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IM ITE - ALL > Pulmonary and Critical Care > Flashcards

Pulmonary and Critical Care Flashcards

1
Q

4 Pulmonary Function Tests to measure static lung function

A

Spirometry
Flow-volume loops
Lung volumes
DlCO

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2
Q

decreased DLCO and reduced lung volumes

A

Pulmonary fibrosis

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3
Q

decreased DLCO and normal lung volumes

A

Pulmonary vascular disease, anemia

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4
Q

decreased DLCO and airflow obstruction

A

COPD, bronchiectasis

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5
Q

increased or normal DLCO and airflow obstruction

A

Asthma

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6
Q

increased DLCO

A

Pulmonary hemorrhage, left-to-right shunt, HF, polycythemia

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7
Q

normal DLCO and reduced lung volumes

A

Obesity (extrapulmonary)

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8
Q

Spirometry findings to diagnose airflow obstruction (Asthma, COPD, bronchiectasis)

A
  • FEV1/FVC <70%
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9
Q

Spirometry findings to diagnose airflow obstruction (Asthma)

A
  • ≥ 12% improvement of FEV1 or FVC and increase ≥ 200 mL from baseline from bronchodilator challenge indicates reversible airway disease
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10
Q

Spirometry findings to diagnose restrictive lung disease

A

TLC < 80%

↓ vital capacity and ↑ residual volume

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11
Q

Characteristic findings with Asthma

A

Nasal polyps and Aspirin sensitivity

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12
Q

Rule out test for Asthma

A

normal bronchoprovocation test

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13
Q

Drugs to be discontinued in Asthma

A

BB (use selective BB such as Metoprolol, Atenolol) and stop ASA and NSAIDs

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14
Q

Intermittent Asthma: Symptoms and Tx

A

≤ 2x/weekly, nocturnal Sx ≤ 2x/month
Asymptomatic and normal PEF between exacerbations
Tx: SABA PRN

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15
Q

Mild Persistent Asthma: Sx and Tx

A

Sx > 2x/week or <1x/day, nocturnal Sx >2x/month

Tx: SABA + low dose inhaled glucocorticoid

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16
Q

Moderate Persistent Asthma: Sx and Tx

A

Sx: daily use of SABA, nocturnal Sx ≥ 1x/week, acute nocturnal exacerbations ≥ 2x/week
Tx: SABA + low dose inhaled glucocorticoid
Add: LABA (salmeterol or formoterol) or medium dose inhaled glucocorticoid or long term controller med (leukotriene modifier or theophylline)

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17
Q

Severe Persistent Asthma: Sx and Tx

A

Sx: continuous limiting physical activity, frequent nocturnal Sx
Tx: high dose inhaled glucocorticoid + LABA and possibly oral steroids

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18
Q

When is Omalizumab (monoclonal antibody targeting IgE) indicated in asthma management

A

Inadequate control of Sx w/ inhaled glucocorticoids
Evidence of allergies to perennial aeroallergen
IgE levels 300-700kU/L

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19
Q

Adverse effects of inhaled glucocordicoids

A

thrush, hoarseness, osteopenia (need Ca and Vit D supplementation and early DEXA)

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20
Q

Use of this medication increases mortality when used as single agent

A

LABA

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21
Q

Theophylline used with what medications causes toxicity

A

Fluoroquinolones and Macrolides

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22
Q

Exercise induced asthma Tx

  • Infrequent Sx
  • Sx >2x weekly
A

Infrequent Sx: add cromolyn 15 min before exercise

Frequent Sx >2x/weekly: add Montelukast/Zafirlukast to regular asthma medications depending on severity

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23
Q

Tx of asthma in pregnancy

A

early addition of glucocorticoids is indicated in rapid reversal during excerbation

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24
Q

Tx of severe asthma exacerbation

A

frequent albuterol adminsteration, IV glucocorticoids and inhaled ipratropium
IV magnesium given for life threatning exacerbations
Intubate is signs of respiratory failure

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25
Q

When is continuous O2 therapy recommended in COPD

A

Exercise arterial PO2 ≤ 55mmHg or O2 sat ≤88%

arterial PO2 55-60mmHg w/ signs of tissue hypoxia

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26
Q

what is recommended in COPD when FEV1 <50%

A

Pulmonary rehab

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27
Q

At what FEV1 is lung volume reduction surgery indicated

A

FEV1 ≤ 20%

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28
Q

Patient with Cystic Fibrosis + Abdominal pain

A

Intussusception

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29
Q

Confirmatory test for Cystic Fibrosis

A

Sweat chloride test followed by genetic testing

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30
Q

Cystic Fibrosis patients present with persistent respiratory infections with

A

Pseudomonas aeruginosa or Burkholderia cepacia

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31
Q

What therapy has shown to improve survival and quality of life in pulmonary fibrosis

A

lung transplant

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32
Q

Lofgren Syndrome

A

fever, B/L hilar lymphadenopathy, erythema nodosum, ankle arthritis

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33
Q

Heerfordt Syndrome (uveoparotid fever)

A

anterior uveitis, parotid gland enlargement, facial palsy and fever

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34
Q

Diagnosis of Sarcoidosis

A

Definite diagnosis requires clinical picture, pathologic demonstration of noncaseating granulomas and exclusion of alternate explanations

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35
Q

When can diagnosis of Sarcoidosis be made without histological studies

A

Lofgren and Heerfordt syndromes

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36
Q

Treatment for sarcoidosis

A

Glucocorticoids

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37
Q

Treatment of choice for asymptomatic sarcoidosis

A

None

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38
Q

Treatment for occupational asthma or reactive airway disease

A

inhaled glucocorticoids

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39
Q

Gold standard for diagnosis of occupational lung disease

A

specific inhalation challenge test (spirometry or PEF before and after work)

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40
Q

When are observation and therapy without thoracentesis reasonable with pleural effusions

A

Heart failure, small parapneumonic effusions or following CABG surgery

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41
Q

Light’s criteria

A

Pleural fluid protein/serum protein ratio >0.5
Pleural fluid LDH >200U/L (or >2/3 of upper limit of normal)
Pleural fluid LDH/ serum LDH ratio >0.6

Need 1 criterial met to be considered exudative

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42
Q

Discordant findings in light’s criteria

A

In the setting of ongoing diuresis, serum to pleural fluid albumin gradient is >1.2 g/dL the fluid is most likely transudative

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43
Q

Causes of Bloody pleural fluid

A

malignancy, pulmonary infarction, asbestosis

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44
Q

Causes of >50,000 WBC in pleural fluid

A

empyema, complicated parapneumonic effusion

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45
Q

Causes of lymphocytosis >80% in pleural fluid

A

TB, lymphoma, chronic RA, sarcoidosis

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46
Q

causes of pH <7.0 in pleural fluid

A

complicated parapneumonic effusion, TB, RA, lupus pleuritis, esophageal rupture

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47
Q

Causes of Pleural fluid amylase to serum amylase ration >1

A

pancreatic disease, esophageal rupture, cancer

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48
Q

Causes of Pleural fluid glucose <60mg/dL

A

complicated parapneumonic effusion or empyema, cancer, TB, RA, lupus pleuritis, esophageal rupture

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49
Q

When is chest tube drainage indicated in parapneumonic pleural effusion

A

pH <7.2

pleural fluid glucose <60mg/dL

50
Q

Diagnosis to consider when chylothorax is diagnosed in premopausal woman

A

Pulmonary LAM (lymphangioleiomyomatosis)

51
Q

Risk factors for spontaneous pneumothorax

A

tall men who smoke
cocaine use
Marfan syndrome

52
Q

most common cause of secondary pheumothorax

53
Q

When is pleurodesis indicated

A

after 2nd spontaneous pneumothorax

54
Q

How is pulmonary HTN diagnosed

A

pulmonary artery perssures ≥ 25mmHg

55
Q

Groups in pulmonary HTN

A

Group 1: Primary Pulmonary HTN
Group 2: Left sided heart failure
Group 3: Respiratory disease (COPD, ILD, OSA, etc)
Group 4: chronic veneous thromboembolism

56
Q

Evaluation of Group I Pulmonary HTN

A

Echo: PAP >40mmHg
TEE or Echo w/ bubble to evaluate for intracardiac shunts
Right heart cath to confirm diagnosis and degree of PH
Left heart cath and coronary angiography to exclude LV dysfunction

57
Q

Next step after diagnosis of PAH is confirmed

A

vasoreactive test using vasodilator agents while measuring PAP changes with right heart cath

58
Q

2 diagnostic criteria for chronic thromboembolic pulmonary HTN

A

PAP ≥ 25mmHg in absence of left HF

V/Q scan evidence of chronic thromboembolism

59
Q

Group I PAH treatment

  • Disease that is responsive to vasoreactive testing
  • Mild to Moderate disease
  • Severe disease
  • Treatment refractory disease
A
  • CCB
  • PO meds: PDE-5 inhibitors (Sildenafil or tadalafil) or endothelin receptor antagonists (Bosentan)
  • IV prostacyclin analogue (Epoprostenol)
  • Lung or heart-lung transplant
60
Q

Treatment for CTEPH causing PH

A

life-long anticoagulation

61
Q

Screening TTE for Pulmonary HTN

A

Scleroderma, liver transplant candidates w/ portal HTN, 1st degree relatives of pts w/ familial PAH, pts w/ congenital heart disease w/ shunts.

62
Q

Signs suggestive of Pulmonary AVM

A

Hemoptysis
Mucocutaneous telangiectasias
evidence of R->L pulmonary shunts (hypoxemia, polycythemia, clubbing, cyanosis, stroke, brain abscess)

63
Q

Tx for large pulmonary AVM > 2cm

A

Embolectomy or surgery

64
Q

Lung cancer screening

A

Ages 55-79 w/ 30pack yr smoking hx, those who currently smoke or have quit within last 15 years. Annual low dose CT until age 80 or quit date >15yrs

65
Q

Initial study for hemoptysis

A

Chest X-ray

66
Q

Diagnostic test for hemoptysis

A

Fiberoptic bronchoscopy

67
Q

Definition of solitary pulmonary nodule

A

lesion of lung parenchyma ≤ 3 cm in diameter that is not associated with lymphadenopathy and is not invading other structures.

68
Q

Best diagnostic test for solitary pulmonary nodule

69
Q

First best diagnostic study for solitary pulmonary nodule

A

comparison with pervious chest x-ray

70
Q

Most common primary malignancies that metastasize to lung

A

Carcinomas (colon, kidney, breast, testicle and thyroid)
Sarcomas (bone)
Melanoma

71
Q

Anterior mediastinal masses (4Ts)

A

Thymoma, Teratoma, Thyroid and Terrible Lymphoma

72
Q

Middle mediastinal masses (2)

A

lymph nodes, cysts (pericardial, bronchogenic, etc)

73
Q

Posterior mediastinal masses (1)

A

Neurogenic tumors

74
Q

Apnea hypopnea index:

Mild, Moderate, Severe

A

Mild: AHI 5-15
Mod: AHI 16-30
Severe: AHI >30

75
Q

Screening questionnaire for OSA

76
Q

Treatment of choice for OSA

77
Q

Common features of ARDS (3)

A
  • Acute onset (<1week) of respiratory Sx and hypoxia
  • B/L lung opacities on imaging not otherwise explained by other processes
  • Respiratory failure not explained by HF or volume overload
78
Q

Arterial PO2/FiO2 of Mild, Moderate and Severe ARDS

A

Mild: 200-300mmHg
Mod: 101-200 mmHg
Severe: ≤ 100mmHg

79
Q

Contraindications for NPPV (5)

A 
Respiratory arrest
Arterial blood pH < 7.1
Medical instability
Inability to protect airway and/or excessive secretions
Uncooperative or agitated patient
80
Q

Characteristic findings of auto PEEP

A

wheezing, marked expiratory prolongation, drop in BP, restlessness

81
Q

Stratagies to minimize auto PEEP

A
  • treat airway obstruction (bronchodilators in COPD)
  • decrease RR or TV
  • Increase peak inspiratory flow rate
  • prolong the expiratory phase
  • allow permissive hypercapnia
  • sedate or paralyze patient
82
Q

What interventions in intubated patients can reduce risk of developing VAP (2)

A
  • Semirecumbent position

- selective decontamination of oropharynx (using topical gentamicin, colistin or vancomycin)

83
Q

When is extubation considered

A

when patient is able to maintain arterial O2 >90% on FiO2 ≤ .5, PEEP <5 H2O and pH 7.3

84
Q

Cardiac output, PCWP and SVR in Shock

1) Cardiogenic
2) Hypovolemic
3) Obstructive
4) Anaphylactic
5) Septic

A 
Cardiogenic: ↓ CO, ↑ PCWP, ↑ SVR
Hypovolemic: ↓ CO, ↓ PCWP, ↑ SVR
Obstructive: ↓ CO, ↓ PCWP, ↑ SVR
Anaphylactic: ↑ CO, normal PCWP, ↓ SVR
Septic: ↑ CO, ↓ SVR
85
Q

SIRS Definition

A 
2 or more of following: 
Temp >38C (100.4F) or <36C (96.8F)
HR >90/min
RR >20/min or arterial PCO2 <32 mmHg
Leuk >12000 or <4000 w/ 10% bands
86
Q

When is enteral nutrition recommended in ICU pts

A

recommended at 24-48hrs post admission in hemodynamically stable pts.
25-35kcal/kg/day

87
Q

When is parentral nutrition recommended in ICU pts

A

should not be started before day 7 of acute illness

88
Q

Target BP and Tx for Hypertensive encephalopathy

A

↓ by 15-20% or DBP to 100-110

Tx: Nicardipine, Labetalol, Nitroprusside

89
Q

Target BP and Tx for Ischemic stroke

A

treat if SBP >220 or DBP >120. ↓ by 15%

Target BP<185/110 if candidate for thrombolyticsTx: Nicardipine, Labetalol, Nitroprusside

90
Q

Target BP and 1st line Tx for Hemorrhagic stroke

A

BP 160/90 or mean BP 110

Tx: Nicardipine or Labetelol

91
Q

Target BP, HR and 1st line Tx for Aortic dissection

A

SBP 100-120
Esmolol or labetalol, add nitropursside as needed
Target HR <65/min

92
Q

Target BP and 1st line Tx for MI

A

MAP 60-100

Nitroglycerine and BB

93
Q

Target BP and 1st line Tx for acute left sided HF

A

MAP 60-100

Nitroglycerine and/or Nitroprusside (lowers SVR and improves forward flow)

94
Q

Target BP and 1st line Tx for acute kidney injury

A

↓ 20-25%
Fenoldopam, Nicardipine, BB
ACE inhibitor if scleroderma renal crisis

95
Q

Target BP and 1st line Tx for Preeclampsia, eclampsia

A

SBP 130-150, DBP 80-100

Labetelol, hydralazine

96
Q

Target BP and 1st line Tx for sympathomimetic drug

A

↓ BP by 20-25%
Nicardipine, Nitroprusside
Give Benzodiazepine first, avoid BB

97
Q

Target BP and 1st line Tx for Pheochromocytoma

A

↓ BP by 20-25%

Tx: Phentolamine, Nitroprusside

98
Q

Concentration of epi for anaphylaxis vs anaphylactic shoc

A

Anaphylaxis: IM or subq Epi 0.3-0.5 mg of 1:1000

Anaphylactic shock: IV Epi (1:10,000)

99
Q

Causes of cues for angioedema:

A

Hereditary (low C1 inhibitor and C4 levels)
Acquired C1 inhibitor deficiency (low C1q levels)
ACE inhibitor effect (low C1 inhibitor and C4 levels)

100
Q

Antidote for Acetaminophen toxicity

A

N-acetylcysteine

101
Q

Antidote for Benzodiazepines toxicity

A

Acute benzo use: Flumazenil

Chronic benzo use: Observe b/c reversal w/ flumazenil may potentiate seizures

102
Q

Antidote for Beta Blocker toxicity

A

Glucagon, calcium chloride, pacing

103
Q

Antidote for CCB toxicity

A

Atropine, glucagon, calcium, pacing

104
Q

Antidote for Digoxin toxicity

A

Dig immune fab

105
Q

Antidote for heparin toxicity

A

Protamine sulfate

106
Q

Antidote for narcotic toxicity

107
Q

Antidote for salicylates

A

urine alkalinization, hemodialysis

108
Q

Antidote for TCA

A

blood alkalinization (sodium bicarbonate), alpha agonists

109
Q

What carboxyhemoglobin level is diagnostic for severe acute carbon monoxide poisoning

110
Q

Methanol and Ethanol poisoning treatment

A

Fomepizole

Dialysis (if severe)

111
Q

Anion gap and osmolar gap for ethanol, isopropyl alcohol, methanol, ethylene glycol poisioning

A

Ethanol: NO anion gap, N/A osmolar gap
Isopropyl alcohol: NO anion gap, YES osmolar gap
Methanol: YES anion gap, YES osmolar gap
Ethylene glycol: YES anion gap, YES osmolar gap

112
Q

Sympathomimetic drugs:
What are some examples
Physical manifestation

A

Examples: Cocaine, Amphetamines, ephedrine, caffeine

Manifestations: tachycardia, hypertension, diaphoresis, agitation, seizures, mydriasis

113
Q

Tx for Sympathomimetic drugs

Which drugs to avoid

A

Benzos for agitation

Avoid: BB for HTN, haloperidol can worsen hyperthermia

114
Q

Cholinergic drugs:
Examples
Manifestations

A

Examples: Organophosphates, carbamates, physostigmine, edrophonium, nicotine

Manifestations: confusion, bronchorrhea, bradycardia, miosis

115
Q

Tx for Cholinergic drugs

A

External decontamination for organophosphate poisioning

Atropine, Pralidoxime, mechanical ventilation

116
Q

Anticholinergic drugs:
Examples
Manifestations

A

Examples: antihistamines, TCA, antiparkinson’s agents, atropine

Manifestations: hyperthermia, dry skin and mucous membranes, agitation, delirium, tachycardia, tachypnea, htn, mydriasis

117
Q

Tx for Anticholinergic drugs

A

Physostigmine for peripheral and CNS symptoms

Benzos for agitation

118
Q

Indications for Long term O2 therapy in COPD patients

A

1) Chronic respiratory failure or severe resting hypoxemia, arterial PO2 ≤ 55mmHg or SpO2 of 88% on RA
2) Evidence of pulmonary HTN, right sided heart failure, Polycythemia in combo with arterial PO2 < 60 or SpO2 <88% on RA

119
Q

Indications for lung transplant referral in advanced COPD

A

1) History of exacerbations associated with acute hypercapnia arterial PCO2 >50mmHg
2) Pulmonary HTN, cor pulmonale or both despite O2 tx
3) FEV 1 <20% of predicted or DLCO <20% of predicted
4) Homogeneous distribution of emphysema

120
Q

Absolute contraindications for lung transplant (7)

A

1) malignancy within last 2 years
2) hx of Hep B or C infection with evidence of significant lung damage
3) Recent cigarette smoke
4) drug or alcohol abuse
5) severe psychiatric illness
6) medication non compliance
7) poor social support

121
Q

Relative contraindications for lung transplant (2)

A

1) age >65

2) history of significant co morbidities

122
Q

Weaning criteria for spontaneous breathing trial

A

1) ability to tolerate weaning trial for 30 minutes
2) maintain RR <35/min
3) maintain SpO2 atleast 90% w/o arrhythmias, sudden increase in HR and BP, or development of respiratory distress, diaphoresis or anxiety.

IM ITE - ALL (2 decks)

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