Flashcards in UWorld - Med/Pulm-CC Deck (38):
What are the features of acute bronchitis and initial steps to care?
Cough productive of yellow purulent sputum following URI, rhonchi that clear with cough, possible to have small amounts of blood
Tx = Supportive care initially
What is the indication for emergent bronchoscopy?
major, life threatening, hemoptysis
What is the first step that should be taken if a patient presents with clinical features highly suggestive of PE?
1. Start IV heparin infusion if no contraindication to anticoagulation (then do CT and stop heparin if no PE)
2. Diagnostic test to evaluate for PE if anticoag is contraindicated (consider IVC filter if PE +)
What are the flow volume loop features of fixed upper airway obstruction? Possible causes of this?
Lung volume ranging from 1.7 - 6.3, with proportional decreases in inspiration and expiration flow rates (basically same as normal but stunted)
-Food stuck in throat, laryngeal edema from anaphylaxis
What characteristics are consistent with Flail chest?
Blunt thoracic trauma, respiratory distress despite bilateral chest tubes, multiple rib fractures on CXR
What is the proper management protocol for someone with acute exacerbation of COPD (AECOPD)?
1. inhaled short acting bronchodilators, glucocorticoids and Abx
2. Noninvasive positive pressure ventilation (NPPV)
3. Mechanical ventilation only if Hypercapnic pt. + poor mental status, hemodynamic instability, or profound acidemia (pH
What are some key signs of pneumothorax in someone with COPD, and what is the cause of this?
Acute onset chest pain and SOB, w/ markedly reduced breath sounds, chest hyperresonant to percussion
Cause = dilated apical alveoli (blebs)
Differences between Transudative vs. Exudative effusions?
Trans = imbalance of hydrostatic/oncotic pressures -> fluid similar to serum (high glucose, low cells etc.)
Exud = pleural/lung inflammation (pneumonia, malignancy) -> increased capillary/pleural membrane permeability (high LDH, high protein, low glucose, WBCs)
How do beta-agonists affect potassium ion levels and what can result from excess beta-agonist effects?
Reduce K+ by driving ions into cells --> Significant hypokalemia -> muscle weakness, arrhythmia, and EKG changes
What pathophysiological abnormality occurs in Pulmonary embolism?
V/Q mismatch leading to A-a gradient
What can lead to elevated A-a gradient?
Any process that results in impaired gas exchange: interstitial disease, V/Q mismatching (PE)
What are chest radiographical findings that may be seen w/ PE?
Atelectasis, infiltrates, pleural effusions, Westemark's sign (peripheral hyperlucency due to oligemia), Hampton's Hump (peripheral wedge of lung opacity from infarction), Fleischer sign (enlarged pulm artery), or NORMAL
What does low diffusion of CO (DLCO) indicate?
Impaired diffusion across alveolar/epithelial membrane
DLCO Decreases w/ interstitial diseases
How can you distinguish asthma from obstructive lung diseases?
Dyspnea, wheezing, cough, and a positive bronchodilator response (>12% increase in FEV1) confirm asthma
Only asthma shows complete reversibility of the obstruction w/ bronchodilators (partial reverse in COPD early stage)
What pulmonary complications can occur in patients w/ diffuse systemic sclerosis (SSc)?
Pulmonary fibrosis (interstitial fibrosis)
What is light's criteria used for and how does it work?
Distinguishes transudative vs. exudative pleural effusion. Exudate characters:
1. Pleural fluid protein/serum protein ration > 0/5
2. Pleural fluid LDH/serum LDH > 0.6
3. Pleural fluid LDH >2/3 upper limit of normal serum LDH
What acid base abnormality can result from opioid use?
Hypoventilation --> subsequent resp acidosis (compensatory rise in bicarb)
What is the clinical presentation for a Pancoast tumor?
#1 - Shoulder pain
-Horner's syndrome (Ipsilateral ptosis, miosis, enopthalmos, anhidrosis), C8-T2 neuro involvement (weak/atrophy of hand muscles, pain/paresthesia of 4/5 digits/medial arm/forearm)
-Supraclavicular lymph node enlargement, weight loss
What are the methylxanthine drugs and their clinical use? Cromolyn?
1. aminophylline - phosphodiesterase inhibitors that cause bronchodilation (not useful for acute COPD)
2. Cromolyn - Mast cell stabilizer (prevents histamine and LKT release) used to treat asthma
How do you differentiate chronic bronchitis vs. bronchiectasis?
CB- Chronic productive cough for 3 months in 2 successive years, cigarette smoking is leading cause
Bronch - More assoc. w/ hx of recurrent respiratory tract infxns and chronic cough w/ daily production of copious mucopurulent sputum, crackles, ronchi, and wheezing more common
How can you differentiate chronic bronchitis and panacinar emphysema w/ COPD?
-Both have obstructive pattern (FEV1/FVC
What are the features of non-allergic rhinitis and how do you treat this?
-Nasal congestion, rhinorrhea, sneezing, postnasal drainage, erythematous nasal mucosa
-Onset at >20 y/o w/ no obvious allergic triggers, but may worsen w/ season change
Tx: Topical aka intranasal anti-histamines (Azelastine, Olopatadine) or intranasal glucocorticoids
How can one assess increased sound transmission over a consolidated lung lobe?
Ask patient to say letter E, if it sounds like A w/ nasal/bleating quality via stethoscope this is egophony and suggests consolidation
-Crackles often heard
A patient presents with candida esophagitis presents w/ hypoxia, what is the most likely cause and what pulmonary function would be impeded?
Most likely HIV/AIDS -> Pneumocystis jiroveci pneumonia (PCP) --> alveolar interstitial inflammation --> areas of V/Q mismatch --> increased A-a gradient
What are the ideal ventilator settings for a patient w/ ARDS and why? What is the best way to increase oxygenation?
1. Low tidal volumes, helps prevent lung damage and decrease mortality
2. PEEP, prevents alveolar collapse at the end of expiration -> Increases FRC and decreases work of breathing
--> you can increase oxygenation by increasing PEEP
What is the pathophysiology of ARDS?
Inflammatory mediators released, secondary to local or distant injury, go on to damage the alveoli. This leads to increased capillary permeability -> pulmonary edema
-Injury can be from sepsis, severe bleeding, severe infection, toxic ingestion, or burns
What is the goal for PaO2 for patients on ventilators w/ ARDS? How can you achieve this and prevent over treatment?
-Maintain paO2 >60
-Keep FiO2 low early on if possible to prevent O2 toxicity of lungs (i.e. below 50-60% range)
Why does oxygen saturation change with position changes when a lung lobe is consolidated?
-Physiological shunting of blood flow to poorly consolidated regions increases if patient lies on the side of body w/ consolidated lobe (more blood to less Oxygenated regions results in less oxygenation overall)
What is the most important intervention to increase oxygenation in patients w/ ARDS?
How does respiratory rate affect resp alkalosis?
increasing RR would worsen alkalosis, because it would generate more bicarb
What are the main pulm values and vent settings that should be maintained in patients w/ ARDS?
-Keep FiO2 below
What is sudden dyspnea in the setting of underlying malignancy, chest pain, tachycardia and hypoxia highly suggestive of? What would result from this condition?
-Prothrombotic state of malignancy puts this patient at high risk for a massive pulmonary embolism
-This would increase pulm vasc resistance --> RV dilation -> compress on LV decreasing preload and CO
What are causes of exudative effusion?
Infection (PNA, TB), malignancy, pulmonary embolism, connective tissue disease, iatrogenic
What is the presentation of aspiration PNA?
Fever, leukocytosis, parenchymal infiltrates
What can be an indication of worsening prognosis in someone with asthma and why?
Normal/increased PCO2 b/c signifies CO2 retention which could be from air trapping and/or resp muscle fatigue
What paraneoplastic syndromes are associated w/ small cell lung CA? squamous cell?
Small Cell- ACTH and SIADH
Squamous - PTHrP
What is the most common acid/base disturbance in PE?
Resp alkalosis from hyperventilation as patient tries to overcome hypoxia and V/Q mismatch