Day 6 - Pulm3 Flashcards
Studies helpful for dx PE
ABG - resp alk due to low oxygenation; D-dimer (normal makes PE less likely, elevated less specific - for r/o), Compressive venographyUS of lower extremity of PE (absence not tell you anything), CXR - usually normal, may have pleural effusion or Hampton’s hump, EKG - sinus tachycardia, nonspecific ST & T changes, S1q3t3; V/Q scan if not able to get CT w/ IV contrast, accurate to confirm high probability (must also have clinical scenario); (1) CT w/ IV contrast - pulmonary angiogram or PE protocol; NOT give contrast if metformin or renal failure; Pulmonary angiogram gold standard but invasive so rarely performed
Indications for thrombolytics
(1) STEMI (within 12 hours (2) Cerebral infarction - embolism/thrombosis (3, 6 if direct hrs)
Vasodilators used in pHTN
(1) Prostanoids - epoprostel, troprostenil, ilioprost; (2) Endothelin recepton antagonists - bosentan, ambrosentan; (3) Cyclic GMP diphosphodiesterase inhibitors (e.g., sildenafil); (4) CCBs, dihydroperidine - e.g., nifedipine
Tx OSA
(1) Wt loss (2) Avoid alcohol & other CNS depressants or sedatives (3) CPAP at night (4) Oral appliance to protrude mandible forward (5) Stimulant modafinil=Provigil if excessive daytime sleepiness (6) uvulopaleto (UVP?) surgery
Rapid sequence activation components
Need airway rapid; (1) Rapid acting sedative (e.g., etomidate, propofol) (2) Paralytic - not always needed, but makes intubation easier, risk if not get airway (e.g., etomidate, midazolam, ketamine, propofol; sucinylcholine)(3) Preparation for intubation - ET tube, mac blade, suction, preoxygenation, pretreatment (lidocaine if blunt intracranial elevation, fentanil for blunting pain response blunt & decrease bp, atropine to decrease secretions and prevent bradycardia in children) (4) watch bulb pass thru cords, may use cricoid pressure for better visualization (5) secure ET tube, CXR, pulse ox, ventilator
S/sx croup
Inflx of larynx, trachea, & bronchi; Barking seal cough (low pitch); Respiratory obstruction w/ inspiratory stridor; Sx worse at night
Tx croup
Humidified O2, Racemic epinephrine q 1-2 hr, Dexamethsaone, Prednisolonef for several days
Course of croup
12-72 hrs of mild fever & coryza, progresses to barking cough; Peak respiratory distress at 24-48 hrs; Resolution w/i week
Indications for admission w/ croup
Hypoxia, Respiratory distress, Toxic appearance, Depressed mentation, Stridor, No improvement after 5 hrs of steroids
Home tx croup
Cool mist humidifier, but no proven benefit;
Characteristic feat. of epiglotitis
Fever, sore throat, dysphagia, drooling, toxic appearance, progression to respiratory distress with inspiratory distress, muffled speech (hot potato voice like peritonsilar abscess), cyanosis, sniffing dog position (to maximize airway diameter); Leukocytosis; Lateral neck XRay - thumb sign (enlarge epiglottitis)
RSV bronchiolitis
1-3 days of mild URI sx, cough w/ prolonged expiration, crackles, expiratory wheezes (looks more like asthma than croup); Possible respiratory distress - nasal flaring, retractions, tachypnea, grunting, possible apnea in infants; Complete resolution usually takes 1 mo.
Tx RSV bronchiolitis
Oxygen & IV fluids (i.e., supportive care) as needed; Albuterol nebs or Racemine epi; Benefit of epi in kids under 12 mo. of age; Steroids NOT affected (given for croup); Ribavirin controversial, expensive, and generally not used
Indications for admission w/ RSV bronchiolitis
Toxic, resp distress, hypoxia, 95% as cutoff, unable to care for child at home
How lecithin:sphingomyelin ratio used
Mature lungs typically at 35 wks; Lecithin increases while sphingomyelin remains constant; > 2.0 = fetal maturity, 1.5-1.9 = 50% mature,
CXR distinguishes NRDS vs. transient tachypnea of newborn
Low lung volumes, diffuse ground glass infiltrates with air bronchiograms; v. Increased lung volumes, flattening of diaphragms, prominent vascular markings from hilum, sunburst pattern, fluid streaking in interlobular fissures w/ or w/o pleural effusions
Tx NRDS
Surfactant (intubate & put down ET tube in four different positions); CPAP, intubation or mechanical intubation
CF dx
Sweat chloride test (cl concentration > 60 meq/L on two+ occassions); CFTR gene mutation (test of choice); Transepithelial chloride secrection - abnormalities in transport across nasal epithelium;
Tx pulmonary components of CF
Beta agonists, DNAase-1 (decrease sputum viscosity, or aerosolized n-acetylcysteine), Hypertonic saline (chronic cough), Physiotherapy (e.g., aerobic exercise), Azithromycin; In this case, can give fluoroquinolones to children (tx Pseudomonas)
Tx GI components of CF
Pancreatic enzyme replacement during meals, Fat solube vitamin replacements (ADEK), Nutritional counseling
