Airways and Respiratory Flashcards
(71 cards)
What are the causes of bronciolitis?
Respiratory syncytial Virus<br></br>human metapneumovirus, <br></br>adenovirus, <br></br>influenza, <br></br>rhinovirus and <br></br>parainfluenza virus
Apnea risk factors in bronchiolitis
prematurity, <br></br>less than 3 months old, <br></br>previous episode of apnea, <br></br>underlying cardiorespiratory disease, immunodeficiency
Admission criteria in bronchiolitis:
<ul> <li>prematurity,</li> <li>persistent tachypnea or work of breathing,</li> <li>dehydration,</li> <li>Need for oxygen supplementation,</li> <li>apnea (witnessed or risk factors, even if well appearing)</li> </ul>
Complications of cystic fibrosis
<p>Acute respiratory exacerbations<br></br>Pneumonia<br></br>PneumoTx<br></br>Chronic inflammation leading to bronchiectasis<br></br>Cor pulmonale<br></br>Meconium ileus<br></br>Pancreatic insuff (DM, FTT, pancreatitis, malabsorption)</p>
Initial ventilator setting for intubated asthmatic patient:
“<ul><li>Respiratory rate low (6-8/min) to start</li><li>Small tidal volumes (6ml/kg of ideal body weight)</li><li>Fast inspiratory flow rate (≥ 100L/min) to allow a long expiratory time (I:E >1:4 ie inspiratory to expiratory ratio of 1:4 or more)</li><li>FiO2 100% initially then titrated down to keep sats > 90%</li><li>Minimal or no PEEP (≤5)</li><li>Agoal of a plateau pressure of less than 30mmHg. If the plateau pressure is too high, decreasing the respiratory rate<br></br></li><li><img></img><br></br></li></ul>”
Severe asthma Mx
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What are the causes of atypical pneumonia
<p>–<em>Legionella pneumophila</em></p>
<p>–<em>Mycoplasma pneumoniae</em></p>
<p>–<em>Chlamydia pneumoniae</em></p>
<p>–<em>Chlamydia </em><em>psittaci</em></p>
<p>–Fungal pneumonia <em>(Candida, Aspergillus, Cryptococcus, </em>etc<em>)</em></p>
<p>-Viral pneumonia<em> (HSV, CMV, RSV, EBV, VZV, </em>etc<em>)</em></p>
<p>When should you consider testing for atypical causes of pneumonia?</p>
<p>–Severe pneumonia</p>
<p>–Known outbreak (ie. Legionella)</p>
<p>–Definite findings of other non-pulmonary site of infection (chlamydia, VZV, etc)</p>
<p>–Significant immunosuppression</p>
<p>Match the etiologic agent with its typical chest radiograph appearance</p>
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CURB-65
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<p>According to North American Guidelines, list 2 potential classes of oral antibiotics that could be appropriate as first line outpatient treatment for pneumonia</p>
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<p>What are the <strong>most</strong> important MRSA/Pseudomonas risk factors when considering empiric coverage?</p>
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<p>Name 3 names or classes of antibiotics to cover pseudomonal respiratory infections</p>
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<p>Name 3 names or classes of antibiotics to cover MRSA respiratory infections</p>
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<ul> <li>Distinguish between aspiration pneumonitis and aspiration pneumonia</li> </ul>
<p>–Aspiration pneumonitis = acute reaction to chemical insult</p>
<p>–Aspiration pneumonia = occurs 24-72h after initial aspiration event, secondary bacterial infection</p>
<p>aspiration pneumonia. List 2 oral and 2 parenteral medication regimes for this condition</p>
<p>–Requires oral anaerobic coverage:</p>
<ul> <li>Amoxicillin + Clavulin</li> <li>Amoxicillin + Metronidazole</li> <li>Clindamycin</li> <li>Moxifloxacin OR Levofloxacin +/- Metronidazole</li> <li>Ceftriaxone + Metronidazole</li> <li>Piperacillin/Tazobactam</li> <li>Carbapenem</li> </ul>
DDx of fever + hemoptysis
<ul> <li>Infection <ul> <li>Pneumonia</li> <li>TB</li> <li>Bronchitis</li> </ul> </li> <li>Vascular <ul> <li>PE</li> <li>AVM</li> <li>Pulm hge</li> </ul> </li> <li>Malignancy</li> <li>Bronchiectasis</li> <li>Granulomatous dis</li> </ul>
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<p>Risk Factors for TB Infection</p>
<ul> <li>(Travel/work in endemic area)</li> <li>Contact withtuberculosis positive individual</li> <li>Immunocompromised (esp. HIV)</li> <li>Elderly</li> <li>Nursing home resident</li> <li>Alcoholism</li> <li>Illicit drug users</li> <li>Prisoner resident/staff</li> <li>Health care worker</li> <li>Homeless shelters</li> <li>First nation reserves</li> </ul>
Rx of TB
<p>RIPE</p>
<ul> <li>Rifampin</li> <li>Isoniazide</li> <li>Ethambutol</li> <li>Pyrazinamide</li> </ul>
SE of TB meds
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What is the definition of Massive hemoptysis?
<p>–>500ml over 24h</p>
<p>–>100ml over 1hr</p>
<p>–Hemoptysis associated with hemodynamic instability</p>
<p>–Clinically: <em>streaking vs. vials</em> vs. <em>frank </em>bright red blood</p>
<ul> <li>What temporizing measure can be considered before intubation/ while awaiting definitive management of massive hemoptysis?</li> </ul>
Nebulized TXA
<p>Light’s Criteria of pleural effusion</p>
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Transudative vs Exudative pl effusion
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O2 +/- NIPPV
Ventolin/atrovent
D-Dimer
BNP
ABG/VBG
Lactate
CXR
ECG
Hyper-expansion, flattening of hemi-diaphragms
Chronic COPD
Absence of consolidation
–Worsening SOB with 2/3 of:
- Increased amount of sputum
- Increased purulence of sputum
- Increased cough severity/frequency
–Respiratory muscle fatigue
–Progression to respiratory failure
–Respiratory acidosis
–Refractory hypoxia/ hypercarbia
- Name 5 contraindications to NPPV
–Uncooperative patient
–Obtunded/ AMS
–Unable to clear airway secretions
–Hemodynamically unstable
–Respiratory arrest
–Pneumothorax
–Recent facial/GE surgery
–Facial burns
–Extreme obesity
–Poor NPPV mask fit
What RFs increase the risk of a severe/life-threatening asthma exacerbation?
In patients being discharged from the ED with asthma, what should be discussed?
What historical features would increase your suspicion of PE in this patient?
Entire leg swelling
Collateral superficial vv or varicose vv
Tenderness along DVS
Unilateral pitting edema
White or blue discolouration of leg (Phlegmasia cerulea/alba dolens)
NOAC==> pregnant, Cancer
Thrombolytics in PE
Outpatient anticoagulation in PE?
Difficult BVM? List 4 things you can try to improve bag-mask ventilation
–Reposition the patient
–Insert oral/nasal airway
–2-person BMV
–Change mask size
–Lube/muco/tegaderm to beard
–Consider foreign body
What are 4 features predictive of difficult airway/intubation?
MMAP
- Measure (3,3,2 – hypomental distance, mouth opening, and bite test)
- Mallampati
- Atlanto-occipital extension
- Pathology (upper airway)
what factors should be present to consider awake intubation?
–Predictors of difficult airway or BVM
–Avoiding supine positioning (tracheal fracture)
–Difficult physiology (ie. acidosis – important to maintain compensatory ^ RR)
–Cooperative patient
–Time to prepare/set up (ie. not crash intubation)
–Back-up available
–Reposition yourself / patient
–Three B’s… BURP, Boogie, Blade
–Different tube size
–Alternate intubation technique/ device (VL)
–Different operator/intubator
–Rescue device
- Surgical airway
- Prepare equipment
- Position
- Pre-oxygenate
- Pre-treat with fluids
- Pharmacology: induction and paralysis
- Position
- Place tube and confirm
- Post-intubation care
List 3 induction agents, doses, and 1 potential side effect for each (exclude allergy).
Contraindications to Succinylcholine?
–Personal or familial history of:
- malignant hyperthermia
- skeletal muscle myopathies (MS, Muscular Dystrophy)
–Glaucoma, penetrating eye injury
- Can increase IOP
–After major burns, multiple trauma/crush injury, extensive denervation of skeletal muscle, upper motor neuron injury, CVA
- Why?
Hyperkalemia
EtCO2: waveform
CXR
POCUS
Post-intubation Care
- Secure tube
- Analgesia
- Sedation
- Lung protective ventilator settings
- HOB at 30 deg
- OG/NG
- ABG 20-30 mins post to assess oxygenation
Mode- Volume assist control
Tidal Volume- 8cc/kg
Flow rate- 60L/min
RR- 15
FiO2- 30-50%
PEEP- 5-10
–Displacement of the ETT
–Obstruction of the ETT
–Patient — especially pneumothorax; also: pulmonary embolism, pulmonary edema, collapse, bronchospasm
–Equipment — ventilator problems
–Stacked breaths — a reminder about bronchospasm and ventilator settings
-Tracheal deviation, JVD (tension PTX)
-Pedal edema, anasarca, swelling (CHF, renal failure)
-Unilateral leg swelling/ redness, JVD (PE)
-Altered LOC, confusion (DKA, toxic ingestion, sepsis)
-Pallor (anemia)
-New cardiac murmur (endocarditis, ACS, CHF)
-Stridor (airway obstruction, angioedema vs infectious)
-Pregnancy
-Smoking (incombination with OCP)
-Active malignancy
-PMHx of a known clotting disorder
-Family history of VTE/ clotting disorder
-CHF
-Varicose veins
-No other diagnosis as likely as DVT
(Note: no historical features from the stem are accepted “other historical features”)
-Hemoptysis
-Palpitations
-Chest pain
-Lightheadedness
-Fatigue
-Syncope
(Note: historical (not physical exam) features only.
Also, no features of DVT are accepted, only for PE)
--(no marks for d.dimer. This patient is high risk as per Well’s score - straight to imaging)
-Results may:
--Help determine the patient’s disposition/ need for admission (PESI score)
--Change treatment decisions if the patient became unstable (lytics, heparin)
-Any DOAC: mechanical heart valves, significant renal impairment, pregnancy, breastfeeding
-Enoxaparin/Dalteparin/Fondaparinux: Hx of HIT, renal failure
-Heparin: Hx of HIT
-TPA: (absolute CIs) Hemorrhagic CVA, ischemic CVA (3 months), structural cerebrovascular disease/AVM, CNS neoplasm, recent CNS surgery, recent head trauma with fracture or brain injury, active bleeding, known bleeding diathesis
-Mg SO4
-Continuous salbutamol / ipratropium
-NS bolus 20 mg/kg
-Epinephrine IM
-Salbutamol infusion
-HFNC
-Intubation
Disposition: pediatric ICU
Bougie
6-0 ETT"
Paralytic- rocuronium (0.6-1.2mg/kg) or succinylcholine (0.6-1.5mg/kg)
Pressor- Norepi 5-20 mcg/min, Epi 5-20 mcg/min, Phenyl 100-300mcg/min
Tidal Volume: 6-8cc/kg
Resp rate: 12-16
Inspiratory flow rate: 60L (can be titrated higher)
FiO2: 60% (higher is acceptable)
PEEP: 5-10 is acceptable to start (less then 15 is acceptable)
Inability to protect the airway against aspiration
Failure to ventilate
Failure to oxygenate
Anticipation of a deteriorating course that will eventually lead to respiratory failure
-Previous intubation
-Multiple ER visits/ frequent exacerbations
-Recent/ chronic steroid use
-Home O2 use
-Medical Comorbidities (CVD, other chronic lung disease, major psychosocial disorder, substance abuse)
-Altered mental status, confusion
-Rising pCO2
-Worsening respiratory acidosis
-Significant tachypnea: RR>30
-Significant hypoxia, despite O2 therapy
-Cyanosis/ poor perfusion/ hemodynamic instability/ arrhythmias
-Ventolin 2.5 mg nebulizer or 4-8 puffs, back to back
-Atrovent 500 µg nebulizer x3
-IV corticosteroids: solumedrol
-Antibiotics:
---Cetriazone + azithromycin
---Respiratory fluorquinolone
-Consider BiPAP, CPAP, Heliox
-Prep for/ consider intubation
-Suction mouth, examine for FB
-Take off the collar/ use manual in line neck stabilization to allow for mouth opening
-Change masks (smaller, larger)
-Use 2 person technique for BVM
-Use adjunctive airway devices (NPA, OPA)
-Add PEEP
-Beard: apply muco/gel/tegaderm to face for better seal
-Obese: wrap cheeks around face, use ramp
-Auscultating bilateral breath sounds
-Absence of gastric sounds with breaths
-Misting of ETT with breaths
-Improving O2 sats or pO2 on ABG
-Good BVM compliance
(No marks for CXR - does not distinguish trachea vs esophagus)
