Pulmonology and CritCare Flashcards
most important initial screening test for pulmonary hypertension
echocardiogram with bubble study
gold standard both to establish the diagnosis of PH and to guide selection of appropriate medical therapy
Right heart catheterization (RHC) with pulmonary vasodilator testing remain
The definition of precapillary PH or PAH requires (1) an increased mean PAP (____) (2) a pulmonary capillary wedge pressure (PCWP), left atrial pressure, or left ventricular end-diastolic pressure (LVEDP) ≤____ (3) PVR > Wood units.
- mPAP >20 mmHg
- <=15 mmHg
- > 3
**based on ch 283, the mean pulmonary artery pressure (mPAP) used to bdiagnose PH has been lowered from ≥25 mmHg to >20 mmHg.
In pulmonary hypertension, A decrease in mPAP by _____ to an absolute level _____ without a decrease in CO is defined as a positive pulmonary vasodilator response, and responders are considered for long-term treatment with calcium channel blockers (CCB)
≥10 mmHg
≤40 mmHg
Vasoreactivity testing should be reserved mainly for patients with idiopathic or hereditary PAH
A soluble guanylyl cyclase stimulator approved for treatment of PAH
Riociguat
Examples of false-negative findings in PET scan for lung tumor (3)
carcinoid tumors
bronchioloalveolar cell carcinomas
or in lesions <1 cm in which the required threshold of metabolically active malignant cells is not present for PET diagnosis.
Examples of false positive PET scan for lung tumor
pneumonia
granulomatous diseases.
gold standard for mediastinal staging
Mediastinoscopy
however, transbronchial needle aspiration (TBNA) allows sampling from the lungs and surrounding lymph nodes without the need for surgery or general anesthesia.
Asthma can present at any age, with a peak age of ____
3 years
major risk factor for asthma
Atopy
“hygiene hypothesis” proposes that lack of infections in early childhood preserves the ___ cell bias at birth, whereas exposure to infections and endotoxin results in a shift toward a predominant protective ___ immune response.
Th2
Th1
Exercise-induced asthma (EIA) typically begins after exercise has ended, and recovers spontaneously within about ____.
30 min
EIA is best prevented by regular treatment with ______
It may be prevented by prior administration of β2 -agonists and antileukotrienes, but is best prevented by regular treatment with ICS, which reduce the population of surface mast cells required for this response
Definition of reversibility in asthma
Reversibility is demonstrated by a >12% and 200-mL increase in FEV1 15 min after an inhaled short-acting β2 -agonist (SABA; such as inhaled albuterol 400 μg) or in some patients by a 2–4 week trial of oral corticosteroids (OCS) (prednisone or prednisolone 30–40 mg daily)
The increased airway hyperresponsiveness (AHR) is normally measured by methacholine or histamine challenge with calculation of the provocative concentration that reduces FEV1 by _____
20% (PC20)
with a value ≤400 μg indicative of airway reactivity
Challenge with exercise and/or cold, dry air can be performed, with a positive response recorded if there is a ≥10% drop in FEV1 from baseline
most effective controllers for asthma
ICS
Among the 4 characteristics symptoms of asthma, which 2 would need to be present 2x/week to qualify for partially controlled/ uncontrolled asthma
Daytime symptoms
Need of reliever
Limitation of activities and nighttime awakening need to be present at least once a week only for it to qualify for partually controlled
For acute severe asthma, a high concentration of oxygen should be given by face mask to achieve oxygen saturation of >____.
90%
mainstay of treatment for acute severe asthma
high doses of SABA given either by nebulizer or via a MDI with a spacer.
Definition of corticosteroid resistant asthma
failure to respond to a high dose of oral prednisone/prednisolone (40 mg once daily over 2 weeks), ideally with a 2-week run-in with matched placebo.
The mainstay of treatment for Hyeprsensitivity pneumonitis is _______
antigen avoidance
Hypereosinophilic syndromes (HES) constitute a heterogeneous group of disease entities manifest by persistent eosinophilia >_____ eosinophils/ μL in association with end organ damage or dysfunction, in the absence of secondary causes of eosinophilia
1500
How do you differentiate Allergic bronchopulmonary aspergillosis (ABPA) from asthma?
ABPA is a distinct diagnosis from simple asthma, characterized by prominent peripheral eosinophilia and elevated circulating levels of IgE (>417 IU/mL).
Central bronchiectasis is described as a classic finding on chest imaging in ABPA but is not necessary for making a diagnosis
most common cancer associated with asbestos exposure
Lung cancer
Occupational disease that may present with crazy paving on HRCT
Silicosis = with characteristic HRCT pattern known as “crazy paving”
Calcification of hilar nodes may occur in as many as 20% of cases and produces a characteristic “eggshell” pattern.
mnemonic: pag crazy ka, silly ca (silica)
Caplan syndrome is the combination of ___ and ___
Caplan syndrome, first described in coal miners but subsequently in patients with silicosis, is the combination of pneumoconiotic nodules and seropositive rheumatoid arthritis.
Remember na Caplan is seen in coal workers pneumoconiosis and silicosis
The major site of increased resistance in most individuals with COPD is in airways____ diameter
≤2 mm
Emphysema most frequently associated with cigarette smoking, is characterized by enlarged air spaces found (initially) in association with respiratory bronchioles.
Centrilobular emphysema
usually most prominent in the upper lobes and superior segments of lower lobes and is often quite focal.
C-C (cigarette, centrilobular)
Type of emphysema is commonly observed in patients with α1 AT deficiency
Panlobular emphysema
The 3 most common symptoms in COPD ____
cough, sputum production, and exertional dyspnea
The change in pH with Pco2 is _____/10 mmHg acutely and ____/10 mmHg in the chronic state.
0.08 units
0.03 units (c-3rd letter of the alphabet, c- chronic)
The main role of ICS in COPD is to _____
reduce exacerbations
the only pharmacologic therapy demonstrated to unequivocally decrease mortality rates in patients with COPD.
Supplemental O2
For COPD patients with resting hypoxemia (resting O2 saturation ___ in any patient or ___ with signs of pulmonary hypertension or right heart failure), the use of O2 has been demonstrated to have a significant impact on mortality
≤88%
≤89%
The strongest single predictor of exacerbations is a _______
history of a previous exacerbation
Bacteria frequently implicated in COPD exacerbations include (3)
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
a pathologic hallmark of interstitial pulmonary fibrosis
Usual interstitial pneumonia
Diseases that satisfies the exudative criteria using Light’s criteria and would have a glucose < 60 mg/dL
Malignancy
Bacterial infections
Rheumatoid pleuritis
Light’s criteria misidentify )___% of transudates as exudates.
~25%
o If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative effusion, the difference between _________ should be measured.
protein levels in the serum and the pleural fluid
If this gradient is >31 g/L (3.1 g/dL), the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion.
You can also compute for serum - pleural fluid albumin. Cut off is 1.2 g/dL
A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >_____ is virtually diagnostic that the effusion is secondary to congestive heart failure.
1500 pg/mL
Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include:
- Loculated pleural fluid
- Pleural fluid pH< 7.20
- Pleural fluid glucose <3.3 mmol/L (60 mg/dL)
- Positive Gram stain or culture of the pleural fluid
- Presence of gross pus in the pleural space
Pulmonary embolism - exudative or transudative?
exudative
How do you diagnose ptb using pleural fluid studies?
The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL).
mnemonic (1nter40n- y) IFN-y –> 140
pleural TAG level to diagnose chylothorax
Thoracentesis reveals milky fluid, and biochemical analysis reveals a triglyceride level that exceeds 1.2 mmol/L (110 mg/dL).
The most common cause of chylothorax is _____
trauma
most commonly thoracic surgery
The initial recommended treatment for primary spontaneous pneumothorax is ______
simple aspiration
Criteria for diagnosing OSA
Diagnosis requires the patient to have
(1) either symptoms of nocturnal breathing disturbances (snoring, snorting, gasping, or breathing pauses during sleep) or daytime sleepiness or fatigue that occurs despite sufficient opportunities to sleep and is unexplained by other medical problems; and
(2) five or more episodes of obstructive apnea or hypopnea per hour of sleep
OSAHS also may be diagnosed in the absence of symptoms if the AHI is >15 episodes/h.
The most common daytime symptom in OSA is _____
excessive sleepiness
The gold standard for diagnosis of OSAHS is
overnight polysomnogram
Definition of hypopnea
30% reduction in airfow for at least 10 s and commonly results in a ≥3% drop in oxygen saturation and/or a brain cortical arousal.
standard medical therapy with the highest level of evidence for efficacy for OSA
CPAP
What constitutes qSOFA
respiratory rate >22, altered mental status, or systolic blood pressure <100
Needs to fulfill 2/3 to diagnose sepsis
Criteria for stopping spontaneous breathing trial
The spontaneous breathing trial is declared a failure and stopped if any of the fd occur:
o (1) respiratory rate >35/min for >5 min,
o (2) O2 saturation <90%
o (3) HR > 140/min or a 20% increase or decrease from baseline,
o (4) systolic blood pressure 180 mmHg, or
o (5) increased anxiety or diaphoresis.
Reason why H2 blockers are preferred for PPI in iCU setting
Histamine receptor-2 antagonists are preferred over proton pump inhibitors because the latter are associated with increased incidence of C. difficile colitis and pneumonia
The most common cause of distributive shock is
sepsis
Type of shock with dec CVP, PCWP, SVR but inc CO
Distributive
Type of shock with dec CVP, PCWP, CO but inc SVR
Hypovolemic
key difference between hypovolemic and distributive is the CO and SWR
CO is dec in hypovolemic but inc in distributive
Type of shock that will have inc CVP, PCWP, SVR but dec CO
Cardiogenic/ Obstructive however obstructive may present with either inc or dec PCWP. The rest of the parameters are same as cardiogenic
The shock index (SI) is defined as ______
defined as the HR/systolic blood pressure (SBP) with a normal SI being 0.5–0.7.
An elevated SI (>0.9) has been proposed to be a more sensitive indicator of transfusion requirement and of patients with critical bleeding among those with hypovolemic (hemorrhagic) shock than either HR or BP alone
In sepsis ____ are the most common gram-positive isolates, while _ are the most common gram-negative isolates.
S. aureus and S. pneumoniae
E. coli, Klebsiella species, and Pseudomonas aeruginosa
every 1-h delay of antibiotic administration among px w/ sepsis, a _____ increase in the odds of in-hospital death is reported
3–7%
Why is dopamine avoided as first line therapy for MI with cardiogenic shock?
Dopamine should be avoided as first-line therapy for MI with CS based on hemodynamic and proarrhythmogenic effects
While several prior trials demonstrated that mechanical ventilation in the prone position improved arterial oxygenation without a mortality benefit, a recent trial demonstrated a significant reduction in 28-day mortality with prone positioning (32.8 to 16%) for patients with severe ARDS with Pao2/Fio2 of _____
Pao2 /Fio2 < 150 mm Hg
The only class A recommendation therapy for ARDS
Low TV
5 Class B recommendations for ARDS
High PEEP
Minimize LA pressures
Prone position
ECMO
Early muscular blockade
Definition of moderate ARDS
PF ratio 100 to <= 200
Hence mild = <300
severe <= 100
The most important group of patients who benefit from a trial of NIV are those with ____ and ____
COPD exacerbations and respiratory acidosis (pH <7.35)
ventilatory weaning task force cites the ff conditions as indicating amenability to weaning:
PEEP
Fio2
Maximal inspiratory pressure
Minute ventilation
(1) Lung injury is stable or resolving;
(2) gas exchange is adequate, with low PEEP (< 8 cmH2 O) and Fio2 (0.5);
(3) hemodynamic variables are stable, and patient is no longer receiving vasopressors;
(4) the patient is capable of initiating spontaneous breaths.
(5) Maximal inspiratory pressure < -30 cm H2O
(6) Minute ventilation < 10 LPM
According to NTP If resources are limited, you have the option to prioritize those with TB risk factors as primary clients for chest X-ray screening.
Risk factor include:
a. contacts of TB patients
b. those ever treated for TB (i.e. with history of previous TB treatment);
c. people living with HIV (PLHIV);
d. elderly (> 60 years old);
e. diabetics;
f. smokers;
g. health-care workers;
h. urban and rural poor (indigents); and
i. those with other immune-suppressive medical conditions (silicosis, solid organ transplant, connective tissue or autoimmune disorder, end-stage renal disease, chronic corticosteroid use, alcohol or substance abuse, chemotherapy or other forms of medical treatment for cancer).
Screening by chest X-ray may be done every ____ for patients labeled as presumptive TB
1x a yr
Diagnostic test that should be requested for presumptive TB with unknown HIV status
Request Xpert MTB Rif Test
(SM/TB LAMP if Xpert not available)
Xray not needed . only for those for screening but without symptoms
if HIV +, need to do BOTH symptom and CXR screening so this time even if asymptomatic, need to do cxr
Among TB contacts, Who should be screened with CXR
If drug sensitive, All 5 years old and above (symptom screening only for < 5 years old)
If chest X-ray not available, do symptom screening
If drug resistant, ALL contacts
Diagnostic test for screening TB contacts
Gene Xpert
How frequent should you ff up TB contacts
every 6 months for 2 years
primary diagnostic test for PTB and EPTB in adults and children.
rapid diagnostic test (RDT), such as Xpert MTB/RIF
Can you use saliva as sample for Gene Xpert for screening for PTB?
For Xpert, testing should be performed on any collected spot sputum sample regardless whether it is sputum or saliva.
For SM, examine the specimen to see that it is not just saliva. Mucus from the nose and throat, and saliva from the mouth are not good specimens. Repeat the process if necessary.
Interpretation for these results for Gene Xpert
T
RR
TI
N
I
T = Mycobacterium tuberculosis (MTB) detected, rifampicin resistance not detected.
RR = MTB detected, rifampicin resistance detected.
TI= MTB detected, rifampicin resistance indeterminate.
N= MTB not detected.
I= Invalid/no result/error.
In which cases of should you repeat Gene xpert in patients with RR as initial result
For those who are at low risk for MDR-TB (i.e. new TB cases who are not DR-TB contacts) but with an Xpert result ofRR MTB detected with rifampicin resistance, the patient can be classified as bacteriologically confirmed TB (BCTB), but recollect a fresh sputum sample for repeat the Xpert MTB/RIF test and follow the second result on Rifampicin
resistance for the treatment decision.
However, in PLHIV in which mortality from the TB co-infection is high, there is no need to repeat the Xpert test as it will result in significantly delaying initiation of treatment.
The patient may be treated based on the result of the initial test.
How do you differentiate the ff?
Monoresistant TB
Polydrug resistant TB
MDR TB
XDR TB
Monoresistant TB
with resistance to one first-line anti-TB drug, except rifampicin whether bacteriologically confirmed or clinically diagnosed
Polydrug resistant TB
with resistance to more than one first-line anti-TB drug, other than both isoniazid and rifampicin, whether bacteriologically confirmed or clinically diagnosed
MDR TB
Positive for MTB complex with resistance to at least both isoniazid and rifampicin
XDR TB
Positive for MTB complex with resistance to any fluoroquinolone(FQ) and to at least one second-line injectable drug (e.g. amikacin,streptomycin), in addition to multidrug resistance
Regimen 1 for DS TB
2HRZE/4HR
for PTB or EPTB (except central nervous system [CNS], bones, joints) whether new or retreatment
Regimen 2 for DS TB
2HRZE/10HR
for EPTB of CNS, bones, joints whether new or retreatment,
Body weight range that requires 3 tablets of TB meds
38-54 kg
Body weight range that requires 4 tablets of TB meds
55-70
Screening used for DM in TB patients
If not a known diabetic, screen all TB patients ≥ 25 years old for diabetes using a fasting or random plasma blood glucose test (Cut-off level ≥ 7 mmol/L or 126 mg/dl for fasting; 11.1 mmol/L or 200 mg/dl for random).
When should Antiretroviral drugs be given in px with TB and HIV?
TB treatment should be initiated first, followed by ART as soon as possible within the first eight weeks of treatment.
If with profound immunosuppression (e.g. CD4 counts less than 50 cells/mm3), HIV-positive TB patients should receive ART within the first two weeks of initiating TB treatment.
What TB drug may have a major side effect of psychosis and convulsion?
Isoniazid
What TB drug may have a major side effect of Thrombocytopenia, anemia, shock
Rifampicin
What TB drug may have a major side effect of Oliguria or albuminuria
Rifampicin
What is the treatment for peripheral neuropathy caused by Isoniazid?
Give pyridoxine (Vit B6) 50–100 mg daily for treatment; it can also be given 10 mg daily for prevention
What is the treatment for Arthralgia due to hyperuricemia due to pyrazinamide
Give aspirin or NSAID; if persistent, consider gout and request uric acid determination, manage accordingly or refer
When do you schedule of sputum follow-up examinations for PTB on DS-TB regimen?
When can you clear patient for work based on infectiousness?
After one week of uninterrupted treatment for clinically diagnosed TB cases.
After a negative follow-up SM for bacteriologically confirmed TB cases.
If patient wishes to return to work sooner, SM may be repeated (outside of the regular schedule) at least two weeks after treatment initiation.
How many months of interrupted treatment is required for designating patient as lost to follow up?
2 CONSECUTIVE months
When do you label a patient as treatment failed
If positive sputum at the end of 5th month
MDR-TB and RR-TB treatment shall be started within ____ from diagnosis.
seven days
individuals who require further evaluation to assess eligibility for TB preventive treatment:
a. PLHIV aged 1 year and older (regardless of history of contact);
b. all household contacts of bacteriologically confirmed PTB;
c. children less than 5 years old who are household contacts of clinically diagnosed PTB;
d. close contacts of bacteriologically confirmed PTB (outside the household); and
e. other risk groups:
* patients receiving dialysis
* patients preparing for an organ or hematological transplantation
* patients initiating anti-tumor necrosis factor (TNF) treatment patients with silicosis.
eligible groups for preventive TB regimen that do not require TST.
They may be offered TPT once active TB is ruled out:
a. PLHIV aged 1 year or older;
b. children less than 5 years old who are household contacts of bacteriologically
confirmed PTB; and
c. individuals aged 5 years and older with other TB risk factors (i.e. PLHIV, diabetes,
smoking, those with immune-suppressive medical conditions, malnourished,
with multiple TB cases in same household) and who are household contacts of
bacteriologically confirmed PTB.
What are the treatment regimens for LTBI
Most common cause of pleural effusion
LV failure
How do you diagnose hemothorax?
Pleural fluid/Serum Hct ratio >0.5
Recommended medication as both maintenance and reliever tx for asthma
ICS formoterol
Preferred OCS for pregnant women
prednisone
Clinical disorders associated with ARDS that causes direct lung injury
Pneumonia
Aspiration of gastric contents
Pulmonary contusion
Near drowning
Toxic inhalation injury
severe trauma, sepsis –> indirect lung injury
Goals for ARDS
TV
Plateau pressure
RR
Fio2
Spo2
pH
MAP
TV <=6 cc/kg
PP <= 30cm H2O
RR <= 35
Fio2 <=60%
Spo2 88-95%
pH >=7.3
MAP >=65
take note: lahat may equal sign
In COPD patients with acute hyperbaric respi failure a ph of ____ is an indication for NIV
7.25-7.35
Cut off for cuff leak test (exhaled TV)
< 110 mL = positive leak test (no leak)
meaning a significant laryngeal edema is preventing a leak despite the cuff being deflated
basically negativity/positivity of cuff leak test is referring to the absence/presence of laryngeal edema NOT leak
In patients with active influenza or history of influenza, infection within 2 weeks of development of CAP, ____ / ____ should be added to CAP regimen
Vancomycin 15 mg/kg q8 OR Linezolid 600 mg q12
Think of MRSA
Predominant cell in gray hepatization in pneumonia
Neutrophil
Fibrin deposition is also abundant
Predominant cell in resolution phase in pneumonia
Macrophage
Most important risk factor for antibiotic resistant pneumonia
Prior antibiotic use in the past 3 months
Diagnostic threshold of ___ CFU is needed for diagnosis of pneumonia using endotracheal aspirate
10^6
10^3 for more distal sources
For hospitalized patients with CAP, when is a follow up CXR recommended?
4-6 weeks (Harrisons)
Based on PSMID 2020
We recommend posttreatment chest x-rays after a minimum of 6 to 8 weeks among patients with CAP to establish baseline and to exclude other conditions
When do you expect the following ssx to resolve after pneumonia?
fever
chest pain and sputum production
cough and breathlesness
fever - 1 week
chest pain and sputum production - 1month
cough and breathlesness - 6 weeks
What is the most potent risk factor for developing active TB?
HIV co-infection
What should you request if sputum microscopy is positive after the intensive phase?
Gene xpert
Level of anti trypsin to qualify for a1 antitrypsin augmentation therapy provided there is ABNORMAL CT findings
< 50 mg/dL or <11 uM
Strong indications for starting corticosteroids in px with COPD
Hx of hospitalization for COPD exacerbation
> = 2 moderate exacerbation per year
Blood eosinophil > 300 cells/uL
Hx of concomitant asthm
Which set of COPD px may undergo air travel without further assessment
Resting O2 >95%
6 minute walk oxygen >84%
Roflumilast may only be considered in COPD px if
with FEV <50% predicted and if with chronic bronchitis
** additional info: Azith may be used in former smokers
Which set of COPD px will likely benefit from lung volume reduction surgery
Upper lobe dominant emphysema and low exercise capacity post rehab
Initial imaging of choice for initial evaluation of px with suspected ILD
HRCT
Apnea-Hypopnea index of someone with moderate OSA
15-29 events/hr
Px with silicosis are at risk of developing infection with these organisms (3)
MTB
atypical mycobacteria
fungi
due to alveolar macrophage dysfunction
Phase of pneumonia that corresponds with the successful containment of the infection and improvement in gas exchange
Gray hepatization
no new erythrocytes are extravasating, and those already present have been lysed and degraded. The neutrophil is the predominant cell, fibrin deposition is abundant, and bacteria have disappeared
Pneumonia pattern most common in nosocomial pneumonias
A bronchopneumonia pattern is most common in nosocomial pneumonias, whereas a lobar pattern is more common inbacterial CAP.
Possible pneumonia pathogens for those with dementia, stroke or with dec level of consciousness
Oral anaerobes
G- bacteria
Possible pneumonia pathogens for those with structural lung disease
P. aeruginosa
B. cepacia
S. aureus
Define good catch sputum sample
(To be suitable, a sputum sample must have >25 neutrophils and <10 squamous epithelial cells per low-power field.)
No equal sign!
The sensitivity and specificity of the sputum Gram’s stain and culture are highly variable. Even in cases of proven bacteremic pneumococcal pneumonia, the yield of positive cultures from sputum is ≤50%.
Most common isolate in blood cultures of px with pneumonia
S. pneumoniae
The yield from blood cultures, even when samples are collected before antibiotic therapy, is disappointingly low. Only 5–14% of cultures from hospitalized CAP patients are positive, and the most common pathogen is S. pneumoniae.
What variables constitute CURB 65
confusion (C);
urea>7 mmol/L (U);
respiratory rate ≥30/min (R);
SBP ≤90 mmHg OR DBP ≤60 mmHg (B)
an age of ≥65 years.
With a score of 1 or 2, the patient should be hospitalized unless the score is entirely or in part attributable to an age of ≥65 years
Among patients with scores of ≥3, mortality rates are 22% overall; these patients may require ICU admission
According to Harrisons, What antibiotics may be given to outpx with pneumonia
Take note amox only if no comorbs but if with co morbs, need to be coamox
FQ only for those with comorbs.
Which of the 2 (PPSV 23 vs PCV13) produces T-cell–dependent antigens, resulting in long-term immunologic memory.
PCV13 produces T-cell–dependent
antigens, resulting in long-term immunologic memory.
Three factors are critical in the pathogenesis of VAP:
colonization of the oropharynx with pathogenic microorganisms
aspiration of these organisms from the oropharynx into the lower respiratory tract
compromise of normal host defense mechanisms.
The most obvious risk factor for VAP
endotracheal tube, which bypasses the normal mechanical factors preventing aspiration
Because endotracheal intubation is a risk factor for VAP, the most important preventive intervention is to avoid intubation or minimize
its duration.
major risk factor for infection with MRSA and ESBL-positive strains.
Frequent use of β-lactam drugs, especially cephalosporins
The major difference from CAP is the markedly lower incidence of atypical pathogens in VAP; the exception is ______
Legionella
can be a nosocomial pathogen, especially with local epidemics due to breakdowns in the treatment of potable water in the hospital.
According to Harrisons, What antibiotics may be given to in px with VAP/HAP
Refer to table
7- or 8-day course of therapy is just as effective as a 2-week course and is associated with less frequent emergence of antibioticresistant
strains.
The only pathogens that may be more common in the non-VAP population are ____ because of a greater risk of macroaspiration and the lower oxygen tensions in the lower respiratory tract of these patients.
anaerobes
In COPD patients
PaO2 remains normal or near normal until FEV1 decreases to about _ % of predicted
PCO2 elevation is expected when FEV1
decreases to less than _ % of predicted
50%
25%
hence mauuna o2 bumaba
three interventions that have been demonstrated to improve survival of patients with COPD
smoking cessation
oxygen therapy in chronically hypoxemic patients
lung volume reduction surgery (LVRS) in selected patients with emphysema
Thoracentesis is required for the which set of patients with heart failure and pleural effusion
- Unilateral
- Bilateral but not comparable in size
- Presence of fever
- Presence of pleuritic chest pain
most common cause of secondary
pneumothorax
COPD
Rapid recovery and liberation from mechanical
ventilation is expected for most ARDS cases during days 7-21. Which phase of ARDS is this?
Proliferative
Treatment for aerophagia in px using CPAP
most common symptom in pulmonary
embolism
Unexplained breathlessness
Treatment for difficulty exhaling in px using CPAP
Which pattern of interstitial lung disease is most commonly seen in patients with rheumatoid arthritis?
UIP if IPF and RA
Non specific interstitial pneumonia for other Connective tissue dse
What is the most common underlying cause of
blood-tinged sputum and small volume
hemoptysis?
Viral bronchitis
Average diurnal PEF variability in asthma is > ___%
10
FEV that will indicate good response after the initial management of an acute exacerbation of asthma?
FEV1 or PEF 60-80% of personal best
Test that may be done to test for compliance to ICS
FeNO
Elevated levels (>35–40 ppb) in untreated patients are indicative of eosinophilic inflammation.
Levels >20–25 ppb in patients with severe asthma on moderate- to high-dose ICS indicate either poor adherence or persistent type 2 inflammation despite therapy
How long should you hold SABA before performing reversibility testing in asthma
4 hrs
LABA-ICS –> 12 hrs
most typical pathophysiologic finding in COPD?
Persistent reduction in forced expiratory flow rates
As part of diagnosis and assessment of patients with COPD, arterial blood gases should be assessed when the peripheral oxygen saturation is less than ___
92%
Severity of COPD if FEV1/FVC is 50 to <80 % of predicted
Moderate
Mild >=80
Moderate 50- <80%
Severe 30-< 50%
Very Severe < 30%
Barotrauma and hyperventilation are potential disadvantages of what form of mechanical ventilation?
AC mode
how long (__ hrs /day) is long term oxygen therapy for COPD?
At least 15h/day
second most common site of extrapulmonary tuberculosis is
pleura
Description of mmrc 2 in copd
“I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking at my own pace on the level.”
Oral anticoagulant does not need “bridging” with parenteral anticoagulation prior to initiation as treatment for venous thromboembolism
apixaban and rivaroxaban
Many patients with ARDS who will not enter the fibrotic phase may recover lung function after how may weeks from the initial pulmonary injury?
3-4 weeks
Treatment of choice for chylothorax
chest tube insertion + octreotide
expected pulmonary function test among patients with asbestosis
Restrictive pattern with a decrease in both lung volumes and diffusing capacity
_____bronchiectasis is described as a classic finding on chest imaging in ABPA but is not necessary for making a diagnosis
Central
Based on 2024 GINA guidelines, what is the only ICS-LABA that may be used as antiinflammatory relieved
ICS-formoterol
Based on 2024 GINA guidelines consider stepping down when symtoms of asthma are well controlled and lung function are stable for at least __ months
3
the preferred mode of ventilation for patients in whom it is desirable to regulate peak airway pressures, such as those with preexisting barotrauma, and for post– thoracic surgery patients, in whom the shear forces across a fresh suture line should be limited
PCV
In pneumomediastinum _________ sign, is a crunching or clicking noise synchronous with the heartbeat and is best heard in the left lateral decubitus position
Hamman’s
Hallmark of alveolar hypoventilation
High PCO2 with normal pH
3 tumors that cause 75% of all malignant pleural effusions are
lung CA, breast CA and lymphoma
Secondary TB has predilection to which segment of the lungs
apical and posterior segments of the upper lobes
Most commonly involved lung zones in primary TB
middle and lower lung zones
Classic finding in pulmonary ARTERIAL hypertension
isolated reduction in DLCO
2 main goals of COPD therapy
The two main goals of therapy are to provide symptomatic relief (reduce respiratory symptoms, improve exercise tolerance, improve health status) and reduce future risk (prevent disease progression, prevent and treat exacerbations, and reduce mortality)
Adventitious lung sound that is a manifestation of obstruction of medium-sized airways, most often with secretions
Rhonchi
Crackles, or rales, are commonly a sign of alveolar disease.
A total lung capacity <__% of the patient’s predicted value defines restrictive pathophysiology
80
The excursion between full and minimal lung inflation is called ______ and is readily seen to be the difference between volumes at two unrelated stiffness extremes—one determined by the lung (TLC) and the other by the chest wall or airways (RV).
vital capacity
Functional residual capacity constitutes which lung volumes
ERV + RV
What airway pathology can present with DLCO > 100%
What airway pathology can present with TLC > 100%
The total amount of air exhaled is the ___
FVC
Diseases that present with scooping of the flow volume loop
In diseases that cause lower airway obstruction, such as asthma and emphysema, flows decrease more rapidly with declining lung volumes, leading to a characteristic scooping of the flow-volume loop
hallmark of asthma
Airway hyperresponsiveness is a hallmark of asthma
Structural abnormalities associated with airway hyperresponsiveness in asthma
In asthma, airway wall thickness is associated with disease severity and duration. This thickening, which may result from a combination of smooth-muscle hypertrophy and hyperplasia, subEPIthelial collagen deposition, airway edema, and mucosal inflammation, can result in a tendency for the airway to narrow disproportionately in response to stimuli that elicit increased airway muscle tension
IL-___ induces B-cell isotype switching to production of IgE
IL-4 induces B-cell isotype switching to production of IgE
IL-__ induces airway hyperresponsiveness, mucus hypersecretion, and goblet cell metaplasia
IL-13 induces airway hyperresponsiveness, mucus hypersecretion, and goblet cell metaplasia
IL-__me has a critical role in regulating eosinophils. It controls formation, recruitment, and survival of these cells
. IL-5 has a critical role in regulating eosinophils. It controls formation, recruitment, and survival of these cells
Goals of asthma therapy
Regular use of beta agonists has been associated with tachyphylaxis of the bronchoprotective effect and possible increased airway reactivity. This may be more common in patients with a polymorphism at the ___th amino acid position of the β2 -receptor.
Regular use has been associated with tachyphylaxis of the bronchoprotective effect and possible increased airway reactivity. This may be more common in patients with a polymorphism at the 16th amino acid position of the β2 -receptor.
Frequent short-acting β-2 agonist use has been associated with increased asthma mortality resulting in decreased enthusiasm for use in isolation without inhaled corticosteroidsa
Examples of ultra long LABA
These agents (indacaterol, olodaterol, and vilanterol) have a 24-h effect. They are only used in combination with ICSs in the treatment of asthma.
pneumocystis pneumonia prophylaxis should be administered for those asthmatic px maintained on a daily prednisone dose of ≥___
20 mg
MOA of montelukast and zafirlukast
leukotriene receptor antagonist
inhibits cysteinyl leukotriene type-1 (CysLT1)
moderately effective in asthma
Zileuton - 5 LOX inhibitor
T/F
Patients with aspirin exacerbated respiratory dse should avoid all NSAIDs
These patients should avoid inhibitors of cyclooxygenase-1, (aspirin and NSAIDs) but can generally tolerate inhibitors of cyclooxygenase-2 and acetaminophen
They should be treated with leukotriene modifiers.
Aspirin desensitization can be undertaken to decrease upper respiratory symptoms and to allow chronic administration of aspirin or NSAIDs for those that require it.
Dupilumab and the IL-5–active biologics appear to be particularly helpful and appear to be superseding aspirin desensitization in management except when chronic administration of aspirin or NSAIDs is required for another therapeutic indication.
ACO is common in which subset of population
Elderly and smokers
SABA overuse based from GINA 2023 is defined as
> = 3 200 dose canisters per yr
mortality is inc if >=1 canister per month
Based on GINA 2023 when should lung function test be repeated after dx of asthma
3-6 months
First step before initiating asthma tx
Record evidence and dx of asthma
Doses of inhaled corticosteroids for asthma
Add on therapy for STEP 5 asthma control based on GINA 2023
How often should patients with asthma be reviewed?
1-3 months after treatment and every 3-12 months after that
BUT in pregnancy asthma should be reviewed every 4-6 weeks
What should be given in asthma px during surgery if they are on long term high dose ICS or >2 weeks OCS in the past 6 months?
Intraop hydrocortisone
T/F OCS in asthma should always be tapered
False
No need for tapering if < 2 weeks
Additional note: pred should be given in AM
Target O2 sat in asthma px in acute exacerbation as per GINA 2023
93-95%
Management of asthma exacerbations in primary care
When should you follow up px with asthma after any exacerbation?
2-7 days
CXR findings in hypersensitivity pneumonitis
Chest x-ray findings in HP are nonspecific and can even lack any discernible abnormalities. In cases of acute and subacute HP, findings may be transient and can include ill-defined micronodular opacities or hazy ground-glass airspace opacities
Stronges predictor for hypersensitivity pneumonitis
Although not meant as a set of validated diagnostic criteria, a clinical prediction rule for predicting the presence of HP has been published by the HP Study Group. They identified six statistically significant predictors for HP, the strongest of which was exposure to an antigen known to cause HP
Mainstay of tx for hypersensitivity pneumonitis
antigen avoidance
Although glucocorticoids do not change the long-term outcome in these patients, they can accelerate the resolution of symptoms. While there is significant variability in the approach to glucocorticoid therapy by individual clinicians, prednisone therapy can be initiated at 0.5–1 mg/kg of ideal body weight per day (not to exceed 60 mg/d or alternative glucocorticoid equivalent) over a duration of 1–2 weeks, followed by a taper over the next 2–6 weeks.
Diagnostic criteria for acute eosinophilic pneumonia
Loffler syndrome is associated with which parasites
Loffler syndrome refers to transient pulmonary infiltrates with eosinophilia that occurs in response to passage of helminthic larvae through the lungs, most commonly larvae of Ascaris species (roundworm). Symptoms are generally self-limited and may include dyspnea, cough, wheeze, and hemoptysis. Loffler syndrome may also occur in response to hookworm infection with Ancylostoma duodenale or Necator americanus.
classic finding on chest imaging in ABPA (ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS)
Central bronchiectasis is described as a classic finding on chest imaging in ABPA but is not necessary for making a diagnosis. Other possible findings on chest imaging include patchy infiltrates and evidence of mucus impaction
Treatment for ABPA
Systemic glucocorticoids may be used in the treatment of ABPA that is persistently symptomatic despite the use of inhaled therapies for asthma. Courses of glucocorticoids should be tapered over 3–6 months, and their use must be balanced against the risks of prolonged steroid therapy.
Antifungal agents such as itraconazole and voriconazole given over a 4-month course reduce the antigenic stimulus in ABPA and may therefore modulate disease activity in selected patients. Newer azole agents may be used as well.
The use of monoclonal antibody against IgE (omalizumab) has been described in treating severe ABPA, particularly in individuals with ABPA as a complication of cystic fibrosis.
Other monoclonal antibodies used in severe eosinophilic asthma, such as those targeting IL-5 (or its receptor) or targeting IL-4-receptor-alpha, may be considered as well in refractory cases
EOSINOPHILIC GRANULOMATOSIS WITH
POLYANGIITIS (EGPA) is AKA as
allergic angiitis granulomatosis or Churg-Strauss
syndrome
Hallmark finding of EGPA
Systemic eosinophilia is the hallmark laboratory finding in patients with EGPA and reflects the likely pathogenic role that the eosinophil plays in this disease.
Eosinophilia >10% is one of the defining features of this illness and may be as high as 75% of the peripheral white blood cell count.
It is present at the time of diagnosis in >80% of patients, but may respond quickly (often within 24 h) to initiation of systemic corticosteroid therapy.
most common CT findings of EGPA
The most common CT findings include bilateral ground-glass opacity and airspace consolidation that is predominantly subpleural. Other CT findings include bronchial wall thickening, hyperinflation, interlobular septal thickening, lymph node enlargement, and pericardial and pleural effusions.
Involvement of these systems in EGPA most often portend a poor prognosis
Myocardial, GI, and renal involvement most often portend a poor prognosis.
Light’s criteria
most common cause of an exudative pleural effusion
In many parts of the world, the most common cause of an exudative pleural effusion is tuberculosis (TB)
2nd- malignancy
The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL).
If the pleural hemorrhage exceeds ___ mL/h, consideration should be given to angiographic coil embolization, thoracoscopy, or thoracotomy
200
The major risk factors for OSA are
The major risk factors for OSA are obesity, male sex, and older age
A 10% weight gain is associated with a >30% increase in AHI.
Even modest weight loss or weight gain can influence the risk and severity of OSA. However, the absence of obesity does not exclude this diagnosis
A partially obstructed breath, typically within a hypopnea or RERA, identified by a flattened or “scooped-out” inspiratory flow shape
Flow limited breath
How do you classify OSA
Average effect of CPAPon BP
Although the overall impact of CPAP on blood pressure levels is relatively modest (averaging 2–4 mmHg), larger improvements are observed among patients who have a high AHI, report daytime sleepiness, or have resistant hypertension
Lifestyle modifications for OSA
As appropriate, treatment should aim to reduce weight; optimize sleep duration (7–9 h); regulate sleep schedules (with similar bedtimes and wake times across the week); encourage the patient to avoid sleeping in the supine position; treat nasal allergies; increase physical activity; eliminate alcohol ingestion (which impairs pharyngeal muscle activity) within 3 h of bedtime; and minimize use of opiate medications. Sedative hypnotic medications have inconsistent effects on OSA but should be avoided in most patients with moderate to severe OSA
Most commonly performed surgery for OSA
Uvulopalatopharyngoplasty (removal of the uvula and the margin of the soft palate) is the most commonly performed surgery for OSA and, although results vary greatly, is generally less successful than treatment with oral appliances.
Cheyne-Stokes breathing is treated by
optimizing therapy for heart failure
Central sleep apnea (CSA) is caused by
CSA is often caused by an increased sensitivity to Pco2 , which leads to an unstable breathing pattern that manifests as hyperventilation alternating with apnea
prevailing mechanism for the development of emphysema
The elastase:antielastase hypothesis remains a prevailing mechanism for the development of emphysema
T/F
The absolute annual loss in FEV1 tends to be highest in mild COPD and lowest in very severe COPD
True
paradoxical inward movement of the rib cage with inspiration is called _____ sign
Some patients with advanced disease have paradoxical inward movement of the rib cage with inspiration (Hoover’s sign), the result of alteration of the vector of diaphragmatic contraction on the rib cage due to chronic hyperinflation
Management of COPD based on Harrisons
Based on Harrisons, when should you consider LAMA + LABA+ ICS in px with COPD
The main role of ICS is to reduce exacerbations. In population studies, patients with an eosinophil count of <100 cells per microliter do not benefit, while benefit increases as eosinophil counts rise above 100
A trial of ICS should be considered in patients with frequent exacerbations, defined as two or more per year or in patients hospitalized with one exacerbation
** based on GOLD, dpaat eoino >300
Recommended vaccines for COPD px based on Harrisons
Patients with COPD should receive the influenza vaccine annually. Pneumococcal vaccines and vaccination for Bordetella pertussis are recommended.
B-P-I
If asthma, recommended covid 19 vaccine, not bordatella
T/F
Based on CPG 2023, LABA + LAMA is preferred over LAMA or LABA monotherapy among stable COPD patients in the primary care setting with FEV1<80% or mMRC≥2
True
Among stable COPD patients in the primary care setting with FEV1<80% or mMRC≥2* and are not in exacerbation, we recommend the use of LABA/LAMA combination therapy over LAMA or LABA monotherapy
T/F
Based on CPG 2023, ICS may be given in COPD px with increased risk for exacerbations and absence of concurrent respiratory infection
True
Among stable COPD patients in the primary care setting with FEV1<80% or mMRC≥2* with increased risk for exacerbations and absence of concurrent respiratory infection**, we recommend the use of inhaled corticosteroids in combination with inhaled long-acting bronchodilators
Among stable COPD patients in the primary care setting with FEV1≥80% or mmRC<2* and are not in exacerbation, we suggest the use of LAMA monotherapy over LABA monotherapy or LABA/LAMA combination therapy
T/F
Based on CPG 2023, adding methylxanthines to LABA in COPD px has no benefit
False
Among stable COPD patients in the primary care setting, we recommend against adding oral methylxanthines to inhaled long-acting bronchodilator
Recommended bronchodilator in COPDIAE
Among patients with COPD,recommend the use of SABA+SAMA (combination therapy) in the management of acute exacerbation.
In situations where SABA+SAMA is not readily available, SABA may be used
Based on CPG 2023, when is initiation of antibiotics recommended in px with COPD
Among outpatients with COPD, we recommend initiation of oral antibiotics in the presence of at least two of the following symptoms: increased dyspnea, increased frequency of cough, increased sputum volume or purulence
T/F
As per CPG 2023, oral steroids are recommended among COPD patients in exacerbation with worsening symptoms and not responding to bronchodilators
True
Among COPD patients in exacerbation with worsening symptoms and not responding to bronchodilators, we recommend the use of short course* oral steroids in the primary care setting
short course = 5 days of 30 mg prednisolone
As per CPG 2023, when should we refer COPD px to higher level of care
Among COPD patients managed at the primary level, we recommend referral of any of the following conditions that are associated with higher risk of mortality to higher level of care: presence of uncontrolled diabetes or cardiovascular disease, previous hospitalization for acute exacerbation within the past year, hospital readmission within 30 days, and use of long-term oxygen therapy
CXR findings of past exposure to asbestos
Past exposure to asbestos is specifically indicated by pleural plaques on chest radiographs, which are characterized by either thickening or calcification along the parietal pleura, particularly along the lower lung fields, the diaphragm, and the cardiac border. Without additional manifestations, pleural plaques imply only exposure, not pulmonary impairment
Difference between mesothelioma and lung CA with regard to exposure risk
Mesothelioma, both pleural and peritoneal, are also associated with asbestos exposure. In contrast to lung cancers, these tumors do not appear to be associated with smoking.
Relatively shortterm asbestos exposures of ≤1–2 years, occurring up to 40 years in the past, have been associated with the development of mesotheliomas
Definition of complicated silicosis and progressive massive fibrosis
Calcification of hilar nodes may occur in as many as 20% of cases and produces a characteristic “eggshell” pattern. Silicotic nodules may be identified more readily by HRCT. The nodular fibrosis may be progressive in the absence of further exposure, with coalescence and formation of nonsegmental conglomerates of irregular masses >1 cm in diameter (complicated silicosis).
**same cut off of >=1cm for complicated coal workers pneumoconiosis
These masses can become quite large, and when this occurs, the term progressive massive fibrosis (PMF) is applied
Usual location of complicated coal workers pneumoconiosis
Complicated CWP is manifested by the appearance on the chest radiograph of nodules ≥1 cm in diameter generally confined to the upper half of the lungs
Asbestosis - lower lungs
Diagnosis of chronic beryllium disease
Fiberoptic bronchoscopy with transbronchial lung biopsy usually is required to make the diagnosis of CBD.
Others:
The test that usually provides this evidence is the beryllium lymphocyte proliferation test (BeLPT).
This condition results from exposure to moldy hay containing spores of thermophilic actinomycetes that produce a hypersensitivity pneumonitis
Farmer’s lung
A patient with acute farmer’s lung presents 4–8 h after exposure with fever, chills, malaise, cough, and dyspnea WITHOUT wheezing.
ILDthat will present with Bilateral subpleural reticular changes most prominent in lower, posterior lung zones. Traction bronchiectasis and honeycombing common. Classic usual interstitial pneumonia (UIP) pattern is considered diagnostic
IPF
ILD that will present with Peripheral subpleural ground glass and reticular patterns. Traction bronchiectasis is common, but honeycombing is rare
Non specific interstitial pneumonia
Idiopathic NSIP is often treated with oral steroids (prednisone), cytotoxic agents (mycophenolate, azathioprine, and cyclophosphamide), or biologics (rituximab)
ILD that will present as Respiratory bronchiolitis with adjacent inflammatory and fibrosing changes. Pigment-laden macrophages
Respiratory bronchiolitis associated ILD
Most common complaint in px with ILD
Progressive dyspnea, most frequently noted with exertion, is the most common complaint in patients presenting with an ILD
PFT of px with ILD
Most forms of ILD will eventually result in a restrictive deficit on pulmonary function testing. A restrictive deficit is typified by a reduced total lung capacity (TLC) and symmetrically reduced measures of forced expiratory volume in 1 s (FEV1 ) and forced vital capacity (FVC). A reduction in the diffusing capacity of the lung for carbon monoxide (DlCO) is also common and may precede a reduction in lung volumes; however, there is more measurement variability in DlCO measurement and the test is less specific for ILD
standard of care in the initial evaluation of a patient with a suspected ILD.
High-resolution CT (HRCT) chest imaging is now considered to be standard of care in the initial evaluation of a patient with a suspected ILD.
tandard of care for patients with advanced and rapidly progressive ILDs
lung transplantation remains the standard of care for patients with advanced and rapidly progressive ILDs.
most common ILD of unknown cause
IPF is the most common ILD of unknown cause
Most common HRCT finding of cyrptogenic organizing pneumonia
The most common imaging findings include patchy, sometimes migratory, subpleural consolidative opacities often with associated ground-glass opacities.
Peribronchiolar or perilobar opacities can be present, and sometimes a rim of subpleural sparing (often referred to as a REVERSED HALO or ATOLL SIGN) can be seen, which can aid in the diagnosis
Corticosteroids can result in substantial clinical improvement in many patients but usually need to be continued for at least 6 months as relapse rates are high
most common pulmonary manifestation of systemic sclerosis
ILD
Cyclophosphamide has a modest benefit in preservation of lung function and is associated with significant toxicity. Mycophenolate has recently been shown to have similar efficacy and improved tolerability. Clinical trials have demonstrated that antifibrotic therapy (e.g., nintedanib) may benefit patients with systemic sclerosis associated pulmonary fibrosis
The most common imaging pattern of ILD in patients with RA
The most common imaging pattern of ILD in patients with RA is a UIP pattern, although NSIP patterns are not uncommon
Characteristics of anti-synthetase syndrome
The anti-synthetase syndrome is characterized by positive anti-synthetase antibodies, myositis, fever, Raynaud’s phenomenon, mechanic’s hands, arthritis, and progressive ILD
Immunosuppressive (e.g., prednisone) and cytotoxic (e.g., mycophenolate, azathioprine, cyclophosphamide, and calcineurin inhibitors) agents are often used in patients with progressive ILD
The most infectious TB patients
The most infectious patients have cavitary pulmonary disease or, much less commonly, laryngeal TB and produce sputum containing as many as 105 –107 AFB/mL
additional note:
Because persons with both HIV infection and TB are less likely to have cavitations, they may be less infectious than persons without HIV co-infection
T/F
Those with culture-negative pulmonary TB and extrapulmonary TB are essentially noninfectious
True
The lesion forming after initial infection is called __________ is usually peripheral and accompanied by transient hilar or paratracheal lymphadenopathy, which may or may not be visible on standard chest radiography (CXR
The lesion forming after initial infection (Ghon focus) is usually peripheral and accompanied by transient hilar or paratracheal lymphadenopathy, which may or may not be visible on standard chest radiography (CXR)
The Ghon focus, with or without overlying pleural reaction, thickening, and regional lymphadenopathy, is referred to as the Ghon complex
Most commonly involved lung segments in post primary or adult type PTB dse
It is usually localized to the apical and posterior segments of the upper lobes, where the substantially higher mean oxygen tension (compared with that in the lower zones) favors mycobacterial growth.
Hemoptysis in PTB, however, may also result from rupture of a dilated vessel in a cavity AKA _______ aneurysm) or from aspergilloma formation in an old cavity
Hemoptysis, however, may also result from rupture of a dilated vessel in a cavity (Rasmussen’s aneurysm) or from aspergilloma formation in an old cavity
Characteristic pleural fluid in px with TB pleuritis
The fluid is straw-colored and at times hemorrhagic; it is an exudate with a protein concentration >50% of that in serum (usually ~4–6 g/dL), a normal to low glucose concentration, a pH of ~7.3 (occasionally <7.2), and detectable white blood cells (usually 500–6000/μL). Neutrophils may predominate in the early stage, but lymphocyte predominance is the typical finding later
Most commonly involved parts of the spine in px with Pott’s dse
Whereas the upper thoracic spine is the most common site of spinal TB in children, the lower thoracic and upper lumbar vertebrae are usually affected in adults
How long should steroids be used in CNS TB as per WHO guidelines
The WHO now recommends that adjuvant glucocorticoid therapy with either dexamethasone or prednisolone, tapered over 6–8 weeks, should be used in CNS TB.
preferred initial diagnostic option for pulmonary TB
The Xpert MTB/RIF assay is the preferred initial diagnostic option for pulmonary TB ensuring a sensitivity of 81% and a specificity of 98%, and therapy should be started on the basis of a positive result because treatment delays may be fatal. A negative Xpert MTB/RIF result, however, does not exclude a diagnosis of TB. Culture remains the gold standard.
Management for TB IRIS
IRIS can result in serious neurologic complications or death in patients with CNS TB. Therefore, ART should not be initiated during the first 8 weeks of TB treatment in patients with TB meningitis.
BUUUUT
ART should be started within the first 2 weeks of TB treatment for profoundly immunosuppressed patients with CD4+ T-cell counts of <50/μL.
Glucocorticoids have been used for severe paradoxical reactions; prednisolone given for 4 weeks at a low dosage (1.5 mg/kg per day for 2 weeks and half that dose for the remaining 2 weeks) has reduced the need for hospitalization and therapeutic procedures and has hastened alleviation of symptoms, as reflected by Karnofsky performance scores, quality-of-life assessments, radiographic response, and C-reactive protein levels
Genes associated with INH resistance
katG and inhA
Gene associated with Rifampicin resistance
rpo B
TB regimen dosing
Groupings of second line TB drugs
Group A drugs include three classes of oral agents: the fluoroquinolones levofloxacin and moxifloxacin; the oxazolidinone linezolid; and the recently introduced diarylquinoline bedaquiline, which was granted accelerated approval by the FDA in late 2012.
Group B drugs include two other oral agents: clofazimine and cycloserine (or its analogue terizidone).
Group C drugs include the nitroimidazole delamanid; imipenemcilastatin or meropenem; the injectable aminoglycosides amikacin and streptomycin
With the recommended 6-month standard first-line regimen, >80% of drug-susceptible TB patients will have negative sputum cultures at the end of the
second month of treatment.
By the end of the third month, the sputum of virtually all patients should be culture negative
treatment failure should be suspected when a patient’s cultures (or sputum smears, when cultures are not available) remain positive after 3 months of treatment
The most common adverse reaction of significance among people treated for drug-susceptible TB is
The most common adverse reaction of significance among people treated for drug-susceptible TB is hepatitis
Gene involved in pyrazinamide and ethambutol resistance
pyrazinamide in the pncA gene (up to 98%), that to ethambutol in the embB gene (50–65%),
Management for MDR/RR TB
two main approaches are now recommended by the WHO to treat MDR/RR-TB: (1) an individualized longer regimen of 18–20 months’ duration (or 15-17 months after culture conversion) consisting of an optimal combination of oral drugs chosen according to a rational approach and using the WHO priority grouping of medicines; and (2) a shorter, all-oral, bedaquiline-containing regimen of 9–12 months’ duration.
Criteria for Offering a Shorter All-Oral Regimen (9−11 Months) to Patients with Confirmed Multidrug- or Rifampin-Resistant (MDR/RR) Tuberculosis (TB)
Cutoff tuberculin test for organ transplant recipient
> = 5 mm
Cutoff tuberculin test for Persons with fibrotic lesions consistent with old TB on chest radiography
> = 5 mm
Cutoff tuberculin test for Recent immigrants (≤5 years) from high-prevalence countries
> =10mm
Cutoff tuberculin test for injection drug users
> =10mm
Tuberculosis Preventive Tx Regimen
What constitutes SOFA score
What constitutes APACHE score
The neuromuscular blocking agent ___________ is occasionally used to facilitate mechanical ventilation in patients with profound ventilator dyssynchrony despite optimal sedation, particularly in the setting of severe ARDS. Use of these agents may result in prolonged weakness—a myopathy known as the postparalytic syndrome.
cisatracurium
T/F All ICU px without contraindication to anticoag should receive DVT prophylaxis
True
All ICU patients are at high risk for this complication because of their predilection for immobility. Therefore, all should receive some form of prophylaxis against DVT if feasible
T/F Prophylaxis against stress ulcers is necessary for all ICU patients
False
Prophylaxis against stress ulcers is not necessary for all ICU patients.
It should only be administered to high-risk patients, such as those with coagulopathy or respiratory failure requiring mechanical ventilation
When parenteral feeding is necessary to supplement enteral nutrition, delaying this intervention until day ___ in the ICU results in better recovery and fewer ICU-related complications.
When parenteral feeding is necessary to supplement enteral nutrition, delaying this intervention until day 8 in the ICU results in better recovery and fewer ICU-related complications.
Studies have shown that most ICU patients are anemic as a result of
chronic inflammation
Diagnostic criteria for ARDS
key difference between volume control and PCV
The key difference between volume control and PCV is that an inspiratory (or “driving”) pressure is set instead of a tidal volume in PCV; thus, every time the ventilator delivers a breath, it raises the airway pressure to the set amount above PEEP until inspiratory flow decreases below a set threshold, therefore ending inhalation. Thus, the resulting tidal volume will vary depending on the compliance of the lung
PCV is often used to limit peak airway and lung distending (plateau) pressures in situations where high pressure can cause harm, such as in ARDS or after thoracic surgery with fresh suture lines in the airways or lung parenchyma
Difference betwen PSV and PCV
no mandated ventilation, or set mechanical respiratory rate, on PSV, and ventilator support is entirely patient triggered and controlled.
Key Features of different MV settings
Common contraindications to NIV
Most hypercapnia cases in the ICU is due to
most hypercapnia is due to inadequate alveolar ventilation (VA) from an increase in the fraction of dead space (VD)
Hypercapnia in the context of low tidal volume (6 mL/kg) ventilation for ARDS often causes acute respiratory acidosis that can be managed with higher respiratory rates, up to 30 breaths/min. Respiratory acidosis is often tolerated down to a pH of 7.2, so-called “permissive hypercapnia,” but progressive acidosis may require intravenous alkalinizing therapy (e.g., sodium bicarbonate or tromethamine) or accepting an increase in VT .
VAP prevention interventions
head-of-bed elevation to at least 30–45° (70% VAP reduction compared to supine position), specialized endotracheal tube use with a suction port above the cuff to minimize aspirated secretions (50% VAP reduction), minimization of ventilator circuit tubing changes (prevents bacterial entry), and hand hygiene before handling the ventilatory circuit.
Adverse effects of hypercapnia
Patients passing an SBT have a >__% chance of successful extubation
70
Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia
Gross hemoptysis is associated with what type of pneumonia
Gross hemoptysis is suggestive of necrotizing pneumonia (e.g., that due to CA-MRSA).
Criteria for severe CAP based from Harrisons
Methicillin resistance in S. aureus is determined by the _____ gene, which encodes for resistance to all β-lactam drugs
mecA
Outpx tx for CAP
Note FQ only for those with comorbid if outpatient
Monotherapy with a macrolide is recommended in the new guidelines only if there are contraindications to amoxicillin or doxycycline and there is documented low risk of macrolide resistance (<25%)
Routine coverage of anaerobes is unnecessary unless dentition is poor or there is a lung abscess or necrotizing pneumonia
In px tx for CAP
If in px non severe, may give FQ alone
When does CXR findings resolve in px with CAP?
Chest radiographic abnormalities are slowest to resolve (4–12 weeks), with the speed of clearance depending on the patient’s age and underlying lung disease
For a hospitalized patient, we generally recommend a follow-up radiograph ~4–6 weeks later. If relapse or recurrence is documented, particularly in the same lung segment, the possibility of an underlying neoplasm must be considered.
Fever and leukocytosis will resolve after how many days in px with CAP
Fever and leukocytosis usually resolve within 2–4 days in otherwise healthy patients with CAP, but physical findings may persist longer
1 week in CAP guidelines
Prevention strategy for Oropharyngeal colonization with pathogenic bacteria
Prevention strategy for large volume aspiration
Prevention strategy for ventilator circuit humidification
Prevention strategy for altered respiratory host defenses
Empiric tx for HAP and VAP
A 7- or 8-day course of therapy is just as effective as a 2-week course and is associated with less frequent emergence of antibioticresistant strains.
Most impt preventive intervention for VAP
Because endotracheal intubation is a risk factor for VAP, the most important preventive intervention is to avoid intubation or minimize its duration
When should you request for sputum GS/CS in px with CAP as per 2020 PSMID guidelines
CAP MR and HR and MDRO risk
not for CAP LR
When should you request for blood CS in px with CAP as per 2020 PSMID guidelines
We recommend blood cultures
for patients with moderate and high risk CAP.
Based on 2020 PSMID guidelines, what are the empiric abx for CAP LR
Based on 2020 PSMID guidelines, what are the empiric abx for CAP MR
for CAP MR -> 3rd gen
Definition of sepsis and septic shock
Most common cause of sepsis
pneumonia
The most common secondary infections included ________
The most common secondary infections included catheter-related bloodstream infections, ventilator-associated infections, and abdominal infections
Gold std for diagnosing sepsis
There is no specific test for sepsis, nor is there a gold-standard method for determining whether a patient is septic
For every 1-h delay among septic patients, a ___% increase in the odds of in-hospital death is reported
3-7%
5 components of sepsis bundles
This management bundle includes five components: (1) measurement of serum lactate levels, (2) collection of blood for culture before antibiotic administration, (3) administration of appropriate broad-spectrum antibiotics, (4) initiation of a 30 mL/kg crystalloid bolus for hypotension or lactate ≥4 mmol/L, and (5) treatment with vasopressors for persistent hypotension or shock.
Serum lactate levels should be remeasured if initial level ≥2 mmol/L
Empiric abx for severe sepsis with no obvious source
TZP if immunocompetent is 4.5g IV q6
but if immunocompromised 3.375 q4
Hypovolemic shock is most commonly related to
Hypovolemic shock is most commonly related to hemorrhage, which may be external (secondary to trauma) or internal (most commonly upper or lower gastrointestinal [GI]) bleeding
Regardless of type, shock progresses through a continuum of three stages which are
Regardless of type, shock progresses through a continuum of three stages. These stages are compensated shock (preshock), shock (decompensated shock), and irreversible shock
How do you perform passive leg raise test
The passive leg raise (PLR) test can predict responsiveness to additional intravenous fluid (IVF) by providing the patient with an endogenous volume bolus.
While the patient is resting in a semirecumbent position at a 45° angle, the bed is placed in Trendelenburg position such that the patient’s head becomes horizontal and the legs are extended at a 45° angle. There is then an immediate (within 1 min) assessment of changes in CO (or pulse pressure variation as a surrogate). It is important to emphasize that one does not merely look for changes in blood pressure; if the shock patient is mechanically ventilated there is the option of looking at changes in SV variation (or pulse pressure variation) during the respiratory cycle to assess volume responsiveness.
A >12% SV variation suggests a volume-responsive state.
What pressure is used as a surrogate for LA pressure when using a pulmonary artery catheter
The PCWP is used as a surrogate for LA pressure.
Definition of cardiogenic shock
The clinical presentation is typically characterized by persistent hypotension (<90 mmHg systolic blood pressure [BP]) or <60-65 mmHg mean arterial pressure unresponsive to volume replacement or by the use of vasopressors needed to maintain adequate BP (systolic >90 mmHg) and is accompanied by clinical features of peripheral hypoperfusion, such as elevated arterial lactate (>2 mmol/L).
5 categories of cardiogenic shock
Equalization of diastolic pressures in pulmonary artery catheter suggests
cardiac tamponade
Advantages of culprit only PCI with staged revascularization vs immediate multivessel PCI in px with cardiogenic shock
Approximately 80% of Cardiogenic shock patients present with multivessel coronary artery disease. In these patients, culprit-only PCI with possible staged revascularization is the method of choice because it reduces mortality and requirement for renal replacement therapy at 30 days and 1 year in comparison to immediate multivessel PCI, as shown in the CULPRIT-SHOCK trial. The major driver for the reduction in the composite endpoint was a reduction in 30-day mortality
Why is dopamine avoided as first line tx for MI with cardiogenic shock?
Dopamine should be avoided as first-line therapy for MI with CS based on hemodynamic and proarrhythmogenic effects
Management of isolated RV cardiogenic shock
Management of isolated RV CS includes fluid administration to optimize right atrial pressure (10–15 mmHg); avoidance of excess fluids, which shifts the interventricular septum into the LV; catecholamines; early reestablishment of infarct-artery flow; and right-sided MCS
Difference between Acute fulminant myocarditis vs Acute MI as a cause of cardiogenic shock
Acute myocarditis causes CS in a small proportion of cases. These patients are typically younger than those with CS due to acute MI and often do not have typical ischemic chest pain. Echocardiography usually shows global LV dysfunction. Initial management is the same as for CS complicating acute MI but does not involve revascularization.
Beneficial effects of MV with PEEP on pulmonary edema
Mechanical ventilation with positive end-expiratory pressure can have multiple beneficial effects on pulmonary edema, as it: (1) decreases both preload and afterload, thereby improving cardiac function; (2) redistributes lung water from the intraalveolar to the extraalveolar space, where the fluid interferes less with gas exchange; and (3) increases lung volume to avoid atelectasis.
Treatment for high altitude pulmonary edema
High-altitude pulmonary edema often can be prevented by use of dexamethasone, calcium channel–blocking drugs, or long-acting inhaled β2 -adrenergic agonists. Treatment includes descent from altitude, bed rest, oxygen, and, if feasible, inhaled NO; nifedipine may also be effective.
Target O2 for pulmonary edema
> 92%
> 98% is detrimental
Diuretic of choice for pulmonary edema
Furosemide is also a venodilator that rapidly reduces preload before any diuresis occurs and is the diuretic of choice.
The initial dose of furosemide should be ≤0.5 mg/kg, but a higher dose (1 mg/ kg) is required in patients with renal insufficiency, chronic diuretic use, or hypervolemia or after failure of a lower dose.
Cardiac output increases by ___% in pregnancy, with most of the increase due to an increase in stroke volume
40
In pregnant px The diagnosis of hypertension requires the measurement of two elevated blood pressures at least __ h apart.
4
Meaning of HELLP syndrome
The HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is a special subtype of preeclampsia with severe features and is a major cause of morbidity and mortality.
Preeclampsia can be diagnosed without proteinuria in the presence of symptoms or laboratory abnormalities raising concern for end-organ damage which include
Specific clinical features qualify as evidence of severe disease, including severe hypertension (blood pressure ≥160/110 mmHg), new-onset symptoms (headache not responsive to medications, visual changes, unremitting severe epigastric pain, or pulmonary edema), or laboratory abnormalities signifying thrombocytopenia (platelets <100 × 109 /L), renal insufficiency (creatinine >1.1 mg/dL), or liver impairment (elevation of transaminases to twice the normal concentration).
Definition of gestational hypertension
The development of elevated blood pressure after 20 weeks of pregnancy in the absence of preexisting chronic hypertension or proteinuria is referred to as gestational hypertension.
The definitive treatment of preeclampsia
The definitive treatment of preeclampsia is delivery of the fetus and placenta
Expectant management of preeclampsia with severe features remote from term affords some benefits for the fetus but at significant risk to the mother. For women with preeclampsia with severe features, delivery is recommended unless the patient is <34 weeks and eligible for expectant management in a tertiary hospital setting.
Indications for delivery prior to 34 weeks include unremitting symptoms, development of laboratory abnormalities, or severe range blood pressures refractory to medical management
first-line agents to manage severe hypertension in preeclampsia
Labetalol or hydralazine IV are the first-line agents to manage severe hypertension in preeclampsia with consideration of oral agents once blood pressure is controlled.
preferred agent to prevent eclampsia in patients with preeclampsia with severe features and for treatment and prevention of recurrent seizures in patients with eclampsia.
Magnesium sulfate is the preferred agent to prevent eclampsia in patients with preeclampsia with severe features and for treatment and prevention of recurrent seizures in patients with eclampsia. Magnesium sulfate is administered as an IV loading dose followed by a continuous infusion, with care taken in patients with impaired renal function or pulmonary edema
Target BP in chronic hypertension in pregnancy
The target blood pressure is in the range of 130–150 mmHg systolic and 80–100 mmHg diastolic to balance maternal safety with fetal perfusion
Women with moderate to severe mitral stenosis (mitral valve area ≤1.5 cm2 ) who are planning pregnancy and have either symptomatic disease or pulmonary hypertension should undergo _______ prior to conception,
valvuloplasty
For women with symptomatic aortic stenosis or severe aortic stenosis with a peak gradient >__ mmHg, treatment before pregnancy should be considered.
50
For most diseases, an aortic root diameter <___ mm portends a favorable pregnancy outcome, whereas a diameter >__ mm is an indication for prepregnancy repair
40
50
50 magic number for repair of aortic
Impaired glycemic control during the critical first _____ weeks of pregnancy leads to the increased risk of spontaneous abortion and congenital anomalies seen in pregnancies affected by DM and highlights the importance of prepregnancy glycemic control
5-8
Target glucose parameters in pregnant px
Fasting blood glucose levels should be maintained at <5.3 mmol/L (<95 mg/dL), with postprandial targets of <7.8 mmol/L (140 mg/dL) or <6.7 mmol/L (120 mg/dL) at 1 and 2 h, respectively
Average daily insulin needs during pregnancy
Average daily insulin needs increase from 0.7–0.8 units/ kg in the first trimester, to 0.8–1 units/kg in the second trimester, and 0.9–1.2 units/kg in the third trimester
What additional test should be requested for post partum px with GDM?
GDM confers a 7- to 10-fold increase in the risk of developing type 2 DM later in life, with a 10% risk within 5 years of delivery. All women with GDM should have a 4- to 12-week 2-h 75-g GTT to screen for DM or impaired glucose tolerance.
Since the increased thyroxine requirement occurs as early as the fifth week of pregnancy, one approach is to increase the thyroxine dose by ___% as soon as pregnancy is diagnosed and then adjust the dose according to TSH.
30
(two additional pills weekly)
Treatment for pregnant px with VTE
Anticoagulant therapy with low-molecular-weight heparin (LMWH) or unfractionated heparin is indicated in pregnant women with VTE
Anticoagulants increase the risk of epidural hematoma in women receiving neuraxial analgesia in labor and must be withheld prior to placement. Prophylactic LMWH must be stopped 12 h before placement of an epidural catheter, whereas therapeutic LMWH must be withheld for a full 24 h.
The most common causes of Pulmonary Hypertentsion (PH) are
left heart or primary lung disease
the primary test used to screen and diagnose chronic thromboembolic pulmonary hypertension (CTEPH)
Ventilation-perfusion (V. /Q . ) scanning is the primary test used to screen and diagnose CTEPH, which should be considered in any patient with PH of unclear etiology
The definitive diagnostic procedure remains pulmonary angiography since contrast enhancement in this study provides detailed information on webbing, stricture, and vascular tapering patterns pathognomonic for CTEPH.
How do you differentiate different types of PH according to hemodynamic phenotypes?
> > > combined
inc in PAWP but not PVR = isolated postcapillary
WHO PH classification with PAWP >15 mmhg
PH due to left heart dse
The hallmark of this PH phenotype is elevated left atrial pressure with resulting pulmonary venous hypertension
Trial that demonstrated improved symptoms, 6-MWD, and WHO FC in patients treated with bosentan
The randomized, placebo-controlled, phase 3 Bosentan Randomized Trial of Endothelin Antagonist Therapy (BREATHE)-1 trial comparing bosentan to placebo demonstrated improved symptoms, 6-MWD, and WHO FC in patients treated with bosentan
The Endothelin Antagonist Trial in Mildly Symptomatic Pulmonary Arterial Hypertension Patients (EARLY) study comparing bosentan to placebo demonstrated improved PVR and 6-MWD in patients with WHO FC II
Trial that demonstrated that ambrisentan improves exercise tolerance, WHO FC, hemodynamics, and quality of life in patients with PAH
Several studies, including the phase 3, placebo-controlled Ambrisentan in Pulmonary Arterial Hypertension, (ARIES)-1 trial, have demonstrated that ambrisentan improves exercise tolerance, WHO FC, hemodynamics, and quality of life in patients with PAH.
Trial that investigated macitentan effects on PAH
More recently, the Study with an Endothelin Receptor Antagonist in Pulmonary Arterial Hypertension to Improve Clinical Outcome (SERAPHIN) trial randomized 742 PAH patients to receive placebo or macitentan, which is an ETA/B antagonist with optimized receptor binding affinity. The majority of patients were on some form of background PAH therapy. Over an average treatment duration of 85 weeks, the hazard ratio for achieving the composite primary endpoint of PAH-related clinical worsening, which included death or disease progression, was decreased by 45% in the 10-mg dose arm.
the sole approved pharmacotherapy for CTEPH patients for whom surgical pulmonary endarterectomy is ineffective or contraindicated
Riociguat
Trial that demonstrated benefits of combination of taladafil and ambrisentan in PAH
The role of early, aggressive therapy with combination oral treatments was addressed in the landmark Initial Use of Ambrisentan plus Tadalafil in Pulmonary Arterial Hypertension (AMBITION) trial. Treatment-naïve, incident PAH patients (n = 500) were randomized to a combination of ambrisentan and tadalafil, ambrisentan monotherapy, or tadalafil monotherapy. Up-front combination therapy with ambrisentan and tadalafil was associated with a 50% lower risk of clinical worsening (composite of death, lung transplantation, hospitalization for PAH worsening, and worsening PAH) when compared with the monotherapy group
When do you start px on IV prostacyclin based on vasoreactivity test?
negative vasoreactivity test, high risk (syncope + advanced HF)
Low- or intermediate (Int)-risk patients are initiated on combination oral therapy, which generally includes an endothelin receptor antagonist and phosphodiesterase type 5 inhibitor
FDA approved therapies for PAH
Empiric tx for CAP HR
Routine anaerobic coverage for suspected aspiration pneumonia is NOT recommended, unless ______ is suspected
lung abscess or empyema
empiric treatment of patients with moderate to high risk CAP and with risk factors for MRSA
empiric treatment of patients with moderate to high risk CAP and with risk factors for ESBL
Note: ESBL + culture within 1 yr –> risk of ESBL pa rin
empiric treatment of patients with moderate to high risk CAP and with risk factors for P. aeruginosa
Note: prior tracheostomy: risk factor for P. aeruginosa
Based on PSMID 2020 guidelines ,As soon as diagnosis is established, treatment of community acquired pneumonia, regardless of risk, should be initiated within __ hours
As soon as diagnosis is established, treatment of community acquired pneumonia, regardless of risk, should be initiated within 4 hours
Based on PSMID 2020 guidelines, Among patients with low to moderate risk CAP, a treatment duration of ___ days is recommended as long as the patient is clinically stable (afebrile within 48 hours, able to eat, normal blood pressure, normal heart rate, normal respiratory rate, normal oxygen saturation, and return to baseline sensorium).
Among patients with low to moderate risk CAP, a treatment duration of 5 days is recommended as long as the patient is clinically stable (afebrile within 48 hours, able to eat, normal blood pressure, normal heart rate, normal respiratory rate, normal oxygen saturation, and return to baseline sensorium).
2016 guidelines: afebrile 24h
Based on PSMID 2020 guidelines, what are the recommended vaccines to prevent pneumonia?
Administration of both influenza and pneumococcal vaccine is recommended to prevent pneumonia, hospitalization and mortality in adults 50 years old and above.
When is influenza testing recommended in px with high risk CAP as per PSMID 2020 guidelines?
We recommend testing of respiratory secretions for influenza through rapid molecular testing using rapid nucleic acid amplification tests during periods of high influenza activity (July to January) for patients with high risk CAP preceded by influenza-like illness symptoms (sore throat, rhinorrhea, body malaise, joint pains) and any of the following risk factors:
* Aged 60 years and above
* Pregnant
* Asthmatic
* Other co-morbidities: uncontrolled diabetes mellitus, active malignancies, neurologic disease in evolution, congestive heart failure class II-IV, unstable coronary artery disease, renal failure on dialysis, uncompensated COPD, decompensated liver disease
The most strongly and consistently associated risk factors for CAP due to MRSA were
The most strongly and consistently associated risk factors for CAP due to MRSA were previous MRSA colonization or infection, especially of the respiratory tract, within 1 year
T/F There is decreased risk of developing hypersensitivity pneumonitis in smokers
True
6 predictors of HP
- exposure to known antigen (strongest predictor)
- presence of serum precipitin
- recurrent ssx
- inspiratory crackles
- ssx developing 4-8 hrs after exposure
- weight loss
Tx for IPF
Pirfenidone + Nintedanib
Most common granulomatous IPF
sarcoidosis
A 28-year-old female, diagnosed asthmatic more than 20 years ago and on maintenance inhaled corticosteroids, consulted the emergency room for substernal chest pain radiating to the neck. She had slightly bulging suprasternal notch, with crepitus on palpation, clear breath sounds on all lung fields. Chest x-ray was noted to have curvilinear lucencies of the mediastinum. What is the management plan?
a. analgesic and oxygen
b. anticoagulation and inhaled steroid
c. chest tube insertion
d. needle aspiration
a. analgesic and oxygen
DIAGNOSIS: Pneumomediastinum
* Symptoms: severe substernal chest pain with or without radiation into the neck and arms
* Signs: subcutaneous emphysema in the suprasternal notch and Hamman’s sign (crunching or clicking noise synchronous with the heartbeat)
* Usually no treatment is required but will be absorbed faster by inspiring high concentrations of oxygen. If mediastinal structures are compressed, the compression can be relieved with needle aspiration.
A 32-year-old female was sent to the emergency room for shortness of breath. On chest x-ray, there was note of small pleural effusion on the left. Thoracentesis was done and pleural fluid analysis showed: clear, light yellow, RBC–0, WBC –9 x 106/L (neutrophils 10%, lymphocytes 90%) exudative by Light’s criteria; Glucose: >60mg/dL (not low) Gram stain: no polymorphonuclear cells, no organism; Culture: no growth AFB smear: negative; Cytology: no atypical cells. What is the next step in the management?
a. serum antinuclear antibody (ANA) test
b. spiral computed tomography scan
c. repeat thoracentesis and pleural fluid analysis
d. thoracoscopy with pleural biopsy
b. spiral computed tomography scan
Pulmonary embolism
- Most overlooked in the differential diagnosis of an undiagnosed pleural effusion
Which of the following causes transudative effusion?
a. Asbestos exposure
b. Peritoneal dialysis
c. Rheumatoid pleuritis
d. Viral infection
b. Peritoneal dialysis
A 62-year-old male, chronic smoker, was diagnosed with bronchiectasis localized on the right middle lobe on chest CT scan. What test or procedure should be recommended?
a. α1 antitrypsin levels
b. bronchoscopy
c. CT-guided percutaneous biopsy
d. HIV screening
b. bronchoscopy
Focal bronchiectasis
Evaluation: almost always requires bronchoscopy to exclude airway obstruction by an underlying mass or foreign body.
The following intervention/s have been proven to increase survival in his case:
A. Long term oxygen therapy (>8hours/day)
B. Triple therapy with ICS+LABA+LAMA
C. Dual bronchodilator therapy with LABA+LAMA
D. None of the above
D. None of the above
Long term oxygen >15h/d
A 28-year old male, PLHIV came in to your clinic for clearance to return to work. He has been maintained on oral antiretrovirals for 4 years, his latest CD4 is 1200/mm3 . Part of his pre-employment check is a tuberculin skin test, and his test result was read as 12mm induration. He is asymptomatic, weighs 65kgs, with no cough or sputum production, and his chest CT scan is normal, his Xpert MTB-Rif also came in negative. What is the next best course of action?
A. Perform an Interferon Release Assay Test
B. Begin treatment with Isoniazid 300mg once a day for 6 months and clear for work
C. Begin treatment with HRZE 4 tablets once a day and clear for work after 2 weeks of treatment
D. No treatment is needed and clear for work
B. Begin treatment with Isoniazid 300mg once a day for 6 months and clear for work
A 54/F, diabetic was treated for bacteriologically confirmed PTB already completed 2 months of intensive phase HRZE and 3 1/2 months of maintenance phase HR. However due to the lockdown caused by the COVID pandemic, she forgot to follow-up with the DOTS center and stopped her medications. After 2 months of treatment interruption, she returned to the clinic due to cough and fever, and sputum AFB showed 2+. How will you proceed with the treatment?
A. Continue with the remaining months of HR
B. Restart continuation phase
C. Continue treatment with HR and prolong to compensate
D. Do sputum Xpert MTB-Rif
D. Do sputum Xpert MTB-Rif
Since 2+ on AFB
A 24-year old female medical student came to your clinic for episodic shortness of breath which is worse at night or during exertion. She mentioned that these episodes started when she was in her teenage years but she chose to “brush it off” because her symptoms would recur very seldom (less than twice per year). Upon her entry into medical school, she noted that she would have shortness of breath, associated with chest tightness most prominent during the night and when she talks for a prolonged period of time. In the last 3 months however, these episodes would occur three times a week and would often wake her up during sleep almost nightly. She does not, however, complain that these symptoms limit her activity. She also has not taken any medication for these symptoms. Upon your assessment, what is the level of control of her condition?
a. Well controlled
b. Partly controlled
c. Uncontrolled
d. Poorly controlled
b. Partly controlled
Nightime awakenings
Daytime symptoms
After 6 days of in-hospital management, the patient with COPD was successfully discharged on several inhaler medications. After 3 weeks, he went back to your clinic for scheduled follow-up but he complained of dry mouth. Which among the following medications could have probably caused this adverse reaction?
a. Indacaterol
b. Tiotopium
c. Budesonide
d. Salbutamol
b. Tiotopium
Most common side effect of tiotropium = dry mouth
A young asthmatic was rushed to the emergency room for sudden, progressive dyspnea with chest pain after she was exposed to her friend’s furry pet cat. At the ER, she was in obvious respiratory distress. She can speak in phrases, and is awake and fully oriented to her surroundings. Her vital signs are as follows: BP 120/70 HR 110 RR 28 O2sats 95% at room air. On auscultation, there is decreased breath sounds bilaterally with no wheezing or crackles. Which of the following statements is true about the management of her case?
a. Chest x-ray should be done immediately to rule out other causes of dyspnea such as pneumonia, heart failure, or pneumothorax
b. A normal PCO2 in the arterial blood gas is a sign of clinical improvement after initiation of treatment
c. Oxygen therapy should be started if oxygen saturations is <95%
d. Lung function measurement is recommended if available
d. Lung function measurement is recommended if available
Objective measurement of lung function (e.g., peak expiratory flow [PEF] or spirometry) helps assess the severity of the exacerbation, guide treatment, and monitor response to therapy.
Not recommended in COPDIAE
What histopathologic findings in usual interstitial pneumonia (UIP) distinguish it from non-specific interstitial pneumonia (NSIP)?
a. honeycomb changes
b. interstitial inflammation
c. lymphocytic infiltration
d. presence of fibrosis
a. honeycomb changes
- UIP - honeycomb changes and fibroblast foci (subepithelial collections of myofibroblasts and collagen), fibrotic changes alternate with areas of preserved normal alveolar architecture consistent with temporal and spatial heterogeneity
- NSIP - honeycomb changes are usually absent and fibroblast foci are rare, varying amounts of interstitial inflammation and fibrosis with a uniform appearance
Which of the following is TRUE of interstitial lung diseases (ILD) associated with connective tissue diseases (CTD)?
a. Antifibrotic therapy is proven to improve survival and delay disease progression.
b. Cytotoxic agents like cyclophosphamide may be useful and have shown variable success.
c. Hallmark histopathologic findings is consistent with usual interstitial pneumonia.
d. They are most commonly observed in systemic lupus erythematosus compared to other CTDs
b. Cytotoxic agents like cyclophosphamide may be useful and have shown variable success.
Cyclophosphamide has a modest benefit in preservation of lung function and is associated with significant toxicity
Which is TRUE of the physiologic abnormalities in COPD?
a. PaO2 immediately decreases once FEV1 starts to decline
b. PaCO2 immediately increases once FEV1 starts to decline
c. Shunt physiology is the major determinant of elevation in PaCO2
d. V/Q mismatch accounts for all of the reduction in PaO2
c. Shunt physiology is the major determinant of elevation in PaCO2
Ventilation-perfusion mismatching accounts for essentially all of the reduction in Pao2 that occurs in COPD
PaO2 usually remains near normal until the FEV1 is decreased to ~50% of predicted
Elevation of Paco2 is not expected until the FEV1 is <25% of predicted
Which is TRUE of the pharmacologic management of stable phase COPD?
a. Chronic use oral glucocorticoids is recommended for very severe COPD or category D patients
b. Long-acting muscarinic agonists (LAMA) reduce exacerbations and mortality rate
c. Long-acting beta agonists (LABA) provide symptomatic relief with no effect on frequency of exacerbations
d. Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option
d. Theophylline can improve airflow and vital capacity but is not considered as first-line therapy option
Theophylline produces modest improvements in airflow and vital capacity, but is not first-line therapy due to side effects and drug interactions.
Chronic use of oral glucocorticoids are not recommended because of an unfavorable benefit/risk ratio LAMA improve symptoms and reduce exacerbations, but only seen to have trend to reduction of mortality.
LABA provide symptomatic benefit and reduce exacerbations, though to a lesser extent than a LAMA.
A 65-year-old female with COPD on glycopyrronium bromide inhaler was admitted to the emergency room because of worsening dyspnea. She was received tachypneic RR 30, with intercostal muscle retractions. Which of the following is the appropriate management of her inhaled drug/s?
a. Add inhaled corticosteroid and continue glycopyrronium bromide
b. Add inhaled salbutamol and continue glycopyrronium bromide
c. Start budesonide nebulization
d. Start salbutamol/ipratropium bromide nebulization
d. Start salbutamol/ipratropium bromide nebulization
Short-acting inhaled beta-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilator to treat an acute exacerbation.
What is the mechanism by which exercise triggers asthma?
a. Hyperventilation increases cholinergic bronchoconstriction
b. Hyperventilation triggers mast cell mediator release
c. Increase in airway inflammation with increased numbers of eosinophils during exercise
d. Inhibition of breakdown of kinins during exercise leads to bronchoconstriction
b. Hyperventilation triggers mast cell mediator release
- Results in increased osmolality in airway lining fluid and triggers mast cell mediator release, resulting in bronchoconstriction Mechanisms of the triggers of asthma
*Stress-induced bronchoconstriction through cholinergic reflex pathways
*Viral infection increase airway inflammation, increased number of neutrophils
*Inhaled allergens activate mast cells with bound IgE directly leading to the immediate release of bronchoconstrictor mediators
*Beta-blockers increase cholinergic bronchoconstriction
Which group of inflammatory mediators is primarily responsible for bronchoconstriction in asthma?
a. Chemokines
b. Cytokines
c. Mast cell-derived
d. Transcription factors
c. Mast cell-derived
- Limitation of airflow is due mainly to bronchoconstriction (from mast cell mediators), but airway edema, vascular congestion, and luminal occlusion with exudate may contribute.
Mast cell-derived mediators
* Histamine, prostaglandin D2, and cysteinyl-leukotrienes
* Contract airway smooth muscle, increase microvascular leakage, increase airway mucus secretion, and attract other inflammatory cells
Which is TRUE of asthma in pregnancy?
a. Most patients will have worsening of asthma control during pregnancy.
b. Inhaled corticosteroid is under FDA Category D – with evidence of human risk, but potential benefits of use outweigh the risk.
c. If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects.
d. Corticosteroids and short-acting beta-agonists are contraindicated during breastfeeding.
c. If oral steroid is needed, prednisone is preferred to protect the fetus from its systemic effects.
If an OCS is needed - better to use prednisone rather than prednisolone as it cannot be converted to the active prednisolone by the fetal liver, thus protecting the fetus from systemic effects of the corticosteroid.
What is the most effective treatment of a worsening type 2 brittle asthma?
a. Continuous infusion of beta-agonist
b. Intravenous steroid
c. Omalizumab
d. Subcutaneous epinephrine
d. Subcutaneous epinephrine
- Type 1 brittle asthma – OCS or continuous infusion of β2-agonists
- Type 2 brittle asthma – subcutaneous epinephrine (suggests that the worsening is likely to be a localized airway anaphylactic reaction with edema)
A 20-year-old female consulted the clinic for intermittent shortness of breath. On history, she was prescribed with salbutamol tablets during acute episodes of dyspnea when she was 7 years old. She then became asymptomatic until 2 months ago when she recurrence of symptoms and was again advised to nebulize with salbutamol. Thereafter, she noted to have at least 3 episodes of dyspnea per week usually during exercise that requires nebulization, but no limitations in daily activities and no night time symptoms. What will you advise her?
a. Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose budesonide inhalation with salbutamol as reliever.
b. Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose fluticasone/salmeterol inhalation with salbutamol as reliever.
c. Start daily low dose budesonide inhalation with as needed salbutamol and follow up after 1 month for monitoring.
d. Start daily low dose fluticasone/salmeterol inhalation with as needed salbutamol and follow up after 1 month for monitorin
b. Perform spirometry with reversibility test to support asthma diagnosis and then start daily low dose fluticasone/salmeterol inhalation with salbutamol as reliever.
Confirm first the diagnosis of asthma before starting controller medications then initiate appropriate medication (STEP 2 – low dose ICS + SABA reliever)
A 32-year-old female, diagnosed asthmatic on as needed salbutamol inhalation, consulted your clinic for advice after she was rushed that same morning to the local health center for shortness of breath not relieved by an increase in frequency of her inhaler. She improved after several doses of salbutamol nebulization and single dose of oral prednisone. She was sent home with oral prednisone and was advised to immediately consult an internist or pulmonologist. How will you manage her corticosteroid and inhaled medication?
a. Continue prednisone for 5 days and increase salbutamol to three times a day.
b. Continue prednisone for 5 days, as-needed salbutamol and start low dose inhaled corticosteroid.
c. Discontinue prednisone, continue as-needed salbutamol and start low dose inhaled corticosteroid.
d. Discontinue prednisone, increase salbutamol to three times a day.
b. Continue prednisone for 5 days, as-needed salbutamol and start low dose inhaled corticosteroid.
Initiate regular ICS-containing controller therapy, reduce reliever to as-needed and continue oral steroid for 5-7 days
Short-term systemic corticosteroids (e.g., prednisone) for 5–7 days are standard after a moderate or severe asthma exacerbation to suppress airway inflammation. Stopping prednisone prematurely increases the risk of relapse.
A 25-year-old female, a famous singer, recently diagnosed to have bronchial asthma through spirometry, refuses to comply with prescribed daily inhaler because of fear of the possible side effects on the quality of her voice. She had allergic rhinitis for the past 5 years. She only has occasional twice a month symptoms of shortness of breath relieved by salbutamol tablets. What can you recommend her?
a. Inhaled salbutamol PRN
b. Inhaled tiotropium daily
c. Oral montelukast daily
d. Oral salbutamol PRN
c. Oral montelukast daily
Leukotriene receptor antagonists (LTRA) may be used as initial controller treatment for some patients who are unable or unwilling to use ICS, for patients who experience intolerable side-effects from ICS or for patients with concomitant allergic rhinitis.
Which is TRUE of bronchodilators in the treatment of asthma?
a. Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists.
b. In acute severe asthma, anticholinergics should be given before β2-agonists, as they have faster onset and are more effective in bronchodilation.
c. Inflammatory cells also express β2 receptors, β2-agonist use will also decrease the number of these cells in the airway causing a reduction in airway hyperresponsiveness.
d. The mechanism of action of theophylline is the prevention of cholinergic nerve-induced bronchoconstriction and mucus secretion.
a. Concomitant administration of inhaled corticosteroids prevents tolerance of mast cells of β2 agonists.
Tolerance is a potential problem with any agonist given chronically. Mast cells become rapidly tolerant, but their tolerance may be prevented by concomitant administration of ICS. Corticosteroids also activate anti-inflammatory genes such as mitogen-activated protein (MAP) kinase phosphatase-1 and increase the expression of β2-receptors.
Only strategy that reduces mortality in cardiogenic shock
Rapid revascularization
PCI = preferred
Definition of sudden cardiac arrest
unexpected death without obv extracardiac death
<1 hr if witnessed
extended to <24h if unwitnessed
For CAP with bacteremia involving likely MDR pathogens such as P. aeruginosa and MRSA, the recommended antibiotic treatment duration is:
a. 7-14 days
b. 7-21 days
c. 14-21 days
d. ≥ 28 days
d. ≥ 28 days
Which of the following is the MOST likely pathogen in a primary lung abscess?
a. Legionella pneumophila
b. Nocardia spp.
c. Prevotella spp.
d. Staphylococcus aureus
c. Prevotella spp.
It is an anaerobe
S. aureus - more common in secondary lung abscess
What is the underlying pathology in a primary spontaneous pneumothorax?
a. Chronic obstructive pulmonary disease
b. Emphysema
c. Pleural blebs
d. Positive pleural pressure
c. Pleural blebs
Which occupational dust is responsible for chest tightness and significant drop in FEV1 toward the end of the first day of the workweek or the “Monday chest tightness”?
a. Coal
b. Cotton
c. Fungal spores
d. Grain
b. Cotton
Byssinosis
mnemonic: Busy (Byssi) pag Monday
A 65-year-old male, newly diagnosed with COPD (FEV1 80% predicted) was prescribed with formoterol/budesonide metered dose inhaler for mild symptoms of breathlessness with strenuous activity. He complains of exercise limitations despite compliance to medications. What will you recommend?
a. Add roflumilast
b. Add theophylline
c. Shift to LABA/LAMA
d. Start oral corticosteroids
c. Shift to LABA/LAMA
Provides superior bronchodilation compared to ICS/LABA. Improves symptoms such as breathlessness and exercise capacity.
mode of MV with potential to hyperventilate and cause barotrauma
AC mode
mode of MV with potential for dysyncrhony
IMV
Mode of MV that assures synchrony
PSV
Difference between PSV vs PCV in terms of variables
PSV = flow cycled, PATIENT triggered
PCV = time cycled, time triggered
both are pressure limited
Definition of life threatening hemoptysis
Once established as hemoptysis, the degree of blood that is being expectorated (volume and frequency) is the next step as massive or life-threatening hemoptysis (>400 mL of blood in 24 h or >150 mL at one time) requires emergent intervention
Tuberculosis had long been the most common cause of hemoptysis worldwide, but it is now surpassed in industrialized countries by bronchitis and bronchiectasis
T/F PE may present with hemoptysis
Pulmonary embolism with parenchymal infarction can present with hemoptysis, but pulmonary emboli do not commonly cause hemoptysis.
Next step in evaluation of hemoptysis after CT scan
Bronchoscopy
patients with risk factors for malignancy (i.e., age >40 or a smoking history) should undergo additional testing. First, chest computed tomography (CT) with contrast should be obtained to better identify masses, bronchiectasis, and parenchymal lesions.
A CT looking for pulmonary embolism should be considered if the history and physical examination are consistent with that diagnosis.
Following a CT, a flexible bronchoscopy should be performed to exclude bronchogenic carcinoma unless imaging reveals a lesion that can be sampled without bronchoscopy.
Endotracheal intubation should be avoided unless truly necessary, since suctioning through an endotracheal tube is a less effective means of removing blood and clot than the cough reflex. If intubation is required, take steps to protect the nonbleeding lung either by selective intubation of one lung (i.e., the nonbleeding lung) or insertion of a double-lumen endotracheal tube
Cause of death in hemoptysis
Patients rarely die of exsanguination but, rather, are at risk of death due to asphyxiation from blood filling the airways and airspaces.
Procedure of choice in controlling bleeding due to hemoptysis
Because most life-threatening cases of hemoptysis arise from the bronchial circulation, bronchial artery embolization is the procedure of choice for control of the bleeding. However, bronchial artery embolization can have significant complications such as embolization of the anterior spinal artery. However, it is generally successful in the short term, with >80% success rate at controlling bleeding immediately, although bleeding can recur if the underlying disease (e.g., a mycetoma) is not treated.
Surgical resection has a high mortality rate (up to 15–40%) and should not be pursued unless initial measures have failed and bleeding is ongoing. Ideal candidates for surgery have localized disease but otherwise normal lung parenchyma.
Causes of impaired cough airway clearance
Definition of chronic cough
> 8 weeks
T/F All px with chronic cough should have a CXR done
In virtually all instances, evaluation of chronic cough merits a chest radiograph.
How long does it take before cough due to ACE-I decreases?
ACE inhibitor–induced cough occurs in 5–30% of patients taking these agents and is not dose-dependent. ACE metabolizes bradykinin and other tachykinins, such as substance P. The mechanism of ACE inhibitor–associated cough may involve sensitization of sensory nerve endings due to accumulation of bradykinin.
Any patient with chronic unexplained cough who is taking an ACE inhibitor should have a trial period off the medication, regardless of the timing of the onset of cough relative to the initiation of ACE inhibitor therapy. In most instances, a safe alternative is available; angiotensin receptor blockers do not cause cough. Failure to observe a decrease in cough after 1 month off medication argues strongly against this etiology
History suggestive of cough variant asthma
Cough alone as a manifestation of asthma is common among children but not among adults. Cough due to asthma in the absence of wheezing, shortness of breath, and chest tightness is referred to as “cough-variant asthma.”
A history suggestive of cough-variant asthma ties the onset of cough to exposure to typical triggers for asthma and the resolution of cough to discontinuation of exposure. Objective testing can establish the diagnosis of asthma (airflow obstruction on spirometry that varies over time or reverses in response to a bronchodilator) or exclude it with certainty (a negative response to a bronchoprovocation challenge—e.g., with methacholine). In a patient capable of taking reliable measurements, home expiratory peak flow monitoring can be a cost-effective method to support or discount a diagnosis of asthma.
The most common cause of respiratory hypoxia is
ventilationperfusion mismatch resulting from perfusion of poorly ventilated alveoli.
Amount of reduced hb to cause cyanosis
In general, cyanosis becomes apparent when the concentration of reduced hemoglobin in capillary blood exceeds 40 g/L (4 g/dL)
Most common cause of peripheral cyanosis
Probably the most common cause of peripheral cyanosis is the normal vasoconstriction resulting from exposure to cold air or water
R to L shunt = central
mMRC of px with shortness of breath walking on level ground or with walking up a slight hill
1
Initial assessment of dyspnea includes history and pe +
Walking oximetry
Peak flow assessment
Bronchoprovocation testing and/or home peak-flow monitoring may be useful in patients with intermittent symptoms suggestive of asthma who have a normal physical examination and spirometry; up to one-third of patients with the clinical diagnosis of asthma do not have reactive airways disease when formally tested.
A 23-year old college student was admitted to the hospital for a 2-day history of fever and chills. His symptoms began 3 days after his return from a Mediterranean Cruise with his family and friends. He has no comorbidities, and is living an active and sporty lifestyle. At the hospital’s emergency room, he was seen awake, alert, conversant and not in respiratory distress. He is oriented and complains that he feels “very ill”. He also had bouts of diarrhea amounting to 4x watery stools per day. His vital signs are as follows: BP 120/75 mmHg RR 24 HR 110 Temp 39C O2sats at room air-94% Laboratory results showed leukocytosis with elevated neutrophil counts, hypokalemia of 3.1 mmol/L, and hyponatremia of 120 mmol/L. SARS-COV2 RT-PCR came back negative. What is the most likely infecting organism?
a. Streptococcus pneumoniae
b. Legionella pneumophila
c. Klebsiella pneumoniae
d. Mycoplasma pneumoniae
b. Legionella pneumophila
Since with hyponatremia and went on a cruise
Airway hyperresponsiveness is defined clinically by which of the following test/s:
a.Reduced FEV1/FVC ratio of less than 0.70
b.FEV1 increase of 12% and 200mL after 15 minutes of short-acting beta agonist inhalation
c.A drop in FEV1 of 20% after a methacholine challenge test
d.All of the above
c.A drop in FEV1 of 20% after a methacholine challenge test
FEV1 increase of 12% and 200mL after 15 minutes of short-acting beta agonist inhalation = REVERSIBILITY
A 54 year-old policeman sought consult due to progressive dyspnea and sputum production of 2 months duration. He has no fever, no weight loss, and sputum is characterized as whitish in character and moderate in amount. His breathlessness is characterized as “progressive”, previously noted only upon carrying heavy loads but now he notes that this will occur even on climbing up the second floor of his apartment. His chest x-ray reveals normal findings and the CBC, 12-lead electrocardiogram, and blood chemistry all reveal normal results. What will be the most appropriate diagnostic step?
a. Perform chest CT scan
b. Order for a sputum Gene Xpert MTB/RIF
c. Order for an arterial blood gas
d. Order for lung volume studies
d. Order for lung volume studies
Lung volume study is also a lung function test similar to PFT
A 70-year old retired businessman consulted at your clinic for shortness of breath that he didn’t notice until 3 months ago. Dyspnea is associated with activity, especially after playing a game of tennis. 2 weeks prior to consult and during a trip to Europe, his friends noted that he is weaker and will pause for a while to catch his breath after walking a few minutes during their city tour. He denies fever, weight loss, sputum production, night sweats, and palpitations. At your clinic, he was weak-looking, and ambulatory (albeit very slow and assisted by her caregiver). He is a current cigarette smoker and smokes 1-2 packs per day. His vital signs are: BP-130/80 mmHg HR-95/minute RR-23/minute O2sats-90% He has no neck vein engorgement On chest examination, he has decreased air entry, and bilateral wheezing. His apex beat is at the 5th ICS of midclavicular line, and you noted a right ventricular heave. He also has bipedal edema. How would you grade the severity of his functional impairment?
mmrc 3
since will pause after a few mins
A 23 year-old office worker sought second opinion at your clinic for chronic productive cough since she was 15 years old. She had repeated bouts of hospitalizations due to recurrent pneumonia. Despite the IV antibiotic therapy, her cough did not completely resolve and she would still have yellowish phlegm, sometimes turning to greenish color. Upon examination, you hear crackles and wheezing over the left upper lung field. Xpert MTB/RIF is negative and sputum cultures grew Pseudomonas.What is the most likely underlying pathology causing her symptoms?
a.Cystic Fibrosis
b.Chronic Aspiration
c.Idiopathic Pulmonary Fibrosis
d.COPD
a.Cystic Fibrosis
Recurrent pneumonia since 15y/o
CF associated bronchiectasis common in upper lung field
P. aeruginosa is common among CF
This finding indicates previous exposure to asbestos and not necessarily pulmonary disease:
a. Thickening or calcification along the parietal pleura on chest x-rays
b. Benign pleural effusion
c. Irregular or linear opacities in the lower lung fields on HRCT
d. Decreased DLCO on pulmonary function testing
a. Thickening or calcification along the parietal pleura on chest x-rays
Pleural plaques (thickening or calcification of the parietal pleura) are a marker of asbestos exposure but do not necessarily indicate active disease or impairment.
60-year-old male with ARDS secondary to pneumonia was intubated upon admission due to severe hypoxemia and respiratory failure. ABG on low tidal volume ventilation showed pH 7.3 pCO2 50 mmHg pO2 80 mmHg HCO3 20 mEq/L sO2 90% at FiO2 80%. What is the recommended approach to managing his hypercapnia?
a. Increase the respiratory rate to lower PaCO2 levels
b. Administer sodium bicarbonate to correct respiratory acidosis
c. Switch to high-frequency oscillatory ventilation (HFOV) to improve ventilation
d. Permissive hypercapnia with a target pH >7.3 and adequate oxygenation
d. Permissive hypercapnia with a target pH >7.3 and adequate oxygenation
A. Increasing minute ventilation by increasing the respiratory rate or tidal volume will, therefore, often paradoxically worsen hypercapnia by increasing gas trapping and VD/ VT
C. Higher minute ventilation usually worsens hyperinflation and can cause barotrauma B and
D. Respiratory acidosis is often tolerated down to a pH of 7.2, so-called “permissive hypercapnia,” but progressive acidosis may require intravenous alkalinizing therapy (e.g., sodium bicarbonate or tromethamine) or accepting an increase in VT.
A 20-year-old male presents with exercise-induced wheezing and shortness of breath. He has no other respiratory symptoms. His physical examination is unremarkable, and spirometry shows a reversible airflow obstruction. What is the recommended treatment for this patient?
a. Short-acting beta-agonist as needed before exercise.
b. Leukotriene receptor antagonist as a daily controller medication.
c. Inhaled corticosteroids as a daily controller medication.
d. Long-acting beta-agonist as a daily controller medication
Pretreatment with an SABA can increase the threshold of ventilation required to induce bronchoconstriction. LABAs may extend the period of protection, but their use alone in asthma is to be discouraged. For occasional exercise, ICS/LABA can be used, but regular use may expose the patient to unnecessary doses of ICS. If regular exercise is undertaken, then LTRAs may provide protection and can be used regularly.
A 30-year-old pregnant woman with a history of mild intermittent asthma is currently not on any asthma medications. She experiences occasional symptoms but has no history of asthma exacerbations. What is the preferred treatment for her asthma during pregnancy?
a. Short-acting beta-agonist as needed.
b. Low-dose inhaled corticosteroids (ICS) as a controller medication.
c. Oral corticosteroids as a controller medication.
d. Leukotriene receptor antagonist as a controller medication
a. Short-acting beta-agonist as needed.
There is extensive experience suggesting the safety of inhaled albuterol, beclomethasone, budesonide, and fluticasone, with reassuring information on formoterol and salmeterol in pregnancy.
Animal studies have not suggested toxicity for montelukast, zafirlukast, omalizumab, and ipratropium
Chronic use of OCS has been associated with neonatal adrenal insufficiency, preeclampsia, low birth weight, and a slight increase in the frequency of cleft palate
A 45-year-old male with severe asthma has been using a high-dose inhaled corticosteroid (ICS), a long-acting beta-agonist (LABA), and a long-acting muscarinic antagonist (LAMA) without adequate control. He experiences frequent exacerbations despite optimal adherence hence given oral steroids as well. What would be the appropriate step in managing his asthma? a. Start montelukast as an add-on therapy.
b. Give cromolyn sodium as an add-on therapy.
c. Initiate omalizumab as an add-on therapy
d. Increase the ICS dose to maximum.
c. Initiate omalizumab as an add-on therapy
Severe and difficult-to-treat asthma, which composes ~5–10% of asthma, is defined as asthma that, having undergone appropriate evaluation for comorbidities and mimics, education, and trigger mitigation, remains uncontrolled on step 5 therapy or requires step 5 therapy for its control.
A 40-year-old male with COPD presents with recurrent exacerbations despite using a long-acting bronchodilator. He experiences two or more moderate exacerbations or at least one severe exacerbation annually. What is the recommended treatment for his COPD?
a. Continue the current long-acting bronchodilator and add an inhaled corticosteroid.
b. Start triple therapy (long-acting bronchodilator + inhaled corticosteroid + long-acting muscarinic antagonist).
c. Discontinue the current bronchodilator and start a long-acting muscarinic antagonist as monotherapy.
d. Increase the dose of the current bronchodilator
b. Start triple therapy (long-acting bronchodilator + inhaled corticosteroid + long-acting muscarinic antagonist).
A 65-year-old male with COPD presents with very severe airflow limitation and frequent exacerbations despite using triple therapy (long-acting muscarinic antagonist + long-acting bronchodilator + inhaled corticosteroid). Eosinophil level is less than 100. His CAT score indicates a significant impairment of health status. What is the recommended treatment for his COPD?
a. Continue the current medication and add an oral corticosteroid.
b. Initiate roflumilast as an add-on therapy.
c. Begin leukotriene receptor antagonist.
d. Maximize the dose of the current inhaled corticosteroid
b. Initiate roflumilast as an add-on therapy.
A 30-year-old male with no co-morbids consulted due to 4-day history of cough with yellowish phlegm and fever Tmax 38.3C. COVID-19 RT PCR yielded negative results. What is the best empiric treatment for this patient?
a. Amoxicillin 1gm TID
b. Sultamicillin 750mg BID
c. Levofloxacin 750mg OD
d. Cefuroxime axetil 500mg BID
a. Amoxicillin 1gm TID
A 48-year-old female hypertensive and asthmatic patient was recently admitted for 3 days due to pneumonia showing bilateral infiltrates on chest X-ray. She wanted to check when is the best time to repeat a chest X-ray after admission and when will her infiltrates on chest x-ray disappear. You may advise her that she can have her chest x-ray repeated after ______ weeks and that chest radiographic abnormalities in CAP are expected to resolve in _____ weeks.
a. 3-4 weeks; 4-6 weeks
b. 4-6 weeks; 4-12 weeks
c. 4-6 weeks; 6-12 weeks
d. 3-4 weeks; 6-12 weeks
b. 4-6 weeks; 4-12 weeks
What is the LEAST likely pathogen associated with multi-drug resistant cases of VAP?
a. Pseudomonas aeruginosa
b. Acinetobacter spp.
c. Serratia marcescens
d. Legionella pneumophila
c. Serratia marcescens
Which of the following symptoms is unusual for OSA?
a. Dyspnea
b. Dry mouth
c. Mood disturbances
d. Headache
a. Dyspnea
Hitory of myocardial infarction came in due to worsening dyspnea, decreased functional capacity and bilateral lower extremity edema. He has no history of pulmonary embolism. You are suspecting pulmonary hypertension. A right heart catheterization was done showing an mPAP of 25mmHg, PVR > 3.0 WU and PAWP > 15mmHg. What is the most likely cause of his pulmonary hypertension?
a. CTEPH
b. COPD
c. Left heart failure
d. Idiopathic pulmonary hypertension
c. Left heart failure
since PAWP >15
Among patients newly diagnosed with PAH and with positive vasoreactivity test, what is the most appropriate treatment strategy?
a. Tadalafil
b. Bosentan
c. Low dose CCB
d. High dose CCB
d. High dose CCB
A 40/M consulted due to positive smear microscopy after 2 months of HRZE treatment. He is compliant with his medications. What will you advise him?
a. Continue intensive phase of treatment and repeat smear microscopy at the end of 3rd month
b. Continue intensive phase of treatment and request for Xpert MTB/Rif
c. Proceed with continuation phase of treatment and request for Xpert MTB/Rif
d. Proceed with continuation phase of treatment and request for Xpert MTB/Rif at the end of 5th month
d. Proceed with continuation phase of treatment and request for Xpert MTB/Rif at the end of 5th month
** supposedly smear microscopy
Xpert MTB/RIF test is NOT used for follow-up examination to monitor treatment because current- generation PCR-based tests are unable to determine MTB viability and may test positive even with nonviable or dead bacilli
A 33-year-old patient had a 2-month history of cough, intermittent fever and weight loss. She was diagnosed with PTB and was started on HRZE, which she only took for 3 weeks. She consulted 5 weeks after stopping the treatment due to persistence of symptoms. What is the appropriate management for this patient?
a. Continue HRZE and prolong to compensate for missed doses
b. Request for a smear microscopy and decide on continuation of treatment based on results
c. Continue treatment and request for Xpert MTB/Rif
d. Consider patient as “lost to follow-up”
b. Request for a smear microscopy and decide on continuation of treatment based on results
A 22/M with HIV infection consulted you for TB preventive treatment after being exposed to a co-worker who was diagnosed with bacteriologically-confirmed PTB. He had no previous history of TB and TB treatment; and denies any symptoms. What will you advise him?
a. Do a tuberculin skin test
b. Request for a chest x-ray
c. Request for Xpert MTB/Rif
d. Offer TB preventive treatment
b. Request for a chest x-ray
Screening for PLHIV : CXR
Diagnosis for presumptive: Gene xpert
CC, 61 years old male had a teleconsultation with you for chronic cough that was not responsive to multiple antibiotics and anti Koch. His previous Chest Xray showed profuse miliary infiltration or consolidation. His HRCT showed multiple small nodules and diffuse ground-glass densities with thickened intralobular and interlobular septa that is polygonal in shape. What is the likely pertinent exposure you should ask your patient to further support your diagnosis?
a. Coal mining in San Mateo, Rizal
b. Sandblasting procedures on confined factory in Mindoro
c. Previous residence in the foothills of the Sierra Madre
d. Farming in Nueva Ecija
b. Sandblasting procedures on confined factory in Mindoro
Workers heavily exposed through sandblasting in confined spaces tunneling through the rock with high quartz content (15-25%), or the manufacture of abrasive soaps may develop acute silicosis with as little as 10 months exposure Clinical and pathologic features are similar to those of pulmonary a;lveolar proteinosis.
The chest radiograph may show profuse miliary proliferation or consolidation and there is a characteristic HRCT pattern known as “crazy paving “ Crazy paving: diffuse ground glass densities with thickened intralobular and interlobular septa producing polygonal shapes.
Which of the following diagnostic methods is appropriate to obtain diagnosis for chronic beryllium disease?
a. HLA DR1 genotyping
b. Specific IgE antibody titers
c. Specific IgG precipitating antibody titers
d. Transbronchial biopsy of lung tissue
d. Transbronchial biopsy of lung tissue
With early disease, both chest imaging studies and pulmonary function tests may be normal. Fiberoptic bronchoscopy with transbronchial lung biopsy usually is required to make the diagnosis of CBD
FT, 63 years old female presented with productive cough and brownish plugs of mucus. She was unresponsive to multiple antibiotics and bronchodilators. Further work up showed circulating IgE 1300IU/mL, peripheral eosinophilia 2000/uL and positive serum precipitins for Aspergillus. What is the likely classic finding in her Chest CT?
a. Central bronchiectasis
b. Diffuse ground glass opacities
c. Crazy paving pattern
d. Consolidation in the upper lobe
a. Central bronchiectasis
Central bronchiectasis is described as a classic finding on chest imaging in ABPA but is not necessary for making a diagnosis
Allergic bronchopulmonary asperigilosis (ABPA) is an eosinophilic pulmonary disorder that occurs in response to allergic sensitization to antigens from Aspergillus species fungi.
Asthmatic phenotype accompanied by cough with production of brownish plugs of mucus - predominant clinical presentation Distinct diagnosis from asthma: prominent peripheral eosinophilia and elevated circulating levels of IgE (often >1000 IU/ml) Establishing a diagnosis of ABPA also requires establishing sensitivity to Aspergillus antigens by skin test reactivity and/or direct measurement of circulating specific IgE to Aspergillus.
Positive serum precipitins for Aspergillus or direct measurement of circulating specific IgG to Aspergillus can be used as an adjunct diagnostic criterion.
A 22-year-old female admitted due to 5-day cough and dyspnea. She denies any significant health problems. At the ER, she is unresponsive with palpatory BP of 60mmHg HR 140 RR 30 temp 38.1 O2 sat 70% at room air. PE revealed crackles mid to base lung fields. She was subsequently intubated and hooked to norepinephrine due to unresponsiveness of blood pressure to increase despite fluid challenge. However, a further decline in MAP was observed. What causes the decline in her MAP?
A. Mechanical ventilation can impede venous return from positive pressure ventilation
B. Increased endogenous catecholamine secretion
C. Vasodilatory effects of norepinephrine
D. Position of the patient
A. Mechanical ventilation can impede venous return from positive pressure ventilation
A 59-year-old male presented with cough and dyspnea for 6 days. BP 120/70 HR 110 RR 29 temp 39.1 O2 sat 85% at room air. PE neck veins distended; crackles heard from mid to base on both lung fields. CXR showed bilateral opacities and pulmonary congestion. ABG pH 7.25; pCO2 49 pO2 72 HCO3 18 SO2 86%. This is consistent with what phase of ARDS?
A. Proliferative phase
B. Exudative phase
C. Fibrotic phase
D. Recovery phase
B. Exudative phase
The exudative phase encompasses the first 7 days of illness after exposure to a precipitating ARDS risk factor, with the patient experiencing the onset of respiratory symptoms.
Proliferative phase - lasts from approximately day 7 to day 21
Fibrotic phase - 3-4 weeks
A 52-year-old female presented with dyspnea for 5 days. She had bouts of productive cough with yellowish sputum for 6 days. BP 140/60 HR 120 RR 26 temp 39.1 O2 sat 85% at room air. PE neck veins distended; symmetric chest expansion with crackles heard from mid to base on both lung fields. CXR showed bilateral opacities and pulmonary congestion. COVID RT PCR positive. What is your goal and limit in the management of her Acute Respiratory Distress Syndrome?
A. Plateau pressure < 40 cmH2O
B. pH 7.29
C. MAP of 64 mmHg
D. SpO2 of 88%
D. SpO2 of 88%
A 21-year-old male consulted due to recurrent bouts of nonproductive cough. No fever, dyspnea, abdominal pains or weight loss. CXR was normal. Family history revealed his father is asthmatic and maintained on inhaler. If you are suspecting for an asthma, which of the following is an expected appearance in his pulmonary function test?
A. Scalloping
B. Reversibility is defined as a > 12% increase in the FEV1
C. Diurnal peak flow variability of >12%
D. Absolute increase of ≥200 mL at least 20 min after administration of a β2-agonist
For the diagnosis of ASTHMA, PFTs show:
● The flow-volume loop may show a characteristic scalloping
● Reversibility is defined as a ≥12% increase in the FEV1 and an absolute increase of ≥200 mL at least 15 min after administration of a β2-agonist or after several weeks of corticosteroid therapy.
● Diurnal peak flow variability of >20%
GINA = diurnal peak flow variability >10%
Which is consistent with aspirin exacerbated respiratory disease?
A. They can generally tolerate inhibitors of cyclooxygenase-2 and acetaminophen
B. These patients can take occasional inhibitors of cyclooxygenase-1
C. Leukotriene modifiers should be avoided
D. IL-2–active biologics appear to be particularly helpful
A. They can generally tolerate inhibitors of cyclooxygenase-2 and acetaminophen
A 52-year-old male came in for consult due to cough. He works as a miner for 12 years. PE revealed occasional rales without wheezing. CXR have irregular opacities first noted in the lower lung fields. HRCT showed ground glass appearance. What is your diagnosis?
A. Silicosis
B. Asbestosis
C. Coal worker’s Pneumoconiosis
D. Byssinosis
B. Asbestosis
A 32-year-old female consulted due to dyspnea for 6 hours. She had fever, chills and body malaise. She works as a baker. She noted symptoms after exposure to the newly arrived wheat flour in the bakery. What is the possible offending antigen of her hypersensitivity pneumonitis?
A. Aspergillus species
B. Coffee bean dust
C. Sitophilus granaries
D. Botrytis cinerea
C. Sitophilus granaries =Miller’s lung
D. Botrytis cinerea= wine makers lung
Which of the following is an initial hemodynamic change seen in clinical stage B of Pulmonary Hypertension?
A. Decrease in Pulmonary vascular resistance
B. Increase in cardiac output
C. Decrease in pulmonary artery pressure
D. Decrease in right atrial pressure
C. Decrease in pulmonary artery pressure
In PAH, initial changes in the histopathophenotype of distal pulmonary arterioles precedes significant changes in hemodynamics or the development of symptoms in most patients (clinical stage A). As vascular remodeling progresses, there is an increase in pulmonary vascular resistance (PVR), pulmonary artery pressure (PAP), and right atrial pressure (RAP). In clinical stage B, symptoms are evident and, when diagnosed, prompt early, aggressive treatment. Effacement of pulmonary arterioles results in severely increased PVR that promotes right heart failure, defined by a decrease in cardiac output (CO) and PAP. Patients in clinical stage C have severe symptoms and require full therapeutic intervention.
A patient suspected of PH underwent a confirmatory test to diagnosis the disease, Workup showed mPAPA 22mmHG, Pulmonary artery wedge pressure of 17mmHG and Pulmonary vascular resistance of 2 WU. What is the PH classification
A. PH is excluded
B. Precapillary PH
C. Isolated Capillary PH
D. Combined PH
C. Isolated Capillary PH
Which of the following is a treatment goal in pulmonary arterial hypertension(PAH) to achieve a low clinical risk profile?
A. Patient with minimal to moderate symptoms
B. WHO FC II or III
C. 6-WMD >440m
D. Cardiac index >2.0L/min per m2
C. 6-WMD >440m
A Clinical trial including midly symptomatic PAH patient compared Bosentan to placebo and showed improved PVR and 6MWD in patient with WHO FC II. What is the name of Clinical trial?
A. ARIES
B. EARLY
C. SERAPHIN
D. BREATH
A 35y.old patient with PTB is undergoing treatment with a 6 month standard first-line regimen. The patient’s sputum culture was positive at the start of treatment. When should the sputum of virtually ALL patients be expected to become negative, indicating good response to treatment?
A. By the end of 2nd month
B. By the end of the 3rd month
C. By the end of the 5th month
D. By the end of the 6th month
B. By the end of the 3rd month
2nd month >80% negative
A 42yold patient with drug-susceptible TB is undergoing the standard first-line TB treatment regimen. After one month of treatment, the patient present with severe knee and joint pain. Despite giving pain reliever and anti-hyperuricemic drug, the patient developed gouty arthritis. What is the most appropriate change to the TB treatment regimen for this patient?
A. Give steroids to alleviate the symptoms then continue the current regimen for another 1 month (to complete 2 months of pyrazinamide) with close monitoring of uric acid.
B. Discontinue pyrazinamide and continue with HRE for 9 months
C. Discontinue pyrazinamide and continue with HRE for 2 months then HR for 7 months
D. Switch pyrazinamide to streptomycin and continue with HRE to complete 2 months then HR for 4 months
C. Discontinue pyrazinamide and continue with HRE for 2 months then HR for 7 months
A patient with HIV and TB meningitis is about to begin TB treatment. The healthcare team is considering the timing of ART initiation. What is the recommended approach to minimize the risk of IRIS-related complications in this patient
A. Start ART immediately with TB treatment
B. Delay ART initiation for 2 weeks
C. Delay ART initiation for 8 weeks
D. Do not start ART until TB treatment is treatment
Answer: A. Delay ART initiation for 8 weeks
A 62-year-old female with a history of lung carcinoma presents with progressive dyspnea. Chest X-ray reveals a large pleural effusion. Thoracentesis is performed, and the pleural fluid is exudative with a low glucose level. Cytology initially returns negative for malignant cells.Given the high suspicion of malignancy despite negative cytology, what is the most appropriate next step in the diagnostic workup?
A. Repeat thoracentesis and send the fluid for additional cytologic evaluation
B. Do CT- or ultrasound-guided needle biopsy of pleural thickening or nodules
C. Perform thoracoscopy with pleural biopsy and pleurodesis
D. Initiate empirical chemotherapy for lung carcinoma
C. Perform thoracoscopy with pleural biopsy and pleurodesis
Risk factors for Legionella infection include EXCEPT:
A. Diabetes
B. HIV infection
C. Age >70 years old
D. Severe renal disease
C. Age >70 years old
A 45-year-old female, obese, with poorly-controlled diabetes presents to the clinic with a 5-day history of productive cough with greenish phlegm, low-grade fever, mild shortness of breath and chest pain aggravated by deep breathing or coughing. Vital signs were as follows: Temperature: 37.8°C (100°F), Blood Pressure: 128/78 mmHg, Heart Rate: 88 bpm, Respiratory Rate: 25 breaths per minute, Oxygen Saturation: 96% on room air. On auscultation, there are crackles on right base. Chest xray showed infiltrated on right lower lung. He was prescribed with Nitrofurantoin 2 months ago for UTI. Which of the following is the correct outpatient antibiotic regimen to prescribe:
A. Amoxicilline 1gm TID + Azithromycin 500mg OD on 1st day then 250mg OD for 4 days
B. Co Amoxiclav 625mg BID + Clarithomycin 500mg BID
C. Cefuroxime 500mg BID + Doxycycline 100mg BID
D. Levofloxacin 500mg OD
C. Cefuroxime 500mg BID + Doxycycline 100mg BID
B. co-amoxiclav should be TID
.A 68-year-old male on chronic hemodialysis is admitted to the ICU following a stroke and requires mechanical ventilation. On the seventh day of intubation, he develops a fever of 39°C, increased sputum production, and a new infiltrate on chest X-ray. The patient has a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. His vital signs are as follows: Blood pressure: 130/85 mmHg Heart rate: 110 bpm Respiratory rate: 24 breaths per minute Oxygen saturation: 92% on 40% FiO2 Which of the following empirical antibiotic regimen would be the most appropriate initial therapy for this patient?
A. Ceftriaxone + Azithromycin
B. Piperacillin-tazobactam + Vancomycin
C. Levofloxacin + Cefepime
D. Meropenem + Linezolid + Amikacin
D. Meropenem + Linezolid + Amikacin
Double coverage (1 per column)
A 60-year old female was recently diagnosed with diffuse large B-cell lymphoma. She underwent chemotherapy using R-CHOP. A week later, she developed fever and diarrhea. PE showed low BP (80/60) and oral mucositis. She has no central venous line. CBC showed severe neutropenia. What is the recommended antibiotic of choice?
A. Piperacillin + Tazobactam
B. Cefepime + Vancomycin
C. Imipenem + Cilastatin
D. Meropenem
B. Cefepime + Vancomycin
Add vanco for septic shock and neutropenic
