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Boards > Pulm > Flashcards

Pulm Flashcards

1
Q

Utility of pulse ox reading in asthma or COPD exacerbation

A

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.

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2
Q

Preferred diagnostic test to work up OSA in patient with high pretest

A

Home sleep testing (need sleep study if cardiovascular disease, who sometimes need advanced settings (bilevel))

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3
Q

Subsolid vs solid nodules and screening guidelines

A

Subsolid or part solid nodules or more likely to be malignant than solid nodules and require shorter interval for screening

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4
Q

Average doubling time of subsolid, cancerous nodules

A

3-5 years

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5
Q

Recommended follow-up of lung nodule 6-8 mm in size

A

Follow up CT at 6-12 months and then every 2 years for 5 years

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6
Q

Guidelines used for lung nodule monitoring

A

Fleischner Society Guidelines.

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7
Q

Use of PET/CT in nodule workup

A

solid nodule that is greater than 8 mm in size

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8
Q

Vocal cord dysfunction vs. asthma

A

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

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9
Q

Treatment of vocal cord dysfunction

A

speech therapy utilizing cognitive behavioral techniques

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10
Q

why do we use CPAP in OSA

A

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

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11
Q

Treatment for severe carbon monoxide poisoning

A

Hyperbaric oxygen therapy

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12
Q

Positive findings on cardiac exam for patients with pulmonary HTN

A

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

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13
Q

next step in suspected pHTN workup if TTE is unrevealing

A

Right heart cath

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14
Q

Breathing pattern associated with central sleep apnea

A

Cheyne-stokes breathing and apnic period

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15
Q

Obstructive vs central sleep apnea in terms of physiology

A

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.

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16
Q

conditions that lead to central sleep apnea

A

CHF
Drugs or substances
Idiopathic

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17
Q

Management of central sleep apnea associated with CHF

A

Diuretics

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18
Q

Management of patient with COPD/Asthma overlap syndrome

A

LABA + steroid. You never give a LABA alone without a controller medication because this is associated with increased mortality in asthma patients.

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19
Q

Use of roflimulast in COPD + evidence for roflimulast

A
  • add-on therapy in severe COPD associated with chronic bronchitis and a history of recurrent exacerbations
  • has been shown to reduce frequency of exacerbations
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20
Q

management of COPD patient with upper-lobe predominant emphysema and significant exercise limitations

A

Lung volume reduction surgery

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21
Q

management of patient with IPF who has progressed and is desatting on hiflo

A

NO INTUBATION, guidelines recommend palliative care because intubation is futile.

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22
Q

Presentation of cough-variant asthma

A
    • cough, no other asthma symptoms.
    • cough triggered by temperature changes, exercise, laughter, and strong scents and perfumes
    • normal spirometry
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23
Q

Contraindication to IO access

A

Osteoporosis

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24
Q

Board answer to what access patient in shock should have

A

Peripheral wide bore catheter

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25
Q

Procedure for biopsieing peripheral nodule

A

CT-guided transthoracic needle aspiration

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26
Q

Next step for nodule with high risk of malignancy according to boards

A

proceed directly to surgery without biopsy (wedge resection)

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27
Q

Size threshold of large nodule warranting resection

A

Greater than 30 mm

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28
Q

Lower end of nodule size suggesting benign

A

Less than 8 mm

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29
Q

Clinical feature differentiating ILD from asbestosis from other ILD

A

Parietal pleural plaques

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30
Q

Third line in shock if persistently hypotensive after levo and vaso

A

Stress dose steroids (hydrocortisone)

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31
Q

Why you don’t uptitrate vaso

A

Leads to ischemia, which outweighs added pressor benefit

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32
Q

Management of patient with neuromuscular disease (eg ALS) and chronic hypoventilation

A

BiPaP

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33
Q

Most effective measure to reduce risk of recurrent pneumothorax

A

Stop smoking

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34
Q

CVID diagnosis

A

Low antibody levels (IgG, IgA, IgM)

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35
Q

CVID presentation

A

chronic respiratory tract infections + GI tract involvement with chronic diarrhea and malabsorption

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36
Q

Presentation of late complement deficiency

A

Recurrent invasive gonococcal and meningococcal infections

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37
Q

Treatment of pulmonary HTN from COPD

A

supplemental oxygen

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38
Q

Description of pulmonary HTN on cardiac exam

A

Prominent pulmonic sound

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39
Q

Initial treatment of pulmonary arterial hypertension

A

IF change in PA pressure from nitric oxide –> CCBs

IF no change –> Bosentan (pulmonary vasodilator)

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40
Q

First step in evaluating patient for potential occupational exposure

A

Request a Material Safety Data Sheet (details chemicals and health risks associated with substances at workplace)

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41
Q

Diagnosis of myasthenia gravis

A

acetylcholine receptor (AChR) antibody test

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42
Q

Treatment for cyanide poisoning

A

hydroxocobalamin

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43
Q

Typical setting of cyanide poisoning

A

Fire or occupational exposures

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44
Q

Treatment of benzo overdose

A
  • 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)
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45
Q

Presentation of acute hypersensitivity pneumonitis

A

fever + dyspnea + flu-like symptoms

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46
Q

CT findings in hypersensitivity pneumonitis

A

ground glass opacities + centrilobular micronodules that are upper and midlobe predominant

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47
Q

Primary treatment for hypersensitivity pneumonitis

A

Remove patient from offending agent

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48
Q

Intervention to reduce COPD admissions

A

chronic macrolide therapy (antiinflammatory effect)

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49
Q

what I need to remember about hypoxia

A

Lower threshold for ABG even if satting well

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50
Q

ARDS presentation

A

bilateral opacities + hypoxemia +

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51
Q

ARDS management

A

early intubation, no BiPaP

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52
Q

Lung condition associated with connective tissue disease

A

pulmonary arterial HTN

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53
Q

Cryptogenic organizing pneumonia symptoms

A

same as CAP but prolonged

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54
Q

Cryptogenic organizing pneumonia on plain film

A

bilateral diffuse alveolar infiltrates with normal lung volumes

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55
Q

secondary spontaneous pneumothorax definition

A

pneumothorax in a patient with underlying lung disease

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56
Q

management of secondary spontaneous pneumothorax

A

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)

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57
Q

indication for pulmonary rehab

A

FEV1 less than 50%

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58
Q

Management of patient with hypercapnea from neuromuscular disease

A

BiPaP

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59
Q

BP goals in hypertensive emergency

A

No more than 25% in first hour
160 within next 2-6 hours
Cautiously to normal within next 24-48 hours

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60
Q

Definition of hypertensive emergency

A

Greater than 180 SBP or 120 DBP + end organ damage

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61
Q

cyanide poisoning labs

A

elevated lactic acid (disrupts oxidative phosphorylation leading to anaerobic metabolism) + inappropriately elevated oxyhemoglobin saturation

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62
Q

patient in house fire answer

A

cyanide poisoning

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63
Q

patient in house fire labs

A

usually some carboxyhemoglobin from carbon monoxide poisoning, some methylene blue but not toxic level, and significant cyanide poisoning (higher than carbon monoxide)

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64
Q

treatment for cyanide poisoning

A

hydroxocobalamin

65
Q

Management of patient with high pretest for CF but negative sweat chloride test

A

Repeat sweat chloride test (mainstay of diagnosis)

66
Q

Chronic abx for CF?

A

Yes, oral macrolide antibiotics typically prescribed (can’t use quinolones because of resistance).

67
Q

treatment for heat stroke

A

Evaporative cooling (sprayed water and cooling fans)

68
Q

management of patient in cardiac arrest due to hypothermia

A

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.

69
Q

Treatment for high-altitude cerebral edema

A

Steroids (dexamethasone, vascular leak leads to brain swelling) + descend to lower elevation

70
Q

Management of patient with hilarity adenopathy, asymptomatic

A

No further evaluation, no CT chest given asymptomatic

71
Q

Vent settings in ARDS

A

low TV + high PEEP + limit plateau pressure (no more than 30)

72
Q

TV in ARDS

A

6 ml/kg

73
Q

what is actigraphy

A

Measures movement and ambient light to estimate nightly sleep periods

74
Q

first step in evaluation of daytime sleepiness

A

Make sure patient is getting enough sleep with actigraphy

75
Q

What is a complicated parapneumonic effusion?

A

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

76
Q

Pathophys of complicated parapneumonic effusion

A

bacterial invasion of pleural space (this explains variable response to abx)

77
Q

What is an empyema

A

Bacterial infection of pleural space that results in frank pus on visual inspection of pleural fluid OR positive gram stain

78
Q

High vs standard dose flu shot

A

High dose is approved for people over age 65 and has been shown to be more effective than standard-dose

79
Q

Pneumovax indications

A

1) chronic medical conditions (heart, liver, and lung disease) + diabetes + cigarette smokers
2) all people at age 65

80
Q

PCV13 indications

A

1) Asplenia
2) CSF leak
3) cochlear implants
4) immunosuppression

81
Q

PCV13 and PCV23 schedule

A

always at least 1 year apart

82
Q

Imaging findings of CTEPH on CT-PA

A
  • vascular webs, intimal irregularities, luminal narrowing
83
Q

Criteria for ability to be weaned off ventilator

A

1) Pass 30 minute SBT
2) Follow commands
3) Clear secretions
4) Patent upper airway

84
Q

What is “cuff leak”

A
  • 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
85
Q

How do you treat a loculated empyema

A

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.

86
Q

Answer to older adult presenting with persistent dyspnea and a cough following viral URI

A

methacholine challenge testing (asthma is under diagnosed in older patients)

87
Q

What is “recruitment” + problem with it

A

Application of high PEEP to recruit collapsed alveoli. Can drop people’s pressure.

88
Q

How does nitric oxide work?

A

Selectively dilates the pulmonary vasculature, thereby decreasing VQ mismatch.

89
Q

Bronchiectasis presentation

A

Chronic cough with sputum production + hemoptysis

90
Q

HRCT findings in bronchiectasis

A

bronchial wall thickening + cysts + airway dilatation with lack of tapering

91
Q

Acute interstitial pneumonia on CXR

A

Bilateral alveolar opacities consistent with pulmonary edema

92
Q

How to evaluate for ICU-acquired weakness

A
  • Medical Research Council muscle scale (Score less than 48 is diagnostic of ICU-acquired weakness).
93
Q

First line therapy for cryptogenic organizing pneumonia

A

Steroids

94
Q

HRCT findings in cryptogenic organizing PNA

A

Extensive ground-glass changes bilateral with several areas of nodular consolidation that are peripherally predominant and along bronchovascular bundles

95
Q

Evidence for use gastric residual volume monitoring

A

No longer recommended because it doesn’t affect outcomes.

96
Q

Chest CT findings of respiratory bronchiolitis-associated interstitial lung disease

A

centrilobular micronodules

97
Q

respiratory bronchiolitis-associated interstitial lung disease clinical features

A

active smoker + asymptomatic

98
Q

CT findings in IPF

A

Basal and peripheral-predominant septal line thickening + traction bronchiectasis + honeycombing

99
Q

Pulmonary Langerhans cell histiocytosis clinical features + radiographic features

A
  • middle and upper zone thin-walled cysts

- young adult with cough, dyspnea, and pHTN patient

100
Q

TB CXR presentation

A

Bilateral upper-lobe fibrosis + volume loss of upper lobes + cavitation + bilateral calcified hilar lymphadenopathy

101
Q

Radiographic features of aspergiloma

A

Round mass with a pulmonary cavity or cyst

102
Q

asthma management during pregnancy

A

Inhaled glucocorticoids are safe

- treatment of asthma in pregnancy is basically the same as in non pregnant patients

103
Q

best study modality for evaluating mediastinal structures

A

Contrast-enhanced chest CT

104
Q

next step for recurrent effusion if concern for malignancy

A

thoracoscopy and pleura biopsy

105
Q

Characteristics of exudative pleural fluid

A
  • 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
106
Q

Sensitivity of cytology for malignancy

A

Low, only 60%

107
Q

How to reduce snoring

A

Sleep on side
Drink loss
Lose weight

108
Q

Management of recurrent malignant effusion

A

Indwelling pleural catheter placement (Pleurx) (50-70% of people achieve spontaneous pleurodesis after 2-6 weeks)

109
Q

Features of serotonin syndrome

A

Hyperthermia, tremor, hyperreflexia, clonus

110
Q

Serotonin syndrome treatment

A
  • mainly supportive
  • benzos as needed to keep patient calm and control blood pressure
  • only use cypropheptadine in severe cases of agitation or hyperthermia
111
Q

Malignant hyperthermia setting

A

following inhaled anesthesia agents or neuromuscular blockade

112
Q

NMS vs. serotonin syndrome

A
  • NMS develops subacutely during days or weeks, serotonin syndrome develops within hours
  • hyporeflexia in serotonin syndrome, hyperreflexia and myoclonus in serotonin syndrome
113
Q

First step in management of hypotensive patient with hemorrhagic/hypovolemic shock from variceal bleed

A

Transfusion RBCs, NOT EGD

114
Q

Treatment for isopropyl alcohol (rubbing alcohol) poisoning

A

Supportive care

115
Q

Procedure used for biopsy of mediastinal lymph node

A

Endobronchial US-guided transbronchial needle aspiration

116
Q

Management of acute opioid overdose

A
  • 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
117
Q

Opioid overdose presentation and vitals

A

miosis + respiratory depression + confusion + hypothermia + bradycardia + hypotension

118
Q

First line for obesity hypoventilation syndrome

A

CPAP or BiPaP

119
Q

Management of acute exacerbation of bronchiectasis

A

Levofloxacin for 10-14 days (need quinolone for pseudomonas coverage)
- No evidence for steroids

120
Q

Clinical significance of parasternal heave/lift/thrust

A

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)).

121
Q

Hypothermia treatment

A

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

122
Q

How long to code hypothermic patient

A
  • 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)
123
Q

Appearance of fixed upper airway obstruction on flow volume loop

A

Flatting of both inspiratory and expiratory curves

124
Q

Cause of chronic shortness of breath post intubation

A

Tracheal stenosis

125
Q

Obstructive pattern of flow-volume loop

A
  • normal initial portion of expiratory flow loop with increased concavity of terminal portion (airway narrowing during exhalation)
  • see photo online
126
Q

Next step after CXR in patient with hilar adenopathy suggesting sarcoidosis

A

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

127
Q

Features of malignant effusion

A

low pH + glucose

128
Q

Uncomplicated parapneumonic effusion definition

A

pH greater than 7.2 + glucose greater than 60

129
Q

Management of uncomplicated parapneumonic effusion

A
  • antibiotics alone

- no need for chest tube

130
Q

Treatment of bronchiectasis exacerbation

A
  • Base abx on previous sputum culture result

- IF no previous data available, use a quinolone to empirically cover for pseudomonas for 10-14 days

131
Q

What is wrist actigraphy?

A

Measures movement and ambient light to estimate nightly sleep periods. Mechanism for tracking if you’re getting enough sleep.

132
Q

First step in evaluation of daytime sleepiness

A

Make sure patient is getting enough sleep over night with actigraphy

133
Q

Strongest indication for CPAP with OSA

A
  • excessive daytime sleepiness (it hasn’t shown a benefit on other outcomes, like AF, mortality, A1c, inconsistent effects on BP)
134
Q

Initial management of acute hemorrhagic shock (variceal bleed)

A

IF hypotensive –> transfuse PRBCs (even in HgB is above 7)

135
Q

PFT’s with pulmonary hypertension

A

Reduced DLCO with normal lung volumes

136
Q

When to start enteral feeds in the ICU + advance

A

at 24-48 hours, advance by 48 to 72 hours

137
Q

Treatment of asthma during pregnancy

A
  • 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.)
138
Q

Management of high altitude cerebral edema

A

Steroids

139
Q

Clinical features of acute mountain sickness

A

HA, fatigue, nausea, vomiting, disturbed sleep (it’s mild end of the spectrum)

140
Q

Nightly BiPAP indications

A

Severe COPD

Neuromuscular weakness

141
Q

Management of acute hypoxemic respiratory failure per boards

A

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)

142
Q

Management of respiratory distress in severe IPF

A

Palliative care, including morphine (never intubation. it is irreversible)

143
Q

Rule out active TB

A

Sputum sample for Acid-fast bacillus x3

144
Q

Features of reactivation TB

A
  • upper lobe
  • cavitation
  • cough, hemoptysis, night sweats,
145
Q

Complication to know of with chronic silicosis

A

TB infection

146
Q

Aspergillus clinical features

A
  • usually arises from colonization of a preexisting pulmonary cavity or cyst
  • Cavitation
147
Q

How to go about obtaining tissue for diagnosis if patient has nodule with hot lymph node on PET/CT

A

***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

148
Q

Preferred approach to biopsying pulmonary lymph node

A
  • endobronchial US-guided transbronchial needle aspiration is preferred over CT-guided (less invasive and higher risk of procedural complications)
149
Q

Lymph nodes in the mediastinum not accessible by endobronchial US

A

Posterior mediastinal lymph nodes

150
Q

Treatment for cyanide poisoning

A

hydroxocobalamin (removes cyanide from mitochondrial respiration system)

151
Q

Typical process for determining nodule management

A

Calculate malignancy risk
IF low –> Serial CT’s
IF intermediate –> biopsy
IF high –> proceed directly to surgery

152
Q

CTEPH diagnostic criteria

A

1) Mean PA pressure of 25 mm Hg or higher

2) Imaging evidence of chronic thromboembolism

153
Q

Acronym for anterior mediastinal masses

A 
Terrible T's
Thymoma
Teratoma/germ cell tumor
"Terrible" lymphoma
Thyroid
154
Q

Persistent cough and dyspnea in elderly person following URI think

A

asthma (undiagnosed in elderly population

155
Q

Subsolid lung nodule surveillance period

A

6-12 months

then *q2 years for 5 years

156
Q

SBP goals in treatment of hypertensive emergency

A

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

157
Q

Vaccination for chronic lung disease

A

pneumovax

158
Q

Treatment of empyema

A

Instillation of intrapleural TPA

159
Q

Empyema that is incompletely drained means

A

located typically

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