ICM II - Respiratory Exam 2 Case Studies
What is the pack history for an individual that smokes two packs a day for the last 5 years?
10 year pack history
A patient says they "rip 1 JUUL pod a day". What is this equivalent to in cigarettes?
20 cigs
A patient comes in with a nicotine addiction. Tell me about the physiologic addiction to nicotine and the behavioral addiction to tobacco?
2mg nicotine absorbed/cigarette (~5 inhalations/cigarette), initial adrenal effect (epinephrine) - HR, BP, RR Peak brain levels in 10 seconds: Endorphins - brief euphoria (seconds) Dopamine - reward circuits (minutes) Alters reward learning, stress reaction and self-control) Behavioral: Enjoy: feel, smell, sight of tobacco Ritual: obtaining, handling, lighting, smoking Associations with smoking: people, places, activities
How many toxins released from cigarettes versus vaping?
7,000 toxins - Cigarettes 5,500 toxins - Vaping
What are the laboratory findings of asthma?
>PFTs: spirometry (forced expiratory volume in 1 second [FEV1], forced vital capacity [FVC], FEV1/FVC ratio) before and after the administration of a short-acting bronchodilator, with reversibility of obstruction after the bronchodilator. >Arterial blood gases: may show respiratory alkalosis and an increase in the alveolar-arterial oxygen difference; in severe exacerbations, hypoxemia develops, and the Paco2 normalizes. Increased PaCO2, respiratory acidosis in resp failure Imaging: - hyperinflation, but bronchial wall thickening and diminished peripheral lung vascular shadows Diagnostic procedures: bronchial provocation testing with histamine or methacholine when suspected but spirometry is non-diagnostic >Exercise challenge and skin testing for environmental allergies
What are the differential diagnosis of asthma?
>Vocal cord paralysis or dysfunction >Foreign body aspiration or laryngotracheal mass >Tracheal stenosis or tracheomalacia >Airway edema (eg, angioedema or inhalation injury) >Chronic obstructive pulmonary disease >Bronchiectasis >Allergic bronchopulmonary aspergillosis >Cystic fibrosis >Eosinophilic pneumonia >Bronchiolitis obliterans >Eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome) >Psychiatric causes such as conversion disorder
humans only reservoir first sign = lymphadenopathy fatigue, weight loss, weakness, fever, night sweats, dyspnea, chest pain, COUGH MORE THAN 2 weeks cough with yellow/green sputum or hemoptosis bilateral cavitary lesions fibrothorax right upper lobe infiltrate
Active TB
What are the benefits to the body after a patient quits smoking?
After 20 minutes, BP, HR go down, hands and feet get warmer 8 hours: CO returns to normal, O2 lvls up After 24 hrs: heart attack risk is lower 48 hrs: body free of nicotine, nerve endings adjust to missing nicotine, sense of taste and smell start to improve 72 hours: bronchial tubes start to relax, easier to breathe 2-13 weeks: exercise is easier, blood circulates better 1 year: heart disease risk is cut in half 5 years: cervical cancer risk same as NS, stroke risk same as NS, cancer risk of mouth, throat, esophagus and bladder cut in half 10 years: lung cancer risk is cut in half
Pt presents with DKA (an acute acid base disorder) and has altered mental status. What test should be ordered to evaluate this disorder?
Arterial Blood Gas
What should you do as a physician assistant to assess tobacco use?
Ask: - current/past use, qualify use (mg Nicotine/day) Advise: current user: strong, clear, personal Assess: motivation to quit, willing and ready -> have a ready implementable plan, barriers/ambivalence Assist: support, anticipate difficulties, prepare withdrawal, counseling, resources, pharmacotherapy Arrange: follow-up
A patient presents with no audible wheezing, but you hear increased expiratory time and the patient has a cough that is induced by rapid expiration. Her pulmonary function test results are obstructive lung disease. What is the most likely diagnosis?
Asthma
edema/inflammation of airway mucosa bronchial muscle hypersensitivity smooth muscle hypertrophy bronchorrhea/mucus plug symptoms: wheezing, dyspnea, cough normal physical exam tachypnea, tachycardia normal or obstructive spirometry respiratory alkalosis
Asthma
A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had these symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months and since her new roommate and his cat moved in. She has no exercise-induced or nocturnal symptoms. The patient smokes occasionally when out with friends, drinks socially, and has no history of drug use. Examination is notable for mild end-expiratory wheezing. What is the most likely diagnosis and how did you think through this?
Asthma What other causes of SOB? Environmental allergies? Associated disease? Severity of condition? No audible wheezing on exam so look for increased expiratory time, cough induced by rapid expiration PFT - obstruction Allergen reduction, smoking cessation should be evaluated Treatment considerations: # of episodes per week, PEFR, etc.
What are the treatments for asthma?
Bronchodilators and anti-inflammatory medications like: >Long acting B2 agonists (often in combo with inhaled corticosteroids), systemic corticosteroids, leukotriene modifiers, mediator inhibitors, and phosphodiesterase inhibitors. >"rescue" therapies include short-acting inhaled β2-agonists >inhaled anticholinergics, theophylline, magnesium Outpatient/Maintenance therapy Assessing asthma control Acute exacerbations Bronchial thermoplasty Biologic therapy Allergen immunotherapy
A patient present with nausea, anxiety, constipation, dry mouth, constipation, had one seizure, is has some neuropsych impairment. Pt states was recently prescribed a new medication for smoking cessation. What medication?
Bupropion ER 150 mg (Zyban)
37 y/o with headache, dizziness, nausea, gneeral malaise. Everyone in house has the symptoms. She has chalked it up to all of the people in the house are feeling like this. It may be daycare. could be the flu. It is winter. What is suspected?
Carbon Monoxide
What has a greater affinity for heme? oxygen carbon monoxide
Carbon Monoxide
55 y/o male presents to urgent care with lingering ab pain and fatigue for 1-2 weeks. He works in a factory with the fluid that makes the bubbly christmas ornaments. His coworkers are concerned because he has been acting confused and not making much sense. He has been working a lot of overtime as the holiday season is in full swing, business is booming. What do you suspect?
Carbon Monoxide poisoning
23 year old male presents to ED. he is unconscious tachypneic, breathing shallow, lips cyanotic. Mother reports he was working in garage on car. When she went to leave an hour later, she found him unresponsive on the ground.
Carbon monoxide poisoning
A patient presents with altered mental status, cherry red lips/skin and headache. They also complained. What is the diagnosis and what is the treatment?
Carbon monoxide poisoning remove from the source, no risk features of CO poisoning and mild-moderate symptoms - ED observation and 100% O2 via NRB mask until symptoms resolved and COHb <3% d/c after symptom resolution and COHb normalization high risk features/severe CO poisoning - secure airway, stabilize vitals, hyperbaric O2 Intubation, mechanical vent prn supportive care prn intentional poisoning/suicide attempt = emergency psych consult
A patient present with nausea, vivid dreams, insomnia, and some neuropsychiatric symptoms. Pt states was recently prescribed a new medication for smoking cessation. What medication?
Chantix (Varenicline)
A patient is diagnosed with pulmonary hypertension, but has no limitation of physical activity. They have no dyspnea, fatigue, chest pain, or near syncope with exertion. What classification according to New York Heart Association?
Class I
What class of pulmonary hypertension when a patient has slight limitation of physical activity including no symptoms at rest, but ordinary physical activity like walking up the steps, causes dyspnea, fatigue, chest pain, or near syncope?
Class II
What class of pulmonary hypertension results in marked limitation of physical activity? They have no symptoms at rest, but less than ordinary activity (house activities) causes dyspnea, fatigue, chest pain, or near syncope?
Class III
What class of pulmonary hypertension results in inability to perform any physical activity without symptoms? There is evidence of right heart failure. They have dyspnea and fatigue at rest and worsening of symptoms with activity.
Class IV
What are the signs and symptoms of PE?
Clinical findings depend on the size of embolus and preexisting cardiopulmonary status Dyspnea (75-85%) Chest Pain (65-75%) Tachypnea may be the only sign and is reliably found in more than 50% of patients Less common: fever, hemoptysis, cough, crackles (rales), angina, and an accentuated pulmonary component of the second heart sound Hormans sign - pain with dorsiflexion of the ankle and suggests DVT in ipsilateral lower extremity, rare finding
What is the best diagnostic test to assess for carbon monoxide poisoning? ABG co-oximetry pulse-oximetry EKG CT/MRI
Co-oximetry
How do you measure CO levels in blood? How is it expressed?
Co-oximetry of arterial or venous blood; only accurate measurement tool. It measures the total hemoglobin, oxyhemoglobin, methemoglobin, and COHb saturation. expressed as % of hemoglobin saturation
What is your plan for a patient that wants to quit smoking?
Consider team approach (MA, pharmacist, counselor) commit to quit date - within the next couple days, reschedule an appointment for the quit date. advise an accountability partner - someone that will hold them to their quit date, willing to confront the friend, not a spouse environment sweep counseling medications patient resources follow-up
A toxicant known for impacting the CNS and cardiac tissue, being fatal within 1-15 minutes, and affecting the mitochondria and cell oxygenation, may also impact the pulse oximetry. What is this poisoning and how does it impact the pulse ox reading?
Cyanide poisoning Pulse ox is normal or high despite cellular hypoxia
What are the lab findings and imaging findings in PE?
ECGs are abnormal in 70%, usually with sinus tachycardia and nonspecific ST-T changes Acute respiratory alkalosis, hypoxemia, and widened arterial-alveolar O2 gradient (A-a DO2) d-dimer is very sensitive but not specific for VT Imaging: Atelectasis, infiltrates, pleural effusions, westermark sign, hampton hump V/Q scan can exclude PE if findings are normal or make diagnosis high probability Helical CT = initial diagnostic study of choice because very sensitive and non-invasive, but does not require IV radiocontrast dye Venous thrombosis studies include lower Doppler ultrasonography and may establish need for tx, invasive with high suspicion for PE Pulmonary angiography is reference standard for diagnosis of PE but is invasive
What are the essentials of diagnosis regarding asthma?
Episodic or chronic symptoms of airflow obstruction Reversibility of airflow obstruction, either spontaneously or after bronchodilator therapy Symptoms frequently worse at night or in the early morning Prolonged expiration and diffuse wheezes on physical examination Limitation of airflow on pulmonary function testing or positive bronchoprovocation challenge
What are the symptoms and signs of asthma?
Episodic wheezing and difficulty breathing, chest tightness, and cough Excess sputum production Symptoms are frequently worse at night Common aeroallergens include dust mites, cockroaches, cats, and pollen Nonspecific precipitants include exercise, respiratory tract infections, rhinitis and sinusitis, postnasal drip, aspiration, gastroesophageal reflux, changes in weather, and stress Tobacco smoke increases symptoms and decreases lung function Certain medications (including aspirin and nonsteroidal anti-inflammatory drugs) may be triggers Nasal findings consistent with allergy and evidence of allergic skin disorders Wheezing with normal breathing or a prolonged forced expiratory phase
What are the etiologies of carbon monoxide?
Fire-related, intentional, accidental, and chronic low-level exposure
What are the treatments of PE?
Full anticoagulation with heparin should begin with the diagnostic evaluation in patients with a moderate to high clinical likelihood of PE and no contraindications. LMWHs are as effective as unfractionated heparin and do not require coagulation monitoring. Warfarin or factor Xa inhibitors such as rivaroxaban are options for oral anticoagulation therapy. The durations of treatment are 3 months of anticoagulation after a first episode provoked by a surgery or a transient nonsurgical risk factor, 6 to 12 months for unprovoked or recurrent episode with a low to moderate risk of bleeding, 6 months for an initial episode with a reversible risk factor, 12 months after initial idiopathic episode, and 6 to 12 months to lifelong in patients with irreversible risk factors or recurrent disease. Thrombolytic therapy increases intracranial hemorrhage but is indicated in hemodynamically unstable patients. Surgery Pulmonary embolectomy is an emergency procedure with a high mortality rate performed at few centers. Therapeutic Procedures Catheter devices that fragment and extract thrombus have been used on small numbers of patients. Inferior venal caval (IVC) interruption (IVC filters) may be indicated when a significant contraindication to anticoagulation exists or when recurrence occurs despite adequate anticoagulation. IVC filters decrease the short-term incidence of PE but increase the long-term rate of recurrent DVT; thus, provision should be made for their removal at the time of insertion.
What group gathers diseases that localize directly to pulmonary arteries leading to structural changes, smooth muscle hypertrophy, and endothelial dysfunction? This group includes idiopathic pulmonary arterial hypertension, heritable pulmonary arterial hypertension, HIV infection, portal hypertension, drugs and toxins, connective tissue disorders, congenital heart disease, schistosmiasis, primary veno-occlusive disease, and pulmonary capillary hemangiomatosis.
Group 1
Pulmonary venous hypertension secondary to left heart disease. Often referred to as "post-capillary" pulmonary hypertension. This group includes left ventricular systolic or diastolic dysfunction and valvular heart disease. What group?
Group 2
What group is pulmonary hypertension secondary to lung disease or hypoxemia? This group is caused by advanced obstructive and restrictive lung disease, including COPD, interstitial lung disease, pulmonary fibrosis, bronchiectasis, as well as other causes of chronic hypoxemia, like sleep disorder, alveolar hypoventilation, and high-altitudes.
Group 3
What group is pulmonary hypertension secondary to chronic thromboembolism? Pts with pulmonary hypertension due to thromboembolic occlusion of proximal and distal pulmonary arteries. DOES NOT include tumors or foreign objects
Group 4
What group is pulmonary arterial hypertension secondary to hematologic, systemic, metabolic, or misc causes? Pts have pulmonary hypertension secondary to hematologic disorders (hemolytic anemia, splenectomy), systemic disorder (sarcoidosis, vasculitis, pulmonary Langerhans cell histocytosis, neurofibromatosis type 1), metabolic disorders (glycogen storage, thyroid disease), and misc causes (tumor, end-stage renal disease).
Group 5
What are the kinetics of CO?
Half Lives: room air = 250-320 min high flow O2 = 90 min Co 100% hyperbaric O2 = 30 minutes
What is the greatest risk of secondhand smoke and death?
Heart Disease
A patient presents to your ED complaining of a headache and confusion. Co-oximetry reveals a COHb saturation of 18%. What is the most appropriate initial treatment? emergent psychiatric consult hyperbaric oxygen (HBO) therapy endotracheal intubation high-flow oxygen therapy (NRB) How does it change if the patient becomes unconscious?
High-Flow Oxygen therapy (NRB) Hyperbaric oxygen therapy if unconscious
poor tissue oxygenation can be caused by hypoxemia symptoms: tachypnea, dysnpnea, cyanosis, tachycardia, mental status change treated with oxygen therapy Can cause vasoconstriction --> pulmonary hypertension leading to right heart failure
Hypoxia
What are the risk factors for pulmonary embolism?
Immobility , hyperviscosity, increased central venous pressures, vessel drainage (trauma, prior DVT, orthopedic surgery), hypercoagulable states
A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had these symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months and since her new roommate and his cat moved in. She has no exercise-induced or nocturnal symptoms. The patient smokes occasionally when out with friends, drinks socially, and has no history of drug use. Examination is notable for mild end-expiratory wheezing. What are the salient features of this patient's problems?
Intermittent shortness of breath and chest tightness; environmental triggers; family history; wheezing on physical examination
A 57-year-old man has a right total knee replacement for severe degenerative joint disease. Four days later, he develops shortness of breath and right-sided pleuritic chest pain. He is in moderate respiratory distress with respiratory rate 28 breaths/min, heart rate 120 beats/min, blood pressure 110/70 mm Hg, and oxygen saturation 88% on room air. Cardiopulmonary examination is normal. The right leg is postsurgical, healing well, with 2+ pitting edema, calf tenderness, erythema, and warmth; his left leg is normal. What are some differential diagnosis here? Why is one more likely?
MI, pneumothorax, cardiac tamponade, pulmonary embolism. PE is more likely because of pleuritic quality of chest pain, normal cardiopulmonary exams, post-surgical onset
A 57-year-old man has a right total knee replacement for severe degenerative joint disease. Four days later, he develops shortness of breath and right-sided pleuritic chest pain. He is in moderate respiratory distress with respiratory rate 28 breaths/min, heart rate 120 beats/min, blood pressure 110/70 mm Hg, and oxygen saturation 88% on room air. Cardiopulmonary examination is normal. The right leg is postsurgical, healing well, with 2+ pitting edema, calf tenderness, erythema, and warmth; his left leg is normal. His CT scan shows extensive bilateral pulmonary emboli. How do you decide if massive or submassive PE? What treatment should you administer regardless of thrombolysis decision?
Massive PE indicates hemodynamic compromise (cardiogenic shock) and is treated by thrombolysis Submassive PE - role of thrombolysis is less clear BP is likley below baseline, not in shock so use echocardiogram. Heparin or low-molecular-weight heparin
What are the groups of Americans that are impacted by cigarette smoking? This roughly impacts 34 million people
Men Adults 25-64 years old Lower education Below poverty level Midwest and South uninsured or Medicaid Disabled Serious psychological distress american indians, alaskans, and multiracial Lesbians, gays, and bisexuals
A person is getting ready to paint some old cabinets. They used paint stripper and now is experiencing symptoms of headache and is feeling confused. What could he have been exposed to? What is it causing? How long does this patient need to be observed and how much oxygen?
Methylene chloride Carbon monoxide poisoning exposure requires at least 8 hours observations and 100% O2
What are the differential diagnosis of PE?
Myocardial infarction (heart attack) Pneumonia Pericarditis Heart failure Pleuritis (pleurisy) Pneumothorax Pericardial tamponade
A patient comes in and wants to quit smoking. He would like to pursue some smoking cessation pharmacotherapy. What would you prescribe/offer for OTC suggestions?
Nicotine replacement therapy (NRT): Patch (OTC) - 21 mg for more than .5 pack a day -14mg less than .5 pack a day Lozenge (OTC) - more recommended than the gum, dissolves over 20-30 minutes, start with 4mg in the AM if smoke first in AM, so do 2 mg if not. Gum (OTC) Inhaler (Nicotrol) -Rx Nasal Spray (Nicotrol NS) - Rx ---> Chew until tingling and leave between tongue and cheek until tingling. Not as user friendly. Re-chew for 30 min. Varenicline (Chantix) - Rx Sustained release bupropion (zyban) - Rx Clinidine, nortriptyline - not effective
Is the pulse oximetry reading accurate in poor perfusion states like anemia, methemglobinemia, or cyanide poisoning?
No
A 63-year-old man with a long history of cigarette smoking comes to see you for a 4-month history of progressive shortness of breath and dyspnea on exertion. The symptoms have been indolent, with no recent worsening. He denies fever, chest pain, or hemoptysis. He has a daily cough of 3-6 tablespoons of yellow phlegm. The patient says he has not seen a physician for over 10 years. Physical examination is notable for normal vital signs, a prolonged expiratory phase, scattered rhonchi, elevated jugular venous pulsation, and moderate pedal edema. Hematocrit is 49%. Which of the following therapies is most likely to prolong his survival? A Atenolol B Enalapril C Oxygen D Prednisone E Theophylline
Oxygen
A 42-year-old man is admitted to the intensive care unit after an automobile accident. He suffered a compound fracture of the femur and also had internal bleeding from a ruptured spleen and liver hematoma. He has undergone splenectomy and fixation of the femur fracture. He is intubated and sedated following surgery. His hemoglobin after surgery is 5.2 g/dL. His oxygen saturation is 92%, and his PaO2 is 72 mmHg on FiO2 of 0.6. A pulmonary artery catheter was placed during surgery. His cardiac output is 7.8 L/min. A lactate level is 4.8 mmol/L. Which of the following is the least important factor affecting oxygen delivery in this patient? a. cardiac output b. hemoglobin concentration c. PaO2 d. SaO2
PaO2
What are the essentials of diagnosis and general considerings regarding pulmonary embolism?
Predisposition to venous thrombosis, usually of the lower extremities Usually dyspnea, chest pain, hemoptysis, or syncope Tachypnea and a widened alveolar-arterial PO2 difference Elevated rapid D-dimer and characteristic defects on CT arteriogram of the chest, ventilation-perfusion lung scan, or pulmonary angiogram Considerations: third most common death in hospitalized pts, often not recognized before death Several risk factors PE develops in 50-60% of pts with lower extremity DVT, 50% asymptomatic
A patient presents with an increase in pulmonary vascular resistance that is leading to an increase in pulmonary systolic pressure greater than 30 mm Hg or the mean pressure is greater than 20 mm Hg. What is this potential diagnosis here?
Pulmonary Hypertension
A patient presents with dyspnea both at rest and upon exertion. They have a nonproductive cough, malaise, fatigue, and anginal pain. There is syncope with exertion and insufficient cardiac output. After the physical examination they found jugular vein distention, accentuated pulmonary valve component of second heart sound, right sided third heart sound, tricupsid regurgitation murmur, hepatomegaly and lower extremity edema. What is the likely diagnosis? Why can cyanosis result? Why would hemoptysis be concerning?
Pulmonary Hypertension Cyanosis can occur when pts have open patent foramen ovale and right-to-left shunt due to increased right atrial pressure Hemoptysis: rare and life-threatening because signifies the rupturing of the pulmonary artery
fully oxygenated form of hemoglobin oxyhemoglobin diminish/weaken contact between subunits higher pH no 2,3 BPG binding lower CO2 increased oxygen affinity
R form of hemoglobin
When should you NOT use nicotine replacement therapy?
Recent MI, unstable angina, significant coronary disease within 2 weeks
What are the things that should be addressed in clinician counseling? what are the 5 As to quit?
Relevance, risks, rewards, roadblocks, relapse, repeat Ask, Advise, Assess, Assist, arrange Could also use ask, advise, refer, or ask, advise, connect
What are not useful in carbon monoxide diagnosis?
Routine ABG and pulse-oximetry are not useful ABG will likely be ordered anyways but you are not going to use this to determine the CO poisoning routinely.
A patients has a cravings, anxiety/irritability, depressed mood, anger, restlessness, poor concentration, insomnia, hunger, and headache. What are these withdrawal symptoms from?
Smoking Withdrawal Quitter's Flu (headache, fatigue, irritability, insomnia, sore throat)
A patient is prescribed chantix (varenicline), which is for what? How do you use it?
Smoking cessation Start 1 week before quit date Days 1-3: 0.5 mg qAM Days 4-7: 0.5 mg BID Weeks 2-12 (24 wks): 1mg BID Take after eating with full glass water ($450 - 500/month) Adverse effects: nausea, sleep - vivid dreams/insomnia, neuropsy symptoms Precautions: renal impairment, pregnancy/breast feeding, adolescents
A patient wants to start a smoking cessation program. Chantix is out of their budget, so you would like to prescribe bupropion ER 150mg (Zyban) instead. When should this be started, how to use it? What are the adverse effects and precautions?
Start 1+ weeks before quit date. Days 1-3: 150 mg qAM Continued: 150 mg BID (12-26 weeks) Take 8 hours apart not in the late evening (insomnia) Adverse effects: nausea, anxiety/concentration difficulty, dry mouth, constipation, seizures, neuropsych symptoms Precautions: no -> seizures no-> eating disorder hepatic impairment, pregnancy, breast feeding, adolescents
A 57-year-old man has a right total knee replacement for severe degenerative joint disease. Four days later, he develops shortness of breath and right-sided pleuritic chest pain. He is in moderate respiratory distress with respiratory rate 28 breaths/min, heart rate 120 beats/min, blood pressure 110/70 mm Hg, and oxygen saturation 88% on room air. Cardiopulmonary examination is normal. The right leg is postsurgical, healing well, with 2+ pitting edema, calf tenderness, erythema, and warmth; his left leg is normal. What are the immediate management and diagnostic priorities in this unstable patient? What should you use if the ECG only shows sinus tachycardia and chest radiography is clear lung fields? Would you order a d-dimer test here?
Supplemental oxygen, IV access, ECG, chest radiography Order a CT scan No, because this is a high probability scenario not intermediate
increase/strengthen contacts between subunits deoxy form of hemoglobin lacks an oxygen species lower pH 2,3 BPG binding higher CO2 reduced oxygen affinity
T form of hemoglobin
A patient presents with asthma symptoms. They state most of the time asthma keeps them from school activities. They have SOB more than once a day. They had coughing, wheezing, and chest tightness 2 or 3 times this week. They used a rescue inhaler 3 times or more in a day. How controlled do you suspect their asthma to be? What are the 6 steps of treatment of asthma exacerbations?
Uncontrolled Oxygen to >90% Bronchodilators - nebulizer if available Corticosteroids - 0.5-1mg oral or IV Lab evaluation - ABG, CBC, BMP, respiratory vital testing Assessment of response to therapy Adjunct therapy - Mg, anticholinergics, terbutaline, heliox
What would radiographs and CT scans depict in pulmonary hypertension?
Vascular structures "pruning" prominent pulmonary arteries enlarged cardiac silhouette
Why is V/Q scanning used in pulmonary hypertension?
Very sensitive Used to rule out other forms of dyspnea, can differentiate chronic thromboembolic pulmonary hypertension from idiopathic pulmonary arterial hypertension Determines the clot burden; if central and large, these chronic pulmonary emboli may be surgically resected normal ventilation and perfusion (V/Q) scans rule out chronic thromboembolic disease
A patient presents with anemia. There are concerns that the tissue oxygenation could be compromised due to decreased Hb carrying capacity. Will the percentage of saturated molecules remain the same? Will the pulse oximetry be impacted by anemia?
Yes - stays the same and no, anemia does not impact the pulse ox.
A patient presents with pulmonary hypertension, decompensated right heart failure with volume overload. Should they be admitted to inpatient?
Yes, the symptoms are severe. Pts with group 1 and functional class III or IV should be admitted to a specialized center for initiation of advanced therapies
A patient is interested in smoking cessation and wanted to know what activities there are to prevent smoking and promote quitting. What are they?
aggressive media campaigns, tobacco taxes, access to treatment, smoke-free policies, statewide tobacco control programs
differentiate between ventilatory and oxigenatory failure assess effectiveness of mechanical ventilation evalues acid base disorders (sepsis, DKA, renal failure) rule out hypercarbia in patient with altered mental status obtained from radial, brachial, or femoral artery heparinized syringe process immediately tells pH, CO2, paO2, HCO2, sO2, fiO2
arterial blood gas
Why is carbon monoxide dangerous?
avidly binds to HgB resulting in anoxia: affinity 200-250x higher than O2 Reduces oxygen-carrying capacity Alters delivery of oxygen to cells Can cause respiratory complications potentially fatal or leading to permanent organ damage The smoke inhalation is so dangerous for the lungs, and in combo with burns, then people are 50X higher to die.
Patient presented with drowsiness and headache from a suspected suicide attempt. Now the patient is unconscious and into respiratory failure. The doctor notes a cherry red appearance as part of the symptoms. What is the suspected poisoning and how will this impact the pulse oximetry reading?
carbon monoxide and the pulse oximetry could be falsely elevated
What is carbon monoxide?
colorless, odorless, tasteless, non-irritating gas produced by combustion of carbon-containing materials Normal atmospheric presence <10 ppm - higher in urban areas
What would a PFT show in pulmonary hypertension?
combination of decreased single-breath diffusing capacity, normal FVC on spirometry, normal TLC on lung volume measurement, increased wasted ventilation on cardiopulmonary exercise testing is suggestive of pathologically increased pulmonary arterial pressures Aoki: decreased DLCO in disproportion to other findings
What are the indications of an arterial blood gas to be ordered?
differentiate between ventilatory and oxigenatory failure Assess effectiveness of mechanical ventilation Sepsis, DKA, renal failure (acid base disorder evaluation) organic acid poisoning rule out hypercarbia in a patient with altered mental status
What is this scan depicting and what is the condition?
globus pallidus lesions (CT/MRI) - basal ganglia cells particularly sensitive to neurotoxic effect of CO on CNS -bilateral, symmetric, more common in severe toxicity mental confusion, it is important to get this scan, More helpful in ruling out the other causes of neurological deficits/establishing alternative diagnosis
Of the following options, what is the most likely source of carbon monoxide poisoning? smog automobile exhaust improper ventilation methylene chloride
improper ventilation
Why is the echocardiogram with Doppler useful in pulmonary hypertension cases?
it assesses the underlying cardiac disease. It can estimate the right ventricular systolic pressure, which can be estimated based on the tricupsid jet velocity and right atrial pressure. Severity of the pulmonary hypertension can be assessed based on right ventricular size & function
What are the most common causes of death in asthma patients?
mucus plugging, refractory acidosis, tension pneumothorax
Pulse oximetry measures the percentage of bound hemoglobin. It does not differentiate between ____ and ______ Falsely elevated in _____ poisoning.
oxyhemoglobin (HbO2), carboxyhemoglobin (HbCO2) carbon monoxide poisoning.
dyspnea, fever, productive cough chills, pleuritic pain, malaise rales/ronchi dullness to percussion lymphadenopathy lobar and consolidations = typical diffuse, ground glass opacity = atypical
pneumonia
How does hyperbaric oxygen work and when do you use it?
provides 100% O2 at higher pressures than atmospheric pressure (2-3x greater), arterial oxygen pressure becomes elevated to increase O2 delivery, diffusion to tissues Shortens COHb half-life Benefits uncertain; may reduce incidence of subtle neuropsych sequelae Indications: COHb>25% >20% pregnant patient Metabolic acidosis >50y/o Cerebellar findings on neuro exam
respiratory alkalosis right ventricular strain increased perfusion increased dead space decreased lung compliance Hampton's Hump/Westermarks
pulmonary embolism
clubbing, JVD, edema mPAP over 25 increased s2 tricuspid regurgitation hepatomegaly dyspnea on exertion syncope chest pain/pressure
pulmonary hypertension
measures oxyegn percentage of oxygen saturated hemoglobin LED emits 2 waves lengths 660 (red), 960 (infrared) doesn't differentiate between HbO2 and HbCO, so not good for CO poisoning
pulse oximetry
What is the degree of carboxyhemoglobinemia a function of?
relative amounts of CO and O2 in the environment duration of exposure minute ventilation
What is the most important prognostic factor in pulmonary hypertension?
right ventricular function
What is the gold standard for diagnosis and quantification of pulmonary hypertension? When should it be preformed?
right-sided cardiac catheterization prior to initiation of advanced therapies Cardiac cath is helpful in differentiating pulmonary arterial hypertension from pulmonary venous hypertension by assessment of drop in pressure across pulmonary circulation, known as transpulmonary gradient.
What are the laboratory findings in pulmonary hypertension?
routine blood work - normal ABG - idiopathic pulmonary hypertension have normal PaO2 at rest but hyperventilation with decrease in PaCO2. Pts should be evaluated for HIV and collagen vascular disease ECG - right ventricular hypertrophy (right axis deviation, incomplete right bundle branch block), right atrial enlargement (peaked P wave in inferior and right-sided leads)
What are the etiologies of carbon monoxide poisoning?
smoke inhalation (fire), automobile exhaust in enclosed space, poorly functioning heating systems, improper venting, methylene chloride, hurricane aftermath, smoking/hookah, smog, underground electrical cable fires
Why do you need special considerations with asthma during pregnancy?
uncontrolled asthma presents a greater threat of fetal harm than any of the inhaled medications Could worsen (most common) or improve during pregnancy significant alterations in respiratory mechanics during the 3rd trimester may contribute to worsening respiratory symptoms.
How do you treat group 1 pulmonary hypertension?
vasodilator therapy FDA approved indication,
