Rosen's 10th > Respiratory > Flashcards

Respiratory Flashcards

(157 cards)

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1
Q

Name the most commonly encountered pathogen in hospitalized patients, especially those requiring the intensive care unit

A

Streptococcus pneumoniae

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2
Q

In a pt with PNA and GI or neuro symptoms, what bacteria should be considered?

A

Legionella

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3
Q

Name 4 most likely bacterial pathogens for PNA in adults

A

S. pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae

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4
Q

List 7 factors with increased risk of S. pneumo PNA

A
  • diabetes
  • cardiovascular disease
  • alcoholism
  • sickle cell disease
  • splenectomy
  • malignancy
  • immunosuppressive illness
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5
Q

List 4 pt populations where Pneumococcal 23 vaccine is recommended

A
  • underlying illness
  • age >65
  • smokers
  • chronic lung disease
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6
Q

List 7 clinical factors that suggest anaerobic PNA

A
  • any risk of aspiration
  • CNS depression
  • swallowing dysfunction
  • severe peridontal disease
  • fetid sputum
  • pulmonary abscess
  • empyema
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7
Q

List 6 common viruses causing PNA

A

RSV
Parainfluenza
Influenza A
Influenza B
Metapneumovirus
COVID

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8
Q

List 3 fungal infections that can cause PNA

A
  • Histoplasma capsulatum
  • Blastomyces dermatitidis
  • Coccidioides immitis
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9
Q

List 6 clinical presentations related to Pneumocystic jiroveci PNA

A
  • Subacute
  • Fatigue
  • Exertional dyspnea
  • Non-productive cough
  • Pleuritic chest pain
  • Fever
  • HIV
  • malignancy
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10
Q

List 5 factors for reactivation of TB infection

A
  • diabetes
  • renal failure
  • immunosuppressive therapy
  • malnutrition
  • HIV
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11
Q

List classic clinical features of pneumococcal PNA

A
  • abrupt onset of a single shaking chill
  • fever
  • productive cough
  • rust-coloured sputum
  • pleuritic chest pain
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12
Q

What bacteria does currant-jelly sputum suggest?

A

Klebsiella pneumoniae

  • from necrotizing area
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13
Q

List 4 types of rash that can accompany Mycoplasma infection PNA

A
  • maculopapular
  • vesicular
  • urticarial
  • erythema multiforme
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14
Q

List 2 bacterial PNAs associated with Cystic Fibrosis

A

S. aureus
P. aeruginosa

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15
Q

List 5 pathogens that pts with blood Ca, on chemo, or transplant pts, are at risk for

A

CMV
Varicella
HSV
Aspergillus
P. jiroveci

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16
Q

List 6 PNA pathogens common in HIV pts

A

S. aureus
S. pneumoniae

  • Mycobacterium avium complex
  • CMV
  • aerobic gram-negative bacilli
  • Cryptococcus neoformans
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17
Q

List 4 risk factors for severe COVID disease

A

Obesity
Advanced age
HTN
Comorbidities

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18
Q

List 4 PNA pathogens that pts from nursing homes and long term care are at risk for

A
  • P. aeruginosa
  • K. pneumoniae (including resistant strains)
  • Acinetobacter spp.
  • MRSA
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19
Q

List 8 non-infectious pulmonary processes that can lead to PNA

A
  • exposure to mineral dusts (silicosis)
  • exposure to chemical fumes (chlorine & ammonia)
  • toxic drugs (bleomycin)
  • radiation
  • thermal injury
  • oxygen toxicity
  • immunologic disease (sarcoidosis, anti-GBM, collagen vascular dz)
  • environmental hypersensitivity (farmer’s lung dz)
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20
Q

List 3 reasons when ABX should be given after an aspiration event?

A

*pt develops signs of bacterial PNA

  • new fever
  • expanding infiltrate appearing >36hr after aspiration
  • unexplained deterioration
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21
Q

List 3 bacterial DDx for this CXR

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • gram-negative bacilli
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22
Q

List 1 bacterial PNA suggestive of this CXR

A

Mycoplasma
= pathcy interstitial infiltrates

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23
Q

List 1 bacterial PNA suggestive of this CXR

A

Pneumocystis jiroveci
= bilateral interstitial infiltrates that begin in the perihilar region

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24
Q

List ABX for outpatient CAP tx

A

**Healthy, no ABX in last 3 mos:
**

1) Doxycycline 100mg PO BID x7d

2) Amoxicillin 1000mg PO TID x7d

Co-morbidities, or yes ABX in last 3 mos:

1) AmoxClav 875/125mg PO TID x7d

2) Cefuroxime 500mg PO BID x7d
+ Azithromycin 500mg PO D1, then 250mg PO D2-5

3) Levofloxacin 750mg PO OD x5d

4) Moxifloxacin 400mg PO OD x7d

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25
List 2 major & 9 minor criteria for Severe CAP
MAJOR: - invasive mechanical ventilation - septic shock w/ vasopressors MINOR: - RR >30 - P:Fi ratio <250 - multilobar infiltrates - confusion/disorientation - Urea >7 - WBC <4 - PLT <100 - Hypothermia - hTN req'ing aggressive IVF
26
List ABX for inpatient CAP tx
**Immunocompetent pts:** 1) CTX 2g IV q24h + Azithro 500mg IV q24h 2) Levoflox 750mg IV q24h 3) Moxiflox 400mg IV q24h **Severe PNA in ICU:** 1) CTX 2g IV q24h + Levoflox 750mg IV q24h + Vancomycin 15mg/kg IV q12h **Risk for MRSA, Pseudomonas, ABX in last 90d, Severe PNA w/ neutropenia or bronchiectasis:** 1) Cefepime 2g IV q12h + Levoflox 750mg IV q24h + Vancomycin 15mg/kg IV q12h **Presumed PJP:** 1) TMP-SMX 5mg/kg PO q6h +/- CTX if severe
27
What are additional ABX to include for aspiration PNA
Clindamycin Metronidazole PipTazo Meropenem
28
Outline CURB-65 rule
- Confusion - Uremia >7 - RR >30 - BP <90 systolic, or <60 diastolic - Age >65 Risk of 30-day mortality 0 = 0.7% 2 = 9.2% 5 = 57% 0-1 = outpt mgmt 2 = inpt mgmt 3+ = consider ICU
29
List ABX tx for rhinosinusitis (if needed at all)
Amoxicillin 500mg PO TID x5d or AmovClav 875/125mg PO BID x5d or Doxycycline 100mg PO BID x5d
30
List DDx for Infectious Etiologies of Pharyngitis
BACTERIAL: - GAS - GBS - Fusobacterium - Neisseria gonorrhoeae - Corynebacterium diphtheriae - Chlamydia - Mycoplasma pneumoniae - Arcanobacterium haemolyticum VIRAL: - Rhinovirus - Coronavirus - Parainfluenza - Adenovirus - Influenza - Coxsackie - HIV - EBV - HSV - CMV FUNGAL: - Candida ADJACENT INFXNS: - RPA - Parapharyngeal abscess - Epiglottitis - Ludwig angina
31
List 8 DDx for Non-Infectious causes of Pharyngitis
- Tumor - Autoimmune disease - Neurogenic pain - Foreign body - Trauma - Medication induced - Stevens-Johnson syndrome - Allergic reaction - Esophageal reflux - Environmental exposure
32
Name 3 areas of tonsils
Pharyngeal tonsils Palatine tonsils Lingual tonsils
33
List s/s of EBV pharyngitis
Classic triad: 1. fever 2. tonsillar pharyngitis 3. posterior cervical lymphadenopathy exudate tonsillar hypertrophy petechiae at soft-hard palate stridor splenomegaly pruritic morbilliform rash
34
List 5 suppurative complications of GAS pharyngitis
- AOM - mastoiditis - meningitis - PTA - RPA - necrotizing fasciitis - hematogenous spread to distant sites
35
List the illness associated with Fusobacterium infection
Septic Jugular Vein Thrombophlebitis = Lemierre syndrome
36
List 6 ABX tx options for GAS pharyngitis
1) Penicillin V - oral Peds = 250mg PO BID or TID x10d Adult = 500mg PO BID x10d 2) Penicillin G - IM <27kg = 600k units IM >27g = 1.2mill units IM 3) Amoxicillin 50 mg/kg (max 1000mg) PO OD or 25 mg/kg (max 500mg) PO BID x10d 4) Cephalexin 20mg/kg/dose (max 500mg) PO BID x10d 5) Clindamycin 7mg/kg/dose (max 300mg) PO TID x10d 6) Azithromycin 12mg/kg (max 500mg) PO OD x5d --> All with Dexamethasone 0.6mg/kg (max 10mg) PO x1
37
List 2 ABX tx options for Fusobacterium and anaerobics pharyngitis
1) CTX 2g IV q24h + Metronidazole 500mg IV q8h 2) PipTazo 3.375g IV q6h
38
List 4 ABX tx for Diphtheria pharyngitis
ANTI-TOXIN (request from PH) + Adults = all meds x14d - Azithromycin 500mg PO/IV q24h - Erythromycin 500mg PO/IV q6h - Penicillin G 25k units/kg (max 1mill units/dose) IV q6h - Penicillin V 500mg PO q6h Peds = all meds x14d - Azithromycin 10mg/kg PO/IV q24h - Erythromycin 10mg/kg PO/IV q6h - Penicillin G 25k units/kg (max 1mill units/dose) IV q6h - Penicillin V 10mg/kg PO q6h
39
List ABX tx for Gonococcal pharyngitis
CTX 500mg IM x1 + Doxycycline 100mg PO BID x7d
40
List 2 tx options for Herpes pharyngitis
1) Acyclovir 200mg PO 5x/d x7d 2) Valacyclovir 1g PO BID x7d
41
List tx for mild and severe Candida pharyngitis
MILD: Clotrimazole troches or Nystatin swish/swallow MOD-SEVERE: Fluconazole 200mg PO on D1, then 100-200mg PO OD x7d Peds = 6-12mg/kg (max 200mg) PO OD
42
What can form in back of throat in Corynebacterium diphtheriae?
Toxin-producing strains create a pseudomembrane - gray/green to black - adheres to mucosal tissue - friable can obstruct the airway
43
List 3 distant sites that Corynebacterium diphtheriae pharyngitis can affect
Myocarditis Neuritis Acute tubular necrosis
44
Outline Centor Score for GAS pharyngitis
FACE Fever >38 Adenopathy no Cough Exudative tonsillar hypertrophy 1 point each 0-1 = no further testing 2+ = rapid antigen
45
List 3 clinical features that exclude pts from having Centor Score applied
- Immunocompromised - Complicated comorbidities - Symptoms >5d
46
List 11 clinical factors that indicate tx of influenza
- documented or suspected influenza cases in hospitalized patients - children <2 yrs - adults >65 yrs - pregnant women - <2 weeks postpartum - immunosuppression - chronic cardiac dz - chronic lung dz - chronic renal dz - chronic liver dz - chronic hematologic dz
47
List 5 clinical features of pts who need admission for pharyngitis
- stridor - difficulty managing secretions - phonation changes - hTN - altered mental status
48
List 5 DDx for chronic laryngitis
>3 wks of symptoms - GERD - overuse of the voice - trauma - thermal burn - chemical burn - irritants - allergic reactions
49
List 5 DDx for acute laryngitis
most causes of pharyngitis RPA anaphylaxis angioedema tumour thyroiditis chemical injury thermal injury foreign body
50
List 6 risk factors for epiglottitis
Adult (non-vaccinated) DM2 Immunosuppressed SUD Tobacco EtOH
51
List DDX for bacterial causes of epiglotittis
Haemophilus influenzae Streptococcus pneumoniae Staphylococcus sp
52
What is the XR sign for epiglottitis?
Thumb sign = epiglottis >5.5mm
53
Outline tx for epiglottitis, including ABX & adjunct meds
CTX + Vanco (or Clinda) If Immunocompromised: Cefepime OR PipTazo + Vanco - Nebulized epinephrine - Dexamethasone 10mg
54
List ABX tx for RPA, PTA, and Ludwigs
CTX + Metronidazole or Clinda + Levofloxacin Immunocomp: Cefepime + Metro or PipTazo + Vanco ?MRSA: add Vanco or Linezolid
55
List 5 risk factors for developing a PTA
- smoking - dental or periodontal disease - recent streptococcal tonsillitis - mononucleosis - obstruction or infection of the Weber glands
56
List 8 DDX of Suppurative Pharyngeal Infections
PTA Parapharyngeal abscess RPA Retropharyngeal cellulitis Retropharyngeal tumors Benign hypertrophy of tonsils Meningitis Hematoma 2/2 trauma Carotid artery aneurysm Lymphoma Tendinitis of longus colli muscle
57
Describe Ludwig angina
- rapidly progressive - bilateral - gangrenous cellulitis of all submandibular spaces - can rapidly lead to death within hours
58
List 5 causes of Ludwig angina
- dental infection of mandibular molars - mandibular fracture - tongue piercing - lingual laceration - oral malignancy with infection - suppurative parotitis - adjacent H&N infections
59
List classic clinical features of Ludwig angina
- drooling - elevation of floor of mouth + tongue - woody consistency to floor of mouth - brawny edema to submandibular region = bull neck
60
List lateral neck XR findings suggestive of RPA
1) Space from anterior-inferior aspect of C2 VB to posterior pharyngeal wall >7mm 2) Retrotracheal space at C6 VB >14mm (peds) or >22mm (adults)
61
List 6 common pathogens causing acute rhinosinusitis
Rhinovirus Adenovirus Influenza Parainfluenza S. pneumo H. flu Moraxella catarrhalis
62
List 3 clinical diagnostic criteria for bacterial rhinosinusitis
1) >10d persistent symptoms w/out improvement 2) 3-4d of severe symptoms including fever >39, nasal discharge or facial pain w/out improvement 3) Onset of progressive symptoms w/ worsening symptoms after initial improvement
63
What is gold standard for dx of bacterial rhinosinusitis?
Culture of secretions obtained via sinus puncture
64
List symptoms mgmt options for rhinosinusitis
acetaminophen 650mg (15 mg/kg for children) q6h ibuprofen 800mg (10 mg/kg for children) q8h nasal irrigation w/ saline 1-2 sprays each nostril q4h intranasal fluticasone or mometasone 2 sprays in each nostril OD
65
What is the minimum amount of pleural fluid needed to see effusion on US and CXR, respectively?
US = 50cc CXR = 200cc
66
List 6 risk factors for PRIMARY spontaneous PTX
Male Marfan syndrome MV prolapse Smoking Changes in ambient atmospheric pressure Genetics
67
List 15 Causes of SECONDARY Spontaneous Pneumothorax
- COPD - Asthma - Cystic fibrosis - Necrotizing bacterial PNA with lung abscess - TB - Sarcoidosis - IPF - Lymphangiomyomatosis - Tuberous sclerosis - Pneumoconioses - Primary lung cancers - Pulmonary or Pleural metastases - Marfan syndrome - Ehlers Danlos - Scleroderma - RA - Pulmonary infarction - Endometriosis
68
List symptoms of primary spontaneous PTX
Sudden ipsilateral chest pain Dyspnea Dull steady ache (later)
69
List 6 signs of primary spontaneous PTX
Sinus tachycardia Hypoxia Decreased breath sounds Hyperresonance to percussion Unilateral hemithorax enlargement Unequal chest wall movement Absent tactile fremitus Inferior displacement of liver/spleen
70
List 7 signs of tension PTX
Hypoxia Increased WOB Tachycardia hTN JVD Displaced trachea Cardiac arrest
71
List 8 DDx for spontaneous PTX
PE PNA Tumour Pleural effusion MI Pericarditis Pericardial effusion Pneumomediastinum Spontaneous hemopneumothorax
72
List 3 diagnostic imaging tests to dx PTX
US CXR CT
73
Outline UK guidelines for PTX size
= measurement of the intrapleural distance at the level of the hilum Small <1cm Moderate 1-2cm Large >2cm
74
Outline USA guidelines for PTX size
= measuring from the apex to the cupola (dome top) Small <3cm Large >3cm
75
List 3 findings on US for PTX
1. No lung sliding 2. No B lines 3. Presence of pathologic lung point
76
List 4 procedural tx options for spontaneous PTX
Aspiration Tube thoracostomy VATS Thoracotomy
77
List 15 Causes of Pleural Effusion
TRANSUDATIVE - CHF - Cirrhosis with ascites - Nephrotic syndrome - Hypoalbuminemia - Myxedema - Peritoneal dialysis - Glomerulonephritis - SVC obstruction - PE EXUDATIVE - Bacterial PNA - Bronchiectasis - Lung abscess - TB - Viral illness - Primary lung cancer - Mesothelioma - Pulmonary or pleural metastases - Lymphoma - RA - SLE - Pancreatitis - Subphrenic abscess - Esophageal rupture - Abdominal surgery - Pulmonary infarction - Uremia - Drug reactions - Postpartum - Chylothorax
78
Outline cause of transudate and exudate pleural effusions
- transudative effusion develops due to an increase in hydrostatic pressure or decrease in oncotic pressure within the pleural microvessels ex) CHF - exudative effusions contain a relatively high amount of protein, reflecting an intrinsic abnormality of the pleura ex) Parapneumonic effusion
79
List DDx causing pleural fluid w/ pHs of <7.3 & <7.0?
pH <7.3: - parapneumonic effusion - malignancies - rheumatoid effusions - tuberculosis - systemic acidosis pH <7.0: - empyema - esophageal rupture - indication for tube thoracostomy
80
Outline Light's Criteria
Pleural Fluid = Exudative if 1+ is met: 1) Fluid Protein/Serum Protein >0.5 2) Fluid LDH/ Serum LDH >0.6 3) Fluid LDH >2/3x ULN of Serum LDH
81
List 4 DDx for bloody pleural fluid
Traumatic tap Trauma Neoplasm Pulmonary infarction
82
List 5 contraindications to thoracentesis
Coagulopathy Bleeding d/o Chest wall infection Pleural adhesions Hx of Pleurodesis
83
List 8 complications of thoracentesis
PTX HTX Lung laceration Shearing of catheter tip Infxn Transient hypoxia 2/2 VQ mismatch Hypotension Re-expansion pulmonary edema
84
At what volume aspirated is re-expansion pulmonary edema a risk?
>1500cc drained at once
85
List 6 causes of COPD exacerbation
- viral infections - bacterial infections - environmental pollutants - particulate matter - thrombotic disease - temperature changes
86
List 4 most common s/s of COPDe
- Dyspnea - Cough - Increased sputum production - Increased sputum purulence
87
List 3 indications for abx in COPDe
- Signs of LRTI - Increased purulence of sputum - Respiratory failure
88
List 3 tachyarrhythmias common in COPDe
Afib Aflutter Multifocal atrial tachycardia
89
What is O2 sat goal in COPD pts
88-92%
90
Outline ideal ventilator settings (RR, Vt, pH) for an intubated COPD patient
RR 10-14 Vt =/<8cc/kg predicted body weight Resp acidosis with pH >7.2 is tolerated
91
List 6 risk factors for developing COPD
- Male - Age >40 - Smoker - Occupational exposures - Indoor air pollution - Genetics (A1AT deficiency)
92
List 8 common concomitant comorbid conditions in pts with COPD
- Ischemic heart disease - AFib - HF - Metabolic syndrome - MSK disease - Anxiety - Depression - Lung cancer
93
What spirometry result is diagnostic of COPD?
FEV1/FVC <0.7, after bronchodilators
94
Outline the GOLD ABCD assessment tool
A = mild symptoms, 0-1 exacerbations, no admission B = severe symptoms, 0-1 exacerbations, no admission C = mild symptoms, 1-2+ exacerbations, hx of admissions D = severe symptoms, 1-2+ exacerbations, hx of admissions
95
List 3 most common bacterial and 1 most viral causes of COPDe
- Haemophilus influenzae - Streptococcus pneumoniae - Moraxella catarrhalis - Rhinovirus
96
List 4 clinical features of a COPDe pt that should warrant investigation of PE
No clear exposure No infectious risk Pleuritic pain Signs of HF
97
Outline simple definition of mild, moderate, severe COPDe
Mild = only worsened symptoms Moderate = receives abx + systemic glucorticoids Severe = requires ED visit
98
Outline Classification of Respiratory Failure in COPD Exacerbation
NO RESP FAILURE - Mild tachypnea w/ RR 20-30 - Normal WOB - Baseline mental status - Mild hypoxemia responsive to O2 via np - No hypercapnia ACUTE RESP FAILURE - Significant tachypnea w/ RR >30 - Inc WOB w/ accessory muscle use - Baseline mental status - Hypoxemia responsive to FiO2 <35% - Hypercapnia w/ PaCO2 50-60 + pH >7.25 SEVERE RESP FAILURE - AMS - Hypoxemia req'ing FiO2 >35% - Hypercapnia w/ PaCO2 >60 or pH <7.25
99
List 10 DDx for COPDe
PNA PTX Pleural effusion PE Pulmonary edema Cardiac arrhythmia Pericardial effusion Heart failure Malignancy Pathologic rib fractures Chest wall trauma Metabolic acidosis with compensatory tachypnea
100
List 4 common EKG findings in a COPD pt
- P pulmonale = large peaked Ps (>2.5 mm) in II, III, aVF, & (>1.5 mm) in V1-2 - Low QRS voltage - RAD - Poor R wave progression (<3mm in V3) in precordium
101
List 2 goal targets in COPDe when it comes to supplemental O2
Sats 88-92% PaO2 >60
102
List 3 indications for NIPPV in COPDe
1) Respiratory acidosis - PaCO2 >45 - pH <7.35 2) Severe dyspnea, resp muscle fatigue, accessory muscle use 3) Persistent hypoxemia despite supplemental O2
103
List 7 indications for mechanical ventilation in COPDe
1. Unable to tolerate NIPPV 2. NIPPV failure 3. Persistent diminished consciousness 4. Respiratory/Cardiac arrest 5. Persistent inability to remove secretions 6. Hemodynamic instability, not responsive to IVF or vasoactives 7. Life threatening hypoxemia not corrected by less invasive interventions
104
List 4 contraindications to NIPPV in COPDe
1) Active vomiting & high risk aspiration 2) Respiratory arrest 3) Facial trauma 4) Depressed mental status not 2/2 high PaCO2
105
List 2 contraindications to mechanical ventilation in COPDe
1) Appropriate for NIPPV 2) Pt wishes, goals of of care not for intubation
106
List 7 ideal ventilator setting in COPDe
- Volume assist control - RR 10-14 - Vt =/< 8cc/kg - Square inspiratory waveform - Inspiratory time 0.8-1 sec - PEEP = 5 - titrate O2 to sat 88-92%
107
List 4 common causes of elevated peak pressures on a ventilated patient
Kinked tubing PTX Mucus plugging Mainstem intubation
108
List 5 general guidelines for when to admit pts with COPDe
1. Significant worsening of symptoms from baseline 2. Inadequate response of symptoms to ED mgmt 3. Significant comorbid conditions (PNA, HF) 4. Worsening hypoxia or hypercarbia (from baseline) 5. Inability to cope at home or insufficient home resources
109
Outline 2 general types of asthma exacerbation/deterioration
1. Slow Onset - progressive deterioration - over 6hrs to days - 80% of cases - female predominance - triggers of URTI - airway inflammation - slower response to tx 2. Sudden Onset - rapid deterioration - w/in <6hrs - 20% of cases - male predominance - triggers of allergens, exercise, psychosocial stress - bronchospastic - faster response to tx
110
List 4 s/s of Near-Fatal Asthma exacerbation
aLoC (confused, drowsy) Silent chest Poor respiratory effort Elevated PaCO2
111
List 8 risk factors for asthma exacerbations
- Female - Hx of 1+ exacerbations in the past year - Poor adherence to medication plan - Uncontrolled symptoms - Incorrect inhaler use - Chronic sinusitis - Smoking - Black - Low SES
112
List 9 risk factors for Death from Asthma
ASTHMA HX: - Hx of near-fatal asthma requiring ETT + mech vent - Hospitalization or ED visit for asthma in the past year - Current use or recently stopped using oral corticosteroids - Not currently using an ICS - SABA overuse, >1 cannister/month - Poor adherence with asthma meds +/- poor adherence with (or lack of) a written asthma action plan OTHER FACTORS: - Psychosocial problems - Psychiatric disease - Food allergy
113
List 6 DDx for chronic cough
- Cough-variant asthma - ACEi use - GERD - Chronic sinusitis - Postnasal drip - Inducible laryngeal obstruction
114
List 5 pre-tx for exercise induced asthma
- Nasal breathing or face mask to warm and humidify air - Avoid known allergens - Pre-exercise warm up - ICS + SABA 5-10mins pre-exercise - ICS + LABA use in general - Cromolyn - Montelukast - Ipratropium
115
List the tetrad of clinical features in Aspirin-Exacerbated Respiratory Disease (AERD)
TETRAD OF: 1. Nasal polyps 2. Eosinophilic sinusitis 3. Asthma 4. Sensitivity to COX1 inhibitors (ASA)
116
List 10 DDx for Asthma
Cardiac conditions: - Valvular heart disease - CHF COPD exacerbation Pulmonary infection: - PNA - Allergic bronchopulmonary aspergillosis - Löffler syndrome (eosinophilic pulm dz 2/2 parasitic worms) - Chronic eosinophilic PNA Upper airway obstruction: - Laryngeal edema - Laryngeal neoplasm - FB - Vocal cord dysfunction Endobronchial disease: - Neoplasm - FB - Bronchial stenosis Pulmonary embolus Cystic fibrosis Carcinoid tumor Allergic/anaphylactic reaction Adverse drug reaction (ACEi) Miscellaneous conditions: - Eosinophilic Granulomatosis with Polyangiitis (EGPA) - GERD - Hyperventilation with panic attack - Noncardiogenic pulmonary edema - Addison’s disease - Invasive worm infection
117
What is O2 sat goal in Asthma?
94-98%
118
List 4 BW abnormalities present after salbutamol use
Hypokalemia Hypophosphatemia Hypomagnesemia Hyperlactemia
119
List 5 clinical findings in severe asthma
HR >120 RR >30 Accessory muscle use (or absent in 50% due to tiring out) PaO2 <60 PaCO2 >42
120
Define subacute lack of asthma control
>4 outpt visits/year >5 SABA rx's/year
121
List nebulized doses for salbutamol and ipratropium in asthma exacerbation
Salbutamol = 2.5-5.0mg q20min x3 - or continuous for 1h if ++ severe Ipratropium = 0.5mg q20min x3
122
List asthma exacerbation treatments
O2 Salbutamol Ipratropium Systemic corticosteroids MgSO4
123
List 8 short-term (hr -ds) side effects of steroid use in asthma exacerbations
- Increased serum glucose - HypoK - Fluid retention & weight gain - Mood alterations including psychosis - HTN - PUD - Aseptic necrosis of the femur - Rare allergic rxns
124
List 3 clinical indications to give MgSO4 in asthma exacerbations, and what does Mg prevent?
1. Adults w/ severe attack (PEF <25%) 2. Adults + kids w/ persistent hypoxia after initial tx 3. Kids with PEF <60% after 1hr of care *Decreases need for hospital admission
125
List 8 side effects of MgSO4 infusion administration
*Dose related - warmth - flushing - sweating - n/v - muscle weakness - loss of DTR - hypotension - respiratory depression
126
List 4 clinical benefits of Heliox in Asthma exacerbation
1. Reduces resistance with gas flow thru airways with non-laminar flow 2. Reduces respiratory muscle work 3. Increases the diffusion of CO2 4. Improve alveolar ventilation
127
List 3 clinical indications to give Heliox in Asthma exacerbation
- severe airflow obstruction (PEF < 30% + rapid onset of symptoms w/in 24hrs) - hx of labile asthma or previous intubation - inability to be adequately mechanically ventilated
128
List 6 indications for intubation in asthma exacerbation
- coma - altered consciousness - cardiac or respiratory arrest - paradoxical breathing pattern - refractory hypoxemia - failure of NIPPV
129
List 4 complication of mechanical ventilation in asthmatics
Hypoxemia Hypotension Nosocomial infections Barotrauma
129
Severe asthma in pregnancy is associated with what 2 things?
Gestational DM Delivery <37 weeks
130
List 6 features of "near fatal" asthma
Acute Severe Asthma WITH - aLoC - exhaustion - poor respiratory effort - silent chest - hTN - cyanosis - PEF <33% - Hypoxia O2 sat <92% - PaO2 <60
131
List 8 pt factors & clinical features w/ increased likelihood of admission in asthma exacerbation
- Female - Older age - Non-White - Use of >8puffs B-agonist in prev 24hr - Past hx of intubations or asthma admissions - Previous use of PO corticosteroids - Need for rapid medical intervention on ED arrival - RR >22 - O2 sat <95% - Final PEF <50% predicted
132
List 8 DDx for respiratory Diphtheria
Streptococcal pharyngitis Viral pharyngitis (EBV, Adenovirus, HSV) Tonsillitis Gonococcal pharyngitis Acute necrotizing ulcerative gingivitis (ANUG) Acute epiglottitis Mononucleosis Laryngitis Bronchitis Tracheitis Candida albicans (thrush) Rhinitis
133
How does proning a pt help?
Proning increases oxygenation by improving ventilation-perfusion matching and increasing the recruitment of lung
134
At what deoxyHGB concentration level is cyanosis apparent?
~50
135
List 4 primary causes of hypoxemia
1) Ventilation-Perfusion mismatch - VQ mismatch 2) Hypoventilation 3) Diffusion limitation 4) Low levels inspired O2
136
List causes of HIGH V/Q ratios
= Increased dead space PE Emphysema Pulm HTN
137
List causes of LOW V/Q ratios
= Right to Left shunt PNA Asthma ARDS Large PTX Pulm edema Congenital heart defects PDA
138
List 5 causes of hypoventilation
- Depressed central respiratory drive - Drug toxicity - Respiratory muscle weakness - Morbid obesity - Upper airway compromise
139
List 2 causes of diffusion limitation as it relates to hypoxemia
= impaired diffusion of oxygen across the alveolar-capillary interface - Interstitial pulmonary fibrosis - COPD
140
List factors that shift Hemoglobin-Oxygen Dissociation Curve to the RIGHT
- increased lactic acid - Low pH - elevated temperature ex) exercising muscle tissue favour O2 delivery to tissues, so at a given PaO2 , Hgb saturation drops & O2 is released to tissues
141
List 3 factors that shift Hemoglobin-Oxygen Dissociation Curve to the LEFT
- High pH - lower temperatures - increased MetHGB ex) pulmonary capillary beds higher O2 binding at any given PaO2
142
List 5 DDx of Peripheral Cyanosis
1) Low cardiac output states - Shock - LV failure - Hypovolemia 2) Environmental exposure (cold) 3) Arterial occlusion - Thrombosis - Embolism - Vasospasm (Raynaud phenomenon) - PVD 4) Venous obstruction 5) Redistribution of blood flow from extremities - Peripheral AV fistulae
143
List 20 DDx of Central Cyanosis
1) Decreased arterial oxygen saturation - High altitude >8000 ft - Drug toxicity - Respiratory muscle weakness - Upper airway compromise - Obesity hypoventilation syndrome - Interstitial pulmonary fibrosis - Emphysema - PE - PHTN - PNA - Large PTX - ARDS 2) Anatomic shunts - Pulmonary AV fistulae - Intrapulmonary shunts - Endocardial cushion defects - VSD - Coarctation of aorta - Tetralogy of Fallot - Total anomalous pulmonary venous return - Hypoplastic LV - Pulmonary vein stenosis - Tricuspid atresia & anomalies - Premature closure of foramen ovale - Dextrocardia 3) Disorders of HGB - Methemoglobinemia - Sulfhemoglobinemia - Polycythemia
144
List 8 DDx for clubbing
Idiopathic pulomanry fibrosis Cystic fibrosis Bronchiectasis Neurogenic tumours Idiopathic Hereditary Cyanotic heart lesions Infective endocarditis Cirrhosis Crohns disease Ulcerative colitis Celiac disease Regional enteritis
145
List 4 DDx for splinter hemorrhages
Infective endocarditis SLE Scleroderma RA
146
Define Massive Hemoptysis
>100mL blood loss or 1/2 cup of blood in 24hrs or Bleeding rate >100mL/hr
147
List 6 clinical factors associated w/ high short-term mortality 2/2 hemoptysis
Alcoholism Active cancer Aspergillosis Pulmonary artery involvement Multifocal pulmonary infiltrates Need for mechanical ventilation at time of admission
148
List 20 DDx of Hemoptysis
Airway Disease: - Bronchitis (acute or chronic) - Bronchiectasis - Neoplasm (primary and metastatic) - Trauma - FB - Cystic fibrosis Parenchymal Disease: - TB - PNA - Lung abscess - Fungal infection - Neoplasm Vascular Disease: - PE - AVM - Aortic aneurysm - Pulm HTN - GPA - SLE - Goodpasture syndrome Hematologic Disease: - Coagulopathy (cirrhosis or warfarin therapy) - DIC - Platelet dysfunction - Thrombocytopenia Cardiac Disease: - Congenital heart disease (especially in children) - Valvular heart disease - Endocarditis Miscellaneous: - Cocaine - Postprocedural injury - Tracheal-arterial fistula - SLE
149
List 5 Critical causes of Hemoptysis
DIC Tracheo-innominate artery fistula Aortobronchial fistula Iatrogenic (postprocedural) hemoptysis PE
150
List 8 Emergent causes of Hemoptysis
Trauma Bronchiectasis PNA Abscess/fungal infection Oral anticoagulant overdose Endocarditis CHF Acute Pulmonary Edema
151
What is most lethal sequela of massive hemoptysis?
HYPOXIA not hemorrhage/hypovolemia
152
Outline empiric mgmt/tx of massive hemoptysis
Airway control Bleeding lung down FFP 2-4 units IV Vitamin K 10mg IV TXA 2g IV PLT transfusion for target >50-60 Bronchoscopy IR embolization Thoracotomy
153
Name best first imaging test for massive hemoptysis
CT chest
154
List 8 risk factors for Legionella infection
Age >50 Smoking Chronic AUD DM2 Chronic Liver disease Chronic kidney failure COPD Malignancy Organ transplant Immunosuppressant medication use Chronic steroid use
155
List 4 anaerobic bacteria that can cause Aspiration PNA
Fusobacterium Bacteroides Peptostreptococcus Prevotella
156
List 8 causes of ARDS
Sepsis Aspiration pneumonitis Infectious PNA Severe trauma & Multiple fractures Pulmonary contusion Burns & Inhalation injury TRALI & Massive transfusions Hematopoietic stem cell transplant Pancreatitis Near drowning injury Thoracic surgery Drugs - Amio - Chemo - Radiation - Defuroxamine - Phenobarbital
Rosen's 10th
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