AG-ACNP – Respiratory Questions and Answers Graded A+

AG-ACNP – Respiratory Questions and Answers Graded A+ 58 yo. M presents to ED with complaints of dry cough. CXR revealed generalized, inflamed film throughout. What is the most likely diagnosis? Pneumonitis What drug has been known to prevent nosocomial PNA? Sulcarafate (Carafate) - Mucosal Protective Agent What is an initial finding associated with a pulmonary embolism? Respiratory Alkalosis - secondary to increased RR and blowing off CO2 What is diagnostic of pulmonary HTN? 2D echo Your patient is intubated on the following settings: SIMV/FiO2 .6/PEEP 5. You notice shunting. What should your next action be? Increase PEEP from 5 to 10 to recruit alveoli and increase surface area to improve oxygenation 32 yo. M with PMH significant for mitral valve replacement now complains of wheezing during physical activity 2-3 times/week. What should you do next? Send patient for pulmonary function testing. What is the pathology of asthma? Increased responsiveness/hyperresponsiveness of the trachea and bronchi to a stimuli. Acute inflammation Narrowing of airways Hypertrophy of smooth muscle Mucosal plugging of airways What are the hallmark signs and symptoms of asthma? Respiratory distress at rest Difficulty speaking in sentences RR > 28 Pulsus paradoxus > 12 mmHg What PFT value is suggestive of an obstructive disease? Decreased FEV1 Which acid-base imbalance is associated with asthma? Respiratory Alkalosis with mild hypoxemia What PFT values would indicate hospitalization of an asthmatic patient? Decreased FEV1 <30% predicted OR does not increase to at least 40% predicted after 1 hr. Peak flow is <60 L/min initially OR does not increase to >50% predicted after 1 hr tx What are the ominous findings associated with an asthma exacerbation? Extreme fatigue Lethargy ABG - hypercapnea >pCO2 >45 mmHg = EMERGENCY What is the outpatient daily management drug for asthma? Inhaled Corticosteroids - Budesonide (Pulmicort) What side effect is associated with inhaled corticosteroids? Candidal infection of the oropharynx, dry mouth, and sore throat. Educate patient to rinse mouth. What drug is indicated for breakthrough symptoms, rescue therapy and before exercise in the asthma patient? Short acting beta-2 adrenergic agonist - Albuterol (Proventil) If symptoms persist in the asthma patient, what pharmacological interventions are indicated? Increase inhaled corticosteroids or add long acting beta-2 adrenergic agonist - Salmeterol (Serevent) What is the indications for ipratroprium bromide (Atrovent)? Secretion management. Inhaled anticholinergic What drug is indicated in the chronic management of asthma? Antileukotrienes - montelukast (Singulair) Which drugs are associated with the BBW - Do not take during acute asthma exacerbation? Long acting beta-2 agonists Antileukotrienes What is the inpatient management of an acute asthma attack? O2 IVF ABG Albuterol 0.3 cc in 3 mL NSS q30-60 mins Corticosteroids - Methylprednisolone 60-125 mg IV x 1 then 20 mg IV q4-6 hrs Anticholinergic - Atrovent MDI 2-6 puffs q4-6 hrs Define status asthmaticus. Severe, acute asthma that is unremitting and poorly responsive. What are the gold standard interventions for status asthmaticus? IV D51/2NS Intubation Cont. pulse ox ABG q 10-20 min How often do you monitor pulse ox and ABGs in status asthmaticus? Continuous pulse ox ABG q10-20 min Define chronic bronchitits. Excessive secretion of bronchial mucous AMB PRODUCTIVE cough >3 mo. for >2 consecutive years Define emphysema. Abnormal, permanent enlargement of alveoli. What ABG is associated with chronic bronchitis? Why? Hypercapnia, hypoxemia. Air is trapped in alveoli and overtime chemoreceptors reset to accommodate high CO2 levels. What CXR findings are associated with COPD? Hyperinflation - low, flattened diaphragm Bulla, blebs What is the outpatient management of COPD? Postural drainage Smoking cessation Inhaled ipratroprium bromide (Atrovent) or sympathomimetics - anticholinergics - secretion management 58 yo. M presents to ED with PMH significant for COPD, home O2 2L NC. Pt is coughing up purulent, thick, yellow mucous. What would you do as the ACNP? O2 NC 2-4 L min or 24-28% venti mask Start antibiotics - 7-10days Ampicillin or amoxicillin 500 mg QID PO for 7-10days Doxycyline 100 mg BID Bactrim DS 1 tablet BID What is the most common clinical presentation of Tuberculosis? Pulmonary disease. TB is a systemic dx that is often asymptomatic. What are the classic signs and symptoms of TB? Dry cough progressing to productive with blood tinged sputum Night sweats Fever, chills Weight loss Identify the definitive diagnosis of TB. Culture of M. tuberculosis x 3 PPD + - send for CXR CXR - Small, homogenous infiltrates in upper lobes True or False: A positive PPD is diagnostic for active TB dx? False. Positive PPD shows exposure, not active disease. What are the drugs used in initial TB treatment? Isoniazid 300 mg Rifampin 600 mg Pyrazinamide 1.5-2.0 gm Ethambutol 15 mg/kg Explain the duration of TB therapy Isoniazid 300 mg, Rifampin 600 mg, pyrazinamide 1.5-2.0 gm and ethambutol 15 mg/kg daily x 2 months THEN Isoniazid 300 mg and Rifampin 600 mg daily x 4 months What is duration of therapy for a patient with HIV diagnosed with TB? NINE months What is the monitoring protocol for patient newly diagnosed with pulmonary TB? Weekly sputum smears and cultures for SIX weeks then MONTHLY after negative cultures What labs should be evaluated at baseline when initiating TB therapy? Liver function tests CBC serum Creatinine What is the risk with ethambutol? Changes in visual acuity Red-green color blind For those with a positive PPD test, what drug is indicated and for how long? INH x 6 months High risk - 5 mm induration Moderate risk - 10 mm induration Low risk - 15 mm induration Define PNA. Inflammation of the LOWER respiratory tract What microorganism is most responsible for community acquired pneumonia (CAP)? Strep. pneumoniae - gram + What is the gold standard in diagnosing PNA? CXR - infiltrates Blood cultures x 3 Identify the management of CAP in the healthy adult < 60 yo? Macrolides - azithromycin (Zithromax) - clarithromycin (Biaxin) - erythromycin OR Doxyclycline Identify the management of CAP in the adult >60 yo with comorbidities? Fluroquinolone - levofloxacin (Levaquin) - ciprofloxacin (Cipro) What is the inpatient ICU management of a patient dx with PNA? Beta lactam - ceftriaxone (Rocephin) PLUS either azithromycin (Zithromax) or fluroquinolone What is the inpatient ICU management of a patient with Psuedomonas PNA? Antipneumococcal, antipseudomonal beta lactam - Piperacillin-tazobactam (Zosyn) - cefepime (Maxipime) - Meropenem (Merrem) PLUS either ciprofloxacin (Cipro) or levofloxacin (Levaquin) What is used in CAP MRSA PNA? Vancomycin or linezolid. What consult is necessary when ordering Linezolid? Infectious Disease consult What are the microorganisms associated with HAP? Staphylococcus aureus Streptococcus pneumoniae Haemophilius influenzae VAP is associated most commonly with what microorganism? Pseudomonas Explain the pathology of a pneumothorax. Gas enters into pleural space Increased pleural pressures Impairs respiration Collapsed lung What are the hallmark signs and symptoms of a pneumothorax? Chest pain Dyspnea Cough Diminished breath sounds on affected side Hypotension What is the gold standard for diagnosing a pneumothorax? CXR At what point does a pneumothorax become symptomatic and require intervention? When the pneumothorax is >20% What intervention is used first in the management on a non-emergent pneumothorax? Chest tube placement 4th-5th ICS MAL What is the immediate intervention indicated for a tension pneumothorax? Needle thoracostomy 2nd ICS MCL What is the leading cause of inpatient hospital death? Pulmonary Embolism. Identify the risk factors of a pulmonary embolism. Immobility Venous stasis Hypercoagulable states Endothelial damage Recent surgery of a long-bone PO contraceptives What are the hallmark signs and symptoms of a pulmonary embolism? ACUTE SOB Hypotension Tachycardia Chest pain Hemoptysis What ABG values are associated with a pulmonary embolism? Hypoxemia (SaO2 <90%, PaO2 <80 mmHg) Hypocapnia (pCO2 <35 mmHG r/t reflexive hyperventilation What are the diagnostics indicated for pulmonary embolism? VQ scan Spiral CT scan Pulmonary angiography What is the medical management of a pulmonary embolism? O2, intubation IVF Heparin 80 u/kg bolus Heparin 18 u/kg/hr - PTT 1.5-2 x normal Coumadin SIMULTANEOUSLY - INR 2-3 What is the goal INR for Coumadin tx with pulmonary embolism? INR 2-3 What is the goal PTT for Heparin therapy with PE? PTT 1.5 - 2 x normal (Normal: PTT 60-90 seconds) What is the pathology of ARDS? Transudative fluid build up in alveoli related to systemic inflammatory process that impairs ventilation and perfusion. What are the signs and symptoms associated with ARDS? ACUTE severe dyspnea Respiratory distress Wheezes What is the hallmark feature of ARDS? Refractory hypoxemia - giving O2 and it doesnt help CXR - whited out with diffuse bilateral infiltrates What is the management of a patient with ARDS? Mechanical ventilation - Low tidal volume, Increase PEEP TV 5-7 or 6-8 ml/kg ideal body weight Peak inspiratory flow 1-1.2 L PRN PEEP 10 cmH20 What is the PaO2/FiO2 ratio indicative of ARDS? PaO2/FiO2 ratio <200 - shunting Will respond to PEEP What is the difference between Assist Control and Spontaneous Intermittent Mandatory Ventilation? Assist Control - preset TV and RR. Patient can breathe over set RR but will get preset TV SIMV - Preset TV and RR, but patient can breathe over vent rate at whatever TV they pull Define Continuous Positive Airway Pressure (CPAP) Breathing spontaneously but at greater pressure than atmospheric. Define Pressure Support. Unassisted inspiratory support but preset airway pressure is delivered with each breath. Define PEEP and the associated side effects. Maintains intrathoracic airway pressure above atmospheric throughout expiration to recruit alveoli and increase ventilation and perfusion. side effects - barotrauma, decreased cardiac output True of False: Once tidal volume on ventilator has been established, it is appropriate to change when patient's status changes. False. Once a TV is set, you do NOT change the TV. What are the mechanical ventilation settings indicated for a patient that has acutely decompensated? AC/FiO2 100%/RR 12/TV 450 No PEEP No Pressure Support What parameters need to be met in order to wean a patient from mechanical ventilation? FiO2 40%, SaO2 >92% SIMV - RR over vent rate HDS Consult pulm/RT Cough Gag reflex What is the gold standard for diagnosing a pleural effusion? CXR - blunting of the costophrenic angles (shark fins) A lower than normal PaO2 indicates hypoxemia PaCO2 reflects alveolar ventilation ARDS is Respiratory failure with hypoxia loss of lung compliance pulmonary edema