Pulmonary (Exam #2) Flashcards
1
Q
What is always the initial study for pulmonary diagnostics, and what is the preferred view?
A
X-RAY (PA view)
2
Q
What are the six anatomical landmarks that should be considered when reviewing pulmonary diagnostic imaging?
A
- Airway
- Bones
- Cardiac silhouette/PA
- Diaphragm
- Edges
- Fields
3
Q
Why would you consider a high resolution CT (HRCT) over a low dose CT (LDCT), and vice versa?
A
- HRCT: better detail
- LDCT: less detail but good for SCREENING
4
Q
What is the primary risk associated with CT scans (compared to an x-ray), and in what population should this be most considered?
A
MORE RADIATION
- Pediatrics are more radiosensitive than adults
5
Q
What are pediatrics at increased risk for with CT (2)?
A
- Leukemia
- Brain tumors
6
Q
What is there a link between with pregnant women and CT scans?
A
In utero exposure linked to pediatric CA mortality
7
Q
What type of contrast is used for CT? What type of contrast is used for MRI?
A
- CT: iodine
- MRI: Gadolinium
8
Q
What three conditions should be evaluated with contrast on CT scan?
A
- Vessels
- Malignancy
- Chest trauma
9
Q
When using contrast with CT, which three complications/risks should be considered?
A
- Allergic reaction to contrast
- Contrast-induced nephropathy (CNI) = AKI
- Development of lactic acidosis if taking Metformin
10
Q
What two medications can be used to pre-treat an allergy to Iodine contrast?
A
- Prednisone
- Benadryl
11
Q
What two conditions (either or) must be met to be considered contrast-induced nephropathy (CNI)?
A
- Serum Cr >0.5 mg/dL
OR - > 25% from baseline
12
Q
Before using CT WITH contrast, what five risk factors should be considered?
A
- 60+ years old
- History of renal disease
- HTN with meds
- DM
- Taking Metformin
13
Q
What is the preferred method for assessing pulmonary vasculature, and why?
A
CTPA (CT Pulmonary Angiography) - Less invasive - Less expensive - Less time (than Catheter-Directed Pulmonary Angiography (Direct PA))
14
Q
What is the gold standard for PE evaluation?
A
Catheter-Directed Pulmonary Angiography (Direct PA)
15
Q
What two exams should be considered if Catheter-Directed Pulmonary Angiography (Direct PA) is inconclusive, but there is still high suspicion for a PE?
A
- CTPA
- V/Q scan
16
Q
What is the primary risk associated with Magnetic Resonance Imaging (MRI/MRA)?
A
Nephrogenic systemic fibrosis
17
Q
What are the two primary indications for using a V/Q scan?
A
Test of choice for…
- Diagnosis of PE in pregnant women
- Negative CR but high PE suspicion
18
Q
How is a PET scan measured, and what finding is considered “possible malignancy”?
A
FDG via measurement of SUVs
- SUV >2.5 = possible malignancy
19
Q
What finding is considered normal on US, and what finding is indicative of PTX on US?
A
Normal: seashore sign/motion lung beach
- PTX: barcode/stratosphere sign
20
Q
What pulmonary diagnostic tool is commonly used in patients with obstruction of trachea or proximal bronchus?
A
Rigid Bronchoscopy
21
Q
What two things can be determined using FEV-1/FVC ratio?
A
- Determine obstructive vs. restrictive
- Define severity of obstruction
22
Q
What position is preferred for spirometry testing, and why?
A
Sitting preferred
- Less likelihood of syncope
23
Q
What is the technique for spirometry testing (5 steps)?
A
- TIGHT SEAL over mouthpiece
- Relax and breathe normally
- Take deep breath in
- Forcefully exhale all air
- Take another deep breath in, then STOP
24
Q
What test is used to evaluate reversibility, and for what disease is this often used?
What two findings are indicative of reversibility?
A
Bronchodilator Testing (specifically for asthma, which is reversible) - Reversibility if FEV-1 increases by 12% AND 200 mL
25
What is the technique for bronchodilator testing (3 steps)?
1. Perform spirometry to obtain a baseline value
2. Using nebulizer or inhaler, 2-4 puffs of bronchodilator medication (hold for 5-10 seconds)
3. Perform spirometry again, 15 minutes after medication inhaled
26
What is another name for the Methacholine Challenge Test, and for what disease is this often used? What is the technique for this test (2 steps)?
What finding is indicative of a positive test?
Bronchoprovocation (specifically to confirm diagnosis of asthma)
1. Give Methacholine (vasoconstrictor) via nebulizer
2. Perform spirometry at 30 seconds and 90 seconds → (Methacholine concentration increases during this time)
- Positive test if FEV-1 decreases by 20%
27
What type of disease are these conditions classified as: Asthma, Asthmatic Bronchitis, COPD, Cystic Fibrosis, Emphysema, Upper Airway Obstruction? What does this mean?
Obstructive Disease
- Trouble blowing OUT air
- High lung volume
28
What type of disease are these conditions classified as: Pulmonary Fibrosis, infectious lung disease, thoracic deformities, Pleural Effusion, tumors, neuromuscular diseases, obesity? What does this mean?
Restrictive Disease
- Trouble getting air IN
- Reduced lung volume
29
What are these tests results indicative of: TLC and RV increased; FEV-1 and FEV-1/FVC decreased; FVC normal (hint: think GENERAL)?
Obstructive Disease
30
What are these tests results indicative of: TLC, FVC, RV and FEV-1 decreased; FEV-1/FVC normal or increased (hint: think GENERAL)?
Restrictive Disease
31
What is the technique for Diffusion Capacity (DLCO) testing (3 steps)?
What finding is indicative of a positive test?
1. Inhale a single breath of gas (helium/CO)
2. Expire
3. Measure exhalation
- Diseased lungs = higher CO levels measured in exhaled gas
32
What condition specifically involves cough (nocturnal) often longer than 3 weeks; wheezing?
Asthma
| - Wheezing is HALLMARK
33
What condition specifically involves increased AP diameter from air trapping, wheezing with prolonged expiratory phase?
Asthma
34
Which two triads are associated with Asthma, and what are the three components of each?
- ASA Triad/Samter’s Triad: sinus disease with nasal polyps, ASA sensitivity, severe asthma
- Atopic Triad: atopic dermatitis, allergic rhinitis, asthma
35
What is the diagnostic test of choice for Asthma, and at what age range is it recommended?
Spirometry
| - Recommended >5 years
36
What are the five components of Intermittent Asthma?
- Symptoms less than/equal to 2 days/week
- Nighttime awakenings less than/equal to 2 nights/month if 5+ years; none if 0-4 years
- FEV-1 >80%
- Normal activity
- Less than/equal to 2 days/week SABA use to control sxs
37
What are the five components of Mild Persistent Asthma?
- Symptoms 2+ days/week (NOT daily)
- Nighttime awakenings 3-4 nights/month if 5+ years; 1-2 nights/month if 0-4 years
- FEV-1 >80%
- Minor limitations in activity
- 2+ days/week SABA use to control sxs
38
What are the five components of Moderate Persistent Asthma?
- Daily symptoms
- Nighttime awakenings 1+ nights/week if 5+ years (not nightly); 3-4 nights/month if 0-4 years
- FEV-1 60-80%
- Some activity limitations
- Daily SABA use to control sxs
39
What are the five components of Severe Persistent Asthma?
- Symptoms throughout the day
- Nighttime awakenings nightly if 5+ years; 1+ nights/week if 0-4 years
- FEV-1 <60%
- Extremely limited physical activity
- SABA use several times/days to control sxs
40
What is the recommended treatment for Intermittent Asthma?
SABA as needed
| - Note: used in all stages PRN
41
What is the recommended treatment Mild Persistent Asthma?
Daily low dose ICS (inhaled corticosteroid)
| - Montelukast/Cromolyn if peds
42
What is the recommended treatment Moderate Persistent Asthma (2, consider age)?
- Medium dose ICS + referral if 0-4 years
| - Low dose ICS + LABA if 5+ years
43
What is the recommended treatment Severe Persistent Asthma (2)
- Medium dose ICS + LABA
| - Montelukast + referral
44
If Asthma is poor controlled, what are the treatment options for Step 5 and Step 6 (2 each)?
Step 5:
- High dose ICS + LABA
- Montelukast + referral
Step 6:
- High dose ICS + LABA + OCS (oral corticosteroids)
- Montelukast + OCS + referral
45
What is the recommended follow up for Asthma?
Follow up should occur 3 months initially
| - Then every 3-12 months depending on severity
46
What are the three possible results of PEFR (Peak Expiratory Flow Rate), and what disease is it used to evaluate?
Asthma (Acute Asthma Exacerbation)
- Green: >80% = good control
- Yellow: 50-80% = caution, SABA + med
- Red: <50% = medical emergency/ED
47
What condition involves inflammation → small airway disease AND/OR parenchymal destruction → airflow limitation?
COPD
48
What condition involves infiltration of submucosal layer by neutrophils; causes mucous gland enlargement → hypersecretion → loss of ciliary transport?
COPD
49
What component of COPD involves airway inflammation, airway remodeling = breathing through small straw?
Small airway disease
50
What component of COPD involves loss of alveolar attachments, decreased elastic recoil = balloon vs. brown bag?
Parenchymal destruction
51
What condition involves dyspnea, chronic cough, sputum production; DOE is early sxs?
COPD
52
What condition involves tobacco smoke, host factors (AATD, asthma, childhood URIs), occupation hazards, pollution?
COPD
53
Why is tobacco smoking a significant risk factor for COPD?
- Smoking stimulates elastase → elastase creates degenerative changes in elastin, release of cytotoxic oxygen radicals from WBCs = further tissue damage
54
What is the most common cause of Cor Pulmonale, and what is this?
RHF due to lung etiology
55
What condition involves barrel chest (increased AP diameter), prolonged expiration, abnormal breath sounds (decreased, wheezing, rhonchi), pursed lip breathing, tripod positioning, cyanosis?
COPD
56
What condition involves pursed lip breathing, tripod positioning, cyanosis?
COPD
57
What is the required diagnosis for COPD?
Spirometry
58
What condition should be considered if sxs in young patient (less than 45 years), non-smoker, FH of emphysema? What disease is this a risk factor for?
Alpha-1 Antitrypsin (AAT)
| - Risk factor for COPD
59
Which condition involves CXR showing signs of air trapping; blebs or bullae = emphysema?
COPD
60
What is the 1st line treatment for COPD? What two other treatment measures should also be considered?
Prevent progression
- Smoking cessation
Also, vaccinations (Influenza and Pneumococcal) and supplemental O2 (15+ hours/day → increased survival)
61
What is the treatment recommendation for Grade A COPD?
Bronchodilator
62
What is the treatment recommendation for Grade B COPD (2)?
- LAMA
OR
- LABA
63
What is the treatment recommendation for Grade C COPD?
LAMA
64
What is the treatment recommendation for Grade D COPD (2)?
- LAMA
OR
- LAMA-LABA
65
What are the two classifications of bronchodilators, and what is the name hint for each?
- Beta2-Agonist ("-erol")
| - Anticholinergic ("-ium")
66
What is the recommended short-acting Beta2-Agonist to treat COPD? Long-acting (2)?
- SABA: Albuterol
| - LABA: Salmeterol or Formoterol
67
What is the recommended short-acting Anticholinergic to treat COPD? Long-acting (2)?
- SABA: Ipratropium bromide
| - LABA Tiotropium bromide or Umeclidinium
68
When are corticosteroids recommended for treatment of COPD, and what are the two LABA-ICS we learned about?
Mostly used if COPD + Asthma
- Advair
- Symbicort
69
What is the recommended treatment for those with COPD + alpha-1 antitrypsin deficiency (AAT)?
Antiprotease Therapy
70
What condition involves acute changes in baseline dyspnea, cough, sputum to warrant a change in therapy?
Acute Exacerbations of COPD
71
What is the most common trigger associated with Acute Exacerbations of COPD?
Respiratory illness (viral vs. bacterial)
72
What is the recommended treatment for Acute Exacerbations of COPD (2)?
- Increase frequency of SABA (Beta2 Agonist recommended)
| - Oral steroids (Prednisone 40mg daily for 5 days)
73
What is the recommended oral steroid dose for Acute Exacerbations of COPD?
Prednisone 40mg daily for 5 days
74
How do you classify Acute Exacerbations of COPD (mild vs. moderate/severe)? What is the treatment for moderate/severe?
- Mild: worsening of 1 of 3 cardinal sxs
- Moderate/Severe: worsening of 2 OR 3 of 3 cardinal sxs = need abx (Macrolide or Fluoroquinolone); if severe, also hospitalization
75
What education/treatment is always considered for bronchitis AND pneumonia?
- Smoking cessation
| - Vaccinations
76
What is the most common etiology of Bronchitis?
VIRAL
| - Influenza A & B
77
If Bronchitis is not viral, what is the second most common etiology (hint: pathogen)?
BACTERIAL 2nd
| - Bordetella pertussis
78
What condition involves cough +/- sputum production for 5+ days for 1-3 weeks?
ACUTE Bronchitis
79
What does the presence of purulent sputum indicate?
NOTHING
| - Certainly does not indicate bacterial infection
80
What condition involves at least 3 months of cough and sputum on most days of month for 2 consecutive years?
CHRONIC Bronchitis
81
What two PE findings are most commonly seen with Bronchitis? Which two findings should be negative?
- Wheezing
- Rhonchi that clears with coughing
Negative for crackles/rales or signs of consolidation
82
What is the recommended treatment for Bronchitis? Which four medications might be considered?
SUPPORTIVE
- NSAIDs
- Ipratropium
- Antitussives
- Albuterol/SVN
83
Which medication should always be avoided in the treatment of Bronchitis?
NO CODEINE
84
What specific condition involves prolonged progressive cough with whopping sound?
Bacterial Bronchitis
| - Bordetella pertussis = “Whooping Cough”
85
What specific condition involves catarrhal (1-2 weeks) of URI/fever → paroxysmal (2-6 weeks) of cough and “whooping” → convalescent (weeks to months) where cough gradually resolves?
Bacterial Bronchitis
| - Bordetella pertussis = “Whooping Cough”
86
What is the recommended diagnosis method for Bacterial Bronchitis (Bordetella pertussis = “Whooping Cough”)? What other two methods are often used, and in what time period?
Bacterial culture
- PCR if first 4 weeks
- Serology if 2-8 weeks
87
What is the treatment for Bacterial Bronchitis (Bordetella pertussis = “Whooping Cough”), and what is the primary goal?
Antibiotics
| - Used to decrease transmission NOT resolve sxs
88
What are the two antibiotics that can be used to treat Bacterial Bronchitis (Bordetella pertussis = “Whooping Cough”)?
- Macrolides (Azithromycin or Clarithromycin, Erythromycin)
OR
- Bactrim
89
What two conditions should ALWAYS be reported to the State Health Department?
- Bacterial Bronchitis (Bordetella pertussis = “Whooping Cough”)
- TB
90
Influenza (Viral Bronchitis) is typically considered self-limited, but what complication should always be considered?
PNA
91
What 7 populations are considered high-risk for Influenza (Viral Bronchitis)?
- <2 years
- 65+ years
- Immunocompromised
- Underlying chronic disease
- Pregnant
- Morbidly obese
- Resident of nursing home/chronic care facility
92
What condition involves fever, HA, myalgia, malaise?
Influenza (Viral Bronchitis)
93
What two medications should be considered for treatment of Influenza (Viral Bronchitis), and within what time period?
Within 48 hours of sxs onset:
- Tamiflu
- Relenza
- NOTE: reduces duration of sxs but not sxs themselves
94
What condition is an acute infection of pulmonary parenchyma?
Pneumonia
95
What specific condition involves aspiration from oropharynx?
Community-Acquired Pneumonia (CAP)
96
What specific condition involves inhaled contaminated droplets; via blood; infected pleura; pathogens proliferate faster/more than macrophages can handle → inflammatory response to increase defenses?
Community-Acquired Pneumonia (CAP)
97
What is the most common etiology of Community-Acquired Pneumonia (CAP), and what are the two most common etiologies?
BACTERIAL
- Streptococcus pneumoniae for typical
- Mycoplasma pneumonia for atypical
98
What specific condition involves acute onset fever and cough +/- sputum, hemoptysis, SOB, sweats, CP?
Community-Acquired Pneumonia (CAP)
| - TYPICAL
99
What condition involves decreased/bronchial breath sounds, crackles/rales, signs of consolidation (dullness, increased tactile fremitus, bronchophony – spoken words louder/clearer, egophony – spoken “E” heard as “A”)?
Community-Acquired Pneumonia (CAP)
100
What condition involves infiltrate, consolidation, cavitation on CXR?
Community-Acquired Pneumonia (CAP)
101
What might be seen on labs for Community-Acquired Pneumonia (CAP)?
Leukocytosis with left shift = bacterial
102
What newer diagnostic test is being used for Community-Acquired Pneumonia (CAP) (hint: can differentiate bacterial vs. viral)?
Procalcitonin and CRP
103
What is the #1 predictor of good outcome for Community-Acquired Pneumonia (CAP)?
Right site of care
| - OP vs. IP vs. ICU
104
What is the specific recommended treatment for uncomplicated Community-Acquired Pneumonia (CAP) (2)?
ABX FOR 5 DAYS:
- Macrolide (Azithromycin)
OR
- Doxycycline
105
What is the specific recommended treatment for complicated Community-Acquired Pneumonia (CAP) (__ + __, OR __)?
ABX FOR 5 DAYS:
- Beta-Lactam (Augmentin) + Macrolide (Azithromycin)
OR
- Levaquin
106
What nine conditions classify as complicated Community-Acquired Pneumonia (CAP)?
- Recent abx use
- COPD
- Liver/renal disease
- CA
- DM
- CHF
- Alcoholism
- Immunocompromised
- Asplenia
107
What condition is CURB-65 used for, and what are the conditions?
Pneumonia Risk Stratification:
- Confusion
- Urea/BUN HIGH
- Respiratory rate high
- BP high
- 65+ years
108
What condition involves 48+ hours after admission; high risk if ICU or mechanical ventilation?
Hospital-Acquired Pneumonia (HAP)
109
What condition involves subtype of HAP that developed 48-72 hours after intubation?
Ventilator-Associated Pneumonia (VAP)
110
What condition involves altered upper respiratory tract flora (2)?
- Hospital-Acquired Pneumonia (HAP)
| - Ventilator-Associated Pneumonia (VAP)
111
What conditions indicate a diagnosis of Hospital-Acquired Pneumonia (HAP) or Ventilator-Associated Pneumonia (VAP) (__ AND __)?
- New/progressive infiltrate on imaging
AND
- 2+ of fever, purulent sputum, leukocytosis
112
What is the recommended treatment for Hospital-Acquired Pneumonia (HAP)
and Ventilator-Associated Pneumonia (VAP)?
Abx PROMPTLY
113
What specific condition is associated with HIV/AIDS (low CD4 count)?
Pneumocystis jirovecii PNA (PCP)
114
What specific condition involves gradual onset fever, nonproductive cough, SOB?
Pneumocystis jirovecii PNA (PCP)
115
What specific condition involves reticular/groundglass opacities on CXR?
Pneumocystis jirovecii PNA (PCP)
116
What is the specific recommended treatment for Pneumocystis jirovecii PNA (PCP)?
BACTRIM
- High mortality if NOT treated
- Abx prophylaxis if high risk
117
What specific condition involves displacement of gastric contents to lung → injury and infection?
Aspiration PNA
118
What three conditions are considered risk factors for Aspiration PNA?
- Post-op state
- Neuro compromise
- Anatomical defect
119
What specific condition involves RLL infiltrate most common on CXR?
Aspiration PNA
120
What is the recommended treatment for Aspiration PNA?
ABX
121
What condition involves progressive scarring of lung tissue around alveoli?
Interstitial Lung Disease (ILD) = Diffuse Parenchymal Lung Disease (DPLD)
122
What condition is considered irreversible?
Interstitial Lung Disease (ILD)
123
What condition involves process of fibrosis and aberrant healing response?
Interstitial Lung Disease (ILD)
124
What condition involves progressive DOE, persistent nonproductive cough +/- systemic sxs?
Interstitial Lung Disease (ILD)
125
What condition involves crackles (“velcro-like”)?
Interstitial Lung Disease (ILD)
126
What condition involves
Interstitial Lung Disease (ILD)
127
What condition involves inspiratory squeaks/high-pitched rhonchi?
Interstitial Lung Disease (ILD)
128
What is the recommended treatment for Interstitial Lung Disease (ILD)?
Lung tissue biopsy
129
What condition involves groundglass appearance, reticular “netlike” CXR?
Interstitial Lung Disease (ILD)
130
What finding is indicative of poor prognosis for Interstitial Lung Disease (ILD)?
Honeycombing on CXR
131
What is the preferred imaging for Interstitial Lung Disease (ILD)?
HRCT
| - Greater diagnostic accuracy
132
What three labs should be ordered to rule out autoimmune associated with Interstitial Lung Disease (ILD)?
- ANA
- RF
- CCP
133
What finding on PFT is indicative of Interstitial Lung Disease (ILD)? What other diagnostic test can be seen with early disease?
RESTRICTIVE disease
- Low TLC
- Low FEV-1 and FVC
- Normal FEV-1/FVC ratio
Reduced DLCO seen with early disease
134
What is the most common type of Interstitial Lung Disease (ILD)?
Idiopathic Pulmonary Fibrosis (IPF)
135
What specific condition involves gradual onset DOE and nonproductive cough (6+ months)?
Idiopathic Pulmonary Fibrosis (IPF)
136
What specific condition involves velcro/coarse crackles (inspiratory); digital clubbing?
Idiopathic Pulmonary Fibrosis (IPF)
137
What specific condition HCRT (reticular opacities, traction bronchiectasis, honeycombing); restrictive pattern on PFTs?
Idiopathic Pulmonary Fibrosis (IPF)
138
What specific condition is associated with usual interstitial PNA (UIP) (seen on HRCT and lung biopsy)?
Idiopathic Pulmonary Fibrosis (IPF)
139
What are the three recommended treatments for Idiopathic Pulmonary Fibrosis (IPF)? What is the definitive cure for Idiopathic Pulmonary Fibrosis (IPF)?
Lung transplant = definitive
- Treat for GERD
- Nintedanib (TKI)
- Pirfenidone
140
What condition involves non-necrotizing granulomas?
Sarcoidosis
141
What condition presents as female AAs 20-40 years, non-smoker?
Sarcoidosis
142
What condition involves DOE, CP, cough; Erythema nodosum, Lupus pernio, Granulomatous uveitis, arthralgias?
Sarcoidosis
143
What condition involves hilar adenopathy on CXR? What two findings will be seen on labs?
Sarcoidosis
- Elevated serum ACE
- Elevated serum calcium
144
What type of tissue biopsy can be used for Sarcoidosis?
EBUS-TBLB tissue biopsy
145
What is the 0, 2 and 4 staging on CXR for Sarcoidosis? At what staging level is treatment recommended?
- 0 = normal
- 2 = hilar adenopathy + diffuse infiltrates
- 4 = fibrosis
No treatment until stage 2 OR symptomatic
146
What is the recommended pharmacologic treatment for Sarcoidosis?
Steroids +/- immunosuppressants
147
What condition involves inhalation of mineral dust, and what are the three types?
Pneumoconiosis
- Silicosis
- Coal Worker’s Pneumoconiosis (CWP)
- Asbestosis
148
What specific condition involves fibronodular lung disease due to inhalation of silica dust?
Silicosis
| - Type of Pneumoconiosis
149
What risk factor makes Silicosis (type of Pneumoconiosis) worse?
Smoking
150
What condition is also called the "Black Lung"?
Coal Worker’s Pneumoconiosis (CWP)
| - Type of Pneumoconiosis
151
What condition involves inhalation of coal dust; black masses?
Coal Worker’s Pneumoconiosis (CWP)
| - Type of Pneumoconiosis
152
For Silicosis and Coal Worker’s Pneumoconiosis (CWP) (types of Pneumoconiosis), what two diagnostic tests are typically recommended? What finding will be seen with Silicosis?
CXR then HRCT
| - “Crazy paving” pattern on HCRT for Silicosis
153
For Silicosis and Coal Worker’s Pneumoconiosis (CWP) (types of Pneumoconiosis), if chronic SIMPLE, what finding will be seen on imaging?
Eggshell pattern
154
What is the exposure time and expected progression for chronic SIMPLE Silicosis and Coal Worker’s Pneumoconiosis (CWP) (types of Pneumoconiosis)?
- 10-12 years exposure
| - Non-progressive once exposure eliminated
155
For Silicosis and Coal Worker’s Pneumoconiosis (CWP) (types of Pneumoconiosis), if chronic COMPLICATED, what finding will be seen on imaging?
Angel-wing
156
What is the exposure time and expected progression for chronic COMPLICATED Silicosis and Coal Worker’s Pneumoconiosis (CWP) (types of Pneumoconiosis)?
- 20 years exposure
| - Progressive even after no exposure
157
For all three types of Pneumoconiosis, what is the recommended treatment?
If acute (not chronic), what additional treatment can be considered?
Supportive (tx will NOT change disease course)
If acute, consider steroids
158
With Asbestosis (type of Pneumoconiosis), what does smoking put you at increased risk for?
Smoking increases risk for bronchogenic CA
159
What specific condition involves lower lung opacities and pleural plaques on CXR?
Asbestosis
| - Type of Pneumoconiosis
160
For which specific condition is lung biopsy NOT recommended?
Asbestosis
| - Type of Pneumoconiosis
161
What form of CA most associated with Asbestosis
Mesothelioma
| - Rare, poor prognosis
162
What specific condition involves repetitive inhalation of antigens in susceptible host?
Hypersensitivity Pneumonitis
163
Of al the Interstitial Lung Diseases (ILD), which type is considered reversible?
Hypersensitivity Pneumonitis
164
Which specific condition involves etiology of causative agent – bacteria/fungi/mold; proteins/chemicals; environmental exposures (birds, hot tub)?
Hypersensitivity Pneumonitis
165
What three medications are recommended treatment for Hypersensitivity Pneumonitis, and which is best for chronic stages?
- Steroids (usually for chronic)
- Bronchodilators
- Antihistamines
166
Which specific condition involves systemic vasculitis of small/medium vessels?
Granulomatosis with Polyangiitis (GPA)
167
What specific condition involves necrotizing granulomas?
Granulomatosis with Polyangiitis (GPA)
168
What specific condition involves infiltrates and cough; renal failure; skin (palpable purpura, ulcers); ocular, ENT, MSK, cardiac, PNS?
Granulomatosis with Polyangiitis (GPA)
169
What specific condition involves stellate-shaped peripheral pulmonary aa. on CT Chest?
Granulomatosis with Polyangiitis (GPA)
170
What specific condition involves elevated ESR/CRP and C-ANCA?
Granulomatosis with Polyangiitis (GPA)
171
What specific condition involves proteinuria or RBC casts (glomerulonephritis)?
Granulomatosis with Polyangiitis (GPA)
172
What two specialties should be consulted for Granulomatosis with Polyangiitis (GPA)?
Rheum AND Pulm
173
What are the two recommended medications for treatment of Granulomatosis with Polyangiitis (GPA)?
- Cyclophosphamide/Rituximab
| - Steroids
174
What are two possible causes of Treatment-Related ILD, and what is the recommended treatment?
- Drug-induced
- Radiation-induced
Discontinue drug and begin steroids
175
Interstitial Lung Disease (ILD) can be associated with what group of diseases?
Connective Tissue diseases
| - Absence of extrapulmonary symptoms does NOT exclude CT disease
176
What three subtypes of Interstitial Lung Disease (ILD) are most associated with smoking? If smoking cessation is achieved, what will be the result?
- RB-ILD (Respiratory Bronchiolitis-Associated ILD)
- DIP (Desquamative Interstitial Pneumonitis)
- PLCH (Pulmonary Langerhans Cell Histiocytosis)
Most patients have significant improvement/complete remittance with smoking cessation
177
What is a possible complication of Interstitial Lung Disease (ILD), and how does this occur?
Cor Pulmonale
| - As lungs stiffen, pulmonary aa. dilate → blood backs up into heart and causes RV dysfunction
178
What is the most significant risk factor associated with lung CA?
SMOKING
179
For lung CA, what is small, smooth, well-defined lesion (“coin lesion”); often benign?
Solitary Pulmonary Nodule (SPN)
180
What is the most common type of Solitary Pulmonary Nodule (SPN) if benign?
Infectious granulomas
181
What is the diagnostic process for Solitary Pulmonary Nodule (SPN) (hint: what is the recommended radiography)?
1. Review old films
| 2. Helical CT without contrast
182
Diagnostically, what three findings are more indicative of a BENIGN Solitary Pulmonary Nodule (SPN)?
- Minimal growth in 2 years
- Calcification
- Small/smooth/well-defined
183
Diagnostically, what four findings are more indicative of a MALIGNANT Solitary Pulmonary Nodule (SPN)?
- Rapid growth
- NO calcification
- Poorly defined or irregular
- Larger size (5+ cm)
184
If solid SPN is 8+ mm with LOW probability of malignancy, what is the recommended diagnostic plan?
CT at 3 months
| - If no growth, f/u CT at 9-12 and 18-24 months
185
If solid SPN is 8+ mm with INTERMEDIATE probability of malignancy, what is the recommended diagnostic plan?
FDG PET scan/CT +/- biopsy
186
If solid SPN is 8+ mm with HIGH probability of malignancy, what is the recommended diagnostic plan?
Biopsy or excision
187
If solid SPN is 6-8 mm, what is the recommended diagnostic plan?
CT at 6-12 months
188
If solid SPN is <6 mm, what is the recommended diagnostic plan?
No follow up required
| - Optional CT at 12 months
189
What are the three types of Non-Small Cell Carcinoma (NSCLC)?
- Adenocarcinoma
- Squamous Cell Carcinoma
- Large Cell Carcinoma
190
What type of lung CA arises centrally and is aggressive with poor prognosis?
Oat Cell Carcinoma
| - Type of Small Cell Lung Cancer (SCLC)
191
What type of lung CA is strongly associated with smoking?
Oat Cell Carcinoma
| - Type of Small Cell Lung Cancer (SCLC)
192
What type of lung CA involves hilar mass, mediastinal LAD; cough?
Oat Cell Carcinoma
| - Type of Small Cell Lung Cancer (SCLC)
193
What type of lung CA commonly involves brain metastasis?
Oat Cell Carcinoma
| - Type of Small Cell Lung Cancer (SCLC)
194
What three types of paraneoplastic syndromes are associated with Oat Cell Carcinoma (type of SCLC)?
- SIADH
- Cushing’s
- Eaton-Lambert
195
What two syndromes are associated with Oat Cell Carcinoma (type of SCLC)?
- Paraneoplastic syndromes (SIADH, Cushing’s, Eaton-Lambert)
| - SVC syndrome
196
What is the most common type of Non-Small Cell Lung Cancer (NSCLC)?
Adenocarcinoma
197
What type of lung CA arises peripherally and is often due to smoking?
Adenocarcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
198
What two types of lung CA metastasize to distant organs?
- Adenocarcinoma
- Large Cell Carcinoma
Both types of Non-Small Cell Lung Cancer (NSCLC)
199
What type of lung CA is more associated with SVC Syndrome?
NSCLC > SCLC
200
What type of lung CA is associated with thrombophlebitis, clubbing?
Adenocarcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
201
What type of lung CA can arise centrally OR peripherally?
Large Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
202
What type of lung CA extends into hilum/mediastinum; slow growth?
Squamous Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
203
What type of lung CA involves cough/hemoptysis?
Squamous Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
204
What type of lung CA can be associated with PTH (hypercalcemia)?
Squamous Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
205
What type of lung CA can cavitate; may be able to detect via sputum cytology?
Squamous Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
206
What type of lung CA can be associated with excess hCG production?
Large Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
207
What is the most common symptom associated with a primary lesion lung CA?
COUGH
208
While hemoptysis may be indicative of CA, what condition is it most associated with?
Bronchitis
209
If lung CA presents as pleural effusion, pericardial effusion, hoarseness, what type of etiology should be considered?
Intrathoracic spread
210
What two syndromes are associated with intrathoracic spread of lung CA?
- SVC Syndrome
| - Pancoast Syndrome
211
What is the gold standard diagnosis for SVC Syndrome?
Superior vena cavogram
212
What specific condition involves SOB, facial swelling, dilated neck veins? What condition is this associated with?
SVC Syndrome
| - Associated with intrathoracic spread of lung CA
213
What specific condition involves tumor involving superior sulcus that compresses brachial plexus/cervical SNS?
Pancoast Syndrome
| - Associated with intrathoracic spread of lung CA
214
What specific condition involves ipsilateral side of tumor, if pain: proximal → distal (closer to tumor)?
Pancoast Syndrome
| - Associated with intrathoracic spread of lung CA
215
What specific condition may involve Horner’s syndrome (injury to SNS of face = miosis, anhidrosis, ptosis)?
Pancoast Syndrome
| - Associated with intrathoracic spread of lung CA
216
What specific conditions are triggered by altered immune response to neoplasm?
Paraneoplastic syndromes
| - Associated with lung CA, specifically Oat Cell Carcinoma (SCLC)
217
What specific conditions can involve hematologic findings like hypercalcemia (bone destruction), anemia, leukocytosis, thrombocytosis, hypercoagulation?
Paraneoplastic syndromes
| - Associated with lung CA, specifically Oat Cell Carcinoma (SCLC)
218
What specific conditions can involve endocrine findings like PTH-like substance (hypercalcemia); excess HCG production (gynecomastia, milky nipple discharge); SIADH (irritable, restless, personality changes, AMS); Cushing’s Syndrome (muscle weakness, weight loss, HTN, hirsutism) = worse prognosis?
Paraneoplastic syndromes
| - Associated with lung CA, specifically Oat Cell Carcinoma (SCLC)
219
What specific conditions can involve endocrine findings like Eaton-Lambert Syndrome (low ACh → muscle weakness, hyporeflexia)?
Paraneoplastic syndromes
| - Associated with lung CA, specifically Oat Cell Carcinoma (SCLC)
220
What is the most common site of metastasis for lung CA? What other three sites should be considered?
LIVER MOST COMMON
| - Also bone, adrenal glands, brain
221
What is the GOLD STANDARD diagnostic tool for lung CA? What other diagnostic tool should also be utilized?
TISSUE BIOPSY
| - Also, PET with FDG
222
What staging system is used for SCLC? Describe it.
Limited vs. Extensive
- Limited: ipsilateral hemithorax
- Extensive: extends beyond hemithorax + pleural effusions
223
What staging system is used for NSCLC? Describe it.
TNM system
- T (primary tumor)
- N (nodal involvement)
- M (distant metastases)
224
What PFT finding is the strongest indicator of post-op complications with lung CA?
FEV-1 <60%
225
What is the recommended treatment for SCLC? How well does this typically work?
Chemotherapy regardless of stage
| - Initially responds well but aggressive so relapse common
226
What is the recommended treatment for NSCLC?
Surgical resection
227
What stage of NSCLC has the best prognosis?
Stage 1 has best prognosis with surgery (75% 5-year survival)
228
If a patient is in late stages of NSCLC (late = IIIB-IV), what treatment is recommended?
Radiation or combination chemo
229
Generally, is SCLC or NSCLC more aggressive? Which has the worse prognosis?
SCLC is more aggressive = worse prognosis
230
What diagnostic tool is used for screen for lung CA in high-risk patients? What is considered high risk?
LDCT
- Current smokers
- Quit within 15 years
- 20 pack-year hx with 1 RF
231
What three medications can be considered for smoking cessation?
- Wellbutrin (Zyban)
- Chantix
- Nicotine replacement (prescription or OTC)
232
If prescribing Wellbutrin (Zyban), what risk in children should be considered? What other two side effects should be considered?
Increased risk of suicide in children/young adults
| - AE of seizures, weight loss
233
What condition requires prolonged exposure; MUST be active to spread?
TB
234
What condition involves fever; cough (dry, 3+ weeks); pleuritic CP; weight loss; primarily affects lungs?
TB
235
What is the most common form of TB, and how does it typically present?
Latent TB (LTBI) = most common
- NO symptoms
- CANNOT to be transmitted
236
Why would TB go from latent to active?
Active if immune system unable to fight infection (esp. HIV or DM)
237
What condition involves risk factors of immunocompromised (HIV, DM, children, silicosis); immigrants from areas of high exposure; IVDU; close living quarters?
TB
238
What condition involves posttussive crackles; dull/decreased fremitus?
TB
239
Under what two conditions would a CXR be indicated to test for TB?
- Positive infection
| - Symptomatic
240
Which test involves intradermal forearm; read in 2-3 days; measure induration? What disease is it evaluating for?
TST (Mantoux Tuberculin Skin Test)
| - Evaluating for TB
241
In what population would a TST test result of 15+ mm be seen?
Positive in anyone (even without TB risk factors)
242
In what seven populations would a TST test result of 10+ mm be seen?
- Recent immigrants from countries with high TB rates
- HIV-negative IVDU
- Lab personnel
- Residents/employees of prisons, HC facilities, etc.
- Persons with certain high-risk medical conditions
- Children <4 years
- Children exposed to adults at high risk
243
In what five population would a TST test result of 5+ mm be seen?
- HIV+
- Recent contact with active TB
- Evidence of TB on CXR
- Immunosuppressed patients
- Organ transplant patients
244
What test should be considered for evaluation of TB that can be used in place of TST if non-compliance concerns or received BCG?
IGRA
| - Blood TB test
245
What condition involves CXR findings of the apical/posterior upper lobes?
TB
246
What is Ghon lesion (calcified parenchymal granuloma), ipsilateral calcified hilar lymph node? What disease is this associated with?
Ranke Complex
| - Associated with TB
247
What three tests can be done using sputum collection? How is sputum collected performed?
Sputum: 3 specimens 8-24 hours apart
- Smear = Acid Fast Bacilli (AFB)
- Cytology = Nucleic Acid Amplification Test (NAA)
- Culture = gold standard
248
If AFB and NAA both positive, what does this indicate, and what is the next treatment step?
TB disease is presumed = start treatment
249
If TB culture is positive, what does this indicate, and what is the next treatment step?
TB disease confirmed = treatment + Drug Susceptibility Testing (DST)
250
If TB culture is negative but TB suspected still, what is the next treatment step?
Treatment and monitor response
251
What test can be used to identify M. tuberculosis and Rifampin resistance for TB?
Xpert MTB/RIF Assay
252
When treating a patient for TB, what should always be utilized?
Direct Observed Treatment (DOT) for ALL patients with TB disease
253
If ACTIVE TB, what is the treatment (2)?
- INITIALLY, RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) daily for 2 months then repeat CXR, AFB smear and culture
- CONTINUATION: RIF and INH daily for 4 months
254
What medication involves the side effect of orange-red compounds, and what disease is it used to treat?
RIF (Rifampin)
| - Treats TB
255
What medication involves the side effect of hepatotoxicity, peripheral neuropathy, and what disease is it used to treat?
INH (Isoniazid)
| - Treats TB
256
What medication involves the side effect of hepatotoxicity, and what disease is it used to treat?
PZA (Pyrazinamide)
| - Treats TB
257
What medication involves the side effect of optic neuritis, and what disease is it used to treat?
EMB (Ethambutol)
| - Treats TB
258
If LATENT TB, what is the treatment (2)? What if pregnant or children 2-11 years?
INH and Rifapentine for 12 weekly doses if 12+ years
| - INH ONLY if pregnant or children 2-11 years
259
Under what three conditions is someone considered NOT infectious with TB and can go home?
- 2 weeks of treatment regimen
- 3 negative sputum smears
- Sxs improve
260
Under what four conditions would someone who is STILL infectious with TB be allowed to go home?
- Strict follow-up
- DOT arranged
- No children <5 or immunocompromised in home
- Restricted travel except health-care visits
261
If a patient has MDR-TB, what does this mean?
Does not respond to at least RIF and INH
262
If a patient has XDR-TB, what does this mean?
Extensively drug resistant (responds to fewer drugs, including Fluoroquinolones)
263
What is the purpose of the BCG Vaccine, and in to who is it recommended?
Decrease risk of severe complications due to TB
| - Single dose at birth recommended in developing countries unless IC or pregnant
264
What condition involves common in OH and Mississippi River valleys; more common if HIV/AIDS or IC?
Histoplasmosis
265
What condition involves etiology of soil contaminated with bird/bat droppings; spelunking?
Histoplasmosis
266
What type of Histoplasmosis occurs in healthy people; CXR can show residual granulomas?
Asymptomatic Primary Histoplasmosis
267
What type of Histoplasmosis involves mild fever, fatigue, few resp. sxs for 1 week-6 months?
Acute Symptomatic Pulmonary Histoplasmosis
268
What type of Histoplasmosis occurs in IC; fever, fatigue, cough, SOB + multiple organ involvement; can be fatal?
Progressive Disseminated Histoplasmosis
269
What type of Histoplasmosis occurs in older COPD patients; progressive lung changes (apical cavities)?
Chronic Pulmonary Histoplasmosis
270
Which three diagnostic tests are recommended for both Histoplasmosis and Coccidioidomycosis (Valley Fever)?
- ID test (Immunodiffusion)
- CF (Complement Fixation)
- Antigen detection (EIA test)
271
How can you differentiate Histoplasmosis from TB on CXR?
Histoplasmosis: hilar LAD, patchy/nodular infiltrates in LOWER lobes
- TB occurs in UPPER lobes
272
What is the recommended treatment for Acute Symptomatic Pulmonary Histo if mild/moderate (2)?
- <4 weeks = NO treatment
| - >4 weeks = Itraconazole
273
What is the recommended treatment for Acute Symptomatic Pulmonary Histo if moderate/severe?
Amphotericin B
| - Then Itraconazole
274
What is the recommended treatment for Progressive Disseminated Histo?
Amphotericin B
| - Then Itraconazole
275
What condition involves etiology of contaminated soil; endemic to desert/Western hemisphere?
Coccidioidomycosis (Valley Fever)
276
What condition is worse if IC, pregnant, DM, African or Filipino ethnicity?
Coccidioidomycosis (Valley Fever)
277
What condition is often asymptomatic; primary infection involves fever, cough, pleuritic CP, fatigue, erythema nodosum, CAP 1-3 week post-exposure?
Coccidioidomycosis (Valley Fever)
278
What three areas of the body are affected by Coccidioidomycosis (Valley Fever) Disseminated Disease?
- Lungs
- Bones
- Brain
279
What is the recommended treatment for Coccidioidomycosis (Valley Fever)?
NONE
280
What is the recommended treatment for Coccidioidomycosis (Valley Fever) if high-risk/Disseminated?
What if the patient is pregnant, and why?
"-azole" (Fluconazole, Itraconazole)
| - Amphotericin B if severe or pregnant because -azole are teratogenic
281
What conditions should indicate consideration of Cocci (__ AND __or__or__)?
```
- Pulmonary complaints
AND
(1+ of 3 E’s)
- Erythema nodosum
- Erythema multiforme
- Eosinophilia
```
282
What type of lung CA arises centrally (main bronchus)?
Squamous Cell Carcinoma
| - Type of Non-Small Cell Lung Cancer (NSCLC)
283
What is the recommended treatment for Chronic Pulmonary Histo?
Itraconazole for 1 year
284
What is the recommended treatment for HIV/AIDS and Histo?
Amphotericin B + Itraconazole
