Pulmonary and Critical Care Medicine Flashcards
Diagnostic Imaging pleural effusion
- CXR should be performed as the first test
2.U/S is a helpful addition to CXR for identification of small effusions
3.CT with contrast include the ability to detect small amounts of pleural fluid; the assessment of coexisting intrathoracic abnormalities, such as pulmonary masses and malignant pleural disease
multiseptated (loculated) pleural effusion is ……..
exudate
Indications for Diagnostic Thoracentesis
new effusion of unclear etiology and > 1 cm of fluid thickness
Pleural fluid triglycerides, support the diagnosis of chylothorax if it’s
> 110 mg/dL (1.24 mmol/L)
Complicated parapneumonic effusions treatment
- drainage.
Options for drainage include early surgical intervention via video-assisted thoracoscopic surgery and chest tube drainage with or without the combined use of intrapleural fibrinolytics and a mucolytic agent (deoxyribonuclease, or DNase).
Malignant Pleural Effusion treatment
Repeat therapeutic thoracentesis is appropriate for patients with poor prognosis (less than 3 months) and slow reaccumulation of fluid.
Patients with rapid reaccumulation of fluid and dyspnea should be offered more definitive management. Indwelling pleural catheters with intermittent outpatient drainage
Nonmalignant Pleural Effusion treatment
If diagnostic uncertainty persists, additional evaluation with imaging (chest CT with contrast) and possible thoracoscopy should be considered.
Options for management include tunneled pleural catheters, pleurodesis, or both after careful discussion with a multidisciplinary team.
considered a large pneumothorax if
If the lung margin is greater than 2 cm away from the chest wall at the level of the hilum
Management of Pneumothorax
if <2 cm on chest radiograph, minimal symptoms
Needle aspiration or admit to hospital for observation and supplemental oxygen (PSP may be managed as an outpatient if good access to medical care)
Management of Pneumothorax
if >2 cm on chest radiograph, breathlessness, and chest pain
Insertion of a small-bore (<14 Fr) thoracostomy tube with connection to a high-volume low-pressure suction system
Management of Pneumothorax
if Cardiovascular compromise (hypotension, increasing breathlessness) regardless of size
Emergent needle decompression followed by thoracostomy tube insertion
Note: If persistent air leak (>48 hours), refer to an interventional pulmonologist or thoracic surgeon
Intervention to prevent recurrence of pneumothorax.
chemical and mechanical pleurodesis
in pneumothorax
1. Air travel should be avoided
2.scuba diving
- until complete resolution
- not recommended unless definitive therapy such as surgical pleurectomy has been applied.
Pleural-fluid LDH level in exudative pleural effusion
> 2/3 upper limit of normal for serum LDH
Diagnoses suggested by elevated pleural fluid amylase
Pancreatitis, esophageal rupture
Pulmonary Hypertension definition
resting mPAP of 20 mm Hg or greater
Classification of Pulmonary Hypertension
- PH (includes idiopathic and heritable disease, disease associated with use of drugs or toxins, connective tissue diseases, HIV infection, congenital heart disease, schistosomiasis, and portal hypertension; also includes vasoresponsive PAH and PAH attributable to pulmonary venoocclusive disease or pulmonary capillary hemangiomatosis)
2.PH due to left-sided heart disease
3.PH due to lung diseases or hypoxia
4.Chronic thromboembolic pulmonary hypertension and other pulmonary artery obstructions
5.PH with unclear or multifactorial causes
Evaluation of Suspected Pulmonary Hypertension
- ECHO (should not be used to confirm a PH diagnosis because is often inaccurate)
2.PFT, HRCT, Sleep Study
3.serologic tests for underlying connective tissue disease, hepatitis, and HIV are advised
- V/Q scan to evaluate for chronic thromboembolic PH
5.Right heart catheterization is essential to confirm a diagnosis of PH
When V/Q scan suggests chronic thrombus, additional imaging to evaluate the extent of CTEPH is indicated.
Digital subtraction angiography
current guidelines recommend that patients with CTEPH undergo screening for
thrombophilia
Chronic Thromboembolic Pulmonary Hypertension (Group 4)
treatment
Anticoagulation and consideration of thromboendarterectomy are indicated for CTEPH.
Lifelong anticoagulant therapy is indicated in all patients to help prevent further thromboembolism.
In inoperable patients and those who have persistent PH after thromboendarterectomy, balloon pulmonary angioplasty or medical therapy (Riociguat) should be considered.
apnea-hypopnea index : mid
5-14
apnea-hypopnea index moderate
15-30
apnea-hypopnea index severe
> 30
The most important risk factor for obstructive sleep apnea is
obesity
Overnight pulse oximetry for
asymptomatic with a low pretest probability, normal overnight oximetry might support the decision to avoid further testing.
OSA treatment
1.bariatric surgeon should be considered for patients with BMI ≥35 who have not benefited from or are intolerant of positive airway pressure therapy.
2. CPAP or BIPAP in hypoventilation syndrome
On polysomnography, absence of respiratory effort associated with loss of airflow for at least 10 seconds.
central apnea
Initial management of CSA
- should target modifiable risk factors (reduction or elimination of opioids improves CSA &Medical optimization of heart failure)
- CPAP may occasionally be useful, especially in patients with overlapping OSA
- oxygen during sleep may be indicated for who have hypoxia during sleep, as well as for those who cannot use or tolerate CPAP
CPAP treatment alternative for mild/moderate OSA
Oral appliance
Diagnosis suggested by nocturnal absence of respiratory effort and airflow
CSA
DLCO
Mild
> 60
DLCO
moderate
40-60
DLCO
severe
< 40
An increase from baseline in FEV1, FVC, or both of at least …………relative to the predicted value indicates a positive bronchodilator response
10%
in obstructive pattern FEV1/FVC ratio
< 0.70
TLC is normal or even increased in
pure obstructive disease
If FEV1 or FVC is reduced and the FEV1/FVC ratio is 0.70 or greater
restrictive pattern may be interpreted, but measurement of TLC is needed to confirm this.
If TLC is less than 80% of predicted (or the lower limit of normal), a restrictive pattern is present.
coexisting obstructive and restrictive pulmonary disorders
FEV1/FVC ratio»_space;
TLC»_space;
low FEV1/FVC ratio (obstructive) and a low TLC (restrictive) are both present
In cases of suspected inaccurate pulse oximetry by finger probe, changing to
an earlobe probe or forehead probe is indicated.
Positive bronchial challenge test result
FEV1 > 0.2 ml or 12 %
Allergic Bronchopulmonary Aspergillosis
diagnosis
1.presence of asthma
2.elevated IgE levels
3.positive skin tests to Aspergillus antigens
4.increased Aspergillus-specific IgE and IgG levels
5.either central bronchiectasis or infiltrates.
Allergic Bronchopulmonary Aspergillosis
treatment
Management is aimed at
1.suppressing the enhanced immunologic response with systemic glucocorticoids
2.reducing the fungal antigenic burden with antifungal agents
target interleukin-5 (IL-5)
- mepo (lizumab)
- res (lizumab)
- benra (lizumab)
anti-IgE biologic
omalizumab
inhibitor of IL-4 and IL-13
dupilumab
BA management in Step 1
SABA as needed
Or ICS & SABA as needed
BA management in Step 2
Daily low dose ICS & SABA as needed
Or
ICS & SABA as needed
BA management in Step 3
Daily & as needed combination low dose ICS- formoterol
BA management in Step 4
Daily & as needed combination medium dose ICS - formoterol
BA management in Step 5
Daily medium to high dose ICS- LABA + LAMA & SABA as needed
BA management in Step 6
Daily high dose ICS - LABA + oral steroid + SABA as needed
Consider add-on
Anti IgE
Anti IL5,
Anti IL4/ IL13
Cystic Fibrosis is
autosomal recessive
results in abnormally thick secretions that are difficult to clear.
the initial test for CF is
Sweat chloride testing
Abnormal results on repeat testing are diagnostic of CF
Genetic testing confirms the diagnosis and helps with prognosis.
treatment of CF
airway clearance
antibiotic therapy
nutritional support
psychosocial support.
Bronchiectasis is diagnosed by
HRCT.
Diagnostic criteria include an airway diameter that is greater than that of its accompanying vessel and lack of distal airway tapering
treatment of bronchiectasis focuses on
clearing the airway
treating infections
preventing exacerbations
Patients should also be encouraged to exercise, which can improve airway clearance and symptoms.
Surgical resection should be considered in patients who have localized disease with persistent symptoms despite therapy.
Treatment of Exacerbations of bronchiectasis
Therapy is guided by routine sputum and AFB culture results.
Empiric antibiotic therapy is recommended and may be based on previous culture data until the results of the current sputum culture become available.
If previous data are not available, a fluoroquinolone can be started to ensure Pseudomonas coverage until sputum culture results are available.
The 2023 guidelines recommend adding inhaled glucocorticoids in COPD if:
- if eosinophil count exceeds 300/uL,
- if exacerbations are uncontrolled and the eosinophil count is > 100/uL
- if the patient has significant asthmatic features along with COPD.
selective phosphodiesterase-4 inhibitor that is used to reduce the frequency of exacerbations in patients with severe COPD who have primarily symptoms of chronic bronchitis.
Roflumilast
Indications for long-term oxygen therapy
- Hypoxia: PaO2 ≤55 mmHg (7.32 kPa) or SaO2 ≤88 %
- In the presence of cor pulmonale
PaO2 ≤59 mmHg (7.85 kPa) or SaO2 ≤89 %
Hematocrit > 55 %
Clinical evidence of right HF
Ideal patients for lung volume reduction therapy
1.upper-lobe-predominant emphysema,
2.FEV1 and DLCO of 20% of predicted or higher, and
3.low exercise tolerance after completion of pulmonary rehabilitation.
Antibiotic class for severe COPD with frequent exacerbations
Macrolide
LÖfgren syndrome
1.Acute
- Erythema nodosum
- Arthritis
- Hilar adenopathy
Heerfordt Waldenström
- Subacute to chronic
- Fever
- Parotid enlargement
- Uveitis
- Facial palsy
Asbestos exposure, progressive Dyspnea, pleurtic chest pain , bloody pleural effusion
Mesothelioma
Patient with silicosis are at risk concurrent…….infection
TB
- Asbestosis involves the ……. Lung
- Silicosis involves the ….. lung
- Lower
- Upper
recommend serologic testing to exclude CTD-associated DPLD.
Routine testing with
CRP,
ESR,
ANA,
RF, ACCP
myositis panel.
smoking-related DPLDs, the primary management is
smoking cessation.
Glucocorticoids may be considered with severe disease or in those with refractory symptoms.
treatment of Hypersensitivity Pneumonitis
Removal of exposure to the offending antigen
Glucocorticoids and sometimes other immunosuppressants are often used for those with more severe symptoms.
Management of patients with IPF
oxygen supplementation for hypoxemia and antifibrotic therapies
- nintedanib
-pirfenidone
treatment of Cryptogenic Organizing Pneumonia
Patients with COP respond well to glucocorticoid therapy. Relapses of COP with tapering of glucocorticoids are common
treatment of Acute Interstitial Pneumonia
Management includes ventilatory support and critical care, as it does for patients with ARDS.
often treated with high-dose glucocorticoid
Single Pulmonary Nodule Follow-Up <6 mm
low risk no f/u
high risk at 12 months
Single Pulmonary Nodule Follow-Up 6 - 8 mm
6-12 months then 18-24 moths
Single Pulmonary Nodule Follow-Up > 8 mm
at 3 months with
1. CT or
- PET or
- tissue sampling
Solitary Subsolid Lung Nodule Follow-Up Pure ground glass & Part solid nodule
if < 6 mm no f/u
Pure ground glass ≥6 mm CT at 6-12 months to confirm persistence, then CT every 2 years until 5 years
Part solid nodule ≥6 mm CT at 3-6 months to confirm persistence; if unchanged and solid component remains <6 mm, annual CT should be performed for 5 years
types of lung cancer
1.small cell cancer ( smoker,cerntral,SIADH)
2.non-small cell cancer
-adenocarcinoma (peripheral , non smoker)
-large cell carcinoma (peripheral )
-squamous cell carcinoma ( smoker,cerntral)
Annual lung cancer screening should be performed in
patients aged 50 through 80 years who have no symptoms of lung cancer, have at least a 20-pack-year smoking history, and are current smokers or have quit within the last 15 years.
Cessation of lung cancer screening should be considered in
1.those who have not smoked in 15 years,
2.those with limited life expectancy, and
3.those who would not be candidates for or would not be willing to undergo surgery.
Diagnosis suggested by headache, nausea, disturbed sleep at altitude
Acute mountain sickness
Treatment for high-altitude cerebral edema
Dexamethasone, oxygen, descent
Drug treatments for high-altitude pulmonary edema
Nifedipine, PDE-5 inhibitor
Possible complication in air travel for patients with asthma or COPD
Pneumothorax
Oxygen saturation level requiring supplemental O2 during air travel
<92%
Test to determine need for supplemental O2 during air travel
Hypoxia altitude simulation testing
Enteral nutrition should start within
24 to 48 hours of admission.
Alleviate hypoxemia by MV
Increasing FIO2
Increasing PEEP
Improve respiratory alkalosis BY MV
( Hypocapnia )
Decreasing respiratory rate
Decreasing tidal volume
Improve respiratory acidosis BY MV
( Hypercapnia)
Increasing respiratory rate
Increasing tidal volume
Berlin definition of ARDS
- Symptoms must have begun within 1 week of a known clinical insult
- Bilateral opacities consistent with pulmonary edema on CXR
- Respiratory failure ( not explained by HF or fluid overload)
- Arterial pO2/FiO2 < 300 with PEEP at least 5
Severity of ARDS
PaO2/FiO2 ration on MV settings PEEP >= 5
Mild 201- 300
Moderate 101-200
Severe =< 100
ARDS VENTILATOR SETTING
FiO2 100 % and lower < 60 % ASAP
TV 6-8 ml /kg
PEEP start at 5 and titrate to plateau pressure =< 30 cmH2O
CO low
PCWP high
SVR high
Which type of shock
Cardiac shock
CO low
PCWP low
SVR high
Which type of shock
Hypovolemic shock
CO high
PCWP low
SVR low
Which type of shock
Distributive shock
Indication of prone position in ARDS
If pO2/FiO2 ratio < 150 and FiO2 at least 60
At least 12-16 hours a day
Therapeutic treatment of severe refractory respiratory failure resulting from ARDS
ECMO
Diagnosis of Hereditary angioedema by
- Quantitive & functional levels of C1 esterase inhibitor and
- C4 complement level
Treatment of malignant hyperthermia
- DC the triggering agent
2.Active cooling
3.Muscle relaxant dantrolene every 5 to 10 minutes until muscle rigidity and hyperthermia resolve.
TREATMENT OF Serotonin syndrome
removing the offending agent and supportive care.
Cyproheptadine is sometimes used if benzodiazepines fail to control symptoms.
TREATMNET OF Neuroleptic malignant syndrome
- stopping the triggering agent (or reinstating the withdrawn dopaminergic agent)
- active cooling
- supportive care including IV fluid administration.
- Evidence for pharmacotherapy is anecdotal, but options include benzodiazepines, dantrolene, and bromocriptine.
Neuroleptic medications can be reintroduced after a waiting period of at least 2 weeks, usually at lower dose, with care to avoid dehydration and concomitant administration with lithium.
Neuroleptic Malignant Syndrome & Serotonin Syndrome
Neuroleptic Malignant Syndrome:
tetrad of fever, mental status changes, dysautonomia AND muscle rigidity.
Serotonin Syndrome:
fever, mental status changes, dysautonomia, hyperreflexia, and other muscle abnormalities.
Patients with high levels of carboxyhemoglobin (25% and greater) and evidence of organ ischemia should be treated with
hyperbaric oxygen if possible.
Heat stroke treatment
- Evaporative cooling ( water mist & fans )
- Immersion in ice water for only young patients when they remain severely symptomatic despite evaporative cooling.
- acetaminophen is not effective for heat stroke
Diagnose glucocorticoid-responsive asthma with
fractional exhaled nitric oxide testing
