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ACNP Certification > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Asthma Defintion

A

*Obstructive disease* characterized by an increased responsivenss of the trachea and bronchi to various stimuli

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2
Q

List several Asthma Triggers

A
  • Dust mites
  • Pets
  • Cockroaches
  • Indoor molds
  • Exercise
  • Cigarette smoke
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3
Q

List several Asthma Signs/Symptoms

A

**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
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4
Q

List changes in airways r/t asthma

A
  • 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
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5
Q

Are most allergens indoor or outdoor for asthma pts?

A

Indoor

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6
Q

What finding is present in the CBC/Diff in asthma pts?

A
  • Slight WBC elevation with eosinophilia
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7
Q

Criteria for intubation in Status Asthmaticus

A

worsening ABG’s,

decreased O2 sats,

RR>30,

behavioral changes

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8
Q

ABG findings in asthma

A

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)

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9
Q

List ominous signs of asthma

A

Ominous signs include

fatigue,

absent breath sounds,

paradoxical chest/abd movement,

inability to mainatain recumbency,

cyanosis (never sign of anything in adult but death)

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10
Q

CXR findings in asthma

A

Hyperinflation

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11
Q

PFT criteria for asthma

A

Improvement of FVC or FEV1 of 15% or FEF 25-75 of 25% after inhaled bronchodilator

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12
Q

Examples of:

SABA

Inhaled corticosteroid

LABA

Inhaled-anticholinergic

Anti-leukotriene

A

Albuterol/proventil, alupent/metoproterenol

Budesonide/Pulmicort, Traimcinolone/Azmacort, “corts”

Salmeterol/Serevent, “erol’s”

Ipatropium bromide/ Atrovent

Monteleukast sodium/Singulair

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13
Q

List meds/ classes for the out-pt tx of Asthma

A
  1. Short-Acting B Adrenergic agonist (SABA)(Albuterol/proventil) for symptom relief or before exercise
  2. Daily maintainence with inhaled corticosteroids“corts” (Budesonide/Pulmicort, Triamcinolone/Azmacort)
  3. Continue Short-Acting B2 Adrenergic agonist (SABA) for symptom breakthrough
  4. If symptoms persist, increase inhaled corticosteroid or add Long-Acting B2 Adrenergic agonist (LABA)(Salmeterol/serevent), other options are theophylline or antimediators
  5. Inhaled anticholinergics (ipatropium bromide/atrovent) if a lot of secretions
  6. Antileukotrienes (montelukast/singulair) useful for chronic asthma maintainence (long-term stabailization)
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14
Q

4 step med tx of in-pt asthma

A
  • 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
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15
Q

6 steps for out-pt asthma tx

A
  1. SABA
  2. Inhaled corticosteroid
  3. Add SABA for breakthrough
  4. LABA
  5. Anticholinergic
  6. Anti-leukotriene
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16
Q

Criteria for hospitalization in asthmatics

A

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

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17
Q

Inpatient Management of Asthma

A

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

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18
Q

Status Asthmaticus

A

Severe, acute asthma presenting in an unremitting, poorly responsive, life-threatening manner. Clinical findings not reliable indicators of severity of asthma.

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19
Q

8 steps for Status asthmaticus managment

(1-5 meds)

A
  1. O2
  2. IV D5 1/2 NS
  3. Inhalation and parenteral simpathomimetics (albuterol, acqueous epi)
  4. Methylprednisolone 60-125 or hydrocortisone 300 mg IV
  5. Atrovent
  6. Continuous pulse ox
  7. ABG q 10-20 min
  8. Intubate (falling ABG’s, decreased O2 sats, RR>30, behavioral changes)
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20
Q

Define Chronic Bronchitis and Emphysema

A

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*

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21
Q

CXR findings in chronic bronchitis

A

bulla,

blebs,

hyperinflation,

low, flat diaphragm

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22
Q

Chronic Bronchitis Signs/Symptoms

A

*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
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23
Q

Emphysema Signs/Symptoms

A
  • 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

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24
Q

What is the mainstay of tx for COPD?

A

Mainstay of therapy is: inhaled bronchodilators or sympathomimetics (Albuterol/xopenex)

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25
Q

What are the PFT and ABG findings in COPD?

A
  • FEV1 and other other measures of expiratory air reduced
  • TLC, FRC, RV may be increased
  • Increased paCO2
  • Increased HCO3
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26
Q

List several out-patient COPD Management strategies

A
  • D/C smoking
  • Avoid irritants/allergens
  • Postural drainage
  • Pulm rehab
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27
Q

Medication tx for In-patient COPD management

A

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
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28
Q

TB causative agent:

A

Systemic dz caused by M. tuberculosis. Pulmonary dz most common clinical presentation.

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29
Q

Extra-pulmonary manifestations of TB

A

May involve lymphatics,

genitourinary,

meninges,

peritoneum,

heart

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30
Q

TB Signs/Symptoms

A
  • Majority pts asymptomatic
  • Fatigue, anorexia
  • Dry cough progressing to productive and occ. blood tinged
  • Weight loss, low grade fever
  • Night sweats
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31
Q

What are the CXR findings in TB?

A

Small, hemogenous infiltrate in upper lobes by CXR (honeycomb appearance)

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32
Q

TB Diagnostics

A
  • 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

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33
Q

TB Baseline Evaluation

A

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

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34
Q

TB Drug therapy and duration

A

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

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35
Q

Tx for conflicting PPD and CXR

A

IF PPD + and CXR -, start INH therapy

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36
Q

How often should a pt with TB be monitored?

A
  • Weekly sputum smears and cx for 1st 6 weeks after initiation of therapy, then monthly until neg cx documented
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37
Q

When should suspicion be raised of drug-resistant TB?

A

Continued sx or + cx after 3 months should raise suspicion of drug resistance

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38
Q

List risk factors for TB

A

Patients at increased risk in crowded living conditions,

institutionalized,

HIV,

diabetes,

CRI,

malignancy,

malnutrition,

immunosuppressed

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39
Q

What are the criteria for + PPD in various populations?

A
  • 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
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40
Q

Pneumonia defintion

A

Inflammation of the lower respiratory tract as microorganisms gain access by aspiration, inhalation, or hematogenous dissemination

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41
Q

Most common causative organism in CAP?

A

Strep pneumoniae is most common etiology of CAP

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42
Q

List common PNA signs and symptoms

A
  • ***Lung consolidation on physical exam*** differential confirmation exam finding
  • Fever
  • Chills
  • Purulent sputum
  • Malaise
  • Increased fremitus
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43
Q

PNA Diagnostics

A
  • Elevated WBC
  • Infiltrates on CXR
  • GS and culture
  • ABG if resp failure suspected
  • CXR and consider 3 BC’s
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44
Q

IDSA/ATS Guidelines for Management of CAP

A
  • 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)
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45
Q

What age determines tx for CAP?

A

Younger than or older than 60 and consider previous ATB treatment and comorbidities also!

46
Q

What exam finding differentiates between PNA and bronchitis?

A

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

47
Q

ATb tx for In-Pt ICU Management PNA

A
  • 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

48
Q

What is the ATB regimen for in-pt Pseudomonas PNA?

A

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

49
Q

What medication is substituted for the beta-lactam for PCN allergic pts with PNA?

A

Aztreonam

50
Q

What is the most common causative agent in ventilator patients?

A

Psuedomonas

51
Q

What is the ATB tx regimen for MRSA PNA?

A
  • Add Vancomycin or linezolid to the above tx regimen

Get an ID consult with linezolid

52
Q

What is HAP?

A
  • PNA that occurs >48 hrs after admission which was NOT incubating at time of admission (includes VAP and HCAP)
53
Q

Most common agents in HAP?

A

Staph aureus, strep pneumoniae, H. influenza

54
Q

VAP

A
  • PNA that occurs >48-72 hrs after ET intubation
  • Pseudomonas most common causative organism
55
Q

What is a national mandate for prevention of VAP?

A

Raise HOB

56
Q

HCAP

A
  • 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
57
Q

Most common agents in HCAP?

A

Staph aureus

Pseudomonas

MRSA

58
Q

Atypical PNA causative agents

A

Legionella, mycoplasma, chlamdophylia

Do NOT have a cell wall and so not tx with ATB therapy

59
Q

CXR presentation of atypical PNA vs typical?

A

Typical presents and is read on CXR as lobar PNA,

Atypical is read as bilateral infiltrates

60
Q

Pneumothorax

A

Gas in the pleural space that raises pleural pressures and can impair respiration resulting in collapsed lung

61
Q

List PTX signs/symptoms

A
  • 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
62
Q

What is percussion sound in PTX on the affected side?

A

Hyperresonnance

63
Q

What is the diagnostic test for PTX?

A

CXR

64
Q

What type of PNA is suspected with RML involvement?

A

Aspiration PNA

65
Q

PTX Management

A
  • <20% PTX in asymptomatic pt - no intervention
  • CT used 1st if available, if emergent, needle thoracostomy
66
Q

What is the correct anatomical insertion for a CT?

A

CT placement up and over the ribs at 4th or 5th ICS at MAL

67
Q

What is the correct anatomical location for emergent needle decompression of PTX?

A

Needle thoracoscopy 2nd ICS, MCL

This is the least expensive, least invasive tx!

68
Q

PE

A

Diagnosed based on clinical suspicion, hx important as well as results of diagnostic studies.

Predisposing risk factors are present in the history.

69
Q

List common PE Risk Factors

A
  • Prolonged bed rest/immobility
  • Oral contraceptives
  • Surgery on long bones
  • Venous stasis
  • Hypercoagulable states
  • Cardiac thrombi
70
Q

List common PE Signs/Symptoms

A
  • 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
71
Q

What is the hallmark symptom of PE?

A

Tacchycardia and unexplained dyspnea

72
Q

PE Diagnostics

A
  • 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
73
Q

What is the cause of death in PE?

A

Failure of the right ventricle due to inabilty to handle the force through the pulmonary artery

74
Q

What are the indications for pulmonary angiography in suspected PE?

A

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

75
Q

What is the least expensive, least invasive test for PE?

A

VQ scan

76
Q

What is the leading cause of in-hospital death?

A

PE

77
Q

PE Management

A
  • 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)
78
Q

What is the anticoagulation regimen for PE?

A
  • 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)
79
Q

What are the indications for intubation in PE?

A

Worsening hypercapnea with progressive obtundation

80
Q

ARDS Signs and Symptoms

A

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**

81
Q

ARDS Diagnostics

A
  • Refractory hypoxemia is hallmark feature (continuous O2 does not help)
  • CXR may be “whited out” or have diffuse bilateral infiltrates
82
Q

ARDS Management

A

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

83
Q

Mechanical Ventilation Modes

A
  • 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
84
Q

Key Vent Settings

A
  • 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
85
Q

Post arrest vent settings

A
  • use 100% fiO2,
  • AC mode with rate 12,
  • TV 5-7 mL/kg
86
Q

TV settings

A

5-7mL/kg ideal body weight (about 350-500)

Don’t change this setting once you set it!

87
Q

General Guidelines for vent weaning

A
  • 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
88
Q

PFT’s

A

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
89
Q

List 3 obstructive diseases

A

Chronic bronchitis

Emphysema

Asthma

90
Q

Obstructive vs Restrictive

A

*Obstructive diseases characterized by reduced airflow rates

(asthma, COPD, Emphysema)

*Restrictive diseases characterized by reduced volumes

(PNA, pulmonary fibrosis, cyctic fibrosis, lobectomy, ARDS, sarcoidosis)

91
Q

List acute and chronic diseases causing restrictive airflow?

A

Acute:

  • PNA, ARDS

Chronic:

  • pulmonary fibrosis,
  • cyctic fibrosis,
  • lobectomy,
  • sarcoidosis
92
Q

CXR findings in Pleural Effusion

A

CXR will show blunting, shadowing, shunting of the costophrenic angle (sharp fins at the end of the lungs)

93
Q

Exudates

A

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!

94
Q

List 4 types of pleural effusions and describe fluid

A

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

95
Q

List common PNA PEARLS for elderly

A
  • 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
96
Q

PNA CXR findings in elderly

A

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
97
Q

Normal Gerontology Changes

A

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)

98
Q

Pt making sounds around the ET tube indicates:

A

Cuff leak

99
Q

Name the hallmark feature of ARDS

A

*Refractory hypoxemia is hallmark feature, O2 doesn’t help

100
Q

List 5 causes of true night sweats

A
  1. TB
  2. HIV/AIDS
  3. Menopause
  4. Lymphoma
  5. Endocarditis
101
Q

What is the normal percussion sound of the chest?

A

(Normal percussion sound is resonance)

102
Q

Reasons to intubate in Status Asthmaticus

A

Falling O2 Sats

RR 30’s

Bad ABG’s

Behavior Changes

103
Q

Atypical causes of PNA?

A

Walking PNA: Legionella, mycoplasma, chlamdophylia

Shows as bilateral interstitial infiltrates, reg PNA are lobar/bronchal

104
Q

What is the management of pleural effusion?

A

Thoracentesis

105
Q

RML localized infiltrate?

A

Aspiration PNA

106
Q

What PFT componant is diagnostic for COPD?

A

FEV1 / FVC ratio <70%=.07

107
Q

CURSA for admission of PNA

A

Confusion

Uremia BUN>19

RR >30

SBP <90

Age >65

If 3 or more, admit!

108
Q

What drug does not increase risk of PNA by raising stomach pH?

A

Carafate

109
Q

What drug is used to reduce ICP during intubation and suctioning?

A

Lidocaine

110
Q
A

ACNP Certification (17 decks)

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