pulmonary Flashcards
airway changes in asthma
narrowed airways, hypertrophy of smooth muscle, mucosal edema, thickened epithelial basement membrane, hypertrophy of mucus glands, acute inflammation, plugging by thick mucus
what would ABG demonstrate in asthma exacerbation?
mild hypoxemia- low PO2,
respiratory alkalosis- elevated pH, decreased pCO2- hyperventillation
how does levalbuterol (Xopenex) work? what is it used for?
stimulates enzymes that convert ATP to cAMP- relaxes bronchial smooth muscles
maintanence for asthma
low dose inhaled corticosteroid- budesonide (fluticasone) +/- long acting beta agonist (LABA)- salmeterol
combo inhalers: symbicort, advair
severe asthma treatment
high dose ICS + LABA + oral corticosteroid
what is anaphylaxis epinephrine dosing?
- 3-0.5 mg subcutaneous
1: 1000 mg/mL
status asthmaticus treatment
airway support: oxygen, ABG q 10-20 minutes, intubation, pulse oximetry
IV fluids, IV steroids,
atrovent or inhaled sympathomimetics
COPD: chronic bronchitis vs emphysema
bronchitis- intermittent dyspnea, earlier onset, copious sputum, stocky/ obese body habitus, percussion normal, increased hematocrit
emphysema- progressive/ constant dyspnea, later onset 50+, mild clear sputum, thin body habitus, increased A-P diameter, percussion hyper resonant, TLC increased
COPD: FEV1, TLC, FRC, RV
FEV1- expiratory flow reduced
TLC increased
Functional Residual Capacity- increased
Residual Volume- increased
PPD testing
shows exposure of TB, not diagnostic for active disease
active TB diagnostics
culture of M. tuberculosis x 3
acid fast bacillus smears- presume evidence of active TB
small homogenous infiltrate in upper lobes by CXR
TB medication regimen (RIPE)
Rifampin 600 mg isoniasid 300 mg pyrazinamide 1.5-2.0 gm ethambutol 15 mg/kg daily RIPE 1st 3 drugs daily for 2 months, then 4 more months of INH and RIF daily if HIV, treat for 9 months
monitoring for TB
weekly sputum smears and cultures in 1st 6 weeks, then monthly until negative cultures.
possibly monthly labs: LFTs, CBC, serum creatinine
ethambutol considerations (TB drug)
test for visual acuity and red/green color perception
if positive PPD, what is treatment
6 months of INH (isoniazid)
what defines positive PPD?
5 mm measurement HIV
10 mm measurement in immigrants
15 mm measurement in general population
what is most common community acquired pneumonia CAP bug
strep. pneumoniae
mortality score for CAP: PORT
Patient Outcomes Research Team score- based on age (-10 for women) and points for each 20 relevant characteristics
PORT > 130- ICU
PORT 70-130 inpatient stay
CURB 65 scoring
Confusion- mental test score < 8 BUN > 19 Respiratory rate > 30 SBP < 90 or DBP < 60 Age > 65 moderate to high risk- hospitalization
what are macrolid antibiotics?
azithromycin, clarithromycin, erythromycin, and roxithromycin
antibiotic coverage for inpatient CAP- nonsevere (acute care) or severe (ICU)
beta-lactam (PCN and cephalosporins), + macrolid (azithro) OR fluroquinolone (levaquin, ciprofloxacin)
severe (need pseudamonas coverage): pip-tazo OR meropenem, or cefepime + AMG (amikacin) / azithro
if MRSA- above + vanc or linezolid
outpatient CAP coverage
amoxicillin or doxycycline or macrolide (azithro)
what is viral CAP coverage
zanamivir, peramivir, zanamivir
possible to have secondary bacteria infection
what are HAP bugs?
Staph aureus
Strep pneumoniae
Haemophilus influenzae
HAP coverage routine, vs MRSA, vs high risk of mortality
routine HAP: 1 antibiotic: pip-tazo OR cefepime OR levofloxacin OR imipenem or meropenem
MRSA coverage- add vanco or linezolid
high mortality: TWO agents PLUS MRSA coverage- avoid 2 beta lactams
pip-tazo, cefepime, levo or cipro, imipenem or meropenem, amikacin or gentamicin or tobramycin
azteronam
cefepime, meropenem, vancomycin (common UVA regimen)
VAP coverage
MRSA and double antipseudomonal coverage: beta-lactam and non-beta lactam antibiotics
vancomycin + Piptazo OR cefepime OR meropenem OR aztreonam + levo OR cipro OR amikacin OR gentamicin OR colistin
needle thoracostomy placement:
2nd intercostal space, mid clavicular line
chest tube placement:
4th or 5th ICS, mid axillary line
sarcoidosis
interstitial lung disease; CXR, PFTs, ABGs, biopsy of lung parenchyma for diagnosis (bronchoscopy)
tx: corticosteroids,
immunosuppressive agents: azathioprine, methotrexate, cyclophosphamide
control ventillator setting
preset TV and RR
assist control ventilator
preset volume, but patient can trigger extra breath
pressure support
respiratory rate determined by patient, inspiratory effort unassisted but preset airway pressure with each breath (PEEP)
SIMV
preset RR and TV, but patient can take extra breaths at whatever TV they normally do- likely lower
when is BiPAP commonly used?
for COPD patients, or to wean from the ventilator
obstructive disease PFTs:
reduced airflow rates; decreased FVC/ FEV1, but lung volumes are normal or above normal
restrictive disease PFTs, diagnoses
morbid obesity, sarcoidosis, pulmonary fibrosis
reduced volumes- TLC, FRC, RV, and reduced expiratory flow rate
pleural fluid exudate characteristics:
protein to serum protein ratio > 0.5
LDH to serum LDH ratio > 0.6
pleural fluid LDH (lactate dehydrogenase) greater than 2/3 upper limit of normal serum LDH
exudate- cream looking: protein and LDH
transudate fluid
clear looking, no protein/ LDH elevation
CXR findings can determine type of pneumonia….
Bacterial: bronchopneumonia, lobar pneumonia
Viral: bilateral interstitial infiltrates
Aspiration: R middle lobe or diffuse involvement
