question

What FEV1/FVC ratio on spirometry is consistent with airflow obstruction?

answer

70%

question

What is used to characterize the degree of obstruction?

answer

the degree of reduction in FEV1

question

What is considered moderately reduced FEV1?

answer

50-80%

question

What is considered severely reduced FEV1?

answer

34-49%

question

What is considered very severely reduced FEV1?

answer

less than 34%

question

In patients with obstruction, what additional test on spirometry should be performed?

answer

bronchodilator challenge (2-4 puffs of a short acting B2 agonist) which helps differentiate between asthma and COPD

question

What is considered a positive bronchodilator response?

answer

an increase in FEV1 of 12% or 200ml

question

What does a normal FEV1/FVC ratio reflex?

answer

normal lung function or may indicate a restrictive lung defect however, if the FEV1 and FVC are reduced proportionately with each other and are below the predicted normal values, the spirometry results are consistent with a restrictive defect, which may be confirmed by further testing demonstrating low lung volumes

question

In patients with clinical symptoms suggestive of bronchospastic disease (such as cough or unexplained dyspnea) but with normal spirometry, what test may be diagnostically helpful?

answer

bronchial challenge testing (methacholine) uses a controlled inhaled stimulus to induce bronchospasm in association with spirometry; a positive test is indicated by a drop in the measured FEV1 PD20 (provocative dose 20%) is the dose of methacholine that causes a significant drop in the FEV1 of 20% or greater; the ability to achieve a PD20 at low concentrations of methacholine indicates more easily induced obstruction and is sensitive for detecting asthma similar principles apply to other forms of bronchial challenge testing, such as exposure to cold air or exercise, in which case a 10% drop in FEV1 from baseline in the context of a supporting clinical picture is diagnostic

question

What measurement on spirmoetry can determine whether restriction is due to a primary parenchymal process or chest cage restriction from factors such as obesity, muscle weakness, or scoliosis?

answer

TLC

question

What will TLC and RV be in obstructive lung diseases?

answer

elevated TLC is suggestive of hyperinflation and high compliance increased RV is suggestive of air trapping

question

What will the flow volume loop look like in asthma?

answer

reduction in peak expiratory flow and concave curvature for the expiratory limb while the inspiratory limb remain normal; significant change is seen after bronchodilator response

question

What does the flow volume loop look like in COPD?

answer

significant reduction in peak expiratory flow and concave appearance of the expiratory limb; no significant change is seen after bronchodilator response

question

What does the flow volume loop look like in fixed obstruction/tracheal stenosis?

answer

flattening of the peak inspiratory and expiratory flows

question

How is the diffusing capacity for carbon monoxide performed?

answer

having the patient take a single, deep breath containing a very low percentage of carbon monoxide and measuring the amount of subsequently exhaled carbon monoxide following a short period of breath holding carbon monoxide is rapidly and efficiently taken up by hemoglobin, and the amount absorbed is determined by the amount of blood recruited to the pulmonary alveolar capillary bed and the surface area available for diffusion

question

What is DLCO useful for measuring?

answer

the capacity for gas transfer through the alveolar-capillary membrane

question

What clinical disorders can elevate DLCO levels?

answer

clinical disorders that recruit blood to the alveoli (cardiac shunt, asthma, erythrocytosis, alveolar hemorrhage)

question

What clinical disorders can reduce DLCO?

answer

conditions that decrease permeability across the alveolar-capillary membrane, or otherwise interfere with gas transfer for example: a reduced DLCO in a patient with a low TLC or restriction on spirometry is suggestive of a parenchymal or interstitial process DLCO may also be diminisehd in COPD (from parenchymal destruction) or in conditions that affect the pulmonary vasculature such as pulmonary HTN or chronic pulmonary thromboembolic disease

question

What test is useful to assess diability and prognosis in chronic lung conditions?

answer

6 minute walk test (6MWT) simple pulse ox and oxygen desaturation studies performed at rest and with exertion assess the need for oxygen supplementation O2 sat, HR, dyspnea and fatigue level, and distance walked at a normal pace in 6 minutes are recorded; this relatively simple maneuver quantifies exercise tolerance, determines effective interventions, and helps predict morbidity and mortality this test is commonly used before, during, and after pulmonary rehab programs

question

What is pulse oximetry?

answer

noninvasive measurement of arterial hemoglobin saturation 2 light emitting diodes and a photodetector that measures the pulsatile fraction of hemoglobin and algorithmically estimates the arterial hemoglobin saturation in general, resting oxygen saturation less than or equal to 95% or a desaturation with exercise greater than or equal to 5% is considered abnormal

question

What can falsely elevated pulse ox levels?

answer

carboxyhemoglobin (the pulse ox cannot distinguish oxygen bound or cabon monoxide) if the presence of carboxyhemoglobin is suspected, co-oximetry is the preferred test to measure oxyhemoglobin ***also painted nails***

question

What is the equivalent daytime radiation of a PA/lateral radiograph?

answer

10 days

question

What is the equivalent daytime radiation of a routine CT? Equivalent number of chest radiographs?

answer

3 years 400 CXR's

question

What is the equivalent daytime radiation of a HRCT? Equivalent number of chest radiographs?

answer

89 days 43 CXR's

question

What is the equivalent daytime radiation of a CTPA? Equivalent number of chest radiographs?

answer

4.3 years 750 CXR's

question

What is the equivalent daytime radiation of a low-dose CT? Equivalent number of chest radiographs?

answer

68 days 33 CXR's

question

What is the equivalent daytime radiation of a FDG-PET/CT? Equivalent number of chest radiographs?

answer

5.4 years 809 CXR's

question

What test is the most effective lung cancer screening and imaging for lung nodules and lung parenchyma?

answer

low dose chest CT

question

What are some examples of when to order contrast enhanced CT vs HRCT?

answer

contrast- to better evaluate mediastinal structures including lymphadenopathy HRCT- indicated if diffuse parenchymal lung disease is suspected (this test should not be used to evaluate suspected lung disease with a focal abnormality or to evaluate pulmonary nodules

question

When can PET/CT be helpful?

answer

patient with a pulmonary nodule or other findings suggestive of malignancy for example: if a pulmonary nodule is identified but no previous imaging is available, PET/CT can help determine the activity of the nodule, as long as the nodule is approximately 1cm or larger also can be used for staging cancer, monitoring response to treatments, and surveillance for recurrence

question

What is fiberoptic bronchoscopy?

answer

an endoscopic technique that allows for the visualization of the tracheobronchial lumen and sampling of suspected areas of disease, including the endobronchial mucosa, lung parenchyma, and accessible lymph nodes rigid bronchoscopy requires general anesthesia, larger lumen may be necessary for some therapeutic bronchoscopies such as attempted retrieval of a foreign body flexible bronchoscopy can be performed under light to mdoerate sedation, and, although the flexible bronchoscope's lumen is smaller than that of a rigid bronchoscope, it does allow instruments to be used to help increase its diagnostic yield

question

What are indications for bronchoscopy? (10)

answer

1. hemoptysis 2. stridor or localized wheeze 3. pulmonary infections; (especially if they are progressive despite appropriate abx therapy or occur in immunocompromised patients) 4. diagnosis and/or staging or bronchogenic carcinoma 5. diagnosis of pulmonary metastases 6. evaluation of a pulmonary nodule 7. persistent pulmonary infiltrate 8. mucus plugging 9. foreign body aspiration 10. diffuse parenchymal lung disease

question

What are the major complications of bronchoscopy? (2)

answer

1. pneumothorax (1-4%) 2. significant bleeding (1%) should be avoided in patients who cannot tolerate possible adverse events, which include hypotension, tachycardia, severe hypoxemia, and bronchospasm should be postponed in a patient with a recent MI or who requires high amounts of supplemental oxygen (although hypoxemia, even when severe, is not an absolute contraindication)

question

What is asthma?

answer

common chronic respiratory condition characterized by reversible airway obstruction that is caused by airway inflammation and bronchial hyperresponsiveness it is a heterogeneous disorder with various phenotypes rather than one condition

question

What % of the US population does asthma affect?

answer

8%

question

What is allergic asthma strongly associated with?

answer

1. personal or family hx of allergies or atopy (maternal asthma in particular) 2. maternal smoking while pregnant 3. exposure to environmental tobacco smoke in childhood

question

Which populations does asthma have a higher prevalence and severity in?

answer

lower income, children, and black populations lil wayne needs an inhaler

question

What is the underlying pathophysiology in asthma?

answer

airway inflammation chronic airway inflammation results in the production and release of multiple mediators that may result in epithelial damage, smooth muscle hypertrophy, airway fibrosis, and remodeling in some patients airway inflammation is usually triggered at the epithelial level epithelial stimulation and initiation of inflammation can occur with viral or bacterial infections or exposure to noxious chemicals

question

What is the underlying pathophysiology of allergic asthma?

answer

exposure of the airway to allergens following sensitization causes mast cell degranulation and initiation of an inflammatory cascade allergen exposure triggers mast cell activation and a robust response from the T-helper 2 (Th2) subset of lymphocytes; immediate release of histamine and interleukins recruits other cell types, and the activation of Th2 lymphocytes further potentiates airway inflammation the Th2 response appears to be modulated by Treg cells, a newly discovered, seemingly protective lymphocyte subset; some patients also experience a late-phase asthmatic response, which manifests as a secondary decrease in FEV1 4-8 hours after immediate exposure

question

What do bronchial biopsies in patients with allergic and even nonallergic asthma demonstrate?

answer

accumulation of eosinophils, mast cells, and CD4+ T lymphocytes when chronic, this results in airway remodeling with structural changes such as mucus cell hyperplasia, subepithelial thickening of basement membrane, smooth muscle hypertrophy, connective tissue deposition, and airway fibrosis***

question

What are the risk factors that can predispose individuals to asthma?

answer

indoor environmental allergens, environmental tobacco smoke, and viruses common allergens are indoor mold, house dust, domestic animals, and cockroaches breast feeding, exposure to microbial diversity, and avoidance of environmental tobacco smoke have been associated with reduced incidences of asthma

question

What will patients with asthma classically present with?

answer

history of episodes of coughing, chest tightness, SOB, and wheezing the cough may be spastic and dry or may be productive of mucus some patients may identify the onset of symptoms with specific triggers such as known allergen exposure, inhaled irritants, respiratory tract infections, and exercise

question

In patients with suspected asthma, what is the first step in evaluation?

answer

spirometry to assess for the presence and severity of airway obstruction (as indicated by a reduced FEV1/FVC ratio) and its reversibility (with a 12% or greater improvement in FEV1 after administration of a bronchodilator) between attacks and exacerbations, spirometry can be normal in patients with suspected asthma; therefore, a bronchial challenge test may be helpful for diagnosis if positive or make the diagnosis less likely if negative

question

What are the characteristics of COPD? (which can mimic asthma)

answer

airway obstruction is less reversible; typically seen in older patients with smoking history

question

What are the characteristics of vocal cord dysfunction? (which can mimic asthma)

answer

abrupt onset and end of symptoms; monophonic wheeze; more common in younger patients; confirm with laryngoscopy or flow-volume loop

question

What are the characteristics of heart failure? (which can mimic asthma)

answer

dyspnea and often wheezing; crackles on auscultation; limited response to asthma therapy; cardiomegaly; edema; elevated BNP; other features of heart failure

question

What are the characteristics of bronchiectasis? (which can mimic asthma)

answer

cough productive of large amounts of purulent sputum; rhonchi and crackles are common; may have wheezing and clubbing; confirmed by CT imaging

question

What are the characteristics of allergic bronchopulmonary aspergillosis? (which can mimic asthma)

answer

recurrent infiltrates on CXR; eosinophilia; positive skin testing to Aspergillus antigens, high IgE levels, positive to Aspergillus; frequent need for glucocorticoid treatment

question

What are the characteristics of cystic fibrosis? (which can mimic asthma)

answer

cough productive of large amounts of purulent sputum; rhonchi and crackles are common; prominent clubbing; may have wheezing GI symptoms due to pancreatic insufficiency with possible sinus diseases are common, but recurrent respiratory tract infections may be present without GI or other systemic involvement

question

What are the characteristics of mechanical obstruction? (which can mimic asthma)

answer

more localized wheezing; if central in location, flow-volume loop may provide a clue

question

What are the characteristics of eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome)? (which can mimic asthma)

answer

autoimmune small-vessel vasculitis presents with peripheral eosinophilia, lung symptoms similar to asthma; skin changes such as purpura and sensory or motor neuropathy are other systemic symptoms; +ANCA in 40-60% patients, mostly p-ANCA

question

What will CXR show in asthma?

answer

often normal may demonstrate widened rib spaces and a flattened diaphragm, resulting from air trapping due to chronic airflow obstruction

question

What is the exhaled nitric oxide testing for asthma?

answer

newer noninvasive breath test that when elevated, may support the diagnosis of asthma in the appropriate clinical context nitric oxide is normally present in airways but is increased in certain types of airway inflammation (asthma, eosinophilic airway inflammation)

question

What is the most common form of asthma in adults?

answer

allergic asthma

question

What are some characteristics of allergic asthma?

answer

symptoms may be seasonal, requiring trigger avoidance and stepping up of asthma therapy during times of known exacerbations individuals with perennial allergies may need more sustained controller therapy, with modification (stepping up or stepping down) of treatment based upon sequential monitoring and assessment additionally, superimposed viral infections or other nonallergic triggers (such as sinus diseases) may exacerbate underlying allergic asthma

question

What are some characteristics of cough-variant asthma?

answer

can present with a persistent or episodic cough in the absence of other common symptoms usually associated with asthma extrinsic triggers such as cold air or irritants can stimulate or make the cough worse spirometry and bronchial challenge testing can be helpful to establish the diagnosis and distinguish asthma from other causes of cough, such as upper airway cough syndrome (rhinosinusitis, postnasal drip) and gastroesophageal reflux

question

What are the 3 most common causes of a cough with a normal CXR?

answer

1. asthma 2. GERD 3. postnasal drip Angstenism

question

What are some characteristics of exercise-induced bronchospasm?

answer

in EIB, symptoms occur in patients with asthma with exercise that requires increased respiratory ventilation increased ventilation, particularly of cool, dry air, causes drying of airway surfaces, which triggers bronchoconstriction via several mechanisms when the airway drying phenomenon is reversed, a rebound effect (with recruitment and infiltration of inflammatory cells) causes asthma symptoms in patients with dyspnea with exercise but normal spirometry, methacholine challenge testing can be useful to assess the degree to which symptoms are related to hyeperreactivity of the lungs

question

How can EIB be managed if symptoms occur only a few times per week?

answer

inhaled short-acting B2 agonists (such as albuterol) given 5-20 minutes prior to exercise; this therapy can be protective for 2-4 hours inhaled glucocorticoids are useful in minimizing the number and severity of exercise-induced asthma episodes antileukotriene therapy is also effective for the chronic management of patients with EIB nonpharmacologic management including warming and humidifying inhaled air with nasal breathing, as well as covering the nose and mouth during exercise in colder environments a 10-minute pre-exercise warmup (to achieve a 60% to 80% of maximum heart rate) may decrease the occurence of exercise-related bronchospasm for up to 4 hours

question

What are some characteristics of occupational asthma?

answer

approximately 10% of workers exposed to known sensitizing agents have asthma; farmers, factory workers, and hairdressers, among others, are at risk exposure to animal allergens, plants, grains, wood dust, and chemicals, even at low levels, can act as sensitizers through responses similar to other forms of asthma serial monitoring of peak flows throughout the workday, with comparison to a baseline time period away from exposures, can be helpful to support the diagnosis*** similarly, spirometry before and after rechallenge with workplace exposures is helpful to confirm the diagnosis

question

What are some characteristics of aspirin-sensitive asthma? (AKA aspirin-exacerbated respiratory disease or Samter triad)

answer

includes severe persistent asthma, aspirin sensitivity, and hyperplastic eosinophilic sinusitis with nasal polyposis asthma is worsened by exposure to aspirin or other NSAIDs, likely because of the inhibition of COX and the resulting increase in leukotriene synthesis treatment consists of avoidance of aspirin or NSAIDs along with typical asthma management for patients that require aspirin use (such as those with CAD), an aspirin desensitization procedure can be performed successful desensitization down-regulates leukotriene receptors and modifies interleukin sensitivity, which may improve asthma symptoms in some patients

question

What is Reactive Airways Dysfunction Syndrome?

answer

the development of respiratory symptoms in the minutes or hours after a single inhalation of a high concentration of irritant; airway hyperresponsiveness then persists for an extended period of time examples of exposures include inhalation of strong fumes, particulate matter (such as wood smoke), or chemical irritants (such as cleaning supplies)

question

What are some characteristics of virus induced bronchospasm?

answer

associated bronchospasm may be limited only to the duration of the infection virus induced bronchospasm in patients without asthma typically resolves 6-8 weeks after a respiratory infection annual influenza vaccinations are a key part of the management of patients with asthma

question

What are some characteristics of allergic bronchopulmonary aspergillosis?

answer

chronic hypersensitivity reaction that occurs in response to colonization of the lower airways with Aspergillus species the resulting inflammation causes impaired mucociliary clearance with expectoration of mucus plugs, destruction of pulmonary parenchyma with bronchiectasis, difficult to control asthma, and weight loss diagnosis is confirmed by clinical history, testing (positive skin testing to Aspergillus antigens, high IgE titers to Aspergillus, peripheral eosinophilia), and radiographic findings (proximal bronchiectasis, pleural thickening, transient infiltrates, or atelectasis) treatment includes systemic glucocorticoids, inhaled glucocorticoids may reduce the need for higher doses of systemic glucocorticoids (antifungal therapy (with fluconazole) may be helpful in conjunction with glucocorticoids)

question

What are common contributing factors to asthma? (5)

answer

1. GERD 2. Sinus disease (treatment of bacterial or allergic sinusitis with nasal glucocorticoids can reduce symptoms of asthma) 3. OSA 4. Vocal cord dysfunction 5. Obesity

question

What is vocal cord dysfunction characterized by? (3)

answer

1. mid-chest tightness with exposure to triggers 2. difficulty breathing in 3. partial response to asthma medications (often misdiagnosed as severe asthma resulting in unnecessary intubations and high health care utilization) flow-volume loop will show flattening of the inspiratory limb adduction of the vocal cords during inhalation seen on laryngoscopy is the gold standard of diagnosis speech therapy training exercises (to control the laryngeal area and maintain airflow) and treatment of GERD can result in dramatic improvement in PVCM disorder symptoms

question

How often should spirometry be performed in patients with asthma?

answer

if changes in symptoms occur during times of symptom stability, spirometry should be performed yearly

question

What psychiatric condition is significantly associated with asthma?

answer

depression

question

What do short-acting B2-agonists do in patients with asthma?

answer

help relieve the acute symptoms of chest tightness, wheeze, SOB, and cough but do NOT improve the underlying problem of airway inflammation B2-agonists are sympathomimetic agents that act on airway B receptors that activate adenylate cyclase, increasing cyclic adenosine monophosphate levels; these activate protein kinase A, which phosphorylates regulatory proteins that mediate bronchodilation

question

What do anticholinergic agents do in patients with asthma?

answer

dilate bronchial smooth muscle by decreasing the constrictive cholinergic tone in the airways (less effective than B2-agonists) ipratroprium can be used as adjunctive quick-relief therapy during asthma exacerbations

question

What is the mainstay of asthma treatment?

answer

inhaled glucocorticoids; they have been shown to improve and control symptoms, reduce exacerbations, and improve lung function

question

When inhaled glucocorticoids alone do not achieve asthma control, what should be added?

answer

long acting B2-agonist has proved to be effective as step-up therapy

question

What are the 2 different components of severity of asthma?

answer

1. intermittent 2. persistent

question

What are the 3 different types of persistent asthma?

answer

1. mild 2. moderate 3. severe

question

How often are the symptoms of intermittent asthma? Nighttime awakenings? SABA use for symptoms control (not prevention of EIB)? Interference with normal activity? Lung function?

answer

Symptoms: < or equal to 2 days/week Nighttime awakenings: < or equal to 2x/month SABA use for symptom control: 80% predicted, normal FEV1/FVC ratio

question

How often are the symptoms of mild persistent asthma? Nighttime awakenings? SABA use for symptoms control (not prevention of EIB)? Interference with normal activity? Lung function?

answer

Symptoms: >2 days/week but not daily Nighttime awakenings: 3-4x/month SABA use for symptom control: >2 days/week but not more than 1x/d Interference with normal activity: minor limitation Lung function: FEV1 >80% predicted; FEV1/FVC ratio normal

question

How often are the symptoms of moderate persistent asthma? Nighttime awakenings? SABA use for symptoms control (not prevention of EIB)? Interference with normal activity? Lung function?

answer

Symptoms: daily Nighttime awakenings: >1x/week but not nightly SABA use for symptom control: Daily Interference with normal activity: some limitation Lung function: FEV1 >60% but <80% of predicted; FEV1/FVC reduced at <5%

question

How often are the symptoms of severe persistent asthma? Nighttime awakenings? SABA use for symptoms control (not prevention of EIB)? Interference with normal activity? Lung function?

answer

Symptoms: throughout the day Nighttime awakenings: often 7x/week SABA use for symptom control: several times/day Interference with normal activity: extremely limited Lung function: FEV1 5%

question

Although expensive, what drug has been shown to reduce ED visits and is cost effective in moderate to severe persistent asthma with: 1) symptoms inadequately controlled with inhaled glucocorticoids, 2) allergies to perennial aeroallergens, 3) serum IgE levels between 30-700 U/ml?

answer

omalizumab

question

How many steps are there in the stepwise approach to asthma therapy?

answer

6

question

What is step 1 of asthma therapy? What type of asthma is it used for?

answer

SABA PRN intermittent asthma

question

What is step 2 of asthma therapy? What type of asthma is it used for?

answer

Preferred: low-dose IG Alternative: cromolyn, LTRA, nefocromil, or theophylline mild persistent asthma

question

What is step 3 of asthma therapy? What type of asthma is it used for?

answer

Preferred: low-dose IG + LABA OR medium dose IG Alternative: low-dose IG + LTRA, theophylline, or zileuton moderate persistent asthma

question

What is step 4 of asthma therapy? What type of asthma is it used for?

answer

Preferred: medium-dose IG + LABA Alternative: medium-dose IG + LTRA, theophylline, or zileuton severe persistent asthma

question

What is step 5 of asthma therapy? What type of asthma is it used for?

answer

Preferred: high-dose IG + LABA AND consider omalizumab for patients who have allergies severe persistent asthma

question

What is step 6 of asthma therapy? What type of asthma is it used for?

answer

Preferred: high-dose IG + LABA + oral glucocorticoid AND consider omalizumab for patients who have allergies

question

When should stepping down on therapy be considered?

answer

when asthma is well controlled at least 3 months

question

What should be checked prior to stepping up therapy for asthma?

answer

first check adherence, environmental control, and comorbid conditions also check for good inhaler technique***

question

What are some common side effects of LABA therapy?

answer

anxiety, tremor, headache

question

What vitamin deficiency is associated with a lower level of asthma control, and supplementation has been associated with a greater response to inhaled glucocorticoid therapy?

answer

vitamin D

question

When are patients considered to have severe refractory asthma?

answer

if they have multiple exacerbations per year, a need for high dose inhaled or oral glucocorticoids, an inability to step down therapy without compromising asthma control, or a history of multiple hospitalizations or intubations

question

Are inhaled glucocorticoids considered safe for asthma therapy during pregnancy? What are some unique features of asthma during pregnancy?

answer

Yes, and abundant long-term safety evidence exists for budesonide 1/3 of pregnant patients will have worsening of asthma, 1/3 will have no change, and 1/3 will have improvement in symptoms lack of asthma control increases the risk for preeclampsia and preterm labor for mothers and low birth weight, small gestational size, and preterm delivery for the infant

question

What is COPD characterized by?

answer

persistent, progressive airflow limitation, which arises from structural lung changes due to chronic inflammation as a result of inhaling noxious particles or gases chronic inflammation causes narrowing of the small airways and decreased elastic recoil of the lung, which diminishes the capacity of the airways to remain open during expiration the resulting increase in air trapping and hyperinflation contributes to progressive airflow limitation 3rd most common cause of death worldwide and a major cause of chronic morbidity, resulting in an increasingly substantial economic and social burden

question

What are the characteristic symptoms of COPD?

answer

chronic dyspnea, cough, and sputum production

question

What is the pathophysiology of COPD?

answer

chronic inflammation triggered and maintained by inhalation of toxic particles and gases, most commonly from tobacco smoke inflammation disrupts normal repair mechanisms and results in thickening and narrowing of the small airways (obstructive bronchiolitis) the inflammatory response also causes release of proteases that dissolve a portion of the adjacent lung tissue, including elastin, the major component of the connective tissue in the lung parenchyma that tethers the small airways open the loss of elastin causes a decrease in the elastic recoil of the lungs that normally keeps airways open during exhalation; proteases also damage the airspaces distal to the terminal bronchioles, resulting in permanent enlargement of airspaces with loss of diffusing surface (emphysema)

question

What does the decrease elasticity of the lung parenchyma in COPD cause?

answer

the decreased elasticity of the lung parenchyma causes both static and dynamic hyperinflation; static hyperinflation occurs because of the loss of the recoil properties of the lung resulting in the inability to fully exhale, leading to permanent increases in end-expiratory lung volumes; in contrast, dynamic hyperinflation occurs when patients begin to inhale before full exhalation of the previous breath has been completed, such that inspiratory air volume exceeds expiratory volume, trapping air within the lungs with each successive breath progressive hyperinflation expands the lungs, flattening and reducing the mechanical effectiveness of the diaphragm, making use of accessory muscles of breathing more crucial, and markedly increasing the work of breathing as chest wall compliance decreases

question

What is the single most clinically efficacious and cost-effective way to prevent COPD, to slow progression of established disease, and to improve survival?

answer

smoking cessation (although 20% of COPD patients are non or never smokers)

question

Patients with COPD have a higher frequency of what comorbid conditions?

answer

cardiovascular disease, weight loss, muscle wasting, weakness, and osteopenia that adversely affect prognosis and significantly contribute to morbidity and mortality

question

Can screening for COPD with spirometry be performed in asymptomatic patients?

answer

NO

question

What FEV1/FVC ratio is diagnostic for COPD in the correct clinical context and differentiates COPD from asthma, which shows reversible airflow obstruction?

answer

postbronchodilator fixed FEV1/FVC ratio less than 70%

question

What should patients be assessed for if they are found to have an FEV1 of less than 35% of predicted?

answer

adequacy of oxygenation with either ABG or pulse ox

question

When should patients be tested for alpha-1 antitrypsin deficiency?

answer

patients who develop symptoms of COPD and have reduced FEV1/FVC ratio at a young age (<40 years) these patients are often misdiagnosed with asthma for many years they usually have basilar emphysema they may also have concurrent liver disease***

question

What is the GOLD classification (2015)?

answer

Global initiative for chronic Obstructive Lung Disease; uses spirometric measures to provide a more objective classification of COPD severity; a higher GOLD category indicates increased risk

question

What are the 4 different GOLD categories and their associated spirometry findings?

answer

GOLD 1: mild; FEV1 >80% predicted GOLD 2: moderate: 50% FEV1 <80% of predicted GOLD 3: severe; 30% <FEV1 <50% of predicted GOLD 4: very severe: FEV1 <30% of prediceted

question

What are the updated GOLD categories for COPD?

answer

A, B, C, D

question

What are the characteristics of category A COPD? Spirometric classification? Exacerbations per year? CAT score (COPD assessment test)? mMRC Score (modified medical research council)?

answer

Characteristics: low risk, fewer symptoms Spirometric classification: GOLD 1-2 Exacerbations per year: <1 CAT score: <10 mMRC score: 0-1

question

What are the characteristics of category B COPD? Spirometric classification? Exacerbations per year? CAT score (COPD assessment test)? mMRC Score (modified medical research council)?

answer

Characteristics: low risk, more symptoms Spirometric classification: GOLD 1-2 Exacerbations per year: 10 mMRC score: >2

question

What are the characteristics of category C COPD? Spirometric classification? Exacerbations per year? CAT score (COPD assessment test)? mMRC Score (modified medical research council)?

answer

Characteristics: high risk, fewer symptoms Spirometric classification: GOLD 3-4 Exacerbations per year: >2 CAT score: <10 mMRC score: 0-1

question

What are the characteristics of category D COPD? Spirometric classification? Exacerbations per year? CAT score (COPD assessment test)? mMRC Score (modified medical research council)?

answer

Characteristics: high risk, more symptoms Spirometric classification: GOLD 3-4 Exacerbations per year: >2/>1 with hospital admission CAT score: >10 mMRC score: >2

question

What are the criteria for potential referral of patients with COPD to a pulmonary specialist? (12)

answer

1. Diagnosis of COPD at 2/year) despite adequate treatment 3. Rapid disease course (decline in FEV1, progressive dyspnea, decreased exercise tolerance, unintentional weight loss) 4. Severe COPD (FEV1 <50% of predicted) despite optimal treatment 5. Need for Oxygen therapy 6. Onset of a comorbid condition (especially cardiovascular disease or event) 7. Diagnostic uncertainty (for example, coexisting COPD and asthma) 8. Symptoms disproportionate to severity of airflow obstruction 9. Confirmed or suspected alpha-1 antitrypsin deficiency 10. Patient request for a second opinion 11. Patient is a potential candidate for lung transplant or lung-volume reduction surgery 12. Patient has very severe disease and requires elective surgery that may impair respiratory function

question

Are pharmacologic agents able to reduce the progressive decline in lung function seen in patients with COPD?

answer

No however they may reduce the frequency and severity of exacerbation, reduce hospitalizations, reduce symptoms, and improve exercise tolerance

question

What is the recommended first choice of treatment for COPD GOLD category A?

answer

short-acting anticholinergic PRN OR short acting B2- agonist PRN

question

What is the recommended first choice of treatment for COPD GOLD category B?

answer

Long acting anticholinergic OR long acting B2- agonist

question

What is the recommended first choice of treatment for COPD GOLD category C?

answer

inhaled glucocorticoid + long acting B2- agonist OR long acting anticholinergic

question

What is the recommended first choice of treatment for COPD GOLD category D?

answer

inhaled glucocorticoid + long acting B2- agonist AND/OR long acting anticholinergic

question

How long do SABA's/SAMA's last for?

answer

onset is within minutes lasts 3-6 hours

question

What are examples of inhaled short-acting B2-agonists?

answer

albuterol, fenoterol, levalbuterol, metaproterenol, pirbuterol, terbutaline

question

What are examples of inhaled short-acting anticholinergic agents?

answer

ipratroprium

question

What are exampled of long acting anticholinergic agents?

answer

tiotroprium, aclidinium, umeclidinium, glycopyrronium

question

What are examples of inhaled long acting B2-agonists?

answer

salmeterol, formoterol, arformoterol, indacaterol, olodaterol

question

When are inhaled glucocorticoids recommended for COPD?

answer

highly symptomatic patients with frequent exacerbations

question

What should patients be monitored for when taking inhaled glucocorticoids?

answer

adverse drug effects such as osteopenia, hyperglycemia, and cataracts

question

What are examples of inhaled glucocorticoids?

answer

fluticasone, budesonide, mometasone, ciclesonide, beclomethasone

question

What are brand name examples of LAMA (long acting anti-muscarinic)? (1)

answer

Spiriva (tiotropium) (usually first line)

question

What are brand name examples of SABAs? (3)

answer

1. Ventolin (albuterol) 2. Proventil (albuterol) 3. Proair (albuterol)

question

What are brand name examples of LABA? (1)

answer

Serevent (salmeterol)

question

What are brand name examples of combo inhaled corticosteroid/LABA? (4)

answer

1. Advair (fluticasone/salmeterol) 2. Symbicort (budesonide/formoterol) 3. Dulera (formoterol/mometasone) 4. Breo (fluticasone furoate/vilanterol)

question

What are brand name examples of SABA/SAMA? (1)

answer

Combivent (ipratropium bromide/albuterol) don't combine SAMA and LAMA*

question

Is oral glucocorticoids noninferior to IV therapy for management of acute exacerbations of COPD?

answer

Yes; however, critically ill patients and those with nausea are candidates for IV glucocorticoids

question

What should the taper be when sending patients home with oral glucocorticoids after an exacerbation of COPD?

answer

the optimal dose and duration is not known; however data shows that shortened duration and reduced daily dosing of glucocorticoid therapy can decrease the total glucocorticoid exposure without worsening outcomes (study showed that prednisone 40mg daily for 5 days was not inferior to prednisone 40mg daily for 14 days with regard to re-exacerbation within 6 months)

question

When should methylxanthines be used for COPD?

answer

tend to be used in selected patients with late-stage disease or for patients in whom other preferred therapies have proved ineffective for symptomatic relief; they may also be used when other medications are not available or affordable

question

What are some examples of methylxanthines?

answer

theophylline, aminophylline side effects: tachycardia, nausea/vomiting, disturbed pulmonary function, and disturbed sleep; narrow therapeutic index; overdose can be fatal with seizures and arrhythmias

question

When is the phosphodiesterase 4 Inhibitor roflumilast used for COPD?

answer

add on therapy in severe COPD (categories C & D) associated with chronic bronchitis and a history of recurrent exacerbations despite other therapies; it has been shown to improve symptoms and reduce risk and frequency of exacerbations in these individuals side effects: diarrhea, nausea, weight loss, headache, and some psychiatric adverse events (anxiety, depression, insomnia) contraindicated in patients with liver impairment and has significant drug interactions

question

When should antibiotics be given for COPD exacerbations?

answer

only if it is an infectious exacerbation

question

What oral mucolytic drug has been shown to improve mucociliary clearance and modulate the inflammatory response?

answer

N-acetylcysteine (may be helpful in patients with moderate to severe COPD; in other patients may be minimal benefit and routine use is not recommended)

question

What drug is very effective to treat dyspnea in severe COPD?

answer

oral and parenteral opioids

question

Who is pulmonary rehab recommended for?

answer

all symptomatic patietns with an FEV1 less than 50% of predicted and specifically for those hospitalized with an acute exacerbation of COPD may also be considered in symptomatic or exercise-limited pateitns with an FEV1 greater than or equal to 50% of predicted

question

What is pulmonary rehab?

answer

education, functional assessment, nutrition counseling, and follow-up to reinforce behavioral techniques for change exercise training component (>30 minutes 3x weekly for 6-8 weeks) has been shown to improve endurance, flexibility, and upper and lower body strength

question

Which patients should be evaluated for oxygen therapy?

answer

all stable patients with an FEV1 less than 35% of predicted or in patietns with clinical symptoms or signs suggestive or respiratory failure or right-sided heart failure a determination of the need for long-term oxygen therapy is initially based on resting arterial pO2 or oxygen saturation values, which should be repeated and confirmed twice over a 3 week period if resting O2 sat is less than 88%, ABG should be performed and long-term oxygen therapy should be initiated when starting long-term oxygen therapy, a 6 minute walk test should be performed to assess and titrate oxygen levels with activity

question

Use of long-term oxygen therapy (>15 hours/day) has been shown to prolong life in patients meeting what criteria? (2)

answer

1. chronic respiratory failure and/or severe resting hypoxemia, defined as an arterial pO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal to 88% breathing ambient air, with or without hypercapnia 2. if there is evidence of pulmonary hypertension, peripheral edema suggesting right-sided heart failure, or polycythemia, in combination with an arterial pO2 less than 60 mm Hg or oxygen saturation less than 88% breathing ambient air

question

What are the benefits of noninvasive mechanical ventilation is select patients with COPD?

answer

may improve breathing pattern, diminish dyspnea, and increase oxygenation, resulting in improved sleep continuity, symptoms of daytime somnolence, exertional dyspnea, and awake arterial pO2 levels

question

Who are candidates for noninvasive mechanical ventilation in patients with COPD?

answer

patients with stable severe and very severe COPD used in a select subset of patients with pronounced daytime hypercapnia in patients with both COPD and OSA, CPAP improved both survival and risk of hospital admissions

question

Which patients are eligible for lung volume reduction surgery in patients with COPD? (7)

answer

1. severe COPD 2. remain symptomatic despite maximal pharmacologic therapy 3. completed pulmonary rehab 4. evidence of bilateral predominant upper-lobe emphysema on CT scan 5. postbronchodilator total lung capacity of >100% AND residual lung volume >150% of predicted 6. maximum FEV1 >20% and 20% of predicted 7. ambient air arterial pCO2 45

question

What are the benefits of lung volume reduction surgery in patients with COPD?

answer

improves mechanical efficiency of respiratory muscles and increases the elastic recoil of the lungs to improve expiratory flow and reduce exacerbations not shown to increase survival

question

What are the recommended criteria for lung transplantation in patients with COPD? (5)

answer

1. history of exacerbations associated with acute hypercapnia (arterial pCO2 >50)*** 2. pulmonary HTN 3. cor pulmonale 4. pulmonary HTN and cor pulmonale 5. FEV1 <20% of predicted with DLCO <20% of predicted OR homogeneous distribution of emphysema

question

What are common complications of lung transplantation?

answer

1. acute rejection 2. opportunistic infections (CMV, Candida, Aspergillus, Cryptococus, Pneumocystis, Pseudomonas, Staphylococcus) 3. bronchiolitis obliterans 4. lymphoproliferative disease 5. overall increased postoperative mortality double lung transplant has similar or slightly higher survival rates compared with single lung transplantation

question

What is an exacerbation of COPD?

answer

a sustained worsening of the patients COPD exacerbations are marked by increased breathlessness and are usually accompanied by increased cough and sputum production the degree of exacerbation is considered mild when a change in the clinical condition is noted but no change in medication is necessary; an exacerbation is considered moderate when medication changes are made; a severe exacerbation results in hospitalization

question

What are the strongest predictors of exacerbation of COPD? (2)

answer

1. hx of previous exacerbation 2. baseline severity of airflow limitation

question

What % of COPD exacerbation may be appropriately treated at home?

answer

80% treatment at home is reasonable in patients with less severe lung disease who do not have significant accompanying illnesses and who are experiencing mild to moderate exacerbations

question

What are the criteria for assessment of COPD exacerbations? (12)

answer

Medical History: 1. Severity of COPD based on degree of airflow limitation 2. Duration of worsening of new symptoms 3. Number of previous episodes (exacerbations/hospitalizations) 4. Comorbidities 5. Current treatment regimen 6. Previous requirement for mechanical ventilation Signs/Degree of Severity: 1. Use of accessory respiratory muscles 2. Paradoxical chest wall movements 3. Worsening or new onset of central cyanosis 4. Development of peripheral edema 5. Hemodynamic instability 6. Deteriorated mental status

question

What are the criteria for hospital admission for an acute exacerbation of COPD? (9)

answer

1. Marked increase in intensity of symptoms (such as sudden onset of resting dyspnea) 2. severe underlying COPD 3. Onset of new physical signs (such as cyanosis, peripheral edema) 4. An exacerbation that fails to respond to initial medical management 5. presence of high-risk comorbid conditions (such as heart failure or newly occurring arrhythmias) 6. frequent exacerbations 7. advanced age 8. patient inability to care for him- or herself 9. inadequate home care available

question

What are the criteria for ICU admission for an acute exacerbation of COPD? (4)

answer

1. Despite adequate, appropriate treatment (oxygen, noninvasive ventilation), the patient experiences: a) persistent/worsening hypoxemia (arterial pO2 <40 AND/OR b) severe/worsening respiratory acidosis (pH <7.25) and requires endotracheal intubation with mechanical ventilation 2. Severe dyspnea that responds inadequately to initial emergency therapy 3. changes in mental status (such as confusion, lethargy, coma) 4. Hemodynamic instablity with need for vasopressors

question

What are oxygen goals in the management of an acute exacerbation of COPD?

answer

supplemental oxygen to maintain an arterial pO2 greater than 60 or an O2 saturation of 88-92%

question

What are the indications for antibiotics in an acute exacerbation of COPD? (3)

answer

1. increased dyspnea, sputum volume, and sputum purulence 2. two of the preceding symptoms if one of the two symptoms is increased purulence 3. requirement for mechanical ventilation (invasive or noninvasive) commonly used regimens include an advanced macrolide, a cephalosporin, or doxycycline if symptoms do not respond to initial antibiotic therapy, sputum cultures should be obtained, particularly to assess if Pseudomonas aeruginosa is present (abx treatment length is usually 5-10 days)

question

What is bronchiectasis?

answer

irreversible pathologic dilation of the bronchi or bronchioles resulting from an infectious process occurring in the context or airway obstruction, impaired drainage, or abnormality in antimicrobial defenses the pattern of lung involvement varies greatly with the underlying cause and may be focal or diffuse

question

What does focal bronchiectasis result from? (2)

answer

extrinsic changes (airway tumor, aspirated foreign body, scarred or stenotic airway) intrinsic changes (bronchial atresia)

question

What does diffuse bronchiectasis result from?

answer

diffuse bronchiectasis is more commonly associated with underlying systemic or infectious disease (bacterial infection, nontuberculosis mycobacterial infection, reactivated TB, cystic fibrosis)

question

What are the causes of bronchiectasis? (12)

answer

1. Congenital (cystic fibrosis, primary ciliary dyskinesia) 2. Infections (typical and atypical mycobacterial infection; recurrent infection, postinfectious) 3. Inhalation (recurrent aspiration, chronic hypersensitivity pneumonitis, smoke inhalation) 4. Traction (scarring); (asbestosis, radiation therapy) 5. Systemic inflammatory disorders collagen vascular disease (RA, scleroderma, SLE; sarcoidosis) 6. Local immunologic reactions (allergic bronchopulmonary aspergillosis, asthma, lung transplant rejection) 7. Autoimmune disease (RA, Sjogren syndrome) 8. Connective tissue disease (tracheobronchomegaly (Mounier-Kuhn syndrome), Cartilage deficiency (Williams-Campbell syndrome), Marfan syndrome) 9. Immune deficiency (immunoglobulin deficiency, HIV infection, Job syndrome (elevated IgE, eczema, and recurrent respiratory infection), agammaglobulinemia, common variable immune deficiency, secondary immunodeficiency (CLL, HIV)) 10. Inflammatory bowel disease (ulcerative colitis, crohn disease) 11. Obstruction (tumor, foreign body, lymphadenopathy) 12. Other (alpha-1 anti-trypsin deficiency, yellow nail syndrome (nail dystrophy, lymphedema, and pleural effusions), Young syndrome (azoospermia and recurrent sino-pulmonary infection due to ciliary dysfunction)

question

What part of the lungs does CF typically affect?

answer

upper lung fields

question

What disease typically affects the mid-lung fields?

answer

MAC infection

question

What diseases typically affects the lower lung fields?

answer

chronic recurrent aspiration, end stage fibrotic disease, or recurrent infections associated with immunodeficiency more commonly affect the lower lung fields

question

What are the symptoms of bronchiectasis? What will PFT's show? What are some PE findings?

answer

chronic cough with purulent sputum and recurrent pneumonia (in both smokers and non-smokers) PFT's show mild to moderate airflow obstruction, which may overlap with other disease findings (COPD) PE findings: crackles, and/or wheezing on lung auscultation; digital clubbing

question

What test is diagnostically definitive for bronchiectasis?

answer

high-resolution CT

question

What is the treatment for bronchiectasis?

answer

if a modifiable cause for bronchiectasis has been identified, treat the cause no data supports the routine use of short or long acting bronchodilators or long term use of systemic steroids pulmonary rehab programs are associated with significant improvements in exercise capacity and fewer outpatient and ED visits***

question

What does cystic fibrosis result from?

answer

Autosomal recessive disorder (occurs in 1/2000-3000 live births) mutations in the CF transmembrane conductance regulator gene (CFTR) which causes epithelial mucus dehydration and viscous secretions, which then cause occlusion of respiratory airways and contribute to the persistent airway infections and progressive tissue destruction that characterizes CF

question

What other organs are affected in CF? (3)

answer

can obstruct the pancreatic ducts, biliary tree, and vas deferens

question

What are the conditions suggesting the possible diagnosis of CF in adults? (8)

answer

1. recurrent pancreatitis 2. male infertility 3. chronic sinusitis 4. severe nasal polyposis 5. nontuberculous mycobacterial infection 6. allergic bronchopulmonary aspergillosis 7. bronchiectasis 8. positive sputum culture for Burkholderia cepacia (pathognomonic)***

question

What is the diagnosis of CF based on?

answer

combination of compatible clinical findings in conjunction with either biochemical (sweat testing, nasal potential difference) or genetic (CTFR mutations) techniques

question

What are associated comorbidities in adults with CD?

answer

DM, infertility, osteoporosis, liver disease***

question

What are the pillars of CF management?

answer

airway clearance, antibiotic therapy, nutritional support, and psycho-social support

question

What is diffuse parenchymal lung disease?

answer

represents a heterogeneous group of disorders that are classified based on similar clinical, radiographic, physiologic, and pathologic criteria the term DPLD excludes pulmonary HTN and COPD most commonly present with dyspnea and cough and imaging abnormalities are most often diffuse rather than focal rare (70 cases per 100,000 persons)

question

What % of DPLD's are idiopathic?

answer

30-40%

question

What is the gold standard for diagnosis of DPLD of both unknown and known causes?

answer

pulmonary pathologic specimens however, for the idiopathic forms of disease, histopathologic patterns correlate with disease prognosis as well as response to anti-inflammatory treatment (such as glucocorticoids)

question

What are the known causes of DPLD? (6)

answer

1. Drug induced (amiodarone, methotrexate, nitrofurantoin, bleomycin) 2. Smoking related (ground glass opacities and thickened interstitium) 3. Radiation (may occur 6 weeks to months after therapy) 4. Chronic aspiration 5. Pneumoconioses (asbestosis, silicosis, beryliosis) 6. Connective tissue diseases

question

What are the different connective tissue diseases that cause DPLD? (5)

answer

1. RA (may affect the pleura, parenchyma, airways, and vasculature; can range from nodules to organizing pneumonia to usual interstitial pneumonitis) 2. Systemic sclerosis (nonspecific interstitial pneumonia pathology is most common) 3. Polymyositis/dermatomyositis (poor prognosis) 4. Other connective tissue diseases (varies) 5. Hypersensitivity pneumonitis (immune reaction to inhaled low-molecular weight antigen; noncaseating granulomas are seen)

question

What are the unknown causes of DPLD? (2)

answer

1. Idiopathic interstitial pneumonia 2. Sarcoidosis (variable clinical presentation: ranging from asymptomatic to multiorgan involvement

question

What are the different causes of idiopathic interstitial pneumonia? (3)

answer

1. Idiopathic Pulmonary Fibrosis (chronic insidious onset of cough and SOB, usually in a patient >50 yo (honeycombing, bibasilar infiltrates with fibrosis; diagnosis of exclusion)) 2. Acute Interstitial Pneumonia (dense bilateral acute lung injury similar to acute respiratory distress syndrome; 50% mortality rate) 3. Cryptogenic Organizing Pneumonia (may be preceded by flu-like illness; radiograph shows focal areas of consolidation that may migrate from one location to another)

question

What are the 4 stages of sarcoidosis lung involvement?

answer

1. hilar lymphadenopathy 2. hilar lymphadenopathy plus interstitial lung disease 3. interstitial lung disease 4. fibrosis non-caseating granulomas are hallmarks

question

What are the rare DPLD with well-defined features? (3)

answer

1. Lymphangioleiomyomatosis (affects women in their 30's and 40's; associated with spontaneous pneumothorax and chylous effusions; chest CT shows cystic disease) 2. Chronic eosinophilic pneumonia ("radiographic negative" heart failure, with peripheral alveolar infiltrates predominating; peripheral blood eosinophilia and eosinophilia on bronchoalveolar lavage) 3. Pulmonary alveolar proteinosis (median age of 39 years, males predominate among smokers but not in nonsmokers; diagnosed via bronchoalveolar lavage, which shows abundant protein in the airspace; chest CT shows "crazy paving" pattern)

question

What will plain CXR show in patients with DPLD?

answer

may show increased interstitial reticular or nodular infiltrates in different patterns of distribution may be normal in up to 20% of patients, therefore, if clinical suspicion is high, evaluation should not stop if CXR is normal

question

What is the diagnostic tool of choice for evaluation of DPLD?

answer

correlation between HRCT*** findings and surgical biopsy histopathology findings

question

When should the diagnosis of DPLD be considered in patients who have a more insidious (>6 months) onset of cough and dyspnea? (2)

answer

once infection, heart failure, and COPD are ruled out when restrictive or combined obstructive/restrictive pattern on PFT

question

What are the 8 different thoracic radiology patterns for parenchymal findings in DPLD?

answer

1. Septal (peripheral: short lines that extend to the pleura; central: polygonal arcades that outline the secondary pulmonary lobule) 2. Reticular (on radiograph: interlacing lines that suggest a net) 3. Nodular (spherical lesions (<1cm) with widespread distribution; locations: centrilobular, lymphatic (septal), or random) 4. Reticulonodular (on radiograph: intersection of innumerable lines producing the effect of micronodules; HRCT: discerns the location of nodules as either septal or centrilobular) 5. Ground glass (hazy increased opacity with preservation of bronchial and vascular markings) 6. Consolidation (dense opacity that obscures vascular markings, unlike ground-glass opacity) 7. Honeycomb change (closely approximated ring shadows that resemble a honeycomb; typically subpleural with well-defined walls) 8. Mosaic attenuation (patchy regions of differing attenuation)

question

What are the lung findings associated with Acute interstitial pnuemonia?

answer

diffuse ground glass with consolidation

question

What are the lung findings associated with organizing pnuemonia?

answer

patchy ground glass, consolidation, peripheral and basal predominance

question

What are the lung findings associated with idiopathic pulmonary fibrosis/usual interstitial pneumonia?

answer

basal- and peripheral-predominant septal line thickening with traction bronchiectasis and honeycomb changes

question

What are the lung findings associated with nonspecific interstitial pneumonia?

answer

ground glass, basal predominance

question

What are the lung findings associated with respiratory bronchiolitis?

answer

centrilobular nodules and ground glass opacity in an upper-lung predominant distribution

question

What are the lung findings associated with desquamative interstitial pneumonia?

answer

basal- and peripheral predominant ground glass opacity with occasional cysts

question

What are the lung findings associated with hypersensitivity pneumonitis?

answer

acute: centrilobular micronodules that are upper and mid-lung predominant chronic: mid- and upper- lung predominant septal lung thickening with traction bronchiectasis; usual interstitial pneumonia pattern may be seen

question

What are the lung findings associated with sarcoidosis?

answer

upper-lobe predominant fibrosis; mediastinal and hilar lymphadenopathy; cystic changes including development of aspergilloma; airways-centered changes

question

What diffuse parenchymal lung diseases are tobacco smoke associated with? (3) What is the primary mangement for smoking related DPLD?

answer

multiple DPLD's including idiopathic pulmonary fibrosis 1. respiratory bronchiolitis-associated interstitial lung disease is used to describe disease in active smokers who have imaging findings of centrilobular micronodules with a pathologic finding of respiratory bronchiolitis on biopsy 2. desquamative interstitial pneumonia is due to extensive, diffuse macrophage filling of alveolar spaces with predominant cough and dyspnea symptoms and b/l ground glass opacities on chest imaging 3. Pulmonary Langerhans cell histiocytosis is characterized by thin-walled cysts with accompanying nodules and is often associated with pulmonary HTN all these diseases are subacute and present in active smokers; PFT's usually reveal an obstructive pattern with a severely decreased DLCO in individuals with more severe disease cessation of smoking is the primary management for smoking-related DPLD

question

What is the prevelance of pulmonary manifestation in individuals with known connective tissue disease?

answer

extremely high and these patients typically present with dyspnea

question

All patients with DPLD should be clinically assessed for what?

answer

an underlying autoimmune disorder because of its effect on prognosis, drug therapy recommendations, and management of comorbidities

question

What is the primary cause of mortality in systemic sclerosis?

answer

progressive pulmonary disease cyclophosphamide may have some short-term benefit in treating the lung disease, and managing the gastroesophageal dysmotility associated with systemic sclerosis may help avoid aspiration and further lung injury

question

What are the most common sources of antigens causing hypersensitivity pneumonitis? (3)

answer

1. thermophilic actinomces 2. fungi 3. bird droppings symptoms wane 24-48 hours after removal from exposure and recur with re-exposure to respiratory antigens (symptoms include fevers, flu-like symptoms, cough, and SOB) recurrence of symptoms with exposure to the respiratory antigen is the hallmark of this disorder, and careful attention to the history will help identify the cause subacute and chronic forms of the disease also occur and are believed to be associated with more chronic low-level exposures to inhaled antigen (Bird fancier's disease)

question

What are the radiographic findings in hypersensitivity pneumonitis?

answer

CXR may demonstrate b/l hazy opacities, while high resolution CT shows findings of ground glass opacities and centrilobar micronodules that are upper- and mid-lung predominant

question

What is the primary treatment for hypersensitivity pneumonitis?

answer

primary treatment is removal of the offending antigen glucocorticoids are used for patients with more severe symptoms and for those with evidence of fibrosis

question

What are the 5 classic drug induced DPLD?

answer

1. amiodarone 2. methotrexate 3. nitrofurantoin 4. busulfan (30 days to 1 year after exposure) 5. bleomycin (1-6 months after exposure)

question

What symptoms will patients present with from radiation induced DPLD?

answer

cough, SOB, and occasionally fever, and malaise occurs 6-12 weeks after exposure

question

What is the most pathognomonic feature of radiation induced DPLD?

answer

imaging finding of a nonanatomic straight line demarcating involved versus uninvolved lung parenchyma most abnormalities occur within the radiation field, it is possible for changes to occur outside of the field as well typically, acute changes will resolve within 6 months, but some patients may be left with a well-demarcated area of fibrosis, volume loss, and bronchiectasis

question

What is the treatment of radiation induced DPLD?

answer

treatment is determined by the severity of symptoms for patients with evidence of organizing pneumonia, there is likely a benefit to the use of glucocorticoids

question

What is the most common idiopathic interstitial pneumonia? Who does it typically occur in? What is the usual presentation?

answer

IPF; occurs predominantly in older individuals (diagnosis of IPF is rare in those younger than 60 years of age) gradual onset of dyspnea and cough over months to years is typical

question

What does PE show in patients with IPF?

answer

dry inspiratory crackles at the bases nearly 50% will have clubbing more severe disease is associated with secondary pulmonary HTN and right-sided heart failure on examination

question

What will PFT show in patients with IPF?

answer

restrictive pattern with a reduced diffusing capacity however, an isolated reduction in diffusing capacity and normal PFT can also be seen

question

How is IPF diagnosed?

answer

by exclusion

question

What is the estimated average survival of patients with IPF?

answer

3-5 years (however, there is variability in the disease course)

question

What is the most common cause of death in patients with IPF?

answer

respiratory failure for patients who develop severe respiratory distress for which there is no underlying reversible cause, supportive mechanical ventilation is of little long-term benefit; therefore, the most recent evidence-based consensus statement recommends against mechanical ventilation for individuals with acute respiratory failure due to either progression or an acute exacerbation of IPF; in these circumstances, the focus should be on palliation of the patients underlying dyspnea

question

What is the treatment of IPF?

answer

primarily supportive, with optimization of fitness and oxygenation, as well as treatment of associated conditions; lung transplantation (only therapy that prolongs life) may be appropriate in a select subset of patients therapies in the past focused on anti-inflammatory therapy (prednisone) with or w/o immunomodulators (azathioprine) but these therapies should be avoided because they were associated with increased mortality when compared with placebo

question

What are the 2 new FDA approved drugs for IPF?

answer

1. nintendanib (TKI that blocks pathways that lead to activation of the fibroblast) 2. pirfenidone (regulates TGF-b and TNF-a)

question

What part of the lung does nonspecific interstitial pneumonia predominantly affect? What is the patient population?

answer

predominantly affects the lower lobes of the lung, tends to affect a younger patient population, and is strongly associated with connective tissue disease (most often systemic sclerosis)

question

What is organizing pneumonia?

answer

patchy process that involves proliferation of granulation tissue within alveolar ducts, alveolar spaces, and surrounding areas of chronic inflammation many known causes of this pattern, including acute infections and autoimmune disorders like RA

question

What is the term cryptogenic organizing pneumonia?

answer

used for individuals who have organizing pneumonia but do not have a clear associated cause

question

How will patients with COP present?

answer

symptoms over 6-8 weeks that mimic community acquired pneumonia the vast majority of individuals will present with symptoms of less than 3 months duration; patients typically present with b/l diffuse alveolar opacities on CXR with normal lung volumes patients may also present with multiple large nodules or masses that are predominantly peripheral typically an intitial empiric treatment for infection is given but fails; subsequently noninfectious causes are then considered a bronchoscopic or surgical lung biopsy may be necessary to establish the diagnosis

question

What is the treatment for COP?

answer

glucocorticoids; prognosis is typically favorable

question

What is the presentation of acute interstitial pneumonia?

answer

develops rapidly over days to weeks and results in progressive hypoxemic respiratory failure CXR reveals b/l alveolar opacities consistent with pulmonary edema; these findings cannot be discerned from ARDS

question

What is the treatment for acute intersitial pneumonia?

answer

glucocorticoids and supportive care, but mortality is 50% low tidal volume ventilation***

question

What is sarcoidosis?

answer

multisystem granulomatous disease of unclear cause with a predilection for the lung

question

What % of patients with sarcoidosis have pulmonary involvement?

answer

more than 90%; but is often asymptomatic

question

What are the 5 stages of pulmonary sarcoidosis and their respective radiographic pattern?

answer

Stage 0: Normal Stage 1: hilar lymphadenopathy w/ normal lung parenchyma (>90% will have spontaneous resolution w/o treatment) Stage 2: hilar lymphadenopathy w/ abnormal lung parenchyma (20% spontaneous improvement w/o treatment) Stage 3: no lymphadenopathy with abnormal lung parenchyma (20% spontaneous improvement w/o treatment) Stage 4: parenchymal changes with fibrosis and architectural distortion

question

How is sarcoidosis diagnosed?

answer

exclusion usually requires tissue biopsy

question

What are the 3 clinical presentations of sarcoidosis that do NOT warrant a biopsy?

answer

1. asymptomatic b/l hilar lymphadenopathy with no evidence of fevers, malaise, or night sweats to suggest a malignancy 2. Lofgren syndrome: b/l hilar lymphadenopathy, migratory polyarthralgia, erthema nodosum, and fevers 3. Heerfordt syndrome: anterior uveitis, parotiditis, fevers (uveoparotid fever), and facial nerve palsy

question

What are the mainstay of therapy for symptomatic pulmonary sarcoidosis?

answer

glucocorticoids

question

What is lymphangioleiomyomatosis?

answer

rare disorder that occurs sporadically in women or in associated with tuberous sclerosis manifests as a diffuse cystic lung disease due to infiltration of smooth muscle cells into the pulmonary parenchyma diagnosis is based on imaging studies with diffuse thin-walled cysts as well as spontaneous pneumothoax, angiomyolipomas, and elevated vascular endothelial growth factor-D immunosuppression with sirolimus has demonstrated promise in limiting progression of pulmonary disease

question

What are the clinical manifestations of occupational lung disease?

answer

rhinitis, asthma, COPD, constrictive bronchiolitis, and restrictive diseases symptom onset may be acute (reactive airways disease/small airways dysfunction as occurs in acute chlorine gas exposure) as well as prolonged or subacute with a significant latent period (as with asbestosis)

question

What are conditions that should increase clinical suspicion of occupational lung disease? (7)

answer

1. The patient raises a concern about possible exposures at work. 2. There is a temporal relationship to clinical symptoms and work: a) symptoms worsen during or after work; b) symptoms abate or improve with time off or away from the workplace 3. coworkers are affected with similar symptoms 4. there are known respiratory hazards at work (these can be identified by Material Safety Data Sheets from the workplace) 5. Failure to response to initial therapy or symptoms that are further exacerbated upon returning to work 6. Onset of a respiratory disorder without typical risk factors 7. Clustering of disease in one geographic area

question

What is the management for occupational lung diseases?

answer

overriding principle in management is prevention, consisting of interventions in the workplace to avoid exposures as well as early identification of coworkers who may also be at risk

question

What is asbestos?

answer

a silicate mineral fiber previously used as an insulating material that is a major cause of lung disease (use has been virtually eliminated since its peak in the 1980's)

question

What is the latency period between exposure and disease development?

answer

15-35 years

question

What is asbestos exposure commonly associated with? (4)

answer

1. Construction 2. Automotive servicing 3. Shipbuilding 4. Mining industries

question

What is the pathophysiology of asbestosis?

answer

asbestos fibers are inhaled and are deposited at the level of airway bifurcations and the alveolus; the lung may clear fibers (typically shorter fibers), whereas others are transported to the interstitium or via the lymphatics to the pleura parietal plaques are the most common finding the initial process begins with an alveolitis; if the fiber burden is low, this can resolve spontaneously; with a higher burden, proinflammatory and cytotoxic agents are released by macrophages with resultant recruitment of fibroblasts; if the process if sustained, collagen deposition leads to irreversible chronic fibrosis

question

What are the most common form of disease with asbestos exposure?

answer

pleural plaques***: characterized by smooth, white, raised, irregular lesions affecting predominantly the parietal and, very rarely, the visceral pleura pleural plaques are asymptomatic in the absence of parenchymal disease and are typically incidentally identified on routine CXR

question

What other types of lung pathology can be found in asbestosis? (3)

answer

1. pleural fibrosis 2. pleural effusions (exudative and is often hemorrhagic; eosinophils are present in nearly 1/3rd of patients) 3. mesothelioma

question

What is the risk of lung cancer in patients with a history of smoking and history of asbestos exposure?

answer

14.4 times higher

question

What is the risk of lung cancer in patients with asbestosis with the additional risk of smoking?

answer

36.8 times higher

question

What is silicosis?

answer

a spectrum of fibrotic lung diseases related to the inhalation of silica dust

question

What is the most common form of silica?

answer

quartz; an any occupation that disturbs the earth's crust involves potential risk

question

What occupational industries are at risk for silicosis?

answer

any industry working with rock or sand mine workers are often exposed to multiple dusts and radon***

question

What is simple silicosis?

answer

marked by profusion of small rounded nodules that are upper lobe predominant the disease course may be accelerated (3-10 years after exposure) or latent (>10 years after exposure) the lesions may become confluent and lead to progressive massive fibrosis

question

The incidence of what infection is increased in patients with silicosis?

answer

tuberculosis; and symptoms should prompt an evaluation for possible infection

question

What are the 2 main types of abnormalities that affect the pleura?

answer

1. pleural effusion 2. pneumothorax

question

What are the vast majority of pleural effusions in the US the result of? (3)

answer

1. heart failure 2. pneumonia 3. malignancy

question

What are the signs/symptoms of pleural effusions?

answer

vary but commonly include dyspnea, cough, and pleuritic chest pain additional features such as fever, orthopnea, or concurrent arthralgia may provide clues to the underlying cause history of travel, prior and current occupation, medication use, prior surgery, malignancy, place of residency, and prior asbestos exposure should also be elicited

question

What are important tests in the initial evaluation of pleural effusions?

answer

CXR and thoracic ultrasound

question

How much pleural fluid must be present to show evidence of a pleural effusion on PA CXR? Lateral films?

answer

PA CXR- 200ml Lateral CXR- 50ml

question

What are the indications for a thoracentesis?

answer

any new unexplained pleural effusion observation and initiation of therapy w/o diagnostic thoracentesis are reasonable in the setting of known heart failure or small parapneumonic effusions, or following CABG however, any atypical features (such as fever, pleurisy) or failure to respond to therapy in these patients should prompt consideration of a diagnostic thoracentesis

question

How can pleural fluid appear? (4)

answer

1. serous 2. serosanguinous (blood stained) 3. hemorrhagic 4. purulent blood fluid is often seen with malignancy, PE with lung infarction, trauma, benign asbestos effusion, or post-cardiac injury syndrome purulent fluid can be seen in empyema and lipid effusions (putrid odor can point to an anaerobic infection and the smell of ammonia to an urinothorax)

question

What is Lights criteria?

answer

an effusion is considered an exudate if any of the following are met: 1. Pleural fluid total protein/serum total protein >0.5 2. Pleural fluid LDH/serum LDH >0.6 3. Pleural fluid LDH >2/3rd the upper limit of normal for serum LDH

question

What are transudative pleural effusions usually the result of? Exudative?

answer

an imbalance between hydrostatic and oncotic pressures, whereas exudates result primarily from inflammation or impaired lymphatic drainage (such as infections, inflammation, or malignancy)

question

When can Light criteria occasionally misclassify transudative effusions as exudates?

answer

in the setting of ongoing diuresis (in this case it is reasonable to determine the serum albumin to pleural fluid albumin gradient: if it is greater than 1.2 g/dL (12g/L), the underlying process is likely transudative)

question

What are the 8 different causes of transudative pleural effusions?

answer

1. heart failure 2. hepatic hydrothorax 3. nephrotic syndrome 4. hypoalbuminemia 5. unexplained (trapped) lung 6. urinothorax 7. atelectasis 8. peritoneal dialysis

question

What are the 11 different causes of an exudative pleural effusion?

answer

1. parapneumonic effusions 2. malignancy 3. PE 4. TB 5. Autoimmune diseases (RA, SLE) 6. Benign asbestosis exposure 7. Post-CABG 8. Pancreatitis 9. Post-MI 10. Yellow nail syndrome (lymphatic disorders) 11. Drugs

question

What is the differential diagnosis in a pleural effusion with a glucose level less than 60? (6)

answer

1. Rheumatoid pleurisy 2. Complicated parapneumonic effusion or empyema 3. Malignant effusion 4. TB pleurisy 5. Lupus pleuritis 6. Esophageal rupture

question

What pleural fluid studies suggests pancreatic disease, esophageal rupture, and malignant effusions?

answer

pleural fluid to serum amylase ratio >1.0

question

What pleural fluid triglyceride level is characteristic of a chylothorax?

answer

>110 a level <50 excludes the diagnosis between 50-110: should be investigated with a lipoprotein analysis looking for chylomicrons

question

What is the most likely test to yield a positive mycobacterial culture for a pleural effusion?

answer

pleural biopsy

question

What test should be performed when malignancy is suspected on a pleural effusion but the cytology is negative?

answer

repeat cytology if first specimen is negative***

question

What is the next step in management if malignancy is suspected but 2 cytologies are negative on pleural effusion?

answer

thoracoscopy (allows for biopsy of pleural sites) diagnostic sensitivity >90%

question

What is the mortality rate associated with a pleural space infection?

answer

20%

question

What is a parapneumonic effusion?

answer

exudative pleural effusions that occur adjacent to a bacterial pneumonia and result from migration of excess interstitial lung fluid across the visceral pleura; although inflammatory cells are present, parapneumonic infections are STERILE typically these are small and uncomplicated and resolve with resolution of the pnuemonia if bacteria from the pneumonia invade the pleural space a complicated parapneumonic effusion or empyema will result***

question

What is empyema?

answer

clear infection of the pleural space with the presence of pus pleural effusions greater than 10mm in depth on CXR and associated with a pneumonic illness should be sampled; in general, these require thoracostomy tube drainage when the pH is less than 7.2 or the pleural fluid glucose level is less than 60

question

What are the most typical bacteria causing pleural space infection? (4)

answer

1. Streptococcus pneumoniae 2. Streptococcus milleri 3. Staphylococcus aureus 4. Enterobacteriaceae anaerobes have also been culturesin 36-72% of empyemas so empiric coverage should include anaerobes

question

What are the pleural characteristics of an uncomplicated parapneumonic effusion? What will pleural fluid chemistry show? How is it managed?

answer

Pleural characteristics: a) small (10mm to 7.2, glucose >60 Management: a) abx and serial f/u to ensure resolution; if no resolution or ongoing sepsis, consider thoracentesis b) abx, thoracentesis, and serial f/u to ensure reoslution; if no resolution or ongoing sepsis, consider repeat thoracentesis and need for drainage

question

What are the pleural characteristics of a complicated parapneumonic effusion? What will pleural fluid chemistry show? How is it managed?

answer

Pleural characteristics: loculated or thickened pleura Pleural fluid chemistry: pH <7.2 or glucose <60 Management: abx, thoracostomy tube drainage, serial f/u; if no resolution, consult thoracic surgeon for possible thorascopic debridement

question

What are the pleural characteristics of an empyema? What will pleural fluid chemistry show? How is it managed?

answer

Pleural characteristics: bacterial organisms seen on gram stain or aspiration of pus on thoracentesis Pleural fluid chemistry: pH <7.0 Management: abx, thoracostomy tube drainage, early consultation with a thoracic surgeon for possible thorascopic debridement

question

How to manage a malignant pleural effusion?

answer

repeat therapeutic thoracentesis is appropriate for patients with poor prognosis (<3 months) and slow re-accumulation of fluid in patients with more rapid recurrence of fluid, more definitive measures are warranted: indwelling pleural catheters with intermittent drainage (managed as an outpatient) is commonly the procedure of choice (significant symptom relief and 50-70% of patient achieve spontaneous obliteration of the pleural space (pleurodesis) after 2-6 weeks chemical pleurodesis with talc is also very effective with a success rate of 60-90% depending on the degree of lung re-expansion pleurectomy and pleuroperitoneal shunt are other management options but are rarely performed

question

What is a primary spontaneous pneumothorax? Secondary?

answer

PSP: a person w/o underlying lung disease SSP: a person with underlying lung disease

question

What are risk factors for PSP? (5)

answer

1. smoking 2. tall stature 3. family history 4. Marfan syndrome 5. thoracic endometriosis

question

How to manage a primary spontaneous pneumothorax that is <2cm on CXR, with minimal symptoms?

answer

observation alone; may be managed as an outpatient if easy access to medical care is available if clinical symptoms change

question

How to manage a primary spontaneous pneumothorax that is >2cm on CXR, with breathlessness, and chest pain?

answer

needle aspiration; if reaccumulation then insertion of a small-bore (<14 Fr thoracostomy tube)

question

How to manage a primary spontaneous pneumothorax that is presenting with clinical instability regardless of size?

answer

emergent needle decompression followed by thoracostomy tube insertion

question

How to manage a secondary spontaneous pneumothorax that is <2cm on CXR, with minimal symptoms?

answer

admit to hospital for observation and supplemental oxygen

question

How to manage a secondary spontaneous pneumothorax that is >2cm on CXR, with breathlessness, and chest pain?

answer

insertion of a small-bore (<14 Fr) thoracostomy tube

question

How to manage a secondary spontaneous pneumothorax that is presenting with clinical instability regardless of size

answer

emergent needle decompression followed by thoracostomy tube insertion

question

What are the recurrence rates of PSP? SSP?

answer

PSP: 23-50% over the first 5 years SSP: 50% over the first 5 years intervention to prevent recurrence includes both chemical and mechanical pleurodesis, which is recommended in all SSP and after the second occurrence of a PSP all patients should be counseled against air travel until complete resolution of the pneumothorax has been confirmed by CXR; in addition, diving should be discouraged permanently unless a definitive prevention plan (such as surgical pleurectomy) has been performed

question

How should a large, hemodynamically significant pneumothorax (tension pneumothorax) be managed?

answer

high-flow supplemental O2 and emergent needle thoracostomy followed by thoracostomy tube placement and hospitalization

question

What are the features of the pulmonary vasculature?

answer

it is a system of low pressure and high compliance, such that in healthy individuals, pulmonary artery pressures remain relatively unchanged during states of stress and high flow, such as exercise

question

What is the normal mean pulmonary artery pressure?

answer

approximately 15mm Hg

question

What is pulmonary HTN?

answer

a resting mean pulmonary artery pressure of 25mm Hg or greater

question

Unabated, PH will eventually lead to what?

answer

right ventricular failure and may directly contribute to death

question

What are the 5 different groups of Pulmonary Hypertension?

answer

1. PAH; pulmonary veno-occlusive disease and/or pulmonary capillary hemangiomatosis 2. Pulmonary HTN due to left-sided heart disease 3. Pulmonary HTN due to lung diseases and/or hypoxia 4. Chronic thromboembolic pulmonary hypertension 5. Pulmonary HTN with unclear or multi-factorial causes

question

What is different about pulmonary artery hypertension compared with PH?

answer

localized to small pulmonary arterioles resulting in high pulmonary vascular resistance

question

What are the 5 different causes of pulmonary artery HTN?

answer

1. Idiopathic 2. Heritable (BMPR2; ALK1; Unknown) 3. Drug and toxin induced (including illictis) 4. Associated with: (Connective tissue diseases (systemic sclerosis***), HIV, Portal HTN, Congenital heart disease, Schistosomiasis, Chronic hemolytic anemia) 5. Persistent pulmonary HTN of the newborn

question

What are the 3 causes of Pulmonary HTN due to left-sided heart disease?

answer

1. Systolic dysfunction 2. Diastolic dysfunction 3. Valvular disease

question

What are the 7 causes of Pulmonary HTN due to lung diseases and/or hypoxia?

answer

1. COPD 2. Interstitial lung disease 3. Other pulmonary diseases with mixed restrictive and obstructive pattern 4. Sleep disordered breathing 5. Alveolar hypoventilation disorders 6. Chronic exposure to high altitude 7. Developmental abnormalities

question

What are the 4 different causes of pulmonary HTN with unclear or multi-factorial causes?

answer

1. hematologic disorders: myeloproliferative disorders, splenectomy 2. systemic disorders: sarcoidosis, pulmonary Langerhans cell histiocytosis: lymphangioleiopmyomatosis, neurofibromatosis, vasculitis 3. Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid disorders 4. Others: tumoral obstruction, fibrosing mediastinitis, chronic kidney failure on dialysis

question

What is the vast majority of cases of PH attributed to?

answer

left-sided heart disease (group 2) and hypoxic respiratory disorders (group 3)

question

With all causes of PH, what will happen to the RV?

answer

RV hypertrophy and dilatation develop over time in response to pulmonary artery pressure overload, at which point mismatch of myocardial oxygen supply and demand can result in ischemia, arrhythmias and RV failure

question

What are the symptoms initially in patients with PH and what can they progress to?

answer

symptoms may be minimal initially with exertional dyspnea and fatigue as the disorder progresses, RV impairment may be heralded by exertional chest pain, syncope, and peripheral edema

question

What will the cardiovascular exam show in patients with PH?

answer

depends on the severity of disease but may show jugular venous distention, a prominent jugular venous a wave, parasternal heave, a widened split S2 with a prominent pulmonic component, or right sided regurgitant murmurs as the RV dilates as RV dysfunction progresses, hepatomegaly, ascites, and peripheral edema develop

question

What is the initial test for patients suspected of having PH?

answer

echocardiography because echo may underestimate true pulmonary artery pressures, right heart catheterization should be considered after a normal echo if the index of suspicion for PH is high

question

What is the treatment for PH groups 2-5?

answer

directed at the underlying condition

question

What is the advanced therapy for patients with PAH?

answer

vasodilators (does not have a role in groups 2-5) actually, advanced therapy with vasodilators may be harmful in patients with PH due to LV dysfunction (group 2) or lung disease (group 3) because of the potential for pulmonary vasodilators to overload a compromised LV and to worsen V/Q mismatching, respectively

question

What % of patients who have an acute PE will go on to develop chronic thromboembolic PH?

answer

<5%

question

What is the pathophysiology of CTEPH?

answer

the organized thrombus incorporates into the pulmonary artery endothelium, thereby increasing pulmonary vascular resistance and pressures and eventually leading to right-sided heart failure

question

What % of patients with CTEPH will NOT report a history of PE?

answer

>25%

question

What are the 2 diagnostic criteria for CTEPH?

answer

1. documentation of PH (pulmonary artery pressure >25) by right heart cath in the absence of left heart pressure overload 2. compatible imaging evidence of chronic thromboembolism

question

What test is a sensitive indicator of CTEPH and is the preferred first imaging modality?

answer

V/Q scan then get conventional pulmonary angiography to characterize the extent and distribution of organized thrombus and determine suitability for surgical intervention

question

What therapy is indicated in all patients with CTEPH to help prevent further thromboembolism?

answer

anticoagulant therapy (generally lifelong)

question

What is the only definitive therapy for CTEPH?

answer

pulmonary thromboendarterectomy

question

What drugs are implicated in PAH? (5)

answer

1. fenfluramine 2. phentermine 3. dexfenfluramine 4. cocaine 5. amphetamines

question

Is anticoagulation in patients with PAH recommended?

answer

Yes, because PAH predisposes to in-situ pulmonary vascular thrombosis and embolism

question

What supportive measures should be considered in patients with PAH? (5)

answer

1. diuretic therapy 2. supplemental O2 3. anticoagulation 4. digoxin (improves RV function in some patients and helps manage dupraventricular dysrhythmias that are common in this population) 5. exercise training (improves functional limitations)

question

What pharmacologic therapies are available for PAH? (4)

answer

1. CCB's (only for patients with acute vasodilator response at cath; acute response does not assure chronic response) 2. Prostanoids (epoprostenol, treprostilnil, iloprost): supplements endogenous levels of prostacyclin (PGI2), a vasodilator with anti-smooth muscle proliferative properties 3. Endothelin-1 receptor antagonists (bosentan, ambrisentan): blocks action of endogenous vasoconstrictor and smooth muscle mitogen endothelin; class wide risk of liver injury and teratogenicity; liver chemistry testing and pregnancy testing for reproductive age women are required 4. Phosphodiesterase 5 inhibitors (sildenafil, tadalafil): prolongs effect of intrinsic vasodilator cyclic GMP by inhibiting hydrolysis by phosphodiesterase 5

question

What is a solitary pulmonary nodule?

answer

a lesion less than 3cm in size surrounded by normal lung parenchyma

question

What are the different causes of solitary pulmonary nodules?

answer

1. malignancy (primary lung and metastatic cancer) 2. granulomas 3. hamartomas 4. vascular malformations

question

What is a subcentimeter pulmonary nodule?

answer

a SPN that is 8mm or smaller the risk of malignancy is divided into low and high risk High risk: older than 50 years is high risk, hx of smoking, environmental or occupational exposures (ex asbestos and radon), diagnosis of COPD, hx of radiation therapy, possibly a family hx of lung cancer

question

How should a SPN that is less than or equal to 4mm with low pretest probability (minimal or absent hx of smoking and of other known risk factors) be followed up? High pretest probability (history of smoking or of other known risk factors)? (size is the average of length and width)

answer

Low pretest probability: no follow up needed High pretest probability: follow up CT at 12 months; if unchanged, no further follow up

question

How should a SPN that is 4-6mm with low pretest probability (minimal or absent hx of smoking and of other known risk factors) be followed up? High pretest probability (history of smoking or of other known risk factors)?

answer

Low pretest probability: follow up CT at 12 months; if unchanged no further follow up High pretest probability: initial follow up CT at 6-12 months then at 18-24 months if no change

question

How should a SPN that is 6-8mm with low pretest probability (minimal or absent hx of smoking and of other known risk factors) be followed up? High pretest probability (history of smoking or of other known risk factors)?

answer

Low pretest probability: initial follow up CT at 6-12 months then at 18-24 months if no change High pretest probability: initial follow up CT at 3-6 months then at 9 to 12 months and 24 months if no change

question

How should a SPN that is >8mm with low pretest probability (minimal or absent hx of smoking and of other known risk factors) be followed up? High pretest probability (history of smoking or of other known risk factors)?

answer

Low pretest probability: follow up CT at around 3, 9, and 24 months; dynamic contrast enhanced CT, PET, and/or biopsy High pretest probability: same as for low-risk patient

question

What is the first step in management of a solitary pulmonary nodule?

answer

assess the pretest probability of malignancy if prior imaging of the chest is available, it should be reviewed as a low-risk and inexpensive way to assess the stability or growth of the SPN

question

What are the management recommendations for SPN's between 8-30mm with low pretest probability of malignancy (<5%)?

answer

surveillance CT at 3-6, 9-12, and 18-24 months (re-evaluate for PET imaging, tissue diagnosis, or excision if evidence of growth)

question

What are the management recommendations for SPN's between 8-30mm with intermediate pretest probability of malignancy (5-65%)?

answer

PET/CT imaging: tissue diagnosis or excision if the nodule demonstrates high metabolic activity, as defined by the concentration of uptake of the tracer (fluorodeoxyglucose) at least short-term surveillance if negative, but consider more aggressive evaluation depending on individual patient factors

question

What are the management recommendations for SPN's between 8-30mm with high pretest probability of malignancy (>65%)?

answer

surgical excision (consider PET/CT imaging for staging first)

question

What is a pulmonary mass?

answer

a lesion >3cm in diameter

question

What is the first step in evaluating a pulmonary mass?

answer

biopsy for tissue diagnosis or surgical resection (if no evidence of metastatic disease is found)

question

What is the second most common cancer diagnosed in the US but is the leading cause of cancer deaths?

answer

lung cancer

question

What % of lung cancers can be attributed to cigarette smoking or exposure to second-hand smoke?

answer

80-90%

question

What are additional risk factors for lung cancer?

answer

exposure to asbestos, ionizing radiation, radon, and arsenic

question

What are the 5 different kinds of NSCLC? What is the % of all lung cancers?

answer

1. Adenocarcinoma (38%) 2. Squamous cell carcinoma (20%) 3. Large cell carcinoma (3%) 4. Adenosquamous carcinoma (0.6-2.3%) 5. Sarcomatoid carcinoma (0.3%) NSCLC represents 80% of all lung cancers

question

What are the 4 different types of neuroendocrine tumors found in the lung? What is the % of all lung cancers?

answer

1. Small cell lung cancer (14%) 2. Large cell lung cancer (3%) 3. Typical carcinoid tumor (1-2%) 4. Atypical carcinoid tumor (0.1-0.2%)

question

What are the USPSTF recommendations for lung cancer screening?

answer

patients between the ages of 55-79 years who have a 30 pack year or more history of smoking and who are currently smoking or quit within the last 15 years annual low-dose CT imaging should continue until comorbidity limits survival or the ability to tolerate surgical resection, or the patient reaches the age of 80 years

question

What are the 3 different subtypes of adenocarcinoma (preinvasive lesions)?

answer

1. atypical adenomatous hyperplasia 2. adenocarcinoma in situ (AIS)- most commonly presents as an incidental finding of ground-glass opacification on chest CT 3. minimally invasive adenocarcinoma 5 year survival rates are 100% after surgical resection for all 3 pre-invasive lesions

question

What type of lung cancer is the most common to present in children and adolescents?

answer

bronchial carcinoid tumors most lesions involve the proximal airways, so patients may present with symptoms related to endobronchial narrowing or obstruction, including post-obstructive pneumonia

question

What is the survival rate for a typical carcinoid tumor?

answer

it is considered low rate with an excellent 5-year survival rate of 92-100%

question

What % of patients with bronchial carcinoid tumors will present with symptoms of carcinoid syndrome?

answer

1-5%

question

What are the symptoms of carcinoid syndrome?

answer

flushing, bronchospasm, and diarrhea caused by the release of vasoactive substances, including serotonin associated with larger tumor size and the presence of liver metastases

question

What are atypical carcinoid tumors characterized by?

answer

higher number of observed mitoses or the presence of necrosis on pathology and are considered intermediate grade malignancies higher tendency to metastasize and are associated with a lower 5-year survival rate of 61-88% although invasion of lymph nodes by typical carcinoid tumors may not decrease survival, it is associated with a worse prognosis in patients with atypical carcinoid tumors once a diagnosis is made, surgical resection is recommended for both types of bronchial carcinoid tumors even when lymph node involvement is documented

question

What is the most significant risk factor for the development of mesothelioma?

answer

exposure to airborne asbestos fibers

question

How do patients with mesothelioma most commonly present?

answer

symptoms of a slowly enlarging pleural effusion usually accompanied by the presence of pleural plaques or calcifications

question

What is the most common cause of an anterior mediastinal mass?

answer

thymoma; other causes include lymphoma (2nd most common) and teratoma

question

What paraneoplastic syndrome is associated with thymoma?

answer

myasthenia gravis (35-40% of patients with a thymoma) other less common paraneoplastic syndromes include pure red cell aplasia, nonthymic cancers, and acquired hypogammaglobulinemia

question

What is the most common cause of a middle mediastinal mass?

answer

lymphadenopathy

question

What is the most common cause of a posterior mediastinal mass?

answer

neurogenic tumor

question

What is the most common cause of excessive daytime sleepiness?

answer

overall lack of time devoted to the sleep period

question

How should patients with excessive daytime sleepiness be counseled?

answer

maintain a consistent sleep-wake schedule that allows for 8 hours of sleep

question

What is fatigue?

answer

lack of energy that prevents mental or physical activity at the intensity and/or pace desired (rarely the result of a primary sleep disorder)

question

What are the different categories for excessive sleepiness? (2)

answer

extrinsic (circumstantial) and intrinsic (disease-related)

question

What are the 4 different causes of extrinsic daytime sleepiness?

answer

1. insufficient sleep duration (or inadequate opportunity for sleep) 2. circadian rhythm disturbance (shift work sleep disorder, jet lag) 3. drug-, substance-, or medical condition-related hypersomnia 4. environmental sleep disorder (ambient noise, pets)

question

What are the 5 different causes of intrinsic daytime sleepiness?

answer

1. sleep-disordered breathing syndromes, such as OSA and central sleep apnea 2. narcolepsy 3. idiopathic hypersomnia 4. restless leg syndrome and periodic limb movement disorder 5. circadian rhythm sleep disorders

question

What sleep latency is a clear indicator of pathologic sleepiness?

answer

<5 minutes whereas more than 15 minutes is considered normal

question

What is jet lag?

answer

a syndrome resulting from desynchronization of the internal circadian clock with the local destination time following air travel across multiple (usually more than 5) time zones re-synchronization takes on average 1.0-1.5 days for every hour change in time zone

question

What is shift-work sleep disorder?

answer

insomnia during the daytime sleep period and resultant sleepiness during the nighttime work period modafinil is approved for use in SWSD, should only be used after conservative measures such as sleep hygiene counseling are tried

question

What is obstructive sleep apnea?

answer

a common condition defined by narrowing or occlusion of the upper airway during sleep, resulting in repetitive interruption of the sleep cycle

question

What are apneas? Hypopneas?

answer

apneas- characterized by complete cessation of airflow hypopneas- reductions in airflow both are typically accompanied by oxyhemoglobin desaturations and are terminated by an awakening from sleep may be quantified during diagnostic sleep testing by the apnea-hypopnea index (AHI)

question

What AHI is indicative of mild OSA? Severe OSA?

answer

AHI of 5-15 is mild OSA AHI >30 is severe OSA

question

What is the most important risk factors for OSA?

answer

obesity regional distribution of adipose tissue concentrated in the trunk and neck imparts the highest risk tonsillar hypertrophy, macroglossia, terognathia/micrognathia, and upper airway mass lesions can cause upper airway narrowing cigarette smoking is a risk factor alcohol and sedative drugs can worsen OSA endocrinopathies such as PCOS and advanced hypothyroidism can increase the risk of OSA

question

What are symptoms of OSA?

answer

loud snoring, gasping, and breathing pauses obseved by a bed partner are common subjective complaints include frequent awakenings, dry mouth, snorting, and non-restorative sleep; nocturia is common in men with OSA Excessive daytime sleepiness, mood alterations, difficulty concentrating, and problems completing tasks at school or the workplace

question

How is OSA diagnosed?

answer

polysomnography (gold standard) out-of-center sleep testing performs comparably to polysomnography in patients without comorbid cardiopulmonary disease who have a high pretest probability of moderate to severe OSA overnight pulse ox alone has a high rate of false-positive and false-negative results and has not been validated as a screening tool for OSA; its use should be limited to patients with low pretest probability, few symptoms, or in patients who prefer to avoid treatment

question

What is the treatment for OSA?

answer

all patietns should be counseled on behavior modifications, particularly weight loss in those who are overweight or obese positive airway pressure is the preferred therapy for nearly all patients with symptomatic OSA

question

What are alternatives to positive airway pressure in the treatment of OSA?

answer

oral appliances, upper airway surgery

question

What is central sleep apnea?

answer

the loss of neural output originating from the respiratory centers in teh CNS to the respiratory pump machinery, resulting in pauses in breathing CSA is manifested by the absence of respiratory effort associated with loss of airflow for at least 10 seconds determined by sleep testing compared with wakefulness, ventilation normally decreases during sleep and is primarily determined by blood CO2 tension (arterial pCO2), with a lesser influence from oxygen tension; the stimulus to breathe decreases along with areterial pCO2 until the apneic threshold is reached, at which point ventilation ceases; common to all CSA syndromes is the propensity to intermittently cross the apneic threshold, which causes a pause in breathing that destabilizes further ventilation

question

What are the risk factors for CSA?

answer

heart failure (manifests as Cheyne-Stokes breathing- characterized by a pattern of ventilation with periods of waxing and waning tidal volumes) opioid analgesics*** atrial fibrillation, brain-stem lesions, possibly kidney failure high-altitude periodic breathing is a form of CSA

question

How is CSA diagnosed?

answer

in-lab polysomnography

question

What is the treatment for CSA?

answer

the strongest indication for treatment of CSA is the presence of sleep-related symptoms, and therapy should first target management of modifiable co-morbid conditions or risk factors CPAP may occasionally be useful (especially in patients with overlapping OSA); however, CSA may be exacerbated by CPAP (known as "complex sleep apnea" or "treatment emergent CSA") Adaptive servoventilation often suppresses CSA during polysomnography but has not yet been shown to improve important outcomes in those with heart failure

question

What are the sleep-related hypoventilation syndromes? (5)

answer

1. COPD 2. Obesity hypoventilation syndrome 3. Myxedema 4. Neuromuscular disease (muscular dystrophy, ALS, myasthenia gravis, Guillain-Barre syndrome, phrenic nerve injury, polio, cervical spine injury) 5. kyphoscoliosis

question

What is the cardinal sign of obesity hypoventilation syndrome?

answer

daytime hypercapnia; reflecting reduced ventilation during wakefulness and sleep that is not attributed to another cause

question

What causes high-altitude related illnesses?

answer

although the proportion of air comprised of oxygen remains constant at 21% as altitude increases, diminishing barometric pressure reduces the amount of oxygen available for gas exchange, resulting in a condition known as hypobaric hypoxia

question

At what elevations does high altitude related illnesses generally occur?

answer

above 2,500 meters (approximately 8,200 feet) young age and the level of physical fitness have not been shown to be protective

question

What are the 2 key risk factors for HAI's?

answer

1. destination altitude 2. rate of ascent gradual ascension allows acclimization and a decreased risk for HAI

question

What is the physiologic response to hypoxic stress associated with hypobaric hypoxia?

answer

increase in ventilation, which is a key pathophysiologic mechanism in high-altitude periodic breathing (HAPB) hypoxia-induced hyperventilation drives the arterial pCO2 toward the apneic threshold, with a decrease in RR and eventual rise in arterial pCO2; this results in increased respiratory drive and recurrent hyperventilation these cycle apneas and hyperpneas are associated with repetitive arousals from sleep, often with paroxysms of dyspnea and usually occurring the first night at elevation

question

What medication accelerates the acclimatization process to high altitude by inducing a slight metabolic acidosis to stimulate ventilation and enhance gas exchange?

answer

acetazolamide

question

WHat is acute mountain sickness?

answer

the most common HAI and is characterized by headache, fatigue, nausea/vomiting, and disturbed sleep acetazolamide may be used to prevent acute mountain sickness for mild symptoms- aspirin, NSAIDs, or antiemetics

question

What is high altitude cerebral edema?

answer

more extreme manifestation of acute mountain sickness that tends to occur at elevations above 3000-4000 meters (approximately 9,800-13,000 feet) vascular leak leads to brain swelling, resulting in manifestations that range from confusion and irritability to ataxic gait to coma and death

question

How is high altitude cerebral edema treated?

answer

immediate descent from altitude dexamethasone, supplemental O2, and hyperbaric therapy may be used in addition to descent from altitude

question

What is high-altitude pulmonary edema?

answer

vascular leak driven by hypoxia leads to pulmonary edema; results from increase in pulmonary arterial pressures within 2-4 days of ascent to altitudes >2500 meters (8,200 feet) symptoms of cough, dyspnea, and exertional intolerance are usually insidious but occasionally may occur abruptly and awaken a patient from sleep treatment of choice is supplemental O2 along with rest (both acutely reduce pulmonary arterial pressures) may also use vasodilators such as nifedipine*** or phosphodiesterase-5 inhibitors (sildenafil or tadalafil) diuretics and nitrates are not recommended in this setting***

question

What are airplane cabin pressures equivalent to?

answer

1500-2500 meters (5000-8200 feet) resulting in an inspired oxygen tension between 110 and 120mm Hg (about 70% of the levels encountered at sea level) this correlates with an arterial pO2 of approximately 60mm Hg

question

What oxyhemoglobin saturation indicates a likely need for in-flight supplemental O2 to prevent hypoxia?

answer

less than 92% at sea level

question

What is the recommendation for patients who are already on long-term supplemental O2 for flying?

answer

doubling the flow rate during flight is typically adequate to prevent hypoxia

question

What are the indications for ICU admission? (7)

answer

1. Unstable airway 2. Unstable blood pressure 3. Unstable mental status 4. Life-threatening cardiac arrhythmias 5. respiratory failure 6. severe metabolic derangement 7. need for frequent (more than every 2 hours) measurement of vital signs

question

When should rapid responses be called?

answer

1. changes in vital signs: a) HR 139 b) Systolic BP 200 c) RR 35 d) Temperature 39.0C (102.2 F) e) Oxygen saturation less than 85% 2. development of altered mental status or coma

question

What are the considerations when determining the purpose and goals of invasive or noninvasive ventilation in a patient with respiratory failure? (5)

answer

1. What is the cause of the failure? -hypoxia, hypercapnia, or both 2. How quickly will the patient recover? -noninvasive ventilation can be considered if recovery is quick (as long as there are no contraindications); otherwise use invasive ventilation 3. What is the best tidal volume for this patient? -6-8ml/kg of ideal body weight is a safe starting point for most forms of respiratory failure (<6ml/kg for most patients with ARDS) 4. What should the minute ventilation be for this patient? -minute ventilation equals tidal volume times the RR; setting a normal minute ventilation of 6-8L/min is a starting point; it may need to be higher for metabolic acidosis or catabolic states or in situations where dead space is increased; it may need to be higher when lung-protective strategies are used 5. How much oxygen is needed? -start with an FiO2 of 1.0 and quickly decrease while following pulse ox to target oxygen saturation at 92% to 95% for most patients; use PEEP at an initial setting of 5cm H2O; increase PEEP to decrease high FiO2 need via alveolar recruitment and optimal airway pressures

question

What 3 disease states does noninvasive ventilation in critically ill patients prevent intubation in those with respiratory failure? (3)

answer

1. COPD 2. Heart failure 3. Obesity hypoventilation syndrome

question

What benefits is noninvasive ventilation associated with in immunocompromised patients?

answer

decreased ICU mortality, intubation rate, and ICU length of stay

question

What are the 3 major potential contraindications to noninvasive ventilation?

answer

1. Medical instability 2. Inability to protect airway 3. Mechanical issues patient needs to have a level of mentation that will allow for both the placement of a tight mask and some ability to interact with the staff***

question

What are some potential complications of NIV? (4)

answer

1. mask pressure skin breakdown 2. sinus congestion 3. gastric distention 4. eye irritation

question

What are the 4 different causes of medical instability which contraindicates the use of noninvasive ventilation?

answer

1. Respiratory or cardiac arrest 2. Severe acidosis (initial pH <7.25; failure to improve after 1-2 hours) 3. Hemodynamic instability/ severe cardiac arrhythmias 4. Active upper GI bleeding

question

What are the 3 different causes of inability to protect airway which contraindicates the use of noninvasive ventilation?

answer

1. excessive secretions/inability to clear secretions 2. severe bulbar dysfunction 3. encephalopathy or agitated delirium

question

What are the 5 different causes of mechanical issues which contraindicates the use of noninvasive ventilation?

answer

1. Large air leak due to inability to fit mask 2. Recent facial trauma or surgery 3. Recent transsphenoidal surgery or high esophageal anastomosis 4. Upper airway obstruction 5. Intolerance to delivered pressure

question

What are factors associated with failure of NIV? (3)

answer

1. need for vasopressors 2. kidney replacement therapy 3. presence of ARDS

question

In most patient populations, is NIV helpful in preventing reintubation in those with established respiratory failure after extubation?

answer

NO

question

What are the 3 different modes of mechanical ventilation?

answer

1. Breath control (refers to the method by which the mechanical breath is delivered; if the tidal volume and inspiratory flow are designated, the breath is classified as volume controlled (VC); conversely, if the breath is delivered based on a preset inspiratory pressure, the breath is pressure controlled (PC)) 2. Breath sequence: Spontaneous and mandatory are the 2 types of breaths; a mandatory breath is started (triggered) or ended (cycled) by the machine; ventilators may also be set to allow triggering of a mandatory breath coordinated with the patient inspiratory effort; if the breath is both triggered and cycled by the patient, it is a spontaneous breath; by definition, a mandatory breath is always assisted, but a spontaneous breath may or may not be assisted; there are 3 breath sequences: a) continuous mandatory ventilation(CMV): all breaths are mandatory; a preset frequency represents the minimum number of mandatory breaths per minute; the patient may trigger breaths at a higher frequency b) Intermittent mandatory ventilation (IMV): spontaneous breaths are allowed between or during mandatory breaths; a preset frequency represents the maximum number of mandatory breaths per minute c) Continuous spontaneous ventilation (CSV): all breaths are spontaneous 3. Targeting scheme: this refers to a variety of ventilator algorithms that can be used to tailor mechanical ventilation to the patients continuously changing lung characteristics and respiratory effort; these option are often proprietary, vary between ventilatory, and range from simply maintaining a constant airway pressure during a pressure-controlled breath to use of artificial intelligence based algorithms to achieve specific treatment goals

question

How often should patients be assess for their readiness to be weaned from mechanical ventilation?

answer

daily; should have sedation withdrawn and perform a spontaneous breathing trial

question

What are the most frequently used ventilator modes?

answer

see page 66 choose a ventilatory mode by indicating the method of breath control followed by the breath sequence

question

What is the rapid shallow breathing index?

answer

the RR to tidal volume ratio it is used to see if a spontaneous breathing trial will be successful a patient with an RSBI of less than 105 has an approximately 80% chance of being successfully extubated, whereas an RSBI of greater than 105 virtually guarantees weaning failure

question

What are other criteria that have been suggested for a successful weaning trial? (3)

answer

1. the ability to tolerate a weaning trial for 30 minutes (in most patients, SBT failure will occur within approximately 20 minutes) 2. maintain a RR of less than 35/min 3. keep an oxygen saturation of 90% without arrhythmias; sudden increases in heart rate and blood pressure; or development of respiratory distress, diaphoresis, or anxiety once the SBT is tolerated, the ability to clear secretions, a decreasing secretion burden, and a patent upper airway are other criteria that should be met to increase extubation success

question

What is ventilator associated pneumonia (VAP)?

answer

pneumonia that occurs at least 48 hours after endotracheal intubation patients suspected of having VAP should undergo lower respiratory tract sampling, followed by microscopic analysis and culture of the specimen nonbronchoscopic sampling methods are simple suctioning of the ET tube and mini-bronchoalveolar lavage, which involves use of a telescoping catheter (instead of a bronchoscope) to instill and aspirate physiologic saline for microbiologic analysis

question

What are the indications for invasive monitoring (using pulmonary artery catheter to determine the stroke volumes and cardiac output)? (4)

answer

1. Cardiogenic shock requiring supportive therapy 2. Severe heart failure requiring vasoactive therapy 3. Differentiating high-output heart failure from sepsis 4. Differentiating and/or treating causes of pulmonary hypertension other noninvasive devices are more attractive to use in unstable patients; in resuscitating hemodynamically unstable patients, the ability to predict intravascular volume status and responsiveness to fluids (defined as an increase in CO >15% following an adequate fluid challenge) is important; bedside ultrasound to assess vena caval dimensions induced by positive-pressure ventilation appears to be highly predictive of volume responsiveness and is a noninvasive alternative to PAC

question

What vasopressor is the first-line agent for septic shock? Second line?

answer

norepinephrine followed by epinephrine (vasopressin is considered a second-line agent (although it has been shown to be effective in less severe sepsis) that can be added to decrease the dose and side effects of norepinephrine)

question

What is the major side effect of dopamine?

answer

tachycardia; making this agent useful to increase cardiac output in the presence of a relative bradycardia

question

What receptors does norepinephrine act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: alpha 1 > beta 1 Clinical Use: first line in septic shock, other refractory shock Common side effects or contraindications: some arrhythmias; digital ischemia

question

What receptors does dopamine (low) act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: DA > beta 1 Clinical Use: historically used for kidney failure, but no evidence of effectiveness for this indication Common side effects or contraindications: arrhythmias, ischemia

question

What receptors does dopamine (medium) act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: beta 1 > beta 2 Clinical Use: septic or cardiogenic shock Common side effects or contraindications: arrhythmias, ischemia

question

What receptors does dopamine (high) act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: alpha 1 > beta 1 Clinical Use: first-line for septic shock, other refractory shock Common side effects or contraindications: arrhythmias, ischemia

question

What receptors does epinephrine (low) act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: beta 1 > beta 2 Clinical Use: second-line for septic or cardiogenic shock Common side effects or contraindications: arrhythmias, ischemia

question

What receptors does epinephrine (high) act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: alpha 1 = beta 1 Clinical Use: second-line for septic shock, other refractory shock Common side effects or contraindications: arrhythmias, ischemia

question

What receptors does phenylephrine act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: alpha 1 Clinical Use: milder shock states, least risky through peripheral IV line Common side effects or contraindications: lowest arrhythmia risk, not as powerful as other vasopressors

question

What receptors does vasopressin act on? What is its clinical use? What are common side effects or contraindications?

answer

Receptors: vasopressin receptors Clinical Use: second vasopressor for septic shock only, add to catecholamine vasopressor Common side effects or contraindications: splanchnic, mesenteric, and digital ischemia

question

What is the preferred initial IV route in administering fluid resuscitation?

answer

large-caliber IV peripheral access

question

Use of what is associated with a reduction in failure of central line catheter placement and vessel injury, as well as prevention of pneumothorax?

answer

ultrasound guided central line placement

question

What are the 4 broad categories of central access?

answer

1. PICC 2. temporary nontunneled 3. long-term tunneled 4. implanted port when IV access cannot rapidly be obtained, intraosseous (I/O) access is an immediate alternative; sites for I/O access in adults include 1-2cm below the tibial tuberosity and the humeral head; alternative access should replace the I/O within approximately 24 hours of placement to minimize complications

question

What is the ideal sedation for ventilated patients?

answer

when compared with deep sedation, light sedation (a drowsy and cooperative patient) reduces ICU-related PTSD, time on the ventilator, and mortality (unless contraindicated such as ARDS, ventilator dyssynchrony)

question

What type of sedation is ideal for ventilated patients?

answer

using non-benzodiazepine based sedatives are preferred owing to the increased ICU delirium associated with benzo use analgesia-based sedation is an alternative method to benzo use that does not result in an increase in days on the vent or in the ICU opioids are considered the drug class of choice for treatment of non-neuropathic pain in critically ill patients, including mechanically ventilated adult patients in the ICU; an opioid analgesic should be given as an interrupted infusion

question

When should mobilization of patients in the ICU begin?

answer

within 48 hours of admission, along with careful attention to pain, agitation, and delirium; reduces ICU and hospital length of stay, shortens return to independence, and improves survival

question

What is ICU-acquired weakness?

answer

includes critical illness polyneuropathy (with axonal nerve degeneration) and critical illness myopathy (with muscle myosin loss), resulting in profound muscle weakness the pathophys is multifactorial including dysfunctional microcirculation that leads to neuronal and axonal injury, inactivation of sodium channels, myonecrosis secondary to the catabolic state, acute muscle wasting of critical illness, and mitochondrial dysfunction of skeletal muscles

question

What are risk factors for ICU-acquired weakness?

answer

1. hyperglycemia 2. sepsis 3. multiple organ dysfunction 4. SIRS associated with long-term functional disability, prolonged ventilation, and in-hospital mortality

question

What is post-intensive care syndrome?

answer

new or worsening physical, cognitive, or mental health problems arising after a critical illness that persist beyond the initial hospital discharge this term can be applied to either the patient or family member, as both report a wide range of impairment after hospital discharge

question

When should initiation of enteral nutrition recommended following ICU admission?

answer

at 24-48 hours following admission IF the patient is hemodynamically stable***, with advancement to goal by 48-72 hours the presence of abdominal distention, decreased passage of stool or flatus, or vomiting indicates that patient may have gut ischemia or another GI problem and tube feeds should be discontinued or slowed gastric residual volumes of 200-500ml are safe (increasing residual volumes may signal a need to hold or reduce the feeding volume) simple formula for calculating caloric need in patients in the ICU is 25-35kcal/kg/d based on actual body weight (propofol add fat calories and should be included) for patients who cannot tolerate enteral feeding, TPN should NOT be started before day 7 of an acute illness (studies show that late feeding (after 7 days) is associated with faster recovery and fewer complications as compared with early feeding)

question

What are the ICU Choosing Wisely Top Five?

answer

1. Don't order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions 2. Don't transfuse erythrocytes in the hemodynamically stable, non-bleeding patients in the ICU who have a hemoglobin concentration greater than 7 g/dL 3. Don't use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay 4. Don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation 5. Don't continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort

question

The presence of what symptoms/signs helps identify patients with significant airway compromise? (3)

answer

1. stridor 2. drooling 3. voice change

question

How is the diagnosis of epiglotittis confirmed?

answer

direct visualization of the epiglottis or by the presence of epiglottal edema on lateral neck radiographs abscesses in the peritonsillar, retropharyngeal, and parapharyngeal space, as well as Ludwig angina (b/l infection of the submandibular space) can present with similar symptoms and cause life-threatening upper airway obstruction in addition to ensuring airway patency, treatment consists of antibiotics along with surgical drainage of abscesses when present

question

What are noninfectious causes of upper airway obstruction? (5)

answer

1. trauma 2. foreign body 3. external compression from tumor or thyroid disease 4. inhalational injuries 5. angioedema

question

What is shock?

answer

general deficiency in vascular perfusion, leading to tissue ischemia and dysfunction

question

What are signs of shock? (2) What are symptoms of shock? (6)

answer

Signs: 1. low blood pressure w/ lack of response to fluids 2. prolonged capillary refill time Symptoms: 1. Lightheadedness 2. AMS 3. Diaphoresis 4. Decreased urine output 5. Increased serum creatinine level 6. Chest pain or other ischemic pain the blood pressure of a patient in shock may be within normal parameters, but it may be relatively low compared with baseline pressure for that individual (such a situation will sometimes lead to organ dysfunction, in which case the organ specific manifestations may be the key to early diagnosis of the shock state)

question

What are the 3 basic types of shock?

answer

1. Hypovolemic (inadequate perfusion in the setting of decreased blood volume) 2. Cardiogenic (poor perfusion from decreased cardiac function) 3. Distributive (loss of vascular tone) obstructive shock is a subset of cardiogenic shock in which there is mechanical blockage in the central circulation, as can occur with massive PE or tension pneumothorax

question

What should be assessed in shock after blood pressure is found to be low?

answer

cardiac output and systemic vascular resistance

question

What type of shock will have low cardiac output?

answer

cardiogenic and hypovolemic

question

What are the 3 factors that control stroke volume?

answer

1. Preload 2. Contractility 3. Afterload

question

What type of shock has decreased preload?

answer

hypovolemic shock

question

What is the pathophysiology of hypovolemic shock? What measures should be taken to restore perfusion? What measures can be taken to reverse the cause of shock?

answer

Pathophysiology: decreased effective circulating volume diminishes preload and the heart is unable to maintain adequate output Measures to restore perfusion: IV fluids and blood transfusions Measures to reverse the cause of shock: control sites of bleeding, control other fluid loss

question

What is the pathophysiology of cardiogenic shock? What measures should be taken to restore perfusion? What measures can be taken to reverse the cause of shock?

answer

Pathophysiology: cardiac function is impaired, either because of damage or disease to the heart muscle, arrhythmia, or obstruction of the central circulation of heart valves Measures to restore perfusion: IV fluids or diuresis to optimize preload, inotropic medications, maintenance of an appropriate heart rate Measures to reverse the cause of shock: coronary revascularization, thrombolysis, treatment of underlying rhythm disturbance, relief of obstruction

question

What is the pathophysiology of distributive shock? What measures should be taken to restore perfusion? What measures can be taken to reverse the cause of shock?

answer

Pathophysiology: loss of vascular tone leads to pooling of blood in capacitance spaces, decreasing the circulating volume Measures to restore perfusion: IV fluids and vasopressors Measures to reverse the cause of shock: antibiotics and control of infectious source

question

What is hypoxic respiratory failure?

answer

usually characterized by an arterial pO2 of 60mm Hg or less or an oxygen saturation of 89% or less while breathing ambient air, and/or an arterial pO2/FiO2 ratio of 200mm Hg or less

question

What is hypoxemic respiratory failure common caused by?

answer

V/Q mismatch conditions (also called intrapulmonary shunt), in which blood flows through capillaries adjacent to alveoli that are not ventilated V to Q may be high if the unbalance is toward more ventilation than perfusion (ex. PE) V to Q may be low if unbalanced toward more perfusion and less ventilation (ex. atelectasis, pneumonia)

question

What is ARDS?

answer

a clinical syndrome that can result from a variety of insults to the lungs, leading to alveolar and interstitial inflammation and edema, with a complex milieu of inflammatory cells and protein there is a heterogeneous but often widespread damage to the alveolar epithelium and vascular endothelium, as well as surfactant dysfunction leading to alveolar instability and collapse the pathologic desciprtion of this process is diffuse alveolar damage

question

What are the consequences of ARDS?

answer

worsening gas exchange leading to profound hypoxia due to low V/Q mismatch the changes can severely reduce lung compliance, making adequate ventilation difficult and further worsening hypoxia pulmonary artery pressure is also increased, which can worsen oxygen delivery by decreasing overall cardiac output

question

How is ARDS diagnosed? (Berlin definition criteria; 3)

answer

1. presentation within 1 week of known insult, or with worsening respiratory symptoms 2. PaO2/FiO2 5cm H2O 3. b/l otherwise unexplained opacities seen on frontal chest imaging

question

What are the different severity of ARDS?

answer

1. Mild: PaO2/FiO2 200 2. Moderate: PaO2/FiO2 100 3. Severe: PaO2/FiO2 <100

question

What are pulmonary causes of ARDS? (5)

answer

1. pneumonia 2. aspiration 3. inhalation injury 4. near drowning 5. drugs

question

What are nonpulmonary causes of ARDS? (3)

answer

1. Sepsis 2. Pancreatitis 3. Infusion reactions some cases of ARDS may be caused or made worse by mechanical ventilation, especially if lung protective strategies are not used (ventilator induced lung injury)

question

What is volutrauma?

answer

when the mode or settings on the ventilator lead to overdistention of alveoli

question

What is atelectrauma?

answer

when the mode or settings on the ventilator lead to repeated opening and closing of alveoli

question

What is biotrauma?

answer

when the mode or settings on the ventilator lead to a release of inflammatory mediators in the lung or systemic circulation

question

What are the lung-protective strategies used in patients with ARDS? (3)

answer

1. limiting tidal volume given to 6ml/kg of ideal body weight 2. limiting plateau pressure in the respiratory cycle to no more than 30cm H2O 3. use adequate PEEP to prevent the collapse of unstable alveolar units in the expiratory phase of the cycle there is evidence that even lower tidal volumes may be better for the lungs and that higher levels of PEEP than those previously recommended may be more protective (use a PEEP level that achieves adequate oxygenation with an FiO2 of less than 0.6 and does not cause hypotension) limit volume and pressure as much as patients can tolerate, even allowing blood levels of CO2 to rise somewhat in exchange for more protective volumes and pressures (permissive hypercapnia); a pH of 7.25 or even lower may be acceptable in order to ventilate the lungs as gently as possible

question

What other non-mechanical treatments should patients with ARDS receive? (2)

answer

1. conservative fluid management, which consists of limited IV boluses and using diuretics to keep CVP's at lower targets 2. prone positioning (16 hours/day) may result in a mortality benefit for selected patients with ARDS on mechanical ventilation steroids have no benefit in ARDS*** ECMO may be beneficial in a very select group of patients (no other organ damage and good prognosis)

question

Which selected patients is prone positioning beneficial for?

answer

patients with severe ARDS for whom the risk/benefit ratio of such positioning is low goal is to improve oxygenation to an arterial pO2/FiO2 ratio of at least 150 (some patients cannot be placed prone owing to their weight or other comorbid conditions)

question

How is atelectasis treated? (4)

answer

1. chest physiotherapy 2. incentive spirometry 3. ambulation (including early mobilization after surgery) 4. positive airway pressure

question

When does hypercapnic, or ventilatory, respiratory failure occur?

answer

when alveolar ventilation is inadequate to clear the CO2 produced by cellular metabolism, and the level of CO2 increases in the blood usually not due to gas exchange abnormalities, since CO2 is more soluble than oxygen and therefore diffuses more readily between the alveolar air space and pulmonary capillary blood

question

What are the 3 reasons for decreases alveolar ventilation?

answer

1. decreased respiratory drive 2. restrictive defects of the lung, chest wall, or respiratory muscles 3. conditions that increase dead space in the lungs so that much of the inspired air does not reach areas of gas exchange with the blood

question

What is decreased respiratory drive most often due to?

answer

sedative and analgesic drugs that suppress the respiratory center in the brainstem ex. opiates, benzodiazepines, barbiturates, and any other sedating meds strokes usually do not suppress respiratory drive unless they increase intracranial pressure, which can lead to brainstem herniation hypoglycemia and hypothyroidism can also sometimes suppress respiratory drive

question

What are restrictive ventilatory defects? What are the 3 types of diseases that cause it?

answer

decrease in the total lung capacity or the vital capacity 1. parenchymal lung disease, in which fibrotic or infiltrated lung tissue loses its mechanical compliance 2. extrapulmonary restriction due to chest wall disease, in which the spine, ribs, or other thoracic structures limit lung expansion 3. neuromuscular weakness, in which the lungs can be passively expanded to normal volume but the patients ability to take a full breath is limited by weakness of the respiratory muscles

question

What will spirometry show in patients with neuromuscular weakness?

answer

restriction defect but normal diffusing capacity

question

What are signs on PE of neuromuscular weakness?

answer

paradoxical inward motion of the abdomen with inspiration and other signs of accessory muscle use for breathing ALS: also get slurred speech, trouble swallowing liquids, choking, and coughing

question

How does obstructive lung disease cause ventilatory failure?

answer

the resistance to expiratory flow causes air trapping, leading to elevated intrathoracic pressure known as auto-PEEP or intrinsic PEEP airway resistance to flow causes incomplete exhalation before the next breath is initiated by the mechanical venilator; this "trapped" volume of air may be small with each breath, but it can build up over many breaths to a significant volume of unexpired air in the chest leading to auto-PEEP which hyperinflates the chest and reduces fresh gas entry into the alveoli patients with ventilatory failure from obstructive lung disease may be hypoxic but usually respond readily to supplemental oxygen; if hypoxia is profound or refractory to oxygen therapy, alternative diagnoses should be considered

question

What will ABG show in patients with severe asthma exacerbation?

answer

hypocapnia; but a normal or mildly elevated CO2 level can be a sign of respiratory muscle fatigue and impending failure

question

When should patients with a severe asthma exacerbation be admitted to the ICU for close monitoring and aggressive therapy?

answer

if the FEV1 and peak expiratory flow do not respond to aggressive bronchodilator and glucocorticoid therapy to above 40% of predicted if the patient is unable to perform FEV1 or PEF maneuvers or has AMS, increasing work of breathing, or agonal respiration, immediate intubation is usually indicated

question

What can autoPEEP lead to if unchecked?

answer

if autoPEEP is not recognized when the patient is mechanically ventilated, increasing pressure within the chest can cause decreased venous return to the heart, resulting in cardiovascular instability (if this is observed, the immediate response is to disconnect the ventilator circuit from the patients ET tube to allow for a prolonged exhalation to release auto-PEEP (slow the RR, decrease tidal volume, and increasing the inspiratory flow rate while tolerating respiratory acidosis are ways to increase the exhaled volume with each cycle)

question

What is sepsis?

answer

an intense host inflammatory response to a known or suspected infection that causes systemic manifestations remote from the site of infection the sepsis response causes generalized vasodilation, increased microvascular permeability, and widespread cellular injury that result in multiorgan dysfunction

question

What is severe sepsis?

answer

sepsis that causes inadequate organ perfusion or outright organ dysfunction

question

What is septic shock?

answer

sepsis-related hypotension that persists despite fluid resuscitation

question

What are the diagnostic criteria for sepsis?

answer

see page 78

question

What fluid is first line therapy for septic patients and what amount should be given?

answer

crystalloid infusion (NS or LR; LR may reduce risk of AKI in patients requiring large volume resuscitation due to lower chloride content) 30ml/kg body weight (most patients receive between 2-4L initially)

question

What should be used to measure adequacy of resuscitation?

answer

central venous pressure (goal of 8-12) urine output of 0.5ml/kg/h or greater is also indicative of adequate fluid resuscitation (may not be useful in patients with AKI)

question

What should be used to measure the adequacy of oxygenation?

answer

central venous oxygen saturation (ScvO2); reflects the balance between oxygen delivery and consumption an ScvO2 greater or equal to 70% is recommended as a target for adequacy of resuscitation

question

What do the Surviving Sepsis Campaign guidelines recommend in regards to initiation of inotropes and blood transfusion?

answer

measurement of CVP and serial measurement of ScvO2 to assess the adequacy of resuscitation, with failure to achieve the target ScvO2 during the first 6 hours of resuscitation (studies that did not use CVP or ScvO2 showed no difference in outcomes)

question

What do the current Surviving Sepsis Campaign guidelines recommend in regards to lactate measurements?

answer

serial plasma lactate measurements to assess the adequacy of resuscitation among patients with elevated lactate levels, resuscitation is targeted to reduce levels by 10% to 20% over the first 6 hours (while aggressive fluid resuscitation is efficacious in the first several hours of sepsis management, judicious fluid administration is warranted thereafter, as IV volume overload can contribute to pulmonary edema and pleural effusions)

question

At what mean arterial pressure should vasopressors be initiated?

answer

when MAP is < 65mm Hg

question

What vasopressor is considered first line for sepsis?

answer

norepinephrine dopamine is known to cause tachyarrhythmias and should be reserved for selected patients with hypoperfusion and relative bradycardia vasopressin, epinephrine, and phenylephrine typically are added when norepinephrine alone is insufficient

question

When should broad empiric antimicrobial coverage be initiated in patients diagnosed with sepsis (even if obtaining cultures is incomplete)?

answer

within 1 hour of diagnosis (in patients with septic shock, mortality increases with each hour that appropriate antibiotic therapy is delayed) 2 sets of blood cultures should be obtained before antibiotic infusion, in addition to cultures from the suspected infection site

question

When should empiric abx coverage for Candida be considered in patients with sepsis? (4)

answer

1. recent abx use 2. use of TPN 3. colonization in multiple sites 4. impaired immune function

question

When should identification and control of the source of infection be achieved in sepsis?

answer

ideally within 12 hours using the highest yield and lowest risk diagnostic intervention available abx alone may be insufficient to control infection in a variety of scenarios, such as severe colitis, necrotizing fasciitis, and ascending cholangitis***

question

What is the recommendation for hydrocortisone in the current Surviving Sepsis Campaign guidelines?

answer

no mortality reduction*** may use in patients with persistent shock despite fluids and vasopressors with a daily total dose of 200mg of IV hydrocortisone (stress dosing is only indicated for patients who are persistently hypotensive with baseline adrenal insufficiency, as well as in at-risk patients, such as those on chronic, low-dose systemic glucocorticoids)

question

What is the recommended glucose target for patients with sepsis according to the NICE-SUGAR trial?

answer

between 144-180 ACP guidelines recommend a goal between 140-200

question

What is the ACP guidelines on thrombosis prophylaxis in patients with thrombocytopenia?

answer

use mechanical rather than pharmacologic DVT prophylaxis when platelet count is less than 50,000

question

What are patients with tracheobronchial injury at risk for?

answer

airway necrosis, mucosal sloughing, bleeding, copious secretions, atelectasis, pneumonia, and ARDS

question

What lung injuries can cocaine inhalation cause? (5)

answer

1. bronchospasm and sputum production 2. pulmonary edema 3. pulmonary hemorrhage 4. pneumothorax 5. thermal upper airway injury (in the case of free-basing cocaine and use of crack cocaine pipes)

question

What other chemical agents can cause upper airway irritation and respiratory distress?

answer

chlorine, ammonia, and riot control agents phosphene gas can cause life-threatening ARDS

question

What are skin and mucosa signs and symptoms of anaphylaxis?

answer

Symptoms: pruritis of skin, oropharynx, genitals, palms, soles Signs: flushing, urticaria, angioedema 85% of patients

question

What are respiratory signs and symptoms of anaphylaxis?

answer

Symptoms: dyspnea, chest and throat tightness, stridor, cough, hoarseness, sneezing, rhinorrhea Signs: wheeze, stridor, respiratory distress 70% of patients

question

What are cardiovascular signs and symptoms of anaphylaxis?

answer

Symptoms: lightheadedness, chest pain, palpitations Signs: hypotension, tachycardia > bradycardia 45% of patients

question

What are GI signs and symptoms of anaphylaxis?

answer

Symptoms: Pain, nausea, vomiting, diarrhea 45% of patients

question

What are Neurologic signs and symptoms of anaphylaxis?

answer

Symptoms: sense of impending doom, headache Signs: encephalopathy 15% of patients

question

What is the treatment of anaphylaxis?

answer

early administration of epinephrine (either IM or continuous IV infusion) H1 antihistamines relieve skin symptoms systemic glucocorticoids reduce the risk of recurrent or persistent symptoms repeat epi administration may be needed until antihistamines or glucocorticois become effective

question

What medications can cause nonallergic angioedema?

answer

ACE inhibitors (triggers via elevation of bradykinin levels)

question

What are some hereditary and acquired causes of angioedema?

answer

C1 inhibitor deficiency (treatment centers on therapies to counter aberrant bradykinin and complement activation)

question

What is hypertensive emergency?

answer

elevation of systolic BP greater than 180 and/or diastolic BP greater than 120 that is associated with end-organ damage (may be different in pregnant patients) an equal degree of BP without evidence of end-organ damage is considered hypertensive urgency

question

What is the treatment for hypertensive emergency?

answer

rapid tightly controlled reductions in BP that avoid overcorrection

question

What is the presentation of Hypertensive encephalopathy? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: confusion, headache, vision changes Initial diagnostic Studies: head CT to exclude stroke and hemorrhage Target BP: decrease by 15-20% or DBP to 100-110 First line agents: Nicardipine, labetolol, nitroprusside risk of cyanide toxicity with nitroprusside

question

What is the presentation of ischemic stroke? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: focal deficit, CNS depression, seizure Initial diagnostic Studies: head CT Target BP: treat if SBP >220 or DBP >120; decrease by 15% First line agents: Nicardipine, labetolol, nitroprusside target BP <185/110 if a candidate for thrombolytic therapy

question

What is the presentation of hemorrhagic stroke? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: focal deficit, CNS depression, seizure Initial diagnostic Studies: head CT Target BP: BP 160/90 or MAP 110 First line agents: nicardipine, labetolol +/- intracranial pressure monitor to target BP

question

What is the presentation of aortic dissection? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: chest, back pain; asymmetric BP; acute aortic regurgitation Initial diagnostic Studies: CXR with wide mediastinum; CTA Target BP: SBP 100-120 First line agents: esmolol or labetolol first; add nitroprusside PRN target HR <65

question

What is the presentation of MI? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: chest pain, dyspnea, nausea Initial diagnostic Studies: EKG, troponin Target BP: MAP 60-100 First line agents: nitroglycerin, B-blocker avoid hydralazine

question

What is the presentation of acute left-sided heart failure? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: dyspnea, crackles Initial diagnostic Studies: CXR Target BP: MAP 60-100 First line agents: nitroglycerin and/or nitroprusside caution with CCB, B-blockers, hydralazine

question

What is the presentation of acute kidney injury? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: usually no symptoms Initial diagnostic Studies: increased creatinine, proteinuria Target BP: decrease by 20-25% First line agents: fenoldopam, nicardipine, B-blocker ACE if scleroderma renal crisis***

question

What is the presentation of preeclampsia, eclampsia? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: SBP >160 or DBP >110, edema, seizures Initial diagnostic Studies: proteinuria, increased liver chemistry studies, increased creatinine, decreased platelets Target BP: SBP 130-150, DBP 80-100 First line agents: Labetolol, hydralazine Avoid ACE inhibitors and nitroprusside Delivery=cure***

question

What is the presentation of sympathomimetic drug use? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: diaphoresis, mydriasis, increased BP Initial diagnostic Studies: History and urine drug screen Target BP: decrease by 20-25% First line agents: nicardipine, nitroprusside benzodiazepine first***, avoid b-blockers***

question

What is the presentation of pheochromocytoma? What are the initial diagnostic studies? What is the target BP? What are the first-line agents?

answer

Presentation: increase HR, diaphoresis, headache Initial diagnostic Studies: urine and plasma metanephrines Target BP: decrease by 20-25% First line agents: phentolamine, nitroprusside avoid B-blocker

question

What is severe hyperthermia?

answer

life-threatening elevation of core body temperature to greater than 40.0C (104.0 F) unlike fever which stems from an inflammatory response, hyperthermia is due to a failure of normal thermoregulation

question

What is heat stroke?

answer

occurs with high ambient temperature and humidity and is defined by the presence of temps greater than 104F and encephalopathy (often associated with hypotension, GI distress, and weakness; may have shock, multiorgan failure, rhabdomyolysis, and MI) typically occurs in healthy individuals undergoing vigorous physical activity in warm conditions (in contast, the majority of patients with nonexertional heat stroke are older than 70 years or have chronic medical conditions that impair thermal regulation) medications and recreational drugs with anticholinergic, sympathomimetic and diuretic effects, including alcohol, pose added risk

question

What is the suggestive history for heat stroke? What are key exam findings? What is the treatment?

answer

Suggestive history: environmental exposure Exam findings: encephalopathy and fever Treatment: evaporative cooling, ice water immersion avoid ice water immersion if nonexertional heart stroke***

question

What is the suggestive history for malignant hyperthermia? What are key exam findings? What is the treatment?

answer

Suggestive history: exposure to volatile anesthetic Exam findings: masseter muscle rigidity; increased arterial pCO2 Treatment: stop inciting drug, dantrolene monitor and treat hyperkalemia and increased arterial pCO2 (mixed respiratory and metabolic acidosis, muscle rigidity, hyperkalemia, rhabdomyolysis)

question

What is the suggestive history for neuroleptic malignant syndrome? What are key exam findings? What is the treatment?

answer

Suggestive history: typical > atypical antipsychotic agent; onset over days to weeks Exam findings: altered mentation, severe rigidity, increased HR, increased BP, no clonus, hyporeflexia Treatment: stop the inciting drug, dantrolene, bromocriptine resolves over days to weeks, mentation change first

question

What is the suggestive history for severe serotonin syndrome? What are key exam findings? What is the treatment?

answer

Suggestive history: onset within 24 h of initiation or increasing drug dose, GI prodrome Exam findings: agitation, clonus, increased reflexes, rigidity Treatment: stop inciting drug, benzodiazepines, cyproheptadine resolves in 24 h

question

When should cooling be continued in patients with heat stroke?

answer

when rectal temp falls to approximately 101.3 F (38.5C)

question

What differentiates serotonin syndrome from neuroleptic malignant syndrome?

answer

presence of hyperreflexia and myoclonus in SS***

question

What is seen on EKG in patients with hypothermia?

answer

Osborn or J waves (typically occurs when temp is less than 33.0C (91.4 F)

question

What is the treatment for accidental hypothermia?

answer

passive external re-warming, which entails removing wet clothing and covering the patient with insulating material, especially the head and neck may use warming blankets, or a forced heated air blanket (in hemodynamically stable patients with moderate hypothermia) when passive external rewarming proves inadequate, may administer warmed IV fluids (42.0C (107.6 F)); may also try body cavity lavage (bladder, colon, stomach; may rewarm by peritoneal or pleural space also) Bypass is recommended for patients in cardiac arrest because it maximizes the rewarming rate and can provide hemodynamic support (conventional treatment for ventricular arrhthymias and asystole is often ineffective until the temp is raised to greater than 30.0C (86.0 F)

question

What are common sources for ethanol poisoning? What are the major findings? Is there an anion gap? Is there an osmolal gap? What is the treatment?

answer

Common sources: alcoholic beverages Major findings: CNS depression, nausea/emesis Anion gap: NO Osmolal gap: NA Treatment: Supportive care

question

What are common sources for isopropyl alcohol poisoning? What are the major findings? Is there an anion gap? Is there an osmolal gap? What is the treatment?

answer

Common sources: Rubbing alcohol, disinfectants, antifreeze Major findings: CNS depression, ketone elevation Anion gap: NO Osmolal gap: YES Treatment: Supportive care

question

What are common sources for methanol poisoning? What are the major findings? Is there an anion gap? Is there an osmolal gap? What is the treatment?

answer

Common sources: windshield wiper fluid, de-icing solutions, solvents, "moonshine" Major findings: CNS depression, vision loss, hypotension Anion gap: YES Osmolal gap: YES Treatment: Fomepizole, ethanol (second-line), dialysis (if severe), folic acid

question

What are common sources for ethylene glycol poisoning? What are the major findings? Is there an anion gap? Is there an osmolal gap? What is the treatment?

answer

Common sources: antifreeze, de-icing solutions, solvents Major findings: CNS depression, acute kidney injury, hypocalcemia, hypotension Anion gap: YES Osmolal gap: YES Treatment: fomepizole, ethanol (second-line), dialysis (if severe)

question

What is the MOA of fomepizole?

answer

alcohol dehydrogenase (prevents breakdown of methanol and ethylene glycol into toxic metabolites (ethanol can be used to compete for alcohol dehydrogenase activity when fomepizole is unavailable, but titration can be difficult)

question

What are symptoms of carbon monoxide poisoning?

answer

headache, confusion, nausea, vomiting, and loss of consciousness

question

What will pulse ox show in patients with carbon monoxide poisoning?

answer

will be normal because standard pulse ox cannot distinguish oxyhemoglobin from carboxyhemoglobin need co-oximetry which measures carboxyhemoglobin levels to make the diagnosis (normal carboxyhemoglobin levels are less than 3% but can be 10-15% in heavy smokers)

question

What is the treatment for carbon monoxide poisoning?

answer

100% oxygen and/or hyperbaric oxygen therapy reduces the half-life of carboxyhemoglobin from 5 hours to 90 minutes (hyperbaric reduces half-life to 30 minutes; used when carboxyhemoglobin levels are >25% (or 20% in pregnant patients), persistent organ ischemia, and loss of consciousness) carbon monoxide poisoning resulting from smoke inhalation should prompt consideration of concomitant cyanide poisoning

question

When does cyanide poisoning occur?

answer

fire and occupational exposures and rarely from medications such as sodium nitroprusside cyanide disrupts oxidative phosphorylation, forcing cells to convert to anaerobic metabolism despite adequate oxygen supply; the result in severe cases is multiorgan failure with coma, seizures, and cardiovascular symptoms, including hypotension, bradycardia, heart block, and ventricular arrhythmias lactic acidosis and inappropriately elevated ScvO2 which manifests as BRIGHT RED VENOUS BLOOD***, cherry red skin color***

question

What is the treatment for cyanide poisoning?

answer

sodium thiosulfate in combination with either hydroxycobalamin or nitrites avoid nitrites when concomitant carbon monoxide poisoning is suspected because methemoglobinemia can further impair oxygen delivery avoid sodium thiosulfate in patients with acute kidney injury due to conversion of cyanide to thiocyanate

question

What are examples of opiods? What are examination findings when abused? What is the antidote?

answer

Examples: heroin, oxycodone, fentanyl analogs Exam findings: decreased HR, decreased temp, decreased BP, decreased RR, miosis Antidote: naloxone

question

What are examples of benzodiazepines? What are examination findings when abused? What is the antidote?

answer

Examples: lorazepam Exam findings: CNS depression, usually normal vital signs and eye examination Antidote: flumazenil

question

What are examples of sympathomimetics? What are examination findings when abused? What is the antidote?

answer

Examples: cocaine, methamphetamine, MDMA (ectasy), Bath salts ("plant food") Exam findings: shared findings: increased HR, increased BP, increased temperature, diaphoresis, mydriasis, agitation, seizure, increased CK, increased liver enzymes, increased creatinine cocaine: 30 min duration, MI prominent Methamphetamines: violent agitation prominent, duration 20 hours MDMA (ectasy): decreased sodium, serotonin syndrome Bath salts ("plant food"): hallucinations, violent agitation, duration up to 48 hours, negative urine drug screen Antidote: benzodiazepines are first line agent for agitation, avoid b-blockers for HTN, haloperidol may worsen hyperthermia

question

What are examples of hallucinogens? What are examination findings when abused? What is the antidote?

answer

Examples: dextromethorphan, LSD, PCP, Synthetic cannabinoids ("Spice", "K-2") Exam findings: Dextromethorphan: increased HR, BP, agitation, come LSD: mild increased HR, BP; rare increase temp and hemodynamic instability PCP: variable mental status: agitation > CNS depression, nystagmus Synthetic cannabinoids ("Spice", "K-2"): increased HR, agitation > marijuana, increased Cr, negative UDS Antidote: benzodiazepines are first line for agitation, haloperidol is second line

question

What are manifestations of sympathomimetic agents? What are examples? (4)

answer

tachycardia, HTN, diaphoresis, agitation, seizures, mydriasis 1. Cocaine 2. Amphetamines 3. Ephedrine 4. Caffeine

question

What are manifestations of cholinergic agents? What are examples? (5)

answer

"SLUDGE" (salivation, lacrimation, increased urination and defecation, GI upset, emesis); Confusion, Bronchorrhea, Bradycardia, Miosis 1. Organophosphates (insecticides, sarin) 2. Carbamates 3. Physostigmine 4. Edrophonium 5. Nicotine

question

What are manifestations of anticholinergic agents? What are examples? (5)

answer

Hyperthermia, dry skin and mucous membranes, agitation/delerium, tachycardia/tachypnea, HTN, mydriasis 1. Antihistamines 2. TCA 3. Antiparkinson agents 4. Atropine 5. Scopolamine

question

What are manifestations of opiods agents? What are examples? (2)

answer

Miosis, Respiratory depression, lethargy/confusion, hypothermia, bradycardia, hypotension 1. Morphine and related drugs 2. Heroin

question

What is the reason to be extremely cautious when using flumazenil and only use it under the guidance of a toxicologist for benzo OD?

answer

precipitates seizures

question

What is the reason to avoid B-blockers in patients abusing cocaine and other stimulants?

answer

cocaine has B-adrenergic activity that produces vascular smooth muscle relaxation; use of b-blockers in this setting therefore may exacerbate HTN and should be avoided

question

When should activated charcoal be withheld?

answer

if the patient is at risk of aspirating or more than 1-2 hours have elapsed since the time of ingestion

question

What are the key clinical findings for acetaminophen ingestion/toxicity? What is the treatment?

answer

Key clinical findings: increased LFTs, increased Cr, increased INR, cerebral edema, vomiting Treatment: N-acetylcysteine transfer to liver transplant center if severe

question

What are the key clinical findings for salicylate ingestion/toxicity? What is the treatment?

answer

Key clinical findings: mixed respiratory alkalosis/AG metabolic acidosis, tinnitus, agitation, confusion Treatment: bicarbonate infusion, dextrose target urine pH 7.5-8.0; hemodialysis if AKI or severe toxicity

question

What are the key clinical findings for B-blocker/CCB ingestion/toxicity? What is the treatment?

answer

Key clinical findings: decreased HR, BP, heart block, AMS if B-blocker Treatment: atropine 1mg IV up to 3 doses, glucagon, calcium chloride, vasopressors, cardiac pacemaker, high dose insulin and glucose, IV lipid emulsion treatment may be added sequentially or initiated simultaneously depending on severity of case and response to treatment

question

What are the key clinical findings for Digoxin ingestion/toxicity? What is the treatment?

answer

Key clinical findings: decreased HR, arrhythmia, nausea, emesis, abdominal pain, confusion, weakness Treatment: digoxin specific antibody use of antibody lowers K+; hemodialysis is not effective

question

What are the key clinical findings for TCA ingestion/toxicity? What is the treatment?

answer

Key clinical findings: decreased BP, sedation, seizure, anticholinergic signs, arrhythmia Treatment: bicarbonate infusion titrated to QRS duration; benzodiazepines for seizure physostigmine contraindicated***

question

What are the key clinical findings for antihistamine ingestion/toxicity? What is the treatment?

answer

Key clinical findings: anticholinergic signs including agitation and seizures Treatment: benzodiazepines; physostigmine if isolated anticholinergic OD

question

What are the key clinical findings for sulfonylurea ingestion/toxicity? What is the treatment?

answer

Key clinical findings: decreased glucose, confusion, seizure, anxiety, diaphoresis, tremor Treatment: dextrose + octreotide, glucagon IM = temporizing monitor for decreased blood glucose for 48 hours if large ingestion

question

What are the key clinical findings for metformin ingestion/toxicity? What is the treatment?

answer

Key clinical findings: increased lactate, abdominal pain Treatment: hemodialysis for severe decreased pH or AKI glucose usually normal if isolated metformin ingestion

question

What are the key clinical findings for lithium ingestion/toxicity? What is the treatment?

answer

Key clinical findings: GI distress, confusion, ataxia, trmor, myoclonic jerks, diabetes insipidus Treatment: hemodialysis if lithium level >4 or severe symptoms serum level can guide need for hemodialysis, confirm diagnosis

question

What are the key clinical findings for SSRI/SNRI ingestion/toxicity? What is the treatment?

answer

Key clinical findings: agitation, clonus, increased reflexes, rigidity, fever, increased HR Treatment: benzodiazepines, cyproheptadine if severe venlafaxine has increased cardiac toxicity

question

What is the presentation for acute cholecystitis and cholangitis? Diagnostic imaging?

answer

Presentation: persistent peritoneal RUQ or epigastric pain, fever, emesis, positive Murphy sign Diagnostic imaging: US, EUS and ERCP for diagnosis and treatment of cholangitis increased alkaline phosphatase, increased bilirubin suggests cholangitis but typically not cholecystitis

question

What is the presentation for bowel obstruction? Diagnostic imaging?

answer

Presentation: cramping pain, emesis, distention, obstipation, dehydration Diagnostic imaging: radiograph: dilated loops of bowel with air-fluid levels; CT scan: identifies cause, complications top causes: incarcerated hernia, adhesions, volvulus, intussusception

question

What is the presentation for acute appendicitis? Diagnostic imaging?

answer

Presentation: classic: periumbilical pain then RLQ pain, emesis, increased leukocyte count Diagnostic imaging: often unnecessary; CT or US if unclear pain quality and location vary with appendix location

question

What is the presentation for peptic ulcer perforation? Diagnostic imaging?

answer

Presentation: abrupt peritoneal pain, later distention and hypovolemia Diagnostic imaging: radiograph: free air; CT scan if unclear surgery necessary in majority of cases

question

What is the presentation for acute mesenteric ischemia? Diagnostic imaging?

answer

Presentation: pain > than examination findings, vomiting, hypotension, risk factors for clotting, embolism Diagnostic imaging: CT angiography or conventional arteriography standard CT and serum lactate can be normal early in course

question

What is the presentation for toxic megacolon? Diagnostic imaging?

answer

Presentation: pain, diarrhea, increased temp, HR, BP, confusion Diagnostic imaging: radiograph: dilated colon, air-fluid levels in colon; CT scan if unclear causes: inflammatory bowel disease, C. diff infection

question

What is the presentation for ruptured AAA? Diagnostic imaging?

answer

Presentation: increased BP, abdominal and/or flank pain, pulsatile mass Diagnostic imaging: unnecessary if high suspicion and unstable; CT or US if unclear Risk factors: older age, male, smoking, HTN, family hx of aneurysm

question

What is the presentation for ectopic pregnancy with tubal rupture? Diagnostic imaging?

answer

Presentation: increased BP, Hb, hCG, abdominal pain, vaginal bleeding Diagnostic imaging: transvaginal US high mortality without early surgery

question

Which patients have the most benefit from therapeutic hypothermia?

answer

patients who are not responding appropriately to verbal commands after ROSC following V-fib or pulseless v-tach arrest due to asystole and PEA is associated with poor neurologic outcomes and the benefit of cooling in these settings is unclear

question

What are ideal temperatures to cool patients down to and what time frame?

answer

cool patients to 32.0 -34.0 C (89.6-93.2 F) for 12-24 hours followed by gradual rewarming at 0.25-0.5C/hour (0.45-0.9F/hour)

MKSAP 17 Pulmonary and Critical Care Medicine – Flashcards

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