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Diagnostic Criteria
Proliferative
Progressive lung injury
Early pulmonary fibrosis
Lasts from day 7 – 21 days of illness
Shift to a lymphocyte-predominant pulmonary
infiltrate
Proliferation of Type II pneumocyte along alveolar
basement membranes
Alveolar type III procollagen peptide – marker of
pulmonary fibrosis with a protracted clinical
course and increased mortality
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
Fibrotic
Initiation of ductal and interstitial fibrosis leading
to emphysema-like changes
Intimal proliferation pulmonary hypertension
Increased mortality
Clinical Characteristics
tachypnea - earliest sign dyspnea
low pO 2, low PCO2
fine rales
CXR clear or few scattered infiltrates
cyanosis, dyspneic
prominent rales
extensive infiltrates
intractable hypoxemia
Treatment
General Principles
Treat underlying medical and surgical disorder
Minimize procedures and their complications
Deep venous thrombosis prophylaxis, stress gastritis, CVP
catheter infections
Treat nosocomial infection
Provide adequate nutrition
Low VT in ARDS
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
DIC
Functional recovery within 6 months from ARDS
ECMO in ARDS
Table 258-1
Major
Etiologies of
Bronchiectasis
and Proposed
Workup
Genetic causes (e.g., cystic Measurement of Table 258-2 Microbial Path ogen s Causing Cavitary Lung
fibrosis, Kartagener's chloride levels in Infection
syndrome, 1 antitrypsin sweat (for cystic
deficiency) fibrosis), 1 antitrypsin
levels; nasal or
respiratory tract
brush/biopsy (for Aspiration-Prone Host
dyskinetic/immotile
cilia syndrome);
genetic testing Anaerobic bacteria plus microaerophilic and/or anaerobic
streptococci, Gemella spp.
Autoimmune or Clinical examination
rheumatologic causes (e.g., with careful joint Embolic (endovascular) lesions: usually Staphylococcus aureus,
rheumatoid arthritis, exam, serologic testing Pseudomonas aeruginosa, Fusobacterium necrophorum a
Sjögren's syndrome, (e.g., for rheumatoid
inflammatory bowel factor). Consider
disease); immune-mediated workup for allergic
disease (e.g., allergic bronchopulmonary Endemic fungi: Histoplasma, Blastomyces, Coccidioides spp.
bronchopulmonary aspergillosis,
aspergillosis) especially in patients
with refractory Mycobacteria: M. tuberculosis, M. kansasii, M. avium
asthma a
The sympathomimetic amines dopamine reserved for refractory patients and is not recommended in
and dobutamine the setting of ischemia or MI.
Digitalis Glycosides - inotropes Physical Methods
Intraaortic Counterpulsation Reduction of venous return reduces preload. Patients without
Other causes hypotension should be maintained in the sitting position with
Iatrogenic cardiogenic shock the legs dangling along the side of the bed.
Acute STEMI complicated by pulmonary edema is Inotropic and Inodilator Drugs
associated with in-hospital mortality rates of 20– The sympathomimetic amines dopamine and dobutamine
40%. (see above) are potent inotropic agents. The bipyridine
Reexpansion pulmonary edema phosphodiesterase-3 inhibitors (inodilators), such as
High-altitude pulmonary edema milrinone (50 g/kg followed by 0.25–0.75 g/kg per min),
dexamethasone, calcium channel- stimulate myocardial contractility while promoting
blocking drugs, or long-acting inhaled 2- peripheral and pulmonary vasodilation. Such agents are
adrenergic agonists. indicated in patients with cardiogenic pulmonary edema and
descent from altitude, bed rest, oxygen, severe LV dysfunction.
and, if feasible, inhaled nitric oxide
For pulmonary edema resulting from upper airway
of hypoalbuminemia, hyponatremia, or hypochloremia.
Furosem ide is also a venodilator that reduces preload rapidly,
before any diuresis, and is the diuretic of choice. The initial
dose of furosemide should be 0.5 mg/kg, but a higher dose (1
mg/kg) is required in patients with renal insufficiency,
chronic diuretic use, or hypervolemia or after failure of a
lower dose.
Nitrates
Nitroglycerin and isosorbide dinitrate act predominantly as
venodilators but have coronary vasodilating properties as
well. They are rapid in onset and effective when
administered by a variety of routes. Sublingual nitroglycerin
(0.4 mg x 3 every 5 min) is first-line therapy for acute
cardiogenic pulmonary edema. If pulmonary edema persists
in the absence of hypotension, sublingual may be followed Causes of Respiratory Failure
by IV nitroglycerin, commencing at 5–10 g/min. IV
nitroprusside (0.1–5 g/kg per min) is a potent venous and
arterial vasodilator. It is useful for patients with pulmonary
edema and hypertension but is not recommended in states of
reduced coronary artery perfusion. It requires close
monitoring and titration using an arterial catheter for
continuous BP measurement.
Morphine
Given in 2- to 4-mg IV boluses, morphine is a transient
venodilator that reduces preload while relieving dyspnea and
anxiety. These effects can diminish stress, catecholamine
levels, tachycardia, and ventricular afterload in patients with
pulmonary edema and systemic hypertension.
Angiotensin-Converting Enzyme (ACE) Inhibitors
ACE inhibitors reduce both afterload and preload and are
recommended for hypertensive patients. A low dose of a
short-acting agent may be initiated and followed by
Chron ic Ventilatory Disorder
increasing oral doses. In acute MI with heart failure, ACE
inhibitors reduce short- and long-term mortality rates.
reflected in abnormal PaCO 2
Other Preload-Reducing Agents
PaCO2 = (k)(V.CO2)/V. A,
IV recombinant brain natriuretic peptide (nesiritide) is a
where V. CO2 carbon dioxide production
potent vasodilator with diuretic properties and is effective in
k is a constant
the treatment of cardiogenic pulmonary edema. It should be
V. A is fresh gas alveolar ventilation
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
Treatment:
few well-controlled treatment studies.
reassurance and frank discussion
Identifying and eliminating habits that perpetuate hypocapnia
(yawning or sigh breathing)
breathing exercises and diaphragmatic retraining may be
Treatment: beneficial for some patients.
weight reduction Beta-blockers (sym pathetically mediated symptoms)
continuous positive airway pressure (C PAP) therapy during
sleep Once neural input has been delivered to the respiratory pump muscles,
normal gas exchange requires an adequate amount of respiratory
muscle strength to overcome the elastic and resistive loads of the
respiratory system (F ig. 264-1A, Chap. 252). In health, the strength of
the respiratory muscles readily accomplishes this, and normal
respiration continues indefinitely.
Hypoventilation
Central Hypoventilation Syndrome
shortness of breath and diminished exercise tolerance.
Ondine's curse or congenital central hypoventilation
Episodes of increased dyspnea and sputum production are
syndrom e (C CHS).
hallmarks of obstructive lung diseases, such as chronic
Abnormalities in the gene encoding PHOX2b, a transcription
obstructive pulmonary disease (C OPD)
factor with a role in neuronal development
whereas progressive dyspnea and cough are common in
have absent respiratory response to hypoxia or hypercapnia,
interstitial lung diseases. Excessive daytime somnolence,
mildly elevated PaCO2 while awake, and markedly elevated
poor quality sleep, and snoring are common among patients
PaCO2 during non-REM sleep.
with sleep-disordered breathing. Sleep disturbance and
Compensate V E to "normalize" PaCO2 during exercise.
orthopnea are also described in neuromuscular disorders.
Treatment
NIP PV
mechanical ventilation
phrenic nerve or diaphragmatic pacing at centers
with experience performing these procedures.
Hyperventilation
ventilation in excess of metabolic requirements (CO2
production) leading to a reduction in PaCO2
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
Mallampati Grading
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
BRONCHIECTASIS
Pathogenesis
Clubbing
Reid ’s Classification
Bronchograp hy
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
Table 258-1
Major
Etiologies of
Bronchiectasis
and Proposed
Workup
a
Lemierre's disease.
b
Often in a young patien t with influenza.
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION KRENOVIANTZ ’17
MEDICINE III- PULMONOLOGY JEVAI M.D.
Treatment
Eliminate identifiable problem
Bronchial hygiene - chest PT
Control infection -antibiotics
reverse airflow obstruction - bronchodilators
Bronchial artery embolization, resection, transplant
Comp lications:
Recurrent infection
hemoptysis
Prognosis:
- repeated infection leands to decline in FEV 1 50 – 55
ml/year