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105 Cards in this Set

  • Front
  • Back
Sarcoidosis -
What is it
Systemic dis.
unknown etiology
noncaseating granulomas
In US - MC in Black females
30's-40's
Sarcoidosis -
Hx/PE
Fever
cough
malaise
arthritis - knees, ankles
wt. loss
dyspnea

GRUELING
Granulomas noncaseating
RA
Uveitis
Erythema nodosum
Lymphadenopathy
Interstitial fibrosis
Negative TB test
Gammaglobulinemia

MC - lung
can also involve -
neurologic
eye
myocardial
rheumatologic
GI
skin

acute presentations -
• lofgren's syndrome -
hilar adenopathy
arthritis
erythema nodosum
• heerfordt-waldenstrom syn -
uveitis
parotid enlargement
facial palsy
fever
Sarcoidosis -
Dx
Definitive Dx - Bx

CXR
transbronchial or video-
assisted thoracoscopic Bx
PFTs - normal or restrictive
inc. serum ACE
hypercalcemia
hypercalciuria
lymphopenia
inc. alk phos -
if liver involved
Kveim skin test
skin anergy
Sarcoidosis -
Tx
All pts. - ophthalmologic exam
if organ impairment - trial steroids
steroids a must if -
CNS
uveitis
hypercalcemia

80% - become stable or
spontaneously resolve
20% - dev. progressive disease
Cystic Fibrosis -
What is it
AR
mutation in CFTR gene
on chromosome 7
=> def. in chloride channel
disease of exocrine glands -
mainly respiratory & GI
MC severe genetic disease
of whites in US
Cystic Fibrosis -
Hx/PE
Hx -
■ respiratory -
recurrent pulm infections
Pseudomonas
S. aureus
bronchiectasis
hemoptysis
chronic sinusitis
cough
dyspnea
cyanosis
digital clubbing
■ GI -
meconium ileus
malabsorption syn
greasy stools
flatulence
pancreatitis
rectal prolapse
esoph varices
biliary cirrhosis
■ abnorm glucose tolerance
DM Type 2
salty-taste sweat
unexplained hyponatremia
infertility - males

PE -
cough
rhonchi
rales
hyperresonance to percussion
nasal polyps
growth retardation
digital clubbing
Cystic Fibrosis -
Dx
Sweat chloride test -
> 60 mEq/L if < 20 y/o
> 80 mEq/L if adult

genetic testing
Cystic Fibrosis -
Tx
Chest physical therapy
bronchodilators
anti-inflammatory agents
ABx
DNase
pancreatic enzymes
vit D,A,K,E

if severe -
lung transplant
pancreas transplant
COPD -
What is it
Chronic progressive dis.
dec. lung function
airflow obstruction
generally due to -
chronic bronchitis or
emphysema
4th MCC of death in US

chronic bronchitis -
prod. cough for at least
3 mos. a yr for 2 consec. yrs

emphysema -
pathologically defined
terminal airway destruction
smoking - centrilobular
A1-antitrypsin def. -
inherited, panlobular
most pts. have parts of both
nearly all are smokers
COPD -
Hx/PE
Sxs often minimal or
nonspecific until advanced
(lost > 50% of lung function)
barrel chest
use of accessory chest mus
JVD
end-expiratory wheezing
muffled breath sounds

emphysema -
"pink puffer"
dyspnea
pursed lips
minimal cough
dec. breath sounds
late hypercarbia/hypoxia
less reactive airways
bet. exacerbations

chronic bronchitis -
"blue bloater"
prod. cough
cyanotic but mild dyspnea
periph edema
rhonchi
early hypercarbia/hypoxia
COPD -
Dx
■ PFTs - diag. test of choice
FEV1 -
best predictor of survival
(after bronchodilator)
■ bronchitis -
inc. pulmonary markings
normal DLCO
■ emphysema -
small heart size
inc. in retrosternal space
dec. DLCO


■ CXR -
dec. markings
hyperinflated lungs
flat diaphragm
thin-appearing heart &
mediastinum
pathognomonic of emphysema -
parenchymal bullae
subpleural blebs
■ PFTs -
FEV1/FVC < 80%
■ ABGs -
pts. have baseline inc. PCO2
in acute exacerbation -
rising inc. PCO2
■ BC
■ gram stain & sputum Cx -
if febrile or prod. cough
COPD -
Tx
■ Ipratropium -
1st line
metered dose inhaler
can use with B2 agonist
■ 2nd line -
albuterol
terbutaline
metaproterenol
inhaler
■ 3rd line -
aminophylline
oral theophylline

■ to decrease mortality -
home O2 and stop smoking
home O2 - if PaO2 <55
cor pulmonale - if PaO2 <59

■ exacerbation -
O2 - keep PaO2 at 60
ABx - cover H. influ & pneumococcus
systemic steroids

■ vaccines -
h. influ - yearly
pneumococcus - every 5 yrs.
COPD -
Complications
Hypoxemia with nocturnal desat
if chronic low PO2,
=> secondary erythropoeisis
pulmonary HTN => cor pulmonale
chronic vent failure -
early chronic bronchitis
end of emphysema

chronic resp failure
pneumonia
bronchogenic carcinoma
Bronchiectasis -
What is it
Dis. of bronchi & bronchioles
cycles of infection &
inflammation
=> perm. remodeling,
dilation of bronchi,
suppuration

50% with primary ciliary dyskinesia -
have Kartagener's
(situs inversus
sinusitis
infertility)

assoc. with -
pulmonary infections -
esp. pseudomonas, h. influ
hypersensitivity reactions
CF
immunodef.
aspiration
autoimmune dis.
IBS

complications -
massive hemoptysis
amyloidosis
cor pulmonale
visceral abscesses
Bronchiectasis -
Hx/PE
Hx-
yellow or green sputum
cough
dyspnea
possible hemoptysis
halitosis

PE -
rales
wheezes
rhonchi
purulent mucus
Bronchiectasis -
Dx
■ CXR -
early - normal
advanced -
cysts
tramtracks (bronchi crowding)
inc. markings
honeycombing
■ high-resolution CT -
best noninvasive test
dilation of airway
varicose constriction
no airway taper
ballooned cysts
■ IgM, IgA, IgG -
to determine subclass def.
Bronchiectasis -
Tx
• Increase drainage -
bronchodilators
chest PT
postural drainage

• ABx -
when mild Sxs or sputum inc.
rotate ABxs
amoxicillin
TMP/SMX
amoxicillin/clavulanic
• IV ABx -
if significant Sxs or pneumonia
cover gram neg
aminoglycosides
quinolones
ceftazidime

• surgery if -
localized & enough function
massive hemoptysis

• vaccines -
h. influ - every year
pneumococcus - every 5 yrs.
Pneumoconiosis -
What is it
Occupational lung injury
affects pulmonary interstitium
dev. after long-term,
high concentration exposure
to inhaled particles

alveolar macrophages engulf
=> inflammation & fibrosis

inc. risk with -
level & duration of exposure
Pneumoconiosis -
Dx
CXR
High-res CT -
if normal CXR
but suspect pneumoconiosis
Pneumoconiosis -
Tx
No cure
supportive therapy
O2 supplementation
stop smoking
alert appropriate agency
Asbestosis -
Where Exposed
When does it present
Manufacture of
tile or brake linings
insulation
construction
demolition
building maintenance
pipes
shipyards
presents 15-20 yrs.
after initial exposure
Asbestosis -
Dx
CXR -
linear opacities at lung bases
pleural plaques

Bx -
necessary
asbestos bodies
"barbell shaped"
Asbestosis -
Complications
Inc. risk of mesothelioma
inc. risk of bronchogenic Ca -
adenocarcinoma
squamous cell Ca

smoking inc. risk of
bronchogenic Ca
(smoking not additive with
mesothelioma)
Coal Workers' Pneumoconiosis -
Where Exposed
Anthracosis
Black Lung Disease
work in underground coal mines

worse -
inc. exposure
higher rank/hardness
inc. silica content
Coal Workers' Pneumoconiosis -
Dx
CXR -
small nodular opacities (<1cm)
upper lung zones

increased -
IgG
IgA
c3
ana
RF

spirometry -
shows restrictive dis.
Coal Workers' Pneumoconiosis -
Complications
Progressive massive fibrosis

Caplan syndrome -
Coal Workers' Pneumoconiosis
RA
rheumatoid nodules
in lung periphery
Silicosis -
Where Exposed
Mines or quarries -
sandblasting
glass
pottery
silica
Silicosis -
Dx
CXR -
small nodular opacities (<1cm)
upper lung zones
eggshell calcifications

Bx

spirometry -
shows restrictive dis.
Silicosis -
Complications
Inc. risk of TB -
need annual PPD
pos. is >10

progressive massive fibrosis

acute form -
massive exposure
=> lung failure in mos.
Berylliosis -
Where Exposed
Aerospace plant
nuclear plant
electronics plant
ceramics
foundries
plating
dental material sites
die manufacturing
Berylliosis -
Dx
CXR -
diffuse infiltrates
hilar adenopathy
Berylliosis -
Complications
Chronic steroid Txs
Pulmonary Edema -
What is it
Abnormal accumulation of fluid
in extravascular space
Pulmonary Edema -
Hx/PE
Hx -
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
Cheyne-Stokes breathing
cough
cyanosis

PE -
rales on inspiration
musical rhonchi
murmurs - if cardiogenic
Pulmonary Edema -
Dx
CXR -
enlarged heart
prominent pulmonary vessels
Kerley B lines
"bat's-wing" appearance
of hilar shadows
perivascular cuffing
peribronchial cuffing
Pulmonary Edema -
Tx
Tx underlying cause
diuretics
arrhythmia management
inotropes & afterload
reduction in some cases
Pulmonary Edema -

If due to inc. capillary
hydrostatic pressure,
list precipitating events
MI
mitral stenosis
heart failure
fluid overload
Pulmonary Edema -

If due to inc. capillary
permeability,
list precipitating events
Sepis
radiation
O2 toxicity
ARDS
toxins
Pulmonary Edema -

If due to
reduced lymph drainage,
list precipitating event
Inc. central venous pressure
Pulmonary Edema -

If due to
dec. interstitial pressure,
list precipitating event
Rapid removal of
pleural effusion
Pulmonary Edema -

If due to
dec. colloid pressure,
list precipitating event
Hypoalbuminemia
Pneumothorax -
What is it
Collection of air in
pleural cavity
can => partial or
complete lung collapse
Pneumothorax -
What is a Primary Spontaneous
Pneumothorax
No underlying lung dis.
rupture of subpleural
apical blebs or bullae
tall, thin young males
Pneumothorax -
What is a Secondary
Spontaneous Pnemothorax
Underlying lung dis.
rupture of bleb or bulla
in pts. with -
COPD
TB
PCP
Pneumothorax -
What is a
Traumatic Pneumothorax
Complication of blunt &
penetrating chest injuries
Pneumothorax -
What is an Iatrogenic
Pneumothorax
Thoracocentesis
subclavian line placement
mech ventilation
bronchoscopy
Pneumothorax -
What is a Tension Pneumothorax
Lung or chest wall defect
acts like one-way valve
inspiration - air into cavity
expiration - air trapped
life-threatening condition
can => shock & death

causes -
penetrating trauma
infection
CHF
mechanical vent
Pneumothorax -
Hx/PE
Unilat pleuritic chest pain
dyspnea
tachypnea
dec. or absent breath sounds
hyperresonance
dec. tactile fremitus

tension pneumothorax -
resp distress
falling O2 sat
hypotension
distended neck veins
tracheal deviation
Pneumothorax -
Dx
CXR -
visceral pleural line
lung retraction
from chest wall
(best seen in end-expiratory films)
Pneumothorax -
Tx
Small -
may reabsorb spontan
O2 therapy

large -
chest tube placement
pleurodesis

tension -
emergency
immed needle decompression
in 2nd ICS at midclavic line
chest tube
do not wait for CXR
Pulmonary Embolism -
What is it
Risk Factors
95% orig from DVTs in
deep leg veins
can =>
pulmonary infarction
RHF
hypoxia

risk factors -
Virchow's triad:
stasis
endothelial injury
hypercoag states
Pulmonary Embolism -
Hx/PE
Hx -
MC Sx - dyspnea & tachy

sudden-onset dyspnea
pleuritic chest pain
low-grade fever
cough

PE -
hypoxia
hypocarbia
resp. alkalosis
tachypnea
tachy
fever
loud P2
prominent jugular a waves- RHF
Homan's sign
Pulmonary Embolism -
Dx
Suspect in hospitalized or
bedridden pt. if -
dyspnea
tachy
normal CXR

■ ABG -
resp. alkalosis
PO2 < 80
■ CXR -
usu normal
may show pleural effusion
Hampton's hump
Westermark's sign
atelectasis
■ EKG -
not diagnostic
S1Q3T3
rt.-axis deviation
RV strain pattern
sinus tachy - most common sign
■ V/Q scan - 1st test
■ Helical (spiral) CT
with contrast -
sensitive for PE in
prox. pulm arteries
■ pulm angiogram -
gold standard
Pulmonary Embolism -
Tx
Heparin - 5 days
warfarin -
start day 1
for 6 mos.
if hemodynamically unstable -
thrombolytics
if thrombolytics contraindicated -
embolectomy
pregnant - LMWH for 6 mos.

■ heparin -
bolus then wt-based continuous
■ warfarin -
3-6 mos.
indef. if
underlying predisposition
keep INR 2-3
■ IVC filter -
if anticoag contraindicated
if recurrent emboli with Tx
■ DVT prophylaxis -
low-dose subq heparin
LMWH
venodyne boots
early ambulation -
most effective
if severe - thrombolysis
Acute Resp Distress Syndrome -
What is it
Inc. permeability of
alveolar-capillary barrier
=> influx of fluid into alv.
diffuse damage to
alv. & cap endothelium
causes -
sepsis
pneumonia
aspiration
infection
severe trauma
massive blood transfusion
inhaled/ingested toxins
trauma
drug OD
acute pancreatitis
Acute Resp Distress Syndrome -
Hx/PE
Acute onset in 12-48 hrs.

progression of Sxs -
■ normal PE
resp. alkalosis
■ hyperventilation
hopocapnia
widening A-a gradient
■ acute resp failure
tachypnea
dyspnea
dec. lung compliance
rales
diffuse chest infiltrates
■ severe hypoxemia -
unresponsive to therapy
inc. intrapulm shunting
metab & resp acidosis
Acute Resp Distress Syndrome -
Dx
ABG - dec. PaO2 and
inc. or normal PaCO2
Swan-Gatz catheter -
normal CO
normal CWP
inc. pulmonary artery pressure

Acute onset of resp distress
PaO2/FIO2 ratio < 200 mmHg
b/l pulm infiltrates on CXR
no evidence of cardiac origin
(normal cap wedge P = 18 mmHg)
Acute Resp Distress Syndrome -
Tx
Treat underlying d/o
mechanical support with inc. PEEP
and permissive hypercapnea
steroids - controversial


(no standard successful Tx
■ treat underlying dis.
■ maintain adequate perfusion
■ maintain O2 at goals of -
FIO2 < 0.6
PaO2 > 60 mmHg
SaO2 > 90%
■ mechanical vent -
low PEEP
inc. inspiratory times
■ support CO -
inotropes
cautious fluid admin
■ steroids -
no if sepsis & ARDS -
inc. mortality)
Solitary Pulmonary Nodule -
What is it
< 3 cm
1/3 malignant
completely surrounded by
lung parenchyma
no assoc. atelectasis
no assoc. pleural effusion
usu found incidentally on CXR
risk of malig. inc. with age

causes -
granuloma
carcinoma
hamartoma
metastasis
bronchial adenoma
pneumonia

• calcification -
points towards benign

• popcorn calcification -
made by hamartoma

• bull's-eye calcification -
made by granuloma
Solitary Pulmonary Nodule -
Hx/PE
Often asymp
may have -
chronic cough
dyspnea
SOB
Solitary Pulmonary Nodule -
Dx
Compare serial CXRs
chest CT

characteristics favoring Ca -
> 45-50 y/o
new lesions
larger lesions
no calcification
irreg calcification
> 2 cm
irregular margins

characteristics favor benign -
< 35 y/o
no change
central/uniform calcification
< 2 cm
smooth margins
regular margins
Solitary Pulmonary Nodule -
Tx
low-risk -
< 35 y/o
nonsmoker
calcified nodule
CXR every 3 mos. for 2 yrs.
if no change in 2 yrs,
can stop

high-risk -
> 50 y/o
smoker
is likely to have cancer, so
open-lung Bx and remove
Primary Lung Cancer -
What is it
Types
Risk Factors
No. 1 cause of cancer death
risk factors -
smoking major cause
nonsmoker- gets adenocarcinoma
radon
asbestos

• MC -
adenocarcinoma
squamous cell ca

• squamous cell ca -
central
PTHrp => hypercalcemia
cavitary lesions
mets by direct extension into:
hilar & mediastinum

• small cell ca -
central
grows fast
early Dx doesn't improve prognosis
mets early to -
brain, liver, bone, adrenals
SIADH
ACTH
Lambert-Eaton syndrome
MCC of venocaval obstruction

• large cell ca -
peripheral
early - cavitary lesions
late - distant mets

• adenocarcinoma -
peripheral
mets to same sites as small cell
association with asbestos
pleural effusions with
high hyaluronidase levels
Dx - thoracotomy with pleural Bx
bronchoalveolar ca -
subtype of adenocarcinoma
low-grade ca
find in single or multiple nodes
Primary Lung Cancer -
Hx/PE
MC Sx at time of Dx - cough
hemoptysis
chest pain
wt loss
dyspnea
hoarseness - nonresectable
repeated pneumonic processes

crackles
atelectasis
paraneoplastic syn
Horner's syn -
if Pancoast's tumor
Primary Lung Cancer -
Dx
Usu 1st noted as nodule on CXR
■ lung CT

■ sputum cytology -
highest yield - squamous cell
■ bronchoscopy -
best for central
■ needle aspiration Bx -
peripheral nodules with
pleural fluid aspirate
■ mediastinoscopy -
mediastinal

■ 90% with malignant effusions -
unresectable
usually adenocarcinoma
■ atelectasis -
central airway obstruction
Primary Lung Cancer -
Tx
Nonresectable if -
wt. loss > 10%
bone pain
CNS Sxs
superior vena cava syndrome
hoarseness
mediastinal adenopathy on contralateral
involves:
trachea
esophagus
pericardium
chest wall

small cell ca -
resectable treated with chemo
etoposide & platinum (VP16)
surgery not indicated

nonsmall cell ca -
that are resectable, treated with
chemo and RT or CAP
(cyclophosphamide,
adriamycin,
platinum)
effusions - tetracycline
complications - RT (palliative)

prognosis -
squamous cell ca - best
small cell ca - worst
Primary Lung Cancer -
Complications
SPHERE of complications -
SVC syndrome
Pancoast's tumor
Horner's syndrome
Endocrine (paraneoplastic)
Recurrent laryngeal Sxs
(hoarseness)
Effusions -
pleural, pericardial

also -
airway obstruction
lung abscess
chronic interstit fibrosis
Interstitial Lung Disease -
What is it
Classic type of restrictive
lung disease
alveolar septal thickening
=> fibroblast prolif,
collagen deposited,
pulmonary fibrosis

causes -
most connective tissue dis.
occupational lung exposures
drugs
pulmonary edema
pulmonary veno-occlusive dis.
idiopathic
Interstitial Lung Disease -
Hx/PE
Shallow, rapid breathing
dyspnea with exercise
nonproductive cough

cyanosis worsened by exercise
rales
finger clubbing
Interstitial Lung Disease -
Dx
CXR -
■ reticular pattern -
more pronounced at bases
■ honeycomb pattern if severe

TLC low
FVC low
FEV1/FVC > 80% (inc.)
Interstitial Lung Disease -
Tx
Supportive
steroids
cytotoxic agents
immunomodulatory substances
Hypersensitivity Pneumonitis -
What is it
Type III hypersensitivity
reaction to environmental
or occupational antigens

acute, subacute & chronic
all forms -
alveolitis
acute interstit inflammation
lymphocytes infiltrate
if long-term exposure -
=> granulomas & fibrosis
Hypersensitivity Pneumonitis -
Hx/PE
■ Acute -
dyspnea
fever
shivering
cough -
starts 4-6 hrs after exposure
■ chronic -
progressive dyspnea

fine b/l rales
Hypersensitivity Pneumonitis -
Dx
CXR -
■ acute:
normal (10%)
miliary nodular infiltrates
■ chronic:
fibrosis in upper lobes
Hypersensitivity Pneumonitis -
Tx
Avoid ongoing exposure
steroids
cytotoxic agents
immunomodulatory substances
Hypersensitivity Pneumonitis
Farmer's Lung -
What causes it
Spores of actinomycetes
from moldy hay
Hypersensitivity Pneumonitis
Bird Fancier's Lung -
What causes it
Antigens from -
feathers
excreta
serum
Hypersensitivity Pneumonitis
Mushroom Worker's Lung -
What causes it
Spores of actinomycetes
from compost
Hypersensitivity Pneumonitis
Malt Worker's Lung -
What causes it
Spores of Aspergillus clavatus
Hypersensitivity Pneumonitis
Grain Handler's Lung -
What causes it
Grain weevil dust
Hypersensitivity Pneumonitis
Bagassosis -
What causes it
Spores of actinomycetes
from sugarcane
Hypersensitivity Pneumonitis
Air Conditioner Lung -
What causes it
Spores of actinomycetes
from air conditioners
Asthma -
What is it
Dis. of chronic airway
inflammation
caused by variety of
triggering stimuli
=> reversible bronchoconstrict
inflammation,
mucous plugging,
smooth muscle hypertrophy

• Intrinsic -
nonimmunologic
nonatopic
cold air
exercise
infections
emotional upset
severe
prognosis - less favorable

• extrinsic -
atopic
inc. IgE
positive family Hx
prognosis good

• respiratory infections -
MC stimuli to cause exacerbations
kids - RSV
adults - rhinovirus

• pharmacologic stimuli -
aspirin
tartrazine (coloring agent)
B-adrenergic antag

• aspirin sensitivity-
nasal polyposis
adults
Asthma -
Hx/PE
Hx -
cough
dyspnea
episodic wheezing
chest tightness
worse at night or early a.m.
h/o -
freq. ER visits
intubations
PO steroid use

PE -
tachypnea
tachy
dec. breath sounds
wheezing
prolonged expiratory duration-
(dec. I/E ratio)
hyperresonance
accessory muscle use
possible pulsus paradoxus
dec. O2 sat - late sign
Asthma -
Dx
ABG -
mild hypoxia & resp. alkalosis
PFTs
spirometry
CBC
CXR - hyperinflation
methacholine challenge
Asthma -
Tx
Avoid allergens

acute -
O2
bronchodilators (B agonists)
ipratropium
steroids
to avoid intubation in severe-
pos. airway pressure
Heliox

chronic -
FEV1
peak flow
ABGs
bronchodilators
steroids
cromolyn
theophylline
Montelukast

ASTHMA meds for exacerbations-
Albuterol
Steroids
Theophylline
Humidified O2
Magnesium
Anti-leukotrienes
Hypoxemia -
What is it
Dec. blood O2 content
due to alv. hypoventilation
causes -
right-to-left shunt
hypoventilation
↑ blood velocity
dec. inspired O2 tension
airway obstruction
V/Q mismatch
diffusion impairment
Hypoxemia -
Hx/PE
Dec. HbO2 sat
cyanosis
tachypnea
SOB
pleuritic chest pain
altered mental status
Hypoxemia -
Dx
Pulse oximetry
CXR
pulm embolism evaluation
ABG
calculate A-a
Hypoxemia -
A-a Calculation
What does ↑ A-a mean
Alveolar O2 - ABG O2
PAO2 - PaO2

[150-1.2(pCO2)] - PaO2

5-15 mmHg is normal
↑ A-a gradient -
V/Q mismatch
diffusion impairment
↑ in all hypoxemia except -
hypoventilation
low altitude
Hypoxemia -
Tx
Tx underlying cause
O2
if on vent, ↑ O2 sat by -
↑ FIO2,
↑ PEEP or
↑ I/E ratio

hypercapnic -
↑ minute ventilation -
↑ TV or ↑ RR
Pleural Effusion -
What is it
Abnorm accumulation of
fluid in pleural cavity
transudative or exudative
Pleural Effusion -
What is Transudative
Intact capillaries
=> protein-poor pleural fluid
causes -
CHF
nephrotic syn
cirrhosis
protein-losing enteropathy

ratio of pleural prot
to serum prot -
< 0.5

ratio of pleural LDH
to serum LDH -
< 0.6
Pleural Effusion -
What is Exudative
Inflammation
=> leaky capillaries
protein-rich pleural fluid
causes -
malig
TB
bact. infection
viral infection
PE with infarct
collagen vas. dis.
pancreatitis
hemothorax
chylothorax
traumatic tap

ratio of pleural prot
to serum prot -
> 0.5

ratio of pleural LDH
to serum LDH -
> 0.6
Pleural Effusion -
Hx/PE
Often asymp
dyspnea
pleuritic chest pain
dec. breath sounds
dullness to percussion
dec. tactile fremitus
Pleural Effusion -
Dx
■ CXR -
blunting of costophrenic angles
decubitus CXR
■ pleural fluid analysis -
LDH
protein
gram stain
CBC
culture
cytology
■ needle Bx - Dx TB effusion
■ definitive Dx -
thoracocentesis or
open Bx
Pleural Effusion -
Tx
■ Transudative -
Tx underlying condition
thoracocentesis if dyspneic
■ malignant -
pleurodesis:
if unresponsive to RT or chemo
thoracocentesis
pleuroperitoneal shunt
pleurectomy
■ parapneumonic -
if empyema -
chest tube drainage
■ hemothorax -
chest tube
Sleep Apnea -
What is it
Risk Factors
Obstructive, central, mixed

■ obstructive -
recurrent episodes
partial or complete closure
of upper airway
resp. efforts continue

■ central -
episodic cessation of airflow
& resp. efforts
due to loss of central drive

■ mixed

■ causes -
abnorm in feedback control
of breathing during sleep
dec. sensitivity of
upper airway muscles
or inspiratory muscles
to stimulation
anatomic abnorm

■ risk factors -
male
obesity
sleep sedatives
nasal obstruction
hypothyroidism
macroglossia
micrognathia
acromegaly
Sleep Apnea -
Hx/PE
Daytime sleepiness
systemic HTN
when severe -
pulmonary HTN
cor pulmonale

impaired concentration
loud snoring
during sleep -
gasping
choking
recurrent arousals
Sleep Apnea -
Dx
Sleep studies
(polysomnography)
Sleep Apnea -
Tx
Obstructive -
wt. loss
nasal CPAP

central -
acetazolamide
progesterone
supplemental O2


early Tx essential
mandibular advancement devices
body repositioning
surgery
no alcohol, sedatives

■ kids -
most cases due to
tonsil/adenoid hypertrophy
correct via surgery
Atelectasis -
What is it
Collapse of part or all of lung
• MC seen -
immediate postop period
secondary to poor inspiration
or no coughing
• other causes -
mucous plug
tumor
obstruction
Atelectasis -
Hx/PE
• Acute -
dyspnea and hypoxemia
fever
tachy
• chronic -
may be asymp
Atelectasis -
Dx
• Upper lobe -
trachea to affected side
lower lobe - elevation of
corresponding part of diaphragm
massive - mediastinal shift
Atelectasis -
Tx
• To prevent -
deep breathing and coughing
incentive spirometer
pulmonary toilet

• bronchoscopy -
removal of mucous plugs
for spontaneous atelectasis