Pulm and Critical Care V

Question 1

What is the recommended treatment for patients with SIADH who have severe hyponatremia (e.g. seizures, coma)?

Answer 1

Hypertonic (3%) saline

Question 2

What is the recommended treatment regimen for patients with intermittent asthma?

Answer 2

Short-acting β2-agonist, PRN

Question 3

What is the recommended treatment regimen for patients with mild persistent asthma?

Answer 3

daily low-dose inhaled corticosteroid and SABA PRN

Question 4

What is the recommended treatment regimen for patients with moderate persistent asthma?

Answer 4

daily long-acting β2-agonist, daily low-dose ICS, SABA PRN

or daily medium-dose ICS with SABA PRN

Question 5

What is the test of choice to diagnose pulmonary embolism in clinically stable patients with a high likelihood of PE (modified Wells > 4)?

Answer 5

CT angiography

in patients with low likelihood of PE (modified Wells < 4), D-dimer testing can help rule out PE due to high negative predictive value

Question 6

What is the underlying cause of low glucose in complicated parapneumonic effusions?

Answer 6

High metabolic activity of leukocytes and/or bacteria

Question 7

What is the underlying etiology for aspiration pneumonia in patients with impaired consciousness and/or advanced dementia?

Answer 7

impaired swallowing and cough reflex

Question 8

What is the underlying etiology in a patient with severe COPD who develops altered consciousness and seizures after administration of supplemental O2?

Answer 8

O2-induced CO2 retention

patients have a decreased respiratory drive and loss of compensatory vasoconstriction

Question 9

What is the underlying etiology of aspirin-exacerbated respiratory disease?

Answer 9

aspirin-induced prostaglandin/leukotriene imbalance

this is a non-IgE-mediated reaction (pseudo-allergic reaction); treatment includes avoidance of NSAIDs and/or administration of leukotriene receptor antagonists (e.g. montelukast)

Question 10

What maternal pathology is associated with increased risk for neonatal respiratory distress syndrome?

Answer 10

Maternal diabetes

maternal diabetes results in fetal hyperinsulinism, which antagonizes cortisol and blocks maturation of sphingomyelin

Question 11

What medications should be administered to patients with severe asthma exacerbation?

[…], […], […]

Answer 11

inhaled short-acting β2 agonists, inhaled ipratropium, systemic corticosteroids

additional bronchodilation with one-time infusion of IV magnesium sulfate may be added if no improvement appreciated after an hour

Question 12

What paraneoplastic syndrome presents with euvolemic hyponatremia?

Answer 12

SIADH

other common findings include low serum osmolality (< 275 mOsm/kg) and high urine osmolality (> 100 mOsm/kg)

Question 13

What physiologic change helps compensate for chronic respiratory acidosis and hypercapnia in patients with COPD?

Answer 13

Increased renal HCO3 retention

i.e. compensatory metabolic alkalosis; similar changes may occur with other pulmonary pathologies (e.g. obesity hypoventilation syndrome)

Question 14

What pneumonia complication is characterized by frank pus or bacteria in the pleural space?

Answer 14

Empyema

Question 15

What regions of the lung are most commonly involved in supine patients with aspiration pneumonia?

[…] and […]

Answer 15

posterior segments of upper lobe and superior segments of lower lobe

Question 16

What risk factor acts synergistically with asbestos to increase risk of lung cancer?

Answer 16

Smoking

asbestos alone increases risk by nearly 6-fold; smokers with asbestos exposure have nearly 59-fold increased risk

Question 17

What test/imaging study is the best diagnostic test for bronchiectasis?

Answer 17

high-resolution CT scan of the chest

characteristic findings include bronchial dilation, lack of airway tapering, and bronchial wall thickening (arrows)

Question 18

What test/imaging study should be ordered first to evaluate an older patient with a 30 pack-year smoking history and recurrent episodes of pneumonia in the same anatomic location?

Answer 18

CT scan of chest

in patients > 50 with significant smoking history (> 30 pack-years), it is essential to evaluate for lung malignancy; CT scan has better sensitivity than CXR

Question 19

What type of pleural effusion, transudative or exudative, is characterized by pH 7.30 - 7.45?

Answer 19

Exudative

normal pleural fluid pH is 7.60; transudative effusions typically have higher pH (7.40 - 7.55)

Question 20

What type of pleural effusion, transudative or exudative, is characterized by pH 7.40 - 7.55?

Answer 20

Transudative

normal pleural fluid pH is 7.60; exudative effusions typically have lower pH (7.30 - 7.45)

Question 21

What type of pleural effusion, transudative or exudative, is commonly seen with pneumonia (e.g. parapneumonic effusion)?

Answer 21

Exudative

Question 22

What type of pleural effusion, transudative or exudative, is commonly seen with pulmonary embolism?

Answer 22

Exudative (typically a small, bloody effusion)

due to hemorrhage or inflammation

Question 23

What type of V/Q mismatch is worsened in COPD patients with O2-induced CO2 retention?

Answer 23

Dead space

at baseline, hypoxic vasoconstriction shunts blood away from non-functional alveoli; supplemental O2 increases blood flow to these areas

Question 24

What type of V/Q mismatch may occur in patients with pneumonia?

Answer 24

Right-to-left intrapulmonary shunt

due to alveoli filling with inflammatory exudate; results in hypoxemia

Question 25

What ventilator setting change is best for a 65 kg patient with the following ABG and the ventilator settings: ## Footnote pH: 7.42 PaO2: 105 mmHg PaCO2: 37 mmHg FiO2: 80% PEEP: 7 mmHg VT: 380 mL RR: 14/min

Answer 25

What ventilator setting change is best for a 65 kg patient with the following ABG and the ventilator settings: ## Footnote pH: 7.42 PaO2: 105 mmHg PaCO2: 37 mmHg FiO2: 80% PEEP: 7 mmHg VT: 380 mL RR: 14/min Decrease FiO2 FiO2 should be reduced to prevent oxygen toxicity; in general FiO2 \< 60% is considered safe

Question 26

What ventilator setting change is best to improve oxygenation in a patient with the following settings: ## Footnote FiO2: 70% PEEP: 5 mmHg VT: 400 mL RR: 24/min

Answer 26

What ventilator setting change is best to improve oxygenation in a patient with the following settings: FiO2: 70% PEEP: 5 mmHg VT: 400 mL RR: 24/min Increase PEEP if high levels of FiO2 (\> 60%) are required to maintain oxygenation, PEEP should be increased to allow for reductions in FiO2 as oxygenation improves

Question 27

What ventilator setting change is best to improve respiratory alkalosis in a 70 kg patient with the following settings: ## Footnote FiO2: 40% PEEP: 5 mmHg VT: 450 mL RR: 18/min

Answer 27

What ventilator setting change is best to improve respiratory alkalosis in a 70 kg patient with the following settings: FiO2: 40% PEEP: 5 mmHg VT: 450 mL RR: 18/min Decrease RR the patient is on an appropriate tidal volume (70 kg \* 6ml/kg = 420mL), thus, decreased RR is the most appropriate management

Question 28

What warming technique is best for patients with mild hypothermia?

Answer 28

Passive external warming remove wet clothing, cover with blankets

Question 29

What warming technique is best for patients with moderate hypothermia?

Answer 29

Active external warming warm blankets, heating pads, warm baths

Question 30

What warming technique is best for patients with severe hypothermia?

Answer 30

Active internal warming warmed pleural or peritoneal irrigation, warmed humidified oxygen

Question 31

When using a ventilator, prolonged FiO2 levels \> [...]% are associated with oxygen toxicity.

Answer 31

When using a ventilator, prolonged FiO2 levels \> **60**% are associated with oxygen toxicity. thus it is usually preferable to increase PEEP to allow for lower levels of FiO2 if oxygenation needs to be increased

Question 32

When using a ventilator, the goal is to keep PaO2 between [...] - [...] mmHg.

Answer 32

When using a ventilator, the goal is to keep PaO2 between **55 - 80** mmHg.

Question 33

When using a ventilator, the goal is to keep SpO2 between [...] - [...]%.

Answer 33

When using a ventilator, the goal is to keep SpO2 between **88 - 95**%.

Question 34

Which part of the mediastinum (anterior, middle, posterior) are bronchogenic cysts usually found?

Answer 34

Middle mediastinum other middle mediastinal masses include tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, and aortic aneurysms of the arch

Question 35

Which part of the mediastinum (anterior, middle, posterior) are neurogenic tumors usually found?

Answer 35

Posterior mediastinum other posterior mediastial masses include enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, and aortic aneurysms

Question 36

Which part of the mediastinum (anterior, middle, posterior) are thymomas usually found?

Answer 36

Anterior mediastinum other anterior mediastinal masses include thyroid neoplasm, teratoma, and lymphoma

Question 37

Which type of lung cancer is associated with Cushing's syndrome (ectopic ACTH) and SIADH?

Answer 37

Small cell carcinoma

Question 38

Which type of lung cancer is associated with hypercalcemia (ectopic PTHrP production)?

Answer 38

Squamous cell carcinoma

Question 39

Which type of parapneumonic effusion is characterized by low pH, low glucose, and positive gram stain & culture?

Answer 39

Empyema positive gram stain & culture helps distinguish empyema from complicated pleural effusion; both are managed with antibiotics and drainage

Question 40

Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by glucose \<60 mg/dL?

Answer 40

Complicated

Question 41

Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by glucose \> 60 mg/dL?

Answer 41

Uncomplicated

Question 42

Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by pH \<7.2?

Answer 42

Complicated

Question 43

Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by pH \> 7.2?

Answer 43

Uncomplicated

Question 44

Which type of pleural effusion, exudative or transudative, is commonly caused by decreased plasma oncotic pressure or elevated hydrostatic pressure?

Answer 44

Transudative e.g. hypoalbuminemia, CHF

Question 45

Which type of pleural effusion, exudative or transudative, is commonly caused by increased capillary permeability or disruption to lymphatic outflow?

Answer 45

Exudative e.g. malignancy, infection, PE