#6: Pulm Flashcards
(56 cards)
1
Q
Signs of Acute Respiratory Distress
- RR > ___
- Retractions/use of _____
- _____ abd wall movement w/inspiration
- Pulse ox < _____
- ______ (coloring)
- Unable to speak more than _____
- ______ or_______ (behav/alertness)
A
Signs of Acute Respiratory Distress
- RR > 30
- Retractions/use of accessory muscles
- Paradoxical abd wall movement w/inspiration
- Pulse ox < 90%
- Cyanosis (coloring)
- Unable to speak more than 1 word or short phrase
- agitated or lethargy (alertness)
2
Q
Management of Acute Respiratory Distress
- what is always done 1st?
- What 2 types of meds can you give
- 2 advanced measures of treatment
A
Management of Acute Respiratory Distress
- 1st = ABCs
- meds = albuterol, ipatroprium
- 2 advanced measures = intubation, chest decompression
3
Q
2 major Sxs in asthma
A
Asthma Sxs
- Wheezing
- SOB
4
Q
Labs in Asthma
- What seen on CBC
- what seen on Chemistries
- what ABG levels a/w severe asthma
A
Labs in Asthma
- CBC - leukocytosis
- Chemistries - LOW electrolytes
- ABG levels a/w severe asthma
- PaCO2 > 40 and PaO2 < 60
5
Q
CXR in asthma
- reasons why to get on for asthma (7)
A
CXR in asthma: indications
- r/o other pulm d/o
- new onset asthma
- fever
- aytypical exam
- refractory to tx
- elderly
- Possible aspiration/FB
6
Q
What 2 signs are a/w severe obstruction in asthma
A
2 signs a/w severe obstruction in asthma
- silent chest
- Pulsus paradoxus > 20
7
Q
Asthma Tx
- what is the mainstay of tx (gen + spp)
A
Asthma Tx
- mainstay = beta agonists –> albuterol
8
Q
Asthma Tx
- what gets added to albuterol Tx
- what other class of drugs can be given
- what 2 spp drugs in class, which for severe - what can be given for severe cases that is a smooth muscle relaxer
- what is Heliox 80:20
- how does it help asthma (2 ways)
A
Asthma Tx
- Anticholinergic (ipatroprium) added to albuterol Tx
- CCS (prednison, IV methyl if severe)
- Mg = severe cases (smooth muscle relaxer)
- qHeliox 80:20 = 80:20 mix of helium + O2
- decr resistance + helps meds distribute further into tree
9
Q
Asthma: Home vs inpatient
- when can pts go home (peak flow)
- what 2 things necessitate ICU care
A
Asthma: Home vs inpatient
- home if peak flow > 70% of their best + improved in ER
- what 2 things necessitate ICU care
- resp insuffic
- refractory to tx
10
Q
Pt presents w/ tachypnea, productive cough, insp/expiratory wheezing, decr air movement, accessory muscle use, pursed lip breathing, confusion and LV dsyfunction seen w/testing
Dx?
A
COPD
11
Q
- Tachypnea
- Tachycardia
- Cyanosis
- agitation
- HTN
- resp acidosis
are signs of ______
A
signs of of hypoxemia
- Tachypnea
- Tachycardia
- Cyanosis
- agitation
- HTN
- resp acidosis
12
Q
Dx of COPD
- what is seen on CXR
- what is seen on EKG + and lead to ____
- What is best test for measuring Tx response
- suspect resp acidosis - what test to do?
A
Dx of COPD
- CXR - hyperinflation + flattened diaphargm
- EKG - hypoxia: can lead to ischemic changes
- best test for measuring Tx response = PFTs
- suspect resp acidosis –> ABG
13
Q
COP Tx goals
- for O2 sat
- for PaO2
- meds you give (sim to what)
A
COP Tx goals
- O2 sat goal = 90-92%
- PaO2 goal > 60
- meds = sim to asthma
(albuterol, ipatroprium, CCS - pred/methyl)
14
Q
COPD Tx
- what is the ratio for albuterol/ipratropium
- then what given - When are ABX given for COPD exacerbation
- alternative options to mechanical ventilation
A
COPD Tx
- albuterol/ipratropium 2:1 then continous albuterol
- ABX ALWAYS given for COPD exacerbation
- alt to mechanical ventilation = CPAP/BiPAP
15
Q
- muscle fatigue
- worsening acidosis
- AMS
- refracotry hypoxia
- awake/alert pts needing short term assistance
are indications for _______
A
indications for CPAP/BiPAP for COPD
- muscle fatigue
- worsening acidosis
- AMS
- refracotry hypoxia
- awake/alert pts needing short term assistance
16
Q
- worsening despite max therapy
- incr fatigue w/worse vital
- incr agitation/restless d/t hypoxia
- decr LOC d/t hypercarbia
are indications for _______
A
indications for intubation in COPD tx
- worsening despite max therapy
- incr fatigue w/worse vital
- incr agitation/restless d/t hypoxia
- decr LOC d/t hypercarbia
17
Q
What are 2 severe Sxs that indicate pts w/COPD need admitted to ICU
A
Severe Sxs —> ICU for COPD
- AMS
- Acidosis
18
Q
COPD D/c after acute exacerbation
- when can pts go home
- what should be done to daily meds and what added
tell them to stop smoking (duh)
A
COPD D/c after acute exacerbation
- go home when no lab/XR abn
- incr daily meds and add Steroids
19
Q
Pt presents w/ productive cough, SOB, fever, chills and pleuritic CP. On exam you find focal rales, decr breath sounds, egophany and rhonchi. CXR show lobar consolidation and effusion
What type of PNA is this
A
Typical PNA
20
Q
- S. Pneumo
- Viral
- S. aureus
- Klebsiella
- H flu
- pseudomonas
- M cattaralis
Are causes of which type of PNA
A
Causes of Typical PNA
21
Q
Pt presents w/ non-productive cough, mild SOB, Malaise, and insidious Sxs as well as ear pain. On exam you note focal rales and bullous myringitis. On CXR you see segmental infiltrates.
What type of PNA is this
- what spp organism is the cause
Tx for this type of PNA in general?
A
Atypical PNA
- spp organism = Mycoplamsa (bullous Myringitis)
- Tx = Macrolides
22
Q
- Legionella
- Chlamydia
- Mycoplasma
Are causes of which type of PNA
A
Causes of Atypical PNA
23
Q
ill looking, cachectic, HIV pt presents w/ cough, elevated LDH and patchy infiltrate on CXR
What type of PNA is this/cause
Tx? (2 things)
A
PJP
Tx = Steroids and Bactrim
24
Q
What cause of PNA is MC in winter/spring, a/w watery diarrhea, bradycardia in elderly and HYPOnatremia
A
Legionella
- MC in winter/spring, a/w watery diarrhea, bradycardia in elderly and HYPOnatremia
25
What cause of PNA is in upper lobes, a/w bloody sputum, empyema is complication and commonly seen in alcoholics, DM, and COPD
Klebsiella
- upper lobes, a/w bloody sputum and empyema and commonly seen in alcoholics, DM, and COPD
26
Causes of PNA
1. What cause of PNA is MC in pts w/CF
2. What cause is a/w IVDU
Causes of PNA
1. pts w/CF = MC cause is P. aeruginosa
2. MC in IVDU = S. aureus
27
if elderly pt comes in w/AMS what test should always be done and why
elderly + AMS --> ALWAYS get CXR to r/o PNA
28
Labs for PNA
1. what types of pts should get labs for
2. what basic labs should you get
3. when to get lactate level
4. when to get LDH
5. what type of cult
Labs for PNA
1. high risk pts should get labs
2. basic labs = CBC, CMP
3. get lactate level if suspect sepsis
4. get LDH if HIV+ or at risk
5. blood culture
- note: sputum cult = rare
29
PNA Tx
1. Anaerobes
2. S. Pneumo
3. S. aureus
4. H flu
5. Legionella
PNA Tx
1. Anaerobes = Clinda
2. S. Pneumo = PCN
3. S. aureus = oxacillin
4. H flu = Ceftriaxone
5. Legionella = Erythromycin
30
Aspiration PNA
1. how long after aspiration does it present
2. what area of lung is it MC
3. What must Tx cover
note: a/w delayed CXR findings
Aspiration PNA
1. presents w/in 1 hr of aspiration
2. MC in RLL
3. Tx cover aerobes + anaerobes
31
PNA d/c
what is used to determine if pt can go home (2 things)
PNA d/c based on
1. PORT score
2. PSI
32
what dz is charac by diffuse bilat pulm infiltrates and severe hypoxemia and is d/t diffuse alveolar injury
ARDS
33
Dx of ARDS
1. what measure used to r/o cardiogenic pulm edema
2. what is classic sign on CXR
Dx of ARDS
1. PCWP <18 = r/o cardiogenic pulm edema
2. WHITE OUT ON CXR
34
Tx of ARDs
1. admit to ___
2. what type of support do they need
3. what types of meds
4. severe cases -->
Tx of ARDs
1. admit to ICU
2. resp support (intubate)
3. meds = pressors
4. severe cases --> ECMO
35
FB aspiration
1. what is main Sx (other = wheezing)
2. What type of CXR films should you get
3. What type of neck XRs to get
FB aspiration
1. what is main Sx = STRIDOR (other = wheezing)
2. type of CXR films = decubitus expiratory films
3. type of neck XRs = neck AP/Lat soft tissue
36
FB aspiration Tx
1. what to do if pt NOT spont breathing
2. what to do if pt in distress
3. what is last resort if FB inferior to vocal cords
FB aspiration Tx
1. pt NOT spont breathing --> hemlich + prep surg airway
2. pt in distress --> surgical airway or OR
3. last resort if FB inferior to vocal cords
- push it into mainstem bronchus w/ambo bag or ET tube
37
clot in pulm artery --> decr perfusion --> infarct/death
PE (Pulmonary Embolism)
38
Pathophys of PE: Virchow's Triad
| - whats included in it that leads to clot formation
Pathophys of PE: Virchow's Triad
1. endothelial damage
2. venous stasis
3. hypercoagulability
39
PE Presentation
1. MC Sx and MC sign
2. What is the classic triad
PE Presentation
1. MC sx = pleuritic CP and MC sign = tachypnea
2. Classic Triad = hemoptysis, dyspnea, CP
40
Pt presents w/ SOB, DOE, pleuritic CP, calf pain, anxiety, palpitations, hemoptysis. PE shows tachycardia, tachypnea, hypoxia, rales, wheezes, fever and swollen R lower leg
Dx?
Dx = PE
41
Dx of PE: When is D-dimer useful for PE
- what types of pts
- what does low # mean
D-dimer
- useful for LOW risk pts
- low # = low risk of PE --> helps r/o PE
42
Dx of PE: Wells Criteria
1. what value gives you high likelihood of PE
2. what value gives low likelihood
Dx of PE: Wells Criteria
1. >6 = high likelihood of PE
2. < 4 = low likelihood
43
Dx of PE: PERC score (rule out criteria)
1. if pt answers yes to 1 what does that mean
2. if pt answers no to all what does that mean
3. what is it trying to determine
Dx of PE: PERC score (rule out criteria)
1. if pt answers yes to 1 --> CANT r/o PE
2. if pt answers no to ALL --> very unlikely have PE --> d/c
3. trying to determine whether any further dx testing is needed
44
What is the BEST imaging modality for PE
what 2 tests = best to r/o other causes
CT pulm angiography = best test for PE
r/o other causes = CXR and EKG
45
EKG and PE
1. MC finding
2. what triad also seen
EKG and PE
1. MC = sinus tachycardia
2. triad = S1Q3T3
- deep S in 1
- Q in 3
- inverted T in 3
other findings: RBBB, a-fib
46
Tx of PE
1. stable pt
2. unstable pt
3. shock tx
4. severe HoTN -->
5. shock, resp distress or cardiac arrest --> what types of meds given
5. unstable, proven PE, on pressors --> what can be done (but rare)
Tx of PE
1. stable pt --> Lovenox
2. unstable pt --> Heparin
3. shock tx --> IV fluids
4. severe HoTN --> DA
5. shock, resp distress or cardiac arrest --> what types of meds given --> Thrombolysis (tPA, streptokinase)
5. unstable, proven PE, on pressors --> Embolectomy (rare)
47
If a pt is high risk for PE what is next step
high risk for PE --> CT pulm angiography
48
Pleural Effusion
- 4 MC causes
- main Dx test to Dx
Pleural Effusion: MC causes
1. CHF
2. PNA
3. CA
4. PE
main dx test = CXR
49
Pt presents w/ dyspnea, cough, CP, LE edema, orthopnea, night sweats and wt loss, fever and purulent sputum. On PE you hear diminished breath sounds, dullness to percussion, egophony and pleural friction rub
Dx?
Dx = Pleural effusion
50
Transudate vs exudate
- which is bilat + a/w CHF, fluid overloa,d cirrhosis, hypoablumin
- which is unilat + a/w infxn, connective tissue dz, pancreatitis, CA
Transudate vs exudate
- Transudate = bilat + a/w CHF, fluid overloa,d cirrhosis, hypoablumin
- Exudate = unilat + a/w infxn, connective tissue dz, pancreatitis, CA
51
Tx for Pleural Effusion
1. 2 options if its large
2. what procedure to do if want cells for malig
3. what procedure for recurrent malig effusions
Tx for Pleural Effusion
1. large --> thoracentesis or chest tube
2. want cells for malig --> thoracentesis
3. recurrent malig effusions --> pleurodesis
52
Pt presents w/ acute onset of L sided CP and decr breath sounds on. Vitals: RR = 26, HR = 130 and BP 90/56. PE and further testing shows subQ emphysema and hyperresonance
Dx?
Dx = Pneumothorax
53
When pt has spont pneumothorax w/PNA
| - what 3 organisms are likely the cause
Causes of spont pneumothorax w/PNA
1. PJP
2. TB
3. S. aureus
54
Dx Pneumothorax
1. what types of CXR films want
2. why need to get CT
3. what does CXR show if tension pneumo
Dx Pneumothorax
1. types CXR films = upright inspir/expiratory films
2. need to get CT to determine % of PTX
3. Tension pneumo on CXR --> mediastinal shift to unaffected side
55
Tx of Pneumothorax
1. what is main for of Tx and what is always given w/it
2 what procedure done for it
3. what procedure do some pts need eventally
4. tx for tension pneumo
Tx of Pneumothorax
1. air resorption at 1-2%/day w/ 3-4 of O2
2. procedure = chest tube
3. eventually some need thoracostomy
4. tension pneumo --> IMMED needle decompression
56
Tx of Pneumothorax: Primary vs Secondary
1. what is tx for primary + < 15% PTX by CT
2. what is tx for primary + > 15% AND secondary
Tx of Pneumothorax: Primary vs Secondary
1. Tx for primary + < 15% PTX by CT = observe
2. primary + > 15% AND secondary = chest tube + H2O suction
