Right shift=Decreased hemoglobin affinity for O2 (O2 readily goes from blood into tissues)

Causes:

Acidosis

Increased PCo2

Increased temperature

Increased 2,3-BPG

Abnormal hemoglobin

Left shift= Increased hemoglobin affinity for O2 (readily moves from lungs to blood)

Causes

Alkalosis

Decreased Pco2

Decreased Temp

Decreased 2,3-BPG

Carboxyhemoglobin (CO poisoning)

Methemoglobin (Fe change in heme group)

Major: Diaphragm and external intercostals

Minor: Scalene, sternocleidomastoid

Abdominal muscles

Internal intercostals 

Elasticity (recoil after stretch)

Compliance (ease at which lungs/chest stretch)

If compliance increases,  there will be a loss in elasticity.

What things have an impact on airway resistance?

Length, radius and cross sectional area as well as density, velocity and viscosity of gas.

Increased by parasympathetic response (bronchoconstriction)

Decreased by B2 activation (bronchodilation)

Edema

Obstruction

Po2 in inspired air

Amount left in dead space between breaths

Pa02 (O2 in plasma)

Hemoglobin concentration

Oxygen sat

Dissolved in plasma (10% in veins, 5% in arteries)

Bicarb (60% veins, 90% arteries)

Carbamino compounds like hemoglobin (30% in veins, 5% arteries)

Binding of o2 to hgb helps push Co2 out

Dissociation of o2 from hgb helps c02 diffuse into blood

Dorsal Respiratory Group (DRG) in the medulla

Diaphragm and intercostal muscles

Pao2 </=50

OR

Pac02 >=50 AND pH <7.25

Muscle Weakness:

Guillain-Barre syndrome

Mysathenia gravis

Obesity

Pectus excavatum

Pain (from surgery/trauma)

Very low V/Q mismatch (very low ventilation of well perfused areas)

Atelectasis

Asthma

Pulmonary edema

Pneumonia

When there is more ventilation than perfusion

Pulmonary embolus

Chlorpheniramine

Diphenhydramine

Cetirizine (Zyrtec)

Fexofenadine (Allegra)

Loratadine (Claritin)

Desloratadine (Clarinex)

These drugs are not to be used as a monotherapy and especially not for acute attacks of asthma. Why?

What is one drug in this class?

Long acting Beta Agonists (LABAs)

Because they take a long time to take effect. They last for up to 12 hours though. Used When short acting and corticosteroids ineffective at management.

Example: Salmeterol (Serevent)

Formoterol

Arformoterol

Indacaterol

Salmeterol

What is type of B agonist?

Ipratroprium (Atrovent)

Tiotropium (Spiriva)

Aclidinium (Tudorza Pressair)

Used for bronchospasm when beta-agonists are not tolerated or inconjunction with them

Drying of nasal mucosa

Epistaxis

Bitter taste

Contraindicated in peanut/soybean/soya lecithin allergy

Depress immune response

Decrease mucus production

Sensitize bronchial smooth muscle to B agonists

Used when refractory to other treatments for 5-7 days then pt is switched to inhaled form

Systemic steroids can cause lots of SE (adrenal gland atrophy, peptic ulcers, hyperglycemia) after 10 days

Side effects of Beclomethasone

Contraindications?

Hoarseness

Dry mouth

Changes in taste

Cataracts 

Impaired growth in peds

Oropharyngeal candidiasis

Contraindications: active infection

How do leukotriene modifiers work? Side effects? Examples

Zileuton (Zyflo CR) blocks lipoxygenase stopping production of leukotrienes

Zafirlukast (Accolate) and Montelukast (Singulair) block leukotriene receptors

Few SE: HA, cough, Gi upset, congestion, increased infections if older

Contraindicated in severe hepatic dysfx

Inhibit release of histamine from mast cells

Anaphylaxis, angioedema, bronchospasm

Cromolyn, Nedocromil

They bind to IgE preventing inflammation

Serious side effects: anaphylaxis, bleeding, severe dysmenorrhea

example: omalizumab (Xolair)

Name the short acting muscarinic antagonist

Name the two long acting muscarinic antagonists

Short acting: ipratropium

Long acting: Tiotropium and aclidinium (Pressair)

When Spo2 is 89% or less

@2-4lpm for 18H at least

Smoking cessation

Influenza and Pneumococcal Vaccination

SABA/SAMA

LABA/LAMA

Can add ICS (LABA+LAMA+ICS)

PDE4 inhibitors(for pts with severe exacerbations)

ABX

Mucolytics (if no ICS)

Pulmonary Rehab

Azithromycin (z-pack) continuously

Moxifloxacin (pulse therapy: 5 days every 8 weeks)

K increases

H ions pushed into cells to raise pH at expense of exchanging them for K into blood.

What is normal O2 sat (for book)?

What is normal pO2?

Spo2: 96-100%

Po2: 65-100mmHg

Give normal values for

pH

pCo2

HCO3

pH: 7.35-7.45

pCo2: 35-45mmHg

HCO3: 22-26mEq/L

If ABG: pH high, HCO3 high, and PaCo2 high

What is the pt in?

Partially compensated alkalosis

(Not fully compensated since pH not normal, partially since pac02 is elevated to address alkalosis)

If ABG: pH normal, paco2 25, HCO3 20

What is pt in?

S. aureus

P. aeruginosa

(Gram negs)

Cause what type of pneumonia?

Difference between expectorant and mucolytic

Give one example of each

Expectorants reduce the thickness of the mucus (guaifenesin)

Mucolytics actually break the mucus apart (acetylcysteine "Mucomyst")

Hypoxia from decreased perfusion

Cardiovascular problem

Not sensed by chemoreceptors

Stagnant hypoxia

Hypoxia from low po2 in arteries

Respiratory problem

Possible causes: altitude, hypoventilation

Sensed by chemoreceptors

Response from body is to open more capillaries and vasodilate

Hypoxia due to inability of RBCs to carry oxygen 

Sensed by chemoreceptors

Hypoxia due to tissue cells inability to use O2

example: cyanide poisoning

Not sensed by chemoreceptors

Rifampin

Isoniazid (INH)

Pyrazinamide

Ethambutolol

GI upset/bleeding

Metabolized in liver

Hepatotoxicity

Renal tubular necrosis

Depressed Resp

Hypotension

Constipation

SABA

Non-invasive mechanical vent (CPAP)

Consider:

Systemic corticosteroids (no more than 5-7 days!)

ABX

Not for acute attacks for sure.

There may be benefit in maintenance however many risks so assuming this is why not included in algorithm from GoldCOPD. 

So..no?