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Flashcards in Pulmonary and Critical Care Deck (122):
1

4 Pulmonary Function Tests to measure static lung function

Spirometry
Flow-volume loops
Lung volumes
DlCO

2

decreased DLCO and reduced lung volumes

Pulmonary fibrosis

3

decreased DLCO and normal lung volumes

Pulmonary vascular disease, anemia

4

decreased DLCO and airflow obstruction

COPD, bronchiectasis

5

increased or normal DLCO and airflow obstruction

Asthma

6

increased DLCO

Pulmonary hemorrhage, left-to-right shunt, HF, polycythemia

7

normal DLCO and reduced lung volumes

Obesity (extrapulmonary)

8

Spirometry findings to diagnose airflow obstruction (Asthma, COPD, bronchiectasis)

- FEV1/FVC <70%

9

Spirometry findings to diagnose airflow obstruction (Asthma)

- ≥ 12% improvement of FEV1 or FVC and increase ≥ 200 mL from baseline from bronchodilator challenge indicates reversible airway disease

10

Spirometry findings to diagnose restrictive lung disease

TLC < 80%
↓ vital capacity and ↑ residual volume

11

Characteristic findings with Asthma

Nasal polyps and Aspirin sensitivity

12

Rule out test for Asthma

normal bronchoprovocation test

13

Drugs to be discontinued in Asthma

BB (use selective BB such as Metoprolol, Atenolol) and stop ASA and NSAIDs

14

Intermittent Asthma: Symptoms and Tx

≤ 2x/weekly, nocturnal Sx ≤ 2x/month
Asymptomatic and normal PEF between exacerbations
Tx: SABA PRN

15

Mild Persistent Asthma: Sx and Tx

Sx > 2x/week or <1x/day, nocturnal Sx >2x/month
Tx: SABA + low dose inhaled glucocorticoid

16

Moderate Persistent Asthma: Sx and Tx

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

Severe Persistent Asthma: Sx and Tx

Sx: continuous limiting physical activity, frequent nocturnal Sx
Tx: high dose inhaled glucocorticoid + LABA and possibly oral steroids

18

When is Omalizumab (monoclonal antibody targeting IgE) indicated in asthma management

Inadequate control of Sx w/ inhaled glucocorticoids
Evidence of allergies to perennial aeroallergen
IgE levels 300-700kU/L

19

Adverse effects of inhaled glucocordicoids

thrush, hoarseness, osteopenia (need Ca and Vit D supplementation and early DEXA)

20

Use of this medication increases mortality when used as single agent

LABA

21

Theophylline used with what medications causes toxicity

Fluoroquinolones and Macrolides

22

Exercise induced asthma Tx
- Infrequent Sx
- Sx >2x weekly

Infrequent Sx: add cromolyn 15 min before exercise
Frequent Sx >2x/weekly: add Montelukast/Zafirlukast to regular asthma medications depending on severity

23

Tx of asthma in pregnancy

early addition of glucocorticoids is indicated in rapid reversal during excerbation

24

Tx of severe asthma exacerbation

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.