Pearls from Dr. Darryl Abrams

ARDS in patient with influenza H1N1

2016-06-08

  • 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
    ARMA
    ACURASYS
    PROSEVA
    CESAR

    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

    2016-08-11

  • 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

    2016-08-29

  • 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

    2017-01-30

  • 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

    2017-03-08

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

    2017-06-08

  • 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

    2017-07-13

  • 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

    2017-09-21

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

    2017-11-16

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

    2017-12-13

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

    2018-01-17

    62yo F w/ pHTN crisis 2/2 PDA

    2018-02-26

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

    2019-04-03

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

    2019-06-17


    Created by Christopher Kelly
    Book be65e564ffbc09cd3ee32372501a5ece813f14b576dc711ff66870a4906e7f62
    Know a hypochondriac? Get them the best-selling book 'AM I DYING?!: A Complete Guide to Your Symptoms, and What to Do Next'
    The information on the website does not constitute official guidelines except where explicitly stated.
    It is not meant to replace the advice of a health professional.