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Respiratory Flashcards

1
Q

trepopnea =

A

dyspnea worse when lying on one side

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2
Q

resp distress vs resp failure

A

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

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3
Q

what causes depressed LOC in resp failure and what causes agitation

A

hypercpania = dLOC
hypoxemia= agitation

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4
Q

5 causes of hypoxemia

A

hypoventilation
rt-to-lt shunt
vq mismatch
diffusion impairment
low inspired fio2

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5
Q

causes of hypercapnia

A

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

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6
Q

treatment of hypercapnia

A

increase ventiliation by increasing RR or tidal volume, using NIPPV, mechanical ventilation etc

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7
Q

define acute, subacute and chronic cough. when to xray chornic cough

A

acute <3/52, subacute 3-8/52, chronic >8/52
xray chronic cough at 8 weeks

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8
Q

what is central cyanosis

A

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)

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9
Q

pleural effusion vs hemo/pneumo

A

pleural effusion = fluid in potential space between visceral and parietal pleura

hemo/pneumo = inside pleural space

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10
Q

causes of pleural effusoins

A

transudative: heart failure, cirrhosis, nephrotic syndrome

exudative: malignancy, pneumonia with parapneumonic effusion, PE

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11
Q

transudative vs exudative criteria

A

lights criteria, exudative if one of:

-pleural/serum protein >0.5
-pleural/serum LDH >0.6
-pleural LDH > 2/3 ULN of serum LDH

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12
Q

standard tests to send for pleural effusion

A

pleural fluid: gram stain and culture, cell count, protein, LDH, glucose, cytology

serum: LDH, protein

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13
Q

mgmt of pleural effusion

A

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)

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14
Q

definition of massive hemoptysis

A

no universally accepted defn.
-100-1000 mL/24 hr, generally midpoint of 600 mL/24 h accepted
-basically, any bleeding that is life threatening.

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15
Q

90% of hemoptysis comes from?

A

bronchial arteries

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16
Q

2 reasons COPD pre-disposes to hemoptysis

A
  1. neoangiogenesis of fragile vessels to supply chronic inlfamm
  2. can lead to bronchiectasis which is big risk factor
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17
Q

some causes of hemoptysis

A

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.

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18
Q

w/u minor self limiting hemoptysis

A

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

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19
Q

mgmt of massive hemoptysis

A

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

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20
Q

acute bronchitis = ?

A

self-limiting infection of large airways, presents like cough (+/- fever) without evidence of pneumonia

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21
Q

common causes of bronchitis

A

most viral: influenza A&B, coronavirus, rsv, adenovirus, rhinovirus

bacteria ID’d in 6% of pts, much higher in COPD

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22
Q

clinical features and duration of acute bronchitis

A

fever, mild dyspnea, cough (purulent or non-purulent)… last for > 5 days to 3-4 weeks

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23
Q

common cold most causative agents (3)

A

rhinovirus, coronavirus, adenovirus

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24
Q

symptoms and time course of influenze

A

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.

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25
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
26
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
27
causative agent in pertussis
Bordetella pertussis
28
symptoms of pertussis
initially presents like common cold, but then after about 1 week, you get prolonged paroxysms of cough
29
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
30
how to dx pertussis
often clinical if known outbreak or known contact but also done by nasopharyngeal swab
31
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
32
3 atypical pneumonia pathogen
legionella pneumoniae, mycoplasma pneumoniae, chlamydia pneumoniae
33
gram positive cocci in clusters?
staph aureus
34
gram positive diplococci?
strep
35
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
36
in whom cxr can be normal despie having pneumonia
severe immunocomp (AIDS) or neutropenia
37
asplenic pts are at risk for what pneumonia and why?
strep pneumo, klebsiella and H influnza, b/c they are encapsulated
38
what makes atypicals atypical?
they don't have a cell wall, therefor don't respond to beta lactams
39
Aspiration vs aspiration pma vs aspiration pneumonitis
1. GI contents in lung 2. When they cause infection 3. When they cause inflammation
40
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
41
a few causes of non-infectious pulmonary infiltrates
-pneumonitis (chemical, radiation, drug induced) -sarcoid -cancer -ARDS -fat embolie alveolar hemorrhage -cryptic organizing pneumonia
42
causes of empyema (which = pus in pleural space)
pneumonnia/parapneumonic, iatrogenic, trauma, esophageal perf, extension of intrabdominal surgery
43
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
44
TB bacterium?
mycobacterium tuberculosis
45
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
46
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
47
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
48
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
49
tx of active TB
isoniazid, rifampin, pyrazinamide, ethambutol
50
primary vs secondary PTX
primary= occur in absence of lung dz, seocondary = occur with lung dz, can be primary or secondary spontaneous vs traumatic
51
RF for primary spontaneous PTX
cigarettes, marfans, MVP, male gender, changes in ambient pressure
52
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
53
%age of secondary spontaneous PTX associated with hemopneumo
5%
54
what is deep sulcus sign?
indicated PTX in supine cxr
55
what defines a "small" PTX?
< 20% or < 3 cm apex to cupula or < 2 cm interpleural distance at hilum
56
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**
57
secondary spontaneous PTX mgmt
small size catheter or chest tube and admit with water seal or heimlich
58
mgmt of large (primary or seconadry) or bilateral PTX
chest tube and admit maybe dont need to admit the large primary spont
59
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.
60
how long to abstain from flying after ptx
1-2 WEEKS
61
suction settings for water seal?
10-20 mmHG
62
wheeze in severe asthma?
in advanced aiwary obstruction, you can have absence of wheeze, aka "silent chest"
63
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
64
asthma mimics
acute heart failure upper airway obstruction PE fb aspiration airway tumors interstitial lung dz
65
asthma medications
MDI or nebs - ventolin/atrovent oral or IV steroids IV magnesium EPI Ketamine IV salbutamol inhaled anesthetics
66
magsulf dose in asthma
2g over 20 mins
67
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
68
investigation to consider in severe asthma
ABG/VBG, PaCO2 > 42 think of potential for resp failure (bc fatiguing, co2 should be low!)
69
Best way to deliver medications in asthma
MDI! Only use nebs if pt cannot use mdi
70
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
71
Ventolin order after initial back to back in adults
4-8 puffs q1h prn
72
non smoking COPD RF
alpha 1 antitrypsin occupational dust chemical exposure air pollution
73
COPD diagnosis and severity
FEV1/FVC < 0.7 = COPD mild FEV1 > .8 mod 50-79 severe 30-49 v severe <30
74
cxr finding in chronic bronchitis
none unless bronciectasis is present
75
cxr findings of emphysema (3)
hyperinflation, increased AP diameter (barrell chest), flattened diaphragm
76
77
Triggers for aeCOPD
Asthma Chf Pma Viral illness PE!!! TB Acute abdomen Metabolic disturbance
78
Imdications for NIPPV in copd
Acidosis Hypercapnia Hypoxemia Severe dyspnea with clinical signs of fatigue or inc wob
79
Abx in aecopd, indications
If increased sputum parlance and increased dyspnea or inc sputum
80
hypoxemia PaO2 value on ABG
<60 mmhg
81
5 causes of hypoxemia and a few examples of each wit a-a gradient
pg 585 FA
82
ABG definition of hypercapnia
CO2 >45
82
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)
83
symptoms of hypercapnia
HA, confusion, lethargy, seizure, coma, cardiovascular collapse
84
symptoms of hypoxemia
impaired judgement, motor dysfunction, fatigue, drowsiness, respiratory distress, respiratory distress
85
3 main features of ARDS
radid onset dyspnea, hypoxemia, bilateral pulmonary infiltrates
86
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,
87
lung protective ventilation in ARDS
tidal volume 6 ml/kg, add PEEP to keep fio2 < 60 %, keep plateau pressure < 30
88
treatment of ARDS
treat underlying cause, supportive mechanical ventilation
89
Pao2/FiO2 ARDS severity
arterial oxygen to inspired oxygen: 200-300 mild 100-200 mod <100 severe all of these include PEEP of 5
90
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
91
symptoms and dx of pneumomediastinum
pleuritic CP, dx is usually on cxr or CT
92
mgmt of pneumomediastinum
usually resolve on own, admit for obs if concern for pneumo, mediastinitis, esophageal perf
93
s/s of mediastinitis
CP, fever, tachycardia, systemic toxic sign
94
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
95
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
96
PE workup
PERC if neg done, if + then wells. wells high risk --> CTPE wells low risk --> d dimer then years or age adjusted dimer

CCFP EM (23 decks)

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