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Pulmonary Flashcards

1
Q

Alveolar O2 formula?

Normal A-a gradient?

A

PAO2 = 713*FiO2 - PaCO2/0.8
On room air (21% O2), this is:
PAO2 = 150 - PaCO2/0.8

Normal A-a gradient is <15 mm Hg.
Increases with aging but should always be <30 mm Hg

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2
Q

Cause(s) of hypoxemia with a normal A-a gradient

A

Hypoventilation, low inspired oxygen

(Everything else that causes hypoxemia - V/Q mismatch, shunts, barriers to diffusion - causes an elevated A-a gradient).

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3
Q

Light criteria for an exudative effusion

A

At least one of:

  • Pleural fluid protein / serum protein ratio > 0.5
  • Pleural fluid LDH / serum LDH ratio > 0.6
  • Pleural fluid LDH > 2/3 the upper limit of normal for serum LDH
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4
Q

Diagnostic workup of new pleural effusion

A

Thoracocentesis, unless clearly due to CHF

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5
Q

Berlin Criteria (2012) for diagnosis of ARDS

A
  1. Acute onset within 1 week of insult
  2. Bilateral CXR opacities not explained by other lung pathology
  3. Respiratory failure not explained by heart failure or volume overload
  4. Decreased PaO2 / FiO2 ratio, <300, on at least 5 cm H2O of pEEP
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6
Q

How can the severity of ARDS be graded?

A

PaO2 / FiO2 (P/F) ratio:
<100: Severe
<101-200: Moderate
<201-300: Mild

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7
Q

CXR finding in ARDS?

What else can cause a similar image?

A

Bilateral lung opacities (pulmonary edema)

Can also be seen in CHF and volume overload

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8
Q

What is a key intervention in ARDS?

A

PEEP, up to 15-20 cm H2O

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9
Q

O2 saturation goal in ARDS

A

88-95% saturation (PaO2 55-80)

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10
Q

In a ventilated patient with volume control, what can cause an elevated peak inspiratory pressure (PIP)?

How can you tell the difference?

A

Increased airway resistance or decreased pulmonary compliance

Check with inspiratory hold:

  • The “Plateau Pressure” here reflects only pulmonary compliance.
  • The difference between this and PIP (the “Delta Pressure” reflects airway resistance.
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11
Q

Extrapulmonary involvement of sarcoidosis (5)

A
  1. Skin lesions (e.g. erythema nodosum)
  2. Uveitis
  3. Arthralgias
  4. Hypercalcemia
  5. Heart disease
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12
Q

Sarcoidosis on CXR

A

Bilateral hilar lymphadenopathy, reticular infiltrates, +/- scattered opacities

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13
Q

What is Lofgren syndrome?

A

Acute sarcoidosis with erythema nodosum and arthralgias

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14
Q

Manifestations of sarcoidosis heart disease

A
  1. Restrictive cardiomyopathy early, dilated cardiomyopathy late
  2. AV block and other conduction defects
  3. Arrhythmias and sudden cardiac death

(Seen in 5% of sarcoidosis patients, due to noncaseating granuloma in the heart)

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15
Q

Mechanism of hypercalcemia in sarcoidosis?

Treatment?

A

Mechanism: 1-alpha hydroxylse in the granuloma activates viatmin D (converts 25-vitamin D to 1,25-vitamin D)

Treatment: Glucocorticoids (reduce activation by the granuloma)

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16
Q

Treatment for sarcoidosis

A

Monitor if asymptomatic.

Glucocorticoids if symptomatic

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17
Q

Hypoxia with a petechial rash and neurological signs after trauma

A

Fat embolism from long-bone fracture to lungs

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18
Q

Mechanism of secondary spontaneous pneumothorax

A

Rupture of alveolar blebs due to chronic destruction of alveolar sacks

(seen in chronic lung disease like COPD and CF)

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19
Q

Diagnostic test for aspiration pneumonitis?

Treatment?

A

Diagnosis: upright CXR
Treatment: supportive care only

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20
Q

Pattern of PFTs and DLCO in interstitial lung disease

A

Restrictive pattern and decreased DLCO (restrictive pattern with normal DLCO seen with chest wall deformities)

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21
Q

Time course of aspiration pneumonitis and pneumonia

A

Pneumonitis: cough +/- hypoxemia within hours of aspiration of gastric contents

Pneumonia: symptoms several days after aspiration of oropharyngeal secretions

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22
Q

Hypersensitivity pneumonitis:

Presentation?

CXR findings?

A

Presentation: cough, dyspnea, fever, malaise (so it is pneumonia-like) in association with trigger (bird droppings, molds in farming)

CXR: Ground glass / hazy opacities

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23
Q

Secondary polycythemia in an obese man - likely diagnosis?

A

Obstructive sleep apnea

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24
Q

Three most common causes of chronic cough?

An initial test/trial in each?

A
  1. Postnasal drip (upper-airway cough syndrome) (try empiric antihistamine)
  2. Asthma (PFTs)
  3. GERD (try empiric PPI)
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25
Mechanism of chronic nonproductive cough in ACEIs
Decreased metabolism of kinins and substance P
26
Most effective treatment for allergic rhinitis
Glucocorticoid nasal sprays (fluticasone, mometasone)
27
Oropharyngeal physical exam finding that may be seen in allergic rhinitis?
Pharyngeal cobblestoning (streaks of lymphoid tissue)
28
Appearance of flow-volume loop in obstructive lung disease
Scooped-out pattern during exhalation (low flow in later, effort-independent phase)
29
Pattern of PFTs and DLCO in asthma
PFTs: Obstruction (FEV1/FVC < 0.7) that is reversible, >12% increase in FEV1 w/ bronchodilator DLCO: normal
30
Pattern of PFTs and DLCO in COPD
PFTs: Obstruction (FEV1/FVC < 0.7) that is irreversible or only partially reversible DLCO: often reduced but may be normal in early disease
31
Patient with severe asthma attack has normal PaCO2. Next step?
Intubation (impending respiratory failure)
32
Pulsus paradoxus with a normal heart, pericardial space, and pericardium
Severe asthma and COPD (when generating highly negative (up to 40 mm Hg) intrathoracic pressures during inspiration, so blood pools in lungs)
33
Asthma, chronic rhinosinusitis with nasal polyps, and bronchospasm after receiving a medication
Aspirin-induced respiratory disease (AERD) (can be seen with any NSAID)
34
Sensory complication of aspirin-induced respiratory disease
Anosmia (due to nasal polyps from chronic rhinosinusitis)
35
When is long-term suppelemntal oxygen started in COPD?
SaO2 < 89% (PaO2 55 mm Hg) ORA in patients with cor pulmonale, right heart failure, or hematocrit >55% SaO2 <88% (PaO2 <59 mm Hg) ORA in anyone else
36
Mechanisms of oxygen-induced CO2 retention in COPD
1. Decreased respiratory drive 2. V/Q mismatch (normally poorly perfused areas get more perfused due to more O2) 3. Haldane effect (CO2 binds better to deoxygenated blood)
37
Some common causes of digital clubbing What is something noteable that does NOT cause digital clubbing?
Causes: Lung cancer, chronic lung infection, interstitial pulmonary fibrosis, endocarditis, cyanotic congenital heart disease COPD alone does NOT cause digital clubbing (so think cancer if you see this)
38
Theophylline toxicity
1. CNS stimulation (headache, insomnia, seizures) 2. Arrhythmia 3. GI effects (N/V) (Can be induced by illness or inhibition of cytochromes)
39
Treatment for all acute COPD exacerbations? Moderate-to-severe? How is this defined?
1. Oxygen (to SpO2 of 88-92%) 2. Inhaled bronchodilators 3. Systemic glucocorticoids Moderate-to-severe: add antibiotics Moderate-to-severe: at least 2 cardinal symptoms (increased dyspnea, increased sputum volume, incerased sputum purulence) or need for NPPV or intubation
40
What can be done to delay or avoid intubation in a COPD exacerbation?
Non-invasive positive pressure ventilation (NPPV)
41
Cardinal symptoms of COPD exacerbation
1. Increased dyspnea 2. Increased sputum volume 3. Increased sputum purulence
42
Cause of panacinar emphysema in a young person? Manifestation outside the lung
Alpha-1-antitrypsin (AAT) deficiency Also leads to liver disease (e.g. hepatitis, cirrhosis, HCC)
43
CT finding that is pathognomonic for PE
Opacified wedge-shaped infarct
44
Rare but specific signs of PE on CXR (3)
Westermark's sign: area of hyperlucency distal to a visible pulmonary vessel Hampton's hump: peripheral wedge of lung opacity due to infarct Fleischner sign: enlarged pulmonary artery
45
Rare but classic sign of PE on EKG
S1Q3T3: - Deep S wave in I - Q wave in III - Inverted T wave in III
46
Treatment for PE with hemodynamic instability
Thrombolytics, if they are not contraindicated (if fails or CI, then go to embolectomy)
47
Poor prognostic factors on EKG after PE
Atrial fibrillation, RBBB
48
When do you empirically anticoatulate prior to imaging in PE?
1. PE likely by Wells criteria 2. Moderate-to-severe respiratory distress 3. No reltive CI to coagulation
49
Modified Wells criteria for PE
``` 3 points: - Clinical signs of DVT - Alternate diagnosis less likely 1.5 points: - Previous DVT or PE - Tachycardia (>100) - Recent surgery/immobilization 1 point: - Hemoptysis - Cancer ``` PE unlikely if 4 or less, likely if over 4 (4.5 or more) (Original criteria was 2 or less was low, 2-6 was moderate, and over 6 was high)
50
Diagnostic test if DVT is likely but no signs of PE
LE Ultrasound | Do NOT go looking for PE with CTA or V/Q scan unless they have signs of PE
51
Follow up of first unprovoked venous thromboembolism
CXR and age-appropriate cancer screening If other signs of malignancy (e.g. weight loss, pain), then perform more extensive cancer screening (e.g. CT chest/abdomen/pelvis) (Generally only test for inherited thrombophilias with suggestive history - family history, age unde 45, recurrence, multiple/unusual sites)
52
Options for initial monotherapy of PE or DVT
Direct Factor Xa inhibitors: Rivoroxaban, apixaban | Warfarin and dabigatran require initial treatment with heparin as well
53
Who should get an IVC filter?
Proximal DVT (popliteal on up) without severe swelling or limb-threatening ischemia and with CI to anticoagulation or in whom appropriate anticoagulation has failed.
54
Who should receive antivirals for influenza?
1. High risk for complications (65 or older, chronic illness, pregnancy) 2. Anyone who presents within 48 hours of symptom onset
55
Treatment for acute bronchitis
Symptomatic treatment
56
Most common causes of post-influenza pneumonia
Pneumococcus and Staph aureus
57
Rapidly progressing, necrotizing post-influenza pneumonia in a young person
Staph aureus
58
Pneumococcal vaccine recommendations
Over 65: both PCV13 and PPSV23 Risk for encapuslated organisms (asplenic, immunocompromise): both PCV13 and PPSV23 Other chronic disease under 65: PPSV23 alone
59
First-line treatment for community acquired pneumonia
No recent antibiotics or major comorbidities: macrolide (e.g. azithromycin) or doxycycline With recent antibiotics or comorbidities: add a beta-lactam (e.g. ceftriaxone), or just use a respiratory fluoroquinolone (e.g. levofloxacin or moxifloxacin)
60
Tool for predicting community-acquired pneumonia severity and management:
``` CURB-65: one point for each of Confusion Urea >20 Respirations >30 BP low (systolic <90, diastolic <60) 65 years or older ``` 0: low mortality, outpatient 1-2: Intermediate mortality, likely admission 3 or more: high mortality, urgent admission
61
Treatment for empyema?
Drainage and 2-4 weeks antibiotics
62
Fever, productive cough, large pleural effusion, and pleuritic chest pain in a patient with pneumonia
Empyema
63
Types of effusion associated with pneumonia? Criteria for each? Treatment for each?
``` Uncomplicated parapneumonic effusion: Few WBCs (<50,000), relatively normal pH (>7.2), glucose may be normal or low ``` ``` Complicated parapneumonic effusion: Many WBCs (>50,000), acidic pH (<7.2), low glucose (<60) ``` Empyema: frank pus in the pleural space, lab values like complicated Treatment: uncomplicated requires antibiotics only. Complicated and empyema require drainage and antibiotics.
64
Presentation of bronchiectasis Diagnostic test(s)? Findings?
Chronic cough with large amounts of mucopurulent speeding (+/- hemoptysis, dyspnea, congestion, fatigue, weight loss). Test: high-resolution CT, shows bronchial dilation and bronchial wall thickening
65
Treatment options for pneumonia when aspiration suspected
- Amp/sulbactam (IV if inpatient) or amoxicillin/clavulanate (PO if outpatient) - Clindamycin - Metronidazole + amoxicillin or penicillin
66
Most common organisms for ventilator-associated pnuemonia
Gram-negative rods (Pseudomonis, E. coli, Klebsiella pneumonia) or gram positive cocci (Strep and Staph aureus)
67
Causes of pneumonia with high fever and relative bradycardia
Legionella and Chlamydia (both intracellular gram negatives)
68
Common cause of pneumonia with high fever and diarrhea? Diagnostic test?
Bug: Legionella Test: Urine Legionella antigen
69
Pneumonia associated with hyponatremia
Legionella (damage to JG cells that secrete renin)
70
Treatment for Legionella
Fluoroquinolones (levofloxacin) or macrolides (azithromycin)
71
TB patient on RIPE has mild AST/ALT elevation. Next step?
Continue (due to isoniazid, will likely resolve) | If frank hepatitis occurs, then must stop isoniazid and switch to second-line medications
72
Triad of digital clubbing, arthralgias, and ossifying periostitis
Hypertrophic pulmonary osteoarthropathy (HPOA): excess proliferation of skin and bone associated with lung disease such as lung cancer, mesothelioma, TB, bronchiectasis, emphysema
73
Definition of single pulmonary nodule
1. Single rounded opacity 2. <3 cm 3. Completely surrounding by lung parencyhma 4. No associated lymphadenopathy
74
Management of SPN with benign features on CT? Suspicious for malignancy? Intermediate?
Benign serial CT Suspicious for malignancy: surgical excision Intermediate - go to size: If 8 mm or larger: biopsy or FDG-PET If 4 mm or less and low cancer risk: no follow-up 5-7 mm or 4 or less with intermediate risk: serial CT
75
Specific symptoms of Pancoast tumors
1. Referred shoulder pain 2. Horner symptom (sympathetic chain invasion) 3. Brachial plexus invasion leading to arm motor and sensory symptoms 4. Supraclavicular lymph node
76
Paraneoplastic syndrome(s) associated with lung SCC
Hypercalcemia (PTHrp)
77
Paraneoplastic syndrome(s) associated with small cell lung cancer
1. Cushing syndrome (ACTH production) 2. SIADH 3. Lam`bert-Eaton myasthenic syndrome (antibodies against NMJ Ca2+ channels)
78
Lung cancer most associated with necrotizing and cavitation on CT
SCC
79
Location of different types of lung cancer
SCC and SCLC: central | Adenocarcinoma and large cell: peripheral
80
Hallmark of asbestosis on CXR
Pleural plaques | Bibasilar reticulonodular infiltrates, honeycombing, and bilateral pleural thickening may be seen
81
Recurrent pneumonia in the same area of lung: diagnostic test?
CT to look for obstructing mass

UWorld Medicine HY (7 decks)

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