Clinical Assessment Module 3 Pulm Flashcards

Question

* 41 Y.O. female smoker presents c/o SOB. * HPI: Onset this morning at 0830 with sudden onset SOB. Pain in R chest, sharp. Worse with inspiration. No cough. * Meds – OCPs. * Exam – WD/WN/WF. Sitting on exam table. Anxious. –V.S. – P-108, RR-28, BP-101/68, T-38.0, SaO2-90% RA -- What do you think? --

Answer 1

Notes: THEY new EXACTLY What TIME! THIS IS TELLING Chest pain- heart, aorta, pulmonary embolism Left sided chest pain is more concerning then right side pain Sharp pain- less concerned about heart because usually dull pain inspiration worse- less concerned with heart issues… doesn’t usually change with inspiration with heart issues HR- high RR- high BP- low (soft) T- elevated O2- low Smoker, birth control, certain spot of chest, sharp, no cough, tachy, high RR, BP soft from no blood to left side of heart), saturation drops, and fever a bit can occur Further exam: * Heart - reg, no murmur * Lungs – vesicular (normal) * Percussion normal, no egophany or whispered pectoriloquy, fremitus normal. * Abdomen – benign * Extremities – pulses 2+, No edema DDX – ACS, Anxiety, Pneumonia, Heart failure, Pulmonary embolism, pneumothorax (maybe, sharp pain, specific area but tympani with percussion) Other diagnostics: * CXR (to see if there is a pneumothorax) * ABG (arterial blood gas) how well lungs are exchanging oxygen * EKG (inexpensive and easy… not sensitive but it is SPECIFIC) * CBC (INFECTION- THEN WBC-no role in this case), D-Dimer (fibrin degradation process– people form clots they break down and release this D-Dimer) (but it can be elevated for a lot of reasons) (makes it sensitive but not specific) , sputum Cx (fever so she could get this?) , Troponin-I * Chest CTA (CT angiogram) gold Standard.. Have to put dye but puts strain on kidneys… cant use this on people with renal disease * VQ scan (people with chronic lung disease already have VQ abnormalities) * Lower extremity venous Doppler (look at deep veins) if positive the suspicion for PE goes WAY UP! Normal lung exam except for pain with inspiration- hallmark of pulmonary embolism WHAT IS IT? Pulmonary Embolism

Answer 2

Tx: * Anticoagulation (use 1 of these 4 things) * Heparin (IV at hospital) * Low molecular weight heparin (sub Q injection… can go home) * Warfarin (provoked DVT- 6 months) * Factor X-A inhibitor (Riv. Doesn’t need to be monitored like warfarin and effectively immediately) BUT doesn’t have an antidote * Oxygen (maybe dependent) * Pain control (pain with inspiration) * Vena cava filter (uncommon)--- clot gets trapped from filter

Answer 3

criteria of whether they have PE or not Pretest probability Can give some ideas of what to do it you cant use a diagnostic test listed previously

Answer 4

* Hr- high * Rr- high * Bp- soft * Temp- no fever * O2- stat * Saturation really made him feel not anxiety but before thought maybe that Further exam: * Heart - reg, no murmur * Lungs – vesicular * Percussion tympanic RUL, no egophany or whispered pectoriloquy, fremitus normal. * Abdomen – benign * Extremities – pulses 2+, No edema DDX – ACS, Anxiety (yes, until o2 and exam), Pneumonia (no consolidation), Heart failure, Pulmonary embolism (less likely with tympani) , pneumothorax Other diagnostics: * CXR– tool of choice for diagnosising this… but rarely obvious on a chest x-ray * Ask for end exhalation views (want it to be as dense as possible – more squished) * ABG * EKG * CBC, D-Dimer, sputum Cx, Troponin-I (no Acute coronary syndrome don’t need this) * Chest CTA– maybe … chest x-ray may give answer * VQ scan * Lower extremity venous Doppler NOTES: Exam= tympani leans towards maybe spontaneous pneumothorax Right upper lobe… think about gravity… air escaping lung and going into space.. The air will go up in the water like a bubble… so you will here tympani upwards because of this If you have fluid trapped it will go down! **WhaT is it?** Pneumothorax

Answer 5

Tx: * Observation vs. chest decompression (needle aspiration) * \<2-3 cm * \>3 cm * Needle aspiration * Chest tube * Oxygen * Pain control * pleurodesis

Answer 6

* Hr- little high * Rr- good * Bp- fine * T-fine * SaO2-fine * What are we worried about in these vital signs- not worried about vital signs Further exam: * Heart - reg, no murmur * Lungs – vesicular except she wheezes when she coughs * Percussion normal, no egophany or whispered pectoriloquy, fremitus normal. * Abdomen – benign * Extremities – pulses 2+, No edema DDX – ACS, Pneumonia (not likely but not uncommon for someone with obstructive disease to then get a bacterial infection), Heart failure, Pulmonary embolism (no pain), bronchitis, pneumothorax Other diagnostics: * CXR– get the chest x-ray if available …but this can be a clinical diagnosis * EKG-- +/- * CBC, D-Dimer, sputum Cx, Troponin-I (for ruling out ACS don’t need that here) * Chest CTA * VQ scan * Lower extremity venous Doppler **WHAT IS IT?** Acute Bronchitis

Answer 7

•Tx: –Possibly bronchodilators, cough suppressants –Tincture of time (reassurance) –Consider antibiotics (not necessarily needed) * Frequently follows colds * And cough can last for weeks * Want to treat the symptoms

Answer 8

* P- high * RR-normal * BP- high * T- normal * O2- low * Lung cancer would have more hemoptysis * CANCER- UNEXPLAINED WEIGHT LOSS! Further exam: * Heart - reg, no murmur * Lungs – Almost inaudible. (ALMOST CAN’T HEAR THEM) * Abdomen – benign * Extremities – pulses 2+, No edema DDX – ACS, Pneumonia (no signs of consolidation), Heart failure, Pulmonary embolism, pneumothorax (only inaudible over a certain side, and would have hypotension and pulse), COPD Other diagnostics: * CXR– yes! * EKG * CBC, ABG, D-Dimer, sputum Cx, Troponin-I * Chest CTA (for PE) * VQ scan (for PE) * Lower extremity venous Doppler * Bronchoscopy (if chest x-ray does not help… these do) **WHAT IS IT??** COPD

Answer 9

* Acute Tx: * Short acting Beta adrenergic, anticholinergic, or combination * Steroids (in combination only) * Maintenance Tx * Possibly LABA * Long acting Anticholinergics * Theophylline * PDE-4 inhibitors * Other approaches * Oxygen * Smoking cessation * Vaccinations * Rehab * Education * Nutrition * Lung volume reduction surgery Emphysema vs. chronic bronchitis NOTES: Regulate breathing on pH of blood– medullary= breathing control.– CO2 level regulates all of our breathing…. Breathe out to remove carbon dioxide from blood In COPD cant remove carbon dioxide effectively and receptors get messed up in midbrain … so o2 sensors stimulate COPD people to breathe… by giving COPD patients oxygen it removes their want to breathe … but don’t try to get it to 98% spO2 get it to 80-90% On ambulance ride- not going to kill them if you give too much O2– but if you admit them in the hospital and put them on 4% O2 and then now it's at 98% they slowly decrease their respiration and carbon dioxide levels slowly increase they have hypoxic drive so they can become comatose and die. :(

Answer 10

* Barrel chest and air trapping so when they try to take a deep breathe very little air comes in or out. * So COPD usually hardly any breath * COPD= blue bloaters

Answer 11

* P-high * Rr-high * Bp-soft * T-ok * O2-low Further exam: * Heart - reg, no murmur * Lungs – crackles from bases to 2/3 up to the apex bilateral * Percussion dull in bases, no egophany or whispered pectoriloquy, fremitus normal. * Abdomen – benign * Extremities – pulses 2+, 3+ bilateral LE edema DDX – ACS (no chest pain), Anxiety, Pneumonia (crackles), Heart failure (fluid drains out in the lungs– crackles), Pulmonary embolism, pleural effusion Other diagnostics: * CXR- YES * EKG- YES * CBC (hemoglobin!), BNP (marker for heart failure… increases with atrial stretch), D-Dimer (don’t get D-dimer if no worry about PE), sputum Cx, Troponin-I (YES!) * Chest CTA * 2D Echo– (YES!... Picture of heart) * VQ scan * Lower extremity venous Doppler * Pulmonary Ultra sound (US)– chest filled with air and US doesn’t do well with air but there is a new technique to use US for heart failure it is sensitive and specific NOTES: EDEMA! Diabetes ACS- nausea! (suspicion of MI--- Do work up for MI) REASON FOR EVERY TEST! KNOW WHAT TO DO IF IT’S positive OR negative **WHAT IS IT?** CHF

Answer 12

* Tx: * _Diuresis_ (gets them out of acute heart failure) * Oxygen * Possibly * ACE-I * Beta blocker (cardio protective for people who have had an MI) * Aldosterone antagonist (reduce fluid retention and people in heart failure) NOTES: CHF because they now have wall motion abnormality because they had an MI last week (remmeber from the case) Cant lay flat because of fluid and gravity Had the big one (MI) (last week) not having it now

Answer 13

* 2 dimensional image * Focus without a lens * Magnification * Alignment (must be straight on) * Crowding * Fluid and tissue density * Anatomical variation or abnormality (breasts)

Answer 14

* The standard chest examination * PA (Posterior-Anterior) and lateral chest x-ray * Films are read together * AP (Anterior- Posterior) portable or supine * AP/Lateral

Answer 15

Need distance to focus rays because there is no lens Only the straight rays make it

Answer 16

Always LEFT SIDE of patient against receptor Because of heart So put heart as close to receptor as we can get so that it is in focus as best as can

Answer 17

* Why PA and not AP? * Why left side against the film on the lateral view? o It diminishes the effect of blurring and magnification on the heart. •On the AP film, the heart shadow is magnified and blurred because it is an anterior structure. You want the heart to be as close to the receptor (plate) as possible, so must be facing backwards

Answer 18

* On the AP supine film there is more equalization (cephalization) of the pulmonary vasculature when the size of the lower lobe vessels are compared to the upper. * X Ray tube is closer to the receptor NOTES: AP- heart will be bigger Supine- equalize vasculature (cephalization) See vasculature more prominent in bases of lungs when standing (gravity)…. If we cephalization when standing--- heart failure **when patient laying supine it minics the cephalization and can look like pathology, but in fact its how the patient was positioned so need to know this when interpreting the xray**

Answer 19

AP is a tougher xray to read and harder to interpret since farther away from the receptor

Answer 20

* Turn off stray lights, optimize room lighting * Patient Data (name, date, old films) * Routine Technique: oAP/PA oSupine, erect, portable •Quality issues o Inspiration o Exposure/penetration o Rotation

Answer 21

•The patient should be examined in **full inspiration.** o Diaphragm at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib.

Answer 22

•A good PA film oThe thoracic spine disc spaces should be barely visible through the heart but bony details of the spine are not usually seen Look at spine disc spaces… want to make sure they are a little visible through heart

Answer 23

left- over penetration (removes details, makes it so you miss something) right- under penetrated (everything looks brighter, can't interpret this)

Answer 24

•Observe that the spine appears to darken as you look caudally. o This is due to more air in lung in the lower lobes and less chest wall. •The sternum should be seen edge on. Want to see spinal canal and more seen as you go down caudally

Answer 25

* The patient must be imaged flat against the cassette * If there is rotation of the patient, the structures may look very unusual * Observe the clavicular head alignment with spinous process NOTES on Picture: * Clavicle front * Spinous process back * So to see if they are turned can see that it wont be middle

Answer 26

OMG KNOW YOUR ANATOMY ## Footnote In front LUL goes all the way to bottom!!!! no way! that's crayzeee

Answer 27

•Conduct a directed search o Avoid simply gazing at the film o Have a planned search in mind

Answer 28

* Lungs: Trachea, L & R mainstem bronchi, abnormal shadowing, or lucency * Pleura: effusion, thickening, calcification * Heart: thorax: heart width \> 2:1 ? Heart Borders. Cardiac configuration? * Mediastinum: contour, width, mass? * Hila: masses, lymphadenopathy * Pulmonary vessels: artery or vein enlargement * Soft tissues: subcutaneous emphysema, mastectomy * Bones: lesions or fractures

Answer 29

Emphysema ## Footnote Chronic obstructive pulmonary disease Barrel chest Lower hemi diagrams (flattened) Looks over exposed

Answer 30

Pleural Effusions Air goes up fluid goes down Cant see the costaphrenic angle and meniscus from fluid (this would be seen in the corner between the diaphram and the ribs, in Pleural effusion this is obliterated)

Answer 31

Large Pleural Effusion Now a bucket of fluid and an air fluid line on the left side the line at the top is the key to differentiate between conslidation like pneumonia, it has pushed everything to the right side

Answer 32

Pneumothorax Lines markings inside and no markings outside, look for visceral line \*\*make sure expiratory view!\*\*

Answer 33

Right Sided Pneumo-thorax Right side… all open space

Answer 34

Resolved Pneumo-thorax with Sub Q air ## Footnote A lot of sub Q emphysema Don’t want air under left diaphragm…. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Great explanation from Ruth: :) "I'm pretty sure the air under the left diaphragm is gastric air - the sub Q air is the grainy texture throughout the right and mid torso, very diffuse. He described it as "rice crispies" under the skin that popped and crackled."

Answer 35

Right sided tension pneumothorax o Right sided lucency o Leftward mediastinal shift o **This is a medical emergency**

Answer 36

* One of the most useful signs in chest radiology * Elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung * Most commonly associated with infiltrates * If an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border * Commonly applied to: * Heart * Aorta * Chest wall * Diaphragm NOTE on X-RAY Border of something is obscured in chest

Answer 37

Silhouette Sign * The right heart border is silhouetted out * Which lobe does the infiltrate affect? infiltrative process, but you can't tell which lobe since all the lobes (think about bates picture) overlap here, you can't tell

Answer 38

you can tell where the consolidation is here because you think about the structure of the lung. the fluid/pus or whatever is stays here because its is contained within one lobe, thats why its not all the way at the bottom near the diaphram

Answer 39

Burring of right hemi diaphragm so right lower lobe …. Silhouette

Answer 40

what was said in class:R oblique fissure BUT confusing card but pneumonia looks like RUL

Answer 41

again said this in class R oblique fissure but looks like RUL

Answer 42

R oblique fissure Because of aorta being obscured

Answer 43

•60 year-old male with shortness of breath and orthopnea o _Cardiomegaly_ o Marked prominence of the pulmonary vascularity o Increased density in the small vasculature and alveolar spaces o _Kerley B lines_ **HEART FAILURE**– heart dilates and gets bigger (hypertrophy or dilation--floppy bag) **Bronchial cupping--**can see thickness of it because full of fluid

Answer 44

Post Operative Acute Pulmonary Edema

Answer 45

Severe HF: Before and after treatment Heart failure from heart Cardiomegaly

Answer 46

* Imaging/procedural testing * PFTs (peak flows) * VQ scan * Chest CTA (CT scan with pulmonary angiography) * Thoracic US * MRI (rarely for chest unless looking for masses) * Bronchoscopy * Thoracoscopy * Thoracentesis (pulling fluid out) * Echocardiagram

Answer 47

Pulmonary function test Used for obstructive disease \*\*pay attention to the first image on the left, the exhale loop above the x axis, thats normal, but when see the second line, it is characteristic of obstructive lung disease\*\*

Answer 48

VQ Scan Showing PE ## Footnote Nuclear imaging …. Vs…. Perfusion Whole lung is ventilated but not perfused So embolism blocking that

Answer 49

Chest CTA showing PE Dark area where not perfusing LOT

Answer 50

bullus emphasema CT BIG BALLS OF EMPHYSEMISIS CHAnGES… WHERE SURFACE AREA IS GONE

Answer 51

* CBC, CMP * D-Dimer * ABG * Fluid studies o Cytology o Culture o Other

Answer 52

pnuemonia She said this like 93840928 times during class so think you might want to know it....

Answer 53

1. the lumen gets narrower 2. the muscles around the tube contract

Answer 54

you want them to exhale completely because it hightlights where there is more air usually for lung xray, you have the patient inhale all the way, but that will hide the pneumothorax, so you need t ohave the patient exhale compeltely and then it wil highlight it

Answer 55

2-3 observe \>3 decompress can do this by needle aspiration or chest tube

Answer 56

coronary syndrome....Heart failure!!! which leads to pulmonary edema!!!

Answer 57

it will be more opaque because of breast tissue this is important to keep in mind because you don't want to confuse this opacity with pathologic disease

Answer 58

BEHIND THE HEART this is important

Answer 59

1) Spirometry : Measure Volume of Air Movement 2) Body Plethysmography: Total Lung Capacity + Residual Volume 3) Inhalation Challenge Tests: Nebulized Meds Followed by Spirometry 4) Exercise Stress Tests: Followed by Spirometry

Answer 60

1) Arterial Blood Gas 2) Carbon Monoxide Diffusion Capacity (DLCO)

Answer 61

* Measures Amount of O2 + CO2 in Blood * Measure Acidity + Alkalinity * Avoid Unless Necessary (Invasive)

Answer 62

Measures How Well Lungs Transfer CO into Blood

Answer 63

Degradation Product of Fibrin – Indicates Ongoing Activation of Hemostatic System Reference [Concen] \< 0.5 ug/mL FEU **Causes of Elevated D-Dimer:** * Pregnancy * Rheumatoid Arthritis * Trauma * Elevated Triglycerides * Heart + Liver Disease 1. Clinical Setting Where There is a Need to R/o Thrombotic Cause of Symptom 2. Never Rely SOLELY on a D-Dimer to R/i or R/o a **Pulmonary Embolus** (Helps to Exclude Dx – Not Make One) 3. A D-Dimer(-) is Most Valid and Useful When Test is Completed on People Who are Low Risk for Thrombosis

Answer 64

Can Detect Pulmonary Embolism

Answer 65

Can Detect Abnormalities Well picture: pulmonary embolism

Answer 66

* Small Amount of Radioactive Material to Study Ventilation + Perfusion * Radioactive Material is **Inhaled** – Allowing the Capture of Images of Air Movement within Lungs

Answer 67

Gold Standard dx PE * Provides Very Clear Image of Blood Flow within the Lungs * Usually Performed AFTER Other Tests FAIL to Provide Answers * Potentially **Serious Risks** – Heart Arrhythmia, Renal Damage from Dye

Answer 68

Right Saddle Embolus Bridges Across the Pulmonary Artery From Heart as it Divides into Right + Left Pulmonary Arteries – Causes Sudden Death

Answer 69

CT angiogram

Answer 70

R/o Pulmonary Embolism in **Pregnancy/Allergy** * Traditionally Reserved for Pregnant Women or Patients with Renal Disease (Pulmonary Angiogram Too Risky) * Use of Helium-3 + Other Gases Have Greatly Increased the Value of MRI

Answer 71

Direct Visual Exam of **Larynx + Upper Airway** * Investigate Suspected Bleeding * Sample Tissue if Cancer Suspected * Sample Fluid to ID Pathogens * Assess Burns + Smoke Inhalation

Answer 72

Collect Specimens from Smaller Airways + Alveoli that Cannot be Visualized **(Fluid Exam)** * Saline Infused, Suctioned, Examined * May Reveal Neoplastic Cells * Fluid Cultured to Determine Pathogen

Answer 73

Visual Examination of **Lung + Pleural Spaces** * Video Assisted Thoracoscopic Surgery VATS * Obtain Tumor Samples

Answer 74

Removal of Fluid in Pleural Space **(Effusion)** * Main 2 Reasons Done – Relieve SOB + Obtain a Sample for Diagnostic Testing Complications (Low Risk) – * May Puncture Lung * Cause Pneumothorax * Puncture Spleen or Liver

Answer 75

1. Ask yourself what you will gain 2. Never go “searching” without a reason – use your clinical skills to determine differential diagnosis 3. Select the test based on your differential diagnosis

Answer 76

* Rales/crackles * **Symmetric Findings** * Occurs first in most dependent portion of lower lobes * As disease progresses, sounds heard throughout

Answer 77

* Rales/crackles * **Heard over distinct area, restricted to a specific lung region** * The consolidation associated w/ pna causes central lung sounds to be heard in periphery (use “eee” and “aaah” tests to determine if this is occurring) * Tactile Fremitus Increased

Answer 78

Distinct, harsh, diffuse crackles (think of Velcro)—Looks like cob webs

Answer 79

* Rhonchi * Cough \>5 days * Airway passages are inflamed * Tip: Don’t always need abx (viral)

Answer 80

_Severe:_ * Breathing will produce very little sound * Wheezing in severe emphysema indicates a superimposed acute inflammatory process

Answer 81

* Decreased tactile fremitus * Dullness to percussion * Absence of breath sounds

Answer 82

Chronic Bronchitis + Emphysema _Chronic Bronchitis:_ Cough & Sputum most days of 3mo of two successive years _Emphysema:_ Loss of elastic recoil of lung & histologic changes of small airways & destruction of walls of alveoli _Nat’l Inst for Hlthcre Excell Dx Crit:_ * Age \>35 * Hx of Smoking * Long standing production of sputum, cough, SOB w/o clear variations throughout the day

Answer 83

_Pink Puffers:_ * have good ventilation of alveoli * Near normal O2 * Low/normal CO2 in blood * No cyanosis _Blue Bloaters:_ * Poor ventilation of alveoli * Low oxygen * Heart failure common

Answer 84

Inflammation of airways **Constriction of flow** Often present w/ increased RR & HR (working hard to breath) Intercostal Retractions (Pediatrics) **Wheeze** _Critical Hx in Acute Asthma Pts:_ * “Have you ever been intubated?” * **Prior need for intubation should increase your suspicion of severe dz** * Any hx of IC admission for asthma? * 3 or more ED visits, 2 or more admissions in the last year * The hx should put you on alert that this pt could decompensate rapidly _Tips:_ * **Carefully assess tactile fremitus, breath sounds, & perussion** * It is the combination of these findings which will help you differentiate between diagnosis * You may have to do the exam components more than once to work out what is going on **_Red Flags:_** * Cyanosis * Decreased level of activity awareness * Rapid Pulse * Severe anxiety * Sweating * Increased time for expiration (doubles that on inspiration) _Further Testing:_ * PulseOX-measures oxygen sat (at rest&ambulation) * Measurement of distanced walked in certain time * Have the pt attempt stair climbing (watch for SOB) * This indicates the pt’s functional status **Chest XRAY “Gold Standard”** _CT Scan_- used to evaluate finding on CXR or in trauma setting w/ obv injury or if pt obviously very ill, but no findings on CXR _MRI_-used less frequently-typically to take a closer look at a tumor, adjunct structures

Answer 85

Pulmonary Edema \*\*there is fluid on the inside of the lungs, so you on't see the fluid where the lungs are, not in the costoverteral angles like pleural effusion...starts at the bottom of the lungs because the fluid falls to gravity :)\*\*

Answer 86

Pulmonary Fibrosis

Answer 87

bronchitis

Answer 88

pleural effusion

Answer 89

Pink puffer

Answer 90

blue bloater

Answer 91

**Inspection/ Observation:** * Breathing Pattern (fast, slow, shallow, struggling, etc) * Use of Accessary Muscles * Color of nail beds, skin * Cyanosis of Nail Beds * Perioral Cyanosis * Deformity? (Pectus excavatum) * Tripod position **Anatomy:** * Anterior View: RUL, LUL, RML, RLL, LLL * Right Lateral View: RUL, RLL, RML * Left Later View: LUL LLL **Palpation:** * Assess for tenderness * Equal Expansion * Tactile Fremitus * Consolidation: When normally air filled lung becomes engorged w/ fluid or tissue (i.e pna). Fremitus becomes more PRONOUNCED. * Pleural Effusion: Fluid collection in the potential space that exists between the lung and chest wall. Displaces lung upwards. Fremitus over effusion is DECREASED. **Percussion:** * _Generally:_ * Resonant over air * Dull over fluid or tissue * _Pleural effusions/ pneumonia:_ * Deadened tone * _Chronic (emphysema) or acute (pneumothorax_ * Hyper-resonant (drum-like) * _Tip_: Try doing percussion quickly-it will sometimes assist you in hearing the different tones **Ausculatation:** _Right lower lobe:_ Heard best in right axilla _Lower lobes:_ Bottom ¾ of the posterior fields _Upper lobes:_ Anterior chest and top ¼ of posterior fields _Vesicular(Normal):_ Soft sound of rushing air on inspiration, no, or minimal sound, on expiration. _Wheezing (lower airway):_ Whistling sound secondary to air being forced through narrowed airways _Strider_: Wheezing heard only on inspiration and typically caused by mechanical obstruction at level of trachea/upper airway (epiglottis) _Rales/Crackles:_ Scratchy sounds-occur in assoc w/ processes that lead to fluid accumulation in alveolar & interstitial spaces (Pulm edema) _Rhonchi:_ Gurgling type sounds (slurping thru a straw) _Egophony:_ * Increased resonance of voice sounds transmitted through consolidation or other abnormal areas * High nasal quality * Patient says “eee”; you hear “eee” over healthy lungs * over consolidation it sounds like “aaay”

Answer 92

RR is about 14-20 per min in normal adults and upto 44 per min in infants

Answer 93

slow breathing slow breathing may be secnodary to diabetic coma, durg induced repiratory depression, and increased intracranial pressure

Answer 94

breathing punctured by frequent sighs should alert you to the possibility of hyperventilation syndrome- a common cause of dyspnea and dizziness. ocassional sighs are normal

Answer 95

rapid shallow breathing Rapid shallowing breathing has a number of **causes**: * restircitve lung disease * pleuritic chest pain * elevated diaphragm

Answer 96

* Periods of deep breathing alternate with periods of apnea (no breathing). * children and aging people normally may show this pattern in sleep * Other causes * heart failure * uremia * drug induces repiratory depression * brain damage (typically on both sides of the cerebral hemispheres or diencephalon)

Answer 97

* In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to air flow. * Casues: * asthma * chronic bronchitis * COPD

Answer 98

Rapid Deep Breathing * Casues * exercise * anxiety * meatbolic acidosis * in comatose patient consider * infarction * hypoxia * hypoglycemia affecting midbrain or pons

Answer 99

deep breathing due to metabolic acidosis may be fast, normal in rate or slow

Answer 100

Biot's breathing * unpredictable irregularity * breaths may be shallow or deep, and stop for short periods * casues * repiratory depression * brain damage medullary level

Answer 101

from partial airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body

Answer 102

Mucoid: white or gray Purulent: yellow or green

Answer 103

anaerobic lung abscess tenacious sputum in cystic fibrosis

Answer 104

bronchiectasis or lung abscess

Answer 105

Rare: infants, children, adolescents common: cystic fibrosis

Answer 106

Stomach blood is draker and mixed with food particles compared to that or Resp. tract

Answer 107

* coronary artery disease: 2-4 X higher * Stroke: 2-4 X higher * Peripheral vascular disease: 10 time higher * COPD Mortality: 12-13 time higher * Lung Cancer mortality: 23 times higher in men, 13 times higher in women

Answer 108

Ask about tobacco use Adivse to quit Assess willingness to make a quit attempt Assist in quit attempt Arrange follow up

Answer 109

**Precontemplation-** I dont want to quit **Contemplation-** i am concerned but not ready to quit now **Preparation-** I am ready to qut **Action-** I just quit **Maintenance-** i quit 6 months ago

Answer 110

* bronchiectasis * congenital heart disese * pulmonary fibrosis * cystic fibrosis * lung abscess * malignancy

Answer 111

high pitched wheeze ominoous sign of upper airway obstruction in larynx or trachea

Answer 112

pneumothorax pleural effusion atelectasis

Answer 113

chronic fibrosis of the underlying lung or pleura

Answer 114

* unilateral pleural effusion * pneumothorax * neoplasm due to decreased transmission of low frequency sounds

Answer 115

* unilateral pneumonia increased transmission through conolidated tissue

Answer 116

dullness replaces resonance when fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussing fingers * lobar pneumonia (the alveloi are filled with fluid and bloof cells * pleural accumulations of serous fluid (pleural effusion) * blood (hemothorax) * Pus (empyema) * fibrous tusse * tumor

Answer 117

heard over the hyperinflated lungs of COPD and asthma _unilateral hyperressonace_ siggests a large pneumothorax or a large air filled bulla in the lunh

Answer 118

abnormally high level suggests pleural effusion or a high diaphragm as in atelectasis or phernic nerve paralysis

Answer 119

alight it is probably due to the excessive amount of chest hair.....get out the wax... you have to wax this patient just kidding! either press harder or wet the hair! never listen over clothes!

Answer 120

you may hear muscle contraction sounds- muffled low pitched rumbling or roraring noises change the patients position

Answer 121

inspriatory and expiratory sounds are about equal often heard in 1st and 2nd interspaces anteriorly and between the scap

Answer 122

expir. sounds last longer than inspiratory ones insitiry of expir sound: loud Pitch of expir sound: relativ. high heard over manubrium

Answer 123

inspir and expiratory sounds are about equal intensity of expir: very loud pitch or expir: relativ. high heard over the trachea in the neck

Answer 124

bronchitis atelectasis

Answer 125

abnormal. in lungs: pneumonia, fibrosis, early HF Abnorm. in airways: bronchitis, bronchiectasis

Answer 126

narrowed airways asthma COPD bronchitis

Answer 127

secretions in large airways

Answer 128

wheezing hx of smoking, age and decreased breath sounds diagnosis: spirometry and other pulm testing

Answer 129

louder voice sounds

Answer 130

sit leaning forward lips pursed during exhalation arms supported o their knees or a table

Answer 131

pleural fluid usuall sinks to the lowest part of pleural space (posteriorly in a supine patient)

Answer 132

behind right breast!

Answer 133

* **process**: inflammation of trachea and large bronchi * **Location**: upper sternal or on either sife of the sternum * **quality**: burning * **severity**: mild to mod * **timing**: variable * **aggrevating factors**: coughing * **relieving factors**: lying on the involved side * **associated symptoms**: cough

Answer 134

* **process:** inflamm. of the pariteal pleura like in pleurisy, pneumonia, pulm infarction, neoplasm * **Location:** chest wall overlying the process * **quality**: sharp, knife like * **severity**: severe * **timing**: presistent * **aggrevating factors:** deep inspiration, coughing, movements of the trunk * **relieving factors**: n/a * **associated symptoms:** underlying illness

Answer 135

* **process**: excessie mucus prodiction in bronchi, followed by chronic obstuction of airways * **timing:** chornic productive cough followed by slowly progressive dyspnea * **aggrevating factors**: exertion, inhaled irritants, repir. infections * **relieving factors**: expectoration; rest, though dyspnea may become persistent * **associated symptoms**: chronic productive cough, recurrent resp. infeciton, wheezing * **setting**: Hx smoking, air polluntants, recurrent resp infections

Answer 136

* **Process**: * overdistention of air spaces distal to terminal bronchioles, * destuction of alceolar septa, * alveloar enlargement and * limitaiton of expiratory air flow * **timing**: * slowly progressive dyspnea * mild cough later * **aggrevating factors**: exertion * **relieving factors:** rest * **associated symptoms:** cough, scant mucoid sputum * **setting**: smoking, air pullutants, familial deficency in alpha1-antitrypsin

Answer 137

* **Process:** * reversible bronchial hyperresponsiveness involving release of inflamm. mediators * increased airway secretions * bronchoconstrition * **Timing:** * acute episodes seperated by symp free periods * nocturanl episodes common * **Aggrevating Factors:** * variable, allergens, irritants, resp infec, exercise, emotion * **Relieve:** seperation form aggravating factors * **Assoicated symp:** wheezing, cough, tightness * **setting:** envir and emotion conditions

Answer 138

* **Process:** inflamm of lung parenchyma from the respiratory bronchioled to the alveoli * **Timing:** acute illness * **associated symptoms:** * pleurtic chest pain * cough * sputum * fever * **setting:** varied

Answer 139

* **Process**: leakage of air into pleural space through blebs on visceral pleura, resulting partial or complete collapse of lung * **timing:** suden onset of dyspnea * **associated symptoms**: pleurtic pain, cough * **setting:** often previously healthy young adult

Answer 140

* **Process:** sudden occlusion of all or part of pulmonary arterial tree by a blood clot that usually orginates in deep veins of legs or pelvis * **timing:** sudden onset of dyspnea * **associated symptoms:** often none. * pleurtic pain * cough * hemoptysis may follow embolism is pulmonary infarction ensues * symptom of anxiety * **setting**: * postpartum or postopertive * bed rest * HF * chronic lung disease * fractures of hip/leg * DVT

Answer 141

* **Process**: overbreathing, resultant respiratory alkalosis * fall in arterial partial pressure of Carbon Dioxide * **timing**: episodic, recurrent * **Aggrevating**: at rest, upsetting event may not be evident * **Relieving:** breathing in and out of a paper of plastic bag may help * **associated symptoms:** * sighing * lightheadedness * numbness/tingeling of hands and feet * palpitations * chest pain * **setting**: often manifestations of anxiety may be present, such as chest pain daiphoresis, palpations

Answer 142

* **Laryngitis:** * ****Dry cough (no sputum) * may become productive * acute * minor illness with hoarseness * associated with viral nasopharyngitis * **Tracheobronchitis:** * ****dry cough * may become productive * acut * viral illness * burning retrosternal discomfort * **Mycoplasma and Viral Pnemonias** * ****dry hacking cough * productive with mucoid sputum * acute febrile illness * malaise * headache * possibe dyspnea * **Bacterial Pnemonia** * ****Pneumococcal: sputum mucoid or purulent * **blood streaked** * **diffusely pinkish** * **rusty** * *KLEBSIELLA:* stick red and jelly-like (typically occurs in older alcoholic men) * acut illness with chills * high fever * dyspnea * chest pain * ususally proceded by acute upper resp. infection

Answer 143

* **Postnasal Drip:** * chronic cough, mucoid or mucopurulent * repeated attempts to clear throat * seen in post. pharynx * associated with allergic rhinitis * **CHronic Bronchitis** * ****chronic cough, mucoid or purulent * **blood streaked or even bloody** * hisroty of smoking * recurrent superimposed infections * wheezing/dyspnea may develop * **Bronchiectasis:** * ****chronic chough * purulent * copious * foul smelling * **blood streaked or bloody** * recurrent bronchopulmonary infection * sinusitis may coexist * **Pulmonary Tuberculosis** * ****cough dry * mucoid or purulent * **blood dtreaked or bloody** * early no symp. * later: anorexia, weight loss, ftigue, fever, night sweats * **LUng abscess:** * ****purulent * foul smelling * **bloody** * febrile * poor dental hygiene * prior episoe of impaired consciousness * **Asthma** * cough * thick mucoid (near end of an attack) * wheezing * dyspnea * cough may occur alone * hx of allergy * **gatroesophageal refux** * ****chronic cough * nigh or early monring * wheezing (night) * early morning horseness * repested attempts to clear throat * history of heart burn and regurgitation

Answer 144

* cough dry to productive * **blood streaked or bloody** * hx of smoking * dyspnea * weight loss

Answer 145

often dry cough (specially on exertion of at night) **PINK FROTHY SPUTUM**

Answer 146

* dry to productive * may be **dark** * **bright red** * **mixed with blood** * dyspnea * anxiety * chest pain * fever * factors that predispose to DVT

Answer 147

* thorax should be wider than deep * lateral is larger than it AP diameter

Answer 148

* depression in lower portion of the sternum * compression of the heart and great vessels may cause murmurs

Answer 149

* increased AP diam. * shape is normal during infancy * accompanies aging and COPD

Answer 150

* sternum siplaced anteriorly * increased AP diameter * costal cartilages adjacent to protruding sternum are drepressed

Answer 151

* multiple rib fractures= results in paradoxical movements of the thorax * on inspiration injured area curved inward * expiration area moved outward

Answer 152

* abnormal spinal curvature and vertebral rotation defrom chest * sitortion of underlying lungs -interpretations of lung findings may be difficult

Answer 153

1. result of series of tiny explosions when small airways, deflated during expiration, pop open during inspiration * explains the late inspirartoy crackels of intersitial lung disease and early HF 2. crackles result from air bubles flowing through secresions or lightly closed airways during respiration * explains at least some coarse crackles **Late Inspiratory crackles:** appear first at base of lungs spread upwar as the condition worsens ie. intersitual lung diease (pulm fibrosis) and HF **Early inspirartory crackles:** coarse ie. chronic bronchitis, asthma **Midinspiratory and expiratory crackles:** heard in bronchiectasis (not specific for this diagnosis however)

Answer 154

* when air flows rapidly thorugh bronchi that are narrowed nearly to the point of closure * sometimes can hear at the mouth as well as chest wall * asthma : heard only in expiration or in both phases of the respiratory cycle * COPD * HF * Rhonchi: suggest secretion in larger airways * chronic bronchitis: you can clear wheezes and rhonchi with coughing

Answer 155

sometime in **severe obstructive pulmonary disease** patietn is unable to force enough air through the narrowed bronchi to produce wheezing. resulting in *silent chest* this is ominous and warratns immediate attention

Answer 156

patrial obstuction of a bronchus seen with tumor or foreign body may be inspir. or expir. or both

Answer 157

* **wheeze that is entirely or predominantly inspiratory** * louder in the neck than over the chest wall * indicated partial obstruction of the larynx or trachea * immediate attention

Answer 158

* inflamed or roughened pleural surface grate against each other as they are momentarily and repeatedly delayed by increase friction * creaking sounds * usually during expiration * resemble crackles but produced by diff athologic processes. * dicrete... sometimes can merge into continuous sound * confined to small area of chest wall * heard on both phases of respiration * when inflammed pleural surfaces are seperated by fluid and sound disappears

Answer 159

* series of precordial crackles synchronous with heart beat not with respiration * best heard on left lateral position (due to mediastinal emphysema)

Answer 160

bronchi chronically inflammed and productive cough is present. airway obstruction may develop * Percussion: resonant * Breath Souds: vesicular * Advenitious sounds: none (or scattered coarse crackles in early inspriation and perhaps expiration, or wheezes or rhonic) * Tactile frem/voice sounds: normal

Answer 161

increased pressure in the pulm viens casues congestion and intersitial edema * percussion sound: reson. * breath sounds: vesicular * adventitious sounds: late inspir. crackles in deendent portions of lung, possible wheeze * tactile fremitus/voice sounds: normal

Answer 162

Alveoli dill with fluid aor blood cells, as in pneumonia, pulmonart edema, or pulmoary hemorrhage * percussion sound: dull over the airless area * breath sounds: bronchial over involved area * adventitious sounds: Late inspiratory crackles over involv. area * tactile fremitus/voice sounds: increased over involv. area with bronchophony, egophony, and whipered pectoriloquy

Answer 163

when a plug in a mainstem bronchus obstructs air flow, affected lung tissue collapses into an airless state trachea may be shifted toward involved side * percussion sound: dull over airless area * breath sounds: usually absent when bornchial plug persists. expetion is upper right lobe atelectasis where adjacent tracheal sounds may be transmitted * adventitious sounds: none * tactile fremitus/voice sounds: usually absent when the bronchial plug persists. exception (R. upper love atelectasis) may be increased

Answer 164

fluid accumlates in the peural space, speerated air filled lung from the chest wall, blocking the transmission of sound trachea may be shifted away from large effusion * percussion sound: dull to flat over fluid * breath sounds: decreased to absent, bornchial breath sounds may be heard near top of large effusion * adventitious sounds: none * tactile fremitus/voice sounds: decreased to absent, may be increased toward top of a large effusion

Answer 165

when air leaks into the pleural space, usually unilaterally, lung recoils from the chest wall. pleural air blcks transmission of sound trachea shifted toward opposite side if much air * percussion sound: hyperresonant or tympanic over the pleural air * breath sounds: decreased to absent over pleural air * adventitious sounds:none * tactile fremitus/voice sounds: decreased to absent over pleural air

Answer 166

slowly pogressive disrder in which the distal air spaces enlarge and lungs become hyperinflated. chronci bronchitis is often assoiated * percussion sound: hyperresonant * breath sounds: decreased to absent * adventitious sounds: none, or the crackles, wheezes, and rohonchi or assoiated chronic bronchitis * tactile fremitus/voice sounds: decreased

Answer 167

widespread narrowing of the trachobronchial tree diminshs air flow to a fluctuating degree. during attacks air flow decreases further and lungs hyperinflate. * percussion sound: resonant to diffusely hyperresonant * breath sounds: often obscured by wheezes * adventitious sounds: wheezes, possibly crackles * tactile fremitus/voice sounds: decreased

Answer 168

* Age: 5 or older * advantages: * newer inhaler have a dose counter * delivery of medication in less than 2 min * portable durable * lower medication dose needed vs neb * diadvantages * older inhalers do not have dose counter * techinique and coordination may be difficult * propellant may taste bad or irritate airways

Answer 169

* Age * if less then 4 use VHC with mask * 4 or older use VHC * advantages: * VHC enhances MDI tech * VHC decreased topical side effects of inhaled corticosteriods (ICS) * albuterol MDI with VHC is as effective as neb for asthma exacerbation * diadvantages: * bulky * lack of coverage by some insurance * limited testing * potential for increased systemic side effecxts with inhaled corticosteriod (ICS)

Answer 170

* Age: any age, usually infants or elderly * advantages: * no coordination * O2 may be dellivered simutaneously with medications * diadvantages * requires 5-15 min to deliver med * limited number of medications available for neb * not portable

Answer 171

* Age: any age, usually infant or elderly * advantages: * more portable than jet neb * faster delivery of meds than jet neb * diadvantages * heat generated from neb breaks down suspension for nebulization * do not use with budesonide suspension for nebulization

Answer 172

* Age: * Aeroizer: 5 and older * diskus: 4 years of age and older * flexhaler: 6 years and older * twisthaler: 12 years and older * advantages: * easy to use * has dose counter * sweet taste * quick delivery of med * diadvantages * limited porfict stability 30-45 days after opening * optimal delivery of medication in children less than 4 years old is not feasible because high inspiratory volume needed * amount of lactose filler is insuficent to cause concern in lactose intolerance

Answer 173

1. remove cap and shake 2. exhale all air away from the inhaler 3. place mouthpiece in mouth with lips tightly around inhaler 4. to deliver: push down on the canister **one time** while inhaling a slow steady breath. a puff or mist of medication id sprayed out of the inhaler into the mouth 5. hold breath for 10 seconds 6. exhale 7. wait 1 min. if the dose is to be repeated 8. recap the inhaler when done 9. rinse your mouth with water if the medication is an inhaled corticosteroid. Remember: * prime the MDI the first time it is used or its beeen more then 10 days. Prime the inhaler by spraying 4 sprays into the air * for patients who cannoy hold their breath for 10 seconds, instruct them to hold their breath as long as possible * do not immerse the canister of medication in water at any time * if a counter is not availble on the inhaler, the patient should tally the numbers of puffs used to determine when the inhaler is empty

Answer 174

* Peak flow meters measure your peak expiratory flow rate (PEFR), a number that correlates with how open the lung's airways are * as asthma worsens and the airways narrow, the **PEFR decreases.** * Monitoring can help you (the patient) and your healthcare provider determine the most appropriate asthma treatment plan. The patient needs to be aware of this to help with management: The management of asthma relies on a patient's ability to monitor their asthma regularly. Self-monitoring includes assessing the frequency and severity of symptoms (such as wheezing and shortness of breath) and measurement of lung function with a **peak flow meter**.

Answer 175

* Experts recommend that people with moderate to severe persistent asthma have a peak flow meter at home and know how to use it * A peak flow meter is small, inexpensive, and easy for most patients to use. * patients should use a peak flow meter to: * Regularly monitor lung function and response to treatment over the short- and long-term * Determine the severity of an asthma attack * Assess response to treatment during an attack * asthma diary to record (This can help to show a cause-and-effect relationship between exposure to triggers and decreases in peak flow) * your daily peak flow meter readings * exposure to potential asthma triggers * asthma medication use * asthma symptoms

Answer 176

* Peak flow monitoring should be performed on a regular basis (even when asthma symptoms are not present) * Peak flow should also be checked if symptoms of coughing, wheezing, or shortness of breath develop.

Answer 177

* The peak flow meter should read zero or its lowest reading when not in use. * Use the peak flow meter while standing up straight. * Take in as deep a breath as possible. * Place the peak flow meter in the mouth, with the tongue under the mouthpiece. * Close the lips tightly around the mouthpiece. * Blow out as hard and fast as possible; do not throw the head forward while blowing out. * Breathe a few normal breaths and then repeat the process two more times. * Write down the highest number obtained. * Do not average the numbers. * IMPORTANT: Repeat the test if your tongue partially blocks the mouthpiece or if you cough or spit during the test.

Answer 178

* no "normal" peak flow measurement for everyone. * determine what peak flow value is normal for you. * Ideally, the baseline values should be obtained when the patient is feeling well after a period of maximal asthma therapy * To determine your normal peak flow measurement: * measure peak flow when you have no asthma symptoms. * Perform three measurements with the same peak flow meter two to four times daily for two to three weeks. * note the highest peak flow measurement achieved; this is the “personal best.” * This number is used to determine if future peak flow measurements are normal or low, and is also used to create a normal range (between 80 and 100 percent of the personal best peak flow measurement). * Readings below the normal range are a sign of airway narrowing in the lungs. * A low peak flow measurement can occur before asthma symptoms such as wheezing or shortness of breath develop. * Remeasure your personal best peak flow value once per year to account for growth or changes in the disease . * verify home peak flow measurements with readings taken with equipment in a healthcare provider's office since this equipment is more sensitive. * PEFR measurements should be periodically correlated with office spirometry, since the PEFR in some cases has been less accurate than measurement of FEV1 in detecting airflow obstruction. * **long term management=** peak flow testing once per day, usually in the morning.

Answer 179

* the PEFR percent predicted correlates reasonably well with the percent predicted value for the forced expiratory volume in one second (FEV ). * Monitoring the PEFR is useful for detecting changes or trends in a patient’s asthma control * significant testing variability makes it important to confirm or exclude airflow limitation with a more reliable test, such as spirometry * Self-monitoring can be performed by subjectively evaluating the frequency and severity of symptoms * Patients can gain further information by monitoring peak expiratory flow rates (PEFRs), which provide an objective measurement of airflow obstruction * can be performed accurately by most adults and children older than five years of age. * PEFR monitoring can provide the patient and clinician with objective data upon which to base therapeutic decisions

Answer 180

conflicting information and results ## Footnote A number of studies failed to demonstrate an advantage of using PEFR monitoring over symptom monitoring to guide self management actions

Answer 181

* The most conservative approach is to have patients monitor their condition using both objective and subjective measures * use a patient diary to record daily PFM readings and the presence of any asthma symptoms. * This dual approach may help patients observe a cause-and-effect relationship between exposure to triggers and decrements in peak flow and/or exacerbations of asthma. * The patient should understand that such monitoring is undertaken to check on the effectiveness of therapy and to give early warning of potential deterioration.

Answer 182

* PEFR values can be compared to age-, gender- and height -matched normal subjects * When determining predicted PEFR values, the reference values should be derived from a peak flow meter, rather than spirometric values * Spirometric values tend to be lower than peak flow meter predicted values

Answer 183

Asthma action plan

Answer 184

* It is suggested that a zone scheme similar to a traffic light system be used to illustrate a plan upon which patients can base self-management decisions: * **GREEN** (80 to 100 percent of personal best) signals "all clear". When readings are within this range and symptoms are not present, the patient is advised to adhere to his or her regular maintenance regimen. * **YELLOW** (50 to 80 percent of personal best) signals "caution", since the airways are somewhat obstructed. * The patient should implement the treatment plan decided upon with the clinician to reverse airway narrowing and regain control. * The wide range represented by the yellow zone can be subdivided above and below the 65 percent level if desired. * **RED** (below 50 percent of personal best) signals "medical alert". Bronchodilator therapy should be started immediately * clinician should be contacted if PEFR measures do not return immediately to the yellow or green zones.

Answer 185

(If the picture is too small I wrote it all out....the pictures never upload big enough) Top of form: * long term meds and dose and instructions * quick relief meds and instructions Bottom of form: Traffic light system Green: * i feel good! Personal best peak flow * PREVENT asthma symp. everyday * take long term control meds * before exercise that ___ puffs of \_\_\_\_ * avoid things that make asthma worse Yellow: * symptoms may be: wheeze, tight chest, cough, SOB, waking up at night, decreased ability to do usual activities * take \_\_\_\_\_ * still dont feel well and peak flow is not back up to green zone after one hour i should: * increase\_\_\_\_ * add\_\_\_\_\_ * call\_\_\_\_\_\_\_ RED: * i feel AWFUL * warning signs: its getting harder to breathe * unable to sleep or do usual acitivities because of breathing problem * MEDICAL ALERT... get help * take _____ until i get help immed. * take\_\_\_\_ * call\_\_\_\_\_ * DANGER! GET HELP IMMED. call 911 if you have trouble walking or talking due to SOB or lips and fingernails are gray or blue

Answer 186

* The peak expiratory flow rate (PEFR, also known as peak flow) is the maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration. * Monitoring the PEFR is useful for detecting changes or trends in a patient’s asthma control. * significant testing variability makes it important to use a more reliable test, such as spirometry, to confirm or exclude airflow limitation suggested by the PEFR. * When determining predicted PEFR values, the reference values should be derived from a peak flow meter, rather than spirometry. * The prolonged expiratory effort of spirometry tends to give a lower peak flow value than that obtained from the brief and rapid exhalation used with a peak flow meter. * PEFR values can be compared to age-, gender- and height-matched normal subjects * The predicted values for black and Hispanic minorities are approximately 10 percent lower than those shown in the tables on UP TO DATE * When instructing a patient on use of a peak flow meter at home, the first step is for the patient to demonstrate adequate peak flow technique. * patient is then asked to monitor and record their PEFR two to four times daily for two weeks, ideally during a time that their asthma is well-controlled. * At the next visit, the two-week baseline results are reviewed to determine that patient’s "personal best" PEFR value. * The personal best is generally the highest PEFR measurement achieved during this post-treatment monitoring period. * An individual patient's normal PEFR range is defined as 80 and 100 percent of their personal best. * This value is used to develop an "asthma action plan” * The frequency of peak flow monitoring depends on the needs of the individual patient.

Answer 187

* **Spirometry**: * most common of the lung function tests used for asthma. * It's a simple, quick, and painless way to check your lungs and airways. * You just take a deep breath and exhale into a hose attached to a device called a spirometer. * records how much air you blow out (FVC, or forced vital capacity) and how quickly you do it (FEV, or forced expiratory volume). * Your score is lower if your airways are swollen or constricted because of asthma or other lung diseases. * Your doctor may want you to have several spirometry lung function tests to monitor your asthma over time. * You might have spirometry before and after you take medication to see if the medication helps. * Your doctor may also want readings taken during exercise to see how your airways react to exercise. * **Peak Flow meter** * measure how well your lungs push out air. * less accurate than spirometry * good way to regularly test your lung function at home -- even before you feel any symptoms. * A peak flow meter can help you know what makes your asthma worse, whether treatment is working, and when you need to seek emergency care. * A peak flow meter is a handheld plastic tube with a mouthpiece on one end, which you breathe into.

Answer 188

* An **obstructive** defect is indicated by a **low** forced expiratory volume in one second/forced vital capacity (**FEV1/FVC**) ratio, * If obstructive defect is present, the physician should determine if the disease is reversible based on the increase in FEV1 or FVC after bronchodilator treatment * asthma is reversible after bronchidilator treatment whereas COPD is not * A **restrictive** pattern is indicated by a **low FVC** {below the fifth percentile (adults) or less than 80% (in patients five to 18 years of age). } * If a restrictive pattern is present, full pulmonary function tests with diffusing capacity of the lung for carbon monoxide testing should be ordered to confirm restrictive lung disease and form a differential diagnosis. * If **both** the **FEV1/FVC** ratio **and** the **FVC** are **low**, the patient has a **mixed defect**. * The severity of the abnormality is determined by the FEV1. * If pulmonary function test results are normal, but the physician still suspects exercise- or allergen-induced asthma, bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge, exercise testing) should be considered.

Answer 189

SPIROMETRY!

Answer 190

THIS MAKES IT ALL COME TOGETHER! SUCH A GOOD PICTURE! ITS IN THE ARTICLE FOR CA "A STEP-WISE APPROACH TO INTERPRETATION OFPULMONDARY FUNCTION TEST" IF YOU WANT TO GO FIND IT

Answer 191

(1) the volume-time curve reaches a plateau, and expiration lasts at least six seconds (2) results of the two best efforts on the PFT are within 0.2 L of each other (3) the flow-volume loops are free of artifacts and abnormalities. \*\*\*\*\*\*IF the patient’s efforts yield flattened flow-volume loops, submaximal effort is most likely; however, central or upper airway obstruction should be considered.\*\*\*\*\*\*\*\*\*

Answer 192

**Step 1: Determine If the FEV1/FVC Ratio Is Low** * GOLD STANDARD: cutoff is less than 70% * but some people say w/ symptoms if people between 5-18 can be ratio less than 85% * _ATS Criteria:_ can also us LLN (lower limit of normal) in adults - less than fifth percentile * if low= indicative of obstructive **Step 2: Determine If the FVC Is Low** * indicating a restrictive pattern, a mixed pattern (ratio and FVC low) **Step 3: Confirm the Restrictive Pattern** * If the patient’s initial PFT results indicate a restrictive pattern or a mixed pattern that is not corrected with bronchodilators, the patient should be referred for full PFTs with DLCO testing. * DLCO is a quantitative measurement of gas transfer in the lungs. Diseases that decrease blood flow to the lungs or damage alveoli will cause less efficient gas exchange, resulting in a lower DLCO measurement. **Step 4: Grade the Severity of the Abnormality** * should grade the severity of the abnormality based on the FEV1 percentage of predicted. _Severity_ _FEV1 percentage of predicted_ Mild \> 70 Moderate 60 to 69 Moderately severe 50 to 59 Severe 35 to 49 Very severe \< 35 **Step 5: Determine Reversibility of the** **Obstructive Defect** * determine if it is reversible based on the increase in FEV1 or FVC after bronchodilator treatment * asthma=reversible * COPD= not * if pt has mixed pattern and after bronchodilator treatment the FVC corrects itself (leaving you with only a low FEV1/FVC) then it is likely a pure obstructive lung disease with air trapping **Step 6: Bronchoprovocation** * If PFT results are normal but the physician still suspects exercise- or allergen-induced asthma, the next step is bronchoprovocation (methacholine challenge, a mannitol inhalation challenge, exercise testing, or sometimes eucapnic voluntary hyperpnea testing.) * When the FEV1 is 70% or more of predicted on standard spirometry, bronchoprovocation should be used to make the diagnosis. * If the FEV1 is less than 70% of predicted, a therapeutic trial of a bronchodilator may be considered **Step 7: Establish the Differential Diagnosis** **Step 8: Compare Current and Prior PFT Results**

Answer 193

* During the DLCO test, patients inhale a mixture of helium (10%), carbon monoxide (0.3%), oxygen (21%), and nitrogen (68.7%) then hold their breath for 10 seconds before exhaling. * The amounts of exhaled helium and carbon monoxide are used to calculate the DLCO. * Carbon monoxide is used to estimate gas transfer instead of oxygen due to its much higher affinity for hemoglobin. * A baseline hemoglobin level should be obtained before DLCO testing because results are adjusted for the hemoglobin level. * HIGH DLCO: asthma * NORMAL DLCO WITH RESTRICTIVE PATTERN: kyphoscolliosis, pleural effusion * NORMAL DLCO WITH OBSTRUCTIVE PATTERN: asthma, bronchiectasis, chronic bronchitis * LOW DLCO WITH RESTRICTION: asbestosis, isiopathic pulm. fibrosis, lymphangitic spread of tumor, tuberculosis, sarcoidosis * LOW DLCO WITH OBSTRUCTION: cystic fibrosis, emphysema * LOW DLCO WITH NORMAL PULMONARY FUNCTION TEST RESULTS: chronic pulm emboli, CHD, intersitial lung disease (early), pimary pulmonary hypertension

Answer 194

The methacholine challenge is highly sensitive for diagnosing asthma; however, its low specificity results in false-positive results. high sensitivity low specificity

Answer 195

The mannitol inhalation challenge has a lower sensitivity for the diagnosis of asthma or exercise-induced bronchoconstriction than the methacholine challenge, but has a higher specificity for the diagnosis of asthma. low sensitivity high specificty

Answer 196

A treadmill exercise test has excellent sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction, but has only modest sensitivity and specificity for the diagnosis of asthma. In this test, baseline spirometry is measured, followed by exercise on a treadmill. The goal is to achieve 80% to 90% of the maximum heart rate within two minutes, and maintain that heart rate for eight minutes. Inhaled medical-grade dry air or an air conditioned room. The patient must wear a nose clip.

Answer 197

1. **FEV1**: forced expiratory volume in one second; total volume of air a patient is able to exhale in the first second during maximal effort 2. **FVC**: forced vital capacity; total volume of air a patient is able to exhale for the total duration of the test during maximal effort 3. **FEV1/FVC ratio:** the percentage of the FVC expired in one second 4. **DLCO**: diffusing capacity of the lung for carbon monoxide 5. **EIB**: exercise-induced bronchoconstriction 6. **LLN**: lower limit of normal, defined as below the fifth percentile of spirometry data obtained 7. **TLC**: total lung capacity; the volume of air in the lungs at maximal inflation 8. **VC**: vital capacity; the largest volume measured on complete exhalation after full inspiration

Answer 198

**OBSTRUCTIVE** * α1-antitrypsin deficiency (seen in COPD) * Asthma * Bronchiectasis * Bronchiolitis obliterans * Chronic obstructive pulmonary disease * Cystic fibrosis * Silicosis (early) **RESTRICTIVE** * Chest wall * Ankylosing spondylitis * Kyphosis * Morbid obesity * Scoliosis * Drugs (adverse reaction) * Amiodarone * Methotrexate * Nitrofurantoin (Furadantin) * Interstitial lung disease * Asbestosis * Eosinophilic pneumonia * Idiopathic pulmonary fibrosis * Sarcoidosis * Silicosis (late) * Neuromuscular disorders * Amyotrophic lateral sclerosis * Guillain-Barré syndrome * Muscular dystrophy * Myasthenia gravis \*\*\*\*\* I know we dont have to know all these... it was one of the charts in the reading... just read it over once and you should be good! just nice to know some differential diagnoses!\*\*\*\*\*

Answer 199

Pulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) [HYPOXEMIA] in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose). do this in people with possible Pnemonia and obstructive lung diseases well can do with anyone but these are some emphasized ones

Clinical Assessment Module 3 Pulm Flashcards

(232 cards)