Pulm Block 2 Flashcards
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
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
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
Inspiratory stridor due to bronchospasm/bronchorrhea
18-24hrs later
Neutrophilic inflammation causing edemal/ulceration
Cytochrome- shock, lactic acidosis, coma
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?
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
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?
PEEP for bronchiolar edema
Daily sputum Gram stains
CCS
ABX
Even if PTs w/ severe body burns and smoke inhalation survive, they need constant f/u monitoring for the development of ? which appears as ?
Bronchiolitis Obliterans
CT shows ground glass, bronchial wall thickening and honey comb appearance
Define Pneumoconioses
How do these PTs present?
How are they Tx?
Chronic fibrotic lung Dzs from inhalation of inorganic dusts
ASx w/ diffuse nodular opacities on CXR
Life shortening Dz w/ supportive Tx
What causes coal dust to be absorbed and turned into Black Lung Dz
What are the growths seen on CXR called?
Alveolar macrophages ingest dust and consolidate in upper lung areas
Coal macules: 2-5mm in upper fields
What is the difference between Simple and Complicated Coal Worker’s Dz?
Complicated Dz complications are similar and seen in ? other pneumoconiosis Dz?
Simple: ASx
Complicated: massive fibrosis w/ irregular masses >1cm w/ upper lung contractions
Complicated silicosis
What causes Silicosis lung dz?
How does this Dz on CXR?
Quarries/mines of quartz, granite, sandstone
Small round opacities
Calcification of hilar lymph nodes- eggshell calcifications
How does Simple Silicosis present?
How does Complicated Silicosis present?
ASx
Normal PFTs
Irregular masses >1cm
Inc upper lung densities
Obstruct/Restrictive PFTs
Silicosis PTs have an increased risk of contracting ? lung infection
Why is there this increased risk?
Infections requiring macrophage defenses: Fungi Atypical mycobacteria TB
Silica is cytotoxic to alveolar macrophages
All silicosis PTs need to have updated/on records results of ? 2 things?
How does asbestosis present?
TB skin test
CXR
Dyspnea
Inspiratory crackles
Clubbing/cyanosis
How does Asbestosis appear on CXRs?
What CXR finding holds the best Dx value?
Linear streaks in lower fields
Various size opacities
Honey comb changes if advanced Dz
Pleural calcifications
What image modality has the best imaging ability of asbestosis?
What does this imaging allow providers to see?
High Res CT
Parenchyma fibrosis
Pleural plaques
What would be seen on PFT in a PT w/ asbestos
What is done for these PTs as Tx?
Restrictive pattern
Reduced FVC and FEV1
Normal/Inc FEV1/FVC ratio
Reduced DLCO
O2 for SoB
Resp PT to remove secretions
Hypersensitivity Pneumonitis is AKA ?
What type of d/o is this?
Extrinsic Allergic Alveolitis
Inflammatory d/o involving alveolar walls and terminal airways
What causes Hypersensitivity Pneumonitis
What causes Bagassosis
Exposure to inhaled organic agent leading to an acute illness
Moldy sugar cane fiber
What causes Sequoiosis
What causes Suberosis
What causes Detergent Worker’s lung
Moldy redwood saw dust
Moldy cork dust
Enzyme additives
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?
Sudden F/C/N
Dyspnea
Crackles, Tachy/Tachy
Neutrophilia/L shift
Inc ESR/CRP
Nodular densities except in Apex/Bases
Restrictive dysfunction
Reduced DLCO
How does Subacute Hypersensitive Pneumonitis present
What is seen on CXRs
How is if definitively Dx?
Wks-Mon of:
Chronic cough
Dyspnea, Anorexia/Wt loss
Fibrosis/honey comb
Lung biopsy
How is Hypersensitive Pneumonitis Tx
What are the 3 types of obstructive airway d/os?
Acute- self limiting/recovery
Severe/protracted: PO CCS w/ 4-6wk taper
Byssiniosis
Industrial bronchitis
Occupational asthma
Define Industrial Bronchitis
This respiratory Dz rarely ?
Chronic bronchitis seen in coal miners, exposure to cotton, flax or hemp
Leads to chronic disability
Define Byssinosis
How does it present?
What happens if exposure is not d/c?
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
Define Silo-Fillers Dz
What is a common finding late in this Dz
Toxic lung injury causing pulmonary edema due to inhalation of N-dioxide
Bronchiolitis obliterans
How is Silo Filler’s related bronchiolitis obliterans prevented?
What happens if exposure is not d/c’d?
CCS
Fatal
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
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
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
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
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
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
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
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
How is Pickwickian Syndrome Tx
Weight loss- improves hypercapnia, hypoxemia
NPPV
Stimulants: Theophylline, Acetazolamide, Medroxyprogesterone
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
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
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
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
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
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
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
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
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
What blood issues can create a hyperviscosity state for DVTs
What can cause increased central venous pressures?
Polycythemia
Pregnancy
CHF/low CO
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
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)
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
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
PTs w/ a massive PE may present w/ ? issue
What is the MC EKG sign?
Syncope
Sinus tach
ST and T wave changes
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
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
What CXR finding is most suggestive of a PE?
What are the MC findings?
Hypoxia w/ normal CXR
Atelectasis
Pleural effusions
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
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
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
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
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
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
How are PEs Tx
Anticoagulation- stops thrombus formations, NO dissolving ability
Allows endogenous fibrinolytic lyses
Heparin then PO Warfarin
INR goal: 2-3
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
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
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
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
When are IVC filters installed?
Recurrent embolisms despite adequate anticoagulation therapy
Chronic emboli w/ PHTN
PTs w/ c/i to anticoagulation therapy
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
Define Interstitial Lung Dzs
How do they present?
Group of d/os causing pulmonary inflammation and fibrosis
Dyspnea, Crackles
Septal thickening
Reticular changes
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
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
What is the major consequence of ILDz?
What is the MC classification?
Impaired gas exchange
idiopathic interstitial pneumonia: Idiopathic pulmonary fibrosis
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
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
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)
? type of sample is often required for definitive Dx of Idiopathic Interstitial Pneumonias
Define Pulmonary Fibrosis
Lung biopsy
Scarring of the lung
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
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
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
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
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
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
What is a rare presentation of Sarcoidosis
What is the trifecta
Uveoparotid Fever
Fever Uveitis Parotitis w/ or w/out CN7 palsy
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
What will be sen on PFTs in sarcoidosis?
How is the Dz staging accomplished?
Restrictive pattern
Dec volume and diffusing capacity
CXRs
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
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
Define Pulmonary Alveolar Protein
What are the usual presenting Sxs
Phospholipids in alveolar spaces from 1* (idiopathic) or 2* causes
Progressive dyspnea/cough
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
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
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
Granulomatosis w/ polyangiitis used to be called ?
This idiopathic Dz is characterized by ?
Wegener’s granulomatosis
Glomerulonephritis
Necrotizing granulomatous vasculitis
Small vessels vasculitis
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
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
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
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
? is AKA Goodpasture Syndrome
Define this Dz
Anti-Glomerular Basement Membrane Dz
Alveolar hemorrhage
Glomerulonephritis
Anti-GBM Abs
How is Anti-Glomerular Basement Membrane Dz Dx
How is it Tx
IgG immunofluorescence and antiGBM Abs
CCS
Cyclophosphmide
Plasmaphoresis
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
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
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
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
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
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
What is the classic CXR finding of Histoplasmosis
How can this be Dx
Diffuse nodular infiltrates
Urine/Serum Ag
Broncho lavage
Blood/Marrow culture
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
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
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
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
How are mod/severe Coccidio infections tx
Define Blastomycosis
Fluconazole
Itraconazole
Amphotericin B- only for severe PTs
Midwest/Canada outdoor man from inhaled spores
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
How is Blastomycosis Tx
Which fungal infection is ubiquitous in nature?
Mild: Azole anti-fungals (Itracon/Ketoconazole)
Mod/Sev: Amphotericin B
Aspergillosis
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
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
What med can be used for acute exacerbations of allergic bronchopulmonary Aspergillosis
How are Aspergillomas w/ cavitary masses Tx
PO Prednisone
Bronchodilators
Surgical ressection
How does PCP present
What is seen on CXR
How is it Tx
ImmComp PTs w/ CD4 <200
Pneumothorax/consolidations on CXR
Bactrim
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
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
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
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
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
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
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
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
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
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
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
Over ventilation of a PT will lead to respiratory ?
Under ventilation will result in respiratory ?
Resp alkalosis
Resp acidosis
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
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
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
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
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
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
CXR of ARDS shows bilateral infiltrates that are not seen ?
What normal findings will be noted
Costophrenic angles
Normal heart size
Small/no effusions
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
Respiratory distress Syndrome is AKA ?
When is this MC seen
Hyaline membrane Dz
Preterm infant <28wks due to surfactant deficiency
When does surfactant development begin?
The lack of this in a baby causes ? reactions
20th week
Neutrophil accumulation
Pulmonary edema
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
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
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)
What is the anatomical reason for pleuritis pain
How is this condition Tx
Parietal pleura: + nerves
Visceral pleura: - nerve
NSAIDs
Indomethacin
Codeine
How is pleura fluid absorbed out of the pleural space
How much is normally present
Lymphatics
5-15mL
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
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
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
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
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
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
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
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
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
How are pleural effusions Tx
Transudative: Tx underlying issue
Malignant: chemo/rad, thoracentesis can be therapeutic
Hemothorax: large bore tube thoracostomy
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
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
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
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
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
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
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
? 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
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
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
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%
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
Thermal airway injuries present as ? issue
Inhalation injuries manifest primarily with ? 2 things
Laryngeal edema
Bronhcospasm
Bronchorrhea
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
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
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
