Missed Respiratory Qs

1. Pts w/emphysema are at ↑risk of CHF (includes panacinar α1-antitrypsin emphysema)
2. This patient most likely has aspiration pneumonia. In absence of complications, the correct treatment should cover oral anaerobes (clindamycin).
3. cystic fibrosis, and is therefore most likely suffering from Pseudomonas pneumonia, necessitating coverage with two agents from different drug classes (meropenem + gentamicin).
4. A nursing home resident with risk factors such as frequent hospitalizations needs to be treated as if she has a nosocomial pneumonia (meropenem, gentamicin, vancomycin). Additionally, common causes of community acquired pneumonia, such as Mycoplasma, need to be covered as well (azithromycin).
5. This patient seems to have a lung abscess or complicated aspiration pneumonia. As previously discussed, oral anaerobes need to be covered, however, given this patient’s history of IVDA, he is likely to be colonized with resistant S. aureus, necessitating the use of vancomycin as well.
6. A D-dimer test can rule out PE and is best used for patients with a low suspicion. Either a chest CT with contrast or V/Q scan is the best choice for stable patients with a high clinical suspicion PE. Pulmonary angiography is the confirmatory test for pulmonary embolism and should be ordered if less-invasive imaging studies are inconclusive for accurate PE evaluation, This test is invasive and should be reserved for cases where preliminary studies such as V/Q scanning and chest CT are inconclusive despite a high clinical index of suspicion. CT angiography and ventilation-perfusion nuclear scan imaging are the preferred screening studies used to detect PE; pulmonary angiography still remains as the gold-standard test, but is invasive and implemented only when initial screening is inconclusive.
7. The time-tested medical treatment for obstructing nasal polyps is oral corticosteroids. The nonspecific anti-inflammatory agent quickly and substantially reduces the size of the inflammatory polyps and improves symptoms. Intrapolyp steroid injection is the next step after medications fail. Intranasal phenylephrine is useful for congestion and to treat epistaxis, but it has limited use for nasal polyps.
8. Squamous cell carcinomas can secrete PTH-related protein, which causes hypercalcemia and low PTH.
9. An opacified hemithorax with the trachea deviated toward the white out is most likely atelectasis.
10. Adenocarcinoma is the most common non-small cell carcinoma of the lung in the United States and arises peripherally from mucin-producing glandular tissue, which is characterized histologically by the presence of glandular formation and mucin production. The identification of mucin is achieved by periodic acid-Schiff (PAS) staining.
1. Tumors that are peripherally-located tend to be adenocarcinomas or large-cell carcinomas and present with cough and dyspnea, along with pleuritic chest pain resulting from irritation of the parietal pleura and chest wall.
2. Centrally-located neoplasms such as squamous cell carcinomas produce symptoms of cough, dyspnea, atelectasis, wheezing, and hemoptysis.
11. Fiberoptic bronchoscopy is the preferred method to evaluate centrally-located lung lesions while CT-guided biopsy remains the preferred method for the evaluation of peripheral lesions.
12. ARDS is a common complication in ICU patients and is most commonly caused by sepsis. Its pathophysiology consists of non-cardiogenic pulmonary edema. The hypoxia is usually not helped with 100% oxygen because of shunting. His fever and hypotension suggests sepsis which is the most common cause of ARDS in hospitalized patients. Chest X-ray will show bilateral infiltrates with ground-glass appearance suggestive of pulmonary edema. ARDS is diagnosed by having a PaO2/FiO2 ratio (FiO2 is the fraction of inspired oxygen) of less than 200
13. An alternative to steroid treatment for asthma includes leukotriene receptor antagonists such as montelukast.

Remember that ABG analysis may show mild hypoxia and respiratory alkalosis. Look for decreased FEV1 on pulmonary function tests. Regarding medication protocols for the treatment of chronic asthma, disease severity can be divided into 3 basic categories: mild, moderate, and severe. Always remember to treat cases of statis asthmaticus (prolonged, non-responsibe asthma attack) with aggressive bronchodilatory therapy, corticosteroids, O2, and intubation if necessary. Remember AIRWAY, AIRWAY, AIRWAY!!!

Mild (infrequent exacerbations): Treat only with inhaled short-acting beta-agonists during an attack.

Moderate (daily and/or occasional nighttime attacks): Treat with inhaled beta-agonist and inhaled corticosteroid with consideration of adjunct therapy with cromolyn or a leukotriene inhibitor.

Severe (multiple daily and nighttime attacks): Treat with inhaled beta-agonist, inhaled corticosteroid, and multiple additional therapies including systemic steroids.

14. Ventilator Settings:
1. Continuous positive airway pressure, or CPAP, is a setting in which a specific pressure is set, allowing the airways to remain open, and allowing spontaneous breaths by the patient.
2. Intermittent mandatory ventilation, or IMV, is similar, in that the patient can also initiate breaths, however, the machine does not support these breaths with a preset tidal volume. There is also a backup rate setting with IMV.
3. Synchronized intermittent mandatory ventilation, or SIMV, also allows the patient to breathe spontaneously, and tries to coordinate a set amount of its own mechanical breaths with these spontaneous breaths, while also allowing spontaneous unsupported breaths in between.
4. Assist-control ventilation, or ACV, is the type of support described, in which the patient initiates a breath and the ventilator subsequently delivers a breath at a preset tidal volume, with a backup rate in place in the event that the patient fails to initiate a breath.
5. Controlled mechanical ventilation, or CMV, is used when the patient is making no respiratory effort – the machine does not allow spontaneous breaths, nor does it support them. A present tidal volume is given at a set rate.
15. Chronic hypertension causes left-sided congestive heart failure which can lead to transudative pleural effusions. This patient with chronic hypertension is presenting with symptoms of left-sided congestive heart failure. Chronic hypertension is the most common cause of this.
1. Bilateral transudative pleural effusions are associated with congestive heart failure.
2. Pleural fluid with a pH greater than 7.3 is consistent with a transudative effusion.