Pulm Flashcards
What does the heart look like on PA and AP?
PA vs AP: heart size-looks larger in AP
Lateral: use the spine and heart for orientation
Describe anatomical structures of the thorax
What do the carina and bronchi look like on CXR?
Where should the trachea be?
Over the vertebrae with the division of the carina.
An aspiration from the right bronchus will end up in what lobe?
RLL
What do the lungs look like on chest x-ray?
The lung fields: left upper and lower, right upper, middle, lower, and posterior lower lung extends superiorly and inferiorly. Usually need 2 views a AP and PA view.
What is the anatomy of the diaphragms on x-ray?
Liver elevates right side just a little. Sometimes we can see gastric bubbles from the stomach
1= right hemidiaphragm-higher because it is right under the heart.
2= left hemidiaphragm-higher at spine
You should be able to define the costophrenic angles and cardiophrenic angles
The costophrenic angles are in yellow, green, and blue
The cardiophrenic angles are in red.
Angles should be sharp
If in cardiophrenic-may be sticky like pneumonia. Usually gets rapped in costophrenic fluid collects at lowest portion and we will get a small sign
What does the heart and blood vessel anatomy look like on chest x ray?
What parts of the heart can we see on chest x ray?
On the PA view, how does heart size look?
Heart diameter should be less than ½ of the chest diameter. If they have a bigger heart than this in this view it indicates CHF
What does the aorta and other vessels look like on chest x ray?
The aorta has a small area that may be visible on the right side. The aortic knob is on the left and the descending aorta along the thoracic vertebrae. There is also the pulmonary trunk and the aortopulmonary window.
What is the aortopulmonary window?
In fetal development it is called the ductus arteriosum which will degrade into the ligamentum arteriosum. it helps develop the aortopulmonary window.
If the ductus arteriosum does not close, what happens?
It will cause a congenital heart defect
Describe the structures of the aorta, pulmonary trunk, and aortopulmonary window
Aorta in red, pulmonary trunk in yellow, and aortopulmonary window in blue
Describe the structure of the pulmonary arteries
L/R pulmonary arteries and L/R hilum
Define these vessels (aortic knob, aorta, pulmonary trunk, right pulmonary artery, and left pulmonary artery) in this picture.
Define these heart areas: aorta (ascending arch, descending), pulmonary trunk, aortopulmonary window.
The circle is the aortopulmonary window
The aortopulmonary window is easier to see on what view of chest x ray?
Lateral
What are the 3 lateral spaces and how do they look on a lateral chest x-ray?
Retrosternal (red), retrocardiac (yellow), and retrotracheal (blue). Vertebrae become darker inferiorly. Spinal processes are whiter as we go down, there is an infiltrate.
How does the scapula look on chest x-ray and how can it be confusing?
When looking at vertebrae on chest x-ray what should we be looking for?
Should see brighter white of spinous process in center of trachea and look for alignment of the vertebrae.
What do the clavicles look like on chest x-ray?
Medial portions of the clavicles should be aligned and acromioclavicular joints should be equidistant to clavicles. The bottom of the clavicle should line up with the bottom of the acromioclavicular joint
Can you identify these things in the following chest x ray?
Trachea and L/R bronchi
L/R hemidiaphragms and costophrenic angles
heart areas and heart borders
Aortic knob, aorta, aortopulmonary window
L/R pulmonary arteries/hila
Vertebrae and spinous processes
Count the ribs
Clavicles, scapula
Any other organs-liver, stomach
Correctly identify an artifact on a chest x-ray.
Breast shadows for an objects, artifacts from clothing, jewelry, pacemakers, wires, or tubes, external or internal hardware from prior surgeries and subcutaneous air, metal snaps from a gown, jewelry, hair, hair bands
Accurately count anterior and posterior ribs on a chest x-ray.
Ribs-anterior vs posterior
Vertebrae-spinous processes, body, transverse processes
Clavicles, Scapulae, Humeruses
Posterior (dorsal) portion runs horizontalish
Anterior (ventral) portion runs at angle
The 1st rib-smaller and broader and the 2nd rib right under 1st
Can you identify these things on the following lateral chest x-ray?
Trachea
L/R hemidiaphragms and costophrenic angles
Heart areas
Aorta, pulmonary trunk, aortopulmonary window
Lateral spaces
vertebrae
This is not a good retrotracheal space and we should be worried mass/abscess right there
What are the indications for a CXR?
This is often the initial imaging modality. Indic: SOB, dyspnea on exertion, chest pain (aortic dissection), Hemoptysis (lung mass, cancer, CXR), increased sputum production
List the things that need to be assessed to determine the quality of a chest x-ray.
Rotation
Inspiration
Position
Exposure
Left hemidiaphragm should be visible to the spine. Thoracic vertebrae should be barely visible behind the heart. Lung markings should extend to the edges (vessels inside the lungs we’re seeing). CXR has the most quality markers. Make sure there is good exposure.
Look at rotation of spinous processes and these should be midway between the medial ends of the clavicles. Make sure positioning is good and the spinous processes should be equidistant from the medial end of each clavicle. Check degree of inspiration and rib counting- should see 9-10 posterior ribs/ 6-7 anterior ribs
Explain the appearance of a chest x-ray if it is over-exposed versus under-exposed.
Make sure there is good exposure.
Too dark means there is over penetration and overexposure. Too bright it is underpenetrated and underexposed.
What is this pathology?
tram tracks
Bronchiectasis is often described as “tram tracks” more severe inflammation in the walls of the bronchus. These are pts that we initially think have COPD and it doesn’t get better. Walls of bronchi are thickened, inflamed, and floppy. Seen better on CT. Two parallel white lines= tram tracks
What is this pathology?
Steeple sign: Kids croup
A narrowing at the start of the trachea and is characterized by laryngotracheal inflammation.
What is this pathology?
Trachieal deviation. Both of these pictures are masses. Masses like lymphoma, sarcoidosis, enlarged mediastinal lymph nodes
Tension Pneumothorax (collapsed lung)
Prior pneumonectomy (where they have taken out a lobe of the lung, now there are pressure differences between the lungs)
What is this pathology?
Bronchial occlusion. Left main bronchus occlusion on left and right upper bronchus occlusion with superior lobe occluded on right image. If it is along the lines of the lobes, this gives a clue that it is not an infection, but an occlusion. Often causes collapse of lung tissue distal to obstruction. Examples include the left main bronchus obstruction and the right upper bronchus obstruction. The collapse will appear brighter and if you see whiteness, this is most likely an occlusion of the bronchus. Can happen in single lobes as well like seen in image 2. Follows lines of fissure of the lobes. Can be caused by thick mucus secretions and plugs (bronchoscopy)
What does fungal pneumonia look like on CXR?
Often bilateral because we are inhaling fungal spore. scattered denser areas in more diffuse ground glass opacities
What is this pathology?
ground glass opacities. Bottom left is normal. Viral pneumonia-tends to be bilateral and less dense on xray (“ground glass”), Covid, flu
What is this pathology?
peribronchial cuffing
Inflammation of walls of smaller bronchi/mucus plugging of small bronchi. Common causes are: bronchiolitis (RSV), cystic fibrosis. Developmental disorders in premature infants. Look like a bright ring with a dark center. We are seeing the ring of the wall inflamed.
What is this pathology?
Bacterial pneumonia- tends to be lobar, unilateral, consolidation, wont follow lines of the lobes. Can often see a consolidation of dense area of fluid/inflammation
‘lobar’= confined to a lobe
What is this pathology?
Aspiration pneumonia -more likely in lower lobes and more common to end up in the right than left.
What is this pathology?
costophrenic angle blunting
PLEURAL EFFUSION. Blunting of the costophrenic angles (bilateral vs unilateral)
Fluids work with gravity and therefore collect at the lowest point. Supposed to be able to see costophrenic angles.
Bilateral: heart problems, backup of fluid. heart failure, liver cirrhosis, nephrotic syndrome, and pancreatitis. Usually non-pulmonary reasons
Unilateral: masses, lung issues-pneumonia and cancer. Usually pulmonary causes.
Bilateral on the left. Unilateral on the right.
Effusions can take up the whole lung, we would just see a little white around the encasing of the lungs.
What is this pathology?
Cavitary lesion in the right lung is fluid filled. cancers can cause this. We can figure out sometimes based on sx and CT, but we will most likely need to biopsy it.
What is cavitary lesion?
Walled off area in the lung caused by an air or fluid level imbalance. Common causes include: TB, fungus like aspergillosis, infection, and malignancy
What is this pathology?
Cavitary lesion in the left lung inferior lobe that is not fluid filled.
Describe how to determine if an infection is more likely bacterial vs viral vs fungal on a chest CT.
Bacterial: lobar, segmented, localized
Viral: diffuse or peribronchial ground glass opacities, bilateral or diffuse
Fungal: diffuse or focal nodules, cavitary lesions, or ground glass opacities
Describe how to determine if an infection is more likely bacterial vs viral vs fungal on a chest x-ray.
Bacterial: lobar, unilateral, consolidation, may include air bronchograms, costophrenic angle blunting
Viral: tends to be bilateral and less dense on xray (“ground glass”), Covid, flu, hyperinflation, thickening of bronchiole walls
Fungal: bilateral, inhaling fungal spore. scattered denser areas in more diffuse ground glass opacities
Compare and contrast the advantages and disadvantages of a CT chest versus a chest x-ray.
Advantages to chest CT: No superimposed structures, high definition of structures, better visualization of nodular opacities, can image vasculature with contrast, high resolution, thin slices, 3D reconstruction often available.
Disadvantages to chest CT: Radiation exposure increased, not portable and there is risk of contrast with allergies
CXR: accessible, cost effective, less radiation, quick
What are the indications for a CTA chest?
IV contrast can be used to enhance vasculature. Indications: SUSPECTED PE, suspected dissection/rupture, evaluate aneurysm, evaluate masses.
What are the indications for a V/Q scan?
Often used to look for PE when CTA can’t be done (contrast allergy or kidney disease). Suspected PE and are unable to do contrast
Describe how to interpret V/Q scan results.
Ventilation scan: nuclear med radioactive aerosol (that doesn’t cross the alveolar membrane, does not get into bloodstream) breathed in/out and images are taken
Perfusion scan: radiolabeled albumin (albumin preferentially goes to the lungs. very low dose, not worrisome after) injected into venous system, aggregates in pulmonary capillaries and images taken.
Compare the two. Images scanned for mismatch-area with ventilation but not perfusion indicates PE (specific for pulmonary embolism and reported as low, intermediate, or high probability).
What is the gold standard for visualization of pulmonary arteries?
Pulmonary angiography and fluoroscopy x-ray
Dye injected into pulmonary arteries individually and images taken. Minimally invasive-right heart catheterization. Gold standard for blood clots, but rarely done
What is this pathology?
This would be going to the left lung. Will usually go into either the radial artery or femoral artery. There are risks for perforation.
They can dissolve the clot by dripping TPA on it or they can go in and physically pull the clot out.
Describe the appearance of the following on an ultrasound:
pleural effusion
US done at the bedside. Blood or fluid is black. Guiding the needle for thoracentesis.
Pleural effusion- dark area between lung and liver/diaphragm
Describe the appearance of the following on an ultrasound:
pneumothorax
Normal pleural line- bright white where movement of pleura is noted in normal lung-sliding and PTX air space if noted, no sliding of pleura
The visceral and parietal pleura slide against each other. Pneumothorax will not slide, looks like a barcode.
Describe the appearance of the following on an ultrasound:
pneumonia
Areas of consolidation appear more heterogenous and bronchograms are noted as bright
Describe the Allen test and how to interpret it.
To assess adequate blood flow of the hand. We would hold/occlude both the radial and ulnar arteries and we will ask the patient to make a fist and then release and we will release pressure form the ulnar artery. If the hand gets its red color back, the test is positive, and this means there is good blood flow through the ulnar artery. If it is negative, it will look like the picture on the right. Right side picture is a negative allen test
Positive means good blood flow and this means we are good to proceed
What are the indications for an ABG?
They are used to assess O2 status and acid/base balance, from the arterial side. They are typically analyzed using blood drawn from radial artery (respiratory therapists)
What are the contraindications for an ABG?
negative allen test. Known vascular disease in the extremity, AV fistula for dialysis in the extremity, expected need for dialysis in near future. Relative contraindications: bleeding disorder or on a blood thinner, low platelet count.
What are the components of an ABG?
PaO2, SaO2, PaCO2, pH, HCO3-
What are the normal ranges of PaO2?
Partial pressure of oxygen (mmHg)- not the same as O2 saturation and normal 80-100 mmHg with 75-100 mmHg
What are the normal ranges for SaO2?
Finger monitor and O2 saturation of hemoglobin and Normal 94-100%
What are the normal ranges for pH?
Normal 7.35-7.45
<7.35 acidosis
>7.45 alkalosis
For ABG analysis anything less than 7.40 is acidic and anything above is alkalytic. Anything outside the normal ranges indicates that the blood is acidic or alkalotic.
What are the normal ranges for PaCO2?
Partial pressure of CO2 (mmHg) Normal 35-45 mmHg
>45=acidosis
< 35 alkalosis
For ABG analysis, determine if acidosis or alkalosis on 40
Anything outside the normal ranges indicates that the blood is acidic or alkalotic.
What are the normal ranges for HCO3-?
Bicarbonate level
Normal 22-26 mEq/L <22= acidosis and >26 alkalosis
What two systems respond to pH changes in the blood?
respiratory and renal systems
What does the renal system do in response to change in the blood pH?
Regulate HCO3-
Longer term response -> 3-5 days to fully adapt
H+ + HCO3- <-> H2CO3 <-> CO2 +H2O
What does the repsiratory system do in response to change in the blood pH?
Regulates level of CO2 by increasing/decreasing rate of respiration. Change in level of CO2 will cause new equilibrium for this equation: H+ + HCO3- <-> H2CO3 <-> CO2 +H2O. Lungs= quick response to pH changes-> minutes
How does the respiratory system respond to acidosis?
Increased respiration rate= more CO2 exhaled= decreased CO2 in blood. Equilibrium shifts to right, reducing H+. Pt will be breathing fast (RR is faster, tachypnic- they are either hypoxic or acidotic)
How does the renal system respond to acidosis?
Reabsorb more HCO3- and excrete more H+
Body is acidic, urine is acidic, longer term response- 3-5 days to fully adapt
How does the respiratory system respond to alkalosis?
Decreased respiration rate= less CO2 exhaled= increased CO2 in blood. Equilibrium shifts to left, increasing H+
How does the renal system respond to alkalosis?
Excrete more HCO3- and reabsorb more H+
longer term response- 3-5 days to fully adapt
What are the four major acid base disorders?
Respiratory acidosis, respiratory alkalosis, Metabolic acidosis, metabolic alkalosis
What is respiratory acidosis?
Increased pCO2 leads to decreased pH. rate of ventilation of CO2 is decreased (COPD, asthma attacks, pneumonia, narcotics- RR drops significantly 4-6 per minute and they die from build up of CO2)
What causes respiratory acidosis?
Decreased ventilation:
Decreased movement of air to the alveoli (Decreased respiratory rate- strokes. Obstruction to flow- bronchial occlusion, mass)
Decreased gas exchange in the alveoli (Increased fluid-pneumonia, pneumonitis. Decreased surface area- emphysema, pulmonary fibrosis).
Decreased perfusion: think PE
What are some sx of respiratory acidosis?
HA, tachycardia, CNS depression, cardiac arrhythmias, lethargic, confused
What are some compensatory mechanisms of respiratory acidosis?
Kidneys renin, HCO3- and excrete H+, takes 3-5 days
What is the therapy for respiratory acidosis?
Artificial ventilation, measures to improve ventilation. CPAP, BiPAP
What are some common causes of repsiratory acidosis?
Central: opiate overdose, stroke, status epilepticus, decreased rate of breathing. Perfusion abnormalities: PE, cardiac arrest, decreased perfusion. Airway abnormalities: obstruction, asthma, COPD, anaphylaxis, decreased flow. Neuromuscular: spinal cord, injury, Guillian-barre syndrome, myasthenia gravis, MS, diaphragm paralysis, decreased flow and rate. Alveolar issues: pneumonia, emphysema, and effusion
What are some sx of respiratory alkalosis?
Lightheadedness, CNS irritability (muscle spasms, alt mental status), cardiac arrhythmias
What causes respiratory alkalosis?
HYPERVENTILATION. Anxiety, fear, stress, CNS disease, drug use (salicylates (aspirin OD starts this way), pregnancy (diaphragm can’t go down as far), sepsis, liver disease, hypoxemia, low O2 (PE, anything that causes this)
What are some compensatory mechanisms for respiratory alkalosis?
Kidneys excrete HCO3- and retain H+
What is respiratory alkalosis?
Decrease pCO2 leads to increased pH. Blowing off more CO2. rate of ventilation of CO2 is increased (anxiety, fever, PE)
What are some therapies for respiratory alkalosis?
Anti-anxiety measure, O2 if due to hypoxia, CO2 rebreathing
What are some common causes of respiratory alkalosis?
Central: anxiety, head trauma, brain tumors, salicylates OD, fever, pain, pregnancy
Peripheral: hyperventilation due to low O2 state, such as PE, pulmonary edema, altitude
Iatrogenic: mechanical ventilation (intubation)
Normal for pregnant females to have respiratory alkalosis- stimulated by progesterone
Salicylate (aspirin) poisoning: respiratory alkalosis- metabolic acidosis
rebreathing= paper bag
What is metabolic acidosis?
Decreased HCO3- leads to decreased pH. either- increased production of an acid (lactic acid from sepsis, ketoacids) OR increased loss of bicarbonate (usually secreted by pancreas and reabsorbed in the large intestine, if not reabsorbed, can be caused by diarrhea)
What is metabolic alkalosis?
Increased HCO3- leads to increased pH. either: increased bicarbonate (tums) OR increased loss of acid (vomiting)
What are some sx of metabolic acidosis?
HA, CNS depression, altered mental status
What are some causes of metabolic acidosis?
Acid production or too much HCO3- lost (diarrhea)
Acid production-poisoning (methanol poisoning), abnormal metabolism (ketoacidosis, lactic acidosis), shock/low perfusion.
Loss of base (HCO3-)- diarrhea, pancreatic fistula- losing bicarb from the colon
What are some therapies for metabolic acidosis?
Correct underlying cause (ketoacidosis, diarrhea, etc.). Improve tissue oxygenation (lactic acid). Consider giving NaHCO3 (sodium bicarbonate-fluid) if pH < 7.0. Can prescribe bicarb but DON’T DO IT ON YOUR OWN. very dangerous because it is typically IV
What are some compensatory mechanisms for metabolic acidosis?
Lungs excrete more CO2 by increasing rate of respiration (Kussmaul breathing)
What are some causes of metabolic alkalosis?
Base accumulation-excessive antacid intake (tums), blood transfusion. Loss of acid-vomiting, gastric suction (NG tube), diuretic use (trigger kidneys to excrete out acid)
What are some sx of metabolic alkalosis?
CNS irritability, eventual CNS depression
What are the ions involved in the anion gap?
Amount of cations (+) has to equal the amount of anions (-).
Major cations: Na+, K+
Major anions: Cl-, HCO3-, phosphate (PO4-)
What are some compensatory mechanisms of metabolic alkalosis?
Lungs retain CO2 (decrease rate of respiration)
What are some therapies for metabolic alkalosis?
Reverse underlying cause (antacids, low Cl-, low K+, vomiting). Almost never give acid (HCl)
What are some causes of metabolic alkalosis?
Caused by administration of base or removal of H+ causes increased HCO3- concentration in extracellular fluid. Volume depletion releases aldosterone and causes reabsorption of Na and HCO3-. Most common cause= vomiting or diuretic use. Vomiting -> chloride leaves body and is replaced by bicarbonate
Explain how to tell if a respiratory acidosis is acute or chronic
Acute: (no compensation, kidneys have not compensated yet) CNS depression-drugs (opiod OD), acute stroke, etc. Acute airway obstruction (aspirations), severe pneumonia or pulmonary edema
Chronic: (compensation-kidneys have a chance to work) Chronic lung disease (COPD, bronchiectasis, pulmonary fibrosis), Chronic neuromuscular disorders (muscular dystrophy, ALS), Chronic respiratory center depression-central hypoventilation and obesity
What are we measuring in the anion gap?
Easier to measure Na, K, Cl, HCO3-. Hard to measure total PO4- -> most is bound to organic molecules
The difference between measured anions and measured cations. Normal anion gap can be calculated from values on BMP.
Describe what an anion gap is, and how to calculate it.
Anion gap= Na - (Cl+ CO2) = 8-16 meq/L when we dont use potassium
When the gap is over 20: this is concerning for an extra acid present
List possible causes of a high anion gap metabolic acidosis.
(HAGMA) Anion Gap > 20
Ketoacidosis (diabetic/alcholic/starvation), renal failure, lactic acidosis, rhabdomyolysis (crush injury or trauma), toxins (methanol, ethylene glycol-antifreeze, paraldehyde, salicylates)
What is the mnumonic to remember some of the causes of a high anion gap?
Retention of 1 or more unmeasured anions. Weak base from acid accumulation. An acidosis going on
M: Methanol/metformin (lactic acidosis, very uncommon but deadly and this is a common med for diabetics)
U: uremia (high BUN)
D: Diabetic ketoacidosis
P: paraldehyde/ phenformin
I: iron/isoniazid (TB)
L: lactate
E: ethylene glycol (antifreeze OD)
S: salicylates (aspirin)
SCUMPILED is similar but includes cyanide
List possible causes of a normal anion gap metabolic acidosis.
(NAGMA)
GI bicarbonate loss (diarrhea/urethral diversions)
Renal bicarbonate loss (renal tubular acidosis, early renal failure, carbonic anhydrase inhibitors, aldosterone inhibitors)
HCl administration
Post Hypocapnia
What is the pathology?
left pleural effusion
What is the pathology?
bilateral metastatic cancer
What is the pathology?
tracheal deviation due to emphysema
What is the pathology?
right middle lobe consolidation
What is the pathology?
right main bronchial occlusion w/ tracheal deviation
What is the pathology?
peribronchial cuffing
What is the pathology?
cavitary lesion
What is the pathology?
empyema
What is the pathology?
tracheal deviation
What is the pathology?
ground glass opacities consistent with viral pneumonia or pneumonitis
What is the pathology?
left pneumothorax
What is the pathology?
COPD-hyperinflation
What is the pathology?
pulmonary hypertension form in-flammed pulmonary trunk and r. pulm artery
What is the pathology?
bilateral pneumothroax
What is the pathology?
right lung nodule
What is the pathology?
Pleural effusion (and metal wires possible from open heart surgery)
possible retrosternal mass
What is the pathology?
pulmonary fibrosis
What is the pathology?
right upper lobe infiltrate, TB, sarcoidosis
Describe the levels of compensation for an acid base disorder.
Compensatory mechanisms will try to bring pH back into normal range. Initially, the primary problem developed and pH moves outside the normal range. Primary issue (PaCO2 ( respiratory) or HCO3- (metabolic)) abnormal, pH abnormal, non-causative value is WNL. “uncompensated”. Opposing value changes in response. Primary issue abnormal, pH abnormal, non-causative value abnormal “partially compensated”. Primary issue abnormal, pH normal, non-causative abnormal. “Fully compensated”
List the indications for pulmonary function tests (PFTs)
Indications: Sx of lung disease/ diagnosis of lung disease (ex-). Screening (genetics), assess treatment efficacy. Pre-op (elective surgeries) evaluation of lung function. Monitoring for medication side effects
List the contraindications against pulmonary function tests (PFTs)
Contraindications: Active or recent respiratory infection. Recent surgery (eye- don’t want to increase IOP, abdomen, chest most critical), recent or current heart issues (puts stress on the heart), known aneurysms in chest, abdomen, brain
List and describe the lung volumes and capacities.
Forced expiratory volume/time (FEVx) ex: FEV1
Forced expiratory flow (FEF) rate
Peak expiratory flow rate (PEFR)- fastest you can get it out
What are the four types of pulmonary disorders?
obstructive, restrictive, pulmonary vasculature, and breathing mechanics
What are obstructive disorders?
“Cant get air out”
Causes: airway and air flow issues. Fixed obstruction (mass, vocal cords). Variable obstruction (mucus/inflammation (COPD, asthma), air trapping (emphysema, air gets stuck in the bullae)
What are pulmonary vasculature disorders??
Makes it hard to do gas exchange
Blood clots and pulmonary hypertension
What are restrictive disorders?
“Cant get air in”
causes: loss of compliance and elasticity of the lung parenchyma (fibrosis, sarcoidosis), anatomical restrictions (scoliosis, obesity, pregnancy)
What are breathing mechanic disorders?
Diaphragm /intercostals. pons/brainstem (respiratory center), phrenic nerve supplies diaphragm)
Describe the interpretation of spirometry results.
Start with FEV1/FVC ratio: interpretation depends on criteria used
ATS criteria- lower limit of normal (LLN)
GOLD criteria- 0.7 (70%) cutoff
Age 5-18 > 0.85 (85%) cutoff.
Then decide if it is FEV1/FVC < LLN meaning it is obstructive or mixed disorder OR if FEV1/FVC >/= LLN meaning it is normal or restrictive disorder
Next look at FVC.
What factors are used to predict the lower limit of normal for a person’s spirometry?
Depending on effort. Based on predicted values for age, height, race, gender. LLN= lower limit of normal- problem with lung function. A person’s age, height, race, gender. Traditionally, 0.7 has been used as a cut off for FEV1/FVC ratio, but is works mainly for middle-aged patients. It leads to false negatives and younger populations and false positives and older populations. A TS stands for American thoracic society GOLD stands for global initiative for chronic obstructive disease.
Give the FEV1/FVC ratio, FVC, TLC, DLCO results expected for asthma
Ratio: low
FVC: normal
DLCO: normal
TLC: normal
Describe how the diffusion capacity of carbon monoxide (DLCO) is measured, and how to interpret it.
DLCO Measures capacity of diffusion across the alveolar-capillary membrane. Carbon monoxide (CO) used because it is not normally present in air/blood and it has a very high affinity for Hgb. (Rate of diffusion is proportional to the membrane surface area and thickness). The procedure is the known quantity of carbon monoxide introduced at inhalation, Quantity of carbon monoxide in exhalation is measured. Difference in values is amount of CO that diffused across the membrane and went into the bloodstream
Give the FEV1/FVC ratio, FVC, TLC, DLCO results expected for pulmonary hypertension
Ratio: normal
FVC: normal
DLCO: low
TLC: normal
Give the FEV1/FVC ratio, FVC, TLC, DLCO results expected for chronci bronchitis
Ratio: low
FVC: normal
DLCO: normal
TLC: normal
Give the FEV1/FVC ratio, FVC, TLC, DLCO results expected for emphysema
Ratio: low
FVC: normal
DLCO: low
TLC: normal
Give the FEV1/FVC ratio, FVC, TLC, DLCO results expected for scoliosis
Ratio: normal
FVC: low
DLCO: normal
TLC: low
Give the FEV1/FVC ratio, FVC, TLC, DLCO results expected for pulmonary fibrosis
Ratio: normal
FVC: low
DLCO: low
TLC: low
What helpful chart did professor Leonardi give to help differentiate diseases?
Explain the bronchodilator challenge, when it is done, and how to interpret it.
Assess response to bronchodilator. If post-bronchodilator FEV1/FVC ratio has > 12% increase and FVC has 200 ml increase, it is reversible. Dx: asthma
If only one or neither criteria met -> irreversible. Dx: COPD or bronchiectasis
Explain the changes in the volume/time graph associated with pulmonary disorders
Restrictive: overall smaller loop for both inhalation and exhalation
Obstructive lung disease: inhalation similar to normal. Exhalation shows “coping” of inward curving of the tracing and peak flow is reduced. Inhalation looks the same, but it sort of dips down and concaves
Obstructive, not lung disease: flattened inhalation= variable extrathoracic issues (masses, vocal cord paralysis, sleep apnea). Flattened exhalation= variable intrathoracic issue (masses, tracheobronchomalacia, bronchus occlusion) both flattened= fixed obstruction (solid tracheal mass, tracheal stenosis)
Explain the bronchoprovocation challenge, when it is done, and how to interpret it.
Bronchoprovocation (methacholine/allergen/exercise)- provoke asthma exacerbation
Exercise testing. If they have an asthma attack related to the stimulant
What does a volume/time graph look like?
Above the x axis= exhalation. below=inhalation. How does shape compare to expected? How does the peak expiratory flow rate compare to extended?
Describe the indications, results and how to interpret them for alpha 1 antitrypsin
A1AT inactivates enzymes that break down collagen and it replaced with scar tissue tends to hit the lungs and the liver. Deficiency of A1AT leads to early onset emphysema and childhood cirrhosis. Emphysema in their 30s even though they are not smokers. s/sx early onset emphysema or childhood cirrhosis. Family member with AAT deficiency. S/sx of protein deficiency on CMP. Serum level measured
Describe the indications, results and how to interpret them for chloride sweat test
Cystic fibrosis is a genetic disorder that impaired chloride transporter in cell membranes- Cl stays within cells and impairs osmosis of water into airways. Less water= thick mucus in the lungs and the pancreas. CF patients have higher levels of Cl in sweat and indications are for positive newborn screening for CF. s/sx of CF at an early age. Better sensitivity than specificity. Negative test will rule it out, but a positive test might be a false result. 29 or less-CF unlikely. 60 or higher– CF likely. 30-59-inconclusive-repeat test and monitor. Zap the sweat glands with a little bit of electricity from an electrode and collect the sweat on a piece of filter paper.
Describe the indications, results and how to interpret them for angiotensin converting enzyme
Found on epithelial cells in lungs and converts angiotensin I to angiotensin II (vasoconstrictor, stimulates aldosterone release) Serum levels are measured. Sarcoidosis where ACE is elevated in many (not all) sarcoidosis patients causes lymphadenopathy and eventually pulmonary fibrosis- calcium may also be elevated, ACE will probably be elevated.
Describe the indications, results and how to interpret them for antineutrophil cytoplasmic antibodies
Have autoimmune function. Attack white blood cell antigens. Have an antigen inside the cytoplasm that the body is responding to. Cause inflammation and destruction of blood vessels (vasculitis) with resultant lung damage. Several different vasculitides affect the lung
Can do a biopsy for staining ANCA antibodies done. C-ANCA-cytoplasmic ANCA, highly specific for GPA.
Sx: hemoptysis (scary for lung cancer, TB, PE)
Always testing for peripheral vasculitis Granulomatosis with polyangiitis (GPA- formerly Wegener’s granulomatosis) Eosinophilic granulomatosis with polyangiitis (EGPA-formerly Churg-Strauss) Microscopic polyangiitis.
angitis= inflammation of the blood vessels
DO C-ANCA testing for these, biggest sx is hemoptysis
GPA will be positive for C-ANCA
EGPA and microscopic polyangitis wil be negative C-ANCA
Describe the indications, results and how to interpret them for pro calcitonin?
best for respiratory stuff
Produced by lung parenchymal cells in response to BACTERIAL toxins
Elevated in bacterial lung infections, not elevated in viral
Not sensitive or specific enough for definitive diagnosis
Major use - guide cessation/ deescalation or escalation of antibiotics
List the criteria used to assess the quality of a sputum sample for culture.
Sputum from deeper in lungs, not from throat
Early am collection is best
Evaluations: acceptable specimen if < 10 epithelial cells and > 25 polymorphonuclear cells (WBC granulocytes) per high power field on microscopy.
Sample rejected if too many epithelial cells present
Gram stain and culture done
May need to order special staining (suspected fungal infection, TB, etc)
Describe the testing for acute TB.
CXR
3 Sputum specimens, at least 8 hrs apart, at least 1 early am
Acid fast stain
NAAT
Culture and sensitivities (up to 1 month)- DEFINITIVE TEST
Upper lobes, cavitary lesions, or miliary TB
Describe the testing for latent TB.
kin test or interferon gamma release assay (IGRA)
Skin test= PPD
IGRA= Quantiferon gold
WBCs form patients infected with TB will release interferon when exposed to TB antigens in vitro
Describe the pathophysiology of an exudate vs a transudate.
Inflammation causes capillaries to leak
Causes: infection and cancer. Fluid= Exudate-fluid contains proteins and cells (WBCs)
Increase in rate of osmosis out of capillaries and into tissues
Causes: increased hydrostatic pressure (increased blood volume, higher BP, where heart failure and kidney failure and cirrhosis come in due to fluid overload). Decreased oncotic pressure (low protein, this can indicate cirrhosis, nephrotic syndrome as well). Fluid= transudate - fluid contains minimal cells or proteins
List Light’s criteria and explain how to interpret.
Light’s Criteria: Effusion is likely an exudate (cancer or infection) if at least one of the following is met:
The ratio of pleural fluid protein to serum protein is >0.5 which indicates leaky vessels (CMP at the same time we are pulling pleural fluid off)
The ratio of pleural fluid LDH (lactate dehydrogenase) to serum LDH is >0.45 (changed from 0.6)
Pleural fluid LDH level is >0.6 x the normal upper limit of serum LDH for the facility we are working in
List PFO3 criteria and explain how to interpret.
Pleural fluid only 3 test combination (PFO3): Effusion is likely an exudate if at least one of the following is met:
Pleural fluid protein > 3.0 g/dL
Pleural fluid cholesterol > 55 mg/dL
Pleural fluid LDH >⅔ the upper limit of normal for serum LDH
This way we only have to measure the pleural fluid, not the blood too.
Explain Wells score for a PE and how to use it.
D dimer (4 RFs or less, above 4 send them straight to imaging): helps rule out PE with low/moderate suspicion (Wells criteria- positive and negative likelihood ratio already included in it), age-related cutoff (The older you get, the higher the normal), will often be elevated after surgery (just do image if concern). EKG-S1Q3T3 pattern
D-dimer comes from a breakdown of clots. Wells criteria
Describe the interpretation of the A-a gradient and when to use it.
A-a gradient= [PAO2-PaO2]
PAO2= partial pressure of O2 in the alveoli
PaO2= partial pressure of O2 in the blood (arteries)
Normal A-a gradient is < 10 because the oxygen in the alveoli should be going into the artery and should have good flow, but does vary with age. Expected A-a gradient is (Age + 10)/4. PaO2 is measured directly on ABG
The biggest thing is that it is related to the FiO2 which is the amount of oxygen in the inhaled air. So if you’re just on room air, room air is 21% so the FiO2 would be 0.21. If they are on supplemental O2- find a chart to get FiO2 value, because it will be higher). Atm pressure- 760, unless at high altitudes. Use mdcalc.
List possible complications from a thoracentesis.
Pneumothorax, reactive pulmonary edema (if >1.5 L removed) where basically it refills very quickly and you make the problem all over again and make it worse. Spread out time of drainage if more than 1.5 L
What is the A-a gradient calculated vs. expected?
PAO2 has to be calculated
We get the calculated and expected numbers and then compare them.
Normal= numbers are close, within 3= ventilation
Elevated= large difference between them = gas exchange issue
Ventilation issues: Mucus plugging, poor ventilation
Gas exchange issues: PE, pneumonia, less surface area for gas exchange
What are the indications of a bronchoscopy?
Concerning sx with hemoptysis (cancer), stridor (wheezing on inhalation, COPD), unilateral wheezing (obstruction), chronic cough (not productive). Evaluation of airway structure and function. Evaluation of airway obstruction-FB, mucus plugging, structures. Evaluation/biopsy of lung or mediastinal mass (must be very close or within a bronchus, do a biopsy of mass during a bronchoscopy, even if it is in the wall of the bronchus, we can stick a needle through the wall of the bronchus and get the biopsy). Diagnosis and management of infection-cavitary lesion, nonresolving pneumonia (BAL). Evaluation of interstitial lung disease (biopsy to diagnose sarcoidosis, pulmonary fibrosis, etc.). Can be done at the bedside or in an endoscopy suite.
What are the complications of a bronchoscopy?
Perforation or injury. Pneumothorax, complications with anesthesia (not fully under). Pulmonologists usually do this.
Describe the special procedures that might by utilized during bronchoscopy.
Bronchoalveolar lavage (BAL) where bronchi are washed with saline and samples are sent for gram staining/culture, cytology (cytology)
Bronchial brushings where surface cells are removed for evaluation/cytology
Biopsy where endotracheal or endobronchial procedure is done for a transbronchial (through the bronchus) needle aspiration (TBNA) of lesions outside of bronchi-often US guided (EBUS-TBNA). The area labeled as P on the below US indicates a mass in the actual wall of the bronchus. Sometimes they will place a stint in to help hold the bronchus open.
What are the indications for a mediastinoscopy?
Lymph node biopsy: lung cancer staging, sarcoidosis, TB, lymphoma
We will go right above the sternal notch, make an incision and insert the scope. This is often times for a lymph node biopsy.
What are the complications of a mediastinoscopy?
Pneumothorax, bleeding lots of major veins and arteries, esophageal injury- will need a feeding tube for 6-8 weeks.
Describe the possible ways to biopsy a lung nodule.
Repeat imaging- least invasive
Sputum Cytology: spit in a cup, won’t be positive a lot of the time. 3 days in a row, early morning samples. Low yield (30-60% positive in lung cancer + patients), AM sample, multiple samples improve diagnostic %
Bronchoalveolar lavage (BAL): initial washing, will wash several times, but use first wash for cytology.
Bronchoalveolar brushings: scrapping a concerning area.
Transbronchial needle aspiration or transthoracic needle aspiration, more invasive, especially if we are going through the wall of the bronchi.
Lymph node biopsy- mediastinoscopy and remove the whole node (lobectomy)- CT surgery
Surgical biopsy
List the concerning features of a lung nodule that might indicate cancer.
Consider more aggressive workup in patients: known primary cancer, immunocompromised (immunosuppressants), significant smoking history, family history of cancer, suspicious morphology (>8mm in size, irregular borders/spiculation meaning tiny little bright spots of calcium, semi-solid appearance, upper lobes). Things to consider: solid vs. semi-solid nodules, size, single vs. multiple, risk factors
Why would we never biopsy an “incidentoloma”?
“Incidentaloma”- most are benign. Most of the time they are scar tissue. NEVER BIOPSY FIRST. New nodule= biopsy is never the right answer. Have to balance invasive workup vs risk of missing a malignancy. Repeat imaging (Fleischner society guidelines)
Cancers tend to double in volume every 100-300 days, if you image it and you image it 6 months later, its not cancer. If you image it and image it again and its 4x bigger, its not cancer, because it is growing too fast. Not immunocompromised, no known cancers. Cancers has a rate that it tends to grow.
Describe the screening criteria for lung cancer.
No current serum or blood marker available. We screen people who do not have sx. The at-risk population= low dose CT scan yearly. At risk= adults, 55-80 yrs, 20+ pack-years hx of smoking, current smoker or quit < 15 yrs ago, “in reasonable good health”- life expectancy of at least a year, people who can tolerate treat if we do find some.
Which types of lung cancer are more likely to be associated with smoking?
small cell lung carcinoma, squamous cell carcinoma
Which types of lung cancer are more likely to occur in the central portion of the lungs?
small cell lung carcinoma, squamous cell carcinoma
Which types of lung cancer are more likely to occur in the periphery of the lungs?
adenocarcinoma, large cell carcinoma
Which types of lung cancer are more likely to cause paraneoplastic syndrome?
small cell lung carcinoma
What helpful chart for lung cancer differentiation did Professor Leonardi give us?
What is paraneoplastic syndrome?
Paraneoplastic syndrome= secrete hormones like antidiuretic hormone (secreting a lot of ADH, makes your body hold onto water which tends to have very low levels of sodium), adrenocorticotropic hormone (ACTH, too much cortisol, you can get hypercortisolism or Cushing Syndrome)
Describe the testing for obstructive sleep apnea, including how to interpret the results.
Significant cause of secondary hypertension (can’t get control of their bp and daytime fatigue. RF: BMI, widened neck Diagnosed by polysomnography (sleep study).
Apnea/Hypopnea index (AHI) is measured over at least 2 hours of sleep
OSA= 5 or more apnea/hypopnea events/ hour (mild: 5-15, moderate 16-30, severe >30).
Treated with CPAP- provides pressure (or night O2), maybe they can go off of their hypertension meds
Sleep apnea 10 sec or more with absent air flow
Sleep hypopnea 10 sec or more with 10-70% decreased air flow with desaturations (at least 3%) or arousal from sleep
A 54 yo patient undergoes PFT testing. Results show FEV1/FVC ratio is low, FVC is normal. Values do not improve after bronchodilator treatment. DLCO is normal. Most likely diagnosis?
COPD (chronic bronchitis)
A 65 yo patient undergoes PFT testing. Results show FEV1/FVC is normal, FVC is low. DLCO is normal. Patient’s BMI is 24 with normal alignment of the spine. Most likely diagnosis?
Restrictive disorder→ not scoliosis, not fibrosis, it is a neuromuscular problem like paralyzed diaphragm disorder or phrenic nerve.
What is this pathology?
This is a right bronchial occlusion. Collapse of lung tissue distal to the occlusion (right bronchus). Whites out the tissue on a CXR
What is this pathology?
bronchiectasis. inflammation of the walls of the bronchioles
“Signet ring” sign on CT.
What is this pathology?
“Tram track” sign on CT
What is this pathology?
fungal pneumonia, aspergillosis. Fungal pneumonia or aspergillosis looks like I just threw snow on there and made it white, some areas of denser white.
What is this pathology?
consolidation with air bronchogram. Bacterial pneumonia.
What is this pathology?
ground glass opacities. Covid.
What is this pathology?
Pneumonia. Hypersensitivity reaction. Has a ground glass appearance, but we will be able to identify and decipher based on how the pt presents. The pt will have been exposed to something that caused inflammation, but they won’t be infected, so they won’t have had a fever, they are not coughing up nasty stuff. These pt may have: had a blood transfusion, been in a fire and got some smoke inhalation, chemicals burning/smoke.
They may be hypoxic and SOB
What is this pathology?
ARDS. These pts will be hypoxic, in distress, and very sick.
What is this pathology?
pleural effusions. Fluid goes in the left lung. Probably a soft tissue window, because we cant see lung tissue, so not a lung window.
What is this pathology?
Cavitary lesions. This is the same cavitary lesion on CXR and CT. This could be cancer, bacterial/fungal infection.
What is this pathology?
Both of these are emphysema at different stages. Chronic bronchitis doesnt show up well on CT, but emphysema does, because we are losing the tissues and forming air filled sac, the bullae. The bullae can pop or burst and it can start to look like soap, but too many and we can get a pneumothorax. Starts at the apices of the lungs and works its way down. Very severe emphysema on the tight picture.
What is this pathology?
siliconiosis. Small, symmetric nodules, often distributed more in upper lobes. Little bright specs and circles. Comes from silica so people we work in cruise ship building, carpentry, granite.
What is this pathology?
asbestosis. More diffuse/irregular distribution of nodules. Often have calcified plaques along the pleural membranes (yellow arrows). Fibrosis on the wall of the pleural cavity and calcified, so it shows up bright white. Calcified plaques on the pleural wall is asbestosis.
What does pneumoconiosis look like on CT?
Multiple scattered small nodules. Inhaled particulates like silicone, asbestos, and coal dust (causes black lung disease-anthracosis). Fibrosis where particles have landed.
What is this pathology?
Pulmonary fibrosis. Replacement if lung tissue with fibrous tissue with white honeycomb appearance. Don’t really know what caused it, can be sarcoidosis, it could be exposure to one of the pneumoconiosis’, but a lot of times, we never know what triggers it. This sounds like your SNAP. CRACKLE. POP ON EXAM.
What is the pathology?
Large saddle PE- both L/R pulmonary arteries blocked- It can grow over days and increase sx. Large clots that migrate to this area can cause death in minutes to hours. Immobilization is the biggest RF
Tachycardia is worrisome
A saddle PE will start in the legs and come up through the venous system and can be deadly within minutes.
These people are in severe distress, because they are not getting any oxygen into their blood or they are getting very minimal. They are SOB, hypoxic, tachycardia, anxiety, they have had a long flight or long travel, or history of immobilization. The wells criteria can help us to diagnose this.
Explain the changes in the flow-volume loop graph for Scoliosis
restrictive pattern
Explain the changes in the flow-volume loop graph for COPD
obstructive pattern
Explain the changes in the flow-volume loop graph for pulmonary fibrosis
restrictive pattern
Explain the changes in the flow-volume loop graph for pulmoary hypertension
normal
Explain the changes in the flow-volume loop graph for emphysema
obstructive pattern with restrictive tendencies
Describe the diagnostic workup options for a lung nodule concerning for cancer.
You will most likely do a bronchoscopy and a brushing if the mass is in the bronchus space and do a biopsy if it is in the walls or lymph nodes. Do a mediastinoscopy if it is in the lymph nodes to where we can’t see or a surgical biopsy.
Describe the symptoms and diagnostic workup for a Pancoast tumor
pancoast tumor that sits on the upper lobe and compresses the brachial plexus that causes shoulder pain that is unrelated to movement. Ipsilateral horner syndrome so they don’t sweat on that side and they can have problems with the size of the pupil and we will see sx of the face as well, can cause cavitary lesion- indicates cancer. Work it up like a lung nodule.
