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Clin Med B 2 > Diagnostics and therapeutic skills > Flashcards

Diagnostics and therapeutic skills Flashcards

1
Q

what should you inspect during pulm exams

A
  • Pattern, depth of breathing
  • Time spent in inspiration and expiration
  • Symmetry of expansion
  • Retractions
  • Digital clubbing¹
  • Acrocyanosis
  • use of accessory muscles
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2
Q

what should be palpated during a pulmonary exam

A
  • tracheal alignment
  • tactile fremitus “99”
  • assess cardiac impulses for heaves and PMI
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3
Q

what is tachypnea

A

above 25 breaths per minute (said in class that its 25)

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4
Q

what is a heave

A

when you feel the heart pushing the chest forward. indicative of enlarged or deviated heart (said in class)

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5
Q

what would increase or decrease tactile fremitus

A
  • increased with consolidation
  • decreased/absent with pleural effusion or pneumothorax
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6
Q

where is the point of maximal impulse palpated and in what position

A

the 4-5th intercostal space in the midclavicular line with the patient in left lateral decubitus position.

abnormal is if the PMI is felt outside of this expected space
(said in class)

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7
Q

what is considered braypnea

A

less than 12 breaths a minute

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8
Q

what should be assessed during percussion in a pulm exam? what could cause abnormal findings during percussion?

A
  • normal lungs are resonant

abnormal:
* dull - consolidation, pleural effusion, tumors, liver
* hyperresonant - air, emphysema, asthma, pneumothorax

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9
Q

where is the point of maximal impulse (PMI)

A

the 5th ICS in the midclavicular line

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10
Q

what are diagnostic modalities for the pulmonary system (BP, CVS, P-COPS)

A

bronchoscopy
Pulmonary angiography

Chest CT/Spiral CT
V-Q scan
Sputum cytology

Pulmonary function testing
Capnography
Oximetry
Peak flow testing
Sputum culture

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11
Q

what are types of PFTs

A
  • spirometry, plethysmography
    (measured against predicted values derived from studies of healthy people of same height, weight, sex, and race) these are the primary types of PFTs

diffusing capacity, 6 minute walk test, peak flow

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12
Q

what are indications for PFTs

A
  • Evaluate patients with respiratory symptoms or rib fracture
  • Assess progression of previously diagnosed lung disease
  • Monitor the efficacy of treatment
  • Evaluate patients preoperatively
  • Monitor for potentially toxic side effects of certain drugs

she said “ this is used with more chronic complaints of SOB or lung problems, not with acute complaints.” She did talk about how acute rib fractures are a indication for PFT

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13
Q

what are considerations for PFTs

A
  • patient cooperation and consistent effort is essential
  • most children 5 and older can perform PFTs
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14
Q

what is tidal volume

A

the volume of air inspired or expired with each normal breath at rest

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15
Q

what is inspiratory reserve volume

A

the maximum volume of air that can be inspired over and above the tidal volume

(the amount you can inhale after youve already inhaled for tidal volume

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16
Q

what is expiratory reserve volume

A

the volume of air that can be expired after the expiration of the tidal volume

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17
Q

what is residual volume

A

the volume of air that remains in the lungs after maximal exhalation

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18
Q

what is spirometry

A

Non-invasive assessment of maximum inspiratory and expiratory volume as well as maximal expiratory effort

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19
Q

how is spirometry performed

A

completed at bedside, in pulm lab or as an incentive spirometer

may be performed pre and post bronchodilator

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20
Q

what are indications for spirometry

A

diagnosing/monitoring lung or neuromuscular diseases that affect breathing

prevention of post-surgical/traumatic complications (in class she gave the example of how when someone has pneumonia or is at risk for pneumonia you want them to take deep breaths to prevent the pneumonia from progressing)

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21
Q

what are contraindications/cautions to spirometry

A
  • <6 weeks since abdominal, intracranial, or eye surgery or a pneumothorax
  • thoracic, abdominal and cerebra aneurysms
  • unstable angina or recent MI
  • acute severe asthma, acute respiratory distress or active TB
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22
Q

what are risks of spirometry

A

minimal risk but could cause dizziness, very rarely causes syncope

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23
Q

what lung volumes can be assessed with spirometry

A
  • vital capacity
  • forced vital capacity
  • forced expiratory volume in one second
  • FEV/FVC
  • peak expiratory flow rate
  • forced expiratory volume over the middle half of expiration
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24
Q

what is vital capacity

A

the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath

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25
Q

Peak expiratory flow (PEF) rate

A

that maximal speed at which air can be exhaled with force

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26
Q

what is forced vital capacity

A

the amount of air that can be forcibly exhaled from the lungs after taking the deepest breath possible

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27
Q

what is forced expiratory volume in one second

A

the amount of FVC you can forcibly exhale in 1 second

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28
Q

what is the gold standard of pulmonary function testing

A

plethysmography

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29
Q

what does plethysmography measure

A

the total volume of air held in the lungs

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30
Q

when is plethysmography indicated

A

when a decreased FVC is found on spirometry

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31
Q

what is the procedure of plethysmography

A
  • Performed in air-tight chamber
  • Nose is obstructed
  • Various transducers measure pressures in the airway and within the box
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32
Q

what are the volume measurements of plethysmography

A

total lung capacity
functional residual capacity
expiratory reserve volume
residual volume
RV/TLC
vital capacity

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33
Q

what is total lung capacity

A

the volume of air in the lungs at maximal inspiration (usually calculated by RV + VC)

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34
Q

what is functional residual capacity

A

the volume of air in the lungs following expiration of the tidal volume (ERV + RV)

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35
Q

what are the three lung volumes that are used to initiate interpretation of plethysmography

A
  • FVC - amount of air moved after the deepest breath possible
  • FEV₁ - amount of air moved in the first 1 second
  • TLC - total amount of air in the lungs at maximal inspiration
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36
Q

what are the classification of lung disease interpreted from PFTs

A

obstructive - difficulty exhaling air from lungs
restrictive - difficulty expanding the lungs during inhalation

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37
Q

what are the three values that are reported with PFT reports

A
  • Actual values - what the patient performed
  • Predictive values - what the patient should have performed (based upon like-wise healthy patients)
  • Percent predicted - a comparison of the actual value to the predicted value

not really a value:
* pre and post bronchodilator responsiveness

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38
Q

what is the expected post bronchodilator responsiveness in adults and in children

A

adults - increased in FEV1>12% AND >.2L

agres 5-18 - increased FEV1 >12%

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39
Q

Im not really sure whats happening here, maybe learn to label this

A

that’s okay we’ll figure it out

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40
Q

what are maximal respiratory pressures

A

measures of respiratory muscle strength that are assessed during plethysmography

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41
Q

what are indications for maximal respiratory pressures

A

unexplained decrease in VC or suspected respiratory muscle weakness

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42
Q

what physical exam finding is found with obstruction (COPD)

A

barrel chest

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43
Q

what is the procedure for maximal respiratory pressures

A

forced expiration (with cheeks bulging) through blocked mouthpiece after a full inhalation

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44
Q

what is the most sensitive PFT

A

diffusing capacity (DLco)

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45
Q

what is diffusing capacity

A

assesses the transfer of oxygen and carbon dioxide

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46
Q

what is the procedure for diffusing capacity

A

patient inhales carbon monoxide (CO) and a tracer gas (methane or helium), holds for 10 sec, exhales forcefully, exhaled air is tested to determine amount of tracer gas remaining

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47
Q

what is a normal result for diffusing capacity

A

normal is >80%

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48
Q

what is a 6 min walk test assessing

A

assesses oxygenation during exertion and the distance a patient can walk

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49
Q

what is the procedure of a 6 min walk test

A

patients walks back and forth on flat surface 100 ft in length for 6 min

50
Q

what should you monitor during the 6 minute walk test

A
  • symptoms (dyspnea and fatigue) at rest and progression of symptoms with walking
  • oxygen saturation at rest and while walking
51
Q

what does peak flow measure

A

peak expiratory flow rate

52
Q

when is peak flow utilized

A

to determine adequate control of asthma

53
Q

what are the normal values of peak flow based on

A

height
age
gender
race

54
Q

what is the interpretation of peak flow

A
  • green = 80-100% “all clear” - no action needed
  • Yellow = 50-80% “caution” - implement treatment plan by PCP
  • Red = below 50% “medical alert” - contact provider and start bronchodilator therapy immediatly
55
Q

what is a pulse oximetry measurement

A

a Noninvasive, non-risky, continuous or intermittent measurement of arterial hemoglobin saturation

Reading is provided as a percentage of hgb that is oxygenated

56
Q

what are indications for pulse oximetry

A
  • CC of pulmonary or cardiac etiology
  • chronic pulmonary or cardiac disease
57
Q

what is normal pulse oximetry

A

95% or higher

58
Q

what are the best locations for pulse oximetry

A
  • location and fit matter! should use finger, big toe, ear, feet or cheek.
59
Q

what are the limitations of pulse oximetry

A

nail polish
pigmented skin
bright lighting
patient movement
improper placement
poor perfusion
CO poisoning

60
Q

what are examples of poor perfusion that could interfere with pulse oximetry

A

hypothermia
anemia
PAD

61
Q

why does CO poisoning interfere with pulse oximetry

A

it is unable to differentiate between CO and O2 bound hemoglobin

62
Q

How does bright light interfere with pulse oximetry

A

Bright light such as sunlight or the operating light on the probe may interfere with the light detector and cause inaccuracy.

63
Q

what is capnography

A

the measurement and and monitoring of the concentration of CO₂ in expiratory gases

64
Q

where does carbon dioxide come from

A

CO2 is produced by cellular metabolism and is eliminated via the lungs

65
Q

what is an early warning of impending hypoxia

A

CO2 will rise 30-60 seconds before O2 drops in respiratory depression

66
Q

what are the four phases of capnography CO2 waveforms

A
  1. dead space ventilation
  2. ascending phase
  3. alveolar plateau
  4. inspiration
67
Q

During capnography, what does Phase one of the CO2 waveform represent

A

phase 1: dead space ventilation represents the beginning of exhalation

68
Q

During capnography, what does Phase two of the CO2 waveform represent

A

phase 2: ascending phase represents a rapid rise in CO2 as air is exhaled

69
Q

During capnography, what does Phase three of the CO2 waveform represent

A

phase 3: alveolar plateau represents CO2 reaching a uniform level during the entire breath stream point D represents the maximum (measured) CO2 concentration at the end of expiration

70
Q

what is hypocapnia and what are etiologies

A

EtCO2 <35mmHg

etiologies:
hypothermia, low cardiac output, pulmonary embolism, hyperventilation

remember this is measuring CO2 coming out of the mouth, not CO2 in the blood (said in class)

71
Q

what is hypercapnia and what are etiologies?

A

EtCO₂ > 45 mmHg = Hypercapnia

Etiologies: Malignant hyperthermia, shivering, fever, sepsis, severe hypothyroidism¹, hypoventilation

remember this is measuring CO2 coming out of the mouth, not CO2 in the blood (said in class)

72
Q

how does hypothyroidism cause hypercapnia?

A

hypothyroidism - severe hypothyroidism leads to hypoventilation with diminished ventilatory response and diaphragmatic muscle dysfunction

(in notes section, didnt talk about it in class so maybe skip this idk)

73
Q

How does obstructive disease present in capnography

A

Obstructed disease results in a rounded ascending phase and upward slope in the alveolar plateau

this slope is known as “shark fin deformity” (said in class)

74
Q

what could cause sudden loss of waveform in capnography?

A
  • ET tube disconnected, dislodged, kinked, or obstructed
  • Sudden loss of circulatory function
75
Q

what could cause actively decreasing EtCO2 in capnography?

A
  • ET tube cuff leak
  • ET tube in hypopharynx
  • Partial obstruction
76
Q

what could cause sudden increase in EtCO2 in capnography?

A

Return of spontaneous circulation

77
Q

what could cause bronchospasm or “shark fin appearance” in capnography

A
  • Asthma
  • COPD
    (obstruction in general)
78
Q

what is this

A

hypoventilation

79
Q

what is this

A

hyperventilation

80
Q

what could cause decreased EtCO2

A
  • apnea
  • sedation
81
Q

what are indications for capnography

A
  • ensuring proper ventilation during general anesthesia or procedural sedation
  • confirmation of proper ET tube placement and ventilator settings
  • ensuring adequacy of chest compressions in cardiac arrest
82
Q

when are sputum cultures indicated?

A
  1. When a patient is admitted to a hospital prior to starting antibiotics
  2. if they have failed empiric therapy
83
Q

what are the collection instructions for sputum culture collections

A
  • collect before initiating antibiotics
  • prefered early morning collection
  • rinse mouth out with plain water
  • breathe deeply to stimulate coughing and expectoration
  • refrigerate the container until processing takes place
    culture specimen prepared within 2 hours of collection is preferred
  • avoid adding saliva or nasopharyngeal secretions to the sputum sample
84
Q

what is sputum cytology

A

sputum collection for evaluation of presence of abnormal cells

85
Q

when is sputum cytology indicated

A

Pulmonary cancer
and
Non-cancerous conditions:
* Pneumonia
* Inflammatory disease
* TB
* Asbestosis

86
Q

what is the difference between conventional and helical CT?

A

conventional obtains images in slices and takes 30-45 minutes

helical is a rotating X ray beam that gives a spiral image. Only takes the time of one held breath

87
Q

what are the advantages of CT over conventional radiography

A
  • Anatomic structures in different planes not superimposed on each other
  • Better contrast resolution
  • Can be reconstructed to provide different visual planes
88
Q

what are advantages of helical (spiral) CT

A
  • Faster and more anatomic coverage
  • Allows for cardiac imaging
  • Eliminates respiratory artifact during breathing
  • Sharper, more high-definition 3D images
89
Q

what are disadvantages to helical (spiral) CT

A

Radiation exposure¹ - measured in units called millisievert (mSv)

  • CXR - 0.1 mSv (10 days of natural background radiation²)
  • Standard Radiation CT chest - 7 mSv (2 years of natural background radiation)
  • Low-dose CT chest - 1.5 mSv (6 months of natural background radiation)
90
Q

which CT would be the worst exposure of radiation

A

standard radiation CT chest

91
Q

what is the least radiation exposure

A

CXR

92
Q

what are indications for CT

A
  • Inconclusive x-rays or abnormality on physical examination
  • Assess cardiothoracic space for tumors and other lesions
    monitor response of tumors to treatment
  • Intrathoracic injury/bleeding
  • Infections
  • Unexplained chest pain
  • Obstructions
  • Provide guidance for biopsies and/or aspiration of the tissue from the chest
93
Q

when is contrast used

A

when you want to highlight the vascular system

94
Q

what are contraindications/cautions to CT

A
  • pregnancy (1st trimester and during non-life threatening conditions)
  • history of large radiation exposure
95
Q

what is the contraindications or cautions to CT contrast

A
  • allergy to dye
  • severe renal impairement GFR<20
  • hyperthyroidism or thyroid goiter
  • pheochromocytoma
  • metformin use
96
Q

what are limitations to CT scans

A
  • body habitus (450+lbs)
  • artifact (metal objects/pacemakers/piercings)
  • barium in esophagus from recent barium study
97
Q

when is contrast indicated

A

vascular disease or to delineate area of concern from adjacent structures

98
Q

what is the MC type of dye used in CT scans

A

iodine dye

99
Q

what should a patient be given prior to radioactive contrast dye

A

Premedicate with prednisone 50 mg orally taken at 13, 7, and 1 hour prior to procedure, or diphenhydramine (Benadryl) 50 mg orally, IV or intramuscularly, 1 hour prior to receiving radiocontrast media.

(in the notes section under slide 58. did not talk about it in class)

100
Q

what is a ventilation and perfusion scan (V-Q scan)

A

a nuclear medicine scan that uses radioactive material to examine air flow (ventilation) and blood flow (perfusion) in the lungs

101
Q

what are indications for a V-Q scan

A

diagnose or rule out a PE when CT is contraindicated

102
Q

How do VQ scans identify PEs

A

they detect poor blood flow in the pulmonary vascularity and uneven air distribution

(im pretty sure this is what this line was talking about)

103
Q

what is the general procedure for a VQ scan

A
  1. radioactive material is inhaled and images are taken to look at the airflow in the lungs
  2. radioactive material is injected IV and additional images are taken to assess the blood flow in the lungs
104
Q

If the ventilation scan is abnormal but the perfusion scan is normal what is the possible diagnosis

A

COPD
Asthma

(indicated abnormal airway in all or parts of the lung)

105
Q

If the perfusion scan is abnormal but the ventilation scan is normal what is the possible diagnosis

A

Pulmonary embolism

106
Q

If BOTH the ventilation and perfusion scans are abnormal what is the possible diagnosis

A

certain types of lung disease such as pneumonia.
could also be indicative of COPD or PE.

basically anything

107
Q

what are the risks associated with VQ scans

A
  • radiation is very minimal
  • pregnancy (smaller amount of radioactive dye is used)
  • breastfeeding (must discard milk for 24 hrs after scan)
  • mild and rare chance of allergic reaction (MC reaction is hives)
108
Q

what is the gold standard diagnostic technique for pulmonary embolism

A

pulmonary angiography

109
Q

what is the procedure of a pulmonary angiography

A
  • performed by interventional radiologist.
  • pt is mildly sedated
  • contrast injected into pulmonary artery branch after percutaneous catheterization via the femoral vein
  • images are obtained via flouroscopy
110
Q

what interpretation of pulmonary angiography is indicative of embolus

A

a filling defect or abrupt cutoff of a small vessel

111
Q

What does it mean if a pulmonary angiography is negative

A

Clinically relevant PE is excluded from possible diagnoses

112
Q

aside from PE what are some other indications for a pulmonary angiography

A
  • AV malformation of the lung
  • Congenital narrowing of pulmonary vessels
  • Pulmonary artery aneurysms
  • Pulmonary hypertension
113
Q

what are risks associated with pulmonary angiography

A
  • Allergic rxn
  • Damage to blood vessel or nerve from needle or catheter
  • Excessive bleeding, blood clot or hematoma formation
  • MI or stroke
  • Injury to nerves at puncture site
  • Kidney damage from contrast dye
114
Q

what is bronchoscopy

A

A procedure used to directly visualize the airways and diagnose lung disease

115
Q

what are the two types of bronchoscopes? which is MC?

A

flexible (MC)
rigid

116
Q

what is the procedure of bronchoscopy

A
  • patient is sedated (general for rigid scope, procedural for flexible)
  • scope passed through mouth or nose and into lungs
117
Q

what are indications for bronchoscopy

A
  • Evaluation and removal of airway FB’s or other obstructions
  • Diagnosis and staging of bronchogenic carcinoma
  • Evaluation of hemoptysis
  • Diagnosis of pulmonary infections
  • Transbronchial lung biopsy
  • Bronchoalveolar lavage
118
Q

what are contraindications for bronchoscopy

A

severe bronchospasms
bleeding diathesis (increased tendency to bleed or bruise)

119
Q

what are complications of bronchoscopy

A

Common:
transient hypoxemia
pneumothorax
hemorrhage

less common:
infection
nasal/laryngeal trauma
bronchospasm
cardiorespiratory arrest

120
Q

how common are major complications in bronchoscopy

A

less than 1% chance

Clin Med B 2 (44 decks)

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