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Pulmonary Emboli
Danger Sign correct answers An older adult complains of sudden onset of dyspnea and coughing.
Cough may be productive of pink-tinged frothy sputum. Other symptoms are tachycardia, pallor,
and feelings of impending doom. Any condition that increases risk of blood clots will increase
risk of pulmonary embolism (PE). These patients have a history of atrial fibrillation, estrogen
therapy, smoking, surgery, cancer, pregnancy, long bone fractures, and prolonged inactivity.
Impending Respiratory Failure (Asthmatic Exacerbation)
Danger Sign correct answers An asthmatic patient presents with tachypnea (>20 breaths/min),
tachycardia or bradycardia, cyanosis, and anxiety.
The patient appears exhausted, fatigued, diaphoretic, and uses accessory muscles to help with
breathing. Physical exam reveals cyanosis and "quiet" lungs with no wheezing or breath sounds
audible. When speaking, the patient may speak only one to two words (cannot form complete
sentence because needs to breathe).
Treatment Plan
Adrenaline injection stat. Call 911. Oxygen at 4 to 5 L/min; albuterol nebulizer treatments;
parenteral steroids, antihistamines (diphenhydramine), and H2 blocker (cimetidine).
After treatment, a good sign is if breath sounds and wheezing are present (a sign that bronchi are
becoming more open). Usually discharge with oral steroids for several days (e.g., Medrol Dose
Pack).
Pulmonary Function Tests correct answers Obstructive dysfunction (reduction in airflow rates)
Asthma, COPD (chronic bronchitis and emphysema), bronchiectasis, others
Restrictive dysfunction (reduction of lung volume due to decreased lung compliance)
Pulmonary fibrosis, pleural disease, diaphragm obstruction, others
Normal Percussion correct answers resonant
Tympany or hyper resonance correct answers Occurs with chronic obstructive pulmonary disease
(COPD), emphysema (overinflating). If empty, the stomach area may be tympanic.
Dull percussion correct answers Associated With
Fluid-filled, pneumonia,
pleural effusion
Address the underlying problem
Bacterial pneumonia with lobar consolidation, pleural effusion (fluid or tumor). A solid organ,
such as the liver, sounds dull.
,Whispered Pectoriloquy correct answers Instruct patient to whisper "99" or "one, two, three."
Compare both lungs. If there is lung consolidation, the whispered words are easily heard on the
lower lobes of the lungs.
Normal: Voice louder and easy to understand in the upper lobes. Voice sounds are muffled on
the lower lobes.
Abnormal: Clear voice sounds in the lower lobes or muffled sounds on the upper lobes.
Tactile Fremitus correct answers Instruct patient to say "99" or "one, two, three"; use finger pads
to palpate lungs and feel for vibrations
Normal: Stronger vibrations are palpable on the upper lobes and softer vibrations on lower lobes
Abnormal: The findings are reversed; may palpate stronger vibrations on one lower lobe (i.e.,
consolidation); asymmetrical findings are always abnormal
Egophony correct answers Normal: Will hear "eee" clearly instead of "bah"
Abnormal: Will hear "bah" sound
Normal: The "eee" sound is louder over the large bronchi because larger airways are better at
transmitting sounds; lower lobes have a softer sounding "eee"
Chronic Obstructive Pulmonary Disease (COPD) correct answers COPD includes both
emphysema and chronic bronchitis. Some patients may also have an asthma component (chronic
obstructive asthma).
Most patients have a mixture; one or the other may predominate. The disease is characterized by
the loss of elastic recoil of the lungs and alveolar damage that takes decades.
The most common risk factors are chronic cigarette smoking and older age. Chronic lung disease
is the third leading cause of death in the United States.
Long-term use of oral corticosteroids increases the risk of correct answers Pneumonia
When you are treating a COPD patient, pick an antibiotic that has coverage against correct
answers Streptococcus pneumoniae and H. influenzae (gram negative).
First-line treatment for mild COPD correct answers is either a SABA or a short-acting
anticholinergic. If poor relief on single agent, add a second agent. If on SABA, add short-acting
anticholinergic (Atrovent).
If short-acting meds are not controlling symptoms, next step is to start correct answers start
patient on a LABA (or a LAMA). Continue using short-acting SABA as needed.
The only drugs for rescue treatment are in the correct answers the SABA class.
is a short-acting anticholinergic. correct answers Ipratropium (Atrovent)
, Emphysema correct answers Permanent alveolar damage and loss of elastic recoil result in
chronic hyperinflation of the lungs. Expiratory respiratory phase is markedly prolonged.
Risk Factors of emphysema/COPD correct answers Chronic smoking (etiology in up to 90% of
cases of COPD), older age (>40 years)
Occupational exposure (coal dust, grain dust)
Alpha-1 trypsin deficiency (rare condition); patients have severe lung damage at earlier ages;
alpha-1 trypsin protects lungs from oxidative and environmental damage
Emphysema Presentation correct answers An elderly man with a history of many years of
cigarette smoking complains of getting short of breath upon physical exertion that worsens over
time; accompanied by a chronic cough that is productive of large amounts of white to light-
yellow sputum (chronic bronchitis) or progressive dyspnea with minimal cough, barrel chest, and
weight loss (emphysema).
Objective Findings
Emphysema component: Increased anterior-posterior diameter, decreased breath and heart
sounds, use of accessory muscles, pursed-lip breathing, and weight loss
Percussion: Hyperresonance
Tactile fremitus and egophony: decreased
CXR: Flattened diaphragms with hyperinflation; bullae sometimes present
Chronic bronchitis component: Productive cough, wheezing, and coarse crackles
Avoid if patient has narrow-angle glaucoma, benign prostatic hyperplasia (BPH), or bladder neck
obstruction. correct answers Anticholinergics (Atrovent, Spiriva):
Safety Concerns of Short-acting beta-agonists (SABAs; albuterol, levalbuterol, or
metaproterenol): correct answers May cause adverse cardiac side effects (palpitations,
tachycardia). Use with caution if patient has hypertension, angina, and/or hyperthyroidism.
Avoid combining with caffeinated drinks.
General TX of COPD correct answers Smoking cessation is very important; options include
nicotine patches or gum, bupropion (Zyban) or varenicline (Chantix), patient education, and
behavioral counseling
Annual influenza vaccination; give pneumococcal vaccine (PPSV23/Pneumovax) and
PCV13/Prevnar); administer 12 months apart
TX guidelines of COPD correct answers Category A (GOLD 1-2)Minimally symptomatic COPD
(low risk of exacerbation)
Short-acting B2 agonist (SABA) PRN alone or in combination SABA with short-acting
anticholinergic (more effective).
Category B (GOLD 1-2)More symptomatic (low risk of exacerbation)
Long-acting B2 agonist (LABA) or long-acting anticholinergic (newer name is long-acting
muscarinic agent (LAMA). May use SABA for rescue PRN.
