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Flashcards in Pulmonary Deck (104):
1

best test to assess presence of reactive airway disease in patient with NO current symptoms

methacholine stimulation testing
- will decrease FEV1 >20% in asthmatic pt

2

pt presents to ED with acute SOB - you are unsure of etiology; what is a good test to perform?

PFTs pre and post bronchodilator - will tell you if it is due to reactive airway disease

3

ventilator settings in asthmatic if pt needs to be intubated

low RR
small TV
high flow

4

initial therapies/management to order in acute asthma exacerbation

1. oxygen
2. continuous oximeter
3. CXR and ABG
4. inhaled albuterol
5. bolus of steroids (methylpred)
6. inhaled ipratropium
7. magnesium

5

when is cromolyn or nedocromil useful

extrinsic allergies, ie hay fever

6

when is montelukast useful

atopic disease

7

when are tiotropium/ipratropium appropriate

COPD

8

when is omalizumab used

high IgE levels with no control with cromolyn

9

obstructive PFTs + normal DLCO

asthma

10

obstructive PFTs + decreased DLCO

emphysema (OOPD)

11

restrictive PFTs with proportionally decreased DLCO

extrathoracic restriction
- obesity, kyphosis

12

restrictive PFTs with disproportionately low DLCO

interstitial lung disease

13

pulmonary alveolar proteinosis

Alveolar filling with floccular material that is PAS+; CXR shows a batwing appearance
Dx. BAL
Tx. whole lung lavage

14

CCS: acute handling of SOB in COPD pt

1. oxygen and ABG
- always reassess after O2 bc it may make the SOB worse by eliminating hypoxic drive
2. CXR
3. Albuterol
4. Ipratropium
5. Bolus of steroids
6. Chest, heart, neuro and extremity exam
7. if fever, sputum or new infiltrate --> add abx

15

what abx are used in acute exacerbation of COPD

ceftriaxone and azithromycin
- add if increasing dyspnea, increase in sputum and sputum purulence

16

EKG findings in COPD

RAH: biphasic P waves in V1
RVH: deep S wave in V1 and tall R wave in v5/6 > 35 mm

17

Lab findings in COPD

1. increased hematocrit
2. reactive erythrocytosis - microcytic
3. increased serum bicarb (metabolic compensation)
4. ABG: respiratory acidosis, low pO2

18

chronic medical therapy of COPD

1. tiotropium or ipratropium inhaler
2. albuterol, levalbuterol or pirbuterol
3. pneumococcal and influenza vaccine
4. smoking cessation
5. inhaled steroids - if FEV1 < 50 and >3 exacerbations/year

19

who gets home oxygen therapy in COPD?

1. No sx of RHF and normal htc?
- pO2 < 55 and O2 sat < 60 and O2 sat < 90%

20

a 35 year old man presents with SOB. You do a CXR and see changes consistent with emphysema and this is supported by PFT results. Lab findings include low albumin level and elevated prothrombin time - dx?

alpha 1 antitrypsin deficiency

21

CF: bronchiectasis

repeat episodes of lung infections
cupfuls of sputum
hemoptysis

22

most accurate test for bronchiectasis

high resolution CT scan of chest

23

Tx. bronchiectasis

chest PT
rotating antibiotics

24

what drugs may cause ILD

nitrofurantoin
TMP-SMX (Bactrim)

25

only form of ILD that is responsive to steroids

berylliosis (granulomatous disease)

26

Pt presents with cough, rales, SOB along with fever, malaise and myalgias. CXR shows bilateral patchy infiltrates and chest CT shows interstitial disease with alveolitis - dx?

Dx. BOOP/COP
- similar presentation to ILD but with systemic findings

27

most accurate diagnostic test for BOOP/COP

open lung biopsy

28

Tx. BOOP/COP

steroids

29

associated findings with sarcoidosis

1. Eyes - anterior uveitis
2. Bells palsy
3. Skin - lupus pernio, erythema nodosum
4. Restrictive CM
5. hypercalcemia - vit D production by granulomas
6. elevated ACE levels

30

best initial test: sarcoidosis

CXR

31

most accurate diagnostic test: sarcoidosis

lung or lymph node biopsy --> non caseating granulomas

32

Tx. sarcoidosis

steroids

33

P/E findings in pulmonary HTN

loud P2
TR
RV heave
Raynaud's phenomenon

34

secondary causes of pulmonary HTN

mitral stenosis
polycythemia vera
COPD
chronic pulmonary emboli
interstitial lung dz

35

PFTs in pulmonary HTN

decreased DLCO
normal PFTs

36

gold standard diagnostic test for pulmonary HTN

right heart catheterization
- increased pulmonary pressure (>25 at rest or > 30 with exercise)

37

Tx. pulmonary HTN

1. bosentan (endothelin inhibitor)
2. epoprostenol/treprostinil (prostacyclin analogs - pulmonary vasodilators)
3. Nitric oxide gas (vasodilate w/o systemic effects)
4. sildenafil
5. CCBs

38

ABG results in PE

hypoxia
increased Aa gradient
respiratory alkalosis

39

poor prognostic factors in PE

1. increased troponins
2. hypotension
3. hemodynamically unstable

40

gold standard to confirm PE

spiral CT
- test of choice if XR is abnormal

41

when are D-dimers appropriate in dx. of PE

when you have a low probability of PE in a patient and you want to RULE OUT the disease

42

single most accurate test for PE

angiography

43

pt with PE presents a few days after with low grade fever - what do you do

14% of pts will have a fever and you do not need to give abx even though clinical picture may resemble pneumonia

44

Management of PE

1. oxygen
2. heparin (warfarin for 6 months with INR 2-3; IVC if contraindication to anti-coag)

45

when do you use thrombolytics in tx of PE

if pt is hemodynamically unstable (BP < 90) and low risk of bleeding

46

when do you use embolectomy in tx of PE

if pt is in shock and death likely within hours or if failed/contraindicated thrombolytics

47

pleural effusion
- best initial test
- most accurate test

initial = CXR
accurate = thoracentesis

48

characteristics of exudative pleural effusion

pleural/ serum protein > 0.5
pleural / serum LDH > 0.5

49

what tests should be ordered on pleural fluid?

gram stain/culture, acid fast stain
total protein
LDH
glucose
cell count w/ diff
TG
pH

50

mild sleep apnea

5-20 apneic events/hour (apnea lasts > 10 sec)

51

severe sleep apnea

> 30 apneic events/hour

52

tx. obstructive sleep apnea

weight loss
CPAP/BiPAP
if not effective --> resection of uvulate, palate and pharynx

53

tx. central sleep apnea

1. avoid alcohol /sedative
2. may respond to acetazolamide or medroxyprogesterone

54

Asthmatic pt presents with worsening asthma symptoms and recently began coughing up brownish mucus plugs and has recurrent upper lobe infiltrates on XR. Labs show eosinophillia and elevated serum IgE. Dx? First step?

dx. allergic bronchopulmonary aspergillosis
first test: aspergillus skin test

55

Tx. ABPA

corticosteroids
- refractory disease: itraconazole

56

Dx. test findings in ARDS

1. normal PCWP (< 18 mmHg)
2. pO2 / FiO2 ratio < 200

57

Tx. ARDS

1. Ventilatory support
- TV at 6 ml/kg
- PIP < 35 cm h20
- PEEP > 10 cm H20
2. prone positioning
3. possible use of diuretics and positive inotropes (dobutamine)
4. transfer to ICU

58

Pulm artery cath results for hypovolemia

CO low
PCWP low
SVR high

59

Pulm artery cath results for cardiogenic shock

CO low
PCWP high (>18)
SVR high

60

Pulm artery cath results for septic shock

CO high
PCWP low
SVR low

61

who should get admitted for pneumonia?

elderly pts > 65
significant comorbidities
vitals: tachycardia, hypotension, PO2<60
failure of outpt tx or unable to take meds PO
change in mental status
poor support system
multilobular involvement

62

pneumonia:
best initial test
most accurate test

initial- CXR
accurate - sputum gram stain and culture

63

Tx. outpatient pneumonia

macrolide (azithromycin) OR
respiratory FQ (levo or moxi)

64

Tx. inpatient pneumonia

ceftriaxone and azithromycin
FQ single agent

65

Tx. ventilator assoc. pneumonia

1. imipenem, Zosyn or cefepime
2. Gentamycin and Vanc

66

recurrent pneumonia in smoker

bronchogenic carcinoma
-order CT scan and flexible bronchoscopy

67

pneumonia following viral syndrome

staphylococcus

68

pneumonia in alcoholics

klebsiella
- carbapenems

69

pneumonia in young, healthy patients

mycoplasma

70

pneumonia with GI symptoms and confusion

legionella

71

pneumonia in persons present at the birth of an animal

coxiella burnetti

72

pneumonia in arizona construction workers

coccidioidomycosis

73

pneumonia in HIV pt with CDC <200

PCP

74

Tx. PCP

Bactrim
Steroids - if PO2 35

75

cough induced by expiration is an indication of...

airway hyperreactivity
- recognized clinical clue for asthma

76

allergen most frequently assoc. with asthma

house dust mites

77

patient that is receiving treatment for TB and is improving clinically, develops a new pleural effusion - what test should you do?

thoracentesis

78

ideal vent settings in ARDS

1. TV < 6 ml/kg
2. limited plateau pressure < 30-35 Cm H2O
- want to achieve PaO2 of 55-80 mmHg
3. ventilator rate < 35 / min

79

single most important prognostic factor in COPD

after adjusting for age, FEV1 (if <40% indicates severe obstruction)

80

what ventilator settings allow you to improve oxygenation in ARDS?

maintain PaO2 of 55-80 or O2 sat 88-95% by adjusting the FiO2 or the PEEP (increasing)

81

who is permissive hypercapnia not safe in?

pts with elevated ICP or a seizure disorder

82

RF for post-op pulmonary complications

upper abdominal/thoracic surgeries
underlying chronic lung dz
history of smoking in last 8 weeks
baseline PaCO2 > 45
duration of surgery >3-4 hours
use of general anesthesia
age > 50
obstructive sleep apnea

83

screening for lung ca

annual low dose chest CT in patients age 55-80 who have a > 30 year pack year smoking history and are either current smokers or quit within the last 15 years

84

termination of lung ca screening

age > 80 or
patient successfully quit smoking for >15 years or
pt has other medical problems significantly limiting life expectancy

85

pt with sarcoidosis comes in and has bilateral erythema nodosum and hilar adenopathy -- management?

high rate of spontaneous remission with good prognosis --> no treatment except observation and periodic check up

86

tx of sarcoidosis if pt is symptomatic or has decreased pulmonary function

corticosteroids

87

best initial test in tb

CXR

88

confirmatory test TB

sputum acid fast stain

89

when do you know that TB is noninfectious

3 consecutive negative results on sputum acid fast smears performed on different occasions

90

Tx. TB

Isoniazid and Rifampin for 6 months
Pyrazinamide and Ethambutol - can stop after 2 months

91

main side effect of TB drugs - when should you stop them due to this s/e

liver toxicity; stop is LFTs > 5x upper limit of normal

92

isoniazid toxicity

peripheral neuropathy (give with pyridoxine)

93

rifampin toxicity

red orange colored bodily secretions

94

pyrazinamide toxicity

do NOT use in pregnancy - teratogenic
hyperuricemia

95

ethambutol toxicity

optic neuritis

96

what TB conditions require treatment for > 6 months

osteomyelitis
meningitis
miliary TB
cavitary TB
pregnancy
if they are a child with any of the above - require 12 months

97

management: asymptomatic pt with TB but no evidence of active TB who has previously been treated for active TBI or LTBI

does not require further TB treatment

98

MC location of epistaxis

anterior nasal septal mucosa --> Kiesselbachs plexus or Littles area
- trickling of blood in upright position

99

next step in management if you cannot stop an episode of anterior epistaxis with nostril pinching

1. cotton pledget impregnated with vasoconstrictor (phenlyephrine 0.25%) and lidocaine 2%
2. followed by silver nitrate chemical cautery or needlepoint electrocautery

100

CF: posterior epistaxis

MC in older adults (men in 50s) with HTN and arteriosclerosis
- Woodruff's plexus
- blood visible in posterior oropharynx in upright position

101

Bezold abscess

neck abscess resulting from an erosion through the medial aspect of the mastoid tip --> swelling behind the ears in pt with other clinical findings consistent with AOM

102

management: button battery lodged in esophagus

immediate removal under direct endoscopic visualization
- if already in the stomach - outpatient management OK

103

patient presents with loud snoring but no other signs or symptoms of OSA, what advice do you give them?

lose weight, stop smoking and avoid alcohol near bedtime

104

what can be used to reduce incidence of ear and sinus barotrauma during diving?

non sedating decongestants i.e. pseudoephedrine