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STEP 2 > Pulm > Flashcards

Pulm Flashcards

1
Q

anti IgE monoclonal antibody

A

omalizumab

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2
Q

tx of asthma steps 1-6

A

1 - SABA
2- SABA + low dose ICS
3 - SABA + ICS + LABA
4 - SABA + max dose ICS + LABA + tiotropium
5 - SABA + ICS + LABA + tio + omalizumab (high IgE)
6 - add oral corticosteroid

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3
Q

severity of asthma and tx

A

intermittent - day sxs = 2/week, night sxs = 2/mo; tx: step 1
mild persistent - day sxs > 2/week but not daily, night sxs 3-4/mo; tx: step 2
moderate persistent - daily sxs, night sxs weekly; tx: step 3
severe persistent - sxs throughout day, almost nightly sxs; tx: step 4-5

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4
Q

tx of exercise-induced bronchoconstriction

A

administer SABA 10-20 mins before exercise

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5
Q

leukotriene inhibitor used as alternative long term control (versus ICS) in patients with asthma and atopy; hepatotoxic and asso with Churg-Strauss syndrome

A

zafirlukast

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6
Q

what can you use in acute, severe asthma exacerbation not response to several rounds of albuterol, while waiting for steroids to take effect?

A

magnesium - helps relieve bronchospasm

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7
Q

ECG findings in COPD

A

RA hypertrophy and RV hypertrophy

A fib and multifocal atrial tachycardia (MAT)

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8
Q

measures that improve mortality in COPD patients

A

smoking cessation, oxygen therapy (directly proportional to the number of hours that the O2 is used), and flu/pneumococcal vaccines

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9
Q

criteria for oxygen use in COPD

A

pO2 below 55 or O2sat below 88%

OR

if there are signs of right HF / strain:
pO2 below 60 or O2sat below 90%

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10
Q

supplemental O2 improves hypoxia but can cause CO2 retention by the following mechanisms

A
  • loss of compensation vasoconstriction in areas of ineffective gas exchange
  • Haldane effect: increase in oxyHb recudes uptake of CO2 from tissues
  • loss of respiratory drive and lower RR –> lower MV (MV = RR x Tv)
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11
Q

hypercapnia does what to brain vessels

A

cerebral vasodilation –> can induce seizures

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12
Q

hypersensitive of the lungs to fungal antigens that colonize the bronchial tree; occurs almost exclusively in patients with asthma and hx of atopic disorders

A

allergic bronchopulmonary aspergillosis (ABPA)

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13
Q

asthmatic patient with recurrent episodes of brown-flecked sputum and infiltrates on CXR

A

ABPA - tx w steroids, recurrent episodes with itraconazole

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14
Q

CF inheritance

A

autosomal recessive

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15
Q

CF and endocrine/exocrine function of the pancreas

A

affects transport across apical surface of epithelial cells in exocrine glands (pancreatic insufficiency –> steatorrhea with vitamin A, D, E, and K malabsorption) but islets are spared - beta cell function (endocrine) is normal until much later in life

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16
Q

dx of CF: which test is most accurate?

A

sweat test (induce with pilocarpine) > genotyping

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17
Q

PFTs in CF

A

show mixed obstructive and restrictive pattern

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18
Q

ivacaftor

A

increases activity of CFTR in 5% of CF patients who have a specific mutation

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19
Q 
common pathogens in CAP and their associations 
COPD - 
recent viral infection - 
alcoholism and DM - 
poor dentition and aspiration - 
young, health - 
hoarseness - 
contaminated water sources, ACs -
birds - 
animals giving birth -
A

common pathogens in CAP and their associations
COPD - Haemophilus
recent viral infection - Staph
alcoholism and DM - Klebsiella
poor dentition and aspiration - anaerobes
young, health - Mycoplasma (asso with bullous myringitis)
hoarseness - Chlamydia pneumoniae
contaminated water sources, ACs - Legionella
birds - Chlamydia psittaci
animals giving birth - Coxiella burnetti

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20
Q

infections asso with dry cough

A

Mycoplasma, viruses, Coxiella, PCP, Chlamydia - these infection preferentially involve the interstitial space (–> bilateral interstitial infiltrates on CXR) and more often leave the space of the alveoli empty –> less sputum production –> dry cough

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21
Q

atypical PNA

A

organism that is not visible on Gram stain or cultural on standard blood agar

22
Q

empyema labs

A

LDH > 60% of serum level, protein >50% of serum level; WBC >1000 or ph <7.2

23
Q

infected pleural effusion or empyema will respond most rapidly to

A

drainage by CT or thoracostomy

24
Q

CURB65

A

confusion, uremia (BUN >20), RR >30, BP low, >/= 65 yo

25
Q

Definition and tx of HAP

A

= PNA developing >48 h after admission or <90 after discharge

Tx:
- antipseudomonal cephalosporin (CEFEPIME or CEFTAZIDIME)
OR
- antipseudomonal penicillin (PIPERACILLIN/TAZOBACTAM)
OR
- CARBAPENEM*

*note IMIPENEM can cause seizures, esp if its kidney excretion is impaired

26
Q

Tx of VAP

A

combine 3 different drugs
1st) 1 drug from those used in the tx of HAP
2nd) a second antipseudomonal
- an aminoglycoside* (GENTAMICIN, TOBRAMYCIN, AMIKACIN)
OR
- a fluoroquinolone (CIPRO, LEVO)
3rd) MRSA agent (VANC, LINEZOLID)

*DAPTOMYCIN should never be used for lungs - it is inactivated by surfactant

27
Q

Tx of CAP

A

healthy patient with no abx in the last 3 months - MACROLIDE or DOXY
patient with comorbidities or abx in the last 3 months - FLUOROQUINOLONE
Inpatient (CURB65): IV FLURO or [CEFTRIAXONE + AZITHRO]

28
Q

lung abscess abx’s

A

clindamycin or penicillin

29
Q

PCP workup

A

CRX - bilateral interstitial infiltrates
ABGs - hypoxia, increased A-a gradient
Elevated LDH levels (a normal LDH means you should not answer PCP as the most likely dx)
Sputum stain, if negative –> bronchoalveolar lavage

30
Q

tx of PCP

A

TMP/SMX, atovaquone, primaquine (C/I in G6PD def) or clinda, pentamidine

for ppx: TMP/SMX, atovaquone, dapsone (also C/I in G6PD def), pentamidine (least efficacious)

add steroids to decrease mortality if PCP is severe

31
Q

Diagnostic test for TB

A

the best initial test if CXR. sputum and culture specifically for acid-fast bacilli - must be done 3x to fully exclude TB. pleural bx is the single most accurate test

32
Q

tx of TB if positive smear

A

RIPE thx; you do not need ethambutol if the organism is sensitive to all the others; after RIPE for first 2 months, stop and ethambutol and pyrazinamide and continue rifampin and isoniazid for 4 months - total of 6 months

tx is extended to >6 months for osteomyelitis, miliary TB, meningitis, pregnancy (because you can’t use pyrazinamide)

use glucocorticoids to decrease the risk of constrictive pericarditis in those with pericardial involvement; they also decrease risk of neurologic complications

33
Q

adverse effects of antiTB medications

A

Rifampin - red secretions
Isoniazid - peripheral neuropathy - give pyridoxine
Pyrazinamide - hyperuricemia
Ethabutol - optic neuritis, affects color vision - renally dose

34
Q

which one has the highest sensitivity? PPD (purified protein derivative) or IGRA (interferon gamma release assay)?

A

equal sensitivity

IGRA has no cross reactivity with BCG, IGRA is preferred because only one visit is needed

35
Q

if a patient never had PPD test before…

A

a second test is indicated within 1-2 weeks if the first test if negative

36
Q

if patient test positive with PPD and has negative CXR…

A

receive 9 months of isoniazid with pyridoxine - reduces lifetime risk of TB from 10% (in those who test positive) to 1%

37
Q

berylliosis

A

similar to sacoidosis, presence of granulomas, respond to steroids

38
Q

agents to decrease progression of idiopathic pulmonary fibrosis

A

pifenidone and nintedanib (inhibit collagen synthesis and fibroblast activity, respectively)

39
Q

sarcoidosis presents with

A

parotid gland enlargement, facial palsy, heart block and restrictive cardiomyopathy, CNS involvement, iritis and uveitis

40
Q

modified Well’s criteria for pretest probability of PE

A

3 points

  • clinical signs of DVT
  • alternative dx less likely than PE
  1. 5 points
    - previous PE/DVT
    - HR >100
    - recent surgery or immobilization

1 point

  • hemoptysis
  • cancer

> 4 - PE likely –> CT or V/Q scan if pregnant –> if negative, do LE doppler
= 4 - PE unlikely –> D dimer

41
Q

imaging for PE

A

CT angiogram - same as spiral CT
use V/Q scan in pregnant patient
if negative, do LE doppler

Angiography is the most accurate test but has 0.5% mortality

42
Q

tx of PE

A

LMWH (enoxaparin) followed by NOAC (xabans, dabigratran) or warfarin

NOACs have rapid onset (no need for bridging thx), no need for INR monitoring, less intracranial bleed than warfarin

if patient develops HIT –> fondaparinux

dabigatran can be reversed by idarucizumab

when is IVC filter the right answer?

  • anticoagulant C/I
  • recurrent emboli while on anticoagulant or therapeutic INR
  • RV dysfunction - because the next embolus could be fatal

when are thrombolytics the right answer?

  • HD unstable patient
  • acute RV dysfunction
43
Q

adenocarcinoma of the lung: incidence, location, associations

A

50%, peripheral, clubbing and hypertrophic osteoarthropathy (clubbing + sudden onset hand and wrist joint pain)

44
Q

squamous cell carcinoma of the lung: incidence, location, associations

A

25%, central, necrosis and cavitation, hypercalcemia

45
Q

small cell carcinoma of the lung: incidence, location, associations

A

15%, central, Cushing, SIADH, Lambert-Eaton

46
Q

large cell carcinoma of the lung: incidence, location, associations

A

10%, peripheral, gynecomastia, galactorrhea

47
Q

first step in the management of newborn with respiratory compromise

A

endotracheal intubation; bag-and-mask ventilation can exacerbate respiratory decline

48
Q

tx of anaphylaxis

A

IM epinephrine - note additional doses may be required for refractory sxs

49
Q

common lung manifestation of systemic sclerosis

A

pulmonary artery hyperTN –> RV enlargement and HF –> RV heave on physical exam

50
Q

hypotension, JVD, and new onset RBBB in postop patient

A

massive PE

51
Q

recurrent PNA with unchanging area of consolidation

A

must r/o lung malignancy causing localized airway obstruction

52
Q

first line tx of SIADH

A

fluid restriction

STEP 2 (15 decks)

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