Topic Notes Flashcards
How many lobes does the right lung have compared with the left one?
Right lung has 3 lobes (superior, middle and inferior) whereas the left lung has 2 lobes (superior (superior and inferior division) and inferior).
List the Chest wall deformities and explain what they are.
The chest wall deformities varies from mild to severe. They are congenital. Severity progresses rapidly in puberty.
- Pectus excavatum (congenital) → depression in lower half of the sternum due to unequal growth of the costal cartilages that connect ribs to sternum. Sunken appearance
- Pectus Carinum (“ pigeon chest”, congenital) → protrusion of the sternum that occurs as a result of an abnormal and unequal growth of costal cartilages.
- Jeune’s syndrome → a form of dwarfism, extremely small chest. Ribs are broad, short and irregularly joined. Bell-shaped inflexible chest cavity. Might need mechanical ventilation.
- Poland syndrome → abnormalities of one side of the chest including absence of pectoralis, under development of breast tissue and areala, rib abnormalities, and inadequate development of arm. Right side more affected.
- Barrel chest: increase AP diameter of chest wall. Most often associated with emphysema.
- Kyphoscoliosis: abnormal curve of the spine on 2 planes: coronal plane (Side to side)and sagittal plane (back to front)
7.
Borders of the lung (for percussion)
- Anteriorly the apex of each lung rises 2-4 cm above the inner third of the clavicle
- 6th rib at mid-clavicular line
- 8th rib at mid-axillary line
- 9th rib at scapular line
- 10th-11th thoracic spinous process at the paravertebral line
- Trachea bifurcates at sternal angle, at the 4th thoracic spinous process posteriorly.
Percussion sounds
- Resonant sounds are low pitched, hollow sounds heard over normal lung tissue.
- Flat - solid areas such as bones.
- Dull or thudlike - when fluid or solid tissue replaces air. pneumonia, pleural effusions, or tumors.
- Hyperresonant - COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax.
- Tympanic - indicate excessive air in the chest, such as may occur with pneumothorax
Pathological respiratory sounds:
- wheeze/ronchi (continuous, high pitched (wheeze), low ronchi, both on I/E, whistling/musical, airway narrowing (asthma, copd)
- stridor (continous, high pitch, mostly on I, whistling, musical, epiglottitis, laryngeal edema, croup)
- inspiratory gasp (continuous, high pitch, I, whoop, pertussis (whooping cough)
- crackles/crepitations (discontinuous, high or low coarse, I clicking, pneumonia, edema, tuberculosis, bronchitis)
- friction rub (discontinous-low pitch- I=E, repeated rhythmic sounds, lung tumors, pleuritis)
- hamman’s sign (discontinous-rasping sound- pneumomediastinum, pneumopericardium)
- ronchi (sounds like snoring)
tactile fremitus decreases when?
effusion, fibrosis, pneumothorax, infiltrating tumor
when is the tactile fremitus increased?
in lobar pneumonia
Indications for CXR (posterior-anteior):
• Infection: exclude pneumonia, positive Mantoux test • Major trauma: exclude widened mediastinum, pneumothorax and haemothorax 10 CXR anatomy • Acute chest pain: exclude pneumothorax, perforated viscus, aortic dissection • Asthma/bronchiolitis: when diagnosis unclear and/or not responding to usual therapy • Acute dyspnoea: exclude heart failure, pleural effusion • Chronic dyspnoea: exclude heart failure, effusion and interstitial lung disease • Haemoptysis • Suspected mass, metastasis or lymphadenopathy anatomy
possible radiological finidings on chest x ray
• Increased transparency (‘hyperlucency’)àincreased air content (e.g. emphysema, air filled cavitation, accumulation in pleural cavity - pneumothorax • Decreased transparency (‘hypolucency’)àconsolidations, fluid accumulations, atelectasis (volume reduction), pneumonia, alveolar disease, interstitial disease • Shadows o round, homogenous - tuberculoma, benign tumor, cysts, metas o infiltrative - inflammatory disease, shows up without sharply demarcated margins o striped - when connective tissue accumulates around lymph vessels, seen with resolving tb, chronic bronchitis, pleural fibrosis o patchy - scattered, dense nodules like those of tb, sarcoidosis o ringed - reflect tb caverna or abscess
HRCT
a narrow slice width is used (usually 1–2 mm), a high spatial resolution image reconstruction algorithm is used, field of view is minimized, so as to minimize the size of each pixel, and other scan factors (e.g. focal spot) may be optimized for resolution at the expense of scan speed. Indications: • diagnosis and assessment of interstitial lung disease (e.g. fibrosis) and other lung diseases (e.g. emphysema, bronchiectasia). • Distribution of nodules. Perilymphatic, centrilobular and random categories. Well defined (interstitial), ill-defined (intra-alveolar). MRI o Perilymphatic à deposits at periphery of the secondary lobule and respect pleural surfaces and fissures. (Sarcoidosis, lymphangitic spread of carcinoma, silicosis, coal worker’s pneumoconiosis) o Centrilobular à deposits at center of the secondary lobule, but spares pleural surfaces. (endobronchial tuberculosis, bronchopneumonia, endobronchial spread of tumor, and again silicosis or coal workers’ pneumoconiosis) o randomly distributed à miliary tuberculosis, fungal pneumonia, hematogenous metastasis and diffuse sarcoidosis
MRI
• When CT is contraindicated. • assess abnormal masses (e.g. cancer) for size, extend and degree of spread • display lymph nodes and blood vessels. • assess disorders of the chest bones (vertebrae, ribs and sternum) and chest wall soft tissue (muscles and fat). • characterize mediastinal or pleural lesions seen by other imaging modalities, such as chest x-ray or CT.
US (3.5 MHz)
• guiding pleural interventional procedures. (empyema drainage and aspiration/biopsy of pleural-based lesions) o However, obesity and massive oedema degrade image quality and CT-guidance might be required. • Detection of pleural pathology – more sensitive than chest radiography at detecting the presence of pleural fluid and differentiating pleural fluid from lung consolidation in the critically-ill patient. o Compared with CT, pleural ultrasonography has a 95 percent sensitivity for the detection of pleural fluid in patients with a “white out” on plain chest radiograph, but is slightly less sensitive in detecting small amounts of fluid.
pulmonary causes of chest pain
Pulmonary causes: o Pulmonary?? o Pulmonary embolism o Pneumonia o Hemothorax o Pneumothorax and tension pneumothorax o Pleuritis
Diagnosing or ruling out an ACS
• ACS: • AMI (both STEMI and NSTEMI) • Stable angina • Unstable angina • ECG and cardiac enzymes are able to diagnose ACS • Angiography (PCI) is used to directly visualize the coronary arteries, and if indicated, placing of stents to reopen narrowed coronaries (angioplasty)
Diagnosing or ruling out aortic dissection
chest patient history and do appropriate tests including a chest CT scan with contrast, MRI, or transesophageal echocardiography.
Diagnosing or ruling out PE
(should be considered in presence of respiratory symptoms, pleuritic chest pain, hemoptysis or history of coagulation abnormalities. Initial tests usually include CT angiography or a lung scan (V/Q scintigraphy), which are sometimes combined with lower extremity venous ultrasound or D-dimer testing. If a PE is suspected, the CXR may be normal, although atelectasis may be seen. • The advantages of CT include a high specificity and sensitivity for PE, and the ability to identify other disease processes that may mimic PE as pneumonia and MI and the ability to scan the leg veins at the same time to look for DVTs. • CT is the most available and thus the initial choice for management, but the gold standard for diagnosing PE is catheter pulmonary angiographyàpassing a catheter from a peripheral vein (femoral) through the right side of the heart and into the pulmonary outflow tract under fluoroscopic guidanceàIodinated contrast is injected and multiple rapid sequence radiographs are done. If an intraluminal filling defect is seen or cut off of the pulmonary arteries, it’s a conclusive sign.
Diagnosing or ruling out tension pneumothorax
when air is trapped in the pleural cavityàleads to severe oxygen shortage, hypotension and progression to cardiac arrest if untreated. Diagnosis is done by physical examination and a medical imaging (CT/X-ray) which show shift of the mediastinum from the affected side. • However, tension PTX is ideally treated before imaging – if tension PTX is suspected, treatment should start before tests are done. • Treatment involves removal of air from pleural cavity by aspiration, chest tube and in some cases surgery is also indicated.
Diagnosing or ruling out cardiac tamponade
(CXR and US) a medical emergency with accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. - Signs of classical cardiac tamponade include three signs, known as Beck’s triad: • Hypotension occurs because of decreased stroke volume • Jugular-venous distension due to impaired venous return to the heart • Muffled heart sounds due to fluid inside the pericardium -Other signs of tamponade include ST segment changes on the ECG, which may also show low voltage QRS complexes, as well as general signs & symptoms of shock (tachycardia, dyspnea and loss of consciousness)
Chest pain algorithm
- On the basis of the above, a number of tests may be ordered: • X-rays of the chest and/or abdomen (CT scanning may be better but is often not available) • ECG • V/Q scintigraphy or CT pulmonary angiogram(PE) • Blood tests: o Complete blood count o Electrolytes and renal function (creatinine) o Liver enzymes o Creatine kinase (and CK-MB fraction in many hospitals) o Troponin I or T (to indicate myocardial damage) o D-dimer (when suspicion for pulmonary embolism is present but low) - Serum amylase to exclude acute pancreatitis • Ultrasound (tamponade)
PHARMACOLOGICAL AND NON-PHARMACOLOGICAL TREATMENT OF STABLE COPD
Bronchodilators, corticosteroids, oxygen therapy, antibiotics, rehabilitation and support, surgery
first line Treatment of pulmonary TB
● Isoniazid ● Rifampicin ● Pyrazinamide “RIPE” Drugs: Rifampin (RA) Isoniazide (INH) Pyrazinamide (PZA) Ethambutol (ETB)
second line treatment of pulmonary TB
- Less effective than first line - Toxic side effects - Unavailable in developing countries ● Aminoglycosides (amikacin, kanamycin) ● Polypeptides ● Fluoroquinolones (ciprofloxacin, levofloxacin) ● Thioamides (Ethionamide) Others: Cycloserine, PAS (para-aminosalicylic acid), Capreomycin, Rifabutin, Linzolid, Bedaquiline, Delamanid
What is the current standard treatment of TBC?
The current standard treatment of TBC consists of 6 months of rifampicin and isoniazid, supplemented by pyrazinamide and ethambutol for the first 2 months. Prolonged treatment is needed to eradicate dormant bacilli.
What are the adverse effects of anti TBC drugs?
Adverse effects: hepatotoxicity
What is a pulmonary abcess?
A lung abscess is a localized collection of pus with in cavitated necrotic lesion in the lung parenchyma.
What are the causes of pulmonary abcesses?
● Oropharyngeal aspiration: most common cause ● Infection of the upper airways: sinusitis and dental abscesses ● Bronchial obstruction ● Pneumonia ● Tuberculosis ● Pulmonary emboli: pulmonary infarction with secondary infection giving rise to an abscess
What are the symptoms of a pulmonary abcess?
- Patient usually complains of a cough with expectoration of large amounts of foul material often accompanied by hemoptysis, fever, weight loss and malaise. Hemoptysis can occur.
How is a pulmonary abcess diagnosed?
- Chest X-ray shows cavitating lesion containing a fluid level. - sputum:?? - DDx: other cavitating lung lesions can be squamous cell carcinoma. Do a bronchoscopy or FNA.
How do you treat pulmonary abcesses? What is the treatment in this case?
- Drainage of pus from the abscess cavity - Percutaneous drainage is achieved by positioning a catheter drainage tube under radiological guidance - Antibiotics in accordance with the likely organism - Surgery: Surgical excision of the abscess is sometimes required
What is community aquired pneumonia?
refers to pneumonia (any of several lung diseases) contracted by a person with little contact with the healthcare system.
What are the causes of community acquired pneumonia?
Its causes include bacteria, viruses, fungi and parasites, but most common pathogens are: • Streptococcus pneumoniae – 60% • Mycoplasma pneumoniae – 10% • Haemophilus influenzae – 10% • Viruses (e.g. influenza) – 10% • Others – 10%
What are the symptoms of community acquired pneumonia?
Common symptoms: • Coughing which produces greenish or yellow sputum • A high fever, accompanied by sweating, chills and shivering • Sharp, stabbing chest pains • Rapid, shallow, often-painful breathing (dyspnoea)
What are the treatment options for community acquired pneumonia?
Depends on severity, microbiological investigation and patients’ response • For community acquired pneumonia, S. pneumonia is the most likely pathogen and amoxicillin 500mg orally is an appropriate ATB. • Where there is suspicion of atypical pneumonia addition of a macrolide ATB such as erythromycin/clarithromycin is required. • In severe pneumonia the initial ATB regimen must cover all likely pathogens and cover potential ATB resistance, IV cefuroxime and clarithromycin are appropriate.
What is hospital aquired pneumonia?
Hospital acquired (nosocomial) pneumonia is defined as pneumonia developing 2 or more days after admission to a hospital for some other reason.
What is the cause/aetiology of a hospital acquired pneumonia?
Aetiology: Use of broad-spectrum antibiotics and impaired host defenses promote the colonization of the nasopharynx of hospitalized patients with Gram-negative organisms. ● Gram negative bacteria- 50% - Pseudomonas aeruginosa, E.Coli, klabsiella, proteus ● Staphylococcus aureus ● Streptococcus pneumoniae ● Anaerobes/fungi
What are the symptoms of a hospital acquired pneumonia?
● Cough with greenish or pus-like phlegm (sputum) ● Fever ● Sharp chest pain that gets worse with deep breathing or coughing
How do you diagnose a hospital acquired pneumonia?
General Investigations: Chest X Ray / Hematology and biochemistry tests Specific investigations: Sputum gram stain/ sputum culture/blood culture/pleural fluid aspiration and examination/antigen detection tests/serological tests Auscultation of lung: Crepitations
How do you treat a hospital acquired pneumonia?
- Sufficient oxygen should be given to maintain arterial pO2>60 mmHG and oxygen saturation>90% - Adequate non sedative analgesia (NSAIDS) should be given to control pleuritic pain. - Gram negative being the most common organisms, combination of aminoglycoside (gentamicin) and third generation cephalosporin (ceftazidime) is commonly used.
What is the clinical course of primary TBC?
- Pattern seen with the first infection in a person without specific immunity to tuberculosis - Acquired by inhalation of organisms from an infected individual by droplet transmission - The lesion typically develops in the peripheral subpleural region of the lung followed by a reaction in the hilar lymph nodes. - Primary complex on CXR; peripheral area of consolidation (GOHN FOCUS) and hilar adenopathy - An immune response develops (positive tuberculin test), the disease may heal or progress - Healing in 4-8 weeks which may leave calcified nodules on the CXR - Bronchial spread of infection may cause progressive consolidation and cavitation of the lung parenchyma and pleural effusion. - Lymphatic spread→ lymph node enlargement→ bronchiectasis of the middle lobe - Hematogenous spread → military TBC and lethal complication of tuberculosis meningitis - Infection spread during this initial illness may lie dormant in any organ of the body, only to reactivate many years later.
What is the clinical course of Secondary TBC?
Apices of the lungs are the most common site - Direct progression of the initial infection - Reactivation of the latent infection - Exogenous reinfection
Diagnosis of TBC?
Identification of M.tuberculosis, Radiological diagnosis CXR. Laboratory diagnosis - Ziehl-Neelsen stain: acid-fast bacteria which appear as red rods on a blue background - Sputum cultures: LOwenstein-Jensen medium 4-7 weeks for positive culture - Biopsy: caseating granuloma
What are some extrapulmonary signs of TBC infection?
Extrapulmonary signs - Pleuritis - Meningitis - Tuberculous cervical lymphadenitis - Urogenital tuberculosis - Pott’s disease when spread to the spine- a form of osteomyelitis
What are the pulmonary signs and symptoms of a TBC infection?
Pulmonary signs and symptoms - Chest pain - Productive prolonged cough - Hemoptysis - Infection may erode the pulmonary artery resulting in Rasmussen’s aneurysm-bleeding
How do you calculate pack years?
What is the test called for smoking addiction?
Fagerstrom test for nicotine dependence.
abnormal breathing patterns
- Cheyne-stokes respiration: periodic breathing of apnea and hyperapnea (HF, stroke, advanced dementia)
- Kussmaul respirations: (metabolic acidosis)
- Air trapping
- Biot’s
- Ataxic
- Bradypnea or Tachypnea
- hyperventilation (hyperpnea)
