Pulmonary Disease Flashcards

Question

Treatment of PE

Answer 1

Supplemental O2 IV fluids for those with hypotension Low-molecular weight heparin should be first line Unfractionated heparin should be used if GFR <40, if considerable risk for bleeding Massive PE that is causing hypotension should receive fibrinolysis (tPA) or thrombectomy Warfarin should be started with LMWH on the same day - target INR 2.5-3.5

Answer 2

Fluid is considered exudative (inflammatory) if ---Infected or inflammatory fluid moves into the pleural space from lung inflammation, impaired lymph drainage, cancer, transdiaphragmatic movement of inflammatory fluid from the peritoneum. ---Most common causes are malignancy, PE, infections, pancreatitis Transudative effusion will usually be normal pleural fluid ---Associated with CHF - increased pulmonary venous pressure so plasma leaks into the alveolar and pleural space

Answer 3

Primary spontaneous pneumothorax: ---Male, tall, slender, smoker, family history Secondary spontaneous pneumothorax: ---Blebs that rupture in the lung, causing small tear in the pleura, leading to tension pneumothorax - Could happen in Emphysema COPD patients, or intubated patients with a bleb - Necrotizing PNA, lung cancer, Tb Iatrogenic pneumothorax: ---Central line placement, transthoracic needle biopsy Traumatic pneumothorax: ---Trauma

Answer 4

Most serious form of pneumothorax Occurs when equilibrium is never reached within the pleural cavity and the pneumothorax continues to expand, putting pressure on all organs within the chest wall Can be caused by any other cause of pneumothorax - just an equilibrium is not met Symptoms include SOB, chest pain, JVD, a falling blood pressure, rising heart rate, hypoxia and a late sign is tracheal deviation away from the affected side. Needs emergency decompression: Insert a 14g IV catheter into 2nd intercostal space at the mid clavicular line. The needle is withdrawn, leaving the catheter in place. This allows decompression to allow the other lung to function while you await a chest tube placement for the affected lung.

Answer 5

If the pneumothorax is <2cm then the pt can be discharged home with close follow up If it is >2cm then can give Nitrogen Washout Maneuver ---Patient is put on non-rebreather and given 100% O2 for 12-24 hours to help nitrogen move from pleural space into the lung and then exhaled.

Answer 6

Aspiration to re-inflate the lung via chest tube is recommended for any secondary spontaneous pneumothorax >2cm If purely air, then can use smaller chest tube (8Fr - 12Fr) Tube is inserted anteriorly (in the 3rd ICS at the midclavicular line) or laterally (in the 5th ICS mid axillary line) and then attached to a closed-chest drainage system (Pleurevac) Larger chest tube is required if there is a hemo/pneumothorax such as in trauma (24Fr - 32Fr)

Answer 7

Bacterial is usually limited to a lobar infiltrate Viral is usually diffuse, hazy, multifocal Peripheral ground glass opacities

Answer 8

50% of community acquired cases are Strep pneumoniae 30% are H. influenzae

Answer 9

PNA that occurs 48 hours after admission Frequently caused by Staph aureus, strep pneumoniae, haemophilus influenzae Need to get a sputum culture to appropriately tailor antibxs Should usually treat broadly with gram negative and MRSA coverage ---MRSA - Linezolid or Vancomycin ---Should cover for Pseudomonas - Cefepime or Zosyn or Levofloxacin If at high risk for mortality or IV antibx in the last 90 days: Need two of the following plus MRSA coverage: Zosyn Cefepime Levofloxacin or Ciprofloxacin Imipenem or Meropenem PLUS Vanc or Linezolid

Answer 10

Primary screening method for Tb infection (active or latent) is the PPD - not diagnostic ---Cutoff of 5mm or more of induration - patients that are HIV+, have abnormal CXR, significant immunosuppression, people who have had recent contact with people with Tb ---Cutoff of 10mm or more induration - Patients with IVDU, residents of nursing homes, prisoners, homeless, minority groups, healthcare workers ---Cutoff of 15mm or more - Young and healthy people, general population Acid-fast bacilli - most sensitive - Need 2 smears to exclude it Newer testing (QuantiFERON Gold and T-spot Tb) offer ELISA assay for rapid results while awaiting acid-fast bacilli test Any positive test should trigger a test for HIV ***Definitive diagnosis by culture of M. tuberculosis x3

Answer 11

4 drug therapy - RIPE: Rifampin Isoniazid Pyrazinamide Ethambutol Therapy continues for 6 months - 9 months with HIV If latent Tb - can just treat with isoniazid for 9 months

Answer 12

Remove patient from the ventilator and hand ventilate with Ambu-bag

Answer 13

Call a code Assist into a more upright position Suction airway to make sure there is nothing obstructing Apply O2 - if needed, take off vent and oxygenate manually Reassure the patient to reduce anxiety Consider administration of bronchodilator Insert an IV Only after these steps have been accomplished can you safely proceed to diagnostics

Answer 14

For mild cases, can administer oxygen and bronchodilators while beginning to treat the underlying cause (PNA) In moderate respiratory failure caused by obstructive pattern, can give non-invasive positive pressure ventilation (CPAP, BiPAP) ----Must not be very hypoxic or acidotic because they could progress to AMS If severe respiratory failure, will need endotracheal intubation with mechanical ventilation

Answer 15

CPAP - Continuous positive airway pressure ---Delivers a constant flow of gas at high pressures ----Will not cycle with regard to respirations ---Provides the equivalent of PEEP (positive end-expiratory pressure) ---Works well for asthma, sometimes COPD BiPAP - Bilevel positive airway pressure ---Cycles in regard to respiration, that is, the device detects when the patient initiates a breath and cycles to another pressure during the inspiratory phase and then when the breath is over, will revert to a lower pressure ------Makes taking a breath easier ---Great for COPD exacerbations, CHF, not as great for asthma

Answer 16

Sedation: Etomidate, propofol Paralysis: Succinylcholine, Rocuronium Pre-oxygenation by bag-valve mask Visualization of the vocal cords by direct laryngoscopy or by video larynoscope Passing the endotracheal tube (supported by stylet) through the vocal cords Remove the stylet carefully and then inflate the cuff at the end of the tube Confirm placement by colorimetric capnography, auscultation of the breath sounds with no gastric gargling, observation of bilateral chest excursion, CXR to assess tube depth Securement of the ETT to the face Then keep on sedative drip so they do not wake up

Answer 17

Shows rapid decrease in pH <7.2 Decreased PaO2:FiO2 ratio Mild ARDS - Ratio is 201-300mmHg Moderate ARDS - Ratio is 101-200mm Hg Severe ARDS - Ratio is <100mm Hg

Answer 18

Acute Phase --Breakdown of the Type I epithelial (alveolar)/endothelial (capillary) barrier due to inflammatory stress causing flooding of the alveoli with protein-rich fluid ---Dysfunction of Type II cells so that surfactant production is impaired ---Alveolar collapse then occurs, leading to impaired gas exchange and increased dead space -------This causes pulmonary HTN ---This itself causes inflammation, causing a chain reaction to spread Proliferative Phase ---With mechanical ventilation there is clearance of alveolar fluid ---Soluble proteins are removed by diffusion between alveolar epithelial cells ---Type II cells begin to differentiate into Type I cells and re-epithelialize denuded alveolar epithelium ---Further epithelialization leads to increased alveolar clearance Recovery Phase ---Gradual resolution of hypoxemia ---Improved lung compliance ---Infiltrates disappear ---PFTs improve, often normalize Fibrotic Phase ---Some people will develop increased fibrin from the amount of damage to the normal lung architecture ---Alveolar space is filled with mesenchymal cells and their products ---Re-epithelialization and new blood vessel formation occurs in disorganized way ---Increased thickening of intersititum due to fibrin which causes decreased lung compliance ---Fibrosing alveolitis and cyst formation

Answer 19

pH 7.35 - 7.45 PaO2 >90 75-89 - mild hypoxia <75 severe hypoxia PaCO2 35 - 45 HCO3 18-24

Answer 20

Maximum pressure during inspiration Should be less than 35

Answer 21

Measure at end of inspiration with hold Measures lung compliance Should be less than 30

Answer 22

Changes in intrathoracic pressure that causes a drop in blood pressure during inspiration. Occurs often in asthma however can also occur in cardiac tamponade and sometimes in pericarditis

Answer 23

Obstructive Cannot get air out - you will have hyper-resonance because of air trapping

Answer 24

Low flattened diaphragm on CXR FEV1 and all other measurements of expiratory airflow reduced (obstructive) Total lung capacity, functional residual capacity and residual volume are increased

Answer 25

Offer them 6 months of isoniazid (INH) Could have Tb but it has just not shown on the CXR yet

Answer 26

Negative pressure room

Answer 27

Need LFTs weekly because medication regimen for Tb is very hepatotoxic CBC, BMP If the pt is taking Ethambutol - need visual acuity testing and red-green color perception

Answer 28

Low severity: Healthy, no use of antibx within the last 3 months, no comorbidities or risk factors for MRSA or pseudomonas: Amoxicillin 1g TID or Doxycycline 100mg BID or Macrolide (Azithromycin or clarithromycin) Moderate to High Severity: Treating for MDR S. Pneumoniae -Respiratory fluoroquinolone (Levofloxacin or Moxifloxacin) - monotherapy or [Augmentin or cefpodoxime] + [Macrolide or doxycycline)

Answer 29

Nonsevere: Monotherapy with respiratory fluoroquinolone (Levofloxacin or moxifloxacin) or Beta lactam (ceftriaxone) + macrolide (azithromycin) Severe - ICU: Ceftriaxone + (IV fluoroquinolone or IV Azithromycin) or If Pseudomonas. aeruginosa suspected - Zosyn or meropenum or cefepime + Azithromycin or If MRSA is suspected: Above + Vancomycin or linezolid

Answer 30

Pseudomonas is most common causative organism Want MRSA coverage and double pseudomonal coverage MRSA Coverage: Vanc or Linezolid Gram negative with antipseudomonal activity: Beta-lactams based: Zosyn Cefepime Imipenem or Meropenem Gram negative with antipseudomonal activity: Non-beta lactam based: Levofloxacin or Ciprofloxacin Genamicin or Tobramycin

Answer 31

Sarcoidosis: Disease of unknown etiology characterized by interstitial lung disease and non-caseating granulomas Most often affects the lungs and lymph nodes in the chest. Symptoms: Progressive dyspnea Nonproductive cough Rales (Velcro crackles) may be noted Diagnostics: CXR for staging PFTs Bronchoscopy with transbronchial biopsy of lung parenchyma for dx Mainstay of therapy is steroids

Answer 32

Refractory hypoxemia is a hallmark feature CXR may be "whited out" or have diffuse bilateral infiltrates

Answer 33

Total lung capacity will be reduced Functional residual capacity will be reduced Residual volume will be reduced Examples of restrictive lung disease: -Morbid obesity -Sarcoidosis -Pulmonary fibrosis

Answer 34

Exudative: ---Ratio of pleural fluid protein to serum protein greater than 0.5 ---Ratio of pleural fluid LDH to serum LDH greater than 0.6 ---Pleural fluid LDH greater than two thirds of the upper limits of normal Transudative: ---a pH of 7.60-7.64 ---Protein content of less than 2% ---Few than 1000 white blood cells per cubic millimeter ---Glucose content similar to that of plasma ---LDH less than 50% of plasma

Pulmonary Disease Flashcards

(58 cards)