Respiratory Flashcards
oral temperature in patient breathing fast
inaccurate
asthma epidemiology
INCREASING
- incidence
- prevalence
- hospital admissions
best initial test in acute asthma exacerbation
PEF and ABG’s
CXR in asthma
NORMAL
most accurate diagnosis of asthma
PFTs
when patient is asymptomatic and want to diagnose asthma
methacholine challenge test
CBC asthma
increase eosinophils
other random dx of asthma
skin testing and IgE levels
STEP 1 asthma tx
saba
STEP 2 asthma tx
+ low dose ICS or (cromolyn, theo, LTRA)
step 3 asthma tx
+ LABA
OR
INCREASE dose of ICS
step 4 asthma tx
saba + MAX dose ICS + LABA
step 5 asthma tx
+ omalizumab
step 6 asthma tx
ORAL steroids
adverse effects with zafirlukast
churg strauss
adverse effects with inhaled steroids
DYSPHONIA and oral candidiasis
anticholinergics in asthma
unknown use
best indication of asthma severity
RESPIRATORY RATE
PEF mainly based on….
HEIGHT, age
NOT weight
tx acute asthma exacerbation
- O2
- albuterol
- steroids
- epinephrine
- magnesium
- ICU–> resp acidosis– intubation
acute asthma best….
epinephrine> albuterol> magneseium
best initial tests for dx COPD
CHEST XR: increase AP diameter and flat diaphragm
DLCO in COPD
decrease in emphysema
NOT in chronic bronchitis
reversibility- complete
bronchodilator response greater than 12% increase and 200mL increase in FEV1
dx of COPD
ABG: increase CO2, decrease O2
CBC: increase Hct
EKG: RA/RV hypertrophy and a.fib or MAT
ECHO: RA/RV hypertrophy and pulmonary HTN
MAT in COPD
multifocal atrial tachycardia
improving mortality in COPD
smoking cessation
O2 tx
influenza and pneumococcal vaccine
O2 use in COPD
O2 less than 55/ sat less than 88%
with pulmonary HTN/ high Hct/ cardiomyopathy:
O2 less than 60/ sat less than 90%
anticholinergics in COPD
YESS ARE EFFECTIVE– no change in mortality
asthmatic not controlled with saba
ICS
COPD not controlled with saba
anticholinergic–> ICS
when medical tx fails in COPD
refer for transplantation
antibiotics for acute COPD exacerbation
macrolides: azithomycin, clarithromycin
cephalosporins: cefuroxime, cefixime, cefaclor, ceftibuten
co-amox
quinolones: levofloxacin, moxifloxacin, gemifloxacin
second line antibiotics in COPD
doxycycline
TMP/SMX
diagnosis of bronchiectasis
HRCT***** only way to diagnose
tx of bronchiectasis
physio
antibiotics– as infection comes: INHALED cold ones, rotate 1 weekly antibiotics
surgical resection if focal
steroids for ABPA
ORAL not inhaled (since inhaled cannot get a big enough dose to be effective)
COPD with pneumonia
haemophilus influ
diabetic or alcoholic with pneumonia
klebsiella
poor dentition or aspiration pneumonia
anaerobes
hoarseness pneumonia
chalmydophila pneumoniae
animals at the time of giving birth pneumonia
coxiella burnetti
rigors in pneumonia
sign of bacteremia
chest pain in pneumonia
pleuritic– PG’s
foul smelling sputum pneumonia
anaerobes
dry cough, not severe,
bullous myringitis
mycoplasma pneumonia
dry pneumonia/ non productive
mycoplasma viruses coxiella pneumocystis chalmydia
best diagnosis for pneumonia
CXR, sputum cultures= USELESS– since often cannot detect organism
first chest X ray for pneumonia
can be falsely negative in 10-20% of cases
sputum grain stain adequate if….
- more than 25 WBC’s
- fewer than 10 epithelial cells
blood cultures for pneumonia
positive in 5-15% cases of CAP– esp with s. pneumonia
dx of pneumonia from hx/exam alone?
NNNNOOOOOO
tests done in pneumonia with severe disease, and unknown aetiology, or not responding to tx
- thoracocentesis
- empyema
- bronchoscopy
thoracocentesis in pneumonia
- pleural effusion analysis
- or if empyema
empyema in pneumonia
LDH above 60%
protein above 50% of serum level
WCC above 1000
pH less than 7.2
bronchoscopy in CAP
RARE– in ICU
dx of mycoplasma pneumonia
- PCR
- cold agglutinins
- serology
- culture special media
dx chlamydophila pneumoniae
- rising serologic titers
dx legionella
- urine antigen
- culture on charcoal yeast extract
dx chlamydia pstiacci or coxiella
- rising serologic titers
dx PCP
- BAL
treatment CAP based on….
SEVERITY OF DISEASE more nb than the cause
outpatient tx CAP
previously health or no antibiotics in past 3 months and mild symptoms
= MACROLIDE or DOXYCYCLINE
comorbidities or antibiotics in past 3 months
= LEVOFLOXACIN or MOXIFLOXACIN
inpatient tx CAP
LEVOFLOXACIN or MOXIFLOXACIN
or
CEFTRIAXONE + AZITHROMYCIN
single factors= reason to hospitalize a patient
HYPOxia
HYPOtension
CURB-65
confusion
Urea: BUN above 30, sodium less than 130, glucose above 250
Resp rate: above 30, pO2 less than 60, pH less than 7.35
BP: bp below 90mmHg
pulse above 125/minute
temperature above 104 farenheit
age: older than 65, or comorbifities: cancer, COPD, CHF, renal failure, liver disease
empyema tx
placement of chest tube for suction
HCW need PCV vaccine?
NOOOOPE
tx of HAP
antipseudomonal cephalosporin: cefepime, ceftazidime
OR
antipseudomonal penicillin: piperacillin/tazo
OR
carbapenems: mero/imi/doripenem
dx of VAP, easiest/least accurate–> dangerous/most accurate
- tracheal aspirate
- BAL
- protected brush specimen
- video-assisted thoracoscopy
- open lung biopsy
tx of VAP
3 different drugs:
- antipseudomonal beta lactam= tx of HAP
- second antipseudomonal:
- gentamicin/tobramycin/amikacin
- ciprofloxacin or levofloxacin - MRSA
- vancomycin
- linezolid
daptomycin for lungs?
NOOOOO, since inactivated by surfactant
culturing endotracheal tube
contamination
aspiration pneumonia
lying flat, upper lobes
sputum culture for lung abscess
NOOOpe, because has anaerobes anyways
tx of lung abscess
clindamycin or penicillin
PCP always has elevated
LDH
negative sputum stain, best diagnostic test…
BRONCHOSCOPY
tx PCP and prophylaxis
TMP/SMX
severe PCP
pO2 less than 70
A-a gradient above 35
what tx for severe PCP
ADD STEROIDS – decreases mortality
toxicity from TMP/SMX switch to
clindamycin + primaquine
OR
pentamidine
when to start PCP prophylaxis
CD4 less than 200
rash or neutropenia from TMP/SMX prophylaxis give….
atovaquone
OR
dapsone (not if G6PD)
CD4 below 50, what additional prophylaxis
ATYPICAL mycobacteria– azithromycin
when to stop prophylaxis of PCP
when CD4 greater than 200 for several months
dx of TB must include…
- clear risk factor
- cavity CXR
- positive smear (done 3 times)
when to use ripE (ethambutol)
when beginning tx and know that it is SENSITIVE to ALL TB meds
side effect of pyrazinamide
hyperuricemia
ethabutol, mgmt adjustments
decrease dose in renal failure
how to decrease risk of TB constrictive pericarditis
STEROIDS
pregnant patients, antibiotic for TB they shouldn’t receive
PYRAZINAMIDE
side note: cannot also receive streptomycin
once the PPD test is positive….
it will always be positive in the future
BCG and PPD
has no effect on recomendations
PPD positive whether or not had BCG
MUST take INH 9mos
benign solitary nodule
- less than 30
- no change in size
- nonsmoker
- smooth borders
- less than 1 cm
- normal lung
- no adenopatthy
- dense, central calcification
- normal PET scan
malignant solitary nodule
- older than 40
- enlarging
- smoker
- spiculated
- large great than 2 cm
- atelectasis
- yes adenopathy
- sparse, eccentric calcification
- abnormal PET scan
what to do if nodule is enlarging
BIOPSY
for high probability lesions best answer
RESECTION
intermediate probability lesions
BRONCHOSCOPY- central
or TRANSTHORACIC NEEDLE BX- peripheral
sputum cytology positive, next appropriate mgmt
RESECTION– since highly specific
most common adverse effect of transthoracic bx
pneumothorax
PET scan for lung cancer
content of lesion is malignant, most accurate if lesion GREATER THAN 1cm
VATS
MOST specific MOST sensitive
byssinosis
cotton
bagassosis
moldy sugar cane
best test for ILD
HRCT
DLCO ILD
DECREASED
dx of sarcoidosis, best initial test
CXR– HILAR ADENOPATHY
most accurate dx of sarcoidosis
bx
additional things for dx of sarcoidosis
ACE elevated
hypercalcemia
hypercalciuria
PFT–ILD
HY– BAL in sarcoidosis
ELEVATED helper cells
CXR PE
NORMAL usually
most common CXR abnormalitiy PE
ATELECTASIS
most common EKG finding for PE
nonspecific ST-T wave changes
ABG in PE– highly suggestive
hypoxia
resp alkalosis
when hx and initial labs very suggestive of PE….
START TREATMENT
gold std dx of PE
spiral ct SCAN
V/Q scan low probability
15% can have a clot
V/Q scan high probability
15% won’t have a clot
V/Q first only in
pregnancy
D-DIMER
screening– sensitivity
not specific
positive D-dimer
doesn’t mean anything
negative D-dimer
EXCLUDES PE
for VQ to have any accuracy must have
normal CXR
abnormal CXR PE
do CT
LL Doppler study
good test if ? V/Q and ? spiral CT
angiography in PE
NOOOOOO RARELY done
IVC filter
contraindications to anticoagulants
recurent emboli on therapeutic warfarin
RV dysfunction- enlarged RV– could have embolus
HIT alternative in PE
fondaprinaux
thrombolytics in PE
hemodynamically unstable
acute RV dysfunction
best initial tests in pulmonary HTN
CXR/ CT: narrowing/pruning of distal vessels
most accurate test in pulmonary HTN
R heart or swan ganz catheter
EKG in pulmonary HTN
RA/RV hypertrophy and R axis deviation
ECHO in pulmonary HTN
RA/RV hypertrophy, doppler estimates pulmonary artery pressure
only cure for pulmonary HTN
LUNG TRANSPLANT
sleep apnea and increased bicarb
OBESITY/HYPOVENTILATION SYNDROME
most accurate test OSA
polysomnography (sleep study)
tx of osa
weight loss
CPAP
CT ARDS
air bronchograms
ARDS definition
p02/FI02 below 300
moderately severe ARDS
p02/FI02 below 200
severe ARDS
p02/FI02 below 100
calculation: p02= 70, FI02=50% oxygen
70/0.5= 140
before starting treatment with PEEP
DECREASE FI02 (since above 50% FI02 is toxic to lungs)
tx of ARDS
6ml per kg of tidal volume
STEROIDS NOT BENEFICIAL
Tx underlying cause
maintain plateau pressure for ARDS
less than 30cm of water
