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Flashcards in Pulmonology/Critical Care Deck (69)
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1
Q

Ventilator assist control mode

A

Patient can initiate breathing, but vent will deliver breaths if RR falls below a set number. Vent is volume-controlled.

2
Q

How to determine an appropriate tidal volume for a patient on a ventilator?

A

~6mL/kg

3
Q

Main vent settings that affect oxygenation? Ventilation?

A

Oxygenation = FiO2 and PEEP. Ventilation = TV and RR.

4
Q

Goals for oxygenation on the ventilator?

A

Keep the PaO2 > 60, the FiO2 < 50-60%.

5
Q

3 most common causes of chronic cough (> 8 weeks)

A

PND, asthma, GERD

6
Q

Chlorpheniramine

A

H1 blocker AND blocks histamine release from mast cells

7
Q

Why ACE-I cause cough

A

Inhibition of degradation of bradykinin and substance P leads to their accumulation in the lungs and irritation

8
Q

What is the cause of hypoxia in patients with PNA?

A

Inflammation of interstitium and alveolar walls, leading to an increased A-a gradient and decreased gas exchange.

9
Q

Indications for oxygen therapy in patients with COPD

A

PaO2 < 55, SaO2 < 88%, Hct > 55% and evidence of cor pulmonale

10
Q

Causes of recurrent PNA involving the same region of the lung?

A

Local anatomic obstruction (bronchial compression from rings/masses or intrinsic obstruction from bronchiectasis, stenosis) and recurrent aspiration.

11
Q

Causes of recurrent PNA involving different regions of the lung?

A

Sinopulmonary dz, vasculitis, bronchiolitis obliterans and immunodeficiency.

12
Q

Symptoms of aspiration PNA? X-ray findings that depend on the patient’s positioning during aspiration event?

A

Indolent sx for days to weeks, foul-smelling sputum and periodontal dz. Lower lobe infiltrate if upright, posterior segment of upper lobes if supine during aspiration event.

13
Q

Appropriate abx for aspiration PNA?

A

Amp-sulbactam and clindamycin

14
Q

DLCO

A

Diffusion capacity of CO2. Measured by comparing the partial pressure of inspired vs. expired CO2 to determine how well CO2 is diffusing across the aveolar-epithelial interface.

15
Q

Next test after determining your patient has restrictive lung disease by the FEV1:FVC?

A

DLCO. NM dz will have a normal DLCO, interstitial lung dz will have a decreased DLCO.

16
Q

ABG typical of acute PE

A

Low PaCO2 due to hyperventilation (high PaCO2 is concerning for impending respiratory failure) and high A-a gradient (due to interstitial V/Q mismatch)

17
Q

Common changes seen in the WBC differential in patients being treated with glucocorticoids?

A

Low eos and lymphs. Elevated PMNs due to mobilization of the marginated neutrophil pool from the bone marrow.

18
Q

SVC syndrome signs/symptoms

A

Dyspnea, venous congestion, swelling of head, neck and arms. CXR will often show a mass.

19
Q

Beck’s triad

A

Tamponade: hypotension, distant heart sounds and JVD

20
Q

Common causes of SVC syndrome

A

Small cell lung cancer, non-Hodgkins lymphoma and fibrosing mediastinitis (secondary to Tb and Histoplasmosis)

21
Q

Initial tx for AECOPD?

A

Short-acting bronchodilators, glucocorticoids and abx.

22
Q

Indications for non-invasive positve pressure ventilation

A

AECOPD, cardiogenic pulmonary edema, acute respiratory failure and to facilitate early extubation.

23
Q

Methylxanthines (aminophylline, theophylline)

A

PDE inhibitors that cause bronchodilation by increasingn levels of cAMP. Can cause tremors and arrhythmias.

24
Q

Indications for invasive mechanical ventilation?

A

Hypercapneic patients with poor mental status, hemodynamic instability, pH < 7.1 or failure of 2 hour trial of NPPV.

25
Q

Immunodeficiency that may present in adult females with recurrent sinopulmonary infections and gastroenteritis, food allergies and autoimmune disease?

A

Selective IgG3 deficiency leading to defective humoral (ab) immunity.

26
Q

Side effects associated with high-dose inhaled corticosteroids

A

Cataracts, adrenal suppression, impaired growth in kids, purpura and interference with bone metabolism.

27
Q

Why is empyema often non-responsive to abx used to treat normal CAP?

A

Initially the infected pleura is colonized by bacteria commonly seen in CAP (S. pneumo, K. pneumo, S. aureus). However, as the infection progresses to empyema, mixed arobes and anaerobes supersede the infection.

28
Q

Characteristic findings on CXR of empyema?

A

Free flowing (early) or loculated (late) pleural effusion/consolidation with air bronchograms.

29
Q

Radiographic evidence of PE

A

Hampton’s hump (peripheral wedge-shaped infarct), Westermark’s sign (sharp cutoff pulm. vessel w/distal hypoperfusion) and pleural effusion.

30
Q

Urine pH in a patient with elevated ICP and increased RR on vent in ICU

A

Increased RR -> respiratory alkalosis -> compensatory metabolic acidosis by secretion of HCO3- in urine -> elevated urine pH

31
Q

Urine pH in a patient with hypovolemia

A

Hypovolemia -> aldosterone secretion -> Na retention, K/H secretion -> decreased urine pH

32
Q

Normal A-a gradient?

A

<15, increases w/age, but > 30 is always elevated no matter what

33
Q

5 causes of hypoxemia

A

Reduced inspired O2 tension (high altitude), hypoventilation (CNS depression), diffusion limitation (interstitial lung dz), shunt (cardiac, ARDS), V/Q mismatch (PNA, obstruction, atelectasis, pulm edema).

34
Q

A-a gradient, PaCO2 and correction with supplemental O2 in each of the 5 causes of hypoxemia?

A

Decrease inspired O2 tension = normal A-a, PaCO2 and corrects w/O2. Hypoventilation = normal A-a, elevated PaCO2 and corrects w/O2. Diffusion limitation = elevated A-a, normal PaCO2, corrects w/O2. Shunt = elevated A-a, normal PaCO2 and no correction w/O2. V/Q mismatch = elevated A-a, normal to elevated PaCO2 and corrects w/O2.

35
Q

Calculate PAO2 at sea level in a patient with a PaO2 of 30?

A

(0.21 x [760 - 47]) - (30/0.8)

36
Q

When is a high-resolution chest CT indicated in a patient with hemoptysis?

A

Recurrent hemoptysis, risk factors for malignancy (quit smoking < 5 years ago/current smoker, spiculated SPN > 2cm, age > 60) or active bleeding > 30mL.

37
Q

Pleural effusion associated w/PE

A

Can be transudative or exudative

38
Q

HIV patients at risk for pneumocystis PNA

A

CD4 < 200

39
Q

Common acid base problem seen in renal failure

A

Metabolic acidosis due to failure to secrete organic anions like sulfate and phosphate.

40
Q

What does alpha-1 antitrypsin do?

A

Counteracts neutrophil elastase

41
Q

When might you see exudative pleural effusions in patients with CHF?

A

25% can be exudative if the patient received aggressive diuretics prior to thoracentesis

42
Q

Light’s criteria of an exudate

A

Pleural fluid protein:serum protein > 0.5. Pleural fluid LDH:serum LDH > 0.6. Pleural fluid LDH > 2/3 upper limit of normal serum LDH.

43
Q

Exudative effusions

A

Malignancy, infection, CT disorders, inflammatory disorders, CABG, usually w/PE and movement of peritoneal fluid to pleural space.

44
Q

Transudate pH? Exudate pH?

A

Transudate = 7.4-7.6. Exudate = 7.3-7.4

45
Q

Normal pleural fluid pH?

A

7.6

46
Q

Why are patients with dementia at higher risk for aspiration pneumonia?

A

They have decreased epiglottic reflex to substances approaching the trachea

47
Q

Treatment for bird fancier’s and farmer’s lung in patients who have been chronically exposed and have restrictive PFTs?

A

Avoidance of the antigen typically results in full recovery. Systemic corticosteroids may speed recovery.

48
Q

Mainstay therapy for patients with ARDS on a ventilator?

A

Low TV (< 6mL/kg) and PEEP (up to 15 cm H2O)

49
Q

Granulomatosis with polyangiitis triad

A

“Wegener’s granulomatosis” presents with a systemic vasculitis, upper/lower airway granulomatous inflammation and glomerulonephritis.

50
Q

Wegener’s antibody

A

C-ANCA against proteinase-3

51
Q

Tx for Wegener’s

A

Cyclophosphamide

52
Q

Apnea vs. hypopnea

A

Apnea = cessation of breathing for > 10s. Hypopnea = reduced air flow leading to a drop in SaO2 > 3%.

53
Q

Risks for OSA

A

Obesity, tonsillar hypertrophy and hypothyroidism

54
Q

How is OHS different from OSA?

A

Obesity hypoventilation syndrome results in increased respiratory work, decreased respiratory drive and hypoventilation through all hours of the day. These patients will have an abnormal ABG and patients with OSA will have a normal ABG.

55
Q

Only therapies proven to improve survival in patients with COPD?

A

Smoking cessation, supplemental oxygen and lung reduction surgery in select patients.

56
Q

ABG findings in COPD? CHF? PE?

A

COPD = respiratory acidosis and hypoxia. CHF = respiratory acidosis, hypoxia and hypocapnia due to pleural effusion, hypoxemia and tachypnea. PE = respiratory alkalosis and hypoxemia.

57
Q

Definiton of an SPN

A

< 3cm coin-shaped lesion in the lateral 1/3 - 1/2 of the lung surrounded by normal parenchyma.

58
Q

SPN workup in a low risk patient? High risk?

A

Low risk (age < 40, non-smoker): check previous CXR, if no change in last 12 months, get serial CXRs q 3 months for 12 months w/o further follow up if it stays the same size the entire time. High risk (smokers): chest CT and FNA w/open lung biopsy if FNA fails.

59
Q

2 most common symptoms in PE

A

Tachypnea and pleuritic chest pain

60
Q

ECG of a-fib

A

Irregular RR intervals, absent P waves and narrow QRS complexes

61
Q

ECG of PE

A

S1Q3T3

62
Q

How is PCP diagnosed in patients with HIV?

A

Confirm CD4 < 200 then hypertonic saline is given for mucus generation. This is 90% specific, but only 50% sensitive for PCP. If the sputum is negative, BAL is 90% sensitive and specific and is the next step.

63
Q

Compare non-allergic rhinitis to allergic rhinits

A

Non-allergic has boggy erythematous nasal mucosa, allergic has pale blue mucosa. Non-allergic is associated with seasons, allergic is associated with triggers. Nonallergic is later onset (>20), allergic presents earlier in life. Non-allergic rarely respond to H1 blockers w/o anticholinergic activity (loratidine).

64
Q

Primary long-term intervention for asthma vs. COPD?

A

Asthma: ICS. COPD: inhaled anti-cholinergic.

65
Q

Clinical differentiation of asthma from COPD?

A

Pts with asthma should have > 12% increase in FEV1 with bronchodilator tx. Airflow is not reversed in COPD.

66
Q

Extra-thoracic presentations of sarcoidosis

A

Erythema nodosum, painful shin lesions, uveitis and polyarthralgia. Elevated Ca2+ and ACE are common but not specific. Dx is by biopsy showing noncaseating granuloma.

67
Q

Renal sx of Goodpasture’s

A

Nephritic range proteinuria (<1.5), acute renal failure, dysmorphic red cells and red cell casts in urine

68
Q

Pattern seen on renal biopsy in patients with Goodpasture’s?

A

Linear IgG deposition along the glomerular basement membrane due to antibody formation against the alpha-3 chain of type IV collagen.

69
Q
A