Step Up- Pulmonary Flashcards
Acid base derrangement present in chronic COPD’ers
Respiratory acidosis with metabolic alkylosis
These two agents together are good for control of COPD
B-agonist with inhaled anticholinergic like ipratropium
This therapy has been shown to increase survival and quality of life in patients with COPD and chronic hypoxemia
Continuous O2
These vaccines should be given to all COPD’ers
Pneumococcal
Influensza
Interventions important in acute COPD exacerbation
B2 agonist with anticholinergic
ABX (azithro or levoflox)
Supplemental O2 to Sat>90%
PPV (invasive or non)
Asthmatic patient with increasing PCO2…cause? Tx?
Cause: Impending respiratory failure
Treatment: Mechanical ventilation
Most common cause of bronchiectasis
CF
PFT in bronchiectasis
reveal obstructive pattern
Infections frequently seen in CF patient?
Pseudomonas
Type of lung cancer that is least associated with smoking?
Adenocarcinoma
65 Year old smoker presents with right sided facial fullness and arm swelling as well as redness and sweating on the right face…dx?
SVC syndrome- obstruction of SVC by mediastinal tumor
65 year old smoke with shoulder pain radiating down the arm and arm weakness
pancoast tumor
Most common sites of lung cancer metastasis?
Brain, bone, liver, and adrenal glands
Proximal muscle weakness and fatigability in a 65 year old smoker? What subtype?
Eaton-lambert syndrome
typically SCLC– Ab again Ca channels presynaptic
What features of the following suggest malignancy in lung nodules…
Age-
Smoking-
Size-
Borders-
Calcification-
Change in size-
Age- >50=50% malignant
Smoking- increses risk
Size- <1cm less likely >2cm more likely
Borders- More irregular= more likely malignant
Calcification- eccentric and asymmetric=more likely malignant. dense and central = less likely
Change in size- enlarging suggests malignancy
Causes of masses in the anterior mediastinum…
4 Ts
Thymoma
Teratoma
Terrible lymphoma
Thyroid tumor
Three general causes of pleural effusions
- increased drainage of fluid in to the pleural space
- Increased production of fluid by pleural cells
- Decreased drainage from the pleural space
Tests to be performed on an exudative effusion…
cell count
pH
Glucose
amylase
triglycerides
micro
cytology
Characteristics of an exudative effusion….
Protien (pleural)/(serum) >0.5
LDH (pleural)/(serum) >0.6
Pleural LDH > upper two thrids of normal serum
With a pleural effusion glucose of <60, what disease should be ruled out….
RA
FEV1/FVC in intersitial lung disease?
increased (restrictive pattern)
Both findings are decreased but the ratio is increased
Most popular extrapulmonary manifestation of sarcoidosis?
Anterior uveitis and erythema nodosum
Granulomatous vasculitis seen in patients with asthma?
Chrug-strauss syndrome
pulmonary infiltrates with rash and eosinophilia and +p-ANCA
Churg-strauss syndrome
egg shell calcifications on CXR
Silicosis
Bilateral linear opcities and hazyn infiltrates on CXR combined with pleural plaques increase the risk of previous exposure to…
Asbestos
Silicosis is associated with an increased risk of this infection
TB
autoimmune disease caused by IgG Ab against glomerular and alveolar basement membranes
Goodpasture syndrome
Presents with hymoptyisis and dyspnea
Causes of acute hypoxemic respiratory failure?
Main mechanism leading to it?
Causes are intrinsic lung pathology- ARDS, PNA, pulmonary edema
Mechanism is a V/Q mismatch
THINK– if PaO2 is low but PCO2 is normal or low then this mean CO2 exchange is taking place however O2 is not!
Cuases of hypercarbic respiratory failure
Underlying lung disease: COPD, Asthma, CF, severe bronchitis
Mechanism of hypercarbic respiratory failure
Either a decrease in minute ventilation or increase in dead space
Minute vent= Tv * f
Will a V/Q mismatch respond to supplemental O2?
Yes
Is hypoxemia 2/2 a shunt responsive to O2?
No– blood flow is good, however there is reduced ventilation in the area of the shunt.
Criteria to Dx ARDS
Hypoxia resistent to O2 supplementation
Bilateral
r/o other causes (like cardiac)
Physiologic event leading to ARDS
Massive atelectasis leading to shunting and poor oxygenation
Damage to alveolar membranes causes increased dead space
How does PCWP help differentiate ARDS from cardiogenic pulmonary edema
PCWP elevated (>18) cardiac cause more likely
PCWP normal/low (<18) ARDS more likely
PCWP goal in ARDS to avoid fluid overload?
12-15mm Hg
Initial Vt in intubated patient?
8-10mL/kg
rate 10-12/min
Should tidal volumes be lower or higher in ARDS?
Lower
What is the effect of PEEP on cardiac output?
decreases it due to decreased venous return
Pressure associated with pumonary HTN?
>25mmHg at rest
>30mmHg during exercise
Patient with RVH and right atrial abnormality with substernal heave
pulmonary HTN
This drug promotes the action of ATIII
Heparin
When to put COPD’ers on O2
PO2 <55 (<60 in right heart failure)
O2 sat <88% (<90% in R sided heart failure)
Asmatic patient with recurrent episodes of brown-flecked sputum on xray
Allergic brochopulmonary aspergillosis
This is the best alternative to TMP/SMX in PCP tx
Pentamadine or primaquine
IV
Alternative to TMP/SMX for PCP prophylaxis
atovaquone or dapsone
This value is diagnostic for ARDS
pO2/FIO2= <300
O2 on abg is 105
Room air= FIO2 of .21 (21%)
105/.21= 500= ARDS
CT finding in ARDS
Consolidation with air bronchograms
Appropriate TV for ARDS?
6mL/kg
Low tidal volumes are best to avoid barotrauma
Target plateau pressure in ARDS
less than 30cmH20
