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AC(E) USMLE Step 2 Respiratory

Terms in this set (169)

Postpartum bleeding, pulmonary sx, CXR nodules
Choriocarcinoma - met of gestational trophoblastic disease
-occur post molar preg or norm preg
sx: vaginal bleed, large uterus, pelvic pain
-MC mets to LUNG
MCC Cor pulmonale
COPD
Cor pulmonale
Right ventricular hypertrophy w/ eventual RV failure due to pulmonary HTN 2/2 to pulmonary disease
Signs of Cor pulmonale
-R-sided heart failure: hepatomegaly, edema, JVD, Right ventricle heave
ECG of Cor pulmonale
(right sided HF)
-right axis deviation (down in lead I, upright QRS in lead aVF)
-P pumonale (peaked P waves)
-RVH (right axis deviation and R wave in V1>7mm)
Causes of transudative pleural effusions
-CHF
-Cirrhosis
-nephrotic syn
Causes of exudative pleural effusions
-Pneumonia, TB
-Malignancy, mets
-viral infection
collagen vascular disease
Lights criteria
-determines exudative effusions:
-pleural /serum protein >0.5
-pleural/serum LDH >0.6
-LDH> 2/3 upper limit of normal LDH
DDx elevated pleural fluid amylase
esophageal rupture
pancreatitis
malignancy
DDx pleural effusion fluid is milky, opalescent fluid
chylothroax (lymph in pleural space)
-MCC cancer, trauma
DDx frankly purulent pleural fluid
empyema (pus in the pleural space)
DDx pleural fluid pH <7.2
Parapneumonic effusion or empyema
Parapneumonic effusion
-non infected pleural effusion 2/2 bacterial pneumonia (vs empyema is infected)
-tx: uncomplicated - abx alone
complicated - chest tube drainage, intrapleural inj of thrombolytics can accelerate drainage, surgical lysis of adhesions may be needed
Arterial blood gases in pulmonary embolism
PaO2 and PaCO2 low due to hyperventilation as body tries to overcome the V/Q mismatch
--> respiratory alkalosis
-elevated A-a gradient
*not diagnostic for PE
Differentiate between COPD and asthma
asthma: inc FEV1 or FVC by 12% after bronchodilator (B2 agonist) proves reversibility of airway obstruction, respiratory alkalosis 2/2 hyperventilation
COPD: respiratory acidosis 2/2 CO2 retention
Both: PFT obstructive pattern (dec expiratory flow rates, dec FEV1, dec FEV1/FVC ratio)
MCC of chronic cough
-bronchial asthma (wheezing, hyperinflated lungs)
-GERD (sx when recumbent or after meals, nighttime cough)
-postnasal drip (cobblestoning of nasal mucosa, nasal congestion)
asthma and nasal polyps
Aspirin sensitive asthma
-avoid aspirin and any NSAIDs in these pts bc may cause severe systemic reaction
Diagnosis?
young patient with constitutional sx, respiratory complaints, erythema nodosum, blurred vision, BL hilar adenopathy
Sarcoidosis
Diagnosis of sarcoidosis
CXR: bilateral hilar adenopathy
elevated ACE
hypercaliuria, hypercalcemia
transbrochial biopsy: noncaseating granulomas*
Primary spontaneous pneumothorax causes
-no underlying cause
-caused by spontaneous rupture of subpleural apical blebs -> leak air into pleural space
-more common in lean tall young men
Secondary pneumothorax causes
-complication of underlying lung disease, most commonly COPD
-COPD pt presents with catastrophic worsening of resp sx due to dilated alveolar blebs that rupture into pleural space
Diagnosis of Pneumothorax v Tension pneumothorax
Pneumothorax:
-CXR shows visceral pleural line -mediastinal shift toward side of pneumo
Tension: *Do NOT get CXR: immediate chest decompression with large bore needle
-mediatinal shift away side of pneumo
-hypotension, distended neck veins
Idiopathic pulmonary fibrosis
-restrictive lung disease of unknwn etiology
-pt presents with chronic progressive dyspnea, nonproductive cough and digital clubbing
-no fever, chest pain
-ABGS: restrictive pattern (dec TLC, FEV1, FVC; normal FEV1/FVC ratio)
-inc A-a gradient, reduced diffusing capacity
Pt with pulmonary and renal findings together
Goodpasture's disease
-affects lungs (cough, dyspnea, hemoptysis)
-affects kidneys (nephritic range proteinuria, acute renal failure, dysmorphic red cells/red cell casts)
-no systemic symp
diagnosis Goodpasture's disease
renal biopsy showing linear IgG antibodies along the glomerular basement membrane
Pancoast syndrome
-neoplasm at pulmonary apex
-at thoracic inlet, compresses inf part of brachial plexus: shoulder pain radiating in ulnar distribution
-Horner's syndrome: miosis, ptosis, anhidrosis
ABG profile in COPD v CHF
COPD: hypoxia, hypercapnia, respiratory acidosis
CHF: hypoxemia, respiratory alkalosis, widened A-a gradient
Treament of COPD
-bronchodilators: B2 agonists, anticholinergics (ipratropium bromide)
-steroids and abx for acute exacerbations
Treatment of asthma - symptoms 2 or more times per week
mild intermittent asthma
*short acting B2 agonist
-no long term meds needed
Treatment of asthma - daily symp
moderate persistent asthma
*short acting B2 agonist
-daily inhaled corticosteroid (low dose) or cromolyn/nedocromil or methylxanthine or antileukotiene
Treatment of asthma - continual symp, limited physical activity
severe persistent asthma
*short acting B2 agonist
-daily inhaled corticosteroid (high dose)
-long acting inhaled B2 agonist or methylxanthine
-systemic corticosteroids
pt with asthma exacerbation hyperventilates (low CO2), few minutes later has normal or high CO2. Why?
May be sign pt is decompensating! due to fatigue
-intubation required
A-a gradient Normal v increased
alveolar-arterial oxygen difference
Normal gradient - when hypoventilation is cause of hypoxemia
Increased in most other causes: V/Q mismatch, shunt
Mechanical Ventilation: decrease oxygenation
-monitored by O2 saturation, PaO2
-decrease FIO2 or PEEP
Mechanical Ventilation: decrease ventilation
- monitored by PaCO2 (hypoventilate, inc PCO2)
-decrease respiratiory rate or tidal volume
DDx interstitial lung diseases associated with granulomas
-sarcoidosis (erythema nodosum, ant uveitis, noncaseating granulomas)
-histiocytosis X (somker, cystic lesions, honeycomb lung)
-Wegeners granulomatosis (resp infxns, glomerulonephritis, pulmonary nodules, c-anca)
-Churg-Strauss (asthma, rash, eosinophilia, p-anca)
Asbestosis findings
-type of pneumoconiosis
-CXR pleural plaques
-inc risk brochogenic carcinoma, malignant mesothelioma
-institial fibrosis, restrictive lung pattern
-no specific tx
Silicosis findings
-type of pneumoconiosis
-CXR *egg shell calcifications
-*localized nodular peribronchial fibrosis in upper lobes
-mining, stone cutting, glass manufacturing
-tx: remove exposure; yearly TB testing
Berylliosis findings
-type of pneumoconiosis
-similar to sarcoid: granulomas, skin lesions, hypercalcemia
-diag: beryllium lymphocyte proliferation test
-tx steroids
MCC pleural effusion
CHF
theophylline toxicity
ciprofloxacin and erythromycin inc toxicity
-CNS stim: headache, insomnia
-GI: N/V
-Cardiotoxicoty: arrythmia
-mech: stimulates epinephrine release, phosphodiesterase inhib
Chronic bronchitis v bronchiectasis sx and diagnosis
chronic bronchitis: nonpurulent expectoration
-diag: PFTs
bronchiectasis: mucopurulent expectoration, responds to abx
-diag: high resolution CT
Mechanical ventilation goals
- maintain alveolar ventilation (PaCO2 40-50)
-correct hypoxemia (good: PaO2 50-60)
-try to keep FiO2<40%
Diagonisis:
well circumscribed verrucous, crusted lesions, bone lytic lesions, lobe consolidation
Blastomycosis - pulmonary fungal infxn endemic to Great Lakes, Mississippi and Ohio River Valley, esp Wisconsin.
-broad based bidding yest in sputum
-tx: itraconazole or amphotericin B
atypical pneumonia v community acquired pneumonia sx
atypical: indolent course, nonproductive cough, extrapulmonary symp: HA, sore throat, skin rash
CAP: rusty colored sputum, less extrapulmonary sx
MCC atypical pneumonia
Mycoplasma pneumoniae
-erythema mulitpforme, will not gram stain bc no cell wall
other causes:
chlaymydia pneumo, Legionella, Coxiella, influenza
diagnose Legionella
urine Legionella antigen test
Diagnose ARDS
-its not h(ARDS) to diagnose:
-Acute onset
-Ratio PaO2/FiO2<=200
-Diffuse infiltration
-Swan-Ganz wedge pressure <18 mmHg
ARDS sx
-acute onset (12-48 hr) tachypnea, dyspnea, tachy, +- fever, cyanosis, diffuse rales, hypoxemia
-hypoxemia, dec lung compliance, non-cardiogenic pulmonary edema
Pathophys ARDS
local/distant tissue injury-->release of inflammatory mediators--> cause alveolar damage, inc alveolar capillary permability, leak proteinaceous fluid into alveoli--> acute onset tachypnea, tachycardia, fever, dyspnea
Emphysema PFTS: FEV/FVC, FVC, TLC, DLco
dec FEV/FVC
normal or dec FVC
normal or inc TLC (also in asthma)
dec DLco
Treatment of acute COPD exacerbtion
-O2
-B2 agonists (albuterol), anticholinergics (ipratropium)
+- corticosteroids, abx
Management of chronic COPD
-smoking cesation, inhaled B2 agonists (albuterol), anticholinergics (tiotropium)
-supplemental O2 if resting PaO2<=55 or SaO2 <=89 or cor pumonale, pulm HTN, hct>55
-pneumococcal and flu vaccines
Restrictive lung disease PFTS: TLC, FVC, DLco, FEV/FVC
dec TLC
dec FVC
dec DLco
normal FEV/FVC
Empyema cause
-intrapleural collection of pus due to bacterial seeding of parapneumonic effusion in the setting of bacterial pnemonia
Bugs associated with Empyema
-same bugs ass w/ pneumonia
-Strep pneumo, Staph aureus, Klebsiella pneumo
-mixed aerobic and anaerobic bacterial population supersedes as infected pleural effusion progresses to empyema (thus it is not very responsive to abx usually used to tx CAP)
Indications for pleural fluid to be drained
-pH<7.2, suggestive of parapneumonitc effusion and empyema
-glucose <60
-must do thoracentesis or thorocostomy/chest tube
treatment of acute asthma exacerbation
-Oxygen
-albuterol - short acting B agonist
-ipratropium - anticholinergic (never use alone)
-systemic IV corticosteriods
-magnesium (severe)
-theophylline (severe, rare)
Management of Flail chest
positive pressure mechanical ventilation allows segment to move normally
PFTs bronchiectasis v emphysema
-BOTH: FEV1/FVC< 0.75; minimal response to bronchodilators; inc RV; inc TLC
-emphysema: dec DLCO
-Bronchiectasis: N DLCO
MCC of massive hemoptysis
Bronchiectasis including CF - from bronchial arteries
MCC of trivial hemoptysis
Bronchitis
Treat ment of postnasal drip
-oral antihistamines,
-decongestants
-abx
nasal irrigation
Features of Sarcoidosis
Granulomas, noncaseating
aRthritis
Uveitis
Erythema nodosum
Lymphaadenopathy
Interstitial fibrosis
Negative TB test
Gammaglobulinemia
aslso: inc ACE, hypercalcemia
Aquired torticollis etiology, management
-MCC: URI, minor trauma, cervical LAD, retropharyngeal abcess
-get cervical XR to eval fracture/dislocation spine
Bronchiolitis bug
RSV
Bronchiolitis presentation
-child <2 yp
-tachypnea, wheezing, crackles, inc RR
-CXR: hyperinflated lungs, flat diaphragm, no consolidation, interstitial infiltrates, atelectasis
-tx: fluid nebulizers
severe: inpt isolation, hydration, O2, albuterol
-RSV inc risk of Asthma in later life
Distinct charac of Legionella pneumonia, diag, tx
-prominent GI symp (diarrhea)
-hyponatremia
-elevated LFTs
-diag: urine Ag
-tx: quinolone or macrolide
FEV1, RV, TLC, FVC, DLCO, compliance in Obstructive lung disease
FEV1 dec
RV inc
TLC inc (emphysema, asthma)
FEV/FVC dec <0.75
FVC N or dec
DLCO dec (asthma)
inc compliance
face and arm swelling, venous distension of neck and chest wall, dyspnea//cough, HA
Superior Vena Cava syndrome
-central tumor (esp small cell lung CA)--> SVC compression
-diag: CXR
-tx: steriods, diuretics, XRT+- chemo after tissue diag
Light criteria of transudate or exudate
Exudate if:
-fluid protein/serum protein >0.5
-fluid LDH/serum LDH >0.6
-pleural fluid LDH > 2/3 upper limit of normal serum LDH
Criteria to start Oxygen therapy
-if PaO2<=55 mmHg or SaO2 <=89% (during rest, exercise or sleep) to pevent cor pulmonale and dec mortality
-goal:PaO2 >=55-60 or SaO2 90-93%
watch for CO2 retention due to inc V/Q mismatch, loss of hypoxemic resp drive
anterior mediatinal mass producing HCG and AFP
nonseminomatous germ cell tumor
-young males, locally invasive
-BHCG high in seminomas and nonsemi germ cell tumors; but nonsemi also produce AFP
Seminoma - what does it produce
-Beta HCG
-does not make AFP (like non-seminomatous gern cell tumors)
Thymoma characteristics
-neoplasm of thymus
-ass w/ myasthenia gravis and pemphigus
Choriocarcinoma features
-form of getational trophoblastic disease occurs in setting of molar preg
-elevated BHCG
COPD tx that decrease mortality
1. O2 therapy
2. smoking cessation
gram positive diplococci refer to
Strep pneumoniae
gram positive cocci in clusters refer to
Staphylococcus
gram negative cocci refers to
Neisseria
gram positive rods refer to
Listeria and Bacillus
gram negative rods refer to
Pseudomonas, Haemophilus, Klebsiella, Legionella
Klebsiella pneumonia features
-alcoholics
-encapsulated gram neg bacillus
-upper lobe pneumonia, currant jelly-like sputum
-grows as mucoid colonies
-common nosocomial infxn
Management of DVT a/w hemodynamic compromise, severe dyspnea, or RV dysfxn
-thrombolytics, tPA (vs heparin), pt must be low bleed risk
-catheter directed therapy, if cant do fibrinolytics or surgery
-thrombectomy, if cant do lysis
-IVC filter, if cant anticoag
Inpt treatment of community acquired pneumonia
-likely strp pneumo
-newer quinolones: levofloxacin, moxifloxacin (not cipro)
OR
-3rd gen ceph + macrolide
Outpt treatment of community acquired pneumo
-likely strep pneumo
-azithromycin or doxycycline
painful skin lesions on shins + bilateral mediastinal adenopathy
Sarcoidosis
Management/workup of potential DVT/PE
-immediate anticoagulation w/ LMWH if high clinical suspicion...then get spiral CT to confirm
-if CI to anticoag or low suspicion for PE, do diagnostic test first
Asthma plus syndrome
Atopy
-asthma+ allergic rhinitis + atopic dermatitis
-produce specific IgE following exposure to allergen
Asthma plus syndrome
ASA-sensitive asthma
-asthma + ASA (aspirin, NSAIDs) sensitivity + nasal polyps
-reaction to all NSAIDs, aspirin with similar mech
-nasal polyps, rash, rhinitis are allergic component
-"pseudo-allergic reaction" due to leukotrienes, COX-1 inhibition
(v allergy IgE reaction to one specific NSAID)
-tx: avoid NSAIDs, use leukotriene receptor antag
Asthma plus syndrome
ABPA
-asthma + pulmonary infiltrates + allergic rxn to aspergillus
asthma plus syndrome
Churg-Strauss
-asthma + eosinophilia + granulomatous vasculitis
open pneumothorax sx tx
-open defect in chest wall
-dec absent breath sounds on affected side, poor ventilation, O2
-intubate, positive pressure ventilation, closure of defect in chest wall w gauze and tape on three sides
-allows pressure to escape, to open pneumo does not become tension pneumo
tension pneumothorax sx, tx
-after blunt or penetrating trauma to chest; air forced into pleural space cannot escape and collapses affected lung
-shifts mediastinum and trachea to opposite side of chest
-absent breathe sounds on affected side, hypertympanic percussion
-tx: needle thoracentesis, then insert chest tube
complicated v uncomplicated parapneumonic effusion
complicated = + gram stain, cx, WBC PMNs or pH<7.2 or glu<60
empyema = frank pus, WBC PMNs
--> NEED drainage, tube thoracostomy
Rheumatoid pleuritis criteria
pleural fluid: low glucose level, eosinophilia, and elevated lactic acid dehydrogenase level
pleural effusion of TB
exudative, lymphocytes, very very high protein >4g/dL
pancreatitis pleural effusion/pseudocyst
-exudative, very high amylase level
Pancoast tumor
-manifestation of lung cancer
-apical tumor
-brachial plexus involvement (C8, T1, T2)
-Horner's syndrome, shoulder pain, rib destruction, atrophy of hand muscles
how long does warfarin take to become therapeutic?
keep bridging heparin for 5-7 days
Winter's formula for compensation
PaCO2 = 1.5(HCO3-) +8
ABGs in asthma v COPD
-asthma: mild hypoxia and respiratory alkalosis; normalizing CO2, resp acidosis and severe hypoxia indicates fatigue and respiratory failure
-COPD: hypoxemia and acute or chronic respiratory acidosis (inc PCO2); in chronic hypercapnia, high conc O2 may suppress their respiratory hypoxic drive--> resp failure
When to give chronic COPD pt supplemental O2
if resting PaO2<=55 mmHg or SaO2 <=89% or insetting of cor pulmonale, pulm HTN, hct>55%, nocturnal hypoxia
Drugs that contribute to interstitial lung disease
amiodarone, busulfan, nitrofurantoin, bleomycin, radiation, long term high O2 (ventilators)
Features of Sarcoidosis
-fever, weight loss, malaise, cough, arthritis
-noncaseating granulomas
-uveitis, erythema nodosum, LAD, interstitial pulm fibrosis, gammaglobulinemia
-inc ACE levels, hypercalcemia, hypercalciuria, inc alk phos
Asbestosis
-work in manufacturing of tile, brake linings, insulation, ships
-CXR: linear opacities in lung bases; calcified pleural plaques
-inc risk bronchoalveolar cancer
-also inc risk mesthelioma
Coal miner's disease
-work in coal mines
-CXR: upper lung small nodular opacities
-progressive massive fibrosis
Silicosis
-work in mines, quarries, glass, pottery, silica
-CXR: egg shell calcifications in upper lung
-inc risk TB
-get annual TB test, progressive massive fibrosis
Berylliosis
-work in high tech field: aerospace, nuclear, electronics plants
-CXR: diffuse infiltrates, hilar adenopathy
-req chronic corticoid steroid treatment
A-a oxygen gradient
(FiO2x(Patm- 47) -(PaCO2/0.8))- PaO2
FiO2 = 0.21 normal; Patm = 760
((FiO2x713) - (PaCO2/0.8))-PaO2
inc A-a gradient ddx
-shunt: alveolar collapse (asthma, COPD), intra-alveolar filling (pneumo, pulm edema), intracardiac shunt, vascular shunt within lungs
-V/Q mismatch: airway dz (asthma, COPD), interstitial lung dz, alveolar dz, pulm vascular dz
-diffusion impairment
diagnose ARDS
Acute onset
PaO2/FiO2<=200 (N FiO2= 21%)
Diffusion infiltration
swan-Ganz wedge pressure <18 (i.e.no cardiac origin, no elevated left atrial P)
What is goal oxygenation on mechanical ventilation?
PaO2>60 mmHg or SaO2>90% on FiO2<=0.6
Criteria for extubation from Mech ventilation: vital capacity, resting minute ventilation (TVxrate), spontaneous resp rate, lung compliance, negative inspiratory force
VC >10-15 mL/kg
minute ventilation >10L/min
RR <33
lung compliance >100 mL/cm water
negative inspiratory force <-25
Criteria for extubation from Mech ventilation: A-a gradient, shunt fraction, PO2(on FiO2 40%), PCO2
A-a <300-500
shunt fraction <15%
PO2 >70
PCO2 <45
ABGs in Pulmonary Thromboembolism
respiratory alkalosis 2/2 to hyperventilation with a PO2<80
D-Dimer usefulness
good "rule out" test in pts; sensitive but not specific
Thrombolysis in PE
indicated only when massive DVT, or PE causing Right heart failure and hemodynamic instability
-otherwise use LMWH
Management of isolated lung nodule
-Serial CXRs, Chest CT
-high risk malignancy? surgical resection
-low risk? CXR or CT every 3 months for 1 year and then every 6 months for another year
Adenocarcinoma
MC lung cancer
-peripheral location
-not ass w smoking
Small cell Lung CA tx
unresectable, radiation and chemo, usually recurs
Non small cell lung CA tx
surgical resection, supplement with radiation or chemo
-palliative radiation and or chemo if unresectable
TLC and RV in obstructive lung disease
inc due to air trapping v dec in restrictive lung disease
Choanal Atresia
-obliteration of post nasal aperture
-px: newborn obligate nose breathers become cyanotic; spells of crying force mouth-breathing improves ventilation
-initial eval: insert cather into nose
-CONFIRM diag: CT scan head with intranasal contrast
-tx: immediate oropharynx intubation until surgery
laryngotracheobronchitis
aka viral croup
barking cough with inspiratory stridor
laryngomalacia
underdevelopment of supraglottic area
-congenital disorder
-persistent stridor first noted early in infancy
Ferruginous bodies found on lung biopsy
asbestos crystals covered by iron residues in lung
MCC OSA in children
adenotonsillar hypertrophy - tx w surgery
"foamy" macrophages found on bronchioalveolar lavage
charachterisitc of amiodarone induced disease
-foamy macrophages ar filled with amiodarone-phospholipidcomplexes
Langerhans cells found in brochoalveolar lavage
-found in eosinophilic granulomatosis (histiocytosis X)
-giant cells with pentilaminar in-foldings of the cell membrane called Birbeck granules
allergic rhinitis
-px: chronic rhinorhhea from continual exposure to allergens
-pale blue nasal mucosa with boggy turbinates
-tx: avoid allergen, topical steroid drops/nasal spray (resolves sx in hours) +- long acting non sedating oral antihistamines: loratadine, fexofenadine +- cromolyn
when is non small cell lung cancer non-resectable
if signs of extrapulmonary spread, like invasion of recurrent laryngeal nerve, pleural effusion, evidence of contralateral lymphadenopathy or invasion to te pulmonary artery
-must do palliative chemotherapy and radiation
Treatment for strep pharyngitis, esp if pt likely to be lost to follow up
-empiric penicillin V x 5 days
-single dose benzathine penicillin G
2 things that reduce mortality in COPD
1) smoking cessation
2) home O2 in pts with advanced disease, acute exacerbations or cor pulmonale
-indication for home O2:
-O2 sat <88%, PaO2<55
-Sat<89%, PaO2<59 if right heart failure, hct>56%
MCC stridor in infant
laryngomalacia
-congenital abnormality of laryngeal cartilage
-inspiratory noises in 2 months of life
-noise increases when baby supine, crying or agitation
Sillicosis is associated with what disease?
-carries a 30x inc risk of developing TB
-silicosis pt MUST have ANNUAL PPD skin tests
-silicosis: restrice lung dz, mining, BL hilar LAD, lymph node calcifications
COPD and high O2 therapy
-pt with chronic hypoxia has pulm vasoconstriction to hypoxic regions, thus inc perfusion to better ventilated areas
-if give high O2, no longer pulm vasoconstriction, and even poorly ventilated areas of lung get perfused
-leading to dec V/Q ration (inc perfusion to poor ventilated areas, dec perfusion to better ventilated areas)
-pt ends up doing worse!
Tx Pulmonary HT/Cor pulmonale
-signs of Right heart failure, pulm art pressure >25
-supplemental O2
-IV vasodilators: NO, prostacyclin, adenosime, sildenafil
-CCB
-anticoagulant: coumadin
signs of pulm HTN
-loud split S2
-S4, flow murmur
-CXR: enlarged central pulm arteries
-ECG: RVH
-Echo and right heart cath show right ventricular overload
evaluate for pulm HTN
-Echo: RVH
-gold standard: Swan ganz >25 or right heart cath >30
diagnostic test for PE
-spiral CT scan chest (but CI: renal insufficiency or contrast allergy!!)
-V/Q scan next choice
diagnostic test for DVT
-lower extremity venous Doppler
-gold standard: lower extremity venogram
Reqs for long term home O2
-PaO2<55 mmHg or SaO2 <88%
-signs of pulm HTN or hct>55% + PaO2<60 mmHg
-nocturnal hypoxia or hypoxia with exercise even if resting awake PaO2>60 mmHg or SaO2>90%
Post influenza pneumonia bug
S aureus pneumonia
acid base in asthma v COPD
asthma: resp alkalosis, with hyperventilation
COPD: resp acidosis with hypoventilation and retained CO2
best prognostic factor in pts with COPD
FEV1
lung consolidation breathe sounds
bronchial breathe sounds (full expiratory phase), dullness percussion, inc fremitus (v pl effusion), egophony, bronchophony
pleural effusion breathe sounds
dullness to percussion, dec breathe sounds, dec tactile fremitus (v consolidation), dec transmitted airway sounds on exam
How to manage tension pneumothorax
-decompress the tension with large bore needle inserted in the second intercostal space, midclavicular line
idiopathic pulmonary fibrosis
-unknown etiology
-progressive abnormal and excessive deposition of collagen in pulmonary interstitium
-progressive dyspnea, nonproductive cough, digital clubbing
-restrictive lung disease pattern
mitral stenosis cause
rheumatic fever
mitral stenosis sx
-orthopnea, progressive worsening dyspnea, PND
-left atrial enlargement, can compress recurrent laryngeal nerve (hoarseness/cough), displace left main stem bronchus
-70% develop A fib!!
-thus tx if symptomatic: antiarrythmics (BBlockers, digoxin)
Time for Fat embolism to become sx
-respiratory distress, mental status changes and petechiae after latenet period of 12-72 hours following initial injury
COPD patient with catastrophic worsening of respiratory symptoms
think ssecondary pneumothorax!!!
due to dilated alveolar blebs that rupture air into the pleural space
Ddx hypoxemia and BL alveolar infiltrates on chest x-ray
-cardiogenic pulmonary edema: PCWP >18
-ARDS: PCWP<18
Nail clubbing and COPD
Nail clubbing NOT associated with COPD
-look for bronchogenic carcinoma, or malignancy as the cause
-Nail clubbing IS associated with heart disease- hypoxemia, pulmonary htn
FiO2
fraction of inspired air that is oxygen
PEEP
-positive end expiratory pressure
-positive pressure applied during exhalationvia resistor exhalation port
-prevents alveolar collapse
-dec preload by inc intrathoracic P, dec venous return
-dec afterload by dec cardiac transmural P
Auto PEEP fxn
-inadequate exhalation time, lungs unable to exhale completely before the next breathe
-increases work of breathing for pt, as must be overcome by pt to trigger breathes
-will dec preload
Inspiratory time
-noramal I:E ratio is 1:2, can alter I
Inspiratory flow rate
-inc flow rate: dec I time, inc E time
-improves ventilation in obstructive disease, but affects resp rate
PIP
-peak inspiratory pressure
-dynamic measurement during inspiration
-determined by airway resistance and lung/chest wall compliance
-inc PIP, inc airway resistance
plateau pressure
-static measurement at the end of inspiration when there is no flow
-determined by respiratory compliance (resistance is not a factor since there is NO FLOW)
-inc plateau pressure--> dec lung or chest wall compliance (eg pneumothorax, pulmonary edema, pneumonia, atelectasis), inc PEEP
Solitary pulmonary nodule low risk of cancer features
diameter <1.5
smooth
<45 yo pt
never smoked or quit >=7 yrs ago
solitary pulmonary nodule intermediate risk of cancer
diameter 1.5-2.2
scalloped nodule
pt age 45-60
current smoker <=1ppd or quit <7 years ago
Solitary pulmonary nodule high risk of cancer
>=2.3 diameter
speculated nodule
age >60 yo
current smoker, >1ppd, never quit
Initial eval of solitary pulmonary nodule
History
CT scan with contrast: size, calcifications, LAN,
Compare with old studies
Management of a solitary pulmonary nodule
-Low risk: serial CT (q 3 mo x 4, then q 6 mo x 2)
-Intermediate risk: PET, transthoracic needle bx or transbronchial bx; if non informative--> Video-assisted thorascopic surgery
-High risk: video assisted thorascopic surgery
allergic rhinitis tx
-first line: intranasal glucocorticoids
-second line: oral antihistamines adjunctive +- oral pseudoephedrine
-child <3 yo: intranasal cromolyn
THIS SET IS OFTEN IN FOLDERS WITH...