Ingrid's Review Flashcards
Trachea
composed of 16-20 C-shaped cartilage rings
-posterior (open) part of ring accommodates the esophagus during swallowing
Carina
location of high concentration of cough receptors
Mainstem Bronchi
Right Bronchi
Right Bronchi
More apt to receive foreign objects aspirated into the trachea or to be “tube” during endotracheal intubation due to being shorter and wider
Bronchioles
transitional airways
Terminal Bronchioles - functions
heat, humidify, and conduct inspired air
Mucous Blanket
mucocilliary escalator
Mucocilliary escalator
submucosal glands and cilia
Submucosal glands
composition of normal mucous - 95% water
Cilia
paralyzed by nicotine
Major muscles of inspiration
diaphragm, sternocleidomastoid, scalene, pectoral minor
Diaphragm
- principle inspiratory muscle
- most important muscle of inspiration
- –contributes to 70% of increase in thoracic expansion
- innervation of left and right phrenic never
Poiseuille’s Law
- flow is decreased by a factor of 4
- responses to bronchodilators (albuterol nebulizer therapy)
LaPlace’s Law
failure of this law = atelectasis
Dalton’s Law
total pressure exerted by a mixture of gases to sum of pressures exerted by each gas
Henry’s Law
when a gas is in contact with a liquid, the gas will dissolve in the liquid in proportion to its partial pressure
Boyle’s Law
decrease in oxygen tension (pressure) results in an increase in the volume
Limbic system - Anxiety
increase in rate and depth of respiration
Temperature
decreased body temperature decreases respiration
Pain
- sudden severe pain brings on apnea
- prolonged pain increases respiratory rate
High altitude
- decrease oxygen tension
- increase in volume (Boyle’s Law)
Irritation of Airways
immediate cessation of breathing followed by coughing or sneezing
Shift to the Left
Increased Hgb affinity for oxygen
Increased Hgb affinity for oxygen
- alkalosis
- hypocarbia
- hypothermia
- decreased 2,3-DPG
- fetal hemoglobin
- carboxyhemoglobin
- methemoglobin
Shift to the Right
decreased Hgb affinity for oxygen
Decreased Hgb affinity for oxygen
- acidosis
- hypercarbia
- hyperthermia
- increased 2,3 - DPG
Carboxyhemoglobin - Pathophysiology
- hemoglobin has a 200 to 250 times greater affinity for CO than O2
- progressive shift to the left
Carboxyhemoglobin - Management
Hyperbaric oxygen therapy aka: dive chamber
Methemoglobin - Pathophysiology
- +2 ferrous to a +3 ferric state
- shift to the left
Methemoglobin - Causes
- nitrates and nitrites
- local anesthetics
Methemoglobin - Managment
methylene blue administration
Fetal Hemoglobin - Pathophysiology
- two beta chains are absent and two gamma chains are present
- shifts to the left
Hypoxia
state of tissue oxygen deficiency
Hypoxemic
- most common type
- decreased PaO2
- COPD, pneumo
Anemic
- decreased hgb availability
- anemia, carboxy/methemoglobin
Circulatory
- stagnant (slow flow) vs AV shunting (no flow)
- cardiogenic vs septic shock
Methemoglobin - Clinical Manifestations
reddish brown blood, cyanosis (blue people)
Histotoxic
- inability of tissue to use oxygen
- seen in cyanide poisoning (sodium nitroprusside toxicity)
normal pH
7.35 to 7.45
normal pCO2
35 to 45
normal HCO3
22 to 26
ROME
respiratory opposite direction and metabolic equal direction
Respiratory Acidosis
can’t breathe = impaired lung mechanics
-do not correct with sodium bicarbonate
Respiratory Alkalosis
CHAMPS Hyperventilate
- CNS disease
- Hypoxia
- Anxiety
- Mechanical ventilation
- Progesterone or pregnancy
- Salicylates or Sepsis
Metabolic Acidosis
MUDPILE CATS
MUDPILE CATS
Methanol, metformin Uremia Diabetic ketoacidosis Paraldehyde, pregnancy Isoniazid (INH) and iron Lactic acidosis Ethylene glycol Carbamazepine Alcoholic ketoacidosis Toluene Salicylates, starvation ketoacidosis
Metabolic Alkalosis
CLEVER PD
- Contraction
- Licorice
- Endocrine excesses
- Vomiting
- Excess alkali
- Refeeding alkalosis
- Post - hypercapnia
- Diuretics
Cardiogenic pulmonary edema
- part of overall problem related to CHF
- cardiomegaly
Non-cardiogenic pulmonary edema
damage to the alveoli or capillary without elevation of the pulmonary capillary wedge pressure
High altitude pulmonary edema
most common cause of death from high altitude illness
-treatment = get them down
Neurogenic pulmonary edema
subarachnoid hemorrhage or head trauma
Reperfusion pulmonary edema
after removal of blood clot
Re-Expansion pulmonary edema
occurs unilaterally status post rapid expansion of collapsed lung in pneumothorax
Opioid Overdose
- particularly seen in heroin overdose
- treatment = naloxone (narcan)
Salicylate toxicity
- generally occurs in elderly patients from chronic salicylate toxicity
- treatment = sodium bicarbonate
Inhalants
- chlorine gas
- ammonia
Pulmonary embolism - causes
Virchow’s triad
- vascular intimal trauma
- venous stasis
- hyper-coagulable state
Pulmonary embolism - clinical manifestations
- dyspnea
- tachypnea
Pulmonary embolism - ECG
sinus tachycardia
Pulmonary embolism - diagnostic gold standard
pulmonary angiography
—CTA or V/Q
WHO classification of pulmonary hypertension
- pulmonary arterial hypertension
- left heart disease
- lung disease and/or chronic hypoxemia
- chronic thromboembolic disease
- miscellaneous
Pulmonary arterial hypertension
-idiopathic, women, poor prognosis
Lung disease/and or chronic hypoxemia
causes include ILD, OSA, COPD and any other cause of chronic hypoxemia
Chronic thromboembolic disease
recurrent PE
Miscellaneous
tumor
Pathophysiology of pulmonary hypertension
- passive resistance of pulmonary venous system
- hyperkinetic
- obstruction
- pulmonary vasoconstriction
ARDS - Berlin Criteria
- acute onset
- refractory to O2
- PCWP <18 mmHg
- bilateral infiltrates on CXR
ARDS - etiologies
- sepsis is most common risk factor
- elderly + UTI + pneumonia
ARDS - clinical manifestations
- dyspnea, tachypnea, and tachycardia
- progressive hypoxemia
ARDS - Diagnostics
ABG = hypoxemia and any ABG possible
-wedge pressure <18
ARDS - Management
- oxygenation
- mechanical ventilation
- fluid management
- -avoid volume overload
- treat underlying cause
Transudative
CHF (most common)
low protein content, few cells
-occurs due to increased hydrostatic pressure or low plasma oncotic pressure
Exudative
- high protein content, may contain some white and red cells
- occurs due to inflammation and increased capillary permeability
- pneumonia, cancer, TB
evaluated pleural fluid amylase
pancreatitis
milky, opalescent fluid
chylothorax
frank, purulent fluid
empyema
blood effusion
malignancy
exudative effusions that are primarily lymphocytic
tuberculosis
ph<7.2
parapneumonic
Glucose <60
RA
empyema - etiologies
untreated exudative pleural effusion
empyema - clinical manifestations
pneumonia most common underlying cause
empyema - management
aggressive drainage of pleura with antibiotic therapy
Chylorthorax - etiologies
tumors - most common cause
-lymphomas
trauma - 2nd most common cause
-surgery is most common cause of traumatic chylorhorax
Chylorthorax - diagnostic findings
triglycerides in pleural fluid
Chylorthorax - management
- no treatment necessary
- fat restriction
- octreotide may be beneficial in some cases
Pleurisy
history, history, history - commonly mimics a heart attack
Pleurisy - etiologies
viral (most common) - may lead to epidemic pleurodynia (aka: Bornholm’s disease) viral pleurisy is a diagnosis of exclusion
Pleurisy - appropriate management
treatment of the underlying etiology
-indomethacin
simple/spontaneous pneumothorax - etiologies
tall, lean, young men +/- smokers
simple/spontaneous pneumothorax - clinical manifestations
mediastinal shift toward side of pneumothorax
Open pneumothorax
penetrating trauma = sucking chest wound
-cover the entry wound with a three-sided occlusive dressing
Tension pneumothorax
accumulation of air within the pleural space such that the tissues surrounding the opening in the pleural cavity act as valves, allowing aria o enter but not escape
-absent breath sounds
tension pneumothorax - CXR or physical exam findings
shift of trachea away from the side of pneumothorax
tension pneumothorax - treatment
chest needle decompression in 2nd or 3rd intercostal space above rib
Hemothorax
- blood accumulating in pleural cavity
- tube thoracotomy
Fail chest/pulmonary contusion
- two or more ribs broken in two or more place
- severe blunt force trauma
Stridor - causes
narrowed upper airway
cough, congestion, and rhinorrhea
viral croup (MC)
drooling, trismus, torticolis, inability to extend the neck or uvular deviation
peritonsillar abscess
“steeple” sign
croup
“thumbprint” sign
epiglottis
Neonatal respiratory distress - causes
transient tachypnea of the newborn is most common cause
Neonatal respiratory distress - clinical findings
respiratory distress, tachypnea, grunting, hypoxia, increased work of breathing
-symptoms may begin at birth and lasts up to 24 hours
Neonatal respiratory distress - Management
- supportive
- oxygen or CPAP may be required
Croup - causes
parainfluenza virus serotypes
Croup - Clinical Findings
barking cough, stridor worse with irritation
- fever usually absent
- cough with no drooling
Croup - CXR
steeple sign
Croup - mangement
Westley criteria to determine severity
- humidified oxygen
- steroid
- racemic epinephrine, nebulizer
Epiglottitis - causes
Hemophilus influenzae type B
Streptococcus spp.
Epiglottitis - clinical findings
- drooling
- tripod positioning or sniff dog positioning
Epiglottitis - CXR
thumbprint sign
Bronchiectasis - causes
cystic fibrosis - pseudomonas most common cause
Bronchiectasis - clinical findings
cough with expectoration of large amounts of purulent ad foul-smelling sputum
- hemoptysis
- halitosis - bad breath
Bronchiectasis - CT Scan
-tram-track appearance
Signet sign
Bronchiectasis - Management
antibiotics are mainstay of treatment
Acute Bronchiolitis
- respiratory syncytial virus (RSV) most common cause
- humidified O@ is mainstay of therapy
Bronchiolitis Obliterans
CXR = cuffing CT = mosaic
Cryptogenic Organizing Pneumonia (COP)
fibrotic scaring
-no response to antibiotics
Cystic fibrosis - causes
autosomal recessive disorder
- meconium ileus and intussusception
- pancreatic insufficiency and pancreatitis
- chloride sweat test
Cystic fibrosis - management
airway clearance therapies -SABA and LABA -antibiotics -decongestants regular exercise and proper nutrition
Community acquired pneumonia - causes
streptococcus pneumonias
Community acquired pneumonia - clinical manifestations
fever, cough, tachypnea, elevated WBC with leftward shift
Community acquired pneumonia - management
empiric antibiotic therapy
-admit all children <3 months
Apparent life-threatening
event in which infant has episode frightening to observer
- apnea
- color change
- changes in muscle tone
- choking or gagging
- breath holding
Apparent life-threatening - causes
50% - idiopathic
identified causes are related to GI, neurologic, and respiratory systems
Apparent life-threatening - clinical manifestations
retinal hemorrhages
Apparent life -threatening - management
hospitalization for patients with unexplained ATLE
-home apnea monitoring
Sudden Infant death syndrome - risk factors
Maternal = smoking and bed sharing Infant = prone sleep position
What do you expect on chest x-ray with asbestos exposure?
- small irregular opacities in lower lung fields
- pleural plaques
- blunting of costrophrenic angle
presentation of sarcoidosis
- noncaseated granuloma
- required the presence of involvement of 2 or more organ systems
What to look for with a person who has worked in coal mines?
- large masses of dust and collagen tissue
- chronic bronchitis
- appears about 10 years after exposure
- inspiratory crackles
- clubbing
- cyanosis
Presentation of IIP
fever, hemoptysis, pleuritic chest pain, bilateral basilar
- wet quality = alveolar filling
- dry quality = no alveolar filling = Velcro rales
Treatment of IIP
- eliminate further exposure
- supplemental oxygen
- glucocorticoids
- refer to pulmonologist
Lofgren’s sign
erythema nodosum and Hilar adenopathy
Simple fibrosis
-fine crackles
-coarse crackles (end inspiration)
CXR = innumerable small rounded opacities in upper lung fields
PMF
no crackles
-small opacities, gradually enlarge and connect to for larger opacities distributed in the upper and middle lung fields
Sings and symptoms of lung cancer
cough, dyspnea, hemoptysis, weight loss, anorexia, clubbing, Horner syndrome, superior vena cava obstruction, bone pain
American College fo Chest Physicians (ACCP)
use 7th edition of TNM (tumor size, nodes, and metastasis) staging system for prognosis and placement into clinical trials
U.S Preventative Service Task Force (USPSTF)
- support annual low dose CT to screen for lung cancer in patients 55 to 80 years of age with at least a 30-pack year history who currently smoke or have quit within past 15 years
- screening every patient for tobacco use and encourage smoking cessation for smokers at every appointment
What are some of the characteristic of malignant nodule?
- subsoild nodules: purse ground glass or part solid in nature, non calcified or eccentric calcification
- irregular or speculated borders
- double in size from 1 month to 1 year
- size is >10 mm
When would a PET scan be cost effective in assessing a nodule?
most cost effective when the clinical pretest probability of malignancy and the results of the CT are discordant
Presentation of lung cancer
cough, weight loss, dyspnea, chest pain, hemoptysis, bone pain, clubbing, fever, night sweats, weakness, anorexia
Diagnostics of lung cancer
CXR, Chest CT, PET Scan
What would make you consider malignant mesothelioma?
asbestos exposure
Central Endobronchial Growth of Primary Tumor
cough, hemoptysis
dyspnea, wheeze
Peripheral Growth of Primary Tumor
- pain from pleura or chest wall involvement
- dyspnea
- lung abscess from tumor cavitation
Regional Spread of Tumor in Thorax
- tracheal obstruction, esophageal compression
- laryngeal paralysis - hoarseness
- Horner’s syndrome = ptosis, enopthalmos, mitosis, and anhidrosis
Malignant Pleural Effusion
-pain, dyspnea or cough
What presentation do you expect with a superior sulcus tumor?
Pancoast syndrome - pain that may arise in the shoulder or chest wall or radiate to the neck
Horner’s syndrome - enopthalmos, ptosis, mitosis, and anhidrosis
What presentation would key you toward bronchial carcinoid tumor?
hemoptysis, cough, focal wheezing, and recurrent pneumonia
How does Strep Pneumoniae present?
productive cough (rusty)
What is atypical CAP?
walking pneumonia - mycoplasma pneumoniae
- fever, dry cough
- bullous myringitis
- erythema multiforme
What infections do you expect to see in AIDS patient?
pneumocystis jiroveci
What infections do you expect to see in a smoker?
- acute bronchitis
- C. pneumoniae (most common in smokers)
Air conditioning can cause what type of infections?
legionella pneumophila
What physical features do you expect to see in someone with pneumonia?
abrupt onset of fever, cough (w/wo sputum), pleuritic chest pain, dyspnea, fatigue, sweats, chills, rigors, anorexia, myalgia, headaches
What is the pathology of bronchitis?
most common cause by virus
- rhinovirus
- coronavirus
- RSV
Treatment of bronchitis
when lasted longer than 2 weeks antibiotics indicated for -elderly patients -patients with underlying cardiopulmonary disease -immunocompromised patients
