Pulmonology Flashcards
normal right atrial pressure
0-7 (reflects venous return during systole and RV EDP during diastole)
normal right ventricular pressure
15-25/3-12 (measured during catheter insertion)
normal pulmonary artery pressure
15-25/8-15 (elevation associated w/ dx that increase pulm artery pressure and affect pulmonic valve)
normal L atrium pressure
3-12
ground glass opacities on CXR or chest CT indicate one of the following:
water, mucus, blood (think diffuse alveolar hemorrhage: which can be anything from infectious to drugs to connective tissue etiology) or pus. fibrosis around the alveoli can give ground glass opacities as well
causes of pulmonary HTN include:
group 1: pulmonary vascular dx (PAH)
group 2: L heart dx
group 3: lung dx or hypoxia
group 4: chromic thromboembolic dx
group 5: misc. (such as hemolytic anemia, sickle cell, sarcoid, etc…)
PCWP represents
an estimation of L atrial pressure
PCWP is measured by
patient in the supine position, and catheter insertion into zone 3 of the lung at the end of expiration
normal PCWP is
6-15 (mean of 9)
importantly, other than L atrium pressure, PCWP also estimates
LV EDP
lots of conditions cause high PCWP, a few causes of low PCWP include
hypovolemia (such as hemorrhagic shock), pulmonary venooclusive dx, obstructive shock due to large PE
normal cardiac index is
2.8-4.2 L/min/m^2
causes of low cardiac index include
systolic/diastiolic HF, severe mitral regurg, hypovolemia, pulmonary HTN, and RV failure
only clinically proven scenario where incentive spirometry is useful
acute chest syndrome
what are values you must check w/ inhalation injury from smoke
methemoglobin and carboxyHb
best way to read a CT chest
A - airway
I - interstitium
C - cavitation
first line for prevention of bronchospasm
albuterol
what should you do if a Pt has failed inhaler use and cannot pull medication very well?
should set that patient up for success and make sure to prescribe the nebulized version of that medication instead
PAH is defined as a resting mean pulm artery pressure of _____ or more
> 25 mmHg
mutations in ____ gene increase risk of heritable PAH
BMPR2 (type II bone morphogenetic protein receptor)
PAH vascular targeted medications
prostaglandins, PDE-5 inhibitors, endothelin receptor antagonists, and soluble guanylate cyclase stimulators
pre-capillary pulm HTN definition
> 3 woods units (mmHg/L per min) PVR on RHC and decreased PCWP pressure <15 (caused by PAH, chronic lung disease, chronic thromboembolism, or certain multi-factorial mech)
post-capillary pulm HTN definition
increased PCWP w/ typically normal PVR (most often caused by L heart dx)
right ventricular systolic pressure (an important indicator of PH when increased) is determined from doppler U/S by:
tricuspid regurg. jet flow + estimated R atrial pressure
___ is the diagnostic test of choice for exclusion of chronic pulmonary thromboembolic pulm HTN (CTEPH)
ventilation/perfusion scan (more sensitive than CTPA in identifying distal issues)
difference between PH d/t PAH vs HFpEF (since they both have normal LV function but with abdominal LV diastolic function)
HFpEF will have increased L atrial size on echo and increased PCWP on RHC (important to distinguish between these 2 things since PAH specific therapies are NOT useful for HFpEF)
If a PCWP cannot be measured by RHC, what is the next step if an accurate one is needed?
LHC for measurement of LVEDP
why are posterior effusions harder to tap?
the ribs are closer together, more round, and that means the neuro-vascular bundles are harder to avoid
why is it so important to distinguish between pre-capillary vs post-capillary pulmonary HTN?
if it is a mixed picture and you start treating this as a pre-capillary disease (such as with PDE-5 inhibitors), you can cause flash pulmonary edema and can be a very serious complication
on BAL, what cell counts are you looking for?
macrophages, lymphocytes, and more importantly, eosinophils (such as for determining eosinophilic PNA)
what are the 2 most common drug causes of PAH?
methamphetamines/cocaine and weight loss drugs (since many have amphetamines in them)
workup for PH
echo, connective tissue dx workup (if warranted), HIV testing, PFTs, V/Q scan (CTEPH), and others depending on hx
Most common cause of AECOPD is
Infectious (specifically viral)
AECOPD is defined as
Any acute worsening of respiratory sx from baseline in a Pt with COPD that requires additional therapy
What is one supplement that you should always check in Pt admitted for AECOPD?
Vitamin D (there are studies linking treatment of vitamin D deficiency and decreased hospitalizations and exacerbations in Pt with COPD since it supports innate immune system against respiratory infections specifically)
Which bronchodilators should you use for AECOPD?
Albuterol and ipratropium bromide (anti-muscarinic) (SAMA)
Dosing of prednisone for AECOPD
40 mg daily for 5 days
Most common abx for AECOPD
Azithromycin 500 mg PO day 1, and then 250 mg 1x daily for 4 days
Blood gas findings for acute asthma exacerbation
Initially respiratory alkalosis, respiratory acidosis is a late finding and pretty indicative of impending respiratory failure
what is the most important number in terms of diagnostics from a pleural effusion?
pH (if significantly low (looking for well below 7.2), then this is very supportive of infectious etiology)
what is the threshold for being able to remove a chest tube from a patient?
if pulling <100 cc/day and clinically improving
what do eosinophils in pleural fluid represent?
either trauma or blood (activation of inflammatory markers cause mobilization of eosinophils)
what should you do first if chest tube is not draining?
check tube placement and flush
what should you do if chest tube is still not flushing w/ empyema that is extremely thick?
initiation of tPa-DNAse therapy
how long do you initiate tPa-DNAse therapy for empyema?
usually 3 days BID (intrapleural)
what is next step if Pt fails chest tube pull (and had multiple chest tubes if neededP and attempted tPa-DNAse if indicated?
VATS (thoracic surgery to do a washout)
how long does a Pt need to be on abx for an empyema?
around 4-6 weeks
how does tPA-DNAse work?
breaks down DNA of extracellular material in empyema/mucus and in combination with the fibrinolytic (tPA) (studies have shown combination of these 2 in combination led to less need for surgical intervention for washout, and interestingly, they were not better than placebo when given on their own compared to combination therapy)
what is Light’s critera?
<0.5 protein (fluid/serum), <0.6 LDH, or <2/3 upper limit of normal LDH is most likely transudative (just think about the more shit in there, there has to be something going on in the pleural fluid producing those cells
what is a potential serious complication of tPA-DNAse therapy?
pleural hemorrhage (this is why clamping and unclamping the chest tube within an hour during therapy is really important)
Pneumonia criteria for hospitalization
CURB-65 (confusion, uremia (>7 mmol), respiratory rate >30, BP <90/<60), age >65
>2 points = hospitalization recommended
what is the clinical triad for DAH?
hypoxemia, drop in Hb of >1, and diffuse infiltrates on imaging
what is one way you can qualify someone for home O2/CPAP if they do not have it already, no sleep study, and need it once they leave the hospital?
you can do bedside spirometry and prove that if it shows a restrictive pattern and the patient is monitored on SpO2 throughout the night on room air and if it proves that there are desaturations at night and this improves with putting a CPAP mask on, this may be able to qualify them for a mask without a sleep study
what will you see in the pleural fluid cell counts with a pancreatic-pleural fistula?
really elevated amylase
