Non-infectious disorders (Raf) Flashcards
Diagnostic criteria for PARDS?
- Age: exclude patients with perinatal lung disease
- Timing: within 7 days of known clinical insult
- Origin of edema: respiratory failure not fully explained by cardiac failure or fluid overload
- Imaging: new infiltrate on chest imaging, consistent with acute parenchymal lung disease
- Oxygenation: on at least CPAP+5, with PaO2/FIO2 ratio of <=300 or SpO2/FiO2<=264
Stratify severity of PARDS?
OI of 8-16 is moderate (100-200)
OI <8 is mild (201-300)
OI >=16 is severe (<=100)
Recommendation for ARDS management based on ARDS net?
- tidal volume of 4-8 mL/kg (lower than prior tidal volumes of 10-15 mL/kg)
- low plateau pressure of <=30 cm H2O (lower than previous standard of 50 cm H2)
Other recommendations for management:
- high PEEP
- minimize fiO2
- prone positioning –>this is the lowest priority recommendation, only for patients with refractory hypoxemia
- don’t forget to treat the underlying cause, eg. pneumonia
Pros/cons of heliox?
- Decreases airway resistance since flow is changed from turbulent flow to laminar flow
- Decreases work of breathing (since helium is less dense so less pressure gradient is required to drive flow)decreased work of breathing and patient is less likely to fatigue
- NOT curative
- NOT routinely recommended for asthma management in ED
- For the patient with respiratory distress who is tiring, it’s a bridge to more definitive management
- Disadvantage: less effective when helium is <70%, so not going to be helpful for patient needing significant amount of oxygen (since can only deliver about 20% oxygen)
- Conditions used for: croup, post-extubation stridor, asthma
Post HSCT, what are the different phases you think of to approach complications?
- Pre-engraftment: day 0-30 (early)
- Post-engraftment: day 30-100 (late)
- Late phase: >100
Post HSCT patient with respiratory symptoms within first 30 days, what is DDx?
Infectious complications:
- Bacteria: pseudomonas, G-, G+
- Fungi: Candida
- Viral: minimal
Non-infectious complications:
- pulmonary edema
- mucositis
- peri-engraftment respiratory distress syndrome
- diffuse alveolar hemorrhage, which is associated for bone marrow recovery
- idiopathic pneumonia syndrome
- veno-occlusive disease, which can be pulmonary or hepatic
What types of infections are seen in late (30-100 days) post transplant?
- Bacteria: staph aureus
- Fungi: PJP, Aspergillus
- Viral/protozoal (quite a few viral infections associated with this stage): EBV, CMV, VZV, adenovirus, Toxoplasma
- this is the phase where you seem to be at risk for most number of bugs
What types of infections are seen in the late phase (>100 days) post engraftment?
- Bacteria: H. influenza, Strep pneumo
- No predisposition for fungal infections
- Viral/protozoal: VZV
(don’t seem to be at risk for that many unusual bugs)
(It seems like just at risk for non-opportunistic organisms
What are late complications (>6 months) post lung transplant ?
- PTLD
- Chronic lung allograft dysfunction
If suspecting PTLD, what imaging investigation to order?
PET scan
What are late non-infectious complications post HSCT?
- these late complications start as early as 2- 3 months post transplant
- Bronchiolitis obliterans, which is often part of chronic GVHD
- ILD - often due to drugs or radiation
- Cryptogenic organizing pneumonia
- PTLD
Patient who is 12 months post HSCT, who has SOB and wheeze, top of differential?
- Bronchiolitis obliterans
- Investigations:
- PFT: non-reversible airflow obstruction
- CT: inspiratory and expiratory –>mosaic attenuation
- Treatment:
- Increased immunosuppression: calcineurin inhibitors, azathioprine, steroids
- Azithro + LTRA + ICS/LABA (FAM)
Patient who is >3 months post HSCT with dyspnea and PFT showing restriction and decreased DLCO?
- ILD
- COP
Gold standard for diagnosis of PE?
CT chest- pulmonary angiography
Risk factors for PE
- Oral contraceptive use
- Pregnancy
- Drugs - heavy cigarette smoking (>=20 packyears, probably difficult to achieve this level for a teenager), IV drug use (in particular injection into femoral veins, which casues direct trauma, irritation, infection), glucocorticoids, antidepressants
- Obesity
- Antiphospholipid antibody syndrome
General risk factors:
- Inherited thrombophilia: factor V Leidein, Prothrombin gene mutation, protein C or S deficiency, antithrombin deficiency
- Acquired:
- Malignancy
- Recent surgery, particularly orthopedic, major vascular, neurosurgery, and cancer surgery
- Major trauma
