Resp Flashcards
Advantages vs disadvantages of thrombolysis for submassive PE
Advantages
- Patients appear to feel better quicker.
- Clots resolve faster (30% to 35% reduction in total perfusion defect at 24h, with minimal improvement if just anticoagulated) early reduction in PAP and RV strain
- Decreased recurrence of PE
- Decreased death or hemodynamic stability (composite endpoint) at 7 days (PEITHO trial)
- Improved functional outcome (unproven, TOPCOAT trial)
- less long term pulmonary hypertension (MOPETT trial)
Disadvantages
- risk of intracerebral haemorrhage (2% in >75y group in PEITHO)
- risk of other haemorrhage (major bleeding, i.e. transfusion needed, ~6% in PEITHO)
- similar improvement at 7 days overall (65% to 70% reduction in total defect regardless of whether thrombolysed or anticoagulated)
- Increased cost
- No mortality benefit proven (improved composite of mortality and haemodynamic stability in PEITHO, as yet unpublished)
- Catheter-directed thrombolysis, if available, may be safer and equally effective
- RV dysfunction can markedly improve over 24 to 48h with systemic anticoagulation (e.g. heparin) in some patients
What are some CXR changes associated with PE
Westermark sign - increased translucency of pulmonary vasculature distal to the thrombosis
Has specificity of 92% (low sensitivity 14%)
Hampton Hump - well defined pleural opacity representing hemorrhage and necrotic tissue following pulmonary infarction. Specificity 82% but sensitivity 22%
Dilated pulmonary arteries
Raised hemidiaphragem with basal atelectasis
What are the criteria for massive and submassive PE
Massive PE - sustained hypotension (SBP<90 for at least 15 minutes), pulselessness or persistent profound bradycardia (HR<40 with signs of shock)
Submassive PE - Without sustained hypotension but with either RV dysfunction or myocardial necrosis
RV dysfunction -
- RV dilation (>0.9 LV diameter) on either apical 4 chamber or CT
- RV systolic dysfunction on TTE
- Elevated BNP or pro BNP
- New ECG changes (RBBB, anteroseptal ST changes or anterolateral T wave inversion)
What clinical factors suggest anaerobic pneumonia and which bugs are involved
Risk factors for aspiration (CNS depression or swallowing dysfunction)
Severe periodontal disease
Fetid sputum
Pulmonary abscess or empyema
Anaerobic pneumonias are typically polymicrobial
- Bacteroides
- Fusobacterium
- Prevotella
- Peptostreptococcus
How does S. Aureus pneumonia present
Associated with influenza
IVDU with hematogenous spread to both lungs with multiple small infiltrates or abscess
Often necrotizing with cavitation and pneumatocele
What are the assosciated microbes for CAP in different populations (alcoholism, COPD, etc)
Alcoholism — Streptococcus pneumoniae, anaerobes, Gram negatives such as Klebsiella pneumonia, tuberculosis
COPD/ smoker — Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Nursing home resident — Streptococcus pneumoniae, Gram negatives, Haemophilus influenzae, S. aureus, Chlamydophila pneumoniae consider tuberculosis and anaerobes (but less common)
Poor dental hygiene — anaerobes
Bat/ cave exposure — Histoplasma capsulatum
Bird exposure — Chlamydophila psitacci, Cryptococcus neoforms, Histoplasma capsulatum
Rabbit exposure — Franciscella tularensis
Farm animals or parturient cats — Coxiella burnetti (Q fever)
Post-infuenza — S. pneumoniae, S. aureus
Brochiectasis, cystic fibrosis — Pseudomonas aeroginosa, S. pneumoniae, Burkholderia cepacia
Sickle cell disease, asplenia — S. pneumoniae, H. influenzae
Suspected bioterrorism — Anthrax
Tropical Australia — melioidosis, Acinetobacter
Potting mix — Legionella longbeachae
Travel to Asia — SARS, tuberculosis, meliodosis
What is CURB-65 and some advantages/disadvantages
Risk tool for 30 day mortality in pts with pneumonia
C - Confusion
U - Urea>7mmol/L
R - RR>30
B - SBP<90 or DBP<60
Age >65
Score 0-1 has 30 day mortality ~3% and can be managed as outpatient
Scores 4-5 need to consider ICU
ADVANTAGES
Performed slightly better in prediction of mortality and need for ICU compared to PSI
Easy to use with most data readily available
DISADVANTAGES
Does not include comorbid illnesses or NH residency
Does not consider psychosocial limitations to otpt therapy
Does not consider saturations in the calculation
What is the Pneumonia Severity Index and some advantages/disadvantages of it
Tool made to pts with CAP at low risk for mortality. Satisfies pts into 5 classes for risk of death at 30 days using hx, exam, background, lab and radiological findings
ADVANTAGES
More accuracy in prognosticating the severity of the illness then CURB65
Takes into account aspects of the pt comorbid illness
DISADVANTAGES
More complicated for physicians to remember
Classifies any pt over 50 as Class 2 at minimum
Which pathogens have highest level of mortality rates for community acquired pneumonia
Gram negatvie (Pseudomona, Klebsiella, E Coli) - 41%
Staph Aureus - 32%
Strep pneumonia and Chlamydia pneumonia - 12 to 15%
Influenza - 9%
Mycoplasma - 1.4%
However, majority of deaths due to Strep Pneumonia due to the prevalence of its total number of cases when compared to Pseudomonas
What is SMART- COP and some advantages/diadvantages
Scoring system to identify pts at risk for intensive respiratory and vasopressor support
S - Systolic <90
M - Multilobar infiltrates
A - Albumin <35
R - RR>25 if less then 50yrs and >30 if over 50yrs
T - Tachycardia >125
C - Confusion
O - Oxygen for <50yrs Sats<93%, PaO2<70, PF<333. For >50yrs Sats<90, PaO2<60 and PF<250
P - pH<7.35
Systolic, Oxygen and pH are 2 pointers.
Scores >5 are high risk and have a 1 in 3 chance of needing IRVS
ADVANTAGES
High sensitivity for pts that will require ICU admission 92%
Performs comparable to the IDSA/ATS minor criteria
Prevents delayed ICU admission (associated with higher 30 day mortality
DISADVANTAGES
Does NOT estimate mortality
Does not apply to pts with significant immunosuppression
Variables such as comorbidities, functional status, frailty not included
What are the contraindications to NIV
Need for emergent intubation eg cardiac arrest or periarrest
Inability to protect airway or clear secretions
Marked hemodynamic instability/Severe upper GI bleeding
Maxiofacial trauma/base of skull fracture
Upper airway obstruction
Untreated PTx
Pt refusal
Intractable vomiting
What are the causes of NIV dyssynchrony and how do you trouble shoot this
Auto PEEP - treat underlying airflow obstruction, increasing PEEP to 80-90% the intrinsic PEEP, Reduce RR or TV, Raise inspiratory flow rate
Reduced flow due to interface leak - ensure appropriate fitting masks and placement, decrease level of pressure support, increase expiratory flow trigger.
Pt discomfort/anxiety - ketamine or midazolam for light sedation
What are indicators of successful management with NIV
Moderate hypercapniea 45<PaCO2<92
Moderate acidemia 7.1<pH<7.35
Improvement in gas exchange, HR, RR within first 2hrs
Younger age
Able to cooperate
Lower acuity of illness
What are the complications of NIV
Raised ICP
Raised intraocular
Gastric distention/vomiting
Aspiration
Hypotension
Local skin damage such as abrasions or pressure ulcers/necrosis due to mask/strap pressure
Eye irritation, sinus pain and epistaxis due to mucosal dryness
Agitation/claustrophobia
What are the risk factors for lung abscess and how are they classified
Primary lung abscess from direct infection in otherwise healthy person. Mostly secondary to aspiration but can also be from direct infection (S. Aureus)
- Episodes of altered consciousness
- Neurological or esophageal disease
- Substance abuse disorder
Secondary lung abscess from predisposing conditions such as septic embolization, preexisting lung cavities/bronchial obstruction or immunocompromise
- Dental pain/procedures
- Immunodeficiency
- Bronchiectasis
- Smoking
- Retropharyngeal abscess or R sided IE
What are the differential diagnosis for cavitary lung lesions
Solitary cavitary lesion:
1) Primary lung cancer. (75% Squamous cell, less pften adenocarcinoma or large cell carcinoma
2) Infection:
- Lung abscess (S. Aureus, Klebsiella, Pseudomonas or polymicrobial aspiration bugs streptococci and anaerobes such as peptostreptococcus, prevotella, bacteroids, fusobacterium)
- Fungal infection (Aspergillosis, cryptococcus, histoplasmosis)
- Tuberculosis.
Multiple cavitary lesions:
1) Metastatic cancer (Head/neck, esophagus, cervix, melanoma, sarcoma, GI malignancy) or lymphoma.
2) Infection:
- Tuberculosis.
- Invasive aspergillosis.
- Coccidiomycosis.
- Septic pulmonary emboli.
3) GPA (granulomatosis with polyangiitis).
4) Rheumatoid nodules
How are pleural effusions classified and list some examples of each
Lights criteria can distinguish between transudative and exudative
- normally recommended if pleural protien >25
Highly sensitive (98%) for exudative causes but specificity is only 83%
Exudative effusion if 1 or more
- Pleural protein/Serum protein >0.5
- Pleural LDH/Serum LDH >0.6
- Pleural LDH >2/3 Serum LDH ULN
ADDITIONAL if above equivocal
Serum albumin-pleural albumin<1.2
Transudative: Immbalance between hydrostatic and oncotic pressues
- CCF
- Nephrotic Syndrome
- Cirrhosis/Hepatic hydrothorax
- Hypoalbuminemia
- Dresslers
- CSF leak
- Atelectasis
- Peritoneal dialysis
Exudative: Increased microcirulation permeability or alteration of plerual lymph drainage
- Malignancy (mesothelioma/lymphoma/bronchial carcinoma/metastatic)
- PE with infarction
- Parapneumonic/Lung abscess
- TB
- SLE, RA, Sarcoidosis
- ARDS
- Pancreatitis
- Eosinophilic and noneosinophilic granulomatosis with polyangiitis
- Chylothorax
- Hypothyroidism
Other then lights criteria, what are some other tests that could be run on pleural fluid and what do their results mean
Absolute protein >30, LDH >20 and specific gravity >1.016 suggestive of exudative cause
pH<7.3 suggests empyema
Glucose<half serum think empyema, malignancy, RA/SLE
Amylase>serum = ruptured esophagus, pancreatitis, malignancy. bacterial pneumonia
Gram stain and culture
Cell Differential
HCT>0.5 = hemothoraxx
What features of a pleuritic tap suggests empyema
Purulent fluid
pH<7.2
Glucose<3 or <half>1000 and WCC>50 000</half>
What are some conditions that typically present as exudative but may be transudative
Malignancy
PE
Amyloidosis
Sarcoidosis
Constrictive pericarditis
Chylothorax
What are the causes of polymorphonuclear and lymphocytic pleural effusions
Polymorphonuclear
- Parapneumonic/Empyema
- PE
- TB
- Asbestosis with benign pleural disease
Lymphocytic
- Malignancy
- TB (maybe predominately granulocytic)
- Sarcoidosis
- RA and SLE
- Chylothorax
How is spontaneous pneumothorax classified
Primary
- Absence of external event and no known underlying lung disease, most frequently to ruptured subpleural blebs
- Age 10-40
- More common in males (3-6x)
- Smoking (x102 in pack a day smoker) and genetic predisposition increase risk
Secondary
- Complication of underlying lung disease
- Age>55
- Males slightly more common
- COPD and in endemic areas TB most common
- CF, malignancy, necrotiing pneumonia
- HIV, Marfan/Ehlers Danlos, endometriosis uncommon causes
Sizing for people >12
- Vertical distance from lung to thoracic cage >3cm (American)
- Horizonatal distance at the level of the hilum from lung to chest wall >2cm (British and approximates 50% PTx volume)
How are spontaneous pneumothorax managed
Depends on etiology (primary vs secondary), symptomology/stability and size
Unstable when
- Tachypnoeac or Hypoxic
- Tachy/bradycardic or Hypotensive
- Unable to speak in sentences or mobilize independently
ALL UNSTABLE PTS GET
- Needle decompression or Finger thoracotomy + ICC insertion
Start everyone with symptom control via O2 and analgesia
PRIMARY
- If small, unilateral without significant breathlessness/pain, oxygenate and rpt CXR in 4-6hrs. If stable or decreasing discharge and rpt CXR in 2-4 weeks (24hrs in children). Otherwise catheter or tube
- If stable but symptomatic or large can attempt needle aspiration (14-16G), aspirate until pt coughs or 2.5L removed, or tube. Depends on pt preference, severity and local expertise. Catheter/tube preferred as widely available, lower failure rates and provided continuous drainage
- All else, including bilateral get tube or catheter insertion
SECONDARY
- All need admission, supplemental O2 and pleural drainage (catheter preferred) and definitive intervention
- Higher rates of recurrence and life-threatening events
- Needs VATS or medical thoracoscopy with blebectomy + surgical or chemical pleurodesis within 3-5 days
- Blood patch or chemical pleurodesis alternatives if declining surgery
- Treatment of underlying lung disease (may exacerbate COPD)
- Need to avoid NIV if possible as PEEP can prolong air leak and progress to tension
What is the discharge advice for someone who has had a pneumothorax
Spontaneous resolution may take 6 weeks (1-2% every 24hrs)
Follow up CXR in 2-4weeks
Avoid extreme exertion until full resolution
Respiratory follow up and when to return to ED (breathlessness)
Stop smoking
Wait 7 days after full inflation for spontaneous before flying
- 14 days for traumatic
Lifelong avoidance of SCUBA diving following spontaneous PTx, unless undergoing pleurectomy or pleurodesis and then cleared by respiratory
- 3 months after traumatic
How is a pneumothorax managed during pregnancy
Conservative management with oxygenation +/-aspiration with PSP similar to normal guideline
Needs catheter or tube thoracostomy if
- SSP
- Develops during labor and delivery
- Fetal distress
Risk of recurrence in future pregnancy so pleurodesis is recommended after delivery
What size catheter/tube is recommended of pneumothorax
Small bore catheter (14 or less) or tube (22 or less) unless unstable pts, concomitant empyema/hemothorax or have failed small bore drainage
How are primary sponatenous pneumothorax managed in children
Focus is on clinical features
CT not recommended (unlike adults where it is useful to diagnose etiology)
Recurrence is 30-40% within 1yrs (median 2months)
If minimal symptoms can observe
- if small observe 4-6hrs and if stable discharge with follow up and rpt CXR in 24hrs
- if large give oxygen and admit for observation
- If significant symptoms (hypoxia, pain, breathlessness) then insert intercostal catheter and aspirate 30ml/kg via 3-way tap.
- Rpt CXR in 4hrs and if improved can remove device and follow up in 24hrs with rpr CXR. Otherwise, underwater seal drainage and transfer to pediatric hospital
RED FLAGS
- Age <12 as less reliable symptoms and size calculations
- Secondary (CF, asthma)
- Foriegn body inhalation
- Recurrence
- Trauma or thoracic surgery
- Large
- Tension
- PPV
Indications for home O2 in COPD
Long term continuous O2 (at least 15hrs per day) shows improved survivability in pts with severe COPD and severe hypoxia when
paO2</=55 when at rest or awake
paO2<60 if concurrent polycythemia (HCT>0.55), PHTN or RHF
Should be assessed 4-8weeks after discharge following exacerbation of COPD and 1 month after quitting smoking
Indications for ABG in ED
SpO2<90% on RA
History of or suspected CO2 retention (VBG NPV100% with pCO2<45)
PEFR<50% predicted
What is the GOLD severity scale
Compare the GENEVA score to the WELLS score
WELLS
Differentials for absent lung sliding
BNP
Level < 100, CCF ruled out (Sensitivity 90% and NPV 89%)
>500 CCF likely (specificty 87% and PPV 90%)
ARDS
PESI and different managment options for PE
Cavitating lung lesions
Causes of mediastinal mass
What are 5 differentials for bilateral patch infiltrates on CXR
APO - cardiogenic and non cardiogenic
Infective - Bacterial/viral, immunocompromised (TB/PCP), aspiration,
Traumatic lung contusions
Alveolar hemorrhages (underlying lung disease, coagulopathy, vasculitis, drug use)
Septic emboli - valvular disease/IE
Alveolar haemorrhages
