Day 6 - Pulm3

Question 1

Studies helpful for dx PE

Answer 1

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

Question 2

Indications for thrombolytics

Answer 2

(1) STEMI (within 12 hours (2) Cerebral infarction - embolism/thrombosis (3, 6 if direct hrs)

Question 3

Vasodilators used in pHTN

Answer 3

(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

Question 4

Tx OSA

Answer 4

(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

Question 5

Rapid sequence activation components

Answer 5

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

Question 6

S/sx croup

Answer 6

Inflx of larynx, trachea, & bronchi; Barking seal cough (low pitch); Respiratory obstruction w/ inspiratory stridor; Sx worse at night

Question 7

Tx croup

Answer 7

Humidified O2, Racemic epinephrine q 1-2 hr, Dexamethsaone, Prednisolonef for several days

Question 8

Course of croup

Answer 8

12-72 hrs of mild fever & coryza, progresses to barking cough; Peak respiratory distress at 24-48 hrs; Resolution w/i week

Question 9

Indications for admission w/ croup

Answer 9

Hypoxia, Respiratory distress, Toxic appearance, Depressed mentation, Stridor, No improvement after 5 hrs of steroids

Question 10

Home tx croup

Answer 10

Cool mist humidifier, but no proven benefit;

Question 11

Characteristic feat. of epiglotitis

Answer 11

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)

Question 12

RSV bronchiolitis

Answer 12

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.

Question 13

Tx RSV bronchiolitis

Answer 13

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

Question 14

Indications for admission w/ RSV bronchiolitis

Answer 14

Toxic, resp distress, hypoxia, 95% as cutoff, unable to care for child at home

Question 15

How lecithin:sphingomyelin ratio used

Answer 15

Mature lungs typically at 35 wks; Lecithin increases while sphingomyelin remains constant; > 2.0 = fetal maturity, 1.5-1.9 = 50% mature,

Question 16

CXR distinguishes NRDS vs. transient tachypnea of newborn

Answer 16

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

Question 17

Tx NRDS

Answer 17

Surfactant (intubate & put down ET tube in four different positions); CPAP, intubation or mechanical intubation

Question 18

CF dx

Answer 18

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;

Question 19

Tx pulmonary components of CF

Answer 19

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)

Question 20

Tx GI components of CF

Answer 20

Pancreatic enzyme replacement during meals, Fat solube vitamin replacements (ADEK), Nutritional counseling