Pulm Flashcards
Utility of pulse ox reading in asthma or COPD exacerbation
Pulse oximetry may be falsely reassuring because patients maintain normal oxygen levels despite high work of breathing, and hypoxemia is a late sign of pending respiratory failure.
Preferred diagnostic test to work up OSA in patient with high pretest
Home sleep testing (need sleep study if cardiovascular disease, who sometimes need advanced settings (bilevel))
Subsolid vs solid nodules and screening guidelines
Subsolid or part solid nodules or more likely to be malignant than solid nodules and require shorter interval for screening
Average doubling time of subsolid, cancerous nodules
3-5 years
Recommended follow-up of lung nodule 6-8 mm in size
Follow up CT at 6-12 months and then every 2 years for 5 years
Guidelines used for lung nodule monitoring
Fleischner Society Guidelines.
Use of PET/CT in nodule workup
solid nodule that is greater than 8 mm in size
Vocal cord dysfunction vs. asthma
VCD = throat tightness + exposure to particular triggers such as strong irritants or emotions + difficulty breathing in + and symptoms that only partially respond to asthma medications + “inspiratory monophonic wheezing”, which is stridor
Treatment of vocal cord dysfunction
speech therapy utilizing cognitive behavioral techniques
why do we use CPAP in OSA
positive airway pressure therapy reduces the frequency of respiratory events during sleep and is associated with reduction in daytime sleepiness and improved sleep-related quality of life
Treatment for severe carbon monoxide poisoning
Hyperbaric oxygen therapy
Positive findings on cardiac exam for patients with pulmonary HTN
jugular venous distention, a prominent jugular venous a wave, parasternal heave, a widened split S2 with a prominent pulmonic component, or murmurs of tricuspid regurgitation as
next step in suspected pHTN workup if TTE is unrevealing
Right heart cath
Breathing pattern associated with central sleep apnea
Cheyne-stokes breathing and apnic period
Obstructive vs central sleep apnea in terms of physiology
Central sleep apnea occurs because your brain doesn’t send proper signals to the muscles that control your breathing. This condition is different from obstructive sleep apnea, in which you can’t breathe normally because of upper airway obstruction.
conditions that lead to central sleep apnea
CHF
Drugs or substances
Idiopathic
Management of central sleep apnea associated with CHF
Diuretics
Management of patient with COPD/Asthma overlap syndrome
LABA + steroid. You never give a LABA alone without a controller medication because this is associated with increased mortality in asthma patients.
Use of roflimulast in COPD + evidence for roflimulast
- add-on therapy in severe COPD associated with chronic bronchitis and a history of recurrent exacerbations
- has been shown to reduce frequency of exacerbations
management of COPD patient with upper-lobe predominant emphysema and significant exercise limitations
Lung volume reduction surgery
management of patient with IPF who has progressed and is desatting on hiflo
NO INTUBATION, guidelines recommend palliative care because intubation is futile.
Presentation of cough-variant asthma
- cough, no other asthma symptoms.
- cough triggered by temperature changes, exercise, laughter, and strong scents and perfumes
- normal spirometry
Contraindication to IO access
Osteoporosis
Board answer to what access patient in shock should have
Peripheral wide bore catheter
Procedure for biopsieing peripheral nodule
CT-guided transthoracic needle aspiration
Next step for nodule with high risk of malignancy according to boards
proceed directly to surgery without biopsy (wedge resection)
Size threshold of large nodule warranting resection
Greater than 30 mm
Lower end of nodule size suggesting benign
Less than 8 mm
Clinical feature differentiating ILD from asbestosis from other ILD
Parietal pleural plaques
Third line in shock if persistently hypotensive after levo and vaso
Stress dose steroids (hydrocortisone)
Why you don’t uptitrate vaso
Leads to ischemia, which outweighs added pressor benefit
Management of patient with neuromuscular disease (eg ALS) and chronic hypoventilation
BiPaP
Most effective measure to reduce risk of recurrent pneumothorax
Stop smoking
CVID diagnosis
Low antibody levels (IgG, IgA, IgM)
CVID presentation
chronic respiratory tract infections + GI tract involvement with chronic diarrhea and malabsorption
Presentation of late complement deficiency
Recurrent invasive gonococcal and meningococcal infections
Treatment of pulmonary HTN from COPD
supplemental oxygen
Description of pulmonary HTN on cardiac exam
Prominent pulmonic sound
Initial treatment of pulmonary arterial hypertension
IF change in PA pressure from nitric oxide –> CCBs
IF no change –> Bosentan (pulmonary vasodilator)
First step in evaluating patient for potential occupational exposure
Request a Material Safety Data Sheet (details chemicals and health risks associated with substances at workplace)
Diagnosis of myasthenia gravis
acetylcholine receptor (AChR) antibody test
Treatment for cyanide poisoning
hydroxocobalamin
Typical setting of cyanide poisoning
Fire or occupational exposures
Treatment of benzo overdose
- supportive care (intubation)
- NO flumazenil (has a short half life, so only reverses it for a little while and it can precipitate seizures and withdrawal if chronic user)
Presentation of acute hypersensitivity pneumonitis
fever + dyspnea + flu-like symptoms
CT findings in hypersensitivity pneumonitis
ground glass opacities + centrilobular micronodules that are upper and midlobe predominant
Primary treatment for hypersensitivity pneumonitis
Remove patient from offending agent
Intervention to reduce COPD admissions
chronic macrolide therapy (antiinflammatory effect)
what I need to remember about hypoxia
Lower threshold for ABG even if satting well
ARDS presentation
bilateral opacities + hypoxemia +
ARDS management
early intubation, no BiPaP
Lung condition associated with connective tissue disease
pulmonary arterial HTN
Cryptogenic organizing pneumonia symptoms
same as CAP but prolonged
Cryptogenic organizing pneumonia on plain film
bilateral diffuse alveolar infiltrates with normal lung volumes
secondary spontaneous pneumothorax definition
pneumothorax in a patient with underlying lung disease
management of secondary spontaneous pneumothorax
pleurX if not surgical candidate or VATS if surgical candidate (this is due to bullae or cysts so additional interventions are needed to close the ongoing leak)
indication for pulmonary rehab
FEV1 less than 50%
Management of patient with hypercapnea from neuromuscular disease
BiPaP
BP goals in hypertensive emergency
No more than 25% in first hour
160 within next 2-6 hours
Cautiously to normal within next 24-48 hours
Definition of hypertensive emergency
Greater than 180 SBP or 120 DBP + end organ damage
cyanide poisoning labs
elevated lactic acid (disrupts oxidative phosphorylation leading to anaerobic metabolism) + inappropriately elevated oxyhemoglobin saturation
patient in house fire answer
cyanide poisoning
patient in house fire labs
usually some carboxyhemoglobin from carbon monoxide poisoning, some methylene blue but not toxic level, and significant cyanide poisoning (higher than carbon monoxide)
treatment for cyanide poisoning
hydroxocobalamin
Management of patient with high pretest for CF but negative sweat chloride test
Repeat sweat chloride test (mainstay of diagnosis)
Chronic abx for CF?
Yes, oral macrolide antibiotics typically prescribed (can’t use quinolones because of resistance).
treatment for heat stroke
Evaporative cooling (sprayed water and cooling fans)
management of patient in cardiac arrest due to hypothermia
Prolonged CPR + active internal rewarming (you can’t treat arrhythmias and systole until temp is raised to 86 deg F) (take cold clothes off, cover with blankets, then body cavity lavage, irrigate colon, stomach)
- Don’t stop CPR even after an hour, there are reports of full recovery even after several hours.
Treatment for high-altitude cerebral edema
Steroids (dexamethasone, vascular leak leads to brain swelling) + descend to lower elevation
Management of patient with hilarity adenopathy, asymptomatic
No further evaluation, no CT chest given asymptomatic
Vent settings in ARDS
low TV + high PEEP + limit plateau pressure (no more than 30)
TV in ARDS
6 ml/kg
what is actigraphy
Measures movement and ambient light to estimate nightly sleep periods
first step in evaluation of daytime sleepiness
Make sure patient is getting enough sleep with actigraphy
What is a complicated parapneumonic effusion?
DEFINITION = pH less than 7.2 + glucose less than 60
*bacteria may be cleared rapidly from pleural space so the gram stain is commonly negative and cultures are usually sterile
Pathophys of complicated parapneumonic effusion
bacterial invasion of pleural space (this explains variable response to abx)
What is an empyema
Bacterial infection of pleural space that results in frank pus on visual inspection of pleural fluid OR positive gram stain
High vs standard dose flu shot
High dose is approved for people over age 65 and has been shown to be more effective than standard-dose
Pneumovax indications
1) chronic medical conditions (heart, liver, and lung disease) + diabetes + cigarette smokers
2) all people at age 65
PCV13 indications
1) Asplenia
2) CSF leak
3) cochlear implants
4) immunosuppression
PCV13 and PCV23 schedule
always at least 1 year apart
Imaging findings of CTEPH on CT-PA
- vascular webs, intimal irregularities, luminal narrowing
Criteria for ability to be weaned off ventilator
1) Pass 30 minute SBT
2) Follow commands
3) Clear secretions
4) Patent upper airway
What is “cuff leak”
- airflow around the ET tube after the cuff of the ET tube is deflated
- absence or minimal cuff leak may be due to laryngeal edema, stenosis, or thick secretions
How do you treat a loculated empyema
Typically Chest tube won’t be able to remove all fluid because it is loculated. So you need instillation of intrapleural tissue plasminogen activator-deoxyribonuclease (dorinase). IF that fails, then patient needs thorascopic or open surgical debridement.
Answer to older adult presenting with persistent dyspnea and a cough following viral URI
methacholine challenge testing (asthma is under diagnosed in older patients)
What is “recruitment” + problem with it
Application of high PEEP to recruit collapsed alveoli. Can drop people’s pressure.
How does nitric oxide work?
Selectively dilates the pulmonary vasculature, thereby decreasing VQ mismatch.
Bronchiectasis presentation
Chronic cough with sputum production + hemoptysis
HRCT findings in bronchiectasis
bronchial wall thickening + cysts + airway dilatation with lack of tapering
Acute interstitial pneumonia on CXR
Bilateral alveolar opacities consistent with pulmonary edema
How to evaluate for ICU-acquired weakness
- Medical Research Council muscle scale (Score less than 48 is diagnostic of ICU-acquired weakness).
First line therapy for cryptogenic organizing pneumonia
Steroids
HRCT findings in cryptogenic organizing PNA
Extensive ground-glass changes bilateral with several areas of nodular consolidation that are peripherally predominant and along bronchovascular bundles
Evidence for use gastric residual volume monitoring
No longer recommended because it doesn’t affect outcomes.
Chest CT findings of respiratory bronchiolitis-associated interstitial lung disease
centrilobular micronodules
respiratory bronchiolitis-associated interstitial lung disease clinical features
active smoker + asymptomatic
CT findings in IPF
Basal and peripheral-predominant septal line thickening + traction bronchiectasis + honeycombing
Pulmonary Langerhans cell histiocytosis clinical features + radiographic features
- middle and upper zone thin-walled cysts
- young adult with cough, dyspnea, and pHTN patient
TB CXR presentation
Bilateral upper-lobe fibrosis + volume loss of upper lobes + cavitation + bilateral calcified hilar lymphadenopathy
Radiographic features of aspergiloma
Round mass with a pulmonary cavity or cyst
asthma management during pregnancy
Inhaled glucocorticoids are safe
- treatment of asthma in pregnancy is basically the same as in non pregnant patients
best study modality for evaluating mediastinal structures
Contrast-enhanced chest CT
next step for recurrent effusion if concern for malignancy
thoracoscopy and pleura biopsy
Characteristics of exudative pleural fluid
- Pleural fluid total protein/serum total protein > 0.5
- pleural fluid LDH/serum LDH > 0.6
- pleural fluid LDH greater than 2/3 the upper limit of normal for serum LDH
Sensitivity of cytology for malignancy
Low, only 60%
How to reduce snoring
Sleep on side
Drink loss
Lose weight
Management of recurrent malignant effusion
Indwelling pleural catheter placement (Pleurx) (50-70% of people achieve spontaneous pleurodesis after 2-6 weeks)
Features of serotonin syndrome
Hyperthermia, tremor, hyperreflexia, clonus
Serotonin syndrome treatment
- mainly supportive
- benzos as needed to keep patient calm and control blood pressure
- only use cypropheptadine in severe cases of agitation or hyperthermia
Malignant hyperthermia setting
following inhaled anesthesia agents or neuromuscular blockade
NMS vs. serotonin syndrome
- NMS develops subacutely during days or weeks, serotonin syndrome develops within hours
- hyporeflexia in serotonin syndrome, hyperreflexia and myoclonus in serotonin syndrome
First step in management of hypotensive patient with hemorrhagic/hypovolemic shock from variceal bleed
Transfusion RBCs, NOT EGD
Treatment for isopropyl alcohol (rubbing alcohol) poisoning
Supportive care
Procedure used for biopsy of mediastinal lymph node
Endobronchial US-guided transbronchial needle aspiration
Management of acute opioid overdose
- Administer naloxone (higher dose, 2 mg IV for apnic patient than standard 0.4 mg dose)
- Dose will eventually wear off, so you need to observe patient, and repeat dosing or put on drip
- Titrate naloxone to respiratory rate of 12/min
Opioid overdose presentation and vitals
miosis + respiratory depression + confusion + hypothermia + bradycardia + hypotension
First line for obesity hypoventilation syndrome
CPAP or BiPaP
Management of acute exacerbation of bronchiectasis
Levofloxacin for 10-14 days (need quinolone for pseudomonas coverage)
- No evidence for steroids
Clinical significance of parasternal heave/lift/thrust
RVH (i.e. enlargement) or very rarely severe LA enlargement (due to the position of the heart within the chest: the right ventricle is most anterior (closest to the chest wall)).
Hypothermia treatment
Basically do everything possible to warm patient (mildly hypothermic usually just require external rewarming, but severely hypothermic patients may require internal warming with body cavity lavage
How long to code hypothermic patient
- until patient is rewarmed to normal body temperature and then eventually call it (can’t treat conduction abnormalities if hypothermic and there are reports of full recovery hours in since hypothermia looks like death)
Appearance of fixed upper airway obstruction on flow volume loop
Flatting of both inspiratory and expiratory curves
Cause of chronic shortness of breath post intubation
Tracheal stenosis
Obstructive pattern of flow-volume loop
- normal initial portion of expiratory flow loop with increased concavity of terminal portion (airway narrowing during exhalation)
- see photo online
Next step after CXR in patient with hilar adenopathy suggesting sarcoidosis
IF asymptomatic – observation, no CT (A lot of patients with stage I pulmonary sarcoidosis have spontaneous resolution of hilar LAD so doesn’t change management)
IF symptomatic – HRCT
Features of malignant effusion
low pH + glucose
Uncomplicated parapneumonic effusion definition
pH greater than 7.2 + glucose greater than 60
Management of uncomplicated parapneumonic effusion
- antibiotics alone
- no need for chest tube
Treatment of bronchiectasis exacerbation
- Base abx on previous sputum culture result
- IF no previous data available, use a quinolone to empirically cover for pseudomonas for 10-14 days
What is wrist actigraphy?
Measures movement and ambient light to estimate nightly sleep periods. Mechanism for tracking if you’re getting enough sleep.
First step in evaluation of daytime sleepiness
Make sure patient is getting enough sleep over night with actigraphy
Strongest indication for CPAP with OSA
- excessive daytime sleepiness (it hasn’t shown a benefit on other outcomes, like AF, mortality, A1c, inconsistent effects on BP)
Initial management of acute hemorrhagic shock (variceal bleed)
IF hypotensive –> transfuse PRBCs (even in HgB is above 7)
PFT’s with pulmonary hypertension
Reduced DLCO with normal lung volumes
When to start enteral feeds in the ICU + advance
at 24-48 hours, advance by 48 to 72 hours
Treatment of asthma during pregnancy
- same as treatment in nonpregnant patients (inhaled steroids and beta agonists are safe in pregnancy. Also- risk to the fetus of untreated asthma are significantly greater than the risks of asthma medications.)
Management of high altitude cerebral edema
Steroids
Clinical features of acute mountain sickness
HA, fatigue, nausea, vomiting, disturbed sleep (it’s mild end of the spectrum)
Nightly BiPAP indications
Severe COPD
Neuromuscular weakness
Management of acute hypoxemic respiratory failure per boards
If deserting on NRB go directly to intubation, rather than NIPPV (controversial per boards with some studies showing increasing mortality due to delay in intubation)
Management of respiratory distress in severe IPF
Palliative care, including morphine (never intubation. it is irreversible)
Rule out active TB
Sputum sample for Acid-fast bacillus x3
Features of reactivation TB
- upper lobe
- cavitation
- cough, hemoptysis, night sweats,
Complication to know of with chronic silicosis
TB infection
Aspergillus clinical features
- usually arises from colonization of a preexisting pulmonary cavity or cyst
- Cavitation
How to go about obtaining tissue for diagnosis if patient has nodule with hot lymph node on PET/CT
***Target lesion that would result in highest potential staging (so target lymph node over nodule)
IF nodule is hilar or mediastinal –> endobronchial US-guided transbronchial needle aspiration
Preferred approach to biopsying pulmonary lymph node
- endobronchial US-guided transbronchial needle aspiration is preferred over CT-guided (less invasive and higher risk of procedural complications)
Lymph nodes in the mediastinum not accessible by endobronchial US
Posterior mediastinal lymph nodes
Treatment for cyanide poisoning
hydroxocobalamin (removes cyanide from mitochondrial respiration system)
Typical process for determining nodule management
Calculate malignancy risk
IF low –> Serial CT’s
IF intermediate –> biopsy
IF high –> proceed directly to surgery
CTEPH diagnostic criteria
1) Mean PA pressure of 25 mm Hg or higher
2) Imaging evidence of chronic thromboembolism
Acronym for anterior mediastinal masses
Terrible T's Thymoma Teratoma/germ cell tumor "Terrible" lymphoma Thyroid
Persistent cough and dyspnea in elderly person following URI think
asthma (undiagnosed in elderly population
Subsolid lung nodule surveillance period
6-12 months
then *q2 years for 5 years
SBP goals in treatment of hypertensive emergency
systolic blood pressure should be reduced by no more than 25% within the first hour; then, if stable, to 160 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours
Vaccination for chronic lung disease
pneumovax
Treatment of empyema
Instillation of intrapleural TPA
Empyema that is incompletely drained means
located typically
