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Step Up to Medicine: Chapter 02 Diseases of the Pulmonary System

STUDY
PLAY
Pnematocoeles Are?
Often form secondarily to an uri caus by streptococcus pneumonia. S aureus can result in blood streaked sputum and multiple midfield lung cavity in CXR suggesting an acute necrotizing pnemonia
Which patients are the most sensitive to asthma-like symptoms? (cough, wheeze, SOB, CHEST tightness) in RX?
ASA (aspirin) sensitive asthema - if patient has asthma or a polyp - the use of ASA could force an exacerbation that resembles asthma like symptoms
BERYLLIOSIS can have similar clinical findings to sarcoid. What is the diagnostic test associated with its diagnosis?
Beryllium lymphocyte proliferation test
O2 delivery systems

1. Low flow v. HIGH flow:
Low: nasal cannula (<0.40 FiO2); Simple face mask (0.4-0.6 FiO2)

High: venturi mask (<0.5 FiO2); nonbreathing mask (0.70-0.80 FiO2)
primary pneumothorax versus secondary pneumothorax?
1. Primary: heathy, tall, young, lean male
-spontaneous subpleural bleds at apex, escape of air yeilds collapsed lung
-recurrence rate 50%/2 years
-sufficient pulmonary reserve therefore not life threatening

2. Secondary: complicated
-underlying disease like COPD, asthema, ILD, CF< TB, life threateneing bc lack of pulmonary reserve
IN COPD = FEV1 is _____ and the FEV1/FEV ratio is?

Pulmonary symptoms?
FEV1< 70% if mild or <50% if severe.

Decreased FEV1/FEV (<0.75-0.80)
Increased TLC, RV, FRC due to air trapping
Decreased vital capacity

Dyspnea, cough ,sputum production; wheezing
Pathophysiology of ARF
1. V/Q mismatch - hypoxia without hypercapnia is the MOST COMMONY MECHANISM THAT DOES REPOND TO O2 SUPPORT AND SUPPLEMENTAL
2. Shunting - little or no ventilation in perfused areas due to collapsed or fluid filled alveoli - the venous shunts to the arterial circulation without O@ ocygenation
3. Hypoventilation leads to hypercapnia
4. Increased CO2 production - hypercarbic
5. Diffusion impairment
How is cor pulmonadle diagnosed?

3 tests:

treatment:
1. CXR - enlargement of the RA, RV, pulm arteries. Right heart enlargment
2. ECG - right axis deviation, P pulmonale (peaked P waves), right venticular hypertrophy
3. Echo - RV dilitation; normal LV size and function; rule our LV dysfunction

Treatment: underlying pulmonary disorder, diuretic therapy cautiously (if preload dep) O2 therapy
CNS: bilateral bells palse CNVII/ CNI optic
Lungs: dry cough, SOB
Skin: eryethma nodosum; plaques; subq nodules
Eyes: anterior uveitis (75%) > posterior
Heart: arrhythmia, HB, sudden death
MUS: bone lesions
SARCOIDOSIS
FEVER CHILLS HISTORY OF HIV HEMOPTYSIS
PNEUMONIA or TB
Whiat treatments are used in acute COPD exacerbations?
BUDENSONIDE
FLUTICASONE

Both are inhaled steroids that are anti-inflammatory in nature.
symptoms of acute Respiratory FAILURE

SIGNS: Diagnosis:
Signs: elevated HR, elevated RR, cannot speak in full sentences

-SOB is the first symptom
-COUGH (+/-)

Signs: 1. talk in complete sentences depends upon underlying cause; use of accessaory muscle (SCM/trap). 2. Tachypnic (elevated RR). 3. Tachycardic (inc HR). 4. Cyanosis. 4. Impaired mentation
What triggers asthma?

4 classic features of asthmatics (clinically)
1. exercise
2. pollens
3. house dust
4. MOLDS
5. cockroaches
6. DOGS/CATS
7. cold air
8. viral infection
9. tobacco smoke
10. BB and ASA

Four major presented findings: SOB, COUGH, WHEEZE, CHEST TIGHTNESS
Which pneumoconiosis increases the risk of bronchogenic carcinoma and malignant mesothelioma?

Rx
Dx:
ASBESTOS

No specific traetment abailable
-bilateral hazy infiltrates with linear, opacities
What is PEEP?
positive pressure applied during mechanical ventilation at the end of passive exhale that keeps alveoli open. differs from CPAP which is used in pts who spontanously breathe. Pts with PEEP are under mechanical ventilation

-2.5-10cm H2o appropriately set
-used in ARDS patients
-good = increases lung compliance/O2 and presvents alveolar collapse
If patient presents with COPD exacerbation - what are the following steps appropriate for its diagnosis?
1. CXR
2. B2 agonist (albuterol)/anticholinergic (ipra)
3. Systemic corticosteroids
4. AB (r/o infection)
5. Supplemental O2 therapy
6. Non-invasive PPV if needed like a CPAP or BIPAP
Parapneumonic effusion treatment:
P effusion + pneumonia
1. uncmplicated = AB alone
2. complicated = EMPYEMA - pus in the effusion
-chest tube draininage
-intrapleural injection of thrombolytic agents (streptokinase, urokinase)
-surgical lysis of adhesions may be required
Acute respiratory failure = either ______ oxygenation or blood or ________ ventilation of _________.
Decrease the O2 of PaO2 (inadequate perfusion)
Decreased the CO2 ventilation of PaCO2

Thus hypoxia is PaO2< 60mmHg and PaCOD > 50 mmHg

Thus hypercapnia PaCO2 > 50 mm Hg
What is the number one diagnosis of a mediastinal mass?
CHEST CT - discovered by CXR incidentally
SIMv = synchronous intermittent mandatory ventilation
TV is NOT determined or preset by ventilation but the RATE is.
-breathe on their own above mandatory rate without help from ventilator (TV of extra breaths is not determined by the ventilator)
-delivers mandatory breath in syncrhony with pts intitiated spontaneous breathe so the two dont overlap
-if the patient breathes spontanously - no preset volume (gets it at rate) if doesnt breathe, gets predetermined breath rate
ALL patients, including those who are pregnant with HCV chronically should receive vaccinations against both ____ and _____ if not already immune.


HAV and HBV
Hepatitis c perinatal transmission is less frequent (2-5%). Increased risk if pt is HIV positive with high HCV viral load. Both interferon and ribairon for the treatment of pts with chronic HCV must be held during pregnancy. Some evidence that sexual transmission of HCV occurs, but the incidence is extremely low. Thus no barrier precaustion between stable monogamous sexual partners is required.
Increased risk of ILD (SOB, later on exertion, COUGH, FIBROSIS) in dividuals with mining, stone cutting

Increased risk of TB
SILICOSIS
signs of ILD that differs from OLD (COPD/CB)
-SOB
-fatigue
-rales at lung base
-clubbing
-pulmonary HTN/cyanosis
-CXR with honeycombing = scarred shrunken lung ciliated air spaces, fibro scars in interstitium.
-CT scan show groundglassing
-FEV1/FVC normal - high in restrictive lun disease, has low TLC and low RV unlike that of obstructive. Also has decreased ERC and decreased TV
-decreased diffusion capacity
Key parameteres of mechanical ventilation
minute ventilation (RR x TV)
FiO2
I:E ratio
PEEP
EGOPHONY ON Lung auscultation:
Say EEE sounds like AA indicates lung consodidation
When might DIGOXIN be used in patients to treat COR PULMONALE?
only is 2/2 LV failure. Otherwise stick to diuretic therapy cautiously
Treatment of ARDS:
Keep O2 sat > 90%
-mechanical ventilation with PEEP
-increased lung olue by opening collapsed alveoli and decreasing the shunt
-fluid management (PCWP 12-15) maintain vasopressors used to mantain BP
-treat underlying cause
-tube feeding > than parenteral
How is sarcoidosis staged?
Stage I = bilateral hilar LAD without infiltrates
Stage II = hilar LAD+ infiltrate
Stage III = diffuse infiltrate without HILAR --> WORST PROG
Stage IV = fibrosis and honeycoming - this is an ILD and thus has restrictive lung pattern....
Diff diagnosis of hemoptysis
1. Bronchitis (50% of cases viral)
2. Lung CA - bronchogenic carcinoma
3. TB
4. Bronchiectass - seen in CF
5. Pneumonia
6. CVD - good pastures, PE with pulmonary infarct, aspergilloma, mitrial stensosis
Inhalation of coal dust (both carbon and silica) by coal workers can either be assymptomatic or result in respiratory disability by fibrosis (ILD)
coal workers pneumoconiosis
How does CF present:

Most common infections;
Most likely treatment?
#1 AR disease in caucasians that includes a defect in the CL- channel @ F508 chromosome 7. This leads to the dec ablity to secrete Cl- in the mucous glands and dec ability to absorb Cl- in the sweat glands leading to think, nonwatery mucus plugging - bronchiectatsis (obstructive), pancreativ insufficiency, GI complicatiosn and increased Cl- sweat > 65

Infection = Pseudomonas aeruginosa (gram -) and treatment is FLUOROQUINOLONEs

Rx: Pancreatic enzyme replacements; FAT soluble vitamin replacement chest percussions and antibiotics
MORGAGI Hernia v. BOCHDALAK's Hernia
Congenitdal diaphragmatic hernia (CDH)
1. Morgagi - herniation through foramen (2%) moragni located adjacent to xiphoid process of sternum/anterior defect of the diaphragm

2. BOCHdalaks - posteriolateral diaphragmatic hernia (95%)/allows passage of adbominal viscera into chest cavity on L side
What is a pneumoconiosis?

example of "dust" particles?
accumulation of dust in the lungs and the tissue reaction 2.2 to its presense:

1. SIlica
2. Beryllium
3. Asbestos
4. Coal dust
5. Graphite
6. Carbon black
7. Aluminum
8. Talc
FiO2 parameter on ventilator
100% set
-quickly titrate and use lowest possible to maintain paO2 50-60mmHg (or sat 90%) to avoid O2 intox
-FiO2 < 60% safe
-FiO2 of 0.5 doesnt result in adequat PaO2 thus add PEEP or CPAP to reduce FiO2 to suppor PaO2 and lower FiO2
Which environmental causes exposures?

Restrictive interstitial lung disease?
Asbestosis
Silicosis
Coal workers pneumoconiosis
Berylliosis
MAJOR COMPLICATIONS OF ASTHMA
1. Status asthmaticus
2. Acute respiratory failure (2/2) respiratory muscle failure
3. Pneumonthorax, atelectasis, penumomediastinum
Incidental discovery of a solitary pulmonary nodule on a radiograph imaging is common. The first step in the workup of such nodules is to:
obtain any previous radiographic lung images.

Absense of growth over time rules out malignancy. If previous radigrpah films are not available thn the nodule is assigned either alow, intermediate or HIGH probability of malignancy based on clinical and radiogrpahic data.

Low: followed by high resolution chest CT
intermediate: further investigated with PET scan and/or biopsy
HIGH probability nodules are removed surgically
Primary lower extremity sites responsible for PE?
Lower extremity DVT
#1 - iliofemoral DVT (area above the knee)
#2 = deep veins of the pelvis
## - calf vein emboli => proximal veins, increase incidence
What is the treatment for NSCLC: SQUAA LC, adenocarcinoma, large cell
1. Surgical removal: if mets out of chest - then not a candidate for removal
2. Radiation therapy prior to surgery - patients with
3. Chemotherapy is of uncertain benefit
NSCLC is staged by TNM, whereas SCLC is staged by?
1. Limited to chest plus supravlacicular node but not cervical/axillary
2. Extensive- outside of chest and SC nodes.
Normal ranges of ABGs? (doesnt req mechanical ventilation)
PaO2 of (50-60)
PaCo2 (40-50)
pH = 7.35-7.50
What causes a pleural effusion?
1. Increased fluid into the plerual space/drainage
2. Increased production of fluid by cells into the pleural space
3. Decreased drainage of fluid from the pleural space
In patients with COPD, which vaccinations are required?
Influenza vaccination annually
Pneumococcus polysaccaride vaccination of 5-6 years
postoperative cholestasis can develop after a prolonged surgery characterized by hypotension, extensive blood loss in tissues, and massive blood replacement.

T or F
T
Alveolar filling diseases causing restrictive lung disease?
-goodpastures
-idiopathy hemosiderosis
-alveolar proteinosis
How might one diagnose air in stomach by auscultation?
ET tube may not have been placed correcly by ventialtion - check bilateral breath sounds and CXR. 3-5 cm above carina
Clinical features of COR PULMONALE
decreased exercise tolerance
cyanosis/digital clubbing
signs of RVHF; hepatomegaly, edema, JVD
parasternal life at P2 (seen in p HTN)
polycythemia vera present if COPD cause of COR pulmonale
Underlying cause of clubbing in patients?
#1 cause is chronic hypoxia
Diff diagnosis: LUNG cancer, CF,ILD, empyema, sarcoid, mesothelioma, heart dz, bacterial endocarditis, cirrhosis, IBD, primary biliary cirrhosis

ORDER CHEST XRAY IF THINK LUNG DISEASE +/-
Causes of COR pulmonale:
1. Right sided counterpart to LV heart dz due to systemic HTN - RVH with eventual RVF from pulm HTN 2/2 pulm disease

2. Doesnt include pulm HTN du to left sided HD like MS of LVF

Causes: 2dary to COPD; recurrent PE, ILD, asthma, CF, sleep apnea, penumoconiosis
Noncaseating granulomas involving the lungs at hilar (LAD). Eyes, skin, heart, MS, CNS also involved.

#1 cause of death = H.D.
#1 population affected:
SARCOIDOSIS
1. AA females <40YO
-85% change of acute (noncronic) infection
Classic criteria of ARDS:
1. hypoxemia that is refractory to oxygen therapy ==> ratio of PaO2/FiO2 </= 200
2. bilateral diffuse pulmonary infiltrates on CXR
3. No evidence of CHF: PCWP </= 18 mm Hg
Fever night sweats wt loss hemoptysis
B SYMPTOMS - associated with TB and HIV
Centrilobar emphysema v. panlobar emphysema
-centrilobar is the most common
-destruction at respiratory bronchioles (proximal) with little distal change.
-upper lungs

-alpha1antitrypsin deficiency
-proximal and distal acini
-goes for bases of lungs
What is the I:E ratio?
amount of time alloted to I in comparison to Expire in 1 breath.

duration of each breath preset by RR. This increases the time spenin in INHALATION and decreases the time spend in EXPIRATION.

Want 1:2 for (I:E)
Mixed capillary (at site of A-->V) and prevapillary causes of PULMONARY HTN:
Lung dz of the parenchyma or of the pulmonary vessels
-includes obstructive - COPD, asthma, CB
-includes restrictive lung disease ILD
-PPH
-kyphoscloliosis
Malignant mesothelioma
2/2 abesteos exposure
-dyspnea, weight loss, cough, bloody effusoin on thoracentesis
-POOR PROG
MODALITIES for Asthma:

1. Rescue inhalants for ACUTE ATTACKS
2. Longer acting with nighttime asthma and exercise induced asthma
3. Decreased airway hyperresponsivity, decreased annual number of exacerbations
Albuterol - ST B2 agonist
Salmeterol LT B2 agonist
Inhaled corticosteroids
-inc risk core throat/candidiasis (thrush)
-increased risk of hoarseness
Diagnosis of lung CANCER
1. CXR =
2. CT scan =
3. Cytoloic sputum exam =
4. Fiberoptic bronchoscope =
5. Transsthoracic needle biopsy =
6. Mediastinoscopy =
1. Most important study for diagnosis but NOT for screening. If greater than 2 years without change in the lesion; then BENIGN
2. Staging lung CA; LOCAL v. DISTAL met
3. CYTO = centra tumor diagnosis (80 %) not peripheral more likely to be detected early.
4. Fiberopti goes 2/2 branches of the tree - good dz of the central CA IF VISIBLE, diagnostic jumps to 95% of causes.
5. TNB = highly accurate, good for peripheral lesions as well - invasice, selected pts only.
6. MED = direct visualization of medistinum
What are the subtypes of the 75% of Lung CA that are 2/2 NSCLC?

Incidence
Location
Spread

How does this compare to that of SCLC?
1. SQCC (30% of all LUNG CA) -- Central location -- Cavitation on CXR
2. Adeno (25% of all LUNG CA) -- Peripheral location -- Pleural involvement (20%) without smoking, may have pulmonary fibrosis
3. Large cell (5-10% of all LUNG CA) -- peripheral

SCLC -- (20-25% all LUNG CA) -- narrow bronchi (associated with LE syndrome) 50-75% mets
Clinical features of mediastinal masses
1. Due to compression or invasion of neighboring structures
2. Cough
3. Chest pain
4. Post obstructive pneumonia
5. Dysphagia
6. SVC
7. Compressed nerves (recurrent laryngeal CN X)
-horners SCG
-diaphragmatic paralysis (C3-c5)
AC Ventilation
assisted controlled ventilation
-guarantees a backup minute ventilation that has been present
-delivers breath when patient intitiates breath
-if the patient doesnt initiate breath, ventillation takes control and delierates a predetermined breathe.
-delivers the same predetermined TV
Primary PULMONARY Htn (PPH?)
1. Pulmonary HTN in absense of heart dz or LUNG dz
2. Diagnosis of exclusion
3. INcreased PA pressure leads to thickening of pulmonary arteriolar walls thus worsense pulm HTN, increases wall thickening
4. #1 in middle aged women
5. Poor prognosis (2-3 years)
Evaluation of hemoptysis
1. CXR
-look if TB, penumonia, granuloma, opacities
-if normal, then increased risk of PE

2. FIBEROPTIVE BRONCHOSCOPY
-perform CXR, if normal, then do this to r/o MALIG
-look for small tumor

3. CT of chest
For lung CA, what lab tests should be ordered/imaging to confirm diagnosis of NSCLC v. SCLC?
CXR, CT scan, TISSUE biopsy

Tissue biopsy is what determines that between NSCLC and SCLC
DI-restrictive lung diseases
AMIODARONE (K+ channel blocker)
NITROFURANTOIN
BLEOMYCIN
ILLICIT DRUG USE
When should a pateint be taken off the ventilator
1. Check if the patient has an adequate respiratory drive
2. Intact cough
3. PaO2 > 79 mmHg PaCo2 < 45
4. O2 saturdation > 90% with PEEP of < 0.5cm H2O; FiO2 < 40-50%
5. TV > 5mL/kg
6. RR < 30 breaths/minute
7. VC = 10-15
8. NegI pressure <-20cm
Recuurent pneumonia in the same lobe location should be a red flag for?
LUNG CA - get CT of the chest
How does elastase result in a change in alveolar wall destruction in emphysema?
excessive elastase will be produced in cases with alpha1antitrypsin or a deficiency of antiprotease activity in lung.
-macrophages and pmns digest human lung
how might pulmonary HTN be characterized?
PAPressure > 25 mm Hg at rest
PAPressure > 30 mm Hg exercise
What are the CLINICAL PEARLS of HYPOXEMIA?
1. To determine the underlying mechanism of hypoxeima
-PaCO2 level
-A-a gradiant
-Response to supplemental O2

2 A-a gradiant is normal if HYPOVENTILATION or low inspired O2 is the only mechanism

3. If V/Q mismatch/shunting presenting then both PaCO2 and A-a gradient elevated

4. Supplemental O2 differs between two mechanisms
What is the number 1 parameter used to decipher ARDS from CHF?
PCWP - if low (< 18mmHg) then ARDS
PCWP - if hi (> 18) cardiogenic PEdema
How to diagnosis primary pulmonary htn
1. Cardiac cathederization
2. CX shows enlarged central pulmonary arteries, increased RV with CLEAR LUNG FIELDS!
3. PFT shows restrictive pattern
4. EKG shows RIGHT DEVIATION 2/2 RVH
Treatment of aspirations and aspirations pneumonia
CAB - airway breathing circulation = SUPPLEMENTAL o2

Penicillin G - to cover gram +
CLindamycin - to cover the anaerobes

If foul smelling sputum think ANAEROBIC COVERAGE NEEDED! go for the good antibiotics for anaerobes (that includes bacteroidies, clostridium, pepto)
How is airway obstruction diagnosed?
BY SPIROMETRY!

Normal --> elevated TLC, elevated RV, elevated FRC
Decreased FEV1
Decreased vital capacity
Clinical features of aspirations pneumonia
~40% develop symptoms 2-3 days post organisms areobic --> anaerobic (primary klebsiella)

-acute repiratory distress
-SOB, cough fever, tachypnia, hypoxemia, frothy sputum

causes = decreased level of consciousness, aspirations by alcohol, vomiting, ileus
HOW is the diagnosis of ASTHMA made?
1. PFT required = obstructive pattern with elevated TLC and RV and elevated FRV however will have lower TV low FEV1 and low FEV1/FVC ratio

2. SPIROMETRY = get before and after albuterol (B2 agonist) if increased FEV1 or FVC by 12%, then confirms the diagnosis.

3. PFR = peak flow rate: (450-650 in males; 250-500 in females); mild >300; moderate = 100-300; severe = <100

4. Bronchovocation test if no PFT
Goodpastures syndrome
Autoimmune (HLA DR2) antigbm type II hs to the alpha3-chain of collagen type 4 (IgG-AB)

1. Hemoptysis *cough up blood
2. SOB
3. Hematuria
4. Burning urination - renal failure and protein in urine

Diagnosis by: TISSUE BIOPSY
What is minute ventilation?
(RR x Vt) = measures ventilation. To decrease PaCO2 in patient, decrease the RR or TV.

Want patients baseline < 45 mmHg (PaCO2)
-initial TV of 8-10 mL/kg is appropriate in most cases (lwoer TV recommneded in patients with ARDS and COPD)
-10-12 breaths /minappropriate
What is ILD - classifications?
Intersitital lung disease (RESTRICTIVE LUNG PATTERN)
-inflammatory lung disease involving the alveolar wall (resulting in widespread fibroelastic proliferations, collagen deposition leading to irreversible firbosis/imparied O2 exchange/change in lung struccture

-environmental lung dz
-ILD with granulomas (sarcoid)
-Alveolar filling disease (ARDS)
-HS lung disease
-DI-RLD
-miscellaneous
Treatment of an acute exacerbation on hospital admission (asthma)?
PEV < 60% of predicted - req systemic steroids

1st - inhaled B2 agonists
-via nebulizer/MDI (metered dose inhalter)
-occurs in min

2nd - corticosteroids
-administer IV intiailly then orally when clinical improvement seen
-then inhaled

3rd - theophylline and IV magnesium
-keep O2 saturation >90%
Workup of PE:
Tests providing basis for treatment of PE with anticoag
1. Intraluminal filling defects in pulm atery on helical CT
2. DVT diagnosed on US and clinical suspician
3. Positive pulmonary angiogram (proves PE)

Rule OUT PE:
1. Low probability V/Q scan or normal helical scan and low clinical suspician
2. Negative pulmonary angiogram
3. Negative D-dimer
Increased intrathoracic pressure causing pulmonary HTN?

Increased blood viscosity causing pulmonary arterial pressure of > 25?
1. Mechanical ventilation with PEEP, COPD, causes pulmonary HTN (>25 mmHg at rest)
2. POLYCYTHEMIA VERA
BENIGN SOLITARY PULMONARY NODULE v. FACTORS THAT FAVOR MALIGNANCY of SPN?
<50 YO, non smoker, <2.0cm nodule, no growth in > 2 years, circular, regular, central laminated with Ca2+

>50YO, prior smoker, >3.0 steady growth, nodule grossly irregular, stippled or eccentric pattern of calcification
What is IDIOPATHYIC PULMONARY FIBROSIS? (IPF?)
ILD with restirctive pattern and honeycoming or ground glass on CXR. Cause is unknown and definitive diasnosis requires a lung biopsy

-presents with gradual SOB, nonproductive cough, dry cough and as survivial of 3-7 years

Treatment: no effective treatment available - majority of patients >70% do not improve with O2, corticosteroids, lung transplant
When does a patient require mechanical ventialtion?
significant respiratory distress (increases RR)
-impaireddec level of consciousness; cannot protect airway
-metabolic acidosis (doesnt adequately compensate with hyperventilation thus hypoV) and decreased pH
-respiratory muscle fatigue
-PaO2 < 70 mmHg or hypercapnia PaCo2 > 50; respiratory acidosis (pH<7.2) with hypercapnia
Diagnosis of PULMONARY HTN
ECG: RVH, RA-deviation, right atrial abnormality (myxoma)

ECHO: dilated pulmonary artery; dilitation/hypertrophy of RA/RV; abnormal movement of IV septum; right heart catheterization shows increased PA pressure
WHen should O2 therapy in patient with COPD be considered?
If PaO2 is 55mmHg or O2 saturaation is < 88%
If PaO2 55-59 mmHg + Polycythemia vera or COR Pulmonale (RCHF)
"All causes of wheezes"?
#1 is asthma but not ALL wheezes are asthma, but all that have asthma do wheeze.

Others:
1. CHF - edema in airways and mucosa
2. COPD - inflammation causes narrowing
3. Cardiomyopathyies - pericardial dz, edema near bronchi
4. Lung CA due to obstruction of AIRWAYS
Treatment of PE:
1. Supplemetnal O2 for hypoxia
2. Acute anticoag therapy of UFMH or LMWH
-start immediately if suspect
-give one bolus with IV infusion 5-10 days to maintain apTT 1.5-2.5x
3. Oral warfarin LT - start hep on day 1 and continue 3-6 months
4. Streptokinase/tPA
local invasion symptoms of lung CA v. metastatic disease sites?
Local invasion:
1. SVC syndrome -obstructed SVC by mesdiastinal tumor = seen in SCLC facrial features = seen in SCLC facial fullness, JVD, ARM edema.
2. Phrenic nerve palsy
3. Recurrent laryneal nerve palse
4. Horner's syndrome (PTOSIS, MIOSIS, ANHIDROS)
5. Pancoast tumor - SUPERIOR SULCUS TUMOR
6. MALIGNANT pleural effusion

Mestastsis: BRAIN BONE LIVER ADRENALS
ILD associated with granulomas
1. Sarcoidosis -along with other organs
2. Histocytosis x - langerhands cells CD1 esterase
3. Wegeners granulomas (sinus infection/hemoptosis plus hematuria)
4. Churg-strauss syndrome (IgE)
CPAP - continuous posistive airways pressure
positive pressure (0-20 cm H20) delivered continuously by ventilator but doesnt change volume of breaths delivered
-the patient breaths on own.
-set PEEP and pressure support
What is the diagnosis of a pleural effusion?
1. CXR - PA and LA view - blunted costophrenic angle - ~250 mL of fluid must accumulate to detect effusion on CXR. Determine if free flowing or loculated.
2. CT scan more reliable than CXR
3. THORACENTESIS - useful if unknown etiology
-75% diagnosis of patients; >10mm think of LLdecub
-therapeutic - drainage for relief
-pneumothorax - complication in 10-15% patients
-send fluid for: CHEMISTRY (protein, glucose); CYTOLOGY; CBC and CULTURE
Necrotizing granulomatous vasculitis that affects:
1. lungs/hemoptysis
2. kidneys (+/- hematuria - RPGN)
3. Upper airway/lower resp
4. cANCA
5. perforated nasal septum
WEGENERS GRANULOMATOSIS
How is COPD monitored?
1. Serial FEV1
2. Pulse Ox
3. Exercise intolerance

VC = IRV + TV + ERV
VC = IC + ERV
FRC = ERV + RV

TLC = IC + FRC
TLC = IRV + TV + ERV + RV = VC + RV
If a 36 yo patients comes to office with cc of progressive fatigue with a PMH of infiltrative TB and a blood culture indicating two populations of RBC (hypochromic and normochromic) - what is the next best step in this patients management if already on the "RIPE" regimen and a lab value status indicating (CBC) microcytic anemia with elevated serum iron levels and decreased TIBC?
Addition of pyridoxine - why?

Because the patient has a probably SIDEROBLASTIC ANEMIA. his condition results from defective heme synthesis that is most commonly 2/2 imparitment in the early steps of heme synethesis. Because the patient is on the TB regimented treatments, and ISONIZED comparitively can act as a antagnosit to pyridoxine, pateints should be expected to have an acquired sideroblastic anemia.

This will result in two groups of RBc on microscopy (one group in which manifests as microcytic hypochromic anemia that simulates iron deficiency anemia, and another group that are normochromic - hence the dimorphic population of cells). The decreased TIBC and elevated iron helps to differenciate sideroblstic anemia from that of iron-def anemia
What complications, then, are associated with mechanical ventilation?
1. Anxiety/agigtation/discomfort
-must sedate, use benzos or morphine, use propofol
2. Difficulty with tracheal secretions
3. Nosocominal pneumonia (if intub > 72 hr)
3. Extubation
5. barotrauma (high PEEP/O2 toxicitiy if FiO2 > 0.6) for greater than 2-3 days.
6. Hypotension 2/2 increased thoracic pressure by PEEP (increased intrathoracic pressure that decreases venous return and increased SVR - and ultimately cor pulmonale
COUGH, DYSPNEA, FLULIKE SYMPTOMS with BILATERAL PATCHY INFILTATES THAT DO NOT GET BETTER WITH ANTIBIOTICS?!
CRYPTOGENIC ORGANIZING PNEUMONIA (COP)

Treatment with steroids
HOw might PPH be treated for?
1. Pulmonary vasodilators like (PROSTCYCLINS - EPOPROSTENOL)
2. CCB decreased PVR
3. Vasodilator trial = O, IV adenosine, ORAL CCB
4. Anticoag with warfarin 2/2 venous statis and prevention of PE
5. Lung transplantation
How to differ on exam: CARDIOGENIC PULMONARY EDEMA v. ARDS?
Cardio: CHF, JVD, EDEMA, Hepatomegaly, P. Edema, Tachypnea, Tachycardia, volume overload.

ARDS: sepsis, increase RR, increased HR, doesnt respond to supplemental O2; cannot ventilate bc high peak airway pressures 2/2 stiff lungs.
DYSPNEA ON FIRST EXERTION RATHER THAN AT REST IS INDICATIVE OF RESTRICTIVE OR OBSTRUCTIVE LUNG DISEASE?
Restrictive
Although the effects of both CARDIOGENIC PULMONARY (FLASH) EDEMA and ARDS are the same, how does the causality differ?
Increaed alveolar capillary permeability causes ARDS; thus the interstitial edema, SOB, increased HR and RR, hypoxemia with shunting that doesnt respond to O2.

In cardiogenic pulmonary edema - congestive hydrostatic forces cause the increased interstitial fluid.
What is an ACUTE COPD EXACERBATION?
-SOB (most often NOT releived by albuterol)
-Increased sputum production and cough that is (NOT relieved by theophylline)
-Increased respiratory failure +/- ventilation (O2 therapy for HYPOXIA)
What is INR?

What increases the value?

"therapeutic range"?
International ratio that reports the PROTHROMBIN TIME (PT) by that of the extrinsic pathway affected by warfarin (wafarin thus increases the INR at clotting factors 2, 7, 9, 10 and protein C and S)

Therapeutic = 2-3
What are some causes of hypersenitivity pneumonitis and differentiates it from other causes?
Acute: flu-like with fever, chills, cough, SOB - CXR infiltrate
Chronic: Restictive lung disease

Extrinsic allergic alveolitis:
1. Farmers lung, modly hay
2. Birds breeders lung
3. Air conditionals lung
4. Bagassosis (sugar cane)
5. Msuchroom workers lung
6. Spores of thermophilic actinomycetes

Diagnosis of IgG and IgA in serum with ILD symptoms
Post capillary causes of pulmonary HTN (> 25 mm Hg)
primary due to L side of heart that will increase pressures on the PULMONARY VEINS like that of MITRIAL stensis (will be a diastolic murmur with OS).

ex: Mitrial stneosis (backs up blood into lungs and icnreases pressure of pulmonary capillary); LV dysfunction (LVH can cause); ATRIAL MYXOMA primary lipoma located in the R atriaum that is most liekly to cause a mid diastolic murmur in patients with no other underlying etiology and CAN result in a thrombus formation that can undergo embolic stroke.; CONSTRICTIVE PERICARDITIS
Mediastinal masses
Cause:
1.
2.
1. Metastatic cancer (#1 lung) most common cause of mediastinal mass in older patients
2. Anterior = thyroid, thymoma, lymphoma
3. Middle = lung, lymphoma, aneurysms, cysts
4. Posterior = neurogenic tumor, esophageal tumor
Chronic treatment of ASTHMA
1. Mild intermittent
2 . Moder persistent
3. Sev persistent
1. Mild intermittent - 2x/week == NONE (chronically)
2. Moderate persistent - daily ---DAILY INHALED corticosteroid
3. SEVERE continuous ---daily inhaled corticosteroids, LT B2 agonist
Ventilation versus oxygenation?
Both are unrelated to one another - o2 saturdation can be 100% with increased PaCO2 and be in ventilary failure

ventilation monitored by PACO2
-to decreased paCO2, must INCREASE or INCREASE TV
-minute ventilation = RR x VT
-to decrease paCO2, want to increase ventilation and thus increase RR and VT

oxygenation monitored by O2 saturation
PaO2 - to decrease PaO2 in the ventilated patient one must either decreased FIo2 or decreased PEEP
CLINCIAL features of a tension pneumothorax?
1. Hypotension - cardiac filling decreased due to compression of great veins
2. JVD
3. Mediastinal deviation away from side of lesion
4. Decreased breath sounds over collapsed lung
5. Hyperresonance
HISTIOCYTOSIS X
-chronic ILD with ABNORMAL PERFORATION OF the langerhan cells of bone marrow that can migrate
-90% smokers
-localized to bone or lung (eosinophilic granuloma or 2dary types - HAND-SULLER CHRISTIAN OR LETTERER-SIWE disease)
Treatment of tension pneumothorax
MEDICAL EMERGENCY - CHEST TUBE IT, LARGE NEEDLE IT!

2-3rd intercostal space in the midclavicular line - then chest tube it
What is the FEF50% for normal , obstructed, restricted lung?
Forced expiratory flow (FEF50%)
-normal = 3.2
-obstructed = 0.5
-restricted = 1.9
Prognosis of patients with PE diagnosis?
1. recurrence common (clinically silent)
-can lead to chroni PULM HTN and CHRONIC COR PULMONALE

2. PULM HTN (2/3) pts
-30% death d/t recurrent PE left undiagnosed
Paraneoplastic syndromes associated with
SQUA CC
SCLC
Adenocarcinoma
1. SQUA CC
- PTHrP-hormone with elevated Ca2 decreased phos and elevated parathyroid hormone)
-hypertrophic pulmonary osteoarthropathy

2. SCLC -
-Lambert eaton syndrome at NMJ;
-SIADH from ectopic tissue;
-ACTH secretion from ectopic tissue (carcinoid?) increased cortisol and increased cushings


3 Adenocarcinoma - hypertrophic pulmonary osteoarthropahty
What are the TWO MAIN TYPES OF LUNG CA?
75% NSCLC 25% SCLC
-SQUAA (30)
-Adenocarcinoma (35%)
-Large cell LC (5-10%)
Increased P2 on auscultation on/at 2nd parasternal border L side with a subtle lift of sternum
PULM HTN
Rare condition due to excess accumulation of surfactant-like protein and phospholipids in alveoli

Symptoms:
CXR:
Dry cough, SOB, rales, HYPOXIA

Diagnositc: LUNG BIOPSY
CXR: ground glass appearance with bilateral alveolar infiltrations that resumble a bat shape
Exudative effusion treatment
Treat underlying disease
-bacterial inf/tb
-viral infectoin
-malignancy
-PE
-CVD
What are the requirements to use NPPV?
1. Neurologically intact - aware, cooperative, protect airway

If doesnt improve, BIPAP should be d/c and conventional therapy for endotrachial intubation and mechanical ventilation.
Gold standard to diagnose PE:

Decision to rule criteria (DUKES!)
Pulmonary angiography - definitive diagnosis of exclude PE but is invasive

Symptoms and signs of DVT = 3 pts
ALT dx less likely thank PE = 3 pts
HR > 100 bpm = 1.5 pts
Immobilization > 3days/surgery past 4 weeks = 1.5 pts
Previous DVT = 1.5 pts
Hemoptysis = 1.0
Malignancy = 1.0
APICAL tumor of the lung involving C8 and T1-T2 nerve roots (radiating) pain down arm: Most common in SQUA CC with CENTRAL cavitation

(+) Association with HORNERS 60% of the time
PANCOAST TUMOR
Pleural effusion
Symptoms/pearls:

1. In increased pleural fluid amylase, think:
2. If milky, opalescent fluid, think:
3. If purulent fluid/pH < 7.2 think:
4. If bloody effusion think:
5. If exudative + lymphocyte think:
6. If pH < 7.2 think:
1. Esophageal rupture, pancreatitis, malignancy
2. Chylothorax
3. Empyema - pus in the pleura
4. Malignant if bloody
5. THINK TB
6. If pH < 7.2, think PARAPNEUMONIC EFFUSION
What is the first treatment for spontanous pneumothorax? Why?
Supplemental O2
-hastens the resorption of air in the pleural space
Hypercapnia --> ___ ____
can lead to SOB, VASODILATION OF CEREBRAL VESSELS with increased intracranial pressure and papilledema and coma
respiratory acidosis
pH<7.35-7.45
PCO2 > 35 mmHg
Granulomatous vasculitis in patients with asthema, increased pulmonary infiltrates and RLD; increased RASH and increased eosinophilia

+ pANCA
Churg strauss syndrome
Tracheomalacia
When a pateint is ventilator dependent for 2 or more weeks, a tracheostomy is usually performed to prevent softening of tracheal cartilage
Interstitial pulmonary inflammation that occurs in patients with prio treatment to breast, lung, lymphoma, thymoma, CANCER

1. Acutely forms 1-6 mo post treatment or chronically 1-2 years later with alveolar thickening and pulmonary fibrosis leding t a dever, couh, chest fullness, pleruitis chest pain and hemoptysis
RADIATION PNEUMONITIS
1. NORMAL CXR
2. CT SCAN - DIFUSE INFILTRATES WITH GROUND GLASS densities with pleural/pericardial effusion
SOB on exertion + syncope + fatigue + chest pain on exertion
PPH / P. HTN
What causes bronchiectasis? How can this be treated
Cause: permanent dilitation of the bronchioles and destruction of the bronchial walls with damaged cilia.

#1 - CYSTIC FIBROSIS most common AR in causcasions (~50%) for delta-F508 CFTR gene mutation

#2 - infection, humoral immunodeficiency or airway obstruction
Hypoxemic respiratory failure and oxygenation

Hypercarbic respiratory failure and oxygenation
1. Lowest concentration of oxygen that provides sufficient O2 to avoid O2 toxicity (free radical)

2. High concentrations of O2 causes CO2 retention especially in patients with COPD because pt doesnt ventilate off of CO2 - thus hyPOventilation.
What are the classic types of COPD?

List the four risk factors:
1. Chronic Bronchitis - productive and chronic cough of sputum for at least 3months/year
2. Emphysema - permanent enlargement of air spaces due to surfactant destruction of alveolar walls at terminal bronchi

Risk factors:
1. Tobacco use (90%) COPD
2. alpha-antitrypsin
3. second hand smoke
4. chronic athsma
Which lung is most common to develop aspirations penumonia 2/2 anatomy?
Lower segment of right upper lobe
upper segment of right lower lobe

Because the RM bronchus follows straight path
Which paraneoplastic syndromes are associated with SCLC (20-25%) of ALL lung CA?
1. SIADH - 10% - ectopic tissue which increased ADH; this causes increased H2O retention that will bind and increase AQP2R while likewise increases that of sodium out. Thus, will have hypoatremia bc body trying to unload with hypervolemia and decrease RAAS

2. ECTOPIC ACTH: SCLC, increased cortisol, increased cushings
3. Lambert-eaton syndrome
Peripheral pulmonary infiltrates with a fever and elevated eosinophils without changes in IgG and IgA
EOSINOPHILIC PNEUMONIA
What is the treatment of SPONTANEOUS pneumothorax?
1. PRIMARY --> If small and patients is asymptomatic then
-OBSERVE - resolves in 10 days
-small CHEST TUBE (one way valve)

2. PRIMARY --> if LARGE/symptomatic (cough, SOB, sudden and UNILATERAL CP
-SUPPLEMENTAL o2
-chest tube placement/insertion

3. CHEST TUBE DRAINAGE
Causes of acute repiratory failure 2/2 shunts? (ittle or no ventilation in perfused areas due to collapsed or fluid filled alveoli - pneumonia - the venous shunts to the arterial circumation without getting oxygenatued and thus results in that of ARF 2/2 decreased oxygenation)
1. Atelectasis (collapsed)
2. Fluid build up in alveoli
-pneumonia/pulmonary edema
3. Drect RIGHT to LEFT shunt d/t congenital abnormality

doesnt respond to supplemental O2
Symptoms of LANGERHANS HISTIOCYTOSIS X?
SOB and COUGH
What are the clinical features of pulmonary embolism
-symptoms
-signs
increased HR, RR, SOB

1. DYSPNEA (72%)
2. PLEURITIS CHEST PAIN (66%)
3. COUGH (27%)
4. Hemoptysis (13%)

1. Tachypnea (RR) *70%) - hypercarbic ventilatory failure
2. Rales (51%)
3. Tachycardia (30%) increased HR
4. S4 (24%)
Types of PULMONARY HTN:
1. Passive = resistance to pumonary venous drainage. Not actively in pulmonary best - further down. Mitrial stensosis, LVF, ATRIAL myomxa (most common cause of a mid diastolic heart murmur)
2. Hyperkinetic = L--> R cardiac shunts that include VSD, ASD, PDA
3. Obstructive = resistance to flow through P. arteries = PE, PA setnosis
4. Obliterative = resistance due to fibrosis PPH (primary pulmonary HTN, CVD, crest)
5. Vasoconstrictive - hypoxia induced (COPD)
What are the risk factors for LUNG CA?
1. Cigarette smoking > 85% of cases
-adenocarcinoma lower associated lung CA to smoking.
2. Passive smoking (2nd hnd)
3. Asbestos: ship building, construction, cars, smoking and asbestos increase risk
4. RADON - found in basements
5. COPD - independent risk factor once smoking considered
What are the clinical features of pulmonary HTN?
Symptoms: SOB on exertion, fatigue, chest pain (exertional), syncope (exertional) with severe disease)

Signs: loud pulmonic component of P2 and lift of the sternum (RV dilitation); when RVfailure occurs = JVD, peripheral edema, ascites
MAINSTAY treatment for PULMONARY ALVEOLAR PROTEINOSIS?
-lung lavage or GSCMF - increase the granulocytes by stimulatied neulasta or filgrastin.
Hypocarbia is common is asthmatics under respiratory distress, why?
Have increased respiratory rate thus should cause PaCO2 to decrease (breathing off the CO2)

Increased PaCO2 is a sign of respiratory muscle fatigue or severe airway obstruction thus INTUBATION may be required
CXR: egg shell calcifications
-localized and nodular peribronchial firbosis of the UPPER LOBES that can be acute (rapid onset + death) or chronic (symptoms yrs post exp)
-#1 symptom = exertional dyspnea
Silicosis
Diagnosis of acute respiratory failure:
1. ABG
2. CXR or CT scan
3. CBC and metabolic panel
4. If cardiogenic P. edema, get enzymes
When are DDIMERs elevated?
PE
DIC (SEPSIS - 2dary)
CHF
PNEUMONIA
POSTop STATE
What are the constitutional symptoms of LUNG CA - both SCLC and NSCLC?
1. Anorexia, weight loss, weakness
2. Indicates advanced stage is cachexia
3. SOB, hemoptysis, cough, wheeze
4. Recurrent pneumonia
Decreased tactile frematis; decreased breath sounds over effusion, dullness to percussion:
pleural effusion
empyema causes:
differs from a parapneumoni effusion becase it is a "complicated" effusion in which contains infection and pus within the pleural space. Number one cuse is 2/2 that of bacterial infectoin like S. pneumonia.

Diagnosis: CXR and CT scan of the chest
Treatment: Thorcentesis wth AB therapy; repeat drainage req bc difficult to eradicate; if persistant than a rib retraction may be required.
What systems are interrupted/dysfun if repirations become decreased and HYPOXIA ensues *HYPOXEMIA?
1. CNS - brain = drug OD; stroke; trauma
2. NM disease = MG, POLIO, GUILLAIN BARRE SYN, ALS
3. Upper airway = obstruction 2/2 to a number of causes like stenosis, paralysis
4. Thorax/pleura = mechanical restriction due to kypho or flial chest
5. CV system = CHF, valvular dz, PE, anemia
6. Lower airway and alveoli = asthma, COPD, pneumonia
Letterer-Siwe disease?
langerhan cells that proliferate into many tissues
What are the side effects of PEEP?
1. Barotrauma = pneumothorax
2. Decreased CO d/t decreased VR in setting of hypovolemia = lowers venous return because increased intrathoracic pressure. Increased SVR due to decreased VR. Can cause COR PULMONALE.
CRYPTOGENIC ORGANIZING PNEUMONITIS (COP) Differs from the other types of restrictive lung diseases in that it?
-inflammatory lung dz; similar CXR to infectious pneumonia (locular or diffuse) - due to viral, medicational, or CTDz that is uaully idiopathic
-AB effective
-spontanous recovery or corticosteroids is mainstay
-relapse common post corticosteroids
Obstructive lung disease:

FEV1
FEV1/FVC
Peak flow (expire)
RV
TLC
VC
decreased FEV1
decreased FEV1/FVS ratio
decreased PEV
increased RV
increased TLC
decreased VC
CHRONIC COUGH WITH LARGE AMOUNTS OF SPUTUM, HEMOPTYSIS (BLOOD) and foul-smelling sputum --> _____

Dx and Rx
BRONCHIECTASIS - cough, SOB, BLOOD (hemoptysis) and persistent recurrent pneumonias

Dx: High reoslution CT scan; PFT of obstructive pattern (elevated TLC and RV and FRV and decreased TV and FEV1 low and FEV1/FVC low; then order a CXR

Rx:
1. Antibiotics if acute exacerbation
2. Bronchial hygiene (hydration/chest percussion, inhaled bronchodilators)
ARDS characteristics = patients at risk for?
SEPSIS OR SEPTIC SHOCK INCREASES THE RISK OF ARDS

1. DIFFUSE
2. INFLAMMATORY
3. NEUTROPHIL ACTIVATION (D/T PULMONARY CIRCULATION)
4. ARISES DUE TO INFLAMMATORY RESPONSE
5. PATHOPHYSIOLOGY
-MASSIVE INTRAPULMONARY SHUNTING DUE TO ATELECTASIS, COLLAPSE ALVEOLI, SURFACTANT DYSFUNCTION --> LEADS TO EDEMA, INCREASED LUNG FLUID, INCREASED A-a O2 DIFF > 20; DECREASED O2 EXCHANGE.
Berylliosis as a pneumoconiosis?
Dx:
Acute rapis onset early death
Chronic: >15 years exposure

-upper lung diffuse pneumonitis
-similar to sarcoidosis (granulomas, skin leisons, hypercalcemia)

dx: beryllium lymphocyte proliferation TEST
rx: glucocorticoid
If anticoagulation is contraindicated in patient with PE (cannot use LMWH, WARFARIN or thrombolytics) what is indicated?
Inferior vena cava filter (greenfield filter placement)

indications - if documented DVT/PE then complication with current anticoag; failure of adequate anti-coag by recurrent DVT/PE; high risk pts with death
If pleural fluid glucose < 60, r/o ____ ____. What else can decrease the glucose in plerual effusion?
Rheumatic Arthritis

TB, Esophageal rupture, malignancy, lupus
SCLC treatment?
1. Chemotherapy #1 for both: LIMITED and EXTENSIVE
2. Radiation therapy useful in limited stage disease (thus lung and superclavicular nodes) and not extensive - inclusive of external chest (BRAIN, BONE, ADRENAL, LIVER)
3. Surgery not good
Causes of tension pneumothorax?
Air trapped within the pleural space such that tissues surrounding pleural cavity act as one way valves allowing air to enter pleura, but not allowing escape.
-accumulation of air under (+) pressure collapses ipsilateral lung and moves mediastinum away from side of pneumothorax.

*Mechanical (barotrauma) ventilation
*CPR
*Trauma
When is a chest x ray ordered in asthmatics
only in SEVERE ASTHMA with PEV < 100 to excluse conditions like:
1. Pneumonia
2. Pneumothorax
3. Foriegn body
Treatment of SARCOID?
Most spontanously resolve in 2 years and do not require meds

Corticosteroids are the treatment of choice 2nd line is MTX
Sources of PE to the lung:
#1 DVT
1. Fat emboli if longbone frature
2. Amnion fluid embolism (post delivery)
3. Air emboli (trauma to thorax or an indwelling V/A line)
4. Septic emboli (bacterial endocarditis - IV drug use)
5. Schistosomiasis
What causes increased CO2 production resulting in hypercapnia?
PaCO2 > 60 mmHg and hypercapnic RF?
DKA
Hyperthermia
Sepsis
(hypercarbia - increased PaCO2 yeilding respiratory FAILURE)
treatment of COPD?
1. SMOKING CESSATION (by age 35, decreasing FEV1 by 25-30mL/year; therefore decrease the rate of decline of FEV1 if quites but doesnt result in complete reversal.
-prolongs survivial
-symptoms get better within one year of cessation

2. B2 agonists inhaled )albuterol - SA; salmeterol - LA
3. Anticholinergic inhaled (ipratropium) - i pray I can breathe
4. Corticosteroid (budesonide/fluticonizone)
If patient develops:

1. Dyspnea
2. Petechiae
3. Mental status change

Think ___ ___ as cause of ___ ___
fat emboli
pulmonary embolism
Restrictive lung disease

FEV1
FEV1/FVC
PEV
RV
TLC
VC
FEV1 = normal to slightly elevated
FEV1/FVC normal to high
PEV is normal
RV is low, normal or HI
TLC low
VC is low

DIFFICULTY GETTING AIR IN!
Hemorrhagic pneumonitis + glomerulonephritis + hemoptisis and increased IgG
Goodpastures syndrome

1. Plasmaphoresis
2. Cyclophosphamide
3. Corticosteroids
How is a transudative effusion treated?
1. LDHp is not created than 2/3 the serum value. LDHp/LDHs is not greater than 0.5 and PROTEINp/proteinS is not greater than 0.6

-diuretics (LOOPS), with salt restriction
-therapeutic thoracentesis only if CXR is lat > 10,, and massive enough to cause dyspnea; chance of pneumothorax is 10-15% thus want to dec RISK
What is NPPV and when is it indicated in patients?
noninvasive + pressure ventilation
1. BIPAP or CPAP
-set with inspiratory and expiratory pressures
-delivery by mask
-admin to pts in attempt to avoid intubation and mechanical ventilation
Predilectation for the lower lobes, inhalation of the asbestos fibers can diffusely insult the lung with restrictive pattern - thus process takes >10-20 years post exposure
Asbestosis (ILD of the lOWER LOBES)
-dyspnea, cough, fatigue, CTD, rales at the bases
DIfferential diagnosis of
1. Anterior mediastinal masses v. MIDDLE mediastinal v. POSTERIOR mediastinal
Anterior: thyroid, teratogenic, thymoma, lymphoma
Middle: Lung CA, lymphoma, aneurysm, cysts, morgagi hernia
Posteiror: neurogenic, esophageal mets, enteric cysts, bochadalaks hernia
Helical spiral Ct scan of the CHEST?
1. >90% sesitivitiy/speificity
2. Visualizes small clots that are < 2mm
3. Replaced V/Q scan as the test of choice
IF EXUDATIVE effusions suspected - what must be performed?
Thoracentesis and do test on the PLEURAL fluid:
1. Diff cell count
2. glucose
3. pH
4. amylase
5. TG
6. Microbiology
7. Cytology
What are the three characteristics of ASTHMA:

"TRIAD"

Extrinsic v. intrinsic asthma?
1. Airway inflammation
2. Hyperresponsitivity
3. Airway obstruction

Extrinsic (most)
-atopic production of IgG to enfironeent with eczema or HAY fever
-asthmatic at young age

Intrinsic
-unrelated to environment
Two types of pneumothorax
1. Traumatic
-transthoracic needle aspiration to diagnose NSCLC to SCLC
-thoracentesis to dx a P effusion
-central line placement

2. Spontaneous pneumothorax
-primary (simple) without underlying lung disease
-spontaneous rupture of subpleural blebs at the apex of the lungs
(paraacinar emphy)
-tall young lean males
-2/2 to lung disease
Two major types of RESPIRATORY FAILURE
1.
2.
1. HYPOXEMIC RF = < 50 mmHg PaO2
-low PaO2 with a PaCO2 low or normal
-PaO2 < 50mmHg/PaCO2 > 60
-present when O2 sat < 90% despite FIO2 > 0.6
-include disease processes of lung itself (ARDS, pneumo, pelmonary edema)

2. HYPERCARBIC RF =
-decreased minut ventilation
-increased phsioloic dead space leads to increased CO2 retention
-caused by BOPD, asthma, CF, bronchitis
-CNS depression (thus diaphragmatic paralysis) cannot ventilate 2/2 accessory muscles being unable to maintain movement
Pt with 2 days SOB, RSided CP, and progressive back pain that has limited her mobility. PMH of breast CA. Had adjuvant therapy with masectomy 6 mo prior and currently on tamoxifen and MVitamin. Temp 100.4, BP 100/60, pules 110, RR 18. Lung examiantion shows decreased breathe sounds in the right base. Chest XR shows infiltrate oscuring the right heart border and sight sidered pleural effusion.

Pleural fluid:
pH = 5.75
nucleated cells = 8050
glucose = 38
protein = 3.9
RBC = 1500
LDH = 620

Serum chemistries show LDH = 310 U/L and protein concentration of 6.1

Most likely ddx?
Can be HF, penumonia, DI-lupus, PE, hypoalbuminemia

What to do? Pt has Right mIDDLE LOBE infiltrate and RS pleural effusion concerning for pneumonia with complicated parapneumonic effsion. Frist step is to differentiate wither the effusion is an exudate or transduate. MUST USE "Lights Criteria" in which one of the following must be present for exudate
1. Pleural Fluid protein/serum protein ratio > 0.5
2. Pleurl fluid LDH/serum LDH ratio > 0.6
3. Pleural fluid LDH > 2/3 of the upper limit of normal for serum LDH

This pt has a PF protein/S protein ratio of (3.9/6.1) which is > 0.5
This pt has a PF LDH/S LDH ratio of (620/310) which is >0.6
And thus she by having at least ONE of three lights criteria fits that of an EXUDATE.

What to do? Pt has exudative effusion - is it complicated or uncomplicated? Complicated fluid has a positive gram stain, postivive culture, pH <7.2 and glucose level <60 and requires chest tube drainage because it is unlikely to resolve spontaneously (HENCE AN EMPYEMA - which is frank pus in pleural space).

This pt has nucleated cells, and low flucose, and a low pH. She fits criteria for a complicated exudative effusion. AND as such she requires BOTH AB therapy AND a chest tube to drain effusion.
Transudative effusion v. EXUDATIVE effusion - CRITERIA?
Transudative: increased Pcapillary pressure in the viseral or parenteral pleura (CHF) or decreased plasma oncotic pressure (hypoalbuminemia 2/2 nephrotic syndrome for example) which will pull nothing into vessel. Ex include CHF, cirrhosis, PE, nephrotic syndrome, peritoneal dialysis, hypoalbuminemia, atelectasis (collapsed lung)

Exudative: increased permeability of pleural surface or decrased lymphatic flow from pleural surface 2/2 damaged pleural membranes/vasculature. Examples includ bacterial pneumonia, malignancy, TB, PE, viral infection, PE, CVD.

USE LIGHTS CRITERIA to dx that of exudative:
-must have one of any three to be diagnosed with a transudative versus an exudative:

1. Pleural LDH/Serum LDH > 0.6
2. Pleural protein/Serum protein > 0.5
3. Pleural LDH > 2/3 upper limit of serum LDH
What tissue biopsy technique performed to dx ILD?
Fiberoptic bronchscopy - only limited amount (transbronchial biopsy)

Open lung biopsy or video assisted thorascopic lung biopsy