Pulmonary and Critical Care Flashcards
(122 cards)
1
Q
4 Pulmonary Function Tests to measure static lung function
A
Spirometry
Flow-volume loops
Lung volumes
DlCO
2
Q
decreased DLCO and reduced lung volumes
A
Pulmonary fibrosis
3
Q
decreased DLCO and normal lung volumes
A
Pulmonary vascular disease, anemia
4
Q
decreased DLCO and airflow obstruction
A
COPD, bronchiectasis
5
Q
increased or normal DLCO and airflow obstruction
A
Asthma
6
Q
increased DLCO
A
Pulmonary hemorrhage, left-to-right shunt, HF, polycythemia
7
Q
normal DLCO and reduced lung volumes
A
Obesity (extrapulmonary)
8
Q
Spirometry findings to diagnose airflow obstruction (Asthma, COPD, bronchiectasis)
A
- FEV1/FVC <70%
9
Q
Spirometry findings to diagnose airflow obstruction (Asthma)
A
- ≥ 12% improvement of FEV1 or FVC and increase ≥ 200 mL from baseline from bronchodilator challenge indicates reversible airway disease
10
Q
Spirometry findings to diagnose restrictive lung disease
A
TLC < 80%
↓ vital capacity and ↑ residual volume
11
Q
Characteristic findings with Asthma
A
Nasal polyps and Aspirin sensitivity
12
Q
Rule out test for Asthma
A
normal bronchoprovocation test
13
Q
Drugs to be discontinued in Asthma
A
BB (use selective BB such as Metoprolol, Atenolol) and stop ASA and NSAIDs
14
Q
Intermittent Asthma: Symptoms and Tx
A
≤ 2x/weekly, nocturnal Sx ≤ 2x/month
Asymptomatic and normal PEF between exacerbations
Tx: SABA PRN
15
Q
Mild Persistent Asthma: Sx and Tx
A
Sx > 2x/week or <1x/day, nocturnal Sx >2x/month
Tx: SABA + low dose inhaled glucocorticoid
16
Q
Moderate Persistent Asthma: Sx and Tx
A
Sx: daily use of SABA, nocturnal Sx ≥ 1x/week, acute nocturnal exacerbations ≥ 2x/week
Tx: SABA + low dose inhaled glucocorticoid
Add: LABA (salmeterol or formoterol) or medium dose inhaled glucocorticoid or long term controller med (leukotriene modifier or theophylline)
17
Q
Severe Persistent Asthma: Sx and Tx
A
Sx: continuous limiting physical activity, frequent nocturnal Sx
Tx: high dose inhaled glucocorticoid + LABA and possibly oral steroids
18
Q
When is Omalizumab (monoclonal antibody targeting IgE) indicated in asthma management
A
Inadequate control of Sx w/ inhaled glucocorticoids
Evidence of allergies to perennial aeroallergen
IgE levels 300-700kU/L
19
Q
Adverse effects of inhaled glucocordicoids
A
thrush, hoarseness, osteopenia (need Ca and Vit D supplementation and early DEXA)
20
Q
Use of this medication increases mortality when used as single agent
A
LABA
21
Q
Theophylline used with what medications causes toxicity
A
Fluoroquinolones and Macrolides
22
Q
Exercise induced asthma Tx
- Infrequent Sx
- Sx >2x weekly
A
Infrequent Sx: add cromolyn 15 min before exercise
Frequent Sx >2x/weekly: add Montelukast/Zafirlukast to regular asthma medications depending on severity
23
Q
Tx of asthma in pregnancy
A
early addition of glucocorticoids is indicated in rapid reversal during excerbation
24
Q
Tx of severe asthma exacerbation
A
frequent albuterol adminsteration, IV glucocorticoids and inhaled ipratropium
IV magnesium given for life threatning exacerbations
Intubate is signs of respiratory failure
25
When is continuous O2 therapy recommended in COPD
Exercise arterial PO2 ≤ 55mmHg or O2 sat ≤88%
| arterial PO2 55-60mmHg w/ signs of tissue hypoxia
26
what is recommended in COPD when FEV1 <50%
Pulmonary rehab
27
At what FEV1 is lung volume reduction surgery indicated
FEV1 ≤ 20%
28
Patient with Cystic Fibrosis + Abdominal pain
Intussusception
29
Confirmatory test for Cystic Fibrosis
Sweat chloride test followed by genetic testing
30
Cystic Fibrosis patients present with persistent respiratory infections with
Pseudomonas aeruginosa or Burkholderia cepacia
31
What therapy has shown to improve survival and quality of life in pulmonary fibrosis
lung transplant
32
Lofgren Syndrome
fever, B/L hilar lymphadenopathy, erythema nodosum, ankle arthritis
33
Heerfordt Syndrome (uveoparotid fever)
anterior uveitis, parotid gland enlargement, facial palsy and fever
34
Diagnosis of Sarcoidosis
Definite diagnosis requires clinical picture, pathologic demonstration of noncaseating granulomas and exclusion of alternate explanations
35
When can diagnosis of Sarcoidosis be made without histological studies
Lofgren and Heerfordt syndromes
36
Treatment for sarcoidosis
Glucocorticoids
37
Treatment of choice for asymptomatic sarcoidosis
None
38
Treatment for occupational asthma or reactive airway disease
inhaled glucocorticoids
39
Gold standard for diagnosis of occupational lung disease
specific inhalation challenge test (spirometry or PEF before and after work)
40
When are observation and therapy without thoracentesis reasonable with pleural effusions
Heart failure, small parapneumonic effusions or following CABG surgery
41
Light's criteria
Pleural fluid protein/serum protein ratio >0.5
Pleural fluid LDH >200U/L (or >2/3 of upper limit of normal)
Pleural fluid LDH/ serum LDH ratio >0.6
Need 1 criterial met to be considered exudative
42
Discordant findings in light's criteria
In the setting of ongoing diuresis, serum to pleural fluid albumin gradient is >1.2 g/dL the fluid is most likely transudative
43
Causes of Bloody pleural fluid
malignancy, pulmonary infarction, asbestosis
44
Causes of >50,000 WBC in pleural fluid
empyema, complicated parapneumonic effusion
45
Causes of lymphocytosis >80% in pleural fluid
TB, lymphoma, chronic RA, sarcoidosis
46
causes of pH <7.0 in pleural fluid
complicated parapneumonic effusion, TB, RA, lupus pleuritis, esophageal rupture
47
Causes of Pleural fluid amylase to serum amylase ration >1
pancreatic disease, esophageal rupture, cancer
48
Causes of Pleural fluid glucose <60mg/dL
complicated parapneumonic effusion or empyema, cancer, TB, RA, lupus pleuritis, esophageal rupture
49
When is chest tube drainage indicated in parapneumonic pleural effusion
pH <7.2
| pleural fluid glucose <60mg/dL
50
Diagnosis to consider when chylothorax is diagnosed in premopausal woman
Pulmonary LAM (lymphangioleiomyomatosis)
51
Risk factors for spontaneous pneumothorax
tall men who smoke
cocaine use
Marfan syndrome
52
most common cause of secondary pheumothorax
Emphysema
53
When is pleurodesis indicated
after 2nd spontaneous pneumothorax
54
How is pulmonary HTN diagnosed
pulmonary artery perssures ≥ 25mmHg
55
Groups in pulmonary HTN
Group 1: Primary Pulmonary HTN
Group 2: Left sided heart failure
Group 3: Respiratory disease (COPD, ILD, OSA, etc)
Group 4: chronic veneous thromboembolism
56
Evaluation of Group I Pulmonary HTN
Echo: PAP >40mmHg
TEE or Echo w/ bubble to evaluate for intracardiac shunts
Right heart cath to confirm diagnosis and degree of PH
Left heart cath and coronary angiography to exclude LV dysfunction
57
Next step after diagnosis of PAH is confirmed
vasoreactive test using vasodilator agents while measuring PAP changes with right heart cath
58
2 diagnostic criteria for chronic thromboembolic pulmonary HTN
PAP ≥ 25mmHg in absence of left HF
| V/Q scan evidence of chronic thromboembolism
59
Group I PAH treatment
- Disease that is responsive to vasoreactive testing
- Mild to Moderate disease
- Severe disease
- Treatment refractory disease
- CCB
- PO meds: PDE-5 inhibitors (Sildenafil or tadalafil) or endothelin receptor antagonists (Bosentan)
- IV prostacyclin analogue (Epoprostenol)
- Lung or heart-lung transplant
60
Treatment for CTEPH causing PH
life-long anticoagulation
61
Screening TTE for Pulmonary HTN
Scleroderma, liver transplant candidates w/ portal HTN, 1st degree relatives of pts w/ familial PAH, pts w/ congenital heart disease w/ shunts.
62
Signs suggestive of Pulmonary AVM
Hemoptysis
Mucocutaneous telangiectasias
evidence of R->L pulmonary shunts (hypoxemia, polycythemia, clubbing, cyanosis, stroke, brain abscess)
63
Tx for large pulmonary AVM > 2cm
Embolectomy or surgery
64
Lung cancer screening
Ages 55-79 w/ 30pack yr smoking hx, those who currently smoke or have quit within last 15 years. Annual low dose CT until age 80 or quit date >15yrs
65
Initial study for hemoptysis
Chest X-ray
66
Diagnostic test for hemoptysis
Fiberoptic bronchoscopy
67
Definition of solitary pulmonary nodule
lesion of lung parenchyma ≤ 3 cm in diameter that is not associated with lymphadenopathy and is not invading other structures.
68
Best diagnostic test for solitary pulmonary nodule
PET scan
69
First best diagnostic study for solitary pulmonary nodule
comparison with pervious chest x-ray
70
Most common primary malignancies that metastasize to lung
Carcinomas (colon, kidney, breast, testicle and thyroid)
Sarcomas (bone)
Melanoma
71
Anterior mediastinal masses (4Ts)
Thymoma, Teratoma, Thyroid and Terrible Lymphoma
72
Middle mediastinal masses (2)
lymph nodes, cysts (pericardial, bronchogenic, etc)
73
Posterior mediastinal masses (1)
Neurogenic tumors
74
Apnea hypopnea index:
| Mild, Moderate, Severe
Mild: AHI 5-15
Mod: AHI 16-30
Severe: AHI >30
75
Screening questionnaire for OSA
STOP-BANG
76
Treatment of choice for OSA
CPAP
77
Common features of ARDS (3)
- Acute onset (<1week) of respiratory Sx and hypoxia
- B/L lung opacities on imaging not otherwise explained by other processes
- Respiratory failure not explained by HF or volume overload
78
Arterial PO2/FiO2 of Mild, Moderate and Severe ARDS
Mild: 200-300mmHg
Mod: 101-200 mmHg
Severe: ≤ 100mmHg
79
Contraindications for NPPV (5)
```
Respiratory arrest
Arterial blood pH < 7.1
Medical instability
Inability to protect airway and/or excessive secretions
Uncooperative or agitated patient
```
80
Characteristic findings of auto PEEP
wheezing, marked expiratory prolongation, drop in BP, restlessness
81
Stratagies to minimize auto PEEP
- treat airway obstruction (bronchodilators in COPD)
- decrease RR or TV
- Increase peak inspiratory flow rate
- prolong the expiratory phase
- allow permissive hypercapnia
- sedate or paralyze patient
82
What interventions in intubated patients can reduce risk of developing VAP (2)
- Semirecumbent position
| - selective decontamination of oropharynx (using topical gentamicin, colistin or vancomycin)
83
When is extubation considered
when patient is able to maintain arterial O2 >90% on FiO2 ≤ .5, PEEP <5 H2O and pH 7.3
84
Cardiac output, PCWP and SVR in Shock
1) Cardiogenic
2) Hypovolemic
3) Obstructive
4) Anaphylactic
5) Septic
```
Cardiogenic: ↓ CO, ↑ PCWP, ↑ SVR
Hypovolemic: ↓ CO, ↓ PCWP, ↑ SVR
Obstructive: ↓ CO, ↓ PCWP, ↑ SVR
Anaphylactic: ↑ CO, normal PCWP, ↓ SVR
Septic: ↑ CO, ↓ SVR
```
85
SIRS Definition
```
2 or more of following:
Temp >38C (100.4F) or <36C (96.8F)
HR >90/min
RR >20/min or arterial PCO2 <32 mmHg
Leuk >12000 or <4000 w/ 10% bands
```
86
When is enteral nutrition recommended in ICU pts
recommended at 24-48hrs post admission in hemodynamically stable pts.
25-35kcal/kg/day
87
When is parentral nutrition recommended in ICU pts
should not be started before day 7 of acute illness
88
Target BP and Tx for Hypertensive encephalopathy
↓ by 15-20% or DBP to 100-110
| Tx: Nicardipine, Labetalol, Nitroprusside
89
Target BP and Tx for Ischemic stroke
treat if SBP >220 or DBP >120. ↓ by 15%
| Target BP<185/110 if candidate for thrombolyticsTx: Nicardipine, Labetalol, Nitroprusside
90
Target BP and 1st line Tx for Hemorrhagic stroke
BP 160/90 or mean BP 110
| Tx: Nicardipine or Labetelol
91
Target BP, HR and 1st line Tx for Aortic dissection
SBP 100-120
Esmolol or labetalol, add nitropursside as needed
Target HR <65/min
92
Target BP and 1st line Tx for MI
MAP 60-100
| Nitroglycerine and BB
93
Target BP and 1st line Tx for acute left sided HF
MAP 60-100
| Nitroglycerine and/or Nitroprusside (lowers SVR and improves forward flow)
94
Target BP and 1st line Tx for acute kidney injury
↓ 20-25%
Fenoldopam, Nicardipine, BB
ACE inhibitor if scleroderma renal crisis
95
Target BP and 1st line Tx for Preeclampsia, eclampsia
SBP 130-150, DBP 80-100
| Labetelol, hydralazine
96
Target BP and 1st line Tx for sympathomimetic drug
↓ BP by 20-25%
Nicardipine, Nitroprusside
Give Benzodiazepine first, avoid BB
97
Target BP and 1st line Tx for Pheochromocytoma
↓ BP by 20-25%
| Tx: Phentolamine, Nitroprusside
98
Concentration of epi for anaphylaxis vs anaphylactic shoc
Anaphylaxis: IM or subq Epi 0.3-0.5 mg of 1:1000
| Anaphylactic shock: IV Epi (1:10,000)
99
Causes of cues for angioedema:
Hereditary (low C1 inhibitor and C4 levels)
Acquired C1 inhibitor deficiency (low C1q levels)
ACE inhibitor effect (low C1 inhibitor and C4 levels)
100
Antidote for Acetaminophen toxicity
N-acetylcysteine
101
Antidote for Benzodiazepines toxicity
Acute benzo use: Flumazenil
| Chronic benzo use: Observe b/c reversal w/ flumazenil may potentiate seizures
102
Antidote for Beta Blocker toxicity
Glucagon, calcium chloride, pacing
103
Antidote for CCB toxicity
Atropine, glucagon, calcium, pacing
104
Antidote for Digoxin toxicity
Dig immune fab
105
Antidote for heparin toxicity
Protamine sulfate
106
Antidote for narcotic toxicity
Naloxone
107
Antidote for salicylates
urine alkalinization, hemodialysis
108
Antidote for TCA
blood alkalinization (sodium bicarbonate), alpha agonists
109
What carboxyhemoglobin level is diagnostic for severe acute carbon monoxide poisoning
>25%
110
Methanol and Ethanol poisoning treatment
Fomepizole
| Dialysis (if severe)
111
Anion gap and osmolar gap for ethanol, isopropyl alcohol, methanol, ethylene glycol poisioning
Ethanol: NO anion gap, N/A osmolar gap
Isopropyl alcohol: NO anion gap, YES osmolar gap
Methanol: YES anion gap, YES osmolar gap
Ethylene glycol: YES anion gap, YES osmolar gap
112
Sympathomimetic drugs:
What are some examples
Physical manifestation
Examples: Cocaine, Amphetamines, ephedrine, caffeine
Manifestations: tachycardia, hypertension, diaphoresis, agitation, seizures, mydriasis
113
Tx for Sympathomimetic drugs
| Which drugs to avoid
Benzos for agitation
| Avoid: BB for HTN, haloperidol can worsen hyperthermia
114
Cholinergic drugs:
Examples
Manifestations
Examples: Organophosphates, carbamates, physostigmine, edrophonium, nicotine
Manifestations: confusion, bronchorrhea, bradycardia, miosis
115
Tx for Cholinergic drugs
External decontamination for organophosphate poisioning
Atropine, Pralidoxime, mechanical ventilation
116
Anticholinergic drugs:
Examples
Manifestations
Examples: antihistamines, TCA, antiparkinson's agents, atropine
Manifestations: hyperthermia, dry skin and mucous membranes, agitation, delirium, tachycardia, tachypnea, htn, mydriasis
117
Tx for Anticholinergic drugs
Physostigmine for peripheral and CNS symptoms
| Benzos for agitation
118
Indications for Long term O2 therapy in COPD patients
1) Chronic respiratory failure or severe resting hypoxemia, arterial PO2 ≤ 55mmHg or SpO2 of 88% on RA
2) Evidence of pulmonary HTN, right sided heart failure, Polycythemia in combo with arterial PO2 < 60 or SpO2 <88% on RA
119
Indications for lung transplant referral in advanced COPD
1) History of exacerbations associated with acute hypercapnia arterial PCO2 >50mmHg
2) Pulmonary HTN, cor pulmonale or both despite O2 tx
3) FEV 1 <20% of predicted or DLCO <20% of predicted
4) Homogeneous distribution of emphysema
120
Absolute contraindications for lung transplant (7)
1) malignancy within last 2 years
2) hx of Hep B or C infection with evidence of significant lung damage
3) Recent cigarette smoke
4) drug or alcohol abuse
5) severe psychiatric illness
6) medication non compliance
7) poor social support
121
Relative contraindications for lung transplant (2)
1) age >65
| 2) history of significant co morbidities
122
Weaning criteria for spontaneous breathing trial
1) ability to tolerate weaning trial for 30 minutes
2) maintain RR <35/min
3) maintain SpO2 atleast 90% w/o arrhythmias, sudden increase in HR and BP, or development of respiratory distress, diaphoresis or anxiety.
