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173 Cards in this Set
- Front
- Back
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the gold standard to dx COPD
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spirometry
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the gold standard for COPD monitoring
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spirometry
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most COPD pt are older than _____________
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40 yo
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GOLD criteria to dx COPD
FEV1/FVC must be |
< 70 %
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GOLD classification for COPD according to
FEV1 |
level 1 : mild > 80 %
level 2 :moderate 80 - 50 % level 3 :severe 50 -30 % level 4 :very severe < 30 % |
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best measure to use post extubation in pt with COPD exacerbation / CO2 retention to decrease rate of re-intubation
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non-invasive ventilation
CPAP/BiPAP for 24 hr |
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what's Heliox
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combination of O2 : helium
decreases resistance to airflow |
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inhaled N-acetylcystein
what ? |
mucolytic agent
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agent used in pt on ventilators to thin the secreations
((mucolytic)) |
inhaled N-acetylcystein
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inhaled N-acetylcystein
side effect |
bronchospasm
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the most likely long-term complication of critical illness
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post-ICU neuropsychiatric illness
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post-ICU neuropsychiatric illness ??
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aquired dementia
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post-ICU neuropsychiatric illness
% of people affected |
75 %
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post-ICU neuropsychiatric illness
risk factors |
pt treated for:
sepsis ARDS age duration of ventilation hypo/hyper-glycemia hypoxia |
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ICU aquired weakness
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-critical illness polyneuropathy
-critical illness myopathy -use of medications : steroids/ NMJ blocekres |
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prolonged neuromuscular blockage
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uncommon condition
prolonged use of paralytic agents esp. in pt with liver impairment |
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type of breathing in pt with Heart failure
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Chyne-stockes breathing
central sleep apnea http://www.youtube.com/watch?v=VkuxP7iChYY |
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Chyne-stockes breathing
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hyperpnea--------apnea------------hyperpnea
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charachteristic of
Chyne-stockes breathing diff. from OSA |
no snoring
no daytime sleepeness not likely to be over-wt associated with heart failure CPAP may worsen CSA |
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manegment of :
Chyne-stockes breathing |
optimizing medications for heart failure (eg, diuresis)
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2nd step in manegment of
Chyne-stockes breathing |
adaptive servoventilation
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adaptive servoventilation
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ounterbalances the shift between hyperpnoea and hypoventilation by applying variable pressure support and thus overcomes the ventilatory overshoot. During hypoventilation the difference between inspiratory and expiratory pressure, that means the pressure support and the tidal volume, increases while it is reduced during hyperventilation. In addition, ASV devices provide an expiratory positive airway pressure to eliminate obstructive apnoeas and hypopnoeas and also apply mandatory breaths to treat central apnoeas
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adaptive servoventilation
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http://www.resmed.com/epn/products/s9_vpap_series/asv.html?nc=patients
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patterns pf breathing
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eupnea
chyne-stock pattern kussmaul bradypnae tachypnea hyperpnea / hyperventilation biot ataxic |
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patterns pf breathing
definitions associations |
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patterns pf breathing
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pulmonary rehabilitation
indications in COPD |
symptomatic COPD
with FEV1 < 50 % |
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pulmonary rehabilitation
contraindications |
pt can't walk
unstable angina recent MI |
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palliation of pt with severe dyspnea in optimal therapy ??
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morphine
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oxygen tharpy indications in COPD
first indication |
1. PaO2 is less than or equal to 55 mmHg. Or hemoglobin oxygen saturation (SaO2) measured by pulse oximeter is less than or equal to 88 percent when breathing room air at rest
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1oxygen tharpy indications in COPD
2nd indication |
2. PaO2 of 56-59 mmHg. Or if the hemoglobin oxygen saturation (SaO2) is equal to or greater than
89 percent when linked to specific conditions. These may include Cor Pulmonale, congestive heart failure or erythrocytosis. (With a hematocrit of greater than 56 |
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definition of acute COPD exacerbation
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any increase in
-cough -sputum -dyspnea -change in sputum color -fever |
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features of granuloma on CT scan
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densly , centrally calcified
smooth boarders |
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benign patterns of calcification in lung masses
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popcorn
lamellar / concentric rings central diffuse pattern |
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bad patterns of calcifications in lung masses
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eccentric
off-center stippled |
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features of lung carcinoid
features CT scan |
low-grade malignancy
neuroendocrine origine 1-2 % of lung ca may present with : hemoptysis / obstruction central airways smooth boarders ((((NOT )) !! calcified |
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ethylene glycol ??
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antifreez
solvent |
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ethylene glycol
metabolism / enzyme |
alcohol dehydrogenase
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ethylene glycol
metabolism products |
glycolic acid
oxalic acid formic acid |
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ethylene glycol toxicity
features |
seizures
coma noncardiogenic pulm. edema cardiovascular collaps renal imparment ca oxalate crystal // envelop-shaped |
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ethylene glycol
manegment |
Fomepizole
+ hemodialysis if features of end-organ damage -raising creatinine -oliguria -hematuria |
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ethylene glycol toxicity
acid - base disturbances |
metabolic acidosis
(((( high osmolar + anion gap )) with metabolic alkalosis--------------------vomitting with resp.alkalosis |
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pneumothorax
small large |
small if < 2 cm
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pneumothorax
classification |
small
large _______________________ spontaneous or not ________________________ primary secondary / underlying pathologt ______________________ tension open |
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pneumothorax
indication for admission |
- resp-distress
- large > 2 cm -if secondary (small or large) |
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pneumothorax
indication for definitive ttt |
if persistant leak after 3-5 days
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pneumothorax
type of definitive ttt |
thoracostomy with pleuredesis
thorcascopic repair with pleuredesis |
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side effects of inhaled steroids
short term long term |
thrush
+ hoarsness _________________________ cataract glucoma osteoporosis |
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features of inadequate perfusion
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low arterial pressure
low venous central pressure tachy-tachy central venous sat < 70 % oliguria acidosis motteled skin cold limbs delerium |
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indication to use steroid in septic shock
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if failed IV fluid and vasopressors to increase BP above 90
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target of Hb in critically ill / septic shock
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10
((recent studies 7-9 are adequate)) |
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indication to transfuse pt with septic shock
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active bleeding
profound anemia CAD |
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clinical features of pt with respiratory muscle weakness
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progressive dyspnea
normal pulm.exam increased residual volume restricted pattern raised diaphram bibasilar atelactasis |
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residual lung volume in
-COPD -pulm.muscle weakness |
COPD : increased
Musc. weakness : decreased |
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dx of insuff. sleep synd
- objective test -subjective test |
-sleep dairy
-wrist acti-graphy |
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dx narcolepsy
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multiple sleep latency testing
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multiple sleep latency testing
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The multiple sleep latency test (MSLT) tests for excessive daytime sleepiness by measuring how quickly you fall asleep in a quiet environment during the day. Also known as a daytime nap study, the MSLT is the standard tool used to diagnose narcolepsy and idiopathic hypersomnia.
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multiple sleep latency testing
method |
The MSLT is a full-day test that consists of five scheduled naps separated by two-hour breaks. During each nap trial, you will lie quietly in bed and try to go to sleep. Once the lights go off, the test will measure how long it takes for you to fall asleep. You will be awakened after sleeping 15 minutes. If you do not fall asleep within 20 minutes, the nap trial will end.
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manegment of symptomatic COPD pt with FEV1 < 60 %
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1
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which is best long acting anti-cholinergic or B2-agonist
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1
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what to order if highly suspecting pleural effusion TB
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1
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TB pleural effusion features
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1
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adenosin deaminase level of > ___________ suggestive of pleural TB
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1
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adenosin deaminase level of < ___________ almost exclude pleural TB
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1
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if positive adenosin deaminase , whats next step ??
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1
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if pleural TB not treated
course |
1
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+ve fast acid bacillus in pleural TB
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1
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+ve TB culture in pleural fluid %
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1
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indications for bilateral phrenic narve pacing
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1
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role of steroid in GBS
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1
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amiodarone induced pulm. toxicity
forms |
1
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amiodarone induced pulm. toxicity
most common form |
1
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amiodarone induced pulm. toxicity
risk factors |
1
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normal CXR
hypoxia/dyspnea |
PE
interstitial lung disease (( up to 20 %)) |
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delirium tremnous syndrome
features |
1
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delirium tremnos syndrome
((alcohol withdrawal syn)) manegment |
1
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delirium tremnous syndrome
onset |
1
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delirium tremnous syndrome
duration |
1
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delirium tremnous syndrome
if not treated |
1
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delirium tremnous syndrome
role of haloperidol |
1
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Haloperidol
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1
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contraindications to non-invasive ventilatuon
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1
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indications for mchanical ventilation
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1
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anaphylaxis manegment
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1
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epinephrine for anaphylaxis
administration routes |
2
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indications for intubation for anaphylaxis
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2
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role of anti-histamine + steroids in anaphylaxis
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2
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epinephrine infusion in anaphylaxis
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2
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pt with diffucult to control asthma
recurrent infiltrate central bronchiectasis eosinophelia elevated IGE |
bronchopulmonary aspergillosis
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bronchopulmonary aspergillosis
what |
2
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best initial test to evaluate for allergic bronchopulmonary aspergillosis
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2
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if positive skin test with features suggestive of bronchopulmonary aspergillosis , next ??
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2
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IgE level suggestive of bronchopulmonary aspergillosis
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2
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epinephrine dose in anaphylaxis
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0
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classification of COPD
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classification of stable asthma
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classification of stable asthma
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COPD Patient Staging Assessment Tool
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severity of asthma attacks
classification |
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classification of asthma attack according to severity
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manegment of chronic asthma
step therapy |
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manegment of chronic asthma
step therapy |
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manegment of COPD
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manegment of COPD
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manegment of COPD
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manegment of asthma exacerbation
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high risk asthma pt , treated at ER
---low threshold of admission |
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steps of treating asthma exacerbation
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criteria to discharge pt from ER
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objective measure at ER for asthma exacerbation
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measure peak expiratory flow (PEF)
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Hypoxemia with a Normal Chest Radiograph
DDx |
Asthma
Pulmonary embolism Early pneumonia Early interstitial lung disease Early pneumocystis pneumonia (PCP) Shunt, eg, atrial or ventricular septal defect, arteriovenous malformation, atelectasis Pulmonary hypertension Chronic alveolar hypoventilation |
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pleural effusion
size estimation small |
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pleural effusion
size estimation moderate |
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respiratory failure
Type 1 definition |
hypoxima without hypercapnia
failure is failure of oxygenation |
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respiratory failure
Type 1 mechanism |
ventilation/perfusion (V/Q) mismatch
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respiratory failure
Type 1 causes |
high altitude
pulmonary embolism) Alveolar hypoventilation / neuromusc....can cause 2 pneumonia or ARDS)....diffusion problem Shunt |
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1
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1
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1
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1
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1
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1
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1
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1
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1
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1
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Type 2 respir. failure
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Hypoxemia with hypercapnia
caused by inadequate alveolar ventilation |
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respiratory failure
Type 2 definition |
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respiratory failure
Type 1 causes |
1-Increased airways resistance (chronic obstructive pulmonary disease, asthma, suffocation)
2-Reduced breathing effort (drug effects, brain stem lesion, extreme obesity) 3- decrease in the area of the lung available for gas exchange (such as in chronic bronchitis) 4-Neuromuscular problems (Guillain-Barré syndrome, myasthenia gravis, motor neurone disease) 5-Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail ches |
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diff. between types of resp. failure
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indications for endotracheal intubation in critical care
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young
nonsmoker pt presenting with recurrent pneumonia CT = mass = obstructing bronchus mass= smooth boarders Dx ?? |
carcinoid tumor
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carcinoid tumor of lung
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slowly growing
malignant 1-2 % of all lung neuroendocrine no relation to smoking recurrent pneumonia due to obstruction hemoptysis / bronchiactasis smooth boarders maneged by resection if possible |
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adenocarcinoma vs carcinoid of lung
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both in young
both non-smokers adeno = obstruction is not commo carcinoid = obstruction is common |
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pt admitied for surgery
found to have COPD exacerbation next step ?? |
delay surgery till back to baseline
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factors increased risk of pulm. post-operative complications in COPD pt
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age
degree of COPD severity smoking poor general health abdomen/thoracic surg |
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common pulm. post-operative complic. in COPD
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-atelactasis
pneumonia increased airway obstruction |
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ROF-lumi-LAST
((roflumilast)) |
PDE-4 inhibitor
used in sever/v.severe COPD not for exacerbation manegment |
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((roflumilast))
DAXAS mechanism of action |
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steps of hyoptension Rx in septic shock
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1-Abx
2-trial of IV challenge NS 0.9% === 1000 ml over 30 min 3-vasopressors if mean arte. press < 65 mmHg 4-steroids if all failed 5-blood if ongoing blood loss / severe anemia |
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Goals of BP / JVP in sepsis
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Mean arterial pressure > 65 mmHg
JVP 8-12 mmHg |
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mean arterial pressure
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2/3 diastolic + 1/3 systolic
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indication of steroids in septic shock
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1-failed measures for reaching target mean pressure
2-suspicion of adrenal insuf. |
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diagnosis of suspected chronic pulm.embolism
test of choice |
ventilation - perfusion scan
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when CT-angio indicated in chronic thromboembolism
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when need to evaluate for possible endartrectomy
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high altitude illness / sickness
forms |
1-acute mountain sickness
((high altitude periodic breathing)) 2-high altitude cerebral edema 3-high altitude pulm. edema |
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((high altitude periodic breathing))
what |
cyclic central apnea-hypopnea
during sleep acute altitude change increased with degree of elevation > 2500 m repeated awakening from sleep |
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2-high altitude cerebral edema
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encephalopathy
vasogenic edema |
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3-high altitude pulm. edema
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capillary leak in response to hypoxemia
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Rx of high altitude sickness
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acetazolamide ((Diamox)
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Diamox / acteazolamide
mechanism to ttt altitude periodic breathing |
acetazolamide's efficacy has been attributed to inhibition of CA in the kidneys, resulting in bicarbonaturia and metabolic acidosis. The result is offsetting hyperventilation-induced respiratory alkalosis and allowance of chemoreceptors to respond more fully to hypoxic stimuli at altitude.
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indicatiuons to place chest tube in paraneumatic effusion
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1-large effeusion > 50 % of hemithorax
2-positive gram stain / cx 3-glucose < 60 4-PH < 7.2 |
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if pleural fluid glucose is < ______________, do chest tube
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60 mg/dl
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if pleural fluid PH is < _____________ insert chest tube
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7.2
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un-expandable lung
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trapped lung
entrapped lung |
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un-expandable lung
risk factors |
Some patients with an unexpandable lung exhibit the typical clinical presentation following therapeutic thoracentesis: (1) the development of an unexpected pneumothorax; (2) inability to fully expand the lung; or (3) the inability to completely drain the effusion due to the development of substernal chest pain.
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sarcoidosis involved predominantly the _________ lobes of lung
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upper
((more apperant in leatral than AP view |
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Velcro Inspir. crackles
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present in Idiopathic pulm. fibrosis
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predominatly lower lobes involvement
causes |
-idiopathic pulm.fibrosis
-asbestos Crypto-organizing pneumonia -heart failure |
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predominatly upper lobes involvement
causes |
-sarcoidosis
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Lung Entrapment
causes |
coronary artery bypass graft surgery, postcardiac injury syndrome, empyema/complicated parapneumonic effusions, uremia, radiation therapy, and rheumatoid pleurisy
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Trapped Lung
cause |
uncommon sequela of prior fibrinous or granulomatosis pleuritis in which a mature fibroelastic membrane develops along the visceral pleural surface and impedes normal lung expansion with pleural fluid drainag
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trapped lung
causes |
oronary artery bypass grafting (CABG), especially when the internal mammary artery is harvested; an empyema or complicated parapneumonic effusion; uremic pleuritis; hemothorax; radiation pleuritis; and rheumatoid pleurisy. Cardiac surgery, given the numbers performed annually, is probably the most frequent cause of a trapped lung
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trapped vs entrapped
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trapped vs entrapped
manommetry |
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manegment of hypercapnic resp. failure related to neuromuscular disorders
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BiPAP
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ARDS ventilator setting
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O2 + PEEP
______________________ limited tidal volume (( 6 L / Kg of ideal body wt)) ideal body wt is not pt actual wt _____________________ minimize platuea pressure of < 30 cm H2O _______________________ reduce FiO2 to < 0.6 ((60 %)) |
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plateau pressure
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![Plateau pressure (PPLAT) is the pressure applied to small airways and alveoli during positive-pressure mechanical ventilation.[1] It is measured during an inspiratory pause on the mechanical ventilator](https://images.cram.com/images/upload-flashcards/36/77/18/5367718_m.gif)
Plateau pressure (PPLAT) is the pressure applied to small airways and alveoli during positive-pressure mechanical ventilation.[1] It is measured during an inspiratory pause on the mechanical ventilator
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PEEP
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Intrinsic PEEP (auto)
Extrinsic PEEP (applied) |
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auto-PEEP
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Incomplete expiration prior to the initiation of the next breath causes progressive air trapping (hyperinflation). This accumulation of air increases alveolar pressure at the end of expiration
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causes o auto-PEEP
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high minute ventilation (hyperventilation)
expiratory flow limitation (obstructed airway) expiratory resistance (narrow airway) |
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Extrinsic PEEP (applied)
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A small amount of applied PEEP (3 to 5 cmH2O) is used in most mechanically ventilated patients to mitigate end-expiratory alveolar collapse
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