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Step 2 CK Pulmonary > Lecturio > Flashcards

Lecturio Flashcards

1
Q

True/False? High PEEP improves oxygenation by recruiting collapsed alveoli and hence a/w reduction in mortality rate in ARDS.

A

False;

High PEEP improves oxygenation but is not a/w lowering the mortality rate in ARDS.

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2
Q

Based on Berlin definition, diagnosis of ARDS requires ___ criteria (list all).

A

-Acute onset

-Diffuse, bilateral opacities not fully explained by another process.

-Absence of HF or fluid overload assessed by echocardiography.

-Mod-severe oxygenation impairment with PaO2/FiO2 ≤ 300 mmHg.

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3
Q

How is the severity of ARDS assessed?

A

based on PaO2/FiO2 ratio on ventilator settings that include PEEP or CPAP ≥ 5 cm as below.

PaO2/FiO2 (mmHg)
≤ 100 —–> Severe ARDS
101 - 200 —-> Moderate ARDS
201 - 300 —-> Mild ARDS

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4
Q

The most critical factor in reducing mortality during ARDS m/m is?

A

avoiding lung injury from mechanical ventilation by maintaining low tidal volume at about 6mL/kg.

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5
Q

Infiltration of the airway mucosa by activated eosinophils and T-lymphocytes best explains the pathogenesis of ____.

A

Asthma.

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6
Q

Matrix metalloproteinase 12 (MMP-12) aka _____ is released by ____.

A

aka macrophage elastase released by macrophages

Cigarette smoke oxidants –> ↓ histone deacetylase-2 –> terminal airspace damage –> emphysematous COPD.

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7
Q

In emphysema (COPD), inactivation of ____ enzyme caused by cigarette smoke oxidants leads to exposure of _____ resulting in increased production of MMP-12, IL-8, and TNF-alpha.

A

↓ histone deacetylase-2 –> exposure of NF-kappa B sites on DNA –> increased production of MMP-12, IL-8, and TNF-alpha –> damage of terminal air spaces.

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8
Q

Another mechanism of cigarette smoke-induced lung injury involves structural death of pulmonary cells mediated by ____.

A

structural death of pulmonary cells mediated by *Rtp801

*Rtp801 is a suppressor of mTOR signaling.

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9
Q

Of the recommended PCV-13, PPSV23, and influenza vaccines that reduce the rate and severity of respiratory symptoms in COPD patients, which vaccine is a/w a significant reduction in the number of AECOPD and hospitalizations in COPD patients?

A

influenza vaccine

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10
Q

Drug classes used to treat pulmonary HTN include — (list all).

A
  1. Prostacyclins–> vasodilation, ↓ platelet
    aggregation, anti-proliferative effect –> ↑ exercise
    - Epoprostenol (IV),
    - Iloprost (inhaled),
    - Treprostinil (IV, inhaled, oral)
  2. ER antagonists: ↑ exercise, ↓ clinical progression
    -Bosentan (NS-ER antagonist)
    -Macitentan (NS-ER antagonist)
    -Ambrisentan (ER-A antagonist)
  3. PDE-5Is: ↑ exercise
    - ↓cGMP metabolism–> prolong NO effects
    - Sildenafil
    - Tadalafil
  4. Soluble Guanyl Cyclase Inhibitors: t/t of CTEPH (chr. TE associated PH)
    -Riociguat
  5. Prostacyclin Agonists:
    -Selexipag: ↓ hospitalizations and
    disease progression.
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11
Q

What are some low-risk indicators that allow patients with pulmonary embolisms to be treated in outpatient settings with oral anticoagulants?

A

-do not require supplemental oxygen
-do not require opioids for pain
-no recent h/o or risk factors for bleeding
-not pregnant
-no serious co-morbid conditions such as IHD, CKD, HTN

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12
Q

What are some clinical features a/w high-risk pulmonary emboli?

A

-advanced age
-active cancer
-COPD
-HR ≥ 100/min
-SBP < 100 mmHg (hypotension)
-SaO2 < 90%

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13
Q

___ is the mainstay inpatient m/m of PE.

A

IV heparin.

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14
Q

Thrombolysis is indicated in which cases of PE?

A

Massive PE with severe right heart strain or hemodynamic instability.

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15
Q

IVC filter placement is indicated in m/m of PE under what conditions?

A

-in patients with recurrent DVT, or
-in patients who cannot be anticoagulated.

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16
Q

Pneumoconiosis caused by ____ presents with non-caseating granulomas similar to sarcoidosis.

A

beryllium

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17
Q

VQ scans are a/w a ___ (? lower, higher) radiation exposure as compared to CT.

A

lower radiation exposure

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18
Q

In PE, VQ scans are reported as ___ probability.

A

low, intermediate, or high probabilities.

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19
Q

What is the best initial t/t in pulmonary HTN (PH) patients who are vaso-reactive i.e. exhibit a decrease in pulmonary artery pressure (PAP) in response to NO?

A

CCB such as extended-release Diltiazem/Nifedipine

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20
Q

When are PAH-specific therapies indicated in t/t of PH?

*PAH: Pulmonary arterial HTN.

A

-non-vaso-reactive (to NO) patients
-vaso-reactive patients who failed CCB therapy

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21
Q

The findings of a cystic, glandular lesion on imaging studies in a child with recurrent pulmonary infections are highly suggestive of _____, fka____.

A

CPAM (Congenital pulmonary airway malformation) fka congenital cystic adenomatoid malformation (CCAM).

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22
Q

What are the risks a/w CPAM?

A

-compromised lung development in-utero

-CHF in-utero or hydrops fetalis (d/t compression of pulmonary venous return).

-High r/o infection or abscess formation

-Rare r/o malignant transformation.

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23
Q

What is the best treatment option for children with CPAM who p/w recurrent pulmonary infections?

A

Lobectomy.

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24
Q

A D-dimer test lacks specificity and may be elevated in ____ conditions/states.

A

-Infections
-Malignancy
-Pregnancy

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25
Q

The triad of S1Q3T3 is classically seen on EKG in ___ patients.

A

PE

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26
Q

____ is the most effective t/t for symptomatic allergic rhinitis.

A

Intra-nasal corticosteroids.

*SE: rhinitis medicamentosa (rebound rhinits)

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27
Q

Chronic use of topical (intra-nasal) decongestants predisposes a patient to _____ condition that manifests as ____.

A

rhinitis medicamentosa that manifests as rebound rhinitis.

Hence, intra-nasal decongestants are not routinely recommended in t/t of allergic rhinitis.

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28
Q

Lung cancer was previously referred to as ____.

A

bronchogenic carcinoma (includes SCLS and NSCLC)

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29
Q

What are the indications for sUrgical drainage of a lung abscess?

A

Abscesses that
-fail to respond to initial antibiotic therapy.

-a/w neoplasms

-caused by congenital malformations.

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30
Q

Horner’s syndrome is most commonly a/w lung tumors of the ___ region, while SVC syndrome is a/w lung tumors in ______ thoracic/pulmonary region.

A

Horners syndrome: a/w apical tumors.

SVC syndrome: tumors in the right superior mediastinum such as RIGHT APICAL/UL TUMOR aka superior sulcus tumor on the right side.

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31
Q

COPD patients are considered to have a severe obstruction with FEV1 less than ____.

A

FEV1 < 50% of the predicted value.

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32
Q

Type I respiratory failure is due to impaired ____, and marked by _____.

A

d/t impaired oxygenation and is marked by PaO2 < 60 mmHg.

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33
Q

Type II respiratory failure is due to impaired ____ and is marked by _____.

A

impaired ventilation, and is marked by PaCO2 > 50 mmHg.

34
Q

An increase of ≥ ___ % BDR may be a better indicator of asthma (reversible obstruction) in children as compared to the criteria of a ≥ 12% increase in FEV1 in response to bronchodilators in adults.

A

≥ 8% in children

35
Q

The PFT measure of ____ is a more sensitive marker of current impairment in asthma than FEV1, whereas ____ is a more useful measure of risk for future exacerbations of asthma.

A

FEV1/FVC ratio is more SN for current impairment .

FEV1 alone is a more useful measure of risk for future exacerbations.

36
Q

When is urgent thrombolysis, or surgical embolectomy indicated in PE patients?

A

Thrombolysis: in hemodynamically unstable patients in whom no CI to thrombolysis exists.

*surgical embolectomy is indicated if CI to thrombolysis exists in hemodynamically unstable patients.

37
Q

A D-dimer test is indicated in suspected PE cases with ___ pre-test probability.

A

-Low pre-test probability (Wells score 0-1), and
-Intermediate pre-test probability (Wells score 2-5)

Wells Criteria (MN: SHIT PMH)
S/o DVT: 3 pt
H/o PE or DVT: 1.5 pt
Immobilization ≥ 3 days: 1.5 pt
Tachycardia HR > 100: 1.5 pt

Post-op (surgery within previous 4 weeks): 1.5 pt
Malignancy: 1 pt
Hemoptysis: 1 pt

38
Q

A peak expiratory flow rate (PEFR) of less than ____ % indicates severe obstruction.

A

< 60%

39
Q

An asthma patient who needs their rescue inhaler > 2 times/week but not daily is categorized as having _____ asthma.

A

mild persistent asthma

40
Q

The step-up t/t for mild persistent asthma includes ___.

A

Daily low-dose ICS (fluticasone)

+

SABA (as needed).

41
Q

An asthma patient with daily asthma symptoms, daily use of SABA, and night-time awakenings > 1/week is categorized as having _____ asthma.

A

moderate persistent asthma

42
Q

The step-up t/t for moderate persistent asthma includes ___.

A

Daily and as-needed “low-dose ICS + LABA”, or alternatives

43
Q

The step-up t/t for severe persistent asthma includes ___.

A

Daily and as-needed “med-dose ICS + LABA”, or alternatives.

44
Q

Mycoplasma pneumoniae is naturally resistant to penicillins because ___.

A

because it lacks a cell wall.

-Gram-negative on staining
-“fried-egg” colonies on Eaton agar

45
Q

Which GI s/s warrant CF screening tests in children?

A

-poor weight gain or FOT
-Fatty stools
-Rectal prolapse
-Deficiency of fat-soluble vitamins

46
Q

Which respiratory s/s warrant CF screening tests in children?

A

-Recurrent cough or pneumonia
-Recurrent sinusitis
-Nasal Polyps
-F/H/O CF
-Pseudomonas lung infection
-Clubbing

47
Q

____ is the goal of antibiotic treatment in CF.

A

Suppression of bacteria as bacteria cannot be completely eliminated from lungs.

48
Q

Which antibiotics are used for long-term bacterial suppression in CF patients, especially children?

A

-Nebulized tobramycin, 28 days-28 days off cycle, or
-Inhaled Aztreonam, or
-Inhaled Cilastatin
-Inhaled Levofloxacin

-Azithromycin for anti-inflammatory effect.

49
Q

What are mucus melting and expectorant strategies of m/m in CF?

A

Mucus Melting/clearance and infection prevention with

-Nebulized 7% saline (osmotic agent draws in water to thin the mucus)

-DNAse to cleave long strands of Neutrophil DNA (e.g. Pulmozyme, Dornase alfa

-Pulmonary toilet

-Asthma m/m (albuterol, CS)

-Immunization for influenza and streptococcus.

-Inhaled antibiotics

50
Q

_____ is the most common cause of hemoptysis, roughly accounting for about __ % of cases.

A

Bronchitis; ~ 50% of cases of hemoptysis.

51
Q

___ is the initial diagnostic test of choice for hemoptysis.

A

CXR.

52
Q

What are the three main pathophysiological phases in ARDS?

A

Phase I: EXUDATIVE
-lasts up to 7 d after exposure to etiologic factor
-Injury to alveolar endothelial cells & alveolar epithelium (Type I pneumocytes) –> -interstitial and alveolar fluid accumulation.
-PMN infiltrates, IL-1, 8, TNF-a, LTB4.

Phase II: PROLIFERATIVE (RECOVERY)
-7-21 d
-lymphocyte-rich pulmonary infiltrate
-organization of alveolar exudate
-recovery proliferation of Type II pneumocytes

Phase III: FIBROTIC (lack of recovery)
-few patients
-require supplemental O2 or Mechanical ventilation.
-extensive fibrosis of alv. ducts and interstitium.
-emphysema-like changes with marked disruption of acinar structure, vascular occlusion, and pulmonary HTN.

53
Q

Birbeck granules on EM are pathognomonic of ____.

A

Langerhans cell histiocytosis (LCH) aka Eosinophilic granuloma.

-Clonal proliferation of Langerhans cells

  • migration of LCs from the BM to multiple organs inciting an inflammatory response.

-organs mc affected: Bones, skin, lungs (smokers), CNS

-Bones: lytic lesions (~ Multiple Myeloma)
-Skin: Eczematous or papular rash
-CNS: DI (pituitary)
-Lungs: in adults who smoke cigarettes**

EM: “TENNIS RACKET” Birbeck granules

54
Q

LCH onset is predominant in which age groups?

A

children; 5 per million children affected each year

55
Q

Treatment with ____ (? oral glucocorticoids, O2) for 2 weeks in AECOPD has been shown to reduce the risk of subsequent exacerbations for the next _____ (duration).

A

oral GC x 2 weeks reduce the r/o subsequent exacerbations for the next 6 months.

*LTOT > 15 hrs/day reduces overall mortality in COPD patients with PaO2 < 55 mmHg or SaO2 < 88% (PaO2 < 59 mmHg or SaO2 < 89 in those with right heart strain, HCt > 51%).

55
Q

Respiratory failure with an acute PaCO2 > ___ mmHg is an indication for NIPPV (CPAP or BiPAP) in patients with AECOPD. However, NIPPV is CI under ___ (list) conditions in AECOPD.

A

PaCO2 > 45 mmHg.

CI to NIPPV
-Cardiovascular instability (NIPPV will further drop the BP)
-AMS (r/o aspiration)
-Profuse secretions (r/o aspiration)
-craniofacial trauma (ineffective NIPPV)
-craniofacial abnormalities
-morbid obesity (poor physiological ventilation)

55
Q

The most common pathogenic agents involved in COPD exacerbations are ___.

A

-H. influenzae,
-Strep. Pneumoniae
-Moraxella Catarrhalis.

55
Q

What are the mainstay anti-pseudomonal agents used in AECOPD patients?

A

-IV Piperacillin-tazobactam q 6-12 hrs,
or
-Alternate agents: Cefepime, Ceftazidime

55
Q

Under what conditions is invasive ventilation indicated in AECOPD patients?

A

If NIPPV is CI in AECOPD patient experiencing life-threatening hypoxemia

+/-

-Hemodynamic instability
-AMS
-poor response to pharmacologics
-severe hypercarbia
-severe acidosis
-respiratory arrest.

55
Q

Pseudomonas is more likely to be a/w a COPD exacerbation under what conditions? How does it dictate treatment?

A

In COPD/AECOPD with risk factors such as

-age > 65 years
-3 or more exacerbations in last year
-comorbidities: bronchiectasis, cardiac
-FEV1 < 50%
-antibiotic use within previous 3 months

Treatment of pseudomonas exacerbation
-Hospitalization
-Anti-psudomonal agents: Piperacillin-tazobactam, cefepime, ceftazidime.

55
Q

Based on the global initiative for chronic obstructive lung disease (GOLD) criteria, COPD patients are stratified based on which criteria?

A

Groups A, B, C, and D are based on

-r/o exacerbations
-hospital admission (HA) in the past 12 mo
-mMRC dyspnea scale (0-4)
-COPD Assessment test (CAT) scale 0-40

55
Q

Describe the GOLD stratifying system for COPD.

A

Gp A: (Low symptoms, LOW risk, No HA)
-LOW symptoms: CAT < 10 or mMRC < 2
-Low risk for acute exacerbation
-No HA in the past 12 mo
-t/t with SABA for symptom relief.

Gp B: (high symptoms, LOW risk, No HA)
-HIGH symptoms: CAT ≥ 10 or mMRC ≥ 2
-Low risk for acute exacerbation
-No HA in the past 12 mo
-start LABA + SABA (as needed).

Gp C: (low symptoms, high risk, HA)
-LOW symptoms: CAT < 10 or mMRC < 2
-HIGH risk for acute exacerbation
-0-1 HA in the past 12 mo
-start LAMA + SABA (as needed).

Gp D: (high symptoms, high risk, HA)
-HIGH symptoms: CAT ≥ 10 or mMRC ≥ 2
-HIGH risk for acute exacerbation
-0-1 HA in the past 12 mo
-Regular t/t with LAMA, or LAMA + LABA, or GC-LABA + SABA (as needed).

55
Q

CAT and *mMRC dyspnea cut-offs for low and high symptom severity scales in COPD are ___.

*modified Medical Research council

A

CAT cut-off
-Low symptom severity: CAT < 10
-High symptoms severity: CAT ≥ 10

mMRC dyspnea scale Cut-offs
Low symptoms: mMRC < 2
HIGH symptoms: mMRC ≥ 2

56
Q

What are the pathophysiologic mechanisms contributing to pulmonary HTN and eventually RVH/RHF (aka Cor Pulmonale) in COPD?

A

Pathophysiologic mechanisms–> RVH/RHF
-Hypoxic pulm. vasoconstriction
-endothelial dysfunction
-Destruction of the pulmonary vascular bed.

57
Q

What ECG changes reflect cor pulmonale in COPD or other advanced lung pathologies?

A

-RAD (d/t RVH)
-RAE (P-pulmonale)–> large, peaked P-waves

58
Q

P-pulmonale are ____ p-waves seen in ____ condition (s), whereas P-mitrale is ____ p-waves seen in _____ condition (s).

A

P-pulmonale
-large, peaked p-waves
-seen in RAE d/t cor pulmonale (RVH/RHF)

P-Mitrale
-bifid p-waves
-seen with LAE d/t MS.

59
Q

The mainstay m/m of AECOPD includes ___.

A

-Systemic CSs (methylprednisolone)
+
Antibiotics
+
Supplemental O2.

60
Q

True/False? Food proteins may trigger asthma in patients with k/h/o asthma.

A

False;

Food proteins do not trigger asthma exacerbations unless there is a known food allergy.

61
Q

___ dietary components can trigger asthma in asthmatic patients with no k/h/o food allergy.

A

-Food additives e.g. metabisulfites (Na- or K-metabisulfite) in wine, beer, oxidants, preservatives (release SO2 –> asthma).

-Food coloring agents

62
Q

Ara-h-1 is a ___ protein that can trigger food allergies.

A

Peanut protein.

63
Q

Inpatient t/t with a macrolide +Beta-lactam or FQ is indicated in CAP patients with a CURB-65 score of ____.

A

2

CURB-65 (Confusion, BUN > 19 mg/dL, RR > 30, SBP <90; DBP < 60; age ≥ 65 yrs).

64
Q

Non-ICU inpatient t/t with a beta-lactam + macrolide, or beta-lactam + FQ is indicated in CAP patients with a CURB-65 score of ____.

A

3 or more

A CURB score of > 4 requires ICU admission.

65
Q

What is the difference between indications for ICS use in m/m of asthma versus COPD?

A

Asthma:
-ICS is added to SABA during the first step-up in mild-persistent asthma and escalated to low-dose ICS + LABA in med-persistent asthma, and med-high dose ICS in severe asthma.

*Chronic COPD: ICS added in Group D (high risk, high exacerbations, HA) group onwards.

*AECOPD m/m with systemic CSs, anti-biotics, and supplemental O2.

66
Q

Respiratory muscle dysfunction leads to ____ type of respiratory failure d/t compromised ventilation.

A

Type II hypercapnic respiratory failure PaCO2 > 50 mmHg (PaO2 will be low or normal)

67
Q

IL- _ induced IgE production is the primary mediator mechanism of extrinsic asthma.

A

IL-4; –> ↑↑↑ IgE production by favoring class-switching among B-cells.

68
Q

What is the underlying pathogenesis in Sarcoidosis?

A

The systemic proliferation of WBCs (macrophages and T-cells) –> formation of non-caseating granulomas in organs.

69
Q

Disease progression in Sarcoidosis can be monitored with ____ levels.

A

Serum ACE levels

70
Q

What are the m/m strategies in Sarcoidosis?

A

See attached Image for details

Asymptomatic: observation

Symptomatic:

-Corticosteroids (first-line)

-MTX: for Refractory cases, cases with neurosarcoidosis, or when steroid tapering is needed.

-NSAIDs for joint pain.

71
Q

maternal INH intake for t/t of TB is not a CI for breastfeeding.
Infant exposure to INH can be minimized by ____ strategy.

A

by breastfeeding <1 hr or > 3 hrs after the maternal dose.

72
Q

The diagnosis of cystic fibrosis (CF) is based on ___ and ___.

A

clinical symptoms + e/o CFTR dysfunction

CFTR dysfunction e/through any below
-Elevated sweat chloride
-2 or more mutations in the CFTR gene
-abnormal nasal potential (voltage) difference (NPD).

73
Q

Langerhans cell histiocytosis (LCH) is aka ____.

A

Eosinophilic granuloma.

Step 2 CK Pulmonary (8 decks)

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