Chapter 14 - Evidence-Based Medicine Principles Flashcards Preview

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Flashcards in Chapter 14 - Evidence-Based Medicine Principles Deck (22)
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1

A sleep study conducted on a 38-year-old adult male patient reveals the following: an average of 12 apneic periods/hr, each lasting at least 20 seconds. During the apneic episodes, the patient does not make any effort to breathe. The patient also complains of chronic day-time sleepiness. Which of the following is the most likely cause of this patient's problem?

  1. obstructive sleep apnea
  2. central sleep apnea
  3. chronic hypothyroidism
  4. high intracranial pressure

2

The most likely cause of this patient's problem is central sleep apnea. Central sleep apnea is characterized by the occurrence of at least 5 or more apneic periods/hr (of 10 seconds or more), during which the patient usually do not make any effort to breathe. Central sleep apnea is most likely due to a defect in the CNS respiratory control mechanism.

2

A patient with status asthmaticus is being mechanically ventilated. Which of the following values are consistent with this condition?

  1. Peak Pressure cm H2O: 20; Plateau Pressure cm H2O: 15; Tidal Volume mL: 600
  2. Peak Pressure cm H2O: 25; Plateau Pressure cm H2O: 20; Tidal Volume mL: 800
  3. Peak Pressure cm H2O: 40; Plateau Pressure cm H2O: 20; Tidal Volume mL: 600
  4. Peak Pressure cm H2O: 60; Plateau Pressure cm H2O: 55; Tidal Volume mL: 800

3

Increased airway resistance is the hallmark of asthma. On a mechanically ventilated patient this is indicated by an increase between the peak and plateau pressures.

3

A 53-year-old patient complains that every winter for the past couple of years she develops a chronic cough usually accompanied by thick sputum. This information indicates that the patient probably has which of the following conditions?

  1. acute asthma
  2. chronic bronchitis
  3. pulmonary fibrosis
  4. congestive heart failure

2

Chronic bronchitis is defined by its symptoms, i.e., a productive cough for at least three months per year for at least two years. Other common findings that can help confirm the diagnosis include a noisy chest, cyanosis, and (in advanced stages) signs of right heart failure (i.e., peripheral edema, and jugular venous distension).

4

Which of the following drugs would you recommend to help control symptoms of a patient with mild persistent asthma?

  1. acetylcysteine (Mucomyst)
  2. albuterol (Proventil)
  3. beclomethasone (Vanceril)
  4. salmeterol (Serevent)

3

For mild persistent asthma daily administration of an anti-inflammatory drug is indicated. This may involve inhalation of a low dose corticosteroid such as beclomethasone (Vanceril) or a mast cell stabilizer such as cromolyn or nedocromil. The leukotriene modifiers montelukast (Singulair), zafirlukast (Accolate), or zileuton (Zyflo) may also be considered. Beta2-agonists like albuterol or salmeterol are generally indicated only for moderate to severe persistent asthma.

5

You are asked to evaluate and recommend therapy for an infant who has contracted bronchiolitis caused by respiratory syncytial virus. Which of the following drugs would you recommend be administered by inhalation to treat this condition?

  1. tobramycin (TOBI)
  2. albuterol (Proventil)
  3. ribavirin (Virazole)
  4. beclomethasone (Vanceril)

2

Currently, the only therapies recommended by the American Academy of Pediatrics to treat bronchiolitis caused by RSV are oxygen (if SaO2 <90%) and bronchodilators (with continuation only if the patient shows response). Inhalation of hypertonic saline (3%) aerosol also shows some promise as a treatment for this disorder. Antibiotics (e.g., tobramycin), corticosteroids (e.g., beclomethasone) and ribavirin are not recommended to treat bronchiolitis.

6

A physician orders intubation and volume control A/C ventilation for a 6 foot 3 inch tall 190 lb (86 kg) adult male patient with ARDS. Which of the following ventilator settings would you aim for to support this patient?

  1. Rate/min: 10; VT (mL): 800
  2. Rate/min: 8; VT (mL): 1200
  3. Rate/min: 20; VT (mL): 900
  4. Rate/min: 15; VT (mL): 900

4

In adult patients with ARDS, the goal is to achieve a tidal volume of 6 mL/kg of predicted body weight, with a plateau pressure (Pplat) < 30 cm H2O. If Pplat > 30 cm H2O at 6 mL/kg, the VT can be reduced to as low as 4 mL/kg. The respiratory rate should be set to approximate the baseline minute ventilation, with the goal to achieve a pH between 7.20 and 7.45. For a six foot 3 inch tall patient with a predicted body weight of 85 kg, the goal would be a VT of about 500 mL with a rate between 10-20/min. In some cases rates as high as 35/min may be needed to maintain the pH above 7.30.

7

You would recommend against using noninvasive positive pressure ventilation (NPPV) for a patient with:

  1. lower extremity trauma
  2. a past history of oral intubation
  3. needing airway protection
  4. FIO2 needs exceeding 40%

3

Absolute contraindications against using NPPV include the following: need for immediate intubation, hemodynamic instability, active cardiac arrhythmias or ischemia, active upper GI bleeding, uncooperative patient, facial burns or trauma, and the need for airway protection.

8

A doctor institutes volume control ventilation for an 80 kg ARDS patient. Which of the following is the maximum pressure you would aim to achieve in this patient?

  1. 50 cm H2O peak pressure
  2. 30 cm H2O plateau pressure
  3. 40 cm H2O peak pressure
  4. 50 cm H2O plateau pressure

2

According to the NHLBI Protocol, the target volume for ARDS patients is 4-6 mL/kg, with a maximum plateau (alveolar) pressure of 30 cm H2O. The ventilator rate should initially be set to match the prior VE, but can be increased as needed up to a maximum of 35/min.

9

All patients with asthma should be prescribed a:

  1. leukotriene modifier
  2. short-acting beta-agonist
  3. oral corticosteroid
  4. long-acting beta-agonist

2

All patients with asthma should be prescribed a short-acting beta-agonist inhaled bronchodilator as needed (PRN). Assuming good asthma education, elimination of triggers and management of comorbidities, drug management is then tailored to the severity of disease and its degree of control.

10

A patient has a pulmonary capillary wedge pressure (PCWP) of 20 mm Hg. Which of the following does this measurement likely indicate?

  1. Left ventricular failure
  2. Tricuspid valve stenosis
  3. Hypovolemic shock
  4. Pulmonary vasodilation

1

Normal pulmonary artery (or capillary) wedge pressures (PAWP/PCWP) range between 6–12 mm Hg. An elevated PAWP is often observed in LV failure/cardiogenic shock, hypervolemia, cardiac tamponade/constrictive pericarditis, mitral stenosis and pneumothorax. The PAWP also may be elevated above normal with application of positive pressure ventilation, especially when combined with PEEP.

11

In reviewing the chart of a 68-year-old patient, you note that the patient has a history of increased sputum production, chronic respiratory acidosis and polycythemia. What is the most likely diagnosis?

  1. Chronic bronchitis
  2. Pneumonia
  3. Tuberculosis
  4. Asthma

1

A patient with a history of increased sputum production, chronic respiratory acidosis and polycythemia most likely has chronic bronchitis.

12

After bronchodilator therapy, you record the following PFT data on a 67-year-old male COPD patient who reports frequent exacerbations of his condition: FEV1/FVC = 59%; FEV1 = 44% predicted. You would characterize the stage of the patient's COPD as:

  1. mild
  2. moderate
  3. severe
  4. very severe

3

Irreversible airflow obstruction is present when the FEV1/FVC ratio after bronchodilator treatment is less than 70% of predicted. The stage of COPD is then gauged by its impact on the predicted FEV1. If the FEV1 is < 50% but ≥ 30% of the patient's predicted value and there is a history of repeated exacerbations, the stage is classified as severe.

13

A doctor institutes volume control ventilation for a 70 kg ARDS patient with a targeted tidal volume of 420 mL. To maintain adequate ventilation with this tidal volume, you would allow a machine respiratory rate as high as:

  1. 20/min
  2. 25/min
  3. 30/min
  4. 35/min

4

According to the NHLBI Protocol, you begin ventilation of ARDS patients with an initial tidal volume of 8 mL/kg IBW, then reduce it by 1 mL/kg every 2 hours until you achieve a VT of 6 mL/kg (minimum of 4 mL/kg). The ventilator rate should initially be set to match the prior VE, but can be increased as needed up to a maximum of 35/min.

14

Which of the following drugs you would NOT recommend for the long-term management of mild persistent asthma in an adult patient?

  1. levalbuterol (Xopenex) 
  2. beclomethasone (Vanceril)
  3. zafirlukast (Accolate)
  4. cromolyn sodium (Intal)

1

Mild persistent asthma normally is treated with daily dosing of an anti-inflammatory drug. Options include a low-dose inhaled corticosteroid (like beclomethasone), or cromolyn sodium (Intal). Children usually begin with a trial of cromolyn or nedocromil. The leukotriene modifier (Montelukast-Singulair) may also be considered. Levalbuterol (Xopenex) is a short-acting beta agonist used primarily for treating exacerbation of symptoms, i.e., as a reliever or 'rescue' medication.

15

A physician orders intubation and volume control A/C ventilation for a 6 foot 3 inch tall 190 lb (86 kg) adult male patient with ARDS. Which of the following ventilator settings would you aim for to support this patient?
 


                         Rate/min                         VT (mL)

A                       10                                      800

B                        8                                      1200

C                      20                                      900

D                      15                                       500

  1. A
  2. B
  3. C
  4. D

4

In adult patients with ARDS, the goal is to achieve a tidal volume of 6 mL/kg of predicted body weight, with a plateau pressure (Pplat) < 30 cm H2O. If Pplat > 30 cm H2O at 6 mL/kg, the VT can be reduced to as low as 4 mL/kg. The respiratory rate should be set to approximate the baseline minute ventilation, with the goal to achieve a pH between 7.20 and 7.45. For a six foot 3 inch tall patient with a predicted body weight of 85 kg, the goal would be a VT of about 500 mL with a rate between 10-20/min. In some cases rates as high as 35/min may be needed to maintain the pH above 7.30.

16

Which of the following patients would benefit LEAST from pulmonary rehabilitation?

  1. a patient with chronic bronchitis
  2. a patient with pulmonary emphysema
  3. a patient with pulmonary fibrosis
  4. a patient with malignant lung cancer 

4

Patients most likely to benefit from pulmonary rehabilitation are those with persistent symptoms due to COPD. Patients are excluded from pulmonary rehabilitation activities if (1) their problem involves cardiovascular instability requiring cardiac monitoring; (2) they have severe arthritis or a neuromuscular abnormality (refer to physical therapy for review); or (3) they have a malignant neoplasms involving the respiratory system.

17

A COPD patient receiving volume control A/C ventilation has failed numerous spontaneous breathing trials (SBTs) via on-ventilator CPAP+pressure support and remains ventilator-dependent after three weeks in a step-down unit. Which of the following would you recommend to help liberate this patient from mechanical ventilation?

  1. switch to airway pressure release ventilation
  2. recommend instituting diaphragmatic pacing
  3. slowly reduce support via decreasing rate SIMV
  4. switch to pressure control A/C ventilation

3

For ventilator-dependent who fail standard SBTs, you should gradually reduce the level of ventilator support using a mode such as SMIV. Once such patients progress to the point where they can provide at least half the needed minute volume via spontaneous breathing, you can consider implementing a standard SBT protocol. However, rather than discontinue ventilatory support after a successful trial, you instead should implement periods of spontaneous breathing of increasing duration, e.g., 30-60-120-240 minutes, until the patient is fully liberated from the ventilator.

18

In managing a patient suffering from an acute asthma attack with O2 and bronchodilators, you note a rise in the PCO2 to 50 mm Hg, with a pH of 7.27. Although anxious, the patient remains alert and cooperative during therapy. Which of the following would you recommend at this time?

  1. administer a beta adrenergic blocking agent
  2. administer a CNS respiratory depressant
  3. intubate and provide mechanical ventilation
  4. continue current management with careful monitoring

4

Mechanical ventilation is often initiated in asthmatic patients once the PaCO2 begins to climb above normal. However, recent evidence suggests that intubation and mechanical ventilation can be avoided -- even in the face of moderate hypercapnia -- as long as the patient remains alert and cooperative during therapy. If, on the other hand, consciousness becomes impaired, mechanical ventilation usually becomes necessary.

19

An 18 year old asthma patient has symptoms a couple times a month, sometimes at night. Between exacerbations, she has near normal peak flows. Which of the following drugs would you recommend to help manage her condition?

  1. Albuterol (Proventil) MDI PRN 
  2. Salmeterol (Serevent) 2 puffs 2x daily
  3. Bbeclomethasone (Vanceril) PRN
  4. Cromolyn sodium (Intal) 2 puffs 4x daily

1

Based on the symptoms and peak flow findings, the patient has mild intermittent asthma. No daily medications are required for the management of mild intermittent asthma. A short-acting beta-agonist (SABA) like albuterol by inhalation should be prescribed as needed (PRN) for quick relief of exacerbations when they occur. Use of short-acting inhaled beta-agonists more than twice a week may indicate the need to for long-term therapy with corticosteroids.

20

A patient whose asthma was well-controlled using a short-acting beta-agonist inhaler PRN and low dose inhaled corticosteroid BID reports that she recently has been experiencing shortness of breath almost daily and is awakened at night with wheezing episodes. Her peak flow, which had been 83% of her predicted normal is now at 66% of the predicted value. Which of the following would you recommend to the patient's doctor as possible changes to the current drug regimen?

  1. switch from inhaled to oral corticosteroid therapy
  2. discontinue the short-acting beta agonist inhaler
  3. switch the short-acting beta agonist from PRN to Q4H
  4. increase the dosage of the inhaled corticosteroid

4

Drug management of patient's with asthma is tailored to the severity of disease and its degree of control. If the patient's control worsens (as here), additional drugs and/or higher doses are prescribed (STEP UP). In this case the doctor should first consider increasing the inhaled corticosteroid dosage. As an alternative, either a long-active beta-agonist or leukotriene modifier (both considered controllers) could be added to the drug regimen. All asthmatics should have access to a short-acting beta-agonist inhaler PRN; however its regular use (e.g., Q4H) can lead to tolerance and failure to relieve patient symptoms. Oral corticosteroids can help control asthma, but prolonged use can lead to serious side effects. Given the higher safety profile of inhaled steroids, upping its dose is the best initial action.

21

A doctor institutes volume control A/C ventilation for an 80-kg ARDS patient. Which of the following is the maximum plateau pressure you should aim to achieve in this patient?

  1. 50 cm H2O peak pressure
  2. 30 cm H2O plateau pressure
  3. 40 cm H2O peak pressure
  4. 50 cm H2O plateau pressure

2

According to the NHLBI protocol, the target volume for ARDS patients is 4–6 mL/kg, with a maximum plateau (alveolar) pressure of 30 cm H2O. The ventilator rate should initially be set to match the prior VE but can be increased as needed up to a maximum of 35 breaths/min.

22

A patient who just suffered severe closed head injury is receiving volume controlled A/C ventilation. His intracranial pressure (ICP) is 23 mm Hg. Which of the following goals would you recommend for initial ventilatory support?

  1. use high-level PEEP to impede venous return
  2. maintain the PaCO2 in the 25 to 30 torr range
  3. decrease the sensitivity to prevent patient triggering
  4. maintain the PaCO2 in the 35-40 torr range

4

The overall goal of managing patients with closed head trauma is to prevent secondary injury by maintaining adequate cerebral perfusion pressure (CPP) and brain oxygenation. Because CPP = mean arterial pressure (MAP) - intracranial pressure (ICP), ventilatory care should aim to (1) maximize arterial oxygenation and (2) avoid actions that would either increase ICP or lower MAP. Goals therefore include maintaining an SaO2 of 100%; keeping the PaCO2 between 35-40 torr (hypercapnia increases ICP); keeping the PIP ≤ 30 cm H2O (minimally affecting MAP); and assuring good patient-ventilator synchrony (helps prevent increases in intrathoracic pressure/ICP). Hyperventilation (PaCO2 < 35 torr) should only be considered if there is an acute deterioration in neurologic status that does not respond to standard brain trauma therapy, such as osmotic diuresis, CSF fluid drainage and sedation/neuromuscular blockade.