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Boards Review > USMLE Pulmonary > Flashcards

USMLE Pulmonary Flashcards

1
Q

Ventation Adjustment

For Oxygenation

for Ventelation (lower CO2)

A
  • *• Oxygenation (increase PaO2)**
  • FiO2
  • PEEP
  • Increase inspiratory time
  • Increase mean airway pressure
  • *• Ventilation (eliminate PaCO2)**
  • Rate
  • Tidal Volume
  • Increase expiratory time (by lowering RATE)
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2
Q

A hypoxia altitude simulation test can be used to predict in-flight hypoxia in patients with COPD

A

Exercise stress test, 6-minute walk test, and pulmonary function tests are part of a pulmonary rehabilitation program or are used to evaluate dyspnea or changes in symptoms. These tests do not play a role in predicting in-flight hypoxia.

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3
Q

Acute Eosinophilic Pneumonia

Vs

Chronic Eosinophilic Pneumonia

A

AEP:

  • High fever, non productive cough, dyspnea, bibasilar inspiratory crackles
  • Hypoxemic respiratory failure
  • Dx:
    • Xray/CT BL Difuse ground glass and reticular opacities
    • Bronchoalveolar lavage > 25% Eosinophils
    • Lung bx: Interstitial and alveolar eosinophils

CEP:

  • Fever cough, progressive dyspnea
  • Rare respiratory Failure
  • Dx:
    • Elevated ESR/CRP
    • IDA (increase plt)
    • Xray: bl peripheral pleural based infiltrates
    • Bronch lavage: > 25% eosinophils
    • Lung Bx: interstitial alveolar eosinophils
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4
Q

Apnea-Hypopnea Index

A
  • The number of apneas and hypopneas
    per hour of sleep
    • Mild OSA = AMI > 5-15/hour associated
    with symptoms
    • Moderate OSA = AMI > 15-35/hour
    • Severe OSA = AMI > 35/hour
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5
Q

ARDs DDx

A

Differential Diagnosis
• Hemodynamic pulmonary edema (CHF, volume overload)
• Diffuse alveolar hemorrhage
• Acute interstitial pneumonitis (Hamman-Rich syndrome)
• Lymphangitic spread of cancer

CHF / Cardiomegaly, Cephlization

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6
Q

Cardiogenic Shock

A

• Results from pump failure and decreased
cardiac output
• Main categories:
- Myopathies
- Arrhythmia
- Mechanical
- Extracardiac/obstructive

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7
Q

Cardiac Temponade

A
  • Pulsus paradoxus
  • Rapid X descent in the neck vein
  • Hypotension
  • Tachycardia
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8
Q

Classifying the Tuberculin Reaction

> 10 mm induration /not erythema

A

• Recent arrivals from high-prevalence countries
• Injection drug users
• Residents and employees of high-risk congregate settings
• Persons with clinical conditions that place them at high risk
- Immunosuppressed
- Diabetes
- Renal Failure
- Hematologic Malignancy

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9
Q

ARDS

A

• P/f ratio (PaO2 / FIO2)- FIO2 100% = 1 / 90% = 0.9
< 200 for ARDS
< 300 for ALI
• Acute onset
• CXR with bilateral infiltrates compatible with pulmonary edema
• Also must rule out cardiogenic pulmonary edema
- PAWP< 18
- No evidence of increased Left Atrial Pressure
• Diffuse Alveolar Damage (DAD) -Histopathologic manifestation of ALI/ARDS

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10
Q

Clinical Factors / Higher risk for cancer

A

• Age greater than 35 years

  • Age < 35, cancer in 1%
  • Age > 50, 15 times greater chance of malignancy

• Smoking history
- Profound impact on the probability of an SPN being malignant

• History of prior malignancy
- In 50-70% of patients with known cancer, the SPN is a metastatic lesion

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11
Q

COPD FEV1 < 60%

What is needed

A
  1. Mono inhaled bronchodilator
    1. long-acting inhaled anticholinergics (Tiotropium) or
    2. long-acting inhaled β2-agonists
  2. ICS must be with B2 agonist (long acting)
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12
Q

COPD STAGES

A

All stages are FEV1/FVC%

STAGE I - FEV1 80%

STAGE II 50-80%

STAGE III 30-50 %

STAGE IV < 30%

Stage II and III respond better to Tiotropium

Anything Less then 60%

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13
Q

CURB 65

A

Confusion

Urea > 20

Respiratory > 20

Blood pressure < 90/60

AGE > 65

Hospitalize

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14
Q

D-dimer assay

A
  • must be done 3 to 4 weeks after warfarin therapy is stopped
  • D-dimer assay performed after a period of anticoagulation therapy have been shown to be predictive of thrombotic recurrence.
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15
Q

DDX

  • Nocturnal asthma
  • OSA
  • GERD
A

Nocturnal Asthma

  • Difficulty to initiate and maintain sleep
  • up w cough / wheezing
  • Responds to Albuteral
  • Trail of LABA with steriods

OSA

  • Difficult to maintain sleep
  • Daytime sleepiness
  • Gasping w awakening and sensation of chocking

GERD

  • Reflux
  • worsen at night / with feeling of heartburn
  • PPI
  • Not the most common cause of Asthma
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16
Q

Delayed diagnosis of mild form of cystic fibrosis

A

Cystic fibrosis are diagnosed during childhood; however, delayed diagnosis can occur in patients with a mild form of cystic fibrosis, who are often misdiagnosed as having asthma when the symptoms are limited to the respiratory tract.

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17
Q

Diagnose a malignant pleural effusion.

A

next step in the evaluation of this patient’s pleural effusion is to repeat thoracentesis and repeat pleural fluid cytology.

  • 65% of positive results obtained on the initial sampling, 27% on the second, and 5% on the third
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18
Q

Diagnose an acute exacerbation of idiopathic pulmonary fibrosis.

A
  • Diagnostic criteria

unexplained worsening of dyspnea in less than 30 days,

high-resolution CT showing new b/l ground-glass opacity and/or consolidation superimposed on a background of findings consistent with usual interstitial pneumonia

no evidence of alternative causes.

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19
Q

Diagnose cryptogenic organizing pneumonia.

A

Cryptogenic organizing pneumonia presents with cough and other symptoms suggestive of community-acquired pneumonia, but the diagnosis should be considered when symptoms and clinical findings persist despite one or more courses of antibiotics.

CT demonstrates bilateral patchy ground-glass opacities and bilateral, lower lobe–predominant, subpleural consolidations

bronchiolitis obliterans organizing pneumonia (BOOP) / COP is the idiopathic form of BOOP.

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20
Q

Diagnose pulmonary arterial hypertension

A

Right heart catheterization is essential to confirm the diagnosis of pulmonary hypertension by direct measurement of mean pulmonary artery pressure.

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21
Q

Diagnose vocal cord dysfunction.

A

During attacks, VCD can be difficult to distinguish from asthma. Potential clues include sudden onset and abrupt termination of the attacks, lack of response to asthma therapy, prominent neck discomfort, lack of hypoxemia, and lack of hyperinflation on chest radiography.

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22
Q

FAMILY Meeting

SPIKE

A

Setup situation/room

Perception of Dz (do they know what the dz is)

Invitation (how much they want to know)

Knowledge (give info of what is the future)

Empathic (I’m sorry)

Strategy (End of life discussions)

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23
Q

Glipizode vs glyburide

A

Glipizide has a shorter life then glyburid

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24
Q

Fat Embolism

A

Seen in

  • Orthopetics surgery
  • Pancreatitis
  • Sick cell
  • Fractures

Symptoms after 24-72 hrs

  • Respiratory Distress
  • Petechia
  • Neurological symtoms
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25
Q

Hemodynamic Profiles of the Shock States

Chart

A
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26
Q

Human Monocytic ehrlichiosis

A

Fever / Malaise, myalgia, chills, HA

Rash (macular, maculopapular, petechial)

Neurologic sx: stiff neck / altered menation

LABS: thrombocytopenia / elevated AST nad ALT LDH ALK

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27
Q

Hypovolemic Shock

A

• Result of decreased preload
• CO = HR x SV, and SV depends on preload
• Decrease in preload therefore leads to
decrease in CO
• Fluid loss
- Diarrhea, Vomiting, Heat Stroke, Burns
• Hemorrhage
- Trauma, Gl Bleeding, Ruptured Aneurysm or Hematoma, Fractures

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28
Q

idiopathic pulmonary fibrosis.

A

Idiopathic pulmonary fibrosis is characterized by progressive dyspnea and cough for more than 6 months and dry inspiratory crackles; classic CT findings include basal and peripheral disease with evidence of honeycomb changes without evidence of ground-glass opacities or nodules.

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29
Q

Ionotropics and Vasopressors

NE

Dopamin

Dobutamin

Vassopressin

A

NE:

  • alph 1 > B1 AE: arrhythmias

Dopamin:

  • Dopaminergics / vasodialation of renal and mesentary / higher risk of arrhythmias

Dobutamin:

  • B >> Alpha recepteros / AE: Hypotension

Vassopressin:

  • Vaso constrictions V1 / delayed onset
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30
Q

Lemierre’s Syndrome

A

Sx: Recent sore throat / neck pain / septic embolism

Labs: WBC > 15000 / CXR / CT Neck show jugular thrombophlebitis

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31
Q

Inhaled Corticosteriods ICS

Needed when FEV1<

Used in conjunction with

Side effects

A
  • FEV1< 60%
  • LABA
  • Dyphonia, Skin bruising, Oral candidiasis
  • Increase risk of pneumonia
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32
Q

Limiting VALI

A
  • Target VT < 6 mL/kg IBW
  • Plateau pressure < 30 cm H2O
  • Best PEEP
  • Permissive hypercapnia

LOWER TIDAL VOLUMES is OK / may cause some hypercapnia - itssss OK buddy

• Oxygen toxicity with high levels of inspired
oxygen cause physiologic and pathologic
changes similar to ARDS
• FiO2 < 0.6 is considered safe

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33
Q

Low-molecular-weight heparin and fondaparinux in advanced kidney disease.

A

Low-molecular-weight heparin and fondaparinux are contraindicated in the setting of advanced kidney disease.

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34
Q

Lung volume reduction surgery

A

Patients on max therapy and have had rehab

  • presence of b/l emphysema
  • bronchodialater total lung capacity > 100 or residual volume greator then 150% of predicted
  • FEV1 of no > 45%
  • and PCO2 no > 60 or PO2 at least 45
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35
Q

Löfgren syndrome

Tx

A

80% of patients with sarcoidosis who present with Löfgren syndrome have spontaneous resolution

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36
Q

Manage acute pulmonary embolism

A

Use **unfractionated heparin **/ LMWH is more difficult to assess than unfractionated heparin. Additionally, because these agents are long acting and not readily reversible, their use would be problematic if the patient became hypotensive and a decision was made to treat with thrombolytic agents or clot extraction.

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37
Q

Manage acute respiratory distress syndrome

A

In patients with acute respiratory distress syndrome, a lung-protective strategy of low tidal volume (6 mL/kg predicted weight) and plateau pressure less than 30 cm H2O is associated with reduced mortality.

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38
Q

Manage hypertensive emergency.

A

In general, the mean arterial pressure should be lowered by no more than 25% in the first hour of treatment and subsequently decreased to systolic levels of 160 mm Hg and diastolic levels between 100 and 110 mm Hg in the next 2 to 6 hours

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39
Q

Manage tricyclic antidepressant overdose.

A

Sodium bicarbonate is the best therapeutic agent in the setting of tricyclic antidepressant overdose

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40
Q

Manage immunizations in a patient with COPD.

A

Influenza recommended annually / High-dose influenza for patients 65 years and older.

One-time revaccination is recommended for patients who were vaccinated 5 or more years ago and were less than 65 years of age at the time of primary vaccination.

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41
Q

Manage ventilatory failure in a patient with Guillain-Barré syndrome

A

Plasma exchange and intravenous immune globulin are both recommended treatment options for patients with Guillain-Barré syndrome (GBS), including its most common variant, acute inflammatory demyelinating polyneuropathy.

  • Systemic corticosteroids are no longer recommended
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42
Q

Manage dyspnea in a patient with end-stage COPD.

A

Opioids are effective in reducing dyspnea in patients with end-stage COPD. palliative care

Low-dose (20-mg) extended-release morphine given daily has been used to relieve dyspnea in patients with advanced COPD.

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43
Q

Measures 8 to 30 mm in a Patient with
Acceptable Surgical Risk

Solitary pulmonary Nodule < 30 mm

A

Low probability :

Serial nigh-resolution CT at 3,
8,12, and 24 months

Intermediate:

Additional Testing + above

PET imaging / Contrast-enhanced CT,
/ Transtrioradc fine-needle aspiration biopsy vs.
Bronchoscopy/ if airbronchopm
present or if operator has expertise with

High Risk

Video-assisted thoracoscopic surgery; examination of a frozen section, followed by resection if
nodule is malignant

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44
Q

Mediastinal LAD

A

Bronch and Transbronchial lung bx recommended

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45
Q

Modes of Ventilation

Assist/Control Ventilation

Pressure Controlled Ventilation (PCV)

Synchronized IMV(SIMV)

A

Assist/Control Ventilation
• Rate(minimal set) and Tidal volume are set
• Pressure is variable
• The patient can trigger breaths at a faster rate
than the set minimum, but only the set volume is
delivered with each b reath

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46
Q

Modes of Ventilation

Assist/Control Ventilation

Pressure Controlled Ventilation (PCV)

Synchronized IMV(SIMV) (not used as much)

A

Synchronized IMV(SIMV)
• At a predetermined interval (respiratory rate), which is set by the operator, the ventilator waits for the patient’s next inspiratory effort
• When the ventilator senses the effort, the ventilator assists the patient by synchronously delivering a mandatory breath

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47
Q

Modes of Ventilation

Assist/Control Ventilation

Pressure Controlled Ventilation (PCV)

Synchronized IMV(SIMV)

A

Pressure Controlled Ventilation (PCV)
• Time or patient triggered, pressure targeted (limited), time cycled ventilation
• The operator sets the length of inspiration (Ti), the pressure level, and the backup rate of ventilation
• Tidal Volume is variable
- Based on the compliance and resistance of the patient’s lungs, patient effort, and the set pressure

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48
Q

lung volume reduction surgery

A

FEV1 of less than 20% of predicted and either a DLCO of less than 20% of predicted or homogeneously distributed emphysema are considered high risk

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49
Q

Modes of Ventilation

  • Spontaneous Modes
  • Pressure Support Ventilation — PSV
A

CPAP
• Helpful for improving oxygenation in patients with refractory hypoxemia and a low FRC (Functional Residual Capacity)
• CPAP setting is adjusted to provide the best oxygenation with the lowest positive pressure and the lowest FiO2

Pressure Support Ventilation — PSV
• Patient triggered, pressure targeted, flow cycled mode of ventilation
• Requires a patient with a consistent spontaneous respiratory pattern
• The ventilator provides a constant pressure during inspiration once it senses that the patient has made an inspiratory effort

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50
Q

Myopathy ICU

  • Critical illness myopathy
  • Rhabdomolysis
  • Guillain Barre Syndrome
  • Prolonged neuromuscular blockade
A

CK elevated

  • Critical illness myopathy
  • Rhabdo

Flaccid Limbs

  • Prolonged neuromuscular blockade
  • Critical illness myopathy

Myalgia

  • Rhabdomyolysis

Prolonged neuromuscular blockade

  • Transient improvement after anticholinestrase

Post infection

  • GBS
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51
Q

Narcolepsy

A
  • Severe daytime hypersomnolence
  • Cataplexy
  • Sleep paralysis
  • Hallucinations when drowsy
  • Polysomnography and Multiple Sleep Latency Test (MSLT) checks hypersomnolence and frequency of rapid eye movement (REM)
  • Treat: stimulants and REM suppression by tricyclic antidepressants and selective serotonin reuptake inhibitors
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52
Q

Non-Small Cell Lung Cancer (NSCLC)

Histologic Cell Types

A
  • 80% of all lung cancers
  • Better survival rates when found in early stages

NSCLC: Histologic Cell Types
• Adenocarcinoma
• Squamous Cell Carcinoma
• Large Cell Carcinoma

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53
Q

Noninvasive Positive pressure ventilation

  • Indications (strongest evidence)
  • CI
A

Indicaitons

  • Sever COPD ph < 7.35 or hypercarbia
  • Acute respiratory failure from cardiogenic pulmonary edema
  • Facilitate early extubation and prevent extubation failure in COPD
  • Hypoxemic respiratory faileure post abd/lung surgery
  • immunosuppressed pt with ARD

CI

  • Unstable cardiac arrhythmia
  • Encephalopathy/GI bleed
  • Respiratory / cardiac arrest
  • Sever Acidosis < 7.1
  • Sophageal anastomosis
  • ARDS
  • Uncooperative / agitated
  • inability to clear secreation
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54
Q

Lung Cancer: Paraneoplastic Syndro mes

  • Non-Small Cell Lung Cancer
  • Small Cell Lung Cancer
A

Lung Cancer: Paraneoplastic Syndromes
• Non-Small Cell Lung Cancer
- Hypercalcemia
- Hypertrophic pulmonary osteoarthropathy
• Small Cell Lung Cancer
- Inappropriate secretion of ADH
- Ectopic ACTH secretion
- Eaton-Lambert syndrome

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55
Q

Normal Pressures

CVP

RV

PA

PCWP

LV

A

Central venous pressure 3–8
R ventricular pressure systolic 15–30
diastolic 3–8
Pulmonary artery press. systolic 15–30
diastolic 4–12
Pulmonary vein/
Pulmonary capillary 2–15
wedge pressure

L ventricular pressure systolic 100–140
diastolic 3-12

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56
Q

LUNG Ca and treatment

A

Tumor has spread to lymph nodes associated with the lung is good for surgery

Anything worse than above no surgery

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57
Q

NSCLC: Treatment Outcomes

A

NSCLC: Treatment Outcomes
Stage 5-Year Survival
Stage I 60-80%
Stage II 40-50%
Stage IIIa 25-30%
Stage IIIb 5-10%

Stage IV < 1%

58
Q
  1. obesity hypoventilation syndrome (OHS)
  2. Cheyne-Stokes breathing
A

daytime hypercapnia (arterial P<small>CO</small>2 >45 mm Hg [6.0 kPa]) that is thought to be a consequence of diminished ventilation related to extreme obesity.

  • Cheyne-Stokes breathing

central sleep apnea characterized by a crescendo-decrescendo ventilatory pattern. It is most commonly seen in men with advanced left ventricular dysfunction who are typically older and thinner than this patient.

59
Q

Lofgren’s

A

Bilateral ankle arthritis

Erythema nodosum

Hilar Adenopathy

60
Q

opioid intoxication.

A

nonfocal neurologic examination, pinpoint pupils, shallow respirations, respiration rate less than 12/min, and hypothermia

61
Q

OSA

SNORING / who to assess for OSA

A
  • Excessive daytime sleepiness?
    • ** ORDER PSG**
  • No Excessive daytime sleepiness
    • > 2 Clinical OSA features
    • ORDER PSG

IF AHI > 15 or AHI > 5 + OSA signs and symptoms start on CPAP

Snoring

Large neck

Hypertension

Day time sleepiness

62
Q

PCN skin testing

A

PCN the treatment of choice for neurosyphilis

Skin test if positive will need to have to desensitize the patient

63
Q

Lithium Toxicity

Acute

Chronic

A
  • No need for charcoal / diuresis, ipecac
  • HD indicated with levels > 4 or levels > 2.5 with symptoms
  • Acute: N/V diarrhea and late developemnt of neurologic symptoms
  • Chronic: Neurological symptoms at times Nephrogenic DI or thyroid dysfunction
64
Q

PE What to look for

ABG / EKG / DX test / Rule out test

A
  • D-Dimer (only to rule out / outpatient)
  • ABG A-a Gradient: ~> 20 / Alkalosis / Hypoxia
  • EKG S1Q3T3 / RBBB / Tachy
  • Diagnosis: Spiral CT/Multislice
65
Q

PEEP

Positive End-Expiratory Pressure

A

• Helps prevent early airway closure and alveolar
collapse at the end of expiration by increasing
(and normalizing) the functional residual capacity
(FRC)ofthe lungs
• Facilitates better oxygenation

66
Q

Persistent cough

A

CXR

if normal then

  • Empiric oral 1st generation Antihistamins for postnasal drip +/- nasal steriod or nasal antihistamin

if still persistent need to work up

  • Asthma
  • GERD
  • Non asthmatic eosinophillic bronchitis
  • Chronic sinusitis
67
Q

Pleural effusion analysis

Pleural protien / serum protien >0.5

Pleural LDH / Serum LDH > 0.6

LDH > 2/3 of normal

A

Tansudate

  • CHF
  • Cirrosis
  • Nephrotic synd
  • PD dialysis

Exudate

  • Cancer
  • Infections
  • CABG
  • PE

RA PH < 7 / LDH > 1000 / Glucose < 30

68
Q

PE in pregnancy

A

US LE - if positive then treat

US LE -ve then CXR

if normal V/Q scan

If abnomal then CT angio

LMWH is preferred tx for PE until 6 weeks post partum

69
Q

Pleural Fluid and Need for Drainage

A
  • An effusion > 40% of hemithorax
  • Presence of air-fluid level
  • Presence of loculations or multi-loculations
  • Marked thickening of pleural membranes on CT
  • Failure to respond to antibiotics
  • Continued fever
  • Positive Gram stain or bacterial culture: strong indication for drainage
  • Low pH (< 7.25)
  • Low glucose
  • High LDH> 1,000
70
Q

llergic Rhinitis

A

Sneezing, watery nasal discharge and pale turbinates ( tx Nasal corticosteriods)

71
Q

Pneumothorax what to do

< 2 cm

> 2 cm

A

Secondary spontaneous pneumothoraces, outpatient management is discouraged; even small (

72
Q

HIV prophylaxis CD 4 Counts

200

150

100

50

A

CD4 Count

  • Bactrim / Dapson / Atovaquone
  • Can stop the meds once CD4 > 200 for 3 months
  • Itraconazole

< 100 or +Ve IgG antiboeis - Toxoplasmosis

  • Bactrim / Dapson + pyrimethrine + leucovorine

< 50 Mycobacterium Avium Complex

  • Azithromycin / Clarithromycin / Rifabutin

VZV - Close contact with sick patients

  • Varicella immune globulin or IVIG within 4 days of exposure
73
Q

posterior mediastinal mass most likely is

A

neurilemmoma (or schwannoma), a benign neoplasm arising from neural tissue and characteristically located in the posterior mediastinum.

74
Q

PPD/TST induration

A
  • HIV / recent TB conatct / CXR fibrotic or nodular changes / transplant

< 10

  • Residents/prisoners / Recent immigrants / IV drug users / childeren exposed to adult TB

TX if positive

  • INH + Rifampentine for 3 months (not for HIV)
  • INH 9 months (give Pyridoxine with it)
  • Rifambin for 4 months
  • INH and Rifampin for 4 months
75
Q

Prevent high-altitude illness.

A

When gradual ascent to the target elevation is not feasible, acetazolamide is the most effective therapy to prevent acute mountain sickness and high-altitude periodic breathing.

Acute Mountain sickness -AMS -The key feature of AMS is headache, along with fatigue, nausea, and sleep disturbance (usually due to high-altitude periodic breathing [HAPB], an altitude-associated respiratory change).

76
Q

Distributive Shock

A

• Causes
- Sepsis
- Pancreatitis, burns, multiple trauma
- Anaphylaxis
- Drug or toxin reactions (Insect bites,
transfusion reactions, heavy metal poisoning)
- Addisonian crisis
- Myxedema coma

77
Q

Pulmonary Capillary Wedge Pressure

A

Left Ventrical End Diastolic Pressure
• If increased, suggestive of elevated volume
• Balloon is inflated, a pressure reading is taken,
the balloon is deflated
• Leaving the balloon inflated will INFARCT
the lung!

78
Q

Pulmonary fibrosis

  • Upper lung
  • Lower lung
A

Upper lung

  • Silicosis / must screen for TB

Lower lung

  • Idiopathic pulmonary fibrosis
79
Q

Pulmonary HTN

A

Group1

  • Due to idiopathic PAH

Group 2

  • Due to left heart disease

Group 3

  • Lung Dz (COPD, ILD, Chronic Hypoxemia)

Group 4

  • Thromboembolic Occlusion of pulmonary vasculature

Group 5

  • Blood D/O
80
Q

Diagnose neuromuscular respiratory failure.

A
  • Patients with vital capacity less than 20 mL/kg
  • patients who cannot generate more than 30 cm H2O of negative inspiratory force
  • patients with declining values are at high risk for ventilatory failure.
81
Q

pulmonary silicosis with pulmonary nodule (upper lung)

A

Evaluate for tuberculosis

82
Q
  1. Diagnose a tuberculous pleural effusion
  2. parapneumonic effusion
A
  1. denosine deaminase level greater than 70 units/L
  2. 10,000 per microliter (10 × 109/L) with a predominance of neutrophils
83
Q

Quick Points / Ventilation

A

• Volume control: Set volume, pressure is variable
• Pressure control: Set pressure, volume is variable
• CPAP and PSV for spontaneously breathing
• Oxygenation: PEEP, FiO2, inspiratory time
• Ventilation: rate, tidal volume, expiratory time
• Adverse effects: barotrauma, airway issues,
VAP, hypotension
• Liberation: wean screen, SBT, airway protection

84
Q

Quick Points ALI

A

• Acute bilateral infiltrates, P/f ratio < 200, no evidence of CHF
• Causes: pneumonia, sepsis, aspiration, trauma, transfusions
• Physiology: severe hypoxemia by shunt and V/Q mismatch
_• Low tidal volume strategy: < 6 mL/kg of IBW
• Maintain plateau pressure < 30 cm
• Permissive hypercapnia_
• Steroids may help early

85
Q

Quick Points Lung cancer

A
  • Lung cancer: #1 cause of cancer related deaths
  • SMOKING, SMOKING, SMOKING!!
  • Symptoms usually when advanced

• Paraneoplastic:
- NSCLC: hypercalcemia
- Small cell: inappropriate secretion of ADH,
ectopic ACTH secretion,
Eaton-Lambert syndrome

• Non-small cell: 80% of all cancers
- No surgery for metastatic or stage NIB
• Small cell: responsive to chemotherapy, high
recurrence rate, limited vs. systemic staging
• Terrible prognosis

86
Q

Quick Points Plural Effusion

A
  • Transudate: CHF, nephrotic, hepatic hydrothorax
  • If exudative, need further evaluation
  • Parapneumonic: complete drainage if with organisms, large, loculated, low PH, high LDH
  • Low glucose: rheumatoid, empyema
  • TB: high protein, lymphocytic, minimal mesothelial cells, high ADA
87
Q

Quick Points

**Pulmonary Embolism **

A

Quick Points
• Risk factors: stasis, immobility, hypercoag state
• CTA now diagnostic test of choice but need contrast
• Treat empirically with high clinical pre-test probability
• LMWH superior to UFH
• Warfarin for long term (except cancer or pregnancy)
• TPA for HD unstable, severe hypoxemia, no change survival
• High-risk prophylaxis: LMWH, then UFH

88
Q

Criteria to wean off Vent

A

Spontaneous breathing for >2 hrs then check

  • RSBI < 105 (Breaths per min / Tv L)
  • Good mental status
  • Few secretion
  • Strong Cough
  • Absent upper airway lesions

If not place on assist control

Consider tracheostomy after 10-14 days

89
Q

Quick Points Sepsis

A
  • Sepsis: systemic inflammatory response to infection
  • Leads to hemodynamic collapse and can lead to multi-organ failure
  • Early cultures and antibiotics
  • Aggressive volume resuscitation
  • Vasopressor support
  • Aggressive volume resuscitation
  • Transfusions and inotropes helpful in early resuscitative phase
  • APACHE > 25 is high High High
90
Q

Quick Points Shock

A

Quick Points
• Hypovolemic shock: low preload
• Cardiogenic shock: low CO, bad pump
• Distributive (vasodilatory) shock: sepsis
- Decreased afterload or SVR
• PA catheter: no proven role in patients with shock
• PCWP: reflective of LVEDP, if high may be suggestive of CHF

91
Q

Quick Points TB

A

• TB spread by droplet
• Risk factors: HIV, silicosis, ESRD, steroids
• Latent TB
- 5 mm: HIV, recent TB contacts, old TB with
CXR changes, organ transplants
- 15 mm: anyone
- 9 months INH
• Active TB: upper lobe, anything goes in HIV
- 4 drugs for 2 months, 4 months INH/rifampin
- Use rifabutin if Pis or NNRTIs

92
Q

Radiation Pneumonitis

Time line

Tx

A

4-12 weeks after neck or thoracic radiation exposure with non responsive pneumonia

Tx : Prednisone for two weeks and taper of 3-12 weeks

93
Q

Rapid shallow breathing index (RSBI)

A

good peridictor of successful extubations …

pontaneous breathing trail for 2 hrs

===== Then

RSBI < 105

Good mental status

Few secretions

Strong cough

Absent upper airway lesions

======== If so Extubate

Else :

Place on Assist control

Daily SBTs

Consider Tracheostomy

94
Q

Classifying the Tuberculin Reaction

> 5 mm induration /not erythema

A

> 5 mm

  • Recent contacts of TB case
  • Persons with fibrotic changes on chest radiograph consistent with old healed TB
  • Patients with organ transplants and other immunosuppressed patients
95
Q

Risk Assessment

A

Cancer Characteristics
• Clinical
- Age
- Cigarette smoking
Active
Former
• 2nd Hand
- History of malignancy
- 1 ° relative with lung cancer

  • *• Radiographic**
  • Size
  • Shape
  • Calcification
  • Density
  • Growth rate
96
Q

Sarcoidosis

Stages

Tx

A

Stage I and II

  • b/l Hilar Adnopathy / paratracheal node enlargement
  • with reticular opacities

Stage III and IV

  • Retidular opacities with no or shrinking hilar adnopathy

Tx:

  • Steriods primary
97
Q

Complications of Nephrotic Syndrome

A
  • Protien malnutrition
  • Hypovolemia
  • Acute renal Failure
  • Thromboembolism
  • Infection
  • Proximal tubular Dysfunc. causing Vit D def
98
Q

SCLC: Staging

  • Limited Stage
  • Extensive Stage
A

SCLC: Staging
• Limited Stage
Defined as tumor involvement of one lung, the
mediastinum, and ipsilateral and/or contralateral
supraclavicular lymph nodes or disease that can
be encompassed in a single radiotherapy port
• Extensive Stage
Defined as tumor that has spread beyond one
lung, mediastinum, and supraclavicular lymph
nodes; Common distant sites of metastases are
the adrenals, bone, liver, bone marrow, and brain

99
Q

SCLC: Treatment

A

• Limited Disease

  • Chemotherapy
  • Concomitant Radiation
  • Prophylactic Cranial Irradiation

• Extensive Disease

  • Chemotherapy
  • Palliative radiation
100
Q

SEPSIS (Early goal directed algorithm for sepsis)

Central Venous Pressure : CVP

Central venous oxygen saturation: ScvO2

MAP

A
  • CVP < 8 mmHG
    • Crystalloid fluids if needed Vasopressors NE
  • CVP > 8 &
    • MAP < 65 then vasopressors NE
    • MAP > 65-90 & ScvO2 < 70 give PRBC if not working give Dobutamine
    • ScvO2 > 70% goal achieved
101
Q

CAP Tx

A

outpatient

Healthy : Macrolides or Doxy

With comorbidity: Flouroquin or b-lactam +mcarolide

Inpatient

Flouroquin or b-lactam and macrolide

Inpatient ICU

Blactam+ macrolide IV or Blactam + flouroquine IV

Lenght of treatement no change 7 days (bacteremia does not change therapy time)

102
Q

Sepsis Management: Resuscitation

A

Hypotension and/or a serum lactate > 4 mmol/L

  • Deliver an initial minimum of 20 mL/kg of crystalloid or an equivalent
  • Vasopressors for hypotension not responding to initial fluid resuscitation to maintain meanarterial pressure (MAP) > 65 mmHg (dopamine or norepinephrine)

Persistent hypotension despite fluid resuscitation and/or lactate > 4 mmol/L

  • Achieve CVP (Central Venous Pressure) > 8 mmHg
  • Achieve a ScvO2 (oxygen Sat in venous blood)> 70% or SvO2 > 65%
    • Hb goal 10
    • Dobutamine
103
Q

Shock / Physiologic determinants

Classification
• Hypovolemic
• Cardiogenic
• Distributive

A
  • Cardiac Output (CO) = heart rate x stroke volume Stroke volume depends on preload, myocardial contractility, and afterload
  • SVR = measure of tone in arterial bed
  • SVR and CO can be used to differentiate between forms of shock
104
Q

SIRS Criteria

  • Sepsis
  • Severe Sepsis
  • Septic Shock
A

• Temperature < 36° C or > 38° C
• Heart Rate > 90 bpm
• Respiratory Rate > 20 breaths/min
or PaCO2 < 32 mmHg
• White Blood Cell Count > 12,000 or
< 4,000 cells/mm3 or > 10% bands

  • Sepsis: Infection PLUS SIRS criteria
  • Severe Sepsis: Sepsis PLUS Organ dysfunction
  • Septic Shock: Sepsis PLUS Shock refractory to fluid resuscitation
  • SHOCK - High Lactate / ABG acidosis / Hypotension ….
105
Q

Small Cell Lung Cancer (SCLC)

A

Small Cell Lung Cancer (SCLC)
• Most aggressive lung cancer
• Responsive to chemotherapy and radiation but
recurrence rate is high even in early stage
SCLC: Cell Types
• Oat Cell
• Intermediate
• Combined

106
Q

Solitary Pulmonary Nodule

A

High Malignancy risk

  • Surgical Excision

Low malignancy risk

  • Serial CT scans

Intermedicate Malignancy Risk

  • < 1 cm Serial CTs
  • > 1 cm PET SCAN
  • then CT vs Excision
107
Q

Solitary Pulmonary Nodule

> 4 mm - 6 mm

A

With risk factors

  • Follow-up at 6- 12 months; if stable, followup at 18-24 months

Without risk factors

  • Follow-up at 12 months;no additional follow-up if stable
108
Q

Solitary Pulmonary Nodule

>6mm to 8mm?

A

With risk factors

  • Follow-up at 3- 6 months; if stable, followup at 9-12 months

Without risk factors

  • Follow-up at 6- 12 months; if stable, followup at 18-24 months
109
Q

Aspirin exacerbated respiratory disease

A
  • Avoid NSAIDS
  • Leukotrine recepter antagonist
  • ASA desensitization
110
Q

Solitary Pulmonary Nodule

=< 4 mm

A

With risk factors

  • Follow-up at 12 months;
  • no additional follow-up if stable

Without risk factors

  • Follow-up is optional
111
Q

Sweat chloride testing

α1-Antitrypsin level measurement

A

If CT changes of bronchiectasis

α1-Antitrypsin deficiency should be evaluated in selected patients with COPD because of the availability of specific therapy.

112
Q

Sympotms of impeding respiratory failure

A
  • pH 45
  • Clinical Signs of respiratory Failure
  • Respiratory rate > 25/min for 2 hrs
  • Hypoxemia
113
Q

TB HIV

ON HAART treatment or not?

A

RIF-based regimens generally recommended for persons

  • Who have not started antiretroviral therapy
  • For whom Pis or NNRTIs are not recommended
    • Isoniazid (INH)
    • Rifampin (RIF)
    • Pyrazinamide (PZA)
    • Ethambutol (EMB)

For patients receiving Pis or NNRTIs, initial treatment phase may consist of

  • Isoniazid (INH)
  • Rifabutin (RFB)
  • Pyrazinamide (PZA)
  • Ethambutol (EMB)

An alternative non-rifamycin regimen includes
INH, EMB, PZA, and streptomycin (SM)

114
Q

TCA overdose manifests

A
  1. Respiratory Depression
  2. Hypotension
  3. Tachycardia
  4. Seizures
  5. Coma
  6. Death
  7. Wide complex tachycardia QRS > 100

TX: Sodium bicarb if QRS prolonged (keep ph 7.45-7.55) if Ingestion of > 5 mg/kg then patint keep in Emergery room regardless of symptoms.

115
Q

The recommendation for step-up therapy in pregnant patient

A

similar to that for nonpregnant patients, with the understanding that it is safer for pregnant women to be exposed to asthma medications with lim ited human safety data than it is to experience ongoing symptoms and exacerbations of asthma.

116
Q

Asthma steps

If SABA is used > 2 days per week meas inadequate

A
  1. SABA
  2. 1+ Low dose ICS
  3. Low dose ICS + LABA or Medium ICS
  4. Meduim dose ICS + LABA
  5. High dose ICS +LABA and Omalizumab for patients with allergies
117
Q

Transudate vs. Exudate Causes

A

Causes of Transudates

  • CHF
  • Hepatic Hydrothorax
  • Nephrotic Syndrome
  • Hypoalbuminemia
  • Peritoneal Dialysis

Causes of Exudative Effusions

  • Parapneumonic
  • Empyema
  • Malignancy (carcinoma, lymphoma,
  • mesothelioma)
  • Pulmonary embolism
  • Tuberculous
118
Q

Alph 1 Antitrypsine Deficiency when to test for it?

A

Panniculitis (adipose tissue inflammation)

Early onset Emphysema < 45

Family history

Basilar emphysema on CXR

119
Q

Transudate vs. Exudate LABS

do not need thoracentesis if < 1 CM

A

Light’s criteria Exudate (one of following):

  • Pleural fluid protein/serum protein ratio greater than 0.5
  • Pleural fluid LDH/serum LDH ratio greater than 0.6
  • Pleural fluid LDH greater than two-thirds the
  • upper limits of normal of the serum LDH
  • Protien gradient > 3.1 and Albumin gradient > 2.1

Quick Hints

Other Studies
• Protein: high in exudates, > 4.0 g/dL in TB
• LDH: if > 1,000, consider empyema, malignancy, rheumatoid pleurisy, paragonimiasis
• Glucose: low level, < 60, suggests one of
the following:
- Rheumatoid pleurisy (less than 30)
- Empyema or complicated parapneumonic
- Tuberculous effusion

120
Q

Treat an acute exacerbation of idiopathic pulmonary fibrosis

A
  • vidence of an acute exacerbation of IPF without a known cause.
  • in-hospital mortality rates of 86% and 97% in this patient population.
  • Initiate palliation with narcotics
121
Q

Treat continuous positive airway pressure–related rhinitis.

A

The addition of in-line heated humidity to continuous positive airway pressure (CPAP) therapy is a simple, effective method to combat CPAP-associated nasal congestion.

Avoid Oxymetazoline nasal sprays - will develop medicamentosa

122
Q

Treat exercise-induced bronchospasm.

A

Use of a short-acting β2-agonist 10 to 15 minutes before exercise prevents exercise-induced bronchospasm in most patients.

123
Q

Treat hypoxemic respiratory failure with continuous positive airway pressure

A
  • CPAP may be used in patients who have respiratory failure after abdominal surgery.
  • NPPV may be used in patients who have respiratory failure after lung resection surgery.
124
Q

Treat neuroleptic malignant syndrome.

A

intravenous fluids and benzodiazepines such as lorazepam.

125
Q

ABPA Allergic Bronchopulmonary Asperigillosis

A

ALTICES

  • Asthma and Cystic fibrosis
  • Lung infiltrate on Xray
  • Test (skin) +ve for asapergillus
  • IgE > 400
  • Central Bronchiectasis
  • Eosinophilia > 500
  • Serum IgG and IgE for A fumigatus

TX: Steriods and Itraconazole

126
Q

Treat pulmonary metastases from colorectal carcinoma

A

•In patients with colorectal carcinoma with metastatic disease to the lung, surgical resection is the primary treatment and is associated with good long-term survival.

127
Q

Treatment Chart

High clinical suspicion for active TB

PIRE (PZA INH RIF EMB)

  • Isoniazid (INH)
  • Rifabutin (RFB)
  • Pyrazinamide (PZA)
  • Ethambutol (EMB)
A
  1. Place patient on initial-phase regimen:
    INH, RIF, EMB, PZA for 2 months
  2. Is specimen collected at end of initial phase (2 months) culturepositive?
    • No : Give continuationphase treatment of INH/RIF daily or twice weekly for 4 months
  3. Yes: Culter positive - Any cavitation on initial CXR?
    • Yes: Give continuation-phase treatment of INH/RIF daily or twice weekly for 7 months (or if HIV +)
  4. No Cavitation: HIV - Give continuation phase treatment of INH/RIF daily or twice weekly for 4 months
128
Q

Treatment Complications
HIT

A

Start direct thrombin inhibitor, like lepirudin or argatroban

129
Q

Unilateral diaphragmatic paralysis

A

Due to phrenic nerve injury C3-C5

Sniff test / Flouroscopy

130
Q

Vent setting what to do?

  1. PO2 high
  2. PO2 Low
  3. PCO2 High
  4. PCO2 Low
A
  1. PO2 high
    1. Decrease FIO3
  2. PO2 Low
    1. Increase PEEP
  3. PCO2 High
    1. Increase RR
    2. increase TV
  4. PCO2 Low
    1. Decrease RR
    2. Decrease TV
    3. Increase sedation
131
Q

Vent variables:

FiO2

Tidal Volume

PEEP

Respiratory Rate

A

FiO2 - effects PO2

PEEP effects PO2

Tidal Volume effects PCO2

RR effects PCO2

132
Q

Ventalation / Wean Screen

A
  • Adequate oxygenation: PO2 > 60 mmHg on FiO2< 0.4-0.5;
  • PEEP < 5-8 cm H2O
  • P/F ratio > 150-200
  • pH > 7.25
  • Stable cardiovascular system (e.g., HR
  • Ability to initiate spontaneous breaths
  • Resolution of disease acute phase
133
Q

Ventilation settings that increase exhaliation / fix air trapping

A

Decrease RR

Tidal Volume

Inspiratory time

134
Q

Well’s Criteria

A
  • Clinical Signs of DVT
  • An Alternative Diagnosis is less likelythan PE
  • HR>100beats/min
  • Immobilization or surgery in previous 4 weeks
  • Previous DVT/PE
  • Hemoptysis
  • Malignancy
135
Q

Wells Criteria

A

Score 3

  • Clinical Signs of DVT
  • PE highly on the list

Score 1.5

  • Prev PE
  • HR > 100
  • Recent Surgery

Score 1

  • Hemoptysis
  • Cancer

< 4 Do D-Dimer

136
Q

Evaluate a ground-glass pulmonary nodule.

A
  • Ground-glass–appearing pulmonary nodules require more than 2 years of follow-up with CT because they may represent slow-growing adenocarcinoma in situ (formerly known as bronchioloalveolar cell carcinomas).
  • GGOs causes low 18-fluoro-deoxyglucose uptake on PET-CT scan, which results in a high number of false negatives unless the lesion has become solid
137
Q

• Peak Inspiratory Pressure (PIP or Ppeak)

A
  • The highest pressure observed during inspiration
  • A constant VT with an increase PIP may indicate a lower lung compliance (CL) or an t in Raw
  • A declining PIP may indicate a leak or a sign of improvement in CL or Raw

PIP - Platue gives the Airway resistance Raw

138
Q

Roflumilast

A

oral phosphodiesterase-4 inhibitor recently approved for use in patients with severe and very severe COPD associated with chronic bronchitis and a history of frequent exacerbations.

139
Q
A
140
Q
A

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