Respiratory Flashcards
trepopnea =
dyspnea worse when lying on one side
resp distress vs resp failure
resp distress = subjective dyspnea and signs of inc wob
resp failure= lungs and vent muscles cannot move enough air adequately oxygenate blood and remove co2
what causes depressed LOC in resp failure and what causes agitation
hypercpania = dLOC
hypoxemia= agitation
5 causes of hypoxemia
hypoventilation
rt-to-lt shunt
vq mismatch
diffusion impairment
low inspired fio2
causes of hypercapnia
depressed central reps drive
CNS structural lesions
drug depression of resp entre eg opiods, sedatievs
thoracic cage d/o
morbid obseity
neuromuscular impairement
toxins: tetanus, botulism
COPD
treatment of hypercapnia
increase ventiliation by increasing RR or tidal volume, using NIPPV, mechanical ventilation etc
define acute, subacute and chronic cough. when to xray chornic cough
acute <3/52, subacute 3-8/52, chronic >8/52
xray chronic cough at 8 weeks
what is central cyanosis
blueish hue of mucous membranes and tongued/t inadequate pulm oxygenation
*differs from peripheral which is usually vasoconstriction (anything causing central will cause peripheral but not other way around)
pleural effusion vs hemo/pneumo
pleural effusion = fluid in potential space between visceral and parietal pleura
hemo/pneumo = inside pleural space
causes of pleural effusoins
transudative: heart failure, cirrhosis, nephrotic syndrome
exudative: malignancy, pneumonia with parapneumonic effusion, PE
transudative vs exudative criteria
lights criteria, exudative if one of:
-pleural/serum protein >0.5
-pleural/serum LDH >0.6
-pleural LDH > 2/3 ULN of serum LDH
standard tests to send for pleural effusion
pleural fluid: gram stain and culture, cell count, protein, LDH, glucose, cytology
serum: LDH, protein
mgmt of pleural effusion
if clincially from HF, can just tx HF and rpt xray, otherwise get diagnostic thora
therapeutic thora if pt has dyspnea, drain up to 1.5L (more can lead oto rexpansion pulm edema)
definition of massive hemoptysis
no universally accepted defn.
-100-1000 mL/24 hr, generally midpoint of 600 mL/24 h accepted
-basically, any bleeding that is life threatening.
90% of hemoptysis comes from?
bronchial arteries
2 reasons COPD pre-disposes to hemoptysis
- neoangiogenesis of fragile vessels to supply chronic inlfamm
- can lead to bronchiectasis which is big risk factor
some causes of hemoptysis
infection: bronchitis, PMA, tuberculosis
lung dz: COPD, bronchiectasis
vascular dz: PE, fistulas
lung cancers
cardiac dz: CHF, CHD, pulm HTN
toxin inhalation: cocaine, meth, heroine etc.
trauma: penetrating injury, contusion, ruptures vessel from decel etc.
w/u minor self limiting hemoptysis
H+P, CXR (will reveal dx 50% of time), f/u PCP or resp depending on findings and suspected dx, if suspect acute bronchitis, f/u PCP
mgmt of massive hemoptysis
assess airway, intubate prn, lay pt affected lung down once tubed, can also intubate mainstem bronchus of affected lung, hopefully rt side. then resuscitate with blood products, then arrange for bronchoscopy vs CT scan vs thoracic surgeon vs respirology
acute bronchitis = ?
self-limiting infection of large airways, presents like cough (+/- fever) without evidence of pneumonia
common causes of bronchitis
most viral: influenza A&B, coronavirus, rsv, adenovirus, rhinovirus
bacteria ID’d in 6% of pts, much higher in COPD
clinical features and duration of acute bronchitis
fever, mild dyspnea, cough (purulent or non-purulent)… last for > 5 days to 3-4 weeks
common cold most causative agents (3)
rhinovirus, coronavirus, adenovirus
symptoms and time course of influenze
fever, malaise, chills, myalgias, HA, sore throat, dry cough rhinitis and fatigue
symptoms can las up to two weeks or longer usually malaise is last to go.
persons at high risk for serious/complicated influenza
children <5 (esp <2)
age >65
chronic comorbs
immunosuppressed
pregnant or 2 wks postpartum
nursing home reisdents
morbidly obese
tx of influenze
oseltamivir 75 bid X5days, ideally started within 48 hrs of symptom onset. can start later too in pts at risk of complication.
PEP 75 mg od 7/7
causative agent in pertussis
Bordetella pertussis
symptoms of pertussis
initially presents like common cold, but then after about 1 week, you get prolonged paroxysms of cough
tx of pertussis
azithro 500 od X1 day then 250 od @ 4 days
alternative is septra or erythromycin/clarithromycin
can prophylaxs against close contacts too
how to dx pertussis
often clinical if known outbreak or known contact but also done by nasopharyngeal swab
CAP vs HAP vs VAP
CAP= not hospitalized or in LTC > 14 days pre infection
HAP: infection occuring >48 hrs after admission
VAP: new infection occudin > 48 hrs after ETT
3 atypical pneumonia pathogen
legionella pneumoniae, mycoplasma pneumoniae, chlamydia pneumoniae
gram positive cocci in clusters?
staph aureus
gram positive diplococci?
strep
CURB 65 score
confusion, urea > 7 mmol/L, resp rate >30, SBP <90, age >65
one or less low risk, 2 is moderate, 3 or more is high risk
in whom cxr can be normal despie having pneumonia
severe immunocomp (AIDS) or neutropenia
asplenic pts are at risk for what pneumonia and why?
strep pneumo, klebsiella and H influnza, b/c they are encapsulated
what makes atypicals atypical?
they don’t have a cell wall, therefor don’t respond to beta lactams
Aspiration vs aspiration pma vs aspiration pneumonitis
- GI contents in lung
- When they cause infection
- When they cause inflammation
RF for aspiration
history of same
aLOC
full stomach
GI disease
neuromuscular dz
abnormality of airway
G or JG tubs
prolonged supination
poor oral hygiene
advanced age or dementia
a few causes of non-infectious pulmonary infiltrates
-pneumonitis (chemical, radiation, drug induced)
-sarcoid
-cancer
-ARDS
-fat embolie
alveolar hemorrhage
-cryptic organizing pneumonia
causes of empyema (which = pus in pleural space)
pneumonnia/parapneumonic, iatrogenic, trauma, esophageal perf, extension of intrabdominal surgery
dx of empyema?
aspiration of pus from pleural space, cxr can suggest dx but makes it hard to differentiate effusion vs empyema, CT can differentiate the two
TB bacterium?
mycobacterium tuberculosis
RF for TB?
immigrant from prevalent area
immunocomp
older age
sud
tobacco use
malnutrition
systemic dz (DM, CKD)
crowded living coniditions
healthacare worker
travel to endemic areas
3 stages of TB and general vibe of each
primary infection –> usually asymptomatic, immunocomp host contains bacteria into granulomas in lungs
latent
active disease –> when latent becomes active, often due to host becoming immunocomp
extra pulmonary manifestations of TB?
-meningitis
-pleural effusion
-miliary TB (disseminated causing hematologic abn, splenomegaly, adenopathy, hyponatremia, millet seed xray)
-bone –> OM, OA, potts disease
testing for TB:
IGRA or tuberculin skin test which can look for latent dz, IGRA is not cross reactive with tuberculin vacccine
active TB: sputum stain for AFB
tx of active TB
isoniazid, rifampin, pyrazinamide, ethambutol
primary vs secondary PTX
primary= occur in absence of lung dz,
seocondary = occur with lung dz,
can be primary or secondary spontaneous vs traumatic
RF for primary spontaneous PTX
cigarettes, marfans, MVP, male gender, changes in ambient pressure
causes of secondary spontaneous PTX
airway dz: COPD, asthma, CF
interstitial lung dz: sarcoid, IPF
infection: HIV, TB, lung abcess
connective tissue: marfan’s, EDS
cancer: lung primary or mets
%age of secondary spontaneous PTX associated with hemopneumo
5%
what is deep sulcus sign?
indicated PTX in supine cxr
what defines a “small” PTX?
< 20% or < 3 cm apex to cupula or < 2 cm interpleural distance at hilum
treatment options for primary spontaneous PTX
think algo from EM cases:
definitions: mildly symptomatic = normal vitals, pain controlled, can mobilize
if small and mildly symptomatic –> obc and rpt cxr in 4 hours. put on supp o2 while observing
if large or symptomatic –> small bore chest tube or needle asp –> rpt cxr in 1 hour
** look at whole algo**
secondary spontaneous PTX mgmt
small size catheter or chest tube and admit with water seal or heimlich
mgmt of large (primary or seconadry) or bilateral PTX
chest tube and admit
maybe dont need to admit the large primary spont
walk through needle aspiration of PTX
freeze down to pleura, used 2nd interspace mid clav or 4th mid axillary. 18G over the needle cath, long enoug to get in. insert while aspirating, once air back sdle soft sheath into pleural cavity, attach 3 way stope cock and IV tubing aspirate until resistance felt.
how long to abstain from flying after ptx
1-2 WEEKS
suction settings for water seal?
10-20 mmHG
wheeze in severe asthma?
in advanced aiwary obstruction, you can have absence of wheeze, aka “silent chest”
Peak flow and symptoms and asthma severity
> 70 % predicted = mild = dyspena with activity
40-69= moderated = dyspnea limits activities/dyspnea with limited activities
20-40 = severe = dyspnea at rest, cannot speak in full sentences.
<20 = life threatening = too dyspneic to speak
asthma mimics
acute heart failure
upper airway obstruction
PE
fb aspiration
airway tumors
interstitial lung dz
asthma medications
MDI or nebs - ventolin/atrovent
oral or IV steroids
IV magnesium
EPI
Ketamine
IV salbutamol
inhaled anesthetics
magsulf dose in asthma
2g over 20 mins
RF for severe asthma/death from asthma
hisotry of hospitalization
>3 ED visits in the last year
>2 SABA cannisters/month
low SES
illicit drug use
medical or psych comorb
difficulty perceiving symptoms severity
investigation to consider in severe asthma
ABG/VBG, PaCO2 > 42 think of potential for resp failure (bc fatiguing, co2 should be low!)
Best way to deliver medications in asthma
MDI! Only use nebs if pt cannot use mdi
Adult ventolin and atrovent doses mdi and neb in asthma exacerbation
Ventolin 10 puffs via MDI q20 min x3 or 5 mg q 20 min neb x3
Atrovent 8 puffs q 20 min x3 or 500 mcg neb q 20 min x3
Ventolin order after initial back to back in adults
4-8 puffs q1h prn
non smoking COPD RF
alpha 1 antitrypsin
occupational dust
chemical exposure
air pollution
COPD diagnosis and severity
FEV1/FVC < 0.7 = COPD
mild FEV1 > .8
mod 50-79
severe 30-49
v severe <30
cxr finding in chronic bronchitis
none unless bronciectasis is present
cxr findings of emphysema (3)
hyperinflation, increased AP diameter (barrell chest), flattened diaphragm
Triggers for aeCOPD
Asthma
Chf
Pma
Viral illness
PE!!!
TB
Acute abdomen
Metabolic disturbance
Imdications for NIPPV in copd
Acidosis
Hypercapnia
Hypoxemia
Severe dyspnea with clinical signs of fatigue or inc wob
Abx in aecopd, indications
If increased sputum parlance and increased dyspnea or inc sputum
hypoxemia PaO2 value on ABG
<60 mmhg
5 causes of hypoxemia and a few examples of each wit a-a gradient
pg 585 FA
ABG definition of hypercapnia
CO2 >45
causes of hypercapnia
depressed central resp drive –> drug OD, OSA
peripheral nerve d/o -> GBS, ALS
neuromuscular junction d/o –> myasthenia
muscle d/o –> muscular dystrophu
lung d/o (COPD, asthma, CF)
chest wall d/o (obesity, kyphoscoliosis)
symptoms of hypercapnia
HA, confusion, lethargy, seizure, coma, cardiovascular collapse
symptoms of hypoxemia
impaired judgement, motor dysfunction, fatigue, drowsiness, respiratory distress, respiratory distress
3 main features of ARDS
radid onset dyspnea, hypoxemia, bilateral pulmonary infiltrates
ARDS triggers
lung: pma, aspiration, embolism (fat, thombus, air), near-drowning, ventilator injury, toxic inhalation
non-lung: TRALI, high altitude, sepsis, DIC, drug reaction, trauma, shock, burn, pancreatitis,
lung protective ventilation in ARDS
tidal volume 6 ml/kg, add PEEP to keep fio2 < 60 %, keep plateau pressure < 30
treatment of ARDS
treat underlying cause, supportive mechanical ventilation
Pao2/FiO2 ARDS severity
arterial oxygen to inspired oxygen:
200-300 mild
100-200 mod
<100 severe
all of these include PEEP of 5
origins of air in pneumomediastinum
most frequently from small alveolar rupture (usually spontaneous, can be from asthma exacerbation, physical exertion, drugs/inhalations or trauma)
, less often from GIT, or large airways
symptoms and dx of pneumomediastinum
pleuritic CP, dx is usually on cxr or CT
mgmt of pneumomediastinum
usually resolve on own, admit for obs if concern for pneumo, mediastinitis, esophageal perf
s/s of mediastinitis
CP, fever, tachycardia, systemic toxic sign
causes of mediastinitis and mgmt
thoracic/cardiac surgery
eso perf
trauma
odontogenic infection
TB
mgmt: broad spectrum ABX, admission, surgical consult bc all cases are life threatening infection
5 groups of pulmonary HTN
1: pulm arterial HTN eg portal HTN
2. pulm venous HTN –> CHF
3. chronic hypoxemic lung dz eg COPD
4. chronic thromboembolic dz
5. miscellaneous eg sarcoid
PE workup
PERC if neg done, if + then wells.
wells high risk –> CTPE
wells low risk –> d dimer then years or age adjusted dimer
