Pulm crit Flashcards
1
Q
how does NPPV improve patient with cardiogenic pulm edema?
A
Decreased preload and afterload
Decreased dead space ventilation, increased tidal volume and increased alveolar/minute ventilation
NPPV increases intrathoracic pressure = reduced venous return
2
Q
PFTs in pulmonary arterial hypertension
A
normal spirometry, reduced DLCO from VQ mismatch
3
Q
PFTs in asthma
A
airway obstruction (FEV1/FVC) <0.7 and normal DLCO
4
Q
nodules with ground glass opacity: halo sign
A
Aspergillosis. can also have cavitations
5
Q
triad for invasive pulmonary aspergillosis
A
fever
pleuritic chest pain
hemoptysis
tx: voriconazole
6
Q
galactomannan
A
typically for aspergillosis
don’t be tricked though, can be false positive in histo and blasto which are assessed with serum/urine testing
7
Q
define complicated pleural effusion
A
- appears moderate to large, free flowing or loculated
- pH <7.2, glucose <60, wbc >50k, LDH >1k
- tx: antibiotics and CHEST TUBE
8
Q
serum bicarb drop in chronic respiratory alkalosis
A
HCO3 drops 4 mEq/L for every 10 mmHg reduction in pCO2
9
Q
central bronchiectasis in asthmatic or CF
A
ABPA. Will also have IgE >417 and IgG, IgE to aspergillus. maybe peripheral eosinophilia
Tx with Corticosteroids + Itraconazole
10
Q
things on PFT not on spirometry
A
- total lung capacity
- DLCO
- methacholine challenge
11
Q
TLC < 80%
A
defines restrictive dz
12
Q
FEV1/FVC < 70%
A
defines obstructive dz
13
Q
what is a positive bronchodilator response for asthma
A
> 12% increase in FEV1
or absolute increase of FEV1 >200mL
14
Q
T/F: Morning headaches is a sx of OSA
A
true
15
Q
When to suspect EGPA (churg strauss)
A
Difficult to control ASTHMA
- > 10% peripheral eosinophilia
- mono/poly-neuropathy
- SINUS dz
- transient/migratory pulm opacities
- glomerulonephritis (KIDNEY)
ABPA does not have kidney involvement and will have bronchiectasis. but it can also present with difficult to control asthma with sinusitis and eosinophilia
ABPA vs EGPA…EGPA has kidnEy involvement
16
Q
features suggestive of A1AT deficiency
A
(test in all new onset COPD) early onset emphysema (<45) emphysema with minimal smoking hx unexplained liver dz can have painful skin nodes (panniculitis)
17
Q
isolated low DLCL
A
pulmonary hypertension
anemia
18
Q
size threshold to tap an effusion
A
> 10mm
19
Q
imaging modality for cteph
A
VQ scan more sensitive than CTa. patient need lifelong anticoag
20
Q
triad for aspirin-exacerbated respiratory disease (AERD)
A
- chronic rhinosinusitis with polyposis
- asthma
- aspirin/NSAID sensitivity
Tx the asthma and add LT receptor antagonist (Montelukast)
21
Q
workup for obesity hypoventilation syndrome
A
- ABG on room air (daytime hypercapnia, hypoxemia)
- Restrictive pattern on PFTs
- polysomnography
- normal TSH, no intrinsic pulm dz on CXR
clues may be dyspnea/cor pulmonale in a patient with OSA sxs, elevated serum bicarb and rbc
22
Q
pleural effusion meeting lights criteria but in the setting of diuretic use
A
may not be accurate. Serum-effusion protein difference >3.1 or serum-effusion albumin gradient >1.2 = true transudate
23
Q
mgmt of obesity hypoventilation syndrome
A
Positive pressure ventilation (nocturnal)
Weight reduction
avoid sedative meds
acetazolamide last line
24
Q
prevention/mgmt of fat embolism
A
prevention: early mobilization of fractures and operative correction
tx: supportive
don’t order LE doppler , no great test
25
negative cytology from thoracentesis for suspected MPE
repeat thora. first study detects 60%, 3 separate can detect 90%. After this would do thoracoscopy
26
T/F: You can have mild to moderate pHTN in COPD and does not need specific tx
true, focus on your corticosteroids, bronchodilators and o2
27
differentiate intrinsic vs extrinsic restrictive lung dz
Intrinsic: DLCO low
Extrinsic: DLCO normal
28
differentiate Goodpasture from GPA
Goodpasture = pumonary renal syndrome = anti-GBM antibody. will not have constitutional vasculitis sxs (fever, wt loss, arthralgia, fatigue) and also no ENT sxs. . Bx shows linear deposits of IgG. Tx with plasmapharesis + steroid/cyclophosphamide
GPA is vasculitis, CXR will have nodules/cavitations and bx shows granuloma in artery, perivascular area. ANCA. Tx steroid/cyclophophamide or rituximab
29
how do you treat acute asthma attack?
ED:
- repeat SABA
- O2 to main >92%
- PO steroids (IV if can't take PO, or respiratory distress)
- inhaled ipratropium prn
DC:
- ICS if they don't have one
- PO steroids for total 3-7 day course
- asthma action plan
30
Asthma tx if patients don't have daily sxs
This is intermittent or mild persistent (step 1, step 2)
Step 1: SABA prn
Step 2: Add lose dose ICS
31
Asthma tx once patients have daily sxs
Step 3 (moderate persistent): ICS (low, medium dose) + LABA
Step 4 severe persistent): Add high dose ICS + LABA or LAMA
Later therapy = Omalizumab (MAB to IgE) and Mepolizumab (Anti IL5...if there is peripheral eosinophilia)
32
pleural effusion with very high LDH
- Rheumatoid (yellow-greenish, lymphocyte predominant)
| - Empyema (purulent, neutrophilic)
33
silicosis
- micronodules in upper lobes
- exposures: coal mining, hard rock mining, sand blasting, quarrying, masonry, ceramic/glass manufacturing
- increased risk of lung cancer and TB, screen for TB @ dx
- associated with scleroderma and rheumatoid arthritis
34
PFTs in ILD
Restrictive pattern:
- Reduced FEV1, FVC and TLC, DLCO
- normal FEV1/FVC ratio
35
PFTs in Asthma
Obstructive pattern with High TLC, normal DLCO
36
PFTs in pHTN
isolated reduced DLCO
37
DLCO in asthma and copd
Asthma: NORMAL DLCO
COPD: DLCO can be normal or low depending on stage (emphsyma is destructive and will decrease DLCO)
38
T/F: Reactive airway disease may have obstructive PFTs and can be dx with methacholine challenge
true, its a nonimmune asthma-like illness occurring after single high-level exposure to pulmonary irritant
39
First line tx for lung abscess
Unasyn or Carbapenem. Don't need to aspirate, will respond well to abx
40
What does GOLD criteria take into account for management?
Symptom burden and risk of exacerbation.
Thus, airflow limitation (FEV1) plays a minimal role in determining therapy
41
first line therapy for COPD patients GOLD category B or higher (moderate-severe sxs and 1 or less exacerbation/year)
LAMA (tiotropium, umeclinidinum, aclidinium, glycopyrrolate)
or
LABA (salmeterol)
42
T/F: Clubbing is not associated with COPD
true. think bronchiectasis, right to left shunt, malignancy, IPF, asbestosis, CF
43
T/F: EGPA will have poorly controlled asthma
true. Other features include peripheral eosinophilia >10%, peripheral neuropathy (mononeuritis monoplex), migratory pulmonary infiltrates on CXR and necrotizing glomerulonephritis
EGPA
44
T/F: Constitutional sxs are typically seen in vasculitis
true
45
Normal PCO2 (ABG) in asthma exacerbation
impending respiratory failure. would expect hyperventilation and low pco2
46
aspirin induced asthma
Samters triad (eosinophilia with nasal polyp, persistent asthma, aspirin sensitivity). DC nsaids, if need aspirin then dessensitize and can add montelukar/zafirlukast (LT inhibitor)
47
Roflumilast (selective PDE-4 inhibitor) role in COPD tx
add-on therapy for severe COPD associated with chronic bronchitis to reduce risk/freq of exacerbation
48
T/F: Home sleep testing can be the preferred dx test for OSA
true, when likelihood is high and absence of cardiopulm/neuromuscular disease (no comobidities)
49
T/F: Overnight pulse ox is a shit test for OSA
true
50
T/F: PET/CT recommended for a solid nodule >8mm
true
51
How long do you follow subsolid lung nodules 6-8mm in size?
@6-12 months
| then q2 years for 5 years
52
CF patient: suppression of chronic pulm infections, mgmt of secretions and acute pulm exacerbations
Chronic pulm infx suppression: inhaled tobramycin
Secretions: recomb human DNase (dornase alfa) or hypertonic saline
Acute exacerbation: anti-pseudomonal abx
53
What is respiratory bronchiolotis-associated ILD associated with?
Active smoker. CXR will have thickened interstituim
54
DPLD in RA
Ranges from nodules to organizing pneumonia to usual interstitial pnuemonitis
55
imaging in IPF
- CXR: peripheral reticular opacities, honeycomb @ lung bases
- HRCT: subpleural cystic changes, traction bronchiectasis
- PFTS: Restrictive
56
T/F: Don't intubate and ventilate respiratory failure IPF patient
true
57
Lofgren syndrome
Sarcoid: fever, bilateral hilar LN, erythema nodosum, ankle arthirtis
High rate of spontaneous resolution/remission
58
Sarcoid like disease from occupational exposure
berryliosis
59
T/F: Serum ACE level will confirm sarcoidosis
false, don't select this. won't confirm dx or help w/mgmt
60
T/F: Typically need a transbronchial bx for sarcoid
true, unless they have all features of lofgren syndrome. always r/o TB and fungal infections (stains, culture on tissue bx)
61
spontaneous ptx in childbearing age (30-40s) female
LAM (lymphangioleiomyomatosis). chyloud effusions also seen, CT shows cystic dz
62
Photographic negative of HF
Chronic eosinophilic pneumonia. Peripheral alveolar infiltrates, eosinophilia on CBC and BAL
63
male smoker 40 years old with BAL showing abundant protein in airspaces
pulmonary alveolar proteinosis
64
T/F: Desquamative interstitial pneumonia has diffuse macrophage filling of alveolar spaces
true, w/ bilateral GGO
65
Eval this in patient with silicosis, fever, cough
TB (increased incidence in silicosis)
Silicosis will have upper lobe micronodules
66
pleural effusion in asbestosis
exudative hemorrhagic or eosinophilic, may be painful
67
Pleural fluid LDH > *** = lights criteria
200 (2/3 ULN)
68
T/F: in the setting of ongoing diuresis, serum to pleural fluid albumin gradient >1.2 = transudate
true
69
Pleural effusion with lymphocytosis >80%
TB
Rheumatoid
Sarcoid
Lymphoma
70
Pleural effusion with low glucose (<60)
```
TB
Parapneumonic/empyema
cancer
rheumatoid
lupus
esophageal rupture
```
71
When does parapneumonic effusion need chest tube drainage?
pH <7.2 or glucose <60
72
chylothorax associated with
pulmonary LAM (premenopausal woman). also may have spontaneous pneumothorax
73
size for placement of chest tube for non-tension pneumothorax
>2cm
74
when is a CCB indicated for tx of phtn
if there is a vasodilator response on right heart cath
75
when would you suspect a pulmonary AVM?
hemoptysis, mucocutaneous telangiectasias, any R->L shunt (clubbing/cyanosis, polycythemia)
76
35% of solitary pulmonary nodules are
bronchogenic carcinoma
77
f/u screening for solitary pulm nodule
<6mm: no f/u
6-8mm: CT @ 6-12 months. consider @ 18-24mo
>8mm: consider PET/CT or sampling @ 3 mo
78
f/u screening for subsolitary nodule
Pure GGO: >6mm CT @ 6-12 mo, then q2 years until 5 years
| Part solid: CT @ 3-6mo, then annual for 5 years
79
Obesity hypoventilation is usually associated with
COPD
| Elevated PCO2 while awake
80
T/F: Polysomnography for ventilatory failure from neuromuscular disease
true, because patients will first hypoventilate during REM sleep. will have sxs of nocturnal hypoventilation (daytime sleepiness, nocturnal awakenings, morning HA)
81
ARDS picture without inciting event, responds to steroids
acute interstitial pneumonia
82
ARDS picture with slower onset over a few weeks after viral prodrome
Cryptogenic organizing pneumonia or hypersensitivity pneumonitis (latter if they have the exposure hx)
83
PTX and right mainstem instubation will increase plat or peak pressure?
both (which = change in lung compliance)
84
tx for serotonin syndrome
stop drug, benzos, cyproheptadine
85
NMS usually related to dopa
true, haldol or PD patient who abruptly stopped L-dopa. give some bromocriptine with dantrolene
86
Tx of HTN emergency from specific cause
Aortic dissection: Esmolol, labetalol
ACS: Esmolol, nitroglycerin
Acute flash pulmonary edema: avoid BB, use nitroprusside/nitroglycerin
AKI: Nicardipine
87
Angioedema differential
WITH urticaria: mast-cell mediated (allergy, nsaids, opiates)
NO urticaria: bradykinin-mediated (all low C1 inhibitor and C4)
- hereditary angioedema (fhx)
- acquired c1 inhibitor def (lymphoma, MGUS, SLE) low C1q levels
- ACE-i
88
Angioedema tx
Mast-cell mediated (with urticaria): epi, antihistamine, steroids. patients should carry epi pen. might be able to just use antihistamine if very stable and no airway compromise
Bradykinin (no urticaria): C1 inhibitor concentrate. if emergency, FFP. Long term tx = danazol and stanozol (boosts c1 esterase inhibitor synthesis in liver)
89
tx for cyanide poisoning
i.e. in a housefire and abnormal LDH. Use Hydroxocobalamin
90
Meds for anticholinergic toxicity (hot, dry, agitated, mydriasis)
physostigmine (peripheral, CNS sxs) and benzo (agitation)
91
Meds for cholinergic toxicity (confusion, bradycardia, miosis, organophosphate poisoning)
external decontamination, atropine, possible vent. add pralidoxime for CNS toxicity, benzos for convulsions
92
inc DLCO
pulmonary hemorrhage
polycythemia
L->R shunt
asthma
93
T/F: Pulse ox and arterial PO2 is normal in cyanide and carbon monoxide poisoning
true, use co-oximetry
94
peripheral eosinophilia, fever and wt loss in a long term smoker
chronic eosinophilic pneumonia. dx with bronch and biopsy or BAL showing high eos
95
dx of ABPA
Skin test (aspergillus), IgG and IgE to aspergillus, opacities in upper lobes. bronchiectasis
96
things to consider with "asthma difficult to control"
- ABPA
- EGPA
- tracheal obstruction, vocal cord dysfunction (flow volume loops and direct larynx visualization during acute episode can be helpful)
- GERD
- DC meds: beta blockers including opthalmo ones (or switch to selective aka metoprolol, atenolol), stop aspirin, stop nsaids
97
Steps for asthma tx
SABA, ICS, LABA
IgE 30-700: Omalizumab (moderate to severe persistent)
Absolute eosinophil >150: Anti-IL 5 mab (mepolizumab, reslizumab)
98
COPD in patient <45 years or strong fhx
measure alpha anti trypsin
99
T/F: Adult bronchiolitis is a mimic of COPD in current/former smokers that poorly responds to bronchodilators but responds to smoking cessation and steroids
True
100
T/F: Bronchiolitis obliterans mimics COPD and presents with dyspnea with no improvement with bronchodilators, usually after lung or stem cell transplant
true
101
T/F: Pulm Langerhans cell histiocytosis is associated with thin-walled cysts with accompanying nodules and pHTN
true
102
Tx of carbon monoxide poisoning
Normal: Normo-baric oxygen treatment
Indications for hyperbaric oxygen: loss of consciousness, neuro deficits, pregnant patients, ischemic cardiac changes, significatn metabolic acidosis, carboxyhemoglobin >25
103
When do you start LABA, LAMA or ICS in COPD?
FEV1 <60%. Monotherapy.
When 60-80%, use inhaled bronchodilator (albuterol)
104
T/F: Macrolides should not be used in COPD
False, they actually decrease exacerbations
105
T/F: PDE-4 inhibitor (Roflumilast) should not be used in COPD
False, this can be used as add-on therapy. can reduce exacerbations
106
T/F: Hypersensitivity pneumonitis and respiratory bronchilitis will have centrilobular miconodules
true, HP in upper and mid lungs
107
most common manifestation of asbestos exposure
bilateral pleural plaques
108
who gets asbestos exposure?
construction
automotive shipbuilding/repair
10-15 year latency period
109
T/F: Mag sulfate relaxes bronchial smooth muscle and helps severe asthma exacerbation
true
110
Apnea-Hypopnea Index score for OSA
>5
111
response to nitric oxide during PAH RHC predicts response to?
CCB (including diltiazem)
