Respiratory MDT Flashcards
Episodic or chronic symptoms of wheezing, dyspnea, or cough
Symptoms frequently worse at night or early morning
Prolonged expiration and diffuse wheezes on physical exam
Asthma
Chronic disorder of the airways characterized by variable airway obstruction, airway hyperresponsiveness, and airway inflammation
Asthma
Plays a central role in the pathogenesis of allergic asthma
IgE
Important in promoting eosinophilic inflammation
Interleukin-5
Most common type of asthma, usually begins in childhood and is associated with other allergic diseases such as eczema, allergic rhinitis, or food allergy.
Allergic asthma
Late asthmatic response
Symptoms 4-6 hours after allergen exposure
Selected individuals may experience asthma symptoms after exposure to aspirin
Aspirin-exacerbated respiratory disease
Triggered by various agents in the workplace and may occur weeks to years after initial exposure and sensitization
Occupational asthma
Women may experience asthma symptoms at predictable times during their menstrual cycle
Catamenial asthma
Begins during exercise or within 3 minutes after its end, peaks within 10-15 minutes, and then resolves by 60 minutes
Exercise-induced bronchoconstriction
This phenomenon is thought to be a consequence of the airways’ warming and humidifying an increased volume of expired air during exercise
Exercise-induced bronchoconstriction
Wheezing precipitated by pulmonary edema in the setting of decompensated heart failure
Cardiac asthma
Cough instead of wheezing as the predominant symptom of bronchial hyperreactivity
Cough-variant asthma
Signs and symptoms:
Episodic wheezing, shortness of breath, chest tightness, and cough.
Symptoms vary over time and in intensity and are often worse at night or early in the morning.
Asthma
Physical findings found in patients with allergic asthma
Mucosal swelling, increased secretions, polyps, eczema, atopic dermatitis, or other skin disorders
Asthma patient:
Arterial blood gas may be normal, but what lab will show an increased result?
Respiratory alkalosis and alveolar-arterial oxygen difference
Asthma:
The combination of an increased PaCO2 and respiratory acidosis may indicate:
Impending respiratory failure and the need for mechanical ventilation
Asthma:
Test used before and after administration of a bronchodilator
Spirometry
1) Assessing asthma control and severity
2) Distinguishing between severe and uncontrolled asthma
3) Personalized pharmacologic therapy for asthma
4) Treatment of modifiable risk factors and control of environmental factors
5) Guided self-management education and skills training
Five important aspect of chronic asthma management; from the Global Strategy for Asthma Management and Prevention
Asthma:
Medication therapy reserved for patients who are acutely ill and those who cannot use inhalers because of difficulties with coordination, understanding, or cooperation.
Nebulizer therapy
Most effective bronchodilator during exacerbations and provide immediate relief of symptoms
SABAs
Most effective in achieving prompt control of asthma during acute exacerbations
Systemic corticosteroids
Asthma medication:
Reverse vagally mediated bronchospasm but not allergen or exercise-induced bronchospasm
Anticholinergics
Potent mediators that contribute to airway obstruction and asthma symptoms by contracting airway smooth muscle, increasing vascular permeability and mucous secretion, and attracting and activating airway inflammatory cells
Leukotriene modifiers
Provides mild bronchodilation in asthmatic patients. It also has anti-inflammatory and immunomodulatory properties, enhances mucociliary clearance, and strengthens diaphragmatic contractility
Phosphodiesterase inhibitor (Theophylline)
Long-term control medications that prevent asthma symptoms and improve airway function in patients with mild persistent or exercise-induced asthma
Mediatory inhibitors (Cromolyn sodium and Nedocromil)
Patients who require monoclonal antibody therapies should be evaluated by a:
Pulmonologist or allergist experienced in their use
Vaccines:
Adult patients aged 19-64 with asthma should receive the:
23-valent pneumococcal polysaccharide vaccine (Pneumovax 23)
Annual Influenza
Common cause of asthma deaths
Asphyxia
administer oxygen immediately
When would you refer an asthmatic patient:
After how many courses of oral prednisone therapy in the past 12 months?
More than 2 courses of oral prednisolone
Sudden onset of asthma-like symptoms following high-level exposure to a corrosive gas, vapor, or fumes
Reactive airway dysfunction syndrome (RADS)
Symptoms:
- Acute single event with exposure to a chemical/irritant
- Mucus membrane irritation of the upper airway
- Dyspnea
- Cough
- Possible wheezing
- Possible hypoxia
Reactive airway dysfunction syndrome (RADS)
RADS is less responsive to:
Beta2 Agonists
Hallmark signs:
Acute exacerbation of symptoms beyond day-to-day variation including increased dyspnea, increased frequency or severity of cough, increased sputum volume or character
COPD
Emphysema
Chronic bronchitis
Chronic obstructive asthma
COPD Subtypes
Airflow limitation that is not reversible
COPD
Usually presents in the 5th or 6th decade of life with symptoms often present for 10 years
COPD
Abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls, without obvious fibrosis
Emphysema
Physical exam:
Over distention of the lungs in the stable state, decreased intensity of breath and heart sounds, and prolonged expiratory phase
Emphysema
“Pink Puffer”
Emphysema predominant
“Blue Bloater”
Bronchitis predominant
Chronic productive cough for three months in each of two successive years in a patient and other causes of chronic cough have been excluded
Chronic bronchitis
Major complaint of dyspnea
Usually presents after age 50
Cough is rare
Patients are thin
Accessory muscle use
Chest is quiet without adventitious lung sounds
Emphysema
Major complaint is productive cough with mucopurulent sputum
Frequent exacerbations due to chest infections
Often present in their 30’s and 40’s
Mild dyspnea
Chronic bronchitis
How many times will you test peak expiratory flow rate?
Three times total
Imaging:
Identifies and can quantify the emphysema phenotype associated with loss of tissue, can detect airway narrowing and wall thickening characteristic of a bronchitis phenotype
CT
Predisposition to venous thrombosis, especially in the legs
Acute onset of dyspnea, pleuritic chest pain, tachypnea, and tachycardia
Elevated rapid D-dimer, characteristic defects on imaging
Pulmonary embolism
Air embolization occurs most commonly after:
Penetrating trauma
Clots that form pulmonary emboli are most commonly from the:
Femoral or pelvic venous beds
Patients with DVT are how likely to develop PE?
50-60%
Venous Stasis
Injury to the vessel wall
Hypercoagulability
Virchow’s Triad (PE/DVT)
Massive embolization causes:
Acute pulmonary hypertension
Right Heart Strain
Systemic hypotension
Shock
Standard for PE diagnosis
Pulmonary Angiography
Fever, cough, along with other symptoms of the lower respiratory tract
Smoking history
Nasopharyngeal or GI Bleed
Hemoptysis
Expectoration of blood can range from blood-streaking of sputum to the presence of gross blood from below the vocal cords or within the lungs.
Hemoptysis
> 500 mL of expectorated blood over a 24-hour period or bleeding at a rate of >100 mL/hour
Massive hemoptysis
Hemoptysis patient, evaluate for:
Tachycardia
Hypotension
Decreased oxygen saturation
Inspect nose and oropharynx
How would you assess the bleeding magnitude in a hemoptysis patient?
Hemoglobin and hematocrit levels, white blood cell count and differential for possible infection
Most important study for hemoptysis patients
Chest CT
Treatment for Hemoptysis
Position the patient - good lung on top
Establish a patent airway
Clear rhinorrhea, hyposmia, and nasal congestion
Malaise, headache, and cough
Erythematous, engorged nasal mucosa on exam
Symptoms last less than 4 weeks and typically less than 10 days
Upper respiratory infection
Most frequent acute illness
Upper respiratory infection
Refers to a mild upper respiratory viral infection involving, to variable degrees, nasal congestion and discharge, sneezing, sore throat, cough, low grade fever, headache, and malaise
“Common Cold”
Colds typically last longer in what kinds of patients?
Smokers
Most common and characteristic initial symptoms are nasal discharge, nasal obstruction, and a dry or “scratchy throat”. Cough is common and tends to appear after the onset of nasal discharge and obstruction.
Upper respiratory infection
Incubation period for most common cold viruses
24-72 hours
Colds usually persist for how many days in the normal host?
3-10 days
Cough associated with midline burning chest pain, fever, and dyspnea
Bronchitis
Primary clinical difference between bronchitis and pneumonia is the presence of:
Infiltrate on the chest X-ray for pneumonia
Excessive production of bronchial mucous and daily productive cough for 3 months in the past 2 years
Chronic bronchitis
Disposition for a patient diagnosed with bronchitis
Modified duty. 1-2 days SIQ.
Antibiotics are not typically recommended for bronchitis, unless the course is prolonged because:
Primary cause is viral etiology
Fever or hypothermia, cough with or without sputum, dyspnea, chest discomfort, sweats, or rigors
Bronchial breath sounds of rales
Parenchymal infiltrate on chest X-ray
Pneumonia
Development of lower respiratory tract infections occurs from:
Aspiration of secretions containing bacteria
Inhalation of infected aerosols
Cough reflex
Mucociliary clearance system
Immune responses
Pulmonary defense mechanisms
Prospective studies have failed to identify the cause of community-acquired pneumonia in what percent of cases?
40-60%
Pneumonia will have two causes in what percentage of cases?
5%
Most common bacterial pathogen identified in most studies of community-acquired pneumonia, accounts for 2/3’s of bacterial isolates.
Streptococcus pneumonia
Constitutional symptoms
Cough with foul-smelling purulent sputum
Dentition is often poor
Aspiration Pneumonia or lung abscess
Periodontal disease and poor dental hygiene are associated with a greater likelihood of:
Anaerobic pleuropulmonary infection
Clearing of pulmonary infiltrates in patients with community-acquired pneumonia can take:
6 weeks or longer
Patients with anaerobic pleuropulmonary infection usually present with:
Constitutional symptoms
Cough with foul odor expectorant
Poor Dentition
Expect a bronchial lesion if:
Patient is missing teeth
Aspiration pneumonia usually effects what lung zones:
1) Posterior segments of upper lobes
2) Superior and basilar segments of the lower lobes
3) Body position at the time of aspiration
Decreased breath sounds, dullness to percussion on affected side. Respiratory distress and hypotension.
Hemothorax
Most commonly is a secondary injury to penetrating trauma
Hemothorax
Physical findings:
-Respiratory distress, tachypnea, variable degrees of hypoxia
- Dullness to percussion, decreased breath sounds
- Hypotension, pulse pressure narrow
Hemothorax
What position would make a smaller hemothorax difficult to detect in patients?
Supine
What volumes of a hemothorax can be seen in chest X-rays?
200-300mL
Treatment for a hemothorax:
Intact airway
Oxygen
Tube thoracotomy
Absent or decreased breath sounds. Hyper resonance to percussion on affected side.
Pneumothorax
Abnormal collection of air within the pleural space
Pneumothorax
Pneumothorax can be classified as:
Spontaneous or traumatic
Spontaneous pneumothorax occurs in what types of patients?
Young, tall, men age 20-40.
Occurs from a rupture of subapical blebs.
Invasive procedures that cause traumatic pneumothorax
Subclavian line placement
Thoracentesis
Lung or pleural biopsies
Barotrauma from positive pressure ventilation
Physical findings:
- Pleuritic chest pain, tachypnea, tachycardia
- Chest pain ranging from minimal to severe and dyspnea
- Diminished breath sounds, decreased tactile fremitus, decreased chest movement, hyper resonance on affect side
Pneumothorax
What imaging would reveal most pneumothoraxes?
Chest X-ray
For stable pneumothorax patients, when would you want to get a second chest X-ray to compare?
3-6 hours
Tracheal deviation from the opposite side with absent lung sounds. Patient is in respiratory distress and hypotension.
Tension pneumothorax
One-way valve air leak occurs from either the lung or the chest wall
Air enters the pleural space but cannot escape
Tension Pneumothorax
Physical findings:
- Respiratory distress, tachypnea, tachycardia
- Hyper resonance to percussion
- Decreased or absent breath sounds to auscultation
- Trachea deviated
- Neck veins distended
Tension Pneumothorax
Where would you insert a needle thoracentesis?
Large bore 16g or larger IV catheter, Second intercostal space at the mid clavicular line
Risk recurrence of tension pneumothorax
50%
Daytime somnolence
History of loud snoring with witnessed apneic events
Overnight polysomnography demonstrating apneic episodes with hypoxemia
Chronic Obstructive Sleep Apnea
Clinical risk factors for Chronic Obstructive Sleep Apnea
Advancing age
Male Gender
Obesity
What acronym is used to diagnose Sleep Apnea?
STOP BANG
How many questions on the STOP BANG questionnaire need to be answered “YES” for high risk of sleep apnea?
3 or more
Sudden onset of intermittent (fleeting) pain in the chest wall
Usually follows an injury or illness
Pain worsened by coughing, sneezing, deep breathing or movement
Pleuritis
Inflammation of the pleura
Pleuritis
In young healthy patients, pleuritis is usually caused by:
Viral respiratory illness or Pneumonia
Pleuritic chest pain may lead to:
Splinting and atelectasis significant enough to produce hypoxemia
Physical findings:
- Dyspnea
- Pain is usually localized, sharp, and fleeting
- Pain is worse by coughing, moving, and breathing
- Friction rub
- Ipsilateral shoulder pain
Pleuritis
When would you get a Chest X-ray in a patient with pleuritis?
To rule out lung disease, pleural effusion, or pneumothorax
Most common injury sustained in blunt thoracic trauma
Rib fractures
What rib fracture would indicate severe trauma because of the necessary force to produce such an injury
First rib
What percentage of rib fractures can not be detected in a Chest X-ray?
50%
What allows for healing of the ribs and prevention of complications in the patient with respiratory failure?
Mechanical Ventilation
Rib fracture patient:
Promotes redistribution of ventilation and perfusion to various lung segments
Continuous body positioning and oscillation therapy
Mainstay treatment for a patient with multiple rib fractures
Rapid mobilization, respiratory support, and pain management
Disposition of young, healthy patients with isolated rib fractures without evidence of serious underlying injuries
Pain medication
Deep breathing exercises
Incentive spirometry
Segment of the chest does not have bony contiguity with the rest of the thoracic cage
Flail chest
Physical findings:
- Pain and respiratory distress
- Tachypnea with shallow respirations secondary to pain
- Crepitus
Flail Chest
Treatment of flail chest
Oxygen
Pain control with opioids
Consider early intubation and mechanical ventilation
- Fatigue, weight loss, fever, night sweats, productive
- Cough >2 to 3 weeks duration, lymphadenopathy
- Chest X-ray: Pulmonary opacities
- Sputum culture positive
Tuberculosis
Major site for Mycobacterium tuberculosis
Lungs
Physical findings:
- Dullness with decreased fremitus
- Crackles or posttussive crackles
- Amphoric breath sounds
- Whisper Pectoriloquy may be heard
- Clubbing
Tuberculosis
Lab test for TB
Acid fast bacilli light microscope (3 consecutive morning specimens)
Percentage of patients with reactive TB involving the apical-posterior segments of the upper lobes
80-90%
Regimen for pulmonary tuberculosis
2-month phase of a 4-drug regimen
Followed by:
4-7 months of rifampin and isoniazid
Regimen for tuberculous meningitis
2-month phase of a 4-drug regimen
Followed by:
7-10 months of Rifampin and Isoniazid
Tapered 6-8 weeks of corticosteroid therapy
Injuries of the lung parenchyma with hemorrhage and edema without associated laceration
Occur in 30-75% of patients with significant blunt chest trauma
Often associated with thoracic injuries such as rib fractures and flail chest
Pulmonary contusion
Most frequent intrathoracic injuries in nonpenetrating chest trauma
Pulmonary Contusion
Most common complication of pulmonary contusion
Pneumonia
Physical Findings:
- Silent during initial trauma evaluation
- Traumatic mechanism and presence of other associated thoracic injuries
- Hypoxia
Pulmonary contusion
When is radiographic evidence of a pulmonary contusion usually apparent?
6 hours after injury
Mainstay treatment for pulmonary contusion:
- Oxygen
- IV Fluids
- Chest physiotherapy
Severe pulmonary contusion therapy
Mechanical ventilation with positive end-expiratory pressure
Percentage of tracheobronchial injuries that die before reaching the hospital
80%
Common clinical symptoms and signs suggestive of injury to the trachea or bronchus are:
- Dyspnea
- Subcutaneous emphysema of the neck or upper thoracic region
- Hoarseness
- Hemoptysis
- Hypoxia
- Persistent pneumothorax despite appropriate tube thoracotomy
CXR findings indicative of tracheobronchial injury:
Subcutaneous emphysema
Pneumomediastinum
Pneumothorax
Peri-bronchial air
Treatment for tracheobronchial injury patients that are in respiratory distress:
Endotracheal Intubation
Why would you want to avoid blind intubation on a tracheobronchial injured patient?
May result in the complete disruption of small tracheal lacerations
Treatment for stable tracheobronchial injury patients:
Immediate bronchoscopy
-Localize the injury and surgically repair
Severe airway obstruction
Immediately life threatening and must be relieved promptly to avoid asphyxia
Acute Respiratory Distress Syndrome (ARDS)
- Trauma to the larynx
- Foreign body aspiration
- Laryngospasm
- Laryngeal edema from burns
- Infections
- Acute allergic laryngitis
Can cause what?
Acute Respiratory Distress Syndrome (ARDS)
What has reduced the number of ARDS deaths?
Heimlich maneuver
Physical findings:
- Stridor respirations
- Retractions of muscles
- Can’t talk or breathe
- May have visible swelling
Acute Respiratory Distress Syndrome (ARDS)
Principal benefits of mechanical ventilation during respiratory failure:
Improved Gas Exchange
Decreased work of breathing
Amount of pressure that will keep alveoli open during expiration. Normal setting is between 5-10cm H2O.
Positive End Expiratory Pressure (PEEP)
Amount of oxygen you are delivering to the patient with normal amount being between 21-100%.
Fraction of inspired oxygen (FIO2)
Ventilation is the control of the amount of _________ in the body
Carbon Dioxide
Buildup of CO2 which leads to more acid building up in the blood
Respiratory Acidosis
Ventilator:
What controls the amount of oxygen in the blood?
FIO2 & PEEP
Ventilator:
This mode of ventilation that can do all the breathing for the patient.
Volume Control Ventilation (VC)
You want the Peak Inspiratory Pressure (PIP) to be below what number to avoid alveolar trauma?
40 cm H2O
This mode of ventilation that is only set if the patient is breathing on their own, but need extra support, or you do not have enough sedation to totally sedate them
Continuous Positive Airway Pressure (CPAP)
Amount of extra pressure the ventilator delivers on inspiration when the patient triggers a breath
Pressure Support (PS)
Ventilator:
Goal to keep CO2 at:
35-45 mmHg
Blood pH should be between:
7.35 to 7.45
Confirm ET tube is in trachea by using:
End-Tidal CO2
Ventilator:
Recommended frequency for cleaning the mouth out with chlorhexidine:
Every 4 hours
Acute onset or worsening of dyspnea at rest
Tachycardia, diaphoresis, cyanosis
Pulmonary rales, rhonchi; expiratory wheezing
X-rays show interstitial and alveolar edema with or without cardiomegaly
Arterial hypoxemia
Pulmonary Edema
