Pulmonary Flashcards
Most important imaging study for diagnosis of Interstitial Lung Disease?
High-Resolution CT (1-2mm cuts of lung tissue)
Interstitial Lung Disease shows a ___ pattern on PFTs
Restrictive
Change to TLC in Interstitial Lung Disease?
Low
Change to FVC in Interstitial Lung Disease?
Low
Change to RV in Interstitial Lung Disease?
Low
Change to DCLO in Interstitial Lung Disease?
Low
Change to FEV1/FVC in Interstitial Lung Disease?
NML
3 conditions that show mixed obstructive and restrictive patterns of lung disease?
Sarcoidosis, Lymphangioleiomyomatosis, Eosinophilic granuloma
Pattern of asbestos-related ILD on CXR?
Involvement of lower lung fields
Pattern of silicosis-related ILD on CXR?
Hilar egg-shell Ca2+
Pattern of sarcoidosis-related ILD on CXR?
Bilateral hilar predominance
Pattern of lymphangioleiomyomatosis-related ILD on CXR?
Pneumothorax in premenopausal female
What is the most common work-related illness?
Pulmonary disease
4 types of inorganic dust that cause interstitial lung disease?
Silicosis, Coal worker’ pneumoconiosis, Berylliosis, Asbestosis
1 type of organic dust that cause interstitial lung disease?
Cotton duct
Alternate name for cotton/flax dust?
Byssinosis
Clinical presentation for Byssinosis?
Symptoms present M-F, Absent S-Su
Best treatment for Byssinosis?
Exposure avoidance
Image of eggshell calcifications seen on XR in silicosis?
If patient with silicosis presents with fever – diagnosis?
Silicone-TB
If patient with silicosis presents with fever – next step of workup?
Silicone-TB
What is the cutoff value for PPD in Silicone-TB?
10mm
5 occupations that have increased risk of silicosis exposure?
Construction, mining, ceramics, sandblasting, masonry
3 aspects of clinical presentation for Caplan Syndrome?
Coal-worker’s pneumoconiosis, RA, Lung nodules
Change to lung in setting of coal-worker’s pneumoconiosis?
Anthracosis … black patches in lung
What accounts for anthracosis (black patches in lung) in setting of coal-worker’s pneumoconiosis?
Carbon-ingesting macrophages
Berylliosis mimics which condition?
Granulomatous sarcoidosis
Which portion of lung is affected by berylliosis?
Upper lung + Hilar lymphadenopathy
3 exposures that increase risk for developing berylliosis?
Fluorescent light bulbs, Aerospace, Electronics
Best treatment for berylliosis?
Corticosteroids
Best test for diagnosing berylliosis?
Beryllium lymphocyte transformation test … (not serum berylliosis level)
Which type of immune response mediates berylliosis?
Cell-mediated
Patient with asbestos exposure is most likely to develop which type of CA?
Squamous cell + Adenocarcinoma (NOT mesothelioma)
Ferruginous bodies seen in asbestos exposure will stain (+) for …
Prussian blue
3 asbestos-related pleural diseases?
Pleural plaques, Pleural effusion, Mesothelioma
What is definition of asbestosis (compared to pleural plaques)?
Asbestosis = ILD in lung bases
Characteristic of pleural effusion in setting of asbestos exposure?
Hemorrhagic
Prognosis of pleural effusion in setting of asbestos exposure?
Benign
Prognosis of mesothelioma in setting of asbestos exposure?
Malignant
Incidence of mesothelioma is affected by ___, but unaffected by ___
Asbestos exposure, Smoking
Best method of diagnosing mesothelioma?
Open pleural biopsy (DON’T do FNB … may seed the lungs/pleura)
Pathogen associated with Hypersensitivity PNA due to moldy hay?
Thermophilic actinomyces
Which lab value is ABSENT in Hypersensitivity PNA?
Eosinophilia
Most common cause of death in ARDS?
Sepsis, Organ failure
Cardiac output in Hypovolemic Shock?
Decreased
Wedge pressure in Hypovolemic Shock?
Decreased
SVR in Hypovolemic Shock?
Increased
Cardiac output in Cardiogenic Shock?
Decreased
Wedge pressure in Cardiogenic Shock?
Increased
SVR in Cardiogenic Shock?
Increased
Cardiac output in Septic Shock?
Increased
Wedge pressure in Septic Shock?
NML
SVR in Septic Shock?
Decreased
Tidal volume of ___ mL/kg is associated with decreased mortality
6
Patient in ICU after septic shock; Recently removed from ventilator; HGB now is 7.9 – at what point should patients in ICU receive blood transfusion?
HGB < 7.0
What are 2 exceptions to rule that ICU should not receive blood transfusion until HGB < 7.0?
Active bleeding; Unstable CAD
ICU admission for COPD exacerbation is associated with ___ year mortality
1
Appropriate duration of oral/IV corticosteroids in COPD exacerbation?
2 weeks
Pulmonary arterial pressure that indicates pulmonary HTN?
Pulmonary arterial systolic pressure > 35 mmHg
Etiology of secondary pulmonary HTN?
Vasoconstriction secondary to COPD, chronic hypoxia, OSA; Scleroderma
Etiology of pulmonary HTN in setting of Scleroderma?
Proliferation of intimal smooth muscle cells
Diagnostic test for Pulmonary HTN?
R heart catheterization
Best treatment for Pulmonary HTN?
CCBs, Lung transplantation
2 tools for diagnosis of PE?
V/Q scan, Helical CT
Hallmark EKG sign associated with PE?
S1-Q3-T3
What accounts for appearance of S1Q3T3 in setting of PE?
R heart strain
Most common finding on chest examination in setting of PE?
Clear breath sounds
Which of the following is NOT a risk factor for DVT – female, advanced age, trauma, recent surgery, homocystinuria?
Female … pregnancy = yes, OCP = yes … but NML women have no increased risk
Is knee surgery OR hip surgery considered a greater risk factor for DVT?
Knee surgery
Best DVT prophylaxis for CA patients?
LMWH
Best treatment for superficial thrombophlebitis?
Not heparin … NSAIDs, rest
2 serious symptoms associated with altitude mountain sickness?
Cerebral edema, Pulmonary edema
3 DOCs for altitude mountain sickness?
Furosemide, Nifedipine, Dexamethasone
DOC for prevention of altitude mountain sickness?
Acetazolamide
Structure of Streptococcus pneumoniae on Gram stain?
Gram (+) lancet-shaped diplococci
Clinical presentation of PNA due to Klebsiella?
Currant jelly sputum
Pathogen responsible for PNA + cattle/sheep exposure?
Q fever, coxsiella
Pathogen responsible for PNA + bird exposure?
Chlamydia psittacosis
Pathogen responsible for PNA + hunters?
Tularemia
Pathogen responsible for PNA + homosexuality?
PCP
Pathogen responsible for PNA + nursing home?
Klebsiella
Pathogen responsible for PNA + ETOH?
Klebsiella
Pathogen responsible for PNA + aspiration, poor dental hygiene?
Anaerobes
Pathogen responsible for PNA + cystic fibrosis?
Pseudomonas
Pathogen responsible for PNA + post-influenza infection?
Staph aureus
Pathogen responsible for PNA + neonate?
GBS
3 most common pathogens responsible for atypical PNA?
Mycoplasma, Leigonella, Chlamydia
2 pathogens causing PNA that are diagnosed with urinary antigen?
Leigonella, Histoplasmosis
Subtype of lung adenocarcinoma that causes peripheral lung CA in non-smoker females?
Bronchoalveolar Carcinoma
Next step of workup for patient with suspected Pancoast Tumor?
CT needle-guided biopsy
Nerve roots of ulnar nerve?
C8-T1
Paraneoplastic syndrome associated with lung adenocarcinoma?
Hypertrophic osteoarthropathy
Paraneoplastic syndrome associated with large cell lung CA?
Gynecomastia
Appearance of small cell lung CA on CXR?
Centrally-located … near hilum
3 Paraneoplastic syndromes associated with small cell lung CA?
SIADH, Eaton-Lambert Syndrome, Cushing Syndrome
Best treatment for brain metastasis?
Surgical resection + whole brain XRT
Treatment of choice for idiopathic interstitial PNA?
Corticosteroids
Which medication can induce Bronchiolitis Obliterans Organizing Pneumonia (BOOP)?
Penicillamine
Diagnostic test for sarcoidosis?
Bronchoscopy with bonchial wall biopsy … looking for non-caseating granulomas
Biopsy shows caseating granulomas … diagnosis?
TB
___ is a condition that mimics sarcoidosis?
Beryllosis
Indication for steroid treatment of sarcoidosis?
Other organ involvement; Hypercalcemia; Neurosarcoidosis
Clinical presentation of neurosarcoidosis?
CN VII involvement
Patient presents with hilar LAD, polyarthralgia (especially involving ankle), erythema nodosum – diagnosis?
Lofgren Syndrome … variant of sarcoidosis
Patient presents with lytic bone lesions, diabetes insipidus, exophthalmos – diagnosis?
Hand-Schuller-Christian Syndrome
Which test confirms diagnosis of Hand-Schuller-Christian Syndrome?
Lung biopsy that shows Langerhans cells
Treatment for Systemic Langerhans cell granulomatosis?
2-chlorodeoxyadenosine (2-CDA)
Additional condition that is treated with 2-CDA?
Hairy cell leukemia
Most common cause of chylothorax?
Lymphoma
Lung condition that may result in chylous pleura effusions?
Lymphangiomyomatosis (LAM)
Best treatment for Churg-Strauss Disease?
Corticosteroids, Cyclophosphamide
Medication that might induce Churg-Strauss Disease?
Leukotriene receptor antagonist
Alternate name for Acute Eosinophilic PNA?
Loeffler Syndrome
2 lab results seen in setting of Loeffler Syndrome?
Eosinophils in blood + sputum
Clinical presentation of aspergilloma?
Massive hemoptysis
Best treatment of aspergilloma?
Surgical removal
Appearance of aspergilloma on CXR?
Fungal ball
Clinical presentation of invasive pulmonary aspergillosis?
Necrotizing PNA in immunocompromised patients (neutropenia)
Best treatment for invasive pulmonary aspergillosis?
Voriconazole
Best treatment for allergic bronchopulmonary aspergillosis?
Steroids … (not antifungals)
Parapneumonic effusion is associated with …
Bacterial PNA
Most common cause of massive hemothorax pleural effusion?
Malignant pleural effusion
What type of pleural effusion is associated with rheumatoid pleurisy?
Exudative
Change to LDH in rheumatoid pleurisy?
Increased
Change to glucose in rheumatoid pleurisy?
Decreased
What distinguishes rheumatoid pleurisy from other exudative pleural effusion?
Low glucose (without WBCs or signs of infection)
2 characteristics of lupus pleuritis?
Bilateral, painful
Most common cause of chylothorax?
Lymphoma
Laterality of chylothorax?
Unilateral
Rare cause of chylothorax?
Lymphangioleiomyomatosis
Epidemiology of hepatic hydrothorax?
ETOH with cirrhosis
Hepatic hydrothorax represents a type of ___ pleural effusion
Transudative
Etiology of hepatic hydrothorax?
Hypoalbuminemia
Best treatment for hepatic hydrothorax?
Salt restriction, diuretics
What is NOT a treatment option for hepatic hydrothorax?
Chest tube, Thoracentesis … (the effusion accumulates too rapidly)
Most common laterality of developing hepatic hydrothorax?
R
3 criteria for exudative pleural effusion?
Pleural fluid protein >2.9, Pleural fluid LDH >60%, Pleural fluid cholesterol >45
WBC >1000 in pleural effusion means …
Exudate
WBC >10,000 in pleural effusion means …
Parapneumonic
WBC >100,000 in pleural effusion means …
Empyema (pus collection)
Eosinophils > 10% in pleural effusion means …
Drug reaction
Lymphocytes > 50% in pleural effusion means …
TB or malignancy
What are 2 markers for TB?
Adenosine deaminase (ADA), IFNg
Next step of workup for patient with TB effusion?
Pleural biopsy
Glucose < 20 in pleural effusion means …
RA
PMN predominance in pleural effusion means …
PNA
High amylase in pleural effusion means …
Pancreatic fistula
High triglycerides (>115) in pleural effusion means …
Thoracic duct injury, Lymphangioleiomyomatosis
Pleural effusion with (+) ANA, low complement means …
SLE
Best next step of workup for patient with suspected pleural mesothelioma?
Open pleural biopsy
What should you NOT do in patient with suspected pleural mesothelioma?
Needle biopsy … may seed the needle track
First step of workup for patient with pulmonary nodules?
Check previous CXR
3 conditions that would warrant biopsy of pulmonary nodules?
CA, Exposure (asbestos), Smoking
Most likely fungal infection – Mississippi, Ohio river valley?
Histoplasmosis
Most likely fungal infection – Chicago, Midwest?
Blastomycosis
Most likely fungal infection – California?
Coccidioidomycosis
Pattern of pulmonary nodule calcification that suggests benign lesion?
Popcorn, laminar, central, diffuse
Pattern of pulmonary nodule calcification that suggests malignant lesion?
Stippled, eccentric
Diameter of pulmonary nodule in which probability of CA is low?
Diameter < 1.5cm
Best treatment for pulmonary nodule in which probability of CA is low?
Serial CXR monitoring every 3 months
Diameter of pulmonary nodule in which probability of CA is high?
Diameter > 2cm
Best treatment for pulmonary nodule in which probability of CA is high?
Resection
When should you add inhaled corticosteroids for patient who has HX of asthma?
When patient begins to use of inhaled b agonist every day
Value of spacers during use of inhaled corticosteroids for asthma?
Decrease AE by decrease amount of drug swallowed each day
Indication for short-term oral corticosteroids in asthma?
Acute outpatient flare
T/F – regular use of inhaled corticosteroids has been shown to improve pulmonary function and reduce mortality in patients with asthma?
True
Which inhaler is indicated for asthmatic patients with b-blocker induced bronchospasm?
Atrovent inhaler
DOC for prevention of exercise-induced asthma in children?
Cromolyn
MOA of cromolyn in prevention of exercise-induced asthma in children?
Mast cell stabilizer
3 drug interactions associated with theophylline?
Increased clearance of phenytoin, phenobarbital, lithium
In patients with atypical symptoms of asthma, which step of workup has high NPV to exclude asthma?
Methacholine challenge
Most common etiology of occupational exposure?
Isocyanates (pesticides)
Which substance is unlikely to induce asthma?
Not silica
Is airflow limitation in COPD reversible?
Not fully
Classic CXR appearance of COPD?
Lung hyperinflation
T/F – 80% of cigarette smokers do not experience marked airflow obstruction?
True
Which intervention should not be prescribed for patient with severe COPD that requires admission?
Inhaled high-dose corticosteroids … Use ORAL or IV steroids!
What is the best prognostic indicator for COPD?
FEV1
What is the only therapy that has been proven to increase lifespan in patients with COPD?
O2
Goal O2 sat in patients with COPD?
90%
Which intervention has been shown to reduce the need for intubation for patients with COPD?
Non-invasive mask ventilation
What is the preferred method of O2 delivery for patients who are acutely ill and may be at risk for developing hypercapnia?
Venturi mask delivery
Change to PE seen in asthma?
Asthmatic patients usually have NML resting PE
Next step of workup to distinguish asthma from COPD in setting of decreased FEV1/FVC?
Bronchodilator challenge (b2 agonist)
Patient with low FEV1/FVC experiences improvement in FEV1 after bronchodilator challenge – diagnosis?
Asthma
Patient with low FEV1/FVC experiences NO improvement in FEV1 after bronchodilator challenge – next step of workup?
Check DCLO
Patient with low FEV1/FVC experiences NO improvement in FEV1 after bronchodilator challenge; DCLO is low – diagnosis?
COPD
Patient with low FEV1/FVC experiences NO improvement in FEV1 after bronchodilator challenge; DCLO is high – diagnosis?
Asthma
In patient with low FVC, TLC – what is next step of workup?
Check DLCO
In patient with low FVC, TLC and low DLCO – what is diagnosis?
Interstitial lung disease
In patient with low FVC, TLC and NML DLCO – what is diagnosis?
Chest wall lesions
2 aspects of clinical presentation seen in males with Cystic Fibrosis?
Bronchiectasis, Aspermia
27 yo male presents with recurrent sinusitis, bronchiectasis, sterility, hearing loss; PE shows heart sounds that are more prominent on R side – diagnosis?
Kartagener Syndrome
Etiology of Kartagener Syndrome?
Defective ciliary function
4 organ systems affected by Kartagener Syndrome?
Sinuses, Bronchi, Sperm, Organ of Corti
Classic CXR finding associated with a1 anti-trypsin?
Lower lobe emphysematous bullae
Inheritance pattern of a1 anti-trypsin?
AR
