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201 Cards in this Set
- Front
- Back
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what is a spine sign?
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summation sign on the spine
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What is the presentation of CMV pneumonitis?
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fever, hypoxia, cough, bilateral interstitial infiltrates
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How is CMV pneumonitis treated?
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Ganciclovir, cidofovir, foscarnet
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What is seen here?
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Adenocarcinoma.
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What is seen here?
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Adenocarcinoma, acinar & solid
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What is this showing the development of?
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Adenocarcinoma
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What is this?
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Asbestos body
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What is this?
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Aspergilloma
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What could this be?
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Aspergillus
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What could this be?
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Aspergillus
|
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What disease is this causing?
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Aspiration pneumonia
Dominated by oral anaerobes. |
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What is this?
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Atypical pneumonia
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What is this organism?
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Blastomycosis
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What part of the airway is shown here?
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Bronchiole
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What does this indicate is a possiblity?
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Bronchopneumonia
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Bronchopneumonia causes
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What is seen here and what is it associated with?
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Bronchopneumonia inflammation
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What part of the airway does this show?
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Bronchus
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What do you see here?
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Carcinoid
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What is this?
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Caseating granuloma
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What cells are these?
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Clara cells
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What does this indicate?
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CMV
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What does this show?
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CMV pneumonia
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What does this show?
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CMV pneumonia
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What disease does this show?
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Coal Workers' Pneumonitis
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What disease does this show?
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Simple CWP
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What disease might this be associated with?
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IPF (UIP)
dense fibrosis |
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What disease might this be associated with?
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Influenza
Diffuse alveolar damage |
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What disease might this be associated with?
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Asbestosis
Diffuse interstitial fibrosis |
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What disease might this be associated with?
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Silicosis
Diffuse micronodular disease |
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What disease might this be?
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Epithelial mesothelioma
|
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What is seen here?
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Fibroblastic foci indicative of UIP
|
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What is this?
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Pulmonary abscess w/fibrin wall
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What is this?
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Fibrotic NSIP
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what is this?
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hamartoma
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what is this?
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histoplasma
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what is this?
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histo
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what is this?
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hypersensitivity pneumonitis
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what is this?
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UIP
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What is this?
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Large cell carcinoma
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What process is seen here?
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Liquefactive necrosis
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What is seen in this pleural effusion?
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Malignant cells
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What is seen in this pleural effusion?
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adenocarcinoma
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What is this?
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mesothelioma
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What is this and what is it related to?
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Microcysts related to pulmonary fibrosis
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What is this?
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Nocardia
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What is this?
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NSIP
See alveolar wall expansion |
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what is this?
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organizing pneumonia
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What malignancy is seen here?
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Papillary adenocarcinoma
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What is this?
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PCP
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what is seen here & what is it related to?
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Pleural fibrosis-->asbestosis
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What is this?
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Pleural plaque
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What is seen here?
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pulmonary abscess
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What does this indicate?
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Sarcoidosis
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What is this and when is it found?
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Noncaseating granuloma-->sarcoidosis
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What is this?
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Noncaseating granuloma-->sarcoidosis
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What is this?
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Sarcomatoid mesothelioma
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What disease is shown?
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Silicosis
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What is this?
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Silicotic nodule
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What is this?
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Small cell carcinoma
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What is this?
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Solitary fibrous tumor
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What is this malignancy?
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Squamous cell carcinoma
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What part of the respiratory tract is this?
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Terminal bronchiole
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What part of the respiratory tract is this?
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trachea
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What part of the respiratory tract is this?
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trachea
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What part of the respiratory tract is this?
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trachea
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What disease is this?
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Wegener's granulomatosis
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What is normal pCO2?
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40mmHg
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What is the cutoff for pulmonary hypertension?
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mPAP>25mmHg at rest
mPAP>30mmHg exercise |
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What is normal HCO3?
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24
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What is normal A-a gradient?
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4+(age/4)
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What is normal anion gap?
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12+/-2
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What is respiratory acidosis?
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pH<7.4
pCO2>40 |
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What is respiratory alkalosis?
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pH>7.4
pCO2<40 |
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What is metabolic acidosis?
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pH<7.4
HCO3 decreased |
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What is metabolic alkalosis?
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pH>7.4
HCO3 increased |
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What are some causes of respiratory acidosis?
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Hypoventilation
CNS depression Thoracic cage abnormality Obstructive lung disease Obesity Hypothyroidism |
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What are some causes of respiratory alkalosis?
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Hyperventilation
Anxiety Pain Chronic liver disease Pregnancy PE Hyperthyroidism CNS stimulation Aspirin |
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What are some causes of anion gap metabolic acidosis?
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Ketoacidosis
Lactic acidosis Uremia MeOH or ethylene glycol poisoning Aspirin OD |
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What are some causes of non-anion gap metabolic acidosis?
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Diarrhea
Renal tubular acidosis TPN Ureteral diversion Pancreas transplant |
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What are some causes of chloride responsive metabolic alkalosis?
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Vomitinig
Nasogastric suctioning Diuretics |
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What are some causes of chloride unresponsive metabolic alkalosis?
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Corticosteroids
Cushings Hyperaldosteronism |
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What is the prototypical perfusion limited gas?
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NO
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What is the prototypical diffusion limited gas?
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CO
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How do you calculate DLCO?
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DLCO=Vco/PACO
Vco=minute ventilation PACO=alveolar pressure of CO |
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What is normal DLCO?
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25ml/min/mmHg
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where do bronchial arteries arise from?
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Aorta & intercostal arteries
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what is the TMG?
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Transmural pressure gradient
TMG=Pinside-Poutside |
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What are the effects of inhalation on the size of the extra- and intra-alveolar vessels?
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Extra-alveolar: lung distension increases TMG-->vessel distension
Intra-alveolar: lung distension decreases TMG-->increased vascular resistance |
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What happens to the PVR & mPAP during exercise?
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mPAP increases
PVR decreases |
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What are the target chemicals for treating patients with pulmonary hypertension?
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Vasodilators: NO & PGI2
Vasoconstrictors: Endothelin-1, 5HT |
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What does PAOP represent?
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Left atrial pressure (LAP) measured from the tip of the Schwan-Ganz catheter
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How do you calculate PVR?
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(mPAP-PAOP)/CO=PVR
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What is the Starling equation?
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Jv=Kfc[(Pc-Pt)-σ(∏p - ∏t)]
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What happens with ACE in the pulmonary circulation?
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Angiotensin I-->Angiotensin II by ACE
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What happens to bradykinin in the pulmonary circulation?
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80% degraded by ACE
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What happens to serotonin in the pulmonary circulation?
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Nearly completely removed.
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What is normal A-a gradient?
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<20mmHg in young people
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What is anatomic shunt?
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Systemic blood enters the left ventricle w/o passing through pulmonary vasculature
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What are physiological causes of anatomic shunt?
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From bronchial & pleural veins
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What are some pathologic causes of anatomic shunt?
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Congenital heart disease
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What is an absolute intrapulmonary shunt?
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True shunt arising from completely collapsed alveoli which remain perfused causing blood to pass through w/o participating in gas exchange
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What is a shunt-like condition?
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Lung unit with relatively low amount of ventilation relative to perfusion-V/Q inequality
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What is V/Q?
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Ventilation-perfusion ratio
V=alveolar ventilation in L/min Q=cardiac output in L/min |
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What does a V/Q of 0 represent?
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0/x
No ventilation-->intrapulmonary shunt |
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What does a V/Q of infinity represent?
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x/0
No blood flow-->dead space ventilation |
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What is the main compensatory mechanism for V/Q mismatch?
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Hypoxic pulmonary vasoconstriction
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What is a normal PAOP?
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<12
Higher indicates type II PH (left heart) |
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What is defined as PAH?
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Pulmonary hypertension due to problems with the pulmonary arteries.
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What are some diseases associated w/PAH (APAH)?
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CT diseases (SLE, RA, scleroderma), congenital shunts (patent foramen ovale), portal hypertension, drugs (anorexigens), HIV infection
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What is group 2 PH?
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Associated with left heart disease
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What is group 3 PH?
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PH due to lung disease and/or hypoxemia
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What is group 4 PH?
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PH related to chronic thrombotic and/or embolic disease
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What is group 5 PH?
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PH related to a variety of causes...
Sarcoidosis, LAM, Eosinophilic granuloma (Histiocytosis X), pulmonary vessel compression |
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What are the mechanisms of vascular injury in PH?
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Endothelial dysfunction
decreased NO synthase decreased PGI2 production increased ET-1 production increased thromboxane production Vascular smooth muscle dysfunction |
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What are the changes seen in PH when it is still reversible?
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Early intimal proliferation
Smooth muscle hypertrophy |
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What vascular changes are seen in irreversible PH?
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In situ thrombosis
Adventitial & intimal proliferation Smooth muscle hypertrophy Plexiform lesion |
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What is sildenafil?
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Phosphodiesterase 5 inhibitor
Used in PH inhibits cGMP breakdown-->perpetuates action of NO Pill form |
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What are the endothelin-1 receptor antagonists (ETRA)?
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Bosentan
Ambrisentan/Sitaxsentan |
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What does bosentan do?
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Blocks ETA and ETB
"Dual ETRA" PH medication |
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What does ambrisentan do?
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ETRA selective for ETA
PH medication |
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What are the prostanoids?
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Epoprostenol
Treprostinil Iloprost |
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How do the prostanoids work?
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Analogs of PGI2
Stimulate adenylate cyclase to produce cAMP |
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What is the problem with epoprostenol?
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IV infusion that must be given continuously
Side effect=fatal rebound hypertension |
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How is iloprost administered?
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inhalation
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How is treprostinil administered?
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IV or SC
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What are the calcium channel blockers?
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Nifedipine, amlopidine, diltiazem
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What do the calcium channel blockers do?
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Vasodilators
Only 10% of patients will have good sustained response Used for PH |
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What are symptoms of PH?
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Dyspnea
Chest pain Syncope Edema (usually of legs) |
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What is LaPlace's law for alveoli?
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P=4T/r
P=pressure T=surface tension of liquid r=radius |
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What LaPlace's law for soap bubble?
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P=2T/r
P=pressure T=surface tension of liquid r=radius |
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What determines the type of airflow?
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Re=2rvd/n
r=radius v=velocity d=density of gas n=viscosity |
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What has turbulent flow?
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Trachea
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What kind of airflow do the smallest airways have?
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laminar
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What is the resistance of laminar flow?
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R=8nl/(pi)r^4
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Where does most of the resistance in the airways come from?
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Middle-sized airways out to division 7
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What is the equal pressure point?
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The point in the airway during forced expiration when IPP is greater than the airway pressure and the airway collapses
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What problems make the equal pressure point happen sooner?
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Low lung volumes (IPF)
High resistance (obstructive diseases) Poor airway traction surfaces (emphysema) |
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What is respiratory failure?
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Failure to maintain adequate oxygen and carbon dioxide homeostasis
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What is hypoxemia respiratory failure?
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Respiratory failure due to too little oxygen
Caused by decreased partial pressure of oxygen, shunt, hypoventilation, V/Q mismatch, impaired diffusion |
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What is hypercapnia?
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too much carbon dioxide in the blood
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What is a clinical situation of low V/Q?
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Alveoli filled with fluid (pus, blood, etc.)
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When is the A-a gradient high?
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V/Q mismatch
Impaired diffusion Shunt |
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What is a Venturi mask?
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Mask that delivers high controlled ventilation to patient at high oxygen levels using Bernoulli's principle
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What is the result of hypoventilation?
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Hypoxemia that is ALWAYS associated with hypercapnia
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What happens in hypercapnic respiratory failure?
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Minute ventilation cannot keep up with PCO2 production
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What are some causes of hypercapnic respiratory failure?
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Depressed respiratory drive
Inadequate neuromuscular competence Excessive respiratory muscle load |
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What are signs and symptoms of respiratory failure?
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Signs & symptoms of hypoxemia and/or hypercapnia:
somnolence dyspnea tachypnea use of accessory muscles |
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What is the course of respiratory failure management?
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Correct underlying problem
Airway Correct hypoxemia Manage acid/base status |
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What is Virchow's triad?
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Major risk factors for DVT/PE
Hypercoagulability Venous stasis Endothelial injury |
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What are some causes of endothelial injury?
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Surgery, invasive procedures
Vasculitis (Behcets or anti-phospholipid antibody syndrome) |
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What clotting factors are related to hypercoagulability?
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V, VIII, X
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What are inherited causes of hypercoagulability?
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Factor V Leiden
Protein C or S deficiency Prothrombin gene mutation 20210 |
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What is Homan's sign?
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Palpable cord felt in DVT
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What is the gold standard of DVT diagnosis?
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Duplex compression ultrasonography
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What are methods of detecting DVT?
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Duplex compression ultrasonography
Helical CT of leg Impedance plethysmography Contrast venography |
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What are the limitations of duplex compression ultrasonography?
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Cannot detect DVT below the knee
Must use serial exams to rule out below the knee DVT |
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If a D-dimer is normal and clinical suspicision of PE is low, what should you do?
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Nothing.
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What would you do if you have a high suspicion of PE?
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either start treatment or chest radiography
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What should you do if chest radiography is abnormal in the evaluation of a possible PE?
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Chest CT arteriography
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How do you treat a massive PE?
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Thrombolytics: tPA
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What is used in treating PE or DVT if the patient has a history of heparin-induced thrombocytopenia?
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Argatroban
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What should tPA be used?
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Massive PE requiring mechanical ventilation & vasopressors
Shock present |
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How long does anticoagulant therapy need to be continued following a PE?
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3 months with INR at 2-2.5
6 months if idiopathic Indefinitely if recurrent |
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What is used as VTE prophylaxis?
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UFH 5000 units BID or TID
LMWH 30mg BID or 40mg QD Compression boots |
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Where is the medullary respiratory center?
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Floor of 4th ventricle
|
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What is the medullary respiratory center responsible for?
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Inspiratory ramp of periodic firing
Independent of afferent stimuli |
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Where is the apneustic center?
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Lower pons
Stimulates/prolongs inspiratory ramp |
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Where is the pneumotaxic center?
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Upper pons
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What does the pneumotaxic center do?
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Inhibits/attenuates inspiration
May fine tune respiration |
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Where are the central chemoreceptors?
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Ventral medulla near exit of CNIX and X
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What do the central chemoreceptors respond to?
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pH changes in the CSF due to increased/decreased bicarbonate content of CSF
Acidosis-->stimulates respiration Alkalosis-->inhibits respiration |
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Where are the peripheral chemoreceptors?
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Carotid bodies & aortic arch
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What do the peripheral chemoreceptors respond to?
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decreases in arterial pO2 and pH, and, to a lesser degree, changes in PCO2
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What is the nature of the response of the peripheral chemoreceptors to changes in PO2?
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PO2<100mmg-->non-linear response that increases rapidly
|
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When do the lung stretch receptors respond?
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Lung distension-->decrease respiratory rate
Act mostly during exercise at high lung volumes |
|
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Where are the irritant receptors?
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Between epithelial cells in the respiratory tract
Result in airway restrction & reduced RR |
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Where are the J receptors?
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In the alveolar walls close to the capillaries
|
|
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What is caused by stimulation of the J receptors?
|
Rapid shallow breathing usually associated with pulmonary vessel distension
|
|
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What are the bronchial C fibers?
|
Fulfill same role as J receptors
Supplied by bronchial aa. |
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What is the gamma system?
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Intramuscular receptors controlling the strength of contraction of the muscles of inspiration
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What is the nature of the response of the respiratory system to rise in CO2?
|
Non-linear increase in ventilation
|
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When does the hypoxic ventilatory response become important?
|
When arterial pO2 drops below 50mmHg
Examples: high altitude, chornic lung disease |
|
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What are the phases of sepsis treatment?
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Recognition
Resuscitation Initial management Maintenance Recovery |
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What is SIRS?
|
Clinical response arising from a nonspecific insult resulting in at least 2 of the following:
Temp. >38C or <36C HR>9BPM WBC>12000 OR <4000 OR >10% immature neutrophils |
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What is sepsis?
|
SIRS with a presumed or confirmed infectious process
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What is severe sepsis?
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Sepsis with signs of at least 1 major organ failure
|
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What is the most consistent feature of sepsis?
|
Neurologic changes
|
|
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What are the most common organisms found in sepsis today?
|
Gram + bactera
Gram - bacteria Fungi |
|
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What are the most common sites of infection in severe sepsis?
|
Respiratory
|
|
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What are some risk factors for sepsis?
|
Male gender
African American Cancer (esp. hematologic) HIV Venous access devices |
|
|
What is involved in the resuscitation phase of sepsis management?
|
Keep patient alive for 24 hours.
A=airway-->intubation B=breathing-->mechanical ventilation C=circulation-->vasopressors, IV access, IV volume, goal-directed therapy |
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How is fluid management done in sepsis treatment?
|
Administer fluid challenge and see changes
|
|
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What are the common vasopressors used in sepsis?
|
Dopamine
Norepinephrine Norepinephrine increases heart contractility, heart rate and causes vasoconstriction Dopamine does the same at high doses. |
|
|
What is goal-directed therapy?
|
Additional goal for 1st 6 hours: get central venous oxygenation>70%
Give RBCs if HgB<10 Give dobutamine if HgB>10 |
|
|
What are the risks of drotecogin alfa?
|
Bleeding
Need risk of dying>risk of bleeding |
|
|
What is seen in an xray of ARDS or ALI?
|
Fluffy white bilateral infiltrate
|
|
|
What is the definition of ALI & ARDS?
|
PaO2/FiO2<300=>ALI
PaO2/FiO2<200=>ARDS |
|
|
What are common causes of direct lung injury?
|
Pneumonia
Aspiration |
|
|
What are common causes of indirect lung injury?
|
Sepsis
Massive trauma Multiple transfusions |
|
|
What is essential in treatment of ALI/ARDS?
|
Low tidal volume ventilation
Fluid balance: perfused kidney vs. dry lung? |
