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CCP 2 Review > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What structures are in the upper Respiratory tract?

A 
Nasal Cavity
Pharynx
- nasopharynx
- Oropharynx
- Laryngopharynx
Larynx
Glottis
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2
Q

Lower Respiratory Tract

A 
Trachea
Primary Bronchi
Bronchioles
Alveolar Duct
Alveolar Sac
- Alveoli
- Capillary
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3
Q

Inspiratory Muscles

A

Chest, Back, Scalenes, Pectoralis major and minor, serrated anterior, latissmus dorsi

Sternocleidomastoid

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4
Q

Expiratory Muscles

A

Abdominal Muslces,

Recurs Abdomomos. Obliques. Transverse abdomen is

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5
Q

Functions of Respiratory System

A 
Gas Exchange
Acid base balance
Phonation
Pulmonary defence and metabolism
- cough mucus clearance
- lung filter
- vasoactive substance metabolism

Lungs also phagocytosis by alveolar macrophages, filter emboli and leukocytes and excrete volatile substances

It modifies or uptake of serotonin, prostaglandins, norepinephrine, bradykinin, (does not metabolize epinephrine or histamine as it is a major source of histamine release)

Converts angiotensin 1- Angiotensin 2

Synthesize of surfactant

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6
Q

Alveolar Gas Equation

A

PA02=Fi02(Pb-PH20)-(PaC02)/RQ

PA02= 0.21 ( 760-47)- (40/0.8)

PA02= 100mmHg

Increasing PaC02 alone will decrease PA02 (and thus Pa02)

Important of preoxygenation

PH20 is saturated vapour pressure of water at body temperature and is normally 47 at atmospheric pressure

Pb= atmospheric pressure is 760mmHg

This equation is the method for calculating the partial pressure of alveolar oxygen (PA02). Assesses lungs are properly transferring oxygen into the blood.

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7
Q

Daltons Gas’s Law

A

Pt= P1+P2+P3

- Partial pressure of one gas increases the other must decrease

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8
Q

Causes of Hypercapnea

A

1) Won’t breath
- Drugs OD
- CNS lesion, SPinal cord lesion

2) Can’t Breith
- Chest wall injuries, kyphoscoliosis

  • Neuromuscular
  • Myasthenia Crisis, GBS< Muscular dystrophy ALS

Obstructive
- COPD, ASTHMA

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9
Q

Kyphoscoliosis

A

Deviation of the normal curvature of the spine in the Sagital and coronal planes

  • caused by congenital abnormalities including spina bifida, infections and vertebral tuberculosis
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10
Q

What is Low Venous Admixture

A

Normal SV02 70 percent

  • Patients in shock with decreased Sv02 will exacerbate hypoxemia
  • Abdnormal high Aa gradient
  • importance of optimizing oxygen delivery in hypoxemia failure

Intubation and MEchanical ventilation will remove WOB

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11
Q

Hypoxemia and Hypoxia definition

A

Hypoxemia= Low Arterial P02

Hypoxia = Low tissue 02

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12
Q

What is Diffusion limitation

A

Disruption of oxygen diffusion across the alveolar capillary interface

  • interstitial lung disease will have abnormal diffusion processs
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13
Q

Cabins are normally pressurized to?

Can this cause hypoxia in a healthy patient

Explain

A

8000 ft

Barometric pressure at sea level 760 mmHg Pi02 150

At 8000 ft barometric pressure 565 mmHg which Pi02 Inspiratory partial pressure of oxygen is 109 which correlates to a Pa02 62 mmHg

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14
Q

What is oxygen extraction equation

A

Sa02-Sv02

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15
Q

What is oxygen delivery to the tissues determined by

A

1) oxygen content in blood= oxygen bound to Hgb + oxygen dissolved
2) Cardiac output

D02= C0 (1.34xHbxSa02)+(0.003)xPa02)

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16
Q

Define

1) Inspiratory Reserve Volume
2) Inspiratory Capacity
3) Expiratory Reser Volume
4) Residual Volume
5) Functional Residual Capacity
6) Vital Capacity
7) Total Lung Capacity

A

1) Inspiratory reserve volume is the amount of air that can be forcibly inhaled after a normal tidal volume
2) Inspiratory Capacity is the sum of the tidal volume and the inspiratory reserve volume
3) Expiratory reserve volume is the amount of air that can be forcibly exhaled after a normal exhaled tidal volume
4) Residual volume is the amount of air left over in the lung after a full exhalation.
5) Functional Residual capacity is the amount of air left in the lungs after Vte exhalation
6) Vital Capacity is the amount of air the lungs can hold minus the residual volume
7) Total lung capacity is the full amount of air in the lungs maximal inhalation

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17
Q

Define Functional Residual Capacity

What is the importance what can cause increased FRC and decreased FRC

A

Residual volume + expiratory reserve volume
- amount of air left in the lungs after a normal expiration

  • Determined when alveolar pressure = 0 no airflow point where inwards recoil of lung is balanced by outwards recoil of the chest wall
  • usually around 2-3 L
  • It acts as a reserve oxygen allowing continued oxygenation

It is affected by

  • lung size- age, height, sex
  • lung and chest wall disease- ARDS, pleural disease ie pneumo/effusion, abdominal pressures, obesity, anesthetics pneumonia and body position

Decreased FRC Causes

  • Increased WOB, AIrway resistance, decreased lung compliance atelectasis/collapse
  • decreased ventilation and oxygenation
  • increased Pulmonary vascular resistance and increased Afterload
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18
Q

Pulmonary Function Tests AKA Spirometry

Definition and how does it help

A

Measures lung volumes and flow

Helps with diagnosis and grade of severity of obstruction and restrictive lung disease

Obstruction= asthma COPD

Restrictive Lung Disease= interstitial lung disease (ARDS, CHF), Obesity, neuromuscular disease

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19
Q

Interpretation of Pulmonary Function Tests

Restrictive VS Obstructive

A

Restrictive
- Low lung volumes and capacities
- Lung or chest wall compliance curves shifted to the right
- FEV1/FVC normal or elevated
DLCO= diffusion capacity for carbon monoxide normal or low

Obstructive

  • Variabile Expiratory
  • Low FEV1/FVC ratio
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20
Q

Asthma Pulmonary Function Tests interpretation

A
  • Episodic
  • FEV1/FVC is the forced exhalation volume in once second to forced vital capacity.
  • Asthma equals increased FEV1 to FVC in severe disease

Asthma FEV1/FVC ratio will improve with bronchodilator therapy

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21
Q

COPD and Pulmonary Function Tests

A

Chronic Bronchitis

  • increased mucus production from goblet cells
  • damaged cilia increase risk of bacteria and pnemonia
  • DLCO normal
    RV, FRC high secondary to air trapping
  • Low Pa02 with cyanosis
  • High PaC02

Emphysema

  • Low DLCO
  • Lung compliance shifts to the left ( increased compliance from loss of elastin and collagen)
  • Total lung capacity, Residual Volume , FRC all increased secondary to air trapping
  • PaC02 slightly increased.
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22
Q

Pulmonary Function Tests Numbers to remember

A

FEV1 < 50 percent sever for obstructive airway disease

FVC<50 percent significant restrictive airway disease.

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23
Q

What is tactile and Vocal Fremitus

A

Palpating of chest wall to detect changes n the intensity of vibrations created by phonation

Decreased in ( lots of air)

Increased in FLUID ( sound vibrates of Fluid) Think of ultra sound sounds vibrates of fluid.

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24
Q

Breath sounds

A

Vesicular- normal
Bronchial higher pitched seen in consolidation
Absent concerning

Crackles
Wheezes
Rhonchi
Strider

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25
What is a VBG VS ABG
VBG good for C02 HCO3 (PH will be 0.02-.004 units lower than arterial) ABG good for PH, Pa02, Sa02
26
What are Limitations of pulse Oximetry
Does not distinguish between oxy Hgb at 940nm - does not distinguish between COhb and Methb from OxyHb MetHb classically reads as 85 percent - intravascular presence of dye - e.g methylene blue - Interference with ambient light, skin tone, nail polish or peripheral shut down Calibrated from healthy volunteers
27
Difference between ETC02 and PaC02
ETC02and PaC02 difference is normally about 2-5mmHg due to normal dead space Larger discrepancy can get worse secondary to Dead Space - PE/ SHOCK ETC02 is lower because of dead space
28
Types of Respiratory failure and Definitions
Type 1 Hypoxemic - Pa02 < 60mmHg, Sa02 92% Consider 6 mechanisms of Hypoxemia Type 2= Hypercapnc - PaC02 > 50mmHg
29
Decision to Intubated in Weakness GBS, MG
VC <20 cc/kg
30
Definition of ARDS ( Berlin Definition)
1) Acute= <1 week 2) bilateral opacities on radiograph 3) non cardiogenic 4) P/F ratio of 300 with at least a peep of 5cm H20
31
ARDS Severity
Mild P/F 200-300 Moderate PF 100-200 Severe P/F <100
32
Stages of ARDS
Stage 1= Early Exudative stage 7-10 days Stage 2= Fibroproliferative stage - 2-3 weeks Stage 3+ Fibrotic stage - Abdnomral lung architecture- fibrosis cyst formations
33
Complications with ARDS and treatment
Ventilator can cause Barotrauma, Volutrauma, Biotrauma, Electotrauma VAPS Disease process can cause fibrosis, RV dysfunction and pulmonary Hypertension which can worsen with PPV Stress ulcers, Delirium, VTEs, Critical illness myopathy Organ dysfunction, kidney,liver
34
When is Prone and ECMO indicated for ARDS
PRONE P/F Ratio <150 Severe PF < 80 - ECMO
35
What is Supportive Management for ARDS
``` Pain management Sedation Nutrition VTE prophylaxis Stress ulcer prophylaxis - drier fluid management Hemodynamics monitor end organ perfusion, arterial lines, central lines ```
36
What is a good assessment prior to transporting patients with high pressures, air trapping, ARDS
POCUS looking for barotrauma
37
Definition of Aspiration
Pneumonitis- generally inflamed reaction to the lower airway caused by chemical irritation from gastric acid Pneumonia active bacterial infection
38
Define Emphysema
Structural changes distal to the terminal bronchioles, destruction of airspace wall floppy alveoli are prone to hyperinflation. Loss of elastin and collegian, Cause by smoking and anti-trypsin 1 deficiency
39
Definition of Chronic Bronchitis
Chronic productive cough for 3 months in each of 2 successive years in which all o other causes of chronic cause have been excluded
40
Difference between Asthma and COP
Asthma has reversibility to its airflow obstruction
41
Pathophysiology of Obstructive Airway Disease
Distal airway- goblet cell and muscular gland hyperplasia, fibrosis, narrowing and collapsed airway - Lung parenchyma- dilation destruction of respiratory bronchioles alveolar ducts and alveoli Pulmonary vasculture- smooth muscle hypertrophy hyperplasia Increased pulmonary hypertension, in creased RV afterload,
42
Staging of COPD
Gold Guidelines Pulmonary Function Tests - Spiromatry airflow limition - FEV1, FVC, FEV1/FVC ratio. Pre and post bronchodilator Post brocnhoddilator <0.7 = obstruction Staging/Severity Mild FEV1 >80 percent Moderate 50-80 Sever 30-50 Very sever FEV <30
43
What is the Haldane Effect
With COPD patients DoxyHb binds to C02 more than OxyHb which increasing OxyHb = more c02 disosolved in blood as HCO+ more PaC02 So more oxygen will bind to hemoglobin in COPD which causes less C02 removal as there is less room for C02 to bind and results in increased C02 in blood PaC02 Will also decrease Hypoxic pulmonary vasoconstriction which can lead to more dead space.
44
What is Hyperventilation Syndrome
Inappropriate minute ventilation resulting in respiratory alkalosis Associated with anxiety, panic attaches
45
How much Cerberal blood flow is reduced with 1mm decrease inPaC02
2 percent
46
What causes tetany and parasthesia in hyperventilation syndrome
Call in carbon dioxide tension leads to respiratory alkalosis.. Alkalosis produces hypocalcemia which induces the tentany of muscles and parasthesia. Muscle spasms. In Alkalosis calcium binds more to albumin decresing ironized calcium
47
What are different transudative Plerual effusions
``` Heart failure Hypoalbuminemia Nephrotic syndrome ( protein loss) Liver Failure ( decreased albumin and portal hypertension Peritoneal Dialysis Atelectasis ```
48
Examples of Exudative Effusions
Infection Malignancy Chylothorax ( lymphatic fluids leaks in the pleural space ) - sever cough and lymphatic flow disorder
49
How much fluid does the pleural lining produce
10ml daily production and absorption produced by serious membrane Can see on chest X-ray with 200ml Ap and 50ml PA CT ultrasound nor sensitive
50
What are Contraindications for thoracocentesis
Overlying infection To small of an effusion / Unsafe Coagulopathy
51
Different types of Effusion
Simple = fee flowing aka uncomplicated Complicated= infectious with loculations Empyema ( infections) - low glucose, low PH High Protein
52
Define Pneumona
Infection of the lung parenchyma - from a bacterial, viral or fungal infection CAP, VAP HAP important for anti-microbial
53
Definition of HAP timeline
>48 hours after admission to hospital
54
Definition of VAP
> 48 hours after being on a ventilator
55
Definition of CAP
Less than 48 hours or presented with
56
Antibiotics for CAP and VAP
CAP - Ceftriaxone and Azithromycin HAP/VAP - Piptaz and Vancomycin (pseudomonas, ESBL , Fungal Cultures poorly sensitive
57
What is Cardiogenic Pulmonary Edema and some causes
Increased Hydrostatic pressures from high filling pressures of the left atrium and thus high pulmonary capillary pressures Caused by Systolic Dysfunction HFrEF EF<40percent - can be ischemic or nonischemic Diastolic Dysfunction HFpEF EF<60 percent - HTN, Renal failure, restricted cardiyopathy Valvular disease - mitral regurgitation and mitral stenosis ect
58
What can precipitate Heart failure
1) Increased Preload - Fluids, Salt intake, non compliant medications - Acute Aortic Regurgitation or mitral regurgitation 2) Decreased Contractility - ischemia/infarct 3) Increased Afterload - HTN - Aortic stenosis - non compliance to meds 4) Tachyarrhythmias - Rapid Afib 5) Dynamic LVOT obstruction (SAM) systolic anterior motion
59
When level is helpful for BNP in diagnosing heart failure
<100 pg/ml BNP helpful to rule out HF 100-400 not helpful what the heck >400 Likely HF
60
What are some findings of Heart Failure on a CXR, Ultra Sound
Cardiomegaly, Pleaural effusion, vascular redistribution, central opacities, Kerley A lines POCUS - Decreaed EF - FULL IVC - diffuse B lines Don’t forget PA catheter with Increaed Wedge pressure is surrogate for LVEDP and LA PW Pressure greater than 20-25mm Hg= cardiogenic
61
Pulmonary Embolism Scoring systems
PERC WELLS YEARS (for pregnancy)
62
Work up For PE
``` D-DImer to help rule out patieints - Troponin, BNP - CBV- leukocytosis is non common - lactate, mixed venous, renal and liver ailure, ABG coats ECG CXR CT Angio (gold standard ( VQ scan ECHO ```
63
Most common ECG Changes
``` Sinus tachycardia= most common RAD RBBB- complete or incomplete - TWI- V1-V4, inferior leads - Rapid AF - non specific it T wave changes Right Arial Enlarchment S1Q3T3 ```
64
Define massive PE and Submassive PE
MASSIVE= SBP<90 for 15 minutes or longer or requiring inotropic support - not caused by bradycardia or pulseless ``` Submassive PE- HD stable but no signs RV dysfunction - Troponin - ECG ECHO - BNP ```
65
Treatment for Massive and Submassive PE
Massive can get fibrinolytics Submassive antioagulatons Both can get catheter direct fibrinolytic or surgical embolectomy
66
How to Manage Acute RV Failure
1) Optimize Preload - passive leg raise small IV blouses 2) Minimize RV afterload - Avoid Hypoxia/Hypercarbia, Acidosis ( will cause pulmonary vasoconstriction by activation voltage baited calcium channels and increases cytotoxic calcium) - Keep alveoli recruited but not overdistened which can compresses capillaries - Minimize sympathetic activation - Vasopressin and Milrinone won’t have as much direct affects on pulmonary vascular use - inhaled nitric oxide (pulmonary vasodilator) - DEL WITH CLOT Optomize LV afterload - - Cornary and end organ copper fusion, norepinephrine vasopressin Contractility - Milrinone, dobutamine, epinephrine Rate and Rhythm - Sinus, not to fast (need diastolic filling)
67
Definition and pathophysiology of Asthma
Reactive Airway disease associated with airway inflammation, intermittent airflow obstruction and bronchial hyper responsiveness Hyper reactivity and inflammation associated with IGe, Mast Cell and eosinophils activations (degranulations) releasing histamine
68
What is a Respiratory Antibiotic Resistant Pathogen
Bacteria that develop defence mechanisms again these drugs making them less effective Examples are beta lactate antibiotic are penicillins and cephalosporins - bacteria produce beta lactamases= enzymes that break the beta lactate structure of the antibiotic - ESBL extended spectrum beta lactamase Need to use antibiotics like carbapenems
69
What are the 4 different Bacteria
1) Gram Positives 2) Gram Negatives 3) Atypicals 4) Anaerobes
70
Describe Gram Positive Bacteria
Colonized in Oral, nasal, ( Staph and strep Skin- Staph corynebacterium GI- Colostridium, enterococcus Disease of ORAL, Upper airway, CAP, HAP , SKIN, Soft Tissue , GI/ GU
71
Gram Negatives. (KEEPS)
- Kleibsiella - Enterbacter - E. coli - Enterococci - Proteus - Serratia GI/GU, UTI, Appendicitis, Cholecycitis.
72
Atypicals
Don’t stain with gram stain Chlamydia, legionella, mycoplasma - no normally colonized Cause cause CAP Responded well to macrolides - azithromycin Does no grow easy in cultures treated empirically
73
Anerobes
Need special medium to grow cultures Can be gra positive or negative GI GU bugs CDIF, Bcteroids, fusobacterim
74
CAP/ HAP/VAP antibiotics CAP - Ceftriaxone, Azithromycin to cover gram positives and Atypicals (Strep Pneumonia) HAP/VAP- Piptazo for gram negative, Consider antibiotic resistant pathogens. MRSA, ESBL, Psudomona, Strentoprhomonas
Same as above
75
MRSA pneumonia Antibiotic
Vancomycin and Linezolid
76
Definition of Pulmonary HTN
Mean pulmonary arterial pressure of > 20mmHG Normal 10-15 mm Hg
77
What is LaPlaces Law
Wall Tenson (T)= Transpural Pressure (P)xRadius(r)/ 2x H. Wall thickness
78
How to Treat RV Failure
1) Monitor IV, 02, 2) arterial line 3) CVC can be used for mixed venous measurements ``` CRAP approach Contractility Rate and Rhythm Afterload Preload ``` Contractility - IF RV Failure secondary to Inferior MI get right side ECG - suspect RV involvement with STE V1, STD V2, III>II ACS Managment 1) DAPT, 60units/kg Heparin followed 12U/kg infusion Inotropic support - EPI if bradycardia - Milrinone 0.125mcg/kg start Pulmonary Vasodilator - Dobutamine 2.5mg/kg start will decrease afterload and give contractility Want to optimize diastolic filling time( helps perfuse Coronary Arteries (80-100) Amiodarone go to for antiarrythmic 150g IV/10 min followed by 1mg/min
79
How to minimize Pulmonary Vascular resistance and Optomize afterload for RV failure
1) Hypoxia, hypercarbia, acidosis, derecruitment, overdestention, and sympathetic stimulation can all INCREASE AFTERLOAD 2) Vasopressor of choice= Vasopressin spares pulmonary vascular but will still need norepinephrine MAP GOAL 65 to ensure coronary perfusion Pulmonary vsoldialtors iNO, IF PE- FIx clot- thromboylysis ACS Inferior MI RV involvement- PCI/Thrombolysis
80
PRELOAD for RV FAILURE AND PULMONARY HTN
RV more Preload Dependend (more than LV)- also sensitive to overload 1) use gentle BOLUS 250 CC POCUS ( look for Septal bowling during diastole suggestive of volume overload - patient may need diuresis
81
How to Ventilate and Intubated RV Failure
1) Minimize peep to allow adequate venous return and Preload 2) Minimize airway pressures and tidal volumes 3) Minimize hypoxemia, hypercarbia and academia 4) Try to avoid intubation and if you do all your medications will cause hypotension 5) Ideally awake intubation to minimize recruitment, Apneic time 6) As RICO says defend the MAP
82
Define Cystic Fibrosis
Autosome recessive process, common in Caucasian population It is cased by mutation in CF tranmembrane conductance regulator (CFTR) protein - deranged transport of CL- which causes thickened sections in lungs, pancreas, liver, intestines, sweat glands, reproductive system Screened in Newborn
83
What are Complications with Cystic Fibrosis
Thick, viscous secretions> very difficult to clear= airway obstructions, airway destruction, bronchiectasis - cough, wheeze, SOB Patients are usually on chronic antibiotics- often resistant to pathogens, pseudomonas MRSA Chronic lung disease = PULMONARY HTN Can have Pneumothorax, hemoptysis, allergic bronchopulmonary aspergillosis
84
Treatment for Cystic Fibrosis
Secretion Clearance - chest physiology - saline nebulizers Bronchodilators/Corticosteroids, Azithromycin, nsaids Antibiotics, vaccinations and transplant
85
Define Interstitial Lung Disease
Also known as diffuse parenchyma lung disease 1) DPLD caused by drugs or associated or rheumatic disease 2) Idopathic interstitial pneumonia 3) Granulomatus All these lung disorders can cause fibrosis, interstitial pneumonia bronchiolitis SOBOE, cough, associated with connective tissue disease (sarcoidosis, vascultitis) - exacerbated by smoking, drugs (restrictive lung disease)
86
Treatment for interstitial lung disease
Steroids, support care, Antibiotics ARDS ventilation strategy
87
What are some disease of the chest wall
Kyphosis, scoliosis (cerebral palsy Muscular dystrophy), Ankylosing spondyltitis( arthritis/inflammation of spine Trauma - flail chest, rib fractures Obesity, acute abdomen, burns, ascites
88
What do chest wall disease do to your FRC Total lung capacity
Decrease them both
89
Difference between primary and secondary spontaneous pneumothorax
Primary spontaneous pneumothorax that happens with a normal lung ie smoking, genetic, young mails Secondary spontaneous pneumothorax is secondary to a diseased lung Ex COPD, TB, Cystic fibrosis, Interstital lung disease lung diseae
90
What is Tuberculosis
Myobacterium tuberculosis - leading infectious cause of death worldwide can be latent, subclinical or active Can be pulmonary or extra pulmonary in the CNS, Lymph nodes, bones, abdomen pericardium or urogenital Latent phase asymptomatic, Symptoms fever cough pleuritic chest pain LNA malaise HIV< immunocompromised, IVDU, CKD DM( chronic disease) Asia affairs South American immigrations, jails

CCP 2 Review (2 decks)

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