3 Pulmonary

Question 1

Asthma severity types: what are each daytime and noctural sxs?

Answer 1

Daytime sxs, noctural sxs:

1. intermittent: <2/wk, <2/mo
2. mild persistent: <1/day, >2 mo
3. mod persistent: >1/day, >1/week
4. severe persistent: >1/day, frequent
5. refractory

Question 2

Asthma severity types: what are their PFTs (FEV1)?

Answer 2

1. intermittent: >80%
2. mild persistent: >80%
3. mod persistent: 60-80%
4. severe persistent: <60%
5. refractory

Question 3

Asthma severity types: what are their txs?

Answer 3

All have SABA

1. intermittent: -
2. mild persistent: low dose ICS
3. mod persistent: LABA + low dose ICS
4. severe persistent: LABA + high dose ICS
5. refractory: PO Steroids

LABA can be replaced with LTA

Question 4

Asthma exacerbation in ED: What PEFR goes into which severity categories? (generalization)

Answer 4

PEFR>70% mild
50-70 mod
<50 severe

Question 5

Asthma exacerbation: the thing that saves lives is ____

Answer 5

steroids

Question 6

Paraneoplastic syndromes of lung cancers:

• squamous
• small cell
• carcinoid

Answer 6

Squamous: PTH-rp (hyperCa)
Small cell: ADH (SIADH), ACTH (Cushing’s), Lambert-Eaton,
Carcinoid: serotonoin syndrome

Question 7

Carcinoid tumor: intestine vs lung, what similarities and differences?
-what lab test?

Answer 7

Same sxs: flushing, wheezing, diarrhea

intestine: liver mets, R sided heart valve dz
lung: serotoin starts in lung, so L sided heart valve fibrosis

5-HIAA urine

Question 8

Which lung ca often has pain, why?

Answer 8

Adenocarcinoma, b/c peripheral irritation of pleura

Question 9

Pleural effusion: how much fluid before visible on CXR?

Answer 9

about 250cc before blunting of costophrenic angle.

Question 10

Light’s criteria

Answer 10

If any positive, then exudate.
(2/3, 0.6, 0.5)

1. LDH <2/3 upper limit normal (200)
2. LDH (effusion/serum <0.6)
3. Total Protein (effusion/serum <0.5)

Question 11

Pleural effusion causes:
Transudate (3 main ones)
Exudate(3 big ones, and more)

Answer 11

transudate: CHF, Cirrhosis (low protein), Nephrotic syndrome (low protein)
USU BILATERAL

exudate: Infection, CA, TB. Also: PE, Hemothorax, chylothorax
USU UNILATERAL

Question 12

Pt with pleural effusion that is loculated. Do what and why?

Answer 12

Can’t do thoracentesis.
Do tube thoracostomy, to prevent empyema formation if parapneumonic effusion. If wait too long and empyema forms, must to thoracotomy.

Question 13

Pleural effusion thoracentesis sample: how many tubes and what tests to order?

Answer 13

Tube 1: CBC with diff (polys for PNA, Lymphs for TB/CA, RBC for hemothorax/CA)

2: cytology (looking for CA)
3. glu, pH, total prot, LDH (for light’s)
4. Gram stain, Cx, acid fast

Other tests possible

Question 14

Pleural effusion: what test for TB? Other than acid fast and lymphs

Answer 14

ADA (adenosine deaminase)

Question 15

Pt with PE. Also has met CA and short life expectancy. How to anticoag?

what is the exception to that rule?

Answer 15

Don’t use warfarin or NOAC.
Use LMWH for rest of life.

If brain mets, do IVC filter b/c risk of ICH

Question 16

PE pt. How to do Hep bridge to warfarin?

Answer 16

5 days Hep, or until INR 2-3, whichever is LONGER

Question 17

How to start Heparin for DVT anticoag

Answer 17

1. loading dose (80u/kg IV)
2. maintenance dose (18u/kg/hr)
3. check PTT in 6h to redose if necessary

target PT 46-70

Question 18

HIT–hep induced thrombocytopenia:

• when does it usu occur after starting Hep, first exposure vs repeat?
• if suspected, do what?

Answer 18

First exposure: 7 days
repeat: 3 days

Stop Hep, draw HIT panel, give Argatroban

Question 19

Severity types of PE (4)

• what’s the difference
• what is tx for each

Answer 19

1. asx PE, incidental discovery–d/c from ED, to LMWH bridge to coumadin
2. sx PE: Stay overnight on floor. No R heart strain (no abnormality with BNP, Trops, or Echo.) d/c with LMWH bridge to coumadin
3. submassive PE: findings of R heart strain, but no hypotension. abnormality of these 3 tests: BNP, Trops, Echo. Transfer to ICU with Hep to Coumadin bridge. Stay in hospital until bridge complete.
4. Massive PE: Hypotensive. give TPA. ICU with pressors.

Question 20

CTEPH: what is this

Answer 20

chronic thromboembolic pulmonary HTN

-outpt workup in pts with Pulm HTN. Do angiography and thrombectomy endovascularly

Question 21

Well’s criteria (8)

Answer 21

3 each:

1. PE most likely dx
2. Signs/sxs DVT
3. 5 each
4. HR>100
5. immobilization >3 days, or surgery w/i 4 weeks
6. hx DVT/PE

1 each:

6. hemoptysis
7. malignancy w/i 6 mo

<2: low prob
2-6: mod prob
>6 high

Question 22

Bronchitis in COPD: definition

Answer 22

productive cough for more than 3 mo in 2 consecutive years

Question 23

Pt in ED with SOB. Has pitting edema, JVD, and HSM.

What hx and signs to differentiate CHF from COPD blue bloater?

Answer 23

In CHF, hx of orthopnea and PND. Also, lung crackles and S3/4

Crackles can be present in COPD

Question 24

Why hypercapnia in COPD? what is significance?

Answer 24

Pink puffers have barrel chests, with air trapping. CO2 is trapped.

Chronic CO2 retention means resp drive is from Low O2, NOT HIGH CO2 (body used to that). So, be careful in giving too high oxygenation, could eliminate hypoxic resp drive.

Question 25

What's main diff between COPD and asthma in PFTs?

Answer 25

Asthma is reversible (with bronchodilators). Both obstructive process

Question 26

COPD exacerbation tx

Answer 26

``` "COPD" Corticosteroids O2 Preventive (Abx) Dilators (Duonebs) ```

Question 27

COPD: when to do chronic home O2?

Answer 27

Strict criteria, to make sure not to eliminate hypoxic drive. (from chronic hypercapnia) If pO2 <55 or spO2 <88%, chronic home O2 indicated with goal spO2 >90%

Question 28

COPD pt in ICU. What target sats?

Answer 28

88-92%

Question 29

COPD outpt meds, in increasing severity of dz?

Answer 29

- SABA - antichol (tiotropium, spiriva) - LABA (formoterol) - ICS (beclomethasone) - PDE4-i (oral) - steroids

Question 30

COPD exac: which abx to use for ppx?

Answer 30

Doxy is best, if no signs of infection /PNA Could also use Azithro. Moxi try to avoid in elderly

Question 31

COPD: what 2 things improve mortality?

Answer 31

1. smoking cessation | 2. home O2 if spO2<88% or paO2<55

Question 32

ARDS: What PaO2 to FiO2 ratio

Answer 32

<200

Question 33

ARDS pt in ICU: What happens if you give too much O2 (high FiO2)?

Answer 33

Superconcentrated O2 means free radicals. Can lead to pulmonary fibrosis. This looks similar to ARDS on CXR.

Question 34

Pt intubate in ICU: When to do tracheostomy? Why?

Answer 34

Laryngeal stenosis concern if pt intubated for 14 days. Do trach soon if you suspect >14 days intubated, otherwise delay.

Question 35

ILD, idiopathic. | what are the names and criteria for the acute and chronic versions?

Answer 35

acute: AIP--acute interstitial pneumonitis. <6 weeks chronic, >6mo insidious: IPF. Instertitial pulmonary fibrosis

Question 36

ILD: drug causes? (2)

Answer 36

bleomycin, amio

Question 37

Silicosis: what 2 things to know

Answer 37

1. CXR finding of upper lobe nodules, looks like TB | 2. Screen annually for TB b/c increased risk

Question 38

Coal miner's lung: what to konw

Answer 38

-Caplan's syndrome: RA. A pt with bilateral symmetrical arthralgia and restrictive lung dz should be worked up for RA. (Rh factor, anti-CCP)

Question 39

asbestosis: what on CXR? What on bx?

Answer 39

pleural plaques. barbell shaped asbestos bodies

Question 40

Hypersensitivity pneumonitis: what is the vignette to know

Answer 40

Pt describes SOB sxs only during workweek. Resolves on weekends or long holidays. HP takes 24h to 'set in' and out. Remove exposure is tx. (pigeon feathers) noncaseating granulomas

Question 41

Sarcoidosis: what extrapulm sxs to know? (4) also, levels of what may be elevated in blood?

Answer 41

- heart block - bells palsy - erythema nodosum - uveitis hypercalcemia from increased 1,25-vitD. Sarcoid can create this.