PULM Neoplasms and FB, VTE, Pulm HTN and cor Pulmonale, Pneumonia Flashcards
Explain the components of Virchow’s Triad
- Venous stasis
- Hypercoagulability (alterations in the constituents of the blood)
- Endothelial injury
–> Recruitment of activated platelets which release microparticles containing proinflammatory mediators that bind neutrophils stimulating them to release their nuclear material and form prothrombotic networks
–> Clot can embolize from the leg to the lung to form pulmonary embolism
Name some of the common risk factors associated with VTE
- Post-operative (recent surgery – especially orthopedic)
- Total hip arthroplasty (THA)
- Total knee arthroplasty (TKA)
- Hip fracture surgery (HFS)
- Pelvic fractures
- Multiple fractures from severe trauma
- Sedentary state (Hospitalized/bedrest, Prolonged travel, lifestyle )
- Malignancy
- Hx VTE in the past
- Pregnancy
- Oral Contraceptives
- Obesity
- Heavy cigarette smoking (>25 cigarettes per day)
- Hypertension
- Inherited hypercoagulable disorders (Inherited Thrombophilia)
Hereditary conditions that predispose to hypercoagulability
(Inherited Thrombophilia)
_•Factor V Leiden Mutatio_n – causes resistance to activated protein C
•Prothrombin Gene Mutation – increases plasma prothrombin concentration
•Deficiency of proteins C and S
•Antithrombin III deficiency
•Anticardiolipin antibodies (antiphospholipid syndrome) **Antithrombin, Protein C and Protein S are naturally occurring coagulation inhibitors.
Surgerys that are risk factors for VTE
- Total hip arthroplasty (THA)
- Total knee arthroplasty (TKA)
- Hip fracture surgery (HFS)
- Pelvic fractures
- Multiple fractures from severe trauma
Describe Well’s Criteria for PE
Decribe Well’s Criteria for DVT
Name the common symptoms associated with:
DVT
PE
DVT:
Unilateral LE swelling (calf)
Pain
Cramping
tenderness
Erythema
Warmth
PE
Tachypnea, hypoxia, tachycardia***
Sudden SOB
Pleuritic chest discomfort
Heart palpitations
Recognize the EKG features of a patient with right heart strain secondary to massive pulmonary embolism
S1, Q3, T3 and R ventricular strain pattern
I – S wave in lead I is seen, should be an R wave
•(none should be going down)
III – pathologic Q wave seen and inverted T wave
V1-V3 – down going T wave, dip very low
* R ventricular strain pattern – T wave inversions in R & anterior precordial leads (V1-V4) +/- inferior leads (II, III, aVF) – associated w/ high pulm pressures – most specific *Complete or incomplete RBBB
Identify patients for whom the PERC rule is appropriate
rule out very low risk pts to avoid unnecessary testing / imaging
MUST HAVE ALL 8
D-Dimer is used in ____ probability patients to rule out DVT.
______-______ probability in PE.
Low probability patients to r/o DVT
Low-Moderate probability in PE
What are the gold standard imaging tests for both DVT and PE
DVT -
Venous duplex ultrasound -> Looking for loss of vein compressibility
PE
CT angiogram w/ contrast **
(CI in kidney failure, contrast allergy and pregnancy)
what is the Imaging test of choice to diagnose PE in patients with kidney failure?
V/Q Scan -
used when CTA is contraindicated
(kidney failure, contrast allergy and pregnancy)
what imaging test is helpful when trying to differentiate MI from PE?
Echo
VTE Prophylaxis in High risk orthopedic patients
UFH for hospitalized patients
LMWH
Oral Factor Xa inhibitors (lower dose than treatment dose)
Pradaxa (direct thrombin inhibitor)
Aspirin should not be used as the sole agent***
What are the primary and secondary therapies for patients with VTE?
Primary therapy – clot dissolution
- thrombolysis (tPA) or
- removal of PE by embolectomy
- (reserved for high risk of adverse clinical outcome)
Secondary therapy – anticoagulation
- with anticoagulants OR
- placement of IVC filter – removed after 2-3 weeks*
What are the indications for placement of an IVC filter?
Complications?
- Active bleeding precludes anticoagulation
- Recurrent venous thrombosis despite intensive anticoagulation
- High risk patients who are not candidates for fibrinolysis
Complications:
Caval thrombosis causing marked bilateral leg swelling
•Double the DVT rate****
What are the causes of a provoked vs unprovoked clot?
what is the difference in duration of anticoagulation?
What anticoagulants would be appropriate for the following specialty groups:
Renal Failure (CrCl <30)
High Bleeding Risk
Malignancy
Pregnancy
- Renal failure (CrCl <30) UFH drip bridge to warfarin
- High bleeding risk - reversal agent may be needed use warfarin
- Malignancy - LMWH long-term
- Pregnancy - LMWH
What is the most common EKG finding with PE?
sinus tachycardia
Define pulmonary HTN?
Diagnostic Criteria: Mean pulmonary artery pressure ≥ ____ mmHg at rest with a pulmonary vascular resistance ≥ ___ wood units
- Abnormal elevation in mean pulmonary artery pressure (mPAP)
- Mean pulmonary artery pressure ≥ 20 mmHg at rest with a pulmonary vascular resistance ≥ 3 wood units
In regards to pHTN: Normal mPAP is __-__mmHg which is measured by right heart catheterization.
8-20 mmHg
Most common cause of pHTN in adults is ?
lung disease
What is the result of longstanding pulm HTN?
Chronic increase in either flow and/or pulmonary venous pressure can increase PVR
pHTN leads to decreased compliance of pulmonary vasculature which causes:
- Progressive increase in the RV afterload -> RV hypertrophy
- •Eventually RV dilated -> decreased contractility -> decreased cardiac output
what are the classes of pHTN?
Class I: pHTN without limitations of physical activity
Class II: pHTN resulting in slight limitations of physical activity. No rest symptoms (Gets symptoms with activity, but only mildly limits the patient)
Class III: pHTN resulting in marked limitations of physical activity. No rest symptoms (Get symptoms with activity and severely limits them)
Class IV: pHTN with inability to perform any physical activities. Evidence of right heart failure. Symptoms at rest.
Group 1 pHTN is caused by?
What do we note about the PAP?
Idiopathic, heritable (caucasions 75%)
parasitic infections (schistomiasis) – most common cause worldwide
SEVERELY elevated PAP >25
what is the diagnostic criteria for Group 1 pHTN?
- Mean PAP > 25 mmHg at rest
- Mean PCWP < 15 mmHg
- Chronic lung disease is mild or absent
- Venous thromboembolic disease is absent
- Other disorders are absent
Treatment for Group 1 pHTN?
ONLY advanced therapy – no underlying cause
Anticoagulation may be warranted in select patient population among Group 1 (idiopathic, hereditary, or drug induced)
Left sided HF most common cause of group __ pHTN.
How do we treat this group?
Group 2 - Caused by Left Heart Diseases
Treat underlying heart disease (ACE, ARBs, BBs, Inotropes, etc)
Treat volume overload (diuretics)
Fix underlying heart valve disease
What is the cause of Group 3 pHTN?
What are the most common causes?
Chronic Lung Dz – most common cause of pHTN
- Obstructive (COPD) / restrictive
- Obstructive sleep apnea
- Hypoxia w/o lung dz
- Developmental lung disorders
Most common causes: COPD & Interstitial lung disease
Treatment of Group 3 pHTN
Supplemental O2
Inhaled bronchodilators
Digoxin
Which pHTN group is caused by pulmonary artery occlusion?
How do we treat this group?
Group 4
Long term anticoagulation
Thromboendarterecty is recommended if treatment fails
Prostanoid agents (IV or inhaled epoprostenol or SQ treprostinil) can be considered
Group 5 pHTN is due to unknown causes. Name some disorders that are noted in this group.
Hematologic disorders – myeloproliferative disorders
Metabolic disorders – Glycogen storage diseases
Systemic disorders – sarcoidosis
Sickle cell dz
Treatment for Group 5 pHTN
Prostanoid agents (IV or inhaled epoprostenol or SQ treprostinil) have been shown to have a good response in Sarcoidosis
Gold standard for the diagnosis and quantification of pHTN?
Right-sided cardiac catheterization
mPAP ≥25 mmHg at rest -> diagnosis of pHTN can be given
mPAP 20-24 mmHg at rest -> further clinical data is needed
Right-sided cardiac catheterization measures?
(4 things)
•RA pressure
RV pressure
- mPAP
- Pulmonary capillary wedge pressure(PCWP) – indirect measurement of the left heart pressure
Echocardiography with Doppler Flow is a useful tool to estimate the?
Estimate the right ventricular systolic pressure
- pHTN is likely if PASP is > 50 mmHg and tricuspids regurgitation velocity (TRV) is > 3.4 m/s
- pHTN is unlikely if PASP < 36 mmHg and TRV ≤ 2.8 m/s
What is one of the most important prognostic factors in regards to pHTN?
Right ventricular function is one of the most important prognostic factors
Worsening RV failure = worsening prognosis
What medications would we use to treat class I symptoms of pHTN?
CCBs
(should only be given to patients who showed response to vasodilation test in cath lab)
What medications would we use to treat class II symptoms of pHTN?
Vasodilate pulmonary system:
Endothelin receptor antagonists
(Ambrisentan, Bosentan, Macitentan)
Phosphodiesterase inhibitors (Sildenafil, Tadalafil)
Guanylate cyclase stimulators (Riociguat)
What medications would we give to patients w/ class III or IV pHTN symptoms (or failed other therapies)?
Prostanoid agents:
(IV or inhaled epoprostenol or SQ treprostinil)
Idiopathic pHTN patients have a poor prognosis and a median survival of ___-___ years.
2-4 years
What is Cor Pulmonale?
What causes it?
Altered structure and/or impaired function of the right ventricle that results from pulmonary hypertension
•systolic and diastolic failure
•Isolated Right sided heart failure due to pulmonary causes **
- COPD
- Idiopathic pulmonary fibrosis
- Pneumoconiosis
- Kyphoscoliosis
What are some Si/Sx of Cor Pulmonale
- Dyspnea at rest
- Finger clubbing
- JVD
- Tricuspid regurgitation
- Right sided S3
- Narrow split S2
- RV heave
- RUQ pain
- Hepatomegaly
- Ascites
Pathophysiology of Cor Pulmonale
Right heart failure results from long standing pulmonary hypertension
Right ventricular hypertrophy develops due to the high pulmonary pressure that it pumps against
Eventually right ventricle loses its contractility
Main cause of death in patients with pulmonary artery hypertension (group 1) is circulatory collapse
What must patients with Cor Pulmonale show on an echocardiogram?
(Think right vs left heart)
•Normal LV function **** (or not cor pulmonale)
- RV and RA dilation
- RV dysfunction
Treatment of Cor Pulmonale
- Therapy is directed at underlying cause
- Oxygen
- Salt and fluid restriction
- Diuresis (loop diuretics, thiazides, and spironolactone)
- Digoxin & Inotropic support (Improve RV failure)
In patients with Cor Pulmonale:
Once signs of heart failure appear, the average life expectancy is ___-___ years
•Survival is even lower when ______ is the cause
2-5 yrs
emphysema
In patients with Cor Pulmonale these tests will show:
CBC
ABG
CXR
CBC - hemoconcentrated (everything decreased)
ABG - Saturation < 85%
CXR - Prominent or enlarged RV and PA
Why is a tenion pneumothorax a medical emergency?
•Progressive build-up pushes the mediastinum to the opposite hemithorax and obstructs venous return to the heart causing cardiac arrest.
Primary pneumothorax occurs in people (with / without) lung disease, while secondary pneumothorax occurs in people (with / without) lung disease.
primary - occurs in people w/out lung disease
secondary - occurs in people w/ lung disease
this type of pneumothorax is:
Caused by rupture of small pulmonary blebs*.
•Patient’s are typically aged 18-40 years, tall, thin and are often smokers
primary pneumo
the most common cause of secondary pneumothorax?
COPD
what treatment is ALWAYS given to pts who have had a pneumothorax?
Supplemental O2 – given in order to maintain oxygenation
•Lowers partial pressure of nitrogen -> accelerate the rate of absorption of air from the pleural cavity and hasten lung expansion
what are the treatments for pneumothorax?
both conservative and surgical?
conservative - Chest decompression via chest tube or pigtail catheter.
surgery - VATs blebectomy
Pleurodesis
supplemental o2
Physical exam findings noted in a moderate to large Pleurall effusion.
Dullness to percussion
- Decreased tactile fremitus
- Diminished or inaudible breath sounds
- Egophony (E to A transition)
- ***Little physical findings for effusions smaller than 250 cc.***
Pleural effusions can either be transudative or exudative.
What criteria helps distingish this? - outline the criteria
Lights Criteria
- Ratio of pleural fluid to LDH is >0.6
- Pleural fluid level of LDH is more then 2/3 the upper limit of reference range for LDH
- Ratio of pleural fluid level of protein to serum is >0.5
Exudative if more then 1 criteria is met
Transudative effusions are due to…?
what is the most common cause?
Largely due to imbalances in hydrostatic and oncotic pressures in the chest:
CHF - #1 cause
- Atelectasis
- Nephrotic syndrome
- Cirrhosis
Exudative Effusions are caused by?
Disease in any organ can cause an exudative effusion, however, more commonly a result from pleural/lung inflammation or impaired lymphatic drainage.
- Pneumonia
- Malignancy
- Pulmonary embolism
what is an infection of the pleural space most commonly seen as a complication of pneumonia, where bacteria escape into the pleural space.**
empyema
how do we treat pleural effusions
DRAIN -thoracentesis and abx
Intrapleural fibrinolytic/antibiotic infusion
VATs thoracoscopy with tube drainage
Clagett Window- open drainage of the empyema cavity
Decortication and pulmonary resection
Pleural fluid analysis most noteably shows what 2 findings?
protein
LDH
when is thoracentesis indicated in the setting of pleural effusions?
what are the contraindications?
Thoracentesis: Effusion of unknown cause
CI:
Systemic anticoagulation
Area of infected skin on chest wall
what are the features of pleural effusion seen on CXR
Pleural effusions of >150 ml are usually seen on CXR = blunting of the costophrenic angle.
Malignant Pleural Effusions (MPE) are caused by?
Increased capillary permeability
Disruption of capillary endothelium Impaired lymphatic drainage
Direct invasion of pleural space by tumor
Malnourishment/hypoalbuminemia
**mostly exudative
RECCURRENT!!!
Primary sites of Malignant Pleural Effusions (MPE)
Primary sites:
Lung 36%
Lymphoma 16%
Breast 15%
Ovary 8%
What are the 2 ways to manage recurrent pleural effusions?
When are the indicated?
- Recurrence of effusion or pneumothorax.
- Symptomatic improvement after thoracentesis*.
Inability to control effusion with chemotherapy
Pleurodesis - Lung re-expansion after thoracentesis*.
Indwelling Catheters - Failure of lung re-expansion after thoracentesis*.
Pleurodesis is considered successful if?
- Apposition of the pleural membranes.
- Adequate pleural drainage from the chest tubes.
- Ability of the lung to re-expand fully.
- Uniform distribution of the sclerosing agent
what are the pros and cons of using an indewlling catheter to treat recurrent pleural effusions?
- Pros:
- Less pain
- Shorter hospital stay
- Cons:
- Obstruction of catheter
- Risk of infection
- Loculation of the effusion
What is Pleurodesis and what are the common sclerosing agents used?
- medical procedure in which the pleural space is artificially obliterated by causing the visceral and parietal pleural to stick together.
- Instillation of a chemical sclerosant
- Pleural abrasion (mechanical)
Sclerosing agents:
- Talc
- Doxycycline
- Bleomycin
- Quinacrine
- Minocycline
what is the most commonly aspirated foreign body?
what are the most common objects involved in fatal childhood FBA.
most common - nuts
fatal childhood FBA - Toy balloons, rubber gloves, and marbles
where do most FBA occur?
right Lung
how do we treat a FBA?
Rigid/Flexible Bronchoscopy
Surgey needed if FBs cannot be removed.
Si/Sx of a FBA
- Severe respiratory distress, cyanosis, mental status change = medical emergency
- Stridor
- Hoarseness
- Dyspnea
- Wheezing
Typical Bacterial causes of Pneumonia
strep pneumonias - rust colored sputum
h. influenzae
M. catarrhalis - most common w/ COPD pts
staph auerus - IVDU or after viral illness
Group A strep
Aerobic gram-negative bacteria associated with pneumonia?
- Klebsiella pneumoniae - currant jelly hemoptysis, red sputum
- EtOH, COPD
- bed bound, associated with cavitary lesions (necrosis of lung)
Atypical bacterial causes of pneumonia include:
- Legionella species - contaminated water - hot tubs, cruise, travel (GI sx – N/V diarrhea)
- Mycoplasma pneumoniae- Most common of atypical
- walking pneumonia, young, college students
(bullous myringitis)
- Chlamydia pneumoniae
- Chlamydia psittaci - bird exposure
Coxiella burnetiid - exposure to farm animals (sheep)
•Histoplasma capsulatum (fungi) is found in???
•bat or bird droppings
•Francisella tularenis (Tularemia) would infect someone who..??
•rabbit exposure/hunter
Abnormal lab findings such as LFT abnormalities are usually seen with what pathogen?
•Legionella species
what are the most common respiratory viruses that cause the flu in adults?
in children??
- Influenza A and B viruses - main cause in adults
- Rhinoviruses
Respiratory syncytial virus/Parainfluenza viruses - main cause in infants/small children
what is gold standard for diagnosing pneumonia?
CXR
2 views - PA and Lateral
CXR findings in:
typical
atypical
Bronchopneumonia
typical - lobar consolidations
atypical - Interstitial infiltrates – around alveoli
Bronchopneumonia - Worse patchy infiltrate, Bilateral at bases
describe the tools used to assess severity of pneumonia?
•Clinical judgment is most important**
CURB-65
- 1 or more think admission, except of only positive is age
- 2 or more -> admit
- 3,4 or 5 -> admit, think ICU?
PSI (Pneumonia severity index): Better tool but very cumbersome
Describe how to use the CURB 65
- 1 or more think admission, except if only positive is age
- 2 or more à admit
- 3,4 or 5 à admit, think ICU?
How would we treat pneumonia in an outpatient setting?
Beta- Lactam (amoxicillin, amoxi-clav, cefepodoxime, cefuroxime)
OR
Macrolide (azithromycin)
OR
Doxycycline
Comorbidities or abx w/in the last 3 mo:
Combo beta lactam reg (beta lactam + macrolide or tetracycline)
OR
Respiratory Fluoroquinolone (Levofloxacin) monotherapy
Inpatient abx treatment for pneumonia
Start abx w/in 4 hours of presentation - assess MRSA & pseudomonas risk
If no risk for either: antipneumo BL + macrolide or tetracycline OR respiratory FQ
MRSA risk: same as above add MRSA agent * (vanco)
Pseudo Risk: Antipseudomonal/antipneumococcal beta-lactam + antipseudomonal FQ (Piperacillin-tazobactam + Levofloxacin)
MRSA & Pseudo risk: Vancomycin + piperacillin-tazobactam + levofloxacin
abx treatment for patient w/ pneumonia in the ICU
- Start Abx within 1 hour of presentation
- Adjunctive glucocorticoids +/-
- Respiratory depression requiring mechanical ventilation
- Sepsis or pressors
- some may need follow up chest x-ray 7-12 weeks later********
what is a risk factor for both HAP and VAP?
•IV antibiotics within the past 90 days
HAP diagnosis criteria?
Must have CXR abnormality and at least one of these:
New lung infiltrate and sign that it’s infectious
New onset of fever
Purulent sputum
Leukocytosis
Decline in oxygenation
treatment for aspiration pneumonia?
First line IV: Ampicillin-sulbactam (unasyn) -> covers anaerobes
_First line PO: A_moxicillin-clavulanate
Alternative
•Metronidazole (PO/IV) + amoxicillin or PCN G
Most common opportunistic infection associated with HIV/AIDs with a low CD4 count???
Opportunistic Pneumonia (PCP)
pathogen that causes Opportunistic Pneumonia (PCP)
Pneumocystis jirovecci pneumonia (PCP)
Without HIV infection the most common risk factor for Opportunistic Pneumonia (PCP) is _______ use
Glucocorticoid use
most common risk factor for pulmonary infection in immunocompromised pts
Neutropenia
Labs and imaging studies to diagnose PCP
CD4 count <200 cells
•ABG
•1-3-beta-d glucagon levels – confirm fungal infection
- PCR
- Sputum
Imaging
•CXR – diffuse, bilateral, interstitial infiltrate
•Chest CT – ground glass appearance
Tx of PCP
Mild dz -TMP-SMX
Moderate dz - TMP-SMX + prednisone PO
Severe dz - TMP-SMX + methylprednisolone (IV)
Alternatives
•Atovaquone - use if Bactrim allergy
immunocompromised patients can take what antibiotic to prevent PCP?
TMX-SMX
Alt: Atovaquone (if allergy)
