Module 3: Lower Respiratory Problems Flashcards

Question

Risk Factors for TB

Answer 1

Poor, underserved, and minorities  Homeless  Residents of inner-city neighborhoods  Foreign-born persons  Living or working in institutions  IV drug users  Overcrowded living conditions  Poverty, poor access to health care  Immunosuppression

Answer 2

Gram-positive, aerobic, acid-fast bacillus (AFB)  Spread via airborne droplets, 1 to 5 um  Can be suspended in air for minutes to hours  Humans are only known reservoir for TB  Transmission requires close, frequent, or prolonged exposure  NOT spread by touching, sharing food utensils, kissing, or other physical contact  Number, concentration, length of time for exposure and immunity influence transmission Once inhaled, droplets lodge in bronchioles and alveoli  Local inflammatory reaction occurs  Ghon lesion or focus—represents a calcified TB granuloma—hallmark of primary TB infection  Granuloma—defense mechanism to wall off and prevent spread  Only 5% to 10% of people with dormant TB will develop active TB; may take months or years M. tuberculosis  Aerophilic (oxygen-loving)—has affinity for lungs  Infection can spread via lymphatics and grow in other organs * Cerebral cortex, spine, epiphyses of the bone, liver, kidneys, lymph nodes, adrenal glands

Answer 3

Resistance to first-line drug therapy (isoniazid and rifampin)  Extensively drug-resistant TB (XDR-TB) resistant to any fluoroquinolone plus at least 1 2nd-line drug **Several causes for resistance  Incorrect prescribing  Lack of case management  Nonadherence to prescribed regimen

Answer 4

Class  0 = No TB exposure  1 = Exposure, no infection  2 = Latent TB, no disease  3 = TB, clinically active  4 = TB, not clinically active  5 = TB suspect

Answer 5

Presentation  Primary, latent, reactivated  Whether pulmonary or extrapulmonary ***Primary TB infection  Starts when bacteria are inhaled, trigger inflammatory reaction  Most people have effective immune response here ***Active TB infection  Primary TB – active disease within 2 years of infection * People co-infected with HIV at greatest risk ***Post-primary TB or reactivation TB  Occurs >2 years after initial infection  Patient infectious if site of TB is pulmonary or laryngeal ***Latent TB infection (LTBI)  Occurs when there is not active TB disease  Positive skin test but asymptomatic  Cannot transmit TB; can develop active TB later * Reactivation can occur with some diseases, stress  Treatment is as important as it is for primary TB

Answer 6

Pulmonary TB  Takes 2 to 3 weeks to develop symptoms  Characteristic initial: dry cough that becomes productive  Other symptoms: fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats  Late: dyspnea and hemoptysis (coughing of blood streaked sputum from lungs/brochial tissues)  Acute, sudden presentation of TB  High fever  Chills, generalized flulike symptoms  Pleuritic pain  Productive cough  ARF  Normal or adventitious breath sounds  Hypotension and hypoxemia may be present Immunosuppressed (e.g., HIV) and older adults— less likely to have fever and other signs of an infection  HIV—carefully assess respiratory problems; rule out PJP or opportunistic diseases  Older adult—change in cognitive function may be the only initial sign  Extrapulmonary TB manifestations—depends on organs infected

Answer 7

Properly treated, TB heals without complications **Miliary TB  Large numbers of organisms spread via the bloodstream to distant organs  Occurs with primary TB or reactivation of LTBI (latent TB infection)  Fatal if untreated  Manifestations progress slowly and vary depending on which organs are infected * Fever, cough, and lymphadenopathy (swelling of lymph nodes) * May include hepatomegaly (enlargement of the liver) and splenomegaly (enlargement of spleen)

Answer 8

Pleural TB—extrapulmonary  Primary TB disease or reactivation of LTBI  Chest pain, fever, cough, unilateral pleural effusion  Empyema (accumulation of pus in pleural space); less common but occurs from large numbers of TB organisms in pleural space

Answer 9

When Tuberculosis (TB) spreads beyond the lungs, it is referred to as extrapulmonary tuberculosis (EPTB), which can affect virtually any organ system in the body. The spread of TB to other organs can lead to various acute and long-term complications, depending on the organs involved. Here are some of the complications associated with TB infection in different parts of the body: Spine (Pott's Disease) Description: Pott's disease is TB of the spine, which is the most common form of skeletal tuberculosis. It involves the destruction of intervertebral discs and adjacent vertebrae, leading to the formation of a "cold abscess" that can spread along fascial planes. Complications: Can result in severe back pain, deformity, and potential compression of the spinal cord, leading to paralysis (paraplegia or tetraplegia) if not treated promptly. Central Nervous System (CNS) Description: TB can affect the CNS, most commonly causing tuberculous meningitis, which is an infection of the membranes covering the brain and spinal cord. Complications: Can lead to a range of severe neurological complications, including headaches, mental status changes, seizures, stroke, and permanent brain damage. It is considered a medical emergency. Abdomen Description: Abdominal TB can involve any abdominal organ, including the peritoneum, lymph nodes, gastrointestinal tract, liver, and spleen. Complications: May cause abdominal pain, ascites (accumulation of fluid in the peritoneal cavity), intestinal obstruction, and generalized systemic symptoms like fever and weight loss. Peritonitis due to TB can lead to severe abdominal tenderness and guarding. Other Organs Kidneys and Urogenital Tract: Genitourinary tuberculosis can affect the kidneys, ureters, bladder, and reproductive organs, leading to chronic pain, hematuria (blood in urine), infertility, and, in severe cases, renal failure. Adrenal Glands: Adrenal TB can lead to Addison's disease, a condition where the adrenal glands do not produce enough steroid hormones, leading to weakness, weight loss, and electrolyte imbalances. Lymph Nodes: TB can cause lymphadenitis, leading to swollen and sometimes draining lymph nodes. Scrofula is a term used for TB lymphadenitis of the neck. Bones and Joints: Besides the spine, TB can affect other bones and joints, leading to chronic pain, swelling, and reduced mobility, most commonly in the hips and knees.

Answer 10

Tuberculin skin test (TST)  AKA: Mantoux test  Screening for TB: Purified protein derivative (PPD)— 0.1 mL ID injection ventral forearm * Inspect site for induration in 48 to 72 hours * Induration—palpable, raised, hardened, or swollen area (not redness)  Indicates development of antibodies following exposure to TB; occurs 2-12 weeks after initial exposure  Measure in mm and record Positive * Greater than or equal to 15 mm induration in low-risk individuals * Greater than 10 mm induration in high-risk * Greater than or equal to 5 mm induration in immunocompromised  False-positive and false-negative reactions may also occur Initial screening: 2-step testing  Recommended for health care workers and those with decreased response to allergens  Initial injection; second injection in 1 to 3 weeks * Initial positive—need further evaluation for active disease, not 2nd injection * Second positive—new infection or boosted reaction to old infection  Negative 2-step testing ensures future positive results accurately interpreted as new infection

Answer 11

Blood test detects INF gamma release from T-cells in response to M. tuberculosis * Includes QuantiFERON ®-TB Gold In-Tube (QFT-GIT) and T-SPOT.TB® tests * Rapid results * Several advantages over TST but increased cost  LTBI can only be diagnosed by excluding active TB

Answer 12

Chest x-ray  Cannot make diagnosis solely on x-ray  May appear normal in a patient with TB  Suggestive findings * Upper lobe infiltrates: TB bacteria thrive in areas of high oxygen concentration, making the upper lobes of the lungs a common site for TB infection. Infiltrates in these areas can be indicative of TB. * Cavitary infiltrates (The formation of cavities, which are hollow spaces within the lung, is a hallmark of reactivation or post-primary TB. These cavities are formed due to the destruction of lung tissue by the bacteria) * Lymph node involvement (Enlarged lymph nodes, particularly in the mediastinum (the central part of the chest separating the lungs), can be a sign of TB, especially in children and HIV-positive individuals) * Pleural and/or pericardial effusion (TB can cause pleural effusion (fluid accumulation in the pleural space) and pericardial effusion (fluid around the heart), both of which can be seen on a chest X-ray)  Other diseases (i.e.; sarcoidosis) can mimic appearance of TB Limitations of Chest X-ray in TB Diagnosis Cannot Confirm TB: A chest X-ray cannot distinguish TB from other diseases with similar radiographic appearances, nor can it determine if the disease is active or latent. May Appear Normal: Some patients with active TB, particularly in the early stages or those with milder forms of the disease, may have a normal chest X-ray. Mimicking Conditions: Diseases like sarcoidosis, fungal infections, and other bacterial pneumonias can have similar radiographic features, complicating the interpretation.

Answer 13

TB sputum culture is gold standard * 3 consecutive sputum samples at 8 to 24 hours intervals; at least 1 specimen in early morning * Initial test: stained sputum smears examined for AFB (acid-fast bacilli (AFB) * Definitive diagnosis = mycobacterial growth—can take up to 6 weeks  Treatment is started while waiting for culture results when suspicion of TB is high * Can also collect samples from other suspected TB site

Answer 14

The treatment of active tuberculosis (TB) disease is a lengthy process that typically involves a two-phase approach with multiple antibiotics to ensure the elimination of the bacteria and to prevent the development of drug resistance. 1. Intensive Phase Duration: Usually the first 2 months of treatment. Purpose: To rapidly kill the tubercle bacilli, thereby reducing the bacterial load and making the patient less infectious. Drugs: A combination of four drugs is used during this phase: Isoniazid: Effective against actively growing and dormant TB bacteria. It is known to increase the risk of hepatotoxicity (liver damage), so liver function tests are often monitored during treatment, especially in patients with pre-existing liver conditions, the elderly, and those with heavy alcohol use. Rifampin (Rifampicin in some countries): Has a potent bactericidal activity and is effective against a broad range of bacteria including Mycobacterium tuberculosis. It can cause liver dysfunction and drug interactions by inducing liver enzymes that metabolize many other drugs. Pyrazinamide: Its exact mechanism is not fully understood, but it's particularly effective during the initial phase of treatment. It is contraindicated in pregnancy and in patients with acute hepatitis due to its potential hepatotoxic effects. Ethambutol: Used to prevent the emergence of resistance. It can cause optic neuritis, leading to visual disturbances, so it's often stopped if the TB strain is known to be susceptible to all four drugs, and the patient is not at high risk of drug resistance. 2. Continuation Phase Duration: Extends for an additional 4 months, making the total usual treatment duration 6 months. Purpose: To eliminate any remaining bacteria and prevent relapse. Drugs: The treatment is continued with two drugs: Isoniazid Rifampin These drugs are continued to ensure the eradication of all TB bacteria and to minimize the risk of developing drug-resistant TB. The total duration of treatment may be extended in certain cases, such as TB meningitis, bone and joint TB, and in patients with drug-resistant TB or HIV co-infection. Monitoring and Considerations Monitoring: Patients on TB treatment require regular monitoring for drug efficacy, adherence, and potential side effects, including liver toxicity. Directly Observed Therapy (DOT): To improve treatment adherence, the DOT strategy is often employed, where a healthcare provider or trained individual observes the patient taking each dose of medication.

Answer 15

Active TB disease  Patients should be taught about adverse/side effects and when to seek medical attention  Nonviral hepatitis is a major side effect for 3 of 4 first- line drugs; liver function tests should be monitored  Alternatives are available for those who develop a toxic reaction to primary drug

Answer 16

MDR-TB  Sensitivity test determines drugs  Initial: Five drugs for at least 6 months after sputum culture is negative * 1-2 first-line, fluoroquinolone, injectable antibiotic and 1 or more second-line  Continuation: 4 drugs for 18 to 24 months  2 new drugs used in combination therapy * Bedaquiline (Sirturo) * Delamanid (Deltyba)

Answer 17

Latent tuberculosis infection (LTBI)  Treatment easier due to fewer bacteria; usually 1 drug  Standard - Isoniazid for 9 months * Inexpensive, effective, taken orally * Can use 6-month plan if adherence issues  HIV patients and those with fibrotic lesions on chest x -ray should take Isoniazid for 9 months  Alternative 3-month regimen of Isoniazid and rifapentine for those not infected with MDR bacilli  4 months of rifampin for those resistant to isoniazi

Answer 18

Live, attenuated strain of Mycobacterium bovis  Given to infants in parts of world with high prevalence of TB  In United States, not recommended due to low risk of infection except for select individuals  BCG vaccine can result in false positive TST

Answer 19

Airborne isolation * Single-occupancy room with 6 to 12 airflow exchanges/hour * Health care workers wear high-efficiency particulate air (HEPA) masks; fit tested

Answer 20

30+ varieties of acid-fast mycobacteria that cause pulmonary disease, lymphadenitis (inflammation of lymph nodes), skin or soft tissue (muscles, ligaments, fat) disease, or disseminated disease (a condition where an infection or other disease process spreads from the initial site to other parts of the body, often affecting multiple organ systems)  Found in tap water, soil, house dust, or bird feces  Symptoms: cough, shortness of breath, weight loss, fatigue, blood-tinged sputum  Diagnosis: culture  Treatment: similar to TB

Answer 21

Caused by endemic or opportunistic fungi  May be life threatening  Transmission: inhalation of spores  Symptoms: similar to bacterial pneumonia  Diagnosis: skin testing, serology, biopsy  Treatment: antifungals

Answer 22

Etiology and pathophysiology  Necrosis of lung tissue from aspiration of bacteria from periodontal disease * Other: IV drug use, cancer, PE, lung infarction, TB, parasitic and fungal diseases, sarcoidosis  Develops slowly; infection results in purulent fluid filled cavity with multiple microbes  Posterior upper lobes most often affected * May erode into bronchi: foul-smelling sputum * May grow into pleura: pleuritic pain  Multiple abscesses—necrotizing pneumonia Clinical manifestations – occur slowly (weeks to months):  Cough-producing purulent sputum; foul smell and taste; hemoptysis  Other: fever, chills, night sweats, pleuritic pain, dyspnea, anorexia, weight loss  Decreased breath sounds; crackles  Complications: pulmonary abscess (a localized collection of pus within the lung parenchyma (lung tissue), typically caused by a bacterial infection. It results from the necrosis (death) of lung tissue and the formation of a cavity filled with pus, dead cells, and other debris) bronchopleural fistula (abnormal connection between the bronchial tubes and the pleural space (the thin fluid-filled space between the two layers of the pleura surrounding the lungs). bronchiectasis: chronic condition characterized by permanent enlargement and scarring of the bronchial tubes. This leads to impaired clearance of mucus, resulting in frequent infections and blockages of the airways, often from CF empyema (accumulation of pus in the pleural space, often arising as a complication of pneumonia, lung abscess, or thoracic surgery) If antibiotics not effective— * Percutaneous drainage of abscess * Surgery: lobectomy or pneumonectom

Answer 23

Disorders that impair movement of the chest wall and diaphragm  2 categories:  Extrapulmonary—Lung tissue normal but caused by issues in either CNS, neuro-muscular or chest wall disorders  Intrapulmonary— Abnormal pleural or lung tissue disorders  Hallmark characteristic: reduced forced expiratory volume (FEV1) on PFTs FEV1: This measures the amount of air a person can forcefully exhale in one second after taking a deep breath. It is a critical measurement in assessing the presence and severity of airway obstruction.  PFTs best way to distinguish restrictive from obstructive respiratory disorders

Answer 24

Collapsed, airless alveoli  Decreased or absent breath sounds  Dullness on percussion  Caused by: secretions obstructing small airways  At risk: bedridden and postop surgery patients  Prevention and treatment * Deep breathing exercises, incentive spirometry, early mobility

Answer 25

Inflammation of the pleura; AKA pleuritis  Etiology: infection, cancer, autoimmune disorders, chest trauma, GI disease, and some medications  Manifestations * Pain—sharp, worse with inspiration * Breathing shallow—reduced movement * Pleural friction rub—peak of inspiration  Treatment—underlying cause and pain management * Teach splinting rib cage when coughing

Answer 26

An abnormal collection of fluid in the pleural space, known as a pleural effusion, is indeed not a disease in itself but a sign or manifestation of other underlying conditions. The pleural space is a thin cavity between the lung and the chest wall, lined by the pleura (a membrane), and normally contains a small amount of lubricating fluid. Pleural effusions develop when there's an imbalance between the production and absorption of this pleural fluid. Causes of Pleural Effusion The formation of a pleural effusion can be due to various mechanisms, including: Increased Pulmonary Capillary Pressure: Often seen in heart failure, leading to fluid leakage from the capillaries into the pleural space. Decreased Oncotic Pressure: Reduced protein levels in the blood, as seen in liver cirrhosis or nephrotic syndrome, can decrease the blood's ability to retain fluid, leading to its accumulation in the pleural space. Increased Pleural Membrane Permeability: Infections, inflammation, or injury can make the pleural membrane more permeable, allowing fluid to enter the pleural space more easily. Lymphatic Flow Obstruction: Conditions that block or disrupt the normal flow of lymphatic fluid can lead to accumulation in the pleural space. Types of Pleural Effusion Based on the protein content and the underlying cause, pleural effusions are classified into two main types: Transudative Effusions: These effusions are typically due to noninflammatory conditions that alter the pressure gradients and fluid balance, such as heart failure, liver cirrhosis, or nephrotic syndrome. Transudative effusions are characterized by low protein content and are generally not due to direct injury or inflammation of the pleura. Exudative Effusions: Result from inflammatory conditions that increase the permeability of the pleural membrane, such as pneumonia, lung cancer, tuberculosis, or autoimmune diseases. Exudative effusions have a higher protein content and often contain inflammatory cells. Empyema Empyema, a specific type of exudative pleural effusion, involves the accumulation of pus in the pleural space, indicating a bacterial infection. This condition requires prompt and aggressive treatment, including antibiotics to combat the infection and drainage procedures (such as thoracentesis, chest tube insertion, or surgery) to remove the purulent fluid and alleviate symptoms.

Answer 27

Clinical manifestations:  Dyspnea, cough, sharp chest pain  Decreased chest movement; dullness, decreased breath sounds on affected side  Chest x-ray and CT—location and volume  Empyema: above manifestation and fever, night sweats, cough, weight loss  Interprofessional and nursing care  Treat underlying cause  Chemical pleurodesis – obliterate pleural space

Answer 28

Diffuse parenchymal lung disease  More than 200 disorders caused by inflammation or scarring (fibrosis) between air sacs (interstitium)  Cause often unknown  Known causes * Inhalation of occupational and environmental toxins, certain drugs, radiation therapy, connective tissue disorders, infection, cancer  Treatment—reduce exposure or treat underlying disease * Corticosteroids, immunosuppressants; transplant

Answer 29

Progressive disorder; chronic inflammation and scar tissue in connective tissue; course is variable  Risk factors: smoking; wood & metal dust  Manifestations: exertional dyspnea (shortness of breath with exertion); dry, nonproductive cough, clubbing (enlargement of fingertips and toes due to chronic low O2 levels), crackles  Progression: weakness, anorexia, weight loss  Diagnostic Studies: * PFTs: Pulmonary Function Tests (PFTs): Typically show a reduced vital capacity (VC) and total lung capacity (TLC), indicating restrictive lung disease. There's also impaired gas exchange, often assessed by reduced diffusion capacity for carbon monoxide (DLCO). High-Resolution Computed Tomography (HRCT): HRCT scans of the chest are crucial for diagnosing IPF and other ILDs, showing characteristic patterns such as reticular abnormalities, honeycombing, and traction bronchiectasis. Open Lung Biopsy (VATS): Video-Assisted Thoracoscopic Surgery (VATS) for lung biopsy is considered the "gold standard" for definitive diagnosis when non-invasive methods are inconclusive. It allows direct visualization and sampling of lung tissue, which is then examined histologically for signs of fibrosis and other abnormalities. Prognosis is poor; no known cure  Median survival rate 2.5 to 3.5 years after diagnosis **Treatment  Corticosteroids and other immune suppressants  Kinase inhibitor drugs  Oxygen  Pulmonary rehabilitation  Lung transplant

Answer 30

Chronic, multisystem granulomatous disease *"Granulomatous" refers to a type of inflammation characterized by the formation of granulomas, which are small, localized nodular inflammations. Granulomas typically form when the immune system attempts to isolate and wall off substances that it perceives as foreign but is unable to eliminate. These substances can include infectious agents like bacteria, fungi, and parasites, as well as non-infectious agents such as foreign materials or certain inflammatory diseases.  Primary affect on lungs * Dyspnea, cough, chest pain; many are asymptomatic  Other: skin, eyes, liver, kidney, heart, lymph nodes  Cause unknown  At risk: blacks and family history  Treatment—suppress inflammation  Follow 3 to 6 months: PFTs, chest x-ray, and CT scan for progression

Answer 31

Traumatic injuries to chest contribute to many traumatic deaths  Range of injuries  Simple rib fractures to cardiorespiratory arrest  Classify primary mechanisms of injury as either blunt or penetrating trauma

Answer 32

Mechanisms of Injury  Blunt * Chest strikes or is struck by an object * Shearing and compression injuries of chest structures * External appearance may be minor but may have severe internal organ damage  Penetrating * Foreign object impales or passes through body tissues creating an open wound

Answer 33

Blunt trauma  Most common ribs 5 through 9 – least protected by chest muscles  Can damage pleura, lungs, heart, and other internal organs **Manifestations  Pain with inspiration and coughing  Splinting  Shallow respirations

Answer 34

Complications  Atelectasis and pneumonia  Taping, using a thoracic binder not recommended  Treatment  Reduce Pain: NSAIDs, opioids, nerve blocks  Patient teaching * Deep breathing and coughing * Incentive spirometry * Appropriate use of analgesics * Early mobility when appropriate

Answer 35

3 or more consecutive fractured ribs in 2 or more places or fractured sternum and several consecutive ribs  Causes unstable chest wall and paradoxical movement with breathing  Flail segment moves opposite  Inspiration—sucked in  Expiration—bulges out  Inadequate ventilation; increased work of breathing (WOB) Physical examination  Rapid, shallow respirations  Asymmetric and uncoordinated chest movement  Inadequate ventilation  Splinting  Crepitus near fractures -Diagnostic study  Chest x-ray Treatment  Ensure adequate ventilation/lung expansion  Adequate oxygenation  Pain management  Other, if needed: * Intubation and mechanical ventilation * Surgical fixation

Answer 36

Caused by air entering pleural cavity  Positive pressure in pleural space causes lung to partially or fully collapse  Increased air in pleural space equals reduced lung volume  Open: opening in chest wall * Penetrating trauma—sucking chest wound  Closed: no external wound  Suspect pneumothorax with chest wall trauma Manifestations  Small pneumothorax * Mild tachycardia and dyspnea  Large pneumothorax * Respiratory distress  Short, shallow, rapid respirations, dyspnea, low O2 saturation * Absent breath sounds over affected area  Diagnostic Study: Chest x-ray  Shows air or fluid in pleural space and reduced lung volume

Answer 37

Types  Spontaneous—happens without trauma or a known cause; two types: Primary Spontaneous Pneumothorax: This form typically occurs in healthy individuals without underlying lung disease. It is often attributed to the rupture of small air-filled blisters (blebs) on the lung's surface. Risk factors include being a tall, thin male, smoking, a family history of pneumothorax, and a previous history of spontaneous pneumothorax. Secondary Spontaneous Pneumothorax: This type occurs in individuals with underlying lung conditions such as chronic obstructive pulmonary disease (COPD), asthma, cystic fibrosis, and pneumonia. The diseased lung tissue is more prone to rupture, leading to a pneumothorax.  Iatrogenic — This form is caused by medical procedures and is considered an accidental complication. Common procedures that can lead to an iatrogenic pneumothorax include: Biopsies: Particularly transthoracic needle biopsies of the lung. Central Venous Catheter Insertion: Especially subclavian catheter placement, where the needle or catheter may inadvertently puncture the lung. Mechanical Ventilation: High airway pressures can lead to alveolar rupture and pneumothorax, especially in patients with acute respiratory distress syndrome (ARDS) or other severe lung conditions. Esophageal Procedures: Procedures involving the esophagus, such as endoscopy or surgery, can sometimes lead to pneumothorax due to the close anatomical relationship between the esophagus and the pleural space.

Answer 38

Tension pneumothorax **Tension pneumothorax is a severe and life-threatening type of pneumothorax where air accumulates in the pleural space and cannot escape, leading to progressively increasing intrapleural pressure. This condition is an emergency because of its rapid impact on respiratory and cardiac function. Mechanism: In a tension pneumothorax, the mechanism often involves a one-way valve effect, where air enters the pleural space during inspiration but cannot exit during expiration. This leads to a continuous buildup of air, causing the affected lung to collapse fully and exert pressure on the mediastinum (the central compartment of the thoracic cavity), which includes the heart and major blood vessels. Consequences Mediastinal Shift: The increasing pressure pushes the mediastinum towards the unaffected side, which can compress the opposite lung and further impair respiratory function. Hemodynamic Instability: The shift and the increased intrathoracic pressure reduce venous return to the heart, leading to decreased cardiac output and potentially rapid cardiovascular collapse. Causes Tension pneumothorax can occur in various contexts: Trauma: Chest injuries that result in a pneumothorax can progress to a tension pneumothorax, especially if the chest wall is breached (open pneumothorax) or if lung tissue is torn (closed pneumothorax). Iatrogenic: Medical procedures, such as central venous catheter insertion or positive pressure ventilation, can inadvertently cause a tension pneumothorax. Spontaneous: Rarely, a primary or secondary spontaneous pneumothorax can evolve into a tension pneumothorax, particularly if a bleb ruptures and creates a one-way valve mechanism. Symptoms and Signs Severe shortness of breath Hypotension and tachycardia Tracheal deviation away from the affected side (a late and ominous sign) Distended neck veins Hyperresonance on the affected side with diminished or absent breath sounds Management Immediate recognition and treatment are crucial to prevent death. Management typically involves the urgent decompression of the pleural space to release the trapped air and relieve the pressure. This is often initially achieved with needle decompression, followed by the placement of a chest tube to continuously evacuate the air and allow the lung to re-expand. Emergency medical intervention is required, and in hospital settings, this condition is treated as a "do not pass go" scenario, meaning immediate action is taken without waiting for imaging confirmation.

Answer 39

Blood in pleural space * Injury to chest wall, diaphragm, lung, blood vessels, mediastinum  Treat with chest tube Hemopneumothorax – occurs with pneumothorax

Answer 40

Chylothorax refers to the accumulation of lymphatic fluid, specifically chyle, in the pleural space. Chyle is a milky fluid rich in fats, which is transported by the lymphatic system from the digestive system to the venous blood circulation. A chylothorax occurs when this fluid leaks into the pleural cavity, often due to damage or obstruction of the thoracic duct or its tributaries. Causes The causes of chylothorax can vary and include: Trauma: Surgical procedures in the chest or neck, or chest injuries, can damage the thoracic duct. Malignancy: Lymphomas, lung cancer, or other cancers that metastasize to the lymph nodes can obstruct or invade the thoracic duct. Idiopathic: In some cases, the cause of chylothorax remains unknown. Treatment Approaches Conservative Management: Dietary Modification: A low-fat diet with medium-chain triglycerides (MCTs) can reduce chyle production. MCTs are absorbed directly into the portal system, bypassing the lymphatic system. Fasting and Total Parenteral Nutrition (TPN): In some cases, temporarily stopping oral intake and providing nutrients via TPN can allow the thoracic duct to heal. Thoracentesis: Repeated drainage of the chylous fluid can relieve symptoms and prevent respiratory compromise. Medical Therapy: Octreotide: This somatostatin analogue can reduce lymph production and is used to treat chylothorax by decreasing the flow of chyle, potentially allowing the site of leakage to seal. Refractory Cases: Surgery: Surgical options include repair or ligation of the thoracic duct, pleuroperitoneal shunting, or other procedures aimed at directly addressing the leak or bypassing the damaged section of the thoracic duct. Pleurodesis: This procedure involves the introduction of a substance (e.g., talc) into the pleural space to induce inflammation and fibrosis, causing the pleural layers to adhere to each other and eliminating the space where chyle can accumulate. Pleurodesis is generally considered when other treatments have failed and the chylothorax is recurrent. Considerations The choice of treatment depends on the cause of the chylothorax, the volume of chyle leakage, and the patient's overall health and underlying conditions. Conservative management is often the first line of treatment, with more invasive procedures reserved for cases where conservative measures fail or when there's a significant or persistent chyle leak. The management of chylothorax often requires a multidisciplinary approach, including input from thoracic surgeons, oncologists, dietitians, and other specialists as needed.

Answer 41

Dependent on severity, underlying cause and hemodynamic stability  Emergency treatment—Cover wound with dressing secured on 3 sides * Inspiration: pulls dressing against wound so air cannot enter pleural space * Expiration: dressing pushes out and air escapes  If impaled object in place, stabilize it with a bulky dressing but do not pull it out Treatments  Chest tubes with water-seal drainage  Other: partial pleurectomy, stapling, or pleurodesis  Tension pneumothorax  Needle decompression— immediate  Chest tube and water-seal drainag

Answer 42

Abnormal accumulation of fluid in alveoli and interstitial spaces  Complication of heart and lung problems  Most common cause: left-sided HF  Can be a life-threatening medical emergency if severe * Dyspnea, diaphoresis, wheezing * 3rd heart sound may be present * Blood-tinged, frothy sputum  CXR is best option for confirming diagnosis Treatment focuses on  Find underlying cause of edema  Reduce amount of fluid in lungs  Care  Place in semi or high Fowler’s  O2 to keep SpO2 greater than 90%  IV diuretics or nitroglycerine  Monitor vs, WOB, breath sounds, output, electrolyte balance, response to treatment

Answer 43

Etiology and Pathophysiology  Blockage of 1 or more pulmonary arteries by thrombus, fat or air embolus, or tumor tissue  Clot in venous system into pulmonary circulation then lodges in small blood vessel and obstructs alveolar perfusion  Most often affects lower lobes Most PEs arise from deep vein thrombosis (DVT)  Venous thromboembolism (VTE) – preferred term to describe spectrum from DVT to PE  Origination: deep veins of legs, femoral or iliac veins, right side of heart (atrial fibrillation) and pelvic veins (especially after surgery or childbirth) * Other: central venous catheters or arterial lines; fat (fractured long bones); air (IV), vegetation on heart valves, amniotic fluid, and cancer A saddle embolus refers to a large thrombus (blood clot) that lodges at a bifurcation (branching point) of a major artery, most commonly the pulmonary artery. This type of embolus is termed "saddle" because it straddles the bifurcation, resembling a saddle on a horse. In the context of pulmonary embolism (PE), a saddle embolus sits at the junction where the main pulmonary artery divides into the left and right pulmonary arteries.

Answer 44

 Immobility or reduced mobility  Surgery within 3 months (especially pelvic and lower extremity)  History of VTE  Cancer  Obesity  Oral contraceptives/ hormone therapy  Smoking  Prolonged air travel  Heart failure  Pregnancy  Clotting disorders

Answer 45

Depend on type, size, and extent of emboli  Appear suddenly or begin slowly  Dyspnea most common; mild-moderate hypoxemia  Other: tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound  Massive PE: change in mental status, hypotension, feeling of impending doom, cardiorespiratory arrest/death

Answer 46

About 10% with massive PE die within 1st hour  Pulmonary infarction – death of lung tissue  Occlusion of medium or large-sized vessel, inadequate collateral blood flow, and preexisting lung disease results in alveolar necrosis and hemorrhage which may result in abscess and pleural effusion  Pulmonary hypertension - condition characterized by increased blood pressure in the pulmonary arteries. In the context of PE, PH can result from the obstruction of pulmonary vessels by emboli, which increases vascular resistance and pressure within the pulmonary artery system. -Results from hypoxemia associated with massive or recurrent emboli which can cause chronic thromboembolic pulmonary hypertension  Right ventricular hypertrophy -Over time, the increased workload on the right ventricle can lead to right ventricular hypertrophy (RVH), where the muscle of the right ventricle thickens. This can progress to right ventricular failure, characterized by symptoms such as leg swelling, increased abdominal girth due to fluid accumulation, and fatigue.

Answer 47

D-Dimer Test Description: The D-dimer test measures a specific type of protein fragment that is produced when a blood clot is degraded by fibrinolysis. Elevated levels of D-dimer can indicate the presence of an active clotting and dissolution process within the body. Usefulness: The D-dimer test is particularly valuable in ruling out PE in patients with a low clinical probability. A normal D-dimer level can be a strong indicator that a PE is unlikely in patients deemed to be at low risk based on clinical assessment and risk stratification tools. Limitations: Sensitivity and Specificity: While D-dimer levels are often elevated in the presence of PE, they can also be elevated in many other conditions, such as recent surgery, trauma, infection, pregnancy, and cancer, making the test less specific. The sensitivity of the test can be limited, particularly for small PEs, leading to false negatives in up to 50% of such cases. False Positives: Due to its lack of specificity, a positive D-dimer test is not diagnostic of PE and requires further investigation with imaging studies, especially in patients with a moderate to high clinical probability of PE.

Answer 48

CT Pulmonary Angiography (CTA) Description: CTA is a specialized form of CT scan that uses intravenous contrast material to visualize the pulmonary arteries. It is currently the most commonly used diagnostic imaging study for suspected PE. Advantages: CTA provides a detailed three-dimensional picture of the pulmonary vasculature, allowing for the direct visualization of clots within the arteries. It is highly sensitive and specific for diagnosing PE. Requirements: The test requires the administration of iodinated contrast material, which can be contraindicated in patients with allergies to the contrast medium or those with significant renal impairment. Considerations: While CTA is highly effective in diagnosing PE, the need for contrast material and radiation exposure are important considerations, especially in pregnant women, individuals with renal insufficiency, or those with a known contrast allergy.

Answer 49

**nuclear medicine test used to assess the circulation of air and blood within the lungs Components of a V/Q Scan Perfusion Scanning: Involves the intravenous injection of a radiolabeled isotope (commonly technetium-99m-labeled macroaggregated albumin). The isotope travels through the bloodstream and lodges in the small capillaries in the lungs. A gamma camera captures images of the distribution of the radioisotope, reflecting blood flow (perfusion) to various parts of the lung. Areas that do not receive blood flow due to blockages (such as those caused by a pulmonary embolism) will appear as defects or "cold spots" on the scan. Ventilation Scanning: The patient inhales a radioactive gas (such as xenon or technetium-99m-labeled aerosol) which distributes throughout the lungs. The gamma camera again captures images, this time of the distribution of the inhaled gas, reflecting ventilation (airflow) in the lungs. Areas that do not receive airflow will show up as defects on the scan. Interpretation A normal V/Q scan indicates both ventilation and perfusion are uniformly distributed throughout the lungs. A mismatch, where ventilation is normal but perfusion is impaired (ventilated but not perfused), is suggestive of a pulmonary embolism. This is because the blood clot blocks blood flow, but air can still enter the lung segment. V/Q scans are typically reported as having a low, intermediate, or high probability of PE based on the pattern and extent of mismatches. Limitations and Considerations While V/Q scans are less invasive than CTA and avoid the use of iodinated contrast, their interpretation can be more complex, especially in patients with pre-existing lung diseases such as COPD, which can also cause mismatches. The specificity of the V/Q scan can be lower than that of CTA, particularly in patients with abnormal chest radiographs or underlying lung conditions. In such cases, the result might be reported as non-diagnostic or of intermediate probability, necessitating further testing.

Answer 50

Arterial Blood Gases (ABGs) Findings: In PE, arterial blood gases often show low PaO2 (hypoxemia) due to impaired gas exchange. However, the pH is often normal because respiratory compensation (increased breathing rate) helps to maintain the acid-base balance. Limitations: Hypoxemia can result from various respiratory and cardiac conditions, not just PE, making this finding non-specific. Chest X-ray Findings: May show signs such as atelectasis (collapse of part of the lung), pleural effusion (fluid in the pleural space), or elevated hemidiaphragm, but these findings are not specific to PE. In many cases of PE, the chest X-ray can be normal or nearly normal. Limitations: While helpful in ruling out other causes of the patient's symptoms, such as pneumonia or pneumothorax, a chest X-ray alone cannot diagnose PE. Electrocardiogram (ECG) Findings: ECG changes in PE can be varied and nonspecific, including tachycardia (fast heart rate), nonspecific ST-segment and T-wave changes, and, in more severe cases, signs of right heart strain such as the S1Q3T3 pattern. Limitations: These changes are not specific to PE and can be seen in many other cardiac and pulmonary conditions. Serum Troponin Levels Findings: Troponin levels may be elevated in PE, indicating right ventricular strain or myocardial injury due to the increased workload on the right side of the heart. Limitations: Elevated troponin levels can also occur in various cardiac conditions, including myocardial infarction, and are not specific to PE. B-type Natriuretic Peptide (BNP) or N-terminal pro b-type Natriuretic Peptide (NT-proBNP) Findings: These peptides can be elevated in cases of significant PE that leads to acute right heart strain or failure, as they are released by the ventricles in response to excessive stretching of heart muscle cells. Limitations: Elevated BNP or NT-proBNP levels can also be seen in other conditions that cause cardiac strain, such as heart failure, and are not specific for PE. While these tests contribute valuable information to the overall clinical assessment, they must be interpreted in the context of the patient's history, physical examination, and other diagnostic findings. The definitive diagnosis of PE typically requires imaging studies such as CT pulmonary angiography (CTA) or a ventilation-perfusion (V/Q) scan.

Answer 51

Initial Management Stabilization: In cases of massive PE with hemodynamic instability, immediate measures to stabilize the patient include oxygen supplementation to relieve hypoxemia and intravenous fluids to support blood pressure. In severe cases, advanced life support measures may be necessary. Anticoagulation Therapy Heparin: Initial anticoagulation often starts with the administration of heparin (unfractionated heparin or low molecular weight heparin) to prevent further clot formation. Heparin acts quickly and can be adjusted based on the patient's response. Oral Anticoagulants: Transition to oral anticoagulants, such as warfarin, direct oral anticoagulants (DOACs) like rivaroxaban, apixaban, or edoxaban, usually follows. The duration of anticoagulation therapy depends on the individual's risk factors for recurrence and the presence of reversible risk factors at the time of the initial event. Thrombolytic Therapy Indications: Thrombolytic (fibrinolytic) therapy is reserved for patients with high-risk (massive) PE with hemodynamic instability, as it can rapidly dissolve the thrombus and restore pulmonary circulation. However, it carries a significant risk of bleeding and is contraindicated in certain patients. Surgical and Interventional Procedures Embolectomy: In cases where thrombolytic therapy is contraindicated or has failed, or in patients who continue to deteriorate hemodynamically, surgical removal of the clot (pulmonary embolectomy) may be necessary. Catheter-Directed Therapy: Less invasive than surgery, this involves the use of catheters to deliver thrombolytic agents directly to the clot or to mechanically break up the clot. Supportive Care Compression Stockings: May be used to prevent the post-thrombotic syndrome, especially after deep vein thrombosis (DVT). Monitoring: Regular follow-up and monitoring for the recurrence of symptoms or signs of bleeding due to anticoagulation therapy. Prevention of Recurrence Risk Factor Modification: Includes addressing modifiable risk factors such as smoking cessation, weight management, and avoiding prolonged immobility.

Answer 52

Oxygen Therapy Administration: Oxygen is administered via a nasal cannula or face mask to patients experiencing hypoxemia due to impaired gas exchange from the PE. The goal is to maintain adequate oxygen saturation and relieve symptoms of hypoxia. Titration: The fraction of inspired oxygen (FiO2) is titrated based on arterial blood gas (ABG) analysis to achieve target oxygen saturation levels, usually above 90% or higher based on the patient's underlying conditions. Mechanical Ventilation: In cases of severe respiratory failure or when the patient's work of breathing is excessively high, mechanical ventilation may be necessary to ensure adequate oxygenation and ventilation. Pulmonary Hygiene Purpose: Maintaining clear airways and preventing atelectasis (collapse of part of the lung) is essential for optimizing lung function, especially in immobilized patients or those with underlying lung disease. Techniques: Include incentive spirometry, chest physiotherapy, and frequent repositioning to promote lung expansion and secretion clearance. Shock Management IV Fluids: Intravenous fluids may be administered cautiously to improve cardiac output and maintain blood pressure, particularly in hypotensive patients. However, fluid management must be carefully balanced to avoid fluid overload, which can worsen respiratory status. Vasopressors: In cases of persistent hypotension despite adequate fluid resuscitation, vasopressors such as norepinephrine may be used to support blood pressure and maintain perfusion to vital organs. Heart Failure (HF) Management Diuretics: For patients showing signs of fluid overload or heart failure, diuretics can help reduce fluid accumulation, alleviate pulmonary congestion, and improve breathing. Pain Management Opioids: Pain, particularly pleuritic chest pain, can be significant in PE and may impair the patient's ability to take deep breaths, leading to atelectasis. Opioids like morphine can relieve pain and reduce the sympathetic stress response, which can be beneficial in acute PE. However, care must be taken to avoid respiratory depression, especially in patients with compromised respiratory function.

Answer 53

Anticoagulation therapy is the cornerstone of treatment for pulmonary embolism (PE) and is typically divided into three phases: initial, longer-term, and extended. The choice of anticoagulant, the duration of therapy, and the addition of fibrinolytic agents depend on the severity of the PE, the risk of bleeding, and the patient's overall health status. Initial Phase (First 7 Days) The goal during the initial phase is to rapidly anticoagulate the patient to prevent further clot formation. Low-Molecular-Weight Heparin (LMWH): Preferred for its predictable pharmacokinetics and lower risk of heparin-induced thrombocytopenia (HIT). It is administered subcutaneously and does not usually require monitoring of the aPTT (activated partial thromboplastin time). Unfractionated IV Heparin: Used in patients with severe renal impairment (where LMWH is contraindicated) or when rapid reversibility is required, such as in anticipation of surgery. It requires continuous intravenous infusion and regular monitoring of the aPTT to ensure therapeutic anticoagulation. Longer-Term Phase (Up to 6 Weeks) After the initial stabilization, the patient may transition to oral anticoagulation or continue on LMWH. Warfarin (Coumadin): A vitamin K antagonist that requires monitoring of the INR (International Normalized Ratio) to maintain a therapeutic range. The initiation of warfarin overlaps with heparin or LMWH for at least 5 days and until the INR is therapeutic for 24 hours. Direct Oral Anticoagulants (DOACs): Alternatives to warfarin include rivaroxaban, apixaban, edoxaban, and dabigatran. These agents have the advantage of fixed dosing and do not require routine monitoring of coagulation parameters. Extended Phase (6 Months and Beyond) Extended anticoagulation may be indicated in patients with recurrent PE, ongoing risk factors for venous thromboembolism (VTE), or unprovoked PE. The decision to continue anticoagulation beyond 6 months is based on weighing the risk of recurrent VTE against the risk of bleeding. Fibrinolytic Therapy Indications: Reserved for patients with massive PE and hemodynamic instability or those with a high risk of mortality, as fibrinolytic agents can rapidly dissolve blood clots. Agents: Include tissue plasminogen activator (tPA) and alteplase (Activase). These drugs activate plasminogen to plasmin, which then degrades fibrin clots. Considerations: Fibrinolytic therapy carries a significant risk of bleeding, including intracranial hemorrhage, and is contraindicated in patients with a high risk of bleeding.

Answer 54

Pulmonary embolectomy is a surgical or interventional procedure considered for the treatment of massive pulmonary embolism (PE), especially in patients who are hemodynamically unstable and for whom thrombolytic therapy is contraindicated due to the risk of bleeding. There are two main approaches to embolectomy: surgical embolectomy and percutaneous catheter-based techniques. Surgical Pulmonary Embolectomy Indications: Typically reserved for patients with life-threatening, massive PE who are in shock or have persistent arterial hypotension, and in whom thrombolysis is contraindicated or has failed. Procedure: Involves the surgical removal of the embolus from the pulmonary artery under general anesthesia, often requiring cardiopulmonary bypass. Considerations: Given its invasive nature, surgical embolectomy is associated with significant risks and is usually considered a last resort. The decision to proceed with surgery is based on a careful assessment of the potential benefits and risks. Percutaneous Catheter Embolectomy Description: A less invasive alternative to surgical embolectomy, this procedure involves the use of catheters inserted through the veins to reach the pulmonary artery and mechanically remove or break up the clot. Techniques: May include aspiration embolectomy, rheolytic thrombectomy (using high-velocity jets of saline to break up the clot), or rotational thrombectomy devices. Advantages: The percutaneous approach generally has a lower risk compared to open surgery and can be performed more quickly, which is crucial in an emergency setting. Endovascular Ultrasound Delivered Thrombolysis Description: This is a novel technique where ultrasound waves are used in conjunction with catheter-delivered thrombolytic drugs to enhance the breakdown of the clot. The ultrasound helps to increase the penetration of the thrombolytic agent into the thrombus, potentially reducing the required dose and the risk of bleeding. Application: This technique may be used in certain centers for patients with intermediate-risk or high-risk PE, particularly when conventional thrombolysis is contraindicated or needs to be used at reduced doses. Inferior Vena Cava (IVC) Filter Purpose: An IVC filter is a device placed in the inferior vena cava to catch and prevent large clots from the lower extremities or pelvis from reaching the lungs. It is considered in patients who have contraindications to anticoagulation or in whom anticoagulation has failed to prevent recurrent PE. Considerations: The use of IVC filters is controversial due to potential long-term complications, including filter migration, fracture, and increased risk of deep vein thrombosis (DVT) at the filter site. The decision to place an IVC filter should be individualized, and in many cases, the filter is considered retrievable and may be removed once the risk of PE has diminished.

Answer 55

Elevated pulmonary artery pressure (> 20 mm Hg) due to an increase in resistance to blood flow through the pulmonary circulation  Mean pulmonary artery pressures * Normal 12 to16 mm Hg * Greater than 25 mm Hg at rest * Greater than 30 mm Hg with exercises  May be primary disease or secondary complication

Answer 56

Five Classes (World Health Organization) based on causes  Group 1: medication, specific disease, genetic link or idiopathic  Group 2: left-sided heart failure  Group 3: lungs and hypoxia  Group 4: CV system and thromboembolism  Group 5: Multifactorial: hematologic, renal or metabolic involvement

Answer 57

Pulmonary hypertension without known cause results in right HF and death if untreated  Previously known as primary pulmonary hypertension  Etiology and Pathophysiology  Uncertain; related to connective tissue disease, cirrhosis, and HIV  Insult to pulmonary endothelium results in vascular scarring, endothelial dysfunction, and smooth muscle proliferation  Affects females more than males

Answer 58

Pulmonary hypertension (PH) is a complex and serious condition characterized by high blood pressure in the arteries of the lungs, which can lead to right heart failure if untreated. The clinical manifestations of pulmonary hypertension can vary widely among individuals and typically progress as the disease advances. Classic Symptoms Dyspnea on Exertion: Shortness of breath during physical activity is one of the earliest and most common symptoms of PH, occurring due to the heart's inability to pump enough blood through the lungs at increased rates required during exertion. Fatigue: Patients often experience profound tiredness or weakness, which can be attributed to the reduced oxygen delivery to the muscles and organs. Other Symptoms Exertional Chest Pain: May occur due to the increased workload on the heart, particularly the right ventricle, as it struggles to pump blood through the narrowed pulmonary arteries. Dizziness and Syncope (Fainting): These symptoms can result from reduced blood flow to the brain, especially during physical activity when the demand for blood flow is higher. Abnormal Heart Sounds: An S3 heart sound, or "ventricular gallop," can sometimes be heard in patients with PH and is indicative of increased fluid volume and pressure inside the heart. Progression of Disease Dyspnea at Rest: As PH progresses, shortness of breath can occur even at rest, indicating a significant impairment of pulmonary blood flow and cardiac function. Right Ventricular Hypertrophy (Cor Pulmonale): Prolonged high blood pressure in the pulmonary artery places a chronic strain on the right ventricle, leading to its enlargement and thickening (hypertrophy). Heart Failure (HF): Advanced PH can lead to right-sided heart failure, characterized by symptoms such as edema (swelling) in the ankles and legs, ascites (abdominal fluid accumulation), and fatigue.

Answer 59

Diagnostics The diagnosis of pulmonary hypertension involves a combination of tests, often beginning with non-invasive methods and progressing to more definitive testing: Right-Sided Heart Catheterization: The gold standard for diagnosing PH, this procedure measures the pressure in the pulmonary arteries directly and assesses the heart's function. Electrocardiogram (ECG): Can show signs of right ventricular strain or hypertrophy. Chest X-Ray: May reveal enlarged pulmonary arteries and changes in the size and shape of the right ventricle. Pulmonary Function Tests (PFTs): Useful for evaluating lung function and ruling out other respiratory conditions. Echocardiogram: Non-invasive ultrasound imaging that can estimate pulmonary artery pressures and assess right ventricular function. CT Scan: Can provide detailed images of the lungs and pulmonary vasculature, helping to identify underlying causes of PH such as chronic pulmonary emboli. Time to Diagnosis The average time from symptom onset to diagnosis is approximately 2 years, often because the early symptoms of PH are nonspecific and can be attributed to other, more common conditions. By the time of diagnosis, the disease may be quite advanced, underscoring the importance of early recognition and intervention in symptomatic individuals.

Answer 60

Early recognition—stop progression  Report: unexplained shortness of breath, syncope, chest discomfort, edema of feet and ankles  Drug therapy  Pulmonary vasodilation, reduce right ventricular overload, and reverse remodeling  Manage edema  Prevent thrombi  Prevent hypoxia  Goal – keep O2 saturation 90% or greater

Answer 61

Surgical interventions for pulmonary embolism (PE) and its complications, particularly pulmonary hypertension (PH), are considered when medical therapy is insufficient or when the condition is life-threatening. These interventions can range from procedures aimed at removing the obstruction in pulmonary arteries to palliative surgeries that alleviate symptoms and improve the quality of life. Pulmonary Thromboendarterectomy (PTE) Description: PTE, also known as pulmonary endarterectomy (PEA), is a complex surgical procedure designed to remove chronic thromboembolic material from the pulmonary arteries. This procedure is indicated for patients with chronic thromboembolic pulmonary hypertension (CTEPH), a form of PH that results from the organization and fibrosis of unresolved pulmonary emboli. Outcome: PTE can be curative for patients with CTEPH, often resulting in significant improvements in symptoms, pulmonary hemodynamics, and exercise capacity. It is the treatment of choice for suitable candidates with this condition. Atrial Septostomy (AS) Description: AS is a palliative procedure performed to create a right-to-left shunt at the atrial level. By creating a small opening between the right and left atria, this procedure reduces right atrial pressure, decreases right ventricular afterload, and improves left ventricular preload. Indications: AS is considered for patients with severe PH and right heart failure who are refractory to medical therapy and not candidates for PTE or lung transplantation. It can improve symptoms and exercise tolerance but is associated with significant risks. Lung Transplant Description: Lung transplantation involves replacing one or both diseased lungs with healthy lungs from a donor. It is a treatment option for advanced lung disease, including end-stage PH when other treatments have failed. Outcome: Lung transplantation can significantly improve the quality of life and survival in selected patients. Recurrence of the original disease in the transplanted lungs is rare, but the procedure carries risks such as rejection and infection. No cure  Treatment can relieve symptoms, improve quality of life, prolong life * Untreated, death can occur within a few years

Answer 62

Chronic increase in pulmonary artery pressures from another disease  Parenchymal lung disease, LV dysfunction, intracardiac shunts, chronic PE, or systemic connective tissue disease  Symptoms: dyspnea, fatigue, lethargy, chest pain; RV hypertrophy and right-sided heart failure  Diagnosis—similar to IPAH  Treatment—treat underlying cause; if irreversible— IPAH therapies

Answer 63

Enlarged right ventricle secondary to disorder of respiratory system; COPD  Pulmonary hypertension preexists; HF **Clinical manifestations  Subtle and often masked by lung symptoms  Exertional dyspnea, tachypnea, cough, fatigue, RV hypertrophy (ECG), increased intensity in S2 heart sound, polycythemia  HF: peripheral edema, weight gain, distended neck veins, full, bounding pulse, enlarged liver

Answer 64

Early identification before irreversible heart changes  Determine and treat underlying cause  Long-term oxygen  Other individualized therapies

Answer 65

Environmental or occupational inhalation of dust or chemicals  Lung damage depends on * Toxicity of inhaled substance * Amount and duration of exposure * Susceptibility of individual **Environmentally induced lung diseases includes  Pneumoconiosis  Chemical pneumonitis  Hypersensitivity pneumonitis

Answer 66

Pneumoconiosis—inhaled mineral or metal dust particles  Classified by origin * Silicosis—sand or rock * Coal worker’s pneumoconiosis—“black lung” results in pulmonary fibrosis * Asbestosis results in mesothelioma; cancer occurs 15 to 19 years from exposure

Answer 67

Inhalation of toxic chemical fumes * Acute—diffuse lung injury; pulmonary edema * Chronic—bronchiolitis obliterans

Answer 68

Extrinsic allergic alveolitis—inhaled allergic antigens * Bird fancier’s lung (feathers and bird droppings) * Farmer’s lung (hay dust) * Acute, subacute, chronic forms

Answer 69

Clinical manifestations (10 to 15 years)  Dyspnea, cough, wheezing, weight loss  Pulmonary function tests: reduced vital capacity  Chest x-ray, CT scans—lung involvement  Cor pulmonale—right heart failure due to diffuse fibrosis  Complication: COPD  Other: acute pulmonary edema, lung cancer, mesothelioma, TB  Late: cor pulmonale Environmental Lung Diseases

Answer 70

Lung transplantation is a viable treatment option for patients with end-stage lung disease when other treatments have failed to provide relief. It involves replacing one or both diseased lungs with healthy lungs from a deceased donor. Diseases that may lead to consideration for a lung transplant include: Chronic Obstructive Pulmonary Disease (COPD): Advanced stage of the disease where medical therapy does not significantly improve symptoms or quality of life. Idiopathic Pulmonary Fibrosis (IPF): A progressive and usually fatal lung disease with no known cause or cure. Cystic Fibrosis (CF): A genetic disorder that damages the lungs and can lead to severe respiratory problems. Idiopathic Pulmonary Arterial Hypertension (IPAH): A rare and progressive condition that increases the pressure in the pulmonary arteries. Alpha-1 Antitrypsin Deficiency: A genetic condition that can cause liver and lung disease, leading to emphysema. Preoperative Care and Evaluation Before a lung transplant, a comprehensive evaluation is conducted to assess the patient's overall health, the severity of lung disease, and suitability for transplantation. This evaluation includes: Medical Assessment: Detailed review of the patient's lung disease history, current lung function, and overall physical health. Psychosocial Evaluation: Assesses the patient's mental health, social support system, and ability to adhere to a complex postoperative care regimen. Contraindications: Certain conditions can preclude a patient from being a transplant candidate, including active infections, certain cancers, severe heart, liver, or kidney diseases, and ongoing substance abuse. United Network for Organ Sharing (UNOS) and Lung Allocation Score (LAS) In the United States, the allocation of donor lungs is managed by the United Network for Organ Sharing (UNOS), which uses a Lung Allocation Score (LAS) to prioritize patients based on the severity of their disease and their projected survival without a transplant versus their expected survival post-transplant. The LAS is a numerical score that ranges from 0 to 100, with higher scores indicating a higher priority for transplant. Postoperative Regimen After a lung transplant, patients must adhere to a strict postoperative regimen that includes: Immunosuppressive Medication: To prevent organ rejection, patients must take lifelong immunosuppressive drugs, which can have significant side effects and increase the risk of infections. Regular Monitoring: Includes frequent check-ups, lung function tests, and monitoring for signs of rejection or infection. Rehabilitation: Pulmonary rehabilitation is crucial for improving lung function, strength, and overall well-being after transplantation.

Answer 71

Surgical procedures  Four types * Single-lung; thoracotomy incision on affected side while opposite lung is ventilated * Bilateral lungs; incision across sternum; donor lungs implanted separately * Heart-lung; median sternotomy incision * Lobes from living-related donor; reserved for those unlikely to survive waiting for a donor to become available; most have cystic fibrosis

Answer 72

Postoperative Care: ICU  Ventilator and hemodynamic support  IV fluids  Immunosuppression * Tacrolimus, mycophenolate mofentil, and prednisone  Nutrition  High risk for multiple complications  Infections are leading cause of death, especially in 1st year

Answer 73

Rejection  Acute: 5 to 10 days * Fairly common in 1st year after transplant * Fever, fatigue, dyspnea, dry cough, O2 desaturation  Chronic: Bronchiolitis obliterans (BOS) * Progressive airflow obstruction unresponsive to bronchodilators and corticosteroids  Prevent/treat complications—infection  Discharge planning/Coordination of care * Self-care, medication management, contacting transplant team, pulmonary hygiene, rehabilitation

Answer 74

Leading cause of cancer-related deaths (25%) in U.S.; more than breast, prostate, colon combined  Estimated 235,000 new cases in 2021; 131,000 deaths expected  High mortality rate; low cure rate  Advances in treatment improving response  Gender considerations  Promoting health equity

Answer 75

Smoking is 80-90% of them Risk related to total exposure to tobacco smoke  Total number of cigarettes smoked  Age of smoking onset  Depth of inhalation  Tar and nicotine content  Use of unfiltered cigarettes Sidestream (secondhand) smoke is also a health risk Other causes of lung cancer include exposure to:  Pollution  Radiation /radon  Asbestos  Industrial agents (radon, coal dust, asbestos, chromium, silica, arsenic, diesel exhaust) increase risk, especially in smokers * Incidence, risk factors, survival vary between genders * Incidence and survivability vary between racial and ethnic populations

Answer 76

Arise from mutated epithelial cells  Tumor development promoted by epidermal growth factor  It takes 8 to 10 years for a tumor to reach 1 cm  Smallest lesion detectable on x-ray  Occur primarily in segmental bronchi and upper lobes Primary lung cancers categorized into 2 subtypes  Non–small-cell lung cancer (NSCLC); 84%  Small-cell lung cancer (SCLC); 13%  Metastasis—direct extension and blood and lymph system  Common sites: lymph nodes, liver, brain, bones, adrenal glands  SCLC and NSCLC account for 97% of lung tumors; other 3% include hamartomas, mucous gland adenoma, mesotheliomas

Answer 77

Squamous cell carcinoma  Slow growing  Early symptoms: cough and hemoptysis Adenocarcinoma  Moderate growing  Most common in nonsmokers Large-cell carcinoma  Rapid growing  Highly metastatic

Answer 78

Very rapid growth  Most malignant  Early metastasis  Associated endocrine disorders  Chemotherapy and radiation  Poor prognosis

Answer 79

Caused by hormones, cytokines, enzymes, or antibodies that destroy healthy cells  May manifest before cancer diagnosed  Associated most with SCLC  Examples: hypercalcemia, SIADH, adrenal hypersecretion, polycythemia, Cushing’s syndrome

Answer 80

Symptoms nonspecific and appear late in disease  May be masked by chronic cough  Depend on type of primary lung cancer, location, and metastatic spread  Often presents as a lobar pneumonia that does not respond to treatment Persistent cough with sputum (most common)  Hemoptysis (Hemoptysis is the medical term for coughing up blood from the lower respiratory tract (bronchi and lungs)  Dyspnea  Wheezing  Chest pain  Localized or unilateral; mild to severe Later manifestations  Anorexia, nausea/vomiting, fatigue, weight loss  Hoarseness  Unilateral paralysis of diaphragm  Dysphagia  Superior vena cava obstruction  Palpable lymph nodes  Mediastinal/cardiac involvement

Answer 81

Chest x-ray (normal, mass or infiltrate, metastasis, pleural effusion)  CT scan (location and extent of mass, mediastinal involvement, lymph node enlargement)  Sputum cytology (rarely used)  Lung biopsy—definitive diagnosis  Pleural fluid analysis  Metastasis  Bone and CT scans—brain, abdomen, and pelvis H & P  CBC with differential  Chemistry panel  Liver, renal, and pulmonary function tests  MRI  PET scan

Answer 82

Lung cancer staging is crucial for determining the extent of the disease, guiding treatment decisions, and assessing prognosis. Non-small cell lung cancer (NSCLC), which accounts for the majority of lung cancer cases, is staged using the TNM system, developed by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). This system takes into account three key components: the size and extent of the primary tumor (T), whether the cancer has spread to nearby lymph nodes (N), and the presence of distant metastasis (M). TNM System T (Tumor): Describes the size of the original tumor and whether it has grown into nearby areas. T is classified from TX (primary tumor cannot be assessed) to T4, based on the size of the tumor and the extent of invasion into surrounding structures. N (Node): Indicates whether the cancer has spread to nearby lymph nodes and how many. N is classified from NX (regional lymph nodes cannot be assessed) to N3, based on the location and number of lymph nodes involved. M (Metastasis): Describes whether the cancer has spread to other parts of the body. M0 means that no distant metastasis is found, while M1 indicates the presence of metastasis. Staging Groups Based on the TNM classifications, NSCLC is grouped into stages I through IV, which may have A or B subtypes to further define the extent of the disease: Stage I: The cancer is confined to the lungs and has not spread to any lymph nodes. This stage is further divided into IA and IB based on the size of the tumor. Stage II: The cancer has spread to nearby lymph nodes or has grown into surrounding structures. This stage is divided into IIA and IIB. Stage III: More extensive lymph node involvement or larger tumor size. Stage III is subdivided into IIIA (limited to one side of the chest and may still be considered for surgery) and IIIB (more extensive disease, generally not considered operable). Stage IV: The most advanced stage, indicating that cancer has spread beyond the lung to other parts of the body. This stage is often associated with a poor prognosis. Treatment Implications Stages I, II, and IIIA: Patients with NSCLC in these stages may be candidates for surgical resection, possibly combined with chemotherapy, radiation therapy, or targeted therapy, depending on specific tumor characteristics and patient health. Stage IIIB and IV: These stages are usually considered inoperable due to extensive local spread or distant metastasis. Treatment typically focuses on systemic therapies such as chemotherapy, targeted therapy, immunotherapy, and palliative care measures to relieve symptoms and improve quality of life.

Answer 83

Small Cell Lung Cancer (SCLC) is an aggressive form of lung cancer characterized by rapid growth and early spread to distant sites. Due to its aggressive nature, the traditional TNM staging system (which considers Tumor size, lymph Node involvement, and Metastasis) used for non-small cell lung cancer (NSCLC) is not typically applied to SCLC. Instead, SCLC is classified into two main stages for the purpose of treatment planning and prognosis: Limited Stage Definition: Limited-stage SCLC is defined as cancer that is confined to one side of the chest and can be reasonably encompassed within a single radiation therapy field. This includes the primary tumor and regional lymph nodes. Treatment: Patients with limited-stage disease may be candidates for more aggressive treatments aimed at cure, which can include combinations of chemotherapy, radiation therapy, and in some cases, surgery. Despite the aggressive nature of SCLC, treatment at the limited stage can lead to significant responses, although the risk of recurrence remains high. Extensive Stage Definition: Extensive-stage SCLC refers to cancer that has spread beyond the limits of a single radiation field, including cancer that has spread to the other lung, distant lymph nodes, or other organs (metastasis). Treatment: For extensive-stage SCLC, the treatment primarily involves systemic therapies such as chemotherapy and immunotherapy. The focus is usually on controlling the disease, alleviating symptoms, and improving quality of life, as the prospects for cure are significantly lower compared to limited-stage disease. Prevalence at Diagnosis At the time of diagnosis, most patients with SCLC have extensive disease due to the cancer's rapid growth and tendency to metastasize early in its course. This extensive spread at diagnosis is a major factor in the overall prognosis and treatment strategy for SCLC patients.

Answer 84

Annually in adults ages 50 to 80 with a history of smoking  20 pack-year history  Current smoker  Quit less than15 years ago  Completed with low dose CT

Answer 85

For early-stage Non-Small Cell Lung Cancer (NSCLC) (Stages I to IIIA) without mediastinal lymph node involvement, surgical resection offers the best chance for a cure. The choice of surgical procedure depends on various factors, including the size and location of the tumor, the patient's lung function, and overall health status. Surgical Procedures for NSCLC Segmental or Wedge Resection: These are limited resection procedures where only a small, localized part of the lung is removed. Segmental Resection: Involves removing a larger portion of the lung tissue, including one or more segments (subdivisions of the lung lobes). Wedge Resection: The removal of a small, wedge-shaped portion of lung tissue that contains the tumor along with a margin of healthy tissue. These procedures are typically considered for smaller tumors or for patients whose lung function may not tolerate more extensive surgery. Lobectomy: The removal of an entire lobe of the lung. Since the lungs are divided into lobes (three on the right and two on the left), a lobectomy can remove a significant portion of lung tissue while leaving the rest intact. Lobectomy is generally the preferred surgical procedure for NSCLC when feasible because it offers a balance between removing all of the cancerous tissue and preserving lung function. Pneumonectomy: Involves the removal of an entire lung and is usually reserved for tumors that are centrally located or involve the main bronchus where less extensive surgery is not possible. Given the significant reduction in pulmonary function, pneumonectomy is considered only when absolutely necessary and after careful evaluation of the patient's ability to tolerate the loss of an entire lung. Video-Assisted Thoracoscopic Surgery (VATS): A minimally invasive surgical technique where the surgery is performed using small incisions and guided by a thoracoscope (a small camera) inserted into the chest. VATS can be used for lobectomies and smaller resections and is associated with less pain and a shorter recovery period compared to traditional open surgery. VATS is particularly useful for tumors located near the outer edges of the lungs. Considerations for Surgery Assessment of Cardiopulmonary Reserve: Prior to surgery, a thorough assessment of the patient's cardiopulmonary function is essential to ensure they can tolerate the loss of lung tissue. Tests may include pulmonary function tests, echocardiography, and sometimes cardiopulmonary exercise testing. Comorbidities: The presence of other medical conditions can impact the choice of surgical procedure and the overall prognosis. Conditions that affect the heart, lungs, or other major organs are particularly important to consider. Adjuvant Therapy: Depending on the specific stage and histopathological findings, adjuvant chemotherapy or radiation therapy may be recommended after surgery to reduce the risk of recurrence.

Answer 86

NSCLC and SCLC  Used as curative, palliative, or adjuvant therapy  Combined with surgery, chemo, targeted therapy  Primary therapy for those who are not surgical candidates due to co-morbidities  Relief of symptoms: dyspnea, hemoptysis, SVC syndrome, and pain  Preoperative to reduce tumor mass  Monitor for complications

Answer 87

Stereotactic radiosurgery (SRS)  High dose of radiation accurately delivered to tumor (outside CNS)  Smaller part of healthy lung exposed  Damages tumor DNA  Therapy is given over 1 to 3 days  Option for nonsurgical, early stage lung cancer

Answer 88

Primary treatment for SCLC  Treatment of nonresectable tumors or adjuvant to surgery in NSCLC  Variety of drugs and protocols  Typically combination of 2 or more drugs  etoposide, carboplatin, cisplatin, paclitaxel, vinorelbine, docetaxel, gemcitabine, and pemetrexed (Alimta)

Answer 89

Block tumor growth; less toxic than chemotherapy  Tyrosine kinase inhibitors—block signals for growth in cancer cells  cetuximab (Erbitux), erlotinib (Tarceva), afatinib (Gilotrif), gefitinib (Iressa), osimertinib (Tagrisso), necitumumab (Portrazza)  Kinase inhibitor—inhibits kinase protein responsible for cancer development and growth  Angiogenesis inhibitor—inhibits growth of new blood vessels

Answer 90

Targets PD-1, a protein on T cells that normally helps keep these cells from attacking other cells in the body  Nivolumab (Opdivo), atezolizumab (Tecentriq), pembrolizumab (Keytruda)  Boosts immune response against cancer cells  Shrink tumor cells or slow growth  Can be used in people with squamous cell NSCLC whose cancer progressed after other treatments