EM E1: Pulmonary

What are the 4 D's of epiglottitis?

Dysphagia, Drooling, Dysphonia, Dyspnea

What imaging is done for epiglottitis?

Direct laryngoscopy unless they are in distress

lateral soft tissue cervical films 90% sensitivity (lat. cervical XR)

What is the key sign on a cervical XR for epiglottitis?

thumbprint sign

What is the tx for epiglottitis?

1st line: Vanco + Ceftriaxone/Cefotaxime + High dose dexamethasone

PCN allergy: Levofloxacin + Clindamycin + High dose dexamethasone

*avoid racemic epi d/t rebound effect

What are sx of a retropharyngeal abscess?

drooling, looks ill, painful neck movements, B/L LAD, bulging post. pharynx

What is the tx for a retropharyngeal abscess?

I&D for most cases, can try meds:

IV abx (Clinda or Unasyn) → ineffective use Vanc; transition to PO as sx improve

± dexamethasone

What are sx of peritonsillar abscess?

Hot potato/muffled voice, drooling, trismus, pt in distress, rancid breath, LAD, deviation of uvula

What is need for culture in a PTA?

aspiration of pus

What should be done 1st in the management of a peritonsillar abscess: antibiotics or needle aspiration?

Antibiotics

What is the tx for peritonsillar abscess?

Augmentin or Ceftriaxone or Pen VK & Metronidazole

What is the primary goal of management of dyspnea?

maintenance of airway, PAO2 >60 mmHg and/or SaO2 ≥90%

What is hypoxemia?

Insufficient delivery of O2 to the tissues

T/F: Patients with hypoxemia always have dyspnea

False

T/F: Patients with dyspnea may not have hypoxemia

True

What is a very late sign of hypoxemia?

Cyanosis

What does a formal diagnosis of hypoxemia require?

ABG analysis

T/F: A normal O2 sat DOES exclude hypoxemia

False

In what patients should you NOT provide supplemental oxygenation to in management of hypoxemia?

pts with right-to-left shunt

What is hypercapnia exclusively caused by?

alveolar hypoventilation (PaCO2 > 45 mmHg)

T/F: Hypercapnia is NEVER from increased CO2 production

True

What is the diagnostic study for hypercapnia?

ABG analysis (serum bicarb increases)

When should you NOT admit a patient with hypercapnia?

COPD pts -typically have chronic hypercapnia

*unless it is worsening

When should patients with hypercapnia be admitted?

pt has CNS symptoms

What lung sound:

high pitched, heard during inspiration, not cleared by cough, intermittent individual sounds, short duration

Crackles

What lung sound:

musical noise during inspiration/expiration, usually louder during expiration, continuous

Wheeze

What lung sound:

rumbling coarse sounds, sounds like a snore, may clear with coughing or suctioning, lower frequency, prolonged duration

Rhonchi

What is an important part of the physical assessment of a patient with asthma?

peak flow measurements

T/F: Wheezing does NOT designate the presence, severity, or duration of asthma

True

In what asthma patients should you order an ABG?

only those whose oxygenation is not restored over 90% with oxygen therapy

*initiate O2 if < 92% sat

What is the tx for acute asthma?

Nebulized short acting beta2-agonist with anticholinergic (albuterol, Duoneb)

± Corticosteroids, Epinephrine

When should you admit an asthma pt?

SaO2 < 92%

FEV1 or PEF 40-70%

pCO2 > 42 mmHg

pO2 < 60 mmHg

What is the tx for acute cough?

antitussives (OTC, Tessalon Perles, Bromfed)

What is the predominant sx of acute bronchitis?

cough (usually productive)

What is the criteria for acute bronchitis?

acute cough, fever >100.4, HR 100-120, RR 20-26, focal CP or lung sounds, absence of rhinorrhea or sore throat

What is the tx for acute bronchitis?

abx therapy may decrease duration/sx, but is not needed -does NOT affect outcome (most cases are viral)

What is the MCC of COPD?

most cases are secondary to tobacco abuse

What is chronic bronchitis?

excessive mucus production with airway obstruction and notable hyperplasia of mucus-producing glands

What is emphysema?

destruction of airways distal to the terminal bronchiole

What are sx of chronic bronchitis?

(blue bloater)

productive cough, w/ progression to intermittent dyspnea, frequent & recurrent pulmonary infections, progressive cardiac/resp failure, edema, & weight gain

What are sx of emphysema?

(pink puffer)

long hx of progressive dyspnea with late onset of nonproductive cough, occasional mucopurulent relapses, eventual cachexia and respiratory failure, pursed lips breathing

What does a CXR of chronic bronchitis show?

increased bronchovascular markings and cardiomegaly

What does a CXR of emphysema show?

small heart, hyperinflation, flat hemidiaphragms, possible bullous changes

What is the 1st line tx for COPD?

Beta2-adrenergic agonist: Albuterol

What is the MCC of bacterial PNA?

Strep pneumo

Which type of PNA is more common in winter and more often affects ‘debilitated’ hosts?

(asthma, COPD, smoking)

H. influenza

What causes aggressive necrotizing lobar PNA, usually seen in immunocompromised pts?

Klebsiella

*tendency to occur in upper lobes

Which type of PNA would present with bloody or rust-colored sputum?

Pneumococci

Which type of PNA would present w/ green sputum?

Pseudomonas, Haemophilus, Pneumococcal

Which type of PNA would present w/ foul-smelling sputum?

Anaerobic infections

Which type of PNA would present w/ currant jelly sputum?

Klebsiella & type 3 pneumococci

Rigors and shaking chills are associated w/ which type of PNA?

pneumococcal pneumonia

How does Legionella PNA present?

HA, malaise, N/V/D

*has predilection for lower lung fields

What would a CXR of Strep pneumo PNA show?

air bronchograms

What would a CXR of Klebsiella PNA show?

cavitary lesions & bulging lung fissures

What would a CXR of S. aureus PNA show?

cavitations and associated pleural effusions

Which type of PNA is the MC organism to affect alcoholics?

*high mortality rate

Strep pneumo

Which type of PNA is seen more in diabetics?

S. aureus

PNA is the #1 infection seen in the elderly. What are the 3 MC pneumonias affecting the elderly?

Pneumococcal, Legionella (atypical), Influenza (viral)

What is the tx for PNA in HIV/AIDS patients?

Bactrim

*if intolerant → Pentamidine

What is the tx for community acquired pneumonia?

Macrolide + 2nd/3rd gen cephalosporin or Augmentin

How does a pleural empyema present?

usually preceded by pulm infection, wt loss, anemia; dec breath sounds, dull to percussion, rales/ronchi

What is the needed to confirm the dx of pleural empyema?

aspiration of pleural fluid

What is aspiration pneumonia?

alveolar infection d/t inhalation of pathogenic material from oropharynx

What is aspiration pneumonitis?

inflammatory chemical injury of the tracheobronchial tree from the inhalation of regurgitated gastric contents

How does aspiration pneumonitis present?

nonproductive cough and tachypnea or trachobronchitis with bloody or frothy sputum, and respiratory distress

How does aspiration pneumonia present?

fever, dyspnea, and productive cough, possible change in mental status or function, lethargy or N/V

What empiric abx is used for aspiration pneumonia?

IV Zosyn

What is a sign of primary TB infection?

granulomas

What are sx of reactivation TB?

fever, night sweats, malaise, fatigue, wt loss, productive cough, hemoptysis, CP, SOB

What is the gold standard test for diagnosis of Tuberculosis?

Sputum culture

How soon do you read a PPD test after administrating?

48-72 hrs

What is the tx for TB?

RIF, INH, PZA, EMB x 2 months; RIF & INH x next 4 months

What is a pneumothorax?

air enters the potential space between the visceral and parietal pleura → lung collapse

What is the tx for a tension pneumothorax?

immediate needle decompression at 2nd ICS MCL

What is the gold standard for diagnosis of pneumothorax?

CXR -upright postero-anterior

What does a CXR of tension pneumothorax show?

tracheal deviation (away from affected side)

What are ssx of pneumomediastinum?

subcutaneous emphysema, Hamman's sign, radiating substernal CP that worsens w/ inspiration, dyspnea, dysphagia, cough

What is Hamman's sign?

*assoc. w/ pneumomediastinum

precordial crunching noise synchronous with the heartbeat, often accentuated during expiration

What is hemoptysis?

expectoration of blood from the respiratory tract below the level of the larynx

Mild hemoptysis = < _____ mL of blood in 24 hrs

20

Moderate hemoptysis = _____ mL of blood in 24 hrs

20-600

Severe/Massive hemoptysis = > _____ mL of blood in 24 hrs

600

What is the tx for hemoptysis?

depends on severity -admit mod/severe

massive → tracheal intubation, FFP, cough suppression