Chest Pain To ARDS

Question 1

Pain 2/2 to inflamation ion of the parietal pleura

Following a URI, Pneumonia or infection,

S/S: local sharp pain that increases with cough, sneezing, or deep RR that radiates to the ipsilateral shoulder
+/i a friction rub on lung auscultation

D/o and Tx?

Answer 1

Plurisy/ Pluertitis

Tx the underlying condition
+Indomethacin and Codine for cough suppression

Question 2

Abnormal fluid in the lung space

S/s dyspnea, cough, respirophasic pain, Increased dullness to percussion, decreased RR sounds

Thoacocentesis reveals milky white fluid with a low pH and positive Gram Stain

Answer 2

Empyema

Dx Thoracocentesis (Dx and Tx)
-if unknown cause or
Clinically: bilateral effusion of CHF (obvious cause)

Tx: ABX and Tube Thoracostomy

Question 3

What is the Tx for frequent recurrent pleural effusions

Answer 3

Pluerodesis

Question 4

Abnormal fluid in the lung space

S/s dyspnea, cough, respirophasic pain, Increased dullness to percussion, decreased RR sounds

Thoacocentesis reveals sterile pleural fluid

D/o and Tx?

Answer 4

Uncomplicated pleural effusion

Dx Thoracocentesis (Dx and Tx)
-if unknown cause or
Clinically: bilateral effusion of CHF (obvious cause)

Tx: ABX for treatment of underlying pneumonia

Question 5

Abnormal fluid in the lung space

S/s dyspnea, cough, respirophasic pain, Increased dullness to percussion, decreased RR sounds

Thoacocentesis reveals fluid with low glucose (less than 60) and low pH (<7.2) with negative Gram stain

D/o and Tx?

Answer 5

Complicated Plerual Effusion

Dx Thoracocentesis (Dx and Tx)
-if unknown cause or
Clinically: bilateral effusion of CHF (obvious cause)

Tx: ABX and tube thoracotomy

Question 6

Effusions due to infection refractory to antibiotics and drainage require

Answer 6

surgical debridement.

Question 7

Chest centesis reveals triglycerides >110 mg/dl

Think?

Answer 7

Chylothorax exudative pleural effusion

Question 8

Esophageal rupture leads to what types of effusion

Answer 8

Exudative

Question 9

Centsesis reveals high amylase with a left sided effusion, think?

Answer 9

Pancreatitis, and or esophageal rupture

Question 10

Plural effusion with frank pus in the plural space with a postive gram stain and refractory fevers

Think ? Tx?

Answer 10

Empyema (Exudative Plural effusion)

Tx Prompt Drainage and ABX

Question 11

Chest centesis reveals an empyma (infection) with cholesterol crystals

Think

Answer 11

Exudative Plueral Effusion 2/2 Rheumatoid

Question 12

Plueral centesis reveals e elated protein with no other findings think>?

Answer 12

TB (exudative effusion)

Question 13

What is the fluid level requirement for centesis of the chest

Answer 13

Need at least 1 cm of fluid in the decubitus view to perform a blind centensis

Otherwise centesis should be guided by U/S

Question 14

What is the lowest level of fluid that can be detected by CT

(Plueral effusion)

Answer 14

10 Ml of fluid

Question 15

Difference between a hemorrhagic plural effusion and a hemothorax

Answer 15

Hemorrhagic pleural effusion—mix of blood & pleural fluid

Hemothorax—gross blood in pleural space
—Pleural fluid hct : blood hct > 0.5

Question 16

difference of Empyema vs chylous effusion

Answer 16

After centrifuge

Empyema—clear fluid over white cells

Chylous effusion—persistently turbid
—Chylomicrons & elevated triglyceride level >100mg/dL

Question 17

Define Lights Criteria

Answer 17

Effusion is exudative if

1. Plerual fluid protein/ serum protein is greater than 0.5
2. Plueral effusion fluid LDH/ serum LDH is greater than 0.6
3. Plueral Fluid LDH is greater than 2/3 the ULN of the serum LDH.

Question 18

What is the most common causes of exudative p. effusion?

Answer 18

CA

Question 19

Tall thin male aged 2-40, with a hx of smoking. Euchroid proportions (marfans)

S/s sudden onset unilateral chest pain, at rest or awoken from sleep
With tachyHr, diminished breath sounds decreased tactile fremitus, and hyper resonance unilateral

D/o? CXR? Tx?

Answer 19

Simple Pneumothorax

CXR: Visceral Pleural Line
(Late complicated findings are tracheal shift, medistinal shift)

Tx: Needle decompression and possible chest tube

If less than 3cm can be treated outpt with f/u at 24hrs

> 3cm needle D to chest tube

Question 20

What conditions place a patient at risk of developing 2nd PneumoTHX ?

Answer 20

complication of pre-existing lung disease

• COPD
• asthma
• cystic fibrosis
• tuberculosis
• pneumocystis pneumonia
• interstitial lung disease

Question 21

Pts at increased risk of Simple Tension Pneumo should be counseled to…

Answer 21

Stop smoking, avoid high alt. Or scuba diving

Question 22

What is the Tx for recurrent tension Pneumos

Answer 22

Resection of blebs and pluordesis

Question 23

What is the O2 delivery of a NC

Answer 23

FiO2: 22-50%

with flow rate of 1-6 liters/min

Question 24

What is the O2 delivery of a simple face mask

Answer 24

Simple face mask can deliver oxygen concentrations of 40% to 60%
with flow rates from 6 to 10 L/min

Question 25

What is the O2 delivery of a Venturi Mask

Answer 25

Venturi principle masks 24% to 60% with flow rates from 4 to 12 L/min

Question 26

What is the O2 delivery of a NRB

Answer 26

Non-rebreather mask with reservoir: FiO2: 50-100% | with flow rates from 10 to 15 L/min

Question 27

What is the O2 delivery of a High Flow NC

Answer 27

High-flow nasal cannula 21-100% fi02 at flow rates of up to 60 liters/min

Question 28

Life threatening abnormal gas exchange with a PaO2 less than 60, SaO2 less than 90% or a PaCO2 >45mmHg Think ?

Answer 28

Acute Resp failure

Question 29

Primary causes of Hypoxemic Resp Failure

Answer 29

``` ARDS Pneumonia Acute lobar acetlectasis Chronic Pulm Edema Lung Contusions ```

Question 30

Common causes of Primary hypercapnic Acute resp. Failure

Answer 30

``` COPD Asthma GBS Rx MG Hypomagnesemia OHS ```

Question 31

Asterixis is a sign of…

Answer 31

Metabolic encephalopathy Seen in acute Resp failure As well as CKD, CHF, Liver failure

Question 32

A pt is at risk of Hypercapnic Resp Failure, and has an SpO2 less than 88.. what is the next intervention

Answer 32

Start O2 with NC 2-4 L.min on 28% O2 target is 92% +/- bronchodilator as needed Obtain ABG

Question 33

A pt is at risk of Hypercapnic Resp Failure, and has an SpO2 greater than 88.. what is the next intervention

Answer 33

No O2 Tx is needed, Monitor and consider ABG

Question 34

A pt is not at risk of hypercapnic resp failure and has an SPO2 less than 85%, what is the best Tx

Answer 34

``` Start O2 4L.min NC Or 5-10L with a nimble mask Or 15L/min of NRB ``` O2 goal of 92-96% Obtain ABG

Question 35

A pt is not at risk of hypercapnic resp failure and has an SPO2 is less than 91%, what is the best Tx

Answer 35

Start 2-4 L NC or other suitable O2 delivery with a O2 goal of 92-96% Consider ABG

Question 36

What is the 1st line O2 tx in pts with COPD

Answer 36

NIPPV (BiPAP)

Question 37

What are the 7 indications for intubation

Answer 37

1. Hypoxemia despite O2 tx 2. Upper Airway Obstruction (Laryngeal edema/ burns) 3. Impaired Airway Protection (Less than 8 intubate) 4. Inability to clear secretions 5. Progressive general fatigue, tachypnea, use of accessory muscle use or AMS 6. Apnea 7. Severe hypoxemia at presentation

Question 38

Right stem intubation leads to what ADE

Answer 38

Atelectasis of the contralateral lung and over distention of the intubated lung

Question 39

Ventilated pt has SubQ emphysema Pneumomediastinum and su Plueral air cysts Think ?

Answer 39

Barotruama Tx: hypoventilation to avoid baratura a

Question 40

What is the general supportive care for Acute Respiratory Failure

Answer 40

Nutrition, Monitor electrolytes, and ovoid oversedation, PPI to prevent ulcers and DVT prophylaxis

Question 41

Non cardiogenic pulmonary edema that leads to acute hypoxemia and RR failure Resp Distress onset within 1 wk of insult, profound dyspnea, hypoxemia refractory to tx, labored RR, tachypnea, crackles, plus multiple organ failure CXR: Bilateral ground glass appearance that spares the costophrenic angles with a NML hr size +bronchograms WIth a PaO2 and FiO2 ration less than 300. MC 2/2 sepsis, diffuse pneumonia, aspiration, or trauma Think? Tx?

Answer 41

ARDS Tx: Identify & treat underlying illness/injury —Broad spectrum antibiotics for sepsis and/or infection General supportive care Tracheal intubation and mechanical ventilation —The lowest levels of PEEP (used to recruit atelectatic alveoli) with supplemental O2 (FiO2 <60%) to maintain SaO2 >88% —Low tidal volume (ideal weight based 6 ml/kg) Prone positioning Monitor cardiac & other organ functions

Question 42

Describe the pathological progression of ARDS

Answer 42

Injury to the lungs, capillaries, and endothelial cells Leads to increased vasc. Permeability and decreased production/activity of surfactant Result: interstitial and alveolar pulmonary edema, alveolar collapse/atelectasis, and hypoxemia

Question 43

What should you rule out before making the Dx of ARDS

Answer 43

Pulm. Edema 2/2 HF

Question 44

Define Mild ARDS

Answer 44

PaO2/FiO2 ration between 200 and 300

Question 45

Define Moderate ARDS

Answer 45

P/F ration above 100 and less than 200

Question 46

define Severe ARDS

Answer 46

P/F ration less than 100

Question 47

Hyaline membrane disease in infants and nearly all preterm pts Caused by deficient pulmonary surfactant in an immature lung Rapid accumulation of neutrophils in the lung that lead to pulmonary edema and actelectasis leading to cytokines inflammatory response S/s tachypnea, cyanosis soon after birth, nasal flaring, with retractions and profound hypoxemia Think ? CXR? Tx?

Answer 47

Neonatal Resp. distress Syndrome CXR: low lung volumes,a nd classic reticulgranular ground glass appearances with air bronchograms Tx: Prevention with antenatal steroids at 23-34 weeks gestation Peep and Nasal CPAP leading up to intubation with exogenous surfactant admin. Intubation criteria is requiring a FIO2 of 0.40% or higher to maintain an O2 sat of 90 or above or any apnea