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Internal Medicine > Pulmonology Step Up > Flashcards

Pulmonology Step Up Flashcards

1
Q

paradoxic movement of abdomen and diaphragm on inspiration

A

sign of impending respiratory failure i.e. severe acute asthma attack

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2
Q

arterial blood gas findings in acute asthma attack

A

LOW PaCO2, LOW PaO2
- increased or normal PaCO2 is a sign of resp. mm fatigue or severe airway obstruction (consider mechanical ventilation); increased A-a gradient

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3
Q

PFTs in asthma

A

decreased expiratory flow rates
decreased FEV1/FVC ratio < 0.75%
increased DLco

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4
Q

in order to dx. asthma, what should the PFT result be after bronchodilator??

A

FEV1 or FVC should increase by 12% or 200 ml after albuterol (B2-agonist)

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5
Q

methacholine challenge

A

FEV1 decreases by > 20% after methacholine challenge, this is suggestive of asthma

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6
Q

quickest method of diagnosis of asthma in acute setting

A

peak expiratory flow rate

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7
Q

first line therapy in acute severe asthma exacerbation

A
  1. inhaled short-acting B2 agonist via nebulizer or MDI
  2. IV steroids - taper when clinical improvement is seen and replace w/ inhaled
  3. oxygen - SaO2 > 90%
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8
Q

in what situations do you use long-acting B2 agonists (salmeterol) in tx of asthma?

A
  1. night-time asthma
  2. exercise-induced asthma
  3. severe, persistent asthma
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9
Q

when do you use inhaled corticosteroids in asthma tx?

A

mild-moderate asthma in addition to short acting B2 agonist

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10
Q

when is montelukast useful for asthma tx?

A
  1. prophylaxis of mild exercise induced asthma
  2. control of mild-moderate disease (lowers need for steroid and bronchodilator requirements)
  3. severe asthma resistant to max doses of inhaled steroids as last resort before using chronic systemic steroids
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11
Q

when can cromolyn sodium/nedocromil sodium be used?

A

only for prophylaxis i.e. before exercise in adults; first-line chronic treatment in children

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12
Q

anticholinergic drugs (tiotropium, ipratropium)

A

useful in pts with heart disease and asthma but they take significant time to achieve max bronchodilation and are only medium potency

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13
Q

FEV1/FVC < 80%, normal TLC and DLco

A

chronic bronchitis

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14
Q

FEV1/FVC < 80%, increased TLC, decreased DLco

A

emphysema

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15
Q

features of centrilobular emphysema

A

smokers, limited to respiratory bronchioles and mostly in upper lung zones

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16
Q

features of panacinar emphysema

A

a1 antitrypsin deficiency, proximal and distal acini affected, mostly in lung bases

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17
Q

sign specific to COPD

A

prolonged forced expiratory time (timed full exhalation of vital capacity > 6 seconds)

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18
Q

to diagnose airway obstruction, one must have….

A

normal or increased TLC

decreased FEV1

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19
Q

definitive diagnostic test in COPD

A

spirometry

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20
Q

PFTs in COPD

A
  1. decreased FEV1 and FEV1/FVC < 0.70
  2. increased TLC, RV and FRC (air trapping)
  3. decreased vital capacity
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21
Q

good screening test in obstruction

A

peak expiratory flow rate – if < 350 L/min, perform PFT

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22
Q

CXR findings in emphysema

A

hyperinflation, flattened diaphragm, enlarged retrosternal space, small heart size and diminished vascular markings

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23
Q

ABG in COPD

A

chronic PCO2 retention, decreased PO2

- respiratory acidosis with metabolic alkalosis (compensation)

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24
Q

most important tx. intervention in COPD

A

smoking cessation - prolongs survival rate

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25
Q

clinical monitoring in pts with COPD

A

serial FEV1 measurements
pulse oximetry
exercise tolerance

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26
Q

which tx. interventions have been shown to lower mortality in COPD?

A

smoking cessation

home O2 therapy

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27
Q

mainstay of long-term treatment in COPD

A

short acting inhaled B2 agonists and inhaled anti-cholinergic drugs (combined they are more efficacious than either alone)
- inhaled steroids may be used as well

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28
Q

what do you give a COPD pt with significant symptoms or recurrent exacerbations?

A

inhaled corticosteroid (budesonide, fluticasone) AND long-acting bronchodilator (salmeterol, formeterol)

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29
Q

role of theophylline in COPD tx

A

only for cases of refractory COPD –> lots of side effects and benefit unclear

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30
Q

criteria for continuous or intermittent long term O2 therapy in COPD

A
  1. PaO2 < 55 mmHg OR
  2. O2 sat < 88% at rest or during exercise OR
  3. PaO2 55-59 mmHg and signs of polycythemia or cor pulmonale
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31
Q

benefit of oxygen therapy in COPD

A

when used for > 18 hr/day, reduces mortality in pts with COPD by controlling pulmonary HTN and thus, cor pulmonale

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32
Q

which two drugs are added for acute COPD exacerbations?

A

systemic steroids

antibiotics

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33
Q

pt presents with acute COPD exacerbation, what steps do you take?

A
  1. CXR - R/O infection etc
  2. inhaled short acting B2 agonist and anticholinergic
  3. IV steroids (methylprednisolone)
  4. antibiotics - azithromycin or levofloxacin
  5. supplemental oxygen
  6. non-invasive positive pressure ventilation
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34
Q

first line drugs in COPD

A

anticholinergic agents - ipratropium bromide, tiotropium (given via MDI)

  • can add B2 agonists if needed (but not first line bc many pts also have heart disease)
  • inhaled corticosteroids are not routinely used in chronic COPD (unless combined with LABA)
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35
Q

best predictor of survival in COPD

A

FEV1 - if < 25%, pts usually dyspneic at rest

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36
Q

which vaccinations should COPD pts routinely get?

A

pneumococcal every 5 years
influenza yearly
H.influenza if not previously vaccinated

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37
Q

diagnostic study of choice in bronchiectasis

A

high resolution CT scan

- signet ring bronchi diameter > accompanying artery

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38
Q

CXR findings in bronchiectasis

A
  1. tram-tracking of bronchi away from hilum
  2. 1-2 cm cysts
  3. nonspecific findings - linear atelectasis, increased markings
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39
Q

main treatment approach to bronchiectasis

A
  1. inhaled bronchodilators
  2. chest physiotherapy
  3. antibiotics for acute exacerbations
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40
Q

limited small cell lung cancer

A

confined to chest and supraclavicular nodes (not cervical or axillary nodes) –> extensive is outside the chest and SC nodes

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41
Q

paraneoplastic syndromes seen in SCLC?

A

SIADH, ectopic ACTH secretion, Eaton-Lambert syndrome

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42
Q

paraneoplastic syndromes in squamous cell ca. of lung

A

PTHrP secretion, hypertrophic pulmonary osteoarthropathy

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43
Q

most impt study for diagnosis of lung cancer

A

CXR - but should NOT be used as a screening tool

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44
Q

study used for staging of lung cancer

A

CT with contrast - can show local/distant mets as well as mediastinal LAD

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45
Q

role of cytological exam of sputum in diagnosing lung cancer

A

can only detect CENTRAL lesions - same goes for fibreoptic bronchoscopy

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46
Q

how do you get a definitive diagnosis of lung cancer?

A

confirmation of pathology with transthoracic needle biopsy

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47
Q

which diagnostic test would be useful for identifying pts with advanced dz who would not benefit from surgical resection?

A

mediastinoscopy - direct visualization of superior mediastinum

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48
Q

best tx. option for NSLC

A

surgery with radiation as adjunctive therapy

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49
Q

who should NOT receive surgery for lung cancer?

A
  1. small cell lung cancer

2. NSCLC pts with mets outside the chest

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50
Q

best tx. option for limited SCLC

A

chemotherapy plus radiation

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51
Q

best tx. option for extensive SCLC

A

chemotherapy alone initially

if pt responds, prophylactic radiation to decrease incidence of mets and prolong survival

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52
Q

factors that favor malignancy in a solitary pulmonary nodule

A 
age > 50 yrs
smoker or previous smoker
size > 3.0 cm and steadily growing
irregular or speculated borders
stippled or eccentric calcifications
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53
Q

criteria for dx. exudative effusion

A 
one of the following:
LDH effusion > 200 IU/ml
LDH pleural/serum > 0.6
protein pleural/serum > 0.5
- none of these can be positive for transudate
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54
Q

pleural fluid w/ elevated amylase

A

esophageal rupture, pancreatitis, malignancy

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55
Q

exudative effusion that is primarily lymphocytic

A

suspect TB and do a pleural biopsy

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56
Q

pleural fluid with a pH < 7.2

A

parapneumonic effusion or empyema

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57
Q

first test to do if you suspect a pleural effusion

A

CXR - PA view, lateral view and lateral decubitus films

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58
Q

minimum criteria for performing a thoracentesis in pleural effusion

A

at least 10 mm thick effusion on lateral internal decubitus CXR –if not, risk of pneumothorax is too high

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59
Q

what do you look for in thoracentesis fluid?

A

chemistry - glucose, protein, LDH, pH
cytology
cell count - CBC w/ differential
culture - gram stain

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60
Q

Tx. of transudative effusions

A

diuretics, sodium restriction

therapeutic thoracentesis - if lots of fluid causing dyspnea

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61
Q

Tx. of uncomplicated parapneumonic effusion

A

antibiotics alone

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62
Q

Tx. of complicated parapneumonic effusion

A

chest tube drainage
intrapleural injection of thrombolytic agents
antibiotics

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63
Q

after which procedures should you obtain a CXR? (3)

A

transthoracic needle aspiration
thoracentesis
central line placement

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64
Q

primary spontaneous PTX

A

occurs in otherwise healthy individuals (usually tall, lean young men) due to spontaneous rupture of subpleural blebs at the apex of the lungs

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65
Q

physical exam signs seen in spontaneous PTX

A

decreased breath sounds on affected side
hyperresonance over chest
decreased/absent tacile fremitus
mediastinal shift toward PTX

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66
Q

confirmatory diagnostic test for spontaneous PTX

A

CXR - shows visceral pleural line

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67
Q

first tx. for spontaneous PTX

A

supplemental oxygen

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68
Q

Tx of spontaneous PTX in symptomatic pt

A

supplemental oxygen

chest tube insertion

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69
Q

what is next best step if you suspect a tension PTX in a pt?

A

do NOT get CXR –> immediate decompression is needed w/ large bore needle or chest tube

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70
Q

how do you perform chest decompression in tension PTX?

A

insert large bore needle in 2nd or 3rd IC space in midclavicular line

71
Q

which drugs are linked to interstitial lung disease?

A 
amiodarone
busulfan
nitrofurantoin
bleomycin
phenytoin
penicillamine
72
Q

what should you do if a pt comes in with digital clubbing?

A

obtain a CXR - there is likely underlying lung disease

73
Q

best diagnostic test for interstitial lung disease

A

high resolution CT scan

74
Q

CXR findings in interstitial lung disease

A

reticular or reticulonodular (ground glass) appearance

75
Q

PFTs in interstitial lung disease

A

decreased lung compliace = increased/normal FEV1/FVC
decreased lung volumes
decreased DLco

76
Q

“honeycomb” lung

A

scarred, shrunken lung - end-stage finding with poor prognosis (airspaces are dilated and there are fibrous scars in interstitium)

77
Q

MC clinical features in idiopathic pulmonary fibrosis

A

progressive exercise intolerance
cough and dyspnea
coarse crackles on auscultation
digital clubbin

78
Q

definitive diagnosis of idiopathic pulmonary fibrosis

A

open lung biopsy - must exclude other causes of ILD

79
Q

Tx. of IPF

A

steroids + azathioprine/cyclophosphamide ] only about 20% of pts will respond to this therapy (best prognostic indicator)
ultimately, need lung transplant

80
Q

Lofgren’s syndrome

A

acute sarcoid syndrome w/ fever, erythema nodosum, bilateral hilar LAD and arthritis

81
Q

Heerfordt Waldenstroms syndrome

A

acute sarcoid syndrome w/ fever, parotid enlargement, uveitis and facial palsy

82
Q

definitive dx. of sarcoidosis

A

transbronchial biopsy showing non-caseating granulomas (in context of clinical picture)

83
Q

CXR finding in sarcoidosis

A

bilateral hilar adenopathy

84
Q

lab findings in sarcoidosis

A
  1. elevated ACE level in serum
  2. hypercalciuria/hypercalcemia
  3. skin anergy
  4. PFTs showing restrictive pattern
85
Q

what type of exam should all pts suspected of having sarcoidosis have?

A

opthalmologic - 25% of cases have uveitis/conjunctivitis

86
Q

Tx. of choice in sarcoidosis

A

systemic steroids - high dose for 2 months, followed by 3 months of dose tapering

87
Q

which conditions in sarcoid MUST be treated with steroids?

A

uveitis
CNS involvement
hypercalcemia

88
Q

what drug can be used in sarcoidosis pts with progressive disease refractory to steroids?

A

methotrexate

89
Q

chronic interstitial pneumonia caused by abnormal proliferation of histocytes

A

Histiocytosis X

90
Q

gold standard for dx. of Wegener’s granulomatosis

A

tissue biopsy

- but if pt is positive for c-ANCA, likelihood of disease is high

91
Q

pt with asthma presents with pulmonary infiltrates, rash and eosinophillia

A

churg-strauss syndrome

92
Q

antibody assoc. with Churg-Strauss

A

perinuclear ANCA (p-ANCA)

93
Q

what is needed to consider diagnosis of asbestosis?

A

history of exposure - shipyard, foundries, mining, insulation, boilers, brake liners

94
Q

CXR findings in asbestosis

A

pleural plaques, calcifications at level of diaphragm and diffuse interstitial fibrosis mainly in lower lobes

95
Q

dx. of asbestosis

A

history of exposure, clinical findings - impt

definitive = lung biopsy showing barbell-shaped asbestos fibers

96
Q

tx. of asbestosis

A

none available - stop smoking!

97
Q

CXR findings in silicosis

A 
eggshell calcifications (rare)
hyaline nodules (1-10 mm) mostly in upper lobes
98
Q

what infectious disease is silicosis associated with and what should these pts do?

A

TB - should get yearly PPDs; if > 10 mm, 9 months isoniazid tx

99
Q

Caplan syndrome

A

rheumatoid nodules in periphery of lung in pts with RA and coexisting pneumoconiosis

100
Q

dx. of berylliosis

A

beryllium lymphocyte proliferation test (blood test)

101
Q

tx. of berylliosis

A

glucocorticoids

102
Q

hypersensitivity pneumonitis (extrinsic allergic alveolitis)

A

inhalation of antigenic agent to alveolar level induces immune-mediated pneumonitis (i.e. moldy hay, avian droppings, air conditioners, compost)

103
Q

hallmark finding in hypersensitivity pneumonitis

A

presence of serum IgG and IgA to inhaled antigen

104
Q

diagnosis of goodpasture’s syndrome

A

tissue biopsy

anti-GBM ab’s on serology

105
Q

Tx. of goodpasture’s syndrome

A

plasmapheresis
cyclophosphamide
steroids

106
Q

pulmonary alveolar proteinosis

A

accumulation of surfactant-like protein and phospholipids in the alveoli

107
Q

CXR findings in pulmonary alveolar proteinosis

A

ground glass appearance w/ bilateral alveolar infiltrates (resembling a bat shape)

108
Q

definitive dx. test for pulmonary alveolar proteinosis

A

lung biopsy

109
Q

Tx. of pulmonary alveolar proteinosis

A

lung lavage

new therapy - GCSF

110
Q

general criteria used to define acute respiratory failure

A
  1. hypoxia - PaO2 < 60 mmHg

2. hypercapnia - PaCO2 > 50 mmHg

111
Q

hypoxemic respiratory failure

A

low PaO2 with low/normal PaCO2 - present when O2 sat. is < 90% despite FiO2 > 0.6

112
Q

hypercarbic (ventilatory) respiratory failure

A

failure of alveolar ventilation due to either a decrease in minute ventilation or an increase in dead space leading to CO2 retention

113
Q

ventilation is monitored by…

A

PaCO2

- to decrease PaCO2 one must either increase RR or Tidal Volume

114
Q

oxygenation is monitered by…

A

O2 sat. or PaO2

- to decrease PaO2 one must either decrease FiO2 or PEEP

115
Q

ventilation, but no perfusion

A

V/Q mismatch

116
Q

perfusion, but no ventilation

A

intrapulmonary shunting

- venous blood is shunted into arterial circulation w/o being oxygenated

117
Q

features of V/Q mismatch respiratory failure

A

hypoxia w/o hypercapnia

- responsive to supplemental oxygen

118
Q

in what scenario is the Aa gradient normal in a setting of hypoxia?

A

hypoventilation

low inspired PaO2

119
Q

indication for NPPV

A

conscious patients with impending respiratory failure in an attempt to avoid intubation/mechanical ventilation

120
Q

success rates for NPPV (BIPAP, CPAP) are greatest for…

A

hypercarbic respiratory failure (esp. COPD pts)

121
Q

who is at highest risk of ARDS?

A

pts with sepsis or septic shock

122
Q

pathophysiology of ARDS

A

massive intrapulmonary shunting secondary to widespread atelectasis, collapse of alveoli and surfactant dysfunction secondary to neutrophil activation, elevated alveolar mb permeability and pulmonary edema

123
Q

clinical features in ARDS

A
  1. dyspnea, tachypnea, tachycardia
  2. progressive hypoxemia - not responsive to supplemental O2
  3. high peak airway pressures due to stiff, noncompliant lungs
124
Q

classic clinical criteria for diagnosing ARDS

A
  1. hypoxemia refractory to O2; ratio of PaO2/FiO2 < 200
  2. bilateral diffuse pulmonary infiltrates on CXR
  3. no evidence of CHF: PCWP < 18 mmHg
125
Q

PCWP

A

pulmonary capillary wedge pressure - reflect left heart filling pressures –> indirect marker of intravascular volume status

126
Q

tx of ARDS

A
  1. supplemental O2
  2. mechanical ventilation w/ PEEP
  3. fluid management - want PCWP bw 12-15
  4. treat underlying cause
127
Q

general indications for mechanical ventilation

A
  1. sig. respiratory distress/arrest
  2. impaired or reduced level of consciousness
  3. metabolic acidosis
  4. respiratory mm. fatigue
  5. sig. hypoxemia (PaO2 < 70) or sig. hypercapnia (PaCO2 > 50)
  6. respiratory acidosis (pH < 7.2) with hypercapnia
128
Q

swan-ganz catheter findings in ARDS

A

normal CO, normal PCWP

increased pulmonary artery pressure

129
Q

acceptable ranges of gas values in mechanical ventilation

A

PaO2 50-60
PaCO2 40-50
pH 7.35-7.50

130
Q

assisted controlled ventilation

A

ventilator delivers breath of predetermined TV when pt initiates breathing AND if pt does not initiate a breath, ventilator takes over at a predetermined rate

131
Q

synchronous intermittent mandatory ventilation

A

patient can breathe on their own above the mandatory set rate; ventilator breaths are synchronized with patient inspiratory effort so the two do not occur at the same time; if no breath initiated by patient, the mandatory breath is delivered by ventilator

132
Q

continous positive airway pressure

A

positive pressure is delivered continuously (0-20 cmH20) by ventilator, but not volume breaths are delivered i.e. pt breathes on his/her own

133
Q

pressure-support ventilation

A

used mostly during weaning; pressure is delivered with an initiated breathe to assist breathing

134
Q

how do you confirm proper endotracheal tube placement?

A

listen for bilateral breath sounds

check postintubation CXR - tip of ET tube should be 3-5 cm above carina

135
Q

difference between PEEP and CPAP

A

PEEP - during mechanical ventilation

CPAP - during spontaneous breathing

136
Q

side effects of high levels of PEEP

A
  1. barotrauma - pneumothorax

2. low CO due to decreased VR

137
Q

can a patient still aspirate with an ET tube?

A

yes

138
Q

preferred agents for sedation in mechanical ventilation

A

benzodiazepines

- opiods for analgesia

139
Q

what should you do if pt is mechnically ventilated for > 2 weeks?

A

tracheostomy - to decrease risk of tracheomalacia (softening of tracheal cartilage)

140
Q

definition of pulmonary HTN

A
  1. mean pulmonary arterial pressure > 25 mmHg at rest or > 30 mmHg with exercise
  2. systolic pulm. aa presure > 40 mmHg at rest
141
Q

main clinical features of pulmonary HTN

A

dyspnea, chest pain and syncope on exertion

142
Q

physical exam findings in pulmonary HTN

A

loud pulmonic cpt of S2 (P2) and subtle lift of sternum (sign of RV dilatation)

143
Q

gold standard for diagnosing pulmonary HTN

A

right heart catheterization

- can be estimated using Doppler 2D echo

144
Q

ECHO changes in pulmonary HTN

A

dilated pulmonary artery
dilated/hypertrophy of RA and RV
abnormal mvt of IV septum

145
Q

vasodilator trial in pulmonary HTN

A

give pt. inhaled NO, IV adenosine and oral CCBs under hemodynamic monitoring to predict response before initiating long-term tx

146
Q

tx. of primary pulmonary HTN

A
  1. CCBs - nifedipine, diltiazem
  2. vasodilators - sildenafil, bosentan, epoprostenol
  3. anticoagulation w/ warfarin
  4. lung transplantation
147
Q

what should you think of if a patient with long bone fracture develops dyspnea, mental status change and petechiae?

A

fat embolism

148
Q

when can you make the diagnosis of PE w/o further testing?

A

when patient has symptoms of PE and a DVT is found

149
Q

which situations can essentially R/O PE?

A
  • low probability V/Q scan (or normal helical scan)
  • negative pulmonary angiogram
  • negative D-dimers and low clinical suspicion
150
Q

ABG levels in PE

A

not diagnostic -> respiratory alkalosis (low PaO2, low PaCO2)
- elevated Aa gradient

151
Q

when should you perform a duplex venous ultrasound of lower extremities?

A
  1. if you suspect DVT

2. if you suspect PE and spiral CT cannot be done or is inconclusive

152
Q

initial diagnostic study of choice for PE?

A

helical CT scan

153
Q

normal V/Q scan

A

virtually R/O PE

154
Q

high probability V/Q scan

A

high sensitivity for PE - tx. pt with heparin

155
Q

if you have low or intermediate probability V/W scan

A

need further testing –> duplex USG, spiral CT or pulmonary angiography to confirm

156
Q

what do you do if dx. of PE is clinically unlikely? (decision rule score < 4)

A

D-dimer test

  • if normal: can R/O PE, no tx
  • if positive: do a CT Scan
157
Q

what do you do if dx. of PE is clinically likely (decision rule score > 4)?

A

spiral CT

  • if no PE (no tx) or if PE (tx)
  • if inconclusive or cannot be done -> do leg USG (if DVT, tx; if no DVT - do V/Q scan or pulm. angiogram)
158
Q

gold standard for diagnosis of PE?

A

pulmonary angiogram

159
Q

main tx. strategy for PE

A
  1. supplemental O2
  2. heparin - LMWH } start immediately based on clinical suspicion
  3. oral warfarin - long term
160
Q

contraindications for heparin

A

active bleeding
heparin induced thrombocytopenia
uncontrolled HTN
recent stroke

161
Q

warfarin tx for PE

A

start with heparin, continue for 3-6 months depending on risk factors; want INR between 2-3

162
Q

which conditions warrant an INR between 2.5-3.5

A

prosthetic mechanical heart valves
prophylaxis of recurrent MI
antiphospholipid syndrome

163
Q

when should you consider thrombolysis in PE management?

A

not routinely used; consider in:

  • pts with massive PE and hemodynamically unstable
  • pts w/ evidence of RHF/cardiogenic shock
164
Q

indications for using an IVC filter in PE management

A
  • contraindication to anticoagulation
  • complication of current anticoagulation
  • failure of adequate anticoagulation
  • pt w/ low pulmonary reserve who is at high risk of death from PE
165
Q

where do aspirated contents usually end up?

A

lower segment of Right UPPER lobe

upper segment of RIGHT lower lobe

166
Q

what antibiotics do you give if you suspect aspiration pneumonia?

A

penicillin G or clindamycin

167
Q

how do you prevent aspiration in high risk patients?

A

keep head of bed elevated

nasogastric tube placement to decompress stomach

168
Q

definition of massive hemoptysis

A

> 600 ml of blood in 24 hrs

169
Q

MCC of massive hemoptysis

A

bronchiectasis

bleeding diathesis

170
Q

what diagnostic studies should be done in a pt w/ hemoptysis?

A

CXR
bronchoscopy
CT scan of chest

171
Q

causes of low DLco

A 
emphysema
sarcoidosis
interstitial fibrosis
pulmonary vascular disease
anemia
172
Q

causes of high DLco

A 
asthma
obesity
intracardiac L-R shunt
exercise
pulmonary hemorrhage
173
Q

normal V/Q ratio

A
  1. 8

- if higher, indicates inadequate perfusion of adequately ventilated lung

Internal Medicine (9 decks)

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