Pulm Flashcards
(201 cards)
1
Q
What is the MC infectious cause of death in the US?
A
Pneumonia
2
Q
Pathophysiology of pneumonia
A
pathogen invades alveoli and neutrophils invade and phagocytize causing inflammation and neutrophilic exudate
3
Q
What are the defense mechanisms of the respiratory tract?
A
cilla, saliva, mucus, immunoglobulins, neutrophils, cough reflex
4
Q
How does tobacco smoking impair host defense?
A
disrupts mucocillary function and macrophage activity
5
Q
How does aging impair host defense?
A
less effective mucocillary clearance and coughing and changes in cell mediated immunity
6
Q
What are the RF of pneumonia?
A
> 65, underlying health problems, impaired immune response
7
Q
What are typical PE finding with pneumonia?
A
dullness to percussion, rhonchi, bronchial breath sounds, reduced breath sounds, egophony, tachycardia and tachypnea
8
Q
When would you perform bronchoscopy (BAL)?
A
immunosuppressed, suspected TB or pneumocystis, foreign body or not responding to Abx
9
Q
What is atypical pneumonia?
A
less ill appearing, CXR appears different and need different Abx
10
Q
What are complications of S. pneumoniae?
A
sinusitis, otitis media, endocardidis, meningitis, empyema
11
Q
What is empyema?
A
pus collecting in pleural space
ph <7.2
high LDH
low glucose <60
12
Q
When is the pneumococcal vaccine administered?
A
> 65 yo or current smokers with compromised immune system2 separate vaccines
13
Q
What populations is associated with H. influenzae pneumonia?
A
COPD, alcoholics, older and immunosuppressed
14
Q
What is Tularemia associated with?
A
rabbits
15
Q
What is Pittacosis associated with?
A
birds
16
Q
What are the sx of walking pneumonia?
A
chilld, non-productive cough, low grade fever, mild SOB
17
Q
What is the MC cause of lower respiratory tract infection in young adults?
A
mycoplasma pneumoniae
18
Q
What is the MC pneumonia in children?
A
RSV (viral pneumonia)
19
Q
What is the MC pneumonia in military recruits?
A
Adenovirus
20
Q
What area of the lung does aspiration pneumonia most commonly occur?
A
RLL or RML
21
Q
What is CURB-65?
A
confusion urea >7 mmol respiratory rate >30 low BP <90/<60 age >65
22
Q
What curb score is high risk?
A
> 2
23
Q
What are danger signs of pneumonia?
A
leukopenia, cavity infiltrates, alcohol abuse, chronic liver dx, asplenia, recent travel, pleural effusion
24
Q
What is MC etiology of typical pneumonia?
A
S. pneumo, H. flu, M. catarrhalis
25
What is MC etiology of atypical pneumonia?
mycoplasma, chlamydia, coxiella burnettii, fungal
26
Whats is MC etiology of alcoholics with pneumonia?
Klebsiella, psdueomonas
27
Whats is MC etiology of COPD pts with pneumonia?
H. flu, pseudomonas, legionella
28
What is MC etiology of dementia pts with pneumonia?
anaerobes, enteric G ⊖
29
What is typical presentation of pneumonia?
Rhonchi, bronchial breath sounds, diminished breath sounds, ⊕ egophony, Fever, tachypnea, tachycardia
30
What is typical presentation of Streptococcus pneumonia?
Single shaking chill, Cough productive of rust color sputum
Fever
Pleurtic pain
Consolidation (diminished breahth sounds, dullnuss, egophony)
31
What is typical presentation of Haemophilus Influenza Pneumonia?
High fever, chills, cough, purulent sputum
Abdominal pain & diarrhea
Pleural effusion common
Appears toxic
32
What tests are diagnostic for H. flu pneumonia?
Urine Ag test
Sputum culture (G⊖rods)
PCR
Hyponatremia and ↑LDH
33
What age group typically gets atypical pneumo?
<40
34
What is etiology of atypical pneumo?
Mycoplasna pneumonia (YA)
Chylamydia pneumoniae (school age kids)
Legionella pneumonphilia (older)
Psittacosis (birds)
Tularemia (rabbits)
35
What is clinical presentation of atypical pneumo?
Gradual onset
Low grade fever, chills
Non-productive cough
Mild SOB
36
What does CXR show for atypical pneumo?
Diffuse or patchy infiltrate on CXR little or no pleural effusion
37
What does CXR show for mycoplasma pneumo?
CXR worse than clinical findings
38
What is clinical presentation of mycoplasma pneumoniae?
```
<40 yo
Gradual onset
Bullus myringitis on TM
Sore throat
Non-productive cough
HA
```
39
What environmental exposure is known for Histoplasmosis?
Planting new grass, yardwork
| Bats/chicken contact
40
Pathophys of fungal pneumo
Spore inhaaled enters lungs and causes hilar adenopathy
41
Define acute bronchitis
inflammatory condition of tracheobronchial tree associated with respiratory infection
42
What is the etiology of acute bronchitis?
Common cold viruses: influenza, adenocirus
Non-viral: M. pneumoniae, C. pneumoniae, B. pertussis
43
Clinical presentation of acute bronchitis
Cough, preceded by nasal and pharyngeal complaints
Purulent sputum
Fever
Substernal chest pain if tracheal involvement
44
What is incubation period for influenza?
1-4 days
45
Clinical presentation of influenza
Sx for 5-10 days
Abrupt onset, myalgias, pounding HA, fatigue, dry cough, sore throat (sometimes)
High fever, tachycardia, no nasal congestion or rhinorrhea
46
Pathyphsy of TB
aerosol droplet gets into lungs and incubates for 2-12 wks when the infection is either cleared, suppressed to latent or infects host
47
What is PPD size to dx TB?
>5 if HIV, immunocompromised or close contact
>10 if high prevalence country
>15 mm everyone else
48
Clinical presentation of active TB
cough, weight loss, anorexia, fever, night sweats, hemoptysis, chest pain and fatigue
49
How do you dx TB?
CXR shows coin lesions or cavitations
50
How does Coccidioidomycosis present?
Asymptomatic typically
| CXR shows dense infiltrate in upper lobe
51
Where is Coccidioidomycosis MC?
Desert areas of SW
52
Where are Histoplasmosis and Blastomycosis MC?
Mississipi-Ohio River
53
Define hypoxia
poor O2 delivery/oxygenation of tissues
54
Define hypoxemia
low arterial O2
55
Define hypocapnea
low arterial CO2
56
Define orthopnea
dyspnea when lying flat
57
Define apnea
cessation of breathing > 10 sec
58
Define hypopnea
decrease in airflow with accompanied by decrease in arterial O2 saturation >4%
59
What is apnea-hypopnea index (AHI)?
severity of sleep apnea based on number of apnea and hyopnea events per hour of sleep
60
What are categories of AHI?
Normal 0-4
Mild 5-14
Moderate 15-29
Severe 30 or more
61
What is Ondine’s Curse?
central sleep apnea stop breathing for 10 or more seconds when asleep
62
What are the medullary centers?
dorsal and ventral respiratory group
63
What is Dorsal respiratory group (DRG)?
Controls inspiratory movements and their timing
64
What is ventral respiratory group (VRG)?
Controls voluntary forced exhalation and acts to increase the force of inspiration. Inactive during quiet breathing
65
What are pontine center?
pneumotaxic center and apneustic center
66
What does pneumotaxic center do?
Coordinates speed of inhalation and exhalation Sends inhibitory impulses to the DRG
Involved in fine tuning of respiration rate
67
What does apneustic center do?
Promotes inspiration and controls depth of breathing . Signals to the DRG in the medulla.
68
What is Cheyne-Stokes Breathing and when is it seen?
rhythmic increase and decrease of respirations followed by 15-60 sec apnea seen in response to hypercapnia such as in central sleep apnea
69
What is Pickwickian syndrome?
obesity hypoventilation syndrome
70
What is hyperpnia?
increased depth and rate of breathing in response to either physiologic (exercise) or pathologic, of respiratory control mechanisms
71
What are indications for mechanical ventilation?
acute respiratory failure, acute on chronic respiratory failure, pulmonary edema, inability to protect airway, neuromuscular dysfunction (ALS) and stabilize chest wall after trauma
72
What is positive ventilation volume cycle?
Volume constant and pressure varies with pts lung compliance
73
What is positive ventilation pressured cycle?
Pressure is constant and volume will vary with patient’s lung compliance
74
What are problems associated with positive pressure ventilation?
Iatrogenic upper airway damage, pneumonia and Lung parenchymal damage
75
What is Expiratory asynchrony?
Patient tries to take a breath when expiring and ventilator doesn't respond
76
Pathophys of central sleep apnea
Brain temporarily srops sending signals to muscles of respiration and theres lack of abdominal and thoracic mvt for 10 sec or longer during sleep
77
Define hypercarbic failure
failure to eliminate CO2
78
When do you give supplemental O2?
80% or lower at rest
79
What is a normal A-a gradient?
5-10 mmHg
80
What conditions mimic ARDS?
CHF, ILD, marijuana or cocaine, cancer
81
What is normal PEEP vs PEEP in ARDS?
5 cm H20 nrml
| ~20 cm H20 ARDS
82
What are RF of ARDS?
age, direct lung injury, pneumonia, sepsis, aspiration
83
What is best tidal volume to ventilate at?
low tidal volume ~6ml/kg
84
Pathyphys of ARDS
Inflammatroy lung injury→diffuse alveolar damage→Inc permeability of alveolar capillary barrier→Pulmonary edema
85
What is hallmark of ARDS?
severe refractory hypoxemia
86
What is normal PaO2/FIO2 ratio?
500
87
What are characteristics of diagnosis or ARDS?
```
Protein RICH edema fluid
CXR: Bilat pulm infiltrates (ground glass)
NO cardiogenic pulm edema present
ABG not responsive to 100% O2
PaO2/FIO2 <300
PEEP >5
PCWP <18 mmHg
```
88
What is the function of PEEP?
prevents airway collapse at end expiration, increases FRC and expands alveoli for increased diffusion
89
What is strong RF of sleep apnea?
obesity
90
Pathophys of PE
Thrombus forms in lower extremity vein →dislodges →travels to pulmonary artery where it gets lodged btwn the artery to capillaries → prevents blood from getting oxygenated distal to the lodged embolism
91
What are the respiratory effects of PE?
inc alveolar dead space
hypoxemia
hyperventilation
92
What is the classic triad of PE?
dyspnea, pleuritic chest pain and hemoptysis
93
What are hemodynamic effects of PE?
Dec area of pulm vascular bed
Diffuse vasoconstriction
Inc pulm vascular resistance
94
What is virchows triad?
hypercoaguality, venous status and vessel wall damage
95
Clinical presentation of PE
```
Dyspnea, sudden tachypnea, tachycardia
Cough
Chest pain
Rales
Fever
Prominent S2
```
96
PE risk factors
M>F mortality
| Elderly, blacks, pregnant (post partum), smokers, OCP, ortho surgery at higher risk
97
What is high risk wells score for PE? Moderate?
>7 high
| 2-6 moderate
98
What are PERC Criteria?
<50 yo
<100 bpm
O2 >95%
No hepoptysis, estrogen use, prior CVT or PE, unilateral leg swelling or recent surgery
99
What is D-dimer test?
fibrin degradation product will be elevated in presence of thrombosis so if clot is present anywhere in the body it will be positive
100
What is S1Q3T3?
wide deep S in lead I, both an isolated Q and T wave inversion in lead III
101
Diagnostic signs of PE
```
Wells prediction rule
Positive D-dimmer (if ⊖ r/o PE)
VQ scan (if CT contraind)
CT is go to if high likelihood
Pulm angiogram
CXR: normal but w/ hypoxiaavascular markings distal to the area of embolus ⊕westmarks sign or ⊕Hampton's hump
ECG: sinus tachy, S1Q3T3
ABG: ↑A-a gradient
```
102
What is westmark's sign
avascular markings distal to area of embolus
103
What is Hamptom's hump?
wedge shaped infiltrate (represents infarction)
104
What is the go to study for high likelihood PE patients?
CT scan
105
What patients should you use caution with for a CT scan?
young females, kidney failure pts
106
What is the gold standard diagnosis for PE and why?
angiogram because you can diagnose and take it out at the same time if high suspicion
107
What is the finding for venous ultrasonography that makes DVT very unlikely?
fully compressible veins
108
What is mean pulm arterial pressure for Pulmonary HTN?
>25 mmHg at rest or >30 mmHg during exercise
109
Clinical presentation of pulmonary HTN
Dyspnea on exertion, fatigue, syncope, cyanosis, edema
| Loud P2, systolic ejection click, ↑JVP
110
Gold standard for diagnosing pulmonary HTN
R sided heart cath which shows that the mean pulmonary artery pressure is >25 mmHg
111
Diagnostic features of pulmonary HTN
CXR: usually normal, may have enlarged heart or pulm arteries
ECG: P pulmonale, RAD, RBBB
Echo: ↑ size of RV
R heart cath shows mean pulm pressure >25
112
Clinical signs of Cor pulmonale
Fatigue, tachypnea, dyspnea on exerttion, peripheral edema, angina
Early ejection click, split S2 with loud P2
113
Diagnostic signs of cor pulmonale
ECG: P pulmonale
Echo: ↑size or R ventricle, regurgitate flow
R heart cath: ↑ PA pressure
114
What is cor pulmonale?
abnormal enlargement of the R side of the heart as a result of disease of the lungs or the pulmonary blood vessels causing R sided heart failure
115
What is the major limitation to gas movement in the body?
thickness and surface area
116
When equilibrium is reached what is limiting exchange of gas at respiratory membrane?
perfusion
| to get more O2 you need to inc blood flow
117
When equilibrium is not reached what is limiting gas exchange?
diffusion
| need to inc pressure gradient to increase O2
118
What patients have limited diffusion capacity?
thickened respiratory membrane decreased surface area such as alveolar edema, pulmonary fibrosis and emphysema
119
What is the net driving pressure for air movement into the lungs?
force of muscle contraction, lung compliance and airway resistance
120
What is normal total lung capacity?
6 L
121
When are elastic recoils of the lung equal but opposite?
FRC
122
What is the function of surfactant?
reduce surface thension and increase compliance
123
What is the major determinant of airway resistance?
radius
124
What is the effect of stimulation of mAChR on bronchial smooth muscle?
bronchoconstriction and increased resistance
125
What is the effect of stimulation of B2AR on bronchial smooth muscle?
bronchodilation and decreased resistance
126
How do we estimate physiologic dead space?
Use concentration of CO2 in expired air and the concentration of CO2 in arterial blood
127
What happens to PAO2 when PACO2 increases?
PAO2 decreases
128
Why is PaO2 slighltly less than PAO2?
bronchial perfusion and thebesian channels
129
What is the effect of sympathetic and parasympathetic regulation on pulmonary vascular resistance?
Sympathetic-->NE --> vasoconstriction
Parasympathetic-->M3-->vasodilation
130
What is dead space
ventilated but not perfused
131
What is a shunt
perfused but not ventilated
132
What is the function of the medulla in control of respiration?
rhythm generator
133
What is the function of the pons in control of respiration?
regulates medulla
134
What is the function of the cortex in control of respiration?
conscious and emotional response
135
What are J receptors?
within alveolar walls that are stimulated when capillaries are engorged with blood during pulmonary edema
136
What is the effect of activation of central chemoreceptors?
hyperventilation in response to decreased pH and increased PaCO2
137
What is the function of peripheral chemoreceptors?
when PaO2 decreases below 60 mmHg they increase ventilation
138
What does it mean when A-a gradient is high?
O2 in alveolus is not getting into arterial blood efficiently
139
What is pleural effusion?
fluid accumulates in pleural cavity and impairs breathing by limiting expansion of lung
140
What are pink puffers?
emphysema hunches, barrel chest, weight loss, dyspnea non productive cough
141
What are blue bloaters?
bronchitis, cough with mucus production, no barrel chest, cyanosis, obese
142
What size particle can reach alveoli?
<4 micrometers with low water solubility
143
What particles affect upper airway?
larger highly water soluble materials
144
What are risk factors for silicosis?
mining, quary work, slate, granite, quartz, pottery sandblasting
145
What are risk factors for berylliosis?
electronics, aerospace, ceramics, tool and dye manufacturing and fluorescent light bulb
146
What are risk factors for byssinosis?
cotton exposure
147
What are risk factors for silo filler disease?
nitrogen dioxide gas exposure
148
What is the function of CFTR gene?
transport chloride ions across membrane
149
What is the MC mutation in CFTR gene?
Delta F508
150
What is the effect of a mutated CFTR gene?
reduces Cl concentration in the secretions drawing Na+ back into the cell and water follows so secretions become thick
151
GI effects of CF
steatorrhea, pancreatitis, rectal prolapse, meconium ileus & plug
152
Signs of acute exacerbation of CF
inc cough, sputum, dyspnea, RR, accessory muscle use, crackles or wheezes, decreased appetite and weight loss
153
Pathophys of CF related diabetes
insulinopenia from B-cell apoptosis
154
What is average life expectancy of CF patients?
about 40 years
155
What is the MC cause of death in patients with CF?
respiratory failure
156
Clinical presentation of CF
Failure to thrive, abnormal stools, nasal polyps, rectal prolapse, cough, wheezing, repeated infections, exercise intolerance, SOB, respiratory failure
157
Epidemiology of CF
White> hispanic> AA
MC life threatening autosomal recessive Disease among whites
Men are infertile
158
Clinical presentation of bronchiectasis
Chronic daily cough, mucopurulent sputum production, hemoptysis
159
Pathophys of bronchiectasis
Airway insult causes inflam response and mucocillary destruction causing secretion stasis and bronchial obstruction and dilation
160
RF of bronchiectasis
CF, HIV, toxic gas exposure, smoking, ciliary dyskinesia
161
What are the hallmarks of acute bronchiectasis exacerbation?
Increasing cough, dyspnea, increase in sputum production of darker color and chest pain
162
Epidemiology of bronchiolitis
Infants and young children
163
Etiology of bronchiolitis
Respiratory syncytial virus (RSV)
164
Clinical presentation of bronchiolitis
Starts with typical URI followed by nasal flaring, tachypnea, retractions, accessory muscle use, wheezing and hypoxia
165
Diagnostic studies of bronchiolitis
CBC might be normal
Nasal swab for rsv
Chest X-ray shows air trapping (not recommended)
166
Why is asthma worse at night?
decrease in catecholamines at night
167
What causes symptoms associated with asthma?
bronchoconstriction, airway thickening and increased mucus
168
Clinical presentation of asthma
Variable sx going on for >10 days and worse at night
| Wheezing, SOB, chest tightness, cough
169
What is hallmark of asthma?
hyperresponsiveness which is an exaggerated response to different stimuli
170
What are triggers of asthma?
allergens, respiratory tract infections, airborne irritants, changes in weather, exercise, drugs
171
What indicated poorly controlled asthma?
daytime asthma or reliever needed more than 2x a week, night time awakening, limitation
172
How frequently should asthma be reviewed?
1-3 mo after start of treatment and then every 3-12 mo
| 1 wk after exacerbation
173
What spirometry values indicate obstructive problem?
FEV1/FVC <70%
174
What qualifies a patient as high risk for COPD exacerbations?
2 or more mild to mod or at least one severe exacerbation in past year
175
Clinical presentation of emphysema
```
Dyspnea
Minimal sputum production
Barrel chest but thin
Hyperresonance
↓ /abs breath sounds
↓fremitus
↑AP lat diameter
Pursed lip breathing and accessory muscle use
Tripoding
```
176
Clinical presentation of chronic bronchitis
```
Persistent productive cough with white/grey sputum
Crackles, rhonchi, wheeezing
Respiratory acidosis
Obese and cyanotic
Accessory muscle use
```
177
What interstitial lung diseases have inflammatory neutrophilic profiles?
IPF, asbestos, silicosis
178
What interstitial lung diseases have inflammatory lymphocytic profiles?
sarcoidosis, hypersensitivity pneumonitis
179
What is the compliance of a normal human lung?
200 ml/cm H2O
180
Clinical presentation of idiopathic pulmonary fibrosis (IPF)
Dry cough, progressive dyspnea on exertion , inspiratory crackles always heard
clubbing
181
What is the survival rate of IPF?
<10 yr (50% to 5 yr)
182
Clinical presentation of non-sepcific interstitial pneumonitis (NSIP)
Dyspnea, cough, fatigue, weight loss, basilar crackles, clubbing less common than in IPF
183
Clinical presentation of respiratory bronchiolitis interstitial lung disease
Mild sx dyspnea, cough, smoking hx
184
Clinical presentation of desquamative interstitial pneumonia
Insidious onset of dyspnea and dry cough and smoking hx
185
Epidemiology of sarcoidosis
20-40 y AA females
186
Pathophys of sarcoidosis
exaggerated T cell response to a variety of Ag causing granuloma formation
187
Clinical presentation of sarcoidosis
low grade fever, fatigue, malaise, weight loss, occasionally night sweats, skin lesions, dyspnea, dry cough, vague chest pain
188
Clinical presentation of hypersensitivity pneumonitis
Cough, SOB, fever, malaise, flu-like sx 4-8 hr after inhaling Ag lasting for 12-48 hr
189
Define pneumoconiosis
accumulation of dust in lungs and tissue reactions to its presence (silicone, asbestos)
190
What size nodule has a high probability of being malignant?
Strong concern for anything >5mm, high probability >20 mm
191
What are benign patterns of nodules?
central, laminar and diffuse
192
What are non-specific potentially malignant patterns of nodules?
popcorn, stippled, eccentric
193
What are classifications of T3 tumor?
large (507 cm), invade something or have second tumor in same lobe
194
Classifications of T4 tumor?
>7 cm, invade something that cant be removed or get a second tumor in diff lobe or lung
195
What is the N component of staging?
N0=no adenopathy
N1=intrapulm or hilar adenopathy
N2=ipsilateral mediastinal adenopathy
N3=contralateral or supraclavicular adenopathy
196
What is M component of staging?
M=metastes
M1a=contralat involvement
M1b=single metastasis
M1c=multiple metastases
197
What is low risk patient for surgical resection?
FEV1>2L
DLCO>60% predicted
Absence of heart disease
198
What is high risk patient for surgical resection?
```
PCO2>45
PO2 <50
FEV1<40% pred
DLCO<40% pred
>80 yo
poor exercise performance
```
199
Define pancoast tumor
tumors in apex of lung that may invade contiguous structures (brachial plexus)
Show Horner's syndrome with unilateral ptosis, meiosis and ipsilateral anhyrdosis
200
What are the most common sites of metastasis?
lung, brest, colon and kidney
201
What is horner's syndrome
miosis, ptosis and anhydrosis
