Pulm 3

Front 1

What is defn of acute resp failure? (gen defn and the criteria (x2))

Back 1

i)Gen: happens when there is inadequate O2 of blood or inadeq ventilation (lose CO2)or both. ii)a)hypoxia: PaO2<60mmHg and PaCO2 >50mmHg. b)hypercapnia: PCO2>50mmHg

Front 2

What structures are necessary for maintaining normal respiration? x6 what are 2 causes for each?

Back 2

i)CNS depression or insult: drugs, stroke ii)neuromuscular dz: MG, ALS iii)upper airway: obstruction; paralysis. iv)thorax and pleura: mechanical restriction->kyphoscoliosis, hemothorax. v)CV/blood: a)CHF, b)valve dz, c)PE, d)anemia vi)lower airways/alveoli: a)asthma, b)COPD, c)ARDS

Front 3

What are the 3 info you need for mech of hypoxemia?

Back 3

i)PaCO2 level ii)Aa gradient iii)response to supplemental O2

Front 4

What are the 2 types of acute respiratory failure? What are their causes? What are the pathophys of each?

Back 4

i)hypoxemic respiratory failure: a)low PaO2 w/PaCO2 low or normal (O2 sat <90%). b)cause: dz process of lung (ARDS, severe pneumonia, edema). c)VQ mismatch; shunt. ii)Hypercarbic (ventilatory) respiratory failure (failure of alveolar ventilation). a)decr in minute ventilation or incr in dead space->CO2 retention and get hypoxemia. b)cause: lung dz (COPD, asthma, bronchitis). c)or NM dz, resp fatigue (hypervent in DKA)

Front 5

What does hypoxemia lead to? What does hypercapnia (and resp acidosis) lead to?

Back 5

i)irrevers damage to organs (esp CNS and CV system). ii)leads to dyspnea and vasodilation of cerebral vessels: incr ICP, H/A, papilledema, coma

Front 6

How is ventilation monitored? How is oxygenation monitored? How are each changed?

Back 6

i)ventilation: by PaCO2, and to decr PaCO2, need to incr RR or incr TV (minute vent=RRxVT. ii)Oxygenation: by O2 sat and PaO2: decr PaO2 by decr FIO2 or PEEP. Ventilation and oxygenation are unrelated

Front 7

What is pathophysiology of VQ mismatch (What are the blood gases)? What are causes? How is it diff from shunt?

Back 7

i)Leads to hypoxia w/o hypercapnia. ii)chronic lung d/o iii)responsive to supplemental O2 whereas shunt isn't

Front 8

What is pathophysio of shunt? What are causes x3?

Back 8

i)Little ventilation in perfused areas (b/c collapsed or fluid filled alveoli)->venous blood shunted to arterial side w/o O2. ii)a)atelectasis b)fluid build up: pnemonia or edema c)congenital dz causing rt to left flow

Front 9

What ABG does hypoventilation lead to? Diffusion impairment? What are causes of hypercapnic respiratory failure? x3

Back 9

i)hypercapnia w/2ndary hypoxemia. ii)hypoxemia w/o hypercapnia. iii)sepsis, DKA, hyperthermia

Front 10

What is the main sx of resp failure? What are 4 signs?

Back 10

i)dyspnea ii)a)can't talk in full sentence, use accessory muscles of resp. b)tachypnea, tachycardia c)cyanosis d)impaired mentation

Front 11

What are 2 types of Noninvasive pos pressure ventilation-NPPV? What is diff? What is the indication of NPPV? Who does it work best in? What must be intact to use it--if not, then use what

Back 11

i)CPAP vs BIPAP. BIPAP has diff insp and expir pressures. ii)pt in impending resp failure to avoid intubation and mech ventilation. iii)hypercarbic resp failure (esp COPD). iv)a)neuro intact b)awake and cooperative c)can protect airway. v)intubate and mechanical ventilation

Front 12

How to DX respir failure? x4 What are mech for differential?

Back 12

i)ABGs: a)hypoxemia=VQ mismatch, shunt, hypoventilation. b)hypercapnia: hypoventilation c)pH: Resp acidosis w/hypercapnia, unless chronic b/c have compensation. ii)CXR or CT iii)CBC and metabolic iv)if cardiogenic edema: get cardiac enzymes

Front 13

How to evaluate pt w/hypoxemia?

Back 13

1st: elevated or non elevated PaCO2? i)nonelevated: A-a grad->if not, then low FIO2; if elev: give O2 and if not better, then shunt (vs VQ mismatch). ii)if elevated: hypoventilation->if Aa grad incr, then another mech is also present like shunt or VQ.

Front 14

How to treat resp failure? x4

Back 14

i)treat underlying d/o (bronchodilate, steroids, Abx, etc). ii)Give O2: a)hypoxemic failure->lowest [O2] b/c of possible O2 tox w/radicals. b)hypercarbic: give some O2, tho hx says hypoxia drives breathing, so that the pt can get worse (esp COPD). iii)NPPV:conscious pts who can breath iv)may need intubation and ventilation w/resp failure

Front 15

What is ARDS? what is the primary mechanism? Is it a primary dz?

Back 15

i)diffuse inflamm process (not only infectious) involving both lungs. ii)neutrophil activation in systemic or pulmonary circulations. iii)2ndary to other conditions causing widespread inflamm process.

Front 16

What is pathophysiology of ARDS? x4. What kinds of PFT is seen?

Back 16

i)*Widespread shunting of blood w/no improvement w/100% O2. Due to atelectasis, collapse of alveoli, surfactant dysfcn. ii)Interstitial edema and alveolar collapse due to incr lung fluid->stiff lungs, incr Aa grad, ineff gas xchange (same effects as cardiogenic pulm edema, but diff cause: cardio is b/c of HSP, whereas ARDS is incr cap permeability). iii)decr pulm compliance: incr WoB. iv)incr dead space: b/c of obstruction and destroyed pulm cap bed. v)Low VC, Low FRC

Front 17

What are causes of ARDS? x5

Back 17

i)sepsis* (pneum, urosepsis, wound infect). ii)aspiration iii)trauma iv)pancreatitis v)intracranial HTN

Front 18

What are clinical features of ARDS? x3

Back 18

i)incr WoB: dyspnea, tachycard, tachypnea. ii)progressive hypoxemia: not helped by O2 iii)pt diff to ventilate b/c of high peak airway pressures b/c stiff, noncompliant lungs

Front 19

What are 3 dx modalities of ARDDS? What do they show?

Back 19

i)CXR: diffuse b/l pulm infiltrates: diuresis improves and vol o/l worsens CXR, but CXR doesn't say if ARDS has improved. ii)ABG: PaO2<60; initial resp alkalosis PaCO2<40, but becomes acidotic. If septic, then may have met acidosis iii)PCWP: indir IV vol status->differentiates from cardiogenic (PCWP <18)

Front 20

How to treat ARDS?x5

Back 20

i)give O2; sat>90% ii)mech ventilate w/PEEP: opens alveoli and decr shunt iii)fluid manage: low IV vol (PCWP 12-15) but if septic, need more fluid. iv)tube feed nutrition v)treat the cause

Front 21

What are complications of ARDS? x3

Back 21

i)permanent lung injury: honeycomb lung or scarred. ii)mech ventilation: barotrauma due to hi press mech ventilation->pneumothorax or pneumomediastinum iii)nosocomial pneumonia b/c of ventilation. iv)line ass'd infections: central lines and pulm A catheters(line sepsis), urinary catheter (uti), nasal tube (sinus infection)

Front 22

What are goals in mechanical ventilation? x2

Back 22

i)maintain alveolar ventilation ii)correct hypoxemia

Front 23

What are reasons for mech ventilation? x5

Back 23

i)impaired or reduced level of consciousness w/inability to protect airway (absent gag or cough reflexes) ii)metabolic acidosis (can't hyperventilate). iii)resp muscle fatigue iv)significant hypoxemia (<70mmHg) or hypercapnia (PaCO2>50). v)resp acidosis (pH<7.2) w/hypercapnia

Front 24

What is used for assessing response to mech vent? What are acceptable values for gas x2 and pH?

Back 24

i)ABGs ii)O2 50-60; iii)CO2 40-50 iv)pH 7.35--7.50

Front 25

What is goal in mech vent? What should initial settings do?

Back 25

i)a)reduce likelihood of barotrauma (high static airway pressure, overinflation) b)atelectasis due to low static pressures and underinflation). ii)rest the resp muscles

Front 26

How do you check correct endotracheal tube placement? On CXR?

Back 26

i)a)b/l breath sounds b)check postintubation CXR ii)tip of ET tube 3-5 cm above carina

Front 27

What are the 4 kinds of ventilator settings?

Back 27

i)Assisted controlled ventilation(resp failure): pt can go over determined rate but not over, and every breath over delivers predetermined tidal vol. ii)SIMV(failure and weaning): breath over the determined rate but the TV not determined; if not breathing, the ventilator gives predetermined breath. iii)CPAP(wean): Pos pressure delivered continously but pt breaths on own. Used to assess if pt can breath on own. Use PEEP or pressure support iv)PressSupportVent (wean): pressure delivered in response to initiated breath to enhance resp efforts. Can add PEEP

Front 28

What are key parameters in mech vent? x4

Back 28

i)Minute vent (RRxTV): adjust to achieve baseline PCO2. Lower TV for COPD and ARDS. 10-12 br/min is good. ii)FIO2: start at 100% and titrate down when PO2 is >60 or O2sat 90%; If FIO2 .5 can't give good PO2, then add PEEP or CPAP (supports PO2 at lower FIO2). iii)Insp:Exp ratio: if incr time in insp, then decr time in exp (1:2 is good ratio). iv)PEEP: pos press maintained at end of passive exhalation to keep alveoli open. Used in ARDS

Front 29

What are adv to PEEP? x3 What are disadv?x2

Back 29

A)i)incr lung compliance and oxygenation: improves gas xchange. ii)prevents alv collapse and atelectasis B)i)barotrauma->pneumothorax. ii)low CO b/c decr venous return, esp if hypovolemic. This is b/c PEEP (like any pos intrathoracic pressure) lowers venous return and incr Pulm VR.

Front 30

What is diff b/w CPAP and PEEP? How are they same?

Back 30

i)CPAP is pos pressure during spontaneous breathing; PEEP is pos press during mech vent. ii)both incr PaO2 at constant FIO2 (lowers intrapulm shunt and VQ mismatch)

Front 31

What are complications of mech vent? x5

Back 31

i)anxiety and discomfort: need Benzos for sedation; opioids for analgesia. ii)tracheal secretions: need suction iii)hypotension: incr intrathoracic pressures->decr venous return iv)tracheomalacia: softened tracheal cartilage. v)GI effects: ulcers and cholestasis v)ET doesn't prevent aspiration

Front 32

What is defn of Pulm htn?

Back 32

i)pulm arterial pressure >25 mmHg at rest or 30 mmHg during exercise

Front 33

What are the 6 pathophysiologic of pulm HTN causes? 2 exs of each?

Back 33

i)passive type: resistance to pulm venous drainage (no dz in pulm vasc bed): MS, LVF. ii)hyperkinetic type: high pulm blood flow (L-R cardiac shunts). VSD, ASD. iii)obstructive type: resistance to flow thru large pulm A's->PE, stenosis of pulm A. iv)obliterative type: resistance to flow thru small pulm vessels (arterioles) due to some parenchymal inflamm leading to fibrosis; PPH, Coll Vasc Dz. v)vasoconstrictive type: resistance to flow due to hypoxia induced vasoconstriction; chronic hypoxemia causes, COPD. vi)increased intrathoracic pressure: mech vent w/PEEP, COPD. vii)increased blood viscosity: P vera

Front 34

What are 2 causes of pulm HTN? 2 exs of each

Back 34

i)postcapillary causes: incr left side of heart->incr pulm venous pressure. MS, LV dysfcn. ii)mixed cap and precap causes: dz of lung parenchyma or pulm vessels (all obstructive and parenchymal dz). COPD, ILD

Front 35

What are symptoms of pulm HTN x3? What are signs? x3

Back 35

i)dyspnea on exertion; chest pain, exertional syncope ii)signs: a)loud P2 b) sternal Lift (RV dilation) c)RVF signs

Front 36

How to DX pulm HTN? x2

Back 36

i)EKG: RVH->rt axis deviation and rt atrial abnl ii)echo: dilated pulm A; abnl movement of IV septum (b/c incr rt ventricular vol); rt heart cath=incr pulm A pressure

Front 37

How does PPH occur? What is PX?

Back 37

i)vicious cycle: get abnl incr in resistance of pulm arterioles->thickens pulm arterioles->incr pulm HTN->incr resistance etc. ii)poor; mostly women

Front 38

How to dx PPH (4)? What is best test?

Back 38

i)cardiac cath is best ii)CXR: large central PA; enlarged RV; clear lung fields. iii)PFTs=restrictive iv)EKG: rt axis deviation and RVH

Front 39

How to treat PPH? x3

Back 39

i)1st do vasodilator trial: inhaled NO, IV adenosine or oral CCBii)pulm vasodilaters: IV prostacyclin; CCBs. iii)warfarin w/INR around 2 iv)lung xplant

Front 40

What is Cor pulmonale? What are 4 causes?

Back 40

i)rt sided LVH 2ndary to HTN (RVH 2ndary to pulm htn). Not due to causes of pulm HTN 2ndary to L sided dz. ii)a)COPD* b)recurrent PE c)ILD d)asthma

Front 41

What are clinical features of cor pulm? x4

Back 41

i)cyanosis and digital clubbing ii)parasternal lift iii)RVH iv)polycythemia if COPD is cause

Front 42

How to DX cor pulm? x3

Back 42

i)CXR: enlarged RA, RV, pulm A's. ii)EKG: rt axis deviation and RVH; "P pulmonale" (peaked P waves). iii)echo: RV dilated w/nl LV size and fcn (to exclude LV cause)

Front 43

How to treat cor pulm? x3

Back 43

i)treat underlying d/o* ii)diuretics cautiously b/c pts might be preload dependent iii)apply O2 longterm if pt hypoxic

Front 44

What are other sources of emboli to lungs besides thrombus? x5

Back 44

i)fat embolism (bone) ii)amniotic fluid embolism: during or after deliver iii)air embolism: trauma to thorax; indwelling lines. iv)septic embolism (IVDU) v)schistosomiasis

Front 45

What are 5 risk factors for DVT/PE?

Back 45

i)malignancy ii)hypercoag states iii)CHF iv)nephrotic syndrome v)trauma or SX

Front 46

Where do most PE's originate from (where is DVT)? x3

Back 46

i)iliofemoral (thromboses in deep veins of lower ext above knee ii)deep veins of pelvis iii)calf veins don't, but can move proximal

Front 47

What is pathophys of PE? x2

Back 47

i)emboli block some of pulm vasculature->incr pulm A p; PVR; RVP. If large, can get cor pulm. ii)Get incr dead space w/ventilation but no perfusion->hypoxemia and hypercarbia cause tachypnea and tachycardia; if large->SOB.

Front 48

When can make DX on clinical findings of PE?

Back 48

i)signs and sxs aren't reliable, but if some Sxs of PE w/DVT, can make dx.

Front 49

What are the sxs of PE? x3 Signs? x3

Back 49

i)a)Dyspnea b)pleuritic CP c)cough ii)a)tachypnea b)rales c)tachycardia. 1/3 of PE pts have signs and sxs of DVT

Front 50

What is gold std to DX PE? Other 4 tests that are good? What are they good for?

Back 50

i)pulm angiography: definitive dx or exclusion but invasive: last resort if serious case (unstable, risk of anticoag high, other test not good). ii)Spiral CT: best noninvasive test; C/I w/RF b/c of contrast. Good for small clots but not for peripheral. iii)VQ scan: if spiral is C/I; good sensitivity and treat w/Heparin. If intermediate result and high clinical suspicion, pulm angio. iv)D dimer: Sn; if normal results w/low suspicion, then PE is unlikely

Front 51

What tests tell you that you can you treat PE w/anticoag? x3. What tests r/o PE x3?

Back 51

i)a)intraluminal filling defects on helical CT+suspicion b)DVT dx'd w/U/S+suspicion. c)pos pulm angiogram: proves PE. ii)a)low probability VQ scan+low suspicion b)Neg pulm angiogram (definite). c)Neg D dimer+low suspicion

Front 52

What is TX for PE? x5

Back 52

i)O2 for hypoxemia ii)Heparin immediately if suspicious->1.5-2.5 aPTT; C/I: active bleeding, uncontrolled HTN, recent stroke, HIT. iii)Warfarin to INR 2-3 x3-6 mths. (lifelong if hypercoag state or malignancy). iv)thrombolytics: a)massive PE who are unstable b)evidence of RHF (they reverse it). v)IVC filter: if C/I anticoag; current complication w/anticoag; pt w/low pulm reserve who may die

Front 53

What are 3 causes of pulm aspiration and which lung does it go to?

Back 53

i)a)acidic gastric contents: damaging to lungs b)aspiration of oropharyngeal flora c)FB/fluid aspiration. ii)rt lung b/c of more straight (lower segments of upper lobe and upper seg of lower lobe)

Front 54

What are 2 causes of pulm aspiration?

Back 54

i)GERD ii)Neuromuscular dz

Front 55

What is presentation of pulm aspiration?x3

Back 55

i)may develop acute resp distress w/no apparent cause or later develops resp dysfcn: cough, SOB, fever, tachypnea, frothy sputum. ii)obstruction w/wheezing iii)+/- fever

Front 56

How to DX pulm aspiration? WHat is seen?

Back 56

CXR: infiltrates like pneumonia. atelectasis and local areas of collapse may be present

Front 57

What is TX of pulm aspiration?

Back 57

i)If see aspiration: a)ABCs b)O2 c)supportive ii)if aspiration pneumonia suspected, give ABx (don't give prophylactically if aspirate) iii)prevention: keep head elevated, NG tube to decompress stomach

Front 58

What are 5 most common causes of acute dyspnea?

Back 58

i)CHF ii)pneumonia iii)bronchospasm iv)PE v)anxiety

Front 59

What kinds of test if dyspnea? x10

Back 59

i)Hx/PE w/VS. ii)pulse oximetry iii)ABG: a)If O2 sat low on pulsimetry b)hypercarbia suspected c)evaluate for acid base abnl iv)CXR: pneumothorax, effusion, infiltrates for ILD/pneumonia v)CBC: anemia, infection vi)EKG: IHD or ventricular hypertrophy vii)echo: evaluate CHF or valves viii)PFTs: if above are nl or ostructive lung dz suspect ix)VQ and spiral CT for PE x)FB aspiration=bronchoscope

Front 60

How to treat dyspnea? x2

Back 60

i)underlying cause ii)mech vent for indications

Front 61

What is DDX for hemoptysis? x7

Back 61

i)*bronchitis ii)lung CA iii)TB iv)bronchiectasis v)pneumonia vi)Good pastures vii)PE w/pulm infarct

Front 62

How to DX hemoptysis on hx and PE?

Back 62

i)r/o trauma to mouth or hematemesis ii)fever, night sweats, wt loss=TB iii)fever, chills, h/o HIV: pneumonia or TB iv)risk factors for PE v)ARF or hematuria=goodpastures

Front 63

What are DX studies for hemoptysis x3

Back 63

i)CXR: indicates pathogenesis: opacity b/c of pulm infarct; granuloma, irreg mass. Does not exclude CA or PE. ii)fiberoptic bronchoscopy: used even if CXR normal if suspect CA. Or can localize site of bleeding. iii)CT chest: complement to bronchoscopy or substitute if C/I to bronchoscopy

Front 64

How to treat hemoptysis x3?

Back 64

i)treat underlying cause ii)suppress cough if aggravates hemoptysis iii)correct bleeding diathesis (but anticoag is tx for PE)