p1 Flashcards
preop management of COPD?
smoking cessation(4-6) wk prior to surgery decreases post-op pulmonary complications(pneumonia and RF) significantly even if small cigarette consumption.
Long-term oxygen therapy in COPD?
Given if resting O2 saturation <88%
have mortality benefit
what about preop corticosteroid, methylxanthine, and antibiotic?
No benefit
future and approach of a patient with RLD?
Decreased VC Normal or increased FEV1/FVC ratio First, do DLCO If normal--CW abnormality and RM weakness if decreased --ILD
Cause for CW abnormality and RM weakness?
CW abnormality
Obesity hypoventilation syndrome
Scoliosis
RM weakness
Myasthenia gravis
ALS
Polio
Gulian barre syndromeILD future?
Progressive dry cough, fatigue, and dyspnea
Crackles, clubbing
Imaging shows peripheral reticular opacities with traction bronchiectasis +/– “honeycomb” appearance of the lung (advanced disease).
Histologic pattern: usual interstitial pneumonia.
cause of ILD?
Dust
Drug
Radiation
Systemic CTD
Dust?
Asbestos
Beryllium
Silicon
Coal worker pneumoconiosis
Drug?
Amiodarone Bleomycin Nitrofurantoin Methotrexate Busulfan
Systemic CTD?
RA
Scleroderma
Sjögrens syndrome
Pathophysiology of ILD?
May involve multiple cycles of lung injury-
inflammation, and fibrosis.
Fibrosis affects the airway, alveoli, and interstitium
Pulmonary HTN symptom?
Progressive dyspnea, fatigue, and weakness
Exertional angina and syncope due to Dec RVO
Abdominal pain and distension
Physical examination?
left the parasternal lift and RV heave
Loud P2 and right side s3
pansystolic murmur due to TR
RSHF sign
Classification?
primary PHTN
due to LSHF
due to chronic lung disease(ILD
Normal FVC and FVC1/FVC ratio?
FVC:80-120%
FVC1/FVC ratio–>80%
In COPD ratio usualy <70
GERD and asthma?
GERD–microaspiration–bronchial hyperactivity and increase vagal tone.
Asma exacerbation during the night and after a meal
Treat with PPI
Normal pH range?
7.35 to 7.45
Normal values for PaCO2?
are usually 35-45 mmHg.
Partial pressure of oxygen (PaO2)?
75 to 100 millimeters
PE and (A-a) oxygen gradient?
increase due to VQ mismatch
(A-a) oxygen gradient?
- 2.5 + 0.21xage
- Patient age/4 + 4
- Between 5–14 inage < 40
How to calculate PA02?
150-PaCO2/0.8
Exercise-induced asthma pathophysiology?
High volume gas and cold air entery—mast cell degranulation–bronchospasm
Management?
Beta agonist-10-15 min prior exercise(first line), should be used in whom require less than daily
Antilukatrine agent 15-20 min before exercise–second line, not tolerate beta-blocker
Both can be used together in the case of high performing athletes
Antiukatrine and steroid for patient daily exercise practice
trigger of anaphylaxis?
FOOD
DRUG
INSECT STING
CM?
hypotension, tachycardia, and tissue edema
strider,horsnesnes and bronchospasm
Urticarial rash, pruritis, and flushing
nausea, vomiting, and abdominal pain
management?
intramuscular epinephrine airway management and resuscitation adjuvant therapy(antihistamin and glucocorticoid)
How to differentiate asthma fromCOPD?
spirometry plus bronchodilator therapy
asthma –reversible
COPD –not reversible/partially reversible
Old patient with lower lobe infiltration?
CAP due to S.pnumonia
If cavity–Lung abscess due to anaerobes(associated foul-smelling sputum, dysphagia and common in alcoholic)
Assist-Control (AC) mode?
Most common methods of mechanical ventilation in the intensive care unit
AC ventilation is a volume-cycled mode of ventilation.
It works by setting a fixed Tidal Volume (VT) that the ventilator will deliver at set intervals of time or when the patient initiates a breath.
How much TV should be adjusted?
6ml/kg
Bird fancier lung and farmer’s lung?
Type of Hypersensitivity pneumonitis due to exposure of bird dropping and mold respectively.
clinical manifestation?
cough, fever, malaise, and breathlessness after 4-6 hr of antigen exposure.
If chronic–restrictive lung disease
CXR?
Ground-glass opacity/heaviness on CXR.
pathophysiology?
chronic inflammation–lung fibrosis
management?
Avoid exposure
Systemic corticosteroid–severe manifestation and acute exacerbation
myasthenic crisis CM?
Increase generalized or oropharyngeal paralysis
respiratory insuficieny
precipitating factor?
Infection and surgery
Pregnancy or childbirth
tapering corticosteroid
medication(aminoglycoside,fluoroquinolone,BB and CCB)
management?
intubation if deteriorating respiratory status(impeding RF)
plasmapheresis, IV Ig, and corticosteroid
impeding RF sign?
tachypnea
shallow breath
respiratory muscle paralysis
choking
alpha 1 antitrypsin deficiency?
Family history of COPD and Liver disease
COPD
Smoking exacerbates
Minimal LFT abnormality
Diagnosis?
Serum A1A level
Pulmonary spirometry
Liver function test
for a patient who presents with subacute/chronic cough
w/o apparent cause and absent parenchymal lesion what first to do?
Emperic 1st generation antihistamin
Combined antihistamines and decongestants
If not respond for 3-4 wk– Immaging
Atelectasis feutcher?
Decrease/absent BS
Decrease TF
Dullness on percussion
The trachea will deviate to the side of the lesion?
What is a solitary lung nodule?
round opaque
<=3 CM
normal surrounding lung parenchyma
no LDP, surrounding PE and athelectasis
How we approach if it is found on routine x-Ray?
ask for previous X-ray >2 years back–If the same-No further test but patient have not/changed size CT
After CT?
Depend on the presence of malignancy fetcher (low density, large, onion skin calcification and speculated border)
Also consider CM suggesting of malignancy(age >40, smoking, previous malignancy, and weight loss)
no malignancy future?
serial CT follow-Up
Borderline?
Biopsy
PET
malignancy future?
Surgical excision
cause of recurrent pneumonia?
depend on region involvement
On the same field?
Local airway obstruction due to intrinsic(tumor, bronchiectasis) or extrinsic cause(tumor or LDP) Recurrent aspiration(alcohol,drug,GERD,dysphagia and seizure) If the patient has a risk of Ca do CT
On different religions?
Immunosuppression
sinopulmonary disease(ISS and CF)
Non-Infectious(Vasculitis, BOOP)
Location of aspiration pneumonia in supine?
posterior segment of UL
the upper segment of LL
How stroke is a risk?
cause dysphagia and impaired cough reflex
Good pasture syndrome CM
Renal—nephritic syndrome
Pulmonary—Cough, SOB, and hemoptysis
Pathophysiology?
Ab against alpha 3 type chain of collagen type 4 in BM of glomeruli and alveoli
Diagnosis of pneumonia requires?
CXR
CM have sensitivity < 50%
Cause of acidosis in seizure patients?
Prolonged muscle contraction—LA—M.Acidosis
Aspiration/muscle spasm—hypoventilation –R.Acidosis
Acid-base disturbance in PE?
Hypoxia/V/Q mismatch—Hypervantlasion-R.Alkalosis
CM of asbestosis?
Develop prolonged asbestos exposure(e,g shipyard, mining)
Develop after 20 years of exposure
Dyspnea, Clubbing, and inspiratory crackle
Increase the risk of L, Ca, and mesothelioma
plural plaqe in CXR
Imaging (CXR) other diagnosis modality?
Lower lob infiltration
Plural plaque
Spirometer show a restrictive pattern
Decrease DLCO
Pulmonary embolism cardiac catheterization evidence?
Elevated RA pressure
Elevated pulmonary artery pressure
Normal or low capillary wage pressure
Cardiac tamponed finding in cardiac catheterization?
Increase with equalization of RA, PA, and PCW pressure
Archnodinic acid metabolism?
First PLA2m metabolize membrane PL to AA
AA metabolize to leukotriene and prostaglandin and thromboxane by LOX and COX respectively
Function?
LT C4E4D4—Bronchoconstriction and increase vascular permeability, inflammatory
B4—chemotaxis and inflammatory
TXA2 and PGD2—bronchospasm and inflammatory
PGE2 and PGI2
Bronchodilator and vasodilation, anti-inflammatory
Did aspirin exacerbate respiratory disease(AERD) CM?
Constellation of morbid obesity, chronic rhinosinusitis, nasal polyposis, or urticarial with AERD
Non-IGE mediated pseudo drug allergic reaction
Patient present with the asthmatic symptom, sinusitis symptom, and facial flushing after 30min-3 Hr of aspirin ingestion
Is due to an imbalance of pro-inflammatory leukotrienes and anti-inflammatory prostaglandins
Management?
Management chronic sinusitis and asthma
Avoidance of NSAID
Desensitize if NSAID is necessary
Anti-leukotriene for respiratory and sinus symptom
The most common diagnostic criteria of anaphylaxis?
Acute illness involving skin
Respiratory or CVS compromise
A drug that exacerbates anaphylaxis?
NSAID and beta-blocker
By increasing non-immunologic mast cell degranulation and unopposed alpha effect
CM of pneumothorax?
Hyper resonant lung
Decrease air entry
Decrease TF
Hypotension/shock— impairing RV preload due to media sternal venous obstruction
Positive end-expiration MV mechanism, benefit, and complication?
Provide above AP pressure at end of expiration
Prevent alveolar collapse, increase FRC and decrease work of breathing
Alveolar injury, pneumothorax, and hypotension
Cause of atelectasis in MV patient?
Mucus plugging
A shift of the ETT to one bronchus thus the other will be atelectatic
–Normally the ET tube should be 2-4 CM above carina
How do ET intubation, bronchoscopy, and endoscopy, and NGT increase the risk of aspiration pneumonia?
Blocking epiglottis closure
Bacteriology profile of AP?
Mixed aerobic, anaerobic, G+ and G- rods and streptococcus
S/E of inhaled corticosteroid?
In both high and low dose—MC oral thrush
High dose-Cushing
Bronchiectasis signs and symptoms?
Cough with daily mucopurulent sputum production
Rhinosinusitis, dyspnea, and hemoptysis
Crackles and wheezing
suspect specially in non smoker patient with chronic cough
pathophysiology?
Infectious insult with impaired clearance
Etiology?
airway obstruction rheumatic disease(RA and Sjogren) chronic or prior infection(aspergillosis and TB) immunodeficiency (hypogammaglobulinemia) congenital(CF and alpha 1 antitrypsin defriciency)
Evaluation?
HRCT for initial diagnosis
Immunoglobulin quantification
CF testing
Sputum culture and pulmonary function testing
Symptom of B-agonist S/E?
- Hypokalemia related (increase cellular k uptake)—weakness, arrhythmia, and ECG change
- Tremor
- Headache
- Palpitation
Drug induced lung injury future?
- Present acutely as hypersensitivity pneumonitis or chronic ILD
- Fever, dry cough and SOB
- Mid lung and lower lung interstitial infiltration with unilateral effusion
- Leukocytosis and eosinophilia
Granulomatosis with polyangiitis(wegners) CM?
Arthralgia, fever, Weight loss, and fatigue
Sinusitis, otitis media, and saddle nose deformity
Bloody or purulent nasal discharge and hearing loss
Lung nodule and cavitation
Dyspnea, cough, and hemoptysis
Rapidly progressive granulomatosis
Livedo reticularis and skin ulceration
Diagnosis?
ANCA—PR3(70)-C-ANCA and MPO(20)-P-ANCA
Leukocytoclastic vasculitis in skin biopsy
Pausini glomerulonephritis in renal biopsy
Granulomatous vasculitis in lung biopsy
Management?
Corticosteroid and immunomodulator
feucher of bronchiectasis?
Cough and mucopurulent sputum production
Rhinosinusitis, dyspnea, and hemoptysis
Crackles and wheezing
risk factors?
Airway obstruction Rheumatic disease(RA and sjhorgen), toxic inhalation Chronic and prior infection(aspergillosis and Tb) Immunodeficiency(hypoglobulinimia) Congenital(CF and alphal1 antitrypsin deficiency)
Evaluation?
High-resolution CT
imunoglobulin quantification
CF testing and sputum culture
PFT
