Pulmonology

Question 1

Main difference between asthma and COPD

Answer 1

Both are obstructive lung diseases

asthma = reversible

Question 2

Why is oral temperature not accurate when a patient is having an asthma exacerbation?

Answer 2

Rapid mouth breathing cools the thermometer

Question 3

The best initial test during an acute asthma exacerbation

Answer 3

Peak expiratory flow (PEF)

or

ABG

CXR is often normal, and although PFTs are the most accurate diagnostic test, they cannot be performed during an acute attack

Question 4

What constitutes a positive methacholine test

Answer 4

A >20% decrease in FEV1

Metacholine is synthetic ACh

Question 5

PFTs in Asthma

Answer 5

Decreased FEV1/FVC

Decrease in FEV1 >20% with the use of methacholine or histamine

Increase in FEV1 >12% and 200 mL with the use of albuterol

Increase in DLCO

Question 6

Treatment of asthma

Answer 6

1. SABA (albuterol)
2. Low-dose ICS (beclomethasone)
3. LABA or increase the dose of ICS
4. Increase dose of ICS to maximum in addition to LABA and SABA
5. Omalizumab (if IgE level is increased)
6. Oral corticosteroids (prednisone)

Question 7

Adverse effects of inhaled steroids

Answer 7

Dysphonia

Oral candidiasis

Question 8

Alternative control agents if a patient with asthma refuses inhaled steroids

Answer 8

Cromolyn and nedocromil (inhibit mast cell mediator release)

Theophylline

Leukotriene modifiers: montelukast, zafirlukast*, or zileuton (best wiith atopic patients)

*Zafirlukast is hepatotoxic and has been associated with Churg-Strauss syndrome (inflammation of small and medium sized blood vessels)

Question 9

True/False

High-dose inhaled steroids rarely lead to the adverse effects associated with prednisone

Answer 9

True

Question 10

What is a good indication of the severity of an asthma exacerbation?

Answer 10

Respiratory Rate

Accessory muscle use is subjective, pulse ox will not show hypoxia until the patient is nearly at the point of imminent respiratory failure

Question 11

The severity of an asthma exacerbation is quantified by:

Answer 11

Decreased peak expiratory flow (PEF)

ABG with an increased A-a gradient

Question 12

The PEF is an approximation of…

Answer 12

Force Vital Capacity

There is no precise “normal” value; look to see how much difference there is from a patient’s baseline

Question 13

When is magnesium indicated during an asthma attack

Answer 13

During a severe exacerbation that is not responsive to several rounds of albuterol while waiting for steroids to take effect (take 4-6 hours)

Best initial therapy = oxygen with SABA and a bolus of steroids

Question 14

How does a patient acquire COPD?

Answer 14

Smoking or alpha-1 antitrypsin deficiency

Tobacco destroys elastin fibers; most of the ability to exhale is from elastin fibers in the lungs passively allowing exhalation

Question 15

PFTs with COPD

Answer 15

Decreased FEV1/FVC (under 70%)

Increased Total Lung Capacity (d/t increase in residual volume)

Decreased DLCO*

Incomplete improvement with albuterol

Little or no worsening with methacholine

*Only with emphysema; a normal DLCO is indicative of chronic bronchitis predominant COPD

Question 16

What improves mortality and delays the progression of COPD

Answer 16

1. Stop smoking
2. Oxygen therapy if pO2 <55 or saturation <88%
3. Influenza and pneumococcal vaccinations

Question 17

Next step:

Asthmatics not controlled with albuterol…

vs

COPD not controlled with albuterol…

Answer 17

Asthma = inhaled steroids

COPD = anticholinergic (tiotropium) then inhaled steroiods if ineffective

Question 18

Treatment of acute exacerbations of chronic bronchitis

Answer 18

Bronchodilators and corticosteroid therapy combined with antibiotics

Coverage should be provided against Strep pneumo, H influenza, and Moraxella

Question 19

Why do you avoid placing a patient with COPD on very-high flow 100% nonrebreather mask?

Answer 19

Dyspneic, hypoxic patients with COPD must get oxygen; however, too much creates a V/Q mismatch (damaged airways that are normally constricted, open when exposed to O2)

The idea of “eliminating hypoxic drive” is NOT accurate

Question 20

Define bronchiectasis

Answer 20

Chronic dilation of the large bronchi (permanent anatomic abnormality)

Question 21

The single mot common cause of bronchiectasis is…

Answer 21

cystic fibrosis

Question 22

Define ABPA

Answer 22

AKA Allergic Bronchopulmonary Aspergillosis

Hypersensitivity of the lungs to fungal antigens that colonize the bronchial tree (occurs almost exclusively in patients with asthma and a history of atopic disorders)

Question 23

Treatment for ABPA

Answer 23

1. Oral steroids (prednisone) for severe cases
2. Itraconazole for recurrent episodes
   * Note: inhaled steroids are NOT effective for ABPA (inhaler cannot deliver a high enough dose of steroids)*

Question 24

Meconium ileus

Recurrent pancreatitis

Biliary cirrhosis

Answer 24

Think cystic fibrosis

Question 25

Why are men and women with CF infertile?

Answer 25

Men: 95% have azoospermia, with the vas deferens missing in 20% Women: chronic lung disease alters the menstrual cycle and thick cervical mucus blocks sperm entry

Question 26

For CF, which test is more accurate: increased sweat chloride or genotyping

Answer 26

Increased sweat chloride: \> 60 (use pilocarpine to induce sweating) Genotyping is not as accurate because there are many different types of mutations leading to CF

Question 27

Treatment for CF

Answer 27

1. **Antibiotics** (Nontypable H influenza, Pseudomonas, Staph aureus, Burkholderia)\* 2. Recombinant human deoxyribonuclease: **rhDNase** (breaks down the massive amounts of DNA left by neutrophils in respiratory mucus) 2. Inhaled bronchodilators (**albuterol**) 4. Pneumococcal and influenza vaccinations 5. Lung transplantation 6. Ivacaftor (increases activity of CFTR in some patients) 7. Daily postural drainage and **percussion** * \*Until adulthood, children with CF are most likely to suffer from Staph aureus infections (pseudomonas becomes predominant in adulthood); if a pt has a history of pulmonary infections it is safe to assume that they are colonized with MRSA and you should tailor abx appropriately*

Question 28

The most common infectious cause of death in the US

Answer 28

CAP: defined as pneumonia occurring before hospitilization or within 48 hours of hospital admission Strep pneumo is the most common cause

Question 29

Pneumonia vs bronchitis

Answer 29

Pneumonia = dyspnea, high fever, and an abnormal CXR

Question 30

Organism-specific association of pneumonia on presentation: 1. Hemoptysis, "currant jelly" sputum 2. Foul-smelling sputum, "rotten eggs" 3. Dry cough, rarely severe, bullous myringitis (inflammation of the tympanic membrane) 4. GI symptoms or CNS symptoms 5. AIDS with CD4 \< 200

Answer 30

1. Klebsiella 2. Anaerobes 3. Mycoplasma 4. Legionella 5. Pneumocystis

Question 31

What does the term atypical pneumonia refer to?

Answer 31

An organism not visible on Gram stain and not culturable on standard blood agar *Mycoplasma, Chlamydophila, Legionella, Coxiella, and viruses*

Question 32

Outpatient treatment of pneumonia

Answer 32

If healthy and no abx in last 3 months = **macrolide** (azithro or clarithromycin) or **doxycycline** Comorbidities or abx within the last 3 months = **respiratory fluoroquinolone** (levofloxacin or moxifloxacin)

Question 33

Inpatient treatment of pneumonia

Answer 33

respiratory fluoroquinolone (levofloxacin or moxifloxacin) or ceftriaxone and azithromycin

Question 34

Reasons to hospitalize patients for pneumonia

Answer 34

Hypoxia and hypotension (\<90) as single factors are a reason to hospitalize a patient **CURB-65** Confusion, Uremia, Respiratory distress, BP low, Age \>65 0-1 point = go home 2 or more = admit

Question 35

Pt admitted for CAP with CXR showing a lobar infiltrate and a large effusion. Started on ceftriaxone and azithromycin. What is the next step?

Answer 35

Thoracentesis to determine if a chest tube is warranted Pleural effusion with pH \<7.2, LDH \>60% serum, or protein \>50% serum suggests an exudate (caused by infection or cancer) Empyema reponds rapidly to drainage by chest tube or thoracostomy (acts like an abscess)

Question 36

Who should receive a pneumococcal vaccine?

Answer 36

**Everyone above the age of 65** should receive the 13 polyvalent vaccine, followed in 6-12 months with the 23 polyvalent vaccine Also recommended for those age \<65 with very high risk comorbid conditions (CSF leaks, SCD, cochlear implants, congenital or aquired asplenia, immunocompromised). For adults \<65 with other chronic medical conditions that increase the risk of invasive pneumococcal disease (heart or lung disease, DM, smoking, chronic liver disease), PPSV23 alone is recommended, followed by sequential PCV13 and PPSV23 at age 66

Question 37

Define HAP

Answer 37

Pneumonia developing **more than 48 hours after admission** or after **hospitalization in the last 90 days** Important to define because we _worry about MRSA and pseudomonas_ in these patients: aka macrolides are not acceptable as empiric therapy

Question 38

Which drugs have activity against Pseudomonas?

Answer 38

Aminoglycosides (gentamicin, tobramycin, amikacin) Ciprofloxacin (not as effective) **Pip/tazo** (and other ureidopenicillins) **Ceftazidime, Cefepime** (good for neutropenic fever) Colistin **Carbapenems** (except Ertapanem) Aztreonam KNOW THIS

Question 39

Treatment for VAP

Answer 39

1. Antipseudomonal beta-lactam: cephalosporin or penicillin or carbapenem 2. Second antipseudomonal: aminoglycoside or fluoroquinolone 3. Methicillin-resistant antistaphylococcal agent: vanc or linezolid

Question 40

Patient is treated for VAP and subsequently develops seizures. What medication were they likely started on?

Answer 40

**Imipenem** Risk of seizure increases with renal failure

Question 41

Can daptomycin be used for pulmonary infections?

Answer 41

No Daptomycin is inactivated by surfactant

Question 42

Which abx are good for a lung abscess?

Answer 42

Clindamycin or penicillin *Sputum culture is always the wrong answer for diagnosing a lung abscess*

Question 43

What is the best initial test for Pneumocystis Pneumonia

Answer 43

**CXR** showing bilateral interstitial infiltrates or an **ABG** showing hypoxia or an increased A-a gradient The **most accurate test is a bronchoalveolar lavage**

Question 44

A normal LDH level means what about PCP

Answer 44

That it is NOT the diagnosis In PCP LDH is ALWAYS elevated

Question 45

Treatment for PCP

Answer 45

TMP/SMX for therapy and for prophylaxis Add steroids to decrease mortality if: pO2 \< 70 or an A-a gradient \>35

Question 46

Toxicity with TMP/SMX for PCP, what do you switch to?

Answer 46

Clindamycin and primaquine OR Pentamidine *Clindamycin with primaquine has more efficacy than pentamidine; however, it is contraindicated in G6PD deficiency (look for AA man with bite cells on smear) -- in this case pentamidine would be the answer if they experienced side effects with TMP/SMX (i.e., neutropenia and a rash)*

Question 47

How does treatment for PCP prophylaxis differ from treatment when a patient experiences adverse side effects with TMP/SMX

Answer 47

Treatment = clindamycin and primaquine\* OR pentamidine Prophylaxis = atovaquone OR dapsone\* *\*Both dapsone and primaquine are contraindicated in those with G6PD deficiency*

Question 48

True/False The use of prophylatic medication for HIV is based on CD4 count and the viral load

Answer 48

False Prophylatic treatment is NOT based on the viral load

Question 49

Recent immigrants Prisoners HIV positive Steroid use Hematologic malignancy Alcoholics DM

Answer 49

Risk factors for TB Also includes: healthcare workers and close contacts

Question 50

Best initial test for TB

Answer 50

**CXR** Sputum stain and culture must be done 3 times to fully exclude TB Pleural biopsy is the single most accurate diagnostic test

Question 51

True/False PPD skin testing is never the best test for TB in a symptomatic patient

Answer 51

True

Question 52

Treatment for TB

Answer 52

**RIPE** Rifampin, Isoniazid, Pyrazinamide, and Ethambutol Use RIPE for the first 2 months, then stop ethambutol and pyrazinamide and continue rifampin and isoniazide for the next 4 months (standard of care is **6 months**)

Question 53

When can you treat TB with just "RIP"

Answer 53

You do not need ethambutol if it is known at the beginning of therapy that the organism is sensitive to all TB medications *(RIPE is used as a 4-drug empiric therapy prior to knowing the sensitivity of the organism)*

Question 54

In what cases should you consider extending TB treatment past 6 months?

Answer 54

For cases complicated by: Osteomyelitis Miliary TB Meningitis Pregnancy (or any other time pyrazinamide is not used)

Question 55

Adverse effects of RIPE

Answer 55

R = red color to body secretions I = peripheral neuropathy (coadminister with pyridoxine/B6) P = hyperuricemia (contraindicated in pregnancy) E = optic neuritis/color vision (decrease dose in RF)

Question 56

When should steroids be added to TB treatment?

Answer 56

To decrease the risk of pericarditis OR To decrease neurologic complication in TB meningitis

Question 57

No risk factors, what constitutes a positive PPD

Answer 57

\> 15 mm of induration (erythema is irrelevant)

Question 58

When should a patient have a second PPD within 1-2 weeks if there first PPD was negative?

Answer 58

When they have never had a PPD skin test before (the first test may be falsely negative)

Question 59

Everyone with a reactive PPD test should have a...

Answer 59

**CXR** to exclude active disease **9 months of isoniazid** (decreases lifetime risk of developing TB from 10% to 1%) regardless of BCG vaccine status *The PPD test should not be repeated once it is positive (it will always be positive in the future)*

Question 60

PET is most accurate with...

Answer 60

larger lesions (\>1 cm) *This is a way of telling whether the content of a lesion is malignant without a biopsy. Malignancy has increased uptake of glucose (sensitivity is 85-95%)*

Question 61

Drugs that cause pulmonary fibrosis

Answer 61

**Bleomycin** Busulfan **Amiodarone** Methylsergide Nitrofurantoin Cyclophosphamide

Question 62

Dyspnea, worse on exertion Fine rales or "crackles" Loud P2 heart sound Finger clubbing

Answer 62

Pulmonary fibrosis

Question 63

PFTs for pulmonary fibrosis

Answer 63

Decrease of everything proportionately (FEV1, FVC, TLC, and RV) FEV1/FVC ratio will be normal DLCO is decreased

Question 64

What type of pneumoconioses responds best to steroids?

Answer 64

Berylliosis (due to the presence of granulomas, which are a sign of inflammation) Associated with electronic manufacturing

Question 65

Diagnostic test for sarcoidosis?

Answer 65

CXR is the best initial test: hilar adenopathy is present in more than 95% of patients Lymph node biopsy is the most accurate: noncaseating granulomas *Elevated ACE, Hypercalciuria, Hypercalcemia, and restrictive PFTs*

Question 66

Treatment for sarcoidosis

Answer 66

Prednisone

Question 67

Diagnostic test for PE

Answer 67

CXR, EKG, and ABG are the best initial tests Angiography is the most accurate test, but can be fatal in 0.5% of cases *After doing an ABG, CXR, and EKG, the "best next step" is most often a CT angiogram*

Question 68

What are the most common findings of PE on the best initial tests?

Answer 68

CXR: usually normal (may show atelectasis) EKG: usually shows sinus tachycardia (nonspecific ST-T wave changes are the most common abnormality, NOT S1, Q3, T3) ABG: hypoxia and respiratory alkalosis

Question 69

When is V/Q scan the answer (over Spiral CT)?

Answer 69

In pregnant patients with suspected PE *The CXR must be normal for the V/Q scan to have any degree of accurac*y

Question 70

What is D-dimer good at?

Answer 70

**A negative test excludes a clot**, but a positive test doesn't mean anything *(AKA very sensitive, but poor specificity)* D-dimer is the answer when the pretest probability of PE is low and you need a simple, noninvasive test to exclude thromboembolic disease

Question 71

True/False You do not need a spiral CT or V/Q scan to confirm a PE if there is a clot in the legs

Answer 71

True (therapy does not change) LE Dopplers are a good test if the V/Q and spiral CT do not give a clear diagnosis

Question 72

Best initial therapy for PE

Answer 72

Heparin (Warfarin should be started at the same time in order to achieve a therapeutic INR of 2-3 x normal as quick as possible) Fondaparinux is an alternative to heparin

Question 73

Rivaroxaban Dabigatran

Answer 73

Oral agents that do not require INR monitoring and can be used for the treatment of pulmonary emboli (reach therapeutic effect in several hours, instead of several days like warfarin)

Question 74

When is IVC filter the right answer after a PE?

Answer 74

1. **Contraindication** to anticoagulants (e.g., melena, CNS bleed) 2. **Recurrent emboli** while on heparin or fully therapeutic warfarin (INR of 2-3) 3. **RV dysfunction** with an enlarged RV on echo (filter is placed because the next embous could be fatal)

Question 75

When are thrombolytics the right answer after a PE?

Answer 75

Hemodynamically unstable patients (systolic BP \< 90 and tachycardia) Acute RV dysfunction *There is no specific time limit in which to use thombolytics as there is in stroke or MI*

Question 76

Define pulmonary hypertension

Answer 76

systolic \> 25 or diastolic \> 8 Primary pulmonary hypertension is by definition idiopathic

Question 77

Diagnostic test for pulmonary hypertension

Answer 77

CXR and CT = best initial test (shows dilation of the proximal pulmonary arteries with narrowing of distal vessels) Right heart or Swan-Ganz catheter = most accurate EKG showing R axis deviation, RA an RV hypertrophy

Question 78

Treatment for pulmonary hypertension

Answer 78

Only lung transplantation is curative for idiopathic pulmonary hypertension - Prostacyclin analogues (PA vasodilators): epoprostenol, treprostinil, iloprost, beraprost - Endothelin antagonists: bosentan, ambrisentan - Phosphodiesterase inhibitors: sildenafil These are all better than CCBs, hydralazine, and nitroglycerin

Question 79

What is the most accurate test for OSA

Answer 79

Polysomnography (sleep study) which shows multiple episodes of apnea *_AHI = Apnea Hypopnea Index_* * None/Minimal: AHI \< 5 per hour* * Mild: AHI ≥ 5, but \< 15 per hour* * Moderate: AHI ≥ 15, but \< 30 per hour* * Severe: AHI ≥ 30 per hour*

Question 80

Define ARDS

Answer 80

Defined as having a pO2/FiO2 ratio below 300 \< 200 = moderately severe \< 100 = severe **Respiratory failure from overwhelming lung injury** or systemic disease leading to severe hypoxia with a CXR suggestive of CHF but normal cardiac hemodynamic measurements (ARDS decreases surfactant and makes the lung cells "leaky" so that the aveoli fill up with fluid)

Question 81

Treatment for ARDS

Answer 81

LTVV (low tidal-volume mechanical ventilation) Use **6 mL per kg of tidal volume** **PEEP** to decreases FIO2 requirement (levels of FIO2 above 50% are toxic to the lungs) Maintain the plateau pressure of less than 30 cm of water