Pulm and Critical Care V Flashcards
What is the recommended treatment for patients with SIADH who have severe hyponatremia (e.g. seizures, coma)?
Hypertonic (3%) saline
What is the recommended treatment regimen for patients with intermittent asthma?
Short-acting β2-agonist, PRN
What is the recommended treatment regimen for patients with mild persistent asthma?
daily low-dose inhaled corticosteroid and SABA PRN
What is the recommended treatment regimen for patients with moderate persistent asthma?
daily long-acting β2-agonist, daily low-dose ICS, SABA PRN
or daily medium-dose ICS with SABA PRN
What is the test of choice to diagnose pulmonary embolism in clinically stable patients with a high likelihood of PE (modified Wells > 4)?
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
What is the underlying cause of low glucose in complicated parapneumonic effusions?
High metabolic activity of leukocytes and/or bacteria
What is the underlying etiology for aspiration pneumonia in patients with impaired consciousness and/or advanced dementia?
impaired swallowing and cough reflex
What is the underlying etiology in a patient with severe COPD who develops altered consciousness and seizures after administration of supplemental O2?
O2-induced CO2 retention
patients have a decreased respiratory drive and loss of compensatory vasoconstriction
What is the underlying etiology of aspirin-exacerbated respiratory disease?
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)
What maternal pathology is associated with increased risk for neonatal respiratory distress syndrome?
Maternal diabetes
maternal diabetes results in fetal hyperinsulinism, which antagonizes cortisol and blocks maturation of sphingomyelin
What medications should be administered to patients with severe asthma exacerbation?
[…], […], […]
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
What paraneoplastic syndrome presents with euvolemic hyponatremia?
SIADH
other common findings include low serum osmolality (< 275 mOsm/kg) and high urine osmolality (> 100 mOsm/kg)
What physiologic change helps compensate for chronic respiratory acidosis and hypercapnia in patients with COPD?
Increased renal HCO3 retention
i.e. compensatory metabolic alkalosis; similar changes may occur with other pulmonary pathologies (e.g. obesity hypoventilation syndrome)
What pneumonia complication is characterized by frank pus or bacteria in the pleural space?
Empyema
What regions of the lung are most commonly involved in supine patients with aspiration pneumonia?
[…] and […]
posterior segments of upper lobe and superior segments of lower lobe
What risk factor acts synergistically with asbestos to increase risk of lung cancer?
Smoking
asbestos alone increases risk by nearly 6-fold; smokers with asbestos exposure have nearly 59-fold increased risk
What test/imaging study is the best diagnostic test for bronchiectasis?
high-resolution CT scan of the chest
characteristic findings include bronchial dilation, lack of airway tapering, and bronchial wall thickening (arrows)
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?
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
What type of pleural effusion, transudative or exudative, is characterized by pH 7.30 - 7.45?
Exudative
normal pleural fluid pH is 7.60; transudative effusions typically have higher pH (7.40 - 7.55)
What type of pleural effusion, transudative or exudative, is characterized by pH 7.40 - 7.55?
Transudative
normal pleural fluid pH is 7.60; exudative effusions typically have lower pH (7.30 - 7.45)
What type of pleural effusion, transudative or exudative, is commonly seen with pneumonia (e.g. parapneumonic effusion)?
Exudative
What type of pleural effusion, transudative or exudative, is commonly seen with pulmonary embolism?
Exudative (typically a small, bloody effusion)
due to hemorrhage or inflammation
What type of V/Q mismatch is worsened in COPD patients with O2-induced CO2 retention?
Dead space
at baseline, hypoxic vasoconstriction shunts blood away from non-functional alveoli; supplemental O2 increases blood flow to these areas
What type of V/Q mismatch may occur in patients with pneumonia?
Right-to-left intrapulmonary shunt
due to alveoli filling with inflammatory exudate; results in hypoxemia
What ventilator setting change is best for a 65 kg patient with the following ABG and the ventilator settings:
pH: 7.42
PaO2: 105 mmHg
PaCO2: 37 mmHg
FiO2: 80%
PEEP: 7 mmHg
VT: 380 mL
RR: 14/min
What ventilator setting change is best for a 65 kg patient with the following ABG and the ventilator settings:
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
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
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
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
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
What warming technique is best for patients with mild hypothermia?
Passive external warming
remove wet clothing, cover with blankets
What warming technique is best for patients with moderate hypothermia?
Active external warming
warm blankets, heating pads, warm baths
What warming technique is best for patients with severe hypothermia?
Active internal warming
warmed pleural or peritoneal irrigation, warmed humidified oxygen
When using a ventilator, prolonged FiO2 levels > […]% are associated with oxygen toxicity.
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
When using a ventilator, the goal is to keep PaO2 between […] - […] mmHg.
When using a ventilator, the goal is to keep PaO2 between 55 - 80 mmHg.
When using a ventilator, the goal is to keep SpO2 between […] - […]%.
When using a ventilator, the goal is to keep SpO2 between 88 - 95%.
Which part of the mediastinum (anterior, middle, posterior) are bronchogenic cysts usually found?
Middle mediastinum
other middle mediastinal masses include tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, and aortic aneurysms of the arch
Which part of the mediastinum (anterior, middle, posterior) are neurogenic tumors usually found?
Posterior mediastinum
other posterior mediastial masses include enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, and aortic aneurysms
Which part of the mediastinum (anterior, middle, posterior) are thymomas usually found?
Anterior mediastinum
other anterior mediastinal masses include thyroid neoplasm, teratoma, and lymphoma
Which type of lung cancer is associated with Cushing’s syndrome (ectopic ACTH) and SIADH?
Small cell carcinoma
Which type of lung cancer is associated with hypercalcemia (ectopic PTHrP production)?
Squamous cell carcinoma
Which type of parapneumonic effusion is characterized by low pH, low glucose, and positive gram stain & culture?
Empyema
positive gram stain & culture helps distinguish empyema from complicated pleural effusion; both are managed with antibiotics and drainage
Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by glucose <60 mg/dL?
Complicated
Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by glucose > 60 mg/dL?
Uncomplicated
Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by pH <7.2?
Complicated
Which type of parapneumonic effusion, uncomplicated or complicated, is characterized by pH > 7.2?
Uncomplicated
Which type of pleural effusion, exudative or transudative, is commonly caused by decreased plasma oncotic pressure or elevated hydrostatic pressure?
Transudative
e.g. hypoalbuminemia, CHF
Which type of pleural effusion, exudative or transudative, is commonly caused by increased capillary permeability or disruption to lymphatic outflow?
Exudative
e.g. malignancy, infection, PE
