM = <150/90
ADA blood pressure goals?
-DM = <140/80
-If over 80 yrs old, avoid bp < 130/65
What lifestyle modifications does the ADA recommend for HTN?
-Weight loss (decreases 5-20 mmHg per 10 kg)
-DASH diet with sodium restriction (8-14 drop)
-Moderate alcohol intake (2-4 drop)
-Increase exercise (4-9 drop)
When should you screen for elevated BP according to the ADA?
At every visit
How have deaths from stroke and MI changed over time?
Decreased
Which group has top mortality from cardiovascular problems?
Blacks
What percentage of HTN is due to primary? secondary causes?
Primary = 95%
Secondary = 5%
Common causes of secondary hypertension?
-Estrogen (OCs, pregnany)
-Renal disease
-Hyperaldosteronism
-Coarctation of aorta
-Pheochromocytoma (increased catacholamines)
-Hypercalcemia
-Thyroid disorders
-Cushings
-Neurologic changes
Complications of HTN?
-Encephalopathy
-Cerebral hemorrhage
-LVH
-CHF
-Renal insufficiency
-Aortic dissection
-Atherosclerosis
What is the proper way to measure BP?
-Arm at heart level
-cuff 80% of arm
-5 minutes after rest
-No nicotine, caffeine within 30 minutes
-Mercury is better than aneroid
-2 measurements 2 minutes apart
HTN - risk factors?
-Age
-Blacks
-Men
-Family history
-Smoking
-Obesity
-Sedentary lifestyle
-High salt diet
-Alcohol
-Low calcium and potassium diet
-DM
Recommended HTN drugs for non-blacks?
-Thiazide
-ACE-I
-ARB
-CCB
Recommended HTN drugs for blacks?
-CCB
-Thiazide
Recommended HTN drugs for CKD?
-ACE-I
-ARB
When should you add on another drug to HTN meds?
-Goal not met within 1 month = increase dose or add second drug
-Dx of stage 2 HTN (>160/100)
When should you refer HTN to specialist?
-BP not controlled with 3 drug regimen
Thiazide diuretics - mechanism of action?
-Inhibits renal sodium and chloride, so you lose plasma volume
-Vasodilation and reduces vascular resistance long-term (possibly)
Thiazide diuretics - side effects?
-Hyponatremia
-Hypokalemia
-Hypercalcemia
-Hyperglycemia
-Hyperlipidemia
-Increased uric acid (gout)
-Sexual dysfunction
Which thiazide diuretic is preferred in clinical trials and is longer acting?
Chlorthalidone
Spironolactone - side effects?
-Hyperkalemia
-Gynecomastia
Beta 1 receptors have what effect? Beta 2 receptors?
Beta 1:
-Increase HR
-Increase Contractility
-Increase Conduction

Beta 2:
-Increase Bronchial muscle relaxation
-Increase arteriolar dilation
Atenolol - mechanism of action?
-Beta blocker
-Increases peripheral resistance
-Decrease plasma renin
-Decreases cardiac output
Beta blockers - contraindications? side effects?
-Asthma
-COPD
-Peripheral vascular disease
-Heart block > 1st degree
-DM (can mask hypoglycemia)

-Increases risk of stroker
-Increases lipids
Carvedilol - mechanism of action?
Alpha antagonist + Beta blocker
Alpha 1 receptors have what effect? Alpha 2 receptors?
Alpha 1:
-Vasocontriction

Alpha 2:
-Inhibits sympathetic output
Prazosin - side effects?
-First doe orthostatic hypotension (give at night)
-Increased risk of heart failure
Clonidine - mechanism of action?
Alpha 2 agonist (decreased sympathetic activity)
Clonidine - side effects?
-Rebound hypertension with sudden d/c
-Drowsiness
-Sedation
-Dry mouth
-Orthostatic hypotension
Angiotensin II - effects?
-Stimulates sympathetic activity
-Vasoconstriction
-Increases aldosterone - increases plasma volume
Enalapril - mechanism of action?
ACE-Inhibitor (blockers angiotensin I to angiotensin II)
Enalapril - contraindications? side effects?
-Potassium sparing diuretic use
-Solitary kidney
-Renal artery stenosis
-Pregnancy

Side effects:
-Hyperkalemia
-Cough
-Dysgeusia (altered taste)
-Angioedema
Losartan - mechanism of action?
-Blocks angiotensin II reeptor site
Aliskiren - mechanism of action?
-Renin inhibitor
Aliskiren - contraindications? side effects?
-Pregnancy

Side effects:
-Hyperkalemia
-Increased uric acid
Nifedipine - mechanism of action?
CCB dihydropyridine (causing smooth muscle relaxation)
Nifedipine - side effects?
-Dizzines
-Flushing
-Headache
-Edema
Non-dihydropyridines?
-Diltiazem
-Verapamil
Direct vasodilators?
-Hydralazine
-Minoxidil
Hydralazine - side effects?
-Fluid retention
-Reflex tachycardia
-Positive ANA tests
Minoxidil - side effects?
-Fluid retension
-Reflex tachycardia
-Hypertrichosis (hair growth)
Hypertensive Urgency - symptoms?
>220/125 without symptoms
Hypertensive Emergency - symptoms?
-Diastolic usually > 130
-Hypertensive encephalopathy (headache, irritability, confusion)
-Hypertensive nephropathy (hematuria, proteinuria)
-Intracranial hemorrhage
-Asortic dissection
Hypertensive Emergency - tx guidelines?
-Reduce pressure by no more than 25% within 2 hours
-Then reduce slowly to 160/100 over 2-6 hours
Malignant Hypertension - definition?
Encephalopathy/Nephropathy + Papilledema
Drugs for Hypertensive Emergency?
-Nicardipine
-Labetolol
-Clevidipine
-Esmolol
-Fenoldopam
-Enalaprilat
-Nitroglycerin (only if MI)
-Nitroprusside (if aortic dissection)
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