Pulmonology and CritCare Flashcards

Question

Occupational disease that may present with crazy paving on HRCT

Answer 1

Silicosis = with characteristic HRCT pattern known as “crazy paving” Calcification of hilar nodes may occur in as many as 20% of cases and produces a characteristic “eggshell” pattern. mnemonic: pag crazy ka, silly ca (silica)

Answer 2

Caplan syndrome, first described in coal miners but subsequently in patients with silicosis, is the combination of pneumoconiotic nodules and seropositive rheumatoid arthritis. Remember na Caplan is seen in coal workers pneumoconiosis and silicosis

Answer 3

Centrilobular emphysema usually most prominent in the upper lobes and superior segments of lower lobes and is often quite focal. C-C (cigarette, centrilobular)

Answer 4

Panlobular emphysema

Answer 5

cough, sputum production, and exertional dyspnea

Answer 6

0.08 units 0.03 units (c-3rd letter of the alphabet, c- chronic)

Answer 7

reduce exacerbations

Answer 8

Supplemental O2

Answer 9

≤88% ≤89%

Answer 10

history of a previous exacerbation

Answer 11

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

Answer 12

Usual interstitial pneumonia

Answer 13

Malignancy Bacterial infections Rheumatoid pleuritis

Answer 14

protein levels in the serum and the pleural fluid If this gradient is >31 g/L (3.1 g/dL), the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion. You can also compute for serum - pleural fluid albumin. Cut off is 1.2 g/dL

Answer 15

1500 pg/mL

Answer 16

1. Loculated pleural fluid 2. Pleural fluid pH< 7.20 3. Pleural fluid glucose <3.3 mmol/L (60 mg/dL) 4. Positive Gram stain or culture of the pleural fluid 5. Presence of gross pus in the pleural space

Answer 17

The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL). mnemonic (1nter40n- y) IFN-y --> 140

Answer 18

Thoracentesis reveals milky fluid, and biochemical analysis reveals a triglyceride level that exceeds 1.2 mmol/L (110 mg/dL).

Answer 19

trauma most commonly thoracic surgery

Answer 20

simple aspiration

Answer 21

Diagnosis requires the patient to have (1) either symptoms of nocturnal breathing disturbances (snoring, snorting, gasping, or breathing pauses during sleep) or daytime sleepiness or fatigue that occurs despite sufficient opportunities to sleep and is unexplained by other medical problems; and (2) five or more episodes of obstructive apnea or hypopnea per hour of sleep OSAHS also may be diagnosed in the absence of symptoms if the AHI is >15 episodes/h.

Answer 22

excessive sleepiness

Answer 23

overnight polysomnogram

Answer 24

30% reduction in airfow for at least 10 s and commonly results in a ≥3% drop in oxygen saturation and/or a brain cortical arousal.

Answer 25

respiratory rate >22, altered mental status, or systolic blood pressure <100 Needs to fulfill 2/3 to diagnose sepsis

Answer 26

 The spontaneous breathing trial is declared a failure and stopped if any of the fd occur: o (1) respiratory rate >35/min for >5 min, o (2) O2 saturation <90% o (3) HR > 140/min or a 20% increase or decrease from baseline, o (4) systolic blood pressure 180 mmHg, or o (5) increased anxiety or diaphoresis.

Answer 27

Histamine receptor-2 antagonists are preferred over proton pump inhibitors because the latter are associated with increased incidence of C. difficile colitis and pneumonia

Answer 28

Distributive

Answer 29

Hypovolemic key difference between hypovolemic and distributive is the CO and SWR CO is dec in hypovolemic but inc in distributive

Answer 30

Cardiogenic/ Obstructive however obstructive may present with either inc or dec PCWP. The rest of the parameters are same as cardiogenic

Answer 31

defined as the HR/systolic blood pressure (SBP) with a normal SI being 0.5–0.7. An elevated SI (>0.9) has been proposed to be a more sensitive indicator of transfusion requirement and of patients with critical bleeding among those with hypovolemic (hemorrhagic) shock than either HR or BP alone

Answer 32

S. aureus and S. pneumoniae E. coli, Klebsiella species, and Pseudomonas aeruginosa

Answer 33

Dopamine should be avoided as first-line therapy for MI with CS based on hemodynamic and proarrhythmogenic effects

Answer 34

Pao2 /Fio2 < 150 mm Hg

Answer 35

High PEEP Minimize LA pressures Prone position ECMO Early muscular blockade

Answer 36

PF ratio 100 to <= 200 Hence mild = <300 severe <= 100

Answer 37

COPD exacerbations and respiratory acidosis (pH <7.35)

Answer 38

(1) Lung injury is stable or resolving; (2) gas exchange is adequate, with low PEEP (< 8 cmH2 O) and Fio2 (0.5); (3) hemodynamic variables are stable, and patient is no longer receiving vasopressors; (4) the patient is capable of initiating spontaneous breaths. (5) Maximal inspiratory pressure < -30 cm H2O (6) Minute ventilation < 10 LPM

Answer 39

a. contacts of TB patients b. those ever treated for TB (i.e. with history of previous TB treatment); c. people living with HIV (PLHIV); d. elderly (> 60 years old); e. diabetics; f. smokers; g. health-care workers; h. urban and rural poor (indigents); and i. those with other immune-suppressive medical conditions (silicosis, solid organ transplant, connective tissue or autoimmune disorder, end-stage renal disease, chronic corticosteroid use, alcohol or substance abuse, chemotherapy or other forms of medical treatment for cancer).

Answer 40

Request Xpert MTB Rif Test (SM/TB LAMP if Xpert not available) Xray not needed . only for those for screening but without symptoms if HIV +, need to do BOTH symptom and CXR screening so this time even if asymptomatic, need to do cxr

Answer 41

If drug sensitive, All 5 years old and above (symptom screening only for < 5 years old) If chest X-ray not available, do symptom screening If drug resistant, ALL contacts

Answer 42

Gene Xpert

Answer 43

every 6 months for 2 years

Answer 44

rapid diagnostic test (RDT), such as Xpert MTB/RIF

Answer 45

For Xpert, testing should be performed on any collected spot sputum sample regardless whether it is sputum or saliva. For SM, examine the specimen to see that it is not just saliva. Mucus from the nose and throat, and saliva from the mouth are not good specimens. Repeat the process if necessary.

Answer 46

T = Mycobacterium tuberculosis (MTB) detected, rifampicin resistance not detected. RR = MTB detected, rifampicin resistance detected. TI= MTB detected, rifampicin resistance indeterminate. N= MTB not detected. I= Invalid/no result/error.

Answer 47

For those who are at low risk for MDR-TB (i.e. new TB cases who are not DR-TB contacts) but with an Xpert result ofRR MTB detected with rifampicin resistance, the patient can be classified as bacteriologically confirmed TB (BCTB), but recollect a fresh sputum sample for repeat the Xpert MTB/RIF test and follow the second result on Rifampicin resistance for the treatment decision. However, in PLHIV in which mortality from the TB co-infection is high, there is no need to repeat the Xpert test as it will result in significantly delaying initiation of treatment. The patient may be treated based on the result of the initial test.

Answer 48

Monoresistant TB with resistance to one first-line anti-TB drug, except rifampicin whether bacteriologically confirmed or clinically diagnosed Polydrug resistant TB with resistance to more than one first-line anti-TB drug, other than both isoniazid and rifampicin, whether bacteriologically confirmed or clinically diagnosed MDR TB Positive for MTB complex with resistance to at least both isoniazid and rifampicin XDR TB Positive for MTB complex with resistance to any fluoroquinolone(FQ) and to at least one second-line injectable drug (e.g. amikacin,streptomycin), in addition to multidrug resistance

Answer 49

2HRZE/4HR for PTB or EPTB (except central nervous system [CNS], bones, joints) whether new or retreatment

Answer 50

2HRZE/10HR for EPTB of CNS, bones, joints whether new or retreatment,

Answer 51

If not a known diabetic, screen all TB patients ≥ 25 years old for diabetes using a fasting or random plasma blood glucose test (Cut-off level ≥ 7 mmol/L or 126 mg/dl for fasting; 11.1 mmol/L or 200 mg/dl for random).

Answer 52

TB treatment should be initiated first, followed by ART as soon as possible within the first eight weeks of treatment. If with profound immunosuppression (e.g. CD4 counts less than 50 cells/mm3), HIV-positive TB patients should receive ART within the first two weeks of initiating TB treatment.

Answer 53

Rifampicin

Answer 54

Rifampicin

Answer 55

Give pyridoxine (Vit B6) 50–100 mg daily for treatment; it can also be given 10 mg daily for prevention

Answer 56

Give aspirin or NSAID; if persistent, consider gout and request uric acid determination, manage accordingly or refer

Answer 57

After one week of uninterrupted treatment for clinically diagnosed TB cases. After a negative follow-up SM for bacteriologically confirmed TB cases. If patient wishes to return to work sooner, SM may be repeated (outside of the regular schedule) at least two weeks after treatment initiation.

Answer 58

2 CONSECUTIVE months

Answer 59

If positive sputum at the end of 5th month

Answer 60

seven days

Answer 61

a. PLHIV aged 1 year and older (regardless of history of contact); b. all household contacts of bacteriologically confirmed PTB; c. children less than 5 years old who are household contacts of clinically diagnosed PTB; d. close contacts of bacteriologically confirmed PTB (outside the household); and e. other risk groups: * patients receiving dialysis * patients preparing for an organ or hematological transplantation * patients initiating anti-tumor necrosis factor (TNF) treatment patients with silicosis.

Answer 62

They may be offered TPT once active TB is ruled out: a. PLHIV aged 1 year or older; b. children less than 5 years old who are household contacts of bacteriologically confirmed PTB; and c. individuals aged 5 years and older with other TB risk factors (i.e. PLHIV, diabetes, smoking, those with immune-suppressive medical conditions, malnourished, with multiple TB cases in same household) and who are household contacts of bacteriologically confirmed PTB.

Answer 63

LV failure

Answer 64

Pleural fluid/Serum Hct ratio >0.5

Answer 65

ICS formoterol

Answer 66

prednisone

Answer 67

Pneumonia Aspiration of gastric contents Pulmonary contusion Near drowning Toxic inhalation injury severe trauma, sepsis --> indirect lung injury

Answer 68

TV <=6 cc/kg PP <= 30cm H2O RR <= 35 Fio2 <=60% Spo2 88-95% pH >=7.3 MAP >=65 take note: lahat may equal sign

Answer 69

< 110 mL = positive leak test (no leak) meaning a significant laryngeal edema is preventing a leak despite the cuff being deflated basically negativity/positivity of cuff leak test is referring to the absence/presence of laryngeal edema NOT leak

Answer 70

Vancomycin 15 mg/kg q8 OR Linezolid 600 mg q12 Think of MRSA

Answer 71

Neutrophil Fibrin deposition is also abundant

Answer 72

Macrophage

Answer 73

Prior antibiotic use in the past 3 months

Answer 74

10^6 10^3 for more distal sources

Answer 75

4-6 weeks (Harrisons) Based on PSMID 2020 We recommend posttreatment chest x-rays after a minimum of 6 to 8 weeks among patients with CAP to establish baseline and to exclude other conditions

Answer 76

fever - 1 week chest pain and sputum production - 1month cough and breathlesness - 6 weeks

Answer 77

HIV co-infection

Answer 78

Gene xpert

Answer 79

< 50 mg/dL or <11 uM

Answer 80

Hx of hospitalization for COPD exacerbation > = 2 moderate exacerbation per year Blood eosinophil > 300 cells/uL Hx of concomitant asthm

Answer 81

Resting O2 >95% 6 minute walk oxygen >84%

Answer 82

with FEV <50% predicted and if with chronic bronchitis ** additional info: Azith may be used in former smokers

Answer 83

Upper lobe dominant emphysema and low exercise capacity post rehab

Answer 84

15-29 events/hr

Answer 85

MTB atypical mycobacteria fungi due to alveolar macrophage dysfunction

Answer 86

Gray hepatization no new erythrocytes are extravasating, and those already present have been lysed and degraded. The neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared

Answer 87

A bronchopneumonia pattern is most common in nosocomial pneumonias, whereas a lobar pattern is more common inbacterial CAP.

Answer 88

Oral anaerobes G- bacteria

Answer 89

P. aeruginosa B. cepacia S. aureus

Answer 90

(To be suitable, a sputum sample must have >25 neutrophils and <10 squamous epithelial cells per low-power field.) No equal sign! The sensitivity and specificity of the sputum Gram’s stain and culture are highly variable. Even in cases of proven bacteremic pneumococcal pneumonia, the yield of positive cultures from sputum is ≤50%.

Answer 91

S. pneumoniae The yield from blood cultures, even when samples are collected before antibiotic therapy, is disappointingly low. Only 5–14% of cultures from hospitalized CAP patients are positive, and the most common pathogen is S. pneumoniae.

Answer 92

confusion (C); urea>7 mmol/L (U); respiratory rate ≥30/min (R); SBP ≤90 mmHg OR DBP ≤60 mmHg (B) an age of ≥65 years. With a score of 1 or 2, the patient should be hospitalized unless the score is entirely or in part attributable to an age of ≥65 years Among patients with scores of ≥3, mortality rates are 22% overall; these patients may require ICU admission

Answer 93

Take note amox only if no comorbs but if with co morbs, need to be coamox FQ only for those with comorbs.

Answer 94

PCV13 produces T-cell–dependent antigens, resulting in long-term immunologic memory.

Answer 95

colonization of the oropharynx with pathogenic microorganisms aspiration of these organisms from the oropharynx into the lower respiratory tract compromise of normal host defense mechanisms.

Answer 96

endotracheal tube, which bypasses the normal mechanical factors preventing aspiration Because endotracheal intubation is a risk factor for VAP, the most important preventive intervention is to avoid intubation or minimize its duration.

Answer 97

Frequent use of β-lactam drugs, especially cephalosporins

Answer 98

Legionella can be a nosocomial pathogen, especially with local epidemics due to breakdowns in the treatment of potable water in the hospital.

Answer 99

Refer to table 7- or 8-day course of therapy is just as effective as a 2-week course and is associated with less frequent emergence of antibioticresistant strains.

Answer 100

50% 25% hence mauuna o2 bumaba

Answer 101

smoking cessation oxygen therapy in chronically hypoxemic patients lung volume reduction surgery (LVRS) in selected patients with emphysema

Answer 102

* Unilateral * Bilateral but not comparable in size * Presence of fever * Presence of pleuritic chest pain

Answer 103

Proliferative

Answer 104

Unexplained breathlessness

Answer 105

UIP if IPF and RA Non specific interstitial pneumonia for other Connective tissue dse

Answer 106

Viral bronchitis

Answer 107

FEV1 or PEF 60-80% of personal best

Answer 108

FeNO Elevated levels (>35–40 ppb) in untreated patients are indicative of eosinophilic inflammation. Levels >20–25 ppb in patients with severe asthma on moderate- to high-dose ICS indicate either poor adherence or persistent type 2 inflammation despite therapy

Answer 109

4 hrs LABA-ICS --> 12 hrs

Answer 110

Persistent reduction in forced expiratory flow rates

Answer 111

Moderate Mild >=80 Moderate 50- <80% Severe 30-< 50% Very Severe < 30%

Answer 112

At least 15h/day

Answer 113

"I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level."

Answer 114

apixaban and rivaroxaban

Answer 115

chest tube insertion + octreotide

Answer 116

Restrictive pattern with a decrease in both lung volumes and diffusing capacity

Answer 117

ICS-formoterol

Answer 118

Hamman’s

Answer 119

High PCO2 with normal pH

Answer 120

lung CA, breast CA and lymphoma

Answer 121

apical and posterior segments of the upper lobes

Answer 122

middle and lower lung zones

Answer 123

isolated reduction in DLCO

Answer 124

The two main goals of therapy are to provide symptomatic relief (reduce respiratory symptoms, improve exercise tolerance, improve health status) and reduce future risk (prevent disease progression, prevent and treat exacerbations, and reduce mortality)

Answer 125

Rhonchi Crackles, or rales, are commonly a sign of alveolar disease.

Answer 126

vital capacity

Answer 127

In diseases that cause lower airway obstruction, such as asthma and emphysema, flows decrease more rapidly with declining lung volumes, leading to a characteristic scooping of the flow-volume loop

Answer 128

Airway hyperresponsiveness is a hallmark of asthma

Answer 129

In asthma, airway wall thickness is associated with disease severity and duration. This thickening, which may result from a combination of smooth-muscle hypertrophy and hyperplasia, subEPIthelial collagen deposition, airway edema, and mucosal inflammation, can result in a tendency for the airway to narrow disproportionately in response to stimuli that elicit increased airway muscle tension

Answer 130

IL-4 induces B-cell isotype switching to production of IgE

Answer 131

IL-13 induces airway hyperresponsiveness, mucus hypersecretion, and goblet cell metaplasia

Answer 132

. IL-5 has a critical role in regulating eosinophils. It controls formation, recruitment, and survival of these cells

Answer 133

Regular use has been associated with tachyphylaxis of the bronchoprotective effect and possible increased airway reactivity. This may be more common in patients with a polymorphism at the 16th amino acid position of the β2 -receptor. Frequent short-acting β-2 agonist use has been associated with increased asthma mortality resulting in decreased enthusiasm for use in isolation without inhaled corticosteroidsa

Answer 134

These agents (indacaterol, olodaterol, and vilanterol) have a 24-h effect. They are only used in combination with ICSs in the treatment of asthma.

Answer 135

leukotriene receptor antagonist inhibits cysteinyl leukotriene type-1 (CysLT1) moderately effective in asthma Zileuton - 5 LOX inhibitor

Answer 136

These patients should avoid inhibitors of cyclooxygenase-1, (aspirin and NSAIDs) but can generally tolerate inhibitors of cyclooxygenase-2 and acetaminophen They should be treated with leukotriene modifiers. Aspirin desensitization can be undertaken to decrease upper respiratory symptoms and to allow chronic administration of aspirin or NSAIDs for those that require it. Dupilumab and the IL-5–active biologics appear to be particularly helpful and appear to be superseding aspirin desensitization in management except when chronic administration of aspirin or NSAIDs is required for another therapeutic indication.

Answer 137

Elderly and smokers

Answer 138

>= 3 200 dose canisters per yr mortality is inc if >=1 canister per month

Answer 139

3-6 months

Answer 140

Record evidence and dx of asthma

Answer 141

1-3 months after treatment and every 3-12 months after that BUT in pregnancy asthma should be reviewed every 4-6 weeks

Answer 142

Intraop hydrocortisone

Answer 143

False No need for tapering if < 2 weeks Additional note: pred should be given in AM

Answer 144

Chest x-ray findings in HP are nonspecific and can even lack any discernible abnormalities. In cases of acute and subacute HP, findings may be transient and can include ill-defined micronodular opacities or hazy ground-glass airspace opacities

Answer 145

Although not meant as a set of validated diagnostic criteria, a clinical prediction rule for predicting the presence of HP has been published by the HP Study Group. They identified six statistically significant predictors for HP, the strongest of which was exposure to an antigen known to cause HP

Answer 146

antigen avoidance Although glucocorticoids do not change the long-term outcome in these patients, they can accelerate the resolution of symptoms. While there is significant variability in the approach to glucocorticoid therapy by individual clinicians, prednisone therapy can be initiated at 0.5–1 mg/kg of ideal body weight per day (not to exceed 60 mg/d or alternative glucocorticoid equivalent) over a duration of 1–2 weeks, followed by a taper over the next 2–6 weeks.

Answer 147

Loffler syndrome refers to transient pulmonary infiltrates with eosinophilia that occurs in response to passage of helminthic larvae through the lungs, most commonly larvae of Ascaris species (roundworm). Symptoms are generally self-limited and may include dyspnea, cough, wheeze, and hemoptysis. Loffler syndrome may also occur in response to hookworm infection with Ancylostoma duodenale or Necator americanus.

Answer 148

Central bronchiectasis is described as a classic finding on chest imaging in ABPA but is not necessary for making a diagnosis. Other possible findings on chest imaging include patchy infiltrates and evidence of mucus impaction

Answer 149

Systemic glucocorticoids may be used in the treatment of ABPA that is persistently symptomatic despite the use of inhaled therapies for asthma. Courses of glucocorticoids should be tapered over 3–6 months, and their use must be balanced against the risks of prolonged steroid therapy. Antifungal agents such as itraconazole and voriconazole given over a 4-month course reduce the antigenic stimulus in ABPA and may therefore modulate disease activity in selected patients. Newer azole agents may be used as well. The use of monoclonal antibody against IgE (omalizumab) has been described in treating severe ABPA, particularly in individuals with ABPA as a complication of cystic fibrosis. Other monoclonal antibodies used in severe eosinophilic asthma, such as those targeting IL-5 (or its receptor) or targeting IL-4-receptor-alpha, may be considered as well in refractory cases

Answer 150

allergic angiitis granulomatosis or Churg-Strauss syndrome

Answer 151

Systemic eosinophilia is the hallmark laboratory finding in patients with EGPA and reflects the likely pathogenic role that the eosinophil plays in this disease. Eosinophilia >10% is one of the defining features of this illness and may be as high as 75% of the peripheral white blood cell count. It is present at the time of diagnosis in >80% of patients, but may respond quickly (often within 24 h) to initiation of systemic corticosteroid therapy.

Answer 152

The most common CT findings include bilateral ground-glass opacity and airspace consolidation that is predominantly subpleural. Other CT findings include bronchial wall thickening, hyperinflation, interlobular septal thickening, lymph node enlargement, and pericardial and pleural effusions.

Answer 153

Myocardial, GI, and renal involvement most often portend a poor prognosis.

Answer 154

In many parts of the world, the most common cause of an exudative pleural effusion is tuberculosis (TB) 2nd- malignancy The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL).

Answer 155

The major risk factors for OSA are obesity, male sex, and older age A 10% weight gain is associated with a >30% increase in AHI. Even modest weight loss or weight gain can influence the risk and severity of OSA. However, the absence of obesity does not exclude this diagnosis

Answer 156

Flow limited breath

Answer 157

Although the overall impact of CPAP on blood pressure levels is relatively modest (averaging 2–4 mmHg), larger improvements are observed among patients who have a high AHI, report daytime sleepiness, or have resistant hypertension

Answer 158

As appropriate, treatment should aim to reduce weight; optimize sleep duration (7–9 h); regulate sleep schedules (with similar bedtimes and wake times across the week); encourage the patient to avoid sleeping in the supine position; treat nasal allergies; increase physical activity; eliminate alcohol ingestion (which impairs pharyngeal muscle activity) within 3 h of bedtime; and minimize use of opiate medications. Sedative hypnotic medications have inconsistent effects on OSA but should be avoided in most patients with moderate to severe OSA

Answer 159

Uvulopalatopharyngoplasty (removal of the uvula and the margin of the soft palate) is the most commonly performed surgery for OSA and, although results vary greatly, is generally less successful than treatment with oral appliances.

Answer 160

optimizing therapy for heart failure

Answer 161

CSA is often caused by an increased sensitivity to Pco2 , which leads to an unstable breathing pattern that manifests as hyperventilation alternating with apnea

Answer 162

The elastase:antielastase hypothesis remains a prevailing mechanism for the development of emphysema

Answer 163

Some patients with advanced disease have paradoxical inward movement of the rib cage with inspiration (Hoover’s sign), the result of alteration of the vector of diaphragmatic contraction on the rib cage due to chronic hyperinflation

Answer 164

The main role of ICS is to reduce exacerbations. In population studies, patients with an eosinophil count of <100 cells per microliter do not benefit, while benefit increases as eosinophil counts rise above 100 A trial of ICS should be considered in patients with frequent exacerbations, defined as two or more per year or in patients hospitalized with one exacerbation ** based on GOLD, dpaat eoino >300

Answer 165

Patients with COPD should receive the influenza vaccine annually. Pneumococcal vaccines and vaccination for Bordetella pertussis are recommended. B-P-I If asthma, recommended covid 19 vaccine, not bordatella

Answer 166

True Among stable COPD patients in the primary care setting with FEV1<80% or mMRC≥2* and are not in exacerbation, we recommend the use of LABA/LAMA combination therapy over LAMA or LABA monotherapy

Answer 167

True Among stable COPD patients in the primary care setting with FEV1<80% or mMRC≥2* with increased risk for exacerbations and absence of concurrent respiratory infection**, we recommend the use of inhaled corticosteroids in combination with inhaled long-acting bronchodilators Among stable COPD patients in the primary care setting with FEV1≥80% or mmRC<2* and are not in exacerbation, we suggest the use of LAMA monotherapy over LABA monotherapy or LABA/LAMA combination therapy

Answer 168

False Among stable COPD patients in the primary care setting, we recommend against adding oral methylxanthines to inhaled long-acting bronchodilator

Answer 169

Among patients with COPD,recommend the use of SABA+SAMA (combination therapy) in the management of acute exacerbation. In situations where SABA+SAMA is not readily available, SABA may be used

Answer 170

Among outpatients with COPD, we recommend initiation of oral antibiotics in the presence of at least two of the following symptoms: increased dyspnea, increased frequency of cough, increased sputum volume or purulence

Answer 171

True Among COPD patients in exacerbation with worsening symptoms and not responding to bronchodilators, we recommend the use of short course* oral steroids in the primary care setting short course = 5 days of 30 mg prednisolone

Answer 172

Among COPD patients managed at the primary level, we recommend referral of any of the following conditions that are associated with higher risk of mortality to higher level of care: presence of uncontrolled diabetes or cardiovascular disease, previous hospitalization for acute exacerbation within the past year, hospital readmission within 30 days, and use of long-term oxygen therapy

Answer 173

Past exposure to asbestos is specifically indicated by pleural plaques on chest radiographs, which are characterized by either thickening or calcification along the parietal pleura, particularly along the lower lung fields, the diaphragm, and the cardiac border. Without additional manifestations, pleural plaques imply only exposure, not pulmonary impairment

Answer 174

Mesothelioma, both pleural and peritoneal, are also associated with asbestos exposure. In contrast to lung cancers, these tumors do not appear to be associated with smoking. Relatively shortterm asbestos exposures of ≤1–2 years, occurring up to 40 years in the past, have been associated with the development of mesotheliomas

Answer 175

Calcification of hilar nodes may occur in as many as 20% of cases and produces a characteristic “eggshell” pattern. Silicotic nodules may be identified more readily by HRCT. The nodular fibrosis may be progressive in the absence of further exposure, with coalescence and formation of nonsegmental conglomerates of irregular masses >1 cm in diameter (complicated silicosis). **same cut off of >=1cm for complicated coal workers pneumoconiosis These masses can become quite large, and when this occurs, the term progressive massive fibrosis (PMF) is applied

Answer 176

Complicated CWP is manifested by the appearance on the chest radiograph of nodules ≥1 cm in diameter generally confined to the upper half of the lungs Asbestosis - lower lungs

Answer 177

Fiberoptic bronchoscopy with transbronchial lung biopsy usually is required to make the diagnosis of CBD. Others: The test that usually provides this evidence is the beryllium lymphocyte proliferation test (BeLPT).

Answer 178

Farmer's lung A patient with acute farmer’s lung presents 4–8 h after exposure with fever, chills, malaise, cough, and dyspnea WITHOUT wheezing.

Answer 179

Non specific interstitial pneumonia Idiopathic NSIP is often treated with oral steroids (prednisone), cytotoxic agents (mycophenolate, azathioprine, and cyclophosphamide), or biologics (rituximab)

Answer 180

Respiratory bronchiolitis associated ILD

Answer 181

Progressive dyspnea, most frequently noted with exertion, is the most common complaint in patients presenting with an ILD

Answer 182

Most forms of ILD will eventually result in a restrictive deficit on pulmonary function testing. A restrictive deficit is typified by a reduced total lung capacity (TLC) and symmetrically reduced measures of forced expiratory volume in 1 s (FEV1 ) and forced vital capacity (FVC). A reduction in the diffusing capacity of the lung for carbon monoxide (DlCO) is also common and may precede a reduction in lung volumes; however, there is more measurement variability in DlCO measurement and the test is less specific for ILD

Answer 183

High-resolution CT (HRCT) chest imaging is now considered to be standard of care in the initial evaluation of a patient with a suspected ILD.

Answer 184

lung transplantation remains the standard of care for patients with advanced and rapidly progressive ILDs.

Answer 185

IPF is the most common ILD of unknown cause

Answer 186

The most common imaging findings include patchy, sometimes migratory, subpleural consolidative opacities often with associated ground-glass opacities. Peribronchiolar or perilobar opacities can be present, and sometimes a rim of subpleural sparing (often referred to as a REVERSED HALO or ATOLL SIGN) can be seen, which can aid in the diagnosis Corticosteroids can result in substantial clinical improvement in many patients but usually need to be continued for at least 6 months as relapse rates are high

Answer 187

ILD Cyclophosphamide has a modest benefit in preservation of lung function and is associated with significant toxicity. Mycophenolate has recently been shown to have similar efficacy and improved tolerability. Clinical trials have demonstrated that antifibrotic therapy (e.g., nintedanib) may benefit patients with systemic sclerosis associated pulmonary fibrosis

Answer 188

The most common imaging pattern of ILD in patients with RA is a UIP pattern, although NSIP patterns are not uncommon

Answer 189

The anti-synthetase syndrome is characterized by positive anti-synthetase antibodies, myositis, fever, Raynaud’s phenomenon, mechanic’s hands, arthritis, and progressive ILD Immunosuppressive (e.g., prednisone) and cytotoxic (e.g., mycophenolate, azathioprine, cyclophosphamide, and calcineurin inhibitors) agents are often used in patients with progressive ILD

Answer 190

The most infectious patients have cavitary pulmonary disease or, much less commonly, laryngeal TB and produce sputum containing as many as 105 –107 AFB/mL additional note: Because persons with both HIV infection and TB are less likely to have cavitations, they may be less infectious than persons without HIV co-infection

Answer 191

The lesion forming after initial infection (Ghon focus) is usually peripheral and accompanied by transient hilar or paratracheal lymphadenopathy, which may or may not be visible on standard chest radiography (CXR) The Ghon focus, with or without overlying pleural reaction, thickening, and regional lymphadenopathy, is referred to as the Ghon complex

Answer 192

It is usually localized to the apical and posterior segments of the upper lobes, where the substantially higher mean oxygen tension (compared with that in the lower zones) favors mycobacterial growth.

Answer 193

Hemoptysis, however, may also result from rupture of a dilated vessel in a cavity (Rasmussen’s aneurysm) or from aspergilloma formation in an old cavity

Answer 194

The fluid is straw-colored and at times hemorrhagic; it is an exudate with a protein concentration >50% of that in serum (usually ~4–6 g/dL), a normal to low glucose concentration, a pH of ~7.3 (occasionally <7.2), and detectable white blood cells (usually 500–6000/μL). Neutrophils may predominate in the early stage, but lymphocyte predominance is the typical finding later

Answer 195

Whereas the upper thoracic spine is the most common site of spinal TB in children, the lower thoracic and upper lumbar vertebrae are usually affected in adults

Answer 196

The WHO now recommends that adjuvant glucocorticoid therapy with either dexamethasone or prednisolone, tapered over 6–8 weeks, should be used in CNS TB.

Answer 197

The Xpert MTB/RIF assay is the preferred initial diagnostic option for pulmonary TB ensuring a sensitivity of 81% and a specificity of 98%, and therapy should be started on the basis of a positive result because treatment delays may be fatal. A negative Xpert MTB/RIF result, however, does not exclude a diagnosis of TB. Culture remains the gold standard.

Answer 198

IRIS can result in serious neurologic complications or death in patients with CNS TB. Therefore, ART should not be initiated during the first 8 weeks of TB treatment in patients with TB meningitis. BUUUUT ART should be started within the first 2 weeks of TB treatment for profoundly immunosuppressed patients with CD4+ T-cell counts of <50/μL. Glucocorticoids have been used for severe paradoxical reactions; prednisolone given for 4 weeks at a low dosage (1.5 mg/kg per day for 2 weeks and half that dose for the remaining 2 weeks) has reduced the need for hospitalization and therapeutic procedures and has hastened alleviation of symptoms, as reflected by Karnofsky performance scores, quality-of-life assessments, radiographic response, and C-reactive protein levels

Answer 199

katG and inhA

Answer 200

Group A drugs include three classes of oral agents: the fluoroquinolones levofloxacin and moxifloxacin; the oxazolidinone linezolid; and the recently introduced diarylquinoline bedaquiline, which was granted accelerated approval by the FDA in late 2012. Group B drugs include two other oral agents: clofazimine and cycloserine (or its analogue terizidone). Group C drugs include the nitroimidazole delamanid; imipenemcilastatin or meropenem; the injectable aminoglycosides amikacin and streptomycin

Answer 201

second month of treatment. By the end of the third month, the sputum of virtually all patients should be culture negative treatment failure should be suspected when a patient’s cultures (or sputum smears, when cultures are not available) remain positive after 3 months of treatment

Answer 202

The most common adverse reaction of significance among people treated for drug-susceptible TB is hepatitis

Answer 203

pyrazinamide in the pncA gene (up to 98%), that to ethambutol in the embB gene (50–65%),

Answer 204

two main approaches are now recommended by the WHO to treat MDR/RR-TB: (1) an individualized longer regimen of 18–20 months’ duration (or 15-17 months after culture conversion) consisting of an optimal combination of oral drugs chosen according to a rational approach and using the WHO priority grouping of medicines; and (2) a shorter, all-oral, bedaquiline-containing regimen of 9–12 months’ duration.

Answer 205

cisatracurium

Answer 206

True All ICU patients are at high risk for this complication because of their predilection for immobility. Therefore, all should receive some form of prophylaxis against DVT if feasible

Answer 207

False Prophylaxis against stress ulcers is not necessary for all ICU patients. It should only be administered to high-risk patients, such as those with coagulopathy or respiratory failure requiring mechanical ventilation

Answer 208

When parenteral feeding is necessary to supplement enteral nutrition, delaying this intervention until day 8 in the ICU results in better recovery and fewer ICU-related complications.

Answer 209

chronic inflammation

Answer 210

The key difference between volume control and PCV is that an inspiratory (or “driving”) pressure is set instead of a tidal volume in PCV; thus, every time the ventilator delivers a breath, it raises the airway pressure to the set amount above PEEP until inspiratory flow decreases below a set threshold, therefore ending inhalation. Thus, the resulting tidal volume will vary depending on the compliance of the lung PCV is often used to limit peak airway and lung distending (plateau) pressures in situations where high pressure can cause harm, such as in ARDS or after thoracic surgery with fresh suture lines in the airways or lung parenchyma

Answer 211

no mandated ventilation, or set mechanical respiratory rate, on PSV, and ventilator support is entirely patient triggered and controlled.

Answer 212

most hypercapnia is due to inadequate alveolar ventilation (VA) from an increase in the fraction of dead space (VD) Hypercapnia in the context of low tidal volume (6 mL/kg) ventilation for ARDS often causes acute respiratory acidosis that can be managed with higher respiratory rates, up to 30 breaths/min. Respiratory acidosis is often tolerated down to a pH of 7.2, so-called “permissive hypercapnia,” but progressive acidosis may require intravenous alkalinizing therapy (e.g., sodium bicarbonate or tromethamine) or accepting an increase in VT .

Answer 213

head-of-bed elevation to at least 30–45° (70% VAP reduction compared to supine position), specialized endotracheal tube use with a suction port above the cuff to minimize aspirated secretions (50% VAP reduction), minimization of ventilator circuit tubing changes (prevents bacterial entry), and hand hygiene before handling the ventilatory circuit.

Answer 214

Gross hemoptysis is suggestive of necrotizing pneumonia (e.g., that due to CA-MRSA).

Answer 215

Note FQ only for those with comorbid if outpatient Monotherapy with a macrolide is recommended in the new guidelines only if there are contraindications to amoxicillin or doxycycline and there is documented low risk of macrolide resistance (<25%) Routine coverage of anaerobes is unnecessary unless dentition is poor or there is a lung abscess or necrotizing pneumonia

Answer 216

If in px non severe, may give FQ alone

Answer 217

Chest radiographic abnormalities are slowest to resolve (4–12 weeks), with the speed of clearance depending on the patient’s age and underlying lung disease For a hospitalized patient, we generally recommend a follow-up radiograph ~4–6 weeks later. If relapse or recurrence is documented, particularly in the same lung segment, the possibility of an underlying neoplasm must be considered.

Answer 218

Fever and leukocytosis usually resolve within 2–4 days in otherwise healthy patients with CAP, but physical findings may persist longer 1 week in CAP guidelines

Answer 219

A 7- or 8-day course of therapy is just as effective as a 2-week course and is associated with less frequent emergence of antibioticresistant strains.

Answer 220

Because endotracheal intubation is a risk factor for VAP, the most important preventive intervention is to avoid intubation or minimize its duration

Answer 221

CAP MR and HR and MDRO risk not for CAP LR

Answer 222

We recommend blood cultures for patients with moderate and high risk CAP.

Answer 223

for CAP MR -> 3rd gen

Answer 224

The most common secondary infections included catheter-related bloodstream infections, ventilator-associated infections, and abdominal infections

Answer 225

There is no specific test for sepsis, nor is there a gold-standard method for determining whether a patient is septic

Answer 226

This management bundle includes five components: (1) measurement of serum lactate levels, (2) collection of blood for culture before antibiotic administration, (3) administration of appropriate broad-spectrum antibiotics, (4) initiation of a 30 mL/kg crystalloid bolus for hypotension or lactate ≥4 mmol/L, and (5) treatment with vasopressors for persistent hypotension or shock. Serum lactate levels should be remeasured if initial level ≥2 mmol/L

Answer 227

TZP if immunocompetent is 4.5g IV q6 but if immunocompromised 3.375 q4

Answer 228

Hypovolemic shock is most commonly related to hemorrhage, which may be external (secondary to trauma) or internal (most commonly upper or lower gastrointestinal [GI]) bleeding

Answer 229

Regardless of type, shock progresses through a continuum of three stages. These stages are compensated shock (preshock), shock (decompensated shock), and irreversible shock

Answer 230

The passive leg raise (PLR) test can predict responsiveness to additional intravenous fluid (IVF) by providing the patient with an endogenous volume bolus. While the patient is resting in a semirecumbent position at a 45° angle, the bed is placed in Trendelenburg position such that the patient’s head becomes horizontal and the legs are extended at a 45° angle. There is then an immediate (within 1 min) assessment of changes in CO (or pulse pressure variation as a surrogate). It is important to emphasize that one does not merely look for changes in blood pressure; if the shock patient is mechanically ventilated there is the option of looking at changes in SV variation (or pulse pressure variation) during the respiratory cycle to assess volume responsiveness. A >12% SV variation suggests a volume-responsive state.

Answer 231

The PCWP is used as a surrogate for LA pressure.

Answer 232

The clinical presentation is typically characterized by persistent hypotension (<90 mmHg systolic blood pressure [BP]) or <60-65 mmHg mean arterial pressure unresponsive to volume replacement or by the use of vasopressors needed to maintain adequate BP (systolic >90 mmHg) and is accompanied by clinical features of peripheral hypoperfusion, such as elevated arterial lactate (>2 mmol/L).

Answer 233

cardiac tamponade

Answer 234

Approximately 80% of Cardiogenic shock patients present with multivessel coronary artery disease. In these patients, culprit-only PCI with possible staged revascularization is the method of choice because it reduces mortality and requirement for renal replacement therapy at 30 days and 1 year in comparison to immediate multivessel PCI, as shown in the CULPRIT-SHOCK trial. The major driver for the reduction in the composite endpoint was a reduction in 30-day mortality

Answer 235

Dopamine should be avoided as first-line therapy for MI with CS based on hemodynamic and proarrhythmogenic effects

Answer 236

Management of isolated RV CS includes fluid administration to optimize right atrial pressure (10–15 mmHg); avoidance of excess fluids, which shifts the interventricular septum into the LV; catecholamines; early reestablishment of infarct-artery flow; and right-sided MCS

Answer 237

Acute myocarditis causes CS in a small proportion of cases. These patients are typically younger than those with CS due to acute MI and often do not have typical ischemic chest pain. Echocardiography usually shows global LV dysfunction. Initial management is the same as for CS complicating acute MI but does not involve revascularization.

Answer 238

Mechanical ventilation with positive end-expiratory pressure can have multiple beneficial effects on pulmonary edema, as it: (1) decreases both preload and afterload, thereby improving cardiac function; (2) redistributes lung water from the intraalveolar to the extraalveolar space, where the fluid interferes less with gas exchange; and (3) increases lung volume to avoid atelectasis.

Answer 239

High-altitude pulmonary edema often can be prevented by use of dexamethasone, calcium channel–blocking drugs, or long-acting inhaled β2 -adrenergic agonists. Treatment includes descent from altitude, bed rest, oxygen, and, if feasible, inhaled NO; nifedipine may also be effective.

Answer 240

>92% >98% is detrimental

Answer 241

Furosemide is also a venodilator that rapidly reduces preload before any diuresis occurs and is the diuretic of choice. The initial dose of furosemide should be ≤0.5 mg/kg, but a higher dose (1 mg/ kg) is required in patients with renal insufficiency, chronic diuretic use, or hypervolemia or after failure of a lower dose.

Answer 242

The HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is a special subtype of preeclampsia with severe features and is a major cause of morbidity and mortality.

Answer 243

Specific clinical features qualify as evidence of severe disease, including severe hypertension (blood pressure ≥160/110 mmHg), new-onset symptoms (headache not responsive to medications, visual changes, unremitting severe epigastric pain, or pulmonary edema), or laboratory abnormalities signifying thrombocytopenia (platelets <100 × 109 /L), renal insufficiency (creatinine >1.1 mg/dL), or liver impairment (elevation of transaminases to twice the normal concentration).

Answer 244

The development of elevated blood pressure after 20 weeks of pregnancy in the absence of preexisting chronic hypertension or proteinuria is referred to as gestational hypertension.

Answer 245

The definitive treatment of preeclampsia is delivery of the fetus and placenta Expectant management of preeclampsia with severe features remote from term affords some benefits for the fetus but at significant risk to the mother. For women with preeclampsia with severe features, delivery is recommended unless the patient is <34 weeks and eligible for expectant management in a tertiary hospital setting. Indications for delivery prior to 34 weeks include unremitting symptoms, development of laboratory abnormalities, or severe range blood pressures refractory to medical management

Answer 246

Labetalol or hydralazine IV are the first-line agents to manage severe hypertension in preeclampsia with consideration of oral agents once blood pressure is controlled.

Answer 247

Magnesium sulfate is the preferred agent to prevent eclampsia in patients with preeclampsia with severe features and for treatment and prevention of recurrent seizures in patients with eclampsia. Magnesium sulfate is administered as an IV loading dose followed by a continuous infusion, with care taken in patients with impaired renal function or pulmonary edema

Answer 248

The target blood pressure is in the range of 130–150 mmHg systolic and 80–100 mmHg diastolic to balance maternal safety with fetal perfusion

Answer 249

valvuloplasty

Answer 250

40 50 50 magic number for repair of aortic

Answer 251

Fasting blood glucose levels should be maintained at <5.3 mmol/L (<95 mg/dL), with postprandial targets of <7.8 mmol/L (140 mg/dL) or <6.7 mmol/L (120 mg/dL) at 1 and 2 h, respectively

Answer 252

Average daily insulin needs increase from 0.7–0.8 units/ kg in the first trimester, to 0.8–1 units/kg in the second trimester, and 0.9–1.2 units/kg in the third trimester

Answer 253

GDM confers a 7- to 10-fold increase in the risk of developing type 2 DM later in life, with a 10% risk within 5 years of delivery. All women with GDM should have a 4- to 12-week 2-h 75-g GTT to screen for DM or impaired glucose tolerance.

Answer 254

30 (two additional pills weekly)

Answer 255

Anticoagulant therapy with low-molecular-weight heparin (LMWH) or unfractionated heparin is indicated in pregnant women with VTE Anticoagulants increase the risk of epidural hematoma in women receiving neuraxial analgesia in labor and must be withheld prior to placement. Prophylactic LMWH must be stopped 12 h before placement of an epidural catheter, whereas therapeutic LMWH must be withheld for a full 24 h.

Answer 256

left heart or primary lung disease

Answer 257

Ventilation-perfusion (V. /Q . ) scanning is the primary test used to screen and diagnose CTEPH, which should be considered in any patient with PH of unclear etiology The definitive diagnostic procedure remains pulmonary angiography since contrast enhancement in this study provides detailed information on webbing, stricture, and vascular tapering patterns pathognomonic for CTEPH.

Answer 258

> > > combined inc in PAWP but not PVR = isolated postcapillary

Answer 259

PH due to left heart dse The hallmark of this PH phenotype is elevated left atrial pressure with resulting pulmonary venous hypertension

Answer 260

The randomized, placebo-controlled, phase 3 Bosentan Randomized Trial of Endothelin Antagonist Therapy (BREATHE)-1 trial comparing bosentan to placebo demonstrated improved symptoms, 6-MWD, and WHO FC in patients treated with bosentan The Endothelin Antagonist Trial in Mildly Symptomatic Pulmonary Arterial Hypertension Patients (EARLY) study comparing bosentan to placebo demonstrated improved PVR and 6-MWD in patients with WHO FC II

Answer 261

Several studies, including the phase 3, placebo-controlled Ambrisentan in Pulmonary Arterial Hypertension, (ARIES)-1 trial, have demonstrated that ambrisentan improves exercise tolerance, WHO FC, hemodynamics, and quality of life in patients with PAH.

Answer 262

More recently, the Study with an Endothelin Receptor Antagonist in Pulmonary Arterial Hypertension to Improve Clinical Outcome (SERAPHIN) trial randomized 742 PAH patients to receive placebo or macitentan, which is an ETA/B antagonist with optimized receptor binding affinity. The majority of patients were on some form of background PAH therapy. Over an average treatment duration of 85 weeks, the hazard ratio for achieving the composite primary endpoint of PAH-related clinical worsening, which included death or disease progression, was decreased by 45% in the 10-mg dose arm.

Answer 263

The role of early, aggressive therapy with combination oral treatments was addressed in the landmark Initial Use of Ambrisentan plus Tadalafil in Pulmonary Arterial Hypertension (AMBITION) trial. Treatment-naïve, incident PAH patients (n = 500) were randomized to a combination of ambrisentan and tadalafil, ambrisentan monotherapy, or tadalafil monotherapy. Up-front combination therapy with ambrisentan and tadalafil was associated with a 50% lower risk of clinical worsening (composite of death, lung transplantation, hospitalization for PAH worsening, and worsening PAH) when compared with the monotherapy group

Answer 264

negative vasoreactivity test, high risk (syncope + advanced HF) Low- or intermediate (Int)-risk patients are initiated on combination oral therapy, which generally includes an endothelin receptor antagonist and phosphodiesterase type 5 inhibitor

Answer 265

lung abscess or empyema

Answer 266

Note: ESBL + culture within 1 yr --> risk of ESBL pa rin

Answer 267

Note: prior tracheostomy: risk factor for P. aeruginosa

Answer 268

As soon as diagnosis is established, treatment of community acquired pneumonia, regardless of risk, should be initiated within 4 hours

Answer 269

Among patients with low to moderate risk CAP, a treatment duration of 5 days is recommended as long as the patient is clinically stable (afebrile within 48 hours, able to eat, normal blood pressure, normal heart rate, normal respiratory rate, normal oxygen saturation, and return to baseline sensorium). 2016 guidelines: afebrile 24h

Answer 270

Administration of both influenza and pneumococcal vaccine is recommended to prevent pneumonia, hospitalization and mortality in adults 50 years old and above.

Answer 271

We recommend testing of respiratory secretions for influenza through rapid molecular testing using rapid nucleic acid amplification tests during periods of high influenza activity (July to January) for patients with high risk CAP preceded by influenza-like illness symptoms (sore throat, rhinorrhea, body malaise, joint pains) and any of the following risk factors: * Aged 60 years and above * Pregnant * Asthmatic * Other co-morbidities: uncontrolled diabetes mellitus, active malignancies, neurologic disease in evolution, congestive heart failure class II-IV, unstable coronary artery disease, renal failure on dialysis, uncompensated COPD, decompensated liver disease

Answer 272

The most strongly and consistently associated risk factors for CAP due to MRSA were previous MRSA colonization or infection, especially of the respiratory tract, within 1 year

Answer 273

1. exposure to known antigen (strongest predictor) 2. presence of serum precipitin 3. recurrent ssx 4. inspiratory crackles 5. ssx developing 4-8 hrs after exposure 6. weight loss

Answer 274

Pirfenidone + Nintedanib

Answer 275

sarcoidosis

Answer 276

a. analgesic and oxygen DIAGNOSIS: Pneumomediastinum * Symptoms: severe substernal chest pain with or without radiation into the neck and arms * Signs: subcutaneous emphysema in the suprasternal notch and Hamman’s sign (crunching or clicking noise synchronous with the heartbeat) * Usually no treatment is required but will be absorbed faster by inspiring high concentrations of oxygen. If mediastinal structures are compressed, the compression can be relieved with needle aspiration.

Answer 277

b. spiral computed tomography scan Pulmonary embolism * Most overlooked in the differential diagnosis of an undiagnosed pleural effusion

Answer 278

b. Peritoneal dialysis

Answer 279

b. bronchoscopy Focal bronchiectasis Evaluation: almost always requires bronchoscopy to exclude airway obstruction by an underlying mass or foreign body.

Answer 280

D. None of the above Long term oxygen >15h/d

Answer 281

B. Begin treatment with Isoniazid 300mg once a day for 6 months and clear for work

Answer 282

D. Do sputum Xpert MTB-Rif Since 2+ on AFB

Answer 283

b. Partly controlled Nightime awakenings Daytime symptoms

Answer 284

b. Tiotopium Most common side effect of tiotropium = dry mouth

Answer 285

d. Lung function measurement is recommended if available Objective measurement of lung function (e.g., peak expiratory flow [PEF] or spirometry) helps assess the severity of the exacerbation, guide treatment, and monitor response to therapy. Not recommended in COPDIAE

Answer 286

a. honeycomb changes * UIP - honeycomb changes and fibroblast foci (subepithelial collections of myofibroblasts and collagen), fibrotic changes alternate with areas of preserved normal alveolar architecture consistent with temporal and spatial heterogeneity * NSIP - honeycomb changes are usually absent and fibroblast foci are rare, varying amounts of interstitial inflammation and fibrosis with a uniform appearance

Answer 287

b. Cytotoxic agents like cyclophosphamide may be useful and have shown variable success. Cyclophosphamide has a modest benefit in preservation of lung function and is associated with significant toxicity

Answer 288

c. Shunt physiology is the major determinant of elevation in PaCO2 Ventilation-perfusion mismatching accounts for essentially all of the reduction in Pao2 that occurs in COPD PaO2 usually remains near normal until the FEV1 is decreased to ~50% of predicted Elevation of Paco2 is not expected until the FEV1 is <25% of predicted

Answer 289

d. Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option Theophylline produces modest improvements in airflow and vital capacity, but is not first-line therapy due to side effects and drug interactions. Chronic use of oral glucocorticoids are not recommended because of an unfavorable benefit/risk ratio LAMA improve symptoms and reduce exacerbations, but only seen to have trend to reduction of mortality. LABA provide symptomatic benefit and reduce exacerbations, though to a lesser extent than a LAMA.

Answer 290

d. Start salbutamol/ipratropium bromide nebulization Short-acting inhaled beta-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilator to treat an acute exacerbation.

Answer 291

b. Hyperventilation triggers mast cell mediator release * Results in increased osmolality in airway lining fluid and triggers mast cell mediator release, resulting in bronchoconstriction Mechanisms of the triggers of asthma *Stress-induced bronchoconstriction through cholinergic reflex pathways *Viral infection increase airway inflammation, increased number of neutrophils *Inhaled allergens activate mast cells with bound IgE directly leading to the immediate release of bronchoconstrictor mediators *Beta-blockers increase cholinergic bronchoconstriction

Answer 292

c. Mast cell-derived * Limitation of airflow is due mainly to bronchoconstriction (from mast cell mediators), but airway edema, vascular congestion, and luminal occlusion with exudate may contribute. Mast cell-derived mediators * Histamine, prostaglandin D2, and cysteinyl-leukotrienes * Contract airway smooth muscle, increase microvascular leakage, increase airway mucus secretion, and attract other inflammatory cells

Answer 293

c. If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects. If an OCS is needed - better to use prednisone rather than prednisolone as it cannot be converted to the active prednisolone by the fetal liver, thus protecting the fetus from systemic effects of the corticosteroid.

Answer 294

d. Subcutaneous epinephrine * Type 1 brittle asthma – OCS or continuous infusion of β2-agonists * Type 2 brittle asthma – subcutaneous epinephrine (suggests that the worsening is likely to be a localized airway anaphylactic reaction with edema)

Answer 295

b. Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose fluticasone/salmeterol inhalation with salbutamol as reliever. Confirm first the diagnosis of asthma before starting controller medications then initiate appropriate medication (STEP 2 – low dose ICS + SABA reliever)

Answer 296

b. Continue prednisone for 5 days, as-needed salbutamol and start low dose inhaled corticosteroid. Initiate regular ICS-containing controller therapy, reduce reliever to as-needed and continue oral steroid for 5-7 days Short-term systemic corticosteroids (e.g., prednisone) for 5–7 days are standard after a moderate or severe asthma exacerbation to suppress airway inflammation. Stopping prednisone prematurely increases the risk of relapse.

Answer 297

c. Oral montelukast daily Leukotriene receptor antagonists (LTRA) may be used as initial controller treatment for some patients who are unable or unwilling to use ICS, for patients who experience intolerable side-effects from ICS or for patients with concomitant allergic rhinitis.

Answer 298

a. Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists. Tolerance is a potential problem with any agonist given chronically. Mast cells become rapidly tolerant, but their tolerance may be prevented by concomitant administration of ICS. Corticosteroids also activate anti-inflammatory genes such as mitogen-activated protein (MAP) kinase phosphatase-1 and increase the expression of β2-receptors.

Answer 299

Rapid revascularization PCI = preferred

Answer 300

unexpected death without obv extracardiac death <1 hr if witnessed extended to <24h if unwitnessed

Answer 301

d. ≥ 28 days

Answer 302

c. Prevotella spp. It is an anaerobe S. aureus - more common in secondary lung abscess

Answer 303

c. Pleural blebs

Answer 304

b. Cotton Byssinosis mnemonic: Busy (Byssi) pag Monday

Answer 305

c. Shift to LABA/LAMA Provides superior bronchodilation compared to ICS/LABA. Improves symptoms such as breathlessness and exercise capacity.

Answer 306

PSV = flow cycled, PATIENT triggered PCV = time cycled, time triggered both are pressure limited

Answer 307

Once established as hemoptysis, the degree of blood that is being expectorated (volume and frequency) is the next step as massive or life-threatening hemoptysis (>400 mL of blood in 24 h or >150 mL at one time) requires emergent intervention Tuberculosis had long been the most common cause of hemoptysis worldwide, but it is now surpassed in industrialized countries by bronchitis and bronchiectasis

Answer 308

Pulmonary embolism with parenchymal infarction can present with hemoptysis, but pulmonary emboli do not commonly cause hemoptysis.

Answer 309

Bronchoscopy patients with risk factors for malignancy (i.e., age >40 or a smoking history) should undergo additional testing. First, chest computed tomography (CT) with contrast should be obtained to better identify masses, bronchiectasis, and parenchymal lesions. A CT looking for pulmonary embolism should be considered if the history and physical examination are consistent with that diagnosis. Following a CT, a flexible bronchoscopy should be performed to exclude bronchogenic carcinoma unless imaging reveals a lesion that can be sampled without bronchoscopy. Endotracheal intubation should be avoided unless truly necessary, since suctioning through an endotracheal tube is a less effective means of removing blood and clot than the cough reflex. If intubation is required, take steps to protect the nonbleeding lung either by selective intubation of one lung (i.e., the nonbleeding lung) or insertion of a double-lumen endotracheal tube

Answer 310

Patients rarely die of exsanguination but, rather, are at risk of death due to asphyxiation from blood filling the airways and airspaces.

Answer 311

Because most life-threatening cases of hemoptysis arise from the bronchial circulation, bronchial artery embolization is the procedure of choice for control of the bleeding. However, bronchial artery embolization can have significant complications such as embolization of the anterior spinal artery. However, it is generally successful in the short term, with >80% success rate at controlling bleeding immediately, although bleeding can recur if the underlying disease (e.g., a mycetoma) is not treated. Surgical resection has a high mortality rate (up to 15–40%) and should not be pursued unless initial measures have failed and bleeding is ongoing. Ideal candidates for surgery have localized disease but otherwise normal lung parenchyma.

Answer 312

In virtually all instances, evaluation of chronic cough merits a chest radiograph.

Answer 313

ACE inhibitor–induced cough occurs in 5–30% of patients taking these agents and is not dose-dependent. ACE metabolizes bradykinin and other tachykinins, such as substance P. The mechanism of ACE inhibitor–associated cough may involve sensitization of sensory nerve endings due to accumulation of bradykinin. Any patient with chronic unexplained cough who is taking an ACE inhibitor should have a trial period off the medication, regardless of the timing of the onset of cough relative to the initiation of ACE inhibitor therapy. In most instances, a safe alternative is available; angiotensin receptor blockers do not cause cough. Failure to observe a decrease in cough after 1 month off medication argues strongly against this etiology

Answer 314

Cough alone as a manifestation of asthma is common among children but not among adults. Cough due to asthma in the absence of wheezing, shortness of breath, and chest tightness is referred to as “cough-variant asthma.” A history suggestive of cough-variant asthma ties the onset of cough to exposure to typical triggers for asthma and the resolution of cough to discontinuation of exposure. Objective testing can establish the diagnosis of asthma (airflow obstruction on spirometry that varies over time or reverses in response to a bronchodilator) or exclude it with certainty (a negative response to a bronchoprovocation challenge—e.g., with methacholine). In a patient capable of taking reliable measurements, home expiratory peak flow monitoring can be a cost-effective method to support or discount a diagnosis of asthma.

Answer 315

ventilationperfusion mismatch resulting from perfusion of poorly ventilated alveoli.

Answer 316

In general, cyanosis becomes apparent when the concentration of reduced hemoglobin in capillary blood exceeds 40 g/L (4 g/dL)

Answer 317

Probably the most common cause of peripheral cyanosis is the normal vasoconstriction resulting from exposure to cold air or water R to L shunt = central

Answer 318

Walking oximetry Peak flow assessment Bronchoprovocation testing and/or home peak-flow monitoring may be useful in patients with intermittent symptoms suggestive of asthma who have a normal physical examination and spirometry; up to one-third of patients with the clinical diagnosis of asthma do not have reactive airways disease when formally tested.

Answer 319

b. Legionella pneumophila Since with hyponatremia and went on a cruise

Answer 320

c.A drop in FEV1 of 20% after a methacholine challenge test FEV1 increase of 12% and 200mL after 15 minutes of short-acting beta agonist inhalation = REVERSIBILITY

Answer 321

d. Order for lung volume studies Lung volume study is also a lung function test similar to PFT

Answer 322

mmrc 3 since will pause after a few mins

Answer 323

a.Cystic Fibrosis Recurrent pneumonia since 15y/o CF associated bronchiectasis common in upper lung field P. aeruginosa is common among CF

Answer 324

a. Thickening or calcification along the parietal pleura on chest x-rays Pleural plaques (thickening or calcification of the parietal pleura) are a marker of asbestos exposure but do not necessarily indicate active disease or impairment.

Answer 325

d. Permissive hypercapnia with a target pH >7.3 and adequate oxygenation A. Increasing minute ventilation by increasing the respiratory rate or tidal volume will, therefore, often paradoxically worsen hypercapnia by increasing gas trapping and VD/ VT C. Higher minute ventilation usually worsens hyperinflation and can cause barotrauma B and D. Respiratory acidosis is often tolerated down to a pH of 7.2, so-called “permissive hypercapnia,” but progressive acidosis may require intravenous alkalinizing therapy (e.g., sodium bicarbonate or tromethamine) or accepting an increase in VT.

Answer 326

Pretreatment with an SABA can increase the threshold of ventilation required to induce bronchoconstriction. LABAs may extend the period of protection, but their use alone in asthma is to be discouraged. For occasional exercise, ICS/LABA can be used, but regular use may expose the patient to unnecessary doses of ICS. If regular exercise is undertaken, then LTRAs may provide protection and can be used regularly.

Answer 327

a. Short-acting beta-agonist as needed. There is extensive experience suggesting the safety of inhaled albuterol, beclomethasone, budesonide, and fluticasone, with reassuring information on formoterol and salmeterol in pregnancy. Animal studies have not suggested toxicity for montelukast, zafirlukast, omalizumab, and ipratropium Chronic use of OCS has been associated with neonatal adrenal insufficiency, preeclampsia, low birth weight, and a slight increase in the frequency of cleft palate

Answer 328

c. Initiate omalizumab as an add-on therapy Severe and difficult-to-treat asthma, which composes ~5–10% of asthma, is defined as asthma that, having undergone appropriate evaluation for comorbidities and mimics, education, and trigger mitigation, remains uncontrolled on step 5 therapy or requires step 5 therapy for its control.

Answer 329

b. Start triple therapy (long-acting bronchodilator + inhaled corticosteroid + long-acting muscarinic antagonist).

Answer 330

b. Initiate roflumilast as an add-on therapy.

Answer 331

a. Amoxicillin 1gm TID

Answer 332

b. 4-6 weeks; 4-12 weeks

Answer 333

c. Serratia marcescens

Answer 334

a. Dyspnea

Answer 335

c. Left heart failure since PAWP >15

Answer 336

d. High dose CCB

Answer 337

d. Proceed with continuation phase of treatment and request for Xpert MTB/Rif at the end of 5th month ** supposedly smear microscopy Xpert MTB/RIF test is NOT used for follow-up examination to monitor treatment because current- generation PCR-based tests are unable to determine MTB viability and may test positive even with nonviable or dead bacilli

Answer 338

b. Request for a smear microscopy and decide on continuation of treatment based on results

Answer 339

b. Request for a chest x-ray Screening for PLHIV : CXR Diagnosis for presumptive: Gene xpert

Answer 340

b. Sandblasting procedures on confined factory in Mindoro Workers heavily exposed through sandblasting in confined spaces tunneling through the rock with high quartz content (15-25%), or the manufacture of abrasive soaps may develop acute silicosis with as little as 10 months exposure Clinical and pathologic features are similar to those of pulmonary a;lveolar proteinosis. The chest radiograph may show profuse miliary proliferation or consolidation and there is a characteristic HRCT pattern known as “crazy paving “ Crazy paving: diffuse ground glass densities with thickened intralobular and interlobular septa producing polygonal shapes.

Answer 341

d. Transbronchial biopsy of lung tissue With early disease, both chest imaging studies and pulmonary function tests may be normal. Fiberoptic bronchoscopy with transbronchial lung biopsy usually is required to make the diagnosis of CBD

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a. Central bronchiectasis Central bronchiectasis is described as a classic finding on chest imaging in ABPA but is not necessary for making a diagnosis Allergic bronchopulmonary asperigilosis (ABPA) is an eosinophilic pulmonary disorder that occurs in response to allergic sensitization to antigens from Aspergillus species fungi. Asthmatic phenotype accompanied by cough with production of brownish plugs of mucus - predominant clinical presentation Distinct diagnosis from asthma: prominent peripheral eosinophilia and elevated circulating levels of IgE (often >1000 IU/ml) Establishing a diagnosis of ABPA also requires establishing sensitivity to Aspergillus antigens by skin test reactivity and/or direct measurement of circulating specific IgE to Aspergillus. Positive serum precipitins for Aspergillus or direct measurement of circulating specific IgG to Aspergillus can be used as an adjunct diagnostic criterion.

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A. Mechanical ventilation can impede venous return from positive pressure ventilation

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B. Exudative phase The exudative phase encompasses the first 7 days of illness after exposure to a precipitating ARDS risk factor, with the patient experiencing the onset of respiratory symptoms. Proliferative phase - lasts from approximately day 7 to day 21 Fibrotic phase - 3-4 weeks

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D. SpO2 of 88%

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For the diagnosis of ASTHMA, PFTs show: ● The flow-volume loop may show a characteristic scalloping ● Reversibility is defined as a ≥12% increase in the FEV1 and an absolute increase of ≥200 mL at least 15 min after administration of a β2-agonist or after several weeks of corticosteroid therapy. ● Diurnal peak flow variability of >20% GINA = diurnal peak flow variability >10%

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A. They can generally tolerate inhibitors of cyclooxygenase-2 and acetaminophen

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B. Asbestosis

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C. Sitophilus granaries =Miller's lung D. Botrytis cinerea= wine makers lung

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C. Decrease in pulmonary artery pressure In PAH, initial changes in the histopathophenotype of distal pulmonary arterioles precedes significant changes in hemodynamics or the development of symptoms in most patients (clinical stage A). As vascular remodeling progresses, there is an increase in pulmonary vascular resistance (PVR), pulmonary artery pressure (PAP), and right atrial pressure (RAP). In clinical stage B, symptoms are evident and, when diagnosed, prompt early, aggressive treatment. Effacement of pulmonary arterioles results in severely increased PVR that promotes right heart failure, defined by a decrease in cardiac output (CO) and PAP. Patients in clinical stage C have severe symptoms and require full therapeutic intervention.

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C. Isolated Capillary PH

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C. 6-WMD >440m

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B. By the end of the 3rd month 2nd month >80% negative

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C. Discontinue pyrazinamide and continue with HRE for 2 months then HR for 7 months

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Answer: A. Delay ART initiation for 8 weeks

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C. Perform thoracoscopy with pleural biopsy and pleurodesis

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C. Age >70 years old

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C. Cefuroxime 500mg BID + Doxycycline 100mg BID B. co-amoxiclav should be TID

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D. Meropenem + Linezolid + Amikacin Double coverage (1 per column)

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B. Cefepime + Vancomycin Add vanco for septic shock and neutropenic

Pulmonology and CritCare Flashcards

(474 cards)