胸腔內科

COPD

定義

1.a common preventable and treatable disease
2.persistent airflow limitation which is usually progressive caused by airway &parenchymal inflammation
永久性的氣流限制，因呼吸道和肺實質的發炎所造成

  1. emphysema vs. chronic bronchitis(2-5)
    -emphysema:肺實質的擴張/破壞，沒有fibrosis(病理學定義)
    -chronic bronchitis:帶痰咳嗽持續>=連續3個月/年 for 連續至少2年，且無其他肺部疾病可解釋這個症狀(臨床定義)

- 病程: 咳嗽、痰→喘→呼吸困難→呼吸衰竭→死亡

Diagnosis and assessment=1+2+3

1.symptoms
-長期cough,有痰,dyspnea(DOE,逐漸惡化),wheezing->後期:經常惡化發作(exacerbation),早晨頭痛,weight loss
-Cough(progress over time，exertional ，persistant)
-chronic cough(may be intermittent and may be unproductive)
-chronic sputum production(any pattern of chronic sputum production may indicate COPD)
2.expose to risk factors:
-抽菸
-環境和職業暴露物質:粉塵,chemical,揮發性物質,氣體
-alpha-1 antitrypsin deficiency(1-2%COPD):(1)early onset(45歲以下) (2)沒有抽菸 (3)有肺臟病家族史 or (4)lower lobe predominant
emphysema
3.肺功能測試
-所有有症狀 or 無症狀但有COPD危險因子且persistant airflow obstruction者應執行測試
-post bronchodilator FEV1/FVC<0.70 confirm the presence of airflow limitation is not fully reversible
-ABG
4.physical examination
-除非FEV1<50%(肺功能嚴重障礙)，不然理學檢查徵象通常不存在
-桶狀胸，hyperresonance，呼吸音↓，吐氣期↑，rhonchi or wheezing may or may not be present
-惡化時:呼吸急促，使用輔助肌，奇脈，發紺


Therapeutic options-->分成A,B,C,D四類病人 ⭐

-確診後先評估嚴重程度 ⭐
-degree of airflow limitation in COPD(GOLD classification):FEV1/FVC<0.70，FEV1:30%,50%,80%，共4級
-Dyspnea score: mMRC, CAT score:咳,痰,悶,喘,限,出,睡,活
-Prognosis:BODE index: BMI、obstructive airflow(FEV1)，dyspnea(mMRC)、exercise運動耐受性


Management of stable COPD: ⭐

Management of exacerbations ⭐ tiny note

-exacerbation定義:症狀加劇(cough，dyspnea，sputum)超過baseline，使得routine 藥物需要改變
-呼吸道感染&空氣汙染是最常見造成急性發作的原因，大部分情況是找不到原因的。
-pneumonia: CXR+assessment of CRP and/or procalcitonin
-pneumothorax: CXR or Sono
-pleural effusion: CXR or Sono
-pulmonary embolism: D-dimer and/or doppler sonogram of lower extremities+CXR
-pulmonary edema due to cardiac related conditions: EKG and cardiac ultrasound+cardiac enzyme
-cardiac arrhythmia(AF,AFlutter):EKG
-HF,MI


-收住院標準:
-治療目標:減少傷害，預防下次發作
-SABA，systemic coritcosteroid，antibiotic，oxygen therapy，NIPPV，Antibiotic
-Antibiotic的使用時機
-Discharge criteria:


COPD and comorbidities

-Lung cancer：常見且為為重要的死因
-Cardiovascular disease：常見且重要
-Osteoporosis, depression/anxiety, obstructive sleep apnea：與較不好的健康狀況、較差的預後相關
-Gastroesophageal reflux (GERD): 與較高的急性發作(acute exacerbations)風險、較差的預後相關




台大內科手冊
----text

Asthma

定義

-一種因許多不同的外在刺激造成的慢性呼吸道發炎疾病及呼吸道過度反應，進而產生不同程度的呼吸道阻塞
-chronic inflammation disorder /w airway hyperresponsiveness+ variable airflow obstruction
-classic triad: paroxysms of cough，dyspnea，wheezing 。其他包括胸悶，痰。
-Asthma is a chronic disease /w episodic exacerbation that are interfered with symptoms-free periods


Diagnosis and Assessment :1+2 ⭐

1.clinical symptoms ✅
-反覆發作的症狀，more than 1 symptoms，每次程度都不同，尤其清晨或晚上發作，有一個trigger，and/or 季節變化
-trigger:
呼吸道刺激物(抽菸、香水等)
過敏原(寵物、塵螨，花粉)
Infection(URI、bronchitis、sinusitis)
Drug(NSAID、ASA，beta blocker)
情緒壓力，冷空氣，運動


-Hx:
問:小時候就開始嗎?有沒有過敏性鼻炎
家族史
*but not specific


-不像asthma 的表現:單獨只出現一個症狀


-physical examination
1.is often normal，最常出現的發現是end-expiratory wheezing
2.presence of nasal polyps息肉, rhinitis, rash -> allergic asthma
-Exacerbation:呼吸速率↑，HR↑，使用輔助肌，冒汗，奇脈


2.variable expiratory airflow limitation(不同程度的呼吸道阻塞)->肺功能測試 ✅
-最大吐氣流速(peak exp flow,PEF): 使用支氣管擴張劑後↑>= 60 L/min，或日夜變化>=20%
-Spirometry: ↓FEV1、↓FEV1/FVC、coved flow-vloume loop
-bronchodilator test:↑FEV1 & >200ml from baseline 在服用2-4口SABA後
-Methacholoine 激發測試:用於肺功能測試正常者，>90%sensitivity: ↓FEV1>=20%
-每次來門診肺功能測試都不同(較不準)


Therapeutic options ⭐

-GINA:過去四個禮拜以來1.白天症狀，2.夜間症狀，3.急救藥物使用次數，4.活動限制。
well control/partly control/uncontrolled:0/1-2/3-4
-ACQ(Asthma control questionnaire)，<=0.75 :well controlled，>=1.5: not well controlled
-ACT氣喘分數， >19: well controlled，<16: poor controlled


Management(p.290) ⭐

-目標:control symptoms，minimize risk of exacerbation
-stepwise approach
-Reliever:SABA(albuterol)，SAMA(ipratropium)
-Controller:ICS，LABA(salmeterol)，LAMA(tiotropium)
-Add-on therapies(pts with severs asthma):LTRA，cromolyn/Nedocromil，Theophylline，anti-IgE therapy，等等...


Management of exacerbations(p.291+小麻2-6) ⭐

-Treatment algorithm
-在急性發作時，客觀評估呼吸道阻塞程度是很重要的
-Mild: PEF or FEV1>70% of predicted or personal best
-Moderate: PEF or FEV1: 40-69%
-Severe: PEF or FEV1: <40%
-瀕臨(Impending)Respiratory failure: <25%


Wheezing的D.D.

-過度換氣(hyperventilation)，恐慌發作(panic attack)
-上呼吸道阻塞或吸入異物;喉部/聲帶功能失調(ex 2' to GERD)
-CHF:cardiac asthma
-COPD
-Bronchiectasis
-ILD(ex Sarcoidosis)
-Vasculitis
-PE


—-

Pleural effusion

定義

-肋膜腔中有液體堆積
-Diagnosis & Management 是基於肋膜積液是 transudate or exudate
-最常見原因:左心衰竭，肺炎，Malignancy(肺部、胸部、lymphoma)，肺栓塞，病毒感染
-較少見但重要:rheumatologic/collagen vascular disease，肝硬化，hepatic hydrothorax，胰臟炎，esophageal rupture，淋巴管阻塞，"trapped" lung


-正常肋膜生理
1.平常約存在10cc.的液體，在影像學檢查上不明顯
2.正常的生化數值: LDH<0.6，Protein<0.5，Glucose 0.6-.8 of Serum。pH=7.6


Transudate:淨水壓或滲透壓改變導致胸水產生增加或吸收減少
-CHF:靜脈壓增加及肺水腫
-肝硬化 OR Nephrotic syndrome: hypoalbuminemia
-Malignancy(10%):阻塞微血管或淋巴管


Exudate:直接或間接cytokine造成肋膜 and/or 血管被破壞，導致微血管通透性增加
-Infection/Pneumonia
-Malignancy
-inflammatory disease(ex. SLE or RA)
-Trauma/surgery
-肺栓塞


肋膜感染、發炎、阻塞的標記常同時存在
-Low Glucose and pH level:微生物 or 免疫細胞代謝，消耗養分&氧氣。酸性物質排除效率下降
-high LDH level: cell turnover and lysis


Diagnosis :Thoracentesis & Light's criteria ⭐

-所有檢查發現的肺炎旁肋膜積液，以及新發生未診斷的積液都應實行胸水抽取檢查
-Transudate:符合所有診斷標準(Light's criteria)
1.Fluid:serum Protein ratio<0.5
2.Fluid:serum LDH ratio<0.6
3.Fluid LDH <2/3 最大上限值of serum(約130-140)


-Exudate:符合任一診斷標準
Fluid:serum Protein ratio>0.5 OR Fluid:serum LDH ratio>0.6 OR Fluid LDH >2/3 最大上限值of serum


-pseudo Exudate:
1.通常是因CHF使用利尿劑治療，肝硬化，腎病症候群
2.Serum to pleural fluid albumin gradient >1,2


肺炎產生的積液那些要引流?-->CPPE
-Simple parapneumonic effusion單純性肺炎旁肋膜積液-> Antibiotics & observation
-Complicated parapneumonic effusion(CPPE)複雜性肺炎旁肋膜積液，符合任一診斷標準
A類:

1/2 hemithorax:積液>1/2胸腔
-Loculated effusion:積液形成一包一包的
-Thickened parietal pleura:肋膜變厚
B類:
-Pus:抽出來是pus
-Culture positve:培養有菌
C類
-pH<7.2 -Glu<60 mg/dl -LDH>600 mg/dl


Hemothorax
-Fluid : serum Hct ratio>0.5


Chylothorax乳糜胸
-TG>110 mg/dl
-胸管破裂，etiology:tumor or 外傷


膿胸(empyema)
-gross pus in the pleural space or positive Gram stain(positive culture is not required for diagnosis ，假陰性機會高)


Lymphocyte predominate Exudative Pleural effusion的鑑別診斷

:Malignancy vs. TB
怎麼分?
-Tuberculous pleuritis
1.Mesothelial cell<5% 2.Pleural biopsy 3.驗ADA(adenosine deaminase):TB>40 U/L


臨床表現

-通常是由胸部影像學發現:CXR，CT，SONO
-臨床常無症狀，Dyspnea是最常見的(在500-1000ml時出現)，但不一定有關
-PE:在大量胸水時較明顯
Dullness to percussion + Absence of fremitus + Diminished breath sound or absence


Management ✅ p.331 or 中文359

臨床上如何評估&引流時機 p.講義 ⭐

Asthma vs COPD vs.ACOS

氣胸

定義

-pathophysiology:肺泡破裂使空氣漏到肋膜腔，反過來壓迫肺臟


-pneumothorax may occur spontaneously or as a result of trauma
-Spontaneous pneumothorax:沒有外傷
1.primary spontaneous pneumothorax:原本沒有肺部疾病者
2.secondary spontaneous pneumothorax:原本就有肺部疾病
(COPD，TB，Silicosis...)
-Traumatic pneumothorax:穿刺傷或鈍器傷
-Iatrogenic(醫源性) pneumothorax
-Tension pneumothorax:持續性地空氣累積在胸腔中，足以讓縱膈腔的結構位移&靜脈回心血流受阻，導致hypotension、氣體交換異常，甚至心肺衰竭。
(對於使用mechanical ventilation(呼吸器)or any procedure in which the thorax is pierced by needle的病人出現症狀時要懷疑)


Diagnosis and Assessment:影像學

-典型症狀:胸痛(突然發生，通常單側)+活動時伴隨喘+病側呼吸聲減少
-小型氣胸PE可能是正常的
-典型PE表現有:患側decreased breath sound，decreased vocal fremitus，hyperresonant percussion
-併發症->張力性氣胸 最常見
-危險因子:瘦高年輕男性，抽菸，肺部疾病


-CXR:
1.患側會看到一條白色的臟層肋膜線(visceral pleural line)
2.臟層肋膜線的外圍因為充滿氣體，所以影像上通常無法看見由肺部血管構成的
肺紋


-張力性氣胸:患側完全無呼吸音，hyperresonant percussion，氣管偏移向健側，頸靜脈怒張，發紺，極度呼吸困難，低血壓、休克
-致命急症要立即處置:細針第五肋間前腋中線引流，胸管引流，Pigtail引流


肋膜與胸廓距離超過3cm的氣胸要引流

  • 3-bottle drainage:順序:fluid,air,suction，別放錯

indication for surgical intervention

-second episode
-persistent air leakage for greater than 7 days
-first episode with unexpanded, "trapped" lung
-hx of contralateral pneumothorax
-bilateral pneumothorax
-occupational risk(driver, airplane pilot)
-large bulla
-large undrained hemothorax

肺炎

定義

-社區肺炎(CAP):未住院或住院未滿48hrs內發生
-院內肺炎(HAP):住院48hrs後，或上次住院結束後14天內發生
-呼吸器相關肺炎(VAP):使用呼吸器48小時以後產生的院內肺炎
-健康照護相關肺炎(HCAP):90天內住院超過2天 or 30天內接受過針劑抗生素治療 or 住在安養院或長期照護機構 or 傷口照護 or 化療 or 洗腎的病人


Diagnosis and Assessment: s/s+CXR(⭐)

-急性感染症狀(fever，體溫下降，
發抖，出汗)
+新的呼吸道症狀(cough，痰，dyspnea，肋膜痛，肺功能檢驗異常)
+/-全身性症狀(噁心，嘔吐，腹瀉，疲倦，肌肉痛，腹痛，食慾差，頭痛)
-Other common features are gastrointestinal symptoms (nausea, vomiting, diarrhea) and mental status changes. Chest pain occurs in 30 percent of cases, chills in 40 to 50 percent, and rigors in 15 percent. Because of the rapid onset of symptoms, most individuals seek medical care within the first few days
-typical(ex.S.pneumoniae
-atypical(Legionella,Mycoplasma,Clamydia,virus):presentation vary from insidious to acute.
-s/s in CAP
-Clinical and imaging feature do not distinguish typical from atypical
-On physical examination, approximately 80 percent are febrile, although this finding is frequently absent in older patients, and temperature may be deceptively low in the morning due to normal diurnal variation. A respiratory rate above 24 breaths/minute is noted in 45 to 70 percent of patients and may be the most sensitive sign in older adult patients; tachycardia is also common. Chest examination reveals audible crackles in most patients. Signs of consolidation, such as decreased or bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony are present in approximately one-third.
-While the clinical features outlined above support the diagnosis of pneumonia, no clear constellation of symptoms and signs has been found to accurately predict whether or not the patient has pneumonia [5,6]. As an example, the sensitivity of the combination of fever, cough, tachycardia, and crackles was less than 50 percent when chest radiograph was used as a reference standard


-physical examination
1,觸:fremitus增加
2.扣:濁音(dull)
3.聽:crackle，支氣管呼吸音


CXR
-The radiographic appearance of CAP may include lobar consolidation and interstitial infiltrates and/or cavitation
-15% case miss(subtle infiltrate)


Therapeutic options

1.severity evaluation
-PSI
-CURB-65:門診/住院/ICU，1/2/>=3
意識混亂confusion
urea>7 mmol/L
respiratory rate>30/min
BP<90/60
大於65歲


咳嗽

定義

Diagnosis and Assessment

  1. Is the cough acute or chronic
  2. are there associated symptoms suggestive of a respiratory infection?
  3. is it seasonal or associated with wheezing?
  4. is it associated with symptoms suggestive of postnasal drip or GERD?
  5. is it associated with fever or sputum? if sputum is present, what is its character?
  6. does the pts have any associated disease or risk factors for disease?
    (smoking，occupational exposure，HIV，etc)
  7. is the pts taking an ACEI?

-最常見:PNDS，BA，GERD

click to edit

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呼吸衰竭

定義 ⭐

-hypercapnic respiratory failure:
急性CO2堆積造成呼吸性酸中毒
:PaCO2>45mmHg，pH<7.35
-低血氧性呼吸衰竭hypoxemic respiratory failure
:正常氣體交換功能嚴重受損所導致低血氧(hypoxemia,動脈血氧分壓PaO2<60mmHg) or 血中氧氣飽和度SaO2 <90%
。通常這種型態的呼吸衰竭會伴隨tachypnea and hypocapnia(呼吸急迫/血中CO2低下)，但若呼吸衰竭情況持續會導致高碳酸血症(hypercapnia)。這種型態的呼吸衰竭原因很多，
↓
總結
:當呼吸功能受損，不能進行有效氣體交換，以致血液中氧氣分壓降低(hypoxemia)，或二氧化碳分壓上升(hypercapnia)，嚴重程度達到無法因應體內組織新陳代謝之需求，而影響到生物體生存時，即稱為呼吸衰竭。定義主要是根據ABG


PaO2<60mmHg or SaO2 <90% or PaCO2>45mmHg，pH<7.35
-急性:數分鐘-幾天內發生
-亞急性:1-3個月
-慢性:持續3個月以上


pathophysiology ⭐ 待補

pathophysiology-2 ⭐ 未完

-hypercapnic respiratory failure: 小麻2-18 ✅ j
-肺泡通氣量過低(->hypercapnia)，但氧氣交換功能正常
1.RR↓(respiratory drive↓):Metabolic alkalosis，primary & secondary neurologic impair
2.NM system
3.CW/Pleura
4.Lung/Airway


-低血氧性呼吸衰竭hypoxemic respiratory failure
-包括氧氣交換功能障礙和氧氣輸送功能障礙
1.氧氣交換功能障礙
-肺部病變
-循環系統
2.氧氣運輸功能障礙

ARDS

Hypercapnic respiratory failure

待補

定義 ⭐

間質性肺病

D:drugs(bleomycin,amiodarone,TKI)
I:Idiopathic interstitial pneumonia(IPF等)
S:Sarcoidosis
C:Collagen vascular disease
O:Occupational exposure


search:當初胸腔科的paper

間質性肺病

原因

  • 藥物與治療相關


    (1) 藥物：要記得bleomycin和amiodarone，其他上網查


    (2) 氧氣治療：oxygen toxicity


    (3) 放射線治療


  • 風濕免疫疾病


    (1) Diffuse cutaneous SSc


    (2) Sjogren's syndrome


    (3) SLE、RA、AS, goodpasture syndrome, LAM等都有可能


  • 職業暴露


    (1) 塵肺症pneumoconiosis:煤礦工人、矽肺症、石綿等


    (2) 過敏性肺炎hypersensitivity pneumonitis→金屬、黴菌等(ex. Farmer’s lung)


  • 其他


    (1)Sarcoidosis


    (2)Pulmonary Langerhan cell histocytosis


    (3)還有其他各種遺傳、特殊的疾病，在此不詳細列出


  • Idiopathic


    (1)Idiopathic pulmonary fibrosis：以雙側下肺葉為主的肺部纖維化



看到interstial pattern要記得先排除掉

  • congestive heart failure的早期
  • infection：病毒感染、不典型細菌感染、PJP等
  • 惡性腫瘤：lymphagetic carcinomatosis

presentation

-all form of pulmonary fibrosis, regardless of etiology, present with

  • Dyspnea, worsening on exertion
  • clubbing finger
  • fine crackles on examination
  • loud P2 heart sound

--


diagnostic test

✅小麻


Sarcoidosis ⭐

(http://www2.cmu.edu.tw/~cmcmd/ctanatomy/clinical/sarcoidosis.html)


https://thetinynotes.com/topic/1117/%E9%A1%9E%E8%82%89%E7%98%A4sarcoidosis

支氣管擴張

定義Link Title

支氣管不可逆的永久擴張，可以局部或瀰漫性的表現


臨床表現

  • 反覆咳嗽及濃痰，有半數的人可能會咳血
  • 喘, wheezing in 75%case
    其他表現包括
    -肺部聽診：Crackles 或 Wheezing 都有可能
    -體重下降
    -anemia of chronic disease
    -clubbing is uncommon

原因

  • cystic fibrosis

  • 感染:


    -肺炎, abscess, TB


    -ABPA(Allergic bronchopulmonary aspergillosis)


  • foreign body or tumor


  • 免疫相關


    -RA, SLE


    -hypogammaglobulinemia


    -IBD


    -α1 antitypsin deficiency


    -移植, HIV


    -等等



診斷⭐

  • 影像學檢查
    -initial test:CXR: Tram track sign (看到兩條平行的線狀陰影)、下肺野肺紋增加，受侵犯肺葉幾乎都會喪失容量(volume)
    -most accurate test:CT:Tram track sign、Signet ring sign
    -痰液檢查確認感染源

治療

-控制感染
-氣道清潔
-難治型: 手術




肺膿瘍

簡介

  • 肺實質因為感染導致壞死，大部分起因自嗆入性肺炎的厭氧菌
  • 台灣的菌種以GNB為主(36%)，厭氧菌(34%)，GPC(26%)
    • 最多的是Klebsiella pneumonia，接著是Streptococcus milleri

診斷

CXR：常看到cavity lesion、air fluid level


治療

  • 抗生素治療(要cover厭氧菌)
  • 抗生素的治療時間：6周
  • 侵入性治療
    • 通常不需要手術介入，因為abscess連結呼吸道，可以自然的drain出
    • 除非是用藥物無效、懷疑有腫瘤、非常大包的膿瘍


Parapneumonic effusion

簡介Link Title

Parapneumonic effusion意指在細菌性肺炎附近出現的肋膜積液，依照其細菌的侵犯程度，可以分成uncomplicated、complicated、最後進展到膿胸empyema


診斷(empyema)

  • 肋膜液之gram stain 或細菌培養陽性


跟肺膿瘍的比較

  • FC.

黴菌感染

麴菌aspergillus

  • 感染後臨床表現依病人免疫力而不同
    • hypersensitivity: ABPA(allergic bronchopulmonary aspergillusis)
    • normal: saprophytic aspergillosis
      • CXR: 空洞中(TBor其他原因)有麴菌球
    • mild immunosuppression: chronic necrotizing aspergillosis
      • CXR: 開洞性肺炎
    • severe immunosuppression: invasive aspergillosis

ABPA

  • 臨床表現
    • 主要在氣喘和囊狀纖維化的患者出現
    • 臨床表現為反覆的氣喘發作與惡化
    • 嚴重的個案會出現支氣管阻塞、發燒、疲倦、褐色痰塊、咳血
    • 少數患者會有過敏性鼻竇炎
  • CXR: pulmonary opacities(浸潤) (transient or chronic), central bronchiectasis
  • 治療
    • oral steroid for severe case; inhaled steroid are not effective for ABPA
    • 若無法降低口服類固醇的劑量, 可以考慮加上抗真菌藥物(如itraconazole或voriconazole) (Grade 2B)，這類藥物通常會使用16周。

invasive aspergillosis

CXR:廣泛性,多片浸潤
CT:
-nodule
-halo sign(ground glass opacity surrounding a pulmonary nodule)
-air crescent sign




肺栓塞

臨床表現

pulmonary functional test