Pulmonology 🫁 Flashcards
Which two parts of mechanical ventilation determine O2?
PEEP and FiO2
When do we not do a thoracentesis 1st for effusion
If we suspect CHF, we do a diuretics trial first
Name some CIs for non invasive ventilation
Agitated patient, high risk of aspiration, non resp organ failure, ARDS, severe acidosis, cardio respiratory arrest, upper airway obs, facial trauma, esophgeal anastomosis
Think airway protection, need for invasive over non invasive, and mechanical issues
Myasthenia crisis Mx
Intubate, and IVig and CSs
4 interventions to decrease mortality in COPD
O2, rehab, Vx, stop smoking
Criteria for long term O2 therapy in COPD patients
- Resting arterial oxygen tension (PaO2) ≤55 mm Hg or pulse oxygen
saturation (SaO2) ≤88% on room air - PaO2 ≤ 59 mm Hg or SaO2 ≤ 89% in patients with cor pulmonale,
evidence of right heart failure, or hematocrit >55%
Lung abcess 1st and 2nd line Abx
Ampi and sulbactam
Then clindamycin 2nd line
Patient on ventilation, what criteria is there for spontaneous breathing trial?
pH > 7.25, adequate O2 on minimal support, intact insp effort and no AMS
Treatment for invasive aspergillosis
Voriconazole and echinocandin.. then voriconazole alone.
Best confirmation Invx for aspergillosis
Bronchoscopy with bronchoalveolar lavage
Signs of transient tachypnoea of the newborn
Risk factors (premature etc.). Signs of resp distress. Increase lung volume and clear breath sounds. Interlobular fissure seen on X-RAY
Contrast aspiration pneumonia and chemical pneumonitis. Main differences in presentation
Chemical (acid) = rapid onset, bilateral,
Pneumonia = unilateral, over days, fever, sputum
What is post surgical atelectasis . How to prevent from occurring
Atelectasis after surgery. Usually after 2 days, due to pain restricting TV and thus causing lobar collapse. Causes low O2, increase RR and elevated pH. Prevent by doing post operative deep breathing excersizes
What is respiratory failure due to asthma. What are the signs. Three steps in Mx
Asthma attack signs, with accessory muscle use, silent chest, wheezing actually decreases. K+ may decrease (alkalosis), lactate may increase, and O2 will go down. Do albuterol, LAMA, CS, Mg first. Can quickly trial NIPPV (not as effective as for COPD). Very low threshold for intubation
Lung issue in CREST syndrome
PAH (literally the pulmonary artery endothelial hyperplasia type) not a Pulm HTN secondary to some fibrosis.
Laryngomalacia
Where the supraglottic structures are flabby and collapse. Causes stridor, worse in supine. Presents in infants
Unilateral choanal atresia presentation
Assume usually until adulthood, causing chronic nasal discharge
What are vascular rings, and how do they usually present
Where the great vessels wrap around the trachea and esooahgus. Presents with biphasic stridor, improved with neck extension.
Can you get pulmonary edema in altitude sickness? Treatment aims?
Yes, from the hypoxia vasoconstriction in the lungs causing very high pressure and thus a transudate. Do things to increase oxygen to reduce the vasoConstriction, and to therefor reduce the edema. Take of backpack to reduce o2 consumé, give o2, decent
Why does someone with bronchopulomary dysplasia have HTN
There is increase circulating catecholamines….. causing HTN
And 5 ways to decrease the risk of VAP
Subglottic secretion suction
Avoid PPI use unless 100% needed
Decrease movement of patient
Avoid excess sedation
Elevate head to a 45° angle
Discuss the concepts of ventilation in ARDS
Aim to limits alveolar distension. So Vt (TV) can be low (6-8). This can cause hypoventilation, but we allow this persmissive hypercapnia. The collapsed airways don’t all open up, so giving high pressure or Vt just damages open alveoli. Prone positioning is good. Still use PEEP to recruit some alveoli. Keep FiO2 at its lowest to avoid oxygen toxicity
Aspiration pneumonia Tx
Same as CAP. ceftriaxone and azithromycin… not as heavily anaerobic as once thought
Presentation of high alititude pulmonary edema, and how to differentiate from pneumonia
Our vasoconstriction is very high in some areas of the lung, causing transudate formation. Presents like patchy pneumonia . But will have not too high Leuk, patient will have recently been at high altitudes, procalcitonin normal. Rapid improvement with supplemental O2
What does increase peak pressure and increase plateau pressure mean for lungs
Increase airflow resistance and decrease compliance respectively
When to give O2 Tx, ABx, nocturnal ventilation in COPD
If o2 less than 88
If AECOPD Hx
If hypercapnia
How to Dx carboxyhemoglobin? How to Tx
Do ABG (tells you the HbCO), since pulse ox doesn’t. And Tx with 100% O2
When is inhaled Nitrates given to a neonate
In neonatal pulmonary hypertension
Recall ARDS mx flowchart
Apnoea and gasping, do bag valve mask ventilation. Improves do CPAP, remains to mechanical vent and consider surfactant. If apnoea or gasping at first , do CPAP.
General Tx ideas for otitis media
Oral Abx (if less than 6mo, or more than 6mo patient with serious signs). Amox is first line, then amox plus clavulanic acid 2nd, clinda if allergic. Tympanostomy if 3 or more episode in 6month, or if continuously for 3months .
Most common non hereditary sensory loss in kids
Cong3tninal CMV infx
Dx criteria for obesity hypoventilation syndrome
BMI above 30. Daytime CO2 elevation. No other cause
bronchiectasis secondary to CF is mostly found where in lung
Upper lobes (characteristic of CF Bronchiec)
What are mandibular tori, and what are the general features of benign oral masses. How to Tx
Bong exostosis of the bone…. Into the floor of the mouth. Symmetrical, painless, smooth mucosal cover, slow growth. Reassure patient
Sialolithiasis and sialdenitis Tx?
Lith, give moist heat, water and milk gland, can give NSAID. If infected, give Abx and consider referral to ENT to remove stone,
Screening for lung cancer (what’s done and indications)
More than 20 pack year history (unless haven’t smoked for more than 15 yrs). Above 50 yo. Yearly low dose CT
BPD Dx
A clinical diagnosis. If a premat still requires O2 after 1 month.
If have nasal foreign body…. How do we manage (if seen or non seen)
Remove… if cannot see refer to ENT
Signs and symptoms of laryngomalacia. General Mx
Floppy larynx on around 6 mos. When Inspire the larynx collapses. Causes nosing breathing and insp stridor, worse when supine, and feeding issues. Often GERD concomitantly. Resolved around 18mo, can do Sx if severe
Out the following in order or lines of Tx for massive hemoptysis
Bronchoscopy
Artery embolisation
Thoracotomy
That order is correct
Links between asthma and atelectasis
Asthma causes mucous plugging and thus atelectasis
Compare and contrast Acute and chronic hypersensitivity pneumonitis (and the Tx)
Acute is early on, high dose exposure, tIII hypersensitivity. Forms nodular interstitial opacities. Just remove exposure.
Whereas chronic is due to long term fibrosis and tIV reaction. These patients have reticular interstitial opacities. Likely need GCs or even lung transplant.
Need to drainage of effusion in adults is based on fluid analysis. But in kids, is this the case?
It’s based more on volume. So large, moderate effusion should be drained
Most common lung CA in young non smokers
Bronchial carcinoid
Chronic aspergillosis clinical diagnosis
More than 3 months of signs and symptoms. IgG to aspergillos, and a caviars leasion
Significance of high bnp and troponin in PE case
Signifies high mortality
Causes of recurrent same lobe pneumonias
Consider obstruction first (do CT). Then consider aspiration causes
If different lobes, may be immunodeficiency issues
Blunt thoracic aortic injury invx (consider if stable or not)
Stable, do CTA. Unstable do Transesoph US
Which bacteria are prevalent in CF patients. Consider ages
At first STAPH STAPH STAPH, then around 20 years old it becomes more pseudomonas.
Review the intubation protocol/ criteria for burns patients.
Always five 100% O2 via a non rebreather mask. Then the criteria for intubation is any of the following: face burn, inflam of oropharynx, stridor, HbCO > 10, confined to a burning building, eyebrow singe,
TACO Tx
O2 therapy, and diuretics (furosemide)
X-ray sign of transient tachypnoea of the newborn
Perihilar streaking. (In the interlobular fissure)
Way to differentiate CHD hypoxia and respiratory hypoxia
If O2 therapy helps, then it’s more likely pulmonology based
Main three causes of neonatal respiratory distress
Pulmonary nodules with surrounding ground glass. In a patient with fever, neutropenia
Halo sign, in invasive aspergillosis.
Diagnostic marker for invasive aspergillosis… issue with the test? What to do if -ve
Galactomannan assay. Not sensitive, so if negative, should do BAL or biopsy
Tx of invasive aspergillosis
2 weeks voriconazole
PCP vs invasive aspergillosis
PCP: non productive, diffuse bilateral infiltrates
Invasive aspergillosis: productive, hemoptysis, more localised halo sign
Main differential for acute SoB when CVC inserted
Tension pneumothorax and air emboli
Out of the two protective/reducing mortality inputs to COPD Mx…. Which is most Important and why
To reduce smoking…. In all patients! O2 therapy only if O2 is less than 88**
How to tell if a hemoptysis is from alveolar or non alveolar causes,
Do Bronchoscopy and serial lavage. Many bloody vials will indicate alveoli and point towards diffuse alveolar haemorrhage
Empyema over 2 weeks and has foul smelling drainage . Cause?
Anaerobe . Others like strep cause over 1 week, and don’t smell foul
Why do we love azithromycin so much for COPD
Because it also decreases neutrophil degradation and remodelling of airway (like an extra effect it has)
What do we see in post nasal drip (on oropharynx)
Cobblestoning
Do we give a bit of oral steroid for acute asthma exac? Why?
We do, to decrease the late stage of inflam. So give once a day ~50 mg. This prevents the reexacerbation
What do we see in PCP on CT
Ground glass, patchy infiltrates
Why is mystethnic crisis often hidden from signs and symptoms
Often due to the inability to look like they are in respiratory distress (no use of accessory muscles)
Myasthenia crisis Mx
Low threshold for intubation (any sign of resp failure, met ac, low TV), and either plasmapheresis/IVIg and CSs
Abx that can worsen or even cause mysasthenic crisis. Name one other famous drug
Quinolones or aminoglycosides. Beta blockers
Main cause of sleep apnoea in peads
Adenotonsillar hypertrophy
What is delayed emergence from anaesthesia? What causes it (3). Mx?
Low RR and more, beyond what is expected (often 30 mins or more). Can be a seizure, stroke, high ICP, drug effect or interaction, metabolic disturbance. Either reintubate or put mask on, and consider reversal agents
Signs and risk factors for severe life threatening asthma
Poor control, previous ICU or intubation visit, use of systemic GCs, emergency visit.
RR more than 30, HR more than 120, sat less than 90, PaCO2 high, peak flow less 50% predicated.
Accessory muscle use, AMS, no wheeze and silent chest, marked accessory muscles, severe SoB
Following trauma, what is likely happening if there is excessive extra pulmonary air (in the pleura). For example, the tube was put in to Tx pneumothorax, yet more air comes out still
Tarcheobronchial injury. Do Bronchoscopy
Patient with ARDS, who then has fluids…. At risk of what? Discuss?
Risk of pulmonary edema. So although we need initial fluids, be very conservative after (dry lung is a happy lung). Have a neutral or negative fluid balance. Limit boluses, give diuretics etc.
Over pride of ARDS Mx
Recap on relationship between FiO2 in ARDS
Do initially fairly high, to then take the ABG to see how bad it is. Lower it, to where PaO2 is roughly 92-96, to avoid O2 tox. Cannot really decrease PEEP, since at least 10 PEEP is needed to recruit
Patient with AECOPD who still has issues with medical therapy? Indications to intubate?
For NIPPV (recall how it helps). If AMS, unstable, pH <7.1, then can intubate. Also if done 2 hour trial with NIPPV, and no improvement, do intubation
Indications and CI for NIPPV
Noninvasive positive pressure ventilation
Indications
(strongest evidence)
• COPD (severe exacerbation, prevent extubation failure)
• Cardiogenic pulmonary edema
• Acute respiratory failure
• Postoperative hypoxemic respiratory failure
• Immunosuppressed patients
Facilitate early extubation
Contraindications
Medical instability
• Cardiac or respiratory arrest (or impending arrest)
• Severe acidosis (pH <7.1)
Acute respiratory distress syndrome
• Nonrespiratory organ failure
• Unstable cardiac arrhythmia/hemodynamic instability
• Encephalopathy (Glasgow Coma Score <10)
• Gastrointestinal bleed
Inability to protect airway
• Uncooperative or agitated
• Inability to clear secretions/high aspiration risk
Mechanical issues
• Recent esophageal anastomosis
• Facial or neurologic surgery, deformity, or trauma
Upper airway obstruction
Two types of shock that aortic dissection can cause
Tamponade (obs) and Hemorrhage (hypovolemia)
RFs for pneumonia
HIV, DM, immuno surp, above 65, COPD, CF, URI, smoker, alcoholic, esoph dysmotlity, PPI, sedatives, quietapine
Risk factors for spontaneous pneumomediastinum
Cough violent, tall and thin male, bad asthma exac.
Mx of spontaneous mediastinum
Rest, analgesia, avoid valsalva
Talk a bit about flail chest
Breakage of 3 or more ribs in at least 2 locations. Causing isolated rib cage that doesn’t move with rest of thorax. Causing increase work of breathing. On X-ray, suspect when there is blunt trauma, desat, and many rib fractures
ID a the associated neonatal pathology with the X-ray findings
Interstitial infiltrates and interlobular fissure prominent
Course margins and cystic changes
Bilateral infiltrates and hyperinflation
Diffuse reticular ground glass and air bronchogram
Transient tachypnoea of the newborn
BPD
Meconium aspiration
NRDSO
Rough pHs of empyema, exudate, transudate and normal
Less than 7.3
7.3-7.45
7.4-7.55
7.6
Resp
Two occasions we might see high amylase in pleural fluid
From pancreatitis extension or boerhave (from saliva)
Diaphragmatic rupture invx and Tx
X-ray first, then CT to Dx. Surgery needed to repair
First line therapy for IPF
Pirefenidone. Antifibrotic
Broad ways to tell between aspiration abcess and Tb
Tb will have our usual risk factors. Air fluid levels seem more in abcess. Putrid foul smelling sputum is an aspiration abcess thing. Tb occurs over weeks, abcess over a week
Which is the only shock with elevated SVO2?
Distributive. Also the only one with elevated cardiac index
LV vs RV apical hypokinesis in shocks?
Cardiogenic and obstructive (PE) respectively
Hall mark signs for meconium aspiration syndrome s
Meconium stained amniotic fluid
What is hepatic hydrothroax
Patients with cirrhosis and the diaphragm has high permeability…. Causing hydrothorax on the right
Two main disease causing very low glucose pleural effusion
RA pleurisy and empyema. Both due to lots of WBCs in the pleural fluid
Main mx for amniotic fluid emboli sydmrome
Supportive. Intubate if needed, give vasopressors. Consider transfusion
Difference between pulmonary nodule and mass
Nodule is 3 cm or less
Factors increasing the likelihood that a pulmonary nodule is malignant
Large size*
• Advanced patient age
• Female sex
• Active or previous smoking
• Family or personal history of lung cancel
• Upper lobe location
• Spiculated radiographic appearance
Size correlates to malignant risk. <0.6cm you can even just reassure. >0.8cm and other risks you should biopsy or excise
Cystic fibrosis is famous for having changes in what portions of the lung
Upper lobes
Patient on steroids. Has pneumonia signs, CXR negative, what to do? And why?
CT, since it can reveal a pneumonia. Steroids can lower the consolidation quantity and make it invisible on CXRAY
When to do lung screening
Above 50, and 20 yr pack Hx (unless quite for more than 15 yrs). Do low dose CT every year
Patient with DVT and severe renal issues. How to anticoag
UFH
Naloxone for opioid withdrawal main aim
Give in small doses and titrate. Otherwise can cause withdrawal. And only need to fix Resp rate, not AMS issues
Child with multiple episodes of croup or upper resp tract infections, what should we expect this patient have
Asthma
Hypersensitivity pneumonitis acute and chronic symptoms
History/PE
Acute: Dyspnea, fever, malaise, shivering, and cough starting 4 to 6 hours after exposure;
the physician should gather a job/travel history to determine exposure
Chronic: Presents with progressive dyspnea; physical examination reveals fine bilateral
rales
Loefflor syndrome vs lofgren syndrome
Loffler syndrome is a form of eosinophilic pulmonary disease characterized by absent or
mild respiratory symptoms (most often dry cough), fleeting migratory pulmonary opacities,
and peripheral blood eosinophilia. Lofgren is a sarcoid type, with bilateral hilar LN, arthritis and erythema nodosum
Pulmonary infiltrates less than 24 hrs after injury… contusion or ARDS
more likely contusion. Infiltrates take longer in ARDS
In left heart failure, PEEP is beneficial, why?
as + intrathoracic pressure causes + preload and low afterload. On the other hand, + PEEP worsens right heart failure (increased intrathoracic and pulmonary vascular pressures).
