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Flashcards in Pulmonary and CP Deck (81)
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approach to pt with mild to moderate Asthma attack


 Hand held nebulizer – asap Albuterol, Atrovent

 Oral Prednisone (60mg) PO (as good as IV initially)

 Peak flow (PEFR) after each neb tx, repeat VS, reassess

 Usually no need for labs, CXR, EKG, ABG, etc



 Walk ‘em, assure f/u, return precautions
--> have them speaking mary had a little lamb her fleece was white as snow

 Oral steroid burst (60mg x5d or tapered dose Rx), inhaled steroid Rx


asthma pt can't go home if

 Not responding to treatment, worsening

 Hypoxic - ambulatory pulse ox <95%

 PEFR not improved to 65- 70% predicted

 ED visit in past 3 days for same

 Exacerbation during steroid burst


hallmark of asthma attack


if not--> another dz process


Other than wheezing what would we likely see in a pt with an asthma attack

Dyspnea, cough, chest “tightness”

Pronged expiratory phase, I:E ratio 1:3 or 4

Tachypnea, tachycardia, HYPOxia, HYPERcarbia

Poor peak expiratory flow measurements (PEFR)


how do you elicit a prolonged expiratory phase

blow out the cake with 100 candles
will hear prolonged exasperation


what is a nl peak flow

Poor peak expiratory flow measurements (PEFR)
650 or 700 is normal


why do we see asthma exacerbations most commonly in the ED

Med non-compliance, viral illness most common reasons


what other pts wheeze


is the person is over 40 and does not have a dx of asthma WATCH OUT


essential questions for pts with asthma

have you had a fever?
have you had any trauma?
have you been sick?
have you had this before?


what is the neb treatment for asthma

albuterol neb 2.5 mg

once, 3x q20min or 10ml/1hr


COPD exacerbation will look like (VS)

BP 170/95,
P 120,
RR 32/min, (not good!)
T 97

pulse ox 93% on 4L nasal canula. 3-4 word sentences, sweating, insists on sitting upright, leaning forward.


treatment goals for COPD

reverse hypoxia, reverse hypercarbia, restore effective ventilation

The retention of CO2 is what brings these people down

pump has to work
alveoli have to work
need to get it out


reasons for COPD exacerbations

1. Disease progression

2. Med non-compliance, out of home O2

3. Infection - viral, bronchitis, pneumonia

4. Cardiac - pump
failure/impairment, arrhythmia

5. Metabolic acidosis, other illness on top

6. Exposure/environment

7. Sedation, drugs


what do we see on a COPD CXR

Hyperexpanded lung fields, narrow cardiac silhouette, flat diaphragms, blunted costophrenic angles


what labs would you want in a COPD exacerbation pt

CXR, lung/cardiac US, EKG, monitor, labs



 Continuous nebulizer treatments
Beta 2 agonists (10mg over 1h)
Inhaled anticholinergics
 Oral steroids, IV if admit
 Antibiotics if appropriate
 Assisted ventilation - NIPPV


antibiotic commonly used in COPD pts


they get the weird bugs


when can you NOT send a COPD pt home

 Not responding, worsening symptoms/signs
 Mental status changes
 If they require a bipap
 Hx recent severe exacerbations/intubation
 Older, co-morbidities
 New arrhythmia
 Uncertain of diagnosis
 Poor ambulatory pulse ox
 Poor home support


presentation of pneumothorax

elevated RR
elevated pulse
94% Room air


focused Hx for pneumothorax

have you had this before?
cardiac and pulm ROS
trauma? syncope?


Pulmonary ROS

Cough? Sputum? Hemoptysis?
o Coughing up blood?
• Shortness of breath (SOB = dyspnea)? • Wheezing?
• Pleurisy?


Cardiac ROS

Chest pain?
• Palpitations?
• Dyspnea on exertion DOE? o SOB on exertion?
• Orthopnea?
o SOB when lying down?
• Paroxysmal nocturnal dyspnea PND?
o Do you awake in the middle of the
night and feel like you have to run
to the window to get air?
• Leg edema?
o Swelling in legs?
• Hx of cardiac problems? (HTN, MI, CHF,
rheumatic fever, heart murmur)?
o **Move to PMH if positive
• Ever had/last EKG?
o **Move to HM: Screening
• Ever had/last heart tests (echo, stress
o **Move to HM: Screening
• Cardiac procedures (cath, stent)
o **Move to PMH: Surgeries if yes


What do you do for suspected pneumothorax

i. IV, O2, monitor; EKG, tx pain
ii. CXR – search edges
1. +/-Expir film, lateral decub; deep sulcus sign if in bed
iii. Bedside ultrasound

looking for absence of “comet tailing”; the friction of pleural sliding

Shock? Or stable now?
1. Can deteriorate quickly
2. Could be obstructive shock
v. Primary or Secondary?
1. Primary pneumo --> spontaneous
2. Secondary pneumo --->a result of something

chest CT
surgery consult


Tx for pneumothorax

1. Treatment depends on size
Pigtail catheter w/ Heimlich valve
Chest tube

2. Small, primary pneumos (<15% total lung) in select cases, a stable patient can go home if:


when can a pneumothorax go home

with a pigtail

Not a secondary pneumo
b. Stable vitals after 3-4hrs
c. Repeat CXR with no enlargement
d. Pt is reliably able to return in 12-24hrs for repeat CXR
e. If catheter re-expansion
i. Stable x6hrs
f. Surgical consult agrees


tension pneumothorax is dx


pt will die if not treated


Pt presentation of pneumothorax (5)

Pt with trauma to the chest

1. Severe dyspnea, sudden change in VS/LOC
2. *Decreased breath sounds affected side
3. *Hypotension
4. *Distended neck veins
5. *Tracheal shift (late)


what is the Tx for tension pneumothorax

iv. Needle thoracentesis: 2nd ICS at MCL

with 16 gauge at second intercostal space mid-clavicular line

v. Follow with chest tube immediately


a. A 54yo woman, hx of breast CA, BIB family. The pt has “not left her bed” and has been c/o chest pain for the past 2 days and seems to be “breathing fast”. Family states chemo/radiation ended 4mos ago. Patient is thin, appears ill, is not talking.
Vitals: BP 108/60, P 110, RR 28, T 99.3 (not a fever), 93% on room air

what is supected in the pt and why

Don’t know yet DDx? PE, sepsis, malnutrition/dehydration, is she in hypovolemic shock?

PE and pulmonary effusion are at the top b/c of hx of chemo

BP is low
P 100
RR 28
T 99.3
93% on room air