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Internal Medicine > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

Aspiration into lobes depends on position: which lobes?

A

Upright - RML, bilateral lower lobes
Recumbent - posterior segment of RUL, superior segment of RLL

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2
Q

Pulmonary contusion - imaging

A

Serial X-ray or chest CT (more sensitive) - patchy, irregular alveolar infiltrates due to bleeding and edema

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3
Q

When does traumatic ARDS manifest?

A

24-48h after injury; affects lungs bilaterally

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4
Q

How does massive PE differ from smaller/segmental PE?

A

Massive: Systolic BP <90, drop in cardiac output, patient falls or has syncope
Smaller: focal pleural irritation, pulmonary ischemia (e.g. chest pain)

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5
Q

What is the most common cancer of the adult larynx?

A

Laryngeal squamous cell carcinoma (>90%) - due to smoking, alcohol

Sx:
Hoarseness persistent >30 days
Airway obstruction
Dysphagia
Referred otalgia (CN IX from base of tongue and CN X from posterior pharyngeal wall)

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6
Q

What is suggested by rapid decompensation and cardiac arrest following central venous catheter placement?

A

Venous air embolism - a large VAE (>50 mL) can lodge in right ventricle or pulmonary arterioles and obstruct flow
Obstructive shock –> cardiac arrest (e.g. pulseless electrical activity)

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7
Q

Air embolism causes

How would arterial air embolism manifest?

A
  1. Trauma –> arterial
  2. Certain surgeries (e.g. neurosurgery –> arterial, otolaryngological)
  3. Central venous catheter
  4. Pulmonary barotrauma

Arterial: stroke (cerebral occlusion), MI (coronary occlusion)

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8
Q

What numbers are useful in diagnostic thoracentesis?

A
  1. Fluid pH (Low = infection, malignancy, or rheumatoid arthritis)
  2. LDH
  3. Protein
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9
Q

How is Zenker diverticulum diagnosed?

A

Swallow study with contrast esophagography

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10
Q

Pulmonary contusion appearance on X-ray

A

Hemorrhage and edema that manifests as irregular, nonlobular opacities

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11
Q

Subcutaneous emphysema over chest

A

Spontaneous pneumomediastinum

Caused by high intraalveolar pressure, which can result from coughing paroxysms or other coughing causes

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12
Q

Acute respiratory distress syndrome - differential from cardiac failure volume overload

A

New bilateral fluffy opacities on chest x-ray but euvolemic, normal JVP, normal LV function

When lung injury has clear etiology, ARDS can be diagnosed with no further testing

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13
Q

ARDS treatment

A

Low tidal volume ventilation
Prone positioning

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14
Q

What test can clarify whether pulmonary edema is cardiogenic or not?

A

Pulmonary artery catheterization - reveals pulmonary capillary wedge pressure

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15
Q

What are the best predictors of postoperative outcome following lung resection?

A

FEV1
DLCO
Those with estimated postoperative value <40% are at elevated risk of morbidity

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16
Q

Value of end-tidal CO2

A

Information about ventilation (CO2 production and clearance)

  1. Monitor ventilation settings
  2. Monitor correct endotracheal tube placement
  3. Measure effectiveness of cardiopulmonary resuscitation
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17
Q

What organ in abdominal injury is difficult to diagnose immediately following trauma?

A

Pancreatic injury - duct injury will lead to peripancreatic fluid collection (upper abdomen free fluid)
May follow blunt abdominal trauma from crushing against vertebral column

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18
Q

Transfusion-related lung injury symptoms

A

Within 6h transfusion:
1. Fever
2. Hypotension
3. Non-cardiogenic pulmonary edema

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19
Q

Empyema appearance based on stage of progression

A

Early - Effusion is free-flowing
Advanced - Effusion is fixed with evidence of loculation

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20
Q

Empyema course compared to uncomplicated pneumonia

A

Weight loss, gradual presentation over 1 week (anaerobic 2-3 weeks)

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21
Q

What is most common cancer to appear in upper cervical LN? How to find primary site?

A

Head and neck SCC
Alcohol and tobacco use significant

Use laryngopharyngoscopy to locate primary mucosal site

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22
Q

What is suggested by anterior or peripheral ground glass opacities of lungs?

A

Blunt force trauma to chest causing pulmonary contusion
Indicative of alveolar hemorrhage and edema
Classic irregular, nonlobular infiltrates

Often negative on initial chest x-ray, may take up to 24h to show there

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23
Q

Timeframe of fat embolism

A

24-72h

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24
Q

Timeframe of ARDS

A

24-72h or longer
Bilateral diffuse infiltrates

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25
What is flail chest?
Fracture >=3 ribs in >=2 locations causing paradoxical motion of part of chest wall, increasing work of breathing Paired with pulmonary contusion and hemorrhage/edema (work of breathing, lower diffusion), can cause respiratory distress
26
What is indicated by rapid reaccumulation of air in intrapleural space despite tube thoracostomy?
Likely tracheobronchial rupture Bronchoscopy for definitive diagnosis (CT may miss small tears) Requires operative repair
27
What is talc pleurodesis?
Obliteration of pleural space to prevent frequent recurrence of effusion (e.g. malignancy) or pneumothorax (e.g. COPD)
28
Bronchogenic cyst - cause, signs, diagnosis
Due to anomalous budding of foregut during development Chest discomfort, nonspecific respiratory symptoms (e.g. recurrent coughing or infections) Diagnose with CT with contrast
29
What measures affect PAO2?
PiO2 and minute ventilation (tidal volume x respiratory rate)
30
What anticoagulant is preferred for treatment of acute PE in patients with malignancy?
Low molecular weight heparin - preferable over DOAC, which may increase bleeding from tumor
31
When is prone positioning used?
Severe acute respiratory distress syndrome and persistent hypoxemia despite optimal mechanical ventilation settings Reduces atelectasis in posterior lung (where most of lung mass is located)
32
Patients with venous air embolism should be placed in what position?
Left lateral decubitus - air bubble hugs right ventricle wall and doesn't block outflow Risk from central venous catheter removal
33
Patients with arterial air embolism should be placed in what position?
Supine - to prevent embolism from traveling to brain and causing stroke
34
Irregular, exophytic growths in clusters on vocal cords
Laryngeal papillomas due to recurrent respiratory papillomatosis Caused by HPV 6, 11 Require surgical debridement, often many times (medical therapy has limited efficacy)
35
What condition causes pulse ox 85 and arterial blood gas SpO2 99%?
Methemoglobinemia - iron is oxidized to methemoglobin, which cannot bind oxygen, and remaining Hgb has increased affinity for oxygen, preventing proper delivery to tissues Caused by topical anesthetics (e.g. benzocaine), dapsone, and nitrates Treat with methylene blue to reduce iron
36
What are platypnea and orthodeoxia?
Platypnea: induced dyspnea in upright position, relieved when supine Orthodeoxia: hypoxia in upright position, improved when supine Both occur with hepatopulmonary syndrome - arteriovenous shunting in lungs after years of liver disease
37
Lung transplant acute vs chronic rejection - signs
Acute: Respiratory dysfunction, new infiltrates, fever; often caused by infection causing tissue damage and allosensitization to donor lung antigens Chronic: Progressive airflow fibrosis --> obstruction and wheezing
38
Most common opportunistic infections after lung transplant
1. CMV (valganciclovir prophylaxis) 2. Pneumocystis 3. Invasive molds (Aspergillus)
39
Chronic silicosis is associated with what comorbidities?
Lung cancer Mycobacterial disease Rheumatoid arthritis
40
Chronic silicosis - appearance?
Annular (eggshell) calcification of hilar and mediastinal LN Simple silicosis: small, nodular fibrotic opacities in upper lung zones Progressive massive fibrosis: coalescent fibrotic masses with severe respiratory impairment
41
How does solitary pulmonary nodule (<=3 cm; larger is called a mass) correlate with malignancy risk?
<0.6 cm low risk, no follow-up >0.8 cm require follow-up; further risk is associated with cofactors When need for tissue diagnosis unclear, can use PET scan
42
Eggshell calcifications of hilar/mediastinal LN
Chronic silicosis
43
Differential lung changes in apex vs base in COPD
Apex: septal destruction, low capillary density -> high V/Q, hypercapnia Base: airway obstruction, perfusion intact -> low V/Q, hypoxemia, vasoconstriction
44
PaO2 vs PaCO2 are governed by what ventilator settings?
PaO2: FiO2, PEEP PaCO2: RR, tidal volume
45
How does DLCO differentiate COPD from severe asthma?
COPD: low DLCO due to alveolar destruction Asthma: high DLCO due to increased blood flow from increased negative intrathoracic pressure during inspiration
46
If ventilator PaCO2 is elevated or low, what to do?
Elevated, pH low: increase RR; increase Vt as last resort low, pH high: decrease Vt, decrease RR; increase sedation as last resort
47
If ventilator plateau pressure >30, what to do?
Decrease Vt and/or adjust PEEP
48
Altitude sickness treatment
Acetazolamide - inhibits bicarb absorption in proximal tubules, assisting metabolic compensation for respiratory alkalosis from higher minute ventilation Peripheral chemoreceptors stimulated by low oxygen, while central chemoreceptors sense elevated pH and limit hyperventilation
49
Why do some people have genetic predisposition to high-altitude pulmonary edema (HAPE)?
Unevenly distributed hypoxic vasoconstriction in response to low PaO2 -> higher perfusion pressure in some areas -> disruption of alveolar-capillary membrane -> pulmonary edema
50
Long-term oxygen supplementation therapy for COPD - requirements
PaO2 <=55 or SpO2 <=88% PaO2 <=59 or SpO2 <=89% if cor pulmonale or secondary polycythemia (hematocrit >55%) Maintain SpO2 between 90-94%
51
FRC and RV in ankylosing spondylitis vs diffuse pulmonary fibrosis
AS: normal/increased due to ribcage fixation Fibrosis: decreased
52
Pharmacologic triggers of bronchoconstriction in asthma
Nonselective > cardioselective beta blockers Aspirin, especially if chronic rhinitis or nasal polyps
53
Most common lung cancer in young adults
Bronchial carcinoid tumor - neuroendocrine derived from Kulchitsky cells Causes proximal airway obstruction symptoms and recurrent pneumonias Carcinoid syndrome less likely than midgut version
54
Pancoast tumor would compress which nerve roots?
C8-T2, causing: Numbness/tingling in hands Shoulder pain As well as Horner and supraclavicular LAD
55
What can masquerade as asthma in young adult women?
Pulmonary artery hypertension However, would cause decreased DLCO
56
Nitrofurantoin pulmonary adverse effect
Hypersensitivity lung injury 3-9 days after med onset SOB, dry cough, erythematous rash, fever
57
Explain obesity hypoventilation
Can't breathe - chest wall and lung compliance decreased, leading to decreased tidal volume and TLC and increased airway resistance Won't breathe - chronic nighttime CO2 leads to compensatory metabolic alkalosis and decreased bicarb excretion; this blunts ventilatory response to increased CO2
58
Recurrent flash pulmonary edema
Renal artery stenosis
59
Aspiration in recumbent position
Posterior segment of upper lobe and superior segment of lower lobe Compare to bibasilar, middle lobe, and lingula in erect position
60
Superior pulmonary sulcus/Pancoast tumor nerve involvement
Lower brachial plexus (ulnar) Phrenic -> hemidiaphragmatic paralysis Horner syndrome (ptosis, miosis, anhidrosis)
61
Acute mountain sickness vs high-altitude cerebral edema
AMS - acetazolamide HACE (decreased PaO2 increases cerebral blood flow, causing lethargy, confusion, ataxia) - dexamethasone Both hace supplemental oxygen
62
Which lung cancer is associated with ACTH secretion vs PTHrP?
SCLC - ACTH, SIADH Squamous cell - PTHrP (sCa++mous)
63
Central lung cancers
Squamous cell - hilar mass, due to squamous metaplasia within the central tracheobronchial tree
64
When do patients with alpha-1 antitrypsin deficiency typically present with COPD?
40s; smokers in their 30s
65
How can NSAIDs or beta blockers exacerbate anaphylaxis?
NSAIDs can cause nonimmunologic mast cell activation Beta blockers can cause unopposed alpha-adrenergic effects
66
Why can bilateral wheezing happen in PE?
Hypoxia -> infarction -> cytokine release -> bronchoconstriction
67
Pleural mesothelioma vs bronchogenic carcinoma from asbestosis
Mesothelioma has unilateral pleural abnormality with large pleural effusion Bronchogenic more common in asbestos exposure and smoking combination
68
Antifibrotic agents in idiopathic pulmonary fibrosis
Pirfenidone Nintedanib
69
Which pneumoconiosis has eggshell calcifications?
Silicosis
70
Which pneumoconiosis has upper lung small nodular opacities (as opposed to lung bases)
Coal worker, silicosis (vs asbestosis in base or berylliosis diffuse with hilar adenopathy)
71
Which pneumoconiosis requires yearly TB test?
Silicosis
72
What is abnormal calcification pattern in pulmonary nodules?
Absent or irregular Normal is central, uniform, or popcorn calcification
73
Mucin+ lung cancer
Adenocarcinoma
74
Small, dark blue cells lung cancer
SCLC - Kulchitsky cells Bronchial carcinoid tumor also has chromogranin A+, but is in nests; carcionoid symtpoms, mass effect; mets rare
75
Lung cancer with apparent thickening of alvelolar septal walls
Bronchioloalveolar subtype of lung adenocarcinoma - actually a carcinoma in situ; less associated with tobacco
76
SCLC treatment
Radiotherapy; chemo if metastatic Rarely operable
77
Large cell carcinoma treatment
Surgery
78
Cardiac paraneoplastic syndromes of lung adenocarcinoma
1. Migratory thrombophlebitis 2. Nonbacterial verrucous endocarditis
79
Acutely branched hyphae on silver stain
Aspergillus
80
Only way to effectively diagnose Blasto
Culture - broad-based budding yeasts

Internal Medicine (23 decks)

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