Pulmonary 2 Flashcards
Pt presents with SOB, fatigue, Edema, Murmur and NORMAL PFTs and DECREASE DLCO. Dx?
Pulmonary HTN
Pt s/p CABG presents with SOB with Exertion. He Desaturates in supine position.
CXR shows Left Hemidiaphragm.
There is a drop in FVC with supine position.
Dx?
What is the best test to diagnose this condition?
Unilateral Diaphragmatic Paralysis (due to phrenic nerve injury after cardiac surgery.)
Sniff Test using Fluoroscopy
Next step in management with a patient with COPD exacerbation who is not responding to bronchodilators, steroids and antibiotics?
When would you intubate?
BIPAP (Noninvasive positive pressure ventilation)
pH < 7.1 OR no improvement after BIPAP
What ratio helps determine successful intubation?
RSBI (Rapid Shallow Breathing Index) RR/ tidal volume < 105
Chronic rhinosinusitis with Polyposis, Asthma and Ingestion of Aspirin leading to Asthma exacerbation? Dx? Rx?
Aspirin Exacerbated Respiratory Disease.
Singulair
In obstructive lung disease what will be the FEV1?
FEV/1/FVC?
FVC?
- Decreased
- Decreased
- Normal to Decreased
In Restrictive Lung Disease what will be the FEV1?
FEV1/FVC?
FVC?
- Decreased
- Normal to Increased (FVC is way lower)
- Decreased
Proper Management to Prevent VAP?
Oral care and Semi-recumbent positioning
Management of COPD:
- Minimal Symptoms <1 exacerbation?
- Moderate to severe < 1 exacerbation?
- Minimal symptoms > 2 exacerbations?
- Moderate to severe > 2 exacerbations?
- SABA prn
- SABA prn + LAMA+/- LABA
- SABA prn + LAMA and for frequent exacerbations LABA +/- ICS
- SABA prn + LAMA + LABA +/- ICS
Pt presents with 4-6 weeks occasional subjective fever, mild SOB, intermittent cough, right sided chest pain, smoked daily, construction worker, LDH 256. CXR shows right sided effusion and pleural thickening. Dx?
BAPE (Benign Asbestos-Related-Pleural-Effusions. Can happen 10-15 years post-exposure.
Pt presents with nonproductive Cough, SOB, JVD, No improvement with lasix, CXR shows Interstitial Markings and Decreased lung volumes?
Dx?
Test?
IPF
High Resolution CT (honeycombing, cystic changes and traction bronchiectasis.
What is the best test to do when you suspect a PE in critically ill and hemodynamically unstable patient?
Bedside transthoracic Echo (quickest) to check for RV disfunction.
If noted immediate thrombolytics are warranted.
What type of acid base disturbance is associated with hepatic cirrhosis?
Respiratory Alkalosis due to Increased minute ventilation due to Increased Estrogen and Progesterone (Happens in Pregnancy too)
Difference in Pleural Fluid from Rheumatoid effusions vs. Empyema?
Rheumatoid effusions have cell count < 5,000 and predominantly lymphocytic. (INFLAMMATORY)
Empyema have cell counts 50,000 and predominantly Neutrophilic. (BACTERIAL)
1 Next step in management for a complicated parapenumonic effusion? (ph < 7.20, low glucose level on PF) ?
- Managed for an uncomplicated effusion?
- Immediate Chest tube placement
- Will drain by itself with Antibiotics
Pt presents with worsening SOB over the last 6 months. An echo shows moderate RIGHT Ventricular dilation and Hypokinesis as well as Increased Flow velocities through the tricuspid valve.
Dx?
What will the spirometry show?
Pulmonary HTN will Show Normal FEV1, and FEV1/FVC ratio.
The TLC may be decreased.
There is also decreased DLCO.
Management of an Asplenic patient who presents with Fever?
Abx + Go to Urgent Care.
Pt reports with SOB and Wheezing after Paint exposure in the work place.
Pulmonary function test are normal.
Dx?
What test is important to establish diagnosis?
Reactive Airway Dysfunction Syndrome
Methacholine challenge test to diagnose Asthma.
What is the next best test when a Heart Failure patients Pleural Effusion may meet Exudative Effusion Criteria after Diuresis?
Calculate Serum Effusion Albumin gradient > 1.2
Next step in management of a patient with radiographic evidence of ABPA?
Skin prick test
Elevated IgE levels and Aspergillus
antibodies.
Pt with restrictive lung chest wall disease pectus excavatum, ankylosing spondylitis and obesity can benefit from what ?
What are the contraindications to BIPAP?
- BIPAP
- Impending Arrest
- Severe Acidosis
- Other failing Organs
- Uncooperative
- Cant Clear secretions
- Mechanical issues (Esophageal anastomosis, FACIAL surgery)
- Which Parapneumonic Effusions require Thoracentesis?
2. Management of NON-Complicated Parapneumonic Effusions?
- Complicated ones (Positive Gram Stain & Culture, LOW PH and LOW Glucose)
OR
Large ones (> 10mm). Also if pt not improving with Abx.
- Non complicated just Require Serial Imaging. (Negative Gram stain etc, Or < 10 mm)
Pt presents with Dyspnea, Fatigue and Pulmonary Artery Pressure > 60 mmHg.
Her Echo is normal.
CT shows no abnormalities.
She had hx of PE 3 years ago.
She does not have any OSA Symptoms.
Had a hx of smoking but has Normal PFTs.
Next Step in Management?
V/Q Scan to evaluate for Chronic Thromboembolic Pulmonary Hypertension.
10 Minutes after Bronchoscope a man becomes Cyanotic with Myoclonic Jerks.
ABG is normal
02 sat is normal
However patient remains Tachynpneic and Doesn’t improve.
Dx? Rx?
Methemoglobinemia due to Anesthetic.
Pulse Ox measures light absorbance between Oxy and Deoxyhemoglobin.
Need a Co-Oximeter to measure Methemoglobin.
Treatment is Methylene Blue.
Pt presents who is a NON-Smoker with Fever, Cough, Shortness of Breath over the last 4 months.
Reports Night Sweats and Weight-loss.
CXR shows bilateral pleural based dense infiltrates involving upper and lower lobes SPARING Central and Peri-hilar lung regions ?
What is the difference between Chronic an Acute?
When does Asbestosis Present? (Commonly confused with the two)
Rx?
Eosinophilic Pneumonia.
Test: Bronchoalverolar lavage >25% Eosinophils.
Peripheral Eosinophils > 6%.
Acute associated with smokers (Develop Hypoxic Respiratory Failure.) It is a rapid course.
Chronic is associated with NON-SMOKERS.
More Insidious course with lots of Relapse.
Remember Asbestosis will present 20-30 years AFTER EXPOSURE.
Rx with steroids (IV Acute, Oral Chronic) 3 month treatment with gradual taper.
Difference between Silicosios and Asbestosis.
Silicosis : Occurs outdoors (Rocks, Coal mining). They have BILATERAL Interstitial infiltrates in the Upper Lung Fields.
Occurs in Plumber, Electricians, Carpentors, janitors (Buildings)
They have Pleural Plaques
