Resp

Question 0

Acute exacerbation of COPD - tests (2) and results

Answer 0

CXR - hyperinflation

ABG - hypoxia, co2 retention, resp acidosis with metab alkalosis compensation

Question 1

Acute exacerbation of COPD - Cardinal Sx (3)

Answer 1

Increased dyspnea
Increased cough (frequent & more severe)
Increased sputum production (change in colour and volume)

Question 2

Acute exacerbation of COPD - management (6)

Answer 2

• O2 (target sat 88-92%)
• inh bronchodilators (eg albuterol) & anticholinergics (eg ipratropium)
• Systemic glucocorticoids
• antibiotics (eg levofloxacin) for: (a) pts with 2/3 Cardinal Sx, (b) mod-to-severe exacerbation, (c) mechanically ventilated pts
• noninvasive positive-pressure ventilation (NPPV) for mod-to-severe exacerbation (if not contraindicated)
• trach intubation if no improvement with NPPV & drugs OR if NPPV is contraindicated

Question 3

ARDS characteristics (5)

Answer 3

• follows significant lung injury (pneumonia, sepsis, trauma, burns, severe bleeding, toxic ingest ions)
• acute resp failure (distress)
• dyspnea, tachypnea, severe hypoxemia
• diffuse alveolar damage due to inflamm mediators released due to tissue injury
• pulmonary edema not due to heart failure or volume overload

Question 4

Acute massive PE - presenting Sx (2) and exam findings (2)

Answer 4

Syncope, hemodynamic collapse

Accentuated P2, elevated CVP (high JVP)

[Usually, RV dilatation (RVH outflow obstruction) - septum gets pushed toward LV, causing deceased LV preload & CO]

Question 5

Criteria for obstructive pattern

Answer 5

FEV1/FVC < 70% predicted

Question 6

Obstructive pattern DDx based on DLCO (3)

Answer 6

Low DLCO: emphysema
Normal: Chronic bronchitis
Increased: Asthma

Question 7

Criteria for restrictive pattern

Answer 7

FEV1/FVC > 70% predicted
FVC < 80% predicted
(low VC)

Question 8

Restrictive pattern DDx based on DLCO (low 4, normal 2, increased 1)

Answer 8

Low DLCO: Interstitial lung diseases, sarcoidosis, asbestosis, heart failure
Normal: Musculoskeletal deformity, Neuromuscular disease
Increased: Morbid obesity

Question 9

DDx for normal spirometry based on DLCO (3 low, 2 high)

Answer 9

Low DLCO: Anemia, PE, Pulm HTN

Increased: Pulm hemorrhage, Polycythemia

Question 10

Criteria for predominant chronic bronchitis COPD subtype

Answer 10

Chronic productive cough (3 months or more) over 2 consecutive years not due to other causes (eg. bronchiectasis)

Question 11

Pt shows obstructive disease on spirometry; next test?

Answer 11

Bronchodilator challenge (increased FEV1 = asthma; no change in FEV1 = COPD)

Question 12

Pt shows restrictive disease on spirometry; how to differentiate interstitial lung disease vs chest wall weakness?

Answer 12

DLCO

Normal DLCO = chest wall weakness
Decreased DLCO = interstitial lung disease

Question 13

What is blastomycosis & where is it endemic?

How to Dx/Tx?

Answer 13

Pulmonary fungal infection; can become systemic (skin and bone lesions) (skin lesions = well-circumscribed verrucous, crusted lesions; bone lesions = lytic)

Endemic to Great Lakes, Mississippi & Ohio River basins

Dx: CXR, sputum culture

Tx: Itraconazole or amphotericin B (for systemic disease)

Question 14

What happens to pulmonary vasculature when alveoli are hypoxic?

Answer 14

Vasoconstriction

Question 15

Causes of chronic hypoventilation (3)

What happens to pCO2 and pH?

Answer 15

COPD
Obesity hypoventilation syndrome
Neuromuscular cuases

pCO2 gradually increases = resp acidosis; kidneys compensate by increasing bicarb retention so pH remains low-normal or just below normal (pH never normalizes or gets overcorrected)

Question 16

Indicators of severity of an asthma attack (5)

Answer 16

Normal to increased pCO2 values (indicates CO2 retention due to severe obstruction and/or resp muscle fatigue)
Speech difficulty
Diaphoresis
Altered sensorium
Cyanosis
"Silent" lungs