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Flashcards in Pulmonary critical care Deck (27):
0

causes of respiratory acidosis:
-drug OD
-CVA
-asthma

-COPD
-obesity
-sleep apnea

1

Causes of respiratory alkalosis
-sepsis
-pulmonary embolism
-pregnancy

-anxiety and pain
-hypoxia
-salicylate intox

2

PFT
* DLCO reduced in diseases of lung itself

* when lung volumes are normal, decreased DLCO suggests pulm vasc problem: PE, PAH, vasculitis

*high DLCO suggests: pulmonary hemorrhage, L-R shunt, polycythemia

3

Obstructive lung diseases

asthma
COPD
bronchiectasis
cystic fibrosis

4

Restrictive lung diseases of parenchymal

sarcoidosis
pulmonary fibrosis
pneumoconiosis
interstitial lung dz due to drugs or radiation

5

Restrictive neumuscular diseases

Gullain Barre syndrome
myasthenia gravis
muscular dystrophies
diaphragm weakness

6

Restrictive lung dx due to chest wall stiffness

kyphoscoliosis
ankylosing spondylitis
obesity

7

Methemoglobinemia

*clinical features: central cyanosis, SOA, blood appears BROWM

*causes: benzocaine spray/local anesthesia, dapsone, nitrides

*tx: IV methylene blue

8

hypoxia in COPD

indications for oxygen home therapy

*PaO2 of 55 or less
*saO2 of 88%or less
*PaO2 56-59 or SaO2 89% or less if edema, P pulmonale on ECG,hematocrit >56%
*noc sats 88% or less

9

stages of COPD

all COPD have FEV1/FVC ,70%

Mild FEV1 80% or more of predicted
moderate FEV1 50-79% predicted
severe FEV1 30-49% predicted
very severe <30% predicted

10

Tx exac of COPD
*keep sats 90-92% and PO2 60-65
*do ABG 30-60min on O2 to check for CO2 retention or acidosis
*bronchodilators:ipatropium & albuterol

*abx cover H influenzae, strep pneumonia, moraxela: quinolone, 3rd gen cephalosporin & macrolide
*steroids IV/po x 2weeks

11

acute exac COPD - indications for noninvasive ventilation

*moderate-severe dyspnea w use of accessory muscles
*pH 45
*RR >25

12

exac COPD indications for invasive ventilation

*if they cant tolerate noninvasive ventilation
*severe dyspnea with RR > 25

*severe hypoxia, severe acidosis pH 60
*impaired mental status, hypotension, shock

13

Bronchiectasis
*chara by permanent abnormal dilatation & destruction of bronchial walls
*PFT: obstructive pattern
*best dx test: HRCT

*s/s: cough, mucopurulent sputum, dyspnea, hemoptysis, pleuritic CP
*CXR: dilated & thickened airways, linear atelectasis, mucus plugs

14

causes of bronchiectasis
*airway obstr: foreign body aspiration, tumors, enlarged nodes
*lung infections: M avium, allergic aspergillosis
*hypogammaglobulinemia,RA, scleroderma

*Kartageners syndrome: bronchiectasis + sinusitis + infertility + situs inversus
*cystic fibrosis

15

Cystic Fibrosis
* CFTR gene mutation, autosomal recessive
*dx: sweat chloride >60
*s/s: recur lung infection (#1 pseudomonas), bronchiectasis, clubbing, steatorrhea,infertility, pancreatitis, DM, obstr biliary dz

*Tx: acute tx infection, prevent infections w inhaled tobramycin
-persistent airway secretions- aerosolized recomb human dnase
-airway obstr- bronchodilators, steroids, chest physiotherapy
-pancreatic insuff- pancreatic enzyme
-severe hemoptysis-bronchial artery embolization

16

causes of acute cough (<3 wks)

-common cold
-allergic or bacterial sinusitis
-bordetella pertussis
-exac of chronic bronchitis

17

causes of subacute cough (3-8 weeks)

*post infection
*asthma
*subacute sinusitis
*B pertussis

18

Causes of chronic cough (>8 wk)

GERD
ACE inhibitors
cough asthma
postnasal drip
chronic or eosinophilic bronchitis

19

factors assoc with increased risk of death from asthma
-prior intubation or ICU admit
-2 or more hosp or 3 or more ER visits in past year
-low socioeconomic status
-use of >2 canister of short acting beta agonist/ month

Signs of life threatening asthma
-altered MS
-paradoxical chest or abdominal movement
-absence of wheezing

20

Mild intermittent asthma:
-day s/s 2or less times/week, noc s/s 2 or less/month
-tx: prn inhaled short acting beta agonist
Mild persistent asthma:
-day s/s>2/wk, noc>2/month, tx low inhaled steroid+prn beta

Moderate persistent:
-daily day s/s, >1/wk noc s/s, tx add low to med dose inhaled steroids + long acting beta agonist
Severe persistent: cont daily s/s, freq noc s/s, add high dose inhaled steroid + systemic steroids

21

Ventilator settings:
VT 5-10ml/kg (ARDS 6ml/kg)
RR 8-14
Min vent pressure not >355
FiO2 lowest to maint PaO2 60 or sat 90%

Inspiratory flow: 60liter/min (most), COPD 100liter/min
trigger sensitivity -1 to -2cm
PEEP 5-10

22

complications of mechanical ventilation:
-toxicity of oxygen-keep FiO2

-hyperinflation (auto PEEP)
-vent assoc pneumonia-onset at least 48hrs after on vent, gram -,staph, anaerobes-prevent w head elevation 45 degrees
-deconditioning of resp muscles
-stress ulcers-PPI or H2 prophylaxis

23

hyperinflation -auto PEEP
-decreases venous return, cardiac output, and decr BP
-increases HR,incr workof breathing,wheezing,expir prolongation

-tx:decrease minute ventilation=>increases expiratory time, increase inspiratory flow, bronchodilators, fluids
-the need to decrease minute ventilation may require tolerating PCO2 above baseline - permissive hypercapnia

24

Transudate pleural effusions:
-protein 3 or less, effusion/serum protein ratio .5 or less
-pleural/serum LDH ratio .6 or less
*causes:
-CHF, constrictive pericarditis

-nephrotic syndrome
-cirrhosis, hepatic hydrothorax, peritoneal dialysis
-PE, atelectasis
-myxedema, SVC obstruction
-hypoalbuminemia

25

Exudate pleural effusion
-protein >3, effusion/serum protein ratio >.5
-pleural/serum LDH ratio >.6, LDH >200
*causes:
-malignancy

-infection: pneumonia, TB, empyema, intra abd abscess (very high WBC)
-dresslers syndrome-pleuritis, pericarditis, pneumonitis
-pancreatitis, esophageal perforation, PE,
-RA, SLE

26

pleural effusion with low glucose <60

bacterial infection
rheumatoid pleurisy
malignancy