respiratory Flashcards
58 yo. M presents to ED with complaints of dry cough. CXR revealed generalized inflamed film throughout. What is the most likely diagnosis?
pneumonitis
Drug known to prevent nosocomial PNA?
sulcarafate (Carafate)
Mucosal Protective Agent
Initial finding associated with pulmonary embolism?
respiratory alkalosis
- s/t ↑ RR = blowing off CO2
Diagnostic of pulmonary HTN?
2D echo
Your patient is intubated on the following settings: SIMV/FiO2 .6/PEEP 5. You notice shunting. What should your next action be?
Increase PEEP from 5 to 10 to recruit alveoli and increase surface area to improve oxygenation
32 yo. M with PMH significant for mitral valve replacement now complains of wheezing during physical activity 2-3 times/week. What should you do next?
Send patient for PFT.
What is the pathology of asthma?
↑ response/hyperresponse of trachea, bronchi to stimuli
- acute inflammation
- widespread airway narrowing
- smooth muscle hypertrophy
- viscid mucus plugging up airways
- mucosal edema, hyperemia, mucus gland hypertrophy
asthma: hallmark s/s - top 3 + 7 more
- difficulty speaking in sentences
- pulsus paradoxus gt 12 mmHg (none in COPD!)
- hyperresonance
respiratory distress @ rest, RR 28+, cough, use of accessory muscles, chest tightness, diaphoresis, HR 110+
PFT value suggestive of obstructive disease?
↓ FEV 1
Which acid-base imbalance is associated with asthma?
Respiratory Alkalosis w mild hypoxemia
asthma PFT values at which hospitalization is recommended x4
FEV 1 lt 30% predicted
– OR –
doesn’t increase to at least 40% predicted after 1 hr tx
PEAK FLOW lt 60 L/min initially
– OR –
doesn’t increase to gt 50% predicted after 1 hr tx
ominous findings assoc w asthma exacerbation
- signs x5
- lab x 1
fatigue, absent breath sounds, paradoxical chest/abd movement, inability to retain recumbency, cyanosis
- hypercapnea: pCO2 45+ = EMERGENCY
- Daily maintenance drug for outpatient asthma mgmt: MOA & name
MOA: inhaled corticosteroid
budesonide (Pulmicort)
SE associated with inhaled corticosteroids used daily as maintenance drug for asthma? x3 + 1 pt education
candidal infection of the oropharynx
dry mouth
sore throat
- educate patient to rinse mouth
Ex: budesonide (Pulmicort)
asthma: outpatient mgmt x 6 meds (class & name) + indications
- SABA - albuterol/Proventil: sx relief, breakthrough, or pre exercise
- inhaled corticosteroid - budesonide/Pulmicort: daily maintenance, ↑ if persistent sx
- LABA - salmeterol/Serevent: for persistent sx
- theophylline or antimediators: for persistent sx
- inhaled anticholinergic - ipratropium bromide/Atrovent: add if necessary (secretions)
- anti-leukotrienes - montelukast/Singulair: chronic asthma maintenance (stabilization)
If asthma sx persist, what pharm interventions are indicated? x4
↑ inhaled corticosteroids
add LABA (salmeterol/Serevent)
add theophylline or antimediators
indications for ipratroprium bromide (Atrovent) & MOA
secretion management in asthma
MOA: inhaled anticholinergic
What drug + MOA is indicated in the chronic management of asthma?
montelukast (Singulair)
MOA: anti-leukotriene
think: stabilization
Which drugs x2 have BBW: “Do not take during acute asthma exacerbation?”
LABA
anti-leukotrienes
asthma: inpatient mgmt
- O2 (2 - 3L/min)
- mild to mod: ABG not necessary if SaO2 90+
- severe: initial ABG
- hydration (PO or IVF)
- inhalation sympathomimetics (alupent, proventil, ventolin)
- corticosteroids if no response to sympathomimetics (methylprednisolone)
- parenteral sympathomimetics in pts unable to cooperate (aqueous epinephrine)
- anticholinergic (atrovent MDI)
Status asthmaticus is…
severe, acute asthma that is unremitting, poorly responsive, and life threatening.
note: clinical findings NOT reliable indicators of severity
status asthmaticus: gold standard interventions x4
IV D5 1/2NS
Intubation (pt looks bad)
Continuous pulse ox
ABG q 10-20 min
Monitor pulse ox and ABGs in status asthmaticus how often?
Continuous pulse ox
ABG q 10-20 min
chronic bronchitis is…
- excessive secretion of bronchial mucus
- productive cough 3+ mo over 2+ consecutive yrs
emphysema is…
abnormal, permanent alveoli enlargement
ABG assoc w chronic bronchitis + why.
hypercapnia + hypoxemia
- air trapped in alveoli, over time chemoreceptors reset to accommodate high CO2 levels
CXR findings associated with COPD
hyperinflation: low, flattened diaphragm
bulla, blebs
COPD: outpt mgmt x4
- smoking cessation
- avoid irritants/allergens
- postural drainage: clear excess secretions
- inhaled: ipratroprium bromide (Atrovent) or sympathomimetics – MAINSTAY
58 yo M w PMH COPD; home O2 2L NC coughing up purulent/ thick/ yellow mucous. Management plan?
O2 NC 2-4 L min or 24-28% venti mask Start antibiotics - 7-10days Ampicillin or amoxicillin 500 mg QID PO for 7-10days Doxycyline 100 mg BID Bactrim DS 1 tablet BID
Most common clinical presentation of TB?
Pulmonary disease.
TB is systemic and often asymptomatic.
TB: classic s/s x4
- MAJORITY ARE ASYMPTOMATIC*
- weight loss
- low grade fever
- night sweats
True or False: A positive PPD is diagnostic for active TB dx?
False. Positive PPD shows exposure; not active disease.
What are the drugs + doses in initial TB treatment?
R I P E
Rifampin 600 mg
Isoniazid 300 mg
Pyrazinamide 1.5 - 2.0 g
Ethambutol 15 mg/kg
TB tx: dosages x3 steps
R I P E
DAILY FOR 2 MO: Isoniazid 300 mg + Rifampin 600 mg + pyrazinamide 1.5-2.0 gm (can include E here)
THEN, DAILY 4 MO: R & I
DROP E: if tb fully susceptible to R & I
TB + HIV: tx duration
9 mo - 1 year
TB: monitoring protocol for newly dx x3 steps
FIRST SIX WEEKS AFTER INITIATION OF TX: weekly sputum smears & cultures
THEN MONTHLY until neg cx documented
IF SX CONTINUE OR + CX AFTER 3 MO: suspect drug resistance
TB: baseline labs ordered with initiation of treatment? What happens to those with normal baseline?
LFT
CBC
serum creat
If normal labs @ baseline, monthly labs not required - but monitor for sx drug toxicity.
TB: ethambutol considerations x2
visual acuity changes, red-green color blindness
+PPD is an indication for which drug & dosage?
INH - 6 mo
pneumonia is…
inflammation of LOWER respiratory tract
- r/t infection via aspiration, inhalation, hematogenous dissemination
most common causative agent of CAP
Strep. pneumoniae
gram + !
pneumonia: gold standard for dx
CXR: infiltrates
Blood cultures x 3
CAP: mgmt for under 65 x4
MACROLIDE - 1 of the following:
- azithromycin (Zithromax)
- clarithromycin (Biaxin)
- erythromycin
OR
TETRACYCLINE: doxy
CAP: mgmt 65+ or comorbs x4
FLUOROQUINOLONE
- levofloxacin (Levaquin)
- ciprofloxacin (Cipro)
- moxifloxacin (Avelox)
- gemifloxacin (Factive)
pneumonia: inpt ICU mgmt (rx only) x3
BETA LACTAM
- ceftriaxone (Rocephin)
p l u s
FLUOROQUINOLONE //or// - azithromycin (Zithromax): resistance likely, avoid
Pseudomonas pneumonia: inpt ICU mgmt (rx only) x5
antipneumococcal/antipseudomonal beta lactam
- piperacillin-tazobactam (Zosyn)
- cefepime (Maxipime)
- meropenem (Merrem)
PLUS
- ciprofloxacin (Cipro)
//or//
- levofloxacin (Levaquin)
community acquired MRSA pneumonia: rx x2
vancomycin
//or//
linezolid
What consult is necessary when ordering Linezolid?
ID
HAP: definition + most common causative organisms
pneumonia that occurs 48 hrs + after admission & not incubating @ admission (VAP, HCAP)
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilius influenzae
VAP: definition + most common causative organism
Pseudomonas
pneumothorax pathophys
gas enters pleural space
↑ pleural pressure = collapsed lung
impairs respiration
pneumothorax: hallmark s/s x3
hyper-resonance affected side (d/t air trapping)
diminished BS & diminished fremitus affected side
mediastinal shift toward unaffected (tension pneumo)
gold standard for pneumothorax dx
CXR
When does pneumothorax require intervention?
when larger than 20% – pt will become symptomatic
Intervention for non-emergency pneumothorax?
chest tube @ 4th - 5th ICS MAL
STAT intervention for tension pneumothorax?
needle thoracostomy @ 2nd ICS MCL
leading cause of inpatient hospital death
pulmonary embolism
pulmonary embolism: risk factors x6
immobility venous stasis hypercoagulable states endothelial damage recent surgery of a long-bone PO contraceptives
pulmonary embolism: s/s x7
acute/abrupt -- dyspnea, tachycardia * most common hypotension chest pain (retrosternal or lateral/pleuritic) hemoptysis, low grade fever, cyanosis
pulmonary embolism: associated ABG x2
HYPOXEMIA
- SaO2 lt 90%, PaO2 lt 80 mmHg
HYPOCAPNIA
- pCO2 lt 35 mmHg r/t reflexive hyperventilation
pulmonary embolism: diagnostics x 6
DIAGNOSIS BASED ON CLINICAL SUSPICION (HX KEY!)
VQ scan ABG Spiral CT D-dimer Pulmonary angiography
pulmonary embolism: medical mgmt
O2
intubation
IVF (for hypotension, ↓ CO)
Heparin 80 u/kg bolus
- then, Heparin 18 u/kg/hr // PTT 1.5 - 2x normal
- simultaneous Coumadin // INR 2-3
if hemodynamic compromise/shock: fibrinolytics, but first PT/PTT must be less than 2x normal
Goal INR for Coumadin tx for pulmonary embolism?
INR 2-3
Goal PTT for Heparin tx for PE?
PTT 1.5 - 2x normal
Normal: PTT 60-90 seconds
ARDS pathophysiology
acute lung injury r/t wide variety of insults;
transudative fluid build up in alveoli r/t systemic inflammatory process
- impairs ventilation and perfusion.
ARDS: s/s x6
ACUTE
severe dyspnea, respiratory distress
cyanosis, tachycardia
rales, wheezes
ARDS: hallmark features x2
REFRACTORY HYPOXEMIA
CXR - whited out w diffuse bilateral infiltrates
ARDS: mgmt x4
- mechanical ventilation
- low TV: 5 - 7 or 6 - 8 ml/kg IBW
- ↑ PEEP: 10 cm H2O
- peak inspiratory flow 1 - 1.2L prn
PaO2/FiO2 indicative of ARDS?
P/F less than 200 = shunting
- responsive to PEEP
What’s the difference between Assist Control and Spontaneous Intermittent Mandatory Ventilation?
AC: preset TV & RR. Pt can breathe over set RR but gets preset TV.
SIMV: preset TV & RR, but pt can breathe over vent rate at whatever TV they pull.
Continuous Positive Airway Pressure (CPAP) is…
spontaneous breathing at greater pressure than atmospheric
Pressure Support is…
unassisted inspiratory support but preset airway pressure delivered with each breath
@ end of inspiration! (PEEP is end of expiration)
What is PEEP + associated AE x2
maintains intrathoracic airway pressure above atmospheric throughout expiration
- recruits alveoli, ↑ ventilation & perfusion
AE: barotrauma, ↓ CO
True of False: after ventilator TV has been established it is appropriate to change when patient’s status changes.
FALSE. Once a TV is set do NOT change it!
What are the mechanical ventilation settings indicated for a patient that has acutely decompensated?
AC / FiO2 1.0 / RR 12 / TV 450
No PEEP
No Pressure Support
What parameters need to be met in order to wean from mechanical ventilation? x6
FiO2 0.4 + SaO2 gt 92% SIMV: RR over vent rate HDS (?) Consult pulm/RT Cough & gag reflex
pleural effusion: gold standard for diagnosis
CXR: blunted costophrenic angles (shark fins)
lower than normal PaO2 r/t hypoxemia
PaCO2 r/t alveolar ventilation
Pulsus paradoxus is seen in COPD: true or false?
FALSE. It is seen in asthma (greater than 12)
pulsus paradoxus
exaggerated drop of SBP 10+ during inspiration
- along w ↓ pulse wave amplitude
asthma: diagnostics test x4 and values x5
CBC + PFT + ABG + CXR
slight ↑ WBC + eosinophilia
PFTs: abnormalities typical of OBSTRUCTIVE dysfxn (FEV1 lt 30% / peak flow lt 60 L/min)
general improvement in FVC or FEV1 ~15% //OR// FEF 25-75 of 25% after inhaled bronchodilator
initially RESPIRATORY ALKALOSIS + mild hypoxemia
CXR unnecessary to r/o ddx, MAY show hyperinflation
FEF 25-75
the avg forced expiratory flow during middle (25 - 75%) portion of FVC
it’s a PFT
LABA BBWs
↑ association of asthma-related deaths d/t misuse
SABA is for rescue, NOT LABA
Which drug class indicated for asthma rescue therapy + example?
SABA: albuterol (Proventil)
SABA & LABA stand for…
+ example of each
short-acting beta-2 adrenergic agonist - albuterol (Proventil) & long-acting beta-2 adrenergic agonist - salmeterol (Serevent)
SABA achieves what in asthma & COPD?
bronchodilation
asthma inpt mgmt: inhalation sympathomimetics + dosages x3
alupent (0.3 cc in 5% sol) in 2.2 mL NS q 30 - 60min
proventil, ventolin 0.3 cc in 3 mL NS q 30 - 60 min
asthma inpt mgmt: when to check ABG?
severe attack only, not necessarily for mild to moderate
asthma inpt mgmt: corticosteroid for pt who do not respond to sympathomimetics dosage x1
methylprednisolone 60 - 125 mg IV x1
- then 20 mg IV q 4 - 6 hr until attack broken
in-patient suffering from asthma attack does not respond to proventil - what is your next step?
administer corticosteroid: methylprednisolone 60 - 125 mg IV x1
- then 20 mg IV q 4 - 6 hr until attack broken
asthma inpt mgmt: parenteral sympathomimetic & indication x1
aqueous epinephrine 1:1000 0.1 - 0.5 mL SQ q 30 - 90 min
- may repeat x4
in-patient with asthma attack is fatigued and unable to take inhaled meds - what is your next step?
parenteral sympathomimetic: aqueous epinephrine 1:1000 0.1 - 0.5 mL SQ q 30 - 90 min
- may repeat x4
asthma inpt mgmt: anticholinergic example + dosage x1
ipratropium bromide (Atrovent) MDI 2 - 6 puffs q 4 - 6 hrs
status asthmaticus mgmt: 4 gold standard + 4 more
GOLD STANDARD: IV D5 1/2NS Intubation (pt looks bad) Continuous pulse ox ABG q 10-20 min
+
- O2
- methylprednisolone 60 - 125mg OR hydrocortisone 300 mg IV STAT
- inhalation/parenteral sympathomimetics
- consider atrovent
Your status asthmaticus pt’s SaO2 begins to drop - what is your priority order?
ABG - monitor q 10 - 20 minutes
chronic bronchitis: s/s x5
intermittent mild - mod dyspnea sputum: copious, purulent percussion: normal chest AP diameter: normal stocky, obese habitus
COPD is…
chronic bronchitis + emphysema
- pts usually have features of both -
chronic bronchitis: typical pt profile x4
- 35+ @ sx onset
- stocky, obese
- chest AP diameter normal
BLUE BLOATERS
emphysema: typical pt profile x4
- 50+ @ sx onset
- thin, wasted
- chest AP diameter increased
PINK PUFFERS
emphysema: s/s x5
progressive, constant dyspnea sputum: mild, clear percussion: normal chest AP diameter: increased thin, wasted habitus
COPD: dyspnea in chronic bronchitis vs emphysema
chronic bronchitis: mild - moderate & intermittent
emphysema: progressive & constant
bula & blebs on CXR indicative of (COPD)?
chronic bronchitis
hematocrit in COPD
- often ↑ if PaO2 less than 55 mmHg or nocturnal desaturation
- most common in chronic bronchitis (but seen w emphysema)
- evaluate for hypoxemia @ rest, exertion, sleep
COPD: expected PFT *
- FEV 1 * + other EXPIRATORY airflow measures REDUCED *
TLC, FRC, RV /may/ be increased
COPD: diagnostics x3
PFT: ↓ FEV1/expiratory airflow + ↑ TLC, FRC, RV (maybe)
ABG: ↑ PaCO2, HCO3
CXR: low, flattened diaphragm
COPD: expected ABG
↑ PaCO2 & HCO3
mainstays of COPD mgmt (outpt)
inhaled –
ipratroprium bromide (Atrovent)
or
sympathomimetics
COPD: inpt mgmt
- O2 1 - 2L/min NC or venti @ 24-28%
- pharm progression as for inpt asthma
- purulent sputum = abx 7 - 10 days (ampicillin, amoxicillin, doxy, bactrim)
inpt COPD + purulent sputum = x3 meds
ampicillin or amoxicillin 500 mg QID OR doxy 100 mg BID OR bactrim 1T BID
TB: s&s 4x classic + 3 more
- MAJORITY ARE ASYMPTOMATIC*
- weight loss
- low grade fever
- night sweats
fatigue, anorexia, dry cough progressing to productive and sometimes blood-tinged
night sweats: 4 top ddx
TB
menopause
AIDS
endocarditis
TB diagnostics*
*culture: M. tuberculosis x3 = definitive dx
* CXR: small, homogenous infiltrate in upper lobes (honeycomb)
AFB smears: presumptive evidence of active TB
PPD: shows exposure (NOT DIAGNOSTIC FOR ACTIVE DISEASE)
TB: definitive diagnosis
culture of M. tuberculosis x3
TB: stereotypical CXR presentation
small, homogenous infiltrate in upper lobes (honeycomb)
TB: mgmt x3
- notify health department of all cases
- hospitalization not required; consider if non-compliant or likely to expose others (place in negative pressure room)
TB: hospitalization guidelines
not required; consider if non-compliant or likely to expose others
- place in negative pressure room
TB: why are baseline LFTs important to establish with initiation of treatment?
INH is extremely hepatotoxic
Which TB drug is associated with red-green colorblindness?
Ethambutol
+ PPD: 3 levels
HIGH / 5mm: HIV+, case contacts, CXR typical for TB
MODERATE / 10mm: high risk groups - health care, prison, immigrants (high prev area), IVDU, CKD, DM, immune suppression
LOW / 15mm: all others (joe schmoe)
pneumonia: s/s
lung consolidation on PE, increased fremitus
purulent sputum
fever, chills, malaise
pneumonia: diagnostics x5
CBC: ↑ WBC (low in immunocompromised & elderly) CXR: infiltrates sputum cx, gram stain ABG: if resp failure suspected consider blood cx: x3
HCAP: definition x4 + common organisms (likely x2 + less x3)
- hospitalized in acute care hospital 2+ days w/in 90 days of infection
- resided in nursing home or LTCF
- rec’d recent IV abx, chemo, wound care w/in past 30 days of infection
- attended hospital or HD clinic
more similar to HAP than CAP
- likely: Staph aureus, Pseudomonas
- less: Strep pneumo, H flu, MRSA
pneumothorax: s/s - hallmark x3 + general x4
hyper-resonance affected side (d/t air trapping)
diminished BS & diminished fremitus affected side
mediastinal shift toward unaffected (tension pneumo)
chest pain, dyspnea, cough, hypotension
when is pulmonary angiography appropriate in PE?
when clinical data + VQ scan contradictory
OR
pt @ significant risk d/t anticoagulants have high probability VQ scan
what is the key to diagnosis of pulmonary embolism?
clinical suspicion - history is crucial
SVO2 normal vs in ARDS
normal: 60 - 80
in ARDS: higher (not using O2 received)
types of pleural effusions & appearance x4
transudate: clear
exudate: creamy (protein/LDH)
empyema: pus
hemorrhagic: blood
pleural effusion: exudate only lab features x3
1+ of these characteristics of the pleural fluid:
- protein : serum ratio gt 0.5
- LDH : serum ratio gt 0.6
- LDH gt 2/3 upper limit of normal
what happens with increased tidal volume
increased alveolar ventilation
FVC
forced vital capacity
- volume of gas forcefully expelled from lungs after maximal inspiration
FEV1
forced expiratory volume
- volume of gas expelled in first second of FVC maneuver
FEV 25-75
forced expiratory volume
- maximal mid-expiratory airflow rate
PEFR
peak expiratory flow rate
- maximal airflow rate achieved in FVC maneuver
TLC
total lung capacity
- volume of gas in lungs after maximal inspiration
FRC
functional residual capacity
RV
residual volume
- volume of gas remaining in lungs after maximal expiration
PFTs: obstructive vs restrictive diseases
obstructive: reduced airflow rates
- FVC, FEV1, PEFR
restrictive: reduced volumes
- TLC, FRC, RV
PFTs: airflow rates x4
FVC
FEV1
FEV 25-75
PEFR
PFTs: volumes x3
FRC
TLC
RV
FVC vs FRC
forced vital capacity vs functional residual capacity
FVC: airflow
FRC: volume
What happens to TLC and VC in older adults?
total lung capacity constant
↓ vital capacity bc ↑ residual volume
What happens to AP diameter in older adults?
↑
What happens re: thoracic percussion in older adults?
hyper resonance
physiologic reasons pneumonia is more serious in older adults x5
alveoli collapse more easily
↓ cilia, cough reflex, response to hypoxia/hypercapnia
↑ mucus-producing cells
most common causative agents of pneumonia in older adults x4
Strep pneumo, staph aureus
& gram negs: H flu, Moraxella catarrhalis, Klebsiella
typical aspiration pneumonia CXR
localized to right middle lobe
what pulmonary dysfunction is PEEP responsive?
shunting
what’s the difference between pressure support and PEEP?
pressure support is at the end of inspiration
PEEP is at the end of expiration
