MKSAP Pulm/Crit Care Flashcards
What presents as middle and upper zone thin walled cysts with accompanying nodules in smokers, and is typically associated with PH?
Pulmonary Langerhans cell histiocytosis
What presents with cough and dyspnea, and centrilobular micronodules on imaging and GGOs in upper lung predominant distribution in smokers, and has tan pigmented macrophages on biopsy?
Respiratory bronchiolitis associated ILD
What is the management for solid lung nodules <6 mm, 6-8 mm, and >8 mm?
<6 mm CT at 12 months if high risk
6-8 mm CT at 6-12 months, then 18-24 months
>8 mm consider CT at 3 months, PET/CT, or tissue sampling
What 4 malignant tumors occur in the anterior mediastinum?
Thymoma, thyroid, lymphoma, and teratoma/germ cell tumor
What medication should all patients with asthma have?
Inhaled glucocorticoid
Can combine with LABA for PRN use or daily use, or with an as needed SABA
What is the MOA for Omalizumab and Mepolizumab/Reslizumab?
- Anti-IgE - used in patients w/ asthma with elevated IgE (30-700) and sensitivity to allergens
- Anti-IL-5, reduces eosinophil levels - used in patients w/ eosinophil levels >150 cells/microL
What is the criteria for O2 therapy in COPD?
PaO2 55 mmHg or less, or O2 sat 88% or less
PaO2 59 mmHg or less, or O2 sat 89% or less if patient has cor pulmonale, HF, or erythrocytosis
What lung disease presents w/ “crazy paving” pattern on chest CT and BAL shows proteinaceous material in and around alveolar macrophages?
Pulmonary alveolar proteinosis
Which lung disease presents in smokers with cough and dyspnea, and w/ basal predominant and peripheral predominant ground glass opacities with occasional cysts?
Desquamative interstitial pneumonia
How does acute hypersensitivity pneumonitis present - sx and on CT?
Flu-like illness - fevers, cough, fatigue within 12 hours of exposure
Ground glass opacities; centrilobular micronodules that are upper and mid lung predominant
What are two therapies for IPF?
Nintedanib and Pirfenidone
How does IPF present on CT?
Basal and peripheral-predominant septal line thickening w/ traction bronchiectasis and honeycomb changes
How does NSIP present on CT?
Bilateral lower lobe reticular changes, ground glass opacities (diffuse or basal predominance, immediate subpleural/peripheral sparing); no honeycombing
What presents w/ cough, fever, and malaise for 6-8 weeks, consolidation or GGOs, peripheral nodules and nodules along the bronchovascular bundle? What is the treatment?
Cryptogenic organizing pneumonia
Steroids
What presents with upper zone predominant w/ centrilobular or perilymphatic nodules, and eggshell calcification in hilar lymph nodes? What is found in BAL during the acute phase of this disease?
- Chronic simple silicosis
2. Milky effluent from BAL in acute silicosis
What are some causes of pleural fluid acidosis? Name 4.
Parapneumonic, malignancy, rheumatoid pleuritis, lupus pleuritis, esophageal rupture
What are some causes of glucose <60 in pleural fluid? Name 5.
Malignancy, empyema, parapneumonic effusion, TB, esophageal rupture, rheumatoid pleuritis, lupus pleuritis
What are the 5 classes of pulmonary hypertension? Name at least 3 causes of class 1 & 5.
1: pulmonary arterial - heritable, connective tissue diseases, HIV, schistosomiasis, drugs, toxins, portal HTN
2: left heart disease
3: lung disease
4: CTEPH
5: multifactorial - sarcoidosis, sickle cell, idiopathic
What is the most sensitive imaging study to diagnose CTEPH? What medication can be used after thromboendarterectomy in CTEPH for persistent PH?
- V/Q scan
2. Riociguat - vasodilator
What are some drugs that can lead to group 1 pulmonary hypertension? Name 5.
Interferon alfa, dasatinib, imatinib, methamphetamine, cocaine, appetite suppressants (phentermine, fenfluramine)
What is the MOA of bosentan/ambrisentan? Epoprostenol/treprostinil/iloprost?
- Endothelin-1 receptor antagonist
2. Prostacyclin analogues
What is the preferred anti-coagulant in pulmonary arterial HTN?
Warfarin
What are therapies in the absence of supplemental oxygen and descent for people w/ high altitude pulmonary edema?
Nifedipine, Sildenafil, Tadalafil
What are two treatments for acute mountain sickness besides descent?
Acetazolamide, Dexamethasone
Using the apnea-hypopnea index what is classified as mild, moderate, and severe OSA?
Mild: 5-15/hour
Moderate: 15-30/hour
Severe: >30/hour
What is the Braden scale?
Clinical criteria used to define risk of pressure injury in ICU
What values FVC is suggestive of neuromuscular weakness?
FVC >20% decrement in supine position compared with upright position
What kind of poisoning occurs with house fires and can present w/ HA, anxiety, nausea, metallic or bitter almond odor/taste? What are 3 treatment options?
- Cyanide poisoning
2. Hydroxocobalamin (preferred), Amyl nitrite, sodium thiosulfate
At what levels of carboxyhemoglobin should hyperbaric oxygen be used on carbon monoxide poisoning?
25-40% or higher, or for victims with lower levels who are pregnant
At what levels of methemoglobin should methylene blue be used?
20-30% or higher
What is the qSOFA criteria?
RR>22, SBP <100, AMS
qSOFA score of 2 or greater predicts increased mortality
What is the two criteria for diagnosing septic shock?
Hypotension requiring pressors to maintain MAP >65 mmHg, serum lactate >2 after adequate volume resuscitation
What is the goal BP for patients w/ aortic dissection? Patients with severe pre-eclampsia or eclampsia?
- SBP <120 mmHg
2. SBP <140 mmHg
What is the goal BP in first hour in hypertensive emergency? Then next 2-6 hours?
- SBP reduced by no more than 25% in 1st hour
2. 160/100 mmHg within next 2-6 hours; then normal during following 24-48 hours
What is the management for heat stroke?
Evaporative cooling (sprayed water and cooling fans) May need ice immersion for exertional heat stroke in younger patients
Which has hyperreflexia and myoclonus - neuroleptic malignant syndrome or serotonin syndrome?
Serotonin syndrome
What is the management for mild vs. moderate vs. severe hypothermia?
Mild - cover with insulating material
Moderate - warm blankets, forced heated air blanket
Severe - body cavity lavage w/ warm fluids
What condition does scooped out inspiratory loop suggest? Narrowed inspiratory & expiratory loops?
- COPD/Asthma
2. Restrictive lung disease
What condition does flattened inspiratory loop suggest? Flattened expiratory loop? Flattened inspiratory & expiratory loops?
- Intrathoracic obstruction
- Extrathoracic obstruction
- Fixed obstruction (tracheal stenosis)
What causes reduced DLCO + reduced lung volumes? Reduced DLCO + normal lung volumes? Reduced DLCO + airflow obstruction? Increased or normal DLCO + obstruction? Increased DLCO and normal lung volumes?
- Pulmonary fibrosis
- Anemia, pulmonary vascular disease
- Emphysema, bronchiectasis
- Asthma
- Pulmonary hemorrhage, left to right shunt, polycythemia
How do you diagnose exercise-induced asthma if the patient has normal spirometry?
Bronchoprovocation test
What condition is associated w/ injury to small airways, presents w/ dyspnea w/o improvement to bronchodilators, and can be associated with lung or stem cell transplant?
Bronchiolitis obliterans
What condition should be considered in patients w/ CF and acute abdominal pain?
Intestinal intussusception
What condition should be ruled out in a patient w/ nephrotic syndrome and pleural effusion?
PE since this often occurs in patients w/ nephrotic syndrome
In the setting of diuresis what can be used to make diagnosis of transduative fluid in the pleural space?
Serum to pleural fluid albumin gradient >1.2 g/dL
What condition should be considered when chylothorax is diagnosed in a pre-menopausal woman? What is the tx for this condition?
- Pulmonary LAM (lymphangioleiomyomatosis)
2. Sirolimus
What mean pulmonary artery pressure and systolic pulmonary artery pressure is diagnostic of pulmonary HTN?
> 25 mmHg
>40 mmHg
What condition is associated w/ hemoptysis, mucocutaneous telangiectasias, evidence right-to-left pulmonary shunts (hypoxemia, polycythemia, clubbing, stroke, brain abscess), and/or pulmonary nodules?
Pulmonary AVMs
What is the management for pure ground glass nodule <6 mm vs >6 mm? Part solid nodule?
- No follow up if <6 mm; CT at 6-12 months if >6 mm, then CT every 2 years until 5 years
- No follow up if <6 mm; CT at 3-6 months if >6 mm and part solid, then annual CT for 5 years
What masses are found in the middle mediastinum? Posterior mediastinum?
- Lymphadenopathy, cysts (pericardial, bronchogenic, esophageal)
- Neurogenic tumors - schwannomas are most common in adults
What is the management for minimally symptomatic patients with mild OSA?
Weight loss
When should mechanical or chemical pleurodesis be considered in pneumothorax?
After first episode of secondary spontaneous pneumothorax, or after 2 episodes of primary spontaneous pneumothorax
What has been found to lower rate of surgical referral and decrease hospital stay of patients w/ empyema?
tPA-DNase +/- streptokinase
What is the management for benzodiazepine overdose?
Assurance of adequate ventilation, monitor for agitation
Flumazenil is not recommended as it can precipitate seizures
What subgroup of patients is roflumilast indicated for? What are some side effects?
- Severe COPD associated w/ chronic bronchitis and hx of recurrent exacerbations
- Diarrhea, nausea, weight loss, headaches, psych effects (anxiety, depression, insomnia); contraindicated in liver impairment; has significant drug interactions
How does aspirin-exacerbated respiratory disease present? What is the management?
Severe persistent asthma, aspirin sensitivity, and hyperplastic eosinophilic sinusitis w/ nasal polyposis
Tx: stop NSAIDs or ASA, start montelukast +/- prednisone
What are the management options for recurrent pleural effusions in setting of malignancy?
Indwelling pleural catheter - shorter hospital stay and less dyspnea when compared to talc pleurodesis
Talc pleurodesis - associated w/ increased pain and longer hospital stay
Repeat thoracentesis if poor prognosis and slow reaccumulation of fluid
What is the initial step in evaluation of a patient with excessive daytime sleepiness?
Wrist actigraphy (measures movement and ambient light to estimate sleep periods during 1-2 week time frame) or sleep diary
What is the first line therapy for progressive DPLD and systemic sclerosis?
Mycophenolate
How do you calculate RSBI and what number is a predictor of successful extubation?
Respiratory rate/tidal volume (in liters)
<105 is predictive of successful extubation
What are strategies for correcting auto-PEEP, which causes airtrapping? Name 3.
Reducing minute ventilation (reduce tidal volume or respiratory rate), increase expiratory time, or use bronchodilators/inhaled corticosteroids to relieve airway obstruction
How should vent settings be modified if pO2 is low? pCO2 is high? pcO2 is low?
- Increase PEEP
- Increase RR or increase tidal volume
- Decrease RR or decrease tidal volume or increase sedation
What presents w/ dyspnea on exertion or orthopnea in the setting of an elevated hemidiaphragm and >10% decrease in forced vital capacity when in supine position? What conditions is it associated with? How is it diagnosed?
- Unilateral diaphragmatic paralysis
- Phrenic nerve injury under cardiac surgery, neck surgery, tumor, trauma, viral infection (herpes, polio)
- Fluoroscopic “sniff” test - patient sniffs forcefully under fluoroscopy, the normal diaphragm moves downward during inspiration while paralyzed size has paradoxical upward movement
What presents w/ fever, dyspnea, cough, pleuritic chest pain, leukocytosis, +/- pleural effusion in a patient 4-12 weeks after radiation? What is the treatment?
- Acute radiation pneumonitis
2. Prednisone for 2 weeks, then gradual taper over 3-12 weeks
What is the FEV1 and how often do daytime symptoms and nighttime symptoms occur in the following: mild persistent asthma, moderate persistent asthma, severe persistent asthma?
Mild: symptoms more than twice a week but no more than once a day; nighttime symptoms more than twice a month; FEV1 >80%
Moderate: daily symptoms; nighttime symptoms at least once a week; FE1 60-80%
Severe: daily symptoms; frequent nighttime symptoms; FEV1 <60%
What does a drop in BP of >10-12% on inspiration w/ mechanical ventilation suggest?
Hypovolemia
What is the first step in diagnosis of ABPA? How is the diagnosis confirmed? What is the treatment?
- Skin prick test
- Serum IgE >417 IU/mL or >1000 ng/mL and positive serum antibodies against aspergillus
- Itraconazole and steroids
When can neuroleptic malignant syndrome present besides as an effect of anti-psychotic medications?
In parkinson disease after withdrawal, dose reduction, or a switch in dopamine agents (referred to as parkinsonism-hyperpyrexia syndrome)
What presents with cyanosis, pulse ox ~85%, normal paO2, dark blood after exposure to oxidizing substances (dapsone, nitrites, topical/local anesthetics)?
Methemoglobinemia
