respiratory

Question 1

AVAPS

Answer 1

lets you set a minute ventilation on BiPAP to guarantee that the pt will definitely blow off CO2

Question 2

3 goals of BiPAP

Answer 2

oxygenation
support work of breathing
ensure airway protection

Question 3

how to assess a pt on BiPAP

Answer 3

pt: pulse ox, RR, mental status
machine: TV and minute ventilation

=

pt: oxygenation, work of breathing, ?hypercapnia
machine: ?hypoventilation
- TV 6 cc/kg = 400 mL
- minute ventilation 6-7 L/min

Question 4

What is the one situation in which a pt on BiPAP needs an ABG?

Answer 4

s/p sedation - to see if the somnolence is 2/2 hypercapnia or medication effect

Question 5

BiPAP sedation (4 options)

Answer 5

for immediate control –> ketamine dissociation
- only sedates for 30-60m, so have a second agent ready

if pt can wait –> Precedex
- since boluses can cause hemodynamic instability, start gtt high (1-1.4 mcg/kg/hr) and downtitrate over 30-90m

if tachypneic –> tiny Fentanyl doses

Haldol or Zyprexa
- no respiratory drive suppression

** benzos are unpredictable and can cause confusion or paradoxical agitation **

Question 6

how to titrate BiPAP in CHF

Answer 6

ramp up ePAP aggressively to achieve high mean airway pressures

example: 10/5 to 15/10 to 18/14

Question 7

how to titrate BiPAP in everything but CHF

Answer 7

ramp up iPAP to increase driving pressure, i.e. support work of breathing

example: 10/5 to 15/5 to 18/5

Question 8

driving pressure =

Answer 8

Pplat - PEEP

Question 9

Why is driving pressure possibly a better way to ventilate in ARDS as opposed to the ARDSNet protocol?

Answer 9

normalizing target TVs to predicted body weight per ARDSNet doesn’t account for varying proportions of lung not available for ventilation in ARDS (“baby lung” concept)

if you take 2 lungs w/different compliance 2/2 ARDS and give them the same PEEP, the bad lung (w/lower compliance) gets more mechanical stress

driving pressures let you tailor the ventilation to the amount of FUNCTIONAL lung available to you

Question 10

ketamine awake intubation

Answer 10

be ready w/RSI meds, paralytic, failed airway equipment

typical pt: HOP killer where you don’t want any hemodynamic changes

• position: seated, semi-recumbent
• dry out and pre-treat anxiety/gag: glycopyrrolate, Versed, Zofran, suction, pad mouth dry
• anesthesia: neb 5 cc 4% lido, topicalize tongue w/4% x2, atomize 10 cc 4% lido into epiglottis and below
• dissociation: ketamine
• laryngoscopy +/- paralytic
• if pt coughs: spray more lido or push ketamine 50 mg to sedate

Question 11

DSI

Answer 11

be ready w/RSI meds, paralytic, failed airway equipment

typical pt: hypoxic but too agitated to BVM

• dissociation: ketamine until you can oxygenate better
• paralytic
• laryngoscopy

Question 12

air embolus risk factors

Answer 12

invasive lines
recent surgical site, especially laparoscopic and OBGYN procedures
pressure gradients: PPV, overventilation, diving
barotrauma, i.e. blast injury
chest trauma
orogenital sex during pregnancy

Question 13

air embolus immediate tx

Answer 13

lower the head

Question 14

CAP tx

Answer 14

Levaquin

ceftriaxone + azithro/doxy

Question 15

transudate vs exudate

Answer 15

exudates:

• protein ratio > 0.5
• LDH ratio > 0.6 and > 2/3 upper limit of normal

Question 16

good lung down? bad lung down?

Answer 16

• to improve V/Q mismatch and oxygenation = good lung down

- to tamponade hemoptysis or pulmonary abscess = bad lung down

Question 17

When can you observe a PTX?

Answer 17

< 20% in a healthy pt - may observe w/100% O2 and repeat CXR in 6h

Question 18

angioedema management

Answer 18

supportive
consider airway for the unlucky 10%
standard anaphylaxis therapy
FFP if hereditary or acquired (i.e. not ACEi-induced)

Question 19

Lemierre’s syndrome

Answer 19

infected clot of jugular vein 2/2 bacterial pharyngitis > looks like a PTA but pt is toxic-appearing

can get septic pulmonary emboli