Pulmonary Flashcards
1
Q
What are the advantages of MDCT?
A
The advantages of MDCT are: 1) large sections can be scanned in a single breath, and 2) images are collected precisely when flow of contrast is in the system of interest.
2
Q
What conditions are diagnosed by high resolution CT scan?
A
HRCT is indicated to diagnose interstitial lung diseases, emphysema from alpha-1-antitrypsin deficiency, bronchiectasis, and lymphangitic spread of cancer.
3
Q
In which diseases do you see a reduced DLCO?
A
Reduced DLCO is seen in emphysema, ILD, pulmonary vascular diseases, and anemia.
4
Q
Which diagnosis comes to mind in a hyperventilating patient with a normal A-a gradient?
A
A hyperventilating patient with normal A-a gradient is likely suffering from anxiety.
5
Q
What is a simple formula for calculating the A-a gradient?
A
A-a gradient = 149-[PaO2 +(1.25 X PaCO2)] when breathing room air at sea level.
6
Q
Name 3 factors that, for a specific pO2, cause a decrease in hemoglobin O2 saturation?
A
Temperature, acidosis, and Phosphorus (2,3-DPG) all decrease O2 saturation for a given PaO2
7
Q
What does CO poisoning do to the oxyhemoglobin dissociation curve?
A
CO poisoning shifts the oxyhemoglobin dissociation curve to the left by preventing the O2 from binding to hemoglobin.
8
Q
What are the symptoms of methemoglobinemia? It’s treatment?
A
Methemoglobinemia presents with perioral and peripheral cyanosis (>25%), fatigue and dyspnea (35-40%), and coma/death (>60%).
9
Q
What is vital capacity? Which smaller lung volumes make it up?
A
Vital capacity is the volume you have available for breathing and comprised of the inspiratory reserve volume (IRV), tidal volume (TV), and expiratory reserve volume (ERV).
10
Q
Characterize the differences in the flow-volume loops for obstructive and restrictive airway diseases.
A
Restrictive flow-volume loops have a similar appearance to normal but with smaller volumes. In obstruction the loop has reduced flow and a concave appearance.
11
Q
When is the methacholine bronchoprovocation test performed?
A
Methacholine or other bronchoprovocation tests are done to see if a patient with normal spirometry has bronchial hyperreactivity.
12
Q
What is the DLCO in emphysema? In asthma? In ILD?
A
DLCO is reduced in emphysema and ILD but normal in asthma.
13
Q
What are the results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with intrathoracic restriction? In extrathoracic restriction?
A
In intrathoracic restriction the RV, VC, and TLC are reduced while FEV1 and FEV1/FVC are normal. In extrathoracic restriction VC and TLC are reduced but RV, FEV1, and FEV1/FVC are normal.
14
Q
What are the results of VC, TLC, FEV1, FEV1/FVC, and RV in patients with obstruction?
A
In obstructive lungs disease the FEV1, FEV1/FVC are reduced. The RV may be reduced or normal. The TLC and VC are increased.
15
Q
What is the difference in the DLCO in extrathoracic restriction vs. intrathoracic?
A
DLCO is normal in extrathoracic restriction and reduced in intrathoracic restriction.
16
Q
What skin finding is a predisposing factor for IgE-mediated asthma?
A
Eczema is a predisposing factor for asthma.
17
Q
What is the “asthma triad”?
A
The “asthma triad” is allergic asthma, aspirin sensitivity, and nasal polyposis.
18
Q
What comorbidities exacerbate asthma?
A
Asthma is exacerbated by GERD, allergic rhinitis, ABPA, OSA, stress, and smoking.
19
Q
In the management of asthma, the initial treatment is based on ______. After therapy is started, the focus is on _______.
A
The initial treatment of asthma is based on severity. After therapy is started, the focus is on asthma control and response to therapy.
20
Q
What spirometry findings are required to diagnose asthma?
A
To diagnose asthma one must find reduced FEV1 and FEV1/FVC ratio on spirometry.
21
Q
How do you diagnose exercise-induced bronchospasm?
A
Exercise-induced bronchospasm is diagnosed by >10% drop in FEV1 after graded exercise on a treadmill or stationary bike.
22
Q
Describe the relationship between symptom-based monitoring and the peak expiratory flow rate.
A
Peak expiratory flow is most useful in those with moderate-to-severe asthma and those who cannot reliably describe symptoms of exacerabation. In all other groups symptom-based monitoring is equally effective.
23
Q
What is the short-acting drug of choice for asthma exacerbations?
A
Albuterol is the short-acting bronchodilator of choice for asthma exacerbations.
24
Q
What is the preferred drug for chronic treatment of persistent asthma?
A
All patients with persistent asthma should be treated with inhaled corticosteroids.
25
An oral corticosteroid (OCS) is recommended if the peak flow is
An oral steroid is indicated if peak flow is <80% after 3 treatments with a SABA.
26
According to the expert panel guidelines, when is ipratropium used during inpatient treatment of an asthma exacerbation?
According to expert guidelines, ipratropium is indicated for the management of moderate-to-severe asthma exacerbations.
27
What are the signs and symptoms of theophylline toxicity? What is a therapeutic level?
Signs of theophylline toxicity include nausea, headache, tremulousness, and palpitations. The therapeutic range for theophylline is 5-15mcg/mL.
28
What is the preferred treatment for a new patient having asthma symptoms >2 days/week, but not daily, and not more than once a day?
The preferred treatment for a new patient with asthma symptoms >2 days/week but not daily and not more than once per day is a low dose inhaled steroid.
29
What is the preferred regimen for patients who are on medium-dose inhaled corticosteroids and still require albuterol daily?
The preferred regimen for patients who still require daily albuterol despite medium-dose inhaled steroids is the addition of a LABA.
30
What is the preferred treatment for patients with exercise-induced bronchospasm?
Albuterol used 15-30 minutes before exercise is the preferred treatment for EIB. If this occurs daily, an inhaled steroid should be added. Montelukast is also useful for >50% of patients with EIB.
31
For an acute exacerbation, what peak flow measurement requires intervention with medications?
In an acute exacerbation of asthma, a peak flow <80% is an indication to add medicine.
32
For an acute exacerbation, at what peak flow do you tell your patients to go to the ED?
If the peak flow is <50% the patient should go to the ED.
33
For patients being treated for asthma exacerbations in the ED, at what peak flow do you consider hospitalization?
If a patient continues to maintain peak flows 40-69% after treatment, they should be admitted.
34
Explain permissive hypercapnia.
Permissive hypercapnia is controlled hypoventilation through the use of smaller tidal volumes. This prevents development of auto-PEEP.
35
What ventilator settings are appropriate for a patient intubated for a severe exacerbation of asthma?
A patient intubated for severe asthma exacerbation should be ventilated with low rate, small tidal volume, and high inspiratory flow rate.
36
What is the specific definition of COPD?
COPD is diagnosed when patients have symptoms of dyspnea, cough, and sputum production with evidence of irreversible airflow obstruction.
37
In COPD, what are the symptoms of disease in the large airways? The small airways?
COPD of the large airways causes cough and mucus production presenting as chronic bronchitis. In the small airways COPD causes airflow obstruction with hyperinflation.
38
What is the specific definition of chronic bronchitis?
Chronic bronchitis is defined as cough with sputum production for at least 3 consecutive months within at least 2 consecutive years.
39
What is the significance of clubbing in a patient with COPD?
Clubbing should not be present in COPD alone. Its presence in a patient with COPD should prompt evaluation for other pathology including ILD or lung cancer.
40
What is a strong prognostic indicator in COPD?
FEV1 is a strong prognostic indicator in COPD.
41
A COPD patient with evidence of right heart failure has a resting PaO2 of 58mmHg. How many hours a day should he be on supplemental oxygen?
A COPD patient with evidence of right heart failure and PaO2 of 58mmHg should use supplemental oxygen 24 hours/day.
42
What are the benefits of pulmonary rehabilitation? Does it improve mortality?
It is unclear whether pulmonary rehab programs improve mortality. They do improve strength and endurance, symptoms, quality of life, and decreases hospitalizations.
43
Describe the emergent workup of a patient with an apparent COPD exacerbation.
The workup of a patient with a COPD exacerbation should include CXR, ECG, and ABG. Spirometry and peak flow should not be used to diagnose or assess the severity of a COPD exacerbation.
44
A 30 year old smoker presents with COPD and emphysematous bullae in the bases. What disease should you suspect?
Alpha-1-antitrypsin deficiency should be suspected in a young patient with COPD and emphysematous bullae at the bases.
45
What is the single environmental agent that worsens lung disease in all types of alpha-1-antitrypsin deficiency?
Smoking worsens lung disease in all types of A-1-AT deficiency.
46
What are the inhaled treatments for cystic fibrosis?
DNAse and inhaled hypertonic saline are two inhaled treatments for CF that aide airway flow and clearance. Inhaled aminoglycosides are commonly used to decrease airway colonization.
47
Name the common clinical features of all interstitial lung diseases.
The common clinical features of all ILDs include dyspnea, diffuse disease on CXR, restrictive PFT with a decreased DLCO and elevated A-a gradient.
48
What disease do you think of when a patient presents with recurrent pneumonia each time she cleans her birdcage?
“Bird fanciers lung” is caused by reaction to feathers or bird droppings.
49
Characterize the CXR abnormalities in patients with a history of significant asbestos exposure.
Asbestos exposure causes bilateral, mid-thoracic pleural thickening, plaques, and calcifications.
50
Smoking and asbestos increase the risk of what types of lung cancer?
Smoking has a synergistic effect with asbestos to increase the risk of squamous cell and adenocarcinoma of the lung (but not small cell and non-small cell).
51
What type of CT scan assists with the diagnosis of idiopathic pulmonary fibrosis (IPF)? What findings are seen in early IPF?
High resolution CT (HRCT) is used in IPF and demonstrates ground-glass opacities in ⅓ of patients with true fibrosis.
52
What is the typical presentation of a patient with IPF?
IPF typically presents with dyspnea, cough, dry midinspiratory (“Velcro”) crackles, and a diffuse interstitial process on CXR.
53
How do you evaluate patients with IPF?
The diagnostic workup of IPF includes HRCT, PFTs, ABG, and a functional assessment (6 minute walk test).
54
Characterize the differences in presentation between IPF and COPD.
IPF differs from COPD in that it presents with restrictive PFTs and often is associated with clubbing.
55
What finding in a pleural effusion can be helpful in distinguishing rheumatoid arthritis as an etiology?
The pleural effusion in RA is typically exudative and can have a uniquely very low glucose level.
56
In what pulmonary disease is pulmonary hypertension out of proportion to the amount of pulmonary disease? What causes this?
In scleroderma the pulmonary HTN is often out of proportion to the amount of pulmonary disease due to intimal proliferation of the pulmonary artery.
57
What are the indications for treatment of sarcoidosis with steroids?
75% of patients with sarcoid improve without treatment. Treatment with systemic steroids is indicated for persistent hypercalcemia and evidence of other organ involvement (eyes, heart, CNS, Lungs (severe symptoms), and skin),
58
What is the potential lung complication of lymphangioleiomyomatosis?
Pneumothorax can occur in lymphangioleiomyomatosis.
59
Which vasculitis is c-ANCA+ and anti-PR3+?
GPA (formerly Wegener’s) is associated with c-ANCA and anti-PR3.
60
Characterize the typical presentation of a patient with granulomatosis with polyangiitis.
GPA typically presents with some combination of upper respiratory tract and paranasal sinus involvement, granulomatous pulmonary vasculitis with large (sometimes cavitary) nodules, and with necrotizing glomerulonephritis.
61
An asthma patient with worsening symptoms and peripheral eosinophilia makes you think of which disease?
In an asthma patient with worsening symptoms and peripheral eosinophilia think eosinophilic granulomatosis with polyangiitis (EGPA).
62
EGPA is associated with what medications?
EGPA can be unmasked in the asthma patient on leukotriene modifiers who is weaning oral steroids.
63
Describe the differences in the presentations of Loffler syndrome, acute eosinophilic pneumonia, and chronic eosinophilic pneumonia.
Loffler syndrome is a self-limited pulmonary eosinophilia that is transient with minimal pulmonary symptoms. It may present with migratory peripheral infiltrates on CXR. Acute eosinophilic pneumonia is an acute, febrile pulmonary illness with hypoxemic respiratory failure resembling ARDS. Chronic eosinophilic pneumonia is a subacute illness with cough, wheeze, night sweats, and low-grade fever.
64
What is the workup of the uncontrolled asthmatic that you suspect has ABPA?
The workup of ABPA starts with skin test for Aspergillus. This is followed by IgE level and Aspergillus IgG and IgE serologies.
65
Which organisms cause chronic pneumonia in patients with pulmonary alveolar proteinosis?
Patients with alveolar proteinosis are predisposed to non-resolving pneumonias caused by Nocardia, mycobacteria, or endemic fungi.
66
Which autoimmune disease are associated with pulmonary hemorrhage? Which cardiopulmonary diseases?
Autoimmune diseases associated with pulmonary hemorrhage include Goodpasture syndrome, SLE, GPA, microscopic polyangiitis, IPH. Cardiopulmonary diseases associated with pulmonary hemorrhage include PE, pulmonary AVMs, aortic aneurysm, pulmonary hypertension, septic emboli, and mitral stenosis.
67
What common physical exam findings are seen in pulmonary hypertension?
Patients with pulmonary hypertension often present with loud P2, tricuspid regurgitation, and a RV heave.
68
What are the 1st tests you order in the workup of PH? What follow-up test is done if the 1st tests are suggestive?
The first line tests in the diagnosis of pulmonary hypertension are EKG and echocardiogram. If these are suggestive, a right heart cath is performed.
69
Which test of lung function, when low, indicates a poor prognosis in pulmonary hypertension?
Reduced DLCO may be the only PFT finding in pulmonary hypertension. A very low DLCO signifies a poor prognosis.
70
What is the usual cause of pulmonary embolism in hospitalized patients?
PEs in hospitalized patients are usually due to inadequate VTE prophylaxis.
71
Characterize the clinical findings seen with massive PE.
Massive PE is characterized by hypotension (SBP<90 for >15 minutes or requiring inotropic support), pulselessness, of persistent bradycardia.
72
What symptoms and physical exam findings are seen more with submassive PE?
Patients with submassive PE have normal BP but signs of RV dysfunction or myocardial necrosis (elevated troponins or BNP).
73
What is the 1st step in evaluating a patient with possible pulmonary embolism?
Assessing pre-test probability using a validated measure, like the Wells score, is the first step in evaluating a patient for possible PE
74
What happens to the A-a gradient in most patients with PE?
The A-a gradient is elevated in most patients with PE. However, this is not perfect because some patients have preexisting conditions that increase their A-a gradient at baseline and some patients are hyperventilating which can reduce the A-a gradient.
75
What is the imaging of choice to diagnose PE in the nonpregnant patient with normal renal function and no dye allergy?
The imaging study of choice for PE is CTA.
76
In a low clinical probability scenario, what does a normal V/Q scan imply with regard to the probability of PE?
When coupled with a low clinical probability, a normal V/Q essentially eliminates PE as a diagnosis.
77
In a patient with low clinical probability of venous thromboembolism, what is the significance of a negative D-dimer? A positive one?
A negative D-dimer in a low risk patient excludes DVT/PE as a diagnosis. The D-dimer has low specificity, so a positive test in a patient with low clinical probability suggests that more testing is needed.
78
Know perfectly the 4 items in “Putting it All Together - How to Diagnose PE.”
1. Use clinical prediction rules to determine pre-test probability of DVT/PE.
2. If low probability, a negative D-dimer excludes PE.
3. U/S legs of those with intermediate-to-high probability. If positive treat for PE.
4. In those with intermediate-to-high probability with negative U/S perform CTA or V/Q scan.
79
What effect does LMWH have on PTT? On factor 10a?
LMWH does not effect PTT. LMWH inactivates factor 10a.
80
Should PTT be monitored in patients on LMWH? How are factor 10a levels used?
PTT should not be monitored in patients on LMWH. Factor 10a levels can be used to monitor LMWH.
81
In which situations do you use LMWH to treat thromboembolism? Unfractionated heparin?
LMWH is usually preferred treatment (over UFH) in VTE but should be avoided in patients with impaired renal function.
82
What are the major complications with HIT type II? Describe the treatment.
HIT type II occurs 4-10 after treatment with heparin is initiated. It caused a >50% drop in platelets with associated thrombosis. Patients with HIT should be treated with lepirudin or argatroban. Lepirudin is contraindicated in chronic renal disease.
83
In which patients is warfarin absolutely contraindicated?
Warfarin is contraindicated in pregnant women.
84
When are thrombolytics used to treat PE?
Thrombolytics are used in massive PE causing hemodynamic instability.
85
What are the indications for a vena cava filter?
Vena cava filters are indicated in patients with recurrent VTE with adequate anticoagulation or in patients with recurring VTE when anticoagulation therapy is contraindicated.
86
What is the 1st choice for VTE prophylaxis in the hospitalized at-risk patient?
LMWH is the first choice for VTE prophylaxis in hospitalized patients. Pneumoatic compression device is indicated for patients at highest risk of bleeding. Stocking are no longer recommended as they can cause skin damage.
87
Name the causes of transudative pleural effusions.
The most common causes of transudative effusion are LV dysfunction, cirrhosis, and nephrotic syndrome.
88
What 3 conditions must be met for an effusion to be called a “transudate”?
All 3 conditions of Light’s criteria need to be negative to consider an effusion transudative. These include: E/S protein ratio <0.5, E/S LDH ratio >0.6, and effusion LDH <200 (or
89
What clinical and laboratory features make a pleural effusion complicated?
A complicated pleural effusion is diagnosed if any of the following are present: 1) loculations on imaging, 2) pH <7.20, 3) glucose < 60, 4) positive Gram stain or culture.
90
What is the definition of empyema?
Empyema is diagnosed when there is visible frank pus in the pleural space.
91
What specific tests for M. tuberculosis are available to diagnose TB using pleural fluid?
MTB specific tests that are available to diagnosed TB from pleural fluid include adenosine deaminase (ADA), IGRA, and PCR for TB DNA.
92
What diagnostic tests are done for suspected pleural TB?
If TB specific tests are unavailable, pleural biopsy with culture and pathology has the highest yield (65-90%).
93
What is the definition of hemothorax?
Hemothorax is a grossly bloody pleural effusion with a hematocrit >½ the hematocrit of peripheral blood.
94
Define chylous effusion. What causes it?
Chylous effusions are white-colored, exudative effusions with a triglyceride level >110 mg/dl.
95
What conditions can result in secondary pneumothorax?
Secondary PTX can be caused by COPD (most common cause), PCP, CF, LCH, LAM, and barotrauma.
96
What are the most common causes of bacterial sinusitis?
The most common bacterial causes of sinusitis are pneumococcus, H. Influenzae, and Moraxella.
97
What is Lemierre syndrome?
Lemierre syndrome is septic thrombophlebitis of the internal jugular vein resulting from spread from an adjacent tonsillar abscess.
98
Identify the organisms that cause typical and atypical community-acquired pneumonia.
Typical CAPs are caused by pneumococcus, H. influenzae, S. aureus, GNRs, and Moraxella. Atypical CAPs are caused by Mycoplasma, Chlamydophila, Legionella, endemic fungi, and viruses.
99
When is it appropriate to start doing a full workup in CAP?
A full workup of CAP is indicated in 1. a patient with risk factors for severe disease (underlying structural lung disease or uncontrolled comorbidities), 2. severe presentations (requiring ICU), and 3. patients who are unresponsive to empiric therapy.
100
Detail the characteristics that a sputum sample must have to be considered an adequate specimen.
A sputum sample is adequate only if there are >25 neutrophils and <10 epithelial cells.
101
List the tests that you need to order for patients with severe of unresponsive CAP.
In patients with severe or unresponsive CAP consider antigen tests for pneumococcus and Legionella in addition to blood and sputum cultures. HIV testing may also be indicated.
102
Be familiar with the Pneumonia Severity Index.
PSI uses demographic factors, comorbid illnesses, physical exam, and laboratory variables to evaluate severity and predicted mortality of pneumonia.
103
Which patients are at increased risk for infection with DRSP?
Consider DRSP in the following groups: >65 years old, recent (<3 months) beta-lactam exposure, alcoholism, immunosuppression, multiple comorbidities, and exposure to child in daycare.
104
A patient with known influenza develops a cavitating pneumonia. Besides pneumococcus, what organism should you consider?
Think of S. aureus and in particular, CA-MRSA in a patient who develops a cavitating pneumonia after influenza infection.
105
A patient who works on an animal farm develops pneumonia. What organism should you think about?
Think of Coxiella Burnetti (Q fever) in pneumonia patient who works around cattle and/or sheep.
106
What organisms should you consider if pneumonia develops in a patient who spent an afternoon in a bat cave in Mississippi?
Histoplasma capsulatum should be considered in pneumonia patient who went spelunking in Mississippi.
107
What organism should you think about if pneumonia develops in a patient who drove through an Arizona dust storm?
Think coccidioides in patient who has traveled to southwest.
108
What organism should you consider if a chronic, cavitating pneumonia develops in a male logger from Arkansas?
Think Blastomyces dermatidides in patient from southeast, mid-Atlantic, and central states, particularly Arkansas and Illinois.
109
Name 2 drugs that are recommended to treat outpatient CAP patients without risk factors for DRSP.
Macrolides (azithromycin or clarithromycin) or doxycycline are recommend for outpatient treatment of CAP in patients without risk factors for DRSP.
110
Name 2 regimens recommended to treat inpatient CAP in the non-ICU patient.
Inpatient CAP in the non-ICU setting can be treated with either a respiratory fluoroquinolone or the combination of a beta-lactam plus either a macrolide or doxycycline.
111
What antibiotics do you use for empiric treatment of the ICU patient with cavitary pneumonia and risk factors for P. aeruginosa?
In the ICU CAP patient with cavitary pneumonia, you should add either linezolid or vancomycin to the initial regimen to cover CA-MRSA.
112
What are the diagnostic possibilities for the unresponsive patient with apparent pneumonia?
In the patient who is not responding to initial antibiotic therapy for CAP consider these possibilities: 1. wrong diagnosis (not an infectious infiltrate), 2. empiric coverage does not cover the causative organism, or 3. there is a new infection.
113
Name some potential pulmonary complications of pneumococcal pneumonia.
Lung abscess, pneumatoceles, and empyema are all potential complications of pneumococcal pneumonia.
114
Describe the patients who should be vaccinated with PPSV23.
PPSV23 should be given to those over 65, smokers, those with chronic illnesses (CHF, COPD, asthma, DM, cirrhosis), those that are functionally or anatomically asplenic, and those who are immunosuppressed.
115
Name some potential complications of staphylococcal pneumonia.
Complications of staphylococcal pneumonia include empyema (frequent), immune-complex type of glomerulonephritis, and pericarditis.
116
What drug choices are available for targeted treatment of S. aureus pneumonia?
S. aureus pneumonia should be treated with linezolid or vancomycin.
117
The “bulging fissure sign” is seen with what organism that causes pneumonia?
“Bulging fissure sign”, a lobar consolidation where the affected lung is expanded, is associated with Klebsiella pneumonia.
118
Which antibiotics must be added for empiric treatment of pneumonia in the ICU patient with risk factors for Pseudomonas?
The patient with risk factor for Pseudomonas pneumonia should be treated with 2 anti-pseudomonal drugs. These should include an anti-pseudomonal penicillin with the addition of a quinolone or an aminoglycoside.
119
Describe the microbiologic characteristics of Moraxella.
Moraxella on Gram stain is usually described as Gram negative cocci. They often line up side-by-side and look like a pair of kidneys.
120
What are the extrapulmonary manifestations of infection with Mycoplasma pneumoniae?
Extrapulmonary manifestations of Mycoplasma include hemolytic anemia, splenomegaly, erythema multiforme (and Stevens-Johnson syndrome), arthritis, myringitis bullosa, pharyngitis, tonsillitis, and neurologic changes (ie. confusion).
121
Pneumonia caused by C. pneumoniae can be biphasic. What is the characteristic throat symptom in the 1st phase? The 2nd phase?
Patients with C. pneumoniae can present with a biphasic illness presenting first with sore throat then 2-3 weeks later with hoarseness and pneumonia.
122
Pneumonia in a patient with associated mental status changes and diarrhea should make you think of what organism?
You should consider Legionella in a pneumonia patient with mental status changes and diarrhea.
123
Your patient returns from a trip to the southwest U.S. and comes to you with erythema nodosum. Which fungus do you include in your differential?
Erythema nodosum in a patient returning from the southwest US should prompt you to consider Coccidioides immitis infection.
124
Which endemic fungus causes hilar adenopathy, focal alveolar infiltrates, and multiple lung nodules?
Histoplasma capsulatum causes hilar adenopathy, focal alveolar infiltrates and multiple lung nodules.
125
Describe the microbiologic characteristics of Blastomyces.
Blastomyces dermatitidis appears as “broad-based budding yeast” on KOH prep.
126
Which patients are at increased risk for complications from infection with novel H1N1?
H1N1 is most common in young people and pregnant women.
127
Name the drug options for empiric treatment of influenza.
Oseltamivir or zanamivir should be used to treat influenza as most cases of influenza A/H3N2 have developed resistance to amantadine and rimantadine.
128
Which organisms are the usual causes when a patient requires intubation and then develops pneumonia within the first couple of days after admission?
The usual organisms of CAP should be suspected when a patient develops pneumonia within 1-4 days of intubation.
129
Characterize the organisms that cause pneumonia in patients who have been in the ICU on the ventilator for >5 days.
After 5 days on a ventilator, suspect hospital organisms that have colonized the oropharynx and upper airway.
130
Describe the presentation of a patient with an aspiration pneumonia.
Aspiration pneumonia generally presents with infiltrate in the RLL, RML, or in some cases the bilateral lower lobes.
131
Describe the presentation of a patient with a lung abscess.
Lung abscess often presents with indolent cough with purulent, often fetid, sputum.
132
Describe the differences between primary TB. latent TB, and reactivation TB.
Primary TB occurs with inhalation of M. tuberculosis. It may either disseminate, typically to sites of high oxygen content, or generally be contained by the immune system. Latent TB is the presence of a non-active TB infection. LTBI has a 5% chance of reactivation in the first 2 years and 5% chance after that. Reactivation TB typically affects the upper lung zones.
133
How do you make the diagnosis of active pulmonary TB?
Active TB is diagnosed by presence of prior infection (positive PPD or IGRA) with signs/symptoms of illness including CXR abnormalities and systemic symptoms.
134
What is the percentage of patients who have active pulmonary TB and nonreactive TB skin tests?
25% of patients with active pulmonary TB have a non-reactive PPD.
135
What do you do differently to read the TB skin test in the patient who has received BCG vaccine?
Nothing is done differently in the setting of prior BCG vaccination.
136
In which direction relative to the arm is the TB skin test read?
The PPD is read along the long axis of the arm. It is the diameter of induration rather than just redness.
137
In which groups of patient is a reactive TB skin test of 5mm or more significant? 10mm or more? 15mm or more?
A 5mm PPD is positive in HIV and other immunosuppressed patients, close contacts of TB patients, and those with CXR evidence of prior TB infection. A PPD has to be 15mm to be positive in those with no known risk factors. In all others, a 10mm PPD is positive.
138
List some of the reasons why a patient with true latent TB might have a negative TB skin test?
It can take 10 weeks to react to a PPD after exposure to TB. Immunosuppressed patients and those with sarcoid may also exhibit anergy. Some patients have T-cells with “impaired memory”. This can be sorted out with a two stage PPD (second one given one week after first) to demonstrate “booster effect”.
139
What are you going to do for a patient who is high-risk for TB disease but has a negative skin test?
In a high-risk patient in whom you strongly suspect TB, you should begin TB therapy even though the PPD is negative while you continue workup.
140
What is the booster effect seen with TB skin testing?
Some patients have impaired T-cell memory resulting in delayed response to PPD testing. A second PPD is placed one week after the first. If positive this is considered a true positive and exhibits the “booster effect”.
141
What is the definition of a “new converter”?
A “new converter” is a patient who has a positive PPD when it has been previously negative. A two stage PPD should be done to confirm lack of “booster effect” in someone who has not had a PPD performed in a while.
142
Which patients should be screened with IGRA tests?
IGRA is preferred over PPD in those who are noncompliant (will not return for reading) and in those who have received BCG. It is also preferred in children <5 years of age.
143
Can a patient with a negative TB skin test still have TB? What about with a negative IGRA?
Both the PPD and the IGRA can have false negative results. Continue workup in the patient suspected of having TB.
144
What is the usual treatment for latent TB?
Latent TB is treated with INH for 6-9 months or 3 months of weekly INH and rifampin given by direct observation, or daily INH and rifampin for 3 months, or daily rifampin for 4 months.
145
What are the 4 drugs used to treat active TB? How long is each one given?
Rifampin, INH, Pyrazinamide, and Ethambutol are the initial treatment for active TB. These 4 drugs are given for 2 months. After the first 2 months, INH and rifampin are given for an additional 4 months.
146
What side effects can result from the different antimycobacterial drugs? What is the required screening?
INH, rifampin, and pyrazinamide all can cause hepatotoxicity. INH can cause peripheral neuropathy, and this risk can be decreased with supplementation of vitamin B6 (pyridoxine). Ethambutol is associated with decreased visual acuity which often begins with decreased color perception. Streptomycin is ototoxic and nephrotoxic.
147
What is Lady Windermere syndrome?
Lady Windermere syndrome describes a female non-smoker with cough productive of purulent sputum and interstitial infiltrates due to non-tuberculous mycobacterium infection.
148
What do you do for the healthy patient with a single sputum sample positive for M. kansasii?
A single sputum culture positive for MAC in a healthy patient is not indicative of disease and does not require followup.
149
A patient returns from a vacation to Mexico with complaints of chronic drainage from a recent tummy tuck incision. What is the likely organism?
Cutaneous infection following plastic surgery in a patient who has been exposed to soil or water is likely due to NTM, in particular M. abscessus, M. fortuitum, M. chelonae, and M. marinum.
150
What are the 2 most common causes of pneumonia in patients with HIV/AIDS?
The most common cause of pneumonia in the HIV/AIDS patient is bacterial pneumonia with PCP being the second most common cause of pneumonia.
151
What is the preferred regimen for the treatment of Pneumocystis jiroveci? How about with a PaO2 = 60mmHg?
The first line drugs for PCP are trimethoprim/sulfa (IV or PO) or pentamidine IV. If the pO2 is <70 steroids should be given.
152
Discuss the various types of Aspergillus pulmonary infections.
Invasive pulmonary aspergillosis typically occurs in immunosuppressed patients. Allergic bronchopulmonary aspergillosis is an allergic reaction to aspergillosis presenting with cough, mucus plugging, and recurrent pulmonary infiltrates and eosinophilia in a patient with asthma or CF. Aspergilloma is a fungus ball which grews in a prevsious cavity and can present with hemoptysis.
153
What is the recommended treatment of invasive pulmonary aspergillosis?
Voriconazole is the preferred treatment for invasive pulmonary aspergillosis.
154
Name some causes of noninfectious pulmonary infiltrates.
Some causes of noninfectious pulmonary infiltrates include drugs (MTX, amiodarone, bleomycin, gold, crack), hemorrhage, leukemic infiltrates in ALL, and radiation pneumonitis.
155
Characterize the ARDS Network approach to fluid management in patients with ARDS.
The FACT trial demonstrated that a conservative fluid replacement strategy was better than a liberal fluid replacement strategy.
156
Describe the ventilator-induced lung injury that can happen when treating ARDS.
VILI (ventilator-induced lung injury) can arise from overdistension of the alveoli and the cyclic opening and closing of atelectatic alveoli.
157
For ARDS, what is considered the optimal ventilator setting for tidal volume?
The optimal TV setting in ARDS is 6 ml/kg.
158
Describe the specifics of permissive hypercapnia.
Respiratory acidosis may decrease lung injury and be protective. Therefore, the focus should be on oxygenation and pCO2 can be allowed to rise.
159
Name the DESAT causes of failure to wean.
Drugs (sedatives), endotrachial tube and electrolyte imbalances, secretions, alkalemia, too high a pO2 and too low a pCO2 just prior to extubation are the most common causes of failure to wean from a ventilator.
160
What are the two categories of actions you keep in mind when adjusting a ventilator?
Adjustments of a ventilator either 1. change alveolar ventilation (TV and rate) or 2. alter oxygenation (FiO2, PEEP, and inspiratory/expiratory ratio.
161
When should you use PEEP?
PEEP should be used only with diffuse lung injury.
162
A patient with severe COPD is placed on the ventilator. She suddenly becomes hypotensive. What steps do you follow to stabilize her?
A patient with COPD who becomes hypotensive when put on a ventilator has likely developed auto-PEEP. This should be managed fist by disconnecting the patient from the ventilator and slowly baggin the patient. During this phase you should look for PTX and mucus plugs and check ventilator function. Then the patient should be reconnected to the ventilator with setting that allow for a longer expiratory phase.
163
What is the best route to provide nutrition for a mechanically ventilated patient?
An enteral route is preferred for feeding a ventilated patient because it maintains the integrity of the intestinal epithelium.
164
What is the refeeding syndrome, and how do you prevent it?
Refeeding syndrome occurs when a malnourished patient is fed with a high carbohydrate load. This results from a dramatic increase in insulin levels resulting in swift uptake of glucose, potassium, phosphate and magnesium into cells.
165
Discuss the potential complications of pulmonary artery catheters.
Potential complications of pulmonary artery catheters include puncture of nearby arteries, bleeding, neuropathy, air embolism, pneumothorax, and arrhythmias.
166
Predict PA catheter values in hypovolemic shock. In cardiogenic shock.
In hypovolemic shock the PCWP pressure is very low. In cardiogenic shock it is high
167
A patient presents with E. coli sepsis. Predict cardiac output, wedge pressure, and SVR in relation to normal values.
In a patient with sepsis the CO can be high, low, or normal. The PCWP would be low. The SVR would be very low.
168
Discuss the causes of obstructive sleep apnea.
OSA can be caused by abnormal upper airway anatomy, myxedema, and obesity.
169
What should be avoided in patients with sleep apnea?
Alcohol and sedatives should be avoided in OSA as they may worsen the condition.
170
Describe the obesity hypoventilation syndrome and how it relates to OSA.
Obesity hypoventilation syndrome is defined by hypoventilation while awake. The 2 main findings are BMI > 35 (most patient) and pCO2 >45 while awake.
171
List some of the risk factors for the development of lung cancer, besides smoking cigarettes.
Asbestos exposure alone increases lung cancer risk 6X. Asbestos exposure combined with smoking increases risk 60X that of normal. Certain other exposures like uranium, nickel, beryllium, coal, steel, silica also increase risk. Radon exposure in underground mines increases risk though home/office exposure has not been shown to increase risk.
172
Which lung cancers are usually central in the chest?
Squamous cell and small cell lung cancers are usually centrally located.
173
Which lung cancers are usually peripheral?
Adenocarcinoma and large cell lung cancers are usually located peripherally.
174
Which lung cancer is most likely to cavitate?
Squamous cell lung cancer is the most likely to cavitate.
175
For patients with a lung mass and palpable cervical lymphadenopathy, what procedure is useful for the diagnosis?
In this situation the lymph node should be biopsied as it will yield both diagnosis and staging information and is less risky than lung biopsy.
176
How sensitive are pleural fluid analyses for diagnosing lung cancer?
If three samples are submitted, the diagnostic yield for lung cancer with malignant effusion is >90%.
177
Define stage I non-small cell lung cancer.
Stage I NSCLC is defined as T1-T2a with N0 and M0.
178
Characterize the course of small cell lung cancer.
Small cell lung cancers grows fast and metastasizes early. It is also more likely than the other forms of lung cancer to be associated with paraneoplastic syndromes.
179
Which types of calcifications indicate a benign solitary pulmonary nodule?
A solitary pulmonary nodule is more likely to be benign if there is “popcorn” calcification (hamartoma), laminated (granuloma), or if multiple, punctate foci or a dense central calcification.
180
What do you do with the solitary pulmonary nodule in the patient with risk factors for cancer?
High risk patients with a pulmonary nodule require a diagnosis obtained by CT-guided aspiration, bronchoscopy, surgical resection. PET may also help to sort benign from malignant.
181
Which lung cancers are associated with hypercalcemia? With SIADH? With gynecomastia? With HPOA?
Hypercalcemia is most associated with squamous cell. SIADH, ectopic ACTH, and Eaton-Lambert syndrome are associated with small cell lung cancer. Gynecomastia is linked with large cell lung cancer. HPOA is most associated with adenocarcinoma but can be seen in all 3 NSCLC types.
182
List the causes of superior vena cava syndrome, both malignant and nonmalignant.
SVC syndrome is often caused by the centrally located lung cancers (SCCa and small cell). Lymphoma and metastatic tumors also cause this. Permanent central venous lines are also an emerging cause.
183
What are the most common causes of anterior mediastinal masses? Posterior? Middle?
Anterior mediastinal masses are thymoma, thyroid, lymphoma, teratoma, and aortic aneurysm. Posterior mediastinal masses include neurogenic tumors, esophageal lesions, aortic aneurysm, and hernia. Middle mediastinal masses include lymphoma, cysts, adenopathy, hernia, and aortic aneurysm.
