Pulm Flashcards
1
Q
Utility of pulse ox reading in asthma or COPD exacerbation
A
Pulse oximetry may be falsely reassuring because patients maintain normal oxygen levels despite high work of breathing, and hypoxemia is a late sign of pending respiratory failure.
2
Q
Preferred diagnostic test to work up OSA in patient with high pretest
A
Home sleep testing (need sleep study if cardiovascular disease, who sometimes need advanced settings (bilevel))
3
Q
Subsolid vs solid nodules and screening guidelines
A
Subsolid or part solid nodules or more likely to be malignant than solid nodules and require shorter interval for screening
4
Q
Average doubling time of subsolid, cancerous nodules
A
3-5 years
5
Q
Recommended follow-up of lung nodule 6-8 mm in size
A
Follow up CT at 6-12 months and then every 2 years for 5 years
6
Q
Guidelines used for lung nodule monitoring
A
Fleischner Society Guidelines.
7
Q
Use of PET/CT in nodule workup
A
solid nodule that is greater than 8 mm in size
8
Q
Vocal cord dysfunction vs. asthma
A
VCD = throat tightness + exposure to particular triggers such as strong irritants or emotions + difficulty breathing in + and symptoms that only partially respond to asthma medications + “inspiratory monophonic wheezing”, which is stridor
9
Q
Treatment of vocal cord dysfunction
A
speech therapy utilizing cognitive behavioral techniques
10
Q
why do we use CPAP in OSA
A
positive airway pressure therapy reduces the frequency of respiratory events during sleep and is associated with reduction in daytime sleepiness and improved sleep-related quality of life
11
Q
Treatment for severe carbon monoxide poisoning
A
Hyperbaric oxygen therapy
12
Q
Positive findings on cardiac exam for patients with pulmonary HTN
A
jugular venous distention, a prominent jugular venous a wave, parasternal heave, a widened split S2 with a prominent pulmonic component, or murmurs of tricuspid regurgitation as
13
Q
next step in suspected pHTN workup if TTE is unrevealing
A
Right heart cath
14
Q
Breathing pattern associated with central sleep apnea
A
Cheyne-stokes breathing and apnic period
15
Q
Obstructive vs central sleep apnea in terms of physiology
A
Central sleep apnea occurs because your brain doesn’t send proper signals to the muscles that control your breathing. This condition is different from obstructive sleep apnea, in which you can’t breathe normally because of upper airway obstruction.
16
Q
conditions that lead to central sleep apnea
A
CHF
Drugs or substances
Idiopathic
17
Q
Management of central sleep apnea associated with CHF
A
Diuretics
18
Q
Management of patient with COPD/Asthma overlap syndrome
A
LABA + steroid. You never give a LABA alone without a controller medication because this is associated with increased mortality in asthma patients.
19
Q
Use of roflimulast in COPD + evidence for roflimulast
A
- add-on therapy in severe COPD associated with chronic bronchitis and a history of recurrent exacerbations
- has been shown to reduce frequency of exacerbations
20
Q
management of COPD patient with upper-lobe predominant emphysema and significant exercise limitations
A
Lung volume reduction surgery
21
Q
management of patient with IPF who has progressed and is desatting on hiflo
A
NO INTUBATION, guidelines recommend palliative care because intubation is futile.
22
Q
Presentation of cough-variant asthma
A
- cough, no other asthma symptoms.
- cough triggered by temperature changes, exercise, laughter, and strong scents and perfumes
- normal spirometry
23
Q
Contraindication to IO access
A
Osteoporosis
24
Q
Board answer to what access patient in shock should have
A
Peripheral wide bore catheter
25
Procedure for biopsieing peripheral nodule
CT-guided transthoracic needle aspiration
26
Next step for nodule with high risk of malignancy according to boards
proceed directly to surgery without biopsy (wedge resection)
27
Size threshold of large nodule warranting resection
Greater than 30 mm
28
Lower end of nodule size suggesting benign
Less than 8 mm
29
Clinical feature differentiating ILD from asbestosis from other ILD
Parietal pleural plaques
30
Third line in shock if persistently hypotensive after levo and vaso
Stress dose steroids (hydrocortisone)
31
Why you don't uptitrate vaso
Leads to ischemia, which outweighs added pressor benefit
32
Management of patient with neuromuscular disease (eg ALS) and chronic hypoventilation
BiPaP
33
Most effective measure to reduce risk of recurrent pneumothorax
Stop smoking
34
CVID diagnosis
Low antibody levels (IgG, IgA, IgM)
35
CVID presentation
chronic respiratory tract infections + GI tract involvement with chronic diarrhea and malabsorption
36
Presentation of late complement deficiency
Recurrent invasive gonococcal and meningococcal infections
37
Treatment of pulmonary HTN from COPD
supplemental oxygen
38
Description of pulmonary HTN on cardiac exam
Prominent pulmonic sound
39
Initial treatment of pulmonary arterial hypertension
IF change in PA pressure from nitric oxide --> CCBs
| IF no change --> Bosentan (pulmonary vasodilator)
40
First step in evaluating patient for potential occupational exposure
Request a Material Safety Data Sheet (details chemicals and health risks associated with substances at workplace)
41
Diagnosis of myasthenia gravis
acetylcholine receptor (AChR) antibody test
42
Treatment for cyanide poisoning
hydroxocobalamin
43
Typical setting of cyanide poisoning
Fire or occupational exposures
44
Treatment of benzo overdose
- supportive care (intubation)
- NO flumazenil (has a short half life, so only reverses it for a little while and it can precipitate seizures and withdrawal if chronic user)
45
Presentation of acute hypersensitivity pneumonitis
fever + dyspnea + flu-like symptoms
46
CT findings in hypersensitivity pneumonitis
ground glass opacities + centrilobular micronodules that are upper and midlobe predominant
47
Primary treatment for hypersensitivity pneumonitis
Remove patient from offending agent
48
Intervention to reduce COPD admissions
chronic macrolide therapy (antiinflammatory effect)
49
what I need to remember about hypoxia
Lower threshold for ABG even if satting well
50
ARDS presentation
bilateral opacities + hypoxemia +
51
ARDS management
early intubation, no BiPaP
52
Lung condition associated with connective tissue disease
pulmonary arterial HTN
53
Cryptogenic organizing pneumonia symptoms
same as CAP but prolonged
54
Cryptogenic organizing pneumonia on plain film
bilateral diffuse alveolar infiltrates with normal lung volumes
55
secondary spontaneous pneumothorax definition
pneumothorax in a patient with underlying lung disease
56
management of secondary spontaneous pneumothorax
pleurX if not surgical candidate or VATS if surgical candidate (this is due to bullae or cysts so additional interventions are needed to close the ongoing leak)
57
indication for pulmonary rehab
FEV1 less than 50%
58
Management of patient with hypercapnea from neuromuscular disease
BiPaP
59
BP goals in hypertensive emergency
No more than 25% in first hour
160 within next 2-6 hours
Cautiously to normal within next 24-48 hours
60
Definition of hypertensive emergency
Greater than 180 SBP or 120 DBP + end organ damage
61
cyanide poisoning labs
elevated lactic acid (disrupts oxidative phosphorylation leading to anaerobic metabolism) + inappropriately elevated oxyhemoglobin saturation
62
patient in house fire answer
cyanide poisoning
63
patient in house fire labs
usually some carboxyhemoglobin from carbon monoxide poisoning, some methylene blue but not toxic level, and significant cyanide poisoning (higher than carbon monoxide)
64
treatment for cyanide poisoning
hydroxocobalamin
65
Management of patient with high pretest for CF but negative sweat chloride test
Repeat sweat chloride test (mainstay of diagnosis)
66
Chronic abx for CF?
Yes, oral macrolide antibiotics typically prescribed (can't use quinolones because of resistance).
67
treatment for heat stroke
Evaporative cooling (sprayed water and cooling fans)
68
management of patient in cardiac arrest due to hypothermia
Prolonged CPR + active internal rewarming (you can't treat arrhythmias and systole until temp is raised to 86 deg F) (take cold clothes off, cover with blankets, then body cavity lavage, irrigate colon, stomach)
- Don't stop CPR even after an hour, there are reports of full recovery even after several hours.
69
Treatment for high-altitude cerebral edema
Steroids (dexamethasone, vascular leak leads to brain swelling) + descend to lower elevation
70
Management of patient with hilarity adenopathy, asymptomatic
No further evaluation, no CT chest given asymptomatic
71
Vent settings in ARDS
low TV + high PEEP + limit plateau pressure (no more than 30)
72
TV in ARDS
6 ml/kg
73
what is actigraphy
Measures movement and ambient light to estimate nightly sleep periods
74
first step in evaluation of daytime sleepiness
Make sure patient is getting enough sleep with actigraphy
75
What is a complicated parapneumonic effusion?
DEFINITION = pH less than 7.2 + glucose less than 60
*bacteria may be cleared rapidly from pleural space so the gram stain is commonly negative and cultures are usually sterile
76
Pathophys of complicated parapneumonic effusion
bacterial invasion of pleural space (this explains variable response to abx)
77
What is an empyema
Bacterial infection of pleural space that results in frank pus on visual inspection of pleural fluid OR positive gram stain
78
High vs standard dose flu shot
High dose is approved for people over age 65 and has been shown to be more effective than standard-dose
79
Pneumovax indications
1) chronic medical conditions (heart, liver, and lung disease) + diabetes + cigarette smokers
2) all people at age 65
80
PCV13 indications
1) Asplenia
2) CSF leak
3) cochlear implants
4) immunosuppression
81
PCV13 and PCV23 schedule
always at least 1 year apart
82
Imaging findings of CTEPH on CT-PA
- vascular webs, intimal irregularities, luminal narrowing
83
Criteria for ability to be weaned off ventilator
1) Pass 30 minute SBT
2) Follow commands
3) Clear secretions
4) Patent upper airway
84
What is "cuff leak"
- airflow around the ET tube after the cuff of the ET tube is deflated
- absence or minimal cuff leak may be due to laryngeal edema, stenosis, or thick secretions
85
How do you treat a loculated empyema
Typically Chest tube won't be able to remove all fluid because it is loculated. So you need instillation of intrapleural tissue plasminogen activator-deoxyribonuclease (dorinase). IF that fails, then patient needs thorascopic or open surgical debridement.
86
Answer to older adult presenting with persistent dyspnea and a cough following viral URI
methacholine challenge testing (asthma is under diagnosed in older patients)
87
What is "recruitment" + problem with it
Application of high PEEP to recruit collapsed alveoli. Can drop people's pressure.
88
How does nitric oxide work?
Selectively dilates the pulmonary vasculature, thereby decreasing VQ mismatch.
89
Bronchiectasis presentation
Chronic cough with sputum production + hemoptysis
90
HRCT findings in bronchiectasis
bronchial wall thickening + cysts + airway dilatation with lack of tapering
91
Acute interstitial pneumonia on CXR
Bilateral alveolar opacities consistent with pulmonary edema
92
How to evaluate for ICU-acquired weakness
- Medical Research Council muscle scale (Score less than 48 is diagnostic of ICU-acquired weakness).
93
First line therapy for cryptogenic organizing pneumonia
Steroids
94
HRCT findings in cryptogenic organizing PNA
Extensive ground-glass changes bilateral with several areas of nodular consolidation that are peripherally predominant and along bronchovascular bundles
95
Evidence for use gastric residual volume monitoring
No longer recommended because it doesn't affect outcomes.
96
Chest CT findings of respiratory bronchiolitis-associated interstitial lung disease
centrilobular micronodules
97
respiratory bronchiolitis-associated interstitial lung disease clinical features
active smoker + asymptomatic
98
CT findings in IPF
Basal and peripheral-predominant septal line thickening + traction bronchiectasis + honeycombing
99
Pulmonary Langerhans cell histiocytosis clinical features + radiographic features
- middle and upper zone thin-walled cysts
| - young adult with cough, dyspnea, and pHTN patient
100
TB CXR presentation
Bilateral upper-lobe fibrosis + volume loss of upper lobes + cavitation + bilateral calcified hilar lymphadenopathy
101
Radiographic features of aspergiloma
Round mass with a pulmonary cavity or cyst
102
asthma management during pregnancy
Inhaled glucocorticoids are safe
| - treatment of asthma in pregnancy is basically the same as in non pregnant patients
103
best study modality for evaluating mediastinal structures
Contrast-enhanced chest CT
104
next step for recurrent effusion if concern for malignancy
thoracoscopy and pleura biopsy
105
Characteristics of exudative pleural fluid
- Pleural fluid total protein/serum total protein > 0.5
- pleural fluid LDH/serum LDH > 0.6
- pleural fluid LDH greater than 2/3 the upper limit of normal for serum LDH
106
Sensitivity of cytology for malignancy
Low, only 60%
107
How to reduce snoring
Sleep on side
Drink loss
Lose weight
108
Management of recurrent malignant effusion
Indwelling pleural catheter placement (Pleurx) (50-70% of people achieve spontaneous pleurodesis after 2-6 weeks)
109
Features of serotonin syndrome
Hyperthermia, tremor, hyperreflexia, clonus
110
Serotonin syndrome treatment
- mainly supportive
- benzos as needed to keep patient calm and control blood pressure
- only use cypropheptadine in severe cases of agitation or hyperthermia
111
Malignant hyperthermia setting
following inhaled anesthesia agents or neuromuscular blockade
112
NMS vs. serotonin syndrome
- NMS develops subacutely during days or weeks, serotonin syndrome develops within hours
- hyporeflexia in serotonin syndrome, hyperreflexia and myoclonus in serotonin syndrome
113
First step in management of hypotensive patient with hemorrhagic/hypovolemic shock from variceal bleed
Transfusion RBCs, NOT EGD
114
Treatment for isopropyl alcohol (rubbing alcohol) poisoning
Supportive care
115
Procedure used for biopsy of mediastinal lymph node
Endobronchial US-guided transbronchial needle aspiration
116
Management of acute opioid overdose
- Administer naloxone (higher dose, 2 mg IV for apnic patient than standard 0.4 mg dose)
- Dose will eventually wear off, so you need to observe patient, and repeat dosing or put on drip
- Titrate naloxone to respiratory rate of 12/min
117
Opioid overdose presentation and vitals
miosis + respiratory depression + confusion + hypothermia + bradycardia + hypotension
118
First line for obesity hypoventilation syndrome
CPAP or BiPaP
119
Management of acute exacerbation of bronchiectasis
Levofloxacin for 10-14 days (need quinolone for pseudomonas coverage)
- No evidence for steroids
120
Clinical significance of parasternal heave/lift/thrust
RVH (i.e. enlargement) or very rarely severe LA enlargement (due to the position of the heart within the chest: the right ventricle is most anterior (closest to the chest wall)).
121
Hypothermia treatment
Basically do everything possible to warm patient (mildly hypothermic usually just require external rewarming, but severely hypothermic patients may require internal warming with body cavity lavage
122
How long to code hypothermic patient
- until patient is rewarmed to normal body temperature and then eventually call it (can't treat conduction abnormalities if hypothermic and there are reports of full recovery hours in since hypothermia looks like death)
123
Appearance of fixed upper airway obstruction on flow volume loop
Flatting of both inspiratory and expiratory curves
124
Cause of chronic shortness of breath post intubation
Tracheal stenosis
125
Obstructive pattern of flow-volume loop
- normal initial portion of expiratory flow loop with increased concavity of terminal portion (airway narrowing during exhalation)
- see photo online
126
Next step after CXR in patient with hilar adenopathy suggesting sarcoidosis
IF asymptomatic -- observation, no CT (A lot of patients with stage I pulmonary sarcoidosis have spontaneous resolution of hilar LAD so doesn't change management)
IF symptomatic -- HRCT
127
Features of malignant effusion
low pH + glucose
128
Uncomplicated parapneumonic effusion definition
pH greater than 7.2 + glucose greater than 60
129
Management of uncomplicated parapneumonic effusion
- antibiotics alone
| - no need for chest tube
130
Treatment of bronchiectasis exacerbation
- Base abx on previous sputum culture result
| - IF no previous data available, use a quinolone to empirically cover for pseudomonas for 10-14 days
131
What is wrist actigraphy?
Measures movement and ambient light to estimate nightly sleep periods. Mechanism for tracking if you're getting enough sleep.
132
First step in evaluation of daytime sleepiness
Make sure patient is getting enough sleep over night with actigraphy
133
Strongest indication for CPAP with OSA
- excessive daytime sleepiness (it hasn't shown a benefit on other outcomes, like AF, mortality, A1c, inconsistent effects on BP)
134
Initial management of acute hemorrhagic shock (variceal bleed)
IF hypotensive --> transfuse PRBCs (even in HgB is above 7)
135
PFT's with pulmonary hypertension
Reduced DLCO with normal lung volumes
136
When to start enteral feeds in the ICU + advance
at 24-48 hours, advance by 48 to 72 hours
137
Treatment of asthma during pregnancy
- same as treatment in nonpregnant patients (inhaled steroids and beta agonists are safe in pregnancy. Also- risk to the fetus of untreated asthma are significantly greater than the risks of asthma medications.)
138
Management of high altitude cerebral edema
Steroids
139
Clinical features of acute mountain sickness
HA, fatigue, nausea, vomiting, disturbed sleep (it's mild end of the spectrum)
140
Nightly BiPAP indications
Severe COPD
| Neuromuscular weakness
141
Management of acute hypoxemic respiratory failure per boards
If deserting on NRB go directly to intubation, rather than NIPPV (controversial per boards with some studies showing increasing mortality due to delay in intubation)
142
Management of respiratory distress in severe IPF
Palliative care, including morphine (never intubation. it is irreversible)
143
Rule out active TB
Sputum sample for Acid-fast bacillus x3
144
Features of reactivation TB
- upper lobe
- cavitation
- cough, hemoptysis, night sweats,
145
Complication to know of with chronic silicosis
TB infection
146
Aspergillus clinical features
- usually arises from colonization of a preexisting pulmonary cavity or cyst
- Cavitation
147
How to go about obtaining tissue for diagnosis if patient has nodule with hot lymph node on PET/CT
***Target lesion that would result in highest potential staging (so target lymph node over nodule)
IF nodule is hilar or mediastinal --> endobronchial US-guided transbronchial needle aspiration
148
Preferred approach to biopsying pulmonary lymph node
- endobronchial US-guided transbronchial needle aspiration is preferred over CT-guided (less invasive and higher risk of procedural complications)
149
Lymph nodes in the mediastinum not accessible by endobronchial US
Posterior mediastinal lymph nodes
150
Treatment for cyanide poisoning
hydroxocobalamin (removes cyanide from mitochondrial respiration system)
151
Typical process for determining nodule management
Calculate malignancy risk
IF low --> Serial CT's
IF intermediate --> biopsy
IF high --> proceed directly to surgery
152
CTEPH diagnostic criteria
1) Mean PA pressure of 25 mm Hg or higher
| 2) Imaging evidence of chronic thromboembolism
153
Acronym for anterior mediastinal masses
```
Terrible T's
Thymoma
Teratoma/germ cell tumor
"Terrible" lymphoma
Thyroid
```
154
Persistent cough and dyspnea in elderly person following URI think
asthma (undiagnosed in elderly population
155
Subsolid lung nodule surveillance period
6-12 months
| then *q2 years for 5 years
156
SBP goals in treatment of hypertensive emergency
systolic blood pressure should be reduced by no more than 25% within the first hour; then, if stable, to 160 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours
157
Vaccination for chronic lung disease
pneumovax
158
Treatment of empyema
Instillation of intrapleural TPA
159
Empyema that is incompletely drained means
located typically
