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Respiratory Flashcards

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1
Q

3 most common causes of community acquired pneumonia

A

Acquired outside healthcare setting or ≤48 h after hospital admission

  1. Strep pneumoniae (most common)
  2. Haemophilus influenzae
  3. Mycoplasma pneumonia
  4. Chlamydia pneumoniae, 5. Respiratory viruses
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2
Q

3 most common causes (organisms) to cause HAP/VAP

A
  1. Pseudomonas
  2. MRSA
  3. Enterobacter
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3
Q

3 most common causes of atypical pneumonia

A
  1. Mycoplasma
  2. Legionella
  3. Chlamydia,
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4
Q

3 most common causes of pneumonia in the immune compromised

A
  1. Pseudomonas,
  2. Fungi (Aspergillus)
  3. Pneumocystis jirovecii (PJP)
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5
Q

3 most common cause pneumonia in the elderly/comorbid population

A

S. pneumoniae
H. influenzae
Moraxella catarrhalis
Staph aureus

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6
Q

List 5 RF for CAP

A
  1. DM
  2. CV disease
  3. EtOH/ AUD
  4. Sickle cell disease
  5. Splenectomy
  6. Malignancy
  7. Immunosuppressive illness
  8. MM
  9. HIV / AIDs
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7
Q

Common organism in aspiration pneumonia

A

Klebsiella Pneumoniae

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8
Q

List 3 extra pulmonary manifestations associate with mycoplasma pneumonia

A
  1. Dermatologic:
    - Erythema multiforme or
    - Stevens–Johnson syndrome

Neurologic:
- Encephalitis
- Guillain–Barré syndrome

  1. Hematologic:
    - Cold agglutinin–mediated hemolytic anemia
  2. myocarditis/ pericarditis
  3. arthritis
  4. otitis
  5. hepatitis
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9
Q

A 19-year-old university student presents to the ED with 10 days of dry cough, low-grade fever, malaise, and sore throat.

Reports fatigue and mild shortness of breath.

Denies chest pain or hemoptysis.

T 38.2 °C, HR 90, BP 115/70, RR 20, SpO₂ 95% on room air.

CXR: bilateral patchy interstitial infiltrates out of proportion to mild clinical findings.

Most likely organism?
Management?

A

Mycoplasma pneumoniae pneumonia (atypical / “walking” pneumonia).

First line:
Doxycycline 100 mg PO BID × 7–10 days
or
Azithromycin 500 mg day 1, then 250 mg daily × 4 days

β-lactams are ineffective (organism lacks cell wall).

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10
Q

List 4 sources of legionella exposure (reservoirs)

A
  • freshwater
  • plumbing
  • air-conditioning cooling towers
  • whirlpool spas
  • humidifiers
  • ice machines
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11
Q

How is legionella transmitted?

A

Inhalation or aspiration of contaminated water droplets — no person-to-person spread

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12
Q

List 4 RF for legionella pneumonia

A
  • Older age
    male sex,
  • smoking
  • chronic lung disease
  • immunosuppression
  • recent travel or hotel/hospital stay
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13
Q

What is the classic clinical feature ‘triad’ for legionella pneumonia?

A
  1. Pneumonia
  2. Diarrhea
  3. Hyponatremia (SIADH common)

Other features:
- high fever
- relative bradycardia ***
- dry/minimally productive cough

CXR»Rapidly progressive, patchy or multilobar infiltrates

Often severe, ICU admission common

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14
Q

How is legionella diagnosis confirmed?

A
  1. Urinary Legionella antigen (L. pneumophila serogroup 1) → rapid and specific (80% of cases)
  2. PCR on sputum or BAL
  3. Culture on BCYE agar (definitive but slow)
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15
Q

How is legionella pneumonia treated?

A

First-line
Levofloxacin 750 mg PO/IV daily
x 7–10 days (mild)
x 10–21 days (severe/
immunocompromised)

Alternative
Azithromycin 500 mg PO/IV daily x 7–10 days

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16
Q

List 5 severe complications of legionella

A
  1. ARDS
  2. Renal failure
  3. Hepatic dysfunction
    4.Sepsis
  4. Rhabdomyolysis
  5. Myocarditis
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17
Q

What infection control precautions are needed for patients admitted with legionella

A

Standard precautions only (no isolation required).

Investigate environmental source if outbreak suspected.

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18
Q

List 3 endemic causes of fungal pneumonia.

Include the Geographic Location / Source

A
  1. Histoplasma capsulatum
    - Mississippi & Ohio River valleys
    - Farmer exposed to bird/bat droppings
  2. Blastomyces dermatitidis
    - Great Lakes, Southeastern U.S., Canada
    - hunter near great lakes
  3. Coccidioides immitis
    Southwestern U.S., Mexico (“Valley Fever”)
    -healthy traveler to arizona
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19
Q

List 3 opportunistic (fungal) causes of pneumonia

A
  1. Aspergillosis
    -Neutropenic / transplant
    - Halo sign on CT
  2. Cryptococcus neoformans
    -HIV (CD4 <200)
    -meningitis + pulm. nodules
  3. Pneumocystis jirovecii (PJP)
    - HIV, diffuse ground-glass opacities
  4. Candida spp.
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20
Q

A 45-year-old man with a history of RA on chronic prednisone

presents with fever, cough, and pleuritic chest pain.

CT chest shows nodular infiltrates with surrounding ground-glass halo.

Sputum culture grows mold with septate hyphae and acute branching.

Most likely diagnosis?
List 1 radiographic and 1 lab investigation to confirm diagnosis?

A

Invasive pulmonary aspergillosis.

Imaging: Halo sign on CT (hemorrhagic infarction).

Lab: Positive galactomannan antigen or β-D-glucan assay.

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21
Q

List 3 forms of aspergillosis

A

Invasive aspergillosis — fever, pleuritic pain, hemoptysis, nodular infiltrates.

Aspergilloma — fungus ball in preexisting cavity (e.g., old TB).

Allergic bronchopulmonary aspergillosis (ABPA) — hypersensitivity in asthmatics.

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22
Q

How is aspergillosis treated?

A

Voriconazole (first-line), Amphotericin B if refractory.

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23
Q

20 F, originally from the Philippines, presents with 4 weeks of cough, fever, night sweats, and 5 kg weight loss.

He reports mild hemoptysis.

T 38.3°C, HR 95, RR 20, BP 110/70, SpO₂ 95% RA.

Exam: mild crackles over the right upper lung.

CXR >

Most likely diagnosis?
How is diagnosis confimed?

A

Pulmonary TB ~Mycobacterium tuberculosis.

Gold standard for diagnosis:
- Sputum AFB smear & culture 3 x early-morning samples

Others:
1. NAAT / PCR
- Rapid detection + rifampin resistance

  1. TB skin test (TST) or IGRA Detects latent infection
  2. HIV testing
    - Co-infection risk high
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24
Q

What steps should be taken for infection control of pulmonary TB in the ED?

A

Airborne precautions immediately:
1. Negative-pressure isolation room
2. N95 mask for all staff
3. Limit movement of patient

Notify infection control and public health.

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25
Outline initial management for confirmed pulmonary TB
RIPE therapy: (for 2 months) - Rifampin - Isoniazid - Pyrazinamide - Ethambutol Followed by Rifampin + Isoniazid (for 4 months) - vitamin B6 (pyridoxine) with isoniazid. Directly observed therapy (DOT) recommended. Notify public health for contact tracing.
26
List 5 complications associated with pulmonary TB
Hemoptysis (from cavitary lesions or Rasmussen aneurysm) Pleural effusion Miliary/disseminated TB TB meningitis Drug resistance (MDR-TB, XDR-TB)
27
40 M w/ PMHx HIV (CD4 80 cells/mm³ 2 months ago) presents with progressive dyspnea, dry cough, and fever for 2 weeks. NO chest pain or sputum production. T 38.0°C, HR 110, BP100/65, RR: 28, SpO₂ 88% RA CXR: bilateral diffuse interstitial (ground-glass) infiltrates. LDH = 560 U/L (elevated). ABG: PaO₂ = 62 mmHg on room air. Most likely diagnosis? What diagnostic tests confirm the diagnosis?
PJP Diagnostic tests: 1. BAL - Stain (silver, Giemsa) or PCR for Pneumocystis DNA 2. β-D-glucan - Non-specific fungal marker (usually elevated)
28
Outline the treatment for PJP in the immune compromised host
1. TMP-SMX x 21 days or Alternatives: 2. Clindamycin + Primaquine 3. Atovaquone (mild) Adjunctive corticosteroids: Indicated when PaO₂ <70 mmHg or A–a gradient >35 mmHg 1. Prednisone 40 mg PO BID × 5 days, then taper over 21 days Supportive care: - Oxygen - IV fluids Begin ART after 2 weeks (to avoid IRIS)
29
What is the empiric prophylaxis for PJP prevention?
TMP-SMX 1 DS tablet daily (or 3x/week) Indicated if CD4 <200 or AIDS-defining illness
30
What are 3 severe consequences of PJP?
Respiratory failure / ARDS Pneumothorax (from cyst rupture) Immune reconstitution inflammatory syndrome (IRIS) after ART initiation
31
What is the causative organism and typical host for Cryptococcus neoformans
Organism - Cryptococcus neoformans (encapsulated yeast) or C. gattii Reservoir - Soil contaminated with pigeon droppings Transmission - Inhalation of spores → pulmonary infection → hematogenous spread At-risk groups - HIV/AIDS (CD4 <100), transplant patients, prolonged steroids
32
List 5 investigations support the diagnosis of disseminated cryptococcous neoforms
1. CXR - Diffuse or nodular interstitial infiltrates; occasionally focal consolidation 2. Sputum / BAL clx - Cryptococcus growth 3. Serum cryptococcal antigen (CrAg) - Rapid and highly sensitive screening test 4. CSF analysis (LP) - ↑ opening pressure - mild lymphocytic pleocytosis, - low glucose - ↑ protein - India ink stain positive for encapsulated yeast 5. CSF & serum CrAg titers Confirm diagnosis and monitor response 6. CT/MRI brain - Rule out mass lesion before LP
33
Outline the management for confirmed cryptococcous
Antifungal therapy: Induction phase: Amphotericin B (liposomal 3–4 mg/kg IV daily) + Flucytosine (25 mg/kg PO QID) × ≥2 weeks Consolidation phase: - Fluconazole 400–800 mg PO daily × 8 weeks Maintenance: - Fluconazole 200 mg PO daily ≥1 year (secondary prophylaxis) Manage elevated intracranial pressure: - Measure opening pressure at LP - Remove 20–30 mL CSF if pressure >25 cm H₂O - Repeat therapeutic LP daily until pressure normalized Avoid acetazolamide or steroids (not beneficial) Delay ART initiation by ~4–6 weeks after antifungal therapy to reduce risk of IRIS (immune reconstitution inflammatory syndrome).
34
What are the diagnostic and treatment differences between C. neoformans and C. gattii?
35
What is the causative organism and transmission route of pneumatic plague
Organism: Yersinia pestis gram-negative coccobacillus Reservoir Rodents (rats, prairie dogs, squirrels) Vector Flea bites — for bubonic form Transmission (pneumonic form) - Person-to-person via respiratory droplets from infected individuals Incubation 1–3 days for pneumonic plague (short and fulminant)
36
What are the 3 clinical forms of plague?
1. Bubonic plague - Most common; via flea bite → painful buboes (inguinal, axillary) Septicemic plague - Dissemination w/o buboes - sepsis - DIC - purpura (“black death”) 3. Pneumonic plague Primary (inhalation) or secondary (from bacteremia); - fulminant necrotizing pneumonia - most contagious form
37
clinical features of pneumonic plague
High fever/ chills Hemoptysis dyspnea chest pain Rapid deterioration → sepsis, ARDS, shock, DIC
38
How is pneumonic plague diagnosis confirmed?
PCR or DFA testing Confirmatory Others: Gram stain / culture of sputum or blood ---> Gram-negative bipolar (“safety-pin”) coccobacilli
39
What is the immediate ED management for suspected pneumonic plague (yersina pestis) (include isolation/ infx control precautions)
Isolation / Infection Control 1. Droplet precautions immediately 2. Negative-pressure isolation room 3. PPE- N95 mask, gown, gloves, eye protection 4. Notify infection control, public health, and bioterrorism response team 5. Quarantine close contacts and give post-exposure prophylaxis Empiric Antimicrobial Therapy: 1. Gentamicin 5 mg/kg IV daily x 10d 2. Streptomycin 15 mg/kg IM BID (classic therapy, if available) Alternatives: Doxycycline 100 mg IV/PO BID Ciprofloxacin 400 mg IV BID Levofloxacin 750 mg IV daily Duration: 10 days (or until 3 days after afebrile)
40
What is post-exposure prophylaxis for close contacts of pneumonic plague
Doxycycline 100 mg PO BID × 7 days, or Ciprofloxacin 500 mg PO BID × 7 days Close monitoring for 10 days after exposure
41
52 M, large cattle veterinarian, presents with fever, severe headache, and a dry cough for 6 days. T 39.2°C, HR 110, BP 105/65 RR 22, SpO₂ 93% RA. CXR: patchy segmental consolidation in the right lower lobe. LFTs: mildly elevated transaminases. CBC: normal WBC with mild thrombocytopenia. No response to amoxicillin started 3 days ago. Most likely diagnosis? How is diagnosis confirmed?
Coxiella Burnetii - Rickettsial Acute Q fever caused by Coxiella Burnetii - Rickettsial 1. Pneumonia — dry cough, fever, atypical pattern 2. Hepatitis — fever + ↑ LFTs ± hepatomegaly Gold standard Dx: 1. Serology (IFA – indirect immunofluorescence) **4-fold rise in Phase II IgG titers (acute infection) 2. PCR for Coxiella burnetii
42
How is acute Q fever treated?
Doxycycline 100 mg PO/IV BID × 14 days (first-line) Pregnant patients TMP-SMX (alternative) Chronic Q fever (endocarditis) Doxycycline + Hydroxychloroquine for ≥18 months
43
What are the major clinical syndromes of Q fever?
Acute Q fever 1. Pneumonia — dry cough, fever, atypical pattern 2. Hepatitis — fever + ↑ LFTs ± hepatomegaly Chronic Q fever Usually months–years later in immunocompromised or with valvular disease → endocarditis, vascular graft infection, osteomyelitis
44
What is the causative organism and route of transmission of Q fever
Organism - Coxiella burnetii - Gram-negative bacterium Classification Rickettsia-like organism (not true Rickettsia) Reservoirs Sheep, goats, cattle (placenta, amniotic fluid, feces, milk) Transmission Inhalation of contaminated aerosols (birth products, manure, wool)
45
A 32-year-old man from rural Manitoba presents to the ED with fever, myalgia, nausea, and increasing shortness of breath over 3 days. Recent mouse infestation T 38.7°C, HR 120, BP 95/60, RR 30, SpO₂ 88% RA. Exam: ill-appearing, bibasilar crackles, no rash or murmurs. POCUS: normal LV function, B-lines bilaterally, no PCE Most likely diagnosis and causative agent?
Hantavirus Pulmonary Syndrome (HPS) caused by a North American hantavirus (usually Sin Nombre virus) Reservoir: - Rodents, esp. deer mice (Peromyscus maniculatus) in North America Transmission - Inhalation of aerosolized rodent excreta
46
Describe the phases of Hantavirus Pulmonary Syndrome
1. Prodromal (3–5 days) - Fever, chills, myalgia, malaise - GI upset; resembles viral illness 2. Cardiopulmonary (2–7 days) - Cough, dyspnea - pulmonary edema - hypotension - hypoxia 3. Diuretic (recovery) - Diuresis, improving oxygenation 4. Convalescent - Weeks of fatigue and weakness
47
List 4 laboratory findings consistent with hanta virus How id diagnosis confirmed?
1. Thrombocytopenia 2. Hemoconcentration 3. Mild transaminitis 4. Elevated creatinine, BUN 5. ABG: Hypoxemia with respiratory alkalosis early → metabolic acidosis later Confirmatory test: Serum IgM / IgG for hantavirus, or RT-PCR for viral RNA
48
What is the acute management for suspected hanta virus
Supportive Care (mainstay) ABCs **Early intubation and mechanical ventilation (low tidal volume, ARDS strategy) - Judicious fluids, vasopressors for hypotension ECMO (VV or VA) — consider in refractory hypoxia or shock (improves survival) No antiviral proven effective
49
47 F , works at a pet store that sells exotic birds, presents with 10 days of fever, headache, dry cough, and myalgia. T 39.0°C, HR 105, BP 110/70, RR 24, SpO₂ 94% RA. CXR: patchy unilateral lower lobe infiltrate. WBC 4.5 ×10⁹/L mild thrombocytopenia, AST/ALT mildly elevated. Most likely Dx? Tx?
Psittacosis (ornithosis) — pneumonia caused by Chlamydia psittaci. Reservoir Birds: parrots, parakeets, pigeons, poultry (especially psittacine birds) Transmission Inhalation of aerosolized dried feces or secretions from infected birds Treatment: Doxycycline 100 mg PO/IV BID × 10–14 days (first-line) Alternative (pregnant / intolerance) Azithromycin 500 mg x 1, then 250 mg daily × 4 days
50
What laboratory and radiologic findings support the diagnosis of Psittacosis (ornithosis) How is diagnosis confirmed?
Normal or low WBC mild thrombocytopenia Mild transaminitis CXR= Patchy, often unilateral lower lobe infiltrates, may progress to diffuse pneumonia Definitive test: → Serology (microimmunofluorescence or complement fixation) showing 4-fold rise in antibody titer
51
List 4 common pathogens that cause pneumonia in patients presenting from PCH/nursing home
- Pseudomonas aeruginosa - K. pneumonia - Acinetobacter - MRSA
51
List 4 complications of Psittacosis
1. IE 2. myocarditis 3. hepatitis 4. inflammatory arthritis 5. keratoconjunctivitis 6. encephalopathy
52
List 3 common pathogens that cause COPDe
- S. pneumonia - H. flu - Moraxella cattarhalis
53
Common pathogens that cause pneumonia in pts with HIV
- Common bacterial pathogens - P. jiroveci - M. tuberculosis - S. Aureus - MAC - CMV - Cryptococcus neoformans
54
List 3 common pathogens to cause "lobar" pna on CXR
"typicals" - S. Pneumo -H flu - Moraxella
55
List 3 common pathogens to cause "patchy infiltrates" pna on CXR
- chlamydophila -mycoplasma -legionella - fungi
56
List 2 common pathogens to cause "interstitial pattern" pna on CXR
-PJP -Viruses
57
List 6 common infectious causes of cavitating lesion on CXR
1. TB 2. S. Aureus **especially post-influenza 3. Anaerobes (Bacteroides, Fusobacterium) **aspiration 4. Pseudomonas aeruginosa (HAP/VAP) 5. Fungal (Aspergillus, Histoplasma capsulatum, Blastomycosis) 6. Parasitic Echinococcus granulosus (hydatid cyst rupture)
58
DDx Cavitary lesions on CXR 'CAVITY'
Cancer- bronchogenic, mets Autoimmune/ granulomatous - Wegener's, RA Vascular - septic/non-septic emboli Infectious - TB/MRSA/MSSA/Klebsiella, Coccidiomycosis, Cryptococcus, blasto Trauma - pneumatocele Youth - bronchogenic cyst, CPAM (congenital pulmonary airway malformation)
59
Outline the minor (9) and major (2) criteria for severe CAP
Minor: 1. RR > 30 2. PaO2/FiO2 >250 3. Multilobar infiltrates 4. aLOC 5. Uremia (BUN >20) 6. Leukopenia (WBC <4) 7. PLT < 100 8. Hypothermia (T <36) 9. Hypotension Major: 1. Invasive mechanical ventilation 2. Septic shock (need for pressors)
60
Antimicrobial Tx for: a. CAP (immune compromised pt) b. Severe PNA (ICU) c. Presumed PJP
61
CURB-65 Criteria — Pneumonia Severity Assessment
Confusion Uremia (BUN > 7mmol/L) RR > 30 bpm SBP < 90 or DBP< 60 > 65 AGE Interpretation: 30 day mortality increases as increase factors present: 0 = 0.7%= outpatient 2 = 9.2% = consider admission 5 = 57% = admit (>4 ICU)
62
List the components of Pneumonia Severity Index (PSI / PORT Score)
Demographics: - sex - nursing home resident - age Comorbidities: - neoplastic disease - liver disease - CHF - cerebrovascular - renal disease Clinical Exam: - AMS - RR > 30 - SBP < 90 - Temp >40 or <35 - HR > 125 Labs: - pH <7.35 - BUN >30 - Na <130 - Gluc >250 (≥ 14 mmol/L) - hematocrit <30% - PaO2< 60 - pleural effusion Low-risk (I–II): outpatient treatment Moderate-risk (III): consider ED observation / short admission High-risk (IV–V): hospital or ICU admission
63
Describe the SMART-COP Score — Predicting Severe Pneumonia (ICU / IRVS Need)
Systolic BP < 90 (+ 2) Multilobar infiltrates (+1) Albumin < 35 g/L (+1) RR ≥ 25 (+1) Tachycardia ≥ 125 (+1) Confusion (+1) Oxygenation: (+2) PaO₂ < 70 or SpO₂ ≤ 93% (age < 50 yrs) PaO₂ < 60 or SpO₂ ≤ 90% (age ≥ 50 yrs) pH < 7.35 (+2)
64
Berlin criteria for diagnosing ARDS
1. Onset within 7d of known clinical insult or new/worsening respiratory symptoms 2. (new) Bilateral opacities on CXR 3. Not explained by CHF or volume overload 4. Oxygenation (PEEP >5) PaO2/ FiO2 ratio <300 Moderate <200 Severe <100
65
List 8 causes of ARDS
1. Pneumonia (bacterial, viral, aspiration) 2. Aspiration of gastric contents 3. Inhilation injury 4. Pulmonary contusion 5. Near drowning 6. Sepsis 7. Severe trauma or burns 8. Pancreatitis 9. TRALI 10. VALI
66
Ideal VENT setting for ARDS
Goals: SpO₂ 88–95% PaO₂ 55–80 mmHg PaCO2 <100 pH >7.1 Ventilation Low TV (6 mL/kg) Plateau pressure ≤ 30 PEEP 5-10 RR: 12-14 I:E= 1:2
67
Common outpatient antimicrobials for out patient PNA management
68
GOLD Definition — Chronic Obstructive Pulmonary Disease (COPD)
COPD is a common, preventable, and treatable disease characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.”
69
COPD diagnostic criteria
Clinical suspicion: ≥40 years old - chronic cough -sputum or progressive dyspnea - risk exposure (smoking, biomass) **Spirometry (required) - FEV1/FVC after bronchodilators of < 0.7
70
GOLD Spirometric Classification (Airflow Limitation Severity)
71
List 5 common triggers for COPD exacerbation
1. Viral or bacterial respiratory infection (most common) 2. Air pollution or environmental irritants 3. Particulate matter 4. Poor medication adherence or inhaler technique 5. Heart failure or pulmonary embolism
72
GOLD 2025 ABE Grouping Symptom & Exacerbation Assessment
73
Box 60.1 Classification of respiratory failure in COPDe
Acute resp failure: RR >30 WOB + accessory muscle use Mentation @ baseline Hypoxia responsive to FiO2 >35% PaCO2 50-60 + pH >7.25 Severe: aLOC Hypoxia requiring >35% FiO2 PaCO2 > 60 or pH <7.25
74
List 8 DDx for acute COPDe
75
List 4 typical CXR findings in COPDe
1. Hyper inflated lungs 2. Decreased vascular markings 3. Increased AP diameter 4. Flattened diaphrams
76
List 5 common ECG findings in COPD
1. P pulmonale: - large > 2.5mm peaked P waves in II, III, aVF and > 1.5mm in V1/V2 2. Low QRS voltage (hyperinflated lung between chest wall and heart) 3. Poor R. wave progress (< 3mm in V3) 4. RVH 5. RAD
77
Outline the ED management for COPDe
1. Oxygen Target SpO₂ 88–92% Avoid hyperoxia → CO₂ retention 2. Bronchodilators Nebulized salbutamol ± ipratropium 3. Corticosteroids Prednisone 40 mg PO daily × 5 days or methylprednisolone IV 4. Antibiotics Amox-clav, doxycycline, azithromycin x5-7d 5. NIV (BiPAP) pH < 7.35, hypercapnia, respiratory distress 6. Intubation If NIV fails or altered LOC
78
List 3 indications for NIPPV for COPDe
1. Resp acidosis pH 7.25–7.35 and/or PaCO₂ > 45 mmHg 2. Severe dyspnea and RR > 24/min 3. Persistent hypoxia despite supplemental O2
79
List 3 contraindications for NIPPV in COPDe
1. Active emesis 2. Respiratory arrest 3. Facial trauma 4. dLOC (not related to PaCO2)
80
List 6 indications for invasive mechanical ventialtion in COPDe
1. Unable to tolerate NIV 2. NIV failure 3. dLOC 4. cardio respiratory arrest 5. Inability to clear secreations 6. Hemodynamic instability 7. Life threatening hypoxia not corrected by less invasive measures
81
List inital BiPAP setting for COPDe
IPAP: 12-15 mmH2O - Increased q2-3min by 2-3 to max of 25cmH2O EPEP: 5 mmH2O FiO2 titrated to 88-92% IPAP (Inspiratory Positive Airway Pressure): aids ventilation (↑ tidal volume, ↓ CO₂) EPAP (Expiratory Positive Airway Pressure): maintains alveolar recruitment (improves oxygenation, ↓ work of breathing)
82
List initial invasive mechanical ventilation setting for COPDe
Volume assist control RR 10 bpm Tidal volume < 8mL/kg PEEP 0-5 Titration of FiO2 to 88-92% Square inspiratory waveform w/ inspiratory time of 0.8-1second
83
Box 60.3 General guidelines for admission of the patient with COPD
84
GOLD recommendations for starting antibiotics in COPDe
○ Increased sputum purulence AND increased dyspnea or increased sputum volume ○ Requiring invasive or non-invasive ventilation
85
Asthma definition
chronic inflammatory disorder of the airways characterized by: - variable and reversible airflow obstruction - airway hyper- responsiveness - leading to episodic symptoms of impaired breathing
86
Box 89.2 List 6 RF for Asthma-Related Death
Asthma History: 1. HX of near fatal asthma requiring intubation and mechanical ventilation 2. Hospitalization or ED visit for asthma in the past year 3. Current or recent use of oral corticosteroids 4. Not currently using inhaled corticosteroid 5. Over use of SABAs (>1 canister in 1 month) 6. Poor adherence with asthma medications Other: 7. Psycho/social problems 8. Psychiatric disease 9. Food allergy in pt with asthma
87
Box 89.1 List 10 DDx for Wheezing / Asthma Mimics
Upper airway 1. Vocal cord dysfunction 2. laryngeal edema 3. foreign body 4. anaphylaxis 5. Laryngeal neoplasm Lower airway 1. COPD 2. bronchitis 3. aspiration Vascular 1. PE Cardiac 1. CHF 2. valvular disease Other 1. Carcinoid, tracheobronchial tumor 2. hypersensitivity pneumonitis 3. Pneumonia 4. Vaping lung inury 5. GERD 6. Adverse drug reaction
88
List 5 objective findings in asthma assessment
1. HR >120 2. RR >30 3. Accessory muscle use 4. ABG-PaO2 <60 or PaCO2 >42 5. PFTs
89
Describe the pathophysiology of asthma
Airway inflammation (eosinophilic → chronic structural remodeling) Bronchial hyperreactivity → reversible bronchoconstriction Mucus hypersecretion and mucosal edema Triggers: allergens, viral URTI, exercise, cold air, smoke, medications (NSAIDs, β-blockers)
90
List 4 diagnostic tests that can be performed in ED to determine the severity of asthma
1. Peak expiratory flow (L/sec) -measured serially in response to therapy PEF >70 mild PEF 40-69 moderate PEF <40 severe 2. ABG - rising PaCO₂ / acidosis → impending respiratory failure
91
List the components of the clinical severity assessment for asthma in adults
92
Outline the initial ED management for mild-moderate asthma exacerbations (PEF >40%) (medical therapies + dosing)
1. ABCs - Maintain SpO2 >90% 2. β₂-Agonist (SABA) - Salbutamol/Albuterol Nebulized 2.5 mg q 20 min x3 then re-asses MDI (w/ Spacer) 6-12 puffs q20 min x3 3. Ipatropium (SAMA) Nebulized 0.5 mg q 20 min x3 or MDI 8 puffs q 20 min x 3 **combivent q20 min x3** 4. Systemic corticosteroids Prednisone 50 mg po daily or Methylprednisone 125 mg IV x1 then daily
93
Outline the initial ED management for severe asthma exacerbations (PEF <40%) (medical therapies + dosing)
1. ABCs - Maintain SpO2 >90% 2. β₂-Agonist (SABA) - Salbutamol/Albuterol Nebulized 5 mg q 20 min x3 then re-asses or continuous if severe 3. Ipatropium Nebulized 0.5 mg q 20 min x3 or combivent 4. Systemic corticosteroids Methylprednisone 125 mg IV x1 then daily 5. MgSO4 2g IV over 20 min (PEF <25%) 6. Ketamine for intubation +/- infusion for sedation ***Consider IV epinephrine or terbutaline If β₂-agonist refractory Noninvasive ventilation (BiPAP) If pH < 7.35, CO₂ retention, but protecting airway
94
List 4 indications for intubating severe asthma exacerbation
1. Exhaustion or altered LOC 2. Silent chest or poor air entry despite therapy 3. Persistent hypoxemia (PaO₂ < 60 on FiO₂ > 0.6) 4. Rising or severely elevated PaCO₂ with acidosis (pH < 7.25) 5. Cardiac/respiratory arrest 6. Inability to protect airway 7. Failure of NIV
95
Outline a mechanical ventilation strategy for for severe asthma requiring intubation Describe rationale for I:E ratio
1. Tidal Volumes: 6-8 mL/kg 2. Low ventilation rate < 10 breath/min 3. High inspiratory flow rates > 60L/min 4. I:E ration 1:4 Problem is expiratory airflow obstruction → air trapping → auto-PEEP Prevent this by prolonging expiratory time → increase the I:E ratio (longer E phase).
96
List 4 ventilation strategies for prolonging I:E ration for patients with asthma
97
Outline the criteria for admission to hospital vs DC home for patients presenting with mod-severe asthma exacerbation List 5 additional factors with increased likelihood of admission
Discharge -PEF/FEV₁ ≥70% predicted - minimal symptoms - stable 60 min after last SABA - good air entry - SpO₂ >94% on room air Ward admit - PEF 40–69% - persistent wheeze or need for frequent β₂-agonists ICU admit - PEF <40% - CO₂ retention - altered LOC - hypoxemia despite O₂ Additional factors: 1. Female sex, older age 2. >8 SABA puffs in previous 24h 3. Severity of exacerbatoin 4. PHx of intubations or asthma admissions 5. Previous use of OCS
98
List Discharge Medications and Follow-Up
Prednisone 50 mg PO × 5–7 days Inhaled corticosteroid (ICS): start or resume before discharge Short-acting β₂-agonist: PRN with spacer Spacer technique review and education Written asthma action plan Follow-up: within 48–72 h with primary care or respirology
99
List 5 clinical features of EBV pharyngitis/ Infectious Mononucleosis
Caused by Epstein–Barr virus (HHV-4), a B-cell lymphotropic herpesvirus ***Results in lymphoid tissue hyperplasia (tonsils, spleen, liver, nodes). 1. Prodrome triad - fever, tonsillar exudates, posterior cervical LN 2. Splenomegaly 3. Hepatomegaly 4. Palatal petechiae 5. Maculopapular rash **Especially after ampicillin / amoxicillin
100
List 6 Differential Diagnosis of Exudative Pharyngitis
1. EBV 2. CMV monomucleosis 3. GAAS pharyngitis 4. Acute HIV 5. Diptheria 6. Adenovirus
101
How is EBV pharyngitis diagnosed?
Heterophile antibody (Monospot) Positive after 1 week; sensitivity ~85–90% EBV-specific serology Diagnostic if: VCA IgM + / EBNA IgG – = acute infection
102
Outline the management for EBV pharyngitis/ infectious mononucleosis
Supportive - Rest, hydration, antipyretics, analgesia Corticosteroids - Only if airway compromise, massive tonsillar hypertrophy, or hemolytic anemia / thrombocytopenia (e.g. dexamethasone 10 mg IV × 1) Avoid antibiotics - Unless bacterial co-infection proven Avoid contact sports ≥3 weeks due to splenic rupture risk
103
List 5 complications associated w/ EBV pharyngitis
1. Tonsillar hypertrophy → obstruction 2.Autoimmune hemolytic anemia **Coombs-positive 3. Splenic rupture 4. Aseptic meningitis 5. Guillain-Barré 6. encephalitis 7. Mild hepatitis / cholestasis
104
List 5 clinical features of GAS pharyngitis
**Group A β-hemolytic Streptococcus pyogenes ACUTE ONSET 1. Fever 2. severe sore throat 3. ANTERIOR cervical LN 4. Exudative pharyngitis 5. "sand-paper" rash >> scarlete fever
105
List 4 non-suppurative and 4 suppurative complications of GAS pharyngitis
Non-suppurative: 1. Scarlet Fever - blanchable, sand paper rash, Forcheimer spots on palate, strawberry tongue 2. ARF 3. HSP 4. Perimyocarditis 5. Strep TSS 6. Erythema nodosum 7. PSGN Suppurative: 1. AOM 2. Mastoiditis 3. Meningitis 4. Peritonsillar and retropharyngeal abscess 5. Necrotizing fasciitis 6. Hematogenous spread 7. Osteomyelitis 8. Sinusitis 9. Cervical lymphadenitis
106
List the components of the Centor / McIsaac Clinical Scoring System
Age: 3-14 (+1) >45 (+1) Tonsillar exudate (+1) Tender anterior cervical lymphadenopathy (+1) Fever >38°C (+1) Absence of cough (+1)
107
How is diagnosis of GAS pharyngitis confirmed?
Rapid antigen detection test (RADT) Sensitivity 70–90%, Specificity >95% Throat culture (gold standard) Sensitivity 90–95% ~result in 24–48 h
108
Outline the treatment for GAS pharyngitis
Penicillin V 500 mg PO BID 10 days Amoxicillin 500 mg PO BID x 10 days **Antibiotics shorten illness by ~1 day and prevent rheumatic fever if started within 9 days of onset.
109
A 22-M presents with 5 days of sore throat and 3 days of fever, rigors, and right-sided neck pain. seen 3 days ago at WIC diagnosed with viral pharyngitis. Now he has pleuritic chest pain and cough with small-volume hemoptysis. PMHx: Healthy, University student Exam: toxic, T 39.6 °C, HR 110 tender swelling along right sternocleidomastoid Most likely diagnosis?
Lemierre’s syndrome — Fusobacterium necrophorum pharyngitis with septic thrombophlebitis of the internal jugular vein and septic pulmonary emboli. Red Flags for Fusobacterium / Lemierre’s) ✅ Young, previously healthy patient ✅ Severe or prolonged pharyngitis not improving with standard therapy ✅ Toxic appearance with rigors and high fevers ✅ Unilateral neck pain, swelling, tenderness along SCM ✅ Pleuritic chest pain, cough, hemoptysis → septic emboli ✅ Negative rapid strep test or monospot
110
What classic triad defines Lemierre’s syndrome
1. Recent oropharyngeal infection/pharyngitis 2. Internal jugular vein thrombophlebitis 3. Septic emboli, usually to lungs
111
List 3 investigations to confirm the diagnosis of Lemierre’s syndrome
CT neck with IV contrast → IJV thrombosis ± abscess CT chest → multiple peripheral nodules ± cavitation (septic emboli) Blood cultures (anaerobic bottles) → Fusobacterium necrophorum
112
Outline the management for Lemierres syndrome
Antibiotics Ampicillin-sulbactam 3 g IV q6h OR PIP?TAZ 4.5 g IV then 3.375g q6h If penicillin-allergic: Clindamycin 600 mg IV q8h Duration: 3–6 weeks Consult ENT / vascular surgery — drainage of abscess if needed Consider anticoagulation only if thrombus or CNS extension
113
18 M who recently immigrated from Eastern Europe presents with 5 days of sore throat, malaise, and low-grade fever. On exam: - voice muffled and breathing is noisy. Oropharynx has gray-white adherent membrane over the tonsils and soft palate, mild anterior neck swelling (“bull neck”) Most likely diagnosis?
Oropharyngeal diphtheria caused by Corynebacterium diphtheriae. Hallmarks: - Gray adherent pseudomembrane - Bleeds when removed - Bull neck - Low-grade fever (disproportionate to appearance)
114
Outline the immediate ED management for suspected oropharyngeal diphtheria
1. Early airway assessment + controlled intubation — swelling and membrane can cause obstruction. **do not attempt to remove the pseudomembrane (may bleed). 2. Diphtheria antitoxin (DAT) ose: 20,000–100,000 units IV or IM **Horse Serum 3. Antibiotics: x 14 days - Erythromycin 500mg IV QID - PCN G 600 units BID IV then PCN V 250mg PO QID 4. Droplet and contact precautions until 2 negative cultures 24h apart post-therapy. Notify public health — contact tracing and prophylaxis. Vaccinate contacts if not up-to-date (Tdap).
115
List 5 severe complications of Diphtheria
1. Airway obstruction 2. hemorrhage 3. Myocarditis (arrhythmias, heart block) 4. Polyneuritis 5. Renal tubular necrosis 6. Secondary infection 7. Diffuse focal organ necrosis
116
What public health actions are required for Diphtheria exposure ?
Notify public health authority. Culture and prophylax close contacts (erythromycin × 7–10 days). Ensure vaccination (DTaP/Tdap) up to date for all household contacts.
117
45M presents with severe sore throat and halitosis for 3 days. He is a heavy smoker and works as truck driver. Exam reveals gray ulceration of the right tonsil and gingiva, surrounded by erythema. The membrane does not bleed when scraped. He is afebrile but appears uncomfortable. Most likely diagnosis? Causative organism? Tx?
Vincent’s angina ANUG- acute necrotizing ulcerative pharyngitis / gingivitis "trench mouth" Fusobacterium and Borrelia vincentii. Managem,ent: Supportive: saline rinses, analgesia, hydration, improved oral hygiene Antibiotics: - Penicillin V 500 mg PO QID + Metronidazole 500 mg PO TID × 7–10 days, or or -Amoxicillin-clavulanate as monotherapy -Dental / ENT follow-up -CT neck if trismus, swelling, or systemic toxicity
118
List common organisms that cause epiglottis in adults
1. H. Flu type B 2. Strept. pneumoniae 3. Neisseria meningitidis, 4. Staph aureus 5. Klebsiella Immune compromised: - candida - pseudomonas
119
List 5 classic physical exam findings with epiglotitis Gold standard for diagnosis?
1. Toxic and anxious appearance 2. Drooling, dysphagia, odynophagia 3. Tripod posture 4. Stridor or muffled voice 5. Suprasternal retractions Dx: Flexible laryngoscopy is gold standard
120
List 4 radiographic findings on lateral neck XR for epiglotitis
1. Epiglottis width > 5.5mm = thumb sign 2. Thickened aryepiglottic folds 3. Lack of air in vallecula 4. Dilated hypopharynx
121
Outline the management for epiglotitis
Controlled intubation -fibre optic, awake, OR, surgical. 1. Empiric ABX CTX 2 g IV q24h + Vancomycin 2. Dexamethasone 10 mg IV May reduce airway edema 3. Adjuncts - Racemic epinephrine / nebulized epi (esp. children) - Oxygen / heliox
122
What is the most common deep neck space infection in adults
PTA Group A β-hemolytic Streptococcus (Strep pyogenes)**Most common
123
Classic presenting triad for PTA
1. Trismus 2. Uvular deviation 3. Muffled voice.
124
Outline the management for PTA
1. ABCs - early ENT/anesthesia consult for controlled airway 2. Needle aspiration vs I+D of PTA 3. ABX: - Ampicillin-sulbactam 3 g IV q6h, or - Clindamycin 600 mg IV q8h (if penicillin allergic) 4. Dexamethasone 10 mg IV/PO may reduce edema and pain.
125
List 5 admission criteria for PTA
Airway compromise or severe trismus Sepsis or dehydration Failed outpatient management Immunocompromised Bilateral abscesses or extension into deep neck spaces
126
Define "ludwig angina" List 2 common causes/ etiologies
rapidly progressive, bilateral cellulitis of the submandibular space Causes: - Dental infection (2nd / 3rd mandibular molar most common) - Mandibular fracture - Foreign body -sialadenitis - post extraction
127
List 3 clinical features that differentiate Ludwig angina from other pharyngeal infections
1. Trismus 2. “brawny induration” of floor of mouth and submandibular area (not fluctuance) 3. Elevated tongue others: - anterior neck swelling "bulls neck" - muffled hot potatoe voice - stridor - odonophagia - drooling
128
Outline the management for ludwigs angina
1. ABCs Impending obstruction (stridor, inability to handle secretions) Early definitive airway in controlled setting (awake fiberoptic or surgical airway) 2. Antibiotics Ampicillin–sulbactam 3 g IV q6h First-line or Piperacillin–tazobactam 4.5 g IV q6h 3. Steroids 4. ENT consult
129
42-M presents with 5 days of worsening sore throat and neck pain after accidentally swallowing a fish bone. he appears toxic T: 39.2°C, HR 115, and RR 26. He keeps his neck extended and refuses to move it. Oropharyngeal exam: mild posterior pharyngeal fullness, tender anterior cervical lymph nodes, and muffled voice. There is no uvular deviation or trismus.. Most likely diagnosis? Which deep neck space is likely involved?
Retropharyngeal abscess (deep neck space infection). Retropharyngeal space lies between: - Buccopharyngeal fascia (anterior) - Alar fascia (posterior)
130
What imaging study confirms the diagnosis of RPA?
CT neck with IV contrast → reveals rim-enhancing fluid collection in the retropharyngeal space. Suspect of lateral neck XR Widened prevertebral space: * > 7 mm at C2 or > 14 mm at C6 in children * > 22 mm at C6 in adults
131
List 5 RF for RPA in adults
- Immunosuppression - Chronic steroid use - DM - HIV - Tonsillectomy **RPA more common in children.
132
Outline empiric antibiotic therapy for RPA in adults
Ampicillin–sulbactam 3 g IV q6h or Piperacillin–tazobactam 4.5 g IV q6h Add Vancomycin if MRSA suspected
133
List 3 indications for surgical drainage
Abscess > 2 cm on CT Airway compromise No improvement after 24–48 h of IV antibiotics
134
List 4 serious complications of RPA in adults
1. Airway obstruction 2. Mediastinal spread of infection 3. Abscess rupture w/ pus aspiration 4. Involvement of carotid sheath ○ Surrounds carotid artery, IJ, Vagus ○ Can cause: arterial erosion, aneurysm, Lemierre syndrome, palsy of CN IX-XII, mediastinitis
135
Distinguishing Viral vs Bacterial Sinusitis
136
What are three common bacterial pathogens for Acute bacterial rhinosinusitis (ABRS)?
Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis
137
Outline the management for Acute bacterial rhinosinusitis (ABRS)
Supportive: saline irrigation, analgesics, nasal corticosteroid spray. Antibiotics: Amoxicillin–clavulanate 875/125 mg PO BID × 5–7 days. Adjuncts: decongestants (short course), hydration, rest. Return if worsening or orbital symptoms
138
List 3 potentially serious complications of Acute bacterial rhinosinusitis (ABRS)
Orbital cellulitis or abscess (proptosis, vision loss) Cavernous sinus thrombosis (ophthalmoplegia, headache, CN VI palsy) Intracranial extension (meningitis, brain abscess)
139
Mucormycosis
Invasive fungal sinusitis caused by Rhizopus species EXAM clues= Black eschar on nasal turbinates or palate, tender facial swelling, periorbital cellulitis not improving with antibiotics
140
List 5 RF/predisposing factors for mucormycosis
1. Uncontrolled DM 2. Immunocompromised states: hematologic malignancy, stem-cell or solid-organ transplant, neutropenia, corticosteroids 3. Iron overload / deferoxamine therapy 4. Post–COVID-19 or prolonged steroid use 5. Trauma 6. Burns 7. IVDU
141
54-M with poorly controlled DM presents with 3 days of facial pain, nasal congestion, and black nasal discharge. He now has periorbital swelling and decreased vision in the right eye. He appears toxic. T 38.8 °C, HR 112. Exam: right periorbital edema, chemosis, mild ophthalmoplegia, black necrotic lesion on the hard palate, and decreased sensation over the maxilla (CN V2). Most likely diagnosis? Outline management priorities.
Rhino-orbito-cerebral mucormycosis. 1. ABCs 2. Immediate IV liposomal amphotericin B (5–10 mg/kg daily). 3. Urgent ENT and surgical debridement of necrotic tissue. 4. Optimize metabolic status (correct DKA, stop steroids).
142
List 6 complications associated with mucormucosis infx
Cavernous sinus thrombosis Internal carotid artery thrombosis / stroke CNS invasion → abscess, meningitis Facial deformity, blindness Death (mortality 50–80 %)
143
List 4 RF for primary spontaneous pnx
**predisposes apical bleb rupture ○ Marfan syndrome ○ Male sex ○ Smoking/ cannabis/vaping ○ Change in ambient atmospheric pressure
144
List 10 causes of secondary spontaneous pnx
145
British Thoracic Society vs American College of Chest Physicians for measuring pnx
British Thoracic Society define size based measurement of intrapleural distance at level of the hilum: □ Small = < 1cm □ Moderate = 1-2cm □ Large = > 2cm American College of Chest Physicians: measure from apex to the cupola □ Small < 3cm □ Large > 3cm
146
Outline primary pnx management for BTS Approach and ACCP Approach (ie when to observe vs aspirate vs insert CT)
147
When should suction be utilized after CT insertion
- Routine use of suction does not increase the rate at which the lung re-expands or improves patient outcomes --> no longer recommended Use of suction is reserved for situations where lung fails to re-expand after drainage through a water seal device or Heimlich for 24-48 hours
148
List 4 potential complications of large bore CT insertion for pnx
○ Mispositioned tube ○ Pleural space infection ○ Pain at chest tube site ○ Re-expansion pulmonary edema and hypotension are rare
149
List 2 interventions to reduce the rate of recurrence after Recurrent Spontaneous PTX
1. Pleurodesis 2. VATS or open bullae rsxn
150
Outline the discharge criteria for outpatient management of small primary pnx
Avoid air travel until radiographic resolution. Avoid scuba diving indefinitely unless definitive pleurodesis performed.
151
The 6 Ps for pleural effusion etiologies
Pulmonary - Pneumonia - TB - PE - malignancy Pericardial - Pericardial disease - post-cardiac injury Peritoneal - Cirrhosis - pancreatitis Protein (low) - Nephrotic syndrome - Pressure (hydrostatic - CHF Post-traumatic - Hemothorax - chylothorax **Most common cause: heart failure > malignancy > bacterial pneumonia
152
Differentiate between transudtaive from exudative pleural effusions based on pathophysioogy give 3 examples of each
Transudative ↑ hydrostatic pressure or ↓ oncotic pressure Examples: - CHF -cirrhosis (hepatic hydrothorax) - nephrotic syndrome - hypoalbuminemia Exudative ↑ capillary permeability or ↓ lymphatic drainage Examples: - Pneumonia (parapneumonic) - malignancy - PE - TB - pancreatitis - rheumatoid pleuritis
153
List 2 indications and 2 contraindications for diagnostic thoracentesis
Indications: 1. Effusion >10 mm on lateral decubitus film or US 2. Cause unknown, or suspected infection/malignancy. Contraindications: 1. Uncorrected coagulopathy 2. Small/loculated effusion 3. Severe hypoxemia
154
List 2 indications and 2 contraindications for therapeutic thoracentesis
Indications for therapeutic thoracentesis: ○ Massive effusion > 1.5-2L ○ Empyema --> chest tube drainage *pigtail are fine Relative contraindications: ○ Coagulopathy/bleeding disorder ○ History of pleurodesis ○ Chest wall infections
155
Light’s Criteria for Pleural Fluid Analysis
A pleural effusion is exudative if any ONE of the following is true: Pleural / serum protein ratio > 0.5 Pleural / serum LDH ratio > 0.6 Pleural LDH > 2/3 upper limit of normal for serum LDH
156
List 1 etiology for the following pleural fluid findings a. pH < 7.2 b. Glucose < 60 mg/dL c. Cytology d. Amylase ↑ e. Triglycerides > 110 mg/dL
pH < 7.2 - Complicated parapneumonic effusion / empyema Glucose < 60 mg/dL - Infection - rheumatoid - TB - malignancy Cytology - Malignancy Amylase ↑ - Pancreatitis - esophageal rupture Triglycerides > 110 mg/dL - Chylothorax Hematocrit > 50% of blood Hemothorax
157
How to prevent re-expansion pulmonary edema during therapeutic thoracentesis
Remove ≤ 1.5 L at one time to avoid re-expansion pulmonary edema.
158
List 3 indications for tube thoracostomy (pleural effusions)
Empyema / complicated parapneumonic effusion (pH < 7.2, glucose < 60) Hemothorax Massive or recurrent effusions causing respiratory compromise
159
Definition of 'Massive Hemoptysis'
:>100 mL(Rosen's) > 150mL (UTD) or > 1/2 cup of blood loss in any 24 hour periods or bleeding > 100mL/hour, which may result in hemodynamic instability, shock or impaired alveolar gas exchange and has a mortality rate approaching 80%
160
List 10 ddx for hemoptysis
Airway Diasease 1. Bronchitis **Most common cause of mild hemoptysis 2. Bronchiectasis 3. Cystic fibrosis 4. post-infectious 5. Neoplasm 6. Bronchogenic carcinoma 7. Foreign body / trauma 8. Iatrogenic (bronchoscopy, intubation) 9. penetrating injury 10. Inhalation injury 11. tracheitis 12. FUngal infx Parenchymal Disease 1. TB 2. Pneumonia (lung abscess) 3. Fungal 4. Neoplasm Vascular: 1. PE 2. AVM 3. AAA 4. Pulm. HTN 5. Vasculitis (wegners granulomatosis, SLE, goodpastures) Hematologic: 1. Coagulopathy 2. DIC 3. PLT dysfunction Cardiac: 1. IE 2. Congenital heart disease Other: 1. Cociane 2. Procedural injury 3. TE fistula
161
Box 20.2 list 3 critical and 3 emergent diagnoses in patients presenting with hemoptysis
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