Pulm

Question 1

ARDS

Ventilation setting: Respiratory rate, tidal volume, FI02, PEEP

Which affect PaO2?

Which affect PaCO2?

Answer 1

PaO2: FiO2 and PEEP

• too much FiO2–> hyperoxia; goal is to maintain saturation at 92-96% (PaO2 less than 90)
• FiO2 less than 60% considered safe
• Maintain PEEP >10 cmH2O to prevent alveolar collapse

PaCO2: respiratory rate and tidal volume

• lower tidal volumes better for ARDS to prevent alveolar overdistension
• permissive hypercapnia- mild hypercapnia resp acidosis okay to allow for lower tidal volumes

Question 2

Tx for patient with massive hemoptysis (>600 ml blood, >100 ml/hr)

Answer 2

Bronchoscopy

Question 3

Findings in Cor Pulmonale

Answer 3

Right-sided heart failure due to primary pulmonary disease:

• dyspnea/fatigue on exertion
• exertional angina/syncope
• JVD with hepatojugular reflux
• peripheral edema
• Loud P2 2/2 pulmonary HTN
• hepatomegaly with pulsatile liver
• RVH, tricuspid regurgitation, right atrial enlargement
• Elevated pulmonary artery systolic pressure (>25)

Question 4

Most effective tx for allergic rhinitis

Answer 4

Glucocorticoid nasal spray (fluticasone, mometasone)

Question 5

Exudative Effusion causes

Answer 5

Empyema, chylothorax (disruption of thoracic duct, increased triglycerides), malignancy, TB

Question 6

Transudative effusion causes

Answer 6

oncotic/hydrostatic pressure differentials i.e nephrotic syndrome (decreased oncotic), increased pulmonary vascular pressures (cardiac failure, PE- increased hydrostatic)

Question 7

Alpha-1 Antitrypsin deficiency presentation

Answer 7

COPD-like illness in young patient, can also effect liver (elevated LFTs), and skin

Question 8

Exudative effusion pleural fluid characteristics (protein, leukocytes, color)

Chylothorax

Empyema

Tuberculosis

Answer 8

Chylothorax- obstruction of thoracic duct–> lymphocytic leukocytosis, turbid or milky white

Empyema- acute sxs (pleuritic chest pain, fever), neutrophilic leukocytosis (>50,000)

Tuberculosis- high protein (>4), lymphocytic leukocytosis, low glucose (<60), yellow pleural fluid, elevated LDH, low pH

Question 9

SVC syndrome from lung malignancy

Answer 9

Headaches worse when leaning forward, JVD but lack of peripheral edema, facial/upper extremity swelling, prominent collateral veins

Question 10

Decompressing tension pneumothorax increases what?

Answer 10

Venous return (SVC gets compressed during tension pneumothorax which prevents venous return)

Question 11

Left-sided large unilateral pleural effusion in setting of cancer/weight loss

Answer 11

Malignant pleural effusion (exudative)
- CHF would typically cause bilateral transudative pleural effusion and even if it were unilateral it would be on the RIGHT side

Question 12

Complication of thoracentesis

Answer 12

Hemothorax - leads to decreased left ventricular preload

Question 13

Tx of normal vs. severe PCP

Answer 13

Normal: TMP-SMX

Severe (PaO2<70, pulse oximetry<92%)- TMP-SMX with concomitant steroids

Question 14

Fat embolism vs. pulmonary contusion (both can present with ground glass opacities, tachypnea, hypoxemia after MVC and femur repair)

• Timeline
• Sxs

Answer 14

Fat embolism: 12-72 hours after injury; neuro sxs and petechial rash

Pulmonary contusion; <24 hours after crash (usually even sooner); alveolar hemorrhage/edema worsened by fluid resuscitation; non lobular infiltrates

Question 15

Pathophys of pulmonary hypertension

Answer 15

Pulmonary vascular remodeling 2/2 chronic intravascular hemolysis (intimal hyperplasia, medial hypertrophy)–> increased PVR

tx w/ epoprostenol (prostaglandin), lasix