(Test Bank) Pulmonary Respiratory Therapy Secrets

Parsons,Heffner, 3

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Author(s): Parsons, Heffner

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Parsons & Heffner: Pulmonary/Respiratory Therapy Secrets 3E PDF version By m_natee Content I. BEDSIDE EVALUATION 1 TAKING THE PULMONARY HISTORY 2 PHYSICAL EXAMINATION 3 SMOKING CESSATION 4 PULMONARY REHABILITATION 5 PULMONARY DISABILITY EVALUATION 6 PREOPERATIVE ASSESSMENT OF THE PULMONARY PATIENT 7 POSTOPERATIVE PULMONARY CARE II. DIAGNOSTIC IMAGING 8 CHEST RADIOGRAPHS 9 COMPUTED TOMOGRAPHY SCANS AND ULTRASOUND 10 PULMONARY ANGIOGRAPHY AND MAGNETIC RESONANCE IMAGING OF THE CHEST III. LABORATORY EVALUATION 11 ARTERIAL BLOOD GASES 12 PULSE OXIMETRY 13 PULMONARY FUNCTION TESTING 14 CLINICAL EXERCISE TESTING IV. PROCEDURES 15 THORACENTESIS AND PERCUTANEOUS PLEURAL BIOPSY 16 BRONCHOSCOPY 17 INTERVENTIONAL PULMONOLOGY 18 CHEST TUBES 19 FLOW-DIRECTED PULMONARY ARTERY CATHETERS 20 MEDIASTINOSCOPY 21 THORACOSCOPY V. AIRWAY DISEASE 22 ASTHMA 23 CHRONIC OBSTRUCTIVE LUNG DISEASE 24 CYSTIC FIBROSIS VI. INFECTIOUS DISEASE 25 COMMUNITY-ACQUIRED PNEUMONIA 26 NOSOCOMIAL PNEUMONIA 27 ASPIRATION SYNDROMES 28 FUNGAL PNEUMONIA 29 PARASITIC INFECTIONS 30 VIRAL PNEUMONIA 31 PNEUMONIA PREVENTION 32 EMPYEMA AND LUNG ABSCESS 33 TUBERCULOSIS 34 ATYPICAL MYCOBACTERIA VII. PULMONARY COMPLICATIONS OF AIDS 35 INFECTIOUS PULMONARY COMPLICATIONS OF HIV INFECTION 36 NONINFECTIOUS PULMONARY COMPLICATIONS OF HIV INFECTION VIII. PULMONARY VASCULAR DISEASES 37 THROMBOEMBOLIC DISEASE 38 NONTHROMBOTIC PULMONARY EMBOLI 39 PULMONARY HYPERTENSION IX. INTERSTITIAL LUNG DISEASES 40 GENERAL APPROACHES TO INTERSTITIAL LUNG DISEASE 41 SARCOIDOSIS 42 IDIOPATHIC PULMONARY FIBROSIS 43 COLLAGEN VASCULAR DISEASE 44 BRONCHIOLITIS, BRONCHIOLITIS OBLITERANS, AND SMALL AIRWAY DISEASE X. VASCULITIS AND IMMUNOLOGIC DISEASES 45 SMALL VESSEL VASCULITIS: WEGENER'S GRANULOMATOSIS, MICROSCOPIC POLYANGIITIS, AND CHURG-STRAUSS SYNDROME 46 DIFFUSE ALVEOLAR HEMORRHAGE XI. VENTILATORY DISORDERS 47 SLEEP APNEA SYNDROMES 48 ALVEOLAR HYPOVENTILATION XII. OCCUPATIONAL AND ENVIRONMENTAL LUNG DISEASES 49 SILICOSIS, COAL WORKERS' PNEUMOCONIOSIS, AND CHRONIC BERYLLIUM DISEASE 50 ASBESTOS-RELATED LUNG DISEASE 51 HYPERSENSITIVITY PNEUMONITIS AND OTHER DISORDERS CAUSED BY ORGANIC AGENTS 52 OCCUPATIONAL ASTHMA 53 DRUG-INDUCED LUNG DISEASE 54 RADIATION INJURY TO THE LUNG 55 INHALATIONAL INJURIES XIII. LUNG NEOPLASMS 56 SOLITARY PULMONARY NODULES 57 LUNG CANCER 58 MALIGNANT PLEURAL EFFUSIONS 59 SYSTEMIC COMPLICATIONS OF LUNG CANCER 60 BENIGN NEOPLASMS OF THE LUNG 61 PULMONARY METASTATIC DISEASE XIV. RESPIRATORY FAILURE 62 ACUTE RESPIRATORY FAILURE 63 ACUTE RESPIRATORY DISTRESS SYNDROME 64 AIRWAY MANAGEMENT 65 TRACHEOSTOMY 66 NONINVASIVE VENTILATION 67 TRADITIONAL INVASIVE VENTILATION 68 ALTERNATIVE INVASIVE VENTILATORY STRATEGIES 69 WEANING 70 CHRONIC VENTILATORY SUPPORT XV. END-STAGE LUNG DISEASE 71 OXYGEN THERAPY 72 LUNG TRANSPLANTATION XVI. PLEURAL DISORDERS 73 PLEURAL EFFUSIONS 74 PNEUMOTHORAX 75 MESOTHELIOMA 75 MESOTHELIOMA XVIII. SPECIAL CONSIDERATIONS 76 PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE I. BEDSIDE EVALUATION 1 TAKING THE PULMONAR Y HISTORY Karen A. Fagan MD 1. What is dyspnea and what causes it? Dyspnea is the subjective sensation of uncomfortable or difficult breathing. Most patients report dyspnea as "shortness of breath." Patients report dyspnea when their breathing is excessive for the activity that they are doing. The sensation of dyspnea is produced by stimulation of both central and peripheral receptors that monitor respiratory muscle activity, hypoxia, hypercapnia, acid-base status, airway irritation, and changes in the pressure volume characteristics of the lung (i.e., j receptors in lung fibrosis or emphysema). There are many systems and conditions that contribute to dyspnea, including cardiopulmonary, hematologic, psychosocial, and environmental (e.g., high altitude) factors; body habitus (i.e., obesity); fever; and level of exercise. Any situation that increases the work of breathing (i.e., airway obstruction or decreased lung compliance) also contributes to the sensation of dyspnea. 2. Give the features of dyspnea that are important to distinguish in the pulmonary and respiratory history Onset: Acute dyspnea is readily recognized by both patient and physician. Subacute/chronic and progressive dyspnea, however, may be more difficult to characterize. Exercise tolerance or limitation over time may be the most useful way to establish the duration of symptoms in these situations. The patient's report of chang es in exercise capacity over time (from months to years) may identify the onset of symptoms. Dyspnea at rest is a late finding in respiratory disease. Positional complaints: Platypnea, shortness of breath experienced upon assuming the upright position, is most commonly seen in patients with hepa tic disease and intrapulmonary shunts. Orthopnea, dyspnea occurring in the supine position, is most commonly a symptom of cardiac dysfunction. Paroxysmal nocturnal dyspnea is also a feature of many cardiac diseases. Occasionally, patients with upper airway lesions may present with complaints of dyspnea or cough while recumbent. Precipitants: Reliable precipitating factors leading to dyspnea include environmental or occupational exposures, exposure to animals, and exposure to inhalational agents (industrial or recreational). Karnani NG, Reisfield GM, Wilson GR: Evaluation of chronic dyspnea. Am Fam Physician 71(8):1529-1537 , 2005 . 3. What questions should be asked about a patient's smoking history? page 11 page 12 Smoking-related lung disease is common; thus, a complete, reliable smoking history, including the following information, is important in the initial assessment of any patient, especially a patient with pulmonary disease: lAge at which smoking began lType of tobacco used lBreaks in smoking history lAmount of smoking (i.e., pack-years, or packs per day multiplied by the number of years smoked) A physician caring for a smoking patient should assess previous attempts at smoking cessation and should determine ways to improve the patient's success. Information should be sought about the presence of other smokers in the patient's environment, the use of suppo rt groups, the use of pharmacologic treatments (i.e., nicotine replacement), and prior input from medical personnel. 4. Which features of the family history are important when asse ssing a patient with respiratory complaints? Page 1 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=S1There may be a hereditary compone nt in several diseases. All patients should be asked about any respiratory diseases or symptoms in first-degree relatives (i.e., those immediately related to the patient). Early age at onset of emphysema may suggest a deficiency in alpha1 antitrypsin. Cough with purulent sputum production and recurrent infections may sugge st a familial form of bronchiectasis (e.g., cystic fibrosis or Williams- Campbell syndrome). Some patients with pulmonary fibrosis may also have familial forms. Approximately 20% of patients with idiopathic pulmonary arterial hypertension have an affected family member. 5. What information should be obtained from a patient who complains of cough? Cough ing is a common complaint of patients. Althoug h cough can be a nonspecific symptom of many diseases, a good history should begin to limit the differential diagnosis. The history includes descriptions of the onset, quality, duration, associated expectoration, presence of other respiratory symptoms, and changes in voice. Cough may be caused by inflammatory, chemical, mechanical, or psychosocial mechanisms. Sputum production is a key feature of cough. Healthy adults gene rally do not expectorate any sputum during the course of the day; thus, sputum production may be considered abnormal. The consistency and color of the sputum may help identify the source because purulent sputum usually correlates with infectious causes. The presence and quan tity of blood are also important. Fetid-smelling, purulent sputum may indicate the presence of an anae robic infection or a lung abscess. Large quantities of sputum (bronchorrhea) can be seen in some malignancies, bronchiectases, and inflammatory airway diseases. Thick, tenacious sputum associated with mucous plugs can be seen in patients with cystic fibrosis and asthma (especially allergic bronchopulmonary aspergillosis). Rarely, patients report expectoration of a chalky or stone-like object, a broncholith, which can be associated with tuberculosis and some fungal infections. The time of day during which the cough is worst may help identify a cause. Sinusitis or sinus drainage may cause a nocturnal or morning cough. Similarly, gastroesophage al reflux may cause symptoms that are worse at night or when the patient is supine. Upper airway obstruction has the same pattern. Cough after exercise may indicate reactive airway disease. Nocturnal coughing may indicate the presence of cardiac disease, especially when associated with paroxysmal nocturnal dyspnea . Cough that occurs during eating may indicate the presence of a tracheoe sophagea l fistula. KEY POINTS: ESSE NTIALS FOR EVALUATING COMPLAINTS OF DYSPNEA AND COUGH 1.Onset (i.e., acute, chronic, or progressive) 2.Precipitants of symptoms (e.g., environmental exposures or allergens) 3.Positional componen t (e.g., lying down, sitting up, or eating) 4.Sputum production (including color, consistency, and presence of blood) page 12 page 13 A careful list of past and present medication use is important in evaluating a cough. Chronic dry cough ing is seen with the use of angiotensin-converting enzyme inhibitors in as many as 20% of patients treated with these antihypertensive agents. Fortunately, the coughing resolves with cessation of the drug. However, chronic dry coughing with dyspnea may also be a feature of the pulmonary fibrosing diseases; thus, the medication history may be important in distinguishing the diagnosis. Aspiration of foreign bodies may also produce both acute and chronic coughing; this possibility should be considered in children with cough and in adults with a history of impaired consciousness. Hoarseness may be associated with laryngeal sources of cough . An often-overlooked cause of chronic cough is hair or wax in the external auditory canal causing stimulation of the vagus nerve. Holmes RL, Fadden CT: Evaluation of the patient with chronic cough. Am Fam Physician 69(9):2159-2166 , 2004 . 6. Which features of an asthmatic patient's history suggest seve re disease that may require more aggressive treatment? If a patient answers yes to any of the following questions, he or she is at increased risk of developing respiratory failure as a result of an asthma exacerbation: Page 2 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=S1lHave you required mechanical ventilation for an exacerbation in the past? lHave you needed to be seen in the emergency department (ED) or to be hospitalized for asthma in the past year? lHave you been treated with oral corticosteroids for asthma in the past? lHave you had an increase in the use of rescue medications (i.e., inhalers) in the past week? lDo you frequen tly wake at night due to your asthma symptoms? http://www .nhlbi.nih.gov/health/prof/lung/asthma/practgde.htm 7. Define hemoptysis. How are the cause and severity assess ed? Hemoptysis is the expectoration of blood with coughing. It is a manifestation of a number of different processes. It is a frightening, occasionally life-threatening complaint that brings patients to medical attention promptly. Most important in the patient interview is assessment of the quantity and quality of blood and the presence of any associated symptoms. Massive hemoptysis is usually easily assessed. It is generally greater than 600 cc in a 24-hour period and can be quite dramatic. More commonly, patients complain of lesser quan tities such as streaks, specks, or clots. It may be difficult to estimate the amount of blood based on such reports. Use of collection containers may be the best way to establish the amount of blood produced. Other associated symptoms, such as fullness in one side of the chest or a tickle in the airway, can occasionally localize the side from which the bleeding is originating. There are numerous causes of hemoptysis. The presence of associated symptoms may help form a differential diagnosis of the cause. Sputum production, especially when purulent, may point to an infectious cause of the hemoptysis. Weight loss and chronic cough in a patient with hemoptysis who smokes may be an indication of malignancy. Tuberculosis may present with similar symptoms in a patient exposed to the mycobacterium. Hemoptysis in a patient with heart disease and dyspnea while recumbent may be caused by pulmonary edema. The presence of chest pain and acute dyspnea may suggest pulmonary embolism. Corder R: Hemoptysis. Emerg Med Clin North Am, 1(2):421-435, 2003. 8. Can the causes of chest pain be reliably differentiated from one another? No. Chest pain arises from several sites in the thorax and surround ing organs. Although there are features that suggest a particular cause of chest pain, it can be frustrating to accurately establish and treat the cause of the chest pain. History alone can rarely identify the cause of chest pain, but attention to the quality, onset, duration, related symptoms, and precipitating and alleviating factors may help the observant historian more carefully evaluate this serious complaint. Chest pain is usually described as pleuritic or nonp leuritic. page 13 page 14 Pleuritic chest pain, or pain arising from the parietal surface of the pleura, usually can be distinguished easily from other chest pain syndromes by history. It is usually sharp and relates to respiratory muscle movements such as inspiration or coughs. It is freque ntly sudde n in onset and may be episodic. Causes of pleuritic chest pain include pneu monia, pleural effusion, pulmonary infarction, chest wall muscle inflammation, rib fractures, pneu mothorax, and inflammation of the pleura in systemic diseases such as systemic lupus erythematosus and rheumatoid arthritis. Nonpleuritic chest pain can be more difficult to characterize than pleuritic chest pain because both pulmonary and cardiac disease may present in similar ways. Classic anginal chest pain with pressure-like pain, radiation to the arm and jaw with associated shortness of breath, nausea, and diaphoresis may be difficult to distinguish from similar symptoms seen in pulmonary hypertension. Careful attention to medical history of other conditions and risk factors for coronary artery disease may distinguish the cause of this type of pain. Other important causes of nonpleuritic chest pain include musculoskeletal, gastroesophageal, pericardial, and aortic disorders. Subdiaphragmatic processes can also present with referred pain to the chest through irritation of the diaphragm and its surfaces. 9. What information should be obtained about potential environmental exposures and occupational history? Page 3 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=S1Two distinct environments may be important in evaluating a pulmonary patient: the home and the workplace. Before a detailed history of either of these locations is unde rtaken, it is important to have a clear unde rstanding from the patient of the primary symptoms and whether they relate to a particular location or activity. A detailed history of potential exposures in the home encompasses the construction, the site, the furnishings, the heating and cooling systems, any damage to the home (e.g., water damage), the presence of carpeting, the type of linens used, and any pets. This information is of particular interest in patients with hypersensitivity syndromes and asthma or other allergic syndromes. The presence of pets and other animals, currently or previously, may contribute to allergic and asthmatic symptoms. Pet birds are frequen tly overlooked in reporting animals in the home, so it is important to ask about these specifically. A detailed occupational history includes all past and current jobs, specific responsibilities at each location, and information regarding chemicals and other hazardous materials at the workplace. It is especially important to ascertain whether respiratory protection was worn and, if so, what type. Documented exposures should be thoroughly reviewed. If necessary, the patient or physician may reque st job descriptions and material safety data sheets from the work site. This is especially important in patients with concern for particulate-induced lung disease or for workers with exacerbations of their respiratory symptoms in the work environment. 10. What is the most important information to obtain when a patient is being evaluated for an abnormal chest radiograph? KEY POINTS: ESSE NTIALS FOR EVALUATING AN ABN ORMAL CHEST RAD IOGRAPH 1.Obtain previous chest radiographs for comparison. 2.Evaluate for associated symptoms such as cough, weight loss, chest pain, or fever. 3.Obtain a smoking and occupational history (e.g., exposures that may increase the possibility of cancer, fibrosis). page 14 page 15 The most important questions to be addressed when a patient has been referred for evaluation of an abno rmal chest radiograph are the following: lDoes the patient have any previous chest radiographs? lAre they available for comparison with the current films? lCan they be obtained? Direct comparison of prior radiographs may establish a lesion as benign or may sugge st that further evaluation is necessary. 11. A patient's wife complains that he snores and stops breathing at night and that he falls asleep at embarrassing times during the day. What else do you want to know about the patient? lDoes he stop snoring for brief intervals in the night? If so, how does he resume snoring? lDoes he ever have quick, jerky limb movements while asleep? lDoes he complain of not sleeping well or of feeling very sleepy during the day? lDoes he freque ntly take naps? lDoes he have headaches in the morning? lHas he experienced sexual dysfunction? These questions may help characterize several sleep disorders, especially obstructive sleep apnea , which can affect as many as 20% of adults in the United States. Although the patient can frequen tly provide adequate information to the interviewer, it is always important to obtain additional data from family and sleep partners because the patient may have frequen t awakenings that do not fully arouse him but that significantly disturb his sleep. Page 4 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=S12 PHYSICAL EXAMINATION Samer Saleh MD Om P. Sharma MD, FRCP 1. Describe the general principles underlying a successful physical examination The physical examination of the chest should be pursued in an orderly manner through inspection, palpation, percussion, and auscultation. The physical examination is not a routine exercise, but rather a systemic intellectual activity that should be pursued logically and diligently. 2. Which clinical signs best indicate respiratory distress? Rapid respiratory rate and the use of accessory muscles of respiration denote the presence of respiratory discomfort. The rate of normal quiet respiration varies from 12-18 breaths per minute. The diaphragm and the intercostal muscles perform respiration. Accessory muscles of respiration include the scalene muscles and the pectorals. During their use, the nostrils flair, the alae nasi contract, and the sternomastoids elevate the clavicles and the sternum. Large changes in intrathoracic pressure during inspiration and expiration produce retraction of the intercostal muscles during inspiration, particularly if tracheal obstruction exists. Patients with advanced emphysema breathe through pursed lips, a maneuver that helps to increase expiratory flow time. 3. What is the significance of paradoxical respiration? Normal respiration is of two types, thoracic and abdominal. Thoracic respiration, performed by the upper part of the chest, is seen in normal women, anxious subjects, patients with ascites, and patients with diaphragmatic paralysis. In men and young children, respiration is abdominal. During normal respiration, the diaphragm moves down in inspiration (seen as outward movement of the abdominal viscera) and upward in expiration. In paradoxical respiration, the diaphragm moves down in expiration and is sucked in during inspiration. This finding represents diaphragmatic fatigue or paralysis and indicates impending respiratory arrest. In ventilated patients, it reflects ventilator-patient dysynchrony and requires either adjustment of the ventilator or sedation of the patient. 4. How can inspection be useful in a patient with a chest disease? The patient with a barrel-shaped chest whose supraclavicular spaces are retracted on inspiration clearly has emphysema. Retraction of the lower lateral chest wall during inspiration in the same patient is a characteristic called Hoover's sign. A tripod sign is present in patients with respiratory distress when they lean forward on both upper extremities to help stabilize the clavicle for the action of the accessory respiratory muscles. The presence of dilated veins on the chest wall is pathognomonic of superior vena cava syndrome. Impaired movement of part or all of the hemithorax may result from pleural effusion, pneumothorax, pleural tumor, or fibrosis. Gynecomastia in a man with cigarette stains on the fingers is a telltale sign of lung cancer. Sharma O: Symptoms and signs in pulmonary medicine. Dis Mon 41:577-640, 1995. 5. Define subcutaneous emphysema Subcutaneous emphysema is the presence of air in the subcutaneous tissues. It may be caused by the following: air leaking from within the pleura, for example, from a pneumothorax; mediastinal air, for example, from a ruptured esophagus; or gas-forming organisms. Subcutaneous emphysema also may be caused iatrogenically from insertion of chest tubes and central lines. page 16 page 17 6. What is Tietze's syndrome? Careful palpation of the chest sometimes reveals costochondral tenderness, often with swelling, which may be the source of unexplained pain in the chest. The condition, also called costochondritis, may be caused by stress or trauma to rib structures at one or more costochondral junctions. Gilliland B: Relapsing polychondritis and other arthritides. In Braunwald E, Fauci AS, Kasper DL, et al (eds): Harrison's Principles of Internal Medicine, 15th ed. New York, McGraw-Hill, 2001, p 2013. Page 1 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C002358667. How is consolidation distinguished from pleural effusion on pulmonary examination? A combination of percussion and auscultatory findings distinguishes consolidation from effusion (Table 2-1). Table 2-1. PHYSICAL FINDINGS IN PULMONARY CONSOLIDATION AND PLEURAL Condition Inspection Palpation PercussionAuscultation ConsolidationRespiratory rate increased; movements decreased on affected sideNo mediastinal shift; tactile (vocal) fremitus increasedDull Bronchial breathing; bronchophony; whispering pectoriloquy; fine crepitations Pleural effusionMovements diminishedIf large, mediastinum shifted to opposite side; tactile (i.e., vocal) fremitus absentFlat or stony dullBreath sounds absent; sometimes bronchial and egophonic above level of fluid 8. Describe egobronchophony Egobronchophony or egophony is a nasal character imparted to the spoken word because of the presence of overtones. It is easily recognized: when a patient says "E," it sounds like "A." Egobronchophony is best heard over an effusion. It represents the area of consolidated or collapsed lung above the effusion. 9. What are rales, crackles, or crepitations? Crepitations sound like bursting air bubbles and indicate that secretions are present. Table 2-2 summarizes the differences between fine and coarse crackles. 10. How is airway obstruction identified? The presence of wheezes or rhonchi is suggestive of airway obstruction. Both are produced by the rapid flow of air through narrowed bronchi. The walls and secretions of the bronchi vibrate between the closed and barely open positions, similar to the way a reed vibrates in a musical instrument. Wheezes tend to be of a higher pitch and a greater intensity than rhonchi, which have a snoring or moaning quality (Table 2-3). page 17 page 18 Table 2-2. DIFFERENCES BETWEEN FINE AND COARSE CRACKLES Features Fine Crackles Coarse Crackles Sound Explosive interrupted sounds (<250 msec); higher in pitch, simulated by rubbing a lock of hair between the fingersExplosive interrupted sounds (<250 msec); lower in pitch, simulated by bubbling liquid Cause Sudden opening up of previously collapsed alveoli and small airwaysSudden opening up of previously collapsed bronchi and large airways; air bubbling through secretions Phase of respiratory CycleEnd inspiration Early inspiration or, often, expiration Effect of coughDoes not clear May clear Settings Pulmonary fibrosis, pneumonia, and heart failureAcute bronchitis, severe pulmonary edema, and chronic bronchitis Table 2-3. DIFFERENCES BETWEEN WHEEZES AND RHONCHI Features Wheezes RhonchiPage 2 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C00235866Sound Continuous (>250 msec), high-pitched musical sound; usually polyphonicContinuous (>250 msec), low-pitched moaning sound; frequently monophonic Cause Vibration of small airways at point of closureVibration of larger airways at point of closure Phase of respiratory cycleAlmost always inspiratory; occasionally expiratoryAlmost always inspiratory; occasionally expiratory Effect of coughMay change with cough Clears, at least temporarily Diseases Asthma or extrinsic compression of airway by foreign body, tumor, or secretionAcute bronchitis; chronic obstructive pulmonary disease; extrinsic compression of airway; or obstruction of the airway by foreign body, tumor, or secretions 11. Which findings in a patient with bronchospasm are most ominous? A silent chest in a tired and lethargic patient with airway obstruction signifies exhaustion and impending respiratory arrest. Previously heard wheezes disappear because airflow velocity is decreased in obstructed airways and no sounds are produced. Such a situation requires prompt intubation and mechanical ventilation. 12. How is the severity of bronchospasm assessed? Although respiratory rate and pulsus paradoxus are useful indicators, they are neither sensitive nor specific enough for assessing the severity of airway obstruction. The only way to reliably measure airway obstruction is by measuring flow rate either by spirometry or by peak-flow meters. page 18 page 19 13. Describe clubbing and name the five most common pulmonary causes of clubbing Clubbing is a bilateral, symmetric fingernail deformity, originally described by Hippocrates. When associated with periostitis and arthritis, this syndrome is called hypertrophic pulmonary osteoarthropathy. Pulmonary causes of clubbing include bronchiectasis, lung abscesses, pulmonary malignancy, cystic fibrosis, and idiopathic pulmonary fibrosis. Clubbing is not a feature of chronic bronchitis, emphysema, or bronchial asthma. KEY POINTS: COMMON PULMONARY CAUSES OF CLUBBING 1.Lung cancer 2.Bronchiectasis 3.Lung abscesses 4.Cystic fibrosis 5.Idiopathic pulmonary fibrosis 14. What is the significance of hypertrophic pulmonary osteoarthropathy (HOA)? Finger clubbing and HOA are different manifestations of the same disease process. HOA includes clubbing, periosteal inflammation, and synovial effusions. The most frequent cause of HOA is lung cancer. Removal of the cancer may result in disappearance of HOA. Martinez-Lavin M: Hypertrophic osteoarthropathy. In Klippel JH, Dieppe PA (eds): Rheumatology. London, Mosby, 1998, p 8. 15. What are the usual clinical signs in emphysema? Patients with emphysema present with a relatively quiet chest that is often barrel-shaped and is diffusely hyperresonant. Breath sounds are vesicular but significantly reduced in intensity. Adventitious sounds are unusual unless there is concomitant bronchitis or asthma. The expiratory phase of respiration is usually Page 3 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C00235866prolonged. Badgett RG, Tanaka DJ, Hung DK, et al: Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J Med 94:188-196, 1993. 16. Which eye disorders are seen in patients with pulmonary diseases? Episcleritis and uveitis may be seen in patients with systemic lupus erythematosus and rheumatoid arthritis. Patients with ankylosing spondylitis and up to 25% of patients with sarcoidosis have uveitis. Optic nerve involvement with gradual progressive visual loss is also seen in sarcoidosis. Bilateral episodic anterior uveitis is a feature of Behçet's syndrome. It is often associated with retinal vasculitis. Keratoconjunctivitis sicca is a feature of Sjögren's syndrome. Choroid tubercles may be seen in patients with tuberculosis. Wegener's granulomatoses may produce lid edema, nasolacrimal duct obstruction, proptosis, and conjunctival chemosis. James DG, Graham E: Oculo-pulmonary syndromes. Semin Respir Med 9:380-384, 1988. 17. Describe the skin findings associated with pulmonary disease See Table 2-4. Sharma O: Selected pulmonary cutaneous syndromes. Semin Respir Med 9:239-246, 1988. page 19 page 20 Table 2-4. SKIN FINDINGS IN PULMONARY DISEASE Skin Finding Description Pulmonary Disease Cyanosis Bluish discoloration of extremities, usually the tips of fingers or lipsAny disease causing hypoxemia, including cardiac disease; seen with peripheral vascular disease. Lupus pernio Chronic bluish granulomatous infiltration of the nose, cheeks, ears, and, sometimes, the lips and chinSarcoidosis Erythema nodosumPainful red nodules occurring mainly on the shinsPrimary tuberculosis, coccidioidomycosis, sarcoidosis, brucellosis, Behçet's disease Lupus vulgaris Reddish-brown, flat plaques with yellowish- brown nodules on the head, face, neck, arms, and legs (in descending order of frequency); ulceration and scarring are characteristicTuberculosis Splinter hemorrhages Psittacosis pneumonia Horder's spots Faint pink spots on the trunk Psittacosis pneumonia Vesicles Clear lesions 2-5 mm in diameter Varicella pneumonia Cutaneous ulcers Tularemia pneumonia Stevens- Johnson syndrome Mycoplasma pneumonia KEY POINTS: FINDINGS ON FUNDUS EXAMINATION OF THE PULMONARY PATIENT 1.Choroid tubercles in tuberculosis Page 4 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C00235866 2.Papilledema in sarcoidosis 3.Retinal vasculitis in collagen vascular disease and Behçet's disease 4.Papilledema and retinal hemorrhages in hypercapneic respiratory failure 18. What are the pulmonary changes in hepatic cirrhosis? page 20 page 21 Pleural effusions, namely hepatic hydrothorax, can occur in up to 10% of patients with liver cirrhosis. They are more common on the right side than on the left side and can occur in the absence of ascites. Spontaneous bacterial empyema can complicate these effusions. Hepatopulmonary syndrome is characterized by hypoxemia, platypnea (worsening dyspnea in the upright position), and orthodeoxia (worsening hypoxemia in the upright position). It results from right-to-left intrapulmonary shunts. Portopulmonary hypertension is pulmonary arterial hypertension in patients with portal venous hypertension. deCampos J, Filho L, Werebe E, et al: Hepatic hydrothorax. Semin Resp Critical Care Med 22:665-673, 2001. 19. What is the BODE index? The BODE index is a grading system that consists of four variables. The B stands for body mass index. The O stands for the degree of airflow obstruction, measured by the forced expiratory volume in 1 second (FEV1) after a dose of albuterol. The D stands for dyspnea, which is measured by the modified medical research council (MMRC) dyspnea scale. The E stands for exercise capacity, measured by the 6-minute walk test. The BODE index has a score of 0-10; the higher the score, the higher the mortality. It is better than the FEV1 at predicting the risk of death from any cause and from respiratory causes among patients with COPD. Celli BR, Cote CG, Marin JM, et al: The body-mass index, air flow obstruction, dyspnea and exercise capacity index in chronic obstructive pulmonary disease. N Eng J Med 350:1005-1012, 2004. 20. What are the neurologic signs of worsening hypercapnia in a patient with COPD? Hypoxia and acute on top of chronic hypercapnia cause many manifestations in patients with decompensated chronic respiratory failure. Headaches, drowsiness, confusion, and coma (in late stages) can occur. Muscle twitching, tremors, and asterixis are some of the motor signs. Papilledema can occur in up to 10% of patients with respiratory insufficiency and reflects the raised intracranial pressure from hypercapnia-induced cerebral vasodilation. Flame-shaped retinal hemorrhages and distended retinal veins can also be seen on examination of the fundus. Jozefowicz RF: Neurologic manifestations of pulmonary disease. Neurol Clin 7:605-617, 1989. Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E (on 12 December 2006) © 2006 Elsevier Page 5 of 5 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C002358663 SMOKING CESSATION Steven J. Kolpak MD Thomas D. MacKenzie MD, MSPH 1. Describe the prevalence of cigarette smoking in the United States in this century Cigarette smoking became the most popular form of tobacco consumption in the 1920s. Per-capita cigarette consumption rose sharply during World War II and eventually peaked in the late 1960s at over 4000 cigarettes per capita per year. The prevalence of cigarette smoking (i.e., the percentage of the adult population who smoke regularly) peaked at 41% and declined annually until 1990 when the prevalence reached 25%. Since then, the decline has been much less rapid, reaching 23% in 2002. The good news is that the prevalence of smoking among high school students has fallen to a new 12-year low after rising steadily in the 1990s. Currently, 22% of high school students have smoked on at least 1 of the last 30 days, down from a high of 36% in 1997. Centers for Disease Control and Prevention (CDC): Cigarette Smoking Among Adults-United States, 2002. Morb Mortal Wkly Rep 53(20):427-431, 2004. Centers for Disease Control and Prevention (CDC): Cigarette Smoking Among High School Students-United States, 1991-2003. Morb Mortal Wkly Rep 53:499-501, 2004. 2. What two questions best assess a patient's level of nicotine dependence? 1.How soon after awakening do you smoke your first cigarette? (Less than 30 minutes after awakening indicates more severe dependence.) 2.How many cigarettes do you smoke per day? (More than 25 indicates severe dependence.) 3. How do you quantify a person's smoking history? Multiply the average number of packs smoked per day by the number of years of smoking to get the number of pack-years of smoking. For example, a 55-year-old woman who began smoking at age 15 and thinks she smoked an average of 1.5 packs (30 cigarettes) per day has a 60 pack-year smoking history (1.5 packs/day × 40 years). 4. Is smoking cessation counseling effective? With intervention, smoking abstinence rates can be significantly increased. There is a strong dose-response relationship between the intensity (i.e., time spent) of counseling and its effectiveness. Brief advice (<3 minutes) increases quit rates by 30%, low-intensity counseling (3-10 minutes) increases rates by 60%, and high-intensity counseling (>10 minutes) increases rates by over 100%. Likewise, the number of sessions included in the intervention shows a positive association with cessation rates. 5. Describe strategies used to promote smoking cessation in a clinical setting Programs that use several modes of repeated counseling and intervention are the most effective for initial and long-term cessation. Interventions include clinician (physician and nonphysician) individualized counseling, telephone counseling, and group counseling. Self-help materials such as pamphlets, cassettes, and videos work best as an adjunct to clinician advice. The use of carbon monoxide testing and pulmonary function testing to give feedback on parameters related to smoking can double quit rates in primary care settings. page 22 page 23 6. List the five A's of smoking cessation counseling The U.S. Public Health Service lists five steps in the provision of office-based interventions (Fig. 3-1). 1.Ask about smoking at every opportunity: Tobacco exposure should be assessed at every office visit as the fifth vital sign. It raises the awareness of smokers, nonsmokers, and office staff to the importance of cessation. 2.Advise all smokers to stop: Physician advice is a powerful and inexpensive tool for smoking cessation, Page 1 of 6 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C00335866especially when given in a "teachable moment" such as an office visit for bronchitis or a tobacco- related hospitalization. 3.Assess the patient's willingness to quit: To tailor counseling to the individual patient, determine his or her readiness to quit and interest in doing so. If the patient is not interested in quitting, provide a motivational intervention (see question 7). Patients interested in quitting should be offered assistance or referred for intensive treatment. 4.Assist patients in the cessation effort: Any health care provider can assist the patient in setting a quit date, which should be scheduled as soon after the initial counseling session as possible. Offer recommended pharmacotherapies (first-line therapies, such as nicotine replacement systems and sustained-release bupropion [bupropion SR], or second-line therapies, such as clonidine and nortriptyline) to all patients unless these are specifically contraindicated. 5.Arrange follow-up: A follow-up visit or telephone call should occur shortly after the quit date, preferably within the first week. A second follow-up is recommended within the first month, with further contact as needed. 7. List the five R's of motivational interventions The following components of clinical interventions are designed to enhance motivation to quit smoking in patients who are not ready to make an attempt at quitting. 1.Relevance: Information should be provided that is relevant to the patient's sociodemographic characteristics, disease status, health concerns, and social situation. 2.Risks: Acute, long-term, and environmental risks should be discussed with the patient. 3.Rewards: The clinician should highlight potential rewards of stopping that seem relevant to the patient. 4.Roadblocks: Barriers to quitting should be elicited. Discuss characteristics of the different treatments that could eliminate these barriers. 5.Repetition: The motivational intervention should be repeated every time an unmotivated smoker visits the clinic. 8. Name the typical nicotine withdrawal symptoms lCraving for nicotine lAnger lRestlessness lIrritability lAnxiety lIncreased appetite lFrustration lDifficulty concentrating 9. In the absence of treatment, how long can the symptoms of nicotine withdrawal be expected to last? Nicotine withdrawal symptoms begin quickly, as soon as several hours after the last cigarette. They generally peak within the first few days and are usually minimal by 30 days. Some smokers, however, complain of tobacco cravings for months or even years after quitting. 10. What happens to pulmonary function tests with smoking? Upon cessation? page 23 page 24 Figure 3-1 The "Five A's" algorithm.Page 2 of 6 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C00335866The forced expiratory volume in 1 second (FEV1) has been used as the primary measure of pulmonary function in several studies. Among all persons over the age of 45 years, the FEV1 declines at a rate of approximately 20 mL/yr as a natural consequence of aging. In the Lung Health Study, patients with chronic obstructive pulmonary disease (COPD) who continued to smoke showed a steeper rate of decline in FEV1 of about 62 mL/yr. Patients who were able to quit successfully reduced their rate of decline to that of nonsmokers. Scanlon PD, Connett JE, Waller LA, et al: Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease-The Lung Health Study. Am J Respir Crit Care Med 161:381-390, 2000. 11. What are some short-term health benefits of smoking cessation? page 24 page 25 1.The excess risk of premature coronary heart disease falls by one-half within 1 year of abstinence. 2.Some of the toxic effects of cigarette smoking that may lead to cardiac events, such as increased platelet activation, elevated carbon monoxide levels, and coronary artery spasm, are immediately reversible with cessation. 3.Pregnant women who stop during the first 3-4 months of pregnancy eliminate their excess risk of having a low-birth-weight baby. 12. What are some long-term benefits of smoking cessation? Data from 50 years of follow-up on male British physicians suggest that 1.Men who stop smoking before age 50 cut their age-specific mortality rate in half and extend their life by 6 years compared to continuing smokers. 2.Men who quit smoking by age 30 have a similar life expectancy to those who never smoked, which is 10 years longer than that of continuing smokers. Doll R, Peto R, Boreham J, Sutherland I: Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 328:1519, 2004. KEY POINTS: FIVE CANCERS CAUSALLY RELATED TO CIGARETTE SMOKING 1.Lung (all types) 2.Oral cavity (lip, tongue, mouth floor, and pharynx) 3.Laryngeal 4.Esophageal 5.Pancreatic 13. How much weight do people gain after they quit smoking? Several studies on the effects of smoking on weight have shown that ex-smokers gain more weight over time than nonsmokers or active smokers. The typical weight gain associated with smoking cessation ranges from 2.5-4.5 kg (5-10 lb). Women tend to gain slightly more weight than men. Genetic predisposition, younger age, and reduced physical activity may increase the risk for weight gain. Rigotti N: Treatment of tobacco use and dependence. N Engl J Med 346: 506-512, 2002. 14. Who should receive nicotine replacement therapy (NRT) when trying to quit smoking? The U.S. Public Health Service recommends that all persons who are ready to make a quit attempt, in the absence of contraindications, should be offered NRT when trying to quit smoking. Fiore MC, Bailey WC, Cohen SJ, et al: Treating Tobacco Use and Dependence: A Clinical Practice Guideline. Rockville, MD, U.S. Department of Health and Human Services, 2000, pp 71-75. Page 3 of 6 Printed from STUDENT CONSULT: Pulmonary/Respiratory Therapy Secrets 3E 12/12/2006 http://www.studentconsult.com/content/printpage.cfm?ID=C00335866