PULMONARY Flashcards
Danjurr signals:
PULMONARY EMBOLUS CLASSIC CASE STUDY
- An older adult c/o sudden onset of dyspnea and coughing
- Cough may be productive of pink tinged frothy sputum
- Other symptoms are tachycardia, pallor, and feelings of impending doom
- Any condition that increases the risk of blood clots will increase the risk of PE…Ex: Afib, estrogens?, surgery, pregnancy, long bone fractures, and prolonged inactivity
Danjurr signals:
IMPENDING RESP FAILURE (ASTHMATIC PATIENT)
- Asthmatic pt p/w tachypnea (rr>25/min), tachycardia or bradycardia, cyanosis, anxiety.
- Pt looks like shit, theyre exhausted, fatigues, and diaphoretic using accessory muscles to breathe.
- Physical exam reveals cyanosis and “quiet” lungs with no wheezing or breath sounds.
So whats your next step?
- Get Adrenaline injection STAT. O2 4-5 L, albuterol nebulizer treatments, parenteral steroids and antihistamines (dyphenhydramine and cimetidine).
- After treatment, a good sign is if breath sounds and wheezing are present (a sign that bronchi are becoming more open). Usually discharge with oral steroids for several days (i.e., Medrol Dose Pack).
Normal Lung Findings
EEEEgophany
Lower lobes: vesicular breath sounds are soft and low
Upper lobes: Bronchial breath sounds are louder
Egophonys: Normal will hear “eee” clearly instead of “bah.” Abnormal: Will hear “bah” sound.
Normal: The “eee” sound is louder over the large bronchi because larger airways are better at transmitting sounds. The lower lobes have a softer sounding “eee.”
Normal Lung Findings:
TACTILE FREMITUS
Touch my lungs
-Instruct patient to say “99” or “one, two, three.” Use fi nger pads to palpate lungs and feel for vibrations. Normal: Stronger vibrations palpable on the upper lobes and softer vibrations on lower lobes.
Abnormal: The findings are reversed; may palpate stronger vibrations on one lower lobe (i.e., consolidation). Asymmetrical findings are always abnormal.
Normal Lung Findings:
Whispered Pectoriloquy
- Instruct patient to whisper “99” or “one, two, three.” Compare both lungs.
- If there is lung consolidation, the whispered words are easily heard on the lower lobes of the lungs.
Normal: Voice louder and easy to understand in the upper lobes. Voice sounds are muffled on the lower lobes.
Abnormal: Clear voice sounds in the lower lobes or muffled sounds on the upper lobes.
Normal Lung Findings:
PERCUSSION
- Normal: Resonance.
- Tympany or hyperresonance: Chronic obstructive pulmonary disease (COPD), emphysema (overinflation). If empty, the stomach area may be tympanic.
- Dull tone: Bacterial pneumonia with lobar consolidation, pleural effusion (fluid or tumor). A solid organ such as the liver sounds dull.
Normal Lung Findings:
PFT
Measures Severity of Obstructive or Restrictive Pulmonary Dysfunction
-Obstructive dysfunction (reduction in airflow rates). Asthma, COPD (chronic bronchitis and emphysema), bronchiectasis, others
– Restrictive dysfunction (reduction of lung volume due to decreased lung compliance). Pulmonary fibrosis, pleural disease, diaphragm obstruction, others.
COPD
- COPD is a term that includes both emphysema and chronic bronchitis.
- The disease is characterized by the loss of elastic recoil of the lungs and alveolar damage that takes decades.
- The most common risk factor is chronic cigarette smoking and older age.
- COPD is the fourth leading cause of death in the United States.
CHRONIC BRONCHITIS
Loss of elasticity
- Coughing with excessive mucus production for at least 3 or more months for a minimum of 2 or more consecutive years
- Chronic bronchitis component: Productive cough, wheezing, and coarse crackles.
EMPHYSEMA
HYPERINFLATION
- Permanent alveolar damage and loss of elastic recoil results in chronic hyperinflation of the lungs.
- Expiratory respiratory phase is markedly prolonged
Classic Case Elderly male with a history of many years of cigarette smoking complains of getting short of breath upon physical exertion that worsens over time; accompanied by a chronic frequent cough that is productive of large amounts of white to light yellow sputum (chronic bronchitis) or progressive dyspnea with minimal cough, barrel chest, and weight loss (emphysema).
-Emphysema component: Increased AP diameter, decreased breath and heart sounds, use of accessory muscles, pursed-lip breathing, and weight loss. Percussion: Hyperresonance.
Tactile fremitus and egophony: Decreased
Chest x-ray: Flattened diaphragms with hyperinfl ation. Sometimes bullae present.
COPD TX
LABA: Inhaled long-acting β2-agonists: salmeterol, formoterol, olodaterol, and indacaterol, are used on a regular basis, adding short-acting inhaled β2-agonists, usually albuterol, as needed.
LAAA: Long-acting anticholinergic agents: tiotropium, aclidinium, and glycopyrronium.
Combination inhalers of short-acting β2-agonists with anticholinergic agents include fenoterol/ipratropium and salbutamol/ipratropium.
When treating COPD pt pick abx that over
H. Influenza (gram neg)
COPD Exacerbation
FIRST LINE:
Short-acting β2-agonists and anticholinergic agents are first-line therapies in the management of acute, severe COPD.
SABA: albuterol, proventil, xoponex, ventolin
ANTICHOL: Itraproprium bromide
ED Management of COPD Exacerbations
O2
CV monitoring
ABG, after 20–30 min if arterial oxygen saturation remains <90% or if concerned about symptomatic hypercapnia:
Administer bronchodilators
β2-Agonists and/or anticholinergic agents by nebulization or metered-dose inhaler with spacer
Add oral or IV corticosteroids
Consider antibiotics if increased sputum volume, change in sputum color, fever, or suspicion of infectious etiology of exacerbation
Consider adding IV methylxanthine if above treatments do not improve symptoms
Consider noninvasive mechanical ventilation
Evaluation may include chest radiograph, CBC with differential, basic metabolic panel, ECG
Address associated comorbidities
600 Staff
Six
Hundred
Staph
Strep…..#1
H influenza
Staph aerus
ACUTE BACTERIAL PNEUMONIA OR CAP S/S
600 staph
Six Hundred Staph
600 staff
-#1 culprit is STREPtococcus pneumonia AKA PNEUMOCOCKus (gram +)
H influenzae (NEG), staph aerus (POS)
- Acute onset: high fever, chills, productive cough and large amounts of GREEN to RUST colored sputum. Pleuritic chest pain w/cough. decreased breath sounds, dull
- CBC: leukocytes; elevated neutrophils, band forms may be seen
- CXR: Lobar infiltrates, Bilateral
ATYPICAL PNEUMONIA
-#1 culprit MYCOplasma Pneumonia
chlamydia, legionella
-Gradual onset: low grade fever, headache, sore throat, cough, wheezing, someitmes rash
CXR: Intersitital to patchy infiltrates and usually UNILATERAL
VIRAL PNEUMONIA
- Influenza, RSV
- Fever, cough, pleurisy, SOB, scanty sputum production. Myalgias
- Breath sounds: decreased, rales
ACUTE BRONCHITIS
- Dry and severe cough that interrupts sleep
- cough dry to productive, light colored sputum
- can last up to 4-6 weeks
- No antibiotics! just treat symptoms
CAP Organisms
1 Streptococcus aka pneumocockal
Staph aureus (+)
Moraxella catarrhalis (-)
Six(+) Hundred(-) Staph(+) eat Mozarella(-) Arugula(-)
CAP Organisms with COPD/SMOKER
COPD and/or smoking:
Haemophilus influenzae, Pseudomonas aeruginosa, Legionella species, S. pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae
CAP Organims with ETOH
Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacterspecies, Mycobacterium tuberculosis
CAP Classic Case
-older adults presents with sudden onset of high fever (greater than 100.4 F) with chills that is accompanied by a productive vough with purulent sputum GREENY RUSTY nastiness. The patient c/o pleuritic chest pain with coughing and dyspnea.
CAP Physical Findings and Labs
-PE: Auscultation. rhonchi, crackles, wheezing
Percussion. Dullness over affected lobes
TF and Egophany. Increased
Abnl Whispered perliliqui. Whispered words arelouder
-Labs: CXR is the GOLD standard for diagnosing so dont be running to draw a sputum culture, CXR FIRST
CXR: will show LOBAR consolidation in a classic bacterial pneumonia
CBC: Leukocytosis (>10.5) with possile “shift to left” increased band forms. idk wtf that means
CAP Tx- oupatient
SINGLE DRUG THERAPY
Macrolide (first choice)-
Azithromycin, 500 milligrams PO on day 1 and 250 milligrams on days 2–5 (Respiratory fluoroquinolones reserved for those who cannot tolerate or have failed other therapy)
or
Clarithromycin XL, 1000 milligrams PO each day for 7 d
Tetracycline-like macrolide:
Doxycycline, 100 milligrams twice a day for 10–14d (Second-line choice)
CAP tx with pt having comorbidity (etoh, chf, chronic heart, lung, kidney disease, abx in previous 3months, diabetes, splenectomy)
Therapy for Outpatient Management of Patients with Significant Comorbidities
You can either just prescribe a FLOURO OR you can double it up
Fluoroquinolone:
Levofloxacin, 750 milligrams daily for 5 d.
or
Moxifloxacin, 400 milligrams daily for 7–14 d
Alone OR with Blam Macro
β-Lactamase inhibitor PLUS a Macrolide
BLAM: Amoxicillin-clavulanate, 2 grams twice daily
AND
Macrolide: Azithromycin, 500 milligrams PO on day 1 and 250 milligrams on days 2–5
Or 3rd gen cephalosporin plus macrlide (ceftriaxone)
HAP Empiric Tx
Its a three drug tx plan!!!
β-Lactam/β-lactamase inhibitor:
Piperacillin-tazobactam, 4.5 grams every 6 h
plus
Antipseudomonal fluoroquinolone:
Ciprofloxacin, 400 milligrams every 8 h*
plus
Anti-MRSA drug:
Vancomycin, 15 milligrams/kg every 12 h
An aminoglycoside may be substituted in place of the fluoroquinolone. Levofloxacin, 750 milligrams every 8 h, may be substituted for ciprofloxacin. Linezolid, 600 milligrams every 12 h, may be substituted for vancomycin.
Atypical Pneumonia Classic Case
- infection of the lungs by atypical bacteria, more common in children and young adults, AKA “walking pneuomnia” HIGHLY CONTAGIOUS
- Seasonal happening in summer or fall
- Young adult c/o several weeks of fatigue that is accompanied by severe paroxysmal coughing that is mostly nonproductive. gradual onset. illness may have started with cold like symtoms (sore throat, clear rhinitis, low grade fever). Pt continues to go to work/school despite symptoms.
Atypical Pneumonia Organisms
Michael Plasma
MYCOPLASMA pnuemonaie
CHLAMYDIA pneuomoniae
LEGIONELLA pnuemonia
Michael likes
Chicken
Legs
Atypical Pneumonia PE
Auscultation: wheezing and diffused crackles/rhales
Nose: Clear mucus (may have rhinitis or clear mucus)
Throat: Erythematous without pus or exudate
CXR: Diffuse interstitial infiltrates
CBC: may be nl
Atypical Pneumonia Tx
Macrolide:
Azithromycin x5 days
Clarithromycin 500mg BID x10-14 days
Erythromycin 500mg QID x10-14 days
Antitussives (dextromethrophan) prn
Increase fluids and rest
TUBERCULOSIS
- An infection caused by MYCObacterium tuberculosis bacteria. Most common site of infection is in the lungs. Other sites include kidneys, brain, lymph nodes, adrenals, and bone.
- Most contagious forms are pulmonary TB, pleural TB, and laryngeal TB (coughing spreads around aerosol droplets)
- CXR will show cavitations and adenopathy and granulomas on the hila of the lungs.
TB Classic Case
-Adult pt from high risk pop c/o fever, anorexia, fatigue, and NIGHT SWEATS along with milk NONproductive cough (early phase). Aggressive infections (later sign) will have PRODuctive cough with blood stained sputum (hemoptysis) along with weight loss (late sign).
PRIMARY TB CXR
- In primary infection, parenchymal infiltrates in any area of the lung may be found.
- Isolated ipsilateral hilar or mediastinal adenopathy is sometimes the only finding.
- Pleural effusions are usually unilateral and occur alone or in association with parenchymal disease.
- During primary infection, younger patients are more likely to have enlarged hilar lymph nodes, whereas adults more frequently have parenchymal abnormalities and effusions.
High Risk Populations
-immigrants from idk, migrant farm workers, illegal drug users, homeless, inmates of jails and nursing homes, HIV infected, immunocompromised
Primary TB
- When the infection is primary and active, common symptoms include fever, malaise, weight loss, and chest pain.
- Infrequently, a pneumonitis that is similar to a viral or bacterial infection appears.
CXR: n primary infection, parenchymal infiltrates in any area of the lung may be found (Figure 67-2). Isolated ipsilateral hilar or mediastinal adenopathy is sometimes the only finding. Pleural effusions are usually unilateral and occur alone or in association with parenchymal disease. During primary infection, younger patients are more likely to have enlarged hilar lymph nodes, whereas adults more frequently have parenchymal abnormalities and effusions. Hilar adenopathy is present but rarely massive. In some cases, especially in immunocompromised patients, the primary infection may be rapidly progressive and fatal.
Reactivation TB
REACTIVATION TUBERCULOSIS
- When latent infection progresses to tuberculosis reactivation, symptoms may be systemic or pulmonary.
- The most common reactivation symptoms are similar to those of primary tuberculosis and include fever, night sweats, malaise, fatigue, and weight loss.
- Productive cough, hemoptysis, dyspnea, and pleuritic chest pain develop as the infection spreads within the lungs. Physical examination is generally unremarkable, although rales may be noted in areas of pulmonary infection.
Active TB Tx
Daily four-drug (INH, RIF, PZA, ethambutol) therapy for 8 weeks, followed by either INH/RIF or INH/rifapentinefor 18 weeks OR
Daily four-drug therapy for 2 weeks, followed by two times per week for 6 weeks, with subsequent INH/RIF or INH/rifapentine for 18 weeks OR
Three times weekly four-drug therapy for 8 weeks, followed by INH/RIF three times weekly for 18 weeks OR
Daily three-drug therapy (INH, RIF, ethambutol) for 8 weeks followed by INH/RIF for 31 weeks
**Ethambutol causes optic neuritis
LATENT TB TX
- Treatment of latent infection with INH alone is started in those with recent asymptomatic skin test conversion
- any person in close contact with an actively infected patient, and anergic patients with known tuberculosis contact.
- Unless contraindicated, therapy is for a minimum of 9 months for adults, children, and HIV-infected persons.
- Monitor those at risk for INH hepatotoxicity by serial laboratory assessment.
- For those exposed to INH-resistant strains or those who are intolerant, use RIF and PZA for 2 months with hepatotoxicity monitoring.
Youre suppose to memorize this
≥5-mm induration is positive in:
Patients with the human immunodeficiency virus
Patients with close contact with a tuberculosis-infected individual
Patients with abnormal chest radiograph suggestive of healed tuberculosis
Patients with organ transplants and other immunosuppressed patients receiving the equivalent of prednisone >15 milligrams per day for >1 month
≥10-mm induration is positive in patients not meeting the above criteria but who have other risks:
Injection drug users
High-prevalence groups (immigrants, long-term care facility residents, persons in local high-risk areas)
Patients with conditions that increase the risk of progression to active disease (silicosis, diabetes, carcinoma of the head, neck, or lung)
Children <4 y of age
ASTHMA
- Asthma is a chronic inflammatory disorder characterized by increased responsiveness of the airways to multiple stimuli.
- In susceptible individuals, the inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes usually are associated with widespread and varying airflow obstruction.
Peak Expiratory Flow Rate
- measures effectivess of tx, worsening symptoms, and exacerbations. during expiration pt is insctruced to blow hard using the spirometer 3x. the highest value is recoreded (personal best).
- based on Height Age Gender
- PEF is based on HAG*
Asthma-Classic Case
- Young adult patient with asthma c/o worsening, symptoms after a recent bout of viral upper respiratory infection. The patient is using hre albuterol inhaler more than normal (about 2-6 times/day) to treat the symptoms -C/o SOB, wheezing, chest tightness accompanied by dry cough inthe night and early morning 3am that awakens her from sleep.
Asthma Exacerbation
MILD TO MOD: Fev1 >/ = 40%
SEVERE: Fev1 <40%
-give neb: albuterol or levalbuterol by nebuliver may repeat every 20 min for 3 doses. AFTER those neb treatments you need to reassess. If inspiratory and expiroatory wheezing is present its a GOOD sign
STAT ASTHMATICUS: <25
Asthma dx
DIAGNOSIS AND PATIENT MONITORING
-Bedside spirometry provides a rapid, objective assessment of patients and guides therapy. The forced expiratory volume in 1 second (FEV1) and the peak expiratory flow rate (PEFR) rate directly measure the degree of large airway obstruction. Sequential measurements help assess severity and determine response to therapy.
Asthma ABG
With acute attacks, ventilation is stimulated, resulting in a decrease in partial pressure of arterial carbon dioxide (Paco2). Therefore, a normal or slightly elevated Paco2 (e.g., >42 mm Hg) indicates extreme airway obstruction and fatigue and may herald the onset of acute ventilatory failure. Patients with impending respiratory failure almost always have clinical evidence of severe attacks or spirometry demonstrating a PEFR or FEV1 <25% predicted.11
STATUS Asthmaticus
-Status asthmaticus is an acute severe asthma attack that does not improve with usual doses of inhaled bronchodilators and steroids.
- Signs and symptoms include hypoxemia, tachypnea, tachycardia, accessory muscle use, and wheezing.
- *-Wheezing may be absent when airflow is severely reduced.** Rapid treatment is the key to preventing cardiopulmonary arrest.
PEF <25% predicted or personal best
SA Tx-Mg
-In addition to the usual bronchodilators the patient already takes plus early steroids, there is more to do…
MAGNESIUM
IV magnesium sulfate is indicated in the management of acute, very severe asthma (FEV1 <25% predicted).
Mg 1-2g IV over 30 min
Nebulized magnesium is effective and may also improve pulmonary function in severe asthma when it follows aggressive β-agonist and steroid therapy.
-When using magnesium in any form, monitor blood pressure and deep tendon reflexes during administration because hypotension or neuromuscular blockade may occur, although this is exceptionally rare in the doses recommended.
Stat Asthmaticus Tx-NIPPV
NONINVASIVE POSITIVE-PRESSURE VENTILATION
Noninvasive positive-pressure ventilation improves airflow and respirations compared with usual care, and despite little research, it is commonly used in clinical practice for acute life-threatening asthma.
- Noninvasive positive-pressure ventilation decreases the need for intubation, results in clinical improvement, and decreases the need for hospitalization.
- Do not institute noninvasive positive-pressure ventilation if intubation is indicated or in patients with suspected pneumothorax.
Stat Asthmaticus Tx-Ketamine
KETAMINE
- Ketamine inhibits reuptake of noradrenaline and thus increases circulating catecholamines, aiding some with severe asthma.
- An IV bolus dose of 0.2 milligram/kg followed by an infusion of 0.5 milligram/kg/h is sometimes used; higher doses are validated.
- If intubation is needed, ketamine is a good agent to aid during the procedure and after mechanical ventilation starts. Controlled trials substantiating ketamine’s efficacy in treating severe acute asthma are lacking.
Stat Asthamticus TX-EPINEPHRINE
EPINEPHRINE
Although epinephrine is standard treatment for anaphylactic asthma, it is overlooked as an adjunct to treat status asthmaticus. Epinephrine can be given SC or IM, 0.5 milligram in adults (standard adult EpiPen® dose), in refractory situations.
Status Asthmaticus Tx-Mechanical Ventilation
MECHANICAL VENTILATION
- If the patient manifests progressive hypercarbia or acidosis or becomes exhausted or confused, intubation and mechanical ventilation are necessary to prevent respiratory arrest.
- Mechanical ventilation does not relieve the airflow obstruction—it merely eliminates the work of breathing and enables the patient to rest while the airflow obstruction is resolved.
-The potential complications of mechanical ventilation in asthmatic patients include extremely high peak airway pressures with subsequent barotrauma and hemodynamic impairment.
-Mucous plugging is frequent, leading to increased airway resistance, atelectasis, and pulmonary infection.
-Due to the severity of airflow obstruction during the early phases of treatment, the tidal volume may be larger than the returned volume, leading to air trapping and increased residual volume (intrinsic positive end-expiratory pressure).
- Use rapid inspiratory flow rate at a reduced resp frequency 12-14 breaths plus allow adequate time for the expiratory phase to lower the chance of thos effects
- Also, it is reasonable to target adequate arterial oxygen saturation (≥90%) without concern for “normalizing” the hypercarbic acidosis.
- This approach is called controlled mechanical hypoventilation or permissive hypoventilation.
- Ventilation of asthmatic patients requires sedation. Neuromuscular blocking agents may be required, but extended use may cause postextubation muscle weakness.
Initial Mechanical Ventilation Goals
Initial Ventilator Settings and Goals
Ventilator Parameters
Ventilator Settings Mode: Assist-control
FIO2: Begin with 100% oxygen
Tidal volume: 6 mL/kg (ideal body weight) to start
RR: 12 breaths/min
Inspiratory flow rate: 60 L/min
Inspiratory:expiratory ratio: 1:2 or 1:3 ratio
PEEP: Begin with 5 cm H2O, titrate to 10 cm H2O
Ventilation goals
PaO2: 60–90 mm Hg
PaCO2: 40 mm Hg
pH: 7.35–7.45
FIO2 of 40%–60%
Inspiratory peak pressure <35 cm H2O
