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1 USMLE Step 3 Main one > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q
  • SOB - expiratory wheezing
A

asthma

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2
Q
  • hyperventilation/increased RR - decrease in peak flow - hypoxia - respiratory acidosis - possible absence of wheezing
A

SEVERE asthma exacerbation

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3
Q

if asthma diagnosis is unclear

A

PFT before and after inhaled bronchodilators

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4
Q

asthma and reactive airway disease are CONFIRMED with what finding on PFT?

A

INCREASE in FEV1 of greater than 12%

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5
Q

ALL patients with SOB should receive the following

A
  • oxygen - continuous oximeter - CXR - ABG
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6
Q

best INITIAL treatment for asthma exacerbation

A
  • inhaled bronchodilator (albuterol); no maximum dose - steroid bolus (methylprednisolone) - inhaled ipratropium (ACh receptor antagonist) - oxygen - magnesium
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7
Q

when should an asthma patient be placed in the ICU?

A

respiratory acidosis with CO2 retention

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8
Q

what is the indication for intubation and mechanical ventilation in asthma?

A

PERSISTENT respiratory acidosis

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9
Q

best INITIAL treatment for nonacute asthma

A

inhaled bronchodilator (albuterol)

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10
Q

if asthma patient is not controlled on inhaled bronchodilator (albuterol)

A

inhaled steroid

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11
Q

if patient is STILL not controlled on inhaled bronchodilator (albuterol), and inhaled steroids

A

inhaled long-acting beta agonist (LABA) (salmeterol, or formoterol)

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12
Q

alternate long-term controller medications besides inhaled steroids: extrinsic allergies, such as hay fever

A

cromolyn

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13
Q

alternate long-term controller medications besides inhaled steroids: atopic disease

A

montelukast

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14
Q

alternate long-term controller medications besides inhaled steroids: COPD

A
  • tiotropium - ipratropium
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15
Q

alternate long-term controller medications besides inhaled steroids: high IgE levels, no control with cromolyn

A

omalizumab (anti-IgE Ab)

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16
Q

last resort for uncontrolled nonacute asthma (if still not controlled on SABA, inhaled steroids, and LABA)

A

PO steroids (many adverse effects)

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17
Q

treatment for exercise-induced asthma

A

inhaled bronchodilator BEFORE exercise

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18
Q
  • long-term smoker - increasing SOB - decreasing exercise tolerance
A

COPD

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19
Q

treatment for acute exacerbation of COPD

A
  • oxygen (NOT TOO MUCH) - ABG - CXR - inhaled albuterol - inhaled ipratropium - steroid bolus (methylprednisolone)
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20
Q

what should be added in treatment for acute exacerbation of COPD, if fever, sputum, and/or new infiltrate is present on CXR?

A

ceftriaxone and azithromycin for CAP

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21
Q

management of COPD with mild respiratory acidosis

A

BiPAP or CPAP

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22
Q

COPD physical examination findings

A
  • barrel-shaped chest - clubbing of fingers - increased AP diameter mf chest - loud P2 heart sound (pulmonary HTN) - edema (blood backing up d/t pulmonary HTN)
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23
Q

EKG findings in COPD

A
  • right axis deviation (RAD) - right ventricular hypertrophy (RVH) - right atrial hypertrophy (RAH)
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24
Q

CXR findings in COPD

A
  • flattening of diaphragm - elongated heart - substernal air trapping
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25
Q

CBC findings in COPD

A
  • increased hematocrit (sign of chronic hypoxia) - microcytic
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26
Q

chemistry finding in COPD

A

increased serum bicarbonate

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27
Q

mechanism of right heart enlargement in COPD

A

hypoxia = capillary constriction in lungs = diffuse vasoconstriction = increased pressure in RV and RA

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28
Q

expected PFT results in COPD

A
  • decreased FEV1 - decreased FVC (loss of elastic recoil of lung) - decreased FEV1/FVC ratio - increased TLC (d/t air trapping) - increased residual volume (RV) - decreased diffusion capacity lung carbon monoxide (DLCO) (destruction of lung interstitium
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29
Q

chronic treatment for COPD

A
  • tiotropium/ipratropium - albuterol - pneumococcal vaccine - influenza vaccine - smoking cessation - long-term home O2
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30
Q

when is home oxygen indicated in COPD?

A
  • pO2 less than 55 - oxygen saturation less than 88%
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31
Q

what lowers mortality in COPD?

A
  • smoking cessation - home oxygen
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32
Q
  • cirrhosis and COPD - EARLY AGE (
A

a-1 antitrypsin deficiency

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33
Q

CXR findings in a-1 antitrypsin deficiency

A
  • bullae - barrel chest - flat diaphragm
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34
Q

blood test findings in a-1 antitrypsin deficiency

A
  • low albumin - elevated PT (caused by cirrhosis) - LOW a-1 antitrypsin level
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35
Q

treatment for a-1 antitrypsin deficiency

A

a-1 antitrypsin infusion

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36
Q
  • anatomic defect of lungs (from infection in childhood) - profound dilation of bronchi - chronic resolving and recurring episodes of lung infection - VERY HIGH volume of sputum - hemoptysis - fever
A

bronchiectasis

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37
Q

CXR finding in bronchiectasis

A
  • dilated bronchi with “tram tracking”
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38
Q

MOST ACCURATE test for bronchiectasis

A

HRCT (high-resolution CT of chest)

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39
Q

treatment for bronchiectasis

A
  • NO curative treatment - chest PT - rotating antibiotics
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40
Q

causes of interstitial lung disease (ILD)

A
  • idiopathic - occupational exposure - environmental exposure - medication
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41
Q

medications that can cause ILD

A
  • trimethoprim/sulfamethoxazole - nitrofurantoin
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42
Q

ILD cause = what disease? asbestos

A

asbestosis

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43
Q

ILD cause = what disease? glass workers, mining, sandblasting, brickyards

A

silicosis

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44
Q

ILD cause = what disease? coal worker

A

coal worker’s pneumoconiosis

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45
Q

ILD cause = what disease? cotton

A

byssinosis

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46
Q

ILD cause = what disease? electronics, ceramics, fluorescent light bulbs

A

berylliosis

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47
Q

ILD cause = what disease? mercury

A

pulmonary fibrosis

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48
Q
  • SOB with dry, nonproductive cough - chronic hypoxia - 6 months or more of symptoms
A

ILD

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49
Q

PE findings in ILD

A
  • dry rales - loud P2 heart sound (sign of pulmonary HTN) - clubbing
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50
Q

CXR finding in ILD

A

interstitial fibrosis

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51
Q

diagnostic tests for ILD

A
  • CXR - HRCT - lung biopsy - PFT
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52
Q

PFT findings in ILD

A
  • decreased FEV1 - decreased FVC - NORMAL FEV1/FVC ratio (equally decreased) - decreased TLC - decreased DLCO
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53
Q

treatment for ILD

A
  • no specific treatment
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54
Q

if biopsy show inflammatory infiltrate in ILD, what is the treatment?

A

steroid trial

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55
Q

ONLY form of ILD that DEFINITELY responds to steroids

A

berylliosis

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56
Q
  • bronchiolitis and alveolitis - more acute than ILD, presents in days to weeks - cough, rales, and SOB - fever, malaise, and myalgias (ABSENT in ILD)
A

bronchiolitis obliterans organizing pneumonia (BOOP) (aka, cryptogenic organizing pneumonia (COP))

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57
Q

CXR finding in BOOP

A

B/L patchy infiltrates

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58
Q

chest CT findings in BOOP

A

interstitial disease and alveolitis

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59
Q

MOST ACCURATE test for BOOP

A

open lung biopsy

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60
Q

treatment for BOOP

A

steroids (no response to antibiotics)

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61
Q
  • black, female, less than 40 yoa - cough, SOB, and fatigue over a few weeks to months - rales
A

sarcoidosis

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62
Q

best INITIAL test for sarcoidosis

A

CXR (enlarged lymph nodes, and maybe ILD)

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63
Q

MOST ACCURATE test for sarcoidosis

A

lung or LN biopsy (NONcaseating granulomas)

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64
Q

what will BAL show in sarcoidosis?

A

increased # of helper cells

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65
Q

best treatment for sarcoidosis

A

steroids

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66
Q
  • SOB, more often in young women
A

pulmonary hypertension

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67
Q

pulmonary HTN can occur 2/2?

A
  • MS - COPD - PV - chronic PE - ILD
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68
Q

PE findings in pulmonary hypertension

A
  • loud P2 - TR - right ventricular heave - Raynaud’s phenomenon
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69
Q

TTE findings in pulmonary hypertension

A
  • RVH - enlarged RA
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70
Q

EKG finding in pulmonary hypertension

A

RAD

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71
Q

MOST ACCURATE test for pulmonary hypertension

A

right heart catheterization (Swan-Ganz catheterization) (increased pulmonary artery pressure)

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72
Q

treatment for pulmonary hypertension

A
  • bosentan (endothelin inhibitor) - epoprostenol/treprostinil (prostacyclin analogs = pulmonary vasodilators) - CCB - sildenafil
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73
Q
  • SUDDEN SOB - CLEAR lungs - patient with risk factors for DVT: immobility, malignancy, trauma, surgery, hematological abnormalities
A

pulmonary embolism

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74
Q

CXR findings in PE

A
  • MC result is NORMAL - MC ABNORMALITY is atelectasis
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75
Q

EKG findings in PE

A
  • SINUS TACHYCARDIA - MC abnormality is nonspecific ST-T wave changes - RAD/RBBB (uncommon)
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76
Q

ABG findings in PE

A
  • hypoxia - increased A-a gradient - mild respiratory alkalosis (2/2 hyperventilation)
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77
Q

mechanism of right heart strain in PE

A

severe pressure increase in PA and RV d/t clot

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78
Q

standard test to confirm PE

A

CTA

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79
Q

for a V/Q scan to be accurate, the CXR MUST be

A

NORMAL (the less normal the CXR, the LESS accurate the V/Q scan)

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80
Q

if V/Q scan is low-probability, does it exclude PE

A

NO, 15% still have a PE

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81
Q

if V/Q scan is high-probability, does it definitely include PE

A

NO, 15% don’t have a PE

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82
Q

sensitivity of LE doppler

A

70%

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83
Q

if D-dimer is negative

A

PE extremely unlikely

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84
Q

MOST ACCURATE test for PE

A

angiography

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85
Q

patient with PE and CONTRAINDICATION to AC, next step in management

A

IVC filter

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86
Q

treatment for PE

A
  • heparin and O2 - warfarin for AT LEAST 6 MONTHS
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87
Q

treatment for PE in HEMODYNAMICALLY UNSTABLE patient (hypotension)

A

thrombolytics

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88
Q

thrombolytics MOA

A

activate plasminogen to plasmin

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89
Q

best INITIAL test for pleural effusion

A

CXR

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90
Q

next step after CXR for pleural effusion

A

decubitus films with pt lying down

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91
Q

MOST ACCURATE test for pleural effusion

A

thoracentesis

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92
Q

pleural effusion: exudate causes and lab findings

A
  • cancer - infection - HIGH protein (> 50% of serum level) - HIGH LDH (> 60% of serum level)
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93
Q

pleural effusion: transudate causes and lab findings

A
  • CHF - LOW protein (
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94
Q

treatment for SMALL pleural effusion

A
  • NO treatment needed - diuretics can be used, especially for CHF
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95
Q

treatment for LARGER pleural effusion, especially from infection (empyema)

A

chest tube

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96
Q

treatment for LARGE, and RECURRENT pleural effusions

A

pleurodesis

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97
Q

treatment if pleurodesis FAILS

A

decortication (stripping of pleura from lung)

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98
Q
  • obese patient - daytime somnolence - severe snoring - HTN, HA, ED, fat neck
A

sleep apnea

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99
Q

MCC of sleep apnea (95% of cases)

A

fatty tissue of neck blocking breathing

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100
Q

cause of small % of patients with sleep apnea

A

central sleep apnea (decreased respiratory drive from CNS)

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101
Q

how is sleep apnea diagnosed?

A

sleep study (polysomnography)

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102
Q

definition of MILD sleep apnea

A

5-20 apneic episodes/hour

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103
Q

definition of SEVERE sleep apnea

A

more than 30 apneic episodes/hour

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104
Q

treatment for sleep apnea: OBSTRUCTIVE DISEASE

A
  • weight loss - CPAP (continuous positive airway pressure, or BiPAP
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105
Q

if initial treatment for sleep apnea: OBSTRUCTIVE DISEASE is not effective

A
  • surgical resection of uvula, palate, and pharynx
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106
Q

treatment for sleep apnea: CENTRAL SLEEP APNEA

A
  • avoid alcohol and sedative - acetazolamide (causes metabolic acidosis = helps drive respiration) - medroxyprogesterone (central respiratory stimulant)
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107
Q

mechanism of acetazolamide

A

carbonic anhydrase inhibitor

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108
Q
  • asthmatic patient with WORSENING asthma symptoms - brown mucous plug production - recurrent infiltrates - peripheral eosinophilia - elevated serum IgE - central bronchiectasis
A

allergic bronchopulmonary aspergillosis (ABPA)

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109
Q

diagnostic tests for allergic bronchopulmonary aspergillosis (ABPA)

A
  • Aspergillus skin testing - IgE - precipitins - A. fumigatus-specific Ab
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110
Q

treatment for allergic bronchopulmonary aspergillosis (ABPA)

A

ORAL corticosteroids

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111
Q

allergic bronchopulmonary aspergillosis (ABPA) treatment in refractory disease if steroids don’t work

A

itraconazole

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112
Q
  • sudden, SEVERE respiratory failure syndrome - diffuse lung injury 2/2 OVERWHELMING systemic injuries
A

acute respiratory distress syndrome (ARDS)

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113
Q

possible ARDS causes

A
  • sepsis - aspiration of gastric contents - shock - infection: pulmonary or systemic - lung contusion - trauma - toxic inhalation - near drowning - pancreatitis - burns
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114
Q

CXR finding in ARDS

A

diffuse patchy infiltrates that become confluent

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115
Q

wedge pressure in ARDS

A

NORMAL

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116
Q

pO2/FIO2 ratio in MILD ARDS

A

201-300

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117
Q

pO2/FIO2 ratio in MODERATE ARDS

A

101-200

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118
Q

pO2/FIO2 ratio in SEVERE ARDS

A

100 OR LESS

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119
Q

treatment for ARDS

A
  • ventilator - positive end expiratory pressure (PEEP) (keep alveoli open) - prone positioning - diuretics - positive inotropes (dobutamine) - ICU
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120
Q

Swan-Ganz (pulmonary artery) catheterization: HYPOVOLEMIA - cardiac output - wedge pressure - systemic vascular resistance (SVR)

A
  • LOW - LOW - HIGH
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121
Q

Swan-Ganz (pulmonary artery) catheterization: CARDIOGENIC SHOCK - cardiac output - wedge pressure - systemic vascular resistance (SVR)

A
  • LOW - HIGH - HIGH
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122
Q

Swan-Ganz (pulmonary artery) catheterization: SEPTIC SHOCK - cardiac output - wedge pressure - systemic vascular resistance (SVR)

A
  • HIGH - LOW - LOW
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123
Q
  • fever - cough - +/- sputum - SOB
A

pneumonia

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124
Q

CAP organism

A

pneumococcus

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125
Q

HAP organism

A

gram-negative bacilli

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126
Q

CURB 65

A
  • confusion - BUN greater than 19 - RR greater than 30 - BP less than 90/60 - age greater than 65
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127
Q

best INITIAL diagnostic test for pneumonia

A

CXR

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128
Q

MOST ACCURATE test for pneumonia

A

sputum gram stain and culture

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129
Q

pneumonia with SOB, order

A

oxygen

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130
Q

pneumonia with SOB and/or hypoxia, order

A

ABG

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131
Q

OUTPATIENT treatment for pneumonia

A

macrolide OR respiratory fluoroquinolone macrolide = azithromycin/clarithromycin fluoroquinolone = levofloxacin/moxifloxacin

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132
Q

INPATIENT treatment for pneumonia

A
  • ceftriaxone, AND azithromycin OR - fluoroquinolone ONLY
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133
Q

treatment for ventilator-associated pneumonia (VAP)

A
  • imipenem/meropenem, piperacillin/tazobactam, or cefepime AND - gentamicin AND - vancomycin/linezolid
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134
Q

does a positive sputum culture mean pneumonia?

A

NO

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135
Q

specific associations for pneumonia: recent viral syndrome

A

Staphylococcus

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136
Q

specific associations for pneumonia: alcoholic

A

Klebsiella

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137
Q

specific associations for pneumonia: GI symptoms, confusion

A

Legionella

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138
Q

specific associations for pneumonia: young, healthy patient

A

Mycoplasma

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139
Q

specific associations for pneumonia: birth of animal (placenta)

A

Coxiella burnetii

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140
Q

specific associations for pneumonia: Arizona construction worker

A

Coccidioidomycosis

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141
Q

specific associations for pneumonia: HIV with CD4 count less than 200

A

Pneumocystis jirovecii (PCP)

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142
Q

ventilator-associated pneumonia

A
  • fever - hypoxia - new infiltrate - increasing secretions
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143
Q

when should steroids be given in PCP pneumonia?

A
  • pO2 less than 70 - A-a gradient more than 35
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144
Q
  • risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics) - fever, cough, sputum, weight loss, night sweats
A

tuberculosis (TB)

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145
Q

best INITIAL test for tuberculosis (TB)

A

CXR

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146
Q

test to confirm TB

A

sputum acid-fast stain and culture

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147
Q

treatment for TB

A
  1. isoniazid (INH) x 6 mos 2. rifampin x 6 mos 3. pyrazinamide x 2 mos 4. ethambutol x 2 mos
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148
Q

ALL the antituberculosis medications can cause?

A

hepatotoxicity

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149
Q

when should antituberculosis medications be stopped if transaminases become elevated?

A

reach 5x upper limit of normal

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150
Q

adverse effect of isoniazid

A

peripheral neuropathy

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151
Q

adverse effect of rifampin

A

red/orange-colored bodily secretions

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152
Q

adverse effect of pyrazinamide

A

hyperuricemia

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153
Q

adverse effect of ethambutol

A

optic neuritis

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154
Q

which conditions require TB treatment for MORE THAN 6 months

A
  • osteomyelitis - meningitis - miliary TB - cavitary TB - pregnancy
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155
Q

what is a POSITIVE PPD test?

A

5mm: close contacts, pts on steroids, HIV-positive 10mm: risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics, healthcare workers) 15mm: those without increased risk

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156
Q

if a patient has NEVER been tested for TB, how should the patient be tested?

A

2-stage testing (if FIRST test is NEGATIVE, repeat test in 1-2 WEEKS to confirm)

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157
Q

what is the indication for IGRA (interferon gamma release assay) (Quantiferon)?

A

same as PPD

158
Q

what is the lifetime risk for HIV-UNinfected individuals with latent TB infection developing active TB d/t reactivation?

159
Q

what is the lifetime risk for HIV-INFECTED individuals with latent TB infection developing active TB d/t reactivation?

160
Q

if PPD is POSITIVE, next step?

161
Q

if PPD is positive, and CXR is ABNORMAL, next step?

A

sputum staining for TB

162
Q

if sputum staining for TB is POSITIVE, next step?

A

treat with full-dose, 4-drug therapy

163
Q

if PPD is POSITIVE, but CXR is NEGATIVE

A

isoniazid ALONE for 9 MONTHS

164
Q

once a PPD is POSITIVE, should you repeat it?

165
Q

What is stop bang?

A

Method to clinically diagnose sleep apnea

STOPBANG (Snorlax is Tired Ofchoking/gasp in highaltitudeswithighbloodPressure, becauseofhis BMI oldAge Necksize and maleGender) *old

S Snoring, Texecive daytime tiredness, O observed apneas or choking/gasps, P High BP

B BMI>35, A50, N Neck size 30> 17, G male gender

>5% high risk

>3-4 intermediate

>0-2 low

166
Q

What is GOLD criteria in COPD?

A

pulmonary function testing, a postbronchodilator FEV1/FVC ratio of <0.70 is commonly considered diagnostic for COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizes airflow limitation into stages. In patients with FEV1/FVC <0.70:

GOLD 1 - mild: FEV1≥ 80% predicted
GOLD 2 - moderate: 50% ≤FEV1 <80% predicted
GOLD 3 - severe: 30% ≤FEV1 <50% predicted

GOLD 4 - very severe: FEV1 <30% predicted.

167
Q

What is cough variant asthma?

A

Cough variant asthma is a chronic non productive cough which is worse at night and triggered by exercise, allergen expoure, forced expiration. Lack classic symptoms like wheezing, sob. and unremarkable phx exam findings are common. Even in periods of active persistent symptoms.

*Clue* at the case where the patient is normal and cough only exhibited when patient is asked to do a forced expiration.

168
Q

What are the two most common causes of cough?

A

GERD is associated heartburn following meals

Upper airway cough syndrome UACS (post nasal drip) which is accompanied by rhinorrhea

169
Q

What acute asthma exacerbation?

A

Oxygen, Duonebs, IV methylprednisolone, steroid taper,…additional therapy racemic epinephrine, magnessium,

If patient stops wheezing or CO2 begins to rise then intubate

170
Q

What is different in pregnant women during asthma exacerbation?

A

Dont give epinepherine

171
Q

Name short acting beta agonist

A

Fenoterol

Levalbuterol

Albuterol

Terbutaline

172
Q

Long acting beta agonist?

A

Formoterol

Arfomoterol

Indacaterol

Salmeterol

Tulobuterol

Olodaterol

173
Q

Short acting antimuscarinic

A

Ipatropium bromide, Oxitropium bromide

174
Q

Long acting antimuscarinic?

A

Acildinium bromide

Glycopyrronium bromide

Tiotropium

Umeclidinium

175
Q

What are Inhaled corticosteroids?

A

Beclomethasone, Budenoside, Fluticasone

176
Q

Systemic Corticosteroids?

A

Prednisone, Methylprednisolone

177
Q

Phosphodiesterase -4 inhibitors?

A

Roflumilast

178
Q

Methylxanthines?

A

Aminophylline

Theophylline

179
Q

Allergic bronchopulmonary aspregilliosis is seen in what history?

A

Asthma and cystic fibrosis

180
Q

What do you see in on CXR in ABPA?

A

Xray you may see fleeting inflitrates
CT you may see bronchiectais

181
Q

What is diagnostic ABPA?

A

Skin test positive aspergillius fumigatus, esosinophillia >500/uL, IgE > 417 IU/ml, specific IgG and IgE A. fumigatus

182
Q

What factors decrease risk for solitary pulmonary nodules?

A

Remember S3AC

If less than 0.8cm, smooth,non smoking, less than 45, non calcified then the person has a low probability for cancer add male to the mix

183
Q

ABPA is treated?

A

Systemic glucocorticoids and antifungal either itraconazole or voriconazole

184
Q

What is the use of End tidal CO2

A

Use of end tidal co2 to determine whether or not intubation is successful… during CP you want end tidal co2 to be above 10 and End tidal 35-45.

185
Q

Why end tidal?

A

CPR quality assessment

ROSC assessment

ET Tube placement

186
Q

What is another term End Tidal CO2?

A

Persistent capnographic waveform with ventilation.

187
Q

What are the charecteristics of adenocarcinoma?

A

MCC of cancer in females, associated with hypertrophic osteoarthopathy “clubbing”. Bronchioloalveolar subtype: shows hazy inflitrate on CXR and has excellent prognosis.

188
Q

What is Squamous cell carcinoma?

A

Hilar mass arising from bronchus

Cavitation, Cigarette smoking, and hypercalcemia (PTHrp). If inoperable then treated with chemotherapy. Also remember keratin pearls and intercelluar bridges.

189
Q

What is the characteristics small cell (oat cell) carcinoma?

A

May produce ACTH, ADH, or Antibiotics against presynaptic calcium Lambert-eaton syndrome, amplification of myc oncogenes.; Neoplasm of neuroendocrine kulchitisky cells which are dark blue cells.

190
Q

What Brochial carcinoid tumor?

A

Excellent prognosis, metastasis rare. … symptoms usually due to mass…occasionally carcinoid syndrome…serotonin secretion.

191
Q

Recurrent pneumonia in elderly smoker is the first manifestation of??

A

Manifestation of bronchogenic carcinoma: Recurrent pneumonia in elderly smoker is the first manifestation of bronchogenic carcinoma and the best test for obstructive cancer in the lung is flexs bronchoscopy

192
Q

Who should get Low dose CHEST CT scan?

A

Yearly Low Dose CT scan should be provided for patients who are 55-80yrs,

who has had >30 pack year smoking history,

is a current smoker

smoking within the last 15 years.

END study at age 80, quit smoking more than 15 years ago, or unwilling to do surgery

193
Q

If Vq scan shows low probability does that mean PE is ruled out?

A

No PE is excluded but not ruled out unless v/q scan is negatve

194
Q

Patient with OHS has an increased of what during procedure so you have to be very careful

A

OHS is at increased risk for perioperative hypercapnic/hypoxic respiratory failure especially when anesthesia will

195
Q

What do you do in case of pneumothorax?

A

Needle decompression may be done. But the pneumothorax is ultimately treated with chest thorax

196
Q

What is TRALI?

A

Tranfusion related acute lung injury.

After transfusion cytokines are released and cause increased endothial permeability which alveolar capilar pulmonary damage which can ARDS

Clinical features are similar to ARDS like are like inflitraion on cxr, hypoxia, white or pink tracheal aspiration following tracheal intubation.

Mortality : 41-67% + TRALI/ARDS

197
Q

What is TACO?

A

TACO - Tranfusion associated circulatory overload when too much blood is transfused too quickly

198
Q

What is differency between TACO and TRALI clinically?

A

TACO EF <40, TRALI EF >50, TACO PCWP >18, TRALI PWCP <18, FLUID BALANCE in TACO is elevated, Fluid balance in TRALI is neutral. TACO has elevated BNP>1200, TRALI <250 decreased BNP. Temp in taco is unchaged, Temp in trali is febrile. WBC in Trali is decreased but unchanged in Taco.

199
Q

When should you be concern with Chronic cough in children?

A

Chronic cough in children greater than 4 weeks warrants spiromerty so look for duration

200
Q

How do you treat mild croup?

A

Humidified air with or without corticosteroids

201
Q

How to treat moderate to severe croup with involves stridor at rest?

A

Corticosteroids + nebulized epinepherine

203
Q

What is the preventative treatment of bronchiolitis?

A

Give Palivizumab to children <29 weeks gestation, Chronic lung disease of prematurity, hemodynamically significant congenital lung disease

204
Q

A child less than 2 years of age presents with nasal congestion, wheezing/crackles,& respiratory distress(tachypnea, retracitions, nasal flaring)

A

Bronchiolitis

205
Q

How do you treat Bronchiolitis?

A

Supportive care

206
Q

What asthma symptoms seen in intermittent severity?

A

when the patient has symptoms and saba use less than 2 days a week and less than 2 times of nighttime awakenings at night

207
Q

What type of symptoms seen in mild persistent asthma?

A

symptoms and saba use More than 2 times a week but not daily. Nighttime awakenings that are 3-4 times a month. step 2

208
Q

What type of symptoms seen in moderate persistent asthma?

A

Daily symptoms and saba use. Nightime awakening is More than 1 times per week but not nightly

209
Q

What type of symptoms seen in severe persistent asthma?

A

Symptoms and saba use all throughout the day and nighttime awakening 4-7 times a week.

210
Q

Lung cancer screening is associated with what RRR in mortality risk and False positive rate?

A

RRR 20% and False Positive 96%

211
Q

Recurrent Pneumonia in the elderly smoker?

A

What is bronchogenic carcinoma and its first manifistation

212
Q

Signs of TB pleural effusion

A

lymphocyte predominance with exudative effusion with elevated adenosine deaminase and pleural biopsy is required for diagnosis

213
Q

Which Lung nodules are least suspicios for cancer?

A

S3AC, Size,smooth, smoking, age, calification

Size <8mm, smooth, nonsmoking less that forty, popcorn calcification, concentric calcification, or diffuse homogenous calcifications

214
Q

Which Lung nodules are most suspicios for cancer?

A

S3AC, Size,smooth, smoking, age, calification

Size >20mm, spiculed, smoking, age greater 70, no calcification or eccentric calcification.

Hard nodules

215
Q

Common causes of post operative hypoxemia:

Airway obstruction/edema

A

Stridor immediately after surgery, often due to endotrachial or pharyngeal muscle laxity

216
Q

Common causes of post operative hypoxemia:

Residual anestetic effect

A

Diminshed residual effect which occurs immediately after. Associated with anesthetic agens, benzodiazepines, opiates.

217
Q

Common causes of post operative hypoxemia:

Bronchospasm

A

Wheezing which typically occur early within a few hours.

218
Q

Common causes of post operative hypoxemia:

Pneumonia

A

Fever elevated WBC, Purulent secretions, and inflitrate on Xray 1-5 days after operation

219
Q

Common causes of post operative hypoxemia:

Atelectasis

A

Splinting and reduced cough, retain secretions, after thoraabdominal surgeries 2-5 days after.

220
Q

Common causes of post operative hypoxemia:

Pulmonary Embolism

A

Uncommon before 3 days. Chest pain, tachycardia with hypoxia which shows little improvement on supplemental oxygen.

221
Q

Post hypercapnic respiratory failure due anestethesia effect has the following characteristics?

A

Seen often in patients with OSA, notable decreased respiratory drive, depressed stated of arousal, notable decreased respiratory rate, tidal volume, respiratory acidosis, and normal A-a gradient.

222
Q

What us stridor?

A

high-pitched, wheezing sound caused by disrupted airflow. Stridor may also be called musical breathing or extrathoracic airway obstruction. Airflow is usually disrupted by a blockage in the larynx (voice box) or trachea (windpipe).

223
Q

What is respiratory splinting?

A

is when we immobilize something to prevent pain or damage.Respiratory splinting, if performed improperly, can prevent this process and do more harm than good.

224
Q

How do 2,3-BPG levels change in resposne to high altitude?

225
Q

What does a V/Q ratio close to zero indicate?

A

Airway obstruction

226
Q

Which way does CO2 shift the oxygen-hemoglobin dissociation curve?

227
Q

What is the equation for the collapsing pressure of an alveolus?

A

Collapsing Pressure = P = [2(surface tension)]/radius}

228
Q

During which week of gestation are mature levels of surfactant achieves?

A

{{c1::Week 35}}

229
Q

During which week of gestation does lung surfactant production begin?

230
Q

At which vertebral level does the IVC perforate the diaphragm?

A

{{c1::T8}}

231
Q

At which vertebral level does the Vagus Nerve (CN X) perforate the diaphragm?

A

{{c1::T10 (both trunks)}}

232
Q

At which vertebral level does the aorta perforate the diaphragm?

A

{{c1::T12}}

233
Q

What is the mmemonic for diaphram perforation?

A

I 8 10 eggs at 12

IVC 8
Esophagus 10

Aorta 12

234
Q

What is the typical lung Tidal Volume (TV)?

A

{{c1::500 mL}}

235
Q

Which lung volume equates to the volume of air that can still be breathed out after normal expiration?

A

{{c1::Expiratory Reserve Volume (ERV)}}

236
Q

Which lung volume equates to the volume of air that remains in the lung after a maximal expiration?

A

{{c1::Residual Volume (RV)}}

237
Q

Which lung volumes make up lung Inspiratory Capacity (IC)?

A

{{c1::IRV + TV}}

238
Q

Which lung voume cannot be measured on spirometry?

A

{{c1::Residual Volume (RV)}}

239
Q

Which lung volumes make up lung Functional Residual Capacity (FRC)?

A

{{c1::RV + ERV}}

240
Q

Functional) Vital Capacity (VC)?

A

is a lung capacity that equates to the maximum volume of air that can be expired after a maximal inspiration.

241
Q

Which lung volumes make up Total Lung Capacity (TLC)?

A

LITER

{{c1::IRV + TV + ERV + RV}}

242
Q

What is the equation for Minute Ventilation (VE)?

A

VE = VT * RR

243
Q

Which modified form of hemoglobin is used to treat cyanide poisoning?

A

Methemoglobin

We use nitrates to oxidize hemoglobin into methemoglobin which then binds to cyanide. Thiosulfate is then used to bind this cyanide, forming thiocyanate which is renally excreted.

244
Q

What type of drugs do we use to oxidize Hemoglobin into Methemoglobin such that we can treat cyanide poisoning?

A

{{c1::Nitrates}}

We use nitrates to oxidize hemoglobin into methemoglobin which then binds to cyanide. Thiosulfate is then used to bind this cyanide, forming thiocyanate which is renally excreted.

245
Q

What is the treatment for Methemoglobinemia?

A

{{c1::Methylene Blue}}

246
Q

Carboxyhemoglobin??

A

{{c1::Carboxyhemoglobin}} is a modified form of hemoglobin that is bound to CO in place of O2.

247
Q

Which lung volumes make up lung (Functional) Vital Capacity (VC)?

A

{{c1::FRC: TV + IRV + ERV}}

248
Q

Which morphological form of Hemoglobin has lower O2 affinity?

A

Taut (T) form

249
Q

How does Hemoglobin’s affinity for O2 change following an increase in CO2?

A

Decreased affinity; taut form is favoured; dissociation curve shifts to the right; O2 unloading is favoured}

250
Q

Which morphological form of Hemoglobin has high O2 affinity?

A

Relaxed (R) form; 300x more affinity than the taut form

251
Q

Why does fetal hemoglobin (HbF) have a higher affinity for O2?

A

c1::It has lower affinity for 2,3-BPG, which decreases O2 affinity

252
Q

Methemoglobin??

A

is a modified form of Hemoglobin that is oxidized and thereby has a ferric (Fe3+) atom in its heme group.

253
Q

How does the O2-hemoglobin dissociated curve shift in Carboxyhemoglobinemia?

A

{{c1: :Left shift; there is decreased O2 binding capacity and decreased O2 unloading at tissue}}

254
Q

How does Hemoglobin’s affinity for O2 change if there is a right-shift in the Hb saturation curve?

A

Blood easily leaves tissue

255
Q

How does peak expiratory flow (PEF) change in Asthma (Reactive Airway Disease)?

A

{{c1::Decrease}}

256
Q

How does FEV1 change in Asthma (Reactive Airway Disease)?

A

{{c1::Decrease}}

257
Q

How does residual volume change in Asthma (Reactive Airway Disease)?

A

{{c1::Increase}}

258
Q

?????? is a monoclonal antibody that can be used as prophylaxis against RSV in high-risk infants < 2 years of age.

A

{{c1::Pavilizumab}} is a monoclonal antibody that can be used as prophylaxis against RSV in high-risk infants < 2 years of age.

259
Q

{{??}} and {???}} are 2 respiratory infections that do not respond to aerosolized racemic epinephrine.

A

{{c1::Epiglottitis}} and {{c2::Tracheitis}} are 2 respiratory infections that do not respond to aerosolized racemic epinephrine.

260
Q

{{????} is a respiratory disorder that presents with hoarse voice, inspiratory stridor and a characteristic seal-like, barking cough.

A

{{c1::Croup (Laryngotracheobronchitis)}} is a respiratory disorder that presents with hoarse voice, inspiratory stridor and a characteristic seal-like, barking cough.

261
Q

???} is a respiratory disorder described as acute inflammatory illness of the small airways.

A

{{c1::Bronchiolitis}} is a respiratory disorder described as acute inflammatory illness of the small airways.Commonly occurs in children < 3 years of age.

262
Q

What is the onset of Croup?

A

What is the onset of Croup?

{{c1::2-3 days}}

263
Q

What is the most important test to do acutely in patients with pulmonary edema?

A

What is the most important test to do acutely in patients with pulmonary edema?

{{c1::EKG}}

If arrythmia is causing the pulmonary edema, the fastest way to fix is with cardioversion.

264
Q

{?????}} is an acute inflammatory disorder of the upper respiratory ract that especially affects the subglottic space.

A

{{c1::Croup (Laryngotracheobronchitis)}} is an acute inflammatory disorder of the upper respiratory ract that especially affects the subglottic space.

265
Q

What normal lab value essentially rules out Pneumocystis Pneumonia as the most likely diagnosis?

A

What normal lab value essentially rules out Pneumocystis Pneumonia as the most likely diagnosis?

{{c1::A normal LDH}}

It is always elevated

266
Q

Which arrhythmias are seen in COPD patients?

A

Which arrhythmias are seen in COPD patients?

{{c1::A-fib or multifocal atrial tachycardia}}

267
Q

What PEF/FEV1 ratio is seen in mild intermittent asthma?

A

What PEF/FEV1 ratio is seen in mild intermittent asthma?

{{c1::> 80%}}

268
Q

What PEF/FEV1 ratio is seen in mild persistent asthma?

A

What PEF/FEV1 ratio is seen in mild persistent asthma?

{{c1::> 80%}}

269
Q

What is Laryngotracheobronchitis?

A

What is Laryngotracheobronchitis?

{{c1::Viral croup}}

270
Q

What is the most common primary agent causing Bronchiolitis?

A

What is the most common primary agent causing Bronchiolitis?

{{c1::RSV}}

271
Q

What is seen on CXR in Asthma (Reactive Airway Disease)?

A

What is seen on CXR in Asthma (Reactive Airway Disease)?

{{c1::Non specific findings (hyperinflation, depressed diaphragm, peribronchial thickening, atelectasis)}}

272
Q

What are the 5 causes of hypoxemia?

}}

A

What are the 5 causes of hypoxemia?

{{c1::

  1. Hypoventilation:
    - CNS depression, obesity hypoventilation syndrome, muscle weakness, ALS, flail chest normal AA gradient
  2. V/Q mismatch:
    - Hypoxemia due to V/Q mismatch can be corrected with low to moderate flow supplemental oxygen and is characterized by an increased A-a gradient.
    - Common causes include obstructive lung diseases, pulmonary vascular disease (pulmonary embolus), and interstitial diseases.
  3. Right-to-left shunt:
    - Occurs when blood passes from the right to left side of the heart without being oxygenated causing extreme V/Q mismatch (0) and is hard to overcome with supplemental oxygen.
    - Anatomic shunts exist when alveoli are bypassed and include intracardiac shunts (cyanotic CHD), pulmonary arteriovenous malformations, and hepatopulmonary syndrome.
    - Physiologic shunts exist when non-ventilated alveoli are perfused and include atelectasis, pneumonia, ARDS
  4. Diffusion limitation:
    Movement of oxygen from alveolus to capillary is impaired.
    -Interstitial lung disease, emphysema
  5. Reduced inspired oxygen tension:
    -High altitude normal AA gradient
    }}
273
Q

What is seen on PA X-ray of the neck in Croup (Laryngotracheobronchitis)?

A

What is seen on PA X-ray of the neck in Croup (Laryngotracheobronchitis)?

{{c1::Subglottic narrowing (“Steeple” sign)}}

274
Q

What amount of creatinine clearance is an indication for reducing the dose of varenicline (Chantix) in someone trying to quit smoking?

A

What amount of creatinine clearance is an indication for reducing the dose of varenicline (Chantix) in someone trying to quit smoking?

{{c1::< 30 mL/min}}

276
Q

What are the common side effects of varenicline (Chantix)?

A

What are the common side effects of varenicline (Chantix)?

{{c1::Nausea; Trouble sleeping; Abnormal, vivid, strange dreams}}

277
Q

What are the “Five A’s” in discussing tobacco use and cessation?

A

What are the “Five A’s” in discussing tobacco use and cessation?

{{c1::Ask, Advise, Assess, Assist, Arrange}}

278
Q

Ventilator associated pneumonia is treated with which therapy?

A

Ventilator associated pneumonia is treated with which therapy?

{{c1::
-Antipseudomonal beta-lactam (e.g., cephalosporin, piperacillin/tazobacam, or carbapenem)
-Second antipseudomonal agent (e.g., aminoglycoside or fluoroquinolone)
-MRSA agent (e.g., Vancomycin or linezolid)
}}

279
Q

This finding of {???)} is virtually pathognomonic for {??)

A

This finding of {{c1::pleural plaques}} is virtually pathognomonic for {{c1::asbestosis}}.

280
Q

What is the alveolar air pressure at FRC (Functional Residual Capacity)?

A

What is the alveolar air pressure at FRC (Functional Residual Capacity)?

{{c1::0}}

281
Q

The two indications for chest tube placement in parapneumonic effusions are a {??} and {??.

A

The two indications for chest tube placement in parapneumonic effusions are a {{c1::pleural fluid ph <7.2}} and {{c1::glucose of <60}}.

282
Q

How do know check for intubation in the R main stem bronchus?

A

Make sure there is bilateral breath sounds and check cxray

283
Q

Croup is treated by

A

Mild supportive

Severe cortico steriods

284
Q

Pulmonic causes of hemoptysis

Cardiac causes of hemoptysis

Vascular causes of hemoptysis

A

Pulmonic causes of hemoptysis

Bronchitis, lung cancer, bronchectatis

Cardiac causes of hemoptysis

Mitral stenosis, acut pulmonary edema

Vascular causes of hemoptysis

Pulmonary Embolism, AV malformation

285
Q

Infectious causes of hemoptysis

Hematologic causes of hemoptysis

systemic causes of hemoptysis

Other causes of hemoptysis

A

Infectious causes of hemoptysis: TB, Lung abscess,pnuemonia, aspergillosis hy

Hematologic causes of hemoptysis: cougulopathy

systemic causes of hemoptysis: good pastures disease

Other causes of hemoptysis: trauma and cocaine use

286
Q

????? is a respiratory physiological parameter defined as the volume of gas per unit time that reaches the alveoli.

A

{{c1::Alveolar Ventilation (VA)}} is a respiratory physiological parameter defined as the volume of gas per unit time that reaches the alveoli.

VA = (VT - VD) x RR

287
Q

?? is a respiratory physiological parameter that is defined as the total volume of gas entering the lungs per minute.

A

{{c1::Minute ventilation (VE)}} is a respiratory physiological parameter that is defined as the total volume of gas entering the lungs per minute.

VE = VT * RR

288
Q

How do you treat sepsis?

A

Fluids and early antibiotic therapy

289
Q

??????is required if a patient doesn’t respond to fluid resuscitation

A

Vasopressor is required if a patient doesn’t respond to fluid resuscitation

290
Q

qSOFA score?

A

Altered Mental Status

RR >22/min

Systolic Blood Pressure <100

confusion and hypotension, Tychipnea

qSOFA >2

291
Q

How to diagnoses Allergic Bronchopulmonary aspergilliosis?

A

Eosinphilla, Positive skin test aspergillus, postive aspergillus specific IgG, Elevated Aspergillus specific

292
Q

Treatment Allergic bronchopulmonary aspergillios

A

Systemic gluccocortiods, voriconazole, Itraconazole

293
Q

Acute pulmonary embolism has fever should I order ABx?

A

NO, 15% cases have fever so there is no need for antibotics

294
Q

Massive PE can cause the following

A

Massive PE can cause the following

RV dysfunction, decreased RV contractily, Pulmunary hypertension which leads to increased pressure, increased dilatons tricuspid valve annulus and functional tricusspid vavle regurgitation all of which could see on echo.

ECG: RBB, or S1Q3T3

S wave in lead I and Q wave and inverted T wave in lead III

or T-wave inversions in V1-V4

295
Q

What is S1Q3T3?

A

S wave in lead I and Q wave and inverted T wave in lead III

Notably S wave is deeply indented

296
Q

What is the difference in characteristics between massive PE and submassive PE?

A

Massive: TPA and unfractionated heparin

SBP <90, iontropic support needed, pulsesness, and persistent brady

Submassive: LMWH hemodynamic montioring +/- TPA

SBP>90, RV dysfunction, RV dilation on echo ro CT, elevatied BNP greater than 90, likely to see ekg changes, and elevated troponins.

Nonmassive tx with LMWH no thrombolysis

without symptoms of either.

297
Q

Hampton hump

Westermark sign (avascularity distal to the PE)

A

Hampton hump(wedged-shaped infarct)

Westermark sign (avascularity distal to the PE)

Both are signs of PE

298
Q

D-dimer has a ????? sensitivity but poor specificity for PE and a high?????

used to rule-out PE if there is a low ????

A

D-dimer has a high sensitivity but poor specificity for PE and a high negative predictive value

used to rule-out PE if there is a low pre-test probability

299
Q

Treatment of PE includes

A

Medical Non-vitamin K anticoagulation…;ike heparin…. indication: initial therapy in patients with PE in order to prevent further clot formation treatment should not be delayed medication options include low-molecular weight heparin(do not give in renal failure_

unfractionated heparin: which includes dose by monitoring aPTT(preferred in kidney injury/failure)

warfarin indication: typically given around the same time as a non-vitamin K anticoagulant is given dose based on INR (goal is 2-3)

thrombolytic therapy indication: performed in patients with PE who are hemodynamically unstable

Operative embolectomy indication: performed in patients with PE who are hemodynamically unstable and thrombolytic therapy is contraindicated or who fail thrombolysis

IVC filter indication: performed in patients with PE who have a contraindication or failure of anticoagulation

300
Q

In asthma when a child is sleepy and becoming less responsive it means you should be?

A

Be fearful of a child who is sleepy and becoming less responsive because they are likely tiring and retaining CO2

301
Q

What is the constelation of Aspirin-exacerbated respiratory disease (AERD)

A

Can be a constellation known as aspirin exacerbated respiratory disease (AERD)

asthma

chonic rhinositis

nasal polyps

aspirin- or NSAID-induced bronchospasm

caused by shift of arachidonic acid to produce leukotrienes instead of prostaglandins

302
Q

In Asthma normalizing PCO2 means??

A

normalizing PCO2

in acute exacerbation may indicate fatigue and impending respiratory failure, hence clinical picture is important

303
Q

What do you see on PFTs in Asthma?

A

acutely diminished peak expiratory flow rate (PEFR) PEFR < 40% of personal best or < 200 L/min indicates severe obstruction

decreased FEV1 / FVC ratio

increased residual volume and TLC

normal DLCO

304
Q

What test will you use for definitve diagnosis of asthma in a well patient?

A

Methacholine challenge

used for definitive diagnosis or tests for bronchial hyperactivity in a well patient

305
Q

What is the treatment or asthma?

A

Treatment of Acute Exacerbations : Duonebs, methylprednisone, intubation is CO2 normalize

306
Q

In cystic fibrosis

??? is more common in pediatric patients (treat with ???)

?????. are more common in adults (treat with ??????

A

S. aureus is more common in pediatric patients (treat with vancomycin)

Pseudomonal spp. are more common in adults (treat with amikacin, ceftazidime, and ciprofloxacin)

chronic sinusitis

307
Q

What vaccinations should those with cystic fibrosis get?

A

pneumococcal and influenza

308
Q

What endocrine problems does cystic fibrosis cause?

A

diabetes

infertility due to congenital absence of the vas deferens

decreased fertility in females

309
Q

What physical exam findings will u see in emphysema?

A

Physical exam

late hypercarbia/hypoxia

barrel chest (increased AP chest diameter)*

thin, wasted appearance

*pursed-lip breathing*

decreased heart and breath sounds

prolonged expiratory phase

end-expiratory wheezing

scattered rhonchi

*digital clubbing (only in the presence of other comorbidities such as lung cancer, interstitial lung disease, or bronchiectasis)

310
Q

What PFT finding do you see in emphysema??

A

PFTs

decreased FEV1 / FVC

normal or decreased FVC

normal or increased TLC (in emphysema and asthma, specifically)

*decreased DLCO (in emphysema, specifically)*

311
Q

What is COPD defined as?

A

Defined by productive cough for >3 months per year for two consecutive years

312
Q

Treatment of emphysema

A

O2, beta-agonists, anticholingerics, IV steroids, antibiotics

CPAP or BiPAP if the patient’s mental status is intact

313
Q

Lights cretia

A

Light criteria criteria used to differentiate transudative and exudative effusions

protein (pleural)/protein (serum) > 0.5

LDH (pleura)/LDH (serum) > 0.6

LDH > 2/3rds the upper limit of normal serum LDH

based on the Light criteria, a pleural effusion is said to be exudative if any one of the above is met

314
Q

Treatment of Pleural effusion

A

Depends on the underlying cause

e.g., if there is an exudative effusion secondary to a bacterial pneumonia, treat with antibiotics

Procedural

therapeutic thoracentesis indicationi n cases where the pleural effusion is massive and its affecting the patient’s breathing

tube thoracostomy indication in complicated parapneumonic effusions or empyema

315
Q

In CO poisining

Oxygen saturation usually ??????though actualy O2 content is????

this is because pulse oximeter reads ?????

A

Oxygen saturation usually NORMAL though actualy O2 content is LOW

this is because pulse oximeter reads carboxyhemoglobin as normally saturated hemoglobin

316
Q

In CO poising

ABG and serum carboxyhemoglobin level

normal carboxyhemoglobin level is ??? in nonsmokers and ???? in smokers

anion-gap?????due to the build-up of ????

A

ABG and serum carboxyhemoglobin level

normal carboxyhemoglobin level is <5% in nonsmokers and <10% in smokers

anion-gap metabolic acidosis due to the build-up of lactic acid

317
Q

IN CO poising check ECG in elderly because?

A

ECG

check in elderly and those with history of cardiac disease due to increased risk for ischemia

318
Q

Treatment of CO poisining

  1. ????????

must displace carbon monoxide from hemoglobin

>>>>>>

  1. >???????

in patients who are ???????

A

Treatment of CO poisining

  1. 100% oxygen

must displace carbon monoxide from hemoglobin

note: when a patient has smoke inhalational injuries, carbon monoxide and cyanide poisoning should be empirically treated with 100% oxygen and hydroxycobalamin plus sodium thiosulfate, respectively
2. hyperbaric oxygen

in patients who are pregnant, nonresponsive, or experiencing signs of CNS or cardiac ischemia

320
Q

Whare some of the signs of bronchitis?

A

Symptoms

minimal and non-specific until advanced disease

productive cough

cyanosis*

mild dyspnea

hyperventilation

swollen feet/ankles*

hemoptysis

321
Q

What are some physical exam findings of bronchitis?

A

Physical exam

hypercarbia/hypoxia

decreased breath sounds

ronchi

end-expiratory wheezing

barrel-chested

pursed-lip breathing

signs of pulmonary hypertension

RVH

JVD

hepatomegaly

peripheral edema

322
Q

What do you find in PFT of bronchitis?

A

PFTs

decreased FEV1 / FVC

normal or decreased FVC

normal or increased TLC (in emphysema and asthma, specifically)

roughly normal DLCO as opposed to decreased DLCO in emphysema

323
Q

What is the gold standard for diagnosing bronchitis?

A

Lung biopsy

diagnostic gold standard

increased Reid index ( gland layer > 50% of total bronchial wall)

324
Q

Treatment of Bronchitis?

A

O2, beta-agonists, anticholingerics, inhaled/IV steroids, antibiotics

325
Q

What is the best intervention for mortality in bronchitis

A

smoking cessation

best intervention for lowering mortality

326
Q

Berlin Definition of ARDS????

A

Berlin Definition of ARDS

acute onset (within 1 week of clinical insult or worsening respiratory status)

bilateral infiltrates (without an alternative explanation)

respiratory failure not caused by cardiac causes or volume overload

hypoxemia

327
Q

ARDS severit y??

A

ARDS severity

mild

PaO2/FiO2 is 200-300

moderate

PaO2/FiO2 is 100-200

severe

PaO2/FiO2 is < 100

Etiology

328
Q

What is the prognosis of ARDS?

A

Prognosis

severe ARDS has the worst mortality (45%) compared to mild and moderate

329
Q

What is the goal of mechanical ventilation in ARDS?

A

mechanical ventilation indication

to maintain adequate gas exchange while minimizing lung injury

low tidal volume, low plateau pressures, and titrating up positive end-expiratory pressure (PEEP)

330
Q

What setting do you use in ARDS?

A

settings

initial tidal volume to 8 mL/kg (in 70kg 560) and reduce gradually to 6 mL/kg (in 70 kg 420) (low tidal volumes) . you want to achieve an inspiratory plateau airway pressure ≤ 30 cm H2O

titrate PEEP to prevent tidal alveolar collapse

initial respiratory rate to approximate baseline minute ventilation (≤ 35/min)

oxygenation goal is a PaO2 of 55-80 mmHg

pH goal is 7.30-7.45

331
Q

What is are stages of sarcoidosis?

A

Sarcoidosis staging

stage 1

bilateral hilar adenopathy

stage 2

bilateral hilar adenopathy with parenchymal infiltrates

stage 3

diffuse parenchymal infiltrates in the absence of hilar adenopathy

stage 4p

ulmonary fibrosis: demonstrating honeycombing

332
Q

What is the pathogenesis of sarcoidosis?

A

macrophages present antigens to T-cellsTh1 cells are recruited and produce IFN-y, TNF, and IL-2

results in granulation formation

334
Q

How do you treat sarcodosis?

335
Q

Studies confirming Sarcodosis?

A

laboratory abnormalities

hypercalcemia and hypercalciuria

elevated angiotensin-converting enzyme (ACE) levels (~60% of cases)

Biopsy of the affected organ

non-caseating granuloma

336
Q

Notable ROS and Physical exam finding in sarcoidosis?

A

Symptoms

  1. constitutional symptoms (e.g., fever, malaise, and anorexia)
  2. dyspnea
  3. arthralgias

Physical exam

  1. erythema nodosum
  2. anterior uveitis
  3. cranial nerve VII involvement (worrisome for neurosarcoidosis)
337
Q

What is the notable associated sx of sarcodosis?

A

neurosarcoidosis

dilated and restrictive/infiltrative cardiomyopathy

myocarditis

hypercalcemia

erythema nodosum

uveitis

acute interstitial nephritis

lupus pernio

restrictive lung disease

rheumatoid-lie arthropathy

338
Q

Triad of kartenger syndrome?

A

characterized by patients having the triad

situs inversus

chronic sinusitis

bronchiectasis

339
Q

Symptoms of Priminary Cillary dyskinesia?

A

respiratory

  • newborns may present with mild respiratory distress
  • recurrent upper and lower respiratory infections

rhinosinusitis (a cardinal feature)

  • patients may have headache

chronic secretory otitis media

  • accompanied by recurrent acute otitis media
  • can result in a conductive hearing loss

impaired or decreased fertility

ectopic pregnancy

340
Q

Massive Hemothorax Treatment?

A

Non-operative

  • aggressive fluid resuscitation with large-bore IV access before placing chest tube
  • supplemental oxygen

Operative

  • chest tube placement to decompress chest cavity following fluid resuscitation
    • inserted at level of nipple and anterior to midaxillary line
  • CXR or CT scan post-chest tube placement to assess for remaining blood/pathology

emergent thoracotomy

  • if >1500ml removed from chest tube
  • or if bleeding does not stop
341
Q

What is the management of hemoptysis?

A

Conservative

  • patient positioning
    • in cases of severe hemoptysis
    • position patient on the side of the involved lung and intubate the normal lung if necessary
      • e.g., if the source of the bleed is from the right lung, position the patient on the right side

Procedural

  • therapeutic bronchoscopy
    • indication recommended in life-threatening cases
  • bronchovascular artery embolization
    • indication first-line for massive, recurrent, or malignant hemoptysis
  • emergency thoracotomy
    • indicated for massive hemoptysis that does not respond to initial measures (such as bronchoscopy)
342
Q

What is the treatment of pneumothorax?

A

Treatment

  • Non-operative
    • small pneumothoraces may reabsorb spontaneously
  • Operative
    • large and/or tension pneumothoraces may require
      • immediate needle decompression
      • chest tube placement
        • following decompression
          • recurrent pneumothoraces with subcutaneous emphysema should prompt workup for tracheobronchial rupture
      • pleurodesis
        • injection of irritant into pleural space
        • helps scar the two pleural layers together
        • preventing recurrence and pleural effusion
343
Q

What is flail chest?

A

Occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage

3 or more adjacent ribs are fractured in 2 or more places

344
Q

What drugs can cause pulmonary fibrosis?

A

drugs

amiodarone

bleomycin

phenytoin

345
Q

Treatment of Pulmonary fibrosis?

A

Of note, treatment is dependent upon the underlying cause

  • Conservative
    • smoking cessation and influenza and pneumococcal vaccinesindication should be given to all patients with interstitial lung disease, unless contraindicated
  • Medical
    • intravenous corticosteroids
      • first-line therapy for patients for acute respiratory therapy
    • intravenous cyclophosphamide
      • second-line therapy for patients for acute respiratory therapy
346
Q

What is the prognois is open pnuemothorax?

A

Prognosis

not as immediately critical as tension pneumothorax

347
Q

What is flail chest?

A

Physical exam

  • abnormal chest wall movement
    • may not be appreciated if the patient is splinting with pain
  • crepitus over the defect
348
Q

What is the prognosis Flail Chest?

A

Prognosis

good to excellent depending on severity of defect

349
Q

What is the treatment of Tension Pneumothorax?

A

Non-operative

  • do not resolve spontaneously
    • unlike small, simple pneumothoraces
  • supplemental O2 therapy
    • following operative intervention may be required

Operative

  • immediate needle decompression
    • second intercostal space at the midclavicular line with 14 or 16-gauge needle
  • followed by chest tube placement
350
Q

What is the definition of Pulmonary Hypertension?

A

a state of increased mean pulmonary arterial pressure ≥ 25 mmHg (at rest) in the absence of lung or left-sided heart disease

351
Q

What are the physical exam findings of Pulmonary hypertension?

A

Physical examination

  • loud P2 on auscultation
  • right ventricular heave
  • right-sided 4th heart sound
  • murmurs
    • holosystolic murmur of tricuspid regurgitation
    • systolic ejection murmur
    • diastolic pulmonic regurgitation (in severe cases)
352
Q

How to diagnose pulmonary stenosis?

A
  • ECG
    • can demonstrate right ventricular hypertrophy (e.g., right axis deviation)
  • Right heart catheterization confirms the diagnosis of pulmonary hypertension
    • mean pulmonary artery pressure is ≥ 25 mmHg at rest (8-20 mmHg at rest is considered normal)
  • vasoreactivity testing can be performedthis involves administering a short-acting vasodilator followed by measuring the hemodynamics of the pulmonary artery
    • agents that are used include
      • nitric oxide
      • epoprostenol
      • adenosine
      • diltiazem (in patients with positive vasoreactivity testing

Imaging

Echocardiogram

  • estimates pulmonary artery systolic pressure
  • evaluates the right ventricle size, thickness, and function
  • also evaluates the left ventricular function and valvular function

Radiography of the chest

may demonstrate

  • central pulmonary arterial dilatation
  • loss of peripheral blood vessels
  • may find right atrial and ventricular enlargement (suggestive of advanced disease)
353
Q

What granulomatus disease can causes Pulmonary fibrosis?

A

sarcoidosis

granulomatosis with polyangiitis

eosinophillic granulomatosis with polyangiitis

histiocytosis x

354
Q

What alveolar filling disease cause pulmonary fibrosis?

A

alveolar filling disease

Goodpasture syndrome

alveolar proteinosis

pulmonary hemosiderosis

355
Q

COPD is at increase risk for what bacteria so what abx do you want to give?

A

antibioticshigh P. aeruginosa risk

  • levofloxacin
  • piperacillin-tazobactam
  • cefipime
  • ceftazidime

low P. aeruginosa risk

  • moxifloxacin
  • ceftriaxone
  • cefotaxime
357
Q

What radiographic findings on pulmonary edema?

A

findings

cephalization (reflects an elevation in left atrial pressures)

Kerley lines

air bronchograms

pleural effusion

358
Q

60-year-old man presents with increasing shortness of breath. He reports that this symptom worsens when he is in the upright position and improves when he is laying in bed. Medical history is significant for end-stage liver disease due to hepatitis C infection. On physical exam, there is decreased breath sounds on pulmonary auscultation and spider nevi. Arterial blood gas analysis is significant for an alveolar-arterial gradient of 20 mmHg.

What is the most likely diagnosis?

A

Hepatopulmonary Syndrome

Clinical definition

liver disease leading to severe pulmonary vascular complications

359
Q

Pathogensis of hepatorenal syndrome?

A

believed to be due to increased vasodilator (e.g., nitric oxide and carbon monoxide) production secondary to liver disease resulting in

  • ventilation-perfusion (V/Q) mismatch
  • alveolar-capillary oxygen disequilibrium
360
Q

What is the gold standard for diagnosis Hepatorenal syndrome?

A

Labsarterial blood gas (ABG) analysis

indicationswhen there is clinical suspicion for hepatopulmonary syndrome

  • ≥ 15 mmHg is suggestive of HPS
  • ≥ 20 mmHg is suggestive of HPS in patients > 64-years-old
361
Q

When should you preventatively treat Bronchiolitis?

A

Prevention: treat with Palivizumab for P29HC

Preterm <29 weeks gestation

Chronic lung disease of prematurity

Hemodynamically significan congenital heart diseese

362
Q

Bronchiolitis complications??

A

Apnea, infants less than 2 months and respiratory failure

363
Q

Nonallergic rhinits

A

Clinical features nasal congestion/late onset >29/ no obivious allergic rhinitis / perennnial symptoms worsen with season/ erythematous nasal mucosa

TX

MIld: intranasal antihistamine or glucorticoids/ Moderate to serval : combination therapy.

364
Q

Allergic rhinitis??

A

Clinical Features:

Watery rhinnorhea, sneezing, eye symptoms/ early age on onset/ identifiable allergen or seasonal pattern/ pale-blusish nasal mucosa/ associated with other allergic disorders( eczema, asthma, eustachian dysfunction)

TX:

intranasal glucocoticoids/ ANtihistamine

365
Q

Mmenonic for post operative hypoxemia???

A

Post operative hypoxemia-AirAn-I,Spasm-E, Pnue-1-5 , Ate-2-5, PE->3

Airway obstruction/edema -immediate, -stridor s/p intubation

Anestesthesia residual- Immediate, - d/c respiratory drive

Bronchospasm-early - wheezing

Pneumonia- 1-5 days - fever , cxr positve

Atelectasis- 2-5 days - s/p surgery, splinting coug, retained secretions

Pulmonary Embolism - Uncommon befor3 days

366
Q

STOPBANG??

A

(Snorlax is Tired Ofchoking/gasp in highaltitudeswithighbloodPressure, becauseofhis BMI oldAge Necksize and maleGender) *old

367
Q

Prognosis of COPD?

A

FEV1 is most important factor age is second most important factor

368
Q

Gold criteria??

A

All FEV1/FVC <0.7

Gold 1 Mild> 80%

Gold 2 Mod50%<fev></fev>

<p>Gold 3 Severe 30%<fev>

<p>Gold 4 Very Severe 30%<fev>
</fev></p></fev></p>

</fev>

369
Q

Cough variant asthma is noted when ??

A

Look at case where patient is normal and cough only exhibited when patient does peak flow test.

370
Q

What is contraindicated for asthma in a pregnant woman

A

Epinephrine

371
Q

ABPA diagnostic testing?

A

Skin testing or aspergillus; analysis of total IgE (>417) concentrations, Specific Ige for A fumigatus; Eosinophillia (>500/ul)

372
Q

ABPA seen in both asthma and cystic fibrobis but cystic fibrosis complications seen ????????

A

ABPA seen in both asthma and cystic fibrobis but cystic fibrosis complications seen at a younger age

373
Q

ABPA treatment

A

Systemic gluccocorticoids

Voricanozole then Itracanozole

374
Q

Solitary pulmonary nodules : low

Remember S3AC stands for???

A

Remember S3AC

If less than 0.8cm, smooth,non smoking, less than 45, non calcified then the person has a low probability for cancer

Add male to the mix

375
Q

What is end tidal co2???

A

Use of end tidal co2 to determine whether or not intubation is successful… during CP you want end tidal co2 to be above 10

376
Q

Squamous Cell Carcinoma signs?

A

Keratin pearls and intracelluar bridges

Hilar mass arising from bronchus Caviations, Cigarretes, hypercalcemia look for PTHrP

377
Q

Small cell carcinoma signs??

A

May produce ACTH, ADH, or Antibodies against presynaptic calcium channels Lamber-Eaotn syndrome, amplifications of myc oncogenes, Treated with chemotherapy.

378
Q

What Adults at high risk for influenza complications??

WOIIONN

A

W Women who are pregnant and up to 2 weeks postpartum

O Age 65

I Chronic medical illness

I Immunosuppression

O Obesity

N Native American

N Nursing home or chronic care facility resident

379
Q

Infectious Mono clinical features??

A

Fevers

Tonsilitis/pharyngitits +/- exudates

Posterior or diffuse cervical lymphandenotpathy

Signficant fatigue

+/- hepatosplenomegaly

+/- rash after amoxicillin

380
Q

Invasive pulmonary aspergillosis diagnostic workup??

A

Serum biomarkers: galactomannan, B-D-blucan

Sputum samplin for fungal stain and culture

CT Chest, Nodules with ground - glass opacity (halo sign) or cavitations with air fluid levels.

381
Q

Invasive pulmonary aspergillioous

A

Voriconazole

Reduction of immunosupperessive regimen

Surgery

382
Q

Popcorn calcifications are suggestive of what type of nodule

383
Q

Recurrent pneumonia in elderly smoke??

A

Obstruction

Lung cancer: Manifestation of bronchogenic carcinoma: Recurrent pneumonia in elderly smoker is the first manifestation of bronchogenic carcinoma and the best test for obstructive cancer in the lung is flexsig

384
Q

PE pretest probability in vq scan must be ??????until then you cannot rule out PE so it’s the most likely diagnosis

A

PE pretest probability in vq scan must be negative until then you cannot rule out PE so it’s the most likely diagnosis

HENCE you will use the PERC classification

385
Q

Lung Cancer-Low dose ct scan has high sensitivity but is associated with

A

Yearly, 55080, pt with a >30 pack-year smoking history , and current smokrer with the last 15 years

386
Q

OHS is at increased risk for ????????????????failure.

A

OHS is at increased risk for perioperative hypercapnic/hypoxic respiratory failure.

387
Q

TRALI……. and TACO

A

Tranfusion related acute lung injury..

Tranfusion associated circulatory overload

388
Q

Chronic cough in children greater than 4 weeks warrants ???????

so look for duration

A

Chronic cough in children greater than 4 weeks warrants spiromerty so look for duration

389
Q

Treat Croup with ????? and ??????

A

Treat Croup Mild humidified air and corticosteriods

390
Q

What is Rapid sequence Intubation?

A

Makes use of rapidly active sedative etomidate, propofol, midalozam

and paralytic agents succinylcholine and rocuronium

391
Q

SubMassive vs Massive PE

A

xxxxSubmassive PExxx

SBP above 90, RV dysfuntion, RV dilatation ECHO or CT

BNP> 90,

EKG changes

Elevated Troponins

xxxxMASSIVE PExxxx

SBP less than 90 or 40 below baseline,, pulsless, persistent brady cardia

1 USMLE Step 3 Main one (37 decks)

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