Pleural effusion/TFR/PH/sarcoidosis Flashcards
(101 cards)
1
Q
Which respiratory disease is frequent in sarcoidosis ?
A
Co existent asthma is common
2
Q
Causes of increased DLCO ? Name 4.
A
- Pulmonary hemorrhage/polycythemia
- LV failure
- Asthma
- Obesity
3
Q
Causes of isolated decrease in DLCO ?
Name 3.
A
- Pulmonary hypertension
- Early ILD/emphysema
- Anemia
4
Q
Causes of mixed obstructive and restrictive process ?
A
Obese smoker
Bronchiectasis
Sarcoidosis
5
Q
DLCO : anemia ?
A
Decreased
6
Q
DLCO : asthma ?
A
Increased
7
Q
DLCO : emphysema ?
A
Decreased
8
Q
DLCO : LV failure ?
A
Increased
9
Q
DLCO : obesity ?
A
Increased
10
Q
DLCO : pulmonary hemorrhage ?
A
Increased
11
Q
DLCO : pulmonary hypertension ?
A
Decreased
12
Q
Do you need bx in case of asx bilat hilar adenopathy ?
A
No recommendations for or against
Close clinical follow up required if no biopsy
13
Q
Does primary spontenous PTX reoccur ?
A
Yes reoccur 25-50%, most in first year
14
Q
Driving guidelines for OSA : depending on severity of OSA ?
A
Severity of OSA alone is NOT a reliable predictor and should not be used in isolation to assess fitness to drive
15
Q
Driving guidelines for OSA, when should pt be disqualified ?
A
- Excessive sleepiness during the day
- Crash associated with falling asleep in the past five years and no therapy since
- Non compliant with tx (compliant : ≥ 4h > 70% of nights in past 30 days)
16
Q
Duration of prednisone tx for sarcoidosis ?
A
1-3 months at initial dose then SLOW taper to 10mg/d (total tx 1y)
If relapse : MTX
17
Q
How do you diagnose mesothelioma ?
A
Usually cannot be diagnosed from pleural fluid and requires pleural biopsy
18
Q
How do you dx UACS : upper airway cough syndrome ?
A
- Confirmed by response to tx with 1st generation antihistamine / decongestant (bronpheniramine/SR pseudoephedrine)
- Sinus imaging if does not improve
19
Q
How do you manage acute hemoptysis ?
A
- ABC
- Position patient in decubitus position to protect UNAFFECTED LUNG
- Hold anticoag + correct coagulopathy
- Flexible bronchoscopy can be used for localization prior to embolization or imaging if stable enough
20
Q
How many sarcoidosis patients will have remission at a decade ?
A
Two thirds
21
Q
How often should you screen scleroderma patients for PH ?
A
Annually
22
Q
How should you treat cutaneous sarcoidosis ?
A
If low burden : topical steroids, intralesional steroids
If severe : steroids, infliximab
23
Q
How should you treat erythema nodosum in sarcoidosis ?
A
Usually good response to NSAIDs alone
24
Q
How should you treat fatigue in sarcoidosis pt ?
A
Pulmonary rehab is 1st line tx for fatigue
25
Hypoxemia : when should you prescribe home O2 ?
- PaO2 ≤ 55%
- Resting SaO2 ≤ 88%
- PaO2 = 55-59 with
Cor pulmonale or
Pulmonary hypertension or
Persistent erythrocytosis (Hct > 55%)
26
Is relapse common in sarcoidosis ?
After one year of spontaneous remission, relapse is very uncommon
27
Multiple solid nodules : what f/u for low risk patients ? high risk patients ?
LOW RISK
<6mm : none
6-8 and >8 : 3-6m then consider CT at 18-24
HIGH RISK
<6 : optional CT 12m
6-8 and > 8 : 4-6m AND CT at 18-24m
28
PH : which exams should you ask for ?
ETT, PFTs, 6MWT
CT pulm angiogram + V/Q
Abdo US to screen portal HTN
Sleep study
Right heart catheterization
29
PH : which labs should you ask for ?
CBC lytes LFT TSH BNP
Viral hepatitis HIV connective tissus disease
30
PH associated with CTD : which group ?
Group 1
31
PH secondary to schistosomiasis, which group ?
Group 1
32
Sarcoidosis : for skin disease refractory to steroids, which agent should you consider ?
Infliximab
33
Sarcoidosis : stage and chest findings ?
1 : bilat adenopathy
2: adenopathy + parenchymal lesions
3: parenchymal lesions with no ADP
4: fibrosis
34
Sarcoidosis : stage and rate of spontaneous remission ?
Stage 1, 55-90% (75)
Stage 2, 40-70% (50)
Stage 3, 10-30% (25)
Stage 4, 0-5%
35
Should you give steroids to sarcoidosis patients ?
Steroids accelerate remission at the cost of higher risk of recurrence (60-70%)
Indicated if end organ failure from granulomatous inflammation
Dose is 20-40 mg
36
Single solid lung nodule : what f/u if low risk patient ? what if high risk patient ?
LOW RISK
< 6mm : no f/u
6-8mm: 6-12 months then consider 18-24
> 8mm: 3 months, PET, CT, bx
HIGH RISK
<6mm : optional CT 12m
6-8mm : 6-12m AND 18-24
> 8mm : 3 m, PET, CT, bx
37
Treatment indications for OSA ?
- Sx of excessive sleepiness or impaired sleep related QOL
- Comorbid HTN
- Asx pts with severe OSA (AHI > 30)
38
What % of patients present with extra pulmonary sarcoidosis ?
Usually involve the lung (>90%) but up to 30% present with extrapulmonary sarcoid
39
What are absolute contraindications to metacholine challenge ?
Name 4 points.
- Severe airflow limitation FEV1 < 50% or
<1L
- Recent MI or stroke in last 3 m
- Uncontrolled HTN, SBP > 200/100
- Known aortic aneurysm
40
What are high risk features in PTX, indication of chest drain ?
Tension, significant hypoxia, bilateral, >50 with smoking history, hemopneumothorax
41
What are predictors of adverse periop pulmonary events ? Name 3.
- Surgical site (aortic > intrathoracic > upper abdo > abdo)
- Age
- Pre existing lung disease
42
What are relative contraindications to metacholine challenge ? Name 3 points.
- Moderate airflow limitation FEV1 < 60% or < 1.5L
- Pregnancy or nursing mothers (metacholine is category C)
- Use of cholinesterase inhibitor (myesthenia gravis)
43
What are risk factors of primary spontaneous pneumothorax ?
RF : smoking, family history, Marfan syndrome, thoracic endometriosis
44
What are the cutaneous involvement in sarcoidosis ?
Common in 1/3 patients
Lupus pernio, erythema nodosum…
45
What are the daily life recommendations for PTX ?
Against scuba lifelong
No air travel until 7d after PTx resolves on CXR
46
What are the diagnosis criteria for OSA ?
Defined by presence of both :
- Sx
- Objective testing of > 5 apnea/hypopnea events during sleep monitoring
Mild 5-15 events/h
Moderate 15-30
Severe > 30
47
What are the indication of tx in sarcoidosis ?
Pulmonary : bothersom sx, deteriorating lung function on PFTs, development of PH
Extrapulm : eye disease, CNS, cardiac involvement, severe skin disease, hypercalcemia, sx liver disease
Fatigue alone is not an indication.
ICS can be used for mild sx and stable PFTs
48
What are the indications of intercostal drain for parapneumonic effusion ?
- drainage of frank pus
- pH <7.2 [high risk of complicated parapneumonic effusion]
- pH 7.2-7.4 and LDH>900 (consider based on clinical scenario, glucose <4.0, pleural enhancement)
- If pH not available, glucose <3.3
But R/O other causes of low pH such as rheumatoid before.
49
What are the Light’s criteria ?
Pleural fluid is an exudate if ≥ 1 of the following criteria are met :
- Protein in fluid : serum > 0.5
- LDH in fluid : serum > 0.6
- Pleural fluid LDH > 2/3 the upper limit of normal value for serum LDH
50
What are three causes of diaphragmatic weakness ?
- Trauma or surgery
- Mechanical ventilation
- Myopathy / neuropathy
51
What do you see on BAL for sarcoidosis ?
Low CD8 and elevated CD4/CD8 ratio
52
What does PFTs show in sarcoidosis ?
Can show anything +/- reduced DLCO
53
What investigation necessary in case of group 4 PH ?
Group 4 : chronic thromboembolic pulmonary hypertension
APLAS testing for all and if + warfarin
Refer for pulm thromboendarterectomy, anticoagulation
54
What is DDX of hypoxemia with normal AA gradient ?
- Hypoventilation (check PaCO2)
- Low inspired FiO2 (altitude)
55
What is Heerfordt syndrome ?
– Anterior uveitis
– Parotid enlargement
– Fever (uveoparotid fever)
– Facial palsy
56
What is Lofgren syndrome ?
– Bilateral hilar adenopathy
– Erythema nodosum
– Migratory polyarthralgias
– Fever
Seen primarily in women
High likelihood of spontaneous remission
57
What is necessary pre operatively for patients with lung cancer being considered for surgery ?
They need predicted post op FEV1 and DLCO
If BOTH > 60% predicted : low risk
If EITHER < 60 % : high risk
58
What is seen on pathology of sarcoidosis ?
Noncaseating granulomas in involved organs
59
What is the cause of chylothorax ?
Malignancy #1 and most commonly lymphoma
Trauma/surgery, TB, LAM (young woman with cystic lung disease/PTX)
60
What is the cause of low glucose in pleural fluid ?
< 1 mmol : RA, empyema
1-3 mmol : malignancy, TB, SLE
61
What is the cause of lymphocytosis in pleural fluid ?
> 80% TB vs lymphoma
TB often AFB - and would suggest sputum AFB
Can ask for pleural fluid ADA (adenosine deaminase) and IFN gamma tests
62
What is the DDX of clubbing ?
- Neoplastic intrathoracic disease (bronchogenic carcinoma, mesothelioma)
- Suppurative intrathoracic disease (bronchiectasis also)
- Diffuse pulmonary disease
- Cardiac disease (IE also)
- GI like IBD
- Metabolic like Graves
63
What is the DDX of fixed upper airxay obstruction ?
Glotic stenosis (prolonged IET), subglotic stenosis (Wegner’s, sarcoid, polychondritis)
SEND TO ENT
Eg: large goitre
64
What is the DDX of flattening of inspiratory curve ?
= variable extrathoracic obstruction
Vocal cord dysfunction / paralysis
65
What is the DDX of hypoxemia with widened A-a gradient ?
- V/Q mismatch (improves with 100% FiO2) : COPD, PE
- Shunt (does not improve completely with 100% FiO2)
- Diffusion abN (ILD)
For shunt : intracardiac with R->L shunt (eg PFO, ASD, VSD), intrapulmonary (ie pulmonary AVM), physiologic(ie severe pneumonia with perfused alveoli that are not ventilated)
66
What is the DDX of variable intrathoracic obstruction ?
= flattening of expiratory curve
Tracheomalacia of intrathorac airway
67
What is the definition and management of secondary spontaneous PTX ?
Presence of lung disease, COPD +++
Even small ones can lean to sx +++ most likely will require chest drain
Unlikely to spontaneously resolve
68
What is the definition of chylothorax?
TGs > 1.24 mmol + CM in pleural fluid
69
What is the definition of low glucose in pleural fluid ?
Glc < 3, eff/serum < 0.5
70
What is the definition of massive hemoptysis ?
Variable definitionsm 200-600cc / 24h
71
What is the definition of pulmonary hypertension ?
Mean pulmonary artery pressure > 20 on right heart catheterization and PVR > 2 WU is consistent with pre capillary PH
72
What is the etiology of pleural fluid eosinophilia?
Significative if > 10%
Etiology depends on hx :
- Asbestos related (BAPE)
- drugs (ex : nitrofurantoin)
- malignancy (lung)
- infection (parasites)
- PE, eGPA
73
What is the gold standard for TB pleural effusion ?
Tissue sampling for C&S
74
What is the follow up for PTX ?
Close follow up required : every 2-4 days if conservative care. Follow up 2-4 weeks for all
75
What is the formula for A-a gradient ?
A-a = [150- (PaCO2/0.8)]– PaO2
Approximate Normal A-a Gradient for reference: (Age (yrs)/4)+4
76
What is the most helpful finding for OSA ?
Nocturnal choking / gasping (LR 3.3)
Snoring is non specific
77
What is the most specific and most sensitive test for diagnosis of diaphragm weakness / paralysis ?
Most SENSITIVE : MIP
Most SPECIFIC : ultrasound or FVC
A normal MIP excludes respiratory muscle weakness (good neg predictive value) but low MIP does not confirm the presence of resp muscle weakness as poor effort / technique common
MIP more sensitive than supine FVC
78
What is the ocular manifestation of sarcoidosis ?
Anterior uveitis
79
What is the sensitivy of pleural fluid for cytology ?
Beware if suspicion of malignant effusion, sensitivy of cytology only 46%
Can repeat thoracentesis ONCE for increased sensitivity as increases to approx 80%
(at least 25cc, preferrable 50cc)
80
What is the tx of group 1 PH ?
- Vasoreactivity testing to determine if candidate for CCB
- PDE5i or riociguat
- Endothelin receptor antagonist
- Prostanoid
- Influenza/pneumococcal/COVID vaccines
- Supervised exercise
- Avoid pregnancy
81
What is the tx of hemoptysis ?
Arterial embolization # 1 if available
82
What is the tx of OSA ?
- Weight loss
- CPAP / APA, also for asx if comorbidities (HTN), AHI > 30 or critical occupation
83
What is the tx of primary spontaneous PTX ?
Conservative if asx or minimally sx (REGARDLESS OF SIZE)
If sx, look for high risk features : tension, significant hypoxia, bilateral, >50 with smoking hx, hemopneumothorax : if present chest drain
84
What is the typical cardiac involvement in sarcoidosis ?
Heart block
Screen with ECG +/- echo, them cardiac MRI and PET if concern
PH is described
85
What is the typical neurologic involvement in sarcoidosis ?
Cranial nerve palsy
86
What medical conditions are contraindications to PFTs ?
Hemoptysis
Pneumothorax
Unstable cardiovascular status including recent MI
Aneurysms (thoracic, abdominal, cerebral)
87
What should you look for in labs for sarcoidosis ?
- anemia of chronic disease
- lymphopenia
- thrombocytopenia
- hypercalcemia and add 1,25 OH D
88
What should you think of in case of restrictive pattern varying with position ?
Diaphram dysfunction
Vital capacity decreases with lying down by > 10%
Post op scenario of CABG or ALS
89
What should you think of in case of widening of tracheal strip on chest XR ?
Aortic dissection
90
What tx for parapneumonic effusion ?
- See criteria for intercostal drain + sample if > 1cm
- ATB : Beta lactams preferred but if no culture, treat for CAP + anaerobes
Usually at least 3 WEEKS based on clinical and radiographic respond
91
When should you do a thoracentesis for pleural effusion ?
- Suspect exudate
- Cause unclear
- Parapneumonic effusion
(but if less than 1cm on lateral decubitus in context of pneumonia, can follow with RX)
92
When should you suspect PH ?
Dyspnea on exertion, isolated reduced DLCO
93
When should you test for PH in case of PE ?
If dyspnea or exercise intolerance after at least 3 months of uninterrupted anticoagulation post acute PE assess for CTEPH with echo and V/Q lung scan
94
When should you think of carcinoid tumour in context of hemoptysis ?
Young non smoker with lung collapse (endobronchial tumors, can fill lumen)
Preo workup if syspect carcinoid syndrome, TTE to R/O carcinoid heart disease
95
Which extrapulmonary sarcoid need urgent tx ?
Heart, CNS, eyes
96
Which method is better for bx in sarcoidosis patients ?
EBUS guided lymph node sampling rather than mediastinoscopy
97
Which situation in sarcoidosis do NOT require bx ?
Lofgren, Heerfordt, lupus pernio
98
Which surgeries are a contraindications to PFTs?
Recent eye surgery like cataracts
Recent thoracic or abdominal surgery
99
Quel est le gradient A-a normal ?
5-15
100
Chest xray white out differential :
- trachea pulled towards whiteout
- vs pushed away
- vs central
Pulled towards : pneumonectomy, total lung collapse
Pushed away : pleural effusion
Central: consolidation
If bilat: pulmonary edema
101
