Pulmonary

Question 1

ARDS (acute respiratory distress syndrome): definition

Answer 1

Inflammatory lung condition caused by direct or indirect injury to lungs (infection, trauma, HoTN)

Question 2

ARDS: Dx criteria

Answer 2

Acute onset of:

• bilateral diffuse infiltrates caused by non-cardiogenic pulmonary edema/pulmonary capillary leak
• PAWP/PCWP , 19 mm Hg (no evidence of left atrial HTN)
• PaO2/FiO2 ratio of = 300 mm Hg

Question 3

ARDS: initial ventilator management strategy

Answer 3

Initial: Vt= 8 mL/kg

Reduce to ideal Vt of 6 mL/kg (1 mL/kg reduction intervals at every = 2 hrs)

Question 4

Acute asthma relievers (rescue)

Answer 4

SABA:
- Albuterol (Proventil)
- Pibuterol (Maxair)
- Levalbuterol (Xopenex)
Note: Also use 15-30 min before activity to prevent exercise-induced bronchospasm

Question 5

Asthma controller meds: Inhaled corticosteroids (ICS)

Answer 5

• Fluticasone (Flovent)
• Mometasone (Asmanex)
• Budesonide (Pulmicort)
• Beclomethasone (QVAR)
• Ciclesonide (Alvesco)
  Note: Preferred controller Tx for persistent asthma, requires consistent, daily use for optimal effect

Question 6

Asthma controller meds: Inhaled corticosteroids/long-acting beta2-agonist (ICS/LABA)

Answer 6

• Budesonide + formoterol (Symbicort)
• Fluticasone + salmeterol (Advair)
• Mometasone + formoterol (Dulera)
  Note: Only use in Pt whose asthma is not well controlled w/ an ICS alone

Question 7

Asthma controller meds: Leukotriene receptor antagonist, leukotriene modifiers

Answer 7

• Montelukast (Singulair)

Note: Additional benefit w/ allergic rhinitis, most often used in conjunction w/ ICS

Question 8

Asthma reliever meds: Aggressive Tx of inflammation during asthma flare

Answer 8

Systemic corticosteroids:

- Prednisone 40-60 mg/d x 3-10 days

Question 9

Warning Sx of impending respiratory arrest

Answer 9

• Drowsiness or confusion
• Paradoxical thoracoabdominal movement
• Absence of wheezing
• Bradycardia
• Absence of pulsus paradoxus
• Initial PEF or FEV1 < 25% of personal best/predicted value

Question 10

Obstructive pulmonary Dz: definition, examples

Answer 10

Limitation of air flow (reduced airflow rates)
COPD
Emphysema
Bronchitis
Asthma

Question 11

Restrictive pulmonary Dz: definition, examples

Answer 11

Limitation of lung expansion (reduced volumes)
ARDS
Pneumonia
Bronchiolitis
Idiopathic pulmonary fibrosis

Question 12

Chronic bronchitis: definition

Answer 12

Coughing with excessive mucus production for at least 3 or more months for a minimum of 2 or more consecutive years.
It has increased Hct

Question 13

Emphysema: definition

Answer 13

Permanent alveolar damage and loss of elastic recoil result in chronic hyperinflation of the lungs. Expiratory respiratory phase is markedly prolonged.
It has increased AP diameter and hyperresonance to percussion

Question 14

COPD medication: Category A (GOLD 1-2)Minimally symptomatic COPD (low risk of exacerbation)

Answer 14

Short-acting B2 agonist (SABA) PRN alone or in combination SABA with short-acting anticholinergic (more effective).

Question 15

COPD medication: Category B (GOLD 1-2)More symptomatic (low risk of exacerbation)

Answer 15

Long-acting B2 agonist (LABA) or long-acting anticholinergic (newer name is long-acting muscarinic agent (LAMA). May use SABA for rescue PRN.
SABA: albuterol
LAMA: tiotropium bromide

Question 16

COPD medication: Category C (GOLD 3-4)Minimally symptomatic (but high risk of exacerbation)

Answer 16

LAMA is first line. If poor control, use combination LABA and LAMA. Alternative is LABA with inhaled glucocorticoid, methylxanthines (theophylline).
LABA: salmeterol
LAMA: tiotropium bromide

Question 17

COPD medication: Category D (GOLD 3-4)High risk

Answer 17

PDE-4inhibitor (only pulmonologist can Rx this); refer to pulmonologist

Question 18

COPD exacerbations: definition

Answer 18

Acute event characterized by worsening of the Pt’s respiratory symptoms that is beyond the day-to-day variations and leads to a change in medication. Usually 2/2 respiratory tract infection.
- Outpatient Tx is usually sufficient

Question 19

COPD exacerbations: Indications for hospital admission

Answer 19

• Marked increase in intensity of symptoms
• Acute respiratory failure
• Onset of new physical Sx
• Failure to respond to initial medicinal management
• Presence of serious comorbidities (e.g. HF)

Question 20

COPD exacerbations: indications for ICU admission

Answer 20

• Severe dyspnea not responding to initial Thx
• Change in mental status
• Worsening hypoxxemia (PaO2 < 40 mm Hg)
• Worsening acidosis (pH < 7.25)
• Invasive mechanical vent
• Hemodynamic instability