Exam Flashcards
Tidal volume (TV/VT)
Volume of air inspired and expired during normal quiet breathing
INSPIRATORY RESERVE VOLUME (IRV)
The maximum amount of air that can be inhaled after a normal tidal volume inspiration
EXPIRATORY RESERVE VOLUME
Maximum amount of air that can be exhaled from the resting expiratory
RESIDUAL VOLUME
Volume of air remaining in the lungs at the end of maximum expiration; indirectly measured
TOTAL LUNG CAPACITY
Volume of air in the lungs after a maximum inspiration
TLC = IRV + TV + ERV + RV or VC + RV
FUNCTIONAL RESIDUAL CAPACITY
Volume of air remaining in the lungs at the end of a TV expiration
The elastic force of the chest wall is exactly balanced by the elastic force of the lungs
FRC = ERV + RV
VITAL CAPACITY
Volume of air that can be exhaled from the lungs after a maximum inspiration
VC = IRV + TV + ERV
INSPIRATORY CAPACITY
Maximum amount of air that can be inhaled from the end of a tidal volume
IC = IRV + TV
best values spirometry measures
Forced expiratory volume in one second (FEV1)
Forced vital capacity (FVC)
FEV1/FVC%
Obstructive pattern on PFT
DECREASED FEV1,
DECREASED FEF 25-75
Decreased FEV1/FVC - <70% predicted
DDx for obstructive lung dz
asthma
COPD (chronic bronchitis, emphysema)
Restrictive pattern on PFT
Decreased TLC, FVC
Normal or increased: FEV1/FVC ratio
significant bronchodilator response value
FEV1 increase by 12% AND >200ml
bronchodilator response
documents reversible airflow obstruction
what does spirogram measure
forced inspiratory and expiratory flow rate
gold standard
evaluate upper respiratory obstruction
lung volume patterns in obstructive dz*
TLC >120% PREDICTED
RV >120% PREDICTED
lung volume patterns in restrictive dz*
TLC <80% PREDICTED
RV <80% PREDICTED
DLCO (Carbon Monoxide Diffusing Capacity)
pt breathe in carbon monoxide, measure how much of it exhaled
measures gas exchange at alveolar-cap membrane
what is diagnostic of asthma in bronchoprovocation test?
greater or equal 20% increase in FEV1
What value is used to follow disease severity in COPD patients?*
FEV1
marker for obstructive lung dz
Biggest risk for COPD
80-90% TOBACCO SMOKE
VERY HIGH RISK if >40ppy
Causes of COPD
Asthma; 10-30 fold increase risk
childhood respiratory infection
alpha 1-trypsin deficiency
Pathophysiology of COPD
chronic irritation airflow limitation/air trapping gas exchange abnormalities mucus hypersecretion pulm vascular scarring from chronic inflammation --> pulm HTN --> R HF
2 types of COPD
emphysema
chronic bronchitis
(often coexist)
how to diagnose chronic bronchitis
productive cough lasting at least 3 months in 2 consecutive years (exclude other causes)
IRREVERSIBLE
Chronic Bronchitis
increase mucus and inflammation from hyperplasia/hypertrophy of goblet cells/mucus glands
affecting terminal bronchioles
Biggest symptoms of Chronic Bronchitis
excessive mucus –> cough
what can happen eventually with chronic bronchitis?
thickening of airways –> fibrosis –> pulm HTN
Acute Bronchitis
affects LARGE bronchi
from virus/bacteria
Emphysema
permanent destruction of alveolar sac –> enlarged air spaces
pathophysiology of emphysema
loss of lung elasticity destruction of lung parenchyma enlargement of air spaces PERMANENT inadequate gas exchange
Classic COPD Symptoms
chronic cough
sputum (purulent w/exacerbation)
breathlessness + fatigue, DOE
(and wheezing, chest tightness)
population affected with COPD
> 40 yo w/risk factors
What should you consider if pt has COPD AND Clubbing of fingers
lung cancer
Late dz presentation of COPD
muscle wasting, weakness pursed lip breathing* R HF Sx: JVC, Peripheral edema, hepatomegaly depression, anxiety osteoporosis polycythemia (inc epo from hypoxia)
how to Dx COPD
Risk factors and confirm w/spirometry
Spirometry findings for COPD
FEV1/FVC <0.7
reduced expiratory flow
What spirometry value is used to stage COPD and determine treatment?
FEV1
Class IV COPD
FE1 <30% predicted
how to distinguish asthma from COPD?
Do Pre/Post bronchodilator spirometry
asthma will have post bronchodilator change, but NOT COPD
COPD treatment
prevent progression, exacerbation, infections
maintain at least 88% oxygenation
short acting, long acting bronchodilators
STEP UP and CUMULATIVE Tx
What do ALL COPD patients need?
flu and pneumococcal vaccine!
When are inhaled glucocorticoids used in COPD?
Severe cases
helps airway inflammation
s/e: oral thrush, increase risk infection in immunocomp
eg fluticasone
What is the only thing that improves survival for COPD?
Smoking prevention/cessation
O2 therapy
What is the mainstay treatment at EVERY stage of COPD?
Inhaled bronchodilators (BA or anti-cholingeric)
Examples of short acting bronchodilators
Beta agonist: albuterol
Anti-cholinergic: ipratropium
used for sx relief
Examples of long acting bronchodilators
LABA: salmeterol
LAMA: Tiotropium (anti-cholinergic)
used for prevention
When do you recommend pulmonary rehab for COPD patients?
symptomatic pts w/FEV1 <50% predicted class II to IV
When do you prescribe O2 therapy?
PaO2 <55 mmHg
O2 <88%
Signs of COPD exacerbations
inc cough freq/severity
inc sputum/change in sputum - purulent
inc dyspnea
Tx for COPD Exacerbation
sputum culture but start empirical abiotic first
Antibiotics (50% from bacterial infection) - azithro
bronchodilator, systemic corticosteroids (prednisone), O2
Most common chronic illness in children
asthma
Asthma pathophysiology
inflammation and constriction of lumen in small airways (thickened)
obstructive dz - reversible!
Symptoms of Asthma
coughing
wheezing
breathlessness
chest tightness
Causes of asthma
hereditary + environ
RSV as infant
allergen, air quality, tobacco
Triggers of asthma
allergen, virus, exercise, cold air, emotions –> causing bronchial hyperresponsiveness (constriction)
What happens if asthma is chronic and uncontrolled?
airway remodeling (fibrosis, inc mucus, hypertrophy, injury, angiogenesis)
Dz progression of asthma
increase airway edema and mucus hyper secretion
Key of asthma
CONTROL
control the allergy –> control the asthma!
Most bronchoconstriction is what?
IgE-mediated
Strongest predisposing factor to asthma
atopy –> propensity for IgE response
Characteristics of Asthma*
airflow obstruction
bronchial hyper-responsiveness
underlying inflammation
(attacks of impaired breathing)
What should be included in DDx with unexplained dyspnea/cough
asthma
Asthma cough characteristics
non-productive (dry)
episodic
worst at night*
What can you find on PE of asthma
end expiratory wheezing*
inc nasal drainage, mucosal swelling, nasal polyps
What is the gold standard diagnostic tool for asthma
spirometry before and after SABA
How to objectively diagnose asthma?*
FEV1 increase 12% from baseline after SABA (reversibility)
atleast 20% decrease in FEV1 after methacholine (bronchoprovocation test)
How to determine tx for asthma
assess severity (for initial Tx) and control (changes in tx) of symptoms
When is systemic corticosteroids used in asthma?
> or equal 3 wheezing/yr
or 2 eps/6mon
What should everyone with asthma get?
SABA - rescue inhaler - for acute bronchospasm
What is the preferred long term control for all age groups for asthma?
Inhaled corticosteroids - prevent exacerbations, most effective for persistent asthma
When to step down treatment for asthma?
asthma controlled for 3 months
start high and step down once control achieved, maintain lowest effective dose
Tx for severe asthma exacerbation
oral corticosteroids
How is LABA used?
ONLY in combo w/ICS, NOT monotherapy
only for Step 3 and above and greater than 5 yo
(can increase asthma related death in young children)
Sampter’s Triad
(ASA exacerbated asthma)
ASA sensitivity
Asthma
Nasal Polyps
How do you confirm pleural effusion?*
CXR - PA and Lateral view
What is pleural effusion associated with
infection (eg bacterial pneumonia)
malignancy
HF
Trauma
Biggest PE finding in Pleural Effusion
dullness w/percussion
What is the most useful test and treatment for pleural effusion?*
thoracentesis, both Dx and Tx
Function of pleural fluid
lubricant to minimize friction during breathing
surface tension - allows alveoli to inflate maximally
reabsorbed by lymphatics
Types of pleural effusions
transudative
exudative
Transudative pleural effusion
due to increased hydrostatic pressure or low plasma oncotic pressure
causes: HF, cirrhosis, nephrotic syndrome, PE
Exudative pleural effusion
due to inflammation and increased capillary permeability
causes: pneumonia, cancer, TB, viral infection, PE
Lab differences between transudative and exudative fluid*
Transudative fluid: low in protein and LDH
Exudative: high in protein and LDH
Causes of exudative pleural effusion
malignancy infection PE Chylothorax Hemothorax GI dz Collagen dz
Causes of transudative pleural effusion
90% CHF
cirrhosis
kidney failure: nephrotic syndrome
(rarely need intervention)
Light’s Criteria for exudative pleural effusion
- pleural fluid protein/serum protein >0.5
- or pleural fluid LDH/serum LDH >0.6
- or pleural fluid LDH >2/3 normal upper limit of serum LDH
Symptoms of pleural effusion
SOB* Pleuritic pain* Cough* DOE, orthopnea 25% asymp
Pleural effusion on PE
DULLNESS TO PERCUSSION decreased/absent tactile fremitus dec breath sounds egophony friction rub
Mediastinal shift in unilateral pleural effusion
AWAY
What do do if suspect malignancy in pleural effusion?
take 3 diff samples
cytology
glucose
Color differences between transudative and exudative pleural fluid
transudative: very clear
exudative: dark
normal: straw colored
Lab results of pleural effusion w/malignancy
pos cytology
glu <60mg/dl
frank red fluid
Lab results of pleural effusion w/chylothorax
milky fluid
triglyceride >110 mg/dl
Purulent pleural fluid
empyema
Pleural fluid WBC ct >10,000
parapneumonic effusion
acute pancreatitis
Pleural fluid WBC ct >50,000
complicated parapneumonic effusion
empyema
Low glucose levels of pleural fluid
infections
autoimmune
malignancy
What is low pH of pleural fluid and malignancy associated with?
poorer prognosis
What can you get if you remove too much pleural fluid at once?
pulmonary edema
When is pleurodesis used
recurrent effusions (chemically adhere visceral and parietal layers; drain fluid beforehand - eg doxycycline)
VATS (video assisted thoracoscopic surgery)
deflate affected lung –> draw out fluid –> re-inflate lung
low success rate
When is thoracotomy used?
empyema
lung cancer
(involves decortication or pleurectomy)
How is pleural effusion usually diagnosed?
History
description of fluid
Interstitial lung disease
damage to alveolar walls and lung parenchyma from inflammation and resulting fibrosis
Hallmarks of interstitial lung disease
restrictive pattern on PFT
decrease diffusing capacity for carbon monoxide
drugs that cause acute interstitial lung dz
amiodarone
methotrexate
diseases that can cause interstitial lung dz
RA
cancer
sarcoidosis
amyloidosis
Most common type of interstitial lung dz*
idiopathic interstitial fibrosis
Interstitial lung dz affects which population of people generally
> 50 yo
Most common causes of interstitial lung dz
idiopathic pulmonary fibrosis sarcoidosis assoc collagen vascular dz occupation related drug or toxin related
Most common presenting complaint of interstitial lung dz
DYSPNEA** SOB non-productive cough chest tightness/heaviness weight loss, fatigue, anorexia
what is hilar/mediastinal lymphadenopathy associated with in interstitial lung dz?
sarcoidosis
silicosis
lymphoma
what is pleural effusion/thickening associated with in interstitial lung dz
collagen vascular dz
lymphoma
asbestos
“ground glass” on CXR
amiodarone
Inflammation –> potentially reversible
“honey comb” on CXR
Fibrosis
VERY POOR PROGNOSIS - IRREVERSIBLE
What population is associated with idiopathic pulmonary fibrosis?
older, male
BAD prognosis
Pathology of idiopathic pulm fibrosis
triggering event –> inflammation –> damage alveolar-cap basement membrane –> inc perm –> FIBROSIS
End stage of idiopathic pulm fibrosis
destruction of alveolar wall
honeycombing on CXR
What pulm function is reduced in idiopathic pulm fibrosis
DLCO (diffusing capacity) reduced
but normal spirometry ratios
characteristic of sarcoidosis
multiple uniform non-caseating granulomas (lungs and lymph nodes)
most common population with chronic sarcoidosis
north american blacks
What can you get with sarcoidosis
iritis and uveitis
large, “fluffy” nodules on CXR
Sarcoidosis
Sarcoidosis staging*
Stage 0: normal
Stage I: Hilar adenopathy only
Stage II: Hilar adenopathy and parenchymal involvement
Stage III: parenchymal involvement alone
Tx for sarcoidosis
most don’t require treatment
treat if symptomatic, ocular, and other organ involvement (corticosteroids)
pneumoconiosis
hypersensitivity pneumonitis from inhaled dusts/chemicals (occupational)
Hallmark of chronic pneumoconiosis
pulmonary fibrosis in upper lobes
what cancer can you get with asbestos
mesothelioma
Pneumothorax
collapsed lung from air in potential space
Causes of pneumothroax
penetrating trauma
blunt trauma
barro trauma
birth
Signs of pneumothorax
decreased breath sounds - affected side
hyperresonance
tracheal deviation
crepitance - lungs
Tracheal deviation of tension pneumothorax*
AWAY from side w/decreased breath sounds
Tracheal deviation of routine pneumothorax*
TOWARD side w/decreased breath sounds
empyema
purulent fluid in pleural space
stages of empyema
exudative
fibrinopurulent
organizing
empyema causes
pneumonia
mediastinal infection
abscess
empyema necessitans
complication of empyema
goes into chest wall
risk factors of lung abscess*
alcoholism* - most common severe gingivodental dz seizures CV accidents anesthesia
Which side is more commonly affected w/lung abscess*
right side 75%
bronchiectasis
persistent, abnormal dilation of bronchi
which side is more common in bronchiectasis?*
left*
most common type of bronchiectasis
varicose 62%
causes of bronchiectasis
acquired: viral, bacterial, obstruction, heroin
congenital rare
most common symptom of bronchiectasis
persistent cough 75%
pulmonary HTN
elevated pulmonary arterial pressure and secondary right ventricular failure
what’s the mean arterial pressure in pulmonary HTN*
> 20mmHg at rest
How is pulmonary arterial pressure measured?
right heart catheterization
Group 1 pulmonary HTN
pulmonary arterial HTN - RIGHT heart dz
Group 2 pulmonary HTN
pulmonary venous HTN - LEFT heart dz
Group 3 pulmonary HTN
associated w/lung dz
Group 4 pulmonary HTN
associated w/embolitic dz
Group 5 pulmonary HTN
unclear, multi-factorial
Initial complaints of pulmonary HTN
Dyspnea on exertion*
fatigue
lethargy
PE of pulm HTN*
increase pulmonic component of S2 (P2)
What diagnostic test should you first order for pulm HTN*
2D echo w/doppler flow study
Biggest cause of dyspnea in children
infections
foreign body aspiration
Causes of acute dyspnea in adults
(PPOPPA) PE Pulm edema obstructed airway pneumothorax pneumonia asthma/COPD
most common airway obstruction in adults*
food bolus
most common airway obstruction in children*
coins
What should you think w/dyspnea at rest AND pleuritic chest pain
PE
What presentation is most severe w/dyspnea
orthopnea
types of PE
acute: immediately after
subacute: days/weeks after
chronic: pulm htn over years
pulmonary embolism
obstruction of pulmonary arteries/branches by thrombus, air, fat, tumor
locations of PE
Saddle
Lobar
Segmental and Subsegmental
Clot-in-Transit
which locations are the large thrombi
saddle: bifurcation of main pulmonary artery
lobar: uni or bilateral
Which PE is more likely to cause pulmonary infarct and pleuritis*
segmental and subsegmental (branches)*
Clot in transit PE*
TRAVELS THROUGH HEART
HIGH MORTALITY!!
Effects of massive PE
Right heart failure
cardiogenic shock (arterial hypotension)
(submassive + low risk PEs: normal BP)
most common cause of unexpected death in most age groups
PE
3rd most common cause of CV death in US
PE
High population is at high risk for PE?
Hospitalized patient
Dx missed 70%!
acute PE at high risk for:
recurrence
pulmonary HTN
chronic cor pulmonale
where do LE thrombi originate from
valve cusps/bifurcations
areas of low blood flow!!
common causes of fatal PE
axillary and subclavian veins
veins in pelvis
indwelling central venous catheter
1/2 of PEs are what
Asymp!
RV thrombus has**
double mortality!!
cor pulmonale
right sided heart failure from pulmonary HTN (from chronic lung disease like COPD, OSA)
Symptoms of PE*
Dyspnea at rest or w/exertion (73%)
Pleuritic chest pain (66%)
Signs of PE*
Tachypnea (70%)
rales (51%)
Patients without what symptoms are unlikely for PE*
Dyspnea, pleuritic chest pain, tachypnea
Massive PEs sign
systolic BP <90mmHg or drop in atleast 40mmHg from baseline
JVD
only 4% of PEs byt 20-60% mortality
what’s the gold standard to Dx DVT
contrast venography
Labs to order for PE
D Dimer: pos
ABG: hypoxemia, resp alkalosis
Gold standard to diagnose PE*
Pulmonary angiography
1st choice to Dx PE (not gold standard)*
CT pulmonary angiography (spiral)
Well’s criteria
assess whether there’s PE
PERC rule
criteria to rule out PE
for pts w/low Well’s score
need to fulfill all 8 criteria to rule out PE
What you may see on CXR w/PE
Westermark sign: dilation of pulmonary vessels
Tx for PE
- Assess HD stability
- Anticoagulate to prevent progression
- Thrombolytic if massive PE/unstable, inject near location
preferred anticoagulant for PE
DAOAC (Direct acting oral anticoag): eliquis, xarelto
-only HD stable pts
when should you prophylax for PE
Post-op: esp ortho/pelvic surgery on LE - early ambulation, lovenox, pneumatic compression
planned stasis risks: long flights - ASA
what procedure has high mortality in PE
embolectomy
how is cystic fibrosis inherited?
autosomal recessive
Pathophysiology of cystic fibrosis
defect in CFTR gene –> abnormal Cl transport –> mucus more viscous/sticky to bacteria –> promote infection/inflammation
Dx of CF*
Dz in one or more organs
>/= 60mmol/L sweat chloride**
Atypical CF likely present w/
Gi issues
DM infertility
dx >18 yo
when is CF typically Dx?
1 yo
Presentations of CF
Respiratory tract involvement sinus dz pancreatic dz meconium ileus hepatobiliary dz musculoskeletal dz reduced/infertility
How does CF affect male fertility
> 95% infertile bc defects in sperm TRANSPORT
What do most patients eventually get w/CF*
Pseudomonas respiratory infection
pulmonary presentation of CF
Dry hacking (non-productive) cough
lung hyperinflation on CXR
Chronic bronchitis
Sinus presentation of CF
Chronic nasal congestion
10-32% nasal polyps
Pancreatic presentation in CF
pancreatic insufficiency –> fat malabsorption!
resultant poor weight gain
deficient in fat/protein, fat-sol vitamins
Meconium ileus
bowel obstruction by meconium (stool produced in utero) in infants
only 10-20% occurence byt 80-90% w/this has CF!
Advance dz of CF
Distal intestinal obstructive syndrome (DIOS)
clubbing, bronchiectasis
Hepatobiliary presentation in CF
Focal biliary cirrhosis: inc serum alk phos, lobular hepatomegaly from thickened bile
12% cholelithiasis
Musculoskeletal presentation in CF
Reduced bone mineral density
rare: hypertrophic osteoarthropathy: abnormal prolif
hand in bucket sign of CF
Aquagenic wrinkling of palms
white plaques
rare
How to dx non-classic CF (sweat chloride normal)
nasal potential difference
or DNA analysis
Tx goals for CF
Maintain lung function
control infections
clear mucus
nutritional
Tx for CF exacerbations
chest percussion and postural drainage:
bronchodilator 1st
clap on chest/back or vest
loosen mucus
CF medication
pancreatic enzymes bronchodilators vitamin D mucolytics: dornase alfa CFTR potentiators antibiotics
Management/follow-up for CF
Monitor every 2-3 months
resp culture every visit
How to differentiate between chronic bronchitis and emphysema on PFT?
emphysema: INC Residual Volume
How to differentiate between asthma and emphysema w/DLCO?
asthma: inc DLCO
emphysema: dec DLCO
(DLCO unaffected in Chronic bronchitis)
TB w/Night sweats, think…
HIV
Latent TB on CXR
Ghon Lesion –> enlarged hilar nodes
or normal
Ghon lesion
fibrotic, calcified lesion
contain: T cell, macrophage, central necrosis
Reactivation risk of TB in HIV pts
10% risk every year!
How does active TB infection spread?
cavitary open into bronchi, spread by cough
Where do you first see calcifications in TB?
Apices
Late sign of TB*
Hemoptysis
Rasmussen’s Syndrome
What does PPD do?
only screens for TB exposure
test only at risk pts!
How long do you need to isolate pts w/TB
Atleast 2 weeks after Tx or until 3 sequential sputum neg
What’s the minimum initial therapy for TB
3 drugs minimum initially
How long is TB medication taken for ?
6-9 months
1st line agents for TB*
ISONIAZID
RIFAMPIN
ETHAMBUTOL
PYRAZINAMIDE
Causes of false negative in PPD
Anergy, steroids, HIV, malnutrition
Most common causes of community acquired pneumonia
s. pneumoniae
H. influenzae
Mycoplasma
viruses
