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Pneumo/gastro c’est bow > Pleural effusion/TFR/PH/sarcoidosis > Flashcards

Pleural effusion/TFR/PH/sarcoidosis Flashcards

1
Q

Which respiratory disease is frequent in sarcoidosis ?

A

Co existent asthma is common

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2
Q

Causes of increased DLCO ? Name 4.

A
  • Pulmonary hemorrhage/polycythemia
  • LV failure
  • Asthma
  • Obesity
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3
Q

Causes of isolated decrease in DLCO ?
Name 3.

A
  • Pulmonary hypertension
  • Early ILD/emphysema
  • Anemia
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4
Q

Causes of mixed obstructive and restrictive process ?

A

Obese smoker
Bronchiectasis
Sarcoidosis

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5
Q

DLCO : anemia ?

A

Decreased

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6
Q

DLCO : asthma ?

A

Increased

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7
Q

DLCO : emphysema ?

A

Decreased

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8
Q

DLCO : LV failure ?

A

Increased

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9
Q

DLCO : obesity ?

A

Increased

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10
Q

DLCO : pulmonary hemorrhage ?

A

Increased

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11
Q

DLCO : pulmonary hypertension ?

A

Decreased

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12
Q

Do you need bx in case of asx bilat hilar adenopathy ?

A

No recommendations for or against
Close clinical follow up required if no biopsy

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13
Q

Does primary spontenous PTX reoccur ?

A

Yes reoccur 25-50%, most in first year

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14
Q

Driving guidelines for OSA : depending on severity of OSA ?

A

Severity of OSA alone is NOT a reliable predictor and should not be used in isolation to assess fitness to drive

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15
Q

Driving guidelines for OSA, when should pt be disqualified ?

A
  • Excessive sleepiness during the day
  • Crash associated with falling asleep in the past five years and no therapy since
  • Non compliant with tx (compliant : ≥ 4h > 70% of nights in past 30 days)
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16
Q

Duration of prednisone tx for sarcoidosis ?

A

1-3 months at initial dose then SLOW taper to 10mg/d (total tx 1y)
If relapse : MTX

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17
Q

How do you diagnose mesothelioma ?

A

Usually cannot be diagnosed from pleural fluid and requires pleural biopsy

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18
Q

How do you dx UACS : upper airway cough syndrome ?

A
  • Confirmed by response to tx with 1st generation antihistamine / decongestant (bronpheniramine/SR pseudoephedrine)
  • Sinus imaging if does not improve
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19
Q

How do you manage acute hemoptysis ?

A
  • ABC
  • Position patient in decubitus position to protect UNAFFECTED LUNG
  • Hold anticoag + correct coagulopathy
  • Flexible bronchoscopy can be used for localization prior to embolization or imaging if stable enough
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20
Q

How many sarcoidosis patients will have remission at a decade ?

A

Two thirds

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21
Q

How often should you screen scleroderma patients for PH ?

A

Annually

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22
Q

How should you treat cutaneous sarcoidosis ?

A

If low burden : topical steroids, intralesional steroids
If severe : steroids, infliximab

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23
Q

How should you treat erythema nodosum in sarcoidosis ?

A

Usually good response to NSAIDs alone

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24
Q

How should you treat fatigue in sarcoidosis pt ?

A

Pulmonary rehab is 1st line tx for fatigue

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25
Q

Hypoxemia : when should you prescribe home O2 ?

A
  • PaO2 ≤ 55%
  • Resting SaO2 ≤ 88%
  • PaO2 = 55-59 with
    Cor pulmonale or
    Pulmonary hypertension or
    Persistent erythrocytosis (Hct > 55%)
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26
Q

Is relapse common in sarcoidosis ?

A

After one year of spontaneous remission, relapse is very uncommon

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27
Q

Multiple solid nodules : what f/u for low risk patients ? high risk patients ?

A

LOW RISK
<6mm : none
6-8 and >8 : 3-6m then consider CT at 18-24

HIGH RISK
<6 : optional CT 12m
6-8 and > 8 : 4-6m AND CT at 18-24m

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28
Q

PH : which exams should you ask for ?

A

ETT, PFTs, 6MWT
CT pulm angiogram + V/Q
Abdo US to screen portal HTN
Sleep study
Right heart catheterization

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29
Q

PH : which labs should you ask for ?

A

CBC lytes LFT TSH BNP
Viral hepatitis HIV connective tissus disease

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30
Q

PH associated with CTD : which group ?

A

Group 1

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31
Q

PH secondary to schistosomiasis, which group ?

A

Group 1

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32
Q

Sarcoidosis : for skin disease refractory to steroids, which agent should you consider ?

A

Infliximab

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33
Q

Sarcoidosis : stage and chest findings ?

A

1 : bilat adenopathy
2: adenopathy + parenchymal lesions
3: parenchymal lesions with no ADP
4: fibrosis

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34
Q

Sarcoidosis : stage and rate of spontaneous remission ?

A

Stage 1, 55-90% (75)
Stage 2, 40-70% (50)
Stage 3, 10-30% (25)
Stage 4, 0-5%

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35
Q

Should you give steroids to sarcoidosis patients ?

A

Steroids accelerate remission at the cost of higher risk of recurrence (60-70%)
Indicated if end organ failure from granulomatous inflammation
Dose is 20-40 mg

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36
Q

Single solid lung nodule : what f/u if low risk patient ? what if high risk patient ?

A

LOW RISK
< 6mm : no f/u
6-8mm: 6-12 months then consider 18-24
> 8mm: 3 months, PET, CT, bx

HIGH RISK
<6mm : optional CT 12m
6-8mm : 6-12m AND 18-24
> 8mm : 3 m, PET, CT, bx

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37
Q

Treatment indications for OSA ?

A
  • Sx of excessive sleepiness or impaired sleep related QOL
  • Comorbid HTN
  • Asx pts with severe OSA (AHI > 30)
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38
Q

What % of patients present with extra pulmonary sarcoidosis ?

A

Usually involve the lung (>90%) but up to 30% present with extrapulmonary sarcoid

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39
Q

What are absolute contraindications to metacholine challenge ?
Name 4 points.

A
  • Severe airflow limitation FEV1 < 50% or
    <1L
  • Recent MI or stroke in last 3 m
  • Uncontrolled HTN, SBP > 200/100
  • Known aortic aneurysm
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40
Q

What are high risk features in PTX, indication of chest drain ?

A

Tension, significant hypoxia, bilateral, >50 with smoking history, hemopneumothorax

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41
Q

What are predictors of adverse periop pulmonary events ? Name 3.

A
  • Surgical site (aortic > intrathoracic > upper abdo > abdo)
  • Age
  • Pre existing lung disease
42
Q

What are relative contraindications to metacholine challenge ? Name 3 points.

A
  • Moderate airflow limitation FEV1 < 60% or < 1.5L
  • Pregnancy or nursing mothers (metacholine is category C)
  • Use of cholinesterase inhibitor (myesthenia gravis)
43
Q

What are risk factors of primary spontaneous pneumothorax ?

A

RF : smoking, family history, Marfan syndrome, thoracic endometriosis

44
Q

What are the cutaneous involvement in sarcoidosis ?

A

Common in 1/3 patients
Lupus pernio, erythema nodosum…

45
Q

What are the daily life recommendations for PTX ?

A

Against scuba lifelong
No air travel until 7d after PTx resolves on CXR

46
Q

What are the diagnosis criteria for OSA ?

A

Defined by presence of both :
- Sx
- Objective testing of > 5 apnea/hypopnea events during sleep monitoring
Mild 5-15 events/h
Moderate 15-30
Severe > 30

47
Q

What are the indication of tx in sarcoidosis ?

A

Pulmonary : bothersom sx, deteriorating lung function on PFTs, development of PH
Extrapulm : eye disease, CNS, cardiac involvement, severe skin disease, hypercalcemia, sx liver disease

Fatigue alone is not an indication.
ICS can be used for mild sx and stable PFTs

48
Q

What are the indications of intercostal drain for parapneumonic effusion ?

A
  • drainage of frank pus
  • pH <7.2 [high risk of complicated parapneumonic effusion]
  • pH 7.2-7.4 and LDH>900 (consider based on clinical scenario, glucose <4.0, pleural enhancement)
  • If pH not available, glucose <3.3

But R/O other causes of low pH such as rheumatoid before.

49
Q

What are the Light’s criteria ?

A

Pleural fluid is an exudate if ≥ 1 of the following criteria are met :
- Protein in fluid : serum > 0.5
- LDH in fluid : serum > 0.6
- Pleural fluid LDH > 2/3 the upper limit of normal value for serum LDH

50
Q

What are three causes of diaphragmatic weakness ?

A
  • Trauma or surgery
  • Mechanical ventilation
  • Myopathy / neuropathy
51
Q

What do you see on BAL for sarcoidosis ?

A

Low CD8 and elevated CD4/CD8 ratio

52
Q

What does PFTs show in sarcoidosis ?

A

Can show anything +/- reduced DLCO

53
Q

What investigation necessary in case of group 4 PH ?

A

Group 4 : chronic thromboembolic pulmonary hypertension
APLAS testing for all and if + warfarin
Refer for pulm thromboendarterectomy, anticoagulation

54
Q

What is DDX of hypoxemia with normal AA gradient ?

A
  • Hypoventilation (check PaCO2)
  • Low inspired FiO2 (altitude)
55
Q

What is Heerfordt syndrome ?

A

– Anterior uveitis
– Parotid enlargement
– Fever (uveoparotid fever)
– Facial palsy

56
Q

What is Lofgren syndrome ?

A

– Bilateral hilar adenopathy
– Erythema nodosum
– Migratory polyarthralgias
– Fever

Seen primarily in women
High likelihood of spontaneous remission

57
Q

What is necessary pre operatively for patients with lung cancer being considered for surgery ?

A

They need predicted post op FEV1 and DLCO
If BOTH > 60% predicted : low risk
If EITHER < 60 % : high risk

58
Q

What is seen on pathology of sarcoidosis ?

A

Noncaseating granulomas in involved organs

59
Q

What is the cause of chylothorax ?

A

Malignancy #1 and most commonly lymphoma
Trauma/surgery, TB, LAM (young woman with cystic lung disease/PTX)

60
Q

What is the cause of low glucose in pleural fluid ?

A

< 1 mmol : RA, empyema
1-3 mmol : malignancy, TB, SLE

61
Q

What is the cause of lymphocytosis in pleural fluid ?

A

> 80% TB vs lymphoma
TB often AFB - and would suggest sputum AFB
Can ask for pleural fluid ADA (adenosine deaminase) and IFN gamma tests

62
Q

What is the DDX of clubbing ?

A
  • Neoplastic intrathoracic disease (bronchogenic carcinoma, mesothelioma)
  • Suppurative intrathoracic disease (bronchiectasis also)
  • Diffuse pulmonary disease
  • Cardiac disease (IE also)
  • GI like IBD
  • Metabolic like Graves
63
Q

What is the DDX of fixed upper airxay obstruction ?

A

Glotic stenosis (prolonged IET), subglotic stenosis (Wegner’s, sarcoid, polychondritis)

SEND TO ENT
Eg: large goitre

64
Q

What is the DDX of flattening of inspiratory curve ?

A

= variable extrathoracic obstruction
Vocal cord dysfunction / paralysis

65
Q

What is the DDX of hypoxemia with widened A-a gradient ?

A
  • V/Q mismatch (improves with 100% FiO2) : COPD, PE
  • Shunt (does not improve completely with 100% FiO2)
  • Diffusion abN (ILD)

For shunt : intracardiac with R->L shunt (eg PFO, ASD, VSD), intrapulmonary (ie pulmonary AVM), physiologic(ie severe pneumonia with perfused alveoli that are not ventilated)

66
Q

What is the DDX of variable intrathoracic obstruction ?

A

= flattening of expiratory curve
Tracheomalacia of intrathorac airway

67
Q

What is the definition and management of secondary spontaneous PTX ?

A

Presence of lung disease, COPD +++
Even small ones can lean to sx +++ most likely will require chest drain
Unlikely to spontaneously resolve

68
Q

What is the definition of chylothorax?

A

TGs > 1.24 mmol + CM in pleural fluid

69
Q

What is the definition of low glucose in pleural fluid ?

A

Glc < 3, eff/serum < 0.5

70
Q

What is the definition of massive hemoptysis ?

A

Variable definitionsm 200-600cc / 24h

71
Q

What is the definition of pulmonary hypertension ?

A

Mean pulmonary artery pressure > 20 on right heart catheterization and PVR > 2 WU is consistent with pre capillary PH

72
Q

What is the etiology of pleural fluid eosinophilia?

A

Significative if > 10%
Etiology depends on hx :
- Asbestos related (BAPE)
- drugs (ex : nitrofurantoin)
- malignancy (lung)
- infection (parasites)
- PE, eGPA

73
Q

What is the gold standard for TB pleural effusion ?

A

Tissue sampling for C&S

74
Q

What is the follow up for PTX ?

A

Close follow up required : every 2-4 days if conservative care. Follow up 2-4 weeks for all

75
Q

What is the formula for A-a gradient ?

A

A-a = [150- (PaCO2/0.8)]– PaO2

Approximate Normal A-a Gradient for reference: (Age (yrs)/4)+4

76
Q

What is the most helpful finding for OSA ?

A

Nocturnal choking / gasping (LR 3.3)
Snoring is non specific

77
Q

What is the most specific and most sensitive test for diagnosis of diaphragm weakness / paralysis ?

A

Most SENSITIVE : MIP
Most SPECIFIC : ultrasound or FVC

A normal MIP excludes respiratory muscle weakness (good neg predictive value) but low MIP does not confirm the presence of resp muscle weakness as poor effort / technique common
MIP more sensitive than supine FVC

78
Q

What is the ocular manifestation of sarcoidosis ?

A

Anterior uveitis

79
Q

What is the sensitivy of pleural fluid for cytology ?

A

Beware if suspicion of malignant effusion, sensitivy of cytology only 46%
Can repeat thoracentesis ONCE for increased sensitivity as increases to approx 80%

(at least 25cc, preferrable 50cc)

80
Q

What is the tx of group 1 PH ?

A
  • Vasoreactivity testing to determine if candidate for CCB
  • PDE5i or riociguat
  • Endothelin receptor antagonist
  • Prostanoid
  • Influenza/pneumococcal/COVID vaccines
  • Supervised exercise
  • Avoid pregnancy
81
Q

What is the tx of hemoptysis ?

A

Arterial embolization # 1 if available

82
Q

What is the tx of OSA ?

A
  • Weight loss
  • CPAP / APA, also for asx if comorbidities (HTN), AHI > 30 or critical occupation
83
Q

What is the tx of primary spontaneous PTX ?

A

Conservative if asx or minimally sx (REGARDLESS OF SIZE)
If sx, look for high risk features : tension, significant hypoxia, bilateral, >50 with smoking hx, hemopneumothorax : if present chest drain

84
Q

What is the typical cardiac involvement in sarcoidosis ?

A

Heart block
Screen with ECG +/- echo, them cardiac MRI and PET if concern

PH is described

85
Q

What is the typical neurologic involvement in sarcoidosis ?

A

Cranial nerve palsy

86
Q

What medical conditions are contraindications to PFTs ?

A

Hemoptysis
Pneumothorax
Unstable cardiovascular status including recent MI
Aneurysms (thoracic, abdominal, cerebral)

87
Q

What should you look for in labs for sarcoidosis ?

A
  • anemia of chronic disease
  • lymphopenia
  • thrombocytopenia
  • hypercalcemia and add 1,25 OH D
88
Q

What should you think of in case of restrictive pattern varying with position ?

A

Diaphram dysfunction
Vital capacity decreases with lying down by > 10%
Post op scenario of CABG or ALS

89
Q

What should you think of in case of widening of tracheal strip on chest XR ?

A

Aortic dissection

90
Q

What tx for parapneumonic effusion ?

A
  • See criteria for intercostal drain + sample if > 1cm
  • ATB : Beta lactams preferred but if no culture, treat for CAP + anaerobes
    Usually at least 3 WEEKS based on clinical and radiographic respond
91
Q

When should you do a thoracentesis for pleural effusion ?

A
  • Suspect exudate
  • Cause unclear
  • Parapneumonic effusion
    (but if less than 1cm on lateral decubitus in context of pneumonia, can follow with RX)
92
Q

When should you suspect PH ?

A

Dyspnea on exertion, isolated reduced DLCO

93
Q

When should you test for PH in case of PE ?

A

If dyspnea or exercise intolerance after at least 3 months of uninterrupted anticoagulation post acute PE assess for CTEPH with echo and V/Q lung scan

94
Q

When should you think of carcinoid tumour in context of hemoptysis ?

A

Young non smoker with lung collapse (endobronchial tumors, can fill lumen)
Preo workup if syspect carcinoid syndrome, TTE to R/O carcinoid heart disease

95
Q

Which extrapulmonary sarcoid need urgent tx ?

A

Heart, CNS, eyes

96
Q

Which method is better for bx in sarcoidosis patients ?

A

EBUS guided lymph node sampling rather than mediastinoscopy

97
Q

Which situation in sarcoidosis do NOT require bx ?

A

Lofgren, Heerfordt, lupus pernio

98
Q

Which surgeries are a contraindications to PFTs?

A

Recent eye surgery like cataracts
Recent thoracic or abdominal surgery

99
Q

Quel est le gradient A-a normal ?

A

5-15

100
Q

Chest xray white out differential :
- trachea pulled towards whiteout
- vs pushed away
- vs central

A

Pulled towards : pneumonectomy, total lung collapse
Pushed away : pleural effusion
Central: consolidation
If bilat: pulmonary edema

101
Q
A

Pneumo/gastro c’est bow (5 decks)

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