Pulm Block 2 Flashcards

1
Q

What is the trifecta of issues smoke inhalation has on the body?

Why is this type of injury so deadly?

What type of injury affects the whole airway

A

Thermal to upper airway
Impaired tissue oxygenation
Chemical to lower airway

CO binds to Hgb 250x easier than O2, leading cause of poisoning death worldwide

Steam

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2
Q

Smoke inhalation that causes thermal injury to the respirator tract can create ? sound to be heard during PE due to what characteristic injuries

How long can it take for these complications to show and why?

Cyanide poisoning inhibits ? enzyme causing Pts to present w/ ? Sxs

A

Inspiratory stridor due to bronchospasm/bronchorrhea

18-24hrs later
Neutrophilic inflammation causing edemal/ulceration

Cytochrome- shock, lactic acidosis, coma

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3
Q

What finding would be indicative PT has cyanide poisoning?

How are PTs w/ thermal injury smoke inhalation injuries Tx?

What secondary illnesses are present at specific times after the initial injury?

A

Inc venous O2 saturation

High humidity O2
Elevate head to 30*
ABG/PO2 monitoring
Topical Epi- reduces edema/
Suction, gentle 

ARDS: 1-2 days
Pneumonia: 5-7 days

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4
Q

What Tx/management step is added to PTs w/ chemical injury to their airways from gases/products of combustion?

What two Tx types are avoided in these PTs?

A

PEEP for bronchiolar edema
Daily sputum Gram stains

CCS
ABX

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5
Q

Even if PTs w/ severe body burns and smoke inhalation survive, they need constant f/u monitoring for the development of ? which appears as ?

A

Bronchiolitis Obliterans

CT shows ground glass, bronchial wall thickening and honey comb appearance

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6
Q

Define Pneumoconioses

How do these PTs present?

How are they Tx?

A

Chronic fibrotic lung Dzs from inhalation of inorganic dusts

ASx w/ diffuse nodular opacities on CXR

Life shortening Dz w/ supportive Tx

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7
Q

What causes coal dust to be absorbed and turned into Black Lung Dz

What are the growths seen on CXR called?

A

Alveolar macrophages ingest dust and consolidate in upper lung areas

Coal macules: 2-5mm in upper fields

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8
Q

What is the difference between Simple and Complicated Coal Worker’s Dz?

Complicated Dz complications are similar and seen in ? other pneumoconiosis Dz?

A

Simple: ASx
Complicated: massive fibrosis w/ irregular masses >1cm w/ upper lung contractions

Complicated silicosis

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9
Q

What causes Silicosis lung dz?

How does this Dz on CXR?

A

Quarries/mines of quartz, granite, sandstone

Small round opacities
Calcification of hilar lymph nodes- eggshell calcifications

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10
Q

How does Simple Silicosis present?

How does Complicated Silicosis present?

A

ASx
Normal PFTs

Irregular masses >1cm
Inc upper lung densities
Obstruct/Restrictive PFTs

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11
Q

Silicosis PTs have an increased risk of contracting ? lung infection

Why is there this increased risk?

A

Infections requiring macrophage defenses: Fungi Atypical mycobacteria TB

Silica is cytotoxic to alveolar macrophages

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12
Q

All silicosis PTs need to have updated/on records results of ? 2 things?

How does asbestosis present?

A

TB skin test
CXR

Dyspnea
Inspiratory crackles
Clubbing/cyanosis

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13
Q

How does Asbestosis appear on CXRs?

What CXR finding holds the best Dx value?

A

Linear streaks in lower fields
Various size opacities
Honey comb changes if advanced Dz

Pleural calcifications

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14
Q

What image modality has the best imaging ability of asbestosis?

What does this imaging allow providers to see?

A

High Res CT

Parenchyma fibrosis
Pleural plaques

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15
Q

What would be seen on PFT in a PT w/ asbestos

What is done for these PTs as Tx?

A

Restrictive pattern
Reduced FVC and FEV1
Normal/Inc FEV1/FVC ratio
Reduced DLCO

O2 for SoB
Resp PT to remove secretions

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16
Q

Hypersensitivity Pneumonitis is AKA ?

What type of d/o is this?

A

Extrinsic Allergic Alveolitis

Inflammatory d/o involving alveolar walls and terminal airways

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17
Q

What causes Hypersensitivity Pneumonitis

What causes Bagassosis

A

Exposure to inhaled organic agent leading to an acute illness

Moldy sugar cane fiber

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18
Q

What causes Sequoiosis

What causes Suberosis

What causes Detergent Worker’s lung

A

Moldy redwood saw dust

Moldy cork dust

Enzyme additives

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19
Q

How does acute Hypersensitivity Pneumonitis present?

What will be seen on PE?

What would be seen on lab results?

What will be seen on CXR

What would be seen on PFTs?

A

Sudden F/C/N
Dyspnea

Crackles, Tachy/Tachy

Neutrophilia/L shift
Inc ESR/CRP

Nodular densities except in Apex/Bases

Restrictive dysfunction
Reduced DLCO

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20
Q

How does Subacute Hypersensitive Pneumonitis present

What is seen on CXRs

How is if definitively Dx?

A

Wks-Mon of:
Chronic cough
Dyspnea, Anorexia/Wt loss

Fibrosis/honey comb

Lung biopsy

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21
Q

How is Hypersensitive Pneumonitis Tx

What are the 3 types of obstructive airway d/os?

A

Acute- self limiting/recovery
Severe/protracted: PO CCS w/ 4-6wk taper

Byssiniosis
Industrial bronchitis
Occupational asthma

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22
Q

Define Industrial Bronchitis

This respiratory Dz rarely ?

A

Chronic bronchitis seen in coal miners, exposure to cotton, flax or hemp

Leads to chronic disability

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23
Q

Define Byssinosis

How does it present?

What happens if exposure is not d/c?

A

Asthma like d/o in textile workers from inhalation of cotton dust

Tight chest, Cough, Dyspnea- worse on 1st day back to work, better later in week

Chronic bronchitis

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24
Q

Define Silo-Fillers Dz

What is a common finding late in this Dz

A

Toxic lung injury causing pulmonary edema due to inhalation of N-dioxide

Bronchiolitis obliterans

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25
How is Silo Filler's related bronchiolitis obliterans prevented? What happens if exposure is not d/c'd?
CCS Fatal
26
What causes Popcorn Lung What is one of the MC causes of ARDS
Inhalation of diacetyl (butter flavoring) leading to bronchiolitis obliterans Acute aspiration of gastric contents
27
What are the S/Sxs of acute aspiration of gastric contents What is seen on labs? What is seen on CXR?
Cough Wheeze Fever Tachypnea w/ base crackles Fever even w/out infection Hypoxemia Leukocytosis Patches of alveolar opacities in dependent lung fields
28
How are PTs w/ acute aspiration of gastric contents managed? What is the secondary infection risk for these PTs?
Intubate/ventilate Fluids- HOTN management No ABX/CCS 25% of PTs 2-3 days later
29
What can cause Chronic Aspiration of Gastric contents What habits can cause relaxation of the LES which can lead to this d/o?
Primary d/o of larynx/esophagus Smoking Theophylline ETOH Caffeine
30
What pulmonary d/os are linked to GERD and chronic aspiration? What causes Hydrocarbon pneumonitis How are PTs w/ hydrocarbon pneumonitis Tx?
Bronchiectasis Cough Asthma Pulmonary fibrosis Aspiration of ingested petroleum distillates Support/protection: cuffed ET tube
31
How does acute radiation pneumonitis present? What will be seen on CXR? How is this Tx?
Acute onset: 2-3mon after radiation completion Insidious dyspnea, dry cough, angina, weakness, fever Alveolar/nodular opacities in the irradiated areas Prednisone
32
What can radiation pneumonitis progress to? How does this present? What would be seen on imaging?
Pulmonary Radiation Fibrosis Slow onset dyspnea Reduced volumes Opacities Obliterated lung markings Tented diaphragm
33
Obesity Hypoventilation Syndrome is AKA ? What causes this syndrome?
Pickwickian Syndrome Blunted ventilatory drive Inc mechanical load on chest due to obesity- leads to alveolar hypoventilation, hypoxemia, elevated PaCO2
34
How is Pickwickian Syndrome Tx
Weight loss- improves hypercapnia, hypoxemia NPPV Stimulants: Theophylline, Acetazolamide, Medroxyprogesterone
35
# Define OSA What are the risk factors for developing this?
Upper airway obstruction due to loss of pharyngeal muscle tone allowing for passive collapse during inspiration Tonsillar hypertrophy Obesity Micrognathia- small jaw Macroglossia
36
What are additional/non-anatomical risk factors for developing OSA? What PT population is OSA MC in?
Testosterone supplementation Smoking Hypothyroidism Obese, middle age men
37
When is OSA a considered Dx during a PE? What is the first S/Sx that may be reported? What Mallampati score is common for this Dx?
Refractory HTN Personality changes 4
38
What labs are ordered when suspecting OSA? How is OSA severity classified?
CBC- common erythrocytosis TSH/fT4 Apnea Hypopnea Index: number of apnea/hypopnea events per hour of sleep Normal= 0-4 Mild= 5-14 Moderate= 15-29 Severe= +30 or O2 sat <90 for >20% of study
39
What will be seen in a AHI of 5-14 What may be noticed in moderate score PTs? What may be seen in PTs w/ AHI scores of +30
No impairment on life, noticed by family Noticed by PT when energy inc due to weight loss/cessation of ETOH Daytime sleepiness HTN Daytime sleepiness
40
PTs w/ AHI scores above 30 are 3x more likely to develop ? Dzs How is OSA Tx?
CAD HTN Arrythmias DM2 Weight loss Avoid ETOH/Sedatives Mild: oral devices Mod/Sev: nightly nasal CPAP
41
When surgery is considered for OSA, what is the procedure? What procedure is saved for a last resort in PTs w/ arrhythmias and failed conservative Tx?
UPPP- uvulopalatopharyngoplasty Resection of soft tissues Nasal septoplasty Trachoestomy
42
What is NOT used during OSA Tx and why What is the #3 MC cause of death in hospitalized PTs?
O2- dec desaturation, lengthens apneas PEs
43
What "things" can embolize into pulmonary circulation? What is the MC 'thing'?
``` Foreign bodies Fat Rumor cells Air Parasite eggs Septic emboli ``` Thrombus from deep veins of LE
44
What blood issues can create a hyperviscosity state for DVTs What can cause increased central venous pressures?
Polycythemia Pregnancy CHF/low CO
45
What are examples of inherited states of hypercoagulability
Factor V Leiden mutation Deficient/dysfuntion of Antithrombin 3, Prothrombin, Protein C/S Antiphospholipid syndrome- Lupus, anticardiolipin Ab
46
What are two immediate effects when a PE becomes lodged? What are two effects that can become systemic after this obstruction occurs?
Obstructed vascular bed Reflex constriction= wheeze and inc work to breathe Inc dead space Hypoxemia (R to L shunt, dec CO)
47
A massive thrombus can possibly be the cause of ? What Sxs can PTs w/ a PE present with?
R ventricle failure ``` Dyspnea Pain w/ inspiration Cough Hemoptysis Wheeze ```
48
What signs can PTs w/ PEs present w/? What are the top 3 presenting S/Sxs
Tachypnea Crackles S4 Homans sign Dyspnea Pain w/ inspiration Tachypnea
49
PTs w/ a massive PE may present w/ ? issue What is the MC EKG sign?
Syncope Sinus tach ST and T wave changes
50
# Define McGinn White Sign What would an ABG result show in a PT w/ a PE?
S1Q3T3 on EKG for PE and Cor Pulmonale Respiratory alkalosis due to hyperventilation
51
# Define a D-Dimer test What other hematological findings are not Dx but useful for Dx PEs?
Degradation production of cross linked fibrin that i elevated w/ thrombus Troponin I, T, B and BNP: carrelate w/ poor outcome due to R heart strain
52
What CXR finding is most suggestive of a PE? What are the MC findings?
Hypoxia w/ normal CXR Atelectasis Pleural effusions
53
What are two rare/less common CXR findings during a PE? What is the study of choice for suspected PEs?
Westermark sign: proximal central pulmonary artery w/ local oligemia Hampton hump: wedge shaped opacity representing intraparenchymal hemorrhage 2 Helical CT pulmonary angiogram
54
How does a V/Q scan work? These scans are usually done in conjunction w/ ? other study?
Radiolableled albumin into circulation to detect low blood flow Ventilation scan- Xenon gas, distribution is measured q15 sec
55
What V/Q scan results are highly suggestive of PEs 70% of PTs w/ PE have a ? but only 50% of these have a PE on angio
Perfusion defect w/out ventilation defect DVT
56
What is the TOC for proximal DVTs What used to be the gold standard but is now called the reference standard?
Venous ultrasonography Dx= inability to compress femoral/popliteal veins Pulmonary angiography- catheter through vein in groin to heart
57
When is pulmonary angiography warranted? What is the MC used algorithm for Dx PEs?
All other studies are inconclusive Dx must be established Helical CT unavail or c/i Rapid D-dimer Helical CT PA
58
Wells Criteria
``` DAHMN BC DVT Sxs- 3 Alternatives unexplained- 3 HR >100bpm- 1.5 Mobility reduced- 1.5 Nown Hx of DVT- 1.5 Bloody Cough- 1 CA (active or last 6mon)- 1 >6= high <2= low ```
59
How are PEs Tx
Anticoagulation- stops thrombus formations, NO dissolving ability Allows endogenous fibrinolytic lyses Heparin then PO Warfarin INR goal: 2-3
60
What are the anticoagulants used for PE Tx?
LMWH: SQ Enoxaparin IV UFH Fondaparinux: Factor Xa inhibitor All but Fonda 5-7 day combo w/ Warfarin overlap or until INR 2-3 for 24hrs D/c Heparin/Lovenox on day 5 or 6 after INR is in range x 24hrs
61
What are the new Factor Xa inhibitors that are used for PE Tx that don't require Warfarin over lap What are the benefits of using these meds? What are the risks though?
Apixaban Rivaroxaban Edoxaban No INR monitoring Andexxa- reverses Riva/Apixa No way to track/monitor compliance
62
Pregnant PTs w/ DVT risk are managed w/ ? anticoagulant? What meds are used to break up a PE?
LMWH Thrombolytics: Streptokinase, Urokinase, rt-PA Alteplase
63
How do thromblytic therapies work? What are the absolute c/i to using these? What are the major c/i?
Lysis of thrombin to increase plasmin levels but no inc of mortalitiy than heparin/warfarin Active internal bleeding Stroke in past 2mon Uncontrolled HTN Surgery/trauma past wks
64
When are IVC filters installed?
Recurrent embolisms despite adequate anticoagulation therapy Chronic emboli w/ PHTN PTs w/ c/i to anticoagulation therapy
65
How are PTs that are low/med/high risk for VTE formation positioned for prevention?
Low: young admitted for <24hrs, early ambulation Mod/high: low UFH/LMWH/Fondaparinux Mod/High w/ bleeding risk: compression stockings/foot pumps
66
# Define Interstitial Lung Dzs How do they present?
Group of d/os causing pulmonary inflammation and fibrosis Dyspnea, Crackles Septal thickening Reticular changes
67
What location is the issue of ILDz? Because of this location, what issues arise from it's position?
Distal, below bronchioles Obliterated capillaries and fibrosis
68
What is the pathophysiologic reason behind ILDz? What are the 3 MC etiologies? There is a strong correlation to ?
Injury Repair Fibroblast Proliferation Fibrosis Honeycomb PHTN Meds Dusts, in/organic Radiation CT dz
69
What is the major consequence of ILDz? What is the MC classification?
Impaired gas exchange idiopathic interstitial pneumonia: Idiopathic pulmonary fibrosis
70
What Dzs are found in x-rays in the upper lobes What Dzs would be seen in the middle/lower lobes?
Sarcoidosis Silicosis Idiopathic pulmonary fibrosis Subacute eosinophilic pneumonia Asbestosis
71
Hilar and mediastinal adenopathys are not common to ILD but are seen in ? 3 Dzs What would be seen on x-ray of chronic eosinophilic pneumonia
Sarcoid Berylliosis Silicosis Peripheral located infiltrates in uppler/middle lobes w/ clear hilar/central zones
72
What are 4 radiographic features on HRCT typical w/ idiopathic fibrosis Define idiopathic pulmonary fibrosis
Dec lung volume Honeycomb change Peripheral reticular change Lower lobe predominence Intersitial pneumonia w/out a cause (MC of these, 25% of ILDz)
73
? type of sample is often required for definitive Dx of Idiopathic Interstitial Pneumonias Define Pulmonary Fibrosis
Lung biopsy Scarring of the lung
74
# Define Usual Interstitial Pneumonias (UIP) When is a Dx of Idiopathic Pulmonary Fibrosis given
Lung injury characterized by collagen fibrosis w/ scarring in peripheral/pleural w/ honeycomb changes If cause/trigger of UIP is unknown MC form of ILD
75
What would be seen on x-ray of UIP What type of PFT is seen w/ IPF
Dec lung volume/fibrosis Uneven diaphragm Honeycomb Restrictive defect
76
How is IPF Tx? What is the average survivability from onset age to death What is the 2nd MC ILDz?
Prednisone Nintedanib/Pirfenidone O2 if <89% Only definitive: transplant Onset: 5th-6th decade 2-5yrs Sarcoidosis
77
# Define Sarcoidosis What PT population is usually affected? What age range does it usually present at?
Systematic granulomatosis Dz of unknown etiology AfAm/European 3-4th decade
78
What are the presenting Sxs of Sarcoidosis What will be seen on CXR What is an uncommon finding on PE
Cough, Dyspnea, Fatigue, Fever, Weight loss Hilar adenopathy Paratracheal lymphadenopathy Crackles
79
# Define Lofgren Syndrome Why is this important for Dx and PT comfort How is it Tx
Sarcoidosis Triad: Bilateral hilar lymphadenopathy Erythema nodosum Migratory polyarthralgia 95% specific for Dx, no need for biopsy NSAIDs Low dose CCS Colchicine Hydroxychloroquine
80
What is a rare presentation of Sarcoidosis What is the trifecta
Uveoparotid Fever Fever Uveitis Parotitis w/ or w/out CN7 palsy
81
Uveoparotid Fever can progress to ? Sxs and mimic? What lab findings may be seen?
``` Sicca Sxs (Latin for eyes/mouth) Sjogren's syndrome ``` Inc ACE levels Hyper Calcemia/uria Leukopenia Inc ESR
82
What will be sen on PFTs in sarcoidosis? How is the Dz staging accomplished?
Restrictive pattern Dec volume and diffusing capacity CXRs
83
What lab result is Dx for Sarcoidosis What 3 Dx have to be r/o
Biopsy of lymph node, skin lesion or salivary gland showing Noncaseating granulomas Lymphoma, Fungal, TB
84
How is Sarcoidosis Tx Pts w/ ? Sx/finding have the best prognosis What type of f/u or tracking is done for these PTs?
PO CCS Methotrexate if intolerant/poor response to CCS Only hilar adenopathy ``` Opto CXR CMP Annual physical PFTs EKG ```
85
# Define Pulmonary Alveolar Protein What are the usual presenting Sxs
Phospholipids in alveolar spaces from 1* (idiopathic) or 2* causes Progressive dyspnea/cough
86
What did Dr T find unique or interesting about Pulmonary Alveolar Proteinosis What are the defining characteristics of Eosinophilic Pulmonary Syndromes
Spontaneous remission Constitutional Sxs Lung tissue eosinophilia Inc eosiniphils in lavage fluids Peripheral blood eosinophilia
87
What can cause Eosinophilic Pulmonary Syndrome What is often associated w/ acute eosinophilic pneumonia
Meds: Nirto Phenytoin Ampicillin Acetominophen Ranitidine Helminth infection Initiation/resuming smoking
88
How is acute eosinophilic pulmonary pneumonia Tx What is the difference in presentation of this dz in chronic form?
PO CCS More common in women and non-smokers Asthma
89
Granulomatosis w/ polyangiitis used to be called ? This idiopathic Dz is characterized by ?
Wegener's granulomatosis Glomerulonephritis Necrotizing granulomatous vasculitis Small vessels vasculitis
90
What are two unique presenting Sxs of Granulomatosis w/ Polyangiitis What characteristic CXR finding is unique What external findings may be seen on PE
Sinusitis, Ottitis Nodular pulmonary infiltrates w/ cavitation Saddle nose Tracheal stenosis Strawberry gums
91
What Dx test is done for Granulomatosis w/ Polyangiitis Eosinophilic granulomatosis w/ Polyangitis used to be ? syndrome
Serologic (C-ANCA) and lung/sinus/kidney biopsy shows necrotizing granulomatous vasculitis Churg Strauss syndrome
92
What PT population does Eosinophilic granulomatosis w/ Polyangitis affect most This Dz has what transient CXR findings
PTs w/ asthma involving skin and lungs Opacities of multiple nodules
93
How is Granulomatosis w/ Polyangiitis Tx How is Eosinophilic granulomatosis w/ Polyangitis Tx
Cyclophosphamide PO Prednisone Rituximab- antineoplastic monoclonal Ab Bactrim CCS Mepolizumab- interlukin 5 antagonist Cyclophosphamide
94
? is AKA Goodpasture Syndrome Define this Dz
Anti-Glomerular Basement Membrane Dz Alveolar hemorrhage Glomerulonephritis Anti-GBM Abs
95
How is Anti-Glomerular Basement Membrane Dz Dx How is it Tx
IgG immunofluorescence and antiGBM Abs CCS Cyclophosphmide Plasmaphoresis
96
What is the bimodal distribution pattern of Anti-Glomerular Basement Membrane Dz What are the presenting Sxs
Men: 30-40 Women: >60 Hemoptysis Anemia Hypoxemia
97
What Dz would have microscopic hematuria on its results? How does Idiopathic Pulmonary Hemosiderosis
Anti-Glomerular Basement Membrane Dz Young adult/Peds w/ recurrent pulmonary hemorrhage w/ hemosiderin macrophages in lavage fluids
98
How can you differentiate Idiopathic hemosiderosis from Anti-Glomerular Basement Membrane Dz What finding is typical in this Dz How is it Tx
Idopathic hemosiderosis has no renal/anti-GBM involvement Fe deficiency CCS
99
How does Histoplasmosis present Because of these Sxs, what incidental findings may lead to a past Dx
ASx/mild flu Sxs after inhalation fungal spores from dirt/cave in Ohio/MS valley Pulmonary/Splenic calcification
100
What microbes are found in SW US, South, O/M Valley, East and New England regions of the US What microbe is from Northern Mexico?
``` SW: Coccidio South: Blastomycosis O/M Valley: Histo East: RMSF NE: Lyme/Babesiosis ``` Mexico: Paracoccidio
101
What PT presentation would indicate Histo instead of atypical/CAP? What two unique PT population are more susceptible to this Dz
No response to ABX HIV w/ CD4 <100 PTs on TNF blocking agents
102
What is the classic CXR finding of Histoplasmosis How can this be Dx
Diffuse nodular infiltrates Urine/Serum Ag Broncho lavage Blood/Marrow culture
103
What meds are used for Histo Tx How do Coccidio infections present
Mild: Itraconazole Sev: IV Amphotericin B Inhalation of spores from dirt w/ most infections being ASx Very common opportunistic in HIV and endemic areas
104
What is a unique presenting Sx of Coccidio What is the MC presentation Half of the time, what does it look like on CXR
Back ache/pain CAP in endemic areas Unilateral hilar adenopathy
105
How is Coccidio Dx What PT populations are more likely to have this
Serologic tests for IgM/IgG Possible eosinophils, no dx value Phillipino Black Pregnant
106
How does disseminated Coccidio infection present What CXR finding is seen?
More pronounced pulmonary involvement: Lung abscess Meningitis Wart like skin lesions Diffuse miliary pattern
107
How are mod/severe Coccidio infections tx Define Blastomycosis
Fluconazole Itraconazole Amphotericin B- only for severe PTs Midwest/Canada outdoor man from inhaled spores
108
Blastomycosis is ASx unless it's disseminated then it presents as ? How is this Dx
Skin/Bone lesions Prostatitis/Epididymitis CXR- cavitary lesions Sputum culture BALavage Calcofluorfluorescent staining of sputum
109
How is Blastomycosis Tx Which fungal infection is ubiquitous in nature?
Mild: Azole anti-fungals (Itracon/Ketoconazole) Mod/Sev: Amphotericin B Aspergillosis
110
Aspergillosis is usually ASx unless it's in an ImmSupp PT, then it presents as ? This is the MC ? presenting in ? 3 forms
Transplant PTs w/ neutropenia Pulmonary infection: Allergic, Invasive, Aspergilloma
111
Since Aspergillosis is a hard Dx to make, what facts can help aid w/ the Dx What other presentation is unique and can help?
PT w/ Asthma Hx who has worse Sxs, Infiltrates on CXR w/ high Eosinophils/IgE in blood Wax/wane of Sxs
112
What med can be used for acute exacerbations of allergic bronchopulmonary Aspergillosis How are Aspergillomas w/ cavitary masses Tx
PO Prednisone Bronchodilators Surgical ressection
113
How does PCP present What is seen on CXR How is it Tx
ImmComp PTs w/ CD4 <200 Pneumothorax/consolidations on CXR Bactrim
114
# Define Acute Respiratory Failure Normal pH, PCO2 and HCO3 levels ABG gives you what 3 pieces of info
Respiratory dysfunction leading to poor oxygenation/ventilation pH: 7.35-7.45 PCO2: 35-45 HCO3: 22-28 pH PaCO2 PaO2
115
Although ABG criteria for respiratory failure is not absolute, what two criteria are observed for class S/Sxs of respiratory failure include those of the underlying Dz and what 2?
PaO2 <60mm= SaO2 <90% PaCO2 >45mm Hypercapnia Hypoxemia
116
What is the main/chief sign of hypoxemia and hypercapnia What other signs may be present of hypoxemia What other signs of hypercapnia may be present
Dyspnea Dyspnea + HA Tachy Restless Anxiety Confusion Tremor Conjunctival hyperemia HTN Asterixis Tachy
117
If there is suspicion of respiratory failure, what test needs to be ordered? Define Non-ventilatory Define Ventilatory
ABG Ensures oxygenation of vital organs w/ O2 administration Maintains patency of airway and ensured adequate ventilation
118
What is the goal of non-ventilatory respiratory support Enough O2 is given to PTs to maintain O2 sat at ? level
Oxygenate vital organs Lowest amount to maintain SPO2 of 90% or higher
119
How is NPPV delivered to PTs? When is this the first line therapy?
Full face mask or nasal mask COPD w/ hypercapnic failure as long as they can: Protect airway Manage secretions Tolerate mask apparatus
120
What is the benefit of using NPPV in COPD PTs What is the next step if PTs can't handle this Tx or decompensate
Dec need for intubation, length of hospitalization and mortality Intubation
121
What are the seven indications for tracheal intubation
Hypoxemia even w/ O2 Upper airway obstruction No airway protection Severe hypoxemia Apnea Inability to clear secretions Decompensation
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After intubation, why is a CXR needed What are the 2 modes of positive pressure ventilation
Verify tip is at aortic arch, 5cm above charina Controlled mechanical vent Synchronized intermittent mandatory vent- vent delivers minimum number of breaths at a specific tidal volume each minute
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What are the 3 alternate modes on mechanical ventilators Define Tube migration What will be seen to signify this has occurred?
Pressure support Pressure control Continuous pos pressure Tip of ET tube moves into main bronchus Atelectasis of contralateral lung and over distension of intubated lung
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What are the S/Sxs of barotrauma induced ventilator complications? This adverse effect is why PTs on ventilators are set at ? setting?
SubQ emphysema Pneumomediastinum Subpleural air cysts Deliberate hypoventilation
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Over ventilation of a PT will lead to respiratory ? Under ventilation will result in respiratory ?
Resp alkalosis Resp acidosis
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What are the effects on the body of HOTN induced ventilation Why is carb heavy nutrition avoided in PTs that are on ventilators
Elevated intrathoracic pressure= dec venous return Inc CO2 production
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Why do E+ need to be monitored in PTs on ventilators What is given to reduce the stress of the PTs Gi system? Since these PTs are immobile what anticoag therapy are they on?
HypoK and hypoPO4 which worsen hypoventilation PPIs LMWH w/ compression devices
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What are the prognosis for PTs on ventilators due to sedative/opioid OD, COPD w/out intubation or ARDS associated sepsis Define ARDS
Excellent Good Poor Non-cardiogenic form of pulmonary edema leading to hypoxemia respiratory failure
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How is the severity of ARDS determined
PaO2/FIO2 ratios Mild: 200-300mmHg Mod: 100-200mmHg Sev: <100mmHg FIO2- fraction of inhales O2, amount of O2 given to PT
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Regardless of the mechanism of injury, what lung injuries are common w/ ARDS Why are these injuries important
Cappilary endothelial and alveolar epithelial cells Inc permeability and Dec surfactant production= pulmonary edema, atelectasis, hypoxemia
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How does ARDS present In addition to labored breathing, tachy and crackles, what will most PTs present w/ ?
12-48hs post event w/ hypoxemia refractory to O2 Multiples organ failure
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CXR of ARDS shows bilateral infiltrates that are not seen ? What normal findings will be noted
Costophrenic angles Normal heart size Small/no effusions
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How is ARDS Tx ARDS + ? Dx has a 90% mortality rate
Broad ABC Intubate/ventilate w/ lowest PEEP and tidal volume Maintain SaO2>88% Sepsis causing organ failure
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Respiratory distress Syndrome is AKA ? When is this MC seen
Hyaline membrane Dz Preterm infant <28wks due to surfactant deficiency
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When does surfactant development begin? The lack of this in a baby causes ? reactions
20th week Neutrophil accumulation Pulmonary edema
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What happens if infant w/ respiratory distress syndrome develops atelectasis What steps are taken to prevent respiratory distress syndrome?
Cytokine mediated inflammatory response Surfactant therapy via ET tube Antenatal CCS in all PTs 23-34wks pregnant PEEP prevents atelectasis
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What is the definition of persistent severe respiratory distress in PT w/ RDS Define Pleuritis and it's cause
Reqs FiO2 +0.40 to maintain 90% O2 sats Apeneic Inflammation of parietal pleura causing pain URI, Pneumonia, Autoimmune
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What will be seen on PE of pleuritis If a radiating Sx is seen, what is the etiology
Pain w/ inc resp effort Ipsilateral shoulder pain Friction rub Central diaphragmatic parieteal pleura irritation (CN10)
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What is the anatomical reason for pleuritis pain How is this condition Tx
Parietal pleura: + nerves Visceral pleura: - nerve NSAIDs Indomethacin Codeine
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How is pleura fluid absorbed out of the pleural space How much is normally present
Lymphatics 5-15mL
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What are 4 etiology's of pleural effusions
Hemothorax: bleeding Empyema: infection in space Exudate*: inc production from abnormal capillary permeability/dec lymph clearance Transudate*: inc production due to inc hydrostatic/dec oncotic press
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# Define Hydrostatic Pressure Define Oncotic Pressure How do these two work in relation to each other
Press exerted by particular fluid Proteins in blood that displace water, make appearance of less fluid in blood stream Opposite of each other
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What are the S/Sxs of a pleural effusion What may be seen on PE of a larger effusion How are they Dx
Dyspnea Cough Respirophasic pain Dullness to percussion (hyporesonance) Dec breath sounds Thoracentesis
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What would different appearing pleural effusions be caused by
Empyema: clear over white cells Chylous: always turbid w/ chylomicrons, inc TG levels Hemorrhagic: blood and effusion mixture Hemothorax: pleural fluid hct >0.5
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What are the 3 things a pleural effusion sample is tested for? What are the 3 criteria an 'exudate' must meet
``` pH Microbiology: gram, culture Cytology Protein Glucose LD WBC ``` One of: Protein >0.5 Pleural LD/serum LD ratio >0.6 Pleural fluid LD >2/3 of upper limit of normal serum LD
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What is the MC cause of transudate pleural effusion What is the cause of an exudative effusion to have high amylase
Heart failure Esophageal rupture/pancreatitis Usually a L sided effusion
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What would a rheumatoid caused effusion look like What would it look like if it was caused by TB
Empyema Cholesterol crystals Low complement Inc protein
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What are the 2 MC types of malignancys to cause exudative effusion? Since CXRs are the first images ordered for effusions, how much fluid must be present to be seen on certain views?
Lung Breast Upright lateral: 75-100mL Upright frontal: 175-200mL
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How much effusion must be present to perform a blind thoracentesis CTs are able to pick up and ID how much effusion fluid
1cm of fluid on decubitus view 10mL and the etiology
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How are pleural effusions Tx
Transudative: Tx underlying issue Malignant: chemo/rad, thoracentesis can be therapeutic Hemothorax: large bore tube thoracostomy
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# Define parapneumonic pleural effusion How are these Tx if they're un/complicated
Bacterial pneumonia w/ effusion: Unomplicated: ABX Complicated: low pH, low glucose, Neg gram stain/culture Tx w/ ABX and tube thoracostomy if glucose is <60 or pH <7.2
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What type of lab results doe empyema pleural effusions have and how are they Tx?
Purulent appearance Low pH + Gram stain Tx: ABX and tube thoracostomy
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Spot Pneumos can be life threatening if there are underlying ? issues How will the PT present if it's a small/large pneumo?
Asthma COPD Small: mild tachy Large: dec sounds, fremitus and unilateral hyper resonance
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How are pneumothorax's usually revealed on imaging? How are small ones defined and Tx?
Visceral pleural line on CXR <15% Observe and O2 D/c if no progression seen on repeat CXRs
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When are chest tubes placed for Spot Pneumos
Severe Sxs On ventilation Large Secondary Tube placed under waters seal drainage and suction Respond in 3 days
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After needle decompression, what is the definitive care step done for tension pneumos After Tx, PTs need to avoid ? 3 things
Tube thoracostomy Smoking High altitudes Scuba diving
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How are spot pneumos that have blebs and pleurodesis Tx What spirometry result is most consistent with a restrictive pulmonary Dz?
Open thoracotomy w/ resection Reduced expansion of lung parenchyma Asthma/COPD= obstruction
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? type of pneumoconioses is an obstructive lung Dz? Insterstitial syndromes of the lung include ? Dz
Byssinosis SHIT FACEDD Sarcoidosis Histiocytosis IPF Tumor Failure Asbestosis Ceolagen d/o Environmental Dust Drugs
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What is the physiological reason for hypoventilation in abesity hypoventilation? What abnormal corrective mechanism seen in this Dz is unique and not found in other lung Dzs
Blunted ventilatory drive Inc mechanical load Voluntary hyperventilation
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What is the Dx criteria for obesity hypoventilation Why do these PTs in surgery cause concern
BMI +30 Arterial partial pressure of CO2 +45mm Exclusion of other causes Higher risk of respiratory/cardiac failure, intubation
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What is the most serious secondary consequence of hypoxemia Why are PTs that drown in winter more likely to be saved?
Anoxic brain injury Dec brain temp by 10*C= dec ATP demand x 50%
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What type of thermal inhalation injury is not isolated to the upper airway? Smoke inhalation PTs present with Sxs 18-24hrs later due to ? reaction
Steam affects whole airway tract Neutrophil inflammation causing mucosal edema/ulcerations
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Thermal airway injuries present as ? issue Inhalation injuries manifest primarily with ? 2 things
Laryngeal edema Bronhcospasm Bronchorrhea
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What test is conducted serially in inhalation injury PTs Define Reactive Airway Dysfunction Syndrome
CXRs Impaired pulmonary function after inhalation injuries manifesting as airway hyper responsiveness
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What is the leading cause of death from poisoning worldwide? If CO poisoned PT is placed in hyperbaric chamber, how many atmospheres are they palced at to displace CO from Hgb?
Carbon monoxide 2.5-3 atm
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What enzyme is inhibited by cyanide These PTs present with ? 3 common findings What's the quickest result that would indicate PT has cyanide poisoning
Cytochrome, prevents cellular respiration Coma Lactic acidosis Shock Inc venous oxygen saturation