Pulm 2 Flashcards
1
Q
Step up therapy in Asthma
A
SABA –> low-dose ICS-LABA –> medium-dose ICS-LABA –> medium to high dose ICS-LABA + LAMA –> high dose ICS–LABA + oral steroids
2
Q
P to F calculation
A
Suppose the pO2 is 90mmHg on 40% oxygen (FIO2 = .40). The P/F ratio = 90 divided by .40 = 225.
3
Q
P to F interpretation
A
P/F ratio <300 = acute lung injury or mild ARDS
<200 = moderate ARDS
<100 = severe ARDS
4
Q
Obstructive, restrictive, and fixed airway obstruction on flow volume loop
A
See image online
5
Q
obstructive lung disease diagnosis PFTs
A
FEV1/FVC less than 70%
6
Q
treatment of allergic bronchopulmonary aspergillosis
A
- steroids
- antifungals
7
Q
allergic bronchopulmonary aspergillosis clinical features
A
Josh using a huge inhaler + walls made out of asparagus + eosinophil chandelier/aspergillus fumigatus infection can complicate asthma + elevate IgE.
8
Q
Rhinitis medicamentosa is…
A
overuse of nasal decongestants
9
Q
Management of eczema not responding to topical steroids
A
- topical calcineurin inhibitors (tacrolimus, pimecrolimus)
- dupilumab
10
Q
treatment of C1 esterase inhibitor deficiency
A
- bradykinin antagonist
- kallikrein inhibitor
11
Q
Type 1 drug allergy mechanism + presentation
A
- IgE mediated
- Immediate (anaphylaxis)
12
Q
Type 2 drug allergy mechanism + presentation
A
- antibody mediated
- hemolysis
13
Q
Type 3 drug allergy mechanism + presentation
A
- immune complex mediated
- serum sickness
14
Q
Type 4 drug allergy mechanism + presentation
A
- T-cell mediated, delayed
- Contact dermatitis, maculopapular drug rash
15
Q
treatment of morbilloform rash
A
- topical steroids (systemic steroids if necessary)
16
Q
Treatment of fixed drug eruption
A
- self limiting so should resolve on its own
- if not, topical steroid
17
Q
RSBI calculation
A
TV (in liters) over RR
18
Q
Goal RSBI
A
less than 105
19
Q
Proper ET tube position in women and men
A
20-21 cm in women
22-23 in men
20
Q
management of patient with reduced breath sounds following intubation
A
- reposition ET tube (likely intubated right mainstream, which is common due to more vertical orientation)
21
Q
How to differentiate tension pneumo from right mainstem intubation
A
- tension pneumo = tympany on percussion + tracheal deviation + acute cardiovascular collapse (BP will rapidly drop)
22
Q
Criteria for extubation
A
1) RSBI less than 105
2) Normal mental status, following commands
3) Few secretions + strong cough
* absent upper airway lesions
23
Q
When do patients on vent need to be considered for tracheostomy?
A
2 weeks roughly
24
Q
Management of failed SBT
A
- place on assist control
- continue daily SBTs
25
RSBI calculation
RR over TV (**expressed in liters)
26
Cardiac index in hypovolemic shock vs. cardiogenic shock
- slightly reduced in hypovolemic
| - substantially reduced in cardiogenic
27
Wedge pressure in hypovolemic shock vs. cardiogenic shock
- decreased in hypovolemic, increased in cardiogenic shock
28
Mean RA pressure
4
29
Mean wedge pressure
9
30
Mean cardiac index
2.8-4.2
31
Mean SVR
1,150
32
Other goals of ARDS management
- low plateau pressure (less than 30)
| - early administration of paralytics
33
ARDS criteria
- bilateral lung opacities + *no signs of cardiac failure or fluid overload
34
Management of respiratory failure after extubation
Reintubate immediately
| Unless COPD --> then can trial BiPaP
35
Treatment of respiratory impairment in ankylosing spondylitis
- pulmonary rehab
| - noninvasive positive pressure ventilation
36
Physical exam for ankylosing spondylitis
Test for chest expansion
37
Treatment of acute asthma attack
- inhaled beta agonist
- O2
- IV steroids or PO if able to tolerate
38
Discharge meds following admission for acute asthma exacerbation
- short course of oral steroids (no need to taper if used for less than 3 weeks since adrenal axis suppression won't occur)
- inhaled corticosteroid (one hospitalization is an indication for maintenance steroids)
39
Management of patient with pleural effusion + spiculated nodule concerning for cancer with negative thora cytology
- Repeat thora with cytology (initial has low sensitivity but 3 separate thora's can detect up to 90% of malignant effusions because you remove the older degenerated cells with first thora)
40
Indication for pulmonary rehab in COPD
Category B-D disease
41
COPD step up therapy
B = SABA PRN + LAMA or LABA
C = SABA + LAMA IF frequent COPD exacerbations -- LABA + ICS
D = SABA + LAMA + LABA
IF frequent exacerbations ICS
42
COPD step up therapy (in general)
1) Add LAMA or LABA
2) Add ICS
3) LAMA + LABA + ICS (triple therapy)
* ICS is not the preferred treatment of COPD patients
43
How is step up therapy determined in COPD?
Symptom severity (dyspnea while walking uphill, on level surface OR COPD assessment Test score)
44
Evidence for long-term home oxygen therapy in COD
- improves QOL + mortality benefit
45
Indication for O2 therapy in COPD
1) Resting O2 sat less than 88%
| 2) Resting O2 sat less than 89% + right-sided heart failure or erythrocytosis
46
Diagnosis of OHS
ABG showing daytime hypercapnia (PaCO2 over 45) and hypoxemia (PaO2 less than 70)
47
What is nocturnal oximetry used for?
OSA diagnosis
48
What is a chylothorax?
- effusion with milky-white appearance caused by thoracic duct obstruction (often from bulky lymphadenopathy from lymphoma)
49
First step in management of suspected massive PE
IF Hemodynamic instability + high probability of PE --> **bedside TTE before CT-PE
- IF RV dysfunction on TTE, give lytics
50
Nodule size warranting additional management
Greater than 0.8 cm
51
Next step after intermediate probability VQ scan
lower extremity US (intermediate probability VQ scan is nondiagnostic and you need more info for risk-benefit analysis)
52
PFTs of OHS
- Restrictive physiology with normal DLCO
53
Normal FEV1
greater than 80% (of predicted)
54
Normal FEV1 to FVC ratio
greater than 70%
55
Normal FVC
greater than 80% (of predicted)
56
FEV1 to FVC ratio in restrictive lung disease
Normal to *increased
57
Evidence for conversative fluid management in ARDS
Reduced ventilator-free days
58
Acute bronchitis clinical features
- typically following viral URI (that goes lower)
- persistent cough (bronchospasm from transient airway obstruction and hyperactive airways) + no systemic infectious symptoms + wheezing or rhonchi
- with or without purulent sputum
59
Treatment of acute bronchitis
- inhaled beta-2 agonists (relieve bronchial obstruction)
| * NO antibiotics (not infectious)
60
Causes of fixed upper airway obstruction
- obstructive substernal goiter (these extend through thoracic inlet into thoracic cavity and may not be visible on exam. patient may be euthyroid)
- tracheal stenosis
* not tracheomalacia (dynamic obstruction)
61
COPD patients who need workup prior to flying
O2 sat of less than 95% on room air + RF's (FEV1 less than 50%, moderate to severe pHTN)
62
COPD patients who need supplemental O2 during flights
Resting SpO2 less than 92%
| *If on oxygen at home, increase by 1-2L from baseline
63
Permissive hypercapnia goal
Maintain pH above 7.2
64
Management of negative rapid flu antigen in patient with high pretest for flu
- still give treatment (low sensitivity of rapid antigen test)
65
Clinical features of Reactive airway dysfunction syndrome (RADS)
- similar to asthma + following exposure to inhaled irritant (chlorine, ammonia, paint, diesel, bleach)
66
Reactive airway dysfunction syndrome diagnosis
same as asthma (methacholine challenge)
67
Reactive airway dysfunction syndrome treatment
- inhaled steroids
68
Spirometry in pulmonary HTN
- NORMAL, but reduced DLCO
69
What is auto-peep?
- air remaining in the lungs due to incomplete expiration in ventilated patients (this causes alveolar distension and increases risk for ventilator-associated lung injury)
70
How to reduce auto-PEEP
* reduce minute ventilation
- increase expiratory time
- treat airway obstruction
71
Clinical features of malignant pleural effusions + correlation of PH to malignant cell burden
- exudative
- lymphocyte predominant
- low pH is associated with high sensitivity of fluid cytology, whereas high pH is associated with low fluid cytology sensitivity
72
Next step after patient passes SBT
IF underlying lung disease --> always extubatne to noninvasive ventilation
73
management of dyspnea in end-stage lung disease
opioids
74
best variable for differentiating asthma from obstructive lung disease
- reversibility of airway obstruction (not history of smoking)
75
Eosinophilic pneumonia clinical + imaging features
- similar to TB (fever, cough, weight loss)
| - bilateral pleural-based opacities sparing perihilar and central lung regions
76
Chest imaging with asbestosis
- bilateral multi nodular or reticular opacities + pleural plaques
77
Indication for hospice in COPD
- end-stage disease with disabling dyspnea at rest
78
Contraindications to lung volume reduction surgery
- high-risk patients with FEV1 less than 20% or DLCO less than 20% (increased mortality)
79
Presentation of pleuritis
- typically preceding viral infection (viral pleuritis but can have other causes)
- pain worse with movement (breathing, coughing)
80
Treatment of pleuritis
NSAIDs
81
Aspirin exacerbated respiratory disease clinical features
chronic rhino sinusitis + polyposis + asthma + aspirin *OR NSAID sensitivity
(ingestion of NSAID or asthma causes asthma attack)
82
Treatment of aspirin exacerbated respiratory disease
* **leukotriene receptor antagonist (montelukast, zafirlukast)
- avoid NSAIDs
83
CF presentation
- chronic respiratory tract infections
- upper lobe bronchiectasis
- pancreatitis
- absence of vas deferens
84
Most common causes of candidemia
- central lines
- TPN
- immunocompromised
85
Management of candidemia
- catheter removal
| - echinocandin anti fungal
