Final - Pulmonary Conditions Flashcards
Is COPD more common in men or women?
women
physical examination
observation –> vital signs –> auscultation –> palpation –> percussion
Respiratory rate
measure dyspnea at rest and with activity
always compare R to L
dyspnea related to activity
0: breathlessness only on strenuous exercise
1: breathless when hurrying on the level or walking up a slight hill
2: walks slower then other people of same age on the level due to shortness of breath or need to stop for breath when walking at own pace
3: short of breath after few minutes on the level or about 100 yards
4: too breathlessness to leave the house or breathless when dressing or undressed
borg dyspnea scale
0: nothing
0.5: very, very slight
1: very slight
2: slight
3: moderate
4: somewhat severe
5-6: severe
7-8: very severe
9: very, very severe
10: maximal
appearance
ability to speak/phonation (count # syllables/ breath); breathing pattern; facial expression; accessory muscle use; posture …
normal breath sounds
tracheal, bronchial and vesicular sounds
Wet abnormal sounds - central, continuous
Rhonchi: higher up, similar to wheezing but in larger airway –> excessive secretion or swelling
Wet abnormal sounds –> peripheral, discontinuous
Crackles: crackling associated with inspiration due to opening of collapsed airways –> atelectasis or pulmonary edema (pneumonia)
dry abnormal sounds –> central, continuous
Stridor: high pitched sound associated inspiration and obstruction of upper airway for foreign body, epiglottis, tumor
dry abnormal sounds –> central, continuous
wheezing: high pitches musical sounds with inspiration and expiration (asthma)
friction –> extra-pulmonary sounds
pleural friction rub: due to inflammation of pleural membranes; revving sound associated with inspiration or expiration
Egophony, Bronchophony, Whispered pectoriloguy
based on physics principle fluids and solids transmit sound better than gases: louder, more audible transmission with pneumonia, effusion, atelectasis
pulse oximetry
oxyhemoglobin/total hemoglobin
used with virtually all diagnoses
percussion testing
based on principle that sounds resonance is determined by tissue density
used to confirm findings from auscultation and PE
cough
determine effectiveness of cough, productivity
restrictive:
problem getting air in
normal FEV1/FVC ratio
increased respiratory rate
obstructive
problem getting air out
decreases in FEV1 and FEV1/FVC ratio (gold standard)
examples of restrictive disease
SCI, ALS, Obesity, MS, rib damage or abnormality, burns, connective tissue disorder or rheumatoid condition (sarcoidosis, Lupus, etc…), pulmonary fibrosis*
Obstructive Disease
Asthma, emphysema, chronic bronchitis, bronchopulmonary dysplasia
Mixed restrictive and obstructive
bronchiectasis, pulmonary fibrosis*, TB and pneumonia, acute respiratory distress syndrome (ARDS)
Lung Parenchyma Disease (alveoli/bronchioles)
• Obstructive Pulmonary Disease: diseases characterized by air
flow limitation in exhalation phase of breathing (COPD and non-chronic dx)
• Pulmonary fibrosis
• Emphysema: respiratory bronchioles, alveolar ducts & alveoli
• Chronic Bronchitis: bronchi & bronchioles
• Asthma: bronchioles, may involve alveolar ducts & alveoli secondarily
• Pneumonia: infectious disease affecting alveoli, bronchi &
bronchioles
• Acute Respiratory Distress Syndrome (ARDS): fluid in alveoli
and thickening of alveolar-capillary space- COVID-19
Vascular
• Pulmonary Embolism: pulmonary artery
• Congestive Heart Failure: alveolar capillaries and
pulmonary veins and arteries
Pleural Space
- Pneumothorax: chest wall, parietal pleura and pleural space
- Pleural Effusion: pleural space
Neoplastic Disease
- Lung cancer: bronchi & bronchioles
* May affect alveolus & extrapulmonary tissues
Risk Factors for Emphysema
genetic mutations in α1 anti-trypsin, smoking, exposure to 2nd hand smoke or air pollution
What happen with emphysema
Activation of destructive enzymes breakdown alveolar walls, floppy airway (increased compliance), air trapping and decreased surface area for gas exchange
What is the biggest cause of emphysema?
smoking
chronic bronchitis
- Risk factors: same as bronchitis
- Chronic exposure to tobacco smoke or air pollution leads to diminished mucocilliary escalator fx, hypertrophy of goblet cells & bronchiolar smooth muscle and chronic infection –> chronic infection
leads to chronic airway inflammation (air trapping secondary to secretion retention)
Asthma risk factors
allergies, exposure to smoke or smoking, frequent viral or bacterial respiratory infections, stress, exposure to cold air, GERD or exposure to air pollutants
what happens in asthma?
- Irritants lead to reversible inflammatory response in bronchioles
- Irritant can by inhaled, ingested or in contact with skin
- Respiratory infection likely also contributes as well as air temperature
– Bronchial smooth muscle constricts leading to air trapping &
alveolar hyperinflation.
– Increased mucous production and bronchiolar mucosal
inflammation and thickening also occur, leading to fluid
infiltration
Pneumonia Risk Factors
aphasia, immobilization, malnutrition, COPD, heart disease,
AIDS, other chronic diseases, asplenic patients, exposure to
infected patients
Pneumonia
Inflammatory reaction of the distal airway to insult/microorganism
Occurs in stages
Community acquired pneumonia
develops infection prior to hospitalization
Nosocomial pneumonia
- develops infection within 48 hours of hospitalization
Infectious agents related to pneumonia
streptococcus pneumonia (pneumococcus) is the most common cause and prototype. Also: Haemophilus influenza, Staph infections (MRSA), Mycoplasma pneumonia (atypical) and many others
ARDS Risk Factors
severe, systemic or pulmonary insult resulting in strong inflammatory or immune response
things that can cause ARDS
pancreatitis, pneumonia, acute renal failure, shock, etc
ARDS can lead to:
- Pulmonary edema
- Thickening of inter-alveolar-capillary space
- Acute hypoxia
- Stiff lung (reduced compliance)
- Increased work of breathing
- Fibrosis
what exactly is ARDS?
intense inflammatory reaction in distal airway
what is ARDS all about?
- cytokines
- increased lung stiffness (decreased compliance) and increased work of breathing
Lung cancer risk factors
smoking, genetic mutations linked to cancer or neoplastic conditions, exposure to air pollution, second hand smoke or carcinogens
what do 98% of lung cancers arise from?
bronchial epithelium
what does lung cancer typically start as?
“coin lesion” along bronchi with mix of cartilage and epithelial cells
widespread perneoplastic effects from lung cancer
carcinoid syndrome (skin flushing, diarrhea, dyspnea, asthma- like symptoms), cushing syndrome, hyper/hypocalcemia, weight loss, cachexia
pulmonary embolism risk factors
immobilization, thrombophlebitis, other conditions affecting lower extremity movement (SCI, bone fractures, etc…), hospitalization & coagulation disorders
what is a pulmonary embolism
Sudden, life-threatening occlusion of a pulmonary artery by embolism or thrombus –> Leads to ventilation-perfusion mismatching
where are most PEs from?
LE
life threatening ones from above the knee
Congestive Heart Failure Risk Factors
Deconditioning, HTN, smoking, diabetes, atherosclerosis, obesity, hyperlipidemia, MI, valvular heart disease, viral or bacterial infections, hyper/hypothyroidism
complex pathophysiology of congestive heart failure
Typically takes years to develop (5-30 years), but can occur acutely w/
infection –> Heart can’t meet demands of body:
– Heart & vasculature undergoes remodeling.
– Blood “backs up” into pulmonary or systemic system or both.
– Results in edema, SOB, fatigue, exercise intolerance, etc
Pneumothorax Risk Factors
Contusion/trauma, COPD, connective tissue disorders, TB, tall stature (2° to elevated intra-thoracic pressure)
What is pneumothorax?
Air enters pleural space, leading to collapse of lung secondary to penetrating wound into pleural cavity or breech in pleural membrane
resulting in rapid collapse of the lung, down to residual volume
• Ventilation: perfusion mismatching.
• Life-threatening condition
Pleural Effusion risk factors?
pneumonia, connective tissue disorder, CHF, lymphedema, neoplasm, TB, pancreatitis
What is Pleural Effusion?
Transudative or exudative fluid in pleural space resulting from an inflammatory condition or infection (pneumonia), other dx process.
• May have insidious onset and mimic musculoskeletal pain
except pain related to breathing cycle
What is pulmonary fibrosis?
Describes “interstitial lung disease”: conditions where functional lung parenchymal tissue is replaced by scar tissue
• Lung is thickened, stiff, and scarred
What does pulmonary fibrosis typically arise from?
inflammatory process that is triggered by:
• Pneumonia
• Exposure to irritants (smoke, dust, silicon, etc…)
• Autoimmune disease
What does pulmonary fibrosis result in?
increased lung stiffness, decreased diffusion capacity and SOB, especially with Ex
Emphysema history and physical exam
long hx of smoking or second hand smoke. Look for family hx in non-smokers.
– Wheezing, hyper-inflated lung/barrel chest, flat diaphragm, hypertrophy of accessory mm, pink complexion, cachexia, hypercapnia and hypoxemia.
– Heart failure later in disease process
– May or may not have productive cough
Chronic Bronchitis History and Exam
smoking or exposure to pollution
– Wheezing, hyper-inflated lung/barrel chest, flat diaphragm,
reliance on accessory mm, bluish/cyanotic complexion,
hypercapnia and hypoxemia.
– Heart failure develops 10-20 years after respiratory sx.
– Productive cough (worse in AM) with bad breath
Asthma History and Exam
hx of recurrent respiratory infections, runny nose or swollen nasal passages, allergic skin conditions (such as eczema), allergies, smoking or exposure to smoke or pollution, associated with anxiety disorders and other psychological factors –> Exacerbated by viral and other respiratory tract infections.
– Occurs acutely with wheezing, anxiety during
attack, use of accessory mm, reversible with
bronchodilators
Pneumonia History and Exam
Typically occurs acutely, but “walking pneumonia” may be insidious. Common in patients with prolonged bed rest, immune-suppressed patients, elderly, very young, exposure to pt with TB or other respiratory infectious agent, aspiration.
– High fever, crackles or wheezing or diminished breath
sounds, productive couch, hemoptysis and chest pain
good tests for pneumonia
Egophony, bronchophony, whispered pectoriloquy or percussion testing suggest consolidation over involved lung
ARDS
- Recent hx of an acute, serious systemic or pulmonary disease
- Shortness of breath
- Tachypnea
- Tachycardia
- Productive cough (could be dry cough with COVID19)
- Hypoxia (cyanosis)
- Fatigue
- Fever
- Crackles
- Chest pain, especially with deep breathing
- Low blood pressure
- Confusion
Lung Cancer History and Exam
• hx of weight loss, • h/o smoking, exposure to 2nd hand smoke /air pollution or environmental/occupational exposure to carcinogens, • fatigue, • cachexia, • Chronic cough, dyspnea, wheezing or crackles, chest pain & hemoptysis. • SOB
Pulmonary Embolism history and exam
Develops acutely in patients on prolonged bed
rest, with presence of DVT, s/p air travel or with
coagulation dx.
– Acute cyanosis, SOB (primary symptom), hemoptysis and
chest pain (unilateral)
Congestive Heart Failure Exam and history
slowly developing fatigue, orthopnea, SOB, wt. loss/gain (with fluid retention), peripheral edema, JVD, decreased exercise tolerance, etc…
– Develops slowly over years.
– Kerley B-lines on CXR.
– Crackles, 3rd or 4th heart sounds, murmurs,
– Dry, non-productive cough.
Pneumothoraxic exam and history
trauma, COPD (especially emphysema), connective tissue disorders.
– Acute onset of cyanosis, anxiety, midline shift.
Patient may exhibit stridor
Pleural Effusion history and exam
pneumonia, CHF, respiratory disease, prolonged or protracted illness, connective tissue disorders and rheumatoid disorders (SLE, RA,
sclerosis and sarcoidosis).
– Pleural friction rub or diminished breath sounds
over lower lobes, chest pain with inspiration or
expiration, SOB. Possibly fever if associated with
infection
Pulmonary fibrosis exam and history
– Prolonged expose to industrial air pollution, dust or smoking
– Recent history of a lung infection
– History of autoimmune disease
– Idiopathic condition may arise where no discernible cause can be found
Emphysema diagnostic studies
PFT, CXR, ABG, chest measurements, blood tests (-1 anti-trypsin)
gold standard for PE diagnosis
V/Q scan
what can be diagnosed with chest X-ray?
everything except PE and CHF
Management of Emphysema
smoking cessation, pursed lip breathing,
relaxation techniques, bronchodilators, corticosteroids,
inspiratory & expiratory mm strengthening,
supplemental O2, vent in severe dx, lung reduction sx
Chronic Bronchitis Management
smoking cessation, airway
clearance techniques (broncho-pulmonary hygiene),
pursed lip breathing, relaxation techniques,
bronchodilators, corticosteroids, inspiratory/expiratory
mm strengthening, supplemental O2, lung reduction sx.
Pulmonary fibrosis management
very limited treatment options.
Few medications are effective and most pts are not
candidates for meds. O2 is only Rx that helps and effect
is typically transient. Pt education recommended
asthma management
emove irritant, pursed lip breathing,
relaxation techniques, bronchodilators,
Leukotriene modifiers
pneumonia management
ABX, bronchodilators,
corticosteroids, supplemental O2, airway
clearance techniques
ARDS management
ventilation
PE management
anticoagulation, thromboectomy,
thrombolysis (only in specific circumstances),
supplemental O2, bed rest (variable time frame)
CHF management
lifestyle modification, aerobic exercise,
smoking cessation, BP control, DM control, BB,
CCB, ACE-inhibitors and ARBs,
anticoagulants, etc… many, many meds
pneumothorax management
mild- monitor/observation &
supplemental O2 as needed, mild/mod- insert
chest tube and supplemental O2, mod/severe-
ventilation, chest tube, pain med. Chronic PXT-
chemical or mechanical pleurodesis
lung cancer management
surgery (resection), chemotherapy,
radiation therapy (depending on stage, Rx may include
all 3), treatment for any paraneoplastic conditions
COVID
• Produces a special version of ARDS that is
similar in most ways to other types except:
– Mismatch between severity of hypoxemia and
calculated stiffness
– Stiffness or elastance is lower in “most” cases of
Covid-19!
– Covid-19-ARDS is referred to a “L-type ARDS”
– Some patients report less SOB, but still very hypoxic
– Patients still benefit from ventilation w/ PEEP, prone
positioning, supplemental O2, et
silhouette sign
Kerley B lines
CHF
COPD - Hyperinflation - Flat diaphragm, - Barrel chest - Prominent vascular markings
COPD vascular markings
Pneumonia
bronchi of the consolidated lobe
and beginning abscess
formation
Pneumothorax Midline shift - Presence of pleural space (air in pleura) - Increased vascular markings - Increased density of parenchyma
Pneumonia - Density involving a lobe or bronchi - Air bronchogram - Pleural effusion - Lacey
ARDS
- nodular shadowing
- consolidation
- ground glass opacity
Pleuritis
Lung Cancer
