CPR Exam 2 Hubbard DSAs Flashcards
long-term management of pneumothorax
- stop smoking
- avoid: high altitudes, unpressurized flights, scuba diving
*if successful tx no LT complications associated
confirmation and staging of COPD by GOLD standard uses
spirometry *all FEV1/FVC <70% FEV1 measurement: 1. mild : > 80 2. moderate < 80 3. severe < 50 4. very severe <30
*can also test severity via BODE index (BMI, obstruction, dyspnea, exercise intolerance)
imaging of pulm embolism on CXR shows
- focal oligoemia (“west mark sign”)
- wedged shaped density above diaphragm (hampton hump)
- enlarged Pulm A.
common TB signs and sx
maybe be asx early on
-sx: wt loss, chills, fever, and if advanced, hemopytsis and chest pain
prevention of HCAP
- avoid intubation if possible (if needed prompt extubation through frequent weening trials reduced risk)
- minimize manipulation of tube
- hand hygiene
- semi upright/ upright intubated pts
- mouth care
when to use O2 tx in COPD
very severe COPD
-PaO2 < 55 or O2 sat < 88 %
OR
-PaO2 <59 or O2 sat <89 with pulm HTN/corpulmonale or hct >55%
major risk factor of TB
HIV/AIDS
how to tx very severe stable COPD
- SABA
- 1+ elongating bronchodilator (LABA, tiotropium)
- ICS
- long-term Oxygen therapy
- consider surgery (upper lobe emphysema or low baseline excercise capacity)
manifestation of sleep apnea
excessive daytime fatigue, impaired attention, decreased memory, increased risk of MVA
what is the most reliable indicator of degree of dyspnea
patient self report via MRC dyspnea Scale
1 = breathlessness only on strenous excercise
3= walks slower than most, stops after 1 mile of walking
5= too breathless to leave house/ breathless when undressing
follow up procedure for TB
FU often (monthly)
focus on sign and sx (not labs)
get expert consult if no improvement in 3 months
test close contacts for LTBI
how to tx Cryptogenic organizing pneumonia (COP) in both hypersensitivity pneumonitis and sarcoidosis
steroids
sarcoidosis ranges from monitoring –> steroid use
how to tx MDR-TB and XDR-TB
MDR - (isoniazid and rifampin resistant)
XDR - (isoniazid and rifampin and fluoroquinolone, and kanamycin and amkikacin resistant)
Tx for both depends on expert consult and specialty testing
most common causes of acute cough
- viral upper respiratory tract infection (RACE)
- viral lower respiratory tract infection (i.e Flu)
- pneumonia
- acute bronchitis (i.e pertussis)
- asthma
- acute exacerbation of chronic bronchitis
simple helpful interventions to improve ARDS outcomes
- daily ventilator liberation screen
- proper oral care
- DVT prophylaxis
- OMM (lymphatic)
biggest risk factor of head and neck cancer
tobacco and alcohol
tx and prevention for FES
Supportive TX:
- early correction of fracture
- mechanical ventilation
- fluid recusitation
- O2
Prevention:
- early immbolixation of fracture
- intraosseous pressure limitation during bone surgery
- prophylatic corticosteroids
when to use invasive or noninvasive ventilation with COPD pts
noninvasive tx of respiratory acidosis (hyperventilation casusing ph<7.35 and CO2 >45)
*use invasive if respiratory acidosis, plus impaired mental status, hypotension, shock, etc
common causes of COPD exacerbation
- infection (pneumonia, etc)
2. air pollution
sx of lung cancer
hemotypsis , dyspnea, cough, and if small cell lung cancer there is many paraneoplastic syndromes
*small cell is almost exclusively dx in smokers
length of acute vs chronic cough
less than 3 weeks = acute
more than 8 weeks = chronic
*in between is sub acute
how to tx pt with hypercapnia and altered mentation/syncope
immediate endotracheal intubation
risk associated with recurrent pneumocystitis pneumonia related pneumothorax
c/l pneumothorax (both lungs collapse)
**high mortality
determining severity of OSA
AHI + degree of sleepiness + any cardiac issues
leading causes of pleural effusion
CHF, pneumonia, cancer
imbalance of fluid production and removal bc increased hydrostatic pressure and decreased oncotic pressure
major difference in symptoms of pulmonary edema and pleural effusion and pulmonary embolism
edema - acute cough
effusion - dyspnea and chest pain
embolism- cough, dyspnea, pleuritic chest pain, DVT sx
pulm edema can be caused by HF, VHD, pulm HTN, CKD, or nephrotic syndrome. **not caused by pneumonia
embolsim caused by Virchow Triad
pleural effusion commonly caused by HF, pulmonary embolism, kidney failure, trauma, or INFECTION (like pneumonia)
most common causes of Pulm HTN
- Group 2 :left sided heart dz
- Group 3: secondary lung dz and/or hypoxia (COPD, ILD< Sleep apnea)
other: group 4 = thomboembolic , Group 5 = multifactorial (sarcoidosis, thyroid, etc)
two mechanisms of ILD
- distal lung parenchyma damage by
1. inflammation with fibrosis (IPF, NSIP)
2. granulomatous change (COP- sarcoidosis, etc)
how to work up a suspected ACTIVE TB patient
- acid fast bacilli smear and culture
- CXR
- TST and IGRA
* for active or latent: test for HIV if unknown status
tx of pneumonia pleural effusion
- if loculated, pH < 7.2, glucose < 60, gram +, pus THEN abx won’t help alone
1. abx + chest tube drain
2. if still not resolved add video assisted thorascopic surgery - *TPA and DNAase intrapleural tx improves outcomes
PFTs of ILD show
decreased diffusing capacity and decreased lung volume
symptomatic OSA can lead to
secondary HTN (via SNS vasoconstriction)
if severe OSA with hypoxemia can lead to secondary erthyrocytosis (elevated HCT) **therefore order CBC
if untx it can lead to heart problems (increase after load and O2 demand, decreased LV compliance–>CHF)
sx of pulmonary HTN ? advanced pulmonary HTN?
fatigue, exertion dyspnea, possible chest pain/palpitations
*advanced = left parasternal lift with pulmonary edema
sx of pneumomediastinum
- severe substernal chest pain
- subcutaneous emphysema
- Hammans sign (crunching noise with heart beat)
how to tx ARDS
- noninvasive O2 is only temporary
- invasive mechanical ventilation corrects hypoxemia ( high risk of more alveolar damage by “ventilation induced injury”)
- add conservative fluid management to ventilation or replace ventilation with ECMO is available
- HFOV = tx for refractory hypoxemia ( increased RR, low tidal volumes)
CAP out patient dx/tx
outpatient:
dx: CXR and pulse ox
tx: <7 days; NL pt: macroclide or doxycycline ; pt with cardiopulmonary dz: respiratory quinolone, or B-lactam + macrolide/doxycycline combo
how to manage acute dyspnea
- stabilize with O2
2. get CXR to identify underlying cause to tx
massive pleural effusion (entire hemithorax) indicates
lung or pleural cancer
usually exudative vs transudative seen in heart or liver failure
imaging order in FES
CXR, CT of chest and MRI to see brain when CNS is involved
tx of HCAP
if no respiratory failure: ceftriaxone or levofloxacin (respiratory fluoroquinolone)
if risk of MDR (>5 days hospitalized, recent abx) then use antipsuedomonal agent + vancomycin
how to manage pt with hemoptysis
- *get CXR!!
- if chronic sx in >40 yr old male smoker than also get Chest CT and bronchoscopy to rule out malignancy on NL CXR
prognosis predictor of pulm HTN
use right sided heart fxn test (exercise test) over PAP measurement
prevention of CAP pneumonia
-flu vaccine (> 6 months old)
-pneumnococcal vaccine
*23 valent all pts >65, and <65 if combordities
*13 valent all pts >65, or IC/ cochlear implants
(give 13 first, and then 23 > 8 weeks after; if 23 given first, wait >1 yr for 13 to be administered )
what indicated Legionaares Dz (pneumonia by Legionella)
> 50 yo, severe pneumonia, extrapulmonary sx (i.e hyponatremia, HA, diarrhea)
how to tx stable moderate COPD
- inhaled tx (via metered doe inhaler with spacer device, or nebulizer)
- SABA = quick relief
- LABA = monotherapy (possible combined)
- ipatropium/tiotropium = combined tx
- methylxanthine (theophylline)= adjunctive to inhaled tx - pulmonary rehab
when to switch to oral Abx in inpatient CAP tx
sx improve and no fever twice at least 8 hours apart
*discharge when switch is made
how to dx DVT
- use WELLS score to determine probability
- if low- D dimer test. (- rule out, + get US)
- if high get US
* venography is the gold standard but rarely used
CXR dx of pleural effusion
- standard
* Blunt costophrenic angle (if >250ml)
* meniscus sign= large amount of fluid opacify lower thorax - decubitus films (on side)
- measure amount to determine thoracentesis indication (>1cm) and determine if located or free flowing - US -detects locutions and guides thoracentesis
when do you perform thoracentesis of pleural effusion in CHF pts ? what is the major risk ??
- asymmetric PE
2. pneumothorax is major complication
two top differentials with weight loss and hemotypisis
TB (infection) or cancer
when to hospitalize LTBI infection
is respiratory distress, hemopytisis, or systemic dz become present
locations on decubitus films in pt with pleural effusion indicates
empyema (complication of pneumonia )
see WBC> 50,000; high WBC also seen in complicated parapneumonic effusions
4 most predictive COPD indicators
- self reported hx of COPD
- > 40 pack year hx
- age >45
- max laryngeal height <4cm
CAP in patient DX/TX
dx: CXR, 2 blood cultures, routine metabolic panel, pulse ox, CBC; if high risk for drug resistance then culture and stain
tx:
1. administer O2, immediate abx tx (IV abx w/i 6 hrs)
(abx: respiratory quinolone, or B-lactam + macrolide/doxycycline combo )
*use clindamycin if aspiration or lung abscess
ICU pts: alert with isolated hypoxemia or hypercapnia then use noninvasive positive pressure ventilation
ICU pt abx: B lactam + azithromycin/fluroquinolone
>10 days
risk factors of pneumonia
alteration in anatomic barriers, impairment of humoral/cell-mediated immunity, impaired phagocytic function
differentials associated with OSA
- RLD
- GERD
- sinusisits
- epilepsy/narcolepsy
- hypothryoidism
- acromegaly
labs of pneumothorax show
hypoxemia, respiratory alkalosis (hypoventilation), QRS/Twave changes that MIMIC AMI !!
management of pts who do not improve on tx within 72 hours of tx onset in CAP pneumonia
consider M. TB, fungal, viral, pnuemosystis infection
-order more tests and get consultation
most common cause of ARDS
sepsis
what cancer is EBV related and Mediterranean and Far East Assoc.
nasopharyngeal cancer
sx of epiglottitis causing UAO. dx tools? tx?
sx: odynophagia (painful swallowing) sore throat dyspnea and stridor (bc obstruction ) hoarseness fever tachycardia
dx: fiberoptic layrngoscopy and maybe throat culture
tx: secure airway and ABX
oropharynx cancer is assoc with
mainly HPV 16 ( and other high risk HPV 18, 31, 32)
complications of spontaneous pneumothorax
pnuemomediastinum or subcutaneous emphysema
how to tx severe stable COPD
- SABA
- 1+ elongating bronchodilator (LABA, tiotropium)
- add ICS (if repeated exacerbations)
steps in diagnosing mediastinal mass
- identify compartment (anterior, middle, posterior)
- CT scan (VERY IMP)
a- barium study if posterior
b. iodine 131 for goiter - mediastinoscopy or anterior mediastinomy
(official dx for anterior or middle masses)
*alternative dx: video assisted thorascopy (can also tx by removal during procedure)
T/F Use compression stocking to prevent DVT
DO NOT USE COMPRESSION STOCKING IN HIGH RISK PATIENT OF DVT
risk factors for OSA
male
obese
postmenopausal women
how to tx established DVT
- immediate anti-coag with IV heparin
- long term anti-coag with warfarin until INR 2-3 twice more then 24 hours apart
- if extensive thrombosis. use thrombolytics with catheter and then 3 months of anti-coags
* if anti-coag contraindicated then use IVC filter (decreases short term risk, but increases long term risk)
ARDS can present similar too
acute infectious pneumonia (with interstitial pattern or diffuse airspace dz)
(pneumocystisis, bacterial- CAP)
or other noninfectious DZ
*all present with DAD
how to distinguish ARDS from other causes of respiratory distress
identify underlying cause/ inciting event.
ARDS is caused by many things but is a dx of exclusion
indications of HCAP (healthcare associated pneumonia)
pneumonia developing at least 48 hrs after hospitalization
*most common is ventilator associated pneumonia (VAP)
tx of recurrent or b/L pneumothorax or pneumothorax with failed thoracostomy drain
thorascopy or open thoracotomy (surgery)
most common causes of hemoptysis related (acute or chronic) cough
- infection (bronchitis, pneumonia)
2. malignancy
dx of decreased maximum oxygen uptake without identifiable cause
deconditioning
tx of OSA
- lifestyle modification !!
- steroids/decongestant to tx congestion
- if refractory OSA = CPAP
(CPAP non compliant pts use bi-level PAP nasal ventilation or auto-titrating PAP)
*alternative = mandibular advancement device
*unwillingness = surgical tx
tx of pneumocystitis related pneumothorax
no best tx identifies; use hemlich valve with small bore chest tube so they can go home
how to manage pt with CC of chronic dyspnea, unrevealing HX and PE?
cardiopulmonary exercise test or arterial blood gas measurement
5 management strategies of ARDS
- low tidal volumes 2. prone ventilation 3. fluid management 4. cardiopulmonary monitoring 5. corticosteroids
dx of OSA
- Epworth Sleepiness Scale (measures daytime fatigue)
- STOP-BANG questionnaire (screening tool for likelihood)
- polysomnography (PSG) (required for dx)
* PSG + electroencephalogram most accurately confirms dx!
- PSG gives AHI; AHI>5 = OSA - asses for obesity hypoventilation syndrome (PaCO2>45)
triad of sx seen in fat embolism syndrome
- hypoxemia
- neurologic ABNL (confusion, syncope)
- petechial rash (red brown around head neck thorax axilla)
(1-3 days after appropriate insult with no other cause of dz indicated)
other sx: tachypnea, dyspnea
MIMICS ARDS
tx of large primary spontaneous pneumothorax
- aspiration drainage with small bore catheter
- tx symptomatically for cough and chest pain
- CXR every 24 hrs
* placing small bore chest tube attached to one-way heimlich valve can’t prevent tension pneumothorax and be used at home
precursor lesions to head and neck cancers
erythroplakia and leukoplakia
dx criteria for ARDS
bilateral (airspace opacities) infiltrate, acute onset, hypoxemia, no heart failure
with FiO2 <200
dx of HCAP
based on clinical presentation (fever, purulent sputum, decreased oxygen), leukocytosis, and new CXR findings (new/progressive radiographic infiltrates)
tx of mild-moderate COPD exacerbation
home tx with SABA or SABA + OCS/abx
causes of pneumomediastinum
- alveolar rupture
- esophageal/tracheal/ bronchi rupture
- dissection of air from neck or ab (spontaneous pneumothorax)
more at risk population for primary spontaneous pneumothorax
tall, thin males
primary means no underlying cause
how to monitor progression or tx response to pulm HTN
- 6 min walk test
- echocardiogram
- catheterization
tx of venous stasis
sx. edema, shiny atrophic skin, ulcers, varicose veins
tx: compression, decrease prolonged standing, UNNA boot (dressed compression boot to decrease edema and promote ulcer healing)
signs and sx of pleural effusion
sx: dyspnea and chest pain, possible fever (if pneumonia)
- signs: dull percussion, decreased tactile fremitus, decreased breath sounds, pleural friction rub
causes of chronic mediastinitis ? sx? tx?
- histoplasmosis (fibrosing medistinitis )
sx: compression of structures
tx: none - TB (granulomatous LN inflammation)
dx: PPD
sx: asx
tx: RIPE anti-tb tx
imaging ordered in suspected upper airway obstruction
NOT CXR!!!!!
order CT and maybe endoscopy
how to identify/ dx severe pneumonia
CURB-65
-confusion, urea> 20, RR> 30, BP < 90/60 (hypotensive), age >65
*if meet 2 then hospitalize, if meet 3 then ICU
(classic sx: cough, sputum , fever, chills, crackles, bronchial breath sounds, pleural effusion
imaging for ILD
CXR= interstitial reticular or nodular infiltrates
HRCT (CRUCIAL) = distribution and extent of dz
*lung biopsy may be needed for confirmation
VERY common presentation of IPF
progressive dyspnea
dx. of pulm HTN via imagine
CXR= pulm A. enlargement
Confirmation by right heart catheterization (measures PAP)
how to dx Pulmonary embolism
Use wells criteria to determine probability
-low risk - d dimer test
- high risk - CT pulm arteriography ( CT angio) *gol standard, or V/Q mismatch scan
(both can dx, but only NL V/Q excludes)
how to workup chronic dyspnea
1) GET DETAILED HX
- identify chronic conditions, cardiac relations, pulmonary relations, other
how to tx malignant pleural effusion
(seen with bloody effusions)
-drain by chronic indwelling catheter or pleurodesis (pleural space obliteration)
LTBI tx
isoniazid daily for 9 month or
rifampin daily for 4 months or
rifampentine + isoniazid 1/week for 3 months
**direct observation
when and how to perform a lung cancer screen
low-dose CT (LDCT)
if 55-80 yo with >30 yr pack hx
most common causes of acute dyspnea (<4weeks)
pulm embolism pulm edema pneumonia UAO pneumothorax COPD exacerbation
tx of secondary (underlying lung dz) , tension, or severe pneumothorax
chest tube ( tube thoracostomy) until lung expands *thoracostomy drains space of fluid or air
risk factor for laryngeal tracheal stenosis (cause of UAO)
prior intubation or tracheostomy
side note: endotracheal intubation with mechanical ventilation is large risk factor for HCAP
most common causes of chronic dyspnea (> 4 weeks)
- COPD
- asthma (chest tightness)
3, ILD - HF (air hunger)
causes of acute mediastinitis? sx? tx?
- esophageal perforation
sx: ill, chest pain, SOB
tx: mediastinomy, tear repair, pleural drainage - following median sternotomy
sx: wound drainage, sepsis, widened mediastinum
dx: via needle aspiration
tx: drain, decried, abx
tx of severe COPD exacerbation (dyspnea at rest, RR>25, PR >110, accessory M. use)
- hospitalize with O2 tx
2. SABA, anti cholingeric, oral/ IV CS, abx
sx of pulm embolism
sx of DVT ( swelling, erythema, tenderness in affected limb) plus dyspnea, cough, pleuritic chest pain
PE: crackles, tachycardia, tachypnea (bc hypoxic), increased S2 pulmonary component
sx of pneumothorax
chest pain, dyspnea (usually resolves in 24hrs)
- if small = NL PE
- if large = decreased breath sounds, decreased tactile fremitus, decreased chest movement on affected side
how to tx massive hemoptysis ( >200ml/day)
- urgent airway management !
- urgent bronchoscopy and/or bronchial A. embolization
- last resort = surgery
tx of pulmonary embolism
- supportive tx of hypoxic, hemodynamic stability in hospital till stable
- anticoags for 3 months
- obstructive shock due to PE, or acute embolism and pulm HTN/RV failure -(hemodynamically unstable) thombolytic tx
- if hemodynamically unstable but thrombotic contraindication then embolectomy surgery
how to treat UACS for chronic cough
non sedating antihistamines and decongestant
dx of pneumothorax
CXR = visceral pleural line on expiratory film
**deep sulcus sign = ABNL radiolucent costophrenic sulcus seen on supine pts
persistent dry cough with inspiratory crackles leads to dx of
ILD
IPF = dyspnea on exertion, dry cough, crackles on inspiration
how to tx mild stable COPD
SABA inhaled tx as needed
active TB tx
RIPE for 6 months (reassessment at 2 months)
most common causes of chronic cough
- Upper airway cough syndrome ( post nasal drip)
- cough variant asthma
- GERD
others: CB, bronchiectasis, ACE-I
luekyocytosis in the setting of respiratory distress can indicate what dx
pneumonia or sepsis (ARDS)
pathophysiology of ARDS exudative stage
damage to every level of the alveolar-capillary membrane
1. type 1 pneumocyte damage = impaired barrier
2. type 2 damage = atelectasis and decreased compliance
**barrier damage + increased hydrostatic pressure/decreased oncotic pressure –> proteinaceous pulmonary edema
3. pulm edema–> worsening V/Q mismatch –> physiologic shunt (alveoli are perfused, but ventilation fails; persistent with O2 supplementation)
4. hypoxemia (with vasoconstriction) + microthrombi (decreased pulm circulation) + direct endothelial damage = increased pulm A. pressure –> worsening dead space ventilation
**3 and 4 = increased work of breathing
OVERALL- Acure Respiratory Failure by ARDS is caused by permeability damage and decreased lung compliance
what does hypercapnia with tachypnea indicate
high CO2 with increased respiration rate means that pt is experiencing impaired ventilation (possibly due to ARDS) and need emergent attention
how to dx GERD for chronic cough
- PPI tx with reassessment in 3 months
2. 24hr esophageal pH test
what to order if suspected hypoxemia or hypercapnia
O2 saturation and arterial blood gases
sx of general airway obstruction ? upper airway obstruction?
SOB, noisy breathing, wheezing, decreased breath sounds on auscultation
UAO sx: DOE, SOB, stridor, hoarseness (if laryngeal), mulled voice (if vocal cords)
Findings on MRI in Fat embolism syndrome
“starfield” pattern of diffuse puntacte hyperintense lesions in brain
causes of drug induced ILD
amioderone, nitrofurantoin, methotrexate
*MAN
sx of laryngotracheal injury (cause of UAO)
stridor (bc UAO) dysphonia hemotypsis neurologic sx cervical bruising hematomas pneumothorax cervical crepitus
virchow triad of risk of VTE
hypercoagability
endothelial damage
venous stasis
two mechanisms leading to the sensation of dyspnea
- impaired ventilation ( obstruction, decreased chest wall compliance)
- increased respiratory drive ( lund dz, CHF, acidosis, preganancy, behavioral panic attacks, etc)
most common cause of HCAP
micro aspiration of bacteria of oropharynx / upper airway in ill pts
*VAP
Risk factor: endotracheal intubation with mechanical ventilation
tx for IPF
no tx to fix
-supplement O2 and tx pulm HTN with vasodilators if chronic or severe
dx and tx of pneumomediastinum
dx: CXR
tx: none required (O2 supplement decreases recovery time, needle aspiration provides compression relief)
