Your SlideShare is downloading. ×
0
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Pulmonary Pearls
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Pulmonary Pearls

1,311

Published on

Review of common pulmonary medical problems …

Review of common pulmonary medical problems
Edward Omron MD, MPH, FCCP
Pulmonary Medicine
Morgan Hill, CA 95037

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,311
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
32
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • There are 3 reasones why one should obtain a blood gas:
  • This is a typical printout from a blood gas report:
  • Recall altitiude Recall RS Allows to assess properly if the lungs are transferring loxygen appropriately into the blood
  • Transcript

    1. Pulmonary Pearls Edward Omron MD, MPH Pulmonary/Critical Care Medicine
    2. History <ul><li>74 year-old woman presents with 4 days cough, chills, dyspnea and fever </li></ul><ul><li>Hemoptysis with right sided pleuritic chest pain x2 days </li></ul><ul><li>Unable to walk due to dyspnea </li></ul><ul><ul><li>35 pack year tobacco use </li></ul></ul><ul><ul><li>Assisted care facility </li></ul></ul><ul><ul><li>Recent hospital admission for complicated UTI treated with levofloxacin </li></ul></ul>
    3. Physical Exam <ul><li>Respiratory distress </li></ul><ul><li>Temp 101.8 F </li></ul><ul><li>Heart Rate 110 </li></ul><ul><li>Blood pressure 80/55 mm Hg </li></ul><ul><li>Dullness to percussion on right side with crackles </li></ul>
    4. Initial Tests <ul><li>ECG: Sinus Tachicardia with LVH </li></ul><ul><li>WBC: 18,600 </li></ul><ul><li>Creatinine: 1.5, BUN 47 </li></ul><ul><li>ABG </li></ul><ul><ul><li>pH 7.32 </li></ul></ul><ul><ul><li>PaCO2 = 47 mm Hg </li></ul></ul><ul><ul><li>PaO2 = 58 mm Hg on 4 L NC </li></ul></ul>
    5. ER Chest X-RAY
    6. What is the most likely pathogen in this patient? <ul><li>S pneumoniae </li></ul><ul><li>H influenzae </li></ul><ul><li>S aureus </li></ul><ul><li>P aeroginosa </li></ul><ul><li>K pneumoniae </li></ul><ul><li>M tuberculosis </li></ul><ul><li>Other </li></ul>
    7. Initial Treatment in the ER <ul><li>Right IJ central venous access </li></ul><ul><li>Fluid bolus 1 Liter 0.9% NS </li></ul><ul><li>Oxygen converted to 40% venturi mask </li></ul><ul><li>Bipap on the way </li></ul><ul><li>Albuterol / Atrovent neb treatments </li></ul><ul><li>Transduced CVP < 8 mm Hg after fluid bolus and second 1 L 0.9% NS given </li></ul>
    8. What antibiotic regimen would you prescribe in the ER? <ul><li>Beta Lactam </li></ul><ul><li>Respiratory quinolone </li></ul><ul><li>3 rd Generation Cephalosporin+macrolide </li></ul><ul><li>3 rd Generation Cephalosporin+ respirotory quinolone </li></ul><ul><li>Carbopenem+ aminoglycoside </li></ul><ul><li>Vancomycin+ respiratory quinolone </li></ul><ul><li>Vancomycin + extended spectrum penicillin + aminoglycoside </li></ul><ul><li>Zyvox, Zosyn, levafloxacin </li></ul><ul><li>Other </li></ul>
    9. Initial antibiotics given in the ER <ul><li>Ceftriaxone 2 gram and levafloxacin 750 mg </li></ul><ul><li>Rationale: </li></ul><ul><ul><li>Most likely diagnosis was thought to be CAP (Strep pneumo + H influ) </li></ul></ul><ul><ul><li>Atypical pathogen coverage for legionella </li></ul></ul>
    10. Follow Up <ul><li>Urine legionella antigen negative </li></ul><ul><li>Sputum: gram + cocci in clusters 4+ which later grew out MRSA </li></ul><ul><li>Blood Cultures: MRSA, PVL+ or CA-MRSA </li></ul><ul><li>Community Acquired MRSA </li></ul>
    11. Community Acquired MRSA Sensitivity in this patient <ul><li>Oxacillin Resistant </li></ul><ul><li>Fluoroquinolone Intermediate </li></ul><ul><li>Macrolide Resistant </li></ul><ul><li>Cephalosporin Resistant </li></ul><ul><li>Vancomycin Sensitive </li></ul><ul><li>Clindamycin Sensitive </li></ul><ul><li>Linezolid Sensitive </li></ul><ul><li>Septra Sensitive </li></ul>
    12. CA-MRSA Pneumonia <ul><li>MRSA is an increasing threat in all forms of pneumonia </li></ul><ul><li>CA-MRSA is the newest threat to hospitalized patients with pneumonia </li></ul><ul><li>“ Superbug” </li></ul><ul><ul><li>Enhanced antibiotic resistance </li></ul></ul><ul><ul><li>Higher mortality than MSSA strains </li></ul></ul><ul><ul><li>Expresses multiple virulence factors </li></ul></ul>
    13. CA-MRSA: 48 hours of destruction Admission 48 hours later
    14.  
    15.  
    16.  
    17.  
    18.  
    19. Healthcare Acquired Pneumonia <ul><li>Empiric regimen </li></ul><ul><ul><li>Vancomycin 1.5 gm IV </li></ul></ul><ul><ul><li>Zosyn 3.375-4.5 grams q6 or Fortaz 1.5 gm to 2 gm q8 </li></ul></ul><ul><ul><li>Tobramycin 5 mg/kg once daily </li></ul></ul><ul><ul><li>Pharmacy to DOSE! </li></ul></ul><ul><ul><li>ID or Pulmonary to de-escalate therapy next day. </li></ul></ul>
    20. 59 yo with dyspnea and increased work of breathing <ul><li>ABG: pH = 7.27, PCO2= 56, PaO2 = 60 </li></ul><ul><li>Pulse 125, RR = 32, BP= 120/80, Sat 90% RA </li></ul><ul><li>WBC 17K, BUN = 30, Creat 1.2 </li></ul><ul><li>Conversational dyspnea but alert and oriented </li></ul><ul><li>Where should this patient go? </li></ul><ul><ul><li>ICU </li></ul></ul><ul><ul><li>Monitored Bed </li></ul></ul><ul><ul><li>Floor </li></ul></ul><ul><li>How should we manage the airway? </li></ul>
    21. CXR
    22. COPD Management Non-invasive ventilation <ul><li>Very useful in acute exacerbation especially with dynamic hyperinflation and muscle failure. </li></ul><ul><li>Can be tried even in hypercapneic narcosis. </li></ul><ul><li>Night time use for severe COPD with hypercapnia may be of benefit if tolerated. </li></ul>
    23. <ul><li>Non-invasive ventilation </li></ul><ul><ul><li>Hypercapneic failure PCO2> 45 mg Hg </li></ul></ul><ul><ul><ul><li>BIPAP: Initial 10 IPAP/ 5 EPAP cm H2O with FIO2 bleed in to maintain sats at 90%, humidified </li></ul></ul></ul><ul><ul><li>Hypoxic and Hypercapneic ventilatory Failure </li></ul></ul><ul><ul><ul><li>Bipap: Initial 10 IPAP /10 EPAP cm H2O with FiO2 Bleed in to maintain sats at 90%, humidified </li></ul></ul></ul><ul><ul><li>Congestive Heart Failure </li></ul></ul><ul><ul><ul><li>CPAP at 10 cm H2O with FIO2 Bleed in to maintain sats at 90%, humidified </li></ul></ul></ul>
    24. COPD Management <ul><li>For Acute Exacerbations </li></ul><ul><ul><li>Injudicious administration 02 in CO2 retaining pts may cause acute rise in PaCO2. </li></ul></ul><ul><ul><ul><li>Loss of alveolar hypoxemic vasoconstriction causes flooding of vasculature with alveolar CO2 </li></ul></ul></ul><ul><ul><ul><li>NOT LIKELY “loss of hypoxemic drive.” </li></ul></ul></ul><ul><ul><ul><ul><li>Appears as such because sudden rise in PaCO2 causes narcosis. </li></ul></ul></ul></ul><ul><ul><ul><li>Titrate to 90% at all times </li></ul></ul></ul><ul><ul><li>Avoid respiratory depressants </li></ul></ul>
    25. Severe COPD Normal
    26. Severe COPD Normal
    27. ABG INDICATION <ul><li>Oxygenation </li></ul><ul><li>Ventilation </li></ul><ul><li>Acid-Base Status </li></ul><ul><li>The most sensitive indicator of physiologic stress irrespective of etiology </li></ul>
    28. Blood Gas Report( Arterial ) <ul><li>pH (No Units) 7.35-7.45 </li></ul><ul><li>PaCO 2 (mm Hg) 35-45 </li></ul><ul><li>PaO 2 (mm Hg) 110 - 0.5(age) </li></ul><ul><li>HCO 3 - (mmol/L): calc. 22-26 </li></ul><ul><li>B.E. (mmol/L) -2 to 2 </li></ul><ul><li>O 2 saturation: calc. >90% </li></ul>
    29. Changes in PO 2 and PCO 2 as oxygen moves from atmosphere to arterial blood
    30. <ul><li>Alveolar arterial O2 gradient </li></ul><ul><ul><li>The difference in oxygen pressure between alveolar air and arterial blood </li></ul></ul><ul><ul><li>INCREASE in alveolar / arterial pressure gradient indicates either lung disease or a problem with oxygen transfer </li></ul></ul><ul><ul><li>PAO 2 calculated from Alveolar Air Equation </li></ul></ul><ul><ul><li>PaO 2 derived from a blood gas report </li></ul></ul>
    31. ANALYSIS OF OXYGENATION <ul><li>Alveolar Gas Equation </li></ul><ul><ul><li>PAO 2 = FIO 2 (P B - 47) - 1.2(PaCO 2 ) </li></ul></ul><ul><ul><li>PAO 2 defines upper limit of PaO 2 </li></ul></ul><ul><ul><li>FIO 2 is 21% at all altitudes </li></ul></ul><ul><ul><li>Factor 1.2 determined by RQ </li></ul></ul><ul><ul><li>Water vapor pressure = 47 mm Hg </li></ul></ul><ul><ul><li>PAO 2 = 150 - 1.2(PaCO 2 ) at room air </li></ul></ul><ul><ul><li>PAO 2 = 102 </li></ul></ul>
    32. Alveolar-Arterial Oxygen Difference <ul><li>A-aDo 2 = PAO 2 -PaO 2 (from ABG) </li></ul><ul><li>Insight in the patients state of gas exchange </li></ul><ul><ul><li>If elevated, defect in gas exchange </li></ul></ul><ul><ul><li>Proper interpretation of the PaO 2 </li></ul></ul>
    33. Changes in PaO 2 and PAO 2 with age
    34. Arterial Oxygen Values <ul><li>Age L.L. PaO2 U.L. A-aDo2 </li></ul><ul><li>20 84 17 </li></ul><ul><li>30 81 21 </li></ul><ul><li>40 78 24 </li></ul><ul><li>50 75 27 </li></ul><ul><li>60 72 31 </li></ul><ul><li>Max A-aDo2 = 2.5 + Age/5 </li></ul><ul><li>Hypoxemia PaO2 < 70 (relative) </li></ul>
    35. Changes in P(A-a)O 2 with FIO 2
    36. Causes of a low PaO 2 <ul><li>P(B): Altitude </li></ul><ul><li>Alveolar Hypoventilation(Nl A-a Do2) </li></ul><ul><li>V/Q mismatch </li></ul><ul><li>Shunt </li></ul><ul><li>Diffusion Impairment </li></ul><ul><li>Decreased mixed / central venous O 2 content </li></ul>
    37. <ul><li>A 73 yo is brought to the emergency room comatose. The family states she had become confused and had swallowed an excess number of sleeping pills. ABG while breathing room air (FIO 2 = 0.21) shows the PaO 2 , is 42 mm Hg, the PaCO 2 , is 75 mm Hg, and the pH is 7.10. Why is her PaO 2 reduced? </li></ul>
    38. Alveolar Hypoventilation <ul><li>No increase in P(A-a)O2 gradient </li></ul><ul><li>PAO 2 = 150-1.2 (75) = 60 </li></ul><ul><li>A-a gradient = 60 – 42 = 18 Nl </li></ul><ul><li>PaO2 +PCO2 = 120 </li></ul>
    39. Pulse Oximetry <ul><li>Binding sites for O 2 are heme groups </li></ul><ul><li>OXYGEN SATURATION </li></ul><ul><ul><li>% of all heme sites saturated with O2 </li></ul></ul><ul><li>Measures the difference in the light absorbance characeteristics between Oxy Hb and Deoxy Hb </li></ul><ul><li>SpO2 = Oxy Hb x 100 </li></ul><ul><li>Oxy Hb + Deoxy Hb </li></ul><ul><li>ABG SaO2 is a calculated value from PaO2 </li></ul>
    40. Pulse Oximetry Whole Blood PaO2 SaO2 SpO2: Pulse Oximetry ABG
    41. Problem <ul><li>28 yo pt with fevers,chills, SOB,cough </li></ul><ul><ul><li>Taking Dapsone for PCP prophylaxis </li></ul></ul><ul><ul><li>ABG: PaO2 90, PaCO2 35.2, pH 7.43, SaO2 100% </li></ul></ul><ul><ul><li>Pulse oximeter 89% </li></ul></ul><ul><ul><li>PCP Pneumonia, started on Septra, Clinda, and Prednisone </li></ul></ul><ul><ul><li>ABG: PaO2 378, PaCO2 of 35, pH 7.42, SaO2 100% </li></ul></ul><ul><ul><li>Pulse Oximeter 83% </li></ul></ul><ul><ul><li>Whats Happening? </li></ul></ul>
    42. Methemoglobin <ul><li>Oxidation of Fe++ to Fe+++ state </li></ul><ul><li>Met-Hb depresses the SpO2 reading </li></ul><ul><li>Dapsone is an oxidant </li></ul><ul><li>Met-Hb depresses the SpO2 to 80’s </li></ul><ul><ul><li>Further increases in Met-Hb do not depress SpO2 </li></ul></ul><ul><li>Methylene Blue administration is Rx </li></ul>
    43.  
    44. Co-oximetry <ul><li>SpO2 = Oxy-Hb </li></ul><ul><li>Oxy-Hb+Deoxy-Hb+CO-Hb+Met-Hb </li></ul>
    45. Oximetry <ul><li>54 yo WM with headaches, dyspnea and a Kerosene heater at home </li></ul><ul><ul><li>ABG: PaO2 = 89, PaCO2 = 38, pH = 7.43 </li></ul></ul><ul><ul><li>SaO2 from ABG= 98% </li></ul></ul><ul><ul><li>Pulse Oximetry = 98% </li></ul></ul><ul><ul><li>Whats the problem? </li></ul></ul>
    46. Oximetry <ul><li>Carboxyhemoglobin: Hb +CO </li></ul><ul><ul><li>Does not affect PaO2 or pulse oximetry </li></ul></ul><ul><ul><li>P.O. reads CO as oxyhemoglobin </li></ul></ul><ul><ul><li>Need co-oximetry if suspected </li></ul></ul><ul><li>Follow Up: </li></ul><ul><ul><li>PaO2 = 79, PaCO2 = 31, SpO2 = 53%, pH =7.36 </li></ul></ul><ul><ul><li>CO-Hb46% </li></ul></ul>
    47.  

    ×