Misc Pulm Flashcards
Occlusion of deep veins (thrombosis); usually lower extremity =
Occlusion of pulm arterial circ (embolus); usually from thrombus in deep calf veins =
= DVT
= PE
Virchow’s triad
Hypercoagubility
Venous stasis
Endothelial injury
MC preventable death in hospital
PE
Common etiologies of VTE
1) Hereditary - Factor V Leiden (stops Prot.C)
2) Acquired - surgery, trauma, malignancy, age, OCP/HRT, pregnancy, infx, travel
Common presentation
DVT:
PE:
- extremity edema & pain & warmth; palpable cord, Homan’s sign (???)
- sudden dyspnea, pleuritic CP, Tachypnea, Tachycardia, cough
Dx (DVT)
H&P
Calf/thigh circumf
Well’s Criteria
Thrombophilia w/u for fam hx, personal hx
D-Dimer (only if - , strong evidence against)
Venous doppler US - best screening (90%)
Venography - gold stnd, but…pain, contrast rxn, $$$
Dx (PE)
H&P, Well’s Criteria, Thrombophilia w/u, D-dimer
ABGs - show resp alk 2/2 hyperventilation
EKG - S1Q3T3 “Classic”; sinus tach MC
CXR - Westermark’s Sign; Hamptom’s Hump
Helical (spiral) CT = CT angiography (c contrast) - filling defects; Screening test
V/Q scan - for renal dz, pregnancy (not COPD); Screening test; eval matched/ mismatched defects; low/med/high prob.
Pulm angiography - gold stnd; injected contrast reveals filling defect; toxicity issue
Prevention (VTE)
Mechanical (early ambulation, SCDs)
+/- Pharm (UFH, LMWH)
Tx (VTE)
Anticoagulation (UFH, LMWH, warfarin, Xarelto) 3-12 months
IVC filter
Thrombolytic therapy
Surgery (saddle embolus)
Normal Pulm circ pressure
Low-pressure (< 20/10 mmHg), low-resistance, high-capacitance to accomodate large inc in blood flow during exercise s signif inc in press
Pulm artery pressure > 25 or > 30 c exercise
Measured by right heart catheterization
Pulm HTN
Classification (Pulm HTN)
Primary (rare)
Secondary (MC)
Etiology (Pulm HTN)
Primary - genetic
Secondary -
*dec area arterial bed, hypoxia, loss/obstruct vascular bed (lung resection, emphysema, PE), collagen-vascular dz.
*inc venous pressure, constrictive pericarditis, LV failure, MS
Signs/Sxs (Pulm HTN)
(insidious) Dyspnea Fatigue Angina-like CP Edema Syncope Palpitations
Dx (Pulm HTN)
(multi-factorial - find underlying etiology) CXR, CT PFTs Echo Right heart catheterization Other labs/bx...based on suspected cause
Tx (Pulm HTN)
Manage cor pulmonale - diuretics, Na/fluid restriction
Vasodilation - CCB, sildenafil
RV enlargement 2/2 Pulm HTN (inc resistance or high BP in the lungs)
EKG: low volt, R axis dev, poor R wave prog, RVH, RAE
Assoc c COPD & Pulm HTN
Cor pulmonale
Etiology (Cor pulm)
Pulm vascular dz (PE, vasculitis, ARDS)
Pulm parenchymal dx
Obstructive (Asthma, COPD)
Restrictive (IPF, pneumoconiosis)
Signs/Sxs (Cor pulm)
Accentuated S2
Peripheral edema
JVD
Hepatomegaly
Airway obstruction during sleep
Obstructive Sleep Apnea (OSA)
Signs/Sxs (OSA)
Loud snoring Episodes of silence Microarousals Fatigue, HA, cognitive impairment Daytime somnolence
Acute hypoxemic resp failure
Without heart failure
Systemic or Pulm insult only
Acute Resp Distress Synd (ARDS)
MC etiology of ARDS…
and others…
…Sepsis
…Aspiration, toxic inhalation, near-drowning
Signs/Sxs (ARDS)
Pink, frothy sputum
Bilat diffuse pulm infiltrates
Nml pulm capillary wedge press (PCWP < 18)
PaO2/FIO2 < 200
Tx (ARDS)
Underlying cause
Supportive
High mortality (esp. c sepsis)
Phases (ARDS)
1) Exudative - Dyspnea, Tachypnea, resp fatigue/failure, inc work breathing
2) Proliferative - worsening sxs, fibrotic changes start
3) Fibrotic - inc mortality
Peds resp distress syndrome
Premies
Surfactant deficiency
Poor lung compliance
Hyaline membrane dz.
Signs/Sxs (Hyaline mem dz)
Tachypnea, Tachycardia, grunting, intercostal retractions, nasal flaring, cyanosis
Appears in first hours of life; worsens over 1-3 days
Require mech vent
Dx (Hyaline mem dz)
CXR - dec aeration, AIR BRONCHOGRAM
GROUND GLASS, white out like PNA
Prevention & Tx (Hyaline mem dz)
Monitor lecithin/sphingomyelin ratio (amnio)
Mom gets steroids
Baby gets surfactant if < 28 wks
Supportive, mech vent, IVF, endotrach surfact
