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Pulm V: Circulation, Restrictive Dz Cheat Sheet by

Pulmonology

PE (Pulmonary Circul­ation)

Definition
Etiology
Arises from thrombi in the systemic venous circul­ation of the right side of the heart, or from tumors in the venous circul­ation.
Where do more than 90% of pulmonary emboli originate from?
DVT in lower extrem­ities
Virchow's Triad (risk factors)
Venous stasis + endoth­elial injury + hyperc­oag­ulable state (pregn­ancy, cancer, estrogen OCP, nephrotic syndrome)
Clinical features
Tachyc­ardia + tachypnea
Gold standard diagnostic test
Spiral CT
Treatment
Antico­agu­lation (heparin, Lovenox, warfarin) for at least 3 months
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

Definition
Chronic fibrotic lung diseases caused by inhalation of coal dust or various inert/­ino­rga­nic­/si­licate dusts
Clinically important pneumo­con­ioses
Coal workers' pneumo­con­iosis, silicosis, and asbestosis
Clinical Features
Often asympt­omatic, can have dyspnea, inspir­atory crackles, clubbing, and cyanosis
Lab Findings
PGTs show restri­ctive dysfun­ction and reduced diffusing capacity. CXR variable.
Treatment
Supportive (no effective tx availa­ble): O2, vaccines, rehab

Foreign Body Aspiration

Definition
Aspiration of gastric contents, inert material, toxic material, or poorly­-chewed food. Know Heimlich maneuver!
Clinical Features
Chocking, coughing, unexpl­ained wheezing or hemoptysis
Possible Sequelae
Asphyxia, PNA (aspir­ation pneumo­nia),
What is one of the most common causes of ARDS?
Acute gastric aspiration
Lab Studies
Expiratory radiog­raphy may show regional hyperi­nfl­ation caused by a check valve effect
Treatment
Bronch­oscopy for diagnosis and remova­l/t­rea­tment. Cultures should be obtained if post-o­bst­ructive PNA suspected
 

Pulmonary HTN (Pulmonary Circul­ation)

Definition
Present when the pulmonary arterial pressure rises to a level inappr­opriate for a given cardiac output; self-p­erp­etu­ation once present
Primary (idiop­athic) pulmonary HTN
Rare + fatal
Secondary pulmonary HTN
Many causes that develop as a result from oblite­ration and obstru­ction of the pulmonary arterial tree
Hypoxia
Most import­ant­/potent stimulus of pulmonary arterial vasoco­nst­riction (others are acidosis and veno-o­ccl­usive diseases)
Clinical features
Dyspnea, angina­-like pain, weakness, fatigue, edema, ascites, cyanosis, syncope
Signs on physical exam
Narrow splitting and accent­uation of the 2nd heart sound, systolic ejection click
Treatment
Chronic oral antico­agu­lants, CCB to lower systemic arterial pressure, and prosta­cyclin (a potent pulmonary vasodi­lator), and heart-lung transplant

ARDS (Acute adult respir­atory distress syndrome)

Definition
Increased permea­bility of the alveolar capillary membranes --> leads to pulmonary edema and widespread inflam­mation
3 Clinical Settings that account for 75% of ARDS cases
Sepsis syndrome + severe multiple trauma + aspiration of gastric contents
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
Lab Findings
CXR shows peripheral infilt­rates with air bronch­ograms, spares costop­hrenic angle, can get multi-­organ failure
Treatment
Treat underlying precip­itating problems, supportive care (O2, PEEP), high mortality rate. 33% of deaths occur within 3 days of ARDS sx onset
 

Sarcoi­dosis

Definition
Multiorgan disease involving abnormal collec­tions of inflam­matory cells (granu­lomas), most often in the lungs
Classic Patient
Higher incidence in North American black women, and northern European whites
Clinical features
Respir­atory sx (cough, dyspnea of insidious onset, chest discom­fort)
Other extrap­ulm­onary signs/sx
Malaise, fever, erythema nodosum or enlarg­ement of parotid glands­/lymph nodes/­spl­een­/liver
Lab Findings
ACE levels elevated, CXR shows bilateral hilar and right paratr­acheal adenop­ajhty and bilateral diffuse reticular infilt­rates
How to confirm diagnosis
Transb­ron­chial biopsy of the lung or fine-n­eedle node biopsy --> will show non-ca­seating granulomas
Treatment
Cortic­ost­eroids at mainte­nance doses

Idiopathic Fibrosing Inters­titial Pneumonia

General
Most common dx among pts with inters­titial lung disease.
Three histop­ath­ologic patterns w/ different natural histories and treatments
Usual inters­titial PNA, respir­atory bronch­iol­iti­s-a­sso­ciated inters­titial lung disease, and acute inters­titial pneumo­nitis
Clinical Features
Insidious dry cough, exertional dyspnea, consti­tut­ional sx. Exam might show clubbing and inspir­atory crackles.
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)
Treatment
Contro­ver­sia­l--none has been showed to improve survival or QOL

Hyaline Membrane Disease

Definition
Develo­pmental insuff­iciency of surfactant production and structural insuff­iciency in lungs. Most common cause of respir­atory disease in preterm infant
Etiology
Deficiency of surfactant
Clinical Features
Signs of respir­atory distress
Lab Findings
CXR shows air bronch­ograms, diffuse bilateral atelec­tasis causing a ground glass appear­ance, doming of the diaphragm
Treatment
Synchr­onized interm­ittent mandatory ventil­ation. (Can also give exogenous surfactant in delivery room for prophy­laxis)
                   
 

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