6.15.09 thomas pulm board review

7/31/2019 6.15.09 Thomas Pulm Board Review

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Liz Thomas

June 15, 2009


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Definition: Absence of airflow for at least 10seconds despite persistence of respiratoryeffort.

Severity of OSA can be classified based on theapnea-hypopnea index (AHI, number ofapneas plus hypopneas per hour of sleep)

AHI 5-15 = mild

AHI 16-30 = moderate AHI >30 = severe


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Obstructive sleep apnea Inadequate sleep

Poor sleep hygiene

Chronic pain

Shift work Medications

Drug, ETOH abuse

Depression

Insomnia Limb movements

Narcolepsy


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Obesity Craniofacial and upper airway anatomic

abnormalities (enlarged tonsils)

Increasing age Untreated hypothyroidism

Male sex


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Excessive daytime sleepiness Accounts by bed partner of witnessed apneas

and snoring

Awakening with sensation of gasping orchoking

Nocturnal diaphoresis

Morning headaches

Nocturia Alterations in mood


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Requires nocturnal polysomnography Includes electroencephalogram,

electrooculogram, chin electromyogram,respiratory effort, airflow, pulse oximetry andlimb movements


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Conservative approach Weight loss Exercise Improved sleep hygiene Supine preclusion Nasal decongestants

Smoking cessation Avoidance of sedating drugs Avoidance of alcohol

Definitive approach Nasal CPAP Auto-CPAP

Bi-level ventilation Oral appliances Surgery: uvulopalatopharyhgoplasty, laser-assisted uvuloplasty,

improved nasal patency, maxillomandibular advancement


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In patients with AHI >5 associated withcomplaints of daytime sleepiness, CPAPtherapy has been shown to improve quality oflife, cognitive function, and symptoms of

daytime sleepiness. There are also beneficialeffects on mortality, blood pressure andcardiac function.


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A 53-year old man is evaluated for management of OSA whichwas diagnosed 2 months ago when he was evaluated forexcessive sleepiness. Polysomnography performed at that timeshowed an apnea-hypopnea index of 55 events per hour. Theindex normalized to 4 events per hour with CPAP at 18cm H2),which was prescribed for his apnea.

He says now that he cannot tolerate nasal CPAP because of nasalcongestion and he has not used CPAP for two weeks. He hascontinued daytime sleepiness that affects his performance atwork.

Which of the following is the most appropriate management forthis patient's condition at this time?

A) Refer for upper airway surgery for obstructive sleep apnea

B) Change to an auto-titrating positive airway pressure device(APAP) C) Prescribe an oral device to be worn during sleep D) Manage nasal congestion and stress regular use of CPAP


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A 24 year old woman is evaluated for episodes of falling asleepat inappropriate times during the day. Sleepiness occurs mostoften after lunch or while driving a car. She goes to bed atmidnight and gets up for work at 6am. Her only medication isoral contraceptives. She has no symptoms of depression, druguse, restless leg syndrome, hypothyroidism, or insomnia. Shedoes not know whether she snores and no one in her family has

sleep problems. Physical examination reveals normal weight andvital signs.

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

A) Schedule polysomnography B) Counsel for proper sleep hygiene with increase in sleep time

C) Schedule electroencephalography D) Prescribe modafinil


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Acute LungInjury


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V/Q mismatch Shunt

Diffusion abnormality

Decreased mixed venous oxygen Greater acidity and higher temperature of

blood shift the oxyhemoglobin dissociationcurve to the right, lowering the blood oxygen

content for a given oxygen tension


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Pulmonary Acute bacterial or viral pneumonia Gastric aspiration Inhalation injury

Near drowning Pulmonary contusion

Non-pulmonary causes Severe sepsis Hypertransfusion syndrome Acute pancreatitis Transfusion-related acute lung injury Cardiopulmonary bypass


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Failure of NPPV if patient is a candidate initially Severe dyspnea with use of accessory muscles and

paradoxical abdominal motion Respiration rate >35/min Life-threatening hypoxemia (PaO2/FiO2 60mm Hg)

Respiratory arrest Impaired mental status Cardiovascular complications (hypotension, shock,

heart failure) Other complications (metabolic abnormalities, sepsis,

pneumonia, pulmonary embolism, barotrauma,massive pleural effusion)


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Studied in ARMA trial Showed reduction in ARDS mortality from 40% to 30% with a low

(6ml/kg) rather than high (12ml/kg) tidal volume Established "lung protective" ventilator strategies to avoid

ventilator-associated lung injury resulting from excessivestretching of the lung during mechanical ventilation

ALVEOLI study showed no advantage of a higher PEEP comparedto a lower PEEP, both adjusted to maintain adequate oxygenation Current recommendation is to use either a volume- or pressure-

limited mode with a low tidal volume (6ml/kg) while monitoringplateau pressure that should be kept


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Avoid excessive minute volume that contributesto dynamic hyperinflation (auto-PEEP) andalkalemia that results from the compensatorymetabolic alkalosis for chornic hypercarbia

Keep tidal volume small (5-7ml/kg ideal bodyweight)

Backup respiratory rate 10-14/min

Lower rate increases cycle time which permitsmore time for exhalation and emptying of the

lung Shortening Inspiratory time is another way to

increase expiratory time


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Invasive mechanical ventilation should beavoided in patients with asthma if at all possible

Complications include pneumothorax andpneumomediastinum

In needed, the approach is similar to that usedfor COPD patients

Excessive respiratory rates and tidal volumesshould be avoided, plateau pressures should bekept


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Minimizing the duration of mechanical ventilationis desirable to reduce complications

When patients no longer require high levels ofoxygen (SaO2 >89% with FiO2 40%), are

hemodynamically stable, and not excessivelysedated, spontaneous breathing trials using a T-piece or low levels of CPAP or pressure supportshould be initiated

If the patient tolerates SBP for 30-120 minutes

without excessive tachypnea, hemodynamicinstability, or oxygen desaturation, extubationshould be performed


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A 67-year old man is receiving mechanical ventilation for ARDS. Heunderwent laparotomy and diverting colostomy for a ruptureddiverticulum 72 hours ago, and now has a fever to 40.0C and has diffusebilateral infiltrates that have been present for the past 1 day. Two deeptracheal suction specimens are sent for culture and a gram stain shows4+ gram negative rods. The patients oxygen saturation is worsening,and his MAP has dropped to 58mm Hg despite three 1-L boluses ofnormal saline, with only 15mL of urine output in the past hour. He is

also noted to have a lactic acidosis and thrombocytopenia, with aplatelet count now falling to 42,000 in the absence of heparin or H2-antagonist therapy.

Which of the following would be appropriate management for thispatient?

A) Start resuscitation with colloids B) Avoid activated protein C C) Start low-dose dopamin D) Adjust the ventilator with 6mL/kg of ideal body weight and a plateau

pressure


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A 77-year old man on chronic hemodialysis is evaluated in theemergency department for severe dyspnea. He is in respiratory distress,but is alert and responsive. His blood pressure is 216/92, pulse 122, RR44. He is using accessory muscles to breath. He has JVD; lungs havebilateral crackles, and cardiac exam reveals a summation gallop with a3/6 systolic murmur. There is no edema. ABG on 50% O2 by high-flowmask are pO2 64, pCO2 50, pH 7.24. EKG shows sinus tach with non-specific STT wave abnormalities and CXR is pending. He receives

oxygen, nitroglycerine, furosemide, and small doses of morphine butremains very dyspneic.

Which of the following interventions would most likely avoid intubationin this patient?

A) Increasing the dose of morphine; continue nitroglycerine andfurosemide

B) Starting noninvasive continuous airway pressure (4cm H2O) C) Starting noninvasively administered pressure support (8cm H2O) and

PEEP (4cm H2O) D) Increase the FiO2 via face mask


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A 78 year old man is admitted to the ICU from the ED where he had presented with arespiratory arrest and was promptly intubated. The patient has a long history of smoking andof severe COPD on long-term O2 therapy at home and a previous measurement of ABGs on 2Loxygen during a stable state revealed a pO2 of 92mm Hg, pCO2 58mmHg, and pH of 7.45.

Physical examination is notable for a barrel chest and fine expiratory wheezes. Heart soundsare barely audible. ABG just before intubation were pO2 of 220mmHg, pCO2 of 122mmHg,and pH of 7.04 while receiving 100% O2. In the ED , initial ventilator settings wereassist/control mode with a rate of 20/min, tidal volume of 600mL, PEEP of 5cm H2O and FiO2of 50%. CXR shows hyperinflation, extensive bullous emphysema, and a RLL infiltrate.

On arrival to the ICU, he is hypotensive with a systolic pressure of 80mmHg, unresponsive to

an initial fluid bolus. A pulmonary artery catheter is inserted; right atrial pressure is 20cmH2O, pulmonary artery pressure is 66/25 mmHg, pulmonary capillary wedge pressure is21mmHg, and cardiac index is 1.8 L/min/m2. EKG shows a rate of 122/min, sinus rhythmwith multiple premature atrial beats, and nonspecific STT changes. During an accidentaldisconnection from the ventilator, the patients blood pressure and wedge pressure normalizebut deteriorate when he is reconnected.

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

A) Administer more fluids

B) Start dobutamine therapy

C) Obtain a repeat STAT portable chest radiograph D) Lower the respiration rate and tidal volume


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Heterogeneous disorder that includes: Emphysema

Chronic Bronchitis

Obliterative Bronchiolitis

Asthma w/ bronchitis

GOLD: A disease states characterized byairflow limitation that is not fully reversible.Usually progressive and is associated withabnormal inflammatory response


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Stage 0: Normal spirometry, chronic coughand sputum production

Stage I: Mild FEV1/FVC


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GOLD - a report produced by NHLBI & WHOdefines COPD exacerbation as - acuteincrease in sx beyond normal daily variation

Includes one or more of the followingcardinal symptoms (over 2 days): Cough increases in frequency and severity

Sputum production increases in volume and/orchanges character

Dyspnea increases


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It is estimated that: 50-60% COPD exacerbations are due to respiratory

infections

10% are due to environmental pollution

30% are of unknown etiology


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Most infection are thought to be viral, andhave been confirmed by viral culture orserology in 18 - 64% of exacerbation

The most common viruses are


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Viral infections cause the majority of COPDexacerbations; bacterial infections alsotrigger exacerbations

Most common bacterial causes: Haemophilus influenzae Moraxella catarrhalis Streptococcus pneumoniae

Less Common include

Kebsiella, Peduomonas Rarely - Chlamydia and Legionella


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Treatment of exacerbations of COPD includesantibiotics directed against H. influenzae, M.catarrhalis, and S. pneumoniae The use of antibiotics in exacerbations of COPD is

based on placebo-controlled trials that foundthat antibiotics improve clinical outcomes inmany patients with an exacerbation of COPD

Brochodilator, steroids, O2


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"Standard"Doxycycline 100 mg BIDTrimethoprim-sulfamethoxazole DS BIDAmoxicillin 500 mg BID

"Modernized list"

Amoxicillin-clavulanate (Augmentin) 875 mg BIDAzithromycin (Zithromax) Z pack (6-250 mg)Cefpodoxime (Vantin) 200 mg BIDCefuroxime (Ceftin) 250-500 mg BIDCefprozil (Cefzil) 500 mg BIDLoracarbef (Lorabid) 400 mg BID

Levofloxacin (Levaquin) 500 mg QDCiprofloxacin (Cipro) 500 mg BID


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Stable COPD: Bronchodilaters

Anticholinergics

Steroids

(No mucolytics or leukotrienes)


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Bullectomy may reduce sx in pt w/ bullacausing compression of adjoining lung tissue-> improve lung function

Lung Volume Reduction surgery - FEV


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A 72-year-old man is evaluated for progressive dyspnea on exertion anda morning cough productive of thick white sputum. The patient is a life-long cigarette smoker and was diagnosed with chronic obstructivepulmonary disease 4 years ago; he has had two unscheduled office visitsin the past 6 months for bronchitis.

On physical examination, he is thin (BMI 20), his chest is hyperinflated,breath sounds are diminished, he has 1+ ankle edema. Spirometryshows an FEV1 35% of predicted which improves 5% with albuterol. Lungvolume measurement shows a total lung capacity of 140% and residualvolume of 130%; the DLco is 55% of predicted.

Which of the following is the most appropriate therapy for this patient? (A) Albuterol, tiotropium, and inhaled corticosteroids (B) Ipratropium bromide and tiotropium (C) Albuterol/ipratropium bromide inhaler, a long-acting beta-agonist,

and oral corticosteroids (D) Ipratropium bromide and montelukast


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A 45-year-old man is evaluated for mild dyspnea onexertion. He has smoked 1.5 packs of cigarettes a day for30 years. His personal and family medical history isunremarkable.

On physical examination, the chest is clear; cardiacexamination and chest radiograph are normal. Spirometry

shows the FEV1 of 70%, FVC of 75%, FEV1/FVC of 70%.After administration of a bronchodilator, the FEV1 rises to80% and the FVC to 85%; the FEV1/FVC ratio is 75%. Therserum IgE concentration is normal, and there are noeosinophils on the peripheral blood smear.

Which of the following is the most likely diagnosis?

(A) Chronic obstructive pulmonary disease, stage 0 (B) Chronic obstructive pulmonary disease, stage 1 (C) Moderate persistent asthma (D) Restrictive lung disease

6.15.09 thomas pulm board review

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