Pulmonology 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 >25 mmHg
- <=15 mmHg
- > 3
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
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)
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).
When do you schedule of sputum follow-up examinations for PTB on DS-TB regimen?
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
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
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.
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.
Treatment for aerophagia in px using CPAP
Treatment for difficulty exhaling in px using CPAP
