General Pulmonary Reminders

8/7/2019 General Pulmonary Reminders

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General Reminders - Pulmonary

Absent breath sounds = if breath sounds are absent on one side, examiner is toconsider(p. 180):

1. pneumothorax, hydrothorax, or hemothorax2. obstruction of a mainstream bronchus

3. surgical or congenital absence of the lung

Acid-Base status = to monitor arterial blood acid-base status, look at (p. 191):1. pH2. PCO23. serum bicarbonate (HCO3-)

- Normal Values for Arterial Blood Gases(Table 16-1)o PO2 = 104 0.27 x ageo PCO2: 36-44o pH: 7.35-7.45o Alveolar-arterial O2 difference = 2.5 + 0.21 x ageo (HCO3: 25)

Acute RespiratoryFailure = two major functions of respiration are to add oxygen to and

remove carbon dioxide from the blood, in this case, either or bothof these functions decline (p. 224)

Adventitious sounds = extra breath sounds heard during auscultation not heard innormal lungs (p. 180)

Apneustic breathing = consists of sustained inspiratory pauses resulting from damageto the midpons, most commonly caused by a basilar artery infarct(p. 218)

Arterial Blood GasMeasurement (ABG) = evaluation of gas exchange (p. 191)

1. Samples are analyzed for:a. pHb. the partial pressure of arterial oxygen (PaO2)

i. the % Hb saturation is routinely calculatedfrom the PaO2 & is an accurate estimate ofHb saturation except in the case of carbonmonoxide poisoning

ii. PaO2 reflects the adequacy of gasexchange

c. the partial pressure of arterial carbon dioxide(PaCO2)

i. PaCO2 reflects ventilation

Asthma = a chronic inflammatory disorder of the airways (p. 194)1. it is characterized by episodic airway narrowing,

increased airway reactivity to a variety of stimuli &pharmacologic or spontaneous reversibility

2. it is an inflammatory response which involves Mastcells, T lymphocytes, & eosinophils

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3. the trigger or stimulus that provokes the inflammatoryresponse may be exposure to extrinsic allergens orintrinsic host factors with no identifiable external cause

4. some non-allergic factors which can ppt or exacerbateasthma:

a. postnasal dripb. gastroesophageal reflux diseasec. exposure to coldd. exercisee. exposure to gases or fumesf. emotional stressg. hormonesh. respiratory infections

5. Classic Triad of Symptoms:a. Persistent wheezeb. Chronic episodic dyspneac. Chronic cough

6. acute severe asthma: (p. 195)a. aka = status asthmaticus

i. an attack of severe bronchospasm that isunresponsive to routine therapyb. hyperacute asthma:

i. sudden asthmatic attack that can be fatalbefore medical assistance can even begin

Ataxic breathing = a haphazard random pattern of deep and shallow breaths, iscaused by disruption of the respiratory rhythm generator in themedulla (p. 218)

1. aka = Biots breathing

Atelectasis = a collapse of lung tissue affecting part or all of one lung. This

condition prevents normal oxygen absoption to healthy tissues.

Berylliosis = lung inflammation caused by inhaling dust or fumes thatcontain

the metallic element beryllium. Found in rocks, coal, soil, andvolcanic dust, beryllium is used in the aerospace industry and inmany types of manufacturing (answer.com)

Bordetella pertussis = whooping cough (p. 177)

Bronchial breath sounds = are heard over the central airways and are louder and coarserthan vesicular breath sounds, which are heard at the periphery

and the base of the lungs (p 180)1. Brochovesicular sounds are a combo of the 2 & are

heard over medium-sized airways2. Bonchial sounds have a longer inhaled component3. Vesicular sound a have a much longer expiratory

component & are much softer

Bronchiectasis = an abnormal & persistent dilation of the bronchi, results fromdestructive changes in the elastic & muscular layers of bronchialwalls that may be diffue or localized (p. 196)



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1. Common causes, in developed countries:a. Allergic bronchopulmonary aspergillosis

i. Allergic bronchopulmonary aspergillosis isan allergic lung reaction to a type offungus (most commonly Aspergillusfumigatus) that occurs in some people withasthma or cystic fibrosis, causing cough

and wheezing and sometimes fever. Ifuntreated, chronic lung damage maydevelop. The fungus Aspergillus fumigatusflourishes in soil, decaying vegetation,foods, dusts, and water.(http://www.merck.com/mmhe/sec04/ch051/ch051d.html)

b. immunoglobulin deficiencies predisposing tochronic respiratory infections

c. abnormal airway clearance mechanismsd. cystic fibrosis (CF)

i. MOST common

2. Diagnosis:a. History of chronic cough, which may be dry orproductive of large volumes of sputum

i. Can have dry develop into cough w/sputum

b. Blood-streaked sputum commoni. Massive hemoptysis occurs rarely

c. Auscultation crackles over the affected lungsegment

d. Occasionally digital clubbing seen3. Classical Findings:

a. Parallel lines in peripheral lung fields (tram

tracks) that represent thickened bronchial wallsthat do not taper from proximal to distal sites

Bronchiolitis obliterans w/Organizing pneumonia = a rare interstitial lung disease (p. 208)

1. thought to be a response to pulmonary injury resultingfrom infection, inhaled toxin, or autoimmune disease

2. lumen of distal bronchiles found to have inflammatorycells & fibrous tissue accompanied by an adjacentalveolitis

3. disease is patchy, with abnormal and normal lung tissueoften juxtaposed

4. responds well to oral corticosteroids & usually does notcause permanent lung fibrosis

Bronchorrhea = Excessive discharge of mucus from the bronchial mucousmembranes

Bronchospasm = airway smooth muscle contraction (p. 183)

Byssinosis = a chronic, asthma-like narrowing of the airways. Also



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called brown lung disease, byssinosis results from inhalingparticles of cotton, flax, hemp, or jute. (answer.com)

Chest wall disease = any disease that restricts chest wall movement or interfereswith

neuromuscular function may produce hypoventilation. In thesediseases, the total lung capacity & vital capacity are decreased,but the residual volume is usually normal or even increased (p.211)

1. Vertebral disorders:a. Scolosisb. Kyphosis

2. Obesity3. Diaphragmatic paralysis

a. Unilateralb. Bilateral

Cheyne-Stokes respiration = the regular cycleing of crescendo-decrescendo tidalvolumes

separated by apneic or hyponeic pauses (p. 218)

Chronic Bronchitis = persistent cough resulting in sputum production for more than3

months in each of the last 3 years (p. 177)1. Cigarette smoking is the major cause, although exposureto other pollutants may play a role2. Pathologic findings are: goblet cell hyperplasia, mucusplugging, and fibrosis

Chronic ObstructivePulmonary Disease

(COPD) = slowly progressive, irreversible airway obstructionpunctuatedbyperiodic exacerbations of characterized by increased dyspnea,increased sputum production, a change in character of thesputum, & occasionally acture respiratory failure (p. 195)

1. usually takes years to become clinically significant2. dyspnea on exertion is the earliest symptom

a. often not reported until late in disease becausepatients gradually reduce their exercise to avoidsymptoms

3. PE may reveal:a. A-P chest diameter increased

i. Indicating chronic lung overinflationb. Use of accessory muscle of respirationc. Peripheral cyanosisd. On auscultation of chest, decreased breath

sounds & a prolonged expiratory phase4. Pulm Fxn Testing is the most sensitive means of making

the Dx5. Cigarette smoking is by far the most frequent cause6. most pts have elements of both emphysema & chronic

bronchitis



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7. small airway obstruction = the earliest manifestation ofCOPD is in the peripheral airway

8. Treatment: (p. 197)a. No curative therapies rather therapy is aimed to

control symptoms & avoiding harmfulenvironments

b. Pharmacologic therapy

i. Bronchodilators1. sympathomimeticsa. i.e., albuterol, theophylline,

etc.ii. Anti-inflammatories

1. inhaled corticosteroidsiii. Antibioticsiv. Mucolyticsv. Oxygen therapyvi. Airway clearance techniquesvii. Pulmonary rehabilitation programs

viii. Surgical therapy

Chyle = A fluid consisting of a mixture of lymphatic fluid (lymph) andchylomicrons that has a milky appearance. Chylomicrons aresmall fat globules composed of protein and lipid (fat) which arecombined in the lining of the intestine. Chylomicrons are found inthe blood and in lymphatic fluid where they serve to transport fatfrom its port of entry in the intestine to the liver and to adipose(fat) tissue.

Collagen VascularDisease = Collagen is a tough, glue-like protein that represents 30% ofbody

protein. It shapes the structure of tendons, bones, and connectivetissues. Problems with the immune system can affect thesestructures. This is known as collagen vascular disease. Collagenvascular diseases include:

1. Rheumatoid arthritis

2. Systemic lupus erythematosus

3. Scleroderma

4. Dermatomyositis

5. Polyarteritis nodosa

Consolidation = there is increased transmission vocal sounds (p. 180):1. whispered pectoriloquy

2. egophany (e a)

Cough VariantAsthma = patients with asthma often have cough, and on occasion it istheir

only symptom (p. 177)

Crackles = can be course rattles or fine, Velcro-like sounds (p.180)1. Course crackles are often caused by mucus in the

airways

http://www.nlm.nih.gov/medlineplus/ency/article/000431.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000435.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000429.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000839.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001438.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000431.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000435.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000429.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000839.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001438.htm


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or by the opening of large and medium-sized airways2. Fine crackles, produced on inspiration by the opening of

collapsed alveoli, are most common at he bases and areheard in pulmonary edema and interstitial fibrosis, aswell as in healthy elderly patients during deepinspiration

Cystic Fibrosis (CF) = an autosomal recessive genetic disorder that affectsmultiple

organs (i.e., pulmonary, GI, GU) (p. 197)1. Failure to produce normal CFTR (CF transmembrane

conductance regulator) protein results in defectivechloride transport & increased Na reabsorption inairway & ductal epithelia & creates abnormally thick &viscous secretions in the respiratory tracts & in thepancreas

a. These abnormal secretions cause luminalobstruction & destruction of various exocrineducts

2. In patients with CF in upper and lower respiratorytractsprogressive airway obstruction ensues & mostpts die of respiratory failure

3. Diagnose via measuring the concentration of chloride insweat

4. Core treatment: aggressive airway hygiene, nutritionalsupport including pancreatic enzyme replacement,antibiotics, bronchodilators & aerosolized recombinanthuman DNase, which decreases sputum viscosity bydigesting inflammatory cell DNA

5. Discussed during Obstructive Lung Disease Chapter

Diffuse AlveolarHemorrhage = (p. 206)1. discussed in ILD section

- Diffuse alveolar hemorrhage syndrome is persistent orrecurrent pulmonary hemorrhage

o Symptoms and signs of milder diffuse alveolarhemorrhage syndrome are dyspnea, cough, and fever;however, many patients present with acute respiratoryfailure

o http://www.merck.com/mmpe/sec05/ch059/ch059a.html

Drug-Induced Interstial

Lung Disease = See Table 18.6 for Common Drug-Induced Lung Disease1. i.e., Chemotheraputics, Antimicrobials, CV,

Antiinflammatory, Illicit, and Tocolytics2. Discussed under ILD section

Dyspnea = shortness of breath (p. 177)

Emphysema = abnormal enlargement of the air spaces as a result ofprogressive

destruction of alveolar walls (p. 196)



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1. in some pts the air spaces coalesce to form giant,essentially nonfunctional air spaces (bullae) thatcompress surrounding areas of more normal lung

2. Pathology = uncertain but suspect that a repeated &prolonged inflammation releases proteolytic enzymesinto the lungs in amounts too great to be neutralizedthe unopposed protease digests lung tissue and results

in permanent distruction3. Cigarette smoking is the major causes

Empyema = pus in the pleural space (p. 210)

Environmental &Occupational LungInjury = air pollution, noxious gases and fumes, smoke inhalation, high-

altitude injury and drowning and near-drowing (p. 219-220)

Epitaxis = the growth on a crystalline substrate of a crystalline substancethat

mimics the orientation of the substrate (webster.com)

Fremitus = a faint vibration felt best with the edge of the hand against thepts chest wall while the patient speaks (p. 180)

1. Fremitus is increased in pats with underlyingconsolidation

2. Fremitus is decreased over a pleural effusion

Forced ExpirationVolume in 1 sec (FEV1) = the volume exhaled in 1 sec with maximal effort starting from afull

Inspiration (p. 190)

1. the ratio of FEV1 to FVC is the most useful measure ofairway obstruction

Forced Vital Capacity(FVC) = total amount of air exhaled starting from a full inspiration

1. the ratio of FEV1 to FVC is the most useful measure ofairway obstruction

Hammans crunch = hearing a crunching sound timed with the cardiac cycle (p. 180)1. heard in pts with pneumomediastinum

Hematemesis = vomiting of blood

Hemoptysis = coughing up blood1. more than 500 mL of blood in 24 hours is rare but is amedical emergency (p. 178)

Heerfordts syndrome = triad of uveitis, parotitis, & facial nerve palsy [calleduveoparotid fever] (p. 203)1. syndrome discussed during sarcoidosis



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Histoplasmosis = an infectious disease caused by inhaling the microscopic sporesof the fungus Histoplasma capsulatum. Histoplasmosis is anairborne infection. The spores that cause this disease are found insoil that has been contaminated with bird or bat droppings.(answer.com)

Hypercapnia = A condition marked by an unusually high concentration ofcarbon dioxide in the blood as a result of hypoventilation.

Hypercarbia = to have more than normal CO2 (Carbon dioxide) levels in theblood

HypersensitivityPneumonitis = dyspnea that is seasonal or triggered by environmentalexposure

(p. 177)1. can also be a sign of asthma instead of hypersensitivitypneumonitis

- aka: extrinsic allergic alveolitis (p. 205)o

an immunologically mediated disease that results fromrepeated inhalation of & sensitization to certain organicdusts

o symptoms include: cough, dyspnea, fever, chills, &malaise

o there are acute, subacute, and chronic formso early diagnosis allows avoidance of offending agent &

prevents the progression of lung damage

chronic form results in progressive fibrosis &restrictive lung disease

o diffuse crackles are the predominant PEo DDx of any pt w/ restrictive lung diseaseo Should be highly suspected in patients with respiratory

sysmptoms that worsen in certain environmentso Treatment requires eliminating exposure to the

offending antigen.

Systemic corticosteroids can relieve symptoms inthe acute phase.

Although the efficacy of these agents in thechronic form of the disease is less clear, trial ofcorticosteroids is usually given

Hypoventilation = ventilation inadequate to keep PaCO2 from increasing abovenormal (p. 186)

1. produces hypercapnia and progressive atelectasis

Hypoxemia = Insufficient oxygenation of the blood.

Interstitial Lung Disease(ILD) = diseases characterized by diffuse lung injury & inflammationthat

frequently progresses to irreversible fibrosis & severelycompromised gas exchange (p. 201)



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1. Known causes include: pneumoconiosis, hypersensitivitypneumonitis, drugs, and toxic gas inhalation, sarcoidosis,collagen vascular disease, pulmonary vasculitis, alveolarhemorrhage, bronchiolitis obliterans w/ organizingpneumonia, and some rare eosinophil granuloma &lymphangioleiomyomatosis

Kartageners syndrome = immotile cilia; is a rare inherited abnormality of ciliarymicrotubules

that impairs airway clearance (p. 196)1. Classic Triad:

a. Sinusitis, situs inversus (= a condition in whichthe organs of the chest and abdomen arearranged in a perfect mirror image reversal of thenormal positioning), & infertility

i. This was discussed under bronchiectasis

Kussmaul breathing = is the very deep and labored breathing with normal or reducefrequency, found among people with severe acidosis; it is a form

of hyperventilation. The cause of Kussmaul breathing isrespiratory compensation for a metabolic acidosis, mostcommonly occurring in diabetics in diabetic ketoacidosis.(answer.com)

Medialstinal fibrosis = the progressive proliferation of fibrous tissue in themediastinum

that encroaches on major airways & blood vessels & results ininexorably progressive airway or vascular obstruction & death; noeffective therapy is available for this disease. (p. 211)

Mesothelioma = A usually malignant tumor of mesothelial tissue, especially that

of the pleura or peritoneum. (answer.com)

Metabolic Acidosis = a pH imbalance in which the body has accumulated too muchacid and does not have enough bicarbonate to effectivelyneutralize the effects of the acid.

Metabolic acidosis, as a disruption of the body's acid/basebalance, can be a mild symptom brought on by a lack of insulin, astarvation diet, or a gastrointestinal disorder like vomiting anddiarrhea. Metabolic acidosis can indicate a more serious problemwith a major organ like the liver, heart, or kidneys. It can also beone of the first signs ofdrug overdose or poisoning. (answer.com)

The values for Metabolic Acidosis:

pH: HCO3: pCO2:

Metabolic Alkalosis = results from altered metabolism. It is the most common acid-base disorder seen in hospital in the United States. Is a result ofdecreased hydrogen ion concentration leading to increasedbicarbonate and carbon dioxide concentrations, or alternatively a

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direct result of increased bicarbonate concentrations. There arefour mechanisms of metabolic alkylosis:

1. Loss of hydrogen ions Most often occurs via twomechanisms, either vomiting or renally. Vomiting results inthe excretion hydrogen ions and the retention ofbicarbonate. Renal losses of hydrogen occur when excess

aldosterone induces the retention of sodium and hence theexcretion of hydrogen.

2. Shift of hydrogen ions into intracellular space. Seen inhypokalemia. Due to a low extracellular potassiumconcentration, potassium shifts out of the cells, and inorder to maintain electrical neutrality, hydrogen shifts intothe cells, leaving behind bicarbonate.

3. Alkalotic agents Alkalotic agents, such as bicarbonate,administered in excess of excretion capabilities by thekidney can lead to an alkylosis.

4. Contraction alkalosis This results from a loss of water inthe extracellular space which is poor in bicarbonate,typically from diuretic use. Since water is lost whilebicarbonate is retained, the concentration of bicarbonateincreases.

Compensation of Metabolic Alkalosis:

The body attempts to compensate for the increase in pH byretaining carbon dioxide (CO2) through hypoventilation(respiratory compensation). CO2 combines with elements in

the bloodstream to form carbonic acid, thus decreasing pH.

Renal compensation for metabolic alkalosis consists ofincreased excretion of HCO3- (bicarbonate), because thefiltered load of HCO3- exceeds the ability of the renal tubuleto reabsorb it.

The values for Metabolic Alkalosis:

pH: HCO3: pCO2:

Lofgrens syndrome = constellation of erythema nodosum (= a type of skininflammationthat is located in a certain portion of the fatty layer of skin.Results in reddish, painful, tender lumps most commonly locatedin the front of the legs below the knees. The tender lumps, ornodules, range in size from 1 to 5 centimeters. The nodularswelling is caused by a special pattern of inflammation in thefatty layer of skin), arthralgias, & hilaradenopathy (p. 203)

Lung Perfusion = blood flow in the normal lung (p. 184)

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1. the relationship between alveolar & pulmonaryvasculature pressure largely determine this

Lymphangioleiomyo-Matosis = a rare interstitial lung disease (p. 207)

1. disease of pre-menopausal women2. characterized by proliferation of smooth muscle in the

walls of the pulmonary lymphatics and venules &causing mixed obstruction & restriction

3. accelerated during pregnancy4. pathologic cells resemble uterine muscle cells5. therapy: hormonal manipulation has been used w/o

success

Obstructive LungDisease = characterized by decreased airflow rates during expiration,often

accompanied by and elevated functional residual capacityresulting from trapped gas (p. 193)

1. Include: asthma, bronchiectasis, emphysema & chronicbronchitis2. COPD is the term applied to both emphysema & chronicbronchitis, diseases usually caused by cigarette smoking orother chronic irritant inhalation, although long-standingpoorly controlled asthma can also result in COPD

Oximetry = a reliable non-invasive method for estimating arterial Hboxygen

saturation. Relies on the different absorption spectra of oxy-Hband deoxy-Hb to estimate the O2 saturation. Sensors are usually

placed on digits or ear lobes, which allow transmission of lightfrom the source on one side of the tissue to the sensor on theother side. (p. 192)

Oxygen saturation = red blood cells must carry sufficient oxygen through yourarteries to all of your internal organs to keep you alive. Normally,when red blood cells pass through the lungs, 95%-100% of themare loaded, or "saturated," with oxygen to carry. If you have lungdisease or other types of medical conditions, fewer of your redblood cells may be carrying their usual load of oxygen, and youroxygen saturation might be lower than 95%. Your blood oxygenlevel can be measured in two ways.

(http://www.health.harvard.edu/diagnostic-tests/oxygen-saturation-test.htm)

Pack years = Number of pack years = (number of cigarettes smoked per dayx number of years smoked)/20

Pancoasts syndrome = Pancoast tells you where the cancer is, rather than what type itis.

Tumours grow right at the top of the lung (the apex). Thisposition makes them rare, as most lung cancers develop lower



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down in the lungs. The cancer is at the top of the lungs, it mayput P on or damage a group of nerves that runs from the upperchest into your neck & face (brachial plexus). This can haveseveral symptoms:- severe pain in the shoulder of the shoulder blade (scapula)- pain in the arm- Horners sydrome: the medical name for a group of symptoms.

You get flushing on one side of the face & that side doesntswear. The eye on the same side has a smaller (constricted)pupil with a drooping or weak eyelid.

- http://www.cancerhelp.org.uk/help/default.asp?page=10809

Parenchyma = The tissue characteristic of an organ, as distinguished fromassociated connective or supporting tissues

Paroxysmal NocturalDyspnea = dyspnea that occurs on to several hours after lying down and is

associate with congestive heart failure (p.177)1. it is caused by increased venous return to the heart

resulting in mild pulmonary edema2. can also be associated with asthma

Percussion = always compare sides [posterior, anterior, and lateral] (p. 180)1. If dullness present, consider:

a. Pleural effusion, consolidation, a mass, or anelevated diaphragm

2. If hyperresonane is present, consider:a. Pnuemothorax or hyperinflation

Pleural effusion = fluid accumulating in the pleural space (p. 209-210)1. fluid accumulates b/c dynamics are altered by changes

in hydrostatic or osmotic Ps, by increased permeabilityof pleural capillaries, or by lymphatic obstruction

2. Tansduative effusion:a. Result from increases in vascular hydrostatic P or

decreases in plasma oncotic Pb. Treatment:

i. Seldom require drainage, & they willresolve w/o consequence if the underlyingabnormality is corrected

3. Exudateive effusion:a. Result from increases in vascular permeability,

from trauma, or, rarely, from abnormal

communications btwn the pleural space & otherstructures such as the pancreas, esophagus,peritoneal space or lung parenchyma

b. Treatment:i. May or may not require drainage

4. pts may be asymptomatic or may have dyspnea orchest pain

5. pleuritic chest pain is classically described as sharp andis exacerbated by coughing or deep breathing

6. PE signs:



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a. Dullness to percussionb. Decreased breath sounds over the effusionc. Decreased vocal fremitusd. Bronchial breath soundse. Egophany at the superior edge of the effusion

resulting from lung compression7. a pleural effusion of unknown cause requires

thoracentesis8. treatment: depends on the cause & on the degree of

impairment of lung functiona. should be directed at the underlying cause when

known

Pneumochoniosis = lung disease caused by inhalation of inorganic dusts (p. 219)1. 4 major pneumochonioses result from inhalation of:

a. asbestosi. asbestos fibers are not easily cleared from

the lung & continue to stimulate ongoinginflammation & fibrosis

ii.fibers appear on histologic exam asasbestos bodies (ferruginous bodies) b/cof the accumulation of iron & protein ontheir surface over time

b. coal dust

i. Coal Workers pneumoconiosis = resultsfrom long and intense inhalation of coaldust

c. silicai. silicosis = resulting from significant silica

exposureii. radiographical finding:

1. eggshell calcification of hilar nodesd. beryllium

Pneumothorax = air in the pleural space (p. 211)1. Spontaneous pneumothorax:

a. Idiopathic & occurs in young people w/o anyknown predisposition

b. Classic symptoms: dyspnea & sharp chest pain2. Tension pneumothorax:

a. Accumulation of air creating positive P in thepleural space

b. Can cause hempdynamic collapse, therefore it is

a medical emergency that requires immediatedecompression

c. Pts with mechanical ventilation require a chesttube

d. Pts w/o mechanical ventilation, a smallpneumothoaces may resolve w/o intervention

e. Occasionally, needle drainage can be performedw/o reaccumulation

f. Small-bore catheters placed percuaneously maysuffice



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Polysomnography = used to evaluate patients for sleep disturbances. Diagnoses aremade from continuous recordings of an electroencephalogram, anelectrocardiogram, chest wall movement, a diaphragmaticelectromyogram, pulse oximetry, & video-recorded observationduring sleep. From such measurements, it is possible to establishthe presence of sleep-disordered breathing & to distinguish btwnCNS & peripheral causes of the disorder. (p. 191)

Pressure-cycled mode = mechanical ventilation which provides positive P applied duringinspiration during spontaneous breaths (p. 225)

Primary carcinomas ofthe lungs = are classified as small cell or non-small cell carcinomas (p. 213-

214)1. Small cell carcinoma: A highly malignant carcinoma of

the lungs composed of small ovoid undifferentiated cells

2. Non-small cell "non-small cell lung cancer" applies tothe various types of bronchogenic carcinomas (those

arising from the lining of the bronchi); these tumors aredivided into:a. Squamous cell carcinoma

i. carcinoma that arises from squamousepithelium

b. Adenocarcinoma:i. malignant tumor originating in glandular

tissue

c. Large cell (or anaplastic) carcinoma:

i. Carcinoma composed of largeundifferentiated cells

d. Bronchoalveolar carcinoma

e. Note: the highest rate of cure in non-small celllung cancer occurs with complete surgicalresection

3. symptoms vary but can include: cough, hemptysis,dyspnea, or postobstructive pneumonia, chest pain

4. Dx and Eval:a. A lesion that is radiographically stable for more

than 2 years is assumed to be benignb. Cytological exam of sputumc. Fiberoptic bronchoscopyd. Transthoracic needle aspiration

i. A negative needle biopsy does not rule out

malignancye. Thoracoscopic wedge resection

5. See Table 20.2 for International Statging System forLung Cancer (p. 215)

6. Small cell cancer: (p. 215-216)a. Staged and treated differently than non-small cell

lung cancerb. Classifications:

i. Limited stage:

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1. tumor is encompassed entirely w/ina single radiation port

ii. Extensive stage:1. therapy is chemotherapy combined

with irradiationc. small cell lung cancer is very chemosensitive

i. responds with clinical remission but rarely

is patient curedd. small cell lung cancer frequently metastasizes tothe brain

Pulmonary alveolarProteinosis = a rare interstitial lung disease (p. 207)

1. alveoli fill with protein & phospholipids material similarto surfactant2. origin unknown

Pulmonary cachexia = in patients with severe obstructive or restrictive lung disease,the work of breathing may be a major contributor to the resting

metabolic rate. In extreme cases, this increae in energyexpenditure can resulting in weight loss known as pulmonarycachexia (p. 183)

1. with normal lungs, the work of breathing uses only 4-5%of the total calories burned, but in sever lung disease upto 30% of the total-body oxygen consumption can beconsumed by the work of breathing

Pulmonary eosinophilicGranuloma = a rate interstitial lung disease (p. 207)

1. characterized by proliferation of Langerhans cells2. unlike most pts with ILD, these pts have normal lung

volumes3. associated with smoking & has a highly variable course

Pulmonary hamartoma = the most common benign peripheral lung tumor which has acharacteristic popcorn patter of calcification (p. 213)

Pulmonary InfiltratesWith Eosinophilia = discussed in ILD section (p. 207)

1. Eosinophilic Lung Disease = Pulmonary diseaseaffecting the major airways or parenchyma (or both)associated with either blood or tissue eosinophilia (orboth)

a. http://www.learningradiology.com/lectures/chestlectures/eosinophiliclungdisease_files/frame.htm

Pulmonary FunctionTest = evaluates four areas of lung function (p. 189):

1. air flow (spirometry)2. lung volume3. gas exhange (diffusing capacity)4. lung mechanism



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a. Note: variable that affect the standard valuesinclude: age, sex, height, race, and Hbconcentration

b. Pulm Fxn Testing divides the lung into 4 volumesand 3 capacities

i. All volumes except the residual volume canbe measured directly by spirometry

1. Measuring the functional residualvapacity indirectly & subtracting theexpiratory reserve colume calculatesresidual volume

Pulmonary Vasculitis = (p. 206) discussed in ILD section1. Vasculitis refers to a varied group of disorders which allshare a common underlying problem of inflammation of ablood vessel or blood vessels. The inflammation may affectany size blood vessel, anywhere in the body. It may affecteither arteries and/or veins. The inflammation may befocal, meaning that it affects a single location within a

vessel; or it may be widespread, with areas of inflammationscattered throughout a particular organ or tissue, or evenaffecting more than one organ system in the body.Inflammation is a process which occurs when the immunesystem of the body responds to either an injury or a foreigninvader (virus, bacteria, or fungi). The immune systemresponse involves sending a variety of cells and chemicalsto the area in question. Inflammation causes blood vesselsin the area to leak, causing swelling. The inflamed areabecomes red, hot to the touch, and tender. (answer.com)

Respiratory Acidosis = Respiratory acidosis is a condition in which a buildup of carbon

dioxide in the blood produces a shift in the body's pH balance andcauses the body's system to become more acidic. This conditionis brought about by a problem either involving the lungs andrespiratory system or signals from the brain that controlbreathing.

Respiratory acidosis is an acid imbalance in the body caused by aproblem related to breathing. In the lungs, oxygen from inhaledair is exchanged for carbon dioxide from the blood. This processtakes place between the alveoli (tiny air pockets in the lungs) and



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the blood vessels that connect to them. When this exchange ofoxygen for carbon dioxide is impaired, the excess carbon dioxideforms an acid in the blood. The condition can be acute with asudden onset, or it can develop gradually as lung functiondeteriorates. (answer.com)

The values for Respiratory Acidosis:

pH: HCO3: pCO2:

Respiratory Alkalosis = results from increased alveolar respiration (hyperventilation)leading to decreased plasma carbon dioxide concentration. Thisleads to decreased hydrogen ion and bicarbonate concentrations.

1. There are two types of respiratory alkalosis: chronic andacute.

a. In acute respiratory alkalosis, increased levels ofcarbon dioxide are "blown off" by the lungs,

which are hyperventilating. During acuterespiratory alkalosis, the person may loseconsciousness where the rate of ventilation willresume to normal.

b. In chronic respiratory alkalosis, for every 10 mMdrop in pCO2 in blood, there is a corresponding 5mM of bicarbonate ion drop. The drop of 5 mM ofbicarbonate ion is a compensation effect whichreduces the alkalosis effect of the drop in pCO2 inblood. This is termed metabolic compensation.(answer.com)

The values for Respiratory Alkalosis:

pH: HCO3: pCO2:

Respiratory rate = 12-20 respirations per min is the norm

Rub = a pleural sound caused by inflamed pleural surfaces rubbingtogether (p. 180)

Sarcoidosis = systemic disease of elusive origin (p. 201-204)1. noncaseating epithelioid granulomas that contain giant

cells2. can affect any organ system3. commonly affects the lungs and LNs4. most common in adults 20-405. slightly more common in women6. in US, African Americans are more commonly affected7. also prevalent in Scandinavian countries8. Infectious, allergic & environmental exposures have allbeen proposed as triggers of the disease in pts w/ geneticsusceptibility, but neither genetic factors nor specifictriggers have been established

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9. has a distinct immunologic features, including:- circulating CD4+ lymphocytes are decreases

10. symptoms reflect the organ systems involved- most common complaints are cough & dyspnea- fatigue & low-grade fever are less common buthigh fever can occur- skin manifestations- ocular symptoms- liver granulomas- cardiac involvement- neurologic involvement- Heerfordts syndrome- Lofrens syndrome- in general, may have: skin lesions, lacrimal &salivary gland enlargement, cranial nerveabnormalities, or hepatomegaly

11. treatment with systemic corticosteroids though long-term prognosis therapies have not yet been proven

Shock = the profound & widespread failure of adequate tissue perfusion that lead to cellinjury and death (p. 223)1. Four categories of shock:

- hypovolemic:~ may be related to dehydration or

hemorrhage- cardiogenic:

~ signs of L sided heart failure are usuallypresent unless the cause is an isolated RVinfarct

- obstructive:~ results from significant obstruction to blood

flow w/in the CV circuit (i.e., pulmonaryembolism)- distributive:

~ results from systemic vasodilation soprofound that even a hyperdynamic heartcannot produce a cardiac output sufficient tomaintain blood pressure

2. Hypotension and tachycardia are characteristic of shockfrom any cause

- with the exception of cardiogenic shock which maybe accompanied by bardycardia

Shunt = the portion of the blood that goes from the R side of the heart to the L without anopportunity for exchange of O2 & CO2 (p. 186)

1. Via: anatomic shunt (i.e., intracardiac septal defect),from a small % of venous return from cardiac &bronchial circulations that empties directly into the LA,and physiological shunt

Sleep apnea = patients with apnea (= complete cessation of airflow for 10 ormore seconds) and hypopneas (= significant decrease in airflow)are increased in frequency & duration to a degree sufficient to



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fragment sleep & produce clinically significant hypoxia &hypercapnia (p. 217)

1. Obstructive:a. Upper airway obstructionb. Risk factors:

i. Obesityii. Upper airway anatomy

1. i.e., enlarged tonsils, etc.2. Central:

a. Decreased central respiratory driveb. May be due to a structural abnormality of the

brain stem, which may be discovered only atautopsy

c. Lower brain stem and upper pontine lesions maycause central hyperventilation

3. Note: can have a mixture of obstructive and centralsleep apnea

4. Consequences of sleep apnea:a. Excessive daytime somnolence

b. Increased risk for vehicular accidentsc. Irritabilityd. Headachee. HTNf. Increased sudden death (probably resulting from

cardiac arrythmias)5. More common in men6. Weight loss can eliminate or reduce severity7. Hypothyroidism, acromegaly, & amyloidosis are rate

causes of sleep apnea that should be ruled out8. Treat: use a sleeping device to increase airflow, surgery

to remove obstructing anatomic abnormalities,

tracheostomy is a last resort but highly effective

Sputum = does not signify a bacterial infection but is influenced by theconcentration of cellular debris, predominately white cells,present in any inflammatory process (p. 177)

1. sputum is abnormal and should be characterized byquantity, color, presence or absence of blood, & timing

a. frequency and volume of sputum should also beasked of the pt

Stridor = term used to describe noisy breathing in general, and to refer

specifically to a high-pitched crowing sound associated withcroup, respiratory infection, and airway obstruction. Occurs whenerratic air currents attempt to force their way through breathingpassages narrowed by: illness, infection, the presence offoreignobjects, throat abnormalities (answer.com)

Superior Vena CavaSyndrome = results from obstruction of the SVC by central upper lobetumors,

usually the small cell tumors (p. 213)

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1. symptoms: facial & upper extremity edema, dilation ofsuperficial veins over the upper part of the body,cerebral edema & stridor

Swan-Gaz = Invention of the percutaneoud flow-directed pulmonary arterycathetermake continuous measurements of pulmonary arteryand LA pressure and frequent measurements of cardiac outputfeasible. (p. 223)

- soft, flow-directed catheter with a balloon at the tip formeasuring pulmonary arterial pressures, right atrial pressures,left atrial pressure, and reflected left ventricular end-diastolicpressure. The catheter permits evaluation of cardiac functionby assessing the effectiveness of right and left pumping actionof the heart and providing a quantitative measurement ofcardiac output, and by allowing for sampling of mixed arterialvenous oxygen levels and calculation of differences betweenthe two.

- In medicine pulmonary artery catheterization is the insertionof a catheter into a pulmonary artery. Its purpose is

diagnostic; it is used to detect heart failure or sepsis, monitortherapy, and evaluate the effects ofdrugs. The pulmonaryartery catheter allows direct, simultaneous measurement ofpressures in the right atrium, right ventricle, pulmonary artery,and the filling pressure ("wedge" pressure) of the leftatrium. (answer.com)

o A Swan-Ganz:

RA pressures: normal range 0-5

PA pressure: normal range 12-28/3-13

PCWP: normal range 3-11

= Pulmonary Capillary Wedge Pressure

Synchronized intermittentmandatory ventilation(SIMV) = delivers a specified number of breath per minute of a specified

tidal volume synchronized with the pts efforts (p. 225)

Systemic InflammatoryResponse Syndrome(SIRS) = a constellation of clinical signs and symptoms resulting fromthe

host response to various insults (p. 226)1. Sepsis

a. when caused by infection2. Multiple Organ Dysfunction Syndrome3. Adult Respiratory Distress Syndrome

a. lung dysfunction- SIRS = The spectrum of elicited pathophysiologic changes(including blood clotting and changes in metabolism, heart rate,and respiration) resulting from excess production of inflammatorymediators (for example, histamines and leukotrienes), whichorchestrate the process of inflammation through variousprocesses (answer.com)

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Tachypnea = rapid breathing

Thoracentesis = Also known as pleural fluid analysis, it is a procedure thatremoves fluid or air from the chest through a needle or tube.Theusual place to tap the chest is below the armpit (axilla). Understerile conditions and local anesthesia, a needle, a through-the-needle-catheter, or an over-the-needle catheter may be used to

perform the procedure. Overall, the catheter techniques may besafer. Fluid or air is withdrawn. Fluid is sent to the laboratory foranalysis. If the air or fluid continue to accumulate, a tube is left inplace and attached to a one-way system so that it can drainwithout sucking air into the chest. (answer.com)

Ventilation = the primary short-term homeostatic mechanism for maintainingnormal blood pH, the strongest factor controlling ventilation (p

183)

Volumes = broken down:

1. Alveolar volume (VA)= portion of inhaled breath that fills the

respiratory zone is the alveolar volume (p. 183)2. Dead space volume (VD)= portion remaining in the

conducting airways (p. 183)

3. Tidal volume (VT)= the sum of alveolar & dead spaceventilation w/ quiet breathing (p. 183)

Volume-cycled modes = mechanical ventilation which is assist controlled byguaranteeing

a number of breaths per minute at a specificed tidal volume (p.225)

Wheezing = a higher pitched sound which suggestslarge airway obstruction

(p.180)

1. Lower pitched wheeze heard in patients with asthma orCHF

a. It is heard diffusely over all lung fields

2. Localized wheezing can also be heard in conditions suchas pulmonary embolism, obstruction of a bronchus by atumor,, & foreign body aspiration

Whole-bodyPlethysmography = measures the change in pressure with a change in volume,

measures lung volumes more accurately (than Pulm Fxn Test) in

patients with obstructive lung disease, & also permitsmeasurements of airway resistance, but the technique is morecumbersome and time consuming (p. 190)

Food For Thought:

1. The right mainstem bronchus takes off at a less acute angle than the left, & thereforeforeign bodies are more commonly aspirated into the right lung. (p. 181)



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2. The distribution of ventilation in the lungs is unequal, with greater ventilation in thebase & less at the apex in the upright position. The same is true for lung perfusion.This matching of ventilation & perfusion optimizes gas exchange. (p. 183)

3. Pleural disease: (p. 209)a. Fluid normally enters the space from the visceral pleura and is absorbed by

the parietal pleurab. Visceral pleural vessels are supplied from the pulmonary circulation & parietal

pleural vessels are part of the systemic circulationc. Pleural inflammation increases the permeability of the pleural vessels andcauses excessive fluid to enter the space for a given driving force

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General Pulmonary Reminders