mcq r2
TRANSCRIPT
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MED R2
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A 22 year old man with acute myeloid leukemia was treated with allogenic bone marrow transplant 3 months ago. He received cyclosporin 200 mg/day and cotrimoxazole. He had fever and nonproductive cough for 2 days prior to this admission. On physical examination revealed fever 38.3 c and fine crepitationboth lungs. He had no skin rash. The CXR was bilateral interstitial infiltrations.
What is the MOST likely diagnosis?
A. PCP pneumoniaB. Mycoplasma pneumoniaC. CMV pneumoniaD. Staphylococcus pneumoniaE. Aspergillus pneumonia
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Respiratory complication after HSCT
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Immune system after HSCT
Phase I (pre engraftment) 0-30 days
Host defence deficits
1 Neutropenia
2 Damage mucocutaneous barrier translocation of GI and cutaneous bacteria to bloodstream
3 Indwelling intravenous catheter septic emboli
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Organism
Bacteria
gram negative Klebsiella, Pseudomonas, Enterobacteriaceae
gram positive Staphylococcus (coagulase postiveand negative), Enterococcus
Fungus
Candida spp, Aspergillois
Virus
HSV
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• Risk for infection
– Allogenic = Autologous
• Resolve
– ANC > 500, platelet > 20,000 * 3 days
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Phase II ( 30-100 days)
• Decrease or discontinue corticosteroid restore PMN function decrease risk for bacteria and funfus
BUT
Still has immune system dysfunction especially
Decreased CD4/CD8 ratio
Decreased IgA, IgG
Increased risk forCMVPJP Aspergillosis
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Allogenic HSCT
Acute GVHD
skin, GI and liver manifestration
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Phase III ( > 100 days)
Cellular and humoral immune deficit
macrophage dysfunction, impaired PMN chemotaxic
long lasting IgA and IgG deficiency
Risk for
encapsulated organism ( S.pneumoniae, H.influenza, N.meningitidis)
Norcadia,mycoplasma
PCP
CMV
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• Allogenic HSCT chronic GVHD
bronchiolitis obliteran
scleroderma
sicca syndrome
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Febrile neutropenia AIDS
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A 22 year old man with acute myeloid leukemia was treated with allogenic bone marrow transplant 3 months ago. He received cyclosporin 200 mg/day and cotrimoxazole. He had fever and nonproductive cough for 2 days prior to this admission. On physical examination revealed fever 38.3 c and fine crepitationboth lungs. He had no skin rash. The CXR was bilateral interstitial infiltrations.
What is the MOST likely diagnosis?
A. PCP pneumoniaB. Mycoplasma pneumoniaC. CMV pneumoniaD. Staphylococcus pneumoniaE. Aspergillus pneumonia
Suppress T cell
Rapid onset of fever ,non productive cough,dyspnea and hypoxemia Interstitial pattern with tiny pulmonary nodules
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Staphylococcus pneumonia
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Arterial blood gas was drawn from a 16 year-old female immediately after her intubation for a severe asthmatic attack. PaO2 was 350 mm Hg, PaCO2 was 50 mm Hg and pH was 7.30. She remained sedated and paralyzed, breathing at the machine set rate of 12 /min and with a tidal volume of 400 cc. What should the rate be to normalize PaCO2 at 40 mmHg?
A. 14B. 15C. 16D. 17E. 18
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ALVEOLAR VENTILATION EQUATION
หากผูป่้วยม ีCO2 production คงที ่ดงัน ัน้คา่
PACO2 เป็นตวับอก alveolar ventilation
• PACO2 มคีา่ใกลเ้คยีงกบั PaCO2 มาก
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VT
VD
VA
VT = VA + VD หรอื VA = VT – VDAlveolar ventilation = RR x VA = RR (VT-VD)
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“Alveolar ventilation equation”
PACO2 = k x VCO2/RR (VT-VD)
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“Alveolar ventilation equation”
PACO2 = k x VCO2/RR (VT-VD)
PaCO21 = k x CO2 production 1PaCO22 alveolar ventilation 1
k x CO2 production 2alveolar ventilation 2
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PaCO21 = alveolar ventilation 2PaCO22 alveolar ventilation 1
= [Vt(2)-Vd(2)] x RR(2)
[Vt(1)-Vd(1)] x RR(1)
“Alveolar ventilation equation”
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VT เท่าเดมิ
PaCO21 = [Vt(2)-Vd(2)] x RR(2)
PaCO22 [Vt(1)-Vd(1)] x RR(1)
50 = RR(2)
40 12
RR(2) = 15/min
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Arterial blood gas was drawn from a 16 year-old female immediately after her intubation for a severe asthmatic attack. PaO2 was 350 mm Hg, PaCO2 was 50 mm Hg and pH was 7.30. She remained sedated and paralyzed, breathing at the machine set rate of 12 /min and with a tidal volume of 400 cc. What should the rate be to normalize PaCO2 at 40 mmHg?
A. 14
C. 16D. 17E. 18
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A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150.
What is the MOST immediate appropiatemanagement?
A. Switch to ethambutol, olfoxacin and streptomycinB. Stop only PZA and continue the rest 3 drugsC. Replace RIF with olfloxacinD. Add domperidoneE. Split INH to 3 times daily after meal
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A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150.
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Management of drug-induced hepatitis
Of the first-line anti-TB drugs, isoniazid, pyrazinamide and rifampicin can all cause liver damage (drug-induced hepatitis).
Try to rule out other possible causes before deciding that the hepatitis is induced by the TB regimen.
The management of hepatitis induced by TB treatment depends on:
whether the patient is in the intensive or continuation phase
the severity of the liver disease
the severity of the TB
the capacity of the health unit to manage the side-effects of TB treatment
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If liver disease is caused by the anti-TB drugs all drugs should be stopped.
If the patient is severely ill with TB and it is unsafe to stop TB treatment non-hepatotoxic regimen consisting of streptomycin, ethambutol and fluoroquinolone should be started
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• If TB treatment has been stopped wait for LFT to revert to normal and clinical symptoms (nausea, abdominal pain) to resolve restart the anti-TB drugs.
• If it is not possible to perform LFT wait an extra 2 weeks after resolution of jaundice and upper abdominal tenderness before restarting TB treatment.
• If the signs and symptoms do not resolve and the liver disease is severe non-hepatotoxic regimen consisting of streptomycin, ethambutol and a fluoroquinoloneshould be started (or continued) for a total of 18–24 months
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When resolve rechallenge antiTB one by one.
If symptoms recur or LFT abnormal after rechallengelast drug added should be stopped.
In patients who have experienced jaundice but tolerate the rechallenge of rifampicin and isoniazid, it is advisable to avoid pyrazinamide.
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Drug causes hepatitis
Rifampicin
2SHE 10 HE
INH
6-9 REZ
PZA
2 HRE 7 HR
INH and RIF
18-24 EOS
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A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150.
A. Switch to ethambutol, olfoxacin and streptomycinB. Stop only PZA and continue the rest 3 drugsC. Replace RIF with olfloxacinD. Add domperidoneE. Split INH to 3 times daily after meal
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A 65 year old man, 50 kg, was recently diagnosed with active pulmonary TB. He was started on INH 300 mg/day, RIF 600 mg/day, ethambutol 800 mg/day and PZA 1500 mg/day. After 2 weeks of treatment, he complaint of nausea after taking medication. LFT showed AST 130 ALT 120 Alk phos 100, normal TB and DB.
What is the MOST appropiate management>
A. Continue medications, close follow up LFT and symptomsB. Stop all medications, follow up LFT, restart medications
after LFT normalizeC. Stop only INH but continue others, follow up LFTD. Switch to streptomycin, ethambutol and ofloxacinE. Decrease PZA to 1000 mg/day and follow up LFT
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A 65 year old man, 50 kg, was recently diagnosed with active pulmonary TB. He was started on INH 300 mg/day, RIF 600 mg/day, ethambutol 800 mg/day and PZA 1500 mg/day. After 2 weeks of treatment, he complaint of nausea after taking medication. LFT showed AST 130 ALT 120 Alk phos 100, normal TB and DB.
What is the MOST appropiate management>
Active + symptom + AST/ALT > 3 times
A. Continue medications, close follow up LFT and symptomsB. Stop all medications, follow up LFT, restart medications
after LFT normalizeC. Stop only INH but continue others, follow up LFTD. Switch to streptomycin, ethambutol and ofloxacinE. Decrease PZA to 1000 mg/day and follow up LFT
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ผลขา้งเคียงยาวณัโรค
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Which one is incorrect reguarding the toxicity of antiTBdrugs?
A. PZA and hepatitis
B. Ethambutol and retrobulbar neuritis
C. Rifampicin and peripheral neuropathy
D. Streptomycin and renal toxicity
E. Isoniazid and hepatotoxicity
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Side effect of antiTB drugs
Isoniazid
Systemic or cutaneous hypersensitivity reactions
Sleepiness or lethargy
Peripheral neuropathy, optic neuritis, toxic psychosis and generalized convulsions
hepatitis
lupus-like syndrome, pellagra, anemia, and arthralgias
monoamine (histamine/tyramine) poisoning
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RifampicinOrange discoloration of body fluids pruritis with/without rashSevere Hypersensitivity HepatotoxicityTransient asymptomatic hyperbilirubinemiaHepatitis cholestatic pattern Influenza like syndrome GI upset : Nausea, anorexia, abdominal pain Immunological reaction : thrombocytopenia,
hemolytic anemia ,acute renal failure
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Pyrazinamide
gastrointestinal intolerance
hypersensitivity reactions
rises in serum transaminase concentrations
hepatotoxicity
hyperuricaemia
Arthralgia
Rare adverse events sideroblastic anaemia and photosensitivity dermatitis
Contraindication in porphyria
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Streptomycin
Hypersensitivity reactions are rare.
nephrotoxicity
ototoxicity
vertigo
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EthambutolRetrobulbar neuritis (blurred vision, central scotomata, red-green color
blindness) : dose related
50 mg/kg : 15%
25 mg/kg : 1%- 5%
15 mg/kg : < 1%
Peripheral neuritis : rare
Cutaneous reaction
Monitoring VA, color
1. Dose > 15-25 mg/kg
2. Receive drug > 2 month
3. Renal insuff.
Discontinue drug immediatley and permanent if there any sign of visual toxicity
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Which one is incorrect reguarding the toxicity of antiTBdrugs?
A. PZA and hepatitis
B. Ethambutol and retrobulbar neuritis
C. Rifampicin and peripheral neuropathy
D. Streptomycin and renal toxicity
E. Isoniazid and hepatotoxicity
INH
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Which effect of rifampicin is absolute contraindication for prescribing it in future?
A. Flu like symptoms
B. Hepatitis
C. Maculopapular rash
D. Urine discoloration
E. Immune thrombocytopenia
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Contraindication for remedication
• RFP: thrombocytopenia , hemolytic anemia , acute interstitial nephritis
• Etham : visual impairment
• strep : eight nerve damage
• PZA: jaundice
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Management of cutaneous reaction
Itching without rash
symptomatic Rx with antihistamine and continue anti TB drug
Rash
stop all anti TB
when resolved restart one by one with small challenge dose
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Which effect of rifampicin is absolute contraindication for prescribing it in future?
A. Flu like symptoms
B. Hepatitis
C. Maculopapular rash
D. Urine discoloration
E. Immune thrombocytopenia
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Isoniazid Bactericidal
Rifampicin Bactericidal
Ethambutol Bacterioistatic
Pyrazinamide Weakly bactericidal
streptomycin Bactericidal
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CNS penetration
Renal excretion
Pregnancy
INH Excellent Safe Safe
Rifam 10-20% of serum level
Safe Safe
PZA CNS = serum Should reduce limit data but benefit > risk
Etham Only inflammation
Should reduce Safe
Streptomycin
Slight Used with caution
X
(fetal hearing loss)
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Dose
(mg/kg/day)
Cycloserine
Cs
Bacteristatic 10-15 bid
(500-750)
Ethionamide
Et
Bactericidal 15-20 od/bid
(500-750)
Amikacin /
kanamycin / Capreomycin
Am/Km/Cm
Bactericidal 15 IM/IV
5-7 day/weeks
(750-1,000)
Complete X resistant
between Am/Km but
Sm resistant are susceptible to Am/Km
PAS Bacteristatic 150 bid/tid
(8-12 g)
Ofloxacin
O
Bactericidal 7.5-15
(600-800)
X resistant between O
Cx and levofloxacin
Divalent ion interfere absorption
Ciprofloxacin
Cx
Bactericidal 10-20
(1,000-1,500)
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AFB per ml Number of colonies
on cultureCulture report
Number of AFB on smear
(1000X, Ziehl-Nelsen)
Number of
AFB on smear(200-250X
,Fluorescen)
AFB smear
report
< 10 0 - 0 0 -
10-500 < 50 Actual count
0 0 -
500-1,000 50-100 1+ 0 0 -
1,000-2,000 100-200(almost confluent)
2+ 0 0 -
2,000-5,000 >500 (confluent) 3+ 1-2 / 300 field
1-2 / 30 field
5,000-60,000 >500 (confluent) 4+ 1-9 / 100 field
1-9 / 10 field
1+
60,000-600,000
>500 (confluent) 4+ 1-9 / 10 field
1-9 / field 2+
600,000-6,000,000
>500 (confluent) 4+ 1-9 / field 10-90 / field
3+
6,000,000-60,000,000
>500 (confluent) 4+ > 9 / field > 90 / field 4+
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A patient with AIDS was admitted due to severe dyspnea. CXR showed bilateral upper lobe infiltratonand sputum smear showed AFB4+. He was isolated with air borne precaution. On transport him to radiology department for CT chest, you would advise:
A. Surgical mask formpateint and N 95 mask for trolley pusherB. Surgical mask for patient and trolley pusherC. N 95 mask for patient and surgical mask for trolley pusherD.N 95 mask for patient and trolley pusherE. N 95 mask for patient only
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Airborne precaution
• ห้องแยก
• Sputum pot
• N 95 mask
• Surgical mask• เคลื่อนย้ายผู้ ป่วย
Particle < 5 um
• ปิดประตตูลอดเวลา
• ควรใช้ห้องความดนัอากาศเป็นลบ
• ใช้ HEPA filter ก่อนปลอ่ยอากาศออกจากห้อง
• ภาชนะมีฦาปิดให้เติม 2%lysol หรือ 5% hypochloride
• สวมเม่ือเข้าใกล้ผู้ ป่วย
• ผู้ ป่วยสวม
• สวมsurgical mask ให้ผู้ ป่วย
โรคที่พบChicken pox pulmonary tuberculosisHZV measleSARS
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A patient with AIDS was admitted due to severe dyspnea. CXR showed bilateral upper lobe infiltratonand sputum smear showed AFB4+. He was isolated with air borne precaution. On transport him to radiology department for CT chest, you would advise:
A. Surgical mask formpateint and N 95 mask for trolley pusherB. Surgical mask for patient and trolley pusherC. N 95 mask for patient and surgical mask for trolley pusherD.N 95 mask for patient and trolley pusherE. N 95 mask for patient only
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A 63 year old man, a 30 pack year smoker, present with increasing cough with sputum production, fever and progressive weight loss. He worked in a stone quarry for 20 years.
Which one of following in UNLIKELY to be found in is current evaluation?
A. Infection caused by Mycobacteria tuberculosisB. Malignant mesotheliomaC. Upper lobe lung noduleD. Eggshell calcificationE. Positive ANA in serum
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A 63 year old man, a 30 pack year smoker, present with increasing cough with sputum production, fever and progressive weight loss. He worked in a stone quarry for 20 years.
Which one of following in UNLIKELY to be found in is current evaluation?
Silica dust
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Diseases associated with exposure to silica dust
Slilicosis
chronic silicosis
accelerated silicosis
acute silicosis
progressive massive fibrosis
COPD
emphysema
chronic bronchitis
small airway
Mycobacterial infection
MTB
NTM
Immune related
PSS
RA
CRF
SLE
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Silicosis
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Risk factors for TB
• HIV
• Hematologic malignancy and cancer chemotherapy
• DM
• Uremia
• Undernutrition
• Gastrectomy
• Silicosis ( increased risk 2-30 times)
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Risk factor of mesothelioma
asbestos exposure
ionizing radiation
chronic inflammation of pleura Mediterranianfever
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A 63 year old man, a 30 pack year smoker, present with increasing cough with sputum production, fever and progressive weight loss. He worked in a stone quarry for 20 years.
Which one of following in UNLIKELY to be found in is current evaluation?
A. Infection caused by Mycobacteria tuberculosisB. Malignant mesotheliomaC. Upper lobe lung noduleD. Eggshell calcificationE. Positive ANA in serum
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PAHFc II
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Thai guideline for Dx and Rx PH 2011
Pulmonary hypertension
mean pulmonary arterial pressure >= 25 mmHg
Pulmonary arterial hypertension
mean pulmonary arterial pressure >= 25 mmHg
PCWP < 15 mmHg
PVR > 3 wood
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Pulmonary hypertension Diagnostic classification
JACC June 2009:54(1)suppl S: S43-541.4
1.Pulmonary arterial hypertension
1.1. Idiopathic (IPAH)
1.2. Familial (FPAH)
1.3. Associated with (APAH):
1.3.1. Connective tissue disorder
1.3.2. Congenital systemic-to-pulmonary shunts
1.3.3. Portal hypertension
1.3.4. HIV infection
1.3.5. Drugs and toxins
1.3.6. Other (thyroid disorders, glycogen storage disease,Gaucher’s disease, hereditary hemorrhagic
telangiectasia,
hemoglobinopathies, chronic myeloproliferative disorders, splenectomy)
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1.4. Associated with significant venous or capillary involvement
1.4.1. Pulmonary veno-occlusive disease (PVOD)
1.4.2. Pulmonary capillary hemangiomatosis (PCH)
1.5. Persistent pulmonary hypertension of the newborn
1.Pulmonary arterial hypertension
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2. Pulmonary hypertension with left heart disease
2.1. Left-sided atrial or ventricular heart disease
2.2. Left-sided valvular heart disease
3. Pulmonary hypertension associated with lung diseases and/or hypoxemia3.1. Chronic obstructive pulmonary disease3.2. Interstitial lung disease3.3. Sleep disordered breathing3.4. Alveolar hypoventilation disorders3.5. Chronic exposure to high altitude3.6. Developmental abnormalities
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4. Pulmonary hypertension due to chronic thrombotic and/or embolic disease (CTEPH)4.1. Thromboembolic obstruction of proximal pulmonary arteries4.2. Thromboembolic obstruction of distal pulmonary arteries4.3. Nonthrombotic pulmonary embolism (tumor, parasites,foreign material)
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5. MiscellaneousSarcoidosis, histiocytosis X, lymphangiomatosis, compression of pulmonary vessels (adenopathy,tumor, fibrosing mediastinitis)
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แนวทางการวินิจฉัย PH
ขัน้ตอนที่ 1 (PH diagnosis)
ขัน้ตอนที่ 2 (PH classicication)
Hx and PECXREKGEchoRHC
Blood test :antiHIV Cr LFT CBC ANAO2Sat, ABGCTA or V/QPFTPSGRHC
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แนวทางการรักษา PAH
PAH
Avoid pregnancyInfluenza and pneumococcal
vaccinationExercisePsychosocial support
DiureticO2Oral anticoagulantDigoxin
Acute vasoreactivity test
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Acute vasoreactivity test
vasoreactive
Fc I-IIICCB
Good response
yes no
Continue CCB
Poor response
Non vasoreactive/ not perform
PAH specific drug
F/U 3-6 month
Poor response
Combination Tx
Atrial septostomyLung transplant
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ค าแนะน า Fc II Fc III Fc IV
1++ Sildenafil, bosentan Sidenafil, bosentan, iloprost inhaled
2++ Iloprost IV/inhaleCmbination Rx
3+ beraprost Bosentan, sidenafil
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OSA; criteria for Dx
Symptom
PSG AHI >=5/hr + R/O other disease
No symptom
PSG AHI >= 15/hr + R/O other disease
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Risk factor of OSA
1 neck size > 17 inches in male and > 16 inches in female
2 nasal feature eg polyp3 lingual feature eg
macroglossia4 palatal feature eg low lying
soft palate5 enlarge tonsil and adenoid6 oropharynx narrowing7 hereditar syndrome eg
Down syndrome
8 smoking9 obesity10 hypothyroid, acromegaly11 neuro eg stroke, Dchene12 alcohol13 medication BZs14 familial Hx of OSA15 ESRD16 CHF17 HT
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Symptoms
1 excessive daytime sleepiness
2 morning headache
3 nocturia
4 nocturnal chocking
5 witnessed apnea
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Consequences
1 HT2 CAD esp nocturnal ischemia3 arrhymia esp sinus arrhymia, bradycardia, sinus pause,
sinus arrest, VT PVC, AV block4 CHF in Pt with LVEF < 45%, AHI > 15 increase mortality5 PH6 Insulin resistance7 Erectile dysfunction8 depression9 GERD10 stroke11 floppy eyelid syndrome, gluacoma,papilledema
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Rx
1 CPAP
2 uvulopalatopharyngeaopasty
3 oral appliance in mild to moderate pt
4 oromaxillofacial Sx
5 tracheostomy GOLD STANDARD
6 positional Rx
7 weight reduction
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A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?
A. uvuloplastyB. methylphenidateC. weight reductionD. sleep hygiene and reassure E. continuous positive airway pressure
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A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?
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Classic tetrad
Excessive daytime sleepiness (EDS)
Cataplexy : an loss of skeletal muscle tone (triggered by the occurrence of sudden emotion)Sleep paralysis : a brief loss of voluntarymuscle control with an inability to move or speakHypnagogic Hallucinations : visual or auditory and occasionally involve other senses e.g., tactile or vestibular
NARCOLEPSY
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NARCOLEPSY
Nonpharmacologic Management
Pharmacologic Management
Behavioral approaches
Scheduled naps (15-20 min, 2-3 times/day)
Regular sleep wake schedule
Avoidance of frequent time zone changes
Good sleep hygiene
modafinil and armodafinil
sodium oxybate, amphetamines, methylphenidate
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63. A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?
A. uvuloplasty
C. weight reductionD. sleep hygiene and reassure E. continuous positive airway pressure
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A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?
A. Left upper lobe lobectomy
B. Follow up CXR within 2 months
C. Review her last year CXR, if available
D. Empirical treatment with anti-TB drugs: HRZE
E. Percutaneous transthoracic needle aspiration
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A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilaror mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?
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Solitary pulmonary nodule
• Focal, round or oval areas of increased opacity
• Defined as <3 cm
• Not associated with atelectasis or adenopathy
• 90% incidental findings
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Solitary pulmonary nodule
• Most SPN: benign
• 30-40% of SPN are malignant
• Patients with best prognosis are stage IA:
61-75% 5-year survival
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Differential diagnosis
Neoplasm Benign Hamartoma
Inflammory pseudotumor
Malignant Bronchogenic carcinoma
Carcinoid tumor
Lymphoma (NHL)
Metastasis
Infection Granuloma Mycobacteria
Fungi
Septic emboli
Abscess Bacteria (anaerobes, Staph, gram negative)
Round pneumonia
Pneumococci
Parasitic Echinococcus
Dirofilaria (dog heartworm)
(Leef III JL, Klein JS. The solitary pulmonary nodule. Radiol Clin N Am 2002;40:123-143
Solitary pulmonary nodule
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Differential diagnosisInflammatory CNT Wegener’s
granulomatosis
Rheumatoid nodule
Sarcoidosis
Vascular AVM
Hematoma
Pulmonary infarct
Pulmonary artery aneurysm
Pulmonary venous varices
Airway Congenital lesion Bronchogenic cyst
Bronchial atresia
Mucocele
Infected bulla
Leef III JL, Klein JS. The solitary pulmonary nodule. Radiol Clin N Am 2002;40:123-143
Solitary pulmonary nodule
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Solitary pulmonary nodule
• 95% fall into one two groups
- Malignant: either primary or metastatic
- Benign
Infectious ;granulomas (either TB or
fungal)
Benign tumors: hamartomas present in
middle age, grow slowly over years
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Solitary pulmonary nodule
• First step: ensure that the nodule is in fact
solitary and truly arises in the lung parenchyma.
• Up to 20% prove to be entities mimicking a SPN
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Pseudonodule (a) Close-up PA radiograph of the right lung shows a smoothly marginated nodular area of increased opacity projecting over the lung (arrow).
(b) Front and back views of the EKG lead attachment pad
Erasmus JJ. Radiographics 2000;20:43-58
Solitary pulmonary nodule
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Bone island in a 61-year-old man with melanoma. (a) Close-up PA CXR shows a focal area of increased opacity overlying the right seventh rib posteriorly (arrow). (b)Fluoroscopic images show a well-marginated intraosseous lesion (arrow). This finding is consistent with a bone island and obviated further investigation.
Erasmus JJ. Radiographics 2000;20:43-58
Solitary pulmonary nodule
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Diagnostic evaluation
Second step
Aim to distinguish benign VS malignant
• Clinical features
• Radiographic features
• Quantitative models : used to determine the probability that the nodule is malignant
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Clinical features
• Age - Risk of malignancy increases with age
– 3% at age 35-39 years
– 15% at age 40-49 years
– 43% at age 50-59 years
– greater than 50% in patients > 60 years
• Smoking history
• History of prior malignancy
Solitary pulmonary nodule
Manocha S, Sharma S. Solitary pulmonary nodule. http://www.emedicine.com/radio/topic782.ht
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Clinical Features
• Travel history - Travel to areas with endemic
mycosis or a high prevalence of tuberculosis
• Occupational risk factors - Exposure to asbestos,
radon, nickel, chromium, vinyl chloride, and
polycyclic hydrocarbons
Solitary pulmonary nodule
Manocha S, Sharma S. Solitary pulmonary nodule. http://www.emedicine.com/radio/topic782.ht
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Radiographic features
• Size
• Border
• Calcification
• Density
• Growth
• Metabolic activity
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Size
• Generally, smaller nodule, more likely to be
benign
• 80% of benign nodules are less than 2 cm in
diameter
• Small size alone not exclude lung cancer
- 15% of malignant are less than 1 cm
- 42% are less than 2 cm
Solitary pulmonary nodule
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Margins and Contours
• Smooth, most are benign, not at all: 21% of
malignant have well-defined margins
• Lobulated implies uneven growth, up to 25% of
benign nodules
• Irregular: more malignant
• Spiculated (sunburst or corona radiata
appearance): 84-90% are malignant
Solitary pulmonary nodule
Low
Hign
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benign malignant
smooth lobulated Irregular and spiculated
Margin and Contour
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Internal Characteristics
• Overlap of benign and malignant
• Homogeneous attenuation: benign (55%) and
malignant (20%)
• Air bronchograms and Pseudocavitation:
bronchioloalveolar cell carcinoma or lymphoma
Solitary pulmonary nodule
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Solitary pulmonary nodule
Bronchioloalveolarcell carcinoma: pseudocavitation
Erasmus JJ. Radiographics 2000;20:43-58
Air bronchogram:lymphoma
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Benign
Diffuse Central Popcorn Laminar
Indeterminant ;likely malignant
Stipple Eccentric
Calcification
most often seen in hamartomas
typical of a granuloma
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Solitary pulmonary nodule
Time
• Volume Doubling time: most malignant = 30-400
days
• SPN that stable over 2-year indicator of benignity
*Yankelevitz, Am J Roentgenol 1997;168:325-8
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Satellite nodule
• Tiny nodules associate with dominant pulmonary nodule
• High likelihood to be benign
• PPV for benignity: approximately 90%
Solitary pulmonary nodule
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Feature or Characteristic LR
Spiculated margin
Size > 3 cm
Age > 70 yr
Malignant growth rate
Smoker
Upper lobe location
Size < 1 cm
Smooth margins
30-39 yr
Never smoked
20-29 yr
Benign calc
Benign growth rate
5.54
5.23
4.16
3.40
2.27
1.22
0.52
0.30
0.24
0.19
0.05
0.01
0.01
LRs for Selected Radiologic Features of Nodules and Patient Characteristics
(Erasmus JJ. Radiographics 2000;20:59-66)
Solitary pulmonary nodule
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A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?
B. Follow up CXR within 2 months
C. Review her last year CXR, if available
D. Empirical treatment with anti-TB drugs: HRZE
E. Percutaneous transthoracic needle aspiration
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Feature or Characteristic LR
Spiculated margin
Size > 3 cm
Age > 70 yr
Malignant growth rate
Smoker
Upper lobe location
Size < 1 cm
Smooth margins
30-39 yr
Never smoked
20-29 yr
Benign calc
Benign growth rate
5.54
5.23
4.16
3.40
2.27
1.22
0.52
0.30
0.24
0.19
0.05
0.01
0.01
LRs for Selected Radiologic Features of Nodules and Patient Characteristics
(Erasmus JJ. Radiographics 2000;20:59-66)
Solitary pulmonary nodule
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A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked 30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit.
Which of the following is the MOST appropiatemanagement?
A. Symptomatic and supportive treatmentB. Repeat CXR in next 3 monthsC. Inform his family and discuss the most likely
diagnosis and prognosisD.Obtain CT chest include upper abdomenE. Request for diagnosis bronchoscopy
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A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit.
Which of the following is the MOST appropiatemanagement?
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Feature or Characteristic LR
Spiculated margin
Size > 3 cm
Age > 70 yr
Malignant growth rate
Smoker
Upper lobe location
Size < 1 cm
Smooth margins
30-39 yr
Never smoked
20-29 yr
Benign calc
Benign growth rate
5.54
5.23
4.16
3.40
2.27
1.22
0.52
0.30
0.24
0.19
0.05
0.01
0.01
LRs for Selected Radiologic Features of Nodules and Patient Characteristics
(Erasmus JJ. Radiographics 2000;20:59-66)
Solitary pulmonary nodule
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A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked 30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit.
Which of the following is the MOST appropiatemanagement?
A. Symptomatic and supportive treatmentB. Repeat CXR in next 3 monthsC. Inform his family and discuss the most likely
diagnosis and prognosisD.Obtain CT chest include upper abdomenE. Request for diagnosis bronchoscopy
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A 55-year-old man with previous history of stroke came to your clinic for smoking cessation program. He smokes15 cigarettes/day. He begins his first cigarette of the day after breakfast, and the remaining after lunch and dinner.What is the most appropriate method for smoking cessation in this patient?
A. cold turkey
B. cold turkey + behavioral therapy
C. cold turkey + behavioral therapy + bupropion
D. cold turkey + behavioral therapy + varenicline
E. cold turkey + behavioral therapy + nicotine
replacement therapy
![Page 131: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/131.jpg)
Smoking Cessation
NONPHARMACOLOGIC INTERVENTION 5A (ASK,
ADVISE, ASSESS, ASSIST, ARRANGE) : COLD TURKEY +
BEHAVIORAL THERAPY
First line Medication
Nicotine Replacement Therapy : Gum, Patch
Bupropion SR
Varenicline
Combination therapy
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A 55-year-old man with previous history of stroke came to your clinic for smoking cessation program. He smokes15 cigarettes/day. He begins his first cigarette of the day after breakfast, and the remaining after lunch and dinner.What is the most appropriate method for smoking cessation in this patient?
A. cold turkey
B. cold turkey + behavioral therapy
C. cold turkey + behavioral therapy + bupropion
E. cold turkey + behavioral therapy + nicotine
replacement therapy
![Page 137: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/137.jpg)
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< 80%
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250/31080%
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76. Which of the following is not likely to be the potential underlying cause of bronchiectasis?
A. Kartagener's syndrome B. Churg Strauss syndrome C. PanhypogammaglobulinemiaD. Endobronchial carcinoid tumor E. Allergic bronchopulmonary aspergillosi
![Page 146: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/146.jpg)
สาเหตขุอง bronchiectasis
1. Airway obstruction เชน่ endobronchial tumor, foreign body2. Defective host defenses เชน่ hypogammaglobulinemia3. Cystic fibrosis 4. Young's syndrome combination of obstructive azoospermia (with normal spermatogenesis) and chronic sinopulmonary infections (bronchiectasis and sinusitis)5. Rheumatic and other systemic diseases เชน่ rheumatoid arthritis และ Sjögren's syndrome6. Dyskinetic cilia เชน่ Kartagener's syndrome 7. Alpha-1 antitrypsin deficiency 8. Pulmonary infections เชน่ TB9. Allergic bronchopulmonary aspergillosis
![Page 147: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/147.jpg)
76. Which of the following is not likely to be the potential underlying cause of bronchiectasis?
A. Kartagener's syndrome
C. PanhypogammaglobulinemiaD. Endobronchial carcinoid tumor E. Allergic bronchopulmonary aspergillosis
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53. A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is related to this patient?
A. Bihilar lymphadenopathy
B. Normal chest radiography
C. Water balloon–shaped heart
D. Bilateral upper lobe infiltrates
E. Situs inversus and diffuse reticular infiltration
![Page 149: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/149.jpg)
A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is relate to this patients?
![Page 150: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/150.jpg)
Manes Kartagener first recognized this clinical triad
is inherited via an autosomal recessive pattern
Symptoms result from defective cilia motility
Kartagener’s syndrome
bronchiectasis situs inversuschronic sinusitis
Immotile spermatozoa or infertility
Confirmation with biopsy of respiratory mucosa or microscopic examination of sperms
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A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is related to this patient?
A. Bihilar lymphadenopathy
B. Normal chest radiography
C. Water balloon–shaped heart
D. Bilateral upper lobe infiltrates
![Page 153: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/153.jpg)
A flow volume loop of spirometry shows plateau of the inspiratory loop only. What is the most likely cause of this pattern?
A. Small airways narrowing
B. Fixed intra-thoracic obstruction
C. Fixed extra-thoracic obstruction
D. Variable intra-thoracic obstruction
E. Variable extra-thoracic obstruction
![Page 154: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/154.jpg)
Spirometry in Upper Airway Obstruction
Extrathoracic airway Intrathoracic airway
Nose, mouth, pharynx, larynx and the 2 to 4 cm. of the trachea cephaled to the thoracic inlet
Trachea to the main carina
![Page 155: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/155.jpg)
Variable Extrathoracic Obstruction
0
-
- -
0 0
+ +
+
0
0 0
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Variable Intrathoracic Obstruction
- --
0
0 0
+ ++
0
00
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Fixed Obstruction
![Page 158: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/158.jpg)
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A flow volume loop of spirometry shows plateau of the inspiratory loop only. What is the most likely cause of this pattern?
A. Small airways narrowing
B. Fixed intra-thoracic obstruction
C. Fixed extra-thoracic obstruction
D. Variable intra-thoracic obstruction
![Page 160: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/160.jpg)
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Interpretation of spirometry
• Adequate or inadequate test
• Obstructive, restrictive or combine pattern
• If obstructive disease,response to bronchodilator
• Severity
• Flow-Volume loop
![Page 162: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/162.jpg)
Adequate or inadequate
• No artifacts : cough or glottic closure, leak, early termination, obstructed mouthpiece
• Sharp peak flow (time to PEF < 120msec.)
• Expiratory duration greater than 6 seconds or plateau in volume time curve
• Age, sex, height
• 2/3 highest FEV1 , FVCvariation < 0.2L (reproducibility)
![Page 163: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/163.jpg)
Normal Spirometry
![Page 164: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/164.jpg)
Reproducible
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Early Terminate
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COUGH
![Page 167: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/167.jpg)
Poor Effort
![Page 168: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/168.jpg)
Poor Effort
![Page 170: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/170.jpg)
What is pattern of spirometry?
• FEV1/FVC ปกตหิรือผิดปกติ (75%)
• ถ้าผิดปกตเิข้าได้กบั airflow limitation ให้ดตูอ่ว่า
– FVC - FEV1 15 pure obstructive pattern
– FVC - FEV1 < 15 อาจมี restrictive ร่วมด้วย
![Page 171: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/171.jpg)
What is pattern of spirometry?
• ถ้า FEV1/FVC ปกตใิห้ด ูFEV1, FVC วา่ปกติหรือต ่า (ปกติ >
80%)– ถ้าต ่าและ
• FEV1>FVC เข้าได้กบั restrictive pulmonary disease
• FEV1<FVC เข้าได้กบั mixed obstructive with restrictive
pulmonary disease
– ถ้าปกติ ให้ด ูFEF25-75 วา่มากหรือน้อยกวา่ 65%
• ถ้ามากกวา่ 65% ถือวา่ normal PFT
• ถ้าน้อยกวา่ 65% แปลผลเป็น small airway disease
![Page 172: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/172.jpg)
Response to bronchodilator
• เทียบ pre-post bronchodilator 15 min.
• FEV1,FVC improved 12%(15%) and 200cc.
• FEF25-75 improved 35%
![Page 173: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/173.jpg)
FEV1/FVC
obstructive FEV1,FVC
restrictive
FEF 25-75
normal Small airway disease
<75% 75%
abnormal normal
65% <65%
FVC-FEV1
Pure obstructive
Possible mixed restrictive
<15%>15%FVC<FEV1 FVC>FEV1
Mixed obstructive with restrictive
![Page 174: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/174.jpg)
Severity
• Obstructive
Mild Moderate Severe
60-79% 41-59% 40%
• Restrictive
Mild Moderate Severe
60-79% 51-59% 50%
![Page 175: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/175.jpg)
Flow-Volume Loop
![Page 176: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/176.jpg)
Emphysema
![Page 177: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/177.jpg)
Extra thoracic Obstruction
![Page 178: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/178.jpg)
Intra thoracic Obstruction
![Page 179: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/179.jpg)
Fixed Obstruction
![Page 180: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/180.jpg)
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An asthmatic patient’s spirometry reveal FEV1 of 1000 mlFVC 2000 ml FEV1/FVC 50%. After salbutamol inhalation, which spirometric results show the best bronchodialtorresponse?
A. FEV1 1100 ml FVC 2000 ml FEV1/FVC 55%B. FEV1 1100 ml FVC 1500 ml FEV1/FVC 73%C. FEV1 1200 ml FVC 2200 ml FEV1/FVC 54%D. FEV1 1000 ml FVC 1200 ml FEV1/FVC 83%E. FEV1 900 ml FVC 2100 ml FEV1/FVC 55%
![Page 184: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/184.jpg)
Response to bronchodilator
• เทียบ pre-post bronchodilator 15 min.
• FEV1,FVC improved 12%(15%) and 200cc.
• FEF25-75 improved 35%
![Page 185: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/185.jpg)
An asthmatic patient’s spirometry reveal FEV1 of 1000 mlFVC 2000 ml FEV1/FVC 50%. After salbutamol inhalation, which spirometric results show the best bronchodialtorresponse?
A. FEV1 1100 ml FVC 2000 ml FEV1/FVC 55%B. FEV1 1100 ml FVC 1500 ml FEV1/FVC 73%C. FEV1 1200 ml FVC 2200 ml FEV1/FVC 54%D. FEV1 1000 ml FVC 1200 ml FEV1/FVC 83%E. FEV1 900 ml FVC 2100 ml FEV1/FVC 55%
![Page 186: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/186.jpg)
![Page 187: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/187.jpg)
DDx orthopneaCHFV/Q mismatch in posteria part of lungdiaphragmatic paralysis
![Page 188: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/188.jpg)
Unilateral diaphragmatic paralysis
Phrenic nerve injury
Herpes zoster, poliomyelitis, and other viral infections
Cervical spondylosis
Clinical manifestations
usually asymptomatic at rest
may have exertional dyspnea and decreased exercise performance
Imaging
CXR upright elevated hemidiaphragm
PFT
FVC decrease 15-20% in supine position
![Page 189: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/189.jpg)
Bilateral diaphragmatic paralytic
Etiology
• Spinal cord disease
• Motor neuron disease
• Neuropathy
• Neuromuscular junction disease
• Muscle disease
![Page 190: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/190.jpg)
Symptom
orthopnea
PE
abdominal wall paradox
hypoxemia
CXR
bilateral, smooth elevation of the hemidiaphragms and small lung volumes
PFT
FVC may decrease 15 to 25 percent in the supine position
![Page 191: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/191.jpg)
![Page 192: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/192.jpg)
Pulmonary embolism
Symptomsdyspneapleuritic chest painsubsternal chest paincoughhemoptysissyncope
Signstachycardiatachypneasign of DVTfevercyanosis
![Page 193: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/193.jpg)
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On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homan’s sign is negative. What is
the most likely diagnosis?
1. Pneumonia
2. Atelectasis
3. Popliteal thrombosis with PE
4. Iliofemoral thrombosis with PE
5. Pulmonary edema
![Page 200: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/200.jpg)
On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homan’s sign is negative. What is the most
likely diagnosis?
1. Pneumonia
2. Atelectasis
3. Pulmonary edema
![Page 201: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/201.jpg)
The risk for thrombosis is increased in pregnancy, partly because of the increase in the coagulation factors, particularly V, VIII, X, and von Willebrand factor Ag, and partly because of a marked fall in protein S Venous stasis, an important contributor to thrombosis, is caused by uterine compression of the inferior vena cava and the left iliac vein Local trauma to pelvic veins at the time of delivery probably accounts for the peak incidence of thromboembolism in the postpartum period, especially after cesarean section.
Pulmonary Embolism
![Page 202: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/202.jpg)
On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homan’s sign is negative. What is
the most likely diagnosis?
1. Pneumonia
2. Atelectasis
3. Popliteal thrombosis with PE
4. Iliofemoral thrombosis with PE
5. Pulmonary edema
![Page 203: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/203.jpg)
A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed expiratory rhochi diffusely.
The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400 cc O2 sat 99%. The patient was given NB
salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze,
the PIP was 50 cmH2O and Ppla 26 cmH2OWhich one of these condition would be the cause of the ventilator alaem?
1.Fluid overload2.Pneumothorax3.HAP4.Lt.lung atelectasis5.Bited on the ET tube
![Page 204: MCQ R2](https://reader034.vdocument.in/reader034/viewer/2022052212/544e830eaf7959e51e8b4961/html5/thumbnails/204.jpg)
A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed
expiratory rhochi diffusely. The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400
cc O2 sat 99%. The patient was given NB salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the
past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze,
the PIP was 50 cmH2O and Ppla 26 cmH2OWhich one of these condition would be the cause of the ventilator alaem?
↑ PIP
Peak inspiratory pressure = P resistance + P elastance
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LUNG MECHANIC
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LUNG MECHANICS
Paw = AIRWAY PRESSURE
Raw = RESISTANCE
Crs = COMPLIANCE
Paw = PRaw + PCrs (Pplat)
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LUNG MECHANIC
PAW = PR + PE
= Pmusi
P AW =Peak airway pressure
PR = แรงตา้นจากท่อทางเดินหายใจ
PE =แรงตา้นจากการขยายตวัของ ถุงลมและผนงัทรวงอก
Pmusi = แรงของกลา้มเน้ือในการหายใจ
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LUNG MECHANIC
Paw = PRaw + Pclung
Raw = Pressure (cmH2O)Flow (L/Sec)
= Pdyn - Pstat
Flow
Compliance = Volume (ml)Pressure (cmH2O)
= Volume (ml)Pstat - PEEP
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Pressure Resistance
PIP 38 cmH2O Ppla 25 cmH2O
PIP was 50 cmH2O and Ppla 26 cmH2O
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A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed expiratory rhochi diffusely.
The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400 cc O2 sat 99%. The patient was given NB
salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze,
the PIP was 50 cmH2O and Ppla 26 cmH2OWhich one of these condition would be the cause of the ventilator alaem?
1.Fluid overload2.Pneumothorax3.HAP4.Lt.lung atelectasis5.Bited on the ET tube
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A 70 year-old man with COPD, presented with dyspneaon exertion. Physical examination revealed engorged neck vein, right ventricular heaving and pansystolic murmur grade II at left lower sternal border. His current medications were Ipratropium bromide inhaler and slow release theophylline. ABG: PaO2 53mmHg, PaCO2 45mmHg, pH7.38, O2Sat 87%. What is the most appropriate treatment?
A.PrednisoloneB.Steroid inhaler C. Inhale iloprostD.Long term oxygen therapy E. Noninvasive positive pressure ventilation
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Oxygen therapy• Long term administration of oxygen (>15h/day) to
patients with chronic respiratory failure has been shown to increase survival (evidence B)
Indication for long term oxygen therapy (LTOT)
1. PaO2 < 55 mmHg or SaO2 at or below 88% with or without
hypercapnea confirmed twice over a three week period
2. PaO2 < 55mmHg or SaO2 at or below 88% if there is evidence of
pulmonary hypertension, peripheral edema suggesting congestive
cardiac failure or polycytemia( Hct>55%)
COPD and Pulmonary Hypertension
GOLD Guideline 2011
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GOLD Guideline 2011
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GOLD Guideline 2011
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ICS + LABA
or LAMA
ICS + LABA
and
LAMA
SABA or
SAMA
LABA
or LAMA
GOLD Guideline 2011
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19. A 70 year-old man with COPD, presented with dyspnea on exertion. Physical examination revealed engorged neck vein, right ventricular heaving and pansystolic murmur grade II at left lower sternal border. His current medications were Ipratropium bromide inhaler and slow release theophylline. ABG: PaO2 53mmHg, PaCO2 45 mmHg, pH7.38, O2Sat 87%. What is the most appropriate treatment?
A.PrednisoloneB.Steroid inhaler C. Inhale iloprost
E. Noninvasive positive pressure ventilation
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NIVImprove respiratory acidosisDecrease RRDecrease breathlessnessDecrease VAPDecrease LOSDecrease ETTDecrease mortality
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2
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Clue
• AE asthma
• silent chest drowsiness air hunger on BD + steroid
• On MV : VCV vt 600 ml RR 20 PF 60 FiO2 0.6
• Paw 50 Ppl 25
• ABG: pH 7.45 PCO2 30 PO2 200
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• How to set MV in asthma
– Low tidal volume
– High PF to short Ti
– Low RR
– Short Ti prolong Te
– PEEP 3-5 cmH2O : not need to adjust 80% autoPEEP
– FiO2 : lowest to keep PaO2 > 60 mmHg, SaO2 > 90%
– Set alarm
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Answer
• On MV : VCV vt 600 ml RR 20 PF 60 FiO2 0.6 – Accept due to Ppl not above limit
– but accept if decrease Vt, RR, FiO2 but should avoid pH < 7.2 and PaO2 < 60
• Paw 50 Ppl 25 :– Ppl accept : set high Vt alarm to avoid volume
trauma
• ABG: pH 7.45 PCO2 30 PO2 200 – Accept but and decrease FiO2
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• Mx except
1. Decrease VT
2. Decrease RR
3. PF ?
4. Decrease FiO2
5. Increase PEEP : not necessary
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