Dyspnea Flashcards
(95 cards)
1
Q
MC precipitating factors of AHF
A
- Afib
- AMI
- DC of meds (diuretics)
- Increased Na load
- Meds impairing myocardial function
- Physical overexertion
2
Q
- DOE, dyspnea, frothy pink sputum, rsp distress
- Tachycardic, HTN, S3
- Abdominojugular reflux and JVD
dx?
mgmt?
A
- AHF
- O2 >95% (CPAP/BiPAP), NTG, nitroprusside, diuretics, morphine
3
Q
6 AHF classifications
A
- HTN AHF
- Pulm edema
- Cardiogenic shock
- Acute-on-chronic
- High-output failure
- RHF
4
Q
- Preserved LV function
- SBP >140
- CXR: pulm edema
- Onset < 48h
which type of AHF
A
HTN AHF
5
Q
- Rsp distress
- Rales
- Low O2
- CXR
which type of AHF
A
pulmonary edema
5
Q
Tissue hypoperfusion
SBP <90
which type of AHF
A
Cardiogenic shock
5
Q
- Mild-moderate s/s
- Do not meet criteria for others
- SBP 90-140
- Increased peripheral edema
- Onset: several days
which type of AHF
A
Acute-on-chronic
6
Q
- High CO
- Tachycardia
- Warm extremities
- Pulm congestion
which type of AHF
A
High-output failure
7
Q
Most important hx parameter for AHF
A
- h/o AHF
- DOE (84%)
- Paroxysmal nocturnal dyspnea, orthopnea, edema (77-84%)
8
Q
w/u for AHF?
findings?
A
- ECHO!
- CXR: pulm venous congestion, cardiomegaly, interstitial edema; nml possible
- ECG: not helpful
- BNP: helpful if dx uncertain
- Cardiac US: determines other causes for acute dyspnea, LV function and volume status or find signs of pulmonary congestion
9
Q
mgmt for HTN AHF with severe HTN - Pulmonary edema with SBP 150
A
- Vasodilators
- Avoid need for emergent intubation
10
Q
AHF - HoTN persist after NTG, next step?
A
IV fluid bolus 250-1000cc
RV infarction, valvular pathology (AS, hypovolemia, ED meds)
11
Q
High-Risk AHF Pts that require admission
A
- AMS
- Persistent hypoxia
- HoTN
- Elevated trops
- Ischemic ECG changes
- BUN >43
- Cr >2.75
- Tachypnea
- Inadequate UO
12
Q
- asx to sudden death
- **Acute dyspnea **
- Pleuritic CP
- Unexplained tachycardia
- Hypoxemia
- Syncope
- Shock; seizures possible - esp no PE/imaging findings for other DDx
- hypoxemia, tachypnea, tachycardia, hemoptysis, diaphoresis, low-grade fever
- DVT in 50% of pts
dx?
A
PE
13
Q
w/u for PE
A
-
Pretest probability - for probability of disease >2.5%
- low-risk = PERC
- need more testing = Wells - Need additional testing + low/intermediate pretest → D-Dimer
- High pretest/(+) D-Dimer → imaging - CTPA; VQ scan
14
Q
Other causes of elevated D-Dimer
A
- older
- pregnant
- active malignancy
- recent surgery
- liver dz
- rheumatologic dz
- infection
- trauma
- sickle cell
15
Q
mgmt for PE
A
- O2
- IV crystolloid fluids
- UFH / LMWH / rivaroxaban / apixaban / fondaparinux ASAP
- fibrinolytic (if severe PE causing SBP < 90 / decr BP of 40 mmHg)
- add Heparin/LMWH afterwards
16
Q
mgmt if Life-threatening PE + CI to fibrinolysis?
A
Surgical & suction thromboembolectomy
High mortality with open surgical thromboembolectomy
17
Q
PE - mgmt if Failed/CI anticoag; associated DVT
A
IVC filter
18
Q
disposition of PE
A
- Admit to telemetry
- ICU: circulatory compromise; when thrombolytics given and close monitoring is needed
- some low-risk pts can do outpatient tx
19
Q
MCC of bronchitis
A
- Influenza A/B, adenovirus, rhinovirus, parainfluenza, RSV, COVID
- Uncommon: S. pneumo, H. flu, C. pneumo, M. pneumo, pertussis
- More severe in older pts esp with comorbidities
20
Q
- Productive cough; Lasts 3 wks
- Wheezing possible
- Sputum alone does NOT indicate bacterial etiology
- No fever, tachycardia, tachypnea
dx?
A
bronchitis
21
Q
bronchitis criteria
A
- Acute-onset cough (< 3wk)
- No chronic lung dz hx
- Normal VS
- No auscultatory abnormalities that suggest pneumonia.
22
Q
Consider ? in adolescents and young adults whose coughs >2-3 wks, esp if coughing paroxysms with prominent post-tussive emesis or had exposure
A
pertussis
23
w/u for bronchitis
Pulse ox indicated if dyspnea or appears SOB Bedside peak flow testing: reduced FEV1
CXR not required in nontoxic non-elderly pts
24
mgmt bronchitis
1. **No abx**
1. _Pertussis_: **azithromycin** PO - decr coughing paroxysms, limits transmission, _does **NOT** shorten illness_
1. _Airflow obstruction_: **albuterol**
1. Additional agents based on pt
DC for timely f/u with PCP, stop smoking
25
MCC PNA
MC bacterial infection - S. pneumo
26
RF for PNA
rsp tract dz, immunocomp, chronic conditions assoc w/ aspiration, bacteremia, debilitation
27
s/s of PNA
* cough, fatigue, F, dyspnea, sputum, and pleuritic CP
* Tachypnea, tachycardia, low pulse ox, bronchial BS, rhonchi or wheezing
28
criteria for HCAP
hospitalized >48h within 90 d, routine outpatient dialysis, chemo, wound care, or home IV abx, and residents of a nursing facility
29
Aspiration PNA MC happens in what part of the lung
* **RLL** d/t gravity and lung anatomy
* Can happen anywhere in the lung
* Complications: empyema, lung abscess
30
w/u for PNA
* Uncomplicated, healthy - no w/u
* CXR MC
* CBC, BMP, ABG, sputum gram staining & cx, blood cx - better if being admitted to ICU
31
mgmt for outpatient, uncomplicated CAP
1. **Amoxil** or **doxy** PO >5d
2. _macrolide_ if failed
32
mgmt for Outpatient, comorbidities CAP
1. **augmentin** **+ macrolide/doxy**
1. _FQ_
33
mgmt for Inpatient not ICU CAP
1. **Rocephin + macrolide**
1. _FQ_
34
mgmt for ICU CAP
1. **rocephin + FQ**
1. MRSA: add vanc
35
mgmt for inpatient HCAP
1. Levo + cefepime OR pip/taz
1. Add vanc/linezolid for MRSA
36
mgmt for aspiration PNA
1. Prophylactic abx not recommended
1. Witnessed aspirations - Tracheal suction, then bronchoscopy if need to remove large particles
1. PNA: levo + clinda
37
mgmt of empyema in PNA
* Pip/taz; Admit, consult pulm/thoracic surgeon
* Add vanc for MRSA
38
mgmt for lung abscess from PNA
Clinda + rocephin
39
MC RF for spontaneous pneumothorax
smoking
40
difference between primary vs secondary pneumothroax
* Primary: w/o known lung dz
* Secondary: w/ known lung dz (COPD, asthma, CF, ILD, infection, CTD, cancer)
41
pneumothorax that occurs secondary to invasive procedures (**needle lung bx, thoracentesis**, subclavian line, NG tube, PPV)
dx?
what can be done to reduce this complication?
* Iatrogenic
* **US guidance** for central venous catheter insertion for thoracentesis
42
s/s pneumothorax
* MC Sudden onset of dyspnea, ipsilateral pleuritic CP
* Tachycardia MC PE
* Spontaneous: classic PE findings not common
* Traumatic: ipsilateral decreased BS
43
s/s tension pneumothorax
* severe progressive dyspnea, tachycardia (>140), hypoxia, ipsilateral decreased BS;
* Late findings: tracheal deviation AWAY from affected side, distended neck veins, cardiac apical displacement
*
44
w/u for pneumothorax?
findings?
1. Stable → **PA CXR**: Displaced pleural line w/ absent lung markings extending from visceral pleura to chest wall
1. **Supine AP XR**: cardiophrenic recess hyperlucency and CPA enlargement (deep sulcus sign)
1. **CT** → r/o emphysematous bullae
1. Young, healthy → **US**: no lung sliding, comet tail artifacts and a lung pulse in presence of a distinct A lines and visualized lung point.
1. Iatrogenic pneumothorax - CXR after central line placement or transthoracic needle procedures
- May not identify pneumothorax if supine or if there is inadequate time for pneumothorax to develop
45
mgmt for small primary pneumothorax
**observe x 4h on O2, repeat CXR**
1. _No sx and nml CXR_: **return in 24h for repeat exam**, then wkly until resolution
1. _1st time spontaneous of < 20% lung volume in a stable, healthy adult_: **O2 and observe**
46
Locations for needle aspiration or tube throacostomy for pneumothorax
1. anteriorly in 2nd ICS at MCL
1. laterally in 4th/5th ICS at AAL - 5th preferred for needle thoracostomy decompression
47
indications for chest tube thoracostomy
1. failed aspiration
1. large pneumothorax
1. Recurrent pneumothorax
1. bilateral pneumothoraces
1. Hemothorax
1. abnormal VS
1. severe dyspnea
48
mgmt for tension pneumothorax
Needle decompression then tube thoracostomy ASAP
49
re-expansion lung injury from pneumothorax is MC seen when?
mgmt?
* if lung collapse >72h, large pneumothoraces, rapid re-expansion, or negative pleural pressure suction >20 cm
* observation, O2 supp
50
triggers for asthma and COPD
smoking, respiratory infections, exposure to noxious stimuli, adverse response to meds, allergic reactions, hormonal changes during the normal menstrual cycle or pregnancy, and noncompliance with prescribed therapies
51
asthma exacerbations are due to?
expiratory airflow limitations
52
COPD exacerbations are due to?
vent-perfusion mismatch
53
2 forms of COPD? differences?
1. **pulmonary emphysema**: defined in **anatomic pathology**, characterized by destruction of bronchioles and alveoli
1. **chronic bronchitis**: defined in **clinical terms** as a condition of excess mucous secretion in bronchial tree, with a **chronic productive cough for 3 mo in each of 2 consecutive yrs**
54
MC chronic disease of childhood
S/S:
- Dyspnea, chest tightness, cough
- Wheezing w/ prolonged expiration
dx?
asthma
55
w/u for asthma
* **DX: clinically**
* FEV1 and peak expiratory flow rate (PEFR) - **FEV1/PEFR < 40% = severe**
* ABG - if hypercapnia and acidosis in severe cases
* CXR if indicated: Complicating cardiopulm process suspected (temp >38.3, unexplained CP, leukocytosis, hypoxemia)
* pt requires hospitalization
* unknown dx
* EKG
56
general mgmt for asthma and COPD
1. keep SpO2 **>90%** or PaO2 60-70mmHg
1. **1st line: SABA: Albuterol neb**
- Severe (FEV1/PEFR < 40%): **+Ipratropium bromide (DuoNeb)**
- **Terbutaline/EPI** if cannot tolerate aerosols
1. **Prednisone** for exacerbations
- **Methylprednisolone** if cannot tolerate PO
57
* If rsp muscle fatigue, rsp acidosis, AMS, or hypoxia refractory to standard therapies.
* alt to intubation and invasive vent
NPPV: CPAP / BiPAP
***BiPAP** has pro of reducing work of breathing*
58
When NPPV not viable, what is the next step?
oral intubation
* Therapy guided by pulse ox, capnography, and ABG results.
* Continue sedation and therapy for bronchospasm
* Mech vent itself does not relieve airflow obstruction
59
↑ in:
- frequency/severity of cough
- volume or change in sputum
- dyspnea
- Mild: increased regular meds
- Moderate: Requires systemic corticosteroids or ABX
- Severe: Requires ER evaluation
dx?
COPD Exacerbation
60
mgmt for severe asthma exacerbation ONLY (FEV1 < 25% predicted)?
refractory asthma?
1. **Magnesium sulfate** or 80%:20% Heliox
1. Ketamine
61
COPD exacerbations receive ABX if 2 out of 3 findings:
what are the abx?
* ↑ dyspnea, ↑ sputum volume or purulence
* **Macrolide, Bactrim, 3rd gen cephalo**
* **Augmentin or FQ if high-risk** if: >65yo, comorbidities, continuous supplemental O2, hospitalization in last 12 months exacerbation, COPD exacerbation, **FEV1 < 50%**
62
when is Stridor heard?
* **upper airway obstruction**
* Forced air through large airways
* High pitch inspiration
63
Accessory muscle use:
SCM, sternoclavicular, intercostal
64
what is paradoxical abdominal wall movement
the abdominal wall retracts inward with inspiration, indicating diaphragmatic fatigue
65
depressed consciousness is d/t?
hypercapnia
66
what dyspnea imaging
helps differentiate acute cardiac from noncardiac causes
pleural effusion, pneumothorax, pulmonary consolidation, intravascular volume status, cardiac tamponade, cardiac function
Bedside Point of Care Ultrasound
67
low flow vs high flow O2?
1. Low flow oxygen (allows room air to mix with oxygen)
- NC (0.25-4 lpm)
- Simple mask (6-10 lpm)
2. High flow oxygen (pure oxygen)
- NC (4-40 lpm) - provide some positive pressure and decreases amount of room air that is breathed in
- Non-rebreather (10-15 lpm)
68
mgmt goal of hypoxia
1. keep **PaO2 >60 mmHg** or **O2 >90%**
- Lower oxygen goals in patients chronic lung disease (CO2 retainers) - risk of rsp depression in chronically hypercapnic
69
MC cause of stridor in neonates due to a weak larynx
Laryngotracheomalacia
70
Consider what dx in ALL children who present w/ respiratory complaints
Airway Foreign Body
MC: 1-3 years old
71
MC objects and foods for airway FB
* MC Object: Food & toys
* MC Foods: Peanuts, sunflower seeds, carrots, raisins, grapes, hot dogs
72
s/s of airway FB
* **sudden coughing/choking** associated with **gagging, stridor or cyanosis**
* _Laryngotracheal FB_ - stridor, hoarseness or complete apnea
* **Bronchial FB (MC)** - unilateral wheezing and decr breath sounds
73
w/u for airway FB
Imaging: May be normal, _do not delay intervention_
- Tracheal FB: PA & lateral soft tissue neck
- Bronchial FB: PA & lateral CXR - Inspiratory & expiratory: Air trapping
74
* XR shows circular object on AP/PA view, where is the coin FB?
* what if it presented as circular on lateral view?
* esophagus
* trachea
75
Evidence of radiolucent FB may present with:
1. **Unilateral obstructive emphysema**
- D/t FB obstructing expiration→ air trapping & mediastinal shift to opposite side
2. **Focal atelectasis w/ complete obstruction**
3. **Consolidation→ scarring**
76
what airway FB intervention confirms or rules out dx, and is therapeutic to remove FB
Bronchoscope
77
mgmt for complete airway obstruction from FB
1. **BLS**
1. direct **laryngoscopy** with FB extraction (if BLS fails)
1. **orotracheal intubation** with dislodgment of FB more distally (if laryngoscopy fails)
1. If ET intubation fails - needle cricothyroidotomy or emergency **tracheostomy**
1. Consult pulm for **emergent bronchoscopy** if BLS and laryngoscopy fail
78
mgmt for Partial airway obstruction
Bronchoscopy under general anesthesia
79
Prodrome: cough coryza and mild fever
inspiratory stridor,“barking” “seal-like” cough, hoarseness, respiratory distress, fever
dx?
Croup (laryngotracheobronchitis)
80
difference between mild/moderate/severe Croup?
* **mild**: no stridor at rest
* **moderate**: stridor at rest and mild retractions
* **severe**: stridor at rest and severe retractions, anxious or agitated appearing, pale/fatigued
81
soft tissue neck x-ray shows subglottic haziness, narrowing of the superior trachea “steeple sign” with normal epiglottis
dx?
Croup (laryngotracheobronchitis)
82
T/F: Imaging (soft tissue neck x-ray) is
not necessary to make diagnosis if classic presentation
T
83
standard care for croup
minimal disturbance, pulse ox monitor, antipyretics
84
mgmt for mild croup
Outpatient, **single dose of oral dexamethasone**
IM dexamethasone or nebulized budesonide if unable to tolerate oral therapy
85
mgmt for morderate - severe croup
1. **single dose dexamethasone, NEB (racemic) EPI, humidified oxygen**
- Heliox - 70-80% helium and oxygen 20-30% - used as a last resort before intubation
- Intubation if no response to pharmacotherapy
86
Discharge criteria for croup (6)
(must meet all)
1. nontoxic
1. no signs of dehydration
1. O2 sat > 90% on RA
1. reliable caregiver
1. observation with improvement for 3 hours after last epi tx
1. f/u in 24-48 hours with PCP
87
Indications for admission for croup
(only needs to meet one)
1. persistent stridor at rest
1. persistent tachypnea
1. persistent retractions
1. persistent hypoxia
1. >2 doses of nebulized epi are needed
88
Like croup, but more **severe rsp distress & toxic appearing**
- **Thick mucopurulent secretions**→ Upper Airway obstruction
- “Sore Throat” referring to **trachea w/ tenderness to palpation**
dx?
w/u?
mgmt?
1. **Bacterial Tracheitis**
1. Imaging not necessary; **Bronchoscopy** (after airway is secured)
- confirms edema of trachea
- _therapeutic removal of thick mucopurulent tracheal secretions_
- **C&S of secretions to help guide therapy**
1. Intubation and **mech vent**; **Vanc + Unasyn/Rocephin**; Consult pulm
- Alt: FQ (levaquin or cipro) substituted for BL if allergy is present
89
how long do kidneys take to compensate?
Compensation occurs with in **12-24 hours**
90
how long do lungs take to compensate?
Compensation can occur with in **minutes**
91
What is assessed in an ABG?
* pH
* PaCO2 - assesses **rsp component** of acid/base regulation
* PaO2 - the amount of O2 dissolved in serum
* HCO3 - assesses the **metabolic component** of the acid/base regulation
* O2Sat - oxygen saturation of hgb
92
causes of Respiratory Acidosis?
mgmt?
* **alveolar hypoventilation**
* Acute causes: head trauma, chest trauma, lung disease, or excess sedation
* Chronic causes: obesity, COPD, sleep apnea
* tx: increase minute ventilation, bronchodilators with small amounts of O2, invasive ventilation assistance
93
causes of Respiratory Alkalosis?
mgmt?
* **Alveolar hyperventilation** - decr in CO2 = decr H+ = imbalance of cations and anions. The negatively charged proteins bind Ca++ = ionized hypocalcemia.
* Etiologies: CNS tumors or stroke, infections, pregnancy, hypoxia, and toxins (e.g., salicylates), anxiety, pain, and iatrogenic overventilation of patients on mechanical ventilators
* treatment of underlying condition
