amboss respiratory Flashcards
what is the treatment of choice for legionella
levofloxacin
second line therapy for legionella
macrolide such as azithromycin
what is beta-D glucan
PCP
what is the treatment for PCP
Bactrim and prednisone
what do you treat PCP with if the person has an allergy to Sulfa
IV clindamycin and oral primaquine are the first-line treatment for patients with PCP who are allergic to sulfa drugs and therefore cannot be given trimethoprim-sulfamethoxazole.
what is the presentation of epiglottitis
This patient’s high fever, respiratory distress, muffled voice, drooling, and tripod positioning strongly suggest epiglottitis, especially given the fact that his immunization history is unknown. In the tripod position (leaning forward with hands on knees), patients are able to reduce the work of breathing by extending the neck.
what is the treatment for epiglottis
third-generation cephalosporin (e.g., cefotaxime, ceftriaxone) or a beta-lactam with a beta-lactamase inhibitor (e.g., ampicillin/sulbactam, amoxicillin/clavulanate, piperacillin/tazobactam)
characteristics of squamous cell carcinoma
Squamous cell lung carcinoma (SCC) is the most likely diagnosis in this patient, as it is the most common lung cancer in smokers. SCC typically affects the central parts of the lung and may present with hypercalcemia as a result of the production of parathyroid hormone-related protein (PTHrP). On histology, SCC is a solid, epithelial tumor that can have intercellular bridges and keratin pearls.
treatment for croup
cool mist and dexamethasone
if deecompensating then use racemic epinephrine
what causes croup
parainfluenza virus
suggests acute bronchitis
a cough and mild dyspnea on exertion following symptoms of an upper respiratory tract infection. The absence of fever, yellow-greenfish sputum, or signs of consolidation on exam (negative egophony) , which is usually caused by a virus.
what is the treatment for acute bronchitis
supportive treatment only
what does pp65 antigen and cough, fever dyspnea indicate
CMV pneumonia
treatment for CMV penumonia
gancyclovir
treatment of pertusis
macrolides such as erythromycin, azithromycin clarithromycin for all close contacts as well regardless of immunization status
complications of pertusis
pneumothorax
what causes whooping cough
pertusis
The pertussis vaccination is recommended for all children at
2, 4, 6, and 15–18 months, as well as 4–6 years and is routinely administered together with the diphtheria and tetanus vaccine (see ACIP immunization schedule).
alternative to penicillin for tonsillitis
macrolide
what is the presentation of pertusis
this is whooping cough. violent coughing spells with inspiratory stridor or loud/high-pitched breathing sound. can also cause petechial bleeds in the eyes that presents like conjunctivits with foreign body sensation
treatment of peritonsilar abscess
I and D with ampicillin sulbactam
what is given for prevention of RSV
palivizumab
short acting monoclonal antibody that provides passive immunity
what is the therapy for tuberculosis
Isoniazid, rifampin, pyrazinamide, and ethambutol are antibiotic agents used as standard treatment for active TB. Treatment consists of an initiation phase lasting 2 months, using the 4 antibiotics simultaneously (to increase serum concentration, optimize killing of the bacteria, and minimize the risk of developing antibiotic resistance), followed by a continuation phase with only isoniazid and rifampin use for at least 4 months (to reduce the risk of relapse).
what is a contraindication for the PPD test
BCG vaccine
if someone has a positive PPD what is the next step
chest xray to determine if this is latent or active
what are lights criteria for pleural effusion
For exudates
Pleural fluid protein / Total serum protein >0.5;
Pleural fluid LDH / serum LDH >0.6;
Pleural fluid LDH > (2/3 x upper limit of normal serum LDH).
Exudates usually occur due to
inflammation, which leads to leaky capillaries, resulting in protein-rich pleural fluid
what is the outpatient treatment for CAP
Monotherapy with one of the following: Amoxicillin Doxycycline A macrolide (only in areas with a pneumococcal macrolide resistance < 25%) Azithromycin Clarithromycin
what puts people with CAP at risk for resistant bacterial CAP
E.g., chronic disease of the lung, heart, kidneys, or liver; conditions leading to impaired immune function (e.g., diabetes, malignancy, asplenia, alcohol use disorder); treatment with parenteral antibiotics in the past 90 days
what is the treatment for a CAP with likely resistant bacteria
Combination therapy An antipneumococcal β-lactam: Amoxicillin-clavulanate Cefuroxime Cefpodoxime PLUS one of the following: A macrolide Azithromycin Clarithromycin Doxycycline Monotherapy: with a respiratory fluoroquinolone Gemifloxacin Moxifloxacin Levofloxacin
does ertepenem treat Pseudomonas
no
treatment of choice for CAP with high suspicion of pseudomonas
cefepime and levo.
can use zosyn, meropenem, imipenem and fluoroquinolone
Fever, productive cough, pleuritic chest pain, and crackles are all common features of this postoperative complication, which typically occurs 3–5 days after surgery.
pneumonia
what is the managment of a CAP patient with a CURB score of greater than or equal to 2
inpatient management
macrolide and antipseudomonal.
or a respiratory fluoroquinolone (levofloxacin
when do we send someone with CAP to the ICU
septic shock or acute respiratory failure
what is the presentation of tuberculosis
cough, fever, weight loss, productive sputum
what is the best and least invasive way to determine tuberculosis infectino
sputum stain
what is the gram description of strep pneumo
gram positive diplococcus
what is the gram description o f staph aureus
gram positive cocci in clusters
what is the treatment for diaphragmatic rupture
emergency surgery if they are unstable
if they are stable then they need to go to CT scan to rule out other injuries.
what is the definition of acute respiratory distress syndrome
acute dyspnea, hypoxemia, alveolar or interstitial infiltrates. usually occurs in the context of systemic inflammatory response
what are the immediate measures for epistaxis
Fluid resuscitation if the patient is hemodynamically unstable
Keep the patient calm.
Elevate the upper body and bend the patient’s head forward.
Apply cold packs and sustained, direct pressure by pinching the nose at the nostrils for 5–10 minutes in order to occlude the bleeding vessel.
Apply topical vasoconstrictors (e.g., oxymetazoline, phenylephrine)
what is the last step for posterior epistaxis
ligation of the sphenopalantine
what is the last step for anterior epistxis
ligation of the anterior ethmoidal artery
if epistaxis continues after 10–15 minutes
First-line: cauterization of the bleeding vessel using silver nitrate or electrocautery.
Second-line: nasal packing using gauze impregnated with paraffin and antibiotics (covering for Staphylococcus aureus).
Anterior epistaxis: anterior nasal packing
Posterior epistaxis: posterior nasal packing
when laying on your side which lung is better perfused
the dependent lung
In pneumonia, there is decreased ventilation of the
consolidated portion of the lung due to alveolar inflammation (↓ V).
what is the treatment strategy for flail chest
noninvasive positive pressure ventilation or endotracheal intubation
A FEV1 > 1.5L and < 2L with a DLCO of > 60 % of predicted indicates
sufficient preoperative lung function.
what is the gold standard for diagnosing bacterial tonsillitis
throat culture.
when is tracheostomy used over cricothyroidotomy
when the passage is needed long term.
what is bronchiectasis
mainly seen in patients with cystic fibrosis and/or recurrent pulmonary infections. It is characterized by copious mucopurulent sputum, characteristically appears as “tram track” lines due to chronic inflammation and fibrosis of bronchial walls, which can progress to honeycombing.
where can aspiration pneumonia present
can be anywhere in the lung but usually present in the right lower lobe
what is the next step when suspecting oropharyngeal cancer
panendoscopy.
what is the most common cause of epiglottis in adults
Hib
treatmetn for epiglottis
Most sources recommend monotherapy with a third-generation cephalosporin (e.g., cefotaxime, ceftriaxone) or a beta-lactam with a beta-lactamase inhibitor (e.g., ampicillin/sulbactam, amoxicillin/clavulanate, piperacillin/tazobactam or fluoroquinolone (levofloxacin) for sensitive
also consider steroids
bronchopulmonary dysplasia
due to barotrauma and oxygen toxicity is a complication of prolonged mechanical ventilation in premature infants, persistent tachypnea, labored breathing (intercostal and subcostal retractions), FiO2 > 30% to maintain peripheral saturation > 90%, and diffuse granular densities with basal atelectasis on x-ray.
Treatment of bronchopulmonary dysplasia primarily focuses
on limiting oxygen toxicity and preventing complications (specifically pneumothorax, cardiovascular collapse, and neonatal sepsis).
what is galactomannan antigen
aspergillosis
what is the cause of transient tachypnea of the newborn
this is due to delayed resorption of lung fluid
what is the cause of neonatal respiratory distress syndrome
lack of surfactant.
without sufficient surfactant, increased surface tension of alveolar air sacs results in their collapse. The result is respiratory distress (e.g., nasal flaring, expiratory grunting, costal retractions, decreased breath sounds) and bilateral lung opacity on x-ray with low lung volumes and air bronchograms.
what is the first step in management of neonatal respiratory distress syndrome
continuous positive airway pressure ventilation
why is surfactant therapy not initiated immediately for NRDS and intubation
because there is increased risk for bronchopulmonary dysplasia.
coanal atresia presents how
blueish discoloration while feeding with improvement while crying.
there is complete blockage of the bilateral nasal cavities and thus the child cannot breath while feeding
what is the confirmatory test for coanal atresia
CT scan or supine contrast rhinography
what is the treatment for a child with a positive interferon gamma release assay
isoniazid
what is the presentation and localization of croup
raspy voice, barking or unusual cough, high-pitched stridor
inflammation of the subglottic airway
what is the localization of laryngiomalacia
supraglottic larynx
what is the diagnostic test for asthma
spirometry
what is the atopic triad
eczema, asthma, and allergic rhinitis
what is the presentation of acute decompensating asthma
child presents in an acute asthma attack with subcostal retractions and is given albuterol, steroids, and ipitrpoium. then an hour becomes unresponsive, hypercapnic, lethargic
The cardinal symptoms of asthma are
intermittent dyspnea, coughing, and high-pitched expiratory wheezing.
To remember the meds for asthma exacerbations, think ASTHMA
Albuterol, Steroids, Theophylline (rare), Humidified O2, Magnesium (severe exacerbations), Anticholinergics.
when do inhaled steroids take effect
one week to work
The mildest stage of bronchial asthma characterized by symptoms
(or the need to use an inhaler) on ≤ 2 days per week, ≤ 2 nighttime awakenings per month, the ability to perform all routine activities, and normal lung function tests in between the exacerbations.
what are the pulmonary function test results for asthma
Shows signs of obstructive lung disease with increased airway resistance → ↓ FEV1, ↓ Tiffeneau index (FEV1/FVC ratio)
Obstruction is reversible with bronchodilators → diagnostic confirmation via post-bronchodilator test
difference between chronic bronchitis and asthma
bronchitis cough is chronic and progressive, where asthma is episodic.
bronchitis usually has sputum production that occurs in the morning.
diagnosis of chronic bronchitis
usually present with (exertional) dyspnea, cough, end-expiratory wheezes, and an obstructive lung pattern on spirometry, which is the case here. must be present for at least 3 months each year for 2 consecutive years
what is samter’s triad
Samter’s triad is a feature of aspirin-exacerbated respiratory disease (AERD).
symptoms resembling those of a type 1 hypersensitivity reaction (e.g., wheezing, decreased breath sounds, cutaneous flushing) following the administration of aspirin or NSAIDs.
this is a pseudoallergic reaction
what is the difference between OSA and obesity hypoventilation syndrome
obesity syndrome will occur during the day. There will be hypoercapnea and decreased O2 stats
otherwise they present almost exactly the same.
OHS can be diagnosed in patients with BMI ≥ 30 kg/m2 with symptoms similar to OSA (excessive daytime sleepiness, restless sleep, snoring with apneic episodes) and evidence of daytime alveolar hypoventilation on ABG that cannot be otherwise explained.
what is the mechanism of obesity hypoventilation sydnrome
diurnal alveolar hypoventilation
what is the differential for persistent cough
GERD, upper airway cough syndrome and asthma
if someone has a persistent cough that does not improve with diphenhydramine what’s on the differential
GERD and asthma
what is th best first line therpay for upper airway cough syndrome
try and antihistamine
can use cetirizine, diphenhydramine
ground glass opacity on CXR
indicative of infectious process
patients with suspected upper air way cough should be empirically treated with what
first-gen antihistamine for 2 weeks
what is vasomotor rhinitis
condition characterized by an increase in blood flow to the nasal mucosa, which results in nasal congestion, rhinorrhea, and postnasal drip. Not attributable to a known allergic process. Triggers include drugs (e.g., NSAIDs), emotional stimuli (e.g., anxiety, excitement), strong odors (e.g., cigarette smoke, perfume), and cold, dry air.
what does bilateral calcified pleural plaques indicate
asbestosis
what is the most likely cancer to be caused by asbestosis
bronchogenic carcinoam
what are the two most common exposures that cause bronchogenic carcinoma
asbestos and smoking
Decreased lung compliance is a common finding in individuals with
pulmonary fibrosis, pneumothorax, pneumonia, or absence of surfactant (e.g., premature infants).
COPD, which is typically associated with increased lung, due to loss of
compliance elastic alveolar tissue.
what is the cause of cor pulmonale
COPD causes hypoxic respiratory vasoconstriction and pulmonary artery hypertension. this eventually causes right heart hypertrophy and failure leading to increased JVD and peripheral edema
what is the initial therapy for COPD exacerbation
prednisone and albuterol
positive polysaccharide antigen test, silver/PAS-staining of tissue samples that show macrophages filled with dimorphic fungi with septate hyphae.
histoplasmosis
blastomyces infection
a fungal infection that is often asymptomatic, but can cause cough, chest pain, and flulike symptoms. endemic to the Mississippi River area
sputum samples stained with KOH show a broad-based fungus without septate hyphae.
Aspergillus fumigatus infections cause aspergillosis, which may also present with symptoms of
a cough, fever, and malaise.
chronic exposure to the fungus, symptoms usually show a gradual progression rather than the fast onset seen in this patient. Tissue samples further show septate hyphae with a characteristic 45° angle
coccidiodes immitis infection
symptoms of acute pneumonia (e.g., fever, cough, chest pain). the fungus presents with spherules filled with endospores on KOH stain. the disease is most commonly present in the Southwestern US.
Adenocarcinoma is
the most common type of lung cancer seen in non-smokers, is much more common in women (6:1), and is usually located peripherally. A solid lesion ≥ 8 mm with irregular margins in a patient > 40 years of age is highly suspicious for this diagnosis.
next step after a solitary pulmonary nodule found on X ray that is less than 8mm
CT scan to assess for risk of malignancy
Radiologic factors that increase the risk for malignancy include
large nodule size (> 8 mm), location in the upper lung fields, and irregular, spiculated, or scalloped borders.
Clinical risk factors for lung malignancy include
age > 40 years, history of smoking or asbestos exposure, and a positive family or personal history of malignancy.
what does procalcitionin levels suggest
can help differentiate between viral and bacterial causes of illness.
if levels are low then this suggests viral etiology
Patients with acute asthma exacerbation generally initially present with respiratory alkalosis (decreased Pco2) due to tachypnea. what are the poor prognostic signs in asthma attack which are usually indicative of pending respiratory failure
With worsening airway obstruction and increasing respiratory fatigue, Pco2 increases and pH decreases. The absence of wheezing is also a clue regarding the severity of his condition: wheezing is not heard because there is not enough air movement to generate it.
OSA arterial blood gas should be what
Borderline low pH, elevated pCO2, elevated serum bicarbonate concentration, and decreased serum chloride concentration are consistent with compensated respiratory acidosis.
abdominal pain, dyspnea, alcohol use disorder, and Cullen sign (periumbilical hematoma) suggest
acute pancreatitis.
what pulmonary issues can be caused by acute pancreatitis
acute respiratory distress syndrome
what is bronhciolitis obliterans
which occurs as a result of repeated cycles of inflammation and scarring in the small airways, is typically due to inhalation of toxic fumes, graft-versus-host disease in lung transplant patients, or chronic lung infections.
what is the treatment for asymptomatic sarcoidosis
observation. no treatment has to be initiated. the disease has a high rate of remission and can be completely asymptomatic
penetrating inijuries below what level get ex lapo
below 4th intercostal space
clustered air spaces and reticular opacities in the basal lung is indicative of what
pulmonary fibrosis
what is a SE of amiodarone
pulmonary fibrosis
scarring of the extracellular lung matrix
what is the first line therpay for vasomotor rhinitis
intranasal antihistamine
what is the presentation of vasomotor rhinitis
rhinorrhea in response to a nasal irritant like perfume or strong emotional trigger
indicate bronchiectasis
The features of a chronic cough with copious sputum production in a patient with recurrent respiratory tract infections . This diagnosis is confirmed by the CT scan of the chest that shows multiple dilated bronchioles as well as the signet ring sign.
what is a risk of bronchiectasis
bronchial vessel damage leading to hemoptysis
what is the glucose measurement for a pleural exudate
< 60 indicates exudative
what is the screening system for PE
wells score
what is the wells score
Clinical symptoms of DVT 3 PE more likely than other diagnoses 3 Previous PE/DVT 1.5 Tachycardia (Heart rate > 100/min) 1.5 Surgery or immobilization in the past 4 weeks 1.5 Hemoptysis 1 Malignancy 1
what effusion does PE cause
exudative pleural effusion
what is the best management for COPD
In patients with COPD, continuous oxygen therapy for ≥18 hours/day reduces the risk of developing pulmonary hypertension and prevents complications that may arise from pulmonary hypertension. Tobacco cessation and oxygen therapy are the only interventions proven to prolong the survival of patients with COPD.
what should be administered after an inhalation injury, such as a fire, and why
hydroxycobalamin, for cyanoide toxicity
Burning household items (e.g., plastics, furniture, rubber) can release cyanide, which causes toxicity seconds after inhalation. Cyanide binds to the mitochondrial cytochrome complex, which increases anaerobic metabolism and causes lactic acidosis.
Features of cyanide toxicity include
neurologic symptoms (e.g., confusion, agitation, headache), cardiovascular symptoms (e.g., dysrhythmias, atrioventricular block), and skin flushing.
what does increased whispering pectoryloquy indicate
a lung consolidation
what is the treatment for emyema
broad spec antibiotics and chest tube placement t
when do you place a chest tube for empyema
A pleural fluid pH < 7.20 or glucose < 60 mg/dL indicates that effusion very likely requires drainage because these are signs of empyema formation, and empyemas are unlikely to resolve spontaneously.
what to look for if after intubation someone comes bak complaining of progressive dyspnea
laryngoscope to see if there damage/infalmmation due to intubation
clinical features of atelectasis
Large number of affected alveoli or rapid onset → acute dyspnea, chest pain, tachypnea, tachycardia, and cyanosis
Dull percussion note, diminished breath sounds, and decreased fremitus over the affected lung
Possibly tracheal deviation towards the side of lesion
arterial blood gas for atelectasis
Arterial blood gas analysis: hypoxemia, potentially low PaCO2, and respiratory alkalosis
Alveoli that are unable to participate in gas exchange → increased alveolar dead space → increased physiologic dead space
Chest x-ray and CT for atelectasis:
evidence of lobar collapse
Direct signs: displacement of fissures and homogeneous opacification of the collapsed lobe
Indirect signs
Elevation of ipsilateral diaphragm
Displacement of the hilum and mediastinal structures towards the affected side
Loss of volume in the affected side of the chest
Increased lucency and overinflation of the unaffected lung; silhouetting of the diaphragm or the heart border
treatment for atelectasis
Adequate analgesia
Early mobilization
Lung expansion maneuvers that increase positive end-expiratory pressure (PEEP)
Deep breathing exercises
Directed coughing
Intermittent incentive spirometry
Continuous positive airway pressure (CPAP) for patients unable to perform deep breathing exercises.
what is bronchiectasis
irreversible and abnormal dilation in the bronchial tree that is generally caused by cycles of bronchial inflammation in addition to mucous plugging and progressive airway destruction
The most important clinical finding in bronchiectasis is
a chronic cough with copious mucopurulent sputum.
Other symptoms may include dyspnea, rhinosinusitis, and hemoptysis.
