pulm Flashcards
S and S of asthma
respiratory distress at rest diaphoresis RR over 28 pulse >110 pulsus paradoxus >12- unique feature of asthma hyperressonance
astuma ominous signs
fatigue paradoxical chest or ab movment absent breath sounds can be recumbant cyanosis
asthma labs
slight wbc elevation withh eosinophilla
initially resp acidosis with mild hypoxemia on ABG
HYPERCAPNEA IS AN OMINOUS FINDING
A PC02 >45MMMHG INDICATES AN EMERGENCY
A NORMAL PCO2 (35-45) IS A VERY SICK PATIENT
chest x-ray is only useful to rule out other conditions
would show hyperinflation
asthma PFT
hospitilazation with initial FEV-1 is <30% predicted or dose not increase by at least 40% after one hour of vigorous therapy
hospialization is reccomended if peak flow is <60L/min ainitiallly and doesn to improve to >50% predicted after 1 hour of treatment.
general improvment in FVC or FEV1 of 15% or FEF 25-75 of 25% after inhailed bronchodialator
outpatient management of asthma -
short acting B2 adrenergic agonist (albuterol, for symptom releife before exercise
Short acting B2 adrenergic agonist
albuteral or proventil step one
step 2 daily maintenance with inhaled corticosteroids
budesonide (pulmicort) triacinolone (amacort
side effects of step 2 inhaled corticosteroids
(rinse mouth) candidal infection of oropharynx, dry mouth, sore throat,
step 3 asthma
short acting b2 adrenergic agonist - albuterol, proventil for symptom breakthrough
if symptoms persist beyond step 3 then
increase corticosteroid dose or add LONG acting b2 adrenergic agonist (salmeterol (servent) or ipratropium bro- arovent -good for lots of secretions
useful for chronic asthma
antileukotryines- singulair
Inpatient managment of asthma
02 at 2-3 L
mild to mod- abg not necessary, if sa02 is over 90%
abg for less than 90%
hydration oral or IV
inhaled sympathomimetics
alupent (0.3cc in 5% soutions) in 2.2 ml nss q 30-60mins
proventil,
proventil or ventolin inhaled
corticosteroids
methlprednisolone 60-125mg IV x1 and then 20mg q 4or 6 untill attack is broken
can use parenteral sympathomimetics in pts who cant do po
can also use anticholonergic (atrovent
black box on leukotryins and LABA
dont take in acute attack singular or salmeterol
Status asthmaticus def
severe acute asthma presenting in an unremitting, poorly responsive, life thereatening manner,
status asthmaticus management
02
D51/2 ns
inhaled and pareneral sympathomimetics- alupent or proventil or ventolin
methylpred-60-125IV or hydroortisone 300iv now
consider atrovent- 2-6puffs q4-6 anticholinergic
continous pulse ox
freq ABG
tube if necessary
Chronic bronchitis
characterized by excessive bronchial mucous and is manifested by productive cough for 3months or more in at least tow consecutive years
Emphysema
abnormal, permanent enlargement of the alveoli
emphysema symptoms
progressive constant dyspnea onset of symptms after 50 min clear sputum thin increase in chest AP diameter hyperressonant precussion normal hematocrit increased total lung capacity
chronic bronchitis symptoms
intermittant mild to mod dypsnea symptoms onset after age 35 COPIUS PURULENT SPUTEM PRODUCTION stocky body habitus normal chest AP diameter bulla blebs on cxr hyperinfation on cxr HEMATOCRIT INCREASED hypercapnea hypoxia on ABG
COPD fev and volume stuff
FEV is down but TLC< FRC and RV may be up
COPD management outpatint
stop smoking
aovind irritants
postural drainage
INHALED IPRATROPIUM BROMIDE (ATROVENT) OR SYMPATHOMIMETICS (PROVENTIL, VENTOLIN)MAINSTAY OF THERAPY
COPD inpatient
02 at 1-2L per min or 24-28% on venti mask
pharmacologic progression as with asthma
purluent sputem gets abx for 7-10 days
copd inpaitient ABX
ampicilin or amox- 500mg four times per day
doxy 100mg bid or
bactrim DS 1 tab BID
TB def
systemic disease caused by M Tuberculosis. Pulm disease, is the most common clinical presentation, othe sites of involvment include lymphatics, denitourinary, bone, meningies, perotoneum and heart
TB most at risk
crowded living conditions, the institutionalized, HIV +, those with DM, chronic renal players, malignancy, malnutrition and the immunosuppressed.
TB s and S
most are asymptomatic fatigue, annorhexia dry cough, progressign to wet with some blood weight loss and low grade fever night sweats
TB labs
DEFINITIVE DIAGNOSIS BY CULTURE OF M TUBERCULOSIS X 3
AFB ssmear are presumptive evidence of active TB
small momogenious infiltrate in Upper lobes on CR
PPD shows exposure but is not diagnositic for active disease
TB managemnt
local helath department, must be notified
hospitilization is not required
TB meds
Isoniazid 300mg, rifampin 600mg, pyrazinamide 1.5-2.0 gm and ethambutol 15mg per kg per day initially
if the isolate is succeptable tto INH and RIF than you can drop ethambutol
3 drugs for 2 months, and 4 months of INH and RIF daily
TB meds INH
nephro toxic
TB meds consideration
persons iwth HIV should be treated for 9 months
depot injections are available
Pulm tb patient monitoring
weekly sputum smears and cultures for 6 weeks, and then monthly untill negative cultures, persistant symptoms or cultures should raise suspicion for resistance
baseline before TB therapy
liver labs, and watch for red-green color acuity in efambutol
Chemoprophylaxis and PPD
positive PPD of 5mm for an HIV +, contact with a known positive or chest film typical of TB
10mm for immagrants or health care workers
15mm for no in high prevelance groups
Pneumonia def
lower respirartoy infection, strep pneumonia is the most common etilolgical agent of CAP
Pneumonia s and s
fever, shaking chills, lung consolidaiton on physical exam, malise and fremitus
Pneumonia labs
elevated WBC's infiltrates on CXR GS and culture if indicated ABG for respiratory faiure CXR and consider 3 blood cultures
CAP in previously healthy pt abx
macrolide (mycins) or tetracycline (clclines)
CAP in comorbid patints abx
floriquinolone (oxacins) + Amoxicillin/clavulanic acid# Imipenem/cilastatin# Imipenem/cilastatin/relebactam. Ampicillin/flucloxacillin. Ampicillin/sulbactam (Sultamicillin) Ceftazidime/avibactam. Piperacillin/tazobactam. Ceftolozane/tazobactam
Non ICU CAP
oxacins or beta lactam + macrolide or tetracycline
ICU CAP if P aeruginosa suspected
pip/tazo or meropenem or cefepime _ AMG/azithromycin
add vanco if MRSA pnu is suspected
ICU PNU - viral
still gets abx for secondary bacterial infetion- tamflu if in the first 48 hrs
abx for PCN allergy patients
aztreonam
for pseudomonas PNU use
zosyn plus cipro
HAP definition
pneumona that occurs 48hours or more after aadmission whih was not incubation the time of admission includs VA and HCAP, most common is Staphylcoccus aureus or streptococcus
VAP definition
pneumona that arisis more than 48-72 hours after endotracheal intubation pseudomonas is most common orginization
Penumothorax -
gas in the pleural space that raises pleural pressures and can impair respiration, resulting in a “collapsed lung”
S and S of pneumothorax
chest pain, dypsnea, cough
HYPERROSONANCE ON THE AFFECTED SIDE
diminshed breaht sounds and fremitice on the affected side
mediastinal shift towards the unnafected side in the case of tension
hypotension
Pneumothorax labs
CHEST X RAY IS DIAGNOSTIC
abg my be indicated
pneumothorax management
<20% pneumothorax in asymptomatic patinents requires no intervention
chest tube first if available, needle throcostomy
needle thoracostomy site
2nd intercostal space mid clavicular line
chest tube placement site
4th or 5th ics Mid axillary
PE definition
leading cause of inhospital death leads to faillure of left ventricle.
PE S AND S
usually occur abruptly
unexplained dyspnea and taccy are most common
chest pain, retrosternal or lateralized and pleuritic
PE diagnosis
spiral CT
vq scan in all clinicallly stable patients
reflexive hyperventilation causes hypercapnea
pulmonary angiography when clinical data and vq scan contradictory or those at great risk from anticoagulation with high probability VQ scan.
PE managemtn
supplamental 02
IV fluids, for hypotension and reduced Cardiac output
tube for change in mental status
heparin 80u/kg bolus followed by 18u/kg to ptt of 1.5-2x normal, coumadin simultaneus to inr of 2-3
finrinolytic therapy for PE
for those withh hemodynamic compromise or shock before starting hepairn, PT and PT myst be <2x normal
ARDS- management
TV 5-7 or 6-8 ml/kg ideal body weight,
peep of 10
ARDS
refractroy hypoxemia
assist control
pt can trigger and gets set volume
SIMV
preset numebr of breaths at preset volume, can take own breath at whatever volume they want
FVC
volume of gas forcefully expelle from lungs after max inspiration
FEV1
expelled over 1 second
pleural effusion serum protien
one or more of the following equals exudate
pleural fluid protein to serim protein ration is >0.5
pleural fluid LDH to serum LDH ration is >0.6
Pleural fluid LDH is greter than 2-3 the upper limit of normal serum LDH (140-280u/L)
transudates have none of these features
RML think
aspiration PNU
