Respirology Flashcards
What is a positive methacholine challenge?
PC20<4 mg/mL (FEV1 drops by 20% at a methacholine concentration less than 4).
What are the 5 steps in pharmacologic management of asthma?
- ICS-LABA prn
- ICS standing with SABA prn
- ICS/LABA standing with SABA prn
- ICS/LABA standing and prn OR medium dose ICS/LABA standing and SABA prn.
- Tiotropium, macrolides (r/o NTM and bronchiectasis), oral steroids, omalizumab (IgE 30-700), mepolizumab (eosinophils > 300)
What three conditions are treated well with LTRAs?
Aspirin-induced asthma, exercise-induced asthma, allergic rhinitis.
What is Samter’s triad?
Asthma, nasal polyps, sensitivity to ASA/NSAIDs.
How do you treat ABPA?
Prednisone +/- itraconazole.
How do you diagnose severe COPD?
COPD - post-bronchodilator FEV/FVC<70%.
Severe - FEV1<50%.
Name three interventions that have mortality benefit for COPD?
Smoking cessation, pulmonary rehabilitation, home O2 (PaO2<55 or <60 if hct >56%, MPAP>20 mmHg, bilateral edema).
Name two new recommendations from the CTS 2019 COPD guidelines?
- Stress importance of screening women in developed countries for COPD due to exposures to smoke and biomass fuel.
- Everyone gets screened for a1AT upon COPD diagnosis.
What are the two GOLD criteria for COPD stratification?
mMRC breathlessness scale >1 and 2+ exacerbations/year or 1+ exacerbations/year requiring hospitalization.
What are the indications for inhaled corticosteroid therapy in COPD?
Symptoms or exacerbations while on LAMA/LABA, peripheral eosinophils>300.
After starting triple therapy, which three add-on interventions reduce COPD exacerbations?
Roflumilast, azithromycin, NAC.
Who is a candidate for home BiPAP for COPD?
Chronic daytime pCO2>52 and at least 1 hospitalization for acute respiratory failure in the past year.
Ten treatment options for bronchiectasis.
Airway clearance, pulmonary physiotherapy, vaccines, bronchodilators, home O2, chronic antibiotics, mucolytics (DNAse only for CF, hypertonic saline), BiPAP, resection for local disease, transplant.
What four conditions must be ruled out before diagnosing interstitial pulmonary fibrosis?
- CTD (RA, DM, SS, sjogren’s MCTD).
- Drugs and radiation (MTX, amiodarone, Macrobid, bleomycin, checkpoint inhibitors).
- Hypersensitivity pneumonitis (mould, water, birds).
- Pneumoconioses (asbestos, silicosis).
What are the radiographic features of UIP?
Reticular changes, honeycombing, subpleural, basal predominant, absence of inconsistent features (nodules, consolidation, ground glass opacities, cysts).
What is suggestive of an IPF exacerbation?
CT chest showing new ground glass opacities on top of chronic UIP pattern, worsening dyspnea, hypoxemia.
Name 6 causes of exudative pleural effusion.
Malignancy, parapneumonic effusion, tuberculosis, benign asbestos effusion, rheumatoid arthritis, pulmonary embolism.
What are the most sensitive and specific findings for exudative effusion?
Sensitive: all three Light criteria absent.
Specific: cholesterol level>55mg/dL, LDH>200, pleural/serum cholesterol>0.3.
What causes a low pleural glucose (<3 or pleural/serum <0.5)?
<3 - malignancy, TB, lupus.
<1 - rheumatoid arthritis, empyema.
What size primary pneumothorax requires chest tube insertion?
> 2 cm.
What are the features of Heerfordt’s syndrome?
Anterior uveitis, parotid enlargement, facial palsy, fever.
What are the three organs that can cause life-threatening sarcoidosis and how would you work them up?
Ocular - anterior uveitis, refer to ophtho if symptoms.
Neurologic - CN palsy, MRI brain.
Cardiac - new block or cardiomyopathy, screen with ECG, refer for cMRI if abnormal.
How do you diagnose obstructive sleep apnea?
Symptoms (sleepiness, choking, awakenings) and objective testing (>5 apnea/hypopnea events during sleep monitoring).
What conditions are associated with type 1 pulmonary hypertension?
HIV, CTD, portal hypertension, schistosomiasis.
What is the calculation and normal range for the A-a gradient?
A-a = 150 - 1.25 x pCO2 - pO2.
A-a > age/4 + 4 is abnormal.
What are follow up guidelines for single, low risk pulmonary nodule?
< 6mm, no follow up.
6-8mm, CT at 6-12 months then repeat a year later
> 8mm, CT at 3 months +/- PET +/- bx
What are the radiologic findings of NSIP?
Ground glass opacities, reticular changes, traction bronchiectasis, no honeycombing.
What three tests are specific for clubbing?
Interpalyngeal depth ratio > 1.0 (DPD/IPD), Lovebond’s angle > 176, hyponychial angle > 192.
What does variable extrathoracic obstruction look like on PFT and what causes it?
Flat inspiratory (lower) curve, vocal cord dysfunction.
What does variable intrathoracic obstruction look like on PFT and what causes it?
Flat expiratory (upper) curve, tracheomalacia
What does fixed upper airway obstruction look like on PFT and what causes it?
Both curves flat, Wegner’s, sarcoid, polychondritis.
Name 4 causes of isolated reduced DLCO.
Early ILD, early empyema, pulmonary hypertension, anemia.
What are 4 contraindications to methacholine challenge?
- FEV1<50% or <1L
- Recent MI or stroke in past 3 months
- BP>200/100
- Known aortic aneurysm
What are risk factors for primary pneumothorax?
Smoking
Family history
Marfan syndrome
Thoracic endometriosis
When should you step down therapy for asthma?
symptom control x 2 months and low risk of exacerbations.
What are causes of high pleural fluid eosinophilia?
Abestos drugs (nitrofurantoin) malignancy infection (parasitic) PE eGPA
What workup should you obtain for everyone for bronchiectasis?
PFT, Chest CT CBC, IgE, serum immunoglobulins Sweat chloride test Nasal nitric oxide Sputum cultures
What are indications for chest drain for parapneumonic effusions?
Drainage of frank pus/cloudy
positive gram stain/culture
pH < 7.2, or glucose < 3.4
> 50% of hemithorax or loculation on imaging
What are causes of pleural fluid lymphocytosis?
TB vs lymphoma most common
Carcinoma, sarcoidosis, RA, yellow nail syndrome also possible
When should take away drivers license for someone with OSA?
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
Non compliant with therapy
What are follow up guidelines for single, high risk pulmonary nodule?
< 6mm May warrant repeat CT
6-8mm CT 6-12 months, the repeat at 2yr
>8mm CT at 3 month, PET/CT or bx
What are causes of upper lobe ILD?
HASTEN
Hypersensitivity pneumonitis Ankylosing spondylitis Sarcoidosis, silicosis TB Eosinophilic granulomas Neurofibromatosis
What are causes of lower lobe ILD?
BAD RASH
Bleomycin
Amiodarone
Drugs (methotrexate, cyclophosphamide, macrobid)
Rheumatoid lung
Asbestosis/Aspiration
Scleroderma
Hamman-Rich syndrome (idiopathic pulmonary fibrosis)
What is silica exposure associated with?
TB, lung cancer, fibrosis, RA, airflow limitation
