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Flashcards in Pulm Deck (160):
1

Etiology and pathophys of asthma?

Unknown; associated with obesity and atopy secondary to bronchial smooth muscle hypertrophy

2

What happens to expiratory phase of respiration in asthma?

Prolonged

3

Best initial test in acute asthma exacerbation?

Peak expiratory flow (PEF)/ABG

4

Most accurate test asthma exacerbation vs asymptomatic with occasional symptoms?

Asthma exacerbation-PFT
Asymptomatic-Methacholine or histamine challenge (>20% decrease in methacholine)

5

FEV1/FVC in asthma? TLC? RV?

Both decrease, but FEV1 decreases more so

6

3 PFT measures for aiding asthma diagnosis?

DECREASE FEV1/FVC ratio, >12% increase in FEV1 with albuterol, >20% decrease in FEV1 with methacholine/histamine challenge

7

Asthma tx. outpatient
Step 1: Mild intermittent (2 days/wk. +>2 nights/month)
Step 3: Moderate persistent (daily or >1 night/week)
Step 4: Severe persistent (continual, frequent)
Step 5: Increased IgE level
Step 6: Last resort

Step 1: SABA
Step 2: SABA+low dose ICS
Step 3: SABA+low dose ICS+ LABA
Step 4: SABA+HIGH dose ICS+LABA
Step 5: Omalizumab may be added to step 4
Step 6: Oral corticosteroids added to step 4 when all other therapies not sufficient to control symptoms on own!

8

Adverse effect of ICS?

Dysphonia and oral candidiasis

9

What vaccine should be given in all asthma patients?

Influenza/pneumococcal

10

Best indication of severity of asthma in acute setting?

RR

11

Best initial therapy for acute asthma treatment?

Oxygen combined wtih Albuterol (nebulization) and Bolus of steroids

12

Why and when is magnesium used in acute asthma exacerbation?

Magnesium helps relieve bronchospasm. It is only used when asthma not responsive to several rounds of albuterol while waiting for steroids to take effect

13

When do you need endotracheal intubation?

When patient does not respond to oxygen, albuterol, and steroids OR develops respiratory acidosis (increased pCO2)

14

Best initial/Most accurate COPD?

Best initial: CXR
Most accurate: PFT

15

What test can show an increase in RV in COPD?

Plethysmography

16

EKG in COPD?

RAH or RVH secondary to pulm HTN; AFIB or MAT

17

Tx. for improved mortality in COPD

1) Smoking cessation
2) Home oxygen (pO2

18

What 3 conditions would standard for home O2 be pO2

1) Pulm HTN
2) High HCT
3) Cardiomyopathy

19

Tx. for helping improve symptoms for COPD?

1) Inhaled Anticholingeric (tio/ipratropium)--> most effective in COPD
2) SABA/LABA
3) Pulmonary rehab

20

Difference in next line drug when symptoms not controlled with albuterol in COPD vs. Asthma?

Asthma-ICS next line
COPD-Inhaled anticholinergic next line

21

Tx. for severe COPD exacerbation before intubation?

NPPV (noninvasive positive pressure ventilation)

22

When is use of antibiotics indicated for COPD?

-Defined as requiring hospitalization OR having at least 2 of 3 cardinal symptoms (increasing dyspnea, increase suptum production, increase sputum purulence (green, brown))

23

Tx. for acute exacerbations of COPD?

-Bronchodilators (eg albuterol), corticosteroid therapy combined with antibiotics

24

What should coverage be provided against with antibiotic treatment of COPD exacerbation?

S. pneumoniae, H. influenzae, Moraxella catarrhalis.

25

Presentation of bronchiectasis?

Cough, recurrent high volume mucopurulent sputum (>100 mL/day), and hemoptysis

26

Best initial/Most accurate test bronchiectasis?

Best initial: CXR
Most accurate: High-resolution CT scan

27

How do you determine bacterial etiology of recurrent episodes of infection in bronchiectasis?

Sputum culture

28

Treatment bronchiectasis?

-Chest physiotherapy ("cupping and clapping") and postural drainage essential for dislodging plugged up bronchi
-Same antibiotics as COPD exacerbation (rotate antibiotics, 1 weekly each month)
-Surgical resections of focal lesions may be indicated

29

What is ABPA and what patients is it seen in?

Hypersensitivity of lungs to fungal antigens that colonize the bronchial tree. Hx asthma/atopic disorders

30

How do you Diagnose APBA?

Brown-flecked sputum and transient infiltrates on CXR

31

Tx. ABPA?

1) Oral steroids for severe cases
2) Oral Itraconazole for recurrent episodes

32

What is underlying pathophys from mutation in CFTR gene?

Damage chloride and water transport across apical surface of epithelial cells in exocrine glands throughout the body

33

Most accurate test CF?

-Sweat chloride test (Pilocarpine) with >60 meq/L chloride leves

34

Tx. CF?

1) Antibiotics routine (inhaled aminoglycosides almost exclusively limited to CF)
2) Inhaled recombinant human deoxyribonuclease (rhDNase)-->breaks up massive amoutns of DNA in respiratory mucus (from neutrophils) that clogs up airways
3) Inhaled bronchodilators
4) Lung transplantation in advanced disease

35

Common CAP pathogen and association:
H influenzae?

COPD

36

Common CAP pathogen and association:
S. aureus

Recent viral infection (influnza)

37

Common CAP pathogen and association:
K. pneumoniae?

Alcoholism, diabetes

38

Common CAP pathogen and association:
Anaerobes?

Poor dentition, aspiration

39

Common CAP pathogen and association:
M. pneumoniae?

Young, healthy patients

40

Common CAP pathogen and association:
C. pneumoniae?

Hoarseness

41

Common CAP pathogen and association:
Legionella?

Contaminated water sources, air conditioning, ventilation systems

42

Common CAP pathogen and association:
C. Psittaci?

Birds

43

Common CAP pathogen and association
C. burnetii?

Animals at the time of giving birth, veterinarians, farmers

44

CAP physical findings?

Fever, dyspnea, cough, pleuritic chest pain (possible), and abdominal/pain or diarrhea if infection of lower lobes affecting intestines (through diaphragm). Dullness to percussion (if effusion), egophony due to "bronchial" breath sounds

45

Best initial test pneumonia?
Cause of pneumonia?

-CXR
-Sputum gram stain/culture

46

Pathogen causing hemoptysis from necrotizing disease, and "currant jelly" sputum with pneumonia

K. pneumoniae

47

Pathogen causing foul-smelling sputum, "rotten eggs" with pneumoniae

Anaerobes

48

Pathogen causing dry cough, rarely severe, bullous myringitis with pneumoniae

M. pneumoniae

49

Pathogen causing GI symptoms (abdominal pain, diarrhea) and CNS symptoms such as head ache and confusion with pneumoniae

Legionella

50

Pathogen presenting as cause of pneuonia in AIDS with CD4

Pneumocystis

51

Dry or nonproductive cough occur because infection is where?

Interstitial space with more often air spaces of aleveoli are empty

52

What bugs are bilateral interstitial infiltrates seen on CXR?

Mycoplasma, viruses, coxiella, pneumocystitis, chlamydia

53

Infections with a dry/nonproductive cough in pneumonia?

Mycoplasma, viruses, coxiella, pneumocystitis, chlamydia

54

Specific diagnostic test for M. pneumoniae?

PCR, cold agglutins, serology, special culture media

55

Specific diagnostic test for C. pneumoniae?

Rising serologic titers

56

Specific diagnostic test for Legionella?

Urine antigen, culture on charcoal-yeast extract

57

Specific test for C. psittaci?

Rising serologic titers

58

Specific test for C. burnetii

Rising serologic titers

59

PCP best initial/most accurate test?

Best initial? CXR
Most accurate? BAL (Bronchoalveolar lavage)

60

What should you do for new pleural effusions secondary to pneumonia?

TAP them. Analyze pleural effusion (empyema if pH

61

Exception to bronchoscopy being rare for CAP?

Pneumocystis pneumonia

62

Outpatient CAP treatment:
-Previously healthy or no ABX in past 3 months
-Co-morbidities (cancer, COPD, CHF, renal or liver disease) or ABX use in past 3 months

-Macrolide ABX or doxycycline
-Respiratory fluoroquinolone (levofloxacin or moxifloxacin) or B-lactam (eg penicillin/cephalosporins)+macrolide

63

Inpatient CAP treatment:

Respiratory fluoroquinolone OR cefriaxone+azithromycin

64

What are 2 single factors to hospitalize patient for CAP?

Hypoxia and hypotension

65

CURB65 for admission for pneumonia criteria?

-Confusion, Uremia, Respiratory distress (>30 RR, pO265
-2 or higher benefit from inpatient treatment
->4 ICU admission required

66

Transudative vs Exudative pleural effusion

Transudative-NO light criteria; secondary to Increase hydrostatic or decrease oncotic pressure
Exudative-Pleural fluid protein/Serum protein>0.5, Pleural LDH/Serum LDH>0.6, secondary to increased capillary permability

67

Definition of hospital acquired pneumonia?

Pneumonia developing >48 hours after admission or after hospitalization in last 90 days

68

Empiric therapy for hospital acquired pneumonia?

1) Antipseudomonal cephalosporins: cefepime or ceftazidime OR
2) Antipseudomonal penicillin: Piperacillin/tazobactam OR
3) Carbapenems: Imipenem, meropenem, or doripenem

69

What do piperacillin and ticarcillin need to be used with?

B-lactamase inhibitor (tazobactam or clavulanic acid)

70

Best initial test (least accurate and easiest to do) for VAP
Most accurate test (most dangerous) for VAP

1) Tracheal aspirate
2) Open lung biopsy

71

Initial combination treatment for VAP?

1) Antipseudomonal beta-lactam (cephalosporin (ceftazidime or cefepime) OR penicillin (piperacillin/tazobactam) OR carbapenem (imipenem, meropenem, or doripenem)
PLUS
2) Second antipseudomonal agent (aminoglycoside (gentamicin or tobamycin or amikacin) OR fluoroquinolone (ciprofloxacin or levofloxacin))
PLUE
3) Methicillin-resistant antistaphyloccal agent (Vancomycin OR Linezolid)

72

Difference in cause of aspiration pneumonia vs. pneumonitis?

Aspiration Pneumonia-oral cavity microbes infecting lung parenchyma
Aspiration pneumonitis-gastric contents causing lung parenchyma inflammation

73

Best initial test/Most accurate test for lung abscess?

Best initial test-CXR/ABG(increase A-a gradient)
Most accurate test: Chest CT

74

Tx. Lung abscess

Clindamycin or B-lactam w/B-lactamase inhibitor

75

PCP always has what elevated?

LDH

76

PCP treatment for severe (PO235) and if toxicity to TMP-SMX

Severe-add steroids to TMP-SMX
Toxicity-Switch to either Clindamycin and primaquine OR IV Pentamidine

77

PCP prophylaxis?

1) TMP/SMX
2) Atovaquone or dapsone (if toxicity to TMP-SMX)

78

TMP-SMX toxicity?

Rash/neutropenia

79

TB largest risk factor?

Recent immigrants (in past 5 years) from either Haiti, DR, Phillipines, China, India, Mexico, Vietnam

80

Best initial/Most accurate/Best screening for TB?

Best initial-CXR; sputum stain and culture for acid-fast bacilli must be done 3 times to fully exclude TB!
Most accurate-Pleural biopsy
Best screening-PPD

81

What is best management if high clinical suspicion of TB?

Respiratory isolation BEFORE further diagnostic testing

82

Treatment for smear positive TB?

Rifampin, Isoniazid, Pyrazinamide, Ethambutol
1) RIPE for 2 months
2) RI for 4 months
=6 months total

83

What 4 conditions is treatment extended for in TB?

-Osteomyelitis
-Miliary TB
-Meningitis
-Pregnancy (CANT USE PYRAZINAMIDE) or any other time pyrazinamide is not used

84

Common side effect of all TB meds?

-Idiosyncratic liver injury with histology similar to viral hepatitis. DO NOT STOP until transaminases 3-5 time above upper limit

85

Side effect Rifampin and management?
Side effect isoniazid and management?
Side effect pyrazinamide and managment?
Side effect ethambutol and management?

Rifampin-red/orange color urine; continue drug
Isoniazid-peripheral neuropathy, occasional pellegra with problems with niacin metabolism; prevent with pyridoxine co-administration
Pyrazinamide-Hyperuricemia; no treatment unless symptomatic
Ethambutol-Optic neuritis/color vision; manage with decreased dose in renal failure

86

What is considered a positive PPD test?

>5 mm (HIV/AIDS, chronic corticosteroids, close contacts with TB, calcifications on CXR, organ transplant)
>10 mm (Recent immigrant, prisoners, healthcare workers, close contact w/ TB, Hematologic malignancy, alcoholics, DM)
>15 mm (No other risk factors)

87

For someone who has never had TB test what is necessary?

2nd PPD after 1st PPD if first negative. No second test if 1st PPD is positive

88

Treatment for Positive PPD with active TB excluded via CXR?

Isoniazid for 9 months and use pyridoxine (B6)

89

Does previous BCG affect recommendations for treatment?

NO

90

Best initial step for all lung lesions found on CXR?

Compare to size of old X-rays; if not available, perform CT to characterize lesion.

91

What do you need to do for lesion where old x-ray unavailable?

CT to characterize lesion

92

Management of high risk/intermediate risk/low risk lesions?

High-surgical excision
Intermediate-Imaging+biopsy/PET
Low-Monitor with serial CT scan

93

Most common adverse effect of transthoracic biopsy?

Pneumothorax

94

What defines pulmonary fibrosis?

Thickening of interstitial septum of lung between arteriolar space and alveolus

95

Exposure and Disease:
1) Coal
2) Sandblasting, rock mining, tunneling
3) Shipyard workers, pipe fitting, insulators
4) Cotton
5 )Electronic manufacture
6) Moldy sugar cane

1) Coal workers pneumoconiosis
2) Silicosis
3) Asbestosis
4) Byssinosis
5) Berylliosis
6) Bagassosis

96

Pulm fibrosis presentation

-Dyspnea worsening on exertion
-Fine rales or "crackles" on examination
-Loud P2 heart sound
-Clubbing of fingers

97

Best initial/Most accurate test for pulm fibrosis

-Best initial: CXR
-Most accurate: Lung biopsy; high res. CT scan less accurate, but more accurate than CXR

98

CT scan pulmonary fibrosis shows what?

"Honeycombing" in periphery of lung

99

Tx. pulm fibrosis

NOTHING, but if biopsy shows white cell or inflammatory infiltrate, prednisone can be used; can treat berylliosis with steroids (b/c presence of granulomas)

100

Best Initial/Most accurate test sarcoidosis?

Best initial: CXR
Most accurate: Lymph node biopsy

101

Tx. sarcoid?

Prednisone; asymptomatic hilar adenopathy needs no treatment

102

What veins compose of >90% of thrombosis in DVT that become PE?

Deep veins of lower extremities (iliac, femoral, and popliteal)

103

Best initial/most accurate test for PE?

Best initial: CXR/ABG/EKG
Most accurate: Angiography (rarely done)

104

Next best step for history and initial labs suggestive of PE?

Empiric anticoagulation (enoxaparin)

105

When is V/Q scan used first?

Pregnancy

106

When is IVC filter the right answer?

1) Contraindication to use of anticoagulants
2) Recurrent emboli (while on heparin or fully therapeutic warfarin)
3) RV dysfunction (enlarged RV on echo with next embolus even if it is small can be fatal)

107

Best initial/best long term?

Best initial: heparin/LMWH
Best long term: warfarin (can be started on day one)/oral agents (rivaroxaban/dabigatran))

108

When are thrombolytics the right answer?

-Hemodynamically unstable patients (SBP

109

Most patients with PE will have what on CXR?

NORMAL!!

110

Definition of pulm. HTN?

SBP>25 mm Hg, DBP> 8 mm Hg

111

Best initial/Most accurate test for Pulm. HTN?

Best initial test: CXR/CT
Most accurate test: Right heart or Swan-Ganz catheter

112

Tx. of Pulm HTN?

1) Prostacyclin analogues (PA vasodilators): Epoprostenol. treprostinil, iloprost, beraprost
2) Endothelin antagonists: bosentan, ambrisentan
3) PDE-5 Inhibitors: sildenafil

113

MCC of obstructive sleep apnea?

Obesity

114

Most accurate test OSA?

Polysomnography

115

Tx. for OSA?

1) Wt. loss/alcohol cessation (worsen apnea at night)
2) CPAP
3) Uvuloplatopharygoplasty if CPAP fails

116

Difference btwn OSA and obesity hypoventilation syndrome?

Obesity hypoventilation syndrome has INCREASED bicarbonate secondary to PaCO2>45

117

ARDS triad?

1) Severe hypoxia (increase A-a gradient)
2) Poor lung compliance
3) Noncardiogenic pulm. edema

118

What defines ARDS in lab values?

pO2/FiO2

119

ARDS tx. options?

-Low TV mech. ventilation while waiting to see if lungs will recover (6 mL/kg TV)
-PEEP when patient undergoing mech. ventilation to try and decrease FIO2

120

Obstructive diseases with Low, Normal, and High DLCO?

Low-Emphysema
Normal-Chronic bronchitis/Asthma
High-Asthma

121

Restrictive diseases with Low, Normal, and High DLCO?

Low-Sarcoid/Asbestosis, HF, Interstitial lung disease
Normal-MSK deformity, Neuromuscular disease
High-Morbid obesity

122

Normal spirometry diseases with Low, and high DLCO?

Low-Anemia, PE, Pulm HTN
High-Pulm hemorrhage, Polycythemia

123

Ventilation=?

RRxTV

124

What should be lowered for mechanically ventilated patients with resp. alkalosis?

RR

125

What is first step in initial ventilator management of ARDS?

Decrease FiO2 to non-toxic values (ie

126

What is peak airway pressure=?

Resistive pressure + plateau pressure

127

What is plateau pressure?

Pressure measured during an inspiratory hold maneuver when pulmonary airflow and thus resistive pressures are both 0

128

What ventilator settings affect PaCO2?

Minute Ventilation; RR of 10-12 breaths is appropriate and TV of 4-8 mL/kg is appropriate in most cases.

129

What ventilator settings affect PaO2?

FiO2 and PEEP; FiO2 should be 100% initially with quickly titrating down to lowest possible FiO2 to maintain PaO2 of 50-60. PEEP-5 cm H20

130

What lung pathology will you have increased tactile fremitus?

Consolidation (eg lobar pneumonia)

131

What is alveolar hypoventilation?

Presents with respiratory acidosis with decreased pH (40)

132

CAP gold standard diagnosis?

CXR showing infiltrate

133

Tx. legionella?

Resp fluoroquinolones or macrolides

134

Recurrent pneumonia causes in same part of lung?

-Local anatomic obstruction (bronchial compression (eg neoplasm, mediastinal adenopathy, vascular anomaly), intrinsic bronchial obstruction(eg bronchiectasis, retained foreign body))
-Recurrent aspiration

135

Pneumonia causes in different part of lung?

-Sinopulmonary disease (eg CF, ciliary dyskinesia)
-Immunodeficiency
-Noninfectionous (eg vasculitis, bronchiolitis obliterans with organizing pneumonia)

136

Asbestosis imaging?

Pleural plaques

137

Tx. for aspergilloma vs. invasive aspergillosis?

Aspergilloma-surgical resection
Invasive aspergillosis-voriconazole/itraconazole

138

What is Wells criteria for DVT?

+3 points: Clinical signs DVT or alternate diagnosis less likely than PE
+1.5 points: Previous PE/DVT, HR>100, recent surgery/immobilization
+1 point: Hemoptysis, Cancer
>4PE likely-->CT angio
D-dimer

139

What anticoagulation you use in severe renal insufficiency and why?

Unfractionated heparin OVER LMWH, fondaparinux, rivaroxabn b/c reduced renal clearance increases activity and bleeding risk

140

Management of flail chest?

Positive pressure mechanical ventilation

141

MCC cor pulmonale?

COPD

142

Gold standard diagnosis cor pumonale?

Rt. heart cath: RV dysfunction, pulm. HTN and no left heart disease

143

COPD antibiotics?

Macrolides, fluoroquinolones or penicillins/b-lactamase inhibitors for 3-7 days

144

Symptom presentation of GERD induced asthma?

Adult onset asthma worse after exercise, lying down, or eating

145

Massive Hemoptysis initial management?

A-airway
B-breathing
C-circulation

146

Tx. for nonallergic rhinitis?

Mild-intranasal antihistamine or glucocorticoids
Moderate to severe-Combination therapy

147

Tx. for allergic rhinitis?

Intranasal glucocorticoids/antihistamines

148

ARDS cause?

Non-cardiogenic pulm edema from leaky alveolar capillaries

149

Tx. for upper airway cough syndrome (ie postnasal drip)

Oral 1st gen antihistamine (eg chlorpheniramine) or combined antihistamine-decongestant (eg brompeniramine and pseudophedrine)

150

Most common presenting symptom of superior sulcus tumor (pancoast tumor)?

Shoulder pain

151

Definition of idiopathic pulm HTN?

>25 mmHg at rest SBP or >30 mmHg with exercise

152

Presentation of large cell lung carcinoma?

Peripheral, smokers, associated with gynecomastica and galactorrea

153

Side effect of B2 agonist/systemic steroid for acute asthma?

hypokalemia

154

If you have AERD and need to be on NSAIDS, how do you get around it?

Montelukast for desensitization

155

When should you intubate if looking at lab values?

PCO2>50 of PO2

156

Best way to reduce pulm complications post operatively?

Stop smoking preoperatively especially if stopped 8 weeks before surgery

157

Typical vs. Atypical pneumonia
Prodrome?
Fever?
Age?
CXR?
Pathogen
Antibiotic?

TYPICAL (102, >40, Lobular, S. pneumo, Ceftriaxone)

ATYPICAL (>3 days,

158

Child with recurrent pneumonias. what is it?
Same spot?
Different spots?

Same spot-foreign body aspiration
Different spots-immunodeficiency, CF

159

Why get follow up CXR in patient >40 with pneumonia?

Make sure ABX responds and if it does not clear up by 4-6 weeks, suspect something else like bronchoalveolar carcinoma

160

Cause of infant RDS?

Atelectasis from surfactant deficiency