Board Review 2 Flashcards
Which primary malignancies are most associated with tumor emboli to the lung?
Breast, lung, prostate and stomach.
Discuss dx and tx when you see nodularity along the tracheal wall on CT?
Tracheobronchopathia osteochondroplastica. Etiology unknown. Men over 50. Confined to cartilaginous parts of airways. Nodules composed of cartilage or bone; may contain hematopoetic bone marrow elements. Biopsy via bronch quite hard. Asymptomatic to cough to hemoptysis to dyspnea. “Grating” or “scraping” sound with bronchoscope insertion. Remains stable or progresses very slowly. Case reports of laser therapy vs resection.
What part of the trachea is typically involved in amyloidosis?
The posterior membranous portion.
Biots breathing pattern =
Two to four breaths at a time with pauses between them. Regularly irregular. Long acting opiates, altitude, brainstem strokes.
Difference between metastatic and dystrophic pulmonary calcification?
Metastatic is in previously healthy lungs. Dystrophic is in previously injured lungs.
PSOG evidence of REM sleep?
1) REM’s in L- and R-EOG’s; 2) sawtooth theta waves in the EEG leads; 3) nearly absent chin EMG tone
What are signs that CPAP is too high for OSA?
arousals, air leak, central apnea, continuous artifact in snore channel
In LEMS, what are the auto-antibodies directed against?
P/Q voltage gated presynaptic calcium channel receptor
What was the definition of “low functional status” in NETT?
Exercise capacity under 50W.
Aside from the benefit seen in NETT among the under 50W/upper lobe disease group, who did very poorly with LVRS?
FEV1 under 20%, DLCO under 20%, homogenous disease
Medical management for C1 esterase inhibitor deficiency?
Androgenic steroids, Increases hepatic production of C1 esterase inhibitor.
Among patients receiving HSCT, is DAH more common among autologous or allogenic recipients?
Equivalent.
Treatment for babesiosis?
clindamycin plus quinidine
In studies of life-threatening pneumonia, what are the top two organisms isolated?
1) strep pneumo; 2) legionella
Persistent consolidation in the posterior basal segment of the LLL in a young smoker:
pulmonary sequestration; get a CT with contrast yo demonstrate a systemic (aortic) artery supplying the region
Where in the lungs does pulmonary sequestration occur?
90% in the lower lobes, 58% on the left side
Optimal treatment for benign subglottic stensosis?
neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy; gentle serial dilations
First line in active TB in a pregnant patient?
INH, rifampin, ethambutol; avoid pyrazinamide and streptomycin
Discuss CVID.
Pulmonary manifestations: 1) minimal bronchiectasis, 2) sarcoidosis, 3) lymphoproliferative disorders. Most first develop symptoms in adulthood. Failure of B-cell differentiation and impaired immunoglobulin. Upper and lower respiratory tract infections, infectious diarrhea, meningitis, septic arthritis. Organisms: encapsulated bacteria, pneumocystis, NTM, fungi. Treat with IVIg. Low IgG, IgG subclasses, IgA. IgG may normalize in acute illness and total IgG may be normal.
Safety of antifungal therapy in pregnancy?
Amphotericin is actually preferred to the azoles (class B vs class C).
Word association: “cannibalistic” cells in BAL, giant cell interstitial pneumonia?
hard metal disease, cobalt-related ILD
Occupations that expose one to berrylium?
nuclear weapons, ceramics, computer manufacturing)
Characteristics of benign asbestos pleural effusions?
Small, unilateral, PMN-predominant, often eosiniphilic
Do the AVM’s in HHT have a pulmonary or bronchial arterial blood supply?
pulmonary artery
Regimens for latent TB:
1) INH daily/twice weekly for 9 months; 2) INH daily/twice weekly for 6 months; 3) INH plus rifapentene weekly for three months; 4) rifampin daily for 4 months
Histological findings in amiodarone lung toxicity?
interstitial thickening, accumulation of foamy macrophages in the alveoli
Amiodarone lung injury is rare among patients receiving less than ___ mg/day.
400
Pregnancy effects on PFT’s, ABG’s:
Decreased PaCO2; increased tidal volume; no real change in FEV1, FVC; decrease in ERV, RV, FRC
Best screening test for AVM’s in HHT?
bubble study echo
All pulmonary AVM’s with arteries at least ___ in diameter should be embolized.
3 mm
Cardiac sarcoid is clinically apparent in under __% of patients. The most common presentation is __. There is clear benefit to treatment with __.
10, complete heart block, corticosteroids
Best evidence supporting use of pulmonary rehab?
Lower extremity exercise improves exercise capacity, and PR reduces dyspnea.
Time course of radiation-induced lung disease?
Usually clinically apparent within 6-9 months, stable at 2 years.
Four laryngeal signs of GERD:
1) unilateral ulcerated nodule; 2) normal cords with subglottic stenosis; 3) bilateral cord nodules; 4) diffuse laryngeal erythema/hyperemia
When papillary thyroid cancer spreads to the lung, what radiographic pattern does it exhibit?
miliary spread
Renal angiolipomas are associated with…
both LAM and TS
Discuss Mournier-Kuhn syndrome.
Tracheobronchomegaly. 1) congenital; 2) poor clearance, recurrent respiratory infections, bronchiectasis
Triad of Young’s syndrome
infertility, bronchiectasis and sinus infections
Summarize the MWT.
Maintenance of wakefulness test. Sit in a dark room for 40 minutes and stay awake. Not well correlated with anything, of questionable utility.
Ranges of Hounsfeld Units for common lung nodules:
lipomas -50 to -300; soft tissue nodules/masses: 10-70; calcification: 100-400; air: -1,000; bone: 1000; water: 0; normal lung: -750
How fast does pCO2 rise in an apneic patient?
3-6 mmHg/min
What immunodeficiency is associated with ITP, AHA, vitiligo, alopeica, etc?
CVID
Recurrent sino-pulmonary infections and recurrent skin infections:
chronic granulomatous disease
Osteoporosis risk in LMWH vs UFH?
less common in LMWH
Discuss mediastinal lipomatosis.
anterior mediastinal fat, diagnosed on CT, benign, no further workup needed; associated with obesity, glucocorticoid use, Cushing’s syndrome
In a patient s/p recent right heart cath, a contrast-enhancing mass is seen on CT. Diagnosis? Next step?
pulmonary artery pseudoaneurysm; catheter tip spears the lumen wall or the balloon dilates a small vessel; often cause immediate frank hemoptysis, but can be more indolent; next step is pulmonary angiography with wire coil embolization
Key points on post-BMT pulmonary GVHD
1) surgical biopsy is rarely indicated given high risks; 2) ~50% of allo-BMT recipients develop multisystem GVHT; of these, 10% develop OB; 3) risk factors include allo-transplant, busulfan exposure, MTX exposure, immunomismatch; 4) 90% develop it within the first 18 months
Dilated pupil in someone receiving nebs:
ipratropium, leak in mask
What defines ‘favorable response’ in a RHC with vasodilator administration?
Drop in mean PAP by 10 to under 40.
What is the major side effect of bosentan?
liver injury
What patterns of PFT abnormalities have been seen in people exposed to the World Trade Center collapse?
decline in FEV1 and FVc with unchanged ratio
What bugs have been implicated as antigen providers in hot tub lung?
MAI, molds (cladosporium, pullaria, epicocucum)
Discuss key points of A1AT augmentation.
1) Lower mortality and slower rate of FEV1 decline in patients with FEV1 35-64% predicted. 2) Not indicated if still smoking. 3) Benefit greatest (because untreated decline is fastest) when A1AT level is under 35. 4) When dosing, get nadir over 80.
Key points on catamenial pneumothorax.
1) Predominantly right-sided. 2) Typically within 24-48 hours of onset of menstruation. 3) Suppression of ovulation with danazol and OCP’s does not work in more than 50% of cases. 4) Pleurodesis is indicated when recurrent.
Two most common tracheal masses:
1) SCC; 2) adenocystic carcinoma
Flow volume loop in VCD:
flattening during inspiration, consistent with variable extrathoracic obstruction
Key points on pulmonary neuroendocrine cell hyperplasia:
1) exclusively in women aged 45 - 64; 2) due to proliferation of NE cells into the lumens of small airways; 3) no effective therapies; 4) CT shows mosaic attenuation; 5) often associated with carcinoid tumors; 6) NE cells stain positive for chromogranin and bombesin
CT clues to distinguish mesothelioma from other causes of thickened pleura?
1) most have associated pleural effusions; 2) most benign causes do not affect the mediastinal pleura
65 yo m w/ cough, sore throat, tongue pain and elevated ESR:
temporal arteritis; cough is a presenting complaint in 10% of patients with TA/PMR
Utility of PET for brain mets?
Notoriously poor as uptake is so diffuse.
Effects of pMDI on inhaled particles?
1) slows velocity of aerosol, decreasing oropharyngeal impaction; 2) enhanced effectiveness in uncoordinated patients (discharge before inhalation); 3) allows particles to warm and evaporate, minimizing ‘cold freon’ effect
Treatment of esophageal candidiasis in a patient on an inhaled corticosteroid?
fluconazole tablets until at least two weeks after resolution
First step after thoroscopic diagnosis of malignant mesothelioma?
radiation to the puncture site to prevent site metastases, painful subcutaneous nodules
Molecular mediators of AEP?
IL-5, which is a chemoattractant for VEGF
What viral history is associated with PTLD?
EBV-positive lungs into an EBV-negative patient.
Describe subglottic suctioning.
Small catheter above the endotracheal cuff. Continuous drainage. Mixed data, but may decrease VAP rates.
What is the most specific finding in CPET’s that suggests pulmonary vascular disease?
Dead space fraction that increases with exercise.
Key points on lupus pernio:
1) nontender; 2) associated with bone cysts; 3) not pruritic, does not ulcerate;
CT findings in pulmonary amyloidosis:
1) diffuse nodular/reticular changes; 2) extensive mediastinal, parenchymal calcification (in alveolar septal amyloidosis); 3) mediastinal, hilar lymphadenopathy; 4) pleural effusions
Tumors that spread via lymphangitic carcinomatosis?
1) breast followed by stomach, pancreas, prostate, lung
Three pulmonary infections that cause splenic calcifications
histo, TB, brucellosis
Discuss the heritability of Ondine’s Curse.
Autosomal dominant, mutation of PHOX2B gene.
Three most common pathogens in acute chest syndrome?
Chlamydia pneumophilia, mycoplasma pneumonia, respiratory viruses
Pleural fluid studies for chylothorax, pseudochylothorax?
Protein greater than 4, Lymphocytic (300-5000), normal pH, high cholesterol but low triglycerides (under 110). High triglycerides would indicate pseudochylothorax.
What antibiotic can cause methemoglobinemia? What antihypertensive?
metoclopramide; nitrates
Smoker with a lung mass and distal bone pain. Test?
technetium bone scan; assesses for hypertrophic osteoarthropathy
What counts as a positive vasodilator test in PAH?
Drop in MAP by at least 10 to less than 40
Common presentations of carcinoid tumors:
1) cough; 2) incidental; 3) hemoptysis; 4) focal wheeze and difficult-to-control asthma; 5) atelectasis on CXR
Highlights on RRP: population, treatment, site of recurrence, risk of transformation, precaution?
1) children who get HPV from mother; 2) resection, lasers, cidofovir injection; 3) recur at site of mucosal injury; 4) can transform into SCC; 5) laser therapy can aerosolize HPV DNA
In a patient with pulmonary-renal syndrome, negative anti-GBM antibodies and positive p-ANCA…
Still do a kidney biopsy. 38% of Goodpasture’s patients have positive ANCA, and you need to know about plasmapheresis.
Fastest means of diagnosing anthrax? What does the CT show?
Blood cultures; rarely causes pneumonia, so sputum of low yield. CT shows hemorrhagic mediastinitis or lymphadenitis.
How does eosinophilic bronchitis differ from asthma?
No airway hyperresponsiveness.
List a ddx (and an important missing dx) for symmetric mediastinal LAD.
sarcoid, metastatic malignancy (breast, e.g.), CLL, Hodgkin’s; NSCLC should be asymmetric
Sarcoid staging:
I) bilataral hilar LAD, clear parenchyma; II) LAD and parenchymal infiltration; III) parenchymal infiltration and no LAD; IV) fibrosis
Key points on HIV-associated PAH.
1) improves with HAART, epoprostenol; 2) looks histologically like PPH; 3) patients are more likely to die from complications of PH than of infections
Key points on BAC:
1) shows lepidic growth; 2) often chemo-refractory; 3) has recurred post-transplant; 4) up to 50% occur in lungs with preexisting disease; 5) hints that it may be infectious - resembles ovine pulmonary adenocarcinoma (caused by retrovirus), reports of BAC in sheep farmers, report of husband and wife contracting BAC within one year; 6) weakest association with smoking of all lung cancers;
Side effects of rifabutin?
Rash, cytopenias, cholestasis, hepatitis, pseudojaundice, flu-like syndrome, orange secretions.
Side effects of pyrazinamide?
Rash, hepatitis, hyperuricemia, arthralgias, GI distress.
Key points on metal fume fever.
1) Most often zinc, then copper and magnesium. 2) direct toxic effect, not immunologic; 3) thirst, metal taste, flu-like symptoms
Association between Goodpasture’s and smoking?
Nearly 100% of GP patients who develop pulmonary hemorrhage are smokers.
Key points on DVT’s in pregnancy?
1) more often left than right; 2) increased generation of II, VII, X, and fibrin; 3) utility of duplex is lessened because of swelling and leg discomfort; 4) total radiation for x-ray, duplex, VQ scan and CTPE is less than 500 mrad, well under 5000 mrad that has shown no fetal risk in most studies
Most common pulmonary and ICU manifestation of strongyloides? Treatment?
pulmonary: cough, wheeze, sputum; ICU: years after exposure, hyperinfection after immunosuppression - multiorgan failure; ivermectin
Key points on relapsing polychondritis.
1) systemic disease with respiratory involvement in 50%; 2) cartilagenous involvement: ear, nose, airways, costochondral junction; 3) antibodies to Type 2 collagen; 4) no specific lab test; 5) 40% have another associated CTD
Difference in behavior, prognosis between typical and atypical carcinoids?
Typical: better mortality and fewer metastases than atypical.
Three paraneoplastic syndromes with carcinoid tumors:
carcinoid syndrome, ectopic ACTH-producing Cushing syndrome, acromegaly due to GH production
Treatment for carcinoid tumors?
Surgical. Poor results for all alternatives.
Discuss the benefits of spacers in pMDI use.
Downsides of pMDI’s: need for coordination (time activation during slow inspiratory capacity maneuver), high velocity (promotes OP deposition), cold temperature (premature termination of inspiratory effort). Spacer: slows velocity of aerosol, eases timing (can be discharged prior to inhalation), allow propellants to evaporate, reducing particle size and minimizes the cold effect.
Cancers that commonly cause lymphangitic spread in the lungs:
breast is most common; also stomach, pancreatic, prostate, lung
Calcified splenic nodule, think:
histo
Discuss step-up therapy from mild-persistent to moderate-persistent asthma.
Medium-dose ICS vs LABA. LABA option more effective, but increased side effects.
Bottom line on inhaled NO in acute chest syndrome?
Theoretical gain, but unproven, only at anectodal level now. Only advised if enrolled in trials.
Desperation move for acute chest syndrome?
Exchange transfusion. Get HgS below 30%. Anecdotal but recommended.
Electrical therapy for unstable torsades?
Defibrillation. Nothing organized enough to synchronize.
Fat in a pulmonary nodule suggests…
hamartoma
Effect of lying down on lung volumes?
Decreased VC, markedly decreased expiratory reserve and FRC. Increase in inspiratory capacity.
Pralidoxime is given for:
organophosphate poisoning
How big does an ischemic stroke have to be in order to be too big for tPA?
Evidence of a multilobar infarction with hypodensity involving >33 percent of the cerebral hemisphere
A-a gradient?
(FiO2(Patm - PH2O) - PaCO2/.8) - PaO2 or (150 - 1.25PCO2) - PaO2
Important Th2 cytokines
IL-4, IL-4, IL-6, IL-10, IL-13
Important Th1 cytokines
IFN-gamma, TNF-beta, IL-10
How do you estimate MVV?
FEV1 x 40
IgE level for which omalizumab is indicated?
30 to 700 IU per milliliter for patients 12 to 75 years of age
What do we know about DNase in idiopathic bronchiectasis?
Decreases FEV1 and increases frequency of exacerbations.
Example of initial settings on APRV.
P-high - 30, P-low - 0, T-high 5 seconds, T-low 0.6 seconds
Rules of thumb for needing nocturnal NPPV in neuromuscular disease.
FVC under 50% predicted, MIP under -30 or MEP under 40, VC under 15-20 mL/kg. 20-30-40 - VC, MIP, MEP.
A1A phenotypes in increasing order of severity risk?
MM (normal) - MZ (possible mild) - SS (no increase) - SZ (mild) - ZZ (high risk) - Null (100% by age 30)
Lipid laden macrophages in BAL may reflect:
aspiration
