UWORLD Pulmonary And critical Care

Question 1

How to confirm endotracheal tube placement

Answer 1

Checking depth, chest excursion, and bilateral breath sounds.

If bronchial intubation due to excessive depth, retract ETT a few centimeters and recheck placement

Question 2

Needle decompression vs chest tube in pneumothorax

Answer 2

Use Needle decompression for emergency treatment in pt with imminent cardiac arrest. Must always be followed by chest tube.

Avoid needle decompression if there is time for a chest tube (aka pt who has not developed tension physiology)

Question 3

Tension Physiology

Answer 3

Compression of mediastinal structures and marked hypotension.

Can quickly develop from pneumothorax (specially if large)

Question 4

Abdominal compartment syndrome features

Answer 4

Decrease perfusion to intrabdominal organs:

Renal: decreased urine output, increased CR
Lungs: High ventilation pressure
CV: venous return obstruction, decreased CO, JVD

Question 5

Abdominal compartment syndrome mechanism

Answer 5

Massive resus + systemic inflammatory response + increased capillary preameabillity +third spacing = increased intraabdominal pressure = decreased perfusion to intraabdominal organs and thoracic compression

Question 6

Next step in Management of abdominal compartment syndrome

Answer 6

Confirm diagnosis: measurement of bladder pressure

Question 7

TX abdominal compartment syndrome

Answer 7

Temporarily measure: avoid over resus. Decrease abdominal volume (NG), increase abd wall compliance (sedation)

Definitive treatment: surgical decompression

Question 8

Fever post PE

Answer 8

Acute PE can cause fever in 15% of cases. Check for other sites of infection but continue to monitor and continue treatment for PE without Abx (unless other source found)

Question 9

Aerosolized racemic epi use?

Answer 9

Primarily indicated for laryngeal swelling in croup and angioedema

Question 10

COPD exacerbation treatment

Answer 10

inhaled Albetro, IV steroid

ABX if 2 of the following:
Increased sputum purulence
Increased sputum volume
Increased dyspnea
Or mechanical ventilation (counts for 2)

Question 11

Smoker with non resolution of pneumonia or repeat pneumonia in the same location

Answer 11

Suspect presence of an obstructing endobronchial neoplasm leading to a non resolving pneumonia.

CT scan can help in seeing neoplasm amidst consolidation.

If not helpful, broncoscopy

Question 12

Lung mass with low sodium and symptoms. Management

Answer 12

SIADH due to Small cell

Hyponatrmiaa is due to water retention and loss of Na & K.

Correct slowly with water restriction if no neurological symptoms

Severe hypoNa demeclocyline or lithium

Question 13

Causes of post operative hypoxia

Answer 13

Immediate:
Obstruction/ Edema
Residual anesthesia effect
Bronchospasm

1-5days:
Atelectasia
Pneumonia
PE

Question 14

Features of obstruction/ edema caused postop hypoxia

Answer 14

Strider
Often due to endotracheal intubation or pharyngeal muscle laxity

Question 15

Features of residual anesthesia caused postop hypoxia

Answer 15

Use of anesthetic agents, benzodiazepines, opiates
Diminished respiratory drive (decreased respiratory rate or tidal volume)
Hypoventilation leads to respiratory acidosis with normal A-a gradient
Correct with supplemental O2

Question 16

Features of bronchospasm causes postop hypoxia

Answer 16

Early but not immediate
Wheezing

Question 17

Features of pneumonia caused postop hypoxia

Answer 17

Typically 1-5 days post op

Fever elevated white blood cell count
Prurulent secretions
Infiltrate on cxr

Question 18

Features of atelectasia caused postop hypoxia

Answer 18

Typically 2-5 days postop

Thoracoabdominal surgeries

Splinting, reduced cough, retained secretions

Question 19

obstructive sleep apnea and postop hypoxemia

Answer 19

OSA increases risk due to sedation and neuromuscular blocker causing decreased pharyngeal muscle dilator tone and higher propensity for obstructive apneic or hypopneic events.

THis leads to severe hypoventilation and respiratory failure IMEDIATE following surgery

Question 20

Cardiac death criteria for death

Answer 20

Irreversible electric and mechanical asystole (circulatory arrest)

Apnea is universal, requires no formal testing

Confirmed by observation period (~5min) off life support

Question 21

Brain death criteria for death

Answer 21

Brain stem & brain stem activity cease, but heart still beating

Irreversible coma without confounding factors (e.g intoxication)
Absence of brain stem reflexes
Apnea requires formal testing to rule out residual brain stem function

Question 22

Patient breathing above the ventilator set rate with severe neurological damage.

Can donate?

Answer 22

Apnea is NOT PRESENT! Does not meet criteria for death

Question 23

Mass suspicious for lung malignancy.

Best next step in management?

Answer 23

Therapy and prognosis depends on histological type and accurate staging. Important to stage prior to initiating tx.

Clinical Assessment
CT scan or PET
Radionuclide bone scans

Question 24

When is mediastinoscopy indicated for lung mass

Answer 24

scope with mediastinal lymph node sampling is indicated to document the presence or absence of malignancy in pt with suspected nodal involvement on chest CT scanning.

Question 25

Lung cancer screening

Answer 25

annual low-dose helical CT scan

Beginning at age 50

≥20 pack-years who currently smoke or quit within the past 15 years