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51 Cards in this Set

  • Front
  • Back
Px history for respiratory system
I. History
A. family
1. asthma
2. TB
3. Ht disease
B. occupation
1. exposure to inhalants
C. residence
1. current and previous
D. tobacco use
1. personal – pack years
2. second hand
3. inhaled recreational drug use
E. any problems with breathing, frequent colds, cough, sputum (color & quantity), dyspnea (SOB), chest pain (pain on breathing), wheezing, asthma, bronchitis, emphysema, pneumonia, TB, last chest x-ray (if known)
Physical exam for respiratory system
*Inspection- deformities, ribs
*Palpation- tenderness, fremitus (whispering 99 / tactile or audible)
*percussion - above diaphragm is resonant, below is dull (1 finger strike another, diaphragmatic excursion)
*auscultation-
Vesicular- normal, inhale longer than exhale
Bronchial- exhale longer than inhale/trachea area
Broncho-vesicular - inhale = exhale
Area between upper scapula
*abnormal sounds -
Rales- crackles, usu. Inspiration
Rhonchi- wheezes
Friction rub- crackling, grating sound (dermatomyositis)
*vocal sounds- use "99"
Bronchophony- increase clarity + intensity of speech
Egophony- nasal bleating ee / ay
Whispered pectoriloquy - clarity of whispers
***do all on ant. Chest just lateral to R sternum in 4th or 5th ICS
Imaging studies for respiratory system
Chest x ray- post to ant ::: lateral
MRI- find soft tissue mass
CT scan- usually after xray
Ultrasound- ESP of pleural space
*spirometry- measures airflow + lung volume
*bronchoscopy - visual exam of larynx + tracheobronchial tree, sample secretions, biopsy
*thoracentesis- sample pleural fluid
*thoracotomy- lung biopsy
Emergencies for respiratory system
A. any acute chest pain needs primary evaluation
1. must be differentiated from cardiac and other causes
2. most non-cardiac chest pain from pleura or chest wall
3. often accompanied by dyspnea (difficulty breathing)
B. pneumonia, bronchitis, emphysema, asthma may be emergencies
C. hemoptysis
1. coughing up of blood due to bleeding in respiratory tract
2. blood streaked sputum not emergency
3. > 600 ml blood in < 24 hours (kidney basinful)
4. differentiate from hematemesis (vomiting blood) and blood dripping from nose, mouth, nasopharynx
a. patient may be able to feel where bleeding is coming from
5. hx, px, chest x-rays, bronchoscopy
Common cold definition + etiology
VIII. Common cold
A. URI- nose down to post nasopharynx to bronchi
B. usually viral - inflammation in any or all airways
C. etiology
1. viral
a. picorna
i. up to 50% from >100 types of rhino
b. influenza, parainfluenza, respiratory syncytial, corona, adeno
2. fatigue, emotional distress, allergies, midphase of menstrual cycle
3. ***most important factor is presence of specific neutralizing antibody
a. indicates previous exposure and offers protection
Common cold sxs + sns
1. short (1-3 day) incubation
2. abrupt onset
3. nasal or throat discomfort, sneezing, rhinorrhea, malaise, no fever, pharyngitis, laryngitis, tracheitis, watery nasal discharge becoming mucopurulent, cough
4. resolves in 4-10 days if no complications
*if fever- probably the flu
Common cold diagnosis
1. clinical, but nonspecific
2. R/O allergies, bacteria
3. smear of exudate
a. bacteria
b. eosinophils if allergic
Common cold tx
D. treatment
1. warm, comfortable environment
2. prevent direct spread
3. symptomatic relief
4. no antibiotics
5. vit. C, vit. A, zinc, elderberry, garlic, Chinese herbs
6. moderate exercise
Influenza definition + etiology
A. flu, grippe
B. acute viral respiratory illness with fever, coryza, cough, headache, malaise, inflamed respiratory mucous membranes
C. etiology
1. influenza viruses
a. influenza A most frequent cause
2. airborne droplets
3. usually late fall and early winter
Influenza sxs + sns
1. 2 day incubation
2. abrupt onset - sxs within 24 hours
3. ***fever, chills, myalgia, HA, photophobia, sore throat, cough, coryza, watery eyes, N, V
4. up to 3-5 days
5. complications usually respiratory if sxs last > 5 days
Influenza diagnosis
1. nasopharyngeal washings or gargling to isolate virus
2. R/O common cold, bronchitis, pneumonia, mono
Tx same as common cold
Pleurisy definition + etiology
A. inflammation of the parietal pleura
B. etiology
1. underlying lung process (spreads frm visceral to parietal)
2. entry of agent into pleural space
3. transport by bloodstream*
4. trauma
5. asbestos - into alveoli, out of lung into mediastinum + pleura
Pleurisy sxs + sns
1. sudden onset
2. vague discomfort to intense stabbing pain- w/ each breath
3. pain aggravated by breathing and coughing
4. referred pain via intercostal nerves
5. rapid, shallow respiration - tachypnea - cuz it hurts
6. decreased breath sounds
7. pleural friction rub- fluid surrounding lungs (atelectasis)
8. pain subsides if effusion develops
a. dull percussion, no tactile fremitus, decreased or absent breath sounds, egophony at upper border of fluid
Pleurisy diagnosis
1. clinical
2. pleural friction rub is pathognomonic
***if no pain but still diff to breathe - getting worse! Pleural effusion
Pneumothorax definition + etiology
A. air in the pleural cavity
B. etiology
1. trauma or spontaneous
2. simple or complicated with either traumatic or spontaneous
Pneumothorax sxs + sns
1. dyspnea -1st
2. chest pain or pressure
3. cough
4. cyanosis
5. sweating
6. hypotension
7. trachea deviates to opposite side- if severe//atelectasis
8. weak and rapid pulse
Tuberculosis definition + etiology
A. a chronic recurrent infection caused by Mycobacterium tuberculosis
B. most common in lungs (can b anywhere)
C. etiology
1. airborne
2. considerable innate defense against initial infection
3. elderly, infants, diabetics, chemotherapy, HIV+
4. undernourished, unhygienic
*apex of lung, jing bi prone
Tuberculosis sxs + sns
1. very often asx in initial stages
2. not feeling well
3. nightsweats
4. cough - initially non-productive becoming productive with blood tinged sputum
5. dyspnea
6. Simon foci
a. nodular apical scars – most common sites for later active TB
Tuberculosis diagnosis
1. tuberculin skin test - induration > 10 mm in 48 – 72 hours indicates infection but not activity
2. quantiferon-TB gold (QFT-Gold) - px dont don't come back
3. chest x-rays
4. sputum analysis for acid-fast bacilli //
5. sputum culture - very diff to get from lung - bronchi, trachea, mouth contaminates fluid frm lung
Tuberculosis tx
1. usually use 2 drugs with different mechanisms of action (bactericidal, bacteriostatic) to prevent development of resistance
*6-9 months to resolve
Pneumonia definition + etiology
A. acute infection of the lung
B. etiology
1. bacteria
a. streptococcus pneumoniae (pneumoccal pneumoniae), staphylococcus aureus, hemophilus influenza, klebsiella pneumoniae, mycoplasma pneumoniae
2. viral
3. predisposing factors
a. respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airways disease, age extremes, debility, immunosuppressive disorders and therapy, compromised consciousness, dysphagia, exposure to transmissible agents
4. 2 mil a yr in US – 55,000 deaths - common complication
a. 8th leading cause of death together with influenza
b. most common lethal nosocomial infection
5. in ‘developing’ countries, leading cause of death or 2nd to diarrhea
6. 30-50% have no identifiable pathogen
7. sputum cultures contaminate from other areas
Pneumococcal Pneumonia sxs + sns
C. Pneumococcal pnueumonia
1. most common cause of bacterial pneumonia
a. streptococcus pneumoniae
b. 175,000 cases per year with a 7% fatality rate
2. sxs & sns
a. preceded by uri
b. ***sudden onset with a single shaking chill
c. fever, pleurisy, cough, sputum, dyspnea
i. rapid T rise to 105
d. increased HR to 140 (60-90)
e. increased RR to 45 (12-20)
f. blood streaked or rusty sputum
g. tactile fremitus - 99 vibrates
h. percussive dullness
i. bronchial breath sounds- expiration longer than inhalation
j. whispered pectoriloquy - hear 99 loudly
k. suspect in anyone with acute febrile illness with chest pain, dyspnea, cough
l. complications (BIG)
i. contiguous infections
ii. bacteremia- bacteria in xue st
iii. sepsis- septicemia means have bacteremia (organ failure)
Pneumococcal pneumonia labs
a. leukocytosis with shift to the left (@ first have multiple nuclei, as mature they coalesce - w/infection pumping out leukocytes super fast so they aren't fully developed)
i. neutrophilia with lymphopenia
b. gram stain of sputum
c. sputum culture: see what grows then what inhibits growth
***xray- pulmonary infiltrate (shadowy area)
+ dense consolidation: spidery web (congestion)
Tx- penicillin G or V
b. erythromycin, amoxicillin, azithromycin
Staphylococcal pneumonia
1. 2% of infections
a. 15% of nosocomial pneumonias
b. often in patients who are more ill
2. sxs & sns - worse sxs than pneumococcal p. But similar
b. can be more fulminant with more prostration
c. recurrent chills
d. *tissue necrosis and abscess
3. lab and x-ray like pneumococ
4. treatment
a. mortality rate 30-40%
b. slow response to tx
c. produce penicillinase, so must use a penicillinase- resistant penicillin
Hemophilus pneumonia
E. Hemophilus pneumonia - mild but sequelae more serious consid.
1. etiology
a. 2nd only to strep
b. Hib - can cause meningitis, epiglottitis (hemoph infl B)
2. sxs & sns
a. coryza, pleural effusion + bacteremia if left on it's own
3. treatment
a. vaccine
b. ampicillin, amoxicillin
Klebsiella pneumonia
* IV antibiotics right away
1. etiology
a. rare in healthy adults
b. very young or old
c. hospital settings
d. immunocompromised
e. alcoholics
f. up to 50% mortality
2. sxs & sns
a. *currant jelly like sputum from tissue necrosis and abscess
b. fulminant course
3. diagnosis
a. sputum culture
Mycoplasma pneumonia
1. often called walking pneumonia
2. etiology
a. most common pathogen in ages 5-35
3. sxs & sns
a. 10-14 day incubation
b. initially resembles influenza
i. malaise, sore throat, cough
c. gradual progression as sxs increase in severity with time
d. paroxysms of cough
e. *mucoid, mucopurulent, blood streaked sputum
f. 1-2 wks with gradual spontaneous recovery
4. diagnosis
a. usual
b. serologic assays
5. treatment
a. tetracycline, erythromycin
b. almost all pts recover with or without tx
Viral pneumonia
1. etiology
a. many viruses cause lri
2. sxs & sns
a. HA, fever, myalgia, cough with mucopurulent sputum (combo of flu + pneumonia)
3. diagnosis
a. few bacteria on sputum gram stain with a predominance of monocytes
4. may have superimposed bacterial infection
a. strep, staph
Asthma definition + etiology
A. reversible airways obstruction, inflammation, hyperresponsiveness
B. etiology
1. 22 million in US currently
a. 34 million diagnosed in their lifetimes
2. 6 million are children
a. 9.6 million diagnosed at some point in childhood
3. extrinsic – IgE mediated, allergic in nature
a. animal dander, cockroach protein, house dust mite, dust, mold
pollen, air pollution, foods
4. intrinsic – immune system not involved, non-allergic (directly attacks the lung itself)
a. cigarette smoke, wood smoke, dust, odors, fumes, air pollution
changes in temperature, pressure, humidity, aspirin, sulfites, NSAID’s, tartrazine (FD&C yellow dye#5), chemicals, cold air, exercise, emotional upset, uri
Accessory muscles of respiration
Serratus ant, pec minor, intercostals, erector spinae, serratus posterior superior, levator costarum (vert to rib)
C7---breathing
L2--- kidney
Asthma sxs + sns
1. some sx free with occasional mild brief episode
2. others mild coughing and wheezing much of the time with severe sxs following exposure to allergens, viruses, exercise, irritants, psychologic factors
3. wheezing, coughing, SOB, dyspnea, tachypnea, tightness in chest, audible wheezes
4. non-productive cough initially, then tenacious mucoid sputum
5. sitting upright, leaning forward, anxious
6. use of accessory muscles of respiration, struggling for air
7. prolonged exhalation with wheezes in inhalation and most of exhalation
8. if severe - unable to sqpeak more than a few words at a time
a. fatigue, cyanosis
b. decreased wheezing
9. may develop pneumothorax, atelectasis
10. status asthmaticus - emergency
a. severe obstruction persisting for days or wks
Asthma laboratory /imaging /pulmonary fx tests
D. laboratory
1. eosinophilia- if extrinsic
2. allergy testing
3. ABG’s and pH - arteriole blood gasses
a. decreased Pao2, increased Paco2, decreased pH
4. sputum analysis
a. tenacious, rubbery, white
b. eosinophils
c. Charcot-Leyden crystals
E. imaging
1. chest x-rays
a. normal to hyperinflated
F. pulmonary function tests
1. spirometry
a. bronchoprovocation
Asthma diagnosis + differential diagnosis
G. diagnosis
1. wheezing, especially beginning in childhood or early adult
2. family hx of asthma or allergy
3. differential dx
a. foreign body obstruction
i. especially in children with sudden wheezing without hx of respiratory sxs
b. viral uri- often cause wheeze
c. epiglottitis - closes trachea
i. Hib/ hemophilus influenza b
ii. sudden onset -fever, sore throat, hoarse
iii. resp distress - leaning forward, hyperextend neck
iv. emergency room - * do not try to visualize throat
d. bronchitis, pneumonia
e. COPD-mimics asthma
f. Ht failure-fluid buildup in lower lungs/Rales + crackles, edema, hypertension
Asthma tx
H. treatment
1. avoid allergens - extrinsic
2. avoid irritants - intrinsic
3. drug tx
a. controller medications
i. inhaled corticosteroids
b. rescue medications
i. inhaled B-adrenergic agents
B12 great 4 kids
*Magnesium, EPA, vit c. Se, *b6
Bronchitis definition + etiology
* kinda btwn cold + pneumonia

A. acute inflammation of tracheobronchial tree
B. etiology
1. mostly in winter
2. after acute uri (fever, chills, choriza, fatigue, then *cough)
a. air pollutants, chilling, fatigue, malnutrition predispose
Bronchitis sxs + sns
1. sxs of uri
a. coryza, malaise, chills, mild fever, myalgia, sore throat
2. cough
a. initially dry and non-productive
b. shortly, thick sputum which may become abundant and mucopurulent
c. if purulent - bacterial infection
3. if fever persists > 5 days, possible pneumonia
4. cough may last several weeks
5. *few pulmonary signs- not actually in the lungs
a. occasionally rhonchi, rales, and wheezing after cough
Bronchitis diagnosis + tx
1. clinical - sxs & sns
2. chest x-ray to R/O other diseases if sxs serious or prolonged
E. treatment
1. rest
2. fluids
3. do not suppress a productive cough unless keeping person from resting
4. antibiotics only if purulent sputum or persistent high fever
Chronic obstructive pulmonary disease definition
A. increased resistance to airflow during forced expiration
B. several causes
1. narrowing of airways 2o to intrinsic airways disease-bronchitis
2. excess expiratory collapse of airways 2o to emphysema
3. bronchospasm-asthma
C. terms
1. chronic bronchitis
a. mucous hypersecretion and structural changes in bronchi from nonspecific bronchial irritants (bronchiospasm)
2. pulmonary emphysema
a. enlargement of airspaces with destructive changes of alveolar walls
3. chronic asthmatic bronchitis
a. persistent asthma with clinically significant airflow obstruction even with anti-asthma tx
D. COPD usually means emphysema and chronic obstructive bronchitis
Chronic obstructive pulmonary disease etiology
1. emphysema from the effect of proteolytic enzymes released from leukocytes during inflammation - breakdown of alveolar wall
a. any chronic inflammation – smoking
b. age
c. air pollution
d. hyperresponsive airways
e. alpha -1 antitrypsin deficiency
*if px is very young with. Copd
Antitrypsin is protection against proteolytic enzymes
COPD sxs + sns
1. primarily in smokers
a. smoker’s cough
i. often present for decades before dyspnea
2. exertional dyspnea
a. gradually progressive
b. # stairs climbed
c. distance walked
3. sputum production
a. amount and color variable
4. wheezing
a. variable
5. recurrent respiratory infections
6. slowing of forced expiration
a. normally complete in <4 seconds
b. >4 seconds with wheezing at end
7. barrel chest, pursed lip breathing, depressed diaphragm, callused elbows - late stages
8. decreased vesicular breath sounds, rhonchi, tachycardia, decreased heart sounds - variable findings
9. cyanosis, plethora (plethoric - dusky red color face + neck) dependent edema - late sns
COPD lab, imaging, pulmonary fx tests, diagnosis
G. laboratory
1. erythrocytosis- increase rbc/hemoglobin to get more o2
2. eosinophilia if asthmatic bronchitis
H. imaging
1. chest x-rays
a. hyperinflation
i. depressed diaphragm, radiolucency
I. pulmonary function tests
1. spirometry
J. diagnosis
2. any patient with chronic productive cough and exertional dyspnea of unknown etiology
3. slowing of forced expiration
4. physiologic evidence of airways obstruction that persists despite tx
5. R/O specific diseases
Respiratory distress/failure definition + etiology
A. impairment of gas exchange between air and circulating blood (respiratory failure)
1. oxygenation or ventilation problems
B. pulmonary edema, respiratory distress, hypoxemia
C. etiology
1. acute processes that injure the lung
2. pneumonia, aspiration, chest trauma, shock, burns
3. 30% following sepsis - bacteremia becomes septicemia
Respiratory distress/failure sxs + sns
1. within 24-48 hours after initial injury or illness
2. dyspnea, tachypnea, shallow respiration
3. intercostal and suprasternal retraction on inspiration
4. cyanotic or mottled skin
Respiratory distress/failure diagnosis + prognosis
*CRPD "restricted" hardened - like miners lung - impossible to relax fibrous tissue (in asthma just muscles constrict)
Diagnosis
1. ABG’s arteriole xue gasses
2. chest X-ray
3. must search for cause
F. prognosis
1. 50% survival with appropriate tx
2. complications
a. pulmonary fibrosis with prolonged ventilatory support
b. bacterial superinfection of lungs
c. multiple organ system failure, especially renal - KD very sesnsitive to hypoxia
d. complication of invasive life support (pneumothorax)
G. treatment
1. immediate referral
Lung cancer definitions + classifications
A. 1o tumors and metastases
B. classification
1. NSCLC – non small cell lung cancer
a. 80%
b. 3 types
i. adenocarcinoma
ii. squamous cell carcinoma
iii. large cell carcinoma
2. SCLC – small cell lung cancer
a. 20%
b. oat cell carcinoma
c. rare in non-smokers
d. highly aggressive
i. 5 yr survival 6%
Lung cancer epidemiology
C. epidemiology
1. 2nd most common CA in men and women
a. 220,000 new cases each year in US
2. most common cause of CA death in men and women
a. 157,000 die
b. more than prostate(99.7), breast(89%), colorectal(65% survival) combined
3. most common between ages 45-70
Lung cancer etiology
1. 85% due to cigarette smoking
a. highest risk if over 50 and smoked 30 pack years
b. if stop by 50, risk reduced from 1 in 10 to 1 in 50
2. other risk factors
a. second hand smoke
i. increases risk of lung CA by 30%
b. air pollution
c. radon
d. asbestos
e. other chemicals
3. metastatic tumors in lungs from other organs
a. breast
b. colon
c. prostate
d. bladder
e. bone
Lung cancer sxs + sns
E. sxs & sns
1. cough-minimal, dry, outofblue
2. sputum
a. possibly blood-streaked with inflammatory exudates (tb, pneumonia diff. diagnosis)
3. pain in back or chest unrelated to coughing
4. dyspnea, SOB - eventually (more hemoptysis-erode xue vess)
5. hoarseness
3. hemoptysis
4. *localized wheezing
5. atelectasis
6. infection
7. weight loss and weakness (cachexia) are late sxs
8. pleural effusions
9. local spread to nerves
10. many extrapulmonary sxs and sns
a. metastasis common to liver, brain, bone
Lung cancer diagnosis
1. history
2. chest x-ray
3. CT scans
a. spiral CT scan
b. 95% accuracy but about 20% false positives
i. reduced lung CA deaths by 20% in those screened
4. sputum cytology
5. bronchoscopy
6. biopsy
7. thoracotomy
Lung cancer staging
1. NSCLC- non small cell
a. stage 0
i. in situ (small, localized, no spread, well encapsulated)
b. stage I - small
i. IA - small
- small
ii. IB - sl bigger
- slightly larger
c. stage II
i. IIA
- large tumor without lymphatic metastasis
ii. IIB
- small tumor with spread to regional nodes (metastasis)
d. stage III
i. IIIA
- spread to lymph nodes outside the lung
ii. IIIB
- like IIIA but removal not possible
e. stage IV
i. widespread metastasis
2. SCLC
a. limited
i. tumor in one lung and nearby lymph nodes
b. extensive
ii. tumor in both lungs or spread to other organs
Lung cancer survival rate
5 year survival rate 15%
50% stage 1 + 2 potentially curable with surgery
Radiation increasingly used, very specific now
Chemotherapy - ESP in sclc
Targeted drug therapies - leukophoresis (WBC taken out of blood stream) + sensitized to antigen of cancer cells + put back in the body giving them a specific goal- to attack the cancer / in theory great but too early to tell
* angiogenesis- created a lot w blood supply - if can stop the blood supply from growing can straggle the tumor so it dies... Theory behind use of shark cartilage (they don't get cancer) - bogus - the guy made it all up but drug co's tried to make angiogenesis inhibitors but quickly failed...