Pulmonary Flashcards
A pleural effusion makes a ____ sound upon percussion?
Dull
A pneumothorax makes a ________ sound upon percussion?
hyper-resonant
What is pulsus paradoxus?
a drop in systolic blood pressure of 10mmHg or more during inspiration
- sign of lung and/or heart disease
- cardiac tamponade
- pericardial effusion
- asthma/COPS exacerbation
- tension pneumothorax
- large pleural effusions
What is the term for a drop in systolic blood pressure of 10mmHg or more during inspiration?
pulsus paradoxus: caused by
- cardiac tamponade
- pericarditis
- tension pneumothorax
- CHF
- acute asthma exacerbation
- COPD exacerbation
What is the normal pulmonary flow rate?
6 L/min
What is the normal mean pulmonary arterial pressure?
12-15 mmHg
What is the normal PaCO2 value?
35-45 mmHg
What is the normal PaO2 value?
75-100 mmHg
- partial pressure of oxygen in arterial blood
What is the normal SaO2?
95-100%
- percentage of O2 binding sites on hemoglobin that are bound to O2
- arterial O2
- low percentage means high number of empty O2 binding sites on hgb
What value shows the percentage of O2 binding sites on hemoglobin that are bound to O2?
SaO2
What is the difference between PaO2 and SaO2?
- PaO2 = O2 in plasma
- SaO2 = 02 bound to hemoglobin
What 2 conditions can cause a shift to the left on the oxyhemoglobin dissociation curve?
- shift to the left = increased affinity of Hgb for O2
- alkalosis
- hypothermia
What does a shift to the left on the oxyhemoglobin dissociation curve mean?
means that hemoglobin has a higher affinity for O2, doesn’t release it to the tissues and binds to O2 in the lungs easily
- can lead to tissue hypoxia
What does a shift to the right on the oxyhemoglobin dissociation curve?
means that hemoglobin has a weak affinity for O2
- hemoglobin readily dissociates from or releases O2 to tissues
- caused by:
- hypercapnia (high CO2) which creates an acidic environment
- pH < 7.35 or acidic
- hyperthermia
What conditions can cause a shift to the right on the oxyhemoglobin dissociation curve?
- acidosis
- increased tissue metabolism
- increased anaerobic metabolism
- hyperthermia
What is the normal Svo2 value (O2 in venous blood returned to heart)?
60-80%
An SvO2 < 60% is indicative of what?
- amnt of O2 returning to heart
- normal: 60-80%
- increased O2 demand (fever, shivering, increased WOB, pain)
- decreased O2 Supply (may not be oxygenating or may be alkalotic)
An SvO2 < 40% indicates?
- anaerobic metabolism leading to organ dysfunction
- increased O2 demand or decreased oxygenation
An SvO2 > 80% implies?
- decreased tissue extraction of O2
- less O2 demand (sleep, hypothermic)
- decreased O2 delivery and cell uptake (sepsis, shift of curve to the left)
- increased O2 supply (polycythemia, FIO2 > need)
What does PEEP on ventilator stand for?
Positive End Expiratory Pressure
- pressure at end of expiration to keep alveoli from collapsing
What is PEEP in ventilation?
- Positive End Expiratory Pressure
- pressure applied by the ventilator at the end of each breath to prevent alveoli collapse
Which part of the brain controls the involuntary act of breathing?
Brainstem (medulla and pons)
Why should O2 be administered at low flow rates and titrated carefully in patients with chronically high PaCO2?
- patients have lost the normal hypercapnic drive and respond only to changes in PaO2
- increased PaO2 may result in suppression of ventilation
What is the ratio of CO2 to O2 exchange between the alveolus and capillaries?
- 20:1
- 20 CO2 cross from capillaries for every 1 O2
What does FIO2 stand for?
Fraction of Inspired Oxygen
What does the SaO2 measure?
- the amount of O2 bound to hemoglobin
- norm: 95-100%
What ventilator adjustments would be done to treat a patient with respiratory acidosis?
- increase resp rate
- increase tidal volume
How do you increase the tidal volume on a ventilator when in assist control mode?
directly increase the tidal volume
How do you increase the tidal volume on a ventilator when in pressure control or pressure support mode?
increase the inspiratory pressure
What is the goal of treatment for a patient with respiratory acidosis?
to decrease the PaCO2
What is the goal of treatment for a patient with respiratory alkalosis?
to increase the PaCO2
What ventilator adjustments would be done to treat a patient with respiratory alkalosis?
- decrease the resp rate
- decrease the tidal volume
- unless the patient is breathing faster than the vent, need another strategy
What ventilator adjustments would be done to treat a patient who is hypoxic?
- increase the FIO2
- increase Positive End Expiratory Pressure (PEEP)
What information/values are measured in an arterial blood gas (ABG)?
- pH (7.35-7.45)
- PaO2 (80-100 mmHg)
- PaCO2 (35-45 mmHg)
- HCO3 (22-26 mEq/L)
- Base excess (-3 to +3 mEq/L)
- SaO2 (> 98%)
What is the normal PaO2/FiO2 (P/F ratio) ratio range?
- 300-500
- < 300 indicates impaired O2 exchang
A P/F ratio between 200-300 is indicative of what?
impaired O2 exchange
A P/F ratio between < 200 is indicative of what?
severe hypoxemia
Every 10 mmHg shift in PaCO2 has what effect on blood pH?
- produces an opposite shift in the pH
(ex: 10 mmHg shift up = 0.08 shift down in pH = more acidic)
An SpO2 of 90% = PaO2 of _?__
60 mmHg
An SpO2 of 75% = PaO2 of _?__
40 mmHg
An SpO2 of 50% = PaO2 of _?__
27mmHg
What are the indications for a pulmonary artery catheterization (PA Cath)
- differentiate between cardiogenic and pulmogenic cause of pulmonary edema
- to measure CO, CI, SVR, pulmonary vascular resistance, SvO2
- to titrate therapy
How does placement of pulmonary arterial catheter help differentiate between cardiogenic and pulmogenic cause of pulmonary edema?
- cardiogenic = high pulmonary capillary wedge pressures (PCWP) with normal PAP
- pulmogenic = normal PCWP with high PAP
What does the Pulmonary Capillary Wedge Pressure measures?
LV end-diastolic filling pressure or LV preload
- elevated is indicative of left heart failure or mitral valve stenosis
- norm: 4–12 mmHg
What urine output is indicative of low intravascular volume?
< 0.5mL/kg/hr
What is the normal Pulmonary Capillary Wedge Pressure range?
4-12 mmHg
What is the normal Central Venous Pressure range (CVP)?
2-8mmhg (pressure in vena cavae)
- measures
- venous return
- fluid status
- indirect measurement of CO
What is the name for the loss of defined borders on an CXR?
Silhoutte Sign
- sign of fluid builidup
- shows up white, should be black
A displaced trachea that is not midline on XR is indicative of?
- thyroid enlargement
- increased pressure in chest
What is the term for the location of the bifurcation of the left and right bronchi?
carina
What is the carina and where should it be located on a CXR?
- point of bifurcation of the left and right bronchi
- between T4 and T6
Aspiration pneumonia should be suspected when consolidation or fluid is seen in the which lobes?
right middle or lower lobes
How much higher is the right diaphragm when compared to the left?
1-3 cm higher
An elevated diaphragm is indicative of?
- diaphragmatic paralysis
- phrenic nerve injury
What are the types of COPD?
- emphysema
- chronic bronchitis
- bronchospastic airway disease (asthma, reactive airway disease)
What are the cardinal symptoms of COPD?
- dyspnea with exertion
- chronic cough
- increased sputum production
What is the term for the loss of fat body mass or weight loss in patients with advanced lung disease?
Pulmonary cachexia
How long does a patient have to have a chronic cough for to to defined as having chronic bronchitis?
3 consecutive month in 2 consecutive years
What condition is defined as a chronic cough lasting 3 or more consecutive months in 2 consecutive years?
Chronic Bronchitis
What condition describes structural changes associated with COPD that include abnormal and permanent air space enlargements distal to the terminal bronchioles along with destruction of airspace walls without overt fibrosis?
Emphysema
What are the indications for ordering a Pulmonary Function Test (PFT)?
- unexplained dyspnea/cough
- assess severity of pulmonary dysfunction
- to trend pulmonary dysfunction
Spirometry is used to determine which two pulmonary values?
- forced vital capacity (FVC)
- forced expiratory volume (FEV)
What is the gold standard test to diagnose obstructive lung disease?
Forced expiratory volume in one second (FEV1) over Forced vital capacity (FVC)
- FEV1/FVC < 70% = obstructive disease
What FEV1/FVC ratio is indicative of airflow obstruction or an airway obstructive disorder?
< 70%
What is the term for the max amount of air a pt can forcibly exhale from the lungs?
Forced Vital Capacity
What is the normal value for the Forced Vital Capacity?
- max amnt of air that can be forcibly exhaled
- approx 80% of total lung capacity
- males: 4.75-5.5 liters
- females: 3.25-3.75 liters
What is the term for the amount of air that is inhaled and exhaled during a normal respiratory cycle?
Tidal Volume
- 400-500 mL
What are the s/s of COPD?
- dyspnea w/ exertion
- chronic cough
- sputum production
- chest tightness
- pulmonary cachexia
- tripod posture
- normal RR or tachypnea
- mental status changes
- pursed lip breathing
What are the causes of chest tightness felt by patients with COPD?
- increased anteroposterior (AP) chest diameter or “barrel” chest
- acute air retention within the thorax
Hyperresonance upon percussion of the chest is indicative of?
increased air present within the lung tissueW
What diagnostic test(s) are done if COPD is suspected?
- spirometry
- ABG
- pulse oximetry
- H/H
- CXR
In a patient with COPD, oxygenation is deemed adequate when the SaO2 is _______ and the hemoglobin is ________?
- SaO2 > 88%
- Hgb > 10g/dl
What class of drug is Bupropion?
norepinephrine/dopamine reuptake inhibitor
- used to treat depression and quit smoking
Bupropion is used to treat what conditions?
- NE and dopamine reuptake inhibitor
- major depressive disorder
- seasonal affective disorder
- smoking cessation aid
A COPD patient with what FEV1 needs to have an inhaled corticosteroid ordered?
FEV1 < 60
- fluticasone
- budesonide
A patient with an FEV1 < 60 should be prescribed what medication?
an inhaled corticosteroid
- fluticasone
- budesonide
What is used to treat a mild COPD exacerbation?
short acting beta agonist
- albuterol
What is used to treat a moderate COPD exacerbation?
- short acting beta agonist plus:
- ABX and/or
- oral corticosteroids
\What is used to treat a severe COPD exacerbation?
hospitalization/ED
How do anticholinergics/antimuscarinic drugs reduce COPD symptoms?
reduce airway secretions and relax airway muscle tone
Ipratropium bromide (atrovent) is what class of medication?
Short acting muscarinic antagonist or anticholinergic
Tiotropium bromide (Spiriva) is what class of medication?
Long acting muscarinic antagonist or anticholinergic
What is the drug class of choice to treat stable COPD?
short and/or long acting anticholinergics (SAMA, LAMA)
What are the drugs are used to treat COPD patients?
- anticholinergics (SAMA, LAMA)
- bronchodilators (SABA, LABA)
- Corticosteroids
- Phosphodiesterase 4 inhibitors
- guaifenesin (thins mucus)
- acetylcysteine (reduces sputum viscosity)
- O2
Hyperresonance with chest percussion is indicative of what?
increased air within the lung tissue
A hematocrit > 55 ml/dl in a COPD patient is indicative of what?
Secondary Polycythemia d/t chronic hypoxemia
- an increase in all blood cells, especially RBC’s
What might be seen on the CXR of a patient with COPD?
- air trapping
- blebs and bullae
- flattened diaphragm
- hyperinflation
- retrosternal air on lateral view
What are blister like, air filled spaces within the lung that are < 1cm in diameter?
blebs
What are blister like, air filled spaces within the lung that are > 1cm in diameter?
bullae
What would be the impression of a CXR that shows hyperlucency in the upper lung zones, widening of the the intercostal spaces, and 10 or more ribs id’d above the diaphragm?
hyperinflation of the lungs
What research study is the standard for staging and treatment of COPD?
the GOLD study
What are the 3 major categories of respiratory diseases?
- obstructive disease
- restrictive disease
- vascular disease
What are examples of obstructive airway diseases?
- asthma
- COPD
- bronchiectasis
- bronchiolitis
What is the term for a chronic lung disease that causes the airways of the lungs to permanently widen and weaken
bronchiectasis
Chronic rhonchi is associated with what respiratory diseases?
- bronchiectasis
- COPD
Crackles, or rales are common sign of what respiratory disease?
alveolar disease
What is Egophony?
- hearing “AH” when the patient says “EEE”, which is an abnormal sound transmission through consolidated/fluid filled parenchym
- present in PNA
A total lung capacity < 80% of the patient’s predicted value is diagnostic for which type of airway disease?
restrictive
- parenchymal disease
- neuromuscular weakness
- chest wall/pleural diseases
Airway restriction with impaired gas exchange, as indicated by a decreased diffusion capacity of the lung for carbon dioxide (DLCO), suggests which lung disease?
parenchymal lung disease
normal spirometry, normal lung volumes, and a low diffusion capacity of the lung for carbon dioxide (DLCO) should prompt further evaluation for which type of pulmonary disease?
pulmonary vascular disease
- pulmonary embolism
- pulmonary arterial HTN
- pulmonary venoocclusive disease
- vasculitis
An ultrasound of the chest can rapidly diagnose which pulmonary diseaseas?
- pneumothorax
- pleural effusion
- consolidation of lung parenchyma
What is the term for the percutaneous aspiration of fluid from the pleural space?
thoracentesis
What is a thoracentesis?
the percutaneous aspiration of fluid from the pleural space
What is the gold standard method for obtaining respiratory secretions for hematologic, biochemical, microbiological, and/or cytologic analyses?
Bronchoalveolar lavage (BAL)
What action does interleukin 13 have on the body?
Induces:
- airway hyperresponsivenes
- mucus secretion
- goblet cell metaplasia
What are the main interleukins associated with asthma?
Interleukin-4
Interleukin-5
Interleukin-13
What can trigger airway narrowing in a patient with asthma?
- allergens
- irritants
- viral infections
- exercise and cold dry air
- air pollution
- drugs
- hormonal changes
- pregnancy
During a PFT to test asthma, what is/are the requirements needed to prove reversibility?
- a 12% or greater increase in the FEV1 and absolute increase of >200 mL at least 15 mins after administration of a beta-2-agonist or after several weeks of corticosteroid therapy
What is Methacholine?
- cholinergic agonist used to confirm the diagnosis of asthma if PFT is nonconfirmatory
- triggers parasympathetic response, causing bronchoconstriction
Which WBC will be elevated in an asthma patient during an exacerbation ?
- eosinophil > 300 cells/microL
If the eosinophil count is greater than 300 in an asthmatic patient, what type of meds should be given?
medications that target the type 2 inflammatory process
- steroids
Which antibody will be elevated in an asthmatic patient?
IgE
Albuterol is what class of medication?
short acting beta-2 agonist
- aka salbutamol
What is the onset of action for albuterol?
3-5 mins after inhalation
What is the duration of albuterol?
4-6 hours
Salmeterol and Formoterol are what class of medication?
long acting beta-2 agonist
What is the duration of effects for Salmeterol and Formoterol?
- long acting beta-2 agonists
- duration is about 12 hours
What affect do Beta-2 agonists have on potassium?
promotes entry of potassium into the cell
- may cause hyokalemia
what are the major cytokines associated with type two inflammation related to asthma?
Interleukin-4
Interleukin-5
Interleukin-13
what are the most common symptoms associated with asthma?
After exposure to an allergen or trigger:
- Wheezing
- Shortness of breath
- Chest tightness
- increased mucus production
- Cough
what are the goals of asthma therapy?
- Reduction of symptom frequency to 2 or less a week
- Reduction of nighttime awakenings to 2 or less times/month
- reduction of rescue inhaler use to 2 or less times a week
- Maintenance of normal daily activities
what medication classes/types are used in the treatment of asthma?
- short acting beta-2 agonist
- Long acting beta-2 agonist
- Ultra acting beta-2 agonist
- anticholinergics (SAMA, LAMA)
- theophylline
- corticosteroids
- leukotriene modifiers
what is the time of onset for albuterol and how long does it last?
Onset 3 to 5 minutes
Lasts 4 to 6 hours
Formoterol class/type of medication?
- Long acting, beta 2 agonist
- Affect last about 12 hours
which oral cortical steroid should be given to treat an asthma exacerbation and what dose/frequency?
Prednisone 40 to 60 mg a day for one to two weeks
what is the definition of bronchi ectasis?
The irreversible dilation of the bronchi
- Can be focal/localized or diffuse
what is the main cause of focal bronchi ectasis?
An obstruction of the airway
what is the imaging study of choice to confirm the diagnosis of bronchiectasis?
Chest CT - will show dilated airways
- tram tracks: look like worms
- signet ring sign: circle/oval shapes seen on lateral view
What is a normal cause of death for a patient diagnosed with cystic fibrosis?
pulmonary compromise by copious, hyper and sticky, secretions, obstruct, smaller medium sized airways
what are the three most common organisms cultured from sputum of a patient with cystic fibrosis?
- staphylococcus aureus
- haemophilus influenza
- pseudomonas aeruginosa
what effect does cystic fibrosis have on the pancreas?
- called cystic fibrosis of the pancreas
- secretions obstruct pancreatic ducts & impair production and flow digestive enzymes to the duodenum
- Pancreatic insufficiency leads to:
- chronic absorption
- poor growth
- fat soluble vitamins efficiency
- diabetes
How can a pulmonary artery catheter be used to differentiate between cardiogenic and pulmogenic pulmonary edema?
- if cardgiogenic will see high PCWP (< 12) with normal PAP (15-30/5-15)
- if pulmogenic, will see normal PCWP (6-12) with high PAP (30< / 15<)
Which hemodynamic measurement is a measure of preload or RV end diastolic filling pressure?
Central venous pressure (CVP)
What is the term for the total volume of air that is expelled during exhilation?
Forced Vital Capacity (FVC)
