เฉลยข้อสอบ mcq r2ครั้งที่2

Residence Survivalin Chest

7-05-09

Obstructive Lung DiseasesObstructive Lung Diseases

Including Occupational AsthmaIncluding Occupational Asthma

36. Asthma: spirometryFEV1 1000 ml, FVC 2000 ml, FEV1/FVC 50%

After BD; best BD response?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 43%

Reversibility test: Method

The following steps are undertaken:

1.The subject has 3 acceptable tests of FEV1, FVC and PEF (pre-bronchodilator test)

2.The drug is administered

3.Three additional acceptable tests are recorded 10-15 min later for short-acting ß2-agonists, and 30 min later for short-acting anticholinergic agents (post-bronchodilator test)

ATS/ERS 2005

Reversibility test: Method

Drug:• Albuterol/salbutamol

– 100 µg is inhaled in one breath to TLC via spacer device

– 4 separate doses (total dose 400 µg) are delivered at ~30-s intervals

• Other:– Terbutaline (4x250=1000 µg)– Ipratropium bromide (4x40=160 µg)

ATS/ERS 2005

Expressing Bronchodilator Response

Absolute change = FEV1post - FEV1pre ≥200 ml

Percent change = FEV1post - FEV1pre x 100

FEV1pre

≥12%

FEV1 or FVC

ATS/ERS 2005

• Most asthma patients will not exhibit reversibility at each assessment, particularly those on treatment, and the test therefore lacks sensitivity

• Repeated testing at different visits is advised

36. Asthma: spirometryFEV1 1000 ml, FVC 2000 ml, FEV1/FVC 50%

After BD; best BD response?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 43%

Absolute change = FEV1post - FEV1pre ≥200 ml

1. Which of the following sign(s) indicate(s) acute severe asthmatic attack?

A. TachypneaB. Pulsus paradoxusC. Silent chest with severe dyspneaD. B+CE. A,B and C

Severity of Asthma ExacerbationsMild Moderate Severe Respiratory

arrest imminentBreathless Walking

Can lie down

Talking Prefers sitting

At restHunched forward

Talk in Sentences Phrases Words

Alertness May be agitated

Usually agitated

Drowsy or confused

Respiratory rate

Increased Increased Often >30

Accessory m. and suprasternal retractions

Usually not Usually Usually Paradoxical thoracoabdominal movement

Wheeze Moderate, often only end expiratory

Loud Usually loud Absence of wheeze

Pulse/min <100 100-120 >120 Bradycardia Pulsus paradoxus

Absent<10 mm Hg

May be present10-25 m Hg

Often present>25 mm Hg

Absence suggests respiratory m. fatigue

Severity of Asthma Exacerbations

Mild Moderate Severe

PEF after initial bronchodilator % predicted or % personal best

Over 80% Approx. 60-80% <60% predicted or personal best (<100 L/min adults) or response lasts <2 hrs

PaO2 (on air) Normal test not usually necessary

>60 mm Hg <60 mm Hg; Possible cyanosis

PaCO2<45 mm Hg <45 mm Hg >45 mm Hg; Possible

respiratory failure

SaO2 % (on air) >95% 91-95% <90%

1. Which of the following sign(s) indicate(s) acute severe asthmatic attack?

A. TachypneaB. Pulsus paradoxusC. Silent chest with severe dyspneaD. B+CE. A,B and C

43. Which of following sign(s) is/are NOT chraracteristic of acute severe asthma?

A. TachypneaB. Silent chest with severe dyspneaC. Pulsus paradoxusD. Air hungerE. A and C

43. Which of following sign(s) is/are NOT chraracteristic of acute severe asthma?

A. TachypneaB. Silent chest with severe dyspneaC. Pulsus paradoxusD. Air hungerE. A and C

29. ♂ 32 YO: Acute severe asthmatic attack.All of the followings can be used to Mx,

EXCEPT

A. Nasal O2 6 L/min

B. Keep the patient in mild dehydration to prevent ARDS

C. Inhaled salbutamol via nebulizerD. Inhaled ipratropium via inhaler spacerE. Aminophylline iv

ED Management: Acute Asthma

Initial AssessmentHx, PE, PEF or FEV1

Initial Therapy Bronchodilators; O2 if needed

Incomplete/Poor Response

Add Systemic Steroids

Good Response Poor Response

Discharge Admit

Good Response

Observe at least 1 hr

Discharge

Respiratory Failure

Admit to ICU

Initial Treatment

• Oxygen to achieve SpO2 90% (95% in children)

• Inhaled rapid-acting 2 agonist continuously for 1 hr

• Systemic glucocorticoids if no immediate response, or if patient recently took oral glucocorticoid , or if episode is severe

• Sedation is contraindicated in the treatment of an exacerbation

Reassess after 1 hr

PE, PEF, O2 sat and other tests as needed

Management: Acute Asthma in Acute Care Setting

Criteria for Moderate Episode:• PEF 60-80% predicted/ personal

best• Moderate symptoms, accessory

muscle use

Treatment:• Oxygen

• Inhaled 2 agonist + inhaled anticholinergic q 60 min

• Oral glucocorticoids• Continue treatment for 1-3 hrs,

provided there is improvement

Criteria for Severe Episode:• Risk factors for near fatal asthma• PEF < 60% predicted/ personal best• Severe symptoms at rest, chest

retraction• No improvement after initial Rx

Treatment:• Oxygen

• Inhaled 2 agonist + anticholinergic

• Systemic glucocorticoids• IV magnesium

Reassess after 1 hr

PE, PEF, O2 sat and other tests as needed

Good Response within 1-2 hrs:• Response sustained 60 min after last Rx• Physical exam normal• PEF > 70%

• SaO2 > 90% (95% children)

Improved: Criteria for Discharge Home• PEF > 60% predicted/ personal best• Sustained on oral/ inhaled medication

Home Treatment

• Continue inhaled 2 agonist, oral glucocorticoids, consider adding a combination inhaler

• Patient education: Take medicine correctly, review action plan, close follow-up

Reassess after 1-2 hr

Incomplete response within 1-2 hr:• Risk factors for near fatal asthma• Mild to moderate signs• PEF < 60%

• SaO2 not improving

Admit to acute care setting• Oxygen

• Inhaled 2 agonist anticholinergic

• Systemic glucocorticoids• Intravenous magnesium

• Monitor PEF, O2 saturation, pulse

Poor Response within 1-2 hr:• Risk factors for near fatal asthma• Symptoms severe, drowsiness,

confusion• PEF < 30%

• PCO2 > 45 mmHg, PO2 < 60 mmHg

Admit to ICU• Oxygen

• Inhaled 2 agonist + anticholinergic

• Intravenous glucocorticoids

• Consider IV 2 agonist, theophylline

• Possible intubation and MV

Reassess after 1-2 hr

Reassess at intervals

Poor Response (see above):• Admit to ICU

Incomplete response in 6-12 hrs (see above)

• Consider admission to ICU if no improvement within 6-12 hrs

Improved

(see Discharge Home)

Reassess at intervals

29. ♂ 32 YO: Acute severe asthmatic attack.All of the followings can be used to Mx,

EXCEPT

A. Nasal O2 6 L/min

B. Keep the patient in mild dehydration to prevent ARDS

C. Inhaled salbutamol via nebulizerD. Inhaled ipratropium via inhaler spacerE. Aminophylline iv

34. All of the following asthmatic patient should be intubated and on MV, EXCEPT

A. Progressively exhausted and worsening of acidemia despite Tx

B. ABG: pH 5.98, PaCO2 70, PaO2 40, HCO3 13

C. Pneumonia with septic shockD. Increased wheezing during TxE. Semicoma

34. All of the following asthmatic patient should be intubated and on MV, EXCEPT

A. Progressively exhausted and worsening of acidemia despite Tx

B. ABG: pH 5.98, PaCO2 70, PaO2 40, HCO3 13

C. Pneumonia with septic shockD. Increased wheezing during TxE. Semicoma

9. ♂ 17 Y-O. Waking up from a cough 3 times/mo FEV1 >80% predicted, variability 30% Itchy eyes, sneezing and rhinorrhea when exposed to grass pollens

A. As needed SABAB. ICSC. ICS + LABAD. Short course of oral steroidE. Grass pollen desensitization

9. ♂ 17 Y-O. Waking up from a cough 3 times/mo FEV1 >80% predicted, variability 30% Itchy eyes, sneezing and rhinorrhea when exposed to grass pollens

GINA 2004

Asthma Severity Before Treatment

Severe persistent

Moderate persistent

Mild persistent

Mild intermittent

Day symptoms <1/wk >1/wkAttacks may effect activity

Daily Attacks effect

activity

Daily Limited

physical activity

Night symptoms ≤2/mo >2/mo >1/wk Frequent

FEV1 or PEFR >80% >80% 60-80% <60%

PEF variability <20% 20-30% >30% >30%

• N o longer recommended as the basis for on going treatment decisions

• I ts poor value in predicting what treatment ʼ will be required and what a patient s respon

se to that treatment might be.• For this purpose, a periodic assessment of

asthma control is more relevant and useful.

9. ♂ 17 Y-O. Waking up from a cough 3 times/mo FEV1 >80% predicted, variability 30%Itchy eyes, sneezing and rhinorrhea when exposed to grass pollens

Mild persistent asthma + AR/AC

2. Moderate persistent asthmatics (inhaled budesonide 1200 mcg/d) had frequent cough with hoarseness and aspiration. No nocturnal/daytime asthma symptoms. PE: RS -ve. PEF 80% predicted

The NEXT step management should be

A. Add theophylline SRB. Add inhaled LABAC. Switch budesonide fluticasoneD. Use spacer and frequent rinsing mouth after using budesonideE. Add oral fluconazole

GINA 2004

>800 mcg/d = high dose

Estimated Equipotent Daily Doses of ICS for Adults

Low Daily Dose (µg)

Medium Daily Dose (µg)

High Daily Dose (µg)

Beclomethasone dipropionate 200 - 500 > 500 - 1000 > 1000 - 2000

Budesonide* 200 - 400 > 400 - 800 > 800 - 1600

Ciclesonide* 80 - 160 > 160 - 320 > 320 - 1280

Flunisolide 500 - 1000 > 1000 - 2000 > 2000

Fluticasone 100 - 250 > 250 - 500 > 500 - 1000

Mometasone furoate* 200 - 400 > 400 - 800 > 800 - 1200

Triamcinolone acetonide 400 - 1000 > 1000 - 2000 > 2000

Guideline: Recent Update

2008 TAC 2009

Management Approach Based On Control

Step 1 Step 2 Step 3 Step 4 Step 5Asthma education

Environmental controlAs needed

SABAAs needed SABA

Controller options

Select one Select one Add one or more

Add one or both

Low-dose ICS Low-dose ICS + LABA

Medium- or high-dose ICS +

OS (lowest dose)

Leukotriene modifier

Medium- or high-dose ICS

Leukotriene modifier

Anti-IgE

Low-dose ICS + Leukotriene

modifier

Sustained release

theophyllingLow-dose ICS +

sustained release

theophylline

Treatment StepsReduce Increase

Refractory Asthma: Workshop Consensus For Typical Clinical Features

Fahy J. Am J Respir Crit Care Med 2000; 162: 2341–2351.

1 major + 2 minor

Refractory Asthma: Step Approach

1. Confirm diagnosis

2. Evaluate of confounding/ exacerbating factors

3. Optimizes pharmacotherapy

Fahy J. Am J Respir Crit Care Med 2000; 162: 2341–2351.

• Local deposition of ICS in oropharynx and larynx• Depends on dose, frequency of administration,

delivery system

Local AE of ICS

Local side effects

Dysphonia • Most common (over 50% of patients using MDI)• Due to myopathy of laryngeal muscles • Reversible when treatment is withdrawn• Not reduced by using spacers, but DPI Thrush• Elderly, oral steroids, ICS >2 time/day• Spacer + rinsing mouthCough, throat irritation ± reflex bronchoconstriction• Due to surfactants in MDIs• Switching to DPI

Local AE of ICS

6. Scrub nurse: recurrent cough and chest tightness 2 mo. Previously healthy. Atopy –ve. PE/CXR –ve. Spirometry: ↓ FEF25-75%

What is the most appropriate Mx?

A. HEPA mask while workingB. ICSC. HRCT chestD. Methacholine challenge testE. Skin prick test for aeroallergen

Dx: Occupational asthma

Definition

Occupational asthma (OA): • Variable airflow limitation ± airway

hyperresponsiveness • Due to causes and conditions attributable to a

particular occupational environment and not to stimuli encountered outside the workplace

Work-related asthma:• Encompasses both OA and asthma aggravated

by work or work environment

Most common workplace sensitizers in various jobs

Natural history of OA

• Latency period can vary from months to years

• Rhinoconjunctivitis symptoms often precede the onset of asthma symptoms

• Risk of asthma was highest in the first year after notification of occupational rhinitis, and a roughly threefold risk persisted for several years thereafter

Diagnosis

• Symptoms compatible with asthma– Cough– Chest tightness– Dyspnea– Wheeze

• Symptoms relate to workplace • History of exposure agents at least 2 weeks

Diagnosis

• PEFR 4 times/day x 4 wk during periods of work and periods off work

• Spirometry prove reversible airflow obstruction

• Nonspecific challenge test

• Specific inhalation challenge tests with occupational agents are performed in only a few specialized centers

Treatment

• Avoidance• Treat as asthma• Change career

• Effort independent • Suggestive but not specific for small airway

disease• Isolated abnormality may indicate early airway

obstruction (smoking, early asthma) in the presence of borderline FEV1/FVC

FEF25-75%

37. ♂ 50 Y-O; smoked 1 P-Y and quited 10 YDry coughing spells after started new workMorning rhinorrhea and nasal congestionPE: edema and erythema of nasal turbinates, prolonged expiratory phase Spirometry FEV1: pre-BD 65% predicted; post-BD 85% predicted

Tx?A. Inhaled beclomethasoneB. Inhaled ipratropium C. Oral bambuterolD. Oral theophyllineE. Oral zafirlukast

Occupational asthma

1. Absolute change (>200 ml): FEV1post - FEV1pre

2. Percent initial value (>12%): FEV1post - FEV1pre x 100

FEV1pre

3. Percent predicted value (>9%):FEV1post - FEV1pre x 100

FEV1predicted

4. Percent possible improvement: FEV1post - FEV1pre x 100

FEV1predicted - FEV1pre

Expressing Bronchodilator Response

10. ♂ 60 Y-O, smoker: chronic productive cough and intermittent dyspnea

FEV1/FVC 60%, Post-BD FEV1 60% predicted

GOLD not recommended?

A. Smoking cessationB. Influenza vaccineC. Regular inhaled LABAD. Pulmonary rehabilitationE. ICS

All stageAll stageStage II moderateStage II moderateStage III severe

I/C for ICS in COPD

NICE 2004:

• FEV1 <50% predicted

• Repeated exacerbations (≥2 in a year)

GOLD 2007:

• FEV1 <50% predicted (Stage III: Severe and Stage

IV: Very Severe)

• Repeated exacerbations (3 in the last 3 year)

21. A 56-YO COPD patient progressive dyspnea over several years.

PE: mild central cyanosis, ↑ AP Φ of chest wall, ↑ P2, early coarse inspi. crepitation at basal lungs.

Hct 55%, pH 7.38, PaCO2 50, PaO2 58 mmHg

Tx of choice is

A. Digitalis

B. Diuretics

C. Theophylline

D. Continuous low-flow oxygen

E. Phlebotomy

21. A 56-YO COPD patient progressive dyspnea over several years.

PE: mild central cyanosis, ↑ AP Φ of chest wall, ↑ P2, early coarse inspi. crepitation at basal lungs.

Hct 55%, pH 7.38, PaCO2 50, PaO2 58 mmHg

Tx of choice is

A. Digitalis

B. Diuretics

C. Theophylline

D. Continuous low-flow oxygen

E. Phlebotomy

Selection Criteria for Long-term Oxygen Therapy

Oxygen Therapy

• Long-term administration of oxygen (>15 hr/day) to patients with chronic respiratory failure has been shown to increase survival

(Evidence A)

• LTOT also improves hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state

• Goal: O2 sat 90% or PaO2 60 mm Hg

8. Theophylline in COPD + current smoking ↓ theophylline level

A. Smoking low drug absorptionB. Smoking ↑ drug distribution to tissueC. Smoking induce CYTP450 to metabolize the drugD. COPD impair GI absorption of the drugE. COPD enhance liver clearance of the drug

8. Theophylline in COPD + current smoking ↓ theophylline level

A. Smoking low drug absorptionB. Smoking ↑ drug distribution to tissueC. Smoking induce CYTP450 to metabolize the drugD. COPD impair GI absorption of the drugE. COPD enhance liver clearance of the drug

Drug interactions with tobacco smoking

Polycyclic aromatic hydrocarbons (PAHs) in tobacco smoke are believed to be responsible for the induction of

• CYP1A1 (extrahepatic enzyme: lung and placenta)

• CYP1A2• Possible CYP2E1

Zevin S, Benowitz NL. Clin Pharmacokinet. 1999 Jun;36(6):425-38.

CYP1A2 Substrates• Alosetron• Caffeine• Clozapine• Flutamide• Frovatriptan• Melatonin• Mexiletine• Mirtazapine• Olanzapine• Ramelteon• Rasagiline• Ropinirole• Tacrine• Theophylline• Tizanidine• Triamterene• Zolmitriptan

CYP1A2 Inhibitors• Artemisinin• Atazanavir• Cimetidine• Ciprofloxacin• Enoxacin• Ethinyl Estradiol• Fluvoxamine• Mexiletine• Tacrine• Thiabendazole• Zileuton

CYP1A2 Inducers• Barbiturates• Cruciferous

vegetables• Grilled meat• Carbamazepine• Primidone• Rifampin• Smoking

GOLD 2007

Drugs and Physiological Variables that Affect Theophylline Metabolism in COPD

Increased (↓ theo)• Tobacco smoking• Anticonvulsant drugs• Rifampicin• Alcohol

Decreased (↑ theo)• Old age• Arterial hypoxemia (PaO2 <45 mm Hg)• Respiratory acidosis• Congestive cardiac failure• Liver cirrhosis• Erythromycin• Quinolone antibiotics• Cimetidine (not ranitidine)• Viral infections• Herbal remedies (St. Johnes Wort)

Drug Interactions with Tobacco Smoking

Zevin S, Benowitz NL. Clin Pharmacokinet. 1999 Jun;36(6):425-38.

Haloperidol • Clearance increased by 44%; serum concentrations decreased by 70%.

Heparin • Mechanism unknown but increased clearance and decreased half-life are observed. • Smokers may require higher dosages.

Insulin • Insulin absorption may be decreased secondary to peripheral vasoconstriction; smoking may cause release of endogenous substances that antagonize the effects of insulin. • Smokers may require higher dosages

Theophylline • Increased metabolism (induction of CYP1A2); clearance increased by 58–100%; half-life decreased by 63%. • Levels should be monitored if smoking is initiated, discontinued, or changed. • Passive smoking (secondhand smoke) also increases the clearance. • Maintenance doses are considerably higher in smokers

Beta-blocker • Less effective antihypertensive and heart rate control effects. • May be caused by nicotine-mediated sympathetic activation.

Oral contraceptive pills

• Increased risk of cardiovascular adverse effects (e.g., stroke, myocardial infarction, thromboembolism) in women who smoke and use oral contraceptives. • Risk increases with age and with heavy smoking (15 or more cigarettes per day) and is quite marked in women over age 35 years.

8. The maintenance dosage of aminophylline should be reduced in all of the following, EXCEPT

A. Elderly patientsB. Current smokingC. CHFD. Cimetidine treatmentE. Quinolone treatment

8. The maintenance dosage of aminophylline should be reduced in all of the following, EXCEPT

A. Elderly patientsB. Current smokingC. CHFD. Cimetidine treatmentE. Quinolone treatment

19. C/I of bupropion for smoking cessation?

A. Heavy smoking ≥20 cig./dB. DepressionC. Seizure disorderD. Prior Hx of allergy to nicotine patchE. Prior Hx of allergy to penicillin

Bupropion SR

• Atypical antidepressant thought to affect levels of various brain neurotransmitters– Dopamine reward pathway (dependence)– Norepinephrine nicotine withdrawal

• Clinical effects– ↓ Craving for cigarettes– ↓ Symptoms of nicotine withdrawal

Advantages•Easy to use•Can be use with

NRT•Might be beneficial

for patients with depression

Disadvantages•↑ Seizure risk•Should be avoided or used

with caution in–Hx of seizure/cranial trauma–Anorexia/bullemia nervosa–Medications that lower seizure threshold

–Severe hepatic cirrhosis–Concurrent use of any form of Wellbutrin or any MAOI in preceding 14 days

Bupropion SR

19. C/I of bupropion for smoking cessation?

A. Heavy smoking ≥20 cig./dB. DepressionC. Seizure disorderD. Prior Hx of allergy to nicotine patchE. Prior Hx of allergy to penicillin

Bupropion SR

Patients should begin therapy 1-2 weeks PRIOR to their quit date to ensure that therapeutic plasma levels of the drug are achieved

• Initial treatment: 150 mg po q am x 3 days• Then…150 mg po bid

Pharmacologic Methods: First-line Therapy

3 general classes of FDA-approved drugs for smoking cessation:

• Nicotine replacement therapy (NRT)– Nicotine gum, patch, lozenge, nasal spray, inhaler

• Psychotripics– Sustained-release bupropion

• Partial nicotinic receptor agonist – Varenicline

• 1,6,7,8,9-tetrahydro-6,10-methano-6H-pyrazino [2,3h][3]benzazepine

• Partial agonist of α4β2 neuronal nicotinic acetylcholine receptors (nAChR)

• To inhibit dopaminergic activation produced by smoking while simultaneously providing relief from the craving and withdrawal syndrome that accompanies cessation attempts

Varenicline

Mechanism of Action

Varenicline both blocks the nicotine receptors (reducing the addictive power of the drug) and triggers moderate dopamine release to alleviate withdrawal symptoms

7-Day Point Prevalence Abstinence

36.3% P=0.5

Jorenby D, et al. JAMA 2006;296:56-63.

Cessation rates for varenicline were higher at all time points

Plus weekly brief smoking cessation counseling

Incidence of Adverse Events

Nides M, et al. Arch Intern Med. 2006;166:1561-1568.

The FDA Approves New Drug for Smoking Cessation

In May 2006, the Food and Drug Administration approved Chantix (varenicline tartrate) tablets to help cigarette smokers ages 18 and older stop smoking.

The drug received a priority review because of its significant potential benefit to public health. Chantix was reviewed in six months rather than the regular review time of 10 months, says Curt Rosebraugh, M.D., M.P.H., deputy director of the FDA's Office of Drug Evaluation II. "Chantix underwent priority review," Rosebraugh says, "because at the time the application was filed, a preliminary review of the efficacy studies

indicated that smokers treated with Chantix may have a superior rate of smoking cessation compared to Zyban (bupropion), another currently approved product for smoking cessation."

The effectiveness of Chantix in smoking cessation was demonstrated in 6 clinical trials, which included a total of 3,659 chronic cigarette smokers who were treated with varenicline. 5 of 6 studies were

RCT in which Chantix was shown to be superior to placebo in helping people quit smoking. These smokers had previously averaged 21 cigarettes a day for about 25 years.

In 2 of 5 placebo-controlled studies, Chantix-treated patients were also more successful in giving up smoking than patients treated with Zyban. "Both studies had very similar results with approximately 44%

of people taking Chantix having stopped smoking at the end of 12 weeks, compared with 17% of people taking placebo and 30% of people taking bupropion," Rosebraugh says. "Researchers followed study

participants in both studies for a year and found that approximately 22% of people taking Chantix, 16% of people taking bupropion, and 10% of people taking placebo were still smoke-free at the end of the year."

The approved course of Chantix treatment is 12 weeks. Rosebraugh says that for the first 3 days, patients take 0.5 mg once a day, followed by 0.5 mg twice a day for the next 4 days, and then 1 mg

twice a day for the remainder of the treatment period. Patients who successfully quit smoking during Chantix treatment may continue with an additional 12 weeks of treatment that further increases the likelihood of long-

term smoking cessation.

10,40. 52-YO smoker: Moderate COPD + worsening of dyspnea. Tx HTN, CHD and epilepsy.

Which is the most cause of the deterioration of his pulmonary function?

A. PhenytoinB. PropanololC. DigoxinD. PhenobarbitalE. Nitroglycerine

10,40. 52-YO smoker: Moderate COPD + worsening of dyspnea. Tx HTN, CHD and epilepsy.

Which is the most cause of the deterioration of his pulmonary function?

A. PhenytoinB. PropanololC. DigoxinD. PhenobarbitalE. Nitroglycerine

35. Air trapping is a feature of which of the following conditions

A. Panacinar emphysemaB. Senile emphysemaC. Paraseptal emphysemaD. Honeycomb lungE. All of the above

35. Air trapping is a feature of which of the following conditions

A. Panacinar emphysema (alfa-1 antitrypsin deficiency)

B. Senile emphysemaC. Paraseptal emphysema = linear

emphysema (subpleural)D. Honeycomb lung + bronchiolectasis +

Paracicatricial emphysemaE. All of the above

Centrilobular (centriacinar) emphysema: smoking

4. The syndrome of CO2 narcosis:

A. Occurs only with high O2 concentrating inhalation

B. Does not occur in obstuctive lung diseaseC. Does not occur in restrictive lung diseaseD. May be worsened with oxygen

administraionE. Occurs with chronic hypocapnia

4. The syndrome of CO2 narcosis, EXCEPT:

A. Occurs only with high O2 concentrating inhalation

B. Does not occur in obstuctive lung diseaseC. Does not occur in restrictive lung diseaseD. May be worsened with oxygen

administraionE. Occurs with chronic hypocapnia

Critical CareCritical Care

51. Continuous mechanical ventilation may result in which of the following

A. ↑ COB. Enhanced VRC. ↓ Pleural pressureD. ↓ Mean intrathoracic pressureE. ↑ Mean intrathoracic pressure

Positive intrathoracic pressure

51. Continuous mechanical ventilation may result in which of the following

A. ↑ COB. Enhanced VRC. ↓ Pleural pressureD. ↓ Mean intrathoracic pressureE. ↑ Mean intrathoracic pressure

2. PEEP breathing may be of benefit in

A. Acute asthmatic attackB. Acute pulmonary edemaC. Unilateral pulmonary edemaD. B and CE. A, B and C

Indications for NPPV in Respiratory Failure

Acute respiratory failure:• COPD exacerbation**• Acute cardiogenic pulmonary

edema**• Fever/infiltrated in

compromised host**• Fascilitate weaning**• Severe hypoxemic respiratory

failure (ARDS)• Asthma• Post Operative respiratory

failure• In DNI patients

Chronic respiratory failure:

• Neuromuscular diseases**

• COPD• Obesity

hypoventilation syndrome

• Cystic fibrosis and bronchiectasis

** strong evidence

NPPV for AECOPD: Contraindications

• Respiratory arrest• Acute cardiac ischemia or MI• Need to protect airway• Unable to fit / wear mask• (Impaired mental status)

Neuromuscular Diseases Treated with NPPV

• Muscular dystrophies• Post-polio syndrome• High spinal cord lesion• Multiple sclerosis• Bilateral diaphragm paralysis• Amyotrophic lateral sclerosis• Myasthenia gravis• Chest wall deformities

Indications for NPPV in Neuromuscular Diseases

• Abnormal gas exchange– Daytime hypercapnea PCO2 > 45 mmHg

– Nocturnal hypoventilation O2 saturation < 88%

• Progressive muscular weakness– MIP < -60 cm H2O

– FVC < 50%

• Symptoms/signs of respiratory failure

Contraindications for NIPPV in Neuromuscular Diseases

Relative Contraindications• Swallowing or cough impairment• Need for continuous ventilation

Absolute Contraindications• Uncontrollable secretion retention• Inability to cooperate

2. PEEP breathing may be of benefit in

A. Acute asthmatic attackB. Acute pulmonary edemaC. Unilateral pulmonary edemaD. B and CE. A, B and C

28. Alcoholic ♂ (BW 60 kg) with acute pancreatitis

Respiratory failure (CXR: diffuse infiltrate)CMV: TV 500, RR 18, PEEP 8, FiO2 0.6, IF 60 PIP/Ppl 30/20; V/S stableABG: pH 7.35, pO2 70, pCO2 45

Most appropriate next measure?A. ↑ TV to 600B. ↑ RR to 22C. Maintain the same settingD. Switch to PCV mode (PI 20)E. PEEP to 10

28. Alcoholic ♂ (BW 60 kg) with acute pancreatitis

Respiratory failure (CXR: diffuse infiltrate)CMV: TV 500, RR 18, PEEP 8, FiO2 0.6, IF 60 PIP/Ppl 30/20; V/S stableABG: pH 7.35, pO2 70, pCO2 45 P/F ratio =

Most appropriate next measure?A. ↑ TV to 600B. ↑ RR to 22C. Maintain the same settingD. Switch to PCV mode (PI 20)E. PEEP to 10

Protective Lung Strategies

The ARDS Network. N Engl J Med 2000;342:1301-8.

ARDSnet

Predicted body weight: ♂ = 50 + (0.91x [height in cm. - 152.4])

♀ = 4.5 + (0.91 x [height in cm. - 152.4])

80 mm Hg or

Ventilator setting in various conditions

Condition Vt (ml/kg) RR (bpm) I:E ratioNormal 10 10-15 1:1.5 – 1:2

ARDS 6-8 15-20 1:1 – 4:1

Obstructive lung <8-12 8-12 1:3 or IT ≤1 s

Restrictive lung <10 12-20 1:2

Neuromuscular disease

≥12 8-12 1:2

FiO2 0.3-0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 1.0

PEEP 5 8 8 10 10 10 12 14 14 16 16 18-25

PEEP:FiO2 in ARDS NIH ARDS Network Trial

7,38. All of the following are seen in the early stage of ARDS, EXCEPT

A. Severe dyspnea and tachypneaB. Marked hypoxemiaC. Hypercapnia and hypoventilationD. Decreased lung complianceE. CXR: bilateral diffuse pulmonary infiltrates

7,38. All of the following are seen in the early stage of ARDS, EXCEPT

A. Severe dyspnea and tachypneaB. Marked hypoxemiaC. Hypercapnia and hypoventilationD. Decreased lung complianceE. CXR: bilateral diffuse pulmonary infiltrates

48. ARDS has been associated with all of the following, EXCEPT

A. PancreatitisB. Septic shockC. Viral pneumoniaD. Fat embolismE. Severe asthma

Disorders Associated With ALI/ARDS

48. ARDS has been associated with all of the following, EXCEPT

A. PancreatitisB. Septic shockC. Viral pneumoniaD. Fat embolismE. Severe asthma

1. ♀ 25 Y-O (BW 50 kg) with acute severe asthma. ET + muscle relaxant + bronchodilator + steroid

Ventilator - VC-CMV: Vt 500, FiO2 35%, RR 12, PF 50,- PIP 42, Ppl 30, PEEPi 9, I:E 1:1.5- ABG: pH 7.25, pCO2 60, pO2 90

A. ↑ TV to 650 ccB. Apply PEEPe 6 cmH2OC. ↓ Inspiratory flow to 40 L/minD. Change to SIMV modeE. ↑ RR to 20

Ventilator- VC-CMV: Vt 500, FiO2 35%, RR 12, PF 50,- PIP 42, Ppl 30, PEEPi 9, I:E 1:1.5- ABG: pH 7.25, pCO2 60, pO2 90

Mechanical ventilation in adults with acute exacerbations of asthma

Dynamic hyperinflation PEEPi and ↑ Ppl

To decreasing air trapping: allow more time to exhale

• ↑ Inspiratory flow: ↓ TI, ↑ TE

• ↓ TV• ↓ RR • Adding PEEPe (<80% of PEEPi)

Ventilator - VC-CMV: Vt 500, FiO2 35%, RR 12, PF 50,- PIP 42, Ppl 30, PEEPi 9, I:E 1:1.5- ABG: pH 7.25, pCO2 60, pO2 90

↑ TI

21. ♂ 65 Y-O, COPD on VC-CMV: FiO2 0.6, RR 20, Vt 600, PIF 40

ABG: pH 7.30, pCO2 60, pO2 60

Most appropriate Mx?A. ↓ PIFB. ↑ VtC. ↑ RRD. ↑ PEEPE. ↑ FiO2

21. ♂ 65 Y-O, COPD on VC-CMV: FiO2 0.6, RR 20, Vt 600, PIF 40

ABG: pH 7.30, pCO2 60, pO2 60

Most appropriate Mx?A. ↓ PIFB. ↑ VtC. ↑ RRD. ↑ PEEPE. ↑ FiO2

↓ TE

13. Acute severe asthma intubation + ventilatorPatient was still discomfort

Cause?A. Too high PEEP levelB. Insufficient inspiratory flowC. Autotrigger of ventilatorD. Air leak in ventilator systemE. High tidal volume

13. Acute severe asthma intubation + ventilatorPatient was still discomfort

Cause?

A. Too high PEEP levelB. Insufficient inspiratory flowC. Autotrigger of ventilatorD. Air leak in ventilator systemE. High tidal volume

Flow starvation

3. ♂ 75 Y-O with AECOPD. Intubated + manually ventilated

Immediate: SBP 60 mmHg, HR 150 (EKG: sinus tachycardia), SpO2 100%. BS present bilaterally + trachea in midline

2-min later: PEA

The most likely cause is:

A. Bilateral tension PNXB. AMIC. Esophageal intubationD. Acute hyperinflation and auto-PEEPE. Severe pneumonia

2-min later: PEA

17. ♀ 50 Y-O, asthma: severe dyspnea intubation + ventilator still restlessPE: BT 37.2, BP 70/40, HR 120, RR 28, conscious, faint wheezing both lungs; CXR: normalPIP/Ppl 60/45, O2sat 97% (FiO2 0.35)

Most appropriate next step of Mx?

A. Start ATB after S/WB. ABGC. Repeat CXRD. Measure PCWPE. Auto-PEEP determination

17. ♀ 50 Y-O, asthma: severe dyspnea intubation + ventilator still restlessPE: BT 37.2, BP 70/40, HR 120, RR 28, conscious, faint wheezing both lungs; CXR: normalPIP/Ppl 60/45, O2sat 97% (FiO2 0.35)

Most appropriate next step of Mx?

A. Start ATB after S/WB. ABGC. Repeat CXRD. Measure PCWPE. Auto-PEEP determination

12,42. Hyperventilation can be observed in the following EXCEPT

A. Midbrain lesionB. EncephalitisC. CO2 narcosis

D. UremiaE. Salicylate poisoning

12,42. Hyperventilation can be observed in the following EXCEPT

A. Midbrain lesionB. EncephalitisC. CO2 narcosis

D. UremiaE. Salicylate poisoning

24. ♂ 65 Y-O: AECOPD on ventilator betterSpontaneous breath: RR 25, TV 400, MV 10T-piece 1 h later: RR 10, TV 400, MV 4

Most likely cause of change in respiratory profile?A. BronchospasmB. Respiratory m. weaknessC. Excess FiO2

D. Over sedationE. Abdominal distension

24. ♂ 65 Y-O: AECOPD on ventilator betterSpontaneous breath: RR 25, TV 400, MV 10T-piece 1 h later: RR 10, TV 400, MV 4

Most likely cause of change in respiratory profile?A. BronchospasmB. Respiratory m. weaknessC. Excess FiO2

D. Over sedationE. Abdominal distension

30. ♀ 78 YO: Bowel obstruction laparotomy + lysis the adhesions

PO extubated but cyanosis + respiratory distress reintubated (MV: FiO2 0.6)

ABG: pH 7.42, PaCO2 42, PaO2 40.The likely possibilities include all, EXCEPT

A. ET tube is in the right main bronchusB. Overdose of narcotic during anesthesiaC. Retained secretionD. AMI with pulmonary edemaE. Aspiration of gastric content

30. ♀ 78 YO: Bowel obstruction laparotomy + lysis the adhesions

PO extubated but cyanosis + respiratory distress reintubated (MV: FiO2 0.6)

ABG: pH 7.42, PaCO2 42, PaO2 40.The likely possibilities include all, EXCEPT

A. ET tube is in the right main bronchusB. Overdose of narcotic during anesthesiaC. Retained secretionD. AMI with pulmonary edemaE. Aspiration of gastric content

12. ♂ 45 Y-O; 15 P-Y smoking: confused, drowsy

ABG: pH 7.28, PaO2 70, PaCO2 56CXR: normalHx: FEV1/FVC 70%, FEV1 75% predicted

Cause of hypercapnic respiratory failure?

A. Acute pulmonary embolismB. Sedative overdoseC. Cardiogenic pulmonary edemaD. Right left shuntE. COPD

COPD Stage II (moderate)

(A-a)DO2

= 150 – 140

= PAO2 – PaO2

= FIO2 x (Patm – PH2O) – (PaCO2/0.8) – PaO2

(A-a)DO2

= 0.21 x (760 – 47) – (56/0.8) – 70

(A-a)DO2 = 2.5 + 0.21 x age in years

(A-a)DO2

= PAO2 – PaO2

= FIO2 x (Patm – PH2O) – (PaCO2/0.8) – PaO2

(A-a)DO2

= 150 – [PaO2 + (PaCO2/0.8)]

10 = 0.21 x (760 – 47) – (PaCO2/0.8) – PaO2

140 = PaO2 + (PaCO2/0.8)

(A-a)DO2 = 10

(A-a)DO2

27. ♀ 26 YO: sedative overdose comatose + apnea

ET on PCV (FiO2 0.4, RR 20, PIP 15)

ABG: pH 7.22, PaCO2 62, PaO2 200No leakage in tubing system. What should

you do next?

A. Infuse 7.5% NaHCO3 ivB. Check TV of the ventilatorC. Decrease FiO2 to 0.21D. Increase RR to 25/minE. Increase PIP to 20 cm H2O

27. ♀ 26 YO: sedative overdose comatose + apnea

ET on PCV (FiO2 0.4, RR 20, PIP 15)

ABG: pH 7.22, PaCO2 62, PaO2 200No leakage in tubing system. What should

you do next?

A. Infuse 7.5% NaHCO3 ivB. Check TV of the ventilatorC. Decrease FiO2 to 0.21D. Increase RR to 25/minE. Increase PIP to 20 cm H2O

PneumoniaPneumonia

22. ♀ 65 Y-O, DM & HTNFever + productive cough (purulent) 5 dPE: T 38.2, BP 130/80, PR 96, RR 24, no cyanosis, conscious, crackles at RULCXR: RUL consolidationCBC: WBC 14000 (N85%, L15%)

Tx as OPD case ATB?A. AM/CLB. Respiratory quinoloneC. MacrolideD. DoxycyclineE. 3rd generation cephalosporin

OPD case

ATS 2001.

OUTPATIENT THERAPY

INPATIENT THERAPY

NO CARDIOPULMONARY Dz, NO MODIFIERS

GROUP I

CARDIOPULMONARY Dz, +/OR

MODIFIERS

GROUP II

MILD-MODERATE

ILLNESS

SEVERE CAP

CARDIOPULMONARY Dz, +/OR

MODIFIERS

GROUP IIIB

NO CARDIOPULMONARY Dz, NO MODIFIERS

GROUP IIIA

NO RISK FOR P.

AERUGINOSA

GROUP IVA

RISK FOR P. AERUGINOSA

GROUP IVB

ATS/IDSA 2007.

OUTPATIENT THERAPY

INPATIENT THERAPY

NO CARDIOPULMONARY

Dz, NO RISK of DRSP

GROUP I

CARDIOPULMONARY Dz, +/OR RISK of

GROUP II

NON-ICU ICU

RISK of P. aeruginosa / CA-MRSA

A. Macrolide

B. Doxycycline

A. Respiratory Q

B. BL + Macrolide

A. Respiratory Q

B. BL + Macrolide

BL + Azithro

OPD case

Comorbid

Modifiers affecting bacterioligy

Penicillin resistant Streptococcus pneumoniae (PRSP)• Age >65 years• Beta-lactam therapy within the past 3 months• Alcoholism, immunosuppressive illness, exposure to child in

day care center• Multiple medical co-morbiditiesEnteric gram-negatives• Underlying cardiopulmonary disease• Recent antibiotic therapy• Nursing home residence• Multiple medical co-morbiditiesPseudomonas aeruginosa• Structural lung diseases eg. Bronchiectasis• Broad-spectrum antibiotics for >7 days within the past month• Corticosteroid therapy (>10 mg prednisolone)• Severe malnutrition ATS 2001.

ATS/IDSA2007.

• ESRD• IVDU• Prior influenza• Prior antibiotic Rx (especially FQs)

More risk of CA-MRSA in necrotizing pneumonia (Panton-Valentine leukocidin toxin production)

IDSA/ATS 2007. CID 2007.

Risk factors for S. aureus CAP

Risk factors for P. pseudomallei

• DM (asymptomatic infection, clinical disease and bacteremic infection)

• Chronic renal disease and urolithiasis (symptomatic melioidosis)

• Excessive alcohol ingestion• Thalassemia• Chronic lung disease• Kava consumption• ? Malignancies, steroid therapy, pulmonary

hemosiderosis, chronic granulomatous disease, and tuberculosis

35. ♂ 63 Y-O, healthy: 3 d fever, productive cough, chills, Rt. pleuritic chest pain, SOBPE: T 40, PR 136, RR 32, BP 76/48CXR: RUL + RLL alveolar infiltrationO2sat (RA) 75%

ATB?A. Cefotaxime + azithromycinB. Ceftriaxone + ciprofloxacinC. Meropenem + levofloxacin D. Ceftazidime + amikacinE. Imipenem + vancomycin

ATS/IDSA 2007.

OUTPATIENT THERAPY

INPATIENT THERAPY

NO CARDIOPULMONARY

Dz, NO RISK of DRSP

GROUP I

CARDIOPULMONARY Dz, +/OR RISK of

GROUP II

NON-ICU ICU

RISK of P. aeruginosa / CA-MRSA

A. Macrolide

B. Doxycycline

A. Respiratory Q

B. BL + Macrolide

A. Respiratory Q

B. BL + Macrolide

BL + Azithro

6. Which indicates that the pneumonic patient responds to the treatment in the first few days?

A. Fever B. Sputum production and coughC. Follow up CXRD. WBCE. A, B and D

Initial Response for Pneumonia

2/5 of the followings: 1. Lowering of fever ≥1˚c 2. Significant reduction of vasoactive drugs use

(≥10% decrease dose of maximal rate as compared with previous day)

3. Significant increase PaO2/FiO2 (≥10% increase as compared with previous day)

4. Significant improvement of sputum production (purulent non-purulent or have sputum no sputum)

5. Significant reduction of WBC (if baseline ≥12,000) (≥10% reduction as compared with previous value)

6. Which indicates that the pneumonic patient responds to the treatment in the first few days?

A. Fever B. Sputum production and coughC. Follow up CXRD. WBCE. A, B and D

7. What is not criteria for switching ATB for CAP

A. Absence of fever >8 hrB. Intact GI functionC. Tendency for returning of WBC count to

normalD. Decrease radiographic parenchymal

infiltratesE. Decrease breathlessness and cough

Switch from iv to oral ATB therapy

• Hemodynamic stable• Clinical improved

[Afebrile at least 8 hr][Symtom improved (dyspnea and cough)][WBC count improved]

• Able to ingest medications, and have a normally functioning gastrointestinal tract

Strong recommendation; level II evidence

ATS/IDSA 2007.

Criteria for clinical stability

• Temperature ≤37.8°C• Heart rate ≤100 beats/min• Respiratory rate ≤24 breaths/min• Systolic blood pressure ≥90 mm Hg• SaO2 ≥90% or pO2 ≥60 mm Hg on room air• Ability to maintain oral intakea

• Normal mental statusa

a Important for discharge or oral switch decision but not necessarily for determination of nonresponse.

ATS/IDSA 2007.

7. What is not criteria for switching ATB for CAP

A. Absence of fever >8 hrB. Intact GI functionC. Tendency for returning of WBC count to

normalD. Decrease radiographic parenchymal

infiltratesE. Decrease breathlessness and cough

44. All of the following statement influence the prognosis in pneumococcal pneumonia, EXCEPT

A. Type of pneumococcusB. Presence of a positive blood cultureC. Site of the lesionD. Presence of pre-existing chronic bronchitisE. Age of the patient

Decision for Hospitalization1. Age over 65 yr2. Coexisting illnesses: COPD, bronchiectasis, malignancy*, DM,

CRF*, CHF*, chronic liver disease*, chronic alcohol abuse, malnutrition, CVA*, and postsplenectomy. A history of hospitalization within the past year

3. Physical findings: RR >30 bpm*; DBP <60 mm Hg or SBP <90 mm Hg*; HR >125/min*; BT <35 or >40° C*; confusion or level of consciousness*; extrapulmonary sites of infection

4. Laboratory findings:– WBC <4 X 109/L or >30 X 109/L, or ANC >1 X 109/L– PaO2 <60 mm Hg* or PaCO2 >50 mm Hg at room air– Abnormal renal function: Cr >1.2 mg/dL or BUN >20

mg/dL– Unfavorable CXR: multilobar, cavity, rapid spreadinng,

pleural effusion*– Hct <30%* or Hb <9 mg/dL– Evidence of sepsis or organ dysfunction: metabolic

acidosis, coagulopathy– Arterial pH <7.35*

* Increase mortality significantly ATS 2001.

44. All of the following statement influence the prognosis in pneumococcal pneumonia, EXCEPT

A. Type of pneumococcusB. Presence of a positive blood cultureC. Site of the lesionD. Presence of pre-existing chronic bronchitisE. Age of the patient

11,41. which is/are adequate sputum?

A. >25 WBCs and <10 epith. cells/100 power field

B. >25 WBCs and <3 epith. cells/1000 power field

C. >25 WBCs and <5 epith. cells/400 power field

D. Presence of alveolar macrophageE. A + D

11,41. which is/are adequate sputum?

A. >25 PMN and <10 SEC/100 power fieldB. >25 PMN and <3 SEC/1000 power fieldC. >25 PMN and <5 SEC/400 power fieldD. Presence of alveolar macrophageE. A + D

20,50. A 50-YO alcoholic was found delirious with a high fever and coughing up sticky, dark brown sputum. CXR: consolidation of RUL with sagging of the interlobar septum. The most likely Dx is:

A. Pneumococcal pneumoniaB. Staphylococcal pneumoniaC. Klebsiella pneumoniaD. Pseudomonas pneumoniaE. Anaerobic pneumonia

Etiology of CAP

Depend on • Patients’ characteristic (co-morbidities,

modifying factors)• Severity of CAP• Geographic area• Seasonal variation • Intensity of diagnostic work up

Epidemiologic conditions and/or risk factors related to specific pathogens in CAP

Condition Commonly encountered pathogen(s)

Alcoholism S.pneumoniae, oral anaerobes, K.pneumoniae, Acinetobacter spp., TB

COPD and/or smoking H.influenzae, P.aeruginosa, Legionella spp., S.pneumoniae, M.catarrhalis, C.pneumoniae

Aspiration Gram-negative enteric pathogens, oral anaerobes

Lung abscess CA-MRSA, oral anaerobes, endemic fungal pneumonia, TB, atypical mycobacteria

Exposure to bat or bird droppings

Histoplasmosis capsulatum

Exposure to birds Chlamydophila psittaci (if poultry: avian influenza)

Exposure to rabbits Fransisella tularensis

Exposure to farm animals or parturient cats

Coxiella burnetti (Q fever)

HIV infection (early) S.pneumoniae, H.influenzae, TB

HIV infection (late) The pathogens listed for early infection plus Pneumocystis jirovecii, Cryptococcus, Histoplasma, Aspergillus, atypical mycobacteria (esp. M.kansasii), P.aeruginosa, H.influenzae

ATS/IDSA 2007.

Specific clinical features of particular respiratory pathogens

Streptococcus pneumoniae• ↑ A ge, comorbidity, acute onset, high fever, pleuritic ches

t pain Bacteraemic Streptococcus pneumoniae

• Female sex, excess alcohol, DM , COPD , dry cough Legionella pneumophila

• Younger patients, smokers, absence of comorbidity, diarr hea, neurological symptoms, evidence of multisystem inv

olvement (e.g. abnormal LFTs , ↑ serum CK) Mycoplasma pneumoniae

• Younger patients, prior ATB , less multisystem involvement

Chlamydia pneumoniae• Longer duration of symptoms before hospital admission,

headacheBTS 2001 2004.

Most Common Etiologies of CAP

ATS/IDSA 2007.File TM. Lancet 2003; 362: 1991–2001.

Patient type EtiologyOutpatient Streptococcus pneumoniae

Mycoplasma pneumoniaeHaemophilus influenzaeChlamydophila pneumoniaeRespiratory virusesa

Inpatient (non-ICU) S. pneumoniaeM. pneumoniaeC. PneumoniaeH. influenzaeLegionella speciesAspirationRespiratory virusesa

Inpatient (ICU) S. pneumoniaeStaphylococcus aureusLegionella speciesGram-negative bacilliH. influenzae

a influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza.

Radiology and specific pathogen

Cavitation:• S. aureus, Gram-negative bacteria, and anaerob

es• Rare: viral or Mycoplasma pneumonia

Bulging fissure sign:• Lobar enlargement with bulging or ballooning of i

ntralobar fissure• Klebsiella pneumonia (in alcoholics)

B ulging fissure sign

20,50. A 50-YO alcoholic was found delirious with a high fever and coughing up sticky, dark brown sputum. CXR: consolidation of RUL with sagging of the interlobar septum. The most likely Dx is:

A. Pneumococcal pneumoniaB. Staphylococcal pneumoniaC. Klebsiella pneumoniaD. Pseudomonas pneumoniaE. Anaerobic pneumonia

5. Which is most reliable for Dx or pneumococcal pneumonia?

A. Sputum C/S shows S. pneumoniaB. Sputum examination shows adequate

sputum with many GP “lancet-shaped” cocci in pairs

C. CXR: a lobar pattern of infiltrationD. Classic clinical symptom of multiple

shaking chills E. All of the above

CAP: Etiologic Dx

Definite:• Compatible clinical syndrome plus• Recovery of a probable etiologic agent

from an uncontaminated specimen (blood, pleural fluid, transtracheal aspirate, or transthoracic aspirate) or

• Recovery from respiratory secretions of a likely pathogen that does not colonize the upper airways (e.g. M.tuberculosis, Legionella spp., influenza virus, or P.carinii)

IDSA 2000.

CAP: Etiologic Dx

Probable:• Compatible clinical syndrome plus• Detection (by staining or culture) of a

likely pulmonary pathogen in respiratory secretions (expectorated sputum, bronchoscopic aspirate, or quantitatively cultured bronchoscopic BALF or brush catheter specimen)

(B-II)

IDSA 2000.

5. Which is most reliable for Dx or pneumococcal pneumonia?

A. Sputum C/S shows S. pneumonia less sens and spec

B. Sputum examination shows adequate sputum with many GP “lancet-shaped” cocci in pairs sens 50-60% spec >80%

C. CXR: a lobar pattern of infiltrationD. Classic clinical symptom of multiple

shaking chills E. All of the above

5. ♀ 86 Y-O; acute stroke with respiratory failureD7: acute fever + consolidation at RULS/G: intracellular GNB

Empirical ATB?

A. CeftriaxoneB. CeftazidimeC. Cefepime + amikacinD. Cefpirome + metronidazole E. Ciprofloxacin

5. ♀ 86 Y-O; acute stroke with respiratory failure. D7: acute fever + consolidation at RULS/G: intracellular GNB

Empirical ATB?

VAP (GNB)

Am J Respir Crit Care Med 2005(171):388–416.

ATS + IDSA

Definition

• HAP:

Pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission

• VAP:

Pneumonia that arises more than 48–72 hours after endotracheal intubation

Diagnosis (Clinical strategy)

Sensitivity Specificity

CXR infiltrates + 2/3 of

1.fever or 2.leukocytosis/leukopenia or 3.purulent secretions

69% 75%

Fabregas N; et al. Thorax 1999Oct;54(10):867-73.

• Antimicrobial therapy in preceding 90 day• Current hospitalization ≥5 d• High frequency of antibiotic resistance in the

community or in the specific hospital unit• Presence of risk factors for HCAP:

– Hospitalization ≥2 d in the preceding 90 d– Residence in a nursing home or extended care facility– Home infusion therapy (including antibiotics)– Chronic dialysis within 30 d– Home wound care– Family member with MDR-pathogen

• Immunosuppressive disease and/or therapy

ATS2005Risk Factors for MDR-pathogens causing HAP/HCAP/VAP

Combination Therapy• Pseudomonas aeruginosa bacteremia • Broad-spectrum empirical Rx • Pseudomonas aeruginosa

30-50% develop resistance• Severe disease, bacteremia ?

Monotherapy vs. Combination Therapy ?

Initial Antibiotic Therapy

• Initial antibiotic should be given promptly because delays in administration may add to excess mortality resulting from VAP (Level II)

• Initial empiric therapy is more likely to be appropriate if a protocol for antibiotic selection is developed on the basis of the recommendation, but adapted to local patterns of antibiotic resistance, with each ICU collection this information and updating it on regular basis (Level II)

ATS/IDSA2005

Combination Therapy

• No data have documented the superiority of combination therapy compared with monotherapy, except to enhance the likelihood of initially appropriate empiric therapy (Level I)

• Combination therapy should be used if patients are likely to be infected with MDR pathogens (Level II)

• If the patients receive combination therapy with aminoglycoside-containing regimen, the aminoglycoside can be stopped after 5-7 days in responding patients (Level III)

ATS/IDSA2005

Combination Therapy

• Monotherapy with selected agents can be used for patients with severe HAP/VAP in the absence of resistant organisms (Level I)

• If patients receive an initially appropriate antibiotic regimen, duration of therapy should be shortened to 7 days instead of 14-21 days, provided that the etiologic pathogen is not P. aeruginosa and the patient has good clinical response, with resolution of clinical features of infection (Level I)

ATS/IDSA2005

Assessing Response to Therapy

• A serial assessment of clinical parameters should be used to define the response to initial antibiotic therapy (Level II)

• Clinical improvement usually takes 48-72 hours and thus therapy should not be changed during this time unless there is a rapid clinical decline (Level III)

• Non-response to therapy is usually evident by day 3, using clinical parameters (Level II)

ATS/IDSA2005

HAP or VAP Suspected(All Disease Severity)

Late Onset (≥5 d) or Risk Factors for Multi-drug Resistant (MDR) Pathogens

Limited SpectrumAntibiotic Therapy

Broad Spectrum Antibiotic Therapy

For MDR Pathogens

Empiric Antibiotic Therapy for HAP

ATS/IDSA2005

Potential Pathogen Recommended AntibioticsS. PneumoniaeH. InfluenzaeMSSAATB-sensitive enteric GNB- E. coli- K. pneumoniae- Enterobacter spp.- Proteus spp.- Serratia marcescens

Ceftriaxone orLevofloxacin, moxifloxacin, or ciprofloxacin orAmpicillin/sulbactam orErtapenem

ATS2005

Initial Antibiotic Therapy:No Risk Factors for MDR-pathogens, Early onset, and Any Disease Severity

ATS/IDSA2005

Potential Pathogen Recommended AntibioticsPathogens listed above and MDR-pathogen- P. aeruginosa- K. pneumoniae (ESBL+)- Acinetobacter spp.

- MRSALegionella pneumophila

Antipseudomonal cephalosporin (cefepime, ceftazidime) orAntipseudomonal carbapenem (imipenem or meropenem) orBL/BI (piperacillin/tazobactam) plusAntipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) or Aminoglycoside (amikacin, gentamicin, or tobramycin) plusLinezolid or vancomycin

ATS2005

Initial Antibiotic Therapy:Late onset, or Risk Factors of MDR-pathogen, and Any Disease Severity

ATS/IDSA 2005

5. ♀ 86 Y-O; acute stroke with respiratory failure D7: acute fever + consolidation at RULS/G: intracellular GNB

Empirical ATB?

VAP (GNB)Late onset

Optimal Antibiotics Dosing for Empiric Therapy

ATS/IDSA2005

33. 58 YO COPD: respiratory failure ET on MV

D3 of MV: fever, ↑ dyspnea, greenish sputum

CXR: RUL infiltration. Sputum G/S: GNB.Most proper medication?

A. Cloxacillin + AmikinB. Ampicillin + AmikinC. Any 2nd generation cephalosporins +

AmikinD. Any 3rd generation cephalosporins aloneE. Ceftazidime + Amikin

33. 58 YO COPD: respiratory failure ET on MV

D3 of MV: fever, ↑ dyspnea, greenish sputum

CXR: RUL infiltration. Sputum G/S: GNB.Most proper medication?

A. Cloxacillin + AmikinB. Ampicillin + AmikinC. Any 2nd generation cephalosporins +

AmikinD. Any 3rd generation cephalosporins aloneE. Ceftazidime + Amikin

52. HIV patient: chronic non-productive cough and DOE for 4 mo.

CXR: diffuse alveolar-interstitial infiltration.Which of the followings that the patient can

be, EXCEPT

A. Pulmonary TBB. PCPC. Pulmonary cryptococcosisD. CMV pneumoniaE. None of the above

52. HIV patient: chronic non-productive cough and DOE for 4 mo.

CXR: diffuse alveolar-interstitial infiltration.Which of the followings that the patient can

be, EXCEPT

A. Pulmonary TBB. PCPC. Pulmonary cryptococcosisD. CMV pneumoniaE. None of the above

Pleural DiseasesPleural Diseases

11. ♀ 52 Y-O: severe pneumonia on ventilator (PCV + PEEP)Subclavian catheterization 10% Rt. PNX

Most proper Mx?

A. ↑ FiO2 to 1.0

B. Simple aspirationC. Tube thoracostomyD. Discontinuation of PEEPE. Change to PSV mode

11. ♀ 52 Y-O: severe pneumonia on ventilator (PCV + PEEP)Subclavian catheterization 10% Rt. PNX

Most proper Mx?

A. ↑ FiO2 to 1.0

B. Simple aspirationC. Tube thoracostomyD. Discontinuation of PEEPE. Change to PSV mode

Iatrogenic Pneumothorax

• Treatment: tends to be simple as there is less likelihood of recurrence– Observation alone in majority– Simple aspiration

• Patients with COPD are more likely to require tube drainage

• Patients who on positive pressure ventilation should be treated with a chest drain unless immediate weaning is possible

22. ♂ 26 YO, healthy: first episode of 30% Rt. pneumothorax. Optimal Tx?

A. ObservationB. Simple aspirationC. Tube thoracostomyD. Tube thoracostomy with pleurodesisE. Open thoracotomy

22. ♂ 26 YO, healthy: first episode of 30% Rt. pneumothorax. Optimal Tx?

A. Observation: only for pneumothorax <15% B. Simple aspirationC. Tube thoracostomyD. Tube thoracostomy with pleurodesisE. Open thoracotomy

Observation and Supplemental O2

• PSP– Small (<2 cm), asymptomatic– Outpatient + counseling

• SSP– <1 cm or isolated apical pneumothorax, asymptomatic

– Admit + supplement O2

BTS guideline 2003

Simple Aspiration

• PSP– All that need intervention (≥2 cm, symptomatic)

• SSP– <2 cm and age <50 in mild symptomatic– Except: <1 cm or isolated apical, asymtomatic

observe– Simple aspiration admit for observation for at least

24 hours, with prompt progression to ICD if needed– Active treatment of underlying lung disorder

BTS guideline 2003

Tube Thoracostomy:

• I/C for tube thoracostomy or thoracoscopy– Failed aspiration treatment– SSP (except <2 cm, asymptomatic, age <50)– Recurrent spontaneous pneumothorax– Hemopneumothorax

• Chest tube can be removed after 24 hr if there is no radiographic/clinical evidence of recurrence of pneumothorax

BTS guideline 2003

I/C for operative intervention

• 2nd ipsilateral pneumothorax• 1st contralateral pneumothorax• Bilateral spontaneous pneumothorax• Persistent air leak (>5–7 d of tube drainage; air l

eak or failure to completely re-expand)• Spontaneous haemothorax• Professions at risk (e.g. pilots, divers)

Recurrent PNX

BTS guideline 2003

PRIMARY PNEUMOTHORAX

Breathless and/or rim of air >2 cm on CXR?

Aspiration

Successful?

Consider repeat aspiration

Successful?

Intercostal drain

Referral to chest physician within 48 hSuction?

Referral to thoracic surgeon after 5 days

Consider discharge

Remove 24 h after full re-expansion/cessation of air leak without clamping

BTS guideline 2003

SECONDARY PNEUMOTHORAX

Breathless + age >50 Y + rim of air >2 cm on CXR?

Aspiration

Successful?

Intercostal drain

Successful?

Referral to chest physician after 48 h Suction?

Early discussion with surgeon after 3 days

Consider discharge

Remove 24 h after full re-expansion/cessation of

air leak

Admit to hospital for 24 h

Comparison of Guideline Recommendations (Clinically stable patients)

Guideline Definition of large PSP

Small PSP Large PSP

ACCP 2001

>3 cm apical interpleural distance

Observation in ED followed by conservative management as an outpatient

Pleural catheter insertion [tube thoracostomy] and drainage

BTS 2003

Presence of a visible rim of 2 cm between lung and chest wall

Conservative management as outpatient

Simple aspiration

25. ♀ 62 YO: fever and Lt. pleurisy for 2 wkPF analysis: RBC 8000/mm3

WBC 2500/mm3 (N 8%, L 92%, mesothelial cell -)

PF/S P 4.0/7.2 (0.55) PF/S LDH 200/125 (1.60)PF/S sugar 40/108 (0.37)

Which is the MOST likely Dx?A. Malignant pleural effusionB. Lupus pleuritisC. TB pleuritisD. Pleural effusion in RAE. Pulmonary embolism

Assessment of the Patient With a Pleural Effusion

• Symptomatic or asymptomatic at presentation?• Duration of pleural effusion?• Resolution by time interval?• Associated with other CXR abnormalities?• PF analysis: Exudates or transudates?

Asymptomatic• Benign asbestos

pleural effusion• Rheumatoid pleurisy• Nephrotic syndrome• Hypoalbuminemia• Urinothorax• Peritoneal dialysis• YNS

Symptomatic• Bacterial pneumonia• Lupus pleuritis• Post-cardiac injury

syndrome• Carcinomatous

pleural effusion• Pulmonary embolism• CHF

Asymptomatic or Symptomatic at Diagnosis

Light’s criteria for exudates:

if any one of the following criteria are fulfilled:

1) PF LDH >⅔ ULN of serum LDH2) PF/serum protein ratio >0.53) PF/serum LDH ratio >0.6

High sensitivity (98%) but lowers specificity(74%)

Transudates vs Exudates

Heffner JE; Brown LK; Barbieri CA. Chest 1997 Apr;111(4):970-80.

Meta-analysis: 8 studies; 1,448 patientsAll of the following tests have statistically similar diag

nostic accuracy compared with Light’s criteria:

• PF protein >3 (2.9) g/dL• PF/serum protein >0.5• PF cholesterol >45 (54, 55 or 60) mg/dL• PF LDH >60% (0.45) of ULN• PF LDH/serum >0.6• PF/serum cholesterol ratio >0.3• Albumin gradient <1.2 g/dL

Heffner JE; Brown LK; Barbieri CA. Chest 1997 Apr;111(4):970-80.

Sens 87%, Spec 92%

Sens 75%, Spec 80%

Sens 89%, Spec 81%

Transudates vs Exudates

PF Lymphocyte Predominant (>80%) Exudate* (1)

*Consistently but not always >80%; other exudates rarely have 80% lymphocytes

Disease Comment

Tuberculous pleurisy A common cause of exudate; usually 90-95% lymphocytes; acutely, may be PMN predominant

Chylothorax 2,000-20,000 lymphocytes/mL; most common cause is NHL

Lymphoma Often 100% of nucleated cells are lymphocytes; diagnostic yield on cytology or pleural biopsy higher with NHL

*Consistently but not always >80%; other exudates rarely have 80% lymphocytes

Disease Comment

Chronic rheumatoid pleurisy

Often associated with trapped lung/lung entrapment

Sarcoidosis Usually >90% lymphocytes; effusion in >2% of sarcoid patients; discordant exudate (by protein only)

Post-CABG effusions (>2 mo) including PCIS

82-99% lymphocytes; unilateralon left or bilateral; lung entrapment

PF Lymphocyte Predominant (>80%) Exudate* (2)

Diagnosis Usual pH (Incidence) Usual Glucose, mg/dL (Incidence)

Complicated parapneumonic and empyema

4.50–7.29 (~100%) <40 (can be 0) (100%)

Esophageal rupture 5.50–7.00 (~100%) <60 (can be 0) (80-100%)

Tuberculous empyema 6.90–7.05 (100%) 0–30

Chronic rheumatoid pleurisy

7.00 (80%) 0–30 (85%)

Malignancy 6.95–7.29 (33%) 30–59 (30%)

Tuberculous pleural effusion

7.00–7.29 (20%) 30–59 (20%)

Rheumatoid pleurisy 7.15-7.29 (15%) 30-59 (15%)

Diagnoses Associated With PF Acidosis (pH <7.30) and Low Glucose (PF/Serum <0.5)

• PF Analysis: – Always exudative; serous, may be serosanguinous

(10%), never frankly bloody – Total protein >5.0 g/dL (77%)– Nucleated cells 2,000-8,000/µg; classically >90-95

% lymphocytes, 90% have >60% lymphocytes; PMN predominant with acute TB pleuritis and TB empyema

– PF eosinophilia and >5% mesothelial cells make TB unlikely

– Glucose <60 mg/dL, pH <7.30 (20%) [never ≥7.40]

Tuberculous Pleurisy

• Diagnosis:

– PF ADA >40-60 U/L supports the diagnosis if R/O RA and empyema (<40 U/L high NPV for TB)

Tests Sensitivity, %

Pleural biopsy histology 63–85

Pleural biopsy culture 55–80

Pleural fluid culture 13–70

Sputum culture 4–50 (4% with isolated effusion)

Pleural biopsy AFB 5–18

Pleural fluid AFB <5

Give Dx up to 86%

Tuberculous Pleurisy

25. ♀ 62 YO: fever and Lt. pleurisy for 2 wkPF analysis: RBC 8000/mm3

WBC 2500/mm3 (N 8%, L 92%, mesothelial cell -)

PF/S P 4.0/7.2 (0.55) PF/S LDH 200/125 (1.60)PF/S sugar 40/108 (0.37)

Which is the MOST likely Dx?A. Malignant pleural effusionB. Lupus pleuritisC. TB pleuritisD. Pleural effusion in RAE. Pulmonary embolism

Lymphocytic exudate

23. ♀ 50 Y-O, DM, non-smokerTightness of Lt. chest and low-grade fever 2 wkCXR: Lt. pleural effusionPleural tapping: straw-colour, lymphocytic exudatePleural cyto.: suspected malignancyPleural Bx: chronic pleuritis

Most appropriate Mx?A. Repeat thoracentesis for cytology and pleural BxB. BronchoscopyC. CT chestD. AntiTB drugsE. U/S whole abdomen

23. ♀ 50 Y-O, DM, non-smokerTightness of Lt. chest and low-grade fever 2 wkCXR: Lt. pleural effusionPleural tapping: straw-color, lymphocytic exudatePleural cyto.: suspected malignancyPleural Bx: chronic pleuritis

Most appropriate Mx?A. Repeat thoracentesis for cytology and pleural BxB. BronchoscopyC. CT chestD. AntiTB drugsE. U/S whole abdomen

44% 62% 95%

74% 96%

3 cytology: positive diagnosis 70-80%

The yield is less with squamous cell carcinoma, Hodgkin’s disease, sarcoma

Hamm H, Light RW. Eur Respir J 1997; 10: 476-81.

Closed pleural biopsy Fluid cytology Medical thoracoscopy

27. Alcoholic patient: low-grade fever 7 dPE: pleural effusion 1/3 of Lt. lungCBC: Hct 34%, WBC 18000 (N70%)Pleural tapping: yellow turbid, WBC 800 (N70%), glucose 49/90, LDH 294; G/S: GP cocci and GN rod

Most appropriate Mx?A. Ceftriaxone iv. and azithromycin iv.B. BL/BI iv.C. Ertapenem iv. + repeat PF analysis in next 24 hD. BL/BI iv. and ICDE. Cefepime iv. and ICD

27. Alcoholic patient: low-grade fever 7 dPE: pleural effusion 1/3 of Lt. lungCBC: Hct 34%, WBC 18000 (N70%)Pleural tapping: yellow turbid, WBC 800 (N70%), glucose 49/90, LDH 294; G/S: GP cocci and GN rod

Most appropriate Mx?A. Ceftriaxone iv. and azithromycin iv.B. BL/BI iv.C. Ertapenem iv. + repeat PF analysis in next 24 hD. BL/BI iv. and ICDE. Cefepime iv. and ICD

1. Uncomplicated effusion: small-to-moderate effusions that resolve with ATB only without pleural space sequelae

2. Complicated effusion: requires pleural space drainage for resolution of pleural sepsis

3. Empyema: pus in pleural space

DefinitionParapneumonic effusion

CXR & CT:• Large effusion (>40%

of hemithorax)• Air-fluid level• Loculation• Pleural enhancement/

thickening (>5 mm)

Clinical features:• Prolonged symptoms• Anaerobic infection• Failure to respond to

ATB• Virulence of bacterial

pathogen

Complicated effusion: needs to be drainage

Pleural analysis:• Gross pus (absolute I/C for drainage)• Positive Gram stain• Positive bacterial culture• Low pH (<7.30 or <7.20) • Low glucose (PF/serum ratio <0.5) • High LDH (>1,000 IU/L)

Complicated effusion: needs to be drainage

4. ♀ 53 Y-O: abdominal distension 3 moPE: ascites without sign of CLDU/S: ascites, Rt. pleural effusion, normal liver & spleen, solid/cystic mass Ø 5 cm at Rt. AdxPleural & ascitic fluid: straw colored, transudate, malignant cell –ve

Most likely Dx isA. Meigs syndromeB. Krukenberg’s tumorC. Carcinomatosis peritoniiD. Ovarian tumor with cirrhosisE. Ovarian tumor with TB peritonitis

Most likely Dx isA. Meig’s syndromeB. Krukenberg’s tumorC. Carcinomatosis peritoniiD. Ovarian tumor with cirrhosisE. Ovarian tumor with TB peritonitis

Krukenberg tumor

• Ovarian metastasis (goblet-cell carcinoma: adenocarcinoid; signet ring cell)

• Primary malignancy: GI tract (stomach, intestine)• Ascites is usually associated with the tumor

Meigs' syndrome

3 cardinal features:

1. Benign ovarian tumor (fibroma)

2. Ascites and pleural effusion

3. If the tumour is resected, the fluid resolves

Meigs’ syndrome

• Fluid accumulation is probably related to – ? Secretion of fluid from the tumour– ? Substances like VEGF (vascular endothelial

growth factor) that raise capillary permeability• Tends to be right sided but can be bilateral • Fluid analysis

– To DDx malignant ascites/MPE– Transudate although sometimes exudate

Most likely Dx isA. Meig’s syndromeB. Krukenberg’s tumorC. Carcinomatosis peritoniiD. Ovarian tumor with cirrhosisE. Ovarian tumor with TB peritonitis

Pseudomyxoma peritonei

• Intraperitoneal mucinous spread originating from a cystadenoma of the appendix

• Jelly belly

26. ♀ 60 Y-O, DM, smoker: ACS + anticoagulant4 d later: Rt. pleuritic chest pain pleural effusion (1/3 of hemithorax) pleural tapping

- Serosanguinous fluid- WBC 900 (L80%) RBC 140000- LDH 350/600 [0.58], P 2.8/6.0 [0.47]

Most relevant further Ix?A. Pleural fluid cytologyB. CT chestC. Pleural ADAD. Pleural fluid Alb gradientE. Pleural Bx

Post-MI Pleural effusion

Post-cardiac injury syndrome ?

• After cardiac surgery (up to 30%); MI (1-15%)• Clinical:

– Pleuritic chest pain >90%; fever, pericardial rub, dyspnea, and crackles (all >50%)

– 3 wks (2-86 days) following MI ESR (100%; mean, 62 mm/h); WBC (50%)

Postcardiac Injury Syndrome (PCIS)

• CXR: – Pleural effusion 83% (Lt sided/bilateral), Rt si

ded only 17%– LLL infiltrates and cardiac silhouette

• PF Analysis: – Serosanguinous or bloody, 70%– 500-39,000 nucleated cells/µL; PMNs early – PF = serum glucose; pH >7.30 Complement; PF/serum AMA >1.0

Postcardiac Injury Syndrome (PCIS)

Pulmonary Vascular DiseasesPulmonary Vascular Diseases

20. ♂ 65 Y-O: sudden dyspnea + pleurisy Rt. Hx: knee replacement Sx 10 d agoPE: T 38, PR 112, BP 100/60, RR 28, CVS&RS –

veABG (RA): pH 7.48, pCO2 32, pO2 65. CXR: -veV/Q lung scan: intermediate probability for PE

Appropriate further Mx?A. Leg doppler U/SB. CTPAC. Intravenous heparinD. Streptokinase heparinE. Close observe and repeat V/Q scan after 48 h

Clinical: high probability

Van Belle A, et al. JAMA2006;295:172.

Determine if “PE unlikely” or “PE likely”

PE unllikely PE likely

D-dimer

<500 ng/mL >500 ng/mL

PE excluded

Spiral CT pulmonary angiogram (CT-PA)

Negative Positive

PE excluded PE confirmed

Further Ix

Clinical + D-dimer + Spiral CT

23. ♂ 52-YO obese admit in CCU (inferior wall MI).

D3: sudden apprehension, substernal chest discomfort and dyspnea

PE: BP 80/60, distended JVP, RV lift and ↑ P2

ABG: PaO2 38What is your further Mx?

A. EKG for V3R, V4RB. EchoC. Pulmonary angiographyD. Left-sided cardiac catheterizationE. Emergency coronary bypass procedure

23. ♂ 52-YO obese admit in CCU (inferior wall MI).

D3: sudden apprehension, substernal chest discomfort and dyspnea

PE: BP 80/60, distended JVP, RV lift and ↑ P2

ABG: PaO2 38What is your further Mx?

A. EKG for V3R, V4RB. EchoC. Pulmonary angiographyD. Left-sided cardiac catheterizationE. Emergency coronary bypass procedure

24. According to the above patient, he was Tx with O2 flow 6 L/min via nasal cannula.

Expected PaO2?

A. 50 mm HgB. 100 mm HgC. 150 mm HgD. 200 mm HgE. 250 mm Hg

24. According to the above patient, he was Tx with O2 flow 6 L/min via nasal cannula.

Expected PaO2?

A. 50 mm HgB. 100 mm HgC. 150 mm HgD. 200 mm HgE. 250 mm Hg

14. Most sensitive to exclude pulmonary embolism?

A. Normal HRCT chestB. Normal D-dimer (ELISA)C. Normal PaO2 (RA)

C. Absence of RVH with strain on ECGE. Intermediate probability result of V/Q scan

14. Most sensitive to exclude pulmonary embolism?

A. Normal HRCT chestB. Normal D-dimer (ELISA)C. Normal PaO2 (RA)

C. Absence of RVH with strain on ECGE. Intermediate probability result of V/Q scan

29. ♀ 35 Y-O: SLE + APL on high dose PDN + CYCDyspnea + Lt.pleuritic chest pain + hemoptysis 1 dPE: T 38.1, scant crackle at LLLCXR: blunting Lt. CP angle, no definite infiltrationCBC: Hb 10, WBC 4000 (N76%) plt 210000ABG (RA): pH 7.47, pO2 60, pCO2 30

Ceftriaxone. Next step in Mx?A. V/Q lung scanB. FOB with BALC. Diagnostic thoracentesisE. TMP/SMX ivD. Methylprednisolone 1g iv. OD x 3 d

1. Lupus pneumonitis

2. Pulmonary embolism

3. Pulmonary hemorrhage

4. Bacterial pneumonia

5. PCP

Acute Lupus Pneumonitis

• Acute or subacute onset of tachycardia, tachypnea, dyspnea, cyanosis, fever, and cough

• Hemoptysis is infrequent, and clubbing is absent• Association with multiple systemic disease • PE: fine/coarse rale, but sign of pleurisy are rare• ABG: marked hypoxemia [↑ (A-a)DO2] and hyper

ventilation• Most common: air space consolidation

– Unilat./bilat., focal/diffuse, but it tends to lower lung zones

Pulmonary Hemorrhage Diffuse Alveolar Hemorrhage (DAH)

• Triad of anemia, air-space consolidation, and hemoptysis

• CXR: bibasal patchy, alveolar infiltration may become normal within 2-4 days with cessation of bleeding

1. Lupus pneumonitis

2. Pulmonary embolism

3. Pulmonary hemorrhage

4. Bacterial pneumonia

5. PCP

Pleuropulmonary manifestation in SLE

Parenchymal disease• Acute lupus pneumonitis• Interstitial pneumonitis and

fibrosis (IPF)• BOOP• Pulmonary hemorrhage

(DAH)Vascular disease• Thromboembolic disease• Pulmonary hypertension

Pleural disease• Pleuritis ± effusionAirway disease• Obliterative bronchiolitis• Upper airway dysfunction

(epiglottitis, laryngitis, cricoarytenoid arthritis)

• BronchiectasisNeuromuscular disease• Diaphragmatic dysfunction• Shrinking lungs

MalignancyMalignancy

18. ♀ 50 Y-O: Rt. shoulder pain 2 moCT: Ø 5x6 cm mass at Rt. lung apex + 1st rib destruction. LN –ve. Liver & adrenal gland –veBone scan: ↑ uptake at Rt. 1st rib. Others –veDLT: squamous cell carcinoma

A. RUL lobectomy CMTB. RUL lobectomy RTC. RT en bloc resectionD. RT CMTE. CMT alone

NSCLCØ 5x6 cm mass

1st rib destructionLN –ve

Liver & adrenal –veStage II B

28. In patients who have an NSCLC invading the cccc t wall ccc ccc ccccc cccccccccc ccc cccccccc cccccc

surgical resection, cccccccc c cccccccccc ccccccc ccc ccccccccccccc cc ccccc (head CT/MRI plus either

- whole body PET or abdominal CT plus bone scan) a re recommended. Involvement of mediastinal nod es and/or metastatic disease represents a contrain

dication to resection, and definitive chemoradioth erapy is recommended for these patients.

cc cccccccccccccc cc2 29. At the time of resection of a tumor invading th

e chest wall, we recommend that every effort be m ade to achieve a complete resection .

1Grade of recommendation B

Special Treatment Issues in Lung Cancer

- 2ACCP Evidence Based Clinical Practice Guidelines ( nd Editi)

Shen KR, et al. Chest 2007;132:290S-305S.

Chest wall tumor: Mx

NSCLS IIB (T3N0M0: chest wall)

28. 58 YO smoker: 3 cm lung nodule. TBBx: SCCA. No evidence of metastasis or LN.

Tx of choice?

A. RTB. Pulmonary resectionC. ChemotherapyD. Combined RT + CMTE. Combined RT + surgical resection

28. 58 YO smoker: 3 cm lung nodule. TBBx: SCCA. No evidence of metastasis or LN.

Tx of choice?

A. RTB. Pulmonary resectionC. ChemotherapyD. Combined RT + CMTE. Combined RT + surgical resection

T1N0M0 IA

13,45. Central necrosis and cavitation occur most frquent in which of the following cell types of lung cancer?

A. Oat cellB. Giant cellC. AdenocarcinomaD. Squamous cellE. Bronchiolar

13,45. Central necrosis and cavitation occur most frquent in which of the following cell types of lung cancer?

A. Oat cellB. Giant cell: large (41%), pericheral (61%)C. Adenoca: peripheral (65%), nodule (72%)D. Squamous cell: central (64%), cavitate (5%)E. Bronchiolar: peripheral nodule (60%)

9,39. Which of the following complications of lung cancer is an indication for RT?

A. Pleural involvementB. Cerebral involvementC. Pericardial involvementD. Hepatic involvementE. Lymphatic involvement

9,39. Which of the following complications of lung cancer is an indication for RT?

A. Pleural involvementB. Cerebral involvementC. Pericardial involvementD. Hepatic involvementE. Lymphatic involvement

32. 68 YO smoker: 2 wk blood-streaked sputum and increasing weakness.

PE: generalized weakness w/o focal neuro. deficit

Lab: Hct 34%, Na 143, K 4.5, Cl 104, HCO3 25, Ca 12.5, AP 73 U/L

CXR: Rt. hilar fullness. Bone scan normal. Dx?

A. Bronchial carcinoid tumorB. Ectopic parathyroid adenomaC. Squamous cell lung cancerD. Small cell lung cancerE. Pulmonary TB

32. 68 YO smoker: 2 wk blood-streaked sputum and increasing weakness.

PE: generalized weakness w/o focal neuro. deficit

Lab: Hct 34%, Na 143, K 4.5, Cl 104, HCO3 25, Ca 12.5, AP 73 U/L

CXR: Rt. hilar fullness. Bone scan normal. Dx?

A. Bronchial carcinoid tumor (unrelated to smoking, age <50, wheez/hemoptysis, ACTH)

B. Ectopic parathyroid adenomaC. Squamous cell lung cancer (PTHrP)D. Small cell lung cancerE. Pulmonary TB

46. 40-YO smoker: coin lesion in RML field.What is the following informations should be

obtained to help in Mx?

A. Previous CXRB. Hx of previous pulmonary illnessC. CT to detect the calcificationD. History of chronic smokingE. All of the above

46. 40-YO smoker: coin lesion in RML field.What is the following informations should be

obtained to help in Mx?

A. Previous CXRB. Hx of previous pulmonary illnessC. CT to detect the calcificationD. History of chronic smokingE. All of the above

16. ♂ 50 Y-O: dyspnea, chest pain, facial swellingPE: edema of face + both arms, dilated superficial v. at chest and Rt. SPC LN +veCXR: Rt. hilar mass and RUL mass + atelectasisLasix symptoms improved

Most appropriate Mx?

A. Anticoagulant B. RTC. DexamethasoneD. Lymph node BxE. Serum tumor marker

16. ♂ 50 Y-O: dyspnea, chest pain, facial swellingPE: edema of face + both arms, dilated superficial v. at chest and Rt. SPC LN +veCXR: Rt. hilar mass and RUL mass + atelectasisLasix symptoms improved

SVC syndrome

Superior Vena Caval Syndrome

• Symptomatic obstruction is often a prolonged process developing over a period of weeks or longer prior to clinical presentation

• Deferring therapy until a full diagnostic work-up has been completed does not pose a hazard for most patients

• RT prior to biopsy may obscure the histologic diagnosis

16. ♂ 50 Y-O: dyspnea, chest pain, facial swellingPE: edema of face + both arms, dilated superficial v. at chest and Rt. SPC LN +ve, stridorCXR: Rt. hilar mass and RUL mass + atelectasis

Superior Vena Caval Syndrome

• Current management strategies stress the importance of accurate diagnosis of the underlying etiology prior to starting therapy

• Exception: stridor (central airway obstruction or severe laryngeal edema) true medical emergency emergency RT ↓ risk of sudden respiratory failure

CTD and LungCTD and Lung

31. ♀ 40 Y-O: Exertional dyspnea 3 moRaynaud’s phenomenon, sclerodactyly, tight skin of face-hands-forearms, mat-like telangiectasia and +ve ANA (1:1280 centromere and speckle)

Most likely cause of dyspnea?A. Chronic pulmonary embolismB. PAHC. IPFD. Pulmonary alveolitisE. BOOP

31. ♀ 40 Y-O: Exertional dyspnea 3 moRaynaud’s phenomenon, sclerodactyly, tight skin of face-hands-forearms, mat-like telangiectasia and +ve ANA (1:1280 centromere and speckle)

Most likely cause of dyspnea?A. Chronic pulmonary embolismB. PAHC. IPFD. Pulmonary alveolitisE. BOOP

CREST syndrome

Pulmonary involvement• Interstitial pulmonary fibrosis• Isolated pulmonary vascular disease • Organizing pneumonia• Aspiration pneumonia secondary to esophageal

dysmotility• Chest wall restriction• Scar cancer related to long-term lung fibrosis

Systemic Sclerosis

• A pulmonary arteriopathy occurs in limited systemic sclerosis especially in CREST variant

• At autopsy, 80% of CREST syndrome have histopathological changes consistent with PAH, but only 10-15% have clinically significant pulmonary hypertension

• Association between PAH and Raynaud’s phenomenon similarities in pathogenesis of these vasculopathies

Scleroderma

• Pulmonary symptoms are rare presenting manifestation, dyspnea, cough or hemoptysis usually in late stages

• Extent of skin involvement does not correlate with lung function changes

• Digital clubbing is extremely rare

• Fibrosis is increase in serum anti Scl-70 antibody (anti-DNA topoisomerase) 40% of case with diffuse lesion

Interstitial pneumonitis and fibrosis

15. ♀ 55 Y-O: RA on diclofenac 100 mg/d, MTX 10 mg/wk, chloroquine 250 mg/d for 6 moFever and dry cough 1 wkRoxithromycin 300 mg/d not improvedHct 35%, WBC 7500 (N 75%, L 20%, Eo 5%)CXR: interstitial infiltration of both lung field

Most likely Dx?

A. Rheumatoid lungB. Chloroquine toxicityC. MTX toxicityD. CAPE. PCP

Most likely Dx?

A. Rheumatoid lung (RA-ILD)B. Chloroquine toxicityC. MTX toxicityD. CAPE. PCP

Most likely Dx?

Pulmonary complications from MTX

Opportunistic infections • PCP, CMV, Herpes zoster, fungal, mycobacterialNoninfectious conditions • Hypersensitivity pneumonitis • BOOP• Acute lung injury (noncardiogenic pulmonary

edema) • Pulmonary fibrosis • Asthma/hyperreactive airways disease • Pleuritis and/or pleural effusion ? Neoplasm: lymphoma

Risk factors of pulmonary toxicity

• Age greater than 60 years • Rheumatoid pleuropulmonary involvement • Previous use of DMARDs • Hypoalbuminemia (either before or during therapy) • Diabetes mellitus• Higher doses of MTX• Daily, rather than weekly drug administration• Preexisting lung disease• Abnormal PFTs prior to therapy• Concomitant use of drugs which ↓ protein binding of

MTX (eg, aspirin, sulfonamides, chlorambucil, penicillin, phenylbutazone, phenytoin, barbiturates, NSAIDs)

• ↓ Elimination of MTX (eg, renal insufficiency, ascites)• ? Pharmacogenetics

Clinical manifestations

• Acute, subacute (most common), or chronic form• Within the first year of therapy (12 d - 18 y)• Nonspecific: fever, chills, malaise, non-produtive

cough, dyspnea, chest pain, cyanosis• Acute pneumonitis:

– 2-5% of patients treated for RA– Progressive over several weeks

• Subacute pneumonitis:– Progression to pulmonary fibrosis in 10% of patients– Pleural effusions are uncommon– 17% of patients also have cutaneous manifestations of

MTX toxicity– Up to 50% demonstrate peripheral eosinophilia

Most likely Dx?

3. The X-ray appearance of uremic lungs is very similar to:

A. Pulmonary hemosiderosisB. Acute pulmonary edemaC. Miliary tuberculosisD. Bronchilolalveolar cell carcinomaE. None of the above

3. The X-ray appearance of uremic lungs is very similar to:

A. Pulmonary hemosiderosisB. Acute pulmonary edemaC. Miliary tuberculosisD. Bronchilolalveolar cell carcinomaE. None of the above

49. If the anaerobic lung abscess patient fails to respond to the PGS 12 Mu/day Tx for 5 days.

What will you do next?

A. Changing ATB to ClindamycinB. Adding the AminoglycosideC. Checking the adequacy of the postural

drainageD. Do A&C togetherE. Changing ATB to Quinolones

49. If the anaerobic lung abscess patient fails to respond to the PGS 12 Mu/day Tx for 5 days.

What will you do next?

A. Changing ATB to ClindamycinB. Adding the AminoglycosideC. Checking the adequacy of the postural

drainageD. Do A&C togetherE. Changing ATB to Quinolones

53. Which of the following(s) is(are) the indication for surgical resection in lung abscess?

A. Failure to response to proper ATB for 2 wkB. Hemoptysis about 5-20 ml/day for 1 wkC. Hemoptysis >600 ml/dayD. Purulent sputum >600 ml/dayE. Abscess cavity >10 cm in greatest

diameter

53. Which of the following(s) is(are) the indication for surgical resection in lung abscess?

A. Failure to response to proper ATB for 2 wkB. Hemoptysis about 5-20 ml/day for 1 wkC. Hemoptysis >600 ml/dayD. Purulent sputum >600 ml/dayE. Abscess cavity >10 cm in greatest

diameter

TB and Fungal InfectionTB and Fungal Infection

Include HemoptysisInclude Hemoptysis

32. DM patient: cavitary M+ pulmonary TB5 mo: CAT-I and good glycemic control

- Symptom and CXR not improved- Sputum AFB +ve persistently

Tx?A. HRZESB. HRZESOC. ZE SO PASD. RE KO PASE. ZE EtO PAS

32. DM patient: cavitary M+ pulmonary TB5 mo: CAT-I and good glycemic control

- Symptom and CXR not improved- Sputum AFB +ve persistently

Tx?A. HRZE SB. HRZE SOC. ZE SO PASD. RE KO PASE. ZE EtO PAS

36. Toxic effects of isoniazid, EXCEPT

A. Liver damageB. Peripheral neuritisC. Optic atrophyD. Testicular atrophyE. Pellagra

36. Toxic effects of isoniazid, EXCEPT

A. Liver damageB. Peripheral neuritis (B6 deficiency)C. Optic atrophyD. Testicular atrophyE. Pellagra

Fever, skin lesions, lupus-like syndrome, seizure, psychosis, mental disorder

14. The most common cause of failure in Tx or pulmonary TB is/are

A. Primary drug resistant organismsB. Irregular drug intake by the patientC. Drug toxicityD. Inadequate regimenE. Associated underlying disease

14. The most common cause of failure in Tx or pulmonary TB is/are

A. Primary drug resistant organismsB. Irregular drug intake by the patientC. Drug toxicityD. Inadequate regimenE. Associated underlying disease

15. Which is/are INCORRECT about retreatment of pulmonary TB?

A. Low patient complianceB. High drug costC. High incidence of drug side effectsD. High efficacyE. Need intensive clinical data of previous Tx and drug sensitivity test for Mx plan

15. Which is/are INCORRECT about retreatment of pulmonary TB?

A. Low patient complianceB. High drug costC. High incidence of drug side effectsD. High efficacyE. Need intensive clinical data of previous Tx and drug sensitivity test for Mx plan

47. ♂ 25 YO: PTB+ Tx 8 mo (2HES6HE)Monthly sputum AFB: numerous AFB.What is wrong?

A. He may have got a resistant TBB. He may have got an atypical TBC. He may have not taking the drugs

regularlyD. 3rd anti-TB drug should be added to the

current medications (R/Z)E. Drug sensitivity test should be done

47. ♂ 25 YO: PTB+ Tx 8 mo (2HES6HE)Monthly sputum AFB: numerous AFB.What is wrong?

A. He may have got a resistant TBB. He may have got an atypical TBC. He may have not taking the drugs

regularlyD. 3rd anti-TB drug should be added to the

current medications (R/Z)E. Drug sensitivity test should be done

26. All of these statements are the manifestations of post-primary TB, EXCEPT

A. Symptoms that suggest active TB are chronic cough, bloody sputum, night sweat, fever and weight loss

B. Radiographic abnormalities that strongly suggest active TB is upper lobe infiltraion with cavitation

C. Sputum smear usually demonstrate AFB in cases with cavitation

D. Post-primary TB is a common manifestation of full-blown AIDS

E. Definite Dx of TB requires culture that contains M.tuberculosis

26. All of these statements are the manifestations of post-primary TB, EXCEPT

A. Symptoms that suggest active TB are chronic cough, bloody sputum, night sweat, fever and weight loss

B. Radiographic abnormalities that strongly suggest active TB is upper lobe infiltraion with cavitation

C. Sputum smear usually demonstrate AFB in cases with cavitation

D. Post-primary TB is a common manifestation of full-blown AIDS

E. Definite Dx of TB requires culture that contains M.tuberculosis

31. ♂ 42 YO alcoholic: Pulmonary TB HR 6 mo, but sometimes forgot to take his medicine

Now: blood-streaked sputum and weight lossCXR: RUL infiltrate. Sputum AFB: few AFBWhat should you do next?

A. Defer Tx until results of culture are availableB. Prescribe twice-weekly, DOT with HR pending

drug susceptibility test resultsC. Add E into the regimen and wait for drug

susceptibility test resultsD. Add EZS into the regimen and wait for drug

susceptibility test resultsE. Change the regimen to clarithromycin +

ciprofloxacin

31. ♂ 42 YO alcoholic: Pulmonary TB HR 6 mo, but sometimes forgot to take his medicine

Now: blood-streaked sputum and weight lossCXR: RUL infiltrate. Sputum AFB: few AFBWhat should you do next?

A. Defer Tx until results of culture are availableB. Prescribe twice-weekly, DOT with HR pending

drug susceptibility test resultsC. Add E into the regimen and wait for drug

susceptibility test resultsD. Add EZS into the regimen and wait for drug

susceptibility test resultsE. Change the regimen to clarithromycin +

ciprofloxacin

25. ♀ 54 Y-O; old TB lung (adequate Tx 20 Y)Hemoptysis 100 ml/dCXR: cavitary lesion with a nodule inside and

air crescent at RULHx: hemoptysis for several times in the past 1

Most appropriate Mx?A. Start anti-TB drugB. AmpBC. LobectomyD. Oral ATBE. Pulmonary embolization

25. ♀ 54 Y-O; old TB lung (adequate Tx 20 Y)Hemoptysis 100 ml/dCXR: cavitary lesion with a nodule inside and

air crescent at RULHx: hemoptysis for several times in the past 1

Most appropriate Mx?A. Start anti-TB drugB. AmpBC. LobectomyD. Oral ATBE. Pulmonary embolization

Aspergilloma: Natural history

Variable• Remain stable: majority of cases• ↓ Size or resolve spontaneously without treatme

nt: approximately 10% of cases• ↑ Size: rare

Aspergilloma: Symptoms

• Asymptomatic• Hemoptysis usually occurs from bronchial blood

vessels– Mild hemoptysis: most– Severe hemoptysis: esp. in underlying TB

• Other: chronic cough• Fever is rare unless there is 2nd bacterial infectio

Aspergilloma: Treatment

• Asymptomatic: no therapy is warranted• Antifungal agents: no benefit

– Inhaled, intracavitary, and endobronchial instillations

– IV amphotericin B

Itraconazole therapy: variable results

Bronchial artery embolization:• Rarely results in control of hemoptysis because

of the massive collateral blood vessels• Temporizing measure in patients with life-threate

ning hemoptysis

Surgical treatment:• Relatively high mortality rate (1.523%): severe

underlying lung disease, pneumonia, AMI, and IPA

• Significant morbidity (18%): bleeding, residual pleural space, bronchopulmonary fistula, empyema, and respiratory failure

• Asymptomatic: observation• Hemoptysis

– Mild: medical therapy with bed rest, humidified oxygen, cough suppressants, and postural drainage

– Massive• Adequate pulmonary reserves: surgery• Inadequate pulmonary reserve: ? itraconazole

30. ♂ 82 Y-O: massive hemoptysis 1 dHx of old bilat. TB lung and COPD for 10 YLatest spirometry: FVC 37%, FEV1 42%

predicted

Most appropriate Mx?A. Conservative TxB. SxC. Double lumen intubationD. EmbolizationE. Endobronchial blockade

30. ♂ 82 Y-O: massive hemoptysis 1 dHx of old bilat. TB lung and COPD for 10 YLatest spirometry: FVC 37%, FEV1 42%

predicted

Most appropriate Mx?A. Conservative Tx but massive hemoptysisB. Sx but bilat + FEV1 42% predicted

C. Double lumen intubation ? Respiratory failureD. Embolization ? CrE. Endobronchial blockade

MiscellaneousMiscellaneous

33. Which statement is correct about high altitude?

A. FiO2 <0.21

B. Partial pressure of H2O vapor at human temperature will decrease

C. Hypoxemia occurred due to decreased partial pressure of inspired air (PiO2)

D. ABG when climbing to high altitude revealed decreased pO2 and unchanged pCO2

E. Long-term residence at high altitude commonly suffered from pulmonary hypertension

A. FiO2 <0.21

B. Partial pressure of H2O vapor at human temperature will decrease

D. ABG when climbing to high altitude revealed decreased pO2 and unchanged pCO2

High altitude physiologic change

PiO2 decreases 4-5 mm Hg for each 1,000-foot elevation

PiO2 = PB x FiO2

• ↑ Ventilation (when Pao2 <60 mm Hg)

• ↑ CO to maintain adequate oxygen delivery: Do2 = ↓Cao2 x ↑CO

Cao2 = (Hb x 1.39 x ↓Sao2) + 0.0031 (Pao2)

Acute cardiopulmonary responses

Healthy volunteer inspire low FiO2

A. FiO2 <0.21 (=)

B. Partial pressure of H2O vapor at human temperature will decrease ()

D. ABG when climbing to high altitude revealed decreased pO2 and unchanged pCO2 (↓)

Good Luck

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