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MCCEE > Resp > Flashcards

Resp Flashcards

1
Q

Most common cause of chronic cough and not a smoker?

A

GERD
Asthma
Post-nasal drip
ACEI

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2
Q

Respiration patterns?

A

Obstructive:
Prolonged expiration
Asthma, COPD

Kussmaul’s:
Regular deep and fast
Exercise, metabolic acidosis, anxiety

Cheyne-Stroke:
Irregular depth + apneic periods.
Uremia

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3
Q

Most common cause of hemoptysis?

A

Bronchitis

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3
Q

Most common causes of clubbing?

A

• Resp:
Lung ca, bronchiectesis, fibrosis, abscess (NOT COPD)

• CVS:
Endocarditis
AV fistula

• GI:
IBD, celiac, cirrhosis

• Endo:
Graves’ disease

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4
Q

Causes of high DLco?

A

Asthma
Pulmonary hemorrhage
Polycythemia

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5
Q

DDx of cough?

A
  1. Airway Irritant:
    Smoke, dust, fumes.
    Post-nasal drip
    Aspiration of GERD, foreign body, secretions
  2. Airway Disease:
    Asthma, COPD, bronchitis, bronchiectasis.
    Neoplasm or LN
    URTI causing post nasal drip
  3. Parenchymal disease:
    ILD, pneumonia, lung abscess.
  4. CHF
  5. ACEI
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6
Q

DDx of hemoptysis?

A 
1. Airway disease:
Bronchitis 
Bronchiectasis 
Bronchogenic Ca
Bronchial carcinoid tumor
  1. Parenchymal disease:
    Pneumonia, TB, lung abscess.
3. Vascular disease:
PE
High pulmonary venous pressure: LVF / MS
Vascular malformation 
Vasculitis: goodpasture's
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7
Q

Define asthma?

A

It is a chronic airway inflammatory disease.

Due to airway hyperresponsiveness to triggers/antigens leading to reversible bronchospasm causing obstruction.

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8
Q

What is the pathophysiology of asthma?

A

Airway obstruction => V/Q mismatch > hypoxemia > hyperventilation > low PaCO2 > high PH + muscle fatigue > hypo ventilation , high PaCO2, low PH.

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9
Q

What is the pathophysiology of asthma?

A

Airway obstruction => V/Q mismatch > hypoxemia > hyperventilation > low PaCO2 > high PH + muscle fatigue > hypo ventilation , high PaCO2, low PH.

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10
Q

Sx of asthma?

A
  1. Nocturnal cough with sputum
  2. wheeze, chest tightness
  3. Pulsus paradoxus
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11
Q

What are the triggers of asthma?

A
  1. URTI
  2. Allergen (pet dander, dust, mold)
  3. Irritant (smoke)
  4. Drugs (NSAIDs, BB)
  5. Preservatives (sulphite, MSG)
  6. Anxiety, exercise, GERD, cold
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12
Q

Signs of poor asthma control (DANGERS)?

A 
Daytime Sx = or > 4x/week
Activity reduced 
Nighttime Sx = or > 1x/week
GP visit
ER visit
Rescue puffer = or > 4x/week
School absence
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13
Q

What is The pulmonary function of criteria for diagnosis of asthma?

A
  1. Spirometry shows reversible obstruction.
    ⬇️FEV1/FVC 12%
  2. PEF
    ⬆️ PEF after bronchodilator
    PEF > 60%
    Diurnal variation > 8%
  3. Positive methacholine challenge test.
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14
Q

Define COPD?

A

Progressive, irreversible condition characterized by chronic obstruction with periodic exacerbations.

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15
Q

Subtypes of COPD?

A

Chronic bronchitis + emphysema

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16
Q

Chronic bronchitis vs emphysema?

Dx

A

• Chronic bronchitis:
Dx clinically
Productive cough for 3 consecutive mo in 2 successive years.

Due to airway narrowing by mucosal thickening and excess mucus.

• Emphysema
Dx path
Alveolar dilatation and destruction w/o fibrosis, leads to decreased lung recoil.

Low recoil > low expiratory pressure > air trapping > airway collapse.

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17
Q

Types of emphysema?

A

• Centriacinar:
Bronchioles
Smokers
Upper zone

• Panacinar:
Bronchioles, alveolar duct and sac
a1-anti trypsin

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18
Q

Most important risk factor for COPD?

A

Smoking

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19
Q

Sx of bronchitis vs emphysema?

Blue bloaters vs pink puffers

A
  1. Bronchitis:
    - Chronic cough w/ purulent sputum + hemoptysis.
    - Cor pulmonale + peripheral edema.
    - Crackles + cyanosis
    - Prolonged expiration
    - Obese
  2. Emphysema:
    - Exertional dyspnea
    - Pink skin + pursed-lip breathing
    - Barrel chest
    - Cachectic
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20
Q

Investigations of a bronchitis vs emphysema?

A
  1. Bronchitis:
    • PFT:
    ⬇️FEV1, FEV1/FVC, DLco
    N TLC

• CXR:
Normal AP diameter
Inc bronchovascular markings
Enlarged heart in Cor pulmonale

  1. Emphysema:
    • PFT:
    ⬇️ FEV1, FEV/FVC, LDco
    ⬆️ TLC, RV
• CXR:
Inc AP diameter 
Flat hemidiaphragm
⬇️ bronchovascular markings
Bullae
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21
Q

Complications of COPD

A
  1. Polycythemia 2ry to hypoxia
  2. Chronic hypoxemia
  3. Pulmonary HTN
  4. Cor pulmonale
  5. Pneumothorax (Bullae)
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22
Q

How to prolong survival and COPD patients? (3)

A

Smoking cessation
Vaccination
Home oxygen

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23
Q

What is the importance of home oxygen in COPD?

A

Prevents cor pulmonale and decreases the mortality if you use > 15 h/day when PaO2

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24
Q

Define acute exacerbation of COPD

A

Sustained (>24-48 hr) worsening of dyspnea cough or sputum production leading to increased use of medication.

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25
Q

O2 target of acute exacerbation of COPD.

A

88-92% for CO2 retainers.

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26
Q

Management of acute COPD exacerbation

A
  1. ABC
    • consider assisted ventilation if ALOC or poor ABG.
  2. O2 target 88-92 in CO2 retainers
  3. Bronchodilators
    • SABA + anticholinergic nebz 3 back-to-back q15min.
  4. Systemic steroids:
    • IV or oral
  5. Abx if purulent discharge.
    - Simple exacerbation > amoxicillin, 2/3G cephalosporins, TMP/SMX
  • Complicated (FEV1 less than 50%, 4 exacerbations/year, IHD, home O2, chronic oral steroids)
    Fluoroquinolone or amoxi/clavulanate
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27
Q

Definition of a bronchiectasis

A

It’s an irreversible dilatation of airways due to destruction of airways from persistently infected mucus.

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28
Q

Part of the airway is affected in bronchiectasis

A

medium sized airways

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29
Q

What is the most common pathogen in bronchiectasis?

A

P. Aeruginosa

Then, S. Aureus + H. Influenzae

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30
Q

Pathophysiology of the bronchiectasis (3)?

A
  1. Obstruction
    Tumor
    Foreign body
    Thick mucus
2. Post-infection
TB
Pneumonia
Pertussis 
Measles 
Aspergillosis
  1. Impaired defense
    Hypo-gamma
    CF
    Ciliary dysfunction (kartagener’s syndrome)
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31
Q

Sx of bronchiectasis

A

Chronic cough w/ purulent discharge + hemoptysis

Clubbing

Recurrent pneumonia

Local crackle

32
Q

Investigations in bronchiectasis

A
  1. PFT: obstructive pattern
  2. CXR: tram tracking (specific)
    Parallel lines radiating from the hilum.
  3. HRCT (gold standard)
    Signet ring - 100% specific
    Dilated the bronchi w/ thick walls. Bronchus > artery.
  4. Sputum Cx + AFB
  5. Serum Ig
  6. Sweat chloride for CF
33
Q

Is the gold standard test for bronchiectasis

A

HRCT

Shows signet ring sign

34
Q

What’s sarcoidosis?

A

If you pathic noninfectious non-caseating granulomatous multisystem disease with lung involvement in 90%.

35
Q

Sx of sarcoidosis?

A

Asymptomatic or nonspecific

Extra pulmonary Sx:
• CVS: arrhythmia + sudden death
• Ophtha: uveitis 
• Derm: erythema nodosum, papule, lupus
• peripheral lymphadenopathy 
• hepatosplenomegaly
36
Q

Acute syndromes of sarcoidosis? (2)

A

1- Lofgren’s syndrome:
Fever, erythema nodosum, bilateral hilar lymphadenopathy, arthralgia.

2- Heerfordt-Waldenstrom:
Fever, parotid enlargement, anterior uveitis, facial palsy.

37
Q

Dx of sarcoidosis?

A

Biopsy of lymph node for granulomas

38
Q

Labs in sarcoidosis?

A
  • CBC > shows cytopenia if spleen or BM involved.
  • U&E > hypercalcemia/calciuria from VitD activation by granuloma.
  • ECG > for conduction abnormality
  • slit-lamp > uveitis.
  • PFT: obstructive or restrictive or normal
  • CXR > lymphadenopathy + nodular opacities
39
Q

Staging in sarcoidosis?

A
  • Depends on CXR
    • Stage 0
    Normal CXR

• Stage 1
Bilateral hilar lymphadenopathy +/- paratracheal.

• Stage 2
Bilateral hilar lymphadenopathy + Diffuse ILD

• Stage 3
ILD only

• Stage 4
Fibrosis (Honeycombing)

40
Q

Rx of sarcoidosis?

A

85% of stage 1 resolves
50% of stage 2 resolves
Steroids for symptoms + organ involvement.

41
Q

Define hypersensitivity pneumonitis?

A

It is a non-IgG mediated poorly formed granuloma and lymphocytic in for inflammation of the lung parenchyma caused by sensitization to inhaled agents.

42
Q

Types of hypersensitivity pneumonitis and causative organism?

A
  1. Farmer’s lung = thermophilic actinomycetes
  2. Bird breeder = response to bird IgA.
  3. Humidifier + sauna takers = Aurobasidium
43
Q

Presentation of hypersensitivity pneumonitis (acute + chronic)

A

Acute (4-6 hr):
Chills + fever
Cough + dyspnea
CXR: diffuse infiltrates

Chronic: 
Dyspnea + cough
Weight loss
PFT: progressively restrictive. 
CXR: upper lobe reticulonodular pattern
44
Q

Type of immune response in acute vs chronic hypersensitivity pneumonitis?

A

Acute = type III (immune complex)

Chronic = Type IV (cell mediated, delayed hypersensitivity)

45
Q

Rx of hypersensitivity pneumonitis?

A

Avoidance of further exposure

Systemic steroids

46
Q

Who is at risk of asbestosis pneumoconiosis?

A 
Workers in insulations
Shipyards
constructions
Pipe fitters 
Plumbers
47
Q

What is this doses pneumoconiosis?

A

Slowly progressive diffuse interstitial fibrosis induced by asbestos fibers after 10-20 yr exposure.

48
Q

Sx of Asbestosis pneumoconiosis.

A

Paroxysmal non-productive cough with fine end-respiratory crackles

49
Q

CXR finding of asbestosis pneumoconiosis.

A

Lower love reticulonodular pattern
+/- Honeycomb

Plural + diaphragmatic plaques and calcification.

50
Q

Pathology in asbestosis?

A

Ferruginous bodies:
Yellow brown rod shaped structures.
Represent asbestos fibers in macrophages

51
Q

Complication of asbestosis

A

Bronchogenic carcinoma

Lung cancer in smokers

52
Q

Define pulmonary hypertension

A

A mean pulmonary arterial pressure > 25mmHg at rest + > 30 with exercise.
Or pulmonary artery pressure > 40 mmHg at rest.

53
Q

WHO classification of pulmonary HTN?

A
  1. Pulmonary arterial HTN
  2. PHTN due to left heart
  3. PHTN due to lung dz
  4. Chronic thromboembolic PHTN
  5. Others.
54
Q

Causes of arterial PHTN?

A

Idiopathic

Collagen vascular (SLE, RA, scleroderma)
Porto-PHTN
Pulmonary capillary hemangiomatosis
Systemic-pulmonary shunt

Pulmonary vaso-occlusive Dz
SCA

HIV
Schistosomiasis

Drugs + toxins

55
Q

Epidemiology of idiopathic PHT?

A

Young females 36 yr

Associated with anorexic drugs, amphetamine or cocaine use

56
Q

Sx of idiopathic PHTN?

A
  1. Dyspnea, chest pain, syncope

2. RV heave, reynaud’s

57
Q

Dx idiopathic PHTN?

A
  1. CXR: enlarged central pulmonary arteries + RV enlargement.
  2. 2D echo > RV pressure.
  3. CT angio to R/O PE
  4. Cardiac cath > direct measurement of pulmo artery pressure.
58
Q

What is pulmonary embolism

A

It’s a clot in the pulmonary arterial tree with subsequence:

  1. increase in pulmonary vascular resistance
  2. V/Q mismatch
  3. reduced pulmonary blood flow.
59
Q

What is the most common source of pulmonary emboli?

A

Proximal leg thrombi (popliteal, femoral, iliac veins)

60
Q

Risk factors for PE?

A
  1. Stasis:
    Immobilization
    Obesity
    Venous insufficiency
  2. Endothelial damage = post-op / trauma
3. Hypercoagulable state:
Malignancy + Ca Rx
Estrogen administration (OCP, HRT)
Pregnancy + postpartum
Nephrotic syndrome 
Hx of DVT/PE (personal or family) 
Coagulopathies:
Factor V Leiden 
Antithrombin/ protein C/S deficiency
Antiphospholipid antibody syndrome
61
Q

What is Wells’ criteria and what is it used for?

A

Used to predict PE.

Risk factors:
• DVT signs  = 3 points 
• immobilization or surgery in 4wks = 1.5  
• Hx PE/DVT = 1.5
• HR > 100 = 1.5
• Hemoptysis = 1.0
• Ca = 1.0

Clinical probability:
Low (0-2)
Intermediate (3-6)
High > 6

62
Q

How to evaluate suspected PE?

A
  1. Low probability:
    D-dimer (+ve) -> CT (+ve) = PE
    D-dimer (-ve) -> No PE
  2. High probability:
    CT (+ve) -> PE
    CT (-ve) -> Not PE
63
Q

Rx of PE

A
  • Admit
  • O2 + pain management
  • Acute anticoagulant: SC LMWH or IV heparin ASAP.
  • interventional thrombolytic.
  • IV thrombolytic for massive PE
  • IVC filter for recent DVT + absolute # to anyicoagulant.
64
Q

Duration of long-term anticoagulation for PE patient

A
  1. Reversible cause of PE (surgery, trauma, pregnancy): 3-6 mo
  2. Unprovoked PE: 6 mo
  3. Non reversible (Ca, anti phospholipid): indefinite
65
Q

Types of pulmonary vasculitis?

A

Wegener’s granulomatosis
Churg-Strauss syndrome
Goodpasture’s disease

66
Q

Define Wegener’s vs Churg-Strauss vs Goodpasture’s?

A
  1. Wegener’s:
    Vasculitis of medium to small arteries with necrotizing granulomatous lesions.
  2. Chrug-Strauss:
    Allergic rhinitis, asthma, eosinophila
  3. Goodpasture’s:
    Alveolar hemorrhage and granulonephritis 2ry to anti-GMB antibodies that cross-react with basement membrane of kidney and lung.
67
Q

Dx of Wegener’s vs chrug-Strauss vs Goodpasture’s

A
  1. Wegener’s
    CXR: nodules + cavities
    c-ANCA
  2. Chrug-Strauss:
    Eosinophilia + p-ANCA
  3. Goodpasture’s:
    CXR: alveolar infiltrates (hemorrhage)
    ELISA with anti-GMB
    Linear staining on immunofluorescent
68
Q

What is the most common collagen vascular disease affecting the lung?

A

Scleroderma

69
Q

Types oh for pleural effusions

A

Transudative + exudative

70
Q

How to distinguish transudative vs exudative effusions?

A

Modified Light’s Ceiteria

  • Plural/serum protein: > 0.5
  • Plural/serum LDH: > 0.6
  • Plural LDH: > 0.45 upper limit of serum LDH

One or more = exudative

71
Q

Pathophysiology of transudative vs exudative pleural effusions

A
  1. Trans:
    Increased formation and absorption of plural fluid.
  2. Exudate:
    Increased permeability of pleural capillaries or lymphatic system.
72
Q

Causes of transudative vs exudative pleural effusions

A
  1. Trans:
    CHF
    Nephrotic syndrome + cirrhosis
    Peritoneal dialysis + hypothyroidism + CF
  2. Exudate:
    - Infections: bacterial pneumonia + TB
    - Ca
    - Inflammatory: collagen vascular disease + PE
    - Intra-abdominal: subphrenic abscess
    - Intra-thoracic: perforated esophagus
    - Trauma.
73
Q

Simple vs complicated pleural effusion

A
  1. Simple:
    PH > 7.1
    LDH 2.2
  2. Complicated:
    PH 1/2 serum
    Glucose
74
Q

What is pneumothorax?

A

Air in the pleural space that rises intra-pleural pressure and causes partial lung deflation

75
Q

Causes of pneumothorax

A 
Trauma
Iatrogenic (central cath, mechanical ventilation)
Spontaneous:
1ry > healthy tall young males. 
2ry > emphysema + lung cancer
76
Q

Sx of tension pneumothorax

A
  1. Severe respiratory distress
  2. Tracheal deviation to contralateral side
  3. High JVP
  4. Hypotension
77
Q

Sx. Of pneumothorax

A

Dyspnea + pleuritic chest pain
Tracheal deviation
Low tactile/vocal fremitus
Hyperresonance

78
Q

Rx of pneumothorax

A

Small:

  • resolves continuously
  • 100% O2
  • intercostal tube.

Large:
- chest tube w/ underwater seal +/- suction

MCCEE (3 decks)

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