Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Step 2 CK > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

Main difference between asthma and COPD

A

Both are obstructive lung diseases

asthma = reversible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Why is oral temperature not accurate when a patient is having an asthma exacerbation?

A

Rapid mouth breathing cools the thermometer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

The best initial test during an acute asthma exacerbation

A

Peak expiratory flow (PEF)

or

ABG

CXR is often normal, and although PFTs are the most accurate diagnostic test, they cannot be performed during an acute attack

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What constitutes a positive methacholine test

A

A >20% decrease in FEV1

Metacholine is synthetic ACh

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

PFTs in Asthma

A

Decreased FEV1/FVC

Decrease in FEV1 >20% with the use of methacholine or histamine

Increase in FEV1 >12% and 200 mL with the use of albuterol

Increase in DLCO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Treatment of asthma

A
  1. SABA (albuterol)
  2. Low-dose ICS (beclomethasone)
  3. LABA or increase the dose of ICS
  4. Increase dose of ICS to maximum in addition to LABA and SABA
  5. Omalizumab (if IgE level is increased)
  6. Oral corticosteroids (prednisone)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Adverse effects of inhaled steroids

A

Dysphonia

Oral candidiasis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Alternative control agents if a patient with asthma refuses inhaled steroids

A

Cromolyn and nedocromil (inhibit mast cell mediator release)

Theophylline

Leukotriene modifiers: montelukast, zafirlukast*, or zileuton (best wiith atopic patients)

*Zafirlukast is hepatotoxic and has been associated with Churg-Strauss syndrome (inflammation of small and medium sized blood vessels)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

True/False

High-dose inhaled steroids rarely lead to the adverse effects associated with prednisone

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is a good indication of the severity of an asthma exacerbation?

A

Respiratory Rate

Accessory muscle use is subjective, pulse ox will not show hypoxia until the patient is nearly at the point of imminent respiratory failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

The severity of an asthma exacerbation is quantified by:

A

Decreased peak expiratory flow (PEF)

ABG with an increased A-a gradient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

The PEF is an approximation of…

A

Force Vital Capacity

There is no precise “normal” value; look to see how much difference there is from a patient’s baseline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

When is magnesium indicated during an asthma attack

A

During a severe exacerbation that is not responsive to several rounds of albuterol while waiting for steroids to take effect (take 4-6 hours)

Best initial therapy = oxygen with SABA and a bolus of steroids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How does a patient acquire COPD?

A

Smoking or alpha-1 antitrypsin deficiency

Tobacco destroys elastin fibers; most of the ability to exhale is from elastin fibers in the lungs passively allowing exhalation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

PFTs with COPD

A

Decreased FEV1/FVC (under 70%)

Increased Total Lung Capacity (d/t increase in residual volume)

Decreased DLCO*

Incomplete improvement with albuterol

Little or no worsening with methacholine

*Only with emphysema; a normal DLCO is indicative of chronic bronchitis predominant COPD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What improves mortality and delays the progression of COPD

A
  1. Stop smoking
  2. Oxygen therapy if pO2 <55 or saturation <88%
  3. Influenza and pneumococcal vaccinations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Next step:

Asthmatics not controlled with albuterol…

vs

COPD not controlled with albuterol…

A

Asthma = inhaled steroids

COPD = anticholinergic (tiotropium) then inhaled steroiods if ineffective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Treatment of acute exacerbations of chronic bronchitis

A

Bronchodilators and corticosteroid therapy combined with antibiotics

Coverage should be provided against Strep pneumo, H influenza, and Moraxella

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Why do you avoid placing a patient with COPD on very-high flow 100% nonrebreather mask?

A

Dyspneic, hypoxic patients with COPD must get oxygen; however, too much creates a V/Q mismatch (damaged airways that are normally constricted, open when exposed to O2)

The idea of “eliminating hypoxic drive” is NOT accurate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Define bronchiectasis

A

Chronic dilation of the large bronchi (permanent anatomic abnormality)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

The single mot common cause of bronchiectasis is…

A

cystic fibrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Define ABPA

A

AKA Allergic Bronchopulmonary Aspergillosis

Hypersensitivity of the lungs to fungal antigens that colonize the bronchial tree (occurs almost exclusively in patients with asthma and a history of atopic disorders)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Treatment for ABPA

A
  1. Oral steroids (prednisone) for severe cases
  2. Itraconazole for recurrent episodes
    * Note: inhaled steroids are NOT effective for ABPA (inhaler cannot deliver a high enough dose of steroids)*
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Meconium ileus

Recurrent pancreatitis

Biliary cirrhosis

A

Think cystic fibrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Why are men and women with CF infertile?

A

Men: 95% have azoospermia, with the vas deferens missing in 20%

Women: chronic lung disease alters the menstrual cycle and thick cervical mucus blocks sperm entry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

For CF, which test is more accurate:

increased sweat chloride

or

genotyping

A

Increased sweat chloride: > 60 (use pilocarpine to induce sweating)

Genotyping is not as accurate because there are many different types of mutations leading to CF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Treatment for CF

A
  1. Antibiotics (Nontypable H influenza, Pseudomonas, Staph aureus, Burkholderia)*
  2. Recombinant human deoxyribonuclease: rhDNase (breaks down the massive amounts of DNA left by neutrophils in respiratory mucus)
  3. Inhaled bronchodilators (albuterol)
  4. Pneumococcal and influenza vaccinations
  5. Lung transplantation
  6. Ivacaftor (increases activity of CFTR in some patients)
  7. Daily postural drainage and percussion
    * *Until adulthood, children with CF are most likely to suffer from Staph aureus infections (pseudomonas becomes predominant in adulthood); if a pt has a history of pulmonary infections it is safe to assume that they are colonized with MRSA and you should tailor abx appropriately*
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

The most common infectious cause of death in the US

A

CAP: defined as pneumonia occurring before hospitilization or within 48 hours of hospital admission

Strep pneumo is the most common cause

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Pneumonia vs bronchitis

A

Pneumonia = dyspnea, high fever, and an abnormal CXR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Organism-specific association of pneumonia on presentation:

  1. Hemoptysis, “currant jelly” sputum
  2. Foul-smelling sputum, “rotten eggs”
  3. Dry cough, rarely severe, bullous myringitis (inflammation of the tympanic membrane)
  4. GI symptoms or CNS symptoms
  5. AIDS with CD4 < 200
A
  1. Klebsiella
  2. Anaerobes
  3. Mycoplasma
  4. Legionella
  5. Pneumocystis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What does the term atypical pneumonia refer to?

A

An organism not visible on Gram stain and not culturable on standard blood agar

Mycoplasma, Chlamydophila, Legionella, Coxiella, and viruses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Outpatient treatment of pneumonia

A

If healthy and no abx in last 3 months = macrolide (azithro or clarithromycin) or doxycycline

Comorbidities or abx within the last 3 months = respiratory fluoroquinolone (levofloxacin or moxifloxacin)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Inpatient treatment of pneumonia

A

respiratory fluoroquinolone (levofloxacin or moxifloxacin)

or

ceftriaxone and azithromycin

34
Q

Reasons to hospitalize patients for pneumonia

A

Hypoxia and hypotension (<90) as single factors are a reason to hospitalize a patient

CURB-65

Confusion, Uremia, Respiratory distress, BP low, Age >65

0-1 point = go home

2 or more = admit

35
Q

Pt admitted for CAP with CXR showing a lobar infiltrate and a large effusion. Started on ceftriaxone and azithromycin. What is the next step?

A

Thoracentesis to determine if a chest tube is warranted

Pleural effusion with pH <7.2, LDH >60% serum, or protein >50% serum suggests an exudate (caused by infection or cancer)

Empyema reponds rapidly to drainage by chest tube or thoracostomy (acts like an abscess)

36
Q

Who should receive a pneumococcal vaccine?

A

Everyone above the age of 65 should receive the 13 polyvalent vaccine, followed in 6-12 months with the 23 polyvalent vaccine

Also recommended for those age <65 with very high risk comorbid conditions (CSF leaks, SCD, cochlear implants, congenital or aquired asplenia, immunocompromised).

For adults <65 with other chronic medical conditions that increase the risk of invasive pneumococcal disease (heart or lung disease, DM, smoking, chronic liver disease), PPSV23 alone is recommended, followed by sequential PCV13 and PPSV23 at age 66

37
Q

Define HAP

A

Pneumonia developing more than 48 hours after admission or after hospitalization in the last 90 days

Important to define because we worry about MRSA and pseudomonas in these patients: aka macrolides are not acceptable as empiric therapy

38
Q

Which drugs have activity against Pseudomonas?

A

Aminoglycosides (gentamicin, tobramycin, amikacin)

Ciprofloxacin (not as effective)

Pip/tazo (and other ureidopenicillins)

Ceftazidime, Cefepime (good for neutropenic fever)

Colistin

Carbapenems (except Ertapanem)

Aztreonam

KNOW THIS

39
Q

Treatment for VAP

A
  1. Antipseudomonal beta-lactam: cephalosporin or penicillin or carbapenem
  2. Second antipseudomonal: aminoglycoside or fluoroquinolone
  3. Methicillin-resistant antistaphylococcal agent: vanc or linezolid
40
Q

Patient is treated for VAP and subsequently develops seizures. What medication were they likely started on?

A

Imipenem

Risk of seizure increases with renal failure

41
Q

Can daptomycin be used for pulmonary infections?

A

No

Daptomycin is inactivated by surfactant

42
Q

Which abx are good for a lung abscess?

A

Clindamycin or penicillin

Sputum culture is always the wrong answer for diagnosing a lung abscess

43
Q

What is the best initial test for Pneumocystis Pneumonia

A

CXR showing bilateral interstitial infiltrates or an ABG showing hypoxia or an increased A-a gradient

The most accurate test is a bronchoalveolar lavage

44
Q

A normal LDH level means what about PCP

A

That it is NOT the diagnosis

In PCP LDH is ALWAYS elevated

45
Q

Treatment for PCP

A

TMP/SMX for therapy and for prophylaxis

Add steroids to decrease mortality if: pO2 < 70 or an A-a gradient >35

46
Q

Toxicity with TMP/SMX for PCP, what do you switch to?

A

Clindamycin and primaquine

OR

Pentamidine

Clindamycin with primaquine has more efficacy than pentamidine; however, it is contraindicated in G6PD deficiency (look for AA man with bite cells on smear) – in this case pentamidine would be the answer if they experienced side effects with TMP/SMX (i.e., neutropenia and a rash)

47
Q

How does treatment for PCP prophylaxis differ from treatment when a patient experiences adverse side effects with TMP/SMX

A

Treatment = clindamycin and primaquine* OR pentamidine

Prophylaxis = atovaquone OR dapsone*

*Both dapsone and primaquine are contraindicated in those with G6PD deficiency

48
Q

True/False

The use of prophylatic medication for HIV is based on CD4 count and the viral load

A

False

Prophylatic treatment is NOT based on the viral load

49
Q

Recent immigrants

Prisoners

HIV positive

Steroid use

Hematologic malignancy

Alcoholics

DM

A

Risk factors for TB

Also includes: healthcare workers and close contacts

50
Q

Best initial test for TB

A

CXR

Sputum stain and culture must be done 3 times to fully exclude TB

Pleural biopsy is the single most accurate diagnostic test

51
Q

True/False

PPD skin testing is never the best test for TB in a symptomatic patient

A

True

52
Q

Treatment for TB

A

RIPE

Rifampin, Isoniazid, Pyrazinamide, and Ethambutol

Use RIPE for the first 2 months, then stop ethambutol and pyrazinamide and continue rifampin and isoniazide for the next 4 months (standard of care is 6 months)

53
Q

When can you treat TB with just “RIP”

A

You do not need ethambutol if it is known at the beginning of therapy that the organism is sensitive to all TB medications

(RIPE is used as a 4-drug empiric therapy prior to knowing the sensitivity of the organism)

54
Q

In what cases should you consider extending TB treatment past 6 months?

A

For cases complicated by:

Osteomyelitis

Miliary TB

Meningitis

Pregnancy (or any other time pyrazinamide is not used)

55
Q

Adverse effects of RIPE

A

R = red color to body secretions

I = peripheral neuropathy (coadminister with pyridoxine/B6)

P = hyperuricemia (contraindicated in pregnancy)

E = optic neuritis/color vision (decrease dose in RF)

56
Q

When should steroids be added to TB treatment?

A

To decrease the risk of pericarditis

OR

To decrease neurologic complication in TB meningitis

57
Q

No risk factors, what constitutes a positive PPD

A

> 15 mm of induration (erythema is irrelevant)

58
Q

When should a patient have a second PPD within 1-2 weeks if there first PPD was negative?

A

When they have never had a PPD skin test before (the first test may be falsely negative)

59
Q

Everyone with a reactive PPD test should have a…

A

CXR to exclude active disease

9 months of isoniazid (decreases lifetime risk of developing TB from 10% to 1%) regardless of BCG vaccine status

The PPD test should not be repeated once it is positive (it will always be positive in the future)

60
Q

PET is most accurate with…

A

larger lesions (>1 cm)

This is a way of telling whether the content of a lesion is malignant without a biopsy. Malignancy has increased uptake of glucose (sensitivity is 85-95%)

61
Q

Drugs that cause pulmonary fibrosis

A

Bleomycin

Busulfan

Amiodarone

Methylsergide

Nitrofurantoin

Cyclophosphamide

62
Q

Dyspnea, worse on exertion

Fine rales or “crackles”

Loud P2 heart sound

Finger clubbing

A

Pulmonary fibrosis

63
Q

PFTs for pulmonary fibrosis

A

Decrease of everything proportionately (FEV1, FVC, TLC, and RV)

FEV1/FVC ratio will be normal

DLCO is decreased

64
Q

What type of pneumoconioses responds best to steroids?

A

Berylliosis (due to the presence of granulomas, which are a sign of inflammation)

Associated with electronic manufacturing

65
Q

Diagnostic test for sarcoidosis?

A

CXR is the best initial test: hilar adenopathy is present in more than 95% of patients

Lymph node biopsy is the most accurate: noncaseating granulomas

Elevated ACE, Hypercalciuria, Hypercalcemia, and restrictive PFTs

66
Q

Treatment for sarcoidosis

A

Prednisone

67
Q

Diagnostic test for PE

A

CXR, EKG, and ABG are the best initial tests

Angiography is the most accurate test, but can be fatal in 0.5% of cases

After doing an ABG, CXR, and EKG, the “best next step” is most often a CT angiogram

68
Q

What are the most common findings of PE on the best initial tests?

A

CXR: usually normal (may show atelectasis)

EKG: usually shows sinus tachycardia (nonspecific ST-T wave changes are the most common abnormality, NOT S1, Q3, T3)

ABG: hypoxia and respiratory alkalosis

69
Q

When is V/Q scan the answer (over Spiral CT)?

A

In pregnant patients with suspected PE

The CXR must be normal for the V/Q scan to have any degree of accuracy

70
Q

What is D-dimer good at?

A

A negative test excludes a clot, but a positive test doesn’t mean anything

(AKA very sensitive, but poor specificity)

D-dimer is the answer when the pretest probability of PE is low and you need a simple, noninvasive test to exclude thromboembolic disease

71
Q

True/False

You do not need a spiral CT or V/Q scan to confirm a PE if there is a clot in the legs

A

True

(therapy does not change)

LE Dopplers are a good test if the V/Q and spiral CT do not give a clear diagnosis

72
Q

Best initial therapy for PE

A

Heparin (Warfarin should be started at the same time in order to achieve a therapeutic INR of 2-3 x normal as quick as possible)

Fondaparinux is an alternative to heparin

73
Q

Rivaroxaban

Dabigatran

A

Oral agents that do not require INR monitoring and can be used for the treatment of pulmonary emboli (reach therapeutic effect in several hours, instead of several days like warfarin)

74
Q

When is IVC filter the right answer after a PE?

A
  1. Contraindication to anticoagulants (e.g., melena, CNS bleed)
  2. Recurrent emboli while on heparin or fully therapeutic warfarin (INR of 2-3)
  3. RV dysfunction with an enlarged RV on echo (filter is placed because the next embous could be fatal)
75
Q

When are thrombolytics the right answer after a PE?

A

Hemodynamically unstable patients (systolic BP < 90 and tachycardia)

Acute RV dysfunction

There is no specific time limit in which to use thombolytics as there is in stroke or MI

76
Q

Define pulmonary hypertension

A

systolic > 25 or diastolic > 8

Primary pulmonary hypertension is by definition idiopathic

77
Q

Diagnostic test for pulmonary hypertension

A

CXR and CT = best initial test (shows dilation of the proximal pulmonary arteries with narrowing of distal vessels)

Right heart or Swan-Ganz catheter = most accurate

EKG showing R axis deviation, RA an RV hypertrophy

78
Q

Treatment for pulmonary hypertension

A

Only lung transplantation is curative for idiopathic pulmonary hypertension

  • Prostacyclin analogues (PA vasodilators): epoprostenol, treprostinil, iloprost, beraprost
  • Endothelin antagonists: bosentan, ambrisentan
  • Phosphodiesterase inhibitors: sildenafil

These are all better than CCBs, hydralazine, and nitroglycerin

79
Q

What is the most accurate test for OSA

A

Polysomnography (sleep study) which shows multiple episodes of apnea

AHI = Apnea Hypopnea Index

  • None/Minimal: AHI < 5 per hour*
  • Mild: AHI ≥ 5, but < 15 per hour*
  • Moderate: AHI ≥ 15, but < 30 per hour*
  • Severe: AHI ≥ 30 per hour*
80
Q

Define ARDS

A

Defined as having a pO2/FiO2 ratio below 300

< 200 = moderately severe

< 100 = severe

Respiratory failure from overwhelming lung injury or systemic disease leading to severe hypoxia with a CXR suggestive of CHF but normal cardiac hemodynamic measurements (ARDS decreases surfactant and makes the lung cells “leaky” so that the aveoli fill up with fluid)

81
Q

Treatment for ARDS

A

LTVV (low tidal-volume mechanical ventilation)

Use 6 mL per kg of tidal volume

PEEP to decreases FIO2 requirement (levels of FIO2 above 50% are toxic to the lungs)

Maintain the plateau pressure of less than 30 cm of water

Step 2 CK (18 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions