Pulm COPD + ARDS

Question 1

COPD

Answer 1

Path: Emphysema and Bronchitis
Genetics and Smoking

Pt: Pink puffer = emphysema = trapped air

• Hyperresonant
• increased AP diameter, flattened diaphragm
• Pursed lips, prolonged expiration
• CO2 retainer

Blue Bloater = Bronchitis = Hypoxia

• Cyanotic
• Pulmonary HTN
• Right heart failure
• Hepatosplenomegaly
• Peripheral edema

Dx: PFTS: decreased FEV1/FVC……irreversible
CXR can show flattened diaphragms

Tx: Corticosteroids = ICS right arrow Oral Prednisone
Oxygen = PaO2 < 55 or SpO2 < 88%
Prevention = smoking cessation, vaccines
Dilators = Bronchodilators, Ipratropium
Experimental = dont worry about it 
Rehab = exercise capacity increases

Question 2

Escalation of Therapy for COPD

Answer 2

SABA 
SABA + Tiotroprium 
SABA + Tiotroprium + LABA
SABA + Tiotroprium + LABA/ICS
SABA + Tiotroprium + LABA/ICS + PDE-4-i
.....Add oral steroids

Question 3

COPD Exacerbation

Answer 3

Path: Infectious (viral or bacterial)

Pt: Cough, SOB, Productive sputum, wheezing, CO2 retention

Dx: 1st CXR (rule out pneumonia)
ABG = CO2 retention

Tx: CO2 = Bipap
Alubterol and Ipratropium
Oral or IV steroids
Abx = Doxycycline or Azithromycin

F/u: Intubate if CO2 rises

Question 4

ARDS

Answer 4

Path: Non-cardiogenic pulmonary edema

Pt: TRALI, Gram Neg Rods, Near-drowning
Bilateral fluffy infiltrates on CXR
Pulmonary edema

Dx: ARDS Criteria

• P/F ratio < 200
• Echo, BNP, PCWP normal
• Pulmonary edema

Tx: Intubation
PEEP 
Low TV....6cc.kg ideal body weight 
Oxygenation
Paralysis 

F/u: fix the underlying disease

Question 5

CHF v ARDS

Answer 5

ARDS

low PCWP
high LV Fxn
fluffy CXR
Normal 2D Echo
low BNP

CHF

high PCWP
low or normal LV Fxn (clarify, but def not high)
Fluffy CXR
2D Echo shows LV dysfunction
high BNP