Clinical Flashcards
What’s the most common presentation for restrictive lung disease?
cough
What test should you use to distinguish between restrictive and obstructive lung disease? what finding would indicate these diseases?
spirometry
Low FEV1/FVC obstructive. TLC normal or increased
normal or high FEV1/FVC restrictive. TLC decreased
How would you asses the severity of a restrictive lung disease? How do you interpret your findings?
DLCO- diffusion capacity and lung volumes
What tests would you use to differentiate between types of restrictive lung disease?
DLCO, CXR, and lab tests
Decrease DLCO indicates a interstitial or infiltrative lung disease
Normal DLCO suggests Non pulmonary cause: neuro or MSK
What are some useful values to know when you suspect a neuromuscular cause for a restrictive lung disease? What do you do if this is confirmed?
MIP maximal inspiratory pressure
MEP maximal expratory pressure
abnormal in suspected neuromuscular disease like ALS
patient will likely present with other neurologic complains including weakness and fatigue.
Refer to neurologist
Your patient has an increased FEV1/FVC and decreased TLC. DLCO is also decreased. What test would be most appropriate to do first at this point?
Bronchoalveolar lavage
100% O2 15 mins
Spirometry
CXR
Bronchoalveolar lavage to distinguish the type of interstitial lung disease (ILD)
You have a patient with chronic dyspnea that you suspect of having a restrictive lung disease. What other PE findings might be present? What’s one confounding factor to this diagnosis should it be present?
Check for crackles, cyanosis and additional signs (other than ascities) of R heart failure; JVD ect.
chest pain would be confounding and may relate to systemic disease such as lupus, RA, or sarcoidosis.
What are some signs of interstitial lung disease (ILD) or diffuse parenchymal lung disease (DPLD)? Extrinsic disorders? Neuromuscular?
ILD, DPLD- inflammation and scarring of lung tissue on CXR
Extrinsic disorders- disorders that limit expansion of the lungs; chest wall or pleura. (scoliosis or obesity)
Neuromuscular disorders: decrease ability of respiratory muscles to inflate and deflate the lungs.
Discuss the cough reflex: receptor location, nerve involvement and primary brain center involved
Receptor locations-pharynx, larynx and tracheobronchial tree esp carina
Vagus nerve
Medulla
Describe the 3 phases of a cough
- Inspiratory-air in lungs
- Compressive-Glottis closes to build intrathoracic pressure from expiratory muscle contraction
- Expiratory- release of air (50-500mph)
- Recovery breath.
Discuss the causes and consequences of an ineffective cough
Cause
Intrinsic pulmonary diseasese-obstructive and restrictive. Impairment of expiratory flow or excessive secretions
Extrapulmonary disorders-CNS, PNS, chest wall or upper airway conditions
Consequence
Ineffective clearance of airway
Retained secretions
Atelectasis or infections; the latter can lead to bronchiectasis (permanently dilated airways)
What are 10 complications of a cough
- cardiac arrhythmias (vagas nerve involvement)
- syncope (vaso-vagal)
- Herniations
- urinary incontinence (pregnant women)
- Rib fracture
- headaches
- Pneumothorax
- Ruptured blood vessels
- Decreased quality of life
- laryngeal trauma (hoarseness)
How are coughs classified
Acute less than 3 wks
Subacute 3-8wks
Chronic 8 + wks
Compare and contrast hx and PE findings for acute cough
UACS LRI COPD Aspiration Pul embolism CHF
- Upper airway cough syndrom (UACS)
Common etiologies
a. URI- usually viral, post nasal drainage, tubinate erythema.
b. Acute bacterial sinusitis- purulent nasal drainage, headaches, may start as URI (similar)
c. Allergic rhinitis-rhinorrhea, sneezing, congestion, no fever. Pale turbinates
- Lower respiratory infection
Adventitious lung sounds, usually viral- pertussis, pneumonia. - COPD-cough changes
- Aspiration- Sudden chocking and coughing- young and very old. unilateral decreased breathing sounds
- Pulmonary embolism- Risk factors: DVT, surgery. Symptoms-chest pain, dyspnea, tachypnea, tachycardia.
- CHF- Pulmonary congestion
Know the alarm systems for cough related to a potentially life threatening cause
- Hemoptysis- Serious cause: lung cancer, TB, Pul embolism, Pneumonia. Benign: acute bronchitis
- Fever, purulent sputum- Serious cause: Pneumonia, lung absecss. Benign- sinusitis
- Wheezing and SOB- Serious: Asthma, COPD, CHF. Benign: Acute Bronchitis
- Chest pain- Serious: acute coronary syndrome, Pul. embolism. Benign: Pleurisy
- Dyspnea and edema: Serious: Pul. embolism, CHF. no benign
What’s the diagnostic approach to a patient with chronic cough. What investigative studies are useful
Treat symptoms, if ineffective try potential irritants (smoking, ACEI ect) if inneffective look into top 3 causes and treat in turn; any therapy that works you maintain.
Treatment:
UACS- antihistamine, decongestant
Asthma- albuterol, corticosteroids, methcholine challenge
GERD- elevate bed, lose weight, PPI or H2 blocker
Describe the pathophysiology of non-pulmonary cough
Cardiac
GERD-reflex stimulation more than acid as trigger. Suggestive findings dys____everything: taste, swallowing horse voice, acid reflux. May take 3 months to treat.
Swallowing disorders-stroke lead to aspiration pneumonia and death, neuromuscular disorders ALS etc
Congenital- Tracheo-esophageal fistula lead to severe or fatal complications due to aspiration: Trachea attached to side of the esophagus, or the esophagus branching out from the trachea.
Psychogenic- tic
OMT treatment for various cough etiologies
No thoracic pump release with COPD dont rupture a bleb.
Treat- anterior cervical fascia, cervical ME or HVLA, thoracic HVLA.
Which common drug can cause a chronic cough?
ACEI. switch to ARB
What time of day is a smokers cough the worst and why?
First thing in the morning, because the cillia are getting active again and making mucous.
How might you do a simple test to tease out an upper vs lower respiratory tract disorder?
Have the person cough as a test to see if they clear out any obstruction, if it persists it maybe URT disorder.
LRT may present with rales or rhonchi.
What are the three most common causes of chronic cough?
UACS, Asthma, GERD 90%
If non-smoker, with no ACEI, and normal CXR 99% likely
25% multiple causes
Cite differences between pediatric and adult airways
More acute angle of the epiglottis
Larger tongue
Angled vocal cords
Funnel shaped larynx -narrows to the cricoid cartilage
List signs of a child in respiratory distress compared to normal
Distress: use of accessory muscles to breath
Respiratory observations-retraction of chest, nasal flare, tracheal tug, leaning forward, irritability, decreased responsiveness
Increased respiratory rate
Auditory breath changes- grunting, wheezing
Describe signs of clinical respiratory failure
A child that is unable to maintain adequate O2 despite extra effort and breathing rate.
What are some respiratory causes of dyspnea that would be considered obstructive airway problems?
Choanal atresia retropharyngeal abscess papillomas Inflammation/Infection Epiglottitis Croup Foreign body aspiration
Describe epiglottitis
Sudden onset: Life-threatening bacterial infection of the epiglottis
Haemophilus influenza B (Hib)
Swollen epiglottis and aryepiglottic folds
CT-thumbs up sign, or endoscopy see cherry
4Ds
dysphagia, dysphonia (Hot potato voice), drooling, distress
Don’t look at it the airway may occlude.
What are the signs and symptoms of foreign body in the airway
Ball valve (one way valve, easy to breath in, not out) Acute respiratory failure Cyanosis Cough, gagg Stridor Wheeze
Sudden onset
What’s a TEF?
Tracheoesophageal fistula- This is when the esophagus is malformed and can attach to the trachea in various ways. This can lead to aspiration and breathing complications
What’s a diaphragmatic hernia?
When hole in diaphragm that allows the abdominal contents to move into the chest cavity.
What are some characteristic findings for croup on X-ray?
Steeple sign. Caused by inflammation of area around the vocal cords and trachea
Which complication of pierre robin sequence is typical of infant airway obstruction?
Tongue falls back against the posterior pharynx and causes airway obstruction
The obstruction of which airway is especially serious in infants less than 2 months; why? Name a condition in which bone obstructs this airway.
These infants are obligate nose breathers
Choanal atresia is complete nasal obstruction of a newborn due to bony obstruction. This can lead to infant death by asphyxia
How is hemoptysis different from hematemesis?
Hemoptysis-
cough no nausea or vomiting frothy sputum blood tinged sputum persists for days hx lung disease Significant blood loss uncommon asphyxia possible
Hematemesis (opposite)
no cough etc.
hx gastric or liver disease.
What are some common etiologies of hemoptysis in order of frequency of occurrence?
Bronchitis Lung cancer Bronchiectasis Cryptogenic Pneumonia TB
What are some cardiovascular disorders related to hemoptysis; characterize them
Mitral valve stenosis (Rheumatic fever), or L ventricular failure- pink frothy sputum
Describe in general terms the respiratory pathogenesis of hemoptysis
Frequently involves abnormal vasculature at risk of injury: vasculitis, infection, inflammation, malignancies, AVM, crack cocaine use, pulmonary edema (vascular injury and release of RBC; pink frothy sputum) .
If TB cavitary leson erodes blood vessel you can have massive hemoptysis
If pulmonary embolism leads to infarction=dark red hemoptysis.
What are some traceobronchial causes of hemoptysis?
Bronchitis
Bronchiectasis
Bronchogenic carcinoma
What are some pulmonary parenchyma causes of hemoptysis?
TB, Pneumonia, vasculitits, fungal, abscess,
What are some primary vascular causes of hemoptysis?
Pulmonary embolism-DVT leading to infarct; dark red sputum. pleural effusion and atelectasis. CTA good test.
Crack cocaine-injury to alveolar capillary membrane
Cryptogenic-diagnosis of exclusion. 90% fine in 6 months.
Meds-anti-coagulants, aspirin, cocaine, NSAIDS,
Classify hemoptysis
mild specks of blood in sputum
moderate specks to 200ml in 24 hrs
massive greater than 200ml
What labs or procedures are common when investigating hemoptysis?
CXR
CBC w/diff-infections
ESR-infection, autoimmune
HRCT for suspected bronchiectasis
Bronchoscopy with washing for cytology and C&S for suspected: Brochogenic carcinoma
Pulmonary embolus- CT angiography, D-dimer
TB- TST skin test
Biopsy tumors to determine if they’re benign, and to differentiate between small cell and non small cell carcinoma (so you know if chemo is better than surgery)
Massive hemoptysis can lead to what fatal complication? How can you prevent it?
asphyxiation and respiratory arrest due to blood flooding the tracheobronchial tree.
