Diagnostics and therapeutic skills Flashcards
what should you inspect during pulm exams
- Pattern, depth of breathing
- Time spent in inspiration and expiration
- Symmetry of expansion
- Retractions
- Digital clubbing¹
- Acrocyanosis
- use of accessory muscles
what should be palpated during a pulmonary exam
- tracheal alignment
- tactile fremitus “99”
- assess cardiac impulses for heaves and PMI
what is tachypnea
above 25 breaths per minute (said in class that its 25)
what is a heave
when you feel the heart pushing the chest forward. indicative of enlarged or deviated heart (said in class)
what would increase or decrease tactile fremitus
- increased with consolidation
- decreased/absent with pleural effusion or pneumothorax
where is the point of maximal impulse palpated and in what position
the 4-5th intercostal space in the midclavicular line with the patient in left lateral decubitus position.
abnormal is if the PMI is felt outside of this expected space
(said in class)
what is considered braypnea
less than 12 breaths a minute
what should be assessed during percussion in a pulm exam? what could cause abnormal findings during percussion?
- normal lungs are resonant
abnormal:
* dull - consolidation, pleural effusion, tumors, liver
* hyperresonant - air, emphysema, asthma, pneumothorax
where is the point of maximal impulse (PMI)
the 5th ICS in the midclavicular line
what are diagnostic modalities for the pulmonary system (BP, CVS, P-COPS)
bronchoscopy
Pulmonary angiography
Chest CT/Spiral CT
V-Q scan
Sputum cytology
Pulmonary function testing
Capnography
Oximetry
Peak flow testing
Sputum culture
what are types of PFTs
- spirometry, plethysmography
(measured against predicted values derived from studies of healthy people of same height, weight, sex, and race) these are the primary types of PFTs
diffusing capacity, 6 minute walk test, peak flow
what are indications for PFTs
- Evaluate patients with respiratory symptoms or rib fracture
- Assess progression of previously diagnosed lung disease
- Monitor the efficacy of treatment
- Evaluate patients preoperatively
- Monitor for potentially toxic side effects of certain drugs
she said “ this is used with more chronic complaints of SOB or lung problems, not with acute complaints.” She did talk about how acute rib fractures are a indication for PFT
what are considerations for PFTs
- patient cooperation and consistent effort is essential
- most children 5 and older can perform PFTs
what is tidal volume
the volume of air inspired or expired with each normal breath at rest
what is inspiratory reserve volume
the maximum volume of air that can be inspired over and above the tidal volume
(the amount you can inhale after youve already inhaled for tidal volume
what is expiratory reserve volume
the volume of air that can be expired after the expiration of the tidal volume
what is residual volume
the volume of air that remains in the lungs after maximal exhalation
what is spirometry
Non-invasive assessment of maximum inspiratory and expiratory volume as well as maximal expiratory effort
how is spirometry performed
completed at bedside, in pulm lab or as an incentive spirometer
may be performed pre and post bronchodilator
what are indications for spirometry
diagnosing/monitoring lung or neuromuscular diseases that affect breathing
prevention of post-surgical/traumatic complications (in class she gave the example of how when someone has pneumonia or is at risk for pneumonia you want them to take deep breaths to prevent the pneumonia from progressing)
what are contraindications/cautions to spirometry
- <6 weeks since abdominal, intracranial, or eye surgery or a pneumothorax
- thoracic, abdominal and cerebra aneurysms
- unstable angina or recent MI
- acute severe asthma, acute respiratory distress or active TB
what are risks of spirometry
minimal risk but could cause dizziness, very rarely causes syncope
what lung volumes can be assessed with spirometry
- vital capacity
- forced vital capacity
- forced expiratory volume in one second
- FEV/FVC
- peak expiratory flow rate
- forced expiratory volume over the middle half of expiration
what is vital capacity
the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath
Peak expiratory flow (PEF) rate
that maximal speed at which air can be exhaled with force
what is forced vital capacity
the amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible
what is forced expiratory volume in one second
the amount of FVC you can forcibly exhale in 1 second
what is the gold standard of pulmonary function testing
plethysmography
what does plethysmography measure
the total volume of air held in the lungs
when is plethysmography indicated
when a decreased FVC is found on spirometry
what is the procedure of plethysmography
- Performed in air-tight chamber
- Nose is obstructed
- Various transducers measure pressures in the airway and within the box
what are the volume measurements of plethysmography
total lung capacity
functional residual capacity
expiratory reserve volume
residual volume
RV/TLC
vital capacity
what is total lung capacity
the volume of air in the lungs at maximal inspiration (usually calculated by RV + VC)
what is functional residual capacity
the volume of air in the lungs following expiration of the tidal volume (ERV + RV)
what are the three lung volumes that are used to initiate interpretation of plethysmography
- FVC - amount of air moved after the deepest breath possible
- FEV₁ - amount of air moved in the first 1 second
- TLC - total amount of air in the lungs at maximal inspiration
what are the classification of lung disease interpreted from PFTs
obstructive - difficulty exhaling air from lungs
restrictive - difficulty expanding the lungs during inhalation
what are the three values that are reported with PFT reports
- Actual values - what the patient performed
- Predictive values - what the patient should have performed (based upon like-wise healthy patients)
- Percent predicted - a comparison of the actual value to the predicted value
not really a value:
* pre and post bronchodilator responsiveness
what is the expected post bronchodilator responsiveness in adults and in children
adults - increased in FEV1>12% AND >.2L
agres 5-18 - increased FEV1 >12%
Im not really sure whats happening here, maybe learn to label this
that’s okay we’ll figure it out
what are maximal respiratory pressures
measures of respiratory muscle strength that are assessed during plethysmography
what are indications for maximal respiratory pressures
unexplained decrease in VC or suspected respiratory muscle weakness
what physical exam finding is found with obstruction (COPD)
barrel chest
what is the procedure for maximal respiratory pressures
forced expiration (with cheeks bulging) through blocked mouthpiece after a full inhalation
what is the most sensitive PFT
diffusing capacity (DLco)
what is diffusing capacity
assesses the transfer of oxygen and carbon dioxide
what is the procedure for diffusing capacity
patient inhales carbon monoxide (CO) and a tracer gas (methane or helium), holds for 10 sec, exhales forcefully, exhaled air is tested to determine amount of tracer gas remaining
what is a normal result for diffusing capacity
normal is >80%
what is a 6 min walk test assessing
assesses oxygenation during exertion and the distance a patient can walk
what is the procedure of a 6 min walk test
patients walks back and forth on flat surface 100 ft in length for 6 min
what should you monitor during the 6 minute walk test
- symptoms (dyspnea and fatigue) at rest and progression of symptoms with walking
- oxygen saturation at rest and while walking
what does peak flow measure
peak expiratory flow rate
when is peak flow utilized
to determine adequate control of asthma
what are the normal values of peak flow based on
height
age
gender
race
what is the interpretation of peak flow
- green = 80-100% “all clear” - no action needed
- Yellow = 50-80% “caution” - implement treatment plan by PCP
- Red = below 50% “medical alert” - contact provider and start bronchodilator therapy immediatly
what is a pulse oximetry measurement
a Noninvasive, non-risky, continuous or intermittent measurement of arterial hemoglobin saturation
Reading is provided as a percentage of hgb that is oxygenated
what are indications for pulse oximetry
- CC of pulmonary or cardiac etiology
- chronic pulmonary or cardiac disease
what is normal pulse oximetry
95% or higher
what are the best locations for pulse oximetry
- location and fit matter! should use finger, big toe, ear, feet or cheek.
what are the limitations of pulse oximetry
nail polish
pigmented skin
bright lighting
patient movement
improper placement
poor perfusion
CO poisoning
what are examples of poor perfusion that could interfere with pulse oximetry
hypothermia
anemia
PAD
why does CO poisoning interfere with pulse oximetry
it is unable to differentiate between CO and O2 bound hemoglobin
How does bright light interfere with pulse oximetry
Bright light such as sunlight or the operating light on the probe may interfere with the light detector and cause inaccuracy.
what is capnography
the measurement and and monitoring of the concentration of CO₂ in expiratory gases
where does carbon dioxide come from
CO2 is produced by cellular metabolism and is eliminated via the lungs
what is an early warning of impending hypoxia
CO2 will rise 30-60 seconds before O2 drops in respiratory depression
what are the four phases of capnography CO2 waveforms
- dead space ventilation
- ascending phase
- alveolar plateau
- inspiration
During capnography, what does Phase one of the CO2 waveform represent
phase 1: dead space ventilation represents the beginning of exhalation
During capnography, what does Phase two of the CO2 waveform represent
phase 2: ascending phase represents a rapid rise in CO2 as air is exhaled
During capnography, what does Phase three of the CO2 waveform represent
phase 3: alveolar plateau represents CO2 reaching a uniform level during the entire breath stream point D represents the maximum (measured) CO2 concentration at the end of expiration
what is hypocapnia and what are etiologies
EtCO2 <35mmHg
etiologies:
hypothermia, low cardiac output, pulmonary embolism, hyperventilation
remember this is measuring CO2 coming out of the mouth, not CO2 in the blood (said in class)
what is hypercapnia and what are etiologies?
EtCO₂ > 45 mmHg = Hypercapnia
Etiologies: Malignant hyperthermia, shivering, fever, sepsis, severe hypothyroidism¹, hypoventilation
remember this is measuring CO2 coming out of the mouth, not CO2 in the blood (said in class)
how does hypothyroidism cause hypercapnia?
hypothyroidism - severe hypothyroidism leads to hypoventilation with diminished ventilatory response and diaphragmatic muscle dysfunction
(in notes section, didnt talk about it in class so maybe skip this idk)
How does obstructive disease present in capnography
Obstructed disease results in a rounded ascending phase and upward slope in the alveolar plateau
this slope is known as “shark fin deformity” (said in class)
what could cause sudden loss of waveform in capnography?
- ET tube disconnected, dislodged, kinked, or obstructed
- Sudden loss of circulatory function
what could cause actively decreasing EtCO2 in capnography?
- ET tube cuff leak
- ET tube in hypopharynx
- Partial obstruction
what could cause sudden increase in EtCO2 in capnography?
Return of spontaneous circulation
what could cause bronchospasm or “shark fin appearance” in capnography
- Asthma
- COPD
(obstruction in general)
what is this
hypoventilation
what is this
hyperventilation
what could cause decreased EtCO2
- apnea
- sedation
what are indications for capnography
- ensuring proper ventilation during general anesthesia or procedural sedation
- confirmation of proper ET tube placement and ventilator settings
- ensuring adequacy of chest compressions in cardiac arrest
when are sputum cultures indicated?
- When a patient is admitted to a hospital prior to starting antibiotics
- if they have failed empiric therapy
what are the collection instructions for sputum culture collections
- collect before initiating antibiotics
- prefered early morning collection
- rinse mouth out with plain water
- breathe deeply to stimulate coughing and expectoration
- refrigerate the container until processing takes place
culture specimen prepared within 2 hours of collection is preferred - avoid adding saliva or nasopharyngeal secretions to the sputum sample
what is sputum cytology
sputum collection for evaluation of presence of abnormal cells
when is sputum cytology indicated
Pulmonary cancer
and
Non-cancerous conditions:
* Pneumonia
* Inflammatory disease
* TB
* Asbestosis
what is the difference between conventional and helical CT?
conventional obtains images in slices and takes 30-45 minutes
helical is a rotating X ray beam that gives a spiral image. Only takes the time of one held breath
what are the advantages of CT over conventional radiography
- Anatomic structures in different planes not superimposed on each other
- Better contrast resolution
- Can be reconstructed to provide different visual planes
what are advantages of helical (spiral) CT
- Faster and more anatomic coverage
- Allows for cardiac imaging
- Eliminates respiratory artifact during breathing
- Sharper, more high-definition 3D images
what are disadvantages to helical (spiral) CT
Radiation exposure¹ - measured in units called millisievert (mSv)
- CXR - 0.1 mSv (10 days of natural background radiation²)
- Standard Radiation CT chest - 7 mSv (2 years of natural background radiation)
- Low-dose CT chest - 1.5 mSv (6 months of natural background radiation)
which CT would be the worst exposure of radiation
standard radiation CT chest
what is the least radiation exposure
CXR
what are indications for CT
- Inconclusive x-rays or abnormality on physical examination
- Assess cardiothoracic space for tumors and other lesions
monitor response of tumors to treatment - Intrathoracic injury/bleeding
- Infections
- Unexplained chest pain
- Obstructions
- Provide guidance for biopsies and/or aspiration of the tissue from the chest
when is contrast used
when you want to highlight the vascular system
what are contraindications/cautions to CT
- pregnancy (1st trimester and during non-life threatening conditions)
- history of large radiation exposure
what is the contraindications or cautions to CT contrast
- allergy to dye
- severe renal impairement GFR<20
- hyperthyroidism or thyroid goiter
- pheochromocytoma
- metformin use
what are limitations to CT scans
- body habitus (450+lbs)
- artifact (metal objects/pacemakers/piercings)
- barium in esophagus from recent barium study
when is contrast indicated
vascular disease or to delineate area of concern from adjacent structures
what is the MC type of dye used in CT scans
iodine dye
what should a patient be given prior to radioactive contrast dye
Premedicate with prednisone 50 mg orally taken at 13, 7, and 1 hour prior to procedure, or diphenhydramine (Benadryl) 50 mg orally, IV or intramuscularly, 1 hour prior to receiving radiocontrast media.
(in the notes section under slide 58. did not talk about it in class)
what is a ventilation and perfusion scan (V-Q scan)
a nuclear medicine scan that uses radioactive material to examine air flow (ventilation) and blood flow (perfusion) in the lungs
what are indications for a V-Q scan
diagnose or rule out a PE when CT is contraindicated
How do VQ scans identify PEs
they detect poor blood flow in the pulmonary vascularity and uneven air distribution
(im pretty sure this is what this line was talking about)
what is the general procedure for a VQ scan
- radioactive material is inhaled and images are taken to look at the airflow in the lungs
- radioactive material is injected IV and additional images are taken to assess the blood flow in the lungs
If the ventilation scan is abnormal but the perfusion scan is normal what is the possible diagnosis
COPD
Asthma
(indicated abnormal airway in all or parts of the lung)
If the perfusion scan is abnormal but the ventilation scan is normal what is the possible diagnosis
Pulmonary embolism
If BOTH the ventilation and perfusion scans are abnormal what is the possible diagnosis
certain types of lung disease such as pneumonia.
could also be indicative of COPD or PE.
basically anything
what are the risks associated with VQ scans
- radiation is very minimal
- pregnancy (smaller amount of radioactive dye is used)
- breastfeeding (must discard milk for 24 hrs after scan)
- mild and rare chance of allergic reaction (MC reaction is hives)
what is the gold standard diagnostic technique for pulmonary embolism
pulmonary angiography
what is the procedure of a pulmonary angiography
- performed by interventional radiologist.
- pt is mildly sedated
- contrast injected into pulmonary artery branch after percutaneous catheterization via the femoral vein
- images are obtained via flouroscopy
what interpretation of pulmonary angiography is indicative of embolus
a filling defect or abrupt cutoff of a small vessel
What does it mean if a pulmonary angiography is negative
Clinically relevant PE is excluded from possible diagnoses
aside from PE what are some other indications for a pulmonary angiography
- AV malformation of the lung
- Congenital narrowing of pulmonary vessels
- Pulmonary artery aneurysms
- Pulmonary hypertension
what are risks associated with pulmonary angiography
- Allergic rxn
- Damage to blood vessel or nerve from needle or catheter
- Excessive bleeding, blood clot or hematoma formation
- MI or stroke
- Injury to nerves at puncture site
- Kidney damage from contrast dye
what is bronchoscopy
A procedure used to directly visualize the airways and diagnose lung disease
what are the two types of bronchoscopes? which is MC?
flexible (MC)
rigid
what is the procedure of bronchoscopy
- patient is sedated (general for rigid scope, procedural for flexible)
- scope passed through mouth or nose and into lungs
what are indications for bronchoscopy
- Evaluation and removal of airway FB’s or other obstructions
- Diagnosis and staging of bronchogenic carcinoma
- Evaluation of hemoptysis
- Diagnosis of pulmonary infections
- Transbronchial lung biopsy
- Bronchoalveolar lavage
what are contraindications for bronchoscopy
severe bronchospasms
bleeding diathesis (increased tendency to bleed or bruise)
what are complications of bronchoscopy
Common:
transient hypoxemia
pneumothorax
hemorrhage
less common:
infection
nasal/laryngeal trauma
bronchospasm
cardiorespiratory arrest
how common are major complications in bronchoscopy
less than 1% chance
