Pulmonary Flashcards
5 densities on x-ray
gas fat fluid bone metal
The closer an object is to x-ray
the sharper the borders
The farther away an object on x-ray
the more magnified and fuzzy it is
Best view for x-ray
AP
When two structures are the same density on x-ray
the border between them cannot been seen
adequacy for chest x-ray evaluated for
inspiratory effort
penetration
rotation
Disadvantages to AP check x-ray
increased exposure time
changes in magnification
less precise
Inspiration on chest x-ray
helps determine if there are intrapulmonary abnormalities
How to tell if there is adequate inspiration
diaphragm at about 8th-10th pos. rib or 5-6th ant. rib
Pitfall of poor inspiration
crowds lung markings and make it appear as airspace disease
posterior ribs on x-ray
most apparent
run horizontally
anterior ribs on x-ray
harder to see
run 45 degree angle
Sign of good penetration on x-ray
thoracic spine barely visible through the heart
spine appears to darken as you move caudally
Adequate rotation on x-ray
if the spinous process of the vertebral body is equidistant from the medial ends of each clavicle then no rotation present
Measuring the heard on x-ray
should not take up more than 1/2 of thoracic cavity
Costophrenic angles
should curve downward
blunted angles could indicate pleural effusion
5 items to look for on x-ray of chest
gastric bubble breast shadows clavicles ribs spine
Silhouette sign on x-ray
no border between two structures of the same density structures
causes of Kerley B lines
pulmonary edema lymphangitis cancer pneumonia pulmonary fibrosis
Interstitial pattern on chest x-ray
thin white random lines
infection of the interstitium
from virus or mycoplasma
Air space disease pattern on chest x-ray
patch of white opacity resulting from presence of fluid in alveoli
also called consolidation
pneumonia
Honeycomb pattern on chest x-ray
long standing interstitial lung disease and irreversible scaring
Miliary pattern on chest x-ray
TB
Emphysema on chest x-ray
more air than normal in the lungs
air trapping
flattening of diaphragm
Atalectasis on chest x-ray
loss of lung volume
Large bowel on x-ray
haustral markings
peripheral
Small bowl on x-ray
valvulae
central
Extraluminal gas on x-ray
most seen under right diaphragm
occurs with viscus perforation
ABC’s of bone x-ray
A: Alignment
B: bone
C: cartilage
S: soft tissues
Greenstick bone fracture
partial crack and bend in to bone but not a break through
only in children
Spiral fracture
sharp triangular bone ends
Comminuted fracture
broken in multiple pieces
Transverse fracture
clean square break dividing bone cleanly across
Compound fracture
wounds that communicated with the fracture and may expose bone
Compression fracture
bone collapses into itself
Avulsion fracture
small fragments of bone detach from tendons or ligaments
Obstructive Sleep apnea observed
pausing in breathing gasping for air morning HA daily sleepiness frequent night time urination poor school performance night time bed wetting
Risk factors for sleep apnea
male post menopausal female pregnancy obesity large girth neck small mandible down syndrome lung disease heart disease DM neuromuscular disease
How to dx sleep apnea
sleep study (polysomnography) brain waves with EEG, EKG, breathing pulse
What causes snoring
increased resistance deviated septum URI rhinitis soft palate or uvula that is enlarged or relaxed
Symptoms of snoring
being told
walking self up
morning HA
not refreshed
hypopnea
shallow breathing
apnea
no air movement
either obstructive or central
Classification of sleep apnea
5-15 events per hour = mild
15-30 per hour = moderate
>30 = severe
Tx for snoring
nasal steroid
surgery
oral appliance
weight loss
Tx mild-mod apnea
wt loss
oral appliance
ENT consult
tennis ball in shirt to keep from rolling over
Tx of severe apnea
CPAP
Wt loss
When writing a Rx for CPAP
write CPAP plus supplies
include pressure from sleep study
Factors that worsen snoring and sleep apnea
sleep deprivation wt gain URI allergies sedating meds alcohol cold medication
Chronic cough defined
> 15 years of age and cough lasting 8 weeks or more
Subacute cough defined
> 15 years of age lasting 3-8 weeks
Cough defined
normal protective reflex protects from: irritants accumulated secretions aspirated fluid inhaled irritants
Regulator of involuntary coughing
vagal sensory receptors
in mucosa of carina, bronchi and pharynx
Social history with cough
live urban or rurual pets occupation exposure to chemicals tobacco alcohol
Exam for cough
start with x-ray bronchoscopy barium CT 25-50% have multiple causes of cough
3 most common causes of cough
upper airway cough syndrome, post nasal drip
asthma
GERD
Upper airway cough syndrome
most common cause of chronic cough in nonsmoking adults with normal chest x-ray
from mucous or drainage
How is accurate dx of cough confirmed
by resolution or marked improvement of cough following specific tx
Causes of subacute cough
post infection: pneumonia, pertussis, bronchitis
new onset or exacerbation: asthma, GERD
bronchitis
Chronic cough in children
lasts longer than 4 weeks
asthma
URI
GERD
Diff dx of children with chronic cough and no wheeze
recurrent bronchitis postinfectious cough pertussis UACS psychogenic GERD
Evaluation for children with chronic cough
should always include chest radiograph and spirometry at minimum
COPD explained
gradual progression of irreversible airflow obstruction and increased inflammation in the airway and lungs that is different than inflammation caused by asthma, smoking or occupational exposure
COPD defined
cluster of disorders or bronchi, conducting airways and lung parenchyma
airflow limitation
progressive
not reversible
Bronchitis of COPD defined
chronic, persistent cough or sputum production for 3 consecutive months each year for 2 years
periodic acute exacerbations
does not include other lung disease
Emphysema of COPD defined
permanent and abnormal enlargement of any part of the air spaces distal to the terminal bronchioles
destruction of alveolar walls without fibrosis
COPD epidemiology
leading cause of death and disability
4th leading cause of death
Risk factors of COPD
smoking airway hyperactivity childhood resp. infections occupational air pollution poor nutrition crowded living conditions family with COPD Alpha ! antitrypsin deficiency white
Symptoms of COPD
dyspnea
coughing
sputum production
orthopnea soon after reclining
Dx of COPD
based on objective airflow limitation defined as a forced expiratory volume in one second/forced vital capacity ratio of less than 0.70 and symptoms
HPI/PMH on assessment with COPD
history of cough, sputum or dyspnea hx recurrent resp. infections ashtma bronchitis recurrent sinus infections nasal polyps cigarette smoke hazardous environment
Physical exam with COPD
diminished breath sounds early inspiratory crackles wheezing with forced expiration prolonged expiratory time increased resonance on chest percussion barrel chest use of accessory muscles of respiration pursed lip breathing clubbing of fingernails diminished muscle mass in thighs and legs
Significant edema in COPD
indicated right side heart failure and cor pulmonale in pts with pulmonary hypertension
lung disease causes hypertrophy of right ventricles
Consider a dx of COPD in any pt with
dyspnea
chronic cough
sputum production
or a history of exposure to risk factors for the disease.
Confirm dx of COPD with
spirometry
Other diagnostics in COPD
spirometry pulse oximetry CBC ABGs EKG chest x-ray
Mainstay of drug therapy for COPD
short acting anticholinergics (inhaled)
beta 2 agonists (inhaled)
methylxanthines (po)
Anticholinergics for COPD
Ipratoprium bromide metered dose inhaler 18mcg/inhalation, 2-4 puffs, 4-6 times a day
or neb 500mcg/2.5ml
Beta 2 agonists for COPD
Albuterol 90mcg/inhalation 1-2 puffs, 3-4x/day
neb 0.5ml of 0.5% solution 3-4 x/day
Methylxanthines for COPD
Theophylline immed. release tabs 10mg/kg/d in 4 doses
sustained release 10mg/kg in 1-3 doses
Oral corticosteroids for COPD exacerbation
methylprednisone 40-48mg/kg/d divided 3-4 days
prednisone 40-60mg/day, taper by 10mg every 4-5 days, ending with 4-5 days of 5mg/day in 1-3 doses
Inhaled corticosteroids for COPD
beclomethasone dipropionate 42mcg/inhalation
2 puffs 3-4x/day or 4 puffs 2x/day
ax 20 puffs/day
Asthma defined
chronic disease of the airway that causes repeated episodes of wheezing breathlessness chest tightness nighttime or morning coughing
asthma can be controlled
by knowing warning signs
staying away from triggers
following healthcare provider advice
what happens during an asthma attack
airway narrows from muscle constriction
swelling of inner lining
mucus production
who does asthma affect
anyone but common in children 5-17 years old boys more than girls women black low income families
extrinsic factors associated with high prevalence, morbidity and mortality
poverty
urban living
indoor allergens
inadequate disease management
Risk factors for developing asthma
genetics
occupational exposures
environmental exposure
Genetics and asthma
Atopy = body's predisposition to develop an antibody (IgE) in response to allergens rhinitis asthma hay fever eczema
environmental exposures for asthma
house dust mites cockroaches RSV tobacco smoke pets molds birds formaldehyde fragrances trees grass pollen
Reducing exposure to house dust mites
wash beds weekly
avoid down products
limit stuffed animals
less humidity
Treatment of asthma
based on severity, control and responsiveness
reduce exposures to irritants
provide pt education for self management
4 essential components of asthma
assessment and monitoring
pt education
control factors that contribute to asthma
pharmacologic tx
GIP’s six key messages
inhaled steroids asthma action plan asthma severity asthma control follow up visits allergen and irritant exposure control
Medical history s/s of asthma
cough wheeze sob chest tightness pattern of symptoms family history troublesome cough at night cough or wheeze after physical activity seasonal colds lasting more than 10 days relief with tx
Testing for asthma
peak flow
spirometry
Two major categories of asthma tx
long term control
quick relief
Long term asthma control
taken daily reduce inflammation, relax airway and improve lung fx inhaled corticosteroids long acting beta agonists leukotriene modifiers
Quick relief asthma control
used in acute episodes
generally short acting beta agonists
Spacers purpose on inhalers
help pts who have difficulty with inhaler use and can reduce potential adverse effects
Asthma management goals
achieve control of symptoms maintain normal activity levels maintain pulm fx as close to normal prevent exacerbations avoid adverse effects of meds prevent asthma mortality
Using a peak flow meter with mod to severe asthma
every morning
every evening
after an exacerbation
before inhalation of meds
Indications of a severe asthma attack
breathlessness at rest hunched forward speaks in words, not sentences agitated peak flow less than 60% of normal
Important things those with asthma can do
have an individual plan
educated yourself about plans and environmental triggers
seek help from asthma resources
join an asthma support group
Key aspects in asthma tx
requires a team effort
coordinate health to involve: mental and physical health, education, environment, family and community efforts
assess needs of schools
focus on students with symptoms, heath room visits and absenteeism
Cystic Fibrosis defined
multisystem disease
autosomal recessive
mutations in cystic fibrosis trasmembrane regulator protien
body produces thick sticky mucous that clogs lungs and obstructs the pancrease
How common is cystic fibrosis
most common fetal autosomal recessive disease among Caucasians
CF characterized by
dehydration of the airway surface liquid and impaired mucocillary clearance leading to difficulty clearing lungs and chronic infection
symptoms of CF
very salty-tasting skin persistent cough with phlegm frequent lung infections wheezing and SOB poor growth/weight gain frequent greasy, bulky stools
CF survival
70% dx by age 2
female survival worse than males (2-20 yrs old)
Median survival is 37
Diagnosis of CF
sweat chloride concentration >60meql/L with one of the following chronic sinopulmonary disease pancreatic insufficiency salt loss syndomes obstructive azoospermia family history
Pts that should be tested for CF
Infants with pos CF newborn screen, rpt after 2 weeks and 2kg if asymptomatic
infants with symptoms suggestive of CF such as meconium ileus
siblings of a patient with confirmed CF
Facts about sweat chloride test
more likely to be false neg in those <6 months
Other tests for CF
nasal potential difference
immunoreactive trypsin
stool fecal fat
pancreatic enzyme secreation
Organs affected by cystic fibrosis
airways liver pancrease small intestine reproductive
cause of organs affected in CF
deranged transport of chlorid, sodium, bicarb which leads to an increase in secretions in these areas
respiratory clinical manifestations of CF
persistent productive cough hyperinflamation of lung fields pulmonary fx testing showing obstructive airway bronchiolitis pneumonia nasal polyposis sinusitis digital clubbing
bronchiolitis exacerbation in CF
an increased cough with tachypnea
dysplea
malaise
anorexia/wt loss
Effect of CF on sinuses
majority will develop sinus disease
panopacification of paransal sinus
Infections with CF
most common cause in small children is s.aureus and h.influenza
as we age its pseudomonas aeruginosa
Digital clubbing with CF
bulbous swelling at end of finger
schamroth sign = loss of normal angle between nail and nail bed
Nutrition deficiency in CF
due to pancreatic insufficiency
insufficient secretion of digestive enzymes such as lipase, leads to malabsorption of fat and protein
leads to failure to thrive
fat soluble vit deficiency
Infants with CF may present with
hypoproteinemia
edema
electrolyte loss
anemia
How to reverse nutritional malabsorption
vit A
D
E
K
Biliary Disease in CF
focal biliary cirrhosis caused by inspissated bile
elevations of alkaline phosphatase and lobular hepatomegaly
leads to portal hypertension
Infertility with CF
men have abnormal embryologic development of the epididymal duct and vas deferens
females it is r/t to malnutrition as well as thick cervical mucous
The sweat chloride test
chemical that stimulates sweating placed under electrode pad on arm
current passed through and sweat is collected
pos if 60-165
normal is 0-40
validity of sweat test
used for the primary dx of CF
a normal sweat chloride result is sufficient to rule out CF in most
prenatal screening for CF
blood draw in first trimester
aerosolized abx for CF
for the eradication of initial infection and suppression of chronic infection
tobramycin
azithromycin
inhaled adrenergic receptor agonist
ibuprofen
Human DNase in CF
dornase alfa
improve lung fx and reduce exacercations by altering mucous
Lung cancer prevalence
overall survival rate for all stages of lung cancer is 15% at 5 years
Term used for lung cancer
bronchogenic carcinoma
small cell lung cancer
non-small lung cancer
most important risk factor for lung cancer
smoking
20x higher risk of someone who smokes versus someone who doesn’t
Other risk factors for lung cancer
radiation in those treated for other cancers
environmental toxins: asbestos, radon, metals, hydrocarbons
pulmonary fibrosis
genetics
dietary:antioxidants, cruciferous veges can decrease lung ca risk
HIV
Low socioeconomic class
decreased education
Screening for lung cancer
annual low dose CT lung scan for older smokers age 55-80 who are at high risk of
Pathology types of lung cancer
most common are adenocarcidoma
then squamous cell
Signs and symptoms of lung CA
cough hemopysis chest pain dyspnea diaphragmatic paralysis hoarseness malignant pleural effusions
cough in lung CA
most freq with squamous cell and small cell carcinomas
new onset of cough in smoker should raise concern
hemoptysis in lung CA
bronchitis most common cause of this so rule out first
Dyspnea with lung CA
pulmonary fx testing to show flattening of the expiratory and/or inspiratory flow volume from the presence of the tumor
Hoarseness in lung CA
could include persistent hoarseness including both laryngeal cancer and lung CA
Superior vena cava syndrome in lung CA
obstruction causing sensation of fullness in head and dyspnea
dilated neck veins, prominent venous pattern on chest, facial edema
x-ray shows widening of mediastium or right hilar mass
Horners sign in lung CA
bone destruction and atrophy of hard muscles
Lab tests for lung CA
CBC
CMP
lactate dehydrogenase
sputum cytology
Interstitial lung disease aka
idiopathic fibrosing
interstitial pneumonia
sarcoidosis
Evaluation of interstitial lung disease
history and physical routine blood chest x-ray pulmonary fx testing arterial blood gas computed tomography
History for lung disease
age gender smoking? duration of illness prior meds family hx occupational hx environmental exposures
Symptoms to inquire with lung disease
dyspnea cough hemopysis wheezing chest pain (could be pleuritic due to arthritis or lupus)
Clinical findings consistent with connective tissue disease
muscle pain weakness fatigue fever joint pains or swelling photosensitivity Raynauds pleuritis dry eyes dry mouth
physical exam for lung disease
crackles: common in most ILD, less in granulomatous
inspiratory squeaks: late high pitches rhonchi
cor pulmonale: late sign
clubbing
extrapulmonary findings
Creatine kinase for interstital lung disease
for myositis (anti JO-1 antibodies)
Interstitial pattern on chest x-ray with obst airflow suggestive of
sarcoidosis lymphangioleiomyomatosis hypersensitivity pneumonitis tuberous sclerosis COPD with superimposed ILD
Biopsy in ILD
not required to make dx helps to assess disease activity to exclude neoplastic and infectious processes that occassionally mimic chronic, progressive disease identify a more treatable process to establish a definitive dx
Treatment of idiopathic pulmonary fibrosis (IPF)
controversial
no tx to improve survival
Sarcoidosis
multisystem inflammatory, granulomatous disease of unknown etiology
young adults with:
bilateral hilar adenopathy
pulmonary reticular opacities
skin, joint and/or eye lesions
symptoms of sarcoidosis
cough dyspnea chest pain fatigue fever wt loss systemic inflammation: muscle weakness and exercise intolerance maybe chills and night sweats
delay of tx in sarcoidosis
due to nonspecificity of symptoms
Lab testing in sarcoidosis
cbc cmp phosphorus ESR serum gamma globulin angiotensin-converting enzyme chest x-ray pul fx testing arterial blood gas
Lab finding with sarcoidosis
leukopenia
hypercalciuria
ESR elevated
angiotenstion-converting enzyme elevation
This implies diffuse granulomatous hepatic involvement
mod elevation in serum alkaline phosphatase
Staging of sarcoidosis
Stages I-4
Stage 1
bilateral hilar adenopathy, accompanied by right paratracheal node enlargement
Stage 2
bilateral hilar adenopathy with reticular opacities
2/3 undergo spont. resolution while the remainder have progressive disease or little change over time
Stage 3
reticular opacities with shrinking of hilar nodes (upper lung zones)
Stage 4
evidence of volume loss in upper lung zones
conglomerated masses with marked traction bronchiectasis
extensive calcification and caviation
CT for sarcoidosis
hilar and mediastinal lymphadenopathy bronchial wall thickening ground glass opacification parenchymal masses cysts traction bronchiectasis fibrosis
PET scan with sarcoidosis
may be helpful to indentify occult lesions and reversible granulomatous disease
skin lesions with sarcoidosis
maculopapular rash on face and hairline
erythema nodosum
Tx for sarcoidosis
none for stage 1-2 NSAIDS for joint pain low dose prednisone 15-20mg/day inhaled corticosteroids methotrexate cyclophosphamide azathioprine
