PATHO 2 2
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- What will you find when you do a physical exam on an asthmatic?
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1)wheezing
2)hyper-resonant
3)tachypnic
4)elevated HR
5)prolonged expiratory phase
6)Accessory muscle use
7)pulsus paradoxis - Pulsus paradoxis
- During inspiration, systolic pressure drop by 10, because of increase in negative pressure (pleural cavity)
- By the time you hear wheezing, lung volume has decreased by____
- 25 percent
- How do we diagnose asthma?
-
1)Clinical Hx
2)PFT testing
3)LUng volumes
4)DLCO - Yellow Zone precautions
- Oral medications
- Peak Flow Variations due to steroids
- If the person has undergone a steroid burst, muscle weakness can result
- Broncho-provacation tests
-
1)methylcholine
2)Exercise
3)cold air
4)hyperventilation
5)inhaled histamine - When do we stop the methylcholine challenge
- When the FEV1 decreases by greater than 20 percent of the control, or if the person has completed the high doses of methylcholine
- Tests we might order on an ashmatic
-
1)CXR
2)CBCD
3)Allergy tests - Factors which decrease the lumen of the bronchus
- Mucus plugging, edema, inflammation, bronchospasm
- Airway inflammation causes
- Inflammation, and increased permeability of the vessels
- Increased permeability causes
- Leakage of proteins,fluids, and chemical mediators into the airway
- Why young males have a higher incidence of asthma than girls
- They have smaller lungs
- Prognosis for young females with asthma
- 1/3 will get better, 1/3 will stay the same, 1/3 will get worse. Same prognosis when asthmatic females give birth,but may develop severe asthma during menopause
- Allergens
- Dander, dust mites, spores, cockroaches, molds, fungi, respiratory tract infections, air pollution, aspirin, GERD,sulfites, MSG,inflammation, exercise, inflammation
- Asthma may be difficult to differentiate from_____
- viral bronchiolitis, early CHF, and cystic fibrosis
- CHF wheeze caused by
- enlargement of the pulmonary capillaries, causing consequent narrowing the airways
- Cough variant asthma
- Only cough, not wheezing or SOB
- Signs of severe obstruction
- Pulsus paradoxis, accessory muscle use,retractions,hypoxemia, hypercapnia
- Green zone
-
1)Dypsnea with exertion only
2)able to speak in complete sentences
3)expiratory wheezing
4)peak flow 80-100 - Patients with a moderate asthma exacerbation
-
1)Dypsnea with exertion
2)difficulty speaking complete sentences
3)louder expiratory wheezing
4)peak flow 50-80 - Patients with a severe exacerbation
-
1)dypsnea at rest
2)difficulty speaking a few words
3)anxiety, fatigue, confusion,
4)louder exp. wheeze
5)peak flow less than 50 - Mast cell mediators
-
1)leukotrienes
2)histamine
3)cytokines - Response from mast cell mediators
-
smooth muscle constriction, blood vessel dilation (early, response to bronchodilators)
attraction of eosinophils, neutrophils, and macrophages (6-8 hours) - Resolution time for a late phase response
- 12-24 hours
- Rescue meds
-
1)albuterol
2)metaproterenal
3)pirbuterol
4)terbuteraline
5)levalbuterol - Characteristics of rescue meds
-
1)onset within minutes, peak 30-60 minutes
2)effective for 3-6 hours
3)only for relief from acute bronchospasm - Side effects from rescue meds
-
1)anxiety
2)tremor
3)tachycardia
4)headache
5)hypokalemia
6)tolerance
7)metabolic acidosis - Maintenance meds
- 1)salmeterol
- Long acting beta 2 agonists are ____
- lipophilic
- Salmeterol (serevent)
- 1)10 minutes to
- All patient classified as being beyond__ should be using inhaled steroids
- mild intermittant
- Inhaled steroids can take___before patients see a benefit, and ___ before patients see full benefit
- one month, one year
- fluticasone, pulmocort, azmacort,flunisolide,beclomethasone
-
Can cause--
1)throat irritation
2)thrush/horse - Side effects from oral steroids
-
1)cataracts
2)osteoporosis
3)diabetes
4)immunosuppresion
5)hypertension
6)psychosis
7)cardiovascular disease
8)fluid retention
9)muscle wasting
10)menstrual irregularites
11)adrenal suppression - examples of mast cell stabilizers
-
1)cromulyn sodium
2)nedocromil - action of mast cell stabilizers
- 1)prevent the release of histamine
- Action of leukotrienes
-
1)cause smooth muscle constriction
2)chemoattraction
3)increased vascular permeability
4)increased mucus production - Onset of anticholinergics
- 30-60 minutes
- Drugs that have no immediate effects
-
1)inhaled steroids
2)long acting beta agonists
3)cromylyn/necromil
4)antileukotrienes - Fatal effects of albuterol
-
1)lactic acidosis
2)beta one effects on the heart
3)decreased potassium - Individuals who die from asthma
-
1)older than 55
2)sensitive to aspirin
3)poor perceiver of peak flow less than 150 liters per minute
4)have been intubated
5)2 or more hospitalizations in a year
6)poor access to medical care - nasal polyps and asthma
- some asthma patients develop nasal polyps when given aspirin
- 10 to 15 percent of asthmatics die from ____
- occupational exposure
- General Approach to asthma
-
1) determine if the pt. has asthma
--spirometry
--methycholine challenge
--exercise challenge
--chest x ray
2)assess trigger
3)educate
4)establish maximal
5)determine routine
6)emergency phone list, plan - Structural barriers in to the lower airway
- nasal turbinates, epiglottis
- where is the carina
- where the manubrium meets the body of the sternum, 2nd intercostal space, and aortic knob
- if the carina is blunted____
- There may be a tumor located underneath it
- Airway integtrity is maintained by
- Elastic properties of alveoli
- Most common indication for bronchoscopy
- lung cancer
- Fever and bronchoscopy
- 24 hour fever a complication, because the scope must bypass a sterile airway
- Before a bronchoscopy, patient must be NPO for
- 6-8 hours
- 30-90 minutes before a bronchscopy____
- Patient is given atropine, narcotics, and a benzodiazepine
- Atropine is given before a bronchscopy
- To counteract the vagal reflex, as well as the drying effect of secretions
- Just before a bronchoscopy
-
1)lidocaine neb and/or atomizer
2)versed iv
3)neosynephrine to open the airway
4)oxygen is applied to the less open nare - when starting the procedure
- lidocaine in the nose, then pushed into the airway
- What needs to be monitored during a bronchoscopy
-
1)ECg
2)Sat
3)BP
4) RR - How much saline is used for a lavage
- 20-60 cc's. Procedure repeated 4-5 times, 40 cc's returned through a trap
- Lavage is used to diagnose____
-
1)Pneumonia
2)malignancy
3)Interstital disease
4)alveolar hemm - After the bronchoscopy
-
1)monitored until sedation wears off
2)NPO two hours
3)CXR for pneumothorax if biopsies were performed - Benzidiazepines
- versed,ativan-aniolxic, amnesiac effects
- narcotics
- Morphine,fentanyl--suppress cough, relax the pt.
- wheeze heard over only one area of the body
- is most likely a tumor or a foreign body
- Pts. have peripheral edema
- may have CHF and the global wheeze
- Allergic aspergilliosis
- Is a fungal infection that may present as asthma
- Cough variant asthma people
- will have a positive methycholine challenge
- puebescent males and asthma
- males with mild asthma tend to get better, while those with severe asthma tend not to change
- Why do asthmatics need a CXR
- To rule out fibrosis, pneumothorax, pleural effusion, CHF
- CHF could cause ___ and ___
- SOB and wheeze
- Side effects of resecue meds
-
1)anxiety
2)tremor
3)tachycardia
4)hypokalemia
5)headache
6)metabolic acidosis - Airway responsiveness manifests as
-
1)wheezing
2)SOB
3)chest tightness
4)cough - immune cells which affect asthma
-
1)mast cells
2)macrophages
3)neutrophils
4)eosinphils
5)lymphocytes - A post operative complication
- pulpmary abnnormality that produce idenitifiable disease or dysfunction, aversely affecting a patient's clinical course
- Most common post op complication
- Atalectasis
- Highest risks of pulmonary complications
- upper abdominal or thoracic surgery
- What decreases after upper abdominal or thoracic surgery
-
1)VC, Vt, FRC will decrease
2)A-a gradient will increase
(post op days 1-3) - The patient who stops smoking ___ weeks before the surgery is at the least risk of developing pulmonary complications
- Eight
- Morphine
- can cause increased histamine release, which could exacerbate bronchspasm in the surgical pt.
- One of the best predictors of post-op complications
- PCO2 greater than 45, also a greater than 9 second blowout
- Percent of asthmatics who acquire asthma from occupational exposure
- 10-15 percent
- In the supine position, pts will have a ____ FRC
- decreased, because abdominal contents move against the diaphragm
- RAW is defined as_____
- The pressure required to move 1 L/S in and out of the airways
- Phases of the single breath nitrogen washout
-
1)deadspace exhalation
2)transition from deadspace to alveolar ventilation
3)Alveolar plateau
4)closing volumes - Factors determining DLCO
-
1)area of the alveolar capillary membrane
2)driving pressure of the Co
3)thickness of scarring of the alveolar capillary membrane
4)V/Q mismatch - Contraindications to Spirometry
-
1)respiratory isolation
2)aneuryisms
3)acute illness
4)chest pain
5)current tracheostomy - Anticholingerics blocks
- vagal or parasypathetic tone
- Anticholingerics work better in ____ patients
- COPD
- Theophylline is used with _____ medications and ______
-
1)B2
2) steroids - Airway inflammation contributes to
-
1)airway hyperresponsiveness
2)airway limitation
3)respiratory symptoms
4)disease chronicity
) - Varieties of airway limitation
-
1)bronchospasm
2)mucus plug
2)airway remodeling
4)aiway edema - Atopy
- the genetic predisposition for the devleopment of igE medizated response to common aeroallergens
- Fibroblasts, endothelial cells, and epithelial cells
- release cytokines and chemokines
- B and T cells
- are triggered by cytokines, and signal neutrophils (mast cells alert)
- Macrophages
- signal eosinophils, and other macrophages
- IN adult onset asthma
- IGE response to allergens, and family hx not detected
- Risk Factors for asthma
-
1)genetics
2)age
3)race
4)gender
5)environmental/occupational exposure
6)weight
7)Dietary antioxidants - Mild Intermittant asthma
-
1)Less than 2 days a week, 2 nights a month with symptoms
2)PEF or FEV1 80 percent
3)less than 20 percent variability - Mild Persistent
-
1)3-6 days a week with symptoms, 3-4 nights a month
2)less than 80 percent PEF ir FEV1
3)variability 20-30 percent - Moderate Persistent
-
1)daily sx., more than 5 nights a month
2)60-80 percent PEF or FEV1
3)greater than 30 percent variability - Severe Persistent
-
1)continous sx., frequent nighttime interruption, less than 60 percent PEF or FEVI.,
3)Greater than 30 percent variability - Not recommended for asthma
-
1)methylxanthines
2)antibiotics
3)aggresive hydration
4)CPT