Dyspnea + Elkin's notes - Exam 2 Flashcards
When evaluating a pt with dyspnea, what are 2 highlighted clinical findings that would be concerning?
use of the accessory respiratory muscles
inability to speak normally as a consequence of breathlessness
What 3 accessory muscles specifically?
sternocleidomastoid, sternoclavicular, and intercostals
What is paradoxical abdominal wall movement? What does it indicate?
the abdominal wall retracts inward with inspiration
indicating diaphragmatic fatigue
What are the top 5 immediate life threatening causes of dyspnea?
upper airway obstruction
tension pneumo
PE
neuromuscular weakness: myasthenia gravis, Guillain-Barre, botulism
Fat embolism (think fat gobules in the pulm circulation that occur 24-72 hours after trauma)
What are the MC causes of dyspnea?
obstructive airway disease (COPD, astham)
decompensated heart failure
ischemic heart disease: unstable angina, MI
PNA
psychogenic
What will a peak expiratory flow rate tell you?
will help differentiate asthma/COPD from other disorders
decreased in obstructive disease
What will a bedside POC US tell you?
helps differentiate acute cardiac from noncardiac causes
pleural effusion, pneumothorax, pulmonary consolidation, intravascular volume status, cardiac tamponade, cardiac function
What is the initial goal of a pt presenting with dyspnea?
Initial goal of treatment is to maintain oxygenation!!
most will require admission
in the management of hypoxia, what is the goal? What is the exception?
Goal is to keep PaO2 above 60 mmHg or O2 saturation > 90%
Lower oxygen goals in patients chronic lung disease (CO2 retainers)
What is the difference between low flow and high flow oxygen?
Low flow oxygen (allows room air to mix with oxygen)
High flow oxygen (pure oxygen)
How many liters of oxygen is available in nasal canula, simple mask, high flow nasal canula, non-rebreather mask? Which ones are consider low vs high flow?
NC (0.25-4 lpm)- Low
Simple mask (6-10 lpm)- Low
High flow NC (4 lpm in infants with up to 40 lpm or more in adolescent and adults) - High
Non-rebreather (10-15 lpm) - High
Which oxygen vehicle provides some positive pressure and decreases amount of room air that is breathed in?
high flow nasal canula
What is the difference between CPAP and BiPAP?
CPAP: blows constant pressure while you breathe in and out
BiPAP: blows higher pressure while you breathe in and lower pressure when you breathe out
What is the order of O2 therapy as the pt continues to decompensate?
start with supplemental O2 therapy, then move on to noninvasive vent (CPAP or BiPAP) then move to intubate them
_____ is the MC sign present in patients with upper airway obstruction
Stridor
______ is the MC cause of stridor in neonates. What is it due to?
Laryngotracheomalacia
under developed airway that collapses when they breathe
What age range is airway foreign body MC in? What objects?
1-3 years old
food and toys
What are the MC foods that kids swallow and cause an obstruction?
peanuts, sunflower seeds, carrots, raisins, grapes, and hot dogs
How will the presentation differ if the FB is in the Laryngotracheal or bronchial? Which one is MC? What imaging should you order for each?
Laryngotracheal: stridor, hoarseness or complete apnea -> PA and lateral soft tissue neck
Bronchial FB (MC) - unilateral wheezing and decreased breath sounds -> PA and lateral CXR (with inspiratory and expiratory views assess air trapping)
How can you tell if the coin is in the esophagus or trachea?
What are the arrows pointing to?
atelectasis
focal atelectasis with complete obstructions
This image is a bilateral atelectasis in the lung bases due to PE
aka tissues looks a little gray because air is NOT present
What is the management of an airway foreign body? in order!!
What is the technical term for croup? **What are the 2 slam dunk PE findings?
laryngotracheobronchitis
**inspiratory stridor, **“barking” “seal-like” cough,
hoarseness, respiratory distress and fever may also be present
What are the different classifications for croup?
mild: no stridor at rest
moderate: stridor at rest and mild retractions
severe: stridor at rest and severe retractions, anxious or agitated appearing, pale/fatigued
Do you need to do imaging in a classic presentation of croup? **What will you find on xray?
NOT necessary if dx is clear
narrowing of the superior trachea “steeple sign” with normal epiglottis
What is the tx for mild croup?
Outpatient: single dose of oral dexamethasone
IM dexamethasone or nebulized budesonide if unable to tolerate oral therapy
What is the tx for moderate/severe croup? **How long do you need to monitor?
single dose dexamethasone, nebulized (racemic) epinephrine, humidified oxygen
**need to monitor for 3 hours if you give nebulized epinephrine
What is Heliox? When is it used?
70-80% helium and oxygen 20-30% - used as a last resort before intubation in pts with moderate/severe croup
What is the discharge criteria for a pt with croup? (must meet ALL criteria in order to go home)
nontoxic
no signs of dehydration
O2 sat > 90% on RA
reliable caregiver!!
**observation with improvement for 3 hours after last epi tx
f/u in 24-48 hours with PCP
What are the indications for admission for a pt with croup?
persistent stridor at rest
persistent tachypnea
persistent retractions
persistent hypoxia
> 2 doses of nebulized epi are needed
How will the presentation of croup and bacterial tracheitis differ? Why? **What is the PE finding?
similar to croup but with more severe respiratory distress and toxic appearing
bacterial traceitis: Thick mucopurulent secretions result in upper airway obstruction
**“sore throat” referring to the trachea with tenderness on palpation
What do you need to do first in bacterial tracheitis? What should you do next? What will it show?
secure an airway!!
Bronchoscopy (after airway is secured) is needed (consult pulmonology)
confirms present of edema of trachae and will need to therapeutic removal of thick mucopurulent tracheal secretions with C&S to pick abx
What is the management of bacterial tracheitis?
Intubation and mechanical ventilation!
Vancomycin PLUS either Ampicillin/sulbactam (Unasyn) or ceftriaxone (Rocephin)
alt: FQ if beta-lactam allergy present
When do the kidneys start to compensate in an acid-base disturbance? lungs?
kidney compensation occurs with in 12-24 hours
lung compensation occurs within minutes
What are the 5 components of an ABG?
pH
PaCO2
PaO2
HCO3
O2Sat
_____ assesses respiratory component of acid/base regulation vs _____ assesses the metabolic component of the acid/base regulation
PaCO2 - assesses respiratory component
HCO3 - assesses the metabolic component
What is O2Sat?
oxygen saturation of hgb
** What are the normal values of pH, PaCO2 and HCO3? **In order to be consider compensated, what must be true?
compensated the pH must be in the normal value range: 7.35-7.45
What is a common cause of respiratory acidosis?
alveolar hypoventilation from obseity, COPD, sleep apnea
aka something is preventing the exhalation of CO2, CO2 is being retained and thus acidosis
If arterial Pco2 chronically exceeds _____ mm Hg, the respiratory center may be _____, therefore, stimulation for breathing comes from hypoxemia. What should you NOT do to these patients?
60 to 70
depressed
give excessive amounts of O2 because it could decrease respiratory drive in these patients
What is a major cause of respiratory alkalosis?
Alveolar hyperventilation
aka breathing too fast, think anxiety attacks
breathing CO2 out too fast causes pH to rise
What can alveolar hyperventilation lead to?
decrease in CO2 leads to decrease H+ resulting in an imbalance of cations and anions. The negatively charged proteins bind Ca++ (calcium) leading to an ionized hypocalcemia
frothy pink sputum instantly should think _____
heart failure
What agent is preferred in PE with severe renal insufficiency?
heparin
Where is aspiration PNA more likely?
RIGHT lower lobe
PNA: out pt, uncomplicated, no cormorbities CAP. What abx? For how long?
Amoxicillan or doxy
no less than 5 days!
PNA: Out pt, with cormorb, CAP. What abx?
augementin PLUS azithro or doxy
OR
Levo/moxi alone
In pt CAP non ICU. What abx? Add ____ for MRSA. Add ______ hx of P. aeruginosa respiratory isolation
ceftriaxone PLUS Azithro
OR
Levo/Moxi alone
*Add vancomycin if history of respiratory MRSA isolation
*Add Zosyn (piperacillin-tazobactam) if hx of P. aeruginosa respiratory isolation
In pt CAP ICU. What abx? What are the 2 add on abx?
ceftriaxone PLUS Azithro
OR
ceftriaxone PLUS levo
*Add vancomycin if history of respiratory MRSA isolation
**Add Zosyn (piperacillin-tazobactam) if hx of P. aeruginosa respiratory isolation
In pt HCAP. What abx?
levo PLUS cefepime OR pip/taz (add vanc or linezolid for MRSA)
aspiration PNA, what abx?
Levo PLUS clinda
What is an empyema? What abx?
a collection of pus in the pleural space, the cavity between the lung and the chest wall
pip/taz (+/-Vanc for MRSA), admit and consult pulm
Lung abscess. What abx?
clinda PLUS ceftriaxone
What are the different classifications of pneumothorax?
spontaneous- primary
spontaneous- secondary
traumatic
iatrogenic
tension
What is a primary spontaneous pneumothorax? Who is most frequently affected?
pneumo that occurs in the absence of an underlying lung disease
most frequently in smokers
affects mainly tall, thin males between 10 and 40 years of age
What are 2 risk factors for pneumothorax? What is the recurrence rate?
Positive family history and cigarette smoking are risk factors
50% recurrence rate
What is a secondary spontaneous pneumo?
complication of preexisting pulmonary disease
presenting symptoms are often more severe due to an impaired baseline lung function
The etiology of primary spontanous pneumo is unknown, what is one suspected cause?
often a sign of early lung disease with rupture of subpleural apical blebs (small cystic spaces under visceral pleura) in response to high negative intrapleural pressures
What are some causes of iatrogenic pneumos?
positive pressure mechanical ventilation
thoracentesis, pleural biopsy, subclavian or internal jugular vein catheter placement, percutaneous lung biopsy, bronchoscopy with transbronchial biopsy
What is a tension pneumo caused by?
results from air entering pleural space but not escaping so the pleural cavity pressure > atmospheric pressure
What are the 2 most common causes of tension pneumo? Why is a tension pneumo life threatening?
cardiopulmonary resuscitation, or positive-pressure mechanical ventilation
Life-threatening due to cardiopulmonary compromise
** What are the unstable vital signs?
RR > 24
HR <60 or >120
Abnormal BP
O2 <90%
______ is the MC PE finding in pneumo. What are the 2 PE findings if the pneumo is large
tachycardia
Diminished breath sounds and decreased tactile fremitus
What are 3 findings that would make you think tension pneumo?
- severe respiratory compromise and CV collapse, marked tachycardia, hypotension, distended neck veins
unable to speak full sentences - tracheal deviation
- displacement of the PMI
_____ imaging is usually diagnostic for pneumo. Can order what 2 additional views to help detect small ones?
PA CXR
expiratory or lateral decubitus views
______ is indicated for unstable patients with trauma, or patients with suspected tension and is more readily available. What is the con?
pleural US
Requires skilled providers to use and interpret
______ is more sensitive for pneumo than CXR or US
chest CT
What are the 3 different management strategies for a primary spontanous pneumo?
Supplemental oxygen with observation
Aspiration of intrapleural air with needle or catheter
Chest tube or catheter thoracostomy
What are the pt criteria in order to qualify for supplemental oxygen with observation as tx for primary spontaneous pneumo?
Indicated if:
-first PSP
-very small pneumothorax (≤ 3 cm at the apex or ≤ 2 cm at the hilum)
-stable vital signs
-no pleural effusion
all must be present to meet indication
What is considered a small pneumo?
≤ 3 cm at the apex or ≤ 2 cm at the hilum
What is the detailed treatment for supplemental oxygen with observation?
Oxygen at 2-6 L with goal of SpO2 of >96%
Repeat CXR after 4-6 hours
- If improved d/c home
-If no improvement or worsening, aspiration is indicated
Why is oxygen indicated in pneumo?
Supplemental O2 increases pleural air resorption
What is the pt criteria in order to qualify for aspiration with needle or catheter as the tx in PSP?
Indicated if:
first PSP
large pneumothorax (≥ 3 cm at the apex or ≥ 2 cm at the hilum)
stable vital signs
provider with expertise in aspirations
What is the needle/catheter aspiration technique? **Where should the needle/catheter be inserted in aspiration? What are the next steps after you do after a successful aspiration?
2-inch needle 14 G (adults) 16G or small catheter (children)
2.5-4 L should be removed until resistance is met
**anteriorly - midclavicular line 2nd intercostal space
OR
laterally - anterior axillary line 4th or 5th ICS
___________
Observe patient and repeat CXR at 4 hours, if stable remove catheter (if present) and repeat CXR at 2 hours
Discharge if pneumothorax remains resolve, if recurrence occurs insert chest tube and admit
What does lack of resistance after 4Liters of air has been removed when aspiration with a needle/catheter mean? What should you do next?
Lack of resistance after 4 L = persistent air leak
Indication for chest tube
What are the pt criteria to do a chest tube/catheter thoracostomy as tx for PSP?
failed aspiration
large or recurrent pneumothorax
bilat pneumothoraces
hemothorax
abnormal VS
severe dyspnea
What is the procedure for a Chest tube/catheter thoracostomy? **Where is the tube inserted?
10 to 14 French in atraumatic cases and a 14-22 French for larger traumatic leaks
**Location: 4th or 5th intercostal space in the anterior axillary or midaxillary line
Tube/catheter is attached to water-seal system or light wall suction
Admit!!!
What is the management of a secondary spontaneous pneumo?
What is the management of a tension pneumo? **Where is the needle inserted?
through the second anterior intercostal space (between ribs # 2-3) at the midclavicular line or the fifth intercostal space in the anterior or midaxillary line (ATLS recommends 5th ICS in anterior/midaxillary line).
What are the 2 MC s/s of a PE? ______ DECREASES likelihood of PE
chest pain and dyspnea
can have mild fever
wheezing decreases likelihood of PE
**What are the low, moderate, high risk associated point cutoffs for the Wells score?
<2 points = low risk (3.4%)
2–6 points = moderate risk (27.8%)
> 6 points = high risk (78.4%)
What is the next step in a potential PE if the pt has a LOW risk Well’s score?
PERC rules
all 9 must be present to rule out PE!
What are the PERC rules?
______ is a wedge-shaped area of lung oligemia usually from complete lobar artery obstruction.
Westermark’s sign
not very common
_____ is a peripheral dome-shaped dense opacification that is indicative of pulmonary infarction
Hampton’s hump
not very common
What are some EKG changes that are associated with PE?
heart rate >100 beats/min
T-wave inversion in leads V1 to V4
incomplete or complete right bundle branch block
S1-Q3-T3 pattern
What does the S1Q3T3 pattern seen in PE mean?
S1: A deep S wave in lead I (a downward deflection of the QRS complex)
Q3: A Q wave (a small, negative deflection before the R wave) in lead III.
T3: A T-wave inversion (a downward deflection of the T wave) in lead III.
When is a D-Dimer used in the tx of PEs?
only utilized in low-moderate probability cases
_______ is used to confirm dx of PE. What is the associated finding?
CTA chest/pulmonary
segmental or larger filling defects confirms dx
**When is a V/Q scan indicated in PE?
**indicated in renal insufficiency or prior adverse reaction to contrast material
What is the first question you should ask yourself when treating a PE? What is the criteria?
is this pt unstable?
unstable =
SBP < 90 mmHg for a period >15 minutes
OR
a drop in SBP substantially below baseline (generally a drop of >40 mmHg, hypotension requiring vasopressors, or clear evidence of shock)
What is the tx for an unstable PE pt?
unstable - UFH or Fibrinolytic
What is the tx for a stable PE pt?
stable - LMWH or factor Xa
Why is LMWH preferred over UFH?
Greater bioavailability, more predictable dose response, longer half-life compared to UFH
Which factor Xa inhibitors are used in PEs?
apixaban (Eliquis) or rivaroxaban (Xarelto)
**When is UFH preferred in PEs?
**Preferred in severe renal insufficiency and unstable patients
**What are the indications for fibrinolytic therapy in PEs? What are the CIs?
Indications:
1. vital instability
2. elevated troponin
3. elevated B-type natriuretic peptide
4. persistent hypoxemia with distress
______
CIs:
intracranial disease
uncontrolled hypertension at presentation
recent major surgery or trauma (past 3 weeks)
metastatic cancer
______ is typically started directly after the thrombolytic infusion. _____ an be started after 24 hours
heparin
LMWH
When is a surgical embolectomy indicated in PEs?
Utilized in young patients with large, proximal PE accompanied by hypotension
How do you determine admission criteria in a PE? What is the highlighted finding?
Age >80 y
History of cancer
History of heart failure or chronic lung disease
Pulse >110 beats/min this one was bolded in Elkin’s notes
SBP <100 mm Hg
Oxygen saturation <90%
0=low risk and can go home
1= high risk and is admitted
aka pretty much everyone gets admitted
Hx of DOE, PND, orthopnea, edema, frothy pink sputum, respiratory distress, tachycardia, hypertension, JVD, (+) abdominojugular reflux.
What am I?
What is the extra heart sound heard? Why is it happening?
Heart failure
S3 heart sound
results from increased atrial pressure resulting in high pressure flow hitting the left ventricle wall
What will the CXR show of a pt with HF? What lab will be elevated?
pulmonary venous congestion, enlarged heart, interstitial edema
BNP/NT-proBNP - elevated
troponins may also be mildly elevated in HF
Why are BNP and NT-proBNP elevated in HF?
proteins found in the myocardial muscles that are released in higher concentrations when the heart muscle has to work harder than usual
Should assess _____ in HF because the mainstay of tx is ____
renal function
diuretics
When is an echo indicated in HF?
indicated if new or acutely changing HF
concerned about cardiogenic shock or low-outpt syndrome
but NOT necessarily performed in the ED
What is the airway management options in critically ill HF pts?
Supplemental oxygen to keep oxygen saturation at or above 95% (Tintinalli), > 90% (UTD)
Noninvasive positive-pressure ventilation (BiPAP, CPAP)
Intubate extremely ill patients
What is the BP management guidelines in HF? What should you do next?
if BP > 150/100 add IV nitroglycerin or nitroprusside, if BP fails below 100mg stop nitrates
monitor for persistent hypotension
IV loop diuretics
In normatensive HF, what dose of furosemide should you give a HF pt if they are naive? What if they are already on furosemide?
20-40 mg IVP
take pts normal daily dose and multiple it by 1-2.5 times then divided by 2, given every 12 hours
In normatensive HF, what should you do if the pt has NOT improved after administering the correct furosemide dose?
If no improvement double the dose after 30-60 minutes
If still no improvement consider a vasodilator as below
What is the treatment of hypertensive HF? What is considered hypertensive in a HF pt?
First line - Nitroglycerin IV, sublingual
second line: nitroprusside
then diuretics!
What is the goal in treating hypertensive HF?
The goal of treating hypertensive heart failure is to reduce afterload.
What is the difference between preload and afterload?
preload refers to the amount of blood in the ventricles before contraction (systole)
while afterload is the resistance the heart must overcome to eject blood during systole
**Why do you need to tx the HTN first in HF before giving diuretics? What dose in HTN CF?
if the pressure in the vessels are too high the lasix will not be able to work therefore you must lower the pressure first then push the lasix
furosemide (Lasix) 40mg IV or torsemide (Demadex) 10-20 mg IV
What is considered cardiogenic shock? What does the O2 stat need to be above? What is the tx of cardiogenic shock?
signs of hypoperfusion and SBP <90mmHg
give O2 to keep sat > 90% and monitor for impending respiratory failure - use CPAP/BiPAP if needed and be prepared to intubate
IV NS or LR 250 to 500 mL bolus
no improvement with bolus, use vasopressors
What is the disposition for HF?
What is the dx of PNA based on? What does the O2 stat need to be?
fever, cough, and the presence of rales or rhonchi on lung examination with radiographic infiltrate confirmation
at or above 90%
What is the disposition for PNA?
Admit if 2 or more of the CURB-65 criteria:
-Confusion
-Uremia: BUN > 19 mg/dL (7 mmol/L)
-Respiratory rate ≥30 breaths/min
-SBP < 90 mmHg or DBP ≤ 60 mmHg
-Age 65 or older
What are considered comorbities in the context of choosing abx for PNA?
chronic pulmonary, liver, heart, or renal disease, cancer, diabetes, congestive heart failure, alcohol dependence, immunosuppression
recent (< 3m) abx use
smoker
age 65 or older
alcohol dependence
What LACK of PE finding in asthma/COPD is concerning? What does it indicate?
Remember in severe asthma/COPD patients may lack wheezing because of a lack of air flow
What are signs of hypercapnia?
confusion, tremor, plethora, stupor, hypopnea, and apnea
When is a CXR indicated in asthma?
a complicating cardiopulmonary process is suspected (eg, temperature >100.4˚F, unexplained chest pain, leukocytosis, or hypoxemia), when a patient requires hospitalization, and when the diagnosis is uncertain
What is the O2 goal in asthma? PaO2 goal? ____ needs to be monitored in COPD pts. _____ increases risk
Oxygen to keep SpO2 >90% or PaO2 of 60 to 70 mm Hg
Measure end-tidal CO2 because COPD pts may be CO2 retainers
higher risk if non-rebreather mask is used
_____ is first line treatment in asthma and COPD. What increases the risk of SEs?
albuterol 2.5-5 mg via nebulizer every 20-60 min x 3 doses, followed by 2.5-10 mg every 1-4 h or as continuous neb (10-15 mg/h)
SE are more common if doses are given closer together
________ can be added to SABA in more severe presentations of asthma/COPD. What is considered severe? What are the SEs?
ipratropium bromide 5 mg
FEV1 or PEFR <40%
SEs: dry mouth and metallic taste
_____ or _____ every 20 min if unable to tolerate aerosolized therapy or status asthmaticus
SQ terbutaline (Beta2 Agonist)
epinephrine 1:1000
What is indicated in all asthma/COPD pts except those with mild, easily fully reversed episodes of acute asthma? How long should they continue treatment?
steroids!!! route of administration does not matter
Prednisone 40-60 mg PO or methylprednisolone 1mg/kg IV
Continue treatment for 5- to 10-days with a non-tapering course of prednisone (40 to 60 milligrams/d in a single daily dose or its equivalent
When is IV magnesium sulfate recommended?
used ONLY for:
severe asthma exacerbations (FEV1 <25% predicted)
status asthmaticus
severe COPD exacerbation not responding to SABA.
What is the MOA of magnesium sulfate?
Magnesium sulfate is a bronchodilator. It relaxes the bronchial muscles and expands the airways, allowing more air to flow in and out of the lungs.
What are the risks of using magnesium sulfate? What do you need to monitor?
monitor blood pressure and deep tendon reflexes during administration because hypotension and neuromuscular blockade may occur
______ and _____ may also be indicated in status asthmaticus
Epinephrine SC or IM, 0.5 milligram
Mechanical ventilation (BiPAP, CPAP, intubation)
When is mechanical ventilation (BiPAP, CPAP, intubation) indicated in status asthmaticus? Do the meds need to be continued once a pt is intubated?
indicated for respiratory muscle fatigue, respiratory acidosis (due to increased CO2), altered mental status, hypoxia refractory to standard therapy
YES!! all meds above must be continued as intubation does not relieve the airflow obstruction
When are abx recommended in a COPD exacerbation? What abx?
has increased sputum purulence AND either increased sputum volume PR increased dyspnea
OR
for patients who require ventilatory assistance
_______
azithro or clarithro, bactrim or cefdinir
When should Augmentin or FQ be used in a COPD exacerbation?
patients at high risk for poor outcomes
age ≥ 65
comorbidities (CHF or ischemic heart disease)
continuous supplemental oxygen
hospitalization in last 12 months for exacerbation
2 COPD exacerbation
FEV1 < 50%
Chronic steroid use
What are the admission criteria for COPD exacerbation?
When should the decision to admit be made in a pt with asthma?
continue treatment for 1-3 hours and decision to admit should be made within 4 hours
