Chapter 6 - Pulmonary Disorders Flashcards
1
Q
PFTs: What is the FVC?
A
- Volume of gas forcefully expelled after maximum inhalation over the entire course of exhalation
- Normal 80-120% predicted
2
Q
PFTs: What is the FEV1?
A
- Volume of gas expelled in the first second of the FVC
* Normal: 80-120% predicted
3
Q
PFTs: What is the FEV1/FVC?
A
- A comparison of the amount of gas expelled in the first second with total amount of gas expelled
- Normal: within 5% of the predicted ratio
4
Q
PFTs: What is the PEFR?
A
• Maximal airflow rate achieved in FVC maneuver, “peak flow”
5
Q
Obstructive vs. Restrictive Lung Disease: Obstructive + examples
A
- Limitation of airflow
- Reduced airflow rates
- Examples: COPD, emphysema, bronchitis, asthma
6
Q
Obstructive vs. Restrictive Lung Disease: Restrictive + examples
A
- Limitation of lung expansion
- Reduced volumes
- Examples: ARDS, pneumonia, bronchiolitis, idiopathic pulmonary fibrosis
7
Q
PFT Spirogram: COPD vs. Normal
A
- COPD-er: lower FEV1, lower FEV, and it takes longer to expel all air (lungs have less volume and takes longer for lungs to empty)
- Normal: higher FEV1, higher FEV, and it takes less time to expel all air
8
Q
PFT Indications
A
- Persistent cough
- Wheeze
- Breathlessness
- Crackles
- Abnormal CXR
- Monitoring for known pulmonary disease
- Investigation of patients with risk factors
- Pre-op evaluation
- Surveillance after lung transplant
9
Q
PFT Contraindications
A
- MI within the last month
- Unstable angina
- Recent thoracic or abdominal surgery (causes ↑ ICP and intra-abdominal and intra-thoracic pressure)
- Thoracic and abdominal aneurysm
- Current pneumothorax
10
Q
Pathophysiology of asthma
A
• “A common, chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, BRONCHIAL HYPERRESPONSIVENESS, AND UNDERLYING INFLAMMATION”
11
Q
Clinical manifestations of asthma
A
- Recurrent cough, wheeze, SOB, and/or chest tightness
- Symptoms occur or worsen at night, or with exercise, viral respiratory infections, aeroallergens, and/or pulmonary irritants
- Airflow obstruction that is at least partially reversible identified by an increase in FEV1 ≥ 12% from baseline after short-acting-beta-agonist
12
Q
Spirometry vs. peak flow meter for asthma
A
- SPIROMETRY IS NEEDED FOR DIAGNOSIS
* PEAK FLOW METER IS USED FOR MONITORING, NOT DIAGNOSIS
13
Q
Goals of asthma therapy
A
- Reduce impairment
- Reduce risk
- Optimize health and function
14
Q
Assessment of asthma patient
A
- Classify asthma severity (initial visit) and asthma control (follow-up visits)
- Identify precipitating and exacerbating factors, including comorbid conditions that aggravate asthma
- Identify patients at high risk for exacerbations and death from asthma
- Regularly assess patient’s and family’s knowledge and skills for self-management, including medication device technique
15
Q
General treatment guidelines for asthma patient
A
- Short-acting beta2-agonist as acute reliever
- Controller for persistent asthma (inhaled corticosteroid)
- Step-up therapy if not well-controlled
- Written asthma action plan
- Education
16
Q
What are the two types of asthma reliever medications?
A
- Acute reliever (rescue) medications: SABAs
* Aggressive treatment for inflammation during flare: systemic corticosteroids
17
Q
Asthma reliever medications: acute relievers (rescue)
A
- Short-acting beta2-agonists (SABA), such as albuterol (Proventil), pirbuterol (Maxair), levalbuterol (Xopenex)
- Beta2-agonists = activates the beta2 receptors in airways going to the two lungs
- All asthmatics should have a SABA regardless of asthma classification/severity
- Use > 2x/week (except for exercise) suggests a need for better control
- Drug of choice for preventing exercise-induced bronchospasm (EIB). Use 15-30 minutes prior to activity
18
Q
Asthma reliever medications: aggressive treatment for inflammation
A
- Systemic corticosteroids
- Example: prednisone 40-60 mg/d x 3-10 days (average 5-7 days). No therapeutic benefit using an injectable when compared to oral product. Taper usually not needed with this dose and duration
19
Q
What are the 3 types of asthma controller medications?
A
- Inhaled corticosteroids (ICS)
- Inhaled corticosteroid/long-acting beta2 agonist (ICS/LABA)
- Leukotriene receptor antagonists (LTRA), leukotriene modifiers (LTM)
20
Q
Asthma controller medications: inhaled corticosteroids
A
- Mometasone (Asmanex)
- Fluticasone (Flovent)
- Bedusonide (Pulmicort)
- Beclomethasone (QVAR)
- Ciclesonide (Alvesco)
- Preferred treatment for persistent asthma
- Requires consistent, daily use for optimal effect
21
Q
Asthma controller medications: Inhaled corticosteroid/long-acting beta2 agonist (ICS/LABA)
A
- Budesonide + formoterol (Symbicort)
- Fluticasone + salmeterol (Advair)
- Mometasone + formoterol (Dulera)
- ICS with LABA should not be used in patients whose asthma is well-controlled with an ICS alone
22
Q
Asthma controller medications: Leukotriene receptor antagonists (LTRA), leukotriene modifiers (LTM)
A
- Montelukast (Singulair)
* Additional benefit with allergic rhinitis, most often used in conjunction with ICS
23
Q
What are 2 additional medications that can be used for asthma treatment?
A
- Inhaled muscarinic antagonists (aka inhaled anticholinergics)
- Theophylline
24
Q
Additional asthma medications: Inhaled muscarinic antagonists (AKA inhaled anticholinergics)
A
- Bronchodilator via blockage of cholinergic/muscarinic receptors
- Established role in asthma and COPD therapy
- Use primarily for prevention, not treatment, of bronchospasm and prevent asthma flare
- Example of short-acting muscarinic antagonist (SAMA): Ipratropium bromide (Atrovent)
- Example of long-acting muscarinic antagonist (LAMA): Tiotropium bromide (Spiriva)
25
Additional asthma medications: Theophylline
* Mild-to-moderate bronchodilator
* Usually reserved for when standard therapy isn’t working
* Use requires periodic monitoring of theophylline levels, multiple drug-drug interaction potentials limits clinical utility
* S/s of theophylline toxicity: SEIZURES, INTRACTABLE VENTRICULAR DYSRHYTHMIAS, rhabdo, tremor, vomiting, abdominal pain
26
Classification of asthma severity: intermittent
* Symptoms: ≤ 2 days/week
* Nighttime awakenings: ≤ 2x/month
* SABA Use: ≤ 2 days/week
* Recommended step for initiating treatment: Step 1, re-evaluate in 2-6 weeks and adjust accordingly if needed
27
Classification of asthma severity: mild
* Symptoms: > 2 days/week, but not daily
* Nighttime awakenings: 3-4x/month
* SABA Use: > 2 days/week, but not > 1x/day
* Recommended step for initiating treatment: Step 2, re-evaluate in 2-6 weeks and adjust accordingly if needed
28
Classification of asthma severity: moderate
* Symptoms: daily
* Nighttime awakenings: > 1x/week, but not nightly
* SABA Use: daily
* Recommended step for initiating treatment: Step 3, re-evaluate in 2-6 weeks and adjust accordingly if needed
29
Classification of asthma severity: severe
* Symptoms: throughout the day
* Nighttime awakenings: often 7x/week
* SABA Use: severe times per day
* Recommended step for initiating treatment: Step 4, re-evaluate in 2-6 weeks and adjust accordingly if needed
30
Step 1 Asthma Treatment
• SABA PRN
31
Step 2 Asthma Treatment
* SABA PRN
| * Low-dose ICS
32
Step 3 Asthma Treatment
* SABA PRN
| * Medium-dose ICS + LABA
33
Step 4 Asthma Treatment
* SABA PRN
| * High-dose ICS + LABA and consider Omalizumab in those who have allergies
34
Step 5 Asthma Treatment
• High-dose ICS + LABA + oral corticosteroid and consider Omalizumab in those who have allergies
35
When needing to step up or down asthma treatment
* Step up if needed – but first check adherence, environmental control, and comorbid conditions
* Step down if possible – asthma well controlled at least 3 months
* If using a SABA > 2 days/week, their asthma is not well controlled
36
Asthma Exacerbation – Key Indicators and Clinical Management: Mild
* Clinical manifestations: dyspnea only with activity
* Initial PEF or FEV1 (based on personal best): ≥ 70%
* Management: home treatment is okay, SABA, consider systemic corticosteroids, confirm an asthma action plan
37
Asthma Exacerbation – Key Indicators and Clinical Management: moderate
* Clinical manifestations: Dyspnea interferes with or limits usual activity
* Initial PEF or FEV1 (based on personal best): 40-69%
* Management: Requires provider evaluation (either PCP or their pulmonologist), SABA, Systemic corticosteroids, Confirm an asthma action plan
38
Asthma Exacerbation – Key Indicators and Clinical Management: severe
* Clinical manifestations: dyspnea with rest, interferes with conversation
* Initial PEF or FEV1 (based on personal best): < 40%
* Management: ED treatment, likely hospitalization, SABA, systemic corticosteroids, adjunct therapies, confirm an asthma action plan
39
Asthma Exacerbation – Key Indicators and Clinical Management: life-threatening
* Clinical manifestations: to dyspneic to speak, profuse perspiration
* Initial PEF or FEV1 (based on personal best): < 25%
* Management: ED treatment, hospitalization with probable ICU, SABA, systemic corticosteroids, adjunct therapies, confirm an asthma action plan
40
Warning signs of impending respiratory arrest
* Drowsiness or confusion
* Paradoxical thoracoabdominal movement
* Absence of wheezing
* Bradycardia
* Absence of pulsus paradoxus
* Initial PEF or FEV1 < 25% of personal best/predicted value
41
Common oxygenation values based on asthma severity
* Mild: normal PaO2, SaO2 > 95%, PCO2 < 42 mmHg
* Moderate: ≥ 60 mmHg, SaO2 90-95%, PCO2 < 42 mmHg
* Severe: PaO2 < 60 mmHg, SaO2 < 90%, PCO2 ≥ 42 mmHg (ABGs indicated at this stage, when PaO2 < 42, consider respiratory failure and intubation)
42
COPD Pathophysiology
* COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients
* Its pulmonary component is characterized by AIRFLOW LIMITATION THAT IS NOT FULLY REVERSIBLE
* Exacerbations and comorbidities contribute to the overall severity in individual patients
43
What are the most common risk factors for COPD?
* Host factors (genetics)
* Tobacco smoke
* Environmental exposures at home
* Occupational exposures
* Family history of COPD
* Childhood factors
44
What are the most common symptoms of COPD?
* Chronic cough
* Chronic sputum production
* Activity intolerance
* Symptoms typically progress over time
45
Who has at highest risk for COPD exacerbations and COPD death?
* Individuals with COPD with a history of ≥ 2 exacerbations within the last year
* FEV1 < 50% of predicted value and/or
* Hospitalization for COPD exacerbation in the past year
46
Assessment of COPD
Degree of airflow limitation
o SPIROMETRY IS REQUIRED FOR DIAGNOSIS
o FEV1: FVC < .70 (70%) post-bronchodilator confirms persistent airflow limitation/COPD
o Classification of severity determined by FEV1
Alpha-1 antitrypsin deficiency screening
o Perform when COPD develops in patients of Caucasian descent under 45 years old or with a strong family history of COPD
47
Clinical findings in emphysema vs. bronchitis
* Emphysema: increased AP diameter, hyperresonance on percussion, no mucus production
* Chronic bronchitis: normal AP diameter, normal percussion sounds, copious/blood-tinged mucus
* Findings in both: electrolyte triad (hypokalemia, hypochloremia, increased NaHCO3) and spirometric assessment consistent with obstruction
48
Lung Percussion Sounds
* Resonance = normal
* Hyperresonance = air-trapping
* Dull = fluid, collection of cells
49
Step 1 of COPD classification – spirometric classification
• Make the diagnosis of COPD: FEV1/FVC ratio < 70% (0.70)
• Determine the severity (GOLD category)
o GOLD 1 (mild): FEV1 ≥ 80% predicted
o GOLD 2 (moderate): 50% ≤ FEV1 < 80% predicted
o GOLD 3 (severe): 30% ≤ FEV1 < 50% predicted
o GOLD 4 (very severe): FEV1 < 30% predicted
50
Step 2 of COPD classification – symptom assessment
* COPD Assessment Test (CAT) Score
| * Asks questions about coughing, activity, sleep, energy on a scale from 0-5
51
Step 3 of COPD classification – determine exacerbation risk
* 2 or more exacerbations within the last year indicates a high risk
* 1 or more exacerbations with hospitalization in the last year indicates a high risk
* *exacerbation = symptoms require aggressive treatment with corticosteroids
52
Combined Assessment of COPD
* Patient Group A: low risk/less symptoms, GOLD 1-2, ≤ 1 exacerbation, no hospitalizations, CAT < 10
* Patient Group B: low risk/more symptoms, GOLD 1-2, ≤ 1 exacerbation, no hospitalizations, CAT ≥ 10
* Patient Group C: high risk/less symptoms, GOLD 3-4, ≥ 2 exacerbations, ≥ 1 hospitalization, CAT < 10
* Patient Group D: high risk/more symptoms, GOLD 3-4, ≥ 2 exacerbations, ≥ 1 hospitalization, CAT ≥ 10
53
Initial Pharmacologic Therapy for Stable COPD: Group A
* Short-acting or long-acting bronchodilator
| * SABA (Albuterol [Ventolin])
54
Initial Pharmacologic Therapy for Stable COPD: Group B
• LABA + long-acting muscarinic antagonist (tiotropium [Spiriva])
55
Initial Pharmacologic Therapy for Stable COPD: Group C
* Long-acting muscarinic antagonist (tiotropium [Spiriva])
| * Patients with persistent exacerbations may benefit from a second long-acting bronchodilator or a combo LABA + ICS
56
Initial Pharmacologic Therapy for Stable COPD: Group D
* Long-acting muscarinic antagonist (tiotropium [Spiriva])
| * LAMA/LABA can be used as initial therapy in patients with greater dyspnea and/or exercise limitation
57
COPD exacerbation: pathophysiology
* Exacerbation defined as an acute event characterized by worsening of the patient’s respiratory symptoms that is beyond the day-to-day variations and leads to a change in medication
* Usually a product of respiratory tract infection (viral or bacterial)
* Outpatient treatment is usually sufficient
58
COPD exacerbation: indications for hospital admission
* Marked increase in intensity of symptoms
* Acute respiratory failure
* Onset of new physical signs
* Failure to respond to initial medicinal treatment
* Presence of serious comorbidities (i.e., heart failure)
* Insufficient home support
59
COPD exacerbation: indications for ICU admission
* Severe dyspnea not responding to initial therapy
* Change in mental status
* Worsening hypoxemia (PaO2 < 40 mmHg)
* Worsening acidosis (pH < 7.25)
* Invasive mechanical ventilation
* Hemodynamic instability
60
COPD exacerbation: indications for non-invasive mechanical ventilation (NIMV)
* Uncompensated respiratory acidosis
* Severe dyspnea with signs of respiratory muscle fatigue
* Worsening hypoxemia with oxygen therapy
61
COPD exacerbation: indications for invasive mechanical ventilation (IMV)
* Unable to tolerate or fails NIMV
* Respiratory or cardiac arrest
* Decreasing level of consciousness
* Aspiration or vomiting
* Inability to remove secretions
* Unresponsive hemodynamic instability
* Ventricular or supraventricular dysrhythmias
* Worsening hypoxemia unable to tolerate NIMV
62
COPD Treatment – Diagnostics
* ABG (room air): PaO2 < 40 mmHg indicates respiratory failure; PaCO2 < 45 mmHg with a pH < 7.35 indicates respiratory failure
* CXR: to exclude alternative diagnosis
* ECG: evaluate for cardiac dysrhythmias
* CMP & CBC: identify polycythemia, anemia or bleeding; identify electrolyte abnormalities
* Sputum assessment: purulent sputum during an exacerbation is an indication to begin empirical antibiotics, consider cultures
63
COPD Treatment
* Oxygen: to improve hypoxemia with a target saturation of 88-92%
* Bronchodilators: SABAs are first-line, may add on a short-acting anticholinergic
* Systemic corticosteroids: prednisone 40 mg x5 days is recommended therapy
* Antibiotic use
* Non-invasive ventilation: benefits include – improves respiratory acidosis; decreases RR, severity of dyspnea, complications, LOS, mortality, and need for intubation
64
COPD Treatment – antibiotic use
* Give if 3 cardinal symptoms are present – increased dyspnea, increased sputum production, and/or increased sputum purulence
* Give to anyone requiring mechanical ventilation
* If no cultures are available, empiric antibiotics should cover all typical lower and upper airway flora
* Patients on mechanical ventilation require coverage of Pseudomonas aeruginosa
65
Benefits of non-invasive ventilation in COPD exacerbations
* Improves respiratory acidosis
| * Decreases RR, severity of dyspnea, complications, LOS, mortality, and need for intubation
66
Pathophysiology of TB
* Caused by a rod-shaped, aerobic bacterium called Mycobacterium tuberculosis
* Spread via airborne droplets
* Droplets settle in alveoli and are quickly engulfed by alveolar macrophages. The mycobacteria continue to multiply, leading to active or latent TB
67
What is latent TB?
* Found in a person who has acquired TB but is without signs or symptoms of active TB and is unable to spread the disease
* Usually, person has positive TB skin test or serologic test result
* CXR usually normal but sometimes shows abnormality of prior TB
68
Candidates for TB Testing
* People who have spent time with a person known to have or suspected of having active TB
* People who have HIV or another condition that weakens the immune system, creating a high risk for TB
* People who have symptoms of active TB
* People from a country where active TB disease is common (most countries in Latin America, Caribbean, Africa, Asia, Eastern Europe, and Russia)
* People who live somewhere in the US where active TB is more common, such as homeless shelters, migrant farm camps, prison/jail, or some nursing homes
* People who inject illegal drugs
69
Mantoux Tuberculin Skin Test (TST) Risk Factors that support a positive result
* ≥ 5 mm – HIV, recent contact with positive TB person, fibrotic changes on CXR with previous TB infection, organ transplant, immunosuppression
* ≥ 10 mm – immigration in last 5 years from high-prevalence country, IV drug use, employment in high risk setting, age < 4
* ≥ 15 mm – all individuals regardless of risk factors
70
Latent TB vs. TB Disease: Latent TB s/s and labs/diagnostics
* No symptoms
* Positive skin test or serologic result
* Normal CXR
* Normal sputum
71
Latent TB vs. TB Disease: Active TB s/s and labs/diagnostics
* Significant coughing lasting 3 weeks or more, chest pain, hemoptysis or sputum production, weakness/fatigue, weight loss, lack of appetite, chills, fever, night sweats
* Positive skin test or serologic result
* CXR consistent with TB
* Abnormal sputum
72
Latent TB vs. TB Disease: Latent TB Treatment
* Isoniazid (INH) (6-9 months)
* Isoniazid and rifapentine (3 months)
* Rifampin (4 months)
* Direct observation therapy
* If you are taking care of a TB patient, you will have ID and the health department on board
73
Latent TB vs. TB Disease: Active TB Treatment
* Treated by taking several drugs for 6-9 months. First-line anti-TB agents that form the core of treatment regimens include:
* Isoniazid (NIH)
* Rifampin
* Ethambutol
* Pyrazinamide
* Direct observation therapy
* If you are taking care of a TB patient, you will have ID and the health department on board
74
What are the main CAP pathogens?
* S. pneumoniae
* H. influenzae
* M. pneumoniae
* C. pneumonia
* Legionella species
* S. aureus
75
CAP Pathogens: S. pneumoniae
* MOST COMMON
* Gram-positive diplococci
* ≥ 25% drug-resistant (DRSP)
* Diseases caused by S. pneumoniae: COMPS – Conjunctivitis, Otitis media, Meningitis, Pneumonia, Sinusitis
76
CAP Pathogens: H. influenzae
* SECOND MOST COMMON
* Seen more in tobacco users
* Gram-negative bacillus
* ≥ 30% penicillin-resistant via production of beta lactamase. Most cephalosporins are stable in the presence of beta lactamase
* Diseases caused by H. influenzae: COMPS – Conjunctivitis, Otitis media, Meningitis, Pneumonia, Sinusitis
77
CAP Pathogens: M. pneumoniae and C. pneumoniae
* Largely cough-transmitted
* Often seen in people who spend an extended time in close proximity (jails, dorms, LTCs, small offices)
* “Atypical pneumonia” or “walking pneumonia” pathogens
* Characterized by dry cough, less severe signs and symptoms
* Not revealed on Gram stain
78
CAP Pathogens: Legionella species
* Usually contracted by inhaling mist or aspirating liquid that comes from a contaminated water source
* No evidence of person-to-person spread
* Major risk factors for severe disease – old, male, smoker, diabetes
* Not revealed on Gram stain
79
CAP Pathogens: S. aureus
• Largely limited to post-influenza pneumonia
80
CAP Classification for Outpatient Treatment: General Recommendations
* Minimum diagnostic evaluation for CAP – CBC with differential, BUN/Creatinine, CXR
* Additional testing based on patient presentation and comorbidities
* Recommended length of CAP therapy – at least 5 days with evidence of increasing stability, afebrile for 48-72 hours prior to antibiotic discontinuation (average length of therapy is 5-7 days)
81
CAP Classification for Outpatient Treatment: No comorbidities causative organisms
* Likely causative organisms: S. pneumoniae (Gram-positive) (most common), M. pneumoniae (Atypical pathogen), and C. pneumonia (Atypical pathogen)
* Respiratory viruses include influenza A/B, RSV, others
82
CAP Classification for Outpatient Treatment: No comorbidities treatment recommendations
• Oral doxycycline – OR –
• Oral azithromycin, clarithromycin, or erythromycin taking into consideration local S. pneumoniae resistance rates
• For CAP treatment without comorbidity, remember AABCDE (azithromycin, amoxicillin, Biaxin [clarithromycin], doxycycline, or erythromycin) are the antimicrobial recommendations
- typical duration: 5-7 days
83
CAP Classification for Outpatient Treatment: with comorbidities causative organisms
* Likely causative organisms: S. pneumoniae (Gram-positive), H. influenzae (Gram-positive), M. pneumoniae (Atypical pathogen), C. pneumonia (Atypical pathogen), and Legionella species (Atypical pathogen)
* Respiratory viruses include influenza A/B, RSV, others
84
CAP Classification for Outpatient Treatment: with comorbidities treatment recommendations
* Respiratory fluoroquinolone PO (moxi-, levofloxacin) – OR –
* Azithromycin PO PLUS beta-lactam such as amoxicillin-clavulanate
* In CAP with comorbidity treatment, remember PO levo- or moxi- with an alternative PO azithro- with amox-clav are the antimicrobial recommendations
85
Criteria for Hospitalization – PSI/PORT Scoring
* No score: class I – outpatient treatment
* <70 points: class II – outpatient treatment
* 71-90 points: class III – outpatient or inpatient treatment
* 91-130 points: class IV – inpatient treatment (ICU?)
* > 131 points: class V – inpatient treatment (ICU?)
86
Criteria for Hospitalization – CURB-65 Criteria
* Confusion – any change in mental status from baseline or confusion
* Uremia – BUN > 19 mg/dL
* Respiratory rate – RR > 30
* Blood pressure – SBP < 90 and DBP < 60
* 65 years old – age ≥ 65
* Should be hospitalized if someone meets at least 2 criteria
87
Criteria for ICU Admission – Major criteria for CAP
* Septic shock – septic shock requiring vasopressors
* Respiratory failure – respiratory failure requiring mechanical ventilation
* Any one of the major criteria meets ICU admission criteria
88
Criteria for ICU Admission – minor criteria for CAP
* Respiratory rate - > 30 breaths per minute
* PaO2/FiO2 - < 250
* Infiltration – multilobar infiltrates
* Mental status – confusion/disorientation
* Uremia – BUN > 20
* Leukopenia – WBC < 4,000
* Thrombocytopenia – platelets < 1,000
* Hypothermia – core temperature < 36C
* Hypotension – requiring aggressive fluid resuscitation
* Any combination of 3 minor criteria meets ICU admission criteria
89
Hospital-Acquired Pneumonia (HAP) Likely pathogens
- Strep. Pneumoniae
- Staph. Aureus
- H. influenzae
- enteric Gram-negative bacilli (E. coli, Klebsiella pneuomonia, pseudomonas
90
Initial Empiric Therapy for HAP
• Choose 1
o Piperacillin-tazobactam (Zosyn) 4.5 g IV q6h
o Levofloxacin (Levaquin) 750 mg IV daily
o Cefepime (Maxipime) 2 g IV q8h
o Imipenem (Primaxin) 500 mg IV q6h
o Meropenem (Merrem) 1 g IV q8h
• No preference, depends on facility and antibiogram
- add on vanco if high risk for MRSA
91
Initial Empiric Therapy for HAP – general considerations
• Duration of therapy
o Recommendation is to follow procalcitonin (PCT) levels and discontinue therapy when PCT is ≤ 0.25 ng/ml
o Generally, 8 days for susceptible pathogens and 14 days for MRSA/MSSA and drug-resistant organisms
• Tailor therapy to culture results
92
Likely pathogens of Ventilator-associated pneumonia (VAP)
• Same as HAP but with an increased likelihood of Pseudomonas and MRSA
- Strep. Pneumoniae
- Staph. Aureus (MRSA)
- H. influenzae
- enteric Gram-negative bacilli (E. coli, Klebsiella pneuomonia, pseudomonas
93
Initial Empiric Therapy for VAP – 3 categories of antimicrobials needed for treatment
* Gram-positive antibiotics with MRSA activity
* Gram-negative antibiotics with anti-psuedomonal activity (β-lactam agents)
* Gram-negative antibiotics with anti-pseudomonal activity (non-β-lactam agents)
94
Initial Empiric Therapy for VAP – gram-positive antibiotics with MRSA activity
* Choose 1
* Vancomycin (Vancocin) 15 mg/kg IV q8-12h
* Linezolid (Zyvox) 600 mg IV a12h
95
Initial Empiric Therapy for VAP – Gram--negative antibiotics with anti-psuedomonal activity (β-lactam agents)
* Choose 1
* Piperacillin-tazobactam (Zosyn) 4.5 g IV q6h
* Cefepime (Maxipime) 2 g IV q8h
* Ceftazidime (Fortaz) 2 g IV q8h
* Imipenem (Primaxin) 500 mg IV q6h
* Meropenem (Merrem) 1 g IV q8h
* Aztreonam (Azaxtam) 2 g IV q8h
96
Initial Empiric Therapy for VAP – Gram-negative antibiotics with anti-pseudomonal activity (non-β-lactam agents)
* Choose 1
* Levofloxacin (Levaquin) 750 mg IV daily
* Ciprofloxacin (Cipro) 400 mg IV q8h
* Amikacin (Amikan) 15-20 mg/kg IV daily
* Gentamicin 5-7 mg/kg IV daily
* Tobramycin (Tobrex) 5-7 mg/kg IV daily
* Polymyxin E (Colistin) 5 mg/kg IV x1 dose then 2.5 mg x (1.5 x CrCl) IV daily
* Polymyxin B 2.5-3.0 mg/kg/day divided in 2 daily IV doses
97
Initial Empiric Therapy for VAP – general considerations
• Prevention is key
o Prevent intubation, good hand hygiene of providers/clinicians, good patient oral care, and elevate HOB 30-45 degrees (when able)
• Duration of therapy: follow procalcitonin (PCT) levels and discontinue therapy when PCT is ≤ 0.25 ng/ml
• Tailor therapy to culture results
98
Etiology/Pathophysiology of ARDS
• An inflammatory lung condition caused by direct or indirect injury to lungs (infection, trauma, hypotension)
99
Diagnostic inclusion criteria of ARDS
Acute onset of:
o Bilateral diffuse infiltrates caused by non-cardiogenic pulmonary edema/pulmonary capillary leak
o PAWP/PCWP < 19 mmHg (no evidence of left arterial hypertension)
o PaO2/FiO2 ratio of ≤ 300 mg (≤ 300 mg = acute lung injury; ≤ 200 mg = ARDS)
100
Treatment of ARDS – general considerations
* Treat underlying cause
* Support oxygenation, cardiac output, and ventilation
* Optimize lung recovery and prevent lung injury
* Ventilator management
101
Treatment of ARDS – initial ventilator management strategies
• Calculate predicted body weight (PBW):
o Males = 50 + 2.3 x [height in inches – 60]
o Females = 45.5 + 2.3 x [height in inches -60]
• Select ventilator mode (provider preference)
• Initial VT = 8 ml/kg per PBW (if you start at 8, will have to come down to 6 ml/kg)
• Reduce to ideal VT of 6 ml/kg (1 ml/kg reduction intervals at every ≤ 2 hours)
• Set initial rate at approximately baseline (do not exceed 35)
• Adjust VT and RR to meet plateau pressure and pH goals
102
Goals of ventilation therapy in ARDS – oxygenation goal
* Minimum PEEP requirement of 5
| * PaO2 goal of 55-80 mmHg or SpO2 of 88-95% (“lower PEEP/higher FiO2” and “higher PEEP/lower FiO2”)
103
Goals of ventilation therapy in ARDS – plateau pressure goal
• Plateau pressure = pressure applied to airways, measured during inspiratory phase
• ≤ 30 cm H2O
• Check PPLAT every 4 hours and with changes in PEEP and VT changes
o If > 30, decrease VT by 1 ml/kg steps (minimum of 4 ml/kg)
o If < 25, increase VT BY 1 ml/kg steps until PPLAT > 25 or VT = 6 ml/kg
• pH goal (7.30-7.45)
o If pH 7.15-7.30, increase RR (pH > 7.30 or PaCO2 < 25)
o If pH < 7.15, increase RR to 35 and consider increasing VT by 1 ml/kg until pH > 7.15 (may exceed PPLAT target of 30 temporarily)
o If pH > 7.45, decrease RR if possible
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General Ventilator Weaning Parameters
* FiO2 ≤ 40 and PEEP ≤ 8 OR FiO2 ≤ 50 and PEEP ≤ 8
* PEEP and FiO2 values are ≤ the previous day’s settings
* Patient has acceptable spontaneous breathing efforts (can decrease vent rate by 50% to evaluate spontaneous effort)
* Systolic BP ≥ 90 without vasopressor support
* No neuromuscular blocking
105
What does ARDS look like on CXR?
• Like someone “dipped a sponge in white paint and sponge-painted across the CXR”
106
What does a pneumothorax look like on CXR?
* No pleural lines/no lung lines
| * Lung looks “shrunken”
107
Etiology/Pathophysiology of a pneumothorax
• Increased gas in the pleural space from a variety of factors
o Traumatic injury – blunt trauma most common
o Spontaneous – COPD (blebs can burst), asthma, tall/thin males, marijuana smoking (blebs can burst)
• Air trapping and increased pressure can cause a mediastinal shift → compression of the great vessels and heart known as a tension pneumothorax
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Symptoms of a pneumothorax
* Acute onset of SOB
* Tachypnea
* Pleuritic chest pain
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Physical exam findings of a pneumothorax
```
• Hyperresonance to percussion
• Absent breath sounds on the injured side
• Tension pneumothorax
o Severe respiratory distress
o Signs of obstructive shock
o Hypotension
o Distended neck veins (late sign)
o Tracheal deviation (late sign) – away from side of injury
```
110
Diagnostics of a pneumothorax
* CXR is the diagnostic study of choice
| * Air in the pleural space with absence of lung markings
111
Treatment of a pneumothorax
Needle decompression
o First-line therapy form primary pneumothoraces or small secondary pneumothoraces (< 2 cm) and minimally-symptomatic patients
Chest tube placement
o Definitive treatment for patients with appreciable symptoms and/or secondary pneumothoraces > 2 cm
Tension pneumothorax
o Emergent needle decompression with a 14G or 16G IV in the 2nd ICS MCL followed by chest tube insertion
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Etiology/Pathophysiology of a hemothorax
```
Blood accumulation in the pleural space caused typically by some form of traumatic injury
o Blunt trauma
o Penetrating trauma (more common)
Also may be caused by an injury to an adjacent structure
o Costal blood vessels (rib fractures)
o Great vessels
o Liver laceration
o Spleen laceration
o Diaphragmatic injury
```
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Symptoms of hemothorax
* Dyspnea
* Tachypnea
* Pleuritic chest pain
114
Physical exam findings of a hemothorax
* Dullness to percussion
* Decreased breath sounds on the injured side
* Signs of hypovolemic shock
115
Diagnostics of a hemothorax
* CXR is the diagnostic study of choice
| * Blood in the pleural space (white out)
116
Treatment of a hemothorax
* Chest tube placement
* Autotransfusion – if profusely bleeding
* Open thoracotomy in the presence of uncontrolled bleeding
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Etiology/Pathophysiology of a PE
* Thrombus in the arterial system of the lung preventing effective perfusion (not a ventilation problem)
* Most commonly caused by a thromboembolism from a DVT. Most common causes of DVT are blood stasis (not moving around) and polycythemia
* Also seen in patients with an oncologic diagnosis (multiple micro PEs)
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Symptoms of a PE
* Sudden and abrupt onset
* Dyspnea
* Pleuritic chest pain
* Cough
* Hemoptysis
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Physical exam findings of a PE
* Tachycardia and tachypnea
* Rales
* S4 heart sound
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Diagnostics for a PE
* CT angiography (CTA) of chest is diagnostic study of choice
* Ventilation/perfusion (VQ) scan may be considered but often has low utility
* Lab assessment – D-dimer
* Screening via Wells criteria
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Diagnostics for PE – D-dimer
* High sensitivity but poor specificity
* ≤ 500 ng/ml rules out PE
* If > 500, further investigation required. Does not automatically mean a PE
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Diagnostics for PE – Wells criteria
* Score ≤ 0 = low probability (5%)
* Score 1-2 = moderate probability (17%)
* Score ≥ 3 = high probability (53%)
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Treatment for PE
• Anticoagulation (duration depending on cause)
o Unfractionated or low-molecular weight heparin
o Warfarin (Coumadin) – INR goal of 2-3
o Rivaroxaban (Xarelto) 15 mg BID for 1st 3 weeks then 20 mg PO daily
• IVC filter – if anticoagulation is contraindicated
• Thrombectomy – for large proximal PEs with hemodynamic compromise (shock)
• Thrombolysis (TPA 100 mg over 2 hours) – for PEs with hemodynamic compromise (shock) or a massive PE with high risk of hemodynamic compromise (shock)
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Transudative vs. exudative pleural effusion causes
* Transudative – “water”: CHF, constrictive pericarditis, cirrhosis
* Exudative – “cellular material”: lung parenchymal infection, malignancy, PE
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Diagnostic criteria of pleural effusion
* Initially found on CXR. Diagnostic study of choice to evaluate is a thoracentesis for al effusions > 1 cm
* Transudative: specific gravity < 1.016, protein < 3.0 (< 30), and < 200 units LDH
* Exudative: specific gravity > 1.016, protein > 3.0 (> 30), and > 200 units LDH
* Transudative is low because it’s “water” whereas exudative is high because it’s “cellular material”
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Treatment of pleural effusion
* If known to be from fluid overload (CHF or cirrhosis), try diuresis and look for resolution
* Symptomatic effusions – therapeutic thoracentesis, treat underlying disease process
* Parapneumonic effusion (infectious) – antibiotic therapy for pneumonia, tube thoracostomy if > ½ of hemithorax or empyema is present
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You are called to the ED to admit a 48-year-old male for an asthma exacerbation. The patient’s vital signs are as follows: HR 45, RR 24, BP 96/45, pulse ox 87% on 4 LPM via nasal cannula. The peak flow on arrival was 40% of the predicted value. The patient is on continuous albuterol nebulizers and was given a dose of methylprednisolone (Solu-Medrol) 125 mg IV. An ABG was just resulted and reveals the following: pH 7.3, pCO2 50, HCO3 30, and PaO2 55%. The patient appears drowsy with confused conversation and is unable to speak more than a few words during your evaluation. You also note that the patient appears severely short of breath, however there is no audible or auscultate wheezing. What is your priority intervention?
a. Order an additional dose of methylprednisolone (Solu-Medrol)
b. Order a dose of lorazepam (Ativan)
c. Intubate the patient
d. Increase the oxygen to high-flow therapy
c. Intubate the patient
C is correct because: Absence of wheezing means the patient is going into respiratory distress, labs also support this
128
While admitting a 30-year-old female patient for an asthma exacerbation you discover that the patient has been in the ER 7 times in the past 2 months for asthma-related symptoms. She also reports SOB 3-4x/week that she is able to manage at home. The patient is currently on an albuterol inhaler only. Which of the following medications would you add on for this patient?
a. Formoterol (Foradil)
b. Fluticasone (Flovent)
c. Montelukast (Singulair)
d. Ipratropium bromide (Atrovent)
b. Fluticasone (Flovent)
B is correct because: The patient is a poorly controlled asthmatic on a SABA only – the next step would be to add an ICS as she has moved from intermittent to persistent asthma.
129
What is the purpose of referring a patient to pulmonary rehabilitation?
a. Reduce hospitalization
b. Maximize function
c. Restore lost function
d. Increased functional residual capacity
b. Maximize function
B is correct because: doing this to reduce hospitalizations
C and D are incorrect because: not possible with pulmonary disease
130
The typical radiograph appearance of emphysema includes:
a. The presence of Kerley’s lines
b. Redistribution of flow in pulmonary vasculature
c. Flattened diaphragm and increased retrosternal airspace
d. Whitening of the terminal airspaces
c. Flattened diaphragm and increased retrosternal airspace
A is incorrect because: this is seen in acute heart failure
B is incorrect because: this is seen in chronic heart failure
D is incorrect because: this is seen in ARDS
131
Diagnosis of a patient with COPD must include a notation of a:
a. FEV1 < 80% predicted
b. FVC < 80% predicted
c. FEV1/FVC ratio < 0.70 (70%)
d. FEV1/FVC radio of < 1.0
c. FEV1/FVC ratio < 0.70 (70%)
C is correct because: this is the diagnostic criteria for COPD
A is incorrect because: FEV1 determines severity of COPD, not the diagnosis
D is incorrect because: this answer doesn't make sense
132
Which of the following would be indicators for starting antimicrobial therapy in a patient with a COPD exacerbation (select all that apply).
a. An elderly patient with no comorbidities
b. A patient on mechanical ventilation
c. A patient with increased, purulent sputum production
d. A patient being discharged with poor follow-up
e. A patient with a consolidation noted on a CXR
b. A patient on mechanical ventilation
c. A patient with increased, purulent sputum production
e. A patient with a consolidation noted on a CXR
133
You are admitting a 60-year-old male for a COPD exacerbation. The patient arrived in the ER with severe dyspnea. After being on a short-acting beta2-agonist and receiving IV corticosteroids, there was no improvement in symptoms. The ED provider placed the patient on non-invasive mechanical ventilation (NIMV). The ABG results are as follows: pH 7.2, PCO2 50, HCO 27, and a PaO2 35 on 2 LPM nasal cannula. While evaluating the patient you note that after 45 minutes of NIMV he is still symptomatic and is unable to stay awake during your assessment. What is the best course of action for this patient?
a. Continue NIMV and add on a long-acting anti-cholinergic
b. Intubate the patient and admit to the ICU
c. Start the patient on an inhaled corticosteroid
d. Repeat the ABG
b. Intubate the patient and admit to the ICU
B is correct because: patient is showing signs of respiratory failure and impending arrest
A is incorrect because: means you are essentially doing nothing
C is incorrect because: this intervention won't do anything
134
Which of the following methods are proven to prevent ventilator-associated pneumonia? (select all that apply)
a. Prophylactic systemic antibiotics for all intubated patients
b. Non-invasive mechanical ventilation
c. Regular use of oral anti-septic agents
d. Elevating the head of bed to 25 degrees
e. Good hand hygiene
f. Trending procalcitonin levels
b. Non-invasive mechanical ventilation
c. Regular use of oral anti-septic agents
e. Good hand hygiene
D is incorrect because: the HOB should be at least 30 degrees
F is incorrect because: this is used to determine when to discontinue antibiotics
135
An 84-year-old female patient from a long-term care facility was found unconscious and unresponsive in bed. A CXR is consistent with aspiration pneumonia. The nurse practitioner knows the following antibiotic regimen would be the most appropriate first-line therapy
a. Ceftriaxone (Rocephin) 1g IV q24h + metronidazole (Flagyl) 500 mg IV q6h
b. Levofloxacin (Levaquin) 750 mg IV q24h
c. Piperacillin-tazobactam (Zosyn) 3.375 g IV q6h
d. Amoxicillin-clavulanate (Augmentin) 875/125 mg PO twice daily
a. Ceftriaxone (Rocephin) 1g IV q24h + metronidazole (Flagyl) 500 mg IV q6h
136
Which of the following are true about CURB-65 criteria? (select all that apply)
a. Patients should be admitted to the hospital if they meet at least 3 of the 5 criteria
b. The “65” refers to the age criteria
c. Uremia is defined as BUN > 19
d. Respiratory rate is defined as increased if > 24
e. Confused patients should be admitted to the hospital regardless of remaining criteria
b. The “65” refers to the age criteria
c. Uremia is defined as BUN > 19
A is incorrect because: should meet at least 2 of the 5 criteria
D is incorrect because: RR is increased in > 30
E is incorrect because: May do that in practice but is not what the CURB-65 criteria states
137
When determining the duration of antimicrobial therapy for hospital-acquired pneumonia, which of the following is the most accurate indicator of discontinuing antibiotics?
a. Return of the patient’s core temperature to normal
b. Decreasing leukocytosis
c. A procalcitonin level of ≤ 0.25 ng/ml
d. A clinical pulmonary infection score of 11 points
c. A procalcitonin level of ≤ 0.25 ng/ml
138
You have placed a 43-year-old male patient with ARDS on a FiO2 of 100% and PEEP of 5. The ABGs are as follows: pH 7.36, PaCO2 37, PaO2 50, HCO3 23. Which of the following indicators of improvement do you anticipate?
a. pH of 7.4
b. PaCO2 of 40
c. PaO2 of 70
d. HCO3 of 25
c. PaO2 of 70
139
A 50-year-old female patient is diagnosed with ARDS secondary to overwhelming sepsis. The patient’s predicted body weight (PBW) is 176 lbs. (80 kg). What would be the ideal goal tidal volume for this patient?
a. 320 ml
b. 480 ml
c. 640 ml
d. 80 ml
b. 480 ml
C is incorrect because: This is using 8 ml/kg; okay to start here but the goal is to get them down to 6 ml/kg
140
A 62-year-old male patient is placed in the ICU following MI. A central venous catheter has been required and placed in the subclavian vein. The patient complains of mild SOB and right-sided chest pain. He has decreased breath sounds on the right side with hyperresonance to percussion. CXR shows a moderate-sized pneumothorax without the presence of a mediastinal shift. What would be your first action?
a. Insert a chest tube
b. Needle decompression
c. Intubation
d. CT of the chest
a. Insert a chest tube
B is incorrect because: Patient no more than minimal symptoms and the pneumothorax is moderately sized, so we can skip the needle decompression and go straight for the chest tube
141
Which of the following conditions does not cause hypoxemia?
a. Hyperventilation
b. Hypoventilation
c. Right to left shunt
d. Decrease in atmospheric oxygen
a. Hyperventilation
A is correct because: This causes hypocarbia (blowing off too much CO2)
142
Pulmonary embolus results in hypoxemia that will produce a classic constellation of symptoms, such as tachypnea, tachycardia, pale, clammy skin, chest pain, hypotension, and a sense of impending doom. The mechanism of hypoxemia is:
a. Right to left shunting within the vasculature
b. Reactive bronchospasm d/t to extrabronchial pressure
c. Increased dead alveolar space
d. A product of tachypnea
c. Increased dead alveolar space
C is correct because: a PE blocks blood flow, meaning you can't profuse
A is incorrect because: this is seen in ARDS
D is incorrect because: this causes hypocarbia (blowing off too much CO2)
143
In a patient with pulmonary embolism, you would expect to find:
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
b. Respiratory alkalosis
B is correct because: It is a respiratory problem + patients become tachypneic blowing off too much CO2 leading to alkalosis
144
Which of the following patients is most likely to develop a pulmonary embolus?
a. An 18-year-old female on combined oral contraceptives
b. A 72-year-old male with alcoholic cirrhosis
c. A 39-year-old male with paraplegia from a recent traumatic injury
d. A 50-year-old female cigarette smoker
c. A 39-year-old male with paraplegia from a recent traumatic injury
C is correct because: Most common cause of PEs is DVT; most common causes of DVT is immobility and polycythemia
145
Who among the following patients is most likely to have post-op pulmonary complications?
a. A 68-year-old male with a 50-pack year smoking history s/p knee replacement
b. A 60-year-old female with mildly decreased FEV s/p shoulder arthroscopy and debridement
c. A 70-year-old male s/p transverse sigmoid colon surgery
d. A 54-year-old female s/p hysterectomy
a. A 68-year-old male with a 50-pack year smoking history s/p knee replacement
A is correct because: Smoking hx = underlying lung issues + knee replacement = immobility
C is incorrect because: While this guy is the oldest, we have to assume he’s otherwise healthy until stated somewhere
146
You are called to the ER to evaluate a 20-year-old male who was involved in a house fire. The patient reports he has a headache, dizziness, nausea, generalized chest pain, and a sore throat. During your physical exam, you note the patint has a hoarse voice, and is consistently clearing his throat. He also has singed facial hair. What is your first intervention?
a. Order a carboxyhemoglobin level
b. Obtain a pulse ox reading
c. Prepare for intubation
d. Order a CXR
c. Prepare for intubation
C is correct because: He is showing signs of inhalation injury – huge risk of impending airway compromise and so we need to protect the airway
A and D are incorrect because: we will get these eventually but this isn't the first intervention
B is incorrect because: it won't be accurate d/t the CO
147
21. The therapeutic effect of starting CPAP therapy in a patient with OSA include all of the following except:
a. Decreasing apnea
b. Increasing blood pressure
c. Decreasing sleepiness
d. Increasing ejection fraction
b. Increasing blood pressure
B is correct because: should expect a decrease in BP
