1
Q
What are PFT?
A
series of measurements related to lung volumes, rate of airflow, & gas exchange
2
Q
Indications of PFT
A
- symptoms of lung dz/dx of lung dz
- screening
- assess tx efficacy
-pre-op evaluation of lung function - monitoring for med SE
3
Q
Contraindications for PFT.
A
- active or recent resp infx
- recent surgery
- recent or current heart issues
- known aneurysms in chest, abdomen, brain
4
Q
Tidal volume (TV)
A
total volume of air inhaled/exhaled in one normal breath
5
Q
Minute volume
A
tidal volume x # breaths/minute
6
Q
IRV
A
volume that can be forcefully inhaled after normal tidal inspiration
7
Q
IC
A
TV + IRV
8
Q
ERV
A
volume that can be forcefully exhaled after normal tidal expiration
9
Q
RV
A
volume of air left in lungs after all possible air exhaled
10
Q
FRC
A
ERV + RV
11
Q
Slow vital capacity
A
VC measured w/ slower, prolonged exhale
12
Q
VC
A
total volume of air that can be exhaled after a maximum inspiration
13
Q
Forced vital capacity
A
VC measured w/ forceful exhalation
14
Q
TLC
A
VC + RV
15
Q
List the 3 Forced vital capacities & describe?
A
- forced expiratory volume/time (FEV1, FEV2 etc): volume exhaled forcefully during a particular time period
- forced expiratory flow (FEF): rate of flow during FEV25% & FEV75%)
- Peak expiratory flow rate (PFER): maximum rate of flow during forceful exhalation
16
Q
Types of pulmonary disorders
A
Obstructive, Restrictive, Pulmonary vasculature, breathing mechanics, neurologic control
17
Q
Obstructive disorders are issues with
A
the airway & air flow issues
18
Q
examples of fixed obstruction in upper airways
A
masses, mucus plug
19
Q
Examples of variable Extrathoracic obstructions
A
- sleep apnea
- vocal cord issues
20
Q
Examples of variable intrathoracic obstruction
A
- COPD
- asthma
21
Q
Two categories of cause for restrictive pulm disorders
A
- loss of compliance/elasticity
- anatomical restrictions
22
Q
Pulm disorders: pulm vasculature causes
A
- chronic PE
- chronic PHTN
23
Q
Pulm disorders: breathing mechanics causes
A
- diaphragm/intercostals
24
Q
Pulm disorders: Neurological control causes
A
- muscular dystrophy
- stroke
25
Measurements on specialized PFTs
- ABG
- Exercise oximetry "road test"
- 6-min walk test
- Peak flow
- Max inspiratory & expiratory pressure
26
What percentage of O2 will qualify a patient for home O2?
<88%
27
Spirometry procedure
- TV measured 3-5 times
- Forced exhalation for >6 secs measured 3 times
- Bronchodilator challenge (if done)
(BD inhaled; forced exhalations repeated to assess change
Usually, albuterol)
28
What other special test can be done? (spirometry slide)
* used when we suspect asthma*
- bronchoprovocation (methacoline/allergen,exercise)
- exercise testing
29
Results are based on predicted values for...
age, height, race, gender
30
On flow-volume loop, above the x-axis is...
exhalation
31
On flow-volume loop, below the x-axis is...
inhalation
32
What two things are being compared to the normal flow-volume loop?
shape & peak expiratory flow
33
What two things are being observed on the volume/time curve?
- where is the plateau?
- how long did it take to reach it?
34
Draw the spirometry volume/time chart
DONE
35
Draw flow-volume loops
DONE
36
GOLD criteria has a FEV1/FVC ratio of? Who is it used for?
70%
- middle-aged pts to assess COPD severity
37
ATS criteria has a FEV1/FVC ratio of? Who is it used for?
>85%
- >18yo
38
Low FEV1/FVC ratio & normal FVC is indicative of what?
Obstructive lung dz
39
How do you assess a bronchodilator test for obstructive lung dz?
- Ratio has >12% incr and FVC has >200 mL increase--> asthma (reversible)
- only one of the above criteria met--> COPD or bronchiectasis (irreversible)
40
Low FEV1/FVC ratio & low FVC is indicative of what?
Mixed disorder
41
How do you assess a bronchodilator test for a mixed disorder?
- FVC increases to >LLN--> obstruction w/ air trapping (emphysema)
- FVC does not increase to >LLN
mixed disorder
42
Possible methods for lung measurents.
- helium
- N2 washout
- body plethysmography
- radiographic measurements
43
When looking at lung volumes, what will restrictive patterns show.
low TLC confirms (the entire box is smaller)
44
What is DLCO?
measures capacity of diffusion across the alveolar-capillary membrane
45
Should CO normally be present in air/blood
No, & it has a very high affinity for Hgb
46
Causes for decreased DLCO
- interstitial lung dz
- emphysema
- PHTN
- Anemia
47
Causes for normal DLCO
- NM disorders affection resp system
- chronic bronchitis
- asthma
48
Study Slide 35 (full chart) 10 mins
DONE
49
What is A1AT?
inactivates enzyme that breaks down collagen
50
Deficiency of AAT leads to...
- early onset emphysema
- childhood cirrhosis
51
What is CF?
genetic disorder causing impaired Cl- transporter in cell membranes resulting in thick mucous
52
What test can be done to check for CF?
Cl- sweat test
53
Results of Cl- sweat test
- 29 or less --> CF unlikely
- 60 or high --> CF likely
- 30 to 59 --> inconclusive - repeat test & monitor
54
What does ACE stand for & what does it do?
- Angiotensin converting enzyme
- Angiotensin I (from liver)--> to angiotensin II (stimulates aldosterone [Na+ out of urine back into bloodstream] release)--> increases BP
55
Indications for ACE levels
- Sarcoidosis (elevated ACE)
56
Dx testing for A1AT & ACE
serum level measured
57
What does ANCA stand for & what do they do?
- Antineutrophil cytoplasmic antibodies
- attach WBC antigens causing inflammation & destruction of BVs w/ resultant lung damage
58
Hemoptysis w/ ANCA would be...
- Pneumonia
- Autoimmune dz
- Cancer
- TB
59
ANCA can have what vasculitides affect the lungs?
- granulomatosis w polyangiitis (GPA)
- Eosinophilic granulomatosis w/ polyangiitis (EGPA)
- Microscopic polyangiitis
60
Dx test for ANCA
Biopsy
- staining done for ANCA antibodies
61
Common resp pathogens: viruses
flu, paraflu, RSV, coronavirus, metapneumovirus
62
Common resp pathogens: bacteria
Bordetella pertussis, strep pneumo, s. aureus, mycoplasma, Legionella, Klebsiella, H. flu
63
Less common resp pathogens: bacteria
mycobacterium TB
64
Less common resp pathogens: fungi
histoplasmosis, aspergillus, pneumocystis
65
Hallmark symptoms that make you think Legionella.
pneumonia + GI symptoms
66
Outpt. diagnostics for pneumonia
- clinical dx (fever + productive cough)
- testing (CXR, labs, CBC/BMP)
67
ER diagnostics for pneumonia
1. CXR
2. Labs (CBC/BMP, +/- ABG, blood cultures, lactate)
68
On admission from ED diagnostics for pneumo
3. Urine Antigen: strep pneumo & legionella
Blood antigen: mycoplasma pneumonia
4. Procalcitonin: elevated w/ bacterial infx, not w/ viral
5. sputum culture (gram stain & culture
69
What is procalcitonin?
produced by lung parenchymal cells in response to bacterial toxins
70
What is considered a good sputum culture?
< 10 epithelial cells & >25 polymorphonuclear cells
71
Dx tesing for suspected TB
- CXR
- 3 sputum specimens, at least 8 hrs apart, at least 1 early am (acid-fast stain, NAAT, culture & sensitivities)
- skin test or IGRA--> TB antigens in vitro
72
Disorders that can cause a pleural effusion
- Lung infx, lung cancer, PE
- pancreatitis
- HF
- Cirrhosis
- Nephrotic syndrome
73
Two underlying for pleural effusions
- capillaries leaky (infx/cancer)
- increase rate of osmosis into tissues--> incr hydrostatic pressure or decr oncotic pressure
74
Describe exudative fluid & causes.
- PROs + cells
- think infection & cancer (lung)
75
Describe transudative & causes
- minimal PROs + cells
- Pancreatitis, HF, Cirrhosis, Nephrotic syndrome
76
Contraindications for thoracentesis
- bleeding disorder - relative
- skin infx at site
- low volume effusion
77
Complications of thoracentesis.
- pneumothorax
- Reactive pulm edema (if >1.5L removed)
78
what type of fluid analysis is done via thoracentesis?
- Gram stain & culture
- Cell count & differential
- PRO
- LDH
- Glucose
- Cytology
- Cholesterol
79
Light's criteria: usually exudative if AT LEAST ONE of the following
1. ratio of pleural fluid PRO to serum PRO is >0.5
2. ration of pleural fluid LDH to serum LDH is >.45 (changed from 0.6)
3. pleural fluid LDH level is > 0.6 x the normal upper limit of serum LDH
80
Does the new criteria need a serum sample?
NO, no blood needed
- a lot of cells means a lot of cholesterol
81
Imaging for PE
- CTA chest
- V/Q scan
- Venous US or legs (DVT?)
82
Labs for PE
D-dimer or EKG
83
Note
Use Wells' criteria to help us decide whether to do a d-dimer or go straight to imaging
84
A D-dimer test has a cutoff that is related to what?
- age
- d-dimer tend to go up w/ age
85
what is mostly commonly seen on EKG if pt. has a pulmonary embolism?
sinus tachycardia
86
What is the more uncommon things seen on EKG in PEs?
S1Q3T3 pattern
87
Measure of hypoxemia on ABG: Normal PaO2
80 - 100
88
Measure of hypoxemia on ABG: Mild
60 - 79
89
Measure of hypoxemia on ABG: Moderate
40 - 59
90
Measure of hypoxemia on ABG: Severe
< 40
91
Hypoxemia means there a problem b/t
the nose & alveoli
1. ventilation issue
2. gas exchange issue
92
If the etiology of hypoxemia is unclear, what can help narrow the list of causes?
A-a gradient
93
PAO2 means:
partial pressure of O2 in the ALVEOLI
94
PaO2 means:
partial pressure of O2 in the blood (arteries)
95
Does the A-a gradient vary w/age?
YES
96
A-a gradient calculated vs expected: normal (close to equal) is what type of issue?
ventilation issue
97
A-a gradient calculated vs expected: elevated (calc > expected) is what type of issue?
gas exchange issue
98
What is a bronchoscopy?
endoscopic procedure to visualize trachea & major bronchi
99
Where can a bronchoscopy be done?
bedside or endoscopy suite
100
unilateral wheezing: we should be concerned w/?
FB
101
What part of the anatomy can we perform a bronchoscopy?
central or close to the bronchus
102
What part of the anatomy can we NOT perform a bronchoscopy?
more peripheral: beyond the bronchus (further away; deeper)
103
Bronchoscopy complications
- perforation or injury
- pneumothorax
- problems w/ anesthesia
104
What special procedures can be done during a bronchoscopy?
- bronchoalveolar lavage
- Bronchial brushing
- Biopsy
105
Types of biopsies that can be done during bronchoscopy
- Endotracheal or endobronchial
- Transbronchial needle aspiration (TBNA) of lesions outside of bronchi [often ultrasound guided]
106
Describe Mediastinoscopy
endoscopic procedure to examine mediastinum
107
Mediastinoscopy indications
Lymph node biopsy
- lung cancer staging
- Sarcoidosis
- TB
- Lymphoma
108
Mediastinoscopy complications
- Pneumothorax
- Bleeding
- Esophageal injury
109
What is the entry point for a mediastinoscopy?
- sternal notch
outside tubing of the lungs but inside chest (mediastinum)
110
Indication for biopsy
evaluation of mass or lesion
111
Approach for centrally located mass or lesion
bronchoscopy
112
Approach for peripheral mass or lesion
transthoracic needle aspiration (TTNA)
CT or US guided done by interventional radiology
113
If you are at risk for having lung cancer what is the screening plan?
annual low dose CT
114
What makes a person high risk for lung cancer?
- 55-80yo
- 20+ pk-yr
- hx of smoking
- smoker or quit < 15yo ago
- in reasonable health
115
What patients call for a more aggressive workup?
- known primary cancer
- immunocompromised
- significant smoking history
- FHx of cancer
- suspicious morphology
116
Describe suspicious morphology for lung nodule
>8mm in size
- irregular borders
- semi-solid appearance
- upper lobes
117
What criteria do providers use to assess when a patient needs to do repeat imaging?
Fleischer society
118
NOTE
cancers tend to double in volume every 100-300 days
119
Considerations for lung nodules
- solid vs semi-solid nodules
- Size
- Single vs multiple
- RFs
120
What is a Pancoast tumor?
upper lobe of lungs put pressure on lungs/nerves & you get shoulder pain that doesn't change w/ movement
121
Other symptoms of Pancoast tumors
same side of face
- small pupil
- lack of sweating (Horner's syndrome)
122
Paraneoplastic syndrome
symptoms from secreting hormones (ADH) & ^ Ca++
- rashes
- fluid retention
- v Na+ (hyponatremia)
- ISADH
123
Dx for a more concerning nodule
- sputum cytology
- bronchoalveolar lavage
- bronchoalveolar brushings
- transbronchial needle or transthoracic needle aspiration
- lymph node biopsy
- surgical biopsy
124
What measurement is used to determine obstructive sleep apnea?
apnea/hypopnea index (AHI)
125
How long must a sleep study be?
2 hours
126
How many events must you have to have Obstructive Sleep Apnea?
5 or more apnea/hypopnea events/hour
127
What is mild sleep apnea?
5-15
128
What is moderate sleep apnea?
16-30
129
What is severe sleep apnea?
> 30
130
Obstructive sleep apnea tx
CPAP
131
What can obstructive sleep apnea cause?
HTN
Block 2
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