PULM Block I Flashcards
1
Q
Where does the respiratory zone start
A
Bronchiolles, acinus, and alveolar sacs
2
Q
What is an ave. NML tidal volume
A
500 ml
3
Q
What is the tidal volume calc for IBW for an adult male
A
50kg+ 2.3 x (Inches-60)
4
Q
What is the tidal volume calc for IBW for a woman
A
45.5kg+ 2.3(Inches-60)
5
Q
Inpiratory capacity is made of..
A
Tidal volume + inspiratory reserve volume
6
Q
Vital capacity is made of..
A
Exipratory resevere +tidal volume+ inspiratory reserve
7
Q
Functional residual capacity is made of
A
Expiratory resevere volume +residual volume
8
Q
What are the componets of total lund capacity
A
Inspiratory reserve+ Tidal volume+ Exipratory reserve + residual volume
9
Q
What does vesicular breath sounds mean
A
NML
10
Q
What does bronchial lung sounds mean
A
Harsher lung sounds
11
Q
Bronchial breathing is a sign of…
A
Pneumonia or interstitial Dz
12
Q
Cheyne stokes breathing is a sign of
A
Impending doom, HF, ect
13
Q
What is egophany
A
a patient’s recitation of the long E sound is heard on auscultation as a long A sound, is another indication of consolidation typical of pneumonia.
14
Q
Describe tactile fremitus
A
a vibratory sensation noted during breathing, is increased in patients who have consolidated lung from pneumonia, because the vibratory sensation conducts better through such lung tissue and is diminished in patients with pleural effusion
15
Q
What is schamroths sign
A
Clubbing of the fingers as extrapulmonary signs of puml dz
16
Q
What defines acute cough
A
Less than 3 weeks
17
Q
What defines subacute cough
A
3-8 weeks
18
Q
What defines a chronic chough
A
Longer than 8 weeks
19
Q
What are the big three causes of chronic cough
A
Post nasal drip/ Rhinitis
Asthama
GERD
20
Q
Orthopnea MC suggests..
A
CHF
21
Q
What is platypnea
A
Platypnea – opposite of orthopnea; SOB while upright
22
Q
What is trepopnea
A
SOB while laying on the side
23
Q
Massive hemptysis is defined at what volume
A
Greater than 600ml is 24 hrs
24
Q
What is the most common airway dz
A
Bronchitis
25
What is the first two steps in evaluation of non major hemoptysis
HPI and then where is the blood coming from, psuedo vs true hemoptysis
26
What is the defintion of mPAP
Mean pulmonary artery pressure (mPAP) ≥25 mmHg at rest, (measured by right heart catheterization)
(Defines PULM HTN)
Severe if mPAP is ≥35 mmHg or the mPAP is ≥25 mmHg with an elevated right atrial pressure and/or the cardiac index is <2 L/min/m
27
What are the 5 groups of Pulm HTN
Group 1) Pulmonary ARTERIAL hypertension
Group 2) Left Sided Heart Disease
Group 3) Chronic lung disorders and hypoxemia
Group 4) Chronic thromboembolic disease
Group 5) Unidentified mechanisms
28
What does spirometers measure
Tidal vol.
IRV and ERV
Measures airflow rates vs. lung volumes & gas exchange
29
What is the test that can measure Risidual vol.
Body plethysmography
30
What are the C/I for PFT (Spirometry)
ACUTE SEVERE ASTHMA, RR distress, Angina, tension pnthx,
| Ongoing hemoptysis, Acute TB
31
A low FEV1/FVC ratio indicates..
Obstruction
32
What is the FEF 25-75
AKA maximal mid-expiratory flow rate (MMEF)
Indicated patency of small airways
Most sensitive to early obstructions
Measures flow
33
A scooped apperance on spirometry mean s
Obstructive lung dz
FEV1 usually reduced
34
A peaked, narrowed shape on spirometry indicates
A restricitive lung dz
35
A pt presents with a Normal Pttrn FEV1/FVC ratio with a NML FVC
What is the next step in eval
If there is a high suspicion of asthma, consider a bronchO provocation test
36
What defines a reverisble obstructive pattern
Adults: an increase in FEV1 OR FVC of more than 12% AND 0.2 L
5-18 years of age: an increase of > than 12%
37
What is the main bronchoprovacation test
Metha-choline challange
Positive result is a 20% decrease in FEV1 at a cuulative dose of 4mg per mL or less
38
Is screening for COPD with spirometry recommended for AS/s adults?
No! Only look for it in S/s or Hx of smoking
39
What is the 40-50-60/ 70-80-90
| Rule?
When evaluating a SPO2
Assuming normal pH, PCO2 & Hb:
70% SPO2 = PaO2 of 40 mmHg
80% SPO2 = PaO2 of 50 mmHg
90% SPO2 = PaO2 of 60 mmHg
40
What are the common causes of Anion Gap met Acidosis
MUDPILERS
```
methanol
Uremia
DKA
Paraldehyde
Isoniazid
Láctica Acid
ETOH
Rhabdo/renal failure
Salicylates
```
41
An Anion Gap Met Acidosis means what DDX
MUDPILERS
```
Methanol
Uremia
DKA
Paraldhye
Isoniazid
Lactic Acidosis
ETOH
Rhabdo
Salicylates
```
42
What does a non Anion gap met Acidosis mean DDX
HARDUPS
```
Hyperalimenations
Acetazolamide
Renal Tubular Acidosis
Diarrhea
Uretero-Pelvic Shunt
Spirinolactone
```
43
What is the DDX for a Met Alkalosis
Clever PD
```
Contration
Licorice (high urine Cl level)
Endocrine (Conns, Cuchings)
Vomiting
Excess Alkali (urine Cl level)
Refeeding Alkalosis
(Urine Cl level)
```
Post Hypercapnia
Diuretics (urine Cl level)
44
What is the DDX for Resp Alk
CHAMPS
```
CNS dz
Hypoxia
Anxiety
Mech Vent
Progesterone
Slaicylates/ Sepsis
```
45
How do you calc the anion gap
AG= NA- (HCO3+Cl)
or (Na+K) -(HCO3+Cl)
46
What is winters formula
To calc the PCO2 compensation In met acidosis
PCO2= (1.5 x Serum HCO3 )+8
47
How do you calc compensation in met alkalosis
Don’t learn this
48
What are the reasons to order a CXR
```
Pulse >100
RR>24
T>100.4F
Crackles on PE
Signs of consolidation
```
Also consider RR, SpO2, and LOC in elderly pts
(Elderly pts may or may not present with fever in pneumonia)
49
What is the MC cause of sub Acute Cough
Post-infectious cough (3-8 wks)
50
What is the main stay of treatment for chronic cough
Intranasal corticosteroids
51
What are the triad of S/s for asthma
Wheezing , Chest Tightness, Exertional dyspnea
| +/- cough
52
What are the top three MC causes of Chronic Cough
Post nasal drip
Asthma
GERD
53
What does ACEI cause Cough
Release brady kinins
54
Define Chronic Bronchitis
Defined as: productive cough most days for 3 months, over 2 years
55
Define bronachiectasis
Permanent, abnormally dialted bronchi and bronchiolles
Obstructive Airway Dz
Chronic Inflamation or infection leading to progressive airway damage
Chronic inflammatory cells lead to mucus pooling in the airways
56
A pt presents with large volumes of sputum, with accompanied wtih dyspna and hemoptysis
+pleuretic chest pain
+wt loss
+ anemia
You ascultate crackels at the bases of the lungs
ON CXR you see tubular/ cystic structures
(Tracks or rings) with dilated, mucus filled bronchi
Think
Bronchiectasis
If CXR is non difinitive, then order a Chest CT (perferred image)
57
What is the study of choice to Dx bronchiectasis
CT is the study of choice with accuracy above 95%
58
What is the Dx criteria for bronchiesctasis on CT
The imaging definition of Bronchiectasis on CT include bronchus larger than adjacent pulmonary artery and bronchi visible with 1 cm of pleura.
59
What is the TxOC for bronchiectasis
Antibiotics for exacerbations (10-14d)
—Empiric broad spectrum vs. sputum culture
Pseudomonas infection is common
Chest physiotherapy
Postural drainage
Inhaled bronchodilators
NO cough suppressants! Will make the infection stay and get worse!
60
A pt presents with chronic cough, and your collegue wants to give them a cough suppressant, what must you rule out before you can give a pt cough suppressants?
Bronchiectasis
61
What is the MC cause of severe chronic lung Dz in young adults
Cystic fibrosis
62
What is the MC fatal hereditary disease of whites in the US
Cystic fibrosis
63
What is the classic presentation of Cystic fibrosis
Chronic lung disease and pancreatic insufficiency resulting from thick mucus secretions
The pts have Abnormalities in membrane Cl channel
—Mutation of cystic fibrosis transmembrane conductance regulator (CFTR) protein
Resulting in:
—High electrolyte concentration in sweat (Na+, K+, Cl-)
—Abnormally thick & tenacious mucus
64
A young male pt presents with cough, thick mucus production, with decreases exercise tolerance,
PE exam reveals hyperresonant percussion of the chest, with A/P diameter increased, +/- gallstones, steatorrhea, azospermia
On labs you find mild hypoxemia with respiratroy acidosis
A devcrease FVC, FEV1, and TLC
With an elevated RV to TLC ration
Reduced DLCO
Think
Cycstic fibrosis
65
How does cystic fibrosis look on CXR
Hyperinflation early
W/ Apical bullae
Mucus plugging, rings/cysts (bronchiectasis), increased interstitial markings, focal atelectasis
Pneumothorax possible
66
What is the Test to Dx cystic fibrosis
Pilocarpine ionotophoresis sweat test (chlorine sweat test)
Elevated Na & Cl levels in sweat
2 tests on different days
67
What is the Tx approach to Cystic fibrosisi
Early recognition
Refer to CF center
Goals of Tx:
- Clear/reduce secretions
- Reverse bronchoconstriction
- Treat respiratory tract infections
- Replace pancreatic enzymes
- Nutritional/psychosocial support
Rx:
Inhaled recominant human deoxyribonucleas
Inhaled hypertonic saline
Chest physiotherapy
(Postural drainage, percussion/vibration, cough)
Inhaled Bronchodialators (SABA)
ABX:
may be needed for active infections
Azithromycin can be used for long term disease progression
Definitive Tx: Lung Transplant
68
Define bronchiloitis
Generic term for inflammatory processes affecting bronchioles (airways <2mm)
Usually caused by RSV, MC in children
Pleathora of causes in adults
69
A pt presents with a insidious onset of cough a dyspnea, on PE you find tachypnea, crackles and wheezing
PFT show an obstructive pattern with out reversibility
CXRE non diagnostic
CT may show airtrapping similar to asthma
Think
Possible bronchiolitis (may need lung biopsy or specific exposure for DX)
70
What is the Tx approach to bronchiloitis
Cease culprit exposures/drugs
Oral corticosteroids for proliferative type
(Constrictive type unresponsive)
Inhaled bronchodilators
Cough suppressants
Concominant Tx of RSV
Referall to PULM
71
Define epiglottitis
Inflammation/infection of the epiglottis and adjacent supraglottic structures.
72
What are the MC causes of epiglottitis
Causes: Bacteremia and/or direct invasion of the epithelial layer by pathogenic organisms.
Children: Haemophilus influenzae type b (Hib) was the most common infectious cause of epiglottitis in children prior to routine immunization.
73
A young child pt presents with stridor and sitting in the tripod position, with Dysphagia, Drooling, and Distress,
+ feverm sore throat, cough, or tenderness to the ant. Neck
Think
Epiglottitis
74
Should you attempt to visualize the epiglottis in a child with dysphagia, drooling and in distress
NO! May cause acute cardiac arrest
75
What is the gold standard for visualization of the epiglottis in an adult
Laryngoscopy
76
What is a thumb sign on CXR
Epiglottitis
77
What is the Tx approach to epiglottitis
Maintenance of the airway is priority.
IF Not maintaining airway (tripod, respiratory distress).
Bag-valve-ventilation, if O2 remains below high 80s, attempt endotracheal intubation.
If unable, establish emergency surgical airway
Children <12, needle criocothyroidotomy
> 12, Surgical
Supplemental humidified Oxygen.
Monitored in an intensive care unit.
Antibiotics: Third generation cephalosporin (ceftriaxone or cefotaxime) AND antistaph agent active against MRSA (vancomycin). 7-10 day course.
78
Define hypoventilation
Faliure to maintain PaCO2 above 40
79
What is pickwickian syndrome
Obestiy relatedd hypoventilation
```
Blunted ventilator drive
Increased mechanical load on the chest
Daytime hypoventilation
Sleep disordered breathing
Leads to alveolar hypoventilation (elevated PaCO2) & hypoxemia
Comorbid obstructive sleep apnea common
Diagnosis of Exclusion
```
80
Whar are the rsk fxs for Obestiy hypoventilation syndrom e
BMI>40 kg/m2
Pre-existing sleep apnea
Reduced vital capacity on PFTs
Restrictive pattern
81
A pt presents with a BMI greater than 30, has snoring, nocturia, morning headaches, decreased libido, and non refreshing sleep
On ABG you see PACo2 greater than 45 and PaO2 less than 70
What is the Dx at Tx approach
Obstrucive sleep apnia ( pickwiskian)
Tx:
Wt loss (possible bariatric srgy)
Positive pressure vent
Avoid: sedative hypnotics, opiods, or ETOH
82
A middle aged man, slightly obese with refractory HTN
Think
OSA!
83
What is STOP-BANG for OSA
```
Snore loudly
Tired: daytime fatigue, sleepiness
Observed apnea observed
Pressure: Hypertension
BMI >35
Age >50
Neck circumference (>40 cm)
Gender (Male)
```
Greater than 3 of the above = high risk
84
What labs should be ordered for a pt with OSA
CBC, TSH/FT4
Sleep study
85
An epworth Sleep score of
| 1 to 6=
Good score, NML
86
Epworth Sleep Score of 7to8 means
Average score
87
Epworth sleep scale of 9 and above means
Seek advice from a sleep specialist without delay
88
A Apnea hypopnea index of 0-4=
NML
89
Apnea Hypopnea Index of 5-14=
Mild
90
AHI (apnea hypopnea) index of 5-14=
Mild
91
AHI of 15-29=
Moderate sleep apnea
92
A AHI above 30 indicates
Severe OSA
93
A pt with a O2 sat below 90 for more than 20% of a sleep study=
Severe OSA
94
What is the Tx appraoch to OSA
Wt loss!
Strict avoidance of ETOH and sedatives
For mild: Mechanical airway devices
Moderate: Nasal CPAP
(CPAP IS GOLD STANDARD)
Severe: CPAP!
95
What are the indications for a hypoglossal nerve stimulator
For Mod-Severe OSA
BMI< 32
AHI< 50
W/ non concentric airway collapse pn sleep endoscopy
96
What is a MADs device
Mandibular adjustment device for sleep apnea
97
A pt with ungoing sleep apnea, not corrected by wt loss, apliance, or surgery.
Any PAP level beyound BPAP/ CPAP/ or APAP
Or requireing O2 for more than 6 months
What should the pt get in the military
MEB!
Permamnet P2 if PAP is required longer than 12 months
98
What is the differnece between OSA and Obestiy hypoventilation
daytime hypoventelation with Obestiy hypovent
99
What is the only definitive Tx for OSA
TRACHEOTOMY
100
What is the definition of asthma
Asthma is a clinical syndrome of UNKNOWN etiology characterized by RECURRENT EPISODES OF AIRWAY OBSTRUCTION
that resolve spontaneously or as a result of treatment.
These changes occur in the setting of various types of AIRWAY INFLAMMATION that are thought to reflect specific endotypes of this clinical syndrome.
Although airway obstruction is largely reversible, some changes in the asthmatic airway may be irreversible.
101
What is Atopy
Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema).
IgE mediated (Atopic dermatitis)
Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.
102
A pt presents with:
Edema, infiltrates within bronchial walls (eosinophils, lymphocytes)
Epithelial damage– “fragile” appearance on microscopy
Hypertrophy and hyperplasia of smooth muscle
Increased collagen deposition beneath epithelium
Hypertrophy of mucus glands and increase in goblet cells
This is the pathology of what Dz
Asthma
103
What are the triad of sequale of airway remodelling in Asthma
Epithelial damage
Airway fibrosis
Smooth muscle hyperplasia
Chronic inflammation causes release of inflammatory mediators including growth factors
104
What does catamenial mean
Occuring during part of a menstral cycle
| Some pts have asthma only during menses
105
What is the most common inhaled irratant of asthma
Cigarette smoke
106
What is the pathophys of Excercise induced Asthma
Heat and moisture loss + rapid cooling of airway
During exercise, increase respiratory rate introduces cooler, dry air to respiratory tree.
Air is warmed and humidified, epithelial surfaces are cooled and dried
107
How does asprin cause asthma
Aspirin causes production of leukotrienes from arachidonic acid
Aspirin sensitivity linked with nasal polyposis
Asthma triad – Asthma, aspirin sensitivity, and nasal polyps
108
What is samter syndrome
Asprin induced asthma
109
What is the atopic triad
Allergic rhinitis, asthma, eczema
110
A pt presents with wheezing, increased sputum with chest tightness that is all worse at night
Think
Asthma
111
What are the 3 RED FLAG questions for asthma
Have you ever been hospitalized for your asthma?
Have you ever been intubated because of your asthma?
Have you ever been on oral (systemic) steroids for your asthma?
112
A pt with asthma iwth respiratory acidosis indicates
Imprending failure
Ph is low and PCO2 is high
113
What is the common EKG pattern for asthma
Sinuc tach
R axis deviation
RBBB
114
A negative BPT (bronchial provocation testing) means what for asthma
Negative for asthma
| But a postive test does not mean they are postive for asthma
115
What is the pt education for all Asthma pts
Asthma Action Plan!
116
Which pts a recommeneded for allergen mitigation
Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms
(DEC2020 update)
117
How long should a pts S/s be controlled before attempting a step down approach
Controlled S/s x 3 months
118
What is the severity of asthma of the pt below:
Pt presents with S/s less than 2 days a week, and night time awakenings less than 2 times a month
They use their SABA 2 days a week
With no interference in NML activity
The FEV1 is greater than 80% predicted and the FEV1/FVC is NML
Intermittent severity with recommended step 1 tx
119
What is the Tx appraoch for a step 2 Asthma Pt (Nabp)
Low dose ICS
| Alternative LTM, or cromolyn
120
What is the Tx approach to a step 3 (NABP) Asthma
Low dose ICS plus LABA or medium dose ICS alone
121
What is the Step 4 Tx appraoch to (NABP) Asthma
Medium dose ICS plus LABA
Or
Medium dose ICS plus LTM
Add Lama if S/s are still uncontrolled
122
What is the STEP 5 asthma Tx approach to a pt with Asthma
High does ICS plus LABA
Consider omalizumab for pts with allergic asthma or LAMA if still uncontrolled
123
What is the Step 6 approach to ASTHMA (NAEBP)
High does ICS plus LABA plus systemic corticosteroids and consider omalizumab for pts with allergice asthma or LAMA if still uncontrolled
124
If a pt uses SABA more than 2 times a week for Asthma S/s
That would mean
The S/s are uncontrolled and need a step up in Tx
125
What is Single Maintenance and Reliver Therapy used for
moderate-persistent beyond Asthma pts
126
What is the criteria for well controllled asthma pt
S/s less than 2 days a week, with less than 2 awakenings a month
Without interference in activity
FEV1 or peak flow greater than 80% personal best
With more than 1 excacerbation a year
127
Learn Table on slide 53 +56 for Ginna Asthma Tx
Learned it bitch
128
What can FeNO tell you
Fractional exhaled Nitric Oxide
Nitric oxide produced throughout body
Fights inflammation, relaxes smooth muscle
High levels can indicate airway inflammation
Can help determine if steroids will help
Can help monitor asthma control
129
When can you consider step down treatment for an Asthmatic
3 months of Tx with improvement
130
What is the preferred 1st line tx in persistnant Asthma
Anti-Inflammatory Corticosteroids (inhaled)
131
How should salmetrol and formoterol be used in Rx
If added to ICS, effect is equivalent to doubling ICS dose
| Never for monotherapy
132
What is the mediatory inhibitor used in execrice inducsed asthma
Cromolyn
133
How is Tiotropum used in Asthm a
Can be an add on if uncontrolled on ICS + LABA
| Much more commonly used in COPD
134
What are the most effective bronchdilator in acuts S/s
SABA’s
135
How is prednisone used in Asthma Tx
Burst Tx: 5 day course
(Acute asthma exacterbations)
Severe: IV/IM methyl prednisone
Goal of Tx is a FEV1 greater than 50%
136
A peak flow that is less than 50% of the baseline PEFR is what kind of asthma
Severe Asthma!
137
A pt presents with mild exacerbation of Asthma, already takes an ICS, what is the Tx option for the S/s present
5 day oral steroids (prednisone)
138
Failure to respond to treatment by objective criteria (PEFR or FEV 1 ) within 2 hours of arrival at the emergency department is an indication for the use
Oral or IV steroids (prednisone/ methyl prednisone)
139
A pt presetns with impednind respiratry failures, with a PEFR less than 25 percent
What is the intervention
INTUBATE !
140
What medications can not be used in Preg Asthma Pts
Tetracycline
Ipatropium bromide
Terbutaline
Use systemic steroids sparingly
141
What is the FEV1/FVC for COPD
Less than 0.7 (70%)
142
What is the definition of chroninc bronchitis
excessive secretion of bronchial mucus; daily productive cough x 3+ months in 2+ years
Basically the enlargement of mucus glands and proliferation of goblet cells
143
What is the definition of Emphysema
abnormal permanent enlargement of air spaces distal to terminal bronchiole, with wall destruction
144
What is the leading cause of COPD in the USA
Cigarette Smoking
145
What is the genetic cuase (young pts) of COPD
Apla-1 antitripsin defect
146
What is panacinar emphysema
diffuse involvement of acinus (bronchiole, alveolar ducts, sacs & alveoli)
Lower lung more affected than upper lung
Most common in α1- antitrypsin deficiency
147
What is centrilobular emphysema
proximal acinus (bronchiole)
Destruction more irregular with areas of sparred tissue
More common in smokers
Most likely due to peripheral spread of airway disease (bronchitis)
148
A pt presents with SOB, cough, and sputum production, with PULM HTN and inpending respiratory failure
Think
COPD
149
What is the HALLMARK of COPD
Periodic exacerbations = hallmark of COPD
Often precipitated by infection or environment
150
WHat are the PFT findings in COPD
Early: ↓ mid/small airway flow decreased (FEF 25-75%)
Mid: ↓ FEV1 and FEV1/FVC ratio
Late: ↓ ↓ FVC, ↑ TLC especially in emphysema
151
What is GOLD 1 for COPD
Post BronchO FEV1 greater than 80% predicated
152
What is the most common EKG abnmlaity in COPD
SINUS TACH
| Can be MAT, Afib, Aflut
153
Is clubbing a manifestation of COPD
Clubbing is not a manifestation in COPD, and its presence should prompt an evaluation for other conditions, notably lung cancer or pulmonary fibrosis
154
What is the role of Varenicline
Smoking Cessation Medication (Chanitx)
155
What is the cutoff for O2Tx in COPD
Resting 88% O2 sat
156
What is the preferred Inhaled broncho dilator in COPD
Ipatropium
| Can be combined w/ albuterol
157
What is the tx approach to Exacterbations of COPD
SABA +/- short acting anticholinergic
(albuterol +/- ipratroprium)
Consider antibiotics
Consider systemic steroid burst
158
What are teh mMRC scales
```
Dyspnea w/
O- excerceise
1-hurrying/hills
2-Normal walking pace
3-100 yards or a few minutes
4-rest
```
159
What is the number of ribs for a good/NML CXR
8-10
160
What effect does sympathetic stimulation have on the airways
Epi causes bronchodilation and increases beat freq of cilia
161
What effect does parasympathetic have on the airways
Ach causes slight contraction of smooth muscle and increase in mucous production
162
What is the role of surfactant
Lowers surface tension of alveolar fluid, maintaining patency of the alveolar sacs
163
O2 content in arterial blood depends on what two things
PO2 and Hg level
164
Tissue oxygenation depends on what three fxs
PO2, Hg level and CO
165
What are the three ways CO2 is carried in our blood
Bicarbonate (largest component)
Carbaminohemoglobin
Dissolved CO2
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-
166
What percent of Tidal Volume reaches the Resp zone
70%,
| 30% remains in anatomical dead space
167
A loud seconds heart sound indicates..
Pulm HTN
168
Dullness on percusión of the chest means..
Consolidation, need to order a CXR
169
What is the per Kg for NML TV
5ml/kg
170
What is egophany
a patient's recitation of the long E sound is heard on auscultation as a long A sound, is another indication of consolidation typical of pneumonia.
171
Fine crackles are a sign of..
Heart Failure, Interstitial Lung Dz, Alveolar filling D/o
172
Coarse crackles are a sign of..
Bronchitis
173
Wheezing is a sign of..
Asthma./ COPD
174
Rhonchus is a sign of…
Rhonchus is a musical, low-pitched sound typically heard in expiration and sometimes during inspiration; it often resolves with coughing.
Is often a sign of Bronchitis, or COPD
175
Stridor is a sign of..
Upper airway obstruction, Laryngeal or tracheal inflammation, masses or lesions in the upper airway, or external compression
176
A pleural friction rub is a sign of…
Pleural inflammation or pleural tumors
177
A pt presents with absent lung sounds.. think
Obstruction, Large effusion, or collapse (PNTHX)
178
What effect do anemia and polycythemia have on Cyanosis
Anemia – may prevent cyanosis from appearing
Polycythemia – may show cyanosis in mild hypoxemia
179
What is the most common airway irritant
Cig Smoke
180
What are the common causes of acute cough
Common Cold
Acute Bacterial Sinusitis
Pertussis
COPD exacerbations
Allergic rhinitis
Irritants
181
A pt presents with chronic cough, and it is determined that the cause if a post nasal drip
What is the empiric tx
Antihistamine/ decongestant, with nasal saline irrigation
182
A pt presents with chronic cough and it is determined that asthma is the cause..
What is the Approach
Eval with spirometry, bronchodilator reversibility, Methacholine challenges, then treat with ICS, Beta Adrenergic Inhalers, LRAs
183
A pt presents with chronic cough and GERD is determined to be the cause
What is the Tx approach
Empiric tx with PPI and change diet/ Lifestyle
184
A pt presents with inadequate response to empiric tx for Asthma/GERD/ Post nasal drip
What is the next step in eval
Many options:
24 hr esophageal PH monitoring (GERD)
Endoscopy
Barium Swallow study
HRCT
Sinus imaging
Bronchoscopy
Echo
Polysomnogram
185
When should ICS be used for chronic cough
Inhaled corticosteroids can reduce cough but should be used only AFTER evaluation by chest radiography and often spirometry.
186
Define Paroxysmal Noctural Dyspnea
Unlike orthostatic, the onset is not immediate upon laying down
Suggests: Cardiac decompensation
Peripheral edema
187
What are the level 1 tests that should be ordered on a pt with CC of Chronic dyspnea
```
CBC
BMP
CXR
ECG
Spiromerty
Pulse Ox
```
188
What is the working DDX of Hemoptysis
Bronchitis, Bronchiectasis, and Carcinoma are the top 3
Then infx causes: TB, abcess, Pneumo, Fungal infection
And last lesions: PE, Pulm HTN , Pulm Edema
189
Any pt that presents with hemoptysis should get what w/u
CBC,
Urinalysis
Coag panel (PT/ INR)
With a CXR and ECG
190
A pt presents with Hemoptysis (non massive)
CXR shows infiltrates
What is the tx approach
Start ABX
Resolution? = Repeat CXR in 6-8 weeks, if ABN send to CT (chest)
No resolution?= CT (chest) and Pulm consult
191
A pt presents with Non massive Hemoptysis and there is a mass on CXR was is the tx approach
Perform Bronchoscopy and pulm consult
192
A pt presents with non massive Hemoptysis and on CXR there is parenchyma dz
What is the approach
Chest Ct
If there is no specific findings, then perform Bronchoscopy and Pulm referral
193
A pt presents with non massive Hemoptysis and the CXR is NML
What is the approach
Consider ABX,
If it does not resolve, send to chest CT
194
What are the suggestion criteria for carcinoma
Postive CXR, age over 40, w/ smoking Hx, and Hemoptysis greater than 1 week
195
Do Lungs contain sensory fibers
NO!
So if a pt has pulm chest pain think
Parietal pleura, diaphragm or medistinal d/o Which are usually the result of inflammation or malignancy
196
What are the indications for PFTs
Assessment of type/extent of lung dysfunction
Diagnosis of dyspnea/cough causes
Detection of early dysfunction
Prognostic assessment
Perioperative risk
Health status prior to physical exercise
197
What is the most readily available and useful PFT
Spirometry
198
How long should the pt exhale on a Spirometry
6 seconds
199
FVC on spiromerty measures
Is an indication of lung/chest expansion
Good indicator of effort
Measures total volume a pt can blow out rapidly after a deep inhalation
MEASURES VOLUME!
200
A pt with a reduced FVC but a NML FEV1/FVC ratio.. means
Restrictive pattern
Reduction in lung volumes
Imagine trying to take in a breath with a tight band around your chest
201
What are the two separate definitions of abnormal flow rates
FEV1 & FVC (independently): <80% of predicted is abnormal (adults)
FEV1/FVC ratio < 70% is abnormal
202
A pt presents with a FEV1/FVC ratio that is normal, yet the FVC is decreased.. what is the next step in eval
This is a restrictive pattern
Determine the severity
And then refer for Full PFTs as necessary
203
A pt presents with a reduced FEV1/FVC ratio yet the FVC is NML
What is the next step in eval
This is an obstructive pattern
Determine severity And reversibility
If its reversible: that’s asthma
If its not: COPD (or other cause)
204
A pt presents with a FEV1/FVC that is decreased AND the FVC is decreased
What is the next step in eval
This is a mixed pattern,
Determine severity
Does the FVC improve with a bronchodilator>?
Yes: pure obstruction likely, COPD/ Air trapping
No: refer for full PFTs
205
What is the GOLD criteria for COPD
FEV1/FVC ratio of less than 0.7
206
What is the degree of severity in a FEV1 % predicted
```
>70= Mild
60-69= mod
50-59=mod severe
35-49= severe
<35 = very severe
```
207
What defines reversibility of an obstructive pattern
Increase in FEV1 or FVV of more than 12% AND of 0.2L
208
What is GOLD 1
First the pt has a FEV1/FVC ratio of less than 0.7
Then post bronchodilator FEV1 % predicted of 80%
209
What is GOLD 2
A post bronchodilator improvement of 65%
210
What is GOLD 3
A post bronchodilator FEV1% predicted of less than 50% but not less than 35 %
211
What is GOLD 4
A post bronchodilator FEV1 % predicted of less than 35 %
212
What two patterns should get Full PFT work/ups
Restrictive and Mixed patterns that do not respond to bronchodilators
213
What is the 5 step approach to reading PFTs
1. Look FEV1/FVC ratio
2. Look at FVC
(Determine pattern, Restrictive, Obstructive, mixed)
3. Determine severity
(Mild, Mod, Mod Severe, ect)
(except in COPD)
4. Ask if Full PFTs are needed
(Restrictive pattern or mixed with out brocnhco response)
5. Asses for reversibility
(Post bronchodilator: increases in 12% ratio AND 0.2L)
(Asthma/COPD)
214
When is bronchoprovacation (methacholine challenge) test recommended
Bronchoprovocation testing is recommended for patients with normal results on pulmonary function testing but a history that suggests exercise- or allergen-induced asthma.
215
What is the DDX of an obstructive pattern on PFT
Asthma, COPD, Alpha- Antitrypsin def.
216
What three drugs can cause a restrive pattern on PFT
Amiodarone
Methotrexate
Nitrofurantoin
217
What is the gold standard for evaluating lung VOLUMES
Body Plethysmogrpahy
Measurement of air pressure and volume changes within closed box as patient respires.
Can calculate TLC using Boyle’s Law (most accurate)
218
What does DLco measure
measures rate of alveolar/ capillary gas transfer
Helpful in diffuse infiltrative lung disease or emphysema
Can help differentiate emphysema vs. chronic bronchitis (both COPD)
Results dependent on alveolar surface area and pulmonary blood flow
219
What must be measured FIRST before evaluating an DLco
Hgb! Can be reduced in Anemic pts
220
An elevated DLco means
THink Asthma, obesity, polycythemia, pulm hem, exercise
| Increased capillary flow
221
A decreased DLco means
Think Emphysema, Lung Dz, PVD
| Decreased cap flow
222
What does a peak flow meter measure
Measures peak flow through device
Useful for monitoring progression of symptoms or acute exacerbations
May dictate change in treatment regimen or need for emergent intervention
ASthma/ COPD action planning
223
What are the findings on PFTs in a pt with obesity and asthma
Asthma will be more severe
Reduced ERV, VtCap,
Increased DLco
Increase work of breathing
224
How is U/S used in Pulm
Can be the 1st screen for Pneumonia, Pulm edema, or a PTNTHX
(NOT GOLD STANDARD)
225
What defines large vs small opacity
Small less than 1 cm
| Large greater than 1 cm
226
How does bacterial pneumonia look on CXR
Lobar pattern
227
What does a diffuse pattern on CXR mean
Suspect Alveolar damage, edema, or viral Pneumo
228
What does Mulitfocal pattern on CXR mean
Suspect bronchopneumonia, aspiration, or vasculitis
229
What does a perihilar pattern on CXR mean
Suspect Vol. overload, or pulm hem
230
What is the use of Bronchoscopy in pulm
Allows direct vis
Can eval airway
Dx carcinoma and staging
Eval Hemoptysis
Dx pulm infx s
231
What is bronchoalveolar lávate
Bronchoscopy plus a wash/collection that is sent for analysis:
- Cell count
- Cytology
- Cultures
232
What is Dr T definition of an acid
A chemical substance, usually a liquid, which contains hydrogen (protons) and can react with other substances to form salts.
233
What is Dr T definition of a base
A chemical species that donates electrons, accepts protons, or releases hydroxide (OH-) ions in aqueous solution
234
What is PaO2
Measures the partial pressure of O2 in the Arterial Blood
235
What is PaCO2
Measures the partial pressure of CO2 in arterial blood
236
What is HCO3
CALCULATED concentration of bicarbonate in arterial blood
237
What is the B/E
base excess/ deficit
Calculated relative excess or deficit or base in arterial blood
238
What is SaO2
Calculated arterial sat
239
What are the NML values for
| pH/PaO2/ PaCO2/HCO3/B/E/SaO2
7. 35-7.45/75-100/35-45/22-26/
| - 4-+2/95-100%
240
As a pule ph falls ____ for each 10 mmHg rise in PCO2
Winters formula
0.1 for each 10 mmHg
241
What is the Henderson hasselbach equation
PH=pKA +log (conjugate base/acid)
242
Where would Tb show up on a CXR
Upper zones of the lung
243
Where would sarcoidosis show up in a CXR
Upper lung zone
244
Where would asbestos show up on a CXR
Basal lung zones
245
What is the difference between oxygenation and ventilation
Oxygenation: getting O2 in
Ventilation: getting CO2 out
246
What are the MEASURED components of an ABG
PH, PaO2, PaCO2
247
What are the calculated parts of Ann ABG
HCO3, Base Excess, SaO2
Except when SaO2 is combined with Co-Ox then it is measured
248
What is the ABG standard format
pH|PaCO2|PaO2|HCO3-|
| O2 Saturation
249
What is the Henderson Hasselbach equation for ABGS
pH = 6.1 + log [HCO3-/(0.03 x PaCO2)]
250
What is the DDX FOR ACUTE RESP ACIDOSIS
Anything that causes hypoventilation
```
CNS depression
Airway obstruction
Pneumonia
Pulm edema
PNTHX
```
251
What is DR T approach to ABGS
1 Are values in normal range?
2 Acidosis vs Alky
3 ROME
4 Compensation >?? M
252
Sometimes pts can cough so forcefully that a cough alone can cause other complications.. such as..
Syncope
Dysarrthymias
HA
Subconjunctival Hem
Inguinal hernias
GERD
253
What is the MC cause of Acute (less than 3 wks) cough
Viral RTI/ Acute Bronchitis
254
A pt presents with a cough for 2 weeks, with chest wall tenderness, wheezing on auscultation, Rhonchi that clears after the cough
Think
Acute bronchitis
255
What is the Tx approach to acute cough
Antitussives, Anti-inflammatory, mucyolytics, Antihistamines, Decongestants, or bronchodilators,
DO NOT GIVE ABX
256
What are the Three most common causes of Chronic Cough
PND (DRIP), Asthma, GERD
```
Lesser:
ACEI
Post infectious
Cystic fibrosis
Ect ect
```
257
What is THE most common cause of Chronic cough in non smokers
Post Nasal Drip
258
A pt presents with Rhinorrhea, Nasal congestion, And a throat tickle for 8 weeks..
No Hx of tobacco use
On PE you see cobblestoning in the oropharynyx
What is the Likely Dx and tx
Post Nasal drip for Chronic Cough
I trabas al corticosteroids
Oral antihistamines
Oral decongestants
Oral montelukast
ABX only when justified
1-2 weeks of initial tx should resolve cough
259
A pt presents with wheezing on PE, with chest tightness and exertional dyspnea
Think
Hallmark findings of Asthma
260
What is the initial Tx approach to Asthma
| Don’t think step, just think right away
ICS with a PRN saba x 6-8 wks
If pt is unable to tolerate an ICS then you can use motelukast
261
A pt presents with increased cough at night, and while supine, and increased cough after eating
Think
GERD
Up to 50% of pts also have heartburn/ waterbrash
262
What is the Tx approach to a pt with chronic cough from GERD
Start a PPI
Stop smoking
Change diet (fatty foods, caffeine, ETOH)
Lose wt if obese
3 months of therapy should resolve S.s.
263
What is the Study OC when evaluating Bronchiectasis
CT
The imaging definition of Bronchiectasis on CT include bronchus larger than adjacent pulmonary artery and bronchi visible with 1 cm of pleura.
264
What is the most common fatal hereditary dz of whites in the US
Cystic fibrosis
265
What is the oral med for specie gene mutation in Cystic fibrosis
Ivacaftor
266
What is the prognosis for CF
Median survival 36-37 yrs
Death usually pulmonary complications:
Pneumonia, pneumothorax, hemoptysis
Terminal chronic respiratory failure & cor pulmonale
267
What are the relevant Hx exposure for Bronchilolitis
Viral infx (RSV)
Toxic Fumes ( ammonia, diacetyl)
Organ transplant
Or connective tissue D/o like RA or Sjogren Syndrome
268
What are the common causes of Epiglottitis
```
Bacterial :
H. Influenza B
H. parainfluenza
Strep Pneumo
Staph Aureus
Beta Strep
P. multicida
Moraxella Catahris
Klebsiella
```
Viral :
HSV1
H. Zoster
EBV
Fungal:
Candida
269
What are the three Ds of epiglottitis
Dysphagia, Distress, and Drooling
270
A pt presents with stridor, muffled voice, fever, and sore throat
Think
Epiglottitis
271
What are the Two ABX for Epiglottitis
Ceftriaxone or Cefotaxime plus Vanc for 7-10 days
272
What are the common aspirates in children vs infants
Food items are the most common items aspirated by infants and toddlers, whereas nonfood items (eg, coins, paper clips, pins, pen caps) are more commonly aspirated by older children.
273
What is the classic triad of aspiration FB
Wheezing, cough, and diminished Lung sounds
| Also cough, Tachypnea, stridor
274
A child presents with cough, Tachypnea, and stridor
Also wheezing and diminished breath sounds,,.
Think
Aspiration of FB
275
What are common CXR findings in a lower airway FBA
Hyper inflated lung, atelectasis, medistinal shift, or pneumonia
Normal findings do not rule out FBA, and hx should prompt bronchoscope
276
What is the tx approach to FBA with sever airway obstruction
Dislodgement using back blows and chest compressions in children <1.
Heimlich maneuver in older children.
Intubation, oxygen
Rigid bronchoscopy
277
What is the Tx approach to FBA without complete obstruction
Conduct PE, plain radiograph of chest and neck (pending symptoms), CT, bronchoscopy.
278
What is the approach to removing a FBA
Children : rigid bronchoscope
| Adult: flexible bronchoscope
279
A pt presents with a Suspected/ Known FBA, and they are S/s and unstable
What is the next step
Emergency managment for airway obstruction
280
What is the step by step approach for a suspect FBA that is stable
Plain Radiograph
If FB detected the bronchoscopy
If NML: then if high index of suspicion you can order either a CT scan, or perform bronchoscopy
If CT scan and CXR are normal then observe and have pt f/u in 2-3 days
281
What is the algorithmic approach to a complete airway obstruction
Are there S/s of obstruction
(Tripod, sniffing, severe distress, grunting, muscle use, cyanosis, or unable to speak)
Emergency call to Anesthesia
If the pt becomes unresponsive:
Start CPR with compressions, Prior to each attempt at Resuce breathing evaluate airway for obstruction dislodgement
If the pt remains conscious:
Age less than 1: back blows x 5
Chest thrusts x5 alternating
Child Q year old: hemiliech
Obstruction should be cleared within 1 minute
If not then perform direct laryngoscope with magill forceps
If still unable to remove obstruction
Consider a cric or intentional right stem RSI to push the FB into the Right stem then position the pt with the right side down to ventilate the left lung
Then proceed immediately to the OR
282
What is something you have to observe for in a FBA post removal
Post obstructive pulm edema
283
What are the key steps to prevent FBA
Vigilant at 6 months age
hard or round foods should not be given to children less than 4
Feeding should be done upright
Chewable meds should only be given after 3 years old
284
What is central sleep apnea
Cessation of effort or in adequate vent drive
Can be from narcotics, or idiopathic
285
A pt presents with daytime hypoventilation and also complaints of sleep disordered breathing
Think
Obesity Hypoventilation syndrome (pickwickian)
286
A pt presents with CC of decreased libido and non restorative sleep ,
Wife states he constantly snores, and awakenes gasping for air
He has morning HA and concentration difficulties,
He states he often falls asleep at work and sometimes while driving
Think
OHS
287
What does an epworth score of 1-6 mean
Good sleep !
288
What does a epworth score of 7-8 mean
Average score ( could improve)
289
What does an epworth scale greater than 9 mean
Refer to sleep specialist without delay!
290
What are the complications of OHS
Pulm HTN
HF
Cor pulmonale
OSA complications like HTN stroke, MI, MVA, hyper somnolence
291
What are the REQUIRED criteria for OHS
BMI greater than 30 (greater than 40 is only a RSK fx)
Daytime Hypoventilation of a PaCO2 greater than 45 at sea level
Hypoxia of a PaO2 less than 70
W/ sleep disordered breathing
And an absense of any other possible Dx
292
Define OSA
Upper airway obstruction due to loss of pharyngeal muscle tone allows pharynx to collapse passively during inspiration
293
What are the increased Rsk fx for OSA
Anything that narrows the airway
Micrognathia, macro gloss is, obesity, tonsilar hypertrophy
Is worse if the use ETOH or drink/sedative prior to sleep
294
Testosterone supplementation can lead to what sleep d/o
OSA
295
A pt presents with Morning sluggishness, HA’s, cognitive impairment, recent weight gain, impotence
Think
OSA
296
What are the three S’s of OSA
Snoring, Sleepiness, and Sig other reports S./s
297
A pt with a mallampati score of IV is at an increased risk of..
OSA
298
What does a complete polysomnography include
Electroencephalography
Electro-oculography
Electromyography
ECG
Pulse oximetry
Measurement of respiratory effort and airflow
-apneic episodes
299
What determines the severity of OSA
the Apnea Hypoxia Index
300
Pts with sever OSA are at an increased risk of…
HTN
DM
CAD
Arrhythmias
301
What is the definitive last resort tx option for pts with OSA that have life threatening arrhythmias and have failed conservative tx
Tracheostomy or maxilofacial srgry
302
Should supplemental O2 be used for pts with OSA
Supplemental O2 should not be routinely used
Lessens desaturations…but lengthens apneas!
303
What is the typical onset of Asthma and what pts have the highest risk of death
Onset typically before 25 y/o
Highest RSK: 15-24 y/o blacks
304
Once IgE antibodies are activated what happens
Mast cells are trigged to release histamine and leukotrines
That cause bronchoconstriction
And increased permeability
Which leads to compounding bronchocon and inflammation
305
What are the 4 common precipiatants of asthma
Allergens, inhaled irritants, URI, and exercise
306
What is the aspirin asthma triad compared to the atopic triad
Asthma triad – Asthma, aspirin sensitivity, and nasal polyps
atopic triad;
Allergic rhinitis, asthma, eczema
307
What effect does asthma have on RV and FRC
Increases both due to air trapping
308
What is an ominous late finding on ABG in asthma pts
rising PCO2
309
A pt presents with hunched shoulders, accessory muscle use on RR, and unable to lie down, there is no wheeze on auscultation
Think
Severe asthma (ominous)
310
What are the signs of impending doom for a pt with asthma
AMS. Paradoxical Abd RR, Absent wheezing, bradycardia, and absent pulsus paradoxus
311
For asthma was is the essential tool in evaluating response to interventions
Peak Flow meter
312
What is the 4 step approach to asthma Tx
1) Assess severity vs control
2) Patient education
3) Control of environmental factors & comorbidities
4) Pharmacologic agents
313
What are the 5 goals of asthma Tx
1. Allow activities
2. Allow sleep
3. Minimize use or rescue inhalers
4. Prevent unscheduled care
5. Maintain lung function
Goals met=controlled
314
What is the severity of the following asthma pt:
Pt presents with S/s on more than 2 days of the week, but not daily
The awaken from sleep 3-4 times a month
The use there SABA more than 2 days a week but not more than 1 time a day
They have minor limitation of activities
The FEV1 is greater than 80-% predicted, and the FEV1/FVC ratio is NML
Mild Severity
Recommend Step 2 tx
315
What is the severity of the following asthma pt
Pt presents with daily s/s with night time awakening more than 1 time a week but not nightly,
They use their saba daily, and have some limitations of activity
The FEV1 is 60-80% predicted with a 5% reduced FEV1/FVC ratio
Persistent moderate severity of asthma
Recommend stand 3 or 4 tx and consider short course of oral steroid (prednisone)
316
What is the severity of the following asthma pt
Pt presents with S/s consistent throughout the day and they are not able to sleep adequately on any day of the week
They use their saba several times a day
With extremely limited activities
The FEV1 is less than 60% predicted and the FEV1/FVC ratio is reduced more than 5%
Persistent severe asthma severity
Recommend Step 5 or 6 tx with a short course of oral steroids (prednisone )
317
If a pt uses their SABA more than 2 times a week at any step in Tx, this indicates…
They need a step up in tx
318
What pts should get SMART (ICS= formoterol tx)
Asthma pts with moderate persistent or worse severity
319
What is GINA step 1
As need low dose ICS-formoterol (budensonide+ formoterol)
| With an as needed SABA
320
What is GINA step 2
Daily low dose ICS
| Or as needed low dose ICS+formoterol
321
What is GINA step 3
A low dose ICS+LABA
With as needed ICS+formoterol reliever
322
What is GINA step 4
Medium dose ICS+ LABA
With as needed ICS+formoterol for relief
323
What is GINA step 5
High Dose ICS-LABA
Plus refer for phenotypic assessment
And add on tiotropioum, anti IGE medications
With as need low dose ICS formoterol for relief
324
What is NonGina step 1
No controller needed
| SAba for relief
325
What is non Gina step 2
Low dose ICS
| Plus SABA for relief
326
What is NOn Gina step 3
Low dose ICS plus LABA or Medium dose ICS alone
327
What is non Gina step 4
Medium dose ICS plus LABA
add a LAMA if still uncontrolled
328
What is nongina step 5
High dose ICS plus LABA consider adding omalizumab for pts with allergic asthma
Add LAMA is still uncontrolled
329
What is nongina step 6
High-dose ICS plus LABA plus systemic corticosteroids and consider omalizumab for patients with allergic asthma or LAMA if still uncontrolled
330
What is a not well controlled asthma pt
S/s greater than 2 days a week
With 1-3 night time awakening
With some limitation of activity
Using their SABA more than 2 days a week
FEV1 60-80% personal best
And more than 2 exacerbations a year
Recommend step up one level in tx and reveal in 2-6 weeks
331
What is a very poorly controlled asthma pt
S/s throughout the day
With more than 4 night time awakenings
Extremely limited activity
With SABA use several times a day
FEV1 is less than 60% predicted personal best
With more than 2 exacerbations a year
Recommend: Consider short course
of oral steroids
Step-up 1 or 2 steps
Reevaluate in 2 weeks
332
A pt with a Gina assessment score of 1-2 means
Partially controlled asthma pt
333
A pt with a Gina score of 3-4 means
uncontrolled asthma pt
334
What is the pt education for ICS
Rinse mouth and inhaler out after each use to prevent thrush
335
If giving an asthma pt systemic corticosteroids. What is the approach
Always attempt to decrease dose if possible
Add Ca/Vit D, monitor DEXA
Do NOT d/c rapidly!
336
What is albuterol
SABA
337
What is proventil
SABA
338
What is ventolin
SABA
339
What is xoponex/ levalbuterol
SABA
340
What is beclomethasone
ICS
341
What is budesonide
ICS
342
What is fluticasone
ICS
343
What is mometasone
ICS
344
What is salmeterol
LABA
345
WHat is formoterol
LABA
346
What is tiotropium
LAMA
347
What is the only ROLA
ICS plus femoterol
348
What are the alternatives to ICS in mild persistent asthma
LRA.. zileuton, zafirlukast, montelukast
Alternates to ICS in mild persistent asthma—oral
Still less effective than ICS
Zileuton --LFT monitoring & not for mild persistent
349
What is omalizumab
recombinant/monoclonal antibodies
Anti-IgE antibodies
Binds IgE w/o activating mast cells
$$$, newer, injection q 2-4 weeks
350
What is the oral steroid combo for severe asthma
Severe: Prednisone/methylprednisolone 1mg/kg q 6-12 hrs x 48h
Goal: ≥ 50% of FEV1
351
A pt with a PEFR and FEV1 greater than 80 is having what severity asthma attack
None really
352
A pt with a PEFR >80% and a FEV1 >70 is having what severity asthma attack
Mild
353
A pt with a PEFR Greater than 60 with a FEV1 45-70 is having what severity asthma attack
moderate
354
A pt with a PEFR less than 50 and a FEV1 less than 50 is having what level asthma attack
Severe
355
Using more than 12 puffs of a SABA in a 72 hour period means what
They need to step up their tx
356
How can pts use a self directed quadrupling of their inhaled ICS
For an acute exacerbation, a self-directed quadrupling of an inhaled glucocorticoid can abort the exacerbation and reduce the number of severe exacerbations by about 20%.
357
Define status asthmaticus
PEFR or FEV 1 does not increase to greater than 40% of the predicted value with treatment
Pa co 2 increases without improvement of indices of airflow obstruction
Develops major complications such as pneumothorax or pneumomediastinum
358
When should a pt be admitted to the ICU for an asthma exacerbation
If after an initial bronchodilator and 3 dose of inhaled bronchodilator
The response is an FEV1 or PEFR less than 40%
With a PCO2 greater than 42
S/s drowsiness or confusion
Then admit to ICU
359
When should a pt with asthma exacerbation be admitted to a hospital ward
If after After initial bronchodilator
After 3 doses of inhaled bronchodilator
Response is a FEV1 ro PEFR of 40-69% and they have mild to moderate S/s
360
When should you refer an asthma pt
Atypical presentations
Complicated comorbid
Suboptimal response
High dose ICS
2+ systemic steroids in 12 months
Any life threatening/hospitalizations in 12 mos
Social/psychiatric issues interfering
361
What is the effect of smoking on the airways
Hypertrophy and hyper proliferation of mucus glands
Paralysis of Cilia
Smoking always leads to bronchitis in the airways
And always leads to emphysema in the parenchyma
362
What is an A1-antiryspin deficiency
A defect that leads to elastin degradation
Can be hetero and homozygous
Leads to COPD in the 3rd or 4th decade of life
363
A pt presents with a daily cough for 3 months, is cyanosis at rest, +wheezes and Ronchi,
States they get multiple lung infections a year, and is overwt
Think
Bronchitis
364
A pt presents with severe Dyspnea, is very thin, in apparent resp distress, lung sounds are very quiet, and has no peripheral edema,.
Think
Emphysema
365
What does a loud P2 sound tell you
Hepatic congestion, or Pulm HTN.. la
366
What is GOLD 2 for COPD
Post BronchO FEV1 from 50-79% predicted
Moderate
367
What is GOLD 3 for COPD
Post Broncho FEV1 of 30-49% predicted
Severe
368
What is GOLD 4
Post Broncho FEV1 of <30% predicated
Very severe
369
What is the ABG finding in Chronic Bronchitis
Resp Acidosis
370
What study would you order to do a w/u for lobectomy
CT
371
A pt with recurrent pneumonia, hemoptysis and clubbing
Think
Bronchiectasis not COPD
372
All adults with COPD or bronchiectasis should be tested for …
alpha-1 antitrypsin deficiency,
373
What does Roflumilast do
Phophodiesterase-4 inhibitors
decreases inflammation and promotes smooth muscle relaxation/bronchodilation
Used in COPD Tx
374
When should ABX be considered in a pt with COPD
Age >65
FEV1 <50% predicted
3+ exacerbations per year
Comorbidities (cardiac, DM, depression)
Increased sputum purulence or quantity + dyspnea
375
A pt presents with less than 4 exacerbations a year, and the FEV1 is greater than 50% predicted
What is the recommended ABX
Macrolides
(Azithromycin or clarithromycin)
or Doxy
Common strep infection
376
A 66 year old pt Preston’s with more than 4 exacerbations of COPD a year and the FEV1 is less than 50 but greater than 35
What is the recommended ABX tx
Augmentin
| Or
Fluoroquinolones
levo, Moxifloxacin
377
A pt is a resident in a nursing home, with 4 or more exacerbations of COPD a year, with a FEV1 below 35 % predicted
What is the recommended ABX
IV ABX
Penicillin
Or Cephalosporin
378
Describe the Outpt treatment for COPD
Exercise with Physiotherapy
If A1 deficiency is present the supplement with A1- antitrypsin
379
What is the role of Pulm rehab for COPD
Does not change lung function
Can improve quality of life
Can improve exercise performance
“… comparable to or greater than the benefit achievable with pharmacotherapy.” –Goldman-Cecil
380
What are the Surgery options for a PT with COPD
Bullectomy
-Giant bulla who have persistent symptoms despite medical tx and rehabilitation
Lung reduction surgery
—Not for those with FEV1 <20%
Lung transplant
—COPD =25% of lung transplants in USA
381
A COPD pt has 1 exacerbation in the past 12 months, with no Hospitalizations.
Presents with Few S/s
MMRC 0-1
And a CAT less than 10
What is the severity Catagory and appropriateTx
Cat A
Can use a SAMA or SABA PRN
382
A pt presents with COPD, and Has less than 1 exacerbation a year, and has never been hospitalized for his condition
However he has multiple S.s
MMRC is greater than 2
And his CAT is greater than 10
What is his severity catagory
And appropriate Tx
CAT B
1st: LAMA or LABA
383
A pt with COPD presents with a MMRC of 0-1 with a CAT less than 10, has had 2 exacerbations and 1 hospitalization
What is the severity CAT and appropriate Tx
Cat C
LAMA
384
A t presents with ≥2 exacerbations and 1 hospital related hospitalization, with a MMRC greater than 2 and a CAt above 10
What is the severity CAT and appropriate Tx
CAT D
| LAMA + LABA
may consider add on ICS
385
What is an MMRC of 0
Dyspnea only with strenuous exercise
386
What is a MMRC of 1
Dyspnea when hurrying up hills
387
What is a mMRC of 2
Dyspnea when walking, and moving slower that people at same age at a normal pace
388
What is a mMRC of 3
Dyspnea at 100 yards of walking or within a few minutes
389
What is a mMRC of 4
Dyspnea when undressing or unable to leave the house
390
When should you admit a pt with COPD
If the S/s do not respond to tx
```
They have worsening
Hypoxemia
Hyper apnea
Peripheral edema
Or there is a change in LOC
```
Also can admit if there is inadequate home care
Or inability to sleep or eat
391
What is the approach to Inpt COPD management
Maintain O2 sat above 90
Rx: Ipatropium plus SABA
Prednisone x 5 days
With Broad ABX
(Levofloxacin, Azithromycin, or augmentin)
392
What is the BODE index
BMI
OBSTRUCTION
DYSPNEA
EXERCISE
Evaluates Prognosis of COPD
```
4 year survival estimate:
0-2 points: 80%
3-4 points: 67%
5-6 points: 57%
7-10 points: 18%
```
393
A Bode Score of 0-2 means what survival rate
80%
394
A Bode score of 3-4 means what survival rate
67% over 4 years
395
A bode score of 5-6 means what 4 yr survival rate
57%
396
A bode score over 7 means what 4 yr survival rate
Less than 18%
397
A COPD pt presents with more than 2 exacerbations a year
He is taking a LABA, LAMA and an ICS
What is the approach for managment
Refer to specialist
398
What is the role of NIPPV in COPD
NIPPV can shorten the hospital stay, reduce the need for endotracheal intubation and mechanical ventilation, and reduce mortality in individuals being treated for an exacerbation of chronic obstructive pulmonary disease complicated by hypercarbic respiratory failure.
399
What is the third leading cause of hospital deaths
PE
400
What are the physiological effects of a PE
Reflex bronchoconstriction
Promotes wheezing & increased work of breathing
Massive thrombus may cause R ventricular failure
401
What are the ECG findings in a PE
Most common: sinus tach and non-specific ST and T wave changes
RVH, R axis deviation, or a RBBB
S1Q3T3 (mcGinn White Sign)
402
What is Westermark Sign and Hamptons Hump
Findings of PE on CXR
Prominence of proximal central pulmonary artery with local oligemia (Westermark sign)--uncommon
Wedge shaped, pleural based opacity that represent intraparenchymal hemorrhage (Hampton’s hump)--uncommon
Common findings are atelectasis and pleural effusions
403
What is the initial Dx study of choice for a PE
CTPA!
Always order BUN/ CrCL for kidney function as this requires contrast
404
According to uptodate, if a pt has a NML CXR and you suspect a PE
What is the test of Choice for PE in pregnancy
V/Q scan
405
What is the test of choice for a proximal DVT
Venous US
406
When should PULM angio be used to Dx a PE
Consider if other studies are inconclusive and diagnosis of PE must be established with certainty or Helical CT is not available/contraindicated
Be aware of contrast induced renal failure
407
What is the criteria to use Contrast in a pt
| Think renal
EGFR less than 30 is a C/I
Contrast Allergy=no!
CrCL greater than 1.5=no!
408
Once a PE is confirmed, what is the Tx approach
| Same for DVT
LMWH followed by oral warfarin x5-7 days to INR goal
(Lovenox SQ)
INR goal of 2-3
(alt: NOAC/DOAC)
409
What is the reversal agent for Heparin
Protamine sulfate
410
How is a DVT managed in a pregnant pt
Pregnant patients: DVT managed with LMW heparin until delivery
411
What is the reveresal agent for Factor Xa drugs
Adnexanet alfa
412
When should thrombolytics (Alteplase) be used for a PE
Pregnant patients: DVT managed with LMW heparin until delivery
413
When should an IVC filter be used for a PE
Recurrent embolism despite adequate anticoagulation
Chronic recurrent embolism with pulmonary HTN
Pts with a Major contraindication to anticoagulation who have or at high risk for developing PE/DVT
414
When should surgery removal of a PE be done …
Surgical removal of acute PE only for absolute emergency, and outcome often is death
—-Pulmonary embolectomy
Pts with unsuccessful or contraindication to thrombolytics
415
A pt with a SBP less than 90
Or a shock index greater than 1
SaO2 less than 95%
With RVSP greater than 40
+/- cardiac bio markers
What is the treatment of this PE
Are they contra to fibrinolytics
(Any Hx of recent bleeding, GERD, TIA in 6months? )
Then Alteplase if no C/I
100mg/2hrs
416
When should echo be used in evaluating a PE
Use in severely hypoxemic or hemodynamically compromised
417
What is the reverasal agent for dabigatran
Idarucizumab
418
When would you do a Bronchial provacation test for Asthma >?
Bronchial provocation testing—inhaled histamine or methacholine
Use IF asthma is suspected, but spirometry nondiagnostic
419
What is the effect of adding ICS and LABAs
Beta-adrenergic agonists/LABAs (salmeterol & formoterol)
If added to ICS, effect is equivalent to doubling ICS dose
