CPR Exam 2 Hubbard DSAs Flashcards
(131 cards)
1
Q
long-term management of pneumothorax
A
- stop smoking
- avoid: high altitudes, unpressurized flights, scuba diving
*if successful tx no LT complications associated
2
Q
confirmation and staging of COPD by GOLD standard uses
A
spirometry *all FEV1/FVC <70% FEV1 measurement: 1. mild : > 80 2. moderate < 80 3. severe < 50 4. very severe <30
*can also test severity via BODE index (BMI, obstruction, dyspnea, exercise intolerance)
3
Q
imaging of pulm embolism on CXR shows
A
- focal oligoemia (“west mark sign”)
- wedged shaped density above diaphragm (hampton hump)
- enlarged Pulm A.
4
Q
common TB signs and sx
A
maybe be asx early on
-sx: wt loss, chills, fever, and if advanced, hemopytsis and chest pain
5
Q
prevention of HCAP
A
- avoid intubation if possible (if needed prompt extubation through frequent weening trials reduced risk)
- minimize manipulation of tube
- hand hygiene
- semi upright/ upright intubated pts
- mouth care
6
Q
when to use O2 tx in COPD
A
very severe COPD
-PaO2 < 55 or O2 sat < 88 %
OR
-PaO2 <59 or O2 sat <89 with pulm HTN/corpulmonale or hct >55%
7
Q
major risk factor of TB
A
HIV/AIDS
8
Q
how to tx very severe stable COPD
A
- SABA
- 1+ elongating bronchodilator (LABA, tiotropium)
- ICS
- long-term Oxygen therapy
- consider surgery (upper lobe emphysema or low baseline excercise capacity)
9
Q
manifestation of sleep apnea
A
excessive daytime fatigue, impaired attention, decreased memory, increased risk of MVA
10
Q
what is the most reliable indicator of degree of dyspnea
A
patient self report via MRC dyspnea Scale
1 = breathlessness only on strenous excercise
3= walks slower than most, stops after 1 mile of walking
5= too breathless to leave house/ breathless when undressing
11
Q
follow up procedure for TB
A
FU often (monthly)
focus on sign and sx (not labs)
get expert consult if no improvement in 3 months
test close contacts for LTBI
12
Q
how to tx Cryptogenic organizing pneumonia (COP) in both hypersensitivity pneumonitis and sarcoidosis
A
steroids
sarcoidosis ranges from monitoring –> steroid use
13
Q
how to tx MDR-TB and XDR-TB
A
MDR - (isoniazid and rifampin resistant)
XDR - (isoniazid and rifampin and fluoroquinolone, and kanamycin and amkikacin resistant)
Tx for both depends on expert consult and specialty testing
14
Q
most common causes of acute cough
A
- viral upper respiratory tract infection (RACE)
- viral lower respiratory tract infection (i.e Flu)
- pneumonia
- acute bronchitis (i.e pertussis)
- asthma
- acute exacerbation of chronic bronchitis
15
Q
simple helpful interventions to improve ARDS outcomes
A
- daily ventilator liberation screen
- proper oral care
- DVT prophylaxis
- OMM (lymphatic)
16
Q
biggest risk factor of head and neck cancer
A
tobacco and alcohol
17
Q
tx and prevention for FES
A
Supportive TX:
- early correction of fracture
- mechanical ventilation
- fluid recusitation
- O2
Prevention:
- early immbolixation of fracture
- intraosseous pressure limitation during bone surgery
- prophylatic corticosteroids
18
Q
when to use invasive or noninvasive ventilation with COPD pts
A
noninvasive tx of respiratory acidosis (hyperventilation casusing ph<7.35 and CO2 >45)
*use invasive if respiratory acidosis, plus impaired mental status, hypotension, shock, etc
19
Q
common causes of COPD exacerbation
A
- infection (pneumonia, etc)
2. air pollution
20
Q
sx of lung cancer
A
hemotypsis , dyspnea, cough, and if small cell lung cancer there is many paraneoplastic syndromes
*small cell is almost exclusively dx in smokers
21
Q
length of acute vs chronic cough
A
less than 3 weeks = acute
more than 8 weeks = chronic
*in between is sub acute
22
Q
how to tx pt with hypercapnia and altered mentation/syncope
A
immediate endotracheal intubation
23
Q
risk associated with recurrent pneumocystitis pneumonia related pneumothorax
A
c/l pneumothorax (both lungs collapse)
**high mortality
24
Q
determining severity of OSA
A
AHI + degree of sleepiness + any cardiac issues
25
leading causes of pleural effusion
CHF, pneumonia, cancer
| imbalance of fluid production and removal bc increased hydrostatic pressure and decreased oncotic pressure
26
major difference in symptoms of pulmonary edema and pleural effusion and pulmonary embolism
edema - acute cough
effusion - dyspnea and chest pain
embolism- cough, dyspnea, pleuritic chest pain, DVT sx
pulm edema can be caused by HF, VHD, pulm HTN, CKD, or nephrotic syndrome. **not caused by pneumonia
embolsim caused by Virchow Triad
pleural effusion commonly caused by HF, pulmonary embolism, kidney failure, trauma, or INFECTION (like pneumonia)
27
most common causes of Pulm HTN
- Group 2 :left sided heart dz
- Group 3: secondary lung dz and/or hypoxia (COPD, ILD< Sleep apnea)
other: group 4 = thomboembolic , Group 5 = multifactorial (sarcoidosis, thyroid, etc)
28
two mechanisms of ILD
- distal lung parenchyma damage by
1. inflammation with fibrosis (IPF, NSIP)
2. granulomatous change (COP- sarcoidosis, etc)
29
how to work up a suspected ACTIVE TB patient
1. acid fast bacilli smear and culture
2. CXR
3. TST and IGRA
* for active or latent: test for HIV if unknown status
30
tx of pneumonia pleural effusion
- if loculated, pH < 7.2, glucose < 60, gram +, pus THEN abx won't help alone
1. abx + chest tube drain
2. if still not resolved add video assisted thorascopic surgery
* *TPA and DNAase intrapleural tx improves outcomes
31
PFTs of ILD show
decreased diffusing capacity and decreased lung volume
32
symptomatic OSA can lead to
secondary HTN (via SNS vasoconstriction)
if severe OSA with hypoxemia can lead to secondary erthyrocytosis (elevated HCT) **therefore order CBC
if untx it can lead to heart problems (increase after load and O2 demand, decreased LV compliance-->CHF)
33
sx of pulmonary HTN ? advanced pulmonary HTN?
fatigue, exertion dyspnea, possible chest pain/palpitations
| *advanced = left parasternal lift with pulmonary edema
34
sx of pneumomediastinum
- severe substernal chest pain
- subcutaneous emphysema
- Hammans sign (crunching noise with heart beat)
35
how to tx ARDS
* noninvasive O2 is only temporary
- invasive mechanical ventilation corrects hypoxemia ( high risk of more alveolar damage by "ventilation induced injury")
- add conservative fluid management to ventilation or replace ventilation with ECMO is available
- HFOV = tx for refractory hypoxemia ( increased RR, low tidal volumes)
36
CAP out patient dx/tx
outpatient:
dx: CXR and pulse ox
tx: <7 days; NL pt: macroclide or doxycycline ; pt with cardiopulmonary dz: respiratory quinolone, or B-lactam + macrolide/doxycycline combo
37
how to manage acute dyspnea
1. stabilize with O2
| 2. get CXR to identify underlying cause to tx
38
massive pleural effusion (entire hemithorax) indicates
lung or pleural cancer
| usually exudative vs transudative seen in heart or liver failure
39
imaging order in FES
CXR, CT of chest and MRI to see brain when CNS is involved
40
tx of HCAP
if no respiratory failure: ceftriaxone or levofloxacin (respiratory fluoroquinolone)
if risk of MDR (>5 days hospitalized, recent abx) then use antipsuedomonal agent + vancomycin
41
how to manage pt with hemoptysis
* *get CXR!!
| - if chronic sx in >40 yr old male smoker than also get Chest CT and bronchoscopy to rule out malignancy on NL CXR
42
prognosis predictor of pulm HTN
use right sided heart fxn test (exercise test) over PAP measurement
43
prevention of CAP pneumonia
-flu vaccine (> 6 months old)
-pneumnococcal vaccine
*23 valent all pts >65, and <65 if combordities
*13 valent all pts >65, or IC/ cochlear implants
(give 13 first, and then 23 > 8 weeks after; if 23 given first, wait >1 yr for 13 to be administered )
44
what indicated Legionaares Dz (pneumonia by Legionella)
>50 yo, severe pneumonia, extrapulmonary sx (i.e hyponatremia, HA, diarrhea)
45
how to tx stable moderate COPD
1. inhaled tx (via metered doe inhaler with spacer device, or nebulizer)
- SABA = quick relief
- LABA = monotherapy (possible combined)
- ipatropium/tiotropium = combined tx
- methylxanthine (theophylline)= adjunctive to inhaled tx
2. pulmonary rehab
46
when to switch to oral Abx in inpatient CAP tx
sx improve and no fever twice at least 8 hours apart
| *discharge when switch is made
47
how to dx DVT
1. use WELLS score to determine probability
- if low- D dimer test. (- rule out, + get US)
- if high get US
* venography is the gold standard but rarely used
48
CXR dx of pleural effusion
1. standard
* Blunt costophrenic angle (if >250ml)
* meniscus sign= large amount of fluid opacify lower thorax
2. decubitus films (on side)
- measure amount to determine thoracentesis indication (>1cm) and determine if located or free flowing
3. US -detects locutions and guides thoracentesis
49
when do you perform thoracentesis of pleural effusion in CHF pts ? what is the major risk ??
1. asymmetric PE
| 2. pneumothorax is major complication
50
two top differentials with weight loss and hemotypisis
TB (infection) or cancer
51
when to hospitalize LTBI infection
is respiratory distress, hemopytisis, or systemic dz become present
52
locations on decubitus films in pt with pleural effusion indicates
empyema (complication of pneumonia )
| see WBC> 50,000; high WBC also seen in complicated parapneumonic effusions
53
4 most predictive COPD indicators
1. self reported hx of COPD
2. >40 pack year hx
3. age >45
4. max laryngeal height <4cm
54
CAP in patient DX/TX
dx: CXR, 2 blood cultures, routine metabolic panel, pulse ox, CBC; if high risk for drug resistance then culture and stain
tx:
1. administer O2, immediate abx tx (IV abx w/i 6 hrs)
(abx: respiratory quinolone, or B-lactam + macrolide/doxycycline combo )
*use clindamycin if aspiration or lung abscess
ICU pts: alert with isolated hypoxemia or hypercapnia then use noninvasive positive pressure ventilation
ICU pt abx: B lactam + azithromycin/fluroquinolone
>10 days
55
risk factors of pneumonia
alteration in anatomic barriers, impairment of humoral/cell-mediated immunity, impaired phagocytic function
56
differentials associated with OSA
- RLD
- GERD
- sinusisits
- epilepsy/narcolepsy
- hypothryoidism
- acromegaly
57
labs of pneumothorax show
hypoxemia, respiratory alkalosis (hypoventilation), QRS/Twave changes that MIMIC AMI !!
58
management of pts who do not improve on tx within 72 hours of tx onset in CAP pneumonia
consider M. TB, fungal, viral, pnuemosystis infection
| -order more tests and get consultation
59
most common cause of ARDS
sepsis
60
what cancer is EBV related and Mediterranean and Far East Assoc.
nasopharyngeal cancer
61
sx of epiglottitis causing UAO. dx tools? tx?
```
sx: odynophagia (painful swallowing)
sore throat
dyspnea and stridor (bc obstruction )
hoarseness
fever
tachycardia
```
dx: fiberoptic layrngoscopy and maybe throat culture
tx: secure airway and ABX
62
oropharynx cancer is assoc with
mainly HPV 16 ( and other high risk HPV 18, 31, 32)
63
complications of spontaneous pneumothorax
pnuemomediastinum or subcutaneous emphysema
64
how to tx severe stable COPD
- SABA
- 1+ elongating bronchodilator (LABA, tiotropium)
- add ICS (if repeated exacerbations)
65
steps in diagnosing mediastinal mass
1. identify compartment (anterior, middle, posterior)
2. CT scan (VERY IMP)
a- barium study if posterior
b. iodine 131 for goiter
3. mediastinoscopy or anterior mediastinomy
(official dx for anterior or middle masses)
*alternative dx: video assisted thorascopy (can also tx by removal during procedure)
66
T/F Use compression stocking to prevent DVT
DO NOT USE COMPRESSION STOCKING IN HIGH RISK PATIENT OF DVT
67
risk factors for OSA
male
obese
postmenopausal women
68
how to tx established DVT
1. immediate anti-coag with IV heparin
2. long term anti-coag with warfarin until INR 2-3 twice more then 24 hours apart
3. if extensive thrombosis. use thrombolytics with catheter and then 3 months of anti-coags
* if anti-coag contraindicated then use IVC filter (decreases short term risk, but increases long term risk)
69
ARDS can present similar too
acute infectious pneumonia (with interstitial pattern or diffuse airspace dz)
(pneumocystisis, bacterial- CAP)
or other noninfectious DZ
*all present with DAD
70
how to distinguish ARDS from other causes of respiratory distress
identify underlying cause/ inciting event.
| ARDS is caused by many things but is a dx of exclusion
71
indications of HCAP (healthcare associated pneumonia)
pneumonia developing at least 48 hrs after hospitalization
| *most common is ventilator associated pneumonia (VAP)
72
tx of recurrent or b/L pneumothorax or pneumothorax with failed thoracostomy drain
thorascopy or open thoracotomy (surgery)
73
most common causes of hemoptysis related (acute or chronic) cough
1. infection (bronchitis, pneumonia)
| 2. malignancy
74
dx of decreased maximum oxygen uptake without identifiable cause
deconditioning
75
tx of OSA
1. lifestyle modification !!
2. steroids/decongestant to tx congestion
3. if refractory OSA = CPAP
(CPAP non compliant pts use bi-level PAP nasal ventilation or auto-titrating PAP)
*alternative = mandibular advancement device
*unwillingness = surgical tx
76
tx of pneumocystitis related pneumothorax
no best tx identifies; use hemlich valve with small bore chest tube so they can go home
77
how to manage pt with CC of chronic dyspnea, unrevealing HX and PE?
cardiopulmonary exercise test or arterial blood gas measurement
78
5 management strategies of ARDS
1. low tidal volumes 2. prone ventilation 3. fluid management 4. cardiopulmonary monitoring 5. corticosteroids
79
dx of OSA
1. Epworth Sleepiness Scale (measures daytime fatigue)
2. STOP-BANG questionnaire (screening tool for likelihood)
3. polysomnography (PSG) (required for dx)
* PSG + electroencephalogram most accurately confirms dx!
- PSG gives AHI; AHI>5 = OSA
4. asses for obesity hypoventilation syndrome (PaCO2>45)
80
triad of sx seen in fat embolism syndrome
1. hypoxemia
2. neurologic ABNL (confusion, syncope)
3. petechial rash (red brown around head neck thorax axilla)
(1-3 days after appropriate insult with no other cause of dz indicated)
other sx: tachypnea, dyspnea
MIMICS ARDS
81
tx of large primary spontaneous pneumothorax
1. aspiration drainage with small bore catheter
2. tx symptomatically for cough and chest pain
3. CXR every 24 hrs
* placing small bore chest tube attached to one-way heimlich valve can't prevent tension pneumothorax and be used at home
82
precursor lesions to head and neck cancers
erythroplakia and leukoplakia
83
dx criteria for ARDS
bilateral (airspace opacities) infiltrate, acute onset, hypoxemia, no heart failure
with FiO2 <200
84
dx of HCAP
based on clinical presentation (fever, purulent sputum, decreased oxygen), leukocytosis, and new CXR findings (new/progressive radiographic infiltrates)
85
tx of mild-moderate COPD exacerbation
home tx with SABA or SABA + OCS/abx
86
causes of pneumomediastinum
1. alveolar rupture
2. esophageal/tracheal/ bronchi rupture
3. dissection of air from neck or ab (spontaneous pneumothorax)
87
more at risk population for primary spontaneous pneumothorax
tall, thin males
| primary means no underlying cause
88
how to monitor progression or tx response to pulm HTN
1. 6 min walk test
2. echocardiogram
3. catheterization
89
tx of venous stasis
sx. edema, shiny atrophic skin, ulcers, varicose veins
tx: compression, decrease prolonged standing, UNNA boot (dressed compression boot to decrease edema and promote ulcer healing)
90
signs and sx of pleural effusion
sx: dyspnea and chest pain, possible fever (if pneumonia)
| - signs: dull percussion, decreased tactile fremitus, decreased breath sounds, pleural friction rub
91
causes of chronic mediastinitis ? sx? tx?
1. histoplasmosis (fibrosing medistinitis )
sx: compression of structures
tx: none
2. TB (granulomatous LN inflammation)
dx: PPD
sx: asx
tx: RIPE anti-tb tx
92
imaging ordered in suspected upper airway obstruction
NOT CXR!!!!!
| order CT and maybe endoscopy
93
how to identify/ dx severe pneumonia
CURB-65
-confusion, urea> 20, RR> 30, BP < 90/60 (hypotensive), age >65
*if meet 2 then hospitalize, if meet 3 then ICU
(classic sx: cough, sputum , fever, chills, crackles, bronchial breath sounds, pleural effusion
94
imaging for ILD
CXR= interstitial reticular or nodular infiltrates
HRCT (CRUCIAL) = distribution and extent of dz
*lung biopsy may be needed for confirmation
95
VERY common presentation of IPF
progressive dyspnea
96
dx. of pulm HTN via imagine
CXR= pulm A. enlargement
| Confirmation by right heart catheterization (measures PAP)
97
how to dx Pulmonary embolism
Use wells criteria to determine probability
-low risk - d dimer test
- high risk - CT pulm arteriography ( CT angio) *gol standard, or V/Q mismatch scan
(both can dx, but only NL V/Q excludes)
98
how to workup chronic dyspnea
1) GET DETAILED HX
| - identify chronic conditions, cardiac relations, pulmonary relations, other
99
how to tx malignant pleural effusion
(seen with bloody effusions)
| -drain by chronic indwelling catheter or pleurodesis (pleural space obliteration)
100
LTBI tx
isoniazid daily for 9 month or
rifampin daily for 4 months or
rifampentine + isoniazid 1/week for 3 months
**direct observation
101
when and how to perform a lung cancer screen
low-dose CT (LDCT)
| if 55-80 yo with >30 yr pack hx
102
most common causes of acute dyspnea (<4weeks)
```
pulm embolism
pulm edema
pneumonia
UAO
pneumothorax
COPD exacerbation
```
103
tx of secondary (underlying lung dz) , tension, or severe pneumothorax
```
chest tube ( tube thoracostomy) until lung expands
*thoracostomy drains space of fluid or air
```
104
risk factor for laryngeal tracheal stenosis (cause of UAO)
prior intubation or tracheostomy
| side note: endotracheal intubation with mechanical ventilation is large risk factor for HCAP
105
most common causes of chronic dyspnea (> 4 weeks)
1. COPD
2. asthma (chest tightness)
3, ILD
4. HF (air hunger)
106
causes of acute mediastinitis? sx? tx?
1. esophageal perforation
sx: ill, chest pain, SOB
tx: mediastinomy, tear repair, pleural drainage
2. following median sternotomy
sx: wound drainage, sepsis, widened mediastinum
dx: via needle aspiration
tx: drain, decried, abx
107
tx of severe COPD exacerbation (dyspnea at rest, RR>25, PR >110, accessory M. use)
1. hospitalize with O2 tx
| 2. SABA, anti cholingeric, oral/ IV CS, abx
108
sx of pulm embolism
sx of DVT ( swelling, erythema, tenderness in affected limb) plus dyspnea, cough, pleuritic chest pain
PE: crackles, tachycardia, tachypnea (bc hypoxic), increased S2 pulmonary component
109
sx of pneumothorax
chest pain, dyspnea (usually resolves in 24hrs)
- if small = NL PE
- if large = decreased breath sounds, decreased tactile fremitus, decreased chest movement on affected side
110
how to tx massive hemoptysis ( >200ml/day)
1. urgent airway management !
2. urgent bronchoscopy and/or bronchial A. embolization
3. last resort = surgery
111
tx of pulmonary embolism
- supportive tx of hypoxic, hemodynamic stability in hospital till stable
- anticoags for 3 months
- obstructive shock due to PE, or acute embolism and pulm HTN/RV failure -(hemodynamically unstable) thombolytic tx
- if hemodynamically unstable but thrombotic contraindication then embolectomy surgery
112
how to treat UACS for chronic cough
non sedating antihistamines and decongestant
113
dx of pneumothorax
CXR = visceral pleural line on expiratory film
| **deep sulcus sign = ABNL radiolucent costophrenic sulcus seen on supine pts
114
persistent dry cough with inspiratory crackles leads to dx of
ILD
| IPF = dyspnea on exertion, dry cough, crackles on inspiration
115
how to tx mild stable COPD
SABA inhaled tx as needed
116
active TB tx
RIPE for 6 months (reassessment at 2 months)
117
most common causes of chronic cough
1. Upper airway cough syndrome ( post nasal drip)
2. cough variant asthma
3. GERD
others: CB, bronchiectasis, ACE-I
118
luekyocytosis in the setting of respiratory distress can indicate what dx
pneumonia or sepsis (ARDS)
119
pathophysiology of ARDS exudative stage
*damage to every level of the alveolar-capillary membrane
1. type 1 pneumocyte damage = impaired barrier
2. type 2 damage = atelectasis and decreased compliance
**barrier damage + increased hydrostatic pressure/decreased oncotic pressure --> proteinaceous pulmonary edema
3. pulm edema--> worsening V/Q mismatch --> physiologic shunt (alveoli are perfused, but ventilation fails; persistent with O2 supplementation)
4. hypoxemia (with vasoconstriction) + microthrombi (decreased pulm circulation) + direct endothelial damage = increased pulm A. pressure --> worsening dead space ventilation
***3 and 4 = increased work of breathing
OVERALL- Acure Respiratory Failure by ARDS is caused by permeability damage and decreased lung compliance
120
what does hypercapnia with tachypnea indicate
high CO2 with increased respiration rate means that pt is experiencing impaired ventilation (possibly due to ARDS) and need emergent attention
121
how to dx GERD for chronic cough
1. PPI tx with reassessment in 3 months
| 2. 24hr esophageal pH test
122
what to order if suspected hypoxemia or hypercapnia
O2 saturation and arterial blood gases
123
sx of general airway obstruction ? upper airway obstruction?
SOB, noisy breathing, wheezing, decreased breath sounds on auscultation
UAO sx: DOE, SOB, stridor, hoarseness (if laryngeal), mulled voice (if vocal cords)
124
Findings on MRI in Fat embolism syndrome
"starfield" pattern of diffuse puntacte hyperintense lesions in brain
125
causes of drug induced ILD
amioderone, nitrofurantoin, methotrexate
| *MAN
126
sx of laryngotracheal injury (cause of UAO)
```
stridor (bc UAO)
dysphonia
hemotypsis
neurologic sx
cervical bruising
hematomas
pneumothorax
cervical crepitus
```
127
virchow triad of risk of VTE
hypercoagability
endothelial damage
venous stasis
128
two mechanisms leading to the sensation of dyspnea
1. impaired ventilation ( obstruction, decreased chest wall compliance)
2. increased respiratory drive ( lund dz, CHF, acidosis, preganancy, behavioral panic attacks, etc)
129
most common cause of HCAP
micro aspiration of bacteria of oropharynx / upper airway in ill pts
*VAP
Risk factor: endotracheal intubation with mechanical ventilation
130
tx for IPF
no tx to fix
| -supplement O2 and tx pulm HTN with vasodilators if chronic or severe
131
dx and tx of pneumomediastinum
dx: CXR
tx: none required (O2 supplement decreases recovery time, needle aspiration provides compression relief)
