Pulmonary Medicine PDF

Pulmonary Core Skills and Knowledge - 1/3 of visits to primary care are d/t respiratory complaint - Respiratory conditions are the reason for 25% of medical admissions to the hospital - Pulmonologists provide a large amount of inpatient care (acute PNA, exacerbations of COPD, resp...

Pulmonary Core Skills and Knowledge - 1/3 of visits to primary care are d/t respiratory complaint - Respiratory conditions are the reason for 25% of medical admissions to the hospital - Pulmonologists provide a large amount of inpatient care (acute PNA, exacerbations of COPD, resp failure) - Outpatient care is given in general clinical -- initial investigation and dx of pts with respiratory symptoms - Care is shared with specialist clinics for health promotion and improvement of quality of life for patients - Procedures performed by respiratory physicians - Bronchoscopy - Endobronchial ultrasound scanning - Pleural interventions - Key skills in respiratory medicine - Manage respiratory emergencies - Respiratory failure, massive pleural effusions. Pneumothorax. And large lung-volume hemoptysis - Interpretation of basic exam findings and respiratory investigation s - Chest x-ray, arterial blood gas, and spirometry with confidence - Understand common treatments for respiratory conditions - Inhaled and nebulized medications, home oxygen therapy, and non-invasive ventilation Top 10 respiratory conditions 1. Acute and chronic cough 2. Asthma 3. COPD 4. Pneumonia 5. Pulmonary tuberculosis 6. Pneumothorax 7. Pleural effusions 8. Lung Cancer 9. Bronchiectasis 10. Interstitial lung disease Top 10 Concepts in Respiratory Medicine 1. Smoking cessation 2. Self-management of chronic conditions 3. Admission avoidance 4. Home oxygen therapy 5. Multidisciplinary cancer care 6. Respiratory failure 7. Atopy 8. The 'treatment ladder' approach to asthma and COPD 9. Management of chest drains 10. Dx and staging of lung cancer Thoracentesis: - A process to remove excess fluid from the space between the lungs and the chest wall (pleural space) - Can be diagnostic or therapeutic - Diagnostic -- used to dx a condition - Therapeutic -- remove fluid from a pleural effusion Top 10 Respiratory Medications: 1. Oxygen 2. Beta 2 agonists 3. Antimuscarinics 4. Oral and inhaled corticosteroids 5. Combination inhalers 6. Antihistamines 7. Leukotriene receptor antagonists 8. Mucolytics 9. Monoclonal antibodies 10. Antifibrotics Evaluation of the pulmonary patient: - History - Respiratory symptoms - Cough, sputum production, breathlessness, chest pain, hemoptysis, wheezing - Specify acuity (acute vs chronic), change over time ("is this different than your normal") change in symptoms with location - Systemic symptoms - Weight loss - Malaise - Night sweats - Occupational exposure - All previous occupations, with focus on exposures to asbestos and organic material (hay, mushrooms, cotton, animals) - Establish any relationship of symptoms to work - Smoking - Smoking history -- duration of smoking and number of cigarettes smoked per day - Attempts made to stop smoking, including use of nicotine replacement substances, such as e-cigarettes - Recreational drug use - Anything inhaled - Family history - Respiratory conditions such as emphysema, bronchiectasis or cystic fibrosis - Childhood history - Prematurity, childhood infection such as whooping cough (pertussis) or measles - Travel history - May be relevant is assessing risk factors for tuberculosis (TB) - Physical exam: - Posture -- able to lit fat, sitting up, leaning forward - Color - Ability to speak - Any audile noise associated with breathing -- audible to the naked ear - Respiratory rate - Pain on breathing - Fever - Cachexia - Pupils (Horner's syndrome) - Pursed lips - Central cyanosis - Jugular venous pressure -- raised? Pulsatile? - Used of accessory muscle -- intercostal indrawing (work of breathing) - Hands -- clubbing, Tar staining, peripheral cyanosis Lung Anatomy:  Physical exam -- examination of the chest - Inspection - Color, deformity, breathlessness, scars, asymmetry of movement - Prominent veins, intercostal indrawing, scoliosis - Palpation - Tracheal position - Supraclavicular fossa nodes - Apex beat/apical impulse - Investigate painful areas - Tenderness to palpation -- costochondritis, rib fracture - Accentuate normal chest excursion -- place hands on the patients back with thumbs pointed toward spine - Hands should lift symmetrically - Tactile Fremitus (replaces by vocal resonance) - Normal lung transmits a palpable vibratory sensation called fremitus - Felt with ulnar sides of hands firmly against either side of the spine while the patient says "ninety-nine" - Consolidation -- fremitus is more pronounced - Pleural fluids -- fremitus is decreased - Percussion - Percussion -- technique that makes use of the fact that striking a surface which covers an air-filled structure will produce a resonant note, but over a fluid, a dull sound - Ask pt to give themselves a hug to pull scapula laterally, away from the percussion field - Work down the "alley" that exists b/w scapula and vertebral column - Strip DIP of left middle finger with tip of tight middle finger - Keep remainder of fingers from touching the pt - Goal is to recognize that some points as you move down towards the lung bases., the quality of sounds changes -- this normal occurs when you leave the thorax so you should be able to note where the lower edge of the lung is and it should match both sides - Dull -- consolidation, collapse - Stony dull -- fluid (effusion) - Hyperresonant -- pneumpthorax - Auscultation - Breath sounds -- have different acoustic properties based on anatomical characteristics of the location where you are listing - Bronchial - Arise from the tracheobronchial tree - Loud, harsh, high pitched - Typically heard over the trachea or at the right apex, mostly during expiration - Vesicular - Arise from the finer lung parenchyma - Soft, ow pitched, predominately inspiratory - Appreciated at the posterior lung bases - Adventitious sounds -- sounds heard in additional to expected breath sounds - Crackles (rales) -- Velcro fasteners, rubbing hair b/w fingers - Generated by small airways snapping open on inspiration -- mainly inspiratory - Course -- larger airway, deeper pitched, course crackles - Fine- smaller airway, higher pitched - Rhonchi -- course, loud sounds caused by air movement though constricted larger airways (tracheobronchial tree) - Wheezes -- musical sounds caused by air movement though constricted small airways (bronchioles) - Stridor -- high pitched sound originating from upper airway on inspiration - Rubs -- grating sound coming from inflamed pleura rubbing against one another - Usually inspiratory and expiratory - Confused with crackle but distinguished by the rub's biphasic, localized quality *\*The first trait that assists in the classification of adventitious sounds is whether the sounds are continuous or intermittent.  For example, rhonchi and wheezes are continuous sounds whereas crackles are not. Crackles could be counted by the examiner as discrete acoustic events \[\250ms, constant, like the whirring of a fan\].  The next thing to note is the pitch:  wheezes and fine crackles are high pitched, whereas rhonchi and coarse crackles are low pitched. * *Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.* *Sometimes it\'s helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.* *If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side. Get help if the patient is unable to move on their own. In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine.* *Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.* *What can you expect to hear? A few basic sounds to listen for:* *A healthy individual breathing through their mouth at normal tidal volumes produces a soft inspiratory sound as air rushes into the lungs, with little noise produced on expiration. These are referred to as vessicular breath sounds.* *Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction, secretions, and/or associated mucosal edema. As this most commonly occurs in association with diffuse processes that affect all lobes of the lung (e.g. asthma and emphysema) it is frequently audible in all fields.* *In cases of significant bronchoconstriction, the expiratory phase of respiration (relative to inspiration) becomes noticeably prolonged. Clinicians refer to this as a decrease in the I to E ratio. The greater the obstruction, the longer expiration is relative to inspiration. Occasionally, focal wheezing can occur when airway narrowing if restricted to a single anatomic area, as might occur with an obstructing tumor or bronchoconstriction induced by pneumonia.* *Rales (a.k.a. crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear. Pulmonary edema is probably the most common cause, at least in the older adult population, and results in symmetric findings. This tends to occur first in the most dependent portions of the lower lobes and extend from the bases towards the apices as disease progresses.* *Pneumonia, on the other hand, can result in discrete areas of alveolar filling, and therefore produce crackles restricted to a specific region of the lung. Very distinct, diffuse, dry-sounding crackles, similar to the noise produced when separating pieces of velcro, are caused by pulmonary fibrosis, a relatively uncommon condition.* *Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea\... known as tubular or bronchial breath sounds) to the periphery. In this setting, the consolidated lung acts as a terrific conducting medium, transferring central sounds directly to the edges. It\'s very similar to the noise produced when breathing through a snorkel. Furthermore, if you direct the patient to say the letter \'eee\' it is detected during auscultation over the involved lobe as a nasal-sounding \'aaa\'. These \'eee\' to \'aaa\' changes are referred to as **[egophony]**. The first time you detect it, you\'ll think that the patient is actually saying \'aaa\'\... have them repeat it several times to assure yourself that they are really following your directions!* *Secretions that form/collect in larger airways, as might occur with bronchitis or other mucous creating process, can produce a gurgling-type noise, similar to the sound produced when you suck the last bits of a milk shake through a straw. These noises are referred to as ronchi.* *Auscultation of patients with severe, stable emphysema will produce very little sound. These patients suffer from significant lung destruction and air trapping, resulting in their breathing at small tidal volumes that generate almost no noise. Wheezing occurs when there is a superimposed acute inflammatory process (see above).* *Most of the above techniques are complimentary. Dullness detected on percussion, for example, may represent either lung consolidation or a pleural effusion. Auscultation over the same region should help to distinguish between these possibilities, as consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. Similarly, fremitus will be increased over consolidation and decreased over an effusion. As such, it may be necessary to repeat certain aspects of the exam, using one finding to confirm the significance of another. Few findings are pathognomonic. They have their greatest meaning when used together to paint the most informative picture.* Vocal Resonance: - The assessment of the density of lung tissue, performed by auscultating the chest and asking someone to speak - Increase vocal resonance suggests increased density - PNA, atelectasis, lung mass - Reduced vocal resonance suggests and increase in the amount of air - Pneumothorax, emphysema, hemothorax, pleural effusion, obesity - How to assess - Auscultate the pt's chest, starting at top to bottom, as they perform the following: - Bronchophony -- ask patient to say "blue balloons" or "ninety-nine" - Heard louder over consolidation - Egophony -- ask the patient to say "eee" - "eee" is distorted to "aaa" by consolidation - Whispered pectoriloquy -- ask the patient to whisper "blue balloons" or "ninety-none" - Heard more clearly over consolidation ***Pneumothorax*** *Inspection: Diminished chest movements on the affected side.* *Palpation: Diminished chest movements on palpation. Decreased vocal fremitus on the affected side.* *Percussion: Tympanic note on percussion of the affected side.* *Auscultation: Diminished breath sounds and vocal resonance on the affected side.* ***Pleural effusion*** *Inspection: Fullness of intercostal spaces and diminished chest movements on the affected side. The apical impulse may not be visualized.* *Palpation: Diminished chest movements on palpation of the affected side. Decreased vocal fremitus on the affected side. Trachea may be shifted to the opposite. The apical impulse may not be palpable.* *Percussion: Stony dullness on percussion of the affected side.* *Auscultation: Diminished breath sounds and vocal resonance on the affected side. Egophony may be present on the upper border of the effusion.* ***Consolidation*** *Inspection: Diminished chest movements on the affected side.* *Palpation: Diminished chest movements on palpation of the affected side. Increased vocal fremitus on the affected side.* *Percussion: Dullness on percussion of the affected side.* *Auscultation: Bronchial breathing sounds may be present. Increased vocal resonance on the affected side may be associated with bronchophony and whispering pectoriloquy.*  Forming a Differential by Presenting Symptoms: - Runny nose, nasal congestion, sneezing (rhinorrhea, viral URI, thin secretions) - Cough -- most common symptom of lower respiratory tract disease - Cause by mechanical or chemical stimulation of cough receptors in the epithelium of some portions of the airway - Smoker have cough worse in the am - Productive cough = chronic bronchitis - Dry cough at night = reflux of asthma - Sputum -- 100mL of mucus is produces daily in a healthy, non smoking person - Cigarette smoking is the most common cause of excess mucous production - Yellow or green = presence of cellular material (epithelial or immune cells) - Production of large amounts = bronchiectasis - Hemoptysis - Most common cause is acute infection -- but should not be assumed without investigation - Pink, frothy sputum = pulmonary edema - Massive hemoptysis (\>200mL in 24 hrs) = bronchiectasis or TB, or late stage lung CA - Breathlessness - A sense of awareness of increased respiratory effort that is unpleasant and recognized by the patient as inappropriate - Wheezing - Common complaint and results from airflow limitation d/t any cause - NOT diagnostic of asthma - Can be vocal cord dysfunction, COPD, bronchiolitis - Chest pain - Most common type of chest pain in respiratory disease is localized sharp pain, often termed pleuritic - Made worse by cough or deep breaths and can be localized by the pt A screenshot of a medical report Description automatically generated +-------------+-------------+-------------+-------------+-------------+ | Diff Dx: | General: | Categories | Base Diff | Management | | | | | Dx on: | | +=============+=============+=============+=============+=============+ | Cough | -most | -Acute: | -Acute vs | -all pt | | | healthy | lasting \