Pulmonary System

Question 0

Empyema

Answer 0

• Infected pleural effusion
• Needs to be drained
• Usually drained with a chest tube
• Decortication if the empyema is solid

Question 1

Post-op Pneumonia

Answer 1

• Atypical= mycoplasma, legionella, chlamydia
• Hospital acquired= gram neg rods, staph, anaerobes
• Aspiration= anaerobes
• Sx: sudden onset, fever, productive cough, dyspnea, night sweats, pleuritic chest pain. Atypical= gradual onset, dry cough, HA, myalgia, sore throat, GI sx.
• PE: decreased bronchial breath sounds, rales, wheezes, dullness to percussion, egophony, tactile fremitus.
• Dx: PE, CXR, CBC, sputum gram stain/culture, nasopharyngeal aspiration, blood culture, ABG.
• Tx: IV Abx (extended spectrum cephalosporin or carbapenem, add aminoglycoside or FQ for coverage of resistant organisms).
• Complications: pleural effusion, empyema, lung abscess, necrotizing pneumonia, bacteremia.

Question 2

Pleural Effusion

Answer 2

• Fluid in the pleural space
• Caused by: infection, CHF, SLE/RA, pancreatitis, trauma, pulmonary embolism, renal disease, cirrhosis, malignancy, postpericardiotomy
• Sx: dyspnea, pleuritic chest pain, decreased breath sounds, dullness to percussion, egophony
• Dx: Thoracentesis
• Tx: pigtail catheter, thoracostomy

Question 3

Pneumothorax

Answer 3

• Collapse of lung with air in pleural space
• Tension PTX= dyspnea, JVD, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from the affected side, hyperresonance on the affected side.
• CXR= air w/o lung markings is seen outside the white pleural line.
• Need to give pt supplemental O2-PTX is almost all Nitrogen so will increase the nitrogen gradient causing the PTX to resolve faster.
• Tx: Rapid thoracostomy incision-OR-needle thoracostomy in the 2nd intercostal space midclavicular line followed by tube thoracostomy(chest tube).
• Chest tube: 1) suction until PTX resolves 2) water seal for 24 hrs 3) remove chest tube if no PTX or air leak is present after 24hrs.
• Can occur after placement of central line-always need a CXR after placement.
• Spontaneous: atraumatic, occur in tall/thin, dx with CXR, tx with chest tube.

Question 4

Lung Neoplasms

Answer 4

-Nodules- seen on CXR
-Benign: 45-50yo, smoker, new/enlarged lesion, absent/irregular
calcification, irregular margins, >2cm

• Cancer= leading cause of cancer death in US
• Small cell(SCLC): highly correlated with cigarette exposure, central location, neuroendocrine origin, mets usually found on presentation in intrathoracic and extrathoracic sites (brain, liver, bone)
• Non-small cell(NSCLC): most common are adenocarcinoma, SCC, large cell carcinoma. Less likely to metastasize at early stage.
• Adenocarcinoma: Most common lung cancer, peripheral
• SCC: central location
• Large cell: least common
• Nodules: asx or have chronic cough, dyspnea, and SOB.
• Cancer: cough, hemoptysis, dyspnea, wheezing, pneumonia, chest pain, wt loss, possible abnormal resp exam.
• Dx: CXR or CT, FNA for peripheral lesions, bronchoscopy for central lesions
• Tx: Nodules= Surgical resection of nodules that are high risk for malignancy. Otherwise follow with CXR or CT every 3 mos for 1 yr, then every 6mos. SCLC=radiation and chemo. NSCLC= Surgical resection in early stages.

Question 5

Pulmonary Emboli

Answer 5

• DVT embolizes
• RFs: post op, trauma, paralysis, immobility, CHF, obesity, BCP/tamoxifen, cancer, advanced age, polycythemia, MI, HIT syndrome, hypercoagulable state.
• Sx: SOB, tachypnea, hypotension, chest pain, fever, loud pulmonic component of S2, hemoptysis.
• Labs: decreased PO2 and PCO2 due to hyperventilation
• Dx: CT angiogram, VQscan, pulmonary angiogram is TOC.
• CXR= Westermarks sign (cant see pulmonary vessels)
• EKG= flipped T waves or ST depression
• Tx: If stable= anticoagulation(heparin then coumadin) or Greenfield filter (placed in IVC via jugular vein). If unstable= thrombolytic therapy.

Question 6

Penetrating Lung Trauma

Answer 6

• Presentation: chest pain, hemoptysis, tenderness, bruising, back pain, difficulty breathing, deformed chest, fainting, trouble swallowing, abdominal pain.
• Dx: CXR, CT.
• Tx: Surgery, chest tube, intubation, mechanical ventilation

Question 7

Blunt Lung Trauma

Answer 7

• Most common cause is MVA
• More common in kids because less protection from chest wall
• Sx: pain, shock, respiratory distress, hemoptysis, sternal tenderness, subcutaneous emphysema
• Dx: CXR- large PTX or pneumomediastinum
• Tx: intubation, mechanical ventilation, chest tube.

Question 8

What kind of sounds will you hear with stethoscope in a PTX?

Answer 8

-hyperresonance