Lecture 7: Pulmonary Flashcards

Question

Diagnosis Pulmonary Embolus (1st from DVT) * What does the ABG and pulse oximetry show? * What does the EKG show? * What does the CXR show?

Answer 1

Most useful for low pretest probability * If negative (<500)

Answer 2

Test of choice for Pregnant Patient if * +U/S for DVT * Although usually not done and treated prophylactically

Answer 3

* Unfortunately most are “non-diagnostic” and radioactive medium is damaging to the fetus nearly as much as radiation from CT * Used if patient allergic to Iodine * Ventillation/Perfusion * Mismatch - Ventillation but NO Perfusion(vessels) ## Footnote VENTILLATION/PERFUSION SCAN=A MISMATCH Can ask for low cut (about a 12 xray chest) for a pregnant patient.

Answer 4

* Possibly radiologist or technician dependent * 80% sensitive * 85% specific * May miss small sub-segmental embolus * Best for patients with abnormal CXR * Typical ER test

Answer 5

* Gold Standard for PE – but not an ER test * Typically done in patients that need clot treatment * Positive results consist of a filling defect or sharp cutoff of the affected vessel * Generally is a safe procedure * Contra-indicated in patients with pulmonary hypertension

Answer 6

Thrombectomy * Hypotension with contraindications to thrombolysis * Interventional radiologist will only do this if there is a right heart strain

Answer 7

All that wheezes is not asthma (ARDS i.e. non-cardiogenic pulmonary edema) Wheezing: * Upper Airway (usually stridor) – FB, angioedema, croup, epiglottitis, tracheitis * Lower Airway: Asthma, Bronchiolitis, COPD ## Footnote Cough and see if upper airway clears to see the cause.

Answer 8

* Common, non-specific symptom, frequently associated with acute URI * Protective reflex: clear secretions and foreign debris from tracheobronchial tree

Answer 9

* Smoking * Postnasal drip (worsen in supine position) (only @ night+ cobblestone appearance) * Cough Variant Asthma (premature at birth) * GERD (wake up with sour taste in mouth) * ACE or ARB medications (Switch to ARB)

Answer 10

* Blue color of skin and mucous membranes * Increased amount of ”reduced” hemoglobin or deoxyhemoglobin * Consider possible tissue hypoxia

Answer 11

* CO is a clear, odorless gas * Hemoglobin binds to **CO with 230- 270 times more affinity** than it binds to Oxygen * COHb shifts the oxydissociation curve to the **left** so that Hb gives off less oxygen at the tissue level ## Footnote Carboxyhemoglobin Holds onto O2

Answer 12

* Patient has fatigue, malaise, flulike symptoms, nausea, trouble thinking and concentrating, poor memory; stroke, coma, seizure, respiratory arrest. * May have myocardial ischemia, dysrhythmias, hypotension and cardiac arrest. * CO crosses placenta

Answer 13

* Entire family or co-workers with same symptoms * More prevalent with winter weather

Answer 14

* Can you trust the pulse ox? NOOOOO * A saturation gap is the difference between the pulse ox and the saturation of oxygen on the ABG. There would be a gap in CO poisoning * Gap > 5 is considered significant * Pulse oximetry gives spuriously high readings because the device confuses COHb for OxyHb * Get an ABG done – look for carboxy and methhemoglobin levels.

Answer 15

Hyperbaric Chamber is the treatment of choice Half life of CO: * 320 min (air), * 90 min (100% O2), * 20 min (Hyperbaric O2 Chamber).

Answer 16

* CO and toxic products of combustion * Cyanide exposure if combusting wool, silk, plastics * Symptoms: Headache, nausea, drowsiness, confusion and coma * Physical exam: damage to breathing passages/soot – can take up to 24hrs to develop from exposure

Answer 17

Diagnosis usually with ABG and CXR Treatment * Simple inhalation: Oxygen * Complex (due to physical findings) – intubation

Answer 18

* If Cyanide suspected (diffuse cyanosis) – Amyl nitrite (forms methemoglobin with high affinity for cyanide) * Give fire victims High flow O2, not amyl nitrite (CO is predominant)

Answer 19

Can develop ARDS

Answer 20

* Methemoglobinemia most commonly caused by nitrites, nitrates, benzocaine * Methemoglobin cannot bind oxygen * Methemoglobinemia can be hereditary * Sulfhemoglobinemia most commonly caused by pyridium

Answer 21

* One clue: Oxygen won’t help (no >O2 sat) * Second clue: Patient’s blood is chocolate brown * Get ABG and look for gap in measured and calculated oxygen. If it is >5, then another hemoglobin is involved (methemo or carboxy) * Differential – amiodarone or viagra intake

Answer 22

## Footnote ARDS: fulminant, end-stage, final common pathway of MSOF (multisystems organ failure)

Answer 23

* Supportive care * Correct underlying disorder * Mechanical ventilation (early) * Consider CPAP, BiPAP, PEEP(E-T)

Answer 24

Pulmonary edema, Pleural effusion, post infusious, malignancy?

Answer 25

Large ones should be drained with chest tube Role of Thoracentesis * Diagnostic * Therapeutic

Answer 26

* Antibiotics not indicated if symptoms <2 weeks (unless smoker or has +CXR) MIPS measure 116. * Bronchodilators for wheezing (atrovent or similar)

Answer 27

* Acute Exacerbation of Chronic Bronchitis (increased cough, increased sputum, increased purulence of sputum) * 2/3 of the patients with chronic bronchitis who have an acute exacerbation will have a bacterial etiology with H.flu, Strep pneum, Moraxella, and atypical species (mycoplasma) * TX: doxycycline, macrolide, augmentin, fluoroquinolone (not cipro) *

Answer 28

peds patients with asthma, bronchiolitis or croup

Answer 29

CXR RML * Infiltrate

Answer 30

C) Klebsiella

Answer 31

* Rust colored sputum * Abrupt onset chills/rigor/chest pain (70%) * Cough may be absent early in disease * Usually signs of consolidation on exam * WBC ― 12-25,000

Answer 32

* CXR ― lobar consolidation, pleural effusion (10%) * Lab ― sputum culture positive 50%/blood 30%/rusty (blood-positive)sputum * Treatment ― penicillin high incidence of resistance/erythromycin or quinolones

Answer 33

* 1% of bacterial pneumonias * Patient at risk for aspiration * Sudden onset * Post-influenza/IVDA * Toxic appearing patient

Answer 34

* Patchy infiltrates leading to necrotizing pneumonia/cavitations * Complications: cavitation/pneumothorax/empyema * Treatment: Vancomycin->Must cover MRSA

Answer 35

* The bacteria remain largely susceptible to aminoglycosides and cephalosporins. * Varying degrees of inhibition of the beta-lactamase with clavulanic acid have been reported.

Answer 36

* Severe pneumonia * Cyanosis, confusion, systemic illness * CXR: bilateral lower lobe infiltrates, occasionally associated with empyema

Answer 37

* Hospital acquired (Ventilator assisted patient in ICU) * Cystic Fibrosis patients * Cefepime covers pseudomonas IV, Cipro PO (only time cipro is given above the belt)

Answer 38

Psittacosis – P for parrots (Chlamydia psittaci) * Bird (parrots, pigeons) handlers and nursing homes * Endocarditis, DIC * Treatment: tetracycline/erythromycin

Answer 39

* Sheep, goats, cattle – vets, farmers * Treatment: tetracycline

Answer 40

* Older children, young adults, Elderly * No cell wall – gram stain doesn’t help * Sputum with WBC’s * Empiric treatment for CAP * Macrolide Class Antibiotic i.e. Azithromycin

Answer 41

* Risk: smoking, alcohol use, chronic lung disease, transplant patients and immunosuppressed. * Possibly caused by inhaled contaminated aerosols from domestic water systems/AC * Can test by Urine

Answer 42

* 2-10 day incubation (or as short as 24 hrs) * Patient looks sick (toxic) * Pontiac fever is the mildest form of Legionella pneumonia * Legionnaires disease is the severe form of the infection * Treatment: erythromycin for at least 3 weeks

Answer 43

* Patients with Legionnaires' disease usually have: * fever * chills * muscle aches * Most have diarrhea * loss of coordination (ataxia) * 1/3 of the patients have AMS * Relative Bradycardia ## Footnote relative bradycardia is noted in all legionella infections with fever of 102 and can also be seen in Typhus and Rocky Mountain Spotted Fever as well as various endemic diseases seen in underdeveloped countries

Answer 44

* Laboratory Findings include: * may show that patients’ kidneys (10% have microscopic hematuria) and liver (Elevated LFTs) are not functioning properly. * Chest X-rays often show pneumonia initially in unilateral lobar distribution progressing to bibasilar consolidation, patchy infiltrates, occasional hilar adenopathy and sometimes pleural effusions. * WBC 10,000-20,000 * Gram stain: polys(wbc’s), no bacteria

Answer 45

* Headache * Malaise * Hacking, non-productive cough for 4-6 weeks * Low grade fever * Chills are frequent, but rigors are rare. * May have bullous myringitis

Answer 46

* Macrolide antibiotics (azithromycin, clarithromycin or erythromycin) are advised as first line treatment. * Other antibiotic classes, tetracyclines, doxycycline and fluoroquinolones (in particular, levofloxacin and moxifloxacin), may be used as well.

Answer 47

* Significant mortality and morbidity with influenza and parainfluenza viruses, Varicella zoster, Herpesvirus * Occurs during flu season * CXR: patchy densities or interstitial infiltrates * WBC: 4,000-15,000 (typically leukopenia) * Complicated by ARDS

Answer 48

TX: Oxygen, bedrest, analgesics, decongestants, expectorants, possible antihistamines, bronchodilators for wheezing, limited steroid use, possible ventilator support * Acyclovir: herpes * Amantadine or Tamiflu: Influenza A * Aerosolized ribavirin: RSV * Ramdesivir: SARS-CoV

Answer 49

Severe acute respiratory syndrome coronavirus 2 Third serious coronavirus outbreak * More deadly and virulent than SARS 2002 outbreak * Less deadly but more virulent than MERS 2012 outbreak Third cause of death in the US in 2020 and 2021 * Heart disease and cancer still leading

Answer 50

* Single strand RNA-encapsulated viruses enter through animal host * Expressed via ACE2 enzyme (HTN patients on ACEi were affected more) * Incubation period of 3-7 days * Develop typical flu-like symptomatology * Very few can develop ARDS due to cytokine storm

Answer 51

* Within 20 days most patients that are going to survive will be extubated by this time. * 20% are asymptomatic, 61% mild symptoms, 14% severe, 5% critical

Answer 52

Antigen test ($20-$30) * False negative rate up to 50% * False positive rate nearly zero PCR RNA/NAAT (about $75) * False negative rate 2-37% * False positive rate nearly zero

Answer 53

Antibody test * False negative rate 0-30% and depends on collection time following disease

Answer 54

B/l PNA with normal to low WBC, lymphopenia, normal procalcitonin, elevated ferritin, Dimer and CRP = COVID

Answer 55

Pre-exposure prophylaxis * Evusheld (tixagevimap co-packaged and administered together with cilgavimab; intramuscular injection) Post-exposure prophylaxis and early treatment of COVID patients * Bebtelovimab (monoclonal AB) – only one available in FL

Answer 56

Not authorized for the pre-exposure prevention of COVID-19 or for initiation of treatment in those requiring hospitalization due to severe or critical COVID-19

Answer 57

* Multisystem Inflammatory Syndrome in Children * Well appearing children that suddenly deteriorate, sometimes weeks after mild to no symptoms of + SARS-CoV-2 * Age 5-9 most prevalent, and male (62%)>female (38%) * Labs DO NOT align with clinical appearance (kids look better than the labs) * See elevated D-Dimer, troponin and CRP/ESR, lymphopenia * Mortality is low, most symptoms resolve quickly

Answer 58

* 80% with fever, abd pain, N/V/D, transaminitis and cardiac dysfunction, edema of hands/feet (some look like acute appendicitis with negative imaging) * 44% had conjunctivitis * 20% with fever and rash – Kawasaki like

Answer 59

* Transplant patients * HIV patients (pneumocystis carinii) * 1st 30 days – expect C.diff.

Answer 60

* Emerged in 1981 in New York and California in gay men and IVDAs * Opportunistic disease in immunosuppressed patients, particularly in HIV seropositive patients * Nonspecific presentation, slow and insidious onset, fever, dyspnea, cough, weight loss, chest pain, night sweats, fatigue * WBC normal * CXR diffuse bilateral interstitial or alveolar infiltrates =>Bat Wing Appearance

Answer 61

* 90% have elevated LDH; Many will have concomitant TB * Rx---- Bactrim or Pentamidine (if allergic)

Answer 62

Child with broken blood vessels in eyes and bruising on face due to pertussis coughing.

Answer 63

Bronchiolar plugging in neonate with pertussis pneumonia * Cause cough/apnea

Answer 64

* Runny nose * Low-grade fever (generally minimal throughout the course of the disease) * Mild, occasional cough * Apnea — a pause in breathing (in infants)

Answer 65

* Paroxysms (fits) of many, rapid coughs followed by a high-pitched "whoop" * Vomiting (throwing up) * Exhaustion (very tired) after coughing fits

Answer 66

* Detection of organisms by polymerase chain reaction (PCR), and testing serum for antibodies to pertussis toxin * Erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons >1month of age * <1 month of age, azithromycin

Answer 67

* Bacterial infection of the epiglottis * Swelling can interfere with breathing = a medical emergency! * Thumb sign

Answer 68

* NO tongue depressor – result in spasm and respiratory arrest * Rapid onset – drooling, posturing to protect airway, stridor

Answer 69

Appears acutely ill, anxious, quiet, shallow breathing with the head held forward (sniffing position), insisting on sitting up – Early symptoms insidious but rapid progression

Answer 70

* Causes acute airway obstruction; caused by influenza and parainfluenza viruses * Peak incidence: between 6 months and 3 years * The critical site is immediately below the larynx, where edema narrows the subglottic trachea. this area has an inverted "v" appearance that is characterisitc of croup

Answer 71

* HPIV-1 (parainflu 1) is most likely to cause symptoms in kids * Characteristic “Seal Bark” * Usually have other URI symptoms

Answer 72

Treatment is supportive in nature, but for moderate/severe Sxs: * Humidified oxygen * Single dose of dexamethasone (any route) improved symptoms and reduced return visits * Nebulized epinephrine reduced length of hospitalization

Answer 73

CURB-65, PORT, ATS – CURB 65 vs PORT * Both still used; CURB 65 easier; PORT proven to be more accurate * Look up either on MdCalc

Answer 74

* Aspiration pneumonia

Answer 75

Lung abscess * Lung Abscess Note air-fluid level

Answer 76

* Localized suppurative necrotizing infection in lung parenchyma * 10% require surgical intervention * These can be seen from periodontal disease (anaerobic/gm +) * CXR: cavitation with an air-fluid level

Answer 77

* Mycobacterium tuberculosis-aerobic rod * Transmission through inhaled droplets, time and exposure dependent * Usually latent, asymptomatic infection occurs with a positive skin test conversion

Answer 78

* Reactivation (upper lobe) occurs when a host’s immune system is compromised * Highest risk: young, old, debilitated, HIV

Answer 79

* Upper Lobes (Re-activation) * Lower Lobes (Initial Infection) * Increasing Frequency * Is an AIDS Defining Illness

Answer 80

## Footnote * Beware of local laws regarding involuntary hospitalization (this is a public health hazard)

Answer 81

* Air in the pleural space between parietal and visceral pleura * Primary spontaneous pneumothorax results from rupture of a subpleural bleb in individuals without lung disease * Marfans ## Footnote Thin, tall and smokers. Almost always are smokers, not always tall or thin

Answer 82

* Secondary spontaneous pneumothorax occurs in COPD patients * Central line placement 16% * 1.25% pneumothorax volume re-absorbed/day(> rate with O2) ## Footnote Thin, tall and smokers. Almost always are smokers, not always tall or thin

Answer 83

Pneumothorax * Super small so get CT to quantative the size to see the treatment * If under 15% then obs

Answer 84

* Pleural defect creates one way valve and leads to positive pressure in pleural space → shift of mediastinum → compression of SVC → hypotension → arrest * Triad of JVD/decreased breath sounds/hypotension * Other signs include unilateral chest expansion/cyanosis/tracheal deviation (late sign)

Answer 85

* Diagnosis clinically; if stable, wait for CXR! * Treatment: needle thoracostomy in 2nd ICS at MCL (field) follow-up with chest tube (hospital)

Answer 86

The pleural space is the space between the inner and outer lining of the lung. It is normally very thin, and lined only with a very small amount of fluid.

Answer 87

If fluid, such as blood, or air, gets into the pleural space, the lung can collapse, preventing adequate air exchange. Chest tubes are used to treat conditions that can cause the lung to collapse, such as: * air leaks from the lung into the chest (pneumothorax) * bleeding into the chest (hemothorax) * after surgery or trauma in the chest (pneumothorax or hemothorax) * lung abscesses or pus in the chest (empyema).

Answer 88

* Chest tubes are inserted to drain blood, fluid, or air and allow full expansion of the lungs. * The tube is placed in the pleural space. The area where the tube will be inserted is numbed (local anesthesia). The patient may also be sedated. * The chest tube is inserted between the ribs into the chest and is connected to a bottle or canister that contains sterile water. * Suction is attached to the system to encourage drainage. A stitch (suture) and adhesive tape is used to keep the tube in place. ## Footnote The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics).

Answer 89

* Recovery from the chest tube insertion and removal is usually complete, with only a small scar. * The patient will stay in the hospital until the chest tube is removed. * While the chest tube is in place, the nursing staff will carefully check for possible air leaks, breathing difficulties, and need for additional oxygen. * Frequent deep breathing and coughing is necessary to help re-expand the lung, assist with drainage, and prevent normal fluids from collecting in the lungs.

Answer 90

– 1⁄4 Infectious(non-TB) – 1⁄4 Neoplastic – 1⁄4 Other: TB, cardiovascular, vasculitis, etc. – 1⁄4 Undetermined – Epistaxis (false positive)

Answer 91

Minor * Treat underlying cause Massive * Consider selective mainstem intubation of non-bleeding lung * Angiogram/bronchoscopy/surgery

Answer 92

* Reversible airway obstruction * Reduction of airway diameter caused by smooth muscle contraction, bronchial edema and thick mucous secretions * Increased airway resistance, decreased expiratory flow rates, air trapping * With increased work of breathing, patient develops hypoxemia, hypercarbia, and respiratory muscle fatigue with ventilatory failure

Answer 93

* Beta adrenergics (smaller airways) albuterol * Usually expect a response after 6mg of albuterol – receptors are now saturated * Anticholinergic agents (ipratropium bromide)(larger airways) * Corticosteroids (PO/IV not Aerosol) acute

Answer 94

* Magnesium 1-2 grams over 15 minutes in severe asthma (smooth Muscle relaxer) after the above drugs failed * Intubation and Ventilation

Answer 95

* Chronic airflow obstruction * Exertional dyspnea and cough * Chronic, productive cough * Hemoptysis is frequent * Expiratory wheezing (especially forced end-expiration) * Decompensation is frequent: super-imposed URI ## Footnote Don’t give too much O2 – knocks out respiratory reflex. No permissive hypoxia, only hypercapnia.

Answer 96

CXR (COPD)

Answer 97

* Over time, patient develops chronic hypoxemia * Eventually becomes markedly hypercarbic * Chronic Respiratory Failure (50-50) * 30% are on home-oxygen therapy which reduces mortality

Answer 98

* Goal is pO2 of 60 with 90% saturation at rest * Allow permissive hypercarbia (respiratory drive), not hypoxia * Mainstay of TX: bronchodilators, anticholinergic * Acute Exacerbations: add short course of steroids, antibiotics if indicated by sputum * Noninvasive positive pressure ventilation through a mask has better outcomes than intubation ## Footnote Try to get O2Sat at 90 to maintain respiratory drive. Give them to BiPAP. Increase the EPAP.

Answer 99

* Descent or Ascent direct effect of pressure changes on the body * Occurs secondary to the Compression or Expansion of air and nitrogen in bodily spaces – Generally safe to ascend or descend 30ft per minute with supply, 60ft/min if no air supply

Answer 100

* Symptoms can develop 4.5-6.5 ft depth * Decompression Sickness can develop if patient flies within 12-24hrs of the dive * Treatment with High Flow O2 to have NITROGEN WASHOUT

Answer 101

* In Denver, the air has 17% less oxygen in it than at sea level. In Aspen, there is 26% less oxygen in the air. At the top of Mt. Everest, there is 1/3 the amount of oxygen in the air as at sea level * **High altitude is a hypoxic environment**. * Increasing altitude=decreasing atmospheric pressure=relative hypoxia * Acclimatization is key of prevention ## Footnote Advise COPD pat against skiing.

Answer 102

* Acute Mountain Sickness (AMS) * High Altitude Cerebral Edema (HACE) * High Altitude Pulmonary Edema (HAPE) * High Altitude Retinal Hemorrhage (HARH) * Chronic Mountain Polycythemia (CMP) * Ultraviolet Keratitis (Snow Blindness) * Symptoms range from SOB/dizziness/nausea/weakness to ataxia/AMS/Coma

Answer 103

* Descend * Oxygen * Motrin * Nifedepine * Acetazolamide (preventitive)

Answer 104

Nifedepine to cause vasodilation of pulmonary artery Acetazolamide improves arterial oxygenation during sleep. * Contra-indicated with Sulfa Allergy * Causes HCO3 excretion, creating hyperchloremic acidosis and thus increasing respiratory rate, leading to respiratory alkalosis

Answer 105

* Phlebotomy for chronic polycythemia * Advise against altitude for COPD/Sickle Cell and pregnancy patients

Answer 106

Drowning – death within 24 hours * Generally receive CPR Near-drowning – survival past 24 hours * Generally do not receive CPR

Answer 107

* Neurogenic pulmonary edema, Pneumonia, ARDS etc. * Plus complications of hypothermia

Answer 108

* Prolonged head immersion * L.O.C. * Period of apnea * CPR required

Answer 109

* Cough, breathlessness * Retrosternal discomfort * Cyanosis, tachycardia * Tachypnoea, wheeze or Crackles in chest * Pink frothy sputum * Reduced consciousness

Lecture 7: Pulmonary Flashcards

(169 cards)