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Clin Med II Exam 1 Pulm > Disorders of Pulmonary Circulation & Pleural Diseases > Flashcards

Disorders of Pulmonary Circulation & Pleural Diseases Flashcards

1
Q

what is a pulmonary embolism?
what category does it fall under?
what are some things that can embolize (get stuck and clot?)

A

PE: pulmonary embolism is a blood clot within the pulmonary artery or its branches which obstructs blood flow to the lungs

blocking blood flow therefore decreases oxygenation

PE’s are a type of venous thromboemoblism (VTE)

other VTEs…
- PE
- DVT
- supervisical vein thrombosis

types of things that can embolize
- thrombus (blood clot)
- tumor (piece of tumor breaks)
- amniotic fluid (pregnancy)
- air
- fat
- parasite egg

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2
Q

what causes a thrombus to form in the first place? (prior to it traveling to the lungs?)

thing of the triad & what conditions favor thrombi to form

A

only need 1 condition from ANY of the categories to put a pt. at risk for developing a thrombus

  1. hypercoaguable state
    - malignancy
    - pregnant
    - trauma
    - recent surgery
    - IBD
    - sepsis
    - thrombophilia
  2. Vascualr Wall Injury
    - trauma or surgery
    - venipuncture
    - chemical irritant
    - heart valve replaced or dzed.
    - atherosclerosis
    - cathethers
  3. Circulatory Stasis
    - A fib (b/c weird blood flow creates a slow and stop of blood in the r. atrium –> creates clot)
    - left ventricular dysfunction
    - immobile
    - venous insufficiency
    - venous obstruction (tumor, pregnant, obese)
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3
Q

how does a thrombus become a PE?
where do they originate? whats MC?

A

thrombus comes from venous throughout the body –> travels to the pulmonary system after the right side of the heart –> gets stuck in the small pulmonary arteries –> PE happens

most commonly (95%) the PE comes from a DVT
- specifcially a proximal (above the knee) DVT
- can also come from distal DVT
- can also come from superfiscual vein thrombosis (least likely)

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4
Q

what are symptoms and signs of a pt. having a PE?

what are some key physical exam findings?

A

symptoms
- often, asymptomatic
- “classic triad” = dyspnea/SOB, pleuritic chest pain, hemoptysis
- light headed
- syncope

signs
- tachycardia
- tachypnea
- hypoxia
- low grade fever

physicial exam
- shallow breathing
- wincing on respiration
- accessory muscle use
- + Homans sign – pain in calf during dorsiflextion

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5
Q

what are 2 tools that can be used to help determine pts. risk for having a PE?

A

Wells Criteria
- the pre-test probability of the pt. having a PE
- based on signs and symptoms prior to imaging and work-up

PERC Rule
- ** LOW RISK PT> ONLY**
- allows to r/o PE as a ddx. if no criteria are present & pre-test prob. < 15%

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6
Q

how are PE’s classifed?
(time & risk)

A

Time
- acute = days
- subacute = weeks
- chronic = months

Risk
- Massive = high risk
hemodynamically unstable –> immediate intervention
- submassive = intermediate risk
right ventricel strain
- low-risk = low risk
no right ventricel strain

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7
Q

what kind of labs to take when dx. a PE? what imaging?

A

Labs
- d-dimer : released during clot breakdown (high = high) not specific but yes senstive so good to check for R/O
- troponin : released when myocardium under pressure
- NTproBNP: released when the ventricles are beind stretched

  • EKG too

Imaging
- CT chest angiography = initial test of choice
- pulmonary angiography = gold standard
- chest xray
- doppler US
- VQ scan
- TTE

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8
Q

what are some EKG findings you have have in a PE?

A
  • sinus tachycardia is most common finding
  • S1Q3T3 pattern is not a common finding – but a classic finding of a PE
    • this is a wide S in lead 1
    • a Q wave in lead 3
    • a TWI wave in lead 3
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9
Q

what are some imaging findings with a PE?

(on chest xray)

A

chest xray
- typically will be normal
- discrete findings may include ….
- 1. Westermarks sign : absent pulmonary vasculature (white lines) in areas distal to the PE
- 2. Hampton’s Hump : a wedge-shaped infiltrate showing an area of infarction in the lung

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10
Q

indication for using a doppler US on a PE pt?

A
  • no reuqired as part of the work-up for a PE
  • helpful to look at lower extremities

INDICATIONS FOR US
1. massive or submassive PE (becuase if there is an additional clot that breaks off and joins –> it an be fatal)
2. renal disease which prevents CT angiography from being useful

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11
Q

specifics about the CT chest angiography for a PE

  • whats it used for
  • contraindications
A
  • also called helical CT
  • Best tool for INITIAL SCREENING
  • sensitive for detecting a proximal emboli over a distal emoboli

THIS REQUIRES CONTRAST –> WATCH IN RENAL DISEASE PT.

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12
Q

what is a V/Q scan? how does it help with a PE?

A
  • nuclear med scan which the tracer is inhaled
  • measures the ratio between ventilation and perfusion
    -** mismach of the ratio con indicate the PE**

– not often used as the answer is usually “intermediate”

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13
Q

Describe the process of a pulmonary angiography? when is it used?

A

PULMONARY ANGIOGRAPHY IS GOLD STANDARD dx. of a PE
- diagnositc and therapeudic minimally invasive procedure

when is it conducted?
- only will be done if there is suspicion for a PE but the CT and the V/Q are negative

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14
Q

what is a transthoracic echo? (TTE)
when is it conducted?
what will it detect?

A
  • an echo that will look specifically at the wall (interventricular septum) between the right ventricle and the left ventricle
  • assessing for right ventricle strain
    • this is seen when the IVS is bowing the wrong way (pressure increased in the right ventricle forces it out when it should be the opposite direction)

when is it conducted and helpful?
- in a massive or submassive PE this can be seen

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15
Q

what are the principles of management of a PE? what are the 4 goals of therapy?

A
  1. determine if pt. is stable or unstable
  2. determine if the pt. need admission to the hospital
  3. determine if the pt. is a canidate for anticoag. therapy (and choose most appropriate)
  4. involve the interventional team as deemed appropriate
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16
Q

what classifies a PE pt. as stable?
what is the course of management?

A
  • normal cardiac biomarkers
  • normal vital signs
  • normal results from the TTE

management
- most will be able to be managed outside the hospital
- unless they are a bleed risk (like a recent surgery) then thye should be monitored in the hospital for treatmetn with anticoags.

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17
Q

what classifies a PE pt. as unstable? what is the course of action?

A
  • abnormal cardiac biomarkers (troponin & NPproBNP)
  • abnormal vitals
  • large clot burden
  • evidence of right heart strain (TTE)

course of action
- admit them

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18
Q

what are some questions to ask to determine if you pt. is a canidate for anticoag. medication

A
  • risk factor to bleed or bleeding disorder?
  • fall risk?
  • any medications which may make them bleed? asprin?
  • baseline renal function?
  • platelet count?
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19
Q

what anticoags are used for PE management?
what are some big indications for one over another? contraindications?

A
  1. unfractionated heprin
    - PTT must be monitored serial Q6
    - short 1/2 life – so if a problem leaves blood quickly
    - protamine reversal agent
  2. LMWH (enoaxaparin)
    - no titration to monitor
    - pt. inject self
    - no use for crCL < 30
  3. DOACS
    - must look at pt. renal function (crcl vary by medication)
    - oral pills = better compliance
    - dont have access to reversal agent
  4. warfarin
    - PT/INR must be monitored every 1-3 days and adjusted
    - heavily influenced by vit. K
    - lots of drug-drug interactions
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20
Q

what is the duration of treatment for PE?

A

initial event: treat for 3 months

pt has risk factors or reoccuring event: treat for 12 months
** becuase the reoccurant PE and DVT are worse**

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21
Q

your pt. isnt a canidate for anticoags.

how does an IVC filter work?

  • indications for who gets IVC
A
  • those who anticoags. are not an option for treatment
  • those who have massive or submassive PEs who also have significant clot burden of DVT where the compoudning clot could be fatal

** the filter is only left in for a few months**

22
Q

your pt. is unstable– with a PE
- what is your treatment?

how does perfusion therapy work? what are the two types

contraindications?

A

thrombolytic therapy
- the administration of widespread thrombolytics to breakdown the clot (recombinant tPA)
- given through catheter

embolectomy
- surgical removal of the clot
- catheter removal of the clot

contraindications
- bleeding risk of any kind
- recent surgery or stroke
- pregnant
- over 75

23
Q

What is Pulmonary Hypertension?
how is it diagnosed?

A

PH: any condtion that causes elevated pressures in the pulmonary artery

Diagnosis
- can be made clinically
- CONFIRM DX. with a right sided heart catheterization –> MAP > 20 mmHg will confirm

24
Q

what is cor pulmonale?

how is it related to pulmonary hypertension?

A

cor pulmonale: right sided heart failure as a result of pulmonary hypertension

the pulmonary hypertension (elevated pressure) blocks/backs up so much that it creates heart failure on the right side as result

25
Q

explain the pathology behind pulmonary HTN

what is primary pulm. HTN?
secondary?

A
  • there is an increase in pulmonary arterial pressure (systoloic) as a result of increased resistance in the vascularture

primary: changes in the WALL of the pulmonary arteries is the problem
- abnormal proliferation and contraction of the smooth muscle in the wall leads to fiberosis and destruction
- idopathic (dont know why the walls are detroyed)
- familiail –> inheritance pattern of wall destruction

secondary: the walls are okay –> another reason causing HTN
- accomidation of excess inflow of blood/pressure in the pulmonary artery without any changes to the anatomy (walls)
- think of pulmonary or cardiac diseases
- hypoxemia, left sided herat disease, CTEPH

26
Q

when there is pulmonary hypertension what is the framwork of thinking for where the problem is??
3 main areas & examples of disease states

A
  1. problem before the lungs
    - PE
    - medications
    - liver disease (less production of vasodialtor triggers)
    - HIV (inflammatory state)
  2. problem in the lungs themselves
    - COPD
    - parenchymal lung disease
    - OSA/OHS
  3. problem after the lungs
    - heart failure
    - valvular disease
    - congenital disease
27
Q

what are some pt. symptoms of pulmonary hypertension

A
  • dyspnea (most common)
  • symptoms of chest pain (not pleuritic)
    examples….
    weakness/fatigue
    syncope
    swelling
    productive cough
    AMS
    cool extremities
28
Q

what are some clinical signs of pulmonary hypertension?

A

-cyanosis/hypoxia
- a fixed S2 sound (shouldnt be)
- systolic ejection click ( sound of blood going into congested artey)
- RV heave
- signs of right sided herat failure
peripheral edema
jugular venous distension
right-sided heart sound (S3 – shouldnt hear)
- hepatomegaly (b/c of backup blood flow)

29
Q

what is the diagnosis criteria for pulmonary HTN

A
  • clinically can be dx. if there is signs/symptoms of right sided heart failure (increased venous backup) & echo with increase pulmonary artery pressure

a confirmatory dx. can be made with a right sided heart catheterization reading a pulmonary artery pressure > 20 mmHg

30
Q

what are some other diagnostic test which can be preformed when suspected a pulmonary HTN

A
  • CBC (check for polycythemia)
  • EKG: check RBBB, RA enlarged and hypertrophic
  • CXR: plumonary edema, enlarged pulmonary trunk
  • echo: large right sidede ventricle; see a left-right shunt
  • then confirm via right sided heart cath
31
Q

What is the treatment for pulmonary hypertension?

A
  • treat the underlying cause and manage symptoms!
  • the treatment will vary for what group of pulm. HTN the pt. is in
32
Q

treatment for Group 1 Pulm. HTN?
(those with pulmonary arterial HTN)

A
  1. vasodialators
    - first line: calcium channel blockers
    - phosphodiesterase-inhibitors (sildenafil)
    - prostacyclins (‘prost)
  2. oxygen therapy
33
Q

treament for group 2 pulm. HTN
(those with left heart disease)

A
  • medication for their heart failure
  • medical or surgical management of the valvular disease
34
Q

treatment for group 3 pulm HTN
( those with pulmonary disease)

A
  • smoking cessaion
  • oxygen therapy
35
Q

treatment group 4 & 5 pulm. HTN
(CTEPH & misc.)

A

4 - anticoags. and surgery
5. target specific cause

some may need lung transplant

36
Q

what is the prognosis for pulmonary HTN?
who has the worst? best?

A

worst prognosis
- age > 50, male and in class III or IV

CTEPH: best prognosis
chronic lung disease: worst

37
Q

what is a pleural effusion?

A

abnormal collection of fluid in the pleural cafivty

pleural is the thin lining of potential space between the viseral (lung) pleural and the parietal (chest wall) pleaural

38
Q

pathophysiology of a pleural effusion
- how does fluid enter the space normally (2 ways)
- two types of plural effusions

A

normally, fluid enters the pleural cavity
1. by the capillaries in the parietal pleura & then is removed via the lympathics in the parietal pleura
2. by the visceral pleura from the lung interstitial space and then removed by holes in the diaphram (or vise versa)

two types of effusions
1. transudative –> volume issue/overload
2. exudative –> malignancy, infection
- empyema & parapneumontic effusions & chylothroax are types of exudative

39
Q

described a transuative plural effusion

A

transudative: a volume overload issue
- increased hydrostatic or decreases oncotic pressure causing increase in fluid from circulation to enter the pleural space = effusion

think kidney failure, liver failure, low protein

40
Q

describe exudative pleural effusion

include definitions of empyema, parapneumonic effusion and chlyothroax

A

exudative: increased permiability of the pleural (due to inflammation or infection)
- pneumonia
- malignancy
- TB
- PE
- RA
- lupus
- viral or parasitic diease

specifically…
empyema: a collection of PUS in the pleaural (less fluid, more pus)
parapneumonic effusion: an infection of the pleural space due to pneumonia
chylothorax: lymph in the space (kids)

41
Q

what are some signs and symptoms of a pleural effusion

A

symptoms
- dyspena
- chest pain (pleurtic)
- cough
- asymptomatic

signs
- decreased breath sounds (the sound is blocked by the fluid)
- dullness to percussion
- decreased fremitus
- hear a pleural friction rub ( wont glide)
- tachypnea
- hypoxia

42
Q

what is used to diagnose a pleural effusion

A

dx. can be made with a chest xray
gold standard dx. is a thorocentesis

43
Q

how do you treat a pleural effusion

A

thorocentesis is gold standard
- do via US guided
- then run studies on the fluid you pull to determine the contents

44
Q

after thorocentesis–> what type of studies are ordered for pleural fluid
what is the name of the criteria which allows you to decide if its exudative v transudative?

A

studies ordered for pleural fluid
- gram stain
- total protein (high protein = exudative)
- pH
- cytology –> cancer cells
- AFB and fungal cx.

** also consider the color of the fluid– bloody? serous? purulent?

Lights Criteria : will determine if its transudative (negative lights) or exudative (positive lights)

45
Q

once pleural studiess are done for a pleural effusion … what is the next steps in management (treatment goals)

A
  1. determined transudative v exudative
  2. treat underlying causes based on ^^
  3. consider chest tube for those with consistent reoccurance of pleural effusion control the source
46
Q

what is a pneumothorax?
spontaneous v traumatic v tension v hemothorax

A

air in the pleural place causing a complete or partial collapse of the lung tissue (due to an increase in pressure/volume in the pleural space)

types
spontaneous: occur without an injury or insult to the lungs or thorax (think tall thin men whos alveoli spontaneously rupture)

traumatic: due to a penetrating injury or nonpenitrating (MVA/rib fracture)

tension: LIFE-THREATENING buildup of air but ther pressure is so much – no where to go & shifts

mediastinum ** TO CONTRALATERAL SIDE**

hemothorax: blood

47
Q

difference between primary and secondary pneumothorax

A

primary: no underlying lung disease
- tall thin male 20-40 y/o
- smoker
- family hx.

secondary: a patient with UNDERLYING LUNG DISEASE
- asthma, CF, TB, interstitial lung disease, emphysema

48
Q

signs and symptoms of a pneumothorax
(what is specific to tension??)

A

symptoms
- often non-symptomatic
- unlateral chest pain
- dyspnea

signs
- decreased tactile fremitus, hyperresonance to percussion
- decreased breath sounds
- unequal respiratory expansion
- tachycardia & pena
- hypotenstion –> think tension
- increased JVP –> tension
- abnormal SBP –> tension

49
Q

diagnosis of pneumothorax

A
  • CXR –> see decreased lung markings and sulcus sign
  • get pulse ox and ABG for hypoxia
50
Q

treatmetn of a pneumothorax
(small v large)

A

small: observation and serial CXR – can go away on its own

large: needle aspiration (2nd midclav. line) ot chest tube
- spirometry, pain control and O2 if needed

Clin Med II Exam 1 Pulm (9 decks)

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