Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
117 Cards in this Set
- Front
- Back
|
pulmonary function tests |
spirometry (mechanical ventilation)
Dlco (gas exchange) methacholine challenge test (bronchial hyperreactivity) TLC |
|
|
restrictive pattern
|
FEV1/FVC > 80%
|
|
|
obstructive pattern
|
FEV1/FVC < 80%
seen in emphysema, chronic bronchitis, asthma, bronchiectasis |
|
|
↓DLco
|
if FEV1/FVC < 80% suggests emphysema
if FEV1/FVC > 80% suggests interstitial lung disease or mild left heart failure |
|
|
↑DLco
|
suggests hemorrhage such as in Goodpasture
|
|
|
methacholine test
|
bronchoprovocation in patients with cough or wheezing who have normal pulmonary function tests, for possible asthma
do basal and postprovocation spirometry postitive test if baseline FEV1 decreased >20% |
|
|
A-a gradient formula
|
150 - (1.25 x PaCO2) - PaO2 normal: 5-15mmHg; increases with age and all forms of hypoxemia except hypoventilation and high altitude
|
|
|
solitary pulmonary nodule
|
1/3 are malignant
first step in management is looking for previous image study if none available then consider if patient is high or low risk for cancer low risk nonsmoker <35 --> x-ray every 3 months for 2 years, if no growth stop follow-up high risk smoker >50 --> open-lung biopsy and removal due to cancer risk |
|
|
transudative pleural effusion
|
↓hydrostatic pressure or ↓oncotic pressure; usually bilateral and equal
low LDH and proteins in fluid and serum (200, 0.6, 0.5) need all three values for diagnosis, else exudate |
|
|
exudative pleural effusion |
due to local process; usually unilateral; need further investigation; high LDH and proteins in fluid and serum (200, 0.6, 0.5); don't need all three values high to make diagnosis
|
|
|
transudative causes of pleural effusion
|
heart failure
nephrotic syndrome liver disease pulmonary embolism atelectasis |
|
|
exudative causes of pleural effusion
|
pneumonia
cancer (lung, breast or lymphoma) pulmonary embolism drug-induced pancreatitis TB RA SLE |
|
|
transudative pleural effusion with no apparent cause
|
consider pulmonary embolism which can be either transudative or exudative
|
|
|
indications of thoracocentesis
|
any new and unexplained pleural effusion --> rule out empyema
decubitus x-ray --> <1cm free-flowing fluid --> minimal risk if non-free fluid need ultrasound guidance |
|
|
malignant pleural effusions
|
due mostly to breast cancer, lung cancer and lymphoma
send thoracocentesis fluid for cytologic exam also |
|
|
hemorrhagic pleural effusion
|
seen in mesothelioma, metastatic lung or breast cancer, pulmonary embolism with infarction and trauma
|
|
|
lymphocytic-predominant pleural effusions
|
suggests TB due to tuberculin hypersensitivity
check ↑adenosine deaminase and postivie PCR for TB acid-fast and culture of fluid are only positive in 30% |
|
|
respiratory compromise and distress
|
presents with shortness of breath, dyspnea, tachypnea (>30) and associated symptoms such as agitation, confusion or ↓consciousness
|
|
|
evaluation of respiratory distress
|
ensure patent airway
focus on quickness of onset and associated symptoms most important lab test is arterial blood gases then B-natriuretic peptide and chest x-ray |
|
|
acute respiratory distress with fever, cough or sputum
|
suggests infectious etiology
|
|
|
acute respiratory distress without systemic symptoms
|
suggests airway obstruction, cardiac disease or thromboembolism
|
|
|
chronic respiratory distress
|
suggests interstitial lung disease or COPD
|
|
|
common lung physical exam findings
|
diffuse wheezing --> asthma
localized wheezing --> foreign object rales --> pneumonia, interstitial disease, heart failure dull percusion --> pneumonia or atelectasis normal exam --> pneumocystis jirovecci, central respiratory problems |
|
|
B-natriuretic peptide in acute dyspnea
|
elevation is sensitive for heart failure but can also be elevated in cor pulmonale and acute right ventricular failure (thromboembolism)
|
|
|
chest x-ray without parenchymal infiltrates in acute dyspnea
|
suggests thromboembolism
central respiratory depression neuromuscular disease upper airway obstruction |
|
|
chest x-ray hyperinflation in acute dyspnea
|
suggests asthma and COPD
|
|
|
chest x-ray with focal infiltrates in acute dyspnea
|
suggests bacterial, viral or fungal pneumonia, aspiration or pulmonary hemorrhage
|
|
|
chest x-ray with diffuse edema in acute dyspnea
|
suggests heart failure or ARDS
|
|
|
ICU indications in respiratory failure
|
persistent hypoxemia --> hospitalization
ICU indications --> need for mechanical ventilation close monitoring increasing oxygen demand continuous nursing |
|
|
indications for intubation and/or mechanical ventilation
|
respiratory acidosis and hypercapnia in asthmatic patient
upper airway injury (burns, laryngeal edema, trauma) neurologic airway depression (often with loss of gag and cough reflexes) |
|
|
respiratory distress in hospitalized patients
|
inpatient who develops dyspnea, tachypnea and/or hypoxemia should raise possiblity of pulmonary embolism or aspiration
|
|
|
types of asthma
|
intrinsic (50%) is secondary to nonimmunologic stimuli (infections, irritating inhalants, cold air and emotional); extrinsic (20%) due to allergens
|
|
|
asthma stimuli
|
infections (RSV, rhinovirus), drugs (aspirin/NSAIDs, coloring agents, betablockers), allergens, cold air, emotions
|
|
|
asthma presentation
|
tachypnea, tachycardia, diffuse wheezing, use of accesory muscles, diminished breath sounds, hyperresonance, intercostal retractions
|
|
|
asthma poor prognosis factors
|
fatigue
diaphoresis pulsus paradoxus inaudible breath sounds decreased wheezing cyanosis bradycardia |
|
|
asthma diagnosis
|
initial tests for acute attacks --> ↓PaCO2, ↑pH, normal or ↓PaO2
severe attack -->↓PaO2, ↑PaCO2, ↓pH chest x-ray to rule out infection as cause spirometry --> obstructive pattern that reverses with beta agonist (FEV1 reverses by 12%) methacholine test --> ↓FEV1/FVC of 20% |
|
|
acute asthma management
|
O2
metered inhaled beta agonists --> albuterol/salbutamol, terbutaline salmeterol is long-lasting for nocturnal variant catecholamines may be used but not routinely aminophylline and theophyline have modest potency and are not routine anticholinergics (ipratropium) if heart disease (slow onset, medium potency) |
|
|
chronic asthma management
|
acute exacerbations: systemic prednisone 10-14 days along with inhaled albuterol; inhaled corticosteroids are first line maintenance; cromolyn is first line maintenance in children and prophylaxis in adults; zileuton, zafirlukast, mmonteleukast for severe asthma resistant to maximum doses of inhaled steroids
|
|
|
mild asthma definition and treatment
|
symptoms ~2 days/week and rare night symptoms
FEV1 is normal no long-term control needed only inhaled beta agonists for attacks |
|
|
moderate asthma definition and treatment
|
symptoms on most days and at least 5 nights/month with FEV1 60-80%
treat with daily inhaled steroids (also cromolyn specially in children) maybe also salmeterol |
|
|
severe asthma definition and treatment
|
daily symptoms, frequent night symptoms and hospital emergencies with FEV1 <60%; daily inhaled steroids, daily inhaled salmeterol along with antileukotriene drug and possibly low-dose oral steroid
|
|
|
physical exam in emphysema
|
distant breath sounds
pink skin thin barrel chest accesory muscles symptoms of right heart failure and clubbing |
|
|
physical exam in chronic bronchitis
|
rhonchi and wheezes
signs of cyanosis weight gain symptoms of right heart failure and clubbing |
|
|
chest x-ray findings in COPD
|
chronic bronchitis --> increased pulmonary markings
emphysema --> bilateral hyperinflantion, diaphragm flattening, small heart size, increase in retrosternal space |
|
|
COPD diagnosis and work-up
|
↓FEV1/FVC
FEF 25-75 ↑RV and TLC emphysema has ↓DLco and chronic bronchitis has normal DLco FEV1/FVC after bronchodilation will stay the same also order --> EKG --> right axis deviation and hypertrophy CXR CBC --> increased hematocrit electrolytes --> increased bicarbonate ABG --> assess need of home O2 if CO2 retention |
|
|
COPD complications
|
hypoxemia with nocturnal desaturation
secondary erythrocytosis cor pulmonale chronic ventilatory failure CO2 retention |
|
|
maintenance treatment for COPD
|
first-line --> ipratropium via metered inhaler;
inhaled albuterol inhaled pneumococcal vaccine yearly influenza vaccine smoking cessation if PO2 < 55 or SaO2 < 88% --> home O2 corticosteroids are not used in COPD if above fails --> theophylline (watch for cytochrome inhibitors and inducers) |
|
|
only treatment that reduces mortality in COPD
|
home O2 supplementation and smoking cessation
home oxygen for hypoxemia (PaO2<55mmHg or saturation <88%) pneumococcal vaccine every 5 years, influenza vaccine yearly and haemophilus vaccine if unvaccinated |
|
|
COPD exacerbation general management
|
1) measure O2 saturation (pulse oximetry)
2) arterial blood gases 3) chest x-ray 4) check theophylline levels 5) CBC and ECG 6) hospital admission if significant hypercapnia or hypoxemia 7) intubation and mechanical ventilation if pH drops (not CO2 retention) 8) specific treament spirometry is NOT done or useful in exacerbation |
|
|
COPD exacerbation specific treatment
|
1) O2 supplementation
2) inhaled albuterol and ipratropium concomitantly 3) IV (bolus) or oral methyl prednisolone for 2 weeks 4) antibiotics despite normal x-ray (ceftriaxone + azithromycin 5) council on smoking cessation 6) teach optimal use of MDI no benefit in IV theophylline and avoid opiates and sedatives |
|
|
bronchiectasis etiology
|
secondary to recurrent pneumonias, TB, fungal or abscess
cystic fibrosis, immotile cilia syndrome (50% Kartagener) |
|
|
bronchiectasis presentation
|
suspect in anyone with
chronic cough foul-smelling sputum hemoptysis recurrent pulmonary infections sinusitis immune deficiencies presents with purulent copious sputum, wheezes, crackles and history of recurrent pneumonias (specially gram- and pseudomonas) |
|
|
bronchiectasis diagnosis
|
early chest x-ray may be normal or severe cases show 1-2cm cysts and crowding of bronchi; chest CT is best noninvasive test
|
|
|
bronchiectasis treatment
|
bronchodilators, chest physical therapy, postural drainage, rotating gram- antibiotics
surgery in cases of localized bronchiectasis or massive hemoptysis yearly influenza vaccine and pneumococcal vaccine with booster at 5 years |
|
|
bronchiectasis complications
|
massive hemoptysis, amyloidosis, cor pulmonale, visceral abscesses
|
|
|
interstitial lung disease general presentation
|
exertional dyspnea
nonproductive cough crackles pulmonary hypertension clubbing restrictive pattern |
|
|
interstitial lung diseases
|
idiopathic pulmonary fibrosis
sarcoidosis pneumoconiosis --> asbestosis, silicosis, coal pneumoconiosis |
|
|
idiopathic pulmonary fibrosis presentation
|
exercise intolerance, dyspnea, coarse crackles
|
|
|
idiopathic pulmonary fibrosis diagnosis
|
reticular or reticulonodular pattern on chest x-ray
high res CT restrictive pattern on PFTs increased macrophages on bronchoalveolar lavage (nonspecific) lung biopsy |
|
|
idiopathic pulmonary fibrosis treatment
|
steroids with or without azathioprine works in 20%; the rest develop fatal lung disease
|
|
|
idiopathic pulmonary fibrosis prognosis
|
20-40% 5-year survival; best prognostic factor is response to steroids as evidenced in PFTs
|
|
|
sarcoidosis presentation
|
"GRAIN"
gammaglubilinemia rheumatoid arthritis ACE increase interstitial fibrosis non-casseating granuloma hilar and left paratracheal adenopathy hypercalcemia due to vitamin activation by macrophages uveitis/conjunctivitis in >25% chest x-ray findings restrictive or normal PFTs |
|
|
chest x-ray findings in sarcoidosis
|
four stages found (not progressive)
bilateral hilar adenopathy hilar adenopathy with reticulonodular parenchyma reticulonodular parenchyma alone honeycombing of bilateral lung fields with fibrosis |
|
|
sarcoidosis diagnosis
|
biopsy of affected tissue showing noncasseating granulomas; all patients should have ophthalmologic exam
|
|
|
sarcoidosis prognosis
|
80% remain stable or spontaseoulsy resolves; 20% progress to organ compromise
|
|
|
sarcoidosis treatment
|
no treatment is effective
if organ compromise may use trial of high-dose steroids if uveitis, CNS involvement or hypercalcemia --> steroids are mandatory |
|
|
pneumoconiosis general presentation
|
dyspnea, shortness of breath, cough, sputum, cor pulmonale, clubbing, restrictive pattern, ↓DLco, hypoxemia with ↑A-a
|
|
|
ocupations associated with asbestosis
|
mining, milling, foundry work, shipyards, pipes, break linings, insulation, boilers; history of exposure necessary for Dx
|
|
|
asbestosis x-ray findings
|
diffuse or local pleural thickening, pleural plaques, calcifications near diaphragm, pleural effusions, lower lobe interstitial infiltrate
|
|
|
asbestosis associated cancers
|
lung adenocarcinoma or SCC
pleural mesothelioma is less common |
|
|
asbestosis diagnosis
|
history of exposure + lung biopsy showing barbell-shaped asbestos fibers
|
|
|
asbestosis treatment
|
no effective treatment; must stop smoking due 75x increased risk of cancer
|
|
|
ocupations associated with silicosis
|
mining, quarrying, tunneling, glass and pottery making, sandblasting
|
|
|
silicosis x-ray findings
|
1-10mm nodules throughout the lungs, most prominent in upper lobes
in progressive massive fibrosis nodules are >10mm and coalesce |
|
|
silicosis diagnosis
|
history of exposure + lung biopsy showing silica particles
pathologic lesion is the hyaline nodule |
|
|
silicosis treatment
|
no effective treatment; should have yearly PPD test and if >10mm --> INH prophylaxis for 9 months
|
|
|
Lofgren syndrome
|
acute sarcoidosis presentation with erythema nodosum, arthritis, hilar adenopathy
|
|
|
Heefordt-Waldenstrom syndrome
|
acute sarcoidosis presentation with fever, parotid enlargement, uveitis and facial palsy
|
|
|
Caplan syndrome
|
rheumatoid nodules in periphery of lung, rheumatoid arthritis and coesxisting pneumoconiosis (usually CWP)
|
|
|
coal worker's pneumoconiosis x-ray findings
|
small round parenchymal densities
usually in upper half of lungs progressive massive fibrosis has 1cm densities in whole lung |
|
|
coal worker's pneumoconiosis immunologic findings
|
↑IgA, ↑IgG, ↑C3, ANA and rheumatoid factor
|
|
|
pulmonary embolus site of origin
|
most are from above-the-knee deep veins which result from distal deep vein thrombosis; in patients with catheters it can originate from upper limb, subclavian and internal jugular veins
|
|
|
criteria for high-risk pulmonary embolism patients
|
immobilized patients
oral contraceptives pregnancy recent surgery (specially orthopedic, knee replacement has 70% risk) cancer history (prostate, breast, pelvic, abdominal) acquired thrombophilia (lupus anticoagulant, nephrotic syndrome) inherited thrombophilia (factor V Leiden, protein C/S deficiency, antithrombin III deficiency) need 1 risk factor and consistent signs and symptoms for high-risk label |
|
|
signs and symptoms consistent with pulmonary embolism
|
sudden onset of dyspnea, tachypnea, thigh/calf swelling, pleuritic chest pain, hemoptysis, tachycardia, ↑P2
|
|
|
when to consider pulmonary embolism
|
all patients with dyspnea and normal chest x-ray
|
|
|
nonspecific routine tests for dyspnea; may suggest PE
|
arterial blood gases show hypoxemia with ↑A-a
chest x-ray (normal in PE) ECG (to exclude others) shows S1, Q3, T3, tachycardia |
|
|
specific tests for pulmonary embolism
|
best initial test is spiral CT scan; V/Q scan (if normal excludes PE); angiogram is gold standard
|
|
|
deep venous thrombosis specific tests
|
best intial test is compression or duplex ultrasound; venogram is rarely done; MRI
|
|
|
tests for DVT and PE
|
D-dimer is most sensitive; can only exclude thromboembolism if normal levels
may also be high in surgery, infection, trauma, pregnancy and DIC normal D-dimer and CT scan rule out thromboembolism in 98% of low-risk patients |
|
|
tests results that exclude pulmonary embolism
|
normal CT + normal D-dimer in low-risk patients
normal CT + normal doppler in low-risk patients V/Q scan is completely normal |
|
|
generalities of pulmonary embolism diagnosis
|
all patients should be on heparin during diagnosis and imaging; if PE is suspected start CT scan right after chest x-ray; if all tests are negative but it's high-risk patient --> angiogram; normal CT + normal D-dimer or doppler excludes PE in low-risk patients
|
|
|
pulmonary embolism treatment
|
1) O2
2) start heparin before confirmation and during work-up 3) concomitant warfarin 4) if hemodynamically unstable or massive PE --> thrombolytics (tPa, streptokinase) |
|
|
heparin considerations in pulmonary embolism
|
if LMWH then no need to follow PTT and less chance of heparin-induced thrombocytopenia
HIT is associated with more thrombotic events, not bleeding diathesis, and is treated with new anticoagulants (argatroban, lepirudin) start heparin immediately |
|
|
warfarin considerations in pulmonary embolism
|
monitor PT
titrate to INR of 2-3 skin necrosis can occur if protein C deficiency already present contraindicated in pregnancy (use LMWH 6 months instead) |
|
|
contraindications of anticoagulation therapy in PE
|
contraindicated in patients with recent neurosurgery or eye surgery; use inferior vena cava filter instead
|
|
|
post thrombotic syndrome
|
pain
edema hyperpigmentation skin ulceration in 2/3 of PE patients compression stockings can prevent it |
|
|
fat embolism
|
acute dyspnea, petechiae in neck or axilla, confusion, 3 days after long bone fracture or after CPR; no anticoagulation necessary
|
|
|
ARDS etiology
|
sepsis
trauma DIC Goodpasture SLE drug overdose toxin inhalation drowning |
|
|
ARDS presentation
|
dyspnea, tachypnea, diffuse rales and ronchi
|
|
|
ARDS diagnosis
|
chest x-ray --> diffuse interstitial or alveolar infiltrates
ABGs --> ↓PaO2, ↑PaCO2 Swan-Ganz --> normal cardiac output and capillary wedge pressure but ↑pulmonary artery pressure |
|
|
ARDS treatment
|
treat underlying cause; mechanical ventialtion with positive end-expiratory pressure
|
|
|
ARDS prognosis
|
70% mortality
|
|
|
sleep apnea
|
cessation of airflow >10s at least 10-15/hour of sleep + daytime somnolence
confirm with polysomnography treat obstructive with weight loss and nasal continuous positive airway pressure (CPAP) treat central with acetazolamide, progesterone and O2 |
|
|
lung cancer etiology
|
90% of cases are directly related to cigarette smoke; nonsmokers develop adenocarcinoma; all lung cancers are associated with smoking; active smokers have 10x greater risk; 40 pack-year history increases risk 60-70x; asbestos increases risk 75x
|
|
|
types of lung cancer
|
most common is adenocarcinoma (40%); squamous cell carcinoma, small cell and large cell
|
|
|
centrally located lung cancers
|
squamous cell and small cell
|
|
|
peripheral located lung cancers
|
adenocarcinoma and large cell
|
|
|
lung cancer paraneoplastic syndromes
|
SCC --> hypercalcemia (PTH-like peptide)
small cell --> SIADH and Eaton-Lambert |
|
|
lung cancer metastasis
|
SCC --> direct extension to hilar node and mediastinum
small cell and adenocarcinoma --> liver, adrenals, brain, bones |
|
|
lung cancer presentation
|
cough
weight loss dyspnea hemoptysis chest pain recurrent pneumonic processes hoarseness |
|
|
lung cancer diagnosis
|
sputum cytology (specially SCC)
bronchoscopy for centrally located lessions needle aspiration biopsy if highly suspicious and nonspecific bronchoscopy findings or peripheral lession |
|
|
symptoms of unresectable lung cancer
|
weight loss >10%
bone pain extrathoracic metastasis CNS symptoms SVC syndrome hoarseness contralateral mediastinal adenopathy |
|
|
lung cancer treatment
|
resectable small cell --> VP16 (etoposide, platinum); resectable non-small --> CAP (cyclo, adriamycin, platinum) and radio
|
|
|
lung cancer prognosis
|
5-8% 5-year survival
after resection of SCC --> 30-35% after resection of large-cell and adeno --> 25% |
|
|
atelectasis etiology
|
most common is postsurgery; also mucuous plug, foreign body or tumor
|
|
|
atelectasis presentation
|
tachycardia, dyspnea, fever, hypoxemia
|
|
|
atelectasis diagnosis
|
ipsilateral trachea deviation --> upper lobe
mediastinal deviation --> massive atelectasis elevation of hemidiaphragm --> lower lobe atelectatic lobe looks denser, consolidated and smaller than normal contralateral lobe |
