เฉลยข้อสอบ MCQ R2ครั้งที่2

Residence Survival in Chest
7-05-09
Obstructive Lung Diseases

Including Occupational Asthma
36. Asthma: spirometry FEV1 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 2-agonists, and 30 min later for short-acting anticholinergic agents (post-bronchodilator test)
ATS/ERS 2005
Reversibility test: Method

Drug: Albuterol/salbutamol 100 g is inhaled in one breath to TLC via spacer device 4 separate doses (total dose 400 g) are delivered at ~30-s intervals Other: Terbutaline (4x250=1000 g) Ipratropium bromide (4x40=160 g)
ATS/ERS 2005
Expressing Bronchodilator Response

FEV1 or FVC Absolute change = FEV1post - FEV1pre 200 ml AND = FEV1post - FEV1pre x 100
FEV1pre
Percent change
12%
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
ATS/ERS 2005
36. Asthma: spirometry FEV1 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. Tachypnea B. Pulsus paradoxus C. Silent chest with severe dyspnea D. B+C E. A,B and C
Severity of Asthma Exacerbations

Mild Breathless Talk in Alertness Respiratory rate Accessory m. and suprasternal retractions Wheeze Pulse/min Pulsus paradoxus Walking Can lie down Sentences May be agitated Increased Usually not Moderate, often only end expiratory <100 Absent <10 mm Hg Moderate Talking Prefers sitting Phrases Usually agitated Increased Usually Loud 100-120 May be present 10-25 m Hg Severe At rest Hunched forward Words Usually agitated Often >30 Usually Usually loud >120 Often present >25 mm Hg Respiratory arrest imminent
Drowsy or confused Paradoxical thoracoabdominal movement Absence of wheeze Bradycardia Absence suggests respiratory m. fatigue
Severity of Asthma Exacerbations

PEF after initial bronchodilator % predicted or % personal best PaO2 (on air) PaCO2 SaO2 % (on air) Mild Over 80% Moderate Approx. 60-80% Severe <60% predicted or personal best (<100 L/min adults) or response lasts <2 hrs <60 mm Hg; Possible cyanosis >45 mm Hg; Possible respiratory failure <90%
Normal test not usually necessary <45 mm Hg >95%
>60 mm Hg <45 mm Hg 91-95%
1. Which of the following sign(s) indicate(s) acute severe asthmatic attack? A. Tachypnea B. Pulsus paradoxus C. Silent chest with severe dyspnea D. B+C E. A,B and C
43. Which of following sign(s) is/are NOT chraracteristic of acute severe asthma? A. Tachypnea B. Silent chest with severe dyspnea C. Pulsus paradoxus D. Air hunger E. A and C
43. Which of following sign(s) is/are NOT chraracteristic of acute severe asthma? A. Tachypnea B. Silent chest with severe dyspnea C. Pulsus paradoxus D. Air hunger E. 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 nebulizer D. Inhaled ipratropium via inhaler spacer E. Aminophylline iv
ED Management: Acute Asthma

Initial Assessment Hx, PE, PEF or FEV1 Initial Therapy Bronchodilators; O2 if needed Good Response Observe at least 1 hr Incomplete/Poor Response Add Systemic Steroids Good Response Discharge Discharge Respiratory Failure
Admit to ICU
Poor Response Admit
Management: Acute Asthma in Acute Care Setting

Initial Treatment Oxygen to achieve SpO2 u 90% (95% in children) Inhaled rapid-acting F2 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
Reassess after 1 hr PE, PEF, O2 sat and other tests as needed
Criteria for Moderate Episode: PEF 60-80% predicted/ personal best Moderate symptoms, accessory muscle use Treatment: Oxygen Inhaled F2 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 F2 agonist + anticholinergic Systemic glucocorticoids IV magnesium
Reassess after 1-2 hr

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 F2 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 F2 agonist s 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 F2 agonist + anticholinergic Intravenous glucocorticoids Consider IV F2 agonist, theophylline Possible intubation and MV
Reassess at intervals
Reassess at intervals
Improved (see Discharge Home)
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
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 nebulizer D. Inhaled ipratropium via inhaler spacer E. 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 shock D. Increased wheezing during Tx E. 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 shock D. Increased wheezing during Tx E. 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 Tx? A. As needed SABA B. ICS C. ICS + LABA D. Short course of oral steroid E. 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 Tx? A. As needed SABA B. ICS C. ICS + LABA D. Short course of oral steroid E. Grass pollen desensitization
GINA 2004
Asthma Severity Before Treatment

Severe persistent
No longer recommended as the basis for ongoing treatment decisions Day symptoms <1/wk >1/wk Daily Daily Attacks may Attacks effect Limited Its poor value in predictingactivity treatment willactivity effect what activity physical be required and what a patient s response to that >2/mo >1/wk Frequent Night symptoms 2/mo treatment might be. FEV1 or PEFR >80% >80% 60-80% For this purpose, a periodic assessment of <60% PEF variability 20-30% >30% asthma control <20% is more relevant and useful.>30%
Mild intermittent
Mild persistent
Moderate persistent
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 Tx?
Mild persistent asthma + AR/AC
A. As needed SABA B. ICS C. ICS + LABA D. Short course of oral steroid E. Grass pollen desensitization
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 SR B. Add inhaled LABA C. Switch budesonide fluticasone D. Use spacer and frequent rinsing mouth after using budesonide E. Add oral fluconazole
>800 mcg/d = high dose
GINA 2004
2008
Estimated Equipotent Daily Doses of ICS for Adults

Low Daily Dose (g) Medium Daily Dose (g) > 500 - 1000 > 400 - 800 > 160 - 320 > 1000 - 2000 > 250 - 500 > 400 - 800 > 1000 - 2000 High Daily Dose (g) > 1000 - 2000 > 800 - 1600 > 320 - 1280 > 2000 > 500 - 1000 > 800 - 1200 > 2000
Beclomethasone dipropionate Budesonide* Ciclesonide* Flunisolide Fluticasone Mometasone furoate* Triamcinolone acetonide
200 - 500 200 - 400 80 - 160 500 - 1000 100 - 250 200 - 400 400 - 1000
Guideline: Recent Update
2008
TAC 2009
Management Approach Based On Control

Reduce
Step 1
As needed SABA Controller options
Treatment Steps
Step 2 Step 3 Step 4
Increase
Step 5
Select one Low-dose ICS Leukotriene modifier
Asthma education Environmental control As needed SABA Select one Add one or more Low-dose ICS + Medium- or highLABA dose ICS + LABA Medium- or highLeukotriene dose ICS modifier Low-dose ICS + Sustained release theophylling Leukotriene modifier Low-dose ICS + sustained release theophylline
Add one or both OS (lowest dose) Anti-IgE
Refractory Asthma: Workshop Consensus For Typical Clinical Features

1 major + 2 minor
Fahy J. Am J Respir Crit Care Med 2000; 162: 23412351.
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: 23412351.
Local AE of ICS
Local deposition of ICS in oropharynx and larynx Depends on dose, frequency of administration, delivery system
Local side effects
Local AE of ICS
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 mouth Cough, throat irritation reflex bronchoconstriction Due to surfactants in MDIs Switching to DPI
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 working B. ICS C. HRCT chest D. Methacholine challenge test E. Skin prick test for aeroallergen
6. Scrub nurse: recurrent cough and chest tightness 2 mo. Previously healthy. Atopy ve. PE/CXR ve. Spirometry: FEF25-75% What is theDx: Occupational asthma most appropriate Mx? A. HEPA mask while working B. ICS C. HRCT chest D. Methacholine challenge test E. Skin prick test for aeroallergen
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
FEF25-75%
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
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 working B. ICS C. HRCT chest D. Methacholine challenge test E. Skin prick test for aeroallergen
37. 50 Y-O; smoked 1 P-Y and quited 10 Y Dry coughing spells after started new work Morning rhinorrhea and nasal congestion PE: edema and erythema of nasal turbinates, prolonged expiratory phase Spirometry FEV1: pre-BD 65% predicted; post-BD 85% predicted Tx? A. Inhaled beclomethasone B. Inhaled ipratropium C. Oral bambuterol D. Oral theophylline E. Oral zafirlukast
37. 50 Y-O; smoked 1 P-Y and quited 10 Y Dry coughing spells after started new work Morning rhinorrhea and nasal congestion PE: edema and erythema of nasal turbinates, Occupational prolonged expiratory phase asthma Spirometry FEV1: pre-BD 65% predicted; post-BD 85% predicted Tx? A. Inhaled beclomethasone B. Inhaled ipratropium C. Oral bambuterol D. Oral theophylline E. Oral zafirlukast
Expressing Bronchodilator Response

1. Absolute change (>200 ml): 2. Percent initial value (>12%): FEV1post - FEV1pre 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
37. 50 Y-O; smoked 1 P-Y and quited 10 Y Dry coughing spells after started new work Morning rhinorrhea and nasal congestion PE: edema and erythema of nasal turbinates, prolonged expiratory phase Spirometry FEV1: pre-BD 65% predicted; post-BD 85% predicted Tx? A. Inhaled beclomethasone B. Inhaled ipratropium C. Oral bambuterol D. Oral theophylline E. Oral zafirlukast
10. 60 Y-O, smoker: chronic productive cough and intermittent dyspnea FEV1/FVC 60%, Post-BD FEV1 60% predicted GOLD not recommended? A. Smoking cessation B. Influenza vaccine C. Regular inhaled LABA D. Pulmonary rehabilitation E. ICS
10. 60 Y-O, smoker: chronic productive cough and intermittent dyspnea FEV1/FVC 60%, Post-BD FEV1 60% predicted GOLD not recommended? A. Smoking cessation B. Influenza vaccine C. Regular inhaled LABA D. Pulmonary rehabilitation E. ICS All stage All stage Stage II moderate Stage II moderate Stage III severe
I/C for ICS in COPD

NICE 2004:
FEV1 <50% predicted
GOLD 2007: FEV1 <50% predicted

(Stage III: Severe and Stage IV: Very Severe)
Repeated
Repeated exacerbations (2 in a exacerbations (3 in year) the last 3 year)
21. A 56-YO COPD patient progressive dyspnea over several years. PE: mild central cyanosis, AP 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 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 Why? A. Smoking low drug absorption B. Smoking drug distribution to tissue C. Smoking induce CYTP450 to metabolize the drug D. COPD impair GI absorption of the drug E. COPD enhance liver clearance of the drug
8. Theophylline in COPD + current smoking theophylline level Why? A. Smoking low drug absorption B. Smoking drug distribution to tissue C. Smoking induce CYTP450 to metabolize the drug D. COPD impair GI absorption of the drug E. 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
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)
GOLD 2007
Drug Interactions with Tobacco Smoking

Haloperidol Heparin Insulin Clearance increased by 44%; serum concentrations decreased by 70%. Mechanism unknown but increased clearance and decreased half-life are observed. Smokers may require higher dosages. 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 Increased metabolism (induction of CYP1A2); clearance increased by 58100%; 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 Less effective antihypertensive and heart rate control effects. May be caused by nicotine-mediated sympathetic activation.
Theophylline
Beta-blocker
Oral Increased risk of cardiovascular adverse effects (e.g., stroke, myocardial infarction, contraceptive thromboembolism) in women who smoke and use oral contraceptives. pills Risk increases with age and with heavy smoking (15 or more cigarettes per day) and is quite marked in women over age 35 years.
Zevin S, Benowitz NL. Clin Pharmacokinet. 1999 Jun;36(6):425-38.
8. The maintenance dosage of aminophylline should be reduced in all of the following, EXCEPT A. Elderly patients B. Current smoking C. CHF D. Cimetidine treatment E. Quinolone treatment
8. The maintenance dosage of aminophylline should be reduced in all of the following, EXCEPT A. Elderly patients B. Current smoking C. CHF D. Cimetidine treatment E. Quinolone treatment
19. C/I of bupropion for smoking cessation? A. Heavy smoking 20 cig./d B. Depression C. Seizure disorder D. Prior Hx of allergy to nicotine patch E. 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
Bupropion SR
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
19. C/I of bupropion for smoking cessation? A. Heavy smoking 20 cig./d B. Depression C. Seizure disorder D. Prior Hx of allergy to nicotine patch E. 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 Then150 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
Varenicline
1,6,7,8,9-tetrahydro-6,10-methano-6H-pyrazino [2,3h][3]benzazepine Partial agonist of 4 2 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
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

Plus weekly brief smoking cessation counseling
50.3%
**
P=0.5
36.3%
**
20.8%
30.5% 23.4% 17.3%
Cessation rates for varenicline were higher at all time points
Jorenby D, et al. JAMA 2006;296:56-63.
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 longterm 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. Phenytoin B. Propanolol C. Digoxin D. Phenobarbital E. 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. Phenytoin B. Propanolol C. Digoxin D. Phenobarbital E. Nitroglycerine
35. Air trapping is a feature of which of the following conditions A. Panacinar emphysema B. Senile emphysema C. Paraseptal emphysema D. Honeycomb lung E. 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 emphysema C. Paraseptal emphysema = linear emphysema (subpleural) D. Honeycomb lung + bronchiolectasis + Paracicatricial emphysema E. 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 disease C. Does not occur in restrictive lung disease D. May be worsened with oxygen administraion E. 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 disease C. Does not occur in restrictive lung disease D. May be worsened with oxygen administraion E. Occurs with chronic hypocapnia
Critical Care
51. Continuous mechanical ventilation may result in which of the following A. CO B. Enhanced VR C. Pleural pressure D. Mean intrathoracic pressure E. Mean intrathoracic pressure
Positive intrathoracic pressure
51. Continuous mechanical ventilation may result in which of the following A. CO B. Enhanced VR C. Pleural pressure D. Mean intrathoracic pressure E. Mean intrathoracic pressure
2. PEEP breathing may be of benefit in A. Acute asthmatic attack B. Acute pulmonary edema C. Unilateral pulmonary edema D. B and C E. A, B and C
Indications for NPPV in Respiratory Failure

Chronic respiratory failure: Acute respiratory failure: COPD exacerbation** Neuromuscular diseases** Acute cardiogenic pulmonary COPD edema** Obesity hypoventilation Fever/infiltrated in compromised syndrome host** Cystic fibrosis and Fascilitate weaning** bronchiectasis Severe hypoxemic respiratory failure (ARDS) Asthma Post Operative respiratory failure In DNI patients ** 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 attack B. Acute pulmonary edema C. Unilateral pulmonary edema D. B and C E. 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 stable ABG: pH 7.35, pO2 70, pCO2 45 Most appropriate next measure? A. TV to 600 B. RR to 22 C. Maintain the same setting D. 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 stable ABG: pH 7.35, pO2 70, pCO2 45 P/F ratio = 116 Most appropriate next measure? A. TV to 600 B. RR to 22 C. Maintain the same setting D. Switch to PCV mode (PI 20) E. PEEP to 10
ARDS
Protective Lung Strategies
80 mm Hg or
Predicted body weight:
= 50 + (0.91x [height in cm. - 152.4]) = 4.5 + (0.91 x [height in cm. - 152.4])

ARDSnet
The ARDS Network. N Engl J Med 2000;342:1301-8.
Ventilator setting in various conditions

Condition
Normal ARDS Obstructive lung Restrictive lung Neuromuscular disease
Vt (ml/kg) RR (bpm)
10 6-8 <8-12 <10 12 10-15 15-20 8-12 12-20 8-12
I:E ratio
1:1.5 1:2 1:1 4:1 1:3 or IT 1 s 1:2 1:2
PEEP:FiO2 in ARDS
FiO2 PEEP 5 8 8
NIH ARDS Network Trial

1.0 10 10 10 12 14 14 16 16 18-25
0.3-0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9
7,38. All of the following are seen in the early stage of ARDS, EXCEPT A. Severe dyspnea and tachypnea B. Marked hypoxemia C. Hypercapnia and hypoventilation D. Decreased lung compliance E. CXR: bilateral diffuse pulmonary infiltrates
7,38. All of the following are seen in the early stage of ARDS, EXCEPT A. Severe dyspnea and tachypnea B. Marked hypoxemia C. Hypercapnia and hypoventilation D. Decreased lung compliance E. CXR: bilateral diffuse pulmonary infiltrates
48. ARDS has been associated with all of the following, EXCEPT A. Pancreatitis B. Septic shock C. Viral pneumonia D. Fat embolism E. Severe asthma
Disorders Associated With ALI/ARDS
48. ARDS has been associated with all of the following, EXCEPT A. Pancreatitis B. Septic shock C. Viral pneumonia D. Fat embolism E. 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 cc B. Apply PEEPe 6 cmH2O C. Inspiratory flow to 40 L/min D. Change to SIMV mode E. RR to 20
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 cc B. Apply PEEPe 6 cmH2O C. Inspiratory flow to 40 L/min D. Change to SIMV mode E. RR to 20
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)
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 cc TI B. Apply PEEPe 6 cmH2O C. Inspiratory flow to 40 L/min D. Change to SIMV mode E. RR to 20 TI
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
Flow Time
Most appropriate Mx? A. PIF B. Vt C. RR D. PEEP E. 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
Flow Time
Most appropriate Mx? A. PIF TE B. Vt C. RR D. PEEP E. FiO2
13. Acute severe asthma intubation + ventilator Patient was still discomfort
Paw
Time
Cause? A. Too high PEEP level B. Insufficient inspiratory flow C. Autotrigger of ventilator D. Air leak in ventilator system E. High tidal volume
13. Acute severe asthma intubation + ventilator Patient was still discomfort Flow starvation Paw
Time
Cause? A. Too high PEEP level B. Insufficient inspiratory flow C. Autotrigger of ventilator D. Air leak in ventilator system E. High tidal volume
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 PNX B. AMI C. Esophageal intubation D. Acute hyperinflation and auto-PEEP E. Severe pneumonia
17. 50 Y-O, asthma: severe dyspnea intubation + ventilator still restless PE: BT 37.2, BP 70/40, HR 120, RR 28, conscious, faint wheezing both lungs; CXR: normal PIP/Ppl 60/45, O2sat 97% (FiO2 0.35) Most appropriate next step of Mx? A. Start ATB after S/W B. ABG C. Repeat CXR D. Measure PCWP E. Auto-PEEP determination
17. 50 Y-O, asthma: severe dyspnea intubation + ventilator still restless PE: BT 37.2, BP 70/40, HR 120, RR 28, conscious, faint wheezing both lungs; CXR: normal PIP/Ppl 60/45, O2sat 97% (FiO2 0.35) Most appropriate next step of Mx? A. Start ATB after S/W B. ABG C. Repeat CXR D. Measure PCWP E. Auto-PEEP determination
12,42. Hyperventilation can be observed in the following EXCEPT A. Midbrain lesion B. Encephalitis C. CO2 narcosis D. Uremia E. Salicylate poisoning
12,42. Hyperventilation can be observed in the following EXCEPT A. Midbrain lesion B. Encephalitis C. CO2 narcosis D. Uremia E. Salicylate poisoning
24. 65 Y-O: AECOPD on ventilator better Spontaneous breath: RR 25, TV 400, MV 10 T-piece 1 h later: RR 10, TV 400, MV 4 Most likely cause of change in respiratory profile? A. Bronchospasm B. Respiratory m. weakness C. Excess FiO2 D. Over sedation E. Abdominal distension
24. 65 Y-O: AECOPD on ventilator better Spontaneous breath: RR 25, TV 400, MV 10 T-piece 1 h later: RR 10, TV 400, MV 4 Most likely cause of change in respiratory profile? A. Bronchospasm B. Respiratory m. weakness C. Excess FiO2 D. Over sedation E. 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 bronchus B. Overdose of narcotic during anesthesia C. Retained secretion D. AMI with pulmonary edema E. 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 bronchus B. Overdose of narcotic during anesthesia C. Retained secretion D. AMI with pulmonary edema E. Aspiration of gastric content
12. 45 Y-O; 15 P-Y smoking: confused, drowsy ABG: pH 7.28, PaO2 70, PaCO2 56 CXR: normal Hx: FEV1/FVC 70%, FEV1 75% predicted Cause of hypercapnic respiratory failure? A. Acute pulmonary embolism B. Sedative overdose C. Cardiogenic pulmonary edema D. Right left shunt E. COPD
12. 45 Y-O; 15 P-Y smoking: confused, drowsy ABG: pH 7.28, PaO2 70, PaCO2 56 CXR: normal COPD Stage II (moderate) Hx: FEV1/FVC 70%, FEV1 75% predicted Cause of hypercapnic respiratory failure? A. Acute pulmonary embolism B. Sedative overdose C. Cardiogenic pulmonary edema D. Right left shunt E. COPD
(A-a)DO2
(A-a)DO2 = PAO2 PaO2 = FIO2 x (Patm PH2O) (PaCO2/0.8) PaO2 = 0.21 x (760 47) (56/0.8) 70 = 150 140 = 10
(A-a)DO2 = 2.5 + 0.21 x age in years
(A-a)DO2
(A-a)DO2 = PAO2 PaO2 = FIO2 x (Patm PH2O) (PaCO2/0.8) PaO2 10 = 0.21 x (760 47) (PaCO2/0.8) PaO2 = 150 [PaO2 + (PaCO2/0.8)] 140 = PaO2 + (PaCO2/0.8)
12. 45 Y-O; 15 P-Y smoking: confused, drowsy ABG: pH 7.28, PaO2 70, PaCO2 56 (A-a)DO2 = 10 CXR: normal Hx: FEV1/FVC 70%, FEV1 75% predicted Cause of hypercapnic respiratory failure? (A-a)DO2 A. Acute pulmonary embolism B. Sedative overdose C. Cardiogenic pulmonary edema D. Right left shunt E. COPD
27. 26 YO: sedative overdose comatose + apnea ET on PCV (FiO2 0.4, RR 20, PIP 15) ABG: pH 7.22, PaCO2 62, PaO2 200 No leakage in tubing system. What should you do next? A. Infuse 7.5% NaHCO3 iv B. Check TV of the ventilator C. Decrease FiO2 to 0.21 D. Increase RR to 25/min E. 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 200 No leakage in tubing system. What should you do next? A. Infuse 7.5% NaHCO3 iv B. Check TV of the ventilator C. Decrease FiO2 to 0.21 D. Increase RR to 25/min E. Increase PIP to 20 cm H2O
Pneumonia
22. 65 Y-O, DM & HTN Fever + productive cough (purulent) 5 d PE: T 38.2, BP 130/80, PR 96, RR 24, no cyanosis, conscious, crackles at RUL CXR: RUL consolidation CBC: WBC 14000 (N85%, L15%) Tx as OPD case ATB? A. AM/CL B. Respiratory quinolone C. Macrolide D. Doxycycline E. 3rd generation cephalosporin
22. 65 Y-O, DM & HTN Fever + productive cough (purulent) 5 d PE: T 38.2, BP 130/80, PR 96, RR 24, no cyanosis, conscious, crackles at RUL CAP CXR: RUL consolidation CBC: WBC 14000 (N85%, L15%) Tx as OPD case ATB? A. AM/CL B. Respiratory quinolone C. Macrolide D. Doxycycline E. 3rd generation cephalosporin
22. 65 Y-O, DM & HTN Fever + productive cough (purulent) 5 d PE: T 38.2, BP 130/80, PR 96, RR 24, no cyanosis, conscious, crackles at RUL CXR: RUL consolidation CAP CBC: WBC 14000 (N85%, L15%) OPD case Tx as OPD case ATB? A. AM/CL B. Respiratory quinolone C. Macrolide D. Doxycycline E. 3rd generation cephalosporin
CAP
OUTPATIENT THERAPY
INPATIENT THERAPY
NO CARDIOPULMONARY Dz, NO MODIFIERS GROUP I
CARDIOPULMONARY Dz, +/OR MODIFIERS GROUP II
MILD-MODERATE ILLNESS
SEVERE CAP
NO CARDIOPULMONARY Dz, NO MODIFIERS GROUP IIIA
CARDIOPULMONARY Dz, +/OR MODIFIERS GROUP IIIB
NO RISK FOR P. AERUGINOSA GROUP IVA
RISK FOR P. AERUGINOSA GROUP IVB
ATS 2001.
CAP
OUTPATIENT THERAPY
INPATIENT THERAPY
NO CARDIOPULMONARY Dz, NO RISK of DRSP GROUP I
CARDIOPULMONARY Dz, +/OR RISK of DRSP GROUP II
NON-ICU
ICU
RISK of P. aeruginosa / CA-MRSA A. B. Macrolide Doxycycline A. B. Respiratory Q BL + Macrolide A. B. Respiratory Q BL + Macrolide BL + Azithro
ATS/IDSA 2007.
22. 65 Y-O, DM & HTN Fever + productive cough (purulent) 5 d PE: T 38.2, BP 130/80, PR 96, RR 24, no cyanosis, conscious, crackles at RUL CXR: RUL consolidation CAP CBC: WBC 14000 (N85%, L15%) OPD case Tx as OPD case ATB? Comorbid A. AM/CL B. Respiratory quinolone C. Macrolide D. Doxycycline E. 3rd generation cephalosporin
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-morbidities Enteric gram-negatives Underlying cardiopulmonary disease Recent antibiotic therapy Nursing home residence Multiple medical co-morbidities Pseudomonas aeruginosa Structural lung diseases eg. Bronchiectasis Broad-spectrum antibiotics for >7 days within the past month Corticosteroid therapy (>10 mg prednisolone) ATS 2001. Severe malnutrition ATS/IDSA2007.
Risk factors for S. aureus CAP

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 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, SOB PE: T 40, PR 136, RR 32, BP 76/48 CXR: RUL + RLL alveolar infiltration O2sat (RA) 75% ATB? A. Cefotaxime + azithromycin B. Ceftriaxone + ciprofloxacin C. Meropenem + levofloxacin D. Ceftazidime + amikacin E. Imipenem + vancomycin
35. 63 Y-O, healthy: 3 d fever, productive cough, chills, Rt. pleuritic chest pain, SOB PE: T 40, PR 136, RR 32, BP 76/48 CXR: RUL + RLL alveolar infiltration O2sat (RA) 75% ATS/IDSA 2007. ATB? A. Cefotaxime + azithromycin B. Ceftriaxone + ciprofloxacin C. Meropenem + levofloxacin D. Ceftazidime + amikacin E. Imipenem + vancomycin
CAP
OUTPATIENT THERAPY
INPATIENT THERAPY
NO CARDIOPULMONARY Dz, NO RISK of DRSP GROUP I
CARDIOPULMONARY Dz, +/OR RISK of DRSP GROUP II
NON-ICU
ICU
RISK of P. aeruginosa / CA-MRSA
A. B.
Macrolide Doxycycline
A. B.
Respiratory Q BL + Macrolide
A. B.
Respiratory Q BL + Macrolide
BL + Azithro
ATS/IDSA 2007.
35. 63 Y-O, healthy: 3 d fever, productive cough, chills, Rt. pleuritic chest pain, SOB PE: T 40, PR 136, RR 32, BP 76/48 CXR: RUL + RLL alveolar infiltration O2sat (RA) 75% ATB? A. Cefotaxime + azithromycin B. Ceftriaxone + ciprofloxacin C. Meropenem + levofloxacin D. Ceftazidime + amikacin E. Imipenem + vancomycin
6. Which indicates that the pneumonic patient responds to the treatment in the first few days? A. Fever B. Sputum production and cough C. Follow up CXR D. WBC E. 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 cough C. Follow up CXR D. WBC E. A, B and D
7. What is not criteria for switching ATB for CAP A. Absence of fever >8 hr B. Intact GI function C. Tendency for returning of WBC count to normal D. Decrease radiographic parenchymal infiltrates E. 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

a
Temperature 37.8C 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
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 hr B. Intact GI function C. Tendency for returning of WBC count to normal D. Decrease radiographic parenchymal infiltrates E. Decrease breathlessness and cough
44. All of the following statement influence the prognosis in pneumococcal pneumonia, EXCEPT A. Type of pneumococcus B. Presence of a positive blood culture C. Site of the lesion D. Presence of pre-existing chronic bronchitis E. Age of the patient
Decision for Hospitalization

1. Age over 65 yr 2. 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 q 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 pneumococcus B. Presence of a positive blood culture C. Site of the lesion D. Presence of pre-existing chronic bronchitis E. 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 macrophage E. A + D
11,41. which is/are adequate sputum? A. >25 PMN and <10 SEC/100 power field B. >25 PMN and <3 SEC/1000 power field C. >25 PMN and <5 SEC/400 power field D. Presence of alveolar macrophage E. 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 pneumonia B. Staphylococcal pneumonia C. Klebsiella pneumonia D. Pseudomonas pneumonia E. 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 Alcoholism COPD and/or smoking Aspiration Lung abscess Commonly encountered pathogen(s) S.pneumoniae, oral anaerobes, K.pneumoniae, Acinetobacter spp., TB H.influenzae, P.aeruginosa, Legionella spp., S.pneumoniae, M.catarrhalis, C.pneumoniae Gram-negative enteric pathogens, oral anaerobes CA-MRSA, oral anaerobes, endemic fungal pneumonia, TB, atypical mycobacteria Histoplasmosis capsulatum
Exposure to bat or bird droppings Exposure to birds Chlamydophila psittaci (if poultry: avian influenza) Exposure to rabbits Fransisella tularensis Exposure to farm animals or Coxiella burnetti (Q fever) parturient cats 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 Age, comorbidity, acute onset, high fever, pleuritic chest pain Bacteraemic Streptococcus pneumoniae Female sex, excess alcohol, DM, COPD, dry cough Legionella pneumophila Younger patients, smokers, absence of comorbidity, diarrhea, neurological symptoms, evidence of multisystem involvement (e.g. abnormal LFTs, serum CK) Mycoplasma pneumoniae Younger patients, prior ATB, less multisystem involvement Chlamydia pneumoniae Longer duration of symptoms before hospital admission, headache
BTS 2001 2004.
Most Common Etiologies of CAP

Patient type
Outpatient
Etiology
Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydophila pneumoniae Respiratory virusesa S. pneumoniae M. pneumoniae C. Pneumoniae H. influenzae Legionella species Aspiration Respiratory virusesa S. pneumoniae Staphylococcus aureus Legionella species Gram-negative bacilli H. influenzae
ATS/IDSA 2007.
Inpatient (non-ICU)
Inpatient (ICU)
influenza A and B, adenovirus, respiratory syncytial virus, and parainfluenza.
File TM. Lancet 2003; 362: 19912001.
Radiology and specific pathogen

Cavitation: S. aureus, Gram-negative bacteria, and anaerobes Rare: viral or Mycoplasma pneumonia Bulging fissure sign: Lobar enlargement with bulging or ballooning of intralobar fissure Klebsiella pneumonia (in alcoholics)
Bulging 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 pneumonia B. Staphylococcal pneumonia C. Klebsiella pneumonia D. Pseudomonas pneumonia E. Anaerobic pneumonia
5. Which is most reliable for Dx or pneumococcal pneumonia? A. Sputum C/S shows S. pneumonia B. Sputum examination shows adequate sputum with many GP lancet-shaped cocci in pairs C. CXR: a lobar pattern of infiltration D. 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) (A-I)
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 infiltration D. Classic clinical symptom of multiple shaking chills E. All of the above
5. 86 Y-O; acute stroke with respiratory failure D7: acute fever + consolidation at RUL S/G: intracellular GNB Empirical ATB? A. Ceftriaxone B. Ceftazidime C. Cefepime + amikacin D. Cefpirome + metronidazole E. Ciprofloxacin
5. 86 Y-O; acute stroke with respiratory failure. D7: acute fever + consolidation at RUL S/G: intracellular GNB Empirical ATB?
VAP (GNB)
A. Ceftriaxone B. Ceftazidime C. Cefepime + amikacin D. Cefpirome + metronidazole E. Ciprofloxacin
ATS + IDSA
Am J Respir Crit Care Med 2005(171):388416.
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 4872 hours after endotracheal intubation
Diagnosis (Clinical strategy)
CXR infiltrates + 2/3 of 1.fever or 2.leukocytosis/leukopenia or 3.purulent secretions
Sensitivity Specificity 69% 75%
Fabregas N; et al. Thorax 1999Oct;54(10):867-73.
Risk Factors for MDR-pathogens causing HAP/HCAP/VAP

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:

ATS2005
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
Monotherapy vs. Combination Therapy ?

Combination Therapy Pseudomonas aeruginosa bacteremia Broad-spectrum empirical Rx Pseudomonas aeruginosa 30-50% develop resistance Severe disease, bacteremia ?
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) are likely to be infected with MDR pathogens (Level II)
Combination therapy should be used if patients
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) day 3, using clinical parameters (Level II)
Non-response to therapy is usually evident by
ATS/IDSA2005
Empiric Antibiotic Therapy for HAP HAP or VAP Suspected (All Disease Severity) Late Onset (5 d) or Risk Factors for Multi-drug Resistant (MDR) Pathogens
No Limited Spectrum Antibiotic Therapy
Yes Broad Spectrum Antibiotic Therapy For MDR Pathogens
ATS/IDSA2005
ATS2005
Initial Antibiotic Therapy:

No Risk Factors for MDR-pathogens, Early onset, and Any Disease Severity Potential Pathogen Recommended Antibiotics S. Pneumoniae Ceftriaxone or H. Influenzae Levofloxacin, moxifloxacin, or ciprofloxacin or MSSA ATB-sensitive enteric GNB Ampicillin/sulbactam or Ertapenem - E. coli - K. pneumoniae - Enterobacter spp. - Proteus spp. - Serratia marcescens
ATS/IDSA2005
ATS2005
Initial Antibiotic Therapy:

Late onset, or Risk Factors of MDR-pathogen, and Any Disease Severity Potential Pathogen Recommended Antibiotics Pathogens listed above and Antipseudomonal cephalosporin MDR-pathogen (cefepime, ceftazidime) or - P. aeruginosa Antipseudomonal carbapenem (imipenem or meropenem) or - K. pneumoniae (ESBL+) BL/BI (piperacillin/tazobactam) - Acinetobacter spp. plus Antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) or Aminoglycoside (amikacin, gentamicin, or tobramycin) plus - MRSA Linezolid or vancomycin Legionella pneumophila
ATS/IDSA 2005
5. 86 Y-O; acute stroke with respiratory failure D7: acute fever + consolidation at RUL S/G: intracellular GNB Empirical ATB?
VAP (GNB) Late onset
A. Ceftriaxone B. Ceftazidime C. Cefepime + amikacin D. Cefpirome + metronidazole E. Ciprofloxacin
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 + Amikin B. Ampicillin + Amikin C. Any 2nd generation cephalosporins + Amikin D. Any 3rd generation cephalosporins alone E. 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 + Amikin B. Ampicillin + Amikin C. Any 2nd generation cephalosporins + Amikin D. Any 3rd generation cephalosporins alone E. 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 TB B. PCP C. Pulmonary cryptococcosis D. CMV pneumonia E. 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 TB B. PCP C. Pulmonary cryptococcosis D. CMV pneumonia E. None of the above
Pleural 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 aspiration C. Tube thoracostomy D. Discontinuation of PEEP E. 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 aspiration C. Tube thoracostomy D. Discontinuation of PEEP E. 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. Observation B. Simple aspiration C. Tube thoracostomy D. Tube thoracostomy with pleurodesis E. Open thoracotomy
22. 26 YO, healthy: first episode of 30% Rt. pneumothorax. Optimal Tx? A. Observation: only for pneumothorax <15% B. Simple aspiration C. Tube thoracostomy D. Tube thoracostomy with pleurodesis E. 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 Recurrent PNX st contralateral pneumothorax 1 Bilateral spontaneous pneumothorax Persistent air leak (>57 d of tube drainage; air leak or failure to completely re-expand) Spontaneous haemothorax Professions at risk (e.g. pilots, divers)
BTS guideline 2003
PRIMARY PNEUMOTHORAX
Breathless and/or rim of air >2 cm on CXR? Yes Aspiration Successful? No Consider repeat aspiration Successful? No Intercostal drain Successful? No Referral to chest physician within 48 h Suction? Referral to thoracic surgeon after 5 days Consider discharge
BTS guideline 2003
No
Yes
Yes
Yes
Remove 24 h after full re-expansion/cessation of air leak without clamping
SECONDARY PNEUMOTHORAX
Breathless + age >50 Y + rim of air >2 cm on CXR? Yes Intercostal drain Successful? No Referral to chest physician after 48 h Suction? Yes Remove 24 h after full re-expansion/cessation of Successful? air leak No Consider discharge Early discussion with surgeon after 3 days BTS guideline 2003 No No Yes Yes Admit to hospital for 24 h Aspiration Successful?
Comparison of Guideline Recommendations

(Clinically stable patients)
Guideline ACCP 2001 Definition of large PSP Small PSP Large PSP Pleural catheter insertion [tube thoracostomy] and drainage Simple aspiration
>3 cm apical Observation in ED interpleural distance followed by conservative management as an outpatient Presence of a visible rim of 2 cm between lung and chest wall Conservative management as outpatient
BTS 2003
25. 62 YO: fever and Lt. pleurisy for 2 wk PF 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 effusion B. Lupus pleuritis C. TB pleuritis D. Pleural effusion in RA E. 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 or Symptomatic at Diagnosis

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
Transudates vs Exudates
Lights criteria for exudates: if any one of the following criteria are fulfilled: 1) PF LDH > ULN of serum LDH 2) PF/serum protein ratio >0.5 3) PF/serum LDH ratio >0.6
High sensitivity (98%) but lowers specificity (74%)
Heffner JE; Brown LK; Barbieri CA. Chest 1997 Apr;111(4):970-80.
Transudates vs Exudates
Meta-analysis: 8 studies; 1,448 patients All of the following tests have statistically similar diagnostic accuracy compared with Lights criteria: PF protein >3 (2.9) g/dL PF/serum protein >0.5 PF cholesterol >45 (54, 55 or 60)Sens 75%, Spec 80% mg/dL PF LDH >60% (0.45) of ULN PF LDH/serum >0.6 PF/serum cholesterol ratio >0.3 Sens 89%, Spec 81% Albumin gradient <1.2 g/dL Sens 87%, Spec 92%
Heffner JE; Brown LK; Barbieri CA. Chest 1997 Apr;111(4):970-80.
PF Lymphocyte Predominant (>80%) Exudate* (1)

Disease Tuberculous pleurisy Comment A common cause of exudate; usually 90-95% lymphocytes; acutely, may be PMN predominant 2,000-20,000 lymphocytes/mL; most common cause is NHL Often 100% of nucleated cells are lymphocytes; diagnostic yield on cytology or pleural biopsy higher with NHL
Chylothorax Lymphoma
*Consistently but not always >80%; other exudates rarely have 80% lymphocytes
PF Lymphocyte Predominant (>80%) Exudate* (2)

Disease Chronic rheumatoid pleurisy Sarcoidosis Comment Often associated with trapped lung/lung entrapment Usually >90% lymphocytes; effusion in >2% of sarcoid patients; discordant exudate (by protein only) 82-99% lymphocytes; unilateralon left or bilateral; lung entrapment
Post-CABG effusions (>2 mo) including PCIS
*Consistently but not always >80%; other exudates rarely have 80% lymphocytes
Diagnoses Associated With PF Acidosis (pH <7.30) and Low Glucose (PF/Serum <0.5)
Diagnosis Complicated parapneumonic and empyema Esophageal rupture Tuberculous empyema Chronic rheumatoid pleurisy Malignancy Tuberculous pleural effusion Rheumatoid pleurisy Usual pH (Incidence) Usual Glucose, mg/dL (Incidence) 4.507.29 (~100%) <40 (can be 0) (100%) <60 (can be 0) (80100%) 030 030 (85%) 3059 (30%) 3059 (20%) 30-59 (15%)
5.507.00 (~100%) 6.907.05 (100%) 7.00 (80%) 6.957.29 (33%) 7.007.29 (20%) 7.15-7.29 (15%)
Tuberculous Pleurisy
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/g; 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:
Tests Pleural biopsy histology Pleural biopsy culture Pleural fluid culture Sputum culture Pleural biopsy AFB Pleural fluid AFB Sensitivity, % 6385 5580 1370 450 (4% with isolated effusion) 518 <5
Give Dx up to 86%
PF ADA >40-60 U/L supports the diagnosis if R/O RA and empyema (<40 U/L high NPV for TB)
25. 62 YO: fever and Lt. pleurisy for 2 wk PF 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) Lymphocytic exudate Which is the MOST likely Dx? A. Malignant pleural effusion B. Lupus pleuritis C. TB pleuritis D. Pleural effusion in RA E. Pulmonary embolism
23. 50 Y-O, DM, non-smoker Tightness of Lt. chest and low-grade fever 2 wk CXR: Lt. pleural effusion Pleural tapping: straw-colour, lymphocytic exudate Pleural cyto.: suspected malignancy Pleural Bx: chronic pleuritis Most appropriate Mx? A. Repeat thoracentesis for cytology and pleural Bx B. Bronchoscopy C. CT chest D. AntiTB drugs E. U/S whole abdomen
23. 50 Y-O, DM, non-smoker Tightness of Lt. chest and low-grade fever 2 wk CXR: Lt. pleural effusion Pleural tapping: straw-color, lymphocytic exudate Pleural cyto.: suspected malignancy Pleural Bx: chronic pleuritis Most appropriate Mx? A. Repeat thoracentesis for cytology and pleural Bx B. Bronchoscopy C. CT chest D. AntiTB drugs E. U/S whole abdomen
MPE
Closed pleural biopsy

44%
Fluid cytology
62%
Medical thoracoscopy
95%
74%
96%
97%
3 cytology: positive diagnosis 70-80% The yield is less with squamous cell carcinoma, Hodgkins disease, sarcoma
Hamm H, Light RW. Eur Respir J 1997; 10: 476-81.
27. Alcoholic patient: low-grade fever 7 d PE: pleural effusion 1/3 of Lt. lung CBC: 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 h D. BL/BI iv. and ICD E. Cefepime iv. and ICD
27. Alcoholic patient: low-grade fever 7 d PE: pleural effusion 1/3 of Lt. lung CBC: 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 h D. BL/BI iv. and ICD E. Cefepime iv. and ICD
Definition Parapneumonic effusion

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
Complicated effusion: needs to be drainage

Clinical features: Prolonged symptoms Anaerobic infection Failure to respond to ATB Virulence of bacterial pathogen CXR & CT: Large effusion (>40% of hemithorax) Air-fluid level Loculation Pleural enhancement/ thickening (>5 mm)
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)
4. 53 Y-O: abdominal distension 3 mo PE: ascites without sign of CLD U/S: ascites, Rt. pleural effusion, normal liver & spleen, solid/cystic mass 5 cm at Rt. Adx Pleural & ascitic fluid: straw colored, transudate, malignant cell ve Most likely Dx is A. Meigs syndrome B. Krukenberg s tumor C. Carcinomatosis peritonii D. Ovarian tumor with cirrhosis E. Ovarian tumor with TB peritonitis
4. 53 Y-O: abdominal distension 3 mo PE: ascites without sign of CLD U/S: ascites, Rt. pleural effusion, normal liver & spleen, solid/cystic mass 5 cm at Rt. Adx Pleural & ascitic fluid: straw colored, transudate, malignant cell ve Most likely Dx is A. Meig s syndrome B. Krukenberg s tumor C. Carcinomatosis peritonii D. Ovarian tumor with cirrhosis E. 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
4. 53 Y-O: abdominal distension 3 mo PE: ascites without sign of CLD U/S: ascites, Rt. pleural effusion, normal liver & spleen, solid/cystic mass 5 cm at Rt. Adx Pleural & ascitic fluid: straw colored, transudate, malignant cell ve Most likely Dx is A. Meig s syndrome B. Krukenberg s tumor C. Carcinomatosis peritonii D. Ovarian tumor with cirrhosis E. 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 + anticoagulant 4 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 cytology B. CT chest C. Pleural ADA D. Pleural fluid Alb gradient E. Pleural Bx
26. 60 Y-O, DM, smoker: ACS + anticoagulant 4 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]
Post-MI
Pleural effusion
Most relevant further Ix? A. Pleural fluid cytology Post-cardiac injury syndrome ? B. CT chest C. Pleural ADA D. Pleural fluid Alb gradient E. Pleural Bx
Postcardiac Injury Syndrome (PCIS)

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 o ESR (100%; mean, 62 mm/h); o WBC (50%)
Postcardiac Injury Syndrome (PCIS)

CXR: Pleural effusion 83% (Lt sided/bilateral), Rt sided only 17% LLL infiltrates and o cardiac silhouette PF Analysis: Serosanguinous or bloody, 70% 500-39,000 nucleated cells/L; PMNs early PF = serum glucose; pH >7.30 q Complement; PF/serum AMA >1.0
26. 60 Y-O, DM, smoker: ACS + anticoagulant 4 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 cytology B. CT chest C. Pleural ADA D. Pleural fluid Alb gradient E. Pleural Bx
Pulmonary Vascular Diseases
20. 65 Y-O: sudden dyspnea + pleurisy Rt. Hx: knee replacement Sx 10 d ago PE: T 38, PR 112, BP 100/60, RR 28, CVS&RS ve ABG (RA): pH 7.48, pCO2 32, pO2 65. CXR: -ve V/Q lung scan: intermediate probability for PE Appropriate further Mx? A. Leg doppler U/S B. CTPA C. Intravenous heparin D. Streptokinase heparin E. Close observe and repeat V/Q scan after 48 h
20. 65 Y-O: sudden dyspnea + pleurisy Rt. Hx: knee replacement Sx 10 d ago PE: T 38, PR 112, BP 100/60, RR 28, CVS&RS ve ABG (RA): pH 7.48, pCO2 32, pO2 65. CXR: -ve V/Q lung scan: intermediate probability for PE Appropriate further Mx? A. Leg doppler U/S B. CTPA C. Intravenous heparin D. Streptokinase heparin E. Close observe and repeat V/Q scan after 48 h
20. 65 Y-O: sudden dyspnea + pleurisy Rt. Hx: knee replacement Sx 10 d ago Clinical: high probability PE: T 38, PR 112, BP 100/60, RR 28, CVS&RS ve ABG (RA): pH 7.48, pCO2 32, pO2 65. CXR: -ve V/Q lung scan: intermediate probability for PE Appropriate further Mx? A. Leg doppler U/S B. CTPA C. Intravenous heparin D. Streptokinase heparin E. Close observe and repeat V/Q scan after 48 h
20. 65 Y-O: sudden dyspnea + pleurisy Rt. Hx: knee replacement Sx 10 d ago Clinical: high probability PE: T 38, PR 112, BP 100/60, RR 28, CVS&RS ve ABG (RA): pH 7.48, pCO2 32, pO2 65. CXR: -ve V/Q lung scan: intermediate probability for PE Appropriate further Mx? A. Leg doppler U/S B. CTPA C. Intravenous heparin D. Streptokinase heparin E. Close observe and repeat V/Q scan after 48 h
Clinical + D-dimer + Spiral CT

Determine if PE unlikely or PE likely
PE unllikely D-dimer
PE likely
<500 ng/mL PE excluded
>500 ng/mL
Spiral CT pulmonary angiogram (CT-PA)
Negative
Further Ix
Positive
PE excluded
PE confirmed
Van Belle A, et al. JAMA2006;295:172.
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 38 What is your further Mx? A. EKG for V3R, V4R B. Echo C. Pulmonary angiography D. Left-sided cardiac catheterization E. 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 38 What is your further Mx? A. EKG for V3R, V4R B. Echo C. Pulmonary angiography D. Left-sided cardiac catheterization E. 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 Hg B. 100 mm Hg C. 150 mm Hg D. 200 mm Hg E. 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 Hg B. 100 mm Hg C. 150 mm Hg D. 200 mm Hg E. 250 mm Hg
14. Most sensitive to exclude pulmonary embolism? A. Normal HRCT chest B. Normal D-dimer (ELISA) C. Normal PaO2 (RA) C. Absence of RVH with strain on ECG E. Intermediate probability result of V/Q scan
14. Most sensitive to exclude pulmonary embolism? A. Normal HRCT chest B. Normal D-dimer (ELISA) C. Normal PaO2 (RA) C. Absence of RVH with strain on ECG E. Intermediate probability result of V/Q scan
29. 35 Y-O: SLE + APL on high dose PDN + CYC Dyspnea + Lt.pleuritic chest pain + hemoptysis 1 d PE: T 38.1, scant crackle at LLL CXR: blunting Lt. CP angle, no definite infiltration CBC: Hb 10, WBC 4000 (N76%) plt 210000 ABG (RA): pH 7.47, pO2 60, pCO2 30 Ceftriaxone. Next step in Mx? A. V/Q lung scan B. FOB with BAL C. Diagnostic thoracentesis E. TMP/SMX iv D. Methylprednisolone 1g iv. OD x 3 d
29. 35 Y-O: SLE + APL on high dose PDN + CYC Dyspnea + Lt.pleuritic chest pain + hemoptysis 1 d PE: T 38.1, scant crackle at LLL CXR: blunting Lt. CP angle, no definite infiltration CBC: Hb 10, WBC 4000 (N76%) plt 210000 ABG (RA): pH 7.47, pO2 60, pCO2 30
DDx:
Ceftriaxone. Next step in Mx? 1. Lupus pneumonitis A. V/Q lung scan 2. Pulmonary embolism B. FOB with BAL 3. Pulmonary hemorrhage C. Diagnostic thoracentesis 4. Bacterial pneumonia E. TMP/SMX iv 5. PCP D. Methylprednisolone 1g iv. OD x 3 d
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 hyperventilation 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
DDx: 29. 35 Y-O: SLE + APL on high dose PDN + CYC 1. Lupus + Lt.pleuritic chest pain + hemoptysis 1 Dyspneapneumonitis d Pulmonary embolism 2. PE: T 38.1, scant crackle at LLL 3. Pulmonary hemorrhage CXR: blunting Lt. CP angle, no definite infiltration 4. Bacterial pneumonia CBC: Hb 10, WBC 4000 (N76%) plt 210000 5. PCP ABG (RA): pH 7.47, pO2 60, pCO2 30
Ceftriaxone. Next step in Mx? A. V/Q lung scan B. FOB with BAL C. Diagnostic thoracentesis E. TMP/SMX iv D. Methylprednisolone 1g iv. OD x 3 d
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 effusion Airway disease Obliterative bronchiolitis Upper airway dysfunction (epiglottitis, laryngitis, cricoarytenoid arthritis) Bronchiectasis Neuromuscular disease Diaphragmatic dysfunction Shrinking lungs
Malignancy
18. 50 Y-O: Rt. shoulder pain 2 mo CT: 5x6 cm mass at Rt. lung apex + 1st rib destruction. LN ve. Liver & adrenal gland ve Bone scan: uptake at Rt. 1st rib. Others ve DLT: squamous cell carcinoma Tx? A. RUL lobectomy CMT B. RUL lobectomy RT C. RT en bloc resection D. RT CMT E. CMT alone
18. 50 Y-O: Rt. shoulder pain 2 mo CT: 5x6 cm mass at Rt. lung apex + 1st rib destruction. LN ve. Liver & adrenal gland ve Bone scan: uptake at Rt. 1st rib. Others ve DLT: squamous cell carcinoma Tx? A. RUL lobectomy CMT B. RUL lobectomy RT C. RT en bloc resection D. RT CMT E. CMT alone
Stage II B
NSCLC 5x6 cm mass 1st rib destruction LN ve Liver & adrenal ve
Special Treatment Issues in Lung Cancer

ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)
28. In patients who have an NSCLC invading the chest wall and are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection, and definitive chemoradiotherapy is recommended for these patients. Grade of recommendation 2C 29. At the time of resection of a tumor invading the chest wall, we recommend that every effort be made to achieve a complete resection. Grade of recommendation 1B
Shen KR, et al. Chest 2007;132:290S-305S.
Chest wall tumor: Mx
18. 50 Y-O: Rt. shoulder pain 2 mo CT: 5x6 cm mass at Rt. lung apex + 1st rib destruction. LN ve. Liver & adrenal gland ve Bone scan: uptake at Rt. 1st rib. Others ve DLT: squamous cell carcinoma Tx? NSCLS IIB (T3N0M0: chest wall)
A. RUL lobectomy CMT B. RUL lobectomy RT C. RT en bloc resection D. RT CMT E. CMT alone
28. 58 YO smoker: 3 cm lung nodule. TBBx: SCCA. No evidence of metastasis or LN. Tx of choice? A. RT B. Pulmonary resection C. Chemotherapy D. Combined RT + CMT E. Combined RT + surgical resection
28. 58 YO smoker: 3 cm lung nodule. TBBx: SCCA. No evidence of metastasis or LN. Tx of choice? T1N0M0 IA A. RT B. Pulmonary resection C. Chemotherapy D. Combined RT + CMT E. Combined RT + surgical resection
13,45. Central necrosis and cavitation occur most frquent in which of the following cell types of lung cancer? A. Oat cell B. Giant cell C. Adenocarcinoma D. Squamous cell E. Bronchiolar
13,45. Central necrosis and cavitation occur most frquent in which of the following cell types of lung cancer? A. Oat cell B. 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 involvement B. Cerebral involvement C. Pericardial involvement D. Hepatic involvement E. Lymphatic involvement
9,39. Which of the following complications of lung cancer is an indication for RT? A. Pleural involvement B. Cerebral involvement C. Pericardial involvement D. Hepatic involvement E. 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 tumor B. Ectopic parathyroid adenoma C. Squamous cell lung cancer D. Small cell lung cancer E. 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 adenoma C. Squamous cell lung cancer (PTHrP) D. Small cell lung cancer E. 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 CXR B. Hx of previous pulmonary illness C. CT to detect the calcification D. History of chronic smoking E. 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 CXR B. Hx of previous pulmonary illness C. CT to detect the calcification D. History of chronic smoking E. All of the above
16. 50 Y-O: dyspnea, chest pain, facial swelling PE: edema of face + both arms, dilated superficial v. at chest and Rt. SPC LN +ve CXR: Rt. hilar mass and RUL mass + atelectasis Lasix symptoms improved Most appropriate Mx? A. Anticoagulant B. RT C. Dexamethasone D. Lymph node Bx E. Serum tumor marker
16. 50 Y-O: dyspnea, chest pain, facial swelling PE: edema of face + both arms, dilated superficial v. at chest and Rt. SPC LN +ve CXR: Rt. hilar mass and RUL mass + atelectasis Lasix symptoms improved Most appropriate Mx? A. Anticoagulant B. RT C. Dexamethasone D. Lymph node Bx E. Serum tumor marker
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 swelling PE: edema of face + both arms, dilated superficial v. at chest and Rt. SPC LN +ve, stridor CXR: Rt. hilar mass and RUL mass + atelectasis Most appropriate Mx? A. Anticoagulant B. RT C. Dexamethasone D. Lymph node Bx E. Serum tumor marker
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 Lung
31. 40 Y-O: Exertional dyspnea 3 mo Raynaud 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 embolism B. PAH C. IPF D. Pulmonary alveolitis E. BOOP
31. 40 Y-O: Exertional dyspnea 3 mo Raynaud 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 embolism B. PAH CREST syndrome C. IPF D. Pulmonary alveolitis E. BOOP
Systemic Sclerosis
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
Scleroderma
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 Raynauds phenomenon similarities in pathogenesis of these vasculopathies
Interstitial pneumonitis and fibrosis

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
15. 55 Y-O: RA on diclofenac 100 mg/d, MTX 10 mg/wk, chloroquine 250 mg/d for 6 mo Fever and dry cough 1 wk Roxithromycin 300 mg/d not improved Hct 35%, WBC 7500 (N 75%, L 20%, Eo 5%) CXR: interstitial infiltration of both lung field Most likely Dx? A. Rheumatoid lung B. Chloroquine toxicity C. MTX toxicity D. CAP E. PCP
15. 55 Y-O: RA on diclofenac 100 mg/d, MTX 10 mg/wk, chloroquine 250 mg/d for 6 mo Fever and dry cough 1 wk Roxithromycin 300 mg/d not improved Hct 35%, WBC 7500 (N 75%, L 20%, Eo 5%) CXR: interstitial infiltration of both lung field Most likely Dx? A. Rheumatoid lung (RA-ILD) B. Chloroquine toxicity C. MTX toxicity D. CAP E. PCP
Pulmonary complications from MTX

Opportunistic infections PCP, CMV, Herpes zoster, fungal, mycobacterial Noninfectious 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
3. The X-ray appearance of uremic lungs is very similar to: A. Pulmonary hemosiderosis B. Acute pulmonary edema C. Miliary tuberculosis D. Bronchilolalveolar cell carcinoma E. None of the above
3. The X-ray appearance of uremic lungs is very similar to: A. Pulmonary hemosiderosis B. Acute pulmonary edema C. Miliary tuberculosis D. Bronchilolalveolar cell carcinoma E. 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 Clindamycin B. Adding the Aminoglycoside C. Checking the adequacy of the postural drainage D. Do A&C together E. 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 Clindamycin B. Adding the Aminoglycoside C. Checking the adequacy of the postural drainage D. Do A&C together E. 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 wk B. Hemoptysis about 5-20 ml/day for 1 wk C. Hemoptysis >600 ml/day D. Purulent sputum >600 ml/day E. 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 wk B. Hemoptysis about 5-20 ml/day for 1 wk C. Hemoptysis >600 ml/day D. Purulent sputum >600 ml/day E. Abscess cavity >10 cm in greatest diameter
TB and Fungal Infection

Include Hemoptysis
32. DM patient: cavitary M+ pulmonary TB 5 mo: CAT-I and good glycemic control - Symptom and CXR not improved - Sputum AFB +ve persistently Tx? A. HRZES B. HRZESO C. ZE SO PAS D. RE KO PAS E. ZE EtO PAS
32. DM patient: cavitary M+ pulmonary TB 5 mo: CAT-I and good glycemic control - Symptom and CXR not improved - Sputum AFB +ve persistently Tx? A. HRZE S B. HRZE SO C. ZE SO PAS D. RE KO PAS E. ZE EtO PAS
36. Toxic effects of isoniazid, EXCEPT A. Liver damage B. Peripheral neuritis C. Optic atrophy D. Testicular atrophy E. Pellagra
36. Toxic effects of isoniazid, EXCEPT A. Liver damage B. Peripheral neuritis (B6 deficiency) C. Optic atrophy D. Testicular atrophy E. 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 organisms B. Irregular drug intake by the patient C. Drug toxicity D. Inadequate regimen E. Associated underlying disease
14. The most common cause of failure in Tx or pulmonary TB is/are A. Primary drug resistant organisms B. Irregular drug intake by the patient C. Drug toxicity D. Inadequate regimen E. Associated underlying disease
15. Which is/are INCORRECT about retreatment of pulmonary TB? A. Low patient compliance B. High drug cost C. High incidence of drug side effects D. High efficacy E. 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 compliance B. High drug cost C. High incidence of drug side effects D. High efficacy E. Need intensive clinical data of previous Tx and drug sensitivity test for Mx plan
47. 25 YO: PTB+ Tx 8 mo (2HES 6HE) Monthly sputum AFB: numerous AFB. What is wrong? A. He may have got a resistant TB B. He may have got an atypical TB C. He may have not taking the drugs regularly D. 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 (2HES 6HE) Monthly sputum AFB: numerous AFB. What is wrong? A. He may have got a resistant TB B. He may have got an atypical TB C. He may have not taking the drugs regularly D. 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 loss CXR: RUL infiltrate. Sputum AFB: few AFB What should you do next? A. Defer Tx until results of culture are available B. Prescribe twice-weekly, DOT with HR pending drug susceptibility test results C. Add E into the regimen and wait for drug susceptibility test results D. Add EZS into the regimen and wait for drug susceptibility test results E. 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 loss CXR: RUL infiltrate. Sputum AFB: few AFB What should you do next? A. Defer Tx until results of culture are available B. Prescribe twice-weekly, DOT with HR pending drug susceptibility test results C. Add E into the regimen and wait for drug susceptibility test results D. Add EZS into the regimen and wait for drug susceptibility test results E. Change the regimen to clarithromycin + ciprofloxacin
25. 54 Y-O; old TB lung (adequate Tx 20 Y) Hemoptysis 100 ml/d CXR: cavitary lesion with a nodule inside and air crescent at RUL Hx: hemoptysis for several times in the past 1 Y Most appropriate Mx? A. Start anti-TB drug B. AmpB C. Lobectomy D. Oral ATB E. Pulmonary embolization
25. 54 Y-O; old TB lung (adequate Tx 20 Y) Hemoptysis 100 ml/d CXR: cavitary lesion with a nodule inside and air crescent at RUL Hx: hemoptysis for several times in the past 1 Y Most appropriate Mx? A. Start anti-TB drug B. AmpB C. Lobectomy D. Oral ATB E. Pulmonary embolization
Aspergilloma: Natural history

Variable Remain stable: majority of cases Size or resolve spontaneously without treatment: 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 infection.
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 lifethreatening hemoptysis
Surgical treatment: Relatively high mortality rate (1.5 23%): 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 d Hx of old bilat. TB lung and COPD for 10 Y Latest spirometry: FVC 37%, FEV1 42% predicted Most appropriate Mx? A. Conservative Tx B. Sx C. Double lumen intubation D. Embolization E. Endobronchial blockade
30. 82 Y-O: massive hemoptysis 1 d Hx of old bilat. TB lung and COPD for 10 Y Latest spirometry: FVC 37%, FEV1 42% predicted Most appropriate Mx? A. Conservative Tx but massive hemoptysis B. Sx but bilat + FEV1 42% predicted C. Double lumen intubation ? Respiratory failure D. Embolization ? Cr E. Endobronchial blockade
Miscellaneous
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
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
High altitude physiologic change
PiO2 = PB x FiO2
PiO2 decreases 4-5 mm Hg for each 1,000-foot elevation
Acute cardiopulmonary responses

Ventilation (when Pao2 <60 mm Hg) CO to maintain adequate oxygen delivery:
Do2 Cao2 = Cao2 x CO = (Hb x 1.39 x Sao2) + 0.0031 (Pao2)
Healthy volunteer
inspire low FiO2
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
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