Intro to Pulmonology Flashcards
Dependent lobe of the lung
Right lower lobe
Right bronchus (vs. left)
- more vertical
- larger
- more posterior
Physical exam - inspection
- pursed lip breathing
- accessory muscle use
- clubbing
- cyanosis
- edema
- chest wall
- –> barrel chest
- –> kyphosis
- –> pectus excavatum
- –> pectus carinatum
Physical exam - palpation
- Expansion of the hemithoraces –> inspect and palpate
- Tracheal shifts
- loss of volume (atelectasis) –> shifts TOWARDS loss
- increase in volume (effusion, pneumothorax) –> shits AWAY from increase - Crepitus
- 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)
Physical exam - percussion
- Normal/resonant = normal lung
- Hyperresonance/tympanitic = increased air –> pneumothorax or hyperinflation (COPD, emphysema)
- Dull = consolidation, atelectasis
- Flat = effusion
Physical exam - ausculation –> breath sounds
- Normal/vesicular –> hear inspiration clearly, but only a short portion of expiration
- Bronchial of tubular –> expiration is as prominent and sometimes more prominent than inspiration
- normal over the trachea. abnormal over the lung
- consolidation - Decreased breath sounds –> atelectasis, effusion, pneumothorax
- Stridor –> mostly inspiratory coarse wheeze heard over the neck and due to upper airway narrowing
Physical exam - auscultation –> adventitial sounds
- 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 - Wheezing –> high pitched, generally heard on expiration
- seen in asthma + COPD - Ronchi –> lower pitched wheezing
Physical exam - auscultation –> voice generated sounds
- Egophany = patient says “e” and it sounds like “a” –> consolidation
- Whispered pectoriloquy = a patient’s whispering of “1,2,3” is exaggerated –> consolidation
Physical exam - auscultation –> pleural friction rub
Creaking sound generated by the inflamed visceral and parietal pleural surfaces rubbing together
Physical exam findings - Asthma/COPD
- Inspection
- pursed lip breathing
- barrel chest - Palpation
- decreased fremitus bilaterally - Percussion
- hyperresonance bilaterally - Auscultation
- wheezing or rhonchi bilaterally
Physical exam findings - Pneumothorax
- Inspection
- hyperinflation of ipsilateral hemithorax - Palpation
- decreased movement with inspiration of ipsilateral hemithorax
- ipsilateral decreased fremitus
- contralateral tracheal shift
- subcutaneous crepitus - Percussion
- hyperresonance of ipsilateral hemithorax - Auscultation
- decreased breath sounds over ipsilateral hemithorax
Physical exam findings - Pleural effusion
- Inspection
- Palpation
- decreased movement with inspiration of ipsilateral hemithorax
- ipsilateral decreased or absent fremitus
- contralateral tracheal shift - Percussion
- dull of flat over ipsilateral hemithorax - Auscultation
- decreased breath sounds over the ipsilateral hemithorax
- occasionally pleural rub
Physical exam findings - Consolidation
- Inspection
- Palpation
- increased fremitus over consolidated areas - Percussion
- dull over consolidated areas - Auscultation
- over consolidated areas
- –> bronchial breath sounds
- –> egophagny
- –> whispered pectoriloquy
Physical exam findings - Bronchial obstruction with atelectasis
- Inspection
- Palpation
- decreased movement with inspiration of ipsilateral hemithorax
- ipsilateral tracheal shift
- ipsilateral decreased fremitus - Percussion
- dull over ipsilateral hemithorax - Auscultation
- decreased breath sounds over ipsilateral hemithorax
Physical exam findings - Fibrosis
- Inspection –> clubbing
- Palpation
- Percussion
- Auscultation –> crackles, usually bilaterally
Lung pathology - methods for obtaining pathologic speciments
- Cough –> sputum for gram stain
- Percutaneous needle aspirate –> stain cells of small pieces of lung tissue
- Bronchoscopy
- –> bronchioalveolar lavage = stain cells in fluid
- –> transbronchial needle aspirate = stain cells
- –> small pieces of lung tissue - 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
Pathologic patterns that occur in response to lung injury
- 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
Mechanisms of injury of the lung
- Inhalational injury (exogenous) –> starts with epithelial injury
- microbes, toxins, allergens, smoke, mineral dusts, gastric acid, environmental spills, illicit substance abuse, etc… - Hematogenous (endogenous) –> starts with endothelial injury
- sepsis, autoimmune disease, drug of med toxicity - “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 - the overall background pattern of lung injury ovserved on the slide under low power AND
- by history/physical, whether or not this organization pattern has a readily identifiable etiology or is of unknown cause
Pathologic terms to describe lung injury
- 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
What can/can’t spirometry measure?
Measures:
- FVC
- Tidal volume
- FEV1
- FEV1:FVC ratio
Can’t measure
- TLC
- FRC
- RV
3 steps to interpreting spirometry
- Look at the shapes of the volume time curve –> may be:
- obstructed
- not obstructed –> normal or restricted - Look at the FEV1/FVC ratio –> may be:
- normal (or increased)
- decreased - 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
Definition and grading of obstruction
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
Definition and grading of restriction
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
Mixed ventilator defect
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
Lung volume testing
Measures FRC –> perform spirometry to add/subtract to conclude a TLC and RV
- low TLC defines restriction
Two methods
- Body plethysmography
- Gas dilution
- –> helium
- –> nitrogen washout
DLco
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
Fixed upper airway obstruction
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
Variable intrathoracic upper airway obstruction
Below the thoracic inlet (e.g. tracheal neoplasm)
- airway is more obstructed during exhalation –> inspiration will look normal, expiration will look decreased
Variable extrathoracic upper airway obstruction
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
