resp exam 1 Flashcards
(206 cards)
1
Q
which are the 3 values you can’t directly measure and why
A
Residual volume, functional residual capacity and TLC (because residual volume cant be directly measured and these all include residual volume
2
Q
which value is decreasd in a patient with obesity
A
ERV: the maximum volume of air that can be exhaled from the end expiratory tidal position
3
Q
anything below ___ is a normal PFT value
A
LLN
4
Q
FVC is
A
forced vital capacity: the total volume that can be forcefully expired from a maximum inspiratory effort
5
Q
in obesity which value is decreased and which is increased
A
ERV and FRC are decreased and IC is increased
6
Q
what does FEV1 reflect and what is a normal value
A
upper airway patency: should be 80% of FVC
7
Q
what does it mean when a flow volume loop is flattened
A
vocal cord dysfunction
8
Q
what does a low FVC mean and how do you confirm
A
possible restriction, confirm by looking at lung volumes
9
Q
which value can be used to determine the presence of reversibility
A
FEV1: (asthma or COPD) a 10% or more increase post bronchodilator is considered significant
10
Q
will COPD or asthma patients demonstrate full reversibility
A
patients with asthma demonstrate full reversibility which is not seen in patients with COPD
11
Q
what test is the gold standard for TLC
A
plethysmography (measures residual volume, confirms presence of restriction)
12
Q
total lung capacity = ___+___
A
residual volume + FVC
13
Q
which test is reserved for patients that cannot perform plethymosgraphy
A
nitrogen wash, not as accurate
14
Q
what are the 2 restriction categories
A
parenchymal like pulmonary fibrosis, and extraparenchymal like obesity, chest wall deformity(kyphosis)
15
Q
in which type of restriction is diffusion capacity decreased
A
parenchymal, it is normal with extraparenchymal
16
Q
when does hyperinflation occur
A
when the total lung capacity is above 120%
17
Q
what is used to measure DLCO
A
carbon monoxide bc of high hemoglobin affinity so its able to measure diffusion across membranes
18
Q
what could decrease DLCO
A
thickened alveolar-capillary barrier (fibrosis), decreased blood flow (embolus), decreased Hgb(anemia), decrease in surface area (most commonly emphysema)
19
Q
what are two instances where DLCO can rise above 140%
A
CHF and polycythemia due to diffuse alveolar hemorrhage (RBCs in alveoli lead to increased abs of CO)
20
Q
which test is used to assess the need for supplemental O2 with exertion and endurance
A
six minute walk (pulse oximetry and HR monitored during the test)
21
Q
when is supplemental oxygen prescribed
A
when the sat is less than or equal to 88% or 89% if the patient also has polycythemia, right heart failure, cor pulmonale during six minute walk
22
Q
what is the GOLD criteria used for
A
to help grade COPD and determine therapy
23
Q
what must the FEV1/FVC ratio be to determine COPD
A
below 70%
24
Q
COPD grade 1 FEV1?
A
greater than 80%
25
^grade 2?
between 50% and 80%
26
^grade 3?
between 30% and 50%
27
^grade 4?
below 30% or 50% + chronic resp failure
28
what are the other chronic diffuse restrictive disorders
pneumoconioses, idiopathic interstitial fibrosis and infiltrative disorders such as sarcoidosis, and hypersensitivity pneumonitis
29
which type of emphysema is the most common
centriacinar
30
centriacinar emphysema first affects respiratory ___
bronchioles
31
what does "pan" mean in panacinar emphysema
the entire acinus not the entire lung
32
what is paraseptal emphysema most likely assoc with
spontaneous pneumothorax in young adults due to rupture of bullae from vaping
33
where is the most common space to see bullous emphysema
apical is most common
34
what are the inflammatory mediators that damage lung structures
LTB4, IL-8 and TNF
35
when are the majority of people diagnosed with emphysema
below age 40
36
what is the role of smoke particles in emphysema
it paralyses the cila and causes influx of neutrophils and macrophages
37
what is the first symptom of emphysema
dyspnea
38
what type of bronchitis is productive cough but no physiologic evidence of airflow obstruction
simple chronic bronchitis
39
hyperreactive airways with intermittent bronchospasm and wheezing?
chronic asthmatic bronchitis
40
what bronchitis is airflow obstruction + assoc emphysema
obstructive chronic bronchitis
41
in older pt with chronic bronchitis you may see ____ of the bronchiolar wall
fibrosis
42
what is the reid index in chronic bronchitis
increased >0.5
43
how could you diagnose atopic asthma
high total serum IgE or RAST for antibodies, also wheal and flare rxn skin test
44
what is a mucous plug/inspissated mucus a result of
its coughed up during an asthmatic attack (status asthmaticus), it is a cast of the bronchial tree formed by inspissated mucus
45
what two things are needed to cause bronchiectasis
obstruction and iinfection
46
why would a male pt with bornchioectasis have sterility
he probs has primary ciliary diskinesis (inmorile cilia syndrome), causing sperm dysmotility
47
what lung lobe does CF most commonly affect in bronchioectasis
upper and central lobe
48
what lung lobe does immunodeficiency most commonly affect in bronchioectasis
lower lobe
49
CF is a disorder of ____ transport affecting___
epithelial ion transport affecting fluid secretion
50
what are the mucus secretions like in CF and what do they lead to
abnormally viscin, lead to airway and pacreatic duct blockages → eventually leading to pancreatic insufficiency
51
what is the classic biomechanical abnormality in CF and what gene is defective
high sodium chloride level in sweat, CFTR gene
52
what are the most common causes of death in CF
cardiopulmonary: lung infections w pseudomonas and bronchioectasis--> right heart failure
53
what does CF affecting the pancreas cause
exocrine gland atrophy and fibrosis
54
what are the most common bacteria in pulmonary cystic fibrosis
pseudomonas aeruginosa and burkholderia cepacia
55
what can CF cause if it affects the reproductive system
infertility in mails due to absence of vas deferens
56
what is pulmonary htn defined as
25 mmHg or more at rest
57
what is the clinical presentation of pulmonary htn
dyspnea and fatigue progressing to cyanosis, resp distress, RVH and decompensated cor pulmonale and death
58
what is the most common cause of pulmonary htn
idiopathic
59
what are the other 4 causes
arterial htn, left sided heart disease, lung disease, hypoxia or chronic thromboembolic htn
60
what protein signaling pathway is involced in idiopathic pulmonary htn
defects in BMPR2 signaling → lead to dysfunction of endothelium and proliferation of vascular smooth muscle
61
pulmonary htn causes ____ hypertrophy of the pulmonary muscular and elastic arteries and ____ ventricular hypertrophy
medial, right
62
Bronchiolitis is defined as
nonspecific inflammatory injury affecting small airways without cartilage
63
in a patient with cough and chronic SOB w/o asthma or COPD you should suspect
bronchiolitis obliterans
64
airway obstruction in bronchiolitis obliterans is (reversible or irreversible)
irreversible
65
which cells cause cellular bronchiolitis?
inflammatory cells like lymphocytes, neutrophils and eosinophils
66
which type of bronchiolitis is not assoc w respiratory symptoms and presents with tan macrophages (smokers macrophages) on histo?
Respiratory bronchiolitis-assoc interstitial lung disease (RB-ILLD)
67
How can you differentiate RB-ILLD and interstitial pneumonia
RB-ILLD lacks fibroblastic foci (pneumonia has fibrosis)
68
how do you differ blebs and bullae?
blebs are <1-2 cm in diameter and are subpleural, bullae are >2 cm and occupies pleural cavity
69
how much do you generally have to smoke to get COPD
20 pack years
70
what is the major contributor to worldwide prevalence of COPD and what are two less common causes
biomass fuels w indoor cooking and heating, IV drug use and HIV infections are less common causes
71
what syndrome is more prone to COPD and pneumothorax, and what is the deficiency
Marfans, type 1 collagen deficiency
72
what is a difference between asthma and COPD in the persistence of symptoms
COPD has daily progressive symptoms (asthma has good days and bad days)
73
COPD has ___ to percussion
hyperressonance, bc of the emphysema
74
what could you see in advanced COPD on PE
cyanosis, JVP elevation and peripheral edema
75
are patients with AAT1 deficiency likely to develop COPD
not likely if they do not smoke
76
significant reversibility is defined by
an increase in FEV1 or FVC of 10% or more
77
the GOLD criteria is used for? what test do you need?
stage patients with COPD< use post-bronchodilator FEV1/FVC and FEV1
78
what is mandatory FEC/FVC post bronchodilator to meet criteria for COPD
less than 0.7
79
what is the difference between stage E and stage A and B criteria in GOLD staging
Group E two+ moderate exacerbations or 1 with hospitalization, Group A and B are 0-1 moderate exacerbations NOT leading to hospitalizations
80
what oxygen test can be performed to determine the presence of hypercapnia
ABGS
81
when should you presvribe long term oxygen therapy
if oxygen saturation is less than or equal to 88% or PaO2 is less than 55mm Hg
82
what is a spacer used for and when do you five it
always provide, it doubles the amt of medicine reaching the lung in COPD
83
what is the first line therapy for COPD and waht does it target
LABA targets symptoms and exacerbations
84
if using a single agent should you use LABA or LAMA
LAMA is preferred bc they have a greater effect on exacerbation reduction
85
when do you give a SABA
consider for all patients, prescribe to all symptomatic patients
86
when should you give LAMA/LABA
in patients w advanced disease (B and E) or persistent sx
87
when should you consider ICS in the context of triple therapy
pt w hx of exacerbation because it reduces exacerbations even more than LAMA/LABA
88
what patient would benefit from a PDE4 inhibitor
pt w very severe COPD (3 or 4 GOLD) and history of exacerbations
89
can you give steroids for exacerbations?
yes, some pt are even stroid dependent. generally not used for long txt tho
90
what are the 3 signs you should give antibiotics in exacerbations
change in amt, color of sputum and increased dyspnea(only need 2/3)
91
asthma characterized by ____
chronic airway inflammation
92
most common asthma phenotype? when does it start
allergic asthma, starts in childhood
93
triggers for allergic asthma? respond well to
pollen, cat dander, foot etc. respond well to ICS
94
the triggers exercise, viral infection, mold weather and cigarette smoke belong in what asthma phenotype
non allergic asthma
95
how could you treat aspirin induced asthma
LTRA and biologics
96
when does exercise induced bronchoconstriction occur?
minutes after exercise
97
TRAIN in asthma stands for
triggers, reversibility, age of onset, intermittent symptoms, nocturnal symptoms
98
if a spirometry test and x rays are normal, can you rule out asthma?
no, spirometry may be normal in between exacerbations or when asthma is controlled. xrays are used to rule out other diseases
99
what are the rescue inhaler use, daytime symtpms and nocturnal symptoms in mild persistent asthma
rescule inhaler and symtpms: more than 2x week but not daily, nocturnal symptoms: 3-4x p month
100
which asthma pt are considered controlled
intermittent
101
what do u prescribe in intermittent asthma
prn ICS/SABA
102
mild persistent asthma prescription
daily inhaled corticosteroid or LTRA if u cant use ICS
103
Moderate?
combination: ICS/LABA
104
severe?
multiple agents like ICS+ LABA/LAMA and steroids
105
what could give a false diagnosis of asthma
vocal cord dysfunction: pt are anxious and dont respont to asthma treatment
106
name the 5 pulmonary htn groups in order
arterial htn, l heart disease, lung disease/hypoxia, Pulm a. obstruction, unclear or multifactorial
107
how do u diagnose and confirm pulm htn
echo diagnose, r heart catherization confirms
108
most common initial sx of pulm htn
dyspnea and fatigue
109
which symptom is common and specific to pulm htn
exertional syncope
110
nebulizers are preferred for what
severe asthma or COPD
111
down side of dry powder inhalers?
theyre irritating and require high airflow
112
MOA of B2 agonist?
increase cAMP --> smooth muscle relaxation and inhibits release from mast cells
113
what contributes to the safety of b2 agonists
they have low affinity for b1 (cardiac) receptors
114
when do u use SABAs
txt of acute bronchospasms in asthma and COPD (initially and in all stages of asthma txt)
115
why cant u give LABAs by themselves
bc they have no direct anti inflammatory effect and can increase risk of fatal asthma attack (they facilitate anti inflammatory actions of ICS )
116
what do u give LABAs with
ICS or LAMA
117
what accounts for LABA duration of action
slow release from lipid membranes
118
most common b2 agonist side effect
tremor
119
other side effects of b2 agonists?
cardiovascular stimulation (rare), hypokalemia (watch K+ sparring) and hyperglycemia
120
what cortical arousal pathway does B2 take to cause CNS stimulation
locus ceruleus--> NE--> cerebral cortex (restlessness)
121
which asthma drug has a black box warning of asthma related death
products thathave laba alone
122
which LABA has a nebulization solution available
formoterol (salmeterol is a DPI)
123
which LABA has a faster onset of action
Formeterol is faster than salmeterol (both have 12 hr duration)
124
in anaphylaxis ___ can be added after emergency epinephrine
inhaled SABA
125
which beta agonists have tablet formulations
albuterol and terbutaline (not recommended bc of side effects unless children or ppl that cant take the other forms)
126
Ipratropium is a (type of drug)
SAMA (the other iums are LAMAs: tiotropium and aclidinium bromide)
127
muscarinic antagonists MOA
prevent bronchoconstricting effects of ach on m3 muscarinic receptors. reduce parasympathetic tone
128
what do you comine muscarinic antagonists for maximal airway dilation
beta agonists
129
from most likely to least likey what are the muscarinic antagonists side effects
dry mouth, constipation or difficulty urinating, increased HR (ocular effects possible if sprayed to eye accidentally)
130
SAMA principal use
COPD, can use in asthma if SABA intolerant, best if used in SABA /SAMA combo in both COPD and severe asthma
131
SAMA ROA
MDI or nebulization
132
LAMA principal use
long term management of stable copd
133
diff between SAMA and LAMA?
LAMA has greater selectivity for M3 receptor (less side effects), and longer duration of action
134
what combo is given for stable severe copd
LAMA/LABA soft mist inhaler (once daily--> great adherence)
135
name the two systemic glucocorticoids
prednisone and methylprednisone (all the other -sone are ICS)
136
what drug is used for initial traditional daily maintenace for persistent asthma
ICS (combined w SABA as needed)
137
are ICS fast acting
no, the improvement is delayed up to one week (no immediate benefit)
138
when do you give systemic glucocorticoids
in severe asthmatic attacks and COPD exacerbations
139
how long can you give oral prednisone, why?
for 1-2 weeks, if longer they can cause hypothalamic pituary adrenal axis suppression
140
which is the only individual drug available as a solution for nebulization
budesonide
141
when do you use LABA/ICS combinations
in asthma control for better symptom control (but u still need to use SABA)
142
when do you use ICS/LAMA/LABA 3x combos
fda indication for COPD (incorporates all possible mechanisms for maximal reduction of airway resistance)
143
when do you use theophylline
in asthma when pt cant use inhaled agents
144
Roflumilast mechanism of action
PDE4 inhibitor (anti-inflammatory)
145
when do you use roflumilast
to reduce frequency of exacerbations of COPD (not used for asthma)
146
Roflumilast side effects
nausea, diarrhea , weight loss and headache
147
what is montelukast approved for
prophylaxis and maintenance of asthma, may be used in children 6-12
148
montelukast is very effective for
aspirin exacerbated respiratory disease (AERD)
149
montelukast common side effect
dyspepsia (pain in upper abdomen)
150
omalizumab is restricted for whaat pt
severe asthma w evidence of allergic sensitization (hx of severe exacerbation respond best)
151
benralizumab targets what receptor
IL-5 receptor in eosinophilic asthma
152
what is the most common sympton of PE
dyspnea at rest or w exertion, pleuritic pain (most symptoms vary some are asymptomatic)
153
pulmonary manifestations of pulmonary embolism?
may be normal, but consistent with consolidation (esp when assoc w infarct)
154
lower extremity findings of PE?
swelling, redness, warmth
155
what syndrome is assoc w higher risl for venous thromboembolism (VTE)
antiphospholipid antibody syndrome
156
most common genetic cause of VTE?
factor V leiden mutation
157
^what other mutations
prothrombin, antithrombin III, protein C and protein S
158
what score do u use to catergorize PE
wells score (low risk less than 2, high risk more than 6)
159
Aa gradient in PE?
elevated
160
what acid base disorder in PE
alkalosis bc tachypnea (also hypoxemia)
161
PE V/Q ration?
increased, normal ventilation but no perfusion (bc clot0
162
a normal D dimer can exclude ___ in a low risk pt
pulmonary embolus, intermediate and high risk need to be worked up)
163
what two things do you look for in PE x ray
hamptons hump ( pulmonary infarct), westermarks sign (pleural effusion)
164
gold standard for PE suspicion
CTPA
165
what diagnostic test can identify source of PE
doppler (also used if CTPA cannot be performed)
166
when do you use V/Q for PE and what do u see
if pt cant do CTPA , mismatch defect: ventilation but no perfusion
167
if a pt has both decreased ventilation and perfusion on V/Q they most likely have
lobar pheumonia
168
EKG on PE?
tachycardia and nonspecific St wave changes, right ventricular strain pattern if big clot
169
txt for PE
anticoagulants: heparin then transition to oral anticoagulants like factor XA inhibitors (xaban) and direct thrombin inhibitor)
170
why is warfarin not preferred over the other oral anticoagulants
it is diffucult to manage bc it requires monthly INR check ups, it also interacts with meds and leafy green vegetables
171
how long should anticoagulant therapy last in a patient with a first thromboembolic event occurring in the setting of reversible risk factors
long term therapy for 3 months
172
when should you give lifelong anticoagulation if not contraindicated
in patients who have recurrent VTE or irreversible risk factors
173
when should you consider thrombolytic therapy
in hemodynamically unstable patients systolic BP <90 mmHg and respiratory distress/failure, or patients with right ventricular strain pattern on echo
174
abs contraindications of thrombolytic therapy?
prior ICH, cerebrovascular lesion, malignant neoplasm, stroke, aortic dissection
175
when would you use an IVC filter?
to treat PE in patients with a contraindication to anticoagulation (active bleeding like GI, CNS bleed, recent CNS surgery)
176
pregnancy ___ the risk of VTE
increases (has nonspecific symptoms like low O2 levels post partum)
177
if you suspect VTE in a pregnant person what test should you order
lower extremity doppler if positive patient should be anticoagulated (if negative do an X-ray)
178
what should you do if a pregnant patient has an abnormal chest x ray
CTPA (dont do V/Q bc its sensitivity decreases with abormal chest x ray)
179
what is the best anticoagulant to use during pregnancy
LMWH throughout pregnancy and for 4-6 weeks post partum (IVC if anticoagulation contraindication)
180
how should you treat primary spontaneous pneumothorax
surgical treatment because recurrence rate is very high
181
what does iatrogenic pneumothorax mean and what are three examples
its secondary to diagnostic or therapeutic medical intervention (close proximity to the lungs): thoracocentesis, bronchoscopy and central line placement
182
pneumothorax usually develops at ___
rest
183
which pneumothorax is thought to arise from thoracic endometriosis
catamenial pneumothorax
184
what is the common presentation of catamenial pneumothorax
seen in women aged 30-40 and symptoms present within 48 hrs of menstruation , right side most common
185
which condition is assoc with chylothorax and causes spontaneous pneumothorax
lymphangioleiomyomatosis : characterized by thin walled cysts in women of child bearing age
186
pneumothorax has ____ tactile fremitus
decreased
187
what can be mistaken for a pneumothorax and lead to unnecessary intervention
a vertical skin line
188
what diagnostic test can distinguish between large bulla and pneumothorax
CT
189
how do you manage small pneumothoraxes
observation w x rays, they heal spontaneously. u might need o2 to expedite resorption
190
what do you use to repair underlying defect in patients w PSP
video assisted thoracoscopic surgery (VATS)
191
what is pleurodesis and what is it usually used for
the pleura stick together by using talc to induce inflammation, used with pt with nonresolving pleural effusions
192
what is pneumomediastinum usually caused by and how do you treat
most commonly due to secondary to pneumothorax, can also be due to rupture of esophagus. treat underlying cause and manage conservatively
193
primary stressor causing altitude illness, how maby feet leads to it?
hypoxemia, 8,000 ft or higher
194
what is the most common form of altitude illness, symptoms and how do you resolve
acute mountain sickness, malaise, resolves 24-72 hrs after acclimatization
195
when does high altitude cerebral edema occur, what symptoms?
in indiv with AMS or HAPE in elevation over 10,000 ft. encephalopathic symptoms: medical emergency
196
which altidude illness has breathlessness at rest and pink frothy sputum
high altitude pulmonary edema
197
the difference between PiO2 and PaO2 ___ at high altitudes because of increased ventilation
narrows
198
arterial oxygen saturation (SaO2) is well maintained while awake until ____
3000 meters
199
what is the txt of choice in HAPE, what else can you use
descent txt of choice, u can use acezolamide, difedipine and dexamethasone until descent is possible or prophylactically
200
what is the most common cause of COPD exacerbation
infection (tracheobronchitis) get a gram stain
201
in what stage can exacerbation of asthma occur
any stage!
202
what are signs of a severe asthma exacerbation
tachypnea, tachycardia, accessory muscle use, unable to speak in full sentences and pulsus paradoxus
203
how could you identify status asthmaticus
lack of response to SABAs
204
how do you identify COPD exacerbation
dyspnea/ cough that worsens over 14 days
205
wht other differential should you consider in COPD exacerbation
pneumonia, take a chest x ray
206
what is the target O2 sat for a pt w exacerbation
92% and above
