Respiratory Emergencies Lecture

Question 1

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

Answer 1

Risk factors for death from asthma

Question 2

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

Answer 2

General measures to take with asthma pts

Question 3

What is the onset for inhaled beta2 agonists (ie Albuterol)

Answer 3

~5 mins

Question 4

Relax bronchial smooth muscle
decrease histamine release
inhibit microvascular leakage into the airways
increase mucociliary clearance

Answer 4

MOA of beta 2 agonist (ie Albuterol)

Question 5

Continuous nebulization of albuterol is used for what kind of asthma cases?

Answer 5

Moderate to severe

Question 6

What is the nebulized albuterol dosage for an adult/child over 50 kg?

Answer 6

15 mg (18 ml)

Question 7

What is the nebulized albuterol dosage for a child under 50 kg

Answer 7

7.5 mg (9 ml)

Question 8

How frequently should you….

evaluate patient’s subjective response, physical exam and lung function (PFM)?

Answer 8

after each treatment

Question 9

2 common side effects of albuterol

Answer 9

Tachycardia
Tremor

Question 10

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

Answer 10

Levalbuterol

Question 11

_________ speed recovery and reduce reucrrence

Answer 11

steroids

Question 12

• Inhibit airway inflammation,
• Reverse β-receptor down-regulation,
• Block leukotriene synthesis,
• Inhibit cytokine production and adhesion protein activation

Answer 12

Steroids

Question 13

Do inhaled corticosteroids play a role in acute asthma exacerbation?

Answer 13

NO!

Question 14

Solumedrol 125 mg IV

PO Prednisone 1-2 mg/kg

..which one is pediatric dosing and which one is adult dosing

Answer 14

Solumedrol IV= adult

Prednisone PO= kid

Question 15

Standard of care for severe asthma exacerbations!

*produces bronchodilation

Answer 15

Epinepherine

Question 16

What route is best to give Epinepherine during an acute asthma exacerbation?

Answer 16

IM!

(adult dose= 0.3-0.5 mg IM q20 mins for up to 3 doses)

Question 17

Why is Terbutaline a good alternative to Epinepherine?

Answer 17

Less cardiac side effects!

(it is more expensive tho)

Question 18

Selective beta2-agonist acts directly on beta2-receptors,
relaxing bronchial smooth muscle, relieving bronchospasm,
and reducing airway resistance.

Answer 18

Terbutaline

Question 19

Why isn’t Theophyline great?

Answer 19

Mild bronchodlator effects
Toxicity levels are common

Question 20

What does Magnesium Sulfate do to smooth muslce?

Answer 20

Relaxes it!

*efficacy is controversial, but essentially no down side

Question 21

Helium is about ___% as dense as room air

Answer 21

25

Question 22

Heliox-driven nebulizer treatments should have the gas set at a rate of _____

Answer 22

8-10 L/min

(with double the usual amount of albuterol)

Question 23

A warning sign of severe asthma exacerbation:

an impaired pulmonary function with peak flow (PFM) less than…

Answer 23

80-100 L/min

Question 24

pO2 <60 mmhg

pCO2 > 45 mmhg

Answer 24

Signs of severe asthma exacerbation

Question 25

Mental status changes Cardiac arrhythmias Pulsus paradoxus \>20 mmhg Pneumothorax

Answer 25

Signs of **severe asthma exacerbation**

Question 26

Severe, prolonged asthma attack which cannot be broken by usual treatment ## Footnote **severe acidosis**

Answer 26

Status asthmaticus

Question 27

- 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

Answer 27

Criteria for admission

Question 28

First line agents used to treat **acute bronchospasm in COPD and asthma**

Answer 28

Beta-Adrenergic agonists | (ie Albuterol)

Question 29

Levalbuterol can be given at ________ the dose of Albuterol

Answer 29

one half

Question 30

Beta-Adrenergic agonists (1st line) Anticholinergics (adjunct) Steroids (all acute exacerbations)

Answer 30

treatments for acute exacerbations of COPD and asthma

Question 31

What percentages of Heliox are Helium and Oxygen?

Answer 31

80% Helium 20% Oxygen

Question 32

Weight loss- thin Dyspnea on exterion Cough only in AM Barrel chest Tachypnea ..COPD or Asthma?

Answer 32

COPD

Question 33

Enlarged accessory muscles Clubbing of fingers Pursed lips Prolonged expiratory phase +/- Wheezing or rhonchi COPD or asthma?

Answer 33

COPD

Question 34

step 1= medication therapy and supplemental oxygen step 2= positive pressure ventilation step 3= intubation

Answer 34

Step-wise approach to management of **COPD**

Question 35

A useful alternative to intubation \*can be given by continuous positive airway pressure (CPAP) improves gas exchange, decreasing hypoxia and reducing work of breathing

Answer 35

Noninvasive partial pressure ventilation (NPPV)

Question 36

Any patient with changes in mental status, increased respiratory distress with cyanosis, acute deterioration or exhaustion should be.....

Answer 36

Intubated or mechanically ventilated

Question 37

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

Answer 37

Criteria for hospital admission

Question 38

Are sputum cultures really helpful in choosing antibiotic therapy?

Answer 38

NO

Question 39

Which 2 antibiotics are generally appropriate for outpatient therapy of COPD excaberations with pneumonia , fever, etc.

Answer 39

Macrolides Fluoroquinolones

Question 40

Pts with COPD often develop hypoexemia and hypercarbia over time, which normally causes: 1. 2. 3.

Answer 40

1. respiratory acidosis 2. tachypnea 3. hyperventilation

Question 41

Excessive supplemental oxygen can cause **respiratory depression** and **respiratory arrest** _secondary to loss of their..._

Answer 41

Hypoxemia-induced ventilatory drive

Question 42

Congenital lack of primary lung antiprotease- alpha 1 antirypsin \*leads to increase protease tissue destruction and emphysema in adults

Answer 42

Alpha-1 Antitrypsin deficiency syndrome

Question 43

a neutrophil elastase inhibitor whose major function of which is to protect the lungs from protease-mediated tissue destruction

Answer 43

Alpha 1 Antitrypsin

Question 44

6: 1 male:female 20: 1 smoker:non smoker ## Footnote **Abrupt pleuritic chest pain +/- dyspnea Can occur with increased intrathoracic pressue Often tachycardc, tachypneic, decreased breath sounds**

Answer 44

Spontaneous pneumothroax

Question 45

MC risk factor for spontaneous pneumothorax?

Answer 45

Smoking (chronic lung disease and infections are also predisposing factors)

Question 46

\_\_\_\_\_\_\_\_ pneumothorax occurs secondary to invasive procedures such as transthoracic needle biopsy, subclavian line placement, nasogastric tube, etc

Answer 46

Iatrogenic

Question 47

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

Answer 47

Pneumothorax

Question 48

\_\_\_\_\_\_\_\_ pneumothorax is caused by positive pressure in the pleural space leading to decreased venous return, hypotension and hypoxia

Answer 48

Tension pneumothorax

Question 49

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**

Answer 49

Pneumothorax

Question 50

True or False... A signs/symptoms of a trauma to the chest do not often correlate to the extent of lung collapse

Answer 50

True

Question 51

Exam will often show... Abnormal wall movements Hyperresonance, tympany Subcutaneous emphysema Look for flail chest and sucking chest wound

Answer 51

Trauma exam of chest

Question 52

In unstable patients (those with tension pneumothorax or pneumothorax with underlying lung disease), when should **needle thoracostomy and tube thoracostomy be done?**

Answer 52

BEFORE radiography! \*you want to do this ASAP

Question 53

Needle decompression Chest tube placement ..should be done for?

Answer 53

Trauma patients

Question 54

Any concern for tension pneumothorax, what must you do early?

Answer 54

Needle decompression

Question 55

Pleuritic CP Dyspnea Hemoptysis

Answer 55

PE "classic triad"

Question 56

Dyspnea Pleuritic CP Cough Hemoptysis Atypical symptoms not uncommon: syncope, wheezing, AMS

Answer 56

PE

Question 57

Physical exam can be normal Tachycardic, tachypneic, hypoxic Pleural friction rub Diaphoresis S3, S4 gallop

Answer 57

PE

Question 58

Recent long distance travel Recent surgery Recent immobilization Hemoptysis Hx of clotting disorder Hx of cancer

Answer 58

Risk factors for PE

Question 59

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)

Answer 59

**WELLS score for PE** under 4, PE unlikely 4.5-6: moderate PE likelihood \>6: high PE likelihood

Question 60

**Streptococcus pneumonia** Staph aureus Klebsiella pneumoniae Pseudomonas aeruginosa Haemophilus influenza

Answer 60

Common bacterial caues of pneumonia

Question 61

Cough Fatigue Fever Dyspnea Sputum production Pleuritic chest pain

Answer 61

Pneumonia

Question 62

Outpatient community aquired pneumonia (CAP) treatment

Answer 62

Azithromycin