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Inhalation of infectious particles

• Streptococcus pneumoniae
• 20 to 75% of patients

A lower respiratory tract infection that develops in hospitalized patients more than 48 after admission

• New onset of fever
• Recent history of vomiting, seizure, or syncope, during which aspiration may have occured
• Purulent endotracheal secretions
• new pulmonary infiltrate

• pulmonary tuberculosis
• nocardosis
• Pyogenic lung abscess
• staphylococcal
• gram negative pneumonias
• Fungi

• Pseudomonas aeruginosa
• Acinetobacter
• Stenotrophomonas maltophilia

• 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

• 2-3% of all COPD
• Genetic emphysema, inherited

• Cough
• Phlegm production
• Wheezing
• 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

• 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
• Asterixis

Dimpling inward of the chest wall at the level of the diaphragm on inspiration

Asthma is reverseable

• Chronic daily phlegm production, which established the diagnosis of chronic bronchitis
• Diminished vascularity on the chest radiograph
• Decreased difusing capacity

The diminished FEV1 obtained on spirometry can be normalized after use of an inhaled bronchodilator

To distinguish COPD (emphysema and/or chronic bronchitis) from asthma

• 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

Asthma as a primary inflammatory disease of the airways, with clinical manifestations of increased bronchial hyperractivity and airflow obstruction due to inflammation

• 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

• 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

The history plays a key role suggesting, and later establishing, the diagnosis of asthma

• Episodic wheezing
• Shortness of breath
• Chest tightness
• Coughing
• Confirmation of the diagnosis of asthma requries demonstration of reverserable airflow obstruction

• 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

• 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

• Outpatient setting 
• Emergency department
• Hospital

Detect early stages of airway obstruction

The patients personal best value, which can be established during a 2 to 3 week asymptomatic period when the patient is being treated optimally

15% or more can provide evidence of reversibility of airway obstruction

• An immediate hypersensitivity reaction that usually subsides in about 30 to 60 minutes
• Drop in FEV1 and PEFR

• 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

• 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

• Albuterol
• Metaproterenol
• Pirbuterol
• Terbutaline
• Salmeterol
• Formoterol
• Arformoterol

• 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

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

• Antibiotics and bronchopulmonary hygiene
• CPT

• Chronic production of large quantities of purulent
• Foul smelling sputum
• Hemoptysis
• Radiographic conformation (tram tracks)

These disorderd are grouped together because of similarities in their clinical presentation, plain chest rediographic apperance, and physiologic features

A restructive physiologic impairment

• Asbestosis
• 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

• 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

Area between the capillaries and alveolar space

• DOE, slowly progressive
• Non productive cough
• Sputum
• Hemoptysis
• Wheezing
• Nonrespiratory symptoms, such as myalgia, arthralgia, or sclerodactyly, resulting from connective tissue disease 

Bilateral inspiratory, fine crackles

The cystic pattern reflects end stage fibrosis

Is a cell mediated immune reaction to inhaled antigens in suceptible persons

• Sudden shortness of breath
• Chest pain
• Fever
• Chills
• Malaise
• Cough that may be productive of purulent sputum

• 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)

• Chemotherapeutic agents
• Antibiotics
• antiarrhythmic drugs
• Immunosuppressive agents

• Rheumatoid arthritis
• Scleroderma
• Sjogrens syndrome
• Polymyositis/ dermatomyositis
• Systemic lupus erythematosus

An idiopathic multisystem inflammatory disorder that commonly involves the lung

The inflammatory cells collect in microscopic nodules called granulomas

Young adults than it is among older persons

Bilateral hilar lymphadenopathy without parenchymal opacities

• Cough
• Chest pain
• Dyspnea
• Wheezing

• Immunosuppression with oral corticosteriods and cytotoxic agents such as azathioprine
• Prednisone

• 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

Hydrostatic and oncotic pressures are abnormal

• Most common cause of pleural effusions
• Elevation of pressure in the left atrium and pulmonary veins
• Increases interstitial fluid in lung

• 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

Exudative pleural effusions has more protein and inflammatory cells present that transudative

• Congestive heart failure
• Cirrhosis
• Nephrotic syndrome
• Hypoalbuminemia
• Lymphatic obstruction
• Peritoneal dialysis
• Atelectasis
• Central venous catheter in pleural space
• Urinothorax

• Carcinoma
• Lymphoma
• Mesothelioma

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

• 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

• Chest Radiography
• Ultrasound
• Thoracentesis
• Chest thoracotomy tubes
• Thoracospy
• Pleurodesis
• Shunt or catheter

Insertion of needle into the pleural space for sampling and or reexpansion

• Intercostal artery laceration
• Infection
• Pneumothorax

• 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

• 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

• 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

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 placed to underwater seal
• This procedure can be done by it underwater to see whether an air leak is continuing after lung expansion

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

• Due to obstruction of a medium sized pulmonary artery
• Occurs at the lung bases, are pleural based, and may be accompanied with pleural effusion

Cardiovascular failure rather than respiratory failure

• 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

The main hemodynamic consquences of PE is increased resistance to blood flow caused by obstruction of the pulmonary arterial bed

• The extent of the cross sectional area of the pulmonary circulation involved
• The underlying cardiopulmonary reserve
• The neurohumoral response to the embolism

Greater than 40 mm Hg

• Tachypnea
• Tachycardia
• Crackles
• All may be transient

• (Prophylaxis)
• Prophylactic therapy

characterized by an elvation in mean pulmonary arterial pressure greater than 25 mm Hg at rest or 30

• Heart murmurs
• Right ventricular failure
• Cyanosis

A low DLCO and normal mechanics

• Vasodilator therapy
• Calcium channel blockers
• Oxygen therapy

• Exertional breathlessness (Dyspnea)
• Nonproductive cough