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crazysupermedic
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what evaluates respiratory capacity and the ability for a pt to get air out; also used to evaluate obstructive or restrictive disease
pulmonary function test
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what is used to monitor asthmatics, the pt is to blow as hard and fast as the can out
peak flow monitors
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which device is used to diagnose obstructive/restrictive disease
spirometer
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what are some indications for the use of spirometry
- to determine presence, location and severity of dz
- etiology
- reversibility
- operability
- disability
- progression and prognosis
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the amount of air contained in the fully expanded lung is known as what
total lung capacity (everything but the residual volume)
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the maximum amount of air that can be exhaled is known as what
vital capacity (80% of air blown out in 1 sec and tested for 6 seconds)
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spirometry measures ______ volumes of _____ involved in ventilation
different
air
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the volume of air that enters the lung during a normal breath is known as what
tidal volume
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the amount of air remaining after maximum expiration is known as what
residual volume
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what indicates the degree of lung and chest expansion, is a good indicator of patient effort, and measures volume
forced vital capacity
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what measures the total amount of air that a patient can blow out as rapidly as possible after inhaling as deeply as possible
forced vital capacity
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what indicates patency of large airways, indicates both large and small airway function, and measures volume
forced expiratory volume 1 (FEV1)
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what measures the amount of air forcefully blown out during the first second of the effort
forced expiratory volume 1 (FEV1)
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a reduced FEV1/FVC ratio may imply what
airway obstruction
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FEV1/FVC ration is directly affected by what
height and age
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the percentage of FVC that occurs in the 1st second of the effort is known as what
FEV1/FVC ratio
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what indicates patency of small airways, measures flow generated during the mid-portion of the forced expiratory maneuver, is least effort dependent and measures FLOW
FEF25-75 (maximal mid-expiratory flow rates MMEF)--- midblows
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what indicates large airway patency, measures the highest flow that can be generated by the pt forcefully blowing after fully inflating the lungs, IT IS VERY EFFORT DEPENDENT, and measures FLOW
peak expiratory flow (PEF)
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this can be used to diagnose lung disease
spirometry
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this type of lung disease is when there is a decrease in vital capacity (lung volume) but no decrease in the FEV1:FVC ratio
restrictive
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this type of lung disease has a marked decrease in FEV1:FVC ratio, the vital capacity may be normal or decreased
obstructive
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definition: FEV1 or FVC increases >200cc or 12% after given a bronchodilator
reversibility
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what are some restrictive D/O's
- neurologic D/O (ie Guillan Barre, ALS etc)
- tumors (space occupying lesions)
- cavitations
- pneumonia
- fibrosis (sarcoidosis)
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if the FEV1/FVC is greater than 80, and the FVC is decreased this is consistent with what type of pattern
restrictive
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what are some examples of obstructive D/O's
- asthma
- emphysema
- chronic bronchitis
- cystic fibrosis
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if the FEV1/FVC is lower than 80, this is consistent with what type of pattern
obstructive
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which test reflects the ability of the lung to transfer gas across the alveolar/capillary interface
single breath carbon monoxide
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when would the diffusing capacity DLCO be increased and why
- pulmonary hemorrhage
- CHF
- asthma
it is due to increased pulmonary capillary blood volume
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which test aids in the evaluation of suspected asthma, when spirometer is normal
methacholine challenge (histamine)
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what constitutes a positive bronchial provocation test
if the FEV1 falls greater than 20%
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what can assess lung function by analyzing pH, partial pressure of O2, and partial pressure of CO2
arterial blood gases
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what monitors hemoglobin O2 saturation
pulse ox
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what is a hereditary, congenital bodily predisposition to a disease or metabolic or structural abnormality
diathesis
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what are some complications of a capillary puncture
- infection
- excessive bleeding
- thermal injury
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when are capillary punctures not recommended
- poor peripheral perfusion
- edematous extremities
- unstable cardiovascular parameters
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a cough duration greater than 8 weeks is known as what type of cough
chronic
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what type of cough usually has a self-limited origin, is 3 weeks or less, and is usually a viral URI
acute cough
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what is thought to be the most common overall cause of chronic cough
chronic bronchitis (due to cigarette smoking)
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what is the single most common cause of chronic cough in non-smokers
postnasal drainage
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what are some symptoms that accompany PND
- rhinorrhea
- nasal congestion
- sensation of drainage or tickle in oropharynx
- throat clearing
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which type of radiologic view is used to see the sinuses
waters view
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what is characterized by a productive cough on most days for 3 months in 2 consecutive years
chronic bronchitis
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a postinfectious cough is usually caused by what
- respiratory virus
- mycoplasma species
- chlamydia pneumonia
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what is important to remember when evaluating and treating a cough
treatment fails in a significant proportion of nonresponders due to inadequate intensity or duration of treatment
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what are the essentials of diagnosis for asthma/acute bronchitis
- episodic or chronic symptoms of airflow obstruction
- sx's frequently worse at night or early morning
- prolonged expiration and diffuse wheezing
- limitation of airflow on PFT's or a positive bronchial provocation
- complete or partial reversibility
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Definition: a respiratory disease of increased irritability of the tracheobronchial tree, and is a reversible obstructive airway disease
asthma
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what are the characteristics of asthma
- airway obstruction
- airway inflammation
- airway hyper-responsiveness
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what pathogen normally affects pts with DKA
S. Pneumo; S. Aureus
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what pathogen normally affects alcoholics
Klebsiella; Anaerobes
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what pathogens normally affect pts with COPD
H. flu; Moraxella Catarallis; Legionella
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what pathogens normally affect organ transplant pts
Pneumocystis; CMV; Legionella
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what pathogens normally affect sickle cell pts
S. Pneumo
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what pathogens normally affect HIV, CD4 >200
S. Pneumo; H flu; TB
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what pathogens normally affect pts with HIV, CD <200
Pneumocystis; Histo; Crypto
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what is the possible pathogen in air conditioners or hot tubs
Legionella pneumophila
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what is the possible pathogen within travel in the SW USA
coccidoides immitis
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what is the possible pathogen in military training camps
adenovirus; mycoplasm pneumo
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what is the possible pathogen in homeless shelters or jail
S. Pneumonia or MTB
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what is the possible pathogen with exposure to birds
chlamydia psittaci
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what is the possible pathogen with exposure to mice
hantavirus
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what is the possible pathogen with parturient animals
coxiella burnetti
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what is the pathogen with bat caves or excavations
histoplasma capsulatum
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what are some patient evaluations (PE) when suspecting pneumonia
- fever >100.4
- tachycardia, tachypnea
- increased breathe sounds, tactile fremitus, consolidation
- wheezes or rhonci
- crackles or crepitant rales
- decreased pulse ox +/-
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what are some consolidation signs when evaluating a pt with pneumonia
- dullness to percussion
- increased tactile fremitus (increased vibration on 99)
- egophony (e to a changes)
- bronchial breathe sounds crackles (rales)
- whispered pectoriloquy
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what is the possible pathogen when a pt has periodontal disease
anaerobes, polymicrobial
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what is the possible pathogen when a pt has a bullous myringitis
mycoplasma pneumonia
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what is the possible pathogen when a pt has an absent gag reflex, altered mental status
polymicrobial aspiration/ anaerobes
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if a pt is in your office what is the diagnostic criteria for pneumonia
H&P, CXR, sputum, empiric tx
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if there is a pt in a nursing home, what is the diagnostic criteria for pneumonia
H&P, consider CXR, empiric tx
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if the pt is in the ER, what is the diagnostic criteria for pneumonia
H&P, CXR, Labs
*if prognosis if good, empiric tx as outpt
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if you have focal opacity on a CXR, what pathogens can you suspect
- S. Pneumonia, L. Pneumophilia
- S. aureus, C. pneumonia
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if you have multifocal opacities on a CXR what pathogens can you suspect
S. Aureus, L. pneumophilia, S. Pneumo
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if you have an interstitial pattern on a CXR, what pathogens can you suspect
viruses, M. pnueumonia, pneumocystis carnii, C. psittaci
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what labs should be ordered for a pt in the ER for suspected pneumonia
- CBC (differential)
- electrolytes, renal function, liver enzymes
- O2 saturation (ABG if COPD)
- consider HIV serology especially ages 15-54
* if more than 2 pneumo's within 6 months be concerned with their immune system
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what should you consider if there is significant effusion in a pt with pneumoniat
thoracentesis
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which microbial test should be be run on all ICU pts
urine legionella antigen
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in typical pneumonia, what is bacterial pneumonia normally caused by
streptococcus pneumonia
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what are some clinical features in a typical bacterial pneumonia
- sudden onset of fever
- chills
- purulent sputum
- signs of consolidation
- leukocytosis
- CXR with patchy or lobar infiltrates
- pleuritic chest pain with splinting
- THEY LOOK SICK!
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what is atypical pneumonia normally caused by
mycoplasma pneumonia
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which type of pathogen normally affects young people in crowds to include school teachers
mycoplasma pneumonia
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what are some clinical features of atypical pneumonia
- gradual onset
- dry cough
- abnormalities on CXR despite minimal PE findings other than rales
- predominance of extrapulmonary sxs (dry cough, HA, malaise, myalgias, nausea and vomiting, diarrhea)
- May or may not have pleurisy or appear sick
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what is the designations of typical and atypical pneumonias based on
the ability of the pts defense mechanism and virulence of infecting organism
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what is the most common pathogens for outpts without co-morbidities and age <60
- strep pneumo
- mycoplasma pneumo, resp viruses, H flu
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what is the empirical therapy for outpts without co-morbidities and age <60 for pneumo
macrolide zithromax or doxy for 10-14 days
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what are the most common pathogens for outpts with co-morbidities and age > 60 for pneumo
streptococcus pneumo, staph aureus, resp viruses, H flu, aerobic gram neg bacilli
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what is the empirical therapy for outpts with comorbidities or age >60 with pneumo
- beta-lactamase inhbitor (augmentin)
- OR
- 2nd generation cephalosporin (ceftin) or beta lactam cefuroxime
- OR
- IV ceftriaxone (rocefin) 1. give with steril water IM
- 2. dilute into IV bag
- 3. mix with lidocaine
- plus a macrolide or doxy
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what is the most common pathogen in hospitalized severely ill CAP
strep pneumo, legionella, aerobic gram-neg, pseudomonas aeruginosa, resp viruses, mycoplasma
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what is the empirical therapy for severely ill pts (hospitalized) CAP
combination of macrolide and 3rd generation cephalosporin (Fortaz) or other antipseudomonal agent (cipro)
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if you get an CXR on a pt and has a consolidation infiltrate and progressing good with no set backs, when must you repeat the CXR
4-6 weeks
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what is the medication that treats influenza At
tamiflu
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what are the findings in HAP
- fever
- leukocytosis
- purulent sputum
- new filtrate on CXR
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what labs should be run for HAP
- blood cultures x 2
- gram stain and culture of sputum
- tap fluid for exam
- check chemistry tests
- fungal stains and cultures
- serological tests
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in a HAP, which procedure should be used to obtain a good bacteria specimen
fiberoptic bronchoscopy
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if a pt is on a vent and they acquire pneumo what do you want to consider
- atelectasis
- pulmonary edema
- aspiration
- hemorrhage
- effusion
- PE
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what is the treatment for a pt on a vent that acquires pneumonia
broad spectrum and an aminoglycosides
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this type of pneumo follows an URI and has a lobar consolidation on a CXR
strep pneumo
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what is the DOC and alternate for strep pneumo
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this type of pneumonia is common in alcoholics, diabetics, and HAP and will show a lobar consolidation on CXR
klebsiella
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what is the treatment for klebsiella pneumo
cefotaxime (claforan)
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this type of pneumonia is common in CAP, often hits young adults in the summer and fall, often has an atypical presentation compicated by bullous myringitis with an extensive patchy infiltrate on CXR
mycoplasma pneumo
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what is the DOC for mycoplasma pneumo
zithromax
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this type of pneumo is often seen in the summer or fall with exposure to contaminated construction site, water source, or air conditioner, has a patchy or lobar consolidation on CXR
legionella
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what is the DOC for legionella pneumonia
zithromax (macrolide)
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this type of pneumo is often seen in preexisting lung disease, elderly, pts on long term high dose corticosteroids or immunosuppressive therapy
moraxella catarrhalis
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what is the preferred and alternative tx for moraxella catarrhalis
2nd or 3rd generation cephalosporin (rocefin)
Augmentin- bactrim/septra
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which type of pneumo is normally seen in AIDs pts, immunosuppressive or cytotoxic therapy and cancer
pneumocystis jiroveci
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what is the preferred tx for pneumocystis jiroveci
trimethoprim-sulfamethoxazole or pentamidine plus prednisone
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what is the treatment for anaerobic pneumo
clindamycin
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in anaerobic pneumonia and lung abscess, what is required for an empyema
tube thoracostomy
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