Pulmonary Flashcards
Obstructive lung disease
Airway narrow: restrict air mvt + often air trapping
FEV1/FVC ratio <70% (bcz FEV1↓) and RV↑
Causes: Asthma, Bronchiectasis, COPD, Cystic fibrosis, Obstruction (tracheal, bronchial)
Asthma (triggers, PE)
Reversible airway obstruct* (bronch hyperreactiv, infl, mucous plug, smooth M. hypertrophy)
Trig: allergens, URIs (multiple), cold air, exo, meds (NSAIDs/aspirin), stress
Ass w/ childhood eczema
Dry cough, episodic wheez, dyspn +/- tight chest (worse night/early morn); prolong expirat*, ↑access M. use, tachypn, tachycard
Late: ↓breath sounds (no wheez), cyanosis, ↓SaO2
Asthma (dg)
- Spirometry/PFTs (#1): ↓FEV1/FVC, ↑RV, ↑TLC but all Nl betw/ exacerb
- Methacholine challenge: if PFTs Nl but asthma suspic*
- ABGs: first acute resp alkalo +/- mild hypoxia; if resp acid or sev hypox so sev resp distress !!! hospit
- CXR: Nl to hyperinglat*
Asthma (ttt)
Avoid allergens/triggers
-Acute: O2, SABA (#1); ipratropium, systemic CS, Mg2+ if sev
Intubat*: sev or PCO2>50 or PO2<50
-Chronic: LABA +/or inhaled CS, systemic CS, cromolyn (just prophyl), theophylline (rare).
W/ inhaled ttt, can take PO antileukotr (zileuton, montelukast)
Asthma (4 types + chronic ttt)
- Mild interm: ≤2d/wk or ≤2 nights/mo; just PRN SABA
- Mild persist: >2x/wk but <1x/d or >2 nights/mo; low-dose inhal CS/day + PRN SABA
- Mod persist: daily or >1 night/wk; low/med-dose inhal CS/day and LABA/day + PRN SABA
- Sev persist: continual, fqt; high-dose inhal CS/day and LABA/day; possible PO CS; PRN SABA
Bronchiectasis (RF, PE)
Fibrosis, remodel, permanent dilat* of bronchi
By recurr inf/infl of bronch
Ass w/ Hx cystic fibr, pulm infs, hypersens, immdef, airw obstr, aspir, autoimm ds, IBD, ABPA, TB, MAC inf
Chronic productive cough, dyspn +/- hemoptysis; wheez, rhonchi, purulent mucus (yellow/green)
Bronchiectasis (dg, ttt)
Dg: CXR (↑bronchovasc marking, tram lines); high-resolut* CT (defin; dilated airw, balloon cysts); spirometry (↓FEV1/FVC)
ttt: AB (PO+inhal), inhal CS; bronch hygiene (cough, postural drainage, physiottt); surg (lobectomy or lung transplant)
Chronic obstructive pulmonary disease (2 types)
-Chronic bronchitis: product cough >3mo/y for 2 consecut years (dg clinic)
Overweight, edematous
Early hypercarbia/hypoxia (blue)
-Emphysema: destruc+dilat* distal to terminal bronchioles (dg histopath); 2* to smok (centrilobular) or to alpha1-antitr def (panlobular)
Thin, pursed lips
Late hypercarbia/hypoxia (pink)
Chronic obstructive pulmonary disease (PE, dg)
Most ptts combinat* of 2 types
Barrel chest, access chest M, JVD, end-expir wheez, dyspn on exert*, muffled breath sounds
Dg: PFTs (defin; ↓FEV1/FVC; Nl/↑TLC; ↓DLCO); CXR (hyperinfl lungs, parench bullae, subpleural blebs); ABGs (hypoxemia + resp acid, ↑PCO2); Gram/Cx sputum if inf
Chronic obstructive pulmonary disease (ttt)
O2 and stop smok: only ttt to improve survival
!!! not high O2 bcz worsen ventil/perfus* mismatch
-Acute exac: SABA + ipra/tiotrop, IV+/-inhal CS, AB, O2,
If sev: NIV w/ BiPAP or intubat*
-Chron exac: LABA + tiotrop, syst/inhal CS, O2, smok cessat*, pneumoc+flu vaccines
Restrictive lung disease
Loss of lung compliance (↑stiff + ↓expans*)
FEV1/FVC ≥70; ↓FVC and Nl FEV1; ↓RV
Alveolar, interstitial lung ds, inflammatory, idiopathic pulm fibrosis, neuromuscular, thoracic wall
Interstitial lung disease (causes)
Group of dso; inflammat* +/or fibrosis of interstitium
- Expo related: coal work pneumocon, asbest, silic, berylli, hypersens pneumo, radiat*, drugs (amiod, busulf, bleomy, long-term high-dose O2)
- Ass w/ system ds or connect T ds: polymyos, dermatomyo, sarcoid, amyloid, vasculitis, CREST
- Idiop: idiop pulm fibrosis, COP, acute interst pneumo
Interstitial lung disease (PE, dg)
Shallow rapid breath, dyspn w/ exert*, chron nonprod cough +/- cyanosis, inspir squeaks, crackles, clubbing, RHF
Dg: CXR/CT (#1; retic/nodul/ground-glass, honey comb if sev); PFTs (↓TLC, ↓FVC, ↓FLCO, Nl FEV1/FVC); surg biopsy (defin, confirm)
Interstitial lung disease (ttt)
Avoid expo
Anti-infl or immunosuppr (CS)
Antifibrotic (for IPF)
Surg (lung transplant)
Systemic sarcoidosis (PE)
Noncaseating granulomas; esp black women
~30-40yo
Fev, cough, malaise, ↓weight, dyspn, arthritis
Exam: lungs, liver, eyes, skin (eryth nodos), nerv, heart, kidney
Löfgren sd: type of sarc w/ triad arthritis, eryth nodosum, bilat hilar adenopathy
Systemic sarcoidosis (dg, ttt)
Dg: CXR/CT (#1; hilar LNpathy, nodules); biopsy (defin; LN or lung; noncaseating granulomas)
PFTs (restric or obstruct; ↓DLCO); ↑serum ACE; hyperCa; ↑ALP; …
ttt: systemic CS
Hypersensitivity pneumonitis (causes, PE)
Alv thick + noncaseat granulom
2* to environm expo (mold, hot tubs, down feather Ag)
- Acute: dyspn, fev, mal, shiv, cough 4-6h after expo
- Chronic: progr dyspn, fine bilat rales
Hypersensitivity pneumonitis (dg, ttt)
Dg: job/travel Hx; CXR/CT (esp upper lobe fibrosis in chronic)
ttt: avoid ongoing expo; CS
Pneumoconiosis
RF: prolong expo + inhal of small inorganic particles
4 types: asbestosis, coal worker’s ds, silicosis, berylliosis
ttt: avoid triggers, support ttt, O2
Asbestosis
Insulat, construct, demolit*, shipbuilding
After 15-20y of expo
Linear opacities at bases, interst fibrosis, calcif pleural plaques, ferruginous bodies
↑R mesothelioma (rare), lung cancer (higher in smokers)
Coal worker’s disease
Underground coal mines
Small nodular opacities (<1cm) in upper lobes
Compl: progr massive fibrosis
Silicosis
Mines, quarries or glass, pottery, silica
Small nodular opacities (<1cm) in upper lobes; eggshell calcifications
↑R of TB (skin test/y); progr massive fibrosis
Berylliosis
Aerospace, nuclear, electronics plants, ceramics, dental, dye
Diffuse infiltrates, hilar adenopathy
ttt: chronic CS
Eosinophilic pulmonary syndromes
Eosino pulm infiltrat + periph bld eosino
Includes ABPA, Löffler sd, acute eosino pneumonia, drug-induced (NSAIDs, nitrof, sulfonam)
Dyspn, cough, bld-tinged sputum, fev
Dg: CBC (eosino); CXR (pulm infiltrates)
ttt: remov cause or ttt underl inf (helminths); CS
Hypoxemia (etiologies, PE, dg)
↓PO2 by V/Q mismatch, R-L shunt, hypoventil, altitude, diffus* impairment
Cyanosis, tachypn, SOB, pleur chest pain, alter ment stat
Dg: ABGs (#1; A-a gradient), ↓SpO2, CXR (r/o pneumonia, atelect, pleur effus, pneumothor, ARDS)
↑A-a gradient: shunt, V/Q mismatch, diffus impair
Hypoxemia (ttt)
Underl cause
Give O2 before eval
If mechan ventil: ↑O2 (by ↑FiO2 or ↑PEEP) or ↑ventilat* (by ↑RR or ↑TV)
If hypercapnia: ↑ventilat* (to ↑CO2 exchange)
Acute respiratory distress syndrome (RF)
Resp failure w/ refract hypoxemia + ↓lung compliance + noncardiog pulm edema + PaCO2/FiO2 ≤300
Endoth injury first
Trigg: sepsis, pneumonia, aspirat*, multiple bld transfu, inh/ing toxins, trauma
Morta 30-40%
Acute respiratory distress syndrome (PE)
Acute (12-48h): tachypn, dyspn, tachycard, fev, cyano, labored breath, diffuse high-pitched rales, hypoxemia
Phase 1 (acute): Nl PE, resp alkal
Ph2: 6-48h: hyperventil, hypocapn, wide A-a grdt
Ph3: acute resp failure, tachypn, dyspn, ↓lung compl, diff rales, diff chest opacity (CXR)
Ph4: sev hypoxemia unresp to ttt, ↑intrapulm shunt, metab+resp acidosis
Acute respiratory distress syndrome (dg, ttt)
Dg: Berlin criteria: acute onset (<1wk) resp distress; PaO2/FiO2 ≤300 w/ PEEP/CPAP5; bilat pulm infilt CXR; resp failure not complet explain by heart failure
ttt: underl cause + adeq perfus; mechan ventil w/ low TV; PEEP (then titrate); PaO2 >55 or SaO2 >88%; slowly wean from ventil then extubat trials
Pulmonary hypertension / Cor pulmonale (types)
Cor pulm = right-side heart failure due to pulm HTN
PAP >25 (Nl =15); 5 categories
- Pulm arterial HTN
- ↑pulm venous pressure from left-side heart ds
- Hypoxic vasoconstr 2* to chron lung ds
- Chron thromboembolic ds
- Pulm HTN w/ unclear/multifactorial etiology
Pulmonary hypertension / Cor pulmonale (PE)
Dyspn on exert, fatig, lethargy, syncop w/ exert, chest pain, sympt of right CHF (edem, abdo dist, JVD)
Hx of COPD, interst lung ds, heart ds, SCD, emphys, PE
Loud split S2, flow murmur, S4, parasternal heave; hypoxemia on exert*
Pulmonary hypertension / Cor pulmonale (dg, ttt)
Dg: CXR (larg central pulm art), ECG (RVH)
Echocard (#1) + right heart cath (defin): RV overload
ttt: O2, anticoag, vasodil, diuret (if R CHF)
Underl cause
If Pulm art HTN: prostanoids, endothelin recept antag, PDE inhib
Pulmonary thromboembolism (RF, etiologies)
95% emboli from DVTs in leg
Leads to pulm infarct*, right HF, hypoxemia
Virchow triad (predisposing fact): venous stasis, endothelial injury, hypercoagulability Other etiologies of emboli: amniotic fluid, fat, air, cholest
Pulmonary thromboembolism (PE)
Sudden/subacute dyspn, pleurit chest pain, low-grade fev, cough, tachypn, tachycard, rare hemoptysis
Hx of immobil; hypoxia + hypocarbia (resp alkal)
Loud P2, prominent jugular A waves w/ right HF
Pulmonary thromboembolism (dg)
- D-dimer (#1 to r/o PE; when low suspic*)
- CT pulm angiogram w/ IV contrast (defin!!!)
- ABGs: resp alkal (hyperventil, PO2<80)
- CXR: atelect, pleur effus*, Hampton hump
- ECG: sinus tachycard, rare S1Q3T3
- V/Q scan: just if CT scan CI (↑crea, pgnt); areas of mismatch
- LE venous US: spec/sens for DVT not PE (just to dg DVT)
Pulmonary thromboembolism (ttt)
- Anticoag: acute (heparin bolus then infus* or LMWH subcut); chronic (3-6mo or during predispo; INR 2-3)
- IVC filter: if anticoag CI and LE DVT dg or if recurr PE while anticoag
- Thrombolisis: if massive PE w/ right HF + hemodyn instabil
- DVT prophyl: immobil ptt; subcut heparin or LMWH, intermitt LE compress, early ambulat (+++)
Lung nodules
Esp asympt; chronic cough, dyspn, SOB
Always ask abt smok, Hx of expo bcz ↑R cancer
Recent immigrant (TB); SW US (coccidio); Ohio river valley (histopl)
ttt: surg resect* if ↑R malign; follow-up w/ serial CXR/CT if ↓R; invasive dg procedure if size ↑
Benign vs Malignant lung nodules
Benign: <35yo, nonsmok, no change, smooth margins, central/uniform/popcorn calcificat*, <2cm
Malignant: >45-50yo, smoker, new/enlarging, irreg margins, absent/irreg calcificat*, >2cm
Lung cancer (RF, PE)
#1 cause of cancer death in US RF: tobacco (except bronchoalv carcinoma), radon, asbest
Cough, hemoptysis, dyspn, wheez, pneumonia, chest pain, ↓weight, +/- crackles/atelectasis Horner sd (Pancoast tumor at apex); SVC sd; Hoarsness (recurr laryngeal nerv involv); Many paraneopl sds
Lung cancer (dg, ttt)
Dg: CXR or CT (#1); FNA (CT-guided for periph les); bronchoscopy (for central les)
Meta esp: Liver, Adrenals, Brain, Bone
ttt: SCLC (unresectable; radiat* + chemoth; usual recurr; low survival rate)
NSCLC (surgical resect* if early; w/ radiat* or chemoth depend on stage; palliative radiat* +/or chemoth if sympt but unresect)
Small cell lung cancer
Cigarette expo; Central locat*
Neuroendocrine (Kulchitsky cells); myc oncogene
Chromogranin A ⊕
Ass w/ paraneopl sd (ACTH, SIADH, Lambert-Eaton, myelitis)
Often ⊕ meta intrathor + extra thor (brain, liver, bone)
Non-small cell lung cancer
Adenocarcinoma (#1 fqt)
Squamous cell carcinoma
Large cell carcinoma
Less likely to meta at early stage
Adenocarcinoma
Peripheral; #1 in nonsmoker
KRAS, EGFR, ALK mutat*; ass w/ hypertroph osteoarthrop
Histo (glandular; Mucin⊕)
Bronchoalv carcinoma (subtype; adenoK in situ; CXR similar to pneumonia; excellent pg); apparent thick alv walls
Squamous cell carcinoma
Central; hilar mass from bronchus
Smokers (98%)
Cavitat*; hyperCalcemia (PTHrP)
Keratin pearls, intercellular bridges
Large cell carcinoma
Peripheral
Highly anaplastic, undifferentiated; poor pg
Pleomorphic giant cells; B-hCG
Bronchial carcinoid tumor
Excellent pg
Sympt by mass effect; rare carcinoid sd (5-HT, flush, diarrh, wheez)
Nests of neuroendocrine cells; chromogranin A ⊕
Pleural effusion (2 types)
Transudate: ↑PCWP or ↓oncotic pressure
(CHF, cirrhosis, nephrotic sc)
Exudate: ↑pleural vasc permeab
Any of Light’s criteria
(pneumonia, TB, cancer, PE, collagen vasc ds, pancreatitis, trauma)
Pleural effusion (PE, dg, ttt)
Dyspn, pleur chest pain, cough, dull to percuss, ↓breath sounds, pleur frict rub
Dg: CXR (#1; sometimes lateral decub view)
Thoracocentesis: for new >1cm in decub
ttt: underl cause; if complicated effus* or empyema then chest tube drain + AB or pleurodesis
Pneumothorax (types)
- 1* spont: rupture subpleural apical bleb
- 2* PT: 2* to COPD, trauma, inf, iatrog, ⊕P* mechan ventil
-Tens* PT: pulm/chest wall defect (1-way valve; air trap); tracheal deviat* → SVC compress* → cardiac arrest, hemod instab; !!! shock-death unless immed ttt
Pneumothorax (PE, dg, ttt)
Acute unilat pleur chest pain, dyspn, tachypn, ↓/no breath sounds, hyperreson, ↓tact fremitus, JVD
Tens* PT: resp distress, hypoxia
Dg: CXR (lung retract); Tens PT clinical dg
ttt: immed for tens* PT (needle decompr then chest tube)
If small, spontan resolut*; give O2
