Pulmonolgy Flashcards
What are the important settings of a ventilator?
TV
RR
FiO2
PEEP
Tidal volume and respiratory rate are used to control?
Ventilation= RR xTV
FiO2 and positive expiatory pressure are used to control?
Oxygenation
When do we consider weaning a patient off ventilation?
When they can maintain good oxygenation with and FiO2 between 40-50%. when the PEEP is < 5cm. The patient should not be making excessive secretions. Mental status is good, and the patient is hemodynamically stable.
What is the purpose of BiPAP
It provide positive pressure on inspiration and on expiration.
What is a spontaneous breathing trial?
It is similar to the function of BiPAP. There is positive pressure on inspiration and expiration, but the TV and RR are controlled by the patient. Whether the patient is ready to be weaned of ventilator support is determined by the rapid shallow breathing index.
What RSBI is considered appropriate to wean a patient off ventilation?
<105
All patients on mechanical ventilation should be started on what prophylactic therapy?
proton pump inhibitors to prevent ulcer formation
What is dead space?
Ventilation is good but perfusion is bad. A good example is PE.
What types of shunts are there?
Physiological shunts: poor ventilation good perfusion. Obstrutction of the bronchi.
Anatomic shunts allow blood to bypass the pulmonary system (think Eisenmeger, pulmonary AV malformations)
What type of shunt is resistant to oxygen therapy?
anatomic shunts, physiologic shunts can partially be corrected with oxygen.
What is ARDS?
Is usually a complication of drowning or sepsis, burns, pancreatitis that results in activation of proteases and cytokines that can cause fluid leakage into the alveolar space.
What long-term consequence of ARDS?
pulmonary fibrosis
What is the common finding of ARDS on chest X-ray?
Bilateral infiltrates present on chest X-ray
True or False. If a patient has a PCWP >18 they are capable of having ARDS?
False, remember that ARDS is not a cardiogenic process so if the PCWP is > 18 the disease presentation is not ARDS.
What is the treatment for ARDS?
Positive pressure ventilation (usually mechanical intubation) and treatment of the underlying cause of ARDS.
If a patient has unexplained pulmonary symptoms and has a history of smoking or occupational exposure what is the next best step in diagnosis?
Spirometry, which will help to differentiate between restrictive and obstructive lung diseases.
What happens to the FVC in restrictive lung disease?
Decreases
What happens to the FEV1 in restrictive lung diseases?
Decreases
What happens to the FEV/FVC rations in restrictive lung disease?
Increases >0.8
What happens to the FEV in obstructive lung disease?
Decreases
What happens to the FEV/FVC ratio in obstructive lung disease?
Decreases <0.8
What happens to the FRC in obstructive lung disease?
It increases, mainly because the residual volume is increasing.
What happens to the FRC in restrictive lung disease?
it decreases
___ is a disorder of hyperactive airways?
Asthma
What are the two types of asthma?
Allergic and intrinsic
What is intrinsic asthma?
Usually precipitated by weather changes or exercise not usually precipitated by an allergen.
True or False. Upon introduction of a bronchodilator asthma is a reversible airway obstruction?
True,
What is the definitive diagnosis of asthma?
PFT
What is the stepwise management of uncontrolled asthma?
PRN albuterol, inhaled steroids, LABA, oral steroids
What is the treatment for a patient with an acute asthma exacerbation?
Oxygen, SABA and SAMA
What are important vaccinations to consider in patients who have recent asthma exacerbations?
Flu and PCV
What is the strongest risk factor for COPD.
Smoking
What happens to the DCLO in a patient with emphysema?
It goes down. Remember that there is a airway component and a lung parenchymal component to emphysema.
What happens to the DCLO in a patient with COPD?
It’s normal
What factors reduced the risk of mortality in COPD patients?
Smoking cessation and home oxygen for patients with an oxygen saturation <88% at baseline.
What is the treatment for acute COPD exacerbation?
Oxygen, SABA and anti-muscarinic, corticosteroid, and anti-biotic (macrolide)
What is the best predicitor of prognosis for pulmonary disease?
FEV1
A patient that is 30 year old with no smoking history presents to the ED with severe shortness of breath. LFT’s are slightly elevated. What is the likely diagnosis?
Alpha 1 anti-trypsin
What is the most common cause of COPD exacerbations?
Infections
What are the most common infectious organisms to cause a COPD exacerbation?
Strep. P
H. In
Moraxella Cat.
What are the etiologies for chronic dry cough?
A GAP; Ace inhibitors, GERD, asthma, and post-nasal drip.
What is the pathophysiology behind coughs with ACE inhibitors?
bradykinins are elevated, due to the breakdown of bradykinins this is also the pathophysiology for angioedema
A patient with chronic cough and sore throat and hoarse voice probably is probably suffering from chronic cough due to?
GERD
What is the difference between Kartagener’s syndrome and Cystic fibrosis.
While both can cause infertiility remember that situs inversus is typial for Kartageners
PE presentation of atelectasis?
Dullness to percussion, decreased breath sounds +/- tracheal deviation.
What is the first step in diagnosis of a patient with a solitary nodule?
Always see if you can get an older CXR or CT for comparison
A solitary lung nodule ____ always needs to be biopsied?
3cm
What is the next step of diagnosis of a pulmonary nodule after comparing with a previous chest X-ray?
Get a CT scan to determine the characteristics of the nodule (regular/irregular/lamellar/calcification/homogenous/ground glass)
If a pulmonary nodule is centrally located how do you obtain the biopsy?
US guided trans-bronchial biopsy
If a pulmonary nodule is peripherally located how do we obtain a biopsy?
CT guided peripheral biopsy
A patient presents to your office with lid lag and miosis, pain in the ulnar nerver , and hoarse voice what is the diagnosis?
Horner’s syndrome, due to a superior sulcus tumor or pancoast tumor
A patient presents with swelling face neck, arms with distended collaterals.
Superior vena cava syndrome
What are common tumors of the anterior mediatstinum?
AT&T: Anterior, Thyroid, Teratoma, ad thymoma
What are common tumors of the middle mediastinum?
pneumonic CML: lymph nodes and cysts
What are common tumors in the posterior mediatstinum?
PEN: esophageal cancers, neural tumors (schwannomas, neurofibromas, neuroblastomas)
What are the physcial exam findings for a patient with pleural effusion?
Dullness to percussion, decreased breath sounds, and decreased tactile fremitus. On CXR and pleural effusion may look like blunting of the costophrenic angles
What is the next step in management of a patient with unilateral pleural effusions?
Thoracocentesis, cytology
What is Factor V leiden?
Mutation in the gene encoding for the upregulation of Va (which converts X -> II) and less so the anti-coagulant for V.
What are the absolute contraindications to anti-coagulation?
Bleeding disorder, history of hemorrhagic stroke, and platelet count < 25,000
What are DOAC’s
Direct oral anti-coagulants, which include apixaban, rivaroxaban, edoxaban. Rememeber the X in the name indicates the drug directly inhibits factor 10 .
A patient with inadequate oxygenation should increase FiO2 or PEEP pressure initially?
Always try PEEP first, one because this expands the alveoli to optiize gas exchange, but increasing the FIo2 increases the risk for oxygen toxicity. If the oxygenation does not improve after adjusting PEEP then increase the FiO2.
What is the next step in managment for a patient with hemoptysis?
Identify if the patient is stable? If they are then a CT scan can be done to locate the source of bleeding. If not ABC’s and bronchscopy to locate the source, if bronchoscopy is not successful then arteriogram to locate the source of bleeding.
When would we be inclined to place a tracheostomy versus circothyroidotomy?
We place a trach for those patients that require chronic breathing support versus circothyroidotomy is for those patients who only need acute respiratory support.
98% of patients with cystic fibrosis have a missing _______ in males ?
vas deferens
Why would you prefer to use Amoxicillin over ampicillin?
Amoxicillin, covers gram (+) organisms and gram (-) including H.In, E.coli, and salmonella. It also can be given in the oral form
What’s are the most common causes of SVC syndrome?
Cancer: Small cell or non- Hodgkin lymphoma
What is the diagnostic modality for identifying SVC?
Chest X-ray
In the absence of any clear provoking factors for DVT and VTE, what is the next thing we need to consider?
Age appropriate cancer screening
What is the difference in symptoms of a lower respiratory tract infection that is viral versus bacterial?
A patient with a viral infection will have arthralgias, fatigue, whereas a patient with bacterial infection will have infiltrates on chest X-ray and a productive cough.
What is the pathophysiology behind hereditary angioedema?
Inhibitors of C1 esterase cause an accumulation of bradykinin and thus the patient can present with multiple areas of edema without uticaria or pruritus.
For patients with an ABG that shows hypoxemia what can we do to the ventilator settings to maintain Po2 >60
Increase the PEEP or FIO2
In patient with an ABG showing hypercapnia what can we do to maintain the PCO2 <40?
We can increase the RR or increase the tidal volume
Pulmonary hypertension is considered when the pulmonary artery pressure is greater than?
20
Causes of acute bronchitis primarily consist of?
adenovirus, coronavirus
