Pulm Flashcards
1
Q
Etiology and pathophys of asthma?
A
Unknown; associated with obesity and atopy secondary to bronchial smooth muscle hypertrophy
2
Q
What happens to expiratory phase of respiration in asthma?
A
Prolonged
3
Q
Best initial test in acute asthma exacerbation?
A
Peak expiratory flow (PEF)/ABG
4
Q
Most accurate test asthma exacerbation vs asymptomatic with occasional symptoms?
A
Asthma exacerbation-PFT
Asymptomatic-Methacholine or histamine challenge (>20% decrease in methacholine)
5
Q
FEV1/FVC in asthma? TLC? RV?
A
Both decrease, but FEV1 decreases more so
6
Q
3 PFT measures for aiding asthma diagnosis?
A
DECREASE FEV1/FVC ratio, >12% increase in FEV1 with albuterol, >20% decrease in FEV1 with methacholine/histamine challenge
7
Q
Asthma tx. outpatient
Step 1: Mild intermittent (2 days/wk. +>2 nights/month)
Step 3: Moderate persistent (daily or >1 night/week)
Step 4: Severe persistent (continual, frequent)
Step 5: Increased IgE level
Step 6: Last resort
A
Step 1: SABA
Step 2: SABA+low dose ICS
Step 3: SABA+low dose ICS+ LABA
Step 4: SABA+HIGH dose ICS+LABA
Step 5: Omalizumab may be added to step 4
Step 6: Oral corticosteroids added to step 4 when all other therapies not sufficient to control symptoms on own!
8
Q
Adverse effect of ICS?
A
Dysphonia and oral candidiasis
9
Q
What vaccine should be given in all asthma patients?
A
Influenza/pneumococcal
10
Q
Best indication of severity of asthma in acute setting?
A
RR
11
Q
Best initial therapy for acute asthma treatment?
A
Oxygen combined wtih Albuterol (nebulization) and Bolus of steroids
12
Q
Why and when is magnesium used in acute asthma exacerbation?
A
Magnesium helps relieve bronchospasm. It is only used when asthma not responsive to several rounds of albuterol while waiting for steroids to take effect
13
Q
When do you need endotracheal intubation?
A
When patient does not respond to oxygen, albuterol, and steroids OR develops respiratory acidosis (increased pCO2)
14
Q
Best initial/Most accurate COPD?
A
Best initial: CXR
Most accurate: PFT
15
Q
What test can show an increase in RV in COPD?
A
Plethysmography
16
Q
EKG in COPD?
A
RAH or RVH secondary to pulm HTN; AFIB or MAT
17
Q
Tx. for improved mortality in COPD
A
1) Smoking cessation
2) Home oxygen (pO2
18
Q
What 3 conditions would standard for home O2 be pO2
A
1) Pulm HTN
2) High HCT
3) Cardiomyopathy
19
Q
Tx. for helping improve symptoms for COPD?
A
1) Inhaled Anticholingeric (tio/ipratropium)–> most effective in COPD
2) SABA/LABA
3) Pulmonary rehab
20
Q
Difference in next line drug when symptoms not controlled with albuterol in COPD vs. Asthma?
A
Asthma-ICS next line
COPD-Inhaled anticholinergic next line
21
Q
Tx. for severe COPD exacerbation before intubation?
A
NPPV (noninvasive positive pressure ventilation)
22
Q
When is use of antibiotics indicated for COPD?
A
-Defined as requiring hospitalization OR having at least 2 of 3 cardinal symptoms (increasing dyspnea, increase suptum production, increase sputum purulence (green, brown))
23
Q
Tx. for acute exacerbations of COPD?
A
-Bronchodilators (eg albuterol), corticosteroid therapy combined with antibiotics
24
Q
What should coverage be provided against with antibiotic treatment of COPD exacerbation?
A
S. pneumoniae, H. influenzae, Moraxella catarrhalis.
25
Presentation of bronchiectasis?
Cough, recurrent high volume mucopurulent sputum (>100 mL/day), and hemoptysis
26
Best initial/Most accurate test bronchiectasis?
Best initial: CXR
| Most accurate: High-resolution CT scan
27
How do you determine bacterial etiology of recurrent episodes of infection in bronchiectasis?
Sputum culture
28
Treatment bronchiectasis?
- Chest physiotherapy ("cupping and clapping") and postural drainage essential for dislodging plugged up bronchi
- Same antibiotics as COPD exacerbation (rotate antibiotics, 1 weekly each month)
- Surgical resections of focal lesions may be indicated
29
What is ABPA and what patients is it seen in?
Hypersensitivity of lungs to fungal antigens that colonize the bronchial tree. Hx asthma/atopic disorders
30
How do you Diagnose APBA?
Brown-flecked sputum and transient infiltrates on CXR
31
Tx. ABPA?
1) Oral steroids for severe cases
| 2) Oral Itraconazole for recurrent episodes
32
What is underlying pathophys from mutation in CFTR gene?
Damage chloride and water transport across apical surface of epithelial cells in exocrine glands throughout the body
33
Most accurate test CF?
-Sweat chloride test (Pilocarpine) with >60 meq/L chloride leves
34
Tx. CF?
1) Antibiotics routine (inhaled aminoglycosides almost exclusively limited to CF)
2) Inhaled recombinant human deoxyribonuclease (rhDNase)-->breaks up massive amoutns of DNA in respiratory mucus (from neutrophils) that clogs up airways
3) Inhaled bronchodilators
4) Lung transplantation in advanced disease
35
Common CAP pathogen and association:
| H influenzae?
COPD
36
Common CAP pathogen and association:
| S. aureus
Recent viral infection (influnza)
37
Common CAP pathogen and association:
| K. pneumoniae?
Alcoholism, diabetes
38
Common CAP pathogen and association:
| Anaerobes?
Poor dentition, aspiration
39
Common CAP pathogen and association:
| M. pneumoniae?
Young, healthy patients
40
Common CAP pathogen and association:
| C. pneumoniae?
Hoarseness
41
Common CAP pathogen and association:
| Legionella?
Contaminated water sources, air conditioning, ventilation systems
42
Common CAP pathogen and association:
| C. Psittaci?
Birds
43
Common CAP pathogen and association
| C. burnetii?
Animals at the time of giving birth, veterinarians, farmers
44
CAP physical findings?
Fever, dyspnea, cough, pleuritic chest pain (possible), and abdominal/pain or diarrhea if infection of lower lobes affecting intestines (through diaphragm). Dullness to percussion (if effusion), egophony due to "bronchial" breath sounds
45
Best initial test pneumonia?
| Cause of pneumonia?
- CXR
| - Sputum gram stain/culture
46
Pathogen causing hemoptysis from necrotizing disease, and "currant jelly" sputum with pneumonia
K. pneumoniae
47
Pathogen causing foul-smelling sputum, "rotten eggs" with pneumoniae
Anaerobes
48
Pathogen causing dry cough, rarely severe, bullous myringitis with pneumoniae
M. pneumoniae
49
Pathogen causing GI symptoms (abdominal pain, diarrhea) and CNS symptoms such as head ache and confusion with pneumoniae
Legionella
50
Pathogen presenting as cause of pneuonia in AIDS with CD4
Pneumocystis
51
Dry or nonproductive cough occur because infection is where?
Interstitial space with more often air spaces of aleveoli are empty
52
What bugs are bilateral interstitial infiltrates seen on CXR?
Mycoplasma, viruses, coxiella, pneumocystitis, chlamydia
53
Infections with a dry/nonproductive cough in pneumonia?
Mycoplasma, viruses, coxiella, pneumocystitis, chlamydia
54
Specific diagnostic test for M. pneumoniae?
PCR, cold agglutins, serology, special culture media
55
Specific diagnostic test for C. pneumoniae?
Rising serologic titers
56
Specific diagnostic test for Legionella?
Urine antigen, culture on charcoal-yeast extract
57
Specific test for C. psittaci?
Rising serologic titers
58
Specific test for C. burnetii
Rising serologic titers
59
PCP best initial/most accurate test?
Best initial? CXR
| Most accurate? BAL (Bronchoalveolar lavage)
60
What should you do for new pleural effusions secondary to pneumonia?
TAP them. Analyze pleural effusion (empyema if pH
61
Exception to bronchoscopy being rare for CAP?
Pneumocystis pneumonia
62
Outpatient CAP treatment:
- Previously healthy or no ABX in past 3 months
- Co-morbidities (cancer, COPD, CHF, renal or liver disease) or ABX use in past 3 months
- Macrolide ABX or doxycycline
| - Respiratory fluoroquinolone (levofloxacin or moxifloxacin) or B-lactam (eg penicillin/cephalosporins)+macrolide
63
Inpatient CAP treatment:
Respiratory fluoroquinolone OR cefriaxone+azithromycin
64
What are 2 single factors to hospitalize patient for CAP?
Hypoxia and hypotension
65
CURB65 for admission for pneumonia criteria?
- Confusion, Uremia, Respiratory distress (>30 RR, pO265
- 2 or higher benefit from inpatient treatment
- >4 ICU admission required
66
Transudative vs Exudative pleural effusion
Transudative-NO light criteria; secondary to Increase hydrostatic or decrease oncotic pressure
Exudative-Pleural fluid protein/Serum protein>0.5, Pleural LDH/Serum LDH>0.6, secondary to increased capillary permability
67
Definition of hospital acquired pneumonia?
Pneumonia developing >48 hours after admission or after hospitalization in last 90 days
68
Empiric therapy for hospital acquired pneumonia?
1) Antipseudomonal cephalosporins: cefepime or ceftazidime OR
2) Antipseudomonal penicillin: Piperacillin/tazobactam OR
3) Carbapenems: Imipenem, meropenem, or doripenem
69
What do piperacillin and ticarcillin need to be used with?
B-lactamase inhibitor (tazobactam or clavulanic acid)
70
Best initial test (least accurate and easiest to do) for VAP
| Most accurate test (most dangerous) for VAP
1) Tracheal aspirate
| 2) Open lung biopsy
71
Initial combination treatment for VAP?
1) Antipseudomonal beta-lactam (cephalosporin (ceftazidime or cefepime) OR penicillin (piperacillin/tazobactam) OR carbapenem (imipenem, meropenem, or doripenem)
PLUS
2) Second antipseudomonal agent (aminoglycoside (gentamicin or tobamycin or amikacin) OR fluoroquinolone (ciprofloxacin or levofloxacin))
PLUE
3) Methicillin-resistant antistaphyloccal agent (Vancomycin OR Linezolid)
72
Difference in cause of aspiration pneumonia vs. pneumonitis?
Aspiration Pneumonia-oral cavity microbes infecting lung parenchyma
Aspiration pneumonitis-gastric contents causing lung parenchyma inflammation
73
Best initial test/Most accurate test for lung abscess?
Best initial test-CXR/ABG(increase A-a gradient)
| Most accurate test: Chest CT
74
Tx. Lung abscess
Clindamycin or B-lactam w/B-lactamase inhibitor
75
PCP always has what elevated?
LDH
76
PCP treatment for severe (PO235) and if toxicity to TMP-SMX
Severe-add steroids to TMP-SMX
| Toxicity-Switch to either Clindamycin and primaquine OR IV Pentamidine
77
PCP prophylaxis?
1) TMP/SMX
| 2) Atovaquone or dapsone (if toxicity to TMP-SMX)
78
TMP-SMX toxicity?
Rash/neutropenia
79
TB largest risk factor?
Recent immigrants (in past 5 years) from either Haiti, DR, Phillipines, China, India, Mexico, Vietnam
80
Best initial/Most accurate/Best screening for TB?
Best initial-CXR; sputum stain and culture for acid-fast bacilli must be done 3 times to fully exclude TB!
Most accurate-Pleural biopsy
Best screening-PPD
81
What is best management if high clinical suspicion of TB?
Respiratory isolation BEFORE further diagnostic testing
82
Treatment for smear positive TB?
Rifampin, Isoniazid, Pyrazinamide, Ethambutol
1) RIPE for 2 months
2) RI for 4 months
=6 months total
83
What 4 conditions is treatment extended for in TB?
- Osteomyelitis
- Miliary TB
- Meningitis
- Pregnancy (CANT USE PYRAZINAMIDE) or any other time pyrazinamide is not used
84
Common side effect of all TB meds?
-Idiosyncratic liver injury with histology similar to viral hepatitis. DO NOT STOP until transaminases 3-5 time above upper limit
85
Side effect Rifampin and management?
Side effect isoniazid and management?
Side effect pyrazinamide and managment?
Side effect ethambutol and management?
Rifampin-red/orange color urine; continue drug
Isoniazid-peripheral neuropathy, occasional pellegra with problems with niacin metabolism; prevent with pyridoxine co-administration
Pyrazinamide-Hyperuricemia; no treatment unless symptomatic
Ethambutol-Optic neuritis/color vision; manage with decreased dose in renal failure
86
What is considered a positive PPD test?
>5 mm (HIV/AIDS, chronic corticosteroids, close contacts with TB, calcifications on CXR, organ transplant)
>10 mm (Recent immigrant, prisoners, healthcare workers, close contact w/ TB, Hematologic malignancy, alcoholics, DM)
>15 mm (No other risk factors)
87
For someone who has never had TB test what is necessary?
2nd PPD after 1st PPD if first negative. No second test if 1st PPD is positive
88
Treatment for Positive PPD with active TB excluded via CXR?
Isoniazid for 9 months and use pyridoxine (B6)
89
Does previous BCG affect recommendations for treatment?
NO
90
Best initial step for all lung lesions found on CXR?
Compare to size of old X-rays; if not available, perform CT to characterize lesion.
91
What do you need to do for lesion where old x-ray unavailable?
CT to characterize lesion
92
Management of high risk/intermediate risk/low risk lesions?
High-surgical excision
Intermediate-Imaging+biopsy/PET
Low-Monitor with serial CT scan
93
Most common adverse effect of transthoracic biopsy?
Pneumothorax
94
What defines pulmonary fibrosis?
Thickening of interstitial septum of lung between arteriolar space and alveolus
95
```
Exposure and Disease:
1) Coal
2) Sandblasting, rock mining, tunneling
3) Shipyard workers, pipe fitting, insulators
4) Cotton
5 )Electronic manufacture
6) Moldy sugar cane
```
1) Coal workers pneumoconiosis
2) Silicosis
3) Asbestosis
4) Byssinosis
5) Berylliosis
6) Bagassosis
96
Pulm fibrosis presentation
- Dyspnea worsening on exertion
- Fine rales or "crackles" on examination
- Loud P2 heart sound
- Clubbing of fingers
97
Best initial/Most accurate test for pulm fibrosis
- Best initial: CXR
| - Most accurate: Lung biopsy; high res. CT scan less accurate, but more accurate than CXR
98
CT scan pulmonary fibrosis shows what?
"Honeycombing" in periphery of lung
99
Tx. pulm fibrosis
NOTHING, but if biopsy shows white cell or inflammatory infiltrate, prednisone can be used; can treat berylliosis with steroids (b/c presence of granulomas)
100
Best Initial/Most accurate test sarcoidosis?
Best initial: CXR
| Most accurate: Lymph node biopsy
101
Tx. sarcoid?
Prednisone; asymptomatic hilar adenopathy needs no treatment
102
What veins compose of >90% of thrombosis in DVT that become PE?
Deep veins of lower extremities (iliac, femoral, and popliteal)
103
Best initial/most accurate test for PE?
Best initial: CXR/ABG/EKG
| Most accurate: Angiography (rarely done)
104
Next best step for history and initial labs suggestive of PE?
Empiric anticoagulation (enoxaparin)
105
When is V/Q scan used first?
Pregnancy
106
When is IVC filter the right answer?
1) Contraindication to use of anticoagulants
2) Recurrent emboli (while on heparin or fully therapeutic warfarin)
3) RV dysfunction (enlarged RV on echo with next embolus even if it is small can be fatal)
107
Best initial/best long term?
Best initial: heparin/LMWH
| Best long term: warfarin (can be started on day one)/oral agents (rivaroxaban/dabigatran))
108
When are thrombolytics the right answer?
-Hemodynamically unstable patients (SBP
109
Most patients with PE will have what on CXR?
NORMAL!!
110
Definition of pulm. HTN?
SBP>25 mm Hg, DBP> 8 mm Hg
111
Best initial/Most accurate test for Pulm. HTN?
Best initial test: CXR/CT
| Most accurate test: Right heart or Swan-Ganz catheter
112
Tx. of Pulm HTN?
1) Prostacyclin analogues (PA vasodilators): Epoprostenol. treprostinil, iloprost, beraprost
2) Endothelin antagonists: bosentan, ambrisentan
3) PDE-5 Inhibitors: sildenafil
113
MCC of obstructive sleep apnea?
Obesity
114
Most accurate test OSA?
Polysomnography
115
Tx. for OSA?
1) Wt. loss/alcohol cessation (worsen apnea at night)
2) CPAP
3) Uvuloplatopharygoplasty if CPAP fails
116
Difference btwn OSA and obesity hypoventilation syndrome?
Obesity hypoventilation syndrome has INCREASED bicarbonate secondary to PaCO2>45
117
ARDS triad?
1) Severe hypoxia (increase A-a gradient)
2) Poor lung compliance
3) Noncardiogenic pulm. edema
118
What defines ARDS in lab values?
pO2/FiO2
119
ARDS tx. options?
- Low TV mech. ventilation while waiting to see if lungs will recover (6 mL/kg TV)
- PEEP when patient undergoing mech. ventilation to try and decrease FIO2
120
Obstructive diseases with Low, Normal, and High DLCO?
Low-Emphysema
Normal-Chronic bronchitis/Asthma
High-Asthma
121
Restrictive diseases with Low, Normal, and High DLCO?
Low-Sarcoid/Asbestosis, HF, Interstitial lung disease
Normal-MSK deformity, Neuromuscular disease
High-Morbid obesity
122
Normal spirometry diseases with Low, and high DLCO?
Low-Anemia, PE, Pulm HTN
| High-Pulm hemorrhage, Polycythemia
123
Ventilation=?
RRxTV
124
What should be lowered for mechanically ventilated patients with resp. alkalosis?
RR
125
What is first step in initial ventilator management of ARDS?
Decrease FiO2 to non-toxic values (ie
126
What is peak airway pressure=?
Resistive pressure + plateau pressure
127
What is plateau pressure?
Pressure measured during an inspiratory hold maneuver when pulmonary airflow and thus resistive pressures are both 0
128
What ventilator settings affect PaCO2?
Minute Ventilation; RR of 10-12 breaths is appropriate and TV of 4-8 mL/kg is appropriate in most cases.
129
What ventilator settings affect PaO2?
FiO2 and PEEP; FiO2 should be 100% initially with quickly titrating down to lowest possible FiO2 to maintain PaO2 of 50-60. PEEP-5 cm H20
130
What lung pathology will you have increased tactile fremitus?
Consolidation (eg lobar pneumonia)
131
What is alveolar hypoventilation?
Presents with respiratory acidosis with decreased pH (40)
132
CAP gold standard diagnosis?
CXR showing infiltrate
133
Tx. legionella?
Resp fluoroquinolones or macrolides
134
Recurrent pneumonia causes in same part of lung?
- Local anatomic obstruction (bronchial compression (eg neoplasm, mediastinal adenopathy, vascular anomaly), intrinsic bronchial obstruction(eg bronchiectasis, retained foreign body))
- Recurrent aspiration
135
Pneumonia causes in different part of lung?
- Sinopulmonary disease (eg CF, ciliary dyskinesia)
- Immunodeficiency
- Noninfectionous (eg vasculitis, bronchiolitis obliterans with organizing pneumonia)
136
Asbestosis imaging?
Pleural plaques
137
Tx. for aspergilloma vs. invasive aspergillosis?
Aspergilloma-surgical resection
| Invasive aspergillosis-voriconazole/itraconazole
138
What is Wells criteria for DVT?
+3 points: Clinical signs DVT or alternate diagnosis less likely than PE
+1.5 points: Previous PE/DVT, HR>100, recent surgery/immobilization
+1 point: Hemoptysis, Cancer
>4PE likely-->CT angio
D-dimer
139
What anticoagulation you use in severe renal insufficiency and why?
Unfractionated heparin OVER LMWH, fondaparinux, rivaroxabn b/c reduced renal clearance increases activity and bleeding risk
140
Management of flail chest?
Positive pressure mechanical ventilation
141
MCC cor pulmonale?
COPD
142
Gold standard diagnosis cor pumonale?
Rt. heart cath: RV dysfunction, pulm. HTN and no left heart disease
143
COPD antibiotics?
Macrolides, fluoroquinolones or penicillins/b-lactamase inhibitors for 3-7 days
144
Symptom presentation of GERD induced asthma?
Adult onset asthma worse after exercise, lying down, or eating
145
Massive Hemoptysis initial management?
A-airway
B-breathing
C-circulation
146
Tx. for nonallergic rhinitis?
Mild-intranasal antihistamine or glucocorticoids
| Moderate to severe-Combination therapy
147
Tx. for allergic rhinitis?
Intranasal glucocorticoids/antihistamines
148
ARDS cause?
Non-cardiogenic pulm edema from leaky alveolar capillaries
149
Tx. for upper airway cough syndrome (ie postnasal drip)
Oral 1st gen antihistamine (eg chlorpheniramine) or combined antihistamine-decongestant (eg brompeniramine and pseudophedrine)
150
Most common presenting symptom of superior sulcus tumor (pancoast tumor)?
Shoulder pain
151
Definition of idiopathic pulm HTN?
>25 mmHg at rest SBP or >30 mmHg with exercise
152
Presentation of large cell lung carcinoma?
Peripheral, smokers, associated with gynecomastica and galactorrea
153
Side effect of B2 agonist/systemic steroid for acute asthma?
hypokalemia
154
If you have AERD and need to be on NSAIDS, how do you get around it?
Montelukast for desensitization
155
When should you intubate if looking at lab values?
PCO2>50 of PO2
156
Best way to reduce pulm complications post operatively?
Stop smoking preoperatively especially if stopped 8 weeks before surgery
157
```
Typical vs. Atypical pneumonia
Prodrome?
Fever?
Age?
CXR?
Pathogen
Antibiotic?
```
TYPICAL (102, >40, Lobular, S. pneumo, Ceftriaxone)
ATYPICAL (>3 days,
158
Child with recurrent pneumonias. what is it?
Same spot?
Different spots?
Same spot-foreign body aspiration
| Different spots-immunodeficiency, CF
159
Why get follow up CXR in patient >40 with pneumonia?
Make sure ABX responds and if it does not clear up by 4-6 weeks, suspect something else like bronchoalveolar carcinoma
160
Cause of infant RDS?
Atelectasis from surfactant deficiency
