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PANCE/EOC > Pulm #5 > Flashcards

Pulm #5 Flashcards

1
Q

What is a pneumothorax?

A

-Air in the pleural space leading to collapse of the lung from positive intrapleural air pressure

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2
Q

What is a primary spontaneous pneumothorax vs a secondary spontaneous pneumothorax?

A
  • Primary: atraumatic and no underlying lung disease. Tall, thin men who are smokers
  • Secondary: underlying lung disease
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3
Q

A tension pneumothorax is any type in which

A

positive air pressure pushes the trachea, great vessels, and heart to the contralateral side

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4
Q

Symptoms and physical exam findings of a pneumothorax

A
  • Chest pain, unilateral and pleuritic. Sudden, dyspnea
  • Hyperresonance to percussion, decreased fremitus, and decreased breath sounds
  • Tension: Increased JVP, systemic hypotension, pulsus paradoxus
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5
Q

Initial diagnostic for a pneumothorax

A
  • Chest radiograph (expiratory upright view)
  • -Companion lines: visceral pleura line running parallel with ribs
  • -Decreased peripheral markings
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6
Q

Treatment for small PSP < 3 cm from chest wall at apex

A

Observation and supplemental oxygen

  • May be discharged if stable and repeat films after 6 hours excludes progression
  • Chest tube thoracotomy is worse on repeat films
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7
Q

Treatment for large PSP ( > 3 cm from chest wall at the apex)

A

Needle or catheter aspiration vs chest tube or chest thoracotomy

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8
Q

If the pneumothorax is a stable secondary spontaneous type, what is the treatment?

A

Chest tube or catheter thoracotomy + hospitalization

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9
Q

If the pneumothorax is a tension type from a car accident, during CPR, or PEEP ventilation, what is the treatment?

A

-Needle aspiration followed by chest tube thoracostamy

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10
Q

Patient education if they have a pneumothorax?

A

-Avoid pressure changes for 2 weeks (high altitudes, smoking, unpressurized aircrafts, scuba diving)

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11
Q

What is pulmonary hypertension defined as?

A

Elevated mean pulmonary arterial pressure > 20 mmHg with a pulmonary vascular resistance > 3 Wood units

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12
Q

What is the pathophysiology of pulmonary hypertension?

A

Increased pulmonary vascular resistance leads to RVH, increased RV pressure and eventually right sided heart failure

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13
Q

Primary pulmonary HTN most commonly affects middle-aged or young women. It is a defect in what gene?

A

BMPR2

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14
Q

Symptoms and PE findings of pulmonary HTN

A
  • Dyspnea, fatigue, cyanosis edema
  • Accentuated S2
  • Signs of right-sided HF: increased JVP, peripheral edema, ascites
  • Pulmonary regurgitation, right ventricular heave, systolic ejection click
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15
Q

Diagnostics for pulmonary HTN

A
  • CXR: enlarged pulmonary arteries, signs of right sided HF
  • ECG: Cor Pulmonale (RVH, right axis deviation)
  • Echo: large right ventricle, RVH
  • Right heart catheterization: DEFINITIVE
  • CBC: Polycythemia and increased hematocrit
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16
Q

In a primary pulmonary HTN case, what is the initial treatment?

A

-Vasoreactivity trial with inhaled Nitric oxide, IV Adenosine or CCB

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17
Q

And if the patient is vasoreative, what are the first line medications

A

CCB (first line)

  • Prostacyclins (Esoprostenol)
  • PD5-inhibitors (Sildenafil)
  • Oxygen therapy
  • Long term anticoagulation in some
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18
Q

What is the definitive treatment in pulmonary HTN

A

-Heart-lung transplant

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19
Q

70% of pulmonary embolisms arise from

A

deep vein in the legs (majority of the rest are from pelvic veins)

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20
Q

Risk factors for a DVT?

A
  • Virchow’s Triad
  • -Intimal damage: trauma, infection, inflammation
  • -Hypercoagulability: Protein C or S deficiency, Factor V Leiden, OCP, Pregnancy, Smoking
  • -Stasis: immobilization, surgery, sitting > 4 hours
21
Q

Symptoms of a PE

A
  • Sudden onset of dyspnea + pleuritic chest pain + hemoptysis
  • Tachypnea, tachycardia, fever
  • Positive Homan Sign (not specific)
22
Q

a CXR is the first diagnostic ordered to evaluate chest pain. What is highly suspicious of a PE?

A

-Normal CXR in the setting of hypoxia

23
Q

However, what are other classic but rare findings of a PE on a CXR?

A
  • Westermark’s Sign: avascular markings distal to the PE

- Hampton’s Hump: wedge-shaped infiltrate due to infarction

24
Q

What does an ECG show in a PE?

A

Nonspecific ST/T changes and sinus tachycardia most commonly

-Right heart dysfunction: S1Q3T3 (wide deep S in lead 1; isolated Q and T wave inversion in III)

25
Q

What ABG is seen in a PE?

A

Respiratory alkalosis (secondary to hyperventilation

26
Q

When is a D-dimer helpful in a PE diagnostics?

A

-Only if negative and a low-suspicion for PE

27
Q

What are the confirmatory tests for a PE?

A
  • Helical (spiral) CT angiography: best initial test to confirm PE
  • V/Q scan: used when CT cannot be performed (pregnancy, increased Creatinine)
  • Pulmonary angiography: GOLD STANDARD DEFINITIVE
28
Q

Treatment for a PE if the patient is hemodynamically stable

A

-Anticoagulation: Heparin bridge + Warfarin or Dabigatran, Rivaroxaban, Apixaban

29
Q

When do you use an IVC filter if the patient is stable?

A
  • Anticoagulation is contraindicated (recent bleed, bleeding disorder)
  • Anticoagulation is unsuccessful (INR 2-3 on Warfarin, PE despite anticoagulation)
  • if RV dysfunction is seen on Echo
30
Q

In a hemodynamically unstable patient (SBP < 90, RV dysfunction), what is the treatment for a PE?

A
  • Thrombolysis

- Thrombectomy or Embolectomy: unstable or massive PE if thrombolysis contraindicated or ineffective

31
Q

What is the Well’s Criteria for a PE?

A
  • 3 points added
  • -Signs and symptoms of DVT
  • -PE is #1 diagnosis or likely
  • 1.5 points added
  • -Heart rate > 100
  • -Immobilization at least 3 days OR surgery in past 4 weeks
  • -previous DVT or PE
  • 1 point added
  • -Hemoptysis
  • -Malignancy with treatment within 6 months
32
Q

Point Scoring System for Well’s Criteria

A
  • Low probability of PE: < 2 points = May consider D-dimer
  • Moderate probability of PE: 2-6 points = CTA or high-sensitivity D-dimer
  • High probability of PE: > 6 points = CTA
33
Q

What are the three categories of PE Prophylaxis?

A
  • Early ambulation: low risk, minor procedures in patients < 40
  • Elastic stockings/compression stockings/boots: moderate risk
  • LMWH: orthopedic or neurosurgery, trauma
34
Q

Risk factors for sleep apnea

A
  • Obesity (strongest)
  • Age (60’s and 70’s)
  • Male Gender
35
Q

Symptoms of Sleep Apnea

A
  • Snoring, unrestful sleep –> daytime sleepiness
  • Nocturnal choking
  • Large neck circumference, crowded oropharynx, micrognathia (small lower jaw)
36
Q

What is the first-line diagnostic for sleep apnea?

A

In-laboratory polysomnography (15 or more events per hour)

37
Q

What is also used to quantify person’s perception of sleepiness and fatigue?

A

Epworth Sleepiness Scale

38
Q

Management of sleep apnea

A
  • Behavioral changes: weight loss, no ETOH, change in sleep positioning
  • CPAP is mainstay of treatment
  • oral appliances if CPAP doesn’t improve
  • Tracheostomy is definitive!
39
Q

Neonatal Respiratory Distress Syndrome is from

A
  • Insufficiency of surfactant production by an immature lung

- Primarily a lung disease in premature infants

40
Q

What is the MCC of death in first month of life

A

-Neonatal respiratory distress syndrome

41
Q

Surfactant production begins ______ weeks and by _____ weeks, enough surfactant is produced

A

24-28 weeks

by 35 weeks enough is produced

42
Q

Risk factors for Neonatal Respiratory Distress Syndrome

A
  • Caucasians
  • Males
  • Multiple births
  • Maternal Diabetes
  • C-section delivery
  • perinatal infections
43
Q

What is seen on CXR for neonatal respiratory distress?

A

-Bilateral diffuse reticular (ground glass) opacities + air bronchograms

44
Q

Treatment for neonatal respiratory distress syndrome?

A
  • Exogenous surfactant via endotracheal tube to open alveoli

- CPAP

45
Q

How to prevent neonatal respiratory distress syndrome

A

Antenatal glucocorticoids given to mature lungs if premature delivery expected (between 24-36 weeks)

46
Q

What are some signs of increased risk of a solitary pulmonary nodule?

A
  • Spiculated (radial shadow, like spokes)
  • large ( > 2 cm)
  • Irregular borders
  • Asymmetric calcification
  • Upper lobe location
  • > 40 years of age
  • Smoker
  • Abnormal PET scan
47
Q

What are some signs of decreased risk of a solitary pulmonary nodule?

A
  • Well circumscribed smooth borders
  • Small < 1 cm
  • Dense diffuse calcifications
  • < 30 years old
  • Nonsmoker
  • No change in size
  • Normal CT scan
48
Q

Diagnostic imaging for a solitary pulmonary nodule

A
  • CXR: initial test that revealed nodule
  • CT chest: to determine if malignant
  • PET scan: to determine metabolic functioning of nodule

PANCE/EOC (63 decks)

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