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Step 2 CK > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Etiologies of obstructive pulmonary disease

“ABCO”

A

Asthma
Bronchiectasis
COPD/CF
Obstruction (tracheal/bronchial)

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2
Q

FEV1/FVC ratio of ____ suggests obstruction

A

FEV1/FVC ratio < 70%

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3
Q

FEV1/FVC ratio ____ suggests restriction

A

> 70%

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4
Q

Other conditions that can cause wheezing other than asthma?

A

COPD, foreign body. anything that causes airway constriction

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5
Q

Asthma should be suspected in kids with multiple episodes of ______

A

croup and URIs associated with dyspnea

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6
Q

Name some common triggers for asthma

A

allergens, URIs, cold air, exercise, drugs, stress

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7
Q

Samter’s triad

A

Asthma, aspirin sensitivity, nasal polyps

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8
Q

late signs of asthma

A

no wheezing. no breath sounds. cyanosis. decreased O2 sat.

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9
Q

When PFTs are normal but asthma is still suspected what challenge test can be helpful?

A

Methacholine

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10
Q

expected ABG for acute asthma exacerbation early on?

A

respiratory alkalosis

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11
Q

If a patient with asthma has anormalizing PCO2 and a respiratory acidosis- what might this mean?

A

Impending respiratory failure. Patient might not be able to work as hard to blow off PCO2

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12
Q

CXR for asthma

A

normal appearance to hyperinflation and flattening of diaphragm

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13
Q

consider intubation for asthma when PCO2 > ___ or PO2 < ____

A

50, 50 mm Hg

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14
Q

Cromolyn is useful for?

A

exercise induced bronchospasm and only as prophylaxis not in acute attacks

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15
Q

Mild intermittent asthma symptoms occur?

A

< 2 days/week

< 2 night/month

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16
Q

treat mild intermittent asthma with?

A

PRN short acting B-dilator

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17
Q

FEV in mild intermittent asthma is?

A

> 80%

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18
Q

Mild persistent asthma symptoms?

A

> 2 X/week but < 1/day

> 2X/month

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19
Q

Meds for mild persistent asthma

A

daily low dose corticosteroid

PRN albuterol

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20
Q

Mod persistent asthma symptoms

A

daily

> 1 night/week

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21
Q

Meds for mod persistent asthma

A

low-medium inhaled corticosteroid and long acting inhaled B agonist (salmeterol)
PRN albuterol

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22
Q

Severe persistent asthma symptoms

A

continual

frequent

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23
Q

Meds for severe persistent asthma

A

high dose inhaled CS and long acting inhaled B-agonist
Possible PO CS
PRN albuterol

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24
Q

Bronchiectasis

A

caused by recurrent infection and inflammation in bronchi/bronchioles that lead to fibrosis, remodeling, permanent dilation of bronchi

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25
Q

CXR for bronchiectasis shows

A

increased bronchovas markings and “tram lines”

dilated airways and ballooned cysts

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26
Q

Presentation of bronchiectasis

A

chronic productive cough of yellow/green sputum, dyspnea, hemoptysis, hallitosis

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27
Q

Treatment for bronchiectasis:
Meds:
Lifestyle:
Surgery:

A

Meds: antibiotics for bacterial infections. inhaled CS
Lifestyle: cough control, postural drainage, chest PT
Surgery: lobectomy for localized or lung transplant for severe

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28
Q

Diagnosis of chronic bronchitis

A

productive cough for >3 months per year for 2 consecutive years

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29
Q

Emphysema diagnosis

A

destruction and dilation of structures distal to terminal bronchioles (pathologic diagnosis)

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30
Q

Smoking causes _____ destruction while A1AT causes _____ destruction

A

centrilobular ; panlobular

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31
Q

what are the only two interventions proven to improve survival in COPD patients?

A

Smoking cessation and O2 therapy

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32
Q

Treatments for COPD

“COPD”

A

C: corticosteroid
O: O2
P: prevention (smoking cessation and pneumo and influenza vaccines)
D: dilators (B-ag, anticholinergics)

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33
Q

Parenchymal bullae and subpleural blebs are pathognomonic for?

A

emphysema

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34
Q

Etiologies of restrictive lung disease

A

Alveolar: edema, hemorrhage, pus
Interstitial: ILD
Inflammatory: sarcoid, cryptogenic organizing pneumonia
Idiopathic pulmonary fibrosis
Neuromuscular: Myesthenia gravis, phrenic nerve palsy, myopathy
Thoracic wall: kyphoscoliosis, obesity, ascites, pregnancy, ankylosing spondylitis

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35
Q

Interstitial lung disease

A

heterogenous group of disorders characterized by inflammation and/or fibrosis of interstitium

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36
Q

What are the exposure related types of interstitial lung disease?

A

coal workers pneumoconiosis, asbestosis, silicosis, berylliosis, hypersensitivity pneumonitis, radiation

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37
Q

Systemic disease or connective tissue disease associated interstitial lung disease?

A

polymyositis/dermatomyositis, sarcoidosis, amyloidosis, vasculitis, dermatomyositis, CREST

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38
Q

What might you see on CT for patients with ILD?

A

Honey-combing (reticular, nodular, ground glass pattern)

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39
Q

Presentation of Interstitial lung disease

A

shallow, rapid breathing, dyspnea on exertion, chronic non-productive cough. cyanosis, inspiratory squeeks or velcro-like crackles, clubbing, right heart failure

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40
Q

List medications or interventions that can cause or contribute to interstitial lung disease?

A

Amiodoarone, busulfan, nitrofurantoin, bleomycin, radiation, long term high O2 concentration

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41
Q

PFTs would show

A

normal FEV/FVC. Low TLC, low FVC, low diffusing capacity

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42
Q

Surgical biopsy is the definitive test used to confirm?

A

IPF

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43
Q

In late stages of IPF, the only treatment may be?

A

lung transplantation

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44
Q

Lofgren syndrome

A

type of sarcoidosis with a triad: arthritis, erythema nodosum, bilateral hilar adenopathy

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45
Q

Systemic sarcoidosis is characterized by what on histology

A

non-caseating granulomas

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46
Q

Sarcoid can present as

A

fever, cough, malaise, weight loss, dyspnea, arthritis

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47
Q 
Diagnosis of sarcoid
CXR/CT:
Biopsy: 
PFTs: 
Other findings:
A

CXR/CT: lymphadenopathy and nodules
Biopsy: definitive test **- noncaseating granuloma
PFTs: restrictive or obstructive with decreased diffusion capacity
Other: elevated serum ACE levels, hypercalcemia, hypercalciuria, increased alk phos

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48
Q

Clinical features of Sarcoidosis

“GRUELING”

A 
G: granuloma
aRthritis
Uveitis
Erythema nodosum
Lymphadenopathy (hilar)
Interstitial fibrosis
Negative TB
Gammaglobulinemia
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49
Q

Treatment for sarcoid?

A

systemic corticosteroids for deteriorating resp function, constitutional symptoms, hypercalcemia, extrathoracic organ involvement

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50
Q

Hypersensitivity Penumonitis

A

alveolar thickening and noncaseating granuloma caused by environmental exposure to (mold, hot tub, down feathers)

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51
Q

Acute presentation of hypersensitivity pneumonitis?

A

dyspnea, fever, malaise, shivers, cough starting 4-6 hours after exposure

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52
Q

Upper lobe fibrosis is a common feature in?

A

chronic hypersensitivity pneumonitis

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53
Q

Name the common pneumoconiosis

A

asbestosis, berylliosis, silicosis, coal miners

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54
Q

history, imaging finding, complications: asbestosis

A

hx: manufacture tile, brakes, insulation, construction, demolition, shipbuilding (15-20 years after exposure)
Imaging: linear opacities** at lung bases and interstitial fibrosis. calcified pleural plaques
Complications: increased mesothelioma risk (rare) and lung cancer. risk of lung cancer is higher in smokers

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55
Q

history, imaging finding, complications: coal miners

A

hx: coal mine
Imagine: small nodular (<1cm) opacities in upper lung lobe
Complication: progressive massive fibrosis

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56
Q

history, imaging finding, complications: silicosis

A

hx: work in mines or quarries or with glass, pottery, silica
Imaging: small (<1cm) nodular opacities in upper lung zones: eggshell calcifications!
Complication: risk of TB, need annual TB skin test. Progressive massive fibrosis

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57
Q

history, imaging finding, complications: berylliosis

A

hx: high tech fields (space, nuclear, electronic plants)
Imaging: diffuse infiltrates, hilar adenopathy
Comp: chronic corticosteroid treatment

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58
Q

Calcified pleural plaques in asbestosis are indicative of?

A

benign pleural disease

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59
Q

Name the eosinophilic pulmonary syndromes

A

Allergic bronchopulmonary aspergillosis
Loffler syndrome
Acute eosinophilic pneumonia
Drug Induced (NSAID, nitrofurantoin, sulfonamides)

60
Q

Presentation of eosinophilic pulm syndromes

A

dyspnea, cough, possible blood tinged sputum, and/or fever

61
Q

Diagnosis of pulm syndromes?

A

CBC: peripheral eosinophilia
CXR: pulm infiltrates

62
Q

Name the causes of hypoxemia (low PO2)

A 
V/Q mismatch
Right to left SHUNT
Hypoventilation
Low inspired O2 content
Diffusion impairment
63
Q

When will the A-a gradient be normal in cases of hypoxia?

A

If the problem is hypoventilation or low inspired O2, the A-a gradient will be normal

64
Q

If the problem is V/Q mismatch or shunting, the A-a gradient will?

A

Increase

65
Q

Initial test for diagnosis of hypoxia?

A

ABGs. Calculate the A-a gradient

66
Q

Further diagnosis/work up for hypoxia?

A

pulse ox monitoring.

CXR: evaluate for infiltrates, ARDS.

67
Q

In hypercapnic patients ______ ventilation to ______ CO2 exchange.

A

Increase, Increase

68
Q

Mechanical ventilator parameters that affect Oxygenation?

A

FiO2 and PEEP

69
Q

Mechanical ventilator parameters that effect ventilation?

A

respiratory rate, tidal volume

70
Q

Summarize approach for working up/managing hypoxic patients when A-a is normal.

A

If A-a gradient is normal, is PaCO2 increased? If not, hypoxia likely due to decreased FiO2 (high altitude). If PaCO2 is increased, hypoxia likely caused by hypoventilation. (decreased resp drive, neuromuscular disease)

71
Q

Summarize approach for working up/managing hypoxic patients when A-a is NOT normal.

A

You ask: Is PaO2 correctable with O2? If no, this is due to SHUNT (intracardiac shunt, vascular shunt in lungs). If PaO2 correctable with O2 -> V/Q mismatch (asthma, COPD, ILD, atelectasis, pneumonia, pulmonary edema, pulm vasc disease)

72
Q

Common triggers for acute respiratory distress syndrome

A

sepsis, pneumonia, aspiration, multiple blood transfusions, inhaled/ingested toxins, trauma

73
Q

What is ARDs?

A

acute respiratory failure with refractory hypoxemia, decrease lung compliance and pulmonary edema (PaCO2/FiO2 ratio < 300)

74
Q

Pathogenesis of ARDs is thought to be dependent on?

A

endothelial injury

75
Q

CXR for ARDs?

A

Diffuse alveolar filling, diffuse opacity

76
Q

Criteria for ARDs diagnosis according to Berlin definition?

A
  1. acute onset < 1 week
  2. A PaO2/FiO2 < 300 with PEEP/CPAP > 5 H2O
  3. Bilateral pulm infiltrates on CXR
  4. Resp failure cannot be completely explained by heart failure
77
Q

Treatment for ARDS

A
  1. treat underlying disease
  2. maintain adequate perfusion to prevent end organ damage
  3. mechanical ventilation with low tidal volumes (4-6cc/kg of ideal body weight) to reduce lung injury
  4. Use PEEP to recruit collapsed alveoli. Titrate PEEP and FiO2 to achieve best Oxygenation
  5. goal oxygenation PaO2 > 55 mm Hg or SaO2 > 88%
78
Q

What is oxygenation foal for ARDs patients?

A

PaO2 > 55 mm Hg or SaO2 > 88 %

79
Q

What is normal pulmonary arterial pressure?

A

15 mm Hg

80
Q

Mean pulmonary artery pressure greater than ____ defines pulm htn

A

25

81
Q

What criteria for extubation from mechanical ventilation is the most predictive of success?

A

Frequency/tidal volume ratio < 105

82
Q

Causes of pulmonary htn include?

A

left heart failure, mitral valve disease, increased pulm vein resistance, hypoxic vasoconstriction 2ndary to chronic lung disease, chronic thromboembolic disease, idiopathic

83
Q

Exam findings for patients with pulm htn

A

loud, palpable S2, often split, flow murmur, S4 or parasternal heave.

84
Q

Pulm htn findings on chest c-xray

A
  1. enlargement of pulm arteries
  2. ECG shows RVH
  3. Echo (initial test) and right heart cath (definitive test) show signs of right ventricle overload
85
Q

Pulm embolism presents as

A

sudden onset or subacute dyspnea, pleuritic chest pain, low-grade fever, cough, tachypnea, tachycardia, hemoptysis (rare)

86
Q

Dyspnea, tachycardia and a normal CXR should raise suspicion for?

A

PE

87
Q

Initial test if low suspicion of PE?

A

D-dimer

88
Q

Is D-dimer sensitive or specific?

A

sensitive. It’s most useful to “rule out”

89
Q

What is the definitive test for diagnosing PE?

A

CT pulmonary angiogram with IV contrast/spiral CT

90
Q

Hampton hump

A

a wedge shaped infarct that may be seen on CXR and is indicative of PE

91
Q

Westermark sign

A

oligemia/collapse of vessels that may be seen on CXR distal to a PE

92
Q

ECG findings for PE

A

most common is sinus tachycardia

Classic S1Q3T3 is rate- signifies acute right heart strain

93
Q

When should you use a V/Q scan to help with PE diagnosis?

A

If contraindications to CT scanning. (kidney disease, pregnancy)

94
Q

Treatment for PE Acute and Chronic

A

Acute: Heparin bolus and then Heparin infusion or LMW heparin subcu

Chronic: Anticoag for 3-6 months (INR 2-3)

95
Q

When should an IVC filter be placed?

A

In patients with lower extremity DVT if anticoagulation is contraindicated or if patients experience recurrent emboli while anticoagulated

96
Q

What is the most effective DVT prophylaxis?

A

early ambulation

97
Q

Diagnose lung nodule based on hx clues

  1. recent immigrant
  2. southwestern US
  3. Ohio River Valley
A
  1. TB
  2. Coccidiodomycosis
  3. Histoplasmosis
98
Q

Divide lung cancers into 2 broad groups

A

small cell lung cancer

non-small cell

99
Q

what are the most common types of NSCLC

A

adenocarcinoma, squamous cell carcinoma, large cell carcinoma

100
Q

What type of lung cancer is most likely to metastasize at an early stage?

A

small cell lung cancers

101
Q

What lung cancers are found centrally?

A

Squamous cells and small cells

102
Q 
Characteristics of benign lung nodules: 
age:
smoke:
change: 
calcification: 
margin: 
size:
A 
age: < 35
nonsmoker
no change from old CXRs
central, uniform, popcorn calcification
smooth margin
< 2 cm
103
Q 
Characteristics of malignant lung nodules: 
age:
smoke:
change: 
calcification: 
margin: 
size:
A 
Age 45-50
smoker
new or enlarging lesions
absent/irregular calcification
irregular margin
Size > 2
104
Q

Location, characteristics, histology: small cell (oat cell) carcinoma

A

L: central
characteristics: undifferentiated-> very aggressive
may produce ACTH (cushing syndrome), SIADH, or antibodies against presynaptic Ca2+ channels (Lambert-Eaton syndrome) or neurons (paraneoplastic myelitis/encephalitis). Amplification of myc onc genes common.

Histology: neuroendocrine Kulchitsky cells - small dark blue cells (chromogranin A (+))

105
Q

Location, characteristics, histology: Adenocarcinoma

A

L: peripheral
Character: most common lung cancer in non-smokers and overall
Histology: glandular, stains mucin (+)

106
Q

Location, characteristics, histology: squamous cell carcinoma

A

L: central
Characteristic: hilar mass arising from bronchus. Produces PTH -> hyperCalcemia
Histology: Keratin pearls and intercellular bridges

107
Q

Location, characteristics, histology: Large cell carcinoma

A

L: peripheral
Characteristic: anaplastic undifferentiated tumor, poor prognosis, less responsive to chemo, remove surgically
Histology: pleomorphic giant cells. can secrete B-hCG

108
Q

Location, characteristics, histology: Bronchial carcinoid tumor

A

Character: excellent prognosis. mets rare. symptoms due to mass effect. Carcinoid syndrome (5-HT secretion -> flushing, diarrhea, wheezing)
Histology: nets of neuroendocrine cells. chromogranin A +

109
Q

Is small cell carcinoma operable?

A

NO- treat with chemo

110
Q

Kulchitsky cells

A

small dark blue neuroendocrine cells of small cell carcinoma. They are positive for chromogranin A

111
Q

Hypertrophic osteoarthropathy

A

clubbing

112
Q

which type of lung cancer is associated with clubbing

A

adenocarcinoma

113
Q

Bronchioalveolar subtype (great prognosis) of adenocarcinoma will show what on CXR?

A

Hazy infiltrates similar to pneumonia

114
Q

Histology for bronchioalveolar subtype of adenocarcinoma

A

grows along alveolar septa-> apparents thickening of alveolar walls

115
Q

Which type of cancer is NOT associated with smoking?

A

bronchoalveolar subtype of adenocarcinoma

116
Q

Lung cancer mets are often found in “LABBs”

A

Liver
Adrenals
Brain
Bones

117
Q

What type of lung cancer is associated with gynecomastia?

A

Large cell

118
Q

ACTH, SIADH ass lung cancer?

A

small cell

119
Q

Hypercalcemia, PTH ass lung cancer?

A

squamous cell

120
Q

Lung cancers associated with dermatomyositis?

A

ALL

121
Q

Lung cancer associated with peripheral neuropathy, subacute cerebellar degeneration, lambert-eaton syndrome?

A

small cell

122
Q

Lung cancer associated with migratory thrombophlebitis, nonbacterial verrucous endocarditis?

A

adenocarcinoma

123
Q

lung cancers associated with anemia, DIC, eosinophilia, thrombocytopenia, acanthosis nigricans?

A

ALL

124
Q

Lung cancer assocaited with hypercoagulability

A

adenocarcinoma

125
Q

Horner syndrome

A

miosis, ptosis, anhidrosis

126
Q

Common cause of horner syndrome?

A

Pancoast tumor at apex of lung

127
Q

SVC syndrome

A

obstruction of SVC with supraclavicular venous engorement and facial swelling

128
Q

hoarseness as presenting symptom in lung cancer

A

secondary to recurrent laryngeal nerve involvement

129
Q

Diagnosis of lung cancer

A

CXR or CT (initial test)
Fine needle aspiration (CT guided) for peripheral lesions

Bronchoscopu (biopsy or brushing) for central lesions

130
Q

Pleural effusion

A

abnormal accumulation of fluid in pleural space

131
Q

How do you classify pleural effusions?

A

Transudative or Exudative

132
Q

Transudative pleural effusion:

A

2ndary to elevated PCWP or decreased oncotic pressure

133
Q

Exudative

A

2ndary to increase pleural vasc permeability

134
Q

Causes of transudative pleural effusion

A

CHF, Cirrhosis, Nephrotic Syndrome

135
Q

Cause of exudative pleural effusion

A

Pneumonia, TB, Malignancy, PE, Collagen vascular disease (RA, SLE), Pancreatitis, Trauma

136
Q

Diagnosis of pleural effusion

A

Initial test- CXR shows costophrenic angle blunting. Lateral decubitus view to assess loculation

137
Q

When is thoracentesis indicated?

A

for new effusions > 1 cm in decubitus view except when there are bilateral effusions and clinical evidence of CHF.

138
Q

Lights criteria

A

Pleural protein/serum protein > .5
Pleural LDH/serum LDH > .6
Pleural fluid LDH more than 2/3 upper limit of normal

139
Q

How can you classify an effusion as an exudate?

A

If it meets any of Light’s criteria

140
Q

Complicated parapneumonic effusions and empyemas require _______ and _____ for treatment

A

antibiotics and chest tube drainage

141
Q

Presentation of pneumothorax

P-THORAX

A 
Pleuritic chest pain
Tracheal deviation
Hyperresonance
Onset sudden
Reduced breath sounds and dyspnea
Absent fremitus (asymmetric chest wall)
X-ray shows collapse
142
Q

Treatment of tension pneumothorax?

A

Needle decompression (2nd intercostal space midclavicular line) first and then chest tube placement

143
Q

Diagnosis of tension pneumothorax should be made?

A

Clinically and followed by immediate treatment

144
Q

Treatment for small pneumothoraces?

A

Supplemental O2 is helpful. most will resorb spontaneously

145
Q

Large, symptomatic pneumothoraces require?

A

chest tube placement

Step 2 CK (26 decks)

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