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Clin Med2: Pulmonology > Pulmonary Critical Care - Rob DeShane > Flashcards

Pulmonary Critical Care - Rob DeShane Flashcards

1
Q

what is respiratory failure

A

occurs when lungs fail to oxygenate the arterial blood accurately and/or fail to prevent CO2 retention.
therefore categorized as Type I (hypoxemic) and type II (hypercapnic)
commonly encountered in ICU

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2
Q

what is ARF

A

Acute Respiratory Failure

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3
Q

what is Bellows

A

thoracic cage

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4
Q

What are mechanisms of type 1 respiratory failure

A

inadequate partial pressure of O2 in the alveolus (PAO2)
ventilation/perfusion mismatch
shunt (intrapulmonary, intracardiac)
diffusion abnormality
lower pulmonary arterial oxygenation (Mvo2)

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5
Q

what can alveolar hypoventilation lead to

A

both low PAO2 and high PCO2 due to decreased total volume of inhaled/exhaled air per minute (minute vent)

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6
Q

what is normal minute ventilation

A

between 5 and 8 L/Minute

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7
Q

what are causes of hypoxemia due to low FIO2

A

high altitude
smoke inhalation
hypoventilation (CNS depression)
COPD

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8
Q

what is diffusion abnormaliteis

A

inability of lung to transport O2 in/out of blood at alveolar-capillary membrane
may be seen in membrane thickening and diffusion disorders

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9
Q

what can cause diffusion abnormalities

A

pulmonary fibrosis, asbestosis, pneumoconiosis, diffuse lung granulomatosis and pneumonectomy

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10
Q

how do you assess oxygenation

A

Assessed by PaO2
ABG
estimated oxygen status with pulse oximetry*
A-a gradient
PF ratio*
CXR

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11
Q

what is A-a gradient

A

difference between the oxygen concernation in the alveloi and arterial system. can help narrow the differential diagnosis for hypoxemia

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12
Q

how is A-a gradient calculated

A

alveolar oxygen pressure (paO2) - arterial oxygen pressure (paO2)

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13
Q

how do you calculate EXPECTED A-a gradient

A

(age + 10) / 4
there is a physiologic dead space as there is heterogeneity between ventilation/perfusion of apex vs base of lung that is affected by age

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14
Q

What is the PF ratio

A

measured: PaO2 / FiO2
value used in definition of ARDS - wide scale acceptance as a measurement of abdomal oxygenation

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15
Q

what is the normal PF ratio

A

> 400 about the equivalent of PaO2 > 85mmHg on 0.21% FiO2 (RA)

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16
Q

what is the PF ratio of a patient on supplemental O2 that is indicative of RF

A

< 300

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17
Q

what is normal PaO2

A

75-100

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18
Q

How is hypoxemia defined

A

PaO2 < 60mmHg

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19
Q

what is a normal VT amount in an adult

A

400-500ml

20
Q

What is another name for type 2 respiratory failure

A

acute ventilator failure

21
Q

what are the basic mechanisms underlying hypercapnic respiratory failure

A

hypoventilation
increased CO2 production
increased deadd space
decreased Vt

22
Q

where is the respiratory center located

A

medulla oblongata and pons

23
Q

what can cause respiratory center depression

A

brain injuries: TBI, hemorrhage, stroke
toxic encephalopathy
CNS infections
myxedema
OSA
NCSE
Narcotics

24
Q

what can cause increased CO2 production

A

burns
sepsis
agitation
exercise
hyperthermia/malignant hyperthermia
hyper caloric intake / carb rich diet
shivering, seizure or tremor

25
Q

what causes increased dead space ventilation

A

COPD
interstitial pulmonary disease
acute reduction in cardiac output
PE
acute pulmonary hypertension
PPV: namely PEEP

26
Q

what are other causes of decrease vt

A

low chest wall compliance (obesity, kyphoscoliosis, ankylosing spondylitis)
low lung compliance (ARDS, PNA, fibrosis, atelectasis)
hyperinflation (auto peep, high levels of PEEP)

27
Q

How do you assess ventilation

A

best: ABG
capnometry
End tidal CO2 measurement
transcutaneous COs not as reliable in adults as neonates
CXR

28
Q

what are clinical manifestation of acute respiratory failure

A

may be subtle/non specific
tachypnea/bradypnea
irregular respiratory pattern: gasping, nasal flaring or use of accessory muscles
intercostal retractions/paradoxical respiratory pattern
tachycardia/HTN
arrhythmias
distress/apprehensive
Diaphoresis
AMG
cyanosis

29
Q

what do hypercapnic patients exhibit

A

encephalopathy
somnolence/coma
asterixis
seizure/tremors/myoclonic jerks
papilledema and congested conjunctiva may be present

30
Q

what is the Ph and PaCO2 for Hypercapnic respiratory failure

A

pH < 7.35
paCO2 >50mmHg

31
Q

how do we treat respiratory failure

A

supplemental O2
non-invasive vent: BiPaP/CPaP
mechanical vent

32
Q

what are secondary treatment for RF

A

IF PE: systemic anticoag vs catheter directed lytic therapy vs thromboctomy
if CHF: diuresis
if PNA: aggressive pulmonary hygiene/mucolytics
arrest seizure
reverse narcotics with narcan

33
Q

how much does supplemental O2 increase oxygen percentage

A

3-4% per 1L of O2

34
Q

What is ARDS

A

adult respiratory distress syndrome - non-cardiogenic pulmonary edema

35
Q

what is the pathogenesis of ARDS

A

diffuse inflammatory process involving BOTH lungs
lung consolidation likely from systemic activation of circulating neutrophils which will become sticky and adhere to ………

fibrin deposition in the lungs - ultimately lungs filled with inflammatory exudate rather than watery edema fluid

36
Q

What are direct pulmonary causes for ARDS

A

chest trauma/ lung contusion
acid aspiration
near-drowning
inhalation lung injury
PNA

37
Q

what are extrapulmonary cuases of ARDS

A

pancreatitis
DIC
cardiopulmonary bypass
burns
massive transfusion therapy
fat embolism
sepsis/shock
elevated ICP (TBI/ICH)

38
Q

what are clincial manifestation for ARDS

A

significant respiratory distress
dyspnea, tachypena
increase work of breathing and accessory muscle use
hallmark: hypoxemia despite high concentrations of inspired O2, evidence of an increased shunt fraction, decreased pulmonary compliance and increased VD ventilation

39
Q

how do you diagnose ARDS

A

Berlin Criteria
timing: within 72 hours of recognized risk factor and identified within 7 days of disease onset
CXR: bilateral opacities consistent with pulmonary edema
origin on Pulmonary edema: ARDS may be present in setting of coexisting cardiogenic edema or volume overload in the opinion of treating doc

40
Q

how is ARDS managed

A

identify/treat underlying or predisposing cause of ARDS
LUNG PROTECTIVE ventilatory support strategy
restore/maintain HD function (conservative fluid replacement strategy, vasopressors/inotropes)
prevent complication of critical illness

** ASSESS for infectious or not

41
Q

what are the downstream affects of LPVS

A

permissive hypercapnea
hypercapnic acidosis may have potential benefits
PEEP can have potential profound HD consequences
need for NMB/sedating agents

42
Q

what instences should steroid be used for ARDS

A

pneumonia and COVID and early moderate to severe ARDS

43
Q

what are symptoms of foreign body aspiration

A

cough most common
less common: wheezing, dyspnea,….

44
Q

what are risk facrots for FB aspiration

A

neurological deficits with swallowing difficulties
AMS
NM disease
….

45
Q

what is seen on exam with FB lodged in trachea/main-stem bronchi

A

stridor
persistent cough
significant dyspnea
loud wheezing localized to side of FB
absence of breath sounds affected side

46
Q

what position should patient with FB airway obstruction be put into

A

trendelinberg

Clin Med2: Pulmonology (13 decks)

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