Pulmonary Emergencies

Question 1

what blood gas abnormalities indicate acute respiratory failure from pulmonary causes?

Answer 1

PaCO2 > 50 with acidosis (pH < 7.25)
PaCO2 > 40 with severe distress
PaO2 < 60 or sat < 90% on 0.4FiO2

Question 2

What are basic goal tidal volumes with intubation?

Answer 2

7-10mL/kg

Question 3

Management strategies for acute primary hypoxemia

Answer 3

High-flow supplemental O2
PEEP - cpap or bipap
ETT
Assistad ventilation

Question 4

Management of primary hypoventilaion

Answer 4

Supplemental O2
support ventilation with oral/nasal pharyngeal airway
bagmask ventilation

Question 5

How can inspiratory:expiratory ratio be altered to improve obstructive lower airway disease?

Answer 5

increase I:E = extend exhalation time = better elimination of Co2

Question 6

What doses of morphine can be used for sedation of an intubated patient?

Answer 6

0.1-0,2mg/kg q1-2 hrs
or
0.1mg/kg/hr continuous infusion

Question 7

What dose of midazolam can be used for sedation in an intubated patient?

Answer 7

0.1-0.2mg/kg q1-2hrs or as continuous infusion

Question 8

What is a reasonable course of action when aspiration has occurred and it is unclear if the patient is suffering from pneumonitis or pneumonia?

Answer 8

defer antibiotic treatment in favour of careful observation in a well-appearing child and empirically treat only those with tenuous respiratory status or compelling clinical evidence of infection

Question 9

What are the 2 patterns of aspiration pneumonia?

Answer 9

localized necrotizing bacterial pneumonia, abscess or empyema - anaerobic organisms
large aspirates of acidic contents - aerobics eg. pseudomonas and Staph

Question 10

Abx for aspiration pneumonia?

Answer 10

Pip tazo or clinda if pen allergic

Question 11

what investigations should be obtained in a suspected CF exacerbation?

Answer 11

CXR
Sputum culture
chemistries
CBC

Question 12

How can mild CF exacerbations be treated?

Answer 12

10-14 day course of oral abx covering the usual organisms affecting CF patients - H. flu, staph aureus, pseudomonas, stenotrophomonas, burkholderia cepacia, achromobacter
may need inhaled therapy as well

Question 13

How should severe CF exacerbations be treated?

Answer 13

IV antibiotics and hospitalization
abx coverage based on prior resp culture results
always double cover for pseudomonas

Question 14

Why do CF patients get pneumothorax?

Answer 14

mucous plugging and air trapping - increased intrapulmonary pressure and lung structure already weakened from chronic inflammation

Question 15

What diagnosis is important to consider in CF patients with wheeze?

Answer 15

ABPA (Allergic Bronchopulmonary Aspergillosis)

Question 16

What are the symptoms of ABPA?

Answer 16

chronic wheeze that is difficult to control
decline in pulmonary function
chronic cough
transient infiltrated on CXR
symptoms respond well to oral steroids

Question 17

What are the diagnostic criteria for ABPA?

Answer 17

elevated total serum IgE
positive skin reactivity to Aspergillus
positive specific serum antibodies to Aspergillus

Question 18

When is methylpred indicated in management of pulmonary hemorrhage?

Answer 18

allergic, vasculitic, and idiopathic hemorrhage

Question 19

What is the preferred management for severe pulmonary hemorrhage?

Answer 19

Aggressive fluid resuscitation followed by positive-pressure ventilation with PEEP

Question 20

What is the biggest risk factor for PE?

Answer 20

central venous catheter

Question 21

What is the most common ECG finding in PE?

Answer 21

Sinus tachycardia

Question 22

What ECG changes indicate cor pulmonale?

Answer 22

right axis deviation, new complete right bundle branch block, T-wave inversion in leads V1-V4, dominant R-wave in V1, right atrial enlargement, and the classic “S1, Q3, T3”

Question 23

What CXR findings are suggestive of PE?

Answer 23

segmental pulmonary infiltrate with an ipsilateral elevated hemidiaphragm

Hampton hump and Westermark sign

Question 24

For what type of PE is CTA less sensitive?

Answer 24

peripheral subsegmental emboli beyond main, lobar, or segmental pulmonary arteries

Question 25

What is the treatment of PE?

Answer 25

IV heparin (1st line)
IV LMWH (2nd line)

Question 26

What are the common bacteria found in CF exacerbations?

Answer 26

Staph aureus
Pseudomonas Aeruginosa
Stenotrophomonas maltophilia
Bulkholderia cepacia

Question 27

Groups at high risk for severe bronchiolitis

Answer 27

Infants born prematurely (<35 weeks’ gestation)

<3 months of age at presentation

Hemodynamically significant cardiopulmonary disease

Immunodeficiency

Question 28

Indications for admission in bronchiolitis

Answer 28

Signs of severe respiratory distress (eg, indrawing, grunting, RR >60/min)

Supplemental O2 required to keep saturations >90%

Dehydration or history of poor fluid intake

Cyanosis or history of apnea

Infant at high risk for severe disease

Family unable to cope