Pulmo Topics Flashcards
Medical history, respiratory symptoms and signs
Differential diagnosis of dyspnoe, cough, chest pain and hemoptoe
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4.) Hemoptysis : expectoration of blood from the lower respiratory tract - not a commonsymptom
Possible Sources of bleeding : Bronchial Arteries (90% of cases), Pulmonary Arteries(5%),Systemic arteries (5%), Difuse Alveolar Haemorrhage (0.2%)
Common Etiologies :
A. Pulmonary : Infection (Tuberculosis, Aspergillosis, Acute viral/bacterial) is themost common cause of hemoptysis, Lung Cancer (2nd most common cause),Bronchiectasis, Lupus Pneumonitis
B. Cardiac : Congestive Heart failure (brown sputum), pulmonary hypertension
C. Vascular : pulmonary embolism (pink,frothy sputum), vasculitis, pulmonary arteryaneurysm/rupture
D. Haematologic : Coagulopathy, Anticoagulant use, Thrombocytopenia
E. Trauma: Lung Contusion, Airway Trauma, Foreign Body
F. Iatrogenic: Lung biopsy, Airway stenting, Right Heart/Pulmonary Catheterization
G. Rare but interesting : Thoracic Endometriosis - only in women
H. Difuse Alveolar Haemorrhage : common result of immune-mediated vasculitis orconnective tissue disease which results in hemorrhage from the microcirculation
Lung function tests, types, indications, devices, and minimal requirement of acceptability
Static and dynamic lung volumes, flow-volume loops, evaluation of lung function tests, pharmacodynamic test
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open.With forced exhalation, loss of structural support results in trachea narrowing and aplateau of diminished flow.Airflow is maintained briefly before airway compression occur.
Evaluation of lung function test:
- Obstructive Disorders : characterized by reduced airflow due to increased airwayresistance in exhalation.
FEV1 is reduced and FEV1:FVC ratio which should be morethan or equal to 80% is reduced.
Decrease in FEV1> Decrease in FVC ~ FEV1:FVC <0.7
Ex: Emphysema, COPD, Asthma, Tumors- Restrictive Disorders : characterized by a reduction in lung volume (decrease in TLC>80%).
Decreased lung volume results in a decrease in airflow, however airflow relativeto lung volume is increased.
So, FEV1;FVC ratio is normal or increased.
- Ex: Intrinsic (ILD, Lobectomy) and Extrinsic (Obesity, Kyphosis, Pneumothorax,Neuromuscular disorders
Pharmacodynamic Test : Bronchial Challenge Testing and/or Bronchodilator ResponsivenessTesting which are used to diferentiate obstructive pulmonary disorders (irreversible COPD vsreversible Asthma)
Bronchial Challenge (Methacholine Challenge Test):
- Indication: patients who are suspected of Asthma (airway hyperresponsiveness).
- Procedure: PFTs are performed before and after administration of increasing doses ofmethacholine. Methachoine is a synthetic analogue of acetylcholine that is a non-specificbronchial irritant.
- Interpretation is based on the dose of methacholine that results in ≥20 reduction inFEV1 from baseline. Patients showing this reaction at low doses of methacholine (<1mg/mL) is diagnostic of airway hyperresponsiveness i.e bronchial asthma.
Whereasresponse at high doses (>16 mg/mL) excludes the diagnosis. Results between 1 and 16mg/mL are inconclusive.
Bronchodilator Responsiveness:
- Indication : To diferentiate whether airways obstruction is reversible (asthma) orirreversible (COPD).
- Procedure: FEV1 and airway resistance are measured before and after the inhalation of a fast-acting bronchodilator (albuterol)
- Interpretation: Positive Response (obstruction has a reversible component) is definedas an increase in FEV1 by 12% or 200 ml of its initial value.
This indicates asthma orairway hyperresponsiveness
Diffusion capacity, blood gas evaluation (normal values, deviations. Evaluation of the pulmonary circulation
Chest imaging: chest Xray, CT, MRI, PET-CT
Chest X-ray abnormalities, scintigraphy, ultrasound
Brochoscopy: types, sampling procedures, indications, contraindications, adverseevents
Role of clinical laboratory test in the diagnosis of respiratory diseases (including investigations for allergy and autoimmunity)
Diagnosis and treatment of pulmonary embolism
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compromise.
Its Absolute contraindications include
- Patients with previoushistory of stroke,
- Active external/internal bleeding,
- Recent surgery,
4.intracranial injury/tumor.
Relative Contraindications include
- > 75 years,
2.Pregnancy, - Recent puncture/ injury to a major vessel
● Embolectomy - reserved for patients who remain hypotensive (<90mmHg)despite supportive therapy
Treatment choice depends on whether the patient is stable or unstable (in cases ofmassive PE, hypotension, shock)
- In low risk - anticoagulation- In intermediate risk
- anticoagulation + monitoring for deterioration and based onthat we determine if further measures are needed
- In high risk- anticoagulation + other measures (thrombolysis, embolectomy,catheter directed therapy)
Epidemiology, sign, symptoms, pathomechanism, phenotypes and diagnosis of asthma
Epidemiology, sign, symptoms, etiology, phenotypes and diagnosis of COPD
Epidemiology, sign, symptoms, etiology, types and diagnosis of lung cancer
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Diferential diagnosis needs to be clarified between
- Primary lung cancer (SCC, adenocarcinoma, SLCL, LCC)
- Lung metastases (from breast, colorectal, prostate, bladder or head/neck cancer, orRCC or melanoma)
- Pulmonary neuroendocrine tumor (bronchial carcinoid)
- Benign lung tumors (pulmonary hamartoma, other tumors - lipoma, neurofibroma,leiomyoma)
- Infectious granulomas (TB, non-tuberculous mycobacteria, histoplasmosis)
- Inflammatory conditions (sarcoidosis, granulomatosis with polyangiitis)
Epidemiology, sign, symptoms, pathomechanism, cause and diagnosis of tuberculosis
Role of smoking (traditional and new type cigarettes) in the development of respiratory diseases, support for smoking cessation
Treatment of asthma, definition, and treatment of severe asthma
Treatment of COPD and alpha- 1 antitrypsin deficiency
Respiratory aspects of COVID-19, its diagnosis and treatment
Evaluation of operability of lung cancer, Surgical and radiation therapy
Drug treatment of lung cancer
Prevention, monitoring, long-term care and palliative treatment of lung cancer
Treatment of tuberculosis and non-tuberculotic mycobacterial infections
Pneumothorax and pleural fluid: causes, types, diagnosis, and treatment
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Pleural effusion: An excessive amount of fluid between pleural layers that impairs theexpansion of the lungs.
The fluid can be transudative or exudative.
Transudative pleural fluid is extravascular fluid with low protein content and a lowspecific gravity (< 1.012) that accumulates due to high capillary hydrostatic pressure, anddecreased capillary oncotic pressure.
Most often caused by congestive heart failure, chronickidney and liver disease, and pulmonary embolism.
Exudative pleural fluid is extravascular fluid with high protein content and a high specificgravity (< 1.012) that accumulates due to high capillary permeability.
Most often caused bypulmonary infections, malignancies, inflammatory conditions (pancreatitis, autoimmunedisease), injury and pulmonary embolism. Can occur post-CABG.
Clinical features:
● Symptoms:
○ Dyspnea
○ Pleuritic chest pain
○ Dry, nonproductive cough
● Physical exam:
○ Inspection and palpation show asymmetric expansion and reduced tactilefremitus
○ Auscultation shows faint or absent breath sounds, pleural friction rub
○ Diagnosis:Percussion shows dullness over the area of efusion
Diagnosis
Percussion shows dullness over the area of efusion
★ CXR – shows blunting of the costophrenic angle, large efusion, tracheal deviation awayfrom the efusion (space-occupying lesion)
★ Thoracic US – hypoechoic or anechoic collection in the lower margins of the pleural★
★ Types:➔ ➔ cavity (costodiaphragmatic recess).
Can detect fluid amounts as low as 20 mL
Chest CT – gold standard ; but use is limited because of radiation and contrast exposure
Pleural fluid analysis
Types:
- Parapneumonic effusion: accumulation of exudate in the pleural cavity in response topneumonia, complicated by extension of bacterial infection into the pleural space
◆ Treated with antibiotics.
May progress to empyema!
- Pleural empyema: accumulation of pus
◆ Caused by pneumonia most commonly
◆ Pleural fluid analysis: exudate with low pH and low glucose
◆ Treated with antibiotics and chest tube - Nontraumatic hemothorax: accumulation of blood
◆ Presents with hypotension and tachycardia
◆ Pleural fluid analysis: high RBC count, high hematocrit➔ ◆ Treated with chest tube insertion and draining.
- Malignant pleural effusion: cancer-related barrier dysfunction of the capillary walls →increased permeation of plasma protein, blood cells, and tumor cells
◆ Caused by either direct invasion of the pleural space or distant metastases.
Most common: lung cancer, breast cancer
◆ Pleural fluid analysis: cell-rich exudate with abnormal cytology
- Chylothorax: accumulation of lymphatic fluid from the thoracic duct (chyle)
◆ Caused by trauma, malignancy, congenital lymphatic anomalies (e.g.,lymphangiectasis)
◆ Rarely presents with chest pain
◆ Pleural fluid analysis: cloudy, milky exudate with high lipids and triglycerides - Pseudochylothorax
◆ Caused by chronic pleural inflammation
◆ Pleural fluid analysis: exudate, thats shows high cholesterol with crystals
These last three are treated by chest tubes and treatment of the underlying cause.
Treatment is based on cause.Procedures that can be used:
● Therapeutic thoracentesis to remove pleural fluid that compromises cardiac and/orrespiratory function and/or carries a risk of infection
● Tube thoracostomy for recurrent pleural efusion or urgent drainage of infected and/orloculated efusions
● Pleurodesis, chemical or surgical obliteration of the pleural space in case of recurrentmalignant efusions.
Treatment of community-acquired and nosocomial pneumonia
Diagnosis of lung abscess and empyema
Interstitial lung diseases (IPF and PPF associated with systemic diseases)
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chemokines.
Subacute and chronic forms of hypersensitivity pneumonitis are thought totransition more towards type IV hypersensitivity reactions.
Histologically, chronic hypersensitivitypneumonitis is characterized by interstitial inflammation and alveolar destruction.
Symptoms
★ Shortness of breath
★ Cough
★ Flu-like illness, including fever, chills, muscle or joint pain, or headaches
★ Chest pain
★ Extreme tiredness
★ Long-term bronchitis
★ Weight loss
★ Clubbing
Treatment = If a specific cause is identified, it’s really important to completely avoid exposure to it. Otherwise,anti-inflammatory medication (steroids) can be used for a few weeks or months, as well asimmunosuppression (azathioprine).
Complications of ILDs
● Collapsed lung (pneumothorax).
● Lung infections.
● High blood pressure in your lungs (pulmonary hypertension).
● Right-sided heart failure (cor pulmonale).
● Respiratory failure. In the end stage of chronic interstitial lung disease, respiratory failureoccurs when severely low blood oxygen levels.
● Lung cancer.
Overall treatment of ILDs
➔ Corticosteroids. Drugs like prednisone can help reduce inflammation.
➔ Anti-fibrotic and cytotoxic drugs. These medications can slow down lung scarring.They include azathioprine, cyclophosphamide, pirfenidone and nintedanib.
➔ Biologic drugs. Medications like rituximab are sometimes used to treat autoimmunediseases and other causes of ILD.
➔ Treatment for GERD, as it can worsen ILDs.
➔ Pulmonary rehabilitation. Breathing exercises and physical therapy can make thelungs stronger and breathing easier.
➔ Oxygen therapy. Your provider will prescribe extra oxygen if you don’t have enoughgetting to your blood or tissues. It’s delivered through a mask or tube in your nose.
➔ Lung transplant. Some people with severe cases of ILD get a lung transplant.
Sarcoidosis
Acute and chronic respiratory failure, diseases, conditions requiring ICU treatment
Principles of oxygen therapy
Respiratory aspects of sleep apnea (diagnosis and treatment of obstructive sleep apnea)
Diagnosis and treatment of bronchiectasis and cystic fibrosis
★ Sweat glands: salty sweat, possible electrolyte wasting
★ Genital: infertility/reduced fertility, obstructive azoospermia in men, amenorrhea inwomen
★ Gastrointestinal: meconium ileus (in newborns), pancreatic disease, liver and bile ductabnormalities, intestinal obstruction, rectal prolapse
Diagnosis:Presence of typical clinical features of CF (e.g. chronic sinopulmonary disease, gastrointestinaland nutritional irregularities, syndromes of salt loss, obstructive azoospermia) requires afollow-up with confirmatory testing – pilocarpine and an electric current can be used to triggersweat for a sweat chloride test ≥ 60 mmol/L, physiologic tests include abnormal nasal potentialdiference test or intestinal current measurement, and of course, genetic testing.
Treatment:Lung function is preserved by combining pharmacological and nonpharmacologicalinterventions to improve mucociliary clearance, reduce mucus viscosity, and mobilizesecretions.
● Pharmacological interventions
○ High-dose ibuprofen: can slow the progression of lung disease
○ Bronchodilators: SABA (e.g. albuterol), LABA (e.g. salmeterol)
○ Mucolytics
● Nonpharmacological interventions
○ Airway clearance techniques: a mainstay of CF treatment that loosens andmobilizes mucus secretions – conventional chest physiotherapy (posturaldrainage with percussion and/or clapping), alternative methods (high-frequencychest compression, airway oscillating devices, positive expiratory pressuredevices), huff coughing
○ Exercise (e.g. swimming, jogging, cycling
Pulmonary exacerbations in patients with CF are often triggered by chronic lung infections.Consider treatment after detection of pathogens in routine sputum cultures.Eradication regimens: P. aeruginosa → inhaled tobramycin, MRSA → inhaled vancomycin + oralantibiotics, + extrapulmonary eradication.
Respiratory complications:
● Allergic bronchopulmonary aspergillosis (ABPA), occurs in ∼10% of individuals with CF.
● Pulmonary emphysema — pneumothorax, cor pulmonale
The median life expectancy of patients with CF is 39 years. Individuals with CF who havepancreatic suficiency tend to present with mainly pulmonary symptoms in late childhood/earlyadulthood and generally have a milder course of disease.
The main determinant of life expectancy is the severity of pulmonary disease:chronic respiratory infections and mucus plugging → bronchiectasis (irreversible) → progressiverespiratory failure → death.
