ILD case history

Question 1

Interstitial filtrates acronym is

SHIT FACED, what does that stand for?

Answer 1

S: sarcoid

H:Hypersensitivity penumonitis

I:interstitial lung disease

T: tumor, TB

F: fungal

A: asbestosis

C: collagen vasc

E: eosinophil granuloma

D: drugs

Question 2

Chest xray: scratchy lung fields =

Answer 2

interstitial involvement of suppporting tissue of lung parenchyma: see fine or coarse reticular opacities or small nodule

Question 3

With interstitial infiltrates on xray, what kind of biopsy will we do?

Answer 3

we will use transbronchioal biopsy and do 6, get 95% dx of interstitial infiltrates

Question 4

Diagnostically we see granuloma and you can see large granuloma

Submucosa dominated by granulomas. See interstitium w/ granulomas as well. Look like sarcoidosis but call it non-necrotizing granulomas. Pathologists can’t call this sarcoidosis, need what two things to compare it to?

Answer 4

Need microbiology correlation before you make definitive dx as well as comparing to clincal picture

Question 5

What do you see on histology?

Answer 5

Well circumscribed, non-necrotizing epitheliod cell granuloma with multinucleate giant cells

Question 6

Descibe this open lung biopsy

Answer 6

Granulomas w/ lymphatic distribution pattern; discreate and well-circumscribed following broncovascular bundles and interstitial septa

Question 7

Describe Stage I Sarcoidosis:

Nodes: looks like jumbo shrimp.. get lateral chest xray

Answer 7

Jumbo shrimp = Stage I

Question 8

Describe Stage II sarcoid on xray

Answer 8

Stage II sarcoid: nodes and scrathy lungs

Question 9

Describe Stage III sarcoidosis

Answer 9

Very scratchy, NO NODES

Question 10

What do we see in stage IV sarcoidosis

Answer 10

very bad fibrosis

Question 11

Therapy recommendation for sarcoidosis?

dyspnea, with decreased FVC below 70% and cough/wheezing

Answer 11

prednisone or inhaled corticosteroids

Question 12

What do fluffy markings on xray indicate?

Answer 12

Consolidation- any pathologic process that fills the alveoli

Question 13

What is the pneumonic for alveolar infiltrates?

Answer 13

Pecan Pie:

PCPIE

P = pus

C- cells (RBS/eosinos/tumor)

P-protein

I-inflammatory

E-edema (cardiac or non cardiac)

Question 14

Berlin Criteria for ARDS

Answer 14

ARDS while on PEEP >/= to 5 cm H20

Timing: acuteness of illness 7 days

Fluid overload assessed by clinical judgement- echo if no risk factor

CXR or CT findings: bilateral infiltrates

Question 15

What does Lung Protective Ventilation consist of?

Answer 15

Low Tidal Volume and Low Plateau Pressure

Question 16

In the Acute Lung injury randomized trial, patients were given two different tidal volumes:

12 ml/kg or 6 ml/kg

Which patients faired better?

Answer 16

Patietns with 6 ml/kg did better. Mortality prior to hospital discharge when from 40% in the 12 ml/kg group to 30% in the 6 ml/kg group and had more ventiliatory free days

Question 17

In ventilator protocol our tital volume is 6 ml/kg, but what about PEEP? Do you want lower PEEP/Higher FiO2 OR

higher PEEP/lower Fi02?

Answer 17

Doesn’t matter, PEEP being high or low doesn’t contribute significanlty to overall mortality

16 is a nice sweet spot

Question 18

FACTT; Fluid and Catheter Treatement Trial compared LIBERAL (up to 6 L/day) vs Conservative (no fluid other than daily)

What did we see in ventilatory free results?

Answer 18

Tx with conservative fluid therapy resulted in 14.5 ventilator free days vs 12 ventilator free days in pts with liberal fluid

Question 19

Key points:

____ tidal volumes preferred

____ fluid management after ‘just right’ early resuscitation is preferred

_____ positioning for more sever ARDS

_____ for pts with severe ARDS

Answer 19

small tidal volumes

conservative fluid volumes

Prone position for more severe ARDS

Paralysis for severe ARDS

Question 20

Key point on

PEEPS

Nutrition

B-agonists

Surfactant

Statins and salmon

Answer 20

choose your peep, no right or wrong

nutrition; both grandmas right

B-agonists shouls stay in OLD

Surfactant for children, not adults

Statis and fluids shouldn’t be in the water