Studied by 45 people
Shortness of breath (SOB)
A subjective feeling of difficult, labored, or uncomfortable breathing
respiratory distress
Patient presents to the ER with SOB. On a physical exam you note that his breathing is tachypneic, abnormal breath sounds bilaterally, accessory muscle use. You struggle to collect a history as the patient is taking breaths between each word. This is a sign of
cyanosis, inability to maintain respiratory effort, depressed mental status, decreased pulse oximetry, CO2 capnography, Decreased O2, Increase CO2, decreased pH on abg/vbg
Signs of impending respiratory arrest (respiratory failure)
change in ability to move air in and out of the lung, change in ability to facilitate diffusion of oxygen in/CO2 out
What 2 factors lead to respiratory failure?
Alveolar-arterial gradient (A-a)
What measures the overall efficiency of oxygen uptake from alveolar gas to pulmonary capillary blood
high altitude, hypoventilation
Why type of hypoxemia will have a normal A-a gradient?
V/q mismatch, impaired gas diffusion (exercise), R-L shunt (basically just an issue in the lungs)
What types of hypoxemia will caused an elevated A-a gradient?
V/Q mismatch
The air moving in and out with each breath and the circulation of blood should match within the anatomical regions on the lungs to optimize oxygenation, if doesn’t we get a…
PE
What would be an example of a V/Q mismatch that has a circulatory issue (AKA air movement without blood)
pneumonia
What would be an example of a V/Q mismatch that has an air space compromise (AKA circulation without air)?
respiratory system
Primary metabolic imbalances are compensated with a change in the
renal excretion of bicarb
Primary pulmonary imbalances are compensated with a change in
TLC normal/high, FVC normal/low, FEV1 very low, FEV1/FVC low
How will your spirometry results look in someone with an obstructive lung disease?
TLC low, FVC low, FEV1 low, FEV1/FVC normal/high
How will your spirometry results look in someone with a restrictive lung disease?
Obstructive
What type of lung disease is characterized by air being trapped in the lungs and a difficulty exhaling all air from lungs
Restrictive
What type of lung disease is characterized by a difficulty fully expanding the lungs
Group III
What class of pulmonary hypertension is due to lung disease and chronic hypoxia?
Group IV
What class of pulmonary hypertension is due chronic thromboembolism?
RVH (R axis deviation)
Pulmonary HTN will lead to what type of cardiac remodeling
physical obstruction, loss of pulmonary capillaries, stiff lung parenchyma, chronic hypoxia and acidosis
What are some things that can cause pulmonary HTN?
pulmonary HTN
Patient presents to the ER with SOB and chest pain. Patient reports fatigue, a cough, and that the SOB is exacerbated when walking. On a physical example you note swelling in the extremities and abdomen, jugular vein distention and an auscultated accentuated pulmonary valve closure. What is your #1 draft pick of a differential?
BNP, EKG, CT chest w/ angio, echo, R-sided cardiac catheterization
What can you order to help confirm your diagnosis of pulmonary HTN?
R-sided cardiac catheterization
What is the gold standard of diagnosing pulmonary HTN?
Right axis deviation, peak P wave in inferior/right sided leads
What changes might you see on an EKG positive for pulmonary HTN?
calcium channel blockers
What is considered 1st line treatment for pulmonary HTN patients with a positive acute vasodilator response?
endothelin receptor antagonist, phosphodiesterase inhibitors
What treatments for pulmonary HTN have NO vasoconstrictive effects?
Aerobic exercise (nothing super heavy), vaccinations, no pregnancy
Recommendations for pulmonary HTN patients?
Cor pulmonale (pulmonary heart disease/failure)
A progression of pulmonary HTN in which the RV has begun to dysfunction
COPD
What is the most common cause of chronic Cor pulmonale
Supplemental O2 (ABCs 1st fam), EKG, CXR, troponin, BNP
Patient presents to the ER for SOB and Chest pain. He also reports fatigue and swelling in his lower extremities. On a physical exam you note signs of accessory muscle use and patient is in the tripod position. Lung sounds show crackles and rales. What test do you want to order?
bronchodilators/vasodilators, NO diurectics, transplant (last resort)
Okay for our SOB/chest pain homie the EKG shows RVH and the chest xray looks like this. It’s giving Cor Pulmonae what is our treatment plan?
PE (pulmonary embolism)
A blockage within pulmonary circulation that is the 3rd leading cause of death in hospitalized patients
Thrombotic (most common), air, fat, amniotic fluid, cholesterol
What can cause a PE
DVT
Most PEs of thrombotic nature come from a
Venous stasis, injury to blood vessel wall, hyper-coagulability
What is involved with Virchow’s triad of thrombosis?
CT pulmonary angiogram, troponin (chest pain duh)
Patient presents to the ER with a stabbing chest pain radiating through to the back. He reports pain is exacerbated with deep inspiration and that he is coughing up blood. Hx is positive for a PE 4 years ago. Vitals are stable with the exception of HR 125, RR 27. Your amazing, awesome, beautiful ED tech hands you this EKG. Based on this (his wells criteria is like 7) what should you order?
Postive PERC
In a PE workup, when would you do a D-dimer (low sensitivity)?
PERC
The following are criteria for which algorithm: Above 50, HR >100, O2 sat less than 95 on room air, unilateral leg swelling, hemoptysis, Recent trauma/surgery, Prior PE/DVT, Hormone use
Wells
The following are criteria for which algorithm: S/S of a DVT, PE is most likely, HR > 100, immobilization for 3 days, surgery in last 4 weeks, prior PE/DVT, malignancy with treatment within 6 months, palliative care
CXR, CT pulmonary angio (gold standard), V/Q scan, venous doppler ultrasound
What imaging studies are included in a PE workup?
pregnant patients, severe contrast allergy
When would use a V/Q scan in a PE work up
non compressible vein
How does a DVT look on ultrasound
Wells, PERC (30)
Diagnostic algorithms for PEs
Direct acting oral anticoagulants (DOACs)
What is the 1st line anticoagulation treatment for most PE patients?
Low molecular weight heparin (LMWH), warfarin (watch that INR)
Other medications for PE peeps
1st time offender with known temporary cause
What PE patient is on anticoagulation for 3 months?
Any unknown cause or malignancy
What PE patient is on anticoagulation indefinitely?
IVC filters
What can we use for PE patients that have contraindications for anticoagulants or those with recurrent PEs even on anticoags?
Respiratory acidosis partial compensation
pH 7.33 (7.35-7.45)
PaCO2 49 (35-45)
HCO3 30 (22-26)
obstructive
What type of lung disease is this
Metabolic acidosis
pH 7. 25 (7.35-7.45)
PaCO2 42 (35-45)
HCO3 14 (22-26)
Respiratory acidosis
pH 7.28 (7.35-7.45)
PaCO2 49 (35-45)
HCO3 24 (22-26)
Normal to high
How would you expect your FEV1/FVC to look with this flow loop
Fully compensated respiratory alkalosis, metabolic acidosis
pH 7. 40 (7.35-7.45)
PaCO2 19 (35-45)
HCO3 14 (22-26)
Metabolic alkalosis partial compensation by respiratory acidosis
pH 7.50 (7.35-7.45)
PaCO2 51 (35-45)
HCO3 33 (22-26)
Mixed respiratory/metabolic acidosis
pH 7.10 (7.35-7.45)
PaCO2 51 (35-45)
HCO3 14 (22-26)
Respiratory acidosis
pH 7.28 (7.35-7.45)
PaCO2 53 (35-45)
HCO3 25 (22-26)
Respiratory acidosis partially compensated by metabolic alkalosis
pH 7.26 (7.35-7.45)
PaCO2 55 (35-45)
HCO3 32 (22-26)
Fully compensated respiratory alkalosis
pH 7.45 (7.35-7.45)
PaCO2 19 (35-45)
HCO3 14 (22-26)
obstructive
FEV1 → decreased
FVC → normal
TLC → increased
FEV1/FVC → decreased
restrictive
FEV1 → decreased
FVC → decreased
TLC → decreased
FEV1/FVC → normal
obstructive
FEV1 → decreased
FVC → decreased
FEV1/FVC → decrease
Note
Flashcard