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Med 1 > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Most common emphysema in smokers

A

Centrilopular emphysema

limited to proximal resp bronchioles

Upper lung fields

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2
Q

alpha 1 antitrypsin deficiency emphysema

A

panlobar emphysema

Proximal and distal,

lung bases

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3
Q

2 COPD types

A

Chronic bronchitis and Emphysema

2 can co-exist and often do!!

4th cause of death in US

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4
Q

Chronic bronchitis def

A

productive couch of sputum for 3 months / yr for at least 2 consecutive yrs

excess mucus production narrows airways, inflammation and scanning and smooth muscle hyperplasia

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5
Q

Emphysema def

A

perm enlargement of air spaces 2/2 alveoli destruction

Excess protease (elastase)or decrease in anitprotease (alpha1 antitrypsin) -> tobacco increases PMNs and elastase activity

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6
Q

COPD risk factors (4)

A

tobacco (90%)
alpha 1 antitrypsan def
environemental
chronic asthma

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7
Q

Pink puffers (4)

A

Predominat emphysema

thin 2/2 increased energy expenditure,

Lean forward w/ breath

Barrel chested (air trapping)

Pursed lips w/ prolonged expiration, distress breathing

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8
Q

Blue bloaters (4)

A

predominant bronchitis

Overweight and cyanotic

Chronic cough/sputum

cor pulmonate may be present

Resp rat normal/increased - No distress

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9
Q

premature emphysema in Pt or Pts family <50 look for?

A

alpha 1 antitripsan

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10
Q

COPD acid base?

A

respiratory acidosis w/ metabolic alkalosis compensation

chronic pCO2 retention and decreased pO2

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11
Q

Tx of COPD(6)

A
  1. quite smoking, rate of decline slows but does not reverse damage. Symptoms improve in a yr
  2. Oxygen?
  3. Inhaled beta 2 agonists - symptomatic relief
  4. Anticholinergics (ipratropium) slow symptomatic relief but last longer
  5. combinedinations
  6. inhaled corticosteriods? may help but limited evidence (bedesonide, fluticasone)
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12
Q

Acute vs chronic treatment of COPD

A

give steriods acutely, Chronically give anticholinergics and beta2 agonistic

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13
Q

COPD CXR

A

hyperinflation, flat diaphragm, enlarged retrosternal space, diminished vascular markings

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14
Q

Criteria for long term O2 in COPD

A

PaO2 55mmHg

or O2 sat <85% at rest/exercise

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15
Q

Vaccines in COPD (2)

A

influenza

Strep pneumo q5-6yrs

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16
Q

Acute COPD exacerbation def

A

persistent increase in dyspnea not relived w/ bronchodialatirs, cough and sputum

Get a CXR

Systemic steroids + usual baseline medications; maybe Abx

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17
Q

Complications of COPD (3)

A

exacerbations

Secondary polycythemia (HCt>55% m or >47% women)

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18
Q

Acute Severe asthma attack characterized by:

A

Tachypnea, diaphoresis, incomplete sentences, accessory muscle use

Paradoxic movement of abdomen and diaphragm on inspiration

Wheezing on inspiration and expiration

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19
Q

Triad of asthma

begins when?

A

airway inflammation
hyperresonnance
reversible obstruction

can begin at ANY age

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20
Q

Wheezing found in (5)

A 
Asthma
CHF - edema and congestion
COPD - inflamed and bronchospasm
Cardiomyopathies - edema around bronchi
lung CA- central tumor
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21
Q

PFTs in asthma
FEV1/FVC

FEV1 w/ albuterol
W. methacholine/histamine

diffusion capacity?

A

decreased FEV1/FVC < 0/75

FEV1 improves by 12% w/ albuterol, decreases by >20% w/ methacoline

Diffusion capacity increases

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22
Q

Peak expiratory flow in asthma

Normal?

A

Normal is 450-650

Mild >300
Mod -severe 100-300
severe <100

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23
Q

Med to induce asthma test

A

methacoline

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24
Q

ABG is asthma see?

A

Hypocarbia is common; maybe hypoxemia

PcCO2 normal or increased, attacks may lead to decline in PaCO2 (hyperventilate)

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25
Q

Avoid what medication in asthmatics?

A

beta blockers

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26
Q

Side effects of inhaled corticoseriods(2)

A

Sore throat
oral candidiasis

use a spacer or rinse mouth

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27
Q

Tests to order in acute exacerbation (3)

A

PEF - decreased
ABG - A-a increased
CXR - r.o infiltrates

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28
Q

Mild intermittent asthma

  • def
  • Rx
A

symptoms <2 /wk

just a SA beta 2agonist

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29
Q

Mild persistent asthma

  • def
  • Rx
A

symptoms >2x/wk but not everyday

low dose inhaled corticosteroid

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30
Q

Moderate persistant asthma

  • def
  • Rx
A

daily symptoms, frequent exacerbations

  • daily inhaled cortiocosteriod(low dose)
    /methylxanthine/antileukotriene
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31
Q

Severe persistent

  • def
  • Rx
A

continual symptoms, frequent exacerbations, limited activity

Daily high dose cortiosteriod and locating inhaled beta 2 agonist

IV/oral may be needed to get under control

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32
Q

Role of cromolyn sodium in asthma

A

only PPX prior to exercise

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33
Q

complications of asthma (3)

A

status asthmaticus - no response to standard meds

acute resp failure - muscle fatigue

Pneumo/atelectasis/pneumomediastinum

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34
Q

TX of acute severe asthma exacerbation

A 
inhaled beta 2 agonists - via nebulizer(or MDI-equally effective but amount differs)
Corticosteriods - IV but maybe oral
-3rd line is IV magnesium
-supplemental O2
-ABx?, Intubation?
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35
Q

Nasal polyps and asthma think

A

ASA sensitive asthma

avoid ASA and NSAIDs

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36
Q

Bronchiectasis

A

perm abnormal dilation/destruction of bronchial walls w/ cilia damage

infection w/ obstruction percipitates

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37
Q

Most common cause of bronchiectasis

A

CF - half of all cases

infection, hummoral immunodeficiency, airway obstruction

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38
Q

Features of bronchiectasis

A

chronic cough w/ mucopurulent, fowl smeeling sputum
dyspnea
hemoptysis - rupture near surface
recurrent/persistent pneumonia

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39
Q

Dx of broniectasis

A

High res CT**
PFTs show obstruction
CXR is abnormal but nonspecific
maybe bronchoscope

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40
Q

TX of bronchiectsais

A

Abx for exacebations

Bronchial hygene - hydration, chest physiotherpy, bronchodialatores

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41
Q

CF defect?

5 systems hit

A

Autosomal recessive conditon
- Defect in Cl channel protein -> impaired H2O and Cl movement and thick viscous fluids in:

Resp tract
Exocrine Pancreas
Sweat glands
Intestines
Genital urinatory
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42
Q

pneumonia infections in CF think of

A

Pseudomonas

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43
Q

Tx of CF

A

pancreatic enzymes, chest physio, fat soluble vitamins, vaccines, inhaled recombinant human deoxyribonuclease

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44
Q

2 categories and 5 types of Lung CA and prevalence

Location

A

Small cell - 25%- Central w/ widespread METS

Non small cell 75% -

  • squamous cell - central cavitation (30%)
  • adenocarcinoma, - peripheral pulm scars (35%)
  • large cell - peripheral (5-10%)
  • bronchoalveolar
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45
Q

Smoking has lowest risk for which lung CA

A

adenocarcinoma

otherwise 85% of all lung CA

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46
Q

Other than smoking, risks for lung CA

A

asbestos, radon in basements, COPD

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47
Q

NSCLC staged by?

SCLC staged by?

A

TNM system

SCLC

  • limited (in chest -> supraclavicular nodes - no cervical or axillary)
  • extensive: outside
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48
Q

local manifestations of lung CA - commonly squamous (2)

A

airway involvement - wheezing, cough, hemoptysis,

Recurrent postbstructive pneumonia

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49
Q

Superior vena cava syndrome is?

A

5% of Pts w. lung CA -> obstruction of SVC

facial fullness, falial/arm edema, dilated veins over arms/chest, JVD

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50
Q

Local invasion of lung CA can lead to (6)

A 
superior vena cava syndrome
phrenic nerve pasly
recurrent layngeal nerve palsy
horner's syndome
Pancoast tumors
malignant pleural effusion - BAD
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51
Q

Horner’s syndrome (3)

A

unilateral facial anhidrosis, ptosis and miosis

can be 2/2 invasion of cervical sympathetic chancy apical tumor

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52
Q

Pancoast tumor is?

A

Superior sulcus tumor - C8-T1-T2,

Shoulder pain radiating down the arm; weakness, horners (60%)

Usually squamous cell CA

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53
Q

Paraneoplastic syndromes in lung CA (4)

A

SCLC:
SIADH (10%); Ectopic ACTH; Eaton-Lambert Syndrome (myasthenia gravis picture w/proximal weakness)

Squamous Cell:
rPTH

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54
Q

Eaten Lambert Syndrome

A

Seen in SCLC -

similar to myasthenia graves, w/ proximal weakness, diminished DTRs, paresthesias

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55
Q

3 tests in a Lung CA Dx

A

CXR (NOT a screener, stability over 2 yrs -> benign, pleural effusions to be tapped)

CT - for staging

tissue biopsy - SCLC vs NSCLC

  • cytologic of sputum can be useful central tumors (80%), variable results and not specific, early detection
  • bronchoscope: to 2ry bronchiloles
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56
Q

Role of transthoracic needles in lung CA

A

suspicious pulm masses or lesions, peripheral lesions

Only in select Pts

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57
Q

Prognosis of lung CA

A

5yr survival is 15%

85% of SCLC have extensive disease at time

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58
Q

Tx of NSCLC

A
  1. Surgery: if METS, then NOT a candidate, can have recurrence
  2. Radiation adjunct
  3. Chemo?
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59
Q

Tx of SCLC

A

limited disease: Chemo and radiation

Extensive: Chemo alone initially -> ppx radiation

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60
Q

Solitary Pulm Nodule DDs

1st thing?

A

infectous granuloma, bronchiogenic carcinoma, hamartoma, bronchail adenoma

get CXR, stable 2 yrs benign

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61
Q

Solitary Pulm nodule suspicious if: (6)

A
  1. old Pt, >50
  2. Smoking
  3. > 3cm size
  4. Irregular borders
  5. eccentric asymetric calcification (dense central benign
  6. Change in size in 2yrs
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62
Q

SPN on CXR and difference if >1cm vs <1cm w/ interned probability nodules

A

1cm get a PET scan

High prob biopsy

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63
Q

Ddx of Anterior mediastinal mass (4)

A

thyroid
teratogenic tumors
thymoma
lymphoma

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64
Q

Ddx of Middle mediastinal mass(5)

A 
lung CA
lymphoma
aneurysms
cysts
morgagni hernia
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65
Q

Ddx of posterior mediastinum (5)

A 
neurogenic tumors,
esophageal masses
enteric cysts
aneurisms
Bochdaleks hernia
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66
Q

Features of mediastinal masses

A

2/2 compression
Cough, chest pain, dyspnea, post obtrictive pneumonia, dysphagia, SVC syndrome, compression of nerves (recurrent laryngea, horners, phrenic)

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67
Q

Transudative effusion causes(7)

A

CHF; Cirrosis, PE, Nephrotic, peritoneal dialysis, hypalbumineria, atelectasis

elv capillary pressures or parental pleura/decreased oncotic pressure

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68
Q

Exudative effusion causes (5)

A

Infection (bacteral/TB); malignancy(lung, breast, lymphoma); viral infection; PE; Collagen vascular disease

increased perm of pleural surfaces or decreased lymph flow

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69
Q

If exudative effusion suspected get what tests?

A

differential cell count
Glucose
pH 0.5
LDH-pleural/LDH serum = >0.6

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70
Q

Chylothorax

A

milky oplascent fluid (lymph) in pleural space

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71
Q

empyema

A

pus in pleural space

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72
Q

bloody effusion think?

A

possible malignancy

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73
Q

Tests for effusion (3)

A

CXR - blunting of phrenic angle (>250mL to see), lateral better

CT more reliable

Thoracentesis - if unknown etiology, can be therapeutic
- 4C’s - Chemistry, cytology, cell count, culture

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74
Q

Parapneumonic effusion vs empyema

A

noninflected pleural effusion 2/2 bacterial pneumonia

vs

pleural is infected

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75
Q

empymea causes

A

exudative pleural effusion untreated, most often 2/2 bacterial pneumonia

76
Q

Tx of empyema

A

Aggressive drainage and ABx

infection is resistant and common recurrence

77
Q

Always get a CXR post these procedures to r/o pneumothorax (3)

A

thransthoracic needle aspiration
thoracentesis
central line placement

78
Q

Tx w/ ___ hastens reaborbtion of air in pleural space post pneumo

A

oxygen

79
Q

Risk factor of spontaneouss pneumo

A

tall, lean young men

recurrence 50% in 2 yrs

80
Q

Secondary pneumothorax due to

A

lung diease: COPD*, asthma, interstial lung disease, neoplasms, CF, TB

81
Q

Features of pneumothorax (7)

A

ipsilateral chest pain, dyspnea, cough, decreased breath sounds, hyperresonnat, decreased tactile remits, mediastinal shift

82
Q

Tx of primary pneumothorax and secondary

A

small

  • observe (10Days resolve)
  • small chest tube

Large/symptoms

  • supplemental O2
  • chest tube

Secondary - chest tube

83
Q

Causes of tension pneumo (3)

A

Mechanical ventilation
CPR
Trauma

mediastinum shifted away, hypotensive w. cardiac filling impaired

84
Q

Tx of tension Pneumo

A

Immediate decompression w/ large bore needle in 2nd/3rd intercostal space midclavicular w/ chest tube

85
Q

Malignant mesothelioma
cause?
Symptoms?

A

2/2 asbestos exposure

dypsnea, weight loss, cough, bloody effusion

not all mesotheliomas malignant, benign(not asbestos) have good prognosis

86
Q

ILD suspected ask about (2)

A

medication Hx - drugs known to be toxoc(chemo, gold, Amiodarone, pencillamine, nitrofurantoin, bleomycin, phenytoin)

Previous jobs ( asbestos, silicon, beryllium, coal)

87
Q

ILD associated granulomaa (4)

A

Sarcoidosis
Histiocytosis X
Weenrs
Churg Strauss syndrome

88
Q

Alveolar filling diseasein ILD (3)

A

goodpastures, idiopathic pulm hemosiderosis, alveolar proteases

89
Q

Honeycombing of lung

A

scarred shrunken lung, end stage finding and poor prognosis

Found in many ILD

90
Q

Dx of Interstitial lung disease - (6)

A

CXR - nonspecific, reticular, ground glass, honey combing

High res CT - best extent of fibrosis

PFTs - restrictive pattern w/ increase w/ FEV1/FVC increased
LOW diffusing capacity DLco

Broncheoalveolar lavage - controversial

Tissue biopsy - often required

UA - glomerular injury

91
Q

Clubbing of nails ?

Think of

A

convexity of nail- distal pharynx enlarges
- 2/2 chronic hypoxia
DDx: pulm disease (lung CA, CF, ILD, empyema, sarcoid, mesothelima); CHF, bacterial endocardits, biliar currhosis, Inflam bowel disasea, PBC

92
Q

Sarcoidosis characteristics (4)

A

noncaseating granulomas on CXR, mtpl organs

  • African American women
  • 75%<40yrs
  • good prognosis usually
93
Q

Clinical features of sarcoidois (7)

A

Constitutional symptoms
Lungs - dry cough, dyspnea
Skin(25%) - erythema nodosum, plaques
Eyes(25%) -impairment w/ uveitis (anterior* v posterior), conjuntivitis
Heart (5%)-arrythmia, blocks, death
Muscular Skeletal(25-50%)- arthalgias and bone lesions
Nervous system - cranial nerve VII, optic nerve

94
Q

Bilateral hilar adenopathy on CXR

A

50% of sarcoidosis cases

95
Q

Weird labs in sarcoidosis(2) and definitive diagnosis

A

Elv ACE enzyme (50%-80%)
hypercalciuria/calcemia

Must see noncaseating granulomas in context of clinical presentation

Also decreased FEV1/FVC, lung volumes, decreased DLco

96
Q

4 stages of Sarcoidosis on CXR

A

1- bilateral hilar adenopathy w/o parenchymal infiltrates
2- adenopathy w/ infiltrates
3- diffuse infiltrates w.o hilar adenopathy
4. pulm fibrosis w/ honecombing

97
Q

Tx of sarcoidosis

A

Most resolve/improve in 2 yrs w/o Tx

Systemic corticosteriods choice, though unclear indications

methotrexate for progressive/refractory

98
Q

Histiocytosis X is?

often found w?

3 variants?

A

Chronic interstitial pneumonia 2/2 abnormal profile of histiocytes (langerhans)

smokers 90% of time

3 variants -

  • eosinopilic granuloma,
  • Systemic forms Letterer Siwe disease + hand scholar christian syndrome
99
Q

Findings and prognosis of histiocytosis

A

find: dyspnea, nonproductive coughm pneumo?, lytic bone lesions? DI

CXR honeycombing and CT cystic lesions

Prognosis variable w/ corticosteriods

100
Q

Wegeners granulomatous is?

A

Rare, characterized by necrotizing granulomatous vasculitis

Affects: Lungs, kidneys, upper airway

101
Q

Manifestations of wegners? (3)

Gold standard diagnosis

A

upper and lower respiratory infections, glomerulonephrtitis, pulm nodules

Tissue biopsy w/ C-ANCA +

102
Q

Rx of Wegeners

A

immunosuppressors and glucocorticoids

103
Q

Churg Strauss Syndrome is?

Presents w/ ?(3)

A

granulomatous vasculitis seen w/ ASTHMA

Pulm infiltrates, rash and eosionophila (significant blood eosinophils common)

systemic vasculitis may result in skin, muscle and nerve lesions

P-ANCA +

104
Q

Tx of Churg strauss?

A

systemic glucocorticoids

105
Q

ANCA associated ILD

pANCA?
cANCA?

A

pANCA - churg strauss, also maybe goodpastures

cANCA - Wegeners granulomatosis

106
Q

Pneumoconiosis is?

A

accumulation od dust in lungs and tissue reacts

Dust implicates: silica, beryllium, asbestos, coal, graphite, carbon, aluminum, talc

107
Q

pleural plaques CXR in?

A

asbestosis

hazy infiltrates w/ bilateral linear opacites

108
Q

egg shell calcifications CXR in ?

A

silcosis

109
Q

Coal workers lungs

A

no significan resp disability, some complicated w/ fibrosis

110
Q

Asbestosis

location
timeline
risks?

A

diffuse interstitial fibrosis of lung -> lower lobes

> 15-20ys post exposure
- increased risk of BRONCHOGENIC carcinoma (w/smoking) and malignant mesotheliomas

111
Q

Silicosis

location
forms
sources

Higher risk of?

A

localized and nodular peribronchial fibrosis (upper)

acute/chronic onset - exertion dyspnea, retricitve pattern

mining, stones, glass cutter

Risk of TB

112
Q

Berylliosis

forms

Test?

A

Acute - oneymonitis
Chronic - ~sarcoidosis w/ granulomas, skin lesions, hypercalcemia

beryllium lymphocyte prolif test

Glucocorticoid therapy

113
Q

Common Hypersensitivity pneumonitis (5)

A 
Farmer's lung - hay
bird breeders - avian droppings
air conditioners
Bagassosis - moldy sugar cane
mushroom worker - compost

leads to restrictive lung disease

114
Q

Hallmark finding of ILD w/ hypersensitivity

A

serum IgG and IgA to inhaled antigen

115
Q

Eosinophilic pneumonia features

A

fever, peripheral eosinophilia

acute/chronic
CXR perioheral pulm infiltrate

Glucocorticoids

116
Q

Goodpastures syndrome is due to?

See?(2)

A

Autoimmune disease 2/2 IgG antibodies against glomerular and alveolar basement membranes

hemorragic pneumonitis and glomerulonephritis(renal failure)

117
Q

Dx of goodpastures w/?(2)

Rx?

A

tissue biopsy

antiglomerular basement membrane proteins

prognosis poor - plasmapheresis, cyclophosphamide, corticosteroids

118
Q

Pulm alveolar preoteinosis is?

See?

CXR?

A

rare- accumulation of surfactant like proteins and phospholipids in alveoli

Dry cough, dyspnea, hypoxia and rales

ground glass appearance w/ bilateral alveolar infiltrates like a bat

119
Q

ground glass appearance w/ bilateral alveolar infiltrates that resemble a bat is?

A

pulmonary alveolar proteinosis

120
Q

Tx for pulmonary alveolar proteinosis?

A

lung lavage, granulocyte colony stimulating factor

NO steriods

121
Q

Idiopathic pulm fibrosis
Characteristics
Dx
Rx

A

gradual onset w/ dyspnea +nonproductive couph, survival 3-7yrs

Dx w/ CXR growing glass/honeycomb/normal; through exclusion, maybe open lung biopsy

Rx is supplemental o2, corticosteriods, transplant

122
Q

Cryptogenic organizing pneumonitis (COP) is?

Rx?

A

inflam lung disease ~ pneumonia on CXR and clinically

often idiopathic

Abx not effective

Spontaneous recovery may occur but usually corticosteroids, can have relapse w. cessation

123
Q

Radiation pneumonitis is?

CXR is?

Tx?

A

5-15% of thoracic irradiation for lung/brast/ lymphoma/thyroma CA

Acute 6months -chronic 2yrs

fever, cough, fullness, dypnea, pleuritic chest pain, hemoptysis

CXR normal, CT* diffuse infiltrates

Corticosteroids

124
Q

Severe hypercapnia effect on cerebral vasculature

A

increased intracranial pressure w/ papilladema, HA, impaired consciousness, coma

125
Q

3 things needed to determine mechanism of hypoxemia

A

PaCO2

A-a gradient(normal if hypoventilation or low inspired PO2 is only mech)

response to oxygen

V/Q mismatch or shunting shows both PaCO2 and A-a gradient elevated

126
Q

Ventilation is

A

elimination of CO2

127
Q

Hypoxia is? on ABG

A

PaO2 50mmHg

128
Q

Hypercapneia is ?

A

partial pressure of CO2 >50mmHg

129
Q

Insult to which systems can lead to acute respiratory distress?(6)

A

CNS- drugs, stroke, trauma
Neuromuscular -myasthenia gravis, polio, gullian barre, ALS
Upper airway - obstruction, spasm
thorax and pleua - mechanical restricitoin- kyphosis, flail chest
CV - CHF, valve disease, PE, anemia
Lowe airway -asthma, COPD, pneumonia

130
Q

2 types of acute respiratory failure

A

Often overlap

hypoxemic respiratory failure - O2< 90%,
-V/Q mismatch and intrapulm shunting are major pathophys mech

Hypercarbic respiratory failure - decrease in vent or increase in physiologic dead space -> Co2 retention, can be lung disease, also neuromuscular

131
Q

ventilation and oxygenation are UNRELATED

A

O2 sat can be 100% but Pt has very high PaCO2 and vent failure

132
Q

V/Q mismatch leads to?

A

hypoxia w/o hypercapnia
most common hypoxemia

Responds to oxygen

133
Q

Intrapulmonary shunts is?

Causes?

A

little/none ventilation in perfuse area (collapsed/fluid filled alveoli) -> venous blood to arterial w/o oxygenation

atelectasis, fluid buildup in alveoli (pneumonia, edema)

Hypxoa NOT responsive to O2

134
Q

Causes of Respiratory failure (5)

A

V/Q mismatch - Chronic lung disease

Intrapulm shunting - pneumonia/edema

Hypoventilation - hypercapneia

Increased CO2 production - sepsis, DKA, hyperthermia

Diffusion impairment - ILD: hypoxemia w/out hypercapnea

135
Q

Alveolar-arterial oxygen differece is normal when?

A

hypoventilation is cause of hypoxemia

increased in most others

136
Q

Oxygen use in respiratory failure

  • hypoxemic
  • hypercarbic
A

hypoxemic: lowest concentration to avoid toxicity, free radical production

hypercarbic - concerns w/ use due to hypoxemia drives RR, slowing it down and increasing PaCO2

137
Q

Use of NPPV (noninvassive positive pressure ventilation) vs intubation for respiratory failure

A

NPPV/CPAP in conscious pts only - intact, awake and protects airway

If cannot breath intubate

138
Q

Adult respiratory Distress ARDS is

A

diffuse inflammatory process of both lungs where PMNs go cra-cra

  1. Massive intrapulmonary shunting of blood -> hypoxemia w/ NO improvement on 100% O2
    - increase in alveolar cap permeability causes fluid build up
  2. Decreased pulm compliance
  3. increased dead space
  4. low vital capacity

not the primary disease, a response

139
Q

Sepsis or septic shock be concerned for

A

ARDS

140
Q

Causes of ARDS?

A 
Sepsis*
Aspiration of gastric contents
Severe trauma/Fxrs(Pancreatitis, mtpl/massive transfusion, near drowning)
Drug overdose
INtracranial HTN
Cardiopulm bypass
141
Q

Hypoxemia refractory to O2 Tx, bilateral diffuse pulm infiltrates on CXR, No evidence of CHF (PCWP <18)

Think of

A

ARDS

142
Q

Dx of ARDS

A

CXR - bilateral infiltrates w/o CHF

ABGs - hypoxemia, Resp Alkalosis -> resp acidosis as breathing work increases

Pulm artery catheter - differentiate between ARDS and cariogenic pulm edema (<18mm HG ARDS likely)

Bronchoscope?- if ill

143
Q

TX of ARDS (5)

A
  1. Oxygenate
  2. Mechanical vent w/PEEP required
  3. Fluid management - pull fluid w/ pressors
  4. Tx cause
  5. Nutrition w/ tube feeding
144
Q

Mechanical ventilate when(5)

A

significant respiratory distress
impaired/reduced consciousness- can’t protect airway
Metabolic acidosis that Pt can’t compensate
Resp muscle fatigue
Significant hypoxemia PaO250mmHg

145
Q

Assisted control vent

A

gives breath at predetermined rate if not met by the Pt .

Predetermined tidal volume that is the same whether Pt initiated or machine

146
Q

Synchronous intermittent mandatory ventiliation

A

Breath rate minimum for machine vs PT

However additional breaths do not have same tidal volume as machine breaths

147
Q

CPAP -

A

Positive pressure 0-20mmHg given continuously but no vole breaths delivered

Pt breathes on own

PEEP and pressure support

148
Q

Pressure support vent

A

during weaning.

Pressure only when Pt initiates brath

149
Q

I: E ratio

A

inspiratory expiratory ratio - duration of time in each phase 1:2 usually

150
Q

Settings on Vent

A
  • I:E ratio

- FiO2 start at 100 but decrease as able-> barotrauma if his

151
Q

Complications of vents

A

ET tube does not prevent aspiration from occuring

nosocomial pneumonia risk >72 hrs

Traceomalcea occurs w/ prolonged ET tube use - tracheostomy

152
Q

Pulm HTN defined (7 causes)

A

Mean arterial pressure > 25mmHg at rest, 30mmHg exercise

Passive - venous blockage (ex mitral stenosis, LV failure
Hyperkinetic - high flow (L->R shunts)
Obstructive type - in pulm Arteries (PE, stenosis)
Obliterative type - small pulm inflam (Primary pulm HTN, collagen vascular disease)
Vasoconstrictive - hypoxia induced (COPD, OSA)
INtrathoracic pressure - mech vent, COPD
Blood viscosity - Polycythemia

153
Q

Cause of pulm HTN tests?

A

CXR, PFTs, ABGs, serology, echo, Cardiac cath

If unknown then ->V/Q

154
Q

Symptoms of pulm HTN

A

Hard to determine - dyspnea, fatigue, chest pain, syncope

Eventual R HF signs

**Loud pulm component of second heart sound (P2) and subtle sternum lift may be only finding

155
Q

Dx of Pulm HTN w/

A

ECG - RV Hypertrophy

Echo - dialated pulm art, hypertrophy, abnormal septum movement

156
Q

Primary pulmonary HTN

who?

A

Dx of exclusion
-> thickened pulm arteriolar walls which compounds the problem

young/middle age women

poor prognosis
CXR show clear lung fields*

157
Q

Tx of primary pulmonary HTN

A

pulm vasodialators - IV prostacycline- epoprostenol

CCBs

Warfarin - INR~2

158
Q

Cor pulmonale def?

most common causes?

A

RV hypertrophy w/ RV failure from pulm HTN 2/2 pulm disease

COPD*, PE, ILD, asthma, sleep apnea,

159
Q

Pulm embolism sources/situations (6)

A 
DVT - usual
Fat - long bone fractures
Amniotic fluid - peri birth
Air - trauma to thorax, venous/arterial lines
Septic embolism - IV drugs
Schistosomiasis
160
Q

Dx of Cor pulmonale - 3 tests

A

CSR - enlarged RA, RV, pulm arteriers
ECG - R axis deviation, P pulmonale
Echo - RV dysfunction, normal LV

161
Q

long bone Fx w/ AMS and petechiae think

A

fat embolism

162
Q

Tx of Cor pulmonale

A

Tx underlying disorder
diuretcs cautiosly, preload dependent
long term oxygen?

163
Q

Most DVT PE’s originate from?

A

deep veins above the knee, occasionally the pelvis

calf veins have low risk, instead progression risk

164
Q

Risk factors for DVT

A 
Age >60
Malignancy
Prior Hx
hereditary hypercoaguable state 
Prolonged immobilization
Cardiac disease - CHF
obesity
Nephrotic syndrome
Major surgery
major trauma 
Pregnancy
165
Q

PE recurrences and prognosis

A

usually clinically silent, but recurrence is common
Undiagnosed motality -> 30%
Diagnosed mortality is 10% in 1st hr, if survive 30% die of recurrent PE if untreated

166
Q

Signs + Symptoms of PE - PIOPED study

A

Dyspnea (73%); pleuritic chest pain (66%), cough (37%); hemoptysis (13%); syncope if large

tachypnea (70%), rales (51%), Tachycardia (30%), S4, low grade fever

167
Q

Work of PE

A

Intraluminal filling defects on HELICAL CT - worry about renal Pts and IV contrast
DVT on US w/ clinical suspicion
+ pulm angiogram

r/o

  • low prob V/Q scan
  • pulm angio
  • d dimer w/ low suspicion
168
Q

modified Wells Criteria for PE (7 factors)

A

4+

Symptoms/Signs - 3
Alt Dx less likely - 3
HR >100   -1.5
Immobile >3 days 1.5
Prior Hx - 1.5
Hemoptysis -1.5
Malignancy -1
169
Q

Definitive Dx of PE is

A

Pulm angiogram but invasive

0,5% mortality risk and rarely done

170
Q

D dimer role in PE

A

negative test r/o, looks for fibrin degradation product

positive tells you shit

171
Q

Initial TX of PE

A

Heparin , start Warfarin as well to get to goal INR - to prevent future clots (does not lyse original)

Oxygen

172
Q

Contraindications to heparin

A

active bleeding
uncrontrolled HTN
recent stroke
heparininduced thrombocytopenia

173
Q

Thrombolytic therapy in PE

A

speeds up lysis of clot but no evidence improves mortality

maybe in Pts hemodynamically unstable or R HF

174
Q

IVC indications(4)

A

Once placed have high risk of recurrent DVT but lower risk of PE

Contraindicated to antocoag w/ documented DVT or PE
Complication of current Tx
Failure of adequate anticoag w/ recurrent DVT/PE
Pt w/ low pulm reserve

175
Q

Pulm Aspiration consequences

Which lung most often affected?

A

Risk of pneumonia in 40% 2-4 days after w/ mixed organisms

Right side - more straight path, esp lower segments R Upper lobe and Upper segments of R lower lobe

176
Q

Risks for pulm aspiration

A

reduced level of consciousness, alcoholism, extubation, excessive vomitting, Tube feeds/trachs, anesthesia/surgery, neuromuscular disease, esophageal disorders

177
Q

Tx of pUlm aspiration

A

witnessed -> ABCs
Aspiration pneumonia give Abx (penicillin or cloned)
Obstruction - bronchoscope

178
Q

Most common causes of acute dyspnea(5)

A

CHF exacerbation, pneumonia, bronchospasm, PE , anxiety

overall a lot of cardio, pulm, psychiatric, chest wall abnormalities, neuromuscular and systemic disease

179
Q

Paroxysmal nocturnal dyspnea

A

in COPD, excessive airway secrestions accumulate at night -> airway obstruction and dyspnea to awaken at night,

180
Q

Baseline O2 sats in COPD pts

A

may be low, drives RR

Chronic CO2 retainers have normal pH but elv bicarb

181
Q

Massive hemoptysis definition and most common cause

A

> 600mL over 24hrs

commonly bronchiectasis and bleeding diathesis

TX w/ bronchial artery embolism or ballon tampanode

182
Q

Ddx of hemoptysis

A

Common causes
- bronchitis (50%), lung CA, TB, bronchiectasis, pneumonia, idiopathi (30%)

Others - good pastures, PE, aspergilloma, mitral stenosis, hemophilia

183
Q

DLco

low causes vs High

A

CO is diffusion limited gas

Low- emphysema, sarcoidosis, fibrosis, pulm vas disease, anemia

High - asthma (increased Capilalry blood volume), obesity, intracardiac L-R shunt, obesity, exercise, Pulm hemorrhage

184
Q

normal V/q mismatch

A

around 0.8 meaning there normally is less perfusion than ventillation (some shunting)

185
Q

Eval of hemoptysis - 3 exams

A

CXR
Bronchioscope, even if normal CXR and concern for CA
CT chest

Med 1 (11 decks)

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