Lecture 8: Dyspnea Readings

Question 1

Classifications of Acute HF

Answer 1

1. HTN acute HF: preserved LVEF, SBP > 140, Pulm edema
2. Pulmonary edema
3. Cardiogenic shock: hypoperfusion + SBP < 90
4. Acute on chronic HF: SBP 90-140, mild-mod S/S, takes days
5. RHF: low output, JVD, hepatomegaly, hypotension

Question 2

Top symptom for acute heart failure

Answer 2

DOE

Question 3

Top 3 symptoms generally unique to acute HF

Answer 3

1. PND
2. Orthopnea
3. Edema

Question 4

CXR findings for acute HF

Answer 4

• Pulmonary venous congestion
• Cardiomegaly
• Interstitial edema

Most specific

Question 5

Management of acute HF

Answer 5

1. O2 > 95%
2. Afterload reduction if pulm edema present
3. NTG based on BP
4. Nitroprusside if ^ fails
5. Loop diuretics for volume overload
6. Persistent hypotension post ntg = bolus NS
7. Morphine (debateable, but can relieve anxiety/congestion)

Question 6

High-risk patient characteristics for acute HF that may suggest ICU

Answer 6

• AMS
• Persisten hypoxia
• Hypotension
• Trop elevation
• Ischemic EKG changes
• BUN > 43
• Cr > 2.75
• Oliguria

Question 7

Top 2 MC symptoms in a PE

Answer 7

• Dyspnea
• Pleuritic chest pain

Question 8

C

Criteria used for evaluate PE

Answer 8

• PERC Rules (all 9 to r/o PE)
• Wells’ score

Question 9

Wells’ score breakdown for PE

Answer 9

• > 6 = HIGH RISK
• 2-6 = mod
• < 2 = low-risk

Question 10

Test of choice to diagnose PE

Answer 10

CT pulmonary angiography

Question 11

What finding on a V/Q scan has a 100% sensitivity to r/o PE?

Answer 11

Homogenous scintillation

Question 12

Sample PE algorithm

Answer 12

Question 13

What kind of pt with a PE should NOT use LWMH?

Answer 13

Severe renal insufficiency

Use UFH instead

Question 14

What are the primary outpatient tx options for a PE?

Answer 14

• LWMH
• Xarelto
• Eliquis

Question 15

When is systemic thrombolytics indicated for PE?

Only alteplase approved

Answer 15

• Hypotension < 90
• BP dropped by > 40

Start UFH or LWMH after

Question 16

When is IVC filter indicated for PE?

Answer 16

• AC is contraindicated or failed
• Submassive PE associated with DVT

Question 17

MCC of bronchitis

Answer 17

• Flu A/B
• Adeno
• Rhino
• Parainfluenza
• RSV
• Corona

VIRAL

Bacterial is way rarer

Question 18

Predominant feature of acute bronchitis

Answer 18

Coughing (productive just suggests inflammation)

Question 19

Clinical diagnosis of acute bronchitis

Answer 19

1. Acute-onset cough < 3 weeks
2. Absence of chronic lung disease
3. Normal vitals
4. Absence of pneumonia lung sounds

Question 20

If we suspect pertussis instead of bronchitis, what is the tx?

Answer 20

Azithromycin

Question 21

When are BDs indicated for acute bronchitis?

Answer 21

• Evidence of airflow obstruction
• Give some albuterol

Question 22

MCC of classic pneumonia

Answer 22

Strep pneumo

Question 23

What symptom suggests bacterial PNA is due to an anaerobe?

Answer 23

Aspiration

Question 24

S/S of bacterial PNA

Answer 24

• Cough/fatigue/fever/dyspnea
• Sputum production
• Pleuritic chest pain
• Tachypnea/tachycardia
• Bronchial breath sounds + rhonchi => consolidation

Question 25

What makes bacterial PNA considered healthcare associated?

Answer 25

* Hospitalized for > 48h in past 90d * Dialysis/wound care/SNF * Home IV Abx therapy

Question 26

Where does aspiration PNA tend to consolidate?

Answer 26

RLL due to gravity and bronchial tree | Will lead to empyema or abscess

Question 27

ABX for uncomplicated, outpatient CAP

Answer 27

**azithromycin or doxycycline** | elkins notes says amoxil and not azithromycin!

Question 28

ABX for comorbidities, outpatient CAP

Answer 28

* **Levofloxacin** * **Augmentin + azithromycin** | Oral FQs are used after macrolide failure usually.

Question 29

ABX for inpatient CAP (but not ICU)

Answer 29

* Levofloxacin * Rocephin + Azithromycin

Question 30

ABX for inpatient ICU CAP

Answer 30

* Rocephin + levofloxacin +/- vanco (MRSA)

Question 31

ABX for inpatient HCAP

Answer 31

* Levofloxacin + cefepime/piptazo * Also add vanco or linezolid

Question 32

ABX for witnessed aspiration PNA

Answer 32

1. Immediate tracheal suction 2. Bronchoscopy 3. Levofloxacin + clinda

Question 33

ABX for empyema

Answer 33

* Piptazo * Add vanco for MRSA

Question 34

ABX for lung abscess

Answer 34

Clinda + rocephin

Question 35

MC 2 symptoms and MC sign for pneumothorax

Answer 35

* Suddet onset dyspnea * **Ipsilateral pleuritic chest pain** * Sinus Tachycardia

Question 36

In what type of pneumothorax is ipsilateral decreased breath sounds likely to occur?

Answer 36

Traumatic pneumothorax

Question 37

Clinical hallmarks of tension pneumothorax

Answer 37

* Severe, progressive dyspnea * Tachycardia > 140 * Hypoxia * Ipsilateral decreased breath sounds ## Footnote Tracheal deviation, distended neck veins, and PMI displacement are late and infrequent.

Question 38

Primary imaging for a stable pneumothorax pt

Answer 38

PA CXR showing displaced pleural line with absent lung markings.

Question 39

What signs on a supine AP CXR suggest pneumothorax?

Answer 39

* Cardiophrenic recess hyperlucency * CPA enlargement (deep sulcus sign)

Question 40

How do we confirm a emphsematous bulla vs a pneumothorax?

Answer 40

CT Chest

Question 41

Quick and easy Imaging for a young, healthy patient with pneumothorax?

Answer 41

Bedside US

Question 42

Management of pneumothorax

Answer 42

* Tension: needle decompression + tube thoracostomy * 2-4 LPM of O2 to help pleural air resorption * If small: monitor for 4 hrs on supplemental O2 and repeat CXR. Improved = 24h f/u. * Aspiration for small primary or secondary * Chest tube thoracostomy for big or recurrent, also admit

Question 43

Where is needle aspiration done for pneumothorax?

Answer 43

* Anterior 2nd ICS at midclavicular * Laterally in 4/**5th** ICS anterior axillary | 14G, 2 in needle, 18G in children

Question 44

Two main forms of COPD

Answer 44

* Emphysema * Chronic bronchitis

Question 45

Main physiologic cause of acute asthma exacerbations vs COPD exacerbations

Answer 45

* Asthma: Expiratory airflow is limited * COPD: V/Q mismatch

Question 46

RFs for death from asthma exacerbation?

Answer 46

1. 2+ admits or 3+ ER visits for asthma in past year 2. > 2 canisters of SABAs a month 3. Poor, drugs, psych

Question 47

Hypoxia S/S

Answer 47

* Tachypnea * Cyanosis * Agitation * Apprehension * Tachycardia * HTN

Question 48

Hypercapnia S/S

Answer 48

* AMS * Plethora * Stupor * Hypopnea * Apnea

Question 49

How is asthma severity measured?

Answer 49

* FEV1 * Peak expiratory flow rate | < 40% in either = severe

Question 50

Management of acute asthma/COPD exacerbations

Answer 50

* O2 > 90% * SABAs for bronchospasms (inhaled first) * SC SABAs 2nd: terbutaline or epi * Adjuvant therapy for SABA: ipratropium * Prednisone PO or methylprednisolone in the ED * Empiric ABX for COPD with sputum changes. (Doxy/azithro/Augmentin) * **IV MgSO4 for asthma FEV1 < 25%** * NPPV if they seem tired af * ETT if ^ fails

Question 51

Admission criteria for asthma

Answer 51

* Failed outpatient tx * Persistent/worsening dyspnea * PEFR/FEV1 < 40% * Hypoxia/hypercarbia/AMS

Question 52

Admission criteria for COPD

Answer 52

* Fialed outpatient tx * Frequent exacerbations post-discharge * Severe dyspnea * Worsening status * Can't take care of self at home

Question 53

What should you AVOID in asthma/COPD exacerbations?

Answer 53

* Respiatory depression drugs * BBs * Antihistamines * Decongestants * Mucolytics

Question 54

What is the role of heliox in asthma/COPD exacerbations?

Answer 54

Lower airway resistance to deliver drugs in severe

Question 55

Discharge meds for asthma/COPD exacerbations

Answer 55

Oral steroids (5-10d of prednisone)