Pulmonary 1 Flashcards
- Rx for COPD and FEV1 < 60% ?
- Rx for COPD and FEV1 < 50%?
- Appropriate Add-On Therapy for pt with Severe COPD associated with Chronic Bronchitis and hx of Recurrent Exacerbations?
- Rx for COPD with Severe Resting Hypoxemia (P02 < 55mmgh, 02 Sat 88%) or P02 55-60mmgh with Signs Polycythemia, PH, R-CHF
- Management of a patient with COPD who has completed Lung Rehab, Exercise Program, on Maximal therapy, Normal BMI but still has Significant Exertional Dyspnea?
- LABA or LAMA
- Add on Pulmonary Rehab
- Roflumilast, BIPAP, Azithromycin
- Continuous 02 therapy
- Lung Reduction Surgery (to improve mortality, exercise tolerance and quality of life)
What is the recommended follow up for long nodules 6-8mm in size?
Every 6-12 months
then every 2 years for 5 years due to slow rate of growth ( doubling time is around 2-5 years)
Asthma Management
- Mild Persistent asthma( >2 Days a week, > 2 Nights month)?
- Moderate persistent asthma (Daily, > 1 night week)?
- Severe persistent? (All day, All night)
Step 1-2 SABA + Low Dose ICS prn
LABA + Low Dose ICS prn
Step 3 LABA+ Low Dose ICS daily
Step 4 LAB+ Medium Dose ICS daily
Step 5 LABA+ High Dose ICS+ LAMA Daily
Consider Biologic Therapy (Anti-iGE or Anti-IL5/5R) Omalizumab
Exudative Pleural Effusion with Hx of Asbestos Exposure.
Dx?
Malignant Pleural Mesothelioma
Medication for patient with Asthma and symptoms inadequately controlled with inhaled steroids, evidence of allergies to perennial aeroallergen, serum IgE levels 30-700?
Omalizumab (inhibits IgE)
PT found Unconscious, was using Propane Fueled Heater, Carboxyhemoglobin level is 50%.
Next step in management?
Hyperbaric Oxygen Therapy
Rx for a patient with Central Sleep Apnea and Cheyne-stokes breathing pattern and Heart Failure symptoms?
Lasix
Pt with hx of diffuse cutaneous sclerosis presents with 6 months of progressive dyspnea. Dx?
Do a high resolution CT to check for Diffuse Parenchymal Lung Disease: Nonspecific Interstitial Pneumonia
Next step in diagnosing cough variant asthma when spirometry is normal?
Methacholine challenge test
Next step in management of hospitalized patient with dyspnea and hx of COPD AND NOT responding to COPD treatments?
CT Pulmonary Angiography (CTA) to evaluate for PE
Management of Chronic Hypoventilation due to neuromuscular disease (ALS)?
BIPAP
Start when patients have HYPERcarbia or Respiratory Symptoms.
Pt presents with progressive Exertional Dyspnea, fatigue, Edema, Near Syncope event, Pulmonary Artery Systolic pressure is 50mmg hg on Right Heart Cath.
Dx?
Test?
Rx?
What if there was a change with inhaled nitric oxide?
Group 1 PAH.
Echo with Bubble study to r/o Shunt (ASD),
Do Right heart cath to Confirm and Check for Vasodilatory response
Left heart Cath and Angiography to exclude LV dysfunction .
Rx: Bosentan
CCB
(the inhaled nitric oxide determines responsiveness to CCB- cheaper, less side effects).
Lung heart transplant when medications are not successful.
Management of Benzodiazepine Over Dose in Chronic Users?
Monitor for signs of Agitation
Do not use Flumazenil it has a short half life and DOES NOT Give SUSTAINED Reversal so patients can go into seizure.
Management of Hypertensive Emergency?
No more 25% decrease in Systolic in the first hour
Goal of 160 systolic in next 6 hours
Goal of normal over 24-48 hrs.
Management of Cyanide Poisoning?
Hydroxocobalamin
(It combines to Cyanide to make Cyanocobalamin which is Water Soluble)
AND
02 therapy or Hyperbaric 02 when carboxyhemoglobin level is > 25%.
Management of a Hypothermic patient with no pulse and unresponsiveness
CPR and Active Re-warming with Warm Blankets, Removing Clothing, body cavity lavage with Warm fluids.
Treatment of High Altitude Cerebral edema N/V/, AMS, confusion, irritability)?
Treatment for high altitude pulmonary edema?
Dexamethasone and Decend to lower elevation
Nifedipine
Management of Asymptomatic patient with stage 1 pulmonary sarcoidosis?
Observation
75% pt is Spontaneous Resolution of hilar lymphadenopathy
When is Multiple Sleep latency Testing indicated?
When pt has Pathological Day TIME Sleepiness.
EVALUATE FOR NARCOLEPSY
Pt with Complicated PNA has Serous fluid with negative gram stain and culture.
Diagnosis and why does this occur?
Treatment?
What if the gram stain was positive?
Complicated Parapneumonic Effusion ( the bacteria are rapidly cleared from pleural space).
Rx with thoracostomy.
Empyema.
Pt with Reccurent PE presents with Exertiona Dyspnea.
There are Cannon A waves,
Wide split 02
Echo shoes dilated R ventricle
V/Q shows multiple mis match defects
R cath shows mean Pulmonary Arterial Pressure 58mmg and NORMAL Capillary Wedge Pressure.
Diagnosis ?
Rx?
Chronic thromboembolic Pulmonary Hypertension
Pulmonary Thromboendarterectomy
What is the most appropriate Intrapleural Treatment of Empyema (pleural fluid and positive gram stain) ?
Tissue plasminogen activator - deoxyribonuclease.
Loculated empyemas that will not drain with thoracostomy Alone. given TPA to lower the rate of surgical intervention (The need for Video Assisted Thorascopic Surgery or Open Debridement VATS)
Pt presents with Upper and Lower Lip swelling as well as Urticaria after eating at a picnic.
Next step in management?
Epi
What helps decrease mortality and improve survival in severe ARDS patients?
Low tidal volumes and prone positioning (at least 12 hrs per day as standard management. )
What is the initial test to assess of ICU acquired muscle weakness for a patient who has has resolved from initial infection but cannot be weaned from vent?
Medical Research Council Muscle Scale
Score < 48 considered diagnostic of ICU acquired weakness.
Idiopathic Interstitial Pneumonia:
- Pt presenting with progressive dyspnea. Initially treated for PNA when she she had fevers and sputum production but that has resolved.
CXR and CT show new ground glass changes b/l with several areas of nodular consolidation along the peripheral.
Dx? Rx? - Pt presents with dense Bilateral Acute Lung Injury similar to ARDS?
- Chronic insidious dyspnea and cough in older patients with honeycomb changes, reticular densities, infection and HF ruled out.
- Cryptogenic Organizing Pneumonia
Respond well to steroids, tapper slowly during the subsequent 6 months.
- Acute Interstitial Pneumonia
- IPF
Presents in older patients > 60 yrs of age presenting with progressive dry cough and SOB. Ct shows extensive parenchymal involvement with, traction bronchiectasis, honeycomb changes Dx? Rx?
IPF.
Lung transplant.
Pirfrenidone can slow progression of disease. do not intubate these patients.
Pt with NO symptoms, 35 pack year Smoking Hx.
CT scan shows centrilobular micronodules, NO traction Bronchiectasis, NO Honeycombing, NO Mediastinal or Hilar Lymphadenopathy, Ground Glass Opacities.
Dx?
Test?
Rx?
Respiratory Bronchiolitis Associated Interstitial Lung Disease
Some patients can be symptomatic
These are found on low dose lung CTs
Management is smoking cessation
Presents in young patients, CT shows THIN Walled Cyst with accompanying nodules.
Pulmonary Langerhans Cell Histiocytosis
What diagnosis should be considered when a patient with Silicosis develops respiratory impairment, hemoptysis, and Upper Lobe Cavitary Disease on CXR.
Diagnosis and Why does this happen?
Next Step in Management?
TB
Silicosis affects macrophages and puts patients at risk for development of TB as well.
Do sputum sample for acid fast bacillus.
Pt presents with cough, hemoptysis, dyspnea, weight loss, fever, fatigue and chest pain.
CXR shows Pulmonary Cavity or Cyst.
Sputum culture and IgG positive.
Dx?
Aspergilloma
Affects areas of preexisting pulmonary cavity or devitalized lung
Safest inhaler glucocorticoid in pregnancy?
Which medication to avoid in pregnancy with asthma?
Budesonide
Zileuton (leukotriene receptor antagonist. others are safer in pregnancy
What is the best management that will decrease hospital stay in a patient with recurrent pleural effusion?
Indwelling pleural catheters
- Formula to calculate Plasma Osmality?
- How to Calculate for Osmol gap?
2Na + Glucose/18 + BUN/2.8
Measured - Calculated > 10 then there is a gap.
What produces a plasma osmol gap but NO Anion Gap? Rx?
Isopropyl alcohol poisoning.
Supportive care
IsoproNO
What produces an Elevated Osmol gap and Positive Anion Gap Metabolic acidosis?
Rx?
Ethylene glycol ingestion (antifreeze) and Methanol.
Rx with Fomepizole because their active metabolites cause eye blindness and renal dysfunction respectively.
Pt presents with Daytime Hypercapnia, Apnea-hypopnea index of 6, BMI 40. Dx?
Obesity Hypoventilation Syndrome
CPAP/Bipap
Weight loss
Rx of Acute Bronchiectasis ( low grade fever, progressive cough, purulent sputum production)?
Levofloxacin
Inhaled Tobramycin can be used also
When is Pleurodesis indicated for Pneumothorax?
After Second Occurrence of Primary Spontaneous Pneumothorax and after First Occurrence of Secondary Spontaneous Pneumothorax (2/2 lung disease)
Test and Rx for Sarcoidosis?
Pt needs Transbronchial lung biopsy.
Topical (for oral and eye disease ) and Oral Steroids.
Immunosuppressive Therapy for refractory symptoms
- Rx for Acute Mountain Sickness
2.Rx for High-altitude Cerebral Edema
- Rx for High-altitude Pulmonary Edema
- Acetazolamide, Dexamethasone and Supplemental 02
- Immediate Decent from altitude, dexamethasone, Supplemental 02, hyperbaric therapy
- Supplemental 02 + Rest
Name the Shock:
- Low cardiac output, elevated PCWP, High SVR
- Low cardiac output, low PCWP, High SVR
- High cardiac output, normal PCWP, LOW SVR
- High cardiac output (early) that can become (late) and LOW SVR + fever and leukocytosis
- Cardiogenic Shock
- Hypovolemic Shock
- Anaphylactic Shock
- Septic Shock
