Exam Flashcards
1
Q
Tidal volume (TV/VT)
A
Volume of air inspired and expired during normal quiet breathing
2
Q
INSPIRATORY RESERVE VOLUME (IRV)
A
The maximum amount of air that can be inhaled after a normal tidal volume inspiration
3
Q
EXPIRATORY RESERVE VOLUME
A
Maximum amount of air that can be exhaled from the resting expiratory
4
Q
RESIDUAL VOLUME
A
Volume of air remaining in the lungs at the end of maximum expiration; indirectly measured
5
Q
TOTAL LUNG CAPACITY
A
Volume of air in the lungs after a maximum inspiration
TLC = IRV + TV + ERV + RV or VC + RV
6
Q
FUNCTIONAL RESIDUAL CAPACITY
A
Volume of air remaining in the lungs at the end of a TV expiration
The elastic force of the chest wall is exactly balanced by the elastic force of the lungs
FRC = ERV + RV
7
Q
VITAL CAPACITY
A
Volume of air that can be exhaled from the lungs after a maximum inspiration
VC = IRV + TV + ERV
8
Q
INSPIRATORY CAPACITY
A
Maximum amount of air that can be inhaled from the end of a tidal volume
IC = IRV + TV
9
Q
best values spirometry measures
A
Forced expiratory volume in one second (FEV1)
Forced vital capacity (FVC)
FEV1/FVC%
10
Q
Obstructive pattern on PFT
A
DECREASED FEV1,
DECREASED FEF 25-75
Decreased FEV1/FVC - <70% predicted
11
Q
DDx for obstructive lung dz
A
asthma
COPD (chronic bronchitis, emphysema)
12
Q
Restrictive pattern on PFT
A
Decreased TLC, FVC
Normal or increased: FEV1/FVC ratio
13
Q
significant bronchodilator response value
A
FEV1 increase by 12% AND >200ml
14
Q
bronchodilator response
A
documents reversible airflow obstruction
15
Q
what does spirogram measure
A
forced inspiratory and expiratory flow rate
gold standard
evaluate upper respiratory obstruction
16
Q
lung volume patterns in obstructive dz*
A
TLC >120% PREDICTED
RV >120% PREDICTED
17
Q
lung volume patterns in restrictive dz*
A
TLC <80% PREDICTED
RV <80% PREDICTED
18
Q
DLCO (Carbon Monoxide Diffusing Capacity)
A
pt breathe in carbon monoxide, measure how much of it exhaled
measures gas exchange at alveolar-cap membrane
19
Q
what is diagnostic of asthma in bronchoprovocation test?
A
greater or equal 20% increase in FEV1
20
Q
What value is used to follow disease severity in COPD patients?*
A
FEV1
marker for obstructive lung dz
21
Q
Biggest risk for COPD
A
80-90% TOBACCO SMOKE
VERY HIGH RISK if >40ppy
22
Q
Causes of COPD
A
Asthma; 10-30 fold increase risk
childhood respiratory infection
alpha 1-trypsin deficiency
23
Q
Pathophysiology of COPD
A
chronic irritation airflow limitation/air trapping gas exchange abnormalities mucus hypersecretion pulm vascular scarring from chronic inflammation --> pulm HTN --> R HF
24
Q
2 types of COPD
A
emphysema
chronic bronchitis
(often coexist)
25
how to diagnose chronic bronchitis
productive cough lasting at least 3 months in 2 consecutive years (exclude other causes)
IRREVERSIBLE
26
Chronic Bronchitis
increase mucus and inflammation from hyperplasia/hypertrophy of goblet cells/mucus glands
affecting terminal bronchioles
27
Biggest symptoms of Chronic Bronchitis
excessive mucus --> cough
28
what can happen eventually with chronic bronchitis?
thickening of airways --> fibrosis --> pulm HTN
29
Acute Bronchitis
affects LARGE bronchi
| from virus/bacteria
30
Emphysema
permanent destruction of alveolar sac --> enlarged air spaces
31
pathophysiology of emphysema
```
loss of lung elasticity
destruction of lung parenchyma
enlargement of air spaces
PERMANENT
inadequate gas exchange
```
32
Classic COPD Symptoms
chronic cough
sputum (purulent w/exacerbation)
breathlessness + fatigue, DOE
(and wheezing, chest tightness)
33
population affected with COPD
>40 yo w/risk factors
34
What should you consider if pt has COPD AND Clubbing of fingers
lung cancer
35
Late dz presentation of COPD
```
muscle wasting, weakness
pursed lip breathing*
R HF Sx: JVC, Peripheral edema, hepatomegaly
depression, anxiety
osteoporosis
polycythemia (inc epo from hypoxia)
```
36
how to Dx COPD
Risk factors and confirm w/spirometry
37
Spirometry findings for COPD
FEV1/FVC <0.7
| reduced expiratory flow
38
What spirometry value is used to stage COPD and determine treatment?
FEV1
39
Class IV COPD
FE1 <30% predicted
40
how to distinguish asthma from COPD?
Do Pre/Post bronchodilator spirometry
| asthma will have post bronchodilator change, but NOT COPD
41
COPD treatment
prevent progression, exacerbation, infections
maintain at least 88% oxygenation
short acting, long acting bronchodilators
STEP UP and CUMULATIVE Tx
42
What do ALL COPD patients need?
flu and pneumococcal vaccine!
43
When are inhaled glucocorticoids used in COPD?
Severe cases
helps airway inflammation
s/e: oral thrush, increase risk infection in immunocomp
eg fluticasone
44
What is the only thing that improves survival for COPD?
Smoking prevention/cessation
| O2 therapy
45
What is the mainstay treatment at EVERY stage of COPD?
Inhaled bronchodilators (BA or anti-cholingeric)
46
Examples of short acting bronchodilators
Beta agonist: albuterol
Anti-cholinergic: ipratropium
used for sx relief
47
Examples of long acting bronchodilators
LABA: salmeterol
LAMA: Tiotropium (anti-cholinergic)
used for prevention
48
When do you recommend pulmonary rehab for COPD patients?
```
symptomatic pts w/FEV1 <50% predicted
class II to IV
```
49
When do you prescribe O2 therapy?
PaO2 <55 mmHg
| O2 <88%
50
Signs of COPD exacerbations
inc cough freq/severity
inc sputum/change in sputum - purulent
inc dyspnea
51
Tx for COPD Exacerbation
sputum culture but start empirical abiotic first
Antibiotics (50% from bacterial infection) - azithro
bronchodilator, systemic corticosteroids (prednisone), O2
52
Most common chronic illness in children
asthma
53
Asthma pathophysiology
inflammation and constriction of lumen in small airways (thickened)
obstructive dz - reversible!
54
Symptoms of Asthma
coughing
wheezing
breathlessness
chest tightness
55
Causes of asthma
hereditary + environ
RSV as infant
allergen, air quality, tobacco
56
Triggers of asthma
allergen, virus, exercise, cold air, emotions --> causing bronchial hyperresponsiveness (constriction)
57
What happens if asthma is chronic and uncontrolled?
airway remodeling (fibrosis, inc mucus, hypertrophy, injury, angiogenesis)
58
Dz progression of asthma
increase airway edema and mucus hyper secretion
59
Key of asthma
CONTROL
| control the allergy --> control the asthma!
60
Most bronchoconstriction is what?
IgE-mediated
61
Strongest predisposing factor to asthma
atopy --> propensity for IgE response
62
Characteristics of Asthma*
airflow obstruction
bronchial hyper-responsiveness
underlying inflammation
(attacks of impaired breathing)
63
What should be included in DDx with unexplained dyspnea/cough
asthma
64
Asthma cough characteristics
non-productive (dry)
episodic
worst at night*
65
What can you find on PE of asthma
end expiratory wheezing*
| inc nasal drainage, mucosal swelling, nasal polyps
66
What is the gold standard diagnostic tool for asthma
spirometry before and after SABA
67
How to objectively diagnose asthma?*
FEV1 increase 12% from baseline after SABA (reversibility)
| atleast 20% decrease in FEV1 after methacholine (bronchoprovocation test)
68
How to determine tx for asthma
assess severity (for initial Tx) and control (changes in tx) of symptoms
69
When is systemic corticosteroids used in asthma?
> or equal 3 wheezing/yr
| or 2 eps/6mon
70
What should everyone with asthma get?
SABA - rescue inhaler - for acute bronchospasm
71
What is the preferred long term control for all age groups for asthma?
Inhaled corticosteroids - prevent exacerbations, most effective for persistent asthma
72
When to step down treatment for asthma?
asthma controlled for 3 months
| start high and step down once control achieved, maintain lowest effective dose
73
Tx for severe asthma exacerbation
oral corticosteroids
74
How is LABA used?
ONLY in combo w/ICS, NOT monotherapy
only for Step 3 and above and greater than 5 yo
(can increase asthma related death in young children)
75
Sampter's Triad
(ASA exacerbated asthma)
ASA sensitivity
Asthma
Nasal Polyps
76
How do you confirm pleural effusion?*
CXR - PA and Lateral view
77
What is pleural effusion associated with
infection (eg bacterial pneumonia)
malignancy
HF
Trauma
78
Biggest PE finding in Pleural Effusion
dullness w/percussion
79
What is the most useful test and treatment for pleural effusion?*
thoracentesis, both Dx and Tx
80
Function of pleural fluid
lubricant to minimize friction during breathing
surface tension - allows alveoli to inflate maximally
reabsorbed by lymphatics
81
Types of pleural effusions
transudative
| exudative
82
Transudative pleural effusion
due to increased hydrostatic pressure or low plasma oncotic pressure
causes: HF, cirrhosis, nephrotic syndrome, PE
83
Exudative pleural effusion
due to inflammation and increased capillary permeability
| causes: pneumonia, cancer, TB, viral infection, PE
84
Lab differences between transudative and exudative fluid*
Transudative fluid: low in protein and LDH
| Exudative: high in protein and LDH
85
Causes of exudative pleural effusion
```
malignancy
infection
PE
Chylothorax
Hemothorax
GI dz
Collagen dz
```
86
Causes of transudative pleural effusion
90% CHF
cirrhosis
kidney failure: nephrotic syndrome
(rarely need intervention)
87
Light's Criteria for exudative pleural effusion
1. pleural fluid protein/serum protein >0.5
2. or pleural fluid LDH/serum LDH >0.6
3. or pleural fluid LDH >2/3 normal upper limit of serum LDH
88
Symptoms of pleural effusion
```
SOB*
Pleuritic pain*
Cough*
DOE, orthopnea
25% asymp
```
89
Pleural effusion on PE
```
DULLNESS TO PERCUSSION
decreased/absent tactile fremitus
dec breath sounds
egophony
friction rub
```
90
Mediastinal shift in unilateral pleural effusion
AWAY
91
What do do if suspect malignancy in pleural effusion?
take 3 diff samples
cytology
glucose
92
Color differences between transudative and exudative pleural fluid
transudative: very clear
exudative: dark
normal: straw colored
93
Lab results of pleural effusion w/malignancy
pos cytology
glu <60mg/dl
frank red fluid
94
Lab results of pleural effusion w/chylothorax
milky fluid
| triglyceride >110 mg/dl
95
Purulent pleural fluid
empyema
96
Pleural fluid WBC ct >10,000
parapneumonic effusion
| acute pancreatitis
97
Pleural fluid WBC ct >50,000
complicated parapneumonic effusion
| empyema
98
Low glucose levels of pleural fluid
infections
autoimmune
malignancy
99
What is low pH of pleural fluid and malignancy associated with?
poorer prognosis
100
What can you get if you remove too much pleural fluid at once?
pulmonary edema
101
When is pleurodesis used
```
recurrent effusions
(chemically adhere visceral and parietal layers; drain fluid beforehand - eg doxycycline)
```
102
VATS (video assisted thoracoscopic surgery)
deflate affected lung --> draw out fluid --> re-inflate lung
| low success rate
103
When is thoracotomy used?
empyema
lung cancer
(involves decortication or pleurectomy)
104
How is pleural effusion usually diagnosed?
History
| description of fluid
105
Interstitial lung disease
damage to alveolar walls and lung parenchyma from inflammation and resulting fibrosis
106
Hallmarks of interstitial lung disease
restrictive pattern on PFT
| decrease diffusing capacity for carbon monoxide
107
drugs that cause acute interstitial lung dz
amiodarone
| methotrexate
108
diseases that can cause interstitial lung dz
RA
cancer
sarcoidosis
amyloidosis
109
Most common type of interstitial lung dz*
idiopathic interstitial fibrosis
110
Interstitial lung dz affects which population of people generally
>50 yo
111
Most common causes of interstitial lung dz
```
idiopathic pulmonary fibrosis
sarcoidosis
assoc collagen vascular dz
occupation related
drug or toxin related
```
112
Most common presenting complaint of interstitial lung dz
```
DYSPNEA**
SOB
non-productive cough
chest tightness/heaviness
weight loss, fatigue, anorexia
```
113
what is hilar/mediastinal lymphadenopathy associated with in interstitial lung dz?
sarcoidosis
silicosis
lymphoma
114
what is pleural effusion/thickening associated with in interstitial lung dz
collagen vascular dz
lymphoma
asbestos
115
"ground glass" on CXR
amiodarone
| Inflammation --> potentially reversible
116
"honey comb" on CXR
Fibrosis
| VERY POOR PROGNOSIS - IRREVERSIBLE
117
What population is associated with idiopathic pulmonary fibrosis?
older, male
| BAD prognosis
118
Pathology of idiopathic pulm fibrosis
triggering event --> inflammation --> damage alveolar-cap basement membrane --> inc perm --> FIBROSIS
119
End stage of idiopathic pulm fibrosis
destruction of alveolar wall
| honeycombing on CXR
120
What pulm function is reduced in idiopathic pulm fibrosis
DLCO (diffusing capacity) reduced
| but normal spirometry ratios
121
characteristic of sarcoidosis
multiple uniform non-caseating granulomas (lungs and lymph nodes)
122
most common population with chronic sarcoidosis
north american blacks
123
What can you get with sarcoidosis
iritis and uveitis
124
large, "fluffy" nodules on CXR
Sarcoidosis
125
Sarcoidosis staging*
Stage 0: normal
Stage I: Hilar adenopathy only
Stage II: Hilar adenopathy and parenchymal involvement
Stage III: parenchymal involvement alone
126
Tx for sarcoidosis
most don't require treatment
| treat if symptomatic, ocular, and other organ involvement (corticosteroids)
127
pneumoconiosis
hypersensitivity pneumonitis from inhaled dusts/chemicals (occupational)
128
Hallmark of chronic pneumoconiosis
pulmonary fibrosis in upper lobes
129
what cancer can you get with asbestos
mesothelioma
130
Pneumothorax
collapsed lung from air in potential space
131
Causes of pneumothroax
penetrating trauma
blunt trauma
barro trauma
birth
132
Signs of pneumothorax
decreased breath sounds - affected side
hyperresonance
tracheal deviation
crepitance - lungs
133
Tracheal deviation of tension pneumothorax*
AWAY from side w/decreased breath sounds
134
Tracheal deviation of routine pneumothorax*
TOWARD side w/decreased breath sounds
135
empyema
purulent fluid in pleural space
136
stages of empyema
exudative
fibrinopurulent
organizing
137
empyema causes
pneumonia
mediastinal infection
abscess
138
empyema necessitans
complication of empyema
| goes into chest wall
139
risk factors of lung abscess*
```
alcoholism* - most common
severe gingivodental dz
seizures
CV accidents
anesthesia
```
140
Which side is more commonly affected w/lung abscess*
right side 75%
141
bronchiectasis
persistent, abnormal dilation of bronchi
142
which side is more common in bronchiectasis?*
left*
143
most common type of bronchiectasis
varicose 62%
144
causes of bronchiectasis
acquired: viral, bacterial, obstruction, heroin
| congenital rare
145
most common symptom of bronchiectasis
persistent cough 75%
146
pulmonary HTN
elevated pulmonary arterial pressure and secondary right ventricular failure
147
what's the mean arterial pressure in pulmonary HTN*
>20mmHg at rest
148
How is pulmonary arterial pressure measured?
right heart catheterization
149
Group 1 pulmonary HTN
pulmonary arterial HTN - RIGHT heart dz
150
Group 2 pulmonary HTN
pulmonary venous HTN - LEFT heart dz
151
Group 3 pulmonary HTN
associated w/lung dz
152
Group 4 pulmonary HTN
associated w/embolitic dz
153
Group 5 pulmonary HTN
unclear, multi-factorial
154
Initial complaints of pulmonary HTN
Dyspnea on exertion*
fatigue
lethargy
155
PE of pulm HTN*
increase pulmonic component of S2 (P2)
156
What diagnostic test should you first order for pulm HTN*
2D echo w/doppler flow study
157
Biggest cause of dyspnea in children
infections
| foreign body aspiration
158
Causes of acute dyspnea in adults
```
(PPOPPA)
PE
Pulm edema
obstructed airway
pneumothorax
pneumonia
asthma/COPD
```
159
most common airway obstruction in adults*
food bolus
160
most common airway obstruction in children*
coins
161
What should you think w/dyspnea at rest AND pleuritic chest pain
PE
162
What presentation is most severe w/dyspnea
orthopnea
163
types of PE
acute: immediately after
subacute: days/weeks after
chronic: pulm htn over years
164
pulmonary embolism
obstruction of pulmonary arteries/branches by thrombus, air, fat, tumor
165
locations of PE
Saddle
Lobar
Segmental and Subsegmental
Clot-in-Transit
166
which locations are the large thrombi
saddle: bifurcation of main pulmonary artery
lobar: uni or bilateral
167
Which PE is more likely to cause pulmonary infarct and pleuritis*
segmental and subsegmental (branches)*
168
Clot in transit PE*
TRAVELS THROUGH HEART
| HIGH MORTALITY!!
169
Effects of massive PE
Right heart failure
cardiogenic shock (arterial hypotension)
(submassive + low risk PEs: normal BP)
170
most common cause of unexpected death in most age groups
PE
171
3rd most common cause of CV death in US
PE
172
High population is at high risk for PE?
Hospitalized patient
| Dx missed 70%!
173
acute PE at high risk for:
recurrence
pulmonary HTN
chronic cor pulmonale
174
where do LE thrombi originate from
valve cusps/bifurcations
| areas of low blood flow!!
175
common causes of fatal PE
axillary and subclavian veins
veins in pelvis
indwelling central venous catheter
176
1/2 of PEs are what
Asymp!
177
RV thrombus has**
double mortality!!
178
cor pulmonale
right sided heart failure from pulmonary HTN (from chronic lung disease like COPD, OSA)
179
Symptoms of PE*
Dyspnea at rest or w/exertion (73%)
| Pleuritic chest pain (66%)
180
Signs of PE*
Tachypnea (70%)
| rales (51%)
181
Patients without what symptoms are unlikely for PE*
Dyspnea, pleuritic chest pain, tachypnea
182
Massive PEs sign
systolic BP <90mmHg or drop in atleast 40mmHg from baseline
JVD
only 4% of PEs byt 20-60% mortality
183
what's the gold standard to Dx DVT
contrast venography
184
Labs to order for PE
D Dimer: pos
| ABG: hypoxemia, resp alkalosis
185
Gold standard to diagnose PE*
Pulmonary angiography
186
1st choice to Dx PE (not gold standard)*
CT pulmonary angiography (spiral)
187
Well's criteria
assess whether there's PE
188
PERC rule
criteria to rule out PE
for pts w/low Well's score
need to fulfill all 8 criteria to rule out PE
189
What you may see on CXR w/PE
Westermark sign: dilation of pulmonary vessels
190
Tx for PE
1. Assess HD stability
2. Anticoagulate to prevent progression
3. Thrombolytic if massive PE/unstable, inject near location
191
preferred anticoagulant for PE
DAOAC (Direct acting oral anticoag): eliquis, xarelto
| -only HD stable pts
192
when should you prophylax for PE
Post-op: esp ortho/pelvic surgery on LE - early ambulation, lovenox, pneumatic compression
planned stasis risks: long flights - ASA
193
what procedure has high mortality in PE
embolectomy
194
how is cystic fibrosis inherited?
autosomal recessive
195
Pathophysiology of cystic fibrosis
defect in CFTR gene --> abnormal Cl transport --> mucus more viscous/sticky to bacteria --> promote infection/inflammation
196
Dx of CF*
Dz in one or more organs
| >/= 60mmol/L sweat chloride**
197
Atypical CF likely present w/
Gi issues
DM infertility
dx >18 yo
198
when is CF typically Dx?
1 yo
199
Presentations of CF
```
Respiratory tract involvement
sinus dz
pancreatic dz
meconium ileus
hepatobiliary dz
musculoskeletal dz
reduced/infertility
```
200
How does CF affect male fertility
> 95% infertile bc defects in sperm TRANSPORT
201
What do most patients eventually get w/CF*
Pseudomonas respiratory infection
202
pulmonary presentation of CF
Dry hacking (non-productive) cough
lung hyperinflation on CXR
Chronic bronchitis
203
Sinus presentation of CF
Chronic nasal congestion
| 10-32% nasal polyps
204
Pancreatic presentation in CF
pancreatic insufficiency --> fat malabsorption!
resultant poor weight gain
deficient in fat/protein, fat-sol vitamins
205
Meconium ileus
bowel obstruction by meconium (stool produced in utero) in infants
only 10-20% occurence byt 80-90% w/this has CF!
206
Advance dz of CF
Distal intestinal obstructive syndrome (DIOS)
| clubbing, bronchiectasis
207
Hepatobiliary presentation in CF
Focal biliary cirrhosis: inc serum alk phos, lobular hepatomegaly from thickened bile
12% cholelithiasis
208
Musculoskeletal presentation in CF
Reduced bone mineral density
| rare: hypertrophic osteoarthropathy: abnormal prolif
209
hand in bucket sign of CF
Aquagenic wrinkling of palms
white plaques
rare
210
How to dx non-classic CF (sweat chloride normal)
nasal potential difference
| or DNA analysis
211
Tx goals for CF
Maintain lung function
control infections
clear mucus
nutritional
212
Tx for CF exacerbations
chest percussion and postural drainage:
bronchodilator 1st
clap on chest/back or vest
loosen mucus
213
CF medication
```
pancreatic enzymes
bronchodilators
vitamin D
mucolytics: dornase alfa
CFTR potentiators
antibiotics
```
214
Management/follow-up for CF
Monitor every 2-3 months
| resp culture every visit
215
How to differentiate between chronic bronchitis and emphysema on PFT?
emphysema: INC Residual Volume
216
How to differentiate between asthma and emphysema w/DLCO?
asthma: inc DLCO
emphysema: dec DLCO
(DLCO unaffected in Chronic bronchitis)
217
TB w/Night sweats, think...
HIV
218
Latent TB on CXR
Ghon Lesion --> enlarged hilar nodes
| or normal
219
Ghon lesion
fibrotic, calcified lesion
| contain: T cell, macrophage, central necrosis
220
Reactivation risk of TB in HIV pts
10% risk every year!
221
How does active TB infection spread?
cavitary open into bronchi, spread by cough
222
Where do you first see calcifications in TB?
Apices
223
Late sign of TB*
Hemoptysis
| Rasmussen's Syndrome
224
What does PPD do?
only screens for TB exposure
| test only at risk pts!
225
How long do you need to isolate pts w/TB
Atleast 2 weeks after Tx or until 3 sequential sputum neg
226
What's the minimum initial therapy for TB
3 drugs minimum initially
227
How long is TB medication taken for ?
6-9 months
228
1st line agents for TB*
ISONIAZID
RIFAMPIN
ETHAMBUTOL
PYRAZINAMIDE
229
Causes of false negative in PPD
Anergy, steroids, HIV, malnutrition
230
Most common causes of community acquired pneumonia
s. pneumoniae
H. influenzae
Mycoplasma
viruses
