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IM Essentials > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

Diagnose:

Restrictive Lung Disease PFT values

FEV1
FEV1/FVC
TLC
DLCO

A

FEV1: Decreased
FEV1/FVC: Normal
TLC: Decreased
DLCO: Decreased

Examples of Restrictive Lung Disease:

  1. Diffuse parenchymal lung disease
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2
Q

Diagnose:

Cough-variant asthma

A

Bronchial challenge test

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3
Q

Diagnosis:

PFTs show:

  1. TLC decreased
  2. RV increased
A

Respiratory muscle weakness

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4
Q

Diagnosis:

Chronic dyspnea in a patient with a history of recent multiple intubations

A

Tracheomalacia

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5
Q

What diagnostic test can be used to diagnose tracheomalacia in a patient with chronic dyspnea and a history of multiple intubations?

A

Flow volume pulmonary function testing

Expect a flattening of the curve on flow-volume measurements.

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6
Q

Diagnosis:

  1. Dyspnea
  2. Pedal edema
  3. Clear lung fields
  4. Jugular vein engorgement with inspiration (Kussmaul sign)
A

Constrictive pericarditis

Previous cardiac surgery is the second most common cause of constrictive pericarditis. The most common cause is idiopathic.

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7
Q

Management:

Pleural effusion

A

If < 1 cm Observation

If > 1 cm Thoracentesis

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8
Q

Diagnose:

Empyema

A

Use Light’s criteria

  1. Pleural fluid total protein-serum total protein ratio > 0.5
  2. Pleural fluid lactate dehydrogenase level-serum lactate dehydrogenase
    ratio >0.6
  3. Pleural fluid lactate dehydrogenase level > 2/3 x upper limit of normal
    * If neither criterion is met the fluid is almost always a transudate.*

Empyema is pus in the pleural space.

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9
Q

Transudative vs. Exudative:

Pleural fluid leukocyte count <1000

A

Transudative

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10
Q

Transudative vs. Exudative:

  1. HF
  2. Nephrotic syndrome
  3. Hepatic cirrhosis
A

Transudative

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11
Q

Transudative vs. Exudative:

  1. Malignancy
  2. Pneumonia
  3. Collagen vascular disease
  4. Tuberculosis
  5. Trauma
A

Exudative

  1. Malignancy –> lymphocytic predominance
  2. Pneumonia
  3. Collagen vascular disease
  4. Tuberculosis –>lymphocytic predominance
  5. Trauma
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12
Q

Transudative vs. Exudative:

Increased protein content

A

Exudative

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13
Q

Transudative vs. Exudative:

Decreased protein content

A

Transudative

Due to increased hydrostatic pressure or decreased oncotic pressure.

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14
Q

What is the most common cause of a transudative effusion?

A

Heart failure

Pleural fluid-serum protein ratio <0.5
Pleural fluid-serum LHD <0.6

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15
Q

Diagnosis:

  1. Dullness to percussion
  2. Absent or decreased tactile fremitus
  3. Absent or decreased breath sounds over the affected area
A

Pleural effusion (large)

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16
Q

Treatment:

Exercise-induced bronchospasm

A

Inhaled short-acting beta2 agonist 15-20 minutes before exercise

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17
Q

Treatment:

Moderate persistent asthma

A
  1. Long-acting beta2 agonist
  2. Medium-dose corticosteroids
  3. Short acting beta2 agonist PRN

Adding a long-acting beta2 agonist leads to greater improvement in asthma control compared to doubling the dose of inhaled corticosteroid.

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18
Q

Classify the following patient’s asthma according to the National Asthma Education and Prevention Program.

  1. Daily asthma symptoms
  2. Nocturnal awakenings > 1x per week
A

Moderate Persistent

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19
Q

Treatment:

Mild Persistent asthma

A
  1. Low-dose inhaled glucocorticoid

2. Short acting beta2 agonist PRN

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20
Q

True or False:

Long acting beta2 agonist can be added to the therapy for asthma in patients who are NOT receiving a inhaled glucocorticoid therapy

A

False.

LABA should only be added to the treatment of patients whose symptoms are not controlled with medium-dose inhaled glucocorticoid therapy.

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21
Q

How might scheduled doses of albuterol complicate the clinical presentation of worsening asthma?

A

Scheduled albuterol can mask ongoing airway inflammation and the need to provide anti-inflammatory therapy with inhaled glucocorticoids.

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22
Q

Diagnosis:

  1. Asthma symptoms (cough & wheezing)
  2. Normal spirometry findings
  3. Positive Methacholine challenge test
A

Cough-variant asthma

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23
Q

What does a positive methacholine test indicate?

A

airway hyperresponsiveness

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24
Q

Management:

Worsening asthma in pregnant patient previously controlled with medium-dose inhaled glucocorticoid and short-acting beta2 agonist PRN

A

add a long acting beta2-agonist

LABA’s are pregnancy category C drugs, but their benefit outweighs their risks in pregnant patients with uncontrolled asthma.

25
Q

Can you perform a bronchial challenge with methacholine in a pregnant patient?

A

NO!

Methacholine challenge is contraindicated during pregnancy.

*You may be able to conduct a bronchial challenge with mannitol. Mannitol is a pregnancy category C drug.

26
Q

Why are long acting beta2-agonists preferred over theophylline in the therapy of a pregnant patient with worsening asthma?

A

Theophylline metabolism is altered during pregnancy and requires more frequent monitoring of serum levels. Thus, LABA’s are preferred.

Both LABAs and Theophylline are pregnancy category C drugs.

27
Q

Diagnosis:

40 yo M who does not smoke found to have:

  1. Predominantly basilar lung disease
  2. Concurrent liver disease
A

Alpha1-antitrpsin deficiency

Suspect in:

  1. Patients <45 yo
  2. Nonsmokers
  3. Predominantly basilar lung disease
  4. Concurrent liver disease
28
Q

What intervention is most likely to prolong the survival of a patient with hypoxic respiratory failure?

A

Continuous oxygen therapy

  • Long-term oxygen therapy in patients with chronic respiratory failure improves: (1) survival (2) hemodynamics (3) hematologic characteristics (4) exercise capacity (5) mental status. *
29
Q

What are the indications for continuous oxygen therapy?

A

Resting hypoxemia:

  1. arterial PO2 of 55mmHg or less
    - OR-
  2. arterial oxygen saturation of 88% or less
30
Q

Diagnosis:

Prebronchodilator

  1. FEV1 78% of predicted
  2. FEV1/FVC ratio 63%

Postbronchodilator

  1. FEV1 83%
  2. FEV1/FVC ratio 63%
A

Chronic obstructive pulmonary disease

A postbronchodilator FEV1/FVC ratio of less than 70% confirms airflow limitation.

31
Q

What is the gold standard for diagnosis COPD and monitoring its progress?

A

Spirometry

32
Q

According to the American College of Physicians and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, what FEV1/FVC ratio establishes a diagnosis of COPD?

A

FEV1/FVC < 70%

33
Q

Characterize the different levels of COPD as established by the GOLD guidelines.

A

Level 1: Mild COPD; FEV1=80% or greater
Level 2: Moderate COPD; FEV1=50-79%
Level 3: Severe COPD; FEV1=30-49%
Level 4: Very Severe; FEV1=<30%

34
Q

When do you hospitalized a patient with acute exacerbation of COPD? (7)

A

Admit to hospital if:

  1. Severe COPD and advanced age
  2. Significant comorbidities
  3. Marked increase in the intensity of symptoms
  4. Newly occurring arrhythmias
  5. Insufficient home support
  6. Diagnostic uncertainty
  7. Onset of new physical signs
  8. Not responding to initial outpatient medical management
35
Q

Which patients experiencing an exacerbation of COPD are good candidates for noninvasive positive pressure ventilation (NPPV)?

A
  1. Moderate to severe dyspnea
  2. Moderate to severe acidosis (pH <7.35)
  3. Hypercapnia
  4. Respiration rate > 25/min
36
Q

What are the benefits of noninvasive positive pressure ventilation (NPPV) in COPD exacerbations?

A
  1. Reduces mortality rate
  2. Reduces length of hospital stay
  3. Reduces the need for intubation
  4. Improves respiratory acidosis
  5. Decreases the respiration rate
  6. Reduces the severity of breathlessness
37
Q

What are the exclusion criteria for NPPV? (10)

A
  1. Respiratory arrest
  2. Cardiovascular instability (i.e. hypertension, arrhythmias and MI)
  3. Change in mental status
  4. Uncooperativeness
  5. High aspiration risk
  6. Viscous or copious secretions
  7. Recent facial or GI surgery
  8. Craniofacial trauma
  9. Fixed nasopharyngeal abnormalities
  10. Burns
  11. Extreme obesity
38
Q

What are the indications for intubation over noninvasive positive pressure ventilation (NPPV)?

A
  1. Severe acidosis (pH<7.25)
  2. Respiration rate >35/min

Intubation is also indicated in patients who do not benefit from an initial trial of NPPV.

39
Q

What is the most important risk factor for obesity?

A

Weight

Especially in patients with prominent distribution of adipose tissue in the trunk and neck.

40
Q

Treatment:

Obstructive sleep apnea

A
  1. Weight loss

2. Continuous positive airway pressure

41
Q

What are the risk factors for obstructive sleep apnea?

A
  1. Obesity; typically central obesity (most important)
  2. Nasal narrowing or congestion
  3. Large tongue
  4. Low-lying soft palate
  5. Enlarged tonsils and adenoids
  6. Abnormalities of the face and jaw
  7. Use of muscle relaxants
  8. Smoking and alcohol use
  9. Primary medical disorders (acromegaly, androgen therapy, neuromuscular disorders)
    Less important:
  10. Male sex
  11. Postmenopausal state
  12. FHx of OSA
  13. Race (which race?)
42
Q

What is the diagnostic test or choice for confirming obstructive sleep apnea (OSA)?

A

Polysomnography

Apnea-hypopnea index (AHI) of 5-15 indicates mild OSA.

AHI of >30 indicates severe OSA.

43
Q

Define apnea.

A

Cessation of airflow

44
Q

Define hypopnea.

A

Reduction in airflow

45
Q

Diagnosis:

  1. Erythema nodosum
  2. Fever
  3. Arthralgia
  4. Hilar lymphadenopathy
A

Lofgren syndrome

acute presentation of Sarcoidosis

46
Q

Describe the two classical clinical presentations of sarcoidosis.

A
  1. Lofgren syndrome (erythema nodosum, fever, arthralgia, hilar lymphadenopathy)
  2. Heerfordt syndrome (uveitis, parotid gland enlargement and fever)
47
Q

How do you diagnose sarcoidosis?

A

Sarcoidosis is a diagnosis of exclusion requiring:

  1. Multisystem involvment
  2. Histologic evidence of noncaseating granulomas
  3. Clinical presentations of known sarcoid syndromes (e.g. Lofgren and Heerfordt)

If the patient has one of the known clinical presentations, histologic confirmation of noncaseating granulomas is not necessary.

48
Q

Does sarcoidosis appear as a restrictive or obstructive lung disease on PFTs?

A

It can appear as both.

49
Q

What two essential findings are diagnostic of asbestos?

A
  1. History of asbestos exposure with an appropriately long patent period (15-35 years).
  2. Definite evidence of interstitial fibrosis
50
Q

When should you suspect cryptogenic organizing pneumonia?

A

When a patient has symptoms and findings of community-acquired pneumonia (dyspnea, cough), but symptoms and clinical findings persist despite treatment with antibiotics.

51
Q

How are bronchiolitis obliterates organizing pneumonia (BOOP) and cryptogenic organizing pneumonia (COP) connected?

A

COP is the idiopathic form of BOOP.

52
Q

Diagnosis:

CT scan showing:

  1. Basal and peripheral disease
  2. Honeycomb changes but no ground-glass opacities
A

Idiopathic pulmonary fibrosis

53
Q

What diagnostic test is indicated in patients with a moderate to high pretest probability of pulmonary embolism?

A

Chest CT angiography

54
Q

Which two clinical risk prediction scores can be used to generate a pretest probability for pulmonary embolism?

A
  1. Wells score

2. Geneva score

55
Q

What study is most appropriate to evaluate suspected pulmonary embolism in a patient with a serum Cr of 2.1 mg/dL?

A

Ventilation-perfusion scanning

This is the indicated study in patients with kidney failure and a contraindication to contrast enhanced chest CT angiography.

Normal serum Cr=0.7-1.3 mg/dL.

56
Q

How do you evaluate acute pulmonary embolism in a patient with kidney failure?

A

Ventilation-perfusion scanning INSTEAD of chest CT angiography.

57
Q

Treatment:

Pulmonary embolism

A

Initial treatment is:

Unfractionated heparin 
-OR-
LMWH
-OR-
Fondaparinux
58
Q

What diagnostic test is essential to diagnose suspected pulmonary arterial hypertension?

A

Right heart catheterization

This allows you to directly measure the mean pulmonary artery pressure.

IM Essentials (4 decks)

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