Respiratory Emergencies Lecture Flashcards
Prior intubations
Previous ICU admissions for asthma
Recent or frequent ED visits for asthma excaberations
Hospitalizations or ED visits in the last month
Use of 2 or more Albuterol inhalers in the last months
Use of air conditions
Risk factors for death from asthma
Pulse ox monitor
IV
+/- cardiac monitor
Initial peak flow and treatment
Oxygen to maintain SA-O2 or above 95%
Sit patient up
Act quickly before pt fatigues
General measures to take with asthma pts
What is the onset for inhaled beta2 agonists (ie Albuterol)
~5 mins
Relax bronchial smooth muscle
decrease histamine release
inhibit microvascular leakage into the airways
increase mucociliary clearance
MOA of beta 2 agonist (ie Albuterol)
Continuous nebulization of albuterol is used for what kind of asthma cases?
Moderate to severe
What is the nebulized albuterol dosage for an adult/child over 50 kg?
15 mg (18 ml)
What is the nebulized albuterol dosage for a child under 50 kg
7.5 mg (9 ml)
How frequently should you….
evaluate patient’s subjective response, physical exam and lung function (PFM)?
after each treatment
2 common side effects of albuterol
Tachycardia
Tremor
This is an alternative to albuterol
beta 2 receptor with some beta 1 activity
dosage: 0.63-1.25 mg neb TID (adult)
6-11 yo= 0.31 mg neb TID
Levalbuterol
_________ speed recovery and reduce reucrrence
steroids
- Inhibit airway inflammation,
- Reverse β-receptor down-regulation,
- Block leukotriene synthesis,
- Inhibit cytokine production and adhesion protein activation
Steroids
Do inhaled corticosteroids play a role in acute asthma exacerbation?
NO!
Solumedrol 125 mg IV
PO Prednisone 1-2 mg/kg
..which one is pediatric dosing and which one is adult dosing
Solumedrol IV= adult
Prednisone PO= kid
Standard of care for severe asthma exacerbations!
*produces bronchodilation
Epinepherine
What route is best to give Epinepherine during an acute asthma exacerbation?
IM!
(adult dose= 0.3-0.5 mg IM q20 mins for up to 3 doses)
Why is Terbutaline a good alternative to Epinepherine?
Less cardiac side effects!
(it is more expensive tho)
Selective beta2-agonist acts directly on beta2-receptors,
relaxing bronchial smooth muscle, relieving bronchospasm,
and reducing airway resistance.
Terbutaline
Why isn’t Theophyline great?
Mild bronchodlator effects
Toxicity levels are common
What does Magnesium Sulfate do to smooth muslce?
Relaxes it!
*efficacy is controversial, but essentially no down side
Helium is about ___% as dense as room air
25
Heliox-driven nebulizer treatments should have the gas set at a rate of _____
8-10 L/min
(with double the usual amount of albuterol)
A warning sign of severe asthma exacerbation:
an impaired pulmonary function with peak flow (PFM) less than…
80-100 L/min
pO2 <60 mmhg
pCO2 > 45 mmhg
Signs of severe asthma exacerbation
Mental status changes
Cardiac arrhythmias
Pulsus paradoxus >20 mmhg
Pneumothorax
Signs of severe asthma exacerbation
Severe, prolonged asthma attack which cannot be broken by usual treatment
severe acidosis
Status asthmaticus
- Repeat visit within the last 3 days without improvement of symptoms
- Changes in mental status
- *-Failure of post-treatment PFM to increase by more than 15% above initial value, or if absolute PFM is <200 lpm**
- Persistent hypoxia
- Persistent increase in work of breathing
Criteria for admission
First line agents used to treat acute bronchospasm in COPD and asthma
Beta-Adrenergic agonists
(ie Albuterol)
Levalbuterol can be given at ________ the dose of Albuterol
one half
Beta-Adrenergic agonists (1st line)
Anticholinergics (adjunct)
Steroids (all acute exacerbations)
treatments for acute exacerbations of COPD and asthma
What percentages of Heliox are Helium and Oxygen?
80% Helium
20% Oxygen
Weight loss- thin
Dyspnea on exterion
Cough only in AM
Barrel chest
Tachypnea
..COPD or Asthma?
COPD
Enlarged accessory muscles
Clubbing of fingers
Pursed lips
Prolonged expiratory phase
+/- Wheezing or rhonchi
COPD or asthma?
COPD
step 1= medication therapy and supplemental oxygen
step 2= positive pressure ventilation
step 3= intubation
Step-wise approach to management of COPD
A useful alternative to intubation
*can be given by continuous positive airway pressure (CPAP)
improves gas exchange, decreasing hypoxia and reducing work of breathing
Noninvasive partial pressure ventilation (NPPV)
Any patient with changes in mental status, increased respiratory distress with cyanosis, acute deterioration or exhaustion should be…..
Intubated or mechanically ventilated
Marked increase in intensity of symptoms, such as sudden development of resting dyspnea
Severe background COPD
Onset of new physical signs (e.g.,cyanosis, peripheral edema)
Failure of exacerbation to respond to initial medical management
Newly occurring arrhythmias
Older age
Insufficient home support
Criteria for hospital admission
Are sputum cultures really helpful in choosing antibiotic therapy?
NO
Which 2 antibiotics are generally appropriate for outpatient therapy of COPD excaberations with pneumonia , fever, etc.
Macrolides
Fluoroquinolones
Pts with COPD often develop hypoexemia and hypercarbia over time, which normally causes:
1.
2.
3.
- respiratory acidosis
- tachypnea
- hyperventilation
Excessive supplemental oxygen can cause respiratory depression and respiratory arrest secondary to loss of their…
Hypoxemia-induced ventilatory drive
Congenital lack of primary lung antiprotease- alpha 1 antirypsin
*leads to increase protease tissue destruction and emphysema in adults
Alpha-1 Antitrypsin deficiency syndrome
a neutrophil elastase inhibitor whose major function of which is to protect the lungs from protease-mediated tissue destruction
Alpha 1 Antitrypsin
6: 1 male:female
20: 1 smoker:non smoker
Abrupt pleuritic chest pain +/- dyspnea
Can occur with increased intrathoracic pressue
Often tachycardc, tachypneic, decreased breath sounds
Spontaneous pneumothroax
MC risk factor for spontaneous pneumothorax?
Smoking
(chronic lung disease and infections are also predisposing factors)
________ pneumothorax occurs secondary to invasive procedures such as transthoracic needle biopsy, subclavian line placement, nasogastric tube, etc
Iatrogenic
Likely occurs after rupture of sub-pleural bulla allows air to enter the potential space between the parietal and visceral pleura, leading to partial lung collapse
Pneumothorax
________ pneumothorax is caused by positive pressure in the pleural space leading to decreased venous return, hypotension and hypoxia
Tension pneumothorax
Tx depends on size and patient
*often do nothing
*repeat CXR in 24 hours
Can range from asymptomatic to life threatening
chest tube if urgent treatment
needle decompression for emergent treatment
Pneumothorax
True or False…
A signs/symptoms of a trauma to the chest do not often correlate to the extent of lung collapse
True
Exam will often show…
Abnormal wall movements
Hyperresonance, tympany
Subcutaneous emphysema
Look for flail chest and sucking chest wound
Trauma exam of chest
In unstable patients (those with tension pneumothorax or pneumothorax with underlying lung disease), when should needle thoracostomy and tube thoracostomy be done?
BEFORE radiography!
*you want to do this ASAP
Needle decompression
Chest tube placement
..should be done for?
Trauma patients
Any concern for tension pneumothorax, what must you do early?
Needle decompression
Pleuritic CP
Dyspnea
Hemoptysis
PE “classic triad”
Dyspnea
Pleuritic CP
Cough
Hemoptysis
Atypical symptoms not uncommon:
syncope, wheezing, AMS
PE
Physical exam can be normal
Tachycardic, tachypneic, hypoxic
Pleural friction rub
Diaphoresis
S3, S4 gallop
PE
Recent long distance travel
Recent surgery
Recent immobilization
Hemoptysis
Hx of clotting disorder
Hx of cancer
Risk factors for PE
Clinical signs and sxs compatible with DVT
PE judged to be most likely diagnosis
Surgery or bedridden for 3 days during past 4 weeks
Previous DVT or PE
HR > 100 bpm
Hemoptysis
Active cancer (treatment or ongoing within previous 6 mos)
WELLS score for PE
under 4, PE unlikely
4.5-6: moderate PE likelihood
>6: high PE likelihood
Streptococcus pneumonia
Staph aureus
Klebsiella pneumoniae
Pseudomonas aeruginosa
Haemophilus influenza
Common bacterial caues of pneumonia
Cough
Fatigue
Fever
Dyspnea
Sputum production
Pleuritic chest pain
Pneumonia
Outpatient community aquired pneumonia (CAP) treatment
Azithromycin
