Pulmonology Exam II (Sandy PE, Pleural Effusions, Pneumothorax only)

This is the 3rd MC cause of death in hospital patients

pulmonary embolism

1st MC cause of death in hospital patients

Pneumonia

What can precipitate a PE?

Virchows triad (and many more)

What is the MC ddx of a PE

anxiety

1. Surgery > 30 min

2. long bone fracture

3. pregnancy and prolonged vaginal delivery

4. CHF, CVA, immobilized patients

5. BCP's and smoking

ALL of these make you ______?

hypercoagulable

Inflammatory disorders trigger cytokines and cytokines can make you ________. For example Crohn's disease or ulcerative colitis can present with pleuritic chest pain.

hypercoagulable

What is the MC inherited predisposition for a PE?

Factor V Leiden

If a patient develops a DVT or PE out of no where with no risk factors, what should be recommended to the patient?

Genetic work up to make sure they dont have a predisposition to form clots

Occurs when venous thrombus becomes dislodged from its site and enters the pulmonary circulation

Embolization

Half of all patients that have a DVT, had a _____ and they are totally asymptomatic. Why?

PE; bc they got reabsorbed which is good bc they're very small

You most commonly get a DVT's that embolism when they are ______ (location). A DVT at this location has a much higher chance of embolisation.

above the knee

MOST PE's arise from ________ veins of the leg but can also happen in __________

large deep veins; upper extremities

Patient has been sitting in the hospital not moving and you notice that his right arm is tremendous and his left arm isn't. How do you evaluate the patient ? What is the dx?

Doppler

UE PE

This is the MC to embolize into the pulmonary circulation and originates in the deep veins of the calf

Thrombus formation

What should you do if you meet resistance when flushing a central line in the IJ? What is the risk of this?

Inject with TPA. There could be a clot or vegetation, and if you continue pushing it, it will go straight to the right side of the heart and into the pulmonary circulation, causing a PE

This type of embolisms can be seen in patients with pelvic fractures or long bone fractures that cause sheering of blood vessels and patients present with petechial rashes.

Fat embolism

When you see a patient with acute tricuspid endocarditis, what type of patient should you be thinking about and what type of embolism ?

IV drug abusers

Septic emboli

What is the MC cause of death from PE?

Right ventricular failure

Large PEs cause an inc/dec pulmonary vascular resistance and airway resistance

_______ gas exchange

alveolar hyper/hypoventilation

inc/dec pulmonary compliance

___V failure

increased pulmonary vascular resistance and airway resistance

impaired gas exchange

alveolar hyperventilation

decreased pulmonary compliance

RV failure

A PE is very difficult to diagnose clinically because SxS are not specific and depend on?

Size of emboli

What are the 3 MC signs/symptoms of PE?

Dyspnea (most common symptom - most MC)

Tachypnea (most common sign)

Chest pain (pleuritic)

What are some other sxs of a patient with a PE ?

-syncope

-hypotension

-cyanosis

-anxiety

-hemoptysis

-Tachycardia (one of the most specific findings)****

-Low grade fever (inflammatory markers)

-JVD

Usually with a PE, the HR is greater than ?

> 90 bpm

What is the classic EKG finding of PE (recall, this does not occur in all cases)?

S1Q3T3

Significant hypoxia in a patient with a negative CXR should make you suspicious of ____

PE

Although ABG has 0 predictive value for PE, what ABG findings might you see in a patient with a PE?

Respiratory alkalosis due to hyperventilation

Which blood test should always be checked in a patient suspected of having a PE?

D-dimer

D-dimers are great test to show _______ and are useful but they are 97% _______ and not specific so they are so diagnostic

clotting; sensitive

what 2 other things can throw ddimers our of wack? (that weber said)

- recent surgery (ex: tummy tuck 3 weeks ago, comes in with CP)

- covid

A patient has a negative D-dimer and has no risk factors, do you still have to work them up for a PE?

ehh maybe study say that you can let it go (This test has to fit the patient appropriately)

Are chest X-ray good for diagnosing PE?

not really but they do help you

A patient that is in severe distress with hypoxia, chest pain , SOB, tachypnic and pulse ox at 89% on room air and HR is 110 with clear chest x-ray. What should you be suspicious for?

PE because we dont see a lot PE on chest x-ray

Normally CXR will be normal but what is the MC finding on a CXR with a PE ? What else can you see on CXR?

Pleural Effusion with blunting of costophrenic angle (specifically unilateral) - MC

atelectesis (68%)

hemidiaphragm elevation (24-50%)

Focal vasoconstriction distal to an embolus seen on CXR

Westermark sign

What condition is Westermark sign associated with?

PE

Peripheral wedge-shaped density above the diaphragm pointing to the hilum seen on CXR

Hampton's hump

What condition is Hampton's hump associated with?

PE (specific for PE)

Enlarged right descending pulmonary artery seen on CXR

Palla's sign

What condition is Palla's sign associated with?

PE

what is used to evaluate the deep venous system of the lower extremity to rule out DVT?

venous ultrasonography - its not the best test for PE but it's a quick way to know what's going on

Nuclear medicine scan that uses radioactive material to examine airflow (ventilation) and blood flow (perfusion) in the lungs

VQ scan

An abnormal VQ scan is indicative of what condition?

PE

What is the gold standard for diagnosing a PE that can detect emboli 1-2 mm. It is safe but very invasive because it can cause renal dysfunctions.

Pulmonary angiography

(but we dont use it much even tho its the gold standard due to it being very invasive)

What do we utilize more when diagnosing a PE ?

CT pulmonary angiography (CT-PA)

If you cannot utilize a CT-PA due to whatever reason, what test would be the next best to use to evaluate a PE?

V/Q scan

If creatinine is >_____, IV contrast shouldn't be used

>1.5

Patient with creatinine of 3.2 and concerned about PE what's the diagnostic test of choice?

V/Q scan because it DOES NOT USE CONTRAST

______ is comparable to VQ scan for the DX of PE

spiral CT

what is used for rapid triage for acutely ill pts who may have PE?

it can differentiate bw MI, pericardial tamp, aortic dissection, and PE with R sided HF

Echo

common rxns to pulmonary angiography

allergic

renal dysfunction

arrhythmias

IF a PE is likely and a CT-PA is positive what does this mean?

PE confirmed

If a PE is likely and a CT-PA is negative what does this mean?

PE excluded

If a PE is unlikely and a D-dimer assay is <500 ng/mL what does this mean?

PE excluded

If a PE is unlikely and the D-dimer Assay is >500 ng/mL, what must be done next?

CT-PA to r/o PE

What are the Well's criteria for determining a patient's likelihood of a PE?

Holy Hell I Have My Crappy Pulm exam

HR > 100 (1.5 points)

History of DVT or PE (1.5 points)

Immobilization (1.5 points)

Hemoptysis (1 point)

Malignancy (1 point)

Clinical s/s of DVT (3 points)

PE more likely than anything else (3 points)

Based on the Well's criteria, what is the classification of low, moderate and high risk for PE?

Low risk = less than 2 points

Moderate risk = 2-6 points

High risk > 6 points

True/False

HR is one of the BIGGEST thing's weber looks at (HR of 115 with chest pain, dyspnea = CONCERNED)

true

What are the PE Rule out Criteria (PERC rule)? weber likes this

Always HeR Out Here ExPecting US ... have to fulfill all of these to be considered low risk

Age < 50

HR < 100

Oxyhemoglobin > 95%

NO.......

Hemoptysis

Estrogen use

Prior history DVT/PE

Unilateral leg swelling

Surgery or trauma requiring hospitalization in the last 4 weeks

To prevent a PE we can start a patient on heparin or ______ and monitor their INR. Once INR get to _____ we stop both.

Lovanox

2-3

Patients with recurrent PEs despite anticoagulation and fall risks should receive a ________ to prevent future PE

Greenfield filter/ IVC filter

How do we tx a patient with a PE?

Start heparin to lyse the clot followed by at least 6 months of Coumadin (other anticoagulants as well)

(he doesn't like to put anyone on Coumadin because their INR needs to be monitored)

Goal of tx for PE is to maintain an aPTT of ________ x normal control

2-2.5 x

which medication do we use for PE in which thrombocytopenia is less common, there'e no need for coagulation monitoring, and is great for home based tx of PE?

low molecular weight heparin - lovanox

Goal of tx for PE is to monitor plt count bc of risk of

thrombocytopenia

What should you monitor with pts are on coumadin?

what should you beware of?

what should you keep the INR at?

monitor PT and INR

beware of vitamin K

keep INR at 2.5

IIf the INR gets too high bc of too much coumadin, what can you do?

give vitamin K!! bc its the reversing agent of coumadin

start coumadin while on heparin for _____ days. why?

5-7 - bc it takes 5-7 days for coumadin to become therapeutic

This drug, among others, are preferred over Coumadin now, because they work better and do not require monitoring

Xarelto (cost is the problem)

What medication is used to tx PE has the best safety profile and lowest chance of bleed with better compliance. No monitoring required and do have reversal agents. The only problem is the cost of these medications.

Eliquis or pradaxa

what is TPA seen with increased risk of?

hemorrhage

how does tpa work?

it stops clotting throughout the whole body

When do we TPA patients with a PE?

We dont use it unless the patient is literally on deaths doorstep typically last resort for patients with a saddle embolism because the risk of bleeding is so high (double edge sword

what are 2 absolute contraindications of tpa?

major contraindications?

Active internal bleeding, stroke with in 2 months

Uncontrolled HTN, surgery or trauma with in 6 months

Fluid accumulation between the parietal and visceral pleura (pleural space)

Pleural effusion

Since there is too much fluid with a pleural effusion, it causes?

pleuritic pain

SOB

decrease breathe sounds

What are the 5 major types of pleural effusion?

1. Transudate

2. Exudate

3. Empyema (pus)

4. Hemorrhagic (blood)

5. Chylous (lymph)

Normal Pleural fluid is... MUST KNOW

1. Clear, pH ________

2. Protein content less than ____

3. _______ WBCs per cubic mm

4. Glucose content similar to _______

5. LDH level _____ of plasma

6. Na+. K+ and Ca2+ concentration similar to __________

1. Clear, pH 7.60-7.64

2. Protein content less than 2%

3. < 1000 WBCs per cubic mm

4. Na+. K+ and Ca2+ concentration similar to interstitial fluid

5. Glucose content similar to plasma

6. LDH level <50% of plasma

This is the Lytes criteria for distinguishing an exudate from a transudate.

1. Pleural fluid protein: serum ratio >____

2. Pleural fluid LDH: serum ratio > _____

3. Pleural fluid LDH > _____ the upper limit of normal serum LDH

1. Pleural fluid protein: serum ratio > 0.5

2. Pleural fluid LDH: serum ratio > 0.6

3. Pleural fluid LDH > 2/3 the upper limit of normal serum LDH

Exudate will have one or more of the following, while transudate will have NONE of these

1. What is the normal pH of pleural fluid?

2. Inside the pH range you're probably looking at a ______ disease.

3. Outside of the pH range you're probability looking at an _______ disease.

1. 7.60- 7.64 (normal)

2. Transudative

3. Exudative

What is the MC cause of transudative effusion?

What is the MC cause of exudative effusion?

Transudate = CHF

Exudate = Pneumonia

- CHF

-Nephrotic syndrome

-Cirrhosis and Ascites

-Peritoneal Dialysis

-Constrictive Pericarditis

-Superior vena cava obstruction

-P.E (can go both ways)

What are these considered, transudate or exudate ?

transudative

- Pneumonia

- Cancer, P.E

- Empyema, T.B

- Viral , Fungal or Rickettsial infection

- Pancreatic disease (amylase & lipase)

- Asbestos, Sarcoidosis

- Post-MI syndrome

What are these considered, transudate or exudate ?

Exudate

What does it mean when weber said a PE is noncommittal

it cant commit to either transudate or exudate because it can be hemorrhage which falls under exudate

(he said to be very careful with this)

If there is a mix of pleural fluid and blood that clears with each tube that you fill are we concerned about it?

no probably some minor trauma

Grossly bloody plural fluid that continuously fill each vile with blood are we concerned? Why?

Yes because it can be due to trauma, cancer, PE

what does empyema look like??

Purulent and turbid

what does a hemorrhagic effusion look like??

Mix of blood and pleural fluid

what is a chylous effusion due to? what does it look like?

Due to disruption of the thoracic duct

Milky, cloudy fluid

How do we tell the difference between a chylous effusion and an empyemic effusion?

Centrifuge it. If it separates, it is empyema. If it does not separate, it is chyle

What are the symptoms of pleural effusion... Think about it ....

1. If we continuously pour fluid into a small space in the lung and cause compression of the lung, what will this cause?

2. What are you going to hear?

3. On percussion it would be?

4. Do you always have pain?

5. Do you always have a tracheal shift?

6. What test will be positive?

1. Dyspnea (MC) and coughing

2. Crackles

3. Dullness

4. No always but can have pleuritic chest pain

5. Not always but can if its a large effusion

6. Egophony (eee to aaa)

When will there be a tracheal shift with pleural effusion

if its a very large effusion

What is the MC sign of pleural effusion?

dyspnea (this is also the MC sign of PE!! yay)

Greater than ____ cc of fluid must be present on thoracentesis in order for a pleural effusion to be detected on CXR

250 cc

If you TAP a patient and drain their chest, at ____ cc we must stop draining because we can cause hypotension. Stop it, clap it, let them recover for an hour and then continue.

800 cc

Meniscal line on CXR is indicative of ____

Pleural effusion

______ labs will look like this

1. Normal protein, pH (7.63) and LDH

2. WBC < 1,000

3. Glucose= serum glucose

also clear

transudate

_______ labs will look like this

1. Presence of malignant cells

2. Positive culture

3. pH < 7.30

4. Low glucose

5. increase amylase

(bloody or cloudy)

exudative labs

These types of illnesses are very common with effusions on the left side of the chest due to their ducts actually drains into the thorax at the thoracic duct. If you test ______, it will be positive with these.

Pancreatitis and pancreatic cancer

Amylase

When we tx pleural effusions we must tx the ?

underlying disease

Since the MC of transudate effusions is CHF, how do we tx CHF normally?

Diuretics- decrease hydrostatic pressure below the oncotic pressure so the fluid goes into the vessels and we pee it out

(simple, no need to memorize lol)