Pulm/ICU

Question 1

when to think of lymphangitic cancer spread

Answer 1

malignancies: adenocarcinoma (lung, breast, and gastrointestinal tract), melanoma, lymphoma, and leukemia
imaging: peripheral interstitial abnormality plus LAD

Question 2

Severity of obstruction based on FEV1

Answer 2

50-80%: moderate

30-50%: severe

Question 3

Small cell lung cancer

Answer 3

almost exclusively in smokers
presents as a large hilar mass with bulky mediastinal lymphadenopathy
associated Lamber-Eaton w proximal muscle weakness
aggressive and usually disseminated on presentation, but is sensitive to chemo and XRT initially

Question 4

Criteria for lung transplantation

Answer 4

1. history of exacerbations associated with acute hypercapnia (arterial PCO2 >50 mm Hg [6.7 kPa])
2. pulmonary hypertension, cor pulmonale, or both despite oxygen therapy
3. FEV1 less than 20% of predicted with DLCO less than 20% of predicted or homogeneous distribution of emphysema

Contraindications:
malignancy within the last 2 years, infection with hepatitis B or C virus with histologic evidence of significant liver damage, active or recent cigarette smoking, drug or alcohol abuse, severe psychiatric illness, documented nonadherence with medical care, and absence of social support, age >65yrs is a relative contraindication

Question 5

hepatopulmonary syndrome

Answer 5

dilated pulmonary pre capillaries and capillaries -> AV malformation w shunting

Question 6

definitition and management of spontaneous/primary pneumothorax

Answer 6

defined: >2cm
management: high flow O2 and needle drainage (don’t need to start w chest tube as you do w large secondary pneumothorax)

Question 7

indications for omalizumab

Answer 7

moderate to severe persistent asthma with the following characteristics: (1) symptoms inadequately controlled with inhaled glucocorticoids, (2) evidence of allergies to perennial aeroallergens, and (3) serum IgE levels between 30 and 700

Question 8

goal vent settings to present vent assoc lung injury

Answer 8

tidal volume 6ml/kg IDEAL body weight

plateau pressures

Question 9

criteria for lung volume reduction surgery

Answer 9

(1) severe COPD
(2) symptomatic despite maximal pharmacologic therapy
(3) completed pulmonary rehabilitation
(4) evidence of bilateral predominant upper-lobe emphysema on CT
(5) postbronchodilator total lung capacity greater than 100% and residual lung volume greater than 150% of predicted
(6) maximum FEV1 greater than 20% and less than or equal to 45% of predicted and DLCO greater than or equal to 20% of predicted
(7) ambient air arterial PCO2 less than or equal to 60 mm Hg (8.0 kPa) and arterial PO2 greater than or equal to 45 mm Hg (6.0 kPa)

Question 10

COPD and flying

Answer 10

SpO2 >95% -> likely no problems with flying
SpO2 92-95% -> may need in flight supplemental O2, so perform hypoxia altitude simulation test if possible, otherwise 6min walk, if desat to provide in flight supplemental O2

Risk factors for COPD related complications of flying:
COPD with hypercapnia, a recent exacerbation of chronic lung disease, pulmonary hypertension, and restrictive lung disease

Question 11

initial therapy for COPD

Answer 11

PRN anti-cholindergic or beta agonist ->
long acting beta agonist or inhaled anticholinergic AND pulmonary rehab->
inhaled steroid/LABA combo

Question 12

roflumilast

Answer 12

phosphodiesterase-4 inhibitor that is used as add-on therapy to reduce exacerbations in patients with severe COPD associated with chronic bronchitis and a history of recurrent exacerbations despite other therapies

Question 13

indicators for respiratory support for pts w respiratory neuromuscular weakness

Answer 13

1. forced vital capacity

Question 14

TCA overdose

Answer 14

somnolence, hypotension, widening of the QRS interval (100msec considered severe), seizure, and anticholinergic signs (fever, tachycardia, mydriasis, reduced bowel sounds)

Question 15

Fleischner criteria for pulmonary nodules

Answer 15

if any lung Ca risk factors:
repeat in 6-12mo
then again in 18-24mo
if no change in 24mo, can stop screening

Question 16

low dose CT lung cancer screening

Answer 16

annual low dose CT in patients with at least a 30-pack-year history of smoking who are currently smoking or quit within the last 15 years if the patient is between the ages of 55 and 80 years.

Question 17

bronchiectasis

Answer 17

Sx: chronic cough with purulent sputum and recurrent pneumonia
Dx: high resolution CT chest with Airway dilatation with lack of tapering, bronchial wall thickening, and cysts. PFTs may show mild obstruction

Question 18

radiation pneumonitis

Answer 18

increased risk with high dose radiation, pre-existing lung disease, and gemcitabine
presents with dyspnea and cough 6-12wks post exposure
CT with nonanatomic straight line demarcating involved versus uninvolved lung parenchyma
vs radiation fibrosis which presents 6-24mo post exposure and is usually asymptomatic

Question 19

hypersensitivity pneumonitis

Answer 19

presents within 48 hours of a high-level exposure to respiratory antigens
fever, flulike symptoms, cough, and shortness of breath
high-resolution CT imaging of the chest shows findings of ground-glass opacities and centrilobular micronodules that are upper- and mid-lobe predominant

Question 20

idiopathic pulmonary fibrosis CT findings

Answer 20

peripheral- and basal-predominant septal line thickening and honeycomb change
pathologic correlate = usual interstitial pneumonia

Question 21

COPD long term O2 therapy

Answer 21

PaO2

Question 22

when chest tube needed for parapneumonic effusions

Answer 22

pH