Pulmonary Flashcards
Etiologies of obstructive pulmonary disease
“ABCO”
Asthma
Bronchiectasis
COPD/CF
Obstruction (tracheal/bronchial)
FEV1/FVC ratio of ____ suggests obstruction
FEV1/FVC ratio < 70%
FEV1/FVC ratio ____ suggests restriction
> 70%
Other conditions that can cause wheezing other than asthma?
COPD, foreign body. anything that causes airway constriction
Asthma should be suspected in kids with multiple episodes of ______
croup and URIs associated with dyspnea
Name some common triggers for asthma
allergens, URIs, cold air, exercise, drugs, stress
Samter’s triad
Asthma, aspirin sensitivity, nasal polyps
late signs of asthma
no wheezing. no breath sounds. cyanosis. decreased O2 sat.
When PFTs are normal but asthma is still suspected what challenge test can be helpful?
Methacholine
expected ABG for acute asthma exacerbation early on?
respiratory alkalosis
If a patient with asthma has anormalizing PCO2 and a respiratory acidosis- what might this mean?
Impending respiratory failure. Patient might not be able to work as hard to blow off PCO2
CXR for asthma
normal appearance to hyperinflation and flattening of diaphragm
consider intubation for asthma when PCO2 > ___ or PO2 < ____
50, 50 mm Hg
Cromolyn is useful for?
exercise induced bronchospasm and only as prophylaxis not in acute attacks
Mild intermittent asthma symptoms occur?
< 2 days/week
< 2 night/month
treat mild intermittent asthma with?
PRN short acting B-dilator
FEV in mild intermittent asthma is?
> 80%
Mild persistent asthma symptoms?
> 2 X/week but < 1/day
> 2X/month
Meds for mild persistent asthma
daily low dose corticosteroid
PRN albuterol
Mod persistent asthma symptoms
daily
> 1 night/week
Meds for mod persistent asthma
low-medium inhaled corticosteroid and long acting inhaled B agonist (salmeterol)
PRN albuterol
Severe persistent asthma symptoms
continual
frequent
Meds for severe persistent asthma
high dose inhaled CS and long acting inhaled B-agonist
Possible PO CS
PRN albuterol
Bronchiectasis
caused by recurrent infection and inflammation in bronchi/bronchioles that lead to fibrosis, remodeling, permanent dilation of bronchi
CXR for bronchiectasis shows
increased bronchovas markings and “tram lines”
dilated airways and ballooned cysts
Presentation of bronchiectasis
chronic productive cough of yellow/green sputum, dyspnea, hemoptysis, hallitosis
Treatment for bronchiectasis:
Meds:
Lifestyle:
Surgery:
Meds: antibiotics for bacterial infections. inhaled CS
Lifestyle: cough control, postural drainage, chest PT
Surgery: lobectomy for localized or lung transplant for severe
Diagnosis of chronic bronchitis
productive cough for >3 months per year for 2 consecutive years
Emphysema diagnosis
destruction and dilation of structures distal to terminal bronchioles (pathologic diagnosis)
Smoking causes _____ destruction while A1AT causes _____ destruction
centrilobular ; panlobular
what are the only two interventions proven to improve survival in COPD patients?
Smoking cessation and O2 therapy
Treatments for COPD
“COPD”
C: corticosteroid
O: O2
P: prevention (smoking cessation and pneumo and influenza vaccines)
D: dilators (B-ag, anticholinergics)
Parenchymal bullae and subpleural blebs are pathognomonic for?
emphysema
Etiologies of restrictive lung disease
Alveolar: edema, hemorrhage, pus
Interstitial: ILD
Inflammatory: sarcoid, cryptogenic organizing pneumonia
Idiopathic pulmonary fibrosis
Neuromuscular: Myesthenia gravis, phrenic nerve palsy, myopathy
Thoracic wall: kyphoscoliosis, obesity, ascites, pregnancy, ankylosing spondylitis
Interstitial lung disease
heterogenous group of disorders characterized by inflammation and/or fibrosis of interstitium
What are the exposure related types of interstitial lung disease?
coal workers pneumoconiosis, asbestosis, silicosis, berylliosis, hypersensitivity pneumonitis, radiation
Systemic disease or connective tissue disease associated interstitial lung disease?
polymyositis/dermatomyositis, sarcoidosis, amyloidosis, vasculitis, dermatomyositis, CREST
What might you see on CT for patients with ILD?
Honey-combing (reticular, nodular, ground glass pattern)
Presentation of Interstitial lung disease
shallow, rapid breathing, dyspnea on exertion, chronic non-productive cough. cyanosis, inspiratory squeeks or velcro-like crackles, clubbing, right heart failure
List medications or interventions that can cause or contribute to interstitial lung disease?
Amiodoarone, busulfan, nitrofurantoin, bleomycin, radiation, long term high O2 concentration
PFTs would show
normal FEV/FVC. Low TLC, low FVC, low diffusing capacity
Surgical biopsy is the definitive test used to confirm?
IPF
In late stages of IPF, the only treatment may be?
lung transplantation
Lofgren syndrome
type of sarcoidosis with a triad: arthritis, erythema nodosum, bilateral hilar adenopathy
Systemic sarcoidosis is characterized by what on histology
non-caseating granulomas
Sarcoid can present as
fever, cough, malaise, weight loss, dyspnea, arthritis
Diagnosis of sarcoid CXR/CT: Biopsy: PFTs: Other findings:
CXR/CT: lymphadenopathy and nodules
Biopsy: definitive test **- noncaseating granuloma
PFTs: restrictive or obstructive with decreased diffusion capacity
Other: elevated serum ACE levels, hypercalcemia, hypercalciuria, increased alk phos
Clinical features of Sarcoidosis
“GRUELING”
G: granuloma aRthritis Uveitis Erythema nodosum Lymphadenopathy (hilar) Interstitial fibrosis Negative TB Gammaglobulinemia
Treatment for sarcoid?
systemic corticosteroids for deteriorating resp function, constitutional symptoms, hypercalcemia, extrathoracic organ involvement
Hypersensitivity Penumonitis
alveolar thickening and noncaseating granuloma caused by environmental exposure to (mold, hot tub, down feathers)
Acute presentation of hypersensitivity pneumonitis?
dyspnea, fever, malaise, shivers, cough starting 4-6 hours after exposure
Upper lobe fibrosis is a common feature in?
chronic hypersensitivity pneumonitis
Name the common pneumoconiosis
asbestosis, berylliosis, silicosis, coal miners
history, imaging finding, complications: asbestosis
hx: manufacture tile, brakes, insulation, construction, demolition, shipbuilding (15-20 years after exposure)
Imaging: linear opacities** at lung bases and interstitial fibrosis. calcified pleural plaques
Complications: increased mesothelioma risk (rare) and lung cancer. risk of lung cancer is higher in smokers
history, imaging finding, complications: coal miners
hx: coal mine
Imagine: small nodular (<1cm) opacities in upper lung lobe
Complication: progressive massive fibrosis
history, imaging finding, complications: silicosis
hx: work in mines or quarries or with glass, pottery, silica
Imaging: small (<1cm) nodular opacities in upper lung zones: eggshell calcifications!
Complication: risk of TB, need annual TB skin test. Progressive massive fibrosis
history, imaging finding, complications: berylliosis
hx: high tech fields (space, nuclear, electronic plants)
Imaging: diffuse infiltrates, hilar adenopathy
Comp: chronic corticosteroid treatment
Calcified pleural plaques in asbestosis are indicative of?
benign pleural disease
Name the eosinophilic pulmonary syndromes
Allergic bronchopulmonary aspergillosis
Loffler syndrome
Acute eosinophilic pneumonia
Drug Induced (NSAID, nitrofurantoin, sulfonamides)
Presentation of eosinophilic pulm syndromes
dyspnea, cough, possible blood tinged sputum, and/or fever
Diagnosis of pulm syndromes?
CBC: peripheral eosinophilia
CXR: pulm infiltrates
Name the causes of hypoxemia (low PO2)
V/Q mismatch Right to left SHUNT Hypoventilation Low inspired O2 content Diffusion impairment
When will the A-a gradient be normal in cases of hypoxia?
If the problem is hypoventilation or low inspired O2, the A-a gradient will be normal
If the problem is V/Q mismatch or shunting, the A-a gradient will?
Increase
Initial test for diagnosis of hypoxia?
ABGs. Calculate the A-a gradient
Further diagnosis/work up for hypoxia?
pulse ox monitoring.
CXR: evaluate for infiltrates, ARDS.
In hypercapnic patients ______ ventilation to ______ CO2 exchange.
Increase, Increase
Mechanical ventilator parameters that affect Oxygenation?
FiO2 and PEEP
Mechanical ventilator parameters that effect ventilation?
respiratory rate, tidal volume
Summarize approach for working up/managing hypoxic patients when A-a is normal.
If A-a gradient is normal, is PaCO2 increased? If not, hypoxia likely due to decreased FiO2 (high altitude). If PaCO2 is increased, hypoxia likely caused by hypoventilation. (decreased resp drive, neuromuscular disease)
Summarize approach for working up/managing hypoxic patients when A-a is NOT normal.
You ask: Is PaO2 correctable with O2? If no, this is due to SHUNT (intracardiac shunt, vascular shunt in lungs). If PaO2 correctable with O2 -> V/Q mismatch (asthma, COPD, ILD, atelectasis, pneumonia, pulmonary edema, pulm vasc disease)
Common triggers for acute respiratory distress syndrome
sepsis, pneumonia, aspiration, multiple blood transfusions, inhaled/ingested toxins, trauma
What is ARDs?
acute respiratory failure with refractory hypoxemia, decrease lung compliance and pulmonary edema (PaCO2/FiO2 ratio < 300)
Pathogenesis of ARDs is thought to be dependent on?
endothelial injury
CXR for ARDs?
Diffuse alveolar filling, diffuse opacity
Criteria for ARDs diagnosis according to Berlin definition?
- acute onset < 1 week
- A PaO2/FiO2 < 300 with PEEP/CPAP > 5 H2O
- Bilateral pulm infiltrates on CXR
- Resp failure cannot be completely explained by heart failure
Treatment for ARDS
- treat underlying disease
- maintain adequate perfusion to prevent end organ damage
- mechanical ventilation with low tidal volumes (4-6cc/kg of ideal body weight) to reduce lung injury
- Use PEEP to recruit collapsed alveoli. Titrate PEEP and FiO2 to achieve best Oxygenation
- goal oxygenation PaO2 > 55 mm Hg or SaO2 > 88%
What is oxygenation foal for ARDs patients?
PaO2 > 55 mm Hg or SaO2 > 88 %
What is normal pulmonary arterial pressure?
15 mm Hg
Mean pulmonary artery pressure greater than ____ defines pulm htn
25
What criteria for extubation from mechanical ventilation is the most predictive of success?
Frequency/tidal volume ratio < 105
Causes of pulmonary htn include?
left heart failure, mitral valve disease, increased pulm vein resistance, hypoxic vasoconstriction 2ndary to chronic lung disease, chronic thromboembolic disease, idiopathic
Exam findings for patients with pulm htn
loud, palpable S2, often split, flow murmur, S4 or parasternal heave.
Pulm htn findings on chest c-xray
- enlargement of pulm arteries
- ECG shows RVH
- Echo (initial test) and right heart cath (definitive test) show signs of right ventricle overload
Pulm embolism presents as
sudden onset or subacute dyspnea, pleuritic chest pain, low-grade fever, cough, tachypnea, tachycardia, hemoptysis (rare)
Dyspnea, tachycardia and a normal CXR should raise suspicion for?
PE
Initial test if low suspicion of PE?
D-dimer
Is D-dimer sensitive or specific?
sensitive. It’s most useful to “rule out”
What is the definitive test for diagnosing PE?
CT pulmonary angiogram with IV contrast/spiral CT
Hampton hump
a wedge shaped infarct that may be seen on CXR and is indicative of PE
Westermark sign
oligemia/collapse of vessels that may be seen on CXR distal to a PE
ECG findings for PE
most common is sinus tachycardia
Classic S1Q3T3 is rate- signifies acute right heart strain
When should you use a V/Q scan to help with PE diagnosis?
If contraindications to CT scanning. (kidney disease, pregnancy)
Treatment for PE Acute and Chronic
Acute: Heparin bolus and then Heparin infusion or LMW heparin subcu
Chronic: Anticoag for 3-6 months (INR 2-3)
When should an IVC filter be placed?
In patients with lower extremity DVT if anticoagulation is contraindicated or if patients experience recurrent emboli while anticoagulated
What is the most effective DVT prophylaxis?
early ambulation
Diagnose lung nodule based on hx clues
- recent immigrant
- southwestern US
- Ohio River Valley
- TB
- Coccidiodomycosis
- Histoplasmosis
Divide lung cancers into 2 broad groups
small cell lung cancer
non-small cell
what are the most common types of NSCLC
adenocarcinoma, squamous cell carcinoma, large cell carcinoma
What type of lung cancer is most likely to metastasize at an early stage?
small cell lung cancers
What lung cancers are found centrally?
Squamous cells and small cells
Characteristics of benign lung nodules: age: smoke: change: calcification: margin: size:
age: < 35 nonsmoker no change from old CXRs central, uniform, popcorn calcification smooth margin < 2 cm
Characteristics of malignant lung nodules: age: smoke: change: calcification: margin: size:
Age 45-50 smoker new or enlarging lesions absent/irregular calcification irregular margin Size > 2
Location, characteristics, histology: small cell (oat cell) carcinoma
L: central
characteristics: undifferentiated-> very aggressive
may produce ACTH (cushing syndrome), SIADH, or antibodies against presynaptic Ca2+ channels (Lambert-Eaton syndrome) or neurons (paraneoplastic myelitis/encephalitis). Amplification of myc onc genes common.
Histology: neuroendocrine Kulchitsky cells - small dark blue cells (chromogranin A (+))
Location, characteristics, histology: Adenocarcinoma
L: peripheral
Character: most common lung cancer in non-smokers and overall
Histology: glandular, stains mucin (+)
Location, characteristics, histology: squamous cell carcinoma
L: central
Characteristic: hilar mass arising from bronchus. Produces PTH -> hyperCalcemia
Histology: Keratin pearls and intercellular bridges
Location, characteristics, histology: Large cell carcinoma
L: peripheral
Characteristic: anaplastic undifferentiated tumor, poor prognosis, less responsive to chemo, remove surgically
Histology: pleomorphic giant cells. can secrete B-hCG
Location, characteristics, histology: Bronchial carcinoid tumor
Character: excellent prognosis. mets rare. symptoms due to mass effect. Carcinoid syndrome (5-HT secretion -> flushing, diarrhea, wheezing)
Histology: nets of neuroendocrine cells. chromogranin A +
Is small cell carcinoma operable?
NO- treat with chemo
Kulchitsky cells
small dark blue neuroendocrine cells of small cell carcinoma. They are positive for chromogranin A
Hypertrophic osteoarthropathy
clubbing
which type of lung cancer is associated with clubbing
adenocarcinoma
Bronchioalveolar subtype (great prognosis) of adenocarcinoma will show what on CXR?
Hazy infiltrates similar to pneumonia
Histology for bronchioalveolar subtype of adenocarcinoma
grows along alveolar septa-> apparents thickening of alveolar walls
Which type of cancer is NOT associated with smoking?
bronchoalveolar subtype of adenocarcinoma
Lung cancer mets are often found in “LABBs”
Liver
Adrenals
Brain
Bones
What type of lung cancer is associated with gynecomastia?
Large cell
ACTH, SIADH ass lung cancer?
small cell
Hypercalcemia, PTH ass lung cancer?
squamous cell
Lung cancers associated with dermatomyositis?
ALL
Lung cancer associated with peripheral neuropathy, subacute cerebellar degeneration, lambert-eaton syndrome?
small cell
Lung cancer associated with migratory thrombophlebitis, nonbacterial verrucous endocarditis?
adenocarcinoma
lung cancers associated with anemia, DIC, eosinophilia, thrombocytopenia, acanthosis nigricans?
ALL
Lung cancer assocaited with hypercoagulability
adenocarcinoma
Horner syndrome
miosis, ptosis, anhidrosis
Common cause of horner syndrome?
Pancoast tumor at apex of lung
SVC syndrome
obstruction of SVC with supraclavicular venous engorement and facial swelling
hoarseness as presenting symptom in lung cancer
secondary to recurrent laryngeal nerve involvement
Diagnosis of lung cancer
CXR or CT (initial test)
Fine needle aspiration (CT guided) for peripheral lesions
Bronchoscopu (biopsy or brushing) for central lesions
Pleural effusion
abnormal accumulation of fluid in pleural space
How do you classify pleural effusions?
Transudative or Exudative
Transudative pleural effusion:
2ndary to elevated PCWP or decreased oncotic pressure
Exudative
2ndary to increase pleural vasc permeability
Causes of transudative pleural effusion
CHF, Cirrhosis, Nephrotic Syndrome
Cause of exudative pleural effusion
Pneumonia, TB, Malignancy, PE, Collagen vascular disease (RA, SLE), Pancreatitis, Trauma
Diagnosis of pleural effusion
Initial test- CXR shows costophrenic angle blunting. Lateral decubitus view to assess loculation
When is thoracentesis indicated?
for new effusions > 1 cm in decubitus view except when there are bilateral effusions and clinical evidence of CHF.
Lights criteria
Pleural protein/serum protein > .5
Pleural LDH/serum LDH > .6
Pleural fluid LDH more than 2/3 upper limit of normal
How can you classify an effusion as an exudate?
If it meets any of Light’s criteria
Complicated parapneumonic effusions and empyemas require _______ and _____ for treatment
antibiotics and chest tube drainage
Presentation of pneumothorax
P-THORAX
Pleuritic chest pain Tracheal deviation Hyperresonance Onset sudden Reduced breath sounds and dyspnea Absent fremitus (asymmetric chest wall) X-ray shows collapse
Treatment of tension pneumothorax?
Needle decompression (2nd intercostal space midclavicular line) first and then chest tube placement
Diagnosis of tension pneumothorax should be made?
Clinically and followed by immediate treatment
Treatment for small pneumothoraces?
Supplemental O2 is helpful. most will resorb spontaneously
Large, symptomatic pneumothoraces require?
chest tube placement
