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GME - Residency > Pulmonology > Flashcards

Pulmonology Flashcards

1
Q

What scoring ranges does the Pediatric Asthma Score have?

A

1-10

  • 1-2: mild
  • 3: mild-moderate
  • 4-5: moderate
  • 6-10: severe
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2
Q

What are the components of the PAS system?

A

Dyspnea
Oxygen requirement
Work of breathing
Auscultation
RR

Remember that you want to DO WAR on asthma with the PAS.

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3
Q

Review the stages of coughing and the problems and interventions that can be done at each stage.

A

1) Inspiratory phase
2) Glottic stop
3) Expiratory phase
4) Expulsion or ingestion of mucus

  • Neuromuscular disorders affect ability to cough at nearly every stage. A cough-assist device can help, which is essentially a mini puff of air followed by suction (like the inspiratory and expiratory phases).
  • Mucolytic meds and chest PT can help with expulsion of mucus.
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4
Q

Review the different ways of helping with mucus clearance.

A
  • Nebulized hypertonic saline
  • Nebulized Pulmozyme (DNAse)
  • Nebulized N-acetylcysteine (Mucomyst)
  • Acapella (physical vibration of air to help shake clear the secretions)
  • Chest vest and manual PT (physically shaking mucus off)
  • Suction
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5
Q

PETCO2 is usually _____ than PACO2.

A

less

Not all of the CO2 in blood (PACO2) is expired into the alveoli (PETCO2).

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6
Q

What are the different types of capnography?

A
  • Colorimetric capnography: color changing device attached to vent
  • Waveform capnography: plotted data of the PETCO2 over time
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7
Q

Why is capnography helpful in procedural sedation?

A

Rising PETCO2 happens before hypoxemia (it’s more sensitive) in hypoventilation, so it can clue you into a patient who needs more airway support.

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8
Q

Capnography > ____________ has been shown to correlate with adequate CPR.

A

20 mm Hg

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9
Q

If you see a cleft in the capnographic waveform, what might this mean?

A

Patient-ventilator dysynchrony (“fighting the vent”)

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10
Q

A quick loss of PETCO2 indicates what two possibilites?

A
  • Loss of ETT
  • Loss of CO

Essentially, if the CO2 stops coming then it’s either not being produced (because the heart isn’t pumping) or it’s not being detected because the tube dislodged.

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11
Q

Colorimetric capnography turns what color when the patient is exhaling?

A

Yellow (“mellow yellow”)

There is a pH indicator that detects the slight drop in pH when more CO2 enters the air.

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12
Q

What’s a normal PETCO2?

A

35 mm Hg

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13
Q

How does capnography work?

A
  • Qualitative capnography uses a pH paper that turns yellow when CO2 passes through it.
  • Quantitative capnography uses the absorption of infrared light through the nasal cannula line to detect CO2.
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14
Q

Those with simple PTX (no vital sign abnormalities) should be given _____________.

A

supplemental oxygen

This can speed up the resorption of pleural air.

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15
Q

A reduction by __% or more in peak expiratory flow signifies severe asthma exacerbation.

A

50

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16
Q

How should you use the STOP-Bang criteria?

A

People who score <3 on the STOP-Bang are very unlikely to have OSA and can most likely avoid polysomnography.

Criteria:
- Snoring
- Observed apnea
- Daytime somnolence
- Male sex
- BMI greater than 35
- Neck circumference greater than 40 cm
- Age greater than 50 years

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17
Q

The first-line treatment for allergic bronchopulmonary asspergillosis is ____________.

A

gluococrticoids

Steroids decrease the pulmonary inflammation that allows the fungus to thrive, so controlling the inflammation usually resolves the fungal infection.

For severe cases or those that don’t respond to initial steroid treatment, itraconazole or voriconazole can be considered.

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18
Q

Difficult-to-control asthma accompanied by brownish sputum and occasional hemoptysis is suggestive of ________________.

A

allergic bronchopulmonary aspergillosis

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19
Q

A pulmonary nodule, by definition, is an opacity less than or equal to ______ cm in diameter.

A

3

Anything bigger is a mass.

Note: it also has to be rounded and surrounded by pulmonary parenchyma. Anything that is spiculated is not a nodule. Anything surrounded by inflammation, a cavity, or edema is not a nodule.

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20
Q

What is the management of a pulmonary nodule?

A

First, make sure it is a nodule (0.8 - 3.0 cm, not spiculated, surrounded by normal lung).

Second, look for prior imaging. If a nodule has not changed in 2 or more years then no further follow-up is required.

Third, if no further imaging exists then obtain a high-resolution CT of the chest.

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21
Q

Review the risk of malignancy of pulmonary nodules by size.

A
  • Less than 0.6 cm is low risk
  • 0.6 to 2.0 cm is intermediate risk
  • Greater than 2.0 cm is high risk
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22
Q

Flash pulmonary edema is now called __________.

A

SCAPE (sympathetic crashing acute pulmonary edema)

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23
Q

A key feature of SCAPE is what vital sign abnormality?

A

HTN (SBP > 160 or MAP > 120)

What happens in SCAPE is that hypertension leads to pulmonary edema which then leads the body to release epinephrine. The excess epinephrine increases the hypertension and worsens the cycle. This is the spiral that causes SCAPE.

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24
Q

True or false: those with SCAPE will have whiteout on their CXRs.

A

False

Because it is so acute, the fluid has not gotten a chance to accumulate enough in the interstitium to show up on CXR.

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25
Q

Which agent should you give for air hunger in SCAPE?

A

Fentanyl

It treats the air hunger. Morphine has been shown in studies to worsen outcomes.

Many patients will be elderly so avoid benzodiazepines.

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26
Q

What is the definition of pneumonia?

A

Lung inflammation caused by a bacterial, viral, or fungal infection in which the air sacs of the lungs fill with pus and may become solid

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27
Q

Review the criteria and scoring grades of Wells PE.

A
  • Signs of DVT: 3
  • PE most likely diagnosis: 3
  • HR > 100: 1.5
  • Prior DVT/PE: 1.5
  • Immobilization at least 3 days: 1.5
  • Hemoptysis: 1
  • Malignancy within past 6 months: 1

1 is low (D-dimer ok)
2-6 is moderate
7-12.5 is high

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28
Q

A pleural-based wedge infarction (a sign of PE) is called _____________.

A

Hampton hump

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29
Q

Review Light criteria.

A

WBC > 10,000
Fluid to serum protein ratio > 0.5
Fluid to serum LDH radio > 0.6
Fluid LDH > 2/3 ULN

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30
Q

What is the Westermark sign?

A

It is a chest XR finding in which blood is limited to a region and appears radiolucent

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31
Q

Review the EKG findings that can be seen in PE?

A

Sinus tachycardia
RAD
S1Q3T3
Peaked P waves (RA enlargement)

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32
Q

Patients who have decompression of their pneumothorax can have ______________ (particularly if the PTX has been present for several days or more).

A

reexpansion pulmonary edema

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33
Q

Which XR view is most useful for detecting pleural effusion?

A

Lateral decubitus on the affected side

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34
Q

What can cause a false-negative chest X-ray in pneumonia?

A

Dehydration

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35
Q

In what cases would you put a good lung down vs a bad lung down?

A

There are two things that you need to think of: one is that the dependent lung gets more blood flow and the other is that intra-alveolar or intra-bronchial fluid will flow to the the dependent side.

You would thus put a good lung down if someone had a unilateral pulmonary contusion, pulmonary embolism, pneumonia, PTX, or effusion. This would pull blood to the good lung and improve V/Q mismatch.

Your would put a bad lung down in cases of unilateral bronchial bleeding to pull the airway lung to just the affected side.

36
Q

Spirometry generally doesn’t work in kids younger than ______.

A

6 years

37
Q

What is the term for deep, fast breathing?

A

Hyperpnea

38
Q

What size ETT is needed for bronchoscopy?

A

8.0 or bigger

39
Q

How can you use PIP and Pplateau to differentiate between mainstem intubation and PTX?

A

Both will have high PIPs but PTX will have normal plateau.

40
Q

In which patients would you not use lung-protective ventilation?

A

CNS pathology (because hypercapnia leads to increased ICP)

Obstructive lung disease (you may need to lower RR to allow for prolonged I:E ratio)

41
Q

Review the mnemonic for hemoptysis.

A

BATTLE CAMP

Bronchitis
Bronchiectasis
Aspergillosis
TB
Tumor
Legionella
Emboli (PE)
Coagulopathy
Abscess
AI disorders (DAH, GPA)
AVM
Mitral stenosis
PNA

42
Q

The non-code dose tPA for PE is what?

A

Alteplase 100 mg over two hours

43
Q

Why should you not use the term “Ekos”?

A

Ekos is a branded catheter that uses ultrasound to break up clot in addition to delivering thrombolysis. Studies have not demonstrated superiority of Ekos compared to standard catheter-directed thrombolysis.

The proper term is thus catheter-directed thrombolysis.

44
Q

What ventilator settings are most commonly done wrong in the ED and prehospital settings?

A
  • FiO2 too high
  • PEEP too low
  • TV too high
45
Q

A June 2022 meta-analysis showed that lung protective ventilation in the ED led to an all-cause mortality decrease of ____%.

A

5

It also showed that LPV in the ED led to decreased ICU stay, decreased hospital admission duration, and increased rate of LPV in the ICU.

46
Q

A study in 2022 on LPV in the ED showed that even transient hyperoxia in the ED (defined as PaO2 of > 120 mm Hg) led to _____________.

A

mortality increase from 20% to 30%

47
Q

How does PEEP aid oxygenation?

A

Positive pressure is what keeps alveoli open. If you don’t have pressure in the system at between breaths, then your alveoli will collapse.

48
Q

Other than PEEP and FiO2, what other ventilator setting can help with oxygenation?

A

Increased inspiratory time

49
Q

AC is what type of ventilator mode (pressure or volume control)?

A

Volume

You might see it written as AC-VG (assist control, volume guarantee).

50
Q

True or false: there is no minimum RR in pressure-support ventilation (PSV).

A

True

However, most will have apnea alarms and will go into

51
Q

If a patient is at goal mL/kg TV, why should you alter RR to change ventilation?

A

Volutrauma can damage the lungs. If they’re at goal TV then you should change RR to avoid lung injury.

52
Q

In patients with obstructive lung disease who are intubated, you will see what ventilator waveform parameter get smaller as their disease process is treated?

A

The delta between the peak pressure and the plateau pressure

This delta – which is obtainable by doing an inspiratory hold – represents the airway resistance, which will improve as asthma is treated.

53
Q

The alveolar compliance pressure (on a vent waveform) is the delta between the plateau pressure and the _______.

A

PEEP

54
Q

The driving pressure is the peak pressure subtracted by the PEEP. Driving pressures above what pressure are harmful?

A

15 cm H20

55
Q

Review the differential for high peak pressure with normal plateau pressure.

A

This is caused by high airway resistance with normal alveoli:
- Kinked ETT
- Patient biting ETT
- Mucus plugging of ETT
- Obstructive pathology (bronchospasm, asthma, and COPD)

56
Q

Review the differential for high peak pressure with high plateau pressure.

A

This is caused by stiff lungs or external pressure on lungs:
- Pulmonary edema
- Pleural effusion
- ARDS
- PTX
- Mainstem intubation
- Stiff chest wall (e.g., fentanyl chest wall rigidity, massive chest wall burns)
- Abdominal compartment syndrome

57
Q

In general, start TV at _____ mL/kg.

A

6

58
Q

Lung protective ventilation includes plateau pressures < _____ and driving pressures < _____.

A

30 cm H20; 15 cm H20

59
Q

Lung protective ventilation is so important that you should allow for permissive __________ to meet the LPV settings.

A

hypercapnia (7.25 - 7.30)

60
Q

In what three instances should you deviate from lung-protective ventilation?

A
  • TBI patients (who need tight pCO2 control)
  • Asthma/COPD (who might need lower RR to allow for higher I:E ratio, thus needing higher TV)
  • Severe metabolic acidosis (who need high MV to breathe off CO2)
61
Q

Every patient should get an ABG ____ minutes after intubation.

A

20

62
Q

You should use CPAP if a patient has isolated ___________ respiratory failure (hypercapnic or hypoxic).

A

hypoxic

BiPAP delivers a RR of breaths. It thus accomplishes ventilatory support. If you know that someone has isolated hypoxic respiratory failure (i.e., not hypercapnic) then you should use CPAP. BiPAP increases risk of PTX and aspiration and thus should only be used in hypercapnic failure.

63
Q

You see this arterial blood gas:
7.10 / 110 / 80 / 21

How do you know this person has baseline COPD?

A

A person with a pCO2 of 110 that was all acute should have a pH that is much lower than 7.10. This ABG represents acute-on-chronic hypercapnic respiratory failure.

64
Q

You intubate a patient with severe COPD exacerbation. The ventilator starts alarming for high peak pressures. Why are you not concerned (at least initially)?

A

The peak pressure indicates airway resistance, which you would expect to be high in a patient with severe obstructive lung disease. You should check the plateau pressure and make sure this is not also elevated, because if this is also elevated then you should be concerned about restrictive lung processes as well.

65
Q

Looking a a flow diagram on a ventilator, the flow below the x-axis represents what respiratory phase?

A

Expiration

66
Q

You see that a patient’s flow diagram shows that the expiration line does not return fully to the x-axis. What does this represent?

A

Gas trapping (aka breath stacking, aka auto-PEEPing, aka dynamic hyperinflation)

67
Q

What will a lung volume diagram (on a ventilator) show in a patient who is gas trapping?

A

The nadir of the volume will begin to rise. It should be near zero.

68
Q

When you __________ someone, always check in multiple times afterward to review SpO2, EtCO2, blood gases, and ventilator settings.

A

intubate

69
Q

On a Hamilton ventilator, (S)CMV is what type of ventilation?

A

Volume control

70
Q

What is the dose of albuterol (neb and MDI)?

A

Neb: 2.5 mg repeated Q20Min
MDI: 200-400 ug Q2-4H

71
Q

What is the epipen dose for asthma?

A

0.5 mg IM (so two 0.3 mg epipens)

72
Q

The asthma dose of ketamine is ____________.

A

0.4 mg/kg IV (pushed slowly to avoid apnea)

73
Q

If you are putting an asthma patient on BiPAP, you should set the ________ as low as possible.

A

PEEP

They’re already auto-PEEPing.

74
Q

Why do you (likely) need to paralyze intubated asthma patients?

A

You want their RR to be low to allow for a high I:E ratio. If they’re not paralyzed then they might be breathing over the vent.

75
Q

What are three ways to stop hiccups?

A
  • Breath holding (improves hypocapnia)
  • Swallowing dry sugar (irritates the nasopharynx)
  • Pressing on the eyeballs: vagal response
76
Q

Which error is more likely, an exudative pleural effusion being misclassified as transudative or the other way around?

A

Transudative are more liikely to be misclassified as exudative.

Missing an exudative effusion is more serious because those pathologies usually require more than just diuresis (like antibiotics, cancer therapies, or PE treatment). As such, Light’s criteria was designed to be sensitive for detecting exudates. It is not specific for transudates, though, so some transudates will inevitably be misclassified as exudates (especially after diuresis).

77
Q

Review the YEARS criteria.

A

The YEARS criteria were used to help decrease the need for CTAs in patients with only mildly elevated D-dimers. If a patient has no hemoptysis, signs of DVT, pregnancy, and you don’t think PE is the most likely diagnosis then you can avoid CTA for D-dimers < 1000.

78
Q

True or false: sputum production is usually not seen in pneumoconioses.

A

True

Chronic cough is the main feature.

79
Q

The most common clinical sign of PE is what?

A

Tachypnea

80
Q

PTX is air in what space?

A

Intrapleural

81
Q

Ideal body weight is also known as ___________.

A

predicted body weight

82
Q

How does mucoid PsA change the treatment for CF bronchopneumonia?

A

Mucoid (compared to smooth PsA) has developed a biofilm and warrant double coverage (usually tobramycin and other)

83
Q

What is the “tram-tracking” sign on CT?

A

Bronchioles are supposed to taper. If

84
Q

What is DIOS (in CF patients)?

A

Distal intestinal obstruction syndrome

An SBO w/ a transition point. It is not treated surgically or with NG tubes

85
Q

What is the boards answer for antibiotics in COPD?

A

If there is a productive cough, fever, or consolidate then treat with 3rd gen ceph + azith

86
Q

What is the regimen for aspiration PNA?

A

Same as CAP: 3rd gen ceph + azit

87
Q

What is the mechanism behind breath holding causing pneumomediastinum?

A

Alveolar rupture leads to tracking up the bronchial tree – the Macklin effect

GME - Residency (111 decks)

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