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461 Cards in this Set

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Asthma:
3 cardinal features

1. hyperresponsiveness
2. airway obstruction
3. inflammation

Asthma


Airway remodeling

ASTHMA patient lungs with subepithelial fibrosis, increased smooth muscle mass, angiogenesis and hyperplasia of mucous gland and goblet cells

Asthma Severity: Mild Intermitt
a. Symptoms (3)
b. Night Symptoms
c. Lung Function

a. less than or equal 2x a wk
Asx and normal Peak Exp Flow between flares
Flares brief (few hrs to few days)
intensity may vary
b. less than or equal 2 times a month
c. FEV1 or PEF greater than or equal 80%, predicted PEF variability less than 20%

Asthma Severity: Mild Persistent
a. Symptoms (2)
b. Night Symptoms
c. Lung Function
a. Sx greater than 2x a wk, but less than once a day
flares may affect activity
b. greater than twice a month
c. FEV1 or PEF equal or greater than 80%, predicted PEF variability 20-30%
Asthma Severity: Mod Persistent
a. Symptoms (4)
b. Night symptoms
c. Lung Function
a. daily symptoms
daily use of albuterol
flares affect activity
flares equal or greater twice a wk, may last days
b. greater than once a wk
c. FEV1 or PEF greater than 60% less than or equal PEF variability greater than 30%
Asthma Severity: Severe Persist
a. Symptoms (3)
b. Night symptoms
c. Lung Function
a. continual symptoms
limited physical activity
freq flares
b. frequent
c. FEV1 or PEF less than or equal 60% predicted PEF variability greater than 30%
Peak Expiratory Flow - Asthma
1. change of 20%
2. 20-50% change
3. >50%

1. stable disease
2. moderate airway obstruction
3. severe obstruction

Bronchial challenge test
1. what is it
2. goal of test
3. predictive value
4. Do not take this test

bronchoconstrictor which reduces FEV1.


like methacholine or histamine
high negative predictive value (sens not specific)
excludes asthma from patients with atypical pulm symptoms
*asthmatic with typical symptoms

Asthma
Type that does not respond to therapy
ABPA - acute bronchopulmonary aspergillosis

Asthma
Subset of occupational asthma that occurs with no previous history of asthma and high exposure to respiratory irritant

RADS - reactive airway dysfunction syndrome
Asthma
ABPA is______ asthma with imaging (3) and (1) sign

persistent
1. central bronchiectasis
2. pulm infiltrates upper lobes
3. fibrosis
1. brown sputum with Aspergillus

Asthma
ABPA treatment
oral steroids for several weeks
Asthma
worsening condition taking leukotriene receptor blocker with development of pulm infiltrates and eosinophilia during steroid taper
Churg strauss vasculitis
Asthma
exercise induced asthma trigger
exercise in cold dry air
Asthma
exercise induced asthma treatment
beta agonist inhaler
Asthma
Symptoms of Aspirin sensitive asthma (2)
rhinorrhea and nasal congestion

Asthma
Aspirin sensitive asthma but still needs aspirin

see specialist for desensitization
Asthma
mild aspirin intolerance and asthma
leukotriene modifying agent
Asthma
3 big symptoms
cough
wheeze
chest tightness
Asthma
1. breakthrough symptoms
2. exercise induced asthma prophylaxis
short acting beta2 agonist

Asthma
persistent asthma treatment and mainstay controller therapy for asthma

inhaled steroids

Asthma
Side effect of inhaled steroids(2)
thrush and dysphonia related to laryngeal muscle myopathy
Asthma
alternate to inhaled steroids(2)
Cromolyn and Nedocromil

Asthma
persistent asthma not preferred treatment..


If failing albuterol and inhaled steroids...

Leukotriene modifier


add long acting beta 2

Asthma
nocturnal asthma treatment


FEV1/FVC ratio less than 70% on spirometry...

theophylline


indicates airway obstruction

Asthma
moderate to severe persistent asthma with elevated IgE TREATMENT (failed steroids)

Omalizumab (Anti- IgE antbody)

Asthma
2 contraindications for omalizumab...


measures lung ability to transfer gas across alveolar-capillary membrane...

1. overweight
2. IgE > 700


DLCO

COPD
4 major disorders

emphysema
chronic bronchitis
obliterative bronchiolitis
asthmatic bronchitis

COPD
chronic bronchitis clinic definition
productive cough on most days for 3mo in each of 2 straight years
How is COPD different from asthma?
asthmatics have greater reversibility of obstruction
COPD
#1 risk factor

smoking

Spirometry
FEV1/FVC < 70%...


TLC less than 80% predicted...


Low TLC, but increased residual volume...

obstructive lung process


restrictive lung process


resp muscle weakness from neuromusc disease

Emphysema
2 types

1. centrilobular
2. panlobular

Centrilobular emphysema
- lung pathology
- risk factor
- dilation and destruction of resp bronchioles
- tobacco
Panlobular emphysema
- lung pathology
- risk factor
- destruction of whole acinus
- alpha 1 anti trypsin
COPD
blue bloater (ankle edema, enlarged liver, engorged neck veins)
alveolar hypoxia remodel pulm arteries causing RVH and secondary pulm HTN
COPD
key to diagnosis
expiratory airflow limitation
COPD
spirometer 2 values...
which confirm

post bronchodialtor FEV1 <80%
FEV1/FVC less than 70%
airflow limitation

COPD
BODE index correlates with...

BMI, airflow Obstuction, Dyspnea, 6min walk Exertion
(survival)

COPD
DLco

diffusing capacity of carbon monoxide. single breath uptake of CO over 10sec breath hold. measures gas transfer

COPD
DLco in emphysema; asthma; chronic bronchitis

low in emphysema
normal in asthma
mild reduced chronic bronchitis

COPD
end stage COPD ABG (2)

elevated carboxyhgb can cause false normal oxygen saturation via pulse ox. need ABG to eval CO2 retention. arterial hypoxemia and alveolar hypoventilation

COPD
ABG values for resp failure on RA (2)
PaO2 less than 60
PaCO2 greater than 55
COPD
differential (6)
asthma, CHF, bronchiectasis, Tb, obliterative bronchiolitis, diffuse panbronchiolitis
COPD
screen for this condition if early onset COPD and family history of lung or liver disease

alpha1 anti trypsin def

COPD
anticholinergics work better in...


When to initiate treatment with serevent or spiriva ...

COPD treatment


when FEV1 less than 60% predicted

COPD
Do not combine spriva with...

atrovent

COPD
oral anticholinergic.

theophylline

COPD
theophylline level need to be monitored because in can potentiate

steroids

COPD
do not use for regular maintenance...


Do not use alone or for maintenance or rescue in COPD....

oral steroids


inhaled steroids

COPD
recommended vaccines

annual flu shot and pneumovax

COPD
alpha 1 antitrypsin treatment.
problem...
IV infusion of purified protein weekly
expensive

COPD
avoid these meds in stable COPD, why?


Consider this for all symptomatic COPD with FEV1 less than 50% predicted

antitussives because cough is protective


pulm rehab

COPD
treatment if also has rhinitis or asthma

leukotriene modifier

COPD
3 surgeries

bullectomy
lung volume reduction surgery for upper lobe emphysema
lung transplant

COPD
when to use NPPV?
ph, PaCO2, RR

SOB with ph <7.35
PaCO2 >45
RR >25

ILD
Acute (days to weeks) to Subacute (less than 3mo) presentation (8)

Acute interstitial pneumonia
both idiopathic and collagen vasc disease associated ILD
Acute eosinophilic pneumonia
Chronic eosinophilic pneumonia
Cryptogenic organizing pneumonia
Drug induced interstitial lung disease
Diffuse alveolar hemorrhage
hypersensitivity pneumonitis

ILD - physical findings
crackles common in....
less common...
common in fibrosing ILD
less common sarcoid
ILD - physical findings
mid inspiratory squeaks
bronchiolitis
ILD - physical findings
increased P2, RV lift, TR murmur

severe restrictive disease like pulm HTN seen in ILD, scleroderma, PLCH

ILD - physical findings
Clubbing


Most common idiopathic interstitial pneumonia

IPF

ILD - physical findings
erythema nodosum (3)
sarcoid
IBD
behcet
ILD - physical findings
maculopapular exantham (3)
sarcoid
amyloid
Behcet
ILD - physical findings
uveitis/conjunctivits(4)
sarcoid
behcet
IBS
AS
ILD - physical findings
Lacrimal/salivary gland enlargement(2)
sarcoid
Sjogren
ILD - physical findings
adenopathy, hepatosplenomegaly (2)
sarcoid
amyloid
ILD - physical findings
arthritis (5)
collagen vascular disease
IBD
sarcoid
behcet
AS
ILD - physical findings
muscle weakness or tenderness
polymyositis
ILD - physical findings
1. cranial nerve deficit
2. mental retard
1. sarcoid
2. tuberous sclerosis
ILD - lab findings
eosinophilia (4)
eosinophilic pneumonia
sarcoid
systemic vasculitis
drug induced
ILD - lab findings
hemolytic anemia (4)
connective tissue disease
sarcoid
lymphoma
drug induced
ILD - lab findings
normocytic anemia carcinomatosis (3)
diffuse alveolar hemorrhage syndromes
connective tissue
lymphangitic
ILD - lab findings
urinary sediment abnormalities (3)
connective tissue
systemic vasculitis
drug induced
ILD - lab findings
hypogammaglobulinemia
lymphocytic interstitial pneumonia
ILD - lab findings
serum ACE (4)
sarcoid
hypersensitivity pneumonitis
silicosis
Gaucher
ILD - lab findings
anti basement membrane antibody
goodpasture
ILD - lab findings
ANCA (3)
wegener
churg strauss
microscopic polyangiitis
ILD - lab findings
serum precipitating antibodies
hypersensitivity pneumonitis

ILD
most common IIP

IPF - idiopathic pulm fibrosis

ILD
IPF histopathology
fibroblast foci

ILD
IPF Sx (2)
Lung exam
Chest CT (2)

sx: worsening SOB and nonproductive cough
Exam: end insp crackles
CT: peripheral and basal predominant disease, no nodules or opacities

ILD
IPF on PFT
prognosis(2)

restrictive lung process
linked to degree of restriction
less than 3yrs

ILD
IPF treatment

lung transplant

ILD
rapid onset of disease over days to wks that leads to progressive resp failure

acute interstitial pneumonia


or idiopathic diffuse alveolar damage


or Hamman-rich syndrome

ILD
resembles IPF, but younger and less rales on exam
NSIP - nonspecific interstitial pneumonitis
ILD
NSIP chest xray and chest CT
CXR - bilat lower zone opacities
Chest CT - bilat lower lung opacities.
ILD
NSIP on chest CT lacks
honeycombing
ILD
NSIP lung biopsy
homogenous lymphoplasmacytic inflammation +- fibrosis
ILD
NSIP prognosis
level of fibrosis on biopsy
ILD
NSIP treatment
steroids
ILD
lower resp infection that fails antibiotics
COP - cryptogenic organizing pneumonia
ILD
COP Sx (1 common, 1 not)
crackles, not clubbing
ILD
COP chest xray
chest CT
CXR - consolidation
chest CT - airspace consolidation with bronchograms in lower zones with ground glass opacities
ILD
COP PFT (2)
restrictive with low DLCO
ILD
COP biopsy
organizing pneumonia with preserved lung architecture
ILD
COP treatment
24wk taper of steroids
ILD
smoking related disorders (2)
(DIP)- desquamative interstitial pneumonitis
(RB-ILD) - resp bronchiolitis associated interstitial lung disease
ILD
DIP chest xray
ground glass pattern
ILD
DIP chest CT
fibrosis with traction bronchiectasis and honeycombing
ILD
DIP PFT (2)
restrictive lung, low DLCO
ILD
DIP path
pigmented macrophages in alveolar spaces
ILD
DIP treatment (2)
stop smoking and steroids
ILD
RB-ILD vs DIP age
RB-ILD younger
ILD
RB-ILD Chest xray
basilar reticular or reticulonodular in centrilobular distribution
ILD
RB-ILD chest CT
ground glass
ILD
RB-ILD PFT
normal vs mixed rest/obst
low DLCO
ILD
RB-ILD path
similar to DIP
ILD
RB-ILD treatment
stop smoking
steroids
ILD
DIP vs RB-ILD prognosis
RB-ILD can still have significant disease
ILD
acute disease
AIP - acute interstitial pneumonia
ILD
other name for AIP
Hamman-Rich syndrome
ILD
AIP progress
hypoxemic resp failure
ILD
AIP chest xray
diffuse bilat airspace disease
ILD
AIP similar to
ARDS
ILD
AIP path
diffuse alveolar samage
ILD
AIP treatment
IV steroids
ILD
AIP prognosis
poor, die in 2mo
ILD
rarest ILD and seen more in women
LIP-lymphoid interstitial pneumonia
ILD
LIP
chest xray
chest CT(2) - one is not seen in other conditions
honeycombing
ground glass opacity and pervascular cysts
ILD
LIP
BAL
lymphocytosis
ILD
LIP path
interstitial pneumonia with dense lymphoid infiltrate
ILD
LIP path seen in (2)
Sjogren and HIV
ILD
LIP differential
lymphoma
Eosinophilic pneumonia
classic chest xray
no pulm edema
Eosinophilic pneumonia
simple eosinophilic pneumonia
Loffler syndrome
Eosinophilic pneumonia
acute vs chronic lab value
acute eosinophilia may not be seen in periph smear. Check BAL.
Eosinophilic pneumonia
treatment
steroids

LAM
What is it?

lymphangioleiomyomatosis
cystic lung disease affecting child bearing age women
LAM
a. effusion
b. complication
c. PFT

a. chylous
b. PTX
c. physiologic obstruction

LAM
a. give bronchodilator
b. DLCO

a. no help
b. reduced

LAM
histo (2)

LAM smooth muscle cells and cysts

LAM
treatment after PTX

pleurodesis

LAM
prognosis

may lead to ESLD requiring transplant

PLCH
what is it and 2 other names
pulmonary langerhans cell histiocytosis
Histiocytosis X
eosinophilic granuloma of lung
PLCH
who?
young smokers (less than 40yo)
PLCH
25% develop complication
PTX
PLCH
CXR
cysts and nodules
PLCH
path (2)
1. bronchiolocentric cellular infiltration with langerhans cells
2. Birbeck granules - rod shaped structures in cells
PLCH
treatment
stop smoking
Sarcoid
protective?
smoking

Sarcoid
1. uveo-parotid fever
2. eyrethama nodosum, polyarthralgia, and bilat hilar LN that do not warrant histo confirmation....

Heerfordt syndrome
Lofgren syndrome, usually resolves spontaneously

Sarcoid
90% have this involvement
lung
Sarcoid
chest CT
widespread nodules
Sarcoid
Treatment
a. mainstay
b. cutaneous and pulm
a. steroids
b. hydroxychloroquine
Rheumatoid lung disease
physical finding
PFT
clubbing
restrictive defect
Rheumatoid lung disease
who
men with advanced joint disease
Scleroderma
Lung finding
Heart finding
PFT
pulm HTN
R heart failure
restrictive lung
Scleroderma
Chest CT
ILD
Scleroderma
GI finding (2)
esophageal dilation and dysmotility
Scleroderma
path
fibrotic form on nospecific interstitial pneumonitis
Scleroderma
Treatment
cyclophosphamide
polymyositis/dermatomyositis
lung Sx(2)
similar presentation
DOE and nonproductive cough
ARDS
polymyositis/dermatomyositis
Lab (2)
PFT (2)
elevated muscle enzymes
anti Jo-1 Ab
restrictive defect
reduce DLCO
polymyositis/dermatomyositis
imaging
honeycombing
polymyositis/dermatomyositis
therapy(2)
steroids
cytotoxic agens
polymyositis/dermatomyositis
who responds best?
pathologic organizing pneumonia
SLE
at risk for
venous thromboembolism
Sjogren
chest CT expiratory
focal air trapping
Sjogren
treatment(2)
steroids
cytotoxic agents
Diffuse alveolar hemorrhage
linked to...
goodpasture or small vessel vasculitis
Pulm vasculitis
necrotizing granulomatous vasculitis affecting small and medium vessels in lungs and kidney
wegener's granulomatosis
Pulm vasculitis
+ C-ANCA
Wegener's granulomatosis
Pulm vasculitis
Wegener's perform this type of lab
culture to RO infection
Pulm vasculitis
Wegener's UA (3)
red cell casts, RBC, WBC
Pulm vasculitis
Chest CT with nodules, focal consolidation, cavitary and airspace disease
Wegeners
Pulm vasculitis
Wegener's treatment (2)
steroids and cyclophosphamide
Pulm vasculitis
Wegener's treatment after 3-6mo
azathioprine
Pulm vasc
triad of asthma, hypereosin, necrotizing vasculitis
churg-straus
Pulm vasc
Churg straus associated withdrawal of this drug
corticosteroids
Pulm vasc
Churg straus PFT
reversible airflow
Pulm vasc
Churg strauss complication
GI bleed or ischemia
Pulm vasc
Churg straus dx
periph blood eosinophilia
Pulm vasc
Churg straus chest CT
ground glass opacity
Pulm vasc
Churg straus bx
necrotizing vasculitis and granuloma
Pulm vasc
Churg straus treatment
steroids
Pulm vasc
Churg straus treatment refactory to steroids
cyclophosphamide
Pulm vasc
small vessel affecting lung and kidney
microscopic polyangiitis
Pulm vasc
microscopic polyangiitis presents with (2)
glomerulonephritis
hemoptysis
Pulm vasc
microscopic polyangiitis Labs
1 serum, 2 UA
elevated Cr
proteinuria
active sediment on UA
Pulm vasc
microscopic polyangiitis + test
P-ANCA
Pulm vasc
microscopic polyangiitis bx
focal segmental necrotizing glomerulonephritis
Pulm vasc
microscopic polyangiitis
treatment (2)
steroids and cyclophosphamide
Sarcoid
presenting manifestations
2 systems
2 body parts
lymph and pulm systems as well as eyes and skin
Drug Induced Lung Disease
Lab results
eosinophilia
Drug Induced Lung Disease
Chest CT
reticular and ground glass opacities with or without consolidation
Drug Induced Lung Disease
Treatment
steroids
Drug Induced Lung Disease
Hypersensitivity drug rxn symptom
fever
Drug Induced Lung Disease
Drug induced lupus(3)
procainamide
hydralazine
isoniazid

Drug Induced Lung Disease
drug with high attenuation parenchymal lesions and high incidence of pulm toxicity

amiodarone
Drug Induced Lung Disease
chemo drug that causes acute or delayed lung toxicity
nitrosurea carmustine
XRT Lung Disease
Treatment
steroids
XRT Lung Disease
Y shaped CXR
mediastinal lymphoma and Hodgkin due to paramediastinal fibrosis
Hypersensitivity Pneumonitis
other name
extrinsic allergic alveolitis
Hypersensitivity Pneumonitis
pathogensis
cell mediated immunity
Hypersensitivity Pneumonitis
Immunomodulatory role...
modulate severity...
Interferon gamma
IL-10
Hypersensitivity Pneumonitis
farmer's lung cause
thermophilic bacteria in decaying hay and grain
Hypersensitivity Pneumonitis
CBC
leukocytosis
Hypersensitivity Pneumonitis
end stage clinical
cyanosis and R heart failure
Hypersensitivity Pneumonitis
chest xray in early disease
normal
Hypersensitivity Pneumonitis
chest xray in acute disease
diffuse ground glass opacification and fine reticulonodular disease
Hypersensitivity Pneumonitis
chest xray in chronic disease
honeycombing
Hypersensitivity Pneumonitis
Chest CT high res
centrilobular nodules
*more sensitive than chest xray
Hypersensitivity Pneumonitis
biopsy triad
cellular bronchiolitis
lymphoplasmacytic interstitial infiltrate
non-necrotizing granuloma
Hypersensitivity Pneumonitis
Treatment
avoid antigen
oral steroids
Hypersensitivity Pneumonitis
Refractory cases

cytotoxic agents suck as cyclophosphamide and azathioprine

Mesothelioma
cancer of 2 locations...


asbestos is linked to 3 cancers...

pleura mostly and peritoneum


small cell


non small cell


mesothelioma

Mesothelioma
90% cases due to

asbestos exposure
Mesothelioma
Not a RF
smoking
Mesothelioma
other Risk factor
erionite - turkish fiber used in home building
Mesothelioma
clinical
chest pain with pleural effusion
Mesothelioma
confirm dx
surgical lung biopsy
Mesothelioma
prognosis
10% survival in 2 yrs
Mesothelioma
treatment
pemetrexed
Asyphyxiant
most common chemical
carbon monoxide
Asyphyxiant
carbon monoxide path
hgb binds CO rather than o2
Asyphyxiant
CO labwork
carboxyhgb
Asyphyxiant
CO treatment
nonrebreather oxygen and hyperbaric oxygen
Asyphyxiant
odor of rotten eggs
HS
Asyphyxiant
HS treatment
nitrites
Asyphyxiant
HS path
severe metabolic acidosis
Asyphyxiant
hypoxia with AG lactic acidosis but no cyanosis
HCN
Asyphyxiant
cyanide path
inhibit MTCH cytochrome oxidase
Asyphyxiant
Cyanide treatment (3)
100% oxygen, nitrite and thiosulfate
RADS
cause
exposure to chlorine gas and other irritants
RADS
histology
epithelial desquamation, submucosal inflammation and basement membrane thinkening
RADS
similar to...
asthma
RADS
PFT
obstructive pattern
RADS
after exposure, what happens to symptoms away from exposure
little relief
memory loss, impaired judgement and poor concentration can begin 2-28 days after...
CO2 toxicity especially with LOC

Pleural Effusion
Transudate

when hydrostatic pressure greater than clearance

Pleural Effusion
exudates

increased vasc permeability

Pleural Effusion
Light's criteria

exudate if (any of 3)
- fluid protein/eff protein > 0.5
- fluid LDH/serum LDH >0.6
- pleural LDH > 2/3 serum LDH

Pleural Effusion
transudate common cause (3)

CHF
Hepatic hydrothorax
Nephrotic syndrome

Pleural Effusion
nephrotic syndrome differential (1)

pulm embolism

Pleural Effusion
malignant effusion is this type of effusion

exudative

Pleural Effusion
types of exudate (3)

parapneumonic (lots of lymphocytes)
malignant
PE

Pleural Effusion
Parapneumonic effusion thoracentesis
>10mm of pleural fluid on lat decub or US

Pleural Effusion
lymphocytic exudate &
Pleural fluid adenosine deaminase > 70

Tb

Pleural Effusion
most common cause of eosinophil effusion

PTX

PTX
Spont. is primary when
lung is overtly normal
PTX
Primary spont PTX seen in..
CT scan shows...
tall men who smokes
subpleural blebs and bullae
PTX
Secondary PTX most common linked to..
COPD
PTX
women who don't smoke
LAM
PTX
treatment for primary spont PTX: aspirate (2)
if >2cm or if SOB present
PTX
treatment for primary spont PTX if aspiration failed
intercostal tube
PTX
treatment for primary spont PTX is drainage failed
chest surgery
PTX
treatment for secondary spont PTX +/- SOB. >2cm
aspiration
PTX
treatment for secondary spont PTX that fails aspiration
intercostal tube drainage
PTX
tension PTX defined
intrapleural pressure exceeds atmospheric pressure throughout resp cycle
PTX
tension PTX treatment (3)
1. high oxygen
2. cannula in pleural space in 2nd intercostal space to remove air and stabilize patient
3. chest tube in pleural space
PE
dangerous phsyio
increase pulm vasc resistance, increase R heart work, reduce cardiac output, infarction and death
PE
virchow triad
hypercoag
venous stasis
vascular damage
PE
CT scans miss
sub segmental pulm arteries
PE
Lung VQ, chest CT and leg doppler neg, but patient unstable
and PE concern is strong
gold standard test pulm angiography.
PE
measure activity of lovenox and arixtra
Anti-Xa activity
PE
unstable PE treatment to decrease risk of short term embolization
IVC filter

PE


Duration of anticoagulation typically...


refractory hypotension and pulm embolus...

at least 3mo


thrombolytic therapy followed by anticoag

CTEPH
1. Definition
2. prognosis if untreated

chronic thromboembolic pulm HTN
fatal if untreated
CTEPH
Treatment
resect chronic thrombus
CTEPH
physio
increased resistance of pulm arteries.
CTEPH
monitor
2decho after initial acute PE treatment
CTEPH
diagnosis, what do you see?
pulm angiography with tapering of lumen as opposed to vessel cut off seen in acute PE
CTEPH
Treatment
pulm thromboendarectomy
CTEPH
who get it
acute PE patients who do not recover completely

PAH
physio...


mean pulm art pressure...


pulm capillary wedge pressure....


pulm vasc resistance

narrow lumen of small pulm arteries and arterioles.


elevated mean pulm art pressure


normal wedge


increased resistance

PAH
familial and gene

AD with variable penetrance
BMPR2
PAH
lung VQ
moth eaten perfusion pattern

PAH
Differential (2)

connective tissue disorder
HIV

PAH
diagnosis and treatment

R heart cath to diagnose and assess acute vasodilator response before long term vasodilator is attempted.

PAH
Treatment (BP med)

Ca channel blocker to reduce art pressure in acute setting

PAH
IV treatment (3) and the best...
physio of treatment (2)
helps with
prostacyclin (EPOPROSTENOL, treprostinil, and iloprost)
vasodilator and remodeling
cor pulmonale

PAH
treatment that improves DOE
improves...

bosentan- endothelin-1 receptor antogonist. endothelin 1 is potent vasoconstrictor
mortality

PAH
man's favorite treatment

sildenafil. inhibits cGMP phosphodiesterase. cGMP induced by nitric oxide to regulate vascular smooth muscle tone
PAH
Non drug treatment (2)
oxygen because alveolar hypoxemia causes vasoconstriction.
transplant

Pulm nodule
minimum size...


no follow up...

less than 3cm in diameter (surrounded by normal tissue with no LN)


less than 4mm if never smoked or no cancer risk factors. if smoked or still smoking follow up 12mo if no change

Pulm nodule
malignant(3)

spiculated margin
little or no calcification
intermediate doubling time

Pulm nodule
Benign(3)
smooth margin
laminated calcification
double within 30 days or no growth in 2yrs

Lung ca
85%


#1 overall cancer killer

non small cell such as adeno


lung ca kills more than any other

Lung ca
15%


chest xray and lung cancer screening

small cell


not effective

Lung ca
central lesion workup

bronchoscopy

Lung ca
peripheral lesion workup
transthoracic needle aspiration
Lung ca
T - primary tumor
primary lesion size and invasion of contiguous structures
Lung ca
N
thoracic nodules
Lung ca
M
distant mets
Lung ca
stage 4 lung ca
M1
Lung ca
3 cancers that often go to lungs
kidney
colon
breast
Mets to Lung
present as..
asymptomatic single or multiple lung nodule
Mets to lung
prognosis
poor and inoperable
Lung tumor
benign
hamartoma
Lung tumor
Benign on chest xray or CT
eccentric popcorn calcification
Terminal Care
COPD survival scale
BMI
airflow Obstruction
Dyspnea
Exercise capacity
Terminal Care
Medicare criteria (3)
1. medicare part A coverage
2. less than 6mo left
3. revocable agreement that hospice benefits replace medicare benefits
Terminal Care
Medicare criteria for terminal phase of lung disease (3)
1. disabling SOB @ rest
2. frequent ER visits
3. PaO2 <=55
O2 sat<=88
OSA
define

absence of airflow for at least 10 sec despite resp effort

OSA
severity scale

AHI
apnea hypoapnea index
# of apnea + # of hypoapnea/hour sleep

OSA
AHI mild
AHI moderate
AHI severe

mild 5-15
moderate 16-30
severe >30

OSA
hallmark symptom

excess daytime sleepiness.

OSA
common physical findings
obesity
large neck
large tongue/tonsils
OSA
diagnosis
nocturnal polysomnography
OSA
when conservative treatment fails
CPAP
OSA
still sleepy after CPAP
CPAP ineffective or another sleep disorder
OSA
still sleepy after effective CPAP
modafinil
OSA
obstructive hypoapnea
reduction of airflow or aplitude of thoraco-abdominal movement by at least 30% at least 10sec in duration, and oxygen desat of 4% or more
OSA
treatment for anatomical abnormalities
surgery
OSA
treatment for mild to moderate OSA did not tolerate CPAP or surgery
oral device
CSA
non hypercapnic central sleep apnea
sleep unmasks sensitive apnea threshold for CO2.
CSA
who?
CHF with EF<40%
CSA
diagnosis
nocturnal polysomnography

CSA
treatment

treat underlying disease such as treat heart failure to improve cardiac function.

Sleep and COPD
desats occur mostly in..
REM sleep
Sleep and COPD
If on home oxygen, then with sleep
increase by 1L/min at night
Sleep and asthma
asthma worsened by (2)
gerd
OSA
Sleep and asthma
OSA and asthma treatment
CPAP improves asthma control
Sleep and asthma
nadir in peak flow rate when
early morning hours
Sleep
restrictive lung disease as well as pregnancy associate
sleep related oxygen desat
High Altitude
Sleep @ high altitude associate
with hypoxemia
High Altitude
Treatment (2)
1. acetazolamide
2. low dose hypnotics
High Altitude
when does acute mountain sickness occur?
4-36hr after ascent of above 2000m or 6500ft
Acute Mountain Sickness
resolves
after 2-5 days
Acute Mountain Sickness
concern..
transition to HACE, high altitude cerebral edema
Acute Mountain Sickness
less at risk
older people

Acute Mountain Sickness
1. prevention


2. to treat acute mountain sickness or cerebral edema

1. acetazolamide before and after ascent; great for prevention
2. dexamethasone, not for prevention

HAPE
frequency
very rare
HAPE
symptoms occur
2-4 days of ascent
HAPE
Symptoms...
SOB, cough with blood, AMS, and death
HAPE
physio...
blunted vent response to hypoxia, which increase pulm art pressure, leak protein into alveoli
HAPE
prevention

give time to acclimatize

HAPE
Treatment
nifedipine is pulm vasodilator
Air Travel
cabin pressure
altitude less than 8000ft

Air Travel
patients with lung disease

check pulse ox @ sea level.


oxyhgb saturation less than 92% should get in flight supplemental oxygen

High Altitude
breathing pattern with sleep

cresendo-decrescendo ventilation followed by hypopnea or apnea

Resp failure
acute hypoxemic resp failure includes
caridiogenic
Resp failure
what shifts oxyhgb dissociation curve to Right, lowering oxygen content ?(2)
high temp and acidity
Pulm edema
cardiogenic cause vs noncardiogenic
hydrostatic pressure vs permeability related issue

ARDS
define
cardiogenic or noncardiogenic


imaging...

PaO2/FIO2 <= 200
noncardiogenic


alveolar opacities

2 mechanisms of resp failure
1. hypoxic
2. ventilatory

COPD
mechanisms of resp failure (3)

1. airway obstruction
2. auto PEEP
3. resp muscle issue

Acute Vent failure
lab test
PaCO2
Acute vent failure
Lab test if chronic lung disease and why
check pH on ABG. baseline elevated CO2. "hypercapnic"
Acute vent failure
#1 cause
drugs
Acute vent failure
neuromuscular syndrome affects
3 muscle groups
1. inspiratory - diaphragm, intercostal
2. exipratory - abd
3. bulbar - protect airway
If all 3 systems affected, BAD
Acute vent failure
Spinal cord injury. if lesion below C4
C3-C5 phrenic nerve
Phrenic nerve injury

ALS or myasthenic crisis
orthopnea with abdominal paradox in supine
Acute vent failure
Most common cause in acute care setting
acute inflammatory demyelinating polyneuropathy (Guillain BArre)
Acute vent failure
surgical...
How to avoid
neuromuscular blocking agents combined with high dose steroids
check train of 4 stimulation
Acute vent failure
SIRS- how to avoid
tight glycemic control
Acute vent failure
Airway obstruction causers (2)
COPD,
asthma
Acute vent failure
Acute severe asthma signs
tachycardia
tachypnea
accesory muscle use
pulsus paradoxus - pulse and BP drops more than 10 with inspiration

Acute Vent Failure
asthma treatment new....


When to worry about asthma exacerbation....

Mag sulfate with beta agonist


slightly elevated or normal PCO2 may indicate impending resp arrest

Acute Vent failure
obesity hypoventilation rule out

hypothyroid

Mechanical ventilation
CPAP in COPD (2)


in moderate to severe COPD exacerbation...

counterbalance auto PEEP
reduce/eliminate inspiratory threshold load


Noninvasive positive pressure ventilation is standard of care.

Mechanical ventilation
CPAP in ICU (4 indications)

1. acute hypercapnic failure in COPD
2. cardiogenic pulm edema
3. ARF in immunosuppressed
4. weaning extubation COPD

NPPV
patient predictors for success (4)


When is it bad?

improvement in pH, PaCO2, Level of consc., RR
(within 2 hrs of starting NPPV)


delays intubation in high risk patients

VENTS
asthma and vents

avoid intubation due to PTX and pneumomediastinum

Vents
when to wean? (3)
SaO2
FIO2
SaO2 >89%
FIO2 <= 40%
hemodynamic stable
Vents
wean with (2)
T piece or low level CPAP
Vents
Failure to wean over 3 wks
trach
Vents
Settings for acute lung injury and ARDS (2)
lung protective strategy
low tidal volume 6mL/kg
limited plateau pressure <30cm H20
VENTS
vented COPD settings need to minimize adverse effects of
auto PEEP
CPR outcomes
best survival (3)
1. witnessed arrest
2. vfib
3. vtach
severe sepsis
poor prognosis
refractory septic shock. still need IVF and pressors to maintain pressure
sepsis
key component of sepsis physiology
endothelial damage
Sepsis
3 things important to surviving sepsis
a. spont breathing trial
b. ulcer prophylaxis
c. DVT prophylaxis
sepsis
give to high risk of death or 2 organ dysfunction
activated protein C or Drotrecogin alfa

sepsis
Should avoid this drug in sepsis only if BP does not respond to IVF and pressors


IV hydrocortisone

severe sepsis
6 criteria of organ dysfunction

hypoxemia, shock, delerium, thrombocytopenia, high Cr, high bili

shock
? etiology, then check


Defn....

bedside echo


decreased tissue perfusion that results in inadequate oxygen delivery for cellular needs (tissue ischemia)

shock - echo findings
1. PE
2. acute MI
3. hypovolemia
4. sepsis

R vent dilatation
focal wall motion abnormality
poorly filled hyperdynamic L vent
global decrease in contractility

warfare
most potent
nerve agent

warfare
nerve agent treatment for:
1. bronchorrhea
2. muscle weakness

1. atropine
2. pralidoxime

Anaphylaxis
anaphylactic rxn vs anaphylactoid rxn


IV steroids are helpful in...

anyphylactic - IgE mediated
oid - non Ab-antigen mechanism


ANAPHYLAXIS, not angioedema from ACE inhibitor

Anyphalactic shock
due to...(2)
hypovolemia and vasodilation
anyphlactic shock
death from...
refractory bronchospasm, resp failure with airway obstruction, and CV collapse
anyphalaxis
refractory anaphylaxis with low BP and bradycardia due to bblocker, then give...
glucagon
HTN emergency
goals of treatment (2)
MAP by 20-25%
or diastolic BP <120
HTN urgency
captopril side effect and avoid
1. reflex tachycardia
2. ARF with high grade bilat renal stenosis
HTN urgency
Clonidine side effect
sedation
HTN urgency
Labetalol side effect (2)
bradycardia
bronchospasm
HTN urgency
pheochromocytoma treatment
prazosin
HTN emergency
avoid enalapril in...
pregnant women
HTN emergency
med used when there is renal involvement
fenoldopam - dopamine 1 receptor agonist. decreased both preload and afterload
HTN emergency
decreases cerebral and cardiac ischemia
nicardipine
HTN emergency
pheochromocytoma IV med and side effect
phentolamine. tachycardia causing ischemia
HTN emergency
Sodium nitroprusside monitor
thiocyanate
HTN emergency
acute aortic dissection
trimethaphan - ganglionic blocker
HTN emergency
overall treatment and goal
ICU with IV agents. goal is not normal BP, but lower BP to avoid further organ damage
Hyperthermia
104 or 40C
106 or 41
life threatening
brain death
Hyperthermia
1st sign of heat stroke
no sweat
warm, dry skin
Hyperthermia
increased intracellular calcium causing mucle contraction
malignant hyperthermia
Hyperthermia
malignant hyperthermia
expose muscle to halothane or caffeine

Hyperthermia
malignant hyperthermia treatment (5)

stop drug, hydration, oxygen, cooling measures
Dantrolene

Hyperthermia
preventive

pretreat with dantrolene

Hyperthermia
idiosyncratic reaction to neuroleptic meds and antipsychotics (within 2wks after starting meds)

neuroleptic malignant syndrome

Hyperthermia
neuroleptic malignant syndrome and Parkinson.


can occur when quickly stop levodopa or anticholinergic meds
Hyperthermia
neuroleptic malignant syndrome and parkinson treatment

restart meds

Hypothermia
EKG finding
J wave or osborn wave
Hypothermia
treatment and complications
re-warming
compartment syndrome, rhabdo, DIC
ICU nutrition
lab for severe protein and calorie malnutrition
prealbumin less than 5
ICU nutrition
avoid aspiration
TF into small intestine
ICU nutrition
TPN risks
gastric mucosa atrophy and bacteremia from translocation of bacteria from gut to bloodstream
OD
visual complaints -1
Ca oxalate crystals urine -1
no osmolar gap due to ketones - 1
methanol toxicity
ethylene glycol
isopropyl alcohol
OD
alcohol toxicity treatment (2)
IV ethanol and fomepizole
OD
bruxism and jaw clenching
ecstasy
bruxism - teeth grinding
OD
amphetamine treatment (2)
supportive and benzo for agitation
OD
CO poisoning pathophys
shifts L on curve. impairs oxygen offload @ tissue
OD
CO poisoning rare finding
cherry red lips
OD
CO poisoning diagnosis
venous or arterial carboxyHgb
OD
CO poisoning and normal lab
carboxyHgb may be normal due to oxygen already given
OD
CO poisoning treatment
oxygen or hyperbaric oxygen
OD
cocaine OD treatment
if overt psychosis
benzo for agitation
haldol, but can lower seizure threshold
OD
cocaine and cardiac
ASA and NTG
OD
salicylate
alkalinization of urine to pH 7-8 for renal clearance

OD
TCA with cardiotoxicity (arrthymia)

IV Sodium bicarb (blood alkalinaztion)

Rhabdo
pathophys
skeletal muscle damage with myoglobin and CK release into circulation.
Rhabdo
#1 risk factor
etoh abuse
Rhabdo
classic triad
muscle pain, weakness, dark urine
Rhabdo
Urine - 1
blood - 2
myoglobinuria
CK and potassium
Rhabdo
complication
hypovolemia from fluid shifts to muscle
ARF from ATN
Rhabdo
treatment and goal
stop treatment
aggressive IVF for goal of UOP 300cc/hr
No myoglobin in urine
Pulm diagnostic tests
FEV1/FVC less than 70% on spirometry
bronchial challenge test and asthma
DlCO
airway obstruction
sensitive but not specific
lung ability to transfer gas across alv-cap membrane

Pulm diagnostic tests
avoid pulse ox in...

fire or smoke inhalation due to carboxyhgb which looks like oxyhgb to pulse ox

Pulm HTN


defn...


2 main causes

elevation of mean pulm art pressure of 25mm Hg or greater at rest


L side heart dysFN


underlying chronic lung disease

Pulm HTN


if patient with suspected pulm art HTN or uncertain cause of pulm HTN

R heart cath

Pulm HTN


follow up after diagnosis

2decho and 6min walk test

Lung ca


how to stage preoperative NSCL ca or suspected NSCL ca....

PET scan

Lung ca


staging lung ca: endoscopic guided needle aspiration vs mediastinoscopy

endoscopic guided aspiration is better

Lung ca


treatment for stage 1 or 2 NSCL ca....


stage 3 or 4 lung ca treatment...

surgical resection


chemo or chemo +XRT

Lung ca


prognosis of lung ca depends on 2...

stage @ presentation and performance status

Lung tumor


typical carcinoid treatment...

resection


low grade neuroendocrine tumor

Sleep


therapy of excessive daytime sleepiness regardless of cause...

at least 7-8hrs sleep a night

ARDS


physio...


corrected by 3 things...

hypoxemia


mechanical ventilation with supplemental oxygen and PEEP

ARDS


How to avoid ventilator associated lung injury?


4

limit tidal volumes


lower plateau pressure


optimize PEEP


reduce FIO2 to less than 0.6

Intubation


obstructive lung disease and intubation strategy

allow adequate time for exhalation before next delivered breath and minimize airway resistance through PEEP

Intubation


readiness to wean intubation

rapid shallow breathing index

Intubation


daily interruption of sedation and spont breathing trial...

lead to earlier extubation

Critical Care


after stabilized in ICU, sugar goal if severe sepsis and hyperglycemia

less than 180

COPD


symptomatic COPD with FEV1 less than 50% predicted should receive...

pulm rehab

OD


ethylene glycol (antifreeze) poisoning or methanol (wood alcohol) or isopropyl (rubbing) alcohol poisoning treatment...(3)

fomepizole, ethanol, dialysis

PTX


Primary


Secondary


If less than 2cm between chest wall and lung...

primary - no previous lung disease


secondary - previous lung disease, usually COPD


manage inpatient with serial chest xrays, no tube.


Sleep


First step of evaluation for daytime sleepiness.

sleep diary for 1-2wks

Spirometry


evaluate fixed airway obstruction

Flow volume loops, not lung volume measurments

Vents


How to avoid autoPEEP in intubated status asthmaticus or severe airflow obstruction?

allow adequate time for exhalation to avoid stacking breaths and autoPEEP

Asthma


pregnant and not controlled by albuterol and inhaled steroids...


avoid this oral drug...


avoid this asthma test...

add long acting beta agonist


theophylline


methacholine challenge

OSA


nasal congestion and CPAP...


avoid this drug...

humidify CPAP circuit to improve compliance


oxymetazoline nasal spray due to rebound congestion when med is stopped.

Silicosis


If history of silicosis, puts you at risk for...

Tb

PE


unprovoked PE/DVT with completed course of AC and still high DDimer

restart anticoag because of risk of recurrence. should test DDimer 3-4 wks after stopping warfarin

Resp Failure


hypoxemia from atelectasis after abdominal surgery or lung resection

CPAP helps avoid intubation and pneumonia

Resp failure


ARDS with normal BP and kidney function

aggressive diuresis may reduce time on ventilation

Critical Care Illness


best means of nutritional support in critically ill if can tolerate

NG tube with enteral tube feeds

Work Exposure


Coal workers with breathing symptoms: PFT or chest CT

PFT first to eval obstructive disease

ICU


common cause of AMS in ICU

delerium

Lung mass


from posterior mediastinum...


from anterior mediastinum...


from middle mediastinum...

neural tissue origin like schwannoma


anterior: thymus or thyroid


middle: LN

Resp Failure


2 bedside test for resp failure and neuromuscular disorder

vital capacity and maximum inspiratory pressure. VC less than 20 are poor prognosis

COPD


CPAP vs NPPV

use NPPV for moderate to severe COPD. do not use NPPV if high risk COPD, just go to intubation. CPAP is for OSA.

Lung Ca


If abnormal PET scan, next step of workup and why?

mediastinal LN sampling is better than CT guided biopsy for STAGING. During US can see all area LN

Lung Ca


Stage 1 or 2 non-small cell lung ca treatment...


Stage 3 or 4 lung ca treatment...

surgical resection


chemo +/- XRT

Hyperthermia


Neuroleptic malignant hyperthermia is caused by:


treatment:


Not helpful....

antipsychotic agents


stop agent, start IVF, start IV ativan


not helpful dantrolene

Sleep


obese with daytime CO2>45 (hypercapnia) and DOE...


Treatment...

Obesity Hypoventilation syndrome or Pickwickian


CPAP

Lung Ca


if nonsmall cell lung ca is suspicious, and thoracentesis is negative, next step...

repeat thoracentesis and cytology

Interstitial pneumonia


Nonspecific idiopathic interstitial pneumonia with initial negative workup, then in 1 yr....

repeat autoimmune testing


(may test negative initially, but will test positive in the future)

ARDS


mechanical ventilation goal:

PEEP that acheives FIO2 less than 0.6 that does not reduce BP