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Flashcards in Respiratory Emergencies Deck (64)
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1

For a pt with dyspnea, what three questions do we need to ask ourselves?

Does this pt need to be intubated immediately?

Is this rapidly reversible?

Can he/she run?

2

How do we know when to intubate immediately?

Failure to protect the airway?
Failure to oxygenate?
Failure to ventilate?

If yes to any of the above, intubate immediately

3

There are two types of respiratory failure. What are they?

Hypoxemic pO2 less than 60

Hypercapneic
pCO2 >50 (if not a chronic retainer)

4

There are five reasons for a type 1 respiratory failure (due to hypoxemia). What are they?

1. Low PiO2
2. Hypoventilation ( not enough room for oxygen to get in)
3. Diffusion (DLCO)
4. Shunt (CV defect, atelectasis)
5. V/Q mismatch (give oxygen and it wont help a shunt pt. it will help a VQ mismatch)

5

There are two reasons for a type 2 respiratory failure (due to hypercapnia). What are they?

Increased CO2 production


Alveolar hypoventilation

6

What are examples of increased CO2 production that may cause respiratory failure? 3

What are examples of alveolar hypoventilation that may cause respiratory failure? 2

1. (sepsis, fever, burns, etc)

2.
Reduced minute ventilation
(absolute hypoventilation)

Increased dead space
(relative hypoventilation)

7

Signs of hypoxemia
10

1. Cyanosis
2. Restlessness
3. Confusion
4. Anxiety
5. Delirium
6. Tachypnea
7. Bradycardia or tachycardia
8. HTN
9. Cardiac dysrhythmias
10. Tremor

8

Signs of hypercapnia (CO2)
8

1. Dyspnea
2. Headache
3. Hypertension
4.Peripheral and conjunctival hyperemia
5. Tachycardia
6. Tachypnea
7. Impaired consciousness
8. Papilledema

9

How should we evaluate a pt that may be approaching respiratory failure?
5

1. O2 sats
2. ABG’s
3. Chemistry
4. CXR
5. EKG

10

Severe respiratory dysfunction that threatens the function of vital organs. This will show us poor oxygenation and ventilation. What values do we need to look for and what should they be?

Consider if PO2 is less than 60 mmHg or PCO2 is > 50 mmHg

11

Which pts respond best to NIPPV/Bipap?
2

Why does this help?

COPD exacerbations
CHF

Helps relieve the stress on the respiratory muscles from fatigue
(would seem counterintuitive for COPD pts)

12

What do we need to be aware of when assessing a pt for acute asthma attack?
7



What would clue us in that this is impending respiratory failure?
4

1. use of accessory muscles of respiration;
2. fragmented speech;
3. orthopnea;
4. diaphoresis;
5. agitation;
6. low blood pressure (consider anaphylaxis);
7. severe symptoms that fail to improve with initial treatment

1. inability to maintain respiratory effort and rate;
2. cyanosis;
3. depressed mental status;
4. severe hypoxemia (SpO2 ≤ 95% despite high flow O2 by nonrebreather)

13

How would we evaluate a pt who is having an acute asthma attack?
6

1. Measure peak flow if able
2. Supplemental O2
3. ABGs are generally not useful initially
4. CXR generally not useful initially
5. Establish IV access
6. Frequent reassessment to determine if intubation and mechanical ventilation is needed

14

Acute asthma: peak flow. What does it measure?
3

1. Helps give an objective measurement as to the severity of airflow obstruction
2. Peak flow less then 40 % of predicted = severe
3. Measure before and after each nebulizer or MDI treatment

15

Danger signs that signify impending ventilatory failure include:
7

1. Deteriorating mental status
2. Silent chest
3. Pulsus paradoxus (>15 to 20 mmHg)
4. CO2 retention/ elevated pCO2
5. Acidosis
6. Cyanosis
7. Hypoxemia

16

Asthma medical therapy. Which medications would we give?
5

1. Bronchodilators
2. Glucocorticoid
3. Mag sulfate
4. Epi
5. Terbutaline

17

What kind of the following would we give acute asthma pts:
1. Bronchodilators
2. Glucocorticoid

1. Albuterol (inhaled beta 2 agonist)
1. Ipratropium bromide (atrovent) (anticholinergic)
Give with the albuterol
2. Methylprednisolone (Solu Medrol)

18

Why would you give mag sulfate?


Why would you give epi?

Why would you give terbutaline?

For life threatening exacerbations that remain severe after 1 h of intense bronchodilator therapy - benefits unclear

For suspected anaphylactic rxn or unable to use inhaled bronchodilators


For severe asthma unresponsive to standard therapies

19

Emphysema pts will often present with what as their primary complaint? (what will you notice right away?)

Chronic bronchitis pts will present with what as their primary complaint? (How will they appear when they come into your office? 2)

Emphysema predominant pts will often present with dyspnea as their primary complaint
Often uncomfortable appearing; frequently with accessory muscle use

Bronchitis predominant pts will present primarily with chronic productive cough
On exam, frequently
1. overweight and
2. cyanotic but can appear comfortable

20

COPD exacerbation meds?
5

1. Ipratropium-
2. Albuterol-
3. Corticosteroids- Consider: Prednisone 30-40 mg/day x 10-14 days;
Methylprednisolone 125 mg IV for more severe exacerbations
4. Antibiotics- Reasonable; often recommended
5. Oxygenation-
Watch for CO2 retention!

21

What should the FiO2 be?

FiO2 to achieve pO2 > 55-60 or SaO2 to 90-93%

22

Other interventions for COPD exacerbations?

What are the benefits of this intervention?
3

NIPPV

1. 58% reduction in need for intubation
2. Decreased LOS by 3.2 days
3. Decreased mortality

23

When should we intiate NIPPV early?
4

Initiate early if
1. mod/severe dyspnea,
2. acidemia,
3. hypercapnea, or
4. RR >25

24

What are the three kinds of high altitude sickness?
3

1. Acute mountain sickness (AMS)
2. High-altitude pulmonary edema (HAPE)
3. High-altitude cerebral edema (HACE)

25

What is moderate altitude defined as?
What is high altitude defined as?

Moderate altitude: 8000-10,000 feet
High altitude: 10,000-18,000 feet
O2 sat falls below 90%

26

Serial adaptation steps for acclimitization
2

1. Allows tissues to restore oxygen pressures toward sea level values
2. Requires gradual ascents above 8000 feet

27

Hypobaric hypoxic condition pathophysiology?
5

1. Fluid retention
2. Vasoconstriction
3. Pulmonary artery hypertension
4. Increased endothelial permeability
5. Edema

28

AMS Presentation:
1. Onset? (when is it the worst?)
2. Headache plus at least one of following: 4
3. Gradual resolution by _______?

1. Requires several hours at new altitude
Maximum severity 24-48 hours

2.
-GI upset (anorexia and/or nausea)
-Generalized weakness or fatigue
-Dizziness or lightheaded
-Difficulty sleeping

3. 3-4 days

29

Management of AMS?
6

1. Further ascent contraindicated until symptoms resolve
2. Descent if severe symptoms or if worsening
3. Supplemental oxygen
4. Acetazolamide (250 mg at onset and BID-TID)- diuretic
5. Non-narcotic analgesic
6. Antiemetics

30

Why would we want to give acetazolamide? 2
Alternative to acetazolamide?

1. Speeds acclimatization
2. More rapid resolution of symptoms

Alternative: dexamethasone (8 mg loading dose, 4 mg q6h)