Respiratory (11%) Flashcards
PE (everything but treatment)
• Risk factors – venous stasis, immobility, recent surgery, malignancy, hx of VTE
• Virchow’s triad – inflammation, hypercoagulability, and endothelial injury
• Symptoms – abrupt onset of chest pain, SOB, and hypoxia are classic symptoms
o Other – anxious, wheezing, hemoptysis, tachypnea, diaphoretic
• Diagnostics – CTA (PE protocol)
PE Treatment
o Respiratory support
o Hemodynamic support – cautious IVF (can overload RV), levophed, ECMO?
o Anticoagulation
o Reperfusion
o Chronic phase – 3 months anticoagulation if provoked or indefinite anticoagulation if unprovoked (rivaroxaban, dabigatran, apixaban)
Pulmonary Edema
Excess fluid collects within the lungs, leading to impaired gas exchange and respiratory distress
Cardiogenic causes – typically r/t volume overload – valve disorders, acute MI, left-sided HF
Non-cardiogenic causes – typically r/t injury to endothelium – ARDS, PE, opioid overdose, TRALI
Symptoms – acute dyspnea, anxiety, increased WOB, tachycardia, crackles, pink frothy sputum
Treatment – reduce pulmonary fluids – oxygen (non-invasive or invasive helps reduce fluid in vasculature), loop diuretics, nitrates, inotropes
Acute Respiratory Distress Syndrome (ARDS)
An inflammatory lung condition caused by direct or indirect injury to the lungs (infection, trauma, hypotension)
Diagnostic inclusion criteria – acute onset of: bilateral diffuse infiltrates not caused by pulmonary edema, PAWP/PCWP < 19, PaO2/FiO2 ratio of ≤ 200
Treatment – treat underlying cause, support oxygenation and ventilation
Initial vent management strategies – calculate predicted body weight, select vent mode, initial tidal volume of 8 ml/kg (will have to come down to 6 ml/kg), set initial RR at approximately baseline
Goals of vent therapy – minimum PEEP of 5, plateau pressure ≤ 30
Check plateau pressure every 4 hours – if > 30, decrease TV by 1 ml/kg (minimum of 4 m/kg), if < 25, increase by 1 ml/kg (until plateau pressure > 25 or TV is 6 ml/kg)
Monitor pH – if pH 7.15-7.30 increase RR; if pH < 7.15 increase RR to 35 and consider increasing TV by 1 ml/kg until pH > 7.15; if pH > 7.45 decrease RR if able
Respiratory Failure
Hypoxemic – PaO2 < 60 mmHg and PaCO2 normal or < 50 mmHg
Hypercapneic – PaO2 < 60 mmHg and PaCO2 > 45 mmHg
Can be caused by numerous things – COPD, drug overdose, asthma, obesity, chronic bronchitis, rib fractures, neuromuscular disease, PE, ARDS, pulmonary edema, shunting
Stable – treat underlying cause, aggressive respiratory care
Unstable – BiPap or intubate, aggressive respiratory therapy, treat underlying cause
Pneumothorax
Can be caused by trauma (blunt is most common) or spontaneous (COPD, asthma, tall/thin males
Air-trapping and increased pressure can cause mediastinal shift → compression of great vessels and heart (aka tension pneumothorax)
Symptoms – acute onset of SOB, tachypnea, pleuritic chest pain, hyperresonance to percussion, absent breath sounds on injured side
Tension pneumo findings – severe respiratory distress, signs of obstructive shock, hypotension, distended neck veins (late sign), tracheal deviation (late sign)
Diagnostics – CXR is diagnostic of choice, will see air in the pleural space with absence of lung markings
Treatment – needle decompression (first line for primary pneumo, minimal symptoms), chest tube placement (definitive treatment for those with symptoms)
Tension pneumo treatment – emergent needle compression in 2nd ICS MCL followed by chest tube insertion
Angioedema
- An allergic reaction that affects parts of the face like eyes and lips
- Symptoms – swollen face (especially eyes, mouth, lips, tongue), swelling in mouth, throat, or airway
- Management – ABCs!, a definitive airway must be established if edema is extensive or progressing; antihistamines (diphenhydramine, loratadine), H2 blockers (ranitidine or cimeditine), epinephrine, steroids
COPD
- Airflow limitation that is not fully reversible
- Risk factors – tobacco smoke, environmental exposures, occupational exposures, genetics
- Symptoms – chronic cough, chronic sputum production, activity intolerance, symptom progression
- Individuals with COPD with a hx of ≥ 2 exacerbations in the last year, FEV1 < 50%, and/or hospitalization for COPD in the last year are at highest risk for COPD exacerbation and COPD death
- Diagnosis – spirometry is required – FEV1:FVC < 0.70 (70%) post-bronchodilator
- Severity of COPD is determined by FEV1 (GOLD category)
- Initial treatment – low risk/less symptoms – SABA; low risk/more symptoms – LABA + long-acting muscarinic antagonist (tiotropium [Spiriva])
Indications for hospital admission in COPD exacerbation
- Marked increase in symptom intensity
- Acute respiratory failure
- New onset of physical signs
- Failure to respond to initial treatment
- Insufficient home support
Indications for ICU admission in COPD exacerbation
- Severe dyspnea not responding to initial therapy
- Change in mental status
- Worsening hypoxemia (PaO2 < 40 mmHg)
- Worsening acidosis (pH < 7.25)
- Invasive mechanical ventilation
GOLD categories for COPD
- GOLD 1 (mild): FEV1 ≥ 80%
- GOLD 2 (moderate): 50% ≤ FEV1 < 80% predicted
- GOLD 3 (severe): 30% ≤ FEV1 < 50% predicted
- GOLD 4 (very severe): FEV1 < 30% predicted
COPD Exacerbation
- Symptoms – chronic symptoms increase – cough increases in frequency and severity, sputum production increases in volume or changes, dyspnea increases
- Exam findings – diffuse wheezing, tachypnea, features of respiratory distress (pursed lip breathing, accessory muscle use), signs of impending respiratory arrest
- ABG: PaO2 < 40 mmHg or PaCO2 >45 and pH < 7.35 indicates respiratory failure
- Treatment – SABA (albuterol), corticosteroids (prednisone 40 mg daily x5 days), +/- mechanical ventilation, +/- antibiotics
- Give antibiotics if – increased dyspnea, sputum production, and/or increased sputum purulence; and give to anyone mechanically vented
- Antibiotics to give – azithromycin 500 mg BID x3 days, cephalosporin, or Cipro if vented (500-750 mg BID x 7-14 days)
Asthma
- Bronchial hyper-responsiveness and underlying inflammation
- Symptoms – recurrent cough, wheeze, SOB, chest tightness, symptoms can worsen at night or with exercise, airflow obstruction is partially reversible after SABA
- Diagnosis – spirometry is needed to make diagnosis – increase in FEV1 ≥ 12% from baseline after SABA
- Peak flow meter is used for monitoring
- Treatment consists of SABA (acute reliever) + controller for persistent asthma (inhaled corticosteroid – fluticasone, bedusonide))
- Step-up therapy if not well controlled on current regimen
Asthma Exacerbation
- Moderate – dyspnea interferes with usual activity, peak flow 40-69%, requires provider evaluation, SABA, systemic corticosteroids (prednisone 40-60 mg/day x 3-10 days [average 5-7 days])
- Severe – dyspnea at rest, to ED, likely hospitalization, peak flow < 40%, SABA + systemic corticosteroids + adjunct therapies
- Warning signs of impending respiratory arrest – confusion, absence of wheezing, bradycardia, paradoxical thoracoabdominal movement, peak flow < 25%
Interstitial Lung Disease
- Lung tissue becomes damaged and scarred, thick/stiff lung tissue
- Risk factors – environmental toxins (ex: pesticides, asbestos), agriculture and farming, sand/silica, genetics (RA, sarcoidosis), medication-induced (nitrofurantoin, chemo [bleomycin])
- Symptoms – CHRONIC EXERTIONAL DYSPNEA, CHRONIC DRY COUGH, fatigue, bilateral Velco-like crackles, clubbing of nails
- CXR – may look normal in early stages and may progress to reticulonodular infiltrates (ground glass)
- CT – diagnostic of choice, “HONEYCOMBING” is characteristic of pulmonary fibrosis
- Acute management – high dose steroids, antitussives, and antibiotics are ineffective but are still the mainstay of treatment; ABCs – supplemental O2; anxiolytics/morphine
Sleep Apnea
Caused by narrowing of respiratory passages
Risk factors – anatomically narrowed upper airways, obesity, alcohol use, sedative use, nasal obstruction
Symptoms – daytime sleepiness, headaches, fatigue, snoring, breath cessation, inability to concentrate, nocturnal gasping/choking
Exam findings – large tonsils, long uvula, prominent tongue, poor nasal air flow, “bull neck” appearance
Diagnostics – POLYSOMNOGRAPHY may show apneic episodes, desaturations, brady- or tachyarrhythmias
Management – CPAP (FIRST LINE), WEIGHT LOSS, avoid alcohol, surgery, inspire devices
STOP BANG questionnaire
STOP BANG Questionnaire for OSA
Snoring – do you snore loudly? Tired – do you often feel tired during the day? Observed – has anyone observed you stop breathing during sleep? Pressure – do you have HTN BMI – BMI > 35 Age – age > 50 Neck circumference - > 40 cm Gender – male < 3 yes answers = low risk for OSA ≥ 3 yes answers = high risk for OSA
Pleural Effusion
Transudate (“water”) vs. exudate (“cellular material”) effusion
Transudative – CHF, constrictive pericarditis, cirrhosis
Exudative – lung parenchymal infection, malignancy, PE
Symptoms – dyspnea, cough, chest pain (stabbing or sharp, worse with deep inspiration), decreased tactile fremitus, eogphony
Diagnostic – thoracentesis is diagnostic study of choice for all effusions > 1 cm
Fluid comparison – transudative (specific gravity < 1.016, protein < 3.0, LDH < 200) vs. exudative (specific gravity > 1.016, protein > 3.0, LDH > 200)
Treatment – if known to be from fluid overload (CHF or cirrhosis) try diuresis; for symptomatic effusions perform therapeutic thora +/- thoracostomy tube and treat underlying process; for infections effusions treat with antibiotic therapy
Pulmonary HTN
Symptoms – dyspnea, fatigue, dizziness, chest pain, palpitations; chronic pulmonary HTN – loud S2, JVD, tricuspid regurg murmur, peripheral edema
Exam findings – pulmonic regurg (Graham Steele murmur), tricuspid regurg, JVD, S3 gallop, hepatomegaly
TTE – initial investigation of choice
Right heart catheterization – diagnostic
Management – ICU monitoring, oxygen, hemodynamic optimization (norepi +/- vaso), fluid optimization (diuretics +/- UF/CRRT), pulmonary vasodilators (inhaled nitric oxide), phosphodiesterase inhibitors (sildenafil, tadalafil), consult pulmonology
Community-Acquired Pneumonia
- Most common pathogens – strep. pneumoniae (#1), H. influenzae (#2)
- Recommended length of therapy – at least 5 days with evidence of increasing stability (average 5-7 days)
- Treatment (no comorbidities) – macrolide (azithromycin, clarithromycin or erythromycin) or doxycycline
- Treatment (+ comorbidities [i.e., COPD, DM, renal or heart failure]) – Levaquin or macrolide (azithromycin) + amoxicillin-clavulanate [Augmentin]
CURB-65 Criteria for CAP Hospitalization
- Confusion – any change from baseline or confusion
- Uremia – BUN > 19
- Respiratory rate – RR > 30
- Blood pressure – SBP < 90 and DBP < 60
- 65 years old – age ≥ 65 years
- Scores: 1 = outpatient treatment, 2 = admit to inpatient, ≥ 3 = admit to ICU
PSI/PORT Scoring for Hospitalization
- 0 = class I, outpatient treatment
- < 70 = class II, outpatient treatment
- 71-90 = class III, outpatient or inpatient treatment
- 91-130 = class IV, inpatient treatment (ICU?)
- > 131 = class V, inpatient treatment (ICU?)
Empyema
- Collection of pus in the space between the lung and the inner surface of the chest wall
- Usually caused by lung infection
- Risk factors – bacterial pneumonia, TB, chest surgery, lung abscess, chest trauma
- Symptoms – chest pain (worse with deep breath), dry cough, excessive sweating
- Treatment – chest tube to drain pus, antibiotics to control infection
Hospital-Acquired Pneumonia
- Low risk mortality risk and no MRSA risk factors – many options; choose one, Zosyn 4.5g IV q6h, Levaquin 750 mg IV daily, plus many more
- Risk of MRSA – Zosyn 4.5 IV q6h or Levaquin 750 mg IV daily + vancomycin 15 mg/kg IV q8-12h
- High risk of mortality – Zosyn 4.5g IV q6h + Levaquin 750 mg IV daily + vancomycin 15 mg/kg IV q8-12h
- Duration of therapy – follow procal levels, discontinue when PCT ≤ 0.25 (generally 8 days for non-MRSA, 14 days for MRSA)
- Tailor therapy to culture results
Ventilator-Associated Pneumonia
- Same pathogens as HAP but with higher likelihood of pseudomonas and MRSA
- Treatment consists of choosing 3 – Vanco 15 mg/kg + β-lactam (Zosyn 4.5g IV or cephalosporin 2g IV q8h) + non-β-lactam (Levaquin 750 mg IV daily or ciprofloxacin 400 mg IV q8h)
- Prevention is key – prevent intubation, good hygiene, good oral care, etc.
- Duration of therapy – follow PCT, discontinue therapy when PCT ≤ 0.25
Aspiration Pneumonia
- Likely pathogens for pneumonia – staph. Aureus, hemophilus, and strep
- Risk factors – cognitive impairment, pulmonary disease (on vent., poor cough), mechanical (NG, OG, trach., tube feeds)
- Manifestations – coughing, SOB, chest pain, feels like something is stuck, hypoxia, rhonchi, rales, respiratory distress
- Management – ABCs, prophylactic antibiotics until definitive evidence of no infection, using cuffed ETT, utilize speech therapy, prevention
Lung Contusion
- Injury to lung parenchyma
- Consequence of blunt chest trauma
- Develops over the first 24 hours
- Symptoms – chest wall pain, dyspnea, tenderness of palpation, paradoxical chest wall excursion, signs of ventilatory insufficiency (cyanosis, tachypnea, accessory muscle use)
- Diagnostics – CXR, monitor for “blossoming”
- Treatment – ABCs, supportive care (pulmonary hygiene, pain control), O2, intubation or mechanical ventilation, monitor for complications (ARDS, pneumonia)
Rib Fracture
- Most common injury sustained following blunt chest trauma
- Symptoms – pain, dyspnea, tenderness to palpation, crepitus, chest wall deformity, paradoxical chest wall excursion (textbook finding with flail chest)
- Management – ABCs, multimodal pain control (ex: Tylenol, gabapentin, lidocaine patches, flexeril, etc.), aggressive pulmonary hygiene (incentive spirometry, cough and deep breath, mobility), consult trauma surgery for potential operative fixation, thoracostomy tubes as indicated
Hemothorax
- Blood accumulation in pleural space typically caused by some form of traumatic injury (penetrating trauma is more common than blunt)
- Symptoms – dyspnea, tachypnea, pleuritic chest pain, dullness to percussion, decreased breath sounds on injured side
- Diagnostics – CXR is diagnostic study of choice (blood in pleural space = white out)
- Treatment – chest tube placement (wall suction → water seal → discontinue) with follow-up CXR
