Pulmonology Flashcards
beta-blockers are contraindicated in patients with _____ lung disease
obstructive (due to bronchoconstriction)
amiodarone is contraindicated in patients with _____ lung disease
restrictive (due to pulmonary fibrosis)
what are the primary long-term treatments for asthma vs. COPD
asthma: albuterol inhaler
COPD: anticholinergics (ipatropium, tiotropium)
what is the diagnostic test for allergic bronchopulmonary aspergillosis
serum IgE
Pickwickian syndrome involves what three main symptoms
Pickwickian syndrome (obesity hyperventilation) -BMI > 30, daytime hypercapnea/hypoxemia, sleep-disordered breathing
how do patients with Pickwickian syndrome develop decreased respiratory drive
chronic hypercapnia decreases chemoreceptor sensitivity to CO2
a cavitary lesion with adjacent crescent and movement within the lesion with position change in a patient with intermittent hemoptysis for several months should make you think of what disease
aspergillosis (fungus ball moves around in cavitary lesion on position change)
what are some ways to increase functional residual capacity after surgery
coughing, chest physiotherapy, incentive spirometry, ambulation, repositioning, elevate head of bed
a large mediastinal mass with associated elevations in AFP and beta-hCG are suggestive of what disease
non-seminomatous germ cell tumor (seminomatous has only beta-hCG elevation)
treatment for Legionnaire’s
a macrolide or floroquinolone
are proximal or distal deep veins of the leg more common sources of PE’s
proximal (ileofemoral vein)
when a patient who experienced blunt chest trauma experiences worsening dyspnea, hypoxia and alveolar opacities on x-ray after fluid rescucitation what do you suspect was the original problem
pulmonary contusion
fluid rescucitation after contusion leads to pulmonary edema
what three conditions comprise Light’s criteria for determining pleural exudate
- pleural protein/ serum protein > 0.5
- pleural LDH/ serum LDH > 0.6
- pleural LDH > 2/3 the limit for serum LDH
workup algorithm for categories of lung disease diagnosed with spirometry
check FEV1/FVC ratio; if low do albuterol challenge test –> if improves then asthma, if not then COPD
if FEV1/FVC ratio is high check DLCO; if normal then chest wall musculoskeletal weakness, if low suspect interstitial lung disease
popcorn calcification on chest CT suggests
hammartoma
bull’s eye calcification on chest CT suggests
granuloma
how can you differentiate consolidation from pleural effusion on lung exam
consolidation: bronchial breath sounds, dullness to percussion, increased tactile fremitus (good sound transmission)
pleural effusion: decreased breath sounds, dullness to percussion, decreased tactile fremitus (poor sound transmission)
best initial therapy for anaphylactic shock
IM epinephrine (antihistamines, bronchodilators, vasopressors are all secondary to getting epi on board)
what are some extrapulmonary manifestations of sarcoidosis
erythema nodosum (w/ painful shin lesions), high ACE, hypercalcemia, periosteal bone resorption, uveitis, polyarthralgias
a patient with COPD suddenly develops dypsnea and decreased oxygenation; what disease process should you automatically suspect
spontaneous secondary pneumothorax
how do you manage massive hemoptysis (>600mL per day or 100mL per hour)
- secure ABC’s and intubate
- position patient with bleeding lung in dependent position
- bronchoscopy to locate source and provide interventions (electrocautery, balloon tamponade)
- pulmonary artery embolization or thoracotomy if patient does not improve
what value of PaO2/FiO2 is considered severe hypoxemia in ARDS
PaO2/FiO2
what are the different management bundles for mild vs. moderate vs. severe asthma exacerbation
mild: oxygenate, inhaled SABA, steroids
moderate: oxygenate, inhalted SABA + ipatropium, steroids
severe: intubate, inhaled SABA + ipatropium, steroids, consider mag sulfate, to ICU
asthma exacerbation patients with normal PaCO2 are likely experiencing what
decreased respiratory drive due to fatigue (they should be blowing off more CO2 to result in low CO2 due to hypoxemia); you will likely need to intubate soon
massive PE=
PE complicated by hypotension or acute right heart strain (can be evidenced by RBBB or JVD)
in a child with inspiratory stridor, what governs whether you will do laryngoscopy vs. neck x-ray
laryngomalacia is more chronic and no infectious sx ==> laryngoscopy
progressive soft tissue airway compression is usually due to infection and you would see fever ==> neck x-ray
treatment for laryngomalacia
reassurance as most cases resolve by 1.5 years
in severe cases (apnea, cyanosis, rapidly increasing stridor, poor weight gain) do supraglottoplasty
peak airway pressure = _____ + ______
peak airway pressure = resistive pressure (which is flow x resistance) + plateau pressure (the pressure measured at the end of an inspiratory hold)
plateau pressure = _____ + _______
elastic pressure + positive end-expiratory pressure
what is elastic pressure in terms of compliance and tidal volume
elastic pressure = tidal volume / compliance
list some causes of exudative effusion
(cause increased capillary or pleural membrane permeability or lymphatic drainage obstruction)
-PE (sometimes transudative), malignancy, infection, connective tissue disease, trauma
list the modified well’s criteria with associated points (note: >4 = likely PE, go straight to CT angio)
+3: clinical signs of DVT, no higher likelihood dx than PE
+1.5: hx of PE or DVT, HR >100, recent surgery (
what antibiotics should be given to a patient with community acquired pneumonia (healthy vs. comorbidities)
healthy: macrolide or doxycycline
comorbidities (diabetes, CHF, etc.): floroquinolone or beta-lactam + macrolide
list the CURB-65 criteria and how it is used
Confusion, Uremia, RR > 30, BP 65 years
score of 2 or higher ==> admit
score of 4 or higher ==> to ICU
what would you expect for DLCO in emphysema vs. chronic bronchitits
DLCO is normal in chronic bronchitis and decreased in emphysema (due to breakdown of alveolar walls)
which lung cancer produces PTHrP and consequent hypercalcemia
squamous cell lung cancer
which lung cancer is most associated with hypertrophic osteoarthropathy (clubbing)
adenocarcinoma
which vent settings mediate pO2 level?
which vent settings mediate pCO2 level?
pO2 is mediated by FiO2 and PEEP
pCO2 is mediated by tidal volume and RR
below which point is the ideal FiO2 setting to avoid oxygen toxicity
if patient oxygenation is adequate (pO2>60) then lower FiO2 to an ideal of
what happens to lung compliance in COPD
it increases due to break down of elastin and connective alveolar tissues
what is the most common lung cancer seen in nonsmokers and where in the lung is it usually located
adenocarcinoma; located peripherally
Hodgkin’s lymphoma patients s/p chemo and radiation therapy are at increased risk of what major complication of treatment long-term
secondary malignancy due to chemo or radiation (i.e. GI, lung, breast malignancy)
what two major broad categories of diseases are best diagnosed via bronchoalveolar lavage
suspected malignancy and opportunistic infections (i.e. PCP)
which patients are predisposed to allergic bronchopulmonary aspergillosis
asthma and cystic fibrosis patients
a patient with a symptoms of asthma who has an inflammed pharynx and larynx on laryngoscopy likely has what condition
GERD; 75% of patients with asthma also have GERD, which can trigger asthma
complete this triad: nasal polyps, asthma, _____
aspirin intolerance
how can you differentiate between chronic bronchitis and emphysema using PFT’s
DLCO is normal in chronic bronchitis (DLCO > 60%) and abnormal in emphysema (DLCO
predisposing factors for neonatal respiratory distress syndrome
- prematurity
- male sex
- maternal diabetes (fetal hyperinsulinemia causes decreased endogenous cortisol)
- perinatal asphyxia
- Cesarean delivery without labor
how can you differentiate between alveolar hypoventilation and V/Q mismatch
alveolar ventilation (i.e. sedation, obesity, obstructive lung disease) is characterized by high pCO2 whereas in V/Q mismatch (i.e. atelectasis, PE, pulm edema) pCO2 is low due to compensatory tachypnea
normal A-a gradient is _____
what intervention should you attempt in COPD exacerbation patients with hypercapnia before intubating
non-invasive positive pressure ventilation (can decrease intubation rate, hospital LOS, etc.)
when do you use fibrinolytics via chest tube vs. surgery for a pleural effusion that is think and not draining
if it is localized, complex (loculated) or with a thick rim then surgery, if not, streptokinase drainage
also if the patient didn’t have recent surgery
what is Pancoast syndrome
tumor involvement of the brachial plexus, manifesting as radiating pain in ulnar distribution due to T1 and C8 compression as well as shoulder pain
a wedge-shaped pleural opacification in a patient with dyspnea and pleuritic chest pain is likely
pulmonary infarction
list the different respiratory quotients:
- normal
- fatty acid metabolism only
- mainly protein metabolism
- carbohydrate heavy metabolism
-normal: 0.8
-mainly fatty acid: 0.7
-mainly proteins: 0.8
-mainly carbs: 1.0
(this is important because RQ > 1 is harder to wean from vent)
pleural fluid pH for:
- normal
- transudate
- exudate
- normal: 7.6
- transudate: 7.4-7.55
- exudate: 7.3- 7.4
what is contraction alkalosis
when the body is volume contracted aldosterone will increase and promote volume expansion at the cost of dumping H+ resulting in alkalosis
when should you start a COPD patient on home supplemental oxygen
paO2 55% when paO2
what is the recommended tidal volume on a ventilator
6mL/kg of body weight
describe the Haldane effect
increased oxygen will displace H+ on hemoglobin which then combines with bicarb to eventually produce CO2
so increasing oxygen promotes CO2 release into blood stream
a patient with bilateral pleural plaques seen on CXR likely has what exposure and what cancer?
asbestosis (causes b/l pleural plaques, reticulonodular infiltrates and pleural thickening)
bronchogenic carcinoma > mesothelioma
vesicular vs. bronchial breath sounds
vesicular=normal in the pulmonary tissue; soft best heard in inspiration, usually silent expiration
bronchial=abnormal in pulm tissue; suggestive of consolidation; louder, audible, stronger expiratory component
when do you give warmed IV fluids and active warming (warm blankets) vs. IV fluids and passive warming (cold clothing removal)
warmed IV fluids are given for severe hypothermia of
how does hypothermia cause bradycardia and hypotension
cold pacemaker cells develop decreased reactivity
cold-induced diuresis promotes fluid loss
what distinguishes bronchiectasis from chronic bronchitis
bronchiectasis is more associated with recurrent respiratory tract infections and copious amounts of mucopurulent sputum
name two indications for drainage of pleural effusion via thoracostomy
pH
cobblestoning of the posterior pharynx should make you think of…
allergic rhinnitis
first line treatment for PCP? what should you add for patients with PaO2 35?
bactrim; add corticosteroids for PaO2 35
diarrhea and diffuse pulmonary infiltrates in a bone marrow transplant patient
CMV pneumonitis
