Pulmonary Flashcards
Definition of hemoptysis and how much blood is needed for massive hemoptysis?
Coughing up blood from the lower resp tract (distal to larynx). Massive hemoptysis is production of ≥ 600 mL of blood (about a full kidney basin’s worth) within 24 hours.
Etiology of hemoptysis?
Airway Disease
- Inflammatory – bronchitis (most common), bronchiectasis
- Neoplasia: Primary: bronchogenic carcinoma, carcinoid. Secondary: endobronchial metastases
- Foreign Body/Trauma
Pulmonary parenchymal disease
- Infectious - CF, necrotizing pneumonia, TB, fungus, lung abscess
Cardiac/Vascular – pulmonary thromboembolism, primary and secondary pulmonary HTN, cardiac failure, AV malformation, systemic coagulopathy
Immunological: Goodpasture’s (fatigue, weight loss, often hematuria, sometimes edema), Wegener’s
Idiopathic – 10-20% of cases
Risk factors for hemoptysis?
HIV infection, use of immunosuppressants (TB, fungal infection); exposure to TB; long smoking history (cancer); and recent immobilization or surgery, known cancer, prior or family history of clotting, pregnancy, use of estrogen-containing drugs or anticoagulants, and recent long-distance travel (pulmonary embolism).
Physical exam for hemoptysis?
o Vital signs, level of patient distress
o Lung exam + LN
o Heart + legs (edema)
o Skin, mucous membranes (ecchymoses, petechiae, telangiectasia)
Investigations for hemoptysis?
- CXR (70-80% will have an abnormal CXR), CT sometimes indicated (known hx of bronchiectasis)
- Bronchoscopy – direct visualization, acquisition of specimens for diagnostic studies, therapeutically
- Labs: CBC, PT/PTT, TB skin test, urinalysis
Patients with normal results, a consistent history, and nonmassive hemoptysis can undergo empiric treatment for?
Bronchitis
Patients with abnormal results and patients without a supporting history for hemoptysis should undergo?
CT and bronchoscopy
What are the two objectives of hemoptysis?
- Prevent aspiration of blood into the uninvolved lung (which can cause asphyxiation)
- Prevent exsanguination due to ongoing bleeding
Ways to prevent aspiration of blood into the uninvolved lung (which can cause asphyxiation) in hemoptysis?
Positioning the patient with the bleeding lung in a dependent position and selectively intubating the uninvolved lung and/or obstructing the bronchus going to the bleeding lung.
Ways to prevent exsanguination due to ongoing bleeding in hemoptysis?
- Clotting deficiencies can be reversed with fresh frozen plasma and factor-specific or platelet transfusions.
- TXA
- Laser therapy, cauterization, or direct injection with epinephrine or vasopressin can be done bronchoscopically.
Should you use rigid or flexible bronchoscopy in massive hemoptysis?
Rigid
If bronchoscopy doesn’t work for control of bleeding in hemoptysis?
Bronchial Artery Embolization
Thoracotomy + Lung Resection - Today many cases can be managed with bronchoscopy + embolization + medical therapy for the underlying cause. Surgery continues to be used when there is a structural problem with the lung that is not treatable with more conservative therapy (localized, severe bronchiectasis not responding to medical therapy)
What is the definition of pleural effusion?
Excess amount of fluid in the pleural space (up to 25mL)
What is the pathophysiology of pleural effusion?
Disruption of normal equilibrium between pleural fluid formation/entry and/or pleural fluid absorption/exit
Pleural effusions can be broken into which 2 categories?
Transudate
Exudate
Are transudate pleural effusions usually bilateral or unilateral
Usually bilateral, not unilateral
Ddx for transudate pleural effusion?
CHF (most common), liver cirrhosis (causing hypoalbuminemia or hepatic hydrothorax), nephrotic syndrome, hypothyroidism, cardiac valvular disease, peritoneal dialysis, Rheumatoid arthritis (green fluid)
Are exudate pleural effusions usually bilateral or unilateral
Can be bilateral or unilateral
Ddx for exudate pleural effusion?
- Infectious: parapneumonic effusion - pneumonia (most common), TB pleuritis, viral infection, fungal, empyema
- Malignancy: lung carcinoma, lymphoma, metastases, mesothelioma, myeloma
- Inflammatory: RA, SLE, pancreatitis, pulmonary embolism, drug reaction
- Trauma: hemothorax, pneumothorax, chylothorax, iatrogenic
- Other: drug-induced, hypothyroidism
What is Light’s criteria?
Lights (exudative if);
• Pleural LDH: >2/3 ULN for serum LDH
• Pleural fluid:serum total protein ratio >0.5
• Pleural fluid:serum LDH ratio >0.6
What would be found on analysis of complicated exudative effusion
pH <7.2, LDH >1/2 serum, glucose <2.2, positive Gram stain
What should you send the fluid analysis for if pus + microorganisms
pH
What color would the fluid be if chylothorax?
White
Signs and symptoms of pleural effusion
o Often asymptomatic
o Dyspnea: varies with size of effusion and underlying lung function
o Orthopnea
o Pleuritic chest pain
Questions on history for pleural effusion
o Symptoms: OPQRST, previous episodes
o Exertional dyspnea, PND, orthopnea, leg swelling (CHF)
o Cough, hemoptysis, infectious symptoms (fever), hx of aspiration (pneumonia)
o Constitutional symptoms and risk factors for malignancy
o Jaundice, ascites, easy bruising, fatigue, weight loss, risk factors for liver cirrhosis (EtOH use, Hx hepatitis or fatty liver)
o Recent immobility (surgery, travel), hypercoagulability (pregnancy, hormone use, malignancy), unilateral leg swelling, hemoptysis, previous DVT/PE
o Recent infections, exposure to infectious/TB contacts, travel Hx, chest trauma
o Red Flags: Always consider PE-induced pleural effusions have unilateral effusions and pleuritic CP
What would be the expected findings on respiratory exam for pleural effusion
Inspection: asymmetric chest expansion
Percussion: dullness to percussion
Palpation: decreased tactile fremitus
Auscultation: reduced vocal resonance (bronchophony, whispered pectoriloquy, egophony), lung sounds (reduced), pleural friction rub
What are 5 things that differentiate the JVP from carotid
o Biphasic
o Non-palpable
o Occludable
o Abdominal-jugular reflex, pt positioning changes
o Decreases on inspiration (increased intrathoracic pressure causes more RV filling and moves septum towards LV)
What is the abdominojugular reflex?
Abdominojugular reflex = apply midabdomen pressure for 30s, positive if sustained (>10s) 4cm rise in JVP
Besides respiratory exam on physical what else should be performed for pleural effusion?
- Vitals, LN (TB, malignancy)
- CV
- ABDO - Liver
- Extremities: Unilateral leg swelling (PE), pedal edema (CHF)
What lab investigations should be sent for pleural effusion?
CBC-D, lytes, serum LDH, total protein, glucose, LFTs, liver enzymes, Cr
Is PA or lateral more sensitive for pleural effusion on CXR?
Lateral
What usually causes chylothorax?
Caused by traumatic or neoplastic (most often lymphomatous) damage to the thoracic duct
How much fluid needs to be present to detect pleural effusion on PA and lateral CXR?
On PA there needs to be 200 mL, on lateral 50 mL
When is CT indicated for pleural effusion?
CT is not routinely indicated but is valuable for evaluating the underlying lung parenchyma for infiltrates or masses when the lung is obscured by the effusion or when the detail on chest x-rays is insufficient for distinguishing loculated fluid from a solid mass.
What are the indications for thoracentesis?
Indications: Should be done in almost all patients who have pleural fluid that is ≥ 10 mm in thickness on CT, ultrasonography, or lateral decubitus x-ray and that is new or of uncertain etiology. In general, the only patients who do not require thoracentesis are those who have heart failure with symmetric pleural effusions and no chest pain or fever; in these patients, diuresis can be tried, and thoracentesis avoided unless effusions persist for ≥ 3 days.
What should the fluid from thoracentesis be sent for?
Fluid analysis: LDH, total protein, pH, cell count and differential, gram stain and culture
If fluid appearance is bloody what should you order and what’s your ddx?
Get HCT/RBC count > DDx: malignancy + trauma + PE + hemothorax
If fluid appearance is cloudy/white what should you order and what’s your ddx?
Get TG’s > DDx: chylothorax
If fluid has putrid odor what should you order and what’s your ddx?
Get Gram Stain & C&S > DDx: anaerobic infection
When is pleural bx indicated?
Indicated if suspect TB, mesothelioma, or other malignancy
When should tube thoracostomy be done?
If associated pneumothorax, empyema, hemothorax, chylothorax, or complicated parapneumonic effusion (persistent, recurrent, under tension or bilateral)
For treatment, thoracentesis should be done for?
Symptomatic effusions should be drained independent of cause
Treatment for empyema?
In patients with adverse prognostic factors (pH < 7.20, glucose < 60 mg/dL (< 3.33 mmol/L), positive Gram stain or culture, loculations), the effusion should be completely drained via thoracentesis or tube thoracostomy.
What surgical options exist for recurrent pleural effusions?
Pleurodesis for recurrent effusions, intrapleural fibrinolysis for loculated effusions
Approach to cough?
- Start -> Medical history plus examination.
- First determine if cough is reflection of serious illness (PE, pneumonia), exacerbation of RTI (common cold, URTI), exacerbation of pre-existing condition (COPD, UACS, Asthma or bronchiectasis) or secondary to exposure.
- If subacute -> Post-infectious? If yes -> secondary to UACS, asthma, pertussis or acute exacerbation of chronic bronchitis?
- If non-infectious – manage as chronic cough.
Approach to management of chronic cough?
Chronic cough -> systematically direct empiric treatment to most common causes (UACS, asthma, NAEB, GERD) in sequential and additive steps to account for multiple possible causes. Smokers should be counseled and assisted with cessation. ACE-inhibitors should be stopped.
- Start with first-generation A/D - antihistamine/decongestant (UACS treatment).
- If still present – proceed to perform spirometry (may be nondiagnostic) then BPC. Asthma treatment should follow.
- If still present – NAEB – sputum test for eosinophils. CS follow. Treatment with inhaled corticosteroids is recommended
- If still present – GERD – antireflux therapy, proton pump inhibitors, dietary regimen, surgery if all else fails
- If undiagnosed after all this -> referral to cough specialist is indicated. ONLY diagnose psychogenic cough if ALL unusual, somatic and genetic causes have been eliminated.
Ddx for acute cough?
- Upper respiratory infection (URTI) – including acute bronchitis - rhinitis, no red flags, sore throat
- Pneumonia – febrile. ↑HR, ↑RR, signs of consolidation. Can persist and become chronic.
- Influenza – febrile. No signs of consolidation.
- Pertussis – whopping cough, cough-emesis
- Exacerbations of asthma, COPD, CHF
- Allergic rhinitis – allergy symptoms
- Foreign body – new onset in children
- Sinusitis – facial pressure/pain
Ddx of chronic cough?
- Chronic bronchitis
- Post-viral cough can last up to 6 weeks after the acute infection, especially in the context dx of asthma;
- Post-nasal drip (UACS)
▪ Chronic rhinitis
▪ Chronic sinusitis
▪ Vasomotor rhinitis - Whooping cough
- GERD
- COPD
- ACE-inhibitor induced cough.
Physical exam for cough?
O2 saturation, respiratory exam, HEENT (lymph nodes, ears) and precordial exam
Red flags of cough?
- Systemic symptoms: persistent fever (pneumonia, TB); night sweats, weight loss (TB, lung cancer)
- Dyspnea (asthma, congestive heart failure, COPD, interstitial lung disease)
- Hemoptysis (TB, lung cancer); copious sputum production (bronchiectasis)
- Severe thoracic pain/pleurisy (pneumonia, TB, pulmonary embolism)
- Change in character of a chronic cough (esp. in a smoker’s cough)
- History of contact with TB and/or HIV
Risk factors for cough?
Risk Factors: smoking, occupation, exposure, family history of lung CA or other CA, TB status, recent travel
What is chronic bronchitis?
Chronic bronchitis: Persistent cough for at least 3 months per year for ≥ 2 consecutive years. Most common cause in smokers. Most also have COPD.
What is post-nasal drip (UACS)?
Abnormally increased nasal mucus secretion that drips down the back of the throat and can lead to coughing, a feeling of obstruction in the throat, and throat clearing, tickle in throat
History of cough?
- Onset and duration of cough
- Characteristics of the cough: Productive (cough with production of phlegm/mucus), Non-productive (dry cough)
- Timing: Nocturnal cough, Seasonal/geographical variation
- Associated symptoms
- Red Flags
- Medications: ACEI, β-blockers
- Allergies: any known
- PHx: lung (asthma, COPD, CF), heart (CHF, MI, arrhythmias), chronic illness, GI (reflux)
Possible causes of productive cough?
Pneumonia (rust coloured), bronchitis, bronchiectasis (large volume of foul smelling, pulmonary edema (pink, frothy), tuberculosis
Possible causes of non-productive cough?
Asthma, interstitial lung disease, viral pneumonia (e.g., adenovirus. RSV, influenza virus)
Possible causes of nocturnal cough?
Asthma; upper airway cough syndrome (UACS); GERD
Cough; symptoms that would make you consider URI?
URI: rhinorrhea, odynophagia, myalgia, fever: suggestive of UR
Cough; symptoms that would make you consider GERD?
GERD (3rd most common cause of chronic cough) : heartburn or reflux
Cough; symptoms that would make you consider allergic origin?
Allergic origin: itching and watering of eyes, rhinorrhea, pruritus
Cough; symptoms that would make you consider cough-variant asthma?
Cough-variant asthma: exacerbation of cough with activity
Labs for cough?
- Complete blood count: indicated in patients with chronic cough/red flag symptoms if an infective etiology (e.g., neutrophilic leukocytosis in pneumonia, lymphocytosis in TB) or allergic etiology (e.g., eosinophilia in asthma) is suspected
- Tuberculin skin test: patients with suspected TB
- Sputum examination
▪ Sputum culture: suspected bacterial pneumonia, TB
▪ Sputum examination for acid-fast bacilli: suspected TB - Nasopharyngeal swab/deep nasopharyngeal aspirate culture and PCR for pertussis: indicated in patients with subacute/chronic cough, esp. if associated with an inspiratory whoop and/or post-tussive vomiting
- Blood culture: suspected pneumonia
- Arterial blood gas analysis: patients with dyspnea and those with suspected life-threatening causes of acute cough
Chest CT scan for cough?
- Suspected bronchiectasis (diagnostic test)
- Recurrent pneumonia
- Chest x-ray findings suggestive of lung cancer (e.g., mass, hilar lymphadenopathy)
- Inconclusive chest x-ray findings in patients with foreign body aspiration
Chest x-ray for cough?
- Suspected pneumonia or TB
- Chronic cough with abnormal physical examination findings or prolonged history of nicotine abuse
- Red flag symptoms
Bronchoscopy for cough?
- Foreign body aspiration
- Lung cancer
- Suspected tracheoesophageal fistula
X-ray of paranasal sinuses for cough?
Patients with UACS secondary to suspected sinusitis
Test to differentiate between obstructive lung disease (e.g., asthma, COPD) and restrictive lung disease (e.g., interstitial lung disease)?
Spirometry
Treatment of non-life-threatening acute cough (URI, acute bronchitis)?
- Nonpharmacological treatment: Honey,Menthol (vapors), Hydration, lozenges, and humidifiers
- NSAIDs: for myalgia, headaches, fever
- Antibiotics: usually not recommended
- Hypersensitivity pneumonitis: antigen avoidance with/without glucocorticoid therapy
Treatment of life-threatening acute cough?
- Inhalation injury: secure airway (endotracheal intubation/tracheostomy); administer high-flow oxygen; administer aerosolized bronchodilators and N-acetylcysteine with/without heparin; chest physiotherapy
- Treat the underlying cause: See congestive heart failure, pulmonary embolism, asthma, COPD, and acute pericarditis.
Test to differentiate asthma from other obstructive lung disease?
Bronchial challenge test (metacholine challenge test; bronchodilator reversibility test)
Treatment of chronic cough with no abnormal physical examination findings and no history of ACE-inhibitor use?
- Empirical trial of treatment with first-generation antihistamines (e.g., dimetindene, diphenhydramine)- improvement of symptoms within 2 weeks - diagnostic of UACS; treat the underlying cause
- No/partial improvement with antihistamines
o Empirical trial of inhaled bronchodilators or corticosteroids - symptomatic improvement - diagnostic of cough-variant asthma - bronchodilators, corticosteroids, leukotriene receptor antagonists
o Empirical trial of proton pump inhibitors and anti-reflux lifestyle modification - symptomatic improvement - continue PPIs for 8-12 weeks - Treat the underlying cause
Definition of cyanosis?
Physical sign of bluish coloration of the skin due to the presence of >50 g/L of deoxygenated hemoglobin in blood vessels near the skin surface. O2 saturation of arterial blood falls below 85%
Definition of hypoxemia?
An abnormal deficiency in the concentration of O2 in arterial blood. PaO2 <60mmHg or SaO2 < 90
Definition of hypoxia?
Total body is deprived of O2.
What is central cyanosis?
Due to a circulatory or ventilatory problem that leads to poorer blood oxygenation in the lungs or greater O2 extraction due to slowing down of blood circulation in the skin’s blood vessels
Etiology of central cyanosis?
High alveolar-arterial (A-a) gradient
- Shunting: Physiological – atelectasis, ARDS. Anatomical: pulmonary AVM, R-L intracardiac shunt
- V/Q (ventilation-perfusion) mismatch: Obstructive (asthma, COPD), PE, Restrictive
- Diffusion impairment (e.g., restrictive lung disease)
Hypoventilation (elevated PCO2, normal A-a gradient)
- Central control: stroke, narcotics, obesity, hypothyroid
- Peripheral: neuromuscular, chest wall