Sleep Apnea, Resp. failure, Pulmonary Embolism, Sarcoidosis

Question 1

Sleep Apnea

• definition
• types

Answer 1

• abnormal pauses (at least 10s) in the breathing during sleep
• more common in men

-central, obstructive or mixed

Question 2

Sleep Apnea

-symptoms

Answer 2

-snoring, daytime sleepiness, insomnia, nocturia, attention deficit, morning headache, memory loss, shortness of breath

Question 3

Sleep Apnea

• diagnosis
• complications (7)

Answer 3

• gold standard: overnight polysomnography
• systemic arterial hypertension, congestive heart failure, arrhythmias, pulmonary hypertension, stroke, metabolic syndrome, type 2 DM

Question 4

Sleep Apnea

-treatment (4)

Answer 4

• CPAP (continuous positive airway pressure) devices
• orthodontic devices
• weight loss, sleep with a tennis ball on back
• avoid sedatives, alcohol, sleeping pills

Question 5

Respiratory failure

• definition
• types

Answer 5

• the pulmonary system is not able to meet the metabolic demands of the body
• PaO2 <60 mmHg, PaCO2 >50 mmHg
• acute, chronic
• type 1 and 2

Question 6

Respiratory failure

-diagnosis/ evaluation

Answer 6

• arterial blood gases –> most imp. one
• pulse oximetry –> sources of error: poor peripheral perfusion, excessive motion, false nails, carboxyhemoglobin or methemoglobin

Question 7

Respiratory failure

• Type 1
• Type 2

Answer 7

Type 1

• hypoxemic
• PaO2 <60 mmHg and PaCO2 is either normal or decreased
• associated with acute diseases of the lung
• ex: pulmonary edema, pneumonia, pulmonary hemorrhage, collapse

Type 2

• hypercapnic
• PaCO2 >50 mmHg
• hypoxemia is common
• ex: drug overdose, neuromuscular disease, chest wall deformity, COPD, bronchial asthma

Question 8

Respiratory failure

• Acute
• Chronic

Answer 8

ACUTE

• develops over minutes to hours
• pH drops quickly to <7.2
• example: pneumonia

CHRONIC

• develops over days
• pH drops slightly, HCO3 increases
• example: COPD

Question 9

Respiratory failure

-management

Answer 9

• correct hypoxemia
• correct hypercapnia
• non-invasive ventilatory support (IPPV)
• mechanical vent.
  indications: persistent hypoxemia, hypercapnia with severe acidosis

Question 10

Pulmonary embolism

• risk factors
• pathophysiology

Answer 10

• surgery, fractures, pregnancy and childbirth, immobilization, previous venous thrombosis, cancer, oral contraceptive, age >60, BMI >30
• hypoxia + increase PA pressure + vasoconstriction –> right venticle dilation –> myocytes stretching –> increase troponin and BNP

Question 11

Pulmonary embolism

-symptoms

Answer 11

• acute shortness of breath, tachypnea, pain or pressure behind the sternum
• arterial hypotension, syncope, sudden chest pain
• increase D dimer levels
• subfebrile fever, cough, wheezing, hemoptysis
• unexplained fluid in the pleural cavity
• it can be asymptomatic!!!

Question 12

Pulmonary embolism

-indication for the evaluation of PE

Answer 12

-chest pain and/or a small amount of fluid in the pleural cavity

Question 13

Pulmonary embolism

-main tests

Answer 13

• CT pulmonary angiography - 1st choice
• ventilation-perfusion scintigraphy - 2nd choice
• plasma, BNP, troponin –> severity
• ECG, echo
• leg venous US
• D dimer –> NORMAL CONCENTRATION DOES NOT EXCLUDE PE

Question 14

Pulmonary embolism

-treatment

Answer 14

• thrombolytic therapy

- if not effective –> embolectomy

Question 15

Sarcoidosis

• definition
• pathogenesis

Answer 15

• a chronic granulomatous disease of unknown origin
• most common interstitial lung disease

-Ag enters the lungs –> it is presented to T lymphocytes –> macrophages accumulate in the lungs (alveolitis) –> granulomas –> pneumofibrosis or resolution

Question 16

Sarcoidosis

-symptoms

Answer 16

-asymptomatic in 40% of cases

ACUTE

• fever, malaise, dyspnea, cough, arthritis, erythema nodosum, anterior uveitis, weight loss –> disappears between 1-3m.
• Lofgren syndrome –> polyarthritis, erythema nodosum, bilateral hilar lymphadenopathy

CHRONIC
-dyspnea, cough, weakness, skin lesions, eyes/kidney/heart inflammation

-most common –> acute nodular erythema and ankle inflammation

Question 17

Sarcoidosis

-stages and x-ray findings

Answer 17

Stage 0 - normal
Stage 1 - bilateral hilar lymphadenopathy
Stage 2 - bilateral reticular or ground-glass opacities with hilar lymphadenopathy, disseminated, reticulonodular infiltrates
Stage 3 - bilateral reticular or ground-glass opacities WITHOUT hilar lymphadenopathy
Stage 4 - lung fibrosis

Question 18

Sarcoidosis

-when to suspect (2)

Answer 18

• asymptomatic + lymphadenopathy + diffuse nodules or opacities in the lungs chest x-ray or CT
• erythema nodosum, ankle arthritis, inflammation of eyes or salivary glands, chronic skin rash

Question 19

Sarcoidosis

-diagnosis

Answer 19

1. Clinical signs (asymptomatic or Lofgren syndrome) + typical lung findings
2. Typical changes in BAL (bronchoalveolar lavage fluid) (CD4/CD8 >4.0) or typical histological findings (epithelial granuloma WITHOUT necrosis)

Question 20

Sarcoidosis

-differential diagnosis

Answer 20

-tuberculosis, fungal disease, systemic CT disease, exogenous allergic alveolitis, sarcoid reaction to neoplasy

Question 21

Sarcoidosis

• treatment
• observation

Answer 21

• 1st choice: glucocorticoid (alone)
• may add methotrexate, azathioprine or TNF inhibitor
• relapse occurs in 80% of cases after 3m.

-do not give glucocorticoid –> asymptomatic, symptoms are minimal and tolerated, Lofgren syndrome, Stage I, stable disease

• stage I/ acute –> every 6-12 months
• stage II/III/ severe –> every 3-6 months

Question 22

Sarcoidosis

-complications (3)

Answer 22

• pulmonary fibrosis
• chronic resp. failure
• chronic renal impairment due to hypercalcemia and hypercalciuria