Pulmonary Flashcards
Asthma Defintion
*Obstructive disease* characterized by an increased responsivenss of the trachea and bronchi to various stimuli
List several Asthma Triggers
- Dust mites
- Pets
- Cockroaches
- Indoor molds
- Exercise
- Cigarette smoke
List several Asthma Signs/Symptoms
**Pulses paradoxus >12 mm Hg (fall of SBP during inspiration)** not a part of other COPD dz’sRespiratory distress at rest
- Difficulty speaking in sentences
- RR >28/min
- HR >110
- Hyperresonance
- Chest tightness
List changes in airways r/t asthma
- widespread narrowing of the airways
- hypertrophy of smooth muscle
- mucosal edema and hyperemia
- thickening of epithelial basement membrane
- hypertrophy of mucous glands
- acute inflammation
- plugging of airways by thick, viscous mucous
Are most allergens indoor or outdoor for asthma pts?
Indoor
What finding is present in the CBC/Diff in asthma pts?
- Slight WBC elevation with eosinophilia
Criteria for intubation in Status Asthmaticus
worsening ABG’s,
decreased O2 sats,
RR>30,
behavioral changes
ABG findings in asthma
Initially resp alkalosis with mild hypoxemia
- pCO2> 45 is emergent
- normal pCO2 (35-45) is a very sick patient
(asthmatics are hyperventilating and CO2 should be low)
List ominous signs of asthma
Ominous signs include
fatigue,
absent breath sounds,
paradoxical chest/abd movement,
inability to mainatain recumbency,
cyanosis (never sign of anything in adult but death)
CXR findings in asthma
Hyperinflation
PFT criteria for asthma
Improvement of FVC or FEV1 of 15% or FEF 25-75 of 25% after inhaled bronchodilator
Examples of:
SABA
Inhaled corticosteroid
LABA
Inhaled-anticholinergic
Anti-leukotriene
Albuterol/proventil, alupent/metoproterenol
Budesonide/Pulmicort, Traimcinolone/Azmacort, “corts”
Salmeterol/Serevent, “erol’s”
Ipatropium bromide/ Atrovent
Monteleukast sodium/Singulair
List meds/ classes for the out-pt tx of Asthma
- Short-Acting B Adrenergic agonist (SABA)(Albuterol/proventil) for symptom relief or before exercise
- Daily maintainence with inhaled corticosteroids“corts” (Budesonide/Pulmicort, Triamcinolone/Azmacort)
- Continue Short-Acting B2 Adrenergic agonist (SABA) for symptom breakthrough
- If symptoms persist, increase inhaled corticosteroid or add Long-Acting B2 Adrenergic agonist (LABA)(Salmeterol/serevent), other options are theophylline or antimediators
- Inhaled anticholinergics (ipatropium bromide/atrovent) if a lot of secretions
- Antileukotrienes (montelukast/singulair) useful for chronic asthma maintainence (long-term stabailization)
4 step med tx of in-pt asthma
- Inhalation sympathomimetics (metoproterenol & albuterol are in the same drug class)
- Corticosteroids in non-responding pts to sympathomimetics
- Parenteral sympathomimetics in pts unable to cooperate
- Anticholinergic
6 steps for out-pt asthma tx
- SABA
- Inhaled corticosteroid
- Add SABA for breakthrough
- LABA
- Anticholinergic
- Anti-leukotriene
Criteria for hospitalization in asthmatics
Initial FEV1 (forced exp. volume = how much air pt can blow out) is <30% of predicted
OR
does not increase to 40% after 1 hr vigorous therapy
Hospitalization recommended if peak flow (max speed of expiration) is <60 LPM OR >50% predicted after 1 hr of tx
Inpatient Management of Asthma
Supplemental O2 2-3 L/min
Mild to mod asthma, ABG not needed if SaO2 >90% by pulse ox
Severe attack, check ABG
Adequate hydration by oral or IV route
Inhalation sympathomimetics:
- Alupent/ metoproterenol (0.3 mL in 5% sol) in 2.2 mL NS q 30-60 min
- Proventil/albuterol, ventolin 0.3 mL in 3 mL NSS q 30-60 min
Corticosteroids in non-responding pts to sympathomimetics
- Methylprednisolone 60-125mg IV x 1 then 20mg IV Q4-6hrs until attack is broken
Parenteral sympathomimetics in pts unable to cooperate
- Aqueous epi 1:1000 0.1-0.5 mL SQ Q 30-90 min, MR x 4
Anticholinergic (atrovent) MDI 2-6 puffs q 4-6 hrs
Status Asthmaticus
Severe, acute asthma presenting in an unremitting, poorly responsive, life-threatening manner. Clinical findings not reliable indicators of severity of asthma.
8 steps for Status asthmaticus managment
(1-5 meds)
- O2
- IV D5 1/2 NS
- Inhalation and parenteral simpathomimetics (albuterol, acqueous epi)
- Methylprednisolone 60-125 or hydrocortisone 300 mg IV
- Atrovent
- Continuous pulse ox
- ABG q 10-20 min
- Intubate (falling ABG’s, decreased O2 sats, RR>30, behavioral changes)
Define Chronic Bronchitis and Emphysema
Chronic bronchitis: Excessive secretion of bronchial mucous manifested by productive cough x 3 yrs or more in at least 2 consecutive years
(stocky, younger with thick secretions)
Emphysema: abnormal, permanent enlargement of the alveoli
(thin, emaciated)
*Obstructive*
CXR findings in chronic bronchitis
bulla,
blebs,
hyperinflation,
low, flat diaphragm
Chronic Bronchitis Signs/Symptoms
*Obstructive disease*
- Intermittent mild to mod dyspnea
- Onset after age 35
- Copious, purulent sputum
- Stocky body habitus
- Normal AP chest diameter
- Normal percussion
- Bulla, blebs on CXR
- Hyperinflation on CXR
- Hct increased
- Hypercapnea, hypoxemia on ABG
Emphysema Signs/Symptoms
- Progressive, constant dyspnea
- Onset > age 50
- Mild sputum, clear
- Thin, wasted body habitus
- Increased AP chest diameter
- Hyperressonance on percussion
- HCT WNL
- Total lung capacity increased
*Loss of hypercapneic drive
Air is trapped
What is the mainstay of tx for COPD?
Mainstay of therapy is: inhaled bronchodilators or sympathomimetics (Albuterol/xopenex)
What are the PFT and ABG findings in COPD?
- FEV1 and other other measures of expiratory air reduced
- TLC, FRC, RV may be increased
- Increased paCO2
- Increased HCO3
List several out-patient COPD Management strategies
- D/C smoking
- Avoid irritants/allergens
- Postural drainage
- Pulm rehab
Medication tx for In-patient COPD management
O2 1-2 LPM NC or 24-28% venti mask
Pharmacologic progression as for in-pt asthma
Purulent sputum should receive ATB therapy for 7-10 days
- Amoxicillin/Ampicillin 500mg QID
- Doxycycline 100mg BID
- Bactrim DS BID
TB causative agent:
Systemic dz caused by M. tuberculosis. Pulmonary dz most common clinical presentation.
Extra-pulmonary manifestations of TB
May involve lymphatics,
genitourinary,
meninges,
peritoneum,
heart
TB Signs/Symptoms
- Majority pts asymptomatic
- Fatigue, anorexia
- Dry cough progressing to productive and occ. blood tinged
- Weight loss, low grade fever
- Night sweats
What are the CXR findings in TB?
Small, hemogenous infiltrate in upper lobes by CXR (honeycomb appearance)
TB Diagnostics
- Definitive dx Sputum cx of M. Tuberculosis x 3
- AFB smears are presumptive of active TB
- PPD + shows exposure, not diagnostic
Notify health department, use negative pressure room if hospitalized
TB Baseline Evaluation
Baseline Evaluation
LFT’s, CBC, serum creat at baseline
Check for sx of drug toxicitiy in pt’s with normal baseline
Ethambutol pt’s should have visual acuity testing and red-green color perception
TB Drug therapy and duration
Report to local health dept
Hospitalization not req’d but consider if pt is non-compliant or likely to expose susceptible persons
TB Meds: RIPE therapy
Rifampin 600mg,
Isoniazid 300mg,
Pyrazinamide 1.5-2 gm
Ethambutol 15mg/kg
- If isolate proves to be fully susceptible to INH and RIF, then 4th drug may be dropped
- Continue 1st three drugs daily for 2 months, then 4 more months of INH and RIF daily
*tx HIV pts x 9 months
Tx for conflicting PPD and CXR
IF PPD + and CXR -, start INH therapy
How often should a pt with TB be monitored?
- Weekly sputum smears and cx for 1st 6 weeks after initiation of therapy, then monthly until neg cx documented
When should suspicion be raised of drug-resistant TB?
Continued sx or + cx after 3 months should raise suspicion of drug resistance
List risk factors for TB
Patients at increased risk in crowded living conditions,
institutionalized,
HIV,
diabetes,
CRI,
malignancy,
malnutrition,
immunosuppressed
What are the criteria for + PPD in various populations?
- 5mm - HIV pts, contacts of a known case, or persons with CXR typical for TB
- 10mm - Immigrants from high prevalence areas or those in high risk groups, (health care workers)
- 15mm - General population
Pneumonia defintion
Inflammation of the lower respiratory tract as microorganisms gain access by aspiration, inhalation, or hematogenous dissemination
Most common causative organism in CAP?
Strep pneumoniae is most common etiology of CAP
List common PNA signs and symptoms
- ***Lung consolidation on physical exam*** differential confirmation exam finding
- Fever
- Chills
- Purulent sputum
- Malaise
- Increased fremitus
PNA Diagnostics
- Elevated WBC
- Infiltrates on CXR
- GS and culture
- ABG if resp failure suspected
- CXR and consider 3 BC’s
IDSA/ATS Guidelines for Management of CAP
- Healthy patients <60 with no comorbidities and no recent ATB therapy = macrolide (azithromycin) clarithromycin (Biaxin), e-mycin or doxy
- Pts with comorbidities or >60 with no recent ATB therapy = Fluoroquinolone *floxins* such as levofloxacin (levaquin), gemifloxacin (factive), or moxifloxacin (avelox)
What age determines tx for CAP?
Younger than or older than 60 and consider previous ATB treatment and comorbidities also!
What exam finding differentiates between PNA and bronchitis?
Lung consolidation on physical exam
*young adult will clear with coughing in bronchitis, not in PNA
*physical exam not enough to clear a pt of PNA, need CXR
ATb tx for In-Pt ICU Management PNA
- O2 as indicated
- Beta-lactam: cefotaxime(claforan), ceftriaxone(rocephin), or ampicillin-sulbactam(unasyn) PLUS
- Either azithromycin(zithromax) or a flouroquinolone (levaquin)
* For PCN allergic pts, resp flouroquinolone and aztreonam are recommended
What is the ATB regimen for in-pt Pseudomonas PNA?
An anti-pneumococcal, anti-psuedomonal beta lactam:
pipercillan-tazobactam (zosyn), cefepime (maxipime), imipenem (primaxin) or meropenem
PLUS:
either ciprofloxacin/cipro, or levofloxacin (levaquin) 750mg
OR the above beta lactam plus an aminoglycoside and azithromycin
OR the above beta-lactam plus and aminoglycoside and an anti-pneumococcal flouroquinolone
*for PCN allergic pts, substitute aztreonam for the above beta-lactam
What medication is substituted for the beta-lactam for PCN allergic pts with PNA?
Aztreonam
What is the most common causative agent in ventilator patients?
Psuedomonas
What is the ATB tx regimen for MRSA PNA?
- Add Vancomycin or linezolid to the above tx regimen
Get an ID consult with linezolid
What is HAP?
- PNA that occurs >48 hrs after admission which was NOT incubating at time of admission (includes VAP and HCAP)
Most common agents in HAP?
Staph aureus, strep pneumoniae, H. influenza
VAP
- PNA that occurs >48-72 hrs after ET intubation
- Pseudomonas most common causative organism
What is a national mandate for prevention of VAP?
Raise HOB
HCAP
- Acute care Hospitalization w/in 90 days of infection for 2 or more days, resided in a NH or LTC facility, received IV ATB therapy, chemo, or wound care w/in past 30 days of current infection, or received HD services
- Organism in HCAP are more similar to those of HAP than CAP, higher rate of staph aureus and psuedomonas aeruginosa, and less strep pneumoniae, H. influenzae, and MRSA
Most common agents in HCAP?
Staph aureus
Pseudomonas
MRSA
Atypical PNA causative agents
Legionella, mycoplasma, chlamdophylia
Do NOT have a cell wall and so not tx with ATB therapy
CXR presentation of atypical PNA vs typical?
Typical presents and is read on CXR as lobar PNA,
Atypical is read as bilateral infiltrates
Pneumothorax
Gas in the pleural space that raises pleural pressures and can impair respiration resulting in collapsed lung
List PTX signs/symptoms
- Chest pain, dyspnea, cough
- Hyperressonance on affected side
- Diminished breath sounds and diminished fremitus on affected side
- Mediastinal shift toward the unaffected side (Tension)
- Hypotension
What is percussion sound in PTX on the affected side?
Hyperresonnance
What is the diagnostic test for PTX?
CXR
What type of PNA is suspected with RML involvement?
Aspiration PNA
PTX Management
- <20% PTX in asymptomatic pt - no intervention
- CT used 1st if available, if emergent, needle thoracostomy
What is the correct anatomical insertion for a CT?
CT placement up and over the ribs at 4th or 5th ICS at MAL
What is the correct anatomical location for emergent needle decompression of PTX?
Needle thoracoscopy 2nd ICS, MCL
This is the least expensive, least invasive tx!
PE
Diagnosed based on clinical suspicion, hx important as well as results of diagnostic studies.
Predisposing risk factors are present in the history.
List common PE Risk Factors
- Prolonged bed rest/immobility
- Oral contraceptives
- Surgery on long bones
- Venous stasis
- Hypercoagulable states
- Cardiac thrombi
List common PE Signs/Symptoms
- Abrupt (looks like an MI)
- Unexplained dyspnea and tacchycardia are most common
- Chest pain (retrosternal or lateralized and pleuritic)
- Hemoptysis
- Low grade fever
- Hypotension
- Cyanosis
What is the hallmark symptom of PE?
Tacchycardia and unexplained dyspnea
PE Diagnostics
- VQ scan in all clinically stable pts
- ABG: hypoxemia (SaO2
- Hypocapnia (pCO2
- Spiral CT/D-dimer
- Pulmonary angiography (CT angio) when clinical data and VQ scan are contradictory, or for those with high risk from anti-coagulation have a high probabilty VQ scan
What is the cause of death in PE?
Failure of the right ventricle due to inabilty to handle the force through the pulmonary artery
What are the indications for pulmonary angiography in suspected PE?
Pulmonary angiography (CT angio) when clinical data and VQ scan are contradictory,
or for those with high risk from anti-coagulation have a high probabilty VQ scan
What is the least expensive, least invasive test for PE?
VQ scan
What is the leading cause of in-hospital death?
PE
PE Management
- Supplemental O2
- IV for hypotension and reduced CO
- Intubation indicated for *worsening hypercapnea with progressive obtundation*
- Heparin 80U/kg bolus with infusion of 18 u/kg/hr to maintain pTT of 1.5-2x normal
- Coumadin to reach INR 2-3
- Fibrinolytic therapy if hemodynamic comprimise or shock (pTT and PT <2x normal)
What is the anticoagulation regimen for PE?
- Heparin 80U/kg bolus with infusion of 18 u/kg/hr to maintain pTT of 1.5-2x normal
- Coumadin to reach INR 2-3
- Fibrinolytic therapy if hemodynamic comprimise or shock (pTT and PT <2x normal)
What are the indications for intubation in PE?
Worsening hypercapnea with progressive obtundation
ARDS Signs and Symptoms
Acute lung injury attributable to wide variety of insults
Trauma
Sepsis
Signs/Symptoms
- Severe dyspnea/respiratory distress
- Cyanosis, tachycardia
- Rales and wheezes
***Refractory hypoxemia is hallmark feature, O2 doesn’t help**
ARDS Diagnostics
- Refractory hypoxemia is hallmark feature (continuous O2 does not help)
- CXR may be “whited out” or have diffuse bilateral infiltrates
ARDS Management
Mechanical ventilation with PEEP
- TV 5-7 mL/kg BW
- Peak inspiratory flow 1-1.2 L as needed
- PEEP 10 cm H2O (moderate levels)
Treatment of underlying infection/cause
Mechanical Ventilation Modes
- Control Mode: Vent does all the work, pre-set TV and RR
- Assist-Control: Same as control but pt can trigger the vent, same volume is delivered if triggered
- Synch Intermittent Mandary Ventilation/ Intermittent Mandatory Ventilation (SIMV/IMV): Preset # of breath at a preset TV , pt can take own breath at thier own TV (after met set # breaths)
- CPAP: Spontaneous breathing at pressure greater than atmospheric
- PS (Pressure Support): Inspiratory effort with higher preset pressure delivered with each breath on top of PEEP
- PEEP: Maintains intra-thoracic airway pressure above atmospheric throughou expiration
Key Vent Settings
- Mode
- FiO2: RA is 21%, Give lowest amount to provide acceptable paO2 >60, high concentrations over long periods are toxic to lung tissue
- TV: Amount of gas delivered with each breath, 5-7mL/kg ideal body weight (about 350-500), higher volumes increase alveolar ventilation
- Don’t adjust TV once established, including during weaning
Post arrest vent settings
- use 100% fiO2,
- AC mode with rate 12,
- TV 5-7 mL/kg
TV settings
5-7mL/kg ideal body weight (about 350-500)
Don’t change this setting once you set it!
General Guidelines for vent weaning
- Ready to wean at FiO2 40%,
- 98% sat on SIMV (breathing over vent)
- and hemodynamically stable (Don’t wean on pressors)
- O2 sat guides weaning, may need to increase rate as decrease FiO2
PFT’s
Airflow rates:
- FVC: Volume of gas forcefully expelled after maximal inpiration
- FEV1: Volume of gas expelled in the first second of the FVC manuver
- FEV25-75: Maximal mid-expiratory airflow rate
- PEFR: Maximal airflow rate achieved in FVC manner
Volumes:
- TLC: Volume of gas in lungs after maximal inspiration
- FRC: Functional Residual Capacity
- RV: Remaining volume in lungs after maximal expiration
List 3 obstructive diseases
Chronic bronchitis
Emphysema
Asthma
Obstructive vs Restrictive
*Obstructive diseases characterized by reduced airflow rates
(asthma, COPD, Emphysema)
*Restrictive diseases characterized by reduced volumes
(PNA, pulmonary fibrosis, cyctic fibrosis, lobectomy, ARDS, sarcoidosis)
List acute and chronic diseases causing restrictive airflow?
Acute:
- PNA, ARDS
Chronic:
- pulmonary fibrosis,
- cyctic fibrosis,
- lobectomy,
- sarcoidosis
CXR findings in Pleural Effusion
CXR will show blunting, shadowing, shunting of the costophrenic angle (sharp fins at the end of the lungs)
Exudates
Exudates: (caused by CHF, nephrotic syndrome)
*Protein to serum ratio >0.5*
Pleural fluid LDH to serum LDH >0.6
Pleural fluid LDH >2/3 upper limit of normal LDH
**Transudates have none of these features!
List 4 types of pleural effusions and describe fluid
Transudates: clear fluid (caused by inflammation diseases such as PNA, lupus, cancer)
Exudates: Cream/yellow, increased LDH to serum LDH ratio or protein concentration
Empyema-pus
Hemorrhagic-blood
List common PNA PEARLS for elderly
- 50% all cases over age 65
- LTC facility have 30% risk of development over 2 yr period
- Common pathogens: strep pneumoniae, gm neg bacilli (H. flu, Moraxella catarrhalis, Klebsiella) and staph
- Classis signs may be absent
- Confusion
PNA CXR findings in elderly
CXR: multiple presentations based on pathogenesis
- bacterial PNA may be present in multiple locations (broncho, lobar, etc);
- viral PNA may present as bilateral interstitial infiltrates,
- aspiration PNA may be localized to RML or have diffuse involvement
Normal Gerontology Changes
TLC stays constant but Vital Capacity (volume air forcibly exhaled) decreases because residual volume (amoutn air remaining in lungs after max expiration) increases
Hyperresonance: indicates air trapping
Chest wall becomes rigid
Lungs stiffer
Decreased alveolar surface area by 20% (diminished exercise capacity)
Pt making sounds around the ET tube indicates:
Cuff leak
Name the hallmark feature of ARDS
*Refractory hypoxemia is hallmark feature, O2 doesn’t help
List 5 causes of true night sweats
- TB
- HIV/AIDS
- Menopause
- Lymphoma
- Endocarditis
What is the normal percussion sound of the chest?
(Normal percussion sound is resonance)
Reasons to intubate in Status Asthmaticus
Falling O2 Sats
RR 30’s
Bad ABG’s
Behavior Changes
Atypical causes of PNA?
Walking PNA: Legionella, mycoplasma, chlamdophylia
Shows as bilateral interstitial infiltrates, reg PNA are lobar/bronchal
What is the management of pleural effusion?
Thoracentesis
RML localized infiltrate?
Aspiration PNA
What PFT componant is diagnostic for COPD?
FEV1 / FVC ratio <70%=.07
CURSA for admission of PNA
Confusion
Uremia BUN>19
RR >30
SBP <90
Age >65
If 3 or more, admit!
What drug does not increase risk of PNA by raising stomach pH?
Carafate
What drug is used to reduce ICP during intubation and suctioning?
Lidocaine
