Pulmonology Flashcards
Diagnose:
Restrictive Lung Disease PFT values
FEV1
FEV1/FVC
TLC
DLCO
FEV1: Decreased
FEV1/FVC: Normal
TLC: Decreased
DLCO: Decreased
Examples of Restrictive Lung Disease:
- Diffuse parenchymal lung disease
Diagnose:
Cough-variant asthma
Bronchial challenge test
Diagnosis:
PFTs show:
- TLC decreased
- RV increased
Respiratory muscle weakness
Diagnosis:
Chronic dyspnea in a patient with a history of recent multiple intubations
Tracheomalacia
What diagnostic test can be used to diagnose tracheomalacia in a patient with chronic dyspnea and a history of multiple intubations?
Flow volume pulmonary function testing
Expect a flattening of the curve on flow-volume measurements.
Diagnosis:
- Dyspnea
- Pedal edema
- Clear lung fields
- Jugular vein engorgement with inspiration (Kussmaul sign)
Constrictive pericarditis
Previous cardiac surgery is the second most common cause of constrictive pericarditis. The most common cause is idiopathic.
Management:
Pleural effusion
If < 1 cm Observation
If > 1 cm Thoracentesis
Diagnose:
Empyema
Use Light’s criteria
- Pleural fluid total protein-serum total protein ratio > 0.5
- Pleural fluid lactate dehydrogenase level-serum lactate dehydrogenase
ratio >0.6 - 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.
Transudative vs. Exudative:
Pleural fluid leukocyte count <1000
Transudative
Transudative vs. Exudative:
- HF
- Nephrotic syndrome
- Hepatic cirrhosis
Transudative
Transudative vs. Exudative:
- Malignancy
- Pneumonia
- Collagen vascular disease
- Tuberculosis
- Trauma
Exudative
- Malignancy –> lymphocytic predominance
- Pneumonia
- Collagen vascular disease
- Tuberculosis –>lymphocytic predominance
- Trauma
Transudative vs. Exudative:
Increased protein content
Exudative
Transudative vs. Exudative:
Decreased protein content
Transudative
Due to increased hydrostatic pressure or decreased oncotic pressure.
What is the most common cause of a transudative effusion?
Heart failure
Pleural fluid-serum protein ratio <0.5
Pleural fluid-serum LHD <0.6
Diagnosis:
- Dullness to percussion
- Absent or decreased tactile fremitus
- Absent or decreased breath sounds over the affected area
Pleural effusion (large)
Treatment:
Exercise-induced bronchospasm
Inhaled short-acting beta2 agonist 15-20 minutes before exercise
Treatment:
Moderate persistent asthma
- Long-acting beta2 agonist
- Medium-dose corticosteroids
- 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.
Classify the following patient’s asthma according to the National Asthma Education and Prevention Program.
- Daily asthma symptoms
- Nocturnal awakenings > 1x per week
Moderate Persistent
Treatment:
Mild Persistent asthma
- Low-dose inhaled glucocorticoid
2. Short acting beta2 agonist PRN
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
False.
LABA should only be added to the treatment of patients whose symptoms are not controlled with medium-dose inhaled glucocorticoid therapy.
How might scheduled doses of albuterol complicate the clinical presentation of worsening asthma?
Scheduled albuterol can mask ongoing airway inflammation and the need to provide anti-inflammatory therapy with inhaled glucocorticoids.
Diagnosis:
- Asthma symptoms (cough & wheezing)
- Normal spirometry findings
- Positive Methacholine challenge test
Cough-variant asthma
What does a positive methacholine test indicate?
airway hyperresponsiveness
Management:
Worsening asthma in pregnant patient previously controlled with medium-dose inhaled glucocorticoid and short-acting beta2 agonist PRN
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.
Can you perform a bronchial challenge with methacholine in a pregnant patient?
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.
Why are long acting beta2-agonists preferred over theophylline in the therapy of a pregnant patient with worsening asthma?
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.
Diagnosis:
40 yo M who does not smoke found to have:
- Predominantly basilar lung disease
- Concurrent liver disease
Alpha1-antitrpsin deficiency
Suspect in:
- Patients <45 yo
- Nonsmokers
- Predominantly basilar lung disease
- Concurrent liver disease
What intervention is most likely to prolong the survival of a patient with hypoxic respiratory failure?
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. *
What are the indications for continuous oxygen therapy?
Resting hypoxemia:
- arterial PO2 of 55mmHg or less
- OR- - arterial oxygen saturation of 88% or less
Diagnosis:
Prebronchodilator
- FEV1 78% of predicted
- FEV1/FVC ratio 63%
Postbronchodilator
- FEV1 83%
- FEV1/FVC ratio 63%
Chronic obstructive pulmonary disease
A postbronchodilator FEV1/FVC ratio of less than 70% confirms airflow limitation.
What is the gold standard for diagnosis COPD and monitoring its progress?
Spirometry
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?
FEV1/FVC < 70%
Characterize the different levels of COPD as established by the GOLD guidelines.
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%
When do you hospitalized a patient with acute exacerbation of COPD? (7)
Admit to hospital if:
- Severe COPD and advanced age
- Significant comorbidities
- Marked increase in the intensity of symptoms
- Newly occurring arrhythmias
- Insufficient home support
- Diagnostic uncertainty
- Onset of new physical signs
- Not responding to initial outpatient medical management
Which patients experiencing an exacerbation of COPD are good candidates for noninvasive positive pressure ventilation (NPPV)?
- Moderate to severe dyspnea
- Moderate to severe acidosis (pH <7.35)
- Hypercapnia
- Respiration rate > 25/min
What are the benefits of noninvasive positive pressure ventilation (NPPV) in COPD exacerbations?
- Reduces mortality rate
- Reduces length of hospital stay
- Reduces the need for intubation
- Improves respiratory acidosis
- Decreases the respiration rate
- Reduces the severity of breathlessness
What are the exclusion criteria for NPPV? (10)
- Respiratory arrest
- Cardiovascular instability (i.e. hypertension, arrhythmias and MI)
- Change in mental status
- Uncooperativeness
- High aspiration risk
- Viscous or copious secretions
- Recent facial or GI surgery
- Craniofacial trauma
- Fixed nasopharyngeal abnormalities
- Burns
- Extreme obesity
What are the indications for intubation over noninvasive positive pressure ventilation (NPPV)?
- Severe acidosis (pH<7.25)
- Respiration rate >35/min
Intubation is also indicated in patients who do not benefit from an initial trial of NPPV.
What is the most important risk factor for obesity?
Weight
Especially in patients with prominent distribution of adipose tissue in the trunk and neck.
Treatment:
Obstructive sleep apnea
- Weight loss
2. Continuous positive airway pressure
What are the risk factors for obstructive sleep apnea?
- Obesity; typically central obesity (most important)
- Nasal narrowing or congestion
- Large tongue
- Low-lying soft palate
- Enlarged tonsils and adenoids
- Abnormalities of the face and jaw
- Use of muscle relaxants
- Smoking and alcohol use
- Primary medical disorders (acromegaly, androgen therapy, neuromuscular disorders)
Less important: - Male sex
- Postmenopausal state
- FHx of OSA
- Race (which race?)
What is the diagnostic test or choice for confirming obstructive sleep apnea (OSA)?
Polysomnography
Apnea-hypopnea index (AHI) of 5-15 indicates mild OSA.
AHI of >30 indicates severe OSA.
Define apnea.
Cessation of airflow
Define hypopnea.
Reduction in airflow
Diagnosis:
- Erythema nodosum
- Fever
- Arthralgia
- Hilar lymphadenopathy
Lofgren syndrome
acute presentation of Sarcoidosis
Describe the two classical clinical presentations of sarcoidosis.
- Lofgren syndrome (erythema nodosum, fever, arthralgia, hilar lymphadenopathy)
- Heerfordt syndrome (uveitis, parotid gland enlargement and fever)
How do you diagnose sarcoidosis?
Sarcoidosis is a diagnosis of exclusion requiring:
- Multisystem involvment
- Histologic evidence of noncaseating granulomas
- 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.
Does sarcoidosis appear as a restrictive or obstructive lung disease on PFTs?
It can appear as both.
What two essential findings are diagnostic of asbestos?
- History of asbestos exposure with an appropriately long patent period (15-35 years).
- Definite evidence of interstitial fibrosis
When should you suspect cryptogenic organizing pneumonia?
When a patient has symptoms and findings of community-acquired pneumonia (dyspnea, cough), but symptoms and clinical findings persist despite treatment with antibiotics.
How are bronchiolitis obliterates organizing pneumonia (BOOP) and cryptogenic organizing pneumonia (COP) connected?
COP is the idiopathic form of BOOP.
Diagnosis:
CT scan showing:
- Basal and peripheral disease
- Honeycomb changes but no ground-glass opacities
Idiopathic pulmonary fibrosis
What diagnostic test is indicated in patients with a moderate to high pretest probability of pulmonary embolism?
Chest CT angiography
Which two clinical risk prediction scores can be used to generate a pretest probability for pulmonary embolism?
- Wells score
2. Geneva score
What study is most appropriate to evaluate suspected pulmonary embolism in a patient with a serum Cr of 2.1 mg/dL?
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.
How do you evaluate acute pulmonary embolism in a patient with kidney failure?
Ventilation-perfusion scanning INSTEAD of chest CT angiography.
Treatment:
Pulmonary embolism
Initial treatment is:
Unfractionated heparin -OR- LMWH -OR- Fondaparinux
What diagnostic test is essential to diagnose suspected pulmonary arterial hypertension?
Right heart catheterization
This allows you to directly measure the mean pulmonary artery pressure.
