Pulmonology/Critical Care

Question 1

What IL-5 inhibitors can be used in difficult to control asthma with elevated eosinophil counts?

Answer 1

Mepolizumab, reslizumab

• consider if blood eos >150/uL
• IL-5 is a pro-eosinophilic cytokine molecule.

Question 2

What does NO-reactivity during right heart catheterization predict in PAH?

Answer 2

Response to CCB, which is the preferred therapy

Question 3

What class of medications do Bosentan, Ambrisentan, and Macitentan belong to? Side effects?

Answer 3

Endothelin-1 receptor antagonists, used in PAH

- watch out for liver injury, teratogenicity

Question 4

Treatment for LAM?

Answer 4

Sirolimus (mTOR inhibitor)

Question 5

What should be performed after the first episode of secondary spontaneous pneumothorax?

Answer 5

Pleurodesis or VATS is indicated to prevent recurrence

Should also be considered after second episode of Primary Spontaneous Pneumothorax (PSP)

Question 6

Strongest indication for treatment of OSA?

Answer 6

Excessive daytime sleepiness

Question 7

PAH treatment

Answer 7

1) If responsive to NO –> CCB

2) If not responsive to NO –> prostanoids, endothelin-1 receptor antagonists (e.g. bosentan), PDE-5 inhibitors

Question 8

Hypertensive encephalopathy blood pressure treatment target

Answer 8

1) Systolic BP reduction by 25% in first hour
2) If stable, lower to SBP 160 within next 2 to 6 hours
3) Return to normal within 24-48 hours

Question 9

Treatment for high-altitude cerebral edema

Answer 9

Dexamethasone

Vascular leak at altitude >3000m leads to brain edema (e.g. confusion, irritability, ataxia, coma, death)

Question 10

Initial step in evaluation of excessive daytime sleepiness (if minimal concern for OSA)

Answer 10

Sleep diary or actigraphy

Multiple sleep latency testing is helpful for pathologic daytime sleepiness (e.g. narcolepsy)

Question 11

Definition of complicated parapneumonic effusion

Answer 11

Pleural studies:

1) pH <7.2
2) Glucose < 60 mg/dL

Tx: Thoracostomy drainage + Abx

Differs from empyema in that empyema has frank pus and/or positive gram stain (positive culture not required)

Question 12

Findings in respiratory bronchiolitis-associated ILD

Answer 12

Active smokers, usually asymptomatic and discovered on screening CT chest for Lung CA

CT chest findings: Centrilobular micronodules, respiratory bronchiolitis

Biopsy: tan-pigmented macerophages

Question 13

Findings in Pulmonary Langerhans cell histiocytosis

Answer 13

Seen in young adults with dyspnea

CT with middle/upper zone thin-walled cysts, accompanying nodules

Usually associated with pulmonary hypertension

Question 14

Chronic silicosis patients are at elevated risk for which infection?

Answer 14

Tuberculosis

Chronic silicosis affects macrophage function

Question 15

Non-gap metabolic acidosis + osmolal gap = ?

Treatment?

Answer 15

Isopropyl alcohol ingestion (methanol and ethylene glycol have AGMA)

Treatment: Given there are not other toxic metabolites with isopropyl ingestion, care is supportive

Consider blocking ADH with fomepizole with ethylene glycol and methanol ingestion due to toxic metabolite production

Question 16

Features of acute radiation pneumonitis

Answer 16

Consider if patient has pneumonia that does not respond to antibiotics, occurring 4-12 weeks after radiation therapy

Sx: Fever, dyspnea, cough, pleuritic chest pain
Can see leukocytosis
~10% have pleural effusion

Tx: Prednisone x2 weeks, then taper