Lung Flashcards

1
Q

What are the 3 mechanisms of impaired alveolar oxygen diffusion?

A
  1. ↓ Surface area
  2. ↓ driving pressure
  3. diffusion distance
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2
Q

What 3 things can cause ↓surface area mediated alveolar-capillary oxygen diffusion impairment?

A
  1. alveolar destruction (COPD/emphysema)
  2. loss of capillaries (embolism, pulmonary HTN)
  3. alveolar filling defect (fluid, pus, blood)
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3
Q

What 2 things can cause alveolar-capillary oxygen diffusion impairment by ↓ driving pressure?

A
  1. bronchiole obstruction (asthma)
  2. alveolar filling defect (pneumonia)
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4
Q

What can cause alveolar-capillary oxygen diffusion impairment by ↑ diffusion distance?

A

wide alveolar capillary space (fibrosis, edema)

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5
Q

How does emphysema/COPD cause alveolar-capillary oxygen diffusion impairment? (i.e. via which mechanism)

A

alveolar destruction → ↓ surface area

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6
Q

How does a PE or pulmonary HTN cause alveolar-capillary oxygen diffusion impairment? (i.e. via which mechanism)

A

loss of capillaries → ↓ surface area

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7
Q

How does fluid, pus or blood cause alveolar-capillary oxygen diffusion impairment? (i.e. via which mechanism)

A

alveolar filling defect → ↓ surface area

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8
Q

How does asthma cause alveolar-capillary oxygen diffusion impairment? (i.e. via which mechanism)

A

bronchiole obstruction (inflammation) → ↓ driving pressure

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9
Q

How does pneumonia cause alveolar-capillary oxygen diffusion impairment? (i.e. via which mechanism)

A

alveolar filling defect→ ↓ driving pressure

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10
Q

How does fibrosis or edema cause alveolar-capillary oxygen diffusion impairment? (i.e. via which mechanism)

A

wide alveolar-capillary distance → ↑ diffusion distance

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11
Q

What is the MC pulmonary ssx?

A

dyspnea!

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12
Q

This spirometry reading, FEV1/FVC ratio < 70%, is dx of which type of lung dz?

A

obstructive

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13
Q

Is it possible to determine restrictive lung dz physiology from spirometry tests?

A

NO!! Need to do lung volume tests

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14
Q

subepithelial collagen deposition leading to ↑ bronchial wall thickness

A

severe asthma

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15
Q

Main inflammatory mediators of asthma

A

eosinophils

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16
Q

Airway inflammation is primarily mediated by CD4(+) T-cells and eosinophils in which airway dz?

A

asthma

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17
Q

Airway inflammation is primarily mediated by CD8(+) T-cells and M∅/ PMNs in which airway dz?

A

COPD

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18
Q

What are the 2 things necessary to dx COPD?

A
  1. evidence of airflow obstruction (FEV1/FVC < 70%)
  2. clinical ssx (cough, sputum prdn., or dyspnea)
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19
Q

2 useful tests (other than spirometry) used to dx asthma

A
  1. methacholine challenge test
  2. peak flow variation
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20
Q

What are the 4 pathologic locations restrictive thoracic disorders can occur?

A
  1. pleural cavity
  2. interstitium (lung parenchyma)
  3. Neuromuscular
  4. Thoracic/Extrathoracic
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21
Q

How are the timing of clinical ssx different b/w asthma and COPD?

A
  • asthma: intermittent and variable
  • COPD: persistent and progressive worsening
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22
Q

How does a patients cough differ b/w asthma and COPD?

A
  • asthma: nocturnal cough or on exertion
  • COPD: morning cough w/ sputum
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23
Q

What are the 2 broad categories of COPD? What are their characteristic pathologic findings?

A
  • chronic bronchitis: inflammation & excess mucus d/t hyperplasia of mucous glands
  • emphysema: breakdown of alveolar membranes
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24
Q

Compare the prevelance and mortality trends of asthma and COPD

A
  • asthma: ↑prevelance, ↓mortality
  • COPD: ↑prevelance, ↑mortality
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25
Q

How can asthma be fatal?

A

mucous plugs

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26
Q

How is the clinical dx of chronic bronchitis COPD defined?

A

presence of chronic productive cough for 3 months in each of 2 successive years in a patient in whom other causes of chronic cough have been excluded

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27
Q

What is the most significant pathologic feature of asthmatic bronchial airways?

A

reduced airway lumen area

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28
Q

What is a normal A-a gradient?

A

10

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29
Q

What can ↑ fremitus on lung exam indicate?

A

lung consolidation (e.g. pneumonia)

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30
Q

What are 3 things ↓ fremitus on lung physical exam indicate?

A
  1. pneumothorax
  2. pleural effusion
  3. emphysema
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31
Q

What is the normal percussive tone of the lung heard on physical exam?

A

resonant- air filled tissues produce a higher resonant tone

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32
Q

Give a pathologic example that can cause dullness to percussion on lung physical exam

A

lobar pneumonia

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33
Q

Give 2 pathologic example that can cause a hyperresonant sound to percussion on lung physical exam

A
  • emphysema
  • pneumothorax
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34
Q

What is stridor?

A

inspiratory wheeze

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35
Q

What are 3 criteria that factor into the 4 COPD classifications by GOLD criteria?

A
  • classification of airway flow obstruction (1,2,3,4)
  • symptoms measured by mMRC (0-1, ≥2) or CAT (< 10, >10) score
  • exacerbation hx (0, 1, ≥2)
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36
Q

Which medication used alone (monotherapy) is contraindicated in COPD pts. ? How can it be used?

A

inhaled corticosteroids (ICS)

-used in combination w/ long acting β-agonist (LABA)

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37
Q

Which medication used alone (monotherapy) is contraindicated in asthma pts. ?

A

long acting β-agonists

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38
Q

What factor is key in the tx of COPD?

A

smoking cessation

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39
Q

What class of drugs are the cornerstone of asthma therapy?

A

inhaled corticosteroids

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40
Q

Which values are expected to be low on a lung volumes test in a patient w/ restrictive lung dz?

A
  • RV
  • FRC (RV + ERV)
  • TLC (IRV + TV + ERV + RV)
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41
Q

In what lung dz might you see respiratory acidosis? Why?

A

COPD→ obstructive, can’t get air out →CO2 can’t get out either

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42
Q

What are 3 radiographic findings found in patients w/ COPD?

A
  • hyperinflation
  • ↑ retrosternal airspace
  • bullae
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43
Q

When is tx w/ supplemental oxygen indicated in COPD patients?

A

if they have baseline, exercise, or sleep related pO2 < 55 OR SpO2 ≤ 88% or ≤ 89% w/ evidence of cor pulmonale

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44
Q

How is compliance of the lung altered in obstructive vs. restrictive lung dz?

A

obstructive: ↑compliance
restrictive: ↓compliance

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45
Q

How does long term lung damage in asthma patients occur (3 steps)? At what stage of asthma does this begin to happen?

A

acute response →chronic inflammation →airway remodeling =

long-term damage

-occurs even in mild asthma!

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46
Q

What is the purpose of a metacholine challenge test in asthma patients?

A

to determine Rx dose (highly sensitive) → use muscarinic agonist → determine dose @ which FEV1 ↓20%

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47
Q

What is the pathophysiology of airway remodeling in asthma?

A

cell proliferation and ↑ECM

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48
Q

What are 3 non-pharmalogical tx for COPD?

A
  1. oxygen therapy
  2. vaccination
  3. pulmonary rehab
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49
Q

What are 2 types of drugs that can be used to tx COPD exacerbations?

A
  1. Roflumilast (PDE-4 inhibitor)→ use in combo w/ LABA
  2. Azithromycin (Abx)
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50
Q

What type of procedure can an asthma patient have done if they are not responding to Rx?

A

bronchialthermoplasty → ↓ airway mm.

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51
Q

What are the 4 classifications of asthma patients (+ ssx and FEV1) used for tx?

A
  1. mild-intermittent

(FEV1 >80%, exacerbations ≤ 1-2x/wk + nighttime ssx ≤ 1-2x/mo.)

  1. mild-persistant

(FEV1 > 80%, exacerbations > 2x/wk + nighttime ssx > 2x/mo.)

  1. moderate-persistant

(FEV1 > 60%, exacerbations > 2x/wk + nighttime ssx > 1x/wk.)

  1. severe-persistant

(FEV1 < 60%, frequent exacerbations & nighttime ssx)

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52
Q

What are the 4 broad categories of restrictive thoracic disorders?

A
  1. pleural
  2. insterstitial (lung parenchyma)
  3. neuromuscular
  4. thoracic/extrathoracic
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53
Q

What are 3 types of pleural restrictive lung dzs?

A
  1. pneumothorax (spontaneous, trauma, tension)
  2. effusion (transudate, exudate)
  3. asbestosis
54
Q

parietal/visceral pleura contain pain fiber innervation

A

parietal

visceral = NO PAIN

55
Q

What are 3 broad reasons pleural fluid can accumulate?

A
  1. changes in hydrostatic forces (= transudation)
  2. ↑ leak across capillaries (=exudation)
  3. ↓ flow through lymphatic stoma
56
Q

What is the protein content and cellularity of transudate vs exudate:

A
  • transudate: poor protein, low cell counts
  • exudate: protein rich, cellular
57
Q

bilateral hilar lymphadenopathy (CXR/CT) w/ non-caseating granulomas (path)

A

sarcoid mediated ILD

58
Q

CXR/CT: upper lobe nodules w/ egg shell calcification of LNs

Pathology: birefringent particles

A

environmental ILD d/t silicosis

59
Q

How does asbestos exposure affect smokers?

A

↑ risk of malignancy

60
Q
  • clinical presentation: hemoptysis
  • CXR: cavitary lesions
  • c-ANCA
A

Wegener’s granulomatosis

61
Q

In what types of jobs might you be exposed to silica?

A
  1. sandblasting
  2. foundry work
62
Q

Lower lobe predominant fibrotic changes

A

idiopathic pulmonary fibrosis (dx of exclusion)

63
Q

insidious onset of SOB and dry cough

A

interstitial lung dz

64
Q

What is the tx for tension pneumothorax? When should you start tx?

A
  • 100% O2 + pleural decompression
  • MUST START IMMEDIATELY!! (i.e. don’t wait for CXR results)
65
Q

pleural calcified plaques

A

asbestosis

66
Q

What are LIGHT’s criteria for establishing an exudative pleural effusion?

A

need ≥ 1 of any of the criteria (if not → transudate)

  1. pleural fluid : serum total protein > 0.5
  2. pleural fluid : serum LDH > 0.6
  3. pleural fluid LDH > 2/3 upper limit of normal serum LDH
67
Q

What is the gold standard clinical test for PE? When should you consider using this test?

A

pulmonary angiogram (however rarely done anymore) → consider using in patients w/ (-) or indeterminante non-invasive tests AND there is no plausible competing dx

68
Q

CXR: pleural based wedge shaped density (Hampton’s Hump)

A

PE (however, it’s rarely seen)

69
Q

Describe the Well’s criteria for pretest probability assessment of PE:

A
  • 3 pts = DVT ssx, PE highest on ddx
  • 1.5 pts = HR > 100, surgery hx w/in 4 wks, > 3 days immobile, hx of VTE
  • 1 pt = hemoptysis, malignancy

score ≥ 4 pts → PE likely → spiral CT angiogram

70
Q

What are the defining criteria (2) of pulmonary HTN?

A
  1. resting mean pulmonary arterial pressure ≥ 25mmHg (measured via R. heart catheterization)
  2. normal pulmonary capillary wedge or left atrial pressure (≤ 15mmHg)
71
Q

inactivating mutation in BMPR2 gene (normally inhibits vascular SM proliferation)

A

pulmonary arterial hypertention

72
Q

MCC of pulmonary HTN

A

pHTN d/t left-heart dz

73
Q

What are the 5 WHO classification groups for pHTN?

A
  1. pulmonary arterial HTN (PAH) (idopathic or BMPR2 mut.)
  2. PH d/t left ♥︎ dz (MC) (systolic/diastolic, valvular)
  3. PH d/t lung dz or hypoxia (COPD or obstruction sleep apnea)
  4. Chronic thromboembolic PH
  5. Miscellaneous/ multifactorial
74
Q

What 3 pathogenic processes cause narrowing in PAH?

A
  1. Vasoconstriction (↑endothelin, ↓prostacyclin, ↓NO)
  2. SM proliferation
  3. Thrombosis
75
Q

ssx: unexplained dyspnea, syncope

PE: accentuated P2, RV heave

Pathology: plexiform lesions

A

PAH

76
Q

Which 3 tests should you do for an initial evaluation for dx of PAH?

A

-ECG

-CXR

-Echocardiogram

77
Q

List the findings consistent w/ PAH for each of the following tests:

  • ECG
  • CXR
  • Echocardiogram
A

-ECG: RVH, right axis deviation

-CXR: prominent vasculature in the hilum

-Echocardiogram: (est. of PA systolic pressure) → presesence of conditions that contribute to PH (e.g. valvular ♥︎ dz, LV systolic dysfunc., impaired diastolic func. etc.)

78
Q

“Gold Standard” for dx of PAH (and differentiation from other causes of PH)

A

right ♥︎ cardiac catheterization

79
Q

Which 3 signs of right sided HF are predictors of poor survival for patients w/ PAH?

A
  • high right atrial pressure
  • low cardiac index
  • High BNP levels in the blood
80
Q

What is the natural hx (survival w/o tx) of patients w/ idiopathic PAH?

A

50% die w/in 3 years

81
Q

What are 3 specific drug classes used for tx of PAH?

A
  1. PDE-5 inhibitors (↑NO)
  2. Endothelin receptor antagonists (vasodilation)
  3. Prostanoids
82
Q

Define apnea and hypopnea:

A
  • apnea: air flow stops ≥ 10s
  • hypopnea: reduction in airflow for 10s
83
Q

What are the 3 classifications of Obstructive sleep apnea (OSA)?

A
  • Mild: 5-15 apnea + hypopnea / hr
  • Moderate: 16-30 apnea + hypopnea /hr
  • Severe: > 30 apnea + hypopnea/ hr
84
Q

How is obstructive sleep apnea diagnosed?

A

polysomnogram (sleep study)

85
Q

Define obstructive sleep apnea

A

air flow stops ≥ 10s → complete blockage of the airway despite efforts to breathe

86
Q

Tx of choice for OSA

A

CPAP→ functions as an air splint → effective in 90%

87
Q

What are 4 non-pharmacological (not CPAP) tx for OSA?

A
  • avoid alcohol
  • avoid sleep deprivation
  • lose weight
  • positional therapy (avoid supine sleep position)
88
Q

Define central sleep apnea

A

air flow stops ≥10s w/ absence of respiratory effort (aka CNS doesn’t realize you’re not breathing)

89
Q

Which CVDzs are assoc. w/ OSA and CSA?

A
  • OSA: HTN
  • CSA: CHF
90
Q

Cheyne-strokes (crescendo-decrescendo respiratory pattern)

A

CSA + CHF

91
Q

What is the peak age range for OSA in children? What physiologic even does this time period coincide with?

A

ages 2-7 → coincides w/ peak lymphoid hyperplasia (tonsils)

92
Q

Define Sudden Infant Death Syndrome (SIDS)

A

unexplained death of infant after autopsy, death scene examination and clinical review (dx of exclusion)

93
Q

1 prevention of SIDS

A

supine sleeping (‘back to sleep campaign’)

94
Q

What are some signs and ssx of sleep disordered breathing?

A
  • excessing daytime sleepiness
  • unrefreshing sleep
  • snoring
  • witnessed apneas
  • HTN
  • CHF
  • excessive/ redundant pharyngeal tissue
95
Q

What is the common pathophysiology of mycobacterial and fungal pneumonias?

A

intracellular pathogens of macorphages→ granulomas

96
Q

What is the ddx (4) of upper lobe infiltrate and adjacent hilar adenopathy?

A
  • lung cancer
  • mycobacterial dz (e.g. TB or no-TB mycobacteria)
  • Fungi (histo, blasto, coccidio)- acute phase
  • sarcoidosis
97
Q

Endemic mycoses of the Ohio and Mississippi River valley areas

A

histoplasmosis

98
Q

What are the 4 broad clinical spectrums of histoplasmosis (based on time course and location of dz)

A
  1. acute localized
  2. acute diffuse
  3. chronic
  4. disseminated
99
Q

Both acute and chronic histoplasmosis are upper/lower lobe predominant

A

upper

100
Q

How does acute localized pulmonary histo look on CXR?

A

localized pulmonary infiltrate w/ accompanying hilar adenopathy

101
Q

How does chronic pulmonary histo look on CXR?

A

cavitary (mimics TB and non-RB mycobacteria)

102
Q

In acute/chronic pulmonary histo, the organism can be isolated in the sputum

A

chronic

103
Q

How is histoplasmosis typically contracted?

A

bird or bat droppings (in Ohio/Mississippi river valley area)

104
Q

Which pt. pop. gets chronic histo? What about disseminated histo?

A
  • chronic: peeps w/ pre-existing lung dz
  • disseminated: immunocomprimised
105
Q

Which drug ↑ your risk of contracting disseminated histo?

A

TNF inhibitor

106
Q

Pathology: silver stain → helmet morphology

A

histoplasmosis

107
Q

broad-based budding yeast

A

blastomycosis

108
Q

Co-infx w/ what dz greatly escalates progression from latent → active TB infx?

A

HIV

109
Q

What is the key distinction of TB from all other chronic pneumonias?

A

TB transmission is person-to-person ONLY

110
Q

Tissue destruction w/ TB infx is primarily d/t what?

A

host’s inflammatory response

111
Q

Pathophysiology of latent TB infx:

A

both w/in m∅s and extracellularly → caseous granulomas

no clinical signs or ssx

112
Q

Pathophysiology of active TB infx:

A

chronic, progressive dz primarily in lungs

113
Q

What are the dx criteria for a latent TB infx (for both TB skin test and new INFƔ release assay)?

A

TB skin test (TST):

  • (-) CXR &
    • (+) TST ≥ 10 mm OR
    • (+) TST 5-10mm if they have HIV, are immunosuppressed, or have close contact to person w/ active TB
    • ≥ 15 mm in very low TB incidence areas

INFƔ release assay (IGRA) (replacing TST → more specific + unaffected by BCG vaccine):

  • (-) CXR & (+) IGRA
114
Q

What is the duration of tx for latent and active TB?

A

active: 6 mo
latent: 9 mo

115
Q

Which type of lung cancer has a high prevelance of paraneoplastic syndromes?

A

small cell lung cancer

  • ACTH → Cushing’s
  • ADH → SIADH
116
Q

MC type of lung cancer

A

adenocarcinoma

117
Q

What are the 5 stages of lung cancer? What are they corresponding tx strategies?

A

Stage 0 : carcinoma in situ- early form

Stage 1: localized → surgery

Stage 2: early, locally advanced → surgery + adjuvant chemo

Stage 3: Late, locally advanced → (3a) neoadjuvant chemoXRT +/- surgery

Stage 4: metastasized → (3B + 4) palliative chemo + hospice

118
Q

Who should you be screeing for lung cancer w/ an annual low-dose CT?

A
  • age: 55-75
  • (+) smoking hx of 30 pack-years OR
  • exsmokers who quit smoking < 15 years ago
119
Q

When does normal pleural space have a negative pressure?

A
  • during inhalation → “breathing sucks”
  • @ FRC
120
Q

When does normal pleural space have a positive pressure?

A

w/ active exhalation or valsalva

121
Q

early hospice intervention improves/deminishes median survial, patient and family satisfaction in stage IV lung cancer?

A

improves

122
Q

What is the caveat of the fixed < 70 % FEV1/FVC ration for obstructive lung dz?

A
  • underdx in the young peeps
  • overdx in the old peeps

FEV1/FVC naturally ↓ w/ age

123
Q

↓ FVC suggests restrictive/obstructive lung physiology

A

restrictive→ need lung volumes to confirm restrictive pathology

124
Q

How is ‘air-trapping’ defined (via lung volumes) in obstructive lung dz?

A

air trapping = ↑RV > 120% of predicted value

125
Q

How is ‘hyperinflation’ defined (via lung volumes) in obstruction lung dz?

A

hyperinflation = TLC > 120% predicted

126
Q

What are 2 exam findings indicitive of lung hyperinflation found in COPD patients?

A
  • hyperresonance
  • distant breath sounds
127
Q

What are 3 exam findings evident of airflow obstruction found in COPD patients?

A
  • prolonged expiratory phase
  • ↓ breath sounds
  • wheezing
128
Q

List the 4 stages by GOLD criteria of COPD and their corresponding FEV1 values

A

I: Mild → FEV1 ≥ 80%

II: Moderate → 50-80%

III: severe → 30-50%

IV: very severe → < 30% (or FEV1 < 50% + respiratory failure)

129
Q

MCC of transudative pleural effusion

A

LV ♥︎ failure

130
Q

classic finding on PE: crackles at lung bases (velcro rales)

A

idiopathic pulmonary fibrosis

131
Q
A