Pulm

Question 1

Acute Bronchiolitis defintion, MCC, sx, dx, tx

Answer 1

*infection/inflammation of bronchioles

*MCC: RSV, rhinovirus, influenza, parainfluenza, adenovirus
*MC in first 2 months- 2 years of life

Risks: premature (<37wk), lack of breast feeding, <6 months, smoke exposure, crowded conditions

*Viral Prodrome (fever, URI sx for 1-2 days) 🡪 respiratory distress

*Expiratory wheeze, crackles
*Hyperinflation, tachypnea
*Increased RR, grunting, intercostal retractions, nasal flaring

*Clinical diagnosis
*Nasal swab

*CXR: nonspecific
increased bronchovascular markings hyperinflation

Supportive
*fluids, suction, antipyretics
*Bronchodilators

Question 2

Epiglottitis defintion, MC ages, sx, dx, tx

Answer 2

*severe, potentially life-threatening inflammation of the epiglottis

MC children 3mo-6yrs; males 2x MC

3 Ds: dysphagia, drooling, distress
*fever, odynophagia
*inspiratory stridor
*dyspnea, hoarseness
*muffled “hot potato” voice
*tripod position

dx: Laryngoscopy – definitive (performed when securing the airway)
*cherry-red epiglottis w/ swelling
Lateral cervical x-ray:
*thumbprint sign

tx: Maintaining the airway most important component of management
Dexamethasone – airway edema
Antibiotics:
*ceftriaxone, cefotaxime
*+/- ampicillin, penicillin, or vancomycin

Question 3

Acute Respiratory Distress Syndrome defintion, sx, dx, tx

Answer 3

Acute, diffuse inflammatory form of lung injury & respiratory failure due to a variety of causes

sx: *acute dyspnea
*hypoxemia *refractory to O2

dx: CXR: bilateral diffuse pulmonary infiltrates
-spares the costophrenic angles

PaO2/FIO2 ratio <300

PCWP <18mm *>18mm seen in cardiogenic pulm edema

tx: Noninvasive or mechanical ventilation
*CPAP w/ full face mask
*PEEP
*low tidal volume

Treat the underlying cause

Question 4

RSV defintion, sx, dx, tx

Answer 4

MCC of lower respiratory tract infections in children worldwide; virtually all children contract it by age 3

Leading cause of pneumonia & bronchiolitis in infants

sx: *rhinorrhea
*wheezing/cough *can persist months
*low-grade fever
*nasal flaring & retractions
*nail bed cyanosis

dx: Nasopharyngeal secretions RSV antigen test
CXR: diffuse infiltrates

tx: supportive
Indications for hospitalization: moderate tachypnea w/ feeding difficulties, visible retractions, & oxygen desaturation
*supportive: albuterol via nebulizer, antipyretics, humidified oxygen
*steroids (controversial)
*sxs resolve within 5-7d

Question 5

Asthma defintion + atopic triad

Answer 5

Asthma: chronic inflammatory disease characterized by bronchial hyperresponsiveness, episodic exacerbations, & reversible airflow obstruction

atopic triad: asthma, allergic rhinitis, eczema

Question 6

Allergic vs nonallergic asthma

Answer 6

Allergic Asthma (MC): begins w/ intermittent symptoms
➀ airway hyperreactivity
in childhood & usually associated w/ atopy
➁ inflammation
▪︎IgE-mediated type 1 hypersensitivity to an allergen ➂ bronchoconstriction
▪︎mast cell degranulation & histamine release

Nonallergic: onset >40yo, not
related to atopy, poor response to standard treatment

Question 7

Aspirin induced asthma

Answer 7

Samters triad
» asthma
» chronic rhinosinusitis w/ nasal polyps
» sensitivity to ASA & other NSAIDs

chronic, dry cough w/o other asthma characteristics
Exercise-Induced Bronchoconstriction (EIB): acute

Question 8

Asthma sx, PE, dx, tx

Answer 8

sx:
wheeze cough
SOB
chest tightness

PE
widespread, high-pitched, musical wheezes
▪︎MC w/ expiration, characteristic of asthma
▪︎usually absent between exacerbations
Other possible findings:
▪︎prolonged expiratory phase
▪︎hyperinflation, hyperresonance to percussion

dx
DX: asthma S/SXS + reversible airflow obstruction

Pulmonary function tests (PFTs):
➀ Spirometry ⇢ obstructive pattern
⇣ FEV1/FVC ratio, ⇣ FEV1, FVC

tx:
daytime sx: SABA prn
maintenance: ICS/LABA

Question 9

SABA meds and MOA

Answer 9

Albuterol (ProAir HFA, ProAir RespiClick, Ventolin HFA, Proventil HFA)
Levalbuterol (Xopenex)

MOA: binding at beta-2 receptors causes relaxation of bronchiole smooth muscle/bronchodilation
Indications: ALL PATIENTS W/ ASTHMA, used PRN for acute symptoms (quickly reverses bronchospasm)

Question 10

SAMA meds and MOA

Answer 10

Ipratropium (Atrovent HFA)

MOA: block constricting action of acetylcholine at M3 receptors in bronchial smooth muscle resulting in bronchodilation; also ⇣ mucus secretion
Indications: may be used in combination w/ SABAs during exacerbations

Question 11

Inhaled ICS meds and MOA

Answer 11

Fluticasone (Flovent HFA/Diskus, Arnuity Ellipta)
Budesonide DPI (Pulmicort Flexhaler)
Beclomethasone (Qvar)
Mometasone (Asmanex HFA)
Ciclesonide (Alvesco HFA)

MOA: block late-phase reaction to allergen, reduce airway hyperresponsiveness, potent & effective anti-inflammatory medications; ⇣ symptoms, ⇡ lung function, improve QOL, & reduce risk of exacerbations
Indications: FIRST LINE for long-term maintenance therapy, initiated in step 2

Question 12

Croup definition, sx, dx, tx

Answer 12

*inflammation of the larynx & subglottic airway

MC 6mo-6yrs; esp. in fall & winter

Etiologies:
*Parainfluenza type 1 MCC

sx: *”seal-like barking” cough
*inspiratory stridor, hoarseness
*dyspnea, low-grade fever
URI sxs (coryza) 🡪 prior, during, or after

dx: Clinical dx
Frontal cervical x-ray:
*steeple sign

tx:
Mild (no stridor at rest, no respiratory distress):
*supportive
-cool humidified air mist
-hydration
-oxygen if SpO2 <92%
*dexamethasone

Moderate (stridor at rest w/ mild-mod retractions):
*dexamethasone PO or IM + supportive
*nebulized Epi
*observe 3-4hrs

Severe (stridor at rest w/ marked retractions):
*dexamethasone + nebulized Epi + hospitalization

Question 13

Foreign Body Aspiration causes, sx, dx, tx

Answer 13

causes:
Occurs when a foreign body enters the airways & causes choking

MC food – can be life-threatening

80% in mainstem or lobar bronchus right > left

Risk Factors: institutionalization, advanced age, poor dentition, alcohol, sedative use

sx:
*inspiratory stridor (if high in airway)
*wheezing
*decreased breath sounds (if low in airway)

dx:
CXR (expiratory radiograph)
*regional hyperinflation of the affected side

ABG: necessary for appropriately evaluating ventilation, may be useful for following the progression of respiratory failure when it is of concern

tx
Remove foreign body w/ a bronchoscope
*rigid bronchoscopy (children)
*flexible (adults)

Complications: pneumonia, ARDS, asphyxia

Question 14

Hemoptysis definition and MCC

Answer 14

Coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs
MCC include:
bronchitis (50%): hemoptysis, dry cough, cough w/ phlegm

  tumor mass (20%): hemoptysis, chest pain, rib pain, tobacco hx, weight loss, clubbing 

  tuberculosis (8%): hemoptysis, chest pain, sweating  bronchiectasis, pulmonary catheters, trauma, pulmonary hemorrhage 

TX: treat the underlying cause

Question 15

Flu transmission, sx, dx, tx

Answer 15

A associated w/ more severe outbreaks than B

Transmission: primarily via airborne respiratory secretions (sneezing, coughing, talking, breathing), contaminated objects

sx
ABRUPT ONSET
*HA
*fever, chills
*malaise
*URI sxs
*pharyngitis
*pneumonia
*myalgias

dx
rapid nasal swab

tx:
Mild disease, healthy:
- supportive: acetaminophen, rest, fluids

Oseltamivir
- >65yrs, CVD, pulmonary disease, immunosuppression, chronic liver disease, hemoglobinopathies

Question 16

Lung cancer types

Answer 16

Non small cell lung carcinoma (85%)
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Small cell lung carcinoma (most aggressive)
Carcinoid tumors

Question 17

NSCLC cancer types and locations

Answer 17

Adenocarcinoma
* Most common: 40–50% of lung cancers
* Location: peripheral; arises from cells that line the alveoli and
produce mucus

Squamous cell carcinoma
* ~20% of lung cancers
* Location: central; arises from squamous cell that line the
proximal tracheobronchial tree

Large cell carcinoma
* 2% of lung cancers
* Location: peripheral or central – Small cell lung carcinoma
* About 15% of all lung cancers
* Location: central; usually begins in the main bronchi

Question 18

SCLC causes

Answer 18

Small cell lung carcinoma (SCLC) - 15% of
all lung cancers
* Highly aggressive
* 80% have metastatic disease at the time of
diagnosis
* Almost always occurs in smokers

Question 19

Paraneoplastic syndrome; name the cancer that goes with the hormones: ACTH, ADH, Beta-HCG, parathyroid hormone

Answer 19

Small cell carcinoma can secrete adrenocorticotropic hormone (ACTH)
– Release of cortisol from the adrenal glands = Cushing syndrome (high blood glucose, high blood pressure, hyponatremia)

Small cell carcinoma can secrete antidiuretic hormone (ADH)
– Water retention; patient will have edema, increase blood pressure, and
concentrated urine

Large cell carcinoma can secrete beta-human chorionic gonadotropin

Squamous cell carcinoma can secrete parathyroid hormone
– Depletion of calcium from the bone causing them to be brittle; increased calcium in the blood

Question 20

Lung cancer dx and tx

Answer 20

First ⇢ CXR Central: transbronchial biopsy

Then ⇢ CT w/ contrast *Carcinoid: pink/purple, well-vascularized

tx
NSCLC: surgical excision, radiation + chemo
SCLC: chemo + radiation, no surgery

Question 21

Lung cancer screening

Answer 21

Screening: USPSTF recommends ANNUAL low-dose CT screening for those 55-80 who have no sxs of lung cancer + a 30PPY smoking hx who currently smoke or have quit within 15yrs

Question 22

Pertussis dx and tx

Answer 22

dx:
*throat culture, PCR
*lymphocytosis common

tx:
Supportive:
*oxygenation, nebulizers, mechanical ventilation

Antibiotics:
*azithromycin, erythromycin

Complications: pneumonia

Question 23

Pertussis phases/sx

Answer 23

Catarrhal phase: URI sxs lasting 1-2wks
*most contagious

Paroxysmal phase: severe paroxysmal coughing fits w/ inspiratory whooping sound after cough fits
*may have post-coughing emesis
*often lasts 2-4wks

Convalescent phase: resolution of the cough

Question 24

Bronchiectasis defintion

Answer 24

Bronchiectasis: irreversible & abnormal dilation of bronchial tree that produces chronic respiratory symptoms
Acute Exacerbation: a deterioration in symptoms that require a change in regular treatment (e.g., adding antibiotics, ⇡ airway clearance techniques)

Question 25

Bronchiectasis sx, dx, tx

Answer 25

Classic S/SXS: chronic productive cough w/ mucopurulent & tenacious sputum + HX of exacerbations
▪︎cough most days of the week for months to years
▪︎cough (98%), daily sputum production, dyspnea
▪︎rhinosinusitis, hemoptysis, recurrent pleurisy

MC Exam Findings: crackles (MC, 75%), wheezing, digital clubbing (2%)

dx:
LABS: CBC, IgG, IgM, IgA, sweat chloride test for CF, sputum smear/culture for bacteria, mycobacteria, & fungi

PFTs: obstructive impairment MC
▪︎normal/⇣ FVC, ⇣ FEV1, ⇣ FEV1/FVC

CXR (nondiagnostic): linear atelectasis, dilated & thickened airways (tram or parallel lines, ring shadows on cross section), irregular peripheral opacities that may represent mucopurulent plugs

Multidetector CT (MDCT) or HRCT:
▪︎lack of tapering of bronchi (tram track appearance)
▪︎signet-ring sign: dilated, air-filled bronchus & pulmonary
artery ⇢ airway-to-arterial ratio ≥1.5
▪︎airway visibility within 1cm of a costal pleural surface or
touching the mediastinal pleura

tx:
▪︎smoking cessation
▪︎regular chest physiotherapy to clear secretions
▪︎nebulized hypertonic saline

Exacerbation prevention ⇢ ABX
▪︎indications: ≥3 exacerbations/year
▪︎duration: at least 3mo

⊖Pseudomonas ⇢ macrolide (azithromycin)
*sputum stains/culture to r/o
non-TB mycobacteria first
⊕Pseudomonas ⇢ inhaled ABX (tobramycin)

Question 26

Pneumonia: CAP definition, sx, dx, tx

Answer 26

Community-Acquired Pneumonia (CAP)
*outside hospital or within 48h of admission

sx: CAP: acute onset fever, cough (+/- sputum), dyspnea

dx:
LABS: CBC, CMP, CPR, procalcitonin
*leukocytosis w/ left shift
*procalcitonin
<0.25ng/dL suggests viral
≥0.25ng/dL suggests bacteria

CXR: AP + lateral views
*lobar consolidations
*interstitial infiltrates
*cavitations

VIRAL: bilateral, multifocal, patchy or ground-glass opacities
*dense consolidations, pleural
effusion & abscess should be
absent
BACTERIAL: dense lobar or alveolar
consolidations

tx:
CAP, outpatient:
*Amoxicillin + macrolide (preferred)
– Doxycycline is macrolide alternative

⊕heart, lung, liver, or kidney disease, diabetes, alcoholism, malignancy, asplenia, immunosuppression, or use of abx in last 3mo:
*Augmentin + macrolide (preferred)
– Doxycycline is macrolide alternative
*FQ monotherapy (alternative)

CAP, inpatient, non-ICU:
*antipneumococcal beta lactam + macrolide
*FQ monotherapy

CAP, inpatient, ICU:
*antipneumococcal beta lactam + Azithromycin
*preferred
*antipneumococcal beta lactam + FQ

Question 27

Pneumonia: nosocomial definition

Answer 27

– Hospital-Acquired Pneumonia (HAP)
*acquired >48h after admission
– Ventilator-Associated
Pneumonia (VAP)
*acquired >48h after endotracheal intubation

Question 28

PJP sx, dx, tx

Answer 28

PCP: interstitial pneumonia caused by the yeast-like fungal organism Pneumocystis jirovecii

Transmission: airborne

*AIDS-DEFINING ILLNESS ⇢ CD4 <200/µL

sx:
S/SXS: gradual onset fever, dry cough, & dyspnea progressing over days to weeks
▪︎fatigue, chills, CP, weight loss
▪︎5-10% of patients are asymptomatic

PE: tachypnea, crackles & rhonchi, ⇣ SpO2 (e.g., <90%)

LABS: CD4 <200/µL, ⇡ LDH, ⇡ 1-3-beta-D-glucan

dx:
CXR: diffuse, bilateral perihilar infiltrates

HRCT: bilateral patchy or nodular ground glass opacities

DX ⇢ microbiologic identification via staining &/or PCR of a respiratory specimen
▪︎PCR preferred

tx: TX: TMP-SMX x21d

Question 29

Pneumothorax definition

Answer 29

PTX: a collection of air within the pleural space between the lung (visceral pleura) & the chest wall (parietal pleura) that can lead to parietal or complete pulmonary collapse
PATHO: ⇡ intrapleural pressure ⇢ alveolar collapse ⇢ decreased V/Q ratio & ⇡ right-to-left shunting

Question 30

Primary vs secondary spontaneous pneumothorax

Answer 30

Primary Spontaneous PTX (PSP): occurs in patients w/o clinically apparent underlying lung disease
▪︎caused by ruptured subpleural apical blebs
RF: smoking (90%) ⇢ up to 20-fold ⇡ in risk (risk ⇡ w/
▪︎MC affects tall, thin males, ♂︎ > ♀︎ ~6:1
cumulative # of cigarettes smoked)
▪︎peak incidence 16-25yo ▪︎family hx, male, young, homocystinuria, tall/slim

Secondary Spontaneous PTX (SSP): occurs as a complication of underlying lung disease
▪︎♂︎ > ♀︎ ~3:1, peak incidence 60-65yo
▪︎Marfan syndrome, malignancy
▪︎COPD (smoking): rupture of bullae in emphysema ▪︎infections: TB, PCP (alveolitis, rupture of a cavity)
▪︎Catamenial PTX ⇢ thoracic endometriosis (rare)
▪︎CF: bronchiectasis w/ obstructive emphysema & bleb

Question 31

Traumatic vs tension pneumothorax

Answer 31

Traumatic PTX: a type of PTX caused by trauma (e.g., penetrating injury, iatrogenic trauma)
▪︎blunt trauma (e.g., MVC in which thorax hits steering wheel or rib fracture occurs)
▪︎penetrating injury (e.g., gunshot or stab wound)
▪︎Iatrogenic PTX ⇢ mechanical ventilation w/ high PEEP (barotrauma), thoracentesis, CVC
placement, bronchoscopy, lung biopsy (usually closed PTX)
PATHO:
▪︎Closed: air enters through a hole in the lung (e.g., d/t blunt trauma)
▪︎Open: air enters through a lesion in the chest wall (e.g., d/t penetrating trauma)

Tension PTX (TPTX): a life-threatening variant of PTX characterized by progressively ⇡ pressure within the chest & cardiorespiratory compromise
PATHO: ➀ disrupted visceral pleura, parietal pleura, or tracheobronchial tree
➁ 1-way valve mechanism ⇢ air enters the pleural space on inspiration but cannot exit
➂ progressive accumulation of air in pleural space & ⇡ ⊕pressure within the chest
➃ collapse of ipsilateral lung, compression of contralateral lung, trachea, heart, & SVC;
angulation of IVC
➄ impaired respiratory function, ⇣ venous return to the heart ⇢ reduced CO ⇢ hypoxia & hemodynamic instability

Question 32

Pneumothorax sx

Answer 32

S/SXS: sudden, severe &/or stabbing ipsilateral pleuritic CP & dyspnea
PE: ⇣/absent breath sounds, hyperresonance to percussion, ⇣ fremitus on the ipsilateral side

⊕subcutaneous emphysema: infiltration of air under the dermal layers of the skin
▪︎distention/bloating of chest, neck, face
▪︎palpation ⇢ crackling sensation (crepitus)

Question 33

Tension pneumothorax sx

Answer 33

Tension PTX: ▪︎severe acute respiratory distress: cyanosis, restlessness, diaphoresis
▪︎reduced chest expansion on the ipsilateral side, distended neck veins
▪︎hemodynamic instability (e.g., tachycardia, hypotension, pulsus paradoxus)

ABG indications: tachypnea, accessory muscle use, SpO2 <92%, hx of hypercapnia
▪︎possible findings ⇢ hypoxemia & respiratory alkalosis

Question 34

pneumothorax dx

Answer 34

DX: CXR
▪︎ipsilateral pleural line + absence of bronchovascular markings past the pleural line
▪︎⊕deep sulcus sign: abnormally deepened costophrenic angle on ipsilateral side **SUPINE film

Size assessment cut-off ⇢ cm between pleural line & chest wall at level of the apex
▪︎PSP: 3cm
▪︎SSP: 2cm

Tension PTX: clinical DX based on S/SXS of tachycardia,
hypotension, & severe dyspnea
▪︎supportive CXR findings:
*tracheal shift to contralateral side

Question 35

Primary vs secondary vs traumatic pneumothorax tx

Answer 35

TX: assess stability ⇢ requires ALL of the following to be considered stable:
➀ RR <24 breath/min
➁ SpO2 >90% on RA
➂ HR 60-120bpm
➃ normal BP
➄ able to speak in whole sentences

Primary Spontaneous PTX (PSP):
▪︎stable, small (≤3cm) PSP ⇢ usually resolves spontaneously within ~10d
▪︎observation +/- supplemental O2 (6L/min x6h to target SpO2 >96%)
▪︎repeat CXR after 3-6h
» stable or improving ⇢ DC home w/ outpatient f/u CXR in 24h
» enlarging ⇢ chest tube
▪︎stable, large (>3cm) PSP ⇢ chest tube preferred over needle/catheter aspiration

Secondary Spontaneous PTX (SSP):
▪︎stable, small (<2cm) SSP ⇢ admit + chest tube (⇡ risk of developing TPTX d/t underlying lung disease)
▪︎if asymptomatic, observation &/or needle aspiration can be considered
▪︎stable, large (≥2cm) SSP ⇢ admit + chest tube

Traumatic/tension PTX, bilateral PTX, or unstable:
▪︎emergency chest tube thoracostomy ⇢ admit
▪︎if chest tube is delayed, perform needle decompression

Chest tube placement: superior rib margin, anterior to midaxillary line in 5th ICS (nipple line)
Needle/catheter aspiration: superior rib margin in 2nd ICS, midclavicular line

Definitive TX: surgical pleurodesis ⇢ VATS (preferred), medical thoracoscopy
▪︎indications: prolonged air leak >5d, recurrent PTX, bilateral PTX, high-risk of recurrence

Question 36

PE definition, MCC, sx, PE

Answer 36

PE: luminal obstruction of ≥1 pulmonary arteries, typically
d/t blood thrombi from DVT

MCC ⇢ DVT
Non-thrombotic: fat, air, bacterial

PATHO: thrombus formation ⇢ DVT (MC iliac vein) ⇢ embolize
to pulmonary arteries via IVC ⇢ partial/complete obstruction

Saddle Thrombus: blood clot that lodges at the bifurcation of the
pulmonary trunk as it splits into the R/L pulmonary arteries
▪︎can obstruct flow through the pulmonary arteries & lead to R heart strain, hemodynamic instability,
&/or death

S/SXS: acute onset dyspnea (MC), pleuritic CP, cough +/- features of DVT (e.g., unilateral leg swelling)
▪︎hemoptysis is unusual presenting symptom (13%)

PE: tachypnea, rales, tachycardia, ⇣ breath sounds MASSIVE: arrythmias (e.g., AFIB), presyncope,
▪︎accentuated pulmonic component of S2 syncope, hemodynamic collapse (<10%)

Question 37

PE wells score

Answer 37

+3: sx of DVT
+3: PE dx likely
+1.5: tachycardia
+1.5: surgery/immobilization
+1.5: hx of DVT/PE
+1: hemoptysis
+1: malignancy

Question 38

PE dx

Answer 38

CBC/CMP: +/- leukocytosis, ⇡ ESR, ⇡ serum lactate, ⇡ LDH, ⇡ AST

ABG: +/- hypoxemia, ⇡ A-a O2 gradient, respiratory alkalosis, hypocapnia

EKG ⇢ nonspecific: tachycardia, nonspecific ST/T changes

CXR ⇢ nonspecific abnormalities common: atelectasis, effusion

The following signs are rare, but should raise suspicion for PE:
▪︎Hampton’s hump: shallow, hump-shaped opacity in the
periphery of the lung w/ its base against the pleural surface
▪︎Westermark’s sign: sharp cutoff of pulmonary vessels w/ distal
hypoperfusion
▪︎Palla’s sign: enlarged descending pulmonary artery w/ a
“sausage” appearance

PE suspected ⇢ calculate PTP using Wells score
➀ Wells <2: low PTP ⇢ PERC to determine if D-dimer indicated
▪︎all 8 criteria fulfilled = no further testing indicated
▪︎all 8 criteria not fulfilled ⇢ D-dimer
➁ Wells 2-6: intermediate PTP ⇢ D-dimer
➂ Wells >6: high PTP ⇢ CT pulmonary angiography (CTPA)
▪︎D-dimer not needed

D-dimer ⇢ <500ng/mL = ⊖/normal
≥500ng/mL = ⊕ ⇢ get CTPA
▪︎for patients >50yo, age-adjusted cutoff value (ng/mL) = age x 10
» ex. 65yo patient ⇢ <650ng/mL as cutoff value for ⊖D-dimer

CTPA w/ contrast: intraluminal filling defects of pulmonary arteries

V/Q scanning ⇢ alternative if CTPA contraindicated

Question 39

PE tx

Answer 39

▪︎supplemental O2 to target SpO2 ≥90%
▪︎IV fluids for hypotensive patients

Initial Anticoagulation (first 5-10d):
▪︎SQ LMWH or fondaparinux

Long-term AC (minimum of 3mo): DOACs
▪︎thrombin inhibitor: dabigatran
▪︎factor Xa inhibitors: rivaroxaban (Xarelto),
apixaban (Eliquis), edoxaban

Indications for AC >3mo:
▪︎unprovoked PE w/ low/moderate bleeding risk
▪︎provoked PE secondary to chronic RF
▪︎active cancer w/ any bleeding risk

Contraindications to AC: significant active bleed, recent high-risk bleed (e.g., ICH), recent major surgery, severe thrombocytopenia

IVC filter: AC is contraindicated or risk of bleeding is unacceptably high

Hemodynamically unstable ⇢ reperfusion
▪︎tPA (e.g., alteplase, reteplase, tenecteplase)
▪︎DC anticoagulation before tPA, resume after
Alternatives: catheter-directed thrombolysis, embolectomy

Absolute contraindications to thrombolysis:
▪︎active bleeding
▪︎prior ICH
▪︎ischemic stroke ≤3mo ago
▪︎structural intracranial disease (AVM, neoplasm)
▪︎bleeding diathesis

Question 40

Pleural effusion transudative vs exudative

Answer 40

▪︎fluid between pleural layers impairs lung expansion ▪︎normal pleural fluid volume 10-20mL

Transudative: ⇡ hydrostatic pressure + ⇣ plasma oncotic pressure
▪︎CHF (MCC): 81% bilateral
▪︎cirrhosis w/ ascites (hepatic hydrothorax): 70% right sided
▪︎nephrotic syndrome: usually bilateral, subpulmonic
▪︎hypoalbuminemia: uncommon, >90% bilateral
▪︎atelectasis: ⇡ intrapleural ⊖pressure

Exudative: ⇡ capillary permeability
▪︎pneumonia
▪︎pulmonary embolism: ⊕effusion in 30%, exudative ~80%
▪︎cancer: lung, breast, or lymphoma MC
▪︎autoimmune (e.g., SLE, RA, sarcoidosis, vasculitis)

Question 41

Pleural Effusion sx, dx, tx

Answer 41

sx: S/SXS: dyspnea, pleuritic CP (retrosternal), dry cough ⇣ tactile fremitus, ⇣ breath sounds

dx:
CXR: blunting of costophrenic angle ⇢ meniscus sign
▪︎lateral XR, posterior CP∠ (A):
» ~75mL fluid needed to blunt CP∠
▪︎frontal XR, lateral CP∠ (B):
» ~200mL fluid needed to blunt CP∠

definitive DX ⇢ thoracentesis
Light’s criteria: 1+ of the 3 ⇢ exudative
➀ pleural fluid LDH >2/3 ULN serum LDH
➁ pleural fluid protein/serum protein >0.5
➂ pleural fluid LDH/serum LDH >0.6

tx: therapeutic thoracentesis
▪︎treat underlying cause

Question 42

TB pathogen + TB disease vs infection

Answer 42

Mycobacterium Tuberculosis (mTB)
*bacilli (rod-shaped), strict aerobes, acid fast (won’t gram stain)

Tuberculosis Disease: newer term for active TB *contagious
Tuberculosis Infection: newer term for latent TB (LTBI) *not contagious

Question 43

Primary vs progressive vs latent TB

Answer 43

Primary TB: usually asymptomatic w/ no radiographic signs
Progressive Primary TB: high fever d/t TB pneumonia, pleurisy w/ effusion, lymphadenitis

LTBI: asymptomatic, PPD⊕ *not transmissible
*Lifetime risk of reactivation is 10% w/ 5% within first 2yrs
Active Pulmonary/Reactivation TB: cough ≥2wks (starts dry, becomes productive), hemoptysis, night sweats, fever, weight loss, LAD, pleuritic chest pain

Question 44

TB dx and tx

Answer 44

CXR: *findings variable & nonspecific
*Primary TB: hilar &/or mediastinal LAD, pleural effusion, segmental or lobar consolidation
*LTBI: +/- Ghon/Ranke Complex (peripheral calcified nodule & hilar LAD)
*Reactivation TB: fibrocavitary apical disease
*AIDS, CD4+ <200: diffuse, miliary, hilar/mediastinal LAD

Sputum: x3 samples, ≥8h apart, at least 1 early-morning specimen
*AFB smear, mycobacterial culture, NAAT
– ⊕NAAT w/ or w/o ⊕AFB smear is sufficient for DX in at-risk pts
Definitive: ⊕sputum culture

Extrapulmonary TB:
*Vertebral TB (Pott): osteolytic lesions on plain film
*TB Lymphadenitis (Scrofula): single swollen non-tender cervical LN
*meningitis, ocular, renal, pericarditis, salpingitis, peritonitis, intestinal

tx:
First: RIPE x2mo
*Rifampin (RIF)
*Isoniazid (INH)
*Pyrazinamide (PZA)
*Ethambutol (EMB)

Then: continuation x4mo
*Rifampin + Isoniazid

Question 45

RIPE drugs SE

Answer 45

Rifampin
SE: Thrombocytopenia, flu-like sxs, orange-colored secretions (tears, urine), GI upset, hypersensitivity, fever, hepatitis

Isoniazid
SE: Hepatitis (esp. >35yrs), peripheral neuropathy, drug-induced lupus, rash, abdominal pain, high anion gap acidosis, cytochrome P450 inhibition

Pyrazinamide
Hepatitis & hyperuricemia, GI sxs, arthritis, photosensitive dermatologic rash

Ethambutol
Optic neuritis 🡪 scotoma, color perception problems (red-green), visual changes, peripheral neuropathy, GI sxs, rash

Question 46

COPD definition and causes

Answer 46

*COPD is characterized by persistent respiratory symptoms & airflow limitation
▪︎caused by a mixture of small airway obstruction & parenchymal destruction
*Formerly subdivided into chronic bronchitis & emphysema
▪︎Chronic Bronchitis: productive cough for ≥3mo/y for 2+ consecutive years
▪︎Emphysema: enlargement of airspaces distal to the terminal bronchioles
accompanied by destruction of the airspace walls
» Centrilobular (MC): respiratory bronchiole destruction
*classically seen in smokers, usually affects the upper lobes

Etiology:
▪︎SMOKING MCC*
▪︎air pollution, occupational hazard exposures
▪︎⍺1-antitrypsin deficiency, impaired lung maturation
▪︎early childhood infections, bronchiectasis

Comorbidities: heart disease, OSA, metabolic syndrome,
depression, osteoporosis

PATHO: begins with chronic airway inflammation that progresses to emphysema, a condition characterized by irreversible bronchial narrowing & alveolar hyperinflation ⇢ loss of diffusion area leads to V/Q mismatch w/ resultant hypoxemia & hypercapnia

Question 47

COPD sx pink puffer vs blue bloater

Answer 47

pink puffer: emphysema
non cyanotic and thin
dyspnea
accessory msucle use, tachypnea
prolonged expiration
hyper resonance, decreased breath sounds
cachectic
barrel chest
pursed lip breathing
tripod position

Blue bloater: chronic bronchitis
cyanotic and obese
rales
peripheral edema
JVD
severe mismatch: hypoxemia and hypercapnia
productive cough

Question 48

COPD dx

Answer 48

Gold standard/confirmatory: spirometry ⇢ demonstrates airflow limitation that is irreversible/only partially reversible w/ SABA
▪︎postbronchodilator FEV1/FVC <0.7, FEV1 ⇣
▪︎ΔFEV1 postbronchodilator <12% = irreversible bronchoconstriction

% of predicted FEV1 determines
severity of airflow limitation

Additional spirometer findings not required for diagnosis:
▪︎⇡ lung volumes (TLC, FRC, RV)
▪︎⇣ DLCO: establishes presence of emphysema (normal in chronic bronchitis)

CXR: findings only present & diagnostic in severe emphysema
⊕hyperinflation (e.g., enlarged lungs, flattened diaphragm, ⇡ AP diameter)
⊕loss of parenchyma (e.g., ⇣ lung markings, large bullae)

Question 49

COPD tx: group A, B, C, D

Answer 49

Group A: fewer symptoms, low risk
▪︎short-acting or long-acting bronchodilator (i.e., SABA,
SAMA)

Group B: more symptoms, low risk
▪︎long-acting bronchodilator (i.e., LABA or LAMA plus SAMA)

Group E = C + D
Group C: fewer symptoms, high risk
▪︎LAMA

Group D: more symptoms, high risk
▪︎LAMA monotherapy OR combination therapy
▪︎LABA + LAMA if highly symptomatic (e.g., CAT >20)
▪︎ICS + LABA if eosinophils ≥300cell/µL
*ICS should only be used in combo w/ LABA/LAMA

Long-term oxygen therapy (LTOT)

Question 50

COPD exacerbation sx and tx

Answer 50

S/SXS: acute Δ in 1/3 cardinal symptoms
▪︎worsening of dyspnea
▪︎increased severity/frequency of cough
▪︎increased volume/purulence of sputum

PE: wheezing, tachypnea, use of accessory muscles, tachycardia

Short-acting bronchodilators ⇢ SABA +/- SAMA
▪︎mild: standard dose
▪︎moderate/severe: high-dose

Systemic steroids (PO/IV) x5d
▪︎prednisone 30-60mg QD
▪︎methylprednisolone 60-125mg 2-4x/d