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Pulm Flashcards

1
Q

SOB + non productive cough + wheezing

A

Bronchospasm
Caused by reversible inflammation
Triggers can be cold, exercise

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2
Q

Intubated pt with Hypoxia, dullness to percussion, complete opacification of one lung

A

Airway obstruction causing complete atelectasis
Vent -> decreased mucociliary motility -> mucus plug formation
Tx - bronchoscopy

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3
Q

How do you bx a pt that has a centrally located lung mass suspcious for cancer?

A

Bronchoscopy

Peripheral masses - thoracoscopic or needle bx

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4
Q

Decreased diffusion capacity of the lung for CO

A

emphysema

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5
Q

Tx for primary PHTN

A

Prostacyclins, endothelin receptor antagonists or PDE-5 inhibitors
Goal is to vasodilate
Warfarin for all d/t increased risk of DVT/PE
IF they respond to vasodilation - CCB for long term management

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6
Q

Pt gets bronchospasms with NSAID use. Why?

A

Causes a shunting effect and increases production of leukotrienes (potent bronchoconstricotrs)

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7
Q

Silicosis increases the risk of?

A

TB
30x increase
All pts should receive a PPD

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8
Q

Best prognostic indicator in COPD?

A

FEV1

Determines degree of obstruction and monitors progression of dz

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9
Q

FEV1/FVC < 70%

NL DLCO

A

Chronic bronchitis

Asthma

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10
Q

FEV1/FVC <70%

Low DLCO

A

Emphysema

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11
Q

FEV1/FVC 70-80%

low DLCO

A

Interstitial lung dz

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12
Q

Management of acute exacerbation of COPD

A

Bronchodilators, glucocorticoids, abx
If failed -> Non invasive positive-pressure ventilation (NPPV) - PEEP via facemask
If failed -> intubate

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13
Q

What two criteria determine ventilation for a intubated pt?

A

rr x TV
Hyperventilation -> respalkalosis (PO2>100)
Good to start by decreasing the rr

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14
Q

How do you estimate tidal volume for a vent?

A

6mL/kg of ideal body weight

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15
Q

Which test is most sensitive for new onset orthostatic hypotension?

A

Decreased urine sodium (FENa <1%)
Usually caused by underlying hypovolemia
Hypovolemia -> low renal perfusion -> activates RAAS (aldosterone) -> avid uptake of salt and water into the circulation

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16
Q

How is orthostatic defined

A

Drop >20mmHg in SBP

Drop >10mmHg in DBP

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17
Q

sudden onset dyspnea, tachy, tachypnea

A

Pulm embolism
Pleuritic pain, hemoptysis
look for recent travel hx

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18
Q

Most positive impact on survivial in a COPD pt?

A

Long term home oxygen

Proven to prolong survivial

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19
Q

Night time cough -> think?

A

Gerd
Add a PPI
(-prazole)

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20
Q

What is a goal FiO2 while on a vent?

A

<60%, goal is to wean a pt below this to avoid Oxygen toxicity

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21
Q

How does mechanical ventilation improve oxygenation?

A

Increased FiO2

PEEP (decreases dead space)

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22
Q

3 most common causes of chronic cough

A

Upper-aireway cough syndrome (postnasal drip)
Asthma
GERD

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23
Q

Tx for upper-airway cough syndrome (post nasal drip)

A

Chlorpheniramine (1st gen antihistamine, H1 receptor blocker)
Decreases nasal secretions
RF’s - allergies, vasomotos rhinitis, sinusitis

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24
Q

Initial management of PE pt with renal failure

A

Unfractionated heparin

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25
PNA pt has sudden hypoxia and CXR b/l alveolar infiltrates
ARDS Causes impaired gas exchange (V/Q mismatch), lung compliance (stiff lungs d/t loss of surfactant and increased recoil), pulm HTN (d/t hypoxic vasoconstriction
26
Why does PNA cause hypoxia?
V/Q mismatch, intrapulmonary shunting | Difficult to correct hypoxia in the absence of alveolar ventilation
27
Thoracentesis reveals pleural fluid with glucose < 60 and LDH >60
Empyema | Exudative effusion with low glucose d/t the high metabolic activity of WBCs and bacteria
28
COPD pt has sudden dyspnea and severe R sided chest pain Tactile fremitus and decreased breath sounds on R trace ankle edema
Secondary spontaneous PTX s/t rupture of alveolar blebs
29
SOB + dullness to percussion, incerased intensity of breath sounds, increased tactile fremitis
Lung consolidation | Usually s/t lobar PNA
30
Causes of transudative pleural effusion
``` CHF Cirrhosis Nephrotic syndrome Periotneal dialysis Effusion can be b/l or unilateral, pH 7.4-7.55, ```
31
Causes of exudative pleural effusion
``` Infection Malignancy Connective tissue dz Inflammatory disorders Movement of fluid from abdomen to pleural space CABG PEm Caused by inflammation so pH tends to be lower (7.3-7.45) ```
32
New onset shoulder pain | unilateral ptosis, miosis, enophtalmosis, anhidrosis
Pancoast tumore (superior pulmonary sulcus (SPS) Usually caused by malignant lung neoplasm Presents with shoulder pain (referred), Horners syndrome (ipsi ptosis etc), and brachial plexus numbness/tingling
33
Horners occurs d/t tumor invasion into the?
inferior cervical ganglion | Get CXR for a lung mass
34
Former smoker Feels well Pulmonary nodule 2cm, completely surrounded by lung parenchyma No LN
Solitary pulmonary nodule >2cm = High malignancy risk -> surgically excise Also age over 60 and smoking cessation <5yrs increases risk
35
Most common causes of clubbing
Lung malignancy Cystic fibrosis R to L cardiac shunts If you see clubbing look for malignancy
36
COPD pt has an exacerbation and given supplemental O2. He then has a seizure. Why?
O2 supplementation in COPD worsens hypercapnia d/t: 1. increased dead space perfusion, V/P mismatch, and 2. Decreased affinity of oxyhemoglobin for CO2, and 3. Reduced alveolar ventilation goal saturation is 90-93%
37
Definition of COPD
chronic productive cough >3 mo in 2 successive years most likely d/t smoking
38
dyspnea dry cough fine crackles ages 50-70
``` Idiopathic pulmonary fibrosis Restrictive process Reduced DLCO TLC reduced FEV1/FVC NL ```
39
Asthma pt has elevated CO2 on ABG despite SABA, ipratropium, systemic steroids. Now what?
Intubate | OFten failign due to respiratory m. fatigue
40
BMI > 30 PaCO2 >45 (hyper) Exertional dyspnia
Obesity hypoventilation syndrome Causes alveolar hypoventilation Restrictive pattern ABG - hypercapnia, hypoxia, resp acidosis Tx - CPAP, weight loss, no sedatives, acetazolamide if severe
41
Reversible airway obstruction (>12% increase in FEV1) w/ bronchodilators NL DlCO
Asthma
42
FEV1/FVC in Obstructive
<70% | Restrictive >70%
43
How can you determine between asthma and COPD?
Asthma - reversible w/ bronchodilators | COPD - partially reversible/nonreversible, late stage nonreversible
44
Steroids cause a leukocytosis by?
Mobilization of PMN's into the circulation | Also see increased bands from PMN's leaving the bone marrow
45
What changes are expected in OSA?
Hypoxia Hypercapnia w/ compensated metabolic alkalosis Erythrocytosis PHTN Cor pulmonale OSA can be found alone or with obesity hypoventilation syndrome (OHS)
46
Sudden onset of SOB and dysphagia
Think laryngeal edema (anaphylaxis) Fixed upper airway obstruction Decreases airflow on insp and exp See flattening on top and bottom of flow-volume loop Tx - ephinephrin, steroids systemic, antihistamines
47
asthma syx > 2days/wk or 3-4 nightly awakenings/mo
Mild persistant asthma | Need a daily controller med (INH corticosteroid) + a rescue SABA (albuterol)
48
Asthma syx <2/days week, < 2 nighttime awakenings/mo
Intermittent asthma | INH SABA prn (albuterol)
49
Asthma syx w/ SABA use daily, night time awakenings >1/wk but not nightly
Low dose INH corticosteroid + LABA | OR medium dose ICS
50
Asthma syx using SABA throughout the day, nighttime awakenings 4-7x/wk
Medium dose INH corticosteroid + LABA OR High dose INH corticosteroid + LABA AND consider omalizumab if pt has allergies
51
INpt CAP tx
Fluoroquinolone (moxifloxacin) or beta lactam + macrolide (ceftriaxone + azithro)
52
How do you decide to admit a PNA pt?
``` CURB-65 Confusion BUN > 20 Respiration > 30 BP < 90/60 Age > 65 >3 -> definite inpt ```
53
Dyspnea | ECG - irrgular RR intervals, no definite P waves, narrow QRS
Pulm embolism
54
Small cell lung cancer causes which metabolic abn?
SIADH (hyponatremia) | Fluid restriction in asymptomatic pts
55
Most common malignancy in those exposed to asbestos?
Bronchogenic carcinoma CXR - atelectasis and b/l pleural plaques over the diaphragm CT - reticular opacities of the lower lung fields, multiple pleural plaques, and a round 6 cm cavitary mass in the RLL
56
Asbestos exposure | CXR - unilateral pleural abnormalaity w/ large pleural effusion
Pleural mesothelioma
57
``` Young pt (<45) w/ COPD w minimal smoking hx atypical features (basilar dominant dz) ```
Alpha-1 antitrypsin deficiency | Dx - measure serum AAT levels
58
Pt 20 yrs s/p chemo and radiation for Hodgkin lymphoma | presents with SOB, mass on CXR
Secondary malignancy | Hodgkin lymphoma tx with chemo radiation is high risk for secondary solid tumors (lung, breast, thyroid, bone, GI)
59
Decreased breath sounds decreased tactile fremitus dullness to percussion
Pleural effusion
60
Frequent URI's | Glomerulonephritis
Granulomatosis with polyangiitis Vasculitis affecting small and medium vessels Dx - Antineutrophil cytoplasmic Ab (ANCA) + and tissue bx
61
COPD pt presents with palpitations, HA, insomnia, vomiting | EKG - multifocal atrial tachycardia and PVC's
Check serum theophylline levels Toxicity presents as CNS stimulation, GI disturbance, Cardiac arrhythmia's. Cytochrome oxidase inhibitors (medications, diet, dz) can alter the therapeutic window
62
Pancreatitis pt develops ARDS. What is important to remember on ventilation?
Prevent alveolar distention by using a Low tidal volume
63
Immigrant w/ distant hx of TB develops 3 months of weight loss, cough, hemoptysis, fatigue apical cavitary lesion on CT
Chronic pulmonary aspergillosis B syx in a pt with hx of lung dz or immunocompromised Tx - itraconazole
64
New onset SOB in a pt with significant cardiac hx
CHF
65
Male pt w/ large anterior mediastinal mass | Elevated BhCH and AFP
Nonseminomatous germ cell tumor
66
Pt gets episodes of fever, malaise, chills, breathlessness, dry cough CXR - general haziness of both lung fields NL PFTs Bird breeder
Hypersensitivity pneumonitis | Avoid exposure to birds
67
PNA pt drops O2saturation when lying on the affected side. Why?
Intrapulmonary shunting Positional changes that make consolidation more gravity depends worsen V/Q mismatch, increase intrapulmonary shunting and lead to worsened hypoxemia
68
Immunocompromised | CT - pulmonary nodules w/ surrounding ground-glass opacities "halo sign"
Invasive aspergillosis | Tx - voriconazole and echinocandin (caspofungin)
69
RHF d/t PHTN
Cor pulmonale d/t COPD JVD, loud S@, RV heave, hepatomegaly, dependent sitting edema, possible ascites
70
Immigrant orthopnea a fib
Mitral valve stenosis d/t rheumatic heart dz
71
Best way to dx pleural effusion?
thoracentesis
72
Bronchospasam, nasal congestion after taking ASA
Aspirin-exacerbated respirator dz non IgE mediated d/t ASA induced protaglandin/leukotriene misbalance. See in pts with hx of asthma, chronic rinhositis w/ nasal polyposis. Tx - avoid NSAIDs, desensitize, use mentelukate (leukotriene receptor antagonists)
73
pt has lung inflammation hours after aspiration during surgery
Aspiration pneumonitis Acute lung injury d/t chemical burn from gastric content Aspiration PNA takes days to present vs. hours

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