Exam 6 Flashcards
Emphysema definition
Airspace destruction
Loss of elasticity
Enlargement of airspaces distal to terminal bronchiole
Blebs/bullae
Chronic bronchitis definition
Hypertrophy of mucous glands, more secretions
Lots of inflammation
Excess mucus, daily productive cough for 3+ months per year x2 consecutive years
COPD and liver disease
A1 antitrypsin deficiency, may see cirrhosis and/or hepatocellular CA or emphysema in 3rd/4th decade of life
What decade of life do you see COPD?
Usually 5th-6th decade
Early presentation and late presentation
Early- dyspnea, productive cough
Late- pneumonia, pulmonary HTN, cor pulmonale, chronic respiratory failure
Exacerbations of COPD description
Increased cough, dyspnea, sputum production
Often requires change in therapy
Pink puffers
Emphysema
Barrel chest, hyperventilation, weight loss
Blue bloaters
Bronchitis
Cyanosis, cor pulmonale, obesity
Emphysema physical exam
Quiet breath sounds
Barrel chest
Accessory muscles (tripod, pursed lip, intercostals)
Chronic bronchitis exam
Cyanotic, coarse breath sounds, comfortable at rest
Ronchi and or wheezes
When do you perform a bullectomy?
If a single bulla occupies 30% or more of hemithorax
Asthma definition
Clinical syndrome of 3 components:
- Recurrent episodes of airway obstruction that resolve spontaneously or with treatment
- Exaggerated bronchoconstriction in response to stimuli, “airway hyperresponsiveness”
- Inflammation of the airways
Pathology of asthma
Edema and hyperemia of bronchial mucosa
Bronchoconstriction
Infiltration of inflammatory cells and chemokines
4 mediators in acute asthma
Acetylcholine
Histamine
Leukotrienes
Nitric oxide
Atopic triad
Asthma, allergic rhinitis, atopic dermatitis
Samter triad
Asthma, nasal polyps, aspirin sensitivity
Clinical findings of asthma
Episodic wheezing Difficulty breathing Chest tightness Cough with excess sputum Common attacks at night
Exam findings of asthma
Wheezing Hyperresonance to percussion Tachycardia/tachypnea Hypoxia Accessory muscles Nasal secretions, polyps, swelling Atopic dermatitis
Complications of asthma
Exhaustion Dehydration Airway infection Fainting from cough Pneumo Hypercapnia and hypoxia
PEFR suggesting severe obstruction
<200 L/min
Sarcoidosis is characterized by…
Noncaseating granulomatous inflammation
Involvement of lungs, lumps, eyes, skin, liver, spleen, heart, nervous system
Which races is sarcoidosis most common in?
North american black and northern european whites
Symptoms of sarcoidosis
Asymptomatic Malaise, fever Cough Dyspnea Chest discomfort Other organ involvement
Signs of sarcoidosis
Skin changes Lungs (wheezing or normal) Parotid gland enlargement Lymphadenopathy HSM
How often is cutaneous involvement seen in sarcoidosis?
~25% of the time as an early finding
Lofgren syndrome
Erythema nodosum
Polyarthritis
Hilar adenopathy
Fever
95% specificity for sarcoidosis
Which imaging choice is central to evaluation of sarcoidosis? What do you find?
CXR
Symmetric bilateral hilar LAD
Diffuse reticular infiltrates
What three elements need to be present to make the diagnosis of sarcoidosis?
Compatible clinical and radiographic manifestations
Exclusion of other diseases that may present similarly
Histopathologic detection of noncaseating granulomas
Stage 1 sarcoidosis
Bilateral hilar adenopathy, right paratracheal node enlargement
Stage II sarcoidosis
Bilateral hilar adenopathy & reticular opacities
Stage III sarcoidosis
Increased reticular opacities
Shrinking hilar nodes
Stage IV sarcoidosis
Reticular opacities with evidence of volume loss in lung
Pleuritis definition
Chest wall pain due to acute pleural inflammation caused by irritation to the parietal pleura
Pleuritic pain
Localized
Sharp
Fleeting
Worse with sneezing, coughing, deep breathing, movement
Pleural effusion definition
Accumulation of fluid between parietal and visceral pleura
Classifications of pleural effusion
Exudative
Transudative
Empyema
Hemothorax
Exudative effusions
Leaky capillaries, often from infection, malignancy, or PE
Chylothorax
Disruption or obstruction of thoracic duct resulting in leakage of chyle into the pleural space
White, milky
Transudative effusion
Increased hydrostatic pressure or decreased oncotic pressure
Intact capillaries
CHF >90% of cases
Physical exam pleural effusion
Decreased tactile fremitus
Dullness to percussion
Absent/diminished breath sounds
Shift of trachea and heart away
Which CXR view is most sensitive for pleural effusion?
Lateral decubitus
Gold standard to diagnose pleural effusion?
Thoracentesis
Grossly purulent fluid
Empyema
Light’s criteria
Pleural fluid protein : serum protein >0.5
Pleural fluid LDH : serum LDH >0.6
Pleural fluid LDH > 2/3 ULN for serum LDH
Solitary pulmonary nodule
3 cm or smaller in diameter
Rounded opacity
Calcification patterns on CXR that are benign
Diffuse
Central
Popcorn
Laminated
Calcification patterns on CXR that are potentially malignant
Stipples
Eccentric
Spiculated
Histoplasmosis
Bird dung
Infection
Flu like symptoms or asymptomatic
Blastomycosis
Fungus in soil
Asymptomatic or flu like
Infection
Rarely calcify or caseate the lungs
Coccidioidomycosis
Fungus in soil
60% asymptomatic
Moderate flu like symptoms
Severe in HIV patients
Squamous cell carcinoma
Bronchial epithelium
Centrally located
Hemoptysis
Spread locally, hilar LAD and mediastinal widening
**best prognosis
Adenoarcinoma
Peripheral nodules or masses
Metastasize earlier than squamous cell
Better prognosis in bronchioloalveloar cell
Large cell carcinoma
Rapid doubling times
Central or peripheral masses
Small cell carcinoma
Centrally located, bronchial origin
Regional lymph node involvement
Aggressive
Lung cancer clinical findings
Anorexia Dyspnea Weight loss NEW cough or CHANGE in cough Hemoptysis
T1, T2, T3, T4
T1: <3 cm
T2: 3-7 cm
T3: >7 cm
T4: invasion of organs/vertebrae/carina/tumor nodules in same lobe
N0, N1, N2, N3
N0: no lymph involvement
N1: ipsilateral bronchopulmonary/hilar
N2: ipsilateral mediastinal/subcarinal
N3: contralateral hilar/mediastinal, supraclavicular
M0, M1
M0: no metastasis
m1: bilateral lesions
Distant metastasis, malignant pleural effusion
Hypersensitivity pneumonitis
Inflammation in the alveoli secondary to hypersensitivity to organic inhaled dusts
Acute reaction, can become chronic
Microbes, animal proteins, or LMW chemical
Acute findings of hypersensitivity pneumonitis
Malaise, chills, fever, cough, dyspnea
Chronic hypersensitivity pneumonitis findings
Muscle wasting, weight loss
Byssinosis
Inhalation of cotton fiber dust
Typically occuring when patients return to work after weekend or vacation
Cyanide inhalation
Antidote- hydroxocobalamin
Headache, weak pulse, vertigo, abnormal heartbeat, vomiting, death
Carbon monoxide exposure
Colorless, odorless, tasteless gas
Headache, light headed, flu like symptoms, central nervous system toxicity
Physical exam finding on CO inhalation
Cherry red skin (actually pallor is more common from the lack of oxygen)
Silo fillers. Disease
Toxic pulmonary edema from acute inhalation of nitrogen dioxide in recently filled silos
Pneumoconiosis
Chronic, fibrotic lung diseases secondary to hazardous inhalation
Coal workers pneumoconiosis
Chronic exposure to coal >10 years causing interstitial lung disease
CXR shows diffuse small opacities especially in upper lung fields
Silicosis
Fibrosing interstitial lung disease from inhaling fine particles of silica
Eggshell calcification
Asbestosis
Fibrosing interstitial lung disease from exposure to mineral asbestos
Pleural plaques, lower lung involvement, calcified plaques
What causes mesothelioma?
Asbestos
Mesothelioma
Primary tumor arising from surface lining of the pleura or peritoneum
Berylliosis
IARC group 1 carcinogen
Aerospace and fiber optics workers
Non caseating granulomas
Radiation lung disease
Complication of therapy
Fibrosis or pneumonitis
Bronchiectasis
Disease of large bronchi
Permanent dilation and destruction of bronchial wall
Recurrent infection or inflammation
Causes of bronchiectasis
Cystic fibrosis commonly
Infection
Obstruction
Immunodeficiency
Bronchiectasis symptoms
Chronic cough Copious purulent sputum Hemoptysis Rhinosinusitis Weight loss, anemia, fatigue
Signs/exam bronchiectasis
Crackles at lung base
Clubbing
Foul smelling, copious purulent sputum
CXR findings in bronchiectasis
Atelectasis
Tram lines, ring shadows
CT findings in bronchiectasis
Tree in bud opacities
Cystic fibrosis
Most common cause of severe chronic lung disease in young adults
Altered CL and H20 transport across epithelial cells
Thickened mucus, obstructing airway, GI
Signs of CF
Pancreatitis Infertility Chronic lung dz Steatorrhea Cough
Exam of CF
Malnourished Clubbing Barrel chest Apical crackles Gallstones
CF diagnosis
Sweat chloride test
Obstructive sleep apnea
Blockage of airway during sleep, resulting in periods of no breathing
Risk factors of OSA
Age
Gender male
Obesity
Upper airway abnormality
Pickwickian syndrome
Decreased ventilatory drive from obesity
OSA has ______ ventilatory effort during apnea
Increased
Manifestations of OSA
Snoring Waking up gasping or choking Excessive daytime sleepiness Thick neck Large tonsils
Common OSA screening tool
STOP- bang
Atelectasis
Collapse or loss of lung volume/alveolar space
Resorptive atelectasis
Alveolar space filling, commonly pneumonia
Chest wall pain is common with this type
Compressive atelectasis
Pressure from mass effects in chest
Exam with atelectasis
Minimal findings
Maybe decreased breath sounds, crackles, dullness to percussion
5 w’s of atelectasis and post op fever
Wind Water Wound Wonder drugs Walking
Acute respiratory failure
Dysfunction of respiratory system
Abnormal gas exchange, potentially life threatening, threatens end organs
Acute respiratory distress syndrome
Abrupt onset of diffuse lung injury
Severe hypoxemia
Generalized infiltrates
Bilateral infiltrates with pulmonary edema without clinical HF
A common cause of ARDS
Sepsis about 1/3 of the cases
Clinical findings of acute respiratory distress syndrome
Rapid onset of profound dyspnea
Hypoxemia, tachypnea, accessory muscle usage
Diffuse or patchy bilateral infiltrates
Pneumomediastinum
Consider bronchial or esophogeal perforation
Idiopathic interstitial pneumonia
Acute or chronic
Restrictive pattern on PFT
Cryptogenic organizing pneumonia
Previously known as BOOP
Follows flu like illness
DOE
Inflammatory debris in the alveoli
Usually responds to steroids
Goodpastures syndrome
Glomerulonephritis
Pulmonary hemorrhage
Antiglomerular basement membrane antibodies
Granulomatosis with polyangiitis
Classic triad of upper and lower respiratory tract disease and glomerulonephritis
Unusual sign of granulomatosis with polyangiitis
Saddle nose deformity
Church strauss syndrome
Allergic angiitis and granulomatosis
Skin and lung disease
Peripheral eosinophilia
Inspiratory stridor is a sign of….
Upper airway obstruction
Expiratory wheezing is a sign of…
Lower airway obstruction
Acute bronchitis
Self limited inflammation of bronchi due to an upper airway infection
Usually a virus
Typical presentation of acute bronchitis
Cough >5days
Sputum
Wheezing, mild dyspnea
Physical exam in acute bronchitis
Rhonchi that clear with coughing
Wheezing
NO signs of parenchyma consolidation
What are the criteria to order a CXR with a cough?
Abnormal vital signs
Persistent rales or other signs of consolidation
Special populations
Bronchiolitis
Varied inflammatory processes that effect the bronchioles
What is the most common cause of bronchiolitis in children?
RSV
Clinical presentation of bronchiolitis
Viral upper respiratory prodrome followed by increased respiratory effort and wheezing usually 3-6 days after onset of illness
Lung exam in bronchiolitis
Retractions Expiratory wheezing Hyperexpanded chest Hyperresonant to percussion Crackles, rales, rhonchi
Respiratory syncytial virus
Causes acute respiratory tract illness in persons of all ages
4-6 day incubation
Infects small bronchiolitis epithelium- necrosis of epithelial cells, proliferation of bronchiolitis epithelium, release of cytokines and chemokines
Presentation of RSV
Airway obstruction, air trapping, increased airway resistance
Low grade fever, tachypnea, wheezing, cough, rhinorrhea, conjunctivitis
Signs of RSV
Hyperinflated lungs, decreased gas exchange, increased respiratory effort
Epiglottitis i
Inflammation and cellulitis of the epiglottis and adjacent supraglottic structures
Medical emergency
Presentation of epiglottitis
Appears toxic with difficulty breathing
Muffled speech, hot potato voice
Tripod, doesn’t want to lie down
Hoarseness, cough, stridor
X-ray findings of epiglottitis
Thumb sign
Croup
Acute respiratory illness that leads to inflammation in the larynx and subglottic airway
Barry cough, stridor
Anatomic hallmark of croup
Narrowing of the trachea in the subglottic region
Westley croup scores mild moderate and severe
Mild is less than or equal to 2
Moderate is 3-7
Severe is 8 or greater
Ap XR in croup
Steeple sign
Bacterial tracheitis
Exudative bacterial infection of the soft tissue of the trachea
Staph aureus is almost all the cases
Primary and secondary presentation of bacterial tracheitis
Primary- fulminant onset, progression of acute respiratory distress <24hrs after onset of minor symptoms
Secondary- viral respiratory tract infection prodrome 1-3 days prior to onset of severe symptomatology
Signs and symptoms of bacterial tracheitis
Fever Stridor Cough Prefer to lie flat Hoarseness Wheezing
Definitive diagnosis of bacterial tracheitis
Direct visualization of inflamed, exudative covered trachea
What is the #1 infectious cause of death in the US?
Pneumonia
What are the three normal defense mechanisms that are at risk in pneumonia?
Cough reflex
Mucociliary clearance system
Immune responses
Mycplasma pneumoniae
Walking pneumonia, young adults
Legionella pneumophila
Contaminated water sources
Older, sickly men
GI symptoms and abnormal LFTs
Pneumonia history
Fever, chills, rigors, malaise Cough Sputum Chest pain SOB
Physical exam pneumonia
Bronchial breath sounds
Egophony
Dullness to percussion
Increased tactile fremitus
Lobar pneumonia
Bacterial
Interstitial pneumonia
Viral or mycoplasma
Nodular pneumonia
Fungal
Patients with CAP should be treated for a minimum of..
5 days
3 categories of nosocomial pneumonia
Hospital acquired
Ventilator associated
Health care associated
Problems with nosocomial pneumonia
Different pathogens
Different antibiotic susceptibility patterns
Impaired defense mechanisms
High risk pathogens in nosocomial pneumonia
Pseudomonas
MRSA
Acinetobacter
True aspiration pneumonia…
Infection caused by less virulent bacteria, primarily anaerobes
Where does anaerobic pneumonia usually develop in the lungs?
Dependent lung zones
Presentation of anaerobic pneumonia
Constitutional symptoms
Cough
Foul smelling purulent sputum
Pulmonary embolism
Obstruction of the pulmonary artery or one of its branches by something that originated elsewhere within the deep venous circulation
What is the 3rd leading cause of death in hospitalized patients?
PE
How often does a PE develop if you have a DVT?
50-60% of the time
3 acute classifications of PE
Massive
Submissive
Saddle PE
How many PEs result from a DVT?
95% of PE’s
Virchow’s triad
Stasis
Injury
Hypercoagulability
Additional risk factors of PE in women
Obesity
Heavy cigarette smoking >25 a day
HTN
Acute clinical manifestations of PE
Sudden dyspnea onset Plueritic chest pain Cough >2 pillow orthopnea Calf or thigh pain or swelling Wheezing
PE physical exam
Tachypnea (most common)
Tachycardia
Hypoxia
Low grade fever
Late findings: HOTN, hemodynamically unstable
EKG findings
Tachycardia
NSSTTchanges
S1Q3T3 changes
CXR findings of PE
Atelectasis
Westermark sign
Hampton hump
Pleural effusion
What is the imaging diagnostic study of choice for PE?
Helical CT with contrast
What wells criteria values are highly likely for PE?
6 or greater
Ventilation perfusion scan for PE
Identifies mismatch between areas that are ventilated by not perfumed
What is the gold standard test for PE?
Pulmonary angiography
What pharmacologic meaure is started ASAP with PE?
Empiric anticoagulation
Low and high risk 30 day mortality
1%
11%
Which situations with PE indicate indefinite anticoagulation?
Unprovoked PE
>2 or equal to 2 episodes
Pulmonary HTN definition
Elevated pulmonary arterial pressure and secondary RV failure
Mean PA pressure >25mmHg at rest
Pathophysiology of pulmonary HTN
Low pressure, hypoxemia causes PA vasoconstriction, PA pressure rises to an inappropriate level for the CO
Idiopathic pulmonary HTN
Young, middle aged females
Absence of other lung or cardiac diseases
Group 1 PH
Idiopathic, diseases of small pulmonary muscular arterioles, drugs nad toxins
Group 2 PH
Left heart disease
Group 3 PH
Lung diseases or hypoxemia
Group 4 PH
Chronic thromboembolic HG
Group 5 PH
Unclear, multifactorial mechanisms
Clinical presentation of PH
Dyspnea
Fatigue
Chest pain
Signs of PH
Narrow splitting of 2nd heart sound, large pulmonary component
Systolic ejection click
What diagnostic study is needed to confirm diagnosis of HTN?
Right heart catheterization
