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213 Cards in this Set

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Causes of obstructive pulmonary disease

ABCT
asthma
bronchiectasis
cystic fibrosis/COPD
tracheal or bronchial obsxn
What is dyspnea?
SOB
breathlessness
What is obstructive lung disease characterized by?
airway narrowing
restricted air movement
air trapping
ASTHMA

4 characterstics
bronchial hyperreactivity
airway inflammation
mucous plugging
smooth muscle hypertrophy
Symptoms of Asthma
cough
wheezing
dyspnea
chest tightness

sx worse at night or early morning
Physical Exam of Asthma
wheezing
prolonged expiration duration
(decreased I/E ratio)
accessory muscle use
tachypnea
tachycardia
hyperresonance
possible pulsus paraodxus

PERCUSSION
hyperresonance vs dullness
- dullness indicates consolidation
- hyperresonance suggests pneumothorax or filled with air
Late signs of Asthma
decreased breath sounds
decreased O2 saturation
Initial ABG

ASTHMA
mild hypoxia
respiratory alkalosis
Late ABG and what it means

ASTHMA
normalizing pCO2
respiratory acidosis
severe hypoxia

means fatigue and impending respiratory failure
Spirometry/PFTs

ASTHMA
decreased FEV1/FVC
peak flow diminished acutely
increased RV and TLC
CBC and CXR

ASTHMA
CBC
eosinophilia

CXR
hyperinflation
Methacholine challenge
tests for bronchial hyperresponsiveness

useful when PFTs are normal but asthma is still suspected
Tx

Acute Asthma
O2
bronchodilators
(short-acting inhaled b2-agonists)
ipratropium
(never use alone in asthma)
systemic corticosteroids
Asthma

Thresholds for intubation
pCO2 > 50 mmHg

or

pO2 < 50 mmHg
Tx

Chronic Asthma
long-acting inhaled bronchodilators
inhaled corticosteroids
systemic corticosteroids
cromolyn
Adjunct Tx

Chronic Asthma
montelukast
leukotriene blockers
Asthma Triggers
allergens
URIs
cold air
exercise
drugs
stress
Corticosteroids for asthmatic patients

one huge side effect
thrush
General idea behind PFTs for diagnosing obstructive vs restrictive lung diseases
Generally the idea is that if air flow is impeded, the defect is obstructive

If volume is reduced, it's a restrictive defect
Normal value for FEV1/FVC ratio

What's the value for obstructive vs restrictive
80%

Obstructive
< 75

Restrictive
Stays same at 75
What is the normal RV

What happens to RV in obstructive and restrictive
normal
80-120

obstructive
RV increases
>120-200

restrictive
RV decreases
down to 70s
Normal FVC

FVC in restricted
normal
80

restrictive
decreases down to 50s
Meds for Asthma Exacerbation

A
S
T
H
M
A
Albuterol
Steroids
Theophylline (rare)
Humidified O2
Magnesium (severe only)
Anticholinergics
b2-agonist

name a short and long acting and mechanism of action
short = albuterol
relaxes bronchial SM

long = salmeterol
(for ppx)
Name some corticosteroids used for asthma and describe mechanism of action.
inhaled corticosteroids
(ie beclomethasone, prednisone)

inhibits the synthesis of virtually all cytokines
name a muscarinic blocker and mechanism
ipratropium

blocks muscarainic receptors

prevents bronchoconstriction
name a methylxanthine and mechanism

why dont we use it that often?
theophylline

likely causes bronchodilation by inhibiting phosphodiesterase

not used often due to narrow therapeutic toxic index
(cardio and neurotoxicity)
whats the mechanism of cromolyn

how should this be used
prevents the release of vasoactive mediators from mast cells

only effective as ppx for asthma
name some antileukotrienes and mechanism
zileuton
blocks 5-lipoxygenase pathway
(blocks conversion of AA to leukotrienes)

montelukast
zafirlukast
blocks leukotriene receptors
briefly describe what bronchiectasis is
cycle of infection and inflammation of the bronchi/bronchioles

leads to fibrosis, remodeling and **permanent dilation of bronchi**
Bronchiectasis

Associations
hx of pulm infections
hypersensitivity
CF
immunodeficiency
local airway obxsn
aspiration
autoimmune disease
IBD
What do pts with bronchiectasis present with?
frequent bouts of yellow or green sputum production

dyspnea
possible hemoptysis and halitosis
Physical Exam

Bronchiectasis
rales (crackles, "popping open" of small alveoli collapsed by fluid)
wheezes
rhonchi (snoring sounds from secretions in airway)
purulent mucus
occasional hemoptysis
CXR

Bronchiectasis
increased bronchovascular markings

tram lines
(parallel lines outlining dilated bronchi as a result of peribronchial inflammation and fibrosis)
High-Res CT

Bronchiectasis
dilated airways

ballooned cysts
Spirometry

Bronchiectasis
decreased FEV1/FVC

(obstruction)
Tx

Bronchiectasis
antibiotics for infections

consider inhaled corticosteroids

bronchopulmonary hygiene
(cough control, postural drainage, chest physiotherapy)

surgery for severe
lobectomy or lung transplant
MILD INTERMITTENT ASTHMA

Sx
FEV1
Meds
Sx
< 2 days / week
< 2 nights / month

FEV1
> 80%

Meds
no daily meds
PRN short bronchodilator
MILD PERSISTENT ASTHMA

Sx
FEV1
Meds
Sx
> 2/week, but < 1/day
> 2 nights/mo

FEV1
> 80%

Meds
Daily low-dose inhaled corticosteroids
PRN short-acting bronchodilator
MODERATE PERSISTENT ASTHMA

Sx
FEV1
Meds
Sx
> 1 night/week

FEV1
60-80%

Meds
low-medium inhaled corticosteorids + long acting inhaled b2-agonist
PRN short-acting bronchodilator
SEVERE PERSISTENT ASTHMA

Sx
FEV1
Meds
Sx
continual, frequent

FEV1
< 60%

Meds
high-dose inhaled corticosteorids + long-acting inhaled b2-agonist
possible PO corticosteroids
PRN short-acting bronchodilator
COPD

Name the 2 forms
chronic bronchitis
emphysema
What is chronic bronchitis
productive cough for > 3 mo per year for 2 consecutive years
What is emphysema
terminal airway destruction and dilation that may be secondary to smoking (centrilobular) or to alpha1-antitrypsin deficiency (panlobular)
Emphysema

Physical Exam
"pink puffer"

dyspnea
pursed lips
minimal cough
decreased breath sounds

late hypercarbia/hypoxia
pts have thin/wasted appearance
Chronic Bronchitis

Physical Exam
"blue bloater"

cyanosis with mild dyspnea
productive cough
rhonchi

pts are overweight
early signs of hypercarbia/hypoxia
peripheral edema
In COPD patients, chronic hypercapnia in the presence of high concentrations of O2 may lead to what?
suppress patient's hypoxic respiratory drive
Two measures that are proven to improve survival in pts with COPD
smoking cessation

O2
titrated to > 90% SaO2
for > 15 hrs/day
Physical Exam

COPD
barrel chest
accessory muscle use
end-expiratory wheezing
muffled breath sounds
JVD
COPD

CXR
hyperinflated lungs
decreased lung markings
flat diaphragms
thin-appearing heart and mediastinum
CXR of COPD

Pathognonomic of Emphysema
parenchymal bullae or subpleural blebs
PFTs

COPD
decreased FEV1/FVC

normal/decreased FVC

normal/increased TLC (emphysema)

decreased DLCO (emphysema)
ABGs

COPD
hypoxemia

acute or chronic respiratory acidosis (increased PCO2)
Diagnostic workup for COPD
CXR
PFTs
ABGs
gram stain and sputum culture
Tx for COPD

C
O
P
D
Corticosteroids
Oxygen
Prevention (smoking cessation, pneumococcal and influenza vaccines)
Dilators (b2-agonist, anticholinergics)
Tx

Acute Exacerbation of COPD
O2
inhaled b2-agonist (albuterol)
anti-cholinergics (ipratropium, tiotropium)
IV/inhaled corticosteroids
abx
BiPAP
Tx

Chronic COPD
inhaled b2-agonist
anticholinergics (tiotropium)
systemic/inhaled corticosteroids

O2 if:
resting PaO2 is < 55 mmHg or SaO2 is < 89%
cor pulmonale
pulm HTN
hematocrit > 55%
nocturnal hypoxia

smoking cessation
pneumococcal and influenza vaccines
When would you consider intubation in acute COPD exerbation?
severe hypoxemia or hypercapnia

impending respiratory fatigue
changes in mental status
Meds that can cause/contribute to interstitial lung disease
amiodarone
busulfan
nitrofurantoin
bleomycin
radiation
long-term high O2 concentration (eg ventilators)
Restrictive Lung Disease

Characterized by what?
loss of lung compliance
increased lung stiffness
decreased lung expansion

compliance is the ability of the lung to change in volume per change in pressure
Causes of Restrictive Lung Disease

If the lungs *AIN'T* compliant
ALVEOLAR
edema, hemorrhage, pus

INTERSTITIAL LUNG DISEASE
idiopathic, interstititial pna

INFLAMMATORY
sarcoid, cryptogenic organizing pneumonitis

IDIOPATHIC

NEUROMUSCULAR
myasthenia, phrenic nerve palsy, myopathy

THORACIC WALL
kyphoscoliosis, obesity, ascites, pregnancy, ankylosing spondylitis
Cryptogenic Organizing Pneumonitis (COP)
(aka Bronchiolitis obliterans organizing pneumonia - BOOP)
(do not confuse with Bronchiolitis obliterans)

Bronchiolitis - inflammation of the bronchioles

Pneumonia without the infection
What is interstitial lung disease characterized by?

What about advanced stages?
inflammation
fibrosis of the interalveolar septum

advanced stages
cystic spaces in the lung periphery (honey-combing)
What are the causes of interstitial lung diseases?
idiopathaic interstitial pneumonias
collagen vascular disease
granulomatous disorders
drugs
hypersensitivity disorders
pneumoconiosis
eosinophilic pulmonary syndromes
idiopathic pulmonary fibrosis
what is the typical patient presentation of interstitial lung disease
shallow, rapid breathing
dyspnea with exercise
non-productive cough
Physical Exam

ILD
cyanosis
inspiratory squeaks
fine crackles
clubbing
RH failure
Interstitial Lung Disease

CXR/CT Findings
reticular, nodular, or ground-glass pattern

honeycomb pattern (severe disease)
Interstitial Lung Disease

PFTs
decreased TLC, FVC, DLCO

normal FEV1/FVC
Interstitial Lung Disease

Surgical Bx is indicated when?
to confirm a diagnosis of IPF
(idiopathic pulm fibrosis)

if there's evidence of interstitial inflammation and fibrosis
Supportive vs Surgical Tx

Interstitial Lung Disease
SUPPORTIVE
avoid causative agents
corticosteroids for inflammation

SURGICAL
lung transplant in late stages of IPF
Learning the features of sarcoid can be

GRUELING
Granulomas
aRthritis
Uveitis
Erythema Nodosum
Lymphadenopathy
Interstitial Fibrosis
Negative TB Test
Gammaglobinulinemia
Systemic Sarcoidosis

What is this?
What kind of granulomas?
multi-system disease of unknown etiology

non-caseating granulomas
Systemic Sarcoidosis

Patient Population
(Age group and race)
20-30s

African American females
North European Caucasians
Sx of Systemic Sarcoidosis
F
cough
malaise
wt loss
dyspnea
*arthritis*
What organ systems can be affected in Systemic Sarcoidosis?
lungs
liver
eyes
skin (erythema nodosum violaceous skin plaques)
nervous system
heart
kidney
CXR/CT

Systemic Sarcoidosis
lymphadenopathy and nodules are used to stage disease
LN Bx of Systemic Sarcoidosis

What does it reveal?
non-caseating granulomas
PFTs

Systemic Sarcoidosis
Shows a restrictive or obstructive pattern and decreased diffusion capacity
Lab Findings

Systemic Sarcoidosis
increased serum ACE levels
(not sensitive or specific)

hypercalcemia
hypercalciuria
inc alk phos (liver involvement)
lymphopenia
cranial nerve defects
arrhythmias
Tx

Systemic Sarcoidosis
systemic corticosteroids

when respiratory fxn deteriorates
hypercalcemia
extrathoracic organ involvement
Define "constitutional symptoms".
non-specific sx that come from many parts of the body

weight loss, fevers, fatigue, and malaise

chills, night sweats, and decreased appetite
Hypersensitivity Pneumonitis

Brief Description
alveolar thickening and granulomas

secondary to environmental exposure
Hypersensitivity Pneumonitis

Acute Sx
F
cough (4-6 hrs after exposure)
dyspnea
malaise
shivering
Hypersensitivity Pneumonitis

Chronic Sx
progressive dyspnea
fine b/l rales
Type III or IV Hypersensitivity Reaction

is an inflammation of the alveoli caused by a hypersensitive reaction to inhaled antigen (ie organic dusts from occupation)
Hypersensitivity Pneumonitis

CXR/CT of Lungs
variable findings

upper lobe fibrosis is common in chronic disease
Tx

Hypersensitivity Pneumonitis
avoid exposure to inciting agents

corticosteroids to decrease chronic inflammation
What is pneumoconiosis?
diseases from occupational exposure and inhalation of small inorganic dust particles
Treatment

Pneumoconiosis
supportive
avoid triggers
supplemental O2
Asbestosis

History
works in manufacturing of tile or brake linings, insulation, construction, demolition or shipbuilding

pts presents 15-20 yrs after exposure
Asbestosis

Diagnosis
CXR
shows linear opacities at lung bases and interstitial fibrosis

calcified pleural plaques are indicative of benign pleural disease
Asbestosis

Complications
increased risk of mesothelioma (rare) and lung cancer

risk is higher in smokers
Name 4 different kinds of Pneumoconiosis.
asbestosis
coal miner's disease
silicosis
berylliosis
Coal Miner's Disease

History and Occupation
works in underground coal mines
Coal Miner's Disease

Diagnosis
CXR
small nodular opacities (< 1 cm) in upper lung zones

Spirometry
consistent w/ restrictive disease
Coal Miner's Disease

Complications
***progressive massive fibrosis***
Silicosis

History and Occupation
works in mines or quarries or with glass, pottery, or silica
Silicosis

Diagnosis
CXR
small (< 1 cm) nodular opacities in upper lung zones
eggshell calcifications

Spirometry
consistent w/ restrictive disease
Silicosis

Complications
**increased risk of TB**

needs annual TB skin test

progressive massive fibrosis
Berylliosis

History and Occupation
works in high-tech fields
aerospace, nuclear, and electronics plants

ceramic industries
foundries
plating facilities
dental material sites
dye manufacturing
Berylliosis

Diagnosis
CXR

diffuse infiltrates
hilar adenopathy
Berylliosis

Long Term Management
chronic steroids
Eosinophilic Pulmonary Syndromes

Brief Description
eosinphilic pulmonary infiltrates

peripheral blood eosinphilia
Eosinophilic Pulmonary Syndromes

Name 3
allergic bronchopulmonary aspergillosis

Loffler's syndrome

Acute eosinophilic pneumonia
Eosinophilic Pulmonary Syndromes

Sx
F
cough
dyspnea
Eosinophilic Pulmonary Syndromes

Diagnosis
CBC and CXR
CBC
peripheral eosinophilia

CXR
pulmonary infiltrates
Tx

Eosinophilic Pulmonary Syndromes
tx underlying infection

remove extrinsic cause

corticosteroids
Define hypoxemia and what the normal value should be.
low PO2

normal PO2
80-100 mmHg
Name 5 mechanisms behind hypoxemia.
hypoventilation
low inspired O2 content (high altitudes)
diffusion impairment

VQ mismatch
R to L shunt
Acute Respiratory Failure

Name 2 syndromes
hypoxemia
ARDS
Physical Exam

Hypoxemia
decreased HbO2 saturation
cyanosis
tachypnea
SOB
pleuritic chest pain
AMS
Diagnostic Workup

Hypoxemia
Pulse Ox
low HbO2 sat

CXR
pna, atelectasis, large pl eff, pneumothorax

ABGs
increased Aa gradient suggests shunt, V/Q mismatch, diffusion impairment
Tx

Hypoxemia
tx underlying etiology
O2
mechanical ventilation
Mechanical Ventilator Parameters Affecting Oxygenation and Ventilation

What 2 parameters increases oxygenation?
FiO2
PEEP
Mechanical Ventilator Parameters Affecting Oxygenation and Ventilation

What 2 parameters increase ventilation?
respiratory rate
tidal volume
It's not (h)ARDS to diagnose ARDS.
Acute onset
Ratio (PaO2/FiO2) < 200
Diffuse infiltration
Swan-Ganz wedge pressure < 18 mmHg

(low pressure means no cardio involvement)
What is ARDS?
ARDS is a severe oxygenation defect not due to heart failure

It is characterized by:
respiratory failure
refractory hypoxemia
decreased lung compliance
non-cardiogenic pulm edema
PaO2/FiO2 < 200
Explain what the ratio PaO2/FiO2 means.
this is the gradient between inspired O2 and O2 in blood

the lower the ratio, the less the oxygen is getting into the blood and the worse the pts condition

(i.e. on 60% O2, the patient’s PaO2 is less than 120mmHg)
What is thought to be the underlying pathogenesis behind ARDS?
endothelial injury
Common triggers of ARDS.
sepsis
pna
aspiration
multiple blood transfusions
(acute lung injury)
inhaled/ingested toxins
trauma
Mortality rate of ARDS.
30-40%
Acute Sx of ARDS
within 12-48 hrs

tachypnea
dyspnea
tachycardia

fever
cyanosis
labored breathing
diffuse high-pitched rales
hypoxemia
ARDS is classified into 4 stages.

Describe
Phase 1 (acute injury)
normal physical examination

possible respiratory alkalosis
ARDS is classified into 4 stages.

Describe
Phase 2 (6-48 hrs)
hyperventilation
hypocapnia (aka hypocarbia)
widening of the A-a gradient
ARDS is classified into 4 stages.

Describe
Phase 3
ACUTE RESPIRATORY FAILURE
hypoxemia

PHYSICAL EXAM
tachypnea
dyspnea
decreased lung compliance
scattered rales

CXR
diffuse opacities
ARDS is classified into 4 stages.

Describe
Phase 4
refractory hypoxemia
increased intrapulmonary shunting

metabolic and respiratory acidosis
normal PaO2/FiO2 ratio
300-500
What is pulmonary capillary wedge pressure?

What is the normal value?

What is its role in pulmonary edema and ARDS?
PCWP is an indirect measure of LA pressure
(bc it cannot be measured directly)

Normal Value
2-15 mmHg

Role in Pulm Edema
PCWP > 20 mmHg indicates cardiac origin of pulm edema

Role in ARDS
PCWP < 18 indicates no cardiac origin
Tx

ARDS
mechanical ventilation with low tidal volumes to minimize ventilator-induced lung injury

tx underlying disease

maintain adequate perfusion to prevent end-organ damage

PEEP to recruit alveoli, titrate PEEP and FiO2
Tx Goals in ARDS
Goal Oxygenation
PaO2 > 60 mmHg

or

SaO2 > 90% on FiO2 < 0.6
What is the general idea behind extubating patients?
slowly wean patients from ventilation

follow with extubation trials
Causes of pulmonary hypertension.
left heart failure
mitral valve disease
increased resistance in pulm veins (including hypoxic vasoconstriction)
What is a T-piece and what is it used for?
A T-piece is a trach-collar that the patient breaths through to determine if they are ready for extubation

a T-piece trial involves oxygen-flow with no ventilatory assistance

(a T-piece is essentially an endotracheal tube with oxygen flow but no ventilatory assistance)
Criteria for Extubation from Mechanical Ventilation

PULMONARY MECHANICS vs OXYGENATION PARAMETERS

What are the pulmonary mechanic parameters and values?
VC > 10-15 mL/kg

Resting minute ventilation (TV x rate) > 10 L/min

Spontaneous RR < 33 breaths/min

Lung compliance > 100 mL/cm water

Negative inspiratory force < -25 cm water
Criteria for Extubation from Mechanical Ventilation

PULMONARY MECHANICS vs OXYGENATION PARAMETERS

What are the oxygenation parameters and values?
A-a gradient < 300-500 mmHg

Shunt fraction < 15%

PO2 (on 40% FiO2) > 70 mmHg

PCO2 < 45 mmHg
Define Pulmonary Hypertension / Cor Pulmonale.
Pulmonary Arterial Pressure > 25 mmHg
(normal = 15 mmHg)
3 Causes of Pulmonary HTN
left heart failure
mitral valve disease
increased resistance in pulm veins
(includes hypoxic vasoconstriction)
5 Classifications of Pulmonary HTN
Arterial pulmonary HTN

Increase pulm pressure from left-sided heart disease

Hypoxic vasconstriction secondary to chronic lung disease

Chronic thromboembolic disease

Pulmonary HTN with an unclear, multifactorial etiology
Signs and Sx

Pulmonary HTN / Cor Pulmonae
dyspnea on exertion
syncope with exertion
fatigue
lethargy
chest pain
sx of right-sided CHF
Sx of Right-Sided CHF
edema
abdominal distention
JVD
Diseases associated with Pulmonary HTN / Cor Pulmonale
COPD
interstitial lung disease
emphysema
pulmonary emboli
heart disease
sickle cell anemia
Physical Examination

Pulmonary HTN
Cor Pulmonale
loud, palpable S2 (often split)
flow murmur
S4
parasternal heave
Diagnostic W/U

Pulm HTN / Cor Pulmonale

Also what are the results
CXR
enlargement of central pulm arteries

EKG
shows RVH

Echo and RH Cath
shows signs of RV overload
Tx

Pulm HTN
Cor Pulmonale
O2
anticoagulation
vasodilators
diuretics if sx of RH CHF are present

tx underlying cause of pulm HTN
What can a pulmonary thromboembolism lead to?
pulmonary infarction
RH failure
hypoxemia
Factors Predisposing to Thromboembolism
Virchow's Triad

V.I.R.
Venous Stasis
Endothelial Injury
Hypercoagulability
Causes of venous stasis
immobility
CHF
obesity
increased central venous pressure
(aka RA pressure and vena cava pressure)
What is CVP and what is it used for?
central venous pressure
(aka preload)

reflects amount of blood returning to the heart and the ability of the heart to pump blood into the arterial system

approximates RA pressure, which itself is a determinant of RV EDV pressure

changes in CVP in response to infusions of IVF have been used to predict volume-responsiveness (i.e. whether more fluid will improve cardiac output)
Causes of endothelial injury
trauma
surgery
recent fracture
previous DVT
Causes of hypercoagulability
pregnancy, postpartum
OCP use
coagulation d/o
(eg Protein C/S def, Factor V Leiden)
Malignancy
Severe burns
Signs and Sx

Pulmonary Thromboembolism
sudden-onset dyspnea
pleuritic chest pain
low-grade fever
cough
tachpynea
tachycardia
rarely hemoptysis
ABG / Acid-Base Disturbance

Pulmonary Thromboembolism
Respiratory Alkalosis
(secondary to hyperventilation)

PO2 < 80 mmHg
hypoxia

hypocarbia
Physical Examination

Pulmonary Thromboembolism
loud P2

prominent jugular A waves with RH failure
CXR

Pulmonary Thromboembolism
usually normal, but may show:

atelectasis
pleural effusion

Hampton's hump
(wedge-shaped infarct)

Westermark's sign
(oligemia in in the affected zone - reduction in the volume of blood)
EKG

Pulmonary Thromboembolism
EKG is not diagnostic

shows sinus tachy

classic triad
S1Q3T3
(means acute RH strain)

S wave in I
Q wave in III
inverted T in III
CTA w/ IV contrast
(Spiral CT)

Pulmonary Thromboembolism
sensitive for pulmonary embolism
V/Q Scan

Pulmonary Thromboembolism
reveals segmental areas of mismatch

reported as low, indeterminate or high probability of PE
Other types of emboli besides thrombo-emboli
amniotic fluid emboli
(postpartum status)

fat emboli
(fracture)

air emboli
(cardiac surgery)
What is the D-dimer test used for in Pulmonary Thromboembolism?
sensitive but not specific in pts at risk for DVT or PE

most useful as a rule-out test in pts with low clinical suspicion
Tx

Pulmonary Thromboembolism
ANTICOAGULATION
Acute: bolus + UFH/LMWH SQ
Chronic: warfarin or LMWH for at least 6 mo. (Goal INR = 2-3)

IVC FILTER
for LE DVT's when anticoag is contraindicated

THROMBLYSIS
indicated in cases of massive DVT or PE causing RH failure and hemodynamic instability

DVT PPX
tx all immobile pts
- SQ heparin or LMWH
- intermittent pneumatic compression of LE
- early ambulation (most effective)
Dyspnea, Tachycardia, Normal CXR

In a Hospitalized Patient
Suspect PE
Signs and Sx

Lung Nodules
often asymptomatic

but may present with:
chronic cough
dyspnea
SOB
Diagnostic W/U

Lung Nodules
Serial CXRs
to determine nodule's location, progression, and extent

Chest CT
to determine the nature, extent and infiltrating nature of the nodule
Tx

Lung Nodules
Surgical resection is indicated for nodules at high risk for malignancy

Low-risk nodules can be followed with CXR or CT every 3 months for 1 year and then every 6 months for another year.

An invasive diagnostic procedure is indicated if the size of the nodule increases.
Characteristics of Benign Lung Nodules
Age < 35
Nonsmoker
No change from old films
Central, uniform, or popcorn calcification
Smooth margins
Size < 2 cm
Characteristics of Malignant Lung Nodules
Age > 45-50
Smoker
New or enlarging lesions
Absent or irregular calcification
Irregular margins
Size > 2 cm
Lung Nodule

Recent Immigrant
Think TB
Lung Nodule

From Southwest US
Think cocciodiodomycosis
Lung Nodule

From Ohio River Valley
Think Histoplasmosis
Central Lesions

What types of cancers?
Squamous and small cell cancers are sentral lesions.
Lung cancer mets are often found in LABBs.
Liver
Adrenals
Brain
Bone
Leading cause of cancer deaths in US.
Lung Cancer
Risk factors for lung cancer.
smoking
(except for bronchoalveolar cx)
radon or asbestos exposure
Lung cancer can be divided into two types, what are they?
small cell and non-small cell
Characteristics of Small Cell Lung Cancer
highly correlated with cigarette exposure
central location
has a neuroendorcine origin (associated with paraneoplastic syndromes)
mets are often found on presentation in intrathoracic and extrathoracic sites such as brain, liver, and bone
Characteristics of Non-Small Cell Lung Cancer
represents a group of cancers

most common type being:
adenocarcinoma
squamous cell carcinoma
large cell carcinoma

these cancers are less likely than SCLC to metastasize at an early age
Characteristics of Non-Small Cell Lung Cancer

Adenocarcinoma
most common lung cancer
peripheral location

includes bronchoalveolar carcinoma (which is assoc with multiple nodules, interstitial infiltration, and prolific sputum production, but NOT assoc with smoking)
Characteristics of Non-Small Cell Lung Cancer

SCC
central locatoin

98% are seen in smokers
Characteristics of Non-Small Cell Lung Cancer

Large Cell/Neuroendocrine Carcinomas
least common

assoc with poor prognosis
Signs and Sx

Lung Cancer
cough
hemoptysis
dyspnea
wheezing
pneumonia
chest pain
wt loss
Name 4 syndromes of lung cancer.
Horners Syndrome
SVC Syndrome
Paraneoplastic Syndromes
Hoarseness
Horners Syndrome
miosis
ptosis
anhidrosis

in pts with pancoasts tumor at the apex of the lung
SVC Syndrome
obsxn of the SVC with supraclavicular venous engorgement and facial swelling

PROMINENT JVD
Hoarseness in Lung Cancer
impingement of recurrent laryngeal nerve
Paraneoplastic Syndromes of Lung Cancer

Endocrine/Metabolic

Name 4 syndromes and the histologic type for each.
Cushing's Syndrome (ACTH)
Small Cell

SIADH Leading to Hyponatremia
Small Cell

Hypercalcemia (PTHrP)(
Squamous cell

Gynecomastia
Large cell
Paraneoplastic Syndromes of Lung Cancer

Skeletal

Name 2 syndromes and the histologic type for each.
Hypertrophic pulmonary osteoarthropathy
Non-small cell

Digital clubbing
Non-small cell
Paraneoplastic Syndromes of Lung Cancer

Neuromuscular

Name 4 syndromes and the histologic type for each.
Peripheral neuropathy
Small cell

Subacute cerebellar degeneration
Small cell

Myasthenia (Lambert-Eaton syndrome)
Small cell

Dermatomyositis
All
Paraneoplastic Syndromes of Lung Cancer

Cardiovascular

Name 2 syndromes and the histologic type for each.
Thrombophlebitis
Adenocarcinoma

Nonbacterial verrucous endocarditis
Adenocarcinoma
Paraneoplastic Syndromes of Lung Cancer

Hematologic

Name 5 syndromes and the histologic type for each.
Anemia
DIC
Eosinophilia
Thrombocytosis
All

Hypercoagulability
Adenocarcinoma
Paraneoplastic Syndromes of Lung Cancer

Cutaneous

Name 1 syndrome and the histologic type.
Acanthosis nigricans
All
Diagnostic Workup

Lung Cancer
CXR or Chest CT

Fine-needle aspiration (CT guided) for peripheral lesions

Bronchoscopy (biopsy or brushing) for central lesions
Tx

SCLC
unresectable

often responds to radiation and chemotherapy initially but usually recurs

low median survival rate
Tx

Non-SCLC
surgical resection in early stages

supplement surgery w/radiation or chemo (depending on stage)

for unresectable disease, palliative radiation and/or chemo
Causes of Pleural Effusions

Transudates
CHF
cirrhosis
nephrotic syndrome
Causes of Pleural Effusions

Exudates
Pneumonia (parapneumonic effusion)

TB
Malignancy
PE
Collagen Vascular Dis (rheumatoid arthritis, SLE)

Pancreatitis
Trauma
Light's Criteria for Pleural Effusions
Pleural Protein / Serum Protein
> 0.5

Pleural LDH / Serum LDH
> 0.6

Pleural fluid LDH
> 2/3 of upper limit of normal serum LDH

An effusion is an exudate if ANY of the above criteria are met.
Tx

Complicated Parapneumonic Effusions
chest tube drainage
In general, transudate is secondary to what process?
increase in PCWP

or

decrease in oncotic pressure
In general, exudate is secondary to what process?
increased pulmonary vascular permeability
Signs and Sx

Pleural Effusion
dyspnea
pleuritic chest pain
cough
Physical Exam

Pleural Effusion
dullness to percussion

and

decreased breath sounds

over the effusion
When is a thoracentesis indicated for Pleural Effusion?
for new effusions > 1 cm in decubitus view, except with b/l effusions and other clinical evidence of CHF
Tx

Pleural Effusion
tx underlying condition

complicated parapneumonic effusions and empyemas require chest tube drainage and antibiotic therapy

complicated parapneumonic effusions is a pl effusion arising from a pneumonia, lung abscess or bronchiectasis
What is a complicated parapneumonic effusion?
a pleural effusion that arises from a pneumonia, lung abscess or bronchiectasis

uncomplicated responds well to abx

complicated means:
+pus or gram stain positive or a pleural fluid pH < 7.0
Presentation of Pneumothorax

P-THORAX
Pleuritic Pain

Tracheal deviation
Hyperresonance (percuss lungs hyperinflated with air)
Onset sudden
Reduced breath sounds (and dyspnea)
Absent fremitus (asymmetric chest wall)
X-ray shows collapse
What is a pneumothorax?
collection of air in the pleural space that can lead to collapse
Causes of pneumothorax.
penetrating trauma
infection
positive-pressure mechanical ventilation
What is a primary spontaneous pneumothorax?
secondary to rupture of subpleural apical blebs

(usually found in tall, thin young males0
What is a secondary pneumothorax?
secondary to:

COPD
trauma
infections
(TB, Pneumocystis jiroveci)

iatrogenic factors (thoracentesis, subclavian line placement, positive-pressure mechanical ventilation, bronchoscopy)
What is a tension pneumothorax?
a pulmonary or chest wall defect acts as a 1-way valve causing air trapping in the pleural space
Signs and Sx

Pneumothorax
acute onset of unilateral pleuritic chest pain and dyspnea
Physical Examination

Pneumothorax
tachypnea

diminished or absent breath
sounds

hyperresonance

decreased tactile fremitus

JVD secondary to compression of SVC

tracheal deviation

hemodynamic instability
Diagnostic W/U

Pneumothorax
tension pneumothorax should be made clinically followed by immediate treatment

CXR
shows presence of a visceral pleural line and/or lung retraction from chest wall
Tx

Pneumothorax
Tension Pneumothorax

immediate needle decompression
(2nd intercostal space, midclavicular line)
followed by chest tube placement

small pneumothoraces may resorb spontaneously

supplemental O2

Large, symptomatic pneumothoraces require chest tube placement
Definition of ALI.
PaO2/FiO2 ratio of less than 300
(i.e. if the patient is on 30% O2, the PaO2 is less than 90mmHg)

b/l infiltrates on CXR
PCWP of less than 18mmHg