Pulmonology Flashcards
How does ARDS cause pulmonary hypertension?
ARDS> pulm edema> alveoli collapse & decrease lung compliance
=== hypoxia
===== V/Q mismatch via DECREASED ventilation/perfusion ratio
»»»> pulm vessels constrict to shift blood to better ventilated alveoli > HTN
what EMERGENCY procedure is performed in a CICV situation?
crico-thyrotomy
racemic epinephrine is used for what winter time cough complication?
CROUP! Racemic epinephrine is used to treat bronchospasm and laryngotracheobronchitis (croup)
initial management in a child with epiglottis?
endotracheal intubation
asbestos exposure causes what 2 cancers?
mesothelioma
bronchogenic carcinoma
traumatic rupture of what mediastinal structure leads to respiratory distress and subcutaneous emphysema (air trapped in the face/neck/eyelids)?
traumatic bronchial rupture> face emphysema
fractures of the 1st/2nd ribs + depression of the left mainstem bronchus is mnemonic for ___
traumatic aortic rupture
low O2 sats with a NORMAL PaO2 =
methemoglobinemia
what is a common cause of methemoglobinemia in infants that live in high altitude places?
this occurs do to decreased activity in what RBC enzyme?
nitrate poisoning in mountain water> methemoglobinemia
Cytochrome b5 reductase, an enzyme in erythrocytes, reduces methemoglobin (MetHb) back to hemoglobin (Hb).
When compared to adults, infants have lower cytochrome b5 reductase activity, higher levels of fetal Hb (which is easily oxidized to MetHb), and consume more water per kilogram body weight; infants are therefore at higher risk of developing methemoglobinemia.
what are the 2 peripheral lung cancers?
adenocarcinoma & Large cell carcinoma of the lung
which lung cancer is NOT associated with SMOKING & is seen more commonly in women?
adenocarcinoma
adeNOsmoke
what T cell finding on bronchoalveolar lavage (BAL), is specific for Sarcoidosis?
ELEVATED CD4+ T-cell count in (BAL), particularly in association with an increased CD4+/CD8+ ratio, strongly suggests sarcoidosis.
what are the ACE levels in sarcoidosis?
increased
what are the PTH levels in sarcoidosis?
decreased PTH
increased expression of 1α-hydroxylase in macrophages»> hypervitaminosis D»_space; subsequent hypercalcemia = in low PTH levels due to the negative feedback mechanism.
pleural fluid with high levels of adenosine deaminase & lymphocytosis is mnemonic for what type of exudative effusion?
Tuberculosis!!!
mnemonic for the types of exudative effusions that have low glucose levels (<60)?
MEAT has low glucose:
Malignancy
Empyema
Arthritis (rheumatoid pleurisy) & SLE
Tuberculosis
are causes of pulmonary effusion associated with low glucose levels.
what nasopharygeal involvement is mnemonic for Granulomatosis with polyangiitis?
perforation/ulceration of the nasal septum, often leading to a saddle nose deformity
what is secondary bacterial pneumonia?
secondary bacterial pneumonia DIRECTLY LEADS to what other type of pneumonia?
bacterial pneumonia that occurs AFTER/secondary to a previous viral URI (ex. flu)
necrotizing pneumonia
what does necrotizing pneumonia look like on CXR?
CXR: lung cavitation & pneumatoceles (thin walled gas filled cysts)
Depending on patient characteristics, a TST can be positive with an induration > 5 mm, > 10 mm, or > 15 mm
Explain which pts would have a positive TST at each level of induration
> 5mm = HIV, immunocompromised/transplant, hx of TB
> 10mm = healthcare workers, IV drug use, homeless shelters, prisons, immigrants w/ 5 yrs, Children < 5 years of age, SICK pts (low BMI/DM/CKD) bc high risk or reactivation
> 15mm = healthy ppl w/ no other RFs
when does BCG vaccine immunity wane for TB?
it wanes 5 years after getting the vaccine. so always believe a TST induration is positive if its been >5 years after pt received the BCG vaccine
define empyema
Best dx imaging tool? what are the findings?
bacterial infection located in the pleural space!
CT chest= shows a SPLIT pleura sign = lenticular collection of pleural fluid & fibrin located between the pleural and visceral layer
Best management for empyema
place a large bore CHEST TUBE to drain contents + ABs + TPA (breaks the fibrin up)
what does the CXR of a PE look like? Why?
what is the serum pH abnormality in acute PE?
NORMAL CXR! NO ARDS/fluid bc PE causes obstructive shock = no blood can reach the lungs since its backed up by a clot in the pulm artery
= resp alkalosis (due to hyperventilation)
what are the Clx findings of a PE
- tachycardia, tachypnea (hyperventilation)
- CHEST PAIN
- hemoptysis
- hx/presence of a DVT
- hypotension (obstructive shock)
+/- JVD (is massive clot stuck in pulm artery causes backflow to Ratria)
new EKG finding in acute PE?
a new RBBB
what is the equation to dx ARDS?
PaO2 / FiO2 (always 0.21) will be <300 mmHg
what is the most common cause of ARDS?
what are other causes of ARDS?
Septic shock (infection after surgery) Acute pancreatitis!
Drowning ✓
PNA/aspiration ✓
What does Shunt Fraction (Qs/Qt) measure?
remember: Q= perfusion
Shunt Fraction = the amount of venous blood that is NOT oxygenized during a circulatory cycle.
will be HIGH in pulm edema/fibrosis (bc alveolar surface area is destroyed= less gas exchange occurs= dec oxygenation of blood)
Why does shunting take place?
What are the 2 types of shunting?
Shunting takes place to avoid a road block/obstruction
2 types of shunting:
- R>L : blood JUMPS from the RH to the LH (avoids pulm circulation/lungs)
- L>R : blood BACKTRACKS from the LH to the RH (avoids systemic circulation/aorta)
what is the etiology of R>L shunting ?
what does is the Clx sign?
5 Ts of EARLY congenital CYANOSIS:
1) Tetralogy of falot (pulm HTN + open ventricular defect= blood goes from RV> LV)
2) Transposition of the arteries (blood goes from RV> aorta instead of pulm artery)
3) Tuncus arteriosus (only one great vessel so blood goes from RH> systemic circ)
4) Tricuspid atresia (no tricuspid valve> blood goes from RA> LA via atria septal defect)
5) TAPVR (cyanotic bc pulm veins never return oxygenated blood to the LH)
what is the etiology of L>R shunting ?
what does is the Clx sign?
oxygenated blood is pushed backwards from LV>RV instead of going to systemic circulation >>>>septal defects: - ASD - VSD - AV septal defect
Clx = ACYANOTIC bc blood has already been through the pulm circ
What does Bronchiectasis look like on CT imaging?
dilated/enlarged Bronchioles
- parallel tram track sign
- signet ring sign (dilated bronchiole with little pulm arteries artery adjacent to it looks like a diamond ring)
what is the most common cause of non-tuberculous mycobacteria (aka Mycobacterium avium complex (MAC)) in immunoCOMPETENT/heathy pts?
Bronchiectasis!!
what is management/therapy for pts w/ Bronchiectasis?
- smoking cessation
- VACCINES (flu & pneumococal)
- chest physiotherapy & pulm rehab = improves breathing & teaches pulm hygeine
what is the management of Bronchiectasis pts who have had >/=3 exacerbations ?
Long term AB therapy (3 months)
patients that been mechanically ventilated for > 1 week with a Orotracheal intubation should be switched to what form of ventilation?
why?
Switch from Orotracheal to Tracheostomy (small opening in the trachea)
- safer & more comfortable
- pt wont have to be on so many sedation meds
- best way to start to ween pt off ventilation
what nerve is damaged during surgical/emergency airway management?
what vessel is damaged?
recurrent laryngeal nerve
anterior jugular vein
what nerve innervates the cricothyroid muscle?
What are the clinical findings when it is damaged?
The SUPERIOR laryngeal nerve innervated CRICKEYthyroid
> > > monotone voice; cant make high pitched sounds CANT GO UP/SUPERIOR
damage to what nerve > vocal cord paralysis?
Recurrent laryngeal nerve
is the breathing pattern in hypoventilation shallow or deep?
Hypoventilation = shallow (pt takes long, shallow breaths)
is the breathing pattern in hyperventilation shallow or deep?
Hyperventilation = DEEP (pt takes fast DEEP/exaggerated breaths)
a Total lung capacity of 50% is LOW. what pulm disease is this pathognomonic for?
low TLC= lungs CANT expand/dec compliance= restrictive lung disease
what are intrapulm & extrapulm causes of restrictive lung disease?
ILD
- ARDS, PNA, Hypersensitivity, GPA, etc
- Obesity (pregnancy, ascites prevents lung expansion)
- Resp muscle weakness (Myasthenia gravis, ankylosing spondylitis, kyphoscoliosis, Polio, GBS, ALS)
what sympathomimetic appetite suppressant causes pulmonary HTN?
diethylpropion
what is cor pulmonale?
== pulmonary heart disease
- acute (PE) or chronic lung disease > ultimate R ventricle dilation> right sided heart failure
Lights criteria for exudative/empyema ?
- LDH
- Protein
- Glucose
- pleural LDH / serum LDH»_space; 0.6
- pleural protein / serum protein»_space; 0.5
- pleural LDH is greater than 2/3 the upper limit of normal serum LDH (200)
- pleural glucose is < 60 (bacteria eat it up)
what are the acute (wks-months) vs chronic (years) cardiac pathology findings in radiation induced pericarditis?
Acute: radiation kill myocyte & releases inflammatory markers»_space; neutrophilic infiltration of the pericardium!
Chronic: pericardium bc STIFF/Fibrotic >constrictive pericarditis w/ fluid overload (JVD/edema)
what do yo administer to a pt w/ a MASSIVE PE (hemo unstable + cor pulmonale RHF)?
thrombolytic (tpa or rtpa)
chronic complication of ARDS?
ILD/ restrictive lung disease
ARDS = diffuse alveolar damage > proliferation of type II pneumocytes and infiltration of fibroblasts, ultimately leading to progressive interstitial fibrosis and restrictive lung disease.
chronic complication of COPD/emphysema?
spontaneous pneumothorax (alveoli get stretched then pop/deflate)
