Dyspnea - 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?
azithromycin or doxy
PNA: Out pt, with cormorb, CAP. What abx?
levo or augementin PLUS azithro
In pt CAP non ICU. What abx?
levo or ceftriazone PLUS axithro
In pt CAP ICU. What abx?
ceftriaxone PLUS levo PLUS vanc (MRSA)
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
