Pulm/Crit Care

Question 1

Indications for IVC filter placement

Answer 1

Complications of anticoagulation (GI bleed, hemorrhagic stroke)
Contraindication to anticoagulation
Failure of anticoagulation in the setting of a known DVT/PE

Question 2

Lab findings of chronic respiratory acidosis

Answer 2

Elevated bicarb, seen in OSA patients, increases risk of perioperative complications

Question 3

Wells Criteria

Answer 3

3 points:
-Clinical signs of DVT
-Alternate diagnosis less likely
1.5 points:
-Previous PE or DVT
-Tachycardia
-Recent surgery or immobilization
1 point:
-Hemoptysis
-Cancer

If >4, PE likely

Question 4

Si/Sx of pulmonary embolism

Answer 4

Sudden-onset pleuritic chest pain
Loud P2, pleural friction rub
Hypoxemia
Small pleural effusion on CXR (2/2 inflammation of pulmonary infarct)

Question 5

Best modality to evaluate pneumothorax in acute setting

Answer 5

Bedside ultrasonography

Question 6

Causes of nonresolving pneumonia or pulmonary infiltrates

Answer 6

Usually mediated via endobronchial obstruction

Bronchogenic carcinoma (smoker)
Carcinoid tumor (younger, non-smoker)
Bronchoalveolar cell carcinoma
Lymphoma
Eosinophilic pneumonia
Bronchiolitis obliterans organizing pneumonia (BOOP)
Systemic vasculitis
Pulmonary alveolar proteinosis
Drugs (amiodarone)

Question 7

Cough-variant asthma

Answer 7

Chronic nonproductive cough, exacerbated by exercise (esp in cold temperatures) or forced expiration or allergens, commonly occurs at night +/- chest tightness
No wheezing or rhonchi on exam
Dx with PFTs
Treat like asthma

Question 8

Asthma severity:
Intermittent
Mild persistent
Moderate persistent
Severe persistent

Answer 8

Based on symptom frequency/SABA use and nighttime awakenings

Intermittent: 2 days or less a week, 2 times or less a month; step 1 (albuterol prn)

Mild persistent: more than 2 days a week but not daily, 3-4 times a month; step 2 (low dose ICS like fluticasone, beclomethasone, budesonide, mometasone)

Moderate persistent: daily, >1 time/week but not nightly; step 3 (low-dose ICS + LABA such as formoterol, salmeterol, olodaterol OR medium-dose ICS)

Severe persistent: throughout the day, 4-7 times a week; step 4/5 (medium to high-dose ICS + LABA, consider omalizumab in patients with allergies

Question 9

Benign vs malignant patterns of calcification in lung nodules

Answer 9

Benign: popcorn (often seen in pulmonary hamartoma), concentric or laminated, central, diffuse homogeneous

Malignant: eccentric (area of asymmetric calcification), reticular or punctate

Question 10

Exercise-induced bronchoconstriction

Answer 10

Perform bronchoprovocation testing (exercise or inhalation of cold air): if FEV1 decr by >10% -> positive, if decr by 15% -> diagnostic
Tx with albuterol 10-20min before exercise
Can use mast cell stabilizers (cromolyn) if unable to tolerate SABA
If athlete, start ICS with prn SABA

Question 11

Endocrine abnormalities caused by lung cancers

Answer 11

Small cell carcinoma: SIADH (normovolemic hyponatremia)

Squamous cell carcinoma: hypercalcemia due to PTH-rP production

Question 12

Causes of recurrent pneumonia

Answer 12

Aspiration: right middle/lower lobe, dysphagia/dysarthria, altered mentation
Chronic obstructive lung disease: smoking hx, chronic cough, chronic dyspnea
Immunodeficiency
Post-obstructive: hemoptysis, weight loss/cachexia, pneumonia in the same location
Tuberculosis: upper lobe/apical, recent immigrant, institutionalized patient, homeless/lower SES

Question 13

Tuberculous pleural effusion

Answer 13

Si/Sx: fever, cough, pleurisy and weight loss
Thoracentesis reveals a lymphocyte-predominant, exudative effusion; elevated adenosine deaminase levels
Dx: pleural biopsy

Question 14

Asthma exacerbation during pregnancy

Answer 14

Supplemental O2 to maintain sats >95%
Nebulized or inhaled albuterol and inhaled ipratropium
If incomplete response, give systemic steroids and observe

Question 15

Management of choking

Answer 15

If <1: turn face down and give 5 back blows, then turn face up and give 5 chest thrusts
If 1 or more: lean patient forward and give Heimlich (Abdominal thrusts), alternate between back blows and 5 abdominal thrusts, start CPR if becomes unresponsive

Question 16

PFTs pattern

Answer 16

Restrictive: both FEV1 and FVC are decrease fairly proportionally so FEV1/FVC ratio is normal or increased, reduced total lung capacity
Asthma: usu. normal, decreased FEV1/FVC ratio after methacholine
Pulm. hypertension: normal pattern with decreased DLCO
COPD: reduced FEV1/FVC ratio, DLCO also reduced

Question 17

Features of classic allergic bronchopulmonary aspergillosis

Answer 17

Hx of asthma, cystic fibrosis
Recurrent asthma exacerbation, fever, lethargy, cough with production of brown mucus plugs, fleeting infiltrated on lung imaging
Central bronchiectasis on lung CT
Dx testing:
-Skin test positive for Aspergillus
-Eosinophilia >500
-IgE >417
-Speficic IgG and IgE for aspergillus
Tx: glucocorticoids and itraconazole

Question 18

Asthma exacerbation

Answer 18

Mild to moderate (PEF or FEV1 40% or more):

• Inhaled SABA
• PO corticosteroids if no response to SABA or recent steroid use
• O2 if sat <90%

Moderate to severe (<40% PEF or FEV1):

• Inhaled SABA + ipratropium for 1h
• PO/IV steroids
• O2 if sat <90%

Impending or actual resp arrest:

• Inhaled SABA + ipratropium
• IV steroids + mag sulfate
• Consider SQ or IV terbutaline or epinephrine
• O2 or intubation

Question 19

Manifestations of post-op atelectasis

Answer 19

2-5 days after surgery
ABGs with increased A-a gradient
CXR with linear opacifications in bilateral lung bases