Pulm #5 Flashcards
What is a pneumothorax?
-Air in the pleural space leading to collapse of the lung from positive intrapleural air pressure
What is a primary spontaneous pneumothorax vs a secondary spontaneous pneumothorax?
- Primary: atraumatic and no underlying lung disease. Tall, thin men who are smokers
- Secondary: underlying lung disease
A tension pneumothorax is any type in which
positive air pressure pushes the trachea, great vessels, and heart to the contralateral side
Symptoms and physical exam findings of a pneumothorax
- Chest pain, unilateral and pleuritic. Sudden, dyspnea
- Hyperresonance to percussion, decreased fremitus, and decreased breath sounds
- Tension: Increased JVP, systemic hypotension, pulsus paradoxus
Initial diagnostic for a pneumothorax
- Chest radiograph (expiratory upright view)
- -Companion lines: visceral pleura line running parallel with ribs
- -Decreased peripheral markings
Treatment for small PSP < 3 cm from chest wall at apex
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
Treatment for large PSP ( > 3 cm from chest wall at the apex)
Needle or catheter aspiration vs chest tube or chest thoracotomy
If the pneumothorax is a stable secondary spontaneous type, what is the treatment?
Chest tube or catheter thoracotomy + hospitalization
If the pneumothorax is a tension type from a car accident, during CPR, or PEEP ventilation, what is the treatment?
-Needle aspiration followed by chest tube thoracostamy
Patient education if they have a pneumothorax?
-Avoid pressure changes for 2 weeks (high altitudes, smoking, unpressurized aircrafts, scuba diving)
What is pulmonary hypertension defined as?
Elevated mean pulmonary arterial pressure > 20 mmHg with a pulmonary vascular resistance > 3 Wood units
What is the pathophysiology of pulmonary hypertension?
Increased pulmonary vascular resistance leads to RVH, increased RV pressure and eventually right sided heart failure
Primary pulmonary HTN most commonly affects middle-aged or young women. It is a defect in what gene?
BMPR2
Symptoms and PE findings of pulmonary HTN
- Dyspnea, fatigue, cyanosis edema
- Accentuated S2
- Signs of right-sided HF: increased JVP, peripheral edema, ascites
- Pulmonary regurgitation, right ventricular heave, systolic ejection click
Diagnostics for pulmonary HTN
- 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
In a primary pulmonary HTN case, what is the initial treatment?
-Vasoreactivity trial with inhaled Nitric oxide, IV Adenosine or CCB
And if the patient is vasoreative, what are the first line medications
CCB (first line)
- Prostacyclins (Esoprostenol)
- PD5-inhibitors (Sildenafil)
- Oxygen therapy
- Long term anticoagulation in some
What is the definitive treatment in pulmonary HTN
-Heart-lung transplant
70% of pulmonary embolisms arise from
deep vein in the legs (majority of the rest are from pelvic veins)
Risk factors for a DVT?
- 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
Symptoms of a PE
- Sudden onset of dyspnea + pleuritic chest pain + hemoptysis
- Tachypnea, tachycardia, fever
- Positive Homan Sign (not specific)
a CXR is the first diagnostic ordered to evaluate chest pain. What is highly suspicious of a PE?
-Normal CXR in the setting of hypoxia
However, what are other classic but rare findings of a PE on a CXR?
- Westermark’s Sign: avascular markings distal to the PE
- Hampton’s Hump: wedge-shaped infiltrate due to infarction
What does an ECG show in a PE?
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)
What ABG is seen in a PE?
Respiratory alkalosis (secondary to hyperventilation
When is a D-dimer helpful in a PE diagnostics?
-Only if negative and a low-suspicion for PE
What are the confirmatory tests for a PE?
- 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
Treatment for a PE if the patient is hemodynamically stable
-Anticoagulation: Heparin bridge + Warfarin or Dabigatran, Rivaroxaban, Apixaban
When do you use an IVC filter if the patient is stable?
- 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
In a hemodynamically unstable patient (SBP < 90, RV dysfunction), what is the treatment for a PE?
- Thrombolysis
- Thrombectomy or Embolectomy: unstable or massive PE if thrombolysis contraindicated or ineffective
What is the Well’s Criteria for a PE?
- 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
Point Scoring System for Well’s Criteria
- 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
What are the three categories of PE Prophylaxis?
- Early ambulation: low risk, minor procedures in patients < 40
- Elastic stockings/compression stockings/boots: moderate risk
- LMWH: orthopedic or neurosurgery, trauma
Risk factors for sleep apnea
- Obesity (strongest)
- Age (60’s and 70’s)
- Male Gender
Symptoms of Sleep Apnea
- Snoring, unrestful sleep –> daytime sleepiness
- Nocturnal choking
- Large neck circumference, crowded oropharynx, micrognathia (small lower jaw)
What is the first-line diagnostic for sleep apnea?
In-laboratory polysomnography (15 or more events per hour)
What is also used to quantify person’s perception of sleepiness and fatigue?
Epworth Sleepiness Scale
Management of sleep apnea
- 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!
Neonatal Respiratory Distress Syndrome is from
- Insufficiency of surfactant production by an immature lung
- Primarily a lung disease in premature infants
What is the MCC of death in first month of life
-Neonatal respiratory distress syndrome
Surfactant production begins ______ weeks and by _____ weeks, enough surfactant is produced
24-28 weeks
by 35 weeks enough is produced
Risk factors for Neonatal Respiratory Distress Syndrome
- Caucasians
- Males
- Multiple births
- Maternal Diabetes
- C-section delivery
- perinatal infections
What is seen on CXR for neonatal respiratory distress?
-Bilateral diffuse reticular (ground glass) opacities + air bronchograms
Treatment for neonatal respiratory distress syndrome?
- Exogenous surfactant via endotracheal tube to open alveoli
- CPAP
How to prevent neonatal respiratory distress syndrome
Antenatal glucocorticoids given to mature lungs if premature delivery expected (between 24-36 weeks)
What are some signs of increased risk of a solitary pulmonary nodule?
- Spiculated (radial shadow, like spokes)
- large ( > 2 cm)
- Irregular borders
- Asymmetric calcification
- Upper lobe location
- > 40 years of age
- Smoker
- Abnormal PET scan
What are some signs of decreased risk of a solitary pulmonary nodule?
- Well circumscribed smooth borders
- Small < 1 cm
- Dense diffuse calcifications
- < 30 years old
- Nonsmoker
- No change in size
- Normal CT scan
Diagnostic imaging for a solitary pulmonary nodule
- CXR: initial test that revealed nodule
- CT chest: to determine if malignant
- PET scan: to determine metabolic functioning of nodule
