Pulmonology #8 (FBA, Effusion, Pneumothorax, Pulm HTN) Flashcards
MC foreign body aspirated in children
Peanuts
Where is the MC location for a foreign body aspiration?
Right side (due to wider, more vertical, and shorter right main bronchus)
What is the mean age of a foreign body aspiration?
2 years old (absence of molars make it hard to grind food)
Symptoms of a foreign body aspiration
-Sudden onset of choking, cough, and dyspnea
-Wheezing or asymmetric breath sounds
-May be normal or asymptomatic
What is seen on CXR in a child with foreign body aspiration?
Air trapping
What should be ordered if a negative CXR in a symptomatic patient
CT chest
However, what is the definitive diagnostic for a foreign body aspiration?
Rigid bronchoscopy (also therapeutic because the object can be removed)
When should you use a flexible bronchoscopy vs a rigid?
Flexible used for diagnostic purposes when the diagnosis is not clear or the location is unclear
Treatment for FBA
Removal of object via rigid bronchoscopy
In acute choking, perform _________. If this does not work, _______
the Heimlich maneuver
Emergency tracheostomy
Although costochondritis is often idiopathic, what are some things that CAN cause it?
Physical strain, excessive coughing, etc.
Symptoms of costochondritis
-Pleuritic chest pain that is worse with inspiration or certain movements
-Point chest wall tenderness with palpation (MC involves the 3rd, 4th, and 5th ICS)
-Absence of palpable edema
Treatment for costochondritis
NSAIDs
What is the difference between costochondritis and Tietze Syndrome?
Costochondritis has the ABSENCE of palpable edema, whereas Tietze syndrome does have palpable edema
Treatment for Tietze Syndrome?
NSAIDs
What is a pleural effusion?
Abnormal accumulation of fluid in the pleural space
Explain the following terms:
-Empyema
-Hemothorax
-Chylothorax
Empyema: direct infection of the pleural space. Grossly purulent effusion
Hemothorax: gross blood
Chylothorax: increased lymph
What are the two etiologies of pleural effusion
Transudate
Exudate
MCC of Transudate pleural effusion
CHF
Other causes of Transudate pleural effusion
Nephrotic syndrome, cirrhosis
Causes of exudative pleural effusion
Any condition associated with infection or inflammation.
-Pulmonary embolism, malignancy.
Symptoms of pleural effusion
-Dullness to percussion
-Decreased fremitus
-Decreased breath sounds
-Pleural friction rub
Initial test of choice for pleural effusion and what is normally seen
CXR
-Blunting of the costophrenic angles (meniscus sign)
What are the BEST films to evaluate for a pleural effusion?
Lateral decubitus
However, what is the GOLD standard diagnostic for pleural effusion?
Thoracocentesis
A thoracocentesis can be diagnostic and therapeutic. It helps distinguish between transudate and exudate. What criteria is used and what are the three parts?
Light’s Criteria: an exudate is present if any of these three are present.
-Pleural fluid protein: >0.5
-Pleural fluid LDH: serum LDH >0.6
-Pleural fluid LDH >2/3 upper limit of normal
How do you know if an empyema is present?
Pleural fluid pH < 7.2
Glucose < 40 mg
or Positive gram stain
What should you do if an empyema is present?
Chest tube fluid drainage
What is a pneumothorax?
Air in the pleural space, leading to collapse of the lung from positive intrapleural air pressure
What is a primary pneumothorax?
Atraumatic and idiopathic with no underlying lung disease. Mainly affects 20-40 thin men, smokers, with a family history of pneumothorax.
What is a secondary pneumothorax
Secondary spontaneous - due to underlying lung disease (COPD, asthma, etc.)
A tension pneumothorax occurs when
positive air pressure pushes the trachea, great vessels, and heart to the contralateral side
What is a catamenial pneumothorax?
Occurs during menstruation
When does a traumatic pneumothorax occur?
During CPR, thoracocentesis, subclavian line placement, car accident, etc.
Exam findings of a patient with a pneumothorax
-Chest pain: pleuritic, unilateral, non-exertional, sudden. Dyspnea
-Hyperresonance to percussion
-Decreased fremitus
-Decreased breath sounds
Also, what are the specific symptoms of a tension pneumothorax
-Increased JVP, hypotension, pulsus paradoxus
What is the initial diagnostic done for pneumothorax?
CXR: expiratory upright view preferred
-Companion lines (visceral pleural line running parallel with the ribs)
-Decreased peripheral markings
What is the management of a small (<3 cm) primary spontaneous pneumothorax
-Observation and supplemental oxygen
-Repeat films 6 hours to exclude progression
What is the management of a large (>3 am) PSP?
Needle or catheter aspiration vs chest tube vs catheter thoracostomy
What should you do for a tension pneumothorax
Needle aspiration followed by chest tube thoracostomy
What should you advise the patient who has a pneumothorax?
Avoid pressure changes for a minimum of 2 weeks (high altitudes, smoking, scuba diving, etc.)
What is pulmonary hypertension?
Elevated mean pulmonary arterial pressure > 20 mmHg
What happens as a result of the increased pulmonary vascular resistance?
Leads to RVH, increased RV pressure, and eventually right-sided HF
Primary pulmonary HTN, which is idiopathic in nature, MC occurs in
middle-aged or young women
What gene defect is associated with primary pulmonary HTN
-BMPR2 gene defect
Symptoms of pulmonary HTN
-Dyspnea
-Fatigue
-Chest pain
-Weakness
-Cyanosis
-Edema
Other physical exam findings in pulmonary HTN
-Accentuated S2
-Signs of Right-heart failure: increased JVP, peripheral edema, ascites
-Pulmonary regurgitation, systolic ejection click
Diagnostics for pulmonary hypertension
CXR: _______
ECG: _________
Echocardiogram: ________
-enlarged pulmonary arteries
-Cor pulmonale: RVH, right axis deviation, Right BBB
-large right ventricle, RVH
What is the definitive diagnostic for pulmonary HTN?
Right heart catheterization
What is seen on CBC in a patient with pulmonary HTN?
-polycythemia with increased hematocrit
What is the first thing that should be done with the treatment in pulmonary HTN?
Vasoreactivity trial with IV Adenosine, CCB, or inhaled Nitric oxide.
If vasoreactive, what is the treatment?
CCB are first line (Verapamil, Diltiazem, Nifedipine, Amlodipine)
Other treatment options for pulmonary HTN
-PD5-inhibitors (Sildenafil, Tadalfil)
-Oxygen therapy
-Long term anticoagulation in some
Definitive Treatment for pulmonary HTN
-Heart-lung transplant
