USMLE Pulmonary Flashcards
Ventation Adjustment
For Oxygenation
for Ventelation (lower CO2)
- *• Oxygenation (increase PaO2)**
- FiO2
- PEEP
- Increase inspiratory time
- Increase mean airway pressure
- *• Ventilation (eliminate PaCO2)**
- Rate
- Tidal Volume
- Increase expiratory time (by lowering RATE)
A hypoxia altitude simulation test can be used to predict in-flight hypoxia in patients with COPD
Exercise stress test, 6-minute walk test, and pulmonary function tests are part of a pulmonary rehabilitation program or are used to evaluate dyspnea or changes in symptoms. These tests do not play a role in predicting in-flight hypoxia.
Acute Eosinophilic Pneumonia
Vs
Chronic Eosinophilic Pneumonia
AEP:
- High fever, non productive cough, dyspnea, bibasilar inspiratory crackles
- Hypoxemic respiratory failure
- Dx:
- Xray/CT BL Difuse ground glass and reticular opacities
- Bronchoalveolar lavage > 25% Eosinophils
- Lung bx: Interstitial and alveolar eosinophils
CEP:
- Fever cough, progressive dyspnea
- Rare respiratory Failure
- Dx:
- Elevated ESR/CRP
- IDA (increase plt)
- Xray: bl peripheral pleural based infiltrates
- Bronch lavage: > 25% eosinophils
- Lung Bx: interstitial alveolar eosinophils
Apnea-Hypopnea Index
- The number of apneas and hypopneas
per hour of sleep
• Mild OSA = AMI > 5-15/hour associated
with symptoms
• Moderate OSA = AMI > 15-35/hour
• Severe OSA = AMI > 35/hour
ARDs DDx
Differential Diagnosis
• Hemodynamic pulmonary edema (CHF, volume overload)
• Diffuse alveolar hemorrhage
• Acute interstitial pneumonitis (Hamman-Rich syndrome)
• Lymphangitic spread of cancer
CHF / Cardiomegaly, Cephlization
Cardiogenic Shock
• Results from pump failure and decreased
cardiac output
• Main categories:
- Myopathies
- Arrhythmia
- Mechanical
- Extracardiac/obstructive
Cardiac Temponade
- Pulsus paradoxus
- Rapid X descent in the neck vein
- Hypotension
- Tachycardia
Classifying the Tuberculin Reaction
> 10 mm induration /not erythema
• Recent arrivals from high-prevalence countries
• Injection drug users
• Residents and employees of high-risk congregate settings
• Persons with clinical conditions that place them at high risk
- Immunosuppressed
- Diabetes
- Renal Failure
- Hematologic Malignancy
ARDS
• P/f ratio (PaO2 / FIO2)- FIO2 100% = 1 / 90% = 0.9
< 200 for ARDS
< 300 for ALI
• Acute onset
• CXR with bilateral infiltrates compatible with pulmonary edema
• Also must rule out cardiogenic pulmonary edema
- PAWP< 18
- No evidence of increased Left Atrial Pressure
• Diffuse Alveolar Damage (DAD) -Histopathologic manifestation of ALI/ARDS
Clinical Factors / Higher risk for cancer
• Age greater than 35 years
- Age < 35, cancer in 1%
- Age > 50, 15 times greater chance of malignancy
• Smoking history
- Profound impact on the probability of an SPN being malignant
• History of prior malignancy
- In 50-70% of patients with known cancer, the SPN is a metastatic lesion
COPD FEV1 < 60%
What is needed
- Mono inhaled bronchodilator
- long-acting inhaled anticholinergics (Tiotropium) or
- long-acting inhaled β2-agonists
- ICS must be with B2 agonist (long acting)
COPD STAGES
All stages are FEV1/FVC%
STAGE I - FEV1 80%
STAGE II 50-80%
STAGE III 30-50 %
STAGE IV < 30%
Stage II and III respond better to Tiotropium
Anything Less then 60%
CURB 65
Confusion
Urea > 20
Respiratory > 20
Blood pressure < 90/60
AGE > 65
Hospitalize
D-dimer assay
- must be done 3 to 4 weeks after warfarin therapy is stopped
- D-dimer assay performed after a period of anticoagulation therapy have been shown to be predictive of thrombotic recurrence.
DDX
- Nocturnal asthma
- OSA
- GERD
Nocturnal Asthma
- Difficulty to initiate and maintain sleep
- up w cough / wheezing
- Responds to Albuteral
- Trail of LABA with steriods
OSA
- Difficult to maintain sleep
- Daytime sleepiness
- Gasping w awakening and sensation of chocking
GERD
- Reflux
- worsen at night / with feeling of heartburn
- PPI
- Not the most common cause of Asthma
Delayed diagnosis of mild form of cystic fibrosis
Cystic fibrosis are diagnosed during childhood; however, delayed diagnosis can occur in patients with a mild form of cystic fibrosis, who are often misdiagnosed as having asthma when the symptoms are limited to the respiratory tract.
Diagnose a malignant pleural effusion.
next step in the evaluation of this patient’s pleural effusion is to repeat thoracentesis and repeat pleural fluid cytology.
- 65% of positive results obtained on the initial sampling, 27% on the second, and 5% on the third
Diagnose an acute exacerbation of idiopathic pulmonary fibrosis.
- Diagnostic criteria
unexplained worsening of dyspnea in less than 30 days,
high-resolution CT showing new b/l ground-glass opacity and/or consolidation superimposed on a background of findings consistent with usual interstitial pneumonia
no evidence of alternative causes.
Diagnose cryptogenic organizing pneumonia.
Cryptogenic organizing pneumonia presents with cough and other symptoms suggestive of community-acquired pneumonia, but the diagnosis should be considered when symptoms and clinical findings persist despite one or more courses of antibiotics.
CT demonstrates bilateral patchy ground-glass opacities and bilateral, lower lobe–predominant, subpleural consolidations
bronchiolitis obliterans organizing pneumonia (BOOP) / COP is the idiopathic form of BOOP.
Diagnose pulmonary arterial hypertension
Right heart catheterization is essential to confirm the diagnosis of pulmonary hypertension by direct measurement of mean pulmonary artery pressure.
Diagnose vocal cord dysfunction.
During attacks, VCD can be difficult to distinguish from asthma. Potential clues include sudden onset and abrupt termination of the attacks, lack of response to asthma therapy, prominent neck discomfort, lack of hypoxemia, and lack of hyperinflation on chest radiography.
FAMILY Meeting
SPIKE
Setup situation/room
Perception of Dz (do they know what the dz is)
Invitation (how much they want to know)
Knowledge (give info of what is the future)
Empathic (I’m sorry)
Strategy (End of life discussions)
Glipizode vs glyburide
Glipizide has a shorter life then glyburid
Fat Embolism
Seen in
- Orthopetics surgery
- Pancreatitis
- Sick cell
- Fractures
Symptoms after 24-72 hrs
- Respiratory Distress
- Petechia
- Neurological symtoms
Hemodynamic Profiles of the Shock States
Chart
Human Monocytic ehrlichiosis
Fever / Malaise, myalgia, chills, HA
Rash (macular, maculopapular, petechial)
Neurologic sx: stiff neck / altered menation
LABS: thrombocytopenia / elevated AST nad ALT LDH ALK
Hypovolemic Shock
• Result of decreased preload
• CO = HR x SV, and SV depends on preload
• Decrease in preload therefore leads to
decrease in CO
• Fluid loss
- Diarrhea, Vomiting, Heat Stroke, Burns
• Hemorrhage
- Trauma, Gl Bleeding, Ruptured Aneurysm or Hematoma, Fractures
idiopathic pulmonary fibrosis.
Idiopathic pulmonary fibrosis is characterized by progressive dyspnea and cough for more than 6 months and dry inspiratory crackles; classic CT findings include basal and peripheral disease with evidence of honeycomb changes without evidence of ground-glass opacities or nodules.
Ionotropics and Vasopressors
NE
Dopamin
Dobutamin
Vassopressin
NE:
- alph 1 > B1 AE: arrhythmias
Dopamin:
- Dopaminergics / vasodialation of renal and mesentary / higher risk of arrhythmias
Dobutamin:
- B >> Alpha recepteros / AE: Hypotension
Vassopressin:
- Vaso constrictions V1 / delayed onset
Lemierre’s Syndrome
Sx: Recent sore throat / neck pain / septic embolism
Labs: WBC > 15000 / CXR / CT Neck show jugular thrombophlebitis
Inhaled Corticosteriods ICS
Needed when FEV1<
Used in conjunction with
Side effects
- FEV1< 60%
- LABA
- Dyphonia, Skin bruising, Oral candidiasis
- Increase risk of pneumonia
Limiting VALI
- Target VT < 6 mL/kg IBW
- Plateau pressure < 30 cm H2O
- Best PEEP
- Permissive hypercapnia
LOWER TIDAL VOLUMES is OK / may cause some hypercapnia - itssss OK buddy
• Oxygen toxicity with high levels of inspired
oxygen cause physiologic and pathologic
changes similar to ARDS
• FiO2 < 0.6 is considered safe
Low-molecular-weight heparin and fondaparinux in advanced kidney disease.
Low-molecular-weight heparin and fondaparinux are contraindicated in the setting of advanced kidney disease.
Lung volume reduction surgery
Patients on max therapy and have had rehab
- presence of b/l emphysema
- bronchodialater total lung capacity > 100 or residual volume greator then 150% of predicted
- FEV1 of no > 45%
- and PCO2 no > 60 or PO2 at least 45
Löfgren syndrome
Tx
80% of patients with sarcoidosis who present with Löfgren syndrome have spontaneous resolution
Manage acute pulmonary embolism
Use **unfractionated heparin **/ LMWH is more difficult to assess than unfractionated heparin. Additionally, because these agents are long acting and not readily reversible, their use would be problematic if the patient became hypotensive and a decision was made to treat with thrombolytic agents or clot extraction.
Manage acute respiratory distress syndrome
In patients with acute respiratory distress syndrome, a lung-protective strategy of low tidal volume (6 mL/kg predicted weight) and plateau pressure less than 30 cm H2O is associated with reduced mortality.
Manage hypertensive emergency.
In general, the mean arterial pressure should be lowered by no more than 25% in the first hour of treatment and subsequently decreased to systolic levels of 160 mm Hg and diastolic levels between 100 and 110 mm Hg in the next 2 to 6 hours
Manage tricyclic antidepressant overdose.
Sodium bicarbonate is the best therapeutic agent in the setting of tricyclic antidepressant overdose
Manage immunizations in a patient with COPD.
Influenza recommended annually / High-dose influenza for patients 65 years and older.
One-time revaccination is recommended for patients who were vaccinated 5 or more years ago and were less than 65 years of age at the time of primary vaccination.
Manage ventilatory failure in a patient with Guillain-Barré syndrome
Plasma exchange and intravenous immune globulin are both recommended treatment options for patients with Guillain-Barré syndrome (GBS), including its most common variant, acute inflammatory demyelinating polyneuropathy.
- Systemic corticosteroids are no longer recommended
Manage dyspnea in a patient with end-stage COPD.
Opioids are effective in reducing dyspnea in patients with end-stage COPD. palliative care
Low-dose (20-mg) extended-release morphine given daily has been used to relieve dyspnea in patients with advanced COPD.
Measures 8 to 30 mm in a Patient with
Acceptable Surgical Risk
Solitary pulmonary Nodule < 30 mm
Low probability :
Serial nigh-resolution CT at 3,
8,12, and 24 months
Intermediate:
Additional Testing + above
PET imaging / Contrast-enhanced CT,
/ Transtrioradc fine-needle aspiration biopsy vs.
Bronchoscopy/ if airbronchopm
present or if operator has expertise with
High Risk
Video-assisted thoracoscopic surgery; examination of a frozen section, followed by resection if
nodule is malignant
Mediastinal LAD
Bronch and Transbronchial lung bx recommended
Modes of Ventilation
Assist/Control Ventilation
Pressure Controlled Ventilation (PCV)
Synchronized IMV(SIMV)
Assist/Control Ventilation
• Rate(minimal set) and Tidal volume are set
• Pressure is variable
• The patient can trigger breaths at a faster rate
than the set minimum, but only the set volume is
delivered with each b reath
Modes of Ventilation
Assist/Control Ventilation
Pressure Controlled Ventilation (PCV)
Synchronized IMV(SIMV) (not used as much)
Synchronized IMV(SIMV)
• At a predetermined interval (respiratory rate), which is set by the operator, the ventilator waits for the patient’s next inspiratory effort
• When the ventilator senses the effort, the ventilator assists the patient by synchronously delivering a mandatory breath
Modes of Ventilation
Assist/Control Ventilation
Pressure Controlled Ventilation (PCV)
Synchronized IMV(SIMV)
Pressure Controlled Ventilation (PCV)
• Time or patient triggered, pressure targeted (limited), time cycled ventilation
• The operator sets the length of inspiration (Ti), the pressure level, and the backup rate of ventilation
• Tidal Volume is variable
- Based on the compliance and resistance of the patient’s lungs, patient effort, and the set pressure
lung volume reduction surgery
FEV1 of less than 20% of predicted and either a DLCO of less than 20% of predicted or homogeneously distributed emphysema are considered high risk
Modes of Ventilation
- Spontaneous Modes
- Pressure Support Ventilation — PSV
CPAP
• Helpful for improving oxygenation in patients with refractory hypoxemia and a low FRC (Functional Residual Capacity)
• CPAP setting is adjusted to provide the best oxygenation with the lowest positive pressure and the lowest FiO2
Pressure Support Ventilation — PSV
• Patient triggered, pressure targeted, flow cycled mode of ventilation
• Requires a patient with a consistent spontaneous respiratory pattern
• The ventilator provides a constant pressure during inspiration once it senses that the patient has made an inspiratory effort
Myopathy ICU
- Critical illness myopathy
- Rhabdomolysis
- Guillain Barre Syndrome
- Prolonged neuromuscular blockade
CK elevated
- Critical illness myopathy
- Rhabdo
Flaccid Limbs
- Prolonged neuromuscular blockade
- Critical illness myopathy
Myalgia
- Rhabdomyolysis
Prolonged neuromuscular blockade
- Transient improvement after anticholinestrase
Post infection
- GBS
Narcolepsy
- Severe daytime hypersomnolence
- Cataplexy
- Sleep paralysis
- Hallucinations when drowsy
- Polysomnography and Multiple Sleep Latency Test (MSLT) checks hypersomnolence and frequency of rapid eye movement (REM)
- Treat: stimulants and REM suppression by tricyclic antidepressants and selective serotonin reuptake inhibitors
Non-Small Cell Lung Cancer (NSCLC)
Histologic Cell Types
- 80% of all lung cancers
- Better survival rates when found in early stages
NSCLC: Histologic Cell Types
• Adenocarcinoma
• Squamous Cell Carcinoma
• Large Cell Carcinoma
Noninvasive Positive pressure ventilation
- Indications (strongest evidence)
- CI
Indicaitons
- Sever COPD ph < 7.35 or hypercarbia
- Acute respiratory failure from cardiogenic pulmonary edema
- Facilitate early extubation and prevent extubation failure in COPD
- Hypoxemic respiratory faileure post abd/lung surgery
- immunosuppressed pt with ARD
CI
- Unstable cardiac arrhythmia
- Encephalopathy/GI bleed
- Respiratory / cardiac arrest
- Sever Acidosis < 7.1
- Sophageal anastomosis
- ARDS
- Uncooperative / agitated
- inability to clear secreation
Lung Cancer: Paraneoplastic Syndro mes
- Non-Small Cell Lung Cancer
- Small Cell Lung Cancer
Lung Cancer: Paraneoplastic Syndromes
• Non-Small Cell Lung Cancer
- Hypercalcemia
- Hypertrophic pulmonary osteoarthropathy
• Small Cell Lung Cancer
- Inappropriate secretion of ADH
- Ectopic ACTH secretion
- Eaton-Lambert syndrome
Normal Pressures
CVP
RV
PA
PCWP
LV
Central venous pressure 3–8
R ventricular pressure systolic 15–30
diastolic 3–8
Pulmonary artery press. systolic 15–30
diastolic 4–12
Pulmonary vein/
Pulmonary capillary 2–15
wedge pressure
L ventricular pressure systolic 100–140
diastolic 3-12
LUNG Ca and treatment
Tumor has spread to lymph nodes associated with the lung is good for surgery
Anything worse than above no surgery