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Flashcards in Pulmonary Deck (92):
1

COPD

2

Definition of chronic bronchitis?

Chronic productive cough for 3 months of each of 2 successive years

3

Definition of Emphysema?

Abnormal permanent enlargement of alveoli with destruction of alveolar walls without fibrosis

4

Definition of Asthma?

Airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

5

When is asthma NOT considered COPD?

Not all asthma is COPD; if asthma is REVERSIBLE it is not considered COPD

6

What patients are not considered to have COPD yet they have airflow obstruction?

These would be patients with a KNOWN etiology or specific pathology (CF, bronchiectasis, or obliterative bronchiolitis)

7

Number one cause of COPD?

(If you dont get this right youre a dumdum and should no longer be in medical school :-P)

Smoking

8

Technical definition of COPD?

Disease state characterized by airflow limitation not fully reversible. Airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles of gasses

9

What three main things occur in COPD?

  1. Mucus hypersecretion
  2. Disrupted alveolar attachment (desmosomes?)
  3. Mucosal and peribronchial inflammation and fibrosis

10

What happens to diffusion capacity in emphysema?

Decreases (an easy obvious answer)

11

Exposure risk factors for COPD?

  • Tobacco smoking
  • Passive smoking
  • Air pollution
  • Occupational exposure
  • Infections

12

Host factors for COPD?

  • Genetic mutations
    • Such as Alpha-1-antitrypsin deficiency
  • Reduced Lung growth
  • Airway responsiveness

13

Variants of alpha-1antitrypsin deficiency and the way their effects?

  • S varient
    • 60% of normal levels with no pulmonary effects
  • Z varient
    • 10% of normal levels
    • Accumulation of alpha-antitrypsin in the RER of the liver
    • Predisposition of juvenile hepatitis, cirrhosis, and hepatocellular carcinoma

14

FEV1 percentage representing severe disability?

25%

15

What are key indicators in the diagnosis of COPD?

  • Chronic cough
  • Chronic sputum production
  • Dyspnea
  • History of exposure to risk factors
    • Tobacco smoke
    • Occupational exposure

16

Diagnosis of COPD?

  • H & P
  • Lab exam
    • Imaging: XR, CT
    • Pulmonary function testing
      • FEV1/FVC<0.7 (hallmark of obstruction)
      • Decreased IC and Increased TLC/RV/FRC
      • DLCO decrease
  • Arterial blood gases

17

What is a key early finding on the physical exam of COPD?

Decreased breath sounds at the bases

18

Upon initial visualization of a patient with severe COPD, what action is indicative of an obstructive disorder?

Pursing the lips while breathing 

(they also use accessory respiratory muscles)

19

What are 2 very noticible things on an XR of an emphysema patient?

Hyperinflation

Flattened diaphragm

20

What is most important in the diagnosis of COPD?

  • Pulmonary functions testing
  • Understand the flow volume curves
    • Obstructive moves to the lefts
    • Restrictive moves to the right (R.. R)

21

In what COPD will you find decreased DLCO?

Normal DLCO?

  • Decreased
    • Emphysema
  • Normal
    • Bronchitis

22

Lung Cancer

23

What is occuring to the incidence of lung cancer in men?

Women?

Men: declining

Women: plateauing

24

Risk factors?

  • Smoking/second hand smoke
  • Prior radiation therapy
  • Environmental/occupational exposure:
    • Asbestos
    • Beryllium
    • Radon
  • Systemic disease
    • HIV or scleroderma
  • Pulmonary disease
    • COPD and Idiopathic pulmonary fibrosis

25

Is there any prevention?

Suggested CXR but not effective due to cost and likelihood.

No chemoprevention

Smoking cessation

26

Thoracic/pulmonary clinical presentation?

  • cough
  • shortness of breath
  • hemoptysis
  • post-obstructive pneumonia (from endobronchial tumor or bronchial compression from surrounding tumor)
  • Pleural effusion
  • SVC syndrome
    • from high mediastinal tumor. Facial edema

27

If there is fluid in the pleural space on the right side, which way will the mediastium shift?

Towards the left

28

Common metastasis?

  • Bone (Ribs)
  • CNS
  • Liver

29

Extrapulmonary symptoms?

  • Wt loss
  • fatigue
  • fever
  • **digital clubbing
  • paraneoplastic syndromes

30

What is a paraneoplastic syndrome?

Disease/symptom related to but not directly caused by the anatomic presence of cancer

31

Examples of paraneoplastic syndromes?

  • Hypercalcemia
  • SIADH
    • common with hyponatremia and will present with seizures
  • Lambert-Eaton
    • mimics myasthenia gravis but increased strength of contraction with increased stimulation
  • Dermatomyositis
  • Cushings

32

In what cancer is hypercalcemia more common?

SIADH?

Lambert-Eaton?

  • Hypercalcemia
    • Squamos cell
  • SIADH
    • Small cell (responds to chemo)
  • Lamber Eaton
    • Small cell
    • Fatigueable weakness

33

Diagnosis?

"No meat, no treat"

MUST BIOPSY

34

Types of biopsies?

  • Bronchoscope
    • Endobronchial brush or EBUS
  • Fine needle aspirate
    • CT guided for distant
  • Surgical biopsy (less common)

35

Subtypes of NSCLC?

  • Adenocarcinoma
  • Adenosquamos
  • Large cell
  • Squamos
  • Other
    • Mesothelioma
    • Combinations

36

Small cell carcinoma (formerly "oat cell"):

Aggressiveness?

Shape of cells? Stain?

What does it look like at time of diagnosis?

  • Highly aggressive
  • Round/oval cells that are highly basophilic
  • Necrotic at time of diagnosis
    • cancer is expanding faster than the vasculature

37

3 ways to stage? (NOT TNM)

  • By ability to resect (surgery)
    • mediastenoscopy
    • not resectable if metastatic
  • PET scan
    • radiolabled glucose for highly metabolic areas
  • Bronchoscope/EBUS

38

What does TNM staging refer to? (what is the TNM acronym)

  1. T = tumor
  2. N = nodes
  3. M = metastasis

39

What is a pancoast tumor?

How may it present?

 

  • A highly apical NSCLC tumor
  • Presenting symptoms can mimic Horner's 
    • compression of sympathetic ganglia?

40

Prognosis of NSCLC vs Small cell?

  • NSCLC
    • Stage 1: median survival of 59 months
      • most die of non-cancer related disease
    • Stage IV: 4 months
  • Small cell
    • Minimal 5 year survival even if caught early and treated

41

What does the Karnovsky performance status scale measure?

Implications for treatment via the level of functional capacity

42

GAS EXCHANGE AND ABGs 

I DONT EVEN KNOW WHAT THE HELL ABG STANDS FOR?

43

How much CO2 is produced from each molecule of acetic acid in the TCA cycle?

Equation?

  • 2 molecules
  • R = VCO2/VO2
    • R = 1 for carbs
    • R = .8 for protein
    • R = .7 for fat

44

What is the equation for alveolar ventilation? 

VA= VT - VD

  • VA = alveolar ventilation
  • VT = tidal volume
  • VD = dead space 
    • 1ml/ lb of body wt

45

Venous blood perfuses the alveoli at a rate equal to?

Cardiac output (Q)

So this is saying V/Q = 1?

46

What is the equation for oxygen content?

  • O2 content = [Hb] x 1.39 x Hb saturation %
    • = PO2 x .003

47

6 causes of hypoxemia?

  • Reduction in inspired PO2
  • Abnormal diffusion
  • Hypoventilation
  • Ventilation perfusion mismatch
  • Shunt
  • Nonpulmonary factors affecting PaO2

48

Normal inspired PO2:

  • What is PO2 at sea level?
  • What is the PAO2? Why is it different from PO2?

  • PO2 = FO2 (% in atmosphere) x Patm
    • = .21 x 760 = 160mmHg
  • PAO2 = FO2(Patm-47) - (PaCO2/.8)

49

What are two causes of hypoxemia due to reduction in inspired PO2?

  • Decreased FIO2
    • somehow oxygen content in the air is below .21
  • Increased elevation 
    • causes a change in Patm

50

Normal diffusion:

Gas transfer = ?

  • Gas transfer = diffusing capacity x (PA-Pcapillary)
    • Diffusing capacity of the membrane is proportional to the cross sectional area
    • Diffusing capacity is inversely proportional to the thickness of the membrane

51

Causes of hypoxemia due to decreased diffusing capacity?

 

Decreased diffusing capacity in individuals at rest?

  • Fibrosis/inflammatory lung disease: membrane thickening
    • As Thickening increases D.C. decreases
  • Diffuse alveolar destruction: decreased cross sectional area
    • As surface area decreases D.C. decreases

 

At rest decreased diffusion capacity rarely leads to hypoxemia

52

PACO2 = ?

Proportions?

  • PACO2 = (VCO2/VA) x K
    • K = constant
  • PaCO2 = PACO2
  • VE = VA

 

PaCO2 is inversely proportional to VE

53

What occurs to PaCO2 with hypoventilation? PaO2?

Rise in PaCO2 in hypoventilation leads to a proportional decrease in PaO2

54

Given PaCO2 = 80, calculate PAO2.

What is normal PAO2-PaO2?

  • Recall: PAO2 = FO2(Patm-47) - (PaCO2/.8)
    • PAO2 = (.21) (760-47) - (80/.8)
    • PAO2 = 50
  • Normal PAO2-PaO2 <15

55

Causes of hypoventilation stimulated hypoxemia?

  • Decrease in central drive
  • Decrease in functioning of the respiratory pump

56

What does V/Q = 0 indicate? Example?

What does V/Q = infinity indicate? Example

  • V/Q = 0
    • Perfusion but no ventilation
    • Example: a shunt
  • V/Q = infinity
    • Ventilation but no perfusion
    • Example: dead space

57

What can cause a decrease in V/Q?

  • Decrease in V due to airway disease
  • Increase in perfusion
    • Example: pulmonary embolism with shunting to nonembolized areas

58

What can cause an Increase in V/Q?

  • Decrease in perfusion
    • Example: there will be air in places without perfusion such as an area of embolus
  • Emphysema
    • lose of perfusion (due to alveolar destruction) is greater than the decrease in ventilation

59

With a V/Q inequality, how does increased ventilation of normal alveoli affect CO2 elimination? O2?

  • CO2
    • Because CO2 elimination is proportional to alveolar ventilation, alveoli CAN compensate for abnormal alveoli
  • O2
    • The O2 content curve flattens out at higher PO2 and therefore increased ventilation CANNOT compensate for abnormal alveoli

60

What are 3 causes of a shunt?

  1. Normal anatomical shunt
  2. Abnormal anatomical channels in patients with pulmonary hypertension
  3. Blood passing alveoli that are atelectatic or fluid filled

61

3 nonpulmonary factors that decrease PO2?

  1. Decreased cardiac output
  2. Decreased Hb
  3. Increased utilization of O2 by tissues

62

In a normal lung, how can decreased PO2 be increased (if caused by a nonpulmonary factor)

Increase in ventilation

63

Causes of hypercarbia?

  • Decreased respiratory drive
    • Narcotics
    • Obesity hypoventilation syndrome
  • Mechanical impairments to ventilation
    • Neuromuscular disease
    • Thoracic deformity (kyphoscoliosis)
    • Obesity hypoventilation syndrome
  • Severely impaired V/Q matching

*** see last page of notes for acid-base disorders? its mostly just equations. to know or not to know...

64

ILD Article

doin my best hurr 

65

Characterization of interstitial lung diseases?

 
 

Infiltration of cellular and/or noncellular material into the lung parenchyma. ( also alveolar airspaces,
blood vessels, and distal airways)

66

Major physiological consequence of ILDs?

Impaired gas exchange

67

Known causes of ILDs?

  • inhaled organic and inorganic substances
  • drugs
  • radiation
  • systemic disorders
    • connective tissue diseases (CTDs)

68

Most common form of ILD seen clinically? 

IPF, also called cryptogenic fibrosing alveolitis

69

 “definite” diagnosis of
IPF requires evidence of?

UIP ( usual intersitial pneumonia)  characterized by patchy collagen fibrosis with associated scarring distributed in a peripheral, subpleural
fashion with honeycomb changes

70

Clinical presentation for ILD of unknown cause?

Gradually worsening exertional dyspnea with inspiratory crackles (not heard in sarcoidosis) and restrictive lung disease or impaired gas exchange

 

 

71

What will you see on a high resolution CT for ILD?

Presence of bilateral and peripheral opacities and subpleural honeycombing with basal predominance

 

72

Second most common ILD = sarcoidosis.

Characterization of sarcoidosis?

Presence of noncaseating epitheloid granulomas (no finger clubbing or crackles; has nodules)

73

High resolution CT findings of sarcoidosis?

Nodular infiltrates with an upper and mid lung predominance (instead of IPF: basal). Affects peribronchovascular regions, the interlobular
septa, and the pleural surface

 

 

74

Common
forms of hypersensitivity pneumonitis in the United States?

just to fuck with you...

bird fancier’s disease, farmer’s lung disease and
“hot tub lung.” (those are real!!!)

75

types of drugs associated with ilds?

  • chemo - bleomycin
  • cardiovascular drugs - amiodarone
  • abx - nitrofurantoin

76

Drug induced ILD CT?

Shows diffuse alveolar damage, nonspecific interstitial pneumonia, eosinophilic pneumonia, and pulmonary hemorrhage
 

Histologically - nonspecific

77

Pulmonary Langerhans cell histiocytosis characterization?

Where may there be extrapulmonary manifestations?
 

Characterized by the proliferation of Langerhans cells in the lung with destruction of lung parenchyma (cystic changes on CT) and architectural manifestations.

Extrapulmonary manifestations:

  • bone, skin, pituitary, liver, lymph nodes, and thyroid

78

What is the most common ILD associated with a normal XR and sometimes even a normal high resolution CT?

 

Hypersensitivity pneumonitis

79

What ILDs affect peripheral lung zones?

Central

  • Peripheral
    • Chronic eosinophilic pneumonia
    • IPF, cryptogenic organizing pneumonia
  • Central
    • sarcoidosis and berylliosis

80

What is Traction bronchiectasis/bronchiolectasis?

dilatation and distortion of the
bronchi and bronchioles in areas of parenchymal fibrosis

81

Pulmonary function testing in patients with ILDs typically reveals?

restrictive pattern with reduced diffusing capacity

82

SHLEEEP

83

What is obstructive sleep apnea?

Cessation/decrease in airflow in the presence of breathing effort > 10 seconds.

Apnea-Hypopnea index (AHI) > 5 + EDS

84

What is Hypopnea?

Decreased airflow + 4% desaturation

85

What parts of the airway are implicated in an OSA patient?

  • Nasopharynx
  • Velopharynx
    • tongue base and soft palate
  • Hypopharynx
    • lower pharynx

86

What is a trend in the clinical findings of OSA patients?

  • Smaller airways
  • Larger structures that surround the airways

87

What is transmural pressure and how is it related to sleep apnea?

  • Pt = difference between the intraluminal and surrounding tissue pressure
  • At Pt decreases so does the cross sectional area of the pharynx 
  • When the net forces equal the closing pressure, OSA occurs

88

Risk factors for OSA?

  • smoking
  • menopause
  • alcohol use
  • sedative use
  • supine sleeping position

89

What is the "stop" mnemonic?

  • S: snoring (loudly, often)
  • T: tired
  • O: observation of apnea by another person
  • P: blood pressure increase

90

What is the "BANG" mnemonic?

  • B: BMI>35
  • A: age>50
  • N: neck circumference>40cm
  • G: gender - male

91

What is central sleep apnea?

Common findings?

 

Cessation/decrease in airflow in the ABSENCE of respiratory effort. 

  • Males
  • A. fib
  • >60yo
  • hypocarbia

92

Cardiovascular effects from OSA?

  • hypoxemia and hypercapnea
  • Increased negative intrathoracic pressure
  • hypertension
  • heart failure and arrhythmia 
    • bradyarrhythmia common
  • Renal disease
  • Stroke
  • Sudden death
  • 2x prevalence of coronary artery disease