FM ITE Pulmonology

Anaphylactic Shock

• Question:
  • Treat anaphylactic shock
• Answer:
  • – Eliminate exposure of inciting agent
    
  • – Early administration of epi, either IM or continuous IV
    
  • – H1 antihistamines for skin symptoms
    
  • – Glucocorticoids reduce risk recurrent symptoms
    
  • – Fluids, vasopressors for shock
    
  • – Intubation for airway edema

ARDS

• Question:
  • What is the PaO2:FiO2 ratio in mild ARDS?
  • What is the PaO2:FiO2 ratio in moderate ARDS?
  • What is the PaO2:FiO2 ratio in severe ARDS?
  • What 2 vent settings are most important in ARDS?
  • Where should plateau pressure be maintained in the ventilation of a patient with acute respiratory distress syndrome?
• Answer:
  • 200-300
  • 100-200
  • Less than 100
  • low TV and high PEEP
  • Less than 30 mm Hg.

• Question:
  • Treat hypoxemia associated with ARDS
• Answer:
  • – Volume controlled ventilation with Tidal Volume of ≤ 6mL/kg of ideal body weight
    
  • – plateau pressure < 30mm H2O
    
  • – High PEEP, keep plat pressure <30mm H2O
    
  • – Limit IV fluids, and diuretics keep CVP lower
    
  • – Prone positioning if hypoxic with above

Asthma

• Question:
  • PT WITH ASTHMA
    
  • USING ALBUTEROL Inhaler daily and waking up at night once or twice a week
    
  • WHAT SHOULD U PRESCRIBE HER?
    
  • WHAT STAGE OF ASTHMA
• Answer:
  • STAGE 3 MODERATE INTERMITTENT
    
  • (b/c night sx every week)
    
  • = add STEROID AND ANOTHER INHALER (B2 AGONIST)
    
  • Ex: Fluticasone/salmeterol (Advair)

Asthma Exacerbation

• Question:
  • PT WITH RECURRENT ASTHMA EXACERBATION
    
  • CBC= EOSINOPHILIA
• Answer:
  • Allergic bronchopulmonary aspergillosis

Exercise Induced Asthma

• Question:
  • Diagnose exercise induced asthma
• Answer:
  • – Decrease in FEV1 of 15 percent is diagnostic during exercise challenge
    
  • -Methacholine challenge test with spirometry

Asthma during pregnancy

• Question:
  • Treat asthma during pregnancy
• Answer:
  • – GERD management
    
  • – Smoking cessation
    
  • – Inhaled beta-agonists safe, albuterol has most evidence
    
  • – Inhaled glucocorticoids are safe in pregnancy
    
  • – Budesonide safe in pregnancy

Bronchiectasis

• Bronchiectasis is an illness of the bronchi and bronchioles involving obstructive and infectious processes that injure airways and cause luminal dilation.
• In addition to daily viscid, often purulent sputum production with occasional hemoptysis, wheezing and dyspnea occur in 75% of patients.

Emphysema and chronic bronchitis

• forms of COPD, also cause a decreased FEV1/FVC ratio, but the sputum is generally mucoid and luminal dilation of bronchi is not characteristically present.

Bronchiolitis

• is usually secondary to respiratory syncytial virus infection in young children. 

Bronchitis

Acute Bronchitis:

• Question:
  • PT HAS HAD PRODUCTIVE COUGH FOR 10 DAYS
    
  • LOW GRADE FEVER
    
  • RHINORHEA
    
  • Vital Sign Stable
    
  • SHOULD U GIVE ANTIBIOITIC
• Answer:
  • ACUTE BRONCHITIS
    
  • = EVEN 10 DAYS
    
  • = VIRAL
    
  • = SUPPORTIVE CARE ONLY

• Question:
  • What symptom is the hallmark of acute bronchitis?
• Answer:
  • productive cough

• Question:
  • INDICATION FOR CXR FOR PT WITH ACUTE BRONCHITIS
• Answer:
  • bloody sputum, rusty-colored sputum, or dyspnea;
    
  • a pulse rate >100 beats/min;
    
  • a respiratory rate >24/min;
    
  • or a temperature >37.8°C (100.0°F)

COPD

• Question:
  • What Fev1/FVC ratio is diagnostic of COPD?
• Answer:
  • <70

• Question:
  • Treat a patient with COPD
• Answer:
  • – For symptomatic and FEV1 < 60%,
    • monotherapy, use long acting anticholinergic agents (LAMA or LABA)
  • – Pulm rehab FEV1 <50%
  • – Severe resting hypoxemia(<88%) continuous oxygen
  • – Weak evidence for combo inhaled therapies for FEV1 <60%(LAMA, LABA, and inhaled glucocorticoids)
  • – Roflumilast improved as add on therapy
  • – annual influenza vaccine and pneumococcal vaccines

• Question:
  • In patients with COPD, which one of the following inhaled medications has been shown to reduce exacerbations and exacerbation-related hospitalizations?
• Answer:
  • Tiotropium (Spiriva)
    
  • ==
    
  • WRONG ANS
    
  • Ipratropium (Atrovent)

• Question:
  • Treat respiratory failure due to COPD
• Answer:
  • – IV or oral glucocorticoids
    
  • – Short-acting bronchodilators(albuterol/ ipratropium)
    
  • – Oxygen therapy
    
  • – Antibiotic based on severity and underlying etiology
    
  • – Noninvasive ventilation, intubation if obtunded
    
  • – Pulm rehab following discharge

Croup

• Question:
  • 2 YR OLD PT HAS
    
  • FEVER
    
  • BARKING COUGH
    
  • TX
• Answer:
  • CROUP (clinical diagnosis)
    
  • 1ST LINE = JUST SINGLE DOSE = DEXAMETHASONE= ORAL

Hyperthermia

Malignant Hyperthermia

• Question:
  • Treat malignant hyperthermia
• Answer:
  • -Stop offending drug(usually halothane or isoflurane)
    
  • -Increase minute ventilation
    
  • -Bicarb infusion
    
  • -Correction of hyperkalemia
    
  • -Dantrolene

ICU Acquired Weakness

• Question:
  • Treat intensive care unit acquired weakness
• Answer:
  • – Treatment is supportive and includes ongoing physical and occupational therapy
    
  • – Usually found when can’t wean from vent
    
  • – Profound weakness
    
  • – Includes critical illness polyneuropathy
    
  • – critical illness myopathy

Infusion/Transfusion

Propofol related infusion syndrome

• Question:
  • Treat propofol related infusion syndrome
• Answer:
  • DX by acute refractory bradycardia, severe metabolic acidosis, cardiovascular collapse, rhabdomyolysis, hyperlipidemia, renal failure, and hepatomegaly
    
  • – Discontinue propofol
    
  • – Management of HAGMA with bicarb
    
  • – Possible RRT
    
  • – Transvenous pacing when needed

• Transfusion Related Lung Injury
• Question:
  • Treat transfusion related lung injury
• Answer:
  • – Discontinue Transfusion
    
  • – Vent management like ARDS
    
  • – Fluid resuscitation and pressors as needed
    
  • – No evidence for steroids,

Interstitial Lung Disease

• Question:
  • Diagnose interstitial lung disease
• Answer:
  • – Several categories connective tissue disease, occupational exposures, idiopathic disorders, primary disorders
    
  • – Need to rule out HF, infection and COPD
    
  • – Then High Res CT is diagnostic test of choice

Irritant

• Question:
  • What is phosgene and how does it effect lungs?
• Answer:
  • it is a chemical irritant used in WW1. Turned into HCl at level of alveoli and interferes with gas exchange

Laryngeal Carcinoma

• Question:
  • Diagnose laryngeal carcinoma on basis of flow volume loop
• Answer:
  • – Fixed airway obstruction
    
  • – Flattening on both inspiration and expiration on flow volume loop

Legionella

• Question:
  • Pt who had recently been on CRUISE SHIP, NOW HAS:
    
    • productive COUGH- sometime bloody
      
    • HA
      
    • MUSCLE ACHE
• Ans:
  • LEGIONELLA PNEUMONIA
    
  • DIAG= URINE LEGIONELLA ANTIGEN

• Pneumonia caused by Legionella pneumophila is commonly preceded by nonspecific systemic symptoms that may lead a clinician to consider other diagnoses.
• Symptoms may include high-grade fever, malaise, myalgias, anorexia, and headache.
• Gastrointestinal and neurologic symptoms are also common and include nausea, vomiting, abdominal pain, diarrhea, and confusion.
• Focal neurologic signs are less common, but have been reported. L
• ocalizing respiratory symptoms will typically develop later, most often a dry cough and dyspnea.
• From this point on the illness resembles a typical pneumonia with fever, productive cough, pleuritic pain, and breathlessness.

Lung Abscess

• Question:
  • What oral antibiotic can be given for lung abscess?
  • IV?
• Answers:
  • oral -Clindamycin
    
  • IV – unasyn/pennems

Pleural Effusion

• Question:
  • Diagnose cause of pleural effusion
• Answer:
  • Light’s criteria
    
  • Exudate if any of following are positive
    
  • -Pleural fluid total protein/serum total protein >0.5
    
  • -Pleural fluid LDH/serum LDH > 0.6
    
  • -Pleural fluid LDH >2/3 upper limit normal serum LDH

• Question:
  • What two other criteria are used to diagnose an exudative effusion?
• Answer:
  • Pleural protein:serum protein, > 0.5; Pleural
  • LDH:serum, LDH > 0.6.

• Question:
  • Treat a pleural effusion
• Answer:
  • – Thoracentesis for all moderate to large pleural effusions
    
  • – Calculate Light’s criteria, cytology(if indicated)
    
  • – Treat underlying cause based on above
    
  • – If exudative and PH < 7.2 or gluc < 60, place drain as pt has parapneumonic effusion

• Question:
  • Treat a parapneumonic effusion
• Answer:
  • * small (<10mm) free flowing
    • -antibiotics and serial follow up
  • *small to moderate(>10mm or <1/2 hemithorax) free flowing
    • -antibiotics, thoracentesis and serial follow up
  • *Complicated-loculated, thickened pleura, PH <7.2 or glucose < 60 mg/dl
    • – antibiotics, thoracotomy tube drainage, serial follow up and thorascopic debridement if it doesn’t resolve

• Question:
  • Diagnose a malignant pleural effusion
• Answer:
  • – Bloody pleural fluid can happen RBC 5000-10000
    
  • – Cytology x2 increases positive yield for malignancy
    
  • – thoracoscopy should be done if 2 neg cytologies and malignancy still suspected

Pneumonia

• Question:
  • Diagnose pneumonia on basis of physical exam findings
• Answer:
  • – Symptoms- Cough, SOB, pleuritic chest pain, sputum, fevers
    
  • – Signs- Fever, tachycardia, crackles
    
  • – Can have signs of consolidation–> egophony

CAP

• Question:
  • PT TX OUTPATIENT FOR CAP
    
  • WHAT WOULD BE EXPECTED IF TX WITH SAME ANTIBIOTIC FOR 5 DAYS VS LONGER DURATION
• Answer:
  • NO DIFFERENCE IN OUTCOME IF TX WITH SHORTER DURATION OF AB COURSE FOR CAP

• Question:
  • What lobe of lung often has klebsiella pneumonia and what patient population has this?
• Answer:
  • R upper lobe and alcoholics

• Question:
  • CAP antibiotic that causes VF
• Answer:
  • Azithromycin
    
  • – The arrhythmia results from prolongation of the QT interval and is also more common in patients with a prior cardiac history.

Candida Albicans

• Question:
  • Manage candida albicans found in sputum
• Answer:
  • – Candida from sputum is usually contaminant unless patient is immunocompromised
    
  • – If therapy required fluconazole, voriconazole, or lipid amphotericin B

Pneumocystis jirovecci infection

• Question:
  • What lab finding is associated with pneumocystis jirovecci infection?
• Answer:
  • elevated LDH

Pneumoniocosis

• Questions:
  • Working with aerospace / fluorescent bulbs gives you what kind of pneumoconiosis?
  • Mining (sand, sandstone, slate, clay, and granite) gives you what kind of pneumoconiosis?
  • Arc welding gives you what kind of pneumoconiosis?
  • Tan welding gives you what kind of pneumoconiosis?
  • Working on ships/ demolition/ insulation/ fireproof material/ tiles / plumbing gives you what kind of pneumoconiosis?
• Answers:
  • Berylliosis
  • Silicosis
  • Siderosis – iron deposits
  • Stanosis – tin deposits
  • Asbestosis

• Question:
  • Diagnose asbestos related pleural plaques
• Answer:
  • – Construction industry, automotive servicing, shipbuilding associated
    
  • – Pleural plaques are most common
    
  • – Smooth, white, raised, irregular lesions affecting predominantly the parietal pleura
    
  • – Pleural plaques are typically asymptomatic
    
  • – Typically incidentally findings on routine CXR

Berylliosis

• Question:
  • Working with aerospace / fluorescent bulbs gives you what kind of pneumoconiosis?
• Answer:
  • Berylliosis

Silicosis

• Question:
  • Stone cutting, Mining (sand, sandstone, slate, clay, and granite) gives you what kind of pneumoconiosis?
  • RISK FACTOR FOR WHAT LUNG CONDITION
• Answer:
  • SILICOSIS
    
  • ALSO SAND BLASTING
    
  • ===
    
  • high-tech electronics manufacturing industry and results in chronic beryllium lung disease.
    
  • ===
    
  • agricultural dusts (fungal spores, vegetable products, insect fragments, animal dander, animal feces, microorganisms, and pollens)
    
  • can result in “farmer’s lung,” a hypersensitivity pneumonitis

Post Nasal Drip

• Question:
  • PT HAS 3 MONTH OF
    
  • MINIMALLY PRODUCTIVE COUGH
    
  • NO OTHER SX
    
  • PE REMARKABKLE FOR
    
  • swollen nasal turbinates.
    
  • TOW
  • TX WITH WHAT
• Answers:
  • ALLERGIES; post nasal drip–>cough
    
  • TRIAL OF intranasal corticosteroid
    
  • —
    
  • can also given claritin etc
    
  • ===
    
  • causes of chronic cough
    
  • GERD
    
  • ASTHMA
    
  • ALLERGIES

Pulmonary Edema

• Question:
  • Treat pulmonary edema
• Answer:
  • – Cardiogenic, diuresis, tx of heart failure
    
  • – High altitude- oxygen and rest. Nifedipine and PDE-5 inhibitors if needed
    
  • – AVOID diuretics and nitrates in High altitude Pulm edema
    
  • – Non-cardiogenic(ARDS)- High PEEP, low TV, diuresis as tolerated

Pulmonary Embolism

• Question:
  • Which study has highest sensitivity for excluding pulmonary embolism?
• Answer:
  • V/Q perfusion study

• Question:
  • Use D-dimer to exclude pulmonary embolism
• Answer:
  • – Used only if Wells PE score ≤ 4
    
  • – If negative no further testing needed
    
  • – If positive CT-PE

• Question:
  • Wells Score for PE
• Answer:
  • – Signs and symptoms of DVT- 3 points
    
  • – PE most likely dx- 3 points
    
  • – Tachy >100 bpm- 1.5 points
    
  • – Immobilization or surg in previous 4 wks – 1.5 points
    
  • – PM Hx of DVT or PE- 1.5 points
    
  • – Hemoptysis – 1 point
    
  • – Active malignancy- 1 point
    
  • – Score of 4 or less, PE unlikely

• Question:
  • What is the dosing of alteplase for massive pulmonary embolism?
• Answer:
  • Alteplase (fibrinolytic agent, tPA) 
  • 100 mg over 2 hours intravenously.

Fat Embolism

• Question:
  • What is the treatment for a fat embolism?
• Answers:
  • IV fluid and supplemental oxygen

Pulmonary Function Test

FEV1/FVC ratio in obstructive vs. restrictive lung disease

• Obstructive: <0.70
  
• Restrictive: >0.70

• Question:
  • Diagnose extrathoracic airway obstruction on the basis of flow volume loop
• Answer:
  • – Fixed- Volume loop flattened both top and bottom(inspiration and expiration)
    
  • – Variable- Volume loop flattened on bottom(inspiration)

Pulmonary Hypertension

• Question:
  • Types of pulmonary hypertension
• Answer:
  • Type 1- Pulmonary arterial hypertension(disease of small pulmonary arterioles)
    
  • Type 2- Left heart disease
    
  • Type 3- Lung disease(COPD, ILD, OSA, and others)
    
  • Type 4- Chronic thromboembolic disease
    
  • Type 5- Mixed/multifactorial

• Question:
  • Diagnose pulmonary hypertension
• Answer:
  • -Defined by resting mean PA pressure of >25mmHg
  • -Can have unexplained dyspnea, decreased exercise tolerance, syncope/near syncope, chest pain, LE edema
  • -Echo is initial study, PA pressure >40 highly suggestive
  • -Right heart cath to confirm diagnosis and quantify degree of PH
  • -V/Q test of choice for chronic thromboembolic dx

Pulmonary Nodule

• Question:
  • Manage solitary pulmonary nodule, non-smoker
• Answer:
  • <4mm
    • No follow up needed
      
  • 4-6 mm
    • follow up at 12 months, if unchanged, no follow up
      
  • 6-8mm
    • CT at 6-12 months, then 18-24 months
      
  • >8mm
    • CT 3,9, 24 months
      
    • dynamic contrast CT, PET and/or biopsy

• Question:
  • Manage solitary pulmonary nodule, smoker
• Answer:
  • <4mm
    • CT in 12 months
      
  • 4-6 mm
    • follow up at 6- 12 months, then 18-24 months
      
  • 6-8mm
    • CT at 3-6 months, then 9-12 months, and 24 months
      
  • >8mm
    • CT 3,9, 24 months
      
    • dynamic contrast CT, PET and/or biopsy

Respirator Failure

• Question:
  • Treat hypercapnic respiratory failure
• Answer:
  • – COPD exacerbation- steroids, Nebs, resp support, O2
    
  • – Decreased resp drive, remove offending agent, ventilatory support
    
  • – Extrapulmonary restriction- noninvasive or invasive vent support
    
  • – Neuromuscular weakness, acute or chronic ventilatory support depending on prognosis

Tuberculosis

• Questions:
  • What is a positive PPD test for low risk patients?
  • What is positive PPD test for high-risk, homeless, health-care workers, IVDU, foreign-born?
  • What is positive PPD test for immunosuppressed, recent TB contact, abnormal CXR, steroid use?
• Answers:
  • >15mm
  • >10mm
  • >5mm

• Question: 
  • PT WHOSE BRO HAS ACTIVE TB
    
  • HIS PPD TEST= 8MM
    
  • NO SX, PE NORMAL
    
  • CXR NORMAL
    
  • SHOULD U TREAT THIS KID
    
  • IF SO WITH WHAT
• Answer: 
  • YES TX DUE TO CLOSE CONTACT TO ACTIVE TB PT
    
  • AND
    
  • >5MM INDURATION
    
  • TX FOR LATENT TX = INH FOR 9 MONTHS

• Question:
  • TB TEST POSITIVE IF >5MM FOR WHICH POPULATION
• Answer:
  • An induration of 5 or more millimeters is considered positive in
    • -HIV-infected persons
    • -A recent contact of a person with ACTIVE TB disease
    • -Persons with fibrotic changes on chest radiograph consistent with prior TB
    • -Patients with organ transplants
    • -Persons who are immunosuppressed

• Question:

  • An induration of 10 or more millimeters is considered positive in

• Answer: 
  • An induration of 10 or more millimeters is considered positive in
    • -Recent immigrants (< 5 years) from high-prevalence countries
    • -Injection drug users
    • -Residents and employees of high-risk congregate settings:
      • HEALTH CARE WORKERS
      • PRISONER/ JAIL
      • HOME LESS SHELTER
      • NURSING HOME

• Question:
  • An induration of 15 or more millimeters is considered positive in
• Answer:
  • >An induration of 15 or more millimeters is considered positive in any person, with no known risk factors for TB.

• Question:
  • What is the treatment for latent TB in children, pregnant women, and HIV patients?
  • What is it for latent TB in other populations
• Answer:
  • INH for 9 months
  • INH for 6 months in all other populations

• Question:
  • What is treatment for active TB?
• Answer:
  • RIPE

• Question:
  • Which TB medication causes visual impairment?
• Answer:
  • Ethambutol

Misc

Hemoptysis

• Question:
  • What is considered massive hemoptysis?
• Answer:
  • >100ml/hr or >500ml within 24 hour

• Question:
  • Manage hemoptysis
• Answer:
  • – Most common causes bronchogenic carcinoma and bronchiectasis
  • – CXR is initial study, negative doesn’t exclude CXR
  • – Fiberoptic bronch for patients at high risk of lung CA
  • – Chest CT when bronch can’t be done, or bleeding continues following normal bronch
  • – If bleeding localized, put that lung dependent

• Question:
  • Prevent vascular catheter-related infections
• Answer:
  • -Choosing appropriate sites for catheter insertion
    
  • -Using the appropriate type of catheter material
    
  • -Using barrier precautions during insertion
    
  • -Changing catheter administration sets at appropriate intervals
    
  • -Ensuring proper catheter site care
    
  • -Ensuring removal of catheters when no longer essential