Lecture 1 - Pulmonary Disease - Signs and Symptoms Notes | Knowt (2024)

Five Stations of Pulmonary Disease

  • Airway Problems (ABCs)

    • Asthma

    • Bronchiectasis

    • COPD

  • Alveolar Problems

    • Pneumonia

    • CHF

  • Interstitial Problems

    • Pulmonary Fibrosis

  • Pleural Problems

    • Effusion

    • Pleural Metastatic Disease

    • Thickened Pleura

  • Chest Wall Problems

    • Paralyzed Diaphragm

    • Neuromuscular Disease

      • Polio, Muscular Dystrophy, Amyotopic, Lateral Sclerosis, Lambert-Eaton, Myasthenia Gravis

    • Respiratory Depression

      • Opiate Overdose

    • Obesity

    • Kyphoscoliosis

Airway Problems

  • Air flow obstruction

    • Starts BELOW the vocal cords

  • Landmark: pt will feel that they cannot breathe OUT

Presenting Complaints…

  • Asthma

    • Dyspnea / Cough: YES, dry cough

    • Increased Sputum: Only during exacerbation

    • Hemoptysis: Rare

    • Breath Sounds: Expiratory wheezing

  • COPD

    • Dyspnea / Cough: YES

    • Increased Sputum: Only during exacerbation

    • Hemoptysis: May occur during acute bronchitis

    • Breath Sounds: Expiratory wheezing

  • Bronchiectasis

    • Dyspnea / Cough: YES, with increased sputum

    • Increased Sputum: Most patients report copius sputum

      • No increase or decrease during exacerbation

    • Hemoptysis: Massive hemoptysis can occur

    • Breath Sounds: Expiratory wheezing + Crackles

CXR

  • May be “normal” OR…

    • Hyper-inflated lung fields or advanced bronchiectasis

      • Due to inability to exhale —> AIR TRAPPING

        • FLATTENED DIAPHRAGM

    • Complications like pneumomediastinum, pneumothorax, or associated pneumonia

Presenting Complaints Cont…

  • ABG —> Low PaO2

    • Present with HYPERVENTILATION —> lowers PaCO2

  • Asthma

    • High PaCO2, presenting with HYPOVENTILATION / HYPERCARBIA

    • Sign of RESPIRATORY FAILURE —> possible intubation

      • Bad prognosis

    • Inhaled steroids + bronchodilators (Beta2 agonists)

  • COPD / Bronchiectasis

    • High PaCO2 —> advanced disease and poor prognosis

      • Severe COPD —> COR PULMONALE

    • COPD: bronchodilators + muscarinic receptor (m3 receptor blockers) anticholinergics + inhaled steroids

    • Bronchiectasis: inhaled steroids + bronchodilators (+ antibiotics)

  • Hypoxemia improves on supplemental oxygenation

    • Improved V/Q mismatch

Time and Progression of Disease

  • Disease Onset:

    • PaO2 decreases

    • PaCO2 remains

  • Alveolar Hyperventilation:

    • Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

    • PaO2 less severe decrease

    • PaCO2 decreases

  • Chronic Ventilatory Failure:

    • Point at which disease becomes severe and patient begins to become fatigued

    • PaO2 drastically decreases

    • PaCO2 drastically increases

Alveolar Disorders

Presenting Complaints…

  • CHF [cardiogenic pulmonary edema]

    • Dyspnea / Cough: PND / Orthopnea, Dry cough, Pink frothy sputum

    • Examination: B/L coarse crackles, LVS3

    • Fever: NO

    • Investigation: CXR / ECHO

    • Treatment: Ace inhibitors, diuretics, beta blockers, arrhythmia management, surgery

  • Pneumonia

    • Dyspnea / Cough: Dyspnea, Productive cough, Rust colored sputum

    • Examination: Crackles, Whispered pectoriloquy

    • Fever: YES

    • Investigation: CXR

    • Treatment: Early and appropriate antibiotics

  • Hemoptysis

    • Dyspnea / Cough: Dyspnea + Hemoptysis

    • Examination: Depends on the cause of hemoptysis

    • Fever: Depends on the cause of hemoptysis

    • Investigation: CXR, CT scan of chest, Bronchography, Bronchoscopy

    • Treatment: Control bleeding + treat underlying cause

  • ABG —> Low PaO2

    • Present with HYPERVENTILATION —> lowers PaCO2

  • Hypoxemia improves on supplemental oxygenation

    • Improved V/Q mismatch

  • High PaCO2 [hypercarbia]

    • RESPIRATORY FAILURE —> possible intubation

Congestive Heart Failure

  • Systolic, Diastolic, Valvular Disease

  • Alveolar edema occurs

    • Manifests as dyspnea + frothy blood stained sputum + B/L basal crepitations

    • Advanced: Crepitations (rales) extends throughout the lung fields

  • Lung Field Abnormalities

    • Enlarged heart shadow

    • Cephalization

    • Kerley B lines

    • B/L pleural effusion

    • Pulmonary interstitial edema

    • Pulmonary alveolar edema

    • Consolidation

    • AIR BRONCHOGRAM —> SIGN OF ALVEOLAR DISEASE

Pathogens of the Respiratory System

  • Strep. pneumoniae

  • Haemophilus influenzae

  • Moraxella catarrhalis

  • Mycoplasma pneumoniae

Hemoptysis

  • Expectoration of blood

    • Range from blood-streaking of sputum to the presence of gross blood in the absence of any accompanying sputum

  • Can lead to airway obstruction

    • Massive hemoptysis —> Bronchiectasis, TB, Lung cancer

  • Bronchial arteries are generally the source

  • Most sensitive Dx —> Chest CT Scan

    • Bronchoscopy if CT is neg

  • Causes: BATTLE CAMP

    • Bronchitis, Bronchiectasis

    • Aspergilloma

    • Tumor

    • Tuberculosis

    • Lung Abscess

    • Emboli

    • Coagulopathy, Medications [anticoagulation related]

    • Autoimmune Disorders, Arterial Venous Malformation (AVM), Alveolar Hemorrhage

    • Mitral Stenosis

    • Pneumonia

  • Management:

    • Maintain of airway patency

    • Localize the source of the bleeding

      • CT Scan or Bronchoscopy

    • Control the hemorrhage

      • Bronchoscopy, Bronchial Artery Embolization / Surgery

  • Bronchial Embolization Complications:

    • Spinal cord ischemia / infarction (artery of Adamkiewicz)

      • Supplies majority of the perfusion to the lower thorax and upper lumbar areas of the spine

      • Damage leads to Anterior Spinal Cord Syndrome

        • Loss of power [Paraplegia]

        • Decrease in pain and sensation below lesion

        • Impaired bowel and bladder function

    • Ischemia / infarction of aortic tributaries, leg vessels, renal, bowel

Interstitial Problems

  • Fibrosis-Interstitial Lung Disease

  • Pulmonary Vascular Problem

    • Pulmonary Embolism

    • Pulmonary Hypertension

What is the Interstitial Space?

  • A ‘potential space’

  • Disruption leads to type I respiratory failure

  • Interstitial lung disease (ILD) involves not only interstitial space BUT also the alveoli, bronchioles, and blood vessels

    • Gas exchange does NOT occur

Interstitial Lung Disease (ILD)

  • Early ILD:

    • CXR may be normal

    • Ground Glass

  • CXR Changes:

    • Reticulonodular shadowing

    • Loss of volume

    • Widespread / bilateral

    • Honey Combing

  • DX: ILD with CT

  • Known Etiology:

    • Connective tissue disease

    • Drugs

    • Occupational exposures

Presenting Complaints

  • Pulmonary Fibrosis:

    • Dyspnea / Cough: Dyspnea, Dry cough

    • Examination: Late inspiratory crackles

    • CXR: Early - clear; Later - reticulonodular shadow

    • Investigation: High res CT scan, Lung biopsy

  • Pulmonary Embolism:

    • Dyspnea / Cough: Acute dyspnea, Pleuritic chest pain

    • Examination: Tachypnea, Tachycardia, Normal breath sounds

    • CXR: Clear

    • Investigation: CT Angio

  • Pulmonary HTN:

    • Dyspnea / Cough: Chronic dyspnea

    • Examination: No crackles, Tricuspid regurgitation, Murmur, Ascites, Pedal edema

    • CXR: Clear, except for cardiomegaly

    • Investigation: ECHO - screening, Right heart catheter for confirmation

  • ABG —> Low PaO2

    • Present with HYPERVENTILATION —> lowers PaCO2

  • Interstitial Lung Disease:

    • Hypoxemia improves on supplemental oxygenation

      • Improved V/Q mismatch

    • Pts on PFT restrictive lung disorders

    • Treatment: Steroids, Immunosuppressive agents, Lung transplantation, Pirfenidone (Esbriet), Nintedanib (Ofev)

  • Massive Pulmonary Embolism:

    • Hypoxemia may NOT improve on supplemental oxygenation

    • Treatment: Anticoagulation

  • Pulmonary HTN:

    • Treatment: Diuretic, Pulmonary vasodilator therapy, treat underlying cause

  • CXR may be ‘normal’

Pleural Problems

  • Fluid —> Pleural Effusion

  • Air —> Pneumothorax

  • Tumor —> Mesothelioma

  • CXR: NO AIR BRONCHOGRAM

Presenting Complaints

  • Pleural Effusion:

    • Dyspnea / Cough: Dyspnea, Dry Cough

    • Examination: Dull on percussion, Absent breath sounds

    • CXR: Fluid shows whitish appearance

    • Investigation: Thoracentesis

  • Pneumothorax:

    • Dyspnea / Cough: Acute dyspnea, Pleuritic chest pain

    • Examination: Hyperresonant on percussion, Absent breath sounds

    • CXR: Absent lung markings

    • Investigation: CXR

  • Mesothelioma:

    • Dyspnea / Cough: Dyspnea, Pleuritic chest pain, Weight loss

    • Examination: Dull on percussion, Absent breath sounds

    • CXR: Appears like pleural effusion

    • Investigation: Chest CT scan, Pleura biopsy for Dx

  • ABG —> Low PaO2

    • Present with HYPERVENTILATION —> lowers PaCO2

  • Interstitial Lung Disease:

    • Hypoxemia improves on supplemental oxygenation

      • Improved V/Q mismatch

  • Massive Pleural Effusion:

    • Hypoxemia may NOT improve on supplemental oxygenation

    • Treat underlying cause; Drainage of pleural fluid

    • Pleural Thickening:

      • A complication of longstanding pleural effusion results in fibrotic pleura, which splints the lung and prevents its expansion

      • B/L disease may cause restrictive lung disease, which may require decortication

  • Pneumothorax:

    • Under water seal chest tube drainage

  • Mesothelioma:

    • Chemotherapy

Pneumothorax

  • Primary

  • Secondary:

    • > 60 y/o, structural lung disease (COPD, ILD, bronchiectasis)

  • Traumatic

  • Tension

  • Signs / Symptoms: chest pain on affected side

    • Dyspnea

    • Cough

    • Tachypnea

    • Abnormal respiratory movements

  • Dx: CXR taken on respiration

    • Increased translucency

    • Mediastinal shift to UNAFFECTED side in tension

    • Depressed diaphragm

    • Lung collapse

    • Atelectasis

  • Management:

    • Small: < 15% of thoracic volume

      • Observation and O2 for 6 hours and discharge if no enlargement

    • Large: > 15% of thoracic volume OR pts with respiratory distress

      • Pleural drainage

  • Treatment:

    • Observation with O2 (< 15% and no symptoms)

    • Needle aspiration

    • Chest tube

    • Thoracoscopy / Surgery / Pleurodesis

Primary Spontaneous Pneumothorax

  • Ruptured subpleural blebs or bullae at apices, otherwise normal lung

  • Peak age early 20s, Male, 40% recurrence rate

  • Blebs related to congenital abnormalities, inflammation, and smoking

  • Primary Spontaneous Pneumothorax:

    • Small —> observation and O2

    • If lung does not expand or pneumothorax reoccurs, small bore chest tube

    • If recurrent pneumothorax, thoracoscopy and stapling of blebs

Malignant Mesothelioma

  • Tumor of mesothelial cells in pleura, occasionally found in peritoneum/other organs

  • Majority Hx of Asbestos Exposure

  • Weight loss, Chest pain, Recurrent Pleural Effusions, SOB

  • Dx: histology from pleural biopsy

  • Rx: Symptomatic —> RT and chemo

  • Prognosis: Poor, < 2 yrs

Chest Wall Problems

  • Resulting in poor ventilation

  • Muscular problems

  • Diaphragm

  • Neuromuscular Junction

    • Myasthenia Gravis, Lambert-Eaton Syndrome, Gentamicin Toxicity

  • Neuropathy

    • Guillain-Barre Syndrome

  • Motor Nerve

    • Amyotrophic Lateral Sclerosis (ALS)

  • Spinal cord trauma

  • Syringomyelia

  • Syringobulbia

  • Brain stem disorders

  • Encephalopathy - opiates or sedative overdose

Diseases of the Chest Wall

  • Deformity of thoracic cage such as kyphoscoliosis and ankylosing spondylitis

  • Scoliosis: lateral curvature of spine

  • Kyphosis: posterior curvature of spine

  • External dyspnea, rapid shallow breathing

  • Hypoxemia, hypercapnia, and cor-pulmonale supervene

  • PFTs: Restrictive ventilatory defect with normal diffusion

  • Cause of Death: respiratory failure or intracurrent pulmonary infection

  • Treatment: Treat underlying cause and non-invasive [BIPAP] or invasive chronic ventilation

Neuromuscular Disorders

  • Diseases affecting muscles of respiration or their nerve supply

  • Poliomyelitis, Guillain-Barre syndrome, ALS, Myasthenia Gravis, Muscular Dystrophies

    • All lead to dyspnea and respiratory failure

  • PFTs: Reduced FVC, TLC, FEV1

  • Progress monitored by FVC and blood gasses

  • Maximal inspiratory and expiratory pressures are reduced

  • Treatment: Treat underlying cause and non-invasive [BIPAP] or invasive chronic ventilation

Presenting Complaints

  • ABG —> High PaCO2

    • Present with HYPOVENTILATION —> lowers PaO2

  • Hypoxemia will NOT improve on supplemental oxygenation

    • Improved V/Q mismatch

  • Treatment: Treat underlying cause and non-invasive [BIPAP] or invasive chronic ventilation

  • CXR: Kyphosis or scoliosis, elevated diaphragms

  • PFTs: Restrictive ventilatory disorders with normal diffusion

Lecture 1 - Pulmonary Disease - Signs and Symptoms Notes | Knowt (2024)

References

Top Articles
Latest Posts
Article information

Author: Jonah Leffler

Last Updated:

Views: 6283

Rating: 4.4 / 5 (65 voted)

Reviews: 80% of readers found this page helpful

Author information

Name: Jonah Leffler

Birthday: 1997-10-27

Address: 8987 Kieth Ports, Luettgenland, CT 54657-9808

Phone: +2611128251586

Job: Mining Supervisor

Hobby: Worldbuilding, Electronics, Amateur radio, Skiing, Cycling, Jogging, Taxidermy

Introduction: My name is Jonah Leffler, I am a determined, faithful, outstanding, inexpensive, cheerful, determined, smiling person who loves writing and wants to share my knowledge and understanding with you.