Respiratory Flashcards
1
Q
How much do you expect pH to decrease with increase in CO2?
A
decrease 0.08 for every 10 mmHg CO2 rise
2
Q
Infectious insult + Impaired bacterial clearance = dyspnea, hemoptysis, daily mucopurulent sputum, crackles, wheezing
A
Bronchiectasis
3
Q
Etiologies of bronchiectasis
A
- cancer (airway obstruction)
- autoimmune (RA, Sjogrens)
- Aspergillosis, TB
- Hypogammaglobulinemia
- CF, a1at def (congenital)
4
Q
most common causes of digital clubbing
A
- Cystic Fibrosis
- Lung Malignancies
- R to L cardiac shunts
5
Q
most common adverse effect of inhaled steroids
A
oral thrush
6
Q
Triad in obesity hypoventilation syndrome
A
- obesity
- hypercapnia (daytime)
- alveolar hypoventilation (hypoxmia/resp acidosis)
7
Q
causes of transudate pleural effusions
A
CHF
Cirrhosis
Nephrotic Syndrome
Peritoneal dialysis
8
Q
causes of exudative effusions
A
Infections
Malignancy
Pulmonary Embolism
Connective tissue dz
Inflammatory dz
Fluid from abdomen
CABG
9
Q
Light’s criteria for exudative effusions
A
Having at least 1 of the following
Pleural fluid/serum ratio’s:
- -Protein >.5
- -LDH>.6
- -Pleural Fluid LDH > 2/3 of upper limit normal serum LDH
10
Q
most common cause of pleural effusion
A
CHF (and thus transudative)
11
Q
pt has severe asthma exacerbation with impending resp distress. why is a normal/elevated CO2 a poor sign?
A
asthma exac causes hyperventilation/increased resp drive = decreased CO2. if elevated/normal, shows respiratory muscle fatigue –> inability to meet respiratory demands.
–>these patients require intubation
12
Q
whats the difference between enoxaparin, rivaroxaban, and fondaparinux?
A
Enoxaparin = LMWH Rivaroxaban = Oral Factor X inhibitor Fondaparinux = Injection Factor X inhibitor
None of these can be used in patients with poor renal f(x), use unfractionated heparin instead
13
Q
Why do you need a heparin bridge before warfarin?
A
Warfarin inhibits Protein C and S, which are anti-thrombogenic..= state of thrombosis (heparin is anti-thrombin)
14
Q
Criteria for ARDS (4)
A
- Acute onset (<1 week)
- Bilateral infiltrates on chest imaging
- Pulm edema not explained by fluid overload or CHF (i.e. PCWP <18) –>NONCARDIOGENIC PULM EDEMA
- Abnormal PaO2/FiO2 ratios (<300)
15
Q
Pathophys behind ARDS
A
Massive Intrapulmonary shunting of blood, secondary to atelectasis, alveolar collapse and surfactant dysf(x)
–> Increase in lung fluid = stiff lungs, A-a gradient, ineffective gas exchange
16
Q
Severe hypoxemia that does not improve on 100% oxygen
A
ARDS
17
Q
an increase in ____________ causes ARDS, vs _____ causes cardiogenic pulmonary edema
A
Alveolar capillary permeability (ARDS)
Congestive Hydrostatic Forces (CHF/HF)
18
Q
T/F: ARDS will have increase in lung fluid and signs of JVD, edema, hepatomegaly
A
False. ARDS will have increase in lung fluid without any of those cardiogenic signs
19
Q
Patients with _____ have the highest risk of developing ARDS
A
sepsis/septic shock
20
Q
T/F: Pulmonary vasodilators (nitroprusside) help improve tissue oxygenation
A
False…they should be removed in states of hypoxia
21
Q
Does ARDS have respiratory alkalosis or acidosis?
A
Initially have Alkalosis (PaCO2 <40), which switches to acidosis as the work of breathing increases and thus PaCO2 rises
22
Q
what is the most useful parameter in distinguishing ARDS from cardiogenic pulmonary edema?
A
PCWP…this refelcts Left heart filling pressures and indirect marker of intravascular V status….<18 points to ARDS
23
Q
MAP> ____ (at rest) = Pulm HTN
A
25
24
Q
clinical signs of pulmonary htn
A
- Loud P2 (pulmonic component of S2)
- Subtle lift of sternum (RV dilatation)
- if RV failure occurs, will show JVD/hepatomeg/edema etc
25
how will EKG/Echo help assist in dx of Pulm HTN?
Pulm HTN can lead to RV failure...
-EKG will show RV hypertrophy (Right axis deviation/right atrial abnormality)
-ECHO = dilated pulm artery, dilatation of RA and RV, abnormal movement of ventricular septum
26
which vasoactive agents can be used in tx of PAH (after R heart cath and trial of vasodilators tried first)
They lower pulm vascular resistance
- PDE inibitors (sildenafil)
- CCB
- Prostacyclins (Epoprostenol)
- Endothelin receptor antagonists (bosentan)
27
what is cor pulmonale usually secondary to?
COPD!
Defined as RV hypertrophy/failure from pulm htn secondary to pulm disease
PE/Asthma/CF/OSA/ILD also can cause it
28
Clinical features of cor pulmonale
- decrease exercise tolerance
- Cyanosis and digital clubbing
- RV failure (JVD, edema, hepatomegaly)
- Parasternal lift (RV dilatation)
29
why is there tachypnea in PE ?
PE causes dead space in areas of the lung because there is ventilation but no perfusion (dec blood flow)
--> causes Hypercarbia and Hypoxemia, which drive respiratory effort
30
T/F: Most often, PE is clinically silent
True
| -->Recurrences are common, leading to chronic pulm HTN and cor pulmonale
31
What causes most PE-related deaths?
Recurrent PE within first few hours of inital PE...tx with anticoagulatns decreases mortality
32
Signs of PE
-Tachypnea, Rales, Tachycardia, S4, Increased P2
33
PaO2 and PaCO2 levels in PE?
Both are low...PaCO2 is low due to hyperventilation (because dec perfusion= hypoxemia and hypercarbia = stimulation to respiratory drive)
=Resp ALKalosis
34
Initial study of choice for PE
CTa (spiral ct)...only contraindicated if renal dz, for whom V/Q scan works well
Pulmonary angiography = gold standard, but is invasive (rarely performed)
35
PE clinically likely, do a ______study
| PE clinically unlikely, do a ______ study
likely: Spiral CT. if inconclusive, LE ultrasound
Unlikely: D-Dimer. If abnormal, Spiral CT
36
what should you consider as long term prevention in a patient who had PE but has CI to anticoagulation
IVC filter
37
Tx for PE
1. Heparin drip: start as soon as their is any clinical suspicion (prevent recurrent PE)
2. Oxygen
3. Consider thrombolytic therapy (not always given tho)
4. Consider IVC filter if anticoag CI
38
where is aspiration most likely to go?
lower portion RUL
| upper portion of RLL
39
most common causes of acute dyspnea
```
CHF exacerbation
pneumonia
bronchospasm
PE
anxiety
```
40
causes of high DLCO
- Asthma (increases pulm capillary blood V)
- Obesity
- Intracardiac L-R shunt
- Exercise
- Pulmonary hemorrhage
41
causes of low DLCO
- Emphysema
- Sarocoidosis
- Fibrosis
- Pulmonary vascular dz
- Anemia (reduced binding of CO to Hgb)
42
For every 10mm Hg change in PaCO2, there should be a change in pH by ___
.08
- if change is in same direction as change in PaCO2, its metabolic
- if inverse, respiratory
43
T/F: Restrictive dz has reduced FEV1 and reduced FEV1/FVC ratio
False.
Restrictive has reduced FEV1.
However, ratio is actually normal or increased because of FVC decrease
44
signs of ILD
- Inspiratory crackles, digital clubbing
- Progressive exertional dyspnea, persistent dry cough
- CXR = reticular/nodular opacities
45
Pulmonary function tests in ILD
- normal or increased FEV1/FVC
- decreased DLCO
- decreased TLC
- decreased RV
will also see increased A-a gradient
46
What is the pathophys behind changes to A-a gradient and DLCO in ILD (i.e. pulmonary fibrosis)?
Get peri-alveolar collagen deposition
| =decreased gas exchange (A-a) and reduced diffusion capacity of CO
47
Tx of SIADH
FLUID RESTRICTION +/- salt tablets
| Hypertonic saline is only used for severe hyponatremia (sxs of coma, seizure, etc)
48
Progressive exertional dyspnea + dry cough
```
ILD
ILD
ILD
ILD
ILD
ILD
ILD
ILD
```
49
Low FEV1/FVC ratio + increased or decreased DLCO
Low ratio = Obstructive dz
Increased DLCO = Asthma (inc. pulm capillary blood V)
Decreased DLCO = COPD
50
Normal/high FEV1/FVC ratio + increased or decreased DLCO
Normal/high ratio = Restrictive dz
Increased DLCO = Chest wall weakness
Decreased DLCO = ILD
51
why is there pulmonary hypertension in ARDS?
hypoxic vasoconstriction
52
2 ways by which oxygenation can be improved in ARDS pt
1. Increasing fraction of inspired O2 (FiO2)
2. PEEP (via mechanical ventilator)
-->You want to wean FiO2 to <60% asap to avoid risk of oxygen toxicity (free radicals), so once you're higher than this you should increase PEEP
53
most common trigger of COPD exacerbation
URI
54
Why is FVC decreased in COPD
Air Trapping due to progressive airflow limitation
55
solitary nodule > ____ likely malignancy
2cm
56
most common primary lung cancer in smokers and nonsmokers
Adenocarcinoma
57
non-allergic vs allergic rhinitis
Allergic: predom eye sxs, itching, sneezing, identifiable triggers
NAR: Predominant nasal congestion w/o obvious triggers. antihistamine or glucocorticoids.
58
in patient tx for CAP (esp in pt >65)
Fluoroquinolone or beta lactam/macrolide (cef/azithro)
59
Name the mediastinal mass by location:
- Anterior mediastinum
- Middle
- Posterior
Anterior: THYMOMA, retrosternal thyroid, teratoma
Middle: Bronchogenic Cyst, Aortic arch aneurysm
Posterior: all neurogenics i.e. neuroblastoma, esophageal tumor
60
t/f: panacinar emphysema of a1-antitrypsin def is present diffusely throughout the lungs
false, it is predominantly in the lower bases (vs smoking emphysema which is in upper lobes). Presents in 30-40s
61
Whats the next step if you suspect CAP based on sxs (few days of fever, cough, and crackles on exam)?
Need CXR to make dx!! Then you can do empiric antibiotics (don't need cultures)
62
3 most common causes of chronic cough
1. Upper-airway cough syndrome (POSTNASAL DRIP)
- ->responds to anti-histamines
2. Asthma
3. GERD
63
Simple rule of thumb for pleural effusions (exudative vs transudative)
Transudative: Organs failure...heart (chf), liver (cirrhosis, low albumin), lung (PE, atelectasis), kidneys (nephrotic, low albumin)
Exudative: Infectious, Cancerous (ICE ICE Baby)
64
If someone has a parapneumonic effusion, what should you be looking out for?
Empyema. Look for a pt who has received antibiotics but continues to be ill.
65
Empyema vs parapnuemonic effusion
- pH
- Glucose
- Protein
- wbcs
Parapneumonic: Glucose dec, protein inc, pH >7.2, wbc <50k
Empyema: Glucose dec, protein inc, pH <7.2, wbc >50k
66
orthostatic hypotension usually presents in elder patients, due to _______ ; which lab value should you follow?
```
Hypovolemia
Urine Na (hypovolemia = dec renal perfusion = RAAS = decreased urine Na)
```
67
classic triad of fat emboli
Hypoxemia
NEURO dysf(x)
RASH
68
Why would an asthmatic have elevated wbc's after an acute exacerbation?
Most likely will get some glucocorticoid therapy, which causes leukocytosis (by released marginated neutrophils)
69
most common complications of PEEP (i.e. pt in ARDS put on PEEP)
PNEUMOTHORAX
ALVEOLAR DAMAGE
HYPOTENSION
70
t/f: you suspect PE in a pt, next step is CTa
False, next step is heparin drip! and then CTa
71
CT findings PE
WEDGE SHAPED infarction = pathogneumonic (don't call it cancer kid!)
72
describe why R-L intrapulmonary shunting occurs with pneumonia
Alveoli filled with inflammatory exudate = impaired alveolar ventilation in that portion of lung = R to L shunting, meaning perfusion of lung tissue in absence of alveolar ventilation (extreme V/Q mismatch)
-->characteristically cannot improve hypoxemia with increased FiO2 (due to shunting)
73
Patient with urticaria and acute-onset difficulty breathing
Laryngeal Edema = Upper Airway Obstruction!!! aka allergic rxn son
74
Features that make a solitary pulmonary nodule more likely to be malignant
- pt's age (>50)
- hx of smoking
- >2cm
- Irregular borders
- Eccentric asymmetric calcification (vs dense, central calcification = benign)
- enlarging
if suspicious for malignancy, BIOPSY/RESECTION
low probability: serial CT scan
Intermediate probability nodule 1cm or larger: PET scan
75
initial mgmt of acute COPD exacerbation
short acting bronchodilator, glucocorticoids, antibiotic
| -->if sxs persist, go to Non-invasive PPV (facemask support instead of intubation)
76
pathophys behind atelectasis causing pleural effusion
Decreased intrapulmonary effusion (transudative)
other transudative pathophys = increased hydro P (CHF) or dec plasma oncotic p (nephrotic)
77
what is a positive bronchodilator test for asthma (quantitatively)?
>12% improvement of FEV1 post-bronchodilator
78
T/F: Breath sounds and tactile fremitus are decreased with consolidation and pleural effusion
False!
They are increased with consolidation
They are decreased with pleural effusion
79
Examples of resonance, dullness, and hyperresonance with percussion of lung
Resonant: Normal Lung
Dull: Consolidation, Pleural Effusion, Atelectasis (mucus plugging)
Hyperresonant: Emphysema, Pneumothorax
80
3 clinical sxs of asbestosis
Progressive dyspnea
Digital Clubbing
End-inspiratory crackles
81
PFT of asbestosis
Restrictive pattern: decreased lung volume, decreased DLCO, normal FEV1/FVC
82
Cancer in asbestos patient
Bronchogenic cancer >>>>> Mesothelioma
83
Major difference btwn chronic bronchitis and bronchiectasis (both have coughing up of mucus)
CB: Mucus narrows the airways. Seen in smokers, older age.
Bronchiectasis: persistent, abnormal dilation of bronchial walls. Might be a younger patient who doesn't smoke, signs of cystic fibrosis
84
most common cause of hemoptysis
Bronchitis lmao fam
85
In acute COPD exacerbation, do you use inhaled or systemic glucocorticoids?
Systemic!
Inhaled steroids are for long-term albuterol tx; for COPD, dec exacerbation frequency/sxs for do not play a role in acute exacerbation.
86
cardinal sxs of acute COPD exacerbation
increased dyspnea
increased cough
sputum production (change in volume/color)
-->give antibiotics if at least 2 of these present
87
T/F: Secondary malignancy is common in patients with Hodgkins lymphoma tx w/chemo and radiation
True
88
Where does an aspergilloma collect/form?
Previous cavitary lesion
89
Assist Control (AC) mode delivers a predetermined ____ ____ with every breath
Tidal Volume (6ml/kg body wt)
90
Hemoptysis + chest pain on inspiration in patient on OCP and recent travel
Pulmonary Embolism (with likely pulm infarction)
91
Fever, chest pain, and hemoptysis with pulmonary nodules with ground-glass opacities surrounding
```
Invasive aspergillosis (non-cavitary lesion; seen in transplant, immunocomp, or AIDS patients)
-->CT findings = Halo Sign
(PCP unlikely with hemoptysis)
```
92
lots of cough with production of sputum. How can you tell based on responsiveness to medications and smoking status if its bronchitis or bronchiectasis?
Bronchitis is usually exacerbated by viral infections. Usually a smoker.
Bronchiectasis is usually from recurrent bacterial infections and is responsive to antibiotics. usually a non-smoker.
93
T/F: CXR is the best dx test for bronchiectasis
False, need high-resolution CT.
CXR will show linear atelectasis, dilated/thickened airways, irregular peripheral opacities.
94
Increased permeability of the right hemidiaphragm in cirrhosis patients leading to pleural effusion =
Hepatic hydrothorax
95
low glucose concentrations in empyema are due to:
high metabolic activity of wbcs and/or bacteria
96
Empyemas and parapneumonic effusions are _____ effusions
exudative
97
_________ effusions are due to pleural and lung inflammation
Exudative
98
Patients with COPD are candidates for home oxygen therapy when:
SaO2<88% or PaO2<55mmHg
99
Obesity and malignancy as risk factors for _______ in a patient with dyspnea and chest pain
Pulmonary Embolism
100
carcinoma in the apex of the lung that can lead to shoulder/arm pain, hoarseness, and Horner's syndrome
```
Pancoast tumor (Superior sulcus tumor)
-->typically a squamous cell lung cancer or adenocarcinoma (SMOKERS)
```
101
Why would a patient treated for acute asthma exacerbation develop muscle weakness and tremors?
Beta-agonists (albuterol) can cause hypokalemia = muscle weakness, EKG changes, arrythmias, tremors, palpitations, HA
102
JVD and RBBB on EKG developing few days after operation
Massive pulmonary thromboembolism...PE causing Right heart failure
103
noncardiogenic pulmonary edema
ARDS
104
causes of ards
- infection
- trauma
- transfusion
- pancreatitis
105
tx of ARDS
ventilation: high PEEP, low tidal volume, high FiO2
106
what is cough in ACE-I due to?
increased substance P, kinins, PGs, Txa2
107
T/F: Consolidation presents with decreased breath sounds, dullness to percussion
False, dullness to percussion but INCREASED breath sounds...will hear egophany, tactile fremitus etc
108
PE findings of consolidation vs pleural effusion vs pneumothorax
Consolidation: breaths sounds inc; tactile frem inc; dull
effusion: dec/absent breath sounds; dec tf; dull
pneumo: dec/absent breath sounds; dec tf; hyperresonant
109
PE findings of emphysema and atelectasis (mucus plugging)
Emphysema: breath sounds dec; tactile frem dec; hyperresonant
Atelectasis: breath sounds dec; tf dec; dull
110
lung cancer, gynecomastia, galactorrhea
large cell
111
T/F: JVD on expiration = kussmaul sign = constrictive pericarditis/RCM
False. Kussmaul = jvd on INSPIRATION. JVD on expiration seen in COPD etc
112
T/F: Infusion of saline may worsen hyponatremia in a patient with SIADH
True (tx is usually fluid restriction)
113
Why do we tx ARDS patients (tx: ventilation with PEEP) with the tidal volume low?
Low tidal volume prevents overdistention of the alveoli ( a complication of ventilation). this improves mortality
114
T/F: Pleuritic chest pain is not a feature of pneumonia
False
115
signs of invasive aspergillosis
-Triad: Chest pain, Fever, Hemoptysis
-Imaging: Solitary nodule with halo sign
cell markers (beta-d-glucan, galactomannan)
116
causes of low DLCO
Obstructive: Emphysema
Restrictive: ILD; sarcoid, asbestosis, HF
Normal: anemia, PE, Pulm htn
117
causes of high DLCO
Obstructive: Asthma (can also be normal)
Restrictive: obesity
Normal: pulm hem; polycythemia
118
normal DLCO
Obstructive: chronic bronchitis, asthma
restrictive: MSK deformity; neuromuscular dz
119
Smoker with productive cough, DOE, PFT: dec FEV1, normal FVC, dec ratio, normal DLCO
Chronic bronchitis
120
Why is DLCO normal in chronic bronchitis?
DLCO measures gas exchange btwn alveoli and pulm capillaries. CB has no destruction of alveoli (vs emphysema).( However, CB patients may have worse hypoxemia than E. )
121
Why is DLCO low in emphysema?
DLCO measures gas exchange btwn alveoli and pulm caps. Emphysema causes destruction of alveolar walls, so decreased diffusion capacity.
122
CXR dif btwn emphysema and chronic bronchitis
Emphysema: Hyperinflated lungs, dec lung markings
CB: Flattened diaphragm, inc lung markings
123
T/F: CB is associated with more predominant mucus production than bronchiectasis
False, my mneumonic for CB is misleading. Bronchiectasis is associated with literally buckets of mucus, CB can have mild production
124
Low FVC (due to airway destruction from repeated infx), dilated conducting airways on CXR, chronic recurring and resolving episodes of lung infection with high amounts of sputum. May have hemoptysis/fever/clubbing
Bronchiectasis
125
Shoulder pain and Horner's in a smoker
Pancoast
126
what are the features of a pancoast tumor?
- horners
- shoulder pain
- c8-t2 involvement: weakness/atrophy of intrinsic hand muscles; pain/paresthesias of 4th/5th digits, medial arm and forearm
- Supraclavicular LN
- weight loss
127
elevated right atrial pressure, elevated pulmonary artery pressure, normal PCWP in a patient presenting with chest pain/shock/syncope
PE
128
Wells criteria for PE
+3: signs of DVT
+1.5: hx of PE/DVT; HR>100; recent surg/immob
+1: Hemoptysis; cancer
>4: PE likely
129
Empyemas are ___ pleural effusions with ____ glucose due to _____
exudative; low; wbc activity/bacteria
130
Patient has DOE and CXR shows pleural effusion. What's the dx standard and when would you do something different?
Diagnostic thoracentesis --> determine whether it is transudative (tx underlying cause) or exudative.
Only time you don't do this is if you suspect CHF...then, you do ECHO and trial of diuretics.
131
3 biggest causes of malignant pleural effusions (exudative)
Lung carcinoma, Breast carcinoma, Lymphoma
132
T/F: Next best step in all pleural effusions = diagnostic thoracentesis
False. This is USUALLY the best next step.
| Exception: if the patient has CHF, you do ECHO and diuretics instead
133
T/F: A patient with 6months of productive cough with mucus and obstructive PFTs likely has chronic bronchitis
False. Need at least 3 consecutive months in 2 successive years
134
When should you consider A1AT def?
- young patient with COPD
- COPD with minimal smoking hx
- FHx of emphysema or liver dz
- ->LFTs may not be elevated until very late in the dz so don't be a peasant
135
airway hyperreactivity is associated with:
asthma
136
3 most common causes of chronic cough (>8 weeks)
1. Post-nasal drip (upper-airway cough syndrome), i.e. allergic rhinitis etc. Improves with H1 blockers (chlorpheniramine)
2. Asthma
3. GERD
137
what kind of pleural effusions does a PE cause?
Exudative...usually hemorrhagic or inflammatory. Grossly bloody and painful.
138
Asthmatic patients typically have a respiratory ______, with ____pCO2
alkalosis; low pCO2 due to hyperventiilation
| -->elevated/normal pCO2 indicate increasing severity
139
Assist control ventilator mode determines a predetermined ____ with every breath
```
tidal volume (should be 6ml/kg body wt)
-->patient can breathe on their own, but if they don't have a minimum resp rate, then that tidal volume is delivered
```
140
development of digital clubbing and joint pain (acute onset) in a smoker
Hypertrophic osteoarthropathy (get a CXR). Usually ass. w/underlying lung dz like lung cancer, TB, bronchiectasis, emphysema etc
141
T/F: All pleural effusions need drainage (i.e. chest tube)
False.
Small ones do NOT need therapy. Use diuretics...especially if CHF related
Large ones , especially infection related (parapneumonic/Empyema!) need a chest tube
142
What are the options for a recurrent pleural effusion despite chest tube drainage?
Pleurodesis: infuse irritative agent (bleomycin/talcum powder)
Decortication: stripping of pleura from lung
143
Exudative pleural effusion with low pH (<7.2) and low glucose (<60)
Parapneumonic or Empyema
144
uncomplicated vs complicated parapneumonic pleural effusions (exudative)
Un: pH>7.2, Glucose >60, wbc <50K, Tx = ABx
C: pH<7.2, Glucose <60, wbc>50k, Tx= drainage (chest tube) and ABx
145
T/F: Wedge shaped infarct on imaging = PE
True
146
most common tumors causing Pancoast (superior sulcus) tumor
Squamous cell
| Lung adenocarcinoma
147
T/F: COPD decreased total lung volume, functional residual capacity, and residual volume
false, it actually increases all of these (think increased AP diameter)
148
Patient with a hx of asthma/chronic sinusitis w/nasal polyps should be careful of _______ potentially causing ____-exacerbated respiratory disease
Aspirinx2, causes nasal congestion/bronchospasm. Avoid NSAID, give LT-R blockers (montelukast)
149
T/F: In a patient with a hx of asthma and current episode of respiratory distress, absence of wheeze is a positive sign
False, sign of impending resp failure
150
What levels of FiO2 do you not really want to be above?
Worried about oxygen toxicity when >60%. It can be higher but wean down to below this asap. If patient is having problem with oxygenation, increase PEEP instead.
151
A-a gradient bullshit
PAO2 = 150 - (PaCO2/.8)
PAO2 - PaO2 = A-a gradient: normal is 10-15.
Increased A-a = V/Q mismatch (PE is a big one), R-L shunt, diffusion limitation
Normal A-a and hypoxemia= hypoventilation, altitude
152
Tx for hospitalized CAP patient
```
Either:
1. Beta lactam + Macrolide
(ceftriaxone + azithromycin)
or
2. Fluoroquinolone (moxifloxacin)
```
153
how do you decide if CAP patient needs hospitalization?
```
Confusion
Urea>20
RR>30
BP<90/60
65: (age older than this)
Score 0 = outpatient
1-2 = likely inpatient
3-4 = urgent inpatient possibly ICU
```
154
What does pulmonary infarction in the setting of PE cause?
Pleuritic pain and hemoptysis (through inflammation and occlusion of peripheral artery)
155
complications of positive pressure ventilation
- alveolar damage
- PNEUMOTHORAX
- hypotension
156
Post-op patient with hypotension, distended JVP, and new-onset RBBB
PE
157
T/F: PE patients usually have tachypnea, tachycardia and hypoexmia, sometimes have loluidw grade fever
true
158
T/F: Pulmonary contusion is made worse by fluids/intravascular volume expansion
true
159
Someone comes in with suspected PE. What do you do?
1: supportive stuff (oxygen, fluids)
2: assess for absolute CI to anti-coagulation (active bleeding, recent hemorrhagic stroke)
- ->if yes, do dx testing and then IVC filter
3. No CI then proceed by Wells criteria
- ->low prob of PE: Do dx'ic testing
- ->if PE likely, you don't wait for a CT you give anticoagulation now
160
How could blood gases help you distinguish COPD exacerbation from CHF?
COPD: Respiratory ACIDOSIS and hypoxia
CHF: Respiratory alkalosis, hypocapnia and hypoxia
161
Why does your cystic fibrosis patient bruise easily?
Pancreatic insuff --> Vit k defic
162
Chronic nasosinopulmonary infxs, digital clubbing, bronchiectasis, and nasal polyps
Either CF or Kartegeners.
Specifics:
CF = FTT and panc insuff, infertility b/c absent vas def
K: situs inversus, infertility b/c immotile sperm
163
exudative effusion from disruption of the lymphatic flow in the thoracic duct
chylothorax (lots of TGs and leukocytes)
164
what is the first fucking thing youre going to do in a patient with asthma and they provide ABG?
Check to see if he has hypercarbia and need to intubate the fuck out of him
165
Restrictive lung dz: decreased DLCO vs normal
decreased: ILD
normal: chest wall weakness
166
patchy alveolar infiltrate (not necessarily in the anatomical borders), tachypnea/tachycardia/hypoxia within 24 hours of trauma
pulmonary contusion
167
why do glucocorticoids cause changes in CBC labs?
demargination of neutrophils habibi --> leukocytosis
168
chronic cough that is worse at night in the absence of major pathology, regardless of age of onset, should be worked up for:
asthma, PFT the homeboy. chronic means >2months
169
first line for preventing post op pneumonia
incentive spirometry (promotes lung expansion)
170
young guy with chronic low back pain, worse at night and improved with exercise, elevated ESR
ankylosing spondylitis
171
_____ exacerbations are associated with wheezing
asthma
