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Flashcards in Pulmonology Step Up Deck (173):
1

paradoxic movement of abdomen and diaphragm on inspiration

sign of impending respiratory failure i.e. severe acute asthma attack

2

arterial blood gas findings in acute asthma attack

LOW PaCO2, LOW PaO2
- increased or normal PaCO2 is a sign of resp. mm fatigue or severe airway obstruction (consider mechanical ventilation); increased A-a gradient

3

PFTs in asthma

decreased expiratory flow rates
decreased FEV1/FVC ratio < 0.75%
increased DLco

4

in order to dx. asthma, what should the PFT result be after bronchodilator??

FEV1 or FVC should increase by 12% or 200 ml after albuterol (B2-agonist)

5

methacholine challenge

FEV1 decreases by > 20% after methacholine challenge, this is suggestive of asthma

6

quickest method of diagnosis of asthma in acute setting

peak expiratory flow rate

7

first line therapy in acute severe asthma exacerbation

1.inhaled short-acting B2 agonist via nebulizer or MDI
2. IV steroids - taper when clinical improvement is seen and replace w/ inhaled
3. oxygen - SaO2 > 90%

8

in what situations do you use long-acting B2 agonists (salmeterol) in tx of asthma?

1. night-time asthma
2. exercise-induced asthma
3. severe, persistent asthma

9

when do you use inhaled corticosteroids in asthma tx?

mild-moderate asthma in addition to short acting B2 agonist

10

when is montelukast useful for asthma tx?

1. prophylaxis of mild exercise induced asthma
2. control of mild-moderate disease (lowers need for steroid and bronchodilator requirements)
3. severe asthma resistant to max doses of inhaled steroids as last resort before using chronic systemic steroids

11

when can cromolyn sodium/nedocromil sodium be used?

only for prophylaxis i.e. before exercise in adults; first-line chronic treatment in children

12

anticholinergic drugs (tiotropium, ipratropium)

useful in pts with heart disease and asthma but they take significant time to achieve max bronchodilation and are only medium potency

13

FEV1/FVC < 80%, normal TLC and DLco

chronic bronchitis

14

FEV1/FVC < 80%, increased TLC, decreased DLco

emphysema

15

features of centrilobular emphysema

smokers, limited to respiratory bronchioles and mostly in upper lung zones

16

features of panacinar emphysema

a1 antitrypsin deficiency, proximal and distal acini affected, mostly in lung bases

17

sign specific to COPD

prolonged forced expiratory time (timed full exhalation of vital capacity > 6 seconds)

18

to diagnose airway obstruction, one must have....

normal or increased TLC
decreased FEV1

19

definitive diagnostic test in COPD

spirometry

20

PFTs in COPD

1. decreased FEV1 and FEV1/FVC < 0.70
2. increased TLC, RV and FRC (air trapping)
3. decreased vital capacity

21

good screening test in obstruction

peak expiratory flow rate -- if < 350 L/min, perform PFT

22

CXR findings in emphysema

hyperinflation, flattened diaphragm, enlarged retrosternal space, small heart size and diminished vascular markings

23

ABG in COPD

chronic PCO2 retention, decreased PO2
- respiratory acidosis with metabolic alkalosis (compensation)

24

most important tx. intervention in COPD

smoking cessation - prolongs survival rate

25

clinical monitoring in pts with COPD

serial FEV1 measurements
pulse oximetry
exercise tolerance

26

which tx. interventions have been shown to lower mortality in COPD?

smoking cessation
home O2 therapy

27

mainstay of long-term treatment in COPD

short acting inhaled B2 agonists and inhaled anti-cholinergic drugs (combined they are more efficacious than either alone)
- inhaled steroids may be used as well

28

what do you give a COPD pt with significant symptoms or recurrent exacerbations?

inhaled corticosteroid (budesonide, fluticasone) AND long-acting bronchodilator (salmeterol, formeterol)

29

role of theophylline in COPD tx

only for cases of refractory COPD --> lots of side effects and benefit unclear

30

criteria for continuous or intermittent long term O2 therapy in COPD

1. PaO2 < 55 mmHg OR
2. O2 sat < 88% at rest or during exercise OR
3. PaO2 55-59 mmHg and signs of polycythemia or cor pulmonale

31

benefit of oxygen therapy in COPD

when used for > 18 hr/day, reduces mortality in pts with COPD by controlling pulmonary HTN and thus, cor pulmonale

32

which two drugs are added for acute COPD exacerbations?

systemic steroids
antibiotics

33

pt presents with acute COPD exacerbation, what steps do you take?

1. CXR - R/O infection etc
2. inhaled short acting B2 agonist and anticholinergic
3. IV steroids (methylprednisolone)
4. antibiotics - azithromycin or levofloxacin
5. supplemental oxygen
6. non-invasive positive pressure ventilation

34

first line drugs in COPD

anticholinergic agents - ipratropium bromide, tiotropium (given via MDI)
- can add B2 agonists if needed (but not first line bc many pts also have heart disease)
- inhaled corticosteroids are not routinely used in chronic COPD (unless combined with LABA)

35

best predictor of survival in COPD

FEV1 - if < 25%, pts usually dyspneic at rest

36

which vaccinations should COPD pts routinely get?

pneumococcal every 5 years
influenza yearly
H.influenza if not previously vaccinated

37

diagnostic study of choice in bronchiectasis

high resolution CT scan
- signet ring bronchi diameter > accompanying artery

38

CXR findings in bronchiectasis

1. tram-tracking of bronchi away from hilum
2. 1-2 cm cysts
3. nonspecific findings - linear atelectasis, increased markings

39

main treatment approach to bronchiectasis

1. inhaled bronchodilators
2. chest physiotherapy
3. antibiotics for acute exacerbations

40

limited small cell lung cancer

confined to chest and supraclavicular nodes (not cervical or axillary nodes) --> extensive is outside the chest and SC nodes

41

paraneoplastic syndromes seen in SCLC?

SIADH, ectopic ACTH secretion, Eaton-Lambert syndrome

42

paraneoplastic syndromes in squamous cell ca. of lung

PTHrP secretion, hypertrophic pulmonary osteoarthropathy

43

most impt study for diagnosis of lung cancer

CXR - but should NOT be used as a screening tool

44

study used for staging of lung cancer

CT with contrast - can show local/distant mets as well as mediastinal LAD

45

role of cytological exam of sputum in diagnosing lung cancer

can only detect CENTRAL lesions - same goes for fibreoptic bronchoscopy

46

how do you get a definitive diagnosis of lung cancer?

confirmation of pathology with transthoracic needle biopsy

47

which diagnostic test would be useful for identifying pts with advanced dz who would not benefit from surgical resection?

mediastinoscopy - direct visualization of superior mediastinum

48

best tx. option for NSLC

surgery with radiation as adjunctive therapy

49

who should NOT receive surgery for lung cancer?

1. small cell lung cancer
2. NSCLC pts with mets outside the chest

50

best tx. option for limited SCLC

chemotherapy plus radiation

51

best tx. option for extensive SCLC

chemotherapy alone initially
if pt responds, prophylactic radiation to decrease incidence of mets and prolong survival

52

factors that favor malignancy in a solitary pulmonary nodule

age > 50 yrs
smoker or previous smoker
size > 3.0 cm and steadily growing
irregular or speculated borders
stippled or eccentric calcifications

53

criteria for dx. exudative effusion

one of the following:
LDH effusion > 200 IU/ml
LDH pleural/serum > 0.6
protein pleural/serum > 0.5
- none of these can be positive for transudate

54

pleural fluid w/ elevated amylase

esophageal rupture, pancreatitis, malignancy

55

exudative effusion that is primarily lymphocytic

suspect TB and do a pleural biopsy

56

pleural fluid with a pH < 7.2

parapneumonic effusion or empyema

57

first test to do if you suspect a pleural effusion

CXR - PA view, lateral view and lateral decubitus films

58

minimum criteria for performing a thoracentesis in pleural effusion

at least 10 mm thick effusion on lateral internal decubitus CXR --if not, risk of pneumothorax is too high

59

what do you look for in thoracentesis fluid?

chemistry - glucose, protein, LDH, pH
cytology
cell count - CBC w/ differential
culture - gram stain

60

Tx. of transudative effusions

diuretics, sodium restriction
therapeutic thoracentesis - if lots of fluid causing dyspnea

61

Tx. of uncomplicated parapneumonic effusion

antibiotics alone

62

Tx. of complicated parapneumonic effusion

chest tube drainage
intrapleural injection of thrombolytic agents
antibiotics

63

after which procedures should you obtain a CXR? (3)

transthoracic needle aspiration
thoracentesis
central line placement

64

primary spontaneous PTX

occurs in otherwise healthy individuals (usually tall, lean young men) due to spontaneous rupture of subpleural blebs at the apex of the lungs

65

physical exam signs seen in spontaneous PTX

decreased breath sounds on affected side
hyperresonance over chest
decreased/absent tacile fremitus
mediastinal shift toward PTX

66

confirmatory diagnostic test for spontaneous PTX

CXR - shows visceral pleural line

67

first tx. for spontaneous PTX

supplemental oxygen

68

Tx of spontaneous PTX in symptomatic pt

supplemental oxygen
chest tube insertion

69

what is next best step if you suspect a tension PTX in a pt?

do NOT get CXR --> immediate decompression is needed w/ large bore needle or chest tube

70

how do you perform chest decompression in tension PTX?

insert large bore needle in 2nd or 3rd IC space in midclavicular line

71

which drugs are linked to interstitial lung disease?

amiodarone
busulfan
nitrofurantoin
bleomycin
phenytoin
penicillamine

72

what should you do if a pt comes in with digital clubbing?

obtain a CXR - there is likely underlying lung disease

73

best diagnostic test for interstitial lung disease

high resolution CT scan

74

CXR findings in interstitial lung disease

reticular or reticulonodular (ground glass) appearance

75

PFTs in interstitial lung disease

decreased lung compliace = increased/normal FEV1/FVC
decreased lung volumes
decreased DLco

76

"honeycomb" lung

scarred, shrunken lung - end-stage finding with poor prognosis (airspaces are dilated and there are fibrous scars in interstitium)

77

MC clinical features in idiopathic pulmonary fibrosis

progressive exercise intolerance
cough and dyspnea
coarse crackles on auscultation
digital clubbin

78

definitive diagnosis of idiopathic pulmonary fibrosis

open lung biopsy - must exclude other causes of ILD

79

Tx. of IPF

steroids + azathioprine/cyclophosphamide ] only about 20% of pts will respond to this therapy (best prognostic indicator)
ultimately, need lung transplant

80

Lofgren's syndrome

acute sarcoid syndrome w/ fever, erythema nodosum, bilateral hilar LAD and arthritis

81

Heerfordt Waldenstroms syndrome

acute sarcoid syndrome w/ fever, parotid enlargement, uveitis and facial palsy

82

definitive dx. of sarcoidosis

transbronchial biopsy showing non-caseating granulomas (in context of clinical picture)

83

CXR finding in sarcoidosis

bilateral hilar adenopathy

84

lab findings in sarcoidosis

1. elevated ACE level in serum
2. hypercalciuria/hypercalcemia
3. skin anergy
4. PFTs showing restrictive pattern

85

what type of exam should all pts suspected of having sarcoidosis have?

opthalmologic - 25% of cases have uveitis/conjunctivitis

86

Tx. of choice in sarcoidosis

systemic steroids - high dose for 2 months, followed by 3 months of dose tapering

87

which conditions in sarcoid MUST be treated with steroids?

uveitis
CNS involvement
hypercalcemia

88

what drug can be used in sarcoidosis pts with progressive disease refractory to steroids?

methotrexate

89

chronic interstitial pneumonia caused by abnormal proliferation of histocytes

Histiocytosis X

90

gold standard for dx. of Wegener's granulomatosis

tissue biopsy
- but if pt is positive for c-ANCA, likelihood of disease is high

91

pt with asthma presents with pulmonary infiltrates, rash and eosinophillia

churg-strauss syndrome

92

antibody assoc. with Churg-Strauss

perinuclear ANCA (p-ANCA)

93

what is needed to consider diagnosis of asbestosis?

history of exposure - shipyard, foundries, mining, insulation, boilers, brake liners

94

CXR findings in asbestosis

pleural plaques, calcifications at level of diaphragm and diffuse interstitial fibrosis mainly in lower lobes

95

dx. of asbestosis

history of exposure, clinical findings - impt
definitive = lung biopsy showing barbell-shaped asbestos fibers

96

tx. of asbestosis

none available - stop smoking!

97

CXR findings in silicosis

eggshell calcifications (rare)
hyaline nodules (1-10 mm) mostly in upper lobes

98

what infectious disease is silicosis associated with and what should these pts do?

TB - should get yearly PPDs; if > 10 mm, 9 months isoniazid tx

99

Caplan syndrome

rheumatoid nodules in periphery of lung in pts with RA and coexisting pneumoconiosis

100

dx. of berylliosis

beryllium lymphocyte proliferation test (blood test)

101

tx. of berylliosis

glucocorticoids

102

hypersensitivity pneumonitis (extrinsic allergic alveolitis)

inhalation of antigenic agent to alveolar level induces immune-mediated pneumonitis (i.e. moldy hay, avian droppings, air conditioners, compost)

103

hallmark finding in hypersensitivity pneumonitis

presence of serum IgG and IgA to inhaled antigen

104

diagnosis of goodpasture's syndrome

tissue biopsy
anti-GBM ab's on serology

105

Tx. of goodpasture's syndrome

plasmapheresis
cyclophosphamide
steroids

106

pulmonary alveolar proteinosis

accumulation of surfactant-like protein and phospholipids in the alveoli

107

CXR findings in pulmonary alveolar proteinosis

ground glass appearance w/ bilateral alveolar infiltrates (resembling a bat shape)

108

definitive dx. test for pulmonary alveolar proteinosis

lung biopsy

109

Tx. of pulmonary alveolar proteinosis

lung lavage
new therapy - GCSF

110

general criteria used to define acute respiratory failure

1. hypoxia - PaO2 < 60 mmHg
2. hypercapnia - PaCO2 > 50 mmHg

111

hypoxemic respiratory failure

low PaO2 with low/normal PaCO2 - present when O2 sat. is < 90% despite FiO2 > 0.6

112

hypercarbic (ventilatory) respiratory failure

failure of alveolar ventilation due to either a decrease in minute ventilation or an increase in dead space leading to CO2 retention

113

ventilation is monitored by...

PaCO2
- to decrease PaCO2 one must either increase RR or Tidal Volume

114

oxygenation is monitered by...

O2 sat. or PaO2
- to decrease PaO2 one must either decrease FiO2 or PEEP

115

ventilation, but no perfusion

V/Q mismatch

116

perfusion, but no ventilation

intrapulmonary shunting
- venous blood is shunted into arterial circulation w/o being oxygenated

117

features of V/Q mismatch respiratory failure

hypoxia w/o hypercapnia
- responsive to supplemental oxygen

118

in what scenario is the Aa gradient normal in a setting of hypoxia?

hypoventilation
low inspired PaO2

119

indication for NPPV

conscious patients with impending respiratory failure in an attempt to avoid intubation/mechanical ventilation

120

success rates for NPPV (BIPAP, CPAP) are greatest for...

hypercarbic respiratory failure (esp. COPD pts)

121

who is at highest risk of ARDS?

pts with sepsis or septic shock

122

pathophysiology of ARDS

massive intrapulmonary shunting secondary to widespread atelectasis, collapse of alveoli and surfactant dysfunction secondary to neutrophil activation, elevated alveolar mb permeability and pulmonary edema

123

clinical features in ARDS

1. dyspnea, tachypnea, tachycardia
2. progressive hypoxemia - not responsive to supplemental O2
3. high peak airway pressures due to stiff, noncompliant lungs

124

classic clinical criteria for diagnosing ARDS

1. hypoxemia refractory to O2; ratio of PaO2/FiO2 < 200
2. bilateral diffuse pulmonary infiltrates on CXR
3. no evidence of CHF: PCWP < 18 mmHg

125

PCWP

pulmonary capillary wedge pressure - reflect left heart filling pressures --> indirect marker of intravascular volume status

126

tx of ARDS

1. supplemental O2
2. mechanical ventilation w/ PEEP
3. fluid management - want PCWP bw 12-15
4. treat underlying cause

127

general indications for mechanical ventilation

1. sig. respiratory distress/arrest
2. impaired or reduced level of consciousness
3. metabolic acidosis
4. respiratory mm. fatigue
5. sig. hypoxemia (PaO2 < 70) or sig. hypercapnia (PaCO2 > 50)
6. respiratory acidosis (pH < 7.2) with hypercapnia

128

swan-ganz catheter findings in ARDS

normal CO, normal PCWP
increased pulmonary artery pressure

129

acceptable ranges of gas values in mechanical ventilation

PaO2 50-60
PaCO2 40-50
pH 7.35-7.50

130

assisted controlled ventilation

ventilator delivers breath of predetermined TV when pt initiates breathing AND if pt does not initiate a breath, ventilator takes over at a predetermined rate

131

synchronous intermittent mandatory ventilation

patient can breathe on their own above the mandatory set rate; ventilator breaths are synchronized with patient inspiratory effort so the two do not occur at the same time; if no breath initiated by patient, the mandatory breath is delivered by ventilator

132

continous positive airway pressure

positive pressure is delivered continuously (0-20 cmH20) by ventilator, but not volume breaths are delivered i.e. pt breathes on his/her own

133

pressure-support ventilation

used mostly during weaning; pressure is delivered with an initiated breathe to assist breathing

134

how do you confirm proper endotracheal tube placement?

listen for bilateral breath sounds
check postintubation CXR - tip of ET tube should be 3-5 cm above carina

135

difference between PEEP and CPAP

PEEP - during mechanical ventilation
CPAP - during spontaneous breathing

136

side effects of high levels of PEEP

1. barotrauma - pneumothorax
2. low CO due to decreased VR

137

can a patient still aspirate with an ET tube?

yes

138

preferred agents for sedation in mechanical ventilation

benzodiazepines
- opiods for analgesia

139

what should you do if pt is mechnically ventilated for > 2 weeks?

tracheostomy - to decrease risk of tracheomalacia (softening of tracheal cartilage)

140

definition of pulmonary HTN

1. mean pulmonary arterial pressure > 25 mmHg at rest or > 30 mmHg with exercise
2. systolic pulm. aa presure > 40 mmHg at rest

141

main clinical features of pulmonary HTN

dyspnea, chest pain and syncope on exertion

142

physical exam findings in pulmonary HTN

loud pulmonic cpt of S2 (P2) and subtle lift of sternum (sign of RV dilatation)

143

gold standard for diagnosing pulmonary HTN

right heart catheterization
- can be estimated using Doppler 2D echo

144

ECHO changes in pulmonary HTN

dilated pulmonary artery
dilated/hypertrophy of RA and RV
abnormal mvt of IV septum

145

vasodilator trial in pulmonary HTN

give pt. inhaled NO, IV adenosine and oral CCBs under hemodynamic monitoring to predict response before initiating long-term tx

146

tx. of primary pulmonary HTN

1. CCBs - nifedipine, diltiazem
2. vasodilators - sildenafil, bosentan, epoprostenol
3. anticoagulation w/ warfarin
4. lung transplantation

147

what should you think of if a patient with long bone fracture develops dyspnea, mental status change and petechiae?

fat embolism

148

when can you make the diagnosis of PE w/o further testing?

when patient has symptoms of PE and a DVT is found

149

which situations can essentially R/O PE?

- low probability V/Q scan (or normal helical scan)
- negative pulmonary angiogram
- negative D-dimers and low clinical suspicion

150

ABG levels in PE

not diagnostic -> respiratory alkalosis (low PaO2, low PaCO2)
- elevated Aa gradient

151

when should you perform a duplex venous ultrasound of lower extremities?

1. if you suspect DVT
2. if you suspect PE and spiral CT cannot be done or is inconclusive

152

initial diagnostic study of choice for PE?

helical CT scan

153

normal V/Q scan

virtually R/O PE

154

high probability V/Q scan

high sensitivity for PE - tx. pt with heparin

155

if you have low or intermediate probability V/W scan

need further testing --> duplex USG, spiral CT or pulmonary angiography to confirm

156

what do you do if dx. of PE is clinically unlikely? (decision rule score < 4)

D-dimer test
- if normal: can R/O PE, no tx
- if positive: do a CT Scan

157

what do you do if dx. of PE is clinically likely (decision rule score > 4)?

spiral CT
- if no PE (no tx) or if PE (tx)
- if inconclusive or cannot be done -> do leg USG (if DVT, tx; if no DVT - do V/Q scan or pulm. angiogram)

158

gold standard for diagnosis of PE?

pulmonary angiogram

159

main tx. strategy for PE

1. supplemental O2
2. heparin - LMWH } start immediately based on clinical suspicion
3.oral warfarin - long term

160

contraindications for heparin

active bleeding
heparin induced thrombocytopenia
uncontrolled HTN
recent stroke

161

warfarin tx for PE

start with heparin, continue for 3-6 months depending on risk factors; want INR between 2-3

162

which conditions warrant an INR between 2.5-3.5

prosthetic mechanical heart valves
prophylaxis of recurrent MI
antiphospholipid syndrome

163

when should you consider thrombolysis in PE management?

not routinely used; consider in:
- pts with massive PE and hemodynamically unstable
- pts w/ evidence of RHF/cardiogenic shock

164

indications for using an IVC filter in PE management

- contraindication to anticoagulation
- complication of current anticoagulation
- failure of adequate anticoagulation
- pt w/ low pulmonary reserve who is at high risk of death from PE

165

where do aspirated contents usually end up?

lower segment of Right UPPER lobe
upper segment of RIGHT lower lobe

166

what antibiotics do you give if you suspect aspiration pneumonia?

penicillin G or clindamycin

167

how do you prevent aspiration in high risk patients?

keep head of bed elevated
nasogastric tube placement to decompress stomach

168

definition of massive hemoptysis

> 600 ml of blood in 24 hrs

169

MCC of massive hemoptysis

bronchiectasis
bleeding diathesis

170

what diagnostic studies should be done in a pt w/ hemoptysis?

CXR
bronchoscopy
CT scan of chest

171

causes of low DLco

emphysema
sarcoidosis
interstitial fibrosis
pulmonary vascular disease
anemia

172

causes of high DLco

asthma
obesity
intracardiac L-R shunt
exercise
pulmonary hemorrhage

173

normal V/Q ratio

0.8
- if higher, indicates inadequate perfusion of adequately ventilated lung