Pulmonary/ Critical Care Flashcards
What is necrotizing Enterocolitis
inflammation and necrosis of the intestines in view of Gas-producing bacteria
NEC is common in
premature babies ( < 29 weeks)
Low birth weight < 1.5kg
on enteral feeds, formula
Features of NEC on Abdoxray ?
Distended abdomen
Bilious vomit
Bloody stools
Pneumatosis intestinalis ( air in the wall of the intestines)
Pneumoperitoneum ( air in the wall of the abdomen).
What is cystic fibrosis ?
Autosomal recessive disease with cysts in pancreas and fibrosis.
Improper mucus secretion from the lungs
Function of CFTR channel in Sweat glands and other exocrine galnds ?
Sweat glands: reabsorb Cl-
Exocrine glands (pancreas, GI) secretes Cl-
CF has improper —– GENE
CFTR
Sweat galnds: excrete Cl-.. salty sweat
Exocrine glands: No cl- secretion, thick secretions, which clog the pancreatic duct that leads to pancreatic insufficiency ( unable to absorb fat soluble vitamins, Steattorhea: stool that floats on water)
Defective CFTR gene is due to
Deletion of 3 nucleotides and missing phenealanine
CF of CF ?
Coughing copious amounts of pus ( recurrent Sinopulmonary Infections)
Dry skin (loss of Water and salt) Pancreatic insufficiency -> pancreatitis -> Steatorrhea (unable to rebasorb the Fat) Type 1 DM ( in view of pancreatic failure)
Bilateral Nasal polyp in children
Clubbing
Female/ Male infertility
Gallstones (obstructive jaundice, because the bile ducts are clogged)
Clog the intestines –> meconium plug –> meconium ileus
MC organisms causing infection in CF
Before age of 20: Staph. aureus
After age of 20: Pseudomonas
How to diagnose CF ?
Administer Pilocarpine, which is a Parasympathomimetic
Allergic Brunchopulmonary Aspergilosis
seen in CF with siopulmonary infections not resolving with abx. Associated with eosinophilia and IgEs.
What is invasive pulmonary aspergilosis
fungal infection
MC in immunocompromised patients ( Neutropenia, Post-transplant)
CF of invasive Pulmonary aspergillosis
Fever
hemoptysis
Pleuritic chest Pain
Diagnostics of Invasive Pulmonary Aspergillosis ?
Positive cell wall markers ( Beta-d glucan and galactomann)
CT: nodule with ground glass opacitiies ( surrounding halo)
What kind of shoch does PE give ?
Obstructive shock
CF of obstructive shock ? (pre-pulmonary)
high Central venous P. ( preload of Righ. side of the heart)
Low or N Pulmonary Capillary wedge pressures
Low Cardiac Output
High SVR ( hypotension)
CF of Obstructive shock ( Post-Pulmonary)
Obstruction at the level of L. side of the heart
High PCWP
High CVP (everything is congested backwards from hear to the lungs)
low CO
High SVR
CF of Hypovolemic shock
low CVP
Low CPWP
low CO
high SVR
CF of Septic (distributive) shock
Vasodilation i.e
low SVR
Low CVP
low CPWP
high CO
early feature of Septic/ distributive shock ?
bounding peripheral pulses. Increased Cardiac index and stroke vokume increases pilse pressure (sbp-dbp) leading to bounding pulses.
How to differentiate between Gestational Asthma and Dyspnea of Pregnancy
Gestational asthma: more likely in a pt. with asthma previously. Worsens at night. Intermitent
Dyspnea of pregnancy: Persistant, and no diurnal variation.
Pathophysiology behind Dyspnea of pregnancy
increased progesterone that induces medullary respiratory center
What happens in the lungs when Medulllary respirator center is activated in dyspnea of pregnancy ?
hyperventilation –> increase minute ventilation –> increase pa02 and decrease paco2.
The diaphragm position compresses over the basilar alveoli causing atelectasis, decrease residual functional capacity and residual volume
How does LAMA work ?
Blocking muscarinc receptors, preventing bronchoconstriction and reducing mucus secretion.
Lab findings of Empyema or complicated parapneumonic pleural effusion ?
Low in Glucose ( < 60)
Low PH
High in proteins because of increased permeability of vessels
Diff. between empyema and Complicated parapneumonic pleural effusion
Empyema presence of pus or +ve gram stain
Why is fluid glucose low in empyema ?
Because of the high metabolic activity of leukocyte/ bacteria
What is a DAH
bleeding into the alveoli
foul smelling pleural fluids are suggestive of ?
aneorobic oral organisms causing empyema
What is Acute Asthma Exacerbation Rx ?
SABA/ SAMA, Magnesium and Steroids.
Pathophysiology of ACEI causing cough
Inhibt ACE –> acc. of kinins and substance P that increases prostaglandins.
Also activates arachidonic acid pathway –> increased levels of thromboxane -> bronchoconstriction.
Modified Wells score for PE
+3: Other diagnosis is less likely
Signs of DVT
+1.5: previous PE
Tachy
Recent history of immob.
+1: hemoptysis, Malignancy
PE LIKELY >4
PE Unlikely <4
Management of PE, if PE is likely
if PE is likely ( Modified wells score >4) and patient has no Controindications. Start Anti-coagulants before Diagnostic test like CT angio.
CF of Consolidation on chest exam
Increased breath sounds and tactile fremitus
Dullness to percussion
What is the best step in understanding an undiagnosed Pleural Effusion ?
A thorcacocentesis ( investigate if the fluid is transudate or exudate)
When is LTOT indicated ?
COPD patients with spo2 < 88% on RA.
or < 89% in patients with corpulmonale, R. sided HF and Hematocrit > 55%
Patho. Diff between Lambert Eaton Syndrome and Myasthenia Gravis
Lamb: Abs. against volatged gated Calcium channels (pre-synaptic), Improves with movement
MG: Abs. against Ach receptors ( at Neuromuscular jt.)
Woresens with movement
Lambert Eaton has autonomic signs and symptoms.
CF of Myasthenia Gravis
- Ptosis and diplopia ( extraocular
muscle weakness) - Bulbar muscles ( difficulty chewing, swallowing and dysarthria)
- Proximal muscles: Difficulty standing from a chair, hair brushing and climbing stairs
- Resp failure.
Pathophysiology of MG 3 steps
- Abs. block Ach receptors –> no muscle activation and weakness
- Internalization of Ach R. and further weakness
- Complement activation and muscle lysis –>
MG is associated with ?
Lambert Eaton Syndrome ?
Thymoma
Small cell lung cancer
Rx of MG ?
Pyridostigmine ( Inhibits Ach esterese Inhibitor –> increase Ach in synaptic cleft which competes with Achr. Blockers and increase muscle strength).
Features of Amyotrophic lateral Sclerosis
Muscle weakness
( upper and lowe limbs and bulbar muscles) hence dysarthria
along with clumsiness, dropping things
Fasciculations.
Rx of ALS ?
Relouzole
Advantages Mechanical Ventilation
- Protection: preventing alveolar distention ( TV: 6mls/kg)
- Permissive hypercapnia (low Ph, high pco2)
- Oxygenation: aiming spo2 92-96% to aviod Oxygen toxicity ( Pao2: 60-90), Fio2 <60
In Mechanical ventilation paO2 is affected by ?
PEEP and Fio2
In Mechanical Ventilation PaCO2 is affected by ?
TV and Respiratory rate
Diff between Emphysema and Chronic Bronchitis
Emphysema related to distal bronchioles
Chronic bronchitis related to proximal bronchioles
What type of emphysema is caused by COPD, Alpha 1 anti-trypsin ?
COPD: Centrilobular emphysema of upper lobes
Alpha-1 anti: Panacinar of lower lobes
Causes of Emphysema ?
Cigarette smoking
alpha 1 anti-trypsin defic.
Causes of Neonatal Resp. Distress ?
Premature lungs, low surfactant. like having premature neonates or Fetus of Mother with hyperglycemia.
Pathophysiology of mother hyperglycemia on Lung maturation
Hyperglycemia in mother–> hyperglycemia in fetus –> hyperinsulinism–> inhibits cortisol and thus formation of phospholipids important for surfactant.
Features of NRDS on Xray ?
Diffuse reticuloglandular pattern and air bronchograms
the collpased alevoli leads to air in the bronchioles.
Rx of NRDS ?
antenal steroids, ideally 24 hours before birth.
CF of Foreign Body Aspiration
Presents with wheeze unresponsive to albuterol, prolonged expiration and hyperresonance; Unilateral
Sudden onset cough and dyspnea
CXR: mediastinal shift to the unaffected side and hyperinflation of the affected side.
CF of Diaphragmatic rupture ?
Post- MVA
Avulsion or rupture of L. diaphragm most common.
CXR: bowels inside the lungs, might cause stramgulation.
and Mediastinal shift away from the affected side
What is Transient Tachypnea of newborn
a condition where there is delayed resoprtion of fluids in the lungs
Features of Transient Tachypnea of newborns ?
Fluid in the interlobar fissure
What are the features of a Solitary Pulmonary Nodule
< 3cm
no LN involved
Round opacity
Surrounded by Pulmonary Parenchyma
What increases the probability of malignancy in a SPN ?
hx of smoking
large size
female
Older age
irregular borders
location (upper lobes)
Family/ personal hx of lung Cancer.
Management of SPN < 0.6 cm, and > 0.8 cm with high probability of malignancy ?
<0.6 cm no surveillance needed
> 0.8 + high malig –> Bx or excision.
Lung Cancer Screening
Age: 50-80
> 20 pack year Smoking
Currently smoking or quit smoking within 15years
Granulomatosis with polyangitis pathophysiology ?
Small to medium vessels vaculitis, due to Abs against proteinase 3 on surface of Neutrophils.
c-ANCA positive, PR3-ANCA positive
Clinical features of Granulomatosis with polyangitis ?
ENT: chronic Rhinosinusitis
Upper and Lower Resp Tract infections and hemoptysis
Glomerulonephritis ( nephritic syndrome): Pauci immune and cresnteric appearancce ( proliferatio. of epithelial layer of bowmans capsule).
What is Acute bronchitis
Cough lasting > 5 days
post upper viral infection
yellowish sputum occasionally blood tinged
Normal vitals
O/e: Wheeze that clears with cough.
MC organism of Bronchiolitis ?
RSV
Palivizumab used in patients wth high risk of Bronchiolitis
Paradoxical breathing movement of the chest indicates ?
Phrenic nerve injury
Apnea of Prematurity
periods of > 20 seconds of no respiratory effort. asc with bradycardia and Hypoxia.
Related to immuature respiratory centers
Rx of Apnea of prematurity ?
Caffeine which stimulates resp. drive until centers mature ( 34-37 weeks)
CPAP.
causative organism of Croup
-ve sense, RNA Parainfluenza virus
CF of Croup
Barking cough especially at night
Hoarsness of voice ( dysphonia)
Inspiratory stridor
Subglottic edema and obstruction (steeple sign on Xray)
MC 3months and 3 years
Pathophysiology of Croup ?
Edema of proximal trache
hence treating with racemic epinephrine
Rx of Croup ?
Oxygen
Steroids
Nebulized epinephrine ( constriction of subglottic vessels, decrease hydrostatic pressure and as such decrease edema).
What is Acute epiglotitis ?
is a cellulitis of the supraglottic tissue due to H. infleunza B.
Also step pneumonea, staph aureus and Non-typeable H. infl.
CF of Acute epiglotitis ?
Muffled voice
Insp. Stridor
Drooling (dysphagia)
Fever (bacterial infection)
Tripod sign
Intercostal muscle retrations
CXR: thumb sign
Types of Lung Cancer ? and locations
Adenocarcinoma (peripheral)
Small cell Lung cancer (central)
Sqaumous cell lung cancer ( central)
Large cell lung cancer (peripheral)
Which Lung Ca. is asc with hypercalcemia, high PTHrP low PTH ?
Sqamous cell lung cancer
Which Lung Cancer is asc with SIADH, cushing Syndrome and Lambert Eaton Syndrome ?
Small cell Lung Can
Which Lung cancer causes SVC, hoarness and cough ?
Large Cell lung Cancer
Bronchial Carcinoid Ca. is MC in ?
Children/ young adults
CF of Seretonin syndrome
Diarrhea, flushing and hypotension
Type of Pancoast Tumors ?
MC sqamous cell
Location of Pancoast tumors ?
Apec of the lungs
CF of Pancoast Tumors ?
Shoulder pain and Upper limb weakness ( pressing on brachial plexus)
Horner syndrome ( pressing over the sympathetic chain, miosis, ptosis and anhidrosis)
How to prevent Post-op Atelectasis ?
- Deep breathing excercises
- Proper pain control
What are the causes of Post-op Atelectasis ?
Poor pain control (like abdominal pain, that results in poor cheste xpansion and alveolar collapse)
Mucus plug ( causing obstruction of airways and alveolar collapse)
Atelectasis due to bronchial mucus plug on CXR
Huge opacification
Mediastinal shift towards the side of Atelectasis
(o/e: decreased breath sounds and dullness to percussion).
Pulmonary Artery HTN is common in ?
Limited Cutaneous Systemic sclerosis
R ventricular heave ( over the L. parasternum).
When does a Fat Emboli Syndrome occur ?
24-72 hours after a ortho surgery or Fracture
Pathophysiology of GPS ?
anti-GBM abs ( against alpha3 chain of type IV collagen)
Management of Anaphylaxis ?
- IM Epinephrine ( can be repeated every 3-5 mins)
- IV fluids
- Albuterol for bronchoconstriction
- Steroids/ Anti histamines
- Glucagon to reverse Beta-blockers
CF of antiglomelural BM disease ?
Renal: hematuria, RBC cast with dysmoprhic RBCs
Pulmonary: hemoptysis, cough and dyspnea.
In case of Venous air embolism, in what position should the patient be placed and why ?
left lateral Decubitus. It prevents causing obstruction of RV outlet. Keep air emobli on the lateral wall of RV and with administration of oxygen allows for dissolving of air embolus with blood.
MC of CAP ?
Strep Pneumoniae
What is Cor pulmonale ?
Right sided HF due to Lung or Pulmonary vasculature causes (like COPD, PE, Bronchiectasis).
Rx of CAP based on severity
CURB-65
>3: admission to Medical ward… Betalactam+ macrolide or fluoroquinolone ( Avoided in elderly)
Inpt +ICU: Betalactam and macrolide or beta lactam + fluro
Outpt.
CF of Cor Pulmonale
Dyspnea
Cough
Syncope, chest pain on exertion
pitting edema
Possible Ascites
and features of underlying etiology
What is CURB-65 criteria
Used to decide management of patients with CAP
>65 y.o
Confusion
Urea high >20
RR >30
Bp < 90 sbp or <60 dbp
Signs of Cor Pulmonale
Distended Jv
Parasternal heave
Loud second heart sound often split (pulmonary part)
Clubbing
Hepatomegaly
Obstructive Pulmonary disease classification based on DLCO
Decreased DLCO: emphysema
Normal DLCO: Chronic bronchitis
Increased DLCO: Asthma
CF of Sarcoidosis
- Granuloma
- Uveitis anterior
- Erythema nodosum
- Arthritis
- Lupus pernio ( involvement of cheeks and nose)
- ILF
- Negative TB
- gammaglobulenemia
And of course Hypercalcemia signs and symptoms ( due to elevated alpha 1 hydroxylase that increase 1,25 dihydroxyvitamin D)
Guerling mnemonic
CXR findings of
1. chronic bronchitis
2. bronchiectasis
3. emphysema
- thickened bronchiovascular markings
- dilated airways
- obliteration of alveolar septa and hyperlucency of lungs
What type of Granuloma is seen in Sarcoidosis ?
Non-caseating granuloma
Adrenal Insufficiency
Hyoicorticolism ( drops in BP)
Hypoadrenalism ( hyponatremia and Hyperkalemia) exacerbated by release of ADH.
Lofgren Syndrome
Triad of:
Migratory polyarthritis (usually ankles and bilateral)
Erythema nodosum
Bilateral Hilar lymphadenopathy
and fever
If a Patient is having an Asthma attack and he still is maintaining normal PH and CO2 levels what does that indicate
the the patient is unable to keep a good ventilation despite the increased work of breathing due to muscle fatigue
SE of vasopressors
peripheral limbs (digital) ischemia
Mesenteric Ischemia
Acting on both alpha and beta receptors
SCD effect on the lungs
due to intravascular hemolysis –> endothelial injury and pulmonary vessels hyperplasia and remodeling and increased Pulmonary vascular resistance which causes decreased RV outflow and signs of R. sided HF ( hepatomegaly, distended JV and Peripheral edema).
What is Occupational Asthma ?
Asthma related to work place.
Asthma symptoms improve when away from work
Diagnosing Occupational Asthma ?
serial PEFR at home and work place
Skin prick test or Allergy specific serum IgE
Pathophysiology of Clubbing ?
Megakaryocyte escapes fragmantation in the lungs, deposits in distal Connective tissue and release FGF and VEGF leads to connective tissue hypertrophy and capillary permeability and vascularity
Indication for Thoracotomy ?
Bloody output >1.5l
> 200mls/hr over 2 hours
Complications of drowning ?
Aspirated fluid washes out surfactant and leads to hypoxemia and possible RDS.
Must be watched for 8 hours before discharge
What does a cavitary lUNG infiltrate with air fluid level indicate ?
Lung Abscess
ABx used to treat lung abscess of aneorobes g+
Ampicillin-Sulbactam
How does Sleeping position affect perfusion of lung ?
the side that is lower will receive more perfusion with the help of the Gravity
How does sleeping position affect lungs in case of Pneumonia
Patient sleeping on the side where pneumonia is present, means this side is more perfused ( but less ventilated in view of pneumonia) and as a result results in V/Q Mismatch
What is the MC mycosis in the US ?and how is it transmitted ?
Histoplasma Capsulatum. Transmitted from birds/ bats.
presented as granulmona with narrow based budding yeast
MC in cave = capsule
What is the indication of asbestos exposure on cxr
Pleural plaques
Linear opacities at lung bases
Dumbbells like ferriginous in alveolar sputum
What are the complications post Lung Transplant ?
Bronchiolitis obliterans/ Organnizing pneumonia
Pathophysiology of Chronic Bronchitis
Chronic inflammation with lymphocytes of submucosa which will eventually lead to fibromyxoid tissue in the airway lumen leading to obliteration.
Pathophysiology of Kartageners syndrome
defective dynein which leads to dysfunctional Cilia
CF of karatgeners Syndrome
Dextrocardia (Situs Inversus)
Sinopulmonary infections
Bronchiectasis
Infertility
Conductive hearing loss
What is Mesothelioma
is a malignancy that encases the lungs
After exposure 25-40 years of asbestosis
Leads to hemorrhagic pleural effusion
Asbestos exposure is high in
shipyard workers
plumbers
mining
people who work in insulation
tile worker
OSA
Patient hypoxic at night, develops hypercapnia that resolves when patient wakes up
OSA+ OHS (obesity hypoventilation syndrome)
hypoxia continues even during the day which leads to respiratory acidosis, kidneys will compensate for that by retaining HCO3- and decreasing cl- reabsorption.
low chloride.
Why do patients with OHS develop PHTN
in view of chronic hypoxic vasoconstriction
Step by step management of massive hemoptysis ?
- Patent airway (intubation)
- Bronchoscopy
- If it fails pulmonary angiography
- if the upper 2 fail, urgent thoracotomy
How does high flow oxygen affect patients with COPD ?
- High flow oxygen decreases the vasoconstriction (previously induced by hypoxemia) at the alveoli and thus increase v/q mismatch
- decreases respiratory drive ( the body will sense. more oxygen, so will decreade ventilation rate and thus co2 will accumulate)
- Increased oxyhemoglobin will reduce uptake of co2 from the tissues.
thus leading to confusion
Block 4, Q 9
How does hypoxic-ischemic brain injury affects the brain
hypoxia causes cell death and necrosis –> cerebral edema –>increased ICP –> Cushing triad ( bradycardia, htn and abnormal breathing).
What are the major risk factors for Ventilator-associated pneumonia ?
- Acid supression
- Subglottic secretions pooling
- Supine position
- Xs. sedation
- Xs. patient movement while intubated
CF of theophylline toxicity
Insomonia/ headaches
arrythmias
Vomiting
Who is Brunchopulmonary dysplasia diagnosed in ?
newbors who require ventilation > 28 days
What are the pathologic findings of Brunchopulmonary dysplasia ?
Decreased number and septation of alveoli
Common in Mechanically ventilated neonates in view of RDS.
Management of COPD exacerbation
- Oxygen
- Bronchodilators inh ( SABA and SAMA)
- Systemic steroids
- ABX if > cardinal signs
- NIPPV
- Intubation if NIPV fail
- Oseltamivir if Influenza posi.
What is the Antidote to Benzodiazepene ?
Flumazenil
Risk of Lung Ca. with exposed to Asbestose w/o smoking is increased by ?
x6
Risk of Lung Ca. w asbestos and smoking is increased by
x60
CF of interstitial Lung disease ?
progressive dyspnea
dry cough
bibasilar fine crackles
Finger nail clubbing
Asbestose exposure increases the risk of ?
Bronchogenic carcinoma with smoking ( cavitary lesion on xray and weight loss)
Mesothelioma (hemorrhagic Pleural effusion)
Thymus on CXR ?
Common in children < 3 years
Sail sign
Regresses at puberty
What are the best predictors of Post-op Pulmonary Morbidity
pre-op FEV1 and DLCO
Definition of ARDS
- Abnormal X-ray
- Resp. failure less than 1 week of a known trigger
- Decreased PaO2/ fIo2
- Exclusion of cardiogeneic pulmonary edema
Pathophysiology behind ARDS
Acute onset inflammation, leads to increased vascular permeability.
Neutrophils leave BV and attack alveoli, leading to edema ( intra aleveolar and interstitial). leading to hypoxia and hypercapnia
