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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
Q

What is flail chest?

A

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

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26
Q

What is indicated by rapid reaccumulation of air in intrapleural space despite tube thoracostomy?

A

Likely tracheobronchial rupture
Bronchoscopy for definitive diagnosis (CT may miss small tears)
Requires operative repair

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27
Q

What is talc pleurodesis?

A

Obliteration of pleural space to prevent frequent recurrence of effusion (e.g. malignancy) or pneumothorax (e.g. COPD)

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28
Q

Bronchogenic cyst - cause, signs, diagnosis

A

Due to anomalous budding of foregut during development
Chest discomfort, nonspecific respiratory symptoms (e.g. recurrent coughing or infections)
Diagnose with CT with contrast

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29
Q

What measures affect PAO2?

A

PiO2 and minute ventilation (tidal volume x respiratory rate)

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30
Q

What anticoagulant is preferred for treatment of acute PE in patients with malignancy?

A

Low molecular weight heparin - preferable over DOAC, which may increase bleeding from tumor

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31
Q

When is prone positioning used?

A

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)

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32
Q

Patients with venous air embolism should be placed in what position?

A

Left lateral decubitus - air bubble hugs right ventricle wall and doesn’t block outflow

Risk from central venous catheter removal

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33
Q

Patients with arterial air embolism should be placed in what position?

A

Supine - to prevent embolism from traveling to brain and causing stroke

34
Q

Irregular, exophytic growths in clusters on vocal cords

A

Laryngeal papillomas due to recurrent respiratory papillomatosis

Caused by HPV 6, 11

Require surgical debridement, often many times (medical therapy has limited efficacy)

35
Q

What condition causes pulse ox 85 and arterial blood gas SpO2 99%?

A

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
Q

What are platypnea and orthodeoxia?

A

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
Q

Lung transplant acute vs chronic rejection - signs

A

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
Q

Most common opportunistic infections after lung transplant

A
  1. CMV (valganciclovir prophylaxis)
  2. Pneumocystis
  3. Invasive molds (Aspergillus)
39
Q

Chronic silicosis is associated with what comorbidities?

A

Lung cancer
Mycobacterial disease
Rheumatoid arthritis

40
Q

Chronic silicosis - appearance?

A

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
Q

How does solitary pulmonary nodule (<=3 cm; larger is called a mass) correlate with malignancy risk?

A

<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
Q

Eggshell calcifications of hilar/mediastinal LN

A

Chronic silicosis

43
Q

Differential lung changes in apex vs base in COPD

A

Apex: septal destruction, low capillary density -> high V/Q, hypercapnia
Base: airway obstruction, perfusion intact -> low V/Q, hypoxemia, vasoconstriction

44
Q

PaO2 vs PaCO2 are governed by what ventilator settings?

A

PaO2: FiO2, PEEP

PaCO2: RR, tidal volume

45
Q

How does DLCO differentiate COPD from severe asthma?

A

COPD: low DLCO due to alveolar destruction
Asthma: high DLCO due to increased blood flow from increased negative intrathoracic pressure during inspiration

46
Q

If ventilator PaCO2 is elevated or low, what to do?

A

Elevated, pH low: increase RR; increase Vt as last resort
low, pH high: decrease Vt, decrease RR; increase sedation as last resort

47
Q

If ventilator plateau pressure >30, what to do?

A

Decrease Vt and/or adjust PEEP

48
Q

Altitude sickness treatment

A

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
Q

Why do some people have genetic predisposition to high-altitude pulmonary edema (HAPE)?

A

Unevenly distributed hypoxic vasoconstriction in response to low PaO2 -> higher perfusion pressure in some areas -> disruption of alveolar-capillary membrane -> pulmonary edema

50
Q

Long-term oxygen supplementation therapy for COPD - requirements

A

PaO2 <=55 or SpO2 <=88%

PaO2 <=59 or SpO2 <=89% if cor pulmonale or secondary polycythemia (hematocrit >55%)

Maintain SpO2 between 90-94%

51
Q

FRC and RV in ankylosing spondylitis vs diffuse pulmonary fibrosis

A

AS: normal/increased due to ribcage fixation
Fibrosis: decreased

52
Q

Pharmacologic triggers of bronchoconstriction in asthma

A

Nonselective > cardioselective beta blockers
Aspirin, especially if chronic rhinitis or nasal polyps

53
Q

Most common lung cancer in young adults

A

Bronchial carcinoid tumor - neuroendocrine derived from Kulchitsky cells

Causes proximal airway obstruction symptoms and recurrent pneumonias

Carcinoid syndrome less likely than midgut version

54
Q

Pancoast tumor would compress which nerve roots?

A

C8-T2, causing:
Numbness/tingling in hands
Shoulder pain

As well as Horner and supraclavicular LAD

55
Q

What can masquerade as asthma in young adult women?

A

Pulmonary artery hypertension

However, would cause decreased DLCO

56
Q

Nitrofurantoin pulmonary adverse effect

A

Hypersensitivity lung injury 3-9 days after med onset
SOB, dry cough, erythematous rash, fever

57
Q

Explain obesity hypoventilation

A

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
Q

Recurrent flash pulmonary edema

A

Renal artery stenosis

59
Q

Aspiration in recumbent position

A

Posterior segment of upper lobe and superior segment of lower lobe

Compare to bibasilar, middle lobe, and lingula in erect position

60
Q

Superior pulmonary sulcus/Pancoast tumor nerve involvement

A

Lower brachial plexus (ulnar)
Phrenic -> hemidiaphragmatic paralysis
Horner syndrome (ptosis, miosis, anhidrosis)

61
Q

Acute mountain sickness vs high-altitude cerebral edema

A

AMS - acetazolamide

HACE (decreased PaO2 increases cerebral blood flow, causing lethargy, confusion, ataxia) - dexamethasone

Both hace supplemental oxygen

62
Q

Which lung cancer is associated with ACTH secretion vs PTHrP?

A

SCLC - ACTH, SIADH
Squamous cell - PTHrP (sCa++mous)

63
Q

Central lung cancers

A

Squamous cell - hilar mass, due to squamous metaplasia within the central tracheobronchial tree

64
Q

When do patients with alpha-1 antitrypsin deficiency typically present with COPD?

A

40s; smokers in their 30s

65
Q

How can NSAIDs or beta blockers exacerbate anaphylaxis?

A

NSAIDs can cause nonimmunologic mast cell activation
Beta blockers can cause unopposed alpha-adrenergic effects

66
Q

Why can bilateral wheezing happen in PE?

A

Hypoxia -> infarction -> cytokine release -> bronchoconstriction

67
Q

Pleural mesothelioma vs bronchogenic carcinoma from asbestosis

A

Mesothelioma has unilateral pleural abnormality with large pleural effusion

Bronchogenic more common in asbestos exposure and smoking combination

68
Q

Antifibrotic agents in idiopathic pulmonary fibrosis

A

Pirfenidone
Nintedanib

69
Q

Which pneumoconiosis has eggshell calcifications?

A

Silicosis

70
Q

Which pneumoconiosis has upper lung small nodular opacities (as opposed to lung bases)

A

Coal worker, silicosis (vs asbestosis in base or berylliosis diffuse with hilar adenopathy)

71
Q

Which pneumoconiosis requires yearly TB test?

A

Silicosis

72
Q

What is abnormal calcification pattern in pulmonary nodules?

A

Absent or irregular

Normal is central, uniform, or popcorn calcification

73
Q

Mucin+ lung cancer

A

Adenocarcinoma

74
Q

Small, dark blue cells lung cancer

A

SCLC - Kulchitsky cells

Bronchial carcinoid tumor also has chromogranin A+, but is in nests; carcionoid symtpoms, mass effect; mets rare

75
Q

Lung cancer with apparent thickening of alvelolar septal walls

A

Bronchioloalveolar subtype of lung adenocarcinoma - actually a carcinoma in situ; less associated with tobacco

76
Q

SCLC treatment

A

Radiotherapy; chemo if metastatic
Rarely operable

77
Q

Large cell carcinoma treatment

A

Surgery

78
Q

Cardiac paraneoplastic syndromes of lung adenocarcinoma

A
  1. Migratory thrombophlebitis
  2. Nonbacterial verrucous endocarditis
79
Q

Acutely branched hyphae on silver stain

A

Aspergillus

80
Q

Only way to effectively diagnose Blasto

A

Culture - broad-based budding yeasts

Internal Medicine (23 decks)

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