Class 22 review

Question 1

Antitussives

Answer 1

used with dry hacking, non-productive coughs from a common cold and cough due to allergy where
the cough interferes with rest and irritates the throat (NOT pneumonia, COPD, Asthma, or aspiration where the cough assists with airway clearance)

Question 2

Antitussive MOA

Answer 2

dampen cough reflex

Question 3

Antitussive Opioid

Answer 3

MOA: high efficacy, raise cough threshold in CNS, only requires a low dose
codeine – caution with allergy causing bronchoconstriction

Question 4

Antitussive Non-Opioid

Answer 4

MOA: chemically similar to opioids and also acts in the CNS to raise cough threshold, not as high efficacy, but no risk of dependency
In OTC cold and flu medication, higher dose by prescription
Side effects – dizziness, drowsiness, GI upset

Question 5

Expectorants

Answer 5

MOA: promote mucus secretion, making the mucus thinner and easier to remove by cough
Guaifenesin (Benylin) most effective OTC expectorant (higher doses by prescription)

Question 6

Mucolytics

Answer 6

MOA: used to break down thick bronchial secretions – become thinner and easier to remove by
cough
Acetylcysteine (Mucomyst) – one of few available, inhaled, prescription only
Patients with cystic fibrosis, chronic bronchitis (COPD)

Question 7

An infection of the lower respiratory tract results in…

Answer 7

an inflammatory response that leads to accumulation of exudate and fluid in the alveoli, affecting gas exchange. CONSOLIDATION occurs when air in the alveoli is replaced by exudate.

Question 8

Mortality rate of a pulmonary embolus

Answer 8

Mortality of 30% untreated, 6-8% treated

Question 9

The classic triad of symptoms of a patient presenting with a PE are

Answer 9

Dyspnea, chest pain and hemoptysis

Question 10

Atelectasis

Answer 10

Incomplete expansion or collapse of alveoli, caused by hypoventilation, obstruction of the airways, or compression

Question 11

Earliest sign of inadequate oxygenation

Answer 11

Change in behaviour

Question 12

Influenza

Answer 12

• Onset abrupt; 
• Systemic symptoms: 
	◦ fever, myalgia, headache, 
• Sore throat, dry cough
• Subsides in 7 – 10 days
• Risk of pneumonia
• Influenza vaccine
• Antiviral in severe cases in high risk pop.

Question 13

Cold

Answer 13

• Onset gradual and mild symptoms
• Tickling, irritation of throat
• Sneezing → copious nasal secretions
• Nasal congestion
• Elevated temperature
• Malaise, and headache
• Subsides in 3-4 days

Question 14

Pneumonia

Answer 14

• Infection in the alveoli → inflammatory response (exudate, WBC, RBCs, Bacteria)
• Alveoli fill with fluid and exudate and affects gas exchange
• Consolidation occurs as exudate replaces air in alveoli
• LOBAR Pneumonia – most common
• Other types:
◦ Bronchopneumonia (scattered patches of infiltrates both lungs)
◦ Interstitial (infiltrates in alveolar walls between alveoli)

Question 15

Who is at risk for pneumonia ?

Answer 15

• Smokers (4x more likely)
• Alcohol & Substance Addictions 
• Influenza or other viral infection
• Pre-existing lung disease (COPD)
• Neurological disease 
• Renal/cardiac disease
• Immune-suppressed or compromised patient
	◦ Chemotherapy
	◦ Organ transplant
	◦ HIV
• Very young (<5 yo); or Elderly (>85 yo)
• The post-op patient (immobility, pain, procedure length)
• Ventilated patient

Question 16

Alveolar Hypoventilation

Answer 16

Causes both hypoxemia and hypercapnia
This also occurs in:
• Opioid use
• Chest wall injury/ pain
• Neuromuscular respiratory weakness
• Injury to respiratory center (tumour, trauma)
• Restrictive lung disease - any disorder that prevents the lungs from fully expanding e.g. pulmonary fibrosis

Question 17

Pleurisy

Answer 17

Inflammation of the pleura

Question 18

Mechanisms of Hypoxemia Shunt

Answer 18

Blood which arrives at the left ventricle without coming in contact with ventilating alveoli.

Question 19

SpO2 >95%

Answer 19

Adequate unless the patient is hemodynamically unstable or has an O2 unloading problem
> 70 mmHg

Question 20

SpO2 90%

Answer 20

Adequate in almost all patients. Values are at a steep part of the oxygen-hemoglobin dissociation curve. Oxygenation is adequate, but the margin of error is less than for higher values
60 mmHg

Question 21

SpO2 88%

Answer 21

Adequate for patients with chronic hypoxemia if no cardiac problems occur. These values are also used as criteria for the prescription of continuous O2 therapy
55 mmHg

Question 22

SpO2 75%

Answer 22

Inadequate but may be acceptable on a short-term basis if the patient also has CO2 retention. O2 therapy at a low concentration (24-28%) will gradually increase the PaO2. Monitoring dysthymias is necessary
40 mmHg

Question 23

SpO2 <75%

Answer 23

Inadequate. Tissue hypoxia and cardiac dysrhythmias can be expected
< 40 mmHg

Question 24

Is oxygenation shift to the right a good thing?

Answer 24

It is a good thing. Hemoglobin will release oxygen very easily and quickly to try and oxygenate the tissues.

Question 25

Antibiotics used to treat pneumonia (children)

Answer 25

Strep pneumoniae; Pencillins (amoxicillin)

Question 26

Antibiotics used to treat pneumonia (youth & young adults)

Answer 26

Chalmydia pneumoniae; Atypical microbes; Macrolides (azithromycin) or Tetracycline (doxycycline)

Question 27

Antibiotics used to treat pneumonia (older adults)

Answer 27

Strep pneumoniae; Penicillins, Cephalosporins (3rd generation)

Question 28

Antibiotics used to treat pneumonia (adults with chronic lung infections)

Answer 28

some resistant strains; Fluoroquinolones (levofloxacin)

Question 29

Complications of pneumonia

Answer 29

Lung
• Atelectasis
• Pleural effusion
• Empyema
• Pleurisy
• Lung abscess

Other systems
• Pericarditis 
• Bacteremia → Sepsis
• Meningitis
• Endocarditis 

Question 30

Pleural Effusion & Empyema & Hemothorax

Answer 30

Abnormal collection of fluid in the pleural cavity
• Normally fluid enters the pleural cavity through the capillaries & is removed by lymph
• Excess fluid formation or decreased removal can cause collection
◦ Bacterial pneumonia
◦ Viral infection
◦ Pulmonary infarction
◦ Malignancy
◦ Empyema: pus
◦ Hemothorax: blood

Question 31

Flail Chest

Answer 31

• Multiple rib fractures cause instability of the chest wall
• Damaged area (flail) moves paradoxically to the intact portion of the chest
• Inadequate ventilation

Question 32

Pneumothorax

Answer 32

• Caused by air (or another gas) in the pleural cavity resulting in collapse of all or part of the lung
• If air entires the pleural cavity and equalizes the pressure, and the lungs collapse immediately (compression atelectasis)

Question 33

Closed Pneumothorax

Answer 33

• Occurs when air enters the pleural cavity directly from the airways
• Simple or spontaneous pneumothorax is idiopathic and caused by a tear or rupture on the surface of a lung that allows air to reach the cavity through a bronchus
• Secondary pneumothorax is caused by rupture of an emphysematous bleb, erosion of a tumour, or cavitation through the visceral pleura
• The involved area of lung collapses by recoil, and the leak seals with collapse
• The mediastinum shifts toward the affected lung since the pleura vacuum is partially preserved

Question 34

Open Pneumothorax

Answer 34

• Occurs when air enters the pleural cavity through an opening in the chest (ie. traumatic wound or surgery) causing immediate atelectasis
• Sucking wound describes a large opening in the chest wall in which the sound of air moving in and out makes a sucking sound
• During inspiration, mediastinum shifts toward the unaffected side and limits chest expansion. The mediastinum shifts toward affected side during expiration, and impairs venous return to the heart
Moves side to side

Question 35

Tension Pneumothorax

Answer 35

• Most serious form of pneumothorax. Can be open or closed
• Characterized by one-way movement of air caused by a flap of damaged tissue that allows air to move into the pleural cavity during inspiration, but seals off the opening during expiration, preventing the outflow of air
• Causes increasing pressure in cavity, leading to widespread compression atelectasis
• Pressure pushes on mediastinum and displaces the heart while compressing the vena cava and unaffected lung. This results in decreased venous return and gas exchange. Severe hypoxia and respiratory distress develop quickly

Question 36

Pneumothorax Clinical Picture

Answer 36

• Hypoxemia:
◦ decreased ventilation
◦ V/Q mismatch
◦ Mild in closed, moderate in open, severe in tension.
• Systemic signs and symptoms: tachycardia, anxiety, and pallor.
• Atelectasis
• Dyspnea, cough, and chest pain.
• Decreased breath sounds on affected side.
• Unequal lung expansion and mediastinal shift.
• Hypotension and shock caused by decreased venous return (especially in tension pneumothorax).

Question 37

Pulmonary edema

Answer 37

An abnormal accumulation of fluid in the alveoli and the interstitial spaces of the lungs

Question 38

Pulmonary embolism

Answer 38

Blockage of pulmonary arteries by a thrombus, fat or air embolus, or tumour tissue

Question 39

Pulmonary embolism risk factors

Answer 39

immobility, recent surgery, history of DVT, malignancy, obesity, oral contraceptives, hormone therapy, smoking, prolonged air travel, heart failure, pregnancy and clotting disorders

Question 40

Pulmonary embolism Manifestations

Answer 40

• Classic triad – dyspnea, chest pain, hemoptysis (20% presentation)
• Mild to mod hypoxemia
• Small emboli may be asymptomatic
• Massive emboli may cause decreased BP, pallor, severe dyspnea and hypoxemia
• Cough, crackles, fever, altered mentation, tachycardia
• Pleural friction rub
• May lead to pulmonary hypertension (massive or many recurrent)

Question 41

Pulmonary embolism Diagnostic Studies and Tx

Answer 41

• Spiral CT Scan with IV contrast media to visualize blood vessels
• VQ Scan if cannot have contrast media (dye)
• Pulmonary angiography
• D-dimer, aPTT/INR
• ABG
• Supplemental oxygen – possible intubation
• Anticoagulants or fibrinolytics
• Limited activity
• Opioids for pain