PE (Pulmonary Circulation)
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Definition |
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Etiology Arises from thrombi in the systemic venous circulation of the right side of the heart, or from tumors in the venous circulation.
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Where do more than 90% of pulmonary emboli originate from? DVT in lower extremities
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Virchow's Triad (risk factors) Venous stasis + endothelial injury + hypercoagulable state (pregnancy, cancer, estrogen OCP, nephrotic syndrome)
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Clinical features Tachycardia + tachypnea
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Gold standard diagnostic test Spiral CT
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Treatment Anticoagulation (heparin, Lovenox, warfarin) for at least 3 months
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Buzzwords: Dyspnea after surgery, travel (airplane), LE Fx. May have c/o calf pain also. Lung scan with perfusion defects, venous stasis + vessel wall injury + hypercoagulability
Pneumoconioses
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Definition Chronic fibrotic lung diseases caused by inhalation of coal dust or various inert/inorganic/silicate dusts
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Clinically important pneumoconioses Coal workers' pneumoconiosis, silicosis, and asbestosis
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Clinical Features Often asymptomatic, can have dyspnea, inspiratory crackles, clubbing, and cyanosis
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Lab Findings PGTs show restrictive dysfunction and reduced diffusing capacity. CXR variable.
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Treatment Supportive (no effective tx available): O2, vaccines, rehab
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Foreign Body Aspiration
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Definition Aspiration of gastric contents, inert material, toxic material, or poorly-chewed food. Know Heimlich maneuver!
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Clinical Features Chocking, coughing, unexplained wheezing or hemoptysis
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Possible Sequelae Asphyxia, PNA (aspiration pneumonia),
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What is one of the most common causes of ARDS? Acute gastric aspiration
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Lab Studies Expiratory radiography may show regional hyperinflation caused by a check valve effect
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Treatment Bronchoscopy for diagnosis and removal/treatment. Cultures should be obtained if post-obstructive PNA suspected
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Pulmonary HTN (Pulmonary Circulation)
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Definition Present when the pulmonary arterial pressure rises to a level inappropriate for a given cardiac output; self-perpetuation once present
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Primary (idiopathic) pulmonary HTN Rare + fatal
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Secondary pulmonary HTN Many causes that develop as a result from obliteration and obstruction of the pulmonary arterial tree
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Hypoxia Most important/potent stimulus of pulmonary arterial vasoconstriction (others are acidosis and veno-occlusive diseases)
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Clinical features Dyspnea, angina-like pain, weakness, fatigue, edema, ascites, cyanosis, syncope
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Signs on physical exam Narrow splitting and accentuation of the 2nd heart sound, systolic ejection click
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Treatment Chronic oral anticoagulants, CCB to lower systemic arterial pressure, and prostacyclin (a potent pulmonary vasodilator), and heart-lung transplant
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ARDS (Acute adult respiratory distress syndrome)
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Definition Increased permeability of the alveolar capillary membranes --> leads to pulmonary edema and widespread inflammation
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3 Clinical Settings that account for 75% of ARDS cases Sepsis syndrome + severe multiple trauma + aspiration of gastric contents
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Clinical Features Rapid onset of dyspnea 12-24 hrs after the precipitating event, PE shows tachycardia, frothy pink/red sputum, diffuse crackles. Many pts are cyanotic with increasingly severe hypoxemia that is refractory to administered O2
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Lab Findings CXR shows peripheral infiltrates with air bronchograms, spares costophrenic angle, can get multi-organ failure
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Treatment Treat underlying precipitating problems, supportive care (O2, PEEP), high mortality rate. 33% of deaths occur within 3 days of ARDS sx onset
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Sarcoidosis
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Definition Multiorgan disease involving abnormal collections of inflammatory cells (granulomas), most often in the lungs
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Classic Patient Higher incidence in North American black women, and northern European whites
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Clinical features Respiratory sx (cough, dyspnea of insidious onset, chest discomfort)
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Other extrapulmonary signs/sx Malaise, fever, erythema nodosum or enlargement of parotid glands/lymph nodes/spleen/liver
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Lab Findings ACE levels elevated, CXR shows bilateral hilar and right paratracheal adenopajhty and bilateral diffuse reticular infiltrates
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How to confirm diagnosis Transbronchial biopsy of the lung or fine-needle node biopsy --> will show non-caseating granulomas
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Treatment Corticosteroids at maintenance doses
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Idiopathic Fibrosing Interstitial Pneumonia
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General Most common dx among pts with interstitial lung disease.
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Three histopathologic patterns w/ different natural histories and treatments Usual interstitial PNA, respiratory bronchiolitis-associated interstitial lung disease, and acute interstitial pneumonitis
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Clinical Features Insidious dry cough, exertional dyspnea, constitutional sx. Exam might show clubbing and inspiratory crackles.
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Lab Findings CXR shows fibrosis, CT shows fibrosis + pleural honeycombing, PFTs show restrictive pattern (decreased lung volume with a normal to increased FEV1/FVC ratio)
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Treatment Controversial--none has been showed to improve survival or QOL
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Hyaline Membrane Disease
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Definition Developmental insufficiency of surfactant production and structural insufficiency in lungs. Most common cause of respiratory disease in preterm infant
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Etiology Deficiency of surfactant
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Clinical Features Signs of respiratory distress
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Lab Findings CXR shows air bronchograms, diffuse bilateral atelectasis causing a ground glass appearance, doming of the diaphragm
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Treatment Synchronized intermittent mandatory ventilation. (Can also give exogenous surfactant in delivery room for prophylaxis)
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