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					Pulmonary Potpourri:
    Board Review




        May 29, 2009
      Tamara Mahr, MD
   Cooper University Hospital
Hemoptysis
A 36 yr-old woman presents to your office after coughing up 5 -10
     mL of bright red blood the previous day. Three days earlier
     she noted the onset of coryza and frequent nonproductive
     cough. No fever / CP / SOB. The rest of ROS is negative.
     No previous hx of hemoptysis. She smoked 1 ppd x 5 yrs.
Physical exam: normal
Labs: normal
     UA: (-) RBC’s; 40 WBC; 4+ bac; (-) protein / casts

The most appropriate diagnostic plan at this time is:
(A) Fiberoptic bronchoscopy
(B) HRCT of chest
(C) Serum ANCA and anti-GBM antibody
(D) CXR
A 36 yr-old woman presents to your office after coughing up 5 -10
     mL of bright red blood the previous day. Three days earlier
     she noted the onset of coryza and frequent nonproductive
     cough. No fever / CP / SOB. The rest of ROS is negative.
     No previous hx of hemoptysis. She smoked 1 ppd x 5 yrs.
Physical exam: normal
Labs: normal
     UA: (-) RBC’s; 40 WBC; 4+ bac; (-) protein / casts

The most appropriate diagnostic plan at this time is:
(A) Fiberoptic bronchoscopy
(B) HRCT of chest
(C) Serum ANCA and anti-GBM antibody
(D) CXR
                      Key Points
   Most common cause of hemoptysis in non-smoker
     & smokers: acute viral bronchitis
   H&P important in diagnosis
   Initial test: CXR
   Bronch if:
     > 40 pack-year tob hx
     Age > 40
     Recurrent or > 30 cc of blood daily

   Massive hemoptysis: > 200 mL / 24 hrs
     Cause of death = asphyxiation, NOT exsanguination
     Protect airway, adequate O2
     Bronchial artery embolization
What is causing hemoptysis in this 60 yr-old man with severe emphysema?
What is causing hemoptysis in this 40-yr-old with hx
       of chronic cough and bronchorrhea?
PFT’s
                   Spirometry
                             FEV1      Degree of
   Measure of flow &
    volume                            Obstruction
   Obstruction?           > 70%      Mild
   Normal FEV1, FVC,
                           60 - 70%   Mod
    FEV1 / FVC ≥ 80%
   Can suspect            50 - 60%   Mod-
    restriction but need              severe
    to confirm with lung
    volumes                35 - 50%   Severe

                           ≤ 34%      Very
                                      severe
            Reversibility

   Pre- and 10-min-post-albuterol
   12% ↑ in FVC or FEV1
                     AND
   200 cc ↑ in FVC or FEV1
   FEV1 more reliable
   Lack of a signif β-agonist response
    does not always mean irreversibility
                 Lung volumes
   Normal TLC & VC ≥      TLC     Degree of
    80%                            Restriction
                        70 - 80%   Mild
   ↑ FRC 
    hyperinflation
                        60 - 70%   Mod

   ↑ RV > 120%  air
    trapping            < 60%      Severe
Flow-Volume Loop
 Flow-Volume Loop (cont’d)




Extrathoracic Variable Obstruction   Intrathoracic Variable Obstruction
                             I/E
                E/I



Extrathoracic         Intrathoracic
         Diffusing Capacity

   Ability of gas: alv  membrane  cap
   Least accurate of PFT measurements
   DLCO / VA correction factor
   Correct for Hb
   Normal DLCO ≥ 80%

   Isolated low DLCO: anemia, VTE,
    restrictive dz, CHF
      Neuromusc Weakness

   Everything normal
   Except ↓ VC
   Normal DLCO

    Get MIP’s & MEP’s, MVV
   Examples
         Select the most likely flow-volume
                loop for each patient

1.   A 34-yr-old female with
     dyspnea at rest and
     hoarseness after being
     intubated for 20 days for
     pneumonia.

2.   A 70-yr-old man who smoked 2
     ppd x 50 years with severe
     DOE and diminished breath
     sounds B/L.

3.   A 30-yr-old female with goiter.
           Select the most likely flow volume
                  loop for each patient
1.   A 34-yr-old female with
     dyspnea at rest and
     hoarseness after being
     intubated for 20 days for
     pneumonia.

2.   A 70-yr-old man who smoked 2
     ppd x 50 years with severe
     DOE and diminished breath
     sounds B/L.

3.   A 30-yr-old female with goiter.
Asthma
                   * MKSAP14 Pulm & Crit Care
                         Question # 11

A 75-yr-old woman w/ a long-standing hx of asthma is
   evaluated for ↑ nocturnal asthma symptoms & frequent
   need to use Albuterol. Her treatment regimen now
   consists of daily moderate-dose ICS. On exam: she
   has occ wheezing; the exam is otherwise
   unremarkable. Spiro shows FEV1 of 2.2 L (75% of
   predicted).
Which of the following is the most appropriate adjustment
   to this pt’s asthma therapy?

(A)   Double the inhaled corticosteroid dose
(B)   Add theophylline
(C)   Add a leukotriene receptor antagonist
(D)   Add a long-acting β-agonist
(E)   Add anti-IgE antibody
Correct answer: D.
         Adapted from Fig 14: Classifying Asthma Severity.
  NHLBI: National Asthma Education & Prevention Program. EPR-3



            Intermittent      Mild      Moderate       Severe

Symptoms     ≤ 2 d/wk      > 2 d/wk    Daily        Thruout the
                           Not daily                day
PM Awake ≤ 2x/month 3-4x/month > 1x/wk              QHS
                               Not QHS
Albuterol    ≤ 2 d/wk      > 2 d/wk    Daily        Several
                           Not daily                times / day

Rec. Step        1              2              3       4 or 5
Intermittent




      * NHLBI: National Asthma Education & Prevention Program. EPR-3
A 34-yr-old female medical technician is referred to
you with a dx of asthma. Despite initial therapy with
inhaled corticosteroids and beta-agonists, she
remains symptomatic with cough and wheeze.

FEV1 is 78% of predicted and improves 13% after
albuterol.

The most important next step in the management of
this patient is:
(A) Increase the corticosteroid dosage
(B) Perform a methacholine challenge
(C) Perform an inspiratory limb of a flow-volume loop
(D) Add theophylline
(E) Add a leukotriene receptor antagonist
   (B) Perform a methacholine challenge

   All that wheezes is not asthma
     Drug-induced bronchospasm
     Vocal cord dysfunction
     GERD


   MIC is good for R/O asthma
Pleural Effusions
                     * MKSAP14 Pulm & Crit Care
                           Question # 14
A 25-yr-old man is evaluated for a 2 mo. hx of low-grade fevers, cough,
     pm sweats, fatigue, pleurisy, & wt loss. The pt emigrated from
     Mexico 2 yrs ago and now lives in Central CA.
On exam: 100.4°F HR 96 RR 22 94% RA. There is diminished BS
     and vocal fremitus over the rt hemithorax. Left lung is clear.
WBC 9000, 60% neutr, 35% lymphs. LFT’s nl. CXR: mod-sized rt pl
     eff. Thoracentesis: 1 L min turbid, yellow fluid:
3000 WBC / 5% neutr / 85% lymphs
TP 5.5 / LDH 290 / Glu 80 / pH 7.36
Pl fluid Gram, fungal, & AFB stains (-). PPD pending. Cyto (-).
     Serologic tests for fungus (-).

Which of the following is the most likely dx?
(A) Tuberculosis
(B) Pneumococcal parapneumonic effusion
(C) Pulmonary embolism
(D) Malignant pleural effusion
(E) Pleural effusion due to coccidiomycosis
Correct answer: A.
             Light’s Criteria

   Exudative if any one of the following:
     TPpl / TPserum > 0.5
     LDHpl / LDHserum > 0.6
     LDHpl > 2/3 of the upper limit of nl for
      LDHserum
  Etiology    Appearance Predominan    Total WBC    Glucose   Other Clues
                           t WBC
Transudate
CHF                                                           B/L usually
Cirrhosis                                                     5% ascites

Exudate
Empyema       Purulent   Neutrophils   25K-100K    0-60       (+) Cx
                                                              Pt sick
Malignant     Bloody                                          Cyto (+)
                                                              50%
                                                              Older pt
TB            Straw -    Lymphs                               Subacute,
              serosang                                        PPD (+) 50-
                                                              70%
                                                              AFB (+)
                                                              smear, Cx,
                                                              or on pl bx
RA            Green-                               10-20      High RF
              yellow
Chylothorax   Milky                                           TG > 110
      Parapneumonic Effusion

 Chest tube is indicated:
     Purulent effusion (empyema)
     pH < 7.00
     Glucose < 40
     LDH > 1,000
     Positive gram stain
Eosinophilia & the Lung
      Questions
A 41-yr-old man w/ long history of asthma has
increased wheezing over the past 2 months. He was
treated for pneumonia while on vacation a month
ago and still requires prednisone 7.5 mg po daily.

His FEV1- despite prednisone therapy- has fallen
9% over the past 2 months. His cough is more
productive, and at times, forms "casts" of his
airways.

He has increased sinus complaints. His peripheral
blood eosinophil percentage is 11%.

His CT chest is shown:
(A) Hypersensitivity pneumonitis
(B) Chronic eosinophilic pneumonia
(C) Allergic bronchopulmonary
    aspergillosis
(D) Eosinophilic granuloma
(E) Lymphangioleiomyomatosis
    41 y.o. pt w/ hx of asthma
    ↑ Albuterol use
    Fever, prod cough
    (+) Parrot
    CXR: fleeting infiltrates
    WBC 14,000; 18% eos
    ↑ IgE
    (+) skin rxn to Aspergillus
    a.   Allergic bronchopulm aspergillosis (ABPA)
    b.   Hypersensitivity pneumonitis (HP)
    c.   Churg-Strauss
    d.   Loeffler’s syndrome
   A 48 yr-old bird
    fancier with 3
    weeks of dyspnea,
    cough, and fever.




                  Diagnosis?
Hypersensitivity Pneumonitis

   Symptoms start 4-6 hours after exposure
   Fever, chills, sweats, dry cough, dyspnea
   Resolves in 18-24 hours and recur on
    re-exposure
   Radiographic: upper or mid lobes with
    diffuse micronodular and groundglass
    attenuation
              HP: Diagnosis
 4 major + 2+ minor criteria
 Major criteria:
    Compatible hx: temporal association
    Exposure confirmation: hx, environmental investigation,
     serum precipitin testing, BAL antibody
    Compatible CXR / CT chest abnormalities
    BAL lymphocytosis
    Compatible histologic changes on biopsy
    Positive "natural challenge“
 Minor criteria:
    Basilar crackles
    ↓ DLCO
    Hypoxemia (at rest or exercise)
                     HP: Prognosis
 Acute:
      Self-limited
      F / C / cough resolve within days
      Malaise, fatigue, SOB x wks
      ↑ DLCO & FVC in 2 wks
 Subacute / chronic
      More subtle
      Poorer prognosis
      1-10% mortality
      Sequelae: COPD, asthma, & fibrosis

 Cont’d Ag exposure doesn’t always  progression
 Progression may continue despite no further exposure
 Younger age at dx, < 6 mo. exposure assoc w/ complete
  recovery
                   HP: Management
 Serial PFT’s, imaging, sx

 Acute HP:
     ? Corticosteroids, asthma meds
     No controlled trials
     Supportive Rx: Oxygen

 Subacute HP: ? Higher dose steroids X longer

   Source control
   Ventilator system
   Education
   T/c lung transplant as last resort
                            ABPA              HP
Pathogenesis         Obstruction      Restriction
                     Allergy to Asper Anaphylactoid
CXR                  Fleeting         Interstitial
                     infiltrates      pneumonitis,
                                      apical sparing
Labs                 ↑ Eos’philia     Nl eos count
                     ↑↑↑ IgE          Nl IgE
                     (+) Aspergillus Precipitins
Rx                   Add / ↑ Steroids Avoid antigen

 Churg-Strauss = asthma, eos’philia, necrotizing vasculitis
 Loeffler’s syndrome = transient migratory pulm infiltrates +
  asympto. Ascaris, post-Singulair.
Major Diagnostic Features of ABPA

    History of asthma
    Immediate skin test reactivity to aspergillus
     antigens
    Precipitating serum antibodies to A. Fumigatus
    Serum total IgE > 1000 ng/ml
    Peripheral blood eosinophilia > 500 / mm3
    Fleeting lung infiltrates
    Proximal bronchiectasis
    Elevated serum specific IgG and IgA to A.
     Fumigatus
Unusual Infections
                                A
   A 28-yr-old HIV+ female
    with SOB, PaO2 62,
    and LDH of 1000

   Most common bacteria
    involved in pulmonary
    superinfection after
    influenza infection
                                B

   Most common organism
    that infects the lungs of
    patient with PAP
                                C
ILD
                       Case #1

   A 28-yr-old male
    smoker with DOE x
    6 months.
   Physical exam:
    normal.
   PFT’s: mixed
    obstructive and
    restrictive ventilatory
    defect.
Pulmonary Langerhans Cell Histiocytosis




                *From UpToDate
    Pulmonary Langerhans Cell Histiocytosis
         aka Eosinophilic Granuloma
              aka Histiocytosis X
   Young adults 20-40 years old
   M=F
   Caucasian predominance
   Symptoms: dry cough, dyspnea, chest pain
   Physical exam: unremarkable
   Recurrent PTX, arteriopathy, hemoptysis, DI, cystic
    bone lesions
   Radiographic: ill-defined nodules, reticulonodular
    infiltrates, upper lobe cysts, costophrenic angle
    sparing
   PFT’s: normal or restrictive with reduced DLCO
Pulmonary Langerhans Cell Histiocytosis
              (cont’d)

 Diagnosis: BAL, TBBx
 Treatment:
   Smoking cessation
   Steroids and cytotoxic agents: limited
    value
                    Case #2
 A 34-yr-old woman w/ progressive dyspnea
 PFT’s: severe airflow obstruction (FEV1 = 34%)
 Episode of hemoptysis 1 yr ago




                      * From UpToDate
    Lymphangioleiomyomatosis
           aka LAM
   Women of childbearing age
   Caucasians
   Recurrent PTX
   Chylous effusion
   Hemoptysis
   PFT’s = obstruction
               LAM (cont’d)

   Radiographic: normal, interstitial
    opacities, cystic changes, hyperinflation
   TBBx, VATS: components of smooth
    muscle
   Treatment: hormonal manipulation,
    oopherectomy, progesterone therapy,
    lung transplant
                    Case #3


A 70-yr-old male former
  smoker with ↑ dyspnea
  and nonproductive
  cough for 18 - 24
  months.
Physical exam: bibasilar
  crackles and clubbing.
Diagnosis?
                IPF - UIP

   Sporadic case, 5th or 6th decade
   Male : Female = 2:1
   Progressive dyspnea and dry cough
   PFT’s: restrictive pattern with reduced
    DLCO
           IPF – UIP (cont’d)

   Peripheral or subpleural
   Bibasilar reticulonodular opacities
   Architectural distortion with traction
    bronchiectasis
   Honeycombing
   In the right clinical setting, radiographic
    findings may be sufficient
                      Case #4

A 68-yr-old retired
  mechanic who
  sandblasted
  radiators x 20
  years.
(+) Dyspnea on
  exertion and
  chronic cough.
PFT’s: restriction
Abn gas exchange
                 Silicosis

   Mining               Sandblasting
   Tunneling            Tombstones
   Excavating           Ceramics
   Quarrying            Glassmaking
   Stonework            Gemstone worker
   Masonry              Dental technicians
   Polishing            Concrete
   Foundry
                Silicosis (cont’d)
   Chronic “simple” silicosis
           Most common
           Exposure X decades
           < 30% quartz

       Silicotic nodule
            Hilar LN’s
            Parenchymal nodules
            Eggshell calcification
       B/L upper lung zones
Left: Progressive massive fibrosis. B/L upper lung zones.
               Right: Eggshell calcification.
               From www.meddean.luc.edu
                    Silicosis
 Complications:
     Progressive massive fibrosis
     2 - 30x higher risk of TB
     ? Increase lung CA risk
    Assoc w/ RA, scleroderma, SLE

 Clinical diagnosis, open lung biopsy
                      Case #5

   A 48-yr-old metal
    machinist has night
    sweats, chronic
    cough, and
    shortness of breath.
   Transbronchial lung
    bx: noncaseating
    granulomas and
    patchy interstitial
    fibrosis.
                   Berylliosis
   Fluorescent light industry
   Alloys, ceramics, radiographic equipment,
    and vacuum tubes
   Aerospace, electronics, metal, nuclear,
    telecommunications, tool and die, welding

   Beryllium lymphocyte transformation test

   Mimic sarcoidosis
                          Case #6


   A 70-yr-old retired
    construction
    worker, a current
    smoker with DOE.
   Physical exam:
    bibasilar crackles.
                    Asbestos
   Interval between exposure and
     Bronchogenic carcinoma 15-35 yrs
     Mesothelioma 30-40 years

   Pleural plaque is the most common related
    finding
 Asbestos exposure alone increase risk of lung
  cancer minimally

 Asbestos and smoking act synergistically
You are shown a CXR of an elderly man
 with linear diaphragmatic plaques. He
 also has severe scoliosis.
What is the cause of the Ca-tions?

(A)   Asbestosis
(B)   Asbestos exposure
(C)   Healed / old TB
(D)   Silicosis
                           Sarcoidosis


   A 32-yr-old female
    presents with 1-
    week hx of painful,
    tender lumps
    overlying the
    pretibial regions, a
    low-grade fever,
    and polyarthritis.
   BAL: AFB (-)
    Choose the correct statement:

   Cutaneous involvement occurs in 80% of
    all cases
   Cutaneous sarcoidosis is associated with
    a good prognosis
   EN is associated with a good prognosis
   EN occurs in 30% of the cases with
    Löfgren’s syndrome
                   Answer:

   Cutaneous involvement occurs in 80% of
    all cases
   Cutaneous sarcoidosis is associated with
    a good prognosis
   EN is associated with a good prognosis
   EN occurs in 30% of the cases with
    Löfgren’s syndrome
                               Case #7

   A 62-yr-old female
    presents to the ER with
    cough, SOB, and low-
    grade fever.
   LLNS and was healthy
    until 5 weeks ago: viral
    syndrome w/
    paroxysmal cough.
   PE: LLL inspiratory
    crackles.
   WBC = 13,000; nl diff;
    nl chem-7. ↑ESR.
   Sputum gram stain and
    AFB are negative.
      What is your diagnosis?

(A)   Chronic aspiration
(B)   Hypersensitivity pneumonitis
(C)   Non-specific interstitial pneumonia
(D)   Cryptogenic organizing pneumonia
(E)   Sarcoidosis
      What is your diagnosis?

(A)   Chronic aspiration
(B)   Hypersensitivity pneumonitis
(C)   Non-specific interstitial pneumonia
(D)   Cryptogenic organizing pneumonia
(E)   Sarcoidosis
         Cryptogenic Organizing
          Pneumonia aka COP
   5th or 6th decade
   Male = female
   Very specific disease onset < 2 months
   Flu-like illness
   Persistent dry cough, DOE, wt loss, crackles
   Labs: ↑ WBC, ↑ ESR
   Radiographic: B/L diffuse alveolar opacities,
    peripheral
   Dx: open lung biopsy
   Treatment: steroids for 4-8 weeks
   Rapid clin improvement over days–wks
                             Case #8

   A 30-yr-old man
    presents with
    hemoptysis, dyspnea,
    and generalized
    weakness. No sinus
    symptoms.
   PE: pallor and
    bibasilar crackles.
   Hgb 7.8 / Cr 3,
    microscopic hematuria.
   Hypoxemia.



                             Diagnosis?
Goodpasture’s Syndrome
How would you treat this patient?

(A)   Steroids
(B)   Plasmapheresis
(C)    Steroids and plasmapheresis
(D)    Cyclophosphamide
(E)   Steroids + plasmapheresis +
      cyclophosphamide
How would you treat this patient?

(A)   Steroids
(B)   Plasmapheresis
(C)    Steroids and plasmapheresis
(D)    Cyclophosphamide
(E)   Steroids + plasmapheresis +
      cyclophosphamide
Paraneoplastic
 Syndromes
                     Case #1

   64-yr-old man, with 38-pack-year tob hx
   Presents with recent onset of pain in both
    knees and shins
   PE: clubbing, gynecomastia, tenderness
    of both shins, and mild expiratory slowing
    of lung sounds
      Most likely diagnosis?

(A)   RA with pulmonary involvement
(B)   IPF
(C)   Cryptogenic organizing pneumonia
(D)   Hypertrophic osteoarthropathy
(E)   Acromegaly
      Most likely diagnosis?

(A)   RA with pulmonary involvement
(B)   IPF
(C)   Cryptogenic organizing pneumonia
(D)   Hypertrophic osteoarthropathy
(E)   Acromegaly
       Hypertrophic Pulmonary
         Osteoarthropathy
 Common Causes:
   Adenocarcinoma and large cell NSLC
 X-rays of long bones:
   Thickened and raised periosteum
 Therapy:
   Tumor resection
   Somatostatin analog
   Ipsilateral vagotomy
                   Match
1. SIADH                  Small cell lung CA
2. ACTH production
3. Hypertrophic pulm
   osteoarthropathy
4. Lambert-Eaton
   syndrome               Squamous cell
5. Hypercalcemia
6. Cerebellar ataxia
   19-yr-old male presents to ER with acute SOB
    and chest tightness.
   Thin, tall guy. Current smoker, works in Wawa
    store in Camden.
20% PTX
  First episode of PTX. What is the correct answer
     regarding best management of this patient?

(A) Observation with O2 supplementation, rate of re-
    absorption 5% / day, rate of recurrence similar to
    general population
(B) VATS for pleurodesis and bullae wedge resection
(C) Tube thoracostomy with talc pleurodesis
(D) Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
(E) Admit him  tube thoracostomy without pleurodesis
    until air leak resolves
  First episode of PTX. What is the correct answer
     regarding best management of this patient?

(A) Observation with O2 supplementation, rate of re-
    absorption 5% / day, rate of recurrence similar to
    general population
(B) VATS for pleurodesis and bullae wedge resection
(C) Tube thoracostomy with talc pleurodesis
(D) Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
(E) Admit him  tube thoracostomy without pleurodesis
    until air leak resolves
   While preparing for chest tube insertion, he
   informs you that he’s planning to be a flight
                  attendant…
(A) Observation with O2 supplementation, rate of re-
    absorption 5% / day, rate of recurrence similar to
    general population
(B) VATS for pleurodesis and bullae wedge resection
(C) Tube thoracostomy with talc pleurodesis
(D) Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
(E) Admit him  tube thoracostomy without pleurodesis
    until air leak resolves
   While preparing for chest tube insertion, he
   informs you that he’s planning to be a flight
                  attendant…
(A) Observation with O2 supplementation, rate of re-
    absorption 5% / day, rate of recurrence similar to
    general population
(B) VATS for pleurodesis and bullae wedge resection
(C) Tube thoracostomy with talc pleurodesis
(D) Tube thoracostomy with doxycycline pleurodesis
    once air leak resolves
(E) Admit him  tube thoracostomy without pleurodesis
    until air leak resolves
          Sleep Case #1


   A 59-yr-old man is evaluated for
    snoring, abnormal motor behavior
    during sleep, daytime somnolence,
    systemic hypertension, and morning
    headaches.
His polysomnography study
     (PSG) is shown:
Central Sleep Apnea PSG
Critical Care
For each numbered hemodynamic profile, select the most likely
                    etiology of shock.

    SBP            RAP                PAP     PAOP          CI
 (mm Hg)         (mm Hg)            (mm Hg)   (mm Hg)   (L/min/m2)
1. 90/68           18                 36/24     22           1.8
2. 90/46            5                 22/8      6            4.7
3. 88/40           20                 22/16     7            2.2
4. 84/60            3                 18/6      5            1.8
5 . 90/68          18                 32/18     17           1.8

a. Severe hemorrhage
b. Pneumococcal sepsis
c. Anterolateral myocardial infarction
d. Cardiac tamponade
e. Right ventricular myocardial infarction
Respiratory Failure
                 * MKSAP14 Pulm & Crit Care
                       Question # 7
A 63-yr-old woman is in the ER for a 3-day hx of ↑
   dyspnea. She is an ex-heavy smoker and has severe
   COPD, on home O2. Baseline PCO2 = 48. She has ↑
   cough w/ yellow phlegm but is expectorating w/o
   difficulty. No CP.
On exam, she is in mod resp distress and using accessory
   muscles, but she is alert & cooperative. BP 144/82 HR
   122 RR 28. No JVD. Lungs: B/L rhonchi & prolonged
   expir phase. Heart sounds distant. She is not cyanotic
   (on 4 L NC) and has 1+ pedal edema. Hb 13. Bicarb
   31. ABG: 7.28 / 56 / 64. EKG: MAT, no ischemia.
   Resp treatments, IV steroids, & Abx are started.

In addition to the above, which of the following would be
    most appropriate in the pt?
(A) Close observation
(B) CPAP
(C) Prompt intubation
(D) NPPV
Correct answer:
   D. NPPV
         Intubate vs. NPPV

 ↑ Risk of failure or C/I to NPPV:
     Imminent resp arrest
     Severe acidosis pH < 7.1
     Medically unstable. i.e., cardiac ischemia
     Pt cannot protect airway
     Excessive secretions
     Pt uncooperative / agitated
     Recent upper airway or upper GI surgery
                 * MKSAP14 Pulm & Crit Care
                       Question # 24
A 72-yr-old man is hospitalized for gradually ↑ DOE X days.
   On the AM of admission, he develops marked dyspnea
   assoc w/ fever, chills, & dry cough. No CP. He is only
   on a β-blocker at home for HTN.
On ICU admission, he is mildly disoriented and severely
   dyspneic. BP 132/80 HR 112 RR 40 85% on 100%
   NRB. (+) access muscles. No JVD. Lungs: B/L dry
   crackles. Cardiac exam nl. No edema. ABG: 7.17 / 44
   / 52. CXR: new B/L interstitial infiltrates. EKG:
   nonspecific changes.

Which of the following would be the most appropriate
    mngmt for this pt?
(A) CPAP 10 via full face mask
(B) Intub w/ mech ventilation
(C) BIPAP 15/5
(D) 100% NRB
       Correct answer:
B. Intubate w/ mech ventilation
       Indications for Intubation
   Failure of NPPV
   Pt looks terrible!
   Severe hypoxia, ARDS
   Resp arrest
   Impaired MS
     Airway protection
                 * MKSAP14 Pulm & Crit Care
                       Question # 4

A 67-yr-old man is recv’ing mech ventilation for ARDS. He
   underwent laparotomy & diverting colostomy for a
   ruptured tic 72 hrs ago, & now has a fever of 104°F and
   has diffuse B/L infiltrates X 1 day. Two deep ETT
   aspirates are sent for Cx, and Gram: 4+ GNR. The pt’s
   O2 sats worsening. MAP dropped to 58 despite 3 L NS
   boluses, with only 15 mL of UO in the past hr. He also
   has a lactic acidosis and ↓ PLT of 42 in the absence of
   heparin or H2-antagonist therapy.

Which of the following would be appropriate mngmt for this
    pt?
(A) Start resuscitation w/colloids
(B) Avoid activated protein C
(C) Start low-dose dopamine
(D) Adjust the vent with 6 mL/kg of IBW and plateau
    pressure < 30 cm H2O
                  ARDS

   Lung Protective Vent Strategies:
     Low TV 6 cc / kg IBW
     Pplat < 30 cm H2O
    ↓ TV, ↑ rate
     Permissive hypercapnea
Pneumonia
                  * MKSAP14 Pulm & Crit Care
                        Question # 72

A 31-yr-old man is in the ER in Sept. for progressive SOB,
   fever, chills, & persistent dry cough. Two days earlier,
   he had been evaluated for in the ER for fever, chills, rt-
   sided pleurisy, and a dry cough; CXR at that time was
   clear. He was prescribed amoxicillin and was sent
   home. The pt smokes cigs, weighs 100kg; IBW 70 kg.
On exam, he is in mod distress, RR 37, using access
   muscles. BP 140/70 HR 123. Lungs: moist B/L
   crackles. ABG: 7.48 / 28 / 62 on 100% NRB. CXR: rt
   base lobar infiltrate. Sputum & blood cx are obtained.

Which of the following is the most appropriate initial mngmt
    for this pt?
(A) Withhold abx pending cx results
(B) CTX
(C) Azithro + CTX
(D) Vanco / Zosyn / Cipro
   Hospital-acquired PNA (HAP): occurs
    ≥ 48 hrs after admission, was not
    brewing at time of admission
   Vent-associated PNA (VAP): arises ≥
    48-72 hrs post-intubation
   Healthcare-assoc PNA (HCAP)
        Hosp stay ≥ 2 days in last 90 days
        NH or extended care facility resident
        Dialysis pt
        Home wound care / IV Abx / chemo in
        last 30 days



                   ATS Guidelines 2005.
       Risk Factors for MDR
            Pathogens
   Abx in last 90 days
   Current hospitalization ≥ 5 days
   High freq of resistant bugs
   Family member w/ MDR pathogen
   Immunosuppression
A 24-yr-old woman develops sepsis and ARDS postpartum. She
     has been stable on mechanical ventilation. The vent settings
     are: AC RR=24/min TV=800 mL PEEP=10 FiO2=60%
You are called by the nurse because the patient is suddenly
     anxious and agitated.
Measurements during controlled breaths:
      Peak airway pressure = 55 cm H2O (baseline was 35)
      Plateau airway pressure = 50 cm H2O (baseline was 30)
      Tidal volume 720 mL (baseline = 768 mL)

What is the most important next step in the management of this
    patient?

(A)   Sedation with midazolam and observation of patient
(B)   STAT portable CXR
(C)   Endotracheal suctioning and reassessment of patient
(D)   STAT EKG
(E)   Increase ventilatory rate to 28/min and ressessment in 30 min.
A 24-yr-old woman develops sepsis and ARDS postpartum. She
     has been stable on mechanical ventilation. The vent settings
     are: AC RR=24/min TV=800 mL PEEP=10 FiO2=60%
You are called by the nurse because the patient is suddenly
     anxious and agitated.
Measurements during controlled breaths:
      Peak airway pressure = 55 cm H2O (baseline was 35)
      Plateau airway pressure = 50 cm H2O (baseline was 30)
      Tidal volume 720 mL (baseline = 768 mL)

What is the most important next step in the management of this
    patient?

(A)   Sedation with midazolam and observation of patient
(B)   STAT portable CXR
(C)   Endotracheal suctioning and reassessment of patient
(D)   STAT EKG
(E)   Increase ventilatory rate to 28/min and ressessment in 30 min.
A 68-yr-old man, a 56-pack-yr smoker,
  undergoes bronchoscopy under topical
  anesthesia for evaluation of streak
  hemoptysis.
An hour later he notices bluish discoloration of
  his fingers and lips. He has minimal dyspnea
  and his vitals are normal.
ABG: pH 7.38 / pCO2 46 / paO2 86 / SaO2
  56%
                What’s going on?

(A)   Polycythemia from COPD
(B)   Methemoglobinemia
(C)   Right-to-left anatomical shunt
(D)   Shock
A 68-yr-old man, a 56-pack-yr smoker,
  undergoes bronchoscopy under topical
  anesthesia for evaluation of streak
  hemoptysis.
An hour later he notices bluish discoloration of
  his fingers and lips. He has minimal dyspnea
  and his vitals are normal.
ABG: pH 7.38 / pCO2 46 / paO2 86 / SaO2
  56%
                What’s going on?

(A)   Polycythemia from COPD
(B)   Methemoglobinemia
(C)   Right-to-left anatomical shunt
(D)   Shock
Which of the following will prevent VAP?

(A)   Chest PT
(B)   Frequent suction tube changing
(C)   Semirecumbent positioning
(D)   Prophylactic abx
Which of the following will prevent VAP?

(A)   Chest PT
(B)   Frequent suction tube changing
(C)   Semirecumbent positioning
(D)   Prophylactic abx
A patient has been on the vent for a long
  time. Sputum Cx: (+) Pseudomonas.
  There has been no change in his
  condition.
What would you do?
                  Pearls

   Sore throat
   Amoxicillin
   Rash

         Infectious mononucleiosis
                   Pearls

Persistent cough x several weeks started
after upper airway infection
Cough severe & ends with vomiting:

        Etiology: Bordetella pertussis
              Rx : Erythromycin
                Pearls

   Recurrent sinusitis
   Non-responsive to adequate therapy



          Check immunoglobulins
                 Pearls

   When you suspect tuberculous pleural
    effusion and all pleural fluid workup is
    non-diagnostic, next step is:

               Pleural biopsy
                 Pearls

   Tuberculosis prophylaxis in an area
    with < 4% resistance to INH



             INH for 9 months
                 Pearls

   Mild obstructive lung disease
   Colon cancer
   Exercises 3x /week
   Next step before OR:



      Nothing! Proceed with surgery!
Which of the following is least associated with OSA?


(A)   Impaired insulin sensitivity
(B)   Severe pulmonary HTN
(C)   Refractory systemic hypertension
(D)   Early morning sudden death
(E)   Type II Heart Block
 The finding that best predicts that a
 symptomatic patient does not have
                PCP:

(A)   Normal CXR
(B)   Induced sputum that shows no organisms
(C)   CD4+ cell count = 400
(D)   PaO2 = 85 mmHg
(E)   LDH = 185 IU (normal < 200 IU)
Which ventilatory strategy often worsens the
 PaO2/FiO2 ratio in patients with ARDS?


(A)   Pressure controlled–inverse ratio ventilation
(B)   Prone position
(C)   Low TV (6 cc/kg) strategy
(D)   Nitric oxide
(E)   High frequency oscillatory jet vent
          Other References

   Murray & Nadel. Textbook of
    Respiratory Medicine. 4th edition.
   UpToDate
   MKSAP14
   Wissam
    GOOD LUCK!




From the Cooper Pulmonary Dept.

				
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