Pulmonology

Question 1

diminished breath sounds bilaterally with scattered expiratory wheezes & prolonged expiratory phase describes what illness?

Answer 1

COPD

Question 2

In patients with severe, acute asthma, ____ PaCO2 suggests respiratory muscle weakness & impending respiratory failure, which require mechanical ventilatory support.

Answer 2

elevated or inappropriately normal

Question 3

Long-term ____ therapy has been proven to prolong survival in patients with COPD and significant chronic hypoxemia.

Answer 3

supplemental oxygen

Question 4

The criteria for initiating LT Oxygen therapy in COPD pts include:

1. Resting PaO2 __%.

Answer 4

55

59

Hct >55

Question 5

What is the most effective measure to decrease mortality in patients with COPD?

Answer 5

Smoking Cessation

• LTOT is associated with decreased mortality ONLY in pts with COPD + significant hypoxemia (PaO2 <59-55)

Question 6

____ deficiency should be considered in pts with COPD sxs who are <45 or have no/minimal h/o smoking, or a FMH of emphysema or liver disease.

Answer 6

Alpha-1 antitrypsin (AAT)

Tx: IV- AAT supplements + bronchodilators & corticosteroids

Question 7

4 Common causes of chronic cough include

Answer 7

Asthma
GERD
Upper airway cough syndrome (post-nasal drip)
ACE inhibitors

Question 8

Patients can have chronic hypoventilation s/t (3)

resulting in a gradual increase of PaCO2

Answer 8

COPD
Obesity hypoventilation syndrome
Neuromuscular disease (Ank Spondy, MS)

Question 9

Patients with chronic hypoventilation result in gradual increases in PaCO2 that result in chronic respiratory acidosis; to compensate, the kidneys increase HCO3- retention, creating a chronic _____.

Answer 9

secondary metabolic alkalosis

Renal tubular compensation

Question 10

Increased ___ ventilation is the main cause of hypercapnia in COPD and worsens the respiratory acidosis.

Answer 10

dead space

Question 11

All pts with acute exacerbation of COPD should receive inhaled ____ & systemic ____.

PLUS: supplemental oxygen, ABx, and ventilatory support, if indicated.

Answer 11

Bronchodilators (β2 agonists & ipratropium/tiotropium)

Glucocorticoids* (IV methylprednisolone/ PO Prednisone)

*improve lung function, hypoxemia & decrease risk of relapse, treatment failure, and length of hospital stay.

Question 12

The 1st mainstays of treatment for COPD are

inhaled bronchodilators like ___ + ___

Answer 12

Albuterol ( SA β2 agonists)

Ipratropium/ Tiotropium (anti-cholinergic/muscarinic)

Question 13

___ + ___ may be used in the maintenance therapy of

more severe COPD not controlled by bronchodilators

Answer 13

Inhaled steroids (Fluticasone) 
Long-acting β2 agonists (Salmeterol)

Question 14

Patients admitted for acute COPD exacerbation now has headache, delirium, and lethargy. Next best step in evaluation?

Answer 14

get an ABG

rising levels of PaCO2 >75 can cause neuro sxs, coma or seizures

Question 15

CO2 narcosis is when a pt goes into ____

s/t PaCO2 > __

Answer 15

coma

75+

Question 16

pulmonary flow-volume loop characteristic for Asthma/ COPD: “______” pattern

Answer 16

“scooped-out” pattern

Question 17

pulmonary flow-volume loop characteristics for restrictive lung disease:

Answer 17

Low/narrow lung volumes
+
Low expiratory/inspiratory flow rates

Question 18

pulmonary flow-volume loop characteristics for a fixed upper-airway obstruction: “______” pattern

Answer 18

“Cheese-burger” pattern

Flattening of both the top & bottom of the flow-volume loop.

Question 19

DLCO is
__ in chronic bronchitis
and
__ in emphysema predominant COPD

Answer 19

normal

decreased

Question 20

Paradoxical vocal fold motion (PVFM) aka vocal cord dysfunction presents like exercise asthma.

Vocal cords inappropriately adduct (close) during inspiration, causing laryngeal obstruction diagnosed via [imaging].

Long-term treatment primarily consists of therapy with a

Answer 20

Laryngoscopy

speech-language pathologist

*Episodes may be triggered by strong smells, stress, or exercise

Question 21

Transfusion-related acute lung injury typically occurs within minutes to 6 hours of blood product transfusion.

It manifests with acute hypoxemic respiratory failure, crackles/rales, and [seen on CXR] .

Answer 21

BILATERAL pulmonary infiltrates

Question 22

How to differentiate TRALI vs TACO:

1. BNP
2. JVD
3. S3
4. EF

Answer 22

1. TACO = ↑ BNP (vs wnl)
2. TACO = JVD Present (vs none)
3. TACO = S3 Present (vs none)
4. TACO = ↓EF (vs wnl)

Question 23

Hyperinflation on CXR, Wheezing, Dyspnea =
Bronchoconstriction
As seen in (2)

Answer 23

Asthma, chronic bronchitis

Question 24

presents with acute dyspnea, Hypotension, JVD, unilaterally absent breath sounds and pleuritic chest

Answer 24

Tension pneumothorax

Question 25

Increased pulmonary vascular resistance (PVR) leads to Right Ventricular (RV) stress and dilation = 1. Signs of right-sided ___ develop. 2. ↑ Intensity of __ sound. 3. __ DLCO s/t loss of vasculature

Answer 25

1. congestion (pedal edema, hepatomegaly) 2. Pulmonic component of S2 (loud P2). 3. ↓ DLCO * Narrowing of pulm arteries → RV systolic failure & ↓ CO bc impaired LV filling.

Question 26

``` Injury and narrowing of terminal airways non-reversible air outflow limitation ↓ DLCO ± normal CXR Diagnosis? ```

Answer 26

Bronchiolitis obliterans (COPD)

Question 27

Exertional dyspnea ↓ DLCO (parenchymal scarring) Fine inspiratory crackles (velcro) Diagnosis?

Answer 27

``` Pulmonary fibrosis (restrictive lung disease) ```

Question 28

[Medication] may worsen bronchospasm in patients with exacerbation of COPD. Avoid them.

Answer 28

𝛽 blockers

Question 29

Diagnosis is made by renal biopsy showing linear IgG antibodies along the glomerular basement membrane. Diagnosis?

Answer 29

Anti–glomerular basement membrane disease (Goodpasteur's Syndrome) Antibodies agains lung BM (cough, dyspnea, and hemoptysis) and kidneys BM (nephritic range proteinuria <3.5 g/day, acute renal failure, and dysmorphic red cells/red cell casts on UA). Systemic symptoms are uncommon.

Question 30

Presents with RAPIDLY worsening cough, fevers, chills, and dyspnea. CXR = Alveolar infiltrates, Opacification, Consolidation Diagnosis?

Answer 30

Bacterial pneumonia

Question 31

A Chest CT scan showing a peripheral, wedge-shaped infarction is virtually pathognomonic for

Answer 31

pulmonary embolism

Question 32

Pt with dyspnea and JVD CXR = peribronchial thickening; prominent pulmonary vascular markings; and patchy, perihilar opacities General Lung Diagnosis?

Answer 32

Pulmonary Edema

Question 33

(pleural/serum) LDH ratio >0.6 (pleural/serum) protein ratio >0.5 suggest a ____ pleural effusion

Answer 33

Exudative effusion ↳due to inflammation with a ↳pleural fluid pH 7.30–7.45 ➣Normal pleural fluid pH: 7.60

Question 34

Pleural fluid pH <7.30 (+ low pleural glucose <60 mg/dL) or (pleural/serum) glucose ratio <0.5 usually s/t: 1. 2. ➣Normal pleural fluid pH: 7.60

Answer 34

Bacteria (empyema) | Tumors, (& TB, Rheumatoid arthritis)

Question 35

women in early and middle adulthood with chronic progressive dyspnea & inspiratory crackles. CXR = interstitial reticular opacities, parenchymal scars General Lung Diagnosis?

Answer 35

Interstitial lung disease (ILD) ↳can cause PH (group 3)

Question 36

``` Classically triad of: – respiratory distress (tachypnea, hypoxemia) – neurologic dysfunction (confusion) ± petechial rash ± Thrombocytopenia ``` Develop Pulmonary edema (mimicking ARDS after 1-2d) ↳Bilateral ground-glass opacities on chest CT ↳No pulmonary arterial filling defects

Answer 36

Fat Embolism Syndrome

Question 37

A chemical irritation of the lung parenchyma that can lead to ARDS and respiratory failure. + Fever & Leukocytosis Patients with periods of impaired consciousness (seizure, alcohol use, stoke, multiple sclerosis w bulbar sxs) are most commonly affected.

Answer 37

Aspiration pneumonitis *onset is insidious (progressing over several weeks)

Question 38

[↑/↓] Alveolar-arterial oxygen gradient is commonly seen in Pulmonary Embolism

Answer 38

↑ A-a Gradient *Wheezing can occur in acute PE.

Question 39

Hypoalbuminemia can cause transudative pleural effusions due to decreased ___ pressure.

Answer 39

oncotic

Question 40

Non-caseating granulomas in the lungs s/t a reaction from environmental antigens like dust or dandruff. CXR ± reticular, nodular, or alveolar opacities ↳No cavitations Diagnosis?

Answer 40

Hypersensitivity pneumonitis