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2023RCE > Respirology (10-20%) Complete > Flashcards

Respirology (10-20%) Complete Flashcards

1
Q

Asthma Diagnosis requires:

A
  1. History of variable respiratory symptoms (e.g. wheeze, SOB, chest tightness, cough) that vary over time and intensity
  2. Confirmed variable expiratory airflow limitation:
    NEED SPIROMETRY TO HAVE A DIAGNOSIS OF ASTHMA
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2
Q

Positive bronchodilator reversibility (10-15 minutes after 200-400 mcg salbutamol) – Improvement in FEV1 by ____ AND _____ post-Bronchodilator

A

Improvement in FEV1 by >12% AND 200ml post-Brochodilator

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3
Q

Asthma is suspected but normal spirometry, next step?

A

– May repeat SPIROMETRY during times of symptoms
– Can perform methacholine or exercise testing

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4
Q

Methacholine Challenge – look for a drop in FEV1 by ______
– PC20 <4mg/mL = _______
– PC20 4-16 = _________
– PC20 >16 = ________

A

Methacholine Challenge – look for drop in FEV1 by __20%__
– PC20 <4mg/mL = __POSITIVE__
– PC20 4-16 = __borderline__
– PC20 >16 = __negative__

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5
Q

Exercise Challenge
– Fall in FEV1 of ____ and ____ from baseline

A

Exercise Challenge
– Fall in FEV1 of >10% and >200mL from baseline

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6
Q

ASTHMA CONTROL: MUST MEET ALL CRITERIA
Characteristic and Cut off
Daytime symptoms ______ per week
Nighttime symptoms ______ per week
Physical activity ______
Exacerbations ______
Absence from work/school due to exacerbation ______
Need for a reliever (SABA or bud/fom) ______ per week
FEV1 or PEF ______ of personal best
PEF diurnal variation ______
Sputum eosinophils ______

A

Daytime symptoms ≤ 2 d/week
Nighttime symptoms < 1d/ week and mild
Physical activity Normal
Exacerbations Mild (not requiring systemic steroids or ED visit) and infrequent
Absence from work/school due to exacerbation None
Need for a reliever (SABA or bud/fom) ≤ 2 doses per week
FEV1 or PEF ≥ 90% of personal best
PEF diurnal variation <10-15%
Sputum eosinophils <2-3%

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7
Q

ASTHMA: If the patient has symptom control for 2 months and has a low risk of exacerbations. NEXT STEP?

A

Consider stepping down therapy

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8
Q

ASTHMA: Before STEP UP Therapy: Assess and confirm?
_________
_________

A
  • Inhaler technique and adherence
  • All of the Non-Pharm management
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9
Q

LTRAs: Most effective in ______, ______ and ______

A

Most effective in aspirin-exacerbated asthma, exercise-induced symptoms, allergic rhinitis

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10
Q

LTRAs: FDA Black Box Warning?

A

FDA Black Box Warning: increased suicidality in adolescents and adults

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11
Q

Samter’s triad?

A

ASA/NSAIDs allergy
Asthma
Nasal polyps

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12
Q

For patients with Sampter’s Triad whose
asthma is not well controlled on low dose ICS – would you add LTRA or increase ICS dose?”

A

Answer: Offer LTRA given ASA-exacerbated asthma

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13
Q

WORKUP FOR SEVERE ASTHMA:
Peripheral eosinophil count
1. Eosinophils >0.3 – consider _______ before _______ [GINA 2022]
2. Eosinophils >1.5 – consider investigate for conditions such as _______ [GINA 2022]

A

Peripheral eosinophil count
1. Eosinophils >0.3 – consider strongyloides serology before systemic steroids [GINA 2022]
2. Eosinophils >1.5 – consider investigate for conditions such as EGPA [GINA 2022]

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14
Q

For severe asthma:
1. If high IgE and allergies: think
about ________

  1. If high eosinophil count, think
    about ________
A

For severe asthma:
1. If high IgE and allergies: think
about omalizumab

  1. If high eosinophil count, think
    about all the other biologics
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15
Q

Seasonal allergic asthma: start _______ immediately when symptoms commence and continue for _______

A

Start ICS immediately when symptoms
commence, and continue for four weeks after the relevant pollen season ends

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16
Q

Exercise-induced ASTHMA: ________ pre-exercise, if insufficient then ________ pre-exercise, if still insufficient try ________

A

salbutamol pre-exercise, if insufficient then LTRA pre-exercise, if still insufficient try regular ICS

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17
Q

Treatment of ABPA?

A

Prednisone +/- itraconazole.

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18
Q

COPD Diagnosis: ______ is required to make the diagnosis, with a ______ FEV1/FVC _______

A

COPD Diagnosis: Spirometry is required to make the diagnosis, with a post-bronchodilator FEV1/FVC <0.70 or <LLN

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19
Q

COPD: Spirometry result is borderline. Next Step?

A

Rrepeat measurement if
borderline

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20
Q

The severity of Airflow Limitation in COPD:
In pts w/ post-bronchodilator FEV1/FVC <0.70:
* Mild: FEV1 ______
* Moderate: ______ < FEV1 < ______ predicted
* Severe: ______ < FEV1 < ______ predicted
* Very Severe: FEV1 < ______ predicted

A
  • Mild: FEV1 > 80% predicted
  • Moderate: 50% < FEV1 < 80% predicted
  • Severe: 30% < FEV1 < 50% predicted
  • Very Severe: FEV1 < 30% predicted
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21
Q

COPD: Determine the Impact on patients’ health status ?

A

mMRC and/or CAT scores

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22
Q

Test those diagnosed with COPD for __________

A

Alpha-1 antitrypsin ONCE

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23
Q

Three interventions that improve survival in certain subsets of COPD?

A
  1. Smoking cessation
  2. Pulmonary rehabilitation
  3. Supplemental O2 in severe resting hypoxemia
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24
Q

Long-term Oxygen Therapy in COPD? Indications? * Should be offered to patients with PaO2 < _________ or when PaO2< ____ mmHg in the presence of ______, _______ or ________

A

Long-term Oxygen Therapy: increased survival in severe resting hypoxemia
Should be offered to patients with:
1. Severe hypoxemia (PaO2<55 mmHg), or
2. PaO2<60 mmHg in the presence of bilateral ankle edema, cor pulmonale, or Hct >56% (CTS guidelines)

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25
Q

COPD: Moderate resting or exercise-induced moderate desaturation. Oxygen indications?

A

No benefit (NEJM LOTT Trial 2016)

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26
Q

COPD and Pulmonary rehabilitation: Increased survival compared with usual care ______ post AECOPD

A

Increased survival compared with usual care
< 4 weeks post AECOPD

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27
Q

In stable COPD:
Start with ____ monotherapy, If symptoms persist then _____ dual therapy, if still persist then, ______triple therapy

A

Start with LAMA monotherapy, If symptoms persist then LAMA/LABA , if still persist then LAMA/LABA/ICS

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28
Q

In COPD:
DO NOT GIVE _____ monotherapy.
Increases risk of _____

A

DO NOT GIVE:
– ICS monotherapy: increases risk of pneumonia

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29
Q

COPD Rx to Prevent Acute Exacerbations

A
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30
Q

Asthma-COPD Overlap. First-line treatment?

A

LABA-ICS combo

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31
Q

NIV in Stable COPD with Hypercapnia

A

– CTS 2022: Suggest chronic NIV for patients with severe COPD on home oxygen and chronic hypercapnia (PaCO2 ≥52) – Consult your Respirologist!

– Several trials showing reduction in hospital re-admission rates; some showing mortality benefit

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32
Q

Severe emphysema patients with upper-lobe predominant disease and low post-rehabilitation exercise capacity. What increases survival in these patients?

A

Lung Volume Reduction Surgery

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33
Q

1-year mortality after AECOPD?

A

~ 30%

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34
Q

When to give Antibiotics for COPD?

A

Antibiotics should be given in COPD in the presence of three cardinal symptoms (or two of the following if increased purulence* is one of them):
1. Increase in dyspnea
2. Increase in sputum volume
3. Increase in sputum purulence

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35
Q

BIPAP in AECOPD?

A

Recommended (GOLD 2022) if any of:
* pH ≤7.35 with pC02 ≥ 45
* severe dyspnea (impending respiratory failure)
* persistent hypoxemia despite supp oxygen

36
Q

Does BIPAP have a mortality benefit in AECOPD?

A

Yes, Significant mortality benefit and reduction in intubation rate

37
Q

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults (ATS 2020)

A

Treat everyone with varenicline (+/- nicotine patch) even if they are not ready to quit

38
Q

What are the radiographic features of Usual Interstitial Pneumonia commonly seen in Idiopathic Pulmonary Fibrosis?

A
  1. Reticular Changes
  2. Subpleural/Basal predominant
  3. Honeycombing
  4. Absence of inconsistent features (LONG LIST)
39
Q

No role for ___________ or ___________ in Idiopathic Pulmonary Fibrosis due to ___________

A

No role for corticosteroids or immunosuppression in IPF given increased mortality (PANTHER-IPF) !

40
Q

Drug-induced ILD
Associated drugs?

A

Methotrexate
Amiodarone
Nitrofurantoin/Macrobid
Bleomycin
Vaping

41
Q

When to do a thoracentesis?

A
  • Suspect exudate
  • Cause unclear
  • Parapneumonic effusion (as per CHEST guidelines, if less than 1 cm of fluid on lateral decubitus in the context of pneumonia can forgo sampling and instead follow radiographically)
42
Q

Light’s Criteria?

A

Pleural fluid is an exudate if ≥ 1 of the following criteria are met:
* Protein in fluid : serum > 0.5
* LDH in fluid : serum >0.6
* Pleural fluid LDH >2/3 the upper limit of normal value for serum LDH

43
Q

Pleural effusion:
Chylothorax – (TGs >1.24mmol, +CM)

Think of?

A

– Malignancy #1 (most commonly lymphoma)
– Trauma/surgery, TB, LAM /Lymphangioleiomyomatosis, a young woman with cystic lung disease/PTX)

44
Q

Pleural effusion:
Pleural fluid eosinophilia - (>10%)

Think of?

A
  • Asbestos-related (BAPE)
  • Drugs (ex. nitrofurantoin)
  • Malignancy (lung)
  • Infection (parasites)
  • PE
  • eGPA
45
Q

Pleural effusion:
Low glucose - (glc<3, eff/serum<0.5)

Think of?
* <1 mmol: ___________________

  • 1-3mmol: ___________________
A
  • <1 mmol – RA, empyema
  • 1-3mmol – malignancy, TB, SLE
46
Q

Pleural effusion:
Lymphocytosis:
1. >80%?
2. Others?

Think of?

A

– >80% TB vs lymphoma, TB often AFB negative and would suggest sputum AFB

– Carcinoma, yellow nail, sarcoidosis, RA

47
Q

TB suspected?
Pleural fluid is AFB negative. Next step?

A

TB often AFB negative and would suggest sputum AFB

The yield of 3 induced sputum is comparable to bronchoscopy

48
Q

Chest drain needed if (does not need to be surgical chest tube)?

A

– drainage of frank pus/cloudy
– positive gram stain or culture
– pH <7.2 (if unavailable use glucose <3.4 mmol/L)
– >50% of hemithorax or loculations on imaging

ENSURE THAT YOU PAY ATTENTION TO THE SIDE OF THE EFFUSION – IPSILATERAL TO PNEUMONIA

49
Q

Antibiotic duration for Parapneumonic Effusions?

A

Usually prolonged antibiotic course (often at least 3 weeks, based on clinical and radiographic response)

50
Q

Primary spontaneous pneumothorax (PSP): Absence of lung disease

Risk Factors?

A

Smoking*
Family history
Marfan syndrome
Thoracic endometriosis

  • Reoccur 25-50%, most in first year
51
Q

Primary spontaneous pneumothorax (PSP):

<2cm with minimal signs and symptoms?

Next Step?

A

= monitor

52
Q

Primary spontaneous pneumothorax (PSP):

> 2cm or signs and symptoms

Next Step?

A

= needle aspiration +/- chest tube insertion

53
Q

Secondary spontaneous pneumothorax (SSP): Presence of lung disease (Often COPD).

Small SSP:

Next Step?

A

Even small SSP can lead to significant symptoms; often requires admission

More likely to require chest drain given underlying lung abnormalities and risk of
air leak, consult Resp/Thoracic Surgery

54
Q

Conservative (monitoring for 4 hrs in ED, then discharge home with close follow-up) versus Interventional Treatment for moderate-to-large primary spontaneous pneumothorax?

A
  • Conservative management was non-inferior to interventional management
    for radiographic resolution within 8 weeks
  • Bottom line: conservative observational approach may be reasonable in young, healthy patients with a spontaneous pneumothorax that would have otherwise warranted intervention
55
Q

Extrapulmonary sarcoid:
_______, _______, and _______ need urgent
treatment

A
  • Heart, CNS, eyes* need urgent
    treatment!
56
Q

Lofgren’s Syndrome?

A

– Bilateral hilar adenopathy
– Erythema nodosum
– Migratory polyarthralgias
– Fever
– Seen primarily in women
– High likelihood of spontaneous remission

57
Q

Heerfordt’s syndrome?

A

– Anterior uveitis
– Parotid enlargement
– Facial palsy
– Fever (uveoparotid fever)

58
Q

What are the three organs that can cause life-threatening sarcoidosis and how would you work them up?

A
  • Neurologic: Cranial nerve palsy, headache, ataxia, weakness, LP nonspecific lymphocytic inflammation, MRI imaging chest of choice
  • Ocular: Anterior uveitis most common
  • Cardiac: ~5% of patients clinically (more at autopsy), cardiomyopathy, arrhythmia, heart block, screen with ECG +/- echo, then cardiac MRI and PET scan if concern
59
Q

Sarcoid:

Erythema nodosum treatment?

A

Erythema nodosum usually good response to NSAIDs alone

60
Q

Sarcoid:

Fatigue? First-line treatment?

A

Pulmonary rehab is 1st line treatment for fatigue

61
Q

Pulmonary Hypertension (PH)

  • Defined as mean pulmonary artery pressure >______ mmHg on right heart
    catheterization and PVR >_____ WU is consistent with precapillary PH
  • Typically presents with _________ and eventually ________
A
  • Defined as: mean pulmonary artery pressure > 20mmHg on right heart
    catheterization and PVR >2WU (previously PVR > 3WU), is consistent with precapillary
    PH
  • Typically presents with slowly progressive dyspnea on exertion and eventually right
    ventricular failure
62
Q

Pulmonary Hypertension Types

A
63
Q

Dyspnea on exertion, isolated reduced DLCO

Suspect?

The most important screening is?

A

Pulmonary Hypertension

The most important screening is an echocardiogram – Assess how RV is doing!

64
Q

Screen patients with scleroderma annually for ______ with ______ and ______

A

Screen patients with scleroderma annually for PH with echo and DLCO

65
Q

If dyspnea or exercise intolerance after at least 3 months of uninterrupted anticoagulation post-acute PE assess for _______ with _______ and _______

A

If dyspnea or exercise intolerance after at least 3 months of uninterrupted anticoagulation post-acute PE assess for CTEPH with echo and V/Q lung scan

66
Q

Patients with CTEPH

Test for?

If positive? then?

A

APLAS (Antiphospholipid antibodies)

Warfarin

67
Q

Idiopathic Pulmonary Arterial Hypertension in Women?

A

Avoid Pregnancy
Use contraceptives

68
Q

In patients with SSc and unexplained dyspnea
following non-invasive assessment, ______ is
recommended to exclude __________

A

In patients with SSc and unexplained dyspnea
following non-invasive assessment, RHC is recommended to exclude PAH

69
Q

A-a gradient?

Calculation?

Normal range?

A

A-a = [150- (PaCO2/0.8)]– PaO2

Normal A-a Gradient for reference:
(Age (yrs)/4)+4

70
Q

Hypoxemia with Normal A-a gradient:

Means?
Causes?

A

Normal A-a gradient means (normal gas exchange)

– Hypoventilation
1. CNS depression (drugs, stroke, tumor-bleed, meningitis), spinal cord injury, chest wall abnormality, diaphragm dysfunction (ie phrenic nerve injury or myopathy), neuromuscular disorder, obesity hypoventilation
2. Check PaCO2 – if elevated think of hypoventilation

– Low-inspired FiO2 (e.g. altitude)

71
Q

Hypoxemia with Widened A-a gradient:

Means?
Causes?

A
  1. V/Q mismatch (improves with 100% FiO2): E.g. COPD, PE
  2. Shunt (does not improve completely with the administration of 100% FiO2): CAUSE:
    - intracardiac with R->L shunt (eg PFO, ASD, VSD)
    - intrapulmonary (ie pulmonary AVM)
    - physiologic (ie severe pneumonia with perfused alveoli that are not ventilated)

3 Diffusion Abnormality: E.g. ILD

72
Q

Home O2 Requirements (Ontario)?

A

Home O2 Requirements (Ontario)
– PaO2 <= 55
– (SaO2 <= 88%)

– PaO2 = 55-59 with:
* Cor pulmonale
* Pulmonary hypertension
* Persistent erythrocytosis

73
Q

Hemoptysis Differential

A
74
Q

Hemoptysis Management

A
75
Q

When should take away driver’s license for someone with OSA?

A

Need one of:

Excessive sleepiness during major wake periods while driving

Crash associated with falling asleep in the last 5 years if not on effective therapy

Noncompliant with therapy

76
Q

PFT: Flattening of both inspiratory and expiratory curve

A

Fixed upper-airway obstruction (intrathoracic or extrathoracic)

  • Glottic stenosis (prolonged intubation)
  • Subglottic stenosis (Wegner’s, sarcoid, polychondritis)
77
Q

PFT: Flattening of inspiratory curve

A

Variable extrathoracic obstruction
* Vocal cord dysfunction/paralysis

78
Q

PFT: Flattening of expiratory curve

A

Variable intrathoracic obstruction
* E.g. tracheomalacia of intrathoracic airway

79
Q

Isolated decrease in DLCO?

A

– Classically pulmonary hypertension, also early ILD/emphysema, anemia.

80
Q

Increased DLCO?

A

– Pulmonary hemorrhage/polycythemia
- LV failure
- Asthma
- Obesity

81
Q

Restrictive pattern varying with position
– Vital Capacity __________ when lying down by >10%
* Gravity eliminated therefore unmasks __________, confirm with ____________
* May be presented as a ___________ or ___________

A

Restrictive pattern varying with position
– Vital Capacity decreases when lying down by >10%
* Gravity eliminated therefore unmasks diaphragm dysfunction, confirm with MIPs/MEPs
* May be presented as a post-op scenario (e.g. CABG) or NMD (e.g. ALS)

82
Q

Contraindications to PFTs: (BMJ)

A
    1. Hemoptysis
    1. Pneumothorax
    1. Unstable cardiovascular status including recent MI
    1. Aneurysms – thoracic, abdominal or cerebral
    1. Recent eye surgery – eg. Cataracts
    1. Recent thoracic or abdominal surgery
    1. Presence of acute illness that may interfere with test performance
83
Q

Contraindications to Methacholine Challenge: (ATS)
ABSOLUTE?
RELATIVE?

A

– Absolute:
* 1. Severe airflow limitation FEV1<50% or <1L
* 2. Recent MI or Stroke in last 3m
* 3. Uncontrolled HTN, SBP >200/100
* 4. Known Aortic Aneurysm

– Relative:
* 1. Moderate airflow limitation FEV1<60% or <1.5L
* 2. Pregnancy or nursing mothers (methacholine is category C)
* 3. Use of cholinesterase inhibitor (myasthenia gravis)

84
Q

PFTs Perioperatively:

If both predicted post-op ________ and ________ are _______ % predicted no further testing is needed

A

If both PPO FEV1 and DLCO are > 60% predicted no further testing is needed

  • Low risk for perioperative death and cardiopulmonary complications following resection including pneumonectomy
85
Q

Predictors of adverse perioperative pulmonary events?

A
  1. Surgical site (aortic > intrathoracic> upper abdominal> abdominal)
  2. Age, preexisting lung disease
86
Q

The most specific and most sensitive test for diagnosis
of diaphragm weakness/paralysis?

A

Most SENSITIVE = MIP (Maximal inspiratory pressure)

Most SPECIFIC: There isn’t really a good specific test on PFTs for diaphragmatic weakness. Proceed to an ultrasound if you want specificity.

If forced to choose we “guess” FVC… because it’s associated with poor prognosis in diaphragmatic dysfunction as per the ALS CTS guidelines.

87
Q

PFTs: Pregnancy: Following increase/decrease or the same
Total lung capacity?
Functional residual capacity?
Inspiratory Capacity?
Vital Capacity
Expiratory reserve volume?
Tidal volume?
Minute ventilation?

A

Total lung capacity? Same
Functional residual capacity? Decrease
Inspiratory Capacity? Increase
Vital Capacity? Same
Expiratory reserve volume? Decrease
Tidal volume? Increase

2023RCE (20 decks)

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