Respiratory (11%)

Question 1

PE (everything but treatment)

Answer 1

• Risk factors – venous stasis, immobility, recent surgery, malignancy, hx of VTE
• Virchow’s triad – inflammation, hypercoagulability, and endothelial injury
• Symptoms – abrupt onset of chest pain, SOB, and hypoxia are classic symptoms
o Other – anxious, wheezing, hemoptysis, tachypnea, diaphoretic
• Diagnostics – CTA (PE protocol)

Question 2

PE Treatment

Answer 2

o Respiratory support
o Hemodynamic support – cautious IVF (can overload RV), levophed, ECMO?
o Anticoagulation
o Reperfusion
o Chronic phase – 3 months anticoagulation if provoked or indefinite anticoagulation if unprovoked (rivaroxaban, dabigatran, apixaban)

Question 3

Pulmonary Edema

Answer 3

 Excess fluid collects within the lungs, leading to impaired gas exchange and respiratory distress
 Cardiogenic causes – typically r/t volume overload – valve disorders, acute MI, left-sided HF
 Non-cardiogenic causes – typically r/t injury to endothelium – ARDS, PE, opioid overdose, TRALI
 Symptoms – acute dyspnea, anxiety, increased WOB, tachycardia, crackles, pink frothy sputum
 Treatment – reduce pulmonary fluids – oxygen (non-invasive or invasive helps reduce fluid in vasculature), loop diuretics, nitrates, inotropes

Question 4

Acute Respiratory Distress Syndrome (ARDS)

Answer 4

 An inflammatory lung condition caused by direct or indirect injury to the lungs (infection, trauma, hypotension)
 Diagnostic inclusion criteria – acute onset of: bilateral diffuse infiltrates not caused by pulmonary edema, PAWP/PCWP < 19, PaO2/FiO2 ratio of ≤ 200
 Treatment – treat underlying cause, support oxygenation and ventilation
 Initial vent management strategies – calculate predicted body weight, select vent mode, initial tidal volume of 8 ml/kg (will have to come down to 6 ml/kg), set initial RR at approximately baseline
 Goals of vent therapy – minimum PEEP of 5, plateau pressure ≤ 30
 Check plateau pressure every 4 hours – if > 30, decrease TV by 1 ml/kg (minimum of 4 m/kg), if < 25, increase by 1 ml/kg (until plateau pressure > 25 or TV is 6 ml/kg)
 Monitor pH – if pH 7.15-7.30 increase RR; if pH < 7.15 increase RR to 35 and consider increasing TV by 1 ml/kg until pH > 7.15; if pH > 7.45 decrease RR if able

Question 5

Respiratory Failure

Answer 5

 Hypoxemic – PaO2 < 60 mmHg and PaCO2 normal or < 50 mmHg
 Hypercapneic – PaO2 < 60 mmHg and PaCO2 > 45 mmHg
 Can be caused by numerous things – COPD, drug overdose, asthma, obesity, chronic bronchitis, rib fractures, neuromuscular disease, PE, ARDS, pulmonary edema, shunting
 Stable – treat underlying cause, aggressive respiratory care
 Unstable – BiPap or intubate, aggressive respiratory therapy, treat underlying cause

Question 6

Pneumothorax

Answer 6

 Can be caused by trauma (blunt is most common) or spontaneous (COPD, asthma, tall/thin males
 Air-trapping and increased pressure can cause mediastinal shift → compression of great vessels and heart (aka tension pneumothorax)
 Symptoms – acute onset of SOB, tachypnea, pleuritic chest pain, hyperresonance to percussion, absent breath sounds on injured side
 Tension pneumo findings – severe respiratory distress, signs of obstructive shock, hypotension, distended neck veins (late sign), tracheal deviation (late sign)
 Diagnostics – CXR is diagnostic of choice, will see air in the pleural space with absence of lung markings
 Treatment – needle decompression (first line for primary pneumo, minimal symptoms), chest tube placement (definitive treatment for those with symptoms)
 Tension pneumo treatment – emergent needle compression in 2nd ICS MCL followed by chest tube insertion

Question 7

Angioedema

Answer 7

• An allergic reaction that affects parts of the face like eyes and lips
• Symptoms – swollen face (especially eyes, mouth, lips, tongue), swelling in mouth, throat, or airway
• Management – ABCs!, a definitive airway must be established if edema is extensive or progressing; antihistamines (diphenhydramine, loratadine), H2 blockers (ranitidine or cimeditine), epinephrine, steroids

Question 8

COPD

Answer 8

• Airflow limitation that is not fully reversible
• Risk factors – tobacco smoke, environmental exposures, occupational exposures, genetics
• Symptoms – chronic cough, chronic sputum production, activity intolerance, symptom progression
• Individuals with COPD with a hx of ≥ 2 exacerbations in the last year, FEV1 < 50%, and/or hospitalization for COPD in the last year are at highest risk for COPD exacerbation and COPD death
• Diagnosis – spirometry is required – FEV1:FVC < 0.70 (70%) post-bronchodilator
• Severity of COPD is determined by FEV1 (GOLD category)
• Initial treatment – low risk/less symptoms – SABA; low risk/more symptoms – LABA + long-acting muscarinic antagonist (tiotropium [Spiriva])

Question 9

Indications for hospital admission in COPD exacerbation

Answer 9

• Marked increase in symptom intensity
• Acute respiratory failure
• New onset of physical signs
• Failure to respond to initial treatment
• Insufficient home support

Question 10

Indications for ICU admission in COPD exacerbation

Answer 10

• Severe dyspnea not responding to initial therapy
• Change in mental status
• Worsening hypoxemia (PaO2 < 40 mmHg)
• Worsening acidosis (pH < 7.25)
• Invasive mechanical ventilation

Question 11

GOLD categories for COPD

Answer 11

• GOLD 1 (mild): FEV1 ≥ 80%
• GOLD 2 (moderate): 50% ≤ FEV1 < 80% predicted
• GOLD 3 (severe): 30% ≤ FEV1 < 50% predicted
• GOLD 4 (very severe): FEV1 < 30% predicted

Question 12

COPD Exacerbation

Answer 12

• Symptoms – chronic symptoms increase – cough increases in frequency and severity, sputum production increases in volume or changes, dyspnea increases
• Exam findings – diffuse wheezing, tachypnea, features of respiratory distress (pursed lip breathing, accessory muscle use), signs of impending respiratory arrest
• ABG: PaO2 < 40 mmHg or PaCO2 >45 and pH < 7.35 indicates respiratory failure
• Treatment – SABA (albuterol), corticosteroids (prednisone 40 mg daily x5 days), +/- mechanical ventilation, +/- antibiotics
• Give antibiotics if – increased dyspnea, sputum production, and/or increased sputum purulence; and give to anyone mechanically vented
• Antibiotics to give – azithromycin 500 mg BID x3 days, cephalosporin, or Cipro if vented (500-750 mg BID x 7-14 days)

Question 13

Asthma

Answer 13

• Bronchial hyper-responsiveness and underlying inflammation
• Symptoms – recurrent cough, wheeze, SOB, chest tightness, symptoms can worsen at night or with exercise, airflow obstruction is partially reversible after SABA
• Diagnosis – spirometry is needed to make diagnosis – increase in FEV1 ≥ 12% from baseline after SABA
• Peak flow meter is used for monitoring
• Treatment consists of SABA (acute reliever) + controller for persistent asthma (inhaled corticosteroid – fluticasone, bedusonide))
• Step-up therapy if not well controlled on current regimen

Question 14

Asthma Exacerbation

Answer 14

• Moderate – dyspnea interferes with usual activity, peak flow 40-69%, requires provider evaluation, SABA, systemic corticosteroids (prednisone 40-60 mg/day x 3-10 days [average 5-7 days])
• Severe – dyspnea at rest, to ED, likely hospitalization, peak flow < 40%, SABA + systemic corticosteroids + adjunct therapies
• Warning signs of impending respiratory arrest – confusion, absence of wheezing, bradycardia, paradoxical thoracoabdominal movement, peak flow < 25%

Question 15

Interstitial Lung Disease

Answer 15

• Lung tissue becomes damaged and scarred, thick/stiff lung tissue
• Risk factors – environmental toxins (ex: pesticides, asbestos), agriculture and farming, sand/silica, genetics (RA, sarcoidosis), medication-induced (nitrofurantoin, chemo [bleomycin])
• Symptoms – CHRONIC EXERTIONAL DYSPNEA, CHRONIC DRY COUGH, fatigue, bilateral Velco-like crackles, clubbing of nails
• CXR – may look normal in early stages and may progress to reticulonodular infiltrates (ground glass)
• CT – diagnostic of choice, “HONEYCOMBING” is characteristic of pulmonary fibrosis
• Acute management – high dose steroids, antitussives, and antibiotics are ineffective but are still the mainstay of treatment; ABCs – supplemental O2; anxiolytics/morphine

Question 16

Sleep Apnea

Answer 16

 Caused by narrowing of respiratory passages
 Risk factors – anatomically narrowed upper airways, obesity, alcohol use, sedative use, nasal obstruction
 Symptoms – daytime sleepiness, headaches, fatigue, snoring, breath cessation, inability to concentrate, nocturnal gasping/choking
 Exam findings – large tonsils, long uvula, prominent tongue, poor nasal air flow, “bull neck” appearance
 Diagnostics – POLYSOMNOGRAPHY may show apneic episodes, desaturations, brady- or tachyarrhythmias
 Management – CPAP (FIRST LINE), WEIGHT LOSS, avoid alcohol, surgery, inspire devices
 STOP BANG questionnaire

Question 17

STOP BANG Questionnaire for OSA

Answer 17

	Snoring – do you snore loudly?
	Tired – do you often feel tired during the day?
	Observed – has anyone observed you stop breathing during sleep?
	Pressure – do you have HTN
	BMI – BMI > 35
	Age – age > 50
	Neck circumference - > 40 cm  
	Gender – male 
	< 3 yes answers = low risk for OSA
	≥ 3 yes answers = high risk for OSA

Question 18

Pleural Effusion

Answer 18

 Transudate (“water”) vs. exudate (“cellular material”) effusion
 Transudative – CHF, constrictive pericarditis, cirrhosis
 Exudative – lung parenchymal infection, malignancy, PE
 Symptoms – dyspnea, cough, chest pain (stabbing or sharp, worse with deep inspiration), decreased tactile fremitus, eogphony
 Diagnostic – thoracentesis is diagnostic study of choice for all effusions > 1 cm
 Fluid comparison – transudative (specific gravity < 1.016, protein < 3.0, LDH < 200) vs. exudative (specific gravity > 1.016, protein > 3.0, LDH > 200)
 Treatment – if known to be from fluid overload (CHF or cirrhosis) try diuresis; for symptomatic effusions perform therapeutic thora +/- thoracostomy tube and treat underlying process; for infections effusions treat with antibiotic therapy

Question 19

Pulmonary HTN

Answer 19

 Symptoms – dyspnea, fatigue, dizziness, chest pain, palpitations; chronic pulmonary HTN – loud S2, JVD, tricuspid regurg murmur, peripheral edema
 Exam findings – pulmonic regurg (Graham Steele murmur), tricuspid regurg, JVD, S3 gallop, hepatomegaly
 TTE – initial investigation of choice
 Right heart catheterization – diagnostic
 Management – ICU monitoring, oxygen, hemodynamic optimization (norepi +/- vaso), fluid optimization (diuretics +/- UF/CRRT), pulmonary vasodilators (inhaled nitric oxide), phosphodiesterase inhibitors (sildenafil, tadalafil), consult pulmonology

Question 20

Community-Acquired Pneumonia

Answer 20

• Most common pathogens – strep. pneumoniae (#1), H. influenzae (#2)
• Recommended length of therapy – at least 5 days with evidence of increasing stability (average 5-7 days)
• Treatment (no comorbidities) – macrolide (azithromycin, clarithromycin or erythromycin) or doxycycline
• Treatment (+ comorbidities [i.e., COPD, DM, renal or heart failure]) – Levaquin or macrolide (azithromycin) + amoxicillin-clavulanate [Augmentin]

Question 21

CURB-65 Criteria for CAP Hospitalization

Answer 21

• Confusion – any change from baseline or confusion
• Uremia – BUN > 19
• Respiratory rate – RR > 30
• Blood pressure – SBP < 90 and DBP < 60
• 65 years old – age ≥ 65 years
• Scores: 1 = outpatient treatment, 2 = admit to inpatient, ≥ 3 = admit to ICU

Question 22

PSI/PORT Scoring for Hospitalization

Answer 22

• 0 = class I, outpatient treatment
• < 70 = class II, outpatient treatment
• 71-90 = class III, outpatient or inpatient treatment
• 91-130 = class IV, inpatient treatment (ICU?)
• > 131 = class V, inpatient treatment (ICU?)

Question 23

Empyema

Answer 23

• Collection of pus in the space between the lung and the inner surface of the chest wall
• Usually caused by lung infection
• Risk factors – bacterial pneumonia, TB, chest surgery, lung abscess, chest trauma
• Symptoms – chest pain (worse with deep breath), dry cough, excessive sweating
• Treatment – chest tube to drain pus, antibiotics to control infection

Question 24

Hospital-Acquired Pneumonia

Answer 24

• Low risk mortality risk and no MRSA risk factors – many options; choose one, Zosyn 4.5g IV q6h, Levaquin 750 mg IV daily, plus many more
• Risk of MRSA – Zosyn 4.5 IV q6h or Levaquin 750 mg IV daily + vancomycin 15 mg/kg IV q8-12h
• High risk of mortality – Zosyn 4.5g IV q6h + Levaquin 750 mg IV daily + vancomycin 15 mg/kg IV q8-12h
• Duration of therapy – follow procal levels, discontinue when PCT ≤ 0.25 (generally 8 days for non-MRSA, 14 days for MRSA)
• Tailor therapy to culture results

Question 25

Ventilator-Associated Pneumonia

Answer 25

• Same pathogens as HAP but with higher likelihood of pseudomonas and MRSA
• Treatment consists of choosing 3 – Vanco 15 mg/kg + β-lactam (Zosyn 4.5g IV or cephalosporin 2g IV q8h) + non-β-lactam (Levaquin 750 mg IV daily or ciprofloxacin 400 mg IV q8h)
• Prevention is key – prevent intubation, good hygiene, good oral care, etc.
• Duration of therapy – follow PCT, discontinue therapy when PCT ≤ 0.25

Question 26

Aspiration Pneumonia

Answer 26

• Likely pathogens for pneumonia – staph. Aureus, hemophilus, and strep
• Risk factors – cognitive impairment, pulmonary disease (on vent., poor cough), mechanical (NG, OG, trach., tube feeds)
• Manifestations – coughing, SOB, chest pain, feels like something is stuck, hypoxia, rhonchi, rales, respiratory distress
• Management – ABCs, prophylactic antibiotics until definitive evidence of no infection, using cuffed ETT, utilize speech therapy, prevention

Question 27

Lung Contusion

Answer 27

• Injury to lung parenchyma
• Consequence of blunt chest trauma
• Develops over the first 24 hours
• Symptoms – chest wall pain, dyspnea, tenderness of palpation, paradoxical chest wall excursion, signs of ventilatory insufficiency (cyanosis, tachypnea, accessory muscle use)
• Diagnostics – CXR, monitor for “blossoming”
• Treatment – ABCs, supportive care (pulmonary hygiene, pain control), O2, intubation or mechanical ventilation, monitor for complications (ARDS, pneumonia)

Question 28

Rib Fracture

Answer 28

• Most common injury sustained following blunt chest trauma
• Symptoms – pain, dyspnea, tenderness to palpation, crepitus, chest wall deformity, paradoxical chest wall excursion (textbook finding with flail chest)
• Management – ABCs, multimodal pain control (ex: Tylenol, gabapentin, lidocaine patches, flexeril, etc.), aggressive pulmonary hygiene (incentive spirometry, cough and deep breath, mobility), consult trauma surgery for potential operative fixation, thoracostomy tubes as indicated

Question 29

Hemothorax

Answer 29

• Blood accumulation in pleural space typically caused by some form of traumatic injury (penetrating trauma is more common than blunt)
• Symptoms – dyspnea, tachypnea, pleuritic chest pain, dullness to percussion, decreased breath sounds on injured side
• Diagnostics – CXR is diagnostic study of choice (blood in pleural space = white out)
• Treatment – chest tube placement (wall suction → water seal → discontinue) with follow-up CXR