Pearls from Dr. Darryl Abrams

ARDS in patient with influenza H1N1


  • Pulmonary infections associated with pigeons/birds:

    1. Cryptococcus
    2. Chlamydia psittaci (psittacosis)

    Posted 06/08/16 05:41:55 PM by Anna Krigel

  • ARDS diagnostic criteria (Berlin definition):

    1. Acute (respiratory symptoms began within 1 week or have worsened within 1 week)
    2. Bilateral opacities
    3. Respiratory failure not exclusively explained by heart failure
    4. Severe impairment of oxygenation as measured by PaO2/FiO2 ratio
                - Mild ARDS = PaO2/FiO2 >200 but less than or equal to 300, on PEEP of 5 or more
                - Moderate ARDS = PaO2/FiO2 >100 but less than or equal to 200, on PEEP of 5 or more
                - Severe ARDS = PaO2/FiO2 less than or equal to 100, on PEEP of 5 or more

    Posted 06/08/16 07:05:49 PM by Anna Krigel

  • Lessons from the ARMA trial

    - low tidal volume ventilation (6cc/kg predicted body weight vs 12cc/kg predicted body weight) had lower mortality rate (31% vs 40%) and more ventilator free days (12 vs 10 days)
    - can go as low as 4cc/kg predicted body weight, though any lower likely leads to ventilation of dead space
    - allowed for permissive hypercapnea and plateau pressure less than or equal to 30, though average plateau pressure was mid 20s, suggesting lower Ppl is better

    Posted 06/08/16 07:23:15 PM by Anna Krigel

  • Management of moderate to severe ARDS

    1. Paralysis  (ACURASYS) - used cisatracurium continuous drip, did not use train of 4 to assess for paralysis, showed improved mortality in patients with moderate to severe ARDS
    2. Proning (PROSEVA) - proning patients with severe ARDS (PaO2/FiO2 <100) for at least 16 hours had an ICU mortality benefit
    3. ECMO (CESAR) - trial of referral to ECMO center rather than of ECMO intervention itself; many patients in control group did not get low tidal volume ventilation; found increased survival in patients referred to ECMO center 

    Posted 06/08/16 07:25:38 PM by Anna Krigel

  • For further reading...

    Berlin definition

    Posted 06/09/16 06:13:13 PM by Anna Krigel

  • 67 y/o woman with vasculitis presenting with acute SOB found to have DAH


  • Pulmonary Embolus - Immediate bronchoconstriction because of lack of blood flow distal to the clot -> this is to preserve V/Q matching. Bronchoconstriction can happen diffusely leading to wheezing though.

    Posted 08/11/16 09:06:54 AM by Adam Faye

  • ~100 lifetime cigarettes is when you start to see an increase in malignancy

    Posted 08/11/16 09:07:16 AM by Adam Faye

  • Pulmonary Renal Syndromes
    1. Granulomatosis with Polyangitis
      • Small-medium artery vasculitis (systemic necrotizing vasculitis)
      • Often have upper airway manifestations including sinus disease
      • CXR often with multifocal infiltrates/nodules some of which may cavitate
      • *Pauci-Immune GN occurs in ~80% of patients
      • c-ANCA + (antiproteinase-3)
    2. Microscopic Polyangitis
      • Peak incidence between 30-50 y/o
      • Typically p/w RPGN or pulm hemorrhage
      • p-ANCA + (myeloperoxidase)
      • *Pauci-Immune or diffuse necrotizing GN
    3. Churg-Strauss Syndrome
      • Typically have asthma/allergic rhinitis/sinusitis - a/w eosinophilia, migratory pulm infiltrates, purpura
      • Classic Hx is pt. on montelukast and steroids for asthma --> steroids get weaned and asthma flares - think Churg-Strauss
      • Necrotizing *pauci-immune
      • ~40% with p-ANCA + (myeloperoxidase)

    Goodpasture Syndrome:

    Posted 08/11/16 09:31:25 AM by Adam Faye

  • Chronic Eosinophilic Pneumonia:

    Posted 08/11/16 09:34:45 AM by Adam Faye

  • DAH

    Posted 08/11/16 09:36:15 AM by Adam Faye

  • 48 yo M with dysphagia and hematemesis, found to have esophageal tear and likely EOE


  • Causes of esophageal dysphagia:

    Posted 08/29/16 10:02:26 AM by Anna Krigel

  • Reminder of acute upper GI bleed management:

    Posted 08/29/16 10:19:18 AM by Anna Krigel

  • Eosinophilic Esophagitis

    Posted 08/29/16 10:34:08 AM by Anna Krigel

  • For further reading...

    Cochrane Review of PPI before endoscopy in upper GI bleeding
    Eosinophilic Esophagitis Review

    Posted 08/29/16 10:36:20 AM by Anna Krigel

  • 62 y/o gentleman presenting with status asthmaticus needing ECMO/ECCOR


  • Magnesium for acute asthma exacerbations

    Posted 01/30/17 04:40:48 PM by Adam Faye

  • Posted 01/30/17 04:45:49 PM by Adam Faye

  • When intubating asthma patients remember may worsen hypotension:

    Posted 01/30/17 04:51:18 PM by Adam Faye

  • ECMO/ECCOR for status asthmaticus:

    Posted 01/30/17 04:53:20 PM by Adam Faye

  • 87 y/o man w/ MDS, G6PD deficiency, p/w septic shock and progressive hypoxemia, found to have met-Hgbemia


    31yo M with fever and cough p/w severe hypoxemia progressing to ARDS


  • Initial options for managing hypoxemia

    What to do when people remain hypoxemic on mechanical ventilation?

    Posted 06/08/17 12:23:53 PM by Iheanacho (Obi) Emeruwa

  • For further reading...

    High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure
    Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome
    Prone Positioning in Severe Acute Respiratory Distress Syndrome

    Posted 06/08/17 12:40:54 PM by Iheanacho (Obi) Emeruwa

  • 54yoM w/ DM and HTN who presents with AMS, possible salicylate ingestion found to be in metabolic disarray 2/2 DKA


  • In a severely acidemic patient who is tachypneic, if they are intubated make sure ventilator is set to a high enough minute ventilation to keep up with their compensation for acidosis.  

    Posted 07/13/17 03:59:38 PM by Emily Miller

  • For salycilate toxicity: -call poison control. -can use activated charcoal if early enough time period. - Can give Bicarb. - If toxicity is severe patient may need dialysis

    Posted 07/13/17 04:03:27 PM by Emily Miller

  • 83YOF p/w cardiac arrest found to have tension pneumothorax


    33YOM with ARDS 2/2 legionella PNA, s/p ECMO with excellent recovery


    79YOM p/w resp distress found to have flail mitral valve, ?Marfan


    72yo F with 4 mos progressive SOB, found to have large pleural effusion


    62yo F w/ pHTN crisis 2/2 PDA


    71 yo F s/p DDRT p/w SOB and hypoxic resp failure 2/2 methemoglobinemia from dapsone


    65yoF w/SLE and lupus nephritis p/w SOB & hemoptysis found to have DAH


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