Airways and Respiratory Flashcards
What are the causes of bronciolitis?
Respiratory syncytial Virus<br></br>human metapneumovirus, <br></br>adenovirus, <br></br>influenza, <br></br>rhinovirus and <br></br>parainfluenza virus
Apnea risk factors in bronchiolitis
prematurity, <br></br>less than 3 months old, <br></br>previous episode of apnea, <br></br>underlying cardiorespiratory disease, immunodeficiency
Admission criteria in bronchiolitis:
<ul> <li>prematurity,</li> <li>persistent tachypnea or work of breathing,</li> <li>dehydration,</li> <li>Need for oxygen supplementation,</li> <li>apnea (witnessed or risk factors, even if well appearing)</li> </ul>
Complications of cystic fibrosis
<p>Acute respiratory exacerbations<br></br>Pneumonia<br></br>PneumoTx<br></br>Chronic inflammation leading to bronchiectasis<br></br>Cor pulmonale<br></br>Meconium ileus<br></br>Pancreatic insuff (DM, FTT, pancreatitis, malabsorption)</p>
Initial ventilator setting for intubated asthmatic patient:
“<ul><li>Respiratory rate low (6-8/min) to start</li><li>Small tidal volumes (6ml/kg of ideal body weight)</li><li>Fast inspiratory flow rate (≥ 100L/min) to allow a long expiratory time (I:E >1:4 ie inspiratory to expiratory ratio of 1:4 or more)</li><li>FiO2 100% initially then titrated down to keep sats > 90%</li><li>Minimal or no PEEP (≤5)</li><li>Agoal of a plateau pressure of less than 30mmHg. If the plateau pressure is too high, decreasing the respiratory rate<br></br></li><li><img></img><br></br></li></ul>”
Severe asthma Mx
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What are the causes of atypical pneumonia
<p>–<em>Legionella pneumophila</em></p>
<p>–<em>Mycoplasma pneumoniae</em></p>
<p>–<em>Chlamydia pneumoniae</em></p>
<p>–<em>Chlamydia </em><em>psittaci</em></p>
<p>–Fungal pneumonia <em>(Candida, Aspergillus, Cryptococcus, </em>etc<em>)</em></p>
<p>-Viral pneumonia<em> (HSV, CMV, RSV, EBV, VZV, </em>etc<em>)</em></p>
<p>When should you consider testing for atypical causes of pneumonia?</p>
<p>–Severe pneumonia</p>
<p>–Known outbreak (ie. Legionella)</p>
<p>–Definite findings of other non-pulmonary site of infection (chlamydia, VZV, etc)</p>
<p>–Significant immunosuppression</p>
<p>Match the etiologic agent with its typical chest radiograph appearance</p>
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CURB-65
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<p>According to North American Guidelines, list 2 potential classes of oral antibiotics that could be appropriate as first line outpatient treatment for pneumonia</p>
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<p>What are the <strong>most</strong> important MRSA/Pseudomonas risk factors when considering empiric coverage?</p>
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<p>Name 3 names or classes of antibiotics to cover pseudomonal respiratory infections</p>
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<p>Name 3 names or classes of antibiotics to cover MRSA respiratory infections</p>
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<ul> <li>Distinguish between aspiration pneumonitis and aspiration pneumonia</li> </ul>
<p>–Aspiration pneumonitis = acute reaction to chemical insult</p>
<p>–Aspiration pneumonia = occurs 24-72h after initial aspiration event, secondary bacterial infection</p>
<p>aspiration pneumonia. List 2 oral and 2 parenteral medication regimes for this condition</p>
<p>–Requires oral anaerobic coverage:</p>
<ul> <li>Amoxicillin + Clavulin</li> <li>Amoxicillin + Metronidazole</li> <li>Clindamycin</li> <li>Moxifloxacin OR Levofloxacin +/- Metronidazole</li> <li>Ceftriaxone + Metronidazole</li> <li>Piperacillin/Tazobactam</li> <li>Carbapenem</li> </ul>
DDx of fever + hemoptysis
<ul> <li>Infection <ul> <li>Pneumonia</li> <li>TB</li> <li>Bronchitis</li> </ul> </li> <li>Vascular <ul> <li>PE</li> <li>AVM</li> <li>Pulm hge</li> </ul> </li> <li>Malignancy</li> <li>Bronchiectasis</li> <li>Granulomatous dis</li> </ul>
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<p>Risk Factors for TB Infection</p>
<ul> <li>(Travel/work in endemic area)</li> <li>Contact withtuberculosis positive individual</li> <li>Immunocompromised (esp. HIV)</li> <li>Elderly</li> <li>Nursing home resident</li> <li>Alcoholism</li> <li>Illicit drug users</li> <li>Prisoner resident/staff</li> <li>Health care worker</li> <li>Homeless shelters</li> <li>First nation reserves</li> </ul>
Rx of TB
<p>RIPE</p>
<ul> <li>Rifampin</li> <li>Isoniazide</li> <li>Ethambutol</li> <li>Pyrazinamide</li> </ul>
SE of TB meds
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What is the definition of Massive hemoptysis?
<p>–>500ml over 24h</p>
<p>–>100ml over 1hr</p>
<p>–Hemoptysis associated with hemodynamic instability</p>
<p>–Clinically: <em>streaking vs. vials</em> vs. <em>frank </em>bright red blood</p>
<ul> <li>What temporizing measure can be considered before intubation/ while awaiting definitive management of massive hemoptysis?</li> </ul>
Nebulized TXA
<p>Light’s Criteria of pleural effusion</p>
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Transudative vs Exudative pl effusion
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Initial Mx of AECOPD
iv access<br></br>O2 +/- NIPPV<br></br>Ventolin/atrovent
DDX of acute SOB
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Mised Ix for acute SOB
Trop<br></br>D-Dimer<br></br>BNP<br></br>ABG/VBG<br></br>Lactate<br></br>CXR<br></br>ECG
“Interpret this CXR<br></br><img></img>”
<p>Hyper-expansion, flattening of hemi-diaphragms</p>
<p>Chronic COPD</p>
<p>Absence of consolidation</p>
Dxtic criteria for AECOPD
<p>–Worsening SOB with 2/3 of:</p>
<ul> <li>Increased amount of sputum</li> <li>Increased purulence of sputum</li> <li>Increased cough severity/frequency</li> </ul>
Indications for NIPPV in AECOPD
<p>–Respiratory muscle fatigue</p>
<p>–Progression to respiratory failure</p>
<p>–Respiratory acidosis</p>
<p>–Refractory hypoxia/ hypercarbia</p>
<ul> <li>Name 5 contraindications to NPPV</li> </ul>
<p>–Uncooperative patient</p>
<p>–Obtunded/ AMS</p>
<p>–Unable to clear airway secretions</p>
<p>–Hemodynamically unstable</p>
<p>–Respiratory arrest</p>
<p>–Pneumothorax</p>
<p>–Recent facial/GE surgery</p>
<p>–Facial burns</p>
<p>–Extreme obesity</p>
<p>–Poor NPPV mask fit</p>
POCUS pneumothorax
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Risk factors for spontaneous pneumpTx
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Causes of AE asthma
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<p>What RFs increase the risk of a severe/life-threatening asthma exacerbation?</p>
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<p>In patients being discharged from the ED with asthma, what should be discussed?</p>
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<p>What historical features would increase your suspicion of PE in this patient?</p>
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Suspicious features for DVT
> 3 cm calf swelling<br></br>Entire leg swelling<br></br>Collateral superficial vv or varicose vv<br></br>Tenderness along DVS<br></br>Unilateral pitting edema<br></br>White or blue discolouration of leg (Phlegmasia cerulea/alba dolens)
Rx for PE and CI
LMWH==>renal failure<br></br>NOAC==> pregnant, Cancer
<p>Thrombolytics in PE</p>
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<p>Outpatient anticoagulation in PE?</p>
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Difficult BVM
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<p>Difficult BVM? List 4 things you can try to improve bag-mask ventilation</p>
<p>–Reposition the patient</p>
<p>–Insert oral/nasal airway</p>
<p>–2-person BMV</p>
<p>–Change mask size</p>
<p>–Lube/muco/tegaderm to beard</p>
<p>–Consider foreign body</p>
<p>What are 4 features predictive of difficult airway/intubation?</p>
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Assessment for difficult airway
<p>MMAP</p>
<ul> <li><strong>M</strong>easure (3,3,2 – hypomental distance, mouth opening, and bite test)</li> <li><strong>M</strong>allampati</li> <li><strong>A</strong>tlanto-occipital extension</li> <li><strong>P</strong>athology (upper airway)</li> </ul>
<p>what factors should be present to consider awake intubation?</p>
<p>–Predictors of difficult airway or BVM</p>
<p>–Avoiding supine positioning (tracheal fracture)</p>
<p>–Difficult physiology (ie. acidosis – important to maintain compensatory ^ RR)</p>
<p>–Cooperative patient</p>
<p>–Time to prepare/set up (ie. not crash intubation)</p>
<p>–Back-up available</p>
Unable to intubate,,troubleshooting
<p>–Reposition yourself / patient</p>
<p>–Three B’s… BURP, Boogie, Blade</p>
<p>–Different tube size</p>
<p>–Alternate intubation technique/ device (VL)</p>
<p>–Different operator/intubator</p>
<p>–Rescue device</p>
<p>- Surgical airway</p>
“The P””s of RSI”
<ul> <li>Prepare equipment</li> <li>Position</li> <li>Pre-oxygenate</li> <li>Pre-treat with<em> fluids</em></li> <li>Pharmacology: induction and paralysis</li> <li>Position</li> <li>Place tube and confirm</li> <li>Post-intubation care</li> </ul>
<p>List 3 induction agents, doses, and 1 potential side effect for each (exclude allergy).</p>
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<p>Contraindications to Succinylcholine?</p>
<p>–Personal or familial history of:</p>
<ul> <li>malignant hyperthermia</li> <li>skeletal muscle myopathies (MS, Muscular Dystrophy)</li> </ul>
<p>–Glaucoma, penetrating eye injury</p>
<ul> <li>Can increase IOP</li> </ul>
<p>–After major burns, multiple trauma/crush injury, extensive denervation of skeletal muscle, upper motor neuron injury, CVA</p>
<ul> <li>Why?</li> </ul>
<p>Hyperkalemia</p>
ET tube position confirmation
Direct visual confirmation<br></br>EtCO2: waveform<br></br>CXR<br></br>POCUS
<p>Post-intubation Care</p>
<ul> <li>Secure tube</li> <li>Analgesia</li> <li>Sedation</li> <li>Lung protective ventilator settings</li> <li>HOB at 30 deg</li> <li>OG/NG</li> <li>ABG 20-30 mins post to assess oxygenation</li> </ul>
Initial ventilation settings
<p>Mode- Volume assist control</p>
<p>Tidal Volume- 8cc/kg</p>
<p>Flow rate- 60L/min</p>
<p>RR- 15</p>
<p>FiO2- 30-50%</p>
<p>PEEP- 5-10</p>
DOPES
<p>–<strong>D</strong>isplacement of the ETT</p>
<p>–<strong>O</strong>bstruction of the ETT</p>
<p>–<strong>P</strong>atient — especially<strong>p</strong>neumothorax; also: <strong>p</strong>ulmonary embolism, <strong>p</strong>ulmonary edema, collapse, bronchospasm</p>
<p>–<strong>E</strong>quipment — ventilator problems</p>
<p>–<strong>S</strong>tacked breaths — a reminder about bronchospasm and ventilator settings</p>
“<span>What physical exam findings would lead you to consider a differential diagnosis other than an acute exacerbation of COPD? List 5 findings and include the potential alternate diagnosis</span>”
-Absence of air entry, especially focal (PTX, pleural effusion)<br></br>-Tracheal deviation, JVD (tension PTX)<br></br>-Pedal edema, anasarca, swelling (CHF, renal failure)<br></br>-Unilateral leg swelling/ redness, JVD (PE)<br></br>-Altered LOC, confusion (DKA, toxic ingestion, sepsis)<br></br>-Pallor (anemia)<br></br>-New cardiac murmur (endocarditis, ACS, CHF)<br></br>-Stridor (airway obstruction, angioedema vs infectious)
“<span>What other historical features would put her at risk of a DVT?</span>”
-Immobility/ bed rest<br></br>-Pregnancy<br></br>-Smoking (incombination with OCP)<br></br>-Active malignancy<br></br>-PMHx of a known clotting disorder<br></br>-Family history of VTE/ clotting disorder<br></br>-CHF<br></br>-Varicose veins<br></br>-No other diagnosis as likely as DVT<br></br><br></br>(Note: no historical features from the stem are accepted “other historical features”)
“<span>You consider if this patient could also have a pulmonary embolus. What additional historical features could be positive with this diagnosis?</span>”
-Shortness of breath<br></br>-Hemoptysis<br></br>-Palpitations<br></br>-Chest pain<br></br>-Lightheadedness<br></br>-Fatigue<br></br>-Syncope<br></br><br></br>(Note: historical (not physical exam) features only.<br></br>Also, no features of DVT are accepted, only for PE)
“<span>The patient has some of these symptoms with no other clear respiratory diagnosis. Her HR is 110, RR is 30 and O2 sats are 90% on room air. What further testing could be done? How might it change your care of the patient?</span>”
-CT PA of Chest or VQ scan<br></br>–(no marks for d.dimer. This patient is high risk as per Well’s score - straight to imaging)<br></br><br></br>-Results may:<br></br>–Help determine the patient’s disposition/ need for admission (PESI score)<br></br>–Change treatment decisions if the patient became unstable (lytics, heparin)
“<span>List 3 potential medications used in the treatment of DVT/PE, along with a specific contraindication for each</span>”
-<b>Warfarin</b>: pregnancy, other interacting medications<br></br>-Any <b>DOAC</b>: mechanical heart valves, significant renal impairment, pregnancy, breastfeeding<br></br>-<b>Enoxaparin/Dalteparin/Fondaparinux</b>: Hx of HIT, renal failure<br></br>-<b>Heparin</b>: Hx of HIT<br></br>-<b>TPA</b>: (absolute CIs) Hemorrhagic CVA, ischemic CVA (3 months), structural cerebrovascular disease/AVM, CNS neoplasm, recent CNS surgery, recent head trauma with fracture or brain injury, active bleeding, known bleeding diathesis
PRAM Score
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How much initial ventoline in severe asthma in children
5 puff ventolin or 2.5mg aerosol x 3 in first 60 min and ipratropium 5 puff / 250mcg x 1 doses
Failing Rx of severe asthma, what to do?
-Methylprednisolone 2mg/kg IV<br></br>-Mg SO4<br></br>-Continuous salbutamol / ipratropium<br></br>-NS bolus 20 mg/kg<br></br>-Epinephrine IM<br></br>-Salbutamol infusion<br></br>-HFNC<br></br>-Intubation<br></br><br></br>Disposition: pediatric ICU
“<span>You decide to set up for a surgical airway as a back up plan. List the 3 most important pieces of equipment you will need</span>”
“<span>Scalpel</span><br></br><span>Bougie</span><br></br><span>6-0 ETT</span>”
“<span>You decide to proceed with intubation and plan to sedate and paralyze the patient. Your nurse asks you what drugs you would like prepared, list 3 and provide doses.</span>”
<b>Induction</b>- Ketamine (1.5-2 mg/kg) or etomidate (0.3mg/kg) or propofol (least desirable answer given soft pressure, 1.5-2mg/kg)<br></br><b>Paralytic</b>- rocuronium (0.6-1.2mg/kg) or succinylcholine (0.6-1.5mg/kg)<br></br><b>Pressor</b>- Norepi 5-20 mcg/min, Epi 5-20 mcg/min, Phenyl 100-300mcg/min
COVID initial ventilator setting
Mode: Volume control<br></br>Tidal Volume: 6-8cc/kg<br></br>Resp rate: 12-16<br></br>Inspiratory flow rate: 60L (can be titrated higher)<br></br>FiO2: 60% (higher is acceptable)<br></br>PEEP: 5-10 is acceptable to start (less then 15 is acceptable)
Indications for intubation
Inability to maintain airway patency<br></br>Inability to protect the airway against aspiration<br></br>Failure to ventilate<br></br>Failure to oxygenate<br></br>Anticipation of a deteriorating course that will eventually lead to respiratory failure
“<span>Name three historical features that would make this patient’s presentation concerning for a high risk COPD exacerbation?</span>”
-Previous ICU admission<br></br>-Previous intubation<br></br>-Multiple ER visits/ frequent exacerbations<br></br>-Recent/ chronic steroid use<br></br>-Home O2 use<br></br>-Medical Comorbidities (CVD, other chronic lung disease, major psychosocial disorder, substance abuse)
“<span>What objective measures would you look for to categorize this exacerbation as severe/ to signify respiratory failure?</span>”
-Signs of fatigue on physical exam<br></br>-Altered mental status, confusion<br></br>-Rising pCO2<br></br>-Worsening respiratory acidosis<br></br>-Significant tachypnea: RR>30<br></br>-Significant hypoxia, despite O2 therapy<br></br>-Cyanosis/ poor perfusion/ hemodynamic instability/ arrhythmias
“AECOPD,<span>List your next 5 treatments for this patient</span>”
-High flow oxygen<br></br>-Ventolin 2.5 mg nebulizer or 4-8 puffs, back to back<br></br>-Atrovent 500 µg nebulizer x3<br></br>-IV corticosteroids: solumedrol<br></br>-Antibiotics:<br></br><i>—Cetriazone + azithromycin<br></br>—Respiratory fluorquinolone</i><br></br>-Consider BiPAP, CPAP, Heliox<br></br>-Prep for/ consider intubation
“<span>What techniques or strategies can you attempt to improve Bag-Mask Ventilation?</span>”
-Reposition head (better sniffing position)<br></br>-Suction mouth, examine for FB<br></br>-Take off the collar/ use manual in line neck stabilization to allow for mouth opening<br></br>-Change masks (smaller, larger)<br></br>-Use 2 person technique for BVM<br></br>-Use adjunctive airway devices (NPA, OPA)<br></br>-Add PEEP<br></br>-Beard: apply muco/gel/tegaderm to face for better seal<br></br>-Obese: wrap cheeks around face, use ramp
“<span>What other ways can you confirm tube placement in the trachea vs. esophagus?</span>”
-EtCO2<br></br>-Auscultating bilateral breath sounds<br></br>-Absence of gastric sounds with breaths<br></br>-Misting of ETT with breaths<br></br>-Improving O2 sats or pO2 on ABG<br></br>-Good BVM compliance<br></br><br></br>(No marks for CXR - does not distinguish trachea vs esophagus)
