Respirology Flashcards
(135 cards)
1
Q
Diagnosis of ashtma on PFTs
A
PFTs showing obstructive lung disease =↓ FEV1/FVC <0.8
o Reversible (↑FEV1 improves >12% with b-agonists)
o Inducible with Methacoline: Done if FEV1/FVC is initially normal (FEV1 decreases 20% with methacholine)
It’s called reactive airway disease until recurrent presentations
2
Q
Patient with daytime symtoms < 2 /wk, nocturnal symptoms < 2 / month, FEV1 > 80%. Asthma stage and tx?
A
Intermitent. Rescue SABA
3
Q
Patient with daytime symtoms < 1 /day, nocturnal symptoms > 2 / month, FEV1 > 80%. Asthma stage and tx?
A
Mild persistent. Rescue SABA + low dose ICS*
- Could be replaced with Leukotriene Antagonist (e.g. Motelukast) or theophyline
4
Q
Patient with daytime symtoms > 1 /day, nocturnal symptoms > 1 / week, FEV1 60-80%. Asthma stage and tx?
A
Moderate persistent. Rescue SABA + low dose ICS + LABA
ICS could be replaced with Leukotriene Antagonist (e.g. Motelukast)
5
Q
Patient with daytime symtoms > 1 /day, nocturnal symptoms frequent, FEV1 < 60%. Asthma stage and tx?
A
Severe persistent. SABA + high dose ICS + LABA
ICS could be replaced with Leukotriene Antagonist (e.g. Motelukast)
6
Q
Patient with severe persistent daytime and nocturnal symptoms. Asthma stage and tx?
A
Refractory. SABA + high dose ICS + LABA + PO steroids
But PO steroids should be avoided. Try anti IgE (omalizumab) if IgE related asthma.
7
Q
ICS are interchangeable with…
A
LTA – Leukotrien receptor antagonis (e.g., montelukast)
8
Q
Patient with asthma exacerbation + silent chest
A
Medical emergency that might need intubation
9
Q
Rescue treatment for asthma exacerbation
A
racemic epinephrine, subcutaneous epinephrine, magnesium, nebulizer
10
Q
Asthma exacerbation treatment
A
O2 for SATO2 > 92%
Short acting b-agonist: Neb/MDI (metered-dose inhaler)
Short acting anticholinergic: Neb/MDI
Steroids: methylprednisolone 125mg IV / prednisone 40-60 mg PO
11
Q
Ambulatory tx after asthma exacerbation
A
B-agonist MDI + prednisone 1-2 mg/kg x 5 days
12
Q
Types of emphysema
A
centriacinar (smokers) and panacinar (a1 antitrypsin deficiency)
13
Q
Clinical characteristics of Emphysema:
A
- CO2 retention, no hypoxemia, ↑AP dyameter, prolong exhalation, dypnea, minimal cough
- Pink puffers
14
Q
- Hypoxemia, pulmonary hypertension, CHF, edema, productive cough
- Blue bloaters
Dx?
A
Chronic Bronquitis
15
Q
Tx COPD
A
- SABA (albuterol)
- SABA + long acting muscarinic antagonist – LAMA (tiotropium)
- SABA + LAMA + LABA (salmeterol)
- SABA + LAMA + LABA + ICS
- SABA + LAMA + LABA + ICS + Phosphodiesterase 4 inhibitors – PDE4-i (theophylline)
- SABA + LAMA + LABA + ICS + PDE4-i + steroids
16
Q
Chronic treatment of COPD
A
- C: corticosteroids. ICS /Prednisone PO / methylprednisolone IV
- O: oxygen if SAT < 88% or PaO2 < 55. Goal, keep SAT 88-92%
- P: prevention. Influenza and Pneumococcal vaccines, and smoking cessation (first line)
- D: dilators: SABA, LABA, PO (e.g., PDE4-i, theophylin)
- E: experimental (surgery)
- R: rehab
Oxygen and prevention impruve survival
17
Q
What prolongs survival in COPD?
A
Oxygen and smoke cessation
18
Q
Anthonisen classification
A
COPD exacerbation:
* Wheezing/SOB
* Increased Sputum production
* Increased sputum purulence
I worse than III
Anthonisen I or II - - >AB
19
Q
AB in COPD exacerbation
A
Amoxicillin-clavulanic acid (first line), doxycycline, azithromycin (do an ECG first to measure QT)
20
Q
Bx modalities in lung cancer.
Large proximal lesions?
A
EBUS (Endobronchial ultrasound), e.g., Squamous cell carcinoma
21
Q
Bx modalities in lung cancer.
Lesion in periphery?
A
CT-guided percutaneous Bx, e.g., Adenocarcinoma
22
Q
Bx modalities in lung cancer.
In the lung
A
VATS (video-assisted thorascopic surgery)
23
Q
Patient age > 55, quitted smoking <15 years ago, with spiculated nodule > 2 cm. Next step?
A
Resection of the lesion
24
Q
Pleural effusion, thoracocentesis positive for malignancy. Stage of disease?
A
IV (metastasic)
25
Fever, weight loss, hemoptysis and negative CxR for cancer. Next step?
Rule out paraneoplastic syndrome before assuming there is no lung CA.
26
Fever, weight loss, hemoptysis and positive CxR for cancer. Next step?
CT scan
27
Pulmonary mass confirmed with CT scan. Next step?
Bx, PET-CT (stage), and PFTs
28
Lung cancer screening. How and to whom?
Screening with Low dose CT-scan yearly
• Age 55-80
• 30 pack/year history
• Quitted smoking less than 15 years ago
CxR no sensitive or specific, so not recommended!!
29
Pulmonary node definition
Lesion < 3 cm. If > 3 cm, it's called mass
30
Characteristics of a pulmonary node suggestive of cancer
Size > 2cm, spiculated, positive smoking Hx, age > 70
31
Pulmonary node not suggestive of cancer
Size < 8mm, Smooth surface, calcified, no smoking Hx, age < 45
32
Pulmonary node on CxR, next step?
Look old films first!!
33
Pulmonary node without changes compared to previous films. Next step?
No further action needed (not even follow-up)
34
New pulmonary or changing pulmonary node. Next step?
Compare patient’s risks fx and nodule characteristics
• Low risk: serial CTs
• High risk: Bx
35
Lung cancer treated only with chemo/radiotherapy and never with Sx?
Small cell lung cancer
36
SCLC vs NSCL, which one is more common?
SCLC (10-15%); NSCLC (85-90%)
37
Horner's syndrome
Miosis, anhidrosis, ptosis. Associated with Pancoast tumor
38
Tx of SCLC
Chemo + rad, no matter the stage
39
Smoking Hx, lung cancer of central location, ADH-SIADH. Dx?
SCLC
40
Smoking Hx, lung cancer of central location, ACTH-Cushing. Dx?
SCLC
41
No smoking Hx, lung cancer of peripheral location, no paraneoplastic syndrome
Adenocarcinoma
42
Smoking history, lung lesions with salt and pepper histology on microscope. Dx and Next step?
Carcinoid lung cancer (Serotonin paraneoplastic syndrome: flushing, diarrhea, wheezing)
Urinary 5 HIAA.
43
Smoking Hx, lung cancer of central location, hipercalcemia. Dx?
Squamous cell lung cancer. Paraneoplastic syndrome (hyper PTH)
44
Causes of pleural effusion (transudate)
CHF, nephrotic syndrome, cirrhosis, pulmonary embolism
45
Causes of pleural effusion (exudate)
Malignancy, TB, pneumonia
46
Most common cause of exudative pleural effusion
TB is the most common cause worldwide. Pneumonia (PNA), malignancy, and CHF are the most common in the US
47
Pleural Effusion of < 1 cm. Next step?
Observation
48
Loculated pleural effusion. Next step?
Thoracostomy, if it doesn't work, thoracotomy
49
Pleural effusion, > 1 cm, not loculated. Next step?
Is it CHF? If so, diuresis and observe. If it fails or isn't CHF, then tap
50
Pleural effussion is determined to be transudate. Next step?
Treat cause
51
Light's criteria
- LDHf > 2/3 upper limit of normal serum LDH
- LDHf/LDHs > 0.6
- Proteins f/Proteins s > 0.5
At least one --> Exudate
None of them --> transudate
52
Tests to run on a pleural effusion
```
Tube 1: cell count with differential
- PMN: Pneumonia
- Lymph: TB or malignancy
- RBC: Hemothorax or CA
Tube 2: cytology (malignancy)
Tube 3: Glucose, pH, total proteins and LDH (light’s criteria), ADA (TB), triglycerides (chylothorax)
Tube 4: gram stain and culture
```
53
Virchow’s triad?
o Venostasis (e.g., hospitalized, POP, inmobiliztion, car rides, no physical activity)
o Endothelial injury (e.g., POP, trauma, HTN, smoking, cath)
o Hypercoagulative state (e.g., contraceptives, malignancy, pregnancy, coagulopathies)
54
Diagnostic sign of DVT?
Difference of 2 cm between diameters 2 cm below the tibial tuberosity
55
Diagnostic test of DVT?
Ultrasound
o If positive --> DVT
o If negative and low risk --> rule out
o If negative and moderate-high risk --> repeat in 5 to 7 days
56
Labs for PE
ECG, CxR, ABG, CBC, INR, PTT, creatinine, LFTs
57
ECG in PE?
Sinus tachycardia, S1Q3T3 (right heart strain)
58
CxR in PE?
Usually normal unless wedge infraction (Hampton’s hump)
59
ABG in PE?
Hypoxemic, hypocapnic, respiratory alkalosis
60
Fever, Sudden dyspnea, Chest pain. Next step?
PERC criteria first to rule out PE and determine the need of doing the Well’s. If pregnant, do Well's right away.
Criteria: Age ≥50, HR ≥100, O₂ sat on room air <95%, Unilateral leg swelling, Hemoptysis, Recent surgery or trauma, Prior PE or DVT, Hormone use.
If one present, do well's
61
When to do a d-dimer?
Low probability, to rule out PE
62
When to do a CT scan when PE is suspected?
When Well’s is > 3 (moderate probability)
The patient has not CKD
Preferred test in the acute setting
63
When to order a V/Q Scan in the context of pulmonary embolism?
- When Well’s is > 6 (high probability)
- ↑ Creatinine
- Pregnancy
- The CxR is normal
64
What is the gold standard for PE?
Angiogram, HOWEVER IT IS (almost) NEVER DONE because it’s invasive!
65
When to do only a U/S of legs for PE?
Can’t do CT, can’t do VQ scan
66
When IVC filter for PE or DVT?
Proximal DVT + absolute contraindication of anticoagulation
or
Recurrent emboli
67
tPA for PE.When?
massive PE (hypotension + PE)
68
Tx of PE
Warfarin (1972). Bridge always with LMWH or heparin for 5 days or until INR 2-3
69
Heparin-induced thrombocytopenia. Next step?
Draw a HIT panel and change for Argotraban
70
Definition of Acute Respiratory Distress Syndrome (ARDS)
Non-cardiogenic pulmonary edema causing acute respiratory hypoxemic failure
71
Pathogenesis of ARDS
Pulmonary edema --> Less surface area of the alveolar to the capillaries --> O2 can’t cross the barriers since it is diffusion-limited --> V/Q mismatch --> shunt --> HYPOXEMIA
72
Risk factors of ARDS
Septic shock (e.g., caused by pneumonia)
Trauma-related acute lung injury
Drowning
Head trauma, drug overdose
73
Diagnosis of ARDS
ARDS is a clinical Dx made with hypoxemic respiratory failure + bilateral pulmonary edema. You DON’T need a pulmonary edema wedge pressure via Swan Ganz cath
74
PaO2 / FIO2 on ARDS?
< 300
| According to First Aid
75
ARDS VS CHF
- Capillary wedge preausre: ↑ in CHF (hydrostatic pressure); normal or ↓ in ARDS (leaky capilaries)
- LV function (BPN/Echo): ↓ in CHF; normal or ↑ in ARDS (tachycardia)
76
Treatment of ARDS
Intubation
- CO2: Lox tidal volume, high resp. rate (small shallow breaths to maintain CO2 levels)
- O2: Positive End Expiratory Pressure (PEEP), which keeps the alveola open
- Goal of oxygenation: PaO2 > 55mmHg or SpO2 > 88%
Treat the underlying disease
Diuresis (?)
77
Radiologic test to Dx Diffuse parenchymal lung disease (DPLD)?
High-resolution CT: ground-glass opacities
78
PFTs in Diffuse parenchymal lung disease (DPLD)?
↑ or normal FEV1/FVC and diffusion of CO2 is down (↓DLco)
79
General Tx of most Diffuse parenchymal lung disease (DPLD)?
o Steroids (regardless of the pathologic form)
o DMARDS
o Biologics
80
Definition of Acute interstitial pneumonitis (AIP)?
Acute (< 6 weeks) Idiopathic Diffuse parenchymal lung disease
81
Definition of Idiopathic pulmonary fibrosis
Chronic (> 6 weeks) Idiopathic Diffuse parenchymal lung disease
82
What drugs can induce Idiopathic Diffuse parenchymal lung disease
Bleomycin (chemotherapy)
Amiodarone
Radiation
83
What is sarcoidosis ?
Is a primary Idiopathic Diffuse parenchymal lung diseaase. It is autoinmune
84
Epidemiology of sarcoidosis?
Black women
85
Extrapulmonary manifestations in sarcoidosis?
* Heart block
* Bell’s palsy
* Erythema nodosum
* Uveitis
* Arthralgia
86
Dx of sarcoidosis?
CxR: Hiliar bilateral lymphadenopathies
High res CT: Ground glass
PFTs: restrictive pattern
Bx: Non-caseting granulomas
87
Non-necrotizing granulomas
sarcoidosis
88
Hiliar bilateral lymphadenopathies on CxR.
Dx?
sarcoidosis
89
Barbell bodies on pulmonary BX. Dx?
Asbestosis
90
Pleural plaques on CxR. Dx?
Asbestosis
91
Sand blasting or Rock quarry exposure. Lung disease and associations?
Sillicosis
Presents in the upper lung as nodules--> rule out TB
Screen for TB annualy because TB incidence is ↑
92
Aeronautics or Ellectronics manufacturer. Lung disease?
Berylliosis
93
Pneumoconiosis + rheumatoid arthritis. Dx?
Caplan syndrome. Pneumoconiosis is ussualy Coal miners lung
94
Birds fanciers with temporal hypoxemia, dypnea and dry cough which goes away when the person is not working or the exposure is removed. Dx and tx?
Hypersensitivity pneumonitis.
| Tx: Remove exposure. NO NEED FOR STEROIDS!
95
Risk factors for DVT.
Stasis, endothelial injury, and hypercoagulability (Virchow’s
triad).
96
Criteria for exudative pleural effusion.
Pleural/serum protein > 0.5; pleural/serum LDH > 0.6; pleural LDH > 2/3 upper limit.
97
Causes of exudative pleural effusion.
Think of leaky capillaries. Malignancy, TB, bacterial or viral
infection, pulmonary embolism with infarct, and pancreatitis.
98
Causes of transudative pleural effusion.
Think of intact capillaries. CHF, liver or kidney disease, and protein-losing enteropathy.
99
Normalizing PCO2 in a patient having an asthma exacerbation may indicate?
Fatigue and impending respiratory failure.
100
Dyspnea, bilateral hilar lymphadenopathy on CXR, noncaseating granulomas, ↑ ACE, and hypercalcemia.
Sarcoidosis.
101
PFTs showing ↓ FEV1/FVC.
Obstructive pulmonary disease (e.g., asthma).
102
PFTs showing ↑ FEV1/FVC.
Restrictive pulmonary disease.
103
Honeycomb pattern on CXR. Diagnosis? Treatment?
Diffuse interstitial pulmonary fi brosis. Supportive care.
| Steroids may help.
104
Treatment for superior vena cava (SVC) syndrome
Radiation.
105
Treatment for mild, persistent asthma.
Inhaled β-agonists and inhaled corticosteroids.
106
Treatment for COPD exacerbation.
AB: Amoxicillin-clavulanic acid (firs line), doxycycline, azithromycin (do an ECG first to measure QT)
Dilatators MDI with spacer or NEBS
* B-Agonist: Albuterol
* Anticholinergics: Ipratropium
Steroids: Prednisone PO or Methylprednisolone IV
Oxygen aiming at SAT 88-92%
107
Treatment for chronic COPD.
Smoking cessation, home O2, β-agonists, anticholinergics,
systemic or inhaled corticosteroids, flu and pneumococcal
vaccines.
108
Acid-base disorder in pulmonary embolism.
Hypoxia and hypocarbia (respiratory alkalosis).
109
Non–small cell lung cancer (NSCLC) associated with hypercalcemia.
Squamous cell carcinoma.
110
Lung cancer associated with SIADH.
Small cell lung cancer (SCLC).
111
Lung cancer highly related to cigarette exposure.
Small Cell Lung Cancer (SCLC).
112
A tall white male presents with acute shortness of breath.
| Diagnosis? Treatment?
Spontaneous pneumothorax. Spontaneous regression.
| Supplemental O2 may be helpful.
113
Treatment of tension pneumothorax.
Immediate needle thoracostomy.
114
Characteristics favoring carcinoma in an isolated pulmonary nodule.
Age > 45–50 years; lesions new or larger in comparison to old films; absence of calcification or irregular calcification; size > 2 cm; irregular margins.
115
Hypoxemia and pulmonary edema with normal pulmonary capillary wedge pressure.
ARDS.
116
Sequelae of asbestos exposure.
Pulmonary fibrosis, pleural plaques, bronchogenic carcinoma (most common tumour associated), mesothelioma (pleural mass).
117
↑ risk of what infection with silicosis?
Mycobacterium tuberculosis.
118
Causes of hypoxemia.
Right-to-left shunt, hypoventilation, low inspired O2 tension, diffusion defect, V/Q mismatch.
119
Classic CXR findings for pulmonary edema.
Cardiomegaly, prominent pulmonary vessels, Kerley B lines, “bat’s-wing” appearance of hilar shadows, and perivascular and peribronchial cuffing.
120
Best initial tests for asthma exacerbation
Peak expiratory flow (PEF) or ABG
121
Most accurate test for asthma when patient is asymptomatic
%20 decrease in FEV1 with methacoline
122
Best indicator in physical of severity of asthma exacerbation
Resp. Rate.
Accessory muscle use is hard to assess and subjective
123
COPD sx
< 60 years
No hx of smoking
Panlobular emphysema
Alfa 1 antirypsin deficiency
124
Indication of long term O2 therapy
Sat < 88%
Cor pulmonale
Pao2 < 59 mmHg
Goal: sat 88-90%
125
Best inicial and most accurate test for COPD
Best inicial: CxR
Accurate: PFT
- decreased FEV1
- decreased FVC
- decreased FEV1/FVC
- increased TLC
- no improved with b agonist
- no worsening with methacholine
126
When is ipatropium used?
COPD exacerbation
Otherwise, same as asthma exacerbation
127
Wrong answers in COPD
- ICS monotherapy
- spirometry as screening for ASx
- n acetylcysteine
- Terbutaline
128
When to tap a pleural effusion?
When it is
- big enough (more than 1cc)
- not loculated
- not due to CHF
129
Dyspnea, pleuritic chest pain, cough
Dullness to percussion, decreased breath sounds
Dx and best initial test
Pleural effusion
Next step: CxR
130
Pleural effusion with pH < 7.2 and positive gram
Dx and tx
Empyema
Tx with Ab and chest tube
131
Most common abnormality of EKG in PE?
Nonspecific ST-T wave changes
132
Medications that may cause DPLD
Amiodarone
Nitrofurantoin
Bleomycin
Methotrexate (causes fibrosis of lung and liver)
133
Arthritis
Erythema nodosum
Bilateral hilar adenopathy
Lofgren syndrome: type of sarcoidosis
134
Most common type of lung cancer?
Adenocarcinoma
- peripheral
- not associated to smoking
- asbestos exposure
135
PFT findings in Interstitial lung disease
- lung restriction (decrease in TLC and VC)
- decreased lung compliance (increased or normal FEV1/FVC)
- impaired diffusion (decreased DLco)
Other important information.
- hypoxemia (V/Q mismatch)
- pulmonary hypertension and cor pulmonale
