Pulmonology Flashcards
which lobe makes up most of the posterior side?
lower lobe
where do the vast majority of communal infections end up in the lung?
in the R middle lobe–because the bronchus for the right side has a much steeper slope
what structures make up the upper air conduction tract?
nasophayrnx, oropharynx, larynx
what structures make up the lower air conduction tract?
trachea, primary bronchi, bronchial tree bifurcation (bronchioles, alveoli)
what structures make up the respiratory tract?
the respiratory bronchioles and alveoli
which phase of respiration is active?
inspiration
what is the tidal volume? whats a normal amount?
the amount of air we move in and out in respiration. normal is 500 mLs of air per breath
how do you find minute volume?
Respiratory rate x tidal volume=amount of air moved per minute
descibe dyspnea
o Subjective description of difficult, labored or uncomfortable breathing.
• “shortness of breath”
• “breathlessness”
• “not getting enough air”
what physiologic process is difficult for someone with SOB and pursed lips who leans forward?
hard for them to get air out
what disease is signified by “pink puffers”?
usually emphysema
describe orthopnea
dyspnea in recumbent position
what are typical causes of orthopnea?
CHF=pulmonary edema, volume overload, or COPD
what is the nickname for people with orthopnea?
blue bloaters
dyspnea in recumbent position. Can’t breathe against gravity
orthopnea
orthopnea that wakens pt from sleep, feels like drowning. Often described as need to sit up abruptly to breathe after they’ve layed down to sleep. often associated with left sided heart failure
pND
dyspnea in upright position
platypnea
hyperventilation: minute ventilation in excess of metabolic demand
hyperpnea
"When someone blows off more co2 and have alkalosis (getting rid of hydrogen ions) Associated with: hyperventilation hypocalcemia. "
carpopedal spasms
what are some possible causes of carpopedal spasms?
pituitary tumors (hypocalcemia), MI, PE, anxiety attack
tactile vibrations felt from pulmonary tree through chest wall
tactile fremitus
The phenomena of increased volume and clarity of sounds transmitted through a solid or liquid opposed to through air.
Same thing as vocal fremitus except instead of feeling we are listening with our stethoscope
bronchophony/egophony
normal, symmetrical upward and outward movement of the ribs and chest wall during inspiration.
chest wall expansion
Refers to the movement of the diaphragm from its high resting position to its lower, flattened position when it is flexed in inspiration.
diaphragmatic excursion
what are some conditions that can cause a decreased diaphgragmatic excursion?
fluid in pleural space–weighs on diaphragm and diaphgram can’t passively push against it. Phrenic nerve paralysis.
stable complex of carbon monoxide and hemoglobin that forms in red blood cells when carbon monoxide is inhaled, and hinders delivery of oxygen to the body.
carboxyhemoglobin
how do you tx someone with carboxyhemoglobin?
hypobaridc oxygen Put them in a chamber that puts them at much much higher pressure and what happens is it breaks the bind between c02 and hgb and allows o2 to go in and compete
how does a pulse oximeter work?
Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through. Deoxygenated (or reduced) hemoglobin absorbs more red light and allows more infrared light to pass through.
what is vesicular breath sounds?
Soft and low pitch. They are heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration. Because no pressure in there to make noise.
in which breath sounds are most of the disease?
vesicular
what are bronchovesicular breath sounds?
With inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration.
what are bronchial breath sounds?
Louder and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds.
what are rales?
intermittent, nonmusical, brief lung sounds, higher pitched, usually heard first in inspiration and may be heard in both insp/expiration in later disease processes. alveoli get stuck together and pop when opened on inspiration like rice krispies
Relatively high pitched with a musical quality.
wheezing
what can cause rales?
pneumonia, pulmonary edema
when is wheezing normally heard?
usually in expiration, if heard in inspiraton this marks a more advanced disease
like rales but more low pitched; suggstive of secretions in larger airways, changes with cough
rhonchi
what disease processes may cause rhonchi?
chest cold, bronchitis, lower respiratory tract disease
what are the most important pieces of a pulmonary hx?
r/o alarm sx/emergency first, current complaint onset: acute or chronic; ROS of cardiac, pulm, GI; meds and environmental allergies; social: smoking, occupational exposures, asthma, sinusitis, recent respiratory infections, TB exposure, CAD, and esophageal disease, fmhx: pulmonary disease like asthma, COPD and any exposure to second hand smoke.
what are 6 important pulmonary risk factors?
smoking, aspiration (GI tube, alcoholics that pass out), debilitation (alcoholism, age, immunosuppression), chronic disease (DM, CKD, MS, guillan barre, myasthenia gravis), pulmonary diseases (COPD, asthma, cystic fibrosis, emphysema, chronic bronchitis, hereditary antitrypsin 1 deficiency)
what can be caused by the hereditary A
1 antitrypsin deficiency
without this important enzyme, they will make less mucous production to protect lining of alveoli
and they will have respiratory irritation from smoke and will never reproduce mucus in lungs and will have chronic inflammation and emphysema
what should be observed upon inspection during a pulmonary exaM?
shape and movement of chest wall, symmetry (notice any flail chest), deformities, accessory muscle use like carved out above clavicle or retractions in intercostal space, skin color, clubbing of nails,
what do retractions in intercostal space signify?
recruiting accessory muscles to help breathe
what’s the technical name for broken bone ends crunching together?
crepitus
what are you palpating for on a pulmonary exam?
tenderness on chest, instability or crepitus from trauma, chest wall expansion, vocal fremitus
what do you use the vocal fremitus test to assess? what do increased or decreased findings mean?
assessing for fluid or air in chest: increased vibrations (fremitus) indicates fluid in chest,decreased fremitus indicates no contact between lung and hand and signifies possible air in thoracic cavityfrom pneuothorax, pleural effusion, etc
where are bronchovesicular breath sounds heard best?
over the large airways, especially on the right
where will you hear an area of dullness when percussing the chest?
form the 3rd-5th intercostal spaces on the left side=where the heart is
where are breath sounds usually the loudest?
upper anterior chest
what are the most common causes of acute coughs?
URI lower respiratory tract infections acute exacerbation of COPD allergic rhinitis rhinitis due to irritants irritants to bronchial tree
what is the most common cause of subacute coughs?
post inflammatory after pneumonia or something
what are the most common causes of chronic coughs?
COPD chronic sinus drainage asthma GERD If lay down too soon after eating
Meds
ACEI
Think about it whenever you increase a dose
Can be highly delayed—may take 3-6 months
Psychiatric
Anxiety and OCD can manifest as coughs
Up to 25% of smoker have a chronic daily cough
what do each of these alarm sx for cough signify?
Cough with hemoptysis
Cough, fever, and purulent sputum production
Cough with wheezing and dyspnea
Cough with chest pain
Cough with excessive sputum production
Cough with unintentional weight loss
Cough, dyspnea, and lower extremity edema
Cough with hemoptysis–bacterial pneumonias, chronic bronchitis, bronchiectasis, TB, lung abscess, cancer, left ventricular failure or mitral stenosis, pulmonary emboli
Cough, fever, and purulent sputum production
Severe infection
Cough with wheezing and dyspnea
At risk of not breathing anymore
Urgent evaluation and tx
Cough with chest pain
Could be pleuritic if PE
Evaluate quickly and rule out the bad stuff
Cough with excessive sputum production
Think bacterial infections
Or pulmonary edema—could be interstitial fluid leakage
Cough with unintentional weight loss
Think cancer
Tumors need to eat and they will consume calores and weight loss
Always think they have a malignancy unless proven otherwise
Cough, dyspnea, and lower extremity edema–HF
___ of patients presenting to the ER with dyspnea have cardiac or pulmonary etiology.
2/3
what’s in the ddx for cough?
CV, PULM: cancer, PE, pneumonia (or post inflammatory stuff form pneumonia), URI, LTI, COPD or AECB, allergic rhinitis (or d/t irritants) acute bronchitis, emphysema, asthma, foreign body, cystic fibrosis, anaerobic lung abscess,bronchiectasis, pneumothorax GI: GERD, PSYC: anxiety; other: meds: ACEI; smoking (>25%), post nasal drip
SUBACUTE usu d/t post inflammatory from pneumonia; CHRONIC usu d/t COPD, chronic sinus drainage, asthma, GERD, Meds, ACEI
what’s in the ddx for acute dyspnea?
PULM : CHF, pulmonary edema Acute pulmonary embolism (PE) Aspiration Acute infections Spontaneous pneumothorax Traumatic ? Foreign body Exacerbation of COPD Asthma COPD Interstitial lung diseases Chronic pneumonia Chronic pulmonary emboli Pulmonary neoplasia Pleural effusions CARDIAC Cardiac tamponade Myocardial ischemia Pericarditis/endocarditis Mitral valve prolapse (decr. CO) Pulm HTN cardiomyopathies OTHER Anaphylaxis Metabolic acidosis Guillain Barre’ Syndrome Myasthenia Gravis anemia deconditioning neuromuscular disease PSYCH Panic attack/anxiety Hyperventilation
whats in the ddx for chronic dyspnea?
Asthma COPD Interstitial lung diseases Chronic pneumonia Chronic pulmonary emboli Pulmonary neoplasia Pleural effusions • Cardiac Cardiomyopathies CHF Myocardial ischemia Primary pulmonary hypertension Pericardial disease • Miscellaneous Deconditioning Anemia Neuromuscular disease • Psychiatric • Panic attack, anxiety disorders
what are some signs of respiratory failure?
o Look for tachypnea, stridor, accessory muscle use (if diaphragm fatigued)
• Paradoxical abdominal wall movement as consequence of diaphragmtic fatigue.
o Inability to speak as a consequence of the breathlesseness.
• How many words can the pt comfortably say between breaths?
o Agitation or lethargy as consequence of hypoxia.
• Tissues aren’t getting adequate oxygen, brain is getting foggy
• At some point they may get so tired they may just stop breathing
• Intercostal retractions or carved out areas above the clavicles
what are some of the alarm signs of dyspnea?
chest pain (mI), swelling/hives (anaphylaxis) pink frothy sputum (heart failure, pulmnary edema), fever and sputum (bacterial infection), weakness/fatigue (respiratory failure)
what do you do if someone seems about to go into respiratory failure?
o Give Oxygen
• Can put on a CPAP or BPAP
o Anticipate the need for airway control and mechanical ventilation
o If a lesser degrees of dyspnea:
• Allow for a more detailed medical history
what’s in the ddx for hemoptysis?
blood may originate in mouth, pharynx, GI, lungs;
• Bronchitis 20-40%
• Lung cancer 15-30%
• Bronchiectasis 10-20%
• Pneumonia 5-10%
• Tuberculosis 5-15%,
• ENT- following nasal trauma SUPER SUPER COMMON
• Infectious – bronchitis, pneumonia, TB
• Neoplastic – lung CA
• CV – PE, CHF, pulmonary HTN
• Hematologic - ↓ platelets, anticoagulant Rx
• Traumatic – foreign body, ruptured bronchus
• Iatrogenic – lung bx., bronchoscopy
• Inflammatory – bronchiectasis, cystic fibrosis
• GI- esophageal varicies, emesis
what’s in the ddx for wheezing?
“Asthma COPD, especially emphysema PE AnaphylaxisInfection, viral or bacterialTumors
Aspiration, Mitral valve disease, CHF”
is a measure of how much of the substance is needed to satisfy increasing cravings for it
tolerance
is a measure of how difficult it is for the user to quit, the relapse rate, the percentage of people who eventually become dependent, the rating users give their own need for the substance and the degree to which the substance will be used in the face of evidence that it causes harm
dependence
- After one year off cigarettes, the excess risk of coronary heart disease caused by smoking is reduced by ______
- After _____ years of abstinence, the risk of CAD is similar to that for people who’ve never smoked
- Male smokers who quit between ages 35 to 39 add an average of _____years to their lives.
- Female quitters in this age group add ____yrs.
- Men and women who quit at ages 65 to 69 increase their life expectancy by ____ year
- In 5 to 15 years, the risk of stroke for ex-smokers returns to the level of those ______
- 50%; 2. 15, 3. 5, 4. 3; 5. 1, 6. who’ve never smoked
what are the 4 steps in smoking cessation counseling?
ask, advise, assist, arrange
how often should you ask about smoking?
EVERY VISIT
How can you assist someone who wants to stop smoking?
when they are in the contemplation stage: help them notify friends family of their goal, start marking behavior modifications now, let them know the resources that are available to them, be nonjudgmental, still make it a safe/non taboo place to talk if they don’t want to quit yet (don’t push them), address individual reasons why they are afraid to quit, anticipate challenges
what is part of the arrange step of smoking cessation?
quit plan, program, drugs, help them establish a quit date in 2 wks, call patient on quit date, have follow up apps with them about every 2 wks or so for the first 3 months, talk about fears, barriers, strategies for relapse prevention and resources at each visit,help them identify and break patterns (assisting with the breaking habits)
what are some ways to start behavior modification before even quitting?
Changing smoking routine before quit date
Switch to an undesirable brand
Put cigarettes and matches in different and less convenient place, take different ways home, eat breakfast somewhere else,
which lung sound: o Loud and harsh.
o High pitched.
o Heard over the manubrium and neck.
o Primarily hearing non-flexible air conduit with minimal tissue between tube and stethoscope.
o Distinct pause as air switches directions
o Still loud in back but not as loud as if listening in front
tracheal
which lung sound: o Louder and higher in pitch, with a short silence between inspiratory and expiratory sounds.
o Expiratory sounds last longer than inspiratory sounds.
o Primarily hearing non-flexible air conduit under thicker chest wall tissue
o Either side of sternum
bronchial
which lung sound o With inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. (as the air stops moving one direction and starts moving another)
o Detecting differences in pitch and intensity is often easier during expiration.
o Primarily hearing smaller bronchioles with some alveolar sounds
bronchovesicular
which lung sound o Soft and low pitch.
o Heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration (Because there’s not enough pressure anymore in alveolar sacs to hear the air moving in and out)
o Primarily hearing alveolar opening/closing
vesicular
o Relatively high pitched with a musical quality.
o Usually begin as an expiratory phenomenon but with increasing severity can span the entire respiratory cycle.
o Indicates inflammation or constriction of the airways
o Usually in the smaller ones, not in the larger ones
o May be continuous or intermittent in the respiratory cycle.
o Usually have a musical or whistling quality.
o May be audible both to you or the patient without a stethoscope.
o Suggestive of partial airway obstruction from secretions, tissue inflammation, or a foreign body.
o At onset, will typically favor expiration.
o Worsening will spread throughout expiration and into inspiration.
wheezing
o Relatively low pitched and may be described as snoring.
o Suggestive of secretions in larger airways.
o May be inspiratory or expiratory (or both).
o Thicker plug of mucus
o Like when you want to clear your throat—instead of pouring out it rolls out and gets stuck. Can almost feel it vibrating.
o They change a lot when you tell the patient to cough or clear your throat
o Keep your stethoscope there, have them clear their throat (take your ears out) and listen again
o Common in viral bronchitis or chronic bronchitis
o Normal cxray below with hilum/bronchi showing. No infiltrates seen.
o Also sounds like dying animal
o If they cough and it doesn’t change it suggests wheezing
o Heard best at bronchi where mucus sticks
rhonchi
which lung sounds will require tx?
wheezing or crackling. rhonchi typically doesn’t req it just suggests its a viral process
what should we also keep in mind when ordering lab tests?
will the results change my treatment plan?
sputum production ddx
pneumonia bronchitis emphysema \+/- asthma PND
ddx for hypoxemia
PULM: PE Lung cx PTX pneumonia emphysema bronchitis asthma
