USMLE Pulmonary Flashcards
1
Q
Ventation Adjustment
For Oxygenation
for Ventelation (lower CO2)
A
- *• Oxygenation (increase PaO2)**
- FiO2
- PEEP
- Increase inspiratory time
- Increase mean airway pressure
- *• Ventilation (eliminate PaCO2)**
- Rate
- Tidal Volume
- Increase expiratory time (by lowering RATE)
2
Q
A hypoxia altitude simulation test can be used to predict in-flight hypoxia in patients with COPD
A
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.
3
Q
Acute Eosinophilic Pneumonia
Vs
Chronic Eosinophilic Pneumonia
A
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
4
Q
Apnea-Hypopnea Index
A
- 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
5
Q
ARDs DDx
A
Differential Diagnosis
• Hemodynamic pulmonary edema (CHF, volume overload)
• Diffuse alveolar hemorrhage
• Acute interstitial pneumonitis (Hamman-Rich syndrome)
• Lymphangitic spread of cancer
CHF / Cardiomegaly, Cephlization
6
Q
Cardiogenic Shock
A
• Results from pump failure and decreased
cardiac output
• Main categories:
- Myopathies
- Arrhythmia
- Mechanical
- Extracardiac/obstructive
7
Q
Cardiac Temponade
A
- Pulsus paradoxus
- Rapid X descent in the neck vein
- Hypotension
- Tachycardia
8
Q
Classifying the Tuberculin Reaction
> 10 mm induration /not erythema
A
• 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
9
Q
ARDS
A
• 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
10
Q
Clinical Factors / Higher risk for cancer
A
• 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
11
Q
COPD FEV1 < 60%
What is needed
A
- Mono inhaled bronchodilator
- long-acting inhaled anticholinergics (Tiotropium) or
- long-acting inhaled β2-agonists
- ICS must be with B2 agonist (long acting)
12
Q
COPD STAGES
A
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%
13
Q
CURB 65
A
Confusion
Urea > 20
Respiratory > 20
Blood pressure < 90/60
AGE > 65
Hospitalize
14
Q
D-dimer assay
A
- 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.
15
Q
DDX
- Nocturnal asthma
- OSA
- GERD
A
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
16
Q
Delayed diagnosis of mild form of cystic fibrosis
A
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.
17
Q
Diagnose a malignant pleural effusion.
A
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
18
Q
Diagnose an acute exacerbation of idiopathic pulmonary fibrosis.
A
- 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.
19
Q
Diagnose cryptogenic organizing pneumonia.
A
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.
20
Q
Diagnose pulmonary arterial hypertension
A
Right heart catheterization is essential to confirm the diagnosis of pulmonary hypertension by direct measurement of mean pulmonary artery pressure.
21
Q
Diagnose vocal cord dysfunction.
A
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.
22
Q
FAMILY Meeting
SPIKE
A
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)
23
Q
Glipizode vs glyburide
A
Glipizide has a shorter life then glyburid
24
Q
Fat Embolism
A
Seen in
- Orthopetics surgery
- Pancreatitis
- Sick cell
- Fractures
Symptoms after 24-72 hrs
- Respiratory Distress
- Petechia
- Neurological symtoms
25
Hemodynamic Profiles of the Shock States
Chart
26
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
27
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
28
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_.**
29
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
30
Lemierre's Syndrome
Sx: Recent sore throat / neck pain / septic embolism
Labs: WBC \> 15000 / CXR / CT Neck show jugular thrombophlebitis
31
Inhaled Corticosteriods ICS
Needed when FEV1\<
Used in conjunction with
Side effects
* FEV1\< 60%
* LABA
* Dyphonia, Skin bruising, Oral candidiasis
* Increase risk of pneumonia
32
Limiting VALI
* **Target VT** \< 6 mL/kg IBW
* **Plateau pressure** \< 30 cm H2O
* Best **PEEP**
* Permissive **hypercapnia**
***LOWER TIDAL VOLUME***S 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
33
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.
34
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
35
Löfgren syndrome
Tx
80% of patients with sarcoidosis who present with Löfgren syndrome have spontaneous resolution
36
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.
37
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.
38
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**
39
Manage **tricyclic antidepressant** overdose.
Sodium bicarbonate is the best therapeutic agent in the setting of tricyclic antidepressant overdose
40
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.
41
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
42
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.
43
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
44
Mediastinal LAD
Bronch and Transbronchial lung bx recommended
45
**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
46
**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
47
**Modes of Ventilation**
## Footnote
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
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
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
## Footnote
L ventricular pressure systolic 100–140
diastolic 3-12
56
LUNG Ca and treatment
Tumor has spread to lymph nodes associated with the lung is good for surgery
Anything worse than above no surgery
57
NSCLC: Treatment Outcomes
NSCLC: Treatment Outcomes
Stage 5-Year Survival
Stage I 60-80%
Stage II 40-50%
Stage IIIa 25-30%
Stage IIIb 5-10%
Stage IV \< 1%
58
1. obesity hypoventilation syndrome (OHS)
2. Cheyne-Stokes breathing
daytime hypercapnia (arterial PCO2 \>45 mm Hg [6.0 kPa]) that is thought to be a consequence of diminished ventilation related to extreme obesity.
* Cheyne-Stokes breathing
central sleep apnea characterized by a crescendo-decrescendo ventilatory pattern. It is most commonly seen in men with advanced left ventricular dysfunction who are typically older and thinner than this patient.
59
Lofgren's
Bilateral ankle arthritis
Erythema nodosum
Hilar Adenopathy
60
opioid intoxication.
nonfocal neurologic examination, pinpoint pupils, shallow respirations, respiration rate less than 12/min, and hypothermia
61
OSA
SNORING / who to assess for OSA
* Excessive daytime sleepiness?
* ** ORDER PSG**
* No Excessive daytime sleepiness
* \> 2 Clinical OSA features
* **ORDER PSG**
IF **AHI \> 15 or AHI \> 5 + OSA signs and symptoms** start on CPAP
Snoring
Large neck
Hypertension
Day time sleepiness
62
PCN skin testing
PCN the treatment of choice for neurosyphilis
Skin test if positive will need to have to desensitize the patient
63
Lithium Toxicity
Acute
Chronic
* No need for charcoal / diuresis, ipecac
* HD indicated with levels \> 4 or levels \> 2.5 with symptoms
* **Acute**: N/V diarrhea and late developemnt of neurologic symptoms
* **Chronic**: Neurological symptoms at times Nephrogenic DI or thyroid dysfunction
64
PE What to look for
ABG / EKG / DX test / Rule out test
* D-Dimer (only to rule out / outpatient)
* ABG A-a Gradient: ~\> 20 / Alkalosis / Hypoxia
* EKG S1Q3T3 / RBBB / Tachy
* **_Diagnosis_**: Spiral CT/Multislice
65
PEEP
Positive End-Expiratory Pressure
• Helps prevent early airway closure and alveolar
collapse at the end of expiration by increasing
(and normalizing) the functional residual capacity
(FRC)ofthe lungs
• Facilitates better oxygenation
66
Persistent cough
CXR
if normal then
* Empiric oral 1st generation Antihistamins for postnasal drip +/- nasal steriod or nasal antihistamin
if still persistent need to work up
* Asthma
* GERD
* Non asthmatic eosinophillic bronchitis
* Chronic sinusitis
67
Pleural effusion analysis
Pleural protien / serum protien \>0.5
Pleural LDH / Serum LDH \> 0.6
LDH \> 2/3 of normal
Tansudate
* CHF
* Cirrosis
* Nephrotic synd
* PD dialysis
Exudate
* Cancer
* Infections
* CABG
* PE
RA PH \< 7 / LDH \> 1000 / Glucose \< 30
68
PE in pregnancy
**US LE** - if positive then treat
US LE -ve then **CXR**
if normal **V/Q scan**
If abnomal then **CT angio**
LMWH is preferred tx for PE until 6 weeks post partum
69
Pleural Fluid and Need for Drainage
* An effusion \> 40% of hemithorax
* Presence of air-fluid level
* Presence of loculations or multi-loculations
* Marked thickening of pleural membranes on CT
* Failure to respond to antibiotics
* Continued fever
* Positive Gram stain or bacterial culture: strong indication for drainage
* Low pH (\< 7.25)
* Low glucose
* High LDH\> 1,000
70
llergic Rhinitis
Sneezing, watery nasal discharge and pale turbinates ( tx Nasal corticosteriods)
71
Pneumothorax what to do
\< 2 cm
\> 2 cm
Secondary spontaneous pneumothoraces, outpatient management is discouraged; even small (
72
HIV prophylaxis CD 4 Counts
200
150
100
50
CD4 Count
* Bactrim / Dapson / Atovaquone
* Can **stop the meds once CD4 \> 200 for 3 months**
* Itraconazole
\< 100 or +Ve IgG antiboeis - Toxoplasmosis
* Bactrim / Dapson + pyrimethrine + leucovorine
\< 50 Mycobacterium Avium Complex
* Azithromycin / Clarithromycin / Rifabutin
VZV - Close contact with sick patients
* Varicella immune globulin or IVIG within 4 days of exposure
73
posterior mediastinal mass most likely is
neurilemmoma (or schwannoma), a benign neoplasm arising from neural tissue and characteristically located in the posterior mediastinum.
74
PPD/TST induration
* HIV / recent TB conatct / CXR fibrotic or nodular changes / transplant
\< 10
* Residents/prisoners / Recent immigrants / IV drug users / childeren exposed to adult TB
TX if positive
* INH + Rifampentine for 3 months (not for HIV)
* INH 9 months (give Pyridoxine with it)
* Rifambin for 4 months
* INH and Rifampin for 4 months
75
Prevent high-altitude illness.
When gradual ascent to the target elevation is not feasible, acetazolamide is the most effective therapy to prevent acute mountain sickness and high-altitude periodic breathing.
Acute Mountain sickness -AMS -The key feature of AMS is headache, along with fatigue, nausea, and sleep disturbance (usually due to high-altitude periodic breathing [HAPB], an altitude-associated respiratory change).
76
Distributive Shock
• Causes
- Sepsis
- Pancreatitis, burns, multiple trauma
- Anaphylaxis
- Drug or toxin reactions (Insect bites,
transfusion reactions, heavy metal poisoning)
- Addisonian crisis
- Myxedema coma
77
Pulmonary Capillary Wedge Pressure
Left Ventrical End Diastolic Pressure
• If increased, suggestive of elevated volume
• Balloon is inflated, a pressure reading is taken,
the balloon is deflated
• Leaving the balloon inflated will INFARCT
the lung!
78
Pulmonary fibrosis
* Upper lung
* Lower lung
Upper lung
* Silicosis / must screen for TB
Lower lung
* Idiopathic pulmonary fibrosis
79
Pulmonary HTN
Group1
* Due to idiopathic PAH
Group 2
* Due to left heart disease
Group 3
* Lung Dz (COPD, ILD, Chronic Hypoxemia)
Group 4
* Thromboembolic Occlusion of pulmonary vasculature
Group 5
* Blood D/O
80
Diagnose neuromuscular respiratory failure.
* Patients with vital capacity less than 20 mL/kg
* patients who cannot generate more than 30 cm H2O of negative inspiratory force
* patients with declining values are at high risk for ventilatory failure.
81
pulmonary silicosis with pulmonary nodule (upper lung)
Evaluate for tuberculosis
82
1. Diagnose a tuberculous pleural effusion
2. parapneumonic effusion
1. denosine deaminase level greater than 70 units/L
2. 10,000 per microliter (10 × 109/L) with a predominance of neutrophils
83
Quick Points / Ventilation
• Volume control: Set volume, pressure is variable
• Pressure control: Set pressure, volume is variable
• CPAP and PSV for spontaneously breathing
• **Oxygenation**: PEEP, FiO2, inspiratory time
• **Ventilation**: rate, tidal volume, expiratory time
• Adverse effects: barotrauma, airway issues,
VAP, hypotension
• Liberation: wean screen, SBT, airway protection
84
Quick Points ALI
• Acute bilateral infiltrates, P/f ratio \< 200, no evidence of CHF
• Causes: pneumonia, sepsis, aspiration, trauma, transfusions
• Physiology: severe hypoxemia by shunt and V/Q mismatch
_**• Low tidal volume strategy: \< 6 mL/kg of IBW
• Maintain plateau pressure \< 30 cm
• Permissive hypercapnia**_
• Steroids may help early
85
Quick Points Lung cancer
* Lung cancer: #1 cause of cancer related deaths
* SMOKING, SMOKING, SMOKING!!
* Symptoms usually when advanced
• Paraneoplastic:
- NSCLC: hypercalcemia
- Small cell: inappropriate secretion of ADH,
ectopic ACTH secretion,
Eaton-Lambert syndrome
• Non-small cell: 80% of all cancers
- No surgery for metastatic or stage NIB
• Small cell: responsive to chemotherapy, high
recurrence rate, limited vs. systemic staging
• Terrible prognosis
86
Quick Points Plural Effusion
* Transudate: CHF, nephrotic, hepatic hydrothorax
* If exudative, need further evaluation
* Parapneumonic: complete drainage if with organisms, large, loculated, low PH, high LDH
* Low glucose: rheumatoid, empyema
* TB: high protein, lymphocytic, minimal mesothelial cells, high ADA
87
**Quick Points**
**Pulmonary Embolism **
Quick Points
• Risk factors: stasis, immobility, hypercoag state
• CTA now diagnostic test of choice but need contrast
• Treat empirically with high clinical pre-test probability
• LMWH superior to UFH
• Warfarin for long term (except cancer or pregnancy)
• TPA for HD unstable, severe hypoxemia, no change survival
• High-risk prophylaxis: LMWH, then UFH
88
Criteria to wean off Vent
Spontaneous breathing for \>2 hrs then check
* RSBI \< 105 (Breaths per min / Tv L)
* Good mental status
* Few secretion
* Strong Cough
* Absent upper airway lesions
If not place on assist control
Consider tracheostomy after 10-14 days
89
**_Quick Points Sepsis_**
* Sepsis: systemic inflammatory response to infection
* Leads to hemodynamic collapse and can lead to multi-organ failure
* Early cultures and antibiotics
* Aggressive volume resuscitation
* Vasopressor support
* Aggressive volume resuscitation
* Transfusions and inotropes helpful in early resuscitative phase
* APACHE \> 25 is high High High
90
Quick Points Shock
Quick Points
• Hypovolemic shock: low preload
• Cardiogenic shock: low CO, bad pump
• Distributive (vasodilatory) shock: sepsis
- Decreased afterload or SVR
• PA catheter: no proven role in patients with shock
• PCWP: reflective of LVEDP, if high may be suggestive of CHF
91
Quick Points TB
• TB spread by droplet
• Risk factors: HIV, silicosis, ESRD, steroids
• Latent TB
- 5 mm: HIV, recent TB contacts, old TB with
CXR changes, organ transplants
- 15 mm: anyone
- 9 months INH
• Active TB: upper lobe, anything goes in HIV
- 4 drugs for 2 months, 4 months INH/rifampin
- Use rifabutin if Pis or NNRTIs
92
Radiation Pneumonitis
Time line
Tx
4-12 weeks after neck or thoracic radiation exposure with non responsive pneumonia
Tx : Prednisone for two weeks and taper of 3-12 weeks
93
Rapid shallow breathing index (RSBI)
good peridictor of successful extubations ...
pontaneous breathing trail for 2 hrs
===== Then
RSBI \< 105
Good mental status
Few secretions
Strong cough
Absent upper airway lesions
======== If so Extubate
Else :
Place on Assist control
Daily SBTs
Consider Tracheostomy
94
Classifying the Tuberculin Reaction
**\> 5 mm induration /not erythema**
\> 5 mm
* Recent contacts of TB case
* Persons with fibrotic changes on chest radiograph consistent with old healed TB
* Patients with organ transplants and other immunosuppressed patients
95
Risk Assessment
**_Cancer Characteristics_**
• Clinical
- Age
- Cigarette smoking
Active
Former
• 2nd Hand
- History of malignancy
- 1 ° relative with lung cancer
* *_• Radiographic_**
- Size
- Shape
- Calcification
- Density
- Growth rate
96
Sarcoidosis
Stages
Tx
Stage I and II
* b/l Hilar Adnopathy / paratracheal node enlargement
* with reticular opacities
Stage III and IV
* Retidular opacities with no or shrinking hilar adnopathy
Tx:
* Steriods primary
97
Complications of Nephrotic Syndrome
* Protien malnutrition
* Hypovolemia
* Acute renal Failure
* _Thromboembolism_
* _Infection_
* Proximal tubular Dysfunc. causing Vit D def
98
SCLC: Staging
* Limited Stage
* Extensive Stage
SCLC: Staging
• Limited Stage
Defined as tumor involvement of one lung, the
mediastinum, and ipsilateral and/or contralateral
supraclavicular lymph nodes or disease that can
be encompassed in a single radiotherapy port
• Extensive Stage
Defined as tumor that has spread beyond one
lung, mediastinum, and supraclavicular lymph
nodes; Common distant sites of metastases are
the adrenals, bone, liver, bone marrow, and brain
99
SCLC: Treatment
• Limited Disease
- Chemotherapy
- Concomitant Radiation
- Prophylactic Cranial Irradiation
• Extensive Disease
- Chemotherapy
- Palliative radiation
100
SEPSIS (Early goal directed algorithm for sepsis)
Central Venous Pressure : CVP
Central venous oxygen saturation: ScvO2
MAP
* CVP \< 8 mmHG
* Crystalloid fluids if needed Vasopressors NE
* CVP \> 8 &
* MAP \< 65 then vasopressors NE
* MAP \> 65-90 & ScvO2 \< 70 give PRBC if not working give Dobutamine
* ScvO2 \> 70% goal achieved
101
CAP Tx
outpatient
Healthy : Macrolides or Doxy
With comorbidity: Flouroquin or b-lactam +mcarolide
Inpatient
Flouroquin or b-lactam and macrolide
Inpatient ICU
Blactam+ macrolide IV or Blactam + flouroquine IV
Lenght of treatement no change 7 days (bacteremia does not change therapy time)
102
Sepsis Management: **Resuscitation**
Hypotension and/or a serum lactate \> 4 mmol/L
* Deliver an initial minimum of 20 mL/kg of crystalloid or an equivalent
* Vasopressors for hypotension not responding to initial fluid resuscitation to maintain meanarterial pressure (MAP) \> 65 mmHg (dopamine or norepinephrine)
Persistent hypotension despite fluid resuscitation and/or lactate \> 4 mmol/L
* Achieve **CVP (Central Venous Pressure) \> 8** mmHg
* Achieve a **ScvO2 (oxygen Sat in venous blood)\>** 70% or SvO2 \> 65%
* Hb goal 10
* Dobutamine
103
Shock / Physiologic determinants
Classification
• Hypovolemic
• Cardiogenic
• Distributive
* Cardiac Output (CO) = heart rate x stroke volume Stroke volume depends on preload, myocardial contractility, and afterload
* SVR = measure of tone in arterial bed
* SVR and CO can be used to differentiate between forms of shock
104
SIRS Criteria
* Sepsis
* Severe Sepsis
* Septic Shock
• Temperature \< 36° C or \> 38° C
• Heart Rate \> 90 bpm
• Respiratory Rate \> 20 breaths/min
or PaCO2 \< 32 mmHg
• White Blood Cell Count \> 12,000 or
\< 4,000 cells/mm3 or \> 10% bands
* Sepsis: Infection PLUS SIRS criteria
* Severe Sepsis: Sepsis PLUS Organ dysfunction
* Septic Shock: Sepsis PLUS Shock refractory to fluid resuscitation
* SHOCK - High Lactate / ABG acidosis / Hypotension ....
105
Small Cell Lung Cancer (SCLC)
Small Cell Lung Cancer (SCLC)
• Most aggressive lung cancer
• Responsive to chemotherapy and radiation but
recurrence rate is high even in early stage
SCLC: Cell Types
• Oat Cell
• Intermediate
• Combined
106
Solitary Pulmonary Nodule
High Malignancy risk
* Surgical Excision
Low malignancy risk
* Serial CT scans
Intermedicate Malignancy Risk
* \< 1 cm Serial CTs
* \> 1 cm PET SCAN
* then CT vs Excision
107
Solitary Pulmonary Nodule
## Footnote
\> 4 mm - 6 mm
With risk factors
* Follow-up at 6- 12 months; if stable, followup at 18-24 months
Without risk factors
* Follow-up at 12 months;no additional follow-up if stable
108
Solitary Pulmonary Nodule
\>6mm to 8mm?
**With risk factors**
* Follow-up at 3- 6 months; if stable, followup at 9-12 months
**Without risk factors**
* Follow-up at 6- 12 months; if stable, followup at 18-24 months
109
Aspirin exacerbated respiratory disease
* Avoid NSAIDS
* Leukotrine recepter antagonist
* ASA desensitization
110
Solitary Pulmonary Nodule
=\< 4 mm
**With risk factors**
* Follow-up at 12 months;
* no additional follow-up if stable
**Without risk factors**
* Follow-up is optional
111
Sweat chloride testing
α1-Antitrypsin level measurement
If CT changes of bronchiectasis
α1-Antitrypsin deficiency should be evaluated in selected patients with COPD because of the availability of specific therapy.
112
Sympotms of impeding respiratory failure
* pH 45
* Clinical Signs of respiratory Failure
* Respiratory rate \> 25/min for 2 hrs
* Hypoxemia
113
TB HIV
**ON HAART treatment or not?**
RIF-based regimens generally recommended for persons
* Who have not started antiretroviral therapy
* For whom Pis or NNRTIs are not recommended
* Isoniazid (INH)
* **_Rifampin (RIF)_**
* Pyrazinamide (PZA)
* Ethambutol (EMB)
For patients receiving Pis or NNRTIs, initial treatment phase may consist of
* Isoniazid (INH)
* **_Rifabutin (RFB)_**
* Pyrazinamide (PZA)
* Ethambutol (EMB)
An alternative non-rifamycin regimen includes
INH, EMB, PZA, and streptomycin (SM)
114
TCA overdose manifests
1. Respiratory Depression
2. Hypotension
3. Tachycardia
4. Seizures
5. Coma
6. Death
7. Wide complex tachycardia **QRS \> 100**
TX: Sodium bicarb if QRS prolonged (keep ph 7.45-7.55) if Ingestion of \> 5 mg/kg then patint keep in **Emergery room regardless of symptoms**.
115
The recommendation for step-up therapy in pregnant patient
similar to that for nonpregnant patients, with the understanding that it is safer for pregnant women to be exposed to asthma medications with lim ited human safety data than it is to experience ongoing symptoms and exacerbations of asthma.
116
**Asthma steps**
If SABA is used \> 2 days per week meas inadequate
1. SABA
2. 1+ Low dose ICS
3. Low dose ICS + LABA or Medium ICS
4. Meduim dose ICS + LABA
5. High dose ICS +LABA and Omalizumab for patients with allergies
117
Transudate vs. Exudate Causes
**_Causes of Transudates_**
* CHF
* Hepatic Hydrothorax
* Nephrotic Syndrome
* Hypoalbuminemia
* Peritoneal Dialysis
**_Causes of Exudative Effusions_**
* Parapneumonic
* Empyema
* Malignancy (carcinoma, lymphoma,
* mesothelioma)
* Pulmonary embolism
* Tuberculous
118
Alph 1 Antitrypsine Deficiency when to test for it?
Panniculitis (adipose tissue inflammation)
Early onset Emphysema \< 45
Family history
Basilar emphysema on CXR
119
Transudate vs. Exudate LABS
do not need thoracentesis if \< 1 CM
Light's criteria Exudate (one of following):
* Pleural fluid protein/serum protein ratio greater than 0.5
* Pleural fluid LDH/serum LDH ratio greater than 0.6
* Pleural fluid LDH greater than two-thirds the
* upper limits of normal of the serum LDH
* Protien gradient \> 3.1 and Albumin gradient \> 2.1
Quick Hints
**_Other Studies_**
• Protein: high in exudates, \> 4.0 g/dL in TB
• LDH: if \> 1,000, consider empyema, malignancy, rheumatoid pleurisy, paragonimiasis
• Glucose: low level, \< 60, suggests one of
the following:
- Rheumatoid pleurisy (less than 30)
- Empyema or complicated parapneumonic
- Tuberculous effusion
120
Treat an acute exacerbation of idiopathic pulmonary fibrosis
* vidence of an acute exacerbation of IPF without a known cause.
* in-hospital mortality rates of 86% and 97% in this patient population.
* Initiate palliation with narcotics
121
Treat continuous positive airway pressure–related rhinitis.
The addition of in-line heated humidity to continuous positive airway pressure (CPAP) therapy is a simple, effective method to combat CPAP-associated nasal congestion.
Avoid Oxymetazoline nasal sprays - will develop medicamentosa
122
Treat exercise-induced bronchospasm.
Use of a short-acting β2-agonist 10 to 15 minutes before exercise prevents exercise-induced bronchospasm in most patients.
123
Treat hypoxemic respiratory failure with continuous positive airway pressure
* CPAP may be used in patients who have respiratory failure after abdominal surgery.
* NPPV may be used in patients who have respiratory failure after lung resection surgery.
124
Treat neuroleptic malignant syndrome.
intravenous fluids and benzodiazepines such as lorazepam.
125
ABPA Allergic Bronchopulmonary Asperigillosis
**ALTICES**
* Asthma and Cystic fibrosis
* Lung infiltrate on Xray
* Test (skin) +ve for asapergillus
* IgE \> 400
* Central Bronchiectasis
* Eosinophilia \> 500
* Serum IgG and IgE for A fumigatus
**TX:** Steriods and Itraconazole
126
Treat pulmonary metastases from colorectal carcinoma
•In patients with colorectal carcinoma with metastatic disease to the lung, surgical resection is the primary treatment and is associated with good long-term survival.
127
Treatment Chart
High clinical suspicion for active TB
PIRE (PZA INH RIF EMB)
- Isoniazid (INH)
- Rifabutin (RFB)
- Pyrazinamide (PZA)
- Ethambutol (EMB)
1. Place patient on initial-phase regimen:
INH, RIF, EMB, PZA for 2 months
2. Is specimen collected at end of initial phase (2 months) culturepositive?
* No : Give continuationphase treatment of INH/RIF daily or twice weekly for 4 months
3. Yes: Culter positive - Any cavitation on initial CXR?
* Yes: Give continuation-phase treatment of INH/RIF daily or twice weekly for 7 months (or if HIV +)
4. No Cavitation: HIV - Give continuation phase treatment of INH/RIF daily or twice weekly for 4 months
128
Treatment Complications
HIT
Start direct thrombin inhibitor, like lepirudin or argatroban
129
Unilateral diaphragmatic paralysis
Due to phrenic nerve injury C3-C5
Sniff test / Flouroscopy
130
Vent setting what to do?
1. PO2 high
2. PO2 Low
3. PCO2 High
4. PCO2 Low
1. PO2 high
1. Decrease FIO3
2. PO2 Low
1. Increase PEEP
3. PCO2 High
1. Increase RR
2. increase TV
4. PCO2 Low
1. Decrease RR
2. Decrease TV
3. Increase sedation
131
Vent variables:
FiO2
Tidal Volume
PEEP
Respiratory Rate
FiO2 - effects PO2
PEEP effects PO2
Tidal Volume effects PCO2
RR effects PCO2
132
Ventalation / Wean Screen
* Adequate oxygenation: PO2 \> 60 mmHg on FiO2\< 0.4-0.5;
* PEEP \< 5-8 cm H2O
* P/F ratio \> 150-200
* pH \> 7.25
* Stable cardiovascular system (e.g., HR
* Ability to initiate spontaneous breaths
* Resolution of disease acute phase
133
Ventilation settings that increase exhaliation / fix air trapping
Decrease RR
Tidal Volume
Inspiratory time
134
Well's Criteria
* Clinical Signs of DVT
* An Alternative Diagnosis is less likelythan PE
* HR\>100beats/min
* Immobilization or surgery in previous 4 weeks
* Previous DVT/PE
* Hemoptysis
* Malignancy
135
Wells Criteria
Score 3
* Clinical Signs of DVT
* PE highly on the list
Score 1.5
* Prev PE
* HR \> 100
* Recent Surgery
Score 1
* Hemoptysis
* Cancer
\< 4 Do D-Dimer
136
Evaluate a ground-glass pulmonary nodule.
* Ground-glass–appearing pulmonary nodules require more than 2 years of follow-up with CT because they may represent slow-growing adenocarcinoma in situ (formerly known as bronchioloalveolar cell carcinomas).
* GGOs causes low 18-fluoro-deoxyglucose uptake on PET-CT scan, which results in a high number of false negatives unless the lesion has become solid
137
• Peak Inspiratory Pressure (PIP or Ppeak)
- The highest pressure observed during inspiration
- A constant VT with an increase PIP may indicate a lower lung compliance (CL) or an t in Raw
- A declining PIP may indicate a leak or a sign of improvement in CL or Raw
PIP - Platue gives the Airway resistance Raw
138
Roflumilast
oral phosphodiesterase-4 inhibitor recently approved for use in patients with severe and very severe COPD associated with chronic bronchitis and a history of frequent exacerbations.
139
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