Term
| Unilateral Diaphragmatic Paralysis |
|
Definition
Caused by phrenic n. damage or mediastinal tumor
Usually asymptomatic
Confirmed by fluoroscopy |
|
|
Term
| Sxs of Bilateral Diaphragmatic Paralysis |
|
Definition
| Marked dyspnea & difficulty sleeping lying down, max. inspiratory force is markedly decreased |
|
|
Term
| Mngmt of Bilateral Diaphragmatic Paralysis |
|
Definition
| O2, non-invasive positive pressure ventilation or tracheostomy w/ long term mechanical ventilation |
|
|
Term
| Cause of Bilateral Diaphragmatic Disorders |
|
Definition
| Usually due to generalized neuromuscular disease such as Guillain-Barre', Muscular dystrophy, postpolio syndrome, amytrophic lateral sclerosis |
|
|
Term
|
Definition
| Inflammation of pleura, pleuritic pain w/o physical & xray findings suggest pleurodynia-viral inflammation |
|
|
Term
|
Definition
| Fluid collection in potential pleura space |
|
|
Term
|
Definition
| Chylous effusion characterized by milky fluid & elevated pleural triglyceride |
|
|
Term
| Fluid collection in Pleural Effusion is due to |
|
Definition
| Increased fluid formation (CHF, cirrhosis, infection, neoplasm) or Decreased fluid absorption (lymph obstruction, impaired lymph drainage) or both |
|
|
Term
| Sxs of a pleural effusion |
|
Definition
| Dyspnea, non-productive cough, pleuritic pain, symptoms of underlying disease |
|
|
Term
| Physical exam findings of PLeural effusion |
|
Definition
| Diminshed or absent breath sounds, reduced tactile fremitus, dullness to percussion, asymmetric thoracic expansion w/ lagging expansion on affecte side |
|
|
Term
|
Definition
| blunting of costophrenic angle, free pleural fluid gravitates toward dependent portions of lung |
|
|
Term
| Mngmt of Pleural Effusion |
|
Definition
| Thoracocentesis for large effusions or chest tube/water seal drainage for emypema or persistnet effusion |
|
|
Term
|
Definition
Limit fluid removal to 1000-1500ml at at time due to pulmonary edema in expanded lung
Evaluate fluid for pro, LDH, WBC w/ diff, glc & pH
AFB, Gm stain, aerobia & anaerobic cultures, cytology & pleural biopsy |
|
|
Term
|
Definition
| Elevation of hydrostatic pressure (CHF) and decreased plasma oncotic pressure (CIrrhosis, nephrotic syndrome); pleural:serum protein <0.5; pleural"serum LDH <0.6; LDH <200IU; Total protein <3g/dL |
|
|
Term
|
Definition
| Increased capillary permeability (infection, neoplasm); pleural:serum protein >0.5; pleural:serum LDH >0.6; LDH >200IU; total protein >3g/dL |
|
|
Term
|
Definition
| Most commonly follows blunt or penetrating trauma; pts w/ bleeding disorders may develop this following invasive procedures to pleura |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Large french chest tube, adequate drainage mandatory to avoid fibrothorax & traped lung |
|
|
Term
| Categories of Pneumothorax |
|
Definition
| 1. Spontaneous or Primary @. Secondary (underlying lung pathology, trauma or iatrogenic) 3. Tension |
|
|
Term
|
Definition
| Sudden, sharp chest pain & dyspnea |
|
|
Term
| Spontaneous or Primary Pneumothorax is most commonly seen in ___________ |
|
Definition
| Tall persons, marfans syndrome, men younger <40, Smokers |
|
|
Term
| Secondary spontaneous pneumothorax are mostly related to ____________ |
|
Definition
| COPD, asthma, CF, ILD or infection |
|
|
Term
| How would you manage a stable pt w/ a small primary pneumothorax |
|
Definition
| observation in ER for 3-6hrs, D/C if repeat chest radiograph excludes progression, follow up w/in 12-48hrs w/ repeat chest radiograph to document resolution |
|
|
Term
| How would you manage a pt w/ a secondary pneumothorax |
|
Definition
| Hospitalization, observation, pigtail catheter or chest tube placement |
|
|
Term
| How would you manage a pt w/ large pneumothorax, traumatic pneumothorax or requiring positive-presure ventilation |
|
Definition
| Hospitalization and chest tube placement w/ 16-22 F standard chest tube |
|
|
Term
| Which type of pt gets immediate needle decompression before CXR |
|
Definition
|
|
Term
| Sxs of Tension Pneumothorax |
|
Definition
| Severe respiratory distress, absence of breath sounds & hyperresonance on affected side, deviation of trachea away from involved side, distended neck veins |
|
|
Term
|
Definition
| Inflammation of mediastinum usually inectious; most common cause in US is post-op CABG |
|
|
Term
| Findings of Mediastinitis |
|
Definition
| Sternum pain that has increased ince surgery, drainage from wound site, progressive erythema, fever & chills, SOB, back pain, chest wall tenderness, Hammas sign (peridardial crunching sound during systole) |
|
|
Term
| Mediastinitis CXR finding |
|
Definition
|
|
Term
| Most common organism found in mediastinitis |
|
Definition
|
|
Term
|
Definition
| Surgical debridement, IV atbx, delay wound closure until infection control is achieved |
|
|
Term
| Sxs of esophageal perforation |
|
Definition
| neck pain, subcutaneous emphysema |
|
|
Term
| Where is most common esophageal perforation site |
|
Definition
| level of crico-pharyngeal muscle |
|
|
Term
| How do you Dx anterior mediastinal masses? |
|
Definition
5T's
Thymoma, Teratoma, Thyroid tumor, Terribl Lymphoma, Mesenchymal Tumors (lipoma, fibroma) |
|
|
Term
| Sxs of Middle mediastinal mass |
|
Definition
| lymphadenopathy, primory tumors, vascular lesions, duplications cysts |
|
|
Term
| Most posterior mediastinal masses are |
|
Definition
| neurogenic masses (schwannomas, neurofibroma, neuroblastomas, ganglioneuroblastoma, ganglioneuroma) |
|
|
Term
| Leading cause of cancer death |
|
Definition
|
|
Term
| Sxs of Central endobronchial tumor |
|
Definition
| cough, hemoptysis, wheeze, stridor, dyspnea, pneumonitis |
|
|
Term
| Sxs of peripheral lung lesions |
|
Definition
| Pain, cough, dyspnea, Sxs of lung abscess |
|
|
Term
| Sxs of intrathoracic metastatic spread |
|
Definition
| tracheal obstruction, dysphagia, hoarseness, SVC syndrome, pleural effusion, pericardial effusion, resp failure |
|
|
Term
| What is Pancoasts Syndrome |
|
Definition
| Apical tumor growth w/ shoulder pain radiating in ulnar distribution & may lead to significant weakness & muscle atrophy of ipsilateral hand |
|
|
Term
|
Definition
| enopthalmos, ptosis, miosis, unilateral anhydrosis |
|
|
Term
| What type of Lung cancer is extra thoracic metastatic disease most commonly seen in |
|
Definition
>95% small cell
80% adenocarcinoma & large cell |
|
|
Term
|
Definition
| headache, mental status change, papilledema, seizures, syncope |
|
|
Term
| Sxs of Spinal cor compression due to METS |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Endocrine effects of paraneoplastic syndrome |
|
Definition
| caused by hormonal substances produced by lung tumors, hypercalcemia, SIADH, gynecomastia, Cushings, carcinoid syndrome |
|
|
Term
| Hematologic effects of paraneoplastic syndrome |
|
Definition
| anemia, polycythemia, disseminated intravascular coagulation, eosinophilia, granulocytosis, thrombophlebitis |
|
|
Term
|
Definition
| clubbing in 30%, hypertrophic pulmonary osteoarthropathy w/ clubbung, swelling & pain, acanthosis nigricans, dermatomyositis |
|
|
Term
| Neurologic manifestations of Lung cancer |
|
Definition
| retinoptahy, encephalomyelitis, myasthenic syndrome, neuropathies, cerebellar degeneration |
|
|
Term
| How is lung cancer diagnosed |
|
Definition
| 85% are symptomatic at tie of diagnosis & the rest are picked up incidentally by radiography study |
|
|
Term
| What type of radiographic study suggests malignancy |
|
Definition
| Absence of benign pattern of calcification in detected lesion, nodule or mass growing, nodule w/ spiculated or lobulated border, lesion >8mm, thick walled cavitary lesion |
|
|
Term
| WHat size lesion is considered malignant |
|
Definition
|
|
Term
| A 55 y.o with a long hx of smoking has squamous cell cancer of the respiratory tract. This is MOST likely |
|
Definition
|
|
Term
|
Definition
|
|
Term
| CXR of Squamous cell carcinoma |
|
Definition
| hilar mass, mediastinal widening & cavitation |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Most common type of non-small cell carcinoma |
|
Definition
| Adenocarcinoma (including bronchioalveolar cell carcinoma) |
|
|
Term
| 2nd most common type of non-small cell carcinoma |
|
Definition
| Epidermoid (squamous cell carcinoma) |
|
|
Term
| What is the difference in presentation in small cell and non-small cell carcinoma |
|
Definition
| Small cell is widely disseminated at presentation and non-small cell may be localized |
|
|
Term
| How do epidermoid & small cell typically present? |
|
Definition
|
|
Term
| Which type of lung cancer is amendable to early sputum detection |
|
Definition
| Epidermoid due to tendency to originate in central bronchi |
|
|
Term
| Which types of lung cancers usually present as peripheral nodules or masses |
|
Definition
| Adenocarcinoma & large cell |
|
|
Term
|
Definition
| squamous cell carcinoma of large, segmental more central bronchi w/ pulmonary parenchyma; Paraneoplastic syndrome may develop, usually manifested as hypercalcemia |
|
|
Term
| Which type of Cancer is most frequently diagnosed by sputum cytology and closely associated with cigarette smoking |
|
Definition
|
|
Term
|
Definition
| local spreading, hilar adenopathy, mediastinal widening |
|
|
Term
|
Definition
| Arises in 1st & 2nd order bronchi but tends to occur more peripherally, derived from mucosal glands, grow more slowly than SCC or undiffrentiated carcinomas & tends to have better prognosis |
|
|
Term
| Which cancer occurs more often in non-smokers & smokers who have quit and is said to occur in association w/ old trauma, scars, TB & infarctions |
|
Definition
|
|
Term
| Bronchioalveolar Carcinoma |
|
Definition
| variant of adenocarcinoma, arising from epithelium of distal bronchioles, better prognosis than most other primary lung cancers, intra-alveolar spreading, infiltrates large areas of lung parenchyma |
|
|
Term
| Which type of cancer mimics pneumonia |
|
Definition
| Bronchioalveolar Carcinoma |
|
|
Term
|
Definition
| poor prognosis, 5-10% of all lung cancers, (anaplastic) |
|
|
Term
|
Definition
| highly malignant form of neuroendocrine tumor. Very agressive and usualy central with fast spreading in lung parenchyma & LN involvement. Metastasizes widely before primary tumor mass in lung reaches large size. |
|
|
Term
| Which cancer is almost exclusiveky in smokers, amendable to chemotherapy more than radiation and often associated w/ paraneoplastic syndromes from hormonal effects |
|
Definition
|
|
Term
| What is the microscopic pattern of smal cell carcinoma |
|
Definition
| small dark blue cells with minimal cytoplasm packed together in sheets |
|
|
Term
| How do you diagnose cancer? |
|
Definition
| Bronchoscopy w/ endotracheal needle aspiration, brushings & washings, CT guided biopsy, VATS or open thoracotomy |
|
|
Term
| What is the International Staging System (ISS) for non-small cell tumors |
|
Definition
| TNM - Tumor, Node involvement, METS present |
|
|
Term
|
Definition
| small tumor not locally advanced or invasive <3cm |
|
|
Term
|
Definition
| larger tumor that is minimally advanced or invasive >3cm or has associated atelectasis-obstructive pneumonitis extending to hilar region |
|
|
Term
|
Definition
| Any size tumor that is locally advanced or invasive up to but not including major intrathoracic strx direct extension into chest wall, diaphragm, mediastinal pleura or pericardium |
|
|
Term
|
Definition
| any size tumor that is advanced or invasive into major intrathoracic strx. Invades mediastinum, or presence of malignant pleural effusion |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Mets to LN in peribronchial and/or ipsilateral hilar nodes |
|
|
Term
|
Definition
| Mets to ipsilateral mediastinal or subcarinal LNs |
|
|
Term
|
Definition
| Mets to contralateral mediastinal or hilar nodes, or any scalene or supraclavicular nodes |
|
|
Term
|
Definition
| Local or regional disease, no distant metastases |
|
|
Term
|
Definition
| Disseminated disease, distant metastases present |
|
|
Term
|
Definition
| T1-2, N0 M0, 60-80% survival |
|
|
Term
|
Definition
| any T4 or N3, M0 <5% survival rate |
|
|
Term
|
Definition
| any M1, <5% survival rate |
|
|
Term
| What is the treatment of small cell lung cancer |
|
Definition
| Chemotherapy w/ or w/o radiation therapy |
|
|
Term
| What is the treatment for early stage non-small cell lung cancer |
|
Definition
|
|
Term
| What is the treatment for advanced non-small cell lung cancer |
|
Definition
|
|
Term
| What stage cancer is resectable in non-small cell and how is it treated |
|
Definition
I, II, IIIA & selected T3, N2
surgery, radiation therapy for nonoperable pts, postop radiation for N2 |
|
|
Term
| What stage cancer is nonresectable non smal cell and how is it treated |
|
Definition
N2 & M1
If confined to chest, high dose XRT + chemo
If extrathoracic, XRT to symptomatic local sites |
|
|
Term
| When would you use radiation therapy |
|
Definition
| Brain mets, spinal cord compression, weight bearing lytic lesions, symptomatic local lesions, obstructed airway, hemoptysis in non-small cel ung cancer, small cell not responding to chemo |
|
|
Term
| What is the age of most pts w/ carcinoid lung tumors |
|
Definition
|
|
Term
|
Definition
| Involves large bronchi & has endobronchial growth pattern; may be classified as pulmonary adenoma |
|
|
Term
| Which type of tumor secretes biogenic amines |
|
Definition
| Bronchial carcinoid tumors |
|
|
Term
| What is carcinoid syndrome |
|
Definition
| Diarrhea, wheezing, facial flushing, cyanosis, rarely occurs when lesions are confined to lung |
|
|
Term
| Most common primary sites associated w/ lung METs |
|
Definition
| breast, colon, cervix, prostate, head & neck, renal |
|
|
Term
| Which lung cancer is more common than primary lung neoplasms |
|
Definition
| metatstatic lung cancer because so many primary tumors metastasize to lungs |
|
|
Term
| Which cancer has a "lymphangitic" patterin which streaks of tumor appear between lung lobules & beneath pleura in lymph spaces? |
|
Definition
| metastatic adenocarcinoma of prostate |
|
|
Term
| Most benign solitary nodules are _____ |
|
Definition
|
|
Term
| What factors od solitary pulmonary nodules suggest malignancy & need for resection |
|
Definition
| smoking, >35y, >2cm, lack of calcification, chest symptoms, growth of lesion, prior malignancy hx |
|
|
Term
| What radiographic features suggest malignancy in a solitary pulmonary module |
|
Definition
| absence of benign pattern of calcification in detected lesion, growing nodule or mass, spiculated or lubulated nodule, >8mm, thick walled cavitary lesion |
|
|
Term
| Describe evaluation of pulmonary nodules in low prob, intermediate prob & high prob pts |
|
Definition
low-watchful waiting with serial CTs or CXR
intermediate-biopsy
high-surgical resection |
|
|
Term
| Name the type os airway/ventillation methods |
|
Definition
BVM (noninvasive)
tracheal intubation (invasive)
cricothyrotomy (invasive) |
|
|
Term
| What type of airway is used to maintain patency during BMV in pt with intact reflexes |
|
Definition
| nasopharyngeal airway in pt whose upper airway refelexes are intact |
|
|
Term
| What type of airway is used in pts who reflexes are absent during BMV |
|
Definition
| Oropharyngeal airways in pts with absent reflexes |
|
|
Term
| What direction should insertion of oral pharyngeal airway be |
|
Definition
|
|
Term
| How should BMV be performed |
|
Definition
| Place pts head in "sniffing" position extending head on neck and align oral, pharyngeal & laryngeal airway axis |
|
|
Term
| How do you perform BMV in suspected C-spine injury |
|
Definition
| neck must be kept in neutral position in suspected c-spine injury |
|
|
Term
| What rate should you use for BMV |
|
Definition
| TV of 10-15mL/kg and rate of 10-12 breaths/min in adults, 20 in children |
|
|
Term
| What is Selicks maneuver? |
|
Definition
| used in inconscious pts to minimize gastric distention & regurge of gastric contents by applying form downward pressure on cricoid cartilage |
|
|
Term
| How does pulse oximetry reflect oxygentaion |
|
Definition
|
|
Term
| How do you determine the ET tube size for pediatrics |
|
Definition
|
|
Term
| Describe Class I of difficulty of intubation |
|
Definition
| No difficulty; soft palate, uvula, fauces, pillars visible |
|
|
Term
| Describe difficulty of intubation Class II |
|
Definition
| No difficulty; soft palate, uvula, fauces visible |
|
|
Term
| Describe difficulty of intubation Class III |
|
Definition
| Moderate difficulty; soft palate, base of uvula visible |
|
|
Term
| Describe difficulty of intubation Class IV |
|
Definition
| Severe dificulty; only hard palate visible |
|
|
Term
| What pretreatment drugs are used in rapid-sequence intubations |
|
Definition
|
|
Term
| What Paralytic agents are used in rapid-sequence intubations |
|
Definition
| succunylcholine & rocuronium |
|
|
Term
| What induction agents are used in rapid-sequence intubation |
|
Definition
| etomidate, prpofol, ketamine, midazolam |
|
|
Term
|
Definition
| any form of ventilatory support wpplied w/o use of endotracheal tube |
|
|
Term
|
Definition
| Maximize lung space, reduce work of breathing, easy drug delivery |
|
|
Term
| What drugs can be placed down a breathing tube |
|
Definition
| lidocaine, epinepherine, atropine, norepinepherine |
|
|
Term
|
Definition
|
|
Term
| How is Oxygen used as NIV |
|
Definition
| start FiO2 low 28% and slowly increase |
|
|
Term
|
Definition
| continuous positive airway pressure used if primary problem is hypoxemia; decreases number of collapsed alveoli |
|
|
Term
|
Definition
Bilevel Positive Airway Pressure used in hypercarbia to decrease work of breathing
Inspiration=IPAP; decreases CO2 by increasing TV
Expiration=EPAP; improves O2 by increasing FRC (decreases # of collapsed alveoli) |
|
|
Term
| Is there such thing as permissive hypercarbia and hypoxia |
|
Definition
| Permissive hypercarbia is allowed but permissive hypoxia is NOT (think brain & heart) |
|
|
Term
| What are intitial parameters for CPAP |
|
Definition
|
|
Term
| What are initial parameters for BiPAP |
|
Definition
IPAP=8-10cm H2O
EPEP=4-8cm H2O |
|
|
Term
| IPAP must ALWAYS be greater than _____ |
|
Definition
|
|
Term
| What signs/sxs would indicate improvement with NIV |
|
Definition
| decreased RR, improved LOC, improved O2 sats, improved ABG (<CO2, >pH) |
|
|
Term
| What are possible complications of NIV |
|
Definition
| Irritation/pressure necrosis of skin at mask interface, gastric distention <20cmH2O, claustrophobia, barotrauma |
|
|
Term
| Which NIV is usually used for COPD |
|
Definition
|
|
Term
| Which NIV is usually used for CHF/Acute pulmonary edema |
|
Definition
|
|
Term
|
Definition
| Acute dyspnea & hypoxemia within hours if inciting event (sepsis, aspiration, OD, pancreatitis) defined by PaO2/FiO2 <200 |
|
|
Term
| What are physical findings of ARDS |
|
Definition
| tachypnea, tachycardia, febrile or hypothermic, hypotension w/ sepsis or hypovolemia, cyanosis of lips & nail beds, bilateral rales on auscultation (no heart failure, differentiate from cardio pulm edema) |
|
|
Term
|
Definition
| Increased permeability allows leakage of blood into intra-alveolar spaces resulting in edema |
|
|
Term
|
Definition
| PaO2<75mmHg when FiO2>0.5, decreased lung compliance, CXR shows diffuse bilateral interstitia; and alveolar infiltrates w/ a normal sized heart, low-norm PCWP, capillary microvascular membrane damage and complement.coagulation pathways |
|
|
Term
|
Definition
ventilatory support if RR>30 and PaO2<55mmHg, tx of underlying condition is essential, appropriate ventilator & fluid mngmt
*Increasing FiO2 does NOT dramatically improve PaO2 |
|
|
Term
| What classifies hypoxemia |
|
Definition
PaO2 in serum <60mmHg, HbSaO2 <90%
Insufficient delivery of oxygen to tissues |
|
|
Term
|
Definition
| tachypnea, alkalosis, cyanosis, agitation, somnolence |
|
|
Term
| How is Hypoventilation characterized |
|
Definition
| Ventilation is inadequate to keep PaCO2 from increasing, elevated PCO2, Low PO2 |
|
|
Term
| What are causes of diffusion abnormalities |
|
Definition
| ARDS, fibrotic lung disease |
|
|
Term
|
Definition
| w/o compensation will cause PaO2 to fall and PaCO2 to increase |
|
|
Term
| What is the most common cause of hypoxic respiratory failure in critically ill pts |
|
Definition
| Perfusion w/o ventilation shunting |
|
|
Term
| What are pulmonary causes of shunting |
|
Definition
| pneumonia, pulmonary edema, atelectasis, pulmonary hemorrhage |
|
|
Term
| What is dead space ventilation |
|
Definition
| ventilation w/o perfusion caused by low CO or PE |
|
|
Term
|
Definition
measure of how effectively oxygen in your alveoli moves into your pulonary vasculature
PAO2-PaO2 |
|
|
Term
|
Definition
from alveolar gas equation
(0.21)(760mmHg-47mmHg)-(PaCO2/0.8) |
|
|
Term
|
Definition
| Stasis, Endothelial injury, hypercoagulable states |
|
|
Term
| WHat are risk factors for stasis |
|
Definition
| Immobiization, bed rest >48hrs, cast, external fixator, recent hospitalization, long distance travel (>4h) |
|
|
Term
| What are risk factors for endothelial injury |
|
Definition
| Surgery w/in the last 3 months and trauma |
|
|
Term
| Name Non-malignant mutations |
|
Definition
| factor V leiden, protein C deficiency, protein S deficiency, prothrombin, factor VIII and methylenetetrahydrofolate mutation |
|
|
Term
| Name hypercoagulble states |
|
Definition
| malignancy (adenocarcinoma, brain) and non-malignant (pregnancy, postpartum <4wk, estrogen, antiphospholipid Ab) |
|
|
Term
|
Definition
| preexisting resp disease, hx of VT, >60y, stroke, sepsis, CHD, smoking, obesity, blood group A |
|
|
Term
| Describe the pathohysiology of PE |
|
Definition
| LE thrombus > IVC > RV > Pulm arteries |
|
|
Term
|
Definition
| 40-50% with proximal DVT, 5-10% with distal DVT |
|
|
Term
| What is the major pathologic effect of PE |
|
Definition
V/Q mismatch
dead space ventilation in some parts of the lung and overperfusion in others |
|
|
Term
|
Definition
| 90% dyspnea (most common), chest pain (2nd most common), tachypnea >20/min, Tachycardia, hypoxemia, hemoptysis, thrombosis signs, RV gallop, syncope, hypotension, low grade fever, loud P2 & prominent a-wave |
|
|
Term
|
Definition
| prediction crietria for PE |
|
|
Term
| What are primary study option for PE |
|
Definition
| d-dimer strategy combined w/ CT angio, V/Q scan based strategy, pulmonary angiography (gold standard), MRI/MRA |
|
|
Term
| Adjunctive studies for PE |
|
Definition
| ABGs, A-a gradient, EKGs, CXRs, Echos, Doppler |
|
|
Term
| Typical ABG findings in PE |
|
Definition
Hypoxemia, hypocapnia, increased A-a gradient
*15-20% have normal ABGs |
|
|
Term
| classic EKG finding in PE |
|
Definition
- S1 Q3 T3 (seen in under 20% of cases)
- S Wave in Lead I
- Q Wave in Lead III
- T Wave Inversion in Lead III
|
|
|
Term
| What are PE findings on a chest radiograph |
|
Definition
Most commonly cardiomegaly (27%) and atelectasis (most useful in outpatient)
*greatest use to rule out other pathology bc conflicting evidence of poor studies |
|
|
Term
|
Definition
| dilation of pulmonary vessels proximal to embolism along w/ collapse of distal vessels often with sharp cut off |
|
|
Term
|
Definition
| Pleural based opacities w/ convex medial margins |
|
|
Term
|
Definition
WHALE
Westermark sign
Hamptons hump
Atelectasis
Lovely (perfectly normal)
Effusions |
|
|
Term
| Why and how is ultrasound used for PE |
|
Definition
| highly sensitive and specific for diagnosing proximal DVT and combines B-mode scanning to visulie venous compression or clot itself or Doppler flow to evaluate blood flow |
|
|
Term
|
Definition
degradation product of cross-linked fibrin
sensitive but not specific |
|
|
Term
| When is d-dimer detectable |
|
Definition
| >500ng/mL in nearly all cases of VTE but also common in other conditions (ie prgenancy) |
|
|
Term
| Describe lung scan diagnostic strategy in PE |
|
Definition
If V/Q scan is normal, PE is excluded
If V/Q scan & clinical are low prob=PE excluded
If V/Q scan & clinical high prob=PE confirmed
Any other combo=further workup |
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Term
| How does CT angiogram & CT venogram predict PE in low probability assessment |
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Definition
| performed after (+) d-dimer. If NPV 96%, no tx is necessary. If PPV 57% determine if segmental (68%), subsegmental (25%) , main or lobar (97%) PE and tx or repeat |
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Term
| How does CT angiogram & CT venogram predict PE in mod probability assessment |
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Definition
| IF NPV 89-92%, no tx. If PPV 90-92%, tx |
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Term
| How does CT angiogram & CT venogram predict PE in high probability assessment |
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Definition
| If NPV 60-82%, repeat. If PPV 96%, tx |
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Term
| What factors reduce CT sensitivity |
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Definition
| inadequate contrast opaciication, inadequate (old) CT equip to image small vessels, not using reconstructed images. This can cause false negatives |
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Term
| What factors reduce CT specificity |
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Definition
motion artifact, interpretation of a filling defect as PE, interpreting vein or bronchus as artery w/ filling defect, extrinsic vascular compression from neoplasm
This can cause false positives |
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Term
| What is the gold standard for diagnosing PE |
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Definition
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Term
|
Definition
| INvasive test to predict PE. Gold standard. (+) provides nearly 100% certainty and (-) provides >90% certainty |
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Term
|
Definition
| almost similar to angiogram to visualize blood flow but not readily available in all institutions. |
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Term
| What are the Well's criteria? |
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Definition
sxs of DVT-3.0
other dx less likely than PE-3.0
HR>100-1.5
immobilization (3d) or surgery w/in prior 4wks-1.5
Previous DVT/PE-1.5
Hemoptysis-1.0
Malignancy-1.0 |
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Term
| Scoring for Wells Criteria |
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Definition
>6=High probability
2.0-6.0=Mod probability
<2.0=Low probability
>4.0=PE likely
<4.0=PE unlikely |
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Term
| Tx for PE in cliically stable pt |
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Definition
| LMWH or Unfractionated Heparin |
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Term
| Which anticoagulants require monitoring and how are they adminsistered |
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Definition
Heparain via IV
(LMWH and Arixta do not require monitoring and are administered SC) |
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Term
|
Definition
| Fragmin, Lovenox, Innohep |
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Term
| What is the mainstay of tx on PE |
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Definition
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Term
| What should be started along w/ heparin and when should heparn be stopped in PE tx |
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Definition
| Warfarin should be started at same time and they should overlap for at least 5 days. Heparin should be stopped once INR is 2-3 for 2 consecutive days |
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Term
| How long is anticoagulant therapy in a pt with their first even with a transient or reversible risk factor |
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Definition
| VKA for 3-6 mos at INR2-3 |
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Term
| How long is anticoagulant therapy in a pt w/ an unprovoked VTE first or second event |
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Definition
| Long term RX VKA at ONR 2-3 |
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Term
| How long is anticoagulant therapy in a pt with PE & Cancer |
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Definition
| LMWH for 3-6 mos then LMWH or VKA with INR ar 2-3 until cancer resolves |
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Term
| What is the Tx for PE if anticoagulation is contraindicated or if massive bleeding occurs during long term oral anticoagulation |
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Definition
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Term
| What is a greenfield filter |
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Definition
IVC interruption device to prevent embolisms
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Term
|
Definition
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Term
| What is the tx for PE during shock or circulatory collapse |
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Definition
| thrombolytics, thromboectomy or catheter/device removal then LMWH or unfractionated heparin leading to long-term oral anticag |
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Term
| When are thrombolytics used |
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Definition
| Confirmed PE w/ SBP <100mmHg and no contraindications; Severe hypotension (<80mmHg) however no study has demonstrated survival benefit |
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Term
| What is an absolute contraindication to thrombolytic tx in PE |
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Definition
| Hx of hemorrhagic stroke, active intracranial neoplasma, recent (<2mos) intracranial surgery or trauma, active or recent internal bleeding in prior 6 mos |
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Term
| What are relative contraindication of thrombolytic tx in PE |
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Definition
| bleeding diathesis, uncontrolled severe HTN, non-hemorrhagic stroke w/in prior 2 mos, surgery w/in prior 10d, thrombocytopenia (<100,000platelets) |
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Term
|
Definition
| bridges across pulmonary artery from heart as it divides in T&L main PA and can cause sudden death |
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Term
| What are prevention strategies for PE |
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Definition
| prophylax pts at high risk by intermittent pneumatic compression of lower extremities, low-dose heparin, LMWH or arixtra |
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Term
| Name possible predictors of poor PE outcome |
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Definition
| RV dilation or hypokinesis on transthoracic echo, sz, syncope, resp distress, >70y, COPD, CHF, prior PE, SaO2 <94%, T-wave inversion V1-V4 |
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Term
| How is d-dimer effected in pregnancy |
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Definition
| rises w/ each trimester but should not excess 1000ng/mL |
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Term
| Should you anticoagulate before imaging? |
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Definition
| yes if no contraindications |
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Term
| How to tx a known PE during cardiac arrest |
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Definition
| initiate ACLS. If no pulse returns, bolus 100mg tPA or equivalent and continue ACLS for 20 min, if pulse retruns consult surgeon for thrombectomy |
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Term
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Definition
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Term
|
Definition
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Term
| What drugs have been known to cause PHTN |
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Definition
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Term
|
Definition
| Idiopathic, familial, CT disease, CHD, portal hypertension, HIV, drugs & toxins |
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Term
| Types of Pulmonary Venous Hypertension |
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Definition
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Term
|
Definition
| dyspnea w/ exertion (@rest only w/ very advanced disease), fatigue, weakness, angina, syncope |
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Term
| Physical exam findings for PHTN |
|
Definition
| L parasternal lift, pansystolic murmur of TR, RV S3, JVD, hepatomegaly, peripheral edema, ascites, cyanosis, accentuated S2, diastolic murmur of pulm insuff |
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Term
|
Definition
| Enlargement of RV caused by PHTN, signs of RHF & dyspnea, may be acute or chronic |
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Term
| How do you tx cor pulmonale |
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Definition
| O2, diuretics for RVF, and cause of PHTN |
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Term
| What tests do you perform to dx PAH |
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Definition
| H&P, CXR, ECG, Echo, VQ scan, PFTs, oximetry, HIV, ANA, LFTs, fxnl test, RH cath |
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Term
| What would PHTN look like on EKG |
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Definition
| large r-wave in V1 (RVH), RAD, tall peaked p-wave in lead II (RAE) |
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Term
|
Definition
| blood tests, HIV tests, abd U/S, 6min walk test, RH cath & vasoreactivity |
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Term
| What are the criteria that define PAH |
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Definition
mPAP>25mmHg @ rest
mPAP>30mmHg w/ exercise
PCWP <15mmHg
PVR>3units |
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Term
|
Definition
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Term
| PAH is usually associated with |
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Definition
| CT disease, CHD, portal HTN, HIV, drugs & toxins |
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Term
|
Definition
| O2 for hypoxemia, anticoag w/ VKA for pts w/ mod-severe PAH, diuretics for volume overload, tx underlying disorder if present |
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Term
| What is life expectancy of PAH w/o tx |
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Definition
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Term
| What is vaso-reactive challenge |
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Definition
| administer vasodilators to check rxn. If +, use CCB to tx PAH, if (-) use prostanoids, endothelin-Rc antagonist or PDE5 inhibitor |
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Term
| If med tx fails to tx PAH, what is the next step |
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Definition
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Term
| How does rising PCO2 relate to inute ventilation |
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Definition
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Term
| How is ventilatory response related to hypoxemia |
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Definition
| less sensitive and clinically relevent only when PO2 has dropped significantly |
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Term
|
Definition
exists when arterial PCO2 increases above normal
PaCO2 50-80mmHg in most important chronic hypoventilation syndromes |
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Term
| Results of increase PACO2 |
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Definition
| respiratory acidosis leading to compensatory increase in HCO3 & decrease in PaO2. Hypoxemia may induce secondary polycythemia, PHTN, RHF. Gas exchang worsens during sleep resulting in morning headache, impaired sleep quality, fatigue, daytime somnolence, mental confusion |
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Term
| Chronic hypoventilation syndromes impairing respiratory drive that effect peripheral & central chemoRc |
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Definition
| carotid body dysfunction, trauma, prolonged hypoxia, metabolic alkalosis. |
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Term
| Chronic hypoventilation syndromes impairing respiratory drive that effect brainstem respiratory neurons |
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Definition
| bulbar poliomyelitis, encephalitis, brainstem infarction, hemorrhage, trauma, chronic drug administration, primary alveolar hypoventilation syndrome |
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Term
|
Definition
| obesity-hypoventilation in which massive obesity imposes mechanical load on resp system |
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Term
| Risk factors for sleep apnea |
|
Definition
| obesity, increased neck diameter, abnormal upper airway abnormalities |
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Term
| Clinical manifestations of OSA |
|
Definition
| morning headaches, recurrent awakenings, daytime somnolence, snoring or gasping for air in sleep, PHTN & RVF |
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Term
|
Definition
| overnight polysomnography sleep study including sleep staging & resp monitoring |
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Term
| What are the stages of of AHI and how is it calculated |
|
Definition
apnea+hypopnia/total sleep time=AHI
5-14=mild
15-30=moderate
>30=severe |
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Term
| What are conservative tx for OSA |
|
Definition
| weight loss, smoking cessation, positional therapy, avoidance of ETOH, muscle relaxants, sleep deprivation and nasal congestion therapy |
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Term
| What med tx for OSA exist |
|
Definition
| CPAP, oral appliances for mild-mod, surgery |
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Term
|
Definition
| rare idiopathic vasculitis w/ chronic sinusitis, arthralgias, fever, skin rash, hemoptysis, weight loss |
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Term
| How is wegner granulomatosis dx and tx |
|
Definition
| ANCA and biopsy of lung, sinus tisue or kidney showing necrotizing granulomatous vasculitis. ttx w/ immunosuppressive drugs |
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Term
|
Definition
| idiopathic alveolar hemorrhage occurs mostly in men 30-40s w/ hemoptysis, dyspnea, cough, hypoxemia |
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Term
| How do you dx and tx goodpasture syndrome |
|
Definition
| linear IgG deposits in glomeruli or alveoli by immunofluorescence and on the presence of anti-glomerular basement membrane antibody in serum and tx w/ immunosuppressive drugs |
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