Respiratory System Flashcards
3 important Q’s family history
- asthma
- TB
- Heart disease
5 areas of history to ask about
Family
Occupation
Residence
Tobacco use (personal, second hand, inhaled recreational drug use)
Any problems with breathing, frequent colds, cough, sputum, wheezing, asthma, bronchitis, emphysema, pneumonia, TB, last chest X-ray
Physical exam
Inspection
- deformities, ribs
Palpation
- tenderness
- fremitis (vibrations) whispering “99”
Percussion
- wrist movements of one finger striking another
- notes: flat, dull, resonant, hyperresonant, tympanic
- symmetrically down back, 5cm intervals - diaphragmatic excursion
Auscultation
Auscultation of the lungs
- Quality and intensity
A. Vesicular
- inhalation lasts longer than exhale
- most of Lu
B. Bronchial
- exhalation lasts longer tan inhalation
- trachea
C. Broncho-vesicular
- inhalation = exhalation
- between upper scapula
Auscultation of the Lungs
- adventitious or abnormal sounds
- vocal sounds - use “99”
A. Rales, rhonchi, friction rubs
- rales: crackles, usually insp (in Ht failure, often hear in lower lobes)
- rhonchi: wheezes
- friction rub: crackling, GRATING sound
VOCAL sounds
A. Bronchophony (99, 99, 99!) - increased clarity and intensity of speech
B. Egophony - nasal bleating “ee” to “ay”
C. Whispered pectoriloquy - clarity of whispers (not hearing 99 until one is audible)
**do everything also on ant chest just lateral to R sternum in 4th or 5th ICS
Labs
Labs
- blood gases (P02, PCO2, HCO3, pH)
Imaging
A. Chest X-rays - pa (post to ant), lateral
B. MRI
C. CT scan - see more opacities, b vessels
D. ultrasound - esp of pleural space (not often)
Pulmonary Function Testing
Spirometry
- measures airflow of lung volume
(All kinds of data — how fast air is moving into device, how much is coming out)
Other procedures for Lung
A. Bronchoscopy
- direct visual examination of larynx and tracheobronchial tree
- sampling of secretions, biopsy
B. Thoracentesis - sample of pleural fluid (induces pneumothorax)
C. Thoracotomy - lung biopsy (big scar from back lateral chest wall into axilary area)
Emergencies
A. Any acute chest pain needs primary evaluation
- must be differentiated from cardiac and other causes
- most non-cardiac chest pain from pleura or chest wall
- often accompanied by dyspnea
- *chest pain and dyspnea immediate red flag
B. Pneumonia, bronchitis, emphysema, asthma may be emergencies
C. Hemoptysis
- blood streaked sputum not an emergency
- diff from hematemesis and blood dripping from nose
Common cold
- name, what is it?
URI - upper respiratory virus
Usually viral - inflammation in any or all airways (often picornavirus, one of the rhinoviruses)
Common cold
- etiology
- Viral
- picorna- up to 50% from > 100 types of rhino
- influenza, parainfluenza, … - Fatigue, emotional distress, allergies, mid phase of menses cycle
- Most important factor is presence of specific neutralizing antibody — indicates precious exposure and offers protection
Common Cold
- signs and symptoms
- Short (1-3 day) incubation (most transmissible, most contageous)
- Abrupt onset
- Nasal or throat discomfort, sneezing, rhinorrhea (runny nose), malaise, no fever, pharyngitis, laryngitis, tracheitis, watery nasal discharge becoming mucopurulent, cough
- Resolves in 4-10 days if no complications
Common Cold
- diagnosis
- Clinical but non-specific
- R/O allergies, bacteria
- Smear of exudate
- bacteria
- eosinophils if allergic (WBC elevated in parasites and allergies)
Common Cold
- treatment
- Warm, comfortable environment
- Prevent direct spread
- Symptomatic relief
- No antibiotics
- Vit C, Vit A
Influenza
A. Flu, grippe
B. Acute viral respiratory illness with fever, coryza (burning watery discharge from mucous membranes in flu virus — nose, eyes), malaise, inflamed respiratory mucous membranes
Influenza
- etiology
- Influenza viruses
- influenza A most freq cause
- Airborne droplets
- Usually late fall and early winter
Influenza
- signs and symptoms
- 2 day incubation (most contageous here, but poss sl longer d/t fever)
- Abrupt onset - sxs w/in 24 hours
- Fever, chills, MYALGIA (don’t get with rhinovirus, H/A, photophobia, sore throat, cough, coryza, watery eyes, N, V
- Up to 3-5 days
- Complications usually respiratory if sxs lasting > 5 days
Influenza
- diagnosis
- Nasopharyngeal washings or gargling to isolate virus
- R/O common cold, bronchitis, pneumonia, mono
- immunization - includes prevalent strains
- treatment as in common cold, “wet sheet tx”
Pleurisy
- inflammation of the parietal pleura
Pleurisy
- etiology
- Underlying lung process
- Entry agent into pleural space
- Transport by bloodstream
- Trauma
- Asbestos
Pleurisy
- signs and symptoms
- Sudden onset
- Vague discomfort to intense stabbing pain
- Pain aggravated by breathing and coughing (friction causes pain)
- Referred pain via intercostal nerves
- Rapid, shallow breathing (tachypnea)
- Decreased breath sounds
- Pleural friction rub (sounds like grating — moxa on fingers)
- Pain subsides if effusion develops (“pleura edema”)
- dull percussion, no tactile fremitus, decreased or absent breath sounds, egophony at upper border of fluid
Pleurisy diagnosis
- Clinical - pretty clear
- Pleural friction rub is pathognomonic
TX: treat what is underlying; wrap chest with elastic bandages; acetaminophen; NSAIDs; promote coughing
Pneumothorax
- air in the pleural cavity
Pneumothorax
- etiology
- Trauma or spontaneous
- spont in young healthy tall thin males - Simple or complicated with either traumatic or spont
Pneumothorax
- signs and symptoms
- Dyspnea
- Chest pain or pressure
- Cough
- Cyanosis
- Sweating
- Hypotension
- Trachea deviates to opposite side
- Weak and rapid pulse
Tuberculosis
- a chronic recurrent infection caused by mycobacterium tuberculosis
- most common in lungs
Tuberculosis
- etiology
- Airborne exposure - very young, very old, immune compromised
- Considerable innate defense against initial infection
- Elderly, infants, diabetics, chemotherapy, HIV+
- Undernourished, unhygienic
TB
- signs and symptoms
- Very often asx in initial stages
- Not feeling well
- Nightsweats
- Cough - initially non-productive becoming productive with blood tinged sputum
- Dyspnea
- Simon foci - nodular apical scars — most common sites for later active TB
TB
- diagnosis
- TB skin test - induration > (or equal to) 10 mm in 48-72 hours indicates infection but not activity
- Quantiferon - TB fold (QFT-Gold)
- Chest X-rays
- Sputum analysis for acid-fast bacilli
- Sputum culture
Tx: usually use 2 drugs with different MOA to prevent development of resistance (9 mos)
Pneumonia
- acute infection of the lung
Pneumonia
- etiology
- Bacteria
- streptococcus pneumoniae (pneumococcal pneumoniae *most common), staphylococcus aureus, hemophilus influenza, klebsiella pneumoniae, mycoplasma pneumoniae
- Viral
- Predisposing factors
- respiratory viral infections, alcoholism, institutionalization, cig smoking, Ht failure, CO airways Dx, age extremes, debility, immunosuppressive Dx, …. - 2 mil each yr in US - about 55,000 deaths
- most common lethal nosocomial inf (from the hospital)
Pneumococcal Pneumonia
- most common cause of bacterial pneumonia
- streptococcus pneumoniae
- 175,000 cases/yr, 7% fatality rate
Pneumococcal Pneumonia
- signs and symptoms
A. Preceded by URI
B. Sudden onset with a single shaking chill (fever rises so rapidly they get harrowing chill)
C. Fever, pleurisy, cough, sputum, dyspnea
- rapid T rise to 105
D. Increased HR to 140
E. Increased RR to 45
F. Blood streaked or rusty sputum
G. Tactile fremitus (when you percuss over area with excess mucous, sounds really dull)
H. Percussive dullness
I. Bronchial breath sounds
J. Whispered pectoriloquy
K. Suspect in anyone with acute febrile illness with chest pain, dyspnea, cough
L. Complications - contageous infections, bacterimia (bacteria in blood), sepsis
Pneumococcal Pneumonia
- laboratory and X-ray
A. Leukocytosis with shift to the left - *classic place to see this, IMMATURE neutrophils recruited
- neutrophilia with lymphopenia
B. Gram stain of sputum
C. Sputum culture
X-ray
A. Pulmonary infiltrate
B. Dense consolidation
TX: penicillin G or V; azithromycin, amoxicillin, erythromycin
Staphylococcal Pneumonia
- overview
- signs and symptoms
- labs and x-rays
- 2% of infections
- often in patients who are more ill
- 15% of nosocomial pneumonias
- same as pneumococcal but more severe
- can be more fulminant with more prostration
- recurrent chills
- tissue necrosis and abscess
- lab and X-ray same as pneumococcal
- penicillin resistant
Hemophilus Pneumonia
- etiology
- signs and symptoms
- 2nd only to strep
- Hib - can cause meningitis, epiglottitis
- Coryza (watery discharge from mucous membranes in eyes), pleural effusion, bacteremia
- Tx - vaccine, amoxicillin, ampicillin
Klebsiella Pneumonia
- etiology
- signs and symptoms
- diagnosis
- rare in healthy adults
- very young or old
- hospital settings
- *immunocompromised often
- alcoholics
- up to 50% mortality rate
- currant jelly like sputum from tissue necrosis and abscess
- fulminant course
- sputum culture
Mycoplasma Pneumonia “walking pneumonia”
- etiology
- signs and symptoms
- diagnosis
- most common pathogen ages 5-35
- 10-14 day incubation
- initially resembles influenza
- malaise, sore throat, cough
- gradual progression as sxs increase in severity with time
- paroxysms of cough
- mucous, mucopurulent, blood streaked sputum
- 1-2 weeks with gradual spontaneous recovery
- Dx — usual
- serologic assays
- “testing sputum only way to know it’s not pneumococcal pneumonia?”
Viral
- etiology
- signs and symptoms
- diagnosis
- many viruses cause lri (lower respiratory tract infection)
- H/A, fever, myalgia, cough with mucopurulent sputum
- few bacteria on sputum gram stain with a predominance of monocytes
- may have superimposed bacterial infection (if has been going on for a few weeks)
- strep, staph
Asthma
- definition
- reversible airways obstruction, inflammation, hyperresponsiveness
Asthma
- etiology
- 22 million in US currently
- 34 million diagnosed in their lifetimes
- 6 million are children
- 9.6 million diagnosed at some point in childhood
- 3 A’s — asthma, allergies, atopic dermatitis
Asthma
- extrinsic
- IgE mediated, allergic in nature
- animal dander
- cockroach protein
- dust
- mold
- pollen
- air pollution
- foods
Asthma
- intrinsic
- immune system not involved, non-allergic
- cigarette smoke, wood smoke, dust
- odors, fumes, air pollution
- changes in temperature, pressure, humidity
- aspirin, sulfates, NSAID’s, tartrazine (FD&C yellow dye #5)
- chemicals
- cold air
- exercise
- emotional upset
- uri
Asthma
- signs and symptoms
- some sx free with occasional mild brief episode
- others mild coughing and wheezing much of the time with severe sxs following exposure to allergens, viruses, exercise, irritants, psychological factors
- wheezing, coughing, SOB, dyspnea, tachypnea, tightness in chest, audible wheezes
- non-productive cough initially, then tenacious mucoid sputum
- sitting upright, leaning forward, anxious (issue often not getting air in, but getting air out)
- use of accessory muscles of respiration, struggling for air
- prolonged exhalation with wheezes in inhalation and most of exhalation
- if severe - unable to speak more than a few words at a time
- fatigue, cyanosis
- decreased wheezing
- may develop pneumothorax, atelectasis (collapsed lung)
- status asthmaticus - emergency
- severe obstruction persisting for days or wks
Asthma
- lab
- eosinophilia (IgE = extrinsic asthma)
- allergy testing
- ABG’s and pH
- decreased Pao2, increased Paco2, decreased pH
- sputum analysis
- tenacious, rubbery, white
- eosinophils
- Charcot-Leyden crystals **means asthma
Asthma
- imaging
- pulmonary function tests
- (relatively) normal to hyperinflated (diaphragm looks flattened down due to hyperinflation - looks dark)
- spirometry
- bronchoprovocation - stimulate response person is having in their lungs
Asthma
- diagnosis
- wheezing, esp beginning in childhood or early adult
- family hx of asthma or allergy
- differential diagnosis
- a. Foreign body obstruction (esp in children w/ sudden wheezing w/out hx of respiratory sxs)
- b. Viral uri
- c. Epiglottitis
- Hib
- sudden onset - fever, sore throat, hoarse
- resp distress - leaning forward, hyperextended neck
- emergency room - **do not try to visualize throat - bronchitis, pneumonia
- COPD
- Ht failure
Bronchitis
- etiology
- acute inflammation of tracheobronchial tree
- mostly in winter
- after acute uri
- air pollutants, chilling, fatigue, malnutrition predispose
Bronchitis
- signs and symptoms
A. Sxs of uri
- Coryza, malaise, chills, mild fever, myalgia, sore throat
B. Cough
- initially dry and non-productive - shortly, thick sputum which may become abundant and mucopurulent - if purulent - bacterial infection
C. If fever persists > 5 days, possible pneumonia
D. Cough may last several weeks
E. Few pulmonary signs
- occasionally rhonchi, rales, and wheezing after cough
Bronchitis
- diagnosis
- Clinical - signs and symptoms
- Chest x-ray to R/O other diseases if sxs serious or prolonged
Tx - rest; fluids; do not suppress a productive cough unless keeping the person from resting; antibiotics only if purulent sputum or persistent high fever
COPD - Chronic Obstructive Pulmonary Disease
- causes
- increased resistance to airflow during forced expiration
- several causes
- narrowing of airways 2ndary to intrinsic airways disease
- excess expiration collapse of airways 2ndary to emphysema
- bronchospasm
COPD
- terms
- chronic bronchitis
A. Mucous hypersecretion and structural changes in bronchi from non-specific bronchial irritants - Pulmonary emphysema
A. Enlargement of airspace’s with destructive changes of alveolar walls - Chronic asthmatic bronchitis
A. Persistent asthma with clinically significant airflow obstruction even with anti-asthma tx
- COPD usually means emphysema and chronic obstructive bronchitis
COPD
- etiology
- Emphysema from the effect of proteolytic enzymes released from leukocytes during inflammation - breakdown of alveolar wall
- any chronic inflammation - smoking
- age
- air pollution
- hyperresponsive airways
- alpha - 1 antitrypsin deficiency
COPD
- signs and symptoms
- Primarily in smokers
A. Smoker’s cough
- often present for decades before dyspnea - Exertion always dyspnea
A. Gradually progressive
B. # stairs climbed
C. Distance walked - Sputum production - amount and color variable
- Wheezing - variable
- Recurrent respiratory infections
- Slowing of forced expiration (> 4 seconds with wheezing at end)
- Barrel chest, pursed lip breathing, depressed diaphragm, callused elbows - late stages
- Decreased vesicular breath sounds, rhonchi, tachycardia, decreased heart sounds - variable findings
- Cyanosis, plethora, dependent edema - late signs
COPD
- laboratory
- imaging
- pulmonary function tests
- **erythrocytosis
- Eosinophilia if asthmatic bronchitis
- Chest X-rays - hyperinflation (depressed diaphragm, radiolucency)
- Spirometry
COPD
- diagnosis
- Any patient with chronic productive cough and exertional dyspnea of unknown etiology
- Slowing of forced expiration (easy to test)
- Physiologic evidence of airways obstruction that persists despite tx - difficult to treat
- R/O specific diseases
Respiratory distress - Respiratory Failure
- definitions
- etiology
A. impairment of gas exchange between air and circulating blood (respiratory failure)
- oxygenation or ventilation problems
B. Pulmonary edema, respiratory distress, hypoxemia
Respiratory Distress, Failure
- etiology
- Acute processes that injure the lung
- Pneumonia, aspiration, chest trauma, shock, burns
- 30% following sepsis (Septicemia)
Respiratory Distress, Failure
- signs and symptoms
- Within 24-48 hours after initial injury or illness
- Dyspnea, tachypnea, shallow respiration
- Intercostal and suprasternal retraction on inspiration
- Cyanosis or mottled skin
Respiratory Distress, Failure\
- diagnosis
- ABG’s
- Chest X-ray
- Must search for cause
Respiratory Distress, Failure
- prognosis
- 50% survival with appropriate tx
- complications
a. pulmonary fibrosis with prolonged ventilatory support
b. bacterial superinfection of lungs
c. multiple organ system failure, especially renal
d. complication of invasive life support (pneumothorax)
Lung Cancer
- classification
A. 1o (primary) tumors and metastases
B. Classification
1. NSCLC – non small cell lung cancer a. 80% b. 3 types i. adenocarcinoma - grow slowly, hard, often don’t show with any symptoms until late in the disease ii. squamous cell carcinoma iii. large cell carcinoma 2. SCLC – small cell lung cancer a. 20% b. oat cell carcinoma c. rare in non-smokers d. highly aggressive i. 5 yr survival 6%
Lung Cancer
- epidemiology
- 2nd most common CA in men and women
a. 220,000 new cases each year in US
2. most common cause of CA death in men and women
a. 157,000
b. more than prostate, breast, colorectal combined
3. most common between ages 45-70
Lung Cancer
- etiology
etiology
1. 85% due to cigarette smoking a. highest risk if over 50 and smoked 30 pack years b. if stop by 50, risk reduced from 1 in 10 to 1 in 50 - smoking increases risk of all other cancers
- Other risk factors
a. second hand smoke
i. increases risk of lung CA by 30%
b. air pollution - recent studies showing a larger effect
c. radon
d. asbestos - not much seen anymore
e. other chemicals - metastatic tumors in lungs from other organs
a. breast
b. colon
c. prostate
d. bladder
e. bone
Lung Cancer
- signs and symptoms
- cough
2. sputum
a. possibly blood-streaked with inflammatory exudates
3. pain in back or chest unrelated to coughing - with SOB sounds like MMI
4. dyspnea, SOB
5. hoarseness
3. hemoptysis
4. localized wheezing
5. atelectasis
6. infection - acute bronchitis, keeps coming back
7. weight loss and weakness (cachexia) are late sxs
8. pleural effusions
9. local spread to nerves
10. many extrapulmonary sxs and sns
a. metastasis common to liver, brain, bone
Lung Cancer
- diagnosis
- history
2. chest x-ray
3. CT scans
a. spiral CT scan
b. 95% accuracy but about 20% false positives
i. reduced lung CA deaths by 20% in those screened
4. sputum cytology
5. bronchoscopy
6. biopsy
7. thoracotomy
Lung Cancer
- staging (NSCLC)
- NSCLC
a. stage 0
i. in situ - “little bleb”
b. stage I - no metastasis, 50% survival rate
i. IA
- small
ii. IB
- slightly larger
c. stage II - 30% survival rate
i. IIA
- large tumor without lymphatic metastasis
ii. IIB
- small tumor with spread to regional nodes
d. stage III - chemo useless
i. IIIA
- spread to lymph nodes outside the lung
ii. IIIB - on opposite side and farther, 15% survival rate
- like IIIA but removal not possible
e. stage IV - 1% survival rate
i. widespread metastasis
Lung Cancer
- staging (SCLC)
- SCLC
a. limited
i. tumor in one lung and nearby lymph nodes
b. extensive
ii. tumor in both lungs or spread to other organs
Lung Cancer
- prognosis
- 5 yr survival rate 15%
2. 50% stage I and II potentially curable with surgery
a. radiation and chemotherapy added based on tumor size and metastasis
