Pulmonary 3

Question 1

During ACLS. What is a noninvasive indicator for Return of Spontaneous Circulation?

Answer 1

A Rise in ETC02 (End-tidal C02). - effective chest compressions cause a rise in cardiac output which enhances systemic and pulmonary perfusion.

Question 2

1. Which parameter can reduced Ventilator induced lung injury (Barotrauma) in patients with ARDS?
2. What if their ABG reads Acidosis?

Answer 2

1. Lower tidal volumes (4-6 ml/kg) and maintaining plateu pressure of < 30cmH20.
2. A ph of > 7.20 is permissible ( f no contraindications (cerebral edema, Seizure Disorder).

Do not increase RR which will Increase Minute Ventilation and cause Breath Stacking.

Question 3

Ventilar Setup in ARDS?

1. Mode
2. Tidal Volume
3. PEEP
4. Plateau Pressure
5. Rates
6. Goal PH
7. Pa02/Sa02

Answer 3

Remember High PEEP and Low Tidal Volumes.

1. Volume Assist-Control
2. first 8 then 4-6 over 1-3 hrs
3. 5-15, Higher PEEPs for moderate to Severe ARDS
4. < 30
5. <35min
6. > 7.20
7. 55-90/88-95%

Question 4

1. In COPD (Chronic Respiratory Acidosis).
   How much will the Kidney Retain for Every ____ Rise in CO2?
2. What happens acutely?

Answer 4

1. Kidney will Retain 4 mEQ of Bicarbonate for Each 10 mm Hg increase in PC02.
   The PH will only decrease by 0.015.
2. Acutely the kidney will retain 1 MEQ of Bicarbonate.

Question 5

What additional Medication can be added if a patient Suffers from Exercise Induced Asthma?

Answer 5

Singular/Montelukast or Inhaled Corticosteroids.

Question 6

Pt presents with Fever, Dyspnea, Cough, Pleuritic chest pain, Leukocytosis.
Treated with Abx with no improvement in her symptoms. CXR shows Haziness.
CT shows Ground Glass Alveolar infiltrates. 5 Years Ago patient had RADIATION to the CHEST.

Dx?
Rx?

Answer 6

Acute Radiation Pneumonitis.
Can progress to Fibrosis.

Rx: 2 weeks Prednisone.

Question 7

Pt presents with 6 months of Dry Cough and Progressive Exertional Dyspnea.
He owns 2 parrots and Cat. Hx of Smoking. Reports his symptoms improved while on Vacation. PFT Shows Restriction with Impaired Gas exhanged. CT Scan shows Ground Glass opacities. There are Non-caseating Granulomas in the Periphery of The lung on BAL. Dx?

Answer 7

Hypersensitivity Pneumonitis (Extrinsic Allergic Aveolitis). (Birds, Methotrexate)

Avoid Exposure. Steroids.

Question 8

Name 4 Treatments in Palliative Care of COPD?

Answer 8

1. Morphine
2. Facial Cooling
3. Lorezapam
4. Consider Theophylline
   Palliative sedation and Bipap are End of life care.

Question 9

Abnormal Adduction of the Vocal Cords during inspiration that is often misdiagnosed as Asthma. Psychological Stressors are a common trigger. Flow Volume Loop shows flattening of the Inspiratory curve. Dx?

Answer 9

Paradoxical Vocal Fold Motion.

Supportive Care: CPAP Therapy, Avoid Triggers, Speech Therapy

Question 10

What is the workup for suspected Bronchiectasis?

Answer 10

CBC, Immunoglobulin Quantitation, Sputum Cultures (Bacteria, Fungi, Mycobacteria)

Question 11

34 Yo F presents with sharp right sided chest pain that worsens with inspiration, movement, coughing and sneezing. D-Dimer is normal. She has a 15 pack year smoking hx. She is on OCPS. Next Step in management? DX?

Answer 11

1. Indomethacin.

This is Pleurisy.

Question 12

57 yo with cirrhosis presents with worsening abdominal distension. ABG pH 7.48, Pa02 96 mm Hg, PaCO2 28mm Hg. What is the most like;y cause of his primary acid-base disturbance?

Answer 12

Central Stimulation of Ventilation

Question 13

When do heart failure patients meet the criteria for an exudative effusion?

Answer 13

If they receive diuretics, Need to further differentiate with serum-effusion protein difference > 3.1 suggest a true transudatsive effusion.

Question 14

What 2 Strategies will Decrease Auto-Peep (pt breathing over the vent)?

Answer 14

1. Decrease Respiratory Rate (slow down the breath)
2. Bronchodilators and Steroids to Decrease Airway Obstruction

Question 15

What is the next best step for patients underlying lung disease (COPD) and compensated hypercania who meet criteria for Extubation?

Answer 15

Extubate to noninvasive ventilation (it decreases failure and invasive ventilation time.)

Question 16

38 Yo M presents progressive SOB. Smoked cigarettes in college. FEV 1 56%, FVC 68%, FEV1/FVC is 0.66 and Post bronchodilatory FEV1 is 60%. What is the next step in management?

Answer 16

Check serum Alpha-1-Antitrypsin levels

Question 17

34 yo African American man presents with fatigue, cough. He has R Paratracheal and bilateral Hilar Lymphadenopathy.

Dx?
Next Step in Management?

Answer 17

Sarcodosis

Enodbroncial US with Nodal Aspirtion

If that fails then Mediastinoscopy with Excisional Lymph Node Biopsy

Question 18

43 yo M with Malaise, Fatigue, Cough and Hemoptysis.
He had a hx of blurry vision in R eye 4 months ago that resolved spontaneously.
Has small oral lesions present.
ESR is 123.
CXR shows several ill defined nodules with cavitation in both lungs.

Dx?

Answer 18

Granulomatosis With Polyangitiis (Wegners).

They can have Eye, Upper airway and Lower respiratory tract disease along with glomerulonephritis

Question 19

Next step in Management for a Pulmonary Nodule> 0.8cm and a patient high risk of Malignancy?

Answer 19

Surgical Wedge Resection by Thorocotomy or VATS (Video-Assisted Throacscopy- can be diagnostic and Therapeutic.

Question 20

1. Management of an Effusion < 10mm AND Free flowing?
2. Management of an Effusion > 10mm with loculations, 1/2 hemithroax and thickened pleura?

Answer 20

1. Observe
2. Drain

Question 21

Test for Aspergillosis?

What if the Noninvasive test are Inconclusive?

Answer 21

Noninvasive:
Sputum Fungal Stain
Sputum Culture

Serum Fungal Biomarkers:
(Galactomannan (More Specific) , Beta-D-glucan- can be positive in other fungal infections so not specific)

Bronchoscopy with Bronchoalveolar Lavage

            OR

Transbronchial Biospy

           OR 

CT-guided Transthroacic Biopsy.

Question 22

Pt with high risk concern for malignancy has a CT that shows 2.5 CM Spiculated lesion in the R middle lobe 2 cm form the pleural surface and R sided pleural effusion.
Thoracentesis removes 250cc of fluid and is exudative.
Pleural Cytology is negative for malignancy.
Gram stain and Acid-fast bacteria stains are negative.
Culture is negative.

Next step in management?

Answer 22

Repeat Thoracentesis

Repeat Throacentesis can detect up to 90% of malignant cells in high risk patients.

Question 23

1. IV Steroids, Neuromuscular blocking agents, Sepsis. Pt presents with flaccid limbs, facial and respiration weakness but normal sensation?
2. Infection, Medications, Serotonin syndrome, Neuroleptic Malignant Syndrome, ELEVATED CK. Pt presents with mild to moderate limb weakness, muscle swelling, myalgias ?
3. Occurs after using a Prolonged Paralytic agent for days in setting of liver or kidney insufficiency. Pts have Flaccid limbs, Respiratory weakness. Transient improvement after Anti-cholinesterase.

Answer 23

1. Critical Illness myopathy
2. Rhabdomyolysis
3. Prolonged Neuromusclar Blockade

Question 24

Patient presents with cough, dyspnea, nighttime awakenings and wheezing. Symptoms can start ONE MONTH after painting a room using Ammonia. Can be associated with mild SOB and felt IRRITATION and BURNING in his throat. Dx? What Test is done to establish the diagnosis?

Answer 24

Reactive Airway Dysfunction Syndrome.

Methacholine Challenge Test.

Question 25

Indications for Long Term 02 therapy?

Answer 25

1. Sat < 88% or PaO2 < 55 mm Hg
2. Sat < 89% or PaO2 <59mm Hg PLUS Right sided Heart Failure or Erythrocytosis