Pulmonary Approach To Dyspnea, Palpitations, And Fatigue - Dr. Pence Flashcards
Vital signs showing respiratory distress
RR > 20/min
Tachypnea
O2 < 95%
What can be both restrictive and obstructive
Bacterial and viral pneumonia
Pulmonary HTN dx
Mean pulmonary artery pressure (mPAP) >20mmHg
Pulmonary HTN can cause what
Cor pulmonae (RIGTH HF)
= JVD
= bilateral lower leg edema
5 groups that can get pulmonary HTN
- Pulmonary Artery HTN : CT disease, congenital, unknown usually hereditary cause
- Left HF : valvular dysfunction, LV problem
- Pulmonary Disease : ILD, COPD, OSA
- Chronic VTE : chronic small PE
- Miscellaneous : Sickle cell, sarcoidosis, tumor compression
SX Pulmonary HTN
SOB Fatigue Pre-syncope sx CP (JVP, edema, exertion syncope)
How to DX Pulmonary HTN with ECG
- RV hypertrophy
- Right Axis deviation : + AVF, - I
- RBBB : R and R’ seen in V1
- RA enlargement : large peaked P waves on lead II
Pulmonary HTN labs and imaging
- BNP : legates when heart is expanding
- Transthoracic Echocardiogram (TTE) : you can see chamber sizes and pulm artery systolic P (from tricuspid regurgitation gradient)
- Cardiac Catheterization ** GOLD
GOLD for Pulmonary HTN imaging
Swan Ganz Catheter
Protein C and S doe what
BLOCK F8 and F5
Antithrombin III does what
BLOCK : F2 and F10
PE sx
SOB, CP, Palpitations, Unilateral leg edema, can have syncope
Tachycardia, hypoxia
Criteria for blood clot of PE
Wells Criteria
Low probability of DVT or PE order what
D-Dimer
Higher or medium probability of DVT or PE you do what
Imaging study
D- Dimer can be + when
Inflammation state
High Clotting
(If - then you know there is no DVT)
PE EKG
- Sinus tachy + Right Axis deviation + HIGH R in V1
- Inverted T wave V1-V4
- RBBB
- S1Q3T3
Imaging for PE
CT Chest + CONTRAST
V/Q scan ——> no radiation
PE Echocardiogram
- RV is dilated
2. LV barely opening up (can show D-shaped)
Unstable PE is presenting how
Hypotension, RV strain, high cardiac enzymes
TX Unstable PE
- Resuscitation: Ventilation, vasopressin,
- Anti-coags
- Thrombolysis can be repeated, emboli to my, surgery thrombectomy
TX Stable PE
- Heparin = FAST , needs monitoring (increase antithrombin 3)
- Low Molecular Weight Heparin = FAST
- VIT K antagonist (Warfarin, Coumadin) = only when INR is 2-3 (normal)
Newest best anti-coags
Direct Oral Anticoagulants (DOACs)
= Rivaroxaban, Apixaban, Endoxaban, Dabigatran)
= inhibits F10, or dabigatran inhibits F2
Reversal agents for LMWH, Warfarin, DOAC
- LMWH : Protamine Sulfate
- W : Vit K, Prothrombin concentrate, fresh frozen plasma
- DOAC : 10a inhibitors = Andexanet alpha, Dabigatran = idarucizumab
Duration of tx for PE
3 months (Malignancy or genetic mutation, hypercoagability disease = indefinitely)
OSA is what
OBSTRUCTIVE SLEEP APNEA
Disrupted breathing pattern when sleeping (can drops by more then 3% O2 sat, reduced breathing for 10sec or more, then gasping for air)
= tired during day
OSA severity measured by
Apnea Hypopnea Index (AHI) (apnea episodes /hour)
Sleep causes what
Pharyngeal muscles relax
Brain monitors CO2 levels to constrict muscle and increase breathing rate until normal
OSA is associated with what diseases (5)
HTN DM Atrial Fib / flutter CAD Occupational hazards
OSA risks
Large tongue Obesity Craniofacial abnormalities Large tonsils Large LN Male
Questionnaire used for OSA
STOPBANG
DX OSA GOLD STANDARD
Polysomnogram
= records sleep 6-7hr (EEG, ECG, ocular movements, airflow, O2sat)
= gives you the AHI
OSE TX 2
- Continuous Positive Airway Pressure (CPAP) : nasal or oral mast or + P ventilation (low compliance)
- Oral appliances: thrust mandible forward : mild osa , need frequent adjustments
LFT of ILD
- Restrictive pattern
2. Decreased DLCO
ILD does not have what 2 diseases
No primary infection of malignancy
5 types of ILD
- Idiopathic Interstitial Pneumonia. (Idiopathic Pulmonary Fibrosis)
- Granulomatous ILD : Sarcoidosis, GPA, Goodpasture
- CT ILD : RA, SS, Dermatomyositis/Polymyositis
- Hypersensitivity Pneumonia: Farmers lung, bird poop, baker lung
- Pneumoconiosis : Coal, silicosis, asbestosis, berylliosis
Idiopathic Pulmonary Fibrosis Prevalence, SX, PE
- Over 60yo
- SOB, Dry cough, fatigue, can do daily activities
- Velcro like crackles
Idiopathic Pulmonary Fibrosis Imaging and LFT
- CT : fibrosis HONEYCOMBING + traction bronchiectasis
2. Restrictive pattern, low DLCO
Idiopathic Pulmonary Fibrosis TX dont need to know drugs
- O2, Steroids
- Immunomodulators : Azathioprine, cyclophosphamide (moderate benefit)
- Anti-fibrotic therapy : Pirfenidone, Nintedanib (some benefit)
Sarcoidosis is what and prevalence
- Non-caseating granulomas many locations (lungs most common)
- F, AA, 2-3rd decade + 6th decade
Sarcoidosis sx 4
- Asymptomatic (25%)
- Cough, SOB,
- SLE, erythema nodosum
- Anterior uveitis
Sarcoidosis 2 syndromes and what they include
- Lofgren’s Syndrome : Erythema nodosum, hilar LA, fever, arthritis
- Herefordt’s syndrome : anterior uveitis, parotitis, Cranial N 7 palsy, fever
Sarcoidosis labs
High CA
High ACE
High T-cells causing this
Sarcoidosis Radiology and LFT
- Hilar lymphadenopathy
2. Restrictive obstructive or normal
Sarcoidosis TX
- Steroids * + SUPPORT (O2, rehab, nutrition)
- Methotrexate , azathioprine, cyclophosphamide
- Infliximab (TNF -1 inhibitors)
GPA affects what locations and what happens and prevalence
- Lungs, kidneys, sinus
- Small V vasculitis , SOB, Cough, hemoptysis, saddle nose, chronic rhinitis, recurrent Otis media, fevers
- Caucasians middle age
GPA labs and radiology
- C-ANCA
2. Lung nodules, patchy ground glass opacities, hilar LAD
GPA TX
Steroids + Cyclophosphamide*
Goodpasture Syndrome what happens, prevalence, sX
- Anti- Glomerular BM and Anti- Alveolar BM
- Peds, adults , Caucasian
- WL, fever, proteinuria, Hematuria, SOB, cough, Hemoptysis, hypoxemia
Goodpasture Syndrome labs and radiology
- Anti- GBM
2. Bilateral ground glass opacities, = diffuse alveolar hemorrhage (DAH)
Goodpasture Syndrome TX
- Plasmapheresis **
2. Steroids + cyclophosphamide**
CT disorders that can cause ILD 3
- Systemic Sclerosis
- RA
- Dermatomyositis / Polymyositis
Dermatomyositis / Polymyositis Labs
Anti- synthase ABs (myositis, reynoalds, mechanic hands, arthritis, ILD, fever)
RA causing ILD more common in what gender
M ,all other RA sx more in F
Hypersensitivity pneumonitis
Allergic reaction to something inhaled (alveolitis) = farmers, bird poop, woodworkers, bakers
= HISTORY IS IMPORTANT
Hypersensitivity Pneumonitis SX, radiology , LFT
- Cough, SOB, fevers at times
- Diverse, focal consolidation, irregular nodules, honeycombing NOT AT BASES (like in IPF) if chronic
- Restrictive pattern
Hypersensitivity Pneumonitis histology and tx
- PLASMA CELLS **, non-caseating granulomas can be seen
2. Remove Ag (to prevent chronic fibrosis)
Pneumoconiosis is what and caused by what
Inorganic dust inhaled causing inflammation and fibrosis = silicosis = asbestosis = coal workers (or navy) = Berylliosis
Pneumoconiosis LFT and TX
- Restrictive pattern
2. Remove exposure, immunizations, stop smoking, O2 tx
Pneumoconiosis are at risk of what
TB
Silicosis comes from what and what is it, radiology
- Crystalline quartz, miners, stone cutters,, sand blasting, quarry workers,
- Nodular lung disease + calcified hilar LNs + fibrosis if progressing
Asbestosis what is it and radiology and risk of what
- Fibrous material construction, insulation, automobile worker, demolition
- Many nodular opacitis, pleural effusion, pleural fibrosis, blurred cardiac and diaphragm image
- Mesothelioma and lung cancer
Coal miners Pneumoconiosis what is it and sx , radiology
- Coal dust, miners
- Asymptomatic ——> cough, SOB, sputum production
- Nodules usually at apex, patchy infiltrates at base , can lead to fibrosis
Berylliosis what happens and radiology and tx
- Manufacturing alloys, electronic devises , similar to hypersensitivity reaction
- Hilar LAD, diffuse infiltrates
High risk of Lung cancer - Steroids *, remove Beryllium from environment
