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Pulmonary - Read

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  • 1. 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.
  • 2. The American College of Physician 2008 The Core of Internal Medicine A Re-Certification Preparation Course Pulmonary & Critical Care Medicine Charles A. Read, M.D. Director of Adult Critical Care Associate Professor of Pulmonary & CCM Georgetown University Medical Center
  • 3. Question #1 Sepsis • 28 yo man with diffuse petechial rash diagnosed with menigococcemia • LP are compatible with bacterial meningitis • Given IV penicillin and his CXR is normal • T: 39 P: 120 RR: 20 MAP: 68 on NE • FiO2 50% and Peep 5 SaO2 = 100%
  • 4. Question #1: Shock • In past 6 hours he has received 3 L NS • Urine Output has decreased to 0.25 ml/kg • WBC: 22,000 Plat: 40,000 Which of the following interventions is the most appropriate at this time? (A) Transfuse Platelets (B) Increase NE to achieve MAP > 75 mmHG (C) Switch from NE to DA (D) Administer 1000 ml bolus NS (E) Administer furosemide
  • 5. Question #1 • Correct answer : D • Give 1000 ml fluid bolus – Despite the 3 l already he is oxygenating reasonably well and there is still evidence of organ hypoperfusion – Only need to keep Plat >50 K if active bleeding or procedure planned – No evidence that DA better than NE
  • 6. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock Critical Care Medicine 2004 :32(3) 858-873
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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.
  • 12. 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 surgery B) No further evaluation C) Positron emission tomography D) Fiberoptic bronchoscopy with TBBX E) Transthoracic needle biopsy
  • 13. Question #2: Correct answer: B • Hamartoma is the commonest benign pulmonary neoplasm. • Can be diagnosed by CT • Presence of focal areas of fat and calcium are characteristic/pathognomonic
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. Patient Characteristics Which Increase Likelihood of Malignancy • 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. • Exposure History – Smoking – Asbestosis • Previous History of Cancer
  • 18. Characteristic of the Nodule That Alter the Odds: Shape Smooth and round more likely benign although 21% of malignancies have smooth margins Spiculated or Corona radiata sign are highly suspicious for cancer, 88-94% are cancer Lobulated or scalloped border are intermediate probability of cancer. 25% of benign nodules are lobulated
  • 19. 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
  • 20. 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.
  • 21. PET Scanning Nodules • False negatives occur with bronchoalveolar carcinoma, carcinoids and tumors less than 1 cm. • False Positive occur with active infectious and inflammatory processes • It is useful once diagnosis is made in staging as well as to stage the mediastinum preoperatively
  • 22. 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
  • 23. Question #3: Flow-volume loop FEV1 2.22 L ( 64%) FVC 4.96 L (107%) FEV1/FVC 45% FEF 25-75% 2.13 l/sec (60%)
  • 24. Question #3: Flow-volume loop 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
  • 25. Question #3: Flow-volume loop • Correct Answer : D Tracheal Stenosis
  • 26. 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.
  • 27. 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
  • 28. Question #4: RA and the Lung PFTs demonstrate : FEV1 78% predicted FVC 75% predicted FEV1/FVC 86% TLC 70% predicted RV 72% predicted DLCO 66% predicted
  • 29. Which of the following is the most appropriate next step in the management of the patient? A) Cardiopulmonary exercise testing B) Begin a tumor necrosis factor- α antagonist C) Initiate antibiotic therapy D) Stop methotrexate therapy E) Surgical Lung Biopsy Question 4: RA and Lung disease
  • 30. Question 4: RA and Lung disease Correct 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
  • 31. Question 4: RA and Lung disease • When patient with RA develops ILD, infection (particularly when immunosupressed), Drug- induced lung disease abd 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.
  • 32. 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
  • 33. 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 fludroocortisone C) Administer methylprednisolone, 2g IV D) Administer IV Dexamethasone, and perform and ACTH stim test Question #5: steroids in Sepsis
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. Question # 6: Cough 47 yo man 6 months of cough, episodic, worse at night and when exposed to cold air. Brought on with deep breathing and laughter. No PND or GERD symptoms PE, CXR and Spirometry normal. No benefit from acid suppression, nasal steroids or anithistamines He has a family history of allergies
  • 38. Question # 6: Cough Which of the following would likely provide the diagnosis of this patient’s chronic cough? a) 24-hour pH-probe b) CT scan of sinuses c) Bronchoscopy d) Trial of inhaled albuterol e) CT of the chest
  • 39. Question # 6: Cough Irwin RS, Madison JM: The Persistent troublesome cough Am J Resp Crit Care Med 2002; 165:1469-74 • Correct answer is D • Patient has cough variant asthma or post-infectious reactive airway disease (PIRAD) 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
  • 40. Asthma- Airway hyperresponsiveness • Histamine, methacholine, exercise • Positive methacholine challenge- fall in FEV1 of 20% or greater( PC 20 )with 8 mg/ml or less of methacholine • other causes of nonspecific airway responsiveness: COPD, CHF, bronchiectasis, allergic rhinitis • Negative methacholine challenge excludes a diagnosis of asthma with 95% certainty
  • 41. Classification of Severityof Asthma:Clinical Features Before Treatment Step 4 • Continuous symptoms Frequent • FEV1 or PEFR ≤60% Severe • Limited physical activity predicted Persistent • Frequent exacerbations • PEFR variability >30% Step 3 • Daily symptoms >1x/wk • FEV1 or PEFR >60%- Moderate • Daily use of inhaled ≤80% predicted Persistent 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 predicted Intermittent normal PEFR between • PEFR variability <20% exacerbations Symptoms Nighttime Symptoms 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.
  • 42. Mild Intermittent Asthma Classification: Step 1 • No daily medication needed • Short-acting bronchodilator: inhaled beta2-agonists as needed for symptoms •Use of short-acting inhaled beta2-agonists more than two times a week may indicate the need to initiate long- term control therapy •Teach basic facts about asthma •Teach inhaler/spacer technique •Discuss roles of medications •Develop self- management plan •Discuss appropriate environmental control measures to avoid exposure to known allergens and irritants Long-Term Control Quick Relief Education 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.
  • 43. Mild Persistent Asthma Classification: Step 2 Daily medication: • Anti-inflammatory: either inhaled corticosteroid (low dose) or cromolyn or nedocromil. • Sustained-release theophylline. Zafirlukast or zileuton may be considered for patients ≥12 yrs of age, although their position in therapy is not fully established. • Short-acting bronchodilator: inhaled beta2-agonists as needed 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 group education if available. • Review and update self-management plan. Long-Term Control Quick Relief Education 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.
  • 44. Moderate Persistent Asthma Classification: Step 3 Daily medication: • Either • Anti-inflammatory: inhaled corticosteroid (medium dose) OR • Inhaled corticosteroid (low-medium dose) and add a long-acting bronchodilator: either long-acting inhaled beta2-agonist, SR theophylline, or long- acting beta2-agonist tablets. • Short-acting bronchodilator: inhaled beta2-agonists as needed 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 group education if available. • Review and update self-management plan. Long-Term Control Quick Relief Education 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.
  • 45. Severe Persistent Asthma Classification: Step 4 Daily medication: • Anti-inflammatory: inhaled corticosteroid (high dose) AND • Long-acting bronchodilator: either long-acting inhaled beta2-agonist, SR theophylline, or long- acting beta2-agonist tablets AND • Oral corticosteroid • Short-acting bronchodilator: inhaled beta2-agonists as needed 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. Steps 2 and 3 actions, plus: • Refer to individual education/counseling Long-Term Control Quick Relief Education 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.
  • 46. 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
  • 47. Question # 7: Pulmonary Hypertension 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
  • 48. Question # 7: Pulmonary Hypertension 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
  • 49. Question # 7: Pulmonary Hypertension • Correct answer : A Left ventricular dysfunction
  • 50. 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
  • 51. Hemodynamic Profiles Disease CVP PAP PAOP CO SVR Normal 5 25/15 10 5 1000 Distributive Sepsis/AI 3 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
  • 52. 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
  • 53. Question # 7: Pulmonary Hypertension Correct 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 PE Constrictive Pericarditis 10 30/10 30/12 12 3
  • 54. Question # 8: Pleural Effusion 75 yo man with 80-pack yr & 3 months fever, night sweats weight loss, and dyspnea. Dull left chest pain. T: 36.8 P:112 RR: 26 Trachea shifted to right, dullness and decreased breath sounds on left Labs; WBC: 6.8 Liver and renal normal, Protein 5.0g/dl, LDH 188 U/L. CXR complete opacification on left hemithorax with shift of mediastinum to right.
  • 55. Question # 8: Pleural Effusion Pleural Fluid analysis: Cell Count: 980 20% Neutro 55% Lymph 10% mesothelial15% eos Total Protein: 4.5 mg/dl LDH: 1200 U/L Glucose 45 mg/dl pH: 7.2 Gram stain negative; cytology pending
  • 56. Question # 8: Pleural Effusion What is the most likely diagnosis? A) Transudative pleural effusion B) Malignant pleural effusion C) Parapneumonic effusion D) Rheumatoid pleural effusion E) Pleural Effusion associated with esophageal rupture
  • 57. Question #8:Pleural Effusions Correct Answer: B 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 exudative with lymphocytic predominance
  • 58. Question # 8: Pleural Effusion • 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
  • 59. 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.
  • 60. Question # 8: Pleural Effusion • Effusion is a lymphocytic exudative effusion • If it were a massive parapneumonic it would be neutrophilic and patient would be more toxic. • Rheumatoid effusions usually seen in setting of other manifestations of RA • Rupture esophagous would expect low pH 4.0 history of wretching vomitting and are usually not massive
  • 61. 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.
  • 62. 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
  • 63. Question # 9: Sleep Correct 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.
  • 64. 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
  • 65. Question # 10: 55 yo male with severe dyspnea and right sided pleuritic chest pain. PMH: anaphylaxis after normal coronary angiogram PE: T:38.1 P:115 R: 24 BP: 110/70 Portable CXR: normal ABG: (RA) pH: 7.44 PaCO2: 35 PaO2: 60 100% NRB 7.44 PaCO2: 35 PaO2: 150
  • 66. Question # 10: Which of the following is the most appropriate next step in the evaluation of the patient? A) Ultrasound Left Pleural Space B) Ventilation/perfusion lung scanning C) Echo with air contrast injection D) Azithromycin therapy E) Non-contrast helical (spiral) CT scanning
  • 67. Question 10: Correct answer B Pulmonary Embolism • Helical Ct without contrast won’t detect PE • Contrast echo is good for shunt however patient hypoxemia corrects with supplemental O2 and shunt would not cause chest pain • Ultrasound good for small effusions but these would not have such a profound effect • Clear CXR does not support diagnosis of pneumonia
  • 68. Question 10: Pulmonary embolism correct answer: E • 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
  • 69. 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
  • 70. Question # 10: Pulmonary embolism : Correct answer: B • 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
  • 71. 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
  • 72. Question # 11: Abnormal CXR Which of the following findings would warrant a trial of oral corticosteroid therapy? A) Bilateral Anterior uveitis B) Hypercalcemia C) Fever and tender red nodules over the anterior shins D) Abnormal LFTs
  • 73. 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.
  • 74. 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%
  • 75. 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
  • 76. Question 12: Which of the following is the most appropriate next step in the management of the patient? A) Inhaled Nitric Oxide B) Start inverse ratio ventilation C) Insert a needle in the right hemithorax, 2nd anterior space D) Use prone positioning
  • 77. Question 12: Correct answer C • Acute tension pneumothorax, a known complication in patients with Pneumocystis Jiroveci pneumonia.
  • 78. 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 overrcomes lung/chest wall compliance
  • 79. 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: 28 Lungs clear R CVA tenderness Given fluids and Antibiotics She goes into progressive respiratory failure and decision to intubate her.
  • 80. 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
  • 81. • 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 # 13 Correct Answer : B
  • 82. ARDS Mechanical Ventilation ARDS-Net
  • 83. 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)
  • 84. ARDS-Net
  • 85. ARDS-Net
  • 86. 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
  • 87. 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 on to the other. FULL SUPPORT: UNWEANABLE
  • 88. 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
  • 89. 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
  • 90. 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)
  • 91. Question #14: Interstitial lung disease 60 yo man with 1 yr progressive severe DOE and 3 month non-productive cough Smoked 2ppd x 30 yrs quit 3 yrs ago PE: pain both knees without swelling, bibasilar crackles No edema SaO2 on RA at rest 94% with exertion 84% CXR: Lower lobe interstitial linear markings
  • 92. Question #14: Interstitial lung disease HRCT: reticular infiltrates in periphery lower lobes, sub-pleural cysts patchy ground glass opacities, centrilobular emphysema in the apices PFTs: FEV1 =84% FVC = 82% DlCO = 39% ANA = 1:160 ( one dilution above normal)
  • 93. Question #14: Interstitial lung disease Which of the following is the most likely diagnosis? A) Emphysema with “smoker’s lung” B) Systemic lupus erythmatosus with pulmonary involvement C) Idiopathic pulmonary fibrosis D) Idiopathic pulmonary fibrosis with emphysema E) Systemic sclerosis ( scleroderma) with lung involvement
  • 94. Question #14: Interstitial lung disease Correct Answer: C • Counterbalance restrictive effect of fibrosis and obstructive effect of emphysema account for normalization of lung volume. • ANA and RF are often abnormal with IPF • The patient’s age, sex and paucity of extrapulmonary signs or symptoms 1 year out point to IPF over SLE or scleroderma
  • 95. Interstitial Fibrosis • Upper Lobe – Ankylosis Spondylsis – Sarcoid – Tb/ Histo – E. Granuloma (histiocytosis X) – Cystic Fibrosis – PCP • Lower Lobe – Asbestosis – Rheumatologic (RA/Scleroderma) – Aspiration – IPF
  • 96. 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
  • 97. 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
  • 98. Question #15: Lung Cancer Correct 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
  • 99. 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)
  • 100. NonSmall Cell Cancer T 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.
  • 101. NonSmall Cell Cancer N Stage • N0: No nodes. • N1: Ipsilateral hilar or peribronchial. • N2: Ipsilateral mediastinal, subcarinal. • N3: Contralateral hilar, contralateral mediastinal or supraclavicular/scalene.
  • 102. 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
  • 103. 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.
  • 104. 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.
  • 105. Question # 16: Positive PPD Which of the following is the most appropriate next step? A) Treatment for active tuberculosis should be initiated B) Treatment for latent tuberculosis should be initiated C) 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.
  • 106. Question # 16: Positive PPD • 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
  • 107. • 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 Question # 16: Positive PPD