Vascular and Pleural Disease Flashcards
What are the three physiological mechanisms of increased pulmonary pressure?
Flow
Increased Pulmonary vascular Resistance
Increased left heart pressure (increased pulm venous pressure)
What are the three risk factors for venous thrombosis?
Hypercoagulability
Stasis
Injury to vein wall
What is the typical presentation of a deep venous thrombosis?
Swelling - entire leg or below knee Pitting edema Difference in calf size Warmth Homan's sign - pain elicited by foot dorsiflexion
What is the most common test used to diagnose a DVT?
Compression duplex ultrasonography
Vein should collapse when you compress it - doesn’t if clot
Then Doppler to look at blood flow
What test is used for pelvic vein DVT testing?
Venography
Gold standard for all DVT but invasive and requires IV contrast
CT - contrast required
Sometime MRI
Who should not take estrogen containing oral contraceptives?
Individuals who are factor v Leiden positive
What are symptoms of a pulmonary infarction?
Hemoptysis
Pleural rub
Low grade fever
Peripheral wedge shaped defect on CXR - hamptons hump right above diaphragm
What are common symptoms of a PE?
Tachypnea
Acute dyspnea
Chest pain
What symptoms suggest a large PE?
Tachycardia
Syncope
Hypotension
What are lab and imaging findings in a PE?
Hypoxemia, widened Aa gradient, usually paO2 <80
Sometimes atelectasis or small pleural effusion
Westermarks sign - paucity of blood vessels in lobe from infarct
Elevated d dimer
What are the different tests for a PE?
D dimer - high sensitivity, low specificity - can rule it out but not done if suspicion already high
Ct angiogram - high sensitive and specific, requires contrast
VQ scan - if unable to receive contrast, test of choice for chronic PE
Pulmonary angiography - gold standard but invasive and contrast
What is the definition of pulmonary hypertension?
PA systolic > 40 or PA mean > 25
PulmVR usually above 240
What are the five groups of clinical classifications of pulm HT?
1 - pulm arterial hypertension = small vessels, low wedge pressure, has medications, diagnosis of exclusion
2 - pulmonary venous hypertension = left heart, most common, elevated wedge pressure
3 - pulm HT from hypoxia and/or lung disease, oxygen therapy in COPD can prevent, irreversible once develops
4 - chronic PE, can be cured by surgery
5 - miscellaneous and uncommon conditions
What diagnostic tests are used to work up pulm ht?
Echo
Cath
(VQ, not CTA, PFTs and CXR)
What are general radiographic feature of pulm HT?
Enlarged pulmonary arteries
RV dilation
Azygous vein distention
What are radiograph findings of pulmonary VENOUS hypertension?
Cephalization of pulmonary veins
Interstitial edema, Kerley b lines
Alveolar edema
What is this presentation of a person with pleural disease?
Dyspnea
Pleuritic pain (but not with transudative processes)
Cough
Weight loss, fatigue (systemic complaints)
Fever, rigors
What are the six mechanisms responsible for pleural fluid accumulation?
Increased hydrostatic pressure (pulm venous HT)
Decreased oncotic pressure
Decreased intrapleural pressure (like PTX)
Increased permeability of micro vasculature (inflammation)
Lymphatic obstruction
Movement of fluid from peritoneum
What are the most common causes of transudative effusions?
CHF
Hypoalbuminemia
Ascites with hypoalbuminemia
What are the most common causes of exudative effusions?
Inflammation or lymphatic obstruction
Extensive differential
If someone comes in with pain and fever what kind of effusion is present?
Exudative
What lab values differentiate between transudative and exudative effusions?
Ratio of fluid/serum LDH - >.6 exudate, .5 exudate, .3 exudate, >10,000 or RBC»_space;50,000 is exudate
Albumin gradient - >1.2 transudate, <1.2 exudate
What is empyema?
A para pneumonic effusion Always exudate Loculated fluid Ph < 7.2 Glucose < 40 High WBC Continued fever Enlarging effusion
What is a unilateral pleural effusion suspicious for?
TB
If unilateral and positive ppd treat for tb
What are the different effusions in collagen vascular diseases?
RA - uni or bilateral, glucose < 10, RF high
SLE - bilateral, glucose normal, complement low
What does an esophageal rupture present like?
Left pleural effusion
PTX or pneumomediastinum
Ph < 7, amylase >5000
What can cause a bloody effusion (RBC > 100,000)?
Tumor
Trauma
PE with infarction
Tb
What are the common causes of PTX?
Iatrogenic
Trauma
Emphysema with bullae
Necrotizing Bacterial pneumonias (staph, gram -, anaerobes), Tb, Pneumocystis Carinii (PCP)
Necrotizing granulomatous processes (sarcoidosis, eosinophilic)
Non malignant implants on pleura: endometriosis
When is VATS indicated to assess pleural effusions?
Difficult to diagnose pleural effusion when infectious or neoplastic etiology is likely
When can a tension PTX develop?
Patient on a ventilator
Almost never happens in spontaneously breathing patient
What is the treatment of PTX?
Placement of chest tube to drain air using suction
