Pulm 2 Flashcards
first column:
mild to moderate
moderate to severe
thin, cachetic
use of accessory muscles
majorly decreased
decreased
hyperinflation, flattening of the diaphragm, bullae
second column:
prominent
large volume, can be purulent
frequent
obese, cyanotic
sleep apnea common
decreased
minimal to moderate
bronchovascular
acute bronchitis
patho:
Viruses implicated include:
- _____, parainfluenza, RSV, coronavirus, adenovirus, and rhinovirus ( order is from most to least common)
- Human metapneumovirus has also been identified as a causative agent
Bacteria implicated include:
- _____; _____
- 25% “atypical” Bacteria
- Bordetella pertussis; C. pneumoniae and Mycoplasma pneumonia
S/S:
- Cardinal clinical symptom is _____ of recent onset
- More extended period of cough (greater than _____ days) is useful in considering Bronchitis
- Patients usually seek care 4-7 days after onset of cough that is not resolving
- Cough may persist and might worsen over 1-3 weeks
- Associated symptoms:
- _____ production; fever; malaise; wheezing and dyspnea
Diagnosis:
- Acutely ill patients may not be able to distinguish early symptoms from URI
- Protracted cough beyond 1-5 days
- PFTs may become abnormal during this time with significant declines in _____
o If Bacterial: “atypical” bacteria (seen later in course). If concerned, start _____ and get serum levels or _____
o If Virus: rapid diagnostic tests exis
Tx:
•50-85% of patients receive ABX whether or not a bacterial cause has been identified. There is some reduction in cough with ABX tx however, it is not statistically significant
When prescribed, _____ (500mg qd x 3 days) best alternative
Or delay and use only in patients with persistent symptoms.
If atypical pathogens are suspected, consider pertussis and treat accordingly:
_____ x 14 days; _____ x1d or _____
Azithromycin and doxycycline are active against Mycoplasma and chlamydia
During influenza season:
_____ or _____
•_____ alone or in combination with antihistamines reduce the severity of the symptoms including cough
Differential:
- Differentiate from bronchiolitis: both MAY include sputum production, wheezing and shortness of breath; bronchiolitis should present with decreased breath sounds in the area of the lungs involved.
- Differentiate from Bronchiectasis (chronic dilation of bronchi and chronic cough
- Differentiate from Chronic Bronchitis: prolonged cough and sputum production for at least _____ of the year for _____ consecutive years
Influenza A and B
H flu
M Catarrhalis
cough
7
Sputum
FEV1
ABX
procalcitonin
Azithromycin
Erythromycin, azythromycin, doxycycline
Zanamivir
Oseltamivir
NSAIDs
3 months
2
chronic bronchitis
patho:
Chronic
Excessive tracheobronchial mucus production sufficient to cause _____ with _____ for most days of at least 3 months of the year for 2 consecutive years.
Hypertrophy of _____ glands in submucosa of large cartilaginous airways
_____ hyperplasia, mucosal and submucosal inflammatory cell infiltrate, oedema, peribronchial fibrosis, intraluminal _____ and increased _____ in small airways
The major site of airflow obstruction is in the _____ airways and the inflammatory infiltrate consists of neutrophils (in asthma eosinophils)
diagnostics:
Lab findings:
Arterial blood gas:
_____ occurs in advanced disease
Particularly with predominant chronic bronchitis
Compensated _____ occurs in patients with chronic respiratory failure
Particularly in chronic bronchitis with worsening of acidemia during acute exacerbations
CXR: nonspecific _____ and _____ markings
tx:
Increased mobilization of secretions
_____, effective cough training methods, hand-held flutter device and postural drainage
_____ and _____ should be used in selected patients with excessive amounts of retained secretions that cannot be cleared by cough
Expectorants are not recommended; cough suppressants avoided
cough
expectoration
mucus-producing
goblet cell
mucus plugs
smooth muscle
small
Hypoxemia
respiratory acidosis
peribronchial
perivascular
Hydration
Postural drainage
chest percussion
emphysema
patho:
Permanent abnormal distention of air spaces distal to the _____ with destruction of _____ (containing alveolar capillaries) and attachments to the bronchial walls
Denoted by abnormal permanent enlargement of _____ distal to the terminal bronchiole
With destruction of alveolar walls
Without obvious _____
Increase in number and size of _____ –> eventual destruction of alveolar septa and their attachments to terminal and respiratory bronchioles –> distention of alveolar spaces
S/S:
hallmark: _____
tx:
_____ is available for replacement therapy in congential deficiency
severe dyspnea may warrant clinical trial of _____
_____ for intractible dyspnea, may benefit anxious pts, can cause drowsiness
trans nasal psoitive pressure ventilation at home to rest the respiratory muscles
terminal bronchiole
alveolar septa
air spaces
fibrosis
alveolar fenestrae
dyspnea
human alpha 1 antitrypsin
opioid
diazepam
What is alpha-1 antitrypsin deficiency? How is it treated?
Family history and finding of _____ early in life; in the third or fourth decade
Hepatic cirrhosis and hepatocellular carcinoma
Tx: _____ is available for replacement therapy in congenital deficiency
panacinar bibasilar emphysema
Human Alpha 1 antitrypsin
pleural effusion
patho:
Increased fluid due to increased _____ or _____ (Transudates)
Abnormal capillary permeability (Exudates)
Decreased lymphatic drainage (Exudates)
Infection in the pleural space (empyema)
Bleeding into the pleural space (hemothorax)
Transudative:
_____ > 90% of all cases
_____ syndrome
Cirrhosis
_____
Peritoneal Dialysis
PE
Exudative:
Parapneumonic (pus in pleura)
_____
Pulmonary Embolism
_____
Traumatic
_____ (SLE, RA)
Drug induced, Uremia
S/S:
History and physical exam are critical
Dyspnea, cough and pleuritic chest pain are common
Fever: pneumonia, empyema, tuberculosis (Tb)
Hemoptysis: lung cancer, PE, or Tb
Weight Loss: _____, Tb, or lung abscess
Chest Exam:
_____ to percussion
Decreased _____
Signs:
Orthopnea (shortness of breath while lying flat), jvd, or peripheral edema (CHF)
Unilateral extremity swelling (PE)
Ascites (hepatic hydrothorax)
History:
Chest trauma (hemothorax)
Abdominal surgery (post-op effusion)
Post CABG surgery (pericarditis post MI: Dressler’s syndrome)
Alcoholism (pancreatic effusions)
Transudative Effusions
Imbalance in oncotic and hydrostatic pressures
No capillary leak or cytokine activation
Excessive formation or impaired _____
Limits the differential with no additional workup
—CHF, Cirrhosis, or Nephrotic Syndrome
If Exudative (from inflammation of _____ or decreased _____, more investigation required)
Method: _____
Appearance of Pleural Fluid:
-_____
Fetid = Empyema
Urine = Urinothorax
Bloody r/o hemothorax
Milky appearance: Chylothorax (Triglyceride > 110 mg/dL)
Pus : Empyema and complex pleural space
diagnostics:
- _____ and _____ CXR
- Decubiti for layering
- _____ for complex spaces
- _____ for direct visualization
tx:
- Transudative – not a reflection of true pulmonary disease. Treat underlying cause! _____ only done for severe dyspnea, done for therapeutic relief.
- Exudative – must determine the underlying condition! Treatment depends on the cause. Treatment may involve thoracentesis or _____
- Most patients should be _____ (thoracentesis)
–Newly recognized effusion
-Two exceptions:
–Small Effusions (< 1 cm on decubitus, USN required)
–Congestive Heart Failure:
—Thoracentesis only if bilateral effusions not _____
—Fever
—Pleuritic chest pain
—Impending respiratory failure
hydrostatic, oncotic pressures
Congestive Heart Failure
Nephrotic
Hydronephrosis
Malignancy
tuberculosis
Collagen Vascular
Malignancy
Dullness
breath sounds
absorption
pleura
lymphatic drainage
LIGHT’s Criteria
odor
PA
Lateral
CT chest
US
Thoracentesis
tube thoracotomy.
tapped
equal
lights criteria
if the fluid has one or more of the following, it is an exudate:
Pleural fluid total protein/ serum protein _____
Pleural fluid LDH/serum LDH > _____
Pleural fluid LDH > _____ upper limit for serum
Serum albumin minus pleural albumin _____
Pleural fluid total cholesterol _____
glusoce level < ______
>0.5
>0.6
>0.67
<1.2
>60 mg/dL
60
acute bronchiolitis
patho:
- _____ most common cause
- Proliferation and necrosis of _____ develops
- Obstruction occurs from _____ and increase mucus secretion
S/S:
PPP:
- Viral prodrome (fever, URI symptoms) for 1-2 days followed by respiratory distress (eg. Wheezing, tachypnea, nasal flaring, cyanosis, _____, rales)
- PPT:
- Low grade _____, tachypnea, wheezes
- _____ is most common presenting symptom
diagnostics:
- Mainly a clinical diagnosis
- _____ to detect viral load
- _____ is increasingly used
Tx:
PPP:
- _____ mainstay of treatment – _____, IV fluids, _____, mist humidifier, antipyretics (Acetaminophen)
- Mechanical ventilation be indicated if severe
- _____ may be administered if severe lung or heart disease or immunosuppressed
PPT:
NO SABA or coritcosteroids
_____: prophylactic administration, recommended for infants at risk for chronic lung disease of prematurity and congenital heart disease
RSV
bronchiolar epithelium
sloughed epithelium
retractions
fever
apnea
nasal washings
PCR
Supportive measures
humidified oxygen
nebulized saline
Ribivarin
Palvizumab
croup
patho:
- 65% of cases caused by _____ (hPIV)
- Transmitted by large-particle fomites via close person to person contact
S/S:
- Begins with _____ S/S:
- _____, rhinorrhea, pharyngitis without cervical adenopathy and low grade fever
- Symptoms persist for 3-5 days and may be unpredictable resulting in sudden respiratory failure
- raspy barking cough with notable _____, dyspnea and respiratory distress
- Symptoms are generally spasmodic and result from subglottic inflammation and edema
diagnostics:
- X ray shows “_____”; appears like a sharpened pencil.
- Generally on clinical and epidemiologic grounds
- Confirmed by isolation of the virus or detection of viral antigen or RNA in _____.
- _____ (RT-PCR) assay or viral culture
- Difficult in adults due to less shedding of the virus
tx:
For previously healthy children with croup
- General _____; sitting in the lap of the parent or caregiver
- Humidified air (mist) has been shown to have no benefits and actually is associated with adverse effects including anxiety, difficulty with cardio-respiratory monitoring and bacterial and fungal contamination of both hot and cold mist humidifiers
- _____ via “blow-by” method
Mild-moderate croup (i.e.: without stridor or significant chest wall indrawing at rest OR stridor and indrawing without agitation)
- Oral _____ 6mg/kg body weight and observation
- If improved, discharge to home
Severe Croup ( stridor, chest wall indrawing and agitation)
- Blow by _____
- •Inhaled racemic _____ (0.05 mL/kg body weight of a 2.25% solution of racemic epi for nebulization) up to a maximum dose of 0.5 mL; or _____ L-epi (0.5mL/kg of 1:1000 L epi) up to a maximum dose of 5 mL
- Concomitant _____
- Admission to the hospital if no significant clinical improvement is seen after several hours of observation and therapy
- NO ABX or SABA in children with croup
Human Parainfluenza virus
upper respiratory
Coryza
inspiratory stridor
steeple sign
respiratory secretions
Reverse transcription-polymerase chain reaction
comfort
Oxygen
dexamethasone
oxygen
epinephrine
nebulized
dexamethasone
pertussis
patho:
- Acute infection of the respiratory tract caused by _____
- Transmitted by respiratory droplets
S/S:
- Last about 6 weeks and are divided into three consecutive stages:
- _____: characterized by its insidious onset with lacrimation, sneezing and coryza, anorexia and malaise. Hacking Night Cough that becomes diurnal
- _____ state is characterized by bursts of rapid consecutive coughs followed by a deep, high-pitched inspiration (whoop)
- _____ stage begins 4 weeks after onset of the illness with a decrease in the frequency and severity of paroxysms of cough
- Cough persisting more than _____ is suggestive
- Infection may also be asymptomatic
diagnostics:
Clinical findings:
- _____ count is usually 15,000-20,000/mcl (rarely as high as 50,000 mcL or more)
- Diagnosis is established by isolating the organism from the _____ culture
- Special medium (_____) must be requested
- _____ may be availale
tx:
ABX in all suspected cases
Macrolide
- _____
- _____
- _____
Trimethoprim-sulfamethoxazole
B pertussis
Catarrhal stage
Paroxysmal
convalescent
2 weeks
White cell
nasopharyngeal
gengou agar
PCR
Erythromycin
Azithromycin
Clarithromycin
Categories of pulmonary HTN
Group 1 (pulmonary arterial hypertension): Group of diseases, including _____ that directly affect the pulmonary arteries, resulting in structural changes, smooth muscle hypertrophy, and endothelial dysfunction. Other causes beside idiopathic include HIV, drugs, toxins, connective tissue disorders, schistosomiasis, etc.
Group 2: pulmonary hypertension due to _____, this is the most common type because L sided heart failure is quite common.
Group 3: Pulmonary hypertension associated with _____ and/or _____
Group 4: pulmonary hypertension due to _____ and/or _____ disease, pulmonary embolism in the distal pulmonary arteries, embolization of other matters such as tumor cells or parasites
Group 5: anything that doesn’t fit into one of the other categories
idiopathic pulmonary arterial hypertension
L sided heart disease
lung disease
hypoxemia
chronic thrombotic
embolic
WHO classification of symptoms in patients with pulmonary hypertension
- class 1: symptoms do not limit physical activity. ordinary activity does not cause undue _____
- class 2: slight limitation of physcial activity. the patient is comfortable at rest, yet expereinces symptoms with _____ physcial activity
- class 3: marked limitation of physical activity. the patient is comfortable at rest, yet expereines symptoms with _____ physcial activity
- class 4: inability to carry out any physical activity. the patient may experience symptoms even at _____. discomfort is increased by any _____. these patients manifest signs of _____
discomfort
ordinary
minimum
rest
physical activity
right sided heart failure
pulmonary hypertension
patho:
- Whatever the initial cause, pulmonary arterial hypertension involves the vasoconstriction or tightening of blood vessels connected to and within the lungs
- This makes it harder for the heart to pump blood through the lungs
- Over time, the affected blood vessels become both stiffer and thicker: fibrosis
- This increases the BP in the lungs further and impairs blood flow
- Increased workload causes hypertrophy of the right ventricle
- Failure of the right heart: _____
- As the blood flowing through the lung decreases, the left side of the heart receives less blood, and it is _____ poor
- SOB especially during activity
S/S:
- Exertional dyspnea
- Lethargy
- Fatigue
- Other less common sxs:
- Cough
- Hemoptysis
- hoarseness (ie, Ortner’s syndrome)- compression of the left recurrent laryngeal nerve by a dilated main pulmonary artery
PE findings: Heart sounds
- Increased intensity of the pulmonic component of the second heart sound
- May even become palpable
- PH patients: S2 = narrowly split
- Systolic ejection murmur
- In more severe disease: a diastolic pulmonic regurgitation murmur
PE findings: right ventricle failure
- Systemic venous hypertension: elevated jugular venous pressure, right ventricular _____ heart sound, high pitched _____ accompanied by a prominent V wave. In the jugular venous pulse tricuspid _____ is present, _____, _____ liver, peripheral edema, ascites may exist
diagnostics:
Determine this prior to initiation of therapy:
- Functional significance: exercise capacity
- _____/Right heart catheterization: pulmonary artery systolic pressure and right ventricular capacity
- Chest radiograph: Enlargement of the _____ with attenuation of the peripheral vessels
- Oligemic (reduced blood volume) lung fields
- _____ enlargement
- Diminished retrosternal space
- Right arterial _____
- Prominent right heart border
- Occasionally, the underlying cause of the PH is apparent on the chest radiograph (eg, interstitial lung disease)
- EKG: right ventricular hypertrophy or strain (chronic right ventricular overload may exist)
tx:
- In secondary pulmonary HTN:
- Treat underlying disorder
- If hypoxemia or acidosis detected:
- _____ for 15 hours per day
- Permanent _____ if at high risk for thromboembolism
- Group 1:
- Treat any underlying cause
- Medications do not “cure” the underlying lesion, but aim to reduce the pulmonary HTN itself
- First line for Group One is generally considered a _____ ( _____ or _____ )
- Patients must go a “trial run” of a CCB in the cardiac cath lab, and then the medication is prescribed ONLY to positive responders
- For patients in functional class II, medications include oral endothelian receptor antagonists (_____, _____), phosphodiesterase inhibitors (PDE-5 inhibitors) (_____, _____), soluble guanylate cyclase stimulators (riociguat)
- For patients in functional class III or IV, or patients who do not respond to the above therapies, can add _____ agents (IV epoprostenol, SQ and IV teprostenol, inhaled iloprost)
- Group 2: treat cardiac disease
- Group 3: treat underlying cause, supplemental oxygen!
- Group 4: long term anticoagulation
cor pulmonale
oxygen
third
tricuspid murmur
regurgitation
hepatomegaly
pulsatile
ECHO
central pulmonary arteries
Right ventricular
dilation
Supplemental O2
anticoagulation
CCB (Nifedipine or Diltiazem)
ambrisentan, bosentan
sildenafil, tadalafil
prostanoid
pulmonary embolism
patho:
- It is a complication of underlying venous thrombosis
- Under normal conditions, _____ (tiny aggregates of red cells, platelets, and fibrin) are formed and lysed continually within the venous circulatory system
- Under pathological conditions, microthrombi may escape the normal fibrinolytic system to grow and propagate
- Pulmonary embolism (PE) occurs when these propagating clots break loose and embolize to block pulmonary blood vessels
- Thrombosis in the veins is triggered by _____, _____, and _____
- These 3 underlying causes are known as the _____
- All known clinical risk factors for DVT and PE have their basis in one or more elements of the triad
- Thombi only in calf rarely embolize to pulmonary circulation
- About 20% of calf vein thrombi propagate proximally (popliteal/ileofemoralveins)
- Then they break off and embolize to lungs
- Pulmonary emboli will develop in 50-60% of patients with proximal deep venous thrombosis (DVT)
- ½ of those events asymptomatic!
- ~ 70 % of symptomatic PE patients will have lower extremity DVT when you look
S/S:
PE and phyisological effects:
- Physical obstruction from the emboli and resultant vasoconstriction increase _____ (pressure goes up)
- Massive thrombus: might cause _____ failure
- Vascular obstruction
- Increased dead space
- Hypoxemia
- Right to left shunting
- Decreased cardiac output
- _____ depletion
- Atelectasis
- Reflex bronchoconstriction
- wheezing, increased work of breathing
- Classic symptoms:
- _____
- _____
- _____
- Syncope
- Tachypnea
- Classic triad: The classic triad of signs and symptoms of PE (hemoptysis, dyspnea, chest pain) are neither sensitive nor specific
- Might see:
- chest wall tenderness
- back pain, shoulder pain
- upper abdominal pain
- painful respiration
- new onset of wheezing
- any new cardiac arrhythmia
diagnostics:
Workup Labs:
- May show acute _____
- The PO2 on arterial blood gases analysis (ABG) has a zero or even negative predictive value in a typical population of patients in whom PE is suspected clinically
- Pulse oximetry is extremely insensitive, is normal in the majority of patients with PE, and should not be used to direct a diagnostic workup
- The white blood cell (WBC) count may be normal or elevated
- A WBC count as high as 20,000 is not uncommon in patients with PE
- Clotting study results are normal in most patients with pulmonary thromboembolism
- D-Dimer
- Use _____ method
- Test nonspecific, however (-) D-Dimer is strong evidence _____
- Imaging:
- _____ usually normal
- Over time may show atelectasis, may progress to cause small pleural effusion & hemidiaphragm
- Rarely will show _____ sign
- _____ (spiral) pulmonary angiography is usually initial diagnostic study
- A normal helical CT alone does not exclude PE in high risk patients
- Give empiric therapy or further testing
- Pulmonary angiography “gold standard”
- Very _____, but very accurate
- Duplex/Doppler Scan (_____) –
- (-) does not r/o PE
- Compressible = no DVT; Non compressible = DVT
- ECG
- Most common is tachycardia
- Diagnostic Algorithm
- High, moderate, low
- PE unlikely: rapid quantitative _____
- Negative: VTE excluded: follow OFF anticoagulation
- Positive: Helical CT
- Normal: PE diagnosis negative
- Indeterminate: LE U/S or pulmonary angiography
- Findings of PE: treat for. PE
- PE likely by clinical probability: straight to _____
tx:
- Think ABCs: airway, breathing, circulation
- Decide between _____ (clot busting) or _____ (clot preventing)
- Consider fibrinolytic (alteplase) in ____ unstable patients (refractory hypotension, hypoxemia). Patients at high risk of death! Absolute contraindications to fibrinolytics: active _____, stroke
Anticoagulants: not a definitive treatment, does not dissolve clot just prevents new ones from forming
- In a suspected PE, often start with _____
- Can also use _____ (Coumadin)
- LMWH (Enoxaparin) also approved for prophylaxis and treatment of DVT/PE
- Direct oral anticoagulants
How long to anticoagulate?
- First episode (reversible risk factor) PE: _____ anti-coagulation
- First episode (idiopathic) PE: _____
- Nonreversible risk factors or recurrent disease: _____ to indefinitely
- Placement of Filter
- Primary indication for placement of IVC filter in the setting of pulmonary embolism include: contraindications to anticoagulation, major bleeding complications, and recurrent embolization while patient is receiving adequate therapy
Pregnancy:
- DVT and PE common in pregnant women during all trimesters and 6-12 weeks after delivery
- Diagnostic approach should be exactly the same as nonpregnant people
- A nuclear perfusion lung scan is safe in pregnancy
- A chest CT is safe in pregnancy
- Heparin is safe in pregnancy
- Fibrinolysis is safe in pregnancy
- Failure to treat the mother properly is the most common cause of fetal demise
- _____ is NOT safe in pregnancy
risk factors:
- Those factors that increase _____ (venous stasis)
- Bed rest, post-op period, obesity, stroke, other neurologic or musculoskeletal disorders
- Those factors that increase blood viscosity
- _____, polycythemia, low cardiac output
- Hypercoagulable states
- ´Hormone therapy, _____, hematologic disorder
microthrombi
venostasis, hypercoagulability, and vessel wall inflammation
Virchow triad
pulmonary vascular resistance
right ventricular
Surfactant
dyspnea
hemoptysis
chest pain
respiratory alkalosis
ELISA
against PE
Chest radiograph
Westermark
Helical CT
invasive
Ultrasoundography
ELISA D-dimer
helical CT
fibrinolytic
anticoagulant
hemodynamically
internal bleeding
heparin IV
Warfarin
3-6 months
12 months
6-12 months
Warfarin
immobility
Pregnancy
malignancy
chronic bronchiolitis
- Essentials of Diagnosis: insidious onset of cough and dyspnea,
- Irreversible air-flow obstruction on PFT
- Risk factors: _____, viral infections, organ transplantation, _____ disease
Constrictive bronchiolitis:
- Most common finding following _____
- Also seen in RA, medication reactions and chronic rejection following heart-lung, lung or bone marrow transplant
- Diagnosis requires _____
- _____ to tx- progressive
Proliferative bronchiolitis
- Associated with infection, aspiration, ARDS, hypersensitivity pneumonitis, connective tissue diseases and organ transplantation
- More likely to have abnormal _____(compared to constrictive)
- Tx: _____
- Relapse common when meds discontinued
Cryptogenic organizing pneumonitis (COP)
- Typically dry cough, dyspnea and constitutional symptoms for weeks to months prior to seeking medical attention
- History of preceding _____ illness
- PFT reveals restrictive defect and impaired _____
- CXR: bilateral patchy, ground _____ or _____ infiltrates
- Tx: _____
- Many pts have full recovery
Follicular Bronchiolitis
- Associated with _____ disease (RA, Sjogrens)
- Progressive dyspnea
- Chest x-ray shows areas of ground glass opacity
- Treatment involves managing underlying _____ disease
Respiratory Bronchiolitis
- Usually occur without symptoms or physiological evidence of lung impairment
Diffuse Panbronchiolitis
- Diagnosed in Japan
- Most patients has history of chronic pansinusitis
- PFTs: obstructive abnormalities
- Treat with _____
toxic fumes
viral
connective tissue
inhalation injury
lung biopsy
Unresponsive
chest x-ray
steroids
viral
oxygenation
glass
alveolar
steroids
connective tissue
CT
antibiotics
