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175 Cards in this Set
- Front
- Back
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What are the essentials of diagnosis for Hemothorax?
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decreased breath sounds, dullness to percussion on affected side, respiratory distress and hypotension
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What are the general considerations for a patient with a Hemothorax?
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injury to the chest wall, great vessels, or lungs
most commonly secondary to penetrating injury disrupting pulmonary or systemic blood vessels in great vessel injury, 50% die immediately, 25% will live 5-10 min, and 25% will live 30 mins or longer effect on respirations depends on blood loss affected lung becomes collapsed |
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What are the physical findings of a patient with a Hemothorax?
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respiratory distress, tachypnea, variable degrees of hypoxia
dullness to percussion, decreased breath sounds, on affected side hypotension and flattened neck veins depending on the degree of blood loss. pulse pressure narrowing smaller hemothoraces may be difficult to detect in supine patients |
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What lab/imaging findings would you see with a patient with a Hemothorax?
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diagnois is confirmed by chest x-ray. volumes of blood as low as 200-300 mL may be seen on upright x-ray
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What is the treatment for a Hemothorax?
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ensure patient has an intact airway
O2 to correct hypoxia provide suctioning and intubation if necessary tube thoracostomy with a 36 or 40 french chest tube |
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What are the complications of a Hemothorax?
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hypovelemia due to blood loss
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What is the disposition for a Hemothorax?
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MEDEVAC
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What are the essentials of diagnosis for Pneumothorax?
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absent or decresed breath sounds, Hyperresonance to percussion
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What is the difference between primary pneumothorax and secondary pneumothorax?
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Primary pneumothorax occurs without clinically apparent lung disease (Typically young, tall, men age 20-40)
Secondary pneumothorax occurs as a complication of a preexisting underlying pulmonary disease (COPD, pneumonia, CF, asthma, TB, pneumocystis carinii pneumonia infection) |
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What are the classifications of Pneumothorax?
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spontaneous (primary or secondary)
traumatic (chest trauma or iatrogenic) |
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What is the most common cause of a Pneumothorax?
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Traumatic pneumothorax
must always be considered in trauma patients consider some invasive procedures (subclavian line placement, thoracentesis, lung or pleural biopsies, barotrauma from positive pressure ventilation) |
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What are the physical findings of a Pneumothorax?
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Pleuritic chest pain, tachypnea, tachycardia
Chest pain ranging from minimal to severe and dyspnea occur in almost all patients Small pneumothorax physical findings may be minimal Larger pneumothorax: dimminished breath sounds, decreased tactile fremitus, decreased chest movement, hyperresonance on affected side |
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What are the lab/imaging findings of a pneumothorax?
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Chest x-ray will reveal most pneumothoraces
Arterial blood gas can assist with assessment of repiratory insufficiency but is not necessary |
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What is the treatment for a patient with Pneumothorax?
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ensure airway is intact
provide suctioning and intubation if necessary many small pneumothoraces resolve spontaneously as air is absorbed from the pleural space supplemental O2 may increase rate of reabsorption treat symmptomatically for cough and chest pain |
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What is the criteria for and what are you rechecking during treatment of a stable patient with Pneumothorax?
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Vital Signs: Respirations less than 24/min, Heart rate 60-120/min, BP normal, O2 sat more than 90%
Able to speak in sentences Obtain chest x-ray in 3-6 hours and compare with arrival chest x-ray. |
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What is necessary for a large pneumothoraces or an unstable patient?
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Re expansion of the lungs.
Large bore chest tube with water seal drainage and suction may be necessary for secondary, tension, severe symptoms, or pneumothorax on mechanical ventilation Placement of a small bore chest tube attached to a Heimlich valve may permit observation from home with close f/u |
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What is the disposition for a patient with Pneumothorax?
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MEDEVAC
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What are the complications of a Pneumothorax?
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Tension pneumothorax
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During pt education,what should you tell a patient with a hx of Pneumothorax to avoid?
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non pressurized aircraft
altitude SCUBA should refrain from smoking risk of recurrence is 50% |
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What are the essentials of diagnosis for Tension Pneumothorax?
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Tracheal deviation away from the pneumothorax with respiratory distress and hypotension
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What are the general considerations for a patient with Tension Pneumothorax?
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developes when a one way valve air leak occurs from either the lung or the chest wall
Air enters the pleural space but cannot escape increased intrapleural pressure collasped lung shift of the mediastinal contents to the opposite side |
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What are the physical findings of a Tension Pneumothorax?
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Respiratory distress, tachypnea, tachycardia
Hyperresonance to percussion decreased or absent breath sounds on auscultation Trachea may be deviated away from the affected side Neck veins may be distended except in the hypovolemic patient |
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What are the lab/imaging findings of a Tension Pneumothorax?
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Diagnosis is clinical.
Do not delay immediate treatment waiting to obtain x-ray! |
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What is the treatment for a patient with a Tension Pneumothorax?
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Ensure airway is intact
Use O2 to correct hypoxia (2 -15 lpm based on O2 saturation), use caution in long term use with chronic COPD/Emphysema Provide suctioning and intubation if necessary Immediatie needle thoracostomy: 16g or larger catheter inserted at the second intercostal space at the midclavicular line |
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During pt education, what should you alert a patient about that has a hx of Tension Pneumothorax?
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discontinue smoking
future exposure to high altitudes flying non-pressurized aircraft SCUBA diving Risk of recurrence is 50% |
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What is the disposition for a patient with Tension Pneumothorax?
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MEDEVAC
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What are the complications of a Tension Pneumothorax?
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Pneumomediastinum
Subcutaneous emphysema Also consider rupture of esophagus or bronchus |
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What percentage of all trauma deaths are directly attributable to chest trauma?
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20-25%
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What are the general considerations for a patient with a Flail Chest?
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Occurs when a segment of the chest does not have bony contiguity with the rest of the thoracic cage
Usually a significant blunt force is required (MVA or Fall from height) Negative intrathorcic pressure is gernerated on inspiration, the flail segment moves inward, thus reducing tidal volume The major problem is respiratory failure due to the underlying pulomary injury |
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What are the physical findings of a patient that has a flail chest?
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pain and respiration (major symptoms)
Tachypnea with shallow respirations paradoxical chest wall movement may not be seen in a conscious patient due to splinting of the chest wall crepitus is often present patient may be able to compensate initially for the reduced tidal volume by hyperventilating when fatigue or underlying pulmonary injurydevelops, frank respiratory failure may supervene |
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What are the lab/imaging findings for a patient with a flail chest?
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non contributory , diagnosis made based on history and physical exam
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What is the treatment for a patient with a flail chest?
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supplemental O2 is the first line tx (used to correct hypoxia, caution in longterm use with chronic COPD/ Emphysema)
pain control w/ IV morphine or fentanyl should be instituted early Consider early intubation and mechanical ventilation (50% will need early intubation) External chest wall supports (taping, sandbags) not indicated (may reduce pain but will also reduce vital capacity) |
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What is the disposition of a patient with a flail chest?
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MEDEVAC
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What are the general considerations for a pulmonary contusion?
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injuries to the lung parencyhma with hemorrhage and edema without associated laceration
most frequently intrathoracic injuries in nonpenetrating chest trauma occurs in approximately 30-75% of patients with significant blunt chest trauma typically occur at the site of impact often associated with other thoracic injuries such as rib fractures and flail chest, although may occur alone a risk factor for the development of acute respiratory distress syndrome and long-term disability |
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What is the most common complication of a pulmonary contusion?
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Pneumonia
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What are the physical findings for a Pulmonary Contusion?
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often silent during the initial trauma evaluation
significant traumatic mechanism and presence of other associated thoracic and extrathoracic injuries should raise suspicion most important sign is hypoxia (the degree of hypoxemia is relatied to the size of the contusion) large contusions will lead to significant respiratory distress dyspnea, hemoptysis, tachycardia evidence of a chest injury: palpable rib fractures, chest wall bruising, decreased breath sounds, crakles on auscultation |
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What are the lab/ imaging findings of a Pulmonary Contusion?
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chest x-rays may range from patchy interstitial infiltrates to complete lobar opacification
chest x-ray will initially miss a substanial number of contusions as a result of ongoing hemorrhage and edema, contusions will appear on x-rays within 6 hours of injury thoracic CT may provide additional useful information |
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What is the treatment for a patient with a Pulmonary Contusion?
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Use caution with IV fluids
O2 (used to correct hypoxia, use caution with long term use with chronic COPD/ Emphysema patients) chest physiotherapy if severe, use mechanical ventilation with positive end-expiratory pressure |
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What is the disposition for a patient with a Pulmonary Contusion?
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MEDEVAC
Should be admitted for monitoring and respiratory support |
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What are the general considerations for a Diaphragmatic Hernia?
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have been reported in 1-5% of patient sustaining blunt trauma or abdominal trauma
direct violation of the diaphragm significant intra-abdominal or intrathoracic pressure applied to the diaphragm resulting in rupture right side is 3 times less likely to be affected than the left due to it being well protected by the liver up to 50% are missed during initial trauma evaluation delayed presentation may not be significant until the abdominal contents through the diaphragm result in: obstruction, incarceration, strangulation, perforation, death. tear will not heal spontaneously can show signs up to 50 years past after primary traumatic event. |
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What are the physical findings for a patient with a diaphragmatic hernias?
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may be asymptomatic, particularly in the acute phase, or may present with symptoms of bowel obstruction
since early diagnosis is difficult to establish, delayed presentation is common with nonspecific respiratory or bowel complaints |
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What are the lab/imaging findings for a patient with a diaphragmatic hernias?
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Chest x-ray is a valuable screening tool
50% of initial x-rays will be interpreted as normal but will be abnormal in almost 100% of delayed presentations |
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Findings on an upright chest x-ray suggestive of a diaphragmatic rupture include what?
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Elevation or irregularity of the diaphragmatic border
Unilateral pleural thickening Obvious herniation of abdominal contents into the chest cavity Presence of a nasogastric tube in the chest cavity |
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What is the treatment for a patient with a diaphragmatic hernias?
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Find and treat penetrating and blunt trauma
Surgical reduction of the hernia and repair of the diaphragm in all patients Care should taken to avoid abdominal injury when placing a chest tube in patients with concomitant hemothorax and pneumothorax |
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What is the disposition for a patient with a diaphragmatic hernia?
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MEDEVAC
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What are the general considerations for Tracheobronchial Injury?
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Injury to the trachea or bronchus as a result blunt trauma is uncommon but can be quite severe
Approximately 80% of patients will die before they reach a hospital usually the result of a MVA and crush injuries right-sided bronchial injuries occur more commonly and are typically more severe, almost 80% occur within 2 cm of the carina diagnosis is missed in at least 25% of patients during initial evaluation |
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What are the physical findings of a patient with a Tracheobronchial injury?
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Most common clinical signs and symptoms: dyspnea, subcutaneous emphysema of neck and upper thoracic region, hoarseness, hemoptysis, hypoxia, persistant pneumothorax dispite tube thoracostomy
Failure to recognize during initial eval is common May be comfortable on room air or may present in acute respiratory distress |
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What are the lab/imaging findings for a patient with a Tracheobronchial injury?
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Chest x-ray findings indicative of injury: subcutaneous emphysema, pneumomediastinum, pneumothorax, peribronchial air
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What is the treatment for a patient with a Tracheobronchial injury?
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If they are in respiratory distress should be endotracheal intubated (preferably with a bronchoscope)
Stable patients should undergo a bronchoscope immediately to evaluate and locate injury. Operate to repair cricothyroidotomy if needed |
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What is the disposition for a patient with a Tracheobronchial injury?
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MEDEVAC
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What are the general considerations for a rib fracture?
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Most common injury sustained in blunt thoracic trauma
Usually sustainted in MVA Fractures to the first rib usually indicated severe trauma |
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What are the physical findings of a patient with a rib fracture?
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Cause localized pain, crepitus, pain with inspiration, and dyspnea
Can cause pneumothorax or hemothorax Mortality rate increases with the numer of ribs involved Pain may lead to hypoventiliation, atelectasis, retained secretion and pneumonia |
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What are the lab/ imaging findings for a rib fracture?
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Chest x-ray is the screening tool of choice, although 50% cannot be detected
X-ray is usually done to identify complications May also be identified by specific rib x-rays and CT scan |
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What is the treatment for a rib fracture?
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Rapid mobilization, respiratory support, and pain management
Continuous body positioning and oscilliation therapy prevent hypoventiliation and atelectasis For respiratory failure, mechanical ventilation allows for healing of the ribs and prevention of complications For stable patient, incentive spirometry is excellent support therapy Pain control is paramount |
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What is the disposition of a patient with a rib fracture?
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for Young, healthy patients with no other serious underlying injury do not need hospitalization, Pain medication, deep breathing exercises, and incentive spirometry are all that is needed
Hospitalization should be considered for the elderly and those with a serious underlying lung disease |
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What is the general considerations for Traumatic Asphyxia?
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Servere crush injury of the thorax or abdomen can cause retrograde flow of blood from the right heart to the great veins of the head and neck
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What are the physical findings of a patient with traumatic asphyxia?
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Purplish-bluish color of the face and neck
Subconjuntival and retinal hemorrhages are common Intracerebral bleeds are uncommon but loss of consciousness or neurologic abnormalities can be caused by cerebral hypoxia Clinical significance is the possibility of intrthoracic injuries associated with the severe curshing force |
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What is the treatment for a patient with traumatic asphyxia?
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No specific therapy except O2
Other injuries should be treated appropriately |
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What is the disposition of a patient with traumatic asphyxia?
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MEDEVAC . Patient should be hospitalized for observation
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What are the essentials of diagnosis for a pulmonary emoblolism?
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Predisposition to venous thrombosis, especially in the lower extremities
Acute onset of dyspnea, pleuritic chest pain, tachypnea, tachycardia Characteristic defects on ventilation-perfusion lung scan, helical CT scan, or pulmonary angiogram |
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What are the general considerations of a pulmonary embolism?
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Pulmonary emboli occur when an embolus lodges within the pulmonary circulation
Sources of emboli: most commonly thrombi, Air, Amniotic fluid, Fat, Foreign bodies, Parasite eggs, septic emobli, Tumors Lung trauma in which there is laceration of air passages, lung parenchyma, or blood vessels may result in direct communication between these structures Air can enter the pulmonary venous system: caused by low pulmonary venous pressure and increased airway pressue Air emobolism occurs most commonly after penetrating trauma Clots that form pulmonary emobi are most commonly from the femoral or pelvic venous beds |
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What are the risk factors for a patient with pulmonary embolism?
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Venous stasis; increases with: Immobility, hyper viscosity, increased central venous pressure
Injury to the vessel wall; can be due to: Prior episodes of thrombosis, orthopedic surgery, trauma Hypercoagulability; can be caused by: medications, inherited gene defects |
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Depending on the size of the pulmonary embolism, what can possibly occur?
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Small to medium emboli: Obstruction of the pulmonary vasculature, local atelectasis, ventilation-perfusion scan abnormalities, hypoxia
Massive embolism: acute pulmonary hypertension, right heart strain, systemic hypotension, and shock |
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What are the physical findings for a pulmonary embolism?
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Onset is often abrupt and one or more of the DVT risk factors is almost always present
Dyspnea, cough, anxiety, and chest pain Hemoptysis, tachycardia, and tachypnea are common Low grade fever, hypotension, cyanosis, DVT signs, pleural friction rub may be present |
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What are the Lab/ Imaging findings for a pulmonary embolism?
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Operational environment requires the IDC to rely on history and physical exam
Reference standard is pulmonary angiography The ECG may show ST and T wave abnormalities ABG will show hypoxia, possibly respiratory alkalosis due to hyperventilation, and difference Chest x-ray may show atelectasis, infilitrates, effusions Ventilation-perfusion scan, spinal CT, and venous ultrasound |
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What is the treatment for a patient with a pulmonary embolism?
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Respiratory support to correct hypoxia
Anticoagulation therapy ASAP to prevent further clot formation Thrombolytic therapy may be needed for patients with right heart dysfunction, hemodynamic compromise, or cardiogenic shock Drugs are administered to achieve lysis of a thrombus in the pulmonary vasculature |
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What is the disposition for a patient with a pulmonary embolism?
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Needs ongoing anticoagulation and supportive care MEDEVAC ASAP
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What are the complications for a pulmonary embolism?
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Missed diagnosis is common
If anticoagulation or thrombolytic therapy is contraindicated, surgical intervention is needed to remove clot |
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What are the general considerations for Acute Respiratory Distress?
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Can be immediately life threatening and must be relieved promptly to avoid asphyxia
Causes include: trauma to the larynx, foreign body aspiration, laryngospasm, laryngeal edema from thermal injury or angioedema, infections, acute allergic laryngitis Aspiration of foreign bodies occur more frequently in children than adults Elderly and denture wearers are at greater risk Heimlich maneuver has reduced death |
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What are the physical findings of a patient with acute respiratory distress?
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Pronounced stridorous respirations
Retractions of the supraclavicular and suprasternal areas of the chest indicate that there is significant obstruction Patients with complete airway obstruction will not be able to breathe or speak May have visible swelling or mass in the neck Tongue may be swollen, as well as other structures of the mouth. |
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What are the lab/ imaging findings for acute respiratory distress?
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Laryngoscopy may reveal a foreign body, tumor, or obstruction in the larynx or trachea
Chest x-ray may reveal radiopaque obstructions |
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What is the treatment for acute respiratory distress?
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Use a rigid suction device to remove obstructing liquids and particulate matter
Use the Hemlich manuever to remove foreign bodies Therapy should be directed to reduce the edema either by cooling or vasoconstiction and treating the underlying infection or allergy Epinephrine is the most effective medication for angioedema Direct laryngoscopy coupled with the use of forceps is the best method for removing obstructing foreign bodies If less invasive methods fail, immediate cricothyrotomy or tracheostomy is required. |
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What is the disposition of a patient with acute respiratory distress?
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Easy, uncomplicated removals may be sent home following a period of observation with the following instructions, 1. eat more slowly, 2. chew more thoroughly, 3. swallow more carefully
For patients that loose consciousness but seem to be well should be examined and observed and only hospitalized if symptoms develop or persist If the patient has aspirated a significant amount of material in the lungs, hospitalization is appropriate |
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What are the general considerations for massive
aspiration? |
Significant aspiration is likely due to vomitus with particulate matter in the oropharynx
Aspiration may be observed sometimes during airway procedures Vomitus, tube feedings, or paritculate food particles may be observed in the oropharynx or suctioned from the airway |
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What are the physical findings of a patient with massive aspiration?
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Hypoxia, Tachypnea, Respiratory distress, Fever and tachycardia frequently occur, Hypotension may develop
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What are the lab and imaging findings for a patient with a massive aspiration?
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An infiltrate, sometimes extensive, usually appears on x-rays especially in the dependent areas of the lungs
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What is the treatment for a patient with a massive aspiration?
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Airway should be suctioned to clear the aspirated material
Administer O2 Chemical pneumonitis resulting from aspiration does not require antibiotics Most clinicians begin treatment with broad-spectrum antibiotics for bacterial pneumonia Corticosteriods have no proven value in the treatment of aspiration pneumonia |
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What is the disposition for a patient with a massive aspiration?
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MEDEVAC
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What are the general considerations for severe asthma/ COPD?
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May present with severe dyspnea and respiratory distress
Cough is more common and troublesome Usually have wheezing on auscultation of the chest Tachypnea, Tachycardia, cyanosis, chest hyper-expansion, globally dimmished breath sounds A pulsus paradoxus may be present with severe episodes Use of the SCM muscle during inspiration is common Intercostal retractions, nasal flaring, and tripod position may be noted |
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What are the lab/imaging findings of a patient with severe asthma/ COPD?
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Chest x-ray shows only hyperexpanded lung fields
Frequent viral or (rarely) bacterial tracheobronchitis, or exposure to an allergen has exacerbated their chronic underlying disease Peak expiratory flow rate is the most practical objective test of obstruction and the response to treatment available |
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What is the treatment for a patient with severe asthma/ COPD?
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Use O2 to raise SPO2 to at least 95%
Tracheal intubation and mechanical ventilation should be avoided but may be neccessary in acute respiratory failure In adults, b-adrenergi sympathomimetic bronchodilators (albuterol 0.2-0.3 mL in 3 mL normal saline by Neb 20-30 min) should be given in aerosol form if possible In extreme cases, injections may be necessary (Epinephrine 0.2-0.3 mL every 20-30 min SQ or Terbutaline 0.25 mg SQ every 2-4 hours) but can cause tachycardia and may induce myocardial ischemia in patients with conary artery disease and the elderly Corticosteriods (methylprednisolone 125 mg IV or predisone 60 mg orally) should be given to patients early that do not respond adequately to treatment |
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What is the disposition for a patient with severe asthma/ COPD?
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Hospital patients: with significant bronchospasm that does not respond promptly with treatment
Moderate bronchospasm that fails to improve within several hours after treatment Should recieve short-term outpatient corticorsteriod therapy such as predisone 40-60 mg/d with or without a taper over 6-10 days MEDEVAC new onset or worsening asthma/COPD |
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What are the essentials of diagnosis for community- acquired pneumonia?
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Signs and symptoms include: fever or hypothermia, cough with or without sputum, dyspnea, chest discomfort, sweats, or rigors
Bronchial breath sounds or rales are frequent auscultatory findings Parenchymal infiltrate on chest radiograph Occurs outside the hospital or less than 48 hours after admission in a patient who is not hospitialized or residing in a long-term care facility |
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What are the general considerations for a patient with pneumonia?
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Development of lower respiratory tract infections occurs from aspiration of secretions containing bacteria or Inhalation of infected aerosols
Pulmonary defense mechanisms usually prevent a cough reflex, mucociliary clearance system, and immune responses |
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What are the general considerations for community-acquired pneumonia?
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Community-acquired pneumonia occurs when there is a defect in one or more of the normal host defense mechanisms or when a very large infectious inoculum or a highly virulent pathogen overwhelms the host
Bacteria are more commonly identified than viruses. Most common bacterial pathogen identified is S Pneumonia, accounts for approximately 2/3 thirds of bacterial isolates Common viral causes are Influenza virus, respiratory syncytial virus, adenovirus,parainfluenza |
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What are the physical findings of a patient with pneumonia
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Community acquired pneumonia: Acute or subacute onset of fever, cough with or without sputum, dyspnea
Other common symptoms: Rigors, sweats, chills, chest discomfort, pleurisy, hemoptysis, fatigue, myalgias, anorexia, headache, and abdominal pain Common findings: fever or hypothermia, tachypnea, tachycardia, mild arterial O2 desaturation, will appear acutely ill, remarkable for altered breath sounds and rails, dullness to percussion may be present Anaerobic pleuropulmonary infection: fever, weight loss, and malaise, cough with expectoration of foul-smelling purulent sputum, definition is poor, and are rarely edentulous |
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What are the essentials of diagnosis for aspiration pneumonia and lung abscess?
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History of or predisposition to aspiration
Indolent symptoms, including fever, weight loss, malaise Poor dentition Foul-smelling purulent sputum (in many patients) |
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What are the general considerations for aspiration pneumonia/ lung abcess?
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Aspiration of small amounts of secretions occurs during sleep in normal individuals but rarely cause disease
Sequelae of aspiration of larger amounts of material include: nocternal asthma, chemical pneumonitis, mechanical obstruction of airways, bronchiectasis, pleuropulmonary infection Individuals predisposed to disease induced by aspiration include: those with depressed levels of consciousness (drug/alcohol use, seizures, general anesthesia, CNS disease), impaired deglutition, and those with tracheal or nasogastric tubes Periodontal disease and poor dental hygiene Aspiration of infected orophayrngeal contents Onset of symptoms is insidious |
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What are lab/ imaging findings for a patient with pneumonia?
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Chest x-ray may confirm the diagnosis and detect associated lung diseases
It can be used to help assess severity and response to therapy over time |
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What are the radiographic findings for a patient with pneumonia?
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Range from patchy airspace infiltrates to lobar consolidation with air bronchograms to diffuse alveolar or interstitial infiltrates
Additional findings can include pleural effusions and cavitation No pattern of radiographic abnormalities are a specific cause of pneumonia Progression of pulmonary infiltrates during antibiotic use or lack of radiographic improvement indicate an alternative pulmonary process Clearing of pulmonary infiltrates in patients with community-acquired pneumonia can take up to 6 weeks |
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What is the treatment for a patient with pneumonia?
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Antipyretics, cough suppressants as needed
Maintain hydration and oral intake Antibiotic options: Macrolides (Clarithromycin 500mg twice a day, Azithromycin 500mg first dose and then 250mg daily x4 days; or 500mg daily x3 days), Doxycycline 100mg twice a day; Fluoroquinolones (Levofloxacin 500mg daily, Moxifloxacin 400mg daily) Alternate methods: Erythomycin 250-500mg daily x4 days; Amox 500mg 3 times a day or 875 mg twice a day; Second or third generation cephalosporins |
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What is the disposition for a patient with pneumonia?
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Uncomplicated pneumonia can usually be treated on an outpatient basis with antibiotics and supportive care
Admit patient when: Failure of outpatient therapy, exacerbations of underlying disease, complications of pneumonia arise, cognitive dysfunction, psychiatric disease, homelessness, drug abuse, lack of outpatient resources, poor overall functional status |
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What are some complications from pneumonia?
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Empyema, endocarditis, pericarditis, cavitation, necrotizing pneumonia, skin rashes, bacteremia, sepsis, respiratory failure, ARDS, and death
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What are the essentials of diagnosis for bronchitis?
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cough associated with midline burning chest pain, fever, dyspnea
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What are the general considerations for bronchitis?
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Acute bronchitis and pneumonia are common and can be difficult to differentiate. Chronic bronchitis is defined as excessive production of bronchial mucous and daily productive cough for 3 months or more in 2 consecutive years. Suspect pneumonia or bronchitis in any patient presenting with fever, cough, or dyspnea
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What are the physical findings of a patient with bronchitis?
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Diagnosis is based primarily on history and physical
Complaints of cough, fever, and constitutional symptoms Cough is initially dry but can become productive hemoptysis, wheezing, and rales may present |
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What are the lab/ imaging findings for a patient with bronchitis?
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For acute bronchitis, x-ray will usually show no evidence of infiltrate
Not indicated without dyspnea, hypoxia, or significant comorbidity |
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What is the treatment for a patient with bronchitis?
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Acute bronchitis rarely needs aggressive management
Symptomatic treatment if needed: antipyretics, cough suppressants (Benzonatate 100-200mg tid), Short acting beta agonists (Albuterol, Levalbuterol), Expectorants (guaifenesin, robitussin, mucinex), Dextromethorphan 10-20mg q4h, 30mg q6-8h, 60mg q12 |
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What is the disposition for a patient with bronchitis?
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Hypoxic patients and those with significant underlying cardiopulmonary disease may require close monitoring
Modified duty 1-2 days SIQ/LLD as needed Retain onboard |
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What are the complications for a patient with bronchitis?
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Chronic presentation
Significant underlying comorbidity |
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What are the essentials of diagnosis for costochondritis?
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Chest wall pain located in a specific point
Typically costochondral or costosternal junctions Reproducable by palpation |
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What are the general considerations for costochondritis?
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An inflammation of the costal cartilages and/or their sternal articulations
Causes chest pain that is variably sharp, dull, and/or increased with respirations |
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What are the physical findings for a patient with costochondritis?
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Tenderness to palpation in affected areas
Localized erythema and edema |
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What are the lab/ imaging findings for a patient with costochondritis?
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None indicated in acute cases
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What is the treatment for a patient with costochondritis?
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Must rule out/ consider life threatening DDX
Main goal is to detect and treat the underlying lesion or cause Analgesic/ Antipyretic/ NSAIDS |
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What is the disposition of a patient with costochondritis?
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Consider light duty based on pain, activity as tolerated
Refer for severe or persistent pain despite treatment of NSAIDS |
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What are complications for costochondritis?
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Rare unless diagnosis is wrong and a more serious condition is present
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What are the essential diagnosis of pleuritis?
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Sudden onset of intermittent pain in the chest wall
Usually follows an injury or illness Pain worsened by coughing, sneezing, deep breathing, or movement |
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What are the general considerations for pleuritis?
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Inflammation of the pleura can caused by many conditions: setting in which pleuritic pain develops helps narrow the differential diagnosis; young, healthy patients its caused by viral respiratory illness or pneumonia; Trauma to the chest wall
May lead to splinting and atelectasis significant enough to produce hypoxia |
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What are the physical findings of a patient with pleuritis?
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Pleuritic chest pain may produce a sense of dyspnea
Pain is usually localized, sharp, and fleeting Made worse by coughing, moving, and breathing Friction rub may be presented - may lessen or disappear when effusion occurs Pain may refer to the ipsilateral shoulder Fever, myalgias, headache, nasal congestion, or flulike symptoms may also be present |
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What are the lab/ imaging findings for a patient with pleuritis?
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Chest x-ray to exclude underlying lung disease, pleural effusion, or pneumothorax
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What is the treatment for a patient with pleuritis?
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Main goal is to detect and treat the underlying lesion or cause
Analgesic/ Antipyretic/ NSAID (Indomethacin 25mg bid-tid) |
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What are the essentials of diagnosis for pulmonary edema?
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Acute onset or worsening of dyspnea at rest
Tachycardia, diaphoresis, cyanosis Pulmonary rales, rhonchi, expiratory wheezing Radiograph shows interstitial and avelolar edema with or without cardiomegaly Arterial hypoxia |
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What are the typical causes of acute cardiogenic pulmonary edema?
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Acute MI or severe ischemia
Exacerbation of chronic heart failure Acute volume overload of the LV Mitral stenosis |
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What are the most common presentations of acute or subacute deterioration of chronic heart failure?
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Precipitated by discontinuation of medications
Excessive salt intake Myocardial ischemia Tachy-arrhythmias Intercurrent infection Worsening edema and progressive SOB |
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What are the noncardiac causes of pulmonary edema?
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Intra Venous opioids
Increased intracerebral pressure High altitude Sepsis Meds Inhaled toxins Transfusion reactions Shock assimilated intravascular coagulation |
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What are the physical findings for pulmonary edema?
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Presents with severe dyspnea, production of pink, frothy sputum, diaphoresis, cyanosis
Rales are present in all lung fields, as are generalized wheezing and rhonchi May appear acutely or subacutely in the setting of chronic heart failure May be the first manifestation of cardiac disease Less severe decompensations usually present with dyspnea at rest and rales and other evidence of fluid retention but without severe hypoxia |
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What are the lab/ imaging findings of a pulmonary edema?
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Chest x-rays: Pulmonary vascular redistribution, blurriness of vascular outlines, increased interstitial markings, butterfly pattern of distribution of alveolar edema
Heart may be enlarged or normal size depending on whether heart failure was previously present Assessment of cardiac function by echocardiography is important |
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What is the treatment for a patient with pulmonary edema?
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O2 used to obtain adequate oxygenation
In full blown edema, patient should be placed sitting up with legs dangling over the side of the bed Noninvasive pressure support ventilation may improve oxygenation and prevent severe CO2 retention Intubation and mechanical ventilation may be necessary if severe respiratory distress |
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What medications are used for treating a patient with pulmonary edema?
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Morphine (2-8mg IV) is highly effective and may help lessen severe decompensations
Diuretics: Furosemide 20-80 mg IV/IO/PO; Bumetanide 1 mg Nitrate therapy accelerates clinical improvement |
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What is the disposition for a patient with pulmonary edema?
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Most cases, pulmonary edema responds rapidly to therapy
When the patient has improved, the cause or precipitation factor should be ascertained |
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What are the complications for pulmonary edema?
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Bronchospam may occur and may exacerbate hypoxemia and dyspnea
Treatment with inhaled beta-adrenergic agonists or IV aminophylline may be helpful but may also provoke tachycardia and supraventricular arrhythmias |
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What does the respiratory system consist of?
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Upper respiratory system: nose, pharynx, and associated structures
Lower respiratory system: larynx, trachea, bronchi, and lungs |
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What are the two zones of basic respiratory function?
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The conducting zone: consists of a series of interconnecting cavities and tubes that conduct air into the lungs
The respiratory zone: consists of tissues within the lungs where gas exchange occurs |
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What are the four groups of sinuses?
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Frontal
Maxillary (largest) Sphenoid Ethmoidal |
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What are the functions of the nose?
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Filtering, warming and moistening incoming air
Detecting olfactory (smell) stimuli Modifying the vibrations of speech sounds |
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What is the pharynx?
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A funnel-shape tube that starts at the internal nares and extends partway down the neck
Lies just posterior to the nasal and oral cavities and just anterior to the cervical vertebrae Composed of skeletal muscle and lined with mucous membrane |
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What are the 3 components to the pharynx?
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Nasopharynx: upper part; exchanges air with the nasal cavities and recieves mucus-dust packages
Oropharynx: middle portion; opens into the mouth and nasopharynx and has 2 pairs of tonsils Laryngopharynx: connects with both the esophagus and larynx |
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What is the larynx?
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A short tube of cartilage lined by mucous membrane that connect the pharynx with the trachea
Lies midline of the neck anterior to the 4th,5th and 6th cervical vertebrae Contains the thryoid cartilage, epiglottis, cricoid cartilage, and arytenid cartilages |
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What are the two pairs of vocal cords?
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False vocal cords: upper pair; does not produce sound
True vocal cords: lower pair; produces sound during speaking and singing |
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What is the trachea?
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A tubular passageway fro air that is located anterior to the esophagus
Extends from the larynx to the upper part of the fifth thoracic vertebra Divides into Right and left primary bronchi at the T-5 |
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What are the primary bronchis lined with?
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pseudo-stratified ciliated columnar epithelium
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What are the layers that cover the outside and inside of the lungs?
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Parietal pleura: outer layer attached to the wall of the thoracic cavity and diaphragm
Visceral pleura: inner layer that is attached to the lungs |
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What are the Alveoli?
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A cup-shaped outpouching of an alveolar sac
Main sites for gas exchange |
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What is pulmonary ventilation?
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The flow of air between the atmosphere and the lungs, occurs due to differences in air pressure
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What muscles are used during quiet (unforced) inhalation and exhalation?
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Diaphragm: responsible for 75% of the air that enters the lungs
External Intercostals |
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What are the muscles that are used during forced exhalation?
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Internal intercostals
External oblique Internal oblique Transverses abdominis Rectus Abdominis |
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Describe the pressure changes during ventilation:
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Lung exspansion causes air molecules inside the lungs to occupy a larger volume, causing the air pressure inside to decrease
When lung volume decreases, the alveolar pressure increases At rest just before inhalaiton, air pressure inside the lungs is the same as the pressure of the atmosphere (760 mm Hg at sea level) As the volume of lungs increase, the alveolar pressure decreases from 760 to 756 mm Hg As the volume of the lungs decrease, the alveolar pressure rises from 760 to 762 mm Hg |
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What is the normal breathing rate for an adult?
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12-20 breaths per minute
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What is the tidal volume?
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The volume of one breath, 500 mL of air into and out of the lungs
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What is minute ventilation?
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Total volume of air inhaled and exhaled each minute (BPM x TV)
MV = 12 breaths/min x 500 mL/breath |
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What percentage of tidal volume actually reaches the respiratory bronchioles and alveolar sacs?
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About 70% or 350 mL
The other 30% reamins in the conduction airways |
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What is Inspiratory Reserve volume?
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Additional air that is inhaled beyond the normal 500 mL TV
About 3100 mL in males and 1900 in females |
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What is Expiratory reserve volume?
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Additional air expired after a normal inhalation
About 1200 mL in males or 700 mL in females |
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What is residual volume?
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The volume of air that remains even after expiratory reserve volume is expelled
About 1200 mL in males and 1100 mL in females |
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What is Inspiratory capacity?
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The size of tidal volume and inspiratory reserve volume
500 mL + 3100 mL = 3600 mL in male 500 mL + 1900 mL = 2400 mL in females |
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What is Functional residual capacity?
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The sum of residual volume and expiratory reserve volume
1200 mL + 1200 mL = 2400 mL in males 1100 mL + 700 mL = 1800 mL in females |
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What is vital capacity?
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The sum of inspiratory reserve volume, tidal volume and expiratory reserve volume
4800 mL in males and 3100 mL in females |
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What is the total lung capacity?
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The sum of vital capacity and residual volume
4800 mL + 1200 mL= 6000 mL in males 3100 mL + 1100 mL = 4200 mL in females |
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What are the different breathing patterns?
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Eupnea, normal breathing
Costal Breathing, shallow breathing with ribs Diaphramic Breathing, deep breathing |
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What is the definition of coughing?
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A long-drawn deep inhalation followed by a strong exhalation
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What is the definition of sneezing?
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Spasmodic contraction of muscles of exhalation that forcefully expels air through the nose and usually from an irritation of nasal mucosa
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What is the definition of sighing?
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A long-drawn and deep inhalation immediately followed by a shorter but forceful exhalation
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What is the definition of yawning?
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A deep inhalation through a widely opened mouth, producing an exaggerated depression of the mandible
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What is the definition of sobbing?
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A series of convulsive inhalation followed by a single long exhalation
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What is the definition of crying?
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An inhalation followed by many short convulsive exhalations, vocal cords vibrate, characteristic facial expressions
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What is the definition of laughing?
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Same as crying but different facial expressions
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What is the definition of hiccupping?
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Spasmodic contraction of the diaphragm followed by spasmodic closure of the larynx
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Air pressure is the sum of partial pressure in what gases?
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Nitrogen
Oxygen Water vapor Carbon dioxide other gases |
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What is external respiration (pulmonary gas exchange)?
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It is the diffusion of O2 from air in the alveoli of the lungs to blood in the pulmonary capillaries and the diffusion of CO2 in the opposite direction
Occurs in the lungs |
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What is internal respiration ( systemic gas exchange)?
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The exchange of O2 and CO2 between system capillaries and tissue throughout the body
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How is oxygen transported through the body?
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About 98.5% is bound to hemoglobin in RBC's
Oxygen and deoxyhemoglobin (Hb) bind in a reversible reaction to form oxyhemoglobin Hb + O2> Hb - O2 When blood PO2 is high, HGB binds with large amounts of O2 and is fully saturated When blood PO2 is low, HGB releases O2 |
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How does carbon dioxide travel through the blood?
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Transported in 3 main forms: Dissolved CO2 (smallest percent 7% dissolved in blood plasma), Bound to amino acids (about 23% combines with the amino group), and Bicarbonate ions (largest 70%)
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What is the respiratory center?
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The area from which nerve impulses are sent to the respiratory muscles to control respiratory rate
Located in both the Pons and Medulla Oblongata |
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What are the areas of the respiratory center?
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Medullary Rhythmicity area: located in medulla and controls basic rhthym of respiration
Inspiratory area: generates nerve impulses that establish the basic rhythm of breathing Expiratory Area: Neurons of this area supply nerve impulses for forceful exhalation Pneumotaxic Area: located in the upper pons, helps turn off the inspriatory area to shorten the duration of inhalation and to increase the breathing rate Apneustic area: Located in the lower pons, sends excitatory impulses to the inspiratory area that activate it and prolong inhalation |
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What are the cortical influences on respiration?
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Cerebral cortex has connections to the inspiratory center, allows us to hold our breath voluntarily
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What controls how quickly or how deeply we breathe?
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Chemoreceptors: sensory nerves that are respond to chemical levels
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What are other influences on respiration?
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Propriocepter stimulation of respiration
Temperature Pain Irritation of airways Inflation reflex |
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Describe Hypercapnia:
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An increase in the arterial PCO2 above the normal 40mm Hg
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Describe Hypoxia:
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A deficiency in O2, falls from the normal levels
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Describe Hypocapnia:
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When arterial PCO2 falls below 40 mmHg, the central and peripheral chemoreceptors are not stimulated and no impulses are sent
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What are crackles?
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Abnormal sound heard more often during inspiration and characterized by discrete discontuinuous sounds
May be fine, medium or coarse, and will not be not be cleared by coughing |
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What are ronchi?
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Deeper, more rumling, more pronounced during expiration and less discrete than crackles
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What are wheezes?
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A continuous, high-pitched, musical sound (whistle-like) heard during inspiration or expiration
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What are Friction rubs?
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Occurs outside the respiratory tree, it has a dry, crackly, low pitched sound and is heard in both expiration and inspiration
Respiratory rub disappears when breath is held but a cardiac rub does not |
