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419 Cards in this Set
- Front
- Back
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Asthma:
3 cardinal features |
1. hyperresponsiveness
2. airway obstruction 3. inflammation |
|
Airway remodeling
|
ASTHMA patient lungs with subepithelial fibrosis, increased smooth muscle mass, angiogenesis and hyperplasia of mucous gland and goblet cells
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Asthma Severity: Mild Intermitt
a. Symptoms (3) b. Night Symptoms c. Lung Function |
a. less than or equal 2x a wk
Asx and normal PEF 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% |
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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% |
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Peak Expiratory Flow - Asthma
1. change of 20% 2. 20-50% change 3. >50% |
1. stable disease
2. moderate airway obstruction 3. severe obstruction |
|
methacholine challenge test
1. what is it 2. goal of test 3. predictive value 4. Do not take this test |
bronchoconstrictor which reduces FEV1.
high negative predictive value excludes asthma from patients with atypical pulm symptoms *asthmatic with typical symptoms |
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Asthma
Type that does not respond to therapy |
ABPA - acute bronchopulmonary aspergillosis
|
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Asthma
Subset of occupational asthma that occurs with no previous history of asthma and high exposure to respiratory irritant |
RADS - reactive airway dysfunction syndrome
|
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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 |
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Asthma
ABPA treatment |
oral steroids for several weeks
|
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Asthma
worsening condition taking leukotriene receptor blocker with development of pulm infiltrates and eosinophilia during steroid taper |
Churg strauss vasculitis
|
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Asthma
exercise induced asthma trigger |
exercise in cold dry air
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Asthma
exercise induced asthma treatment |
beta agonist inhaler
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Asthma
Symptoms of Aspirin sensitive asthma (2) |
rhinorrhea and nasal congestion
|
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Asthma
Aspirin sensitive asthma but still needs asthma |
see specialist for desensitization
|
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Asthma
mild aspirin intolerance and asthma |
leukotriene modifying agent
|
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Asthma
3 big symptoms |
cough
wheeze chest tightness |
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Asthma
1. breakthrough symptoms 2. exercise induced asthma prophylaxis |
short acting beta2 agonist
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Asthma
persistent asthma treatment |
inhaled steroids
|
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Asthma
Side effect of inhaled steroids(2) |
thrush and dysphonia related to laryngeal muscle myopathy
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Asthma
alternate to inhaled steroids(2) |
Cromolyn and Nedocromil
|
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Asthma
persistent asthma not preferred treatment |
Leukotriene modifier
|
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Asthma
nocturnal asthma treatment |
theophylline
|
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Asthma
moderate to severe persistent asthma with elevated IgE TREATMENT (failed steroids) |
Omalizumab (Anti- IgE antbody)
|
|
Asthma
2 contraindications for omalizumab |
1. overweight
2. IgE > 700 |
|
COPD
4 major disorders |
emphysema
chronic bronchitis obliterative bronchiolitis asthmatic bronchitis |
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COPD
chronic bronchitis clinic definition |
productive cough on most days for 3mo in each of 2 straight years
|
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How is COPD different from asthma?
|
asthmatics have greater reversibility of obstruction
|
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COPD
#1 risk factor |
smoking
|
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COPD
PFT finding |
decline in FEV1
|
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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
|
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COPD
key to diagnosis |
expiratory airflow limitation
|
|
COPD
spirometer 2 values... which confirm |
post bronchodialtor FEV1 <80%
FEV1/FVC less than 0.7 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) |
secondary hypoxemia and hypercapnia
|
|
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... |
COPD treatment
|
|
COPD
Do not combine spriva with... |
atrovent
|
|
COPD
oral anticholinergic. |
theophylline
|
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COPD
theophylline level need to be monitored because in can potentiate |
steroids
|
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COPD
do not use for regular maintenance |
oral steroids
|
|
COPD
recommended vaccine |
annual flu shot
|
|
COPD
alpha 1 antitrypsin treatment. problem... |
IV infusion of purified protein weekly
expensive |
|
COPD
avoid these meds in stable COPD, why? |
antitussives because cough is protective
|
|
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 |
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: honeycombing and traction bronchiectasis |
|
ILD
IPF on PFT prognosis(2) |
restrictive lung process
linked to degree of restriction less than 3yrs |
|
ILD
IPF treatment |
lung transplant
|
|
ILD
IPF - table 15 on p23 |
diagnosis criteria
|
|
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
|
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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
|
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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
|
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ILD
DIP chest CT |
fibrosis with traction bronchiectasis and honeycombing
|
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ILD
DIP PFT (2) |
restrictive lung, low DLCO
|
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ILD
DIP path |
pigmented macrophages in alveolar spaces
|
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ILD
DIP treatment (2) |
stop smoking and steroids
|
|
ILD
RB-ILD vs DIP age |
RB-ILD younger
|
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ILD
RB-ILD Chest xray |
basilar reticular or reticulonodular in centrilobular distribution
|
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ILD
RB-ILD chest CT |
ground glass
|
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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
|
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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
|
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ILD
AIP similar to |
ARDS
|
|
ILD
AIP path |
diffuse alveolar samage
|
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ILD
AIP treatment |
IV steroids
|
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ILD
AIP prognosis |
poor, die in 2mo
|
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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
|
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ILD
LIP path |
interstitial pneumonia with dense lymphoid infiltrate
|
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ILD
LIP path seen in (2) |
Sjogren and HIV
|
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ILD
LIP differential |
lymphoma
|
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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.
|
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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 |
Heerfordt syndrome
Lofgren syndrome |
|
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
high attenuation parenchymal lesions |
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 |
pleura mostly and peritoneum
|
|
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) |
CFH
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
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 |
at least 3mo
|
|
CTEPH
1. Definition 2. prognosis if untreated |
chronic thromboembolic pulm HTN
fatal if untreated |
|
CTEPH
Treatment |
resect chronic thrombus
|
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CTEPH
physio |
increased resistance of pulm arteries.
|
|
CTEPH
monitor |
2decho after initial acute PE treatment
|
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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 |
narrow lumen of small pulm arteries and arterioles
|
|
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 |
R heart cath
|
|
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
size |
less than 3cm in diameter
|
|
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% |
non small cell such as adeno
|
|
Lung ca
15% |
small cell
|
|
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.
|
|
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
treatment(2) |
1. acetazolamide before and after ascent
2. dexamethasone of lower duration than #1 |
|
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 COPD |
prescreen for oxygen to PaO2 is greater than or equal to 50 or for high risk patients, paO2 stable @ sea level.
|
|
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 |
PaO2/FIO2 <= 200
noncardiogenic |
|
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
<Acute vent failure> 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 |
Mag sulfate with beta agonist
|
|
Acute Vent failure
obesity hypoventilation rule out |
hypothyroid
|
|
Mechanical ventilation
CPAP in COPD (2) |
counterbalance auto PEEP
reduce/eliminate inspiratory threshold load |
|
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) |
improvement in pH, PaCO2, Level of consc., RR
(within 2 hrs of starting NPPV) |
|
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
refractory shock treatment |
steroids
|
|
severe sepsis
6 criteria of organ dysfunction |
hypoxemia, shock, delerium, thrombocytopenia, high Cr, high bili
|
|
shock
? etiology, then check |
bedside echo
|
|
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 |
anyphylactic - IgE mediated
oid - non Ab-antigen mechanism |
|
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 |
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 Na 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 |
