RC Respirology Flashcards

Question

Relative Contraindications to PEEP

Answer 1

High ICP Hypotensive RV failure Right to left shunt Barotrauma Bronchopleural fistula

Answer 2

PETCO usually lower Due to anatomical dead space

Answer 3

ROSC (increase by 10-20) Effective CPR Hyperthyroidism Hyperthermia Fever, sepsis Hypoventilation Bronchial intubation

Answer 4

Hypotension, shock Cardiac arrest Hypothyroidism Hypothermia Hyperventilation Apnea Extubation, sudden kink

Answer 5

Mode:volume (but no data > pressure) FiO2: SpO2 88-92 PEEP: minimal, 5 RR: 10-12% Vt: <8 mL/kg PBW I:E target: 1:5 Permissive hypercapnia (pH >7.2, pCO2 <90)

Answer 6

Mode: volume FiO2: 88-95% PEEP: Modest RR: 25-35 Vt: 4-6 mL/kg/PBW I:E target: 1:2 Permissive hypercapnia (pH >7.2) Pplat

Answer 7

Reduced autoPEEP Reduce barotrauma Decrease WOB

Answer 8

Obstruction - prevent autoPEEP Restriction - low tidal volumes

Answer 9

Increased ICP Decrease seizure threshold Arrhythmias, irritable myocardium Increased PVR 2/2 acidosis Decreased placental flow

Answer 10

Not opioids for sedation 2/2 histamine Large ETT to reduce resistance Consider inhaled isoflurane Consider heliox Consider Hodder’s maneuver Consider ECMO

Answer 11

Low density Density is important in turbulent flow (large airways) Viscosity is important in laminar flow (smaller airways)

Answer 12

Tells you what CO2 should be if appropriately compensated Use this to determine goal Ve

Answer 13

Within 7 days of a known insult or worsening symptoms Non cardiogenic pulmonary edema, not due to intravasc volume overload Bilateral pulmonary opacities not explained by nodules, atelectasis, effusion, etc. (CXR OR CT, or lung ultrasound by trained professional) Seen in 2 quadrants (bilat or unilat) Severity grading on PEEP 5 PaO2/FiO2<300 SpO2/FiO2 <315

Answer 14

Inhalation exposures Aspiration Fresh water, salt water aspiration, drowning Fat embolism Reperfusion injury Infections, pneumonia, sepsis Pancreatitis Transfusion reaction

Answer 15

1. Early exudative: 1 week, high permeability pulmonary edema, proteinaceous fluid fills alveoli, hyaline membrane formation, pathology shows DAD 2. Fibroproliferative: 2 weeks, interstitial inflammation, disordered healing, fibrosis 3. Fibrotic: fibrosis, obliteration of normal lung architecture

Answer 16

Dependent opacities, consolidation Bilateral, symmetrical

Answer 17

Increase PEEP, mortality benefit in mod-severe Prone positioning, 12hrs/day, PF <150 mortality benefit (It should be administered within 48 hours, evaluated daily and stopped within 48 hrs if possible) Euvolemia Steroids in some Neuromuscular blockade Inhaled NO ECMO

Answer 18

Improve V/Q matching Improve secretion mobilization + drainage Decrease compressive effects of heart

Answer 19

PaCO2 >60 for >6 hours PF <80 for >6 hours PF <50 for >3 hours Mechanically ventilated <7 days, BMI <40, age 18-65

Answer 20

Disseminated malignancy Known severe brain injury Severe chronic organ dysfunction Severe pulmonary hypertension

Answer 21

Hypotension Barotrauma VALI VAP Airway complications e.g. stenosis, tracheobronchomalacia, fistula formation Critical illness polyneuropathy, myopathy

Answer 22

High Pplat* High PIP* High PEEP* Low compliance* e.g. ILD, COPD, overload

Answer 23

Reduce RR Reduce Vt Increase expiratory time Permissive hypercapnia Increase sedation Reduce PEEP

Answer 24

Reduced sedation Phonation Better secretion management, better mouth care Allows mobility Prevents laryngeal injury Can leave ICU

Answer 25

Bleeding Surgical site infection Dislodgement Tube is kinged or clogged Laryngeal nerve damage Pneumothorax

Answer 26

Dislodgement Trach blockage Tracheal stenosis Tracheobronchomalacia Tracheoesophageal fistula Tracheoarterial fistula

Answer 27

Due to volutrauma Alveolar overdistension Presents with edema, hemorrhage, loss of compliance

Answer 28

Underlying resp condition resolved or improving/on active treatment GCS >8 PaO2 >60 on FiO2 requirements <40% on PEEP <8 PF ratio >150 PaCO2 normal Adequate cough Not requiring frequent suctioning e.g.

Answer 29

RR/TV >105 Predictive of failed extubation

Answer 30

RR/VT = RSBI <105 Maintaining adequate ventilation Maintaining adequate oxygenation No signs of severe fatigue

Answer 31

Reintubation within hours-days

Answer 32

Age >65 Underlying cardiorespiratory disease RSBI >105 Abundant endotracheal secretions Weak or absent cough Positive fluid balance in last 24 hours Respiratory failure was for cardiac origin, PNA, neurological condition

Answer 33

Reduced drive from over sedation or neurological problem Underlying disease not yet resolved Respiratory muscle weakness, deconditioning Development of atelectasis, mucous plugging - poor/weak cough VAP/VALI development Oversedation Under Sedation - anxiety, pain Neuropathy or myopathy from prolonged intubation Malnutrition - respiratory muscle weakness Overnutrition - increased CO2 production Cardiomyopathy, cardiac ischemia Anemia

Answer 34

Anxiety, agitation, diaphoresis Hypertension or hypotension - not between 90-180 Tachycardia - HR >140, arrhythmia Tachypnea - RR >35 x 5 mins Increased work of breathing - accessory muscle use, thoracoabdominal paradox Fall in O2 (<90%), increase in CO2 - hypoxemia and hypercapnia Stridor

Answer 35

Increased CO2 (Bohr effect) Increased H Increased temperature Increased 2,3 DPG

Answer 36

Decreased CO2 (Bohr effect) Decreased H Decreased temperature Decreased 2,3 DPG Increased CO

Answer 37

PAO2 - POI2, PaCO2 Architecture of the lungs

Answer 38

PaO2 Temperature H CO2 2,3 DPG

Answer 39

Carboxyhemoglobinemia Methemoglobinemia Sulfhemoglobinemia

Answer 40

Nail polish Pigments, methylene blue Poor circulation - Raynaud’s, peripheral vascular disease, shock Hemoglobinemia - e.g. methemoglobinemia, sulfhemoglobinemia, thalassemia, sickle cell anemia, spherocytes etc Motion or artifact Technical factors

Answer 41

Headaches, decreased LOC, personality changes, headaches, seizures Arrhythmias, cardiac ischemia Cherry red skin and lips

Answer 42

Supplemental oxygen Hyperbaric oxygen Eucapnic hyperventilation

Answer 43

Severe end organ sx e.g. MI CO-Hb >/25% CO-Hb >/15% if pregnant Severe metabolic acidosis pH <7.1

Answer 44

PaO2 normal SpO2 normal SaO2 decreased CaO2 decreased CvO2 decreased

Answer 45

PaO2 normal SpO2 normal SaO2 decreased (I think Normal) CaO2 normal CvO2 increased

Answer 46

Supplemental oxygen Hydroxocobalamin Nitrites Avoid dialysis

Answer 47

5 mg/kg without epi 7 mg/kg with epi

Answer 48

BZD Lipid emulsion

Answer 49

Pneumothorax untreated - absolute Obstructive lung disease - relative Blebs or bullous disease - relative

Answer 50

CO poisoning Venous or arterial air embolism Decompression sickness

Answer 51

Lidocaine, benzocaine Methylene blue Metoclopramide Dapsone Nitrates Primaquine

Answer 52

Levels >30% Very symptomatic

Answer 53

Neck, facial burns Laryngeal injury - Stridor Tracheobronchial injury - cough, wheezing, melanoptysis Paryncheal injury Systemic toxicity e.g. CO poisoning etc

Answer 54

Insomnia Sleep disordered breathing - OSA, CSA, OHS, Nocturnal Desaturation Hypersomnolence Parasomnias Sleep related movement disorders Circadian rhythm sleep wake disorders Other

Answer 55

4 hrs per night At least 70% of nights in last month

Answer 56

Moderate-severe OSA, not compliant Compliant but involved in MVC where they were at fault - x 1 month until compliance reassessed Drivers admit to experiencing excessive sleepiness during major wake periods or while driving

Answer 57

AHI >/30 in treated or untreated

Answer 58

Uncontrolled cataplexy (on or off treatment) in the past 12 months Uncontrolled daytime sleep attacks or sleep paralysis in the past 12 months Generally no long distance commercial driving

Answer 59

AHI <20 On effective treatment Does not experience excess sleepiness during major wake periods

Answer 60

Everyone should be screened with questionnaires, BMI and studies as needed Recertified annually

Answer 61

PAP - one week, good compliance, good AHI, no sleepiness Oropharyngeal surgery or trach - one month, good AHI, no sleepiness Bariatric surgery - six months, good AHI, no sleepiness

Answer 62

N1 - 5% N2 - 50% N3 - 20% REM - 25%

Answer 63

Usually in N2 Fast burst 0.5-2s of 12-15 Hz activity

Answer 64

Usually in N2 Go up first, then down High-Amplitude/Biphasic

Answer 65

At least 50% of the epoch

Answer 66

At least 20% of the time

Answer 67

Slow wave sleep Deep sleep

Answer 68

Low amplitude, mixed frequency REM atonia → low chin EMG Rapid eye movements May see sawtooth waves

Answer 69

OSA worsens, CSA improves (reduced chemosensitivity so won't be as sensitive to changes in Co2 Hypovent and hypoxemia in NMD or chest wall disorders (bc loss of accessory muscles during atonia) **

Answer 70

1. Narcolepsy 2. REM Rebound 2a. Depression 2b. Medication withdrawal e.g. SSRIs, BZD, alcohol 2c. REM sleep deprivation 2d. Patients undergoing CPAP titration

Answer 71

SSRIs Monoamine oxidase inhibitors Sedative hypnotic drugs, barbiturates Antiepileptics Alcohol

Answer 72

Stimulate: theophylline, acetazolamide, progesterone, thyroid hormone Inhibit: BZD, barbiturates, gabapentinoids, alcohol

Answer 73

Decrease in N3 Increase in N1 and N2 No change in REM Increased WASO - wake after sleep onset More arousal Lower sleep efficiency Body’s clock shifts earlier

Answer 74

Decreased BP, HR, CO (increase in phasic REM) Decreased RR, VT, VE; RR generally increase in REM PaCO2 increase 3-5 mmHg PaO2 decrease 5-8 mmHg; SpO2 decrease 1-2% Increased upper airway resistance

Answer 75

At least 2 hours of sleep Other normal values (not required): 80% efficiency, <30 mins sleep onset, <90 mins REM onset

Answer 76

EEG EOG EMG ECG Airflow (2) Respiratory efforts (2) SpO2 CO2 measurement

Answer 77

Oronasal thermistor - apnea Nasal pressure transducer - hypopnea, RERA

Answer 78

RIP belt (respiratory inductance plethysmography) Esophageal pressure monitoring Diaphragmatic EMG

Answer 79

Within 4 weeks if high risk Within 6 months for all others

Answer 80

Moderate-high pretest probability Do not suspect other sleep disorders Do not have other comorbid diseases Not a titration study

Answer 81

Excessive Daytime Sleepiness on most days with 2 of the following: Snoring Witnessed apneic episodes Witnessed choking during sleep Witnessed gasping during sleep Diagnosed HTN

Answer 82

Cardiorespiratory disease History of stroke Respiratory muscle weakness, NMD Suspicion for hypoventilation

Answer 83

II: Full PSG but done at home III: airflow, effort, ECG, pulse oximetry IV: pulse oximetry

Answer 84

Moderate-severe OSA based on at least 2 hours of recordings 3 hours available for titration

Answer 85

Apnea: decrease in flow >/90% from baseline x >/10 seconds Hypopnea: decrease in flow >/30% from baseline x >/10 seconds and accompanied by desaturation of SaO2 by 3% or arousal

Answer 86

Obstructive: snoring, thoracoabdominal paradox, increased insp flattening of nasal pressure compared to baseline Central: None of the above

Answer 87

Starts out as central, then obstructive

Answer 88

Increase in resp effort or flattening of nasal pressure waveform Event causes arousal or desaturation without meeting appropriate criteria x 10 s

Answer 89

Increase in PaCO2 >55 mmHg x 10 mins Increase in PaCO2 by >/10 mmHg to a value above 50 mmHg x 10 mins

Answer 90

AHI = Apnea + hypopnea/total sleep time RDI = Apnea + hypopnea + RERA/total sleep time

Answer 91

Insufficient sleep Sleep disordered breathing - OSA, CSA, hypoventilation, etc. Central Sleep disorders-Narcolepsy, Kleine-Levin syndrome, Idiopathic hypersomnelence. Circardian rhythm sleep disorders Sleep related movement disorders Parasomnias- RBD, sleep walking, sleep terrors, confusional arousals. Neurologic disorders - Parkinson's, dementia, stroke, MS Medical: -Hypothyroidism , Adrenal insufficiency , Anemia, iron deficiency , CKD, renal failure, hepatic encephalopathy Depression, other psychiatric conditions Medications, substances

Answer 92

OHS Difficult to control HTN Recurrent atrial fibrillation post cardioversion or ablation Pulmonary Hypertension

Answer 93

Cranial nerves 5,7,9,10,11,12

Answer 94

Smoking Elevated BMI Family history Increased age Male, post menopausal Increased mallampati score Tonsil or adenoid hypertrophy Increased neck circumference Retrognathia Micrognathia Macroglossia Nasal abnormalities Low lying palate Hypothyroidism Acromegaly Neuropathy or myopathy

Answer 95

Underlying lung disease Baseline supine SaO2 Low FRC (e.g. obesity) Duration of apneic/hypopneic episodes Frequency of apneic /hypopneic episodes Respiratory efforts in between apneic/hypopneic episodes

Answer 96

Hypertension Coronary artery disease Arrhythmias Stroke Heart failure PH if concomitant OHS Diabetes Erectile dysfunction Depression Cognitive deficits MVCs

Answer 97

Berlin questionnaire STOP-Bang questionnaire (high sensitive, poor specificity)

Answer 98

Symptoms/complications + AHI >/5 AHI >/15

Answer 99

Mild: >/5 - 14.9 Moderate: 15 - 29.9 Severe: >/30

Answer 100

Supine AHI is at least double non supine AHI

Answer 101

Moderate to severe OSA/ AHI >/15 Mild but symptoms (e.g. EDS), reduced QOL, or hypertension Critical occupation

Answer 102

Start at 4 cm H2O Switch to BPAP 15 cm H2O Absolute max 20 cm H2O

Answer 103

Min difference of 4 cm H2O Max difference of 10 cm H20 Min pressure 4 cm H2O, Max pressure of 30 cm H2O

Answer 104

>/2 apneic events >/3 hypopneic events >/5 RERAs >/3 mins snoring Any of this within a 5 min period Want >/ 30 mins without breathing event

Answer 105

1. Optimal: RDI <5 for at least 15 mins, supine sleep observed, REM sleep not interrupted by spontaneous arousals, O2 sat >90% 2. Good: RDI 90% 3. Adequate: RDI not 90% 4. Unaccepted: None of the above are met

Answer 106

Non adherence/compliance Additional medical condition Additional sleep disorder Treatment emergent central sleep apnea Inadequate pressures/not fully controlled Sleep deprivation/insufficient sleep

Answer 107

Modafinil Solriamfetol

Answer 108

Ongoing EDS despite appropriate treatment Concomitant narcolepsy Concomitant circadian rhythm disorder Certain occupations - shift workers (Temporary)

Answer 109

Education Humidity Nasal mask vs. full face mask Treatment of nasal congestion Polypectomy Oral appliance APAP

Answer 110

Improved AHI (all stages) Improved symptoms: Definitely moderate-severe, unclear mild Decreased BP: moderate-severe PAP also improves responsiveness of Afib to tx, ?improve outcome after stroke

Answer 111

Chronic lung disease e.g. COPD Previous UPPP (Uvulopalatopharyngoplasty) Heart failure Central sleep apnea OHS/hypoventilation syndrome Medications causing hypoventilation e.g. chronic opioid use Neuromuscular disease, chest wall disorder

Answer 112

Positional therapy Oral appliances Surgery Hypoglossal nerve stimulation Weight loss

Answer 113

Primary snoring disorder without OSA OSA but intolerant of or unwilling to try PAP (vs. no treatment) To reduce PAP pressures Not responsive to CPAP

Answer 114

Dental malocclusion TMJ pain Gum pain Drooling or dry mouth

Answer 115

UPPP (Uvulopalatopharyngoplasty) Mandibular advancement Tonsillectomy, adenoidectomy Tracheostomy

Answer 116

Intolerant of PAP/high pressures Cannot achieve control with other treatment Other abnormalities prevent adequate mask fitting Other reasons for tracheostomy e.g. craniofacial weakness Patient preference

Answer 117

Mean nocturnal saturation (92) Nadir SpO2 Time spent

Answer 118

<10 = unlikely moderade-severe OSA 10-30 = possible moderate-severe OSA >30= highly suggestive of moderate-severe OSA but technically <5 is normal and >10 is abnormal

Answer 119

Spo2 <88% for >5min Spo2 <90% for >10% of sleep time.

Answer 120

Reduction in SpO2 >/4% for >/10 seconds

Answer 121

Difficulty sleeping or maintaining sleep Adequate opportunities for sleep Affect functioning

Answer 122

Increased WASO Increased sleep latency >/30 minutes Reduced sleep efficiency Reduced sleep time <6-6.5 hours

Answer 123

Medications e.g. stimulants, coffee Psychiatric e.g. depression, anxiety Neurologic e.g. parkinsons, dementia Chronic pain, diabetes, HTN, cancer

Answer 124

1. Primary central sleep apnea 2. Primary central sleep apnea of infancy or prematurity 3. CSA with Cheyne stokes 4. CSA due to medical disorder without Cheyne Stokes - 4a. Central insult e.g. tumour, stroke, encephalitis, polio - 4b. Respiratory muscle weakness e.g. NMD, chest wall disease - 4c. Renal failure - 4d. Atrial fibrillation 5. High altitude periodic breathing 6. Treatment emergent central sleep apnea 7. Medication or substance related

Answer 125

Opioids Benzodiazepines Gabapentinoids Antidepressants

Answer 126

Cessation or reduction in ventilatory effort x >/10 seconds Most common in N1/N2 No effort via RIP belt or diaphragmatic EMG >/5 central events per hour and >50% of total events Snoring and desats are less prominent than OSA

Answer 127

1. - >/3 consecutive central apnea/hypopneas with crescendo and decrescendo changes in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90) 2. - >/5 central apneas/hypopneas per hour associated with crescendo,decrescendo breathing in between recorded over min 2 hours

Answer 128

Symptoms/predisposing condition (HF, neurologic dz, AF) PSG criteria Not better explained by other disorder

Answer 129

Cycle length longer >40 seconds Period of hyperpnea is longer O2 saturation nadir is more delayed (prolonged circulation time) Arousals during hyperpnea whereas at end of apnea with CSA

Answer 130

Heart failure Renal failure Central disease e.g. stroke, tumors Medications e.g. sedatives

Answer 131

1. Apnea 2. Increased circulatory time 3. Increased chemoreceptor responsiveness to CO2 4. Increased loop gain - increase in response size 5. Apnea

Answer 132

TECSA: obstruction relieved, CO2 falls, apnea, high loop gain (treatment emergent central sleep apnea) Altitude: increased vent due to O2, CO2 falls, apnea, high loop gain Opioids: hypoventilation

Answer 133

Increased mortality Occurs in 30% of patients with HF

Answer 134

GDMT of HF, transplantation Nocturnal oxygen CPAP therapy - (not the other OSA tx) - BPAP used with caution bc can have same effect as ASV, so avoid Phrenic nerve stimulation ?Acetazolamide, theophylline [limited evidence]

Answer 135

Improve AHI Improve arrhythmias May improve LV function

Answer 136

adaptive servoventilation (ASV) increased all cause mortality in HFrEF <45% Contraindicated

Answer 137

Idiopathic → BPAP-ST, ASV, CPAP CSA 2/2 hypoventilation → BPAP-ST, ASV > CPAP Altitude → descend, oxygen, acetazolamide Treatment emergent → expectant, ASV > BPAP-ST, oxygen, acetazolamide

Answer 138

Hyperpnea mix with apnea Associated with meningitis

Answer 139

Increased WASO (Wakefullness after sleep onset) Increased N1, N2 Decreased N3 Kind of like aging

Answer 140

Carbonic anhydrase inhibitor Leads to increased bicarbonate excretion Causes metabolic acidosis, stimulates breathing

Answer 141

Idiopathic central alveolar hypoventilation syndrome Congenital central alveolar hypoventilation syndrome Obesity hypoventilation syndrome Sleep related hypoventilation due to disorder, medication, substance

Answer 142

Autosomal dominant PHOX2B gene mutation → loss of RTN Also known as Ondines Curse

Answer 143

Fat produces more CO2 Leptin suppresses respiratory drive Altered respiratory mechanics(TLC N/**reduced at BMI>40,** **FRC reduced**, RV normal/increased, RV/TLC normal/increased, **ERV low**, ).

Answer 144

BMI >30 with OSA (known or suspected) BMI >30 with: - Unexplained dyspnea - Unexplained awake hypoxemia - Pulmonary hypertension, signs of it - Polycythemia, sx of it (e.g. facial plethoraX) - Elevated bicarbonate

Answer 145

Bicarbonate >27 Straight to PaCO2 if high pretest probability

Answer 146

BMI >30 Awake PaCO2 >45 Hypoventilation not explained by another disorder e.g. lung disease (PSG is required to assess for OSA, not absolutely needed for diagnosis but almost always done)

Answer 147

AHI >30 → CPAP first AHI <30 → BIPAP-ST No OSA → BiPAP-ST Weight loss (25-50%), not sole treatment If admitted with resp failure → BIPAP-ST> APAP until sleep study

Answer 148

Oxygen Respiratory stimulants

Answer 149

Primary - Idiopathic hypersomnia - Kleine Levin syndrome - Narcolepsy Secondary - Genetic disorder - CNS disorder e.g. stroke - Parkinsons - Post traumatic - Metabolic encephalopathy

Answer 150

Narcolepsy Idiopathic hypersomnolence Due to PD, post traumatic, genetics, central tumour, metabolic REM rebound: - Depression - Medication withdrawal e.g. SSRIs, BZD, alcohol - REM sleep deprivation - Patients undergoing CPAP titration

Answer 151

PSG the night before (NOT split night) >/ 6 hours of sleep on PSG Withhold REM suppressing medications x 2 weeks

Answer 152

Idiopathic Autoimmune, post infectious Neurosarcoid CNS - strokes, tumors

Answer 153

Sleep attacks during the day and EDS Hypognogic Sleep paralysis +/- cataplexy

Answer 154

Mean sleep onset latency /2 SOREMPs

Answer 155

Selective DA reuptake inhibitor - Modafinil Selective NE and DA reuptake inhibitor - Methylphenidate - Solriamfetol DA reuptake inhibitor - dextroamphetamine H3 blocker - pitolisant Other - Sodium oxybate: GHB - Venlafaxine for cataplexy

Answer 156

Parkinsons MSA, other forms of dementia Stroke, tumour Narcolepsy SSRIs

Answer 157

Changes to make sleeping area safe Melatonin Clonazepam

Answer 158

Insomnia Hypersomnolence REM sleep behavior disorder Restless leg syndrome Excessive daytime sleepiness

Answer 159

Central sleep apnea Hypoventilation Obstructive sleep apnea Insomnia

Answer 160

Iron deficiency Pregnancy Uremia Parkinson disease, spinal cord disease, prolonged immobility SSRIs + other meds Family history Thyroid dysfunction

Answer 161

4 consecutive flexion movements, 5-90 s apart is a series (counts as 1). The movement is 0.5-10 s, 8mV in amplitude above resting EMG Can't be during a resp event.

Answer 162

Periodic leg movement index (PLMI) >/15 per hour Not explained by another cause e.g. other sleep disorder

Answer 163

Urge to move limbs Rest worsens symptoms Getting up/moving relieves Evenings/Night are worse Dysfunction (causes concern) (URGE-D)

Answer 164

Iron replacement -if serum ferritin <75ng/mL or TSAT <20% IV or oral iron supplementation -If serum ferritin 75-100 then only IV iron -If ESRD then use IV iron Sucrose when ferritin <200 and TSAT <200 -IV ferric carboxymaltose (strong recommendation) can use IV LMW iron dextran, IV ferumoxytol, ferrous sulfate, but conditional recommendations Alpha-2-delta calcium channel ligands (Strong recommendation) -gabapentin -gabapentin encarbil (long acting gabapentin) - pregabalin Opioids Peroneal nerves stimulation Dipyridamole Vitamin C if ESRD DO NOT USE: Gabapentinoid - pregabalin, gabapentin DA agonist - pramipexole, ropinirole DA analogue - carbidopa-levodopa

Answer 165

Advanced sleep- wake phase Disorder (light therapy) Delayed sleep phase wake phase Disorder (melatonin) Irregular sleep-wake rhythm disorder (light therapy and no sleep aids for elderly. For younger patients=melatonin) Non 24H Sleep wake rhythm disorder (Strategic melatonin in blind patients) Caused by inbalance between process C and S

Answer 166

Diaphragm - C3/4/5 Intercostals - thoracic nerves Abdominal - lumbar nerves Upper airways - cranial nerves

Answer 167

Cerebral cortex - stroke, cancer Brain stem/basal ganglia - stroke, cancer Spinal cord - trauma, MS Anterior horn cell - polio, post polio, ALS Motor nerves - ALS NMJ - MG, LEMs Muscles - muscular dystrophy (duchenne and becker)

Answer 168

ALS Mid-low c-spine injury airways disease

Answer 169

Obesity T spine injury pregnancy

Answer 170

Sitting and supine VC MIP, MEP SNP Sniff esophageal pressure Phrenic nerve EMG Sniff transdiaphragmatic pressure

Answer 171

Bulbar symptoms UMN symptoms: spasticity, hyperreflexia, extensor plantar LMN: atrophy, fasciculations

Answer 172

Concomitant OSA (?CSA, mixed>OSA) Concomitant hypoventilation - resp muscle weakness Central hypoventilation (loss of cortical drive to breath) Underlying lung (e.g. VQ mismatch due to microatelectasis), heart, PVD disease Upward shift in ventilatory setpoint for PaCO2 by 2-3 mmHg

Answer 173

REM → NREM → daytime Loss of accessory muscles in REM

Answer 174

Clinical symptoms FVC sitting Supine FVC, MIPS, MEPS, SNPs Cough hx, PCF Arterial blood gas/TcCO2 if hypercapnia suspected, or bulbar sx preclude PFT Nocturnal oximetry/PSG if SDB suspected

Answer 175

Orthopnea FVC <50% predicted (Upright reliable<65% Canadian Best Practice 2020) Sitting or supine FVC <80% predicted with sx and other indicator of resp muscle weakness MIPS or SNPS <-40 cm Daytime PaCO2 >45 mmHg Abnormal nocturnal oximetry or symptomatic Sleep disordered breathing: - Sleep disordered breathing as defined by oxygen saturation < 90% for > 5% of the night or < 88% for 5 consecutive minutes or a 10 mmHg increase in TcCO2 during sleep AND any of the following symptoms: dyspnea, morning headache, daytime sleepiness, or non-refreshing sleep.(CTS 2019) *Start with S/T mode over S mode (CTS 2019)

Answer 176

FVC <50% predicted SNP <-40 MIP <-40

Answer 177

HrQOL Some physiological parameters e.g. slowing VC decline, daytime PaCO2 Mortality

Answer 178

Respiratory muscle training Diaphragmatic pacing

Answer 179

HrQOL Mortality

Answer 180

Fluoroquinolones Aminoglycosides Macrolides Beta blockers Procainamide Checkpoint inhibitors Iodinated contrast

Answer 181

Maintenance - pyridostigmine Flare - steroids, PLEX, IVIG

Answer 182

More proximal muscle weakness More ANS abnormalities Less bulbar muscle involvement

Answer 183

Weak cough Bulbar dysfunction - Aspiration pneumonitis, aspiration pneumonia Respiratory muscle weakness - hypoventilation, atelectasis Sleep disordered breathing Dysautonomia and bronchospasm

Answer 184

FVC <60% predicted Onset to admission <7 days Inability to stand, life arms up, life head off pillow Presence of facial weakness Inability to cough

Answer 185

20-30-40 rule (each as separate point) : VC<20 MIP < -30 MEP < 40 Severe bulbar weakness, cannot protect airway Respiratory rate sustained >30 Hypoxemia/SpO2 <92% Hypercarbia >50mmHg Hemodynamic instability

Answer 186

IVIG, PLEX

Answer 187

BMD (Becker) DMD (Duchenne)- worse

Answer 188

VC <40% in DMD VC <60% in other muscular dystrophies Therefore, screening PaCO2 in those with VC <40%

Answer 189

Trauma Idiopathic

Answer 190

Exertional dyspnea Orthopnea Bendopnea Sleep disordered breathing symptoms

Answer 191

Paradoxical motion in unilateral Paradoxical abdominal wall retraction

Answer 192

Imaging Sniff test - ultrasound, fluoroscopy Sitting and supine test MIP, SNP EMG of diaphragm, transdiaphragmatic pressure

Answer 193

MEP/MIP >1.5 for unilateral MEP/MIP >3 for bilateral

Answer 194

Unilateral: occasional hypoventilation, atelectasis Bilateral frequent hyperventilation, atelectasis, PNA, resp failure

Answer 195

Unilateral: plication Bilateral: NIV, pacing

Answer 196

* FVC < 80% associated with symptoms such as tachypnea and use of accessory muscles, tachypnea, excessive fatigue, excessive daytime sleepiness * SNIP < 40 mmHg * MIP < 60 mmHg (?<40 ALS) * Daytime hypercapnia PCO2 > 45 mmHg * Nocturnal saturation < 88% for 5 consecutive minutes

Answer 197

Idiopathic Congenital - spinal/vertebral malformations at birth Cartilage disorders - Marfan syndrome, EHD Bony disorders - e.g. osteopenia, osteoporosis Neuromuscular disorders - e.g. muscular dystrophy, cerebral palsy, Charcot Marie Tooth Post thoracoplasty

Answer 198

Cobb’s angle >110 degrees VC <45 degrees in surgically untreated (we start monitoring at VC <50%) Concomitant NMD Concomitant lung disease

Answer 199

Once FVC <50%, we look for hypercapnic resp failure

Answer 200

Nocturnal NIV +/- O2 Nocturnal O2 if just hypoxemia

Answer 201

Secretion clearance Reduce airway resistance Improve respiratory system compliance Prevent atelectasis Prevent pneumonia Prevent respiratory failure, prevent need for trach or intubation Decrease work of breathing

Answer 202

PCF <270 L/minute MEP <60 cm H2O Bulbar dysfunction Expiratory cough flow tracing - absence of transient increase in expiratory flow (cough spikes)

Answer 203

Atropine Scopolamine Botox injection into salivary glands (submandibular and parotid) Salivary gland RT

Answer 204

PCF <270 L/minute

Answer 205

Lung volume recruitment - glossopharyngeal breathing, bag valve mask Manually assisted cough Mechanical insufflation and exsufflation device

Answer 206

Unconscious or unable to communicate Increased ICP, severe TBI SIgnificant hypotension Pneumothorax, risk for barotrauma e.g. bullous disease Hemoptysis ?Cannot protect their airway e.g. severe bulbar weakness

Answer 207

Loss of consciousness, unable to protect airway Requiring intubation Hemodynamic instability Facial trauma or deformity Hemoptysis Upper GI bleeding, perforation or recent surgery

Answer 208

Non compliance or low duration Pressures are not optimal Disease progression Underlying lung disease Compensation for metabolic alkalosis

Answer 209

Cough assist Secretion mobilization and volume Daytime mouthpiece ventilation Smoking cessation Vaccination

Answer 210

Lymphoproliferative disorders Connective tissue diseases Cryptogenic organizing pneumonia Radiation pneumonitis Sarcoidosis Hypersensitivity pneumonitis NSIP Drug induced pneumonitis

Answer 211

Infections - fungal, PJP, helminthic ABPA Hodgkin’s lymphoma Eosinophilic pneumonia Asthma, bronchitis EGPA Drug induced pneumonitis Bone marrow transplant

Answer 212

Infection Bronchitis Aspiration pneumonia UIP/IPF Asbestosis ARDS, DAD Connective tissue diseases

Answer 213

>25% >50% is especially suggestive of HP or cellular NSIP

Answer 214

Eosinophilic pneumonia Hypersensitivity pneumonitis Organizing pneumonia Occupational asthma Diffuse alveolar hemorrhage ARDS Drug induced sarcoid reaction, vasculitis and lupus Bronchiolitis - obliterative bronchiolitis Fibrosing mediastinitis Pleural effusions Pulmonary hypertension Alveolar hypoventilation

Answer 215

Older age >/2 months of therapy >/400 mg oral daily Total cumulative dose High FiO2 administration Underlying lung disease

Answer 216

Older age Cigarette smoking Higher doses (>400 units) Concomitant radiation Concurrent cisplatin or cyclophosphamide High FiO2 administration Underlying lung disease

Answer 217

Older age Female Renal impairment

Answer 218

Phenytoin Methotrexate

Answer 219

Resting hypoxemia: dyspnea, QOL, ?PH Ambulatory hypoxemia: Exercise tolerance

Answer 220

CPFE* Chronic sarcoidosis* Chronic HP* RB-ILD* LAM PLCH Lymphangitic carcinomatosis Heart failure

Answer 221

Clustered cystic airspaces, 3-10 mm in diameter with walls 1-3mm thick usually subpleural

Answer 222

Small linear opacities with intra and interlobular thickening

Answer 223

Hazy increased lung opacity with preservation of bronchial and vascular markings

Answer 224

Increased attenuation that obscures the margins of vessels and airways

Answer 225

Well defined focal lucency with variable wall thickness bust usually thin (less than 2mm)

Answer 226

small round focal opacity <3mm in size

Answer 227

Patchwork of regions of differing attenuation

Answer 228

INPULSIS 1 and 2: nintedanib in ILD (Primary outcome: annual change in FVC * INPULSIS-1: 125.3 ml/year * INPULSIS-2: 93.7 ml/year Myocardial infarcts: * higher incidence in Nintedanib group 1.5% vs 0.5% * MACE 0.6% nintedanib vs 1.8% placebo Kolb et al. Thorax 2017 (nintedanib) * IPF and preserved lung volume FVC >90% Same rate of lung function decline Same benefit Start early! Less risk of exacerbations ASCEND: Pirfenidone in ILD Primary outcome: * >/= 10% decline in FVC or all cause mortality * 16.5% vs 31.8% (RRR 47.9%; P<0.001; NNT 7) (Mortality benenifit not proven but subsequent metanalysis do support that there is a mortality benefit) SENSIS: Nintedanib in SSc-ILD INBUILD: Non IPF fibrosing ILD PANTHER: Steroids had increased mortality in IPF

Answer 229

FVC <55% DLCO <35%

Answer 230

Prolonged air leak Pneumothorax, hemothorax, pleural effusion Infection Delayed wound healing ILD exacerbation Requirement for intubation

Answer 231

Improved dyspnea Improved QOL

Answer 232

Breathing retraining Relaxation techniques Fans Body positioning Low dose opioids

Answer 233

Genetics - TERC/TERT/MUC5B Smoking Environmental pollution ?Microaspiration

Answer 234

Fibrotic ILD in at least 2 related family members

Answer 235

IPF Familial IPF CTD-ILD (SARD- ILD) Drugs Asbestosis Chronic hypersensitivity pneumonitis

Answer 236

Confident - 90% Probable - 70 to 90 Indeterminate - 50 to 70 Alternative - <50%

Answer 237

Esophageal dilatation Pleural plaques

Answer 238

Surgical lung biopsy Cryobiopsy

Answer 239

Subpleural and/or paraseptal predominance Patchy involvement Dense fibrosis with architectural distortion +/- honeycombing Fibroblastic foci Absence of features suggesting alternative diagnosis e.g. granulomas

Answer 240

Older age Male FVC <50% DLCO <35% Greater extent of fibrosis on CT Hypoxemia at rest or with exertion Low 6MWT, especially <250 meters Lower BMI Certain comorbidities e.g. PH

Answer 241

Absolute reduction in FVC by 10% Absolute reduction in DLCO by 15% Worsening fibrosis on HRCT Worsening level of dyspnea

Answer 242

IPF as opposed to secondary dx Male Older age Heavy smoking Poor baseline FVC Poor baseline DLCO Decline in FVC by 10%, DLCO by 15% over 6 months CPFE PH

Answer 243

Male Smoker >60 years old

Answer 244

GERD Pulmonary hypertension Obstructive sleep apnea Lung cancer

Answer 245

Antifibrotics: nintedanib and pirfenidone Lung transplantation

Answer 246

Improve QOL Reduce the decline of FVC Reduce rate of exacerbation and hospitalization Reduce the mortality

Answer 247

Age >40 FVC >/50 DLCO >/30

Answer 248

Death within 4-5 years of diagnosis

Answer 249

Bad disease at baseline - low FVC, DLCO, 6MWD Infection Pulmonary embolism Aspiration Lung biopsy, bronchoscopy, other procedures Immunosuppressive therapy

Answer 250

50-90% in hospital mortality Median survival 3-4 months

Answer 251

Acute respiratory deterioration <1 month in duration Bilateral GGO with or without consolidation on background of fibrosis Not explained fully by another cause e.g. volume overload

Answer 252

Need two of the three criteria Need them to be occurring in the past year 1. Progression of symptoms 2. Decline in PFTs - FVC >5% within one year - DLCO >10% within one year 3. Worsening radiographic progression

Answer 253

Idiopathic CTD e.g. scleroderma Chronic HP Occupational exposures Chemotherapy Post HSCT, bone marrow, lung

Answer 254

Pleural thickening Associated subpleural fibrosis Concentrated in the upper lobes

Answer 255

Upper zone pleural fibrosis Subjacent intra alveolar fibrosis and alveolar fibroelastosis

Answer 256

Emphysema in upper lobes Fibrosis (usually UIP pattern) in lower lobes

Answer 257

Lung cancer Pulmonary hypertension

Answer 258

Presence of interstitial pneumonia (imaging or pathology) Does not meet CTD criteria Exclusion of other etiologies At least 2 of: clinical criteria, serological criteria, morphological criteria

Answer 259

Idiopathic Connective tissue diseases Drugs/medications Exposures - hypersensitivity pneumonitis Infections, including HIV

Answer 260

Basilar, peripheral OR diffuse Cellular is GGO dominant Fibrotic is reticulation, traction, bronchovascular bundle thickening +/- honeycombs Subpleural sparing

Answer 261

UIP→ fibroblastic foci, honeycombing NSIP→ homogenous fibrosis, no Honey Combing, few fibroblastic foci OP→ MASSON bodies (buds of intraalveolar granulation tissue) Fibrosing HP→ poorly formed granulomas, peribronchiolar, SHAUMANN bodies PPFE→ fibroelastosis, spindle cells.

Answer 262

TNF alpha inhibitors Immune checkpoint inhibitors HAART Interferons

Answer 263

Interstitial lung disease Progressive massive fibrosis Alveolar sarcoid Tracheal stenosis, subglottic stenosis Lower airway obstruction Lymphadenopathy Pulmonary hypertension

Answer 264

Interstitial lung disease Cardiac disease e.g. cardiomyopathy PVOD like lesions Granulomatous inflammation and involvement of vessels → intrinsic sarcoid vasculopathy Fibrosing mediastinitis External compression of PA by lymphadenopathy Portal hypertension

Answer 265

Neuro - hydrocephalus, aseptic meningitis, facial nerve palsy, small fiber neuropathy, optic neuritis, encephalopathy, psychosis Ocular sarcoidosis - anterior uveitis Cardiac sarcoid - cardiomyopathy, heart block, arrhythmias Renal sarcoid - nephrolithiasis Hepatic sarcoid - transaminitis, cholestasis Hypercalcemia, hypercalciuria Rashes Other: spleen, bone marrow

Answer 266

Uveitis Optic neuritis Lofgren’s syndrome Lupus pernio Erythema nodosum Hypercalcemia or hypercalciuria Bilateral hilar adenopathy Perilymphatic nodules Gadolinium enhancement Parotid uptake Osteolysis, cysts/punched out lesion

Answer 267

Medications e.g. OPC, TNF alpha inhibitors Infections e.g. hepatitis B, streptococcus, fungal Inflammatory e.g. sarcoidosis, IBD Malignancy Pregnancy

Answer 268

Paresthesias Numbness Pain Autonomic dysfunction - palpitations, orthostasis, sexual dysfunction

Answer 269

BRAF V600 somatic mutation CD68 marker on biopsy Also is from proliferation of foamy histiocytes rather than granulomas

Answer 270

Lymphadenopathy Nodules or masses Interstitial lung disease Fibrosing mediastinitis Subglottic stenosis, tracheal stenosis Pleural thickening Pleural effusions

Answer 271

Serum and BAL IgG4 can be suggestive Biopsy definitive

Answer 272

Conduction e.g. AV block, BBB, tachyarrythmias, sudden death Cardiomyopathy Coronary artery disease from vasculitis

Answer 273

Cardiac MRI (ATS suggests this first line) Cardiac PET Transthoracic echocardiogram

Answer 274

Anemia, thrombocytopenia, leukopenia Hypergammaglobulinemia Hypercalcemia, hypercalciuria Elevated rheumatoid factor

Answer 275

Sarcoidosis Hypersensitivity pneumonitis Silicosis Berylliosis Asbestosis Tuberculosis Coccidioidomycosis Hodkin’s lymphoma Gaucher’s disease (lysosomal storage disorder caused bya deficiency in the enzyme glucocerebrosidase leading to the accumulation of glucocerebroside in tissues) Hyperthyroidism PBC

Answer 276

Perilymphatic distribution of nodules Miliary nodularity Lymph node enlargement, can have eggshell calcification Galaxy sign (small nodules surrounding larger conglomerate masses) Garland sign (bilateral hilar lymphadenopathy and right paratreacheal lymphadenopathy) Progressive massive fibrosis Signs of fibrosis - reticulation, traction, volume loss Alveolar sarcoidosis Lambda sign (bilateral hilar lymphadenopathy and right paratreacheal lymphadenopathy but lights up on a gallium 67 scan) Panda sign (parotid uptake)

Answer 277

Eggshell Icing sugar

Answer 278

<1 → highly unlikely >4 → highly likely

Answer 279

I: LN → 90% II: LN and parenchymal changes → 70% III: parenchymal changes →20% IV: fibrosis → 0%

Answer 280

If lofgrens or heerfordt no biopsy. If asymptomatic but radiographic findings can do EITHER biopsy OR close follow up. If not confirmed then biopsy (EBUS recommended) Screen with CBC,Cr, ALP (not ALT), Ca, (if Vit D needed do 25 adn 1-25), ECG (not holter or TTE), eye exam

Answer 281

Non caseating granuloma Discrete, well organized granulomas composed of giant cells, histiocytes and surrounded by lymphoblasts Granulomas distributed along lymphatics and bronchovascular bundles Sparse surrounding lymphocytic infiltrate

Answer 282

Non caseating granulomas in both Poorly formed, small, loosely arranged in HP Distribution around bronchioles in HP vs. perilymphatic in Sarcoid Inflammatory infiltrates found at interstitial sites distant from granuloma. Marked lymphocytosis on BAL in HP and >4CD4/CD8 ratio in sarcoid

Answer 283

Heerfordt’s syndrome Lofgren’s syndrome Lupus pernio (blue red to violet smooth shiny nodules and plaques on the head and neck, predominantly on the nose, ears, lips, and cheeks)

Answer 284

Sarcoidosis Sarcoid like reactions to malignancies Lymphoma Hypersensitivity pneumonitis Berylliosis IgG4 disease PLCH Erdheim Chester disease GI diseases e.g. PBC, IBD

Answer 285

Tuberculosis, fungal infections, syphilis Vasculitis Rheumatoid nodules GLILD Bronchocentric granulomatosis

Answer 286

Endobronchial - 70% sensitive EBUS - 80% sensitive; highest yield Transbronchial- 30-50%

Answer 287

African american Age >40 Progressive pulmonary involvement Neuro, cardiac, eye involvement

Answer 288

Erythema nodosum Lofgren’s syndrome Stage I disease Spontaneous improvement or resolution

Answer 289

Improve sx/accelerate remission Improve imaging Increases risk of recurrence

Answer 290

CBC Crea ALP Calcium ECG Eye examination

Answer 291

CBC Crea ALP Calcium

Answer 292

Reduced FVC, reduced DLCO Moderate to severe pulmonary fibrosis Precapillary pulmonary hypertension Deterioration in symptoms, lung function or imaging on follow up - as per BTS, DLCO <65% or drop by >/15%, FVC >70%, or drop by >/10%

Answer 293

Ocular Neuro Renal Hypercalcemia Cardiac

Answer 294

Glucocorticoids Methotrexate TNF-alpha inhibitors Other: MMF, AZA, lef, JAK inhibitor, rituximab

Answer 295

Steroids MTX Infliximab to improve/preserve FVC and QoL

Answer 296

Steroid 20-40 x 4-6 weeks (0.25-0.5mg/kg) evidence 20 as good as 40. Taper 6-18 months

Answer 297

Progression of disease despite steroids Steroid intolerant Unable to tolerate steroids below 10-15 mg oral daily Strong patient aversion to steroids Presence of major comorbidities made worse by steroids e.g. DM, osteoporosis

Answer 298

Steroids Ketoconazole Possibly TNF alpha inhibitors

Answer 299

Exercise training Inspiratory muscle training Methylphenidate, modafinil

Answer 300

Topical steroids Oral steroids, MTX (ok evidence) Infliximab* best evidence

Answer 301

Symptomatic - gabapentin TNF alpha or IVIG

Answer 302

Steroids MTX Infliximab

Answer 303

Steroids Other IST, but not RCT

Answer 304

Age >50 Ventricular tachycardia NYHA III-IV LVEF <40% Echo evidence of abnormal global longitudinal strain Interventricular septal thinning Elevated BNP or trop Cardiac inflammation by PET Late gadolinium enhancement by MRI

Answer 305

Palpitations Chest pain Syncope, near syncope Tachycardia, bradycardia New ECG findings

Answer 306

Floaters Blurry vision Visual field loss

Answer 307

Fibrotic lung disease Exertional chest pain Syncope Prominent P2, S4 Reduced 6MWD Desaturation with exercise Increased PA diameter on CT Elevated BNP

Answer 308

Cardiac sarcoidosis Pulmonary hypertension

Answer 309

Improve symptoms (accelerate remission but increase risk of recurrence) Improve or preserve QOL Improve or preserve FVC Improve radiographic disease burden

Answer 310

Female, non smoker Relevant exposure history Hx getting worse with exposure (4-8 hrs), better away. Squawks on examination

Answer 311

Older age Male Smoker Unidentified exposure Ongoing exposure Low FVC, low DLCO Evidence of fibrosis, extent of fibrosis UIP pattern on imaging, histology Fibrotic NSIP pattern Lower BAL lymphocytosis (<20%)

Answer 312

HP is granulomatous disease ODTS and Silo Filler’s disease cause obliterative bronchiolitis

Answer 313

Isocyanates - spray paints, polyurethane foam, insulation HFA-134a - coolants Drug induced - MTX, bleo, nitro

Answer 314

Infectious - Mycobacterium avium, thermophilic actinomyces, aspergillus, bacillus subtilis Animal proteins - bird serum proteins, droppings, feathers Plants - wood dust, flour dust, seaweed

Answer 315

Lymphocytosis (in BAL) Neutrophilia, lymphopenia Usually no eosinophilia

Answer 316

parynchemal infiltration (GGOs, mosaic attenuation) small airway disease (ill defined centrilobular nodules, air trapping) Distribution (diffuse with possible basal sparing)

Answer 317

- irregular linear opacities/coarse reticulations with lung distortion (may have some mild traction bronchiectasis and honeycombing) - distribution (random or mid lung zone predominante with sparing in the lower lobes) - ill definied centrilobular nodules/GGOs - 3 density pattern often in lobular distribution

Answer 318

Transbronchial in HP Cryobiopsy in fibrotic HP Surgical in both when the others fail

Answer 319

Recommended in non fibrotic HP Suggested in non fibrotic HP Depends on ATS vs. Chest

Answer 320

Observation- Antigen removal Prednisone 0.5 - 1 mg/kg/day x 4-6 weeks then taper over 3 months Steroid sparing agent Antifibrotics

Answer 321

MMF Azathioprine Antifibrotics

Answer 322

75% macrophages 23% lymphocytes 1% mesothelial cells Rare PMNs and eosinophils pH usually 7.6

Answer 323

-5 cm and -30 cm

Answer 324

Pleural LDH >0.45 ULN Pleural Cholesterol >45 +/- Pleural protein >29 Note light’s (LDH>2/3 ULN, PleurProtein>0.5 SerumProtein, PleurLDH>0.6 SerumLDH)

Answer 325

Blood or air in the pleural space Medications Fungal infections, parasitic infections e.g. paragonimiasis ABPA Malignancies EGPA BAPE PE

Answer 326

Post CABG, PCIS Pseudochylothorax, chylothorax Malignancy (including mesothelioma), lymphoma Tuberculosis Rheumatoid arthritis Sarcoidosis Uremic pleuritis Cardiac failure

Answer 327

>50% vs >80% Especially TB, lymphoma, RA

Answer 328

Empyema Esophageal rupture Acute or chronic pancreatitis Pulmonary embolism SLE can start out neutrophilic TB can start out neutrophilic

Answer 329

Empyema Paragonimiasis RA/SLE effusion Malignancy related effusion Esophageal rupture Hemothorax

Answer 330

Tuberculosis MM, WM

Answer 331

P:S albumin <0.6 S-P albumin >12 g/L S-P protein >31 g/L

Answer 332

Methotrexate Nitrofurantoin Amiodarone Phenytoin Ergot alkaloids e.g. bromocriptine Dasatinib Beta blockers

Answer 333

Benign and malignant masses Pleural infections CTD causes Pleural plaques Post hemothorax Post pleurodesis

Answer 334

Pleural plaques, previous asbestos exposure Mesothelioma (~20%) Malignancy e.g. extraskeletal osteosarcoma of the pleura Previous radiation Previous infection e.g. TB, empyema Previous pleurodesis Previous hemothorax

Answer 335

Malignancy Infection Autoimmune Previous talc pleurodesis

Answer 336

Previous infection, empyema CTD - e.g. RA or SLE related effusion BAPE Previous hemothorax Previous pleurodesis Drug reactions

Answer 337

Transudate or borderline exudate fluid Drainage results in pneumothorax ex vacuo Initial (-) intrapleural pressure Pressure falls rapidly bc extremely high elastance No improvement in dyspnea with drainage

Answer 338

Salt and fluid restricted diet Diuresis e.g. furosemide, spironolactone TIPS Transplantation ?Thoracentesis

Answer 339

Early post CABG effusion Late post CABG effusion Post cardiac injury syndrome Hemothorax Chylothorax Pneumothorax/hydropneumothorax Parapneumonic effusion Infectious mediastinitis HF related effusion

Answer 340

Both are usually left sided Both exudative Early usually bloody, eosinophilic (or neuts) Late usually lymphocytic pH and glucose normal

Answer 341

Fever, pleuritis, pleural effusion Exudative, lymphocyte predominance Anti myocardial antibodies pH and glucose normal

Answer 342

Exudative Glucose <1.6 Pleural to serum glucose <0.5 pH <7.3 LDH >700 Protein >30 Lymphocyte predominant Cholesterol >5.18 mmol/L RF elevated >1:320 C3/C4 reduced Cytology shows multinucleated giant cells (tadpole sign)

Answer 343

More symptomatic - almost always has pleuritis Association with lupus flare More likely to be bilateral Requires tx with NSAIDs or prednisone

Answer 344

Idiopathic Trauma Surgery, especially esophageal Lymphoma, metastatic adenocarcinoma Tuberculosis LAM Yellow nail syndrome Chylous ascites Lymphatic malformations

Answer 345

Milky white Exudative Lymphocyte predominant TG >1.24 mmol/L or evidence of chylomicrons (lipoprotein electrophoresis) pH, glucose, LDH normal

Answer 346

Milky white Exudative Lymphocyte predominant Cholesterol >5.18 mmol/L or presence of cholesterol crystals

Answer 347

Tuberculosis Helminth infection e.g. paragonimiasis Rheumatoid arthritis Hemothorax

Answer 348

Dietary changes (low fat, high protein) Fat soluble vitamins Chest tube (unless v small and asx) May need somatostatin/octreotide Sirolimus in LAM Intervention/surgical

Answer 349

Yellow nails Lymphedema Pulmonary symptoms - sinusitis, bronchiectasis, recurrent PNA, effusions

Answer 350

Staph aureus Strep pneumo GNB (pseudomonas, acinetobacter, klebsiella, enterobacteria) Anaerobic bacteria (baceroides, fusobacterium, etc.)

Answer 351

Lentiform shape Split pleura sign (most reliable to differentiate from abscess) Does compress surrounding lung Obtuse angle with the pleura Contrast enhancement Hypertrophy of extrapleural fat

Answer 352

Pleural glucose <3.3

Answer 353

RAPID score components CT/US septations Pleural contrast enhancement Size >400 cc Pleural fluid microbubbles Increased attenuation f extrapleural fat

Answer 354

Size of tube Causative organism

Answer 355

Renal function (BUN) Age (50-70 or >70) Purulent - yes or no (point if not purulent) Infection source CAP/HAP Diet - Serum albumin

Answer 356

Mortality at 3 and 12 months

Answer 357

Empyema - pus, positive gram stain, positive culture Very loculated Very septated Massive effusion (>50% of hemithorax) pH <7.2 Intermediate pH but LDH >900

Answer 358

Bronchopleural fistula Pleural calcifications Pleural thickening Empyema necessitans (pus extending into the chest wall, common with TB) Fibrothorax

Answer 359

Beta lactam + beta lactamase inhibitor Ceftriaxone/FQ + metronidazole Carbapenems Clindamycin Carbapenem + vanco if HAP Duration 2-6 weeks

Answer 360

Within day 3 Should not be favored over chest tube initially VATS is preferred over medical pleuroscopy and thoracotomy

Answer 361

Drainage Debridement (removal of lose debris/dead tissue) Decortication (peel of a thick fibrous layer of pleura)

Answer 362

Reduces volume on imaging Reduces LOS Reduces requirement for thoracic surgery

Answer 363

Very hemorrhagic fluid at baseline Disease with hemorrhage risk e.g. RCC with lung mets Anticoagulation that cannot be stopped Note: Anticoagulation increases risk to 10% (overall risk 4%) but half dose did not change risk

Answer 364

Concurrent administration of anticoagulation Elevated RAPID score Plt count <100,000

Answer 365

Alveolar sacs (most common) Tracheobronchial tree Esophageal Bowel rupture

Answer 366

Hamman’s crunch (crunching with each heart beat or mediastinal crunch) Subcutaneous emphysema High pitched voice

Answer 367

Pneumomediastinum - air around the mediastinum Widened pneumomediastinum Pneumothorax Pleural effusion Subcutaneous emphysema Air under the diaphragm

Answer 368

Catamenial Primary Secondary

Answer 369

Asthenic body habitus Subpleural blebs Smoking - cigarettes, marijuana, snorting cocaine Diving

Answer 370

Bullous lung disease LAM PLCH COPD Asthma Bronchiectasis Thoracic endometriosis Ehler Danlos, Marfans

Answer 371

Traumatic pneumothorax Post CPR pneumothorax On NIV or mechanical ventilation Blocked or kinked chest tube Hyperbaric oxygen treatment Underlying lung disease

Answer 372

IVC compression → reduced RV preload RV compression → reduced LV preload Increased LV afterload Increased RV afterload

Answer 373

Visible lung edge Shifting of mediastinum, deviated trachea Splaying of the ribs

Answer 374

>/2 cm laterally or apically on CXR If using CT, any size that can safely be accessed with imaging support Note PSP can often monitor regardless of size

Answer 375

Lateral edge of pectoralis muscle Lateral edge of latissimus dorsi Fifth intercostal space/nipple line/breast line (base of breast tissue) Base of axilla

Answer 376

Underlying lung disease aka Secondary pneumothorax Age >/50, smoking history Bilateral pneumothorax Hemopneumothorax Tension pneumothorax/hemodynamic compromise Significant hypoxemia

Answer 377

The pneumothorax increases in size despite chest tube insertion Fails to improve after 24-48 hours There is persistent air leak

Answer 378

1.25 - 2.2% per day Increased by 4-6X via oxygen

Answer 379

Recurrent pneumothorax, ipsilateral or contralateral First pneumo BUT: - SSP and significant physiological compromise - Tension pneumothorax/hemodynamic compromise - Spontaneous hemothorax - Bilateral pneumothorax - Persistent air leak 5-7 days, or lung fails to re expand - Pregnant - High risk occupation

Answer 380

VATS > thoracotomy Can do any: bullectomy, pleurectomy, mechanical pleurodesis, chemical pleurodesis

Answer 381

Unwilling to do surgery Unable to do surgery This is because surgical options more effective

Answer 382

PSP → 33% SPS → 13-39% After first recurrence → 60%, after second recurrence → 80%

Answer 383

Conditions: Pneumothorax, Barotrauma, Infections, Malignancies Procedures: wedge biopsies, lobectomy, LVRS, trauma

Answer 384

Treat underlying infection Add suction Second chest tube or bigger chest tube Blood patch Chemical pleurodesis Surgical options

Answer 385

No PFTs x 2-4 weeks No flying until resolved at least x 1 week, but can be longer especially if underlying lung disease (Canadian Association of Thoracic Surgeons recommend 1-3 weeks) No diving ever

Answer 386

Reduce Pplat Reduce autoPEEP → increase expiratory time, reduce Vt, permissive hypercapnia

Answer 387

Mesothelioma Metastases Lymphoma Malignant fibrous tumour Askin tumour (same as ewing sarcoma, chest wall tumour and is malignant) Sarcoma Extraskeletal osteosarcoma

Answer 388

Usually diffuse large b cell lymphoma Usually no associated lymphadenopathy

Answer 389

Lymphoma Primary effusion lymphoma Kaposi sarcoma Other cancers

Answer 390

Lung (adeno) Breast Lymphoma GI/GU

Answer 391

Mets - visceral pleura Meso - parietal pleura

Answer 392

Solitary fibrous tumour of the pleura Lipoma Mesothelial cyst Pleural endometriosis Pleural plaques, thickening (not really masses)

Answer 393

Hypoglycemia, Doege-Potter syndrome (elevated IGF) Hypertrophic pulmonary osteoarthropathy

Answer 394

Thickness > 1 cm Circumferential thickening Involvement of the mediastinal pleura Diaphragmatic thickening > 7 Nodular thickening

Answer 395

Overall, 60%, increase by 15% with the second tap (MAM paper says 20%) Adenocarcinoma 80% Breast 70% Small 50% Mesothelioma 30% Squamous cell 20%

Answer 396

>/25% of the lung is not opposed to the chest wall Is based on CXR

Answer 397

Aspiration has shorter LOS but more need for intervention IPC vs chest tube with talc slurry or poudrage

Answer 398

Talc poudrage preferred Other options IPC, slurry, PP

Answer 399

Improved dyspnea Improved QOL

Answer 400

Talc Doxycycline Bleomycin

Answer 401

Improvement after therapeutic thoracentesis Rapid reaccumulation Prognosis is >1 month Supports to have home care

Answer 402

Chest pain Fever ARDS

Answer 403

Abx Intrapleural enzymes Intrapleural normal saline Extra chest tube Surgical - VATS, decortication

Answer 404

~40 years after exposure

Answer 405

Epithelioid Biphasic Sarcomatoid (worst prognosis)

Answer 406

Asbestos (?dose response) Erionite fibers Thoracic radiation SV40 infection, other viral infections Chronic pleural disease

Answer 407

Pleural thickening with concerning features (see previous) Presence of asbestos exposure Local invasion - chest wall, mediastinum, diaphragm, ribs Usually unilateral changes, usually right side predominance Spreads along pleura and fissures Starts at parietal pleura

Answer 408

Image guided biopsy Medical pleuroscopy Surgical pleuroscopy/VATS

Answer 409

Double immunotherapy - ipilimumab + nivolumab (previously was chemo, but studies show immunotherapy better) Debulking surgery if candidate (epithelioid and ECOG 0-1) Both improve survival SMART TRIAL NEGATIVE (For radiating ports after BUT trend to significance so maybe underpowered) remuniration and palliative care

Answer 410

Histology (Sarcomatoid worst) Stage Age Poor performance status

Answer 411

Cervical Colon Stomach Breast Prostate, pancreas Thyroid Lung Mneumonic: certain cancers spread by plugin the lymphatics

Answer 412

Biopsy - TBBx or surgical

Answer 413

Obstruction and distension of lymphatics by tumour cells

Answer 414

Treat underlying cancer Steroids, but no clear data Opioids for symptom control

Answer 415

RUL: 3 RML: 2 RLL: 5 LUL: 5 LLL: 5 or 4

Answer 416

Lobectomy PPO FEV1 = FEV1 x [1 - (resected segments/19)] Pneumonectomy = PPO FEV1 = FEV1 x [1 - fraction of perfusion to resected lung] Using absolute value Both greater than 60→ Low risk 30-60% stair climb or shuttle walk Any < 30% then CPET

Answer 417

VO2 max FEV1 DLCO In place of CPET can use stair climb or shuttle walk.

Answer 418

SWT <400 m Stair climb <22m

Answer 419

<10 mL/kg/minute (<35%)→ high 10-20 → moderate (35-75%) >20 (>75% predicted) → low

Answer 420

Age Smoking ASA class OSA COPD (especially if FEV1 <60%) Pulmonary hypertension Low albumin Obesity is not a risk factor

Answer 421

Aortic > intrathoracic > upper abdominal > abdominal Duration of surgery Emergency surgery General anesthesia (epidural better) Paralytics

Answer 422

Optimize underlying lung disease prior to surgery Smoking cessation (>8 weeks previous surgery) Avoid GA if possible; regional blocks if possible Avoid long acting neuromuscular blockade Shorter surgery (<3 hours) Laparoscopic CPAP if OSA Lung expansion techniques Pain control

Answer 423

FEV1, FVC, lung volumes, DLCO decrease Decrease compliance Increased resistance Dead space can increase or decrease RV EF reduces, LV function does not change No change in blood gasses

Answer 424

Fills with air, then with fluid Complete opacification takes 4 months

Answer 425

Post pneumonectomy syndrome Post pneumonectomy empyema Bronchopleural fistula Esophagopleural fistula Pulmonary embolism Pneumothorax Hemorrhage Arrhythmias, MI

Answer 426

After 6 months following surgery Almost exclusively after right sided pneumonectomy (it is excessive mediastinal shift/rotation resulting in compression and stretching of the tracheobronchial tree and the esophagus)

Answer 427

Within 72 hours Non cardiogenic edema/ARDS More common during right vs left

Answer 428

Right sided resection Large perioperative fluid load Single lung ventilation High inspired O2 concentrations

Answer 429

Age 55-74 Current smoker or quit within the last 15 years Has at least 30 pack year smoking history Experienced centers

Answer 430

Lung cancer Hemoptysis Lost >/15 lb in the last 1 year Chest CT in the prior 18 months

Answer 431

Different proportion of males/females Inclusion criteria Nodule management protocol - diameter vs volume Control comparison - CXR vs nothing Follow up - different # and intervals

Answer 432

Adenocarcinoma: TTF1 (if negative but adeno much worse prognosis) Squamous cell: CK5/6. P63 Small cell: TTF1 but also neuroendocrine markers (chromogranin, CD56, synaptophysin)

Answer 433

Small cell - usually central, small primary, usually arises in airways, early mets Squamous cell - usually central, bulky lesion, may cavitate Adenocarcinoma - usually peripheral

Answer 434

Smoking Exposures - nickel, radon, asbestos, silica, beryllium, pollution Underlying conditions - IPF, scleroderma-ILD, COPD, HIV Radiation exposure

Answer 435

If >200, have to hire professional If 200-600, have 2 years to fix If >600, have to fix within 1 year

Answer 436

SVC syndrome (more common if R) Horner’s syndrome (T1) Brachial plexus injury (C8, T1, T2) Recurrent laryngeal nerve involvement (more common if L) Also called a pancoast tumour

Answer 437

Miosis, ptosis, anhidrosis Laryngeal nerve dysfunction Ulnar nerve distribution abnormalities/brachial plexus involvement Cerebral edema Also called a pancoast tumour

Answer 438

Confusion 2/2 cerebral edema Facial plethora, Proptosis Facial and neck edema Elevated JVP Collateralization of superficial vessels Cyanosis, hypoxemia

Answer 439

Malignancy - lung ca, lymphoma Thrombosis Indwelling intravascular device Post radiation fibrosis Fibrosing mediastinitis External compression from sarcoidosis, thyroid goiter

Answer 440

Emergency → stent; radiation if not surgical candidate Steroids if already have answer, steroid responsive Anticoagulation if thrombosis Chemotherapy if applicable

Answer 441

Encephalitis LEMS Cushing’s syndrome Hyponatremia Hypercalcemia Hypertrophic pulmonary osteoarthropathy (Triad: digital clubbing, periostitis (new bone growth on the bones), and arthropathy) Rashes - dermatomyositis, acanthosis nigricans, erythema multiforme, pruritus, urticaria

Answer 442

Bone scan - Symmetrical, increased linear uptake along diaphyseal and metaphyseal surfaces of long bones XR - smooth periosteal reaction Triad: digital clubbing, periostitis (new bone growth on the bones), and arthropathy

Answer 443

Myasthenia gravis Red cell aplasia Cushing’s syndrome Addison’s disease

Answer 444

Bone metastases PTHrP Granulomas increasing 1,25 vitamin D Ectopic production of PTH e.g. parathyroid carcinoma

Answer 445

Brain Pleura Adrenals Liver Bone Bone marrow

Answer 446

Squamous cell carcinoma Carcinoid tumour Kaposi sarcoma

Answer 447

Superior mediastinal nodes 1: Highest mediastinal 2R inferior border innominate/brachiocephalic vein). 2L Inferior border aorta on left 3: prevascular adn retrotracheal 4R Upper Border innominate/brachiocephalic. Inferior azygos vein. 4L upper border Aortic arch and inferior Pulmonary artery Aortic nodes 5: subaortic 6 para aortic Inferior mediastinal nodes 7 subcarinal 8 paraesophageal nodes 9 pulmonary ligament nodes Hilar nodes, lobar and subsegmental nodes 10 hilar nodes : 10R azygus 10L Pulmonary Artery 11 Interlobular: 11s between upper lobe bronchus and bronchus intermedius. 11i between the middle and lower lobe bronchi 12 lobar: adjacent to lobar bornchi 13 segmental nodes: adjacent to segmental bronchi 14 sub segmental: adjacent to subsegmental bronchi.

Answer 448

Canada Lymph node score: Clear margins Loss of central hilar structure Central necrosis Short axis diameter >/1 cm Also known as Canada Lymph Node Score

Answer 449

EGFR (15% of canadians with adeno) ALK ROS1 PDL-1 BRAF

Answer 450

Clinical signs or symptoms concerning for brain metastases Clinical stage II, III or IV non small cell lung cancer Maybe IB but definitely not IA

Answer 451

- Discrete mediastinal node enlargement, no distant mets - Node SUV >/2.5 - Peripheral tumour BUT:I nner ⅔ of lung (more central); >/3 cm = greater than T1; Associated with enlarged mediastinal LN >1 cm - Central tumour: Radiographically enlarged or PET avid nodes

Answer 452

Peripheral T1N0 disease not meeting criteria above Bulky tumour invading mediastinal structure - need tissue, but does not need to be from nodes Metastatic disease - biopsy whatever gives you highest stage

Answer 453

CT: sp 80/sn 55 PET: sp 85/sn 80 EBUS: sp 100/sn 90 (ONLY 55% for LYMPHOMA but sp 100%) Mediastinoscopy: sp/100/sn 80

Answer 454

Limited - Chemo + radiation followed by adjuvant immunotherapy - If good response and normal brain MRI can do prophylactic cranial radiation - If VERY Limited consider surgery Extensive - Chemo + immunotherapy - Immunotherapy adds 2-3 months of survival - Cranial Radiation

Answer 455

1. Prophylaxis - Limited stage, good response to chemo - Extensive stage 2. Evidence of brain mets

Answer 456

Limited disease: decrease brain mets, improve survival Extensive disease: decrease brain mets, no change in survival ? (Lancet review 2024 says PCI is associated with survival benefit but when factor in MRI to exclude brain mets then this benefit disappeared suggesting more therapeutic benefit rather than prophylactic)

Answer 457

Brain mets with no targeted mutations Otherwise, we use targeted therapy and if symptomatic/risk herniation, surgical

Answer 458

Cutaneous/rash Uveitis *Pneumonitis Hypothyroidism, hyperthyroidism *Hepatotoxicity *Colitis, diarrhea Pancreatitis *all EGFR -Rash/acne ALK -Cardiac (Bradycardia, HTN)

Answer 459

Median 3 months, can be up to 19 months

Answer 460

G3 or higher

Answer 461

Immune related pneumonitis Radiation recall pneumonitis

Answer 462

Grade 1: Asymptomatic with radiographic changes Grade 1: Continue therapy with close observation, escalate to treatment for symptoms or radiographic worsening Grade 2: Symptomatic but no limitation of usual activity Grade 2: Hold therapy, consider bronchoscopy, institute oral prednisone 1 mg/kg/day if no improvement Grade 3: Symptomatic, with oxygen requirement or limitation of activity Grade 3-4: Discontinue therapy, bronchoscopy, institute oral prednisone 1-2 mg/kg/day or IV corticosteroids at equivalent dose Grade 4: Severe or life-threatening

Answer 463

Cutaneous, rash Ocular toxicity Pulmonary - pneumonitis Colitis, diarrhea Hepatic toxicity

Answer 464

Confirmed ILD as a result Ulcerative keratitis GI perforation SJS, severe skin disease

Answer 465

Opioids, NSAIDs Bisphosphonates, denosumab - osteoclast inhibitors Radiation Steroids Regional anesthesia

Answer 466

1. Atypical adenomatous hyperplasia 2. Adenocarcinoma in situ (<3cm and formerly BAC) 3. Minimally invasive adenocarcinoma (<3cm lepidic predominant with <5mm invasion) 4. Invasive adenocarcinoma (>5mm) - Lepidic - Acinar - Micropapillary - Papillary - Solid predominant 5. Variants of invasive - Invasive mucinous - Colloid - Fetal

Answer 467

Solid nodule GGO nodule, subsolid nodule Mass Multiple pulmonary nodules Patchy consolidation, lobar consolidation Crazy paving

Answer 468

DIPNECH = preinvasive - <5 mm Typical = > 5 mm, <2 mitoses/10 HPF, no necrosis Atypical: 2-10 mitosis or necrosis SCLC: >11/10 mitoses HPF

Answer 469

Dyspnea, wheeze Hemoptysis Carcinoid syndrome - flushing ,telangiectasias, diarrhea Cushing syndrome Acromegaly syndrome

Answer 470

Serum chromogranin A 5-HIAA Somatostatin receptor based imaging e.g. OctreoScan, Gallium PET - low grade/typical only weakly positive

Answer 471

Mainly proximal airways Well vascularized

Answer 472

Number - increased 1-4, decreases >/5 Size Doubling time 20-400 days Enhancement Appearance - subsolid, spiculated, lobular, Carona Radiata (LR 14) Calcification pattern Location - upper lobe Evidence of emphysema Smoking history

Answer 473

Diffuse Central Lamellar Popcorn

Answer 474

Less metabolically active tumors Solid component <8 mm Uncontrolled hyperglycemia

Answer 475

>/35 years old Not immunocompromised No history of cancer Not for cancer diagnosis (applies to incidentally found nodules) No symptoms attributable to lesion

Answer 476

Low: minimal or absent smoking hx or other RF High: hx of smoking or other known RF (e.g. fhx first degree, asbestos/radon/uranium exposure)

Answer 477

Solid nodules - 2 years Subsolid nodules >/5 years

Answer 478

Infectious nodules Inflammatory, vasculitic Vascular (AVM) Hamartoma Hemangioma Fibroma Lipoma Leiomyoma Amyloidoma

Answer 479

Popcorn calcification Heterogeneous attenuation Rounded or lobular borders

Answer 480

Teratoma occur in anterior mediastinum Teratoma also include teeth and bone Teratomas may become malignant

Answer 481

Pipefitter Plumbers Motor vehicle mechanic Construction worker Shipyard worker

Answer 482

Serpentine (long) and amphibole (short) are the two general types 1. Serpentine * Chrysotile (most common) 2. Amphibole * Actinolite * Anthophylllite * Amosite * Tremolite * Crocidolite (Most dangerous/highest risk of mesothelioma)

Answer 483

Exposure at a young age Duration and extent of exposure Amphibole > chrysotile Concomitant smoking

Answer 484

Rounded atelectasis Asbestosis Pleural plaques Pleural thickening Benign asbestos related pleural effusion Mesothelioma

Answer 485

Lower lobe distribution Reticular changes Rounded atelectasis Pleural plaques Honeycombing and interlobular septal thickening Lower lobe distribution Reticular changes

Answer 486

2 or more asbestos bodies per square centimeter of a 5-mu thick lung section in combination with interstitial fibrosis are indicative of asbestosis Asbestos has presence of asbestos bodies Has mild fibrosis of the visceral pleura Fibroblastic foci are infrequent

Answer 487

ATS 2004 need 3/3 2. 1. Evidence of structural change as demonstrated by one or more * Imaging * Histology 1. Evidence of exposure/cause * occupational/environmental history with latency * Markers of exposure (pleural plaques) * Asbestos bodies 1. Exclusion of other diagnosis

Answer 488

Supportive care: * Steroids pred 0.5-1mg/kg for 1-3 months then taper for 1-3 months and steroid sparing agents can be used but unclear benefit. * Smoking cessation and co-existing airways disease treatment * Immunizations * Oxygen * decortication * Lung transplant

Answer 489

Bases (posterolateral) and mediastinal pleura Can also involve the diaphragm Spares apices and costophrenic angles May be calcified but most are not

Answer 490

In general >3 mm thick

Answer 491

Exudative Eosinophilic usually Can be bloody Usually spontaneously resolves, can recur

Answer 492

Electronics Nuclear industry, nuclear weapons Aerospace industry Fluorescent light bulbs Beryllium mining Ceramics

Answer 493

Inhalation Skin

Answer 494

Acute pneumonitis Chronic beryllium disease

Answer 495

Conjunctivitis (no uveitis, or retinal involvement unlike sarcoid) Periorbital edema Nasopharyngitis Tracheobronchitis

Answer 496

Acute pneumonitis: ARDS, non-cardiogenic pulm edema Chronic beryllium disease: sarcoid but LN less likely

Answer 497

Typically on TBBx Granulomas Distribution paraseptal, interlobular septa, peribronchovascular

Answer 498

Positive BeLPT (blood or BAL) (Beryllium lymphocyte proliferation test) Non caseating granuloma and/or mononuclear cells on biopsy Clinical dx if no bx: BAL lymphocytosis or imaging

Answer 499

1 BAL BeLPT 2 blood BeLPT Positive skin patch sensitization test (DON’T do because can lead to sensitization in beryllium naive individuals) +2 Simulation Indices =abnormal BeLPT , + 1 Simulation Indices =borderline

Answer 500

Sensitization: sensitization, no sx, normal biopsy Subclinical: sensitization, + biopsy, no sx/rads CBD: sensitization, + biopsy, +sx/rads

Answer 501

Observe Steroids if symptoms or PFT change with consideration for steroid sparing agents if not tolerated

Answer 502

Acute silicoproteinosis Accelerated proteinosis Chronic, simple silicosis Complicated silicosis, progressive massive fibrosis

Answer 503

Tuberculosis, NTM Lung cancer CTD/Erasmus syndrome (Systemic Sclerosis) PAP Fibrosing mediastinitis

Answer 504

Crazy paving Perilymphatic nodules and upper lobe Mediastinal and hilar LN, eggshell calcification Progressive massive fibrosis Hyperinflation, COPD Cavitary lung disease Ground glass nodules/opacities

Answer 505

Exposure history Imaging findings BAL if silicoproteinosis Biopsy avoided due to PNTX risk

Answer 506

Acute → steroids Chronic → supportive

Answer 507

Simple chronic CWP Complicated CWP, progressive massive fibrosis Caplan syndrome (rheumatoid pneumoconiosis) Not associated with lung cancer unlike others

Answer 508

Crazy paving Perilymphatic nodules Mediastinal and hilar LN, eggshell calcification Progressive massive fibrosis Hyperinflation, COPD Cavitary lung disease (eggshell less common ) Similar as above, but eggshell less common Typically diffuse perilymphatic small nodules 30% have hilar/mediastinal lymph node enlargement but calcification less likely

Answer 509

Cobalt related lung disease Siderosis (iron dust) Metal fume fever (zinc fumes)

Answer 510

Occupational asthma Interstitial lung disease - giant cell interstitial pneumonia Obliterative bronchiolitis

Answer 511

Inorganic: coal, silica, beryllium, asbestos Organic: cotton, tobacco, sugarcane, basically anything can cause HP

Answer 512

Airway obstruction Uniquely worse on the first day of work and then improves Typically with raw cotton exposure

Answer 513

Silo gas = combination of nitrogen dioxide and carbon dioxide Nitrogen dioxide + water in lungs → nitric acid

Answer 514

ARDS Obliterative bronchiolitis

Answer 515

Uranium mining Beryllium Asbestos Silica

Answer 516

Sarcoidosis Berylliosis Silicosis CWP Talcosis

Answer 517

RA SSc SLE DM/PM

Answer 518

Esophageal dilatation Pleural or pericardial effusion Lymphadenopathy C1-2 subluxation

Answer 519

Male Older Smoking RF positive Anti-CCP positive Disease activity MUC5B

Answer 520

Subcutaneous nodules Longstanding RA

Answer 521

Male Older age Rheumatoid nodules

Answer 522

RA-ILD - UIP, NSIP, LIP, OA, CPFE Diffuse alveolar hemorrhage RA pulmonary nodules Caplan syndrome Pulmonary hypertension Pleural effusion Pneumothorax Follicular or obliterative bronchiolitis Bronchiectasis Cricoarytenoid arthritis Vasculitis of vocal cords RA nodules on vocal cords

Answer 523

Nodules Cavities Pleural effusions Pneumothorax Bronchiectasis UIP pattern or others Findings of PH e.g. edema, enlarged heart, etc.

Answer 524

Lymphocytic in NSIP Neutrophilic in UIP

Answer 525

RA-ILD: steroids, MMF, cyclophosphamide, antifibrotics Bronchiectasis: same as others Bronchiolitis: treat RA, consider azithromycin

Answer 526

ILD - NSIP, UIP, OP, PPFE Pulmonary hypertension, PVOD Airway disease - follicular/obliterative bronchiolitis, bronchiectasis Aspiration pneumonitis or pneumonia Lung cancer Chest wall restriction

Answer 527

African american Extensive disease Scl-70 positive CK elevated Cardiac involvement Hypothyroidism

Answer 528

Extent - >20% of lung involved FVC <70% predicted Within 4 years of diagnosis Anti scl-70 Diffuse cutaneous disease

Answer 529

Mycophenolate Cyclophosphamide Tocilizumab Rituximab Nintedanib Nintedanib + mycophenolate

Answer 530

Improve FVC, DLCO → Mycophenolate and cyclo Reduce decline in FVC → ritux, toci, nintedanib Nothing has mortality benefit

Answer 531

6 months x 5 years Annually after 5 years (if they were stable

Answer 532

ILD - NSIP, UIP, OP, DAD Respiratory muscle weakness Aspiration pneumonia Pneumothorax Pulmonary hypertension

Answer 533

1. 2 of: - Fever - Raynaud - Mechanics hands/hiker’s feet - Polymyositis - Non-erosive arthritis - ILD 2. Positive autoantibody (Anti-Jo-1)

Answer 534

Cyclo if very sick MMF, azathioprine

Answer 535

Interstitial lung disease - NSIP, UIP, LIP Acute pneumonitis (similar to AIP) Organizing pneumonia DAH Pleural effusion * most common Shrinking lung syndrome VTE Pulmonary hypertension - PVOD, PAH, Group 2,3,4 Subglottic stenosis, tracheal stenosis Bronchiolitis obliterans Opportunistic infections

Answer 536

Acute cutaneous lupus erythema Panniculitis Discoid lesion Childpain lupus erythematosus (pernio)

Answer 537

Interstitial lung disease - e.g. NSIP, LIP, UIP Organizing pneumonia Bronchiolitis - follicular, obliterative Bronchiectasis Xerotrachea Aspiration pneumonitis and pneumonia Pulmonary hypertension Nodular hyperplasia Pulmonary nodular amyloidosis Pulmonary lymphoma (transformation)

Answer 538

Nodular pulmonary amyloidosis Diffuse amyloidosis Tracheobronchial amyloidosis Amyloidosis of the pleura

Answer 539

Palpable purpura Leukocytoclastic vasculitis Lacrimal gland inflammation Skin ulcerations ?saddle nose deformity ?stawberry gums (gingivitis)

Answer 540

Vasculitis CTD Malignancies Infections - hepatitis B/C/HIV Drug induced (PTU, methimazole, hydralazine, allopurinol) IBD

Answer 541

GPA - 90% c anca/ PR3 MPA - 70% p anca/mpo EGPA - 50% p anca/mpo Anti-GBM - 10%

Answer 542

Hemoptysis Anemia Alveolar opacities

Answer 543

1.Vasculitis - GPA - EGPA - MPA - Drug induced vasculitis 2. Connective tissue diseases - SLE - Anti-GBM - Rheumatoid arthritis - Scleroderma - Others 3. Drugs - TNF-alpha inhibitors - Hydralazine - Anticoagulation - GPIIb/IIIa platelet inhibitors - Amiodarone - Crack cocaine 4. Others - IPH Idiopathic pulmonary hemosiderosis - Left sided pressure increase e.g. mitral stenosis - HHT hereditary hemorrhagic telangiectasias

Answer 544

Hemosiderin laden macrophages >/20% Progressively bloody sequential lavage

Answer 545

GPA MPA EGPA (very rarely) Drug induced ANCA vasculitis Isolated pulmonary capillaritis Anti-GBM/ANCA positive vasculitis

Answer 546

Anti-GBM GPA, MPA, EGPA ANCA negative vasculitis e.g. cryo, IgA disease SLE

Answer 547

Smoking Cocaine use Hydrocarbon fume exposure Hair dye exposure Metallic dust Genetics

Answer 548

Sensitivity 95-100% Specificity 90-100%

Answer 549

Hepatitis C HIV

Answer 550

Advanced age Anti-GBM titre Renal function - crea & need for dialysis at presentation, oligoanuric, % crescents (only pathological parameter)

Answer 551

Steroids, cyclophosphamide PLEX No maintenance Abx if pulmonary involvement

Answer 552

Monitor regularly (Weekly for 6 weeks and should be undetectable x2 occasions then q2weekly x2, then monthly x 6 months Should disappear with treatment May signal recurrence (re-treat)

Answer 553

Wedge shaped opacities due to infarction Nodules Cavities Interstitial lung disease - NSIP, UIP Diffuse alveolar hemorrhage Subglottic or tracheal stenosis Tracheobronchomalacia

Answer 554

Cutaneous - palpable purpura, leukocytoclastic vasculitis ENT - hearing loss, sinusitis, nasal septal perforation, saddle nose, nasal ulcers Renal - GN, renal failure Systemic symptoms

Answer 555

Severe = organ threatening disease E.g. RPGN, DAH, mononeuritis multiplex, optic neuritis

Answer 556

RPGN with crea >354 if not available

Answer 557

RPGN crea >500, need for dialysis (KDIGO) DAH salvage therapy Double positive (with Anti-GBM)

Answer 558

Anti-GBM disease Anti-GBM/ANCA double positivity DAH salvage therapy, critically unwell TTP related DAH Catastrophic APLS DAH

Answer 559

No mortality benefit No impact on ESRD (trend towards improving ESRD progression in high risk patients) Increased risk of infection

Answer 560

p-ANCA (in MPA) Mainly renal, less ENT, less pulmonary (in MPA) Absence of granuloma formation (In MPA)

Answer 561

Behcet’s disease (vasculitis with mouth ulcers, swollen joints and eye inflammation) Hugh Stovin syndrome (large vessel similar to Behcet’s) M 20-40 with dvt and bronchial aneurysms. Pulmonary hypertension Congenital heart disease Syphilis Tuberculosis Behcet’s disease Hugh Stovin syndrome Congenital heart disease Syphilis Tuberculosis

Answer 562

Bronchocentric granulomatosis Lymphomatoid granulomatosis Necrotizing sarcoid granulomatosis GPA, EGPA

Answer 563

Asthma /obstructive airways disease Peripheral nerve (mononeuritis multiplex) Skin disease (purpura, sub cutaneous nodules, urticaria, leukocytoclastic vasculitis) ENT (Nasal polyps), cardiac: effusions, dilated CM, GI, renal

Answer 564

Age >65 Cardiac insufficiency Renal insufficiency GI involvement Absence of ENT symptoms For prognosis and higher score associated with higher mortality

Answer 565

EGPA - ESR and eos count TTE (Don’t stop leukotriene receptor antagonists) GPA - not ANCA

Answer 566

Eosinophilic pneumonia Hypersensitivity pneumonitis Organizing pneumonitis Obliterative bronchiolitis Pneumothorax Pneumomediastinum Drug induced ANCA vasculitis, DAH Pulmonary hypertension Alveolar hypoventilation Aspiration Foreign body granulomatosis Non cardiogenic pulmonary edema E-VALI

Answer 567

Lipoid pneumonia* Eosinophilic pneumonia Organizing pneumonia Hypersensitivity pneumonitis AIP, ARDS VALI

Answer 568

Vitamin E acetate in e-liquids

Answer 569

E cigarette use in 90 days before symptoms Pulmonary infiltrates Negative viral panel, negative cultures, negative other workup

Answer 570

Azathioprine (purine synthesis inhibitor) Hydroxychloroquine (antimalarial) Cyclosporine, tacrolimus (Calcineurin inhibitors)

Answer 571

1. Most common: Pulmonary edema (usually w/o effusion) Pulmonary hemorrhage DAD OP, NSIP, UIP EoPNA 2. Less common: HP Sarcoid like rxn LIP, DIP Constrictive bronchiolitis -predominantly penicillamine PHTN, vasculitis

Answer 572

Age >60 Underlying pleuroparenchymal lung disease Low albumin Reduced kidney function Third spacing e.g. pleural effusion Higher weekly doses Previous use of DMARDS Diabetes

Answer 573

Hypersensitivity pneumonitis* NSIP AIP with non cardiogenic edema* Eosinophilic pneumonia Organizing pneumonia* Diffuse alveolar damage Pleural effusion* Lymphadenopathy Infections e.g. PJP

Answer 574

Transaminitis Stomatitis, nausea/vomiting Mouth sores Macrocytosis, myelosuppression (Increased risk of lymphoproliferative disorders) nephrotoxicity

Answer 575

1.Major criteria HP by histopathology without evidence of infection Imaging findings (diffuse pulmonary ground glass or consolidative opacities) Negative blood culture and sputum culture 2. Minor criteria Dyspnea <8 weeks Non productive cough SpO2

Answer 576

Clinical presentation - toxicity more subacute/acute Blood work - Eos in toxicity Imaging - NSIP/HP in toxicity, UIP in RA-ILD BAL - both can have lymphocytes Biopsy - NSIP/HP/others in toxicity, UIP in RA-ILD

Answer 577

Procainamide Isoniazid TNF-alpha inhibitors Hydralazine

Answer 578

sPAP: 15-30 dPAP: 4-12 mPAP: 8-20

Answer 579

mPAP > 20 PVR > 2 PCWP

Answer 580

Scleroderma - annual with DLCO and TTE (ERS DETECT algorithm, CTS position statement on PH) Portal hypertension, prior to transplantation

Answer 581

BMPR2 (Most Common) EIF2AK4 ALK-1 SMAD9

Answer 582

Schistosomiasis HIV Hepatitis B/C → cirrhosis

Answer 583

Toxic rapeseed oil Amphetamines Dasatinib Fenfluramine St John’s Wort Cocaine Cyclophosphamide (alkylating agents)

Answer 584

Age >70 Atrial fibrillation Diabetes, DLP, HTN, Obesity (>2 factors) LBBB or LVH on ECG LA dilation, LVH, or grade >2 mitral flow on echo

Answer 585

Mitral stenosis** Aortic stenosis* Mitral regurgitation

Answer 586

CTEPH Foreign body emboli Schistosomiasis/parasitic infection Vasculitis PA sarcoma, uterine sarcoma, germ cell tumors, RCC Congenital stenosis, other causes of stenosis Obstruction by lymph nodes

Answer 587

Polycythemia vera Essential thrombocytosis Paroxysmal nocturnal hemoglobinuria CML Sickle cell anemia Thalassemia Hereditary spherocytosis Fibrosing mediastinitis Sarcoidosis PLCH Neurofibromatosis Gaucher’s disease CKD with or without dialysis Pulmonary tumour thrombotic microangiopathy

Answer 588

Altered tone → vasoconstriction Smooth muscle medial hypertrophy Neointimal formation/hyperplasia and fibrosis Microthrombi/n situ thrombosis causing plexiform lesions

Answer 589

Interstitial lung disease Cardiomyopathy Granulomatous inflammation and involvement of vessels → intrinsic sarcoid vasculopathy PVOD lesions Lymph node compression of PA CTEPH Portal hypotension Fibrosing mediastinitis

Answer 590

Estrogen Endothelin 1 Deficiency of prostacyclin

Answer 591

Loud P2 RV heave Tricuspid or pulmonary regurgitation murmurs Elevated JVP, peripheral edema, ascites

Answer 592

NYHA IV ** Syncope Rapid symptom progression pro-BNP >1100 ng/L or BNP > 800 ng/L ** 6MWD <165 m ** RA size >26 cm^2 Pericardial effusion VO2 max <11 mL/kg/minute VE/VCO2 >45 CI <2, SvO2 <60%

Answer 593

CI <2 RAP >14 SvO2 <60% Vasoreactivity

Answer 594

TRV >2.8 m/s RVSP 35 - 40 mmHg RV hypertrophy, RV and RA dilation Flattening of the interventricular septum (can also get bowing) Pericardial effusion Tricuspid regurgitation TAPSE <18 mm IVC >21 mm, <50% collapse with sniff testing

Answer 595

Ventricle: RV/LV basal diameter >1, flattening of septum PA: RV outflow doppler acceleration time <105 ms, PA diameter >/25 mm IVC and RA: diameter >21 mm with <50% collapse with deep inspiration, RA >18 cm^2

Answer 596

RV strain pattern - most sensitive Right axis deviation RBBB RV hypertrophy - R/S >1 in V1 RA enlargement - P pulmonale, P wave >0.25 mV in lead II

Answer 597

Vascular pruning Enlarged pulmonary arteries Enlarged heart - enlarged RV and RA

Answer 598

Mosaic attenuation Enlarged PA >3 cm PA: aorta ratio > 1 RV increased thickness, interventricular septum changes

Answer 599

Direct Fick method Indirect Fick method Thermodilution method

Answer 600

Ferritin <100 Ferritin 100-299 but tSAT <20%

Answer 601

Idiopathic Hereditary Drug and toxin induced (related to anorexigens) It is “suggested” and warfarin is the agent NOTE: This is 2015 recommendation. 2022 says not generally recommended but consider individually

Answer 602

Inhaled nitric oxide IV epoprostenol IV adenosine

Answer 603

>10 mmHg reduction to

Answer 604

Prostacyclin → activates cAMP → inhibits platelet activation, promotes vasodilation Selexipag is prostacyclin receptor agonist Nitric oxide: PDE5i reduce breakdown of cGMP, riociguat stimulates guanylate cyclase which increases production of cGMP. cGMP Endothelin receptor antagonist → inhibition → vasodilation

Answer 605

Prostacyclin - hypotension, flushing, headaches, jaw pain, rebound PH PDEf5 - headaches, flushing, volume overload, priapism Riociguat - headaches, headache, GERD ERA - fluid retention, hepatotoxicity, anemia

Answer 606

Teratogenic: ERAs, riociguat Heart failure: prostacyclins

Answer 607

Tadalafil + ambrisentan AMBITION trial

Answer 608

Conditions associated with left ventricular diastolic dysfunction. 1. Cardiac Obesity Hypertension Diabetes CAD 2. Pulmonary Parenchymal disease (DLCO usually <45%) Treatment of refractory PH

Answer 609

Transplantation Right to left shunt creation

Answer 610

WHO FC 6MWD BNP ECG ABG or pulse oximetry

Answer 611

Small/coincidental defects (<1 c, VSD, <2 cm ASD) → defect closure is C/I Prevalent systemic to pulmonary shunt → may be correctable or non correctable Eisenmenger Syndrome → defect closure is C/I PAH persisting post defect correction

Answer 612

Moderate to severe PH rather than mild-moderate FEV1 >60% in COPD FVC >70% in IPF Low diffusion capacity out of keeping CT abnormalities only modest

Answer 613

PVR >5 This is also prognostic indicator

Answer 614

Large burden of disease Recurrent PEs Insufficiency anticoagulation Hypercoagulable states e.g. splenectomy, antiphospholipid syndrome, ET/PCV, malignancy

Answer 615

VQ scan >97% sensitive, 90% specific CT PA 99% specific, 51% sensitive

Answer 616

Webs and Slits Ring like stenosis Total occlusions

Answer 617

Pulmonary artery sarcoma Fibrosing mediastinitis Sarcoidosis Large vessel vasculitis including takayasu Peripheral pulmonary artery stenosis Congenital pulmonary artery abnormalities In situ pulmonary artery thrombosis Pulmonary Veno Oclusive Disease Moyamoya disease

Answer 618

Blood thinners for all (lifelong) Pulmonary artery endarterectomy Balloon pulmonary angioplasty Riociguat

Answer 619

Reperfusion injury

Answer 620

Dissection Perforation Over dilation

Answer 621

Smooth interlobular septal thickening Centrilobular nodules Mediastinal lymphadenopathy

Answer 622

Hereditary - BMPR2, EIF2AK4 Medications e.g. cyclophosphamide, bleomycin CTD e.g. scleroderma, SLE, sjogren’s, etc. Infections e.g. influenza, HIV, EBV, CMV HSCT

Answer 623

Hemoptysis Hemorrhagic pleural effusions

Answer 624

Obliteration/extensive and diffuse occlusions of pulmonary veins Colander like lesions (recanalized thrombus) No plexiform lesions

Answer 625

1. Warning signs : * 1. rapid progression of symptoms * 1. severely reduced exercise capacity * 1. pre-syncope or syncope on mild exertion * 1. signs of right heart failure. 1. PAH suspected 1. CTEPH suspected

Answer 626

Platypnea = dyspnea in upright position that improves when supine Orthodeoxia = SaO2 drops by >/5% and PaO2 drop by 4 mmHgwhen rising from supine to upright

Answer 627

Hepatopulmonary syndrome PAVMs Intracardiac shunts e.g. PFO Pulmonary parenchymal disorders Other causes of VQ mismatch

Answer 628

V/Q mismatch - Intrapulmonary vascular dilatations Shunt - Pulmonary arteriovenous malformations Diffusion limitation - due to increased diameter from dilatation

Answer 629

Liver disease Intrapulmonary vascular dilatation Abnormal oxygenation (abnormal A-a gradient or PaO2)

Answer 630

Supplemental oxygen Liver transplantation

Answer 631

Idiopathic HHT (>80% of AVM's are from this) Hepatopulmonary syndrome Trauma, prior cardiac surgery Malignant e.g. metastatic thyroid Infections e.g. TB, schistosomiasis CTD e.g. behcet’s, GPA, takayasu

Answer 632

Brain abscess Embolic stroke Platypnea, orthodeoxia Hemoptysis, hemothorax Dyspnea (orthodeoxia), Hypoxemia, cyanosis Pulmonary hypertension

Answer 633

PAVM 30% Epistaxis - 90% Telangiectasias - 80% Cerebral AVMs - 10% Hepatic AVMs → high output heart failure GI bleeding, iron deficiency

Answer 634

Portal hypertension Encephalopathy and other signs of liver dysfunction High output heart failure

Answer 635

Mucosal and skin telangiectasias Pulsatile liver Murmurs and bruits Platypnea and orthodeoxia Cyanosis and clubbing Signs of heart failure e.g. peripheral edema

Answer 636

O2 saturation on room air Contrast echo/bubble echo 100% oxygen Radiolabeled perfusion scan

Answer 637

CT PA Pulmonary angiography

Answer 638

Observation, repeat CT q3-5 years Embolization/embolotherapy Surgical resection Laser ablation

Answer 639

Symptomatic, complications, regardless of size Feeding vessel > 3 mm Progressive enlargement

Answer 640

Autosomal dominant ACVRL1, ENG, SMAD4

Answer 641

Curacao Criteria - Mutation OR (3 for definite, 2 for suspected) - First degree relative with HHT - Multiple mucocutaneous telangiectasias - Visceral involvement of telangiectasias or AVMs - History of recurrent and spontaneous epistaxis

Answer 642

Iron deficiency anemia* Pulmonary AVMs* Cerebral AVMs* GI AVMs Hepatic AVMs

Answer 643

During labor/delivery or within 30 mins of placenta delivery [Cardiopulmonary collapse or sBP <90] AND resp compromise (hypoxemia, dyspnea, cyanosis) DIC Absence of fever

Answer 644

Petechiae Neurological symptoms e.g. coma, seizure Hypoxemia

Answer 645

Fractures, orthopedic surgeries Liposuction, lipoinjection Panniculitis Burns Pancreatitis Fatty liver disease Sickle cell disease Osteonecrosis

Answer 646

Amniotic fluid - supportive Fat embolism - supportive, ?steroids controversial Venous air embolism - left lateral decubitus (durant Mavouver), hyperbaric O2 Arterial air embolism - hyperbaric O2

Answer 647

CF/bronchiectasis/suppurative lung disease Pulmonary hypertension

Answer 648

Colonization with resistant organisms, bronchiectasis Pulmonary hypertension

Answer 649

Overall mean 6.5 years Double lung transplant mean 8 years Single lung transplant mean 5 years

Answer 650

Neuro - tremors, headaches, visual abnormalities, seizures Cardiovascular - hypertension Renal - AKI, hyperkalemia, hyperuricemia, gout MSK - osteoporosis Endo - hirsutism, hyperglycemia Drug drug interactions 1. 1. CYP3A4 enzyme inhibitors * 1. increases calcineurin inhibitor levels * 1. Macrolides (except azithromycin), Azoles, Calcium channel blockers, Grapefruit juice 1. CYP3A4 enzyme inducers * 1. Decreases calcineurin inhibitor levels * 1. Rifampin, Carbamazepine, pheobarbital, pheytoin * 1. St. John’s wort

Answer 651

PjP prophylaxis for all CMV prophylaxis for those at risk HSV for all EBV for those at risk Aspergillus for those at risk

Answer 652

Chronic end stage lung disease who meet both criteria * >50% risk of death from lung disease within 2 years if lung transplant not performed * >80% likelihood of 5-year post transplant survival froma general medical perspective

Answer 653

EARLY: Infections Diffuse alveolar hemorrhage Post engraftment respiratory distress syndrome Radiation pneumonitis Pulmonary edema Aspiration pneumonitis or pneumonia LATE: Infections Organizing pneumonia Obliterative bronchiolitis PPFE and other ILDs PVOD lesions Malignancy (recurrence or secondary)

Answer 654

EARLY: Infections Diffuse alveolar hemorrhage Hyperacute and acute GVHD Pulmonary edema Aspiration pneumonitis or pneumonia LATE: Infections Organizing pneumonia Obliterative bronchiolitis PVOD lesions Malignancy (recurrence or secondary)

Answer 655

Age >20 <45 donor African American donor Female donor Donor smoking history Trauma to donor Blood products ECMO used as bridge Recipient diagnosis of IPF, PAH

Answer 656

Usually within 72 hours Reperfusion injury (the mechanism) Bilateral patchy opacities, ARDS like DAD on pathology

Answer 657

Only GRade 3 has been shown to be associated with poor outcomes

Answer 658

* Early (<8 weeks) : infection and dehiscence * Late (>8 weeks): stenosis and bronchomalacia * Need bronchoscopy to diagnose.

Answer 659

* Acute cellular rejection: T cell mediated highly associated with CLAD and decreased immunosuppression * Acute Antibody Mediated Rejection: B cell binding. DSA and AMR associated with CLAD

Answer 660

Cellular: TBBx (Perivascular monoculear infiltrates) Antibody mediated: DSA, TBBx, CD4 staining

Answer 661

Perivascular and interstitial mononuclear infiltrates → A score Lymphocytic bronchiolitis → mononuclear cell infiltrates in submucosa of bronchioles → B score

Answer 662

PGD: Supportive, ARDS ventilation Acute: * steroids for all, switching maintenence therapy, anti thymocyte (ATG), Basiliximab * ab mediated no standard of care but PLEX/IVIG often tried with anti thymocyte (ATG)

Answer 663

FEV1 decline by >/20% from baseline that lasts for at least 3 months (For definite), and change is not explained by something else (e.g. infection) BOS: FEV1/FVC <0.7 RAS: TLC<90% baseline (or FVC <80% baseline), persistent fibrotic opacities

Answer 664

Previous PGD or acute reflection Infection, especially CMV, colonization with PsA or aspergillus GERD Aspiration Medication/IST non compliance or underdosed Increased donor age Male to female donor

Answer 665

BOS: mosaic attenuation, centrilobular nodules, gas trapping/hyperinflation, bronchiectasis with time, usually not significant opacities RAS: Pleuroparenchymal fibroelastosis, NSIP

Answer 666

BO: Lymphocytic inflammation of submucosa, intraluminal lesion formation, obliteration of airway RAS: PPFE

Answer 667

Address risk factors e.g. GERD Optimize immunosuppression (MMF > Aza, Acro > cyclo) Consider azithromycin (those with neutrophilic BAL especially responsive)

Answer 668

Early: Acute or hyperacute rejection Infectious complications e.g. bacterial, viral, fungal, empyema, surgical site, line infections Bleeding e.g. hemoptysis, hemothorax Dehiscence Anastomotic leak, prolonged air leak Phrenic nerve injury causing diaphragmatic dysfunction Pulmonary embolism, DVT Cardiac arrhythmias Late: Chronic rejection Infectious complications e.g. viral, fungal, bacterial Tracheal stenosis Tracheobronchomalacia Tracheoesophageal and tracheoarterialfistulization Dehiscence PTLD, non melanomatous skin cancer, other malignancies Disease recurrence

Answer 669

First month: MRSA, VRE, pseudomonas, candida, HSV Month 1-6: PJP, aspergillus, nocardia, CMV, EBV, endemic fungi, TB, NTM >6 months: Community organisms

Answer 670

PTLD, lymphoma (B cell predominant) Non melanomatous skin cancer Primary lung cancer Breast cancer

Answer 671

EBV virus, serostatus (highest in R-/D+) Degree of immunosuppression (T cell immunosuppression)

Answer 672

Decrease immunosuppression Rituximab Chemotherapy (CHOP) Surgery/Rads PRN

Answer 673

Bronchogenic carcinoma Idiopathic pulmonary hemosiderosis Giant cell interstitial pneumonitis A1AT deficiency (if smoking) PVOD PAP (hereditary cases) LAM PLCH Sarcoidosis → most common DIP Diffuse panbronchiolitis

Answer 674

CMV infection: evidence of active replication and shedding (e.g. antigenemia, PCR, culture) without attributable signs or symptoms - CMV isolation in the blood by viral isolation, rapid culture, antigenemia, QNAT CMV disease: infection with attribute signs or symptoms; can be viral syndrome or tissue invasive disease - CMV isolation in the lung tissue by viral isolation, rapid culture, histopathology, immunohistochemistry - Also CMV PCR in the blood needed

Answer 675

D+/R- (highest risk) D+/R+ D-/R+

Answer 676

R+/-D- Degree of immunosuppression, use of high dose steroids GVHD Prior CMV viremia

Answer 677

Oral valganciclovir IV ganciclovir Foscarnet is second line treatment Reduction in IST should be considered

Answer 678

* Cystic fibrosis * Primary ciliary dyskinesia * Young syndrome ( Men with sinusitis, infertility due to vas deferens obstruction and bronchiectasis) * Williams- Campbell (bronchomalacia with decreases/absent cartilage around subsegmental bronchi. You get cystic bronchiectasis) * Alpha 1 antitrypsin * Yellow nail syndrome * Mouniere Kuhn syndrome (tracheobronchomegaly and lung sequestration * Kartaaganer syndrome ( situs inversus, chronic sinusitis, and bronchiectasis)

Answer 679

Autosomal recessive Loss of or dysfunctional cilia

Answer 680

Chronic sinopulmonary infection Bronchiectasis Male infertility Situs inversus

Answer 681

Bronchiectasis Chronic rhinosinusitis Situs inversus

Answer 682

Low or absent nasal nitric oxide Genetic testing for confirmation Can do sinus biopsy but can be falsely negative

Answer 683

* Abnormally viscous mucous * Triad of bronchiectasis, chronic rhinosinusitis and infertility due to vas deferens obstruction * Can appear to be similar to CF and primary ciliary dyskinesia (PCD) patients, but they have had normal sweat chloride tests and normal cilia

Answer 684

Chronic sinopulmonary infections Bronchiectasis Male infertility

Answer 685

Yellow nails Respiratory symptoms Lymphedema

Answer 686

Post infectious Idiopathic Immunodeficiency Connective tissue disorders

Answer 687

PsA H. influenzae (SA in CF instead)

Answer 688

CBC IgE, Asp IgG, workup ABPA IGAMs Sputum cultures

Answer 689

Signet ring sign/broncho arterial ratio >1 Tram tracking, non tapering peripheral airways Mucous plugging Bronchial wall thickening Gas trapping

Answer 690

* Active cycle of breathing technique * Autogenic drainage * Gravity positioning * OPEP * Nebulized saline * Remember NMD: Lung volume recruitment (LVR) (aka “breath stacking”) Glossopharyngeal breathing Manual resuscitator Mechanical inspiration Mechanical cough assistance Manually assisted cough (MAC) Mechanical insufflator-exsufflator (MIE)

Answer 691

Inhaled mannitol Inhaled NAC Inhaled dornase alpha Carbocysteine

Answer 692

Airway clearance Pulmonary rehabilitation Mucoactive therapy Chronic abx - azithro for non PsA, inhaled for PsA

Answer 693

Azithro if non PSA Inhaled anti pseudomonas if PSA - tobra, collistin, gentamicin (or azithro if none of these are tolerateD)

Answer 694

ERS 2017 says >3 per year should be offered chronic Abx. Inhaled for those with PSA+/- macrolide

Answer 695

Worsening symptoms Over last 48 hours

Answer 696

LABA in those with significant breathlessness

Answer 697

Localized disease not controlled with medical treatment Post obstructive bronchiectasis due to tumors Massive hemoptysis Recurrent exacerbations Overwhelming sputum production

Answer 698

68 years after Trikafta (2022)

Answer 699

CFTR transmembrane protein mutation Chromosome 7 gene (long arm) Transepithelial chloride channel Abnormally thick mucus, difficulty clearing, infections and colonization

Answer 700

* Class 1 – absent or defective protein synthesis * Class 2 – abnormal processing or transport of the protein to the cell membrane * Class 3 – abnormal regulation of CFTR function, inhibiting chloride channel activation * Class 4 – normal amount of CFTR but reduced function (defective conduction) * Class 5 – reduced synthesis of fully active CFTR * Class 6 – decreased stability of fully processed and functional CFTR

Answer 701

Staphylococcus aureus ** Pseudomonas ** H. Influenza ** Burkholderia cepacia Aspergillus fumigatus NTM Stenotrophomonas

Answer 702

Bronchiectasis Bacterial colonization Recurrent pulmonary infection Mucous plugging and collapse Pneumothorax Hemothorax Gas trapping and obstruction

Answer 703

Sinus - sinusitis, nasal polyps Intestinal - Meconium ileus, DIOS, SIBO, chronic constipation Pancreas - pancreatic insufficiency with steatorrhea and vitamin ADEK deficiency, chronic pancreatitis, diabetes Liver - transaminitis, biliary cirrhosis, fatty liver disease, cirrhosis Reproductive - male/female infertility; absence of vas differences, thickening of cervical mucus MSK - osteopenia or osteoporosis Depression

Answer 704

Chronic constipation DIOS (distal intesinal obstruciton syndrome) SIBO (small intestine bacterial overgrowth) Pancreatitis Appendicitis Intussusception Colon cancer

Answer 705

Age 40 and q5 years or as dictated by polyp Age 30 if previous transplant

Answer 706

Clinical: NBS, family history, sx Sweat chloride test Genetic testing Extended CFTR analysis Functional assays

Answer 707

* Serum immunoreactive trypsinogen assay (elevated is positive) * DNA assay

Answer 708

Malnutrition Anorexia, bulimia Pancreatitis Untreated adrenal insufficiency Untreated hypothyroidism Hypophysitis Technical/test factors

Answer 709

Dehydration Physiologic low sweat rate Hypoproteinemic states Drugs e.g. mineralocorticoids On CFTR modulators (e.g. baby of mother on CFTR modulator during pregnancy) Technical/test factors Malnutrition

Answer 710

* CRMS: children with a positive newborn screen AND one of ** Sweat chloride <30 and 2 CFTR mutations of which 1 has unclear phenotypic consequences ** An intermediate sweat chlorid (30-59) and 1 or 0 CF causing mutations * Note: most will not devlop clinical CF and this has been combined with CF Screen positive Inconclusive Diagnosis (CFSPID) * CFTR-Related Disorder: Do not meet diagnostic criteria for CF or CRMS but are affected by CF related Conditions.

Answer 711

Smoking cessation, vaccinations Airway clearance, bronchodilators Inhaled hypertonic saline Inhaled DNAse Chronic azithromycin +/- modulator therapy

Answer 712

Active cycle of breathing Autogenic drainage Positional therapy Oscillating PEP device - Aerobika, Acapella, flutter valve Percussive vest

Answer 713

Younger F508 delta Higher admissions PsA co infection

Answer 714

Eradication Prevent exacerbations Exacerbation

Answer 715

PsA +/- MRSA

Answer 716

Aztreonam 500 mg oral MWF Tobramycin 300 mg nebulized BID Colistin 150 mg nebulized BID Aztreonam 75 mg nebulized TD * weak evidence 28 days on and off

Answer 717

MSSA: amoxi-clav, doxy, septra - cefazolin, nafcillin MRSA: Septra, doxycycline - Vancomycin, linezolid PsA: cipro - ceftaz, piptazo, mero, tobra, aztreonam Steno: septra, doxy, levoflox - ceftaz, colistin

Answer 718

At least 2 weeks but often longer

Answer 719

Scant <5 cc Mild to moderate 5-240 cc Massive >240 cc

Answer 720

Scant: +/- abx, continue everything Mild/moderate: stop HS, no consensus DNAse, airway clearance; START abx Massive: stop HS, airway clearance, no consensus DNAse; START abx Stop BiPAP if on it (unless mild)

Answer 721

Vitamin K, tranexamic acid Bronchial artery embolization Lung resection Transplantation

Answer 722

No consensus re antibiotics Follow guidelines re: chest tube Hold percussive therapies (including PEP devices) Hold BPAP Do not withhold mucous clearance and aerosols

Answer 723

Not after first episode After recurrence Surgical pleurodesis is preferred

Answer 724

No travel x 2 weeks after resolution No heavy lifting 5 lb x 2 weeks after resolution No spirometry x 2 weeks after resolution

Answer 725

Class I: Nonsense mutation, Decreased synthesis Class II: processing mutation e.g. F508del Class III: Gating mutation e.g. G55D, Class IV: Conductance e.g. R117H Class V: Decreased production Class IV: Decreased stability

Answer 726

F508 del Gating mutation e.g. G551D R117H

Answer 727

Improve symptoms Improve quality of life Improved lung function/FEV1 (10.4%) Improved weight Improve sweat chloride Reduced exacerbation and admission Improved mortality

Answer 728

MAC complex

Answer 729

Annually in spontaneously expectorating Do not need to go hunting for sputum if not spontaneously expectorating and no sx Do not use oropharyngeal swabs

Answer 730

Cold saline Topical epinephrine 1:10,000 Bronchial blocker Wedge with bronchoscopy Lateral decubitus Intubate

Answer 731

Prevent CNS tuberculosis. Prevents disseminated TB. Protection is mainly during childhood (up to age 15)

Answer 732

Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium carnetti Mycobacterium africanum Mycobacterium microti

Answer 733

Age <5 Immunocompromised e.g. HIV

Answer 734

Age <5 HIV

Answer 735

Contacts e.g. household contacts Birth in TB endemic area Immunosuppression Substance abuse Socioeconomic status Malnutrition Certain systemic diseases e.g. COPD, DM, silicosis, renal disease, malignancy

Answer 736

Cavitary disease Upper lung zone disease Laryngeal disease AFB smear positive disease Level of exposure - proximity, time spent with them, environment Coughing, sneezing

Answer 737

Airborne Droplet Percutaneous Ingestion

Answer 738

Smear negative → 2 weeks Smear positive → 2 weeks if 3 consecutive smear negative AFB Smear positive → 4 weeks if persistently positive sputums For rifampin resistance, 4 weeks +/- 3 negative smears

Answer 739

Complicated TB, comorbid conditions Has acute complication of TB e.g. hemoptysis Drug desensitization Is non compliant with medication Cannot isolate safety at home

Answer 740

No shared ventilation with other units (non household members) Everyone in household has already been exposed and if TBST negative, should accept risk of ongoing exposure <5 or immunocompromised patients are already on treatment for latent or active TB

Answer 741

Longer duration IF NOT ON ART Rifampicin rather than rifampin Consideration of timing of ART therapy +/- steroids

Answer 742

Lower lobe distribution Parenchymal consolidation - Opacities, GGO, tree in bud nodules May have cavities Miliary TB Hilar, mediastinal LN →RML collapse More likely to have pleural effusion

Answer 743

Upper lobe distribution (apical, posterior > sup segment > anterior) Consolidation, tree in bud Cavitation 5% have upper lobe fibrocalcific changes

Answer 744

Low pretest probability Diagnosis of active TB in those >12 years old Trending response to treatment Mass testing programs for e.g. immigrants (not including HCW/occupations)

Answer 745

CXR showing apical fibronodular changes typical of healed TB Recent exposure to active TB Certain occupations e.g. HCW, prisoner workers, shelter workers HIV (any stage) IVDU or use of illicit drugs Post HSCT or organ transplant (and pre transplant workup) On immunosuppressive therapies (includes chemo) Lymphoma, leukemia, head and neck cancers Chronic kidney disease requiring dialysis Silicosis

Answer 746

Type IV delayed type hypersensitivity

Answer 747

Contact tracing Serial testing HCP and others

Answer 748

Contact investigation Serial testing of HCW, other populations e.g. inmates, prison workers

Answer 749

Unclear if patient will return Children >10 received vaccine after age 1, unclear when, >/2 vaccines Children >2 but <10 previously received vaccine Adequate training, personnel, facility for TBST not available TBST is contraindicated Previous known NTM infection

Answer 750

Previous allergic reaction, blistering reaction

Answer 751

Technical limitations Prior vaccination Sensitization to NTM (not an issue with IGRA) Rupture of venule at time of injection

Answer 752

Technical limitations HIV Active TB or fungal infection Live virus vaccine in the last 4 weeks Recent infection Steroids >/15 mg x >2-4 weeks Natural waning of immunity

Answer 753

Immunosuppression e.g. HIV, active TB Technical variability

Answer 754

TBST: 77% IGRA: 60-95%

Answer 755

Either can be done to increase sensitivity after negative test IGRA can be done after positive TBST to increase specificity

Answer 756

<5 >/5 >/10

Answer 757

AFB smear (Zeil Nielson, Auramine Rhodamine) - sensitivity 20-80% PCR - sensitivity 70-95% Culture Histopathology

Answer 758

Appropriate clinical and imaging findings Positive TB culture, positive TB PCR +/- AFB

Answer 759

Sputum Induced sputum BAL Tissue Urine (guideline recommends against lipoarabinomannan but can still do culture) Blood Gastric aspirate Stool

Answer 760

Caseating granulomatous inflammation May see organisms, may stain positive for AFB

Answer 761

Tuberculosis NTM, most likely MAC Nocardia Rhodococcus Actinomyces

Answer 762

5-10% 50% of that risk is in the first 2 years Canadian specific can use TSTin3D (McGill online calculator) to estimate the cumulative risk of disease for active TB

Answer 763

3HP = isoniazid and rifapentine weekly x 3 months (First Line) Rifampin daily x 4 months (First line) Isoniazid daily x 9 months (Second Line) Isoniazid daily x 6 months (Alternative) Isoniazid and rifampin daily x 3 months (alternative)

Answer 764

Assess for active TB - CXR → sputum AFB if CXR is abnormal LFTs Creatinine CBC HIV, hepatitis B, hepatitis C

Answer 765

Recent close contact with active TB On immunosuppression Has HIV

Answer 766

Rifampin x 4 months

Answer 767

Isoniazid 5 mg/kg daily → prevent resistance - bactericidal Rifampin 10 mg/kg daily → prevent resistance, relapse - bactericidal Ethambutol 15 mg/kg daily → prevents resistance Pyrizinamide 20 mg/kg daily - bactericidal FQ (moxi/levo) when person has A/E requiring cessation of a first line drug

Answer 768

* isoniazid, rifampin, pyrazinamide and ethambutol daily for the first 2 months followed by isoniazid and rifampin for 4 more months * Suspected susceptibility: ** RIPE daily x 2 months then RIE daily for 4 months * Known susceptibilities: ** RIP daily x 2 months then RI daily x 4 months * Note: should add pyridoxine (Vit B6) 25-50mg/day for all those takine INH at risk for peripheral neuropathy ** people with diabetes, chronic kidney disease, human immunodeficiency virus (HIV) malnutrition, seizure disorder or a history of substance misuse, as well as pregnant or breastfeeding women

Answer 769

R/I/E x 2 months then extend out to 7 months Can also do the drugs in continuation phase (whether R/I or R/I/E 3 times per week)

Answer 770

extensive disease OR baseline cavitary disease on x-ray and smear or culture positive sputum at two months) extension of the continuation phase to seven months for a total of nine months of TB drug therapy (poor evidence).

Answer 771

Isoniazid - peripheral neuropathy, hepatic toxicity, drug induced SLE Rifampin - drug-drug interaction, body fluid discolouration, hepatic toxicity, rash Ethambutol - optic neuropathy, red-green color blindness Pyrazinamide - hepatotoxicity

Answer 772

DOACs, warfarin Oral contraceptives Antifungals Tacro, cyclo Methadone Phenytoin

Answer 773

Billi >3, serum, ALT > 3 ULN with sx, ALT >5 ULN with no sx Can continue ethambutol; consider adding FQ Discontinue, restart slowly with careful monitoring Obviously assess for other causes of transaminitis

Answer 774

BASELINE Cavitary ON CXR + smear/culture positive at 2 months Diabetes and cavitary disease HIV not on ART therapy Solid organ transplant recipients On TNF alpha inhibitors Did not use pyrazinamide in intensive phase TB meningitis TB bone disease if elevated inflammatory markers at end of 6 months

Answer 775

TB meningitis or CD4>50- delay until after 2 weeks of starting TB therapy **Out of concern for Immune REconstitution Inflammatory Syndrome (IRIS) No TB meningitis and/or CD4 <50 - within 2 weeks of starting TB therapy Pred 40 x 2 weeks if CD4 <100, unless active hepatitis B, kaposi, rifampin resistance

Answer 776

Immune REconstitution Inflammatory Syndrome (IRIS) Lymph node enlargement and pulmonary infiltrates. Usually self limited but can warrant steroids.

Answer 777

CBC, crea, LFTs monthly HIV, hepatitis B/C at start of treatment CXR at baseline, then q2 months Sputum smear, culture q2 weeks until smear negative; then 2 and 1 month before end PFT within 6 months of finishing treatment

Answer 778

Recurrence: can be due to either Relapse: same strain Reinfection: different strain

Answer 779

Cavitary disease, smear positive disease Extensive or disseminated disease Drug resistant disease Immunosuppressed Intermittent therapy (not daily), treatment interruptions Was not adherent Should monitor these patients for 12-24 months with sx/imaging/microbiological testing

Answer 780

RIE (omit P) x 9 months

Answer 781

Smear positive Extensive disease Disseminated Intolerance to any first line drugs

Answer 782

+/-PZA All injectables Fluoroquinolones

Answer 783

Pleural* Abdominal* Lymphadenopathy* CNS - tuberculoma, CNS meningitis Bone - vertebral disease, arthritis Cutaneous Genitourinary Ocular

Answer 784

Disease in >?2 non contiguous organs OR isolation in blood, bone marrow, or liver on bx Milliary TB is subset of disseminated TB

Answer 785

Disseminated tuberculosis Other infections: histoplasmosis, mycoplasma, varicella Sarcoidosis, pneumoconiosis, amyloidosis Miliary metastases e.g. thyroid cancer, breast cancer, RCC, melanoma

Answer 786

Fluid analysis Fluid adenosine deaminase Fluid interferon gamma Fluid AFB and culture Histopathology

Answer 787

Low - normal glucose pH >7.3 LDH >500 Neutrophil predominant early on, the lymphocyte predominance <5% mesothelial cells Pseudochylothorax, chylothorax

Answer 788

RIPE x 6 months Chest tube if empyema, may need decortication No steroids No therapuetic thoracenteisis/chest tube for pleural TB associated effusions.

Answer 789

CNS x 9-12 months, requires higher doses of rifampin >15 mg/kg Joint x 9-12 months if markers of severity at 6 months (CRP, ESR)

Answer 790

Basal leptomeningeal enhancement Hydrocephalus Infarcts

Answer 791

Mitigate increased ICP, reduce hydrocephalus and infarction, reduce short term mortality Does not affect disabling neurological consequences or long term survival

Answer 792

120 mg x 1 week 90 mg x 1 week 60 mg x 1 week 30 mg x 1 week 15 mg x 1 wek 5 mg x 1 week

Answer 793

RIPE x 6 months Steroids in HIV negative NOT HIV positive (ART or no ART)

Answer 794

Treating TB in HIV with CD4 <100 to prevent IRIS (Only if on HAART) All patients with meningitis HIV negative patients with pericarditis (No recommendation for or against if HIV+ on therapy with HAART and have TB pericarditis)

Answer 795

Monoresistant: Resistant to any of the first line therapies. Poly drug resistance: Resistant to 2 of the first line therapies (not rifampin) MDR: Resistant to INH + Rifampin with/without resistant to other first line agents. Pre-XDR: MDR TB with additional resistance to any FQ. XDR: Pre-XDR + resistance to bedaquiline/linezolid

Answer 796

initial regimen should include levofloxacin or moxifloxacin AND bedaquiline AND linezolid AND clofazimine AND cycloserine. 5 to 7 months after culture conversion occurs, the total number of drugs in the regimen can be reduced to 4 for a total duration of 18-20 months.

Answer 797

Same as MDR. Ensure 5 drugs in the regimen initially. Cannot use resistant drugs. In order of preference add on: ethambutol, pyrazinamide, delamanid, amikacin, imipenem-cilastatin or meropenem (plus clavulanic acid), ethionamide and p-aminosalicylic acid.

Answer 798

Partial lung resection in carefully selected patients can be used as an adjuvant. Optimally after culture conversion is achieved.

Answer 799

TB: Philippines, Pakistan, Somalia, India MDR: Somalia, China

Answer 800

MAC M. Kansassi M. abscessus

Answer 801

Soli aerosols(All but M. Kansasii) Water aerosols Soft tissue Aspiration

Answer 802

Older age Female Lower BMI Thoracic cage abnormalities, mitral valve prolapse Immunocomp (e.g. HIV, IST, malignancy) but can happen in immunocompetent too Underlying structural lung disease e.g. bronchiectasis, CF, ILD, COPD/asthma Oral steroids >15 mg/day Inhaled fluticasone >800 mcg/day Anti TNF alpha

Answer 803

Older age Male Lowe BMI Immunosuppression - primary immunodeficiency, HIV infection, IST, anti TNF, steroids? Labs: elevated ESR/CRP, hypoalbuminemia Fibrocavitary disease Extent of disease Bacterial load and species and smear positivity

Answer 804

Fibrocavitary Nodular bronchiectatic Other: HP, solitary pulmonary nodule, disseminated

Answer 805

Superficial lymphadenitis (especially cervical) Skin and soft tissue infection Disseminated disease

Answer 806

Fibrocavitary - thick walled cavities, upper lobe predominance Nodules, tree in bud nodularity Bronchiectasis GGO, centrilobular nodules, gas trapping in HP

Answer 807

Scoliosis Pectus excavatum Mitral valve prolapse

Answer 808

Symptoms Imaging consistent with pulmonary disease Exclusion of other diagnoses 2 sputum or 1 BAL If M. abscessus should be speciated ot the subspecies level and checked for macrolide resistance. OR if disseminated x1 blood culture/culture from site of infection

Answer 809

TB - 3 sputums, 1 hour apart is fine NTM - 2 sputums, same species/subspecies should be isolated over interval of >/1 week

Answer 810

Sputum culture q2-3 months Repeat imaging after 6 months

Answer 811

2020 guidelines say treat if diagnosed instead of watchful waiting. (condition and very low evidence) Especially treat if: Positive smear or cavitary disease

Answer 812

* Note rifampicin and rifampin are the same thing * MAC should ** always have a azithromycin if susceptible and if cavitary/macrolide resistant/refractory should have amikacin or streptomycin addedd **Treated 12 months post conversion * Kanasii ** Rifampin susceptible suggest Rifampin, Ethambutolo and either INH or azithro (daily is preferred in most cases) ** Rifampin resistant then add moxifloxacin ** Treated for at least 12 months (regardless of conversion) * Xenopi ** Moxi or Azithro with a total of minimum 3 drugs. ** If cavitary or adanced add amikacin ** Treat 12 months beyond conversion

Answer 813

Abscessus * There is an initial and continuation phase and you need to know if it is Mutational susceptible and inducible susceptible (14 days). * Need 3 active drugs initially * duration - “short vs. long”-Expert opinion

Answer 814

Culture positive after 6 months

Answer 815

Can have chromosomal mutations Mutation and inducible resistance

Answer 816

Fibronodular disease Extensive disease/cavitary disease Macrolide resistant disease Refractory disease

Answer 817

Fibronodular disease Extensive disease/cavitary disease Rifampin resistance

Answer 818

Fibronodular Extensive/cavitary disease

Answer 819

Severe complication e.g. hemoptysis Not responding to medical therapy, refractory disease

Answer 820

MAC x 12 months post first negative culture/culture conversion Kansasii x 12 months fixed Xenopi x 12 months post culture conversion Abscessus - expert opinion

Answer 821

T cell mediated immune defense: PJP, endemic fungi, NTM/TB, crypto Phagocytosis: candida, aspergillus, mucormycosis

Answer 822

ABPA Aspergillus nodule Aspergilloma - unusual to be caused by other fungus Chronic cavitating pulmonary aspergillosis Chronic fibrosing pulmonary aspergillosis Semi invasive pulmonary aspergillosis Invasive pulmonary aspergillosis Tracheobronchitis

Answer 823

Aspergillus IgG - most sensitive IgE specific Aspergillus for ABPA) Serum/BAL - PCR Serum/BAL - galactomannan Sputum/BAL/tissue/blood/other - culture

Answer 824

Pre-existing structural lung disease. COPD Tuberculosis Cystic fibrosis Others

Answer 825

Prolonged neutropenia <500 for >10 days (biggest risk) Transplantation - lung, HSCT Hematological malignancy Steroids >3 weeks Chemotherapy HIV/AIDs Chronic granulomatous disease

Answer 826

At least 3 months in duration Consistent clinical and imaging features Evidence of Asp IgG vs positive sputum/BAL/biopsy culture

Answer 827

Nodules Reverse halo sign (more common with OP and less commonly fungal but mucormycosis most common of the fungal) Atoll sign (same as reverse halo sign) Halo sign is most commonly associated with IPA Air crescent sign (delayed finding) Wedge shaped infarcts Tree in bud opacities

Answer 828

Single - can observe or surgery/embolization if symptomatic Multiple - antifungals (itraconazole) Can give antifungals pre/post surgery if high risk spillage

Answer 829

Observe Itraconazole, vori, posi x 6 months

Answer 830

Voriconazole IV first then po x >/6 weeks need radiographic/clinical improvement. Can also transition to po itroconazole.

Answer 831

Finger in glove, mucous plugging Mucous plugging can cause collapse Bronchial wall thickening Central bronchiectasis Fleeting pulmonary alveolar opacities, usually upper lobes Pulmonary fibrosis in chronic disease

Answer 832

Prednisone 0.5mg/kg x 2-4 weeks then taper to complete over 4 months OR itraconazole for 4 months Itraconazole x 16 weeks/voi/posi (old) Do not use high dose ICS for treatment purposes Do NOT recommend Anti-IL5 agent as first line (nt confirmed by RCT yet) Prednisone Itraconazole x 16 weeks/voi/posi Anti-IL5 agent (not confirmed by RCT yet)

Answer 833

New treat same as Anewly diagnosed ABPA (pred or itraconazole) but no biologic MIld → ICS (No) More than mild → increase oral steroids If refractory (>/=2 in last 2 years) can combine pred adn itraconazole)

Answer 834

Improvement in 8-12 weeks of: * Chest radiograph * IgE level (20% fall) * Clinical symptoms. NOTE: aspergillus IgE and IgG levels or eos may not fall so don’t recheck for response.

Answer 835

Medications e.g. TNF-alpha inhibitors, steroids, IST HIV/AIDs Immune disorders e.g. CVID Hodgkin’s lymphoma Extremes of age

Answer 836

Acute localized pulmonary histoplasmosis Diffuse pulmonary histoplasmosis Chronic pulmonary histoplasmosis Disseminated histoplasmosis

Answer 837

Acute localized pulmonary histoplasmosis - Local infiltrates/pneumonitis (usually lower) Diffuse pulmonary histoplasmosis - Reticulonodular - Miliary Chronic pulmonary histoplasmosis - Apical fibrocavitary Disseminated histoplasmosis - Miliary

Answer 838

Apical infiltrations, fibrosis Cavitation Fibrosing mediastinitis Mediastinal granuloma Can send secondary infection of cavitation Broncholithiasis

Answer 839

Use antigen (urine*, blood, BAL) + antibody for acute disease (local or diffuse) or disseminated disease Use culture (BAL, TBBx) for chronic disease - sputum sensitivity is low Mediastinal disease: ab usually positive; antigen -, culture

Answer 840

Small yeast with narrow based budding

Answer 841

Broncholithiasis → observe, bronchoscopic preferred, surgical Mediastinal granuloma → observe, surgical removal if needed Fibrosing mediastinitis → stent if needed, no antifungals or steroids (unless sarcoid or vasculitis causing it, then can be trialed)

Answer 842

Local primary Diffuse pulmonary coccidioidomycosis Chronic fibrocavitary disease Disseminated

Answer 843

Combination of tests Antigen (urine, serum, BAL) Antibody (EIA preferred) Direct visualization (sputum, BAL, bx material), path - can see spherules Culture

Answer 844

Acute focal pulmonary blasto Acute diffuse pulmonary blasto Chronic pulmonary blasto Disseminated

Answer 845

Brain Bone - OM Cutaneous - crusting, verrucous lesion GU tract

Answer 846

Combination of tests Antigen Antibody Direct visualization, path Culture - gold standard

Answer 847

* Reticular changes, perihilar distribution (more often upper lobe) * Crazy paving (also smooth septal thickening) * Pneumatoceles * Less commonly nodular pattern (granulomatous PJP) * Often hypoxemia is out of proportion to degree of radiographic findings

Answer 848

LDH - sensitive Beta D glucan - sensitive

Answer 849

* Pseudomonas infection * IVIG or olther blood products/albumin * IHDialysis using cellulose membrane * Presence of invasive fungal infection (candida, aspergillus,fusarium, histoplasmosis, PJP). ** Not mucormycosis.

Answer 850

Mucormycosis Cryptococcus Blastomycosis False negative: Hyperpigmented serum (bilirubin or triglyceride elevation) False negative: azitrhomycin or IV pentamidine

Answer 851

Stained respiratory specimens - sputum, BAL - very sensitive in HIV (97% vs 50-60% HIV -) PCR - blood, sputum, BAL - especially useful in HIV - (Sensitivity up to 100% but 20% of normal population colonized) Beta D Glucan (serum) sensitive in HIV (BHIVA 2024)

Answer 852

Septra x 21 days, 15-20 mg/kg IV of TMP component Alternatives: IV pentamidine, primaquine + clinda, atovaquone, dapsone + septra Plus steroids

Answer 853

PaO2 <70 mmHg A-a gradient >/35 mmHg U2D: SpO2 <92% Most effective within 72h of treatment initiation Steroid Regimen (Classic) Prednisone 40 mg BID days # 1-5. Prednisone 40 mg daily days #6-11. Prednisone 20 mg daily days #12-21. Hg U2D: SpO2 <92%

Answer 854

CD4 <200 (continue until >200 for >3 months) CD4 <14%

Answer 855

Septra SS, DS Pentamidine Dapsone Atovaquone

Answer 856

Neutropenia Immunosuppression Broad spectrum abx use Necrotizing pancreatitis TPN CVC Intra abdominal surgical procedures

Answer 857

Diabetes, especially DKA Iron overload, deferoxamine tx Hematological malignancies, HSCT, SOT Glucocorticoid treatment COVID-19 pneumonia neutropenia

Answer 858

Like IPA More pleural effusion atoll sign more than halo

Answer 859

Culture (usually negative) Histopathology*

Answer 860

Liposomal Amphotericin B Surgical debridement IV isavuconazole and IV/PO posaconazole also now recommended as an alternative first line.

Answer 861

HIV CD4<100 SOT, especially lung - High steroids independent RF - High CNI levels independent RF - CMV in last 6 months independent RF Long term steroids, other IST Lymphoma PAP COPD, bronchiectasis

Answer 862

Brain - abscess, meningitis Skin - abscess Bone Muscle

Answer 863

Nodule LN rare

Answer 864

Septra Imipenem Cephalosporins 3rd generation Amikacin

Answer 865

6-12 months normally 12 months at least if immunosuppressed

Answer 866

* Mild or moderate pulmonary disease septra x 6-12 months * Severe: ** Septra IV + amkacin 7.5mg/kg ** OR Imipenem + Amikacin * IV therapy if required is for at least 6 weeks then PO for 6-12 months ** Po options include Septra +/- either minocylcine or amox clav.

Answer 867

* Mild-Moderate ** Oral pen V 2-4g divided into q6 dosing ** Alternative: amoxicillin or Amox clav. * Severe: IV peng G 10-20million units divided into q6h dosing ** CTX is alternative * Duration: ** mild -Moderate 2-6 months ** SeverE: 6-12 months

Answer 868

Poland syndrome (a congenital unilateral absence of the pectoralis major and minor muscles and is a recognized cause of unilateral hyperlucent hemithorax) Mastectomy Pneumothorax Pulmonary embolism - Westermark Vascular pruning Swyer james mcleod syndrome ( unilateral hemithorax lucency as a result of postinfectious obliterative bronchiolitis often adenovirus or mycoplasma pneumoniae) Congenital lobar emphysema CPAM Giant bullous disease Pneumatocele Pneumonectomy

Answer 869

LUL predominantly Mucous filled atretic bronchial stump Hyperlucent lung due to hyperinflation of distal lung (Pores of Kohn) Bronchial atresia is a developmental anomaly characterized by focal obliteration of the proximal segment of a bronchus associated with hyperinflation of the distal lung.

Answer 870

Unilateral hyperlucent lung Larger affected lung Decreased vascularity Contralateral mediastinal shift

Answer 871

Recurrent pneumonia Cyanosis Failure to thrive

Answer 872

Type 1 (Most common 70% ) and 4 -1 or 2 large cysts - associated with malignancy Type 2 - small mixed solid/cystic lesions with 90% associated to bronchial atresia Type 3 - numerous small cysts solid or mixed Technically there is a Type 0 but though are very rare and are lethal at birth

Answer 873

Symptomatic Asymptomatic but: - >20% hemithorax - Concern for malignancy - Frequent complications

Answer 874

BPS has no connection to the tracheobornchial tree and receives its blood supply from systemic ciculation vs. CPAM gets its blood supply via pulmonary circulation

Answer 875

Both Predominantly LLL Dense mass, sometimes with cystic areas Both systemic feeding vessel

Answer 876

Epidemiology (ILS 1:1 ; ELS Male 3: 1) Blood supply ( both from systemic circulation but ILS drains to pulmonary veins and ELS to systemic and is fed from smaller vessels) Location (ILS 60% left base ELS 90% Left with most associated with posterioro congenital diaphramatic hernia) Pleural supply Connection with tracheobronchial tree (ILS has no connection directly but may have bronchopulmonary foregute malformation, ELS does not) Clinical presentation (ILS most likely infections, ELS is asymptomatic through life)

Answer 877

Symptomatic Complications >/20% of the hemithorax Characteristics concerning for malignancy/pleuropulmonary blastoma

Answer 878

Anomalous pulmonary venous return - (tubular structure)* Right lung hypoplasia* Pulmonary artery hypoplasia* Ipsilateral mediastinal shift Dextroposition Pulmonary sequestration

Answer 879

Previous prolonged intubation Previous tracheostomy Previous surgery e.g. lung transplantation Marfan’s syndrome, Ehlers danlos syndrome, scoliosis, pectus excavatum Relapsing polychondritis, other autoimmune conditions Chronic inflammation e.g. CF, bronchiectasis Recurrent infections e.g. bronchitis Multinodular goiter, malignant or benign lesions of neck and mediastinum COPD, asthma, obesity

Answer 880

Non contrast dynamic CT and bronchoscopy (gold) <70% normal, 70-80 mild, 80-90 moderate, >90% severe

Answer 881

Treat underlying cause PAP therapy Airway clearance techniques Stent trial → tracheobronchoplasty (really just focal and proximal tracheobronchial malacia)

Answer 882

Trachea >3 cm RMS > 2.4 cm LMS >2.3 cm

Answer 883

Congenital and idiopathic Previous intubation Previous tracheostomy Previous surgery e.g. lung transplantation Inflammatory e.g. relapsing polychondritis, vasculitis, sarcoidosis, IgG4 disease, Ra, SLE, amyloidosis Infectious e.g. tuberculosis, fungal, bacterial Malignancy Radiation

Answer 884

Treat underlying cause Balloon dilatation Laser cautery Stenting Surgical

Answer 885

* Post intubation, post trauma, post surgery * Malignancy e.g. SCAMM ( da fuq? But squamous cell carcinoma is most common) - maybe they meant it as an acronym… ) * * Squamous cell carcinoma * * Chondrosarcoma * * Carcinoid tumour * * Adenoid cystic carcinoma * * Mucoepidermoid carcinoma * * Metastatic disease * Infectious - e.g. TB * Inflammatory - e.g. RP, GPA, amyloidosis, sarcoidosis * Other - e.g. TBM, TBP OCP

Answer 886

TBM TBPOCP (tracheobronchopathia osteochondroplastica - nodules of cartilage or bone in the submucosa along the tracheal rings) Relapsing polychondritis (inflammation of cartilage in the body)

Answer 887

Chondroma ( slow growing made of cartilage) Leiomyoma (fibroid, smooth muscle tumor) Lipoma Amyloidoma Squamous cell papilloma Hamartoma Hemangioma Tracheobronchomalacia osteochondroplastica -Nodules of cartilage or bone in the submucosa along the tracheal rings)

Answer 888

Squamous cell carcinoma Chondrosarcoma Carcinoid tumour Adenoid cystic carcinoma Mucoepidermoid carcinoma Metastatic disease SCCAMM

Answer 889

Anterior - Teratoma - Thymoma and other thymic tumors - Thyroid - goiter, malignancy - Terrible lymphoma Middle - 3A’s - Adenopathy - lymphoma, sarcoid, silicosis, castleman’s, meds, infxn - Aneurysms - aortic aneurysm, fistulas - Anomalies - bronchogenic cyst - Other - lipomatosis, lymphangiomas, hernias Posterior - Neural tumors e.g. Schwannoma, neuroblastoma - Esophageal process e.g. mass, diverticula - Descending aortic aneurysm - Extramedullary hematopoiesis - Bochdalek hernia

Answer 890

Beta HCG AFP LDH

Answer 891

Thymoma Thymic carcinoma Thymic lymphoma Thymic neuroendocrine (carcinoid tumour) Thymolipoma

Answer 892

Beta HCG is high, AFP normal in seminoma Both high in non seminoma

Answer 893

Atelectasis & Recurrent infections, dyspnea, cough SVC syndrome Pulmonary hypertension Dysphagia Phrenic nerve paralysis

Answer 894

Morgagni hernia (Anterior, asymptomatic) Bochdalek hernia (More common, posterolateral, can cause newborn symptoms due to lung hypoplasia) - “Bochdalek is Back”

Answer 895

Tracheobronchomalacia Tracheal stenosis Subglottic stenosis Tracheal thickening These can cause OSA, post obstructive PNA

Answer 896

Thoracentesis Chest tube insertion Bronchoscopy Transbronchial biopsies Surgical lung biopsies

Answer 897

Warfarin x 5 days, INR <1.5 DOAC 24-48 hours LMWH x 24 hours, 6 hours if DVTp Plavix , prasugrel x 5-7? days Ticagrelor x 7 days Dipyridamol x 24 hours Platelet count >50K

Answer 898

Increased RPO Increased pneumothorax Increased hemothorax Increased pain

Answer 899

RPO Pneumothorax Hemothorax V/Q mismatch immediately post

Answer 900

Age <40 Large volume removed >1.5L ( GRAVITAS study says no) Pressure <-20 cm H2O Duration of collapse >72 hours Size of pneumothorax Diabetes

Answer 901

Pneumothorax not responding to chest tube Pneumothorax on mechanical ventilation Trauma patient Hemothorax Required for talc pleurodesis

Answer 902

NTM Aspergillus Candida Cryptococcus CMV, HSV

Answer 903

Legionella Endemic fungi Tuberculosis PJP Influenza, RSV

Answer 904

Sarcoidosis Hypersensitivity pneumonitis Pneumoconiosis Lymphangitic carcinomatosis Tuberculosis CMV pneumonitis Lung transplant rejection

Answer 905

5 mL/kg without epinephrine 7 mg/kg with epinephrine

Answer 906

No change: VC, RR, lung compliance, resistance Increase: MV, tidal volume, VO2 max, PaO2 Decrease: TLC, FRC, ERV, RV, total respiratory compliance, PaCO2

Answer 907

In pregnancy RV will be decreased and will be increased/same in obesity

Answer 908

SVR decreases, PVR decreases - BP decreases SV increases, HR increases, CO increases Increased blood volume

Answer 909

<50 milligrays or <50 mSv <5 rad

Answer 910

Physiological dyspnea in pregnancy Peripartum cardiomyopathy Tocolytic pulmonary edema Asthma Pulmonary embolism Amniotic fluid embolism Venous air embolism PAVM growth Obstructive sleep apnea

Answer 911

LMWH Warfarin and DOAC contraindicated At least 3 months + 6 weeks postpartum

Answer 912

Fluoroquinolones Aminoglycosides Septra, sulfa drugs Tetracyclines

Answer 913

Hyperventilation Increased HR and CO Hypoxic vasoconstriction Renal compensation, bicarbonate secretion Polycythemia Muscle changes - increase vascularity, increase myoglobin concentration, decrease in muscle fiber size 2,3 DPG shifts the oxygen curve RV hypertrophy Blunted response to acute hypoxemia

Answer 914

Acute mountain sickness High altitude pulmonary edema High altitude cerebral edema Periodic breathing of altitude

Answer 915

Normobaric hypoxic challenge Hypobaric hypoxic challenge Predictive equations Walk test and SpO2 Hypoxic Challenge test

Answer 916

The obstructive algorithm, if at risk for hypercapnia The restrictive algorithm, if either PaO2 <70 OR TLC <50% CF FEV1<50% predicted Severe asthma NMD or chest wall weakness FVC <1L Baseline hypercapnia or risk of hypercapnia

Answer 917

Stable disease previously underwent an HCT without exacerbation/change in treatment COPD with baseline SpO2 >95% and EITHER * MRC 1-2 * Desat to no less than 84% during 6MWT or SWT Previous intolerance to air travel/have had an inflight emergency (should have 2L/min provided as long as no hypercapnia Preterm infants as they should have 1-2 L prn

Answer 918

COPD with resing SpO2 <95%, MRC score 3 or greater, or desat <84% on 6MWT or SWT and hypercapnia Infants with neonatal resp problems Severe asthma with persistent symptoms ILD with SpO2 <95% on exercise or PaO2 <9.42kPa or whose TLCO is <50%. Severe respiratory muscle weakness or chest wall deformity in whom FVC<1L Hypercapnia and at risk of hypercapnia including on meds that are high risk Anyone with type 2 resp failure on home O2.

Answer 919

Note kPa of 9.42 is ~ 70mmHg.

Answer 920

Inspire 15% oxygen (estimate 8000 feet) for 20 min checking sats or ABG ABG pO2 falls below 50 or O2sat <85%

Answer 921

pH falls <7.35 pCO2 increases by 7.5from baseline (1kPa)

Answer 922

If a procedure was done (EBUS, TBBx, etc) * Always get opinion from interventionist. * Wait 1 week post procedure or if pneumo 1 week post resolution on CT * Note limited evidence but apparently trapped lungs are fine to travel with. If PE/DVT * Wait 2 weeks after diagnosis

Answer 923

NYHA WHO class 3 or 4 should have O2 (2L/min if no hypercapnia) If on O2 should double it for the flight if no hypercapnia.

Answer 924

Untreated pneumothorax or not out of time frame Untreated respiratory failure Active infection with risk to others w.g. COVID, TB Bronchogenic cysts (Can cause cerebral air embolism after rupture) Type 2 respiratory failure Baseline O2 >4L (old, not really anymore?)

Answer 925

Barotrauma of descent Nitrogen narcosis Immersion pulmonary edema

Answer 926

Barotrauma of ascent Decompression sickness Arterial air embolism

Answer 927

Descent - lung squeeze below RV, pulmonary edema and hemorrhage Ascent - overinflation and possible rupture (have to exhale) → PNTX, pneumomediastinum, subcutaneous emphysema, air embolism

Answer 928

Non cardiogenic pulmonary edema PNTX Pneumomediastinum Arterial gas embolism Ear trauma Sinus barotrauma Dental barotrauma

Answer 929

Upon surfacing Can be delayed up to 24 hours

Answer 930

Ascension to fast Time of dive Depth of dive (rare <10 m ) Air travel and altitude within 12 hours Right to left shunt

Answer 931

Decompression sickness Barotrauma of ascent - expanding pneumothorax or pneumomediastinum Shallow water blackout(hyperventilation lowers Co2 prior to diving, during breath hold O2 drops, because Co2 is rising but starting at a lower point it never reaches a threshold to cause an inspiration and person loses consciousness seconcdary to hypoxemia, then person draws a breath breathing in water and drowning)

Answer 932

Reduction in FEV1 by >/10% within 30 minutes of exercise Can use cycle ergometer or treadmill

Answer 933

Diagnosis of EIB Assessment of management Assessing fitness for scuba diving

Answer 934

FEV1 <75% predicted Stroke or MI in the last 3 months Uncontrolled hypertension Aortic aneurysm Recent eye surgery or ICP elevation risk

Answer 935

2-4 mins ramp up → rapid needed, otherwise dampens response 4-6 mins at exercise target 60% MVV (preferred), 80-90% maximum HR

Answer 936

Exercise in last 4 hours Took asthma medications Took antihistamines in last 48 hours Warm up too long, didn’t reach in 4 mins Exercised for too long Didn’t reach max exercise

Answer 937

Treatment:SABA Prevention: SABA before exercise, +/- mast cell stabilizing agent and SAMA If using above daily or more: Controller therapy: 1) Daily ICS +/- 2) LABA, 3) LTRA

Answer 938

Chronic rhinosinusitis with nasal polyposis Asthma NSAID/ASA intolerance

Answer 939

NSAIDs that preferentially block COX-1 enzyme Arachidonic acid metabolized through lipoxygenase pathway Increased leukotrienes, cause bronchoconstriction

Answer 940

Maintenance ICS Add on LTRA Nasal polyp surgery, intranasal steroids ASA desensitization Dupilumab

Answer 941

NSAID for another disease Recurrent nasal polyps recurring after surgery

Answer 942

Personal history of atopy Family history of asthma Low birth weight, premature , IUGR Maternal smoking Pollution exposure - vehicle emissions, industrial waste Allergen exposure - dust mites, mold, cockroaches, pet dander, mice LTRIs

Answer 943

IL-5: maturation of eosinophils IL-4: IgE production by cells IL-13: mucous production, hyperresponsiveness, eos recruitment IgE: mast cell degranulation TSLP: downstream signaling

Answer 944

Variable symptoms and intensity Worse at night, upon awakening or after viral infections Often triggered by exercise, allergens, cold air or laughing

Answer 945

Relative: * Pregnancy and nursing mothers. No studies on association with fetal abnormalities/reproductive capacity and no known whether it is excreted in breast milk. * Current use of cholinesterase inhibitor medication (for MG or PD)

Answer 946

* Difficult to treat Asthma: * Uncontrolled Symptoms and or exacerbations despite medium or high dose ICS/LABA or maintenance OCS. May still be issues with inhaler technique, poor adherence, smoking or comorbidities, or improper diagnosis * Severe Asthma: * Uncontrolled despite adherence with maximal optimized high dose ICS/LABA and all contributing factors or if high dose treatment is decreased.

Answer 947

Elevated BMI OSA GERD Rhinosinusitis, post nasal drip Anxiety, depression

Answer 948

Daytime symptoms /90% personal best PEF variability <10-15% Sputum eosinophils <2-3%

Answer 949

Mild: just change in bronchodilators Severe: Systemic steroids, ED or hospitalization required Near fatal: required ICU, mechanical ventilation, respiratory acidosis

Answer 950

Current smoker (studies on tobacco, but others considered) SABA use >2 canisters/year Hx of severe exacerbation Poorly controlled FEV1 <70% Older age Female Elevated BMi Depression, anxiety Others as per GINA: comorbidities (GERD, OSA etc), elevated blood eos

Answer 951

History of near fatal asthma History of severe asthma Hx recurrent ED or hospitalizations in the last year Non adherence Missed appointments Depression, anxiety Substance use Elevated BMI

Answer 952

Action plan - exacerbations Inhaled steroids - symptoms/QOL, lung function, exacerbation, mortality LABA - symptoms, lung function, exacerbation, need for reliever LAMA - lung function, exacerbation (but increased if monotherapy) LTRA - symptoms, lung function, exacerbation, need for reliever Azithromycin - symptoms, exacerbations Biologics Bronchial thermoplasty - exacerbations (increased in first 3 months), not sx or fxn Oral steroids

Answer 953

500 mg oral 3/week Inflammatory phenotype does not predict response

Answer 954

Poor control despite max medical therapy FEV1 > /60% Non smoker >/1 year No hx life threatening exacerbation <3 hospitalization in last 12 months

Answer 955

Increase exacerbation x 3 months Atelectasis Pneumonia

Answer 956

Reduce oropharyngeal deposition and side effects Improve pulmonary deposition and benefits Make actuation coordination easier

Answer 957

Severe = high dose steroids + second controller OR oral steroids for >/50% of the year to keep asthma controlled or uncontrolled despite this

Answer 958

Poor control - control criteria, or ACQ >/1.5 Frequent exacerbations (>/2 per year) requiring OCS (>/3 days) Serious exacerbations (>/1 per year) requiring hospitalizations, ICU, MV in the last year Airflow limitation <80% personal best

Answer 959

Non adherence Inhalation technique Exposures Comorbidities e.g. GERD, OSA, PND, etc. Alternative diagnosis Severe asthma

Answer 960

Rhinosinusitis - tx, CT sinus, ENT referral GERD - 24 hour PH monitoring OSA - PSG Psychiatric - referral EGPA - ANCA ABPA - IgE, RAST, eos VCD - ENT Bronchiectasis - CT chest, CF testing, IGAM, sputum culture

Answer 961

FENO >/25 ppb Sputum eosinophils >2% Serum eosinophils >/150 Asthma allergen driven clinically

Answer 962

Etiology of respiratory symptoms -?inflammatory Predict response to steroids or inhaled steroids Monitor response Guide management - step up, step down Evaluate adherence

Answer 963

Baseline over 50 ppb: >20% increase, >20% decrease Baseline less than 50 ppb: >10 ppb increase, >10 ppb decrease

Answer 964

Atopic asthma Atopy, allergic rhinitis, eczema Eosinophilic bronchitis COPD with mixed inflammatory phenotype Viral infections Acute/chronic rejection of lung including BO

Answer 965

Smokers LTRA Rhinosinusitis Non eosinophilic asthma RADS VCD COPD Bronchiectasis, CF

Answer 966

Improve symptoms Improve FEV1 Reduce exacerbations Reduce OCS - mainly mepo, benra, dupi; resi in post analysis, ?oma

Answer 967

Injection site pain and reaction, nasopharyngitis, headaches Omalizumab - anaphylaxis Dupilumab - hypereosinophilia (do not give if baseline >1.5) Tezepelumab - anaphylaxis

Answer 968

LAMA Azithromycin Anti-TSLP Bronchial thermoplasty (paucigranulocytic asthma)

Answer 969

All → SABA, steroids Additional to consider: SAMA IV magnesium High dose ICS BPAP HFNC if cannot tolerate BPAP IV epinephrine - if anaphylaxis or angioedema component Ketamine - acts as anxiolytic Heliox if component of upper airway obstruction

Answer 970

Consistent history (acute exposure preceding symptoms, no sx before) Airflow obstruction on PFT, non specific bronchial hyperresponsiveness Symptoms arise within 24 hours Symptoms last at least 3 months Exclusion of other causes

Answer 971

Chlorine Oxides of nitrogen Acetic acid Sulfur dioxide Isocyanates

Answer 972

RFs for developing sensitizer induced OA Atopy Higher level of exposure More frequent exposure Cigarette smoking

Answer 973

LMW: isocyanates (polyurethane worker, insulation installer, spray painter), dyes and bleaches (hairdressers), wood dust (carpenter), metal salt (metal plating) HMW: flour dust (baker), animal protein antigens e.g. murine urine (veterinarian, farmer) & shellfish (fish processing), natural rubber latex protein (HCW)

Answer 974

Rhinitis Urticaria, rash

Answer 975

PEF - best validated method - variability >/20%* NSBHR - less sensitive and specific - > 3.2 fold* (NON-SPECIFIC BRONCHIAL HYPERRESPONSIVENESS) Specific inhalation challenge test - FEV1 drop by >/15%* Sputum eosinophils - increase by >1-2% Spirometry - less sensitive and specific

Answer 976

IgE like RAST testing Specific inhalation challenge test

Answer 977

Pre contemplative Contemplative Preparation Action Maintenance

Answer 978

Assess Advise Ask Assist Arrange

Answer 979

Change in mood Weight gain Increased sputum production

Answer 980

Rate of FEV1 decline normalizes Normal MI risk by 1 year ½ cancer risk by 10 years ½ risk of dying in next 15 years

Answer 981

IUGR Premature birth Low birth weight SIDS Bronchopulmonary dysplasia

Answer 982

5% without 30% with

Answer 983

NRT: Nausea, vomiting, diarrhea, insomnia, vivid dreams, local irritation, hypersensitivity Varenicline: nausea, vomiting, diarrhea, bizarre dreams, sleep walking, insomnia Bupropion: decreased seizure threshold, suicidal or homicidal ideation, psychosis, mania or hypomania

Answer 984

NRT: recent ACS or stroke (<2 weeks), uncontrolled BP Varenicline: kidney disease, hypersensitivity Bupropion: <18 (suicidality), seizure disorder, AN/BN, on MAOI, on wellbutrin, hypersensitivity, discontinuation of BZD, alcohol (things that lower seizure threshold)

Answer 985

Men Cigarette smoking (in utero, passive, active), cannabis, vaping Air pollution, biomass fuel burning Occupational exposures e.g. coal, pesticides HIV, childhood infections Genetics e.g SERPINA Early life lung insults, low birth weight

Answer 986

Lung cancer Cardiovascular disease Skeletal muscle dysfunction Osteoporosis Anxiety, depression

Answer 987

Wheezing Barrel chest Decreased cardiac dullness

Answer 988

Hypoxemia - V/Q mismatch Hypercapnia - DH, reached MVV Increased WOB - due to mechanics Muscle deconditioning Cardiac deconditioning, decreased preload for DH

Answer 989

6MWT ISWT, ESWT CPET

Answer 990

CRQ Chronic Respiratory Disease Questionnaire) Evaluated physical functional and emotional CAT SGRQ (St. George Respiratory Questionnaire) CCQ (Clinical COPD Questionnaire)

Answer 991

Referral and listing for transplant Predictor of mortality

Answer 992

BMI: Obstruction (FEV1): Dyspnea (mMRC) Exertion Capacity (6MWT) 0-2: 80% 3-4: 70% 5-6: 60% 7-10: 20%

Answer 993

Influenza annually Pneumococcal COVID-19 as per public health Pertussis if have not had in adulthood Shingles >/50 RSV (If >60 OR chronic lung/cardiac condition)

Answer 994

mMRC <2 CAT <10 FEV1>/80% predicted Risk of future exacerbations (CTS: High Risk of AECOPD” if ≥ 2 moderate AECOPD or ≥ 1 severe exacerbation in the last year (severe AECOPD is an event requiring hospitalization or ED visit))

Answer 995

Low: /2 moderate exacerbations in the last year, >/1 severe

Answer 996

Mild: only change in short acting bronchodilators Moderate: required steroids or abx Severe: required ED visit or hospitalization

Answer 997

Improve dyspnea Improve health status Improve exercise tolerance +/- Reduce risk of exacerbation +/- improve mortality

Answer 998

Moderate-high symptom burden High risk of exacerbation Eos >300

Answer 999

>/2 moderate exacerbations for AECOPD ED visit or hospitalization for AECOPD History of concomitant asthma Blood eosinophils >/300

Answer 1000

Eosinophils <100 Recurrent pneumonias Hx of NTM disease

Answer 1001

Symptomatic, high risk AECOPD group Exacerbate despite triple therapy + chronic bronchitis phenotype for 2 of them

Answer 1002

Decrease exacerbation

Answer 1003

Smoking cessation Appropriate bronchodilators Pulmonary rehabilitation Supplemental O2 in those who qualify LVRS in appropriate patients Bullectomy in certain patients Endoscopic procedures Lung transplantation

Answer 1004

Appropriate bronchodilators - dual and triple Oral therapies as indicated Case management AND education Pulmonary rehabilitation within 4 weeks of AECOPD Smoking cessation Influenza vaccination

Answer 1005

Smoking cessation Triple therapy (SITT) PR within 4 weeks of AECOPD O2 in resting hypoxemia( PaO2 <55 or <60 with core pulmonale/evidence of elevated hgb) NIV acutely, or chronic hypercapnia LVRS in appropriate patients ?Transplant in some

Answer 1006

Walking aids Pursed lip breathing Neuromuscular electrical muscle stimulation Low dose opioids Oxygen in resting hypoxemia

Answer 1007

LVRS Bullectomy Endoscopic procedures Lung transplant

Answer 1008

Symptomatic from emphysema and not CB/asthma Smoking cessation >4 months Heterogeneous emphysema Upper lobe predominant emphysema TLC >/100% RV >/150% FEV 140 m

Answer 1009

Comorbid disease with life expectancy <2 years Severe CAD or other cardiac disorder BMI >31 FEV1 ⅓ chest Extensive pleural symphysis e.g. previous infection, pleurodesis O2 >6L/min PaCO2 >60 mmHg or PaO2 <45 on room air PAP >/35 mmHg Prednisone >20 mg oral daily

Answer 1010

Dyspnea HRQOL Exercise tolerance Lung function Mortality in some → upper lobe emphysema, low baseline exercise tolerance

Answer 1011

Symptomatic Complications >/30% of hemithorax

Answer 1012

Older age Low FEV1 at baseline Previous COPD exacerbations ** Eos >/300 ** Chronic mucous hypersecretion Duration of COPD Pulmonary HTN GERD

Answer 1013

SABA, SAMA Steroids 40 mg oral daily x 5 days - hasten recovery, reduce relapse, improve FEV1 Antibiotics if meet criteria - hasten recovery, reduce relapse IV magnesium

Answer 1014

Amoxi-clav Fluoroquinolones Macrolides Tetracyclines e.g. doxycycline

Answer 1015

pH <7.35, PcO2 >/45 Worsening WOB Persistent and refractory hypoxemia

Answer 1016

Normal - M Deficient - Z/S Dysfunctional - F Null

Answer 1017

-/- (least common) Z/Z Z/S (if they smoke) Z/M (if they smoke)

Answer 1018

Age <65 OR Pack year <20

Answer 1019

Transaminitis Cirrhosis HCC Necrotizing panniculitis GPA/ANCA vasculitis Intracranial aneurysms Fibromuscular dysplasia

Answer 1020

Applicable genotype A1AT level <11 mmol/L or 57 mg/dL (our units)

Answer 1021

AAT <11 umol/L or 57 mg/dL (our units) FEV1 25-80% On maximal pharmacological and non pharm therapy (including PR) Have quit smoking - non-smokers or ex-smokers (nothing in guidelines, funding requires at least 6 months)

Answer 1022

Improve lung density on CT Improve FEV1 Improve mortality

Answer 1023

Mortality benefit in those that qualify Improved dyspnea Improved exercise tolerance Improved physiological effect e.g. ?decreased PH

Answer 1024

Improved HRQOL Improved outdoor mobility Not clear re: dyspnea, exercise capacity

Answer 1025

Resting hypoxemia Resting hypoxemia and comorbidities listed Patient planning for air travel if they meet criteria ?Ambulatory or exertional hypoxemia

Answer 1026

Minimum 8 weeks Minimum 24 sessions, 16 should be supervised

Answer 1027

Necessary HCP, and resources: Cycle ergometer, treadmill, flat open space Vital machines Education material Etc. Baseline intake indicators: Dyspnea Health status Exercise capacity 1 Repetition maximum Aerobic exercise prescription Strength training prescription Exercise indicators Monitoring indicators Education and self management component Post program

Answer 1028

Frequency - 3 sessions Intensity - 60% VO2 max Time - 20 mins each session Type - aerobic - treadmill, free walking, stair climb, ergometer (NOT arm alone)

Answer 1029

Frequency - 2-3 times per week Intensity - 60% of 1-RM Time - 1-3 sets, 8-12 repetitions each Type - weights, resistance bands

Answer 1030

Aerobic exercise endurance Muscle function Health status Others case by case: psychological status, nutrition status, self efficacy, etc.

Answer 1031

COPD - regardless of FEV1 or smoking status ILD PHTN

Answer 1032

COPD - dyspnea, HRQOL, exercise capacity, social/physical fxn, reduce anxiety, depression, ??mortality ILD - dyspnea, HRQOL, exercise capacity PHTN - dyspnea, HRQOL, exercise capacity

Answer 1033

Improved VO2 max Improved O2 pulse Decrease in HR Increased AT Increased muscle mass Decrease dynamic hyperinflation

Answer 1034

New respiratory symptoms post COVID + At least 1 of: new O2 requirements, persistent reticular/fibrotic changes on imaging, new and persistent restriction/obstruction/DLCO impairment on PFTs

Answer 1035

Acute/chronic eosinophilic pneumonia EGPA HES ABPA Infections - parasites, fungal Neoplastic - e.g. paraneoplastic PLCH Lung transplantation

Answer 1036

Idiopathic Smoking - new, increased uptake, different type Inhalation drugs- cocaine, marijuana Medications - daptomycin**, antidepressants Occupational exposures Infections - parasites, fungi

Answer 1037

Acute: diffuse, bilateral GGO, bronchovascular thickening, effusion, LN Chronic: peripheral, bilateral GGO, upper lobe, migrating

Answer 1038

Causes - allergic/atopic causes in chronic Clinical manifestations - symptoms, timeline Relapse - common chronic Imaging Peripheral eosinophils - seen in chronic Both have elevated IgE Both have BAL eos >25% Both are treated with steroids

Answer 1039

Acute onset, <30 days Patchy infiltrates on CXR/CT BAL eos >25% Absence of other specific eosinophilic diseases Diagnostic criteria for CEP is similar, except that timeline is 4-5 months and imaging is peripheral infiltrates

Answer 1040

HE + eosinophilic mediated damage + other causes excluded HE: >1.5 on 2 occasions at least 1 month apart, and >20% (2024 says 10%) on BM, and extensive eos infiltration on pathology

Answer 1041

Type II pneumocytes secrete surfactant Surfactant is mix of proteins + lipids (mainly phosphatidylcholine)

Answer 1042

Idiopathic Primary: Hereditary Autoimmune Secondary (HI/TII): Infections e.g. nocardia, PJP, tuberculosis Inhalation exposures e.g. silicosis, chlorine, bakery powder Transplantation e.g. SOT, HSCT Hematological malignancies e.g. MM, WM Immunodeficiencies e.g. CVID

Answer 1043

Cloudy Foamy macrophages Send for PAS stain on cytology → PAS+ macrophages on background of PAS material

Answer 1044

Anti GM CSF antibodies GM CSF serum levels GM CSF receptor function BAL TBBx - not required for biopsy

Answer 1045

Normal alveolar structure Lipo Proteinaceous material fills terminal bronchioles and alveoli This material stains positive on PAS stain If done, electron microscopy shows lamellar bodies

Answer 1046

Inhaled GM-CSF Therapy Whole lung lavage Treat secondary cause Lung transplantation Rituximab, PLEX - case reports

Answer 1047

Definitive histological diagnosis + PaO2 <65, or A-a >/40 or severe dyspnea/hypoxia at rest or exercise

Answer 1048

LAM = diffuse, random, small cysts BHD = lentiform, paramediastinal, peripheral, subpleural PLCH = bizarre shaped, upper lobe predominant, spare costophrenic angles, nodules/cavities LIP = diffuse, random, GGO in between Amyloid/LCDD = cysts varying sizes/shapes, nodules, cavitations, opacities lower lobes/subpleural

Answer 1049

LAM = HMB-45 positive smooth muscle cells PLCH = S100 and CD1 a positive langerhans cells, intracellular Birbeck granules Amyloid = apple green birefringence by congo red stain LCDD = kappa light chains lacking the above

Answer 1050

Cystic lung disease Group 5 HTN Eosinophilic lung disease

Answer 1051

Rash - brown papules Lytic bone lesions Central diabetes insipidus

Answer 1052

Smoking cessation Steroids in some Chemotherapy in some Transplantation

Answer 1053

Fibrofolliculomas Skin tags Renal tumors

Answer 1054

Angiofibromas Leiomyoma Angiomyolipoma Lymphadenopathy Pleural effusions Meningiomas

Answer 1055

Lung cysts Smooth muscle-like cell (LAM cells) infiltration of parenchyma and lymphatics Stain positive for HMB45, s.m. actin Have ER/PR receptors Express VEGFC/D

Answer 1056

FVC <70% Case by case basis for those who: Resting hypoxemia PaO2 <70 Exercise induced desaturation RV >120% DLCO <80% Progression of disease (FVC loss >/90 cc per year Heavy burden of cysts >30% of lungs Chylous effusion AML >4 cm

Answer 1057

Improve symptoms Improve QOL Stabilize lung function Reduce VEGFD

Answer 1058

Pneumothorax:Pleurodesis after first episode, advised not to air travel x 1 month Chylothorax: chest tubes, consider mTOR inhibitor Angiomyolipoma: embolization, radiofrequency ablation, consider mTOR if >/4 cm

Answer 1059

Abdominal CT for all Brain MRI if symptoms, or increased risk (e.g progesterone) Basically looking for evidence of TSC given that is more common

Answer 1060

Idiopathic Connective tissue diseases Immunodeficiency e.g. CVID Infections e.g. HIV, tuberculosis PAP

Answer 1061

Proliferative - restrictive Obliterative - obstructive Follicular - mixed, restrictive, obstructive Diffuse panbronchiolitis - mixed, restrictive, obstructive

Answer 1062

Proliferative: patchy airspace, migratory, reverse halo, with distribution subpleural/peripheral, peribronchovascular Obliterative: mosaic attenuation, centrilobular nodules, gas trapping bronchial wall thickening, bronchiectasis Follicular: centrilobular nodules, tree in bud Diffuse panbronchiolitis: centrilobular nodules, tree in bud, bronchiectasis

Answer 1063

Distribution peripheral, subpleural, migrating, peribronchovascular, bilat GGO or consolidative alveolar opacities Atoll sign (Reverse halo sign-more common with OP and less commonly fungal but mucormycosis most common of the fungal)

Answer 1064

Surgical lung bx Post transplant BOS can be clinical

Answer 1065

Proliferative - intrabronchial polypoid protrusions (mason bodies) Obliterative - Lymphocytic inflammation of submucosa, in growth of fibromyxoid granulation tissue into airway, obliteration of airway - extrinsic compression of bronchioles by fibroinflammatory process Follicular: hyperplastic lymphoid tissue along bronchial walls that obliterate lumen Diffuse panbronchiolitis: lymphoplasmacytic inflammation of bronchioles; infiltration with lipid laden foamy macrophages, lymphocytes, plasma cells

Answer 1066

Idiopathic Immune deficiency Inhalational injury Infections e.g. COVID Malignancy, chemotherapy, radiation CTD Medications Aspiration Post transplantation

Answer 1067

Post allograft transplantation (HSCT, lung) Inhalational injury e.g. silo, sulfur, silica, diacetyl Infection CTD, especially RA

Answer 1068

Idiopathic CTD, especially Sjogren’s; RA, SLE Infection e.g. TB, HIV Immunodeficiency Chronic inflammatory e.g. bronchiectasis, CF, asthma

Answer 1069

CTD e.g. RA Ulcerative colitis Lymphoma Basically always nonsmokers in Japanese and Korean patients

Answer 1070

Proliferative: steroids Obliterative: depends on cause Follicular: steroids Diffuse panbronchiolitis: erythromycin, bronchodilators

Answer 1071

Azathioprine MMF Obviously treat underlying cause

Answer 1072

GLILD LIP Follicular bronchiolitis Bronchiectasis Organizing pneumonia PAP Recurrent pneumonias

Answer 1073

Granulomas in other organs Non hodgkin’s lymphoma Pernicious anemia Thyroiditis

Answer 1074

Hilar and mediastinal LN Bronchiectasis GG and solid nodular opacities

Answer 1075

Lung cancer Mediastinal lymphoma Breast cancer

Answer 1076

Dose of radiation (usually >40, very rare <20) Volume of lung irradiated (V20 >/30%) Form of radiation e.g. SBRT lower risk Fraction of radiation Previous chemotherapy Underlying lung disease e.g. ILD**, COPD Concomitant chemotherapy Female > male Smoker Older age

Answer 1077

Initial = increased capillary permeability Latent = increased goblet cells Acute exudative = radiation pneumonitis = 1-3 months = epithelial cell sloughing, microvascular thrombosis, alveolar exudate and hyaline membranes Intermediate = 3-6 months = resolution of hyaline membranes Fibrosis = >6 months = fibrosis

Answer 1078

Radiation pneumonitis - within 1-3 months Radiation fibrosis - 6-12 months Radiation recall pneumonitis - really anytime * Pneumonitis in the same radiation field. Usually triggered by systemic treatment or infection.

Answer 1079

Fever, malaise, weight loss Dyspnea Dry cough Pleuritic chest pain

Answer 1080

GGO Consolidation Straight line pattern, radiation port edges Small pleural effusion

Answer 1081

Epithelial and endothelial cell sloughing Fibrin rich alveolar exudate Hyaline membrane formation Microvascular thrombosis

Answer 1082

DIP RB ILD PLCH

Answer 1083

IPAF RA ILD

Answer 1084

Sarcoidosis HP

Answer 1085

Idiopathic Occupational exposures e.g. metal worker Drug reactions Autoimmune conditions

Answer 1086

RB-ILD: centrilobular GGO nodules, upper lobe predominant, preserved lung volumes DIP: GGO, +/- cysts, reticular opacities, lower lobe predominance

Answer 1087

RB-ILD: pigmented macrophages, unlikely to have other cells DIP: pigmented macrophages, may have increased lymphs/eos/neuts

Answer 1088

RB-ILD: can be obstructive, restrictive or mixed DIP: usually restrictive

Answer 1089

E cigarettes Mineral based laxatives Petroleum jelly lubricants (used in tracheostomy care) Nasal decongestants Fire eaters

Answer 1090

Bronchial obstruction PAP Lipid storage and metabolism disorders Chronic inflammatory disorders e.g. CTD

Answer 1091

GGO or consolidation Crazy paving pattern

Answer 1092

Lipid laden macrophages Are detected by oil red O staining

Answer 1093

Age - > 55 years old Smoker, ex smoker Hemoptysis Dysphonia, dysphagia Recurrent pneumonia Prominent dyspnea Systemic symptoms Vomiting

Answer 1094

Type A lactic acidosis - hypoxic or hypoperfusion Type B lactic acidosis - malignancies, drugs and inborn errors of metabolism Albuterol, by creating hyperadrenergic state enhances glycogenolysis and gluconeogenesis, leading to more glucose, pyruvate production. Lipolysis and increased FFA inhibit pyruvate dehydrogenase enzyme, so it doesn’t enter krebs cycle and is reduced to lactate

Answer 1095

Male MaxHR =207-0.78(Age) Female Max Hr=209-0.86(Age)

Answer 1096

Liver disease Intrapulmonary vasodilation Gas exchange abnormalities

Answer 1097

Oxygen content — The arterial oxygen content (CaO2) is the amount of oxygen bound to hemoglobin plus the amount of oxygen dissolved in arterial blood: CaO2 (mL O2/dL) = (1.34 x hemoglobin concentration x SaO2) + (0.0031 x PaO2) where SaO2 is the arterial oxyhemoglobin saturation and PaO2 is the arterial oxygen tension

Answer 1098

Oxygen delivery — Oxygen delivery (DO2) is the rate at which oxygen is transported from the lungs to the microcirculation: DO2 (mL/min) = Q x CaO2 where Q is the cardiac output.

Answer 1099

Oxygen consumption — Oxygen consumption (VO2) is the rate at which oxygen is removed from the blood for use by the tissues. It can be measured directly or calculated. Both approaches assume that all unused oxygen passes from the arterial to the venous circulation. VO2 (mL O2/min) = Q x (CaO2 - CvO2)

Answer 1100

<200: PJP, endemic fungi, aspergillus, candida <100: Toxoplasmosis <50: MAC, CMV

Answer 1101

ILD - OP, NSIP, LIP PAP Emphysema Bronchiectasis Bronchiolitis - obliterative, follicular Pulmonary hypertension HIV Cardiomyopathy causing pulmonary edema Drug reaction to HAART or other medications Various infections Various malignancies

Answer 1102

Skin disease Parenchymal disease Endobronchial disease Mediastinal lymphadenopathy

Answer 1103

Flame shaped, ill defined opacities Interlobular septal thickening Lymphadenopathy

Answer 1104

Legionella Invasive pneumococcal disease Influenza H. influenza HIV Tuberculosis SARS COVID Legally, I have to share COVID-19 news

Answer 1105

Strep Staph H influenza Mycoplasma Atypicals Aerobic gram negative → klebsiella, e. Coli, enterobacter, pseudomonas, serratia, proteus, acintobacter Anaerobes

Answer 1106

Strep Staph - MSSA and MRSA ** Pseudomonas ** Gram negative bacilli

Answer 1107

Klebsiella Staphylococcus Anaerobes Nocardia Actinomyces Rhodococcus TB/NTM Endemic fungi

Answer 1108

Legionella Mycoplasma Chlamydia Viruses

Answer 1109

Interstitial infiltrates - can be reticular, reticulonodular Miliary pattern Airspace opacities or consolidation Peribronchial thickening

Answer 1110

Afebrile x 48 hours AND 100, BP <90, RR>24, SpO2 <90%, normal mental status

Answer 1111

Abscess Cavitation Pleural effusion Bacteremia Resistance to MRSA

Answer 1112

Paralysis Head injury or unconscious Aspiration Chronic lung disease Nasogastric tubes Condensate in ventilator tubing Supine position

Answer 1113

Occur >/48 hours of intubation Not present before intubation/wasn’t the reason for intubation New or progressive infiltrates on imaging Clinical evidence of infection e.g. fever, purulent sputum, leukocytosis, hypoxemia Positive pathogen required by some definitions

Answer 1114

Invasive (BAL, brush, biopsy) > non invasive (endotracheal aspirate) Quantitative (colony forming units) > semi quantitative (1+/2+ growth rates)

Answer 1115

Head of bed elevated 30-45 degrees Mouth hygiene (tooth brushing but no chlorhexidine) Enteral over parenteral nutrition Only clean tubing when there is visible soiling Limit sedation Subglottic drainage Ventilator liberation where possible Maintain physical functioning

Answer 1116

Empyema Meningitis Endocarditis Pericarditis Septic arthritis Invasive streptococcal disease - CSF, blood, pleural, pericardial, synovial

Answer 1117

Age Chronic heart disease Chronic lung disease e.g. asthma requiring medical care in last year Chronic liver disease Chronic kidney disease Diabetes Malnutrition Immunodeficiency Splenectomy, functional asplenia from sickle cell HIV infection HSC transplant SOT transplant Leukemia and lymphoma Immunosuppressive therapy

Answer 1118

>65 or <2 Daycare or institutional setting (exposure to child) Beta lactam use within 3-6 months Medical comorbidities Immunocompromised EtOH

Answer 1119

Severe CAP Not responding to beta lactam Epidemiological factors e.g. outbreak

Answer 1120

Urine legionella antigen PCR Culture

Answer 1121

Azithromycin 500 or levofloxacin 750 Duration: 7 days (mild), 10 days (severe), 14 days (immunocompromised)

Answer 1122

COVID-19 Influenza A and B RSV Parainfluenza Rhinovirus Adenovirus

Answer 1123

>/65 years old Pregnant Postpartum up to 2 weeks Long term care, nursing homes Chronic medical condition - respiratory, renal, liver, etc. Immunosuppression

Answer 1124

Staph aureus Streptococcus

Answer 1125

Rapid antigen test RT-PCR Cultures

Answer 1126

Reduce duration of symptoms Reduce risk of death in inpatients Within 48 hours has best outcomes

Answer 1127

GGO Consolidation Crazy paving Bronchovascular thickening Pleural effusion, LN

Answer 1128

Mild: budesonide, remdesivir, Paxlovid, fluvoxamine Moderate: dexamethasone, remdesivir, tocilizumab, baricitinib Severe: dexamethasone, tocilizumab, baricitinib

Answer 1129

MRNA - pericarditis, myocarditis, Bell’s palsy, anaphylaxis Vector - VTE, GBS, anaphylaxis

Answer 1130

Antiparasitic therapy e.g. albendazole Consider surgical resection Consider percutaneous aspiration

RC Respirology Flashcards

(1222 cards)