Respirology Flashcards
1
Q
Name the 2 criteria needed for a diagnosis of asthma
A
- History of Variable respiratory symptoms that vary over time and intensity
- Confirmed Variable expiratory airflow limitation
- Need spirometry for diagnosis
2
Q
Name 4 clinical phenotypes of asthma
A
- Allergic: Classic asthma, atopy, eosinophilic inflammation, responds to ICS
- Non-allergic: Neutrophilic, eosinophilic or paucigranulocytic inflammation with less response to. ICS
- Adult-onset: Non-allergic, requires higher ICS doses, rule-out occupational asthma
- Asthma associated with obesity: little eosinophilic inflammation
- Associated with persistent airflow limitation: Longstanding asthma causing fixed obstrucion due to airway remodelling
3
Q
How is asthma diagnosed
A
- On PFT. Require presence of 2 criteria
- Expiratory airflow limitation
- Reduced FEV1/FVC confirmed at least once
- Variability, demonstrated by presence of at least one of the following:
- Positive bronchodilator reversibility
- Improvement in FEV1 by >12% and 200ml post bronchodilator
- Improvement in lung function with antiinflammatory treatments x4 weeks
- Improvement in FEV1>12% and 200ml
- Peak flow variability
- Average daily diurnal PEF variability >10%
- Excessive variability in twice daily PEF over 2 weeks
- Positive bronchial challenge test or exercise challenge test
- Positive bronchodilator reversibility
- Expiratory airflow limitation
4
Q
What are the criteria for a positive, borderline and negative methacholine challenge
A
- Look for drop in FEV1 by 20% while giving increasing doses of metacholine. The dose required is your PC20
- PC20 < 4 mg/ml = positive
- PC20 4-16 = borderline
- PC20 > 16 = negative
5
Q
What criteria makes an exercise challenge positive for asthma
A
Fall in FEV1 of > 10% and 200ml from baseline
6
Q
List the CTS asthma control criteria
A
7
Q
List risk factors for severe asthma exacerbation
A
- Any history of a previous severe asthma exacerbation
- poorly controlled asthma as per CTS criteria
- Current smoker
- Overuse of SABA (= use of more than 2 saba inhalers per year)
8
Q
What defines a severe asthma exacerbation
A
- Any one of
- Requires systemic steroids
- Requires ED visit
- Requires hospital admission
9
Q
Describe the stepwise approach to asthma as per the GINA guidelines
A
10
Q
Describe the non-pharmacological treatments for asthma
A
- confirm the diagnosis, education and written asthma action plan
- Weight loss, exercise training
- Allergen/trigger avoidance. allergen immunotherapy
- Smoking cessation
- vaccination
- Avoidance of NSAIDS +/- Beta-blockers
- Treat comorbidities
11
Q
What should be assessed before stepping up asthma therapy
A
- Inhaler technique and adherence
- optimisation of non-pharmacological management
12
Q
When can you consider stepping down asthma therapy
A
If patient has symptom control for 2 months and is low risk for exacerbations
13
Q
When should LTRA be considered in asthma
A
Less effective than inhalers
May be appropriate as initial controller therapy in patients who are intolerant or unwilling to use ICS
Most effective in aspirin induced asthma, exercise induced asthma or allergic rhinitis
LABA-ICS > ICS-LTRA
14
Q
What black box warning is associated with Montelukast
A
Increased suicidality in adolescents and adults
15
Q
What is the difference between uncontrolled and severe asthma
A
16
Q
What workup should be sent in severe asthma
A
- Total IgE
- Peripheral eosinophil count
- Sputum eosinophils and FeNO when available
17
Q
What classes of medications can be considered in severe asthma
A
- Tiotropium mist inhaler
- Macrolides
- Biologics
- Low dose oral corticosteroids
- ?Bronchial thermoplasty in specialized centers
- Role remains uncleat
18
Q
What is Omalizumab and what are the indications for it’s use?
A
Anti-IgE
- Indication
- Allergic asthma with IgE 30-700 sensitive to at least 1 perennial allergen, severe despite high doses ACS and one other controller
19
Q
What are mepolizumab, resilizumab and benralizumab and what are their indications
A
Anti IL-5
- Indications
- Severe eosinophilic asthma (Eos >300) and recurrent exacerbations despite high dose ICS and another controller
20
Q
What is dupilumab and what are it’s indications?
A
Anti IL-4 and IL-13
- Add-on option for severe eosinophilic asthma or those with nasal polyposis moderate-severe atopic dermatitis
21
Q
How is seasonal allergic asthma treated
A
Start ICS immediately when symptoms commence and continue for 4 weeks after relevant pollen season ends
22
Q
How is exercise-induced asthma treated
A
Salbutamol pre-exercise
if insufficient add LTRA pre-exercise
If still insufficient try regular ICS
23
Q
What percent of patients with asthma will have worstening of their asthma symptoms during pregnancy
A
- Rule of thirds:
- 1/3 get better
- 1/3 stay the same
- 1/3 get worst
24
Q
In which trimester of pregnancy are asthma exacerbations most common
A
second trimester
25
Having asthma increases your risk for these 3 conditions during pregnancy
1. Pre-eclampsia
2. Low birth weight
3. pre-term birth
26
How is asthma treated during pregnancy?
The same as outside of pregnancy
\*Budesonide is the ICS with the best evidence for safety in pregnancy but all ICS are likely safe
Do NOT withhold oral steroids if a patient is exacerbating
27
What is the specific triad associated with ASA exacerbated respiratory disease?
1. Asthma
2. nasal polyps
3. ASA/NSAIDs sensitivity
28
How is ASA exacerbated respiratory disease treated?
* Avoid NSAIDS/ASA
* Can treat like normal asthma but _good response to LTRA_
* ASA desensitization can be considered
29
Name 5 asthma plus syndromes/asthma mimics
1. Bronchiectasis
2. EGPA
3. Vocal cord dysfunction
4. ABPA
5. reactive airways dysfunction syndrome
30
What are the symptoms of EGPA
1. _Asthma_
2. Eosinophilia
3. _granulomatous vasculitis:_
1. Cardiac
2. Sinusitis
3. allergic rhinitis
4. transient pulmonary infiltrates
5. purpura
6. neuro
7. GI
4. 30-60% have positive p-ANCA
31
What are the symptoms of vocal cord dysfunction
* Sx:
* Abrupt onset inspiratory stridor
32
How is vocal cord dysfunction diagnosed?
Via laryngoscopy (adduction of vocal cords on inspiration)
33
How is vocal cord dysfunction treated
Speech therapy
\*also education, behavior modification, and treating possible underlying GERD
34
What are the symptoms of ABPA
1. Can complicate asthma
2. Presents with recurrent exacerbations with:
1. Fever
2. brown sputum with "casts"
35
What are the diagnostic criteria for ABPA?
1. Asthma
2. pulmonary infiltrates
3. Skin and serum precipitins to aspergillus
4. Increased total IgE and aspergillus specific IgE \>1000
5. Increased eosinophils
6. Central bronchiectasis
36
How is ABPA treated?
* Corticosteroids (cornerstone of Tx)
* Itraconazole
37
Describe the symptoms of reactive airway dysfunction syndrome
Acute form of irritant induced asthma with symptoms promptly following a single high dose exposure to vapors, gasses or fumes
Lasts \> 3 months
38
How is reactive airways dysfunction syndrome treated
Same way as asthma exacerbation
39
What is the spirometry diagnosis criteria for COPD
FEV1/FVC \< 0.70
40
What is the severity scale of COPD based on airflow limitation on spirometry
* Mild: FEV1 \>80%
* Moderate: FEV1: 50-80%
* Severe: FEV1: 30-50%
* Very severe: FEV1 \<30%
41
List the management goals in COPD patients
* Prevent disease progression
* **Reduce the frequency and severity of exacerbations**
* **Alleviate breathlessness**
* **Improve exercise tolerance and daily activity**
* Treat exacerbations and complications of disease
* Improve health status
* Reduce mortality
42
Describe the stepwise approach to pharmacological management of COPD according to CTS
43
What specific blood test should be done once in all patients diagnosed with COPD?
Alpha-1 antitrypsin
44
Describe the non-pharmacological management of COPD
1. **Smoking cessation** + living in a smoke free environement
1. Increases survival and improves rate of FEV1 decline
2. **Pulmonary rehab** and remaining physically active
1. Most effective therapy to improve dyspnea, exercise capacity and health status
2. Reduces exacerbations if started _following recent (\<4 weeks) exacerbation_
3. Increased survival if started \<4 weeks post exacerbation
3. **Supplemental O2 \***
1. ****Increased survival in severe resting hypoxemia
2. No benefit in moderate resting or exercise induced moderate desaturation
3. Offer to patients with severe hypoxemia (PaO2\<55mmHg) or when PaO2 \<60 and presence of bilateral ankle edema, cor pulmonale or HCT\>56%
4. vaccination
5. self-management and education
6. review of inhaler techniques
7. end of life care
45
Describe the modified MRC dyspnea scale
46
What inhaled therapy should be prescribed in COPD based on severity of disease and risk of exacerbation
\*High risk of exacerbation is defined as 2 or more exacerbations in the past year or 1 or more requiring hospitalization
\*\*LAMA preferred to ICS
No role for ICS monotherapy, increased infection risk.
47
What further escalation of therapy can be considered to _prevent exacerbations_ in patients already on triple therapy
NAC can also be considered
48
What vaccines are indicated in the maintenance treatment of COPD?
1. Influenza
2. Pneumococcal
3. TdAP pertussis
49
What is recommended for the symptomatic treatment of dyspnea in advanced COPD?
1. Oral opioids (not nebulized)
2. Neuromuscular electrical muscle stimulation
3. Chest wall vibration
4. walking aids
5. pursed-lip breathing
6. Continuous O2 therapy for _hypoxemic_ COPD patients **reduces mortality** and **may reduce dyspnea**
not recommended
1. Anxiolytics and antidepressants
2. Supplemental o2 in non-hypoxemic patients
Not enough evidence
1. Acupuncture
2. acupressure
3. destructive auditory stimuli
4. relaxation
5. handheld fans
6. Counseling and support programs
7. psychotherapy
50
What are the diagnostic criteria for ACO
* Required
1. Diagnosis of COPD given risk factors, history, spirometry
2. History of asthma (past Dx, current sx consistent or physiology confirmed with spirometry
3. Spirometry: post-bronchodilator fixed FEV1/FVC \<0.7
* Supportive but not required
1. Documentation of a bronchodilator improvement of FEV1 by 200ml or 12%
2. sputum eosinophils \>3%
3. Blood eosinophils \>300 cells/uL (current or previously documented)
51
How is ACO treated
* 1st line ICS-LABA
* Refractory symptoms, add LAMA
52
How would you treat a COPD patient with severe chronic hypercapnia and a history of hospitalisations for hypercarbic resp failure
If pCO2\>52, NIV. COnsult respirology
53
In which patients should you consider lung reduction surgery
Severe emphysema with upper lobe predominant disease and low post-rehabilitation exercise capacity
54
What are the criteria for lung transplant in COPD patients
* BODE score 7-10 and 1 of
1. Hospitalized with COPDe with PCO2 \>50
2. Pulmonary hypertension/cor pulmonale despite supplemental oxygen
3. FEV1\<20 with DLCO\<20
55
When should antibiotics be used in COPD exacerbation?
1. Presence of 3 cardinal symptoms (2 if one of them is increased purulence)
1. Increase in dyspnea
2. Increase in sputum volume
3. Increase in sputum purulence
56
When antibiotics are indicated in COPD exacerbation, which ones should be used? And for how long
* Depends on local resistance pattern, usually amox-clav, macrolide, tetracycline
* treat 5-7 days
57
What are the indications for steroid treatment in AECOPD
* Moderate to severe exacerbations with 40mg Pred x 5 days
58
When should BIPAP be considered in COPD exacerbation
* If any of:
1. pH\<7.35 or pCO2\>45
2. severe dyspnea (i.e. impending resp failure)
3. persistent hypoxemia despite supplemental O2
59
What is the treatment for smoking cessation
Varencicline + nicotine patch
60
What are the most common symptoms of bronchiectasis
* Chronic resp. disease characterised by cough, sputum production and bronchial infectiom
* Most common symptoms
* Cough with sputum and/or hemoptysis
* dyspnea and fatigue
* rhinosinusitis
* Thoracic pain
61
What are the treatment goals in bronchiectasis
* Prevent exacerbations
* improve QOL
* reduce disease progression
*
62
What are the etiologies of bronchiectasis
63
What should be the workup for bronchiectasis?
1. ABPA testing
1. CBC
2. Total IgE
3. Sensitization to aspergillus
2. Serum immunoglobulins
3. CF sweat test
4. Test for primary ciliary dyskinesia (nasal nitric oxyde)
5. Sputum cultures
Also consider
* RF, Anti-CCP, ANA, ANCA
* Alpha1 antitrypsin
* HIV testing
* Videofluoroscopic swallow study
64
What is the treatment of chronic bronchiectasis
1. Airway clearance
1. Active cycle of breathing technique
2. Mucoactive agents
1. hypertonic saline
2. DNAse only in CF
3. Antimicrobials
1. Inhaled colistin or gentamycin if Pseudomonas colonized
2. Chronic azithromycin if recurrent exacerbations (with or without Pseudomonas colonization ... rule out NTM)
4. Bronchodilators
1. Use if otherwise indicated
2. Offer trial if significant breathlessness
5. Pulmonary rehab
1. If functionally limited by dyspnea (MRC≥1)
6. Vaccines
1. Influenza
2. Pneumococcal
7. Supplemental O2
1. Same criteria as COPD
8. No routine ICS, oral steroids, PDE4-I
Advanced therapies:
1. Consider surgery, lung resection if localized disease
2. Transplant if:
1. Poor lung function plus 1 of:
1. Massive. hemoptysis
2. severe pulmonary hypertension
3. ICU admissions
4. resp failure requiring NIV
3. NIV if resp failure + hypercarbia, especially if recurrent hospitalization
65
How are bronchiectasis exacerbations treated
1. Get sputum culture
2. Use empiric antibiotics and target previously grown organisms
3. 14 day course of ABx, especially if known Pseudomonas colonized
4. IV ABx if unwell, admitted or resistant organisms. Or if failed oral therapies
66
How is major hemoptysis managed in patients with bronchiectasis
1. IV antimicrobials
2. TXA
3. Consider embolization
67
Describe the categorization of ILD
68
What exposures should you ask for on history in a patient with suspected ILD
1. Organic (hypersensitivity pneumonitis)
1. Mould/water damage
2. Birds
3. Farms
4. Feather pillows
5. hot tubs
2. Inorganic (pneumoconiosis)
1. Asbestos
2. mining
3. sandblasting
69
What workup should be sent in all patients with suspected ILD
1. Connective tissue disease workup
1. ANA, RF, Anti-CCP in all
2. Further workup if indicated
2. HRCT chest
3. PFTs +/- 6 minute walk test +/- home O2 assessment
4. Precipitating antibodies for some known antigens for HP
5. Resp and rheum referal
6. Consider lung Bx (sometimes)
70
Around what age do patients develop IPF
6th or 7th decade
71
What is the radiological pattern seen in IPF
UIP
72
What environmental exposure is linked to IPF
Smoking
73
What are the required criteria for the diagnosis of IPF
1. Exclusion of other known causes of ILD
2. UIP pattern on HRCT
3. histology pattern on Bx (if patient had biopsy, **not required)**
74
What are the radiology patterns that fit with a description of UIP and which ones would suggest an alternate diagnosis?
75
How is IPF treated
1. Quit smoking
2. O2 therapy if needed
3. Pulmonary rehab
4. PPI
5. Pneumoxav and influenza vaccine
6. antifibrotic medications
1. Nintendanib
2. pirfenidone
\* no role for corticosteroids or immunosuppression
76
What are the side effects of nintendanib
1. Diarrhea
2. GI upset
3. transaminitis
77
How is an *acute exacerbation* of IPF diagnosed
Worstening dyspnea and hypoxemia with diffuse bilateral ground glass on CT
78
How are acute exacerbations of IPF treated?
1. Rule out infection, HF, PE
2. High dose corticosteroids (1g/day x3 -\> 1mg/kg daily) and empiric antimicrobials
\*Dismal prognosis 50% in hospital mortality
79
Who should get supplemental O2 in IPF?
* Restig hypoxemia -- Same criteria as COPD
* Exertionnal hypoxemia -- (sat\<88%) with improved walk distance or dyspnea on supplemental oxygen
80
Name causes of hypersensitivity pneumonitis
Organic exposures (Moulds, birds)
81
What are the imaging and lab findings in hypersensitivity pneumonitis
Upper lobe predominant
+ precipitating antibodies to antigen
82
How is hypersensitivity pneumonitis treated
Antigen avoidance
steroids
Sometimes MMF or AZA
83
What are causes of pneumoconiosos
Inorganic exposures _years_ ago (asbestos, silica...)
84
What can be found on imaging in pneumoconioses
Variety of different imaging findings
85
How are pneumoconioses treated
Supportive care
transplant
86
What causes CTD associated ILD
1. Scleroderma
2. RA
3. Dermatomyositis
4. Sjogren's
5. MCTD
87
What are the imaging findings in CTD ass. ILD
Variety -- NSIP, UIP, organizing pneumonias and others
88
What is the treatment for CTD ass. ILDs
Treat the CTD
89
What drugs cause drug induced ILD
1. Methotrexate
2. Amiodarone
3. Nitrofurantoin
4. Bleomycin
5. Vaping
90
How is drug induced ILD treated
Drug withdrawl and corticosteroids
91
What are the indications to do a thoracentesis
* Suspected exudate
* cause unclear
* Parapneumonic effusion, not if less than 1cm of fluid on lateral decubitus in context of pnoumonia
\*Aspiration should NOT be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate/CHF
92
What are the light criteria
1. Protein in fluid:serum \>0.5
2. LDH in fluid: serum \>0.6
3. Pleural fluid in LDH \>2/3 ULN value for serum LDH
93
In the setting of an exudate NYD, how can malignancy be ruled out?
1. Repeat thoracentesis _once_ for increased sensitivity
2. CT chest
3. Refer for pleural biopsy
1. Thoracoscopy + pleural Bx is prefered test
2. if obvious area of abnormality on CT, can proceed to CT guided Bx
Mesothelioma can usually not be diagnosed based on pleural fluid alone. Requires pleural Bx
94
List the common, less common and rare causes of pleural transudates
* Common
1. CHF
2. Cirrhosis
* Less common
1. Hypoalbuminemia
2. Peritoneal dialysis
3. Hypothyroidism
4. Nephrotic syndrome
5. Mitral stenosis
* Rare causes
1. Constrictive pericarditis
2. Urinothorax
3. Meigs Syndrome
95
Name the common, less common and rare causes of pleural exudates
* Common
1. Malignancy
2. Parapneumonic effusions
3. Tb
* Less common
1. PE
2. RA and other auto-immune pleuritis
3. Benign asbestos effusion
4. Pancreatitis
5. Post-MI
6. post-CABG
* Rare causes
1. Yellow nail syndrome
2. Drugs
3. Fungal infections
96
What are the causes of a chylothorax
1. Malignancy most common (lyphoma)
2. Trauma/surgery
3. Tb
4. LAM
97
What are the causes of pleural fluid eosinophilia?
* Depends on history
* Asbestos relate (BAPE)
* Drugs (ex. Nitrofurantoin)
* Malignancy (lung)
* infection (parasites)
* PE
* eGPA
98
What are causes of low glucose in a pleural effusion?
\<1 **RA, empyema**
1-3, malignancy, Tb, SLE
99
What are causes of increased lymphocytes in pleural fluid?
\>80% are Tb or lymphoma
Other DDx: Carcinoma, yellow nail, sarcoidosis, RA
100
What are the indications to insert a chest tube?
1. Drainage of cloudy pleural fluid or frank pus
2. Positive gram stain or culture
3. pH\<7.2 (or glucose \<3.4)
4. \>50% of hemithorax or loculation on imaging
101
How should an empyema be treated empirically. For how long
Based on gram stain if available
If not Cover CAP + anaerobes
Requires prolonged ABx course. Usually 3 weeks
102
What are the risk factors for primary spontaneous pneumothorax
1. **Smoking**
2. Family history
3. Marfan
4. Thoracic endometriosis
103
How are primary spontaneous pneumpothoraces treated
* If \< 2cm with minimal signs and symptoms, monitor
* If \>2cm or with signs. and symptoms: needle aspiration +/- chest tube insertion.
* Surgery if persistent leak
104
What are the risk factors for secondary spontaneous pneumothorax
1. **COPD**
2. Tb
3. CF
4. PCP
105
How are secondary spontaneous pneumothoraces managed
1. As they are more likely to lead to significant symptoms, most are drained. Often require admission
2. More likely to require chest drain
106
In sarcoidosis, which organ involvement requries urgent treatment
1. Heart
2. CNS
3. Eyes
107
What other organs, other than lungs, can be involved in sarcoid
1. Heart
2. CNS
3. eyes
4. liver
5. spleen
6. MSK
7. kidneys
108
Describe Lofgren's syndrome
1. Bilateral Hilar lymphadenopathy
2. Erythema nodosum
3. Migratory polyarthralgias
4. Fever
\*Primarily seen in women
\*High likelyhood of spontaneous remission
109
Describe Heerfordt's syndrome
1. Anterior uveitis
2. Parotid enlargement
3. Facial palsy
4. Fever
110
What are the stages of sarcoid?
111
Describe the clinical findings of cutaneous sarcoid
1. Lupus pernio
2. erythema nodosum
3. Others...
112
Describe the findings of liver and spleen sarcoid
1. Elevated LFTs
2. Cholestasis
3. Rarely liver failure
113
What are the neurological findings of Sarcoid
1. _Cranial nerve palsy_
2. headache
3. Ataxia
4. Weakness
5. Non-specific lymphocytic infiltration on LP
114
What are the occular findings of sarcoid
Anterior uveitis
115
What are the cardiac findings of sarcoid
1. Cardiomyopathy
2. Heart block
3. arrythmias
116
What electrolyte is elevated in sarcoidosis
Hypercalcemia
117
What investigations should be done to confirm a diagnosis of Sarcoidosis
1. **CXR +/- CT**
2. PFTs
3. **Biopsy** (tissue or EBUS)
4. CBC: Anemia of chronic disease, **lymphopenia**, thrombocytopenia
5. LBC: **Hypercalcemia**, Cr
6. Albumin
7. LFTs
8. **ECG**
1. If suspecting cardiac involvement do cardiac MRI (ideally) or PET scan
2. Echo if suspecting pulmonary hypertension
9. **Ophtalmology referral**, r/o occular sarcoid
10. Bronchoscopy/BAL: Low CD4, elevated CD4/CD8 ratio
11. 24 hour urine, screen for hypercalciuria
\*Serum ACE level not necessary. 70% sensitive 90% specific for active disease
118
What are the indications for treatment in sarcoidosis
* Pulmonary sarcoid
1. Bothersome symptoms (cough and dyspnea)
2. Deteriorating lung function as measured by PFTs
3. Developpement of pulmonary hypertension
* Extrapulmonary sarcoid
1. **Eye, CNS, cardiac involvement**
2. Severe skin disease, hypercalcemia, symptomatic liver disease
\*Most patients do not require treatment. Steroids make the disease remit faster but increase the risk of recurrence.
119
How is sarcoidosis treated
* Mild respiratory symptoms (_cough and stable PFTs_)
* Treat with inhaled steroids
* Erythema nodosum
* Usually responds to NSAIDs alone
* Almost anything else:
* Treat with prednisone 20-40mg daily
* Usually, treat for 1-3 months at initial dose then slowly taper to 10mg daily. With treatment continued for 1 year
* In the case of relapse, can consider MTX (or less commonly HCQ, LEF, TNF alpha inhibitors)
* MTX can also be used if continued disease despite prednisone or toxicity from steroids
* Pulmonary rehab is first-line for sarcoidosis related fatigue
120
How is pulmonary hypertension defined?
Mean pulmonary artery pressure \>20mmHg and pulmonary vascular resistance \>3WU on right heart catheterisation
121
How does pulmonary hypertension present?
1. Slowly progressive dyspnea on exertion
2. Eventually right heart failure
3. Isolated reduced DLCO
122
What workup should be done when suspecting pulmonary hypertension
1. Echocardiogram:
1. Assess right heart function
2. CBC, LBC, LFTs, TSH, BNP
3. PFTs
4. 6MWT
5. VQ scan
6. CTD serologies
7. Sleep study _if concerns for OSA_
8. HIV
9. **Confirm diagnosis on right heart cath**
123
Describe the 5 WHO groups of pulmonary hypertension
* Group 1: PAH
* Idiopathic, heritable, drug/toxin induced
* Associated with CTD, HIV, portal HTN, schistosomiasis
* Group 2: 2/2 left heart disease
* Systolic or diastolic dysfunction
* Group 3: 2/2 lung disease/ hypoxemia
* COPD/ILD etc...
* Group 4: CTEPH
* Group 5: Others
* 2/2 heme disorders (MPN, splenectomy)
* 2/2 systemic disorders (sarcoid, LCH, LAM)
124
How is group 1 pulmonary hypertension treated?
* Vasoreactive testing to determine if candidate for CCB
* **_PDE5 inhibitor_** or riociguat
* **_endothelin receptor antagonist_**
* **_prostanoid_**
* Influenza/pneumococcal vaccine
125
How is group 2 pulmonary hypertension treated?
Treat the heart failure
126
How is group 3 pulmonary hypertension treated?
Treat the underlying cause
127
How is group 4 pulmonary hypertension treated?
* Refer for pulmonary endarcterectomy
* trial of anticoagulation
128
How is group 5 pulmonary hypertension treated?
Treat the underlying cause
129
How should patients with scleroderma be screened for PH?
Yearly echo and DLCO
130
When should patient with portal hypertension be screened for pulmonary hypertension
During transplant workup
131
When should patients be screened for CTEPH after an acute PE
If they are still short of breath after 3 months of therapeutic anticoagulation
132
How is the A-a gradient calculated and what is the normal value?
Aa=150-PaCO2/0.8
Normal =(age/4)+4
133
Name causes of hypoxemia with a _normal A-a gradient_
* Hypoventilation
* CNS depression
* Spinal cord injury
* Chest wall abnormality
* diaphragm dysfunction
* neuromuscular disorder
* OHS
* Low inspired FiO2
134
Name causes of hypoxemia with a widened A-a Gradient
1. V/Q mismatch
1. COPD, PE
2. Improves with 100% FiO2
2. Shunt
1. Does not completely improve with 100% FiO2
2. Intracardiac, intrapulmonary, physiologic
3. Diffusion abnormality
1. ILD
135
What are the criteria for home O2 (in Ontario)
* PaO2 \<55
* Sat \<88%
* PaO2 55-59 with:
* Cor pulmonale
* Pulmonary hypertension
* persistent erythrocytosis
136
List the differential diagnosis for hemoptysis
1. Infectious
1. Bronchiectasis
2. Bronchitis
3. Tb
2. Neoplastic
1. Carcinoid
1. Young non-smoker with lung collapse
2. Malignant
1. NSCLC or SCLC
3. CTD
1. Anti-GBM
2. GPA (or other vasculitis)
3. SLE
4. Drugs/toxins
1. Cocaine
2. Anticoagulation
5. Vascular
1. Pulmonary AVM
2. Bronchial artery aneurysm
3. PE
137
How is massive hemoptysis managed?
1. ENsure ABCs
2. Decubitus position
3. Hold anticoagulation, correct coagulopathy
4. Image if patient is stable enough
1. CXR/CT
2. bronch
5. Arterial embolization in IR is ideal
1. If not available, then consider rigid bronchoscopy or resection (thoracic surgery)
138
What are the criteria for pulmonary rehab in long COVID?
New/Ongoing respiratory symptoms and functional limitations **after resolution of acute COVID 19**
AND
New or ongoing requirements for supplemental O2
OR at least 1 of
* Persistent radiographic pulmonary abnormalities
* PFTs showing new/persistent reduction in lung volumes, airflow limitations and/or decreased DLCO
139
Give a differential diagnosis for cough
140
Give an approach to chronic cough
1. Exclude ACEi
2. CXR
3. Then test for these conditions _in this order:_
1. Upper airway cough syndrome
1. Give antihistamines/decongestionant and assess for response
2. Sinus imaging if no improvement
2. Asthma
1. Methacholine challenge or empiric ICS
3. Non-asthmatic eosinophilic bronchitis
1. Sputum eosinophils or empiric trial of corticosteroids
4. GERD
1. if "clinic profile". fits, treat. empirically
1. Lifestyle modifications: coffee, chocolate, etc...
2. H2RA/PPI
3. Prokinetic
2. 24hrs pH monitoring on therapy if cough persists
3. If refractory, antireflux surgery
141
What is the physical exam finding with the highest +LR for sleep apnea?
Nocturnal gasping /choking
142
How is sleep apnea diagnosed and what are the severity criteras?
* Sleep study
* Diagnosis: \>5 apnea/hypopnea events/hr
* Mild: 5-15 events/hr
* Moderate: 15-30 events
* severe \>30 events
143
What are the indications to treat sleep apnea?
1. Sx of excessive sleepieness or impaired sleep related QOL
2. Comorbid HTN
3. Asymptomatic patients with _severe_ OSA
4. Critical occupation
144
Wow is sleep apnea treated
1. Weight loss
2. CPAP
3. Oral appliances -- for mild-moderate disease
4. Surgery (rarely)
1. Tonsillectomy if appropriate
2. uvulopalatopharyngoplasty in select patients
145
What are the driving restrictions in OSA?
Severity of OSA alone does not disqualify a person from driving
* Patients should not drive if:
1. The driver admits to experiencing excessive sleepiness during the major wake period while driving
2. The driver experienced a crash associated with falling asleep in the past 5 years if effective therapy has not been instituted in the interim
3. The driver is non-compliant with treatment
146
What are the guidelines for follow-up of solid pulmonary nodules?
147
What are the guidelines for follow-up imaging in sub-solid pulmonary nodules?
148
What are the criteria for lung transplant in COPD?
* FEV1 ≤25% +/- PaCO2 ≥55
* Severe disease, resting hypoxemia \<55mmHg
149
What are the indications for lung transplant in CF
FEV1 \<30% +/- PaCO2 \>50
150
What are the indications for transplant in IPF/ILD
* Symptomatic
* FVC \< 60-65%
151
What are the indications for lung transplant in pHTN
Pulmonary HTN class III or IV or severe
152
What is the differential diagnosis for clubbing
1. Neoplastic intrathoracic disease
1. Bronchogenic carcinoma
2. mesothelioma
2. Suppartive intrathoracic diseases
1. Lung abcess
2. Empyema
3. Bronchiectasis
4. CF
3. Diffuse pulmonary disease
1. Pulmonary fibrosis
4. Cardiac disease
1. Cyanotic CHD
2. IE
5. GI diseases
1. IBD
6. Metabolic diseases
1. Graves
153
What are the contraindications to PFTs?
* Hemoptysis
* Pneumothorax
* Unstable cardiovascular status including recent MI
* Aneurysms
* Thoracic abdominal or cerebral
* Recent eye surgery
* Recent thoracic or abdominal surgery
* Presence of acute illness that may interfere with test performance
154
What are the contraindications to a methacholine challenge?
* Absolute
1. Severe airflow limitation: FEV1\<50% or \<1L
2. MI or stroke in last 3 months
3. Uncontrolled HTN: BP 200/100
4. Known aortic aneurysm
* Relative
1. Moderate airflow limitation: FEV1\<60% or 1.5L
2. Pregnancy or nursing mothers
3. Use of cholinesterase inhibitor
155
What can cause an _isolated_ decrease in DLCO
1. pulmonary hypertension
2. Early ILD or emphysema
3. Anemia
156
What can cause an _increase_ in DLCO?
1. Pulmonary hemorrhage
2. polycytemia
3. L heart failure
157
What causes a restrictive pattern of PFTs which varies with position
Diaphragm dysfunction
158
Name predictors of adverse perioperative pulmonary events
1. Most important: Site of surgery
1. aortic\>intrathoracic\>upper abdo\>abdominal
2. Age
3. Lung disease
159
What is the role of pre-op PFTs and perfusions scans
Calculation of post-op FEV1 and DLCO
160
What can cause diaphragmatic weakness?
1. Idiopathic
2. Trauma or surgery (C3,4,5)
3. Mechanical ventilation
4. Myopathy, neuropathy
1. ALS
2. MG
3. Critical illness myopathy/neuropathy
161
What is the most **sensitive** and the most **specific** test to rule out diaphragmatic weakness
Most sensitive=MIP
Most specific: Not clear. try US. On PFTs probably FVC
