Pulmonary Flashcards
S/s of asthma, workup, and treatment
S/S:bronchoconstriction and dry, plugging of airway with mucus, Respiratory alkalosis
Respiratory distress at rest, can’t finish sentences, use of accessory muscles
Pulses paradoxes and hyperresonance to percussion*
Bad signs: inability to breathe, paradoxical chest and abdominal movement, cyanosis, no breath sounds, tired*
Workup: Obstructive disease
i. PFTs will show obstructive, FEV1 will be less than predicted
ii. Hospitalization is recommended if PFTs do not improve with bronchodilator
f. CXR will show hyperinflation***
Treatment: i. SABA (albuterol)
1. Works by stimulating enzymes that convert ATP to cAMP, releases bronchial smooth muscles***
2. 1st drug for SOB in ED
ii. LABA
iii. SAMA (ipotropium)
1. Anticholinergic
iv. LAMA
v. LABA/ICS (symbicort, advair)
vi. LABA/LAMA/ICS (Trilogy)
TB S/S, labs, s/s, treatment
a. Asymptomatic typically
b. Weight loss, low grade fever, night sweats, dry cough to productive cough
c. Labs:
i. Culture x3
ii. AFB are presumptive of active
iii. Small homogenous infiltrate (honeycomb in the upper right lobe)
iv. PPD only shows exposure (15mm of reaction, 10mm for healthcare workers or high risks, 5mm for HIV)
d. Exposure: 6months of INH
e. Treatment
i. RIPE
ii. Rifampin, INH, Pyrisidomide, Ethambutol (test for red/green color perception)
iii. Someone will be on regimen for 6 months
iv. If HIV positive 9month treatment
v. Meds are hepatotoxic (needs weekly LFTs)
f. Must report to health department
g. Consider hospitalization if patient is noncompliant
h. Those who live with TB positive patient, testing the family
1st
Port pneumonia score
b. PORT score
i. How bad the pneumonia will be
ii. 1-2 outpatient
iii. 3- 24 hr admit
iv. 4- inpatient
v. 5 – ICU
Outpatient CAP treatment
Outpatient CAP
i. Low (s.pna) : Amoxicillan or Doxycycline or a Macrolides (if not resistant)
ii. Mod to high (S.pna + MDR) : (Amoxicillan or Cefpodoxime) + (macrolide OR doxy) OR mono therapy w/ resp fluroqiuinolone
HAP treatment
- No risk, no factors for MRSA: Monotherapy with zosyn OR Cefepime OR levofloxacin OR carbapenem
- Low risk with factors for MRSA : (Zosyn OR Cefepime OR Levofloxacin OR Cipro OR carbapenem) + Vanco or linezolid
- High risk OR IVABX within the past 90 days: TWO (Zosyn OR Cefepime OR Levo OR carbapenem) + Vanco or linezolid
Inpatient CAP treatment
i. Non-severe: B lactam(ceftriaxone) + macrolides or fluroquinolone (levofloxacin or moxi)
ii. Severe: B lactam +IV floroquinolone or macrolides
2. Pseudomonas: Merrem
3. MRSA: Vanco or linezolid
VAP treatment
MRSA Coverage: Vanco or linezolid
Antipseudomonal BETA LACTAMS: Zosyn OR Cefepime OR Carbapenems
Antipseudomonal NON BETA LACTAMS: Fluroquinolone, Gentamycin OR tobramycin OR Polymixin B
What is the A-a gradient
PAO2 -PaO2 larger the difference = pathology hindering transfer of O2 into capillaries
>15 means parenchymal diseae
PFTs for obstructive vs Restrictive
Obstructive: <80%
Restrictive Normal 80-100
Normal lung percussion vs asthma/COPD, bone, gastric
Normal: Resonance
Hyperresonance: Asthma or COPD
Tympani: Gastric
Dull: Bone
Where are the most important allergens encountered in asthma
Indoors
What is a s/s that is present in asthma but not COPD
Pulsus paradoxus >12
Ominous signs in asthma exacerbation
Fatigue, absent breath sounds, paradoxical chest/abdomen movement, inability to maintain recumbency, cyanosis
Is asthma obstructive or restrictive
Obstructive
Obstructive vs restrictive airway disease
Obstructive: can’t get air out
Restrictive: can’t get air in
What is the initial ABG in respiratory distress
Respiratory alkalosis
SABA MOA and examples
Stimulating enzymes that covert adenosine triphosphate into cAMP which relaxes beronchial smooth muscles
Albuterol, levalbuterol
LABA examples
Salmeterol
Formoterol
Oldaterol
SAMA example
Ipratropium (atrovent)
LAMA examples
Tiotropium bromide (Spiriva)
ICS examples
Budesonide/formoterol (symbicort)
Fluticasone/salmeterol (advair)
What do you give asthma patients that are not responding to treatment
Mag sulfate IV
Indications for epinepherine
Stridor and respiratory distress d/t anaphylaxis
Status Asthmaticus treatment
Poorly responsive asthmatic attack
O2, D51/2 NSS, Methylprednisolone or hydrocortisone IV IMMEDIATELY
What is the difference between chronic bronchitis and Emphysema
CB: excessive secretion of bronchial mucus for at least 3 months per year for 2 years
E: Abnormal enlargement of alveoli
What is the difference in S/S of Chronic Bronchitis vs Emphysema
CB: Copious purulent secretions, stocky, obese, normal AP chest
E: Mild clear sputum, thin, wasted, increased chest AP
What are the two major causes of COPD
Smoking and alpha 1 antitrypsin deficiency
What is the diagnostic for COPD
Post bronchodilator FEV1/FVC <0.7
Differentiate between Category A, B, and E COPD tx
A: no-1 mod exacerbation that does not require hospitalization per year, CAT <10, Tx: Bronchodilator
B: No or 1 exacerbation that does not require hospitalization per year, CAT >10, TX: LABA and LAMA
E: >2 moderate exacerbations OR >1 leading to hospitalization, TX: LABA and LAMA (add ICS if eosinophils >300)
What is the most common cause of pneumonia
Strep pneumonia
CURB 65 criteria
PNA treatment
Confusion, BUN >19, RR >30, SBP <90, DBP <60, Age >65
Low: 0-1, outpatient
Moderate: 2, consider brief hospitalization
High: >3, Hospitalization consider ICU
When is HAP suspected
> 48 hours after admission
What organisms are common in HAP
Staph, Strep, and H. Influenza treatment
When is VAP considered and what is the most common causative organism
48-72 hours post intubation
Pseudomonas
What is a VAP prevention absolute mandate
HOB >30
S/s of pneumothorax and treatment
S/S: Hyper resonance on the affected side, diminished breath sounds on the effected side, mediastinal shift toward the unaffected side.
TX: Emergency needle thoracostomy (2nd ICS, midclavicular line), chest tube for non-emergency 4th or 5th ICS mid axillary line
What is Sarcoidosis the s/s, labs, tx
Granulomas of the lungs
S/s: progressive dyspnea and Rales (velcro)
Labs: Bronchoscopy
Tx: Steroids
What is the hallmark feature of ARDS
Refractory hypoxemia w/ bilateral infiltrates
ARDS managment
Intubation
TV 4-6mls/kg of IBW
PEEP 10
16 hours prone
What are the Berlin detentions for the 3 categories of ARDS
<300: mild lung injury
<200 Moderate
<100 Severe
Absolute contraindication to extubation
Vasopressor for BP
Describe an exudative pleural effusion findings
Two or More
Protein >0.5
LDH >0.6
LDH is great her than upper limit of serum LDH
Serum total protein >3
What is a side effect of Ethambutol
Red/green color blindness
How does viral PNA appear on CXR
Bilateral infiltrates
O2 dissociation curve
To the left: higher affinity
To the right: lower affinity
What is the difference in percussion of CB and emphysema
CB: normal
Emphysema: hyper-resonance
Bacterial pneumonia signs on a CXR
Lobular infiltrates
CXR results for aspiration pneumonia
Diffuse involvement
5 step Asthma guideline treatment
Step 1/2: symptoms that last <4-5 days /week, Low dose ICS/fometerol PRN
Step 3: Symptoms most days or waking >1/week, Low dose maintenance ICS/fometerol
Step 4: Daily symptoms waking >1/week, medium maintenance dose ICS fometerol
Step 5: Persistent symptoms and exacerbations, ADD LAMA, high dose maintenance ICS-Fometerol
How to treat a psedomonas infection
Zosyn or carbapenem OR cefepime plus fluroquinolone
