MCQ R2

MED R2

A 22 year old man with acute myeloid leukemia was treated with allogenic bone marrow transplant 3 months ago. He received cyclosporin 200 mg/day and cotrimoxazole. He had fever and nonproductive cough for 2 days prior to this admission. On physical examination revealed fever 38.3 c and fine crepitationboth lungs. He had no skin rash. The CXR was bilateral interstitial infiltrations.

What is the MOST likely diagnosis?

A. PCP pneumoniaB. Mycoplasma pneumoniaC. CMV pneumoniaD. Staphylococcus pneumoniaE. Aspergillus pneumonia

Respiratory complication after HSCT

Immune system after HSCT

Phase I (pre engraftment) 0-30 days

Host defence deficits

1 Neutropenia

2 Damage mucocutaneous barrier translocation of GI and cutaneous bacteria to bloodstream

3 Indwelling intravenous catheter septic emboli

Organism

Bacteria

gram negative Klebsiella, Pseudomonas, Enterobacteriaceae

gram positive Staphylococcus (coagulase postiveand negative), Enterococcus

Fungus

Candida spp, Aspergillois

Virus

HSV

• Risk for infection

– Allogenic = Autologous

• Resolve

– ANC > 500, platelet > 20,000 * 3 days

Phase II ( 30-100 days)

• Decrease or discontinue corticosteroid restore PMN function decrease risk for bacteria and funfus

BUT

Still has immune system dysfunction especially

Decreased CD4/CD8 ratio

Decreased IgA, IgG

Increased risk forCMVPJP Aspergillosis

Allogenic HSCT

Acute GVHD

skin, GI and liver manifestration

Phase III ( > 100 days)

Cellular and humoral immune deficit

macrophage dysfunction, impaired PMN chemotaxic

long lasting IgA and IgG deficiency

Risk for

encapsulated organism ( S.pneumoniae, H.influenza, N.meningitidis)

Norcadia,mycoplasma

PCP

CMV

• Allogenic HSCT chronic GVHD

bronchiolitis obliteran

scleroderma

sicca syndrome

Febrile neutropenia AIDS

A 22 year old man with acute myeloid leukemia was treated with allogenic bone marrow transplant 3 months ago. He received cyclosporin 200 mg/day and cotrimoxazole. He had fever and nonproductive cough for 2 days prior to this admission. On physical examination revealed fever 38.3 c and fine crepitationboth lungs. He had no skin rash. The CXR was bilateral interstitial infiltrations.

What is the MOST likely diagnosis?

A. PCP pneumoniaB. Mycoplasma pneumoniaC. CMV pneumoniaD. Staphylococcus pneumoniaE. Aspergillus pneumonia

Suppress T cell

Rapid onset of fever ,non productive cough,dyspnea and hypoxemia Interstitial pattern with tiny pulmonary nodules

Staphylococcus pneumonia

Arterial blood gas was drawn from a 16 year-old female immediately after her intubation for a severe asthmatic attack. PaO2 was 350 mm Hg, PaCO2 was 50 mm Hg and pH was 7.30. She remained sedated and paralyzed, breathing at the machine set rate of 12 /min and with a tidal volume of 400 cc. What should the rate be to normalize PaCO2 at 40 mmHg?

A. 14B. 15C. 16D. 17E. 18

ALVEOLAR VENTILATION EQUATION

หากผูป่้วยม ีCO2 production คงที ่ดงัน ัน้คา่

PACO2 เป็นตวับอก alveolar ventilation

• PACO2 มคีา่ใกลเ้คยีงกบั PaCO2 มาก

VT

VD

VA

VT = VA + VD หรอื VA = VT – VDAlveolar ventilation = RR x VA = RR (VT-VD)

“Alveolar ventilation equation”

PACO2 = k x VCO2/RR (VT-VD)


PACO2 = k x VCO2/RR (VT-VD)

PaCO21 = k x CO2 production 1PaCO22 alveolar ventilation 1

k x CO2 production 2alveolar ventilation 2

PaCO21 = alveolar ventilation 2PaCO22 alveolar ventilation 1

= [Vt(2)-Vd(2)] x RR(2)

[Vt(1)-Vd(1)] x RR(1)


VT เท่าเดมิ

PaCO21 = [Vt(2)-Vd(2)] x RR(2)

PaCO22 [Vt(1)-Vd(1)] x RR(1)

50 = RR(2)

40 12

RR(2) = 15/min

Arterial blood gas was drawn from a 16 year-old female immediately after her intubation for a severe asthmatic attack. PaO2 was 350 mm Hg, PaCO2 was 50 mm Hg and pH was 7.30. She remained sedated and paralyzed, breathing at the machine set rate of 12 /min and with a tidal volume of 400 cc. What should the rate be to normalize PaCO2 at 40 mmHg?

A. 14

C. 16D. 17E. 18

A 30 year old woman, previously healthy, develop smear positive pulmonary TB. After receiving INH, RIF, Ethambutol and PZA one daily before bedtime for 1 week, she developed progressive nausea vomiting and malaise, the physical findings are unremarkable. The LFT reveals: TB/DB 2.8/1.6, AST/ALT 180/170, Alk phos 150.

What is the MOST immediate appropiatemanagement?

A. Switch to ethambutol, olfoxacin and streptomycinB. Stop only PZA and continue the rest 3 drugsC. Replace RIF with olfloxacinD. Add domperidoneE. Split INH to 3 times daily after meal


Management of drug-induced hepatitis

Of the first-line anti-TB drugs, isoniazid, pyrazinamide and rifampicin can all cause liver damage (drug-induced hepatitis).

Try to rule out other possible causes before deciding that the hepatitis is induced by the TB regimen.

The management of hepatitis induced by TB treatment depends on:

whether the patient is in the intensive or continuation phase

the severity of the liver disease

the severity of the TB

the capacity of the health unit to manage the side-effects of TB treatment

If liver disease is caused by the anti-TB drugs all drugs should be stopped.

If the patient is severely ill with TB and it is unsafe to stop TB treatment non-hepatotoxic regimen consisting of streptomycin, ethambutol and fluoroquinolone should be started

• If TB treatment has been stopped wait for LFT to revert to normal and clinical symptoms (nausea, abdominal pain) to resolve restart the anti-TB drugs.

• If it is not possible to perform LFT wait an extra 2 weeks after resolution of jaundice and upper abdominal tenderness before restarting TB treatment.

• If the signs and symptoms do not resolve and the liver disease is severe non-hepatotoxic regimen consisting of streptomycin, ethambutol and a fluoroquinoloneshould be started (or continued) for a total of 18–24 months

When resolve rechallenge antiTB one by one.

If symptoms recur or LFT abnormal after rechallengelast drug added should be stopped.

In patients who have experienced jaundice but tolerate the rechallenge of rifampicin and isoniazid, it is advisable to avoid pyrazinamide.

Drug causes hepatitis

Rifampicin

2SHE 10 HE

INH

6-9 REZ

PZA

2 HRE 7 HR

INH and RIF

18-24 EOS


A. Switch to ethambutol, olfoxacin and streptomycinB. Stop only PZA and continue the rest 3 drugsC. Replace RIF with olfloxacinD. Add domperidoneE. Split INH to 3 times daily after meal

A 65 year old man, 50 kg, was recently diagnosed with active pulmonary TB. He was started on INH 300 mg/day, RIF 600 mg/day, ethambutol 800 mg/day and PZA 1500 mg/day. After 2 weeks of treatment, he complaint of nausea after taking medication. LFT showed AST 130 ALT 120 Alk phos 100, normal TB and DB.

What is the MOST appropiate management>

A. Continue medications, close follow up LFT and symptomsB. Stop all medications, follow up LFT, restart medications

after LFT normalizeC. Stop only INH but continue others, follow up LFTD. Switch to streptomycin, ethambutol and ofloxacinE. Decrease PZA to 1000 mg/day and follow up LFT

A 65 year old man, 50 kg, was recently diagnosed with active pulmonary TB. He was started on INH 300 mg/day, RIF 600 mg/day, ethambutol 800 mg/day and PZA 1500 mg/day. After 2 weeks of treatment, he complaint of nausea after taking medication. LFT showed AST 130 ALT 120 Alk phos 100, normal TB and DB.

What is the MOST appropiate management>

Active + symptom + AST/ALT > 3 times

A. Continue medications, close follow up LFT and symptomsB. Stop all medications, follow up LFT, restart medications

after LFT normalizeC. Stop only INH but continue others, follow up LFTD. Switch to streptomycin, ethambutol and ofloxacinE. Decrease PZA to 1000 mg/day and follow up LFT

ผลขา้งเคียงยาวณัโรค

Which one is incorrect reguarding the toxicity of antiTBdrugs?

A. PZA and hepatitis

B. Ethambutol and retrobulbar neuritis

C. Rifampicin and peripheral neuropathy

D. Streptomycin and renal toxicity

E. Isoniazid and hepatotoxicity

Side effect of antiTB drugs

Isoniazid

Systemic or cutaneous hypersensitivity reactions

Sleepiness or lethargy

Peripheral neuropathy, optic neuritis, toxic psychosis and generalized convulsions

hepatitis

lupus-like syndrome, pellagra, anemia, and arthralgias

monoamine (histamine/tyramine) poisoning

RifampicinOrange discoloration of body fluids pruritis with/without rashSevere Hypersensitivity HepatotoxicityTransient asymptomatic hyperbilirubinemiaHepatitis cholestatic pattern Influenza like syndrome GI upset : Nausea, anorexia, abdominal pain Immunological reaction : thrombocytopenia,

hemolytic anemia ,acute renal failure

Pyrazinamide

gastrointestinal intolerance

hypersensitivity reactions

rises in serum transaminase concentrations

hepatotoxicity

hyperuricaemia

Arthralgia

Rare adverse events sideroblastic anaemia and photosensitivity dermatitis

Contraindication in porphyria

Streptomycin

Hypersensitivity reactions are rare.

nephrotoxicity

ototoxicity

vertigo

EthambutolRetrobulbar neuritis (blurred vision, central scotomata, red-green color

blindness) : dose related

50 mg/kg : 15%

25 mg/kg : 1%- 5%

15 mg/kg : < 1%

Peripheral neuritis : rare

Cutaneous reaction

Monitoring VA, color

1. Dose > 15-25 mg/kg

2. Receive drug > 2 month

3. Renal insuff.

Discontinue drug immediatley and permanent if there any sign of visual toxicity

Which one is incorrect reguarding the toxicity of antiTBdrugs?

A. PZA and hepatitis

B. Ethambutol and retrobulbar neuritis

C. Rifampicin and peripheral neuropathy

D. Streptomycin and renal toxicity

E. Isoniazid and hepatotoxicity

INH

Which effect of rifampicin is absolute contraindication for prescribing it in future?

A. Flu like symptoms

B. Hepatitis

C. Maculopapular rash

D. Urine discoloration

E. Immune thrombocytopenia

Contraindication for remedication

• RFP: thrombocytopenia , hemolytic anemia , acute interstitial nephritis

• Etham : visual impairment

• strep : eight nerve damage

• PZA: jaundice

Management of cutaneous reaction

Itching without rash

symptomatic Rx with antihistamine and continue anti TB drug

Rash

stop all anti TB

when resolved restart one by one with small challenge dose

Which effect of rifampicin is absolute contraindication for prescribing it in future?

A. Flu like symptoms

B. Hepatitis

C. Maculopapular rash

D. Urine discoloration

E. Immune thrombocytopenia

Isoniazid Bactericidal

Rifampicin Bactericidal

Ethambutol Bacterioistatic

Pyrazinamide Weakly bactericidal

streptomycin Bactericidal

CNS penetration

Renal excretion

Pregnancy

INH Excellent Safe Safe

Rifam 10-20% of serum level

Safe Safe

PZA CNS = serum Should reduce limit data but benefit > risk

Etham Only inflammation

Should reduce Safe

Streptomycin

Slight Used with caution

X

(fetal hearing loss)

Dose

(mg/kg/day)

Cycloserine

Cs

Bacteristatic 10-15 bid

(500-750)

Ethionamide

Et

Bactericidal 15-20 od/bid

(500-750)

Amikacin /

kanamycin / Capreomycin

Am/Km/Cm

Bactericidal 15 IM/IV

5-7 day/weeks

(750-1,000)

Complete X resistant

between Am/Km but

Sm resistant are susceptible to Am/Km

PAS Bacteristatic 150 bid/tid

(8-12 g)

Ofloxacin

O

Bactericidal 7.5-15

(600-800)

X resistant between O

Cx and levofloxacin

Divalent ion interfere absorption

Ciprofloxacin

Cx

Bactericidal 10-20

(1,000-1,500)

AFB per ml Number of colonies

on cultureCulture report

Number of AFB on smear

(1000X, Ziehl-Nelsen)

Number of

AFB on smear(200-250X

,Fluorescen)

AFB smear

report

< 10 0 - 0 0 -

10-500 < 50 Actual count

0 0 -

500-1,000 50-100 1+ 0 0 -

1,000-2,000 100-200(almost confluent)

2+ 0 0 -

2,000-5,000 >500 (confluent) 3+ 1-2 / 300 field

1-2 / 30 field

5,000-60,000 >500 (confluent) 4+ 1-9 / 100 field

1-9 / 10 field

1+

60,000-600,000

>500 (confluent) 4+ 1-9 / 10 field

1-9 / field 2+

600,000-6,000,000

>500 (confluent) 4+ 1-9 / field 10-90 / field

3+

6,000,000-60,000,000

>500 (confluent) 4+ > 9 / field > 90 / field 4+

A patient with AIDS was admitted due to severe dyspnea. CXR showed bilateral upper lobe infiltratonand sputum smear showed AFB4+. He was isolated with air borne precaution. On transport him to radiology department for CT chest, you would advise:

A. Surgical mask formpateint and N 95 mask for trolley pusherB. Surgical mask for patient and trolley pusherC. N 95 mask for patient and surgical mask for trolley pusherD.N 95 mask for patient and trolley pusherE. N 95 mask for patient only

Airborne precaution

• ห้องแยก

• Sputum pot

• N 95 mask

• Surgical mask• เคลื่อนย้ายผู้ ป่วย

Particle < 5 um

• ปิดประตตูลอดเวลา

• ควรใช้ห้องความดนัอากาศเป็นลบ

• ใช้ HEPA filter ก่อนปลอ่ยอากาศออกจากห้อง

• ภาชนะมีฦาปิดให้เติม 2%lysol หรือ 5% hypochloride

• สวมเม่ือเข้าใกล้ผู้ ป่วย

• ผู้ ป่วยสวม

• สวมsurgical mask ให้ผู้ ป่วย

โรคที่พบChicken pox pulmonary tuberculosisHZV measleSARS

A patient with AIDS was admitted due to severe dyspnea. CXR showed bilateral upper lobe infiltratonand sputum smear showed AFB4+. He was isolated with air borne precaution. On transport him to radiology department for CT chest, you would advise:

A. Surgical mask formpateint and N 95 mask for trolley pusherB. Surgical mask for patient and trolley pusherC. N 95 mask for patient and surgical mask for trolley pusherD.N 95 mask for patient and trolley pusherE. N 95 mask for patient only

A 63 year old man, a 30 pack year smoker, present with increasing cough with sputum production, fever and progressive weight loss. He worked in a stone quarry for 20 years.

Which one of following in UNLIKELY to be found in is current evaluation?

A. Infection caused by Mycobacteria tuberculosisB. Malignant mesotheliomaC. Upper lobe lung noduleD. Eggshell calcificationE. Positive ANA in serum



Silica dust

Diseases associated with exposure to silica dust

Slilicosis

chronic silicosis

accelerated silicosis

acute silicosis

progressive massive fibrosis

COPD

emphysema

chronic bronchitis

small airway

Mycobacterial infection

MTB

NTM

Immune related

PSS

RA

CRF

SLE

Silicosis

Risk factors for TB

• HIV

• Hematologic malignancy and cancer chemotherapy

• DM

• Uremia

• Undernutrition

• Gastrectomy

• Silicosis ( increased risk 2-30 times)

Risk factor of mesothelioma

asbestos exposure

ionizing radiation

chronic inflammation of pleura Mediterranianfever



A. Infection caused by Mycobacteria tuberculosisB. Malignant mesotheliomaC. Upper lobe lung noduleD. Eggshell calcificationE. Positive ANA in serum

PAHFc II

Thai guideline for Dx and Rx PH 2011

Pulmonary hypertension

mean pulmonary arterial pressure >= 25 mmHg

Pulmonary arterial hypertension

mean pulmonary arterial pressure >= 25 mmHg

PCWP < 15 mmHg

PVR > 3 wood

Pulmonary hypertension Diagnostic classification

JACC June 2009:54(1)suppl S: S43-541.4

1.Pulmonary arterial hypertension

1.1. Idiopathic (IPAH)

1.2. Familial (FPAH)

1.3. Associated with (APAH):

1.3.1. Connective tissue disorder

1.3.2. Congenital systemic-to-pulmonary shunts

1.3.3. Portal hypertension

1.3.4. HIV infection

1.3.5. Drugs and toxins

1.3.6. Other (thyroid disorders, glycogen storage disease,Gaucher’s disease, hereditary hemorrhagic

telangiectasia,

hemoglobinopathies, chronic myeloproliferative disorders, splenectomy)

1.4. Associated with significant venous or capillary involvement

1.4.1. Pulmonary veno-occlusive disease (PVOD)

1.4.2. Pulmonary capillary hemangiomatosis (PCH)

1.5. Persistent pulmonary hypertension of the newborn

1.Pulmonary arterial hypertension

2. Pulmonary hypertension with left heart disease

2.1. Left-sided atrial or ventricular heart disease

2.2. Left-sided valvular heart disease

3. Pulmonary hypertension associated with lung diseases and/or hypoxemia3.1. Chronic obstructive pulmonary disease3.2. Interstitial lung disease3.3. Sleep disordered breathing3.4. Alveolar hypoventilation disorders3.5. Chronic exposure to high altitude3.6. Developmental abnormalities

4. Pulmonary hypertension due to chronic thrombotic and/or embolic disease (CTEPH)4.1. Thromboembolic obstruction of proximal pulmonary arteries4.2. Thromboembolic obstruction of distal pulmonary arteries4.3. Nonthrombotic pulmonary embolism (tumor, parasites,foreign material)

5. MiscellaneousSarcoidosis, histiocytosis X, lymphangiomatosis, compression of pulmonary vessels (adenopathy,tumor, fibrosing mediastinitis)

แนวทางการวินิจฉัย PH

ขัน้ตอนที่ 1 (PH diagnosis)

ขัน้ตอนที่ 2 (PH classicication)

Hx and PECXREKGEchoRHC

Blood test :antiHIV Cr LFT CBC ANAO2Sat, ABGCTA or V/QPFTPSGRHC

แนวทางการรักษา PAH

PAH

Avoid pregnancyInfluenza and pneumococcal

vaccinationExercisePsychosocial support

DiureticO2Oral anticoagulantDigoxin

Acute vasoreactivity test

Acute vasoreactivity test

vasoreactive

Fc I-IIICCB

Good response

yes no

Continue CCB

Poor response

Non vasoreactive/ not perform

PAH specific drug

F/U 3-6 month

Poor response

Combination Tx

Atrial septostomyLung transplant

ค าแนะน า Fc II Fc III Fc IV

1++ Sildenafil, bosentan Sidenafil, bosentan, iloprost inhaled

2++ Iloprost IV/inhaleCmbination Rx

3+ beraprost Bosentan, sidenafil

OSA; criteria for Dx

Symptom

PSG AHI >=5/hr + R/O other disease

No symptom

PSG AHI >= 15/hr + R/O other disease

Risk factor of OSA

1 neck size > 17 inches in male and > 16 inches in female

2 nasal feature eg polyp3 lingual feature eg

macroglossia4 palatal feature eg low lying

soft palate5 enlarge tonsil and adenoid6 oropharynx narrowing7 hereditar syndrome eg

Down syndrome

8 smoking9 obesity10 hypothyroid, acromegaly11 neuro eg stroke, Dchene12 alcohol13 medication BZs14 familial Hx of OSA15 ESRD16 CHF17 HT

Symptoms

1 excessive daytime sleepiness

2 morning headache

3 nocturia

4 nocturnal chocking

5 witnessed apnea

Consequences

1 HT2 CAD esp nocturnal ischemia3 arrhymia esp sinus arrhymia, bradycardia, sinus pause,

sinus arrest, VT PVC, AV block4 CHF in Pt with LVEF < 45%, AHI > 15 increase mortality5 PH6 Insulin resistance7 Erectile dysfunction8 depression9 GERD10 stroke11 floppy eyelid syndrome, gluacoma,papilledema

Rx

1 CPAP

2 uvulopalatopharyngeaopasty

3 oral appliance in mild to moderate pt

4 oromaxillofacial Sx

5 tracheostomy GOLD STANDARD

6 positional Rx

7 weight reduction

A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?

A. uvuloplastyB. methylphenidateC. weight reductionD. sleep hygiene and reassure E. continuous positive airway pressure

A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?

Classic tetrad

Excessive daytime sleepiness (EDS)

Cataplexy : an loss of skeletal muscle tone (triggered by the occurrence of sudden emotion)Sleep paralysis : a brief loss of voluntarymuscle control with an inability to move or speakHypnagogic Hallucinations : visual or auditory and occasionally involve other senses e.g., tactile or vestibular

NARCOLEPSY

NARCOLEPSY

Nonpharmacologic Management

Pharmacologic Management

Behavioral approaches

Scheduled naps (15-20 min, 2-3 times/day)

Regular sleep wake schedule

Avoidance of frequent time zone changes

Good sleep hygiene

modafinil and armodafinil

sodium oxybate, amphetamines, methylphenidate

63. A truck driver, with BMI 25 Kg/m2, keeps falling asleep. He loses of muscle tone when he laughs with joking TV program. Sleep study shows no sleep apnoea, arousal index 26 times /hour and very short sleep latency. What is the most appropriate management?

A. uvuloplasty

C. weight reductionD. sleep hygiene and reassure E. continuous positive airway pressure

A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?

A. Left upper lobe lobectomy

B. Follow up CXR within 2 months

C. Review her last year CXR, if available

D. Empirical treatment with anti-TB drugs: HRZE

E. Percutaneous transthoracic needle aspiration

A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilaror mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?

Solitary pulmonary nodule

• Focal, round or oval areas of increased opacity

• Defined as <3 cm

• Not associated with atelectasis or adenopathy

• 90% incidental findings


• Most SPN: benign

• 30-40% of SPN are malignant

• Patients with best prognosis are stage IA:

61-75% 5-year survival

Differential diagnosis

Neoplasm Benign Hamartoma

Inflammory pseudotumor

Malignant Bronchogenic carcinoma

Carcinoid tumor

Lymphoma (NHL)

Metastasis

Infection Granuloma Mycobacteria

Fungi

Septic emboli

Abscess Bacteria (anaerobes, Staph, gram negative)

Round pneumonia

Pneumococci

Parasitic Echinococcus

Dirofilaria (dog heartworm)

(Leef III JL, Klein JS. The solitary pulmonary nodule. Radiol Clin N Am 2002;40:123-143


Differential diagnosisInflammatory CNT Wegener’s

granulomatosis

Rheumatoid nodule

Sarcoidosis

Vascular AVM

Hematoma

Pulmonary infarct

Pulmonary artery aneurysm

Pulmonary venous varices

Airway Congenital lesion Bronchogenic cyst

Bronchial atresia

Mucocele

Infected bulla

Leef III JL, Klein JS. The solitary pulmonary nodule. Radiol Clin N Am 2002;40:123-143



• 95% fall into one two groups

- Malignant: either primary or metastatic

- Benign

Infectious ;granulomas (either TB or

fungal)

Benign tumors: hamartomas present in

middle age, grow slowly over years


• First step: ensure that the nodule is in fact

solitary and truly arises in the lung parenchyma.

• Up to 20% prove to be entities mimicking a SPN

Pseudonodule (a) Close-up PA radiograph of the right lung shows a smoothly marginated nodular area of increased opacity projecting over the lung (arrow).

(b) Front and back views of the EKG lead attachment pad

Erasmus JJ. Radiographics 2000;20:43-58


Bone island in a 61-year-old man with melanoma. (a) Close-up PA CXR shows a focal area of increased opacity overlying the right seventh rib posteriorly (arrow). (b)Fluoroscopic images show a well-marginated intraosseous lesion (arrow). This finding is consistent with a bone island and obviated further investigation.



Diagnostic evaluation

Second step

Aim to distinguish benign VS malignant

• Clinical features

• Radiographic features

• Quantitative models : used to determine the probability that the nodule is malignant

Clinical features

• Age - Risk of malignancy increases with age

– 3% at age 35-39 years



– greater than 50% in patients > 60 years

• Smoking history

• History of prior malignancy


Manocha S, Sharma S. Solitary pulmonary nodule. http://www.emedicine.com/radio/topic782.ht

Clinical Features

• Travel history - Travel to areas with endemic

mycosis or a high prevalence of tuberculosis

• Occupational risk factors - Exposure to asbestos,

radon, nickel, chromium, vinyl chloride, and

polycyclic hydrocarbons


Manocha S, Sharma S. Solitary pulmonary nodule. http://www.emedicine.com/radio/topic782.ht

Radiographic features

• Size

• Border

• Calcification

• Density

• Growth

• Metabolic activity

Size

• Generally, smaller nodule, more likely to be

benign

• 80% of benign nodules are less than 2 cm in

diameter

• Small size alone not exclude lung cancer

- 15% of malignant are less than 1 cm

- 42% are less than 2 cm


Margins and Contours

• Smooth, most are benign, not at all: 21% of

malignant have well-defined margins

• Lobulated implies uneven growth, up to 25% of

benign nodules

• Irregular: more malignant

• Spiculated (sunburst or corona radiata

appearance): 84-90% are malignant


Low

Hign

benign malignant

smooth lobulated Irregular and spiculated

Margin and Contour

Internal Characteristics

• Overlap of benign and malignant

• Homogeneous attenuation: benign (55%) and

malignant (20%)

• Air bronchograms and Pseudocavitation:

bronchioloalveolar cell carcinoma or lymphoma



Bronchioloalveolarcell carcinoma: pseudocavitation


Air bronchogram:lymphoma

Benign

Diffuse Central Popcorn Laminar

Indeterminant ;likely malignant

Stipple Eccentric

Calcification

most often seen in hamartomas

typical of a granuloma


Time

• Volume Doubling time: most malignant = 30-400

days

• SPN that stable over 2-year indicator of benignity

*Yankelevitz, Am J Roentgenol 1997;168:325-8

Satellite nodule

• Tiny nodules associate with dominant pulmonary nodule

• High likelihood to be benign

• PPV for benignity: approximately 90%


Feature or Characteristic LR

Spiculated margin

Size > 3 cm

Age > 70 yr

Malignant growth rate

Smoker

Upper lobe location

Size < 1 cm

Smooth margins

30-39 yr

Never smoked

20-29 yr

Benign calc

Benign growth rate

5.54

5.23

4.16

3.40

2.27

1.22

0.52

0.30

0.24

0.19

0.05

0.01

0.01

LRs for Selected Radiologic Features of Nodules and Patient Characteristics

(Erasmus JJ. Radiographics 2000;20:59-66)


A 60-year-old nonsmoker female with a 2-cm left upper lung nodule found on her check-up. She was asymptomatic and chest CT scan showed no evidence of hilar or mediastinal adenopathy but eccentric calcification was demonstrated within the nodule. What is the most appropriate management?

B. Follow up CXR within 2 months

C. Review her last year CXR, if available

D. Empirical treatment with anti-TB drugs: HRZE

E. Percutaneous transthoracic needle aspiration


Spiculated margin

Size > 3 cm

Age > 70 yr


Smoker

Upper lobe location

Size < 1 cm

Smooth margins

30-39 yr

Never smoked

20-29 yr

Benign calc

Benign growth rate

5.54

5.23

4.16

3.40

2.27

1.22

0.52

0.30

0.24

0.19

0.05

0.01

0.01




A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked 30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit.

Which of the following is the MOST appropiatemanagement?

A. Symptomatic and supportive treatmentB. Repeat CXR in next 3 monthsC. Inform his family and discuss the most likely

diagnosis and prognosisD.Obtain CT chest include upper abdomenE. Request for diagnosis bronchoscopy

A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit.



Spiculated margin

Size > 3 cm

Age > 70 yr


Smoker

Upper lobe location

Size < 1 cm

Smooth margins

30-39 yr

Never smoked

20-29 yr

Benign calc

Benign growth rate

5.54

5.23

4.16

3.40

2.27

1.22

0.52

0.30

0.24

0.19

0.05

0.01

0.01




A 75 year old man with severe dementia is found to have a 3 cm nodule in Right lower lobe. He smoked 30 pack years and quit after develop dementia. His family bought him to nursing home last 2 year because of no care giver at home. A CXR at 2 years ago was within normal limit.


A. Symptomatic and supportive treatmentB. Repeat CXR in next 3 monthsC. Inform his family and discuss the most likely

diagnosis and prognosisD.Obtain CT chest include upper abdomenE. Request for diagnosis bronchoscopy

A 55-year-old man with previous history of stroke came to your clinic for smoking cessation program. He smokes15 cigarettes/day. He begins his first cigarette of the day after breakfast, and the remaining after lunch and dinner.What is the most appropriate method for smoking cessation in this patient?

A. cold turkey

B. cold turkey + behavioral therapy

C. cold turkey + behavioral therapy + bupropion

D. cold turkey + behavioral therapy + varenicline

E. cold turkey + behavioral therapy + nicotine

replacement therapy

Smoking Cessation

NONPHARMACOLOGIC INTERVENTION 5A (ASK,

ADVISE, ASSESS, ASSIST, ARRANGE) : COLD TURKEY +

BEHAVIORAL THERAPY

First line Medication

Nicotine Replacement Therapy : Gum, Patch

Bupropion SR

Varenicline

Combination therapy

A 55-year-old man with previous history of stroke came to your clinic for smoking cessation program. He smokes15 cigarettes/day. He begins his first cigarette of the day after breakfast, and the remaining after lunch and dinner.What is the most appropriate method for smoking cessation in this patient?

A. cold turkey

B. cold turkey + behavioral therapy

C. cold turkey + behavioral therapy + bupropion

E. cold turkey + behavioral therapy + nicotine

replacement therapy

< 80%

250/31080%

76. Which of the following is not likely to be the potential underlying cause of bronchiectasis?

A. Kartagener's syndrome B. Churg Strauss syndrome C. PanhypogammaglobulinemiaD. Endobronchial carcinoid tumor E. Allergic bronchopulmonary aspergillosi

สาเหตขุอง bronchiectasis

1. Airway obstruction เชน่ endobronchial tumor, foreign body2. Defective host defenses เชน่ hypogammaglobulinemia3. Cystic fibrosis 4. Young's syndrome combination of obstructive azoospermia (with normal spermatogenesis) and chronic sinopulmonary infections (bronchiectasis and sinusitis)5. Rheumatic and other systemic diseases เชน่ rheumatoid arthritis และ Sjögren's syndrome6. Dyskinetic cilia เชน่ Kartagener's syndrome 7. Alpha-1 antitrypsin deficiency 8. Pulmonary infections เชน่ TB9. Allergic bronchopulmonary aspergillosis

76. Which of the following is not likely to be the potential underlying cause of bronchiectasis?

A. Kartagener's syndrome

C. PanhypogammaglobulinemiaD. Endobronchial carcinoid tumor E. Allergic bronchopulmonary aspergillosis

53. A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is related to this patient?

A. Bihilar lymphadenopathy

B. Normal chest radiography

C. Water balloon–shaped heart

D. Bilateral upper lobe infiltrates

E. Situs inversus and diffuse reticular infiltration

A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is relate to this patients?

Manes Kartagener first recognized this clinical triad

is inherited via an autosomal recessive pattern

Symptoms result from defective cilia motility

Kartagener’s syndrome

bronchiectasis situs inversuschronic sinusitis

Immotile spermatozoa or infertility

Confirmation with biopsy of respiratory mucosa or microscopic examination of sperms

A 35-year-old male is evaluated of infertility. Sperm analysis shows a normal number of sperm, but they are immotile. Past medical history is notable for recurrent sinopulmonary infections. Which of the following CXR is related to this patient?

A. Bihilar lymphadenopathy

B. Normal chest radiography

C. Water balloon–shaped heart

D. Bilateral upper lobe infiltrates

A flow volume loop of spirometry shows plateau of the inspiratory loop only. What is the most likely cause of this pattern?

A. Small airways narrowing

B. Fixed intra-thoracic obstruction

C. Fixed extra-thoracic obstruction

D. Variable intra-thoracic obstruction

E. Variable extra-thoracic obstruction

Spirometry in Upper Airway Obstruction

Extrathoracic airway Intrathoracic airway

Nose, mouth, pharynx, larynx and the 2 to 4 cm. of the trachea cephaled to the thoracic inlet

Trachea to the main carina

Variable Extrathoracic Obstruction

0

-

- -

0 0

+ +

+

0

0 0

Variable Intrathoracic Obstruction

- --

0

0 0

+ ++

0

00

Fixed Obstruction

A flow volume loop of spirometry shows plateau of the inspiratory loop only. What is the most likely cause of this pattern?

A. Small airways narrowing

B. Fixed intra-thoracic obstruction

C. Fixed extra-thoracic obstruction

D. Variable intra-thoracic obstruction

Interpretation of spirometry

• Adequate or inadequate test

• Obstructive, restrictive or combine pattern

• If obstructive disease,response to bronchodilator

• Severity

• Flow-Volume loop

Adequate or inadequate

• No artifacts : cough or glottic closure, leak, early termination, obstructed mouthpiece

• Sharp peak flow (time to PEF < 120msec.)

• Expiratory duration greater than 6 seconds or plateau in volume time curve

• Age, sex, height

• 2/3 highest FEV1 , FVCvariation < 0.2L (reproducibility)

Normal Spirometry

Reproducible

Early Terminate

COUGH

Poor Effort

Poor Effort

http://erj.ersjournals.com/content/vol26/issue3/images/large/erj260511.f1.jpeg

What is pattern of spirometry?

• FEV1/FVC ปกตหิรือผิดปกติ (75%)

• ถ้าผิดปกตเิข้าได้กบั airflow limitation ให้ดตูอ่ว่า

– FVC - FEV1 15 pure obstructive pattern

– FVC - FEV1 < 15 อาจมี restrictive ร่วมด้วย

What is pattern of spirometry?

• ถ้า FEV1/FVC ปกตใิห้ด ูFEV1, FVC วา่ปกติหรือต ่า (ปกติ >

80%)– ถ้าต ่าและ

• FEV1>FVC เข้าได้กบั restrictive pulmonary disease

• FEV1<FVC เข้าได้กบั mixed obstructive with restrictive

pulmonary disease

– ถ้าปกติ ให้ด ูFEF25-75 วา่มากหรือน้อยกวา่ 65%

• ถ้ามากกวา่ 65% ถือวา่ normal PFT

• ถ้าน้อยกวา่ 65% แปลผลเป็น small airway disease

Response to bronchodilator

• เทียบ pre-post bronchodilator 15 min.

• FEV1,FVC improved 12%(15%) and 200cc.

• FEF25-75 improved 35%

FEV1/FVC

obstructive FEV1,FVC

restrictive

FEF 25-75

normal Small airway disease

<75% 75%

abnormal normal

65% <65%

FVC-FEV1

Pure obstructive

Possible mixed restrictive

<15%>15%FVC<FEV1 FVC>FEV1

Mixed obstructive with restrictive

Severity

• Obstructive

Mild Moderate Severe

60-79% 41-59% 40%

• Restrictive

Mild Moderate Severe

60-79% 51-59% 50%

Flow-Volume Loop

Emphysema

Extra thoracic Obstruction

Intra thoracic Obstruction

Fixed Obstruction

An asthmatic patient’s spirometry reveal FEV1 of 1000 mlFVC 2000 ml FEV1/FVC 50%. After salbutamol inhalation, which spirometric results show the best bronchodialtorresponse?

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 55%

Response to bronchodilator

• เทียบ pre-post bronchodilator 15 min.

• FEV1,FVC improved 12%(15%) and 200cc.

• FEF25-75 improved 35%

An asthmatic patient’s spirometry reveal FEV1 of 1000 mlFVC 2000 ml FEV1/FVC 50%. After salbutamol inhalation, which spirometric results show the best bronchodialtorresponse?

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 55%

DDx orthopneaCHFV/Q mismatch in posteria part of lungdiaphragmatic paralysis

Unilateral diaphragmatic paralysis

Phrenic nerve injury

Herpes zoster, poliomyelitis, and other viral infections

Cervical spondylosis

Clinical manifestations

usually asymptomatic at rest

may have exertional dyspnea and decreased exercise performance

Imaging

CXR upright elevated hemidiaphragm

PFT

FVC decrease 15-20% in supine position

Bilateral diaphragmatic paralytic

Etiology

• Spinal cord disease

• Motor neuron disease

• Neuropathy

• Neuromuscular junction disease

• Muscle disease

Symptom

orthopnea

PE

abdominal wall paradox

hypoxemia

CXR

bilateral, smooth elevation of the hemidiaphragms and small lung volumes

PFT

FVC may decrease 15 to 25 percent in the supine position

Pulmonary embolism

Symptomsdyspneapleuritic chest painsubsternal chest paincoughhemoptysissyncope

Signstachycardiatachypneasign of DVTfevercyanosis

On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homan’s sign is negative. What is

the most likely diagnosis?

1. Pneumonia

2. Atelectasis

3. Popliteal thrombosis with PE

4. Iliofemoral thrombosis with PE

5. Pulmonary edema

On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homan’s sign is negative. What is the most

likely diagnosis?

1. Pneumonia

2. Atelectasis

3. Pulmonary edema

The risk for thrombosis is increased in pregnancy, partly because of the increase in the coagulation factors, particularly V, VIII, X, and von Willebrand factor Ag, and partly because of a marked fall in protein S Venous stasis, an important contributor to thrombosis, is caused by uterine compression of the inferior vena cava and the left iliac vein Local trauma to pelvic veins at the time of delivery probably accounts for the peak incidence of thromboembolism in the postpartum period, especially after cesarean section.

Pulmonary Embolism

On the first day following a cesarean section, the patient complains of acute shortness of breath. Her respiratory rate is 26/min. Her pulse is 112/min. Her oxygen saturation is 85% on room air. Her lung are clear. Homan’s sign is negative. What is

the most likely diagnosis?

1. Pneumonia

2. Atelectasis

3. Popliteal thrombosis with PE

4. Iliofemoral thrombosis with PE

5. Pulmonary edema

A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed expiratory rhochi diffusely.

The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400 cc O2 sat 99%. The patient was given NB

salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze,

the PIP was 50 cmH2O and Ppla 26 cmH2OWhich one of these condition would be the cause of the ventilator alaem?

1.Fluid overload2.Pneumothorax3.HAP4.Lt.lung atelectasis5.Bited on the ET tube

A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed

expiratory rhochi diffusely. The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400

cc O2 sat 99%. The patient was given NB salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the

past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze,


↑ PIP

Peak inspiratory pressure = P resistance + P elastance

LUNG MECHANIC

LUNG MECHANICS

Paw = AIRWAY PRESSURE

Raw = RESISTANCE

Crs = COMPLIANCE

Paw = PRaw + PCrs (Pplat)

LUNG MECHANIC

PAW = PR + PE

= Pmusi

P AW =Peak airway pressure

PR = แรงตา้นจากท่อทางเดินหายใจ

PE =แรงตา้นจากการขยายตวัของ ถุงลมและผนงัทรวงอก

Pmusi = แรงของกลา้มเน้ือในการหายใจ

LUNG MECHANIC

Paw = PRaw + Pclung

Raw = Pressure (cmH2O)Flow (L/Sec)

= Pdyn - Pstat

Flow

Compliance = Volume (ml)Pressure (cmH2O)

= Volume (ml)Pstat - PEEP

Pressure Resistance

PIP 38 cmH2O Ppla 25 cmH2O

PIP was 50 cmH2O and Ppla 26 cmH2O

A 25 year old man was intubated on A/C mode ventilation for status asthmaticus. He was sedated and paralyzed. His lung examination showed expiratory rhochi diffusely.

The set tidal volume was 400 cc., RR 15/min, FiO2 0.4, PEEP of 0 cmH2O, PF 80 L/min. PIP 38 cmH2O Ppla 25 cmH2O TV 300-400 cc O2 sat 99%. The patient was given NB

salbutamol q 1 hr, IV steroid, tube feeding and IV fluid. He had positive fluid balance of 1500 cc/day during the past 2 days. On third day of admission, his ventilator alarm went off. The ventilator setting were not changed. His lung examination showed no wheeze,


1.Fluid overload2.Pneumothorax3.HAP4.Lt.lung atelectasis5.Bited on the ET tube

A 70 year-old man with COPD, presented with dyspneaon exertion. Physical examination revealed engorged neck vein, right ventricular heaving and pansystolic murmur grade II at left lower sternal border. His current medications were Ipratropium bromide inhaler and slow release theophylline. ABG: PaO2 53mmHg, PaCO2 45mmHg, pH7.38, O2Sat 87%. What is the most appropriate treatment?

A.PrednisoloneB.Steroid inhaler C. Inhale iloprostD.Long term oxygen therapy E. Noninvasive positive pressure ventilation

Oxygen therapy• Long term administration of oxygen (>15h/day) to

patients with chronic respiratory failure has been shown to increase survival (evidence B)

Indication for long term oxygen therapy (LTOT)

1. PaO2 < 55 mmHg or SaO2 at or below 88% with or without

hypercapnea confirmed twice over a three week period

2. PaO2 < 55mmHg or SaO2 at or below 88% if there is evidence of

pulmonary hypertension, peripheral edema suggesting congestive

cardiac failure or polycytemia( Hct>55%)

COPD and Pulmonary Hypertension

GOLD Guideline 2011

GOLD Guideline 2011

GOLD Guideline 2011

ICS + LABA

or LAMA

ICS + LABA

and

LAMA

SABA or

SAMA

LABA

or LAMA

GOLD Guideline 2011

19. A 70 year-old man with COPD, presented with dyspnea on exertion. Physical examination revealed engorged neck vein, right ventricular heaving and pansystolic murmur grade II at left lower sternal border. His current medications were Ipratropium bromide inhaler and slow release theophylline. ABG: PaO2 53mmHg, PaCO2 45 mmHg, pH7.38, O2Sat 87%. What is the most appropriate treatment?

A.PrednisoloneB.Steroid inhaler C. Inhale iloprost

E. Noninvasive positive pressure ventilation

NIVImprove respiratory acidosisDecrease RRDecrease breathlessnessDecrease VAPDecrease LOSDecrease ETTDecrease mortality

2

Clue

• AE asthma

• silent chest drowsiness air hunger on BD + steroid

• On MV : VCV vt 600 ml RR 20 PF 60 FiO2 0.6

• Paw 50 Ppl 25

• ABG: pH 7.45 PCO2 30 PO2 200

• How to set MV in asthma

– Low tidal volume

– High PF to short Ti

– Low RR

– Short Ti prolong Te

– PEEP 3-5 cmH2O : not need to adjust 80% autoPEEP

– FiO2 : lowest to keep PaO2 > 60 mmHg, SaO2 > 90%

– Set alarm

Answer

• On MV : VCV vt 600 ml RR 20 PF 60 FiO2 0.6 – Accept due to Ppl not above limit

– but accept if decrease Vt, RR, FiO2 but should avoid pH < 7.2 and PaO2 < 60

• Paw 50 Ppl 25 :– Ppl accept : set high Vt alarm to avoid volume

trauma

• ABG: pH 7.45 PCO2 30 PO2 200 – Accept but and decrease FiO2

• Mx except

1. Decrease VT

2. Decrease RR

3. PF ?

4. Decrease FiO2

5. Increase PEEP : not necessary

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