Quiz #3 Flashcards
does restrictive lung disease involve difficulty getting air in or out?
difficulty getting air in
does obstructive lung disease involve difficulty getting air in or out?
difficulty getting air out
what is ventilation?
air in and out
what is respiration?
gas exchange
what is RLD?
abnormal reduction in pulmonary ventilation due to restriction of chest wall or lung expansion
decreased air moving in and out
what is the pathogenesis of RLD?
decreased chest wall compliance (stiff and difficult to expand)
decreased lung volumes and capacities
increased work of breathing (need greater transpulmonary pressure)
what anatomy is affected by restrictive lung disease?
lung parenchyma
thoracic pump
what breathing difficulty is associated with restrictive lung disease?
inspiration
how is tidal volume maintained with restrictive disease?
increased respiratory rate
what inspiratory muscles need to work harder due to decreased compliance?
diaphragm, external intercostals, accessory muscles
what are the 6 classic signs of RLD?
1) tachypnea
2) hypoxemia
3) decreased breath sounds w/dry inspiratory crackles heard at the base of the lungs caused by ateletactic alveoli
4) decreased lung volumes and capacities
5) decreased DLCO
6) cor pulmonale
what is diffusing capacity of the lungs for carbon monoxide (DLCO)?
measures of integrity of the functional unit
measure CO bc Hgb has a higher affinity for it than O2
gas perfusion measurement
dysfunction of alveoli membrane
what is cor pulmonale?
R sided HF
fibrotic pulmonary capillary beds –> pulm HTN –> hypoxemia (low O2 in blood)
caused by pulmonary disease
t/f: <50% DLCO is predictive of restrictive lung disorder
true
what are the 3 symptoms of RLD?
1) dyspnea/SOB
2) dry, non-productive cough
3) muscle wasting (cachexia)
what is the treatment for RLD if the etiology is permanent?
supportive measures
what are supportive measures?
supplemental oxygen
antibiotic therapy for secondary infection
interventions to promote adequate ventilation
interventions to prevent accumulation of secretions
good nutritional support
what is the treatment for RLD if the etiology is reversible?
corrective (chest tube) and supportive (temporary mechanical ventilation)
what is the role of surfactant?
keeps the alveoli open and prevents them from collapsing in on itself
what is respiratory distress syndrome (RDS)?
hyaline membrane disease
lack of complete lung maturation
inadequate surfactant production in alveoli
how is RDS diagnosed?
chest radiograph will show diffuse hazy appear with low lung volumes
how is RDS treated?
CPAP
PEEP
ECMO
surfactant replacement therapy
corticosteroids to mother b4 brith
what should the lungs look like on a chest x-ray?
black
when does normal aging begin?
in 20s
what is the treatment for maturational cuases of restrictive lung dysfunction?
keep aerobically exercising (walk 10 min, 3x/day)
strength training
what are some causes of RLD?
interstitial, infectious, neoplastic, pleural, cardiovascular, neuromuscular, connective tissues, maturational, immunologic, pregnancy, nutrition/metabolic, traumatic, therapeutic, pharmaceudical, radiologic
what are the 3 interstitial causes of RLD?
1) idiopathic pulmonary fibrosis
2) sarcoidosis
3) broncholitis obliterans
what is idiopathic pulmonary fibrosis?
chronic and irreversible
respiratory dysfunction due to fibrotic repsonse driven by abnormally activated alveolar epithelial cells
what is the pathophysiology of idiopathic pulmonary fibrosis?
atypical reparative process after lung epithelium injury (excessive fibroblast activity)
what is the worst environmental factor affecting idiopathic pulmonary fibrosis?
smoking
what is seen on a chest x-ray or CAT scan of idiopathic pulmonary fibrosis?
patchy focal lesions scattered
what is the disease progression in idiopathic pulmonary fibrosis?
steady decline in fxn
epithelial cells become more fibrotic
inflammation followed by repair process followed by fibroblastic phase
acute exacerbations characterized by rapid deterioration in lung fxn
survival rate: 2-3 years after dx
what are the diagnostic tests for idiopathic pulmonary fibrosis?
hx (exclusion of other causes of interstitial lung disease)
high res CT(patchy, peripheral, bibasilar reticular opacities)
chest radiography (opacities/infiltrates)
t/f: chest radiography lacks diagnostic specificity for idiopathic pulmonary fibrosis
true
what is the characteristic appearance of variably sized cysts in a background of densely scarred lung tissue in idiopathic pulmonary fibrosis?
honeycomb
what are the symptoms of idiopathic pulmonary fibrosis?
dyspnea on exertion
nonproductive cough
weight loss
fatigue
sleep disturbances
what are the signs of idiopathic pulmonary fibrosis?
decreased lung capacities
abnormal markings on chest x-ray
inspiratory dry rales
distal clubbing
pulm HTN
pedal edema
what is the treatment of idiopathic pulmonary fibrosis?
antifibrotic drugs
supportive care (supplemental O2)
pulm rehab (exercise)
what is sarcoidosis?
idiopathic multisystems granulomatous inflammatory disorder
primarily affecting black women
unknown etiology
20-40 y/o
what is the hilum?
the entrance of the major arteries and blood vessels from the heart and lungs
what are the 3 distinctive features of sarcoidosis?
1) inflammation: flu-like symptoms, night sweats, jt pain, fatigue
2) granulomas: masses of inflammed tissue
3) pulmonary sarcoidosis: scar tissue in lungs
what are the pulmonary causes of restrictive lung dysfunction?
bronchopulmonary dysplagia
bronchiolitis obliternas
necrosis of BRONCHIOLES
fibrotic lung disease that affects small airways
what is bronchopulmonary dysplagia?
chronic pulmonary syndrome in neonates who’ve been ventilated and receiving high concentrations of O2
what is bronchiolitis obliternas?
infection causing restrictive and obstructive lung dysfunction
what causes bronchiolitis obliterans in children?
viral infection
what causes bronchiolitis obliterans in adults?
toxic fume inhalation, viral, basterial, RA, graft vs host rxn
what lung structure is affected by bronchiolitis obliterans?
bronchioles
what is pneumonia?
inflammation of lung parenchyma beginning in lower respiratory tract
what are the 2 categories of pneumonia?
community acquired
hospital acquired (healthcare or ventilator associated)
what are the 4 types of pneumonia?
bacterial
viral
fungal
chlamydial
what is community acquired pneumonia most often caused by?
staph aureus (bacterial pneumonia)
what are bacterial pneumonias?
streptococcus pneumoniae
pseudomonas aeruginosa
staphylococcus aureus
what bacterial pneumonia has a vaccine?
staph aureus
what bacterial pneumonia is the msot often occuring nosocomial infection?
pseudomonas aeruginosa
what is the most common pneumonia in young children?
viral pneumonia
what is mycoplasma pneumonia?
atypical bacterial pneumonia
walking pneumonia
what pneumonia can emenate from air-conditioning equipment?
legionella pneumophila
what pneumonia is associated with AIDS?
fungal pneumonia
what are the symptoms of bacterial pneumonia?
high fever, chills, dyspnea, tachypnea, nonproductive cough, pleuritic pain
what are the symptoms of viral pneumonia?
moderate fever, dyspnea, tachypnea, nonproductive cough, myalgias
how is pneumonia treated?
antibiotic therapy
O2 (supplemental of vent) may be necessary with refractory hypoxemia (PaO2<60)
postural drainage, percussion, vibration, and assisted coughing
what is refractory hypoxemia?
O2 levels stay the same despite use of supplemental O2
what are neoplastic causes of RLD?
bronchiogenic carcinoma
what is bronchiogenic carcinoma?
malignant growth of abnormal epithelial cells in the tracheobronchial tree
is the risk of lung cancer more closely related to when someone starts smoking or how much someone smokes?
when someone starts smoking
what are the 2 main types of bronchogenic carcinomas?
1) small cell
2) non-small cell
what are the 3 types of non-small cell cancers?
1) adenocarcinoma
2) squamous cell carcinoma
3) large cell carcinoma
what is the most common type of lung cancer?
adenocarcinoma
what lung cancer starts in the bronchi and could present like obstructive lung disease?
squamous cell carcinoma
what lung cancer is rare, but rapidly growing and often not known until it is widespread?
large cell carcinoma
what is the most common lung cancer type in smokers?
small cell cancer
what type of lung cancer metastasizes very quickly to lymph nodes and vascular channels and is already metastatic at diagnosis?
small cell cancer
t/f: 75% of small cell cancers metastasize to the CNS
true
where is small cell cancer located?
bronchial epithelium near the hilar region
where is squamous cell carcinoma located?
bronchial epithelium near the hilar and projects to the bronchi
where is adenocarcinoma located?
mucous glands
tracheobronchial tree
where is large cell carcinoma located?
central or peripheral but often in trachea/large airways
what is the growth rate of small cell cancer?
very rapid
what is the growth rate of adenocarcinoma?
moderate
what is the growth rate of squamous cell carcinoma?
slow
what is the growth rate of large cell carcinoma?
rapid
what are the diagnoistic tests for bronchiogenic carcinoma?
chest x-ray and PET scans
what are the treatment options for bronchiogenic carcinoma?
surgery, radiation, chemo, immunotherapy
what is the most radiosensitive bronchiogenic carcinoma?
small cell followed by squamous
what is the treatment of choice for small cell cancer?
chemo
chemo has a low effect on what type of bronchiogenic carcinoma?
non-small cell
what is pleural effusion?
abnormal amount of pleural fluid in the pleural space
what are the 3 main etiologies of pleural effusion?
cardiac failure, pneuomnia, and malignant neoplasms
what is transudative effusion?
associated with HYDROSTATIC PRESSURE in pleural capillaries
LOW protein content
CARDIOGENIC
increased pulmonary capillary pressures–> fluid in pulmonary interstitium
fluid enters the pleural space, exceeding the drainage capacity of the lymphatics
what is exudative effusion?
INFLAMMATORY PROCESSES produce increased PERMEABILITY of pleural surfaces, allowing proteins and excessive fluid to move into pleural space
HIGH protein content
NON-CARDIOGENIC
what is the most common cardiogenic origin of transudative effusions?
CHF
what is the purpose of the pleural cavity?
lubrication for movement
what is the fluid in the pleural cavity made of?
filtrate from capillaries and lymphatics
what is the difference b/w pleural effusion and pulmonary edema?
pulmonary edema involved fluid int he alveoli
pleural effusion involved fluid in the pleural space
is the parietal pleura high or low pressure?
high pressure
is the visceral pleura high or low pressure?
low pressure
fluid moves from the ___ pleura capillaries into the pleural space and is then reabsorbed into the ___ pleural capillaries
parietal, visceral
t/f: more blood flows from the parietal pleura towards the lungs
true
what is oncotic pressure?
pressure from amount of protein
fluid into capillaries
what is hydrostatic pressure?
fluid out of capillaries
what pleural diseases can cause pleural effusion?
pleuritis
fibrothorax
pneumothorax
emphysema
hemothorax
what is pleuritis?
inflammation of pleura (visceral or parietal)
what is fibrothorax?
visceral pleura becomes fibrotic and destroys pleural cavity
pleural cavity becomes connective tissue
what is pneumothorax?
air in the lungs
what is emphysema?
pus in the lungs
what is hemothorax?
blood in the lungs
what are the 3 types of pneumothorax?
1) closed
2) open
3) tension
what is a closed pneuomothorax?
the amount of air entering the pleural cavity doesn’t increase
collapsed lung
lung or bronchus rupture
what is an open pneumothorax?
air goes in and out
chest wound
what is a tension pneumothorax?
air continually going into the pleural space
wound
air accumulates in the pleural cavity
how is a pleural effusion diagnosed?
hx/exam
chest radiography (white fluid)
thoracoscopy (thoracentesis-analysis of fluid-exudate)
opacity of atelectactic segment/lobe (large hematogenous opacity of fluid)
elevation of hemidiaphragm on affected side
blunting of costophrenic angle
shift of mediastenum toward the affected side
what is the costophrenic angle?
where the diaphragm meets the ribs
what lung sound is indicative of pleural inflammation?
pleural rub
where are bronchial breath sounds normally heard?
normally heard b/w 1st and 2nd rib; anywhere else is abnormal
what is egophany?
e sounds like ah
when is abnormal bronchial breath sounds, pleural rub, and/or egophany heard?
in pleural effusions/inflammation
how is pleural effusion treated?
based off the underlying cause
thoracentesis (needle extracts fluid)
thoracoscopy (scope explores hemithorax)
pleural space chest tube
what are chest drains?
one-way mechanism that lets air/fluid out of the pleural space and prevents outside air/fluid from entering
___ pressure during inspiration causes the water level in the chest tube to rise slightly
negative
____ pressure during expiration pushes air and fluid out of the pleural space and into the chest tube and collection bottle
positive
what helps with fluid drainage in chest tubes?
gravity
t/f: pleural effusion is an indication for bronchopulmonary hygiene techniques
false
why don’t drainage positions work to treat pleural effusions?
bc the fluid is in the pleural space, not the alveoli
what is atelectasis?
incomplete expansion of the lungs or loss of volume
collapsed, nonaerated lung parenchyma
what are the 6 types of atelectasis?
1) obstruction (resorptive)
2) passive
3) adhesive
4) compressive
5) cicatrization
6) congestive
what 2 types of atelectasis can best be treated by pT
obstructive and passive
what types fo atelectasis are most associated with bedrest and surgery?
obstructive and passive
what is obstruction atelectesis?
the most common
due to a tumor, mucus plug, or foreign body
what is passive atelectasis?
simple pneumothorax
associated with bedrest, sedation, anesthesia, and not taking deep breaths
what is adhesive atelectasis?
surfactant deficiency
what is compressive atelectasis?
space occupying lesion
pleural effusion
what is cicatrization atelectasis?
fibrosis
what is congestive atelectasis?
edema and hemorrhage into lung parenchyma from PE
how is atelectasis diagnosed?
chest radiograph
what is the treatment for atelectesis?
manage the underlying cause
deep breathing or incentive spirometry, coughing
what does incentive spirometry measure?
max inspiration with a single breath
what is ARDS?
inflammation causing an increase in pulmonary vascular permeability, lung weight, and loss of aerated tissue
a form of non-cardiogenic pulmonary edema, due to alveolar injury secondary to an inflammatory process, that can be either pulmonary or systemic (extra pulmonary) in origin
what syndrome is described as a”leaky bucket” where excessive fluid is leaking out of endothelial capillary and alveolar membrane?
ARDS
what is a milder case of ARDS?
ALI
what are the pulmonary origins of ARDS?
pneumonia
inhalation injury
aspiration or gastric contents
chest trauma/pulmonary contusion
near drowning
what are the non-cardiogeneic causes of ARDS?
sepsis
major trauma
burns
pancreatitis
fat embolism
hypovolemia
transfusion-related acute lung injury
cardiopulmonary bypass
what is the 3 stage process of ARDS?
1) exudative
2) proliferative
3) fibrotic
what is the exudative stage of ARDS?
inflammatory phase with release of inflammatory mediators causing edema in the lungs
ventilation-perfusion mismatch
reduced compliance
thrombus formation w/in pulmonary capillaries
what is the proliferative stage of ARDS?
synthesis of scarring
what is the fibrotic stage of ARDS?
scars mature into fibrotic tissue
what are the signs of ARDS?
decreased pulmonary capacities and compliance
decreased DLCO
chest x ray shows bilateral opacities (DEFINING CRITERIA)
decreased ABGs
decreased breath sounds over fluid filled areas, wet rales, wheezing, rhonci
tachycardia and maybe arryhthmias due to hypoxemia
what are the symptoms of ARDS?
appearn acutely ill
dyspnic at rest and w/activity
fast, labored breathing
cyanotic
may have impaired mental status, restlessness, headache, anxiety
what are the treatments for ARDS?
treat precipitating cause
mechanical ventilation (lung protective vent, PEEP, and proning)
supportive
prevent/treat complications
what is the goal of lung protective ventilation?
adequate gas exchange and low TV
what is positive end expiratory pressure (PEEP)?
keeps the alveoli open
PREVENTS alveolar collapse
5-15 cm H2O
higher cm H2O=worse condition
what is proning?
delivery of mechanical ventilation with pt in prone to IMPROVE OXYGENATION and IMPROVE LUNG PERFUSION
what are the cardiovascular causes of RLD?
pulmonary edema
pulmonary emboli
what is pulmonary edema?
increased fluid int eh lungs from pulmonary vascular systems starting int he interstitial space and progressing to alveolar space
what are the 2 main categories of pulmonary edema?
cardiogenic and noncardiogenic
what is the primary cause of cardiogenic pulmonary edema?
left ventricular failure
what are causes of cardiogenic pulmonary edema?
LEFT VENTRICULAR FAILURE
ARDS
renal failure
high altitude pulmonary edema
heart disease
how does L ventricular failure result in cardiogenic pulmonary edema?
increased L atrial pressure –> pressure back on pulmonary circulation–> increased microcirculation (hydrostatic pressure)–>fluid spills into interstitial space
the lymphatics don’t work when the pulmonary vascular hydrostatic pressure is >___mmHg
30
pulmonary edema of cardiac origin has ___ protein content
low (transudative)
what are Kerly B lines and what are they indicative of?
short, thin horizontal lines extedning inward from pleural space
indicative of cardiogenic pulmonary edema
what breath sounds are heard in cardiogenic pulmonary edema?
wet rales with decreased breath sounds
bronchospasms and wheezing
are arrythmias common in cardiogenic pulmonary edema?
yes
what are the symptoms of cardiogenic pulmonary edema?
appear in respiratory distress
report sense of suffication
SOB
orthopnea
cough with pink frothy sputum
cynaptic
increased RR
labored breathing
pallor
diaphoresis
how is cardiogenic pulmonary edema managed?
decrease cardiac prelaod (GET FLUID OUR OF HEART) with diuretics, vasodialtors, decreased sodium, and physical activity
maintain oxygenation of tissues with supplemental O2 and mechanical vent as needed
what is a pulmonary emboli?
complication of venous thrombosis that travels from systemic vein (mostly from the legs) to pulmonary circulation
t/f: 1/3 of pulmonary emboli end with death w/in an hour
true
what fraction of ppl with a DVT/PE will have another one within 10 years?
1/3
t/f: PE are clinically silent
true
what are the classical traid of symptoms with PE?
pleuritic chest pain, hemoptosis, and DVT
what % of orthopeadic pts will have a PE w/o blood thinners
80%
what are the pathophysiologic changes associated with PE?
occlusion of pulmonary artery branch leads to edema and hemorrhage
lack of blood flow–>necrosis of alveolar walls–> inflammatory response
a portion of the lung is ventilated but no longer perfused
what is the clinical presentation of PE?
dyspnea
chest pain
hemoptysis
what are the risk factors for DVT?
immobilization
injuries to leg
increased age
inherited clotting disorders
infectious and inflammatory diseases
pregnancy/contraceptives
cancer
smoking
obesity
burns
thrombocytosis
sickle cell anemia
orthopedic pts
how is a PE diagnosed?
CT pulmonary angiography
what 4 things should be involved in DVT risk assessment?
1) advocate for a culture of mobility
2) assess for risk during hx and exam
3) when pts present with conditions that increase their risk, we should be highly suspicious of DVT
4) promote preventative measures for those with high risk
what is the medical intervention for PE?
prevention
anticoagulants
some kind of filtration device
what are the neuromuscular causes of RLD?
SCI
ALS
GBS
myasthenia gravis
duchenne’s muscular dystrophy
what muscles are involved in inspiration?
external intercostals
what muscles are involved in expiration?
internal intercostals
what can cervical SCI cause?
decreased VC and MVV
weak/paralyzed expiratory muscles
weak/absent diaphragm
what can weak/paralyzed expiratory muscles and weak/absent diaphragm lead to?
inability to cough
pulmonary infection
alveolar hypoventilation, hypoxemia, and hypercapnia
what can alveolar hypoventilation, hypoxemia, and hypercapnia lead to?
atelectasis
what is paradoxical breathing?
diaphragm goes up and chest wall goes in with inspiration; diaphragm goes down and chest wall flares with expiration
chest expands and abdomen draws in with inspiration; abdomen pushes out with expiration
how is cervical SCI treated?
strengthen and increase the endurance of any remaining ventilatory muscles
- inspiratory muscle training
- resistance exercise training
- incentive spirometry
secretion clearance techniques
- postural drainage, percussion, vibration, assisted cough, suctioning
what is ALS?
progressive degenerating NS disease involving demyelinated UMNs and LMNs
what are the phases of respiratory involvement in ALS?
phase 1: minimal complications
phase 2: risk for complications
phase 3: respiratory failure with signs of disease progression
phase 4: continuous non-invasive ventilation (NIV)
phase 5: trach, QOL
what lung fxn tests are used in ALS phase 2?
forced vital capacity
max inspiratory pressure
what NIF/MIP is indicative of impaired diaphragm fxn?
above 60
what FVC is indicative of impaired diaphragm fxn?
less than 50%
what is BiPAP?
bilevel positive assisted airway pressure
opens up alveoli and prevents them from collapsing
what is the difference b/w BiPAP and PEEP?
PEEP just keeps the alveoli from collapsing, BiPAP also opens them up
many different mask options
what are these examples of:
mechanical insufflation-exsufflation device
suction devices
cough assist devices
what is GBS?
demyelination of peripheral motor neurons
idiopathic polyneuritis linked to the immune system
what is the treatment for GBS?
heat for pain, PROM, active exercise including breathing
what is myasthenia gravis?
chronic neuromuscular disease characterized by progressive muscular weakness on exertion
autoimmune attack on acetylcholine receptors at the postsynaptic neuromuscular junction
weakness and fatigue of voluntary muscles, SOB, weak and ineffective cough
what is Duchenne’s muscular dystrophy?
genetically determined progressive degenerative myopathy
involvement of diaphragm late in disease
what is the treatment of DMD?
supportive, preserving mobility, and prevention of respiratory infection
what are the s/s of the neuromuscular causes of RLD?
respiratory muscle weakness
decreased breath sounds
SOB/dyspnea at rest
inability to cough
ineffective clearning of secretions
poor voice volume
decrease in life activities
what are connective tissue causes of RLD?
rheumatoid arthritis
systemic lupus erythematosus
scleraderma
polymyositis
what is rheumatoid arthritis?
chronic inflammation of peripheral jts resulting in progressive destruction of articular and periarticular structures
strong correlation with smoking
lung PARENCHYMA changes
decreased chest wall compliance and decreased inspiratory power
pain from pleurisy
how is RA treated?
corticosteroids and immunosuppressant drugs
what is systemic lupus erythematosus (SLE)?
chronic inflammatory connective tissue disorder
most in black women
antigen-antibody reactions
pleurisy
diaphragmatic weakness
BUTTERFLY RASH
how is SLE treated?
reverse autoimmune and inflammatory changes
prevent complications
what is scleroderma?
progressive fibrosing disorder that causes degenerative changes in skin, small blood vessels, esophagus, intestinal tract, lung, heart, kidney, and articular structures
FIBROSIS
idiopathic
more common in women
how is scleroderma treated?
treat specific symptoms
supportive
what are musculoskeletal causes of RLD?
kyphoscoliosis
ankylizing spondylitis
pectus excavatum
pectus carinatum
pregnancy
obesity
what is kyphoscoliosis?
combo of excessive AP and lat curvature of thoracic spine
only 3% have lung dysfxn
how is hyphoscoliosis treated?
orthotic devices
exercise
surgery
pulmonary compromise (immunizations, good hydration, aggressive treatment of pulm infections, avoidance of sedatives, supplemental O2, and resp musc training)
what is ankylosing spondylitis?
chronic inflammatory disease of the spine characterzied by immobility of SI and vertebral jts and ossification of paravertebral ligs
low chest compliance
how is ankylosing spondylitis treated?
maintain good body alignment, thoracic mobility
what is pectus excavatum?
funnel chest
sternal depression and decreased AP diameter
decreased TLC, VC, and max voluntary ventilation
what is pectus carinatum?
pigeon breast
sternum protruding anteriorly
associated with prolonged childhood asthma
how does pregnancy lead to RLD?
decreased chest wall compliance due to downward excursion of diaphragm
closing small airways
ventilation-perfusion mismatch
increased work of breathing
how does obesity lead to RLD?
decreased lung capacities, lung volumes, and respiratory musc strength
increased airway resistance pulmonary diffusion
heterogeneity of ventilation distribution
hypercapnic resp failure
what are traumatic causes of RLD?
crush injuries
penetrating wounds
how does surgical therapy lead to RLD?
pulm dysfxn due to anesthetic agent, surgical incision, pain post-op
