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Speciality Medicine > Lecture 7: Pulmonary > Flashcards

Lecture 7: Pulmonary Flashcards

1
Q

Respiratory distress:
* What is always the highest priority?
* What always come first?
* Any question on any exam, top priority clinically=
* Then _
* Then _

A
  • ABC’s are always the highest priority
  • Airway always comes first
  • Any question on any exam, top priority clinically: Airway
  • Then Breathing
  • Then Circulation

The only exception: ACLS Protocol

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2
Q

What do you need to observe?

A
  • Tachypnea/Skin Color (Pale, blue)
  • Sinus Tachycardia (most deadly)
  • Stridor
  • Accessory Respiratory Muscle Use
  • Tripoding
  • Can the patient speak?
  • Does the patient have AMS? (agitation,lethargy)
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3
Q

Consider NIV
* What is an example?
* Can usually do what?
* Use on patients that do not need what?
* What is contraindicated?

A
  • BiPAP
  • Can usually turn COPD or Asthma or even CHF around and avoid intubation
  • Use on patients that don’t quite need intubation, but are tiring out from SOB.
  • Contraindicated if patient is vomiting
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4
Q

Intubation leads to what?

A

to prolonged hospital stay and increases infection risk which increases mortality and increases liability due to complications

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5
Q

Quick Review of NIV
* NIV provides ventilation assistance with what?
* Unload what?
* _ volumes
* Successful NIV attempt requires that the patient is what? (4)

A

NIV provides ventilation assistance with positive pressure at 2 levels:
– Unload respiratory muscle
– Lung volumes

Successful NIV attempt requires that the patient:
– Can maintain an airway
– Is alert and oriented with a strong respiratory drive
– Has no facial abnormalities that would prohibit a mask seal
– Does not vomit

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6
Q

NIV:
* Typical settings: What mode? Peak airway? CPAP?
* General guidelines: If you need more ventilation, do what? If you need better oxygenation, do what/

A

Typical settings
– Spontaneous mode
– Peak airway pressure range from 8 to 20 cm H2O
– CPAP or positive end-expiratory pressure (PEEP) range from 5-15

General guidelines
– If you need more ventilation (more carbon dioxide [CO2] removal), adjust the peak airway pressure
– If you need better oxygenation, adjust the CPAP/PEEP

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7
Q

NIV Settings: typical starting pressures
* Inspiratory pressure?
* Expiratory pressure?
* Fio2?

A
  • Inspiratory pressure (peak inspiratory pressure [PIP], inspiratory positive airway pressure [IPAP]) 10 cm H2O
  • Expiratory pressure (CPAP/PEEP) 5 cm H2O
  • Fio2: 1.0
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8
Q

NIV settings: Titrate to effect:
* If FIO2 >0.6 to keep SpO2 greater than what?
* If respiratory rate continues to be high, consider what?

A
  • If FIO2 >0.6 to keep SpO2 greater than 92%, consider increasing expiratory pressure level
  • If respiratory rate continues to be high, consider increasing the inspiratory pressure level
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9
Q

Mechanical Ventilation Concepts
* Indicated for what?
* Reduces what?
* Does not treat what?
* Barotruma is associated with that?

A
  • Indicated for respiratory exhaustion or those failing NIV
  • Reduces work of breathing
  • Does not treat obstruction
  • Barotrauma is associated with a high risk of mortality (i.e. pneumothorax
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10
Q

Mechanical Ventilation Concepts: When intubation is indicated
* Patient starts to look what?
* Keep patient what?
* Allow what to rise?

A
  • Patient starts to look tired, pO2 goes down, or they have AMS
  • Keep patient paralyzed (Minimizes risk of barotrauma)
  • Allow pCO2 to rise (permissive hypercapnia)
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11
Q

When intubation is indicated:
* What ketamine for?
* What is etomidate for?
* What is succinylcholine for?
* What is Rocuronium for?

A
  • Ketamine for sedation and bronchodilatation (smooth muscle relaxer – great choice for Status Asthmaticus)
  • Etomidate – Does not take away the respiration,
  • Succinylcholine – excellent for intubation procedure – lasts 10-15 mins
  • Rocuronium – long term paralysis (~45min)
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12
Q

AIRWAY/VENTILATION METHODS? (noninvasive v invasive)

A
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13
Q

What are the most common causes of dyspnea?

A

– COPD
– CHF
– Pneumonia
– Asthma

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14
Q

What are the most life threatening causes of dyspnea?

A
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15
Q

Respiratory Distress
* What is hypoxemia?
* Results from what?

A
  • Hypoxemia – insufficient delivery of Oxygen to the tissue; pO2 less than 60
  • Results from hypoventilation, right to left shunt, ventilation-perfusion mismatch (PE), low inspired oxygen
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16
Q

Hypercapnia
* What is the lab?
* It is exclusivly caused by what?
* What is acute?
* What is chronic?

A

pCO2 > 45
* Is exclusively caused by alveolar hypoventilation.
* Acute: serum bicarbonate may be slightly decreased or be normal on ABG
* Chronic: serum bicarbonate is elevated due to the renal response to increased Pco2 on ABG

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17
Q

Clinical Characteristics: Pulmonary Embolism
* What are the most common sxs?
* What can you use for low risk patients?

A
  • Tachypnea (85%), dyspnea (80%), tachycardia (50%), chest pain (>50%), hemoptysis (~25%), syncope, cardiac arrest (2%)
  • Well’s/PERC/Modified Geneva criteria for risk stratification – Typically only for low risk patients

A classic EKG finding is the S1 Q3 T3 pattern, but it is present in only 10-15% of patients with PE. Non-specific T-wave changes are the most common EKG finding. Other rare findings are Hampton’s Hump or Westermark’s Sign on the CXR. The Well’s criteria is a clinical scoring tool to help one determine the pre-test probability of a pulmonary embolus.

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18
Q

Risk Factors - PE?

A

It is important to note that 30% of patients with PE have no recognizable risk factors

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19
Q

What are the Hypercoagulable states? (5)

A

– Pregnancy
– Protein C/S Deficiency
– AT III deficiency
– Malignancy
– Hormone therapy

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20
Q

What is the virchow’s triad?

A
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21
Q

Fill in for the well’s criteria?

A
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22
Q

What is low, moderate and high scores of the well score?

A
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23
Q

What is the PERC criteria?

A
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24
Q

What si the modified Geneva?

A
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25
Q

Diagnosis Pulmonary Embolus (1st from DVT)
* What does the ABG and pulse oximetry show?
* What does the EKG show?
* What does the CXR show?

A
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26
Q

What is this? What does it represent?

A
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27
Q

What does this show?

A
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28
Q

D-Dimer (FSP)
* What are the two types?
* What are the other causes to have high d-dimer?
* Generally, will need to adjust score if what?

A
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29
Q

When is d-dimer the most useful?

A

Most useful for low pretest probability
* If negative (<500)

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30
Q

VQ Scan
* When is this the test of choice?

A

Test of choice for Pregnant Patient if
* +U/S for DVT
* Although usually not done and treated prophylactically

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31
Q

VQ Scan:
* Unfortunately most are what?
* Used if patient is what?
* What is mismatched?

A
  • Unfortunately most are “non-diagnostic” and radioactive medium is damaging to the fetus nearly as much as radiation from CT
  • Used if patient allergic to Iodine
  • Ventillation/Perfusion
    * Mismatch -Ventillation but NO Perfusion(vessels)

VENTILLATION/PERFUSION SCAN=A MISMATCH
Can ask for low cut (about a 12 xray chest) for a pregnant patient.

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32
Q

CTA < invasive IV dye
* What dependend?
* Senstive and specific?
* May miss what?
* Best for who?
* Typical what?

A
  • Possibly radiologist or technician dependent
  • 80% sensitive
  • 85% specific
  • May miss small sub-segmental embolus
  • Best for patients with abnormal CXR
  • Typical ER test
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33
Q

Pulmonary Angiogram
* What is it?
* Typically don in patients that need what?
* Positive results what?
* Generally what? When it is CI?

A
  • Gold Standard for PE – but not an ER test
  • Typically done in patients that need clot treatment
  • Positive results consist of a filling defect or sharp cutoff of the affectedvessel
  • Generally is a safe procedure
  • Contra-indicated in patients with pulmonary hypertension
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34
Q

Treatment of PE:
* What do you need to give?
* What can you give if hypotensive?

A
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35
Q

What do you give for someone who is hypotensive and contrainications to thrombolysis?

A

Thrombectomy
* Hypotension with contraindications to thrombolysis
* Interventional radiologist will only do this if there is a right heart strain

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36
Q

Wheezing
* All that wheezes is not what?
* What does upper and lower airway wheezing indicate?

A

All that wheezes is not asthma (ARDS i.e. non-cardiogenic pulmonary edema)

Wheezing:
* Upper Airway (usually stridor) – FB, angioedema, croup, epiglottitis, tracheitis
* Lower Airway: Asthma, Bronchiolitis, COPD

Cough and see if upper airway clears to see the cause.

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37
Q

Cough:
* What it is?
* What type of protective reflex?

A
  • Common, non-specific symptom, frequently associated with acute URI
  • Protective reflex: clear secretions and foreign debris from tracheobronchial tree
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38
Q

What are the most common reasons for chronic cough?

A
  • Smoking
  • Postnasal drip (worsen in supine position) (only @ night+ cobblestone appearance)
  • Cough Variant Asthma (premature at birth)
  • GERD (wake up with sour taste in mouth)
  • ACE or ARB medications (Switch to ARB)
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39
Q

Cyanosis:
* What is it?
* increased amount of what?
* Consider what?

A
  • Blue color of skin and mucous membranes
  • Increased amount of ”reduced” hemoglobin or deoxyhemoglobin
  • Consider possible tissue hypoxia
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40
Q

Carbon Monozxide poisoning
* CO is what?
* Hemoglobin binds to CO with what?
* COHb shifts the oxydissociation curve where?

A
  • CO is a clear, odorless gas
  • Hemoglobin binds to CO with 230- 270 times more affinity than it binds to Oxygen
  • COHb shifts the oxydissociation curve to the left so that Hb gives off less oxygen at the tissue level

Carboxyhemoglobin Holds onto O2

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41
Q

oxydissociation curve
* What shifts the curve left and right?

A
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42
Q

CO:
* Patient Sxs?
* May have what?
* Where can CO cross?

A
  • Patient has fatigue, malaise, flulike symptoms, nausea, trouble
    thinking and concentrating, poor memory; stroke, coma, seizure, respiratory arrest.
  • May have myocardial ischemia, dysrhythmias, hypotension and
    cardiac arrest.
  • CO crosses placenta
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43
Q

CO:
* Who else will have symtoms?
* More prevalent when?

A
  • Entire family or co-workers with same symptoms
  • More prevalent with winter weather
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44
Q

CO:
* Can you trust the pulse ox?
* A saturation gap is what? What gap is considered significant?
* Why does pulse ox give spuriously high readings?
* What can you get done?

A
  • Can you trust the pulse ox? NOOOOO
  • A saturation gap is the difference between the pulse ox and the saturation of oxygen on the ABG. There would be a gap in CO poisoning
    * Gap > 5 is considered significant
  • Pulse oximetry gives spuriously high readings because the device confuses COHb for OxyHb
  • Get an ABG done – look for carboxy and methhemoglobin levels.
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45
Q

CO:
* What is the treatment of choice?
* What is the half life of co in different conditions? (3)

A

Hyperbaric Chamber is the treatment of choice

Half life of CO:
* 320 min (air),
* 90 min (100% O2),
* 20 min (Hyperbaric O2 Chamber).

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46
Q

Smoke Inhalation:
* What are products of combusion?
* Cyanide exposure if combusting what?
* What are the sxs? What does the PE show?

A
  • CO and toxic products of combustion
  • Cyanide exposure if combusting wool, silk, plastics
  • Symptoms: Headache, nausea, drowsiness, confusion and coma
  • Physical exam: damage to breathing passages/soot – can take up to 24hrs to develop from exposure
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47
Q

Smoke inhalation:
* Dx usually with what? (2)
* What is the txt? (2)

A

Diagnosis usually with ABG and CXR

Treatment
* Simple inhalation: Oxygen
* Complex (due to physical findings) – intubation

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48
Q
  • If Cyanide suspected (diffuse cyanosis), give what?
  • If CO/ fire victims then give what?
A
  • If Cyanide suspected (diffuse cyanosis) – Amyl nitrite (forms methemoglobin with high affinity for cyanide)
  • Give fire victims High flow O2, not amyl nitrite (CO is predominant)
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49
Q

Smoke inhalation can develop what?

A

Can develop ARDS

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50
Q
A
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51
Q

Dyshemoglobinemia
* Methemoglobinemia most commonly caused by what?
* Methemoglobin cannot bind to what?
* Methemoglobinemia can be what?
* Sulfhemoglobinemia most commonly caused by what?

A
  • Methemoglobinemia most commonly caused by nitrites, nitrates, benzocaine
  • Methemoglobin cannot bind oxygen
  • Methemoglobinemia can be hereditary
  • Sulfhemoglobinemia most commonly caused by pyridium
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52
Q

Dyshemoglobinemia
* What is one clue?
* What is the second clue?
* Get ABG and look for what?
* What is the differential?

A
  • One clue: Oxygen won’t help (no >O2 sat)
  • Second clue: Patient’s blood is chocolate brown
  • Get ABG and look for gap in measured and calculated oxygen. If it is >5, then another hemoglobin is involved (methemo or carboxy)
  • Differential – amiodarone or viagra intake
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53
Q

Tx methylene blue:
* Methemoglobin reduced back to what?
* T 1⁄2?
* Methylene blue accelerates what?

A
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54
Q

What are the different types of Respiratory distress?

A

ARDS: fulminant, end-stage, final common pathway of MSOF (multisystems organ failure)

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55
Q

Acute Respiratory Distress Syndrome
* What are the causes? (9)

A
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56
Q

Acute Respiratory Distress Syndrome
* What is the treatment?

A
  • Supportive care
  • Correct underlying disorder
  • Mechanical ventilation (early)
  • Consider CPAP, BiPAP, PEEP(E-T)
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57
Q

Patient has SOB, what is going on?

A

Pulmonary edema, Pleural effusion, post infusious, malignancy?

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58
Q

Pleural Effusions
* What is this Empyema (exudate)?
* What are the causes?

A
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59
Q

Pleural effusions:
* Large ones should be what?
* What is the role of thoracentesis?

A

Large ones should be drained with chest tube

Role of Thoracentesis
* Diagnostic
* Therapeutic

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60
Q

Bronchitis:
* What is acute bronchitis?
* Usually there is what?
* Most often caused by what?
* MCC of what?

A
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61
Q

Bronchitis:
* What is not indicated?
* What is given for wheezing?

A
  • Antibiotics not indicated if symptoms <2 weeks (unless smoker or has +CXR) MIPS measure 116.
  • Bronchodilators for wheezing (atrovent or similar)
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62
Q

Bronchitis:
* Acute exacerbation of what?
* 2/3 of the patients with chronic bronchitis who have an acute exacerbation will have a bacterial etiology with what?
* What is the txt?

A
  • Acute Exacerbation of Chronic Bronchitis (increased cough, increased sputum, increased purulence of sputum)
  • 2/3 of the patients with chronic bronchitis who have an acute exacerbation will have a bacterial etiology with H.flu, Strep pneum, Moraxella, and atypical species (mycoplasma)
  • TX: doxycycline, macrolide, augmentin, fluoroquinolone (not cipro)
    *
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63
Q

Who should be avoided for chest x-ray?

A

peds patients with asthma, bronchiolitis or croup

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64
Q

What is going on here if patient has cough and fever

A

CXR

RML
* Infiltrate

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65
Q
A
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66
Q

49 year old male with a history of alcoholism develops an acute illness with fever, rigors, chest pain. He has dark brown, tenacious sputum. Chest x-ray demonstrates a lobar infiltrate and some abscess formation. The most likely etiology is:
A) Pneumococcal (Strep pneumoniae)
B) Pseudomonas
C) Klebsiella
D) Legionella
E) Haemophilus influenzae

A

C) Klebsiella

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67
Q

Strep Pneumoniae (Pneumococcal) Pneumonia
* What color of sputum?
* Abrupt onset of what?
* What be absent early in disease?
* Usually signs of what?
* What is the WBC count?

A
  • Rust colored sputum
  • Abrupt onset chills/rigor/chest pain (70%)
  • Cough may be absent early in disease
  • Usually signs of consolidation on exam
  • WBC ― 12-25,000
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68
Q

Strep Pneumoniae (Pneumococcal) Pneumonia
* What does the CXR show?
* What does the lab show?
* What is the txt?

A
  • CXR ― lobar consolidation, pleural effusion (10%)
  • Lab ― sputum culture positive 50%/blood 30%/rusty (blood-positive)sputum
  • Treatment ― penicillin high incidence of resistance/erythromycin or quinolones
69
Q

Haemophilus influenza (Second most Frequent)
* H.flu morphology?
* Prevalent when?
* Patients with what? (5)
* Gradual progression with what?

70
Q

Staph. Aureus Pneumonia
* Patient at risk for what?
* Onset?
* What population is at risk?
* What does the paitnet look like?

A
  • 1% of bacterial pneumonias
  • Patient at risk for aspiration
  • Sudden onset
  • Post-influenza/IVDA
  • Toxic appearing patient
71
Q

Staph. Aureus Pneumonia
* What happens with the lungs?
* What are the complications?
* What is the txt?

A
  • Patchy infiltrates leading to necrotizing pneumonia/cavitations
  • Complications: cavitation/pneumothorax/empyema
  • Treatment: Vancomycin->Must cover MRSA
72
Q

Klebsiella Pneumonia
* Necrotizing lobar pneumonia most often seen where? What do they develop?
* Who is at risk? (5)

73
Q

Klebsiella Pneumonia
* The bacteria remain what? (txt)
* Varying degrees of inhibition of what has been reported?

A
  • The bacteria remain largely susceptible to aminoglycosides and cephalosporins.
  • Varying degrees of inhibition of the beta-lactamase with clavulanic acid have been reported.
74
Q

Pseudomonas
* Severe _
* What are some signs?
* What does the CXR show?

A
  • Severe pneumonia
  • Cyanosis, confusion, systemic illness
  • CXR: bilateral lower lobe infiltrates, occasionally associated with empyema
75
Q

Pseudomonas:
* What type of acquired bacteria?
* What type of patients?
* What is the txt?

A
  • Hospital acquired (Ventilator assisted patient in ICU)
  • Cystic Fibrosis patients
  • Cefepime covers pseudomonas IV, Cipro PO (only time cipro is given above the belt)
76
Q

Atypical Pneumonias: Psittacosis
* What animal is common?
* What can it cause?
* What is the txt?

A

Psittacosis – P for parrots (Chlamydia psittaci)
* Bird (parrots, pigeons) handlers and nursing homes
* Endocarditis, DIC
* Treatment: tetracycline/erythromycin

77
Q

Atypical Pneumonias: Q-fever (Coxiella burnetii)
* What animals, population is common?
* What is the txt?

A
  • Sheep, goats, cattle – vets, farmers
  • Treatment: tetracycline
79
Q

Atypical Pneumonia:
* Common in who?
* No what?
* Sputum with what?
* What is the empiric treatment for CAP?

A
  • Older children, young adults, Elderly
  • No cell wall – gram stain doesn’t help
  • Sputum with WBC’s
  • Empiric treatment for CAP
    * Macrolide Class Antibiotic i.e. Azithromycin
80
Q

Legionnaire’s Pneumonia
* Who is at risk?
* Possibly caused by what?
* Can test by what?

A
  • Risk: smoking, alcohol use, chronic lung disease, transplant patients and immunosuppressed.
  • Possibly caused by inhaled contaminated aerosols from domestic water systems/AC
  • Can test by Urine
81
Q

Legionnaire’s Pneumonia
* What is the incubation period?
* Patients look what?
* What is pontiac fever?
* Legionnaires disease is what?
* What is the txt?

A
  • 2-10 day incubation (or as short as 24 hrs)
  • Patient looks sick (toxic)
  • Pontiac fever is the mildest form of Legionella pneumonia
  • Legionnaires disease is the severe form of the infection
  • Treatment: erythromycin for at least 3 weeks
82
Q

Legionnaire’s Disease
* What are the sxs?

A
  • Patients with Legionnaires’ disease usually have:
  • fever
  • chills
  • muscle aches
  • Most have diarrhea
  • loss of coordination (ataxia)
  • 1/3 of the patients have AMS
  • Relative Bradycardia

relative bradycardia is noted in all legionella infections with fever of 102 and can also be seen in Typhus and Rocky Mountain Spotted Fever as well as variousendemic diseases seen inunderdeveloped countries

83
Q

Legionnaries disease:
* What did the labs show? CXR?
* WBC?
* Gram stain?

A
  • Laboratory Findings include:
    * may show that patients’ kidneys (10% have microscopic hematuria) and liver (Elevated LFTs) are not functioning properly.
    * Chest X-rays often show pneumonia initially in unilateral lobar distribution progressing to bibasilar consolidation, patchy infiltrates, occasional hilar adenopathy and sometimes pleural effusions.
  • WBC 10,000-20,000
  • Gram stain: polys(wbc’s), no bacteria
84
Q

Mycoplasma pneumoniae
* How is M. pneumoniae transmitted?
* Causes what?
* Commonly infects who?
* Most common cause of what?

85
Q

Mycoplasma pneumoniae
* What are the sxs?

A
  • Headache
  • Malaise
  • Hacking, non-productive cough for 4-6 weeks
  • Low grade fever
  • Chills are frequent, but rigors are rare.
  • May have bullous myringitis
86
Q

Mycoplasma pneumoniae
* What is the first line txt?
* What are other antibiotic classes?

A
  • Macrolide antibiotics (azithromycin, clarithromycin or erythromycin) are advised as first line treatment.
  • Other antibiotic classes, tetracyclines, doxycycline and fluoroquinolones (in particular, levofloxacin and moxifloxacin), may be used as well.
87
Q

Viral Pneumonias
* Significant mortality and morbidity with what?
* Occurs when?
* What does the CXR show?
* What is the WBC?
* Complicated by what?

A
  • Significant mortality and morbidity with influenza and parainfluenza viruses, Varicella zoster, Herpesvirus
  • Occurs during flu season
  • CXR: patchy densities or interstitial infiltrates
  • WBC: 4,000-15,000 (typically leukopenia)
  • Complicated by ARDS
88
Q

What is the txt of viral pneumonias?

A

TX: Oxygen, bedrest, analgesics, decongestants, expectorants, possible antihistamines, bronchodilators for wheezing, limited steroid use, possible ventilator support
* Acyclovir: herpes
* Amantadine or Tamiflu: Influenza A
* Aerosolized ribavirin: RSV
* Ramdesivir: SARS-CoV

89
Q

SARS-CoV-2
* What is it?
* What is the difference between SARS 2002, MERS 2012?
* What rank of cause of death?

A

Severe acute respiratory syndrome coronavirus 2

Third serious coronavirus outbreak
* More deadly and virulent than SARS 2002 outbreak
* Less deadly but more virulent than MERS 2012 outbreak

Third cause of death in the US in 2020 and 2021
* Heart disease and cancer still leading

90
Q

Transmission of SARS CoV-2
* What is the morphology?
* Expressed via what?
* What is the incubation period?
* Develop what type of sxs?
* Very few can develop what?

A
  • Single strand RNA-encapsulated viruses enter through animalhost
  • Expressed via ACE2 enzyme(HTN patients on ACEi were affected more)
  • Incubation period of 3-7 days
  • Develop typical flu-like symptomatology
  • Very few can develop ARDS dueto cytokine storm
91
Q

COVID-19 Clinical Course
* What are the sxs?
* Some patients will develop what?
* What does cytokine storm cause?

92
Q

COVID-19 Clinical Course
* Within 20 days most patients that are going to survive will be what?
* What is the breakdown of sxs?

A
  • Within 20 days most patients that are going to survive will beextubated by thistime.
  • 20% are asymptomatic, 61% mild symptoms, 14% severe, 5%critical
93
Q

Laboratory COVID-19 Diagnosis
* What are the two types of tests to determine current infection? What is the difference?

A

Antigen test ($20-$30)
* False negative rate up to 50%
* False positive rate nearly zero

PCR RNA/NAAT (about $75)
* False negative rate 2-37%
* False positive rate nearly zero

94
Q

Laboratory COVID-19 Diagnosis
* What is the test for past infection?

A

Antibody test
* False negative rate 0-30% and depends on collection time following disease

97
Q

Clinical Covid-19 Diagnosis (Delta)
* What can the labs show?

A

B/l PNA with normal to low WBC, lymphopenia, normal procalcitonin, elevated ferritin, Dimer andCRP = COVID

98
Q

Omicron Strain
* Tends to be what? What are the sxs?
* Less what?
* CXR?
* What population is more affected? What seems to work?

99
Q

COVID-19 Treatment
* What is the inpatient txt? MOA?
* What is the choice of pressor?

100
Q

COVID-19 Treatment: NIV
* What is the goal?
* COVID-19 respiratory failure is usually what?
* Oxygenation sometimes what?
* What is superior?

101
Q

COVID-19 Treatment
* What is the pre-exposure prophylaxis?
* What is the post-exposure prophylaxis?

A

Pre-exposure prophylaxis
* Evusheld (tixagevimap co-packaged and administered together with cilgavimab; intramuscular injection)

Post-exposure prophylaxis and early treatment of COVID patients
* Bebtelovimab (monoclonal AB) – only one available in FL

102
Q

COVID-19 Treatment: Outpatient
* PO Therapy for early treatment of COVID-19 (EUA) - To be initiated when?
* What are the two types?
* What is the supportive (off label) meds?

103
Q

COVID-19 Treatment
* Not authorized for what?

A

Not authorized for the pre-exposure prevention of COVID-19 or for initiation of treatment in those requiring hospitalization due to severe or critical COVID-19

104
Q

COVID-19Disposition
* D/C home if what?
* What are the Ongoing evaluation of long-lastingeffects? (3)

105
Q

MIS-C
* In who?
* Well appearing children that suddenly what?
* What age and gender is most prevalent?
* Labs DO NOT align with what?
* See elevated what?
* Mortality?

A
  • Multisystem Inflammatory Syndrome in Children
  • Well appearing children that suddenly deteriorate, sometimes weeks after mild to no symptoms of + SARS-CoV-2
  • Age 5-9 most prevalent, and male (62%)>female (38%)
  • Labs DO NOT align with clinical appearance (kids look better than the labs)
  • See elevated D-Dimer, troponin and CRP/ESR, lymphopenia
  • Mortality is low, most symptoms resolve quickly
106
Q

MIS-C presentation
* 80% with what?
* 44% with what?
* 20% with what?

A
  • 80% with fever, abd pain, N/V/D, transaminitis and cardiac dysfunction, edema of hands/feet (some look like acute appendicitis with negative imaging)
  • 44% had conjunctivitis
  • 20% with fever and rash – Kawasaki like
107
Q

MIS-C: 20% with fever and rash – Kawasaki like
* Race?
* What does the lab work?
* What does 30% require?
* What does 40% require?
* What is the most clinical concern?
* Most have what type of changes?

108
Q

MIS-C Treatment
* What is the goal?
* What should you start? (6)

109
Q

CMV (Cytomegalovirus)
* Common in who?
* What do you expect in the first 30 days?

A
  • Transplant patients
  • HIV patients (pneumocystis carinii)
  • 1st 30 days – expect C.diff.
110
Q

Pneumocystis carinii (30 yrs.)Pneumocystis jiroveci pneumonia
* Emerged when?
* What type of disease?
* What is the sxs?
* What is the CXR?

A
  • Emerged in 1981 in New York and California in gay men and IVDAs
  • Opportunistic disease in immunosuppressed patients, particularly in HIV seropositive patients
  • Nonspecific presentation, slow and insidious onset, fever, dyspnea, cough, weight loss, chest pain, night sweats, fatigue
  • WBC normal
  • CXR diffuse bilateral interstitial or alveolar infiltrates =>Bat Wing Appearance
111
Q

Pneumocystis carinii (30 yrs.) Pneumocystis jiroveci pneumonia
* Elevated what? Many will have what?
* What is the txt?

A
  • 90% have elevated LDH; Many will have concomitant TB
  • Rx—- Bactrim or Pentamidine (if allergic)
112
Q

Pertussis
* What will a lot of childs have?

A

Child with broken blood vessels in eyes and bruising on face due to pertussis coughing.

113
Q

What happens with pertussis pneumonia?

A

Bronchiolar plugging in neonate with pertussis pneumonia
* Cause cough/apnea

114
Q

Sign/sysptoms of pertussis:
* Early symptoms can last for 1 to 2 weeks and usually include what? (4)

A
  • Runny nose
  • Low-grade fever (generally minimal throughout the course of the disease)
  • Mild, occasional cough
  • Apnea — a pause in breathing (in infants)
115
Q

Sign/sysptoms of pertussis:
* As the disease progresses, the traditional symptoms of pertussis appear and include what? (3)

A
  • Paroxysms (fits) of many, rapid coughs followed by a high-pitched “whoop”
  • Vomiting (throwing up)
  • Exhaustion (very tired) after coughing fits
116
Q

Dx/Tx Pertussis
* how is it detected?
* What is the txt? (above and below one month old)

A
  • Detection of organisms by polymerase chain reaction (PCR), and testing serum for antibodies to pertussis toxin
  • Erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons >1month of age
  • <1 month of age, azithromycin
117
Q

Epiglottitis
* What is it?
* Swelling can interfere with what?
* What type of sign?

A
  • Bacterial infection of the epiglottis
  • Swelling can interfere with breathing = a medical emergency!
  • Thumb sign
118
Q

Epiglottitis:
* No what? Why?
* Rapid onset of what?

A
  • NO tongue depressor – result in spasm and respiratory arrest
  • Rapid onset – drooling, posturing to protect airway, stridor
119
Q

Clinical Features in Children (epiglottsis)
* Appears what?
* Early symptoms what?

A

Appears acutely ill, anxious, quiet, shallow breathing with the head held forward (sniffing position), insisting on sitting up
– Early symptoms insidious but rapid progression

120
Q

What are the most common organisms of percussus(4)

121
Q

Treatment of epiglottsis:
* What is the txt to help the patient breathe?
* What is the txt to treat the infection?
* What is corticosterioids?
* Always have what with the patient?
* Emergenet whatt?

122
Q

Croup:
* Causes what? (what bacteria)
* Peak incidence?
* The critical site is where?

A
  • Causes acute airway obstruction; caused by influenza and parainfluenza viruses
  • Peak incidence: between 6 months and 3 years
  • The critical site is immediately below the larynx, where edema narrows the subglottic trachea. this area has an inverted “v” appearance that is characterisitc of croup
123
Q

Croup
* What is the most likely to cause symptoms in kids?
* What is the characteristic?
* Usually have other what?

A
  • HPIV-1 (parainflu 1) is most likely to cause symptoms in kids
  • Characteristic “Seal Bark”
  • Usually have other URI symptoms
124
Q

Treatment of croup?

A

Treatment is supportive in nature, but for moderate/severe Sxs:
* Humidified oxygen
* Single dose of dexamethasone (any route) improved symptoms and reduced return visits
* Nebulized epinephrine reduced length of hospitalization

125
Q

Pneumonia Admission Stratification Tools
* What are the different criteria? What is the difference?

A

CURB-65, PORT, ATS
– CURB 65 vs PORT
* Both still used; CURB 65 easier; PORT proven to be more accurate
* Look up either on MdCalc

126
Q

ATS Pneumonia Admission Guidelines Historical
* Age?
* Hospitalization for what?
* Concomitant what?

127
Q

Immunization
* What groups should be immunized against influenza?

128
Q

Aspiration Pneumonia & Lung Abscess
* What is aspitation pneumonis?
* Who is at risk?
* Serious injury with pH less than what?
* Large volumes=

129
Q

Binge drinking, passed out, what is going on?

A
  • Aspiration pneumonia
130
Q

What is this?

A

Lung abscess
* Lung Abscess Note air-fluid level

131
Q

Lung Abscess
* What is it?
* 10% require what?
* These can be seen from what?
* What does the CXR show?

A
  • Localized suppurative necrotizing infection in lung parenchyma
  • 10% require surgical intervention
  • These can be seen from periodontal disease (anaerobic/gm +)
  • CXR: cavitation with an air-fluid level
132
Q

Tuberculosis
* What is the bacteria?
* Transmission through what?
* What occurs with a positive skin test?

A
  • Mycobacterium tuberculosis-aerobic rod
  • Transmission through inhaled droplets, time and exposure dependent
  • Usually latent, asymptomatic infection occurs with a positive skin test conversion
133
Q

Tuberculosis:
* When does reactive TB occur?
* Who is the highest group?

A
  • Reactivation (upper lobe) occurs when a host’s immune system is compromised
  • Highest risk: young, old, debilitated, HIV
134
Q

TB Skin Test (positive) 48-72 hrs:

135
Q

Tuberculosis:
* Upper Lobes=
* Lower Lobes=
* Increasing what?
* What type of illness?

A
  • Upper Lobes (Re-activation)
  • Lower Lobes (Initial Infection)
  • Increasing Frequency
  • Is an AIDS Defining Illness
136
Q

TB
* What is the txt?
* Admit to what?
* protect who?

A

  • Beware of local laws regarding involuntary hospitalization (this is a public health hazard)
137
Q

Spontaneous & Iatrogenic Pneumothorax
* What is this?
* Primary spontaneous pneumothorax results from what?

A
  • Air in the pleural space between parietal and visceral pleura
  • Primary spontaneous pneumothorax results from rupture of a subpleural bleb in individuals without lung disease
    * Marfans

Thin, tall and smokers.
Almost always are smokers, not always tall or thin

138
Q

Spontaneous & Iatrogenic Pneumothorax
* Secondary spontaneous pneumothorax occurs in who?
* How mcuh volume is reaborbed per day?

A
  • Secondary spontaneous pneumothorax occurs in COPD patients
    * Central line placement 16%
  • 1.25% pneumothorax volume re-absorbed/day(> rate with O2)

Thin, tall and smokers.
Almost always are smokers, not always tall or thin

139
Q

What is going on?

A

Pneumothorax
* Super small so get CT to quantative the size to see the treatment
* If under 15% then obs

140
Q

Tension Pneumothorax
* Pleural defect creates what?
* What is the triad?
* What are other signs?

A
  • Pleural defect creates one way valve and leads to positive pressure in pleural space → shift of mediastinum → compression of SVC → hypotension → arrest
  • Triad of JVD/decreased breath sounds/hypotension
  • Other signs include unilateral chest expansion/cyanosis/tracheal deviation (late sign)
141
Q

Tension Pneumothorax:
* How do you dx?
* How do you tx?

A
  • Diagnosis clinically; if stable, wait for CXR!
  • Treatment: needle thoracostomy in 2nd ICS at MCL (field) follow-up with chest tube (hospital)
142
Q

What is the pleural space?

A

The pleural space is the space between the inner and outer lining of the lung. It is normally very thin, and lined only with a very small amount of fluid.

143
Q
  • If fluid goes into the pleural space, what can happen?
  • What is used to treat? (4)
A

If fluid, such as blood, or air, gets into the pleural space, the lung can collapse, preventing adequate air exchange.

Chest tubes are used to treat conditions that can cause the lung to collapse, such as:
* air leaks from the lung into the chest (pneumothorax)
* bleeding into the chest (hemothorax)
* after surgery or trauma in the chest (pneumothorax or hemothorax)
* lung abscesses or pus in the chest (empyema).

144
Q
  • Chest tubes are inserted to do what?
  • Where is the tube placed?
  • Where is the tube inserted?
  • What is attached to the tube?
A
  • Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs.
  • The tube is placed in the pleural space. The area where the tube will be inserted is numbed (local anesthesia). The patient may also be sedated.
  • The chest tube is inserted between the ribs into the chest and is connected to a bottle or canister that contains sterile water.
  • Suction is attached to the system to encourage drainage. A stitch (suture) and adhesive tape is used to keep the tube in place.

The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics).

145
Q
  • What is the recovery of the chest tube?
  • Where does the patient stay? What does the nursing staff do?
  • What is necessary?
A
  • Recovery from the chest tube insertion and removal is usually complete, with only a small scar.
  • The patient will stay in the hospital until the chest tube is removed.
  • While the chest tube is in place, the nursing staff will carefully check for possible air leaks, breathing difficulties, and need for additional oxygen.
  • Frequent deep breathing and coughing is necessary to help re-expand the lung, assist with drainage, and prevent normal fluids from collecting in the lungs.
146
Q

What are the causes of hemoptysis? (5)

A

– 1⁄4 Infectious(non-TB)
– 1⁄4 Neoplastic
– 1⁄4 Other: TB, cardiovascular, vasculitis, etc.
– 1⁄4 Undetermined
– Epistaxis (false positive)

147
Q

Hemoptysis:
* What is considered massive?
* Death by what?
* What are the indications for admission (5)

148
Q

Hemoptysis Treatment
* What do you do for minor?
* What do you do for massive?

A

Minor
* Treat underlying cause

Massive
* Consider selective mainstem intubation of non-bleeding lung
* Angiogram/bronchoscopy/surgery

149
Q

Acute Asthma
* What is it?
* What is the reduction of airway diameter caused by?
* increased what? Decreased what?
* With increased work of breathing, patient develops what?

A
  • Reversible airway obstruction
  • Reduction of airway diameter caused by smooth muscle contraction, bronchial edema and thick mucous secretions
  • Increased airway resistance, decreased expiratory flow rates, air trapping
  • With increased work of breathing, patient develops hypoxemia, hypercarbia, and respiratory muscle fatigue with ventilatory failure
150
Q

Management of Asthma
* What do you give for smaller airways? What is the max?
* What do you give for larger airways?
* What can you give for more long term?

A
  • Beta adrenergics (smaller airways) albuterol
    * Usually expect a response after 6mg of albuterol – receptors are now saturated
  • Anticholinergic agents (ipratropium bromide)(larger airways)
  • Corticosteroids (PO/IV not Aerosol) acute
151
Q

Management of Asthma
* What can you give after all the other drugs failed?
* What is the worst case situation?

A
  • Magnesium 1-2 grams over 15 minutes in severe asthma (smooth Muscle relaxer) after the above drugs failed
  • Intubation and Ventilation
152
Q

COPD
* Chronic what?
* Exterional what?
* What type of cough?
* What is frequent?
* What type of wheezing?
* Decompensation is frequent=

A
  • Chronic airflow obstruction
  • Exertional dyspnea and cough
  • Chronic, productive cough
  • Hemoptysis is frequent
  • Expiratory wheezing (especially forced end-expiration)
  • Decompensation is frequent: super-imposed URI

Don’t give too much O2 – knocks out respiratory reflex.
No permissive hypoxia, only hypercapnia.

153
Q

What is this?

A

CXR (COPD)

154
Q

ABGs & Discussion of Management COPD
* Over time, the patient will develop what?
* Eventually becomes what?
* What can happen?
* 30% are on what?

A
  • Over time, patient develops chronic hypoxemia
  • Eventually becomes markedly hypercarbic
  • Chronic Respiratory Failure (50-50)
  • 30% are on home-oxygen therapy which reduces mortality
155
Q

ABGs & Discussion of Management COPD
* Goal of pO2?
* Allows what?
* What is the mainstay of TX?
* What do you do for acute exacerbations?
* What has better outcomes than intubation?

A
  • Goal is pO2 of 60 with 90% saturation at rest
  • Allow permissive hypercarbia (respiratory drive), not hypoxia
  • Mainstay of TX: bronchodilators, anticholinergic
  • Acute Exacerbations: add short course of steroids, antibiotics if indicated by sputum
  • Noninvasive positive pressure ventilation through a mask has better outcomes than intubation

Try to get O2Sat at 90 to maintain respiratory drive.
Give them to BiPAP. Increase the EPAP.

156
Q

Barotrauma
* What effects the pressure changed of the body?
* Occurs secondary to what? Generally safe to do what?

A
  • Descent or Ascent direct effect of pressure changes on the body
  • Occurs secondary to the Compression or Expansion of air and nitrogen in bodily spaces
    – Generally safe to ascend or descend 30ft per minute with supply, 60ft/min if no air supply
157
Q

Barotrauma:
* Sxs can develop what?
* Decompression Sickness can develop when?
* What is the txt?

A
  • Symptoms can develop 4.5-6.5 ft depth
  • Decompression Sickness can develop if patient flies within 12-24hrs of the dive
  • Treatment with High Flow O2 to have NITROGEN WASHOUT
158
Q

Pulmonary Air Embolism
* What is this?
* Air bubbles enter where?
* Arterial occlusion from what? (3)
* What is the txt?

159
Q

High Altitude Medical Problems
* In Denver, the air has what? In aspen? At the top of Mt. Everest?
* High altitude is what?
* Increasing altitude=
* What is the key of prevention?

A
  • In Denver, the air has 17% less oxygen in it than at sea level. In Aspen, there is 26% less oxygen in the air. At the top of Mt. Everest, there is 1/3 the amount of oxygen in the air as at sea level
  • High altitude is a hypoxic environment.
  • Increasing altitude=decreasing atmospheric pressure=relative hypoxia
  • Acclimatization is key of prevention

Advise COPD pat against skiing.

160
Q
  • What are all the issues with high altitude problems? (6)
  • What are the sxs?
A
  • Acute Mountain Sickness (AMS)
  • High Altitude Cerebral Edema (HACE)
  • High Altitude Pulmonary Edema (HAPE)
  • High Altitude Retinal Hemorrhage (HARH)
  • Chronic Mountain Polycythemia (CMP)
  • Ultraviolet Keratitis (Snow Blindness)
  • Symptoms range from SOB/dizziness/nausea/weakness to ataxia/AMS/Coma
161
Q

Altitude Problems Treatment
* What should the patient do?
* What can you give? (4)

A
  • Descend
  • Oxygen
  • Motrin
  • Nifedepine
  • Acetazolamide (preventitive)
162
Q

Altitude Problems Treatment
* What does nifedepine cause?
* Acetazolamide: contraindicated with what? What does it cause?

A

Nifedepine to cause vasodilation of pulmonary artery

Acetazolamide improves arterial oxygenation during sleep.
* Contra-indicated with Sulfa Allergy
* Causes HCO3 excretion, creating hyperchloremic acidosis and thus increasing respiratory rate, leading to respiratory alkalosis

163
Q

Altitude Problems Treatment
* Phelebotomy for what?
* Advise against what?

A
  • Phlebotomy for chronic polycythemia
  • Advise against altitude for COPD/Sickle Cell and pregnancy patients
164
Q

Drowning:
* What is drowning? what is near drowning?

A

Drowning – death within 24 hours
* Generally receive CPR

Near-drowning – survival past 24 hours
* Generally do not receive CPR

165
Q

What is the mechanism of drowning?

167
Q

Aspiration of water can cause what late complications? (2)

A
  • Neurogenic pulmonary edema, Pneumonia, ARDS etc.
  • Plus complications of hypothermia
168
Q

Assessing H2O Aspiration:
* What do you need to ask historical factors?

A
  • Prolonged head immersion
  • L.O.C.
  • Period of apnea
  • CPR required
169
Q

Assessing H2O Aspiration:
* What are the sxs?

A
  • Cough, breathlessness
  • Retrosternal discomfort
  • Cyanosis, tachycardia
  • Tachypnoea, wheeze or Crackles in chest
  • Pink frothy sputum
  • Reduced consciousness

Speciality Medicine (12 decks)

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