Pulm Crit Flashcards
1
Q
Pulm Crit
A
Treatment of aspirin-exacerbated respiratory disease consists of symptom treatment with glucocorticoids and removal of the exposure; treatment can also include a leukotriene receptor antagonist.
2
Q
Pulm Crit
A
Roflumilast, a selective phosphodiesterase-4 inhibitor, is used as add-on therapy in severe COPD associated with chronic bronchitis and a history of recurrent exacerbations to reduce risk and frequency of exacerbations.
chronic macrolide therapy is associated with a reduction in the rate of exacerbation in patients with moderate to severe COPD despite optimal maintenance inhaler therapy.
3
Q
Pulm Crit
A
Home sleep testing is the first test indicated in a patient with a high probability of obstructive sleep apnea without underlying cardiopulmonary or neuromuscular disease.
multiple sleep latency testing (MSLT) is used to provide an objective measure of sleepiness. necessary to establish the diagnoses of narcolepsy and idiopathic hypersomnia.
4
Q
Pulm Crit
A
Subsolid lung nodules 6-8 mm in size should be initially followed up at 6-12 months and then every 2 years for 5 years because of the slow rate of growth if such masses are malignant.
5
Q
Pulm Crit
A
Nonspecific interstitial pneumonia (NSIP) is a disease that predominantly affects the lower lobes of the lung. NSIP tends to affect a younger patient population and is strongly associated with connective tissue disease
Hypersensitivity pneumonitis is the result of an immunologic response to repetitive inhalation of antigens and high-level exposure and will often be associated with fevers, flulike symptoms, cough, and shortness of breath, typically during a period of 48 hours.
6
Q
Pulm Crit
A
Early mobilization with physical and occupational therapy and interruption of sedation should be used to prevent and treat delirium in critically ill patients.
7
Q
Pulm Crit
A
Noninvasive bilevel positive airway pressure ventilation does not provide a secure airway and is contraindicated in patients with altered mental status or risk of vomiting because it can increase the risk of aspiration if the patient were to vomit into the mask.
8
Q
Pulm Crit
A
Idiopathic pulmonary fibrosis typically occurs in older individuals with nonproductive cough and progressive dyspnea on exertion; the diagnosis is supported by findings of usual interstitial pneumonitis on a high-resolution CT scan of the chest.
he finding of bilateral, peripheral, and basal predominant septal line thickening with honeycomb changes on CT scan is consistent with usual interstitial pneumonia pathologic p
Hypersensitivity pneumonitis, is associated with an environmental exposure, which was not elicited in this patient.
9
Q
Pulm Crit
A
The most appropriate method to evaluate volume status remains the physical examination; several technologies can help confirm the assessment.
10
Q
Pulm Crit
A
Typical imaging findings in patients with small cell lung cancer (SCLC) include a large mediastinal mass; hyponatremia due to ectopic production of antidiuretic hormone is most often due to SCLC and is rarely seen with other lung tumors.
Typical imaging findings in patients with small cell lung cancer (SCLC) include a large mediastinal mass; hyponatremia due to ectopic production of antidiuretic hormone is most often due to SCLC and is rarely seen with other lung tumors.
11
Q
Pulm Crit
A
Early intubation is indicated for patients with obesity hypoventilation syndrome and hypercapnic respiratory failure who do not improve with noninvasive positive pressure ventilation.
12
Q
Pulm crit
A
Measurement of α1-antitrypsin level is indicated for patients experiencing symptoms of COPD and who are younger than 45 years of age or have a strong family history of COPD.
13
Q
Pulm crit
A
In patients with moderate to severe uncontrolled asthma with the eosinophilic phenotype, treatment with mepolizumab can reduce emergency department visits, hospitalizations, and requirements for inhaled and oral glucocorticoids.
14
Q
pulm crit
A
Cited indications for hyperbaric oxygen therapy include loss of consciousness, ischemic cardiac changes, neurological deficits, significant metabolic acidosis, or carboxyhemoglobin level greater than 25%.
Treat carbon monoxide poisoning with levels of carboxyhemoglobin over 25%, with oxygen.
Cited indications for hyperbaric oxygen therapy include loss of consciousness, ischemic cardiac changes, neurological deficits, significant metabolic acidosis, or carboxyhemoglobin level greater than 25%.
15
Q
pulm crit
A
Transthoracic echocardiography can estimate pulmonary artery pressures and is the preferred initial test if pulmonary hypertension is suspected.
Findings include 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 the right ventricle dilates.
16
Q
pulm crit
A
Weight loss in patients with obesity-related asthma improves asthma control, lung function, and quality of life; reduces asthma medication use; and should be considered an essential part of the treatment plan.
17
Q
pulm crit
A
Both Mepolizumab and omalizumab have been shown to reduce asthma exacerbations in patients with difficult-to-control asthma BUT the patient has to have elevated blood eosinophil counts.
18
Q
pulm crit
A
Initial treatment of central sleep apnea should target modifiable risk factors; medical optimization of heart failure has been shown to improve central sleep apnea and Cheyne-Stokes breathing and should precede other therapies for sleep apnea.
19
Q
pulm crit
A
Patients with a history of asthma-COPD overlap syndrome should not be prescribed a long-acting β2-agonist without concurrent therapy with an inhaled glucocorticoid because of the increased risk of mortality in patients with asthma who are prescribed long-acting β2-agonist monotherapy.
20
Q
Pulm crit
A
Lung volume reduction surgery improves quality of life and survival for patients with upper-lobe predominant emphysema and significant exercise limitations.
21
Q
Pulm crit
A
A postbronchodilator FEV1/FVC of less than 0.70 is diagnostic of airflow obstruction and is consistent with the diagnosis of COPD.
22
Q
Pulm crit
A
For individuals with idiopathic pulmonary fibrosis who develop severe respiratory distress that has no underlying reversible cause, supportive mechanical ventilation is of little long-term benefit; in these circumstances, the focus should be on palliation of the patient’s underlying dyspnea.
23
Q
Pulm crit
A
Patients with diffuse cutaneous systemic sclerosis are at high risk for the development of diffuse parenchymal lung disease, which is the leading cause of death in these patients.
Cardiopulmonary exercise testing is routinely performed to assess prognosis in patients being evaluated for transplantation
Patients with a pulmonary nodule or other findings suggestive of malignancy may require PET/CT
24
Q
Pulm crit
A
Cough-variant asthma refers to asthma in which the predominant manifestation is cough, and without other typical asthma symptoms; the diagnosis is supported by abnormal spirometry or methacholine challenge testing if spirometry is normal.
25
Pulm crit
Patients with a solid indeterminate lung nodule larger than 8 mm and high probability of malignancy should be staged using a PET/CT scan followed by definitive management.
The first step when evaluating a solid pulmonary nodule that is larger than 8 mm is to estimate the probability of malignancy.
If the lesion is larger than 30 mm, the likelihood of malignancy is so high that it typically is resected; in contrast, when the lesion is smaller than 8 mm, the likelihood of malignancy is low and the patient should undergo routine radiological surveillance with serial CT scans.
26
.Pulm crit
Biopsy of the nodule or a transthoracic approach is preferred when the probability of malignancy is intermediate
Furthermore, the sampling procedure is chosen according to size and location of the nodule, availability, and local expertise. Typically, peripheral nodules are sampled using CT-guided transthoracic needle aspiration, and more central lesions are sampled using bronchoscopic techniques.
27
pulm crit
Parietal plaques are the most common radiologic finding in patients with asbestos exposure and are the features that differentiate asbestosis from other interstitial lung diseases.
Although this patient has some CT scan findings consistent with idiopathic pulmonary fibrosis, that diagnosis can only be made in a patient who does not have another plausible cause for fibrosis.
28
pulm crit
Intravenous magnesium sulfate reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulized short-acting β2-agonists, and intravenous glucocorticoids.
29
Pulm Crit
Glucocorticoids are indicated in patients with sepsis who have not achieved hemodynamic stability from intravenous fluid administration and vasopressor therapies.
30
Pulm Crit
Ratio of fev1/fvc less than 70 is obstructive.
recommends an inhaled short-acting bronchodilator (anticholinergic or β2-agonist) for patients with an FEV1 between 60% and 80% of predicted.
31
Pulm Crit
Assisted breathing devices, such as bilevel positive airway pressure, can be prescribed to support gas exchange in patients with neuromuscular disorders and may prolong survival in amyotrophic lateral sclerosis.
32
Pulm Crit
Patients with a primary spontaneous pneumothorax should be encouraged to stop smoking to prevent recurrence.
33
Pulm Crit
Conditions suggesting the diagnosis of cystic fibrosis in adults include chronic asthma-like symptoms, chronic sinusitis, nasal polyposis, recurrent pancreatitis, infertility, and bronchiectasis.
34
Pulm Crit
Patients with pulmonary hypertension secondary to lung disease and associated hypoxemia should be treated with supplemental oxygen.
35
Pulm Crit
Before administering advance therapy for patients with pulmonary arterial hypertension (PAH), particularly idiopathic PAH, vasoreactivity testing directs agent selection by identifying those who may respond to calcium channel blockers.
CCBs such as diltiazem may be used in the setting of PAH when a response to a vasodilator such as nitric oxide is demonstrated during right heart catheterization. When a response is not found, CCBs are not indicated.
36
Pulm Crit
Flumazenil, a γ-aminobutyric acid (GABA)–receptor antagonist, is the antidote for benzodiazepine toxicity, but reversing the benzodiazepine he took could put him at risk for seizures, especially if he is a chronic user.
Fomepizole inhibits alcohol dehydrogenase. It is used to block the metabolism of ethylene glycol and methanol into toxic metabolites when either of these alcohols is ingested.
37
Pulm Crit
Removal of the offending antigen is the most appropriate treatment of acute hypersensitivity pneumonitis.
38
Pulm crit
In patients with severe COPD and frequent exacerbations, chronic macrolide therapy has been shown to decrease COPD exacerbations.
39
Pulm crit
Pulmonary arterial hypertension is commonly associated with connective tissue diseases, such as limited cutaneous systemic sclerosis.
40
Pulm crit
Recurrence prevention with pleurodesis is recommended after the first occurrence of secondary spontaneous pneumothorax.
For patients who are surgical candidates, video-assisted thoracoscopic surgery (VATS) is recommended to locate and staple or resect blebs followed by mechanical pleurodesis.
Clamping or removing the thoracostomy tube is not appropriate when the patient has a secondary spontaneous pneumothorax and the likelihood of recurrence is high.
41
Pulm crit
Patients with COPD who have had two or more acute exacerbations within the last year, who have an FEV1 of less than 50% of predicted, or who have ever been hospitalized for an acute exacerbation are considered to be at high risk for recurrent acute exacerbations.
42
Pulm crit
The patient has chronic respiratory acidosis with a normal alveolar-arterial (A-a) oxygen gradient. BPAP delivers both inspiratory positive airway pressure and expiratory positive airway pressure and improves survival and quality of life of patients with neuromuscular disease. The settings generate a pressure difference that augments the patient's own respiratory muscle activity, leading to an increase in the size of each breath. The PCO2 level will decrease due to the increase in minute ventilation and efficiency of breathing.
43
Pulm crit
Hydroxocobalamin effectively removes cyanide from the mitochondrial respiration system and is the preferred antidote for cyanide poisoning.
44
pulm crit
Negative sweat chloride testing does not exclude the diagnosis of cystic fibrosis in patients with high pretest probability of disease.
45
pulm crit
Patients recommended for lung cancer screening are those aged 50 to 80 years with a greater than 20-pack-year history of tobacco use within the previous 15 years.
46
pulm crit
Daily protocolized interruptions of sedation and analgesia have been shown to decrease the incidence of delirium, the need for diagnostic testing, and the amount of time spent on mechanical ventilation and in the ICU.
47
pulm crit
Patients with nonexertional heat stroke should be treated with evaporative cooling to lower their core temperature to a safe level.
This patient should be sprayed with water, and fans should be used to lower his body temperature to a safe level (usually 38.5 °C (101 °F) through evaporative cooling.
48
pulm crit
A critical first step entails removing wet clothing and covering the patient with insulating material, especially the head and neck. For mildly hypothermic, healthy individuals capable of shivering, this strategy of passive external rewarming alone suffices. Active external rewarming using warm blankets or a forced heated air blanket is commonly used in hemodynamically stable patients with moderate hypothermia. Body cavity lavage with warm fluids is an option for patients with hypothermia that is severe or does not respond to external rewarming.
49
pulm crit
Although the most important treatment of high-altitude cerebral edema is descent to lower elevation, dexamethasone should be administered immediately upon recognition of high-altitude cerebral edema.
Acute mountain sickness is characterized by nonspecific symptoms such as headache, fatigue, nausea, and vomiting, in addition to disturbed sleep. High-altitude cerebral edema is a more extreme manifestation of acute mountain sickness
Acetazolamide accelerates the acclimatization process to high altitude by inducing a slight metabolic acidosis to stimulate ventilation and enhance gas exchange; it can be used prophylactically in patients with a history of altitude illness.
50
pulm crit
This patient should be managed with observation and clinical follow-up. She is incidentally discovered to have bilateral hilar lymphadenopathy likely representing pulmonary sarcoidosis.
Treatment of pulmonary sarcoidosis should be based on symptoms rather than radiographic findings.
51
pulm crit
The use of low tidal volume ventilation and positive end-expiratory pressure is associated with prevention of ventilator-associated lung injury and a reduction in mortality related to acute respiratory distress syndrome.
52
pulm crit
The initial step in the evaluation of the patient with excessive daytime sleepiness is to ensure adequate quantities of sleep on a regular basis using either actigraphy or a sleep diary.
53
pulm crit
An empyema is defined as a bacterial infection of the pleural space that results in frank pus on visual inspection of the pleural fluid or a positive Gram stain.
parapneumonic effusions associated with a pH less than 7.2 or pleural fluid glucose level less than 60 mg/dL (3.3 mmol/L) require thoracostomy drainage in addition to antibiotics.
An uncomplicated parapneumonic effusion is characterized by a pH greater than 7.2 and glucose greater than 60 mg/dL (3.3 mmol/L). These effusions do not require drainage and typically resolve with antibiotic therapy alone.
Pleural fluid acidosis (pH less than 7.3) is seen in complicated parapneumonic effusions, tuberculous pleuritis, rheumatoid and lupus pleuritis, esophageal rupture, and malignancy.
54
pulm crit
Annual influenza vaccination and the pneumococcal polysaccharide vaccine are recommended for all patients with chronic lung disease (COPD, emphysema, asthma).
PPSV23 has the same indications as the PCV13 vaccine, plus it is indicated in immunocompetent people with certain chronic medical conditions such as heart, liver, and lung disease (COPD, emphysema, asthma) and diabetes, as well as in cigarette smokers.
55
pulm crit
Surgical intervention is the only definitive therapy for chronic thromboembolic pulmonary hypertension (CTEPH), and most patients with CTEPH should be referred for evaluation at a specialty surgical center.
56
pulm crit
Patients should be assessed daily for their readiness to be removed from mechanical ventilation by performing a spontaneous breathing trial; one criterion for success is the ability to tolerate a spontaneous breathing trial for 30 minutes.
57
pulm crit
Patients should be assessed daily for their readiness to be removed from mechanical ventilation by performing a spontaneous breathing trial; one criterion for success is the ability to tolerate a spontaneous breathing trial for 30 minutes.
57
pulm crit
Patients should be assessed daily for their readiness to be removed from mechanical ventilation by performing a spontaneous breathing trial; one criterion for success is the ability to tolerate a spontaneous breathing trial for 30 minutes.
58
pulm crit
A “cuff leak” refers to measurable airflow around the endotracheal tube after the cuff of the endotracheal tube is deflated. Absent or minimal cuff leak following deflation of the cuff indicates reduced space between the endotracheal tube and the larynx. Minimal or absent cuff leak may be due to laryngeal edema, laryngeal stenosis, and thick secretions.
59
pulm crit
Instillation of intrapleural tissue plasminogen activator-deoxyribonuclease has been shown to decrease the radiographic pleural opacity, lower the rate of surgical referral, and decrease hospital stay of patients with empyema.
60
pulm crit
The diagnosis of asthma requires demonstrating reversible airflow obstruction; for a patient with symptoms of asthma and normal spirometry, methacholine challenge testing to evaluate for bronchial hyperresponsiveness is indicated.
61
pulm crit
Patients with severe acute respiratory distress syndrome have a demonstrated mortality benefit from low tidal volume ventilation in the prone position.
In chronic bronchitis, the walls of the airways are thickened without dilation of the airways themselves.
Pulmonary Langerhans cell histiocytosis is a rare s
62
pulm crit
Patients who work in industries that expose them to silica dust are at risk for silicosis.cute silicosis, a rare presentation characterized by onset of cough and dyspnea (but no fever) just a few weeks after intense exposure, patchy bilateral opacities on chest radiograph, and a milky effluent from bronchoalveolar lavage (BAL).
63
pulm crit
Initial evaluation for ICU-acquired weakness can be done at the bedside using the Medical Research Council muscle scale.
ICU-acquired weakness is the presence of profound muscles weakness in the setting of a current or recent critical illness. The MRC scale is most appropriately used in awake and cooperative patients.
64
pulm crit
A typical presentation of cryptogenic organizing pneumonia includes cough, fever, and malaise for 6 to 8 weeks that does not respond to antibiotics; patchy opacities on chest radiograph; and ground-glass opacities on CT scan that are peripherally distributed; glucocorticoids are first-line therapy.
Idiopathic pulmonary fibrosis (IPF) is a disease that affects older patients (the mean age of presentation is in the mid- to late 60s) and presents with chronic (longer than 6 months) symptoms of dry cough and shortness of breath.
65
pulm crit
In patients with pulmonary embolism and hemodynamic collapse, treatment with thrombolytics is associated with decreased mortality and improvement in clinical and echocardiographic parameters.
If a patient has a large pulmonary embolism they can become hypotensive from acute right ventricular (RV) failure.
66
pulm crit
Parenteral nutrition should be started as soon as possible for severely malnourished patients or those at high risk of malnutrition for whom enteral nutrition is not possible.
Initiation of enteral nutrition is recommended at 24 to 48 hours following admission if the patient is hemodynamically stable, with advancement to goal by 48 to 72 hours.
67
pulm crit
Respiratory bronchiolitis–associated interstitial lung disease is found in active smokers who have chest CT scan findings of centrilobular micronodules.
RB-ILD is used to describe disease in active smokers who have imaging findings of centrilobular micronodules with a pathologic finding of respiratory bronchiolitis and tan-pigmented macrophages (smokers' macrophages) on biopsy
68
pulm crit
Treatment of asthma during pregnancy is similar to treatment in nonpregnant patients.
Inhaled glucocorticoids are considered safe in pregnancy, and abundant long-term safety evidence exists for budesonide. With the exception of zileuton, most leukotriene modifiers are also considered safe in pregnancy. The treatment of asthma in pregnancy is very similar to treatment in nonpregnant patients.
For patients with persistent symptoms and/or exacerbations despite use of a low-dose glucocorticoid and an as-needed SABA, the preferred step-up therapy is a combination low-dose inhaled glucocorticoid and long-acting β2 agonist such as fluticasone-salmeterol.
69
pulm crit
High-resolution chest CT scan is the preferred advanced imaging modality for suspected diffuse parenchymal lung disease; it can help narrow the differential diagnosis based on the character and distribution of the lung parenchymal abnormalities.
70
pulm crit
For patients with negative cytology in whom malignancy is suspected, thoracoscopy with pleural biopsy allows for direct visualization of the pleural surface and has a diagnostic sensitivity for malignant disease of greater than 90%.
71
Pulm crit
High-resolution CT scan of the chest is standard care for evaluating parenchymal opacities seen on a plain radiograph.
72
pulm crit
Obesity is the strongest risk factor for snoring and obstructive sleep apnea, and in patients with obesity who are otherwise healthy and without other sleep-related symptoms, weight loss is a reasonable first step that often relieves snoring and improves mild obstructive sleep apnea.
73
pulm crit
For patients with a malignant pleural effusion and rapid reaccumulation of fluid, indwelling pleural catheters provide significant symptom relief, and 50% to 70% of patients achieve spontaneous pleurodesis after 2 to 6 weeks.
Repeat therapeutic thoracentesis is appropriate for patients with poor prognosis (less than 3 months) and slow reaccumulation of fluid
74
pulm crit
Classic features of serotonin syndrome include hyperthermia, tremor, hyperreflexia and clonus; treatment is mainly supportive, using benzodiazepines as needed to keep the patient calm and to control blood pressure and heart rate. serotonin syndrome typically develops within hours
Malignant hyperthermia usually occurs with a history of inhaled anesthesia agents or neuromuscular blockade. Clinical features of malignant hyperthermia usually include higher fever, muscle rigidity, and, occasionally, hemorrhage but not hyperreflexia or clonus.
Neuroleptic malignant syndrome happens with neuroleptic medications, such as haloperidol. It usually develops subacutely during days or weeks, Rigidity with hyporeflexia is more common, rather than hyperreflexia and myoclonus in serotonin syndrome.
75
pulm crit
Endobronchial ultrasound-guided transbronchial needle aspiration is the procedure of choice for diagnosing and staging mediastinal and hilar lymphadenopathy in patients with suspected thoracic malignancy.
Most patients undergo chest CT scan as the first imaging modality, either after an abnormal chest radiograph or in evaluation of a symptom. The findings on the chest CT scan determine whether a PET/CT scan is necessary. A PET/CT scan can help in staging and therefore also help guide where to biopsy. For example, if a patient has a solitary pulmonary nodule, a PET/CT scan may help determine if any lymph node involvement is present that was not visible on the chest CT scan.
The next step is to obtain tissue diagnosis. The choice of initial diagnostic testing should be aimed first at identifying potential lymph node involvement or metastatic disease. Tissue diagnosis should then be targeted at the lesion that would result in the highest potential staging.
76
pulm crit
An apnea-hypopnea index (AHI) of 5 to 15 is indicative of mild obstructive sleep apnea (OSA). This patient has mild OSA based upon an AHI of 6. OSA is typically encountered on sleep testing in those with obesity hypoventilation syndrome, with upper airway collapse superimposed on obesity-related hypoventilation. Severe OSA is defined as an AHI of at least 30; OSA severity is not defined by degree or duration of hypoxemia
Obesity hypoventilation syndrome is characterized by daytime hypercapnia, defined as an arterial PCO2 greater than 45 mm Hg that is thought to be a consequence of diminished ventilatory drive and capacity related to extreme obesity.
77
pulm crit
If previous data on bronchiectasis exacerbations are not available, a fluoroquinolone should be started to ensure Pseudomonas coverage until the sputum culture is completed.
78
Which clinical syndrome is associated with organic antigen exposure (e.g.,agricultural dusts, thermophilic fungi, bacteria), fever, cough, and fatigue develop 12 hours later?
Hypersensitivity pneumonitis
79
What major physical exam finding is associated with Hypersensitivity pneumonitis?
Physical examination reveals inspiratory crackles.
80
What is see on CXR and CT in patients with Hypersensitivity pneumonitis?
Chest x-ray may be normal or show diffuse micronodular disease. HRCT shows diffuse
centrilobular micronodules and ground-glass opacities.
81
What is first-line therapy for anaphylaxis?
IM or IV epinephrine is first-line therapy even if the only presenting signs are hives or
pruritus. Repeated doses are often necessary. Adjuvantly use inhaled bronchodilators
for bronchospasm and IV saline for shock or hypotension.
82
What cause of anaphylaxis should be considered in a case of anaphylaxis during surgery or
in a woman during sex?
Consider latex allergy as the cause of anaphylaxis during surgery or anaphylaxis
in a woman during coitus.
83
When should Patients with anaphylaxis undergo venom skin testing and immunotherapy?
Patients with diffuse rash or anaphylaxis from hymenoptera sting (bee, yellow jacket,
and wasp) should undergo venom skin testing and immunotherapy.
84
what is the main difference between Bradykinin-mediated angioedema and Mast cell–mediated angioedema?
Bradykinin-mediated angioedema is NOT associated with urticaria. Mast cell–mediated angioedema is often associated with urticaria, bronchospasm, or
hypotension.
85
How is Bradykinin-mediated angioedema diagnosed?
Diagnose by testing for
quantitative and functional levels of C1 esterase inhibitor and C4 complement levels.
86
How are acute episodes of hereditary angioedema treated?
For hereditary angioedema, treatment of
severe acute episodes of swelling with C1 inhibitor concentrate.
87
What are the 4 cardinal features of asthma?
The cardinal features of asthma are reversible airway
obstruction, inflammation, and airway hyperreactivity.
88
When are PFTs required in the workup of patients with asthma?
In patients with atypical features of asthma, perform PFTs.
89
When is Bronchial challenge testing is indicated for patients with suspected asthma?
Bronchial challenge testing is indicated for patients with a suggestive clinical history for
asthma but normal spirometry.
90
In patients who have dyspnea following exercise but normal spirometry., what test can be used to dx asthma?
Bronchial challenge testing with exercise is indicated to
diagnose exercise-induced asthma in patients who have dyspnea following exercise but
normal spirometry.i
91
What is the clinical significance of a normal bronchoprovocation test?
A normal bronchoprovocation test rules out asthma;
92
Which clinical syndrome is associated with Upper airway and sinus disease that precedes difficult-to-treat asthma and also has flares associated with
use of leukotriene inhibitors and glucocorticoid tapers?
Eosinophilic granulomatosis
with polyangiitis
93
which elevated lab is well known in Eosinophilic granulomatosis with polyangiitis?
Serum p-ANCA may be elevated
94
which clinical syndrome is associated with asthma with eosinophilia, markedly high serum IgE levels, and intermittent pulmonary
infiltrates?
Allergic bronchopulmonary
aspergillosis
95
which clinical syndrome is associated with Chest x-ray shows “photographic-negative” pulmonary edema (peripheral pulmonary edema), striking peripheral blood eosinophilia, fever, and weight loss in a long-term
smoker?
Chronic eosinophilic
pneumonia
96
How is Allergic bronchopulmonary
aspergillosis diagnosed?
Diagnose with positive skin test for Aspergillus and IgG and IgE antibodies to Aspergillus,
characteristic radiographic opacities in the upper lobes
97
How is Chronic eosinophilic
pneumonia diagnosed?
Diagnose by bronchoscopy with biopsy or bronchoalveolar lavage showing a high eosinophil count
98
What is the Hallmark diagnostic finding of Eosinophilic granulomatosis
with polyangiitis?
Hallmark diagnostic finding is eosinophilic tissue infiltrates
99
Which clinical syndrome is associated with Seasonal exacerbations; hay fever and allergen sensitization?
Allergic asthma
100
Which clinical syndrome is associated with Cough without other symptoms. Normal baseline spirometry, (+) bronchoprovocation testing.?
Cough-variant
asthma
101
Which clinical syndrome is associated with Airway obstruction only with exercise or can trigger symptoms in patients with asthma (common)?
Exercise-induced
bronchoconstriction
102
Which clinical syndrome is associated with upper airway obstruction.
Throat tightness, voice dysfunction.?
Vocal cord dysfunction, Paradoxical adduction of the vocal cords during inspiration, causing functional upper airway obstruction.
103
Which clinical syndrome is associated with Follows single high-level exposure to fumes, gases, vapors; persistent asthma ≥3 mo; (+) spirometry or
bronchoprovocation testing?
Reactive airways
dysfunction
syndrome
104
Which clinical syndrome is associated with Asthma and rhinosinusitis precipitated by aspirin or NSAIDs. Adult onset, airway and blood eosinophilia, sinusitis + nasal polyps ?
Aspirin-exacerbated
respiratory disease
105
All patients with asthma require what tx at a minimum?
All patients require a rescue medication (usually a SABA).
106
What tx do All patients with PERSISTENT asthma require?
All patients with persistent asthma require a controller medication (inhaled glucocorticoid–formoterol or inhaled glucocorticoid plus LABA like salmeterol, formoterol.
107
what is the tx for severe asthma associated with type 2 inflammation (↑ IgE or ↑ sputum/blood
eosinophils often associated with atopy?
Treat severe asthma associated with type 2 inflammation (↑ IgE or ↑ sputum/blood
eosinophils often associated with atopy).
Elevated IgE: Omalizumab is a monoclonal antibody directed at IgE for patients with
moderate to severe persistent asthma with the following characteristics:
108
which sx of asthma warrant treatment with Omalizumab?
* inadequate control of symptoms with inhaled glucocorticoids
* evidence of allergies to perennial aeroallergen
* elevated IgE levels
109
what is the tx for resistant asthma with Elevated eosinophils?
Elevated eosinophils: Anti–interleukin-monoclonal antibodies (mepolizumab,
reslizumab, benralizumab, dupilumab). Treatment is reserved for patients with an
absolute eosinophil count >150 cells/μL and severe asthma not controlled with
standard therapy.
110
for asthma patients taking chronic glucocorticoid
treatment what early screening is recommended?
calcium and vitamin D supplements for patients taking chronic glucocorticoid
treatment; early screening for osteoporosis with DEXA
111
In the tx of asthma, when you administer theophylline what other drugs have to be avoided?.
Do not administer theophylline with fluoroquinolones or macrolides (may result
in theophylline toxicity).
112
which asthma meds can not be used as single agents due to increased mortality rate?
Do not use LABAs as single agents in asthma (increased mortality rate).
113
which IV med can be used for patients who have life-threatening asthma exacerbations?
IV magnesium sulfate for patients who have life-threatening exacerbations may
be helpful
114
what is the clinical significance of A normal arterial PCO2 in a patient with severe symptomatic asthma ?
A normal arterial PCO2 in a patient with severe symptomatic asthma indicates
impending respiratory failure.
115
In patients with “asthma” that improves
immediately with intubation, what clinical syndrome should be considered?
Consider vocal cord dysfunction for patients with “asthma” that improves
immediately with intubation.
116
Which clinical syndrome is associated with unexplained flulike symptoms, frontal headache,
lightheadedness, difficulty concentrating, confusion, delirium, coma, dyspnea, nausea,
and chest pain that are often associated with use of a grill or burning heat source
indoors.
Carbon Monoxide Poisoning
117
how do you dx Carbon Monoxide Poisoning?
Order ABG studies and serum carboxyhemoglobin measurement for all patients with neurologic changes, dyspnea, chest pain, or smoke exposure.
118
In evaluating carbon monoxide poisoning, does pulse oximetry help in any way?
Pulse oximetry data are unreliable because the oximeter is unable to differentiate
carboxyhemoglobin from oxyhemoglobin.
119
Which clinical syndrome is associated with Obstructive pulmonary disease , recurrent respiratory infections and infertility ?
Cystic fibrosis
120
Which clinical syndrome is associated with lung dz in current or former smokers; may be idiopathic or associated with other diseases such as RA?
Adult
bronchiolitis
121
Which clinical syndrome is associated with Large-volume sputum production with purulent exacerbations; hemoptysis
Chest x-ray showing “tram lines”; diagnose with HRCT, which will show airway diameter greater than that of its
accompanying vessel and lack of distal airway tapering ?
Bronchiectasis
122
What is the treatment of choice for carbon monoxide poisoning?
Normobaric oxygen therapy is the treatment of choice.
123
What is the treatment of choice for carbon monoxide poisoning vs severe carbon monoxide poisoning?
Hyperbaric oxygen therapy is
indicated for patients with severe carbon monoxide poisoning (characterized by loss of
consciousness and persistent neurologic deficits), patients who are pregnant, or
patients with evidence of cardiac ischemia.
124
What FEV1/FVC ratio level is associated with COPD?
Diagnose COPD when postbronchodilator spirometry shows an FEV1/FVC ratio <0.7 (or
below LLN) associated with symptoms of chronic bronchitis, emphysema, or both.
125
What lab value should be Measured in all patients with COPD?
Measure Alpha-1 antitrypsin (AAT) level in all patients with COPD.
126
what is the MAIN recommendation that is essential in the management of all patients with COPD to reduce the rate of decline in lung function?
Smoking cessation is essential in the management of all patients with COPD to reduce
the rate of decline in lung function.
127
When is pulmonary rehabilitation recommended for patients with COPD?
For symptomatic patients with an FEV1 <50% of predicted, pulmonary
rehabilitation is recommended.
128
What is the recommended tx for patients with COPD and FEV1 <60% of predicted?
For symptomatic patients with COPD and FEV1 <60% of predicted, monotherapy
using long-acting anticholinergic agents (LAMAs or LABAs) is recommended.
129
When is continuous oxygen therapy is recommended For patients with COPD ?
For patients with COPD who have severe resting hypoxemia (arterial PO2 <55 mm
Hg or O2 saturation <88%), continuous oxygen therapy is recommended.
130
Aside from (arterial PO2 <55 mm
Hg or O2 saturation <88%), for patients with COPD what is the other indication for which long-term oxygen therapy?
An additional indication for which long-term oxygen therapy should be considered is an arterial blood PO2 ≤59 mm Hg with signs of tissue hypoxia (polycythemia, PH, right-
sided HF)
131
For patients with severe COPD (bronchitis
variant), what 2 therapy can be added to prevent recurrent exacerbations?
PDE-4 inhibitor (roflumilast) as add-on therapy for severe COPD (bronchitis variant) to prevent recurrent exacerbations
long-term macrolide therapy (bronchitis variant) to prevent recurrent
exacerbations
132
In COPD patients, what therapy can help improve oxygenation, sleep, and decrease daytime somnolence in patients with chronic hypercapnia?
nocturnal noninvasive mechanical ventilation to improve oxygenation, improve
sleep, and decrease daytime somnolence in patients with chronic hypercapnia
133
For severe COPD with
unremitting dyspnea at end of life, what rx is recommended?
palliative use of oral or parenteral opioids in patients with severe COPD and
unremitting dyspnea at end of life
134
Which COPD patients should be considered for lung volume reduction surgery?
consideration of lung volume reduction surgery for patients with upper lobe
emphysema (heterogeneous disease) and low baseline exercise capacity to
improve mortality, exercise capacity, and quality of life
135
For patients with severe Alpha-1 antitrypsin
deficiency, AAT activity level <11 μm, and FEV1 <65%, what is the tx?
augmentation therapy with IV human AAT for patients with severe AAT
deficiency, AAT activity level <11 μm, and FEV1 <65%
136
in what situations can you not use noninvasive ventilation for acute hypercapnic respiratory failure with acidosis?
noninvasive ventilation for acute hypercapnic respiratory failure with acidosis
(unless patient is obtunded, vomiting, or has excessive secretions)
137
Which clinical syndrome is associated with ?
138
Which clinical syndrome is associated with Chronic airway inflammation and bacterial infection, recurrent or persistent respiratory infections with Pseudomonas aeruginosa,
Staphylococcus aureus, Haemophilus influenzae, or Burkholderia cepacia; bronchiectasis;
or hyperinflation. ?
Cystic Fibrosis
139
How is Cystic Fibrosis dx ?
The diagnosis is confirmed by a sweat chloride test followed by genetic testing.
140
Which clinical syndrome is associated with cough and chronic progressive dyspnea after infection and HF have been excluded?
Diffuse Parenchymal Lung Disease
141
How is Cystic Fibrosis treated?
antipseudomonal antibiotics for acute pulmonary exacerbations, aerosolized tobramycin for suppression of chronic pulmonary infections
142
which lung exam findings are seen in Diffuse Parenchymal Lung Disease?
Lung examination findings can range from normal to inspiratory Velcro-like crackles, or
inspiratory squawks suggestive of fibrosis.
143
In a patient with Diffuse Parenchymal Lung Disease what should be seen on CXR?
Look for interstitial reticular or nodular infiltrates on chest x-ray;
144
In a patient with Diffuse Parenchymal Lung Disease and a history of automobile mechanics,
ship builders, what dx should be considered?
asbestos exposure
145
In a patient with Diffuse Parenchymal Lung Disease and a history of active smoking history, what dx should be considered?
(suggests respiratory bronchiolitis–associated interstitial
lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell
histocytosis, smoking-related interstitial fibrosis)
146
What is a KEY hallmark of Diffuse Parenchymal Lung Disease?
Desaturation >4% with ambulation is consistent with a diffusion limitation, a hallmark
of DPLD.
147
What findings are seen on PFTs for DPLD?
Look for restrictive or combined restrictive/obstructive findings on PFTs and low DLCO measurement.
148
If clinical suspicion for DPLD is high, chest x-ray is normal, what should be done next?
Obtain chest HRCT, even if chest x-ray is normal, if clinical suspicion is high.
149
Which clinical syndrome is associated with the presence of DPLD and mediastinal and/or hilar lymphadenopathy?
(sarcoidosis)
150
Which clinical syndrome is associated with DPLD and pleural plaques?
asbestosis
151
what is the tx for DPLD?
When possible, treatment is directed toward the underlying cause (connective tissue
disease), limiting exposure (drug discontinuation), and smoking cessation. The evidence
for glucocorticoid efficacy is weak.
152
What are the 3 most common causes of hemoptysis?
Bronchitis, bronchogenic carcinoma, and bronchiectasis are the most common causes
of hemoptysis.
153
in a pat with hemoptysis, what is important to rule out first?
Confirm that a patient has hemoptysis rather than epistaxis or GI bleeding; then check the platelet count and coagulation parameters.
154
What is the initial study/test, for hemoptysis?
Chest x-ray, a Crucial initial study, but normal findings do not exclude lung cancer
155
In a pt with hemoptysis, high suspicion of cancer and a normal cxr, what is the next in evaluation?
Fiberoptic bronchoscopy, For patients at high risk for lung cancer even if chest x-ray is normal
156
In a pt with hemoptysis, when fiberoptic bronchoscopy is contraindicated or when bleeding persists despite normal bronchoscopic findings, what is the next step in evaluation?
Chest CT
157
What is the cause of death from massive hemoptysis ?
The cause of death from massive hemoptysis is asphyxiation
from airway obstruction.
158
In a pt with hemoptysis, what position should you put them in bed?
If the bleeding site can be localized to one lung, position the
patient with the bleeding lung in the dependent position.
159
COPD and asthma
* neuromuscular disease (MG, ALS, MS)
* restrictive lung diseases (chest wall skeletal disorders, obesity)
* depressed respiratory drive (opioids and sedatives)Chronic hypercapnic respiratory failure occurs most
often in patients with:
160
what 4 conditions are associated with Chronic hypercapnic respiratory failure?
COPD and asthma
* neuromuscular disease (MG, ALS, MS)
* restrictive lung diseases (chest wall skeletal disorders, obesity)
* depressed respiratory drive (opioids and sedatives)
161
In patients with neuromuscular disease, what is shown on PFTs, and diffusing capacity?
In patients with neuromuscular disease, PFTs show restriction on spirometry and lung
volume measurement but normal diffusing capacity. neuromusc wouldnt show any issues with diffusion
162
what level FVC is Suggestive of Neuromuscular Weakness?
>20% decrement in FVC while supine compared with upright position
163
what level Maximal inspiratory pressure (MIP) is Suggestive of Neuromuscular Weakness?
Less than −60 cm H2O or 50% of predicted
164
what level Maximal expiratory pressure (MEP) is Suggestive of Neuromuscular Weakness?
Less than +60 cm H2O or 50% of predicted
165
What test should be ordered if nocturnal hypoventilation is suspected? (daytime sleepiness,
nocturnal awakenings, morning headaches).
Order
polysomnography if nocturnal hypoventilation is suspected (daytime
166
Which clinical syndrome is associated with loss of consciousness, muscle rigidity, seizures, and rhabdomyolysis with kidney failure, DIC, and ARDS?
Severe hyperthermia
167
Which clinical syndrome is associated with loss of consciousness, muscle rigidity, seizures, and rhabdomyolysis with kidney failure, DIC, and ARDS?
Severe hyperthermia
168
what is the tx for Severe
serotonin syndrome?
Stop the inciting
drug
Benzodiazepines
Cyproheptadine
169
Which clinical syndrome is associated with the use of SSRIs and the addition of a
second drug that increases serotonin release or blocks its uptake or metabolism?
The serotonin syndrome
170
Which clinical syndrome is associated with Exposure to volatile anesthetics and Masseter muscle rigidity and ↑ arterial
PCO2?
Malignant
hyperthermia
171
Which clinical syndrome is associated with Altered mentation, severe rigidity, after use of Haloperidol, olanzapine, quetiapine, and
risperidone or withdrawal from L-dopa?
Neuroleptic
malignant
syndrome
172
what is the main symptoms that differentiates Neuroleptic malignant syndrome from Severe
serotonin syndrome?
Severe serotonin syndrome has myoclonus, ↑
reflexes while Neuroleptic malignant syndrome has no myoclonus
173
what is the tx for Neuroleptic malignant syndrome?
Stop the inciting
drug
Dantrolene
Bromocriptine
174
Which clinical syndrome is associated with hypoxemic respiratory failure presenting as noncardiogenic pulmonary edema?
Acute Respiratory Distress Syndrome
175
Which clinical syndrome is associated with Arterial PO2/FIO2 ratio of 201-300 mm Hg, measured with PEEP ≥5 cm H2O ?
Mild ARDS
176
Which clinical syndrome is associated with Arterial PO2/FIO2 ratio of 100-200 mm Hg, measured with PEEP ≥5 cm H2O?
Moderate ARDS
177
Which clinical syndrome is associated with Arterial PO2/FIO2 ratio <100 mm Hg, measured with PEEP ≥5 cm H2O?
Severe ARDS
178
what are the 3 main strategies for prevention of ventilator-associated
lung injury includes:
* lung-protective ventilation using volume-controlled ventilation with a tidal
volume of 4 to 8 mL/kg of ideal body weight (low tidal volume)
* plateau (end-inspiratory) pressure <30 cm H2O (even if this results in
“permissive” hypercapnia and acidosis)
* PEEP
Optimal mechanical ventilation associated with the prevention of ventilator-associated
lung injury includes:
* lung-protective ventilation using volume-controlled ventilation with a tidal
volume of 4 to 8 mL/kg of ideal body weight (low tidal volume)
* plateau (end-inspiratory) pressure <30 cm H2O (even if this results in
“permissive” hypercapnia and acidosis)
* PEEP
179
what strategy treatment in ARDS has mortality benefit?
Use of prone positioning in severe ARDS has a mortality benefit.
180
Which clinical syndrome is associated with critical illness polyneuropathy (with axonal nerve
degeneration) and critical illness myopathy (with muscle myosin loss), resulting in
profound weakness?
ICU-Acquired Weakness
181
what is the most common of the idiopathic interstitial pneumonias?
Idiopathic Pulmonary Fibrosis
182
Which clinical syndrome is associated with gradual onset of a nonproductive cough and dyspnea over several months in older
adults. Physical examination findings include bibasilar crackles (“dry,” end-inspiratory, and “Velcro-like” in quality)?
Idiopathic Pulmonary Fibrosis
183
what is seen on cxr in Idiopathic Pulmonary Fibrosis?
Chest x-ray shows peripheral reticular opacities and honeycomb changes at the lung
bases.
184
what is seen on HRCT in Idiopathic Pulmonary Fibrosis?
HRCT scan reveals subpleural cystic changes and traction bronchiectasis.
185
Should you Do not intubate and mechanically ventilate patients with respiratory failure
caused by IPF.?
Do not intubate and mechanically ventilate patients with respiratory failure
caused by IPF.
186
Which clinical syndrome is associated with this pic ?
Idiopathic Pulmonary Fibrosis
187
Which clinical syndrome is associated with
High-resolution, thin-section chest CT scan showing extensive parenchymal
involvement with fibrotic and honeycomb changes compatible with IPF?
Idiopathic Pulmonary Fibrosis
188
High-resolution, thin-section chest CT scan showing extensive parenchymal
involvement with fibrotic and honeycomb changes compatible with IPF.
189
what are the 2 ways to Improve
respiratory acidosis?
Increasing respiratory rate
Increasing tidal volume:
190
what are the 2 ways to Improve
Improve
respiratory
alkalosis?
Decreasing respiratory rate
Decreasing tidal volume
191
what are the 2 ways to Alleviate
hypoxemia?
Increasing FIO2
Increasing PEEP
192
when can patients be extubated? 4 criteria
When a patient can maintain an arterial O2 saturation >90% breathing FIO2 ≤0.5, PEEP
<5 cm H2O, and pH >7.30, it is reasonable to consider extubation.
193
What is the main method used to reduce in mechanical ventilation time, ICU and hospital
length of stay, and 1-year mortality rates?
Paired daily
spontaneous awakening trials (withdrawal of sedatives) with daily spontaneous
breathing trials result in a reduction in mechanical ventilation time, ICU and hospital
length of stay, and 1-year mortality rates.
194
Which method should not be used as a weaning
mode, because studies have demonstrated it actually takes longer to liberate
patients from the ventilator?
Do not select synchronized intermittent mandatory ventilation as a weaning
mode, because studies have demonstrated it actually takes longer to liberate
patients from the ventilator.
195
Which clinical syndrome is associated with high respiratory rates, which can cause hypotension by
reducing preload?
Watch for auto-PEEP at high respiratory
rates, which can cause hypotension by
reducing preload
196
When should you stop lung cancer screening with annual low-dose CT imaging in patients ?
Stop screening in patients who have
stopped smoking for 15 years.
197
who should be screened for Lung Cancer?
Screen patients between the ages of 50 and 80 years (guidelines vary) who
have a 20-pack-year history of smoking and who are currently smoking or have quit
within the last 15 years.
198
what is the most common tumor of anterior mediastinum; 40% have MG?
Thymus
199
what is the Second most common anterior mediastinal tumor?
Second most common anterior mediastinal tumor; Hodgkin disease is the most common lymphoma
200
what is the most common cause of middle mediastinal masses?
Lymphadenopathy is the most common cause of middle mediastinal masses
201
which route of nutrition is
associated with GI mucosal atrophy and translocation of gut bacteria into the
bloodstream?
Total parenteral nutrition is
associated with GI mucosal atrophy and translocation of gut bacteria into the
bloodstream, which predisposes patients to infection.
202
when is the initiation of enteral nutrition is recommended in ICU pts?
Initiation of enteral nutrition is recommended at 24 to 48 hours following admission.
203
In ICU pts, if necessary, when should patients who cannot tolerate enteral feeding, start total parenteral nutrition?
For patients who cannot tolerate enteral feeding, total parenteral nutrition
should not be started before day 7 of an acute illness.
204
As opposed to TPN, when should parenteral nutrition be started as soon as possible for severely malnourished patients and those at
high risk of malnutrition when enteral nutrition is not possible?
Parenteral nutrition
should be started as soon as possible for severely malnourished patients and those at
high risk of malnutrition when enteral nutrition is not possible. Caloric and protein
205
Which clinical syndrome is associated with daytime hypercapnia, defined as a PCO2 >45 mm Hg, also HF, PH, and volume overload are common?
Obesity-Hypoventilation Syndrome
206
what is the recommended tx for Obesity-Hypoventilation Syndrome?
Weight loss, including bariatric surgery, and bilevel positive airway pressure ventilation
are recommended.
207
some tests for OSA can be done at home and some have to be done in a lab. What are indications to do this in a lab?
In-laboratory polysomnography is the gold standard test for:
* mission critical workers (truck drivers, pilots)
* complicated OSA
* patients with HF, neuromuscular disease, or advanced pulmonary disease
208
what is the main difference between Obesity-
hypoventilation syndrome and OSA?
Obesity-hypoventilation syndrome is usually associated with COPD and always with elevated arterial PCO2 levels when awake.
209
What is the initial treatment of choice for OSA ?
CPAP is the initial treatment of choice for OSA and has been shown to improve quality
of life, cognitive function, and symptoms of daytime sleepiness.
210
for OSA patients who do not benefit from or tolerate CPAP, what alternative tx option is available to improves outcomes?
Maxillomandibular advancement surgery improves the AHI and can be considered for
patients who do not benefit from or tolerate positive airway pressure therapy.
211
Which surgery is recommended in OSA pts if they have to have it?
Uvulopalatopharyngoplasty is a recommended surgical option in patients
requiring surgery.
212
In pts with silicosis, fever, and cough, what else should they be evaluated for?
The incidence of TB is increased in those with silicosis and should be evaluated in
patients with silicosis, fever, and cough.
213
how is occupational asthma dx?
For management occupational asthma, select
spirometry or PEF measurement before and after work (or during vacation).
213
how is occupational asthma dx?
For management occupational asthma, select
spirometry or PEF measurement before and after work (or during vacation).
214
what is the initial management for any new unexplained effusion?
A thoracentesis is indicated for any new unexplained effusion.
215
What Pleural fluid LDH–serum LDH ratio >0.6 suggest an exudative ?
Pleural fluid protein–serum protein ratio >0.5
Pleural fluid LDH >200 U/L (or >2/3 the ULN)
Pleural fluid LDH–serum LDH ratio >0.6
216
What Pleural fluid LDH suggest an exudative ?
Pleural fluid LDH >200 U/L (or >2/3 the ULN)
217
What Pleural fluid protein–serum protein ratio suggest an exudative ?
Pleural fluid protein–serum protein ratio >0.5
218
how many of the criteria have to be met to be exudative?
An effusion is considered an exudate if any one of the above criteria is met.
219
What are the 2 most common exudates vs transudates?
transudates: HF and Cirrhosis
exudates include Parapneumonic and Malignancy
220
In evaluating pleural studies , if you see Bloody pleural fluid (RBC count 5000-10,000/μL), what should you think?
Malignancy, pulmonary infarction, asbestos related
221
In evaluating pleural studies , if you see Lymphocytosis >80%, what should you think?
TB, lymphoma, chronic rheumatoid pleuritis, sarcoidosis, malignancy
222
In evaluating pleural studies , if you see Nucleated cells >50,000/μL, what should you think?
Complicated parapneumonic effusions and empyema
223
In evaluating pleural studies , if you see pH <7.2, what should you think?
Complicated parapneumonic effusion
224
In evaluating pleural studies , if you see Pleural fluid amylase to serum amylase
ratio >1, what should you think?
Pancreatic disease, esophageal rupture
225
In evaluating pleural studies , if you see Glucose <60 mg/dL, what should you think?
Complicated parapneumonic effusion or empyema, TB, rheumatoid pleuritis, esophageal rupture
226
In evaluating pleural studies , if you see Chylothorax (triglycerides >110 mg/dL), what should you think?
Disruption of thoracic duct (surgery, trauma), lymphoma, TB
227
Which Pleural fluid lab is elevated in most TB effusions?
Pleural fluid adenosine deaminase is elevated in most TB effusions.
228
After how many samples of pleural fluid is the yield for positive malignant cytology maximized ?
The yield for positive malignant cytology is maximized after two samples.
229
When should thoracoscopy should be performed for an effusion ?
Thoracoscopy should be performed for an undiagnosed exudative effusion (two
negative cytology examinations) when malignancy is suspected.
230
in what 3 circumstances do Parapneumonic pleural effusion requires chest tube drainage ?
Parapneumonic pleural effusion requires chest tube drainage if Gram stain or culture is
positive, when the pH is <7.2, or if it appears loculated on imaging.
231
What coverage should empyemas include at a minimum?
Anaerobes are cultured in up to 72% of empyemas; empiric antibiotic therapy should
include anaerobic coverage.
232
For patients with malignant effusions what two options do you have to provide symptom relief? and which is more effective?
For patients with malignant effusions, indwelling pleural catheters provide symptom
relief, and up to 70% of patients achieve spontaneous obliteration of the pleural space
(pleurodesis) after 6 weeks. Chemical pleurodesis with talc has a 90% success rate.
233
what syndrome should be evaluated in pts with Pleural effusions associated with nephrotic syndrome?
Pleural effusions associated with nephrotic syndrome are common, but PE should
be excluded in such patients because PE and renal vein thrombosis often occur in
patients with nephrotic syndrome.
234
When chylothorax is diagnosed in a premenopausal
woman, what other dx should be considered?
Consider pulmonary Lymphangioleiomyomatosis when chylothorax is diagnosed in a premenopausal
woman.
235
what is seen on CT in pts with primary
pneumothorax?
Subpleural blebs
and bullae are commonly detected on CT scan and predispose to primary
pneumothorax.
236
Clinical syndrome associated with SOB and no
underlying lung disease in Tall men who smoke ?
Spontaneous pneumothorax
237
Which clinical syndrome is associated with ?
238
Which clinical syndrome is associated with ?
pulmonary LAM in a premenopausal woman presenting with a spontaneous
pneumothorax and lung disease
239
Which clinical syndrome is associated with SOB, in patients with HIV and Pneumocystis jirovecii
pneumonia ?
secondary pneumothorax in patients with HIV and Pneumocystis jirovecii
pneumonia
240
Which clinical syndrome is associated with with falling BP and oxygen saturation, tracheal deviation, and absence of breath sounds in one hemithorax?
tension pneumothorax with falling BP and oxygen saturation, tracheal deviation,
and absence of breath sounds in one hemithorax
241
Which clinical syndrome is associated with premenopausal woman presenting with a spontaneous
pneumothorax and lung disease ?
Lymphangioleiomyomatosis (LAM)?
242
What is the most common cause of secondary pneumothorax?
emphysema as the most common cause of secondary pneumothorax
243
Which clinical syndrome is associated with this pic ?
Large Pneumothorax
244
In evaluating pneumothorax, what is the clinical significance of The presence of lung sliding vs the presence of a lung point ?
The presence of lung sliding with ultrasound imaging indicates no pneumothorax at
that specific location, and the presence of a lung point confirms the edge of a
pneumothorax.
245
Should you wait for chest x-ray results before treating suspected tension
pneumothorax with needle decompression?
Do not wait for chest x-ray results before treating suspected tension
pneumothorax with needle decompression.
246
for patients who have had a repeat primary spontaneous pneumothorax what tx should be considered?
Pleurodesis is performed for a second primary spontaneous pneumothorax and may be
performed after a first occurrence in secondary spontaneous pneumothorax.
247
How does the Management of Pneumothorax change with a pneumo <2 cm on chest x-ray and minimal symptoms vs a lesion >2 cm on chest x-ray, breathlessness, and chest pain?
If GREATER than 2 cm with sxs, Insertion of a small-bore (<14 Fr) thoracostomy tube with connection to a high-volume low-pressure suction system. If LESS than 2 cm wiyh no sxs, Needle aspiration or admit to hospital for observation and supplemental oxygen
248
In dx airflow obstruction such as asthma, COPD, and bronchiectasis, what number indicated obstruction?
FEV1/FVC <0.7 (or below the LLN) indicates airflow obstruction.
249
After use of a bronchodilator, an increase in which numbers and by how much indicates reversible airway obstruction?
A ≥12% increase in either FEV1 or FVC and an increase ≥200 mL from baseline in
either parameter with bronchodilator therapy indicates reversible airway
obstruction.
250
Which type of changes in in FEV1 and FVC suggest restrictive lung disease?
Equal reductions in FEV1 and FVC suggest restrictive lung disease.
251
what does DLCO evaluate?
DLCO evaluates gas transport across the alveolar-capillary membrane.
252
How does the TLC change in obstructive disease vs restrictive diseases?
The TLC is normal or even increased in pure obstructive disease and decreased in restrictive
diseases.
253
Which pulmonary clinical syndrome is associated with ↓ DLCO and reduced lung volumes ?
DPLD
254
Which pulmonary clinical syndrome is associated with ↓ DLCO and normal lung volumes ?
Pulmonary vascular disease, anemia
255
Which pulmonary clinical syndrome is associated with ↓ DLCO and airflow obstruction ?
COPD, bronchiectasis
256
Which pulmonary clinical syndrome is associated with ↑ or normal DLCO and airflow obstruction ?
Asthma
257
Which pulmonary clinical syndrome is associated with ↑ DLCO ?
Pulmonary hemorrhage, left-to-right shunt, polycythemia
258
Which clinical syndrome is associated with the following flow volume loop??
Restrictive
259
Which clinical syndrome is associated with the following flow volume loop??
Obstructive
260
Which clinical syndrome is associated with the following flow volume loop??
Upper airway obstruction
261
What clinical syndrome is suggested by patients with low lung volumes, but a normal DLCO ?
In patients with low lung volumes, a normal DLCO suggests an extrapulmonary
cause (e.g., obesity).
262
How does the Pulse oximetry change in patients with carbon monoxide and cyanide
poisoning?
Pulse oximetry is normal in patients with carbon monoxide and cyanide
poisoning.
263
If smoke inhalation or carbon monoxide poisoning is suspected what should be used instead of pulse ox?
Use co-oximetry when carboxyhemoglobin is suspected (e.g., smoke inhalation, carbon monoxide poisoning)
264
In what unique situation should Cardiopulmonary
exercise testing be done?
Performed for unexplained dyspnea, symptoms disproportionate to the measured pulmonary function abnormality, and other exercise-related symptoms
265
Which test is Useful to assess disability, need for supplemental oxygen, and prognosis in chronic lung conditions?
6-Minute walk test
266
Which clinical syndrome is associated with elevated Fractional exhaled nitric oxide (FeNO) levels?
1. Elevated FeNO levels correlate modestly with blood and sputum eosinophilia (inflammation)
2. Can predict glucocorticoid responsiveness in patients with respiratory symptoms;
267
What is the resting mean pulmonary arterial pressure and a
pulmonary capillary wedge pressure
PH is defined by a resting mean pulmonary arterial pressure of ≥20 mm Hg and a
pulmonary capillary wedge pressure ≤15 mm Hg.
268
Which clinical syndrome is associated with unexplained dyspnea, decreased exercise tolerance, syncope and near-syncope, lower extremity edema with Physical examination findings of RV failure, RV heave, right-
sided S3, widely split S2, increased P2, increased jugular venous distention with a large a wave, and a murmur of TR.?
Pulmonary Hypertension
269
what is the initial evaluation for the Pulmonary Hypertension?
echocardiography as the initial study
270
What is the next step in evaluation after a diagnosis of Pulmonary Hypertension is confirmed?
If the diagnosis of PAH is confirmed, the next step is a vasoreactivity test using
vasodilating agents to measure changes in pulmonary artery pressure with a right heart
catheter in place.
271
In evaluation of pulmonary hypertension, what other diagnostic tests can be used after echo has been done?
right heart catheterization to confirm the diagnosis and quantify the degree of
PH
* left heart catheterization and coronary angiography exclude LV dysfunction as a
cause of PH
272
Which clinical syndrome is associated with after an acute PE, thromboemboli within the pulmonary arteries become remodeled into large occlusive scars?
In some patients (<5%) after an acute PE, thromboemboli within the pulmonary arteries
become remodeled into large occlusive scars, causing Chronic thromboembolic pulmonary hypertension and leading to right-sided
HF.
273
Which clinical syndrome is associated with pulmonary artery pressure ≥20 mm Hg in the absence of left-sided HF and compatible imaging evidence of chronic thromboembolism by V/Q scanning?
Chronic thromboembolic pulmonary hypertension
274
What are the 2 most common causes of pulmonary hypertension?
Most cases of PH are attributed to left-sided heart disease and hypoxic
respiratory disorders.
275
Can a CTA be used to diagnose CTEPH?
Do not select CTA to diagnose CTEPH. A V/Q scan is superior.
276
For patients with diagnosed PAH, what therapy should be used if a patient has been shown to demonstrate a vasodilator response on right heart catheterization?
Calcium channel blockers are used for patients demonstrating a vasodilator
response on right heart catheterization.
277
what is the recommended first-line therapy for PAH if the patient is willing and
able to tolerate it?
Combination therapy with ambrisentan (prostacyclin analogue) and tadalafil (
PDE-5 inhibitor) is the recommended first-line therapy if the patient is willing and
able to tolerate it.
278
What is the only definitive therapy for CTEPH?
Pulmonary
thromboendarterectomy is the only definitive therapy for CTEPH.
279
What additional life-long treatment is indicated in all patients with CTEPH?
Life-long anticoagulant therapy is indicated in all patients with CTEPH.
280
In patients with PAH, which therapy should NOT be used in patients if pulmonary artery pressure is not decreased with a vasoreactivity test?
Do not select calcium channel blockers if pulmonary artery pressure is not
decreased with a vasoreactivity test.
281
What other syndrome is associated sarcoidosis and has 95% diagnostic specificity for sarcoidosis?
Löfgren syndrome (fever, bilateral hilar lymphadenopathy, EN, and often ankle
arthritis)
282
Which clinical syndrome is associated with chest x-ray (bilateral hilar lymphadenopathy ± parenchymal lung disease, or lung
parenchymal disease)?
(sarcoidosis
283
which 3 lab abnormalities can be associated with sarcoidosis?
serum calcium level (kidney stones and hypercalcemia)
* serum PTH level (low) for patients with hypercalcemia/hypercalciuria
* 1,25-dihydroxy vitamin D3 level (high) in patients with kidney stones and
hypercalcemia
284
Which clinical syndrome is associated with this pic ?
Waxy papular lesions on the nose consistent with sarcoidosis.
285
In a pt with suspected sarcoidosis, what other 2 conditions should also be ruled out? and how?
Always rule out TB and fungal infections by ordering appropriate stains and
culture on tissue biopsy.
286
what occupational exposure may cause a sarcoidosis-like clinical syndrome?
Exposure to beryllium (often found in workers in light bulb or semiconductor
factories) may cause a sarcoidosis-like clinical syndrome.
287
what occupational exposure may cause a sarcoidosis-like clinical syndrome?
Exposure to beryllium (often found in workers in light bulb or semiconductor
factories) may cause a sarcoidosis-like clinical syndrome.
288
wat is the tx for progressive or symptomatic pulmonary sarcoidosis; hypercalcemia; or cardiac, ophthalmologic, or neurologic sarcoidosis?
Oral glucocorticoids are
indicated for progressive or symptomatic pulmonary sarcoidosis; hypercalcemia; or cardiac, ophthalmologic, or neurologic sarcoidosis.
289
in treating sarcoidosis, how does the tx differ for associated skin lesions or anterior uveitis, vs nasal polyps or airway disease?
Topical glucocorticoids are prescribed for skin lesions or anterior uveitis, and inhaled
glucocorticoids are used for nasal polyps or airway disease.
290
in treating sarcoidosis, how are patients with glucocorticoid-
refractory disease treated?
Patients with glucocorticoid-
refractory disease are treated with immunosuppressive, cytotoxic, and antimalarial
agents.
291
what is the tx for Do not treat asymptomatic pulmonary sarcoidosis?
Do not treat asymptomatic pulmonary sarcoidosis.
292
Which clinical syndrome is associated with this pic ?
X-ray shows bilateral hilar lymphadenopathy characteristic of sarcoidosis.
Sarcoidosis can be associated with interstitial lung disease.
293
for pts with suspected sarcoidosis, what dx test should be done for interstitial lung disease or nodular lung involvement?
fiberoptic bronchoscopy with transbronchial biopsy and bronchoalveolar lavage
for interstitial lung disease or nodular lung involvement
294
Which clinical syndrome is associated with ?
295
Which clinical syndrome is associated with Low cardiac output, elevated PCWP, and high SVR
also Elevated CVP, S3, pulmonary crackles, edema,?
Cardiogenic shock
296
Which clinical syndrome is associated with Low cardiac output, low PCWP, and high SVR?
Hypovolemic shock
Obvious source of volume loss (hemorrhage, dehydration, diarrhea, nausea/vomiting)
297
Which clinical syndrome is associated with Low cardiac output, variable PCWP, and high SVR ?
Obstructive shock
Consider cardiac tamponade, PE, and tension pneumothorax
298
Which clinical syndrome is associated with High cardiac output, normal PCWP, and low SVR ?
Anaphylactic shock
Rash, urticaria, angioedema, and wheezing/stridor
299
Which clinical syndrome is associated with High cardiac output (early) that can become depressed (late) and low SVR ?
Septic shock
Known or suspected infection
300
How do you diffe cardiac shock from hypveolmic shock?
Both have Low cardiac output and high SVR, but cardiogenic has elevated PCWP, but hypovolemic has low PCWP.
301
How do you differ obstructive shock from hypovolemic shock?
Both have Low cardiac output and high SVR, but hypovolemic low PCWP while obstructive has a variable PCWP.
302
Which two types of shock have low SVR?
septic and Anaphylactic shock
303
what are the 3 components of treating Sepsis and Septic Shock?
1. Fluid resuscitation: Balanced crystalloids
30 mL/kg within first hour
2. Vasopressors: Norepinephrine and then Vasopressin (norepinephrine-sparing agent)
Indicated for persistent hypotension unresponsive to fluids
3. Source identification and control: Blood cultures, cultures of potential sites of infection, chest x-ray, urinalysis
4. Antibiotic therapy: Initiate within 1 h of diagnosis
Narrow coverage based on culture and sensitivity findings
304
In treating patients with septic shock, what is the treatment for persistent hypotension despite fluids and vasopressors?
Hydrocortisone 200-400 mg/d IV for persistent hypotension despite fluids and vasopressors
305
what is the glucose goal for septic shock pts?
Insulin therapy to maintain glucose between 140 and 180 mg/dL
306
In treating patients with Smoke Inhalation, what is the tx for Patients with a visibly damaged airway or stridor?.
Patients with a visibly damaged airway or stridor require immediate intubation.
307
In treating patients with Smoke Inhalation, what lab must be assessed?
Assess carbon monoxide level.
308
if this lab is normal, cyanide poisoning is excluded?
A normal
LDH level excludes cyanide poisoning.
309
Cyanide exposure is common in house fires. How is cyanide poisoning treated?
. Treat cyanide poisoning with hydroxocobalamin.
310
what does a normal oxygen level tell you about a patient with a smoke inhalation injury?
Normal oxygen saturation does not exclude either carbon monoxide or cyanide
poisoning.
311
Which Toxic Syndrome is associated with Tachycardia
Hypertension
Diaphoresis
Agitation
Seizures
Mydriasis
Sympathomimetics:
Cocaine
Amphetamines
Ephedrine
Caffeine
312
Which Toxic Syndrome is associated with Tachycardia
Hypertension
Diaphoresis
Agitation
Seizures
Mydriasis
Sympathomimetics:
Cocaine
Amphetamines
Ephedrine
Caffeine
313
Which Toxic Syndrome is associated with
“SLUDGE”
Confusion
Bronchorrhea
Bradycardia
Miosis
Cholinergic
Organophosphates
(insecticides, sarin)
Carbamates
Physostigmine
Edrophonium
Nicotine
314
Which Toxic Syndrome is associated with
Hyperthermia
Dry skin and mucous
membranes
Agitation, delirium
Tachycardia, tachypnea
Hypertension
Mydriasis
Anticholinergic:
Antihistamines
Tricyclic antidepressants
Antiparkinson agents
Atropine
Scopolamine
315
Which Toxic Syndrome is associated with:
Miosis
Respiratory depression
Lethargy, confusion
Hypothermia
Bradycardia
Hypotension
Opioids
Morphine and related drugs
Heroin
316
what is The first step in evaluation of a Solitary Pulmonary Nodule?
The first step in evaluation is
comparison with previous imaging studies. Stability over time reduces the possibility of
cancer.
317
what is The first step in evaluating a solid pulmonary nodule larger than 8 mm?
Solid
nodules with moderate probability of malignancy should be characterized further with a
PET scan.
318
in evaluating a solid pulmonary nodule larger than 8 mm, a PET scan is done and is negative, what should be done next? what if its positive?
If the PET scan is negative, continued surveillance is warranted, whereas a
positive PET scan result may require resection.
319
in evaluating a solid pulmonary nodule larger than 8 mm, If the probability of malignancy is initially
high, what should be done?
If the probability of malignancy is initially
high, obtain PET scan followed by surgical resection or chemotherapy and radiation.
320
what side lung nodules are considered low risk? and how are these monitored?
Solid nodules 8 mm or smaller are estimated for risk of malignancy. Most can be
monitored with serial CT according to guidelines.
321
What is the recommended CT interval/follow up for a Single Solid Pulmonary Nodule <6 mm in a pt with no risk factors for lung cancer?
No follow-up
322
What is the recommended CT interval/follow up for a Single Solid Pulmonary Nodule 6-8 mm in a pt with no risk factors for lung cancer?
CT at 6-12 months, then consider CT at 18-24 months
323
What is the recommended CT interval/follow up for a Single Solid Pulmonary Nodule >8 mm in a pt with no risk factors for lung cancer?
Consider CT at 3 months, PET/CT, or tissue sampling
324
What is the recommended CT interval/follow up for a Single Solid Pulmonary Nodule >8 mm in a pt with high risk factors for lung cancer?
Consider CT at 3 months, PET/CT, or tissue sampling
325
What is the recommended CT interval/follow up for a Single Solid Pulmonary Nodule 6-8 mm in a pt with high risk factors for lung cancer?
CT at 6-12 months, then CT at 18-24 months
326
What is the recommended CT interval/follow up for a Single Solid Pulmonary Nodule <6 mm in a pt with high risk factors for lung cancer?
Optional CT at 12 months
327
in terms of a pulm nodule, what features related to ground glass nodule suggest malignancy, vs what suggests malignancy in a solid nodule?
Development of a solid
component in a pure ground-glass nodule or enlargement of the solid component
suggests malignancy.
328
what size ground glass lung nodules require follow up with CT at 6-12 months to confirm persistence? and what size requires no follow up?
Pure ground glass <6 mm require No follow-up while those ≥6 mm need CT at 6-12 months to confirm persistence, then CT every 2 years until 5
years
329
As opposed to a sole ground glass nodule, how is a nodule with Part solid nodule monitored when less than 6mm vs more than 6mm?
<6 mm needs no No follow-up while ≥6 mm CT at 3-6 months to confirm persistence. If unchanged and solid
component remains <6 mm, annual CT should be performed for 5 years
330
what sized Pulmonary mass, is highly suspicious for malignancy in a patient with risk factors?
Pulmonary mass, defined as >3 cm in diameter, is highly suspicious for malignancy
in a patient with risk factors.
331
what is the first step in the evaluation of a pulmonary mass, defined as >3 cm in diameter, is highly suspicious for malignancy
in a patient with risk factors?
Either a biopsy for tissue diagnosis (in the absence of
suspected metastases) or surgical resection (if no evidence of metastatic disease) is
typically the first step in the evaluation.
332
As opposed to pts with no mets or without advanced disease, whats the best way to evaluate a pulmonary mass, defined as >3 cm in diameter in patients with radiographic evidence of
advanced-stage disease?
In patients with radiographic evidence of
advanced-stage disease, diagnosis and staging are best accomplished with a single
invasive test at a location that will establish the diagnosis and the stage of disease.
333
Before ordering contrast CT, bronchoscopy, or PET scan to evaluate a parge pulm mass, what should be done first?
Before ordering contrast CT, bronchoscopy, or PET scan, compare current image
with previous image to determine stability over time.
334
In evaluating a large pulm mass, does A nonspecific negative result from fiberoptic bronchoscopy or transthoracic
needle aspiration biopsy reliably exclude the presence of a malignant
growth?
A nonspecific negative result from fiberoptic bronchoscopy or transthoracic
needle aspiration biopsy does not reliably exclude the presence of a malignant
growth.
334
In evaluating a large pulm mass, does A nonspecific negative result from fiberoptic bronchoscopy or transthoracic
needle aspiration biopsy reliably exclude the presence of a malignant
growth?
A nonspecific negative result from fiberoptic bronchoscopy or transthoracic
needle aspiration biopsy does not reliably exclude the presence of a malignant
growth.
335
Which clinical syndrome is associated with patients with acute onset dyspnea, hypoxemia, and pulmonary infiltrates that occur during or within 6 hours after transfusion of any plasma containing blood product.?
Transfusion-related acute lung injury (TRALI) should be considered in patients with acute onset dyspnea, hypoxemia, and pulmonary infiltrates that occur during or within 6 hours after transfusion of any plasma containing blood product. Treatment involves mainly supportive care, stopping the transfusion, and vasopressor support for hypotension. The blood bank should be notifled and the blood donor investigated to prevent future incidents in other recipients.
336
How does Transfusion-related acute lung injury differ from Transfusion-related circulatory overload ?
Transfusion-associated circulatory overload (TACO) usually presents with physical findings suggesting volume overload (e.g., elevated JD, presence of an 53). Measurement of serum brain natriuretic peptide (BNP) or NT-Pro-BNP can also help in distinguishing TRALI from TACO.
337
which 3 types of procedures do not require endocarditis prophylaxis?
1. Gl procedures (eg, endoscopic retrograde cholangiopancreatography, esophagogastroduodenoscopy)
2. * GU procedures (eg, prostatectomy, catheter insertions)
3. Vaginal or cesarean delivery
338
Multifocal atrial tachycardia is most commonly associated with what other underlying condition?
Multifocal atrial tachycardia most commonly occurs in elderly patients with an exacerbation of underlying pulmonary disease (eg, chronic obstructive pulmonary disease), and is characterized by ECG showing an atrial rate > 100/min, irregular R-R intervals, and ≥3 distinct P wave morphologies. Treatment is aimed at correcting the underlying inciting disturbance.
