pulm exam 2

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  1. Most bronchogenic carcinomas present between the ages ______, and few are less than ____ years old
    • 50-70
    • 40
  2. what other factors can be potential carcinogens
    • Ionizing radiation
    • asbestos
    • heavy metals 
    • industrial carcinogens
  3. What are the four major cell types of bronchogenic carcinomas
    • Squamous cell carcinoma
    • adenocarcinoma
    • small cell carcinoma
    • large cell carcinoma
  4. What are the most common carcinomas accounting for about 30 to 35% of primary tumors each
    • Squamous cell
    • adenocarcinoma
  5. What are the carcinomas accounting for 20 to 25% and 15% respectively
    Small cell and large cell
  6. Which type of carcinoma tends to originate in the central bronchi as intraluminal growth
    Squamous cell carcinoma
  7. Which carcinoma can be detected by sputum cytology
    Squamous cell carcinoma
  8. Where does squamous cell carcinoma tend to metastasize
    Regional lymph nodes
  9. This type of carcinoma also occurs centrally and tends to narrow bronchi by the extrinsic compression
    Small cell carcinoma
  10. Which type of carcinomas usually appear in the periphery and metastasize to distant organs
    Adenocarcinoma and large cell
  11. Where does adenocarcinoma and large cell carcinoma metastasize to
    • Liver
    • stomach
    • spleen
    • pancreas
  12. What are the non specific complaints for carcinomas
    • Weight loss
    • cough
    • poor appetite
    • dyspnea
    • hoarseness
    • hemoptysis
  13. This is a tumor of the superior sulcus at the extreme apex of the lungs, it is characterized by severe unremitting pain in the lower part of the shoulder and inner aspect of the arm
    Pancoast tumor
  14. Which tumor can progress to horner's syndrome (miosis, ptosis, enophthalmos, and loss of sweating on the affected side)
    Pancoast tumor
  15. Which plexus does the Pancoast tumor affect
    brachial plexus
  16. What are some examples of paraneoplastic syndromes
    • Cushings syndrome
    • syndrome of inappropriate secretion of anti diuretic hormone
    • hypercalcemia
    • gynecomastia
  17. Which carcinoma can produce SIADH
    Small cell carcinoma
  18. If this is a obstructed by a tumor, it can cause progressive obstruction of venous drainage of the head, neck, and upper extremities
    Superior vena cava
  19. Under tumor complications, what results in hoarseness
    Recurrent laryngeal nerve palsy from tumor destruction of recurrent laryngeal nerve creating laryngeal nerve palsy
  20. What labs need to be ordered for all suspected lung cancer patients
    • CBC
    • LFT
    • electrolytes
    • calcium
  21. What is the definitive diagnosis for the more centrally located carcinomas
    Sputum cytology
  22. What is essential in determining staging, treatment, and prognosis of carcinomas
    Knowing the specific cancer type
  23. If you see a suspicious legion on and xray what is your next choice of scan
    CT
  24. If you want to see if the cancer has metastasized, what it is your choice of study
    MRI
  25. What is the treatment of choice for small cell carcinoma
    Chemotherapy and radiation
  26. What are the major factors for prognosis of carcinomas
    • Cell type
    • age
    • General Health
  27. This is a single round or oval sharply circumscribed pulmonary lesion, up to three centimeters, surrounded by normal lung tissue
    Solitary pulmonary nodule
  28. What disrupts cell function and prevents tissue from taking up oxygen
    Cyanide
  29. What are the symptoms of cyanide poisoning
    • Headache
    • dizziness
    • syncope
    • seizures
    • death
  30. This is a precursor to vitamin B12, binds to cyanide and neutralizes it, is eliminated harmlessly from the body through urination, and is given intravenously and acts immediately
    hydroxocobalamin
  31. What are the side effects of hydroxocobalamin
    Temporary discoloration of the skin and urine
  32. This occurs from inhalation of hot gases injuring mucosal surfaces, complications become evident around 18 to 24 hours, complications include impaired ability to clear oral secretions and airway obstructions, producing inspiratory stridor
    Thermal injury
  33. This results from the toxic gases produced by combustion, it can result in bronchorrhea and bronchospasm's, early with possible labored breathing and cyanosis, ARDS may follow in 1 to 2 days
    Chemical injury
  34. with chemical injury, this can occur causing obstruction, atelectasis, and increasing hypoxemia, often pneumonia follows 5 to 7 days after exposure
    Bronchial sloughing
  35. Why does the treatment of smoke inhalation include
    • Supplemental 02
    • bronchodilators
    • suction of secretions
    • endotracheal intubation
    • chest physical therapy
    • humidified oxygen
  36. For patients that survive smoke inhalation follow-up is needed to monitor for what
    bronchiolitis obliterans
  37. This is caused by ingestion of petroleum distillates, lung injury mainly from vomiting and secondary aspiration, therapy as supportive, protect lungs from repeated aspiration with cuffed endotracheal tube if necessary
    hydrocarbon pneumonitis
  38. This is chronic fibrotic lung disease is caused by inhalation of coal dust and various inert, inorganic, or silicate dusts
    pneumoconiosis
  39. This is caused from extensive or prolonged inhalation of free silica particles forming small rounded opacities through out the lung
    Silicosis
  40. On a chest xray, what strongly suggests silicosis
    Eggshell calcification
  41. Asbestosis is a nodular interstitial fibrosis occurring in which occupations
    Asbestos workers and miners
  42. This is an asthma like disorder in textile workers caused by inhalation of cotton dust, symptoms include chest tightness, cough, dyspnea and usually is worse on Mondays or the first day back to where, and subsides later in the week
    byssinosis
  43. This occurs in extremely obese individuals characterized by hypercapnia, hypoxemia, and elevated hematocrit
    pickwickian syndrome
  44. What it is the treatment for pickwickian syndrome
    Weight loss and medroxyprogesterone acetate (Provera)
  45. How is hypercapnia and hypoxemia corrected in pickwickian syndrome
    Have patient hyperventilate and the PCO2 and PO2 will return to normal
  46. What is the number one arrhythmia associated with pickwickian syndrome
    PVCs
  47. what are the essentials to diagnosing a PE
    • abrupt onset of dyspnea
    • chest pain
    • apprehension
    • hemoptysis
    • syncope
  48. what is the scan of choice for detection of a PE
    spiral CT with contrast
  49. where can PEs arise from
    • thrombi in venous circulation
    • right side of heart (pt has an ASD and the clot can go to the lungs)
  50. 70% of PEs originate as clots in deep veins of ____, mostly in the _____
    • lower extremities
    • calves
  51. what is virchows triad
    • venous stasis (long airplane rides or post-op)
    • venous endothelial injury
    • hypercoagulopathy (OCP, CA)
  52. what is the most common cause of PEs in the Caucasian population
    factor V leiden
  53. what causes factor V leiden thrombopenia
    mutations in the F5 gene
  54. a thrombus in the pulmonary artery has hemodynamic effects that affect what
    causes an increase in pulmonary vascular resistance and at the extremes causes pulmonary HTN and right ventricle failure
  55. what are the pulmonary effects of a PE
    • pt will get reflex bronchoconstriction in the embolized area
    • they will also get increased dead space and loss of alveolar surfactant
  56. what are the signs that a pt will present with for a PE
    • tachycardia
    • tachypnea
    • crackles
    • accentuation of pulmonary component of second heart sound
  57. what are the symptoms of a PE
    • CP (often pleuritic)
    • dyspnea
    • apprehension
    • cough
    • hemoptysis
    • diaphoresis
  58. an ABG will usually note what for a PE
    respiratory alkalosis secondary to hyperventilation (usually PaO2 under 80mmHg)
  59. what is rarely seen on a CXR but is very suggestive of a PE
    Hampton's hump (wedge shaped density pointing towards hilum)
  60. if you have an indeterminant study for a PE after doing a helical CT-PA what should be done next to r/o a PE
    LE U/S or PA (pulmonary angiogram)
  61. this study is reserved for pt's with a suspected emboli but other studies are inconclusive, it is expensive and invasive with potential for complications and is less than the "gold standard"
    pulmonary angiogram
  62. with any IV radio contrast-media, what do you need to worry about
    • acute renal failure
    • allergic reactions
  63. this test measures the plasma level of a degradation product of a cross linked fibrin, is measured by ELISA, and takes about an hour to perform
    D-Dimer
  64. what measurement difference between calves is highly indicative of a DVT
    if one calf is greater than 2cm compared to the contralateral calf
  65. if a DVT is suspected and there are no CI, what should be started
    IV heparin
  66. this sign is said to be present when passive dorsiflexion of the ankle by the examiner elicits sharp pain in the calf
    homans sign
  67. what is the diagnostic study if a DVT is suspected
    U/S
  68. what should be started on pts at risk to prevent DVTs before surgery or on hospital admission
    low dose heparin (5000 units) SQ q 8-12 hours
  69. extremely high risk pt's or surgeries may require what type of prevention
    prophylactic inferior vena cava filter
  70. what is the timeframe to reach full therapeutic effect of coumadin
    5 days
  71. this anti-coag works by activating AT-III to slow or prevent the progression of DVT and to reduce the size and frequency of PE
    heparin
  72. what is the reversal of heparin
    protamine sulfate
  73. what are the medications used for lysis of pulmonary thromboembolia
    • streptokinase
    • urokinase
    • recombinant tissue plasminogen activator (TPA)
  74. what treatment is indicated when recurrent PEs are life threatening and major CIs for anticoag or failure or complications of anticoags or thrombolytic therapy are present
    surgical interruption of inferior vena cava
  75. pain due to acute pleural inflammation is known as what
    pleuritis
  76. explain pleuritis
    inflammation of the pleura that causes loos of lubricant between them, inspiration causes the friction rub when the pleura rub together
  77. how is pleuritis treated
    analgesics and anti-inflammatory drugs
  78. what is another cause for pain that is pleuritic but is not pleuritis
    rib fracture
  79. in a rib fracture or pleuritis, lack of proper ventilation can lead to this
    atelectasis
  80. this may be asymptomatic, may be pleuritic, may cause dyspnea, will notice decreased tactile fremitus on physical exam along with dullness to percussion, distant breath sounds and egophony if large
    pleural effusion
  81. how much fluid must be present in the lateral decubitus to be considered effusion
    > 250ml
  82. what should be done to yield fluid for a diagnosis of the etiology of effusion
    thoracentesis
  83. what accounts for most transudates and is the most common cause of pleural effusion
    CHF
  84. what are the most common causes of exudative effusion
    bacterial pneumonia and CA
  85. TG readings of what can detect a chylothorax
    > 110mg/dL
  86. what labs are used to detect an esophageal perforation
    amylase >200
  87. one treatment option for palliative pain control in a pleural effusion is what
    pleurodesis (they obliterate the pleura with chemicals so it can no longer rub against each other)
  88. what is the treatment for effusion secondary to pneumonia
    preventing the exudative fluid from turning into frank pus
  89. what is required for frank pus
    tube thoracostomy
  90. primary spontaneous pneumothorax usually affects what types of people
    tall thin men between 20 and 40
  91. why do spontaneous pneumos occur in tall thin males
    because of the narrow apices (surface area) for the lungs to attach. they have a congenital bleb and it bursts which develops the spontaneous pneumo
  92. what are some causes for secondary pneumos
    • COPD
    • asthma
    • cystic fibrosis
    • TB
    • pneumocystis pneumonia
  93. this type of pneumothorax is associated with menstruation
    catamenial pneumothorax
  94. what are some clinical finds for a pneumo
    sudden onset of one sided CP and dyspnea, often begins at rest or sleep
  95. what are some clinical findings for a pneumo
    • diminished breath sounds
    • decreased tactile fremitus
    • hyperresonance on one side
  96. if there is severe tachycardia, HoTN, and a mediastinal or tracheal shift what needs to be suspected
    tension pneumo
  97. a pneumo is usually revealed on a CXR by noting what
    a visceral pleural line
  98. most congenital bleb pneumos occur where
    apices
  99. a tension pneumo will result in what
    acute respiratory failure within 5 minutes
  100. what can be associated with a rupture of the esophagus or bronchus
    pneumomediastinum
  101. what is the treatment for a pneumo is <15%
    conservative with bed rest, symptomatic care and serial CXRs
  102. what is the treatment for a pneumo that is > 15%
    a chest tube is usually placed under water sealed drainage and suction is applied until lung expands
  103. this is a primary tumor arising from the surface lining of the pleura or peritoneum, symptoms include insidious onset of SOB, non pleuritic CP, weight loss
    mesothelioma
  104. what will a CXR show with mesothelioma
    nodular, irregular, unilateral pleural thickening, and sometimes unilateral effusion
  105. what are common features of interstitial and mycotic lung diseases
    inflammation and fibrosis of the interalveolar septum (alveolitis)
  106. these diseases will have a decrease in DLCO and ventilator function, usually present with exertional dyspnea and dry cough of insidious onset, and chest exam is notable for fine inspiratory crackles at bases
    interstitial diseases
  107. this disease has a CXR that notes ground-glass, nodular, reticular or reticulonodular infiltrates that may progress to honeycomb lung
    interstitial disease
  108. what is very good for diagnosis of interstitial diseases
    high resolution CT
  109. what is used for pathological diagnosis of interstitial diseases
    lung biopsy
  110. what is the most common diagnosis presenting with interstitial lung disease
    cryptogenic fibrosing alveolitis (idiopathic pulmonary fibrosis)
  111. what is the treatment for cryptogenic fibrosing alveolitis
    • supportive care
    • supplemental O2
    • corticosteroids
  112. what is the prognosis of cryptogenic fibrosing alveolitis
    poor with a 5-year survival rate of about 50%
  113. pts with cryptogenic fibrosing alveolitis have an increased risk of what
    lung cancer
  114. this is a systemic disease of unknown cause with granulomatous inflammation of the lung in 90% of pts, pt may have malaise, fever, and dyspnea of insidious onset
    sarcoidosis
  115. physical findings of this disease include skin rashes, erythema nodosum, parotid gland enlargement, hepatosplenomegaly, lymphadenopathy
    sarcoidosis
  116. the first signs of sarcoidosis is noted on a routine CXR how
    bilateral hilar and paratracheal lymphadenopathy
  117. what is the treatment for sarcoidosis
    oral corticosteroids is indicated for symptomatic pulmonary lesions and constitutional symptoms, hypercalcemia, iritis, arthritis, CNS involvement, granulomatous hepatitis, cutaneous lesions
  118. if a patient has asymptomatic sarcoidosis, how are they treated
    educate and f/u
  119. this is an idiopathic disease hitting a combination of glomerulonephritis, necrotizing granulomatous vasculitis of upper and lower respiratory tracts, and varying degrees of small vessel vasculitis , it usually affects young and middle aged adults
    Wegener's granulomatosis
  120. this is an idiopathic multisystem vasculitis of small and medium-sized arteries that occurs in pts with asthma
    churg-strauss syndrome
  121. how is pulmonary angiitis and granulomatosis treated
    corticosteroids but can have a devastating irreversible lung involvement
  122. this causes an idiopathic recurrent alveolar hemorrhage and rapidly progressive glomerulonephritis, occurs mainly is men who are in their 30's and 40's, and hemoptysis is the presenting symptom
    goodpasture's syndrome
  123. who is goodpastures syndrome diagnosed
    it is made on a characteristic linear IgG deposits in the glomeruli and presence of anti-glomerular basement membrane antibody in serum
  124. what is the current treatment of goodpasture syndrome
    immunosuppressive drugs and plasmapheresis
  125. this disease is linked to bird droppings and bat exposure, is very common along river valleys
    histoplasmosis
  126. what is the treatment for histoplasmosis
    antifungals (amphotericin B)
  127. this is endemic in the soil in many arid regions of the southwestern USA, mexico, and south and central America, is a very common opportunistic infection in HIV-infected pts and symptoms include flu-like with malaise, fever, backache, and cough
    coccidioidomycosis
  128. this disease occurs most often in men of the south central and Midwestern USA and Canada, may often see skin lesions with verrucous cutaneous lesions with abrupt down-sloping border, and can also affect the bone and urogenital system
    blastomycosis
  129. this can colonize the tracheobronchial tree and is usually asymptomatic unless there is marked immunodeficiency
    aspergillosis
  130. what unique condition can aspergillosis cause that leads to wheezing and transient infiltrates
    allergic bronchopulmonary aspergillosis
  131. when should allergic bronchopulmonary aspergillosis be considered in a pt
    when a pt with a hx of asthma develops worsening symptoms, with fleeting infiltrates accomplanied with eosinophilia, high level of IgE, and brown-flecked sputum
  132. how is allergic brochopulmonary aspergillosis treated
    acute exacerbation: oral prednisone, bronchodilators
  133. what is the rough definition of acute respiratory failure by ABGs in a non-COPD pt
    PaO2 <60 (after attempted to increase the PaO2) and a PaCO2 >50
  134. what are some chief signs of hypoxemia
    • cyanosis
    • restlessness
    • confusion
    • anxiety
    • delirium
    • tachypnea
    • tachycardia
    • HTN
    • cardiac arrhythmias
    • tremor
  135. what are some cardinal symptoms of hypercapnia
    dyspnea and H/A
  136. what are some chief sign of hypercapnia
    • peripheral and conjunctival hyperemia
    • HTN
    • tachycardia
    • tachypnea
    • impaired consciousness
    • papilledema
    • asterixis (flapping tremor with hand extended.. like a bird flapping its wings)
  137. for non ventilator support, what is the goal in acute hypoxemic respiratory failure
    to provide adequate oxygenation of vital organs
  138. what is the only mask that will give you an exact FiO2 % up to 40-50% of O2
    venture mask
  139. which mask do you never run <5L/min
    simple mask
  140. which mask has the highest FiO2 on a mask
    NRB
  141. how high should a nasal cannula run
    <6L/min (never above 6L/min)
  142. what determines how long a cylinder will last
    conversion factor
  143. what is indicated for hypoxemia not quickly reversible, for upper airway obstruction, impaired airway protection, poor handling of secretions, and facilitation of mechanical ventilation
    tracheal intubation
  144. how far in an ET tube inserted
    below the vocal cords 1-2 cm above the carina (T4)
  145. this is great for urgent airway management
    orotracheal intubation (but nasotracheal is more comfortable for long term intubation)
  146. the tip of the tube once intubated should be at the level of what
    aortic arch
  147. what are some indications for mechanical ventilation
    • apnea (#1 reason)
    • acute hypercapnia not quickly reversible
    • severe hypoxemia
    • progressive pt fatigue despite appropriate care
  148. this can occur in pts whose lungs are over distended by too great a volume or pressure
    barotrauma
  149. what are some signs of barotrauma
    • subcutaneous emphysema
    • subpleural air cysts
  150. what is a common ventilator complication
    acute respiratory alkalosis from overventilation
  151. what are labs are ordered to check the patients general health while ventilated
    • hematocrit
    • electrolytes
    • kidney functions
  152. this is a special type of respiratory failure, it occurs after a systemic or pulmonary insult, is characterized by respiratory distress, bilateral infiltrates, hypoxemia, noncompliant lungs, and normal pulmonary capillary wedge pressure
    ARDS
  153. what are the common risk factors for ARDS
    • sepsis (very common)
    • aspiration of gastric content
    • shock
    • infx
    • lung contusion
    • non thoracic trauma
    • toxic inhalation
    • near drowning
    • multiple blood transfusions
  154. what are the clinical findings of ARDS
    • rapid onset of profound dyspnea that usually occurs 12-48 hours after the initial event
    • labored breathing
    • tachypnea
    • intercostal retractions
    • crackles
    • marked hypoxemia refractory to supplemental O2
  155. what is the treatment for ARDS
    • general supportive care
    • support of cardiac function with inotropic drugs (dopamine)
    • closely monitor I/O's
  156. what is the major cause of death in ARDS
    multi-organ failure

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