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Flashcards in Pulmonary Emergencies 2 Deck (39):
1

Acute pulmonary edema: presentation
10

1. Dyspnea
2. Frothy pink sputum
3. Pedal edema
4. Ascites
5. Rales
6. Wheezing
7. Hypertension
8. Hypoxemia
9. Restlessness
10. Tachycardia

2

Acute pulmonary edema
etiology? 3

1. From cardiogenic and noncardiogenic sources

2. From sudden increase in left sided intracardiac filling pressures

3. OR increased alveolar capillary membrane permeability

3

Cardiogenic pulmonary edema
Acute cases? 5

1. Ischemia
2. Acute severe mitral regurgitation
3. Acute aortic regurgitation
4. Hypertensive crisis secondary to bilateral renal artery stenosis
5. Stress induced cardiomyopathy

4

Cardiogenic pulmonary edema
Chronic causes? 4

1. Decompensated systolic CHF
2. Decompensated diastolic CHF
3. LVOT (left ventricular outflow tract) obstruction
4. Valvular heart disease

5

Noncardiogenic pulmonary edema
1. MAJOR CAUSE?
2. Other causes? 7

1. Major cause is acute respiratory distress syndrome (ARDS)

2.
-Altitude
-Neurogenic
-Narcotic overdose
-Pulmonary embolism
-Eclampsia
-Transfusion related injury
-Salicylate overdose

6

Etiology of ARDS
10

1. Sepsis
2. Acute pulmonary infection
3. Trauma
4. Inhaled toxins
5. DIC
6. Shock lung
7. Freebase cocaine smoking
8. Post CABG
9. Inhalation of high concentrations of O2
10. Acute radiation pneumonitis

7

Acute pulmonary edema: treatment
Cardiogenic
O2 plus:? 4

Noncardiogenic
O2 plus:? 3

1. Treat underlying cause
2. Ischemia – Rx: nitrates, morphine, diuretics
3. Valvular disease – diuretics
4. Treat arrhythmias – ACLS protocol and diuretics


1. Treat underlying cause
2. If ARDS likely will need intubation and mechanical ventilation with PEEP (positive end expiratory pressure)
3. Diuretics may be somewhat helpful

8

Acute pulmonary edema: treatment
4

1. Assess the airway and the stability of the patient
Do they need to be intubated right away or can they be watched closely while diuretics are given?

2. Furosemide (Lasix) 40-80 mg IV….only if hemodynamically stable
3. Supplemental O2
4. Then target treatment tailored to the underlying cause

9

Aspiration:
1. Massive aspiration requires immediate what?

2. Once intubated can then do what?

3. Treat underlying cause such as? 2

1. protection of the airway from further injury by intubation

2. lavage and suction the lower airway

3.
-Prolonged BVM during CPR
-Neurologic compromise secondary to stroke, SAH, head injuries etc.

10

Asthma: pathophysiology?

INFLAMMATION of the airways with an abnormal accumulation of eosinophils, lymphocytes, mast cells, macrophages, dendritic cells and myofibroblasts.

11

Asthma: pathophysiology:
Reduction in airway diameter caused by what? 4

1. smooth muscle contraction,
2. vascular congestion,
3. bronchial wall edema, and
4. thick secretions.

12

Acute asthma: assessment
1. Beware of? 7
2. Impending respiratory failure? 4

1. Beware of :
-use of accessory muscles of respiration,
-fragmented speech,
-orthopnea,
-diaphoresis,
-agitation,
-low blood pressure (consider anaphylaxis),
-severe symptoms that fail to improve with initial treatment

2. Impending respiratory failure:
-inability to maintain respiratory effort and rate,
-cyanosis,
-depressed mental status,
-severe hypoxemia (SpO2 ≤ 95% despite high flow O2 by nonrebreather)

13

Acute asthma: assessment
6

1. Measure peak flow if able
2. Supplemental O2
3. ABGs are generally not useful initially
4. CXR generally not useful initially
5. Establish IV access
6. Frequent reassessment to determine if intubation and mechanical ventilation is needed

14

Acute asthma: peak flow
1. Helps give an objective measurement as to the what?
2. Peak flow less then ____ % of predicted = severe
3. Measure before and after each what?

1. severity of airflow obstruction

2. 40

3. nebulizer or MDI treatment.

15

Acute asthma: medical therapy

1. Albuterol (inhaled beta 2 agonist)
2. Ipratropium bromide (atrovent) (anticholinergic)
-Give with the albuterol (Duoneb)
3. Methylprednisolone (Solu Medrol)
4. Magnesium sulfate
5. Epinephrine
6. Terbutaline

16

What do the following do for acute asthma:
1. Albuterol (inhaled beta 2 agonist)?
2. Ipratropium bromide (atrovent) (anticholinergic)?
-Give with the albuterol (Duoneb)
3. Methylprednisolone (Solu Medrol)?
4. Magnesium sulfate?
5. Epinephrine?
6. Terbutaline?

1. Bronchodilator
2. Bronchodilator
3. Glucocorticoid. Decreases airway inflammation

4. For life threatening exacerbations that remain severe after 1 h of intense bronchodilator therapy
5. For suspected anaphylactic reaction or unable to use inhaled bronchodilators
6. For severe asthma unresponsive to standard therapies

17

COPD exacerbation
1. Most often precipitated by what?

2. Increase or change in character of usual symptoms of what? 2

3. DDx? 4

1. a viral or bacterial infection

2.
-dyspnea,
-cough or sputum production.

3.
-CHF,
-PE,
-pneumonia,
-pneumothorax

18

COPD exacerbation: work up
5

1. O2 sats

2. ABG in severe exacerbations

3. CXR to assess for signs of pneumonia, acute heart failure, pneumothorax

4. Labs

5. EKG

19

COPD exacerbation: work up
LABS? 3

1. CBC,
2. BMP,
3. BNP (B-type Natriuretic Peptide) +/-

20

COPD exacerbation: Pharmacotherapy
4

1. Supplemental O2 to maintain sats ≥ 90%.

2. Solumedrol (methylprednisolone) 60mg IV

3. Antibiotics to treat a respiratory source of infection and to include pseudomonas coverage
-Ex: Levaquin 750mg IV

4. Inhaled bronchodilators
-Albuterol 2.5mg AND Atrovent 0.05 mg via nebulizer (Duoneb)

21

COPD exacerbation: Treatment
1. Consider hospital admission if? 4

2. If impending respiratory failure?

1. Consider hospital admission if
-Symptoms are severe enough to prevent the patient from doing basic functions like sleeping, preparing meals or walking to the bathroom
-Failure to respond to initial therapy
-High risk comorbidities like pneumonia, CHF, arrhythmia, liver failure, kidney failure or DM
-Worsening hypoxemia

2. If impending respiratory failure:
-Intubation vs. NIPPV

22

Pulmonary embolism
1. What is it?
2. Severity?
3. Forms? 2

1. Obstruction of the pulmonary artery or branches with clot, tumor, air or fat
2. Common and often fatal disease
3. Can be acute or chronic

23

Pulmonary embolism: Signs and Symptoms
11

1. Dyspnea
2. Tachypnea
3. Cough
4. Hemoptysis
5. Syncope
6. Lower extremity edema
7. Cyanosis
8. Diaphoresis
9. Hypotension
10. May have rales on exam
11. Lower extremity pain or erythema

24

Pulmonary embolism: Risk factors
12

1. Pregnancy
2. Obesity
3. Prolonged immobilization
4. Hormones: BCP’s, HRT, SERMs
5. Cancer
6. Trauma
7. Recent joint replacement surgery
8. History of DVT
9. Autoimmune disease
10. HTN
11. Smoking
12. CHF

25

Pulmonary embolism: work up
8

1. CTA of the chest with PE protocol
2. CXR
3. EKG
4. Echo +/-
5. V/Q scan?
6. D-Dimer?
7. Doppler US of the LE
8. Pulmonary angiogram is the OLD “gold standard”

26

Pulmonary embolism: Radiographic findings
3

1. Hampton’s Hump
2. CT with pulmonary infarction
3. PE: Saddle embolism

27

EKG findings: PE? 3

1. S waves in lead II
2. Q waves in lead III
3. Inverted T waves in lead III

28

Acute PE: Treatment/stabilize? 3

1. Supplemental O2
If hypotension
2. Fluid bolus of 500 to 1000 ml NS
3. Vasopressors

29

Vasopressors used to stabilize Acute PE? 4

1. Norepinephrine,
2. Dopamine,
3. epinephrine,
4. dobutamine + norepinephrine

30

Acute PE: treatment for anticoagulation
1. Unfractionated Heparin (UFH) use in who?

2. Low Molecular Weight Heparin (LMWH) Prefered over UFH. Which drugs are these? 2

3. Fondaparinux? Which drug? Give to which pts?

1. use in unstable patients in case you need to stop anticoagulation and trial thrombolytics

2.
-Enoxaparin (Lovenox)
-Dalteparin (Fragmin)

3. Arixtra
-Give if patient has a history of allergy to Heparin or history of heparin induced thrombocytopenia…HITT

31

Acute PE: treatment
1. A vitamin K agonist such as warfarin should be started when?

2. Continue with Lovenox until INR is ___?

3. When to use thrombolytics?

1. on the same day as anticoagulant therapy

2. 2.0

3.
-Patients with acute PE associated with hypotension needing vasopressor support or o/w hemodynamically unstable (“massive PE”) who do not have a high bleeding risk

32

Pneumonia: signs & symptoms
12

1. Cough
2. Fever
3. Chills
4. Pleuritic chest pain
5. Dyspnea
6. Sputum production
7. Mental status changes
8. GI symptoms (N/V/D)
9. Tachypnea
10. Tachycardia
11. Hypoxia
12. Rales, rhonchi or decreased in area of consolidation

33

Pneumonia: work up
5

1. PA and lateral CXR
2. CBC, CMP
3. Blood cultures*
4. Sputum for gram stain and culture*
5. Pneumococcal and Legionella urine antibody tests*

34

Pneumonia:
Indications for admission can be based on a wide variety of objective data? 5

1. SpO2 less than 92%,
2. Febrile less than 35 C or > 40C
3. RR >/= 30,
4. tachycardia >/= 125,
5. low SBP less than 90 mmHg

35

Pneumonia: treatment
7

1. Supplemental O2

2. Intubation or NiPPV if impending respiratory failure

3. Antibiotics to target the most likely pathogen

4. Fluids for dehydration or hypotension

5. Antipyretics

6. Albuterol nebulizer treatments +/-

7. Incentive spirometry

36

Pneumonia: pathogens
1. Most likely pathogen is ?

2. Patients requiring hospital admission (non-ICU)… Common pathogens besides S. pneumoniae? 5

1. Streptococcus pneumoniae

2. Patients requiring hospital
admission (non-ICU)… Common pathogens besides S. pneumoniae:
- respiratory viruses (influenza, respiratory syncytial virus, parainfluenza)
- M. pneumoniae
- H. influenza
- C. pneumoniae
- Legionella

37

Pneumonia: Abx (non-ICU)
3

1. Respiratory fluroroquinolone (levofloxacin, moxifloxacin, gemifloxacin) ex: Levaquin (levoflaxacin) 750mg IV or PO qd
OR
2. Antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) ex: Rocephin (ceftriaxone) 1g IV qd
PLUS
3. Macrolide (azithromycin, clarithromycin, or erythromycin) ex: Zithromax (azithromycin) 500mg PO or IV qd

38

Pneumonia: Pathogens
Hospitalized patients requiring ICU?
5

1. S. pneumoniae,
2. Legionella,
3. gram-negative bacilli,
4. Staphylococcus aureus and
5. consider MRSA

39

Pneumonia: Abx (ICU)
Last slide! 3

1. Antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin
OR
2. Antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin)
OR
3. For penicillin allergy: Respiratory fluoroquinolone PLUS aztreonam