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Clin Med II > Bronchiectasis and Critical Care > Flashcards

Bronchiectasis and Critical Care Flashcards

1
Q

bronchiectasis

A
  • permanent, abnormal dilation and destruction of bronchial walls
  • inflamed and easily collapsible airways -> airflow obstruction
  • chronic cough and viscid sputum
  • may be caused by recurrent inflammation or infection
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2
Q

what disease is highly associated with bronchiectasis

A
  • cystic fibrosis
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3
Q

cystic fibrosis

A
  • abnormal transport of chloride and sodium across epithelium
  • causes thick viscus secretions
  • usually dx in childhood
  • pseudomonas infections common
  • dx with sweat chloride test
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4
Q

clinical features of bronchiectasis

A
  • cough with mucopurulent sputum
  • hx of repeated RTI
  • dyspnea
  • rhinosinusitis
  • hemoptysis
  • recurrent pleurisy
  • fatigue
  • stress incontinence
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5
Q

PE findings for bronchiectasis

A
  • chronic pulmonary crackles
  • wheezing
  • rarely digital clubbing
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6
Q

treatment of bronchiectasis

A
  • treat underlying disease
  • prevent aspiration
  • immunizations
  • abx
  • nebulized hypertonic saline- thin secretions
  • chest PT
  • oscillatory positive expiratory pressure
  • pulm rehab
  • bronchodilators- may thin secretions
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7
Q

purpose of pulmonary rehab

A
  • reduce sx
  • optimize functional status
  • increased participation
  • reduce health care costs
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8
Q

features of pulmonary rehab

A
  • pt assessment and education
  • exs training
  • nutritional support
  • psychosocial support
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9
Q

outcomes of pulmonary rehab

A
  • improved QOL and exs capacity
  • reduced number of severe exacerbations
  • reduced health care utilization
  • improves pt survival
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10
Q

components of pulmonary rehab

A
  • edu about disease, functional status, and habit patterns to promote self care
  • smoking cessation
  • breathing retraining
  • chest PT
  • exercise
  • nutritional support
  • psychosocial support
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11
Q

when to initiate mechanical ventilation

A
  • hypoxemic
  • hypercarbic
  • do not wait until it is an emergency
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12
Q

hypoxemia definition

A
  • SaO2 < 90% on FiO2 > 60%

- pneumonia, pulmonary edema, V/Q mismatch

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13
Q

hypercarbic definition

A
  • pCO2 > 50 mmHg and pH < 7.3

- obstructive lung disease, muscle fatigue, neuromuscular diseases

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14
Q

what is the most common type of mechanical ventilation

A
  • endotrachial intubation through mouth

- ET diameter of 7-8 mm

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15
Q

what drugs should be used during initiation of mechanical ventilation

A
  • paralytic + anesthetic
  • succinylcholine or rocuronium
  • propafol or etomidate
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16
Q

where should ET be if placed correctly

A
  • 3-5 cm above carina

- confirm placement with CXR

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17
Q

complications of mechanical ventilation

A
  • R main stem intubation
  • trachea- esophageal fistula
  • ET tube migration
  • laryngeal damage- ulcers, vocal cord paresis
  • dental trauma
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18
Q

FiO2

A
  • fractioned of inspired oxygen

- amount of oxygen the vent is delivering to pt

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19
Q

PEEP

A
  • positive end expiratory pressure

- det amount of pressure that is in pts airways at the end of each breath

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20
Q

TV

A
  • tidal volume

- size of breath

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21
Q

pressure support

A
  • amount of support the vent gives pt when initiating own breath
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22
Q

benefits of PEEP

A
  • used to prevent alveolar collapse
  • recruits alveoli that have collapsed -> increased surface area for gas exchange
  • reduced FiO2 requirement
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23
Q

harm of PEEP

A
  • reduced CO by decreasing venous return and external constrain of RV
  • may be exaggerated in hypovolemic pts
  • decreased CO -> impaired perfusion
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24
Q

misuse of PEEP

A
  • often used for atelectasis and pulmonary edema- no data to back these practices up
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25
volume control
- pt receives a set volume of air X number of times per min
26
synchronized intermittent mandatory vent (SIMV)
- set RR but pt can initiate breath on their own - good to wean pts off - can cause dyssynchrony during tachypnea
27
assist control (AC)
- good "set it and forget it" mode - good for newly intubated pts or sedated pts - can cause auto-peep during tachypnea- avoid this setting in awake pts
28
auto-PEEP
- vent is trying to exhale but pt breaths in -> vent puts high pressure in airways -> barotrauma
29
pressure control (PC)
- each breath associated with a set amount of pressure given through the vent - TV depends on driving pressure - gives good airway control - not a weaning mode and requires sedation
30
pressure support ventilation (PSV)
- ideal for weaning pts - pts TV and RR are not pre-set - pt receives assistance with each breath or sometimes no assistance - TV and minute volume must be monitored- possible hypoventilation
31
determining if pt is ready for extubation
- reversible cause must be reversed - hemodynamically stable - awake, alert, and following commands - PaO2 > 60 on an FiO2 40-50% - PEEP < 10
32
steps for extubation
- det if pt is ready - pass spontaneous breathing trial - rapid shallow breathing index (RSBI) < 100 - try extubation if pass all these - if they fail det why they failed and try again later
33
what is the rapid shallow breathing index
- ration of RR to TV
34
non-invasive ventilation
- used in pts with respiratory failure - uses a face mask - good for acute onset issues i.e. CHF flash pulmonary edema - uses BiPAP to provide assistance with hypercarbic and hypoxic respiratory failure
35
what is BiPAP
- bilevel positive airway pressure
36
tracheostomy
- preferred in pts with low likelihood of extubation in 5-7 days - more comfortable, less sedation
37
tracheostomy complications
- tracheal stenosis in first 6 mo after removal - accidental decannulation - aspiration - cuff leaks -> possible aspiration
38
what is A-a gradient
- alveolar arterial O2 gradient - A= alveolar O2 - a= arterial O2
39
what does A-a gradient measure
- measures how effective gas exchange is occurring - indicates how much oxygen is getting into blood stream - impt measure for treatment of hypoxemia
40
what does it mean if A-a gradient corrects with O2
- V/Q mismatch - i.e. large PE, COPD - increasing O2 means functioning parts of lungs take up O2
41
what does it mean if A-a gradient does not correct with O2
- there is a shunt- problem at the alveolar membrane | - common in severe atelectasis
42
ARDS
- syndrome that includes: - bilateral infiltrates - progressive respiratory failure - hypoxemia not responsive to increased FiO2 - not a dx on its own, must treat underlying cause
43
majority of causes of ARDS
- sepsis - pneumonia - trauma - multiple transfusions - aspiration of gastric contents
44
phases of ARDS
- exudative - proliferative - fibrotic
45
exudative phase of ARDS
- alveolar edema - high concentration of inflammatory cytokines -> leukocyte recruitment - usually occurs in first 7 days - assoc with bilateral infiltrates
46
proliferative phase of ARDS
- next 7-21 days - assoc with recovery - pts will hopefully be extubated but may have sx - fibrotic changes may occur
47
fibrotic phase of ARDS
- not all pts reach this phase - interstitial fibrosis, emphysema like changes - poor prognosis- higher mortality
48
ARDS treatment
- treat underlying problem - hypoxemia- use lowest vent settings to achieve PaO2 of 55 mmHg - pH > 7.3 at lowest possible TV and RR - fluid management - close supportive care - TV of 6-8 and always look for plateau pressures to protect lungs
49
prognosis of ARDS
- 30% mortality - higher rates of mortality seen in elderly - over ventilation and barotrauma associated with higher mortality
50
benefits of central lines
- good for longer use - more durable - safer access - may be used for dialysis catheters and temp pacing wires
51
internal jugular v central line placement
- easily accessible via US - provides straight shot to RA for pacing wires - confirmed with CXR
52
femoral v central line placement
- large vein easily accessible in emergencies - high rates thrombosis - limited mobility - possible increased infection risk - confirmed with blood gas or gravity test
53
subclavian v central line placement
- ideal vein but requires some skill - theoretical increased risk bleeding and pneumothorax - not as easily viewed with US- use landmarks - confirm with CXR
54
central line data
- central venous pressure- measured via IJV or SCV | - can help determine fluid status
55
what is normal central venous pressure
- 0-20 mmHg
56
complications of central lines
- venous air embolism- place in trandelenburg position - pneumothorax - catheter tip malposition - thrombotic occlusion later - venous thrombosis later - infection
57
common causes of central line infections
- coag neg staph - GNR- pseudomonas - staph aureus
58
arterial lines
- indicated in unstable pts who require vasopressor support or severe HTN - measurements prone to error
59
radial artery line
- less invasive, smaller artery - pt can remain mobile - good for short term use
60
femoral artery line
- easy to access but risk of vessel injury - limited mobility - good for emergency
61
axillary arter line
- most difficult to place - risk of vascular injury but very durable - doesnt impact mobility - good if pt will need line in for an extended period of time
62
how do you place arterial lines
- palpate for pulse | - US is not necessary like central lines
63
arterial line complications
- infection - arterial occlusion - limited mobility
64
swan- ganz catheters measurements
- placed directly into pulmonary artery - direct measurement of right heart filling pressures - indirect measurement of PCWP - measure CO - measure of mixed venous O2 sat
65
how CO measured via swan ganz catheters
- measured via thermo-dilution
66
swan ganz complications
- pulmonary artery injury - ventricular arrhythmias- esp if catheter left in RV - infection
67
how are vasopressors administered
- admin through central line | - monitored with arterial lines
68
vasopressin
- antidiuretic hormone - acts on V1 -> vasoconstriction - used for severe septic shock, vasoplegic states - caution in CAD - longer half life - vasopressor
69
phenylephrine
- most commonly used pressor - alpha 1 agonist -> arterial vasoconstriction - limited cardiac activity so not good for cardiogenic shock - quick on off - good for hypotension from altered vascular resistance - vasopressor
70
norepinephrine
- alpha 1 and beta 1 agonist - predominantly acts on alpha 1 -> increased SVR - rapid on off - good for refractory septic shock - vasopressor
71
dobutamine
- Beta 1 agonist, limited beta 2 - increases CO - less reflex hypotension - used for decomp HF without shock - will increase myocardial O2 consumption and can cause ventricular arrhythmias - inotrope
72
milrinone
- PDE III inhibitor that increases SV by increasing cAMP via vasodilation - slow onset - usually requires bolus - used with other inotropes - hypotension is major downside - inotrope
73
dopamine
- effect varies with dose - intermed- stimulates beta receptors -> increased HR and CO - high- alpha stimulation -> increased SVR - causes arrhythmias - inotrope
74
what is the main purpose of nutrition in the ICU
- feeding gut prevents atrophy of intestinal lining | - acts as barrier to infection
75
how is nutrition administered in ICU
- standard NG tube - dobhoff feeding tube (smaller and more comfortable) - TPN last line- high complication risk, doesn't prevent atrophy
76
when is feeding contraindicated
- shock - bowel obstruction - intestinal ischemia
77
complications of feeding
- aspiration | - diarrhea from sorbitol content

Clin Med II (16 decks)

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