pulmonary Flashcards by Chloe Michaelis

airway changes in asthma

narrowed airways, hypertrophy of smooth muscle, mucosal edema, thickened epithelial basement membrane, hypertrophy of mucus glands, acute inflammation, plugging by thick mucus

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what would ABG demonstrate in asthma exacerbation?

mild hypoxemia- low PO2,

respiratory alkalosis- elevated pH, decreased pCO2- hyperventillation

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how does levalbuterol (Xopenex) work? what is it used for?

stimulates enzymes that convert ATP to cAMP- relaxes bronchial smooth muscles

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maintanence for asthma

low dose inhaled corticosteroid- budesonide (fluticasone) +/- long acting beta agonist (LABA)- salmeterol
combo inhalers: symbicort, advair

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severe asthma treatment

high dose ICS + LABA + oral corticosteroid

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what is anaphylaxis epinephrine dosing?

3-0.5 mg subcutaneous

1: 1000 mg/mL

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status asthmaticus treatment

airway support: oxygen, ABG q 10-20 minutes, intubation, pulse oximetry
IV fluids, IV steroids,
atrovent or inhaled sympathomimetics

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COPD: chronic bronchitis vs emphysema

bronchitis- intermittent dyspnea, earlier onset, copious sputum, stocky/ obese body habitus, percussion normal, increased hematocrit
emphysema- progressive/ constant dyspnea, later onset 50+, mild clear sputum, thin body habitus, increased A-P diameter, percussion hyper resonant, TLC increased

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COPD: FEV1, TLC, FRC, RV

FEV1- expiratory flow reduced
TLC increased
Functional Residual Capacity- increased
Residual Volume- increased

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PPD testing

shows exposure of TB, not diagnostic for active disease

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active TB diagnostics

culture of M. tuberculosis x 3
acid fast bacillus smears- presume evidence of active TB
small homogenous infiltrate in upper lobes by CXR

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TB medication regimen (RIPE)

Rifampin 600 mg
isoniasid 300 mg
pyrazinamide 1.5-2.0 gm
ethambutol 15 mg/kg daily 
RIPE
1st 3 drugs daily for 2 months, then 4 more months of INH and RIF daily
if HIV, treat for 9 months

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monitoring for TB

weekly sputum smears and cultures in 1st 6 weeks, then monthly until negative cultures.
possibly monthly labs: LFTs, CBC, serum creatinine

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ethambutol considerations (TB drug)

test for visual acuity and red/green color perception

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if positive PPD, what is treatment

6 months of INH (isoniazid)

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what defines positive PPD?

5 mm measurement HIV
10 mm measurement in immigrants
15 mm measurement in general population

what is most common community acquired pneumonia CAP bug

strep. pneumoniae

mortality score for CAP: PORT

Patient Outcomes Research Team score- based on age (-10 for women) and points for each 20 relevant characteristics
PORT > 130- ICU
PORT 70-130 inpatient stay

CURB 65 scoring

Confusion- mental test score < 8
BUN > 19
Respiratory rate > 30
SBP < 90 or DBP < 60
Age > 65
moderate to high risk- hospitalization

what are macrolid antibiotics?

azithromycin, clarithromycin, erythromycin, and roxithromycin

antibiotic coverage for inpatient CAP- nonsevere (acute care) or severe (ICU)

beta-lactam (PCN and cephalosporins), + macrolid (azithro) OR fluroquinolone (levaquin, ciprofloxacin)
severe (need pseudamonas coverage): pip-tazo OR meropenem, or cefepime + AMG (amikacin) / azithro
if MRSA- above + vanc or linezolid

outpatient CAP coverage

amoxicillin or doxycycline or macrolide (azithro)

what is viral CAP coverage

zanamivir, peramivir, zanamivir

possible to have secondary bacteria infection

what are HAP bugs?

Staph aureus
Strep pneumoniae
Haemophilus influenzae

HAP coverage routine, vs MRSA, vs high risk of mortality

routine HAP: 1 antibiotic: pip-tazo OR cefepime OR levofloxacin OR imipenem or meropenem MRSA coverage- add vanco or linezolid high mortality: TWO agents PLUS MRSA coverage- avoid 2 beta lactams pip-tazo, cefepime, levo or cipro, imipenem or meropenem, amikacin or gentamicin or tobramycin azteronam cefepime, meropenem, vancomycin (common UVA regimen)

VAP coverage

MRSA and double antipseudomonal coverage: beta-lactam and non-beta lactam antibiotics vancomycin + Piptazo OR cefepime OR meropenem OR aztreonam + levo OR cipro OR amikacin OR gentamicin OR colistin

needle thoracostomy placement:

2nd intercostal space, mid clavicular line

chest tube placement:

4th or 5th ICS, mid axillary line

sarcoidosis

interstitial lung disease; CXR, PFTs, ABGs, biopsy of lung parenchyma for diagnosis (bronchoscopy) tx: corticosteroids, immunosuppressive agents: azathioprine, methotrexate, cyclophosphamide

control ventillator setting

preset TV and RR

assist control ventilator

preset volume, but patient can trigger extra breath

pressure support

respiratory rate determined by patient, inspiratory effort unassisted but preset airway pressure with each breath (PEEP)

SIMV

preset RR and TV, but patient can take extra breaths at whatever TV they normally do- likely lower

when is BiPAP commonly used?

for COPD patients, or to wean from the ventilator

obstructive disease PFTs:

reduced airflow rates; decreased FVC/ FEV1, but lung volumes are normal or above normal

restrictive disease PFTs, diagnoses

morbid obesity, sarcoidosis, pulmonary fibrosis | reduced volumes- TLC, FRC, RV, and reduced expiratory flow rate

pleural fluid exudate characteristics:

protein to serum protein ratio > 0.5 LDH to serum LDH ratio > 0.6 pleural fluid LDH (lactate dehydrogenase) greater than 2/3 upper limit of normal serum LDH exudate- cream looking: protein and LDH

transudate fluid

clear looking, no protein/ LDH elevation

CXR findings can determine type of pneumonia....

Bacterial: bronchopneumonia, lobar pneumonia Viral: bilateral interstitial infiltrates Aspiration: R middle lobe or diffuse involvement