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AGACNP > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Asthma

A

A chronic lung disease that inflames and narrows the airways causing hypertrophy of smooth muscles, mucosal edema, plugging o the sirways by thick, sicid mucus. Characterized by recurrent periods of wheezing, chest tightness, SOB, and coughing that occurs at night or early in the morning.
Caused by dust mites, pets, cockroaches, indoor molds, exercise, cigarette smoke.
Trouble getting the air out, obstructive airway disease.

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2
Q

S/S of asthma

A
  • Respiratory distress at rest
  • Difficulty speaking in full sentences
  • Diaphoresis
  • Use of accessory muscles
  • RR >28
  • Pulse >110
  • Pulsus paradoxus (d/t change in intrathoracic pressure)
  • Hyperresonance

Ominous signs:
-Fatigue
-absent breath sounds
-Paradoxical chest/abdominal movement
-inability to maintain recumbency
-cyanosis (in the adult, cyanosis is never an early sign in anything other than death)

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3
Q

Resonance
Hyperresonance
Dull
Tymphany

A
  • Normal percussion tone of chest: resonance
  • Air trapping: hyperresonance
  • Bone/mall: dull
  • Air: tymphany
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4
Q

Labs/diagnosits of asthma

A

Slight WBC increase with eosinophilia (allergy)
PFTs reveal abnormalities typical of obstructive dysfunction
-Hospitalization is recommended if FEV1 does not improve after bronchodilators or is peak flow is <60 or does not improve after treatment.

Intially will be respiratory alkalosis with mild hypoxemia
CXR to rule out other disorders, and will show hyperinflation.

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5
Q

Management of asthma

A

Stepwise approach
* Step 1:
SABA (short active beta2 agonist)
-Albuterol, levalbuterol PRN
SABAs work by stimulating enzymes that convert ATP to cAMP which in turn relaxes bronchial smooth muscles.
* Step 2:
-Low dose inhaled corticosteroids (ICS)
-Budesonide, fluticasone, triamcinolone
* Step 3:
-Low dose ICS + LABA (long acting beta2 agonist)
-Salmeterol, formoterol
-Combo preparations: Advair (fluticasone + salmeterol) and Symbicort (formoterol + budesonide).
* Step 4:
-Medium dose ICS + Laba
* Step 5:
-High dose ICS + Laba

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6
Q

Inhaled anticholinergics

A

Ipratropium (atrovent)

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7
Q

Inpatient management of asthma

A
  • Supplemental O2
  • Inhaled SABA (albuterol)
  • Inhaled anticholinergics (ipratropium)
  • Systemic glucocorticoids
  • Mag sulfate if above not working
  • Epi for anaphylaxis (stridor or respiratory distres).
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8
Q

Status asthmaticus

A

A term used to describe severe, acute asthma presenting in an unremitting, poorly responsive, life threatening manner.
Clinical findings are not reliable indicators of the severity of asthma

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9
Q

Management of status asthmaticus

A
  • Oxygen
  • IV D51/2
  • Inhaled and parenteral sympathomimetics (epi)
  • IV steroids
  • Consider atrovent (inhaled anticholinergic)
  • Intubate if needed
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10
Q

COPD

A

Umbrella term characterized by airflow limitations.
Emphysema & chronic bronchitis

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11
Q

Chronic bronchitis

A

Characterized by excessive secretion of bronchial mucus and is manifested by productive cough for 3 months or more in atleast 2 consecutive years.

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12
Q

Emphysema

A

Abnormal, permanent enlargement of the alveoli.

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13
Q

S/S of chronic bronchitis

A
  • Intermittent mild to moderate dyspnea
  • Onset of symptoms after age 35
  • Copious sputum production (purulent)
  • Body habitus is stocky/obese
  • Cheat AP diameter is normal
  • Percussion normal
  • Hyperinflation of CXR
  • Hct increased (secondary polycythemia due to chronic hypoxemia)
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14
Q

S/S of emphysema

A
  • Progressive, constant dyspnea
  • Onset of symptoms after age 50
  • Mild sputum (clear)
  • Body habitus is thin/wasted
  • Chest AP diameter increased
  • Percussion hyperresonant
  • Hct normal
  • Total lung capacity increased
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15
Q

Lab/diagnostics of COPD

A
  • Low, flattened diaphragm on CXR
  • FEV1 and all othe measurements of expiratory airflow reduced
  • Total lung capacity, functional residual capacity and residual volume may be increased.
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16
Q

Outpatient management of COPD

A

Stop smoking (imperative)
Avoid irritants or allergens
Postural drainage may clear excess secretions
Inhaled anticholinergics or sympathomimetics (mainstay of therapy); ipratroprium and epi

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17
Q

Inpatient management of COPD

A

O2 at 1-2L
Same pharmacologics as asthma

18
Q

Tuberculosis

A

Systemic disease caused by M. Tubertulosis
Pulmonary disease is the most common clinical presentation.
Increased risk include those pts living in crowded conditions, institutionalized, HIV, DM, renal failure, malignancy, malnutriotn, immunocompromised.

19
Q

S/S of TB

A

Majority of pts are asymptomatic
Unexplained weight loss, low grade fever, night sweats, dry cough progressing to productive and somtimes blood tinged, fatigue and anorexia.

20
Q

Lab/Diagnostics of TB

A

Definitive diagnosis by culture of M. Tuberculosis x3
Small homogenous infiltrates in upper lobes by CXR (honeycomb, classic sign)
PPD test shows exposure, but not diagnostic for active disease.
Acid-fast bacillus (AFB) smears are presumitive evidence of active TB.

21
Q

Management of TB

A

Report to health department
Hospitalization is not required but should be considered if pt is non-compliant or is likely to expose susceptible individuals.

Medication regimen: (RIPE)
Rifampin
Isoniazid
Pyrazinamide
Ethambutol

If the isolate proves to be fully susceptible to Isoniazid and rifampin, then the 4th drug may be dropped

Three drug reigmen should be continued for 2 months, then 4 more months of isoniazid and rifampin. toal of 6 months of treatment, 9 months for pregnant and HIV pts.

22
Q

Monitoring therapy for TB

A

Weekly sputum smears and cultures for first 6 weeks after initiation of therapy, then monthly until negative cultures documented.
Continued symptoms or positive cultures after 3 months should raise concern for drug resistance.
Weekly LFTs
Pts on ethambutol should be tested for visual acuity and red/green color perception.

23
Q

Chemoprophylaxis for TB

A

Those with a positive PPD should recieve 6 months of INH
-A positive test is 5mm for HIV
-A positive test is 10mm for immigrants from high prevalence areas, healthcare workers, high risk groups.
-A postitive test is 15mm for general population

24
Q

Pneumonia

A

Inflammation of the lower respiratory tract as microorganisms gain access by aspiration, inhalation, or hematogenous dissemination.

  • CAP:
    -Streptococcus pneumoniae
  • HAP
    -Staphylococcus aureus, Streptococcus pneumoniae and haemophilus influenzae
  • VAP
    -psudomonas
25
Q

S/S of pneumonia

A

Fever, shaking chills, purulent sputum, lung consolidation on physical exam, malaise, increased fremitus.

26
Q

Lab/diagnositcs of pna

A

Elevated WBC (may be low in immunocompromised or eldery)
Infiltrates on CXR
Consider sputum culture

27
Q

Screening tool for PNA
PORT
CURB-65

A

PORT scoring:
1-2: score <70, low risk, <1% mortality, treat outpt
3: score 71-90, low risk, 2.8% mortality, brief inpatient
4: score 91-130, moderate risk, 8.2% mortality, inpatient stay
5: score >130, high risk, 29.2% mortality, ICU stay**

28
Q

CURB-65

A

Confusion with abbreviated mental test score <8
BUN >19
RR >30
SBP <90 or DBP <60
Age>65

29
Q

Management of CAP outpatient

A

Low severity
* Pathogen: S. pneumoniae, M. pneumoniae, H. influenzae, C. pneumoniae, M. catarrhalis
* Amoxicillin OR doxycycline OR macrolide

Moderate to high severity
* Pathogen: all above plus multiple drug resistance S. pneumoniae
* Amoxicillin/clavulanate or cephalosporin PLUS macorlide or doxycycline OR monotherapy with respiratory fluroquinolone.

30
Q

Management of inpt CAP

A

Nonsevere
* Pathogen: S. pneumoniae, H. influenzae, M. pneumoniae, C. pneumoniae, legionella
* Betalactam + macrolide OR monotherapy with respiratory fluroquinolone

  • Severe
  • S. pneumoniae, S. aureus, legionella, gram-negative bacilli, H. influenzae
  • Beta-lactame + IV fluroquinolone or IV azithromycin

If P. aeruginosa suspected:
* piperacillin/tazobactam or meropenem or cefepime+azithromycin

If MRSA suspected:
* Above+ vanco or linezolid

31
Q

HAP management

A

HAP is pneumonia that occurs 48 hours after admission, which was not incubating at the time of admission (includes VAP)
Common organisms: Staphyococcus aureus, streptococcus pneumoniae, haemophilus influenzae.

If not at high risk of mortality and no factors for likelihood of MRSA:
* Piperacillin/tazobactam OR
* Cefepime OR
* Levofloxacin OR
* Imipenem or meropenem

If not at high risk of mortality but has factors likelihood of MRSA:
* Same as above PLUS vancomycin or linezolid

High risk for mortality or IV antibioitcs within 90 days:
Two of these agents
* Piperacillin/tazobactam
* Cefepime or ceftazidine
* Levofloxacin or ciprofloxacin
* Imipenem or meropenem
* PLUS vancomycin or linezolid

32
Q

VAP management

A

Pneumonia that arises more than 48-72 hours after intubation.
Psudomonas is the most likely pathogen.
MRSA and double antipeudomonal coverage are appropriate.

Antibiotics with MRSA activity:
* Vancomycin or linezolid

Antiboitics with antipseudomonal activity: beta lactam based agents:
* Piperacillin/tazobactam OR
* Cefepime and ceftazidime OR
* Iipenem and meropenem OR
* Aztreonam

Antibiotics with antipseudomonal activity: NON-beta lactam based agents:
* Levofloxacin and ciprofloxacin OR
* Amikacin and gentamicin and tobramycin OR
* Colistin and polymyxin B

33
Q

Pneumothorax

A

Gas in the pleural space that raises pleural pressures and can impair respiration, resulting in collapsed lung.

S/S:
* Chest pain, dyspnea, cough
* Hyperresonance on affected side
* Diminished breath sounds and diminished fremitus on affected side
* Mediastinal shift toward the unaffected side (tension)
* Hypotension

Lab/diagnostics:
* CXR is diagnostic

Management:
* <20% pneumo requires no intervention as the pt is asymptomatic
* Chest tube is used first if available (4th or 5th ICS MAL)
* In emergency, needle thoracostomy (2nd ICS MCL)

34
Q

Sarcoidosis

A

A disease of unknown etiology characterized by interstitial lung disease and non-caseating granulomas.
More common in females ages 20-40

S/S:
* Progressive dyspnea
* Nonproductive cough
* Rales (velcro crackles) may be noted

Lab/diagnostics:
* CXR for staging
* PFTs
* Routine blood work
* Bronchoscopy with transbronchial biopsy of the lung parenchyma for diagnosis

Management:
* Corticosteroids are mainstay of treatment

35
Q

Pulmonary Embolism

A
  • Diagnosed based on clinical suspicion (history very important) and the results of specific diagnostic studies.
  • Predisposing risk factors are often in the history.
  • Leading cause of hospital deaths due to right ventricular failure.

Risk factors:
* Prolonged best rest/immbolity
* Oral contraceptives
* Surgery to long bones
* Venous stasis
* Hypercoagulabe states
* Cardiac thrombi

S/S:
* Usually occur abruptly
* Unexplained dyspnea and tachycardia are most common
* Chest pai (retrosternal or lateralized and pleuritic)
* Hemoptysis
* Low grade fever
* Hypotension
* Cyanosis

Lab/Diagnostics:
* VQ scan should be performed in all clinically stable pts.
* If VQ unable to be performed or inconclusive, do a pulmonary angiography
* ABG will show hypoxemia and hypocapnia

Management:
* Supplemental O2
* IV fluids for hypotension and reduced CO
* Worsening hypercapnia with obtubdation is indicative for intubation
* Heparin bolus, 80u/kg followed by conyinuous infusion of 18u/kg/hr to maintain PTT of 1.5-2xnormal. Begin coumadin simultaneously to an INR of 2-3
* Fibrinolytics in those with hemodynamic compromise or shock

36
Q

ARDS

A

A form of acute lung injury attributable to a wide variety of insults.
Massive pulmonary edema with shunting.

S/S:
* Severe dyspnea and respiratory distress
* Cyanosis
* Tachycardia
* Rales and wheezes

Lab/Diagnostics:
* Refractory hypoxemia is a hallmark feature. No matter how much O2 given, the body doesn’t use it.
* CXR may be “whited out” or have diffuse bilateral infiltrates.

Management:
* Mechanical ventilation with PEEP
* TV 4-6ml/kg IBW (normal 6-8)
* PEEP about 10cmh20
* Treatment of underlying infection

*SVO2 will be high d/t the body not using O2)

37
Q

Pulmonary function tests:
FVC
FEV1
FEV25-75
PEFR

TLC
FRC
RV

A
  • Forced vital capacity; volume of gas forcefully expelled from the lungs after maximal inspiration.
  • Forced expiratory volume in 1 second; volume of gas expelled in the first second of the FVC maneuver.
    The ratio of FEV1/FVC is diagnostic for obstructive lung disease (<70%)
  • FEV25-75- maximal mid-expiratory airflow rate
  • PEFR- maximal sirflow rate achieved in FVC maneuver
  • Total lung capacity; Volume of gas in lung after maximal inspiration.
  • Functional residual capacity
  • Residual volume; volume of gas remaining in lungs after maximal expiration
38
Q

Obstructive diseases and PFTs

A
  • Obstructive diseases are characterized by reduced airflow rates and lung volumes are within normal range or larger.
  • Airway issue, COPD, asthma, bronchitis
  • Values <70%=normal
  • Values >120=air trapping and hyperinflation
    -FVC
    -FEV1
    -FEV25-75
    -PEFR
39
Q

Restrictive diseases and PFTs

A
  • Restrictive diseases are characterized by reduced volume and increased expiratory flow rates.
  • Lung cpacity issues; obesity, sarcoidosis, pulm fibrosis.
  • Values >70%=normal
  • Values >120=air trapping and hyperinflation
    -TLC
    -FRC
    -RV
40
Q

Pleural effusion

A

Increased amount of fluid in the pleural space.
Classified as exudates or transudates to help in differential diagnosis.

Exudate is pleural fluid that have one more more of the following: (cream)
-Pleural fluid protein to serum protein ration >0.5
-Pleural fluid LDH to serum LDH >0.6
-Pleural fluid LDH greate than 2/3 the upper limit of normal serum LDH

Transudates have none of these feaures, they’re clear and have equal glucose levels, pH 7.40-7.55 and WBC <1000

  • Empyema-infection and puss accumulate in pleural space
  • Hemothorax- blood accumulation in pleural space
  • Chylothorax-Due to injury of the thoracic ducts and accumulation of chyle in pleural space. (milky with high triglyceride count).
  • Parapneumonic effusion: pleural effusion that form in the pleural space adjacent to the pneumonia.
41
Q

Coe Pulmonale

A

Right heart failure.
Enlarged right ventricle due to lung disease
S/S:
* Right ventricular heave
* Pulmonary diastolic murmur
* Cyanosis

AGACNP (25 decks)

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