How is tuberculosis spread?
Inhalation of infectious particles
What is the most common pathogen in community acquried pneumonia?
- Streptococcus pneumoniae
- 20 to 75% of patients
Hospital acquried pneumonia
A lower respiratory tract infection that develops in hospitalized patients more than 48 after admission
The signs that tell you that the patient may have acquried a hosipital aquired pneumonia!
- New onset of fever
- Recent history of vomiting, seizure, or syncope, during which aspiration may have occured
- Purulent endotracheal secretions
- new pulmonary infiltrate
What type of lung infection is associated with cavitie chest region?
- pulmonary tuberculosis
- Pyogenic lung abscess
- gram negative pneumonias
What types of organisms are associated with higher rates of mortality in patients?
- Pseudomonas aeruginosa
- Stenotrophomonas maltophilia
Who should be immunized against the flu?
- Individuals older than 60
- Individuals with chronic lung or heart disease
- For whom the morbidity of influenza may be substainal
- Health care workers
A condition characterized by abnormal, permanent enlargement of the airspaces beyond the terminal bronchiole, accompanied by the destruction of the walls of the airspaces without fibrosis
- Chronic productive cough is present for at least 3 months per year for at least 2 consecutive years
- other cases of chronic cough have been excluded
What percentage of COPD patients are alpha-1 antitrypsin deficiency?
- 2-3% of all COPD
- Genetic emphysema, inherited
Symptoms of COPD
- Phlegm production
- Dyspnea on exertion (DOE), often slow but progressive in onset and occurs later in the course of the disease, characteristically in the late 6th or 7th decade of life
- AAT deficiency, in which dyspnea begins sooner in 4th decade
Physical examination of the chest in a patient with COPD!
- Wheezing, diminished breath sounds
- Hyperinflation (+AP diameter) barrell chest
- Flattened diaphgram
- Hoover signs
- Use of accessory muscles
- Edema from cor pulmonale
- Mental status changes caused by hypoxia or hypercapnia
Dimpling inward of the chest wall at the level of the diaphragm on inspiration
What are some signs of respiratory failure in a COPD patient?
What is the difference between asthma and COPD?
Asthma is reverseable
Features that favor COPD!
- Chronic daily phlegm production, which established the diagnosis of chronic bronchitis
- Diminished vascularity on the chest radiograph
- Decreased difusing capacity
The diagonisis of asthma is favored if...
The diminished FEV1 obtained on spirometry can be normalized after use of an inhaled bronchodilator
The major challenge facing the clinician who encounters a patient with airflow obstruction is...
To distinguish COPD (emphysema and/or chronic bronchitis) from asthma
How does plumonary rehabilitaion helps patient with severe COPD?
- Important strategy for improving functional status
- Can enhance excersise capacity, even tho lung function and survival are not improved
- Upper extremity training can enhance ventilatory function
- Strengthen the muscles of the shoulder girdle
- The annual rate of FEV1 declined
Clinical syndrome characterized by airway obstruction, which is partially or completely reversible either spontaneously or with treatment; airway inflammation; and airway hyperresponsiveness (AHR) to a variety of stimuli
Whereas past definations of asthma emphasized AHR and reversible obstruction, newer and more accurate definitions of asthma forcus on....
Asthma as a primary inflammatory disease of the airways, with clinical manifestations of increased bronchial hyperractivity and airflow obstruction due to inflammation
When a patient with asthma inhales an allergen to which he or she is sensitized...
- The antigen cross linkss to specific IgE molecules on the surface of the mast cells in bronchial mucosa and submucosa
- The mast cells degranulate (within 30 minutes), releasing mediators including leukotrienes, histamine, prostaglandins, platelet activating factor, and other mediators
These leukotrienes, histamine, prostaglandins, platelet activating factor, and other mediators released by the degranulate of mast cells lead to...
- Smooth muscle contraction, vascular congestion, and leakage resulting in airflow obstruction, which can be assessed clinically as a drop in the FEV1 or the peak expiratory flow rate.
- This is the early (acute) asthmatic response
How do we determine if a patient has asthma?
The history plays a key role suggesting, and later establishing, the diagnosis of asthma
The classic symptoms of asthma!
- Episodic wheezing
- Shortness of breath
- Chest tightness
- Confirmation of the diagnosis of asthma requries demonstration of reverserable airflow obstruction
If you have a sympton free asthmatic patient what test would be useful?
- Provocative testing can be used to induce airway obstruction
- The accepted criterion for hyperresponsiveness is the demonstration of a decrease in FEV1 by 20% or more after inhalation of methacholine provocation
To help patients better understand PEFR monitoring, a zonal system corresponding to the traffic light system may be helpful!
- Green Zone: Peak flow is 80 to 100% of personal best, no asthma is present, maintenance meds can be continued or tampered
- Yellow Zone: 60 to 80%, may indicate an acute exacerbation, requries temporary step up in treatment
- Red Zone: below 60%, medical alert, requries immediate attention
Peak expiratory flow rate (PEFR) measurement can be used to determine response to therapy in the...
- Outpatient setting
- Emergency department
Daily monitoring of PEFR helps...
Detect early stages of airway obstruction
All PEFR measurements are compared with...
The patients personal best value, which can be established during a 2 to 3 week asymptomatic period when the patient is being treated optimally
Spontaneous variation in selfrecorded PEFR by...
15% or more can provide evidence of reversibility of airway obstruction
Early (acute) asmatic response
- An immediate hypersensitivity reaction that usually subsides in about 30 to 60 minutes
- Drop in FEV1 and PEFR
Late asthmatic response (LAR)
- In 50% of patients airflow obstruction recurs in 3-8 hours
- More sever and last longer that EAR
- Increased influx and activation of inflammatory cells such as mast cells, eosinophils, and lymphocytes
- Is a noncorticosteroid antinflammatory medication
- It has a protective effect against provocative stimuli such as allergens, cold air, and excersise
- Prevents attacks, does not treat attacks
When is the medication cromolyn useful?
- Cough variant and exercise induced asthma
- Cromolyn is the dug of choice for atopic children with asthma
Inhaled and are the most rapid and effective bronchodilators for the treatment of asthma
Some examples of Beta2 agonist!
What are some of the things that cause theophylline (methylxanthines) to change?
- Must maintain therapeutic plasma concentrations of 8-10 mg/L
- By increasing or decreasing hepatic metabolism of the drug
- Condition that tend to increase plasma concentrations include acute viral infection, cardiac failure, hepatic disease, and erthromycin or crimetidine
Conditions that tend to decrease plasma levels of theophylline include
Cigarette smoking and the use of med that increase hepatic clerance such as phenobarbital
- Prevents allergic reactions in asthma patients
- Reduces exposure to indoor/outdoor allergens and irritants
- Remains indoors when pollen count is high
- HEPA air cleaning devices
- Encase mattresses, pillows
- Remove carpets
- Change bedding weekly and wash in hot water
- No warm blooded pets
- Decrease indoor humidity
Refers to the abnormal, irreversible dilation of the bronchi caused by destructive and inflammatory changes in the airway walls
The airway wall is regular and uinformly dilated
An irregular pattern, with alternating areas of constriction and dilatation
Progressive, distal enlargement of the airways, resulting in saclike dilations
What therapy is most needed for bronchiectasis?
- Antibiotics and bronchopulmonary hygiene
Symptoms of bronchiectasis!
- Chronic production of large quantities of purulent
- Foul smelling sputum
- Radiographic conformation (tram tracks)
Interstitial lung disease (ILD)
These disorderd are grouped together because of similarities in their clinical presentation, plain chest rediographic apperance, and physiologic features
ILD have a common radiographic finding...
A restructive physiologic impairment
What the the most common occupational ILD?
- Chronic silicosis
- Coal worker's pneumoconiosis
- Evidence of parenchymal scarring, pleural plaques, fibrosis, effusions, rounded atelectasis, lung cancer, mesothelioma
- Restructive impairments with reduced DLCO, DOE
- Dismal prognosis
- Shipbuilding or insulation work
- Chronic silica exposure
- Chest radiograph shows upper lung zone predominant abnormalities of multiple small nodular opacities
- Enlargement and eggshell calcification of the hilar lymph nodes
- Physiological impairment is quite variable, may remain stable or progress in absence of exposure
- DOE, variable mucus production
- Associated with increased risk of lung cancer and tubercolosis
- Mining, tunneling, sand blasting, and foundry work
Coal worker's pneumoconiosis
- Black lung
- Chronic inhalation of coal dust similar to silicosis in clinical and radiological features
- Cough and SOB with advanced disease
- Both this and silicosis have poor response to therapy, corticosteriods are often tried
Where is the pathopysiology of interstial lung disease?
Area between the capillaries and alveolar space
Symptoms of interstitial lung disease!
- DOE, slowly progressive
- Non productive cough
- Nonrespiratory symptoms, such as myalgia, arthralgia, or sclerodactyly, resulting from connective tissue disease
Common breath sounds of interstial lung disease!
Bilateral inspiratory, fine crackles
The cystic pattern reflects end stage fibrosis
Is a cell mediated immune reaction to inhaled antigens in suceptible persons
Patients with acute Hypersensitivity Pneumonitis usually present to medical attention with...
- Sudden shortness of breath
- Chest pain
- Cough that may be productive of purulent sputum
Common organic antigens know to cause Hypersensitivity Pneumonitis include...
- Bacteria and fungi, found in moldy hay (Farmer's lung) or with central humidifications systems Humidifiers lung)
- Indoor hot tube, and animal protein (Bird breeders lung)
The common drugs that can cause interstital fibrosis...
- Chemotherapeutic agents
- antiarrhythmic drugs
- Immunosuppressive agents
ILD is a well know complication of various connective tissue diseases! th most common disorders are...
- Rheumatoid arthritis
- Sjogrens syndrome
- Polymyositis/ dermatomyositis
- Systemic lupus erythematosus
An idiopathic multisystem inflammatory disorder that commonly involves the lung
The tissue inflammation that occurs in sarcoidosis has a characteristic patter in which...
The inflammatory cells collect in microscopic nodules called granulomas
Sarcoidosis is more common among...
Young adults than it is among older persons
The chest radiograph before symptons of sarcoidosis are...
Bilateral hilar lymphadenopathy without parenchymal opacities
Symptons of sarcoidosis!
- Chest pain
What are the common treatments for patients with Idiopathic Interstitial Pneumonias?
- Immunosuppression with oral corticosteriods and cytotoxic agents such as azathioprine
Transudative pleural effusion
- Any pleural effusion that forms when the integrity of the pleural space is undamanged
- A pleural fluid total protein concentration less than 50% of the serum total protein level and LDH values in the pleural fluid less than 60% of the serum
Transudative pleural effusion forms when...
Hydrostatic and oncotic pressures are abnormal
Congestive Heart failure
- Most common cause of pleural effusions
- Elevation of pressure in the left atrium and pulmonary veins
- Increases interstitial fluid in lung
Exudative Pleural Effusions
- Caused by inflammation in the lung or pleura
- This type of pleural effusion has more protein and inflammatory cells present
- Thoracentesis is often performed to determine the specific biochemical and cellular make up of fluids
- Accounts for 70% of all pleural effusions
What is the difference between transudative and Exudative pleural effusions?
Exudative pleural effusions has more protein and inflammatory cells present that transudative
Common causes of Transudative pleural effusions!
- Congestive heart failure
- Nephrotic syndrome
- Lymphatic obstruction
- Peritoneal dialysis
- Central venous catheter in pleural space
Common causes of exudative pleural effusions!
The kidneys leak more than 3 grams of protein per day into the urine
- Pleural effusion form in pneumonia because inflammation in the lung increases interstitial lung water and pleural fluid production
- Progress to empyema
- The presence of blood in the pleural space
- Pleural fluid hematocrit more than 50% of the serum value
Common cause of hemothorax!
- Seen most commonly after blunt or penetrating chest trauma, a number of medical conditions can give rise to blood in the pleural space
- Any vein or artery in the thorax can bleed into pleural space
Diagnostic procedures for detecting pleural effusions!
- Chest Radiography
- Chest thoracotomy tubes
- Shunt or catheter
Insertion of needle into the pleural space for sampling and or reexpansion
Complications from a thoracentesis!
- Intercostal artery laceration
- No underlying lung disease
- Usually presence of small subpleural blebs
- Young adults
- Lung grows faster than pleura
- Lung disease is present
- Usually COPD, some ILD with obstructive component
- Most occur in patients with severe lung dysfunction
What is the function of the chest tube in a patient with a chest trauma?
- Allow measurement of the rate of bleeding
- To allow the lung to be pulled to the parietal pleural surface to tamponade bleeding
- Allow maximum ventilation
Where should you place the needle in order to decompress the chest?
- Done with an 18-gauge intravenous (jelco) catheter inserted just over the 2nd rib on the anterior chest in the midclavicular line
- Listen for "rush of air" into catheter for confirmation of diagnosis
A complication of rapid lung reinflation!
Reexpansion Pulmonary Edema
Reexpansion Pulmonary Edema
- occurs when lung rapidly reinflates from low volumes
- Can occur with thoracentesis for large inffusions
- Minimize with slow reexpansion, drain less than 1000 mls
It is difficult to determine whether a heimlich valve has an ongoing leak unless...
- It is placed to underwater seal
- This procedure can be done by it underwater to see whether an air leak is continuing after lung expansion
When do you remove the chest tube?
When the recurrence rate is near zero the chest tubes are removed 48 hours after the air leak is no longer is seen in a water tight seal
Pulmonary infaction occur...
- Due to obstruction of a medium sized pulmonary artery
- Occurs at the lung bases, are pleural based, and may be accompanied with pleural effusion
Death from a massive pulmonary emboli is the result of...
Cardiovascular failure rather than respiratory failure
What happens in a lung with a pulmonary embolism?
- Embolic obstruction of the pulmonary artery increases the alveolar dead space, causes bronchoconstriction, and decreases the production of alveolar surfactant
- Response is to increase ventilation which causes dyspnea
- Atelectasis leads to increased intrapulmonary shunting, V/Q mismatch, hypoxemia
- Shock occurs from massive obstruction of pulmonary vasculature, decrease in CO2 and O2
What are the hemodynamic consequences of a pulmonary embolism?
The main hemodynamic consquences of PE is increased resistance to blood flow caused by obstruction of the pulmonary arterial bed
The hemodynamic consequences are determined by...
- The extent of the cross sectional area of the pulmonary circulation involved
- The underlying cardiopulmonary reserve
- The neurohumoral response to the embolism
What is the critical value of the pulmonary arterial pressure?
Greater than 40 mm Hg
What are some physical findings of pulmonary embolism?
- All may be transient
What type of preventage measures can we take to prevent DVT thrombosis from occuring?
- Prophylactic therapy
characterized by an elvation in mean pulmonary arterial pressure greater than 25 mm Hg at rest or 30
What are some of the physical finding of pulmonary hypertension?
- Heart murmurs
- Right ventricular failure
What do pulmonary function test of patients with pulmonary hypertension show?
A low DLCO and normal mechanics
What therapy has been proven to increase survival for patients with pulmonary hypertension?
- Vasodilator therapy
- Calcium channel blockers
- Oxygen therapy
What is the most common compliant patients have with ILD?
- Exertional breathlessness (Dyspnea)
- Nonproductive cough