Pulmonology 4

Occurs when pleural fluid formation exceeds reabsorption

for a pleural effusion to be seen on CXR generally requires ____

protein rich pleural effusions are

usually/always bilateral, occasionally R>>L

pus in pleural space (abscess)

how do you treat an empyema

causes of hemothorax

Acute hypoxemic respiratory failure that occurs after a direct or indirect pulmonary insult that cannot be attributed to heart failure

ARDS chest x-ray is characterized by

ARDS is characterized by PaO2/FIO2 <= ____

Aspiration, Lung contusion and trauma, Inhalational injury, Pneumonia, Near -drowning

Sepsis, Pancreatitis, Hypotension (shock)

associated with a poorer outcome

upon auscultation of lungs in ARDS you will hear

Indications for Mechanical Ventilation typically involves a PaO2 <__mmHg, SaO2 <90% with a elevated PCO2

Treatment of ARDS induced hypoxemia usually requires

ARDS: Mechanical Ventilation Lung Protective Strategies use

ARDS: Mechanical Ventilation Lung Protective Strategies consider _____ to minimize elevated lung pressures

Normal mechanical ventilator tidal volume (___ ml/kg IBW)

Large tidal volumes cause _____ in stiff lungs

mechanical ventilator tidal volume in ARDS patient (___ ml/kg IBW)

Positive End Expiratory Pressure

Used to keep alveoli open during the exhalation phase of respiration

Maintains the Functional Residual Capacity (FRC). The FRC prevents atelectasis

Too much PEEP can lead to

ARDS has a ___% mortality rate

ARDS has a 90% mortality rate in those with

Respiratory dysfunction resulting in abnormal oxygenation and ventilation severe enough to threaten the function of vital organs

Arterial blood gas values consistent with RF: PaO2 value < 60 mmHg, PaCO2 value > __ mmHg, SaO2 value < 90%

The tip of the endotracheal tube should rest at the level of the

The tip of the endotracheal tube should rest at the level of the

Does not allow the patient to breathe between ventilator delivered breaths

Ideal mode for patients that are sedated and paralyzed

low VT and respiratory rates – allow hypercapnia – minimize high inflation pressures – oxygenation is maintained)

method employed to decrease the incidence of barotrauma

results when the lung can no longer accomplish adequate gas exchange, often fatal if left untreated

respiratory compromise is evident when the PaO2 is < __mm Hg on room air

respiratory compromise is evident when the PaCO2 is > __mm Hg

patients in respiratory failure with evidence of severe distress, mental deterioration, or hemodynamic instability usually require _____

the adequacy of ventilator settings needs to be determined with repeated ____

the current preferred mode of ventilation is

in ____ the clinician sets the tidal volume and the lowest allowed respiratory rate, however each spontaneous breath is supported

considered the more physiologic ventilatory mode and is associated with a decreased work of breathing

the most popular mode of ventilation in the 1980's. often associated with asynchrony of spontaneous breaths and assisted breaths

A chronic inflammatory disorder of the airways in which various cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells

PEF or FEV1, PEF Variability > 80%, 20-30%; > 2/wk but < 1/day / > 2 nights/month

PEF or FEV1, PEF Variability > 80% < 20%;< 2 days/wk / < 2 nights/month

Rules of Two: Quick-relief inhaler

Rules of Two: Awaken at night

PEF or FEV1, PEF Variability < 60% - > 30%Continual/Frequent

PEF or FEV1, PEF Variability > 60% - < 80%; > 30%; Daily /> 1 night/wk

Rules of Two: Refill quick-relief inhaler

Inhaled corticosteroids (ICS)

Leukotriene modifiers

Mast cell stabilizers

Methylxanthines

Short-acting beta2 agonists

Anticholinergics

Systemic corticosteroids

Potent anti-inflammatory agent

Primary agent in adults with persistent asthma

Prevent symptoms; suppress, reverse and control inflammation

Inhaled route used in long-term management of asthma, Similar efficacy between ICS agents when given in equipotent doses

Osteoporosis, Glucose intolerance, Fluid and electrolyte disturbances, Weight gain, Cushing’s syndrome, Peptic ulcers, Ocular cataracts, Behavioral disturbances

Oral thrush (candidiasis), Dysphonia, Cough

Spacer, Rinse mouth, Use lowest effective dose, Monitor growth in children?

Only prescribe in combination with ICS in pts with moderate to severe persistent asthma

Salmeterol (Serevent ®) and Formoterol (Foradil ®)

Stimulate beta2 receptors in the airways smooth muscle relaxation, airway opening, decreased hyperresponsiveness

ADR: tachycardia, tremor, EKG changes if OD, DO NOT USE FOR ACUTE SYMPTOMS

Contains fluticasone and salmeterol

Contains budesonide and formoterol

Antagonize pro-inflammatory effects of leukotrienes

ADR’s: rare; few cases of LFT changes

Onset more rapid than inhaled corticosteroids

Potential role as alternative to low-dose inhaled corticosteroids in mild persistent asthma

class: Montelukast (Singulair®)

Class: Zafirlukast (Accolate®)

class: Zileuton (Zyflo®)

approved for allergic rhinitis***

Mast Cell Stabilizers

Inhibit inflammatory cell activation and mediator release, early and late allergen-induced bronchoconstriction

Was first line anti-inflammatory agent in children due to safety profile (but now ICS)

Takes 2 weeks for therapeutic response (4-6 week trial recommended)

Takes 2 weeks for therapeutic response (4-6 week trial recommended)

Potential beneficial effects include bronchodilation, attenuation of early and late phase response to allergen, steroid sparing effect, improved exercise tolerance

Role as an alternative to salmeterol for pts inadequately controlled on inhaled corticosteroids

Used as adjuvant to inhaled corticosteroids for management of nocturnal symptoms

ADR’s and toxicity…

Class: Albuterol (Ventolin®, Proventil®)

Class: levalbuterol (Xopenex®)

Class: pirbuterol (Maxair®)

Indicated for intermittent episodes of bronchospasm

Treatment of choice for management of EIB (albuterol 15 min before exercise)

Used as needed for chronic asthma

Increasing use or > 1 canister/month indicates need to intensify anti-inflammatory therapy

Differences: Less forceful spray, Higher cost, Must be primed, Rinse actuator weekly in warm water, Equally efficacious

May have added benefit with beta-agonist in severe exacerbations

Ipratropium (Atrovent®) Short-acting

Tiotropium (Spiriva®), Long-acting, No role defined for asthma

Same mechanism as ICS

PO to gain prompt control

class: Prednisone

class: prednisolone

class: methylprednisolone

Continue until patient achieves 80% of personal best or symptoms resolve (usually 3-10 days)

Use of this to remove the need for good hand-breath coordination

Results in decreased oropharyngeal deposition and enhanced delivery to the lungs

Recommended for all patients using ICS

Turn liquid medication into a fine mist that is easily inhaled

Pulmicort®, Xopenex®, albuterol, ipratropium available in

Monitoring device that measures peak expiratory flow

Fastest speed at which one can blow air out of the lungs

Should be done in the am and between noon and 2:00pm for 2-3 weeks to establish personal best, then QD

>80%: : continue meds as prescribed

50-80%: : double ICS and schedule short-acting beta-agonist

<50%: Go to ER; start PO steroid

URI, Smoke, Dust, Mold, Pollen, Exercise, Cockroaches, Cold air, Emotional extremes, Pet dander, Some foods, GERD, Allergies, Etc…

a preventable and treatable disease with some significant extrapulmonary effects

Characterized by airflow limitation that is not fully reversible, Progressive, Abnormal inflammatory response of the lungs to noxious particles or gases

characterized by chronic and recurrent excess mucus secretion into the bronchiole tree

occurs on most days during at least 3 months/year for at least 2 consecutive years

characterized by abnormal, permanent enlargement of the airspaces distal to the terminal bronchiole

accompanied by destruction of bronchiole wall, without obvious fibrosis

COPD Staging: FEV1/FVC < 0.70, FEV1 > 80% predicted

COPD Staging: FEV1/FVC < 0.70, 50% < FEV1 < 80% predicted

COPD Staging: FEV1/FVC < 0.70, 30% < FEV1 < 50% predicted

COPD Staging: FEV1/FVC < 0.70, FEV1 < 30% predicted, or FEV1 < 50% + chronic resp failure

double the chance of patients quitting smoking

Reduce risk factors; influenza and pneumo vaccination, Short-acting bronchodilator PRN

Scheduled long-acting bronchodilator(s), Rehab

Inhaled steroids (esp. if mult exac)

Oxygen, Consider surgery

beta 2-agonists - Albuterol

Anticholinergics - Ipratropium

beta 2-agonists - Salmeterol, Formoterol

Anticholinergics - Tiotropium

produce less bronchodilation in COPD patients compared to patients with asthma

Bronchodilator of choice for acute exacerbations

Produces greater bronchodilation than inhaled beta 2-agonists in COPD pts with fewer side effects; slower onset of action

Use has not been associated with mortality benefit, 2 puffs QID

Some studies have shown an improvement in FEV1 as compared to ipratropium, No acute relief of bronchospasm, One inhalation QD

Combination of albuterol and ipratropium

Toxicities: 60% of pts experience adverse effects at serum concentrations of 20-30 mg/LN,V,D, headache, nervousness, Arrhythmia, seizures (conc. > 35 mg/L)

Shown to improve lung function and reported to improve symptoms

Role is 2nd line: use in pts inadequately controlled on optimal bronchodilatory therapy

Role is 2nd line: use in pts inadequately controlled on optimal bronchodilatory therapy

Defined as Low TLC, VC and normal FEV1/FVC.

Increased permeability, Disruption of basement membrane

Intra- alveolar, Interstitial

leading to fibrosis.

asbestos, silica, CWP, and avian and organic antigens

bleomycin, methotrexate, cyclophosphamide, amiodarone, and nitrofurantoin

SLE, RA, Scleroderma, and Polymyositis.

2+ hospitalizations/3+ ED visits in past year

2+ canisters SABA per month

Poor awareness of asthma symptoms; Lower socioeconomic status; Prior exacerbation

Illicit drug use; Major psychosocial or psychiatric illness; Other co-morbidities (CV disease, other lung disease)

Frequent assessment; Maintain O2 sat; Use SABA frequently/continuously; Use of corticosteroids

should be integrated into every step of care including:

Xopenex HFA

ProAir HFA, Proventil HFA, Ventolin HFA

Foradil

Serevent

Atrovent HFA

Spiriva

Combivent

NasalCrom

Beconase AQ, QVAR

Rhinocort Aqua, Pulmicort Respules

AeroBid

Flovent HFA, Veramyst

Nasonex, Asmanex

Nasacort AQ

Advair Diskus

Symbicort

Uniphyl

Singulair

Accolate

Zyflo

Isuprel

Xolair

CLASS: Albuterol

CLASS: Levalbuterol

CLASS: Formoterol

CLASS: Salmeterol

CLASS: Ipratropium

CLASS: Tiotropium

CLASS: Albuterol/ipratropium

CLASS: Cromolyn sodium

CLASS: Beclomethasone

CLASS: Budesonide

CLASS: Flunisolide

CLASS: Fluticasone

CLASS: Mometasone

CLASS: Triamcinolone

CLASS: Fluticasone - Salmeterol

CLASS: Budesonide - Formoterol

CLASS: Theophylline

CLASS: Montelukast

CLASS: Zafirlukast

CLASS: Zileuton

CLASS: Isoproterenol

CLASS: Omalizumab

ORAL drugs

INJECTION drugs