Pulmonology

Question 1

Tests for PE and when do you order them?

Answer 1

• D Dimer: Low probability, rule out DVT/PE
• V/Q scn: Elevated creatinine AND clear lungs
• CT scan: Preferred test for PE
• US legs: Cant do for a CT or a VQ; DVT is treated just like a PE so it approximates diagnosis
• Angiogram: Not for acute management. CT scan is good enough

Question 2

What are the treatments for the different types of PE?

Answer 2

• Most PEs: LMWH to Warfarin bridge
• Submassive PE: Heparin to warfarin bridge
• Massive PE: tPA
• DVT and contraindication to anticoag: IVC filter
• Chronic thromboembolic pulmonary hypertension: Thrombectomy

Question 3

What is the goal INR for someone on warfarin therapy?

Answer 3

2-3

Question 4

What do you do if warfarin is subtherapeutic

Answer 4

Putback on heparin and bridged to therapeutic for a minimum jof 5 days

Question 5

What is the action for INRs in subtherapeutic ranges?

Answer 5

• <5: Hold a dose of warfarin
• 5-9: hold dose, vit K
• >9: Hold dose, vit K, lower dose
• Any with bleeding: FFP and vit K

Question 6

What is the necessary course of action if HIT is afoot?

Answer 6

Stop the heparin and give argatroban after drawing HIT panel

Question 7

Presentation of PE?

Answer 7

Shortness of breath, tachypnea, tachycardia, pleuritic chest pain and clear chest pain

Question 8

What is the presentation of ARDS?

Answer 8

Person who is very sick and in the ICU who has:

• Pulmonary edema
• White out chest xray
• Without a reason for CHF

Question 9

Treatment for ARDS

Answer 9

PEEP which increases interstitial pressures and moves fluid out of the lungs

Question 10

How is ARDS diagnosed?

Answer 10

• Patient with systemic disease and a pulmonary edema likely enough for a diagnosis
• CXR shows white out
• Definitive diagnosis?
  
  • Decreased or normal wedge pressure and increased or normal LV function
  • PaO2 to FiO2 ratio under 200

Question 11

Treatment for CHF and ARDS respectively

Answer 11

• CHF
  
  • Diuresis, control of HTN, PEEP
• ARDS
  
  • PEEP
  • Intubaton
  • Treat underlying disease

Question 12

Treatment of COPD?

Answer 12

• Short acting bronchodialators (ipratropium, albuterol) for acute relief
• Long acting muscarinic agonists (tiotropium)
• Inhaled corticosteroids (bedesonide)
• Oral steroids if refractory

Question 13

Treatment goals and methods for COPDERs

Answer 13

Mnemonic: COPDER

• C: Corticosteroids (mantenance, IV exacerbation, doesnt change mortality)
• O: Oxygen:
  
  • PaO2 <55 or SpO2 <88% titrating to PaO2 55-60 SpO2>90%
• P: Prevention - vaccines - pneumovax (q5y) and flu (q1y), smoking cessation
• D: Dilators - Anticholinergics are better than beta agonists
• E: Experimental
• R: Rehab
  
  • Increased exercise tolerance
  • Decreased dyspnea and fatigue
  • No change in mortality

Question 14

Exacerbation of COPD presents how

Answer 14

• Precipitous drop in SpO2 or increase in productive cough

Question 15

Treatment for COPD exacerbation

Answer 15

• Oxygen while a diagnosis
• Nebulized therapy is crucial
• Ipratropium>albuterol
• IV steroids or PO steroids if no improvement with the neb
• If purulent sputum then go to antibiotics

Question 16

Antibiotics for COPD exacerbation

Answer 16

Amoxicillin, trimethoprim-sulfa, azithromycin, doxy, on a rotating schedule

Question 17

PFTs in COPD

Answer 17

Decreased FEV1, Decreased FEV/FVC ratio, Increased RV, Increased TLC, decreased DLCO, possibly erythrocytosis

Question 18

Diagnosis of Asthma based on PFTs

Answer 18

• Normal FEV1/FVC
  
  • Not active disease
    
    • Methacholine challenge
      
      • If inducible, then asthma
• Decreased FEV1/FVC
  
  • Active disease
  • Bronchodilator PFT
    
    • Irreversible - COPD
    • Reversible - Asthma

Question 19

Treatments for the different types of asthma

Answer 19

• Intermittent: Rescue inhaler
• Mild Persistent: Low dose ICS
• Moderate persistant: Low dose ICS and LABA
• Severe Persistant: high dose ICS and LABA
• Refractory: PO steroids

Question 20

What are the distinctions between asthma types

Answer 20

• Intermittent:
  
  • Daytime <2x/week
  • Nighttime<2x/month
• Mild eprsistent
  
  • Day <1/day
  • Night>2/month
• Moderate persistent
  
  • Day>1/day
  • Night>1//week
• Severe persistent
  
  • Day>1/day
  • Night Frequent

Question 21

Lights criteria

Answer 21

• Transudate
  
  • LDH<2/3 upper limit of normal
  • Total Protein (effusion)/Total protein (serum)<0.5
  • LDH (effusion)/LDH (serum) <0.6
• Exudate
  
  • LDH>2/3 upper limit of normal
  • Total Protein (effusion)/Total protein (serum)>0.5
  • LDH (effusion)/LDH (serum) >0.6

Question 22

Causes of exudates

Answer 22

Malignancy, PNA, TB

Inflammation leading to increased oncotic pressure of interstitium

Question 23

Causes of transudates

Answer 23

CHF, Nephrosis, Cirrhosis, Gastrosis (fluid overload or decreased oncotic pressure)