Pulm w/ Reading Flashcards
Smoke inhalation affects ? part of the airway?
What type of inhalation burn can impact the entire airway
Upper
Steam
Thermal inhalation injuries are usually isolated to ?
Why do PTs w/ inhalation injuries progress and present w/ issues up to 18-24hrs later
Mucosa of supraglottic airway
Neutrophilic inflammation- edema and ulcerations
Inhalation injuries tend to present w/ ? two issues
What needs to be conducted on serial repeat in these PTs?
Bronchospasm
Bronchorrhea
Serial CXRs
What are the 3 effects of smoke inhalation
PTs that survive burns usually do so w/out issues but impaired pulmonary function may manifest as ? syndrome
? is the leading cause of death from poisoning worldwide
Thermal injury, upper airway
Impaired tissue oxygenation
Chemical injury, lower airway
Reactive Airway dysfunction- hyper responsiveness of airway
Carbon monoxide
How are CO poisoning PTs Tx w/ hyperbaric chambers
Cyanide inhibits ? enzyme causing PTs to present w/ ? 3 Sxs
Since it takes so long for lab results to Dx this, what finding is indicative of this type of poisoning
2.5-3 atm x 2-3 Tx sessions
One Tx of 2hrs for severe cases
Cytochrome enzyme: lactic acidosis, coma, shock
Inc venous O2 saturation
What two drugs are in the cyanide antidote kit
What is the adverse effect of using this antidote?
How are Thermal inhalation injuries Tx
Hydroxocobalamin (B12 precursor)
Sodium thiosulfate
Red skin/urine
HEATS Humidified O2 Elevate head 30* ABG/pulse ox monitoring Topical Epi Suction
What are the early and late S/Sxs of chemical inhalation injuries
What injury process makes these PTs at risk for ? two Dzs later
Early: bronchorrhea, bronchospasm
Late: dyspnea, cyanosis
Edema/sloughing= atelectasis, hypoxemia
ARDS 1-2 days
Pneumonia 5-7 days
How is smoke inhalation Tx
What two Txs are avoided
PTs that survive need monitoring to detect development of ?
PEEP
Daily Gram stains
Fluids
Suction O2 Dilators
CCS, ABX
Bronchiolitis obliterans: ground glass, bronchial thickening
What does ‘ground glass” appearance on a CT mean
What do reticular/linear opacities mean
Inc attenuation in lung
Opportunistic infection
Interstitial Dz
Acute alveolar Dz
Pathological involvement of pulmonary interstitium
What is the relationship between silicosis and the development of other Dzs
Define Caplan Syndrome
Macrophage dependent defense invasions:
Collagen vascular Dzs- RA
Atypical Mycobacteria
TB
Rheumatoid nodules in lung in PTs w/ pneumoconiosis and RA
What compensatory Dz may be seen in Silicosis
What will be seen on CXRs
What is seen in complicated silicosis PTs?
Lower lobe emphysema
Egg shell calcifications of mediastinal lymph nodes
Masses in upper lobes
Dyspnea
Obstructive Restrictive PFT
What type of asbestosis has more/less effect on the lung
What are the first initial appearances of asbestos exposure
What finding is a marker of exposure but seen in all exposed PTs
More- chrysotile
Less- amphiboles
Linear calcified opacities over hemidiaphragm and cardiac border
Pleural plaques
What is the “Comet Sign” and where is it seen
What type of Dz is Asbestosis
Thickened pleura due to rounded atelectasis from asbestos
Restrictive
How do Pts w/ asbestosis present
What type of asbestos may be seen in these PTs sputum samples/lung biopsies
Dry cough w/ dyspnea
Digital clubbing
Basal crackles
Ferruginous bodies
What is seen on CXRs if asbestosis is early/late
What finding may be the best Dx clue in absence of other findings and Pt w/ + exposure
Early: linear streaking in lower fields
Late: hone comb
Pleural calcifications
Mesothelioma is a tumor located where?
What is the best image modality to view ? findings
What type of lung dz is silicosis and asbestosis
Pleura and/or Peritoneum
HRCT- fibrosis, pleural plaques
Silicosis: restrictive and obstructive
Asbestosis: restrictive, dec DLCO
Occupational hypersensitive pneumonitis can be from contaminated humidifiers that are infected w/ ? microbes
What is becoming to be one of the MC sources of occupational sources of infections
Most antigenic exposures leading to this issue are ?
Protozoa
Fungi
Recirculated coolants w/ Gram Neg or Atypical mycobacteria infections
Thermophilic actinomycetes fungi
Avian/rat proteins
Mycobacteria
Protozoa
What are two less common sources of hypersensitive pneumonitis
What body reaction is responsible for these hypersensitivities
PCN, MDI (sealant)
IgG Abs
T-lymphocytes
What will be seen on lab results in PTs w/ acute hypersensitive pneumonitis
What would be seen on PFT/ABG results
What test may be done on these PTs to monitor their reactions in the work place?
Neutrophilia w/ L shift
Inc ESR/CRP
Restrictive pattern/red DLCO
Hypoxemia
Work challenge
What would be seen on CXR of acute/chronic hypersensitive pneumonitis
How is a definitive Dx made
Acute: Nodular densities but NOT in bases/apex
Chronic: fibrosis, honey comb
Lung biopsy
How is hypersensitivity pneumonitis Tx
What are the 3 obstructive airway d/os
Acute: self resolving
Chronic: PO CCS taper over 4-6wks
Byssiniosis
Industrial bronchitis
Occupational asthma
How is occupational asthma Dx
How is it Tx
Industrial bronchitis rarely leads to ?
Hx
Spirometry before/after exposure
Peak flow measurement at work
Avoidance and Dilators
Chronic disability
Industrial bronchitis can be caused by ?
Define Byssinosis
How does it present
What happens if exposures are not d/c
Coal Cotton Flax Hemp
Asthma like d/o in textile worker from inhalation of cotton dust
Tight chest, cough, dyspnea on 1st day back to work
Chronic bronchitis
Silo Filler’s Dz
What is a common late finding
This is preventable w/ early ?
Toxic pulmonary edema from inhaled NO
Bronchitis obliterans
CCS
What causes “popcorn” lung
What type of Dz is this
What is unique about Byssinosis
Diacetyl exposure leading to bronchiolitis obliterans
Constrictive bronchiolitis
Obstructive lung Dz, not restrictive like all other pneumoconioses
Due to the pH being <2.5, what series of events happen after inspiration of gastric contents
This series of events is also one of the MC causes of ?
What will be seen on PE/labs
Desquamation
Bronchiolitis
Hemorrhage
Pulmonary edema
ARDS
Cough/wheeze
Fever even w/out infection
Hypoxemia, Leukocytosis
Normally, airway is protected by ? mechanism
What is the name of the syndrome due to aspiration
How are these PTs Tx and what is avoided
Cough reflex
Mendelsohn- large single aspiration followed w/ hypoxia
Intubate, Ventialte, Fluids
No CCS or ABX
What habits can decrease the tone of the LES?
What pulmonary d/os are linked to GERD/chronic aspirations?
Caffeine Alcohol Nicotine Theophylline
Cough Asthma Bronchiectasis Pulmonary fibrosis
What are the phases of the development of radiation pneumonitis
How long does it take for acute radiation pneumonitis to develop and show?
1: alveolar injury leads to pulmonary edema
2: radiation pneumonitis, spontaneous resolution and fibrotic changes
2-3mon w/ dyspnea, cough, pain, fever
What is seen on CXR and PFTs of radiation pneumonitis
How is it Tx
What can this Dz progress into?
Nodular opacities
Red volume, compliance and diffusing
Prednisone
Pulmonary Radiation Fibrosis
Slow dyspnea
What is seen on CXR in Pulmonary Radiation Fibrosis
Define Pickwickian Syndrome
Tented diaphragm
No lung markings
Red volume
Reticular/dense opacities
Obesity Hypoventilation Syndrome: dec ventilatory drive w/ inc mechanical load
What is a unique compensatory reflex in Pickwickian not seen in other lung Dzs
What are the Dx criteria
Most of these PTs will also have ?
Voluntary hyperventilation
BMI +30
Partial CO2 pressure >45mmHg
OSA
What respiratory stimulants can be used when Tx Pickwickian
What lab finding is common when working up OSA
What finding may be heard prior to an apneic episode of a sleeping PT w/ OSA
Medroxyprednisone
Acetazolamide
Theophylline
Erythrocytosis
Snort w/ first breath
What may be the first presenting Sx of OSA
What at home test is done during Dx work up
How is the severity staged?
Personality changes
Nocturnal pulse ox
Norm: 0-4
Mild: 5-14
Mod: 15-29
Sev: 30+, <90% for >20% of study
Pts w/ AHI +30 are at risk for developing ?
What is the 3rd leading cause of death in hospitalized PTs?
CHD HTN Arrhythmia DM
PEs
What can cause a PE
What is the MC?
Septic emboli Tumor cells Air Foreign bodies Fat Eggs- schistosomiasis
Thrombus from deep vein of LE
What are the inherited causes of hypercoagulability
What is the only reliable sign of PEs seen in half of PTs?
Factor V Laden: resistance to activated Protein C
Dysfunction Protein C/S
Antithrombin/Prothrombin mutations
Hyperhomocysteinemia- lupus anticoagulant
Antiphospholipid Abs- anticardiolipin Ab
Tachypnea
What is seen on ABG during a PE?
What does a D-dimer measure
What value does it hold in a medical setting
Respiratory alkalosis and hypoxia due to hyperventilation
Degraded product of cross linked fibrin
Exclusion of PE
What are the MC CXR findings on PTs w/ PEs?
What two findings may be seen?
What findings may be most suggestive of a PE?
Pleural effusion
Infiltrate
Atelectasis
Westermark: oligemic pulmonary artery
Hampton: parenchymal hemorrhage
Normal CXR w/ hypoxemia
What are the top 3 S/Sxs of a PE?
Massive PEs can present w/ ? unique Sx
What is the initial study of choice for suspected PEs
Dyspnea
Pain w/ inspiration
Tachypnea*- only reliable
Syncope
Helical CT-PA
MC EKG finding during PEs
Define McGinn White sign
Sinus Tachy w/ ST/T wave changes
S1Q3T3 EKG finding of massive PE
What D-Dimer result is strongly indicative against a PE
What other blood work findings may be seen
Helical CT have lower sensiivity for detecting PEs located ?
Rapid ELISA <500ng/ml
Troponin and BNP- no value but indicate poor prognosis due to R heart strain
Peripheral/sub-segmental
How does VQ scan work
Ventilation scans are usually done at the same time and show ?
When are these two studies most beneficial
Injected radiolabeled albumin to show dec blood flow
Xenon gas inhalation to show distribution through lungs
Normal/High probability
PTs w/ intermediate risks for PEs get ? test which is the TOC for ?
What VQ scan result is highly suggestive of a PE
Venous US Proximal DVT (Dx= inability to compress femoral/popliteal veins)
+ Perfusion defect
- Ventilation defect
What used to be the Gold Standard for DVTs?
What is it called now?
When is the test conducted?
Pulmonary angiography
Reference standard
Dx is required
All other tests are inconclusive or unavail
What is the MC algorith for identifying PEs
Well’s Criteria
Rapid D-dime
Helical CT PA (V/Q scan if c/i)
Hot DAMN BC HR +100 1.5 DVT Sxs 3 Alternative unexplained 3 Mobility 1.5 Nown Hx 1.5 Bloody cough 1 CA 1 5 or more= likely 4 or less= unlikely
What are the high probability VQ results
What are the low probability?
What is the normal
2 or more large defects w/ normal x-ray
Defect larger thatn x-ray abnormality
Nonsegmental
Defect smaller than x-ray
Matched VQ defecit w/ x-ray
Small subsegmental defect
No defect
What meds are used for VTE Tx
What are the combined w/?
LMWH
IV UFH
Fondaparinux
Low/UnFx combo w/ Warfarin x 5-7 days, d/c after 6 days when INR is in 2-3 range x 24hrs
What are the new Factor Xa inhibitors
What are the benefits
What are the adverse
A/R/E-xaban
No Warfarin bridging
No monitoring
A/R reversed w/ Andexxa
No compliance check
What thrombolytics are used for PE Tx
What are the absolute c/i
What are the major c/i
Strep/Urokinase
rt-PA: Alteplase
Internal bleeding
Stroke, past 2mon
Unctonrolled HTN
Trauma/surgery past 6wks
Chronic/recurrent PEs can cause ? in 1% of PT population
What is the pathophysiology behind ILDz
PHTN
Injury Repair attempt Fibrosis Honeycombing 2* PHTN
What category does Idiopathic Pulmonary Fibrosis fall in
What classes of drugs can cause drug induced/iatrogenic interstitial dz
Chronic Fibrosing Interstitial Pneumonia (Idiopathic Interstitial Pneumonia)
ABX Anti-inflammatory Cardio immunomodulators Anti-eleptics Illicit drugs
What are the 4 alveolar filling d/so
What are the two under interstitial lung dz associated w/ vasculitis
Good pasture
Pulmonary alveolar proteinosis
Pulmonary hemosiderosis
Chronic eosinophilic pneumonia
Granules w/ Poly
Eosinophilic Granules w/ Poly
Common radiographic findings of ILDz
What infiltrate Dzs are in the upper lungs
Which ones are found in the lower lobes
Ground glass
Air bronchogram (acinar rosettes)
Infiltrates
Nodules/reticulonodular infiltrate
Sarcoidosis
Silicosis
Idipathic fibrosis
Subacute eosinophil pneumonia
Asbestosis
Since Hilar and ediastinal adenopathy are not common in ILDzs, which ones cause it
Which Dz presents w/ peripheral locations of upper/middle lobes and clear central zones
Sarcoid Berylliosis Silicosis
Chronic Eosinophilic pneumonia
What radiographic finding would not be typical in a CT image of idiopathic pulmonary fibrosis?
What 4 findings would be typical?
Migratory infiltrates
Dec lung volume
Honey comb
Reticular changes, peripheral
Lower lobe predominence
What is the MC form of ILDz
Define UIP
Define IPF
Idiopathic pulmonary fibrosis
Usual interstitial pneumonia- lung injury causing collagen/honeycombing
Idiopathic Pulmonary Fibrosis- Dx if cause of UIP is unknown
UIP is not specific for IPF and can be seen in ? 4 Dz states
What is seen on PE of IPF
CT Dzs
Asbestosis
Drug induced lung Dz
Chronic hypersensitive pneumonitis
5-6th decade PT w/ exertional dyspnea/cough
Velcro rales
Clubbing
Normal resting SpO2, dec w/ exertion
What is seen on PFT of IPD
What meds are used for Tx of IPF
Red TLC RV and FRC
Low diffusing capacity
Prednisone
Nintedanib/Pirfenidone
Definitive: transplant
What is the 2nd MC ILD
When/what PT population does it affect
Sarcoidosis- granulomatous dz w/out known origin
AfAm/N European during 3-4th decade
Since Sarcoidosis is usually ASx, what incidental CXR findings may be seen?
What PE findings are uncommon
What is the Trfiecta of this Dz that is benefial for PTs
Hilar adenopathy
R paratracheal lymphadenopathy
Crackles
Lofgren: hilar lymphadenopathy Erythema nodosum
Migratory polyarthralgia
No biopsy needed for Dx
Remission in 2-16wks
If meds are needed for Lofgren Syndrome, what can be used
What is a more rare presentation of Sarcoidosis
NSAIDs
Glucocorticosteroids
Colchicine
Hydroxychloroquine
Heerfordt Syndrome- uveoparotid fever (fever uveitis parotitis)
+/- CN7 involvment
Heerfordy syndrome can lead to ? Sxs that can mimic ? syndrome
What is possibly seen on lab results
What is seen on a PFT
Sicca- latin for eyes/mouth
Sjogren
Leukopenia
HyperCa -emia/uria
Inc ACE
Inc ESR
Restrictive, dec volume and DLCO
How is Sarcoidosis Dz staging accomplished
If there’s low clinical suspicion or no Lofgren Syndrome, what test is ordered and seen for suspected Sarcoidosis
How is Sarcoidosis Tx
CXR
Biopsy of skin/parotid/kidney- noncaseating granulomas
PO CCS
Methotrexate if intolerant/no response to CCS
What PT presentation of Sarcoidosis has the best prognosis
What f/u tests are done?
Only hilar adenopathy is present
OC CAPE Optho examp CMP CXR Annual physical PFTs ECG
What causes pulmonary alveolar proteinosis
How is this Dx
Unique fact about this dz
Phospholipid accumulation in alveolar spaces from idiopathic or secondary causes
Lavage w/ milky appearance, PAS + lipoproteinaceous material
Spontaneous remission
PTs w/ Pulmonary Alveolar Proteinosis are at increased risk for ? pulmonary infections
What are the defining characteristics about Eosinophilic Pulmonary Syndromes
Nocardia
Fungi
Eosinophils in blood, lung biopsy and lavage
Blood result not always there
What meds can cause Eosinophilic Pulmonary Syndromes
What is the unique presentation of Chronic Eosinophilic Pneumonia
Phenytoin Ranitidine Acetaminophen Nitro Ampicillin
Helminth or Filariae infection
Women, Non-smokers
Granules w/ Poly
What characterizes this Dz
What unique Sxs does it present w/
What CXR finding is characteristic
Dx w/ ?
Wegeners
Glomerulonephritis
Necrotizing granule vasculitis
Small vessel vasculitis
Sinusitis, Otitis
Tracheal stenosis
Saddle nose
Strawberry gums
Nodular infiltrates w/ cavitation
C-ANCA and biopsy
Eosinophilic Granules w/ Poly
What does it present w/
What is seen on CXRs
How is it Dx?
Churg Strauss
Vasculitis in asthma PTs
Rhinosinusitis
Asthma
Blood eosinophilia
Transient opacities/nodules
Fibrinoid necrotizing granulomas on biopsy
How are the two Granules w/ Poly Tx
Gran w/ Poly: Cyclophosphamide
PO CCS
Rituximab- antiCD20 monoclonal Ab
Bactrim
E Gran w/ Poly:
CCS
Mepolizumab- Interlukin5 antagonis/monoclonal Ab
Cyclophosphamide
Goodpasture Syndrome AKA
What is sen on CXR
What is seen on labs
How is it Dx
How is it Tx
Anti-basemement membrane Dz
Bilateral alveolar infiltrates
Fe deficient anemia
Microscopic hematuria
IgG/ImmFluorescent stain
anti-GBM Abs
CCS, Cyclophosphamide, Plasmaphoresis
Idiopathic Pulmonary Hemosiderosis
How is it Dx
What lab result is typical and what does this Dz NOT involve
How is it Tx
Younger PTs w/ pulmonary hemorrhage
Hemosiderosis macrophages in lavage fluids
Fe deficiency- normal
No renal/BM Ab involvement
CCS
Histoplasmosis
What is seen on CXR
What is this commonly confused as and how is it differentiated?
How is it Dx
How is it Tx
Ohio-Mississippi valley
Adenopathy of nodes
CAP, re-Dx when PT doesn’t respond to ABX
Urine/Serum Ags
BALavage
Blood/marrow culture
Mild: Itraconazole
Severe (meningitis): Amphotericin B IV
Since Histoplasmosis is usually ASx, Dx can be made w/ incidental findings of ?
Coccidio infections can present w/ ? unique Sx
Coccidio is common opportunistic infection ?
Splenic/pulmonary calcifications on x-ray
Back ache
HIV
Endemic areas
Coccidio infections most frequently present as ? and will have ? CXR finding
Who is more likely to have the disseminated version of this Dz
What does this form of the infection present w/?
CAP
Unilateral adenopathy
Filipino, Black, Pregnant
Inc pulmonary Sxs
Lung abscesses
Meningitis
Skin lesions like warts
What is the miliary CXR finding of Coccidio called?
How is a mod/sev Coccidio infection Tx
Fungemia, causes death
Amphotericin B for severe PTs
Fluconazole
Itraconazole
Blastomycosis
Since this usually is ASx, if it is disseminated, how does it present?
How is it Dx
How are mild and mod/sev cases Tx
MC form is primary pulmonary infection in SC/Midwest US and Canada
Skin/bone lesions
Urogenital: prostatitis, epididymitis
CXR
Sputum culture
BALavage
Calcofluo. staining of sputum
Azoles (I/K)
Amphotericin B
Aspergillosis
When is the Dx of Allergic Bronchopulmonary Aspergillosis considered
What unique presentation can help w/ Dx
Unbiquitous in nature
Usually ASx unless ImmSupp (transplant Pt w/ neutropenia)
Asthatic w/ worse Sxs
CXR infiltrates w/ eosinophilia and high IgE
Waxes and wanes until resolution
How is Allergic Bronchopulmonary Aspergillosis Tx?
How does PCP present
PO Prednisone
Bronchodilators
ImmComp PT w/ CD4 <200
Infiltrates on CXR
Tx w/ Bactrim
Normal pH, PCO2 and HCO3 levels
ABGs give you what 3 results
What is the ABG criteria for respiratory failure
pH: 7.35-7.45
PCO2: 35-45
HCO3: 22-28
pH PaCO2 PaO2
PaO2 <60 (=SaO2 <90%)
PaCO2 >45
S/Sxs of respiratory failure include those of the underlying Dz plus ? 2
What is the chief signs of these Sxs?
Hypoxemia
Hypercapnea
Hypoxemia- dyspnea
Hypercapnia: dyspnea and HA
What are the signs of hypoxia?
What are the signs of hypercapnia
TRAC CAD
Tremor Restless Arrhythmia Confusion Cyanosis Anxiety Delerium
PACHI
Papilledema Astheresis Conjuctival hyperemia Impaired LoC
What is the difference between Non-Ventilatory and Ventilatory respiratory support?
When giving O2, how much is given?
Non-Vent: oxygenation of organs w/ O2 administration
Vent: maintain patency of airway and ensure alveolar ventilation
Enough to maintain SPO2 at 90%/+60mmHg of Po2 or higher
What respiratory support is first line choice for COPD pPTs w/ hypercapnic failure
Why is this form preferred?
After intubation, verification must be done to ensure it’s located ?
NPPV, but only if they can manage secretions, maintain airway and tolerate the mask
Dec need to intubate, length of hospitalization and mortality
Level of aortic arch
What are the two modes on mechanical ventilators
What are the alternative modes
What will be seen if an ET tube is migrating into the main bronchus?
CMV/A-C
SIMV
PSV PCV CPAP
Atelectasis- contralateral lung
Over distension- intubated lung
What are the signs of ventilator induced barotrauma
How do we avoid this injury?
What causes resp acidosis/alkalosis
SubQ emphysema
Pneumomediastinum
Subpleural cysts
Deliberate hypoventilation w/ low tidal volume/respiratory rates
Alk: over ventilate
Acid: under ventilate
Why do PTs on ventilators get HOTN?
Why are carb rich nutrients avoided in these PTs
What E+ have to be monitored due to their absence can worsen hypoventilation
Inc intrathoracic pressure dec venous return
Inc CO2 production- can worsen hypercapnea
HypoK
HypoPO4
What are PTs on ventilators fiven to reduce stress on GI system?
What are they put on to dec DVT/PE formation
PTs w/ ? issues put on vents have very low prognosis
PPIs
LMWH or
Compression devices
ARDS associated sepsis
Define ARDS
What Berlin ratio characterizes this issue
Non cardiogenic form of pulmonary edema causing hypoxemic respiratory failure
<300mmHg PaO2/FlO2 ratio
What are the 3 severity levels of ARDS
Regardless of injury, what is the response process leading to ARDS
Since this can develop in 12-48hrs, what major PE finding is indicative of Dx
Mild: 200-300
Mod: 100-200
Sev: <100
_% of air / PaO2 __
Inc permeability/Dec surfactant
Edema Atelectasis Hypoxemia
Hypoxemia refractory to O2
How does ARDS appear on CXR
ARDS is a ? not a ?
What is it’s DDx
Spares angles, norm heart size
+ air bronchograms
Pleural effusions
Sydrome, not a Dz
Pulmonary edema, cardiogenic
How is ARDS Tx
Respiratory distress syndrome is AKA ? and mainly affects ? PTs
Broad ABX
Intubation/ventilation
Low PEEP and tidal volume
FIO2 <60% to maintain SPO2 >88%
Hyaline Membrane Dz
Premature infants due to deficient surfactant
Infants w/ Respiratory Distress Syndrome don’t have surfactant which leads to ? two issues
What would be seen on CXR and ABG
Neutrophil accumulation=
Pulmonary edema
Atelecatsis= cytokine mediated inflammatory response
Ground glass
Hypoxemia
When do we give pregnant PTs steroid prophylactically to prevent Respiratory Distress Syndrome
What is done after birth to prevent the development of thi Dz
23-34wks
PEEP and nCPAP w/ exogenous surfactant therapy
What is the criteria to intubate and provide surfactant to infant
Pleuritis usually has ? 3 etiologies
How would it present
FiO2 of 0.40 or higher to maintain O2 sat >90% or,
Apneic
Viral URI
Autoimmune
Pneumonia
Pain worse w/ breathing/cough
Radiating to ipsilateral shoulder if phrenic nerve involved/irritated
Squeaky sound
Why does pleuritis cause pain
How is it Tx
How is pleural fluid removed from the chest cavity and how much is normally there?
Parietal pleura +innervation
Indomethacin
Codeine- pain, no cough supression
Intercostal nerve blocks (rare)
Lymphatics, 5-15mL
Define Transudate
Define Exudate
Inc production of fluid due to inc hydrostatic/dec oncotic pressure
Inc production due to abnormal permeability/dec clearance
Define Empyema
Define Hemothorax
Infection in pleural space
Bleeding into pleural space
Define Hydrostatic Pressure
Define Oncotic Pressure
What is their relation to each other
Pressure exerted by fluid
Proteins in blood, displace molecules making appearance of less fluid
Work opposite to each other
What is seen on PE of pleural effusions
What appearance does empyema have
What appearance does chylous effusion have?
Dullness to percussion
Hyporesonance
Clear fluid over white cells
Constantly turbid, inc chylomicrons and TGs
How much blood in pleural fluid is Dx for hemothorax
Define Hemorrhagic effusion
What are the 3 things tested for after a thoracentesis
Hct >0.5
Mix of blood and pleural fluid
Protein
Glucose
Lactate dehydrogenase
Define Light’s Criteria
What is the MC cause of transudate effusion
Exudate if one of 3:
Protein >0.5
LD ratio >0.6
Pleural LD >2/3 of upper limit of normal serum
HF
What are the causes of transudates
CHAMPS PCN Cirrhosis HF Acute atelectasis Myxedema PE SVC obstruction
Peritoneal dialysis
Constrictive pericarditis
Nephrotic syndrome
What are 4 unique causes of exudative pleural effusions
TB: inc Protein
Rheumatoid: empyema, cholesterol crystals, low complement
Esophageal rupture and Pancreatitis: high amylase, L sided effusion
Chylothorax: TGs >100
Most exudative effusions are due to ? of what 2 types
What is the first image ordered for effusions and how much is needed to be seen?
CA: lung, breast
CXR
75-100mL on upright lateral
175-200 on upright frontal
1cm on lateral decubitus to do blind thoracentesis
CTs can ID _mL of effusion and help ID the ?
What sign would be seen on CXR of large effusions?
10mL
Etiology- lymphadenopathy, masses, thoracic duct anatomy
Meniscal sign
How are parapneumonic effusion Tx
Uncomplicated= sterile pleural fluids: ABX for pneumonia
Complicated= bacteria invasion= acidosis, low glucose/Neg gram stain; ABX and tube thorocostomy if glucose <60 or pH <7.2
How is empyema effusions Tx
What benefit does doing a thoracostomy have?
How are they Tx if the infection is refractory to ABX
Low pH and Pos Gram stain
ABX and tube thoracostomy
Prevents fibrous encasement in lung and promotes infection clearance
Drain w/ surgical debridement
What causes Primary Spot Pneumos
What is seen on PE?
How is the PE different if it’s a tension pneumo?
Ruptured sub-pleural blebs
Tachycardia
Dec sounds/fremitus
Unilateral hyper resonance
Severe tachy
HOTN
Mediastinal/tracheal shift
How are Spot Pneumos Tx
What is the definitive Tx
What 3 things need to be avoided after?
<15%/<3cm- observe, O2
Repeat CXR, discharge
Tube thoracostomy
High altitude Smoking Diving
What surgical procedure is a possibility post-spot pneumo?
What pathological change is characteristic of COPD
Open thoracotomy w/ resection of the bleb/pleurodesis
Dec elastic recoil pressure
? Dz is characterized by bronchial hyperactivity and reversible airway obstruction
What is the best initial Dx study for PT w/ suspected PHTN
Asthma
Echo
? PT population w/ influenza is at increased risk for complications
What other medical Hx puts PTs at risk w/ this Dx
Influenza
Prior MI
CHF
Lung tumors are ? tumors and secrete
What type of appearance would be most concerning?
Neuroendocrine
Serotonin
Development in adolescence
What are the top 2 MC neuroendocrine tumors
If tumor is secreting serotonin, how do the PTs present
GI
Lung
Flushing
Diarrhea
Bronchospasms
Preventative steps to decrease aspirations include
Define bronchiectasis
Thick fluids
Feeding in upright
Proper PO hygeine
No rushing feed time
Bronchial wall thickening w/ permanent airway dilation due to inflammation
? is the cause of fever, SoB, leukocytosis, HypoNa?
This infection is the only one presenting w/ ? Sxs
How is it Tx
Legionella
GI
Inc liver enzymes
Macrolide
Levlofloxacine
Doxy
What is the most useful Dx test for sarcoidosis
What is the MC Tx approach for lung abscesses
Biopsy of skin lesion
ABX
? microbe is the cause of hot tub infections
What body system is MC involved w/ initial Sxs of Blastomycosis
Legionella
Pulmonary
2nd MC: skin
What is the Dx TOC for Idiopathic Pulmonary Fibrosis
Small pulmonary nodules are ? size and best Dx w/
CT
<30mm
CT w/out contrast
What CXR finding is indicative of Pnemo Jeriveci
? microbe causes croup
Diffuse bilateral infiltrates
Parainfluenza
What med is given for asthma after O2, albuterol, ipratropium, and IV methylprednisone?
What is the acronym for asthma exacerbation Tx
IV MgSulfate
BIOMES Beta agonist Ipratropium O2 Mg Sulfate Epi/Terbutaline Steroids
? tumor causes arm/shoulder pain
What is the MC declared drug allergy?
Non-small cell lung CA w/ pancoast syndrome
Reaction to beta-lactam (amoxicillin)
What lung dz would present w/ PFT results of Dec TLV, Dec residual volume but normal FEV
What PT population is screened annualy for lung CA
ILDz
55-80 w/ Hx smoking 30 pack/year and current smoker or
Quit in past 15yrs
What is the best TOC to confirm a Dx of malignant mesothelioma
? condition creates a restrictive spirometry patter
Biopsy
RA
? procedure is done to biopsy a peripheral nodule
Older PTs w/ pertussis present ? and are Tx w/ ?
Wedge resection
Congestion
Watery eyes
Coughing fits
Dyspnea
Azithromycin
Tx of CAP outPT w/ no MedHx
What meds can be used for Acute bronchitis if PT insists
Amox
Guaifenesin
TB med turns severtions orange
Most likely finding on PE on PT w/ CAP
Rifampin
Crackles on auscultation
? type of microbe is Pertussis
4 phases of allergic reaction
Gram - coccobacillus
Anaphylactic
Cytotoxic
Immune compelx
Cell mediated
