Pulm #5 Flashcards
(48 cards)
What is a pneumothorax?
-Air in the pleural space leading to collapse of the lung from positive intrapleural air pressure
What is a primary spontaneous pneumothorax vs a secondary spontaneous pneumothorax?
- Primary: atraumatic and no underlying lung disease. Tall, thin men who are smokers
- Secondary: underlying lung disease
A tension pneumothorax is any type in which
positive air pressure pushes the trachea, great vessels, and heart to the contralateral side
Symptoms and physical exam findings of a pneumothorax
- Chest pain, unilateral and pleuritic. Sudden, dyspnea
- Hyperresonance to percussion, decreased fremitus, and decreased breath sounds
- Tension: Increased JVP, systemic hypotension, pulsus paradoxus
Initial diagnostic for a pneumothorax
- Chest radiograph (expiratory upright view)
- -Companion lines: visceral pleura line running parallel with ribs
- -Decreased peripheral markings
Treatment for small PSP < 3 cm from chest wall at apex
Observation and supplemental oxygen
- May be discharged if stable and repeat films after 6 hours excludes progression
- Chest tube thoracotomy is worse on repeat films
Treatment for large PSP ( > 3 cm from chest wall at the apex)
Needle or catheter aspiration vs chest tube or chest thoracotomy
If the pneumothorax is a stable secondary spontaneous type, what is the treatment?
Chest tube or catheter thoracotomy + hospitalization
If the pneumothorax is a tension type from a car accident, during CPR, or PEEP ventilation, what is the treatment?
-Needle aspiration followed by chest tube thoracostamy
Patient education if they have a pneumothorax?
-Avoid pressure changes for 2 weeks (high altitudes, smoking, unpressurized aircrafts, scuba diving)
What is pulmonary hypertension defined as?
Elevated mean pulmonary arterial pressure > 20 mmHg with a pulmonary vascular resistance > 3 Wood units
What is the pathophysiology of pulmonary hypertension?
Increased pulmonary vascular resistance leads to RVH, increased RV pressure and eventually right sided heart failure
Primary pulmonary HTN most commonly affects middle-aged or young women. It is a defect in what gene?
BMPR2
Symptoms and PE findings of pulmonary HTN
- Dyspnea, fatigue, cyanosis edema
- Accentuated S2
- Signs of right-sided HF: increased JVP, peripheral edema, ascites
- Pulmonary regurgitation, right ventricular heave, systolic ejection click
Diagnostics for pulmonary HTN
- CXR: enlarged pulmonary arteries, signs of right sided HF
- ECG: Cor Pulmonale (RVH, right axis deviation)
- Echo: large right ventricle, RVH
- Right heart catheterization: DEFINITIVE
- CBC: Polycythemia and increased hematocrit
In a primary pulmonary HTN case, what is the initial treatment?
-Vasoreactivity trial with inhaled Nitric oxide, IV Adenosine or CCB
And if the patient is vasoreative, what are the first line medications
CCB (first line)
- Prostacyclins (Esoprostenol)
- PD5-inhibitors (Sildenafil)
- Oxygen therapy
- Long term anticoagulation in some
What is the definitive treatment in pulmonary HTN
-Heart-lung transplant
70% of pulmonary embolisms arise from
deep vein in the legs (majority of the rest are from pelvic veins)
Risk factors for a DVT?
- Virchow’s Triad
- -Intimal damage: trauma, infection, inflammation
- -Hypercoagulability: Protein C or S deficiency, Factor V Leiden, OCP, Pregnancy, Smoking
- -Stasis: immobilization, surgery, sitting > 4 hours
Symptoms of a PE
- Sudden onset of dyspnea + pleuritic chest pain + hemoptysis
- Tachypnea, tachycardia, fever
- Positive Homan Sign (not specific)
a CXR is the first diagnostic ordered to evaluate chest pain. What is highly suspicious of a PE?
-Normal CXR in the setting of hypoxia
However, what are other classic but rare findings of a PE on a CXR?
- Westermark’s Sign: avascular markings distal to the PE
- Hampton’s Hump: wedge-shaped infiltrate due to infarction
What does an ECG show in a PE?
Nonspecific ST/T changes and sinus tachycardia most commonly
-Right heart dysfunction: S1Q3T3 (wide deep S in lead 1; isolated Q and T wave inversion in III)
