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Flashcards in respiratory Deck (147):
1

58 yo. M presents to ED with complaints of dry cough. CXR revealed generalized inflamed film throughout. What is the most likely diagnosis?

pneumonitis

2

Drug known to prevent nosocomial PNA?

sulcarafate (Carafate)
(Mucosal Protective Agent)

3

Initial finding associated with pulmonary embolism?

respiratory alkalosis
- s/t ↑ RR = blowing off CO2

4

Diagnostic of pulmonary HTN?

2D echo

5

Your patient is intubated on the following settings: SIMV/FiO2 .6/PEEP 5. You notice shunting. What should your next action be?

Increase PEEP from 5 to 10 to recruit alveoli and increase surface area to improve oxygenation

6

32 yo. M with PMH significant for mitral valve replacement now complains of wheezing during physical activity 2-3 times/week. What should you do next?

Send patient for PFT.

7

What is the pathology of asthma?

↑ response/hyperresponse of trachea, bronchi to stimuli
- acute inflammation
- widespread airway narrowing
- smooth muscle hypertrophy
- viscid mucus plugging up airways
- mucosal edema, hyperemia, mucus gland hypertrophy

8

asthma: hallmark s/s - top 3 + 7 more

* difficulty speaking in sentences
* pulsus paradoxus gt 12 mmHg (none in COPD!)
* hyperresonance

respiratory distress @ rest, RR 28+, cough, use of accessory muscles, chest tightness, diaphoresis, HR 110+

9

PFT value suggestive of obstructive disease?

↓ FEV 1

10

Which acid-base imbalance is associated with asthma?

Respiratory Alkalosis w mild hypoxemia

11

asthma PFT values at which hospitalization is recommended x4

FEV 1 lt 30% predicted
-- OR --
doesn't increase to at least 40% predicted after 1 hr tx

PEAK FLOW lt 60 L/min initially
-- OR --
doesn't increase to gt 50% predicted after 1 hr tx

12

ominous findings assoc w asthma exacerbation
- signs x5
- lab x 1

fatigue, absent breath sounds, paradoxical chest/abd movement, inability to retain recumbency, cyanosis

- hypercapnea: pCO2 45+ = EMERGENCY

13

* Daily maintenance drug for outpatient asthma mgmt: MOA & name

MOA: inhaled corticosteroid
budesonide (Pulmicort)

14

SE associated with inhaled corticosteroids used daily as maintenance drug for asthma? x3 + 1 pt education

candidal infection of the oropharynx
dry mouth
sore throat
- educate patient to rinse mouth

Ex: budesonide (Pulmicort)

15

asthma: outpatient mgmt x 6 meds (class & name) + indications

1. SABA - albuterol/Proventil: sx relief, breakthrough, or pre exercise

2. inhaled corticosteroid - budesonide/Pulmicort: daily maintenance, ↑ if persistent sx

3. LABA - salmeterol/Serevent: for persistent sx

4. theophylline or antimediators: for persistent sx

5. inhaled anticholinergic - ipratropium bromide/Atrovent: add if necessary (secretions)

6. anti-leukotrienes - montelukast/Singulair: chronic asthma maintenance (stabilization)

16

If asthma sx persist, what pharm interventions are indicated? x4

↑ inhaled corticosteroids
add LABA (salmeterol/Serevent)
add theophylline or antimediators

17

indications for ipratroprium bromide (Atrovent) & MOA

secretion management in asthma
MOA: inhaled anticholinergic

18

What drug + MOA is indicated in the chronic management of asthma?

montelukast (Singulair)
MOA: anti-leukotriene

think: stabilization

19

Which drugs x2 have BBW: "Do not take during acute asthma exacerbation?"

LABA
anti-leukotrienes

20

asthma: inpatient mgmt

- O2 (2 - 3L/min)
- mild to mod: ABG not necessary if SaO2 90+
- severe: initial ABG
- hydration (PO or IVF)
- inhalation sympathomimetics (alupent, proventil, ventolin)
- corticosteroids if no response to sympathomimetics (methylprednisolone)
- parenteral sympathomimetics in pts unable to cooperate (aqueous epinephrine)
- anticholinergic (atrovent MDI)

21

Status asthmaticus is...

severe, acute asthma that is unremitting, poorly responsive, and life threatening.

note: clinical findings NOT reliable indicators of severity

22

status asthmaticus: gold standard interventions x4

IV D5 1/2NS
Intubation (pt looks bad)
Continuous pulse ox
ABG q 10-20 min

23

Monitor pulse ox and ABGs in status asthmaticus how often?

Continuous pulse ox
ABG q 10-20 min

24

chronic bronchitis is...

- excessive secretion of bronchial mucus
- productive cough 3+ mo over 2+ consecutive yrs

25

emphysema is...

abnormal, permanent alveoli enlargement

26

ABG assoc w chronic bronchitis + why.

hypercapnia + hypoxemia
- air trapped in alveoli, over time chemoreceptors reset to accommodate high CO2 levels

27

CXR findings associated with COPD

hyperinflation: low, flattened diaphragm
bulla, blebs

28

COPD: outpt mgmt x4

- smoking cessation
- avoid irritants/allergens
- postural drainage: clear excess secretions
- inhaled: ipratroprium bromide (Atrovent) or sympathomimetics -- MAINSTAY

29

58 yo M w PMH COPD; home O2 2L NC coughing up purulent/ thick/ yellow mucous. Management plan?

O2 NC 2-4 L min or 24-28% venti mask
Start antibiotics - 7-10days
Ampicillin or amoxicillin 500 mg QID PO for 7-10days
Doxycyline 100 mg BID
Bactrim DS 1 tablet BID

30

Most common clinical presentation of TB?

Pulmonary disease.
TB is systemic and often asymptomatic.

31

TB: classic s/s x4

*MAJORITY ARE ASYMPTOMATIC*
* weight loss
* low grade fever
* night sweats

32

True or False: A positive PPD is diagnostic for active TB dx?

False. Positive PPD shows exposure; not active disease.

33

What are the drugs + doses in initial TB treatment?

R I P E

Rifampin 600 mg
Isoniazid 300 mg
Pyrazinamide 1.5 - 2.0 g
Ethambutol 15 mg/kg

34

TB tx: dosages x3 steps

R I P E

DAILY FOR 2 MO: Isoniazid 300 mg + Rifampin 600 mg + pyrazinamide 1.5-2.0 gm (can include E here)

THEN, DAILY 4 MO: R & I

DROP E: if tb fully susceptible to R & I

35

TB + HIV: tx duration

9 mo - 1 year

36

TB: monitoring protocol for newly dx x3 steps

FIRST SIX WEEKS AFTER INITIATION OF TX: weekly sputum smears & cultures

THEN MONTHLY until neg cx documented

IF SX CONTINUE OR + CX AFTER 3 MO: suspect drug resistance

37

TB: baseline labs ordered with initiation of treatment? What happens to those with normal baseline?

LFT
CBC
serum creat

If normal labs @ baseline, monthly labs not required - but monitor for sx drug toxicity.

38

TB: ethambutol considerations x2

visual acuity changes, red-green color blindness

39

+PPD is an indication for which drug & dosage?

INH - 6 mo

40

pneumonia is...

inflammation of LOWER respiratory tract
- r/t infection via aspiration, inhalation, hematogenous dissemination

41

most common causative agent of CAP

Strep. pneumoniae
gram + !

42

pneumonia: gold standard for dx

CXR: infiltrates
Blood cultures x 3

43

CAP: mgmt for under 65 x4

MACROLIDE - 1 of the following:
- azithromycin (Zithromax)
- clarithromycin (Biaxin)
- erythromycin

OR

TETRACYCLINE: doxy

44

CAP: mgmt 65+ or comorbs x4

FLUOROQUINOLONE
- levofloxacin (Levaquin)
- ciprofloxacin (Cipro)
- moxifloxacin (Avelox)
- gemifloxacin (Factive)

45

pneumonia: inpt ICU mgmt (rx only) x3

BETA LACTAM
- ceftriaxone (Rocephin)

p l u s

FLUOROQUINOLONE
//or//
- azithromycin (Zithromax): resistance likely, avoid

46

Pseudomonas pneumonia: inpt ICU mgmt (rx only) x5

antipneumococcal/antipseudomonal beta lactam
- piperacillin-tazobactam (Zosyn)
- cefepime (Maxipime)
- meropenem (Merrem)

PLUS
- ciprofloxacin (Cipro)
//or//
- levofloxacin (Levaquin)

47

community acquired MRSA pneumonia: rx x2

vancomycin
//or//
linezolid

48

What consult is necessary when ordering Linezolid?

ID

49

HAP: definition + most common causative organisms

pneumonia that occurs 48 hrs + after admission & not incubating @ admission (VAP, HCAP)

Staphylococcus aureus
Streptococcus pneumoniae
Haemophilius influenzae

50

VAP: definition + most common causative organism

Pseudomonas

51

pneumothorax pathophys

gas enters pleural space
↑ pleural pressure = collapsed lung
impairs respiration

52

pneumothorax: hallmark s/s x3

hyper-resonance affected side (d/t air trapping)
diminished BS & diminished fremitus affected side
mediastinal shift toward unaffected (tension pneumo)

53

gold standard for pneumothorax dx

CXR

54

When does pneumothorax require intervention?

when larger than 20% -- pt will become symptomatic

55

Intervention for non-emergency pneumothorax?

chest tube @ 4th - 5th ICS MAL

56

STAT intervention for tension pneumothorax?

needle thoracostomy @ 2nd ICS MCL

57

leading cause of inpatient hospital death

pulmonary embolism

58

pulmonary embolism: risk factors x6

immobility
venous stasis
hypercoagulable states
endothelial damage
recent surgery of a long-bone
PO contraceptives

59

pulmonary embolism: s/s x7

acute/abrupt --
dyspnea, tachycardia * most common
hypotension
chest pain (retrosternal or lateral/pleuritic)
hemoptysis, low grade fever, cyanosis

60

pulmonary embolism: associated ABG x2

HYPOXEMIA
- SaO2 lt 90%, PaO2 lt 80 mmHg

HYPOCAPNIA
- pCO2 lt 35 mmHg r/t reflexive hyperventilation

61

pulmonary embolism: diagnostics x 6

DIAGNOSIS BASED ON CLINICAL SUSPICION (HX KEY!)

VQ scan
ABG
Spiral CT
D-dimer
Pulmonary angiography

62

pulmonary embolism: medical mgmt

O2
intubation
IVF (for hypotension, ↓ CO)

Heparin 80 u/kg bolus
- then, Heparin 18 u/kg/hr // PTT 1.5 - 2x normal
- simultaneous Coumadin // INR 2-3

if hemodynamic compromise/shock: fibrinolytics, but first PT/PTT must be less than 2x normal

63

Goal INR for Coumadin tx for pulmonary embolism?

INR 2-3

64

Goal PTT for Heparin tx for PE?

PTT 1.5 - 2x normal

Normal: PTT 60-90 seconds

65

ARDS pathophysiology

acute lung injury r/t wide variety of insults;

transudative fluid build up in alveoli r/t systemic inflammatory process
- impairs ventilation and perfusion.

66

ARDS: s/s x6

ACUTE
severe dyspnea, respiratory distress
cyanosis, tachycardia
rales, wheezes

67

ARDS: hallmark features x2

REFRACTORY HYPOXEMIA
CXR - whited out w diffuse bilateral infiltrates

68

ARDS: mgmt x4

- mechanical ventilation
- low TV: 5 - 7 or 6 - 8 ml/kg IBW
- ↑ PEEP: 10 cm H2O
- peak inspiratory flow 1 - 1.2L prn

69

PaO2/FiO2 indicative of ARDS?

P/F less than 200 = shunting
- responsive to PEEP

70

What's the difference between Assist Control and Spontaneous Intermittent Mandatory Ventilation?

AC: preset TV & RR. Pt can breathe over set RR but gets preset TV.

SIMV: preset TV & RR, but pt can breathe over vent rate at whatever TV they pull.

71

Continuous Positive Airway Pressure (CPAP) is...

spontaneous breathing at greater pressure than atmospheric

72

Pressure Support is...

unassisted inspiratory support but preset airway pressure delivered with each breath

@ end of inspiration! (PEEP is end of expiration)

73

What is PEEP + associated AE x2

maintains intrathoracic airway pressure above atmospheric throughout expiration
- recruits alveoli, ↑ ventilation & perfusion

AE: barotrauma, ↓ CO

74

True of False: after ventilator TV has been established it is appropriate to change when patient's status changes.

FALSE. Once a TV is set do NOT change it!

75

What are the mechanical ventilation settings indicated for a patient that has acutely decompensated?

AC / FiO2 1.0 / RR 12 / TV 450
No PEEP
No Pressure Support

76

What parameters need to be met in order to wean from mechanical ventilation? x6

FiO2 0.4 + SaO2 gt 92%
SIMV: RR over vent rate
HDS (?)
Consult pulm/RT
Cough & gag reflex

77

pleural effusion: gold standard for diagnosis

CXR: blunted costophrenic angles (shark fins)
lower than normal PaO2 r/t hypoxemia
PaCO2 r/t alveolar ventilation

78

Pulsus paradoxus is seen in COPD: true or false?

FALSE. It is seen in asthma (greater than 12)

79

pulsus paradoxus

exaggerated drop of SBP 10+ during inspiration
- along w ↓ pulse wave amplitude

80

asthma: diagnostics test x4 and values x5

CBC + PFT + ABG + CXR

slight ↑ WBC + eosinophilia

PFTs: abnormalities typical of OBSTRUCTIVE dysfxn (FEV1 lt 30% / peak flow lt 60 L/min)

general improvement in FVC or FEV1 ~15% //OR// FEF 25-75 of 25% after inhaled bronchodilator

initially RESPIRATORY ALKALOSIS + mild hypoxemia

CXR unnecessary to r/o ddx, MAY show hyperinflation

81

FEF 25-75

the avg forced expiratory flow during middle (25 - 75%) portion of FVC

it's a PFT

82

LABA BBWs

↑ association of asthma-related deaths d/t misuse

SABA is for rescue, NOT LABA

83

Which drug class indicated for asthma rescue therapy + example?

SABA: albuterol (Proventil)

84

SABA & LABA stand for...
(+ example of each)

short-acting beta-2 adrenergic agonist
- albuterol (Proventil)
&
long-acting beta-2 adrenergic agonist
- salmeterol (Serevent)

85

SABA achieves what in asthma & COPD?

bronchodilation

86

asthma inpt mgmt: inhalation sympathomimetics + dosages x3

alupent (0.3 cc in 5% sol) in 2.2 mL NS q 30 - 60min

proventil, ventolin 0.3 cc in 3 mL NS q 30 - 60 min

87

asthma inpt mgmt: when to check ABG?

severe attack only, not necessarily for mild to moderate

88

asthma inpt mgmt: corticosteroid for pt who do not respond to sympathomimetics dosage x1

methylprednisolone 60 - 125 mg IV x1
- then 20 mg IV q 4 - 6 hr until attack broken

89

in-patient suffering from asthma attack does not respond to proventil - what is your next step?

administer corticosteroid: methylprednisolone 60 - 125 mg IV x1
- then 20 mg IV q 4 - 6 hr until attack broken

90

asthma inpt mgmt: parenteral sympathomimetic & indication x1

aqueous epinephrine 1:1000 0.1 - 0.5 mL SQ q 30 - 90 min
- may repeat x4

91

in-patient with asthma attack is fatigued and unable to take inhaled meds - what is your next step?

parenteral sympathomimetic: aqueous epinephrine 1:1000 0.1 - 0.5 mL SQ q 30 - 90 min
- may repeat x4

92

asthma inpt mgmt: anticholinergic example + dosage x1

ipratropium bromide (Atrovent) MDI 2 - 6 puffs q 4 - 6 hrs

93

status asthmaticus mgmt: 4 gold standard + 4 more

GOLD STANDARD:
IV D5 1/2NS
Intubation (pt looks bad)
Continuous pulse ox
ABG q 10-20 min

+
- O2
- methylprednisolone 60 - 125mg OR hydrocortisone 300 mg IV STAT
- inhalation/parenteral sympathomimetics
- consider atrovent

94

Your status asthmaticus pt's SaO2 begins to drop - what is your priority order?

ABG - monitor q 10 - 20 minutes

95

chronic bronchitis: s/s x5

intermittent mild - mod dyspnea
sputum: copious, purulent
percussion: normal
chest AP diameter: normal
stocky, obese habitus

96

COPD is...

chronic bronchitis + emphysema
- pts usually have features of both -

97

chronic bronchitis: typical pt profile x4

- 35+ @ sx onset
- stocky, obese
- chest AP diameter normal

BLUE BLOATERS

98

emphysema: typical pt profile x4

- 50+ @ sx onset
- thin, wasted
- chest AP diameter increased

PINK PUFFERS

99

emphysema: s/s x5

progressive, constant dyspnea
sputum: mild, clear
percussion: normal
chest AP diameter: increased
thin, wasted habitus

100

COPD: dyspnea in chronic bronchitis vs emphysema

chronic bronchitis: mild - moderate & intermittent
emphysema: progressive & constant

101

bula & blebs on CXR indicative of (COPD)?

chronic bronchitis

102

hematocrit in COPD

- often ↑ if PaO2 less than 55 mmHg or nocturnal desaturation
- most common in chronic bronchitis (but seen w emphysema)
- evaluate for hypoxemia @ rest, exertion, sleep

103

COPD: expected PFT *

* FEV 1 * + other EXPIRATORY airflow measures REDUCED *

TLC, FRC, RV /may/ be increased

104

COPD: diagnostics x3

PFT: ↓ FEV1/expiratory airflow + ↑ TLC, FRC, RV (maybe)
ABG: ↑ PaCO2, HCO3
CXR: low, flattened diaphragm

105

COPD: expected ABG

↑ PaCO2 & HCO3

106

mainstays of COPD mgmt (outpt)

inhaled --
ipratroprium bromide (Atrovent)
or
sympathomimetics

107

COPD: inpt mgmt

- O2 1 - 2L/min NC or venti @ 24-28%
- pharm progression as for inpt asthma
- purulent sputum = abx 7 - 10 days (ampicillin, amoxicillin, doxy, bactrim)

108

inpt COPD + purulent sputum = x3 meds

ampicillin or amoxicillin 500 mg QID
OR
doxy 100 mg BID
OR
bactrim 1T BID

109

TB: s&s 4x classic + 3 more

*MAJORITY ARE ASYMPTOMATIC*
* weight loss
* low grade fever
* night sweats

fatigue, anorexia, dry cough progressing to productive and sometimes blood-tinged

110

night sweats: 4 top ddx

TB
menopause
AIDS
endocarditis

111

TB diagnostics*

*culture: M. tuberculosis x3 = definitive dx
* CXR: small, homogenous infiltrate in upper lobes (honeycomb)
AFB smears: presumptive evidence of active TB
PPD: shows exposure (NOT DIAGNOSTIC FOR ACTIVE DISEASE)

112

TB: definitive diagnosis

culture of M. tuberculosis x3

113

TB: stereotypical CXR presentation

small, homogenous infiltrate in upper lobes (honeycomb)

114

TB: mgmt x3

- notify health department of all cases
- hospitalization not required; consider if non-compliant or likely to expose others (place in negative pressure room)

115

TB: hospitalization guidelines

not required; consider if non-compliant or likely to expose others
- place in negative pressure room

116

TB: why are baseline LFTs important to establish with initiation of treatment?

INH is extremely hepatotoxic

117

Which TB drug is associated with red-green colorblindness?

Ethambutol

118

+ PPD: 3 levels

HIGH / 5mm: HIV+, case contacts, CXR typical for TB

MODERATE / 10mm: high risk groups - health care, prison, immigrants (high prev area), IVDU, CKD, DM, immune suppression

LOW / 15mm: all others (joe schmoe)

119

pneumonia: s/s

lung consolidation on PE, increased fremitus
purulent sputum
fever, chills, malaise

120

pneumonia: diagnostics x5

CBC: ↑ WBC (low in immunocompromised & elderly)
CXR: infiltrates
sputum cx, gram stain
ABG: if resp failure suspected
consider blood cx: x3

121

HCAP: definition x4 + common organisms (likely x2 + less x3)

- hospitalized in acute care hospital 2+ days w/in 90 days of infection
- resided in nursing home or LTCF
- rec'd recent IV abx, chemo, wound care w/in past 30 days of infection
- attended hospital or HD clinic

more similar to HAP than CAP
- likely: Staph aureus, Pseudomonas
- less: Strep pneumo, H flu, MRSA

122

pneumothorax: s/s - hallmark x3 + general x4

hyper-resonance affected side (d/t air trapping)
diminished BS & diminished fremitus affected side
mediastinal shift toward unaffected (tension pneumo)

chest pain, dyspnea, cough, hypotension

123

when is pulmonary angiography appropriate in PE?

when clinical data + VQ scan contradictory
OR
pt @ significant risk d/t anticoagulants have high probability VQ scan

124

what is the key to diagnosis of pulmonary embolism?

clinical suspicion - history is crucial

125

SVO2 normal vs in ARDS

normal: 60 - 80
in ARDS: higher (not using O2 received)

126

types of pleural effusions & appearance x4

transudate: clear
exudate: creamy (protein/LDH)
empyema: pus
hemorrhagic: blood

127

pleural effusion: exudate only lab features x3

1+ of these characteristics of the pleural fluid:
- protein : serum ratio gt 0.5
- LDH : serum ratio gt 0.6
- LDH gt 2/3 upper limit of normal

128

what happens with increased tidal volume

increased alveolar ventilation

129

FVC

forced vital capacity
- volume of gas forcefully expelled from lungs after maximal inspiration

130

FEV1

forced expiratory volume
- volume of gas expelled in first second of FVC maneuver

131

FEV 25-75

forced expiratory volume
- maximal mid-expiratory airflow rate

132

PEFR

peak expiratory flow rate
- maximal airflow rate achieved in FVC maneuver

133

TLC

total lung capacity
- volume of gas in lungs after maximal inspiration

134

FRC

functional residual capacity

135

RV

residual volume
- volume of gas remaining in lungs after maximal expiration

136

PFTs: obstructive vs restrictive diseases

obstructive: reduced airflow rates
- FVC, FEV1, PEFR

restrictive: reduced volumes
- TLC, FRC, RV

137

PFTs: airflow rates x4

FVC
FEV1
FEV 25-75
PEFR

138

PFTs: volumes x3

FRC
TLC
RV

139

FVC vs FRC

forced vital capacity vs functional residual capacity
FVC: airflow
FRC: volume

140

What happens to TLC and VC in older adults?

total lung capacity constant
↓ vital capacity bc ↑ residual volume

141

What happens to AP diameter in older adults?

142

What happens re: thoracic percussion in older adults?

hyper resonance

143

physiologic reasons pneumonia is more serious in older adults x5

alveoli collapse more easily
↓ cilia, cough reflex, response to hypoxia/hypercapnia
↑ mucus-producing cells

144

most common causative agents of pneumonia in older adults x4

Strep pneumo, staph aureus

& gram negs: H flu, Moraxella catarrhalis, Klebsiella

145

typical aspiration pneumonia CXR

localized to right middle lobe

146

what pulmonary dysfunction is PEEP responsive?

shunting

147

what's the difference between pressure support and PEEP?

pressure support is at the end of inspiration

PEEP is at the end of expiration