COPD chronic smokers alpha 1 antitrypsin disease, chronic bronchitis (excess mucous production mucous hypertrophy) + emphysema destruction of alveoli hyperresonance, decreased breath sounds, crackles
Decreasing mortality – quitting smoking, home oxygen
Mild FEV1 > 80%, moderate 50 – 79, severe 30 – 49, very severe chronic respiratory failure or RHF
>80 albuterol
Add ipratropium 30 to 50 glucocorticoids
<30 oxygen
PaO2 < 55 or O2 sat < 88
COPD exacerbation key COPD who has a change in sputum production increase sputum or change in color
CXR to r/o pneumonia, exacerbation add IV steroids or abx like fluoproquinolones, give NIPPV
Don’t exceed 88-92 as this can cause shunting
COPD PNA zosyn piperacillin tazobactam or cefepime, pseudomonas
Asthma
Acute exacerbation respiratory distress PCO2 normal or elevated, intubate, person with asthma should be hyperventilating their PCO2 should be low, tired can’t blow out PCO2 so respiratory failure is inevtible so intubate
Asthma 4 stages – intermittent, mild persistent, moderate persistent severe persistent
Mild intermittent Albuterol PRN, add low steroids medium then high dose steroid
Acute asthma exerbation
IV steroids and oxygen
COPD IV steroids and oxygen and add antibiotics
Bronchiectasis – permanent dilatation of the airway and loss of cilia
Cystic fibrosis most common cause, obstructive lung disease, diagnosed with high resolution CT, bronchodilators, antibiotics
CF: AR thick chloride transport channels don’t work
Age < 20 staph aureus > 20 pseudomonas in terms of pneumonia treat with pancreatic enzymes, vitamin DEAK, inhaled carnase, breakdown secretions in lung
Pancoast tumors – lung cancer in upper lobe, different manifestations and complications – horner, superior vena cava, phrenic nerve palsy, recurrent laryngeal nerve
SVC: obstructive that impairs drainage of veins to the SVC,
Lung tumor present with edema of the face and arms
Horner – invasion of sympathetic ganglion – ptosis anhidriosis and miosis
Invade brachial plexus – weakness in the right arm
Phrenic nerve palsy – diaphragm to be higher
Laryngeal nerve palsy – voice hoarseness
Smoker central lung tumor SCC, small cell carcinoma
Small cell PTHRP hypercalcemia and hyperphosphatemia with a low PTH, PTHRP causing hypercalcemia
Small cell cancers associated with SIADH, ACTH, and lambert eaton antibodies on presynaptic calcium channels prevents acetylcholine and presynaptic muscular junction
Lambert eaton improves with usage
Myasthenia weaknes with usage
Adenocarcinoma – nonsmokers, on the peripheries
Vignette – nodule on CXR – best next step previous CXR to compare changed CT afterwards, no old imaging – CT
Pneumothorax – one sided decreased breath sounds, decreased fremitus
Tension pneumothorax – tracheal deviation, hypotension, compression of the IVC
Pneumothorax treat with chest tube, tension needle thoracentesis quicker more urgent to release air and then chest tube
ILD – interstitial lung disease ABC – asbestosis beryllium coal, silicosis, sarcoidosis
CXR reticularnodular ground glass or honeycombing asbestosis associated with pleural plaque and mesothelioma
Silicosis egg shell calcifications
Upper lobes – silicosis, TB, aspergillis
Sarcoidosis interstitial lung disease, restrictive cardiomyopathy, CXR bilateral hilar adenopathy, hypercalcemia – granulomas make more calcium ace enzyme elevated
Low PaO2, high PCO2 hypoventilation, difficulty getting air out, obesity hypoventilation or COPD, low PaO2 interstitial lung disease
Four parameters FiO2, PEEP, RR, Vt
PCO2 – RR VT ventilation exhale PCO2 tidal volume, respiratory rate
PaO2 – FIO2 and PEEP
Tidal volume better than respiratory rate
ARDS: systemic infection – pyelonephritis, pancreatis, increased vasodilation of pulmonary capillaries leakage into pulmonary alveoli causing collapse, high peep low tidal volume
Pulmonary hypertension > 25, > 20 pulmonary artery pressure
Lactic acid normal < 1
Aspiration pneumonia – on mechanical ventilation, impaired gag reflexes, dementia / seizures / alcoholics, right lower lobe pneumonias / abscesses, antibiotics that covers anaerobes clindamycin
Pneumocystis jirovecii opportunistic infection with aids or immunosuppressed from organ transplant, prophylaxis and treat with TMP-SMX, when to get steroids when PaO2 < 70 or Aa gradient > 35
AIDS prophylaxis in TMP-SMX for CD4 < 200, presents as atypical pneumonia, fever, nonproductive cough with bilateral interstitial infiltrates
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