Pulm Intro Flashcards
Early inspiratory and expiratory crackles are hallmark for…
Chronic bronchitis
When do you hear late inspiratory crackles
Pneumonia, CHF
When would you hear crackles?
Associated with lung abnormalities- pneumonia (fluid in lungs), fibrosis. Or in airway disease like bronchitis or bronchiectasis.
What do wheezes suggest and when do you hear them?
Narrowed airways- asthma, COPD, bronchitis,
Rub- when do you hear these?
Dry crackling, grating, low pitched sound heard in pleurisy when 2 inflamed surfaces slide by one another
What sounds discontinuous, intermittent, nonmusical, and brief?
Crackles- fine are brief and discontinuous, coarse are louder, last longer, and lower in pitch
What sounds continuous, muscal, and prolonged?
wheezes and rhonchi. Wheezes are high-pitched, rhonchi are low-pitched with snoring quality.
What do rhonchi suggest?
Secretions in large airways. Heard in the chest wall where bronchi are, not over any alveoli.
What would egophony tell you?
If sounds like “ay” then, lobar consolidation like in pneumonia or fibrosis. If absent, pneumothorax.
Decreased tactile fremitus
Emphysema
Increased tactile fremitus
Pneumonia
Types of PFT
clinical assessment, spirometry, lung volume measurements, maximal respiratory pressure measurements, DLCO
When would a 6 min walk test show abnormal results?
When SaO2 decrease more than 4%- further testing needed
When would post-bronchodilator show good response?
If FEV1 increases by more than 12%- means patient responding well to that treatment
Is spirometry good for diagnosing or monitoring asthma?
monitoring because mild asthmatics have normal spirometry between acute exacerbations
What is the gold standard for lung volume measurement?
Body plethysmography
What does plethysmography measure
RV, TLC, FRC (functional residual capacity)
RV and TLC would be ___ in emphysema
increased because of air trapping and hyperinflated lungs
RV and TLC ___ in chronic bronchitis
RV is increased because of air trapping- so more than normal amount of air is still left in lungs after exhalation. TLC is the same.
What does maximal respiratory pressure measurement measure?
respiratory muscle WEAKNESS. Maybe that’s why having a hard time breathing.Also helps to figure out why there are decreases in vital capacity.
Maximal and expiratory pressures are achieved by using what device?
Blocked mouthpiece
What is DLCO helpful to diagnose in?
Restrictive and obstructive lung disease
Procedure of DLCO
Inhale deep breath of 0.3% CO and 10% helium. Hold breath for 10 seconds, then exhale quickly. Alveolar sample of exhaled gas is analyzed- see how much CO diffused from alveoli to RBC.
DLCO increased and decreased in…
Increased in asthma, decreased in COPD, PE, CF, pulmonary vascular disease, anemia
Tests that can be done to assess lung function/analysis
PFT, ABG, Radiologic Imaging, measures of oxygenation
Indications for ABG’s
Assess breathing difficulties, monitor treatment response, monitor ventilation, and assess acid-base status
What is the most common initial screening tool for pulmonary disorders?
CXR
CT scans with IV contrast benefits
Provide further detail, used to evaluate chest pain, dyspnea, tumor, trauma, pneumothorax
What is a subset of CT scan w/contrast where the contrast is timed to be present in the vascular system
CT angiography
Non contrast CT scans
COPD, ILD, bronchiectasis,
What is normal for resting SaO2?
Greater than or equal to 95%
A-a oxygen gradient
Difference between the amount of oxygen in the alveoli and the amount of oxygen dissolved in plasma.
What does a high A-a oxygen gradient show
PE
Normal PaO2/FiO2 ratio
300-500 mmHg
When is oxygenation index used?
In neonates with persistent pulmonary HTN of the newborn
Causes of hypoxemia
V/Q mismatch (PE), hypoventilation, right to left shunt, diffusion impairment, high elevations
Nasal cannula administers oxygen rates between…
1-6L/min
Types of masks
Simple, air entrapment masks (Venturi), partial rebreathing, and nonbreathing systems
What is a Venturi?
Air entrapment mask-more controlled. Not as much exchange between room air and oxygen.
Supplemental oxygen devices
Nasal cannula, masks, enclosure systems (hoods or tents)
What supplemental oxygen device would you use for infants?
Hoods or tents (enclosure systems)- passive so not on face
What device would you use on patient who requires airway assistance but not emergent intubation?
NPPV- noninvasive positive pressure ventilation- COPD, obesity hypoventilation syndrome
Absolute contraindication for NPPV
Need for emergent intubation
Relative contraindication for NPPV
If can’t cooperate, impaired consciousness, facial trauma or surgery, high aspiration risk, anticipated prolonged duration of mechanical ventilation (should go directly to invasive in this case)
NPPV types
Standard ICU ventilator, portable ventilator. Interfaces include face mask, nasal mask-better tolerated but not as effective, and nasal plugs
NPPV modes
CPAP and BIPAP more common. Others- assist control, pressure support ventilation, and proportional assist ventilation
When to use CPAP vs. BPAP?
Use CPAP in more non-urgent conditions, BiPAp in URGENT conditions.
CPAP- how does it work?
Patient initiates each breath, ventilator provides continuous positive airway pressure to keep airways open
How does BiPAP work?
Delivers both inspiratory and expiratory positive airway pressure- when patient not able to initiate his/her own breath
Assist control
Sets the minimal minute ventilation by setting the respiratory rate and tidal volume. patient can still initiate breaths
Pressure support ventilation
Patient triggers each breath, but can’t go all the way so there is pressure support from the ventilation with each breath
Proportional assist ventilation
provides automatic synchrony between the patient and the ventilatory cycle-delivers inspiratory pressure that is proportional to patient effort
NPPV monitoring
Monitor closely in 1st 8 hours of therapy
When is NPPV considered successful?
Improvement in pH and PaCO2 in 30 min-2hours
What if no improvement in alotted time for NPPV or changes in mental status/agitation?
ENDOTRACHEAL INTUBATION
Benefits of NPPV
Improved mortality rates compared to invasive, decreased need to use invasive mechanical ventilation since you have this as an alternative, and decreased incidence of nosocomial infections
Disadvantages of NPPV
poorly tolerated by patients, esp face mask
Invasive positive pressure ventilation indicaions
for insufficient oxygenation and/or ventilation
Most common pulmonary symptoms seen
cough, dyspnea, chest pain, and hemoptysis
PE of dyspnea
HEENT, neck, chest, heart, lower extremities
diagnostic testing of dyspnea
CXR, ABG, spirometry, EKG, cardiac workup
What will distinguish chest pain from other systems?
Pulmonary/pleural problem-pleuritic chest pain vs. regular chest pain with cardiovascualr, musculoskeletal, GI, psychiatric
Pleuritic chest pain questions- to differentiate from CV origin
Does it get worse when you take a deep breath in, when you cough, when you change positions?
PE for chest pain
pulmonary, CV, GI, MS
DIagnostic tesing for pleuritic chest pain
EKG, cardiac markers helpful to evaluate for cardiac etiology. CXR/CT helpful for pulm, esp if associated pulm symptoms
Acute cough
less than 3 weeks
Acute cough cause
Viral- most people will have symptoms resolve in less than 3 weeks
Cough + dyspnea =
More serious illness- evaluate thoroughly. May be chronic lung disease, CHF, or anemia
Persistent cough
3-8 weeks
Chronic cough
more than 8 weeks
Subacute cough
Post-infectious cough that persists for more than 3 weeks
Cause of cough
postnasal drip, asthma, COPD, GERD, ace inhibitors, pertussis
Cough + constitutional symptoms=
carcinoma evaluation
If history of recurrent cough or complicated infections with
consider bronchiectasis (RECURRENT)
What are signs of infection?
fever, tachycardia, tachypnea, sputum
What are signs of consolidation?
crackles, decreased breath sounds, fremitus increased, egophony
PE for cough
evaluate for sings of infection, consolidation, and cardiac disease
Diagnostic studies for cough
ABG, pulse ox, CXR, CT, spirometry for airflow, testing for specific infections- sputum cultures, PCR for pertussis
What is hemoptysis classified as?
Trivial, mild, or massive
Where can bleeding in hemoptysis originate from?
Airways, pulmonary vasculature, or pulmonary parenchyma
Diagnostic testing for hemoptysis
CBC, UA, BMP, coag studies, D-Dimer, CXR/CT, Bronchoscopy
