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Pulmonary > Clinical Pulm > Flashcards

Clinical Pulm Flashcards

1
Q

Common Indications for Pulmonary Function Testing

A
  1. Categorization of the type and severity of physiologic perturbation
  2. Objective assessment of pulmonary symptoms
  3. Documentation of progression of disease
  4. Documentation of the patient’s response to therapy
  5. Preoperative assessment
  6. Screening for sub-clinical disease
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2
Q

Normally FVC and SVC are equal, but when are they different?

A

FVC is usually lower in patients with airway obstruction.

Because extra effort results in airway compression and early airway closure.

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3
Q

Most commonly employed measure of the rate of expiratory flow. If decreased, can indicate what?

A

Forced expiratory volume in 1 second (FEV1)

Decreased:

  • Airway obstruction
  • Less volume in lungs to start with
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4
Q

Important parameter to determine whether there is airway obstruction

A

FEV1/FVC ratio

Less than 0.7 indicates presence of airway obstruction

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5
Q

Clinical examples of obstructive lung disease. (Define)

A

Diseases that lead to increased resistance to airflow.

  • Emphysema
  • Asthma
  • Chronic Bronchitis
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6
Q

Restrictive Lung Disease (Define, types)

A

Diseases that cause a reduction in lung volume

  1. Diseases which decrease lung compliance
    - pulmonary fibrosis
    - pulmonary edema
  2. Decrease chest wall compliance:
    - kyphoscoliosis
  3. Pleural diseases
  4. Diseases of respiratory muscles
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7
Q

What is considered a positive response to a bronchodilator?

A

Increase in FEV1 or FVC of at least 12% and at least 200mL

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8
Q

What is a positive response to a challenge test?

A

A drop in FEV1, FVC, or Peak expiratory flow (PEF) of greater than 20%

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9
Q

What is the exposure of choice to induce bronchospasm in occult asthmatics?

A

Methacholine (a histamine derivative)

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10
Q

Two types of spirometric tracing? Advantages of one over the other?

A
  1. Volume vs. time tracing
  2. Flow vs. volume loop
    Advantages of flow-volume loop over simple volume-time tracing:
    -Assessment of patient effort on repetitive testing
    -Presence of specific patterns for upper airway obstruction
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11
Q

FO2 of gas reaching a patient’s lungs depends on what 3 factors?

A
  • FO2 being delivered to the patient
  • Flow rate of the delivered gas
  • Patient’s spontaneous inspiratory flow rate
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12
Q

Change in trachea position- which way will it deviate towards?

A

Deviates towards side of volume loss (for example, atelectasis) and away from space occupying lesion.

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13
Q

Intercostal retractions are exaggerated in patients with?

Exaggerated bulging?

A

Intercostal retractions: Obstructive airway disease, Pulmonary fibrosis
Exaggerated bulging: Obstructive airway disease (not emptying efficiently)

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14
Q

Kussmaul’s respirations

A

Deep, labored, regular breathing usually associated with severe mtabolic acidosis, particularly diabetic ketoacidosis

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15
Q

Biot’s breathing. Seen in patients with?

A

Similar to cheyene-stokes. Periods of alternating apnea, but respiration pattern is deep regular breaths that terminate aburptly rather than crescendo-descrescendo seen in cheyene stokes.
Patients: Meningitis

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16
Q

Central neurogenic hyperventilation. Seen in patients with?

A

Rapid deep hyperpnea.

Patients: brainstem injury from midbrain to pons.

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17
Q

Apneustic breathing. Seen in patients with?

A

Prolonged inspiratory cramp.

Patients: Neurological linjury to the mid to lower pons

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18
Q

Ataxic breathing. Seen in patients with?

A

Irregular in depth and pace of respiration.

Patients: damage at level of medulla

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19
Q

Use of sternocleidomastoid muscles in respiration generally suggests?

A

That the FEV1 is reduced to 30% of normal

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20
Q

Respiratory paradox

A

Abdomen goes in instead of out during inspiration.
Due to weakened diaphragm, which now gets pulled up by the negative intrathoracic pressure generated by accessory muscles.
Sign of impending respiratory failure.

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21
Q

Crepitation. Caused by? Generally implies?

A

Crackle
Caused by subcutaneous air
Generally: Bronchopleural fistula

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22
Q

Fremitus. Increased fremitus indicates? Decreased fremitus indicates? In which lobe of the lung is fremitus more intense and why?

A

Vibration felt through the chest wall
Increased: Consolidation of the lung
Decreased: airway obstruction from tumor, pneumothorax or pleural effusion
Fremitus is more intense in the right upper lobe since trachea is in direct contact with it, whereas the trachea is separated from the left upper lobe by the aorta.

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23
Q

Percussion sounds: (indications?)
Hyperresonant
Tympanitic
Dull

A

Hyperresonant (emphysematous lung)
Typmanitic (gastric bubble)
Dull (pleural effusion or consolidated lung)

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24
Q

Vesicular breath sounds.

A
  • Made by normal alevoli.
  • Long inspiratory phase then expiratory phase
  • Audible over anterior and posterior chest
  • Normal
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25
Q

Bronchial breath sounds

A
  • Sound from large airways
  • Longer expiration than inspiration
  • Always pathological
  • Reflect consolidadtion of the lung
26
Q

Bronchovesicular breath sounds

A
  • Expiratory and inspiratory phases are roughly equal

- Suggests small degree of consolidation

27
Q

Rales suggest?

A 
Crackling sounds
Suggest parenchymal disease:
-Heart failure
-Pneumonia
-Fibrosis
28
Q

Rhonchi. Most often heard during? Suggest?

A

-Continuous low-pitched sound
-Most often heard during expiration
Suggests airway disease:
-Asthma
-COPD
-Secretions

29
Q

Wheezing. Causes?

A

Obstructive airway disease

Bronchial obstruction from tumor or foreign body

30
Q

Rubs. Caused by? Such as?

A

Casued by inflammatory disease of either or both pleural surfaces:

  • Pneumonia
  • Pulmonary embolism
  • Rheumatologic disease
  • Malignant disease
31
Q

Bronchophony

A

When listening over consolidated lung:

  • words sound closer to ear
  • Syllabus clearly distinguishable
32
Q

Whispered Pectoriloquy. Sign of?

A

Whispered words are audible at the periphery of the lung

-Sign of consolidated lung.

33
Q

Egophony. Sign of?

A

Patient vocalizes “e” but is heard as an “a”

-Sign of consolidated lung

34
Q

Postero-Anterior (PA) radiograph

A

Places patient’s anterior chest wall next to film cassette
Placing heart next to cassette reduces magnification and increases image sharpness
-View taken during deep inspiration
-Quicker, inspiration is improved, heart is less magnified

35
Q

Antero-posterior (AP) radiograph

A

Used when the patient is unable to stand or sit
Increases magnification
Decreases image sharpness

36
Q

Which tissue densities can we see on the radiograph? (In order of increasing density)

A
  • air
  • fat
  • water
  • metal
37
Q

Silhoeutte Sign

A

Loss of normal interface between two structures of different density

38
Q

Left major fissure vs Right major fissure vs Minor fissure

A

Left major fissure: More vertical, separates the LUL from the LLL
Right major fissure: More oblique, separates the RUL and RML from the RLL
Minor fissure: separates the RUL and RML

39
Q

Hila

A

Where the pulmonary arteries and veins and main bronchi enter the lung.
The left hilum is superior to the right in 98% of normal CXRs
The right and left are of same height in 2% of normal CXRs
The right hilum is never normally higher than the left

40
Q

Which diaphragm is slightly higher than the other?

A

Right diaphragm is usually slightly higher than the left.

41
Q

Patients with cardiovascular limitation vs those with respiratory limitation?

A

Cardiovascular limitation:
-Have peak heart rate that exceeds 90% of their predicted value
-Maximum minute ventilation that is far below their MVV
Respiratory limitation:
-Quickly reach their maximum attainable minute ventilation, which will be very close or even greater than their calculated MVV
-Since exercise is terminated early, they will not reach their predicted max heart rate and often don’t reach anaerobic threshold.

42
Q

How is chronic bronchitis diagnosed?

A

Clinically: presence of a productive cough for at least 3 months in each of 2 successive years
On histo, one will see airway inflammation and edema, mucous gland hypertrophy, and excessive bronchial secretions.

43
Q

How is emphysema diagnosed?

A

Histologically: by destruction of alveolar walls leading to permanent airspace enlargement. Also destruction of pulmonary capillary bed.

44
Q

How is asthma characterized?

A

Clinically by airflow obstruction that can either be significantly improved or often completely eliminated with bronchodilator therapy.

45
Q

Bronchiectasis

A

A disease in which bronchi become dilated and fail to effectively clear secretions. This leads to chronic airway infection, excessive bronchial secretions, and a chronic productive cough.

46
Q

How does lung elastic recoil affect FRC and TLC?

A

Decreased elastic recoil often causes FRC and TLC to increase.

47
Q

Cor Pulmonale. What is it. Characterized clinically by? Major cause in COPD patients?

A

Enlargement of the right ventricle due to increased right ventricular afterload from diseases of the lungs or pulmonary circulation
Characterized by:
-Increased jugular venous pressure
-Hepatomegaly
-Peripheral edema
Major cause of increased pulmonary vascular resistance in COPD patients: vasoconstriction due to alveolar hypoxia

48
Q

Clinical features of COPD

A
  • Rhonchi may be present during inspiration and expiration.

- Most consistent finding is a prolonged expiratory time (longer than 4 seconds)

49
Q

COPD radiographic features

A
  • Increased thickness of bronchial walls

- Increased prominence of lung markings

50
Q

COPD Pulmonary Function Testing results

A

Spirometry:

  • FEV1 decreases
  • Reduction in FEV1/FVC ratio is diagnostic of obstruction
51
Q

COPD Arterial blood gases

A

Early stages of COPD:
-Mild or moderate hypoxemia w/o hypercapnia
Later stages:
-More severe hypoxemia, accompanied by hypercapnia w/increased serum bicarbonate

52
Q

Systemic Manifestations of COPD

A
  • Skeletal muscle weakness
  • Bone disease
  • Weight loss
53
Q

COPD Treatment

A

Smoking cessation
Medications: anticholinergics (tiotropium)
beta2 agonists (salmeterol, formoterol)
Inhaled steroids
Oxygen therapy
Pulmonary rehabilitation
Surgical options: lung volume reduction surgery, lung transplantation

54
Q

Early Allergic Response (EAR)

A 
Develops within 10 minutes of allergen exposure
Reaching a max at 30 minutes
Resolving within 1-3 hours
IgE-dependent mechanisms
Initiated by mast cell
55
Q

Cardinal symptoms of asthma

A
  • Wheezing
  • Coughing
  • Chest tightness
  • Shortness of breath
56
Q

Biomarkers in Asthma

A

Sputum eosinophils
Periostin
Exhaled nitric oxide

57
Q

Primary classification of drugs used in asthma

A

Short-acting bronchodilators
Anti-inflammatory drugs
Long acting bronchodilators (long-acting beta-2 agonist)
Monoclonal antibodies

58
Q

pathogenesis of asthma and COPD- agents responsible for early reactions vs late asthmatic reaction.

A

Early: Immediate bronchoconstriction- histamine, tryptase, other neutral proteases, leukotrienes C4 and D4, and prostaglandins.
Late: Sustained bronchocontriction- cytokines produced by Th2 lymphocytes, espec. GM-CSF and IL-4, 5, 9, 13. (Attract/activate eosinophils and stimulate IgE production by B lymphocytes

59
Q

2 categories of treatment for asthma and COPD

A
  1. Drugs that inhibit smooth muscle contraction
    - bronchodilators (beta2-adrenergic agonists, methylxanthines, and anticholinergics
  2. Agents that prevent and/or reverse inflammation
    - glucocorticoids
    - leukotriene inhibitors and receptor antagonists
    - mast cell-stabilizing agents or cromones
60
Q

What 3 classes of bronchodilators are in current use?

A

Beta-adrenergic agonists
Theophylline
Anticholinergic drugs

Pulmonary (6 decks)

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