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Flashcards in Pulmonary Deck (61):
1

3 factors contributing to asthma? Is it reversible?

1) Airway inflammation
2) Bronchial smooth muscle hyperactivity
3) Mucus plugging

Asthma IS reversible

2

Causes of acute exacerbations?

Allergens
Infections
Exercise
Drugs
GERD

3

What 2 medications can cause acute asthma exacerbations?

*Aspirin (decreased prostaglandins in lung & increased bronchoconstriction)

*B-blocker (some B2 (-) = bronchoconstriction)

4

What signs indicate asthma?

Worse at night
Nasal polyps
Aspirin sensitivity
Eczema/atopic dermatitis
Increased length of expiratory phase

5

Best initial test in acute asthma exacerbation?

Most accurate test?

Peak expiratory flow (PEF) or ABG

PFTs --> decreased FEV1/FVC ratio

6

How does FEV1 change during PFT testing?

Overall decreased FEV1/FVC ratio
Albuterol = INCREASE in FEV1 by >12%
Methacholine = DECREASE in FEV1 by >20%

7

What 2 chemicals cause bronchoconstriction?

ACh & histamine

Methacholine is artificial ACh

8

Appropriate treatment for 4 stages of asthma?

Mild intermittent (2 days/wk or >2night/mo): B(+) + ICS
Mod persistent (daily or 1night/wk): B(+) + ICS + LA beta (+)
Sev persistent (continual): above + ICS @ max dose

9

Adverse effects of inhaled steroids (2 of them)?

Dysphonia
Oral candadiasis (thrush)

10

What asthma drug has s/e of hepatotoxicity & associated w/ Churg-Strauss syndrome?

Zafirleukast

11

Best way to assess severity of asthma exacerbation?

Resp rate

12

Tx of acute asthma exacerbation?

O2
Albuterol
Steroids (take 4-6 hrs to take effect)

13

Is Epi used in asthma?

NO - no more effective than albuterol

14

What treatments are NOT effective in acute exacerbations?

Theophylline
Cromolyn & nedocromil
Leukotriene modifiers
Omalizumab
Salmeterol

15

Management to prevent recurrent thromboembolic events in PE?

1) Start heparin and warfarin at same time
2) Once therapeutic INR reached (2-3), stop heparin
3) Continue warfarin for 3-6 months

16

Patients with COPD should receive what vaccinations?

Influenza + Pneumococcal

17

Person w/ hx of COPD presents with sudden onset severe dyspnea and L-sided chest pain. He has decreased breath sounds over L chest. What must you suspect?

Pneumothorax

*With hx of COPD, likely ruptured apical lung bleb (destroyed alveolar tissue causing dilated bleb)

18

What is common in shipbuilders and insulation work?

What are common PE findings?

What is pathognomonic imaging findings?

What are PFT findings?

Asbestos exposure

Progressive SOB, *clubbing, *end-insp crackles

*Pleural plaques

Restrictive lung pattern, decreased lung volume, *decreased diffusion lung capacity, normal FEV1/FVC

19

Why with consolidation are lung sounds louder over the area with consolidation?

Sound conduction through the consolidated area will sound louder, especially during expiration

There will also be dullness to percussion

20

Treatment of acute COPD flare?

O2
Brochodilators (b-agonist or anti-ach)
Systemic glucocorticoids
Abx

21

What is best long term treatment for asthma? COPD?

How to best differentiate b/w asthma and COPD?

COPD: inhaled anti-cholinergic (ipatropium)
Asthma: inhaled corticosteroids

Spirometry w/ albuterol -- asthma has significant improvement in FEV1 post-albuterol

22

Patient has R lung mass w/ mediastinal lymphadenopathy. Past history of smoking for 20 years. Has muscle weakness. What is most likely cause?

Small cell carcinoma

Eaton-Lambert syndrome - association with small cell carcinoma

23

What are the 3 paraneoplastic syndromes of small cell carcinoma?

ADH (SIADH)
ACTH (Cushing syndrome)
Lambert-Eaton syndrome

24

In ARDS, what is timeframe for onset?

The initial best treatment?

After this, what must be decreased to prevent toxicity to the lungs?

Within 1 week of known insult (pancreatitis, fracture, sepsis)

PEEP with increased FiO2

FiO2 must be decreased

25

Best way to improve oxygenation in ARDS?

Increase PEEP (prevents alveolar collapse)

26

In acute asthma exacerbation, what is the sign that impending respiratory arrest if imminent?

Elevated/normal pCO2 --> suggests decreased respiratory drive from respiratory muscle fatigue

*Need to intubate or mechanically ventilate!!

27

How do you calculate partial pressure of ALVEOLAR O2 content?

A-a gradient?

PAO2 = (FiO2 x [Patm - PH2O]) - (PaCO2/R)
or
PAO2 = (FiO2 x 713) - (PaCO2/0.8)

A-a gradient = PAO2 (above formula) - PaO2

28

What is the most common source for symptomatic acute PE's?

Proximal leg veins (iliac, femoral, popliteal)

29

In ARDS, what is:
gas exchange?
lung compliance?
pulm artery pressure?

gas exchange is DECREASED (alveoli are filled with crap and collapse)

DECREASED lung compliance (stiff lungs)

INCREASED pulm artery pressure (pulm HTN)

30

What 2 instances are bronchoalveolar lavage useful?

Evaluating malignancy and opportunistic infections

31

Used to assess severity of pneumonia and decide on admission?

CURB-65

Confusion
Uremia (BUN > 20)
Tachypnea (RR > 30)
Hypotension (BP 65

32

Appropriate tx for inpatient CAP?

Fluuroquinolone (moxi or levo)
OR
B-lactam + macrolide (cephalosporin/-cillin + azithromycin)

33

Chronic cough, worse at night, produces white sputum, and no improvement with antihistamines - what is the cause? Next best test?

Asthma

PFTs to evaluate response to bronchodilator

34

In sarcoidosis, what other organ systems are involved and their signs?

Classic finding on CXR?

Lab findings that can be elevated?

*Erythema nodosum (painful shin lesions)
**Anterior uveitis (eyes) - leukocytes in anterior chamber
*Arthritis (multiple joints)

**B/L hilar adenopathy and reticular opacities/diffuse interstitial infiltrates that can progress to fibrosis

**High Ca, ACE levels

35

What agent causes lung consolidation, lyric bone lesions, and verrucous-crusted skin lesions?

What area is it found?

Blastomycosis
*Broad-budding yeasts

Ohio river, miss
*Wisconsin

36

Hemothorax is a common cause of what pulmonary complication?

What is best mgmt?

Empyema (infection in pleura space)

Surgery to remove empyema

37

Most important prognostic factor in determining if a chest tube needs to be placed in a person with an effusion from pneumonia?

Pleural fluid pH --> if

38

What respiratory side effects occur with aspirin or NSAIDs?

Asthma
Chronic rhino sinusitis with **nasal polyps**

Drug induced leukotriene/prostaglandin imbalance

39

Most important factor in determining prognosis of asthma attack?

NORMAL Pco2 levels --> indicates CO2 retention b/c of severe airway obstruction and air trapping or muscle fatigue
During asthma attack, hyperventilation occurs --> this results in DECREASED Pco2

Other important factors:
Speech difficulty, diaphoresis, altered sensorium, cyanosis, 'SILENT' lungs

40

In asthma, what does NO breath sounds indicate?

Severe airway obstruction!

41

Only 2 modalities proven to decrease mortality in COPD?

Stop smoking
O2 use

42

How does supplemental O2 in people with severe COPD actually make them worse?

The destruction of terminal bronchioles and alveoli causes increase in physiologic dead space --> leads to V/Q mismatch and local hypoxia and hypercapnia --> causes selective vasoconstriction in these areas and lung redirects blood flow to better ventilated alveoli

Supp O2 helps hypoxia but can INCREASE CO2 retention by:
- Loss of compensatory vasoconstriction in areas of ineffective gas exchange = worsens V/Q mismatch
- Increase in oxyhemoglobin = reduces CO2 uptake from peripheral tissues (Haldane effect)
- Decreased resp drive and slowing of resp rate (from peripheral chemoreceptors) = reduced minute ventilation

43

Pulmonary fibrosis causes what changes in lung functions?

Reduced TLC, FRC, RV
FEV & FRC decreased --> ratio is normal/increased

The alveolar fibrosis increases elastic recoil in the airways and results in a restrictive lung disease pattern on PFTs.

44

PFT findings in asthma?

Reversible airway obstruction (>12% increase in FEV1 with bronchodilator) and NORMAL DLCO

45

Asbestos exposure increases risk of what type of cancer?

Bronchogenic carcinoma (most common)

46

28 yo has recurrent nasal discharge and increasing nasal congestion. She came to the ER for severe wheezing after taking naproxen 1 yr ago. She also notices dripping in the back of her throat with her food tasting bland. What is it?

Aspirin exacerbated respiratory disease

*Use of aspirin/NSAIDs*

Triad
1) Asthma
2) Chronic rhinosinusitis/nasal congestion
3) Nasal polyps

47

In children with stridor, what is most likely with:

1) "Barky" cough with rhinorrhea, congestion?
2) Worsening while supine?
3) Acute onset?
4) Improves with neck extension and cardiac abnormalities?

1) Croup (laryngotracheobronchitis)
2) Laryngomalacia
3) Foreign body aspiration
4) Vascular ring (around esophagus and trachea)

48

Person has confirmed PE but also has renal insufficiency. What can you give him?

Unfractionated heparin --> only anticoag that isn't affected by kidneys

LMWH, fondaparinux, rivaroxiban --> all C/I in patients with renal insufficiency (

49

ABG findings in exacerbations of CHF and COPD?

CHF --> hypocapnia, respiratory alkalosis (tachypnea)

COPD --> respiratory acidosis (air trapping)

50

Woman with sudden-onset severe SOB and wheezing is treated with albuterol nebulization and steroids. The next morning, she complains of muscle weakness and can't lift her arms over her head and has mild hand tremors. Why?

Hypokalemia

**B-agonist --> drive K+ INTO cells and lower serum levels
*Weakness, arrhythmias, EKG changes
*Other s/e: tremors, HA, palpitations

51

Inspiratory stridor that is worse when supine or when crying?

Best confirmatory test?

Layngomalacia

Laryngoscopy

52

Sudden-onset dyspnea, chest pain, TACHYCARDIA with a hemorrhagic, exudative pleural effusion + absence of consolidation?

PE

53

How do you calculate peak airway pressure?

Airway resistance + plateau pressure = PAP

Plateau pressure = Elastic pressure + PEEP

Elastic pressure inversely related to lung compliance

54

Any process involving impaired gas exchange results in what physiologic change?

Elevated alveolar (A-a) O2 gradient

*Pulmonary embolism

55

Sudden-onset dyspnea, pleuritic chest pain, low-grade fever, and hemoptysis?

What will you commonly see on physical exam?

PE

Tachypnea
Tachycardia
Hypoxemia

56

What V/Q changes occur in pneumonia?

Consolidation = alveoli fill with exudative fluid and debris --> ventilation is essentially 0 but alveolar blood flow remains intact

Non-ventilated alveoli can't participate in gas exchange --> blood remains deoxygenated when passing through regions of the lung --> acts as physiologic shunt --> increases delivery of deoxygenated blood to L heart and reduces systemic arterial O2 saturation

*If person lies on either side and O2 sat is measured, the lowest part of the lungs (the side you are lying on) will receive highest ventilation and perfusion --> increased blood flow to area of consolidation = increased deoxygenated blood returning to systemic circulation = worsens shunt and O2 sat

57

Best initial steps in mgmt of acute PE?

1) O2 + IV fluids
2) Assess C/I for anticoagulation --> Well criteria
3) Anticoagulate BEFORE confirmatory diagnostic testing

58

Solitary lung nodule is found on CXR. What is next best step?

If there has been a change, next step?

Compare to previous imaging (CXR)

If change from previous films --> CT scan of chest

59

What 3 conditions are associated with small cell carcinoma of the lung?

1) SIADH --> euvolemic with low Na
2) ACTH --> Cushing-like s/s
3) Eaton-Lambert syndrome --> muscle weakness that IMPROVES with use

*Smoking history

60

What extra-pulm finding are you looking for in squamous cell carcinoma?

SCa++mous cell carcinoma --> high Ca

61

Pathophys behind clubbing?

What conditions predispose to clubbing?

Connective tissue proliferation at nail bed and distal phalanx

*Megakaryocytes that skip the normal route of fragmentation w/in pulmonary circulation to enter the systemic circulation --> become entrapped in the distal fingertips due to their large size --> secrete PDGF + VEGF that cause conn tissue hypertrophy and capillary permeability and vascularity = clubbing

**Lung malignancies, CF, R-L cardiac shunts