Restless Legs Syndrome

• Fatigue, anorexia, abdominal pain, tremors, poor coordination, spastic dystonia, and psychiatric or behavioral disorders

• Treat with psycho stimulant (e.g. modafinil)

• Hyperresonanace and diminished breath and heart sounds
• Air trapping and prolong expiratory phase
• History of smoking
• B-Blockers worsen it, especially at higher doses because it's not absolutely B2 selective

• Late inspiratory "Velcro-like" crackles - precedes pulmonary hypertension
• Diminished lung volumes - restrictive lung disease
• Differentiate from COPD via CXR and PFT

• Increased jugular venous pressure, a right ventricular heave, a right-sided S3 or systolic murmur that increases with inspiration, an increased pulmonic sound (P2), or a tricuspid regurgitant murmur
• Can be caused by recurrent or persistent pulmonary emboli
• Can be secondary to Chronic Reynaud's and limited or diffuse cutaneous scleroderma
• In ILD, it is preceded by the "Velcro rales"

• Examine patient upright
• Usually trauma
• Dyspnea and orthopnea but no extreme hypoxia as in pulm emboli
• Nontraumatic causes - malignancy, blood dyscrasias, pulm emboli, necrotizing infxns such as TB

• Maybe related to prior radiation therapy to chest
• JVP
• Prominent x and y descents - rapid right atrial filling
• Kussmaul's sign - increased JVP with inspiration

• Cystic fibrosis pts - 16 to 20% have a pneumothrax
• secondary pneumothorax - underlying lung disease present, more serious, tube thoracostomy
• primary pneumothorax - no underlying lung disease, needle aspiration feasible if pneumothorax < 2cm from chest wall.
• >2 cm from chest wall or secondary lung disease or significant dyspnea = tube thoracostomy

• Can cause breathing muscle weakness and paralysis and compromise ventilatory functions, especially when patient is supine.
• Excessive decrease in FVC when supine (>10%)
• Paradoxical abdominal wall motion with breathing
• Poor inspiratory force normal is < -80 cm H20

• > 1 cm on US or lat. decub. = thoracentesis
• Pus or Gram+ fluid or pH <7.0 = Tube thoracostomy
• If need repeated thoracentesis = Just put in tube
• Persistent sepsis or loculation = video thoracoscopy or thoracostomy
• If thoracentesis is nondiagnostic, do pleural biopsy (esp. helpful in cases of suspected TB)

• Exudative
• lymphocytic predominance, but overall leukocytes usually low (<4000/uL)
• Glucose < 60 or pH <7.3 portends poor prognosis
• RBC >100,000/uL without trauma is usually caused by malignancy

• High doses of B-blockers will cause bronchoconstriction because of presence of B receptors in heart and lungs.
• labetalol and carvedilol - B and a blockade can be used (cautiously and at low doses)
• Ipratropium Bromide, B2-agonists, corticosteroids, atropine, aminophylline, and glucagon can be used to treat B-blocker bronchoconstriction
• Nonselective B-blockers should not be used in asthmatics

• Postnasal drip
• Asthma
• GERD

• Suggested by airway hyperresponsiveness - i.e. coughing with cold air
• confirmed with trial of asthma therapy (Bronchodilators)
• Methacholine challenge has 100% negative predictive value for asthma

• Present in >90% of asthmatics if exercise intense enough
• Airway obstruction in 5-15 mins after exercise starts
• Resolves in 20-30 mins
• Treat with inhaled short-acting B-agonists 5 mins before exercise
• Diagnosed with FEV1 drop of >20% after exercise 

• Used in suspected asthma with episodic symptoms and normal baseline spirometry
• Give increasing doses of methacholine until FEV1 drop by >20%
• The dose that leads to >20% drop in FEV1 is called PC20
• PC20 < 4mg/ml = asthma
• PC20 = 4-16mg/ml = bronchial hyperreactivity
• PC20 > 16 mg/ml = normal (no asthma)

• With Latency - a period exists between exposure and symptom onset
• Without latency - immediate symptom onset upon exposure
• Can have both early AND late asthmatic responses
• Can usually be diagnosed with good history and peak expiratory flow rates at and away from work place.

• Give nebulized albuterol/ipratropium bromide
• Need to get ABG to assess ventilatory function
• Pulse Ox can't assess ventilation
• Mild acute - PCO2 decreased
• Moderate to severe - PCO2 normal
• Ominous - PCO2 elevated - severe obstruction

• In previously well-controlled asthmatics, a short dose of oral corticosteroids will restore control
• Exacerbations can be caused by respiratory tract infections
• In severe exacerbations
  • Immediate IV corticosteroids  
  • Prompt bronchodilators
  • Magnesium sulfate if bronchodilators fail

• Any asthmatic with symptoms >2days/wk or >2nights/month has persistent asthma and needs daily inhaled corticosteroids
• Addition of long-acting B-agonist is more effective than increasing steroid dose
• Theophylline and leukotriene receptor antagonists are 3rd line options after Long-acting B agonists have failed.

• Moderate dose with Long-acting B-agonist is better than high dose
• Side effects: immunosuppression, osteoporosis, glaucoma, cataract, easy bruising, and suppression of the hypothalamic–adrenal axis
• Marginal benefit above 400 ug/d
• If stable, titrate down to a moderate dose

• Influenza vaccine is recommended to all people at risk and those over 65
• Pneumococcal vaccine is for people over 65 years old and people who have had splenectomies, sickle cell disease, immunosuppressed, DM, and cirrhosis.
  • Effects wane after 5 years
  • Single booster dose recommended for people continually at risk and those vaccinated before 65 years old

• Only in COPD do you treat bronchitis with antibiotics
• Bronchitis is usually viral

• Pulmonary rehabilitation improves symptoms, exercise endurance and quality of life.
• Lung Volume Reduction Surgery (LVRS) does not improve survival and is not indicated if FEV1<20%, DLCO2<20%, or homogenous emphysema
• Noninvasive Positive Pressure Ventilation is only used in acute respiratory failure. Not used in stable outpatients with normal PCO2.

• Used in OSA
• Reduce symptoms like daytime sleepiness, resistant hypertension, and morning headache
• Improves mortality by reducing risk for stroke and heart disease.

• Abnormal pulmonary auscultory findings
• diffusely abnormal CXR
• PFT show decreased TLC, FVC, and FEV1, but FEV1/FVC will be normal or increased
• High resolution CT can make the diagnosis, CXR alone cannot.

• Lung disease is most common cause of morbidity and mortality in systemic sclerosis (diffuse cutaneous scleroderma)
• systemic sclerosis is defined as skin changes proximal to elbows
• In systemic sclerosis, both interstitial lung disease and pulmonary hypertension can occur, together or independently.
• Limited cutaneous scleroderma is also known as CREST Syndrome
  • Calcinosis, Reynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasias

• A specific form of chronic fibrosing interstitial pneumonia
• predominantly basilar infiltrates on chest radiograph, restrictive physiology, and evidence of impaired gas exchange.
• bibasilar end-inspiratory dry crackles that have a Velcro-like quality
• Pulmonary hypertension and cor pulmonale
• >50 years old
• progressive dyspnea and nonproductive cough
• symptoms usually >6 months before going to doctor
• May have wt loss, fatigue, and malaise
• Fever is rare

• Can affect eyes, skin, lungs, joints, may be asymptomatic
• >90% have lung involvement
• Dx requires biopsy of noncaseating granulomas AND exclusion of infection
• Stage 0 - CXR normal
• Stage 1 - Hilar LAD
• Stage 2 - Hilar LAD and infiltrates
• Stage 3 - Infiltrates alone
• Stage 4 - Fibrosis

• 1st step is to determine pretest probability of PE using the modified Well's criteria
• 2nd step is a diagnostic test such as a Helical CT with contrast if patient has normal renal function and V/Q scan if patient is renally compromised.
• In massive PE, pt usually never had flat neck veins
• Findings indicating a massive PE
  • Palpable and accentuated S₂ over the second left parasternal space, 
  • a left parasternal precordial heave
  • a holosystolic murmur over the epigastrium that is louder on inspiration
  • a presystolic low-pitched extra sound over the subxiphoid area.
• Anticoagulated patients usually will not have complete resolution of clot within 1 week. Will usually take longer and can be discharged on warfarin if INR is therapeutic despite radiographic findings of persistent perfusion defects.

• Use Heparin or Lovenox for VTE prophylaxis
• Same efficacy for preventing VTE but Lovenox associated with fewer bleeding episodes.
• Do not use aspirin or warfarin for VTE prophylaxis while in ICU.

• SCDs are used for moderate to high risk VTE patients in whom Heparin is contraindicated (HIT)
• Has low adverse side effects but not as good as heparin
• Aspirin alone is ineffective.

• Treat with lovenox instead of warfarin because it reduces "on-treatment" recurrence.
• Warfarin may also cause increased bleeding episodes in cancer patients with VTE.

• Patients who are heterozygous for Factor V Leiden are at increased risk for developing initial episode of VTE but not for recurrent VTE
• Any heterozygous Factor V Leiden pt with recurrent VTE needs to be anticoagulated
• Use warfarin if no contraindications.

• Pregnancy puts women at increased risk for VTE
• DO NOT USE WARFARIN or THROMBOLYTICS IN PREGNANCY
• Heparin and Lovenox are okay

• FEV1/FVC <70% indicates obstructive lung disease
• Asthma has normal DLCO
• Bronchodilator trial: increase in >12% or 200 mL from baseline in either FEV1 or FVC is compatible with asthma.