Pulmonary (Read)

The American College of Physician 2009 The Core of Internal MedicineA Re-Certification Preparation CoursePulmonary & Critical Care Medicine

Charles A. Read, M.D.

Director of Adult Critical Care

Associate Professor of Pulmonary & CCM

Georgetown University Medical Center

Has no relationships with any proprietary entity producing health care goods or services consumed by or used

on patients.

Disclosure of Financial Relationships;

Charles Read, M.D.

Question #1 Sepsis

• 71 to female with confusion fever and flank pain

• T: 38.5 BP: 82/48 P: 123 RR: 27

• Dry mucosa membranes, flank tenderness

• WBC: 15.6 UA 50-100 wbc/hpf

• Metabolic acidosis with high lactic acid

• Antibiotics begun

Question #1: Shock

Which of the following is most likely to improve survival for this patient

(A) 25% albumin infusion(B) Aggressive fluid resuscitation(C) Maintaining Hemoglobin above 12(D) Maintaining a PaCO2 below 50 mmHg(E) Hemodynamic monitoring with a PAC

Question #1

• Correct answer : B • Aggressive fluid bolus• No data to demonstrate colloids are better than

crystalloid• Given blood for Hemoglobin below than 7 in

stable ICU patients and below 10 in shock patient improves out come but not for Hg of 12

• No date for PaCO2 or use of PAC

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Critical Care Medicine 2004 :32(3) 858-873

Surviving Sepsis A: Initial Resuscitation

• 1: Should begin as soon as syndrome recognized. An elevated serum lactate helps to identify . – During first 6 hours the goals should include :

• CVP 8-12mm Hg ( 12-15 mmHg on vent)• MAP > 65 mm Hg• Urine output > 0.5ml/kg/hr• Central Venous or mixed venous O2 sat > 70

• Grade B

Surviving Sepsis A: Initial Resuscitation

• Resuscitation directed for the aforementioned goals within the first 6 hours of presentation improved the 28-day mortality

• Panel judged CV and mixed venous saturation to be equivalent

• Target a higher CVP ( 12-15 mm Hg) in mechanically ventilated patients

Rivers E et al.: Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med 2001;345:1368-77

0

50

100

150

200

250

300

350

0 200 400 600 800 1000 1200

normal

Sepsis

XY(Scatter)3

Oxygen Delivery = DO2 ( ml O2/min)

O2 consumption = Vo2

mlO2/min

ERc= 66% B AC

E

A= Normal resting

B= decrease DO2

C= ERc

D= Shock

E = Sepsis

D

Oxygen Delivery

• CaO2 = (Hgb x SaO2 x 1.36) +(PaO2 x 0.003)

• DO2 = CaO2 x CO x 10

• DO2 : Oxygen Delivery Hgb : Hemoglobin

• CaO2: Oxygen Carry capacity

• SaO2 : Oxyhemoglobin Saturation

• PaO2 : Arterial Oxygen Tension

• CO : Cardiac Output

Physiologic forms of shock

• Hypovolemic: Dehydration/ hemmorhagic

• Distributive: Sepsis, adrenal Insufficiency, neurogenic, anaphylactic, liver failure

• Cardiogenic: Ischemic or non-ischemic cardiomyopathies, negative inotropes

• Obstructive: Pulmonary HTN, PE, Cardiac Tamponade, valvular, pregnancy

Question # 2 : Solitary Pulmonary Nodule

• 65 yo man with severe alzheimer’s dementia and multiple aspiration pneumonias with 2.5 cm RLL nodule. Prior CXR from 9 yrs ago showed it to be 1.5 cm.

• Current CT shows focal areas of both very high and very low attenuation within the mass.

Question # 2 : Solitary Pulmonary Nodule

Which of the following would be the most appropriate management of the pulmonary lesion at this time.A) referral to thoracic surgeryB) No further evaluationC) Positron emission tomographyD) Fiberoptic bronchoscopy with TBBXE) Transthoracic needle biopsy

Question #2:Correct answer: B

• Hamartoma is the commonest benign pulmonary neoplasm which can grow slowly over time.

• Can be diagnosed by CT

• Presence of focal areas of fat and calcium are characteristic/pathognomonic

Definition of Solitary Pulmonary Nodule

• Solitary Pulmonary Nodule

• Solitary: Single well demarcated lesion No associated adenopathy or effusion

• Pulmonary: Completely surrounded by lung parenchyma

• Nodule: well demarcated lesion less than 3 cm. Lesions greater than 3 cm are masses

Epidemiology: Differential Diagnosis for Benign Nodules (70%)

• Infectious Granuloma (80%)– Coccidiodomycosis, histoplasmosis & mycobacteria

• Hamartomas (10%)• Intrapulmonary lymph nodes• Arteriovenous malformations• Parasitic: Echinococcus or Dirofilaria• Pulmonary Infarcts/ Contusions

Differential Diagnosis of Malignant SPN (30%)

• Primary Lung ( 70-90%)– Usually Non-small cell

– Small Cell accounts for only 4 %

• Metastatic Lesions ( 10-30%)– Head & neck, breast, kidney, sarcomas

– Distinguishing metastatic from primary is not so obvious on presentation clinically in

– 44 pt with breast cancer and SPN 43% were Mets and 52% Primary Lung -Casey, Surgery 1984;96:801-804

Patient Characteristics Which Increase Likelihood of Malignancy

• Exposure History– Smoking

• Age: In patient with age greater than 50, the likelihood of cancer approximates their age. In patients less than 35, the likelihood of cancer is low.– Asbestosis

• Previous History of Cancer

Characteristic of the Nodule That Alter the Odds: Shape

Smooth and round more likely benignalthough 21% of malignancies have

smooth marginsSpiculated or Corona radiata sign are highly

suspicious for cancer, 88-94% are cancerLobulated or scalloped border are

intermediate probability of cancer. 25% of benign nodules are lobulated

Characteristic of the Nodule That Alter the Odds

• Calcifications: – Laminated or Central is typical for granuloma– Pop-corn or areas of fat and calcium are

hamartomas– Eccentric or stippled does not exclude cancer

Characteristic of the Nodule That Alter the Odds

• Size: less than 1cm increases likelihood of benignity whereas greater than 2 cm increases likelihood of malignancy (80% are malignant)

• Stability of more than two years makes it likely benign

• Growth makes cancer more likely. The doubling time for cancer is between 3months to 1 year. Benign lesions have doubling times of less than 30 days or greater than 450 days.

Question #3: Flow-volume loop

• 67 yo man with COPD with 3 months of progressive dyspnea and wheezing.

• One year ago he had a CABG complicated by prolonged ICU for ARDS

• PE: Persistent wheeze and JVP normal.

• PFTS: as follows


FEV1 2.22 L ( 64%)

FVC 4.96 L (107%)

FEV1/FVC 45%

FEF 25-75% 2.13 l/sec (60%)


Which of the following is most likely the cause of his dyspnea?

A) Exacerbation of COPD

B) Congestive Heart Failure

C) Late Sequela of ARDS

D) Tracheal Stenosis

E) Constrictive Pericarditis


• Correct Answer : D Tracheal Stenosis

Question #4: RA and the Lung

67 yo man with subtle decrease in exercise tolerance and dry cough. 2yr history of seropositive RA. His joint disease is well controlled since the addition 3 months ago of MTX. 12.5mg q week to prednisone 5mg qd. Smokes 2ppd but no exposure history.

Question #4: RA and the Lung

• PE afebrile with joint deformities

• Subcutaneous nodules on extensor surfaces

• No adenopathy. No JVD or edema

• Bibasilar inspiratory crackles

CXR: Subtle bilateral reticular infiltrates

Question #4: RA and the LungPFTs demonstrate :

FEV1 78% predicted

FVC 75% predicted

FEV1/FVC 86%

TLC 70% predicted

RV 72% predicted

DLCO 66% predicted

Which of the following is the most appropriate next step in the management of the patient?

A) Cardiopulmonary exercise testingB) Begin a tumor necrosis factor- antagonistC) Initiate antibiotic therapyD) Stop methotrexate therapyE) Surgical Lung Biopsy

Question 4: RA and Lung disease

Question 4: RA and Lung diseaseCorrect Answer: D

• Associations:– Pleural Effusions: Exudate Low pH low Glucose– Pulmonary Rheumatoid Nodules & Caplan Nodules– Capillaritis– Pulmonary Hypertension– Pulmonary Fibrosis– Bronchiolitis Obliterans– Drug Induced disease– Upper Airway Obstruction

Question 4: RA and Lung disease

• When patient with RA develops ILD, infection (particularly when immunosupressed), Drug-induced lung disease and complication of RA is in the differential

• No specific test for MTX induced disease but temporal relationship noted.

• CPEX will define impact of the ILD but not help define it

• No other evidence of active RA to begin alternative tx.

Question # 5: Steroids in Sepsis

• 29 yo with active SLE hospitalized with pneumonia. Had been on Prednisone 30 mg/d but weaned off 6 months ago

Febrile WBC 6,000 with left shift Hgb 10 and Plat: 20,000 Mild renal insufficiency

She is hypotensive with BP: 70/40

In addition to fluids and vasopressors which of the following is the most appropriate next step in this patient’s management?

A) Perform an ACTH stim test and initiate steroid therapy if abnormal

B) Initiate therapy with fludroocortisoneC) Administer methylprednisolone, 2g IVD) Administer IV Dexamethasone, and perform and

ACTH stim test

Question #5: steroids in Sepsis

Question #5: Steroids in Sepsis

Correct Answer: D Administer Dexamethasone and do ACTH stim test

Empiric steroids are indicated but hydrocortisone and Methylprednisolone interferes with cortisol measurement

Surviving Sepsis H. Steroids

Rationale: One Multi-centered RCT in patients with severe septic shock showed a significant shock reversal and reduction in mortality in relative adrenal insufficiency (post stim cortisol < 9).

Annane D et al: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288:862-71

Surviving Sepsis H. Steroids

Rational: Two randomized prospective trials and meta-analyses concluded that high-dose steroids for severe sepsis or septic shock are ineffective or harmful.

Bone RC et al: A Controlled clinical trial of high dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med 1987; 317:653-58

Cronin L et al: Corticosteroid treatment for sepsis: A critical appraisal and meta-analysis of the literature. Crit Care Med 1995;23:1430-39

The VA systemic Sepsis Cooperative Study Group: Effect on high-dose glucocorticoid therapy on mortality in patients with clinical signs of sepsis. N Engl J Med 1987; 317: 659-65

Question # 6: Asthma

46 yo woman with persistent asthma for past 6 months her disease has been stable on HDIS + LABA and prn SABA once every week or two.

Which of the following would be the best approach to the patient’s therapy

a) Continue inhaled steroids and LABA and SABA at current dose

b) Discontinue IS + LABAc) Continue LABA and lower the IS dosed) Discontinue LABA and lower IS dose

Question # 6 Asthma

• Correct Answer is C

• Long term inhaled steroid use can be associated with osteoporosis, glaucoma and cataracts. Therefore an attempt to reduce the dose is prudent.

• Lowering the anti-inflammatory should be done isn a step wise fashion.

Classification of Severity of Asthma:Clinical Features Before Treatment

Step 4 • Continuous symptoms Frequent • FEV1 or PEFR 60%Severe • Limited physical activity predictedPersistent • Frequent exacerbations • PEFR variability >30%

Step 3 • Daily symptoms >1x/wk • FEV1 or PEFR >60%-Moderate • Daily use of inhaled 80% predictedPersistent short-acting beta2- • PEFR variability >30%

agonist• Exacerbations 2x per

week

Step 2 • Symptoms >2x/wk but >2x/mo • FEV1 or PEFR 80%Mild Persistent <1x/d predicted

• PEFR variability 20%-30%

Step 1 • Symptoms 2x/wk 2x/mo • FEV1 or PEFR 80%Mild • Asymptomatic and predictedIntermittent normal PEFR between • PEFR variability <20%

exacerbations

SymptomsNighttimeSymptoms Lung Function

National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute. National Institutes of Health (NIH); April 1997. NIH publication No. 97-4051.

Mild IntermittentAsthma Classification: Step 1

• No daily medicationneeded

• Short-actingbronchodilator: inhaledbeta2-agonists asneeded for symptoms

•Use of short-actinginhaled beta2-agonistsmore than two times aweek may indicate the need to initiate long-term control therapy

•Teach basic facts aboutasthma

•Teach inhaler/spacertechnique

•Discuss roles ofmedications

•Develop self-management plan

•Discuss appropriateenvironmental controlmeasures to avoidexposure to knownallergens and irritants

Long-Term Control Quick Relief Education


Mild PersistentAsthma Classification: Step 2

Daily medication:

• Anti-inflammatory:either inhaledcorticosteroid (lowdose) or cromolyn ornedocromil.

• Sustained-releasetheophylline.Zafirlukast or zileutonmay be considered forpatients 12 yrs of age,although their positionin therapy is not fullyestablished.

• Short-actingbronchodilator: inhaledbeta2-agonists asneeded for symptoms.

• Use of short-acting inhaled beta2-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Step 1 actions plus:

• Teach self monitoring.

• Refer to groupeducation if available.

• Review and updateself-management plan.



Moderate PersistentAsthma Classification: Step 3

Daily medication:

• Either

• Anti-inflammatory:inhaledcorticosteroid(medium dose)OR

• Inhaled corticosteroid(low-medium dose)and add a long-actingbronchodilator: eitherlong-acting inhaledbeta2-agonist, SRtheophylline, or long-acting beta2-agonisttablets.


• Use of short-acting inhaled beta2-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Step 1 actions plus:

• Teach self monitoring.

Refer to groupeducation if available.

• Review and updateself-management plan.



Severe PersistentAsthma Classification: Step 4

Daily medication:

• Anti-inflammatory:inhaled

corticosteroid(high dose) AND

• Long-actingbronchodilator:

eitherlong-acting inhaledbeta2-agonist, SRtheophylline, or long-acting beta2-agonisttablets AND

• Oral corticosteroid


• Use of short-acting inhaled beta2-agonists on a daily basis, or increasing use, indicates the need for additional long-term-

control therapy.

Steps 2 and 3 actions,plus:

• Refer to individualeducation/counseling



Positive methacholine challenge- fall in FEV1 of 20% or greater (PC 20 ) with 8 mg/ml or less of methacholineOther causes of nonspecific airway responsiveness: COPD, CHF, bronchiectasis, allergic rhinitisNegative methacholine challenge excludes a diagnosis of asthma with 95% certainty

Methacholine Challenge

CoughIrwin RS, Madison JM: The Persistent troublesome cough

Am J Resp Crit Care Med 2002; 165:1469-74

Differential Diagnosis

Diagnostic study Therapy

Sinusistis/PND

Upper airway cough syndrome (UACS)

CT sinuses Decongestants/anti-inflamatory

Reactive Airways PFT/ methacholine

Bronchodilators

GERD 24 Hour Ph PPI

ACE 0 D/c Med

Question # 7: Pulmonary Hypertension

52 yo women with 1 yr history of progressive dyspnea. She is short of breath climbing one flight. Former heavy smoker and has hypertension.

PE: elevated JVP, Increased P2, pitting edema

CBC, Chem 20, HIV, RF, ANA, and anti-Scl-70 are negative

CXR: Prominent central arteries and clear lung fields


Echo: concentric LVH, EF=55%, dilated RV, normal valves and PA systolic of 59.

PFT normal except DLCO of 40%

V/Q scan: normal ventilation, heterogeneity of perfusion

RHC: RAP= 10, RVP = 50/10, PAP = 50/20, PCWP (PAOP)= 26 CO: 3.1 CI: 2.0


Which of the following is the most likely cause of the patient’s pulmonary hypertension ?

A) Left ventricular diastolic dysfunction

B) Chronic Pulmonary Embolism

C) Primary Pulmonary Hypertension

D) Pulmonary Veno-Occlusive disease

E) Constrictive Pericarditis


• Correct answer : A

Left ventricular dysfunction

5 10

25 125

Normal Hemodynamic Pressure: “nickel, dime, quarter and a buck twenty five for inflation”

RAP/CVP=5

RV/PAP= 25

PAOP/LA=10

LVSBP= 125

Hemodynamic Profiles

Disease CVP PAP PAOP CO SVR

Normal 5 25/15 10 5 1000

Distributive

Sepsis/AI3 12/6 4 8 600

Hypovolemic 3 12/6 4 3 1200

Obstructive (PE/PHTN)

18 40/20 6 2 1600

Cardiogenic 15 30/20 18 2 1600

Hemodynamic Profiles

Disease

Normal

CVP

5

PAP

25/15

PAOP

10

CO

5

SVR

1000

RV Infarct 20 15/10 6 3 1200

Tamponade 15 30/15 15 3 1200

Question # 7: Pulmonary HypertensionCorrect Answer: A

Disease CVP/RAP

5

RVP

25/5

PAP

25/12

PAOP/PCWP

10

CO

5

A: LV failure

10 50/10 50/20 26 3.1

PPH, VOD

PEConstrictive Pericarditis 10 30/10 30/12 12 3

Question # 8: Pleural Effusion

38 yo women with moderate layering pleural effusion.

She has a thoracentesis performed


Pleural Fluid analysis:Cell Count: 300 33% Neutro 52% Lymph

12% mesothelial 3% eosTotal Protein: 1.3 mg/dl LDH: 61 U/L Amylase 15

Glucose 100 mg/dl albumin: 0.7 Cholesterol 35pH: 7.4Gram stain negative; cytology negativeSerum Protein: 4.8 LDH: 220 INR 1.5 Albumin: 2.3Normal UA Normal EKG


What is the most likely diagnosis?

A) Tuberculosis

B) Thoracic endometreosis

C) Hepatic hydrothorax

D) Lymphangieomyomatosis

E) Esophageal Rupture

Question #8:Pleural EffusionsCorrect Answer: C

Light’s criteria:Exudates

1) Pleural Fluid protein/Serum protein >0.5

2) Pleural Fluid LDH/Serum LDH >0.6

3) Absolute pleural fluid LDH > 2/3 upper limit of normal (> 200)

Only need one to make an exudate

This effusion is a Transudate


• Most common cause of transudates in decreasing order are CHF, hepatohydrothorax, nephrotic syndrome, other low albumin states, atelectasis

• CHF usually bilateral (R>L) orthopnea, S3 and evidence of pulmonary edema on CXR

• Nephrotic syndrome has small bilateral effusions and abnormal UA

• Low albumin states have bilateral effusions albumin less than 1.8

• In hepatohydrothorax there is a low albumin state and reduced oncotic pressure as well as transfer of ascites through the diaphragm lymphatics and defect.

Pleural effusions: Results of tests

• Low pH and Low Glucose– Most common : malignancy & infections– Also seen in rheumatoid arthritis– Are prognostic factors for malignancy– Can be used to decide on need to drain a parapneumonic

effusion

• Lymphocytic Predominant Exudates: Malignancy and Tb.– Malignancy: cytology only positive around 40%– Tb: The presence of greater than 5% mesothelial cells

rules this diagnosis out.


• LAM is associated with chylothorax and PTX• Endometriosis will have hemothorax and catemeal

ptx• Rupture esophagous would expect low pH 4.0

history of wretching vomitting and are usually not massive, More commonly left sided

Question # 9: Sleep

45 yo man alternates day, evening and night shifts at work. Drink 6-8 cups of coffee a day to stay awake. His wife reports that he snores and moves his legs when he sleeps.

The accompany image represents one segment of his overnight polysomnogram:

A Pause in ventilation accompanied by desaturation and persistent thoracic cage movement ending with a burst on the EEG.

Question # 9: Sleep

Which of the following disorders does this polysomnogram show ?

A) Obstructive Sleep Apnea

B) Restless leg syndrome

C) Narcolepsy

D) Central Sleep Apnea

E) Cheyne-Stokes breathing

Question # 9: SleepCorrect Answer: A

Obstructive Sleep Apnea:Diagnosis: Cessation of flow but persistent effort accompanying with desaturation. At least 15 apnea/hypopnea /HR

Central Apnea:Diagnosis: Cessation of flow and effort

Narcolepsy: document sleep latency less than 5 min on multiple sleep latency test and early onset of REM.

Question # 9: Sleep

• CPAP is considered the most consistently effective intervention.

• Some find CPAP cumbersome BiPAP may be better

• Uvuloplasty: 40% effective. Reserve for those not tolerating CPAP. Same applies for oral appliances

• Weight loss is difficult to achieve

Question # 10:

24 yo with SOB 4 days after cross country trip

V/Q shows mismatch in RLL & LLL accounting for 25% of perfusion

Hospitalized and tx with heparin and warfarin

1 week later symptoms gone INR in 2-3 range

Repeat V/Q persistent defect of 20%

Question # 10:


A) Continue inpatient LMW heparin

B) Discharge on Warfarin

C) Measure pulmonary artery pressures with exercise

D) Factor V Leiden mutation assay

E) CT angiography

Question 10: Correct answer BPulmonary Embolism

• Only the minority of defects resolve totally in one week

• He has only a 3-4% risk of developing pulmonary hypertension due to CVTE

• Pulmonary hypertension is unlikely to occur acutely

• Factor V leiden mutation is not associated with slower resolution

Question 10: Pulmonary embolism

• Suspicion is that of Pulmonary Embolism– Modified Wells Criteria

• Clinical Signs of DVT 3.0 points• HR > 100 1.5 points• Immobilization 1.5 points• Previous DVT/PE 1.5 points• Hemoptysis 1.0 points• Cancer 1.0 points• PE more likely than any

other diagnosis 3.0 points

< 2.0 = low 2-6 = moderate >6 is high suspicion

Pulmonary Embolism

• Work up: If suspicion is low to moderate a negative d-Dimer helps rule out DX. Positive d-Dimer not helpful

• If suspicion if moderate to high and sign of DVT then Venous Dopplers

• If Suspicion is High: CT scan with PE protocol• If Dye Allergy: Dopplers and V/Q scan• Unstable patient: Dopplers and ECHO to look for

RV strain

Question # 10: Pulmonary embolism :

• High Probability VQ: 85% will have PE– High Prob & High clinical suspicion: 95% will

have PE

• Low probability VQ: 13 % will have PE– Low probability with high clinical suspicion:

43% have PE

• Normal V/Q: only 5% have PE and these have no clinical sequela left untreated

Question # 11: Abnormal CXR

28 yo woman with a persistent cough. Never smoked and travels to Mexico to vacation yearly. CXR shows mild interstitial abnormalities with hilar and mediastinal fullness. PFT’s are normal. A PPD is negative

Question # 11: Abnormal CXR

Which of the following findings would warrant a trial of oral corticosteroid therapy?A) Bilateral Anterior uveitisB) HypercalcemiaC) Fever and tender red nodules over the anterior shinsD) Abnormal LFTs

Question # 11: Sarcoid• Absolute indication for steroids

– Neurologic Sarcoid– Cardiac Sarcoid– Hypercalcemia + renal failure– Occular (treated with topical steroids)

• Relative:– Disabling lung disease– Disfiguring cutaneous

• Patients with adenopathy and no symptoms have 50-90% spontaneous resolution.

• Lofgren’s syndrome: fever, E. Nordosum and adenopathy do well with just NSAIDS.

Question 11: Sarcoid

STAGE CXR Response to systemic steroids

0 Normal N/A

I Adenopathy & Normal Parenchyma

60-80%

II Adenopathy & Infiltrates 50-60%

III Parenchyma & no adenopathy

< 30%

IV Fibrosis & Honey combing < 10%

Erythema Nordosum

Noncaseating Granuloma on Lymph node biopsy

Question 12: Resp Failure on Vent

37 yo admitted to ICU with severe CAP and ARDS. HIV positive not on HAART,. Intubated, BAL performed and begun on Trimethoprim/Sulfa and steroids.

Originally doing well on lung protective vent strategy but over 20 minutes SaO2 drops to 87% despite FiO2 100% PEEP 12. Pulse 132 RR 22 Lung sounds diminished on right

Peak insp Pressure gone from 28 to 38 and SBP down to 80 mmHg

Question 12:


A) Inhaled Nitric OxideB) Start inverse ratio ventilationC) Insert a needle in the right hemithorax,

2nd anterior spaceD) Use prone positioning

Question 12: Correct answer C

• Acute tension pneumothorax, a known complication in patients with Pneumocystis Jiroveci pneumonia.

Peak pressure is the pressure to push the breath in and thus overcome lung/chest wall compliance and air way resistance

Plateau pressure only to hold breath in. Only over comes lung/chest wall compliance

Respiratory decline withPeak & Plateau pressure changes

• If both go up: It is a disease of Respiratory system compliance: PTX, worsening pneumonia, ARDS, Abdominal distention, Atelectasis, Pleural Effusions

• If Peak goes up and plateau is the stays the same : It is a disease of airway resistance: Bronchospasm, biting tube , secretions in the tube

• If both go down: Airway leak, cuff deflation• If no change: Pulmonary embolism

Diagnostic Use

Peak Plat Trachea SaO2

30 25 Midline 95% Baseline

50 40 Shift to left 85% RMS intubation/ R PTX

50 25 Midline 85% Asthma

30 25 Midline 85% Pulm Embolism

50 40 Shift to right 85 Left PTX

Question #13: ARDS/Vent

72yo women is evaluated in the ER for fever & flank pain. Obese BW: 90kg ( IDBW: 60kg)

Febrile: BP: 85/50 P: 132 RR: 28Lungs clear R CVA tendernessGiven fluids and AntibioticsShe goes into progressive respiratory failure

and decision to intubate her.

In addition to 100% FiO2, PEEP of 5 and rate of 24, which would be the most appropriate vent setting?

A) PCV PIP 30, Peep 10 I:E 2:1

B) AC tidal Volume 360

C) AC tidal volume 540

D)PS of 10 cm

Question #13: Pneumonia/Vent

• ARDS-net clinical trial 6ml/kg IBW was superior to 12 ml/kg IBW in terms of survival and development of MODS.

• IBW is based on sex and height

Question # 13Correct Answer : B

ARDS Mechanical VentilationARDS-Net

ARDS-Net

• Multi-centered• Randomized prospective trial• Hypothesis: In patients with ALI and ARDS

would lower tidal volume improve outcome• Randomized to : 6 ml/kg ( Plat 30-25) vs. 12 ml/kg ( plat <50) predicted BW Stopped after 4th interim analysis ( n=861)

ARDS-Net

ARDS-Net

Ventilator modes

• Full support: Patient in arrest, shock– i.e: AC, CMV

• Partial support: Weaning of patients– i.e: PS, SIMV

• Super-duper: Sick lungs where full support does not work– i.e PCV, APRV

Basic Modes: Assist/Control (CMV)

Set: Fio2 Peep Rate TV

Represents two separate modes:

Control mode:

Cycle on: Time Target: Volume Cycle off: Volume

Assist mode:

Cycle on: pressure/flow Target: Volume Cycle off Volume

The rate set is the rate it changes from one to the other.

FULL SUPPORT: UNWEANABLE

Basic Modes: (S)IMV

• Set TV, Peep, FiO2 and Rate

• Cycle on: either Time (control) or Pressure/flow (assist or Synch)

• Target: Volume

• Cycle Off: Volume

• Similar Characteristic to AC

• Full or Partial Support depending on Rate

Basic Modes: Pressure Support(Power Steering)

• Set FiO2 Peep(Cpap) and Pressure• Cycle on: Pressure/Flow (Pure Assist)• Target: Pressure• Cycle Off: Flow

• Pure assist mode. Volume delivered changes based on Compliance

• Can be Full Support ( Psmax) or Partial support depending on level of pressure

Basic Modes: Pressure Control

• Cycle on: Pressure Flow (assist) or Time (control)• Target: Pressure• Cycle off: Time

– Can maintain inspiratory effort and dwell time beyond patient’s effort.

– Recruit alveola with longer time constants– As flow reaches Zero yet the pressure is maintained,

the Pressure set is the Plateau pressure

• Can prolong inspiratory phase to the point of reversing I:E ratio (Needs sedation)

• In volume targeted modes ( AC-CMV, SIMV) as compliance worsens pressure goes up as volume is fixed

• In pressure targeted modes. ( PCV, PSV) as compliance worsens, volumes go down as the pressure is fixed.

Question #14: Interstitial lung disease

33 yo woman with progressive dyspnea

1 PPD x 18 years

No constitutional symptoms or exposures

Small PTX 3 years ago

PE: Prolonged expiratory phase and bibasilar crackles

CVS: Normal Trace edema

CXR: subtle reticulonodular infiltrates

Question #14: Interstitial lung disease

PFTs: PFTs: FEV1: 60% predicted FVC: 75% predicted FEV!/FVC = 60% DlCO = 55%

What is the most important next step in the patients evaluation?

a) Methacholine challengeb) Cardiac Stress Testc) HRCT of chestd) Bronchoscopye) V/Q scan

Question #14: Interstitial lung diseaseCorrect Answer: C

• The exam and CXR support diagnosis of ILD. • HRCT is more sensitive than CXR for ILD and in the

correct clinical setting certain findings are diagnostic. • Methacholine challenge would help with asthma but

would not explain exam, CXR and low DlCo• V/Q and cardiac stress would also not explain the

picture• Bronchoscopy may diagnose certain ILD such as

Infections, Sarcoid and Langerhans usually one needs a larger speciman

Interstitial Fibrosis

• Upper Lobe– Ankylosis Spondylsis

– Sarcoid

– Tb/ Histo

– E. Granuloma (histiocytosis X)

– Cystic Fibrosis

– PCP

• Lower Lobe – Asbestosis

– Rheumatologic (RA/Scleroderma)

– Aspiration

– IPF

Coultas DB, Hubbard R. Lunch JP ed. Idiopathic pulmonary

fibrosis, lung biology in health and disease. NY: Marcel Dekker;

2004, p772 (data from New Mexico)

Idiopathic Pulmonary Fibrosis

Ground glass

Traction Bronchiectasis

Honey Combing

Sarcoidosis

Interstitial disease that follows bronchovascular markings

Associated adenopathy

Lymphangiomyomatosis

Multiple cystic lesions

Seem in Fertile females

Spontaneous ptx

Question #15:Lung Cancer

75yo man with cough and weight loss.

Exam: cachectic, right supraclavicular node

CXR 7 cm mass in right lower lobe

CT: Lung mass several enlarged mediastinal lymph nodes, 3 contralateral nodules and an adrenal mass

MRI: Single posterior fossa lesion

Question #15:Lung Cancer

Which is the best next step in management of the patient?

A) Percutaneous biopsy of right adrenal gland

B) Steriotactic biopsy of brain lesion

C) Aspiration biopsy of supraclavicular node

D) Mediastinoscopy

E) Positron emission tomography

Question #15: Lung CancerCorrect Answer: C

Has advanced metastatic disease

Therefore one should biopsy the most accessible site that will diagnose metastatic disease with the least discomfort or risk to the patient.

STAGING:

Small Cell is : Limited ( within a radiation port) or extensive.

Non-small cell staging is TNM

Lung Cancer

• Most common cause of cancer death in US

• Overall 5 year survival of 15%

• More deaths by lung cancer than the next four most common cancers combined (Colorectal, Breast, Prostate, & Pancreas)

NonSmall Cell CancerT Stage

• T1: < 3cm in diameter, contained within visceral pleura.

• T2: > 3cm in diameter, >= 2cm away from carina, invading into visceral pleura, or lobar atelectasis

• T3: any size, extension into chest wall, diaphragm, mediastinum, (but not great vessels) or <2cm from carina or atelectasis of entire lung

• T4: any size invading into great vessels, heart, trachea, esophagus, vertebrae, main carina or malignant pleural effusion.

NonSmall Cell CancerN Stage

• N0: No nodes.

• N1: Ipsilateral hilar or peribronchial.

• N2: Ipsilateral mediastinal, subcarinal.

• N3: Contralateral hilar, contralateral mediastinal or supraclavicular/scalene.

Non Small Cell Carcinoma Staging N0 N1 N2 N3

T1 IA IIA IIIA IIIB T2 IB IIB IIIA IIIB T3 IIB IIIA IIIA IIIB T4 IIIB IIIB IIIB IIIB M1 IV

TREATMENT Surgery

Neoadjuvant/surgery

Non-Surgical

Small Cell Lung Cancer:Staging

• Limited:– 30-40% of small cell lung cancers.– Confined to the hemithorax, mediastinum, and

ipsilateral supraclavicular lymph node.– Within the confines of radiation port.

• Extensive:– 60-70% of small cell lung cancers.– Any distant spread.

Question # 16: Positive PPD

45 yo man with a pre-employment PPD positive at 22 mm. He is asymptomatic

Emigrated from Sri Lanka 15 years ago. No exposure to Tb but did get the “tuberculosis vaccine” as a child .

CXR is normal.


Which of the following is the most appropriate next step?A) Treatment for active tuberculosis should be initiatedB) Treatment for latent tuberculosis should be initiatedC) Further testing is warranted to look for active

tuberculosis, and sputum induction or bronchoscopy should be performed

D) Skin testing should not have been performed; his reaction is false positive secondary to his earlier vaccination.


• Correct Answer: B treatment for latent infection

• Positive skin test and negative chest x-ray• BCG: 60-80% reduction in incidence of Tb.

False positive reaction occurs in less than 10% of those vaccinated before 1 yr and 25% in those vaccinated after age 5. It would not cause a 22mm reaction

• 5mm positivity: – HIV

– Intimate exposure,

– CXR compatible with fibrotic changes

– Organ transplant or Immunosuppression with steroid of 15 mg/d of prednisone for > 1 month or the equivalent

• 15mm: No risk factors• 10mm everyone else


Date post:	02-Nov-2014
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