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Lectures > Intro to Pulmonology > Flashcards

Intro to Pulmonology Flashcards

1
Q

Dependent lobe of the lung

A

Right lower lobe

Right bronchus (vs. left)

  • more vertical
  • larger
  • more posterior
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2
Q

Physical exam - inspection

A
  • pursed lip breathing
  • accessory muscle use
  • clubbing
  • cyanosis
  • edema
  • chest wall
  • –> barrel chest
  • –> kyphosis
  • –> pectus excavatum
  • –> pectus carinatum
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3
Q

Physical exam - palpation

A
  1. Expansion of the hemithoraces –> inspect and palpate
  2. Tracheal shifts
    - loss of volume (atelectasis) –> shifts TOWARDS loss
    - increase in volume (effusion, pneumothorax) –> shits AWAY from increase
  3. Crepitus
  4. Tactile fremitus = vibration that is palpated on the chest wall when a patient is speaking (“99”)
    - increased = consolidation –> increased sound transmission from large airways to periphery
    - decreased = caused by processes that move the lung away from the chest wall –> pleural fluid (effusion) or air (pneumothorax)
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4
Q

Physical exam - percussion

A
  1. Normal/resonant = normal lung
  2. Hyperresonance/tympanitic = increased air –> pneumothorax or hyperinflation (COPD, emphysema)
  3. Dull = consolidation, atelectasis
  4. Flat = effusion
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5
Q

Physical exam - ausculation –> breath sounds

A
  1. Normal/vesicular –> hear inspiration clearly, but only a short portion of expiration
  2. Bronchial of tubular –> expiration is as prominent and sometimes more prominent than inspiration
    - normal over the trachea. abnormal over the lung
    - consolidation
  3. Decreased breath sounds –> atelectasis, effusion, pneumothorax
  4. Stridor –> mostly inspiratory coarse wheeze heard over the neck and due to upper airway narrowing
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6
Q

Physical exam - auscultation –> adventitial sounds

A
  1. Crackles/rales –> probably from opening of small airways that had been closed
    - generally heard at end inspiration
    - seen with diffuse lung disease (fibrosis) + pulmonary edema
  2. Wheezing –> high pitched, generally heard on expiration
    - seen in asthma + COPD
  3. Ronchi –> lower pitched wheezing
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7
Q

Physical exam - auscultation –> voice generated sounds

A
  1. Egophany = patient says “e” and it sounds like “a” –> consolidation
  2. Whispered pectoriloquy = a patient’s whispering of “1,2,3” is exaggerated –> consolidation
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8
Q

Physical exam - auscultation –> pleural friction rub

A

Creaking sound generated by the inflamed visceral and parietal pleural surfaces rubbing together

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9
Q

Physical exam findings - Asthma/COPD

A
  1. Inspection
    - pursed lip breathing
    - barrel chest
  2. Palpation
    - decreased fremitus bilaterally
  3. Percussion
    - hyperresonance bilaterally
  4. Auscultation
    - wheezing or rhonchi bilaterally
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10
Q

Physical exam findings - Pneumothorax

A
  1. Inspection
    - hyperinflation of ipsilateral hemithorax
  2. Palpation
    - decreased movement with inspiration of ipsilateral hemithorax
    - ipsilateral decreased fremitus
    - contralateral tracheal shift
    - subcutaneous crepitus
  3. Percussion
    - hyperresonance of ipsilateral hemithorax
  4. Auscultation
    - decreased breath sounds over ipsilateral hemithorax
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11
Q

Physical exam findings - Pleural effusion

A
  1. Inspection
  2. Palpation
    - decreased movement with inspiration of ipsilateral hemithorax
    - ipsilateral decreased or absent fremitus
    - contralateral tracheal shift
  3. Percussion
    - dull of flat over ipsilateral hemithorax
  4. Auscultation
    - decreased breath sounds over the ipsilateral hemithorax
    - occasionally pleural rub
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12
Q

Physical exam findings - Consolidation

A
  1. Inspection
  2. Palpation
    - increased fremitus over consolidated areas
  3. Percussion
    - dull over consolidated areas
  4. Auscultation
    - over consolidated areas
    - –> bronchial breath sounds
    - –> egophagny
    - –> whispered pectoriloquy
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13
Q

Physical exam findings - Bronchial obstruction with atelectasis

A
  1. Inspection
  2. Palpation
    - decreased movement with inspiration of ipsilateral hemithorax
    - ipsilateral tracheal shift
    - ipsilateral decreased fremitus
  3. Percussion
    - dull over ipsilateral hemithorax
  4. Auscultation
    - decreased breath sounds over ipsilateral hemithorax
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14
Q

Physical exam findings - Fibrosis

A
  1. Inspection –> clubbing
  2. Palpation
  3. Percussion
  4. Auscultation –> crackles, usually bilaterally
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15
Q

Lung pathology - methods for obtaining pathologic speciments

A
  1. Cough –> sputum for gram stain
  2. Percutaneous needle aspirate –> stain cells of small pieces of lung tissue
  3. Bronchoscopy
    - –> bronchioalveolar lavage = stain cells in fluid
    - –> transbronchial needle aspirate = stain cells
    - –> small pieces of lung tissue
  4. Surgical lung biopsy –> larger pieces of lung tissue
  • **Important distinction
  • –> cytology = loose cells, usually from sputum, fluid or needle aspirate
  • –> histopathology = pieces of tissue from biopsy, can look at architecture
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16
Q

Pathologic patterns that occur in response to lung injury

A
  • acute inflammation = neutrophils
  • diffuse alveolar damage
  • organizing pneumonia
  • granulomatous inflammation
  • usual interstitial pneumonia
  • non-specific interstitial pneumonia
  • neoplasia

***al occur in response to injury of the lung, often unknown why one particular pattern occurs vs. another

17
Q

Mechanisms of injury of the lung

A
  1. Inhalational injury (exogenous) –> starts with epithelial injury
    - microbes, toxins, allergens, smoke, mineral dusts, gastric acid, environmental spills, illicit substance abuse, etc…
  2. Hematogenous (endogenous) –> starts with endothelial injury
    - sepsis, autoimmune disease, drug of med toxicity
  3. “Organizing” pattern of injury –> foci of organization that is a non-specific response to lung injury, probably represents a form of wound healing
    - the pathologic term which is used in a particular instance depends on
  4. the overall background pattern of lung injury ovserved on the slide under low power AND
  5. by history/physical, whether or not this organization pattern has a readily identifiable etiology or is of unknown cause
18
Q

Pathologic terms to describe lung injury

A
  • bronchiolitis obliterans organizing pneumonia
  • organizing pneumonia –> focal
  • organizing diffuse alveolar damage –> seen diffusely throughout the lung
  • fibroblastic foci –> seen on a background of usualy insterstitial pneumonia pattern
  • post infectious organizing pneumonia
19
Q

What can/can’t spirometry measure?

A

Measures:

  1. FVC
  2. Tidal volume
  3. FEV1
  4. FEV1:FVC ratio

Can’t measure

  1. TLC
  2. FRC
  3. RV
20
Q

3 steps to interpreting spirometry

A
  1. Look at the shapes of the volume time curve –> may be:
    - obstructed
    - not obstructed –> normal or restricted
  2. Look at the FEV1/FVC ratio –> may be:
    - normal (or increased)
    - decreased
  3. Look at the FEV1 and FVC values and the percents of their predicted values –> may be:
    - normal
    - low grade severity of obstruction, if present
    - low grade severity of restriction, if present
21
Q

Definition and grading of obstruction

A

Definition:

  • flattened volume-time curve and scooped out expiratory limb of flow volume curve
  • low FEV1/FVC ratio
  • low FEV1

Grade obstruction:
- FEV1 % of predicted value
- FVC % of predicted value
>80% predicted value = normal

22
Q

Definition and grading of restriction

A

Definition:

  • small volume time curves
  • narrow and small flow volume curves
  • normal or increased FEV1/FVC ratio
  • low FEV1 and FVC (and TLC –> can’t measure on spirometry though)

Grade restriction:
- FVC % of predicted value

23
Q

Mixed ventilator defect

A

Obstruction and restriction –> both patterns seen on the same PFT maneuver

  • low FEV1/FVC ratio = obstruction
  • low TLC (need lung volumes) = restriction

Grade severity by FEV1 % of predicted

24
Q

Lung volume testing

A

Measures FRC –> perform spirometry to add/subtract to conclude a TLC and RV
- low TLC defines restriction

Two methods

  1. Body plethysmography
  2. Gas dilution
    - –> helium
    - –> nitrogen washout
25
Q

DLco

A

Reflects the amount of normally functioning alveolar capillary units = alveoli with voth alveolar gas and capillary blood flow

  • reduced by diseases which temporarily or permanently decrease alveolar spaces and/or decrease alveolar capillaries
  • –> emphysema
  • –> fibrosis
  • –> pulmonary vasculature disease

Grading severity –> % of predicted DLco

26
Q

Fixed upper airway obstruction

A

May be either an intrathoracic or extrathoracic upper airway lesion, but we cannot determine the location by the appearance of the FV loop because the lesion is fixed –> the airway will not change size in response to pressure changes

27
Q

Variable intrathoracic upper airway obstruction

A

Below the thoracic inlet (e.g. tracheal neoplasm)

- airway is more obstructed during exhalation –> inspiration will look normal, expiration will look decreased

28
Q

Variable extrathoracic upper airway obstruction

A

Above the thoracic inlet (e.g. vocal cord paralysis)
- upper airway wants to collapse a little bit during inhalation, and is more expanded during exhalation –> curve looks abnormal during inhalation and normal during exhalation

Lectures (46 decks)

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