UWorld Pulm crit Flashcards
What is likely in a postoperative patient with hypotension, jugular venous distension, and new-onset right bundle branch block***
- masssive PE
- RBBB is a sign of right heart strain
Describe the use of diffusion capacity of carbon monoxide (DLCO) in determining the cause of COPD?
- Low: emphysema
- Normal: Chronic bronchitis, asthma
- High: Asthma
Describe the difference on chest x-ray between chronic bronchitis and emphysema?
- Chronic bronchitis: prominent bronchovascular markings and a mildly flattened diaphragm
- Emphysema: decreased vascular markings and hyperinflated lungs
Panacinar emphysema is typical of what disease process?
-Alpha-1-antitrypsin deficiency
Centriacinar emphysema is typical of what disease process
Smoking induced COPD
A patient with recurrent episodes of dyspnea, fever, tenacious sputum production, and hemoptysis along with a physical exam finding of crackles and digital clubbing, is consistent with an exacerbation of what?
bronchiectasis
Describe the pathophysiology of bronchiectasis?
- Infectious insult PLUS impaired bacterial clearance –>
- Bacterial overgrowth–> neutrophil infiltration –> inflammation –> Tissue damage and structural airway changes
In a young patient, the underlying etiology of bronchiectasis is most likely what?
- Cystic fibrosis
- defective chloride and sodium transport –> thick secretions –> impaired mucociliary clearance —> neutrophil recruitment and excessive release of elastase
What organism is a characteristic finding in Cystic fibrosis?
-Pseudomonas aeruginosis
what is normal jugular distension?
-< 10 cm H2O
This can be seen in middle aged patients, and it presents with exertional breathlessness. Lungs will be clear to auscultation. Chest x-ray would show enlargement of the pulmonary arteries with rapid tapering of the distal vessels (pruning) and enlargement of the right ventricle
Primary pulmonary HTN
In a patient with PE . . . Low-molecular weight heparin (enoxaparin), fondaparinux (injection factor Xa inhibitor), and rivaroxaban (oral factor Xa inhibitor) cannot be used in what patients?
-those with severe renal insufficiency (estimated glomerular filtration rate < 30) as reduced renal clearance increases anti-Xa activity levels and bleeding risk
in patient with PE, what anticoagulation is recommended in patients with decreased estimated glomerular filtration rate ?
unfractionated heparin
in a patient with a PE, when is warfarin initiated?
-once the heparin produces therapeutic anticoagulation (goal PTT >1.5-2 times normal)
What is the gold standard for diagnosis of cor pulmonale?
right heart cath
Patients with an acute asthma exacerbation usually have respiratory alkalosis with a low PaCO2 due to hyperventilation. A normal or elevated PaCO2 is alarming and extremely important finding that suggests what?
impending respiratory failure
What is the most efficient test to differentiate asthma and COPD
- Spirometry before and after administration of a bronchodilator (usually albuterol)
- Patients with asthma should show significant reversal (>12% increase in FEV1) in airway obstruction after
What has demonstrated prolonged survival and improved quality of life in patients with COPD with significant chronic hypoxemia?
-Long term supplemental oxygen therapy
Chronic low back pain in an otherwise young healthy man, pain at night, improvement of pain with activity, and elevated ESR are suggestive of ankylosing spondylitis. Patients with this can develop limitations in lung expansion due to what?
-diminished chest wall and spinal mobility
In a patient with mild asthma what medication is first added when albuterol is not enough?
inhaled corticosteroids
Due to evidence of increased mortality as well as treatment failure in asthmatic patients on long-acting beta-2 agonist monotherapy, the addition of a LABA is indicated only in combo with what?
Inhaled corticosteroids
Theophylline has a narrow therapeutic index, and toxicity can occur from accumulation by reduced clearance or decreased metabolism due to saturation of metabolic pathways. what are the symptoms of toxicity?
- CNS stimulation (headache, insomnia, seizures)
- GI (nausea, vomiting)
- Cardiac toxicity (arrhythmia)
What diseases and drugs can inhibit the cytochrome oxidase system and lead to possible theophylline toxicity?
- illnesses: cirrhosis, cholestasis, respiratory infections with fever
- drugs: cimetidine, ciprofloxacin, erythromycin, clarithromycin, verapamil
which lung cancer? PTHrP —> hypercalcemia
Squamous cell carcinom
Which lung cancer? ACTH production, SIADH
Small cell carcinoma
Most patients with ARDS require mechanical ventilation with what goals?
- lung protection: low tidal volume decreases overdistention of alveoli . . . improves mortality in patients with ARDS *****
- adequate oxygenation: high PEEP, goal is arterial partial pressure PaO2 at 55-80 or peripheral saturation SpO2 at 88%-95% . . preventing SpO2 < 88%.
progressive hypoxemia is common in patients with advanced COPD, and studies have shown survival benefit of long-term home oxygen therapy in those with significant chronic hypoxemia. The criteria for initiating long term home oxygen therapy in COPD patients includes what?
- PaO2 <55 or SaO2 <88%***
- PaO2 <59 or SaO2 <89 in patients with cor pulmonale, evidence of right heart failure, or hematocrit >55%
Bacterial pneumonia often causes a pleural effusion. Typically, the effusion is small, sterile, free-flowing, and resolves with antibiotics (uncomplicated). However, if bacterial persistently invade the pleural space, a complicated parapneumonic effusion or empyema may develop. Patients with these pleural space infection tend to have continued symptoms (fever, pleuritic pain) despite adequate antibiotics. Chest x-ray often shows loculation (walled-off pleural fluid). Thoracentesis will show an exudative effusion characterized by what values?
- Low glucose (<60) due to consumption by activated neutrophils and bacterial
- Low pH (<7.2) due to anaerobic utilization of glucose by neutrophils and bacteria
- High protein due to increased microvascular permeability and cellular destruction
Empyemas are differentiated from complicated parapneumonic effusions by the presence of what?
-gross pus or bacterial on Gram stain
Most complicated parapneumonic effusions and all empyemas require what?
drainage (e.g. chest tube) in addition to antibiotics
An acute massive pulmonary embolism can present initially with syncope and shock. Right heart cath will show what?
- elevated right atrial and pulmonary artery pressures
- normal pulmonary capillary wedge pressure
in those diagnosed with COPD, what has been shown to decrease the rate of decline of FEV1 and decrease mortality?
smoking cessation
what type of glucocorticoids are used in management of COPD exacerbation?
Systemic . . . . . inhaled is used in long term management
This decreases the mortality risk of acute PE and should be initiated prior to pursuing confirmatory diagnostic testing in patients with likely probability of acute PE, especially those in moderate to severe distress
early and effective anticoagulation
This manifests with > 3 months of weight loss, cough, hemoptysis, and fatigue in patients with a history of underlying lung disease . .maybe Tb. Imaging usually reveals 1 or more apical cavitary lesions
Chronic pulmonary aspergillosis
- Cough for > 5 days to 3 weeks (+/- purulent sputum)
- Absent systemic findings (e.g. fever, chills)
- Wheezing or rhonchi, chest wall tenderness
Acute bronchitis
Describe the diagnosis and treatment of acute bronchitis?
- Clinical diagnosis, CXR only when pneumonia suspected
- Symptomatic treatment (e.g. NSAIDs and/or bronchodilators)
- Antibiotics NOT recommended
Nonsmoking patients with symptoms of URI and persistent cough productive of yellow, blood-tinged sputum likely has what?
acute bronchitis
Patient has a large anterior mediastinal mass with elevated levels of beta-HCG and alpha fetoprotein, consistent with what?
nonseminomatous germ cell tumor
in what mechanism does an anti-histamine improve cough in post nasal drip syndrome
-in addition to blocking H1 histamine receptors, chlorpheniramine exhibits anti-inflammatory effects by blocking histamine release from mast cells and limiting the secretory response to inflammatory cytokines
Describe Aspirin-exacerbated respiratory disease
- a pseudoallergic reaction to NSAIDs
- not IgE-mediated but typically occur in patients with comorbid asthma, chronic rhinosinusitis with nasal polyposis, or chronic urticaria
What are the MIDDLE mediastinal masses?
- Bronchogenic cysts
- tracheal tumors
- pericardial cysts
- lymphoma
- lymph node enlargement
- Aortic aneurysms of the arch
What are the ANTERIOR mediastinal masses
- thymoma
- retrosternal thyroid
- teratoma
- lymphoma
What are the POSTERIOR mediastinal masses?
-All neurogenic tumors: meningocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, and aortic aneurysms
Describe the pathophysiology behind increased hypoxia when laying on the affected side of pneumonia
- Gravity induces increase in blood flow to the left lung, where there is markedly reduced V due to alveolar consolidation
- The result is a more profound V/Q mismatch (V remains about zero, but Q increases)
- right to left intrapulmonary shunting
Patient being treated for an asthma exacerbation now has leukocytosis with neutrophilic predominance . . . likely reason?
-mobilization of marginated neutrophils from systemic glucocorticoids
The most common causes of secondary digital clubbing are lung malignancies, cystic fibrosis, and right to left cardiac shunts. What is the pathophysiology?
- involves megakaryocytes that skip the normal route of fragmentation within pulmonary circulation (due to circulatory disruption from tumors, chronic lung inflammation) to enter systemic circulation.
- They become entrapped in the distal fingertips due to their large size and release PDGF and VEGF
- These have growth-promoting properties that increase connective tissue hypertrophy and capillary permeability and vascularity
Secondary malignancy is common in patients with Hodgkin lymphoma treated with chemo and radiation. the most common secondary solid tumor malignancies are what?
- Lung (especially in smokers)
- Breast
- Thyroid
- Bone
- GI (e.g. colorectal, esophageal, gastric tumors)
Pneumonia causes hypoxemia due to what?
does increased concentration of inspired oxygen correct this?
- Right to left intrapulmonary shunting and extreme V/Q mismatch
- No
The first step in evaluating a solitary pulmonary nodule is comparison with previous x-rays. What effectively rules out malignancy and no further testing is necessary?
-If a solid lesion revealed on prior imaging is stable in size for > 2 years
Patient with an asthma attack is properly treated and subsequently develops muscles weakness and hand tremor . . what is going on and what do you obtain
- electrolyte panel
- patients on high doses of beta-2 agonists may develop hypokalemia, which may present with muscle weakness, arrhthmias, and EKG abnormalities
- other common side effects of beta-2 agonists include tremor, palpitations, and headache
Long standing mitral stenosis can cause severe left atrial enlargement leading to what on chest radiograph?
elevation of the left main bronchus
What is the best diagnostic test for bronchiectasis
High resolution CT
What type of epinephrine is used in anaphylaxis?
IM . . . not IV due to higher risk of adverse events (e.g. cardiac arrhythmia)
-IV can be used for those who have not responded to initial IM epi
The goal of mechanical ventilation is to maintain arterial partial pressure of oxygen at what?
-PaO2 at 55-80 which roughly corresponds to oxygen saturations 88-95%
What FiO2 levels are generally safe
60% or less
Supplemental oxygen in patients with advanced COPD can worsen hypercapnia due to what?
- a combination of increased dead space perfusion causeing V/Q mismatch
- decreased affinity of oxyhemoglobin for CO2
- Reduced alveolar ventilation
- The goal oxyhemoglobin saturation in these patients is 90-93%
What does CT scan of the chest usually reveal in Aspergillus?
-Nodules with surrounding ground-glass opacities (halo sign)***
Symtoms of Pulmonary HTN
- Dyspnea, fatigue/weakness
- Exertional angina, syncope
- Abdominal distension/pain
What are physical exam signs of Pulmonary HTN
- Left parasternal lift, Right ventricular heave
- Loud P2, right-sided S3
- Pansystolic murmur of tricuspid regurgitation
- JVD, ascites, peripheral edema, hepatomegaly
Characteristics of Limited cutaneous systemic sclerosis
- Scleroderma on head & distal UE
- Prominent vascular manifestations
- CREST syndrome
- Anticentromere antibodies
- Better prognosis than Diffuse cutaneous Systemic sclerosis
Describe the prominent vascular manifestations of Limited cutaneous systemic sclerosis
- Raynaud phenomenon
- Cutaneous telangiectasia
- Pulmonary arterial HTN
Characteristic of Diffuse cutaneous systemic sclerosis
- Scleroderma on trunk and UE
- Prominent internal organ involvement
- Anti-Scl-70 (topoisomerase-1) antibodies
- Anti-RNA polymerase III antibodies
- Worse prognosis than Limited cutaneous systemic sclerosis
Describe the prominent internal organ involvement is diffuse cutaneous systemic sclerosis
- Scleroderma renal crisis
- Myocardial ischemia and fibrosis
- Interstitial lung disease
Describe CREST syndrome
- Calcinosis cutis
- Raynaud phenomenon
- Esophageal dysmotility with reflux
- Sclerodactyly
- Telangiectasia
- Strongly associated with limited cutaneous systemic sclerosis
Describe what the right ventricular heave (parasternal heave) in pulmonary HTN is
an impulse palpated immediately to the left of the sternum that suggests RV enlargement
Describe the possible 3rd heart sound that could be heard in Pulmonary HTN leading to right sided heart failure
-inspiration increases the volume of blood in the right side of the heart; therefore an S3 due to RB volume overload is best heard at the Left lower STERNAL BORDER on end-INSPIRATION
An S3 heard at the apex on end-EXPIRATION is consistent with what?
left ventricular failure
IN systemic slcerosis, What is a common mechanism of pulmonary HTN
hyperplasia of the intimal smooth muscle layer of the pulmonary arteries leading to increased pulmonary vascular resistance
Septal widening with hemosiderin-loaded macrophages is characteristic of what cause of secondary pulmonary HTN
pulmonary edema due to left-sided heart failure
