KC Resp Flashcards
*Causes of shifts to the oxygen dissociation curve
CO2, pH, 2,3 -DPG, Exercise, Temperature
Right shift: favours unloading of oxygen - lower pH, increase 2,3-DPG, increased temperature
Left shift: favours higher oxygen binding - higher pH, decreased 2,3-BPG, lower temperature, methhemoglobin
*65M on septra and pyridium, blood draw chocolate brown, sat 85%, what test do you order?
Methemoglobin level
*What is the pathophysiology of methemoglobinemia
Altered state of hemoglobin where iron in its ferrous F++ form is oxidized to ferric Fe+++, and unable to bind O2. Rest of normal hemoglobin is therefore left shifted and holds on to O2 more tightly.
*Why would O2 sat on ABG be measured as normal?
Measured O2 saturation is normal
*Drugs that cause methemoglobinemia (5)
Septra
Dapsone
Local anesthetics: Benzocaine, Prilocaine, Lidocaine
Metoclopramide
Rasburicase
Nitroglycerin, amyl nitrate
Quinones
*Treatment for methemoglobinemia
Methylene blue
*How does methylene blue work to treat methemoglobinemia
Reduces Fe3+ to Fe2+ by providing electron donor → Hgb now able to bind and offload oxygen
List 1 non-drug related cause of methemoglobinemia and 1 chemical cause
(Box 11.1
Hereditary: NADH methemoglobin reductase deficiency, GPPD deficiency
Chemicals: paraquat, chlorobenzene
List 5 causes of peripheral cyanosis
Low cardiac output states: shock, left ventricular failure, hypovolemia
Environmental exposure to air or water, Raynaud’s
Arterial occlusion: thrombosis, embolism, vasospasm, peripheral vascular disease
Venous obstruction
Redistribution of blood flow from the extremities
List 5 causes of central cyanosis
High altitude
Methemoglobinemia, sulfhemoglobinemia
Impaired pulmonary function: V/Q mismatch (pulmonary embolism, ARDS, pulmonary hypertension, pneumonia, pneumothorax
Anatomic shunt: congenital heart disease
List 2 ways that methemoglobin is reduced
NADH cytochrome b5 reductase: this is often affected by drugs
NADPH uses glutathione; this is the pathway accelerated by methylene blue
What is 1 contraindication to methylene blue?
G6PD deficiency
Pt is cyanotic with +ve methemoglobin levels on co-oximetry, but does not respond to methylene blue. What diagnosis should be considered?
Sulfhemoglobinemia
*2 definitive treatments for massive hemoptysis
- Fibreoptic bronchoscopy
- Bronchial arterial embolization (IR) or
- OR for thoracotomy if embolization fails
*Optimal positioning of patient with known bad lung
Place patient with affected side down
*2 airway maneuvers to minimize VQ mismatch in someone with hemoptysis
Intubate mainstem of unaffected lung, or
Double lumen ETT
Also: bronchial artery embolization
*Most accurate way to diagnose cause of hemoptysis
CT pulmonary angiography
*Most commonly bleeding artery
Bronchial artery (pulmonary arteries are higher volumes, but lower pressures)
*Six infectious causes of hemoptysis
TB
Bronchitis
Bronchiectasis
Pneumonia
Lung abscess
Fungal infection
Aspergillosis
What is the definition of massive hemoptysis?
> 600ml in 24 hours
List 10 differential diagnosis for hemoptysis
Infectious: bronchitis, bronchiectasis, tuberculosis, aspergilloma, parasites, septic emboli
Structural: CF, hypersensitivity pneumonitis, PE with infarction, pulmonary HTN, malignancy, cocaine/ crack lung
Vascular: tracheoarterial fistula, arteriovenous fistulas, aneurysm that erodes into the trachea
Vasculitis: Goodpasture’s syndrome, Wegener’s granulomatosis, lupus, Behcet’s syndrome
Hematological: coagulopathy, DIC, platelet dysfunction, thrombocytopenia
Iatrogenic: bronchoscopy, Swan-Ganz, lung biopsy, foreign body
Trauma: lung contusion, penetrating trauma, foreign body
What is bronchiectasis
Chronic necrotizing infection that leads to bronchial wall inflammation and dilation
What is diffuse alveolar hemorrhage
Pulmonary hemorrhage that originates from the pulmonary microcirculation - alveolar capillaries, arterioles, venules. Presents with hemoptysis with diffuse lung infiltration and anemia. Often autoimmune (vasculitis)
More bloody with serial washings
Patient comes in with massive hemoptysis and a recent trach. Describe 2 maneuvers that you can do
Hyperinflating the trach balloon
Intubating from the oral airway with direct pressure from finger in the tracheostomy home
Tracheal-inominate fistula (late) surgical site early
*3 physiologic mechanisms and example of each for hypoxemic respiratory failure
NOT IN NEW ROSENS
- Low FiO2 (e.g. high altitude)
- Hypoventilation (e.g. opioid misuse, obesity hypoventilation, impaired neural conduction e.g. ALS, Guillain-Barre, high C-spine injury, muscular weakness e.g. myasthenia gravis)
- V/Q mismatch (e.g. COPD, pulmonary embolism, interstitial lung disease)
- Shunt i.e. blood passes from right to left side without being oxygenated (e.g. intracardiac shunt, pulmonary AVM, atelectasis, pneumonia, ARDS)
- Diffusion limitation (e.g. pulmonary fibrosis)
*2 physiologic mechanism and example of each for hypercarbic respiratory failure
NOT IN NEW ROSENS
- Increased CO2 production (e.g. fever, sepsis, burns, over-feeding)
- Decreased alveolar ventilation i.e. decreased RR (e.g. CNS lesion, overdose), decreased tidal volume (e.g. myasthenia gravis, ALS, Guillain-Barre, botulism, spinal cord disease, respiratory muscle fatigue in COPD/asthma exacerbation) increased dead space (e.g. pulmonary embolism, hypovolemia, poor cardiac output)
List 10 critical causes of acute dyspnea
Airway obstruction, anaphylaxis, epiglottitis
PE, tension pneumothorax, flail chest
MI, cardiac tamponade
DKA
Carbon monoxide
Acute chest syndrome
*What vent settings would you tell RT after intubating an asthmatic
Volume control.
Start with 100% o2 and then titrate to sat > 92%
- Small tidal volumes of 6 to 8 ml/kg
- Low respiratory rates of 10 breaths/min or less
- High inspiratory flow rate of 80 L/min or greater
- Long inspiratory to expiratory ratio of 1:4
- Minimal or no PEEP of 5 mmHg or less
*What is the induction agent of choice in asthma?
Ketamine
List 5 signs of impending failure in an asthmatic patient
Accessory muscle use, paradoxical respiration, altered mental status, pulsus paradoxus >10, HR >120, RR>40, normal PCO2 (indicates fatigue, should be low with hyperventilation), quiet chest
List 5 risk factors for death in an asthmatic patient
Asthma History - a near fatal asthma event, hospitialization in the last year, currently using or stopped oral steroids, not using inhaled steroids, over-use of SABA (>1 per month), poor adherance
Psychosocial problems, pschiatric disease, food allergy
List 5 therapies that can be used in acute asthma exacerbations in a stepwise fashion
Salbutamol, Ipratropium bromide, steroids, magnesium, epinephrine IM, ketamine, BIPAP, IV ventolin
Describe the components of the PRAM score. What is mild, moderate, and severe?
Suprasternal retractions: 0 absent, 2 present
Scalene muscle use: 0 absent, 2 present
SpO2: 0 >95%, 1 92-94%, 2 <92%
Air entry: 0 normal, 1 decreased at based, 2 widespread, 3 absent
Wheezing: 0 absent, 1 expiratory, 2 inspiratory and expiratory, 3 audible w/o stethoscope
Mild 0-3; Moderate 4-7; Severe 8-12
List the defining clinical features of AERD (Aspirin exacerbated respiratory disease)
Tetrad: nasal polyps, eosinophilic sinusitis, asthma, sensitivity to COX 1 drugs (ex. aspirin)
NESSAA
List 6 possible triggers for asthma exacerbations
Viral pathogens, exercise, cold air, pollutants, occupational exposures, drugs (aspirin), menstrual, emotional stress
List 6 side effects of steroid use
Hyperglycemia, hypokalemia, fluid retention and weight gain, mood alterations, HTN, peptic ulcer disease, adrenal insufficiency, immunosuppression, necrosis of the femoral head
List 10 causes of wheeze
Cardiac: CHF, valvular
Resp: COPD, Pneumonia, aspergillosis, PE, tumor, non cardiogenic pulmonary edema
Upper airway: foreign body, vocal cord dysfunction, laryngeal edema, laryngeal neoplasm
Anaphylaxis
*What are 3 bacterial pathogens associated with COPD exacerbation (3 normal and 3atypical)
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
- Pseudomonas aeruginosa
- Atypical bacteria (Chlamydia pneumoniae, Legionella)
*What are 4 non-infectious causes of respiratory distress in a COPD patient?
- Air pollution (e.g. nitrogen dioxide, ozone, particulates, dust)
- Pneumothorax
- Pulmonary embolism
- Lobar atelectasis
- Congestive heart failure
- Pulmonary compression (e.g. obesity, ascites, gastric distension, pleural effusion)
- Trauma (e.g. rib fractures, pulmonary contusion)
- Neuromuscular and metabolic disorders
- Medication non-compliance
- Iatrogenic (eg deleterious drugs such as beta blockers or cholinergic agents)
*What are 4 medications to treat a COPDe
- beta-agonist (e.g. salbutamol)
- anti-cholinergic (e.g. ipratropium)
- corticosteroid (e.g. methylprednisolone, or prednisone)
- antibiotic (e.g. cipro)
*3 indications for NIPPV in COPD
- Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal breathing
- Respiratory rate 25 breaths/min
- Moderate to severe acidosis (pH < 7.35)
- Hypercapnia (PaCO2 > 45 mmHg)
New box severe, hypoxic or hypercarbic
*What are indications for intubation in COPD?
- Failure of BiPAP (clinical deterioration)
- respiratory arrest,
- altered level of consciousness,
- cardiovascular instability,
- severe dyspnea and tachypnea,
- life-threatening hypoxia,
- severe acidosis and hypercarbia,
- complications (PTX, PE, barotrauma, massive effusion)
What should spirometry show in a patient with COPD
FEV1/FVC <70%, does not improve w puffers
Define mild, moderate, severe, and very severe COPD based on the GOLD criteria
Mild FEV1>80% predicted, moderate 50-80%, severe 30-50%, very severe <30%
List 3 chronic complications of COPD
Hypercarbia, polycythemia, pulmonary HTN, cor pulmonale
Think about vascular, heart and heme
List 2 potential ECG findings in COPD
cor pulmonale (peaked P waves in leads II, III, and aVF), low QRS voltage (hyperinflated chest), poor R wave progression, Afib, multifocal atrial tachycardia
P wave - because its your atria, its II,III aVF
Poor R wave progression
List 2 potential CXR findings in COPD
Hyperinflated lungs, bullae, decreased vascular markings, small cardiac silhouette
List 2 indications for antibiotics in COPDe
Winnipeg/GOLD criteria
- Increase in sputum purulence + (dyspnea or increase sputum volume)
- Requiring mechanical ventilation
List 5 contraindications for Bipap in COPDe
Instability: respiratory arrest, cardiovascular instability
High aspiration risk
Unable to tolerate mask: uncooperative patient, recent facial or GI surgery, facial trauma, non fitting mask
*5 causes of non infectious stridor
- Foreign body aspiration
- Anaphylaxis
- Upper airway trauma
- Upper airway burn
- Congenital airway anomaly (e.g. laryngeal web, laryngomalacia, vocal cord paralysis, subglottic stenosis, subglottic hemangioma)
*4 XR findings of RPA
The anteroposterior (AP) diameter of the soft tissue along the anterior bodies of C1-4 should be less than 40% of the AP diameter of the vertebral body just behind it.
Retropharyngeal space (2nd vert body) on lateral neck films >7mm (children and adults)
Retrotracheal space (6th vert body) >14mm children, or >22mm in adults
Reversal of the normal lordosis of the cervical spine,
Air-fluid levels in the abscess cavity,
Foreign bodies,
Vertebral body destruction.
*4 physical exam features that point toward RPA rather than another causes
Neck held in extension
Prefer supine position
Unilateral mass on palpation
Rock sign (tenderness on moving larynx and trachea)
Pain in back/shoulder with swallowing
*4 reasons to decompensate
Sitting position
Extension into danger space
Atraumatic atlantoaxial separation
Rupture of abscess into airway
Bleeding from erosion into blood vessels
*22 M with rhinosinusitis. 3 most common organisms
Streptococcus pneumoniae , nontypable H. influenzae , and Moraxella catarrhalis are the primary pathogens responsible for acute bacterial and recurrent acute sinusitis.
*5 risk factors for rhinosinusitis other than URTI / allergic
- Nasal polyps
- immunocompromise
- Nasal instrumentation / sinus surgery
- Smoking (cigarettes)
- Asthma
*6 severe complications of rhinosinusitis
- Orbital cellulitis
- Retro-orbital abscess
- Optic neuritis
- Meningitis
- Subdural empyema
- Brain abscess
- Cavernous sinus thrombosis
*20 F with hoarseness, dysphagia, stridor, fever. Previously healthy. Other than epiglottis what are 3 things on the differential diagnosis.
• - Ludwig’s angina
• - Bacterial tracheitis
• - Retropharyngeal abscess
• - Parapharyngeal abscess
• - Tumor
*What is the best test in an adult to diagnosis epiglottis?
• Direct visualization of epiglottis
*Signs of peritonsillar abscess
- Uvular deviation
- Bulging tonsil
- Effacement of soft palate
- Trismus
- Dysphagia/odynophagia
- Palpable neck mass
- Drooling
- Referred otalgia
- Muffled, hot potato voice
- Inferior medial displacement of infected tonsil
*2 antibiotics for peritonsillar abscess
- Piperacillin-tazobactam
- Ceftriaxone plus metronidazole
- Clindamycin
- Cefoxitin
- Amoxicillin-clavulanic acid
*2 complications of needle aspiration in peritonsillar abscess
- Carotid puncture
- Aspiration
- Incomplete drainage
*2 non-supp complications of strep infection (say in PTA)
- Poststreptococcal glomerulonephritis
- Rheumatic Fever
List 10 organisms that can cause pharyngitis
Viruses: rhinovirus, coronavirus, adenovirus, EBV, influenza, HIV, herpes simplex
Bacterial: Group A step, non group A strep, chlamydia, mycoplasma, gonorrhoea, tuberculosis, fusobacterium necrophorum
List 2 organisms that can cause a membranous pharyngitis
Diphtheria, acranobacterium haemolytica
Patient has a grayish membranous coating on the tongue. List 2 specific management steps
DAT (diphtheria antitoxin) once confirmed (20,000-40,000 units for pharyngeal involvement)
Immunization to prevent further infection
Can also consider Abx in interim ex. Azithromycin
What is the post exposure prophylaxis for carriers or unimmunized contacts of a patient with diphtheria
7 days erythromycin
List 2 viral organisms that can cause exudative pharyngitis
Adenovirus, EBV
List the components of the centor score and describe how it is used clinically
Tonsillar exudates, lymphadenopathy, absence of cough, fever
Score 0-1 no testing, score 2-3 testing, score 4 empiric treatment
What is the most common age for pharyngitis
3-14 +1 point
14-44 - 0
>45 - 1 point
(McIsaacs)
List 5 suppurative and 4 non suppurative complications of GAS
Suppurative: PTA, RPA, PPA, sinusitis, IM, mastoiditis, meningitis, cervical adenines, Lemierre’s, sepsis, osteomyelitis, scarlet fever, pharyngitis
Non suppurative (after original infection resolves, involve distant sites, caused by immune response not direct GAS infection): rheumatic fever, PANDAs, post strep GM
List 3 reasons to treat GAS once diagnosed
Reduce course by ~1 day of sx
Reduce transmission: no longer infectious after 24h abx
Reduce suppurative/nonsuppurative complications: NNT 1/2 million for RF, does not affect post strep GN
List 3 x ray findings in epiglottitis. What is the most common x ray in a patient with epiglottis
thumb printing, obliteration of the vallecula, epiglottic width >5.5mm or aryepiglottic folds. 70% of patients will have a normal x ray
List 10 complications of peritonsillar abscess
Airway compromise/obstruction
Infectious spread: Sepsis, Rupture of abscess and aspiration > pneumonitis , empyema, lung abscess, spread contiguously to the parapharyngeal and retropharyngeal spaces, Ludwig’s angina, Mediastinal involvement (including mediastinitis and pericarditis), Myocarditis
Carotid artery erosion, Jugular vein thrombophlebitis, Septic embolization, Lemierre’s syndrome, cervicothoracic necrotizing
fasciitis
Meningitis and cerebral abscess, Cavernous sinus thrombosis
The retropharyngeal space can extend from the base of the skull to the superior mediastinum
What is Lemierre’s syndrome
Thrombophlebitis of the IJ with anaerobic bacteria, typically secondary to an oropharyngeal infection
What is the most common organisms in Lemierre’s syndrome
Fusobacterium necrophorum
How is Lemierre’s treated
Antibiotics with anaerobic coverage: flagyl + penicillin, clindamycin
Value of anticoagulation is unknown
List 3 symptoms of rhinosinusitis
PODS: facial pain/pressure, obstruction, nasal discharge, smell disorder
Need at least one of obstruction or nasal discharge for diagnosis
When should antibiotics be considered in sinusitis? What is the antibiotic of choice
Sx >7-10 days
Progressively worse after intial improvement
Severe symptoms 3-4 days with fever 39
Amoxicillin
*Outline the curb 65 score
Confusion of new onset
Blood Urea nitrogen greater than 7 mmol/L
Respiratory rate of 30 breaths per minute or greater
Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less
Age 65 or older
*What is the disposition for each curb 65 score
Patients with zero or one feature can receive outpatient care, those with two should be admitted, and ICU care should be considered for those with three or more factors.
*List 4 pathogens that can cause lobar pneumonia
Pneumococci
Klebsiella
H flu
TB
Moraxella
*5 pulmonary complications of bacterial pneumonia
- Respiratory failure
- Sepsis/bacteremia
- Lung abscess
- Empyema (different from lung abscess in that purulent collection in pleural space)
- Treatment failure
- Death
Outline the specific treatment for each case:
i) HIV with low CD4
ii) MRSA positive in ICU with sepsis
iii) Lesions on lips and mucous membranes
iv) Traveler recently returning from New *Mexico
i) HIV with low CD4: TMP-SMX, add ceftriaxone if severe (PCP)
ii) MRSA positive in ICU with sepsis: Piperacillin-tazobactam plus vancomycin
iii) Lesions on lips and mucous membranes: Ensure coverage with acyclovir/valacyclovir (HSV)
iv) Traveler recently returning from New Mexico: Ensure coverage with fluconazole (Coccidioidomycosis)
*What are FIVE radiographic features of PCP?
- Bilateral interstitial infiltrates
- Lobar infiltrates
- Pleural effusions
- Hilar adenopathy
- Parenchymal nodules
- Cavitary disease
*What are FIVE non-infectious conditions that can mimic infectious pneumonia?
- Exposure to mineral dusts (e.g. silicosis)
- Exposure to chemical fumes (e.g. chlorine and ammonia)
- Toxic drugs (e.g. bleomycin)
- Radiation
- Thermal injury
- Oxygen toxicity
- Immunologic disease (e.g. sarcoidosis, Goodpasture’s syndrome, collagen vascular disease)
- Hypersensitivity to environmental agents (e.g. farmer’s lung disease)
- Tumours
*What is the difference between HAP, VAP and HCAP?
HAP = hospital-acquired pneumonia: Occurs >= 48 hours after admission and dose not appear to be incubating at time of admission
VAP = ventilator-associated pneumonia: Occurs > 48-72 hours after endotracheal intubation
HCAP = health-care associated pneumonia: Occurs in non-hospitalized patient with extensive health care contact:
- IV therapy, wound care, or IV chemotherapy within prior 30 days
- Residence in nursing home or other long-term care facility
- Hospitalization in an acute care hospital for 2 or more days within the past 90 days
- Received hemodialysis within the prior 30 days
*Describe the components of the PSI/PORT score
No thank you.
List 3 typical and 3 atypical pathogens for pneumonia
Typical: strep pneumo, hemophilis influenzae, staphylococcus aureus
Atypical: legionella, mycoplasma, chlamydophila
List 3 antibiotic regimes for the outpatient treatment of community acquired pneumonia
Amoxicillin 1g BID for 5 days, azithromycin 500mg PO x1 than 250 mg PO OD x 4 days, doxycycline 100mg PO BID, levofloxacin 750 mg PO OD x 5 days
Are antibiotics needed in aspiration pneumonia
Not needed for witness aspiration of a small amount of non toxic liquid if the patients symptoms resolve in <48 hours
Consider treatment in patients with severe periodontal disease
If needs antibiotics needs coverage for gram -ve: clindamycin, metronidazole, amox-clav
List 6 unique pathogens to consider in an HIV patient with pneumonia
PCP, mycobacterium tuberculosis, mycobacterium avium complex
CMV, varicella, herpes simplex
Cryptococcus
Patient comes from a nursing home with GI symptoms and a broken air conditioner. What is the most likely organisms
Legionella
List 3 organisms that can cause a cavitating pneumonia
Staph (esp. MRSA), streptococcus, tuberculosis, gram -ves (pseudomonas, klebsiella)
Anaerobic
Septic pulmonary emboli, fungal pneumonia
List 5 antimicrobials that can be used for MRSA
Vanco, Septra, Clinda, Linezolid, Daptomycin, Doxycycline, Tigecycline
List the pathogen associated with: alcoholism, bat/cave exposure, bird exposure, soil exposure, farm animal exposure, rabbit exposure, post-influenza, asplenia, HIV, ohio river valley
Alcoholism: gran -ves ex. klebsiella
Bat/cave, missippi: histoplasma
Bird exposure: cryptococcus
Soil exposure: coccidiomycosis
Farm animal exposure: Coxiella burnetii (Q fever)
Rabbits: tularemia
Post influenza: staph aureus
Asplenia: Strep pneumo, H influenza
HIV: PCP
Ohio river valley: coccidiomycosis
North western Ontario: blastomyses
Bullous mryangitis: mycoplasma
*List 5 tests to do on a pleural fluid analysis
Protein
LDH
Culture
Cell count
Gram stain
Glucose
pH
*What radiographic finding on XR dictates need for a thoracentesis
1cm on lateral
5cm on erect view
Mediastinal shift
*What is the pathophysiology of PTX?
Disruption of alveolar-pleural barrier allowing air into pleural space
*Define simple, communicting and tension PTX
- Simple: No communication with atmosphere or any shift in mediastinum or hemi-diaphragm resulting from accumulation of air
- Communicating: Defect in chest wall, most commonly due to penetrating trauma, the loss of chest wall integrity causes the involved lung to paradoxically collapse on inspiration and expand slightly on inspiration
- Tension: Progressive accumulation of air under pressure within the pleural cavity, with shift of the mediastinum to the opposite hemothorax and compression of the contralateral lung and great vessels
*Other than a chest tube direct to wall suction, how can you manage PTX?
- 100% O2
- Needle aspiration
- Chest catheter (e.g. pigtail with Heimlich valve)
- Small bore (8-14 Fr) chest tube
*5 complications of chest tube insertion
- Mechanical (e.g. dislodgement, subcutaneous placement, intra-abdominal placement) - Air leaks
- Blocked drain
- Infection (e.g. pneumonia, empyema, local infection, osteomyelitis, necrotizing fasciitis) - Physiologic (e.g. atelectasis, re-expansion pulmonary edema)
- Bleeding (e.g. intercostal artery or vein laceration)
- Solid organ injury (e.g. lung, liver, spleen, diaphragm, stomach, colon)
- Miscellaneous (e.g. subcutaneous or mediastinal emphysema, persistent pneumothorax, recurrence)
*Repeat CXR of treated PTX (pigtail) shows no improvement, why? (3)
- Dislodged tube
- Incorrect tube position
- Air leak
- Blocked tube
DABI
*Patient is avid diver. When can he dive again after PTX?
“Previous spontaneous pneumothorax is a contraindication unless treated by bilateral surgical pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery.”
*5 Causes of pneumomediastinum
- Asthma exacerbation
- Pneumonia/lower respiratory tract infection
- Viral illness/cough/croup
- Trauma
- Cocaine (i.e. inhalational barotrauma)
- Esophageal perforation (e.g. Boerhaave syndrome, foreign body)
- Deep space neck infection
- Idiopathic
*4 clinical findings of pneumomediastinum
- Pain: Chest pain, neck pain, throat pain
- Hamman’s crunch
- Facial/neck swelling
- Subcutaneous emphysema
- Dyspnea
- Hoarseness
- Stridor
- Foreign body sensation in throat
*2 next diagnostic modalities (after initial finding on CXR)
- CT chest
- Endoscopy
- Bronchoscopy
List 5 risk factors for primary pneumothorax
Cigarette smoking, Marfan’s, male gender, familial, mitral valve prolapse, tall, family history
List 5 causes of secondary pneumothorax
Trauma, Lungdisease: COPD, CF, interstitial lung disease (sarcoidosis), scleroderma, Infection -HIV with pneumocystis infection, tuberculosis, Cancer, Catamenial (with menses due to endometriosis)
Which pneumothoraces can be watched conservatively?
PSP trial (NJEM 2020)
Bottom line: conservative management was non inferior to invasive management
Population: Patients with unilateral spontaneous pneumothorax age 14-50 <32% or 6 cm
Intervention: Small bore chest tube attached to suction x 1 hour. If repeat CXR showed lung expanded the chest tube was clamped and then drain was removed
Control: No chest tube. 4 hours of observation in the ED and repeat CXR. D/C home if CXR stable and requiring no oxygen
Outcome: Primary radiographic resolution 98.5% in intervention and 94.4% in control, therefore concluding that conservative therapy was non inferior to invasive therapy. Complete resolution of symptoms was better in the control group. Serious adverse events were greater in the invasive group.
Describe 3 methods for measuring the size of a pneumothorax
Collins method: does the intrapleural distance at 3 sites >6cm
British Thoracic Society: intrapleural distance at the level of the hilum- small if <1cm, moderate 1-2 cm, large >2cm
American College of Chest Physicians measures from the apex - small <3cm, large >3cm
ABC to estimate size
List 5 causes of false positive lung US findings for pneumothorax
Bullae, hx pleurodesis, hx pneumonectomy, patient in cardiac arrest (not being bagged), R main stem (no lung sliding on L), poor resp effort/silent chest, large effusion
List 5 transudative and 5 exudative cause for a pleural effusion
Transudative: CHF, cirrhosis (low albumin), nephrotic syndrome, dialysis patients, glomerulonephritis
Exudative: malignancy, pneumonia, TB, lung abscess, PE (ischemia and necrosis), pancreatitis
List the Light’s Criteria
Pleural fluid protein/serum protein >0.5
Pleural fluid LDH/serum protein LDH >0.6
Pleural fluid LDH > 2/3rds reference
Positive if any one is present
List 5 complications of thoracentesis
Post expansion pulmonary edema (Generally only if too much fluid is taken off >1.5L), Pneumothorax, Pain, Infection, Hemothorax
Criteria with hemoptysis to only get a CXR
Normal BP
One episode (non-massive)
viral symptoms with blood tinged sputum
No cancer
Objective findings of severe ashtma
RR >30
PaO2 >60
HR >120
Accessory muscle use
Abnormal PFTs
Who gets admitted with COPD?
Worsening from baseline
Inadequete response to treatment in ED
Worsening hypoxia or hypercarbia
Cant cope at home
Significant comorbidities
Criteria for severe CAP - minor and major
Major - invasive mechanical ventilation
septic shock with need for vasopressors
Minor - RR >30
Multilobar infiltrate
Confusion
Hypotensive requiring aggressive fluid resuscitation
What is re-expansion hypotensionsion with pleural disease?
RV is used to push against high afterload, when afterload is removed get dyskinetic RV
