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CCFP EM > Respiratory > Flashcards

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
Q

persons at high risk for serious/complicated influenza

A

children <5 (esp <2)
age >65
chronic comorbs
immunosuppressed
pregnant or 2 wks postpartum
nursing home reisdents
morbidly obese

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26
Q

tx of influenze

A

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

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27
Q

causative agent in pertussis

A

Bordetella pertussis

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28
Q

symptoms of pertussis

A

initially presents like common cold, but then after about 1 week, you get prolonged paroxysms of cough

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29
Q

tx of pertussis

A

azithro 500 od X1 day then 250 od @ 4 days
alternative is septra or erythromycin/clarithromycin

can prophylaxs against close contacts too

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30
Q

how to dx pertussis

A

often clinical if known outbreak or known contact but also done by nasopharyngeal swab

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31
Q

CAP vs HAP vs VAP

A

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

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32
Q

3 atypical pneumonia pathogen

A

legionella pneumoniae, mycoplasma pneumoniae, chlamydia pneumoniae

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33
Q

gram positive cocci in clusters?

A

staph aureus

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34
Q

gram positive diplococci?

A

strep

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35
Q

CURB 65 score

A

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

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36
Q

in whom cxr can be normal despie having pneumonia

A

severe immunocomp (AIDS) or neutropenia

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37
Q

asplenic pts are at risk for what pneumonia and why?

A

strep pneumo, klebsiella and H influnza, b/c they are encapsulated

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38
Q

what makes atypicals atypical?

A

they don’t have a cell wall, therefor don’t respond to beta lactams

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39
Q

Aspiration vs aspiration pma vs aspiration pneumonitis

A
  1. GI contents in lung
  2. When they cause infection
  3. When they cause inflammation
40
Q

RF for aspiration

A

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
Q

a few causes of non-infectious pulmonary infiltrates

A

-pneumonitis (chemical, radiation, drug induced)
-sarcoid
-cancer
-ARDS
-fat embolie
alveolar hemorrhage
-cryptic organizing pneumonia

42
Q

causes of empyema (which = pus in pleural space)

A

pneumonnia/parapneumonic, iatrogenic, trauma, esophageal perf, extension of intrabdominal surgery

43
Q

dx of empyema?

A

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
Q

TB bacterium?

A

mycobacterium tuberculosis

45
Q

RF for TB?

A

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
Q

3 stages of TB and general vibe of each

A

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
Q

extra pulmonary manifestations of TB?

A

-meningitis
-pleural effusion
-miliary TB (disseminated causing hematologic abn, splenomegaly, adenopathy, hyponatremia, millet seed xray)
-bone –> OM, OA, potts disease

48
Q

testing for TB:

A

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
Q

tx of active TB

A

isoniazid, rifampin, pyrazinamide, ethambutol

50
Q

primary vs secondary PTX

A

primary= occur in absence of lung dz,
seocondary = occur with lung dz,

can be primary or secondary spontaneous vs traumatic

51
Q

RF for primary spontaneous PTX

A

cigarettes, marfans, MVP, male gender, changes in ambient pressure

52
Q

causes of secondary spontaneous PTX

A

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
Q

%age of secondary spontaneous PTX associated with hemopneumo

A

5%

54
Q

what is deep sulcus sign?

A

indicated PTX in supine cxr

55
Q

what defines a “small” PTX?

A

< 20% or < 3 cm apex to cupula or < 2 cm interpleural distance at hilum

56
Q

treatment options for primary spontaneous PTX

A

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
Q

secondary spontaneous PTX mgmt

A

small size catheter or chest tube and admit with water seal or heimlich

58
Q

mgmt of large (primary or seconadry) or bilateral PTX

A

chest tube and admit

59
Q

walk through needle aspiration of PTX

A

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
Q

how long to abstain from flying after ptx

A

1-2 WEEKS

61
Q

suction settings for water seal?

A

10-20 mmHG

62
Q

wheeze in severe asthma?

A

in advanced aiwary obstruction, you can have absence of wheeze, aka “silent chest”

63
Q

Peak flow and symptoms and asthma severity

A

> 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
Q

asthma mimics

A

acute heart failure
upper airway obstruction
PE
fb aspiration
airway tumors
interstitial lung dz

65
Q

asthma medications

A

MDI or nebs - ventolin/atrovent
oral or IV steroids
IV magnesium
EPI
Ketamine
IV salbutamol
inhaled anesthetics

66
Q

magsulf dose in asthma

A

2g over 20 mins

67
Q

RF for severe asthma/death from asthma

A

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
Q

investigation to consider in severe asthma

A

ABG/VBG, PaCO2 > 42 think of potential for resp failure (bc fatiguing, co2 should be low!)

69
Q

Best way to deliver medications in asthma

A

MDI! Only use nebs if pt cannot use mdi

70
Q

Adult ventolin and atrovent doses mdi and neb in asthma exacerbation

A

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
Q

Ventolin order after initial back to back in adults

A

4-8 puffs q1h prn

72
Q

non smoking COPD RF

A

alpha 1 antitrypsin
occupational dust
chemical exposure
air pollution

73
Q

COPD diagnosis and severity

A

FEV1/FVC < 0.7 = COPD

mild FEV1 > .8
mod 50-79
severe 30-49
v severe <30

74
Q

cxr finding in chronic bronchitis

A

none unless bronciectasis is present

75
Q

cxr findings of emphysema (3)

A

hyperinflation, increased AP diameter (barrell chest), flattened diaphragm

76
Q
A
77
Q

Triggers for aeCOPD

A

Asthma
Chf
Pma
Viral illness
PE!!!
TB
Acute abdomen
Metabolic disturbance

78
Q

Imdications for NIPPV in copd

A

Acidosis
Hypercapnia
Hypoxemia
Severe dyspnea with clinical signs of fatigue or inc wob

79
Q

Abx in aecopd, indications

A

If increased sputum parlance and increased dyspnea or inc sputum

80
Q

hypoxemia PaO2 value on ABG

A

<60 mmhg

81
Q

5 causes of hypoxemia and a few examples of each wit a-a gradient

A

pg 585 FA

82
Q

ABG definition of hypercapnia

A

CO2 >45

82
Q

causes of hypercapnia

A

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
Q

symptoms of hypercapnia

A

HA, confusion, lethargy, seizure, coma, cardiovascular collapse

84
Q

symptoms of hypoxemia

A

impaired judgement, motor dysfunction, fatigue, drowsiness, respiratory distress, respiratory distress

85
Q

3 main features of ARDS

A

radid onset dyspnea, hypoxemia, bilateral pulmonary infiltrates

86
Q

ARDS triggers

A

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
Q

lung protective ventilation in ARDS

A

tidal volume 6 ml/kg, add PEEP to keep fio2 < 60 %, keep plateau pressure < 30

88
Q

treatment of ARDS

A

treat underlying cause, supportive mechanical ventilation

89
Q

Pao2/FiO2 ARDS severity

A

arterial oxygen to inspired oxygen:
200-300 mild
100-200 mod
<100 severe

all of these include PEEP of 5

90
Q

origins of air in pneumomediastinum

A

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
Q

symptoms and dx of pneumomediastinum

A

pleuritic CP, dx is usually on cxr or CT

92
Q

mgmt of pneumomediastinum

A

usually resolve on own, admit for obs if concern for pneumo, mediastinitis, esophageal perf

93
Q

s/s of mediastinitis

A

CP, fever, tachycardia, systemic toxic sign

94
Q

causes of mediastinitis and mgmt

A

thoracic/cardiac surgery
eso perf
trauma
odontogenic infection
TB

mgmt: broad spectrum ABX, admission, surgical consult bc all cases are life threatening infection

95
Q

5 groups of pulmonary HTN

A

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

CCFP EM (20 decks)

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