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STEP 2 Pulmonary > Pulm. ARDS + PH+ cor pulmonale (09-29) (2) > Flashcards

Pulm. ARDS + PH+ cor pulmonale (09-29) (2) Flashcards

1
Q

UW. ARDS. Risk factors?

A

Infection, trauma, massive transfusion, acute pancreatitis

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2
Q

UW. ARDS. Patho. Lung injury –>?

A

fluid/cytokine leakage into alveoli

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3
Q

UW. ARDS. Patho. leaky capillaries ->

A

crushes alveoli

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4
Q

UW. ARDS. Patho. O2 barier?

A

Bigger diffusion barrier to oxygen.

Less surface area.

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5
Q

UW. ARDS. Patho - mcc?

A

Sepsis is associated with cytokines (IL-1, IL-6, TNF) which can activate inflammatory
cells that injure alveolar and capillary epithelium

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6
Q

UW. ARDS. Patho. accumulation of protein fluid –>

A

Protein rich fluid accumulates in alveoli which disrupts surfactant which leads to alveoli collapse.

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7
Q

UW. ARDS. Patho. V/Q mismatch.

A

.

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8
Q

UW. ARDS. clinical presentation?

A

Sick.
Hypoxemic.
Near drowning or septic shock.

PaO2/FiO2 (oxygen in blood/alveolar oxygen) <300.

Increased A-a gradient.

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9
Q

UW. ARDS. diagnosis. xray?

A

pulmonary edema and bilateral alveolar infiltrate.

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10
Q

UW. ARDS. diagnosis. PCWP (wrong).

A

.

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11
Q

UW. ARDS. diagnosis. what to do to rule out CHF?

A

BNP and cardio echo

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12
Q

UW. ARDS. diagnosis. echo findings, PCWP?

A

Normal or elevated LV function in ARDs.

PCWP is decreased or normal.

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13
Q

UW. ARDS. treatment?

A

Mechanical ventilation very important (yra algoritmas)

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14
Q

UW. ARDS. DPV. what are important measures of oxygenation?

A

FIO2 and PEEP is an important measure of oxygenation.

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15
Q

UW. ARDS. DPV. what affect CO2?

A

Respiratory rate and
tidal volume affect PaCO2

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16
Q

UW. ARDS. DPV. what ,,ventilation”?

A

Low tidal volume ventilation (LTVV)

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17
Q

UW. ARDS. DPV. what volume?

A

(6ml/kg of ideal body weight)

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18
Q

UW. ARDS. DPV. LTVV decreases
the likelihood of over distending alveoli and provoking barotrauma due to
high plateau pressures.

A

.

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19
Q

UW. ARDS. DPV. oxygenation. what starting FiO2, mechanism?

A

Adequate oxygenation: increasing FiO2 by the ventilator improves oxygenation; more than 60% is associated with oxygen toxicity but they are often provided high FiO2 after intubation and then weaned to below 60%.

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20
Q

UW. ARDS. DPV. PEEP mechanism?

A

Increasing PEEP also improves oxygenation by preventing alveolar collapse at the end of expiration; thereby decreasing shunting and the work of breathing.

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21
Q

UW. ARDS. DPV. what PEEP maybe nedded?

A

PEEP levels up to 15-20 cm of H20 might be necessary to maintain
oxygenation.

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22
Q

UW. ARDS. DPV. what is the goal of PO2?

A

The goal is PaO2 between 55 and 80 mmHg and an SpO2 between 88 and 95%.

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23
Q

UW. ARDS. DPV. prone and supine? duration

A

Prone for 16 hours, supine for 8 hours for mild disease and early in the course of
disease.

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24
Q

UW. ARDS. DPV.
Intubation –> Initial settings?

A

Oxygenation: FiO2 100 proc, PEEP 5

Ventilation: Vt 6ml/IBW, RR 14-18

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25
Q

UW. ARDS. DPV.
Intubation –> Initial settings –> Adjust
OXYGENATION
or VENTILATION.

A

.

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26
Q

UW. ARDS. DPV.
Adjust OXYGENATION –> PaO2 > 90 (hyperoxia)

A

Decr. FiO2

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27
Q

UW. ARDS. DPV.
Adjust OXYGENATION –> PaO2 < 60 (hypoxia)?

A

Incr. PEEP

28
Q

UW. ARDS. DPV.
Adjust VENTILATION –> incr. PaCO2 and pH < 7,25 –> ?

A

Incr. RR
incr. Vt as last resort

29
Q

UW. ARDS. DPV.
Adjust VENTILATION –> decr. PaCO2 and pH >= 7,45 –> ?

A

decr. Vt
decr. RR
incr. sedation as last resort

30
Q

UW. ARDS. DPV. Avoid alveolar overdistension.

Evaluate lung compliace. how to do that?

A

measure Pplat with inspiratory hold

*inspiratory hold - pause ventilator briefly after TV is delivered and measure pressure required to hold the lungs at distension on current setting

Goal Pplat =< 30 cmH2O: decr. Vt and/or adjust PEEP

31
Q

UW. ARDS.
Note: noncardiogenic pulmonary edema can also occur when a patient has upper airway obstruction that leads to a large negative intrathoracic pressure (inspiration against obstruction).

32
Q

UW. ARDS. supportive care.
1. treat underlying cause, eg sepsis.

33
Q

UW. ARDS. supportive care.
2. prevent iatrogenic harm ->?

A

Negative fluid balance, timely extubation (eg minimize sedation)

34
Q

UW. ARDS. supportive care.
3. coritcosteroids?

A

+/-
select patients with moderate-severe early ARDS

35
Q

UW. ARDS. prognosis?

A

Mortality: 40 proc. in hospital, mostly due to multiorgan failure

Morbidity: 50proc. with chronic cognitive impairment and physical debility, 25 proc. with chronic pulmonary dysfunction (restriction and decr. DLCO)

36
Q

UW. PH. Classification. group 1?

A

Pulmonary arterial hypertension: idiopathic or due to drugs, HIV, connective tissue disease

37
Q

UW. PH. Classification. group 2?

A

Due to left-sided heart disease

38
Q

UW. PH. Classification. group 3?

A

chronic lung disease (eg COPD, ILD) or hypoxemia

39
Q

UW. PH. Classification. group 4?

A

due to chronic thromboembolic disease

40
Q

UW. PH. Classification. group 5?

A

due to other causes (eg hematologic, sarcoidosis)

41
Q

UW. PH. what pressure?

A

> =25 mmHg or more at rest

42
Q

UW. PH.
Idiopathic
Secondary

Systemic sclerosis and CREST syndrome; hyperplasia of the intimal smooth muscle
layer.

Restrictive lung disease; restrictive pattern on PFTs.

Bronchiectasis; obstructive pattern on PFTs.

Left sided heart failure.

43
Q

UW. PH. symptoms?

A

dyspnea, fatigue/weakness,

exertional angina, syncope

abdominal distension/pain

44
Q

UW. PH. diagnosis? 2 methods

A

cardio echo - can measure pulmonary artery pressure

most accurate - right heart catheterization

45
Q

UW. PH. symptoms. sounds

A

Loud P2, right-sided 3

Pansystolic murmur of tricuspid regurgitation

46
Q

UW. PH. symptoms. chest lifts?

A

left parasternal lift, right ventricular heave

47
Q

UW. PH. symptoms. general symptoms?

A

JVD, ascites, peripheral edema, tender hepatomegaly

48
Q

UW. PH. drugs treatment - in symptomatic idiopathic (group1).
in other groups - treat underlying cause

49
Q

UW. PH. treatment what drugs?

A

Endothelin receptor antagonist (bosentan)
PDE-5-inhibitor (sildenafil), and/or
prostanoids (apoprostenol).

50
Q

UW. PH. what does endothelin? pathway.

A

endotelin-1 joins to endothelin receptor –> vasoconstriction and incr. proliferation of smooth muscles.

Bosentan - inhibitor

51
Q

UW. PH. what does NO? pathway.

A

NO –> cGMP –> vasodilation and decr. proliferation.

PDE-5 inhibitors and Nitrates have positive effect on cGMP.

52
Q

UW. PH. what does prostacyclin? pathway.

A

prostacyclin –> cAMP –> vasodilation and decr. proliferation

Prostacyclin analogues, ar cia tas pats kas prostanoids (apoprostenol).?

53
Q

UW. PH. Early symptoms?

A

dyspnea, weakness, fatigue

54
Q

UW. PH. Late symptoms?

A

chest pain, hemoptysis, syncope, hoarseness (due to compression of recurrent laryngeal nerve)

55
Q

UW. PH. right ventricular failure late in disease.

56
Q

UW. PH. diagnosis (very well know methods)?2

A

xray:
Enlargement of pulmonary arteries with rapid tapering of the distal vessels (pruning)

Enlargement of right ventricle

ECG - right axis deviation (due to right ventricular strain and hypertrophy)

57
Q

UW. PH. untreated leads to cor pulmonale

58
Q

UW. cor pulmonale. definition?

A

Right-sided heart failure (RHF) from pulmonary hypertension

59
Q

UW. cor pulmonale.
RHF due to left-sided or congenital heart disease is NOT considered cor pulmonale.

60
Q

UW. cor pulmonale.
diagnosis? 3

A

xray
ECG
Right heart catheterization (gold standard for diagnosis)

61
Q

UW. cor pulmonale. diagnosis gold standard?

A

Right heart catheterization (gold standard for diagnosis)

62
Q

UW. cor pulmonale.
xray - whats seen?

A

i. Enlarged central pulmonary arteries
ii. Loss of retrosternal air space due to right ventricular hypertrophy

63
Q

UW. cor pulmonale.
ecg changes?

A

i. Right axis deviation
ii. RBBB
iii. Right ventricular hypertrophy
iv. Right atrial enlargement

64
Q

UW. cor pulmonale.
Right heart catheterization (gold standard for diagnosis), whats seen?

A

i. incr. CVP
ii. incr. Right ventricular end-diastolic pressure
iii. inc.r Mean pulmonary artery pressures (>= 25mm Hg at rest)

65
Q

UW. cor pulmonale. treatment.
a) optimizing right ventricular dynamics (preload, afterload, and contractility)?

A

i. Supplemental oxygen
ii. Diuretics
iii. Treatment of underlying etiology

66
Q

UW. cor pulmonale. treatment.
b) what for severe decompensation?

A

IV inotropes are given for severe decompensation

STEP 2 Pulmonary (30 decks)

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