Pathology Flashcards
(48 cards)
1
Q
Emphysema (definition)
A
abnormal condition of the alveoli resulting destruction and loss of elasticity
2
Q
What to expect with emphysema
A
- You will usually be tempted to utilize high FiO2 because of the severity of the hypoxemia. You may also be tested with an emergency, the only time it is appropriate to use 100% oxygen on a chronically obstructed patient.
- There are usually two obstructive simulations on the exam and they are not exteremely challenging.
3
Q
Visual Assessment (Emphysema)
A
- Cyanosis
- Barrel chest
- Accessory muscle use
- Digital clubbing of the nail beds
- Significant history of smoking and/or occupational exposure to smoke or other pulmonary irritant
4
Q
Bedside (Patient Contact) Assessment (Emphysema)
A
- Dyspnea
5
Q
Basic Laboratory Assessment (Emphysema)
A
- Chest X-ray - increased AP diameter, flattened diaphragms, hyperlucency, diminised pulmonary markings
- CBC - polycythemia, increased WBC due to possible infection
- ABGs - compensated respiratory acidosis (high PaCO2, normal pH), moderate to severe hypoxemia
- Sputum culture - often positive for bacteria
6
Q
Decision Making (Emphysema)
A
- Oxygen therapy - low FiO2 (0.24 to 0.28) or 1 to 2 lpm nasal cannula
- Oxygen conserving devices such as liquid oxygen or trans-tracheal oxygen
- Home care education on devices and equipment cleaning
- Rehabilitation efforts (specifics not usually required)
- Aids to help quit smoking such as nicotine replacement therapy
- Bronchodilation medication via MDI or aerosol nebulizers
7
Q
Special Assessments (Emphysema)
A
- PFT - flows are decreased especially middle sized airways (FEF 25-75%) and FEV1
8
Q
Definition (Chronic Bronchitis)
A
condition where the patient has a productive cough 25% of the year for at least two consecutive years
9
Q
What to expect with Chronic Bronchitis
A
The most distinguishing characteristic is that the cough is productive and has been so for a good portion of the year.
10
Q
Visual Assessment (Chronic Bronchitis)
A
- Productive cough, purulent sputum production
- Exposure to pulmonary irritants, like history of smoking
- Frequent infections
11
Q
Bedside (Patient Contact) Assessment (Chronic Bronchitis)
A
- Dyspnea
12
Q
Basic Laboratory Assessment (Chronic Bronchitis)
A
- Chest X-ray - could be normal, or may show hyperlucency, diminished/pulmonary markings
- CBC - possibly increased WBC due to possible infection
- ABGs - could be normal or very slight respiratory acidosis and hypoxemia
13
Q
Special Assessments (Chronic Bronchitis)
A
- PFT - flows are decreased especially middle sized airways (FEF 25-75%) and FEV1
14
Q
Decision Making (Chronic Bronchitis)
A
- Anything that promotes good pulmonaryy hygiene such as chest physiotherapy, hydration therapy when sputum is thick
- Fluid therapy if dehydrated
- Oxygen therapy for hypoxemia
- Aerosolized bronchodilator therapy
- Antibiotic Tetracycline may be preferable
15
Q
Bronchiectasis (Definition)
A
- abnormal condition where the bronchi secret large volumes of pus during abnormal dilation
16
Q
What to expect with Bronchiectasis
A
- Central to this is the Bronchogram diagnostic test. Usually, you will be told of the suspicion of Bronchiectasis.
- Increasingly less common on the test
17
Q
Visual Assessment (Bronchiectasis)
A
- Productive cough, often with blood
- Digital clubbing of the nail beds
- Significant history of infections (recurrent)
18
Q
Bedside (Patient Contact) Assessment (Bronchiectasis)
A
dyspnea
19
Q
Basic Laboratory Assessment (Bronchiectasis)
A
- Chest X-ray - generally normal
- Sputum culture - gram negative bacteria
20
Q
Special Assessments (Bronchiectasis)
A
Bronchogram is the primary test. Characterized as a “tree in winter pattern”
21
Q
Decision Making (Bronchiectasis)
A
- Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick
- Fluid therapy if dehydrated
- Oxygen therapy for hypoxemia
- Aerosolized bronchodilator therapy
- May have consider surgical intervention on some highly affected segments
22
Q
Obstructive Sleep Apnea (Definition)
A
the cessation of breathing during sleep; is usually obstructive in nature but sometimes can be central or a combination of the two (mixed)
23
Q
What to expect with Obstructive Sleep Apnea
A
- This is still somewhat rare on the test but it does show up
- Ot is important to remember to avoid sending the patient home without some sort of ventilatory support
24
Q
Visual Assessment (Obstructive Sleep Apnea)
A
- Spouse or bed partner will complain of snoring and will often report witnessing periods of apnea that exceed 10 seconds
- Excessive upper airway tissue, obesity, thick neck
- Ability to fall asleep quickly
25
Bedside (Patient Contact) Assessment (Obstructive Sleep Apnea)
* Dyspnea
* Frequent urination during sleeping hours
26
Basic Laboratory Assessment (Obstructive Sleep Apnea)
ABGs - could be normal or very slight respiratory acidosis and hypoxemia
27
Special Assessments (Obstructive Sleep Apnea)
* Polysomnography (Sleep study) - determines if obstructive or central
* If no nasal flow AND no chest movement - then CENTRAL sleep apnea
* If no nasal flow WITH chest movement - then OBSTRUCTIVE sleep apnea
28
Decision Making (Obstructive Sleep Apnea)
* If central, ventilatory stimulant medication may be used
* If obstructive, use of CPAP or BiPAP is usually initially indicated with follow-up weight loss or upper airway tissue removal through surgery
* Problem must be corrected immediately, so even if discharging, send devices home with patient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cm H2O
29
Asthma (Definition)
abnormal constriction of the bronchials resulting in sputum production and narrowed airways
30
What to expect with Asthma
* When doing PFTs, always do a pre and post bronchodilator study. Consider effective if 15% or more improvement is noted.
* There are no significant traps in this simulation except that the patient may be unresponsive to bronchodilators. In such a case, you are dealing with Status Asthmaticus. Refer to that disease
31
Visual Assessment (Asthma)
* Accessory muscle use
* Tachycardia
32
Bedside (Patient Contact) Assessment (Asthma)
* Dyspnea
* Wheezing
* Congested cough
* Wet, clammy skin
33
Basic Laboratory Assessment (Asthma)
* ABGs - possible respiratory acidosis, could be hypoxic
* Chest X-ray - hyperinflation, scattered infiltrates, flattened diaphragms
* In allergic cases, may see elevated eosinophil count which can cause yellow sputum
34
Special Assessment (Asthma)
* PFT - decreased flows in FEV1 but diffusion is normal as manifested by DLCO
35
Asthma (Decision Making)
* Oxygen therapy for hypoxemia
* Aerosolized bronchodilator therapy
* Xanthine medication given IV (Aminophylline, etc)
* Promote pulmonary hygiene
* Corticosteroids such as oral or IV prednisone
36
Status Asthmaticus (Definition)
asthma that will not respond to bronchodilation therapy, usually persists more than 24 hours
37
What to expect with Status Asthmaticus
* This simulation will challenge your ability to recognize impeding ventilatory failure. It is very important that you treat it before full ventilatory failure.
* There is a frequent need to repeat actions in this simulation which will make you uncomfortable. Do not be afraid to administer several bronchodilators in succession. The same is true of the subcutaneous epinephrine. If you give one dose, you will likely have to give another, and possibly another. Continue if symptoms show no signs of relief
38
Visual Assessment (Status Asthmaticus)
* Historically non-responsive to bronchodilators. Patient will report the need to take many bronchodilator treatments before feeling better.
* Accessory muscle use and retractions
* Dyspnea
* Wheezing
* Congested cough
* Wet, clammy skin
39
Bedside (Patient Contact) Assessment (Status Asthmaticus)
pulses paradoxus
40
Basic Laboratory Assessment (Status Asthmaticus)
* ABGs - possible respiratory acidosis when tiring, alkalosis at first due to anxiety, could be hypoxic
* Chest X-ray - hyperinflation, scattered infiltrates, flattened diaphragms
41
Decision Making (Status Asthmaticus)
* May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate before full ventilatory failure
* Use subcutaneous epinephrine - 1 mL of 1:1000 strength. May need to give every 20 minutes for up to three consecutive doses
42
Myasthenia Gravis (Definition)
neuromuscular abnormality where muscles experience paralysis starting from the head down to the feet including ventilatory muscles
43
What to expect with Myasthenia Gravis
* This can be a very tricky simulation and it is likely that it will show up on the exam. Especially important is your use of Tensilon to diagnose it and an understanding of the dangerous affects it could have. Must always be prepared to assume ventilation.
* Vt, VC and MIP are key in monitoring this patient for degradation in ventilatory status. Intubate prior to full failure if possible.
44
Visual Assessment (Myasthenia Gravis)
* May have a history of Myasthenia Gravis if not the onset
* Droopy facial muscles and eyelids (Ptosis)
45
Bedside (Patient Contact) Assessment (Myasthenia Gravis)
* Patient will describe slowly feeling weakness generally but feels better with rest
* Double vision (diplopia)
* Dysphagia (difficulty swallowing)
* Shrinking Vt, VC, MIP
46
Special Assessments (Myasthenia Gravis)
Tensilon Challenge Test - positive for Myasthenic crisis if improvement is notied upon the administration of Tensilon
47
Decision Making (Myasthenia Gravis)
* If Tensilon improves condition then, anticholinesterase therapy is indicated including:
* Neostigmine (prostigmine)
* Mestinon (pyridostigmine)
* Ok to do additional Tensilon challenge test to observe progression.
* If symptoms improve with Tensilon and then worsen, the must reverse the anticholinesterase with Atropine
* Always monitor spontaneous ventilatory volumes (Vt and VC) as well as MIP
* Never treat Myasthenia gravis with Tensilon--only use to diagnose. Use the above mentioned drugs to provide maintenance.
* Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since it could take out the respiratory drive
* When VC falls off rapidly (especially if below 1.0 L), then intubate and mechanically ventilate
48
Drug Overdose (Definition)
