Pulmonary Flashcards
Difference in lung compromise between smoking-induced COPD and alpha-1 antitrypsin deficiency-related COPD
- Smoking-induced centriacinar (centrilobular) emphysema➡upper lobes
- AAT deficiency panacinar emphysema➡greater destruction of lower lobes
*Chest x-ray AAT deficiency➡bilateral basilar lucency
Clues to suspect Alpha-1 antitrypsin
- COPD at a younger age (<45 years old)
- COPD with minimal or no smoking history
- Bibasilar predominant COPD
- History of unexplained liver disease
When do you use bronchoprovocation testing with methacholine?
Patients with typical asthma symptoms but normal spirometry
Recommendations for lung cancer screening
- Annual screening→low-dose CT in adults age 55 - 80 who have a 30-pack-year smoking history and currently smoke or have quit within past 15 years
- Discontinue Screening→Once a person has not smoked for 15 years or develops a health problem limiting life expectancy or ability/willingness to have curative lung surgery
Difference of the diffusion capacity of the lung for carbon monoxide between emphysema and chronic bronchitis, and why?
- Low in Emphysema→loss of alveolar capillaries
- Normal in Chronic Bronchitis
Difference between the pleural exudate of tuberculous effusion and malignancy etiology
- Tuberculous→usually lymphocytosis>70%
- Malignancy→lymphocytosis is uncommon
Most common causes of secondary digital clubbing
- Lung malignancies (intrathoracic neoplasms)
- Intrathoracic suppurative diseases (cystic fibrosis, bronchiectasis)
- Right to left cardiac shunts (cyanotic congenital heart disease)
*COPD with or without hypoxemia does not cause digital clubbing
Best initial test in acute exacerbation of asthma
- Peak expiratory flow (PEF)→approximation of the FVC
- Arterial blood gas (ABG)→↑ A-a gradient
Most accurate test for asthma in an asymptomatic patient
> 20% decrease in FEV1 with use of methacholine or histamine
*Less likely to find an ↑ in FEV1 using a SABA (albuterol)→false negative
Findings in the pulmonary function testing in asthma
- ↓ FEV1, FVC and FEV1/FVC
- ↑>12% and 200 mL in FEV1 with albuterol
- ↓>20% in FEV1 with methacholine or histamine
- ↑ Diffusion capacity of the lung for Carbon monoxide (DLCO)
When do you use anticholinergics in chronic asthma management?
If SABA, LABA and inhaled corticosteroids at maximum doses are not sufficient
*Iptratropium, Tiotropium
Typical presentation in acute asthma exacerbation in arterial blood gas. Which finding suggests the patient is getting worse?
- Hyperventilation→Respiratory alkalosis
- ↑ work of breathing→respiratory muscle fatigue→inability to maintain adequate ventilation (hyper)►normal pH and PaCO2 (normalized or elevated from respiratory alkalosis)►impending respiratory collapse
Which are the 3 most common causes of chronic cough? What is chronic cough?
- Chronic cough→lasting >8 weeks
- Upper airway cough syndrome (postnasal drip)
- Asthma
- Gastroesophageal reflux disease (GERD)
What is a solitary pulmonary nodule? What is the first step when evaluating it?
- Rounded opacity, <3cm, completely surrounded by pulmonary parenchyma, No associated with lymph node enlargement
- Determine if nodule is low, intermediate or high malignancy risk
Which is the management of high, intermediate and low malignancy risk solitary pulmonary nodule?
- High risk→surgical excision
- Intermediate risk→FDG-PET, serial CT scans or Bx depending radiographic findings
- Low risk→serial CT scans
First line inpatient non-ICU treatment for community-acquired pneumonia
- Fluoroquinolone: Respiratory→moxifloxacin, levofloxacin
- Beta-lactam + macrolide
Best initial and most accurate diagnostic test for COPD?
- Best initial: chest x-ray
- Most accurate: Pulmonary Function Test
Which sodium disturbance you may find secondary to a pulmonary pathology and why?
Hypotonic Euvolemic Hyponatremia
- Pulmonary pathology (Pneumocystis pneumonia, Ex)→ SIADH
- Infusion of normal saline - worsen hyponatremia
Kartagener syndrome screening test
Decreased nasal nitric oxide
COPD patient with acute-on-chronic respiratory acidosis
Hypoventilation→CO2 narcosis
Pulmonary variable reflected when doing inspiratory hold maneuver?
Pulmonary compliance
Inspiratory hold maneuver➡measure plateau pressure=elastic pressure + PEEP
*Elastic recoil is inverse related to lung compliance; Elastic pressure=TV/compliance. ⬇Compliance (pulmonary fibrosis)➡stiffer lungs, ⬆elastic pressure
Radiologic feature of invasive aspergillosis in the lungs
Chest CT scan: Pulmonary nodules with surrounding ground-glass opacities (“halo sign”)
Pulmonary function test results in a patient with amyotrophic lateral sclerosis (ALS)
- Restrictive pattern (normal or ⬆FEV1/FVC, ⬇VC)➡extrinsic limitation of lung expansion
- Diaphragmatic involvement (weakness)➡⬇FVC, ⬇Maximal inspiratory pressure (reflect diaphragmatic strength), DLCO normal (pulmonar parenchyma and alveoli unaffected)
Best predictors of postoperative outcomes following lung resection surgery
FEV1 and DLCO
First step in evaluating solitary pulmonary nodule (SPN)
Comparison with previous x-ray➡stable lesion in 2-3 years▶malignancy ruled out, no further testing
Chest radiograph findings of pulmonary embolism
- Atelectasis (most common)
- Infiltrates
- Pleural effusions
- Westermark’s sign➡peripheral hyperlucency due oligemia
- Hampton’s hump➡peripheral wedge of lung opacity due pulmonary infarction
- Fleischner sign➡enlarged pulmonary artery
Most likely diagnosis in a nonsmoker young patient with liver disease + emphysema (COPD). Treatment.
- Alpha 1-antitrypsin deficiency
- Replace enzyme
Major manifestation of chronic lung transplant rejection
Bronchiolitis obliterans
- 50% of recipients after 5 years posttransplant
- Obstructive pattern on PFT
Most common type of lung cancer in never smokers
*Clinical associations
Adenocarcinoma
*Lung periphery, clubbing, hypertrophic osteoarthropathy
Conditions associated with bronchiectasis
Chronic bronchial obstruction, tobacco use, cystic fibrosis, primary immunodeficiency disorders, Kartagener syndrome, allergic bronchopulmonary aspergillosis
Most common lung malignancy in young nonsmokers
Bronchial carcinoid tumor
Treatment options that improve mortality and delay the progression of COPD
- Smoking cessation
- Oxygen therapy➡benefit directly proportional to the number of hours used
- Influenza and pneumococcal vaccine
Criteria for oxygen use in COPD
- pO2<55, SatO2≤88%
- If pulmonary hypertension, ⬆hematocrit, right-sided heart disease/failure▶pO2<60, SatO2≤90%
Treatment for allergic bronchopulmonary aspergillosis (ABPA)
- Oral steroids
- Oral itraconazole for recurrent episodes
Single most common cause of bronchiectasis
Cystic fibrosis
*Half of the cases
Treatment for specific mutation on cystic fibrosis
- Ivacaftor + lumacaftor➡⬆activity of CFTR in the 5%
of patients who have a specific mutation - Tezacaftor is an alternative.
Results in the pulmonary function test in a restrictive lung disease
- ⬇of everything proportionately: FEV1, FVC, TLC, and residual volume▶FEV1/FVC ratio will be normal
- ⬇DLCO in proportion to the severity of the thickening of the alveolar septum
When you may use steroids for interstitial lung disease?
- If the biopsy shows white blood cell or inflammatory infiltrate
- Berylliosis is the most likely to respond to treatment with steroids
Which treatment could help to decrease the rate of progression of idiopathic pulmonary fibrosis?
- Pirfenidone: antifibrotic➡❌collagen synthesis
- Nintedanib: tyrosine kinase inhibitor➡❌fibrogenic growth factors➡❌fibroblasts
Best initial test and finding in sarcoidosis
Chest x-ray: Hilar adenopathy
Most accurate test and findings in sarcoidosis
Lymph node biopsy: Noncaseating granulomas
Most accurate test for pulmonary hypertension
Right heart or Swanz-Ganz catheter
Treatment options for idiopathic pulmonary hypertension
- Prostacyclin analogs (PA vasodilators): epoprostenol, treprostinil, iloprost, beraprost, or selexipag
- Endothelin antagonists: bosentan, ambrisentan, macitentan
- Phosphodiesterase inhibitors: sildenafil, tadalafil
- cGMP stimulators: riociguat
- Calcium channel blockers
Gastrointestinal manifestation of Sarcoidosis
- Patchy infiltration by noncaseating granulomas in liver (65%)➡mixed cholestatic and hepatocellular changes▶asymptomatic ⬆AST, ALT, AP; Hepatomegaly
- Reticuloendothelial granulomatous infiltration▶splenomegaly
