board review pulm

Question 1

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

Answer 1

Question 2

obstruction: FEV1/FVC <70% or <LLN

Answer 2

Question 3

PFT obstruction

Answer 3

Question 4

bronchoprovocation

Answer 4

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

Question 5

dx of asthma

Answer 5

Question 6

when is Ig E useful ina sthma

Answer 6

omalizumab

Question 7

eosinophils in asthma

Answer 7

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

Question 8

occupational asthma

Answer 8

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

Question 9

asthma tx

Answer 9

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

Question 10

mild intermittent assthma

Answer 10

rescue

Question 11

then

Answer 11

low dose ICS

Question 12

then

Answer 12

higher dose ICS

Question 13

then

Answer 13

add LABA

Question 14

AERD/NERD

Answer 14

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

Question 15

ABPA

Answer 15

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)

Question 16

exercise-induced asthma

Answer 16

• 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

Question 17

copd tx

Answer 17

Question 18

mild copd

Question 19

vocal cord dysfunction

Question 20

bronchiectasis

Answer 20

signet ring sign

Question 21

bronchiectasis cont’d

Answer 21

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

Question 22

CF dx

Answer 22

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

Question 23

pulm htn

Answer 23

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)

Question 24

phtn dx

Answer 24

• 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

Question 25

pHTN tx

Answer 25

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

Question 26

massive PE

Answer 26

* 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

Question 27

indications for thrombolysis in massive PE

Answer 27

* 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

Question 28

absolute contraindications to lytics

Answer 28

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

Question 29

cor pulmonale

Answer 29

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

Question 30

hepatopulmonary syndrome

Answer 30

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

Question 31

hemoptysis imaging

Answer 31

* Imaging/procedures * If stable CTA-bronchial circulation otherwise CXR, potential DSA, bronchoscopy

Question 32

management of hemoptysis

Answer 32

* 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