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pulm exam 1 Flashcards

1
Q

what is inflammatory lung disease?

A

large group of heterogeneous disorders

inflammatory process involving alveolar wall that can lead to irreversible fibrosis, distortion of lung architecture and impaired gas exchange

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2
Q

are imaging studies useful for inflammatory lung disease?

A

they’re nonspecific, and do not point to a definitive diagnosis

-often need to obtain tissue biopsy

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3
Q

symptoms of interstitial lung disease

A

Cough – usually nonproductive
Dyspnea on exertion
Other symptoms possible secondary to another condition

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4
Q

signs of interstitial lung disease

A 
Rales heard at lung bases
Oxygen desaturation 
Digital Clubbing
 Signs of pulmonary HTN and Cyanosis in advanced disease 
JVD, LE Edema
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5
Q

Pneumoconiosis

A

chronic, fibrotic, occupation lung disease

caused by inhalation of a foreign particle which causes a reaction in the lung which results in fibrotic changes

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6
Q

when does pneumoconiosis appear?

A

20-30 years after constant exposure

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7
Q

what is the most common diagnosis among ILD patients?

A

idiopathic pulmonary fibrosis (increased frequency men and smokers)

typical age 50-70

onset of symptoms 1-2 years prior to diagnosis

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8
Q

prognosis of idiopathic pulmonary fibrosis

A

highly variable disease course
mean survival 3-7 years after initial diagnosis

*treatment is highly controversial, 70% do not improve with therapy and experience progressive disease

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9
Q

what is sarcoidosis?

A

multi-systemic granulomatous disease - inflammatory reaction to one of many possible triggers

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10
Q

where does sarcoidosis affect?

A

90% lung

eyes, skin, liver, spleen, heart, nodes

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11
Q

etiology of sarcoidosis

A

more common in AAs, women

typically 20-30 yo

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12
Q

how does a typical sarcoidosis patient present?

A

young, constitutional symptoms, resp complaints, blurred vision, erythema, nododsum

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13
Q

workup and hallmark of sarcoidosis

A

CXR: Bilateral Hilar and Right Paratracheal Adenopathy

  • Potato nodes
    hallmark: bilateral diffuse reticular infultrates
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14
Q

treatment of sarcoidosis

A

systemic corticosteroids (90% response) - most resolve/spontaneously improve within 2 years

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15
Q

where in the lung is ventilation higher?

A

lung bases (alveoli at the apex are stretched more at baseline, thus worse compliance)

-perfusion is also higher at the lung bases - due to gravity, arterial and venous pressure exceed alveolar pressure at the bases,but alveolar pressure exceeds these vascular pressures at the apices

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16
Q

what disorders decrease ventilation?

A

airway (COPD) and airspace (pneumonia) disorders

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17
Q

what disorders decrease perfusion?

A

pulmonary vascular disorders (PE)

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18
Q

what are the causes of hypoxemia?

A

low inspired partial pressure of oxygen

hypoventilation - alveolar to arterial oxygen difference will be normal (opioids)

ventilation-perfusion mismatch

shunt

diffusion abnormality

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19
Q

a low forced expiratory volume in 1 second/forced vital capacity ration indications what functional classification?

A

obstructive defect

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20
Q

a low FVC and low total lung capacity (TLC) suggests what functional classification?

A

restrictive defect

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21
Q

low FEV1/FVC and low TLC suggests what functional classification?

A

combined defects

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22
Q

low diffusing capacity of the lung for carbon monoxide (DLCO) and hypoxemia suggests what functional classification?

A

gas transfer defect

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23
Q

Rapid, deep respiration due to stimulation of the respiratory center of the brain by ↓ pH, normal during exercise, and common in patient with severe metabolic acidosis (DKA)

A

kussmaul

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24
Q

breath fast for a while then stop, and then breath fast for a while and then slow down. Brain disorders

A

cheyne-stokes

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25
dyspnea when sitting up *liver disease
platypnea
26
dyspnea when supine (HF)
orthopnea
27
dullness in percussion indicates what?
decreased resonance noted with pleural effusion and other diseases
28
hyperresonance with percussion is indicative of what?
increased resonance either due to lung distention (COPD exacerbation) or focal air collections (bullous disease, pneumothorax)
29
are breath sounds increased or decreased in emphysema?
markedly decreased
30
if there is asymmetry in intensity, which side is abnormal?
the side where there is decreased intensity
31
with vesicular breath sounds, which component predominates?
inspiratory (turbulent airflow within the lobar and segmental bronchi) prdominates
32
Continuous musical sound lasting longer than 250 ms | Due to oscillation of opposing airway walls that are narrowed almost to the point of contact.
wheeze
33
clinically, wheezing indicates what?
airflow obstruction, though its absence does not exclude obstruction
34
long continuous adventitious sounds, generated by obstruction to airways Low-pitched, continuous sounds that have a tonal, sonorous quality
rhonchi - may be due to excess mucus in the airway that's moving around
35
localized rhonchi suggests what?
obstruction of any etiology (tumor, foreign body, mucus) rhonchi due to respiratory secretions will often disappear with coughing
36
High-pitched continuous sound heard over the trachea | Due to turbulent flow generated in the upper airway during extrathoracic airway obstruction
stridor - generally inspiratory
37
this tests measures the total amount (volume) of air exhaled during forced expiration (forced vital capacity) and the volume of air exhaled during the first second
spirometry
38
Bronchoprovocation
using maneuver (exercise) or inhaled medication (methacholine) to detect bronchial hyperresponsiveness (one of the defining features of asthma)
39
how much methacholine is given during bronchoprovocation?
concentration required to decrease FEV1 by 20% (PC20) - then give albuteral
40
in a chest CT, what IV contrast useful for?
to help differentiate hilar lumph nodes from pulmonary arteries
41
what is bronchoscopy useful for?
evaluation of pulmonary infections, diagnosing and staging lung cancer, diagnosing sarcoidosis, excluding endobronchial lesions (stenosis or tumor) and therapeutic aspiration (mucus plugging)
42
what is an ultrasound useful for?
diagnosing pneumothorax and pleural effusion (cannot visualize normal lung as air reflects ultrasound waves)
43
what is pulmonary HTN?
elevated pulmonary pressure * Pulmonary artery pressure greater than 25 mmHg at rest (normal is 12-16 mmHg) - elevated PA pressure results in the R ventricle pumping against elevated pressure often resulting in RV failure
44
who should be screened for PAH?
pts with family history of PAH pts with systemic sclerosis (scleroderma) pts with portal HTN being evaluated for liver transplant yearly screening
45
epidemiology of PH
prevalence not known - rare in gen population. at risk groups (HIV, SCD, portal HTN, scleroderma)
46
hallmark symptom of PH
SOB (50%)
47
other clinical manifestations of PH
atypical/exertional CP, exertional dyspnea, fatigue, syncope
48
PE findings for PH
early disease- often unremarkable PE loud pulmonic component of second heart sound, split second heart sound increased JVP signs of RHF (hepatomegaly, ascites, anasarca/edema)
49
diagnostic eval for PH
echocardiogram to start (non invasive, estimate PAP, assess both right and left heart)- better for screening than definitive dx chest xray also good, often incidental findings when CXR ordered for another reason, not good for definitive diagnosis, only suggestive of PH gold standard = lung biopsy
50
is EKG helpful to diagnose PH?
can show right heart hypertrophy or strain, right axis deviation, and RBBB. * cannot make dx of PH with EKG, but helpful in the evaluation of R heart failure
51
what is the preferred imaging for CTEPH (chronic thromboembolic PH)?
V/Q scan ( can see clots very nicely) if CTEPH on V/Q, pulmonary angiography is confirmatory test
52
why is exercise testing good for PH?
***establishes functional baseline - need to find out before tx (also need to know cause of PH) detects PH that is only symptomatic during exercise measures functional class prognostic
53
what is given during a right heart cath (RHC) as a vasodilator to see if change in PAP?
nitric oxide
54
what is a positive response in pulmonary vasoreactivity testing?
decrease in mean PAP by >10 mmHg to an absolute value less than 40 mmHg without change in cardiac output
55
diagnostic criteria of class 1 PH
PAP> 25 mmHg at rest measured by RHC PCWP less than 15 mmHg elevated pulmonary vascular resistance no thromboembolic disease, parenchymal lung disease, or systemic or metabolic disease associated with PH are present
56
diagnostic criteria of class 2
on a right heart cath, the following can confirm L heart disease is the cause of PH: PAP > or equal to 25 mmHg PCWP greater than or equal to 15 mmHg (indicating LHF) reduced CO (can be normal) L atrial enlargement
57
diagnostic criteria of class 3
elevated PAP on RHC PFTs indicating hypoxia CT scan indicating ILD
58
diagnostic criteria of class 4
elevated PAP on RHC evidence of thrombus or thrombi on VQ scan
59
differential Dx for PH
``` angina MI/CAD valvular disease/stenosis COPD CHF ```
60
treatment of PH WHO class 1
no effective primary therapy and advanced therapy and combination therapy is usually called for (only after all causes are exhausted and RHC is done) *treated differently bc therapy is directed at the PH itself not other causes Oxygen therapy (POx > or equal to 90% at rest, with exertion and during sleep) treat fluid overload diuretics (salt restriction, weight monitoring)
61
advanced therapies for PAH that target cellular pathways
endothelin - vasoconstrictor and mitogen nitric oxide - vasodilator and antiproliferative prostacyclin - vasodilator, antiproliferative, and inhibits platelet function
62
most efficacious combination therapy for PAH
combination of tadalafil and ambrisentan
63
treatment of group 2 PH
treat the underlying cause - reduced EF with ACE/ARB, diuretics - preserved EF- treat HTN with beta blockers - valve correction may resolve PH due to valvular cause
64
treatment of group 4 PH
surgery - pulmonary thromboendartectomy can be curative - lifelong anticoagulation
65
T or F: pulmonary HTN is an contraindication to judicious exercise
F - it is important to avoid deconditioning -mild breathlessness is acceptable, but pts should avoid exertional dizziness, near syncope or chest pain
66
prognosis of PH
can be fatal. - those with RHF/RV dysfunction have a poor prognosis - those with 6 min walk distance 150pg/mL
67
which PH group has the worst prognosis?
group 1 - epoprostanol improves survival - advanced therapies improve survival
68
what is the most common cause of bacterial pneumonia?
strep pneumo
69
clinical presentation of CAP
``` fever chills rigor tachycardia pleuritic CP (hurts when breath in) mucopurulent sputum cough shortness of breath nausea, vomiting ``` **Older patients: malaise, confusion common
70
physical exam for CAP
``` 80% are febrile respiratory rate above 24/min tachycardia crackles rales heard over involved SEGMENT increased tactile fremitus ```
71
gold standard to diagnose CAP
CXR leukocytosis (15-30k) if you order a CBC
72
when should sputum culture be used for pneumonia?
``` IDSA/ATS guidlines : sputum culture for hospitalized patients with signs and sx of pneumonia and : ICU admission failure of outpt antibiotic therapy cavitary lesions ETOH abuse structural lung disease pleural effusion ``` * not first line test in a CAP outpatient
73
do you need to know of pneumonia is bacterial or viral?
in theory, no usually treated empirically with antibiotics
74
outpatient tx of CAP
repeat CXR not indicated if patient clinically improving, although smokers and non responders may need another CXR to document resolution of pneumonia and assess presence of malignancy smoking cessation!!
75
risk factors for drug resistance PNA
- age > 65 - recent use of beta-lactam, macrolide, or quinolone (3-6 mos) - ETOH - comorbidities - immunosuppression - exposure to children in daycare
76
inpatient treatment (non ICU) of CAP
respiratory fluoroquinolone alone cephalasporin or carbipenem plus macrolide or doxycyline
77
inpatient ICU treatment of CAP
cover MRSA if admitted to ICU (add vancomycin) empiric therapy - IV beta-lactam plus macrolide or quinolone
78
difference between HCAP and HAP
HCAP - healthcare associated pneumonia : non hospitalized patient exposed to IV therapy/wound therapy in the past 30 days, residents in a nursing facility, hospitalization for 2 or more days within 90 days prior to discharge, attendance at hospital or clinic within prior 30 days HAP- hospitalized aquired pneumonia : pneumonia occurring > 48 hours after admission that was not present at time of admission
79
complications of pneumonia
``` destruction of lung tissue pleural effusion bronchectasis empyema lung abscess ```
80
transmission of legionnaires disease
aerosolization or aspiration of contaminated water (cooling tower, humidifiers, resp equipments) - usually linked to contaminated hot water supply. Not transmitted person to person
81
symptoms of legoinnaires disease
early: malaise, muscle aches, lethargy, and slight headaches. high fever, non-productive cough, abdominal pain, diarrhea late: extreme lethargy, comatose state. impaired kidney and liver functioning, nervous system disorders
82
when to suspect legionnaires disease
when patient is hyponatremic when patient has alot of extrapulmonary symptoms antibiotic failure gram stain shows PMNs with no organisms
83
white in lungs on CXR
blood pus (pneumonia) water (pulmonary edema) cells (cancer) protein or calcium - rare
84
what does a pleural effusion look like on an CXR?
dense white area, transitions through gray to black normal lung as you go higher you will be able to see the other diaphram in the lateral view most layer out in the lateral decubitus position
85
bilateral perihilar opacification ("bat-wing" patter) and cardiomegaly on a CXR is indicative of what?
heart failure
86
what would you see on a CXR for LLL pneumonia?
lose the left hemidiaphragm and descending aorta

clin med (12 decks)

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