Pulmonary Flashcards
What are the advantages of MDCT?
The advantages of MDCT are: 1) large sections can be scanned in a single breath, and 2) images are collected precisely when flow of contrast is in the system of interest.
What conditions are diagnosed by high resolution CT scan?
HRCT is indicated to diagnose interstitial lung diseases, emphysema from alpha-1-antitrypsin deficiency, bronchiectasis, and lymphangitic spread of cancer.
In which diseases do you see a reduced DLCO?
Reduced DLCO is seen in emphysema, ILD, pulmonary vascular diseases, and anemia.
Which diagnosis comes to mind in a hyperventilating patient with a normal A-a gradient?
A hyperventilating patient with normal A-a gradient is likely suffering from anxiety.
What is a simple formula for calculating the A-a gradient?
A-a gradient = 149-[PaO2 +(1.25 X PaCO2)] when breathing room air at sea level.
Name 3 factors that, for a specific pO2, cause a decrease in hemoglobin O2 saturation?
Temperature, acidosis, and Phosphorus (2,3-DPG) all decrease O2 saturation for a given PaO2
What does CO poisoning do to the oxyhemoglobin dissociation curve?
CO poisoning shifts the oxyhemoglobin dissociation curve to the left by preventing the O2 from binding to hemoglobin.
What are the symptoms of methemoglobinemia? It’s treatment?
Methemoglobinemia presents with perioral and peripheral cyanosis (>25%), fatigue and dyspnea (35-40%), and coma/death (>60%).
What is vital capacity? Which smaller lung volumes make it up?
Vital capacity is the volume you have available for breathing and comprised of the inspiratory reserve volume (IRV), tidal volume (TV), and expiratory reserve volume (ERV).
Characterize the differences in the flow-volume loops for obstructive and restrictive airway diseases.
Restrictive flow-volume loops have a similar appearance to normal but with smaller volumes. In obstruction the loop has reduced flow and a concave appearance.
When is the methacholine bronchoprovocation test performed?
Methacholine or other bronchoprovocation tests are done to see if a patient with normal spirometry has bronchial hyperreactivity.
What is the DLCO in emphysema? In asthma? In ILD?
DLCO is reduced in emphysema and ILD but normal in asthma.
What are the results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with intrathoracic restriction? In extrathoracic restriction?
In intrathoracic restriction the RV, VC, and TLC are reduced while FEV1 and FEV1/FVC are normal. In extrathoracic restriction VC and TLC are reduced but RV, FEV1, and FEV1/FVC are normal.
What are the results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with obstruction?
In obstructive lungs disease the FEV1, FEV1/FVC are reduced. The RV may be reduced or normal. The TLC and VC are increased.
What is the difference in the DLCO in extrathoracic restriction vs. intrathoracic?
DLCO is normal in extrathoracic restriction and reduced in intrathoracic restriction.
What skin finding is a predisposing factor for IgE-mediated asthma?
Eczema is a predisposing factor for asthma.
What is the “asthma triad”?
The “asthma triad” is allergic asthma, aspirin sensitivity, and nasal polyposis.
What comorbidities exacerbate asthma?
Asthma is exacerbated by GERD, allergic rhinitis, ABPA, OSA, stress, and smoking.
In the management of asthma, the initial treatment is based on ______. After therapy is started, the focus is on _______.
The initial treatment of asthma is based on severity. After therapy is started, the focus is on asthma control and response to therapy.
What spirometry findings are required to diagnose asthma?
To diagnose asthma one must find reduced FEV1 and FEV1/FVC ratio on spirometry.
How do you diagnose exercise-induced bronchospasm?
Exercise-induced bronchospasm is diagnosed by >10% drop in FEV1 after graded exercise on a treadmill or stationary bike.
Describe the relationship between symptom-based monitoring and the peak expiratory flow rate.
Peak expiratory flow is most useful in those with moderate-to-severe asthma and those who cannot reliably describe symptoms of exacerabation. In all other groups symptom-based monitoring is equally effective.
What is the short-acting drug of choice for asthma exacerbations?
Albuterol is the short-acting bronchodilator of choice for asthma exacerbations.
What is the preferred drug for chronic treatment of persistent asthma?
All patients with persistent asthma should be treated with inhaled corticosteroids.
An oral corticosteroid (OCS) is recommended if the peak flow is
An oral steroid is indicated if peak flow is <80% after 3 treatments with a SABA.
According to the expert panel guidelines, when is ipratropium used during inpatient treatment of an asthma exacerbation?
According to expert guidelines, ipratropium is indicated for the management of moderate-to-severe asthma exacerbations.
What are the signs and symptoms of theophylline toxicity? What is a therapeutic level?
Signs of theophylline toxicity include nausea, headache, tremulousness, and palpitations. The therapeutic range for theophylline is 5-15mcg/mL.
What is the preferred treatment for a new patient having asthma symptoms >2 days/week, but not daily, and not more than once a day?
The preferred treatment for a new patient with asthma symptoms >2 days/week but not daily and not more than once per day is a low dose inhaled steroid.
What is the preferred regimen for patients who are on medium-dose inhaled corticosteroids and still require albuterol daily?
The preferred regimen for patients who still require daily albuterol despite medium-dose inhaled steroids is the addition of a LABA.
What is the preferred treatment for patients with exercise-induced bronchospasm?
Albuterol used 15-30 minutes before exercise is the preferred treatment for EIB. If this occurs daily, an inhaled steroid should be added. Montelukast is also useful for >50% of patients with EIB.
For an acute exacerbation, what peak flow measurement requires intervention with medications?
In an acute exacerbation of asthma, a peak flow <80% is an indication to add medicine.
For an acute exacerbation, at what peak flow do you tell your patients to go to the ED?
If the peak flow is <50% the patient should go to the ED.
For patients being treated for asthma exacerbations in the ED, at what peak flow do you consider hospitalization?
If a patient continues to maintain peak flows 40-69% after treatment, they should be admitted.
Explain permissive hypercapnia.
Permissive hypercapnia is controlled hypoventilation through the use of smaller tidal volumes. This prevents development of auto-PEEP.
What ventilator settings are appropriate for a patient intubated for a severe exacerbation of asthma?
A patient intubated for severe asthma exacerbation should be ventilated with low rate, small tidal volume, and high inspiratory flow rate.
What is the specific definition of COPD?
COPD is diagnosed when patients have symptoms of dyspnea, cough, and sputum production with evidence of irreversible airflow obstruction.
In COPD, what are the symptoms of disease in the large airways? The small airways?
COPD of the large airways causes cough and mucus production presenting as chronic bronchitis. In the small airways COPD causes airflow obstruction with hyperinflation.
What is the specific definition of chronic bronchitis?
Chronic bronchitis is defined as cough with sputum production for at least 3 consecutive months within at least 2 consecutive years.
What is the significance of clubbing in a patient with COPD?
Clubbing should not be present in COPD alone. Its presence in a patient with COPD should prompt evaluation for other pathology including ILD or lung cancer.
What is a strong prognostic indicator in COPD?
FEV1 is a strong prognostic indicator in COPD.
A COPD patient with evidence of right heart failure has a resting PaO2 of 58mmHg. How many hours a day should he be on supplemental oxygen?
A COPD patient with evidence of right heart failure and PaO2 of 58mmHg should use supplemental oxygen 24 hours/day.
What are the benefits of pulmonary rehabilitation? Does it improve mortality?
It is unclear whether pulmonary rehab programs improve mortality. They do improve strength and endurance, symptoms, quality of life, and decreases hospitalizations.
Describe the emergent workup of a patient with an apparent COPD exacerbation.
The workup of a patient with a COPD exacerbation should include CXR, ECG, and ABG. Spirometry and peak flow should not be used to diagnose or assess the severity of a COPD exacerbation.
A 30 year old smoker presents with COPD and emphysematous bullae in the bases. What disease should you suspect?
Alpha-1-antitrypsin deficiency should be suspected in a young patient with COPD and emphysematous bullae at the bases.
What is the single environmental agent that worsens lung disease in all types of alpha-1-antitrypsin deficiency?
Smoking worsens lung disease in all types of A-1-AT deficiency.
What are the inhaled treatments for cystic fibrosis?
DNAse and inhaled hypertonic saline are two inhaled treatments for CF that aide airway flow and clearance. Inhaled aminoglycosides are commonly used to decrease airway colonization.
Name the common clinical features of all interstitial lung diseases.
The common clinical features of all ILDs include dyspnea, diffuse disease on CXR, restrictive PFT with a decreased DLCO and elevated A-a gradient.
What disease do you think of when a patient presents with recurrent pneumonia each time she cleans her birdcage?
“Bird fanciers lung” is caused by reaction to feathers or bird droppings.
Characterize the CXR abnormalities in patients with a history of significant asbestos exposure.
Asbestos exposure causes bilateral, mid-thoracic pleural thickening, plaques, and calcifications.
Smoking and asbestos increase the risk of what types of lung cancer?
Smoking has a synergistic effect with asbestos to increase the risk of squamous cell and adenocarcinoma of the lung (but not small cell and non-small cell).
What type of CT scan assists with the diagnosis of idiopathic pulmonary fibrosis (IPF)? What findings are seen in early IPF?
High resolution CT (HRCT) is used in IPF and demonstrates ground-glass opacities in ⅓ of patients with true fibrosis.
What is the typical presentation of a patient with IPF?
IPF typically presents with dyspnea, cough, dry midinspiratory (“Velcro”) crackles, and a diffuse interstitial process on CXR.
How do you evaluate patients with IPF?
The diagnostic workup of IPF includes HRCT, PFTs, ABG, and a functional assessment (6 minute walk test).
Characterize the differences in presentation between IPF and COPD.
IPF differs from COPD in that it presents with restrictive PFTs and often is associated with clubbing.
What finding in a pleural effusion can be helpful in distinguishing rheumatoid arthritis as an etiology?
The pleural effusion in RA is typically exudative and can have a uniquely very low glucose level.
In what pulmonary disease is pulmonary hypertension out of proportion to the amount of pulmonary disease? What causes this?
In scleroderma the pulmonary HTN is often out of proportion to the amount of pulmonary disease due to intimal proliferation of the pulmonary artery.
What are the indications for treatment of sarcoidosis with steroids?
75% of patients with sarcoid improve without treatment. Treatment with systemic steroids is indicated for persistent hypercalcemia and evidence of other organ involvement (eyes, heart, CNS, Lungs (severe symptoms), and skin),
What is the potential lung complication of lymphangioleiomyomatosis?
Pneumothorax can occur in lymphangioleiomyomatosis.
Which vasculitis is c-ANCA+ and anti-PR3+?
GPA (formerly Wegener’s) is associated with c-ANCA and anti-PR3.
Characterize the typical presentation of a patient with granulomatosis with polyangiitis.
GPA typically presents with some combination of upper respiratory tract and paranasal sinus involvement, granulomatous pulmonary vasculitis with large (sometimes cavitary) nodules, and with necrotizing glomerulonephritis.
An asthma patient with worsening symptoms and peripheral eosinophilia makes you think of which disease?
In an asthma patient with worsening symptoms and peripheral eosinophilia think eosinophilic granulomatosis with polyangiitis (EGPA).
EGPA is associated with what medications?
EGPA can be unmasked in the asthma patient on leukotriene modifiers who is weaning oral steroids.
Describe the differences in the presentations of Loffler syndrome, acute eosinophilic pneumonia, and chronic eosinophilic pneumonia.
Loffler syndrome is a self-limited pulmonary eosinophilia that is transient with minimal pulmonary symptoms. It may present with migratory peripheral infiltrates on CXR. Acute eosinophilic pneumonia is an acute, febrile pulmonary illness with hypoxemic respiratory failure resembling ARDS. Chronic eosinophilic pneumonia is a subacute illness with cough, wheeze, night sweats, and low-grade fever.
What is the workup of the uncontrolled asthmatic that you suspect has ABPA?
The workup of ABPA starts with skin test for Aspergillus. This is followed by IgE level and Aspergillus IgG and IgE serologies.
Which organisms cause chronic pneumonia in patients with pulmonary alveolar proteinosis?
Patients with alveolar proteinosis are predisposed to non-resolving pneumonias caused by Nocardia, mycobacteria, or endemic fungi.
Which autoimmune disease are associated with pulmonary hemorrhage? Which cardiopulmonary diseases?
Autoimmune diseases associated with pulmonary hemorrhage include Goodpasture syndrome, SLE, GPA, microscopic polyangiitis, IPH. Cardiopulmonary diseases associated with pulmonary hemorrhage include PE, pulmonary AVMs, aortic aneurysm, pulmonary hypertension, septic emboli, and mitral stenosis.
What common physical exam findings are seen in pulmonary hypertension?
Patients with pulmonary hypertension often present with loud P2, tricuspid regurgitation, and a RV heave.
What are the 1st tests you order in the workup of PH? What follow-up test is done if the 1st tests are suggestive?
The first line tests in the diagnosis of pulmonary hypertension are EKG and echocardiogram. If these are suggestive, a right heart cath is performed.
Which test of lung function, when low, indicates a poor prognosis in pulmonary hypertension?
Reduced DLCO may be the only PFT finding in pulmonary hypertension. A very low DLCO signifies a poor prognosis.
What is the usual cause of pulmonary embolism in hospitalized patients?
PEs in hospitalized patients are usually due to inadequate VTE prophylaxis.
Characterize the clinical findings seen with massive PE.
Massive PE is characterized by hypotension (SBP<90 for >15 minutes or requiring inotropic support), pulselessness, of persistent bradycardia.
What symptoms and physical exam findings are seen more with submassive PE?
Patients with submassive PE have normal BP but signs of RV dysfunction or myocardial necrosis (elevated troponins or BNP).
What is the 1st step in evaluating a patient with possible pulmonary embolism?
Assessing pre-test probability using a validated measure, like the Wells score, is the first step in evaluating a patient for possible PE
