Diseases-3

• Tests/procedures to "rule out" PE

  • Clinical pre-test probability
  • D-dimer test
  • Computed tomography pulmonary angiography
  • Pulmonary angiography
• Hemodynamic effects of OSA

  Affects systemic hemodynamics by inducing sympathetic activation and increasing left ventricular afterload
• Hemodynamic effects of PAH

  Affects pulmonary hemodynamics by increasing pulmonary vascular resistance and right ventricular afterload, ultimately leading to right heart failure
• Saddle PE

  Large thrombi can lodge at the bifurcation of the main pulmonary artery or lobar branches and cause hemodynamic compromise
• PE and V/Q relationship

  Pulmonary embolism disrupts the normal V/Q relationship, leading to ventilation/perfusion mismatch, impaired gas exchange, and clinical manifestations of hypoxemia and respiratory distress
• Normal pulmonary vascular system

  • Low-pressure, low-resistance
• ABG for a patient with a PE

  Low Paco2 with high pH, Acute respiratory alkalemia severity depends on embolus size
• Clinical signs & symptoms of PAH


  • Fatigue
  • Lethargy
  • Exertional dyspnea
  • Ascites
  • Cool extremities
  • Peripheral edema
  • Hepatomegaly
  • Increased uvula venous pressure
  • Cough
  • Hemoptysis
  • Hoarseness
  • Wheezing
• Criteria to identify when a PE patient is ready to be discharged from the hospital

  • Hesita- 11 criteria, all need to be negative
  • SPESI- 6 criteria, all need to be negative
• What controls change CO2 on HFOV

  Power, amplitude, Hz/frequency
• What controls oxygenation in HFOV

  MPAW, fio2
• Direct lung insult


  • Pneumonia
  • Pulmonary contusion
  • Aspiration
  • Fat emboli
  • Near drowning
  • Inhalation injury
  • Reperfusion pulmonary edema
• Indirect lung insult


  • Severe trauma
  • Non pulmonary sepsis
  • Drug overdose
  • Pancreatitis
  • Cardiopulmonary bypass
  • Disseminated intravascular coagulation
• Appropriate plateau pressure in ARDS

  Less than equal to 30 cm H2O
• Berlin definition to classify ARDS


  • Respiratory failure, not explained by fluid overload or cardiac failure, bilateral lung opacity is not caused by atelectasis pleural effusions or pulmonary nodules
  • Mild ARDS <300
  • Moderate ARDS <200
  • Severe ARDS <100 with PEEP greater than equal to 5
  • Onset of within one week of known clinical insults
• Pathologic changes during ARDS stages

  1. Exudative: occurs within 24 hours last 1-7 days alveolar damage, edema and alveolar hemorrhage, type one pneumocytes destroyed and surfactant deficiency

  2. Proliferative; 7-14 days, proliferation of inflammatory cells, squamous metaplasia

  3. Fibrotic; >14 days, collagen formation, and Hailiazation of alveolar walls
• Management of ARDS patient


  • APRV
  • High frequency oscillation ventilation
  • Prone positioning
  • Extracorporal life support
• Low CPAP setting or T low on APRV


  Release time that eliminates CO2 and can cause auto PEEP
• How to correct an ABG in patients with ARDS

  They tend to be respiratory acidic, we can correct it by increasing respiratory rate or tidal volume or changing the I time
• How to set P high on APRV

  Set typically between 20 and 30, it is essentially plateau pressure
• Changes in the lungs with ARDS

  Lungs become inflamed and filled with fluid, making it harder for oxygen to go into the bloodstream
• Drugs associated with ILD


  • Illicit drug: cocaine and heroin
  • Med drugs: angiotensin- converting enzymes, amiodarone, amphotericin B, beta blockers, bevacizumab, bleomycin, erlotinib, methotrexate, non steroidal anti inflammatory drug, penicilliamine, rituximab, statins, tocainide
• How to confirm diagnosis of ILD

  • Lung function test
  • ABG
  • Cardiac assessment
  • HRCT
  • Biopsy
• PFT results and ILD

  Reduced values, reduced DLCO due to v/q mismatch, normal or elevated FEV1/FVC
• Pharmacological (Drug) solutions to ILD

  • Corticosteroids
  • Nintedanib- intracellular inhibitor
  • Prifendione- antifibrotic, anti-inflammatory, antioxidant
• Population most prevalent for ILD

  Prevalent in adults and males
• Gold standard for diagnosing ILD

  Surgical biopsy