Pulm Flashcards
1
Q
most important treatment intervention for COPD
A
smoking cessation
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)
3
Q
what is normal dec in FEV1 at age 35
A
25-30 ml/yr
4
Q
what is rate of FEV1 decline in smokers?
A
3-4x normal (normal = 25-30 ml/year after age 35)
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)
6
Q
how does absolute long vol compare obs vs res vs normal flow volume loop
A
obs - more vol
res - less vol
7
Q
compare FEF50% obs vs res vs normal flow volume loop
A
obs - FEF50 down
res - FEF50 down less
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
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
10
Q
how long does it take for respiratory symptoms to improve after smoking cessation?
A
11
Q
name a cause of restrictive lung disease
A
diffuse interstitial fibrosis
- idiopathic pulmonary fibrosis
- sarcoid
- autoimmune
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
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
14
Q
drugs for acute COPD exacerbation
A
inhaled corticosteroids (budesonide, fluticasone) antibiotics if infection suspected
15
Q
name two classes of inhaled bronchodilators
A
B agonist eg albuterol (faster, shorter)
anticholinergic eg ipratroprium bromide (more delayed, longer lasting)
16
Q
name 2 inhaled corticosteroids
A
fluticasone
budesonide
17
Q
fluticasone is a…
A
inhaled corticosteroid
18
Q
budesonide is a…
A
inhaled corticosteroid
19
Q
fluticasone and budesonide are…
A
inhaled corticosteroids
20
Q
what are the only 2 interventions shown to reduce mortality in COPDers
A
smoking cessation
home oxygen
21
Q
name two respiratory conditions that contraindicate B blocker use
A
acute COPD
asthma exacerbation
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
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%
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%
25
how does O2 therapy reduce mortality and increase QOL in COPDers?
prevents pulmonary hypertension from hypoxic vasoconstriction
26
Pulm rehab consists of...
education, exercise, physiotherapy... e.g. for COPDer with goal of improving exercise tolerance -- functional status and QOL
27
vaccines for COPDers
flu annually
| strep pneumo q5-6yrs >65yo or v65yo w severe disease
28
normal hematocrit
M 41-53% (say 43-53)
| F 36-46% (say 36-46)
29
T/F beta blockers are used in tx of COPD and asthma
false BBs bronchoconstrict
| beta AGONISTS are used
30
T/F maintanence systemic corticosterioids are used in COPD
F
too many SEs and ^mortality
--> temorary use for ACUTE COPD
31
when is periodic phlebotomy used in tx of COPD?
when hypoxemia causes PCV bad enough for symptoms (fatigue, blurred vision, paresthesias)... plethora is sign of PCV but not significant enough to treat
32
what is plethora
facial redness
ruddy cyanosis
eg with PCV plycyver
33
5 causes of cor pulmonale
```
#1 COPD
pulm fibrosis
pulm vasc disease aka VTE
OSA
chest wall disorders (kyphoscoliosis)
```
34
3 sympx of cor pulmonale
- DOE / fati / leth
- exertional syncope vCO
- exertional angina ^myocardial demand
35
normal JVP waves
```
acxvy
a = atrial contract
c = tricusp closure
x = atrial diastole
v = atrial filling during ventricular contraction
y = passive atrial emptying
```
36
which JVP wave is prominent in cor pulmonale
a wave (atrial contraction)
37
3 heart auscultation findings in cor pulmonale
- loud S2 (inc PA press slams P2 shut)
- tricuspid regurge (holosystolic LLSB... from RV overfilled/dilated)
- distant heart sounds (hyperinflated lungs)
38
liver palpation finding in cor pulmonale
```
pulsatile liver (from congestion)
also hepatomegaly... ascites possible
```
39
define cor pulmonale
RHF from PH
right heart failure
from pulmonary hypertension
40
what proportion of COPD patients get cor pulmonale?
25%
41
2 cxr findings in cor pulmonale
- enlarged central pulmonary arteries
| - loss of retrosternal air space from RVH
42
4 ECG findings in cor pulmonale
RVH
RAD
RBB
RAE right atrial enlargement
43
gold standard for cor pulmonale dx
R heart cath -- ^CVP, ^RVEDP, mean PAP >25mmhg at rest
44
TF
| do not use LABAs (formeterol) as monotherapy in peds because of bbw
T
| don't use LABAs as monotherapy in peds...
45
Tiotropium inhaler is used in ____ not ____
Tiotropium inhaler is used in COPD not asthma
46
Cromolyn nasal spray is typically used for ____
how is it used in asthma
typically used for allergic rhinitis
can be used (though not commonly) prior to exposure to a known trigger of asthma
47
beta receptors in lungs
beta 2
(1 heart, 2 lungs)
heart has beta 1 and 2...
48
pt on carvedilol and lisinopril now has wheezing, which drug most likely cause?
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
49
oral prednisone or IV methylprednisolone for asthma exacerbation in ED?
equivocal
give IV if sicker, vomiting/not tolerating PO, etc
50
when to give steroids for an asthma exacerbation
if do not respond immediately to inhaled bronchodilators
51
when to consider leukotriene antagonist for asthma?
essentially can be considered as an alternate when inhaled corticosteroid is indicated (moderate)
52
role of nedocromil sodium for asthma
for ppx of athletic asthma or asthma with known triggers
53
ipratropium bromide is used as a rescue medication in ___ not ___
ipratropium bromide is used as a rescue medication in COPD not asthma
54
when to give nebulized albuterol/ipratropium before steroids for asthma exacerbation in ED
vitals and ABG stable (not acidotic, not excessively hypoxic or hypercapneic) try nebulizer and move on to steroids if no improvement immediately
55
key signs of anaphylaxis indicating subcutaneous epinephrine
HYPOTENSION... and rash
56
bilateral interstitial infiltrates with wheeze think
CHF... eg in older pt with known heart failure
not asthma (normal cxr)
57
cxr findings in asthma
normal cxr in asthma
| or hyperinflated....
58
which is more immediate "next step" treatment for kid in ED with asthma,
supplemental O2
or
Albuterol Neb
supplemental O2 more immediately "next step"
will also do albuterol neb
59
provide supplemental O2 therapy if SpO2 is low EXCEPT
except for COPDers with SpO2 ^88%
60
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?
get PFTs first, to confirm new dx
Could start LABA+ICS empirically but test wants you to confirm new dx asthma with PFTs
61
Asbestosis increases cancer risk in the setting of ___
the cancer is usually ___
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...)
62
asbestosis causes ____
and with smoking it can cause ____
asbestosis causes INTERSTITIAL LUNG DISEASE
and with smoking it can cause ADENOCARCINOMA
63
lung mass, elevated cortisol, elevated ACTH, despite normal MRI, suggests...
paraneoplastic syndrome from Small Cell Lung Cancer
64
which lung cancer is exquisitely sensitive to chemo / radiation and has probably metastasize by the time you diagnose it
Small Cell Lung Cancer
65
treat small cell lung cancer
chemo and radiation
exquisitely sensitive to chemo / radiation and has probably metastasize by the time you diagnose it
66
TF
| on Step 2, never cut on small cell lung cancer
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
calcifications in lung nodule, benign or malignant?
benign calcifications in lung nodule
68
small lung nodule with calcifications on cxr in asymptomatic young guy -- next step
repeat cxrs for 2 years to track nodule (likely benign -- small, calcifications)
69
who gets screened with CT scan for lung cancer
30ppy smoker
^55yo
have not quit smoking ^10 recent years
(must meet all of the above)
70
when VATS for lung cancer
when bronchoscopy (central, mediastinal) and CT guided (pleural) biopsies can't get to it... so when centrilobular...
71
central pulmonary nodule, how to get to it?
bronchoscopy
72
which lung cancer has paraneoplastic syndrome of hypercalcemia via PTHrp with undetectable PTH level
squamous cell carcinoma
73
paraneoplastic syndromes of small cell lung carcinoma
SIADH
or
Cushing syndrome
74
paraneoplastic syndrome of squamous cell lung carcinoma
hyperparathyroidism
75
paraneoplastic syndromes of specific lung cancers
SCLC - SIADH or Cushings
SCC - HyperParathyroidism
Neurendocrine tumor - Carcinoid syndrome
76
carcinoid syndrome of lung neuroendocrine tumor
flushing wheezing diarrhea
| left-sided lung fibrosis
77
where do PFTs come int to management of lung mass
prior to deciding on surgery -- must assess lung volume and COPD and mets etc before considered a candidate for lobectomy/segmentectomy
78
what lung cancer associated with mesothelioma
adenocarcinoma
79
which is a sign that lung cancer is not resectable
- size
- dyspnea
- hoarseness
- hemoptysis
HOARSENESS
| -indicates local invasion or mets to laryngeal nerve or larynx... either way, incurable with resection
80
Chest CT showing multiple lesions of different sizes on both sides of lung, think...
mets from elsewhere
81
central solitary smoking-associated large lung mass think
SCC (squamous cell carcinoma)
82
central smoking-associated small lung mass think
SCLC
83
how valve stenosis can tell you whether carcinoid came from lung or intestines
R sided valve stenosis - GI
L sided valve stenosis - Lung
84
wheezing, diarrhea, L vs R sided valve stenosis think...
L stenosis think lung carcinoid
R stenosis think intestinal carcinoid
85
when does pleural effusion necessitate thoracotomy/VATS/decortication
when loculated and failed other treatments first
86
1st line treatment of pleural effusion related to CHF
diuretics
87
adenosine deaminase (ADA) elevated in pleural effusion is a marker of...
TB
88
treat parapneumonic effusion (effusion from pneumonia)
thoracostomy (chest tube) and antibiotics
(abx alone insufficient as poor penetration to extraparenchymal space... thoracostomy to break up loculations and free the fluid)
89
2 pulmonary conditions for which heparin is useful
PE
acute interstitial pneumonitis
usual heparin is the wrong answer in the lungs
90
is a large apparently single pleural effusion on axial CT that climbs the lateral wall loculated or not?
loculated
if not, it would settle out in dependent location, not climb the side wall
91
thoracentesis or thoracostomy for loculated pleural effusion?
thoracostomy
92
initial treatment of loculated pleural effusion
thoracostomy
93
```
key pleural effusion characteristics of
CHF
nephrotic syndrome
cirrhosis
TB
PNA
malignancy
```
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
pt w pleural effusion on cxr not complicated by any other signs or symptoms, what to do before thoracentesis
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
how does thoracostomy allow breakup of loculations
access for digital manipulation
96
decortication for loculated pleural effusion means
thoracostomy -- thoracotomy or VATS
97
pt with history of stage IV NSCLC recurrence now with first time unloculated pleural effusion -- thoracentesis or thoracostomy?
thoracentesis - diagnostic and therapeutic
thoracostomy with permanent chest tube for pt self-drainage way down line if fluid reacummulates after repeat thoracenteses
98
probable postop PE in pt with elevated Cr and normal CXR and chest exam
diagnostic test of choice is...
V/Q scan
can be performed because normal cxr and chest exam
CT PE contraindicated because of contrast and elevated Cr
99
when to get V/Q scan instead of CT PE to diagnose PE
if elevated Cr (contrast contraindicated)
| and cxr and chest exam normal
100
when to used-dimer in setting of PE
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
gold standart for dx of pulmonary embolism
when is it actually used
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
postop pt with sob, pleuritic cp, and bibasilar atelectasis on cxr, but stable vitals, and signs of DVT... diagnostic test of choice is...
US lower extremity
dx DVT very uninvasively and treatment of DVT and PE is the same (avoid cost and radiation of CT PE)
103
pt with colon ca mets to liver lung and brain now with PE -- tx
IVC filter
-don't anticoagulate because mets to brain = bleed risk
104
IVC filter decreases risk of PE but increases risk of ___
IVC filter decreases risk of PE but increases risk of DVT
105
TF
| renal failure contraindicates LMWH to Coumadin
T
106
when is starting Coumadin on its own ok
only in atrial fibrillation where there is no clot
| otherwise heparin bridge during hypercoagulable onset
107
how to treat DVT pt with ESRD
heparin infusion bridge to coumadin
| renal failure contraindicates LMWH
108
how does renal failure complicate DVT treatment
renal failure contraindicates LMWH
so do IV heparin to warfarin
109
when to lace IVC filter
if bleed risk contraindicates anticoagulation
if failed warfarin, other anticoagulants
110
when rivaroxaban or other NOACs for DVT?
if warfarin fails
NOACS approved for first line and simple but new and expensive
111
pt treated for GI bleed gets PE on POD5, treat
IVC filter
| don't hep to warf in bleed risk!
112
when is heparin drip needed instead of LMWH to bridge to warfarin for DVT?
what are the drawbacks?
heparin drip only needed if renal failure or sub-massive pulmonary embolism
(inconvenient frequent PTT draws and inpatient)
113
TF
| a DVT in an otherwise healthy patient can be treated as an outpatient
T
| LMWH send home and change to warfarin
114
treat PE in pt with colon ca mets to liver lungs and spine but not brain
LMWH SQ (no bridge!)
CLOT trial showed that LMWH prevents next PE in metastatic pts (but not mortality)
115
normal Cr, mets, but no mets to brain, treat PE
LMWH SQ (no bridge!)
CLOT trial showed that LMWH prevents next PE in metastatic pts (but not mortality)
116
TF
stage IV cancer contraindicates coumadin
how do you treat PE in metastatic cancer?
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
treat PE in metastatic cancer
LMWH SQ as long as not contraindicated by renal failure or bleed risk
IVC filter if high Cr or bleed risk
(Coumadin contraindicated...)
118
TF
| bilateral pulmonary emboli in main pulmonary arteries on CT PE = massive or submassive PE
F
| scary size/location on CT does not determine massive/submassive PE -- the RESPONSE OF THE CV SYSTEM determines this
119
treat bilateral pulmonary emboli in main pulmonary arteries on CT PE with stable vitals
the usual LMWH - Warfarin
just a regular PE if no hypotentsion
120
diagnose massive PE
treat
Hypotension
evidence of heart strain with BNP Trop or Echo
treat with IV heparin or tPA
121
remove IVC filter....
as soon as contraindication to anticoagulation is removed
122
the only 2 therapies that reduce mortality in COPD
smoking cessation
home oxygen therapy (but only in pts with severe hypoxemia SpO2 v88% or PaO2 v55)
123
when does home oxygen therapy reduce mortality like smoking cessation in COPDers
in pts with severe hypoxemia SpO2 v88% or PaO2 v55)
124
how does PaO2 correspond to SpO2
PaO2 60 = SpO2 90
125
chronic hypoxemia can lead to
pulmonary htn
126
tiotropium drug class
inhaled anticholinergic
127
common mgmt for COPD
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
why does high % O2 supplementation depress respiratory drive in COPDers
HYPOVENTILATION
Used to think blunts hypoxic respiratory drive, now know that mechanism is OVERRIDE of appropriate SHUNTING (oxygen is a pulmonary vasodilator...)
129
why do critically ill patients most often have difficulty weaning from ventilator
diaphragmatic dysfunction
...related to changes at the cellular level due to sepsis, steroid use, etc...
130
when to think COPDer is having difficulty weaning from ventilator from hypoventilation vs hyperventilation
and what are the mechanisms of these
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
antibiotic of choice for COPD exacerbation
Doxycycline
2nd lines include Azithromycin, Amoxicillin Clavalunate, Cefuroxime
(avoid broad spec resistance, cost)
132
excessively high tidal volumes on ventilator can cause
pneumothorax
133
PaO2/FiO2 ratio in ARDS
v200
134
when is iatrogenic laryngeal stenosis a concern in the ICU patient
laryngeal stenosis a complication of prolongued intubation
135
guidlines for tracheostomy in intubated ICU patient
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
toxic obtunded febrile patient with severe pulmonary edema diffuse not in lobar distribution think
ARDS... from leaky capillaries not excess fluid
137
EF and PCWP in ARDS
EF up... inc CO in response to third spacing
PCWP down... leaky capillaries third spacing
138
pulmonary edema with normal PCWP is
non-cardiogenic pulmonary edema
| e.g. ARDS if due to inflammation
139
what is transfusion related lung injury (TRALI)
non-cardiogenic pulmonary edema from transfusion -- with hypoxemia, fever, edema
140
ship yard worker risks what pulmonary disease
asbestosis
141
asbestosis on cxr
pleural plaques
142
sarcoidosis on cxr
most common in this demographic
bilateral hylar lymphadenopathy
African Aemerican Females
143
sand-blasting / rock quarry job and upper lobe lung nodules think...
Silicosis
144
Silicosis on cxr
upper lobe lung nodules
145
Pneumoconiosis is caused by occupational exposure to....
heavy metals (gold nickel silver)
146
occupational exposure to heavy metals (gold nickel silver) and insidious hypoxemia over years with ground glass opacificaitons on cxr think...
pneumoconiosis
147
pneumoconiosis
caused by
presentation
cxr
occupational exposure to heavy metals (gold nickel silver)
insidious hypoxemia over years
ground glass opacificaitons on cxr
148
Black Lung Disease
aka
cxr
consider particularly when
aka coal miner's lung
cxr no characteristic findings
consider particularly when Interstitial lung disease and arthritis
149
asbestosis risk increased in these occupations
ship yard
| demolition
150
exposure, cxr in:
```
asbestosis
silicosis
pneumoconiosis
coal-miner's lung
sarcoidosis
```
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
woman probably has sarcoid of lungs... next step
BIOPSY that shit to diagnose (non-caseating granulomas)
152
noncaseating granulomas can produce their own ____ which can lead t ____
noncaseating granulomas can produce their own vitamin D which can lead to hypercalcemi
153
TF
| you can diagnose sarcoid by biopsying e.nodosum on skin
F
| that will just diagnose E nodosum... must biopsy affected sarcoid organ for dx of sarcoid
