Pulm Flashcards

Question

Cor Pulmonale definition, sx, dx, tx

Answer 1

▪︎altered structure (i.e., hypertrophy, dilation) or impaired function of RV d/t pulmonary HTN resulting from a disorder of the respiratory or pulmonary artery system ACUTE: sudden ⇡ in RV afterload results in RV dilation & dysfunction S/SXS: acute onset ⇢ CP, SOB, hypotension, tachycardia, syncope CHRONIC: ⇡ RV afterload leads to progressive RVH that over time results in RV dilation & dysfunction S/SXS: peripheral edema, JVD, right ventricular heave, loud S2 dx ECHO: RV dilation, RVH, RV dysfunction Gold standard ⇢ RHC TX: heart failure medications, ASA, anticoagulation, O2

Answer 2

IPF: MC type of ILD, characterized by irreversible pulmonary fibrosis & impaired pulmonary function ▪︎MC affects men >40yo, smokers S/SXS: gradual onset DOE & dry cough over several months PE: bibasilar inspiratory crackles, digital clubbing PFTs ⇢ restrictive pattern: ⇣ FVC, normal FEV1/FVC, ⇣ DLCO dx CXR: ⇡ reticular markings HRCT: peripheral, basilar-predominant opacities associated w/ honeycombing & traction bronchiectasis-bronchiolectasis BX: honeycombing & traction bronchiectasis TX: supportive ▪︎smoking cessation, supplemental O2 ▪︎influenza/pneumococcal vaccines Antifibrotics: pirfenidone, nintedanib ▪︎may ⇣ mortality/acute exacerbations & slow decline in FVC Only cure ⇢ lung transplant

Answer 3

▪︎airborne asbestos fibers Risk Factors: shipping yards, demolition, insulation, mining, brakes S/SXS: exertional dyspnea MC ▪︎dry cough that transforms into productive ▪︎digital clubbing ▪︎bibasilar, fine end-expiratory rales dx CXR/HRCT ⇢ LOWER LOBES ▪︎pleural plaques, diffuse pleural thickening, effusion ▪︎reticular opacities +/- honeycombing Histology ⇢ ferruginous bodies in alveolar septa PFT: restrictive tx ▪︎removal from exposure, smoking cessation ▪︎supplemental O2, flu/pneumococcal VAX Complications: ⇡ risk of lung cancer

Answer 4

Acute: short-term exposure to a large amount, symptom onset weeks to years S/SXS: rapid onset ⇢ dyspnea, cough, weight loss, fatigue, +/- pleuritic CP & fever Chronic: long-term exposure, remain asymptomatic or symptom onset after decades S/SXS: cough (often productive), DOE dx CXR/HRCT ⇢ UPPER LOBES ▪︎multiple small (<1cm), solitary, rounded opacities ▪︎hilar/mediastinal LN enlargement ⇢ eggshell calcifications ▪︎bilateral diffuse ground-glass opacities BX ⇢ silicotic nodules: spiral appearance w/ hyalinized central zone composed of concentrically arranged collagen fibers tx ▪︎removal from exposure, smoking cessation ▪︎supplemental O2, flu/pneumococcal VAX Complications: ⇡ risk of TB ▪︎annual PPD recommended

Answer 5

S/SXS: most commonly asymptomatic Caplan Syndrome: pneumoconiosis + RA ▪︎cough +/- black sputum ▪︎arthralgia, morning stiffness ▪︎shortness of breath, chest tightness dx CXR/HRCT ⇢ UPPER LOBES ▪︎small, rounded, nodular opacities <1cm in diameter tx ▪︎removal from exposure, smoking cessation ▪︎supplemental O2, flu/pneumococcal VAX Complications: progressive massive fibrosis

Answer 6

Risk Factors: fluorescent light, dental, computer, & aerospace S/SXS: dry cough, SOB PE: cutaneous nodules, bibasilar crackles dx CXR/HRCT ⇢ UPPER LOBES ▪︎multiple small, rounded opacities that can calcify ▪︎upper lobe scarring w/ volume loss & bullae (late) Beryllium lymphocyte proliferation test (BeLPT): ⇡ uptake BX ⇢ noncaseating granulomas, mononuclear cell infiltrates TX: supportive + chronic systemic steroids

Answer 7

▪︎multisystem inflammatory disorder characterized by noncaseating granulomas in 1+ organs/tissues, ♀︎ > ♂︎ 2:1 ▪︎average onset 30-55yo, highest prevalence in Black Americans & northern Europeans, esp. Scandinavian ▪︎lungs MC affected organ (90%), lymph nodes MC extrapulmonary site (70-90%) PATHO: unknown antigen triggers cell-mediated immune response characterized by accumulation of T cells & macrophages, release of cytokines & chemokines, & organization of responding cells into granulomas S/SXS: often asymptomatic in early stages Pulmonary: cough, dyspnea, CP + fatigue, malaise, fever, weight loss Hepatic: LFT abnormalities, hypolucent lesions on CT Lymphadenopathy: hilar/paratracheal mediastinal adenopathy Neuro: cranial neuropathy ⇢ facial nerve palsy (VII), hearing loss (VIII) Cutaneous: papular, nodular, or plaque-like lesions Cardio: heart block, arrhythmias, HF, infarction, ▪︎erythema nodosum ⇢ painful nodules on anterior LE pericardial disease, sudden death

Answer 8

LABS: hypercalciuria, ⇡ ACE, hypergammaglobulinemia, ⇡ ESR PFTs: typically restrictive pattern, ⇣ DLCO CXR: bilateral hilar LAD (BHL) +/- pulmonary infiltrates (i.e., reticular &/or ground glass opacities) IV ⇢ diffuse pulmonary fibrosis (irreversible ⇣ lung function) ▪︎often associated w/ fibrotic-appearing conglomerate masses, traction bronchiectasis, & traction cysts Confirmatory ⇢ BX: noncaseating granulomas TX: glucocorticoids +/- DMARDs Glucocorticoids: prednisone

Answer 9

Community-Acquired Pneumonia (CAP) *outside hospital or within 48h of admission Viral Pathogens (“Atypical” Presentation): *RSV, influenza, parainfluenza *CMV, adenovirus, SARS-CoV-2 Nosocomial Pneumonia – Hospital-Acquired Pneumonia (HAP) *acquired >48h after admission – Ventilator-Associated Pneumonia (VAP) *acquired >48h after endotracheal intubation Pathogens (Nosocomial): *Pseudomonas aeruginosa (cystic fibrosis) *Enterobacter spp. *Acinetobacter spp. *S. aureus (esp. MRSA) RF: recent abx use, prolonged hospitalization (≥5d)

Answer 10

CAP: acute onset fever, cough (+/- sputum), dyspnea EXAM: tachycardia, tachypnea, crackles (rales), rhonchi – tactile fremitus, egophony, dullness to percussion *no clinical features reliably distinguish between different pathogens, but certain features can raise the index of suspicion for certain microbes Legionella: GI (N/V/D), hyponatremia, elevated liver transaminases, CPR >100mg/L Mycoplasma *MC in ambulatory setting S/SXS: gradual onset HA, malaise, low-grade fever +/- sore throat – cough (+/- sputum) follows, may have pleuritic CP/SOB *chest soreness from persistent coughing common complaint – ⊕URI SXS (rhinorrhea, otitis media, sinusitis, cervical LAD) Non-Respiratory Associated Disease: *autoimmune hemolysis (cold agglutinin disease), usually mild *mucocutaneous disease – erythema multiforme, SJS, other skin rashes, mucositis *mild hepatic transaminase elevations *arthralgias & myalgias Nosocomial: new lung infiltrate + ≥2 clinical features of infection S/SXS: new-onset fever, leukocytosis or leukopenia, purulent sputum, decline in oxygenation

Answer 11

LABS: CBC, CMP, CPR, procalcitonin *leukocytosis w/ left shift *procalcitonin <0.25ng/dL suggests viral ≥0.25ng/dL suggests bacteria CXR: AP + lateral views *lobar consolidations *interstitial infiltrates *cavitations VIRAL: bilateral, multifocal, patchy or ground-glass opacities *dense consolidations, pleural effusion & abscess should be absent BACTERIAL: dense lobar or alveolar consolidations Microbiology (only need if inpatient) *blood culture x2 *sputum gram stain + culture *S. pneumoniae urine antigen *PCR for Legionella *PCR for pneumonia (BioFire PN)

Answer 12

CURB-65 Assessment (1pt each) C – confusion U – BUN >19mg/dL (>7mmol/L urea) R – respiratory rate ≥30 B – SBP <90mmHg or DBP ≤60mmHg 65 – age ≥65yo 0-1: outpatient 2: admission ≥3: assess for ICU care (esp. if 4-5)

Answer 13

CAP, outpatient: *Amoxicillin + macrolide (preferred) – Doxycycline is macrolide alternative ⊕heart, lung, liver, or kidney disease, diabetes, alcoholism, malignancy, asplenia, immunosuppression, or use of abx in last 3mo: *Augmentin + macrolide (preferred) – Doxycycline is macrolide alternative *FQ monotherapy (alternative) CAP, inpatient, non-ICU: *antipneumococcal beta lactam + macrolide *FQ monotherapy CAP, inpatient, ICU: *antipneumococcal beta lactam + Azithromycin *preferred *antipneumococcal beta lactam + FQ – Suspect MRSA: ⊕Vancomycin or Linezolid – Suspect Pseudomonas: *beta lactam + FQ *both w/ antipseudomonal coverage ABX REVIEW Anti-MRSA: Vancomycin, Linezolid Respiratory FQ – Levofloxacin, Moxifloxacin, Gemifloxacin (PO) Antipseudomonal FQ: Ciprofloxacin, Levofloxacin Antipneumococcal Beta Lactam: – Augmentin, Ampicillin-Sulbactam (Unasyn) – Ceftriaxone, Cefotaxime, Ertapenem Antipneumo + Antipseudomonal Beta Lactam: – Piperacillin-Tazobactam (Zosyn), Imipenem – Meropenem, Cefepime, Ceftazidime Macrolides: Azithromycin, Clarithromycin Nosocomial (Pseudomonas coverage): *Zosyn or Cefepime – Risk of MRSA: ⊕Vancomycin or Linezolid

Answer 14

PCP: interstitial pneumonia caused by the yeast-like fungal organism Pneumocystis jirovecii Transmission: airborne *AIDS-DEFINING ILLNESS ⇢ CD4 <200/µL S/SXS: gradual onset fever, dry cough, & dyspnea progressing over days to weeks ▪︎fatigue, chills, CP, weight loss ▪︎5-10% of patients are asymptomatic PE: tachypnea, crackles & rhonchi, ⇣ SpO2 (e.g., <90%) LABS: CD4 <200/µL, ⇡ LDH, ⇡ 1-3-beta-D-glucan ▪︎hypoxemia: ⇡ A-a O2 gradient (ref. 5-10mmHg), ⇣ PaO2, ⇣ DLCO dx CXR: diffuse, bilateral perihilar infiltrates HRCT: bilateral patchy or nodular ground glass opacities DX ⇢ microbiologic identification via staining &/or PCR of a respiratory specimen ▪︎PCR preferred ▪︎direct fluorescent antibody (DFA) staining » visualization of cystic or trophic forms TX: TMP-SMX x21d HIV⊕ w/ moderate/severe PCP ⇢ add prednisone PCP prophylaxis ⇢ indicated for CD4 <200/µL ▪︎low-dose TMP-SMX

Answer 15

SPN: single, well-defined lesion ≤30mm in diameter completely located in the pulmonary parenchyma BENIGN: ▪︎Infectious granuloma (MCC): TB, atypical ▪︎Benign neoplasms ▪︎Vascular ▪︎Developmental: bronchogenic cyst ▪︎Inflammatory: granulomatosis w/ polyangiitis MALIGNANT: ▪︎Bronchogenic carcinoma: adenocarcinoma, SCC, ▪︎Metastatic lesions ▪︎Pulmonary carcinoid ▪︎Extranodal lymphoma ▪︎Miscellaneous: plasmacytoma, schwannoma

Answer 16

dx Imaging: chest CT w/o contrast preferred modality ⇢ thin-section (1mm) volumetric scanning FDG PET/CT: avidity measured by standardized uptake value (SUV) Biopsy tx depends on if benign or malignant

Answer 17

MCC of cancer-related deaths in the US Types ⇢ ➀ Small Cell Lung Cancer (SCLC) – 15% ➁ Non-Small Cell Lung Cancer (NSCLC) – 85% *Adenocarcinoma (MC) S/SXS: cough, SOB, fever, weight loss, fatigue *Bronchoalveolar Carcinoma (adeno in situ) Small Cell Lung Cancer (SCLC): *central, aggressive, often METS at presentation *Paraneoplastic: Cushing’s, SIADH, SVC syndrome (face/neck swelling), Lambert-Eaton (proximal muscle weakness, dry mouth, hyporeflexia) Adenocarcinoma: *asbestos exposure Large Cell Carcinoma: *peripheral, slow growing, MC seen in non-smokers *central or peripheral, rare *Paraneoplastic: thrombophlebitis *large peripheral mass w/ prominent necrosis MC *Paraneoplastic: gynecomastia Squamous Cell Carcinoma: *central, often associated w/ hemoptysis *hypercalcemia, +/- elevated PTHrp Pancoast syndrome: shooting arm pain/weakness, Horner’s (ipsilateral miosis, ptosis, anhidrosis) Carcinoid Tumors ⇢ excess secretion of serotonin, histamine, bradykinin *central, GI tract MC site, lung 2nd MC S/SXS: hemoptysis, focal wheezing, recurrent pneumonia *Carcinoid syndrome: flushing, diarrhea, hypotension

Answer 18

dx First ⇢ CXR Central: transbronchial biopsy Then ⇢ CT w/ contrast tx NSCLC: surgical excision, radiation + chemo SCLC: chemo + radiation, no surgery! Screening: USPSTF recommends ANNUAL low-dose CT screening for those 55-80 who have no sxs of lung cancer + a 30PPY smoking hx who currently smoke or have quit within 15yrs

Answer 19

▪︎malignant tumor that develops from mesothelial cells ▪︎Pleural mesothelioma (MC, 80%) ▪︎MCC ⇢ asbestos exposure** ▪︎Peritoneal mesothelioma (rare) ▪︎Pericardial mesothelioma (very rare) Pleural Mesothelioma: ▪︎3 histologic subtypes ⇢ epithelioid (MC), sarcomatoid, biphasic (mixed) S/SXS: dyspnea, CP, cough, night sweats, weight loss, fatigue, pleural effusion dx CXR/CT w/ contrast: unilateral pleural thickening w/ pleural effusion Thoracentesis: bloody, exudative Confirm ⇢ biopsy + immunohistochemistry TX: surgery + chemo + radiation therapy Surgery: pleurectomy/decortication or radical extrapleural pneumonectomy Chemo: cisplatin + pemetrexed

Answer 20

Fungi: Coccidioides immitis, Coccidioides posadasii Region: southwestern US ⇢ Arizona & California Transmission: inhalation of airborne mycelial arthroconidia located in soil RF: HIV, immunosuppressants, advanced age, 2nd half of pregnancy/PP Primary pulmonary infection: onset 7-21d after exposure ➀ asymptomatic/minimally symptomatic disease (60%) ➁ focal pneumonia: chest pain, cough, fever ➂ diffuse reticulonodular pneumonia (less common): ▪︎dyspnea at rest or w/ minimal exertion, fever, night sweats ➃ systemic SXS: night sweats, HA, rash, weight loss, fatigue ➄ immunologic manifestations: » cutaneous ⇢ erythema nodosum, erythema multiforme » rheumatic (“desert rheumatism”) ⇢ symmetric arthralgias of ankles, knees, & wrists Disseminated ⇢ meningitis: hematogenous spread S/SXS: onset weeks-months after 1° infection ⇢ persistent HA MC dx First: enzyme immunoassay (EIA) for IgM & IgG ▪︎IgM ⇡ within 2wks, disappears after 2mo ▪︎IgG ⇡ at 1-3mo ▪︎KOH/wet prep: spherules w/ endospores CXR: unilateral dense infiltrate w/ hilar LAD *MC in upper lobes tx Mild: no treatment Moderate: fluconazole 400mg QD or itraconazole 200mg BID x6-12wks Severe: amphotericin B + azole x12-24wks

Answer 21

Transudative: ⇡ hydrostatic pressure + ⇣ plasma oncotic pressure * Caused by a combination of ↑ hydrostatic pressure in the vasculature and ↓ oncotic pressure in the plasma * Fluid in the pleural space Heart failure (HF) * 90% of cases * Liver cirrhosis * Hypoalbuminemia * Nephrotic syndrome Exudative: ⇡ capillary permeability * Caused by inflammation and ↑ capillary permeability * Fluid rich in protein and LDH in the pleural space Pneumonia * Empyema * Tuberculosis (TB) * Malignancy (most commonly a primary lung cancer) * Connective tissue diseases * Pancreatitis * Asbestos * Post-cardiac injury syndrome ➁ lymphedema Chylothorax: milky white effusion high in TGs caused by trauma ➂ dystrophic yellow nails or neoplastic (MC lymphomatous) damage to thoracic duct ▪︎small pleural effusion (<300mL) often asymptomatic Hemothorax: bloody fluid (pleural Hct >50% peripheral Hct) d/t S/SXS: dyspnea, pleuritic CP (retrosternal), dry cough trauma, spontaneous PTX, coagulopathy, etc. ⇣ tactile fremitus, ⇣ breath sounds, dullness to percussion » pleural friction rub (uncommon) Empyema: pus in the pleural space; can occur as complication to pneumonia, abscess, etc. Trapped Lung: encasement w/ fibrous peel ⇡ ⊖intrapleural pressure caused by empyema or tumor ⇢ transudation of fluid from parietal pleural capillaries; borderline between transudative/exudative

Answer 22

CXR: blunting of costophrenic angle ⇢ meniscus sign ▪︎lateral XR, posterior CP∠ (A): » ~75mL fluid needed to blunt CP∠ ▪︎frontal XR, lateral CP∠ (B): » ~200mL fluid needed to blunt CP∠ DX ⇢ thoracentesis Light’s criteria: 1+ of the 3 ⇢ exudative ➀ pleural fluid LDH >2/3 ULN serum LDH ➁ pleural fluid protein/serum protein >0.5 ➂ pleural fluid LDH/serum LDH >0.6 Additional PF markers: Exudative: ▪︎PF cholesterol >55mg/dL ▪︎PF LDH >200U/L ▪︎PF protein >3.0g/dL ▪︎PF glucose <60mg/dL TX: therapeutic thoracentesis ▪︎treat underlying cause Parapneumonic: ABX Empyema: ▪︎ABX, chest tube drainage ▪︎VATS debridement Hemothorax: ▪︎fluid resuscitation, PRBCs ▪︎chest tube +/- open thoracotomy Malignant: ▪︎therapeutic thoracentesis ▪︎indwelling pleural catheter ▪︎chemical pleurodesis

Answer 23

PE: luminal obstruction of ≥1 pulmonary arteries, typically d/t blood thrombi from DVT MCC ⇢ DVT Non-thrombotic: fat, air, bacterial PATHO: thrombus formation ⇢ DVT (MC iliac vein) ⇢ embolize to pulmonary arteries via IVC ⇢ partial/complete obstruction Saddle Thrombus: blood clot that lodges at the bifurcation of the pulmonary trunk as it splits into the R/L pulmonary arteries ▪︎can obstruct flow through the pulmonary arteries & lead to R heart strain, hemodynamic instability, &/or death S/SXS: acute onset dyspnea (MC), pleuritic CP, cough +/- features of DVT (e.g., unilateral leg swelling) ▪︎hemoptysis is unusual presenting symptom (13%) PE: tachypnea, rales, tachycardia, ⇣ breath sounds MASSIVE: arrythmias (e.g., AFIB), presyncope, syncope, hemodynamic collapse (<10%) ▪︎accentuated pulmonic component of S2

Answer 24

DVT sx: 3 PE sx: 3 tachycardia: 1.5 surgery: 1.5 Previous PE/PVT: 1.5 hemoptysis: 1 Malignancy: 1

Answer 25

CBC/CMP: +/- leukocytosis, ⇡ ESR, ⇡ serum lactate, ⇡ LDH, ⇡ AST ABG: +/- hypoxemia, ⇡ A-a O2 gradient, respiratory alkalosis, hypocapnia EKG ⇢ nonspecific: tachycardia, nonspecific ST/T changes CXR ⇢ nonspecific abnormalities common: atelectasis, effusion PE suspected ⇢ calculate PTP using Wells score ➀ Wells <2: low PTP ⇢ PERC to determine if D-dimer indicated ▪︎all 8 criteria fulfilled = no further testing indicated ▪︎all 8 criteria not fulfilled ⇢ D-dimer ➁ Wells 2-6: intermediate PTP ⇢ D-dimer ➂ Wells >6: high PTP ⇢ CT pulmonary angiography (CTPA) ▪︎D-dimer not needed D-dimer ⇢ <500ng/mL = ⊖/normal ≥500ng/mL = ⊕ ⇢ get CTPA » ex. 65yo patient ⇢ <650ng/mL as cutoff value for ⊖D-dimer CTPA w/ contrast: intraluminal filling defects of pulmonary arteries V/Q scanning ⇢ alternative if CTPA contraindicated

Answer 26

▪︎supplemental O2 to target SpO2 ≥90% ▪︎IV fluids for hypotensive patients Initial Anticoagulation (first 5-10d): ▪︎SQ LMWH or fondaparinux Long-term AC (minimum of 3mo): DOACs ▪︎thrombin inhibitor: dabigatran ▪︎factor Xa inhibitors: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban Indications for AC >3mo: ▪︎unprovoked PE w/ low/moderate bleeding risk ▪︎provoked PE secondary to chronic RF ▪︎active cancer w/ any bleeding risk Hemodynamically unstable ⇢ reperfusion ▪︎tPA (e.g., alteplase, reteplase, tenecteplase) ▪︎DC anticoagulation before tPA, resume after Alternatives: catheter-directed thrombolysis, embolectomy

Answer 27

Mycobacterium Tuberculosis (mTB) *bacilli (rod-shaped), strict aerobes, acid fast (won’t gram stain) Tuberculosis Disease: newer term for active TB *contagious Tuberculosis Infection: newer term for latent TB (LTBI) *not contagious Transmission: airborne respiratory droplet inhalation

Answer 28

Primary TB: usually asymptomatic w/ no radiographic signs Progressive Primary TB: high fever d/t TB pneumonia, pleurisy w/ effusion, lymphadenitis LTBI: asymptomatic, PPD⊕ *not transmissible *Lifetime risk of reactivation is 10% w/ 5% within first 2yrs Active Pulmonary/Reactivation TB: cough ≥2wks (starts dry, becomes productive), hemoptysis, night sweats, fever, weight loss, LAD, pleuritic chest pain CXR: *findings variable & nonspecific *Primary TB: hilar &/or mediastinal LAD, pleural effusion, segmental or lobar consolidation *LTBI: +/- Ghon/Ranke Complex (peripheral calcified nodule & hilar LAD) *Reactivation TB: fibrocavitary apical disease *AIDS, CD4+ <200: diffuse, miliary, hilar/mediastinal LAD Sputum: x3 samples, ≥8h apart, at least 1 early-morning specimen *AFB smear, mycobacterial culture, NAAT Extrapulmonary TB: *Vertebral TB (Pott): osteolytic lesions on plain film *TB Lymphadenitis (Scrofula): single swollen non-tender cervical LN *meningitis, ocular, renal, pericarditis, salpingitis, peritonitis, intestinal

Answer 29

First: RIPE x2mo *Rifampin (RIF) *Isoniazid (INH) *Pyrazinamide (PZA) *Ethambutol (EMB) Then: continuation x4mo *Rifampin + Isoniazid Latent TB Infection (3 options): *3HP: Isoniazid + Rifapentine q1wk x3mo *4R: Rifampin QD x4mo *3HR: Isoniazid + Rifampin QD x3mo

Answer 30

Thrombocytopenia, flu-like sxs, orange-colored secretions (tears, urine), GI upset, hypersensitivity, fever, hepatitis MOA: inhibits RNA synthesis

Answer 31

Hepatitis (esp. >35yrs), peripheral neuropathy, drug-induced lupus, rash, abdominal pain, high anion gap acidosis, cytochrome P450 inhibition MOA: inhibits mycolic acid synthesis Peripheral neuropathy prevented by pyridoxine (B6) Baseline LFTs recommended

Answer 32

Hepatitis & hyperuricemia, GI sxs, arthritis, photosensitive dermatologic rash MOA: inhibits mycolic acid synthesis Peripheral neuropathy prevented by pyridoxine (B6) Baseline LFTs recommended

Answer 33

Optic neuritis 🡪 scotoma, color perception problems (red-green), visual changes, peripheral neuropathy, GI sxs, rash

Answer 34

PTX: a collection of air within the pleural space between the lung (visceral pleura) & the chest wall (parietal pleura) that can lead to parietal or complete pulmonary collapse PATHO: ⇡ intrapleural pressure ⇢ alveolar collapse ⇢ decreased V/Q ratio & ⇡ right-to-left shunting Primary Spontaneous PTX (PSP): occurs in patients w/o clinically apparent underlying lung disease ▪︎caused by ruptured subpleural apical blebs RF: smoking (90%) ⇢ up to 20-fold ⇡ in risk (risk ⇡ w/ ▪︎MC affects tall, thin males, ♂︎ > ♀︎ ~6:1 cumulative # of cigarettes smoked) ▪︎peak incidence 16-25yo ▪︎family hx, male, young, homocystinuria, tall/slim Secondary Spontaneous PTX (SSP): occurs as a complication of underlying lung disease ▪︎♂︎ > ♀︎ ~3:1, peak incidence 60-65yo ▪︎Marfan syndrome, malignancy ▪︎COPD (smoking): rupture of bullae in emphysema ▪︎infections: TB, PCP (alveolitis, rupture of a cavity) ▪︎Catamenial PTX ⇢ thoracic endometriosis (rare) ▪︎CF: bronchiectasis w/ obstructive emphysema & bleb or cyst rupture Recurrent PTX: a second episode of spontaneous PTX, either ipsilateral or unilateral

Answer 35

Traumatic PTX: a type of PTX caused by trauma (e.g., penetrating injury, iatrogenic trauma) ▪︎blunt trauma (e.g., MVC in which thorax hits steering wheel or rib fracture occurs) ▪︎penetrating injury (e.g., gunshot or stab wound) ▪︎Iatrogenic PTX ⇢ mechanical ventilation w/ high PEEP (barotrauma), thoracentesis, CVC placement, bronchoscopy, lung biopsy (usually closed PTX) PATHO: ▪︎Closed: air enters through a hole in the lung (e.g., d/t blunt trauma) ▪︎Open: air enters through a lesion in the chest wall (e.g., d/t penetrating trauma) Tension PTX (TPTX): a life-threatening variant of PTX characterized by progressively ⇡ pressure within the chest & cardiorespiratory compromise PATHO: ➀ disrupted visceral pleura, parietal pleura, or tracheobronchial tree ➁ 1-way valve mechanism ⇢ air enters the pleural space on inspiration but cannot exit ➂ progressive accumulation of air in pleural space & ⇡ ⊕pressure within the chest ➃ collapse of ipsilateral lung, compression of contralateral lung, trachea, heart, & SVC; angulation of IVC ➄ impaired respiratory function, ⇣ venous return to the heart ⇢ reduced CO ⇢ hypoxia & hemodynamic instability

Answer 36

S/SXS: sudden, severe &/or stabbing ipsilateral pleuritic CP & dyspnea PE: ⇣/absent breath sounds, hyperresonance to percussion, ⇣ fremitus on the ipsilateral side ⊕subcutaneous emphysema: infiltration of air under the dermal layers of the skin ▪︎distention/bloating of chest, neck, face ▪︎palpation ⇢ crackling sensation (crepitus) Tension PTX: ▪︎severe acute respiratory distress: cyanosis, restlessness, diaphoresis ▪︎reduced chest expansion on the ipsilateral side, distended neck veins ▪︎hemodynamic instability (e.g., tachycardia, hypotension, pulsus paradoxus) DX: CXR ▪︎ipsilateral pleural line + absence of bronchovascular markings past the pleural line ▪︎⊕deep sulcus sign: abnormally deepened costophrenic angle on ipsilateral side **SUPINE film Size assessment cut-off ⇢ cm between pleural line & chest wall at level of the apex ▪︎PSP: 3cm ▪︎SSP: 2cm Tension PTX: clinical DX based on S/SXS of tachycardia, hypotension, & severe dyspnea ▪︎supportive CXR findings: *tracheal shift to contralateral side *rib splaying, flattening of the ipsilateral diaphragm

Answer 37

TX: assess stability ⇢ requires ALL of the following to be considered stable: RR <24 breath/min normal BP SpO2 >90% on RA able to speak in whole sentences HR 60-120bpm Primary Spontaneous PTX (PSP): ▪︎stable, small (≤3cm) PSP ⇢ usually resolves spontaneously within ~10d ▪︎observation +/- supplemental O2 (6L/min x6h to target SpO2 >96%) ▪︎repeat CXR after 3-6h » stable or improving ⇢ DC home w/ outpatient f/u CXR in 24h » enlarging ⇢ chest tube ▪︎stable, large (>3cm) PSP ⇢ chest tube preferred over needle/catheter aspiration Secondary Spontaneous PTX (SSP): ▪︎stable, small (<2cm) SSP ⇢ admit + chest tube (⇡ risk of developing TPTX d/t underlying lung disease) ▪︎if asymptomatic, observation &/or needle aspiration can be considered ▪︎stable, large (≥2cm) SSP ⇢ admit + chest tube Traumatic/tension PTX, bilateral PTX, or unstable: ▪︎emergency chest tube thoracostomy ⇢ admit ▪︎if chest tube is delayed, perform needle decompression Chest tube placement: superior rib margin, anterior to midaxillary line in 5th ICS (nipple line) Needle/catheter aspiration: superior rib margin in 2nd ICS, midclavicular line Definitive TX: surgical pleurodesis ⇢ VATS (preferred), medical thoracoscopy ▪︎indications: prolonged air leak >5d, recurrent PTX, bilateral PTX, high-risk of recurrence

Pulm Flashcards

(61 cards)