Module 4 - Complex Resp. Flashcards
stimulated neural receptor along the respiratory tree → cough center in the medulla → complex reflex arc efferent pathway to the expiratory musculature
Acute (lasting <3 weeks), subacute (lasting 3 to 8 weeks), and chronic (persisting beyond 8 weeks).
Chronic Cough
Three most common causes of chronic cough with NORMAL chest radiography, no smoking, or an ACE include
corticosteroid-responsive eosinophilic airway diseases (asthma, cough variant asthma, and eosinophilic bronchitis)
upper airway cough syndrome (postnasal drip syndrome)
GERD
A cough associated with constant throat clearing and thick mucus production, especially on rising from bed
Upper airway cough and sinusitis
A cough that lasts for 3 consecutive months for more than 2 consecutive years
chronic bronchitis
A sudden onset of cough in the supine position with an associated sour taste in the mouth
GERD
A cough associated with rhinorrhea or sneezing
Viral or common cold-
Intermittent productive cough associated with wheezing
Asthma
loud hacking cough during the daytime that is nonproductive, leads to exhaustion, and is associated with emotional stress
Psychogenic cough-
Sputum Yellow-green, purulent:
bronchitis
Sputum Pink frothy
pulmonary edema
Sputum Fetid purulent
anaerobic infections
Sputum Rust colored
pneumococcal pneumonia
Chronic inflammation causes structural changes and a narrowing of the small airways and destruction of the lung parenchyma that leads to the loss of alveolar attachments to the small airways and decreases lung elastic recoil.
Cigarette smoke and an occupation that involves regular exposure to a dusty environment are the two major external factors.
COPD
The physical examination findings in early disease are often normal. (SOB, chronic cough, sputum)
Late- clubbing of fingernails, increase AP diameter (barrel chest), increase intercostal space, pursed lip breathing, tripod position, decrease expiratory, increased resonance on chest percussion
Diminished transmission of breath sounds on auscultation is the most reliable finding
COPD
Gold standard dx tool for COPD
Spirometry
A forced expiratory time of 6 seconds or more suggests obstructive pulmonary disease
Treatment for COPD
Smoking cessation***
_____ assessment: grades each question 0-5; all added up at the end for score
Cough; phlegm/mucus; chest tightness; out of breath when walking up a hill/stairs; limited in activities at home; confidence in leaving house despite lung condition; sleep; energy
CAT Assessment for COPD
None (0): No dyspnea except with strenuous activity
Slight (1): SOB when hurrying on the level or walking up a slight hill
Moderate (2): Breathlessness causes slower on-the-level walking than ppl of same age
Severe (3): stops fro breath after walking about 100m or after a few min on same level
Very Severe (4): too breathless to leave house; breathless when dressing/undressing
MRC dyspnea scale: grade 0-4
COPD
First line for intermittent symptoms of COPD
short acting B2 adrenergic agonist (bronchodilator)
first line of maintenance therapy for patients with daily COPD symptoms.
anticholinergics
Treating COPD pts with inhaled corticosteroids
FEV1 rechecked after 3 to 4 months of therapy
Use with LABA - reduces exacerbations for s/s COPD patients, FEV < 60, and repeated exacerbations
COmbination therapy for COPD
#1 anticholinergic and a short-acting β 2 agonist long-acting β 2 agonist and long-acting anticholinergic, and long-acting β 2 agonist and inhaled glucosteroid
When should COPD pt get oxygen therapy
SPO2 < 88%
Prescribe O2 to keep SaO2 at or above 90% → recheck in 60-90 days to see if pt still requiring supplemental O2
What could it be ? …
Chest tightness and constriction
asthma or COPD , foreign body, bronchitis
What could it be ? …
Excessive work or effort
pleural effusion, severe kyphoscoliosis, myasthenia gravis, guillain barre syndrome cystic fibrosis
What could it be ? …
Air hunger
PE, pneumonia, CHF, altitude, cystic fibrosis, metabolic acidosis, hypoxia or hypercapnea, severe anemia or carbon monoxide poisoning.
SUDDEN onset of dyspnea…
heralds serious cardiopulmonary disease (PE, pneumothorax, MI)
Dx cause of dyspnea
PA/ Lateral chest (CHF, COPD, pneumonia)
Pulm/ thromboembolic related= D dimer, V/Q scan, or pulmonary angiography (definitive)
Lower extremities- doppler of lower extremities
Cardiac related = HF exacerbation- BNP or NTproBNP
EKG
Expectoration of blood from the lunch parenchyma or tracheobronchial tree ( small amounts to blood streaked sputum)
Most common causes: acute and chronic bronchitis, lung cancer, pneumonia, tuberculosis (highest in developing countries)
Hemoptysis
What would be an urgent eval with Hemoptysis?
Indications for referral or hospitalization
Abnormal gas exchange, hemodynamic instability, massive hemoptysis ( > 200 mL/ 48 hr or > 50 ml per episode)
Resp comorbidities. Heart disease, a fib, heart valves etc.
Dx Hemoptysis with chest x ray… what to look for?
( to help localize bleeding and identify the cause)
Crescent sign = air-fluid level of lung abscess (mycetoma)
Nodule that suggests neoplasm
Evidence of volume loss
consolidation/ obstruction
Dx Hemoptysis with chest CT… when/ what/ to look for?
Initial eval For pts at high risk of malignancy who have suspicious findings on X Ray.
Consider for pts ( > 40, smoking hx of at least 30 packs-year) who demonstrate negative or non localized findings
single most important and modifiable risk factor for lung cancer
tobacco use
USPSTF 2021 Recommends Lung Cancer Screening for
Adults aged 50-80 years old, with a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.
Discontinue: Once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
Screen with low DOSE CT SCAN annually
s/ s of pneumothorax
S/S: steady ache/tightness in chest, SOB, dyspnea, tachycardia
Sx and tx of pneumothorax
Chest X-ray
Tx: quick evaluation! from PCP → ER
Watch/wait not acceptable in primary care
Patient presentation: SOB, dyspnea on exertion, chest pain, cough, fatigue of unknown origin
P.E.
Validated in primary care and results in lowest risk of missed PE if imaging was withheld
Wells Criteria
If you think your pt has a PE →
ED for eval and management
D dimer + CTA (no CTA for renal failure pt; ventilation perfusion (VQ) scan is best)
Complex multisystem dx that causes high BP in the arteries of the lungs
PH defined as an increase in mean pulmonary arterial pressure (mPAP) >25mm Hg at rest as assessed by right heart catheterization
Pulm HTN
WHO classification groupings for Pulm HTN
Group I (pulmonary arterial hypertension) Causes: idiopathic, familial, HIV, drugs/toxins
Group II (left heart dx) Causes: CAD, HBP, heart valve dx, age
Group III (Lung diseases and/or hypoxemia) Causes: COPD, ILD, low O2 levels
Group IV (Chronic thrombotic and/or embolic dx) Causes: organizing blood clots
Group V (misc) Causes: sarcoidosis, sickle cell anemia, metabolic disorders
early s/s of pulm HTN
Early s/s:
Exertion induced sx; SOB, weakness, angina, syncope
Less common: dry cough, exercise induced n/v
Sx at rest not typical in early PH
mod- severe s/s of pulm HTN
Holosystolic murmur that increases with inspiration, diastolic murmur
Pulsatile liver
Distention of jugular veins
Hepatomegaly
peripheral edema*
Ascites*
Low BP, diminished pulse pressure, cool extremities, reduced cardiac output, peripheral vasoconstriction*
If present with any of these symptoms: PROMPT referral to specialty care
PCP Management of pulm HTN?
After specialist consult and recommendations, PCP should
Offer routine f/u care: 3-6 mos depending on severity and compliance
Address adherence to diet, exercise, appropriate vaccinations, avoidance of pregnancy
Regular testing done by specialty team
Med rec
Systemic dx of unknown cause characterized by presence of noncaseating (no necrotic changes, non-infectious origin) granulomas
Lungs and intrathoracic LN → most common sites
Other sites: skin, eyes, liver, spleen, ENT, neuro, bone marrow, kidney, bone/joint, heart, parotid-salivary gland
Sarcoidosis
Women, 20-50, black, scandinavian, japanese, 1st degree relative with disease
CM
Nonspecific sx: SOB, unexplained cough, fever
Specific sx: bilateral hilar lymphadenopathy, erythema nodosum, polyarthritis, uveitis, Lofgren syndrome, Heerfordt syndrome, Lupus pernio
Referral to pulmonary specialist
Sarcoidosis
How to dx Sarcoidosis
3 criteria needed:
1: compatible clinical and radiological presentation
PCP: CXR for identification, CT scan for staging, diff dx, interstitial changes; specialist: will run further and dx-specific testing
2: pathologic evidence of noncaseating granulomas
3: exclusion of other diseases with similar findings (ex: infections, malignancy)
How to tx Sarcoidosis
Tx not indicated for pt with asymptomatic stage ½ dx; spontaneous resolution common
First line therapy: corticosteroids (10-15 mg/day)
2nd line: methotrexate, azathioprine (Imuran), Leflunomide (Arava), Biologic agents, corticotropin
For refractory or complex cases
(managed by pulm)
sudden onset of REM related muscle atonia precipitated by emotion during wakefulness
Cataplexy
How to Dx Narcolepsy?
Overnight PSG - to exclude underlying causes… if nothing shows up then
Perform MSLT- multiple sleep latency test -
how to tx narcolepsy?
Stimulat meds- dextroamphetamine and methylphenidate
Modafinil = wakefulness promoting agents (not amphetamine based = less risk of habit forming, longer acting = increased insomnia risk)
Cataplexy tx with REM suppressing meds = SSRIs, SNRIs, y-hydroxybutyrate
10% of cases, brain doesn’t signal body to breathe); obstructive (airway collapses) → can co-occur
Central sleep Apnea
STOPBANG acronym for sleep apnea
Snore loudly, tired during day, observed apnea, pressure (treated for HTN), BMI >35, Age >50, Neck >16” female; 17” male, gender (male)
Used for anesthesia for grading difficult airway for intubation; can be used for SA as well
Normal → grade 4 (when sticking out tongue, can’t see soft palate or uvula)
Mallampati score
Sleep Apnea Clinical Score (SACS)
Snoring (3 pts) Apnea (3 pts) Circumference (neck in cm) Systemic HTN (4 pts) Low risk <43; mod 43-48; high >48
no interference between x-ray particles and the casetter; black (air and fat); hypodensity
Radiolucent
interference- blocks radiation; white (bone, metal, calcium in tumors/deposits)
Radiopaque
shades of gray (organs, soft tissues, muscles)
Density of tissues
pt chest up against cassette; pt is backward
PA view
pt facing forward, cassette in back
AP view
Method for reading CXR
AABCDF Method
- Adequacy
- Airways
- Bones
- Circulation
- Diaphragm
- Final Look
step 1: Adequacy
Pt identifiers, who read it, marker from tech (L, R), costophrenic angles visible, apices (top) of lungs visible, dark area above clavicle, full inspiration (defined as 9 or more ribs above diaphragm)
Step 2 airways
Is the trachea midline (sometimes slightly shifted with enlarged thyroid), bronchi, look side to side and top to bottom and compare
Left lung: 2 lobes; upper, lower (middle area called the lingula, butts up against border of the heart)
Step 3 Bones
Sternum, ribs, scapula; as well as spinal process and clavicles
Step 4: Circulation (heart and vessels)
Measure cardiac ratio (can ONLY do in PA film)
Take widest heart dimension compared to widest lung dimension; should be half the size or less of lung
Mediastinal borders
Aortic knob
LV (make sure you can see it + size)
RA
Step 5 Diaphragm
Shape (domed, shaped like 2 hills), height (R 1-3cm higher → normal because liver is below), costophrenic angles
Step 6 Final Look
Corners of the film, tracheal deviation, retrocardiac lung (lateral view), “below” the diaphragm if visible, peri-hilar regions
more comprehensive than spirometry! (done in pulmonary office)
Looks at lung vol, gas exchange, diffusion capacities and more
PFT
Simplest PFT test, looks at vol of inspiration and expiration at 1 and 6 seconds; done in the office
Must withhold inhalers night before for test to be effective
Spirometry
obstructive lung diseases
reduction in airflow- some air remains in lung after full expiration
COPD
ASTHMA
CHF
restrictive lung diseases
reduction in lung volume - difficulty taking air inside the lung
- interstitial lung disease, scoliosis, neuromuscular cause
If FVC/FEV1 both low, but ratio normal
restrictive lung diseases
low FEV1: FVC ratio
obstructive lung diseases
air exhaled in 1 second; norm 80-100
FEV1: VC ratio
method If testing for obstructive lung pattern with spirometry
Albuterol 2-4 puffs, wait 15 min → repeat test
If measures >12% or 200mL → reversible obstructive pattern (asthma)
If no reversal
If don’t fit pattern for COPD; refer to pulmonology for PFTs, bronchoprovocation testing
