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UWORLD ABIM > Pulm crit > Flashcards

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

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2
Q

PFTs in pulmonary arterial hypertension

A

normal spirometry, reduced DLCO from VQ mismatch

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3
Q

PFTs in asthma

A

airway obstruction (FEV1/FVC) <0.7 and normal DLCO

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4
Q

nodules with ground glass opacity: halo sign

A

Aspergillosis. can also have cavitations

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5
Q

triad for invasive pulmonary aspergillosis

A

fever
pleuritic chest pain
hemoptysis

tx: voriconazole

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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

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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
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8
Q

serum bicarb drop in chronic respiratory alkalosis

A

HCO3 drops 4 mEq/L for every 10 mmHg reduction in pCO2

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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

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10
Q

things on PFT not on spirometry

A
  • total lung capacity
  • DLCO
  • methacholine challenge
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11
Q

TLC < 80%

A

defines restrictive dz

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12
Q

FEV1/FVC < 70%

A

defines obstructive dz

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13
Q

what is a positive bronchodilator response for asthma

A

> 12% increase in FEV1

or absolute increase of FEV1 >200mL

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14
Q

T/F: Morning headaches is a sx of OSA

A

true

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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

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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)
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17
Q

isolated low DLCL

A

pulmonary hypertension

anemia

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18
Q

size threshold to tap an effusion

A

> 10mm

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19
Q

imaging modality for cteph

A

VQ scan more sensitive than CTa. patient need lifelong anticoag

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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)

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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

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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

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23
Q

mgmt of obesity hypoventilation syndrome

A

Positive pressure ventilation (nocturnal)

Weight reduction

avoid sedative meds

acetazolamide last line

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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

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25
Q

negative cytology from thoracentesis for suspected MPE

A

repeat thora. first study detects 60%, 3 separate can detect 90%. After this would do thoracoscopy

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26
Q

T/F: You can have mild to moderate pHTN in COPD and does not need specific tx

A

true, focus on your corticosteroids, bronchodilators and o2

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27
Q

differentiate intrinsic vs extrinsic restrictive lung dz

A

Intrinsic: DLCO low
Extrinsic: DLCO normal

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28
Q

differentiate Goodpasture from GPA

A

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

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29
Q

how do you treat acute asthma attack?

A

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
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30
Q

Asthma tx if patients don’t have daily sxs

A

This is intermittent or mild persistent (step 1, step 2)

Step 1: SABA prn
Step 2: Add lose dose ICS

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31
Q

Asthma tx once patients have daily sxs

A

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)

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32
Q

pleural effusion with very high LDH

A
  • Rheumatoid (yellow-greenish, lymphocyte predominant)

- Empyema (purulent, neutrophilic)

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33
Q

silicosis

A
  • 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
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34
Q

PFTs in ILD

A

Restrictive pattern:

  • Reduced FEV1, FVC and TLC, DLCO
  • normal FEV1/FVC ratio
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35
Q

PFTs in Asthma

A

Obstructive pattern with High TLC, normal DLCO

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36
Q

PFTs in pHTN

A

isolated reduced DLCO

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37
Q

DLCO in asthma and copd

A

Asthma: NORMAL DLCO
COPD: DLCO can be normal or low depending on stage (emphsyma is destructive and will decrease DLCO)

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38
Q

T/F: Reactive airway disease may have obstructive PFTs and can be dx with methacholine challenge

A

true, its a nonimmune asthma-like illness occurring after single high-level exposure to pulmonary irritant

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39
Q

First line tx for lung abscess

A

Unasyn or Carbapenem. Don’t need to aspirate, will respond well to abx

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40
Q

What does GOLD criteria take into account for management?

A

Symptom burden and risk of exacerbation.

Thus, airflow limitation (FEV1) plays a minimal role in determining therapy

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41
Q

first line therapy for COPD patients GOLD category B or higher (moderate-severe sxs and 1 or less exacerbation/year)

A

LAMA (tiotropium, umeclinidinum, aclidinium, glycopyrrolate)

or

LABA (salmeterol)

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42
Q

T/F: Clubbing is not associated with COPD

A

true. think bronchiectasis, right to left shunt, malignancy, IPF, asbestosis, CF

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43
Q

T/F: EGPA will have poorly controlled asthma

A

true. Other features include peripheral eosinophilia >10%, peripheral neuropathy (mononeuritis monoplex), migratory pulmonary infiltrates on CXR and necrotizing glomerulonephritis

EGPA

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44
Q

T/F: Constitutional sxs are typically seen in vasculitis

A

true

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45
Q

Normal PCO2 (ABG) in asthma exacerbation

A

impending respiratory failure. would expect hyperventilation and low pco2

46
Q

aspirin induced asthma

A

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
Q

Roflumilast (selective PDE-4 inhibitor) role in COPD tx

A

add-on therapy for severe COPD associated with chronic bronchitis to reduce risk/freq of exacerbation

48
Q

T/F: Home sleep testing can be the preferred dx test for OSA

A

true, when likelihood is high and absence of cardiopulm/neuromuscular disease (no comobidities)

49
Q

T/F: Overnight pulse ox is a shit test for OSA

A

true

50
Q

T/F: PET/CT recommended for a solid nodule >8mm

A

true

51
Q

How long do you follow subsolid lung nodules 6-8mm in size?

A

@6-12 months

then q2 years for 5 years

52
Q

CF patient: suppression of chronic pulm infections, mgmt of secretions and acute pulm exacerbations

A

Chronic pulm infx suppression: inhaled tobramycin
Secretions: recomb human DNase (dornase alfa) or hypertonic saline
Acute exacerbation: anti-pseudomonal abx

53
Q

What is respiratory bronchiolotis-associated ILD associated with?

A

Active smoker. CXR will have thickened interstituim

54
Q

DPLD in RA

A

Ranges from nodules to organizing pneumonia to usual interstitial pnuemonitis

55
Q

imaging in IPF

A
  • CXR: peripheral reticular opacities, honeycomb @ lung bases
  • HRCT: subpleural cystic changes, traction bronchiectasis
  • PFTS: Restrictive
56
Q

T/F: Don’t intubate and ventilate respiratory failure IPF patient

A

true

57
Q

Lofgren syndrome

A

Sarcoid: fever, bilateral hilar LN, erythema nodosum, ankle arthirtis
High rate of spontaneous resolution/remission

58
Q

Sarcoid like disease from occupational exposure

A

berryliosis

59
Q

T/F: Serum ACE level will confirm sarcoidosis

A

false, don’t select this. won’t confirm dx or help w/mgmt

60
Q

T/F: Typically need a transbronchial bx for sarcoid

A

true, unless they have all features of lofgren syndrome. always r/o TB and fungal infections (stains, culture on tissue bx)

61
Q

spontaneous ptx in childbearing age (30-40s) female

A

LAM (lymphangioleiomyomatosis). chyloud effusions also seen, CT shows cystic dz

62
Q

Photographic negative of HF

A

Chronic eosinophilic pneumonia. Peripheral alveolar infiltrates, eosinophilia on CBC and BAL

63
Q

male smoker 40 years old with BAL showing abundant protein in airspaces

A

pulmonary alveolar proteinosis

64
Q

T/F: Desquamative interstitial pneumonia has diffuse macrophage filling of alveolar spaces

A

true, w/ bilateral GGO

65
Q

Eval this in patient with silicosis, fever, cough

A

TB (increased incidence in silicosis)

Silicosis will have upper lobe micronodules

66
Q

pleural effusion in asbestosis

A

exudative hemorrhagic or eosinophilic, may be painful

67
Q

Pleural fluid LDH > *** = lights criteria

A

200 (2/3 ULN)

68
Q

T/F: in the setting of ongoing diuresis, serum to pleural fluid albumin gradient >1.2 = transudate

A

true

69
Q

Pleural effusion with lymphocytosis >80%

A

TB
Rheumatoid
Sarcoid
Lymphoma

70
Q

Pleural effusion with low glucose (<60)

A 
TB
Parapneumonic/empyema 
cancer
rheumatoid 
lupus 
esophageal rupture
71
Q

When does parapneumonic effusion need chest tube drainage?

A

pH <7.2 or glucose <60

72
Q

chylothorax associated with

A

pulmonary LAM (premenopausal woman). also may have spontaneous pneumothorax

73
Q

size for placement of chest tube for non-tension pneumothorax

A

> 2cm

74
Q

when is a CCB indicated for tx of phtn

A

if there is a vasodilator response on right heart cath

75
Q

when would you suspect a pulmonary AVM?

A

hemoptysis, mucocutaneous telangiectasias, any R->L shunt (clubbing/cyanosis, polycythemia)

76
Q

35% of solitary pulmonary nodules are

A

bronchogenic carcinoma

77
Q

f/u screening for solitary pulm nodule

A

<6mm: no f/u
6-8mm: CT @ 6-12 months. consider @ 18-24mo
>8mm: consider PET/CT or sampling @ 3 mo

78
Q

f/u screening for subsolitary nodule

A

Pure GGO: >6mm CT @ 6-12 mo, then q2 years until 5 years

Part solid: CT @ 3-6mo, then annual for 5 years

79
Q

Obesity hypoventilation is usually associated with

A

COPD

Elevated PCO2 while awake

80
Q

T/F: Polysomnography for ventilatory failure from neuromuscular disease

A

true, because patients will first hypoventilate during REM sleep. will have sxs of nocturnal hypoventilation (daytime sleepiness, nocturnal awakenings, morning HA)

81
Q

ARDS picture without inciting event, responds to steroids

A

acute interstitial pneumonia

82
Q

ARDS picture with slower onset over a few weeks after viral prodrome

A

Cryptogenic organizing pneumonia or hypersensitivity pneumonitis (latter if they have the exposure hx)

83
Q

PTX and right mainstem instubation will increase plat or peak pressure?

A

both (which = change in lung compliance)

84
Q

tx for serotonin syndrome

A

stop drug, benzos, cyproheptadine

85
Q

NMS usually related to dopa

A

true, haldol or PD patient who abruptly stopped L-dopa. give some bromocriptine with dantrolene

86
Q

Tx of HTN emergency from specific cause

A

Aortic dissection: Esmolol, labetalol
ACS: Esmolol, nitroglycerin
Acute flash pulmonary edema: avoid BB, use nitroprusside/nitroglycerin
AKI: Nicardipine

87
Q

Angioedema differential

A

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
Q

Angioedema tx

A

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
Q

tx for cyanide poisoning

A

i.e. in a housefire and abnormal LDH. Use Hydroxocobalamin

90
Q

Meds for anticholinergic toxicity (hot, dry, agitated, mydriasis)

A

physostigmine (peripheral, CNS sxs) and benzo (agitation)

91
Q

Meds for cholinergic toxicity (confusion, bradycardia, miosis, organophosphate poisoning)

A

external decontamination, atropine, possible vent. add pralidoxime for CNS toxicity, benzos for convulsions

92
Q

inc DLCO

A

pulmonary hemorrhage
polycythemia
L->R shunt
asthma

93
Q

T/F: Pulse ox and arterial PO2 is normal in cyanide and carbon monoxide poisoning

A

true, use co-oximetry

94
Q

peripheral eosinophilia, fever and wt loss in a long term smoker

A

chronic eosinophilic pneumonia. dx with bronch and biopsy or BAL showing high eos

95
Q

dx of ABPA

A

Skin test (aspergillus), IgG and IgE to aspergillus, opacities in upper lobes. bronchiectasis

96
Q

things to consider with “asthma difficult to control”

A
  • 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
Q

Steps for asthma tx

A

SABA, ICS, LABA

IgE 30-700: Omalizumab (moderate to severe persistent)

Absolute eosinophil >150: Anti-IL 5 mab (mepolizumab, reslizumab)

98
Q

COPD in patient <45 years or strong fhx

A

measure alpha anti trypsin

99
Q

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

A

True

100
Q

T/F: Bronchiolitis obliterans mimics COPD and presents with dyspnea with no improvement with bronchodilators, usually after lung or stem cell transplant

A

true

101
Q

T/F: Pulm Langerhans cell histiocytosis is associated with thin-walled cysts with accompanying nodules and pHTN

A

true

102
Q

Tx of carbon monoxide poisoning

A

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
Q

When do you start LABA, LAMA or ICS in COPD?

A

FEV1 <60%. Monotherapy.

When 60-80%, use inhaled bronchodilator (albuterol)

104
Q

T/F: Macrolides should not be used in COPD

A

False, they actually decrease exacerbations

105
Q

T/F: PDE-4 inhibitor (Roflumilast) should not be used in COPD

A

False, this can be used as add-on therapy. can reduce exacerbations

106
Q

T/F: Hypersensitivity pneumonitis and respiratory bronchilitis will have centrilobular miconodules

A

true, HP in upper and mid lungs

107
Q

most common manifestation of asbestos exposure

A

bilateral pleural plaques

108
Q

who gets asbestos exposure?

A

construction
automotive shipbuilding/repair

10-15 year latency period

109
Q

T/F: Mag sulfate relaxes bronchial smooth muscle and helps severe asthma exacerbation

A

true

110
Q

Apnea-Hypopnea Index score for OSA

A

> 5

111
Q

response to nitric oxide during PAH RHC predicts response to?

A

CCB (including diltiazem)

UWORLD ABIM (10 decks)

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