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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
Avoid what medication in asthmatics?
beta blockers
26
Side effects of inhaled corticoseriods(2)
Sore throat oral candidiasis use a spacer or rinse mouth
27
Tests to order in acute exacerbation (3)
PEF - decreased ABG - A-a increased CXR - r.o infiltrates
28
Mild intermittent asthma - def - Rx
symptoms <2 /wk just a SA beta 2agonist
29
Mild persistent asthma - def - Rx
symptoms >2x/wk but not everyday low dose inhaled corticosteroid
30
Moderate persistant asthma - def - Rx
daily symptoms, frequent exacerbations - daily inhaled cortiocosteriod(low dose) /methylxanthine/antileukotriene
31
Severe persistent - def - Rx
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
32
Role of cromolyn sodium in asthma
only PPX prior to exercise
33
complications of asthma (3)
status asthmaticus - no response to standard meds acute resp failure - muscle fatigue Pneumo/atelectasis/pneumomediastinum
34
TX of acute severe asthma exacerbation
``` 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? ```
35
Nasal polyps and asthma think
ASA sensitive asthma avoid ASA and NSAIDs
36
Bronchiectasis
perm abnormal dilation/destruction of bronchial walls w/ cilia damage infection w/ obstruction percipitates
37
Most common cause of bronchiectasis
CF - half of all cases infection, hummoral immunodeficiency, airway obstruction
38
Features of bronchiectasis
chronic cough w/ mucopurulent, fowl smeeling sputum dyspnea hemoptysis - rupture near surface recurrent/persistent pneumonia
39
Dx of broniectasis
High res CT** PFTs show obstruction CXR is abnormal but nonspecific maybe bronchoscope
40
TX of bronchiectsais
Abx for exacebations | Bronchial hygene - hydration, chest physiotherpy, bronchodialatores
41
CF defect? 5 systems hit
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 ```
42
pneumonia infections in CF think of
Pseudomonas
43
Tx of CF
pancreatic enzymes, chest physio, fat soluble vitamins, vaccines, inhaled recombinant human deoxyribonuclease
44
2 categories and 5 types of Lung CA and prevalence Location
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
45
Smoking has lowest risk for which lung CA
adenocarcinoma otherwise 85% of all lung CA
46
Other than smoking, risks for lung CA
asbestos, radon in basements, COPD
47
NSCLC staged by? SCLC staged by?
TNM system SCLC - limited (in chest -> supraclavicular nodes - no cervical or axillary) - extensive: outside
48
local manifestations of lung CA - commonly squamous (2)
airway involvement - wheezing, cough, hemoptysis, Recurrent postbstructive pneumonia
49
Superior vena cava syndrome is?
5% of Pts w. lung CA -> obstruction of SVC facial fullness, falial/arm edema, dilated veins over arms/chest, JVD
50
Local invasion of lung CA can lead to (6)
``` superior vena cava syndrome phrenic nerve pasly recurrent layngeal nerve palsy horner's syndome Pancoast tumors malignant pleural effusion - BAD ```
51
Horner's syndrome (3)
unilateral facial anhidrosis, ptosis and miosis can be 2/2 invasion of cervical sympathetic chancy apical tumor
52
Pancoast tumor is?
Superior sulcus tumor - C8-T1-T2, Shoulder pain radiating down the arm; weakness, horners (60%) Usually squamous cell CA
53
Paraneoplastic syndromes in lung CA (4)
SCLC: SIADH (10%); Ectopic ACTH; Eaton-Lambert Syndrome (myasthenia gravis picture w/proximal weakness) Squamous Cell: rPTH
54
Eaten Lambert Syndrome
Seen in SCLC - | similar to myasthenia graves, w/ proximal weakness, diminished DTRs, paresthesias
55
3 tests in a Lung CA Dx
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
56
Role of transthoracic needles in lung CA
suspicious pulm masses or lesions, peripheral lesions | Only in select Pts
57
Prognosis of lung CA
5yr survival is 15% | 85% of SCLC have extensive disease at time
58
Tx of NSCLC
1. Surgery: if METS, then NOT a candidate, can have recurrence 2. Radiation adjunct 3. Chemo?
59
Tx of SCLC
limited disease: Chemo and radiation Extensive: Chemo alone initially -> ppx radiation
60
Solitary Pulm Nodule DDs 1st thing?
infectous granuloma, bronchiogenic carcinoma, hamartoma, bronchail adenoma get CXR, stable 2 yrs benign
61
Solitary Pulm nodule suspicious if: (6)
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
62
SPN on CXR and difference if >1cm vs <1cm w/ interned probability nodules
1cm get a PET scan High prob biopsy
63
Ddx of Anterior mediastinal mass (4)
thyroid teratogenic tumors thymoma lymphoma
64
Ddx of Middle mediastinal mass(5)
``` lung CA lymphoma aneurysms cysts morgagni hernia ```
65
Ddx of posterior mediastinum (5)
``` neurogenic tumors, esophageal masses enteric cysts aneurisms Bochdaleks hernia ```
66
Features of mediastinal masses
2/2 compression Cough, chest pain, dyspnea, post obtrictive pneumonia, dysphagia, SVC syndrome, compression of nerves (recurrent laryngea, horners, phrenic)
67
Transudative effusion causes(7)
CHF; Cirrosis, PE, Nephrotic, peritoneal dialysis, hypalbumineria, atelectasis elv capillary pressures or parental pleura/decreased oncotic pressure
68
Exudative effusion causes (5)
Infection (bacteral/TB); malignancy(lung, breast, lymphoma); viral infection; PE; Collagen vascular disease increased perm of pleural surfaces or decreased lymph flow
69
If exudative effusion suspected get what tests?
differential cell count Glucose pH 0.5 LDH-pleural/LDH serum = >0.6
70
Chylothorax
milky oplascent fluid (lymph) in pleural space
71
empyema
pus in pleural space
72
bloody effusion think?
possible malignancy
73
Tests for effusion (3)
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
74
Parapneumonic effusion vs empyema
noninflected pleural effusion 2/2 bacterial pneumonia vs pleural is infected
75
empymea causes
exudative pleural effusion untreated, most often 2/2 bacterial pneumonia
76
Tx of empyema
Aggressive drainage and ABx | infection is resistant and common recurrence
77
Always get a CXR post these procedures to r/o pneumothorax (3)
thransthoracic needle aspiration thoracentesis central line placement
78
Tx w/ ___ hastens reaborbtion of air in pleural space post pneumo
oxygen
79
Risk factor of spontaneouss pneumo
tall, lean young men recurrence 50% in 2 yrs
80
Secondary pneumothorax due to
lung diease: COPD*, asthma, interstial lung disease, neoplasms, CF, TB
81
Features of pneumothorax (7)
ipsilateral chest pain, dyspnea, cough, decreased breath sounds, hyperresonnat, decreased tactile remits, mediastinal shift
82
Tx of primary pneumothorax and secondary
small - observe (10Days resolve) - small chest tube Large/symptoms - supplemental O2 - chest tube Secondary - chest tube
83
Causes of tension pneumo (3)
Mechanical ventilation CPR Trauma mediastinum shifted away, hypotensive w. cardiac filling impaired
84
Tx of tension Pneumo
Immediate decompression w/ large bore needle in 2nd/3rd intercostal space midclavicular w/ chest tube
85
Malignant mesothelioma cause? Symptoms?
2/2 asbestos exposure dypsnea, weight loss, cough, bloody effusion not all mesotheliomas malignant, benign(not asbestos) have good prognosis
86
ILD suspected ask about (2)
medication Hx - drugs known to be toxoc(chemo, gold, Amiodarone, pencillamine, nitrofurantoin, bleomycin, phenytoin) Previous jobs ( asbestos, silicon, beryllium, coal)
87
ILD associated granulomaa (4)
Sarcoidosis Histiocytosis X Weenrs Churg Strauss syndrome
88
Alveolar filling diseasein ILD (3)
goodpastures, idiopathic pulm hemosiderosis, alveolar proteases
89
Honeycombing of lung
scarred shrunken lung, end stage finding and poor prognosis Found in many ILD
90
Dx of Interstitial lung disease - (6)
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
Clubbing of nails ? Think of
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
Sarcoidosis characteristics (4)
noncaseating granulomas on CXR, mtpl organs - African American women - 75%<40yrs - good prognosis usually
93
Clinical features of sarcoidois (7)
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
Bilateral hilar adenopathy on CXR
50% of sarcoidosis cases
95
Weird labs in sarcoidosis(2) and definitive diagnosis
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
4 stages of Sarcoidosis on CXR
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
Tx of sarcoidosis
Most resolve/improve in 2 yrs w/o Tx Systemic corticosteriods choice, though unclear indications methotrexate for progressive/refractory
98
Histiocytosis X is? often found w? 3 variants?
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
Findings and prognosis of histiocytosis
find: dyspnea, nonproductive coughm pneumo?, lytic bone lesions? DI CXR honeycombing and CT cystic lesions Prognosis variable w/ corticosteriods
100
Wegeners granulomatous is?
Rare, characterized by necrotizing granulomatous vasculitis Affects: Lungs, kidneys, upper airway
101
Manifestations of wegners? (3) Gold standard diagnosis
upper and lower respiratory infections, glomerulonephrtitis, pulm nodules Tissue biopsy w/ C-ANCA +
102
Rx of Wegeners
immunosuppressors and glucocorticoids
103
Churg Strauss Syndrome is? Presents w/ ?(3)
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
Tx of Churg strauss?
systemic glucocorticoids
105
ANCA associated ILD pANCA? cANCA?
pANCA - churg strauss, also maybe goodpastures cANCA - Wegeners granulomatosis
106
Pneumoconiosis is?
accumulation od dust in lungs and tissue reacts Dust implicates: silica, beryllium, asbestos, coal, graphite, carbon, aluminum, talc
107
pleural plaques CXR in?
asbestosis hazy infiltrates w/ bilateral linear opacites
108
egg shell calcifications CXR in ?
silcosis
109
Coal workers lungs
no significan resp disability, some complicated w/ fibrosis
110
Asbestosis location timeline risks?
diffuse interstitial fibrosis of lung -> lower lobes >15-20ys post exposure - increased risk of BRONCHOGENIC carcinoma (w/smoking) and malignant mesotheliomas
111
Silicosis location forms sources Higher risk of?
localized and nodular peribronchial fibrosis (upper) acute/chronic onset - exertion dyspnea, retricitve pattern mining, stones, glass cutter Risk of TB
112
Berylliosis forms Test?
Acute - oneymonitis Chronic - ~sarcoidosis w/ granulomas, skin lesions, hypercalcemia beryllium lymphocyte prolif test Glucocorticoid therapy
113
Common Hypersensitivity pneumonitis (5)
``` Farmer's lung - hay bird breeders - avian droppings air conditioners Bagassosis - moldy sugar cane mushroom worker - compost ``` leads to restrictive lung disease
114
Hallmark finding of ILD w/ hypersensitivity
serum IgG and IgA to inhaled antigen
115
Eosinophilic pneumonia features
fever, peripheral eosinophilia acute/chronic CXR perioheral pulm infiltrate Glucocorticoids
116
Goodpastures syndrome is due to? See?(2)
Autoimmune disease 2/2 IgG antibodies against glomerular and alveolar basement membranes hemorragic pneumonitis and glomerulonephritis(renal failure)
117
Dx of goodpastures w/?(2) Rx?
tissue biopsy antiglomerular basement membrane proteins prognosis poor - plasmapheresis, cyclophosphamide, corticosteroids
118
Pulm alveolar preoteinosis is? See? CXR?
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
ground glass appearance w/ bilateral alveolar infiltrates that resemble a bat is?
pulmonary alveolar proteinosis
120
Tx for pulmonary alveolar proteinosis?
lung lavage, granulocyte colony stimulating factor NO steriods
121
Idiopathic pulm fibrosis Characteristics Dx Rx
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
Cryptogenic organizing pneumonitis (COP) is? Rx?
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
Radiation pneumonitis is? CXR is? Tx?
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
Severe hypercapnia effect on cerebral vasculature
increased intracranial pressure w/ papilladema, HA, impaired consciousness, coma
125
3 things needed to determine mechanism of hypoxemia
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
Ventilation is
elimination of CO2
127
Hypoxia is? on ABG
PaO2 50mmHg
128
Hypercapneia is ?
partial pressure of CO2 >50mmHg
129
Insult to which systems can lead to acute respiratory distress?(6)
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
2 types of acute respiratory failure
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
ventilation and oxygenation are UNRELATED
O2 sat can be 100% but Pt has very high PaCO2 and vent failure
132
V/Q mismatch leads to?
hypoxia w/o hypercapnia most common hypoxemia Responds to oxygen
133
Intrapulmonary shunts is? Causes?
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
Causes of Respiratory failure (5)
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
Alveolar-arterial oxygen differece is normal when?
hypoventilation is cause of hypoxemia increased in most others
136
Oxygen use in respiratory failure - hypoxemic - hypercarbic
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
Use of NPPV (noninvassive positive pressure ventilation) vs intubation for respiratory failure
NPPV/CPAP in conscious pts only - intact, awake and protects airway If cannot breath intubate
138
Adult respiratory Distress ARDS is
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
Sepsis or septic shock be concerned for
ARDS
140
Causes of ARDS?
``` Sepsis* Aspiration of gastric contents Severe trauma/Fxrs(Pancreatitis, mtpl/massive transfusion, near drowning) Drug overdose INtracranial HTN Cardiopulm bypass ```
141
Hypoxemia refractory to O2 Tx, bilateral diffuse pulm infiltrates on CXR, No evidence of CHF (PCWP <18) Think of
ARDS
142
Dx of ARDS
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
TX of ARDS (5)
1. Oxygenate 2. Mechanical vent w/PEEP required 3. Fluid management - pull fluid w/ pressors 4. Tx cause 5. Nutrition w/ tube feeding
144
Mechanical ventilate when(5)
significant respiratory distress impaired/reduced consciousness- can't protect airway Metabolic acidosis that Pt can't compensate Resp muscle fatigue Significant hypoxemia PaO250mmHg
145
Assisted control vent
gives breath at predetermined rate if not met by the Pt . Predetermined tidal volume that is the same whether Pt initiated or machine
146
Synchronous intermittent mandatory ventiliation
Breath rate minimum for machine vs PT However additional breaths do not have same tidal volume as machine breaths
147
CPAP -
Positive pressure 0-20mmHg given continuously but no vole breaths delivered Pt breathes on own PEEP and pressure support
148
Pressure support vent
during weaning. Pressure only when Pt initiates brath
149
I: E ratio
inspiratory expiratory ratio - duration of time in each phase 1:2 usually
150
Settings on Vent
- I:E ratio | - FiO2 start at 100 but decrease as able-> barotrauma if his
151
Complications of vents
ET tube does not prevent aspiration from occuring nosocomial pneumonia risk >72 hrs Traceomalcea occurs w/ prolonged ET tube use - tracheostomy
152
Pulm HTN defined (7 causes)
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
Cause of pulm HTN tests?
CXR, PFTs, ABGs, serology, echo, Cardiac cath If unknown then ->V/Q
154
Symptoms of pulm HTN
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
Dx of Pulm HTN w/
ECG - RV Hypertrophy | Echo - dialated pulm art, hypertrophy, abnormal septum movement
156
Primary pulmonary HTN who?
Dx of exclusion -> thickened pulm arteriolar walls which compounds the problem young/middle age women poor prognosis CXR show clear lung fields*
157
Tx of primary pulmonary HTN
pulm vasodialators - IV prostacycline- epoprostenol CCBs Warfarin - INR~2
158
Cor pulmonale def? most common causes?
RV hypertrophy w/ RV failure from pulm HTN 2/2 pulm disease COPD*, PE, ILD, asthma, sleep apnea,
159
Pulm embolism sources/situations (6)
``` DVT - usual Fat - long bone fractures Amniotic fluid - peri birth Air - trauma to thorax, venous/arterial lines Septic embolism - IV drugs Schistosomiasis ```
160
Dx of Cor pulmonale - 3 tests
CSR - enlarged RA, RV, pulm arteriers ECG - R axis deviation, P pulmonale Echo - RV dysfunction, normal LV
161
long bone Fx w/ AMS and petechiae think
fat embolism
162
Tx of Cor pulmonale
Tx underlying disorder diuretcs cautiosly, preload dependent long term oxygen?
163
Most DVT PE's originate from?
deep veins above the knee, occasionally the pelvis calf veins have low risk, instead progression risk
164
Risk factors for DVT
``` Age >60 Malignancy Prior Hx hereditary hypercoaguable state Prolonged immobilization Cardiac disease - CHF obesity Nephrotic syndrome Major surgery major trauma Pregnancy ```
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PE recurrences and prognosis
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
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Signs + Symptoms of PE - PIOPED study
Dyspnea (73%); pleuritic chest pain (66%), cough (37%); hemoptysis (13%); syncope if large tachypnea (70%), rales (51%), Tachycardia (30%), S4, low grade fever
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Work of PE
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
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modified Wells Criteria for PE (7 factors)
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 ```
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Definitive Dx of PE is
Pulm angiogram but invasive 0,5% mortality risk and rarely done
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D dimer role in PE
negative test r/o, looks for fibrin degradation product | positive tells you shit
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Initial TX of PE
Heparin , start Warfarin as well to get to goal INR - to prevent future clots (does not lyse original) Oxygen
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Contraindications to heparin
active bleeding uncrontrolled HTN recent stroke heparininduced thrombocytopenia
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Thrombolytic therapy in PE
speeds up lysis of clot but no evidence improves mortality maybe in Pts hemodynamically unstable or R HF
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IVC indications(4)
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
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Pulm Aspiration consequences Which lung most often affected?
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
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Risks for pulm aspiration
reduced level of consciousness, alcoholism, extubation, excessive vomitting, Tube feeds/trachs, anesthesia/surgery, neuromuscular disease, esophageal disorders
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Tx of pUlm aspiration
witnessed -> ABCs Aspiration pneumonia give Abx (penicillin or cloned) Obstruction - bronchoscope
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Most common causes of acute dyspnea(5)
CHF exacerbation, pneumonia, bronchospasm, PE , anxiety overall a lot of cardio, pulm, psychiatric, chest wall abnormalities, neuromuscular and systemic disease
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Paroxysmal nocturnal dyspnea
in COPD, excessive airway secrestions accumulate at night -> airway obstruction and dyspnea to awaken at night,
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Baseline O2 sats in COPD pts
may be low, drives RR Chronic CO2 retainers have normal pH but elv bicarb
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Massive hemoptysis definition and most common cause
>600mL over 24hrs commonly bronchiectasis and bleeding diathesis TX w/ bronchial artery embolism or ballon tampanode
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Ddx of hemoptysis
Common causes - bronchitis (50%), lung CA, TB, bronchiectasis, pneumonia, idiopathi (30%) Others - good pastures, PE, aspergilloma, mitral stenosis, hemophilia
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DLco low causes vs High
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
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normal V/q mismatch
around 0.8 meaning there normally is less perfusion than ventillation (some shunting)
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Eval of hemoptysis - 3 exams
CXR Bronchioscope, even if normal CXR and concern for CA CT chest

Med 1 (11 decks)

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