Pulmonary Flashcards
(36 cards)
Differential for Wheeze
Pulm:
- Asthma
- COPDe
- Pneumonia
- Allergic or eosinophilic pneumonia
- Neoplasm
- Foreign Body
Upper Airway:
- Croup
- Laryngeal edema / neoplasm
Cardiac:
- CHF
- Valvular heart dusease
Other:
- GERD
- ARDS
Risk Factors for Asthma Death
Hx:
- Prev intubation / ICU
- Two hospitalizations in 1 year
- 3 ED visits in 1 year
- Use of more than 2 MDI cannisters/ mth
- Difficulty perceiving exacerbation
Social:
- Low SES
- inner city
- illicit drug use
Comorbidities:
- CV disease
- Other lung disease
Objective findings of severe Asthma
Pulse > 120
Pulsus paradoxus > 10
RR > 20
Accessory muscle use
PaO2 < 60 or PaCO2 > 40
Therapies for acute severe asthma
O2 > 90%, >95% in preggers and CV disease
Beta Agonists
Inhaled anti-cholinergic
Steroids
Epinephrine
MgSO4
Fluids
Ketamine
Heliox
Leukotriene receptor antagonists
Ventilation Strategy for severe asthma
BiPAP if fails then:
ETT
Low respiratory rate
High I:E ratio 1:4 - 1:5
Volume control 6-8 cc/kg
Minute ventilation 115/kg/min = ~7 L/min average adult (500 cc at 14 breaths)
- Turn off peak pressure
Paralysis
Low PEEP
FiO2 100% and titrate down
FEV1 for asthma guidelines
> 70%, can go home
40-70%, possibly go home, otherwise can admit
<40%, ICU
GOLD Criteria for COPDe
Change in baseline cough, dyspnea, sputum
Gold Classification
FEV1/FVC < 70%
and
Mild: FEV1 > 80%
Moderate: FEV1 50-80%
Severe: 30-50%
Very Severe: < 30%
Factors / Triggers of decompensation in COPD
- Viral
- Bacterial: H. Flu, Strep Pneumo, Moroxella, Pseudomonas
Atypical: Chlamydia, Legionella - Air pollution
- Other critical events: pneumothorax, PE, CHF, pneumonia, obesity, trauma, NM disease, non-compliance
COPDe mimics
Pneumonia
CHF
Asthma exacerbation
PE
Pneumothorax
Pleural effusion
Dysrhythmias
Clinical Features for AECOPD
Cough +/- purulence
Increased WOB or air hunger
Wheeze
altered LOC, irritable (hypercapnea +/- asterixis)
RHF with JVD and peripheral edema
ED Management of AECOPD
Severe:
O2 88-92%
Bag-valve or BiPAP or ETT
in-line beta-agonist and anticholinergic
IV corticosteroid
IV antibiotics
Inidications and Contraindications for PPV in AECOPD
Indications:
- Moderate to severe Dyspneas
- RR > 25
- Acidosis
Exclusion:
- Somnolence / Agitated
- Vomiting
- CV instability
- Respiratory Arrest
- Upper airway obstruction
- Craniofacial trauma
- Mask won’t fit.
ECG Findings of COPD
P pulmonale, peaked P in II, III and aVF
low voltage
Poor R-wave progression
Tachydysrhythmias: A.fib, MAT
Causes of URTI
Viral:
EBV, Adenovirus, Coronavirus, cocksackie, HIV, HMNV, Influenza, VZV
Bacterial:
GAS, H. Flu, gonorrhea, non group A strep, mycoplasma, n. meningiditis
Non-infectious: Kawasaki, SJS, thyroiditis
Trauma
When to given steroids in pharyngitis
Severe symptoms with inability to swallow, airway obstruction, PTA, post-tonsillectomy, EBV
Causes of epiglottitis
H influenza B
Strep
Staph
Viruses
Burns
Mgmt of epiglottitis
Consider intubation in acute onset < 6 hrs
IV abx: Ceftriaxone, Septra
Steroids
Racemic epi
Analgesia
Humidified O2
Observation
Deep spaces of the neck and associated infection
Submandibular Space: Ludwig’s Angina
Parapharyngeal Space: Carotid / Jugular and CN. : Lemierre’s syndrome
Retropharyngeal Space: RPA
Danger space - posterior to retropharyngeal: Base of skull to diaphragm
The prevertebral Space.
Mgmt and predisposition for rhinosinusitis
RF:
- Smoking, immune compromise, structure abnormality, polyps, tumors, trauma, overuse of decongestants. barotrauma, cocaine, instrumentation
Therapy: Flushes, local decongestants (no more than 5 days), 2nd gen antihistamines, Antibiotics if febrile or not getting better, high dose amox - 90 mg/kg = 1 g TID for 7-10 days. Septra or azithro 3 days + decongestants
5 Suppurative and Non-suppurative complications of GABHS.
Supp:
Bacteremia
PTA
Otitis Media
Necrotizing fasciitis
Meningitis
Lemeirre’s
Non-supp:
Rheumatic fever
PANDAS (neuropsych)
PSGN
Scarlet fever
Strep toxic shock
Lateral neck XR of epiglottitis
Obliteration of vallecula
Swelling fo arytendoids
Edema of prevertebral soft tissues
Edematous epiglottitis (thumb) - > 8 mm bad
Pneumonia associative pathogens
EtOH: strep pneumo, anaerobes, gram negatives (klebsiella), Tb
COPD: Strep pneumo, H flu, moroxella
Nursing home: S. Pneumo, gram negatives, H flu, Staph Aureus, chlamydia
Poor Dental: Anaerobes
Bat: Histoplasma
Bird: Histoplamsa, Cryptococcus, Chlamydophilia
Farm animals and Cats: Coxiella burnetti (Q fever)
Sicke / Asplena: S pneumo, H flu
Rabbit: Tularemia (also in terrorism)
Abx for Pneumonia based on disposition
Admit:
CAP - non-immune compromise: Ceftriaxone + Azithro
Severe ICU: Ceftriaxone _+ azithro + vanco
HCAP or bronchiectasis: Cefipine 2g + Cipro + vanco
PCP: Septra
