pulm(chapter 4) Flashcards
hemothorax
bleeding into pleural space
pleural effusion clinical features
dull to flat percussion with reduced or absent breath sounds, friction rub, fremitus. mediastinum will be shifted in large effusion
Standard test for pleural effusion
u/s guided thoracentesis gold standard.send fluid for culture, wbc, cell counts, protein, LDH, pH, glucose, cytology, gm stain culture & sensitivity
xray findings for pleural effusion
blunting of costophrenic angle, loss of sharp demarcation of diaphragm and heart. lateral decubitus differentiates free flowing vs loculated fluid
CT findings in pleural effusion
separates parenchymal and pleural densities
Lights criteria for exudate pleural effusion
- pleural fluid protein to serum protein ratio>.5;
- pleural fluid LDH to serum LDH ratio >.6; or
- pleural fluid LDH >2/3upper limit of normal of serum LDH
tx for transudate pleural effusion
resolve underlying cause
tx for malignant effusion
and common irritants
drainage and pleurodesis. common irritants are doxycycline and talc.
tx of emphyema
drainage and antibiotic therapy
pneumothorax sx
increased unilateral chest expansion, decreased tactile fremitus, hyperresonance, diminished breath sounds, JVD secondary to compression of the SVC
pneumothorax labs/xray
CXR shows presence of pleural air, visceral pleural line is evidence. ABG analysis shows hypoxemia.
- virchows triad
* polycythemia
hypercoagulable state, venous stasis, vascular intimal inflammation/injury
*hyperviscosity
3rd leading cause of deaths in hospitalized pts
DVT
PE pt sx
sudden pleuritic chest pain, dyspnea, low fever, apprehension, cough, hemoptysis(rare), diaphoresis
PE exam findings
accentuation of pulmonary component of 2nd heart sound, tachypnea, tachycardia, crackles,low fever
ABG finding in PE
acute respiratory alkalosis secondary to hyperventilation
PE test to order
*pulmonary angiography(invasive); do spiral CT first
EKG shows S1Q3T3
cor pulmonale seen in 20% of pt with symptomatic PE
what is pulmonary HTN?
pulmonary arterial pressure that rises to a level inappropriate for a cardiac output. it is self perpetuating.
what is primary pulm HTN? occurs in who
idiopathic, rare, and fatal; young females
what is secondary pulm HTN?
develop d/t obliteration and obstruction of pulmonary arterial tree (anything that causes increases in vascular resistance); COPD, PE, polycythemia, Mitral stenosis
what is the potent stimulus for pulmonary arterial vasoconstriction?
hypoxia! also acidosis and veno-occlusive conditions
symptoms of pulm HTN
ascites, cyanosis, syncope, dyspnea, angina like retrosternal chest pain, weakness, fatigue, edema
narrow splitting and accentuation of the second heart sound with an ejection click
pulm HTN
what tests do you order for pulm htn?
ekg will show right ventricular hypertrophy and strain, and atrial hypertrophy. CXR will show enlarged pulm arteries. *rt hrt cath offers more precise hemodynamic monitoring
CT shows diffuse, patchy fibrosis with pleural base honeycombing
idiopathic fibrosing interstitial pneumonia/pulm fibrosis
PFT shows FEV1/FVC ratio nml and decreased lung volume
restrictive. idiopathic pulm fibrosis
asbestosis from what
insulation, demolition, construction
silicosis from what
mining, sand blasting, quarry work, stone work
CXR has irregular parenchymal LINEAR opacities at bases and pleural plaques
asbestosis
mesothelioma from what
asbestosis
CXR has small nodular opacities at upper lung fields; eggshell calcifications
coal workers pneumoconiosis
CXR shows diffuse infiltrates and hilar adenopathy
berryliosis
simple vs complicated sx of pnemoconioses
simple is asymptomatic. complicated has dyspnea, inspiratory crackles, clubbing, and cyanosis.
PFT shows restrictive dysfunction and reduced diffusing capacity
pneumoconioses
pneumoconioses tx
supportive(O2 and vaccinations), corticosteroids in silicosis, smoking cessation
noncaseating granulomatous inflammation in affected organs
sarcoidosis
sarcoidosis mostly affects which organ, s/s
lungs, DRY cough, dyspnea, RALES
races affected by sarcoidosis and how symptomatic
north america black woman and north european whites
50% asymptomatic
extrapulmonary sx for sarcoidosis
hilar nodes, paratracheal
skin: eryathema nodosum and LUPUS PERNIO, maculopapular rash (most common), parotid gland enlargement
eyes: anterior uveititis
cardiac: restrictive CM, arrthymias, heart blocks
rheu: hepatosplenomegaly, fever, malaise, wt loss, arthralgias
neuro: CN palsies especially facial nn 7, diabetes insipidus
LOFGREN syndrome: triad EN, bilateral hilar LAD, polyarthralgias wth fever
lab findings for sarcoidosis
screening test: angiotensin converting enzyme elevated in 40-80% of pts
leukopenia, eosinophilia, elevated erythrocyte sed rate, hypercalcemia, hypercalciuria;
CXR shows symmetric bilateral hilar and right paratracheal adenopathy, and bilateral diffuse reticular infiltrates
sarcoidosis
what test confirms sarcoidosis
transbonchial bx-noncaseating granulomas
sarcoidosis tx
corticosteroids
what is ARDS?
increased permability of the alveolar capillary membranes, which leads to development of protein rich pulm edema; the lung tissue is severely inflammed that is impairs gas exchange secondary to the acute injury
** hypoxemia without hypercarbia
3 clinical settings for ARDS
sepsis syndrome!, severe multiple trauma, aspiration of gastric contents, critically ill, gram neg sepsis, severe pancreatitis, near drowning
S/S of ARDS
acute dyspnea and hypoxemia. multi organ failure if severe
rapid onset profound dyspnea 12-24 after precipitating event, tachypnea, frothy pink or red sputum, diffuse crackles; many pts are cyanotic with increasing severe hypoxemia that does not respond to O2
CXR of ards
bil. diffuse pulmonary infiltrates(similar to CHF)t; infiltrates tend to be peripheral(**spares costophrenic angles) with air bronchograms in 80%
tx for ards
O2 via ET intubation with positive pressure ventilation and low levels of positive end expiratory pressure(PEEP); low tidal volume
xray for aspiration of FB shows what
expiratory xray shows regional hyperinflation caused by a check valve effect
tx for FB aspiration
bronchoscopy
what is hyaline membrane disease
resp. d/s in preterm infant with deficiency of surfactant
what is a exudative pleural effusion
“leaky capillaries”, examples: infection, malignancy, trauma, PE, collagen vascular d/s, pancreatitis
what is a transudative pleural effusion
“intact capillaries”, assoc with increased hydrostatic or decreased oncotic pressure; examples: CHF, atelectasis, renal/liver disease
who is at greatest risk of a pneumothorax
tall, thin males between 10-30; like a basketball player
3 types of pneumothorax
1) primary has no underlying cause(smoking is a risk factor)
2) secondary is a complication of underlying lung disease (COPD, asthma, CF, TB)
3) traumatic
tension pneumothorax symptoms
resp distress, tracheal deviation, hemodynamic instability
CXR in a pneumothorax
visceral pleural line on expiratory film is diagnostic; pleural air; contralateral mediastinal shift in tension pneumothorax
visceral pleural line on expiratory film
pneumothorax
pneumonic for presentation of pneumothorax
P-THORAX pleuritic CP tracheal deviation hyperresonances onset sudden reduced breath sounds(and dyspnea) absent tactile fremitus(asymmetric chest wall) xray shows collapse
exudative fluid think what
pneumonia or malignancy
transudative fluid think what
CHF
bx shows non caseating granulomas
sarcoidosis
signs of pulm HTN
narrow splitting and accentuation of the second heart sound with an ejection click
CXR/CT, EKG, and echo in pulm HTN
what is gold standard?
CXR/CT: enlarged pulm arteries
EKG: RVH, RAH, rt vent strain
echo: pulm arterial pressure but should do a rt hrt cath** for more precise hemodynamic monitoring
tx for primary and secondary pulm HTN
primary: chronic oral anticoagulants, CCB( to lower systemic arterial pressure), prostacyclin(potent pulm vasodilator), diuretics with salt restriction, O2; heart/lung transplant usually needed
seondary: treat underlying cause
prostayclin
potent pulm vasodilator
what is cor pulmonale
right sided hrt failure secondary to severe pulm disease
causes of cor pulmonale
ARDS, PE, COPD, severe asthma, sarcoidosis, lung trauma, surgery
causes of pulm HTN
left heart failure, mitral valve disease, increased resistance in pulm veins(hypoxia and vasoconstriction)
rt axis deviation on EKG
lead 1 has neg QRS and avF has a positive QRS
PE tx
acute: bolus heparin then LMWH
chronic: anticoagulate 3-6 months
westermark sign, hampton hump, atelectasis
PE
idiopathic fibrosing interstitial pneumonia sx and exam
insidious dry cough, exertional dyspnea, constitutional symptoms;
exam shows clubbing and INSPIRATORY crackles
idiopathic fibrosing interstitial pneumonia tx
prednisone may help. give O2, maybe lung transplant
pneumoconioses PFT
PFT shows restrictive dysfunction and reduced diffusing capacity
inspiratory rales/ FEV1, FVC, and lung volumes reduced
pneumoconioses
berylliosis from what
high tech fields
CXR of asbestosis
irregular parenchymal LINEAR opacities at bases and pleural plaques; bx shows asbestos bodies
CXR of coal worker’s pneumoconiosis
small nodular opacities at upper lung fields; eggshell calcifications
CXR of silicosis
2.5 mm nodular opacities at upper and middle lung fields; hilar lymph nodes may be calcified; eggshell calcifications
CXR of berylliosis
diffuse infiltrates and hilar adenopathy
complication of asbestosis
increased risk of lung cancer and mesothelioma
complication of silicosis
increased risk of TB; progressive massive fibrosis
complication of coal worker’s pneumoconiosis
progressive massive fibrosis
complication of berylliosis
requires chronic steroids
2.5 mm nodular opacities at upper and middle lung fields; hilar lymph nodes may be calcified; eggshell calcifications
CXR of silicosis
what is sarcoidosis?
- idiopathic inflammatory disease characterized by granulomas throughout the body
sarcoidosis sx
dry cough, dyspnea of insiduous onset, and chest discomfort
leukopenia, eosinophilia, elevated erythrocyte sed rate, hypercalcemia, hypercalciuria;
angiotensin converting enzyme elevated in 40-80% of pts
sarcoidosis labs
sarcoidosis CXR
symmetric bilateral hilar and right paratracheal adenopathy, and bilateral diffuse reticular infiltrates
eryathema nodosum, enlargement of parotid glands, lymph nodes, liver, spleen
sarcoidosis extrapulmonary sx
dry cough, dyspnea of insiduous onset, and chest discomfort
think sarcoidosis
how serious is ards
90% will die without treatment; 1/3 of deaths occur within 3 days of onset of symptoms. The remaining deaths occur within 2 weeks of diagnosis and are caused by infection
shock, toxic inhalation, near drowning, multiple transfusions, burns, pancreatitis, DIC, TTP, pneumonia, miliary TB, lung contusion, high altitude exposure
other causes of ards
rapid onset profound dyspnea 12-24 after precipitating event, tachypnea, frothy pink or red sputum, diffuse crackles; many pts are cyanotic with increasing severe hypoxemia that does not respond to O2
ards
ards: heart size upper lung venous engorgement pleural effusion pulm capillary wedge pressure organ failure
normal heart size uncommon upper lung venous engorgement small to absent pleural effusion normal pulm capillary wedge pressure multiple organ failure
amiodarone, nitrofurantoin, bleomycin, radiations, and long term O2 concentration
can cause or contribute to interstitial lung disease
hypoxemia, dec lung compliance, pulm edema, PaCO2/FiO2 ratio under 300.
ards
acid base changes in ards
starts off poss resp alkalosis then ends with resp acidosis
criteria for ards dx
1) acute onset (under 1 wk) of resp distress
2) Pa02/FiO2 ratio under 300 with PEEP/CPAP over 5 cm H20
3) bilateral pulmonary infiltrates on CXR
4) resp failure not completely explained by heart failure
goal oxygenation in ards
Pa02 under 55 or Sa02 under 88%
CXR in hyaline membrane disease
air bronchograms, diffuse bilateral atelectasis causing ground glass appearance, doming of diaphram
Tx in hyaline membrane disease
synchronized and intermittent mandatory ventilation. administer exogenous surfactants; steroids if there is a risk of delivery before 34 weeks gestation
air bronchograms, diffuse bilateral atelectasis causing ground glass appearance, doming of diaphram
CXR in hyaline membrane disease
tall peaked T waves
rt atrial hypertrophy
- why is there a high mortality rate with ARDS
due to acute hypoxemic respiratory and organ failure
CXR of interstitial lung disease
reticular opacities and ground glass appearance
reticular opacities and ground glass appearance
CXR of interstitial lung disease
4 stages of sarcoidosis
- BHL (no sx or mild pulm sx)
- BHL + ILD (moderate pulm sx)
- ILD only
- fibrosis (restrictive ds)
lupus pernio
raised purple lesions at tip of nose or cheeks. sarcoidoisis
PFT of sarcoidosis
restrictive pattern: nml or increased ration, normal or decreased FVC, decreased FEV1
decreased lung volumes
sarcoidosis labs
increased ACE levels, hypercalcuria, hypercalcemia, increased vit d.
