Pulmonology Flashcards
(391 cards)
1
Q
- SOB - expiratory wheezing
A
asthma
2
Q
- hyperventilation/increased RR - decrease in peak flow - hypoxia - respiratory acidosis - possible absence of wheezing
A
SEVERE asthma exacerbation
3
Q
if asthma diagnosis is unclear
A
PFT before and after inhaled bronchodilators
4
Q
asthma and reactive airway disease are CONFIRMED with what finding on PFT?
A
INCREASE in FEV1 of greater than 12%
5
Q
ALL patients with SOB should receive the following
A
- oxygen - continuous oximeter - CXR - ABG
6
Q
best INITIAL treatment for asthma exacerbation
A
- inhaled bronchodilator (albuterol); no maximum dose - steroid bolus (methylprednisolone) - inhaled ipratropium (ACh receptor antagonist) - oxygen - magnesium
7
Q
when should an asthma patient be placed in the ICU?
A
respiratory acidosis with CO2 retention
8
Q
what is the indication for intubation and mechanical ventilation in asthma?
A
PERSISTENT respiratory acidosis
9
Q
best INITIAL treatment for nonacute asthma
A
inhaled bronchodilator (albuterol)
10
Q
if asthma patient is not controlled on inhaled bronchodilator (albuterol)
A
inhaled steroid
11
Q
if patient is STILL not controlled on inhaled bronchodilator (albuterol), and inhaled steroids
A
inhaled long-acting beta agonist (LABA) (salmeterol, or formoterol)
12
Q
alternate long-term controller medications besides inhaled steroids: extrinsic allergies, such as hay fever
A
cromolyn
13
Q
alternate long-term controller medications besides inhaled steroids: atopic disease
A
montelukast
14
Q
alternate long-term controller medications besides inhaled steroids: COPD
A
- tiotropium - ipratropium
15
Q
alternate long-term controller medications besides inhaled steroids: high IgE levels, no control with cromolyn
A
omalizumab (anti-IgE Ab)
16
Q
last resort for uncontrolled nonacute asthma (if still not controlled on SABA, inhaled steroids, and LABA)
A
PO steroids (many adverse effects)
17
Q
treatment for exercise-induced asthma
A
inhaled bronchodilator BEFORE exercise
18
Q
- long-term smoker - increasing SOB - decreasing exercise tolerance
A
COPD
19
Q
treatment for acute exacerbation of COPD
A
- oxygen (NOT TOO MUCH) - ABG - CXR - inhaled albuterol - inhaled ipratropium - steroid bolus (methylprednisolone)
20
Q
what should be added in treatment for acute exacerbation of COPD, if fever, sputum, and/or new infiltrate is present on CXR?
A
ceftriaxone and azithromycin for CAP
21
Q
management of COPD with mild respiratory acidosis
A
BiPAP or CPAP
22
Q
COPD physical examination findings
A
- barrel-shaped chest - clubbing of fingers - increased AP diameter mf chest - loud P2 heart sound (pulmonary HTN) - edema (blood backing up d/t pulmonary HTN)
23
Q
EKG findings in COPD
A
- right axis deviation (RAD) - right ventricular hypertrophy (RVH) - right atrial hypertrophy (RAH)
24
Q
CXR findings in COPD
A
- flattening of diaphragm - elongated heart - substernal air trapping
25
CBC findings in COPD
- increased hematocrit (sign of chronic hypoxia) - microcytic
26
chemistry finding in COPD
increased serum bicarbonate
27
mechanism of right heart enlargement in COPD
hypoxia = capillary constriction in lungs = diffuse vasoconstriction = increased pressure in RV and RA
28
expected PFT results in COPD
- decreased FEV1 - decreased FVC (loss of elastic recoil of lung) - decreased FEV1/FVC ratio - increased TLC (d/t air trapping) - increased residual volume (RV) - decreased diffusion capacity lung carbon monoxide (DLCO) (destruction of lung interstitium
29
chronic treatment for COPD
- tiotropium/ipratropium - albuterol - pneumococcal vaccine - influenza vaccine - smoking cessation - long-term home O2
30
when is home oxygen indicated in COPD?
- pO2 less than 55 - oxygen saturation less than 88%
31
what lowers mortality in COPD?
- smoking cessation - home oxygen
32
- cirrhosis and COPD - EARLY AGE (
a-1 antitrypsin deficiency
33
CXR findings in a-1 antitrypsin deficiency
- bullae - barrel chest - flat diaphragm
34
blood test findings in a-1 antitrypsin deficiency
- low albumin - elevated PT (caused by cirrhosis) - LOW a-1 antitrypsin level
35
treatment for a-1 antitrypsin deficiency
a-1 antitrypsin infusion
36
- anatomic defect of lungs (from infection in childhood) - profound dilation of bronchi - chronic resolving and recurring episodes of lung infection - VERY HIGH volume of sputum - hemoptysis - fever
bronchiectasis
37
CXR finding in bronchiectasis
- dilated bronchi with "tram tracking"
38
MOST ACCURATE test for bronchiectasis
HRCT (high-resolution CT of chest)
39
treatment for bronchiectasis
- NO curative treatment - chest PT - rotating antibiotics
40
causes of interstitial lung disease (ILD)
- idiopathic - occupational exposure - environmental exposure - medication
41
medications that can cause ILD
- trimethoprim/sulfamethoxazole - nitrofurantoin
42
ILD cause = what disease? asbestos
asbestosis
43
ILD cause = what disease? glass workers, mining, sandblasting, brickyards
silicosis
44
ILD cause = what disease? coal worker
coal worker's pneumoconiosis
45
ILD cause = what disease? cotton
byssinosis
46
ILD cause = what disease? electronics, ceramics, fluorescent light bulbs
berylliosis
47
ILD cause = what disease? mercury
pulmonary fibrosis
48
- SOB with dry, nonproductive cough - chronic hypoxia - 6 months or more of symptoms
ILD
49
PE findings in ILD
- dry rales - loud P2 heart sound (sign of pulmonary HTN) - clubbing
50
CXR finding in ILD
interstitial fibrosis
51
diagnostic tests for ILD
- CXR - HRCT - lung biopsy - PFT
52
PFT findings in ILD
- decreased FEV1 - decreased FVC - NORMAL FEV1/FVC ratio (equally decreased) - decreased TLC - decreased DLCO
53
treatment for ILD
- no specific treatment
54
if biopsy show inflammatory infiltrate in ILD, what is the treatment?
steroid trial
55
ONLY form of ILD that DEFINITELY responds to steroids
berylliosis
56
- bronchiolitis and alveolitis - more acute than ILD, presents in days to weeks - cough, rales, and SOB - fever, malaise, and myalgias (ABSENT in ILD)
bronchiolitis obliterans organizing pneumonia (BOOP) (aka, cryptogenic organizing pneumonia (COP))
57
CXR finding in BOOP
B/L patchy infiltrates
58
chest CT findings in BOOP
interstitial disease and alveolitis
59
MOST ACCURATE test for BOOP
open lung biopsy
60
treatment for BOOP
steroids (no response to antibiotics)
61
- black, female, less than 40 yoa - cough, SOB, and fatigue over a few weeks to months - rales
sarcoidosis
62
best INITIAL test for sarcoidosis
CXR (enlarged lymph nodes, and maybe ILD)
63
MOST ACCURATE test for sarcoidosis
lung or LN biopsy (NONcaseating granulomas)
64
what will BAL show in sarcoidosis?
increased # of helper cells
65
best treatment for sarcoidosis
steroids
66
- SOB, more often in young women
pulmonary hypertension
67
pulmonary HTN can occur 2/2?
- MS - COPD - PV - chronic PE - ILD
68
PE findings in pulmonary hypertension
- loud P2 - TR - right ventricular heave - Raynaud's phenomenon
69
TTE findings in pulmonary hypertension
- RVH - enlarged RA
70
EKG finding in pulmonary hypertension
RAD
71
MOST ACCURATE test for pulmonary hypertension
right heart catheterization (Swan-Ganz catheterization) (increased pulmonary artery pressure)
72
treatment for pulmonary hypertension
- bosentan (endothelin inhibitor) - epoprostenol/treprostinil (prostacyclin analogs = pulmonary vasodilators) - CCB - sildenafil
73
- SUDDEN SOB - CLEAR lungs - patient with risk factors for DVT: immobility, malignancy, trauma, surgery, hematological abnormalities
pulmonary embolism
74
CXR findings in PE
- MC result is NORMAL - MC ABNORMALITY is atelectasis
75
EKG findings in PE
- SINUS TACHYCARDIA - MC abnormality is nonspecific ST-T wave changes - RAD/RBBB (uncommon)
76
ABG findings in PE
- hypoxia - increased A-a gradient - mild respiratory alkalosis (2/2 hyperventilation)
77
mechanism of right heart strain in PE
severe pressure increase in PA and RV d/t clot
78
standard test to confirm PE
CTA
79
for a V/Q scan to be accurate, the CXR MUST be
NORMAL (the less normal the CXR, the LESS accurate the V/Q scan)
80
if V/Q scan is low-probability, does it exclude PE
NO, 15% still have a PE
81
if V/Q scan is high-probability, does it definitely include PE
NO, 15% don't have a PE
82
sensitivity of LE doppler
70%
83
if D-dimer is negative
PE extremely unlikely
84
MOST ACCURATE test for PE
angiography
85
patient with PE and CONTRAINDICATION to AC, next step in management
IVC filter
86
treatment for PE
- heparin and O2 - warfarin for AT LEAST 6 MONTHS
87
treatment for PE in HEMODYNAMICALLY UNSTABLE patient (hypotension)
thrombolytics
88
thrombolytics MOA
activate plasminogen to plasmin
89
best INITIAL test for pleural effusion
CXR
90
next step after CXR for pleural effusion
decubitus films with pt lying down
91
MOST ACCURATE test for pleural effusion
thoracentesis
92
pleural effusion: exudate causes and lab findings
- cancer - infection - HIGH protein (\> 50% of serum level) - HIGH LDH (\> 60% of serum level)
93
pleural effusion: transudate causes and lab findings
- CHF - LOW protein (
94
treatment for SMALL pleural effusion
- NO treatment needed - diuretics can be used, especially for CHF
95
treatment for LARGER pleural effusion, especially from infection (empyema)
chest tube
96
treatment for LARGE, and RECURRENT pleural effusions
pleurodesis
97
treatment if pleurodesis FAILS
decortication (stripping of pleura from lung)
98
- obese patient - daytime somnolence - severe snoring - HTN, HA, ED, fat neck
sleep apnea
99
MCC of sleep apnea (95% of cases)
fatty tissue of neck blocking breathing
100
cause of small % of patients with sleep apnea
central sleep apnea (decreased respiratory drive from CNS)
101
how is sleep apnea diagnosed?
sleep study (polysomnography)
102
definition of MILD sleep apnea
5-20 apneic episodes/hour
103
definition of SEVERE sleep apnea
more than 30 apneic episodes/hour
104
treatment for sleep apnea: OBSTRUCTIVE DISEASE
- weight loss - CPAP (continuous positive airway pressure, or BiPAP
105
if initial treatment for sleep apnea: OBSTRUCTIVE DISEASE is not effective
- surgical resection of uvula, palate, and pharynx
106
treatment for sleep apnea: CENTRAL SLEEP APNEA
- avoid alcohol and sedative - acetazolamide (causes metabolic acidosis = helps drive respiration) - medroxyprogesterone (central respiratory stimulant)
107
mechanism of acetazolamide
carbonic anhydrase inhibitor
108
- asthmatic patient with WORSENING asthma symptoms - brown mucous plug production - recurrent infiltrates - peripheral eosinophilia - elevated serum IgE - central bronchiectasis
allergic bronchopulmonary aspergillosis (ABPA)
109
diagnostic tests for allergic bronchopulmonary aspergillosis (ABPA)
- Aspergillus skin testing - IgE - precipitins - A. fumigatus-specific Ab
110
treatment for allergic bronchopulmonary aspergillosis (ABPA)
ORAL corticosteroids
111
allergic bronchopulmonary aspergillosis (ABPA) treatment in refractory disease if steroids don't work
itraconazole
112
- sudden, SEVERE respiratory failure syndrome - diffuse lung injury 2/2 OVERWHELMING systemic injuries
acute respiratory distress syndrome (ARDS)
113
possible ARDS causes
- sepsis - aspiration of gastric contents - shock - infection: pulmonary or systemic - lung contusion - trauma - toxic inhalation - near drowning - pancreatitis - burns
114
CXR finding in ARDS
diffuse patchy infiltrates that become confluent
115
wedge pressure in ARDS
NORMAL
116
pO2/FIO2 ratio in MILD ARDS
201-300
117
pO2/FIO2 ratio in MODERATE ARDS
101-200
118
pO2/FIO2 ratio in SEVERE ARDS
100 OR LESS
119
treatment for ARDS
- ventilator - positive end expiratory pressure (PEEP) (keep alveoli open) - prone positioning - diuretics - positive inotropes (dobutamine) - ICU
120
Swan-Ganz (pulmonary artery) catheterization: HYPOVOLEMIA - cardiac output - wedge pressure - systemic vascular resistance (SVR)
- LOW - LOW - HIGH
121
Swan-Ganz (pulmonary artery) catheterization: CARDIOGENIC SHOCK - cardiac output - wedge pressure - systemic vascular resistance (SVR)
- LOW - HIGH - HIGH
122
Swan-Ganz (pulmonary artery) catheterization: SEPTIC SHOCK - cardiac output - wedge pressure - systemic vascular resistance (SVR)
- HIGH - LOW - LOW
123
- fever - cough - +/- sputum - SOB
pneumonia
124
CAP organism
pneumococcus
125
HAP organism
gram-negative bacilli
126
CURB 65
- confusion - BUN greater than 19 - RR greater than 30 - BP less than 90/60 - age greater than 65
127
best INITIAL diagnostic test for pneumonia
CXR
128
MOST ACCURATE test for pneumonia
sputum gram stain and culture
129
pneumonia with SOB, order
oxygen
130
pneumonia with SOB and/or hypoxia, order
ABG
131
OUTPATIENT treatment for pneumonia
macrolide OR respiratory fluoroquinolone macrolide = azithromycin/clarithromycin fluoroquinolone = levofloxacin/moxifloxacin
132
INPATIENT treatment for pneumonia
- ceftriaxone, AND azithromycin OR - fluoroquinolone ONLY
133
treatment for ventilator-associated pneumonia (VAP)
- imipenem/meropenem, piperacillin/tazobactam, or cefepime AND - gentamicin AND - vancomycin/linezolid
134
does a positive sputum culture mean pneumonia?
NO
135
specific associations for pneumonia: recent viral syndrome
Staphylococcus
136
specific associations for pneumonia: alcoholic
Klebsiella
137
specific associations for pneumonia: GI symptoms, confusion
Legionella
138
specific associations for pneumonia: young, healthy patient
Mycoplasma
139
specific associations for pneumonia: birth of animal (placenta)
Coxiella burnetii
140
specific associations for pneumonia: Arizona construction worker
Coccidioidomycosis
141
specific associations for pneumonia: HIV with CD4 count less than 200
Pneumocystis jirovecii (PCP)
142
ventilator-associated pneumonia
- fever - hypoxia - new infiltrate - increasing secretions
143
when should steroids be given in PCP pneumonia?
- pO2 less than 70 - A-a gradient more than 35
144
- risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics) - fever, cough, sputum, weight loss, night sweats
tuberculosis (TB)
145
best INITIAL test for tuberculosis (TB)
CXR
146
test to confirm TB
sputum acid-fast stain and culture
147
treatment for TB
1. isoniazid (INH) x 6 mos 2. rifampin x 6 mos 3. pyrazinamide x 2 mos 4. ethambutol x 2 mos
148
ALL the antituberculosis medications can cause?
hepatotoxicity
149
when should antituberculosis medications be stopped if transaminases become elevated?
reach 5x upper limit of normal
150
adverse effect of isoniazid
peripheral neuropathy
151
adverse effect of rifampin
red/orange-colored bodily secretions
152
adverse effect of pyrazinamide
hyperuricemia
153
adverse effect of ethambutol
optic neuritis
154
which conditions require TB treatment for MORE THAN 6 months
- osteomyelitis - meningitis - miliary TB - cavitary TB - pregnancy
155
what is a POSITIVE PPD test?
5mm: close contacts, pts on steroids, HIV-positive 10mm: risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics, healthcare workers) 15mm: those without increased risk
156
if a patient has NEVER been tested for TB, how should the patient be tested?
2-stage testing (if FIRST test is NEGATIVE, repeat test in 1-2 WEEKS to confirm)
157
what is the indication for IGRA (interferon gamma release assay) (Quantiferon)?
same as PPD
158
what is the lifetime risk for HIV-UNinfected individuals with latent TB infection developing active TB d/t reactivation?
10%
159
what is the lifetime risk for HIV-INFECTED individuals with latent TB infection developing active TB d/t reactivation?
10%/year!
160
if PPD is POSITIVE, next step?
CXR
161
if PPD is positive, and CXR is ABNORMAL, next step?
sputum staining for TB
162
if sputum staining for TB is POSITIVE, next step?
treat with full-dose, 4-drug therapy
163
if PPD is POSITIVE, but CXR is NEGATIVE
isoniazid ALONE for 9 MONTHS
164
once a PPD is POSITIVE, should you repeat it?
NEVER
165
What is stop bang?
Method to clinically diagnose sleep apnea
STOPBANG (Snorlax is Tired Ofchoking/gasp in highaltitudeswithighbloodPressure, becauseofhis BMI oldAge Necksize and maleGender) \*old
S Snoring, Texecive daytime tiredness, O observed apneas or choking/gasps, P High BP
B BMI\>35, A50, N Neck size 30\> 17, G male gender
\>5% high risk
\>3-4 intermediate
\>0-2 low
166
What is GOLD criteria in COPD?
pulmonary function testing, a postbronchodilator FEV1/FVC ratio of \<0.70 is commonly considered diagnostic for COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizes airflow limitation into stages. In patients with FEV1/FVC \<0.70:
GOLD 1 - mild: FEV1≥ 80% predicted
GOLD 2 - moderate: 50% ≤FEV1 \<80% predicted
GOLD 3 - severe: 30% ≤FEV1 \<50% predicted
GOLD 4 - very severe: FEV1 \<30% predicted.
167
What is cough variant asthma?
Cough variant asthma is a chronic non productive cough which is worse at night and triggered by exercise, allergen expoure, forced expiration. Lack classic symptoms like wheezing, sob. and unremarkable phx exam findings are common. Even in periods of active persistent symptoms.
## Footnote
\*Clue\* at the case where the patient is normal and cough only exhibited when patient is asked to do a forced expiration.
168
What are the two most common causes of cough?
GERD is associated heartburn following meals
Upper airway cough syndrome UACS (post nasal drip) which is accompanied by rhinorrhea
169
What acute asthma exacerbation?
Oxygen, Duonebs, IV methylprednisolone, steroid taper,...additional therapy racemic epinephrine, magnessium,
If patient stops wheezing or CO2 begins to rise then intubate
170
What is different in pregnant women during asthma exacerbation?
Dont give epinepherine
171
Name short acting beta agonist
Fenoterol
Levalbuterol
Albuterol
Terbutaline
172
Long acting beta agonist?
Formoterol
Arfomoterol
Indacaterol
Salmeterol
Tulobuterol
Olodaterol
173
Short acting antimuscarinic
Ipatropium bromide, Oxitropium bromide
174
Long acting antimuscarinic?
Acildinium bromide
Glycopyrronium bromide
Tiotropium
Umeclidinium
175
What are Inhaled corticosteroids?
Beclomethasone, Budenoside, Fluticasone
176
Systemic Corticosteroids?
Prednisone, Methylprednisolone
177
Phosphodiesterase -4 inhibitors?
Roflumilast
178
Methylxanthines?
Aminophylline
Theophylline
179
Allergic bronchopulmonary aspregilliosis is seen in what history?
Asthma and cystic fibrosis
180
What do you see in on CXR in ABPA?
Xray you may see fleeting inflitrates
CT you may see bronchiectais
181
What is diagnostic ABPA?
Skin test positive aspergillius fumigatus, esosinophillia \>500/uL, IgE \> 417 IU/ml, specific IgG and IgE A. fumigatus
182
What factors decrease risk for solitary pulmonary nodules?
Remember S3AC
If less than 0.8cm, smooth,non smoking, less than 45, non calcified then the person has a low probability for cancer add male to the mix
183
ABPA is treated?
Systemic glucocorticoids and antifungal either itraconazole or voriconazole
184
What is the use of End tidal CO2
Use of end tidal co2 to determine whether or not intubation is successful… during CP you want end tidal co2 to be above 10 and End tidal 35-45.
185
Why end tidal?
CPR quality assessment
ROSC assessment
ET Tube placement
186
What is another term End Tidal CO2?
Persistent capnographic waveform with ventilation.
187
What are the charecteristics of adenocarcinoma?
MCC of cancer in females, associated with hypertrophic osteoarthopathy "clubbing". Bronchioloalveolar subtype: shows hazy inflitrate on CXR and has excellent prognosis.
188
What is Squamous cell carcinoma?
Hilar mass arising from bronchus
Cavitation, Cigarette smoking, and hypercalcemia (PTHrp). If inoperable then treated with chemotherapy. Also remember keratin pearls and intercelluar bridges.
189
What is the characteristics small cell (oat cell) carcinoma?
May produce ACTH, ADH, or Antibiotics against presynaptic calcium Lambert-eaton syndrome, amplification of myc oncogenes.; Neoplasm of neuroendocrine kulchitisky cells which are dark blue cells.
190
What Brochial carcinoid tumor?
Excellent prognosis, metastasis rare. ... symptoms usually due to mass...occasionally carcinoid syndrome...serotonin secretion.
191
Recurrent pneumonia in elderly smoker is the first manifestation of??
Manifestation of bronchogenic carcinoma: Recurrent pneumonia in elderly smoker is the first manifestation of bronchogenic carcinoma and the best test for obstructive cancer in the lung is flexs bronchoscopy
192
Who should get Low dose CHEST CT scan?
Yearly Low Dose CT scan should be provided for patients who are 55-80yrs,
who has had \>30 pack year smoking history,
is a current smoker
smoking within the last 15 years.
END study at age 80, quit smoking more than 15 years ago, or unwilling to do surgery
193
If Vq scan shows low probability does that mean PE is ruled out?
No PE is excluded but not ruled out unless v/q scan is negatve
194
Patient with OHS has an increased of what during procedure so you have to be very careful
OHS is at increased risk for perioperative hypercapnic/hypoxic respiratory failure especially when anesthesia will
195
What do you do in case of pneumothorax?
Needle decompression may be done. But the pneumothorax is ultimately treated with chest thorax
196
What is TRALI?
Tranfusion related acute lung injury.
After transfusion cytokines are released and cause increased endothial permeability which alveolar capilar pulmonary damage which can ARDS
Clinical features are similar to ARDS like are like inflitraion on cxr, hypoxia, white or pink tracheal aspiration following tracheal intubation.
Mortality : 41-67% + TRALI/ARDS
197
What is TACO?
TACO - Tranfusion associated circulatory overload when too much blood is transfused too quickly
198
What is differency between TACO and TRALI clinically?
TACO EF \<40, TRALI EF \>50, TACO PCWP \>18, TRALI PWCP \<18, FLUID BALANCE in TACO is elevated, Fluid balance in TRALI is neutral. TACO has elevated BNP\>1200, TRALI \<250 decreased BNP. Temp in taco is unchaged, Temp in trali is febrile. WBC in Trali is decreased but unchanged in Taco.
199
When should you be concern with Chronic cough in children?
Chronic cough in children greater than 4 weeks warrants spiromerty so look for duration
200
How do you treat mild croup?
Humidified air with or without corticosteroids
201
How to treat moderate to severe croup with involves stridor at rest?
Corticosteroids + nebulized epinepherine
202
203
What is the preventative treatment of bronchiolitis?
Give Palivizumab to children \<29 weeks gestation, Chronic lung disease of prematurity, hemodynamically significant congenital lung disease
204
A child less than 2 years of age presents with nasal congestion, wheezing/crackles,& respiratory distress(tachypnea, retracitions, nasal flaring)
Bronchiolitis
205
How do you treat Bronchiolitis?
Supportive care
206
What asthma symptoms seen in intermittent severity?
when the patient has symptoms and saba use less than 2 days a week and less than 2 times of nighttime awakenings at night
207
What type of symptoms seen in mild persistent asthma?
symptoms and saba use More than 2 times a week but not daily. Nighttime awakenings that are 3-4 times a month. step 2
208
What type of symptoms seen in moderate persistent asthma?
Daily symptoms and saba use. Nightime awakening is More than 1 times per week but not nightly
209
What type of symptoms seen in severe persistent asthma?
Symptoms and saba use all throughout the day and nighttime awakening 4-7 times a week.
210
Lung cancer screening is associated with what RRR in mortality risk and False positive rate?
RRR 20% and False Positive 96%
211
Recurrent Pneumonia in the elderly smoker?
What is bronchogenic carcinoma and its first manifistation
212
Signs of TB pleural effusion
lymphocyte predominance with exudative effusion with elevated adenosine deaminase and pleural biopsy is required for diagnosis
213
Which Lung nodules are least suspicios for cancer?
S3AC, Size,smooth, smoking, age, calification
Size \<8mm, smooth, nonsmoking less that forty, popcorn calcification, concentric calcification, or diffuse homogenous calcifications
214
Which Lung nodules are most suspicios for cancer?
S3AC, Size,smooth, smoking, age, calification
Size \>20mm, spiculed, smoking, age greater 70, no calcification or eccentric calcification.
Hard nodules
215
Common causes of post operative hypoxemia:
Airway obstruction/edema
Stridor immediately after surgery, often due to endotrachial or pharyngeal muscle laxity
216
Common causes of post operative hypoxemia:
Residual anestetic effect
Diminshed residual effect which occurs immediately after. Associated with anesthetic agens, benzodiazepines, opiates.
217
## Footnote
Common causes of post operative hypoxemia:
Bronchospasm
Wheezing which typically occur early within a few hours.
218
Common causes of post operative hypoxemia:
Pneumonia
Fever elevated WBC, Purulent secretions, and inflitrate on Xray 1-5 days after operation
219
Common causes of post operative hypoxemia:
Atelectasis
Splinting and reduced cough, retain secretions, after thoraabdominal surgeries 2-5 days after.
220
Common causes of post operative hypoxemia:
Pulmonary Embolism
Uncommon before 3 days. Chest pain, tachycardia with hypoxia which shows little improvement on supplemental oxygen.
221
Post hypercapnic respiratory failure due anestethesia effect has the following characteristics?
Seen often in patients with OSA, notable decreased respiratory drive, depressed stated of arousal, notable decreased respiratory rate, tidal volume, respiratory acidosis, and normal A-a gradient.
222
What us stridor?
high-pitched, wheezing sound caused by disrupted airflow. Stridor may also be called musical breathing or extrathoracic airway obstruction. Airflow is usually disrupted by a blockage in the larynx (voice box) or trachea (windpipe).
223
What is respiratory splinting?
is when we immobilize something to prevent pain or damage.Respiratory splinting, if performed improperly, can prevent this process and do more harm than good.
224
How do 2,3-BPG levels change in resposne to high altitude?
Increase
225
What does a V/Q ratio close to zero indicate?
Airway obstruction
226
Which way does CO2 shift the oxygen-hemoglobin dissociation curve?
Right
227
What is the equation for the collapsing pressure of an alveolus?
Collapsing Pressure = P = [2(surface tension)]/radius}
228
During which week of gestation are mature levels of surfactant achieves?
{{c1::Week 35}}
229
During which week of gestation does lung surfactant production begin?
week 26
230
At which vertebral level does the IVC perforate the diaphragm?
{{c1::T8}}
231
At which vertebral level does the Vagus Nerve (CN X) perforate the diaphragm?
{{c1::T10 (both trunks)}}
232
At which vertebral level does the aorta perforate the diaphragm?
{{c1::T12}}
233
What is the mmemonic for diaphram perforation?
I 8 10 eggs at 12
IVC 8
Esophagus 10
Aorta 12
234
What is the typical lung Tidal Volume (TV)?
{{c1::500 mL}}
235
Which lung volume equates to the volume of air that can still be breathed out after normal expiration?
{{c1::Expiratory Reserve Volume (ERV)}}
236
Which lung volume equates to the volume of air that remains in the lung after a maximal expiration?
{{c1::Residual Volume (RV)}}
237
Which lung volumes make up lung Inspiratory Capacity (IC)?
{{c1::IRV + TV}}
238
Which lung voume cannot be measured on spirometry?
{{c1::Residual Volume (RV)}}
239
Which lung volumes make up lung Functional Residual Capacity (FRC)?
{{c1::RV + ERV}}
240
Functional) Vital Capacity (VC)?
is a lung capacity that equates to the maximum volume of air that can be expired after a maximal inspiration.
241
Which lung volumes make up Total Lung Capacity (TLC)?
LITER
{{c1::IRV + TV + ERV + RV}}
242
What is the equation for Minute Ventilation (VE)?
VE = VT \* RR
243
Which modified form of hemoglobin is used to treat cyanide poisoning?
Methemoglobin
We use nitrates to oxidize hemoglobin into methemoglobin which then binds to cyanide. Thiosulfate is then used to bind this cyanide, forming thiocyanate which is renally excreted.
244
What type of drugs do we use to oxidize Hemoglobin into Methemoglobin such that we can treat cyanide poisoning?
{{c1::Nitrates}}
We use nitrates to oxidize hemoglobin into methemoglobin which then binds to cyanide. Thiosulfate is then used to bind this cyanide, forming thiocyanate which is renally excreted.
245
What is the treatment for Methemoglobinemia?
{{c1::Methylene Blue}}
246
Carboxyhemoglobin??
{{c1::Carboxyhemoglobin}} is a modified form of hemoglobin that is bound to CO in place of O2.
247
Which lung volumes make up lung (Functional) Vital Capacity (VC)?
{{c1::FRC: TV + IRV + ERV}}
248
Which morphological form of Hemoglobin has lower O2 affinity?
Taut (T) form
249
How does Hemoglobin's affinity for O2 change following an increase in CO2?
Decreased affinity; taut form is favoured; dissociation curve shifts to the right; O2 unloading is favoured}
250
Which morphological form of Hemoglobin has high O2 affinity?
Relaxed (R) form; 300x more affinity than the taut form
251
Why does fetal hemoglobin (HbF) have a higher affinity for O2?
c1::It has lower affinity for 2,3-BPG, which decreases O2 affinity
252
Methemoglobin??
is a modified form of Hemoglobin that is oxidized and thereby has a ferric (Fe3+) atom in its heme group.
253
How does the O2-hemoglobin dissociated curve shift in Carboxyhemoglobinemia?
{{c1: :Left shift; there is decreased O2 binding capacity and decreased O2 unloading at tissue}}
254
How does Hemoglobin's affinity for O2 change if there is a right-shift in the Hb saturation curve?
Blood easily leaves tissue
255
How does peak expiratory flow (PEF) change in Asthma (Reactive Airway Disease)?
{{c1::Decrease}}
256
How does FEV1 change in Asthma (Reactive Airway Disease)?
{{c1::Decrease}}
257
How does residual volume change in Asthma (Reactive Airway Disease)?
{{c1::Increase}}
258
?????? is a monoclonal antibody that can be used as prophylaxis against RSV in high-risk infants \< 2 years of age.
{{c1::Pavilizumab}} is a monoclonal antibody that can be used as prophylaxis against RSV in high-risk infants \< 2 years of age.
259
{{??}} and {???}} are 2 respiratory infections that do not respond to aerosolized racemic epinephrine.
{{c1::Epiglottitis}} and {{c2::Tracheitis}} are 2 respiratory infections that do not respond to aerosolized racemic epinephrine.
260
{{????} is a respiratory disorder that presents with hoarse voice, inspiratory stridor and a characteristic seal-like, barking cough.
{{c1::Croup (Laryngotracheobronchitis)}} is a respiratory disorder that presents with hoarse voice, inspiratory stridor and a characteristic seal-like, barking cough.
261
???} is a respiratory disorder described as acute inflammatory illness of the small airways.
{{c1::Bronchiolitis}} is a respiratory disorder described as acute inflammatory illness of the small airways.Commonly occurs in children \< 3 years of age.
262
What is the onset of Croup?
What is the onset of Croup?
{{c1::2-3 days}}
263
What is the most important test to do acutely in patients with pulmonary edema?
What is the most important test to do acutely in patients with pulmonary edema?
{{c1::EKG}}
If arrythmia is causing the pulmonary edema, the fastest way to fix is with cardioversion.
264
{?????}} is an acute inflammatory disorder of the upper respiratory ract that especially affects the subglottic space.
{{c1::Croup (Laryngotracheobronchitis)}} is an acute inflammatory disorder of the upper respiratory ract that especially affects the subglottic space.
265
What normal lab value essentially rules out Pneumocystis Pneumonia as the most likely diagnosis?
What normal lab value essentially rules out Pneumocystis Pneumonia as the most likely diagnosis?
{{c1::A normal LDH}}
It is always elevated
266
Which arrhythmias are seen in COPD patients?
Which arrhythmias are seen in COPD patients?
{{c1::A-fib or multifocal atrial tachycardia}}
267
What PEF/FEV1 ratio is seen in mild intermittent asthma?
What PEF/FEV1 ratio is seen in mild intermittent asthma?
{{c1::\> 80%}}
268
What PEF/FEV1 ratio is seen in mild persistent asthma?
What PEF/FEV1 ratio is seen in mild persistent asthma?
{{c1::\> 80%}}
269
What is Laryngotracheobronchitis?
What is Laryngotracheobronchitis?
{{c1::Viral croup}}
270
What is the most common primary agent causing Bronchiolitis?
What is the most common primary agent causing Bronchiolitis?
{{c1::RSV}}
271
What is seen on CXR in Asthma (Reactive Airway Disease)?
What is seen on CXR in Asthma (Reactive Airway Disease)?
{{c1::Non specific findings (hyperinflation, depressed diaphragm, peribronchial thickening, atelectasis)}}
272
What are the 5 causes of hypoxemia?
}}
What are the 5 causes of hypoxemia?
{{c1::
1. Hypoventilation:
- CNS depression, obesity hypoventilation syndrome, muscle weakness, ALS, flail chest normal AA gradient
2. V/Q mismatch:
- Hypoxemia due to V/Q mismatch can be corrected with low to moderate flow supplemental oxygen and is characterized by an increased A-a gradient.
- Common causes include obstructive lung diseases, pulmonary vascular disease (pulmonary embolus), and interstitial diseases.
3. Right-to-left shunt:
- Occurs when blood passes from the right to left side of the heart without being oxygenated causing extreme V/Q mismatch (0) and is hard to overcome with supplemental oxygen.
- Anatomic shunts exist when alveoli are bypassed and include intracardiac shunts (cyanotic CHD), pulmonary arteriovenous malformations, and hepatopulmonary syndrome.
- Physiologic shunts exist when non-ventilated alveoli are perfused and include atelectasis, pneumonia, ARDS
4. Diffusion limitation:
Movement of oxygen from alveolus to capillary is impaired.
-Interstitial lung disease, emphysema
5. Reduced inspired oxygen tension:
-High altitude normal AA gradient
}}
273
What is seen on PA X-ray of the neck in Croup (Laryngotracheobronchitis)?
What is seen on PA X-ray of the neck in Croup (Laryngotracheobronchitis)?
{{c1::Subglottic narrowing ("Steeple" sign)}}
274
What amount of creatinine clearance is an indication for reducing the dose of varenicline (Chantix) in someone trying to quit smoking?
What amount of creatinine clearance is an indication for reducing the dose of varenicline (Chantix) in someone trying to quit smoking?
{{c1::\< 30 mL/min}}
275
276
What are the common side effects of varenicline (Chantix)?
What are the common side effects of varenicline (Chantix)?
{{c1::Nausea; Trouble sleeping; Abnormal, vivid, strange dreams}}
277
What are the "Five A's" in discussing tobacco use and cessation?
What are the "Five A's" in discussing tobacco use and cessation?
{{c1::Ask, Advise, Assess, Assist, Arrange}}
278
Ventilator associated pneumonia is treated with which therapy?
Ventilator associated pneumonia is treated with which therapy?
{{c1::
-Antipseudomonal beta-lactam (e.g., cephalosporin, piperacillin/tazobacam, or carbapenem)
-Second antipseudomonal agent (e.g., aminoglycoside or fluoroquinolone)
-MRSA agent (e.g., Vancomycin or linezolid)
}}
279
This finding of {???)} is virtually pathognomonic for {??)
This finding of {{c1::pleural plaques}} is virtually pathognomonic for {{c1::asbestosis}}.
280
What is the alveolar air pressure at FRC (Functional Residual Capacity)?
What is the alveolar air pressure at FRC (Functional Residual Capacity)?
{{c1::0}}
281
The two indications for chest tube placement in parapneumonic effusions are a {??} and {??.
The two indications for chest tube placement in parapneumonic effusions are a {{c1::pleural fluid ph \<7.2}} and {{c1::glucose of \<60}}.
282
How do know check for intubation in the R main stem bronchus?
Make sure there is bilateral breath sounds and check cxray
283
Croup is treated by
Mild supportive
Severe cortico steriods
284
Pulmonic causes of hemoptysis
Cardiac causes of hemoptysis
Vascular causes of hemoptysis
Pulmonic causes of hemoptysis
Bronchitis, lung cancer, bronchectatis
Cardiac causes of hemoptysis
Mitral stenosis, acut pulmonary edema
Vascular causes of hemoptysis
Pulmonary Embolism, AV malformation
285
Infectious causes of hemoptysis
Hematologic causes of hemoptysis
systemic causes of hemoptysis
Other causes of hemoptysis
Infectious causes of hemoptysis: TB, Lung abscess,pnuemonia, aspergillosis hy
Hematologic causes of hemoptysis: cougulopathy
systemic causes of hemoptysis: good pastures disease
Other causes of hemoptysis: trauma and cocaine use
286
????? is a respiratory physiological parameter defined as the volume of gas per unit time that reaches the alveoli.
{{c1::Alveolar Ventilation (VA)}} is a respiratory physiological parameter defined as the volume of gas per unit time that reaches the alveoli.
VA = (VT - VD) x RR
287
?? is a respiratory physiological parameter that is defined as the total volume of gas entering the lungs per minute.
{{c1::Minute ventilation (VE)}} is a respiratory physiological parameter that is defined as the total volume of gas entering the lungs per minute.
VE = VT \* RR
288
How do you treat sepsis?
Fluids and early antibiotic therapy
289
??????is required if a patient doesn't respond to fluid resuscitation
Vasopressor is required if a patient doesn't respond to fluid resuscitation
290
qSOFA score?
Altered Mental Status
RR \>22/min
Systolic Blood Pressure \<100
confusion and hypotension, Tychipnea
qSOFA \>2
291
How to diagnoses Allergic Bronchopulmonary aspergilliosis?
Eosinphilla, Positive skin test aspergillus, postive aspergillus specific IgG, Elevated Aspergillus specific
292
Treatment Allergic bronchopulmonary aspergillios
Systemic gluccocortiods, voriconazole, Itraconazole
293
Acute pulmonary embolism has fever should I order ABx?
NO, 15% cases have fever so there is no need for antibotics
294
Massive PE can cause the following
Massive PE can cause the following
RV dysfunction, decreased RV contractily, Pulmunary hypertension which leads to increased pressure, increased dilatons tricuspid valve annulus and functional tricusspid vavle regurgitation all of which could see on echo.
ECG: RBB, or S1Q3T3
S wave in lead I and Q wave and inverted T wave in lead III
or T-wave inversions in V1-V4
295
What is S1Q3T3?
S wave in lead I and Q wave and inverted T wave in lead III
Notably S wave is deeply indented
296
What is the difference in characteristics between massive PE and submassive PE?
Massive: TPA and unfractionated heparin
SBP \<90, iontropic support needed, pulsesness, and persistent brady
Submassive: LMWH hemodynamic montioring +/- TPA
SBP\>90, RV dysfunction, RV dilation on echo ro CT, elevatied BNP greater than 90, likely to see ekg changes, and elevated troponins.
Nonmassive tx with LMWH no thrombolysis
without symptoms of either.
297
Hampton hump
Westermark sign (avascularity distal to the PE)
Hampton hump(wedged-shaped infarct)
Westermark sign (avascularity distal to the PE)
Both are signs of PE
298
D-dimer has a ????? sensitivity but poor specificity for PE and a high?????
used to rule-out PE if there is a low ????
D-dimer has a high sensitivity but poor specificity for PE and a high negative predictive value
used to rule-out PE if there is a low pre-test probability
299
Treatment of PE includes
Medical Non-vitamin K anticoagulation...;ike heparin.... indication: initial therapy in patients with PE in order to prevent further clot formation treatment should not be delayed medication options include low-molecular weight heparin(do not give in renal failure\_
unfractionated heparin: which includes dose by monitoring aPTT(preferred in kidney injury/failure)
warfarin indication: typically given around the same time as a non-vitamin K anticoagulant is given dose based on INR (goal is 2-3)
thrombolytic therapy indication: performed in patients with PE who are hemodynamically unstable
Operative embolectomy indication: performed in patients with PE who are hemodynamically unstable and thrombolytic therapy is contraindicated or who fail thrombolysis
IVC filter indication: performed in patients with PE who have a contraindication or failure of anticoagulation
300
In asthma when a child is sleepy and becoming less responsive it means you should be?
Be fearful of a child who is sleepy and becoming less responsive because they are likely tiring and retaining CO2
301
What is the constelation of Aspirin-exacerbated respiratory disease (AERD)
Can be a constellation known as aspirin exacerbated respiratory disease (AERD)
asthma
chonic rhinositis
nasal polyps
aspirin- or NSAID-induced bronchospasm
caused by shift of arachidonic acid to produce leukotrienes instead of prostaglandins
302
In Asthma normalizing PCO2 means??
normalizing PCO2
in acute exacerbation may indicate fatigue and impending respiratory failure, hence clinical picture is important
303
What do you see on PFTs in Asthma?
acutely diminished peak expiratory flow rate (PEFR) PEFR \< 40% of personal best or \< 200 L/min indicates severe obstruction
decreased FEV1 / FVC ratio
increased residual volume and TLC
normal DLCO
304
What test will you use for definitve diagnosis of asthma in a well patient?
Methacholine challenge
used for definitive diagnosis or tests for bronchial hyperactivity in a well patient
305
What is the treatment or asthma?
Treatment of Acute Exacerbations : Duonebs, methylprednisone, intubation is CO2 normalize
306
In cystic fibrosis
??? is more common in pediatric patients (treat with ???)
?????. are more common in adults (treat with ??????
S. aureus is more common in pediatric patients (treat with vancomycin)
Pseudomonal spp. are more common in adults (treat with amikacin, ceftazidime, and ciprofloxacin)
chronic sinusitis
307
What vaccinations should those with cystic fibrosis get?
pneumococcal and influenza
308
What endocrine problems does cystic fibrosis cause?
diabetes
infertility due to congenital absence of the vas deferens
decreased fertility in females
309
What physical exam findings will u see in emphysema?
Physical exam
late hypercarbia/hypoxia
barrel chest (increased AP chest diameter)\*
thin, wasted appearance
\*pursed-lip breathing\*
decreased heart and breath sounds
prolonged expiratory phase
end-expiratory wheezing
scattered rhonchi
\*digital clubbing (only in the presence of other comorbidities such as lung cancer, interstitial lung disease, or bronchiectasis)
310
What PFT finding do you see in emphysema??
PFTs
decreased FEV1 / FVC
normal or decreased FVC
normal or increased TLC (in emphysema and asthma, specifically)
\*decreased DLCO (in emphysema, specifically)\*
311
What is COPD defined as?
Defined by productive cough for \>3 months per year for two consecutive years
312
Treatment of emphysema
O2, beta-agonists, anticholingerics, IV steroids, antibiotics
CPAP or BiPAP if the patient's mental status is intact
313
Lights cretia
Light criteria criteria used to differentiate transudative and exudative effusions
protein (pleural)/protein (serum) \> 0.5
LDH (pleura)/LDH (serum) \> 0.6
LDH \> 2/3rds the upper limit of normal serum LDH
based on the Light criteria, a pleural effusion is said to be exudative if any one of the above is met
314
Treatment of Pleural effusion
Depends on the underlying cause
e.g., if there is an exudative effusion secondary to a bacterial pneumonia, treat with antibiotics
Procedural
therapeutic thoracentesis indicationi n cases where the pleural effusion is massive and its affecting the patient's breathing
tube thoracostomy indication in complicated parapneumonic effusions or empyema
315
In CO poisining
## Footnote
Oxygen saturation usually ??????though actualy O2 content is????
this is because pulse oximeter reads ?????
Oxygen saturation usually NORMAL though actualy O2 content is LOW
this is because pulse oximeter reads carboxyhemoglobin as normally saturated hemoglobin
316
In CO poising
ABG and serum carboxyhemoglobin level
normal carboxyhemoglobin level is ??? in nonsmokers and ???? in smokers
anion-gap?????due to the build-up of ????
ABG and serum carboxyhemoglobin level
normal carboxyhemoglobin level is \<5% in nonsmokers and \<10% in smokers
anion-gap metabolic acidosis due to the build-up of lactic acid
317
IN CO poising check ECG in elderly because?
ECG
check in elderly and those with history of cardiac disease due to increased risk for ischemia
318
Treatment of CO poisining
1. ????????
must displace carbon monoxide from hemoglobin
\>\>\>\>\>\>
2. \>???????
in patients who are ???????
Treatment of CO poisining
1. 100% oxygen
must displace carbon monoxide from hemoglobin
note: when a patient has smoke inhalational injuries, carbon monoxide and cyanide poisoning should be empirically treated with 100% oxygen and hydroxycobalamin plus sodium thiosulfate, respectively
2. hyperbaric oxygen
in patients who are pregnant, nonresponsive, or experiencing signs of CNS or cardiac ischemia
319
320
Whare some of the signs of bronchitis?
Symptoms
minimal and non-specific until advanced disease
productive cough
cyanosis\*
mild dyspnea
hyperventilation
swollen feet/ankles\*
hemoptysis
321
What are some physical exam findings of bronchitis?
Physical exam
hypercarbia/hypoxia
decreased breath sounds
ronchi
end-expiratory wheezing
barrel-chested
pursed-lip breathing
signs of pulmonary hypertension
RVH
JVD
hepatomegaly
peripheral edema
322
What do you find in PFT of bronchitis?
PFTs
decreased FEV1 / FVC
normal or decreased FVC
normal or increased TLC (in emphysema and asthma, specifically)
**roughly normal DLCO as opposed to decreased DLCO in emphysema**
323
What is the gold standard for diagnosing bronchitis?
Lung biopsy
diagnostic gold standard
increased Reid index ( gland layer \> 50% of total bronchial wall)
324
Treatment of Bronchitis?
O2, beta-agonists, anticholingerics, inhaled/IV steroids, antibiotics
325
What is the best intervention for mortality in bronchitis
smoking cessation
best intervention for lowering mortality
326
Berlin Definition of ARDS????
Berlin Definition of ARDS
acute onset (within 1 week of clinical insult or worsening respiratory status)
bilateral infiltrates (without an alternative explanation)
respiratory failure not caused by cardiac causes or volume overload
hypoxemia
327
ARDS severit y??
ARDS severity
mild
PaO2/FiO2 is 200-300
moderate
PaO2/FiO2 is 100-200
severe
PaO2/FiO2 is \< 100
Etiology
328
What is the prognosis of ARDS?
Prognosis
severe ARDS has the worst mortality (45%) compared to mild and moderate
329
What is the goal of mechanical ventilation in ARDS?
mechanical ventilation indication
to maintain adequate gas exchange while minimizing lung injury
low tidal volume, low plateau pressures, and titrating up positive end-expiratory pressure (PEEP)
330
What setting do you use in ARDS?
settings
initial tidal volume to 8 mL/kg (in 70kg 560) and reduce gradually to 6 mL/kg (in 70 kg 420) (low tidal volumes) . you want to achieve an inspiratory plateau airway pressure ≤ 30 cm H2O
titrate PEEP to prevent tidal alveolar collapse
initial respiratory rate to approximate baseline minute ventilation (≤ 35/min)
oxygenation goal is a PaO2 of 55-80 mmHg
pH goal is 7.30-7.45
331
What is are stages of sarcoidosis?
Sarcoidosis staging
stage 1
bilateral hilar adenopathy
stage 2
bilateral hilar adenopathy with parenchymal infiltrates
stage 3
diffuse parenchymal infiltrates in the absence of hilar adenopathy
stage 4p
ulmonary fibrosis: demonstrating honeycombing
332
What is the pathogenesis of sarcoidosis?
macrophages present antigens to T-cellsTh1 cells are recruited and produce IFN-y, TNF, and IL-2
results in granulation formation
333
334
How do you treat sarcodosis?
Steroids
335
Studies confirming Sarcodosis?
laboratory abnormalities
hypercalcemia and hypercalciuria
elevated angiotensin-converting enzyme (ACE) levels (~60% of cases)
Biopsy of the affected organ
non-caseating granuloma
336
Notable ROS and Physical exam finding in sarcoidosis?
Symptoms
1. constitutional symptoms (e.g., fever, malaise, and anorexia)
2. dyspnea
3. arthralgias
Physical exam
1. erythema nodosum
2. anterior uveitis
3. cranial nerve VII involvement (worrisome for neurosarcoidosis)
337
What is the notable associated sx of sarcodosis?
neurosarcoidosis
dilated and restrictive/infiltrative cardiomyopathy
myocarditis
**hypercalcemia**
erythema nodosum
**uveitis**
**acute interstitial nephritis**
**lupus pernio**
restrictive lung disease
rheumatoid-lie arthropathy
338
Triad of kartenger syndrome?
characterized by patients having the triad
situs inversus
chronic sinusitis
bronchiectasis
339
Symptoms of Priminary Cillary dyskinesia?
respiratory
* newborns may present with mild respiratory distress
* recurrent upper and lower respiratory infections
rhinosinusitis (a cardinal feature)
* patients may have headache
chronic secretory otitis media
* accompanied by recurrent acute otitis media
* can result in a conductive hearing loss
impaired or decreased fertility
ectopic pregnancy
340
Massive Hemothorax Treatment?
Non-operative
* **aggressive fluid resuscitation** with large-bore IV access before placing chest tube
* supplemental oxygen
Operative
* **chest tube placement** to decompress chest cavity following fluid resuscitation
* inserted at level of nipple and anterior to midaxillary line
* CXR or CT scan post-chest tube placement to assess for remaining blood/pathology
emergent thoracotomy
* if \>1500ml removed from chest tube
* or if bleeding does not stop
341
What is the management of hemoptysis?
Conservative
* patient positioning
* in cases of severe hemoptysis
* position patient on the side of the involved lung and intubate the normal lung if necessary
* e.g., if the source of the bleed is from the right lung, position the patient on the right side
Procedural
* therapeutic bronchoscopy
* indication recommended in life-threatening cases
* bronchovascular artery embolization
* indication first-line for massive, recurrent, or malignant hemoptysis
* emergency thoracotomy
* indicated for massive hemoptysis that does not respond to initial measures (such as bronchoscopy)
342
What is the treatment of pneumothorax?
Treatment
* Non-operative
* small pneumothoraces may reabsorb spontaneously
* Operative
* large and/or tension pneumothoraces may require
* **immediate needle decompression**
* **chest tube placement**
* following decompression
* recurrent pneumothoraces with subcutaneous emphysema should prompt workup for tracheobronchial rupture
* **pleurodesis**
* injection of irritant into pleural space
* helps scar the two pleural layers together
* preventing recurrence and pleural effusion
343
What is flail chest?
Occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage
3 or more adjacent ribs are fractured in 2 or more places
344
What drugs can cause pulmonary fibrosis?
drugs
amiodarone
bleomycin
phenytoin
345
Treatment of Pulmonary fibrosis?
Of note, treatment is dependent upon the underlying cause
* Conservative
* smoking cessation and influenza and pneumococcal vaccinesindication should be given to all patients with interstitial lung disease, unless contraindicated
* Medical
* intravenous corticosteroids
* first-line therapy for patients for acute respiratory therapy
* intravenous cyclophosphamide
* second-line therapy for patients for acute respiratory therapy
346
What is the prognois is open pnuemothorax?
Prognosis
not as immediately critical as tension pneumothorax
347
What is flail chest?
Physical exam
* abnormal chest wall movement
* may not be appreciated if the patient is splinting with pain
* **crepitus over the defect**
348
What is the prognosis Flail Chest?
Prognosis
good to excellent depending on severity of defect
349
What is the treatment of Tension Pneumothorax?
Non-operative
* do not resolve spontaneously
* unlike small, simple pneumothoraces
* supplemental O2 therapy
* following operative intervention may be required
Operative
* immediate needle decompression
* second intercostal space at the midclavicular line with 14 or 16-gauge needle
* followed by chest tube placement
350
What is the definition of Pulmonary Hypertension?
a state of increased mean pulmonary arterial pressure ≥ 25 mmHg (at rest) in the absence of lung or left-sided heart disease
351
What are the physical exam findings of Pulmonary hypertension?
Physical examination
* loud P2 on auscultation
* right ventricular heave
* right-sided 4th heart sound
* murmurs
* holosystolic murmur of tricuspid regurgitation
* systolic ejection murmur
* diastolic pulmonic regurgitation (in severe cases)
352
How to diagnose pulmonary stenosis?
* ECG
* can demonstrate right ventricular hypertrophy (e.g., right axis deviation)
* Right heart catheterization confirms the diagnosis of pulmonary hypertension
* mean pulmonary artery pressure is ≥ 25 mmHg at rest (8-20 mmHg at rest is considered normal)
* vasoreactivity testing can be performedthis involves administering a short-acting vasodilator followed by measuring the hemodynamics of the pulmonary artery
* agents that are used include
* nitric oxide
* epoprostenol
* adenosine
* diltiazem (in patients with positive vasoreactivity testing
Imaging
Echocardiogram
* estimates pulmonary artery systolic pressure
* evaluates the right ventricle size, thickness, and function
* also evaluates the left ventricular function and valvular function
Radiography of the chest
may demonstrate
* central pulmonary arterial dilatation
* loss of peripheral blood vessels
* may find right atrial and ventricular enlargement (suggestive of advanced disease)
353
What granulomatus disease can causes Pulmonary fibrosis?
sarcoidosis
granulomatosis with polyangiitis
eosinophillic granulomatosis with polyangiitis
histiocytosis x
354
What alveolar filling disease cause pulmonary fibrosis?
alveolar filling disease
Goodpasture syndrome
alveolar proteinosis
pulmonary hemosiderosis
355
COPD is at increase risk for what bacteria so what abx do you want to give?
antibioticshigh P. aeruginosa risk
* levofloxacin
* piperacillin-tazobactam
* cefipime
* ceftazidime
low P. aeruginosa risk
* moxifloxacin
* ceftriaxone
* cefotaxime
356
357
What radiographic findings on pulmonary edema?
findings
cephalization (reflects an elevation in left atrial pressures)
Kerley lines
air bronchograms
pleural effusion
358
60-year-old man presents with increasing shortness of breath. He reports that this symptom worsens when he is in the upright position and improves when he is laying in bed. Medical history is significant for end-stage liver disease due to hepatitis C infection. On physical exam, there is decreased breath sounds on pulmonary auscultation and spider nevi. Arterial blood gas analysis is significant for an alveolar-arterial gradient of 20 mmHg.
What is the most likely diagnosis?
Hepatopulmonary Syndrome
Clinical definition
liver disease leading to severe pulmonary vascular complications
359
Pathogensis of hepatorenal syndrome?
believed to be due to increased vasodilator (e.g., nitric oxide and carbon monoxide) production secondary to liver disease resulting in
* ventilation-perfusion (V/Q) mismatch
* alveolar-capillary oxygen disequilibrium
360
What is the gold standard for diagnosis Hepatorenal syndrome?
Labsarterial blood gas (ABG) analysis
indicationswhen there is clinical suspicion for hepatopulmonary syndrome
* ≥ 15 mmHg is suggestive of HPS
* ≥ 20 mmHg is suggestive of HPS in patients \> 64-years-old
361
When should you preventatively treat Bronchiolitis?
Prevention: treat with Palivizumab for P29HC
Preterm \<29 weeks gestation
Chronic lung disease of prematurity
Hemodynamically significan congenital heart diseese
362
Bronchiolitis complications??
Apnea, infants less than 2 months and respiratory failure
363
Nonallergic rhinits
Clinical features nasal congestion/late onset \>29/ no obivious allergic rhinitis / perennnial symptoms worsen with season/ erythematous nasal mucosa
TX
MIld: intranasal antihistamine or glucorticoids/ Moderate to serval : combination therapy.
364
Allergic rhinitis??
Clinical Features:
Watery rhinnorhea, sneezing, eye symptoms/ early age on onset/ identifiable allergen or seasonal pattern/ pale-blusish nasal mucosa/ associated with other allergic disorders( eczema, asthma, eustachian dysfunction)
TX:
intranasal glucocoticoids/ ANtihistamine
365
Mmenonic for post operative hypoxemia???
Post operative hypoxemia-AirAn-I,Spasm-E, Pnue-1-5 , Ate-2-5, PE-\>3
Airway obstruction/edema -immediate, -stridor s/p intubation
Anestesthesia residual- Immediate, - d/c respiratory drive
Bronchospasm-early - wheezing
Pneumonia- 1-5 days - fever , cxr positve
Atelectasis- 2-5 days - s/p surgery, splinting coug, retained secretions
Pulmonary Embolism - Uncommon befor3 days
366
STOPBANG??
(Snorlax is Tired Ofchoking/gasp in highaltitudeswithighbloodPressure, becauseofhis BMI oldAge Necksize and maleGender) \*old
367
Prognosis of COPD?
FEV1 is most important factor age is second most important factor
368
Gold criteria??
All FEV1/FVC \<0.7
Gold 1 Mild\> 80%
Gold 2 Mod50%
Gold 3 Severe 30% Gold 4 Very Severe 30%
369
Cough variant asthma is noted when ??
Look at case where patient is normal and cough only exhibited when patient does peak flow test.
370
What is contraindicated for asthma in a pregnant woman
Epinephrine
371
ABPA diagnostic testing?
Skin testing or aspergillus; analysis of total IgE (\>417) concentrations, Specific Ige for A fumigatus; Eosinophillia (\>500/ul)
372
ABPA seen in both asthma and cystic fibrobis but cystic fibrosis complications seen ????????
ABPA seen in both asthma and cystic fibrobis but cystic fibrosis complications seen at a younger age
373
ABPA treatment
Systemic gluccocorticoids
Voricanozole then Itracanozole
374
Solitary pulmonary nodules : low
Remember S3AC stands for???
Remember S3AC
If less than 0.8cm, smooth,non smoking, less than 45, non calcified then the person has a low probability for cancer
Add male to the mix
375
What is end tidal co2???
Use of end tidal co2 to determine whether or not intubation is successful… during CP you want end tidal co2 to be above 10
376
Squamous Cell Carcinoma signs?
Keratin pearls and intracelluar bridges
Hilar mass arising from bronchus Caviations, Cigarretes, hypercalcemia look for PTHrP
377
Small cell carcinoma signs??
May produce ACTH, ADH, or Antibodies against presynaptic calcium channels Lamber-Eaotn syndrome, amplifications of myc oncogenes, Treated with chemotherapy.
378
What Adults at high risk for influenza complications??
## Footnote
WOIIONN
W Women who are pregnant and up to 2 weeks postpartum
O Age 65
I Chronic medical illness
I Immunosuppression
O Obesity
N Native American
N Nursing home or chronic care facility resident
379
Infectious Mono clinical features??
Fevers
Tonsilitis/pharyngitits +/- exudates
Posterior or diffuse cervical lymphandenotpathy
Signficant fatigue
+/- hepatosplenomegaly
+/- rash after amoxicillin
380
Invasive pulmonary aspergillosis diagnostic workup??
Serum biomarkers: galactomannan, B-D-blucan
Sputum samplin for fungal stain and culture
CT Chest, Nodules with ground - glass opacity (halo sign) or cavitations with air fluid levels.
381
Invasive pulmonary aspergillioous
Voriconazole
Reduction of immunosupperessive regimen
Surgery
382
Popcorn calcifications are suggestive of what type of nodule
Benign
383
Recurrent pneumonia in elderly smoke??
Obstruction
Lung cancer: Manifestation of bronchogenic carcinoma: Recurrent pneumonia in elderly smoker is the first manifestation of bronchogenic carcinoma and the best test for obstructive cancer in the lung is flexsig
384
PE pretest probability in vq scan must be ??????until then you cannot rule out PE so it’s the most likely diagnosis
PE pretest probability in vq scan must be negative until then you cannot rule out PE so it’s the most likely diagnosis
HENCE you will use the PERC classification
385
Lung Cancer-Low dose ct scan has high sensitivity but is associated with
Yearly, 55080, pt with a \>30 pack-year smoking history , and current smokrer with the last 15 years
386
OHS is at increased risk for ????????????????failure.
OHS is at increased risk for perioperative hypercapnic/hypoxic respiratory failure.
387
TRALI……. and TACO
Tranfusion related acute lung injury..
Tranfusion associated circulatory overload
388
Chronic cough in children greater than 4 weeks warrants ???????
so look for duration
Chronic cough in children greater than 4 weeks warrants spiromerty so look for duration
389
Treat Croup with ????? and ??????
Treat Croup Mild humidified air and corticosteriods
390
What is Rapid sequence Intubation?
Makes use of rapidly active sedative etomidate, propofol, midalozam
and paralytic agents succinylcholine and rocuronium
391
SubMassive vs Massive PE
xxxxSubmassive PExxx
SBP above 90, RV dysfuntion, RV dilatation ECHO or CT
BNP\> 90,
EKG changes
Elevated Troponins
xxxxMASSIVE PExxxx
SBP less than 90 or 40 below baseline,, pulsless, persistent brady cardia
