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Respiratory > Lectures 29 and 30 > Flashcards

Lectures 29 and 30 Flashcards

1
Q

What is pulmonary edema?

A
  • Abnormal accumulation of liquid
    and solute in the interstitial tissues,
    airway and alveoli of the lung
  • Not a disease but a consequence
  • Cardiogenic vs Non-cardiogenic
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2
Q

What’s the sequence of edema accumulation?

A
  • Fluid accumulates faster than it can be absorbed
  • Fluid in the alveoli leads to ventilationperfusion mismatch and
    hypoxemia

Edema accumulates in a step wise fashion
Distal lung units in different regions of the lungs will be at different stages of fluid accumulation because of the regional differences in pressures, differences in their alveolar capillary membrane integrity and their gravitational dependent factors

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3
Q

What is the pathophysiology of pulmonary edema?

A
  • Increase in Pulmonary capillary hydrostatic pressures
  • Decreased Plasma oncotic pressure
  • Capillary wall integrity
  • Lymphatic functions

Tight junctions between the alveolar epithelial cells prevent fluid from going into the alveoli so fluid will move into the peri-bronchial space and then be removed by lymphatics

When that process gets overwhelmed that’s when you get edema accumulation

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4
Q

Describe cardiogenic edema?

A

increase in HP which will traverse the interstitial space resulting in alveolar edema

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5
Q

Describe non-cardiogenic edema?

A

Non-cardiogenic edema is more refractory to TX because the injured epithelial cells cannot actively transport sodium and chloride across the basement membrane to remove water.
And because it is also more protein rich which can be more difficult to clear

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6
Q

What causes increased hydrostatic pressure?

A

Left heart failure
(Cardiogenic)
Overhydration
EX: Too high of an IV rate
Venous compression or venous obstruction like a thrombosis

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7
Q
A
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8
Q

Decreased plasma oncotic pressure is due to?

A

Hypoalbuminemia
Overhydration

EX: Renal disease, hepatic disease, malabsorption (protein losing enteropathy)

Pulmonary lymphatics are usually pretty good at removing fluid from the interstitial space so more often in animals that have hypoalbuminemia youll see them present with ascites more so than the chest

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9
Q

What causes altered lymphatic drainage?

A

UNCOMMON
Cancer
Lymphatic hypoplasia/aplasia
Lymphangitis

Lymphangiectasia is a disease of the GI lymphatic system where they leak lymph a lot

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10
Q

What causes altered capillary membrane permeability?

A

Electric cord shock
Infection/sepsis
Smoke/irritants
Gastric fluid aspiration

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11
Q

What are the predisposing factors for developing non-cardiogenic pulmonary edema?

A

Neurogenic pulmonary edema
– Seizures, electrocution, head trauma, cerebral hypoxia
Post-obstructive pulmonary edema
– Strangulation, laryngeal paralysis, pulmonary re-expansion
Systemic disease leading to ARDS
– Sepsis, shock, severe pancreatitis, uremia, parvovirus, gastric/splenic torsions
Direct pulmonary injury
– Smoke or chemical inhalation, aspiration pneumonia, bacterial/fungal pneumonia, pulmonary contusions/torsions
Profound hypoalbuminemia
Impaired lymphatic drainage
Miscellaneous: drowning, transfusion-related, PTE, high-altitude

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12
Q

What is the consequences of edema?

A

Pulmonary fluid accumulation
Atelectasis
Decreased compliance
– Decreased ability to expand at a given
pressure
– Breathing more difficult
Ventilation-perfusion inequality
Hypoxemia

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13
Q

What are the clinical signs of pulmonary edema?

A
  • Signs can be delayed or rapid
  • Depends on extent of injury and fluid
    accumulation
  • Crackles, harsh bronchovesicular
    sounds
  • Tachypnea, orthopnea, dyspnea, open
    mouth breathing, cyanosis, hemoptysis,
    moist cough may produce foam
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14
Q

How do you DX pulmonary edema?

A

History
Physical examination
–Fragile patients, stabilize first!
Radiology
– Unstructured interstitial or
peribronchial pattern; patchy
infiltrates with ARDS
– Caudodorsal fields most commonly
affected (cats may not follow this trend)
Blood work, blood gases

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15
Q

For DX of pulmonary edema you should always rule out what first and how?

A

Rule out Cardiac Disease!
–Auscultation, does animal have heart murmur?
–Radiology, cardiomegally?
–ECG
–Echocardiogram
–NT-proBNP- dogs with higher Nt-proBNP are more liekly to have heart issues

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16
Q

How do you TX edema?

A

No Stress - cage rest
– Sedatives if necessaryuse with caution
Improve oxygenation
– Supplemental oxygen
– Bronchodilators
– Ventilation
Decrease hydrostatic pressure (cardiac edema)
– Diuretics
– Vasodilators

Identify and treat underlying
diseases
- especially recognize cardiogenic
Supportive
Intubation and ventilation for
severe cases

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17
Q

What is ARDS?

A

Acute respiratory failure due to
non-cardiogenic edema and
inflammation

Underlying cause is severe and diffuse damage of the lung parenchyma resulting in endothelial and epithelial disturbance of permeability and exit of that protein rich fluid

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18
Q

What is ALI?

A

Acute Lung Injury (ALI)
* Lesser degree of inflammation and edema

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19
Q

What are the risk factors for ARDS/ALI?

A

Same risk factors as non-cardiogenic
pulmonary edema
Injury to vascular endothelium
- Aspiration pneumonia
- Bacterial pneumonia
- Sepsis
- Trauma
- Shock

It’s been found in extensive burn patients, as well as patients with severe acute pancreatitis, so leads to injury the vascular endothelium.

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20
Q

Complication factors of ARDS/ALI?

A

So some complicating factors are things like coagulation disturbances, perfusion disturbances and loss of pulmonary surfactant.

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21
Q

WHats the pathology of ARDS/ALI?

A

exudative to proliferative to fibrotic damage

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22
Q

What is the criteria for DX of ARDS/ALI?

A

Rapid onset of respiratory signs
- veterinary medicine < 72 hours

Bilateral pulmonary infiltrates (rads), no
evidence of left atrial hypertension

PaO2: FiO2 ratio
– Severe ARDS <100 mmHg
– Moderate ARDS 100-200 mmHg
– Mild ARDS/ALI 200-300 mmHg
PaO2 = arterial O2
FiO2 = inspired O2

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23
Q

How do you TX ARDS/ALI?

A

Treat underlying disease

Oxygen
- may not be responsive to O2 since
alveoli are flooded

Ventilator for respiratory support

Supportive care

Referral cases

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24
Q

Describe the pleural space and fluid in it?

A

Pleura is a serous membrane
Mediastinum is incomplete
Normal pleural fluid is produced by
transudation
– Pleural liquid in the sheep formed at 0.01
mL/kg per hour, or the equivalent of 0.6
mL/hour in a 60-kg person.

Pleural space is an area of potential space between the lungs and chest wall and normally there is no soft tissue or free air there

Lined by visceral and parietal pleura

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25
Q

What is the pathophysiology of pleural space disease?

A
  • Normal intra thoracic pressure is going to be sub atmospheric so pressure avergae is going to be -5 cmH2O. The negative will help the surfactant which is made by the pneumocytes and this helps keep the lungs inflated and reduce the work of breathing
  • So if you get pleural effusion forming, that’s obviously going to cause a gradual collapse of the lung parenchyma and increasing your intra thoracic pressure.
26
Q

What can cause pneumothorax?

A

Where did the air come from?
- leakage from inside airway or from outside

Trauma
Bullae in the lung
Iatrogenic
Neoplasia
Spontaneous pneumothorax

27
Q

Treatment of pneumothorax?

A
  • Remove air
  • May be one time or need continuous drainage
  • +/- surgery
28
Q

What is the etiology of pleural effusions?

A
  • increased hydrostatic pressure
  • decreased oncotic pressure
  • increased capillary membrane
    permeability
  • lymphatic obstruction

So as pleural effusion forms, there is
gradual collapse of the lung parenchyma
= increase in intrathoracic pressure

29
Q

What are some things that cause development of pleural effusion?

A
  • Increased pulmonary capillary pressure (CHF)
  • Increased capillary permeability (pneumonia)
  • Increased pleural membrane permeability (malignancy)
  • Decreased intrapleural pressure (atelectasis)
  • Decreased plasma oncotic pressure (hypoalbuminemia)
  • Lymphatic obstruction (malignancy)
  • Diaphragmatic defect
  • Thoracic duct rupture, disease
  • Idiopathic chylothorax
30
Q

What are the clinical features of pleural effusions?

A

History

Observation
- breathing pattern

Potential causes:
–Blood, chyle, purulent
–Cardiac, infectious, malignancy

31
Q

What are the clinical signs of pleural effusions?

A
  • Restrictive breathing pattern
    –-> Cannot inflate lungs !
  • Rapid, shallow breathing
  • Respiratory distress
  • Strong abdominal component to
    breathing
  • Muffled lung sounds with effusions or pneumothorax

auscultation is oftentimes going to reveal a more muffled or an audible heart and lung sounds ventrally while normal breath sounds can be preserved dorsally.

Then on percussion, pleural effusion cause causes the thorax is often more dull and you might have a horizontal fluid line demonstratable

32
Q

What should you do on PE if animal has suspected pleural disease?

A

Breathing pattern
Percussion
Auscultation

33
Q

DX approach to animals with pleural disease?

A

Do Not Stress
Ultrasound –TFASTscan in ICU
- On U/S Pleural effusion is black
- You might see white out which is scalping of the ventral lobes and visual lines between the lobes
- Chronic effusions you might see a more rounded lung lobe appearance
Radiology

34
Q

When do you perform thoracocentesis?

A

May need to perform prior to
radiographs, and to stabilize the
patient

35
Q

How do you perform thoracocentesis?

A

Aseptic technique, give supplemental oxygen
Anterior to rib
Level of costochondral junction
Air or fluid

7-9th rib
Local block of lidocaine
You’ll hear a distinct pop herd upon entering the plural cavity with the needle tip.

In general, 5 to 30 mL/hour required to improve ventilatory mechanics.

Dogs and cats generally have an incomplete hemi thorax, so oftentimes it doesn’t necessarily matter which side you tap based on your t-fast.

36
Q

After removing fluid via thoracocentesis you should:

A

– Re-radiograph!
– Remaining fluid
– Underlying disease

37
Q

Lung entrapment and trapped lungs:

A

acute vs chronic effusions, prevents reexpansion due to fibrin, inflammation,
thickening

38
Q

Whats the therapy for patients with pleural disease?

A

Depends on specific etiology
Oxygen and temporary thoracentesis
Chest tubes necessary in some patients

39
Q

Hemothorax is caused by?

A

Coagulopathy
- rodenticide
- congenital
- platelet number/function

Trauma (rib fracture)

Cancer

40
Q

How to DX hemothorax?

A

Hematocrit of pleural effusion is
>20% or is >50% of the patient’s
peripheral hematocrit

41
Q

How to TX hemothorax?

A
  • If it’s a small volume of blood in the thorax and it’s not clinically affecting the patient you can leave it in there to absorb on its own, but if there’s a significant amount, you might need to drain that.
42
Q

What is pure transudate effusion? caused by?

A

Low protein, low cell count
Hypoproteinemia (protein losing
enteropathy)
Early heart failure

Nondegenerate. Neutrophils,
macrophages, mesothelial cells

43
Q

Causes of modified transudate? what might you see on cell types?

A

Feline Cardiomyopathy
Diaphragmatic hernia
Neoplasia
Chyle

Nondegenerate. Neutrophils, macrophages, mesothelial, neoplastic cells,
lymphocytes

44
Q

Describe causes non-septic exudate?

A
  • Neoplastic: Can be obstructive, inflammatory, hemorrhagic; +/ neoplastic cells in the sample
  • Lung lobe torsion, FIP, pancreatitis, lung lobe torsion
45
Q

Describe septic exudate?

A

Systemic signs of illness
Inflammatory leukogram, fever
Cytology shows degenerative neutrophils and bacteria

46
Q

What is pyothorax?

A

Purulent exudate in pleural cavity
Result of bacterial invasion

47
Q

What is the etiology of pyothorax?

A
  • Cause may not be found
  • Migrating foreign bodies, bite wounds, extension from lungs, esophageal
    perforation, parasitic migration,
    hematogenous spread, iatrogenic
  • Cats: multi cat households
    a. similar flora to mouth
    b. Cat bite wounds common cause
48
Q

Organisms in pyothorax?

A

–Primarily Anaerobes
–Actinomyces
–Norcardia
–Pasteurella

49
Q

Clinical signs of pyothorax

A

+/- fever
range from mild to severe

50
Q

DX of pyothorax?

A

Ultrasound – scan in ICU
Radiology
Thoracocentesis
Cytology, Culture/Sensitivity
Basic blood work
CT scan may be useful if foreign body
or abscess
- useful for deciding for surgery

51
Q

TX of pyothorax?

A

Supportive
- Oxygen, intravenous fluids, nutrition
Systemic antibiotics
Drainage
- Needle thoracocentesis
Thoracotomy tubes
Surgery if necessary

52
Q

Prognosis of pyothorax?

A
  • Prognosis highly variable,mortality rate: 0 - 42%, recurrence also variable
  • Cats: fair to good prognosis, low recurrence rate
  • overall reported survival rate of 83% in dogs and 62% in cats
  • Again, the optimal treatment to really determine a successful outcome is not known.
  • So we don’t know the best therapeutic course of action. I think it’s very much patient dependent.
53
Q

Sequela of pyothorax?

A

Constrictive pleuritic
Adhesions
Abscessation

54
Q

Chylothorax

A

Chyle is lymphatic fluid from the gut
Effusion is a mixture of intestinal
and thoracic lymph

  • Remember that the lymphatic system has three primary roles.
  • It’s to maintain fluid balance, generate an immune response, and perform uptake and transport of dietary fats.
55
Q

Causes of chylothroax?

A
  • Congenital abnormalities of thoracic duct
  • Cranial mediastinal masses, neoplasia
  • Fungal granulomas
  • Heart disease (esp. cats)
  • Trauma, lung lobe torsion
  • Thrombosis
  • Idiopathic
56
Q

Clinical signs and DX of chylothorax?

A

Depending on underlying disease
Pleural disease signs
Radiology
Thoracocentesis and analysis

57
Q

Fluid analysis of chylothoraa?

A

Cytology
- Cytology to see macrophages, medium to large lymphocytes and a lot of small lymphocytes

Triglyceride level on fluid and serum
- the level of triglyceride in the plural fluid is going to be greater than it is in the serum.

Attempt to determine etiology

58
Q

TX for chylothorax?

A

Drainage
Diet: +/- low fat diet
Drugs (new ideas)
- Rutin (benzopyrone)
- Octreotide (somatostatin analogue)

No strong conclusion could be drawn regarding the effectiveness of any one surgical method, and no evidence was found to support medical therapy as a primary treatment.

Best available evidence regarding treatment of IC is published in dogs and provides some support for surgical treatment with either TDL + cisterna chyli ablation or TDL + SP.

Surgery - referral
- Obstruction of duct
- Shunts
- Omental drainage
- Pericardectomy

59
Q

What is rutin?

A

Flavonol glycoside
- flavonol quercetin and disaccharide
rutinose
- found in buck wheat

Antioxidant, antiinflammatory,
anticarcinogenic, antithrombotic,
vasoprotective

Used for venous edema

Drug interaction: quinolone antibiotics
- quercetin binds to DNA gyrase sites –
competes with antibiotics

60
Q

What is octreotide?

A

Somatostatin analog
Used in Human medicine for chylothorax
- neonates

Reduces gastric secretions and thus decreased TD lymphatic flow

Octreotide 10mcg/kg SQ TID for 2 - 3 weeks

No evidence based studies
$$$$$

61
Q

Prognosis of chylothorax?

A

Long term sequela
to chylothorax
– Loss of fluids, proteins, vitamins, electrolytes if drained
– Constrictive pleuritis
– Pneumothorax from constant draining

Respiratory (9 decks)

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