Pulmonary Portion Flashcards
(118 cards)
1
Q
what are the three broad types of pneumonia source categories? which one is most common? which are most difficult to treat?
A
- community acquired pnuemonia (CAP)
**most common**
- healthcare/hospital acquired pneumonia (HCAP)
- most difficult to treat - ventilatror associated pneumonia (VAP)
2
Q
what are four important ways to reduce ventalator associated pneumonia (VAP)?
A
- avoid ET tube
- keep head of bed elevated
- reduce sedation
- hand washing
3
Q
what is important to do once you have finished treating pneumonia?
A
post treatment xray
want to make sure everything is cleared up and that the treatment has worked!
4
Q
what is the most common organism seen in pneumoniae overall?
A
s. pneumoniae
5
Q
what four patient populations make you at an increased risk for pneumonia?
A
- ETOH
- asthma
- immunosupressed
- elderly
6
Q
Typical pneumonia
what are four common organisms associated with this and their characterist sputum color? how long do symptoms increase? what are some of the things on the long list of symptoms
A
“common symptoms”, usually responsive to B-lactams
#1 most common: streptococcus pneumoniae (rusty red color)
#2: haemophilis influenzae (green sputum)
staph aureus
klebsiella (currant jelly)
pseudomonas (foul smelling)
SX:
1-10 day increase in cough, purlulent sputum, SOB, dullness to precussion, rigors, tachycardia bronchial breath sounds, tactile fremitis (say 99), friction rub, pleuritic chest pain, night sweats
7
Q
atypical pneumonia
A
“walking pneumonia”
usually unresponsive to beta lactam, use macrolide or fluorquinolone
1. mycobacteria pneumoniae (bullous myringitis..ear)
2. chlamydia pneumonia
3. legionella
4. viruses->
(RSV and parainfluenze in kids, and influenza in adults)
PE: often normal physical exam, can have extrapulmonary symptoms
DX: use macrolides (erythromycin, azithromycin, clarithromycin, doxycycline) or fluoroquinolones
8
Q
what are the three most common organisms that cause community acquired pneumonia (CAP)?
A
#1: streptococcus pneumoniae
#2: haemophilis influenzae (esp in COPD)
#3 mycoplasma pneumoniae (atypical)
9
Q
what are the three common organisms that cause hospital acquired pneumonia?
A
- gram negative pseudomonas
- ancinetobacter
- staph aureus
10
Q
what is the mortality rate in hospital acquired pneumonia?
A
50-70%
11
Q
what are the five tests you use to diagnose pneumonia?
A
- clinical syndrome, empirically
- gram stain- GCP
- sputum culture
- urine tests (only in legionella and pneumococcus)
- xray showing white infiltrate
12
Q
streptococcus pneumoniae=
A
pneumococcus
they are the same thing, so if used in a test question, they mean the same thing, its just an abreviated name for this **important since this is the most common organism to cause pneumoniae**
13
Q
if a patient has pneumonia with MRSA, what should you use to treat?
A
vancomycin
14
Q
streptococcus pneumoniae in pneumonia
(what color is the sputum? what is it sensitive to? what can happen if this is systemic? is there a immunization for this?)
A
- rusty blood colored sputum
- beta lactam sensitivity
- if systemic can cause confusion
**immunizable** this is what the vaccine is for!
15
Q
what is the treatment for patients with pneumonia? how long is the treatment regimen?
A
- 80% can be treated as outpatient with macrolide azithromycin/erythromycin/clarithromycin
(atypical or “walking pneumonia)
- if ths same patient has chronic illness combine with beta lactam
- if MRSA infection use vacomycin or fluroquinolone
**5- 14 day treatment**
16
Q
Explain the new vaccine regimen that is reccomeded?
A
PVC13: childhood vaccination
PV23: used in 65 +
****new recommendations say 65+ recieve BOTH, adults get PCV13 first then PV23 second 8 weeks later***
if they have already had PV23, wait a year and give PVC13
17
Q
explain which pneumonia organism these populations are at the most risk to get:
ETOH-
COPD-
CF-
Air-conditioning-
children
Children
A
ETOH- klebsiella
COPD- haemophilis influenzae
CF-pseudomonas
Air-conditioning-legionella
children
Children
18
Q
what is the most common lung cancer seen in non smokers?
A
adenovirus
19
Q
general bronchogenic carcinoma
“Lung cancer”
what is this the leading cause of? what are the two types? where are the four locations these mets are likely to spread? what is the main cause of these? what are 7 symptoms associated with lung cancer in general?
A
leading cause of cancer in men and women
made of two categories:
- small cell lung carcinoma
- non small cell lung carcinoma
mets to brain, bone, liver, lymph
SX:
****ASYMPTOMATIC, mostly incidental finding on CXR****
- ***change in nature of cough (squamous, small cell)
- hemoptosis
- vague nonpleuritic chest pain
- reccurent pneumonia
- WEIGHT LOSS ANOREXIA ASTHENIC (CLASSIC)
- HYPERCALCEMIA, don’t miss this
cigarette smoking is the main cause, 85% of lung cancer in smokers
20
Q
small-cell carcinoma “oat cell”
is this fast or slow? WHERE IS IT LOCATED? what is the doubling time? what are the 6 paraneoplastic syndroms associated with it? what is the treatment? what is the difference between limited and extensive stage?
A
bad actor!!-grows quickyl metastasizes early!! assume m micrometasizes on presentation!
CENTRAL bronchial epithelium (near hilum because thats where all the vessels are so it can get a lot of nuitrients)
doubleing time: 30 day!!!
limited stage: tumor on the same side of chest, supraclavicular lymph nodes, or both (20% 2 year survival)
extensive stage: anyhting beyond limited stage (5% 2 year survival)
associated paraneoplastic syndromes: cushings, hyponaturemia, SAIDH, periphreal neuropathy, eaton lambert, cerebral degeneration
TX: since it matastasizes so quickly, CHEMO is the treatment
21
Q
squamous cell cancer
which cells does this occur in? where is it located? how can you dianose/what is major symtom? what is a random paraneoplastic syndrome associated with this? what is interesting about the metastsis of this? who is this most common in?
A
MOST COMMON NON-SMALL CELL IN SMOKERS!!!
basal cells of bronchial epithelium
centrally located, frequency hemoptysis and change of cough, CAVITATION
hemoptosis diagnosed with cytology
late metastasis–so if you catch it early in the patient the prognosis is better!
paraneoplastic synderome: hypercalcemia
TX: surgical
22
Q
adenocarcinoma
what is this the most common of? where does the cancer occur and where does it appear? what does it metastasize to? what is the treatment? what are two paraneoplastic syndromes? what can you get it from? smokers or nonsmokers?
A
most common bronchogenic CA
common in non-smokers
peripheral, lung parenchyma
originates in the mucous glands of tracheobrachial tree and appears in the periphreay of lung
moderate growth and metastatic rate
NON SMOKERS, can get from ASBESTOS!!!
paraneoplastic syndrome: thrombophlebitis, PTH-rp
TX: surgical
23
Q
large cell cancer
where is this located? what is the doubling time? is there metastasis? what is the paraneoplastic syndrome? what is the treatment?
A
periphreal or centrally located
cavitation
rapid growth
early metastasis
doubling time 100 days
paraneoplastic syndrome: gynecomastic
TX: surgical
24
Q
bronchial carcinoid tumor
what type of tumor is this? where else is it commonly found? describe what this tumor would look like if you saw it? what does it secrete (4), what are two symptoms you can have with this? what is the treatment?
A
CENTRAL neuroendocrine tumor, slow growth, slow mets
also commonly found in GI tract
typical: SESSILE (attached to base) or pedunulated (cylander)
atypical
pink/purple well vascularized central tumor, pedunculated or sessile
secretes SEROTONIN, ACTH, ADH, MSH
often asymptomatic, but can have hemoptosis and c_arcinoid syndrome_ (diareah from increased serotonin and left sided hear fibrosis)
TX: steroids and surgery, resistant to chemo and radiation
25
what are the three types of non small cell carcinoma?
(NSLC)
**1. squamous, (smokers)** central with cavitary lesions
**2. adenocarcinoma** (non smokers), periphreal, Asbestos
**3. large cell** very aggressive!
26
which is more common, small cell or non small cell lung carcinoma
non small cell carcinoma
80-85% of LC
27
where are four most common places for metastases for lung?
liver-common
bone-symptomatic
adrenal
brain
28
\*\*\*\*\*which cancer is associated with paraneoplastic type syndromes\*\*\*\*\*\*
what are the 6?
SMALL CELL CARCINOMA
associated with:
cushings (buffalo hump), cortico levels, hyponaturemia, SAIDH, periphreal neuropathy, eaton lambert, cerebral degeneration
29
idiopathic pulmonary fibrosis
aka idiopathic interstitial pneumonia
what type of pulmonary condition is this? what is caused by? how long does a patient typically have after diagnosis? what are the three types?
RESTRICTIVE!!
**remodeling of the lung to look like _honeycomb lung_**, fibroblasts come in and lay down fibrosis tissue, can be associated with **age**
dismal prognosis, _3 years from diagnosis_
3 Types:
1. usual interstitial fibrosis
2. respiratory bronchiolitis, associated with this
3. acute interstitial pneumonitis
30
idiopathic pulmonary fibrosis
## Footnote
what are 3 symptoms you would see of this? what are the 3 tests you would use diagnose this? what do you see on them?
SX:
-inspiratory "squeaks" crackles
- clubbing of digits
- progressive dyspnea with dry non productive cough
DX:
**1. chest CT:**
**-diffuse reticular opacities with HONEYCOMBING, ground glass opacities**
**2. PFT shows decrease FEV1 and FVC, so FEV1/FVC appears normal**
**3. lung biopsy** important for confirmation
31
idiopathic pulmonary fibrosis
what is the treatment
none, you're out of luck!!
## Footnote
can give supplement O2 if needed but nothing has been shown to increase survival or quality of life.
lung transplant may be the only choice
32
who wants some pics of idiopathic pulmonary fibrosis?
these help to show honeycombing!!
33
acute bronchitis
## Footnote
What is this condition characterized by? how long does the cough last? what other symptoms might you see? what are 90% caused by (4)? what are the **3** bacteria that cause it in CHRONIC disease? when do you do a CXR?
**inflammation of trachea, bronchi, and bronchioles resulting from RTI or chemical irritant characterized by _COUGH,_ often follors URI**
_COUGH LASTS 10-20 DAYS!!_, SEE EXPIRATORY RALES/RHONCHI
90% caused by viruses including rhinovirus, adenovirus, coronavirus, and RSV
in chronic lung disease, commonly caused by: **haemophilis influenzae, strep pneumoniae, m cartillis**
CXR: ONLY DO IF TRYING TO DISTINGUIS BETWEEN THAT AND PNEUMONIA
34
acute bronchitis
## Footnote
what are the four OTC treatments for this? what is the DOC for bacterial and what two types of patients qualify for this treatment?
- hydration
- expectorants
- analgesics
- cough suppressants (children)
for bacterial: DOC **cephalosporin**
**-reccomended only for ELDERLY pt with underlying cardiopulmonary disease and a cough for \>7-10 days and ANY IMMUNOCOMPRISED PT**
**\*\*\***for acute exacerbations in otherwise healthy.....NO TREATMENT NEEDED\*\*\*\*
35
acute bronchitis in normal host
## Footnote
do you treat this patient? what is the requirement for the length of time before giving them treatment? what are the two abx reccomended if they meet the criteria? what is the treatment for the different age groups?
**THE TREATMENT WITH ABX IN NORMAL PATIENT HAS NOT BEEN CONFIRMED, use bronchodilators instead because they are more effective at getting rid of cough than abx**
exception: **\>10-14 days,** then can treat since this is beyond the viral process and happens in atypical pathogen like *mycoplasma pneumoniae, chlamydophilia, pertussis*
**\>55 years old= macrolide (mycins) or tetracycline**
**\>8= doxycycline**
36
bronchiectasis
## Footnote
explain the pathophys of this aka how does this happen? what are the two ways this can happen?
secondary disease that is caused by infection or other conditions that injure the walls of the airways or prevents the airways from clearing mucous. the mucous build up causes increased infection and each infection causes more damange and eventually the airways can't move air in and out from damage and scarring.
\*can be congenital with CF or from obstruction\*
\*as mucous builds up and stretches everything, the membranes become more floppy and can collapse easier, which is why this is obstructive, not just because of the mucous\*
37
if a patient has bronchiectasis what four infections do you worry about?
the mucous build up creates a perfect breeding ground for pathogens
#1: **haemophilis influenzae (most common in world)**
**#2: pseudomonas (CF, #1 cause in US)**
#3. mycobacterium avium complex (MAC)
4. aspergillis (brown sputum)
38
bronchiectasis
## Footnote
what are the 6 symptoms you would see with a pt with bronchiectasis? what are the 3 tests you would do to test patient for this? what would you see on these?
1. recurrent pneumonia
2. chronic cough
3. **hemoptysis (50-70%), bronchiectasis is main cause of this**
3. **foul smelling mucopurlulent sputum**
4. **clubbing (as seen with CF)**
5. crackles at base
DX:
1. **high resolution CT;** imaging of choice, dilated tortuous airways
**2. CXR;** crowded bronch markings, basal cystic spaces, _Tram Track markings (bronchial wall thickening)_, honeycombing, _signet ring sign (pulmonary artery coupled with dilated bronchus)_
**3. bronchoscopy** warrented to eval hemopytsis and remove secretions
39
bronchiectasis
what are the 4 treatment options?
1. ABX for 10-14 days for infections
2. supressive therapy
3. bronchodilators
4. lung transplant
40
solitary pulmonary nodules
## Footnote
what is the nickname for these? what makes it likely defined? what percent are benign/maligant? how do you diangnose? what are the three treatment for high, medium, and low maligancy risk?
"coin lesions", KEEP IN MIND THIS IS THE FIRST MANIFESTATION OF ANY TYPE OF LUNG CANCER, THIS ISN'T A CANCER TYPE BUT THE CLASSIFICATION FOR _ANY_ FIRST APPEARNCE OF CANCER
Defined:
**Most at asymptomatic**
60% benign, 40% malignant
often infectious granulomas from old reactive TB, fungal infection, or foreign body rxn
DX:
- CT for nodules
- PET for \>1 cm and intermediate probability
TX: if high probability....**RESECT LESION**
if intermediate......**biopsy**
if low... can be watched, need **CT every 3 months for a year, then decrease to every 6 months for two years**
***if***
41
what is kartagener syndrome? what is it associated with?
**associated with bronchiectasis**
classic triad:
1. sinusitis
2. situs inversus
3. infertility
42
what are three symptoms that can help push you towards cancer?
1. hemoptosis
2. fever
3. weight loss
43
sarcoidosis
## Footnote
what is this condition? what type of cells respond to this? what percent of people have lung involvment? what is the intial lesion called? and what about when its progressed? what are the 6 common parts of the body that it effects?
**MULTISYSTEM DISEASE MADE OF NONINFECTIOUS _NONCASEATING GRANULOMAS_** **CAUSING INFLAMMATION IN INVOLVED ORGANS**
the granumlomas form in response to _exagerated T cell response_, these granulomas "masses" take up space and disrupt organ function
90% have lung involvement
* initial lesion in lung called: CD4 T cell alveolitis*
* progression of disease: transforms into noncaseating granuloma*
***most effected: 1. pulmonary 2. lymphadenopathy (_hilar lymph nodes_) 3. skin** (erythema nodosa) **4. lupus pernio 5. PAROTID ENLARGEMENT 6. visual defects** (20%)*
44
what are the three tests you can do to confirm sarcoidosis?
**1. serum blood tests**
**-Leukopenia**
**-eosinophilia**
**-elevated ESR**
**-hypercalcemia**
**-hypercalciuria**
**2. CXR**
**billateral _hilar_ lymphadenopathy**
**2. elevated angiotensin** (40-80%)
**3. needle biopsy** needed to confirm _noncaseating granulomas_
45
what percent of people with sarcoidosis can be asymptomatic?
what is the treatment?
50% can be asymptomatic
Very responsive to **high dose corticosteroids!**
46
what percent of solitary pulmonary nodules are primary lung cancer?
75%
47
what is the structure of influenza? what family? what types?
- single stranded RNA
- orthomyxovirdae family
- A, B, C types
48
what is the composition of influenza A? of these two, how many are there in humans?
hemagglutinin (HA)
neuramidase (NA)
3 HA types in humans
2 NA types in humans
49
pulmonary embolism evaluation
## Footnote
explain the pathway that is followed to rule in or out a PE and determine wha ttesting to do?
INITIAL:
low risk=PERC
everything else=**HELICAL CT angiography**
SECOND:
low PERC-\>WELLS
neg PERC=STOP
THIRD:
HIGH WELLS=helical CT
LOW WELLS=D-dimer
\*\*keep in mind gold standard it pulmonary angriography\*\*
50
what are 3 challenges of containment of influenza?
1. short incubation time (1-7 days)
2. ability for person with asymptomatic infection to transmit virus (can be contagious 1 day before symptoms)
3. early symptoms of illness are likely to be non-specific, delaying recognition (need to get antivirals on board within 48 hours of onset)
51
influenza
## Footnote
what are the three types and which one is most pathogenic? what is the season for this disease, how is it spread and how long can it survive on a surface? how long does it incubate? how long do symptoms last? when is a person contagious? when is peak shedding and what does it correlate with? what is the definition? what is the best choice for diagnosis?
3 types; A (most pathogenic), B, C; neuramidase and hemmaglutinin make up the subtypes
**Fall/winter outbreaks (october-november)**
spread through **aerosolized droplets**, can live on surfaces **2-8 hours**
1. incubates 1-7 days, avg 3
2. symptoms last 3-7 days, but up to 14
**3. contagious 1 day before symptoms, 5-7 days after**
**4. peak shedding 3 days of illness, correlates with fever**
**fever \>100 or 37.8C AND cough or sore throat in absence of know cause, ABRUPT onset,** can have myalgia in legs and lumbosacral area. Emergency if CNS symptoms.
PCR is best choice for diagnosis, can do rapid from throat or nose, but not as good
52
what is the best way to prevent influenza?
## Footnote
what are the two mechanisms of this? which age groups should be considereded for these two methods? what form is the virus in? which patients should you NOT use this in???
IMMUNIZATION!!
1. **inactive intradermal vaccine:** innactive, trivalent, quadrivalent, recombinant, higher antigen, contains 3-4 viruses, 70-90% effective **everyone older than 6 months**
**2. intranasal:** live attentuated, **2-49 year old**, caution in \>50 or pregnant
\*\*\*_don't use if allergic to eggs or gelatin\*\*\*_
53
what are the treatment options for influenza?
how are they used?
when do they need to be started?
who don't you use these in?
**neuriamidase inhibitors**
- oseltamivir
- zanamirvir
used for treatment and prophylaxis
**need to be started within 48 hours**
**don't use in**
54
what do you worry about when a child has influenza and are given asprin? what is the fatality rate?
REYE SYNDROME
(fatty liver and encephalopathy)
happens when pt has viral infection and given asprin, occurs 2-3 weeks after with a **30% fatality rate**
55
what is the structure of influenza? what family? what types?
- single stranded RNA
- orthomyxovirdae family
- A, B, C types
56
what is the composition of influenza A? of these two, how many are there in humans?
hemagglutinin (HA)
neuramidase (NA)
3 HA types in humans
2 NA types in humans
57
what are 3 challenges of containment of influenza?
1. short incubation time (1-7 days)
2. ability for person with asymptomatic infection to transmit virus (can be contagious 1 day before symptoms)
3. early symptoms of illness are likely to be non-specific, delaying recognition (need to get antivirals on board within 48 hours of onset)
58
pleural effusion
## Footnote
what is an effusion? what are two causes? what are the four different types? what are four symptoms? what are the two radiology views you wanna do and what do they show?
abnormal accumulation of fluid in he pleural space
can occur from inflammation of the structures adjacent to the pleural space or lesions within the chest cavity
four types:
**1. transudative**
**2. exudative**
**3. chylothorax**
**4. hemothorax**
_dyspnea, decrease breath sounds and dullness to percussion_
DX:
**AP view:** blunting of costophrenic angle, loss of sharp demarcation of diaphram, **mediastinal shift to uneffected side**
l**at decbutus view**: patient lays on side, allows you to see smaller effusion and differentiate between free flow vs loculated fluid and empyema
**thoracentsis: GOLD STANDARD**, maximal removal 1.5 L in one session
59
transudative pleural effusion
## Footnote
how does a transudative pleural effusion occur? what type of fluid would you find? what is the most common cause of this? what percent of people are effected with this and what test do you do to confirm this? and second most common cause of this?
increase pressure in the capillaries causes it to push out into the lungs this is NOT INFLAMMATION, just fluid relocation
**low protein serous fluid**
**#1 cause: Heart failure 90% of cases** fluid backs up from right side of the heart and increases pressure and pushes it into the lungs **right sided heart failure, BNP \>1,500**
**#2 cause: cirrhosis/nephrotic syndrome**
60
exudative pleural effusion
## Footnote
what is this caused from? what is another name for this? what does the fluid contain and what can form that needs surgical removal? what are the 4 lab characteristics for this? what are the four most common causes? what is the treatment, and the specific 3 treatments if malignancy related? what are the three common cancers that can cause this?
leaky capillaries are cause from **INFLAMMATION FROM INFECTION, the inflammatory mediators cause the capillaries to be leaky and allow fluid into the lungs**
**also called "parapneumonic effusion"**
**_fluid filled with cytokines, WBC, proteins, interleukins, the purlulent fluid can form an empyema that requires surgical removal "infected cyst"_**
**_PH_**
Cause #1: bacterial pneumonia
Cause #2: malignant cause aka lung cancer, metastic breast cancer, and lymphoma
Cause #3: PE
cause #4: TB (confirm with AFB stain)
TX: antibiotics specific for infection type, drainage and if malignant source *portable catheter, chest tube or thoracostomy, sclerotic agent like talc or doxycycline to prevent it from happening again*
61
what percent of pleural effusions are related to malignancy?
25%
HOLY MOLY
62
what are the requirements for thoracentesis for a pleural effusion? (3)
1. pleural fluid protein to serum fluid protein ratio **\>.5**
2. pleural fluid LDH to serum LDH ratio **\>.6**
3. pleural fluid LDH greater than **2/3** the upper limit of normal serum LDH
63
what are 80% of malignant pleural effusions caused by?
asbestos exsposure
malignant mesothelioma
64
Pulmonary Embolism
explain the pathophysiology of this and what happens!
1. pulmonary vascular bed by thrombus
2. **vasoconstriction in pulmonary artery**, this mechanism isn't well understood it just happens in the body as protective function, however, it actually has worse effects and harms the body
3. **increased pulmonary vascular resistance (PuVR)** from vasoconstriction by **neurohumoral reflexes and hypoxia**
4. continues to increase pulmonary artery pressure
5. **increased right heart strain from backed up fluid** leading to **right heart failure THIS IS OFTEN CAUSE OF DEATH**
6. **increased alveolar dead space**, ventilated but not profused, leads to decreased surfactant, atlectasis, and **V/Q mismatch from impaired gas exchange**
7. V/Q mismatch leads to **_right to left shunting_** where blood is redirected to non obstructed lung for oxygenation
all of this causes decreased pulmonary compliance, increased work of breathing so the patient becomes tachypnea and has to work harder to inflate the lungs
65
what are 3 risk factors for DVT? what is this collectively know as?
1. **venous stasis** (immobility, post op, post stroke)
**2. increased venous central pressure** ( decreased cardiac output, CHF)
**3. hypercoagubility** (meds, malignancy, **FACTOR V LEIDEN)**
_collectively known as virchows triad_
- hypercoaguble
- venous stasis
- vascular intima inflammation or injury
\*\*slight difference between two so I included both\*\*
worry specifically about orthopedic, pelvic, or abdominal surgery or OCP
66
pulmonary embolism
## Footnote
what are the 3 symptoms a patient with often present with ? what are 6 signs you may see on examination?
**_tachypnea, dyspnea, pleuritic chest pain (sharp stab) on inspiration_**
must have high suspicion because 50% of pt lack these characteristc symtoms
clinical signs:
**1. crackles**
**2. S4 gallop** (since right ventricle get stiff from the increase in pressure you hear right atrial contraction)
**3. decreased S2 splitting**
**4. friction rub**
**5. positive homans sign** (calf pain with dorsiflexion)
**6. plasma D-Dimer** (elvated in thrombus/degredation of fibrin)
67
pulmonary embolism
## Footnote
what are the four test you use to diagnose and what would you see on each test? Explain the flow chart for PE diagnosis?
**1. CXR-atelectasis, pleural effusions, infiltrates**
- **westermarks sign** (avascular markings distal to embolus)
- **hamptons sign** (wedge shaped infiltrate that shows infarction)
2. **Helical CT angiography**
proximal vessel thromboembolism
**3. EKG- S1Q3T3 classic for cor pulmonae**
**4. Pulmonary angiogram GOLD STANDARD**
-the issue with this test is it is an invasive procedure that puts a catheter in the heart and injecting dye into a high pressure area, people can have a reaction to the dye or the kidney can be effected _only indicated when VQ and CT scans are indeterminant and PE is still suspected_
probability PE 4+
68
pulmonary embolism
## Footnote
what are the four treatment options and order for treating PE? when do you use each and explain them!
FULL ANTICOAGULATION FOR 3-6 MONTHS, LONG IS BETTER AND MOST DO 6 MONTHS \*\*THIS PREVENTS FUTURE CLOTS\*\*
**1. LMWH or unfractioned heparin**
low molecular weight heparin is usually preferred because it has a more predictive dose and is the same if not more effective that unfractioned heparin, but some people still use it **5-7 days while transitioning to warfarin**
2. **warfarin**
goal PTINR 2-3, can use new oral drugs like **dabigatran, rivroxaban, apixaban** they don't need monitoring and may work better than warfarin, but more $$$
_FULL ANTICOAGULATION FOR 3-6 MONTHS, LONG IS BETTER AND MOST DO 6 MONTHS \*\*THIS PREVENTS FUTURE CLOTS\*\*_
3. **Streptokinase, urokinase, TPA**
used in urgent situations to directly lyse intravascular thrombi and accelerate the 1st 24 hours, _does not decrease mortality_ which is why it is used in URGENT cases
**4. mechanical/surgical extraction**
this is **LAST RESORT** when the patient is hemodynamically unstable and is bascailly going to die anyway because the surgery is a basic death sentence by opening them up and taking out the clot
69
when wouldn't you do a mechanical/surgical intervention for PE? (5 things)
1. if the patient is hemodynamically stable
2. active internal bleeding
3. stroke in prior two months
4. trauma in the last 6 weeks
5. uncontrolled hypertension
70
what can you do in a patient who has an absolute contraindication for coagulation for PE prophylaxis?
venal caval interruption filters
71
where is the most common site for development of a thrombus/embolus?
DVT is most common in
**popliteal**
**iliofemoral**
**pelvic veins**
90% arise here!
calf involvement alone is much less risky!
72
what is the test of choice for DVT?
venous ultrasound with doppler (non-invasive)
73
what is the criteria you use to determine the probabillity of DVT/PE?
wells score
## Footnote
over 2 mod probability
over 6 high prob
74
pulmonary hypertension
## Footnote
explain the sequence of event that cause this? what is the most potent stimulus of this pathway and explain why this happens?
patient with hypoxemia...
1. **increase pulmonary vascular resistance**
2. **increase in pulmonary artery pressure**
3. **increase in right ventrical**, increases so much it can't handle the pressure
4. **chronic right ventricle pressure causes right ventricle hypertrophy** where it tries to thicken the walls to make it stronger so it can handle the increase in BV
5. eventually this leads to **right ventrical failure**
_hypoxia is the most important and potent stimulus of pulmonary vasoconstriction_ think about this...its really counterintuitive, if a patient is hypoxic, you would think the body would vasodilate to get more blood to the lungs to be oxygenated but for some strange reason the body decides to vasoconstrict, which only exacerbates the issues because it caues pulmonary hypertension in ADDITION to hypoxemia and creates a positive feedback loop where the body downward spirals into heart failure from hypoxemia
75
pulmonary hypertension
## Footnote
what are the two different causes of pulmonary hypertension? what are the examples under those categories that can cause them? (1/5)
**idiopathic**: unknown cause, rare, fatal within 5 years of diagnosis, **some random correlation with anorexigens** or fat burning pills *fenflouramine, women 30-50, 20% familia*
**secondary:** caused by pretty much any lund disease that causes hypoxemia because it inself is enough to vasconstrict the pulmonary arteries *PE, vasculitis, SLE, emphysema* **chronically increase in venous pressure causes HF and mitral stenosis**, can be congenital like in septal defect
76
explain three causes that can contribute to pumonary hypertension? what is the most important?
1. hypoxemia \*\*\*most important\*\* automatically stimualtes pulmonary arterial vasoconstriction
2. acidosis
3. venocclusive conditions
77
according to the clinical peals book, when looking at the heart, what are four causes of pulmonary hypertension?
**1. left heart could have decreased forward flow** so it backs up into the pulmonary system
**2. increase in flow from the right side of the heart** causing the pulmonary pressure to increase
**3. issues with pulmonary vasculature**
**4. hypoxic vasoconstriction**
\*\*cause can be either cardiac or pulmonary\*\*
78
pulmonary hypertension
## Footnote
what are 8 symptoms you would see with PH?
symtoms:
1. dyspnea exertion and rest
2. retrosternal CP that minics angina
3. increase JVP
4. increase right ventricle impulse
5. loud s2
6. S4 gallop
7. TR murmers
8. systolic ejection click
79
pulmonary hypertension
## Footnote
what are the 3 tests you use to diagnose PH? what are 2 things you find on the first? 3 on the second? and how does the last one work? what three drugs do you test?
**1. CXR**
- dilated/enlarged pulmonary arteries
- pruning vessels
**2. echocardiogram**
- right ventricular hypertrophy
- atrial hypertrophy
- right ventricular strain
**3. cardiac cath (right heart)**
-measure the pulmonary artery pressure, then do drug testing and see if using vasodilators or calcium channel blockers work to decrease hypertension so that you can figure out which drugs can help the patient **adenosine, epoprostenol, nitric oxide**
80
pulmonary hypertension
## Footnote
what are the 5 treatment options for pulmonary hypertension?
1. calcium channel blockers if sensitive from cath, *lower systemic arterial pressure*
2. phosphodiesterase-5 inhibitor **sildenafil** *pulmonary vasodilation*
3. prostacyclins *potent pulmonary vasodilator*
4. endothelin receptor antagonist **bosentan**
5. heart-lung transplant usually needed
81
asthma
## Footnote
what type of OBSTRUCTION is this? when does it typically develope? what are 5 things that can cause it to develope? what are the **3 main characteristics** of asthma?
**ACUTE REVERSIBLE OBSTRUCTION**, can develope anytime but typically
-genetic, inflammatory infiltrates, injury to epithelium, thickening of airway, hyperresonsiveness
3 contirbutory causes:
**1. airway obstruction**-smooth muscle constriction, bronchial wall edema, thick mucous obstruction
**2. bronchial hypersensitivity-** stimulation from a mechanism either _intrinsic (non IgE)_ or _extrinsic (allergen stimulated)_
**3. inflammation of the airways**-leukotrienes, histamine released from mast cells
82
explain the pulsus paradoxus that can be seen in asthma? why can asthma patients have decreased periphreal pulses?
- asthma is obstructive, so patients have a hard time getting air out, the increase in lung volume leads to an increased "sucking" effect where blood is pulled into the heart, the increase pressure and volume strains the right side of the hear and can push the intraventricular septum into left ventricle, causing less outflow and periphreal circulation= decreased periphreal pulses
- systolic pressure drop \>10 mmHg during inspiration
in healthy: the decrease pressures in the chest during inspiration causes the blood to come back to the right side of the heart and go towards the right venticular wall, and there is only a small drop in systolic pressure
In tompenade: the increase blood flow and pressure on the right ventricle during inspiration can't be distributed on the right ventricular wall, and instead is transmitted to the ventircular septum, causing a decrease in left ventricular filling and the reason you see the periphreal pulses decrease since decrease stroke volume and a lower systolic blood pressure
83
what are the four mediators of asthma? what do each of them do?
1. **acetylcholine**- NT released via vagus nerve leading to _bronchoconstriction_
**2. histamine**-_bronchoconstrictor_ in mast and basophils in lungs, in the present of inflammation it promots _capillary leaking_
**3. kinins**-_bronchoconstrictor_ released by mast cells
**4. leukotrienes**-_smooth muscle constrictor_, increased mucous production
84
intrinsic vs. extrinsic asthma
## Footnote
explain the difference between the two? what are examples that can cause them? who are they most common in? is there a genetic link?
**INTRINSIC:**
**1. NONallergic triggers** infections (viral, bacterial), pharmocologic, emotional, occupation, stress, asprin, weather etc.
**EXTRINSIC:**
1. **ALLERGIES**- _largest risk factor for developing astma_, **ATOPY, most common in children/adolescents,** there is genetic disposition (tabacco, smoke, GERD)
85
asthma
## Footnote
what are 3 symptoms you might see with asthma?
* highly variable presentation*
1. coughing/wheezing/chest tightness/SOB
2. **note: in severe asthma, wheezing may decrease or stop because of decreased airflow**
3. decreased FEV1 and FEV1/FVC
86
what is the admission and discharge criteria for a patient and the hospital?
**admission criteria:** Peak expiratory flow rate (PEFR)
**discharge criteria:** Peak expiratory flow rate (PEFR) \>70% predicted
87
explain the four classifications of asthma severtiy and the treatment used for each step? WHAT SHOULD YOU NEVER DO???
**_Intermittent_**:
**FEV1\>80%, symptom frequency**
-DOC SABA, albuterol
**_Mild persistent:_**
**FEV1\>80%, symtom frequency \>2times/week**
- SABA, albuterol +
- inhaled corticosteroid, fluticasone (if already taking this, increase dose)
- if unresponsive, oral corticosteroid, prednisone
**_moderate persistent:_**
**FEV1 60-80**
- above, +most warrent hospitalization/O2 supplementation
- repetitive/continous use of beta agonists in nebulizer with systemic corticosteroid IV
- continous monitoring PEFR and PCO2
**_severe persistent_**:
**FEV1**
-SAME AS ABOVE
\*\*\*\*\*\*\*\*\*\*NEVER SEDATE A PATIENT DURING ACUTE RESPIRATORY EXACERBATION BECAUSE IT CAN DECREASE THEIR RESPIRATORY DRIVE\*\*\*\*\*\*\*\*\*\*\*\*
88
asthma
## Footnote
what are the 5 tests you can do to help diagnose asthma? what are the results you woudl expect to see?
1.
2.
3. (3)
4. (1)
5. (4)
_1. Peak expiratory flow rate (PEFR)_
_2. pulse oximetry_
_3. **PFT GOLD STANDARD, proves reversible obstruction**_
**-decreased FEV1**
**-decrease FEV1/FVC**
\*\*give bronchodilator, then this improves\*\* postivie if **\>10% increase in FEV1 after bronchodilator**
_4. bronchoprovocation challenge test_
give histamine/allergen OR METACHOLINE, and FEV1 decreases by 20%, this is DIAGNOSTIC
_5. arterial blood gas_
Respiratory alkalosis
hypoxemia
PaO2
PCO2
89
what is the atopic triad that you see with extrinsic (allergy induced) asthma?
\*\*this is the greatest predisposing factor for asthma\*\*
1. wheeze
2. eczema
3. rhinnitis
(TYPICALLY AT NIGHT)
90
explain the receptors in asthma to understand how the medications work?
you want to activate the **beta receptor because this causes _relaxation_**
you want BLOCK the **muscarinic receptor** **because this causes _constriction_**
91
what weird condition is randomly assocaited with a persons risk for developing extrinsic (allergy) associated asthma?
ECZEMA
werid!!!
92
what is the single largest risk factor for developing asthma?
ATOPY
ALLERGIES!!!
93
explain the receptors in asthma to understand how the medications work?
you want to activate the **beta receptor because this causes _relaxation_**
you want BLOCK the **muscarinic receptor** **because this causes _constriction_**
94
obstructive sleep apnea
## Footnote
what are the qualitifications to have this? what physical body part fails during this? what are the daytime symptoms and what are the nighttime symtoms? what test is most important for diagnosis?
**repetitive cessation of airflow at the _naso or oropharynx (caused by their passive collapse)_ that occurs during sleep**
**stop breathing for \>10 secs or hypopnea decrease in airflow , must have at least 5 episodes**
daytime symptoms: excessive sleepiness, sore throat, depressing, morning headache
nighttime symptoms: loud snoring, snort or gasp to wake up, apneic episode witnessed
**DX: polysomnograph (PSG) sleep study!!** can do EEG if brain is stimulated, or TSH
95
obstructive sleep apnea
## Footnote
what is the most important treatment for this? what are some lifestyle adjustments you can make?
nasal continous positive airway pressure (CPAP)
## Footnote
literally forces the air in so that way the airway can't collapse
lifestyle changes: loose weight, avoid alcohol before bed, change sleeping positions, pharyngeal surgery
96
obstrucive sleep apnea
what are six RF and which is the most important one??
**OBESITY (85%)...so loose weight**
male
\>40
alochol before bed
**anatomic narrowing of nasopharynx**
**neck size,** large tongue
97
COPD
## Footnote
what number cause of death is this? what is this characterized? what are the two conditions that contribute to this diagnosis? what is the pathophys of this disease and how it occurs?
**3rd leading cause of death in US,** rates increasing
**progressive air flow obstruction**
chronic bronchitis (cough) and emphysema(enlarged sacs) these two contribute to this, it can be one or both, depends on the person
**1. loss of elastic recoil:** smoking leads to chronic inflammation and decreased protective enzymes (alpha-trypsin) and increases damaging enzymes (elastase from neutrophils and macrophages), this causes **alveolar capillary and wall destruction= _decrease gas exchange_ surface area and _elastic recoil_** \*makes expiration active process\*
**2. increased air resistance from above**
98
what is the most contributory cause of COPD?
smoking in 90%
99
what is the only genetic link with COPD?
alpha-1 antitrypsin deficiency
in patients younger than 40, associated with premature COPD
**this enzyme protects the elastin in the lungs from being degrated by elastase released by WBC**
100
what is really important to make sure the COPD patients do?
**VACCINATION**
1. pnuemonia
2. influenza
\*\*\*they can get sicker faster! prefect breading gound\*\*
101
what three bacteria are COPD patients particullarly suceptible to? what do you do for treatment?
1. **s. pneumoniae**
**2. hae influenzae**
**3. moraxella** **catarrhalis**
\*\*\*use antibiotics to treat these! don't usually prescribe COPD patients antibiotics, doesn't help underlying condtion\*\*
102
explain the 3 surgical options considered if a patient has respiratory failure from COPD
1. lung transplant
2. lung volume reduction surgery for diffuse emphysema
3. bullectomy, remove large bullae and reduce deadspace to increase V/Q mismatch (seen in pic, these are seen with emphysema, big floppy airs of the sacs that are huge from elastin destructio nand dn't function. by rmoving this you decrease dead space!
103
COPD staging
## Footnote
explain the four stages of COPD and the medication classes you would use to treat or any other methods?
**_Stage 1_**:
**mild, FEV1\>80%, FEV1/FVC**
-bronchodilators, vaccination
**_Stage 2:_**
**moderate, FEV1 50-80**
short term bronchodilators, long term bronchodilator
**_Stage 3:_**
**severe, FEV1 30-50%**
Short and long term bronchdilators, pulmonary rehab with inhaled glucocorticoids
**_stage 4:_**
**very severe, FEV1 , cor pulmonale**
-above plus O2 therapy, must consider *surgical options* or roflumilast
104
when would you hospitalize a patient for COPD? (5 things)
1. rapid severity
2. worsening hypoxemia
3. advanced age
4. arrythmias
5. poor hom support
105
what do you need to watch for in a patient who has COPD?
cor pulmonale (esp with bronchitis)
multifocal atrial tachycardia, check with EKG
106
emphysema-COPD
## Footnote
explain the pathophys of this and the two many things that happen? what does this cause?
OBSTRUCTIVE
**abnormal and permanent enlargement of the air sacs, causing gradual destructon _without fibrosis,_** the membrane gets damaged and becomes bigger, stretched out and floppier
1. alveoli have decreased elastic recoil
2. bronchioles more likely to collapse
**THIS LEADS TO OBSTRUCTION FROM EXPANDED ALVEOLI, AIR TRAPPING=decreased ability for RECOIL and SHUNTING OCCURS due to issue with perfusion (diffusion)!**
"floppy sacs"
Premature collapse of respiratory bronchioles in expiration results in air trapping; result is “obstructive picture” on PFT’s
the destruction of the alveoli and vasculature leads to *V/Q mismatch with shunting and alveolar dead space*
107
what lab results can suggest COPD? (2)
1. PFT GOLD STANDARD
- FEV1/FVC
2. ABG
- normal early on
- decreased PO2 with progression
- PCO2, usually normal, but can decrease in progression
108
COPD TREATMENT
## Footnote
what is the most improtant factor? what is the goal of treatment? what are the two main classes you use and the drugs within those class? what do you need to do for COR pulmonale?!?!
most important is **_SMOKING CESSATION!!_**
goal of treatment: improve functional state and relieve symptoms
**_Anticholingerics_**
superior to B-agonists in achieving bronchodilation, since COPD has increase airway tone from acteylcholine, has less side effects **ipratropium (short), tiotropium (long)**
**_bronchodilators_**
most important agent to decrease symptoms **albuterol, salmetrol**
**\*\*\*\*if cor pulmonale, USE OXYGEN!!!! this is the only therapy proven to decrease mortality!!!\*\*\*\***
109
emphysema-COPD
## Footnote
Name 8 symptoms you would see on PE. what would you see for the FEV1, FEV1/FVC, DLCO, CXR (2)?
1. tachypnea, tachycardia
2. **barrel chested, increase AP diameter**
3. decrease breath sounds
4. **hypersonance/hyperinflation**
5. pursed lip breathing "pink puffers"
6. respiratory alkalosis
7. wheezing/whistling
8. **prolonged expiratory phase since obstructive**
TESTS:
1. FEV1-decreased
2. **FEV1/FVC- FVC stays the same just takes longer to get it out**
2**. increase RV (**increase in RV since air trapping and can't get air out)
3. decreased DLCO in later stages, increased dead space!
4. CXR: hyperinflation, flattened diaphram
110
what can you see in severe emphysema?
bullae or blebs
"large cystic areas in the lungs
INCREASED DEAD SPACE
111
chronic bronchitis-COPD
## Footnote
explain the pathophys of this and how it occurs?
**cough and plegm for 3 months for 2 years**
**airways clog with mucous cause obstructed airflow**, **particularly obstructs expiration**
1. inflammation of conducting airways, damages the respiratory epithelium causing loss of cilia
2. columnar cells may be replaced by squamous cells (metaplasia)
3. **airway narrowing (remember chronic bronchitis is an inflammatory issue!!!)-\>increases mucous secretion, hypertrophy of glands and smooth muscle, causing bronchospasm**
4. bronchospams increases the work of breathing and decreases ventilation of distal alveoli
5. causes **V/Q mismatch**
**positive feedback loop, continues**
112
what often causes exacerbations of COPD caused from chronic bronchitis? what is the complication you really worry about?
minor URI, esp in winter months
complication: pulmonary hypertension leading to heart failure
113
COPD-chronic bronchitis
## Footnote
what are the 8 symtoms you would see?
1. excessive "smokers" cough
2. excessive phlegm
3. crackles from mucous
4. **increased expiratory since obstructive**
5. **wheezing**/rhonchi
**6. resipiratory alkalosis (the pt is breathing faster immediately as the CO2 rises, so...they are hyperventilating causing alkalosis...initially see patient increase CO2 that initiates the hyeprventilation, but this happens so quickly that you never actually see patient in acidosis)**
7. **periphreal edema and cyanotic "blue bloaters"**
8. decreased FEV1, FEV1/FVC ratio
114
what is the treatment for COPD-chronic bronchitus?
the exact same as emphysema, so see that flashcard!
115
What is the 2 step process in emphysema causing
1st: obstructive issues
2nd: diffusion issues
in the green book how does it explain emphysema in one sentence ?
and what is alveolar septae
Step 1: Elastase startes to break down elastin in CT tissue around alveoli causing the alveoil to get really big! this casues obstructive resp issues because the air is gettig tapped in the huge alveoli. Usually expiration is a passive process due to recoil but with degredation of elastic in CT the alveoli got huge and lost a lot of its recoil causing air trapping and obstructive resp disease. This also negativly effects ventilation but perfusion is still okay (this is a prime example of V/Q mismatch)! because ventilation is affected we see shunting
Step 2: this is more rare in emphysema but still important to understand! The elastase does not stop its degradation of elastin in the CT it continues to the alveoli membrane and begins to degrade the membrane! this is very bad because this will now effect DIFFUSION because it is affecting the membrane. Since diffusion is now effected we have increase DEAD SPACE! this can lead to an area of dead space called a BULLAE and could lead to the patient needed a bullectomy !
IN the green book: it describes emphysema as a condition in which the air spaces are enlearged as a consequence of destruction of alveloar suptea
Alvelolar septum (sputae) separates adjacent alveoli in lung tissue (so this is what i talked about above with the elastase destroying destroying the elastin in the CT causing enlargment!)
116
occupational lung disease
"pneumoconiosis"
what type of lung condition is this? what does the particulate matter cause? what percent of COPD patients have the influence of this? what are the **4** sources of this and where do you get them from?
**RESTRICTIVE**
inhalation of particulate matter that causes fibrosis of interstitial lung disease
duration of exsposure increases severity
15-20% of COPD patients have this involvement
**asbestos-**thermal and electrical insulating
**silicosis-**silica or quartz, stone cutting, glass factories
**pneumoconiosis: "BLACK LUNG",** coal dusts
**beryllium**: nuclear reactor conductor
117
pneumoconiosis
"black lung"
what do you get from this? how does it happen? what are the two major things you would see on the CXR that would suggest this?
inhalation of **coal dust**
coal is inhaled by macrophages, release inflammatory mediators, fibroblast proliferation, and fibrosis and remodeling of intersitial lung
**\*\* nodules/nodular opacities in upper lobe\*\***
**\*\*hyperinflation of lower lobes\*\***
Leads to progressive massive FIBROSIS
118
silicosis
## Footnote
what exsposure caues this? where do you get it? what two things does it cause? and what specific three diseases does it make you at increases risk for?
**silica or quartz exposure**
stone cutting or glass factories, grantie quarries
leads to **calcifications and fibrosis**
increases risk for TB, and connective tissue diseases like RA and schleroderma
