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?
Non-specific interstitial pneumonia
UIP if IPF
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%
What airway pathology can present with DLCO > 100%
What airway pathology can present with TLC > 100%
Goals of asthma therapy
Doses of inhaled corticosteroids for asthma
Add on therapy for STEP 5 asthma control based on GINA 2023
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
Management of asthma exacerbations in primary care
Diagnostic criteria for acute eosinophilic pneumonia
Light’s criteria
How do you classify OSA
CPAP side effects and their treatments
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
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
TB regimen dosing
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
Diagnostic criteria for ARDS
Key Features of different MV settings
Common contraindications to NIV
Adverse effects of hypercapnia
Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia
Criteria for severe CAP based from Harrisons
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
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
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.
Based on 2020 PSMID guidelines, what are the empiric abx for CAP MR
for CAP MR -> 3rd gen
Definition of sepsis and septic shock
Empiric abx for severe sepsis with no obvious source
TZP if immunocompetent is 4.5g IV q6
but if immunocompromised 3.375 q4
5 categories of cardiogenic shock
How do you differentiate different types of PH according to hemodynamic phenotypes?
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
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
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
