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board review > board review pulm > Flashcards

board review pulm Flashcards

1
Q

differentiate flow volume loops for fixed obstruction, variable extra-thoracic and intrathoracic obstruction

A
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2
Q

obstruction: FEV1/FVC <70% or <LLN

A
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3
Q

PFT obstruction

A
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4
Q

bronchoprovocation

A

**Positive if decrease in FEV1 of more than 20%
at a concentration(PC 20) of less than
16mg/ml of methacholine or dose

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5
Q

dx of asthma

A
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6
Q

when is Ig E useful ina sthma

A

omalizumab

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7
Q

eosinophils in asthma

A

Eosinophilic inflammation
* Most commonly serum >/= 150 - 400/microL
* May benefit from mepolizumab/benralizumab etc

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8
Q

occupational asthma

A

15% of adult asthma
* High molecular weight substances: animal and plant allergens,
latex, grains, diisocyanates
* Once sensitized, may react to very low levels of exposure
* Diagnose: spirometry before and after workplace exposure, peak
flow
* Treatment: reduce exposure

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9
Q

asthma tx

A

Asthma treatment
* Remove/avoid environmental allergens
* Allergy shots
* Treat nasal symptoms
* Inhaled corticosteroids
* Inhaled bronchodilators
* Oral steroids
* Adjunctive immunomodulators
* IgE:
* Omalizumab
* Eosinophils:
* Mepolizumab
* Reslizomab
* Benralizumab
* Dupilumab

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10
Q

mild intermittent assthma

A

rescue

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11
Q

then

A

low dose ICS

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12
Q

then

A

higher dose ICS

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13
Q

then

A

add LABA

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14
Q

AERD/NERD

A

AERD/NERD
* Triad: asthma + nasal polyposis + chronic
rhinosinusitis
* + ASA sensitivity
*Intermittent symptoms following ingestion of ASA
or NSAID
*Aspirin desensitization can be used as a treatment
however and chronic use is felt to downregulate the
pathological inflammatory response
*Growing use of anti-IL-5 and anti-IgE therapy

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15
Q

ABPA

A

ABPA
*Immunologic response to inhaled aspergillus
* Other fungal organisms implicated in case reports
*Persistent eosinophilic inflammation
*Classically seen in asthma or cystic fibrosis * Reported in lung transplant, other bronchiectasis etc

dx criteria:
*Both
* Serum IgE specific to Aspergillus
* Elevated total IgE(typically >1000 iu/ml)

  • as well as Two of three of the following:
  • A. fumigatus specific IgG
  • Consistent radiograph
  • Total eosinophil count > 500 cells/microL * International Society for Human and Animal Mycology
    (ISHAM) working group diagnostic criteria for allergic
    bronchopulmonary aspergillosis
  • Treatment: steroids + antifungal (also omalizumab)
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16
Q

exercise-induced asthma

A
  • Pre-existing asthma exacerbated by exercise
  • Symptoms of cough, dyspnea and wheezing(typically following
    completion of exercise)
  • FEV1 drop by 10% or more post-exercise

peak flow meter before and after also works

17
Q

copd tx

A
18
Q

mild copd

A
19
Q

vocal cord dysfunction

A
20
Q

bronchiectasis

A

signet ring sign

21
Q

bronchiectasis cont’d

A

caused by anything that can damage airway - vicious cycle

Bronchiectasis
* Diagnosis
* Symptoms of cough, sputum production and DOE
* High resolution CT
* PFTs with airflow obstruction possibly reduced DLCO
* Treatment
* Bronchodilators
* Physiotherapy/airway clearance***
* Suppressive abx/po or inhaled
* Abx with acute exacerbations
* Steroids unstudied but used

22
Q

CF dx

A

Diagnosis
* Organ dysfunction consistent with CF in at least 1 organ
And
* Two abnormal CFTR mutations
* Sweat chloride >/= 60 mmol/L
* Abnormal nasal potential difference
* Infection/colonization with haemophilus influenzae, staph aureus, and
mucoid pseudomonas aeruginosa
* Pancreatic insufficiency (Exocrine in 85%)
* CFRD also common

  • Treatment:
  • Airway clearance: chest PT, vest, exercise, flutter device
  • Mucolytics: recombinant DNase,hypertonic saline
  • Bronchodilators, antimicrobials, anti-inflammatory
  • Disease modifying agents
  • Improve production, intracellular processing and/or function of CFTR protein
  • Trikafta: ivacaftor + texacaftor + elexacaftor*****
  • Approved for delta F508 homozygotes
23
Q

pulm htn

A

WHO groups 1 – 5. * Group 1 (PAH) - idiopathic, hereditary (BMPR2 mutations), HIV, meds/illicit drugs, connective tissue disease, congenital heart disease
* Group 2 – 2/2 left heart disease/elevated wedge
* Group 3 – 2/2 pulmonary disease and or chronic hypoxic vasoconstriction
* Group 4 – chronic thromboembolic pulmonary hypertension
* Group 5 – misc…chronic hemolytic anemia, sarcoidosis, CKD, fibrosing
mediastinitis
* Defined as an increase in mean pulmonary arterial pressure
(mPAP) at rest as assessed by right heart catheterization
(RHC)
* mPAP > 20 mm Hg (normal10-12 mm Hg) with a normal wedge
* PVR > 2 Wood units
* PAOP </= 15 (except group 2)

24
Q

phtn dx

A
  • PE: Loud P2, TR, RV heave
  • PFTs: Isolated decrease in DLCO
  • Screen: Echo
  • Diagnosis: Right heart catheterization
  • Vasodilator reactivity (iNO or IV epoprostinol) * Decrease in mPAP by >10 mmHg, mPAP <40 mmHg and CO remains
    stable or improves
  • Predicts potential long-term response to oral calcium channel blocker
  • Predicts overall better prognosis
25
Q

pHTN tx

A

Pulmonary HTN Treatment
* Calcium channel blockers IF reactive in cath lab * nifedipine, amlodipine, and diltiazem
* Phosphodiesterase type 5 inhibitors
* Sildenafil, Tadalafil
* Endothelin Receptor Antagonists
* Bosentan, Ambrisentan, Macitentan
* Cyclic GMP Stimulator - CTEPH
* Riociguat
* Inhaled Treprostinil-Group 3 PH-ILD
* Tyvaso
* Prostanoids
* Epoprostenol, Iloprost, Treprostinil

  • Oxygen, diuretics, pulmonary rehab, anticoagulation (some Group 1, Group 4)
  • Transplant
26
Q

massive PE

A
  • Severity
  • Massive - hemodynamic instability
  • SBP < 90 or drop by 40 mmHg or pressor requirement even after fluids
  • Lasting > 15 minutes
  • Sub-massive – none of the above
  • High risk, Intermediate risk, low risk of mortality – PESI score
27
Q

indications for thrombolysis in massive PE

A
  • Thrombolysis
  • Massive PE(sbp < 90 or 40 mmHg < baseline or pressors)
  • PERT team to make multidisciplinary decision
  • High risk factors
  • HR >120
  • CT with dilated RV or reflux of contrast
  • TTE with dilated RV/RV pressure overload/RV systolic dysfunction
  • Elevated BNP
  • Clot in transit
  • Significant hypoxia requiring supplemental oxygen
  • Poor cardiac/respiratory reserve
  • sPESI > 0
  • To give or not to give lytics….
  • Massive PE(high risk)-> give lytics
  • Hemodynamically unstable. Could be BP 89/60, could be on 2 pressors, could be cardiac arrest
  • Submassive PE
  • Intermediate risk-> no one knows
  • No hemodynamic instability, but…..
  • RV dysfunction on echo or CT
  • Elevated BNP
  • Elevated trop
  • Tachycardic etc
  • Low risk-> don’t give lytics
  • None of the above
28
Q

absolute contraindications to lytics

A

Absolute contraindications to fibrinolytic therapy
* Prior ICH or known lesion
* Suspected aortic dissection
* Active bleeding
* Significant head trauma

Relative contraindications to fibrinolytic therapy
* Poorly controlled HTN
* Hx ischemic stroke
* Noncompressible vascular puncture
* Bleeding within 4 weeks
* Recent CPR

29
Q

cor pulmonale

A

RV dilatation, hypertrophy or failure in Group 3 PH.
* Some may include group 1(PAH)
* Classically chronic hypoxic respiratory failure with chronic pulmonary
vasoconstriction
* Treat the underlying caus

30
Q

hepatopulmonary syndrome

A

Hepatopulmonary Syndrome
* Hepatopulmonary syndrome (HPS)
* abnormal arterial oxygenation caused by intrapulmonary vascular
dilatations
* setting of liver disease, portal hypertension, or congenital
portosystemic shunts
* Orthodeoxia and platypnea
* Shunt on TTE bubble study(CT rarely show AVM/shunt)
* Liver transplant

31
Q

hemoptysis imaging

A
  • Imaging/procedures
  • If stable CTA-bronchial circulation otherwise CXR, potential DSA,
    bronchoscopy
32
Q

management of hemoptysis

A
  • Assess and secure airway
  • Consider mainstem intubation
  • If known, place bleeding side down**
  • Bronchoscopy
  • Bronchial blocker, potential diagnostic and therapeutic utility
  • IR
  • Thoracic or cardiac surgery
  • Treat underlying cause
  • Abx
  • FFP, platelets, DDAVP, specific anticoag reversal etc

board review (11 decks)

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