persistent pulmonary HTN

RVH

COPD

Remember, most frequent cause of right sided HF is LEFT sided HF

1. RVH on EKG

2. exertional dyspnea

3. chronic productive cough

4. cyanosis

5. hepatomegaly

6. dependent edema

7. JVD

smoking (90%)

environmental exposures 

age 55-74, >= 30 pack yrs, smoking cessation < 15 

OR

age >= 50, >= 20 pack rys, 1 additional risk factor

adenocarcinoma (35-40%)

squamous cell (25-30%)

large cell (10-15%)

non-small cell (adeno, squamous, large cell)

small cell (10-15%)

carcinoid (<5%)

anorexia/weight loss/cough/hemoptysis

highest rates amoung non-smokers/women

#1 in smokers

peripherally located on CXR/CT

anorexia/weight loss/cough/hemoptysis

95% occur in smokers

centrally located on CXR/CT

Paraneoplastic syndrome  - hypercalcemia, PTHrP production from tumor

Pancoast - SVC syndrome, horner syndrome

anorexia/weight loss/cough/hemoptysis

diagnosis of exclusion

usually peripheral location 

"oat cell" carcionma

paraneoplastic syndromes - SIADH, ATCH, lambert-easten myasthenic syndrome

slow growth

located in GI and lung

centrally located & proximal bronchi

shape 

• irregular
• smooth (type 1)
• lobulated (type 2)
• spiculated (type 3)
• corona radiate (type 4)

location --> usually in upper lobes

Attenuation - ground glass opacity, semisolid, solid

<= 4 mm = annual CT x 3 yrs

> 4-6 mm = CT in 6 months

>6-8 mm = CT in 3 months

> 8mm = PET/CT, possible bx

follow growth - malignant usually double in size every 20-300 days, benign usually double in size either < 20 days (really fast) or >450 days (really slow)

1.  recurrent/chronic lung infections. H. flu MC if not d/t CF; pseudomonas MC if d/t CF
2. hereditary: CF MCC of bronchiectasis in US
3. obstruction: FB aspiration, tumors, severe mucous 

1. daily chronic cough w/ thick mucopurulent (foul smelling) sputum
2. hemoptysis. d/t erosion into bronchial a.  
3. persistent crackles @ bases common. 

bronchiectasis

acute bronchitis & lung Ca MCC of hemoptysis in general

high resolution CT scan

• airway dilation
• lack of tapering of bronchi
• bronchial wall thickening (tram-track apperance)
• mucopurulent plugs
• consolidations
• signet ring sign -pulm. a. coupled w/ dilated bronchus

1. pseudomonas: MC d/t CF
2. mycobacterium avoid complex (MAC) clarithromycin + ethambutol 
3. aspergillus: allergic bronchopneumonia. Thick, brown sputum.  Management: steroids + itraconazole. Sx if sxatic aspergilloma

1. abx: cornerstone. 

• Empiric (Ampicillin, Amox, bactrim)
• Pseudomonal (Fluoroquinolone, Zosyn, Aminoglycoside, Cephalosporin)
• Azithromycin has anti-inflammatory properties

2. Mucus management / chest physiotherapy : bronchodilators, anti-inflammatory; surgery, embolization for bleeding

3. Surgery resection (or transplantation) in severe

idiopathic pulmonary fibrosis (fibrosing interstitial pneumonia)

dyspnea and/or nonproductive cough 

usually gradual onset

CXR/CT scan: diffuse reticular opacities (honeycombing)

ground glass opacities 

BX: honeycombing - large cystic airspaces from cystic fibrotic alveolitis

restrictive dz: decreased lung volumes (decreased TLC, RV)

normal/increased FEV1/FVC

decreased DCLO

smoking cessation, O2 therapy

lung transplant only cure

1. spontaneous pneumo: (atraumatic & idiopathic) believed to be ruptured bleb
2. traumatic
3. tension: + air pressure pushes lungs, trachea, & heart to contralateral side. needle aspiration 2nd ICS MCL followed by chest tube thoracostomy

Primary: no underlying lung dz: mainly affects tall, thin men 20-40y, smokers, fam hx

Secondary: underlying lung dz w/o trauma (ex COPD, asthma), menstruation (catamenial)

1. increased hyperresonance
2. decreased fremitus
3. decreased breath sounds
4. unequal respiratory expansion
5. tachycardia & tachypnea
6. hypotension
7. Tension PTX: increased JVP, pulsus paradoxus

CXR w/ expiratory view preferred

+- companion lines

decreased peripheral lung markings

deep sulcus

1. observation if small <20% often closes spontaneously
2. chest tube placement (thoracostomy); if large PTX
3. needle aspiration if tension PTX followed by chest tube placement. Needle placed in 2nd ICS @MCL of affected side
4. Avoid high altitudes, smoking, unpressurized aircraft, and scuba diving 

viruses

(adenovirus, parainfluenza, influenza, coxsackie)

bacteria 

(S. pneumoniae, H. influ, M. cat, Mycoplasma)

similar to pneumonia

Hallmark is cough (+- productive & may last 1-3 wks)

Diagnosis is usually clinical

1. symptomatic tx of choice: fluids, rest, antitussive agents +- bronchodilators
2. abx no statistical benefit in healthy pts (abx +- beneficial in elderly, COPD, IC or who don't respond to conservative tx)

coal workers' pneumoconioses

silicosis

asbestosis

simple - pneumoconioses usually asxatic

severe - dyspnea, inspiratory crackles, clubbing of fingers, cyanosis

PFT - restrictive dsyfunction & reduced diffusing capacity 

CXR 

1. primarily supportive as no efective tx is available.  O2, vaccinations (pneumococcal, influenza), rehab
2. steroids may relieve the chronic alveolitis in silicosis
3. smoking cessation especially important w/ asbestosis because somking interfers w/ short asbestos fiber clearance from the lung.  Smoking and asbestos are synergistically linked to lung cancer, especially mesothelioma