Can't Breathe
Still Can't Breathe
Bugs
Help Me breathe
Potpouri
100
Light's criteria
What is LDH >200 Fluid LDH:serum LDH >0.6
Fluid protien: serum protein >0.5
Fluid LDH upper 2/3rd of serum LDH
100
Chronic bronchitis definition
Productive cough for 3 months each year for 2 consecutive years
100
Pt presents with dry staccato cough, nasal congestion, conjunctivitis and is afebrile. CXR shows patchy interstitial changes.
What bug?
What treatment?
Chlamydia
PO Erythromycin
100
A patient with history of coronary artery disease, hypertension, and respiratory distress presents to the ED with shortness of breath. He has no history of fever and his symptoms are worsened by the recumbent position. On physical examination, his vital signs are BP, 180/100; HR, 98; RR, 20; and T, 37.8. You notice that in the seated position he has jugular venous distention. His breath sounds are significant for course expiratory rales and diminished sounds at the bases. His chest x-ray demonstrates bilateral pleural effusions seen at the bases obscuring approximately 15% of his lung. Which of the following is an appropriate management strategy?
A: Administer broad-spectrum antibiotic.
B: Administer bronchodilators via nebulizer.
C: Initiate afterload reduction and antidiuretic therapy.
D: Obtain a high resolution CT of the chest.
E: Perform a thoracentesis.
C - this is pulmonary edema 2/2 CHF exacerbation.
100
CURB 65 criteria and what score to consider admission.
Confusion
BUN > 19 mg/dL
Respiratory Rate ≥ 30
Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg
Age ≥ 65
≥2 = admission
200
A 50-year-old female with history of cirrhosis secondary to hepatitis C complains of shortness of breath for 2 weeks with no other symptoms. Her vital signs are within normal limits and her physical examination is unremarkable. Her chest x-ray is shown (Figure 17-6). What is the most likely diagnosis?
B: hydrothorax
This patient’s advanced liver disease suggests that the findings can represent a sympathetic effusion/hydrothorax. Patients with significant cirrhosis and ascites often have impaired lymphatic drainage leading to pleural effusions. If patient is in respiratory distress and the etiology is unclear, determining whether the fluid is an exudate or a transudate would be helpful by comparing pleural fluid protein, lactate dehydrogenase (LDH) to serum protein, and LDH. If ratio of pleural protein to serum is >0.5 or pleural fluid LDH to serum LDH is >0.6, then the fluid is an exudate. Pneumonia is a possibility but is incorrect due to the insidious progression of symptoms, and lack of fever and cough make it slightly less likely. Acquired diaphragmatic hernias are rare and are seen usually after blunt or penetrating trauma. They usually occur on the left side owing to hepatic protection of the right diaphragm. Pulmonary embolism would typically have a more rapid onset.
200
All of the following conditions have an elevated A–a gradient. Which one will NOT be corrected by supplemental oxygen administration?
A: Age-related decrease A–a gradient due to decreased PaO2
B: Arteriovenous (AV) shunt
C: Congestive heart failure
D: Lobar pneumonia
E: Pleural effusion
B.
An arterial venous shunt will not have an appreciable difference in PaO2 by providing supplemental oxygen. With a pleural effusion, there is a ventilation perfusion mismatch. Increasing oxygen supply will allow for greater delivery of oxygen to well-ventilated areas. Pulmonary edema from CHF can be thought of as a problem occupying the alveolar space and supplemental oxygen should improve the A–a gradient. Lobar pneumonia is incorrect due to a similar scenario when the airspace is occluded with inflammatory fluid due to infection. Age-related changes cause an increase in the A–a gradient that ultimately lower the partial pressure of oxygen in arterial blood (PaO2). Again, supplemental oxygen will be helpful.
200
Pt recently had viral upper respiratory infection and recovered one week ago. Now they have productive cough and fever. Xray shows an infiltrate. Which bacteria is likely responsible?
S. Aureus is most common for post viral PNA.
Strep Pneumo is most common cause of general PNAs.
200
Which of the following represent increased dead space ventilation?
A: Acute respiratory distress syndrome (ARDS)
B: Cyanide toxicity
C: Pulmonary embolus
D: Pulmonary hemorrhage
E: Pneumonia
C: PE
With a pulmonary embolism, there is increased dead space ventilation with a relatively higher proportion of ventilation to perfusion (i.e., high V/Q ratio). An area of the lung is receiving oxygen, but due to thrombotic obstruction of pulmonary vessel, there is an area of under perfusion. Pneumonia represents a situation where inflammatory fluid due to infection impairs ventilation while maintaining adequate perfusion (low V/Q). Pulmonary hemorrhage is similar in that blood is present in airspace while maintaining adequate perfusion (low V/Q). ARDS is an extreme case of airway inflammation that compromises oxygenation and sometimes ventilation while maintaining perfusion. Cyanide toxicity represents a cellular inability to upload oxygen due to cyanide.
200
A patient presents with massive hemoptysis. Which of the following is most likely the source of the bleeding?
A: Alveolar vessel
B: Bronchial vessel
C: Intercostal artery
D: Intercostal vein
E: Internal mammary artery
B: “bronchial vessel” is correct, as they are under systemic pressure and thus are more likely to bleed briskly as opposed to choice A, an alveolar vessel, which is under relatively lower pressure. Choices C and D are incorrect, as these vessels do not communicate with the conducting airways and would be an unlikely source of hemoptysis. Choice E, internal mammary artery, is a frequently used vessel for coronary bypass but does not communicate with conducting airway and an unlikely source for brisk hemoptysis.
300
Patient that was intubated acutely deteriorates with bradycardia and hypoxia. Name 3 reasons why.
Displaced endotracheal tube
Obstruction from secretions
Pneumothorax
Equipment fail
300
What is the most common cxr finding for pulmonary embolism?
Pleural effusion
300
Which of the following is considered a risk factor for penicillin resistance?
A: Asplenia
B: History of unsuccessful treatment with macrolide
C: Immunosuppression from alcoholism or cancer
D: Penicillin allergy
E: Premature infants
C: Immunosuppression from alcoholism or cancer
There is no structural similarity between macrolides and penicillin so there is no known cross-resistance. A history of asplenia may predispose an individual to streptococcal infection but not to penicillin resistance.
300
Treatment of auto-PEEP (name two).
What is 1. Decrease resp rate. 2. Decrease TV. 3. Increase expiratory time. 4. Decreasing secretions/suction. 5. Bagging/Disconnect vent.
Autopeep is incomplete expiration prior to the initiation of the next breath causes progressive air trapping (hyperinflation). This accumulation of air increases alveolar pressure at the end of expiration, which is referred to as auto-PEEP
300
Massive hemoptysis is defined as ____.
Most common cause in the US is ____.
>600ml in 4hrs.
In US - MCC = bronchitis. in world = TB
400
A 22-year-old man presents to the emergency department with a three-day history of shortness of breath, fever, and chest pain. He has a history of intravenous drug abuse and diabetes mellitus. Vitals signs are temperature of 103.2ºF, blood pressure of 110/60 mm Hg, respiratory rate of 23 breaths per minute, and 93% pulse oximetry on room air. Physical examination reveals tachypnea, track marks, and coarse lung sounds. Septic pulmonary emboli are found on cxr. How would the most common microbe differ if the pulmonary emboli came from left vs right sided endocarditis?
For infective endocarditis, MCC organism from the right heart is S. Aureus. From Left heart it's either S. Aureus or Strep Viridans.
400
You suspect a 35-year-old man has epiglottitis with impending airway compromise. Which of the following is the best method for confirming the diagnosis?
A Computed tomography of the neck
B Frontal cervical soft tissue radiograph
C Indirect laryngoscopy
D Lateral cervical soft tissue radiograph
C Indirect laryngoscopy
Direct and indirect laryngoscopy both enable visualization of the airway structures, including the epiglottitis. Direct laryngoscopy refers to the use of a laryngoscope to elevate the tongue and supraglottic structures with the patient in a supine position. Indirect laryngoscopy refers to the visualization of the vocal cords without a direct line of sight, using instruments such as a nasopharyngeal laryngoscope. A CT scan of the neck (A) is a very sensitive test; however, it does not have a role in the emergent diagnosis of epiglottitis due to the need for recumbent positioning, travel from the ED, and concern for airway compromise. Lateral cervical soft tissue radiograph (D) has a sensitivity of up to 90% for the diagnosis of epiglottitis. However, a normal-appearing radiograph does not exclude the diagnosis of epiglottitis. Patients with suspected epiglottitis and a normal radiograph should undergo laryngoscopy.
400
Alcoholic pt with lobar pneumonia and productive of red gelatinous sputum. Which lobe of the lung is most often affected?
Right Upper Lobe
400
A 30-year-old female is intubated and placed on mechanical ventilator due to respiratory failure. The patient’s initial ventilator settings include an assist control mode with a ventilator rate of 16 breaths/min, tidal volume of 650, FiO2 of 60%, inspiratory flow rate of 70 L/min, and no positive end-expiratory pressure (PEEP). Approximately 20 minutes later, the respiratory therapist calls you because the patient’s blood pressure has dropped from 120/60 to 70/50 mm Hg. On physical examination, the patient displays bilaterally diminished breath sounds. What is the next intervention?
A: Add PEEP
B: Bolus 1 L normal saline
C: Decrease inspiratory flow rate
D: Perform bilateral needle decompressions
E: Reduce respiratory rate
E: Reduce resp rate
This asthmatic patient has an underlying expiratory flow limitation due to inflammation and thus is susceptible to air trapping that manifests as auto-PEEP. This auto-PEEP can compromise venous return and lead to hypotension. In asthmatic patients, inspiratory flow rate can be adjusted up and devise a low inspiratory–expiratory ratio, which will increase expiratory phase. To avoid breath stacking, the ventilation rate can be decreased as part of a permissive hypoventilation strategy. Choice C is incorrect because you actually want to maintain a vigorous inspiratory flow rate. Choice B is incorrect because the hypotension is due to physiologic obstruction of preload rather than strict volume depletion. Choice A is incorrect because with an elevated auto-PEEP, you want to avoid extrinsic PEEP. Choice D is incorrect because with relief of auto-PEEP, the ventilation and breath sounds should return to normal. Needle decompression is tenuous intervention because if executed, it must be followed by thoracostomy tubes, which is very complicated in a patient receiving positive pressure mechanical ventilation and thus should be avoided.
400
2 kinds of patients that would be considered having a positive PPD at 6mm are:
HIV
Organ Transplant
Close contact/known exposure to TB
500
Patient has recently been diagnosed with TB and is concerned about the side effects for taking the medications. Name the 4 TB meds and 1 key side effect for each.
INH - peripheral neuropathy & hepatitis
Ethambutol - Optic neuritis
Streptomycin - ototoxicity, nephrotoxicity
Rifampin - Hepatitis, discolored body fluids (red/orange)
500
A 93-year-old woman is brought to the emergency department from home by her family for cough and fever progressively worsening over two days. She has a history of mild dementia, osteoporosis, and a previous stroke, which prompted use of a percutaneous endoscopic gastrostomy tube for nutrition. However, she likes the feel of liquids so she sometimes takes sips on her own. She has not been hospitalized recently, and all her immunizations are up to date. Vital signs show HR 104 bpm, BP 124/78 mm Hg, RR 24/min, T 101.3°F, and oxygen saturation 91% on room air. Rhonchi are heard on lung examination. Chest radiograph reveals a right lower lobe pneumonia. What is the most appropriate treatment of this patient?
A: Levofloxacin
B: Ceftriaxone plus azithromycin
C: Ampicillin plus sulbactam
D: Piperacillin plus tazobactam plus vancomycin
C: Ampicillin plus sulbactam
The patient in this question is presenting with signs, symptoms, and a chest radiograph that are consistent with pneumonia. When considering how best to treat this patient, the clinician must consider the most likely organism leading to bacterial infection. A thorough history will help guide the clinician. A history of a previous stroke that has left this patient with a percutaneous endoscopic gastrostomy tube for eating, and knowing that she sometimes drinks liquids on her own when she probably should not, leads the physician toward a diagnosis of aspiration pneumonia. The pathogens that are most commonly associated with aspiration pneumonia include those from the oral cavity, nasopharynx, and stomach. These bacteria (oral anaerobes and streptococci) are generally considered less virulent than typical community-acquired and hospital-acquired pathogens. Patients generally present with several days of progressively worsening symptoms. The major isolated bacteria include Peptostreptococcus, Fusobacterium nucleatum, Prevotella, and Bacteroides species. It is important to recognize, however, that patients with aspiration pneumonia who reside in a hospital or long-term care facility are more likely to grow gram-negative bacilli or Staphylococcus aureus. This patient is coming from a community setting, so she is less likely to have a more virulent pathogen. When bacterial aspiration pneumonia is suspected, antibiotic therapy should be initiated as soon as possible to prevent worsening symptoms and abscess or empyema complication. The best treatment option in this patient is ampicillin plus sulbactam. Alternative regimens include penicillin or amoxicillin plus metronidazole. Another appropriate choice is clindamycin, but this should be reserved for penicillin-allergic patients, and one should keep in mind possible Clostridium difficile complications, particularly in this elderly woman.
500
You have three patients in the Green zone that have shortness of breath. One breathed in Anthrax, another has a bunch of rabbits that might have Tuleremia, and the last is a rat catcher that might have Hanta Virus. Which one of these gets punted into the Blue Iso room?
Rabbit patient - Tuleremia is highly contagious. The other two are not.
500
Pt with dyspnea is found to have mean pulmonary artery pressure of 38mmHg by right heart catheterization at rest.
First line treatment for severe disease is:
Ergoprostenolol.
In ED, our goal is to maintain adequate right ventricular filling pressure with IVF, but this medication is first line for severe disease.
500
Review Questions
Question 17 of 36
A recently immigrated 4-year-old boy is brought in by his mother because of poor feeding, weight loss, and swellings in his neck consistent with lymphadenopathy. The child is diagnosed with likely tuberculosis on chest x-ray. Which of the following statements is true?
A: Child is highly contagious.
B: Children rarely present with primary stage tuberculosis.
C: Drug therapy for children is similar for adult tuberculosis.
D: Extra pulmonary manifestations are common.
E: Severe respiratory distress is common.
D: Extra pulmonary manifestations are common
TB progresses rapidly from primary disease and seeds other organs by the time children present for medical assistance. Choice A is not the right choice because children with tuberculosis are often very ill and have a weak cough and have a smaller tuberculosis burden than a larger adult. Nonetheless, all patients with tuberculosis should be appropriately isolated. Choice B is incorrect as this is the opposite of what occurs in children who contract tuberculosis. Choice C is incorrect as the prevailing recommendation is to treat all children with a positive purified protein derivative (PPD) and an abnormal chest x-ray for multidrug resistant tuberculosis. Choice E is incorrect because younger children have a paucity of symptoms or are asymptomatic when infected with tuberculosis