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clin med > pulm exam 1 > Flashcards

pulm exam 1 Flashcards

1
Q

what is inflammatory lung disease?

A

large group of heterogeneous disorders

inflammatory process involving alveolar wall that can lead to irreversible fibrosis, distortion of lung architecture and impaired gas exchange

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2
Q

are imaging studies useful for inflammatory lung disease?

A

they’re nonspecific, and do not point to a definitive diagnosis

-often need to obtain tissue biopsy

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3
Q

symptoms of interstitial lung disease

A

Cough – usually nonproductive
Dyspnea on exertion
Other symptoms possible secondary to another condition

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4
Q

signs of interstitial lung disease

A 
Rales heard at lung bases
Oxygen desaturation 
Digital Clubbing
 Signs of pulmonary HTN and Cyanosis in advanced disease 
JVD, LE Edema
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5
Q

Pneumoconiosis

A

chronic, fibrotic, occupation lung disease

caused by inhalation of a foreign particle which causes a reaction in the lung which results in fibrotic changes

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6
Q

when does pneumoconiosis appear?

A

20-30 years after constant exposure

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7
Q

what is the most common diagnosis among ILD patients?

A

idiopathic pulmonary fibrosis (increased frequency men and smokers)

typical age 50-70

onset of symptoms 1-2 years prior to diagnosis

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8
Q

prognosis of idiopathic pulmonary fibrosis

A

highly variable disease course
mean survival 3-7 years after initial diagnosis

*treatment is highly controversial, 70% do not improve with therapy and experience progressive disease

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9
Q

what is sarcoidosis?

A

multi-systemic granulomatous disease - inflammatory reaction to one of many possible triggers

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10
Q

where does sarcoidosis affect?

A

90% lung

eyes, skin, liver, spleen, heart, nodes

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11
Q

etiology of sarcoidosis

A

more common in AAs, women

typically 20-30 yo

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12
Q

how does a typical sarcoidosis patient present?

A

young, constitutional symptoms, resp complaints, blurred vision, erythema, nododsum

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13
Q

workup and hallmark of sarcoidosis

A

CXR: Bilateral Hilar and Right Paratracheal Adenopathy

  • Potato nodes
    hallmark: bilateral diffuse reticular infultrates
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14
Q

treatment of sarcoidosis

A

systemic corticosteroids (90% response) - most resolve/spontaneously improve within 2 years

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15
Q

where in the lung is ventilation higher?

A

lung bases (alveoli at the apex are stretched more at baseline, thus worse compliance)

-perfusion is also higher at the lung bases - due to gravity, arterial and venous pressure exceed alveolar pressure at the bases,but alveolar pressure exceeds these vascular pressures at the apices

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16
Q

what disorders decrease ventilation?

A

airway (COPD) and airspace (pneumonia) disorders

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17
Q

what disorders decrease perfusion?

A

pulmonary vascular disorders (PE)

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18
Q

what are the causes of hypoxemia?

A

low inspired partial pressure of oxygen

hypoventilation - alveolar to arterial oxygen difference will be normal (opioids)

ventilation-perfusion mismatch

shunt

diffusion abnormality

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19
Q

a low forced expiratory volume in 1 second/forced vital capacity ration indications what functional classification?

A

obstructive defect

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20
Q

a low FVC and low total lung capacity (TLC) suggests what functional classification?

A

restrictive defect

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21
Q

low FEV1/FVC and low TLC suggests what functional classification?

A

combined defects

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22
Q

low diffusing capacity of the lung for carbon monoxide (DLCO) and hypoxemia suggests what functional classification?

A

gas transfer defect

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23
Q

Rapid, deep respiration due to stimulation of the respiratory center of the brain by ↓ pH, normal during exercise, and common in patient with severe metabolic acidosis (DKA)

A

kussmaul

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24
Q

breath fast for a while then stop, and then breath fast for a while and then slow down. Brain disorders

A

cheyne-stokes

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25
Q

dyspnea when sitting up *liver disease

A

platypnea

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26
Q

dyspnea when supine (HF)

A

orthopnea

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27
Q

dullness in percussion indicates what?

A

decreased resonance noted with pleural effusion and other diseases

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28
Q

hyperresonance with percussion is indicative of what?

A

increased resonance either due to lung distention (COPD exacerbation) or focal air collections (bullous disease, pneumothorax)

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29
Q

are breath sounds increased or decreased in emphysema?

A

markedly decreased

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30
Q

if there is asymmetry in intensity, which side is abnormal?

A

the side where there is decreased intensity

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31
Q

with vesicular breath sounds, which component predominates?

A

inspiratory (turbulent airflow within the lobar and segmental bronchi) prdominates

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32
Q

Continuous musical sound lasting longer than 250 ms

Due to oscillation of opposing airway walls that are narrowed almost to the point of contact.

A

wheeze

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33
Q

clinically, wheezing indicates what?

A

airflow obstruction, though its absence does not exclude obstruction

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34
Q

long continuous adventitious sounds, generated by obstruction to airways
Low-pitched, continuous sounds that have a tonal, sonorous quality

A

rhonchi - may be due to excess mucus in the airway that’s moving around

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35
Q

localized rhonchi suggests what?

A

obstruction of any etiology (tumor, foreign body, mucus)

rhonchi due to respiratory secretions will often disappear with coughing

36
Q

High-pitched continuous sound heard over the trachea

Due to turbulent flow generated in the upper airway during extrathoracic airway obstruction

A

stridor - generally inspiratory

37
Q

this tests measures the total amount (volume) of air exhaled during forced expiration (forced vital capacity) and the volume of air exhaled during the first second

A

spirometry

38
Q

Bronchoprovocation

A

using maneuver (exercise) or inhaled medication (methacholine) to detect bronchial hyperresponsiveness (one of the defining features of asthma)

39
Q

how much methacholine is given during bronchoprovocation?

A

concentration required to decrease FEV1 by 20% (PC20) - then give albuteral

40
Q

in a chest CT, what IV contrast useful for?

A

to help differentiate hilar lumph nodes from pulmonary arteries

41
Q

what is bronchoscopy useful for?

A

evaluation of pulmonary infections, diagnosing and staging lung cancer, diagnosing sarcoidosis, excluding endobronchial lesions (stenosis or tumor) and therapeutic aspiration (mucus plugging)

42
Q

what is an ultrasound useful for?

A

diagnosing pneumothorax and pleural effusion (cannot visualize normal lung as air reflects ultrasound waves)

43
Q

what is pulmonary HTN?

A

elevated pulmonary pressure

  • Pulmonary artery pressure greater than 25 mmHg at rest (normal is 12-16 mmHg)
  • elevated PA pressure results in the R ventricle pumping against elevated pressure often resulting in RV failure
44
Q

who should be screened for PAH?

A

pts with family history of PAH
pts with systemic sclerosis (scleroderma)
pts with portal HTN being evaluated for liver transplant

yearly screening

45
Q

epidemiology of PH

A

prevalence not known - rare in gen population.

at risk groups (HIV, SCD, portal HTN, scleroderma)

46
Q

hallmark symptom of PH

A

SOB (50%)

47
Q

other clinical manifestations of PH

A

atypical/exertional CP, exertional dyspnea, fatigue, syncope

48
Q

PE findings for PH

A

early disease- often unremarkable PE
loud pulmonic component of second heart sound, split second heart sound

increased JVP

signs of RHF (hepatomegaly, ascites, anasarca/edema)

49
Q

diagnostic eval for PH

A

echocardiogram to start (non invasive, estimate PAP, assess both right and left heart)- better for screening than definitive dx

chest xray also good, often incidental findings when CXR ordered for another reason, not good for definitive diagnosis, only suggestive of PH

gold standard = lung biopsy

50
Q

is EKG helpful to diagnose PH?

A

can show right heart hypertrophy or strain, right axis deviation, and RBBB.

  • cannot make dx of PH with EKG, but helpful in the evaluation of R heart failure
51
Q

what is the preferred imaging for CTEPH (chronic thromboembolic PH)?

A

V/Q scan ( can see clots very nicely)

if CTEPH on V/Q, pulmonary angiography is confirmatory test

52
Q

why is exercise testing good for PH?

A

***establishes functional baseline - need to find out before tx (also need to know cause of PH)

detects PH that is only symptomatic during exercise

measures functional class

prognostic

53
Q

what is given during a right heart cath (RHC) as a vasodilator to see if change in PAP?

A

nitric oxide

54
Q

what is a positive response in pulmonary vasoreactivity testing?

A

decrease in mean PAP by >10 mmHg to an absolute value less than 40 mmHg without change in cardiac output

55
Q

diagnostic criteria of class 1 PH

A

PAP> 25 mmHg at rest measured by RHC

PCWP less than 15 mmHg

elevated pulmonary vascular resistance

no thromboembolic disease, parenchymal lung disease, or systemic or metabolic disease associated with PH are present

56
Q

diagnostic criteria of class 2

A

on a right heart cath, the following can confirm L heart disease is the cause of PH:

PAP > or equal to 25 mmHg
PCWP greater than or equal to 15 mmHg (indicating LHF)

reduced CO (can be normal)

L atrial enlargement

57
Q

diagnostic criteria of class 3

A

elevated PAP on RHC
PFTs indicating hypoxia
CT scan indicating ILD

58
Q

diagnostic criteria of class 4

A

elevated PAP on RHC

evidence of thrombus or thrombi on VQ scan

59
Q

differential Dx for PH

A 
angina
MI/CAD
valvular disease/stenosis
COPD
CHF
60
Q

treatment of PH WHO class 1

A

no effective primary therapy and advanced therapy and combination therapy is usually called for (only after all causes are exhausted and RHC is done)

*treated differently bc therapy is directed at the PH itself not other causes

Oxygen therapy (POx > or equal to 90% at rest, with exertion and during sleep)

treat fluid overload diuretics (salt restriction, weight monitoring)

61
Q

advanced therapies for PAH that target cellular pathways

A

endothelin - vasoconstrictor and mitogen
nitric oxide - vasodilator and antiproliferative
prostacyclin - vasodilator, antiproliferative, and inhibits platelet function

62
Q

most efficacious combination therapy for PAH

A

combination of tadalafil and ambrisentan

63
Q

treatment of group 2 PH

A

treat the underlying cause

  • reduced EF with ACE/ARB, diuretics
  • preserved EF- treat HTN with beta blockers
  • valve correction may resolve PH due to valvular cause
64
Q

treatment of group 4 PH

A

surgery

  • pulmonary thromboendartectomy can be curative
  • lifelong anticoagulation
65
Q

T or F: pulmonary HTN is an contraindication to judicious exercise

A

F - it is important to avoid deconditioning

-mild breathlessness is acceptable, but pts should avoid exertional dizziness, near syncope or chest pain

66
Q

prognosis of PH

A

can be fatal.

  • those with RHF/RV dysfunction have a poor prognosis
  • those with 6 min walk distance 150pg/mL
67
Q

which PH group has the worst prognosis?

A

group 1

  • epoprostanol improves survival
  • advanced therapies improve survival
68
Q

what is the most common cause of bacterial pneumonia?

A

strep pneumo

69
Q

clinical presentation of CAP

A 
fever
chills
rigor
tachycardia
pleuritic CP (hurts when breath in)
mucopurulent sputum
cough shortness of breath
nausea, vomiting

**Older patients: malaise, confusion common

70
Q

physical exam for CAP

A 
80% are febrile
respiratory rate above 24/min
tachycardia
crackles
rales heard over involved SEGMENT
increased tactile fremitus
71
Q

gold standard to diagnose CAP

A

CXR

leukocytosis (15-30k) if you order a CBC

72
Q

when should sputum culture be used for pneumonia?

A 
IDSA/ATS guidlines : sputum culture for hospitalized patients with signs and sx of pneumonia and :
ICU admission
failure of outpt antibiotic therapy
cavitary lesions
ETOH abuse
structural lung disease
pleural effusion
  • not first line test in a CAP outpatient
73
Q

do you need to know of pneumonia is bacterial or viral?

A

in theory, no

usually treated empirically with antibiotics

74
Q

outpatient tx of CAP

A

repeat CXR not indicated if patient clinically improving, although smokers and non responders may need another CXR to document resolution of pneumonia and assess presence of malignancy

smoking cessation!!

75
Q

risk factors for drug resistance PNA

A
  • age > 65
  • recent use of beta-lactam, macrolide, or quinolone (3-6 mos)
  • ETOH
  • comorbidities
  • immunosuppression
  • exposure to children in daycare
76
Q

inpatient treatment (non ICU) of CAP

A

respiratory fluoroquinolone alone

cephalasporin or carbipenem plus macrolide or doxycyline

77
Q

inpatient ICU treatment of CAP

A

cover MRSA if admitted to ICU (add vancomycin)

empiric therapy - IV beta-lactam plus macrolide or quinolone

78
Q

difference between HCAP and HAP

A

HCAP - healthcare associated pneumonia : non hospitalized patient exposed to IV therapy/wound therapy in the past 30 days, residents in a nursing facility, hospitalization for 2 or more days within 90 days prior to discharge, attendance at hospital or clinic within prior 30 days

HAP- hospitalized aquired pneumonia : pneumonia occurring > 48 hours after admission that was not present at time of admission

79
Q

complications of pneumonia

A 
destruction of lung tissue
pleural effusion
bronchectasis
empyema
lung abscess
80
Q

transmission of legionnaires disease

A

aerosolization or aspiration of contaminated water (cooling tower, humidifiers, resp equipments) - usually linked to contaminated hot water supply. Not transmitted person to person

81
Q

symptoms of legoinnaires disease

A

early: malaise, muscle aches, lethargy, and slight headaches. high fever, non-productive cough, abdominal pain, diarrhea
late: extreme lethargy, comatose state. impaired kidney and liver functioning, nervous system disorders

82
Q

when to suspect legionnaires disease

A

when patient is hyponatremic
when patient has alot of extrapulmonary symptoms
antibiotic failure
gram stain shows PMNs with no organisms

83
Q

white in lungs on CXR

A

blood
pus (pneumonia)
water (pulmonary edema)
cells (cancer)

protein or calcium - rare

84
Q

what does a pleural effusion look like on an CXR?

A

dense white area, transitions through gray to black normal lung as you go higher

you will be able to see the other diaphram in the lateral view

most layer out in the lateral decubitus position

85
Q

bilateral perihilar opacification (“bat-wing” patter) and cardiomegaly on a CXR is indicative of what?

A

heart failure

86
Q

what would you see on a CXR for LLL pneumonia?

A

lose the left hemidiaphragm and descending aorta

clin med (12 decks)

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