6) Pulmonary (Part 2) Flashcards

1
Q

Virchow’s Triad

A
  • Stasis
  • Endothelial cell injury
  • Hypercoagulable states
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2
Q

Specific risk factors for venous thromboembolism (VTE)

A
  • Malignancy
  • Immobilization
  • Surgery within last 3 months
  • Preexisting respiratory disease
  • Prior Hx of VTE
  • Chronic heart disease
    Stroke
  • Thrombophilia
  • Inflammatory triggers
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3
Q

Inflammatory triggers that can pose risk of VTE

A
  • Infection
  • Tranfusion
  • Erythropoiesis stimulating Rx
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4
Q

Specific risk factors for VTE in women

A
  • Obesity
  • Pregnancy
  • Hypertension
  • Heavy cigarette use
  • Oral Contraceptive Pills/Hormone Replacement Therapy (OCP’s/HRT)
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5
Q

Most common route of VTE

A
  • LE thrombus –> IVC –> R ventricle –> pulmonary arteries
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6
Q

Signs and symptoms of VTE

A
  • Dyspnea (79%)
  • Tachypnea (57%)
  • Pleuritic pain (47%)
  • Leg edema, erythema, tenderness, palpable cord (47%)
  • Cough/hemoptysis (43%)
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7
Q

Other possible findings in VTE

A
  • Tachycardia
  • RV gallop
  • Loud P2, & prominent jugular “a” waves suggest RV failure
  • Syncope or sudden death with massive PE
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8
Q

Typical ABG findings

A
  • Hypoxemia (Low PaO2)
  • Hypocapnia (Low PaCO2)
  • Increased alveolar-arterial oxygen gradient (A-a gradient)
  • 15%-20% have normal ABG’s
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9
Q

A-a gradient

A
  • A measure of how effectively oxygen in your alveoli moves into your pulmonary vasculature
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10
Q

A-a gradient calculation

A
  • PAO2 – PaO2
  • PAO2 is calculated from the alveolar gas equation
  • PaO2 is measured in the arterial blood
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11
Q

A-a gradient measured from the ABG results

A
  • A-a gradient = [ (FiO2) x (Atmospheric Pressure - H2O Pressure) - (PaCO2/0.8) ] - PaO2 from ABG
  • A-a gradient = [.21 x (760-47) – (PaC02/0.8) ] - PaO2
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12
Q

Normal A-a gradient room air

A
  • 10 to 20 mmHg
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13
Q

Increased A-a gradient may be a result of

A
  • V/Q (ventilation-perfusion) imbalance
  • Anatomic shunts
  • Impaired diffusion
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14
Q

Adjunctive studies in the evaluation of PE

A
  • ABG’s
  • EKG’s (S1Q3T3)
  • CXR’s
  • Echocardiograms
  • Doppler (to evaluate for DVT)
  • Cardiac Enzymes and BNP
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15
Q

Primary studies in the evaluation of PE

A
  • D-dimer strategy combined with CT angio
  • V/Q scan based strategy
  • Pulmonary angiography (gold standard, but invasive)
  • MRI/MRA
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16
Q

CXR findings in PE

A
  • That was a “WHALE” of a PE
  • W= Westermark Sign
  • H =Hampton’s Hump
  • A = Atelectasis
  • L = Lovely (Meaning perfectly normal)
  • E = Effusions
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17
Q

Westermark sign

A
  • Seen on plain film radiography CRX
  • Dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels (often with a sharp cut off)
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18
Q

Hampton’s Hump

A
  • Pleural based opacities with convex medial margins on CRX
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19
Q

CRX in PE may show

A
  • Collapse
  • Consolidation
  • Small pleural effusion
  • Elevated diaphragm
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20
Q

Ultrasound

A
  • Duplex scanning with compression will aid to detect any thrombus
  • Highly sensitive and specific for diagnosing DVT
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21
Q

Ultrasound looks for

A
  • Loss of flow signal
  • Intravascular defects
  • Non collapsing vessels in the venous system
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22
Q

D-Dimer

A
  • Degredation product of crossed linked fibrin
  • Detectable above 500 ng/ml in nearly all cases of VTE, but common in many other conditions (sensitive but not specific)
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23
Q

V/Q scanning

A
  1. Radioactive cmpd inhaled (distributes evenly in normal lung)
  2. Radioactive cmpd injected into vein, travels to tissues in blood vessels (no injected material in a region indicated embolus)
  3. “Mismatch” of inhaled and injected cmpds on lung scan images = pulmonary embolus
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24
Q

Acute treatment for pulmonary embolism

A
  • Anticoagulation for most patients
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25
Anticoagulation in acute PE Tx
- Low molecular weight heparin (IE Lovenox); Fondaparinux (Arixtra); or unfractionated heparin - There are some new approved Oral anticoagulants for acute treatment (IE Rivaroxaban (Xaletro))
26
"Massive PE"
- "Massive PE" - hypotensive/unstable patient without a pulse - If no contraindications – systemic thrombolytics - Catheter based therapy to break up the - Surgical Thrombolectomy
27
Tx for acute PE if contraindications to Anticoagulation (IE active hemorrhage, low hemagobin/hematocrit)
- IVC Filter
28
Long term PE Tx
- Anticoagulation (Oral) for at least 3 months | - Most continue beyond that if low bleeding risk
29
Bronchitis
- Usually viral, sometimes bacterial - Non-smokers: M. pneumoniae - Smokers: S. pneumoniae
30
Bronchitis symptoms
- Cough - Fever - Sore throat - Rhonchi - Wheezing
31
Bronchitis diagnosis
- Usually clinical | - CXR rules out other causes
32
Bronchitis Tx
- Rest, fluids, analgesics - Bronchodilators/steroids may be considered - Antibiotics show no benefit for true viral bronchitis (use only if underlying bacterial etiology or high risk patients)
33
Pneumonia organisms
- S. pneumoniae (pneumococcus) - Mycoplasma pneumoniae - Influenza - Gram negative bacilli - Legionella pneumonia
34
Pneumonia clinical features
- Fever - Chills - Productive cough - Pleuritic chest pain
35
Pneumonia physical exam findings
- Signs of consolidation (egophony, increased fremitus) | - Bronchial breath sounds and rales/crackles over the affected areas
36
Pneumonia diagnostic studies
- CXR | - Labs
37
Labs for pneumonia diagnostic studies
- WBC normal or slightly elevated - Sputum for gram stain and culture may detect specific organisms - Blood cultures x 2 may detect specific organisms (especially with septicemia) - Urine antigen test (as indicated) – highly specific for Legionella pneumonia
38
Community acquired pneumonia Tx
- Empiric therapy (outpatient) | - Admit if hypoxic (O2 sat < 90%, septic, etc.) for inpatient empiric therapy
39
Empiric therapy (outpatient)
- Amoxicillin (Streptococcus pneumonia coverage) - Macrolides (EES, azithromycin, or clarithromycin) - Doxycyline/Tetracycline - Respiratory fluoroquinolones - levofloxacin [Levaquin], gatifloxacin [Tequin], moxifloxacin [Avelox]
40
Empiric therapy (inpatient)
- Intravenous beta-lactam (cefuroxime, ceftriaxone [Rocephin], cefotaxime [Claforan]) with a macrolide - Intravenous respiratory fluoroquinolones
41
Viral pneumonia organisms
- Influenza - Parainfluenza - Respiratory syncytial virus (RSV) - Adenovirus
42
Viral pneumonia CXR shows
- Patchy infiltrates
43
Viral pneumonia Tx
- Supportive care | - Flu antiviral drugs reduce duration but not severity of pneumonia caused by Influenza
44
Pneumonia (Pneumococcal)
- S. pneumoniae (most common in adults)
45
Pneumonia (Pneumococcal) symptoms
- Fever - Chills - Rusty sputum
46
Pneumonia (Pneumococcal) diagnosis
- Gram stain = gram postitive diplococci | - CXR = lobar consolidation or effusion
47
Pneumonia (H flu)
- Primarily seen with COPD patients | - Dx: CXR, Gram stain = gram negative coccobacilli
48
Pneumonia (Klebsiella)
- Seen in alcoholics, often due to aspiration - High mortality - S/S: “currant jelly sputum” - Dx: CXR, gram negative bacilli on Gram stain
49
Pneumonia (Mycoplasma)
- “Atypical pneumonia”, seen in close quarters (military), is the most common pneumonia in younger patients - Dx: CXR, Gram’s stain = nothing (no cell wall), positive cold agglutinin test
50
Pneumonia (Legionella)
- “Atypical” air conditioners, Cruise ships, hotels, etc. - S/S: GI and CNS symptoms + fever, cough, etc - Dx: CXR, urine antigen test is definitive
51
Pleural effusion symptoms
- Dyspnea | - Pleuritic chest pain
52
Pleural effusion clinical findings
- Dullness to percussion - Diminished or inaudible breath sounds - Pleural friction rub - Decreased tactile fremitus - Asymmetric thoracic expansion, with lagging expansion on the affected side
53
Some causes of pleural effusion
- Malignancy - Pneumonia - Heart failure - Cirrhosis - Nephrotic syndrome
54
Best next step for pleural efusion
- Thoracentesis
55
Pneumothorax
- Accumulation of air in the pleural space
56
Pneumothorax symptoms
- Sudden onset of dyspnea | - Ipsilateral chest pain
57
Pneumothorax physical exam findings
- Decreased or absent lung sounds (unilateral) - Decreased thoracic expansion (unilateral) - Decreased tactile fremitus (unilateral) - Tachycardia
58
Pneumothorax CXR
- Visceral pleural line on chest radiograph is diagnostic | - Expiratory film will increase sensitivity
59
Primary pneumothorax
- Most commonly seen in tall slim young males, smokers, & Marfan syndrome
60
Primary pneumothorax Tx
- Small pneumothoraces may be managed with O2 tx and repeat observation with CXR - Larger pneumothoraces require chest tube placement
61
Secondary pneumothorax
- Complication of underlying lung disease (IE COPD, Cystic Fibrosis) - TX: chest tube
62
Traumatic pneumothorax
- Penetrating chest trauma - Clinician induced (ie complication from subclavian central line placement) - TX: chest tube
63
Tension pneumothorax
- Medical emergency - TX: immediate placement of large bore needle with a catheter in the 2nd ICS MCL followed by chest tube placement when available.