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