Pulmonary Flashcards
Differential for Wheeze
Pulm:
- Asthma
- COPDe
- Pneumonia
- Allergic or eosinophilic pneumonia
- Neoplasm
- Foreign Body
Upper Airway:
- Croup
- Laryngeal edema / neoplasm
Cardiac:
- CHF
- Valvular heart dusease
Other:
- GERD
- ARDS
Risk Factors for Asthma Death
Hx:
- Prev intubation / ICU
- Two hospitalizations in 1 year
- 3 ED visits in 1 year
- Use of more than 2 MDI cannisters/ mth
- Difficulty perceiving exacerbation
Social:
- Low SES
- inner city
- illicit drug use
Comorbidities:
- CV disease
- Other lung disease
Objective findings of severe Asthma
Pulse > 120
Pulsus paradoxus > 10
RR > 20
Accessory muscle use
PaO2 < 60 or PaCO2 > 40
Therapies for acute severe asthma
O2 > 90%, >95% in preggers and CV disease
Beta Agonists
Inhaled anti-cholinergic
Steroids
Epinephrine
MgSO4
Fluids
Ketamine
Heliox
Leukotriene receptor antagonists
Ventilation Strategy for severe asthma
BiPAP if fails then:
ETT
Low respiratory rate
High I:E ratio 1:4 - 1:5
Volume control 6-8 cc/kg
Minute ventilation 115/kg/min = ~7 L/min average adult (500 cc at 14 breaths)
- Turn off peak pressure
Paralysis
Low PEEP
FiO2 100% and titrate down
FEV1 for asthma guidelines
> 70%, can go home
40-70%, possibly go home, otherwise can admit
<40%, ICU
GOLD Criteria for COPDe
Change in baseline cough, dyspnea, sputum
Gold Classification
FEV1/FVC < 70%
and
Mild: FEV1 > 80%
Moderate: FEV1 50-80%
Severe: 30-50%
Very Severe: < 30%
Factors / Triggers of decompensation in COPD
- Viral
- Bacterial: H. Flu, Strep Pneumo, Moroxella, Pseudomonas
Atypical: Chlamydia, Legionella - Air pollution
- Other critical events: pneumothorax, PE, CHF, pneumonia, obesity, trauma, NM disease, non-compliance
COPDe mimics
Pneumonia
CHF
Asthma exacerbation
PE
Pneumothorax
Pleural effusion
Dysrhythmias
Clinical Features for AECOPD
Cough +/- purulence
Increased WOB or air hunger
Wheeze
altered LOC, irritable (hypercapnea +/- asterixis)
RHF with JVD and peripheral edema
ED Management of AECOPD
Severe:
O2 88-92%
Bag-valve or BiPAP or ETT
in-line beta-agonist and anticholinergic
IV corticosteroid
IV antibiotics
Inidications and Contraindications for PPV in AECOPD
Indications:
- Moderate to severe Dyspneas
- RR > 25
- Acidosis
Exclusion:
- Somnolence / Agitated
- Vomiting
- CV instability
- Respiratory Arrest
- Upper airway obstruction
- Craniofacial trauma
- Mask won’t fit.
ECG Findings of COPD
P pulmonale, peaked P in II, III and aVF
low voltage
Poor R-wave progression
Tachydysrhythmias: A.fib, MAT
Causes of URTI
Viral:
EBV, Adenovirus, Coronavirus, cocksackie, HIV, HMNV, Influenza, VZV
Bacterial:
GAS, H. Flu, gonorrhea, non group A strep, mycoplasma, n. meningiditis
Non-infectious: Kawasaki, SJS, thyroiditis
Trauma
When to given steroids in pharyngitis
Severe symptoms with inability to swallow, airway obstruction, PTA, post-tonsillectomy, EBV
Causes of epiglottitis
H influenza B
Strep
Staph
Viruses
Burns
Mgmt of epiglottitis
Consider intubation in acute onset < 6 hrs
IV abx: Ceftriaxone, Septra
Steroids
Racemic epi
Analgesia
Humidified O2
Observation
Deep spaces of the neck and associated infection
Submandibular Space: Ludwig’s Angina
Parapharyngeal Space: Carotid / Jugular and CN. : Lemierre’s syndrome
Retropharyngeal Space: RPA
Danger space - posterior to retropharyngeal: Base of skull to diaphragm
The prevertebral Space.
Mgmt and predisposition for rhinosinusitis
RF:
- Smoking, immune compromise, structure abnormality, polyps, tumors, trauma, overuse of decongestants. barotrauma, cocaine, instrumentation
Therapy: Flushes, local decongestants (no more than 5 days), 2nd gen antihistamines, Antibiotics if febrile or not getting better, high dose amox - 90 mg/kg = 1 g TID for 7-10 days. Septra or azithro 3 days + decongestants
5 Suppurative and Non-suppurative complications of GABHS.
Supp:
Bacteremia
PTA
Otitis Media
Necrotizing fasciitis
Meningitis
Lemeirre’s
Non-supp:
Rheumatic fever
PANDAS (neuropsych)
PSGN
Scarlet fever
Strep toxic shock
Lateral neck XR of epiglottitis
Obliteration of vallecula
Swelling fo arytendoids
Edema of prevertebral soft tissues
Edematous epiglottitis (thumb) - > 8 mm bad
Pneumonia associative pathogens
EtOH: strep pneumo, anaerobes, gram negatives (klebsiella), Tb
COPD: Strep pneumo, H flu, moroxella
Nursing home: S. Pneumo, gram negatives, H flu, Staph Aureus, chlamydia
Poor Dental: Anaerobes
Bat: Histoplasma
Bird: Histoplamsa, Cryptococcus, Chlamydophilia
Farm animals and Cats: Coxiella burnetti (Q fever)
Sicke / Asplena: S pneumo, H flu
Rabbit: Tularemia (also in terrorism)
Abx for Pneumonia based on disposition
Admit:
CAP - non-immune compromise: Ceftriaxone + Azithro
Severe ICU: Ceftriaxone _+ azithro + vanco
HCAP or bronchiectasis: Cefipine 2g + Cipro + vanco
PCP: Septra
Pneumonias presenting with cavitary lesions
TB
Staph Aureus
Anaerobes
Aerobic gram negatives
Fungal disease
DDx for pneumonia on CXR
Silicosis
Toxic Fumes
Radiations
Immunologic disease
Hypersensitivity pneumonitis
Analysis of pleural effusions
Blood
Chyle
Transudative fluid (increased pressure or decreased oncotic pressure)
Exudate (parapneumonic effusion, empyema, subphrenic abscess)
Light’s Criteria
Pleural:Serum protein > 0.5
Pleural: Serum LDH > 0.6
Pleural LDH > 0.66 ULN
CURB65
Confusion
Urea > 20
RR > 30
BP < 90 /60
65 age
Risk Factors for spontaneous PTX
Tall
Male
Smoker
Changes in air pressure
Marfan
FMHx
8 Causes of secondary PTX
Airway Disease:
- COPD
- Asthma
- Cystic Fibrosis
Infections:
- Necrotizing bacterial
- PJP
- TB
ILD
Neoplasms
Connective tissue disease
Pulmonary infarction
Endometriosis - catamenial
Signs of Tension Pneumo
Tachy > 120
Hypotensive
Hypoxia
Deviation of trachea away from PTX
JVD
PTX size estimate on CXR
> 2 cm at level of HILUM ~ 50% collapse = LARGE
Mgmt of primary and secondary PTX
Small: Conservative
Large: > 20%, can aspirate and reassess after 6 hrs for reaccumulation
- Pigtail if persistent
Cutoff of 3cm from apex.
10 Causes of pleural effusion
Infection
CHF
PE
Malignancy / Neoplasm
Cirrhosis
Nephrotic Syndrome
Connective Tissue Disease
Abdo (Pancreatitis, esophageal rupture)
