Pulmonology Flashcards
diminished breath sounds bilaterally with scattered expiratory wheezes & prolonged expiratory phase describes what illness?
COPD
In patients with severe, acute asthma, ____ PaCO2 suggests respiratory muscle weakness & impending respiratory failure, which require mechanical ventilatory support.
elevated or inappropriately normal
Long-term ____ therapy has been proven to prolong survival in patients with COPD and significant chronic hypoxemia.
supplemental oxygen
The criteria for initiating LT Oxygen therapy in COPD pts include:
- Resting PaO2 __%.
55
59
Hct >55
What is the most effective measure to decrease mortality in patients with COPD?
Smoking Cessation
- LTOT is associated with decreased mortality ONLY in pts with COPD + significant hypoxemia (PaO2 <59-55)
____ deficiency should be considered in pts with COPD sxs who are <45 or have no/minimal h/o smoking, or a FMH of emphysema or liver disease.
Alpha-1 antitrypsin (AAT)
Tx: IV- AAT supplements + bronchodilators & corticosteroids
4 Common causes of chronic cough include
Asthma
GERD
Upper airway cough syndrome (post-nasal drip)
ACE inhibitors
Patients can have chronic hypoventilation s/t (3)
resulting in a gradual increase of PaCO2
COPD
Obesity hypoventilation syndrome
Neuromuscular disease (Ank Spondy, MS)
Patients with chronic hypoventilation result in gradual increases in PaCO2 that result in chronic respiratory acidosis; to compensate, the kidneys increase HCO3- retention, creating a chronic _____.
secondary metabolic alkalosis
Renal tubular compensation
Increased ___ ventilation is the main cause of hypercapnia in COPD and worsens the respiratory acidosis.
dead space
All pts with acute exacerbation of COPD should receive inhaled ____ & systemic ____.
PLUS: supplemental oxygen, ABx, and ventilatory support, if indicated.
Bronchodilators (β2 agonists & ipratropium/tiotropium)
Glucocorticoids* (IV methylprednisolone/ PO Prednisone)
*improve lung function, hypoxemia & decrease risk of relapse, treatment failure, and length of hospital stay.
The 1st mainstays of treatment for COPD are
inhaled bronchodilators like ___ + ___
Albuterol ( SA β2 agonists)
Ipratropium/ Tiotropium (anti-cholinergic/muscarinic)
___ + ___ may be used in the maintenance therapy of
more severe COPD not controlled by bronchodilators
Inhaled steroids (Fluticasone) Long-acting β2 agonists (Salmeterol)
Patients admitted for acute COPD exacerbation now has headache, delirium, and lethargy. Next best step in evaluation?
get an ABG
rising levels of PaCO2 >75 can cause neuro sxs, coma or seizures
CO2 narcosis is when a pt goes into ____
s/t PaCO2 > __
coma
75+
pulmonary flow-volume loop characteristic for Asthma/ COPD: “______” pattern
“scooped-out” pattern
pulmonary flow-volume loop characteristics for restrictive lung disease:
Low/narrow lung volumes
+
Low expiratory/inspiratory flow rates
pulmonary flow-volume loop characteristics for a fixed upper-airway obstruction: “______” pattern
“Cheese-burger” pattern
Flattening of both the top & bottom of the flow-volume loop.
DLCO is
__ in chronic bronchitis
and
__ in emphysema predominant COPD
normal
decreased
Paradoxical vocal fold motion (PVFM) aka vocal cord dysfunction presents like exercise asthma.
Vocal cords inappropriately adduct (close) during inspiration, causing laryngeal obstruction diagnosed via [imaging].
Long-term treatment primarily consists of therapy with a
Laryngoscopy
speech-language pathologist
*Episodes may be triggered by strong smells, stress, or exercise
Transfusion-related acute lung injury typically occurs within minutes to 6 hours of blood product transfusion.
It manifests with acute hypoxemic respiratory failure, crackles/rales, and [seen on CXR] .
BILATERAL pulmonary infiltrates
How to differentiate TRALI vs TACO:
- BNP
- JVD
- S3
- EF
- TACO = ↑ BNP (vs wnl)
- TACO = JVD Present (vs none)
- TACO = S3 Present (vs none)
- TACO = ↓EF (vs wnl)
Hyperinflation on CXR, Wheezing, Dyspnea =
Bronchoconstriction
As seen in (2)
Asthma, chronic bronchitis
presents with acute dyspnea, Hypotension, JVD, unilaterally absent breath sounds and pleuritic chest
Tension pneumothorax
Increased pulmonary vascular resistance (PVR) leads to Right Ventricular (RV) stress and dilation =
- Signs of right-sided ___ develop.
- ↑ Intensity of __ sound.
- __ DLCO s/t loss of vasculature
- congestion (pedal edema, hepatomegaly)
- Pulmonic component of S2 (loud P2).
- ↓ DLCO
* Narrowing of pulm arteries → RV systolic failure & ↓ CO bc impaired LV filling.
Injury and narrowing of terminal airways non-reversible air outflow limitation ↓ DLCO ± normal CXR Diagnosis?
Bronchiolitis obliterans (COPD)
Exertional dyspnea
↓ DLCO (parenchymal scarring)
Fine inspiratory crackles (velcro)
Diagnosis?
Pulmonary fibrosis (restrictive lung disease)
[Medication] may worsen bronchospasm in patients with exacerbation of COPD. Avoid them.
𝛽 blockers
Diagnosis is made by renal biopsy showing linear IgG antibodies along the glomerular basement membrane.
Diagnosis?
Anti–glomerular basement membrane disease
(Goodpasteur’s Syndrome)
Antibodies agains lung BM (cough, dyspnea, and hemoptysis) and kidneys BM (nephritic range proteinuria <3.5 g/day, acute renal failure, and dysmorphic red cells/red cell casts on UA).
Systemic symptoms are uncommon.
Presents with RAPIDLY worsening cough, fevers, chills, and dyspnea.
CXR = Alveolar infiltrates, Opacification, Consolidation
Diagnosis?
Bacterial pneumonia
A Chest CT scan showing a peripheral, wedge-shaped infarction is virtually pathognomonic for
pulmonary embolism
Pt with dyspnea and JVD
CXR = peribronchial thickening; prominent pulmonary vascular markings; and patchy, perihilar opacities
General Lung Diagnosis?
Pulmonary Edema
(pleural/serum) LDH ratio >0.6
(pleural/serum) protein ratio >0.5
suggest a ____ pleural effusion
Exudative effusion
↳due to inflammation with a
↳pleural fluid pH 7.30–7.45
➣Normal pleural fluid pH: 7.60
Pleural fluid pH <7.30 (+ low pleural glucose <60 mg/dL)
or
(pleural/serum) glucose ratio <0.5 usually s/t:
1.
2.
➣Normal pleural fluid pH: 7.60
Bacteria (empyema)
Tumors, (& TB, Rheumatoid arthritis)
women in early and middle adulthood with chronic progressive dyspnea & inspiratory crackles.
CXR = interstitial reticular opacities, parenchymal scars
General Lung Diagnosis?
Interstitial lung disease (ILD)
↳can cause PH (group 3)
Classically triad of: – respiratory distress (tachypnea, hypoxemia) – neurologic dysfunction (confusion) ± petechial rash ± Thrombocytopenia
Develop Pulmonary edema (mimicking ARDS after 1-2d) ↳Bilateral ground-glass opacities on chest CT
↳No pulmonary arterial filling defects
Fat Embolism Syndrome
A chemical irritation of the lung parenchyma that can lead to ARDS and respiratory failure.
+ Fever & Leukocytosis
Patients with periods of impaired consciousness (seizure, alcohol use, stoke, multiple sclerosis w bulbar sxs) are most commonly affected.
Aspiration pneumonitis
*onset is insidious (progressing over several weeks)
[↑/↓] Alveolar-arterial oxygen gradient is commonly seen in Pulmonary Embolism
↑ A-a Gradient
*Wheezing can occur in acute PE.
Hypoalbuminemia can cause transudative pleural effusions due to decreased ___ pressure.
oncotic
Non-caseating granulomas in the lungs s/t a reaction from environmental antigens like dust or dandruff.
CXR ± reticular, nodular, or alveolar opacities
↳No cavitations
Diagnosis?
Hypersensitivity pneumonitis
