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IPAP JUNIOR SEM. > PULM Block I > Flashcards

PULM Block I Flashcards

1
Q

Where does the respiratory zone start

A

Bronchiolles, acinus, and alveolar sacs

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2
Q

What is an ave. NML tidal volume

A

500 ml

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3
Q

What is the tidal volume calc for IBW for an adult male

A

50kg+ 2.3 x (Inches-60)

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4
Q

What is the tidal volume calc for IBW for a woman

A

45.5kg+ 2.3(Inches-60)

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5
Q

Inpiratory capacity is made of..

A

Tidal volume + inspiratory reserve volume

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6
Q

Vital capacity is made of..

A

Exipratory resevere +tidal volume+ inspiratory reserve

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7
Q

Functional residual capacity is made of

A

Expiratory resevere volume +residual volume

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8
Q

What are the componets of total lund capacity

A

Inspiratory reserve+ Tidal volume+ Exipratory reserve + residual volume

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9
Q

What does vesicular breath sounds mean

A

NML

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10
Q

What does bronchial lung sounds mean

A

Harsher lung sounds

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11
Q

Bronchial breathing is a sign of…

A

Pneumonia or interstitial Dz

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12
Q

Cheyne stokes breathing is a sign of

A

Impending doom, HF, ect

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13
Q

What is egophany

A

a patient’s recitation of the long E sound is heard on auscultation as a long A sound, is another indication of consolidation typical of pneumonia.

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14
Q

Describe tactile fremitus

A

a vibratory sensation noted during breathing, is increased in patients who have consolidated lung from pneumonia, because the vibratory sensation conducts better through such lung tissue and is diminished in patients with pleural effusion

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15
Q

What is schamroths sign

A

Clubbing of the fingers as extrapulmonary signs of puml dz

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16
Q

What defines acute cough

A

Less than 3 weeks

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17
Q

What defines subacute cough

A

3-8 weeks

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18
Q

What defines a chronic chough

A

Longer than 8 weeks

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19
Q

What are the big three causes of chronic cough

A

Post nasal drip/ Rhinitis

Asthama

GERD

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20
Q

Orthopnea MC suggests..

A

CHF

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21
Q

What is platypnea

A

Platypnea – opposite of orthopnea; SOB while upright

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22
Q

What is trepopnea

A

SOB while laying on the side

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23
Q

Massive hemptysis is defined at what volume

A

Greater than 600ml is 24 hrs

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24
Q

What is the most common airway dz

A

Bronchitis

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25
Q

What is the first two steps in evaluation of non major hemoptysis

A

HPI and then where is the blood coming from, psuedo vs true hemoptysis

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26
Q

What is the defintion of mPAP

A

Mean pulmonary artery pressure (mPAP) ≥25 mmHg at rest, (measured by right heart catheterization)
(Defines PULM HTN)

Severe if mPAP is ≥35 mmHg or the mPAP is ≥25 mmHg with an elevated right atrial pressure and/or the cardiac index is <2 L/min/m

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27
Q

What are the 5 groups of Pulm HTN

A

Group 1) Pulmonary ARTERIAL hypertension

Group 2) Left Sided Heart Disease

Group 3) Chronic lung disorders and hypoxemia

Group 4) Chronic thromboembolic disease

Group 5) Unidentified mechanisms

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28
Q

What does spirometers measure

A

Tidal vol.

IRV and ERV

Measures airflow rates vs. lung volumes & gas exchange

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29
Q

What is the test that can measure Risidual vol.

A

Body plethysmography

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30
Q

What are the C/I for PFT (Spirometry)

A

ACUTE SEVERE ASTHMA, RR distress, Angina, tension pnthx,

Ongoing hemoptysis, Acute TB

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31
Q

A low FEV1/FVC ratio indicates..

A

Obstruction

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32
Q

What is the FEF 25-75

A

AKA maximal mid-expiratory flow rate (MMEF)

Indicated patency of small airways

Most sensitive to early obstructions

Measures flow

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33
Q

A scooped apperance on spirometry mean s

A

Obstructive lung dz

FEV1 usually reduced

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34
Q

A peaked, narrowed shape on spirometry indicates

A

A restricitive lung dz

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35
Q

A pt presents with a Normal Pttrn FEV1/FVC ratio with a NML FVC

What is the next step in eval

A

If there is a high suspicion of asthma, consider a bronchO provocation test

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36
Q

What defines a reverisble obstructive pattern

A

Adults: an increase in FEV1 OR FVC of more than 12% AND 0.2 L

5-18 years of age: an increase of > than 12%

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37
Q

What is the main bronchoprovacation test

A

Metha-choline challange

Positive result is a 20% decrease in FEV1 at a cuulative dose of 4mg per mL or less

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38
Q

Is screening for COPD with spirometry recommended for AS/s adults?

A

No! Only look for it in S/s or Hx of smoking

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39
Q

What is the 40-50-60/ 70-80-90

Rule?

A

When evaluating a SPO2

Assuming normal pH, PCO2 & Hb:
70% SPO2 = PaO2 of 40 mmHg
80% SPO2 = PaO2 of 50 mmHg
90% SPO2 = PaO2 of 60 mmHg

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40
Q

What are the common causes of Anion Gap met Acidosis

A

MUDPILERS

methanol 
Uremia 
DKA
Paraldehyde 
Isoniazid 
Láctica Acid
ETOH 
Rhabdo/renal failure 
Salicylates
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41
Q

An Anion Gap Met Acidosis means what DDX

A

MUDPILERS

Methanol 
Uremia 
DKA
Paraldhye 
Isoniazid 
Lactic Acidosis 
ETOH
Rhabdo 
Salicylates
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42
Q

What does a non Anion gap met Acidosis mean DDX

A

HARDUPS

Hyperalimenations 
Acetazolamide 
Renal Tubular Acidosis 
Diarrhea 
Uretero-Pelvic Shunt 
Spirinolactone
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43
Q

What is the DDX for a Met Alkalosis

A

Clever PD

Contration 
Licorice (high urine Cl level) 
Endocrine (Conns, Cuchings) 
Vomiting 
Excess Alkali (urine Cl level) 
Refeeding Alkalosis 
(Urine Cl level)

Post Hypercapnia
Diuretics (urine Cl level)

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44
Q

What is the DDX for Resp Alk

A

CHAMPS

CNS dz 
Hypoxia 
Anxiety 
Mech Vent 
Progesterone 
Slaicylates/ Sepsis
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45
Q

How do you calc the anion gap

A

AG= NA- (HCO3+Cl)

or (Na+K) -(HCO3+Cl)

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46
Q

What is winters formula

A

To calc the PCO2 compensation In met acidosis

PCO2= (1.5 x Serum HCO3 )+8

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47
Q

How do you calc compensation in met alkalosis

A

Don’t learn this

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48
Q

What are the reasons to order a CXR

A 
Pulse >100
RR>24
T>100.4F
Crackles on PE
Signs of consolidation

Also consider RR, SpO2, and LOC in elderly pts
(Elderly pts may or may not present with fever in pneumonia)

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49
Q

What is the MC cause of sub Acute Cough

A

Post-infectious cough (3-8 wks)

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50
Q

What is the main stay of treatment for chronic cough

A

Intranasal corticosteroids

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51
Q

What are the triad of S/s for asthma

A

Wheezing , Chest Tightness, Exertional dyspnea

+/- cough

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52
Q

What are the top three MC causes of Chronic Cough

A

Post nasal drip
Asthma
GERD

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53
Q

What does ACEI cause Cough

A

Release brady kinins

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54
Q

Define Chronic Bronchitis

A

Defined as: productive cough most days for 3 months, over 2 years

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55
Q

Define bronachiectasis

A

Permanent, abnormally dialted bronchi and bronchiolles

Obstructive Airway Dz

Chronic Inflamation or infection leading to progressive airway damage

Chronic inflammatory cells lead to mucus pooling in the airways

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56
Q

A pt presents with large volumes of sputum, with accompanied wtih dyspna and hemoptysis

+pleuretic chest pain
+wt loss
+ anemia

You ascultate crackels at the bases of the lungs

ON CXR you see tubular/ cystic structures
(Tracks or rings) with dilated, mucus filled bronchi

Think

A

Bronchiectasis

If CXR is non difinitive, then order a Chest CT (perferred image)

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57
Q

What is the study of choice to Dx bronchiectasis

A

CT is the study of choice with accuracy above 95%

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58
Q

What is the Dx criteria for bronchiesctasis on CT

A

The imaging definition of Bronchiectasis on CT include bronchus larger than adjacent pulmonary artery and bronchi visible with 1 cm of pleura.

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59
Q

What is the TxOC for bronchiectasis

A

Antibiotics for exacerbations (10-14d)
—Empiric broad spectrum vs. sputum culture

Pseudomonas infection is common

Chest physiotherapy

Postural drainage

Inhaled bronchodilators

NO cough suppressants! Will make the infection stay and get worse!

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60
Q

A pt presents with chronic cough, and your collegue wants to give them a cough suppressant, what must you rule out before you can give a pt cough suppressants?

A

Bronchiectasis

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61
Q

What is the MC cause of severe chronic lung Dz in young adults

A

Cystic fibrosis

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62
Q

What is the MC fatal hereditary disease of whites in the US

A

Cystic fibrosis

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63
Q

What is the classic presentation of Cystic fibrosis

A

Chronic lung disease and pancreatic insufficiency resulting from thick mucus secretions

The pts have Abnormalities in membrane Cl channel
—Mutation of cystic fibrosis transmembrane conductance regulator (CFTR) protein
Resulting in:
—High electrolyte concentration in sweat (Na+, K+, Cl-)
—Abnormally thick & tenacious mucus

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64
Q

A young male pt presents with cough, thick mucus production, with decreases exercise tolerance,

PE exam reveals hyperresonant percussion of the chest, with A/P diameter increased, +/- gallstones, steatorrhea, azospermia

On labs you find mild hypoxemia with respiratroy acidosis

A devcrease FVC, FEV1, and TLC
With an elevated RV to TLC ration
Reduced DLCO

Think

A

Cycstic fibrosis

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65
Q

How does cystic fibrosis look on CXR

A

Hyperinflation early
W/ Apical bullae

Mucus plugging, rings/cysts (bronchiectasis), increased interstitial markings, focal atelectasis

Pneumothorax possible

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66
Q

What is the Test to Dx cystic fibrosis

A

Pilocarpine ionotophoresis sweat test (chlorine sweat test)
Elevated Na & Cl levels in sweat
2 tests on different days

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67
Q

What is the Tx approach to Cystic fibrosisi

A

Early recognition
Refer to CF center

Goals of Tx:

  • Clear/reduce secretions
  • Reverse bronchoconstriction
  • Treat respiratory tract infections
  • Replace pancreatic enzymes
  • Nutritional/psychosocial support

Rx:
Inhaled recominant human deoxyribonucleas
Inhaled hypertonic saline
Chest physiotherapy
(Postural drainage, percussion/vibration, cough)
Inhaled Bronchodialators (SABA)

ABX:
may be needed for active infections
Azithromycin can be used for long term disease progression

Definitive Tx: Lung Transplant

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68
Q

Define bronchiloitis

A

Generic term for inflammatory processes affecting bronchioles (airways <2mm)

Usually caused by RSV, MC in children

Pleathora of causes in adults

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69
Q

A pt presents with a insidious onset of cough a dyspnea, on PE you find tachypnea, crackles and wheezing

PFT show an obstructive pattern with out reversibility
CXRE non diagnostic
CT may show airtrapping similar to asthma

Think

A

Possible bronchiolitis (may need lung biopsy or specific exposure for DX)

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70
Q

What is the Tx approach to bronchiloitis

A

Cease culprit exposures/drugs

Oral corticosteroids for proliferative type

(Constrictive type unresponsive)

Inhaled bronchodilators

Cough suppressants

Concominant Tx of RSV

Referall to PULM

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71
Q

Define epiglottitis

A

Inflammation/infection of the epiglottis and adjacent supraglottic structures.

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72
Q

What are the MC causes of epiglottitis

A

Causes: Bacteremia and/or direct invasion of the epithelial layer by pathogenic organisms.

Children: Haemophilus influenzae type b (Hib) was the most common infectious cause of epiglottitis in children prior to routine immunization.

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73
Q

A young child pt presents with stridor and sitting in the tripod position, with Dysphagia, Drooling, and Distress,

+ feverm sore throat, cough, or tenderness to the ant. Neck

Think

A

Epiglottitis

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74
Q

Should you attempt to visualize the epiglottis in a child with dysphagia, drooling and in distress

A

NO! May cause acute cardiac arrest

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75
Q

What is the gold standard for visualization of the epiglottis in an adult

A

Laryngoscopy

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76
Q

What is a thumb sign on CXR

A

Epiglottitis

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77
Q

What is the Tx approach to epiglottitis

A

Maintenance of the airway is priority.
IF Not maintaining airway (tripod, respiratory distress).

Bag-valve-ventilation, if O2 remains below high 80s, attempt endotracheal intubation.

If unable, establish emergency surgical airway
Children <12, needle criocothyroidotomy
> 12, Surgical

Supplemental humidified Oxygen.

Monitored in an intensive care unit.

Antibiotics: Third generation cephalosporin (ceftriaxone or cefotaxime) AND antistaph agent active against MRSA (vancomycin). 7-10 day course.

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78
Q

Define hypoventilation

A

Faliure to maintain PaCO2 above 40

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79
Q

What is pickwickian syndrome

A

Obestiy relatedd hypoventilation

Blunted ventilator drive 
Increased mechanical load on the chest 
Daytime hypoventilation
Sleep disordered breathing
Leads to alveolar hypoventilation (elevated PaCO2) & hypoxemia
Comorbid obstructive sleep apnea common
Diagnosis of Exclusion
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80
Q

Whar are the rsk fxs for Obestiy hypoventilation syndrom e

A

BMI>40 kg/m2
Pre-existing sleep apnea
Reduced vital capacity on PFTs
Restrictive pattern

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81
Q

A pt presents with a BMI greater than 30, has snoring, nocturia, morning headaches, decreased libido, and non refreshing sleep

On ABG you see PACo2 greater than 45 and PaO2 less than 70

What is the Dx at Tx approach

A

Obstrucive sleep apnia ( pickwiskian)

Tx:
Wt loss (possible bariatric srgy)
Positive pressure vent

Avoid: sedative hypnotics, opiods, or ETOH

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82
Q

A middle aged man, slightly obese with refractory HTN

Think

A

OSA!

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83
Q

What is STOP-BANG for OSA

A 
Snore loudly
Tired: daytime fatigue, sleepiness
Observed apnea observed
Pressure: Hypertension
BMI >35
Age >50
Neck circumference (>40 cm)
Gender (Male)

Greater than 3 of the above = high risk

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84
Q

What labs should be ordered for a pt with OSA

A

CBC, TSH/FT4

Sleep study

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85
Q

An epworth Sleep score of

1 to 6=

A

Good score, NML

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86
Q

Epworth Sleep Score of 7to8 means

A

Average score

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87
Q

Epworth sleep scale of 9 and above means

A

Seek advice from a sleep specialist without delay

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88
Q

A Apnea hypopnea index of 0-4=

A

NML

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89
Q

Apnea Hypopnea Index of 5-14=

A

Mild

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90
Q

AHI (apnea hypopnea) index of 5-14=

A

Mild

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91
Q

AHI of 15-29=

A

Moderate sleep apnea

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92
Q

A AHI above 30 indicates

A

Severe OSA

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93
Q

A pt with a O2 sat below 90 for more than 20% of a sleep study=

A

Severe OSA

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94
Q

What is the Tx appraoch to OSA

A

Wt loss!

Strict avoidance of ETOH and sedatives

For mild: Mechanical airway devices

Moderate: Nasal CPAP

(CPAP IS GOLD STANDARD)

Severe: CPAP!

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95
Q

What are the indications for a hypoglossal nerve stimulator

A

For Mod-Severe OSA
BMI< 32
AHI< 50
W/ non concentric airway collapse pn sleep endoscopy

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96
Q

What is a MADs device

A

Mandibular adjustment device for sleep apnea

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97
Q

A pt with ungoing sleep apnea, not corrected by wt loss, apliance, or surgery.
Any PAP level beyound BPAP/ CPAP/ or APAP
Or requireing O2 for more than 6 months

What should the pt get in the military

A

MEB!

Permamnet P2 if PAP is required longer than 12 months

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98
Q

What is the differnece between OSA and Obestiy hypoventilation

A

daytime hypoventelation with Obestiy hypovent

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99
Q

What is the only definitive Tx for OSA

A

TRACHEOTOMY

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100
Q

What is the definition of asthma

A

Asthma is a clinical syndrome of UNKNOWN etiology characterized by RECURRENT EPISODES OF AIRWAY OBSTRUCTION
that resolve spontaneously or as a result of treatment.

These changes occur in the setting of various types of AIRWAY INFLAMMATION that are thought to reflect specific endotypes of this clinical syndrome.

Although airway obstruction is largely reversible, some changes in the asthmatic airway may be irreversible.

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101
Q

What is Atopy

A

Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema).

IgE mediated (Atopic dermatitis)

Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens.

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102
Q

A pt presents with:

Edema, infiltrates within bronchial walls (eosinophils, lymphocytes)

Epithelial damage– “fragile” appearance on microscopy

Hypertrophy and hyperplasia of smooth muscle

Increased collagen deposition beneath epithelium

Hypertrophy of mucus glands and increase in goblet cells

This is the pathology of what Dz

A

Asthma

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103
Q

What are the triad of sequale of airway remodelling in Asthma

A

Epithelial damage
Airway fibrosis
Smooth muscle hyperplasia

Chronic inflammation causes release of inflammatory mediators including growth factors

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104
Q

What does catamenial mean

A

Occuring during part of a menstral cycle

Some pts have asthma only during menses

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105
Q

What is the most common inhaled irratant of asthma

A

Cigarette smoke

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106
Q

What is the pathophys of Excercise induced Asthma

A

Heat and moisture loss + rapid cooling of airway

During exercise, increase respiratory rate introduces cooler, dry air to respiratory tree.

Air is warmed and humidified, epithelial surfaces are cooled and dried

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107
Q

How does asprin cause asthma

A

Aspirin causes production of leukotrienes from arachidonic acid

Aspirin sensitivity linked with nasal polyposis

Asthma triad – Asthma, aspirin sensitivity, and nasal polyps

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108
Q

What is samter syndrome

A

Asprin induced asthma

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109
Q

What is the atopic triad

A

Allergic rhinitis, asthma, eczema

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110
Q

A pt presents with wheezing, increased sputum with chest tightness that is all worse at night

Think

A

Asthma

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111
Q

What are the 3 RED FLAG questions for asthma

A

Have you ever been hospitalized for your asthma?

Have you ever been intubated because of your asthma?

Have you ever been on oral (systemic) steroids for your asthma?

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112
Q

A pt with asthma iwth respiratory acidosis indicates

A

Imprending failure

Ph is low and PCO2 is high

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113
Q

What is the common EKG pattern for asthma

A

Sinuc tach
R axis deviation
RBBB

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114
Q

A negative BPT (bronchial provocation testing) means what for asthma

A

Negative for asthma

But a postive test does not mean they are postive for asthma

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115
Q

What is the pt education for all Asthma pts

A

Asthma Action Plan!

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116
Q

Which pts a recommeneded for allergen mitigation

A

Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms

(DEC2020 update)

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117
Q

How long should a pts S/s be controlled before attempting a step down approach

A

Controlled S/s x 3 months

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118
Q

What is the severity of asthma of the pt below:

Pt presents with S/s less than 2 days a week, and night time awakenings less than 2 times a month
They use their SABA 2 days a week
With no interference in NML activity

The FEV1 is greater than 80% predicted and the FEV1/FVC is NML

A

Intermittent severity with recommended step 1 tx

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119
Q

What is the Tx appraoch for a step 2 Asthma Pt (Nabp)

A

Low dose ICS

Alternative LTM, or cromolyn

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120
Q

What is the Tx approach to a step 3 (NABP) Asthma

A

Low dose ICS plus LABA or medium dose ICS alone

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121
Q

What is the Step 4 Tx appraoch to (NABP) Asthma

A

Medium dose ICS plus LABA
Or
Medium dose ICS plus LTM

Add Lama if S/s are still uncontrolled

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122
Q

What is the STEP 5 asthma Tx approach to a pt with Asthma

A

High does ICS plus LABA

Consider omalizumab for pts with allergic asthma or LAMA if still uncontrolled

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123
Q

What is the Step 6 approach to ASTHMA (NAEBP)

A

High does ICS plus LABA plus systemic corticosteroids and consider omalizumab for pts with allergice asthma or LAMA if still uncontrolled

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124
Q

If a pt uses SABA more than 2 times a week for Asthma S/s

That would mean

A

The S/s are uncontrolled and need a step up in Tx

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125
Q

What is Single Maintenance and Reliver Therapy used for

A

moderate-persistent beyond Asthma pts

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126
Q

What is the criteria for well controllled asthma pt

A

S/s less than 2 days a week, with less than 2 awakenings a month
Without interference in activity

FEV1 or peak flow greater than 80% personal best
With more than 1 excacerbation a year

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127
Q

Learn Table on slide 53 +56 for Ginna Asthma Tx

A

Learned it bitch

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128
Q

What can FeNO tell you

A

Fractional exhaled Nitric Oxide

Nitric oxide produced throughout body

Fights inflammation, relaxes smooth muscle

High levels can indicate airway inflammation

Can help determine if steroids will help

Can help monitor asthma control

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129
Q

When can you consider step down treatment for an Asthmatic

A

3 months of Tx with improvement

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130
Q

What is the preferred 1st line tx in persistnant Asthma

A

Anti-Inflammatory Corticosteroids (inhaled)

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131
Q

How should salmetrol and formoterol be used in Rx

A

If added to ICS, effect is equivalent to doubling ICS dose

Never for monotherapy

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132
Q

What is the mediatory inhibitor used in execrice inducsed asthma

A

Cromolyn

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133
Q

How is Tiotropum used in Asthm a

A

Can be an add on if uncontrolled on ICS + LABA

Much more commonly used in COPD

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134
Q

What are the most effective bronchdilator in acuts S/s

A

SABA’s

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135
Q

How is prednisone used in Asthma Tx

A

Burst Tx: 5 day course
(Acute asthma exacterbations)

Severe: IV/IM methyl prednisone

Goal of Tx is a FEV1 greater than 50%

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136
Q

A peak flow that is less than 50% of the baseline PEFR is what kind of asthma

A

Severe Asthma!

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137
Q

A pt presents with mild exacerbation of Asthma, already takes an ICS, what is the Tx option for the S/s present

A

5 day oral steroids (prednisone)

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138
Q

Failure to respond to treatment by objective criteria (PEFR or FEV1) within 2 hours of arrival at the emergency department is an indication for the use

A

Oral or IV steroids (prednisone/ methyl prednisone)

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139
Q

A pt presetns with impednind respiratry failures, with a PEFR less than 25 percent

What is the intervention

A

INTUBATE !

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140
Q

What medications can not be used in Preg Asthma Pts

A

Tetracycline
Ipatropium bromide
Terbutaline

Use systemic steroids sparingly

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141
Q

What is the FEV1/FVC for COPD

A

Less than 0.7 (70%)

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142
Q

What is the definition of chroninc bronchitis

A

excessive secretion of bronchial mucus; daily productive cough x 3+ months in 2+ years

Basically the enlargement of mucus glands and proliferation of goblet cells

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143
Q

What is the definition of Emphysema

A

abnormal permanent enlargement of air spaces distal to terminal bronchiole, with wall destruction

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144
Q

What is the leading cause of COPD in the USA

A

Cigarette Smoking

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145
Q

What is the genetic cuase (young pts) of COPD

A

Apla-1 antitripsin defect

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146
Q

What is panacinar emphysema

A

diffuse involvement of acinus (bronchiole, alveolar ducts, sacs & alveoli)

Lower lung more affected than upper lung

Most common in α1- antitrypsin deficiency

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147
Q

What is centrilobular emphysema

A

proximal acinus (bronchiole)

Destruction more irregular with areas of sparred tissue

More common in smokers

Most likely due to peripheral spread of airway disease (bronchitis)

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148
Q

A pt presents with SOB, cough, and sputum production, with PULM HTN and inpending respiratory failure

Think

A

COPD

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149
Q

What is the HALLMARK of COPD

A

Periodic exacerbations = hallmark of COPD

Often precipitated by infection or environment

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150
Q

WHat are the PFT findings in COPD

A

Early: ↓ mid/small airway flow decreased (FEF 25-75%)

Mid: ↓ FEV1 and FEV1/FVC ratio

Late: ↓ ↓ FVC, ↑ TLC especially in emphysema

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151
Q

What is GOLD 1 for COPD

A

Post BronchO FEV1 greater than 80% predicated

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152
Q

What is the most common EKG abnmlaity in COPD

A

SINUS TACH

Can be MAT, Afib, Aflut

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153
Q

Is clubbing a manifestation of COPD

A

Clubbing is not a manifestation in COPD, and its presence should prompt an evaluation for other conditions, notably lung cancer or pulmonary fibrosis

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154
Q

What is the role of Varenicline

A

Smoking Cessation Medication (Chanitx)

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155
Q

What is the cutoff for O2Tx in COPD

A

Resting 88% O2 sat

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156
Q

What is the preferred Inhaled broncho dilator in COPD

A

Ipatropium

Can be combined w/ albuterol

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157
Q

What is the tx approach to Exacterbations of COPD

A

SABA +/- short acting anticholinergic
(albuterol +/- ipratroprium)

Consider antibiotics

Consider systemic steroid burst

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158
Q

What are teh mMRC scales

A 
Dyspnea w/
O- excerceise 
1-hurrying/hills
2-Normal walking pace
3-100 yards or a few minutes 
4-rest
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159
Q

What is the number of ribs for a good/NML CXR

A

8-10

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160
Q

What effect does sympathetic stimulation have on the airways

A

Epi causes bronchodilation and increases beat freq of cilia

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161
Q

What effect does parasympathetic have on the airways

A

Ach causes slight contraction of smooth muscle and increase in mucous production

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162
Q

What is the role of surfactant

A

Lowers surface tension of alveolar fluid, maintaining patency of the alveolar sacs

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163
Q

O2 content in arterial blood depends on what two things

A

PO2 and Hg level

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164
Q

Tissue oxygenation depends on what three fxs

A

PO2, Hg level and CO

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165
Q

What are the three ways CO2 is carried in our blood

A

Bicarbonate (largest component)
Carbaminohemoglobin
Dissolved CO2

CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-

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166
Q

What percent of Tidal Volume reaches the Resp zone

A

70%,

30% remains in anatomical dead space

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167
Q

A loud seconds heart sound indicates..

A

Pulm HTN

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168
Q

Dullness on percusión of the chest means..

A

Consolidation, need to order a CXR

169
Q

What is the per Kg for NML TV

A

5ml/kg

170
Q

What is egophany

A

a patient’s recitation of the long E sound is heard on auscultation as a long A sound, is another indication of consolidation typical of pneumonia.

171
Q

Fine crackles are a sign of..

A

Heart Failure, Interstitial Lung Dz, Alveolar filling D/o

172
Q

Coarse crackles are a sign of..

A

Bronchitis

173
Q

Wheezing is a sign of..

A

Asthma./ COPD

174
Q

Rhonchus is a sign of…

A

Rhonchusis a musical, low-pitched sound typically heard in expiration and sometimes during inspiration; it often resolves with coughing.

Is often a sign of Bronchitis, or COPD

175
Q

Stridor is a sign of..

A

Upper airway obstruction, Laryngeal or tracheal inflammation, masses or lesions in the upper airway, or external compression

176
Q

A pleural friction rub is a sign of…

A

Pleural inflammation or pleural tumors

177
Q

A pt presents with absent lung sounds.. think

A

Obstruction, Large effusion, or collapse (PNTHX)

178
Q

What effect do anemia and polycythemia have on Cyanosis

A

Anemia – may prevent cyanosis from appearing

Polycythemia – may show cyanosis in mild hypoxemia

179
Q

What is the most common airway irritant

A

Cig Smoke

180
Q

What are the common causes of acute cough

A

Common Cold

Acute Bacterial Sinusitis

Pertussis

COPD exacerbations

Allergic rhinitis

Irritants

181
Q

A pt presents with chronic cough, and it is determined that the cause if a post nasal drip

What is the empiric tx

A

Antihistamine/ decongestant, with nasal saline irrigation

182
Q

A pt presents with chronic cough and it is determined that asthma is the cause..

What is the Approach

A

Eval with spirometry, bronchodilator reversibility, Methacholine challenges, then treat with ICS, Beta Adrenergic Inhalers, LRAs

183
Q

A pt presents with chronic cough and GERD is determined to be the cause

What is the Tx approach

A

Empiric tx with PPI and change diet/ Lifestyle

184
Q

A pt presents with inadequate response to empiric tx for Asthma/GERD/ Post nasal drip

What is the next step in eval

A

Many options:
24 hr esophageal PH monitoring (GERD)
Endoscopy

Barium Swallow study

HRCT

Sinus imaging

Bronchoscopy

Echo

Polysomnogram

185
Q

When should ICS be used for chronic cough

A

Inhaled corticosteroids can reduce cough but should be used only AFTER evaluation by chest radiography and often spirometry.

186
Q

Define Paroxysmal Noctural Dyspnea

A

Unlike orthostatic, the onset is not immediate upon laying down

Suggests: Cardiac decompensation
Peripheral edema

187
Q

What are the level 1 tests that should be ordered on a pt with CC of Chronic dyspnea

A 
CBC 
BMP 
CXR 
ECG 
Spiromerty 
Pulse Ox
188
Q

What is the working DDX of Hemoptysis

A

Bronchitis, Bronchiectasis, and Carcinoma are the top 3

Then infx causes: TB, abcess, Pneumo, Fungal infection

And last lesions: PE, Pulm HTN , Pulm Edema

189
Q

Any pt that presents with hemoptysis should get what w/u

A

CBC,
Urinalysis
Coag panel (PT/ INR)

With a CXR and ECG

190
Q

A pt presents with Hemoptysis (non massive)
CXR shows infiltrates

What is the tx approach

A

Start ABX

Resolution? = Repeat CXR in 6-8 weeks, if ABN send to CT (chest)

No resolution?= CT (chest) and Pulm consult

191
Q

A pt presents with Non massive Hemoptysis and there is a mass on CXR was is the tx approach

A

Perform Bronchoscopy and pulm consult

192
Q

A pt presents with non massive Hemoptysis and on CXR there is parenchyma dz

What is the approach

A

Chest Ct

If there is no specific findings, then perform Bronchoscopy and Pulm referral

193
Q

A pt presents with non massive Hemoptysis and the CXR is NML

What is the approach

A

Consider ABX,

If it does not resolve, send to chest CT

194
Q

What are the suggestion criteria for carcinoma

A

Postive CXR, age over 40, w/ smoking Hx, and Hemoptysis greater than 1 week

195
Q

Do Lungs contain sensory fibers

A

NO!
So if a pt has pulm chest pain think
Parietal pleura, diaphragm or medistinal d/o Which are usually the result of inflammation or malignancy

196
Q

What are the indications for PFTs

A

Assessment of type/extent of lung dysfunction

Diagnosis of dyspnea/cough causes

Detection of early dysfunction

Prognostic assessment

Perioperative risk

Health status prior to physical exercise

197
Q

What is the most readily available and useful PFT

A

Spirometry

198
Q

How long should the pt exhale on a Spirometry

A

6 seconds

199
Q

FVC on spiromerty measures

A

Is an indication of lung/chest expansion

Good indicator of effort

Measures total volume a pt can blow out rapidly after a deep inhalation

MEASURES VOLUME!

200
Q

A pt with a reduced FVC but a NML FEV1/FVC ratio.. means

A

Restrictive pattern

Reduction in lung volumes
Imagine trying to take in a breath with a tight band around your chest

201
Q

What are the two separate definitions of abnormal flow rates

A

FEV1 & FVC (independently): <80% of predicted is abnormal (adults)

FEV1/FVC ratio < 70% is abnormal

202
Q

A pt presents with a FEV1/FVC ratio that is normal, yet the FVC is decreased.. what is the next step in eval

A

This is a restrictive pattern

Determine the severity
And then refer for Full PFTs as necessary

203
Q

A pt presents with a reduced FEV1/FVC ratio yet the FVC is NML

What is the next step in eval

A

This is an obstructive pattern

Determine severity And reversibility

If its reversible: that’s asthma
If its not: COPD (or other cause)

204
Q

A pt presents with a FEV1/FVC that is decreased AND the FVC is decreased

What is the next step in eval

A

This is a mixed pattern,

Determine severity

Does the FVC improve with a bronchodilator>?

Yes: pure obstruction likely, COPD/ Air trapping

No: refer for full PFTs

205
Q

What is the GOLD criteria for COPD

A

FEV1/FVC ratio of less than 0.7

206
Q

What is the degree of severity in a FEV1 % predicted

A 
>70= Mild 
60-69= mod 
50-59=mod severe 
35-49= severe 
<35 = very severe
207
Q

What defines reversibility of an obstructive pattern

A

Increase in FEV1 or FVV of more than 12% AND of 0.2L

208
Q

What is GOLD 1

A

First the pt has a FEV1/FVC ratio of less than 0.7

Then post bronchodilator FEV1 % predicted of 80%

209
Q

What is GOLD 2

A

A post bronchodilator improvement of 65%

210
Q

What is GOLD 3

A

A post bronchodilator FEV1% predicted of less than 50% but not less than 35 %

211
Q

What is GOLD 4

A

A post bronchodilator FEV1 % predicted of less than 35 %

212
Q

What two patterns should get Full PFT work/ups

A

Restrictive and Mixed patterns that do not respond to bronchodilators

213
Q

What is the 5 step approach to reading PFTs

A
  1. Look FEV1/FVC ratio
  2. Look at FVC

(Determine pattern, Restrictive, Obstructive, mixed)

  1. Determine severity
    (Mild, Mod, Mod Severe, ect)
    (except in COPD)
  2. Ask if Full PFTs are needed
    (Restrictive pattern or mixed with out brocnhco response)
  3. Asses for reversibility
    (Post bronchodilator: increases in 12% ratio AND 0.2L)
    (Asthma/COPD)
214
Q

When is bronchoprovacation (methacholine challenge) test recommended

A

Bronchoprovocation testing is recommended for patients with normal results on pulmonary function testing but a history that suggests exercise- or allergen-induced asthma.

215
Q

What is the DDX of an obstructive pattern on PFT

A

Asthma, COPD, Alpha- Antitrypsin def.

216
Q

What three drugs can cause a restrive pattern on PFT

A

Amiodarone
Methotrexate
Nitrofurantoin

217
Q

What is the gold standard for evaluating lung VOLUMES

A

Body Plethysmogrpahy

Measurement of air pressure and volume changes within closed box as patient respires.

Can calculate TLC using Boyle’s Law (most accurate)

218
Q

What does DLco measure

A

measures rate of alveolar/ capillary gas transfer

Helpful in diffuse infiltrative lung disease or emphysema

Can help differentiate emphysema vs. chronic bronchitis (both COPD)

Results dependent on alveolar surface area and pulmonary blood flow

219
Q

What must be measured FIRST before evaluating an DLco

A

Hgb! Can be reduced in Anemic pts

220
Q

An elevated DLco means

A

THink Asthma, obesity, polycythemia, pulm hem, exercise

Increased capillary flow

221
Q

A decreased DLco means

A

Think Emphysema, Lung Dz, PVD

Decreased cap flow

222
Q

What does a peak flow meter measure

A

Measures peak flow through device

Useful for monitoring progression of symptoms or acute exacerbations

May dictate change in treatment regimen or need for emergent intervention

ASthma/ COPD action planning

223
Q

What are the findings on PFTs in a pt with obesity and asthma

A

Asthma will be more severe

Reduced ERV, VtCap,
Increased DLco
Increase work of breathing

224
Q

How is U/S used in Pulm

A

Can be the 1st screen for Pneumonia, Pulm edema, or a PTNTHX

(NOT GOLD STANDARD)

225
Q

What defines large vs small opacity

A

Small less than 1 cm

Large greater than 1 cm

226
Q

How does bacterial pneumonia look on CXR

A

Lobar pattern

227
Q

What does a diffuse pattern on CXR mean

A

Suspect Alveolar damage, edema, or viral Pneumo

228
Q

What does Mulitfocal pattern on CXR mean

A

Suspect bronchopneumonia, aspiration, or vasculitis

229
Q

What does a perihilar pattern on CXR mean

A

Suspect Vol. overload, or pulm hem

230
Q

What is the use of Bronchoscopy in pulm

A

Allows direct vis

Can eval airway
Dx carcinoma and staging
Eval Hemoptysis
Dx pulm infx s

231
Q

What is bronchoalveolar lávate

A

Bronchoscopy plus a wash/collection that is sent for analysis:

  • Cell count
  • Cytology
  • Cultures
232
Q

What is Dr T definition of an acid

A

A chemical substance, usually a liquid, which contains hydrogen (protons) and can react with other substances to form salts.

233
Q

What is Dr T definition of a base

A

Achemicalspecies that donates electrons, accepts protons, or releases hydroxide (OH-) ions in aqueous solution

234
Q

What is PaO2

A

Measures the partial pressure of O2 in the Arterial Blood

235
Q

What is PaCO2

A

Measures the partial pressure of CO2 in arterial blood

236
Q

What is HCO3

A

CALCULATED concentration of bicarbonate in arterial blood

237
Q

What is the B/E

A

base excess/ deficit

Calculated relative excess or deficit or base in arterial blood

238
Q

What is SaO2

A

Calculated arterial sat

239
Q

What are the NML values for

pH/PaO2/ PaCO2/HCO3/B/E/SaO2

A
  1. 35-7.45/75-100/35-45/22-26/

- 4-+2/95-100%

240
Q

As a pule ph falls ____ for each 10 mmHg rise in PCO2

A

Winters formula

0.1 for each 10 mmHg

241
Q

What is the Henderson hasselbach equation

A

PH=pKA +log (conjugate base/acid)

242
Q

Where would Tb show up on a CXR

A

Upper zones of the lung

243
Q

Where would sarcoidosis show up in a CXR

A

Upper lung zone

244
Q

Where would asbestos show up on a CXR

A

Basal lung zones

245
Q

What is the difference between oxygenation and ventilation

A

Oxygenation: getting O2 in
Ventilation: getting CO2 out

246
Q

What are the MEASURED components of an ABG

A

PH, PaO2, PaCO2

247
Q

What are the calculated parts of Ann ABG

A

HCO3, Base Excess, SaO2

Except when SaO2 is combined with Co-Ox then it is measured

248
Q

What is the ABG standard format

A

pH|PaCO2|PaO2|HCO3-|

O2 Saturation

249
Q

What is the Henderson Hasselbach equation for ABGS

A

pH = 6.1 + log [HCO3-/(0.03 x PaCO2)]

250
Q

What is the DDX FOR ACUTE RESP ACIDOSIS

A

Anything that causes hypoventilation

CNS depression 
Airway obstruction 
Pneumonia 
Pulm edema 
PNTHX
251
Q

What is DR T approach to ABGS

A

1 Are values in normal range?

2 Acidosis vs Alky

3 ROME

4 Compensation >?? M

252
Q

Sometimes pts can cough so forcefully that a cough alone can cause other complications.. such as..

A

Syncope

Dysarrthymias

HA

Subconjunctival Hem

Inguinal hernias

GERD

253
Q

What is the MC cause of Acute (less than 3 wks) cough

A

Viral RTI/ Acute Bronchitis

254
Q

A pt presents with a cough for 2 weeks, with chest wall tenderness, wheezing on auscultation, Rhonchi that clears after the cough

Think

A

Acute bronchitis

255
Q

What is the Tx approach to acute cough

A

Antitussives, Anti-inflammatory, mucyolytics, Antihistamines, Decongestants, or bronchodilators,

DO NOT GIVE ABX

256
Q

What are the Three most common causes of Chronic Cough

A

PND (DRIP), Asthma, GERD

Lesser: 
ACEI 
Post infectious 
Cystic fibrosis
Ect ect
257
Q

What is THE most common cause of Chronic cough in non smokers

A

Post Nasal Drip

258
Q

A pt presents with Rhinorrhea, Nasal congestion, And a throat tickle for 8 weeks..
No Hx of tobacco use

On PE you see cobblestoning in the oropharynyx

What is the Likely Dx and tx

A

Post Nasal drip for Chronic Cough

I trabas al corticosteroids
Oral antihistamines
Oral decongestants
Oral montelukast

ABX only when justified

1-2 weeks of initial tx should resolve cough

259
Q

A pt presents with wheezing on PE, with chest tightness and exertional dyspnea

Think

A

Hallmark findings of Asthma

260
Q

What is the initial Tx approach to Asthma

Don’t think step, just think right away

A

ICS with a PRN saba x 6-8 wks

If pt is unable to tolerate an ICS then you can use motelukast

261
Q

A pt presents with increased cough at night, and while supine, and increased cough after eating

Think

A

GERD

Up to 50% of pts also have heartburn/ waterbrash

262
Q

What is the Tx approach to a pt with chronic cough from GERD

A

Start a PPI

Stop smoking

Change diet (fatty foods, caffeine, ETOH)

Lose wt if obese

3 months of therapy should resolve S.s.

263
Q

What is the Study OC when evaluating Bronchiectasis

A

CT

The imaging definition of Bronchiectasis on CT include bronchus larger than adjacent pulmonary artery and bronchi visible with 1 cm of pleura.

264
Q

What is the most common fatal hereditary dz of whites in the US

A

Cystic fibrosis

265
Q

What is the oral med for specie gene mutation in Cystic fibrosis

A

Ivacaftor

266
Q

What is the prognosis for CF

A

Median survival 36-37 yrs

Death usually pulmonary complications:
Pneumonia, pneumothorax, hemoptysis

Terminal chronic respiratory failure & cor pulmonale

267
Q

What are the relevant Hx exposure for Bronchilolitis

A

Viral infx (RSV)

Toxic Fumes ( ammonia, diacetyl)

Organ transplant

Or connective tissue D/o like RA or Sjogren Syndrome

268
Q

What are the common causes of Epiglottitis

A 
Bacterial : 
H. Influenza B 
H. parainfluenza 
Strep Pneumo 
Staph Aureus 
Beta Strep 
P. multicida 
Moraxella Catahris 
Klebsiella

Viral :
HSV1
H. Zoster
EBV

Fungal:
Candida

269
Q

What are the three Ds of epiglottitis

A

Dysphagia, Distress, and Drooling

270
Q

A pt presents with stridor, muffled voice, fever, and sore throat

Think

A

Epiglottitis

271
Q

What are the Two ABX for Epiglottitis

A

Ceftriaxone or Cefotaxime plus Vanc for 7-10 days

272
Q

What are the common aspirates in children vs infants

A

Food items are the most common items aspirated by infants and toddlers, whereas nonfood items (eg, coins, paper clips, pins, pen caps) are more commonly aspirated by older children.

273
Q

What is the classic triad of aspiration FB

A

Wheezing, cough, and diminished Lung sounds

Also cough, Tachypnea, stridor

274
Q

A child presents with cough, Tachypnea, and stridor
Also wheezing and diminished breath sounds,,.
Think

A

Aspiration of FB

275
Q

What are common CXR findings in a lower airway FBA

A

Hyper inflated lung, atelectasis, medistinal shift, or pneumonia

Normal findings do not rule out FBA, and hx should prompt bronchoscope

276
Q

What is the tx approach to FBA with sever airway obstruction

A

Dislodgement using back blows and chest compressions in children <1.

Heimlich maneuver in older children.

Intubation, oxygen

Rigid bronchoscopy

277
Q

What is the Tx approach to FBA without complete obstruction

A

Conduct PE, plain radiograph of chest and neck (pending symptoms), CT, bronchoscopy.

278
Q

What is the approach to removing a FBA

A

Children : rigid bronchoscope

Adult: flexible bronchoscope

279
Q

A pt presents with a Suspected/ Known FBA, and they are S/s and unstable

What is the next step

A

Emergency managment for airway obstruction

280
Q

What is the step by step approach for a suspect FBA that is stable

A

Plain Radiograph

If FB detected the bronchoscopy

If NML: then if high index of suspicion you can order either a CT scan, or perform bronchoscopy

If CT scan and CXR are normal then observe and have pt f/u in 2-3 days

281
Q

What is the algorithmic approach to a complete airway obstruction

A

Are there S/s of obstruction
(Tripod, sniffing, severe distress, grunting, muscle use, cyanosis, or unable to speak)

Emergency call to Anesthesia

If the pt becomes unresponsive:
Start CPR with compressions, Prior to each attempt at Resuce breathing evaluate airway for obstruction dislodgement

If the pt remains conscious:

Age less than 1: back blows x 5
Chest thrusts x5 alternating

Child Q year old: hemiliech

Obstruction should be cleared within 1 minute

If not then perform direct laryngoscope with magill forceps

If still unable to remove obstruction
Consider a cric or intentional right stem RSI to push the FB into the Right stem then position the pt with the right side down to ventilate the left lung

Then proceed immediately to the OR

282
Q

What is something you have to observe for in a FBA post removal

A

Post obstructive pulm edema

283
Q

What are the key steps to prevent FBA

A

Vigilant at 6 months age

hard or round foods should not be given to children less than 4

Feeding should be done upright

Chewable meds should only be given after 3 years old

284
Q

What is central sleep apnea

A

Cessation of effort or in adequate vent drive

Can be from narcotics, or idiopathic

285
Q

A pt presents with daytime hypoventilation and also complaints of sleep disordered breathing

Think

A

Obesity Hypoventilation syndrome (pickwickian)

286
Q

A pt presents with CC of decreased libido and non restorative sleep ,

Wife states he constantly snores, and awakenes gasping for air

He has morning HA and concentration difficulties,
He states he often falls asleep at work and sometimes while driving

Think

A

OHS

287
Q

What does an epworth score of 1-6 mean

A

Good sleep !

288
Q

What does a epworth score of 7-8 mean

A

Average score ( could improve)

289
Q

What does an epworth scale greater than 9 mean

A

Refer to sleep specialist without delay!

290
Q

What are the complications of OHS

A

Pulm HTN

HF

Cor pulmonale

OSA complications like HTN stroke, MI, MVA, hyper somnolence

291
Q

What are the REQUIRED criteria for OHS

A

BMI greater than 30 (greater than 40 is only a RSK fx)

Daytime Hypoventilation of a PaCO2 greater than 45 at sea level

Hypoxia of a PaO2 less than 70

W/ sleep disordered breathing

And an absense of any other possible Dx

292
Q

Define OSA

A

Upper airway obstruction due to loss of pharyngeal muscle tone allows pharynx to collapse passively during inspiration

293
Q

What are the increased Rsk fx for OSA

A

Anything that narrows the airway

Micrognathia, macro gloss is, obesity, tonsilar hypertrophy

Is worse if the use ETOH or drink/sedative prior to sleep

294
Q

Testosterone supplementation can lead to what sleep d/o

A

OSA

295
Q

A pt presents with Morning sluggishness, HA’s, cognitive impairment, recent weight gain, impotence

Think

A

OSA

296
Q

What are the three S’s of OSA

A

Snoring, Sleepiness, and Sig other reports S./s

297
Q

A pt with a mallampati score of IV is at an increased risk of..

A

OSA

298
Q

What does a complete polysomnography include

A

Electroencephalography

Electro-oculography

Electromyography

ECG

Pulse oximetry

Measurement of respiratory effort and airflow
-apneic episodes

299
Q

What determines the severity of OSA

A

the Apnea Hypoxia Index

300
Q

Pts with sever OSA are at an increased risk of…

A

HTN
DM
CAD
Arrhythmias

301
Q

What is the definitive last resort tx option for pts with OSA that have life threatening arrhythmias and have failed conservative tx

A

Tracheostomy or maxilofacial srgry

302
Q

Should supplemental O2 be used for pts with OSA

A

Supplemental O2 should not be routinely used

Lessens desaturations…but lengthens apneas!

303
Q

What is the typical onset of Asthma and what pts have the highest risk of death

A

Onset typically before 25 y/o

Highest RSK: 15-24 y/o blacks

304
Q

Once IgE antibodies are activated what happens

A

Mast cells are trigged to release histamine and leukotrines
That cause bronchoconstriction
And increased permeability

Which leads to compounding bronchocon and inflammation

305
Q

What are the 4 common precipiatants of asthma

A

Allergens, inhaled irritants, URI, and exercise

306
Q

What is the aspirin asthma triad compared to the atopic triad

A

Asthma triad – Asthma, aspirin sensitivity, and nasal polyps

atopic triad;
Allergic rhinitis, asthma, eczema

307
Q

What effect does asthma have on RV and FRC

A

Increases both due to air trapping

308
Q

What is an ominous late finding on ABG in asthma pts

A

rising PCO2

309
Q

A pt presents with hunched shoulders, accessory muscle use on RR, and unable to lie down, there is no wheeze on auscultation

Think

A

Severe asthma (ominous)

310
Q

What are the signs of impending doom for a pt with asthma

A

AMS. Paradoxical Abd RR, Absent wheezing, bradycardia, and absent pulsus paradoxus

311
Q

For asthma was is the essential tool in evaluating response to interventions

A

Peak Flow meter

312
Q

What is the 4 step approach to asthma Tx

A

1) Assess severity vs control
2) Patient education
3) Control of environmental factors & comorbidities
4) Pharmacologic agents

313
Q

What are the 5 goals of asthma Tx

A
  1. Allow activities
  2. Allow sleep
  3. Minimize use or rescue inhalers
  4. Prevent unscheduled care
  5. Maintain lung function

Goals met=controlled

314
Q

What is the severity of the following asthma pt:

Pt presents with S/s on more than 2 days of the week, but not daily
The awaken from sleep 3-4 times a month
The use there SABA more than 2 days a week but not more than 1 time a day

They have minor limitation of activities

The FEV1 is greater than 80-% predicted, and the FEV1/FVC ratio is NML

A

Mild Severity

Recommend Step 2 tx

315
Q

What is the severity of the following asthma pt

Pt presents with daily s/s with night time awakening more than 1 time a week but not nightly,

They use their saba daily, and have some limitations of activity

The FEV1 is 60-80% predicted with a 5% reduced FEV1/FVC ratio

A

Persistent moderate severity of asthma

Recommend stand 3 or 4 tx and consider short course of oral steroid (prednisone)

316
Q

What is the severity of the following asthma pt

Pt presents with S/s consistent throughout the day and they are not able to sleep adequately on any day of the week

They use their saba several times a day
With extremely limited activities

The FEV1 is less than 60% predicted and the FEV1/FVC ratio is reduced more than 5%

A

Persistent severe asthma severity

Recommend Step 5 or 6 tx with a short course of oral steroids (prednisone )

317
Q

If a pt uses their SABA more than 2 times a week at any step in Tx, this indicates…

A

They need a step up in tx

318
Q

What pts should get SMART (ICS= formoterol tx)

A

Asthma pts with moderate persistent or worse severity

319
Q

What is GINA step 1

A

As need low dose ICS-formoterol (budensonide+ formoterol)

With an as needed SABA

320
Q

What is GINA step 2

A

Daily low dose ICS

Or as needed low dose ICS+formoterol

321
Q

What is GINA step 3

A

A low dose ICS+LABA

With as needed ICS+formoterol reliever

322
Q

What is GINA step 4

A

Medium dose ICS+ LABA

With as needed ICS+formoterol for relief

323
Q

What is GINA step 5

A

High Dose ICS-LABA

Plus refer for phenotypic assessment

And add on tiotropioum, anti IGE medications

With as need low dose ICS formoterol for relief

324
Q

What is NonGina step 1

A

No controller needed

SAba for relief

325
Q

What is non Gina step 2

A

Low dose ICS

Plus SABA for relief

326
Q

What is NOn Gina step 3

A

Low dose ICS plus LABA or Medium dose ICS alone

327
Q

What is non Gina step 4

A

Medium dose ICS plus LABA

add a LAMA if still uncontrolled

328
Q

What is nongina step 5

A

High dose ICS plus LABA consider adding omalizumab for pts with allergic asthma

Add LAMA is still uncontrolled

329
Q

What is nongina step 6

A

High-dose ICS plus LABA plus systemic corticosteroids and consider omalizumab for patients with allergic asthma or LAMA if still uncontrolled

330
Q

What is a not well controlled asthma pt

A

S/s greater than 2 days a week
With 1-3 night time awakening
With some limitation of activity

Using their SABA more than 2 days a week

FEV1 60-80% personal best
And more than 2 exacerbations a year

Recommend step up one level in tx and reveal in 2-6 weeks

331
Q

What is a very poorly controlled asthma pt

A

S/s throughout the day
With more than 4 night time awakenings
Extremely limited activity
With SABA use several times a day

FEV1 is less than 60% predicted personal best
With more than 2 exacerbations a year

Recommend: Consider short course
of oral steroids
Step-up 1 or 2 steps
Reevaluate in 2 weeks

332
Q

A pt with a Gina assessment score of 1-2 means

A

Partially controlled asthma pt

333
Q

A pt with a Gina score of 3-4 means

A

uncontrolled asthma pt

334
Q

What is the pt education for ICS

A

Rinse mouth and inhaler out after each use to prevent thrush

335
Q

If giving an asthma pt systemic corticosteroids. What is the approach

A

Always attempt to decrease dose if possible

Add Ca/Vit D, monitor DEXA

Do NOT d/c rapidly!

336
Q

What is albuterol

A

SABA

337
Q

What is proventil

A

SABA

338
Q

What is ventolin

A

SABA

339
Q

What is xoponex/ levalbuterol

A

SABA

340
Q

What is beclomethasone

A

ICS

341
Q

What is budesonide

A

ICS

342
Q

What is fluticasone

A

ICS

343
Q

What is mometasone

A

ICS

344
Q

What is salmeterol

A

LABA

345
Q

WHat is formoterol

A

LABA

346
Q

What is tiotropium

A

LAMA

347
Q

What is the only ROLA

A

ICS plus femoterol

348
Q

What are the alternatives to ICS in mild persistent asthma

A

LRA.. zileuton, zafirlukast, montelukast

Alternates to ICS in mild persistent asthma—oral
Still less effective than ICS
Zileuton –LFT monitoring & not for mild persistent

349
Q

What is omalizumab

A

recombinant/monoclonal antibodies

Anti-IgE antibodies

Binds IgE w/o activating mast cells
$$$, newer, injection q 2-4 weeks

350
Q

What is the oral steroid combo for severe asthma

A

Severe: Prednisone/methylprednisolone 1mg/kg q 6-12 hrs x 48h

Goal: ≥ 50% of FEV1

351
Q

A pt with a PEFR and FEV1 greater than 80 is having what severity asthma attack

A

None really

352
Q

A pt with a PEFR >80% and a FEV1 >70 is having what severity asthma attack

A

Mild

353
Q

A pt with a PEFR Greater than 60 with a FEV1 45-70 is having what severity asthma attack

A

moderate

354
Q

A pt with a PEFR less than 50 and a FEV1 less than 50 is having what level asthma attack

A

Severe

355
Q

Using more than 12 puffs of a SABA in a 72 hour period means what

A

They need to step up their tx

356
Q

How can pts use a self directed quadrupling of their inhaled ICS

A

For an acute exacerbation, a self-directed quadrupling of an inhaled glucocorticoid can abort the exacerbation and reduce the number of severe exacerbations by about 20%.

357
Q

Define status asthmaticus

A

PEFR or FEV1does not increase to greater than 40% of the predicted value with treatment

Paco2increases without improvement of indices of airflow obstruction

Develops major complications such as pneumothorax or pneumomediastinum

358
Q

When should a pt be admitted to the ICU for an asthma exacerbation

A

If after an initial bronchodilator and 3 dose of inhaled bronchodilator
The response is an FEV1 or PEFR less than 40%
With a PCO2 greater than 42
S/s drowsiness or confusion

Then admit to ICU

359
Q

When should a pt with asthma exacerbation be admitted to a hospital ward

A

If after After initial bronchodilator
After 3 doses of inhaled bronchodilator

Response is a FEV1 ro PEFR of 40-69% and they have mild to moderate S/s

360
Q

When should you refer an asthma pt

A

Atypical presentations

Complicated comorbid

Suboptimal response

High dose ICS

2+ systemic steroids in 12 months

Any life threatening/hospitalizations in 12 mos

Social/psychiatric issues interfering

361
Q

What is the effect of smoking on the airways

A

Hypertrophy and hyper proliferation of mucus glands

Paralysis of Cilia

Smoking always leads to bronchitis in the airways

And always leads to emphysema in the parenchyma

362
Q

What is an A1-antiryspin deficiency

A

A defect that leads to elastin degradation

Can be hetero and homozygous

Leads to COPD in the 3rd or 4th decade of life

363
Q

A pt presents with a daily cough for 3 months, is cyanosis at rest, +wheezes and Ronchi,
States they get multiple lung infections a year, and is overwt

Think

A

Bronchitis

364
Q

A pt presents with severe Dyspnea, is very thin, in apparent resp distress, lung sounds are very quiet, and has no peripheral edema,.
Think

A

Emphysema

365
Q

What does a loud P2 sound tell you

A

Hepatic congestion, or Pulm HTN.. la

366
Q

What is GOLD 2 for COPD

A

Post BronchO FEV1 from 50-79% predicted

Moderate

367
Q

What is GOLD 3 for COPD

A

Post Broncho FEV1 of 30-49% predicted

Severe

368
Q

What is GOLD 4

A

Post Broncho FEV1 of <30% predicated

Very severe

369
Q

What is the ABG finding in Chronic Bronchitis

A

Resp Acidosis

370
Q

What study would you order to do a w/u for lobectomy

A

CT

371
Q

A pt with recurrent pneumonia, hemoptysis and clubbing

Think

A

Bronchiectasis not COPD

372
Q

All adults with COPD or bronchiectasis should be tested for …

A

alpha-1 antitrypsin deficiency,

373
Q

What does Roflumilast do

A

Phophodiesterase-4 inhibitors

decreases inflammation and promotes smooth muscle relaxation/bronchodilation

Used in COPD Tx

374
Q

When should ABX be considered in a pt with COPD

A

Age >65

FEV1 <50% predicted

3+ exacerbations per year

Comorbidities (cardiac, DM, depression)

Increased sputum purulence or quantity + dyspnea

375
Q

A pt presents with less than 4 exacerbations a year, and the FEV1 is greater than 50% predicted

What is the recommended ABX

A

Macrolides
(Azithromycin or clarithromycin)
or Doxy

Common strep infection

376
Q

A 66 year old pt Preston’s with more than 4 exacerbations of COPD a year and the FEV1 is less than 50 but greater than 35

What is the recommended ABX tx

A

Augmentin

Or
Fluoroquinolones
levo, Moxifloxacin

377
Q

A pt is a resident in a nursing home, with 4 or more exacerbations of COPD a year, with a FEV1 below 35 % predicted

What is the recommended ABX

A

IV ABX
Penicillin
Or Cephalosporin

378
Q

Describe the Outpt treatment for COPD

A

Exercise with Physiotherapy

If A1 deficiency is present the supplement with A1- antitrypsin

379
Q

What is the role of Pulm rehab for COPD

A

Does not change lung function

Can improve quality of life

Can improve exercise performance

“…comparable to or greater than the benefit achievable with pharmacotherapy.” –Goldman-Cecil

380
Q

What are the Surgery options for a PT with COPD

A

Bullectomy
-Giant bulla who have persistent symptoms despite medical tx and rehabilitation

Lung reduction surgery
—Not for those with FEV1 <20%

Lung transplant
—COPD =25% of lung transplants in USA

381
Q

A COPD pt has 1 exacerbation in the past 12 months, with no Hospitalizations.

Presents with Few S/s
MMRC 0-1
And a CAT less than 10

What is the severity Catagory and appropriateTx

A

Cat A

Can use a SAMA or SABA PRN

382
Q

A pt presents with COPD, and Has less than 1 exacerbation a year, and has never been hospitalized for his condition

However he has multiple S.s
MMRC is greater than 2
And his CAT is greater than 10

What is his severity catagory
And appropriate Tx

A

CAT B

1st: LAMA or LABA

383
Q

A pt with COPD presents with a MMRC of 0-1 with a CAT less than 10, has had 2 exacerbations and 1 hospitalization

What is the severity CAT and appropriate Tx

A

Cat C

LAMA

384
Q

A t presents with ≥2 exacerbations and 1 hospital related hospitalization, with a MMRC greater than 2 and a CAt above 10

What is the severity CAT and appropriate Tx

A

CAT D

LAMA + LABA
may consider add on ICS

385
Q

What is an MMRC of 0

A

Dyspnea only with strenuous exercise

386
Q

What is a MMRC of 1

A

Dyspnea when hurrying up hills

387
Q

What is a mMRC of 2

A

Dyspnea when walking, and moving slower that people at same age at a normal pace

388
Q

What is a mMRC of 3

A

Dyspnea at 100 yards of walking or within a few minutes

389
Q

What is a mMRC of 4

A

Dyspnea when undressing or unable to leave the house

390
Q

When should you admit a pt with COPD

A

If the S/s do not respond to tx

They have worsening 
Hypoxemia 
Hyper apnea 
Peripheral edema 
Or there is a change in LOC

Also can admit if there is inadequate home care
Or inability to sleep or eat

391
Q

What is the approach to Inpt COPD management

A

Maintain O2 sat above 90

Rx: Ipatropium plus SABA

Prednisone x 5 days

With Broad ABX
(Levofloxacin, Azithromycin, or augmentin)

392
Q

What is the BODE index

A

BMI
OBSTRUCTION
DYSPNEA
EXERCISE

Evaluates Prognosis of COPD

4 year survival estimate:
0-2 points:  80%
3-4 points:  67%
5-6 points:  57%
7-10 points:  18%
393
Q

A Bode Score of 0-2 means what survival rate

A

80%

394
Q

A Bode score of 3-4 means what survival rate

A

67% over 4 years

395
Q

A bode score of 5-6 means what 4 yr survival rate

A

57%

396
Q

A bode score over 7 means what 4 yr survival rate

A

Less than 18%

397
Q

A COPD pt presents with more than 2 exacerbations a year
He is taking a LABA, LAMA and an ICS

What is the approach for managment

A

Refer to specialist

398
Q

What is the role of NIPPV in COPD

A

NIPPV can shorten the hospital stay, reduce the need for endotracheal intubation and mechanical ventilation, and reduce mortality in individuals being treated for an exacerbation of chronic obstructive pulmonary disease complicated by hypercarbic respiratory failure.

399
Q

What is the third leading cause of hospital deaths

A

PE

400
Q

What are the physiological effects of a PE

A

Reflex bronchoconstriction

Promotes wheezing & increased work of breathing

Massive thrombus may cause R ventricular failure

401
Q

What are the ECG findings in a PE

A

Most common: sinus tach and non-specific ST and T wave changes

RVH, R axis deviation, or a RBBB

S1Q3T3 (mcGinn White Sign)

402
Q

What is Westermark Sign and Hamptons Hump

A

Findings of PE on CXR

Prominence of proximal central pulmonary artery with local oligemia (Westermark sign)–uncommon

Wedge shaped, pleural based opacity that represent intraparenchymal hemorrhage (Hampton’s hump)–uncommon

Common findings are atelectasis and pleural effusions

403
Q

What is the initial Dx study of choice for a PE

A

CTPA!

Always order BUN/ CrCL for kidney function as this requires contrast

404
Q

According to uptodate, if a pt has a NML CXR and you suspect a PE

What is the test of Choice for PE in pregnancy

A

V/Q scan

405
Q

What is the test of choice for a proximal DVT

A

Venous US

406
Q

When should PULM angio be used to Dx a PE

A

Consider if other studies are inconclusive and diagnosis of PE must be established with certainty or Helical CT is not available/contraindicated

Be aware of contrast induced renal failure

407
Q

What is the criteria to use Contrast in a pt

Think renal

A

EGFR less than 30 is a C/I
Contrast Allergy=no!

CrCL greater than 1.5=no!

408
Q

Once a PE is confirmed, what is the Tx approach

Same for DVT

A

LMWH followed by oral warfarin x5-7 days to INR goal
(Lovenox SQ)

INR goal of 2-3

(alt: NOAC/DOAC)

409
Q

What is the reversal agent for Heparin

A

Protamine sulfate

410
Q

How is a DVT managed in a pregnant pt

A

Pregnant patients: DVT managed with LMW heparin until delivery

411
Q

What is the reveresal agent for Factor Xa drugs

A

Adnexanet alfa

412
Q

When should thrombolytics (Alteplase) be used for a PE

A

Pregnant patients: DVT managed with LMW heparin until delivery

413
Q

When should an IVC filter be used for a PE

A

Recurrent embolism despite adequate anticoagulation

Chronic recurrent embolism with pulmonary HTN

Pts with a Major contraindication to anticoagulation who have or at high risk for developing PE/DVT

414
Q

When should surgery removal of a PE be done …

A

Surgical removal of acute PE only for absolute emergency, and outcome often is death
—-Pulmonary embolectomy

Pts with unsuccessful or contraindication to thrombolytics

415
Q

A pt with a SBP less than 90
Or a shock index greater than 1
SaO2 less than 95%

With RVSP greater than 40
+/- cardiac bio markers

What is the treatment of this PE

A

Are they contra to fibrinolytics
(Any Hx of recent bleeding, GERD, TIA in 6months? )

Then Alteplase if no C/I
100mg/2hrs

416
Q

When should echo be used in evaluating a PE

A

Use in severely hypoxemic or hemodynamically compromised

417
Q

What is the reverasal agent for dabigatran

A

Idarucizumab

418
Q

When would you do a Bronchial provacation test for Asthma >?

A

Bronchial provocation testing—inhaled histamine or methacholine

Use IF asthma is suspected, but spirometry nondiagnostic

419
Q

What is the effect of adding ICS and LABAs

A

Beta-adrenergic agonists/LABAs (salmeterol & formoterol)

If added to ICS, effect is equivalent to doubling ICS dose

IPAP JUNIOR SEM. (43 decks)

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