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Pulmonology > Other diseases > Flashcards

Other diseases Flashcards

1
Q

obstructive sleep apnea

A

-hypopnea syndrome
-very common but not dx
-Recurrent episodes of partial or complete airway obstruction during sleep
-Caused by Repetitive collapse of the pharynx on inspiration
-Necessitates recurrent awakenings or arousals to re-establish airway patency

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2
Q

sleep apnea epidemiology

A

-20% if defined as an apnea hypopnea (partial) index (AHI) greater than five events per hour
-2-9 % if defined as an AHI > 5 events per hour accompanied by at least 1 symptom known to respond to tx
-more common to be asymptomatic
-desaturate at night

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3
Q

sleep apnea risk factors

A

-Older age
-Obesity***
-ETOH or sedative drugs- also less arousals
-Nasal obstruction
-Smoking
-Craniofacial and upper airway soft tissue abnormalities

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4
Q

hypopnea vs apnea

A

-HYPOPNEA- REDUCTION in airflow
-10-second event during which breathing continues BUT
Ventilation during sleep is REDUCED at least 50% from baseline
-drive to breathe is always there

-APNEA- complete CESSATION of airflow
-Total cessation of airflow for at least 10s
-ventilation is gone
-Can be Obstructive or central:
-1. Obstructive apnea: cessation of airflow but with continued respiratory effort
-2. Central apnea: airflow and respiratory effort are both absent

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5
Q

sleep apnea: pathophysiology

A

-Narrowing of the upper airway during sleep
-Upper airway size in (Obstructive sleep apnea/hypopnea syndrome) OSAHS pts is smaller than normal subjects:
-Due to fat deposition and facial bone structures
-Genetics

-Airway occlusion is LIMITED TO INSPIRATION:
-Exerts negative pharyngeal pressure and reduces the tone of the genioglossus muscle (dont need to know muscle)
-INSPIRATORY DS

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6
Q

comorbidities of sleep apnea

A

-obesity hypoventilation syndrome
-marfan and ehlers-danols
-can cause pulmonary htn, cor pulmone
-hyptension

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7
Q

sleep apnea: signs and symptoms

A

-Sleepiness and daytime somnolence-most common
-Poor concentration
-Fatigue
-Unrefreshing sleep
-Nocturnal choking
-Nocturia
-Depression and decreased libido
-Bed partners report: snoring, apneas, restless sleep, or irritability
-Macroglossia, enlarged tonsils, nasal obstruction
-Hypertension common
-Lower limb edema

-Narrow or “crowded” oropharynx (Mallampati 3 or 4; macroglossia, tonsillar enlargement, narrow palate)
-Obesity
-Large neck circumference ( >17 inch [males]; >16 inch [females])*
-Craniofacial abnormalities -> retrognathia (mandible that is posterior to and behind where it should be from lateral view)

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8
Q

cardinal symptoms of sleep apnea

A

S noring, S leepiness, and S ignificant-other report of sleep apnea episodes
-she didnt say this

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9
Q

nocturia

A

-false sense of fluid overload
-hypoxic
-wake up and have to pee
-Oxygen decreases, carbon dioxide increases, the blood becomes more acidic, the heart rate drops and blood vessels in the lung constrict. The body is alerted that something is very wrong. The sleeper must wake enough to reopen the airway. By this time, the heart is racing and experiences a false signal of fluid overload. The heart excretes a hormone-like protein that tells the body to get rid of sodium and water, resulting in nocturia.“

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10
Q

epworth sleepiness scale

A

-0 = Would never doze
-1 = Slight chance of dozing
-2 = Moderate chance of dozing
-3 = High chance of dozing
-during the day:
-Sitting and reading
-Watching television
-Sitting inactive in a public place (theater, meeting)
-Lying down to rest in the afternoon when circumstances allow
-Sitting and talking to someone
-Sitting quietly after lunch without alcohol
-In a car, while stopped for a few minutes in traffic

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11
Q

spleen apnea: tongue stages

A

-cant see tonsils

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12
Q

sleep apnea: labs

A

-this is really for severe disease
-Secondary polycythemia
-Proteinuria
-Hypothyroidism
-Some may have hypercapnea, lowP02
-Nocturnal cardiac arrhythmia
-Sinus bradycardia, sinus arrest or AV block
-SVT, A fib and VT may occur once airflow is re-established

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13
Q

sleep apnea diff dx

A

-Primary snoring
-Chronic hypoventilation syndrome
-Central sleep apnea- Cheyne-Stokes respiration
-GERD
-Asthma/COPD
-Narcolepsy
-Sz d/o
-Depression

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14
Q

sleep apnea dx: polysomnography

A

-Gold Standard
-sleep study
-Night-to-night variability can occur in mild cases
-Misdiagnosis
-Negative first-night test is insufficient to rule out OSAHS in patients in whom there is a high clinical suspicion
-HOME- nasal cannula, pulse ox, HR, band around chest -> more covered
-sleep center- more testing -> ekg, leg twitch

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15
Q

dx: apnea hypopnea index (AHI)

A

-15 per hour in ASYMPTOMATIC pt
-More than 5 per hour in a pt with symptoms or certain comorbidities
-SYMPTOMS (one or more)
-Excessive daytime sleepiness
-Choking or gasping from sleep
-Recurrent awakenings from sleep
-Feeling unrefreshed after sleep
-Daytime fatigue
-Poor concentration

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16
Q

sleep apnea severity

A

-Mild OSA: between 5 and 14 respiratory events per hour of sleep
-Moderate tOSA: between 15 and 30 respiratory events per hour of sleep
-Severe OSA: > 30 respiratory events per hour of sleep
-dont need to stage on the test

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17
Q

sleep apnea tx

A

-No Etoh or hypnotics
-Wt loss- cure to sleep apnea sometimes
-Nasal continuous positive airway pressure (CPAP)- real tx but noncompliance
-Oral appliances- reposition mandible (not used)
-Stimulant drugs- controlling symptoms -> not treating (if you have to do this your sleep apnea is poorly controlled)
-Surgical procedures - not really used
-Hypoglossal nerve stimulation- new sleep apnea tx- inspire

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18
Q

new sleep apnea tx- inspire

A

-Hypoglossal nerve stimulation
-BMI must be below 32
-Implantable upper airway stimulation device functions like a pacemaker and stabilizes a pt’s throat during sleep to prevent obstruction
-3 components:
-1. programmable neuro-stimulator implanted in chest
-2. pressure sensing lead that detects pt’s breathing
-3. stimulator lead that delivers mild stimulation to the hypoglossal nerve

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19
Q

obesity hypoventilation syndrome*

A

-central issue during the day
-Prevalence: 0.15–0.3% in the general population and 8% in pts undergoing bariatric surgery
-Syndrome distinct from mere obesity and OSA:
-Severe upper airway obstruction, restrictive chest physiology, blunted central respiratory drive*, and pulmonary hypertension
-presence of awake alveolar hypoventilation (PaCO2 ≥45 mmHg) in obese individual (BMI ≥30 kg/m2), which cannot be attributed to other conditions associated with hypoventilation
-respiratory acidosis

20
Q

obesity hypoventilation syndrome: clinical features

A

-CNS- decreased central respiratory drive
-respiratory- restrictive chest physiology, pulmonary HTN, hypoxemia/hypercapnia
-airway- potential difficult airway, obstructive sleep apnea
-cardiovascular- coronary artery disease, congestive heart failure

21
Q

obesity hypoventilation syndrome: dx

A

-dx of exclusion
-Chronic respiratory acidosis (PaCO2 ≥45 mmHg) with compensatory metabolic alkalosis
-Exclude other diseases that can cause or contribute to chronic alveolar hypoventilation or hypercapnia.
-Then assessed for common complications, including pulmonary hypertension and cardiovascular disorders

22
Q

obstructive sleep apnea tx

A

The mainstay of therapy for OHS is CPAP therapy because it improves gas exchange, lung volumes, and sleep-disordered breathing and reduces mortality
-same for obesity hypoventilation syndrome

23
Q

acute respiratory distress syndrome (ARDS)

A

-Acute hypoxemic respiratory failure following a systemic or pulmonary insult WITHOUT evidence of heart failure
-giant white out on xray-> edema, fluid
-Bilateral, widespread radiographic pulmonary infiltrates
-Normal pulmonary capillary wedge pressure (≤ 18 mm Hg)- catheter into heart and tell you pressure -> rules out HF
-PaO2/FIO2 ratio <300- Arterial oxygen over amount of oxygen giving (normal is 500)
-usually septic, trauma, massive GI obstruction

24
Q

FIO2= 80%
PaO2= 60
Giving 80% O2 to pt

A

21% normal FIO2
-PaO2/FIO2 (as a decimal)
-60/.8= 75
-75 is less than 300

25
Q

severity of ARDS

A

-Mild: PaO2/FIO2 ratio between 200-300 mm Hg
-Moderate: PaO2/FIO2 ratio between 100-200 mm Hg
-Severe: PaO2/FIO2 ratio less than 100 mm Hg
-dont need to stage anyone
-the lower the worse

26
Q

common risk factors for ARDS

A

-Sepsis (1/3 of pts)*
-Severe multiple trauma*
-Aspiration of gastric contents*
-Shock
-Infection
-Lung contusion
-Nonthoracic trauma
-Toxic inhalation
-Near-drowning
-Multiple blood transfusions
-Drugs

27
Q

ARDS pathophysiology

A

-Pro-inflammatory cytokines->lung injury
-Damage to capillary endothelial cells and alveolar epithelial cells:
-Increased vascular permeability
-Decreased production and activity of surfactant
-Leads to interstitial and alveolar pulmonary edema, alveolar collapse, and hypoxemia

28
Q

picture

A
29
Q

ARDS symptoms and signs

A

-Rapid onset of profound dyspnea:
-Labored breathing
-Tachypnea
-Intercostal retractions
-Frothy red or pink sputum*
-Diffuse crackles *

-Marked hypoxemia occurs that is refractory to treatment with supplemental oxygen.***
-CANT OXYGENATE
-Many pts with ARDS demonstrate multiple organ failure:
Kidneys, liver, gut, central nervous and cv system

30
Q

ARDS imaging

A

-Chest radiography: May be normal at first
-Bilateral infiltrates usually peripheral:
-Diffuse or patchy
-Infiltrates rapidly become confluent
-Spare costophrenic angles

-Air bronchograms in approx 80% of cases* -> alveoli are filled with fluid
-Heart size normal
-Pleural effusions small or nonexistent (you see this with HF)

31
Q

ARDS diff dx

A

-Physiologic and radiographic syndrome rather than a specific disease
-Must exclude:
-Cardiogenic pulmonary edema: Heart failure

32
Q

ARDS tx

A

-Identification and specific treatment of underlying precipitating and secondary conditions (eg, sepsis)
-Tracheal intubation
-Positive end expiratory pressure mechanical ventilation
-The lowest levels of PEEP (used to recruit atelectatic alveoli) and supplemental oxygen:
-PaO2 above 55 mm Hg or the SaO2 above 88%
-PEEP keeps alveoli open

33
Q

ARDS tx: O2

A

-Efforts should be made to decrease FIO2 to less than 60% as soon as possible in order to avoid oxygen toxicity
-<40% is safe

34
Q

ARDS: fluid management

A

Maintain pulmonary capillary wedge pressure at the lowest level compatible with adequate cardiac output
-dont put then into heart failure

35
Q

ARDS prognosis

A

-Mortality rate associated with ARDS is 30–40% -> 90% if accompanied by sepsis
-Median survival ≈2 weeks
-Survivors: cough, dyspnea, sputum production
-Improves over time

36
Q

pulmonary aspiration syndromes

A

-Results from disorders that impair deglutition:
-Altered consciousness
-Esophageal dysfunction

-Types:
-Aspiration of Inert Material
-Aspiration of Toxic Material
-“Café Coronary”
-Retention of Aspirated FB
-Chronic Aspiration of Gastric Contents
-Acute Aspiration of Gastric contents

37
Q

aspiration of inert material

A

-nontoxic- water, barium
-Particulate matter or large volumes of fluid
-May cause asphyxia if the amount aspirated is massive and if cough is impaired -> water boarding
-Most patients suffer no serious sequelae from aspiration of inert material.

38
Q

aspiration of toxic material

A

-Clinically evident pneumonia
-Hydrocarbon pneumonitis: aspiration of ingested petroleum distillates:
-Gasoline, kerosene, furniture polish
-Lung injury: mainly from vomiting and aspiration

-Symptoms: vomiting, coughing, respiratory distress, cyanosis, fever
-CXR: may initially be normal or near-normal but may significantly progress over the next 12 hours.
-Patchy airspace consolidation, particularly in the lower lobes, especially the medial basal segments
-Therapy is supportive
-right side mc for aspiration

39
Q

lipoid pneumonia (dont focus on this)

A

-Chronic syndrome
-Repeated aspiration of oily materials:
-Mineral oil, cod liver oil, and oily nose drops
-Elderly patients with impaired swallowing
-Cough is present
-Can cause pneumonia and fibrosis
-Dx confirmed by obtaining sputum or bronchial washings containing lipid-laden alveolar macrophages
-constant aspiration

40
Q

Cafe coronary

A

-Acute obstruction of the upper airway by food
-Associated with:
-Difficulty swallowing
-Old age
-Dental problems that impair chewing
-Use of alcohol and sedative drugs

-Heimlich procedure

41
Q

retention of an aspirated foreign body in the tracheobronchial tree

A

-Produce both acute and chronic conditions:
-Including recurrent pneumonia
-Bronchiectasis- dilatation
-Lung abscess
-Atelectasis
-Postobstructive hyperinflation

-CXR: usually suggests the site of the foreign body
-Bronchoscopy: Establish diagnosis and removal -> remove

42
Q

chronic aspiration of gastric contents may result from primary disorders of the larynx or the esophagus

A

-ex. zenkers
-Bronchial asthma, pulmonary fibrosis, and bronchiectasis
-Dx: EGD and barium swallow
-Tx: Dilate, PPI, H2 Blocker, Metoclopramide

43
Q

acute aspiration of gastric contents is often catastrophic

A

-Pulmonary response depends on the characteristics and amount of the gastric contents aspirated.
-The more acidic the material and quantity, the greater the degree of chemical pneumonitis.
-Aspiration of pure gastric acid (pH < 2.5)—–ARDS!
-Extensive desquamation of the bronchial epithelium
-Bronchiolitis
-Hemorrhage
-Pulmonary edema

44
Q

radiographic abnormalities of acute aspiration of gastric contents

A

-ARDS
-Patchy alveolar infiltrates in dependent lung zones
-Appear within a few hours
-Particulate food matter with gastric acid -> Bronchial obstruction may be observed

45
Q

acute aspiration of gastric contents -> ARDS : treatment

A

-Supplemental oxygen
-Maintain the airway
-Usual measures for treatment of acute respiratory failure (ventilation)
-Fluids for Hypotension
-Treatment of superinfection

Pulmonology (19 decks)

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