Pulmonary diseases Flashcards
COPD - Classifications
Two classic types; Chronic Bronchitis and Emphysema.
Chronic B is a clinical diagnosis: chronic cough productive of sputum for at least 3 months per year for at least 2 consecutive years(excess mucus narrows airways, inflammation and scarring).
Emphysema is a pathologic diagnosis: permanent enlargement of air spaces distal to terminal bronchioles due to destruction of alveolar walls.(Excess protease or deficiency of antiprotease -> PMN and macrophages digest human lung)
- The two often coexist.
Most common RF: smoking, a1-antitrypsin-def.
COPD - Symptoms, Dx
Sx:
Cough, sputum production, dyspnea.
Signs:
Prolonged expiratory time, end-expiratory wheezes on forced expiration,decr. breath sounds and/or inspiratory crackles. Tachypnea, tachycardia, cyanosis, use of accessory resp. muscles
Dx:
- Pulmonary function testing (spirometry) = Def. diagnostic test.
- Decreased FEV1 and decr. FEV1/FVC ratio - GOLD staging.
- The FEV1/FVC ratio is < 0,70
- Increased TLC, residual volume, FRC (indicating air trapping)
CXR: Hyperinflation, flattened diaphragm, diminished vascular markings
- Measure A1-antitrypsin levels
Arterial blood gas - Chronic PCO2, retention, decr. PO2.
COPD - Tx
Smoking cessation - the most important intervention (prolongs the survival rate but does not reduce it to the level of someone who has never smoked)
- Inhaled anticholinergic drugs (ipratropium bromide)
- Inhaled B2-agonists (e.g albuterol)
- Those two best in comination - Inhaled corticosteroids (budesonide, fluticasone)
- Theyphylline (oral) - role is controversial
- Oxygen - shown to improve survival and quality of life
- Pulm rehab + Vaccination
- AB given in acute exacerbations
- CPAP-BiPAP given in acute exacerbations if tx above is not enough
- Intubation and mechanical ventilation if needed (if increasing RR, increasing PaCO2and worsening acidosis)
- Do not use inhaled corticosteroids in acute exacerbations.
COPD - Cx
- Acute exacerbations (bc infection, noncompliance, cardiac disease)
- Secondary polycythemia (Hct >55% in men or >47% in women) - compensatory mechanism to chronic hypoxemia
- Pulm HTN and cor pulmonale
Asthma - General
Characteristic by the following triad:
a) Airway inflammation
b) Airway hyperresponsiveness
c) Reversible airflow obstruction
Can begin at any age.
Extrinsic asthma - starts early age, often in combination w/atopy.
Intrinsic asthma - not related to anything else
Asthma - Clinical
SOB, wheezing, chest tightness and cough. Usually occur within 30min of exposure to triggers. Usually worse at night.
Wheezing (during both inspiration and expiration) is most common finding on physical examination.
Asthma - Diagnosis
- Pulmonary function tests (PFT) - Decr in expiratory flow rates, decr FEV1 and decr. FEV1/FVC ratio (<0,70)
- Spirometry before and after bronchodilators
- Peak flow (Peak expiratory flow rate)
- Bronchoprovocation test (when PFT are nondiagnostic)
- CXR - to rule out other
- ABG - Hypocarbia is common. Hypoxemia may be present
Asthma - Tx
- Inhaled B2-agonists (e.g albuterol in acute, salmeterol in nighttime and excercise-induced)
- Inhaled corticosteroids for moderate to severe asthma.
- preferred over oral steroids due to fewer systemic side effects. - Montelukast - Leukotriene modifiers - useful for prophylaxis
- Chromolyn sodium/Nedocromil sodium
- Acute severe asthma:
- Inhaled B2-agonist
- Corticosteroids
- IV magnesium
Asthma - Cx
- Status asthmaticus - does not respond to standard meds.
- Acute Respiratory failure (due to resp. muscle fatigue)
- Pneumothorax, atelectasis, pneumomediastinum
Bronchiectasis - General, Causes
Permanent, abnormal dilation and destruction of bronchial walls with chronic inflammation, airway collapse, and ciliary dysfunction leading to impaired clearance of secretions.
- Less common today bc/o modern AB are used for resp. infections.
Causes:
Cystic fibrosis is most common in western world
Tuberculosis most common in undeveloped countries
Recurrent infections (airway obstruction, immuno.def)
Primary ciliary dyskinesia (e.g Kartagener syndrome)
Bronchiectasis - Clinical, Dx, Tx
Chronic cough with large amount of mucopurulent, foul-smelling sputum, dyspnea, hemoptysis, recurrent pneumonia.
Dx: High-resolution CT-scan
PFTs, Bronchoscopy
Tx:
- AB for acute exacerbations - superimposed infections are signaled by change in quality/quantity of sputum, fever, chest pain
- Bronchial hygiene - hydration, physio, inhaled bronchodilators
Cystic fibrosis
Autosomal recessive - primarily affecting Caucasians
Defect in chloride channel protein -> impaired chloride and water transport, which leads to thick, viscous secretions in the resp.tract, exocrine pancreas, sweat glands, intestines, and GU-tract.
- Obstructive lung disease w chronic pulm. infections (often Pseudomonas)
Tx: Pancreativ enzyme replacement, fat-soluble vitamin supplements, chest physical therapy, vaccines, tx of infection with AB, inhaled recombinant human deoxyribonuclease (rhDNase)
Lung cancer - General
Two subtypes:
a) Small cell lung cancer (SCLC) - 25% of lung cancers
b) Nonsmall cell lung cancer (NSCLC) -75%, includes squamous cell carcinoma, adenocarcinoma, large cell carcinoma and bronchoalveolar cell carcinoma.
RF: Smoking, second-hand smoke, asbestos, radon, COPD
Staging:
a) SCLC is staged by 1) Limited - confined to chest plus supraclavicular nodes, but not cervical or axillary nodes, 2) Extensive - outside of chest and supraclavicular nodes
b) NSCLC - staged via TNM system
Lung cancer - Clinical
Cough, hemopthysis, obstruction, wheezing, dyspnea. Recurrent pneumonia. Anorexia, weight loss, weakness.
If local invasion:
- Superior vena cava syndrome - most commonly occur with SCLC.(-> facial fullness, facial and arm edema, dilated veins over ant. chest, arms and face. JVD)
- Phrenic nerve pasy
- Recurrent laryngeal nerve palsy
- Horner syndrome - due to invasion of cervical sympathetic chain by an apical tumor. (-> unilateral facial anhidrosis, ptosis and miosis
- Pancoast tumor - an apical tumor involving C8and T1-T2, causing shoulder pain radiating down the arm.
- Metastatic disease - brain, bone, adrenal glands, liver
- Paraneoplastic syndromes:
a) SIADH
b) Ectopic ACTH secretion
c) PTH-like hormon secretion
d) Hypertrophic pulm. osteoarthropathy.
e) Eaton-Lambert syndrome
f) Digital clubbing
Lung cancer - Dx and Tx
Dx:
CXR: most important in diagnosis
CT w iv contrast: Useful for staging, checking for metastasis
Cytologic examination of sputum - can diagnose central tumors in 80%.
Fiberoptic bronchoscope - not for peripheral lesions
PET scan - for a bigger picture
Transthoracic needle biopsy- for peripheral lesions
Mediastinoscopy
Tx:
NSCLC:
- Surgery is best option. BUT pts. w metastatic disease outside the chest ar not! candidates for surgery. Recurrence may occur even after complete resection.
- Radiation therapy - in adjunct to surgery
- Chemo - if uncertain benefit
SCLC:
Limited disease: chemo+radiation
Extensive: Chemo, then prophylactic radiation.
Surgery has limited role bc tumors are often nonresectable.
Pleural effusion - General
Caused by one of the following:
- Incr. drainage of fluid into pleural space
- Incr. production of fluid by cells in the pleural space
- Decr. drainage of fluid from pleural space
- Transudative effusions: either:
- Elevated capillary pressure (e.g CHF)
- Decr. plasma oncotic pressure (e.g Hypoalbuminemia) - Exudative effusions:
- Incr. permeability of pleural surfaces or decr. lymphatic flow from pleural surface because of damage to pleural membranes or vasculature. IF suspected exudate: do test of pleural fluid: diff. cell count, protein, LDH, glucose, pH, amylase, TG, microbiology and cytology. Ex.effucion have at least oneof the “Light’s Criteria”: 1) Protein >0,5, LDH>0,6, LDH > two-thirds the upper limit of normal serum LDH.
Pleural effusion - Causes
- CHF most common
- Pneumonia
- Malignancies (lung (36%), breast (25%), lymphoma(10%)
- Pulm embolism
- Viral diseases
- Cirrhosis with ascites
Pleural effusion - Clinical
Sx: Often asymptomatic Dyspnea on excertion Peripheral edema Orthopnea, PND
Signs:
Dullness to percussion
Decr. breath sounds over the effusion
Decr. tactile fremitus
Pleural effusion - Dx and Tx
Dx:
CXR: look for:
- Blunting of costophrenic angle
- About 250ml of pleural fluid must accumulate before an effusion is detected
- Lateral decubitus films: more reliable than PA and lateral CXR for detecting small pleural effusion.
CT: More reliable than CXR for detecting effusions
Thoracocentesis: useful if etiology is not obvious. Also therapeutic - drainage provides relief for large effusions.
Tx:
- Transudative effusion:
- Diuretics and sodium restriction
- Therapeutic thoracentesis - only if its causing dyspnea - Exudative effusions: treat underlying disease
Empyema - Causes and Clinical
Causes:
Exudative pleural effusions, if left untreated, can lead to empyema (pus within the pleural space)
Most cases bc complication of bacterial pneumonia, but other foci of infection can also spread to pleural space.
Clinical:
Those of the underlying disease (pneumonia most common)
Dx: CXR and CT
Tx: Treat with aggressive drainage of the pleura (via thoracentesis) and AB therapy.
- If empyema is severe and persistent, rib resection and open drainage may be necessary.
Pneumothorax - General
Air in the normally airless pleural space.
Two major categories: Spontaneous and traumatic pneumothoraces
- Traumatic pneumothoraces are often iatrogenic.
- Spontaneous pneumothorax occurs without trauma.
Spont. pneumothorax:
- Primary (simple) pneumothorax
- Occurs in healthy individuals
- Bc spontaneously rupture of subpleural blebs at apex of lungs - espace of air from the lung into pleural space causes lung to collapse.
- More common in tall, lean young men
- Usually are healthy enough to spare resp.distress - Secondary (complicated) pneumothorax
- Occurs as a complication of underlying lung disease(e.g COPD, Asthma, Interstitial lung disease, neoplasm, CF, TB)
- More life-threatening bc lack of pulm.reserve in these pts.
Pneumothorax - Clinical, Dx, Tx
Clinical:
- Ipsilateral chest pain, usually sudden in onset
- Dyspnea
- Cough
Physical:
- Decr. breath sounds over affected side
- Hyperresonance over the chest
- Decr. or absent tactile fremitus on affected site
- Mediastinal shift toward the site of pneumothorax
Dx:
CXR . shows the visceral pleural line (Black)
Tx:
- Priamary spontaneous pneumothorax
a) If small and asymptomatic pt.
- Observation - should resolve spontaneously in ca.10d
- Small chest tube may benefit some pt.
b) If larger and/or symptomatic pt.
- Administration of supplemental O2
- Needle aspiration or chest tube insertion to allow air to be released and lung to reexpand. - Secondary spontaneous pneumothorax: chest tube drainage.
