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Medicine > Pulm > Flashcards

Pulm Flashcards

1
Q

most important treatment intervention for COPD

A

smoking cessation

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2
Q

does smoking cessation reverse or slow progression of COPD

A

slows progression, to rate of FEV1 decline comparable to normal person (normal = 25-30 ml/year after age 35… smoking = 3-4x this rate… 75-120 ml/year)

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3
Q

what is normal dec in FEV1 at age 35

A

25-30 ml/yr

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4
Q

what is rate of FEV1 decline in smokers?

A

3-4x normal (normal = 25-30 ml/year after age 35)

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5
Q

how does smoking cessation affect survival in COPDer

A

prolongs survival but does not reach rate of never smoker (rate if FEV1 decline normalizes but was accelerated for a time so absolute FEV1 is still decreased compared to normal)

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6
Q

how does absolute long vol compare obs vs res vs normal flow volume loop

A

obs - more vol

res - less vol

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7
Q

compare FEF50% obs vs res vs normal flow volume loop

A

obs - FEF50 down

res - FEF50 down less

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8
Q

what does FEF50% stand for

A

forced expiratory flow (rate) at 50% of lung volume

e.g. half way along curve on flow volume loop

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9
Q

compare flow volume loop obs vs res vs normal

A

obs - left of normal (more absolute vol), chaired out, low FEF50

res - right of normal (less absolute vol), shape of curve like normal (not chaired) but smaller, low FEF50 but not as bad as obstructive

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10
Q

how long does it take for respiratory symptoms to improve after smoking cessation?

A
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11
Q

name a cause of restrictive lung disease

A

diffuse interstitial fibrosis

  • idiopathic pulmonary fibrosis
  • sarcoid
  • autoimmune
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12
Q

Tx of COPD

A

bronchodilators
-inhaled anticholinergics (ipratroprium bromide)
slower onset but longer lasting
-inhaled B agonist (albuterol)
faster acting but shorter lasting
-combo
-inhaled corticosteroids (budesonide, fluticasone)
anti-inflammatory, may minimally slow FEV1 decline but evidence not great… used in combo w long acting broncho d’s for bad sympx or repeat exacerbations, or in acute exacerbations
-Abx in acute exacerbations
-theophylline (controversial), occasionally used for refractory COPD
-O2 therapy
-pulmonary rehab
-vaccination - flu yearly, strep pneumo q5-6yr for COPD >65 or less than 65 with severe disease

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13
Q

when to use inhaled corticosteroids (budesonide, fluticasone) to tx COPD

A
  • typically combo with long acting bronchodilator for very bad sympx or repeated exacerbations
  • for acute exacerbations, eg with abx for infection

evidence for chronic use or improvement of pulmonary function not great

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14
Q

drugs for acute COPD exacerbation

A 
inhaled corticosteroids (budesonide, fluticasone)
antibiotics if infection suspected
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15
Q

name two classes of inhaled bronchodilators

A

B agonist eg albuterol (faster, shorter)

anticholinergic eg ipratroprium bromide (more delayed, longer lasting)

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16
Q

name 2 inhaled corticosteroids

A

fluticasone

budesonide

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17
Q

fluticasone is a…

A

inhaled corticosteroid

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18
Q

budesonide is a…

A

inhaled corticosteroid

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19
Q

fluticasone and budesonide are…

A

inhaled corticosteroids

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20
Q

what are the only 2 interventions shown to reduce mortality in COPDers

A

smoking cessation

home oxygen

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21
Q

name two respiratory conditions that contraindicate B blocker use

A

acute COPD

asthma exacerbation

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22
Q

when is theophylline used for COPD

A

occasionally for refractory COPD
^cAMP, controversial effectiveness and use, may inc mucociliary clearance, inc resp drive, but less effective than other broncho d’s and more SEs, narrow therapeutic index, needs monitoring of serum levels

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23
Q

when is O2 therapy used in COPD

A

when chornic hypoxemia present duh – determined by ABG (PaO2 55mmhg or…. PaO2 55-58 w PCV plycyver HC>55% or cor pulm RHF or…… O2 sat less than 88%

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24
Q

how to determine COPDer need for O2 therapy?

A

get an ABG (or’s)

  • PaO2 55mmhg
  • PaO2 55-58mmhg + PCV polcyver (HC>55%) or cor pulm RHF
  • O2 sat v88%
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25
Q

how does O2 therapy reduce mortality and increase QOL in COPDers?

A

prevents pulmonary hypertension from hypoxic vasoconstriction

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26
Q

Pulm rehab consists of…

A

education, exercise, physiotherapy… e.g. for COPDer with goal of improving exercise tolerance – functional status and QOL

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27
Q

vaccines for COPDers

A

flu annually

strep pneumo q5-6yrs >65yo or v65yo w severe disease

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28
Q

normal hematocrit

A

M 41-53% (say 43-53)

F 36-46% (say 36-46)

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29
Q

T/F beta blockers are used in tx of COPD and asthma

A

false BBs bronchoconstrict

beta AGONISTS are used

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30
Q

T/F maintanence systemic corticosterioids are used in COPD

A

F
too many SEs and ^mortality
–> temorary use for ACUTE COPD

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31
Q

when is periodic phlebotomy used in tx of COPD?

A

when hypoxemia causes PCV bad enough for symptoms (fatigue, blurred vision, paresthesias)… plethora is sign of PCV but not significant enough to treat

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32
Q

what is plethora

A

facial redness
ruddy cyanosis
eg with PCV plycyver

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33
Q

5 causes of cor pulmonale

A 
#1 COPD
pulm fibrosis
pulm vasc disease aka VTE
OSA
chest wall disorders (kyphoscoliosis)
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34
Q

3 sympx of cor pulmonale

A
  • DOE / fati / leth
  • exertional syncope vCO
  • exertional angina ^myocardial demand
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35
Q

normal JVP waves

A 
acxvy
a = atrial contract
c = tricusp closure
x = atrial diastole
v = atrial filling during ventricular contraction
y = passive atrial emptying
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36
Q

which JVP wave is prominent in cor pulmonale

A

a wave (atrial contraction)

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37
Q

3 heart auscultation findings in cor pulmonale

A
  • loud S2 (inc PA press slams P2 shut)
  • tricuspid regurge (holosystolic LLSB… from RV overfilled/dilated)
  • distant heart sounds (hyperinflated lungs)
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38
Q

liver palpation finding in cor pulmonale

A 
pulsatile liver (from congestion)
also hepatomegaly... ascites possible
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39
Q

define cor pulmonale

A

RHF from PH
right heart failure
from pulmonary hypertension

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40
Q

what proportion of COPD patients get cor pulmonale?

A

25%

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41
Q

2 cxr findings in cor pulmonale

A
  • enlarged central pulmonary arteries

- loss of retrosternal air space from RVH

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42
Q

4 ECG findings in cor pulmonale

A

RVH
RAD
RBB
RAE right atrial enlargement

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43
Q

gold standard for cor pulmonale dx

A

R heart cath – ^CVP, ^RVEDP, mean PAP >25mmhg at rest

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44
Q

TF

do not use LABAs (formeterol) as monotherapy in peds because of bbw

A

T

don’t use LABAs as monotherapy in peds…

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45
Q

Tiotropium inhaler is used in ____ not ____

A

Tiotropium inhaler is used in COPD not asthma

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46
Q

Cromolyn nasal spray is typically used for ____

how is it used in asthma

A

typically used for allergic rhinitis

can be used (though not commonly) prior to exposure to a known trigger of asthma

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47
Q

beta receptors in lungs

A

beta 2
(1 heart, 2 lungs)

heart has beta 1 and 2…

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48
Q

pt on carvedilol and lisinopril now has wheezing, which drug most likely cause?

A

carvedilol
-beta blocker… can block beta 2 in lungs causing bronchoconstriction

Lisinopril can cause angioedema, but this more supraglottic narrowing and inspiratory stridor, not wheezing

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49
Q

oral prednisone or IV methylprednisolone for asthma exacerbation in ED?

A

equivocal

give IV if sicker, vomiting/not tolerating PO, etc

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50
Q

when to give steroids for an asthma exacerbation

A

if do not respond immediately to inhaled bronchodilators

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51
Q

when to consider leukotriene antagonist for asthma?

A

essentially can be considered as an alternate when inhaled corticosteroid is indicated (moderate)

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52
Q

role of nedocromil sodium for asthma

A

for ppx of athletic asthma or asthma with known triggers

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53
Q

ipratropium bromide is used as a rescue medication in ___ not ___

A

ipratropium bromide is used as a rescue medication in COPD not asthma

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54
Q

when to give nebulized albuterol/ipratropium before steroids for asthma exacerbation in ED

A

vitals and ABG stable (not acidotic, not excessively hypoxic or hypercapneic) try nebulizer and move on to steroids if no improvement immediately

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55
Q

key signs of anaphylaxis indicating subcutaneous epinephrine

A

HYPOTENSION… and rash

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56
Q

bilateral interstitial infiltrates with wheeze think

A

CHF… eg in older pt with known heart failure

not asthma (normal cxr)

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57
Q

cxr findings in asthma

A

normal cxr in asthma

or hyperinflated….

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58
Q

which is more immediate “next step” treatment for kid in ED with asthma,
supplemental O2
or
Albuterol Neb

A

supplemental O2 more immediately “next step”

will also do albuterol neb

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59
Q

provide supplemental O2 therapy if SpO2 is low EXCEPT

A

except for COPDers with SpO2 ^88%

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60
Q

pt with new clinical dx moderate persistent asthma s/p move into new dorm room causing daily sx and every other night sx – start on fluticasone/salmeterol or get PFTs?

A

get PFTs first, to confirm new dx

Could start LABA+ICS empirically but test wants you to confirm new dx asthma with PFTs

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61
Q

Asbestosis increases cancer risk in the setting of ___

the cancer is usually ___

A

Asbestosis increases cancer risk in the setting of SMOKING (need additional epithelial damage for cancer)

the cancer is usually ADENOCARCINOMA (peripheral/plearual… even though adenocarcinoma is a classically non-smoker cancer…)

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62
Q

asbestosis causes ____

and with smoking it can cause ____

A

asbestosis causes INTERSTITIAL LUNG DISEASE

and with smoking it can cause ADENOCARCINOMA

63
Q

lung mass, elevated cortisol, elevated ACTH, despite normal MRI, suggests…

A

paraneoplastic syndrome from Small Cell Lung Cancer

64
Q

which lung cancer is exquisitely sensitive to chemo / radiation and has probably metastasize by the time you diagnose it

A

Small Cell Lung Cancer

65
Q

treat small cell lung cancer

A

chemo and radiation

exquisitely sensitive to chemo / radiation and has probably metastasize by the time you diagnose it

66
Q

TF

on Step 2, never cut on small cell lung cancer

A

T
in life, lobectomy or pneumonectomy indicated for non-metastasized sclc…. BUT on the TEST – CHEMO and RADs because exquisitely sensitive to chemo / radiation and has probably metastasize by the time you diagnose it

67
Q

calcifications in lung nodule, benign or malignant?

A

benign calcifications in lung nodule

68
Q

small lung nodule with calcifications on cxr in asymptomatic young guy – next step

A

repeat cxrs for 2 years to track nodule (likely benign – small, calcifications)

69
Q

who gets screened with CT scan for lung cancer

A

30ppy smoker
^55yo
have not quit smoking ^10 recent years

(must meet all of the above)

70
Q

when VATS for lung cancer

A

when bronchoscopy (central, mediastinal) and CT guided (pleural) biopsies can’t get to it… so when centrilobular…

71
Q

central pulmonary nodule, how to get to it?

A

bronchoscopy

72
Q

which lung cancer has paraneoplastic syndrome of hypercalcemia via PTHrp with undetectable PTH level

A

squamous cell carcinoma

73
Q

paraneoplastic syndromes of small cell lung carcinoma

A

SIADH
or
Cushing syndrome

74
Q

paraneoplastic syndrome of squamous cell lung carcinoma

A

hyperparathyroidism

75
Q

paraneoplastic syndromes of specific lung cancers

A

SCLC - SIADH or Cushings

SCC - HyperParathyroidism

Neurendocrine tumor - Carcinoid syndrome

76
Q

carcinoid syndrome of lung neuroendocrine tumor

A

flushing wheezing diarrhea

left-sided lung fibrosis

77
Q

where do PFTs come int to management of lung mass

A

prior to deciding on surgery – must assess lung volume and COPD and mets etc before considered a candidate for lobectomy/segmentectomy

78
Q

what lung cancer associated with mesothelioma

A

adenocarcinoma

79
Q

which is a sign that lung cancer is not resectable

  • size
  • dyspnea
  • hoarseness
  • hemoptysis
A

HOARSENESS

-indicates local invasion or mets to laryngeal nerve or larynx… either way, incurable with resection

80
Q

Chest CT showing multiple lesions of different sizes on both sides of lung, think…

A

mets from elsewhere

81
Q

central solitary smoking-associated large lung mass think

A

SCC (squamous cell carcinoma)

82
Q

central smoking-associated small lung mass think

A

SCLC

83
Q

how valve stenosis can tell you whether carcinoid came from lung or intestines

A

R sided valve stenosis - GI

L sided valve stenosis - Lung

84
Q

wheezing, diarrhea, L vs R sided valve stenosis think…

A

L stenosis think lung carcinoid

R stenosis think intestinal carcinoid

85
Q

when does pleural effusion necessitate thoracotomy/VATS/decortication

A

when loculated and failed other treatments first

86
Q

1st line treatment of pleural effusion related to CHF

A

diuretics

87
Q

adenosine deaminase (ADA) elevated in pleural effusion is a marker of…

A

TB

88
Q

treat parapneumonic effusion (effusion from pneumonia)

A

thoracostomy (chest tube) and antibiotics

(abx alone insufficient as poor penetration to extraparenchymal space… thoracostomy to break up loculations and free the fluid)

89
Q

2 pulmonary conditions for which heparin is useful

A

PE
acute interstitial pneumonitis

usual heparin is the wrong answer in the lungs

90
Q

is a large apparently single pleural effusion on axial CT that climbs the lateral wall loculated or not?

A

loculated

if not, it would settle out in dependent location, not climb the side wall

91
Q

thoracentesis or thoracostomy for loculated pleural effusion?

A

thoracostomy

92
Q

initial treatment of loculated pleural effusion

A

thoracostomy

93
Q 
key pleural effusion characteristics of
CHF
nephrotic syndrome
cirrhosis
TB
PNA
malignancy
A

CHF - transudate (effusion LDH and protein vs serum ratios v.6, no leukocytes

nephrotic syndrome - transudate, low serum albumin

cirrhosis - transudate…

TB - exudate, leukocytes, AFB or ADA (adenosine deaminase) positive

PNA - exudate, leukocytes

malignancy - exudate, cancer on cytology

94
Q

pt w pleural effusion on cxr not complicated by any other signs or symptoms, what to do before thoracentesis

A

dependent xr to check nont loculated and at least 1cm tall and safely tappable

(CT in pt without signs of cancer etc unnecessary radiation and cost)

95
Q

how does thoracostomy allow breakup of loculations

A

access for digital manipulation

96
Q

decortication for loculated pleural effusion means

A

thoracostomy – thoracotomy or VATS

97
Q

pt with history of stage IV NSCLC recurrence now with first time unloculated pleural effusion – thoracentesis or thoracostomy?

A

thoracentesis - diagnostic and therapeutic

thoracostomy with permanent chest tube for pt self-drainage way down line if fluid reacummulates after repeat thoracenteses

98
Q

probable postop PE in pt with elevated Cr and normal CXR and chest exam

diagnostic test of choice is…

A

V/Q scan

can be performed because normal cxr and chest exam

CT PE contraindicated because of contrast and elevated Cr

99
Q

when to get V/Q scan instead of CT PE to diagnose PE

A

if elevated Cr (contrast contraindicated)

and cxr and chest exam normal

100
Q

when to used-dimer in setting of PE

A

not usually

maybe in clinic to rule out PE in low-risk pt without symptoms – aka this is not PE, how do you rule it out – can get a d-dimer

101
Q

gold standart for dx of pulmonary embolism

when is it actually used

A

PE angiogram = gold standard
however invasive, contrast, similar sn sp as CT PE

actually used RARELY, for:

  • MASSIVE PE producing HYPOTENSION (for tPA admin)
  • for thrombectomy
  • extremely high pre-test probability with negative CT
102
Q

postop pt with sob, pleuritic cp, and bibasilar atelectasis on cxr, but stable vitals, and signs of DVT… diagnostic test of choice is…

A

US lower extremity

dx DVT very uninvasively and treatment of DVT and PE is the same (avoid cost and radiation of CT PE)

103
Q

pt with colon ca mets to liver lung and brain now with PE – tx

A

IVC filter

-don’t anticoagulate because mets to brain = bleed risk

104
Q

IVC filter decreases risk of PE but increases risk of ___

A

IVC filter decreases risk of PE but increases risk of DVT

105
Q

TF

renal failure contraindicates LMWH to Coumadin

A

T

106
Q

when is starting Coumadin on its own ok

A

only in atrial fibrillation where there is no clot

otherwise heparin bridge during hypercoagulable onset

107
Q

how to treat DVT pt with ESRD

A

heparin infusion bridge to coumadin

renal failure contraindicates LMWH

108
Q

how does renal failure complicate DVT treatment

A

renal failure contraindicates LMWH

so do IV heparin to warfarin

109
Q

when to lace IVC filter

A

if bleed risk contraindicates anticoagulation

if failed warfarin, other anticoagulants

110
Q

when rivaroxaban or other NOACs for DVT?

A

if warfarin fails

NOACS approved for first line and simple but new and expensive

111
Q

pt treated for GI bleed gets PE on POD5, treat

A

IVC filter

don’t hep to warf in bleed risk!

112
Q

when is heparin drip needed instead of LMWH to bridge to warfarin for DVT?

what are the drawbacks?

A

heparin drip only needed if renal failure or sub-massive pulmonary embolism

(inconvenient frequent PTT draws and inpatient)

113
Q

TF

a DVT in an otherwise healthy patient can be treated as an outpatient

A

T

LMWH send home and change to warfarin

114
Q

treat PE in pt with colon ca mets to liver lungs and spine but not brain

A

LMWH SQ (no bridge!)

CLOT trial showed that LMWH prevents next PE in metastatic pts (but not mortality)

115
Q

normal Cr, mets, but no mets to brain, treat PE

A

LMWH SQ (no bridge!)

CLOT trial showed that LMWH prevents next PE in metastatic pts (but not mortality)

116
Q

TF
stage IV cancer contraindicates coumadin

how do you treat PE in metastatic cancer?

A

T

so use LMWH SQ as long as not contraindicated by renal failure or bleed risk

IVC filter if high Cr or bleed risk

117
Q

treat PE in metastatic cancer

A

LMWH SQ as long as not contraindicated by renal failure or bleed risk

IVC filter if high Cr or bleed risk

(Coumadin contraindicated…)

118
Q

TF

bilateral pulmonary emboli in main pulmonary arteries on CT PE = massive or submassive PE

A

F

scary size/location on CT does not determine massive/submassive PE – the RESPONSE OF THE CV SYSTEM determines this

119
Q

treat bilateral pulmonary emboli in main pulmonary arteries on CT PE with stable vitals

A

the usual LMWH - Warfarin

just a regular PE if no hypotentsion

120
Q

diagnose massive PE

treat

A

Hypotension
evidence of heart strain with BNP Trop or Echo

treat with IV heparin or tPA

121
Q

remove IVC filter….

A

as soon as contraindication to anticoagulation is removed

122
Q

the only 2 therapies that reduce mortality in COPD

A

smoking cessation

home oxygen therapy (but only in pts with severe hypoxemia SpO2 v88% or PaO2 v55)

123
Q

when does home oxygen therapy reduce mortality like smoking cessation in COPDers

A

in pts with severe hypoxemia SpO2 v88% or PaO2 v55)

124
Q

how does PaO2 correspond to SpO2

A

PaO2 60 = SpO2 90

125
Q

chronic hypoxemia can lead to

A

pulmonary htn

126
Q

tiotropium drug class

A

inhaled anticholinergic

127
Q

common mgmt for COPD

A

smoking cessation
home oxygen

inhaled LABA and IPRATROPIUM for symptomatic relief

inhaled LABA + ICS if severe

oral Prednisone for exacerbations

Cetirizine to prevent exacerbations

128
Q

why does high % O2 supplementation depress respiratory drive in COPDers

A

HYPOVENTILATION

Used to think blunts hypoxic respiratory drive, now know that mechanism is OVERRIDE of appropriate SHUNTING (oxygen is a pulmonary vasodilator…)

129
Q

why do critically ill patients most often have difficulty weaning from ventilator

A

diaphragmatic dysfunction

…related to changes at the cellular level due to sepsis, steroid use, etc…

130
Q

when to think COPDer is having difficulty weaning from ventilator from hypoventilation vs hyperventilation

and what are the mechanisms of these

A

hypoventilation if SpO2 98-100%… giving high FiO2 but not ventilating as much (can’t wean because overriding pulmonary shunting according to oxygenation)

hyperventilation if PaCO2 low or near normal (baseline likely a little high, so normal may depress hypercapneic respiratory drive)

131
Q

antibiotic of choice for COPD exacerbation

A

Doxycycline

2nd lines include Azithromycin, Amoxicillin Clavalunate, Cefuroxime

(avoid broad spec resistance, cost)

132
Q

excessively high tidal volumes on ventilator can cause

A

pneumothorax

133
Q

PaO2/FiO2 ratio in ARDS

A

v200

134
Q

when is iatrogenic laryngeal stenosis a concern in the ICU patient

A

laryngeal stenosis a complication of prolongued intubation

135
Q

guidlines for tracheostomy in intubated ICU patient

A

tracheostomy early if expect protracted course (prolongued intubation can lead to laryngeal stensosis)

delay tracheostomy as long as possible if pt likely to recover

this boils down to tracheostomy at about day 14 of intubation

136
Q

toxic obtunded febrile patient with severe pulmonary edema diffuse not in lobar distribution think

A

ARDS… from leaky capillaries not excess fluid

137
Q

EF and PCWP in ARDS

A

EF up… inc CO in response to third spacing

PCWP down… leaky capillaries third spacing

138
Q

pulmonary edema with normal PCWP is

A

non-cardiogenic pulmonary edema

e.g. ARDS if due to inflammation

139
Q

what is transfusion related lung injury (TRALI)

A

non-cardiogenic pulmonary edema from transfusion – with hypoxemia, fever, edema

140
Q

ship yard worker risks what pulmonary disease

A

asbestosis

141
Q

asbestosis on cxr

A

pleural plaques

142
Q

sarcoidosis on cxr

most common in this demographic

A

bilateral hylar lymphadenopathy

African Aemerican Females

143
Q

sand-blasting / rock quarry job and upper lobe lung nodules think…

A

Silicosis

144
Q

Silicosis on cxr

A

upper lobe lung nodules

145
Q

Pneumoconiosis is caused by occupational exposure to….

A

heavy metals (gold nickel silver)

146
Q

occupational exposure to heavy metals (gold nickel silver) and insidious hypoxemia over years with ground glass opacificaitons on cxr think…

A

pneumoconiosis

147
Q

pneumoconiosis
caused by
presentation
cxr

A

occupational exposure to heavy metals (gold nickel silver)
insidious hypoxemia over years
ground glass opacificaitons on cxr

148
Q

Black Lung Disease
aka
cxr
consider particularly when

A

aka coal miner’s lung
cxr no characteristic findings
consider particularly when Interstitial lung disease and arthritis

149
Q

asbestosis risk increased in these occupations

A

ship yard

demolition

150
Q

exposure, cxr in:

asbestosis
silicosis
pneumoconiosis
coal-miner's lung
sarcoidosis
A

asbestosis - shipyard, construction, pleural plaques…adenocarcinoma mesothelioma

silicosis - rock quarry, sand blasting, upper lobe nodules

pneumoconiosis - heavy metals (gold nickel silver), ground glass opacifications

coal-miner’s lung - coal mine, no cxr pattern… interstitial lung disease ish maybe

sarcoidosis - african american female, hilar lymphadenopathy

151
Q

woman probably has sarcoid of lungs… next step

A

BIOPSY that shit to diagnose (non-caseating granulomas)

152
Q

noncaseating granulomas can produce their own ____ which can lead t ____

A

noncaseating granulomas can produce their own vitamin D which can lead to hypercalcemi

153
Q

TF

you can diagnose sarcoid by biopsying e.nodosum on skin

A

F

that will just diagnose E nodosum… must biopsy affected sarcoid organ for dx of sarcoid

Medicine (13 decks)

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