Respiratory Path lecture 1 Flashcards
1
Q
Pulmonary system sole purpose
A
Ventilation
2
Q
2 metabolic functions of pulmonary system
A
- Oxygenate blood
2. Expire CO2
3
Q
Obstructive disorders
A
- -Expiratory flow limitation
- -Typically smaller airways
4
Q
Obstructive disorder examples
A
- -Asthma
- -COPD
- -Bronchiectasis
- -Bronchiolitis
5
Q
How is degree of obstruction tested?
A
- -Pulmonary function testing
- -Often decreased FEV1
6
Q
Restrictive diseases
A
–Reduced total lung capacity/reduced ventilatory elasticity
7
Q
Restrictive disease examples
A
- -Diffuse parenchymal/interstitial lung disease (idiopathic pulmonary fibrosis, occupation lung diseases )
- -Chest wall/pleural disease
- -Massive obesity
- -Neuromuscular disease
8
Q
Measuring degree of restriction?
A
Pulmonary function testing (Total lung capacity)
9
Q
Pulmonary vascular disease
A
- -Thromboembolism (from DVT usually)
- -Pulmonary HTN
- -Pulmonary hemorrhage/vasculitis syndromes
10
Q
Pulmonary edema (from L sided CHF)
A
–Cardiogenic pulmonary edema (chronic coronary artery disease, MI, hypertensive heart disease, cardiomyopathies, aortic or mitral stenosis
11
Q
Non-cardiogenic pulmonary edema
A
Microvascular/alveolar capillary injury (acute respiratory distress syndrome (trauma/shock, sepsis)
12
Q
Pulmonary infectious disease (definition)
A
Infection of distal/alveolar lung (pneumonia/lung abscess or in the airways)
13
Q
Pneumonia
A
Most common infectious disease leading to hospital admission and death in US
14
Q
Diagnosis of pneumonia
A
Need to see pulmonary infiltrates on CT or CXR
15
Q
Subtypes of pneumonia
A
- -Community-acquired
- -Hospital/institution acquired
- -Immunosuppressed forms
16
Q
Space occupying effect
A
Restricting lung expansion or causing lung collapse
17
Q
Effusions
A
- -Transudates (CHF)
- -Exudates (para-pneumonic, malignant)
- -Hemothorax (trauma, aortic aneurysm, dissection rupture)
- -Chylous
18
Q
Pneumothorax
A
–Visceral, pleural air leak secondary to underlying lung pathology
19
Q
Atelectasis
A
Pulmonary collapse (segment, lobe, entire lung)
20
Q
Atelectasis causes
A
- -Usually obstructed bronchus or pleural effusion
- -If unrelieved: risk of pneumonia
21
Q
Bronchiectasis
A
Chronic infection/inflammation of larger airways
- -Irreversible bronchial dilation
- -Chronic micropurulent sputum production
- -Eventual bronchial collapse/obstructive symptoms
- -Unrelated to cigarette smoking
22
Q
Congenital lung disease
A
–Associated w/perinatal death, neonatal respiratory distress with variable survival, delayed symptoms/discovery into adulthood
23
Q
Dyspnea
A
Increased work of breathing due to decreased compliance, increased resistance to flow, impair gas exchange (alveolar injury)
24
Q
Causes of acute onset dyspnea
A
- -Laryngeal edema/anaphylaxis
- -Bronchospasm
- -MI
- -Large PE
- -Pneumothorax
- -Aspiration
- -Inhaled toxic substance
- -Massive hemorrhage or hemolysis
25
Causes of progressive/chronic dyspnea
- -Chronic obstructive or restrictive pulmonary disease
- -CHF
- -Worsening anemia
- -Obesity/deconditioning
26
Expiratory wheezing causes
Suggests airway obstruction (esp. asthma, can occur with peribronchial edema due to CHF
27
Chest pain secondary to respiratory diseases (causes)
- -Irritation of parietal pleura
- -Pneumonia w/secondary pleuritis
- -PE w/lung infection
- -Pneumothorax
- -Lung CA invading chest wall
28
Expiratory wheeze causes
Bronchospasm vs CHF
29
Rhonchi causes
Obstruction of medium -size bronchi w/secretions (bronchitis, bronchiectasis, COPD)
30
Stridor (inspiratory wheezes) causes
Upper airway obstruction (larynx/trachea)
31
Crackles/rales causes
Alveolar disease (pneumonia, pulmonary edema, interstitial/fibrosing disease)
32
Causes of decreased breath sounds
Emphysema, pneumothorax, pleural effusion, pulmonary consolidation
33
Arterial blood gases
Gold standard for assessing adequacy of gas exchange
34
ABG normal values
```
PaO2: 80-95 mmHg
PaCO2: 35-45 mmHg
pH: 7.35-7.45
HCO3: 22-28 meq/L
SaO2: 95-100%
```
35
What are you looking for on CXR?
Pulmonary pleural disease, cardiac enlargement, mediastinal pathology
36
What disease states are usually normal on CXR?
Larger airways disease and pulmonary vascular disease
37
What can you see on CT?
- -Better detail
| - -Small lung lesions, larger airways, lymph nodes, aorta, esophagus, mediastinal masses/cysts
38
What are you looking for on high res CT?
Chronic interstitial and diffuse parenchymal lung disease. Gold standard for these
39
Pulmonary function testing (PFT) use
Est. dx and severity of chronic or restrictive lung disease
40
Spirometry
Look at FEV1/FVC especially
41
What if FEV1/FVC less than 70% of predicted?
Obstructive lung disease (esp. COPD and asthma)
42
What if the FEV1:FVC ratio reverses some w/bronchodilator?
Asthma or asthmatic component to COPD
43
What does it mean if TLC less than 80% of predicted?
Restrictive pathology w/poor respiratory compliance.
44
How do you make dx of atelectasis?
CXR: shows volume loss + pulmonary opacification
45
Primary atelectasis (neonatal)
Rare
| Incomplete expansion of lungs at birth (inadequate surfactant)
46
Secondary atelectasis types
- -99%
| - -Obstructive, resorptive, compression, contraction types
47
Obstructive secondary atelectasis
--Resorption of alveolar gas distal to bronchial obstruction (MUCUS plugging, foreign body aspiration, tumor, extrinsic bronchial compression)
48
What is the most common cause of atelectasis in children?
Obstructive from mucus plugging (asthma, cystic fibrosis)
49
Resorptive secondary atelectasis
Alveolar collapse from pneumonia, poor lung ventilation (neuromuscular weakness/poor cough reflex), post-general anesthesia all compounded by MUCUS SECRETIONS
50
Compression secondary atelectasis
Pulmonary collapse due to mass effect: pleural effusion, pneumothorax, tumor, cysts, congenital abnormalities, lobar hyperinflation/large emphysematous blebs
51
Contraction secondary atelectasis
Pulmonary shrinkage from pleural fibrosis or fibrotic pulmonary interstitial disease
52
What happens with failure to relieve atelectasis?
Increased risk of pneumonia
53
Prophylaxis to reduce risk of atelectasis post-anesthesia
Deep ventilation exercises
54
Asthma
- -Reversible airflow obstruction
| - -Associated with bronchial inflammation and bronchoconstriction
55
Asthma epidemiology
- -300 million people worldwide
- -8% of US pop.
- -90% cases triggered by allergic/atopic disease
- -10% from nonatopic/"intrinsic" causes (such as cold air, exercise, drugs, stress, inhaled irritants)
- -Occupational asthma: 1/3 of occupational lung disease
56
Asthma symptoms
- -Episodic wheezing, dyspnea, cough
| - -+/- mucus/sputum, kids often have cough (predominant sx)
57
Asthma Dx
- -Symptom based
- -Typically no CXR findings
- -PFT: decreased FEV1 and FEV1/FVC with >12% increase w/inhaled B2 agonist or post-steroid trial
58
Asthma histology
Bronchial/bronchiolar mucosal/submucosal inflammation: eosinophils/T lymphocytes, mucosal edema, mucus hypersecretion/plugging, hypertrophied bronchial smooth muscle
59
What % of COPD patients have asthma features?
10%. With response to corticosteroids--probably both diseases present
60
Asthma rx
1. Relief of bronchoconstriction w/beta-2 agonists
2. Inflammation control/suppression: inhaled +/- oral corticosteroids
3. May need 2nd/3rd line drugs for refractory cases
61
Asthma complications
- -Status asthmaticus
- -Allergic bronchopulmonary aspergillosis
- -Chronic eosinophilic pneumonia
62
COPD gen. info
- -4th leading cause of death in US
- -Expiratory airflow obstruction, not fully reversible
- -Slowly progressive/persistent w/ acute exacerbations (often due to infection)
- -80-90% of cases associated with smoking
63
COPD etiology
Abnormal inflammatory response to noxious gas/particles
64
Toxic effects of cigarette smoke on trachea/bronchi
--Submucosal glandular hyperplasia w/abundant mucus production/cough (chronic bronchitis)
65
Toxic effects of cigarette smoke on distal small airways
Mucosal goblet cell hyperplasia and bronchiolitis w/inflammation, increased mucus, edema, fibrosis
66
Alveolar destruction in COPD
Neutrophils/macrophages release elastolytic proteinases and degrade natural anti-proteinase protection
67
Emphysema
Progressive acinar destruction w/permanent air space enlargement
68
Centriacinar emphysema
Vast majority of cases. Predominantly affecting upper lobes
69
Panacinar emphysema
Upper and lower lung field involvement of equal severity.
70
Causes of panacinar emphysema
- -Very advanced common emphysema
| - -Alpha-1 antitrypsin deficiency (may also have associated liver disease
71
Subpleural blebs in emphysema
Can cause pneumothorax or space-occupying mass effect
72
Types of mechanisms of airflow obstruction in COPD
- -mucus plugging
- -decreased alveolar tethering of respiratory bronchioles
- -mixed
73
Mechanism of airflow obstruction w/predominant Bronchitis component in COPD
Mucus plugging
74
Mech. of airflow obstruction w/predominant emphysema component
Decreased elastic/alveolar "tethering" of respiratory bronchioles--airway collapse during expiration w/alveolar air trapping, loss of elastic recoil, hyperinflation.
75
COPD clinical presentation
- -Sedentary lifestyle (avoiding exertional dyspnea)
- -Progressive dyspnea on exertion
- -Evolving cough w/sputum production (mucoid or purulent)
- -Acute chest illness
76
Acute chest illness
Increased cough, purulent sputum, wheezing/dyspnea, episodically occurring (may resemble asthma, CHF, bronchiectasis)
77
Physical exam w/severe COPD disease
- -Systemic wasting
- -Hyperinflated lungs w/barrel chest
- -Decreased breath sounds, wheezes, lung base crackles, distant heart sounds.
- -Use of accessory muscles to breathe
- -Cyanosis
- -Cor pulmonale
78
COPD diagnosis
- -PFT
| - -FEV1/FVC
79
ABG's in mild and severe COPD
- -Mild: mild/mod. hypoxemia w/o hypercarbia (hypercapnea)
| - -Severe: worsening hypoxemia w/hypercarbia
80
Hemogram results in COPD
--If polycythemia present implies chronic hypoxemia.
81
Clinical course of COPD
- -Slowly progressive sx (stable phase) w/periodic exacerbations
- -Chronic hypoxemia induces vasoconstriction/HTN and eventual cor pulmonale
82
COPD exacerbation causes (common)
50% due to bacterial pneumonia (Moraxella, H. influenzae, S. pneumo) w/50% triggered by viral infection
83
Bronchiectasis
Permanent dilation of bronchi/bronchioles
84
Common causes of bronchiectasis
- -Recurrent bronchial infection due to impaired drainage/airway obstruction, host defense deficits
- -Secondary to bacterial pneumonia
85
Bronchiectasis symptoms
- -Cough
- -Daily micropurulent sputum (months to yrs)
- -+/- dyspnea/wheezing.
- -May see sinusitis and hemoptysis
86
Bronchiectasis findings on CT scan
Dilated bronchi (diffuse or focal)
87
Classic bronchiectasis disease associations
- -Cystic fibrosis
- -Airway obstruction from foreign body or tumor
- -Primary ciliary dyskinesia
- -Primary pulmonary infection
- -Connective tissue disease
- -Immune deficiencies
- -Uncertain/unknown (25-50% cases)
88
Pneumonia
Infection involving pulmonary alveolar or interstitial parenchyma
--Most common lethal adult infection
89
Pneumonia sx
- -Acute, rapidly evolving
| - -Cough, fever, pleuritic chest pain, dyspnea, sputum production +/- chills/rigors, GI sx, mental status changes
90
Pneumonia physical exam findings
Rales or evidence of pulmonary consolidation
91
Pneumonia diagnosis
CXR or CT: must see pulmonary infiltrate!!!
--Can have lobar or whole lung consolidation, patchy alveolar infiltrates, interstitial infiltrates, cavitation +/- pleural effusion/empyema.
92
Alveolar exudate inflammation (neutrophilic) pathology in pneumonia
Common bacterial pneumonia
93
Interstitial/alveolar wall inflammation pathology in pneumonia
- -Usually lymphocytic type
| - -Seen in "atypical pneumonia" (mycoplasma, viruses, chlamydophylia)
94
Necrotizing granuloma pathology in pneumonia
Fungi or mycobacteria cause
95
Pulse oximetry findings in pneumonia
Desaturation
96
Inflammatory disease markers in pneumonia
Leukocytosis (usually neutrophilic), increased ESR, CRP.
