Pulmonary Flashcards
(148 cards)
1
Q
Indications for intubation
A
Inability to maintain patent airway
Inability to protect the airway against aspiration
Failure to ventilate
Failure to oxygenate
Anticipation of a deteriorating course that will eventually lead to respiratory failure
2
Q
“fail safe” on ETT in case the end opening of the tube is blocked
A
Murphy eye
3
Q
induction drugs
A
etomidate
ketmine
fentanyl
Versed
propofol
thiopental
methohexital (Brevital)
4
Q
neuromuscular blocking agents (paralytics)
A
succinylcholine
rocuronium
vecuronium
5
Q
how to give rapid sequence intubation meds
A
induction agent first
neuromuscular blocking agent second
rapid IV push
6
Q
Adjuctive meds for intubation
A
atropine - vagolytic (intubation will often cause bradycardia)
lidocaine - vagolytic (decreases intracranial pressure in head injury; decrease airway reactivity in asthma)
fentanyl - decreases intracranial pressure in head injury; prevents vasospasm in vascular emergencies (e.g. MI, aortic dissection, SAH)
ondansetron - if the patient is vomiting
7
Q
How to confirm placement of ETT
A
Colorimetric end-tidal CO2 detector
5 point auscultation (epigastric, bilaterally under the clavicles, bilaterally midaxillary lines)
Mist in tube
Bilateral chest rise
CXR
In normal adults it should be 20-23cm from the teeth
8
Q
inspiratory capacity
A
The maximum volume of air that can be inspired after reaching the end of a normal, quiet expiration
9
Q
expiratory reserve volume
A
The extra volume of air that can be expired with maximum effort beyond the level reached at the end of a normal, quiet expiration
10
Q
residual volume
A
the amount of air that remains in a person’s lungs after fully exhaling
11
Q
vital capacity
A
the maximal volume of air that can be expired following maximum inspiration
12
Q
Four lung volumes
A
inspiratory reserve volume (IRV)
expiratory reserve volume (ERV)
tidal volume (V)
residual volume (RV)
13
Q
Four lung capacities
A
total lung capacity (TLC)
vital capacity (VC)
inspiratory capacity (IC)
functional residual capacity (FRC)
14
Q
inspiratory reserve volume
A
the amount of air a person can inhale forcefully after normal tidal volume inspiration
15
Q
tidal volume
A
the amount of air that moves in or out of the lungs with each respiratory cycle
16
Q
functional residual capacity
A
the volume remaining in the lungs after a normal, passive exhalation
17
Q
total lung capacity
A
the volume of air in the lungs upon the maximum effort of inspiration
18
Q
minute volume
A
the volume of gas inhaled (inhaled minute volume) or exhaled (exhaled minute volume) from a person’s lungs per minute
should be between 4-5 LPM
- MV <4 = acidotic
- MV >5 = alkaloid
19
Q
volume control modes
A
Assist/Control (A/C)
Synchronized Intermittent Mandatory Ventilation (SIMV)
20
Q
pressure control modes
A
Presssure Controlled Ventilation (PCV)
Pressure-Regulated Volume Control (PRVC)
21
Q
Assist/Control (A/C)
A
Most frequently used initial mode
Requires the least effort by the patient
Machine does the work, but the patient can trigger the machine
Tidal volume (vT) and respiratory rate are pre-set (f) regardless of whether the patient breathes spontaneously.
If the patient does breathe spontaneously, the ventilator senses this, and delivers a full breath.
22
Q
A/C can lead to
A
hyperventilation because the patient can breathe over the tidal volume (vT)
23
Q
Synchronized Intermittent Mandatory Ventilation (SIMV)
A
Allows the patient to take a smaller breath if they want, beyond the pre-set rate (f).
Constantly recalculates expected minute volume every 7.5 seconds. If the calculation suggests the minute volume target will not be met, SIMV breaths are delivered at the pre-set tidal volume (vT) to achieve the desired minute ventilation.
Inspiratory pressure support is also used in this mode to help the patient take a deeper breath.
24
Q
Pressure Controlled Ventilation (PCV)
A
The ventilator delivers the breath over a pre-set inspiratory time until a pre-set peak inspiratory pressure (PIP) is reached, regardless of tidal volume (vT)
25
Pressure-Regulated Volume Control (PRVC)
Combines pressure-limited, volume-targeted, time-cycled breaths.
The peak inspiratory pressure (PIP) delivered by the ventilator varies on a breath-to-breath basis to achieve a target pre-set tidal volume (vT)
26
PEEP
Positive end-expiratory pressure
prevents against alveolar collapse
applies a pressure to maintain the reserve volume
used to treat obstructive sleep apnea (CPAP)
27
risks associated with mechanical ventilation
barotrauma - pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum
VAP, including ARDS
rapid-type of disuse
atrophy involving the diaphgragmatic fibers
impair mucociliary motility in the airways
28
pressure control mode in Assist/Control (A/C) ventilation
the breath is delivered until a desired pressure is met, regardless of volume
lower airway pressure is needed
29
volume control mode in Assist/Control (A/C) ventilation
the breath is delivered until a desired volume is met, regardless of pressure
30
flow trigger
the ventilator is set to detect a minimum amount of inspiratory flow, usually 1-6 LPM
31
pressure trigger
the ventilator is set to detect a minimum amount of inspiratory pressure, usually 1-4 cmH2O
32
compliance
ratio between the change in volume and the change in pressure
33
If compliance is decreased, a ___ pressure would be required to reach a certain volume (e.g. vT)
higher
34
Which mode of A/C do you choose if volume is more important?
volume control
35
Which mode of A/C do you choose if pressure is more important?
pressure control
36
What mode of A/C do you choose for restrictive or obstructive lung diseases like pneumonia, COPD, asthma, pulmonary edema ("can't breathe")?
pressure control
37
What mode of A/C do you choose when compliance was never the issue to begin with ("won't breathe"), like in neurological disorders, ingestion of respiratory depressants?
volume control
38
Control mode
The machine does all the work
Tidal volume (vT) and respiratory rate (f) are preset
39
Continuous positive airway pressure (CPAP)
breathing spontaneously but at a pressure greater than atmospheric
40
Pressure Support (PS) mode
inspiratory effort is totally unassisted but a preset amount of airway pressure is delivered with each breath
41
bilevel positive airway pressure (BiPAP)
CPAP + PEEP
42
FEV1
volume of gas expelled in the first second of the forced vital capacity maneuver
43
FEV25-75
maximal mid-expiratory airflow rate
44
PEFR
maximal airflow rate achieved in forced vital capacity (FVC) maneuver
45
Obstructive diseases are characterized by ___; lung volumes ___.
Obstructive diseases are characterized by **reduced airflow rates** (FVC, FEV1, FEV25-75, PEFR); lung volumes **within normal range or larger**
Examples: asthma, bronchitis, emphysema, COPD
46
Restrictive diseases are characterized by ___
Restrictive diseases are characterized by **reduced volumes and expiratory flow rates** (TLC, FRC, RV)
Examples: morbid obesity, sarcoidosis, pulmonary fibrosis
47
How do you adjust the ventilator if your patient is in respiratory acidosis?
increase rate
48
How do you adjust the ventilator if your patient is in respiratory alkalosis?
decrease rate
49
asthma exacerbation: management
supplemental O2
albuterol nebulizers
systemic corticoids
IV magnesium - improves airflow
50
asthma exacerbation: S/Sx
respiratory distress at rest
difficulty speaking in sentences
diaphoresis
use of accessory muscles
hyperresonance
cough
chest tightness
RR >28
HR >110
pulsus paradoxus > 12mmHg
51
asthma: ominous signs
fatigue
absent breath sounds
paradoxical chest/abdominal movement
inability to maintain recumbency
cyanosis
52
asthma: labs, imaging
leukocytosis w/eosinophilia
PFTs: abnormal
respiratory alkalosis with mild hypoxemia
CXR: hyperinflation; not necessary unless ruling out other conditions
53
When do you hospitalize a person with asthma?
FEV1 does not improve after inhaled bronchodilator
Peak flow <60 L/min initially or does not improve after treatment
54
Step-wise approach to managing asthma in adults
STEP 1
- SABA (e.g. albuterol, levalbuterol) PRN
- consider low-dose ICS (e.g. budesonide, fluticasone, triamcinolone)
STEP 2
- low-dose ICS (e.g. budesonide, fluticasone, triamcinolone)
STEP 3
- low-dose ICS (e.g. budesonide, fluticasone, triamcinolone)
- LABA (e.g. salmeterol, formoterol)
STEP 4
- medium-dose ICS
- LABA
STEP 5
- high dose ICS
- LABA
- PO corticosteroids
55
combination ICS + LABA inhalers
Advair (fluticasone + salmeterol)
Symbicort (budesonide + formoterol)
56
inpatient management of asthma
Supplemental O2
SABA
Anticholinergic (ipratropium)
Systemic glucocorticoids (IV methylpred, PO pred) given within 1 hour of admission to the ED
Magnesium
Mechanical ventilation
Anaphylaxis: epinephrine 0.3-0.5 mg SC
57
status asthmaticus
severe, acute asthma presenting in an unremitting, poorly responsive, life-threatening manner
58
status asthmaticus management
O2
IV D5 1/2 NS
inhaled and parenteral sympathomimetics (e.g. ephedrin, isoprotenerol, orciprenalin, salbutamol, terbutaline)
methylprednisolone or hydrocortisone IV
consider atrovent
continuous pulse ox
ABG q10-20 min
intubate early
59
chronic bronchitis S/Sx
- dyspnea
- onset
- sputum
- body habitus
- AP ratio
- percussion
- CXR
- HCT
intermittent mild to moderate dyspnea
onset of symptoms after age 35
copious sputum production (purulent)
body habitus: stocky, obese
AP ratio: normal
percussion: normal
CXR: hyperinflation
HCT: increased
60
emphysema S/Sx
- dyspnea
- onset
- sputum
- body habitus
- AP ratio
- percussion
- HCT
- total lung capacity
progressive, constant dyspnea
onset of symptoms after age 50
mild sputum (clear)
body habitus: thin, wasted
AP ratio: increased (barrel-chested)
percussion: hyperresonant
HCT: normal
Total lung capacity: increased
61
outpatient management of chronic bronchitis and emphysema
lifestyle changes (smoking, allergens)
postural drainage
inhaled ipratropium bromide or sympathomimetics -- mainstay of therapy
inhaled tiotropium bromide (Spiriva) promotes bronchodilation
62
Who is at increased risk for TB?
crowded living conditions
institutionalized
HIV
DM
chronic renal insufficiency
malignancy
malnutrition
immunosuppression
63
TB: S/Sx
most people are asymptomatic
fatigue
anorexia
dry cough progressing to productive and sometimes blood tinged
weight loss
low grade fever
night sweats
64
TB: labs/Dx/imaging
**Definitive diagnosis by culture of M. tuberculosis x3**
-Acid-fast bacillus (AFB) smears are presumptive evidence of active TB
CXR: honeycomb infiltrates in upper lobes
+PPD indicates exposure, not diagnostic for active disease
65
What to do if someone is +PPD with a negative CXR?
isoniazid (INH) for 6 months
66
TB: management (no Hx of HIV)
RIPE:
- Rifampin 600mg
- Isoniazid 300mg
- Pyrazinamide 1.5-2.0g
- Ethambutol 15 mg/kg/day
If fully susceptible to isoniazid, ethambutol may be dropped
Rifampin, isoniazid, pyrazinamide x2 months, then rifampin and isoniazid x4 months
67
TB: management if HIV+
RIPE:
- Rifampin 600mg
- Isoniazid 300mg
- Pyrazinamide 1.5-2.0g
- Ethambutol 15 mg/kg/day
9 months
68
ethambutol monitoring
visual acuity
red-green color perception
69
Criteria for +PPD
HIV+, immunosuppression d/t chemotherapy TNF-alpha inhibitors or glucocorticoids, contacts of a known case, persons with chest film typical for TB, or post-transplant: 5mm
Immigrants from high prevalence areas, high risk groups including healthcare workers: 10mm
All others not in high prevalence groups: 15mm
70
most common organism that causes CAP
strep pneumoniae
71
Patient Outcomes Research Team (PORT) score: class I-II:
-Score
-Risk
-Treatment
Score: algorithm or <70
Risk: low
Treatment: outpatient
72
Patient Outcomes Research Team (PORT) score: class III:
-Score
-Risk
-Treatment
Score: 71-90
Risk: low
Treatment: brief inpatient
73
Patient Outcomes Research Team (PORT) score: class IV:
-Score
-Risk
-Treatment
Score: 91-130
Risk: moderate
Treatment: inpatient
74
Patient Outcomes Research Team (PORT) score: class V:
-Score
-Risk
-Treatment
Score: >130
Risk: high
Treatment: ICU
75
Outpatient CAP: low severity
- criteria
- pathogens
- empiric therapy
Criteria
- healthy
- no use of ABx in the past 3 months
- no comorbidities or risk factors for MRSA or p. aeruginosa
Pathogens:
- S. pneumoniae
- H. influenzae
Empiric therapy: Choose one
- amoxicillin 1g TID
- doxycycline 100mg BID
- macrolide (-mycin)
76
Outpatient CAP: moderate- to high-severity
- criteria
- pathogens
- empiric therapy
Criteria
- comorbidities or risk factors for resistant organisms
Pathogens:
- S. pneumoniae
- H. influenzae
Empiric therapy: choose one
- [augmentin or cephalosporin] + [macrolide or doxycycline]
- respiratory fluoroquinolone (moxifloxacin, levofloxacin)
77
outpatient viral CAP: empiric therapy
oseltamivir or zanamivir if onset of symptoms <48 hrs
78
inpatient CAP: nonsevere
- pathogens
- empiric therapy
Pathogens:
- s. pneumoniae
- h. influenzae
- legionella
Empiric therapy: choose one
- beta lactam + (azithromycin or clarithromycin)
- respiratory fluoroquinolone (levofloxacin, moxifloxacin)
79
inpatient CAP: severe
- pathogens
- empiric therapy
Pathogens
- s. pneumoniae
- s. aureus
- legionella
- gram-negative bacilli
- h. influenzae
empiric therapy
- beta lactam + [IV fluoroquinolone or IV azithromycin]
80
empiric therapy if p. aeruginosa suspected
Choose one:
- pip/tazo
- meropenem
- cefepime
AND
- gentamicin or azithromycin
81
empiric therapy if MRSA suspected
Choose one:
- pip/tazo
- meropenem
- cefepime
AND
- vanc or linezolid
82
most common causative organisms for HAP
S. aureus
Strep. pneumoniae
H. influenzae
83
empiric therapy for HAP if not at high risk for mortality and no risk factors for MRSA
Choose one
- pip/tazo
- cefepime
- levofloxacin
- imipenem or meropenem
84
empiric therapy for HAP if not at high risk for mortality WITH risk factors for MRSA
Choose one
- pip/tazo
- cefepime or ceftazidime
- levofloxacin or ciprofloxacin
- imipenem or meropenem
- aztreonam
AND
- vancomycin or linezolid
85
empiric therapy for HAP with high risk for mortality or IV antibiotics within the past 90 days
Choose two (avoid two beta-lactams)
- pip/tazo
- cefepime and ceftazidime
- levofloxacin or ciprofloxacin
- imipenem or meropenem
- amikacin or gentamicin or tobramycin
- aztreonam
AND
- vancomycin or linezolid
86
HAP
PNA that occurs >48 hrs after admission
87
VAP
PNA that occurs >48-72 hrs after intubation
88
most common causative organism for VAP
pseudomonas
89
empiric therapy for VAP: with MRSA activity
vancomycin or linezolid
90
empiric therapy for VAP: beta-lactams with antipseudomonal activity
pip/tazo
cefepime or ceftazidime
imipenem or meropenem
aztreonam
91
empiric therapy for VAP: non-beta-lactams with antipseudomonal activity
levofloxacin or ciprofloxacin
amikacin or gentamicin or tobramycin
colistin or polymyxin B
92
pneumothorax: S/Sx
chest pain, dyspnea, cough
hyperresonance on affected side
diminished breath sounds and diminished fremitus on affected side
mediastinal shift toward the unaffected side (tension)
hypotension
CXR: air pockets
93
pneumothorax: management
Asymptomatic, no intervention
chest tube 4th or 5th ICS mid axillary line
- if tension PTX, needle thoracotomy before chest tube (2nd ICS MCL)
94
sarcoidosis
disease of unknown etiology characterized by interstitial lung disease and non-caseating granulomas
95
sarcoidosis: S/Sx
progressive dyspnea
nonproductive cough
rales ("velcro crackles") may be noted
lymphadenopathy
swollen painful joints
rash
kidney stones
96
sarcoidosis: labs/Dx
BMP
ABG
Elevated ACE level
CXR: mediastinal lymphadenopathy
PFTs
bronchoscopy with transbronchial biopsy of the lung parenchyma to confirm diagnosis
97
sarcoidosis: management
1st line: corticosteroids
98
When clinical data and V/Q scan are contradictory, what is recommended to evaluate for PE?
pulmonary angiography
99
PE: labs/Dx
VQ scan (cheaper than spriral CT, but often come back indeterminate)
Spiral CT if available
pulmonary angiography
ABG: hypoxemia (SaO2 <90%, PaO2 <80 mmHg)
hypocapnia (PaCO2 <35 mmHg) d/t reflexive hyperventilation
D-Dimer
100
PE: management
supplemental O2
IV fluids for hypotension and reduced CO2
intubate if worsening hypercapnia w/obtundation
Heparin 80 u/kg bolus followed by drip: 18 u/kg/hr, PTT goal 1.5-2 x normal
Coumadin (simultaneously) to INR goal of 2-3
Fibrinolytic therapy if hemodynamically compromised or shock
- PT and PTT must be <2 x normal
101
ARDS: labs, imaging
refractory hypoxemia - hallmark feature
CXR: white out or diffuse bilateral infiltrates
102
ARDS: management
Mechanical ventilation with PEEP ~10cm H2O, TV 4-6 ml/kg IBW
Treat underlying infection
Sedation to allow rest, awaken for neuro exam
103
pleural effusions: chylous
Characteristic milky white appearance
high triglycerides
104
types of pleural effusions
transudate
exudate - protein (LDH), cream colored
empyema - pus
hemorrhagic
105
How do lung capacities change in older adults?
total lung capacity stays the same
vital capacity decreases because residual volume increases
106
Why is it important to hospitalize older adults with PNA?
Alveoli collapse more easily
Number of cilia diminish
Number of mucus-producing cells increases
Decreased cough reflex
Decreased response to hypoxia and hypercapnia
107
Normal pulmonary physiologic changes in older adults
Lungs become stiffer
Respiratory muscle strength and endurance diminish
Chest wall becomes more rigid
Increased AP diameter
Hyperresonance to percussion
Alveolar surface area decreases up to 20%, which reduces maximal oxygen uptake
108
Clinical findings in older adults with PNA
Classic expected signs may be absent
Earliest sign: tachypnea
Weakness; decreased ADLs
Anorexia, poor appetite
Tachycardia
Fever with productive cough
Confusion or mental status change
SOB (late sign)
109
CXR findings in older adults with PNA
May have multiple presentations based on pathogen
- bacterial: bronchopneumonia, lobar pneumonia, or other locations
- viral: bilateral interstitial infiltrates
- aspiration: localized to the right middle lobe or show diffuse involvement
110
treatment for acute bronchospasm
Bronchodilators + IV steroids to augment the bronchodilators
racemic epinephrine nebulizer
111
Exam findings for TB
abnormal breath sounds, esp over upper lobes or involved areas
rales or bronchial breath sounds = consolidation
112
Ominous finding in PE
hypotension – can indicate massive PE, blocking blood flow from R to L heart
113
Wells Criteria
stratifies patients for pulmonary embolism (PE) and provides an estimated pre-test probability
Clinical symptoms, including leg swelling
other Dx less likely than PE
HR >100
Immobilization or surgery within previous 4 weeks
Hx of DVT/PE
Hemoptysis
Malignancy
114
Berlin Definition of ARDS criteria
All of the following criteria must be met: **ARCHI**
-**A**cute onset (within 7 days)
-**R**isk factors for ARDS identified
-**C**ardiac causes ruled out
-**H**ypoxemia
-**I**nfiltrates: bilateral radiographic infiltrates that are not fully explained by effusion, atelectasis, or masses
115
severe asthma exacerbation: PFTs
Peak expiratory flow rate <40% of personal best or <200 L/min
Decreased FEV1:FVC ratio
Increased total lung capacity
116
severe asthma exacerbation: CXR
hyperinflation
117
transudative effusion criteria
Pleural fluid glucose = serum glucose
pH 7.40-7.55
WBC <1000
118
Transudative effusions
Related to imbalance of hydrostatic and oncotic pressures within the chest, or conditions outside of the pleural space
Fluid may move from the peritoneal, cerebrospinal, or retroperitoneal space
119
Exudative effusions
Related to pleural or lung inflammation or impaired lymphatic drainage
120
Exudative effusions: etiologies
infection
malignancy
immunologic responses
lymphatic abnormalities
noninfectious inflammation
iatrogenic causes
fluid omvement from below the diaphragm
pulmonary embolism
121
Light's criteria
Criteria for exudative effusion
1. pleural fluid lactate dehydrogenase (LDH) above 2/3 of the standard upper limit for serum
2. ratio of pleural fluid LDH to serum LDH >0.6
3. ratio of pleural fluid protein to serum protein >0.5
122
PE is associated with which type of pleural effusion
transudative and exudative
123
Risk factors for asthma-related death
Comorbidities
Difficulty perceiving obstruction of the airway or the severity of an exacerbation
Use of illicit drugs
Low SES or residence in an inner-city
Major psychosocial problems or psychiatric disorders
Previous exacerbation requiring intubation or ICU
2+ hospitalizations or 3+ visits to the ED within the past year
2+ refills of a SABA per month
124
Most common cause of pneumonia in older adults (pathogen)
streptococcus pneumonia
125
When treating ARDS, what can improve alveolar recruitment and oxygenation?
increasing PEEP
126
How does the body compensate for reduction of oxygen delivery in chronic hypoxic lung disease (e.g. COPD)?
increased red blood cell mass
127
common complication following extubation
pulmonary edema
128
pulmonary edema: S/Sx
tachypnea
dyspnea
wheezing
bilateral crackles
129
Readiness for a weaning trial: criteria
FiO2 less than or equal to 50%
PEEP less than or equal to 8
RR <30
Minute ventilation less than or equal to 10L/min
130
chylothorax: cause
Result of damage to the thoracic duct, allowing chyle to build up in the pleural space
-usually iso trauma, thoracic surgery
131
pleural effusions: chylous
Characteristic milky white appearance
Elevated triglycerides
Elevated WBC
Elevated protein
132
Very high concentrations of O2 delivered through a ventilator can cause...
damage to pneumocystis and may lead to pulmonary fibrosis
133
Increased PEEP may lead to...
pneumothorax
134
Gold standard for identifying a PE
CT with contrast
135
Most common and serious complication of barotrauma encountered with mechanical ventilation
alveolar-pleural fistula
-causes persistent air leak
136
Anticipated findings of a patient with status asthmaticus
**Elevated pCO2 -- often first sign**
Dehydration d/t significant insensible fluid losses from respiratory tract 2/2 tachypnea
Tachycardia
Spontaneous pneumothorax may occur
137
pulmonary hypertension: Dx
right heart cath is required to confirm diagnosis
138
acute respiratory failure is associated with
malnutrition
139
empyema
Accumulation of purulent material within the pleural space in the lung
140
empyema: causes
malignancy
recent thoracic surgery or trauma
pneumonia
141
empyema: imaging
CT: well-defined fluid accumulation in the pleural space often leading to the displacement of lung parenchyma, vasculature and mediastinal organs
142
empyema: management
culture data via blood and thoracentesis
chest tube
systemic ABx: pip/tazo, vancomycin
143
Most common pathogen associated with atypical CAP
Legionella
144
Legionella PNA: treatment
macrolides (azithromycin)
145
Imaging to further characterize pneumonia beyond CXR
CT chest without contrast
-allows for accurate visualization of the infiltrate and determination of the lobes involved
-contrast is not indicated to evaluate PNA
146
Imaging used to detect pleural effusion
ultrasound
147
optimal placement for ET tube in adults
2-3 cm above the carina
148
rib fractures: management
Pain control to ensure adequate ventilation
Mobilization and respiratory support to prevent hypoventilation and atelectasis
