UWorld - CK - Pulmonary
upper airway cough syndrome
"Sensation of drainage down back of throat" . Colds, virus, rhinitis, sinusitis. Negative chest exam.
PaO2/FiO2 ratio
(PaO2 divided by the FIO2) Essentially an "efficiency" rating of pulmonary oxygen exchange used in critically ill patients receiving more than 50% FIO2, & whose PaO2 ≤ 100 mmHg.
How does ARDS present?
-rapidly progressive SOB, diffuse crackles, bilateral lung infiltrates and resp. failure. -look for recent causes for sepsis
Injuries to major vessels (eg, aorta, subclavian vessels) are more common with fractures of ribs ?
1-3
The criteria for initiating LTOT in patients with COPD include:
1. Resting arterial oxygen tension (PaO2) <55 mm Hg or pulse oxygen saturation (SaO2) <88% on room air 2. PaO2 <59 mm Hg or SaO2 <89% in patients with cor pulmonale, evidence of right heart failure, or hematocrit >55%
management of exercise-induced asthma
1st line: short acting beta agonists 10-20 min. before exercise
how much "cc" is needed for blunting of the costovertebral angles?
250 cc
sail sign
<2 year old CXR - large thymic shadow overlaps with the heart and looks like a "boat sail" = thymus
Survival benefits of home oxygen therapy are significant when it is used for :
>15 hours a day.
Paradoxical breathing
A form of abnormal breathing where the abdomen rises and the chest is pulled inward during inspiration. On expiration the abdomen falls and the chest expands think: ALS!
radiolucent zone between the lungs and chest wall
A pneumothorax
chronic productive cough is a side effect of which antihypertensive drug?
ACE inhibitor
PaO2/FiO2 ≤ 300 mm Hg is needed for:
ARDS diagnosis
treatment for lung abscess
Ampicillin-sulbactam, imipenem, meropenem Alternate: clindamycin
Apnea of Prematurity (AOP)
AoP is a type of central apnea (ie, no respiratory effort) caused by immature central respiratory centers in the brainstem
halo sign on CT is indicative of:
Aspergillosis
what value is needed to indicate daytime hypercapnia in an obese person for obesity hypoventilation syndrome?
Awake daytime hypercapnia (PaCO2 >45 mm Hg)
recurrent cycles of infection and inflammation in the bronchi that leads to fibrosis, remodelling, permanent dilation of bronchi?
Bronchiectasis
Biopsy for pulmonary lesions:
Bronchoscopy is best for biopsy of centrally located lesions, and CT-guided percutaneous biopsy is best for peripheral lesions.
the most common cause for cor pulmonale is:
COPD
idiopathic pulmonary fibrosis (IPF)
CT= honeycomb
Why is it important to differentiate between asthma and COPD in a clinical setting?
Differentiating between the 2 is therapeutically relevant as inhaled corticosteroids are the primary long-term intervention for asthma and a long-acting anticholinergic inhaler is generally preferred for COPD.
patient with SOB, headache and dizzyiNESS + WITHIN SEVERAL DAYS OF ARRIVING AT HIGH ELEVATION ?
High altitude sickness --> high altitude pulmonary edema (HAPE), a potential complication of high altitude illness. look for: noncardiogenic pulmonary edema
what is the protein level in a pleural effusion caused by bacterial infection?
High protein due to increased microvascular permeability and cellular destruction
the best diagnostic test for bronchiectasis?
High resolution CT. --> can demonstrate characteristic bronchial dilation, lack of airway tapering, and bronchial wall thickening.
Hypertrophic osteoarthropathy
Hypertrophic osteoarthropathy (HOA) is a condition where digital clubbing is accompanied by sudden-onset arthropathy, commonly affecting the wrist and hand joints. Hypertrophic pulmonary osteoarthropathy (HPOA) is a subset of HOA where the clubbing and arthropathy are attributable to underlying lung disease like lung cancer, tuberculosis, bronchiectasis, or emphysema.
why do patients with hypovolemia (ex: orthostatic hypotension) have decreased urine sodium?
Hypovolemia causes decreased renal perfusion, leading to activation of the renin-angiotensin-aldosterone system. Aldosterone stimulates aggressive sodium reabsorption in the collecting tubules of the kidney in an effort to sustain blood volume. Consequently, most patients with hypovolemia (unless taking diuretics or experiencing significant renal impairment) have decreased urine sodium. The fractional excretion of sodium (ratio of renal sodium clearance to renal creatinine clearance) is typically <1%
in obesity hypoventilation syndrome, how does the body react to hypercapnia?
In an effort to maintain a normal pH, the kidneys increase bicarbonate retention and decrease chloride reabsorption (via bicarbonate-chloride exchangers in intercalated cells of the distal nephron) to create a compensatory metabolic alkalosis.
looks like Tb infection + hyponatremia + hypokalemia + decreased BP + hypoglycaemia?
Infectious adrenalitis = Addison disease due to Tb
young child with CF diagnosed with influenza. what else should be treated with?
Intravenous vancomycin is therefore the most empiric antibiotic choice (for MRSA)
what is the pH level in a pleural effusion caused by bacterial infection?
Low pH (<7.2) due to anaerobic utilization of glucose by neutrophils and bacteria
a neck that is often described as "woody" or "brawny" but has no associated lymphadenopathy
Ludwig angina
a rapidly progressive cellulitis of the submandibular and sublingual
Ludwig angina As the submandibular area becomes tender and indurated, the floor of the mouth becomes elevated and displaces the tongue posteriorly, which may lead to acute airway obstruction
A. fib vs. multifocal atrial tachycardia?
MAT demonstrates distinct P waves with varying morphology while P waves are absent in atrial fibrillation.
How does maternal diabetes increase risk for neonatal respiratory distress syndrome
Maternal diabetes increases the incidence of RDS by delaying the maturation of pulmonary surfactant production. Maternal hyperglycemia causes fetal hyperglycemia, which in turn triggers fetal hyperinsulinism. High levels of circulating insulin antagonize cortisol and block the maturation of sphingomyelin, a vital component of surfactant.
management for apnea of prematurity
Mild apneic episodes may not require treatment; however, spells that are prolonged, frequent, or associated with bradycardia or hypoxia (as seen in this patient) can cause repeated "watershed" insults to the brain white matter, which can result in cerebral palsy. Therefore, treatment with caffeine therapy and/or noninvasive respiratory support (eg, high-flow nasal cannula, continuous positive airway pressure) is warranted. Caffeine is a methylxanthine that chemically stimulates the respiratory drive and is given until the respiratory centers mature, which is usually at 34-37 weeks postmenstrual age.
complicated vs. uncomplicated parapneumonic effusion
Most parapneumonic effusions are uncomplicated, resulting from increased flow of sterile exudate into the pleural space. These effusions, which are typically small or moderate and free-flowing, have pH and glucose levels near those of serum, as well as relatively low leukocyte and LDH levels . They typically resolve with antibiotic therapy. Complicated effusions involve further inflammation with pleural membrane disruption and contiguous bacterial spread from the pneumonia into the pleural space. These effusions, which are typically moderate or large and can be free-flowing or loculated, have low pH and glucose levels and high leukocyte and LDH levels. Chest tube drainage is required in addition to antibiotics.
What is the most common pathogen in the setting of atypical pneumonia?
Mycoplasma pneumonia
a chronic cough (>8 weeks) is usually due to:
NOTE: LOOK FOR NAGGING COUGH >8 WEEKS!! -upper-airway cough syndrome (postnasal drip) -asthma -gastroesophageal reflux disease (GERD).
are antibiotics recommended for acute bronchitis?
No. most likely due to a virus
is fever a common presentation in acute bronchitis ?
No. if so, most likely pneumonia
what medication can lead to Digital ischemia is used for too long?
Norepinephrine think: in the setting of septic shock
obese man + fell asleep while driving. suspect?
Obstructive sleep apnea Ix: overnight polysomnography.
Tx for invasive aspergillosis
Patients are treated with 1-2 weeks of intravenous voriconazole plus an echinocandin (eg, caspofungin) and then transitioned to prolonged therapy with oral voriconazole alone. The mortality rate is >50%.
who is recommended to get annual screening for lung cancer with a low-dose CT scan of the chest ?
People who have smoked for >30 pack years note: screening should begin at age 55 and continue to age 80
physical examination of cor pulmonale?
Physical examination may show loud P2 (pulmonic component of the 2nd heart sound), tricuspid regurgitation murmur (holosystolic at the left lower sternal border), elevated jugular venous pressure (JVP), peripheral edema, hepatomegaly due to hepatic congestion, and possible ascites.
looks like PE but absent breath sounds?
Pneumothorax
pregnancy and dyspnea
Progesterone likely triggers a sensation of dyspnea and stimulates the respiratory drive in the medulla, resulting in increased minute ventilation, mostly via increased tidal volume and a slight increase in respiratory rate. The hyperventilation increases PaO2 to facilitate oxygen delivery to the fetus and decreases PaCO2 (respiratory alkalosis) to encourage unloading of acidic wastes from the fetus. Because of the gravid uterus, the resting position of the diaphragm elevates in pregnancy, compressing the lower portion of the lungs. -->The resulting basilar atelectasis causes decreased residual volume and functional residual capacity(FRC), as well as a slight decrease in total lung capacity. However, diaphragmatic excursion is not impaired and actually increases, which, combined with increased chest wall expansion, allows for larger tidal volume. Although breathing takes place at a lower baseline lung volume (ie, lower FRC), vital capacity is unchanged.
a decreased FVC is seen in (restrictive or obstructive)?
Restrictive
what sort of breathing pattern does ALS present with?
Restrictive
the most common pathogenic organism in young children with CF?
Staphylococcus aureus, especially in the setting of concurrent influenza infection
Theophylline toxicity
Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (arrhythmia)
OTHER THAN PREMATURITY, what are the risk factors for neonatal RESPIRATORY DISTRESS SYNDROME
The most important risk factor for RDS is prematurity; other factors that increase RDS risk include male sex, perinatal asphyxia, maternal diabetes, and cesarean section without labor.
minute ventilation
The volume of air moved through the lungs in 1 minute minus the dead space; calculated by multiplying tidal volume (minus dead space) and respiratory rate; also referred to as minute volume.
patient has a persistent, dry cough following an acute upper respiratory infection + mild wheezing on examination, but clinical findings are otherwise unremarkable.
This presentation is consistent with acute bronchitis.
treatment for patient with PE + renal insufficiency?
Unfractioned heparin
can nitrofurantoin cause pulmonary fibrosis?
Yes note: look for increased eosinophilia
does influenza present with upper respiratory symptoms (rhinorrhea, sore throat)?
Yes.
is pulmonary hypertension a complication of sickle cell disease?
Yes.
Does PE cause an increased A-a gradient?
Yes. A-a gradient elevation occurs in processes that cause impaired gas exchange.
Is IV Mg used in severe asthma exacerbations?
Yes. Intravenous magnesium sulfate causes bronchodilation and is used for severe, life-threatening asthma exacerbations.
is septic shock associated with bounding pulses?
Yes. a hyperdynamic cardiovascular state occurs in response to peripheral vasodilation with capillary leak and intravascular hypovolemia --> increase in SV, HR and pulse pressure.
Chest x-ray findings in neonatal RDS ?
a diffuse reticulogranular (ground-glass) pattern of the lungs due to widespread atelectasis. Low lung volumes are also characteristic. Diffuse alveolar collapse results in air bronchograms, which represent patent, air-filled bronchioles surrounded by opacified alveoli.
COPD causes respiratory ___________.
acidosis
guy with acute asthma attack. takes inhaled beta agonists but its not working that well anymore. next step in management ?
add inhaled corticosteroid (eg; prednisone) Albuterol + prednisone
obstructive sleep apnea (OSA) in kids is usually due to
adenotonsillar hypertrophy Untreated OSA in children, as in adults, can result in serious cardiovascular complications likely related to disruption of autonomic neural control due to sympathetic activation during periods of hypoxia. Cardiovascular consequences can include systemic hypertension, tachycardia, structural heart changes (eg, right or left ventricular hypertrophy), and pulmonary hypertension
young patient with chronic dyspnea on exertion, decreased breath sounds, slight liver function test (LFT) abnormalities, and a family history of cirrhosis likely has :
alpha-1 antitrypsin (AAT) deficiency.
patient has intermittent episodes of apnea, defined as periods of >20 seconds without respiratory effort. In a preterm infant with a normal physical examination who appears well between episodes, the most likely cause is ?
apnea of prematurity (AoP)
"foul smelling sputum" + periodontal disease" should indicate:
aspiration pneumonia look for: -mixed gram and positive, aerobic and anaerobic infectious organisms -heavy alcohol users
which condition results in tracheal deviation toward side of condition?
atelectasis
Empiric Tx for hospitalised patients with CAP
beta-lactam plus macrolide (eg, ceftriaxone plus azithromycin) should be initiated
sarcoidosis presents as ____ hilar adenopathy
bilateral
"purulent sputum" suggests?
bronchiectasis
Coarse lung markings with cystic changes can be seen in ?
bronchopulmonary dysplasia (BPD), or chronic lung disease that can occur in patients with prolonged (ie, >1 month) oxygen therapy.
flail chest
caused by fracture of ≥3 adjacent ribs in ≥2 places, can produce respiratory distress due to the unstable segment moving paradoxically to respiration. Rib fractures are not present on this chest x-ray.
tactile fremitus is increased in:
consolidation (ex: lobar pneumonia)
which condition causes increased breath sounds?
consolidation (ex: lobar pneumonia)
When TP is suspected, what should be preformed immediately?
decompression (eg, needle thoracostomy) should be performed immediately to prevent cardiovascular collapse Needle thoracostomy can be performed quickly and should precede intubation. Following needle decompression, tube thoracostomy is required for definitive pneumothorax management
DLCO in emphysema
decreased
DLCO in restrictive lung disease is:
decreased
why do Most patients with acute PE demonstrate decreased PaCO2?
due to hyperventilation
A complicated parapneumonic effusion becomes an ?
empyema when the fluid is grossly purulent. In these patients, fluid analysis shows frank signs of bacterial infection with a pH <7.2 (due to acid production by bacteria), low glucose (<40-60 mg/dL due to bacterial/neutrophil utilization), neutrophil-predominant leukocyte counts >50,000/mm3, and significantly elevated LDH (>1,000 IU/L). Gram stain and culture are positive.
Postoperative measures used to decrease the risk of pneumonia are aimed at ?
encouraging lung expansion. These include incentive spirometry, deep breathing exercises, continuous positive airway pressure, and intermittent positive pressure breathing. Of these, incentive spirometry has been shown to be the most effective, and is thus the first line preventive measure. CPAP is used only in patients who develop pulmonary complications in spite of incentive spirometry
First line management for upper airway cough syndrome?
first-generation antihistamine (eg, chlorpheniramine) or combined antihistamine-decongestant (eg, brompheniramine and pseudoephedrine)
what is the initial management of SIADH?
fluid restriction
recurrent sinusitis and otitis, auditory canal ulceration, fatigue, anemia, and microscopic hematuria most likely has :
granulomatosis with polyangiitis (GPA) (formerly known as Wegener granulomatosis), a small- and medium-sized vessel vasculitis.
patient with suspected community acquired pneumonia (fever, cough, crackles in bright lung base) . what is your next step?
guidelines specify that the diagnosis of CAP requires the presence of a lobar, interstitial or cavitary infiltrate on chest imaging (chest x-ray)
Patients receiving high doses of inhaled albuterol can develop clinically significant
hypokalemia, which manifests as decreased deep tendon reflexes and muscle weakness
elevated CO2 is consistent with:
hypoventilation ex: man after seizure who didn't breathe too adequately during the event
slowly progressive dyspnea, dry cough, and fine crackles in the absence of a smoking history likely has
idiopathic pulmonary fibrosis (IPF)
first line preventive measure for postoperative pneumonia?
incentive spirometry
DLCO in asthma
increased
Atypical pneumonia typically has a ______ coure
indolent (slow onset)
the most common precipitating event for myasthenia crisis is:
infection (ex: pneumonia) note: if you see impending resp failure --> elective intubation
Displaced fractures of ribs 9-12 can injure?
intraabdominal organs, including the spleen. Bleeding that irritates the diaphragm may cause referred pain (eg, to the left shoulder).
fever, pleuritic chest pain, and hemoptysis + CT scan of the chest usually reveals nodules with surrounding ground-glass opacities ("halo sign")?
invasive aspergillosis
Recurrent pneumonia occurring in the same anatomic location of the lung raises suspicion for:
localized airway obstruction, which, if present, can lead to impaired bacterial clearance and predisposition to infection (eg, postobstructive pneumonia). Potential causes of localized airway obstruction include: -External bronchial compression due to lymphadenopathy, expanding neoplasm, or vascular anomaly -Internal bronchial obstruction due to a foreign body, bronchiectasis, bronchial stenosis, or, rarely, endobronchial carcinoid Ix: CT scan of the chest
Patchy bilateral infiltrates and lung hyperinflation are seen in ?
meconium aspiration syndrome, which most commonly occurs in term and post-term neonates.
distinct P waves of >3 different morphologies, irregular RR intervals, and an atrial rate >100/min ?
multifocal atrial tachycardia
DLCO in chronic bronchitis
normal
Parapneumonic effusions are exudative effusions that can develop as a complication of?
pneumonia due to inflammation and infection from an adjacent lung infection, resulting in accumulation of fluid in the pleural space.
very low glucose in pleural effusion suggests:
pneumonia with parapneumonic effusion
hyperresonance of the lungs is heard in:
pneumothorax
In patients with ARDS, mechanical ventilation improves oxygenation by
providing an increased fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) to prevent alveolar collapse
D dimer has high _______ and low ________
sensitivity and specificity
rib 9-11 fractures are capable of injuring the?
sleep CT abdomen
The most efficient test to differentiate asthma and COPD is
spirometry before and after administration of a bronchodilator (usually albuterol). Patients with asthma should show significant reversal (>12% increase in forced expiratory volume in 1 second) in airway obstruction after administration of the bronchodilator. Patients with COPD may have partial reversibility with bronchodilators, but restoration of normal airflow after administration of a bronchodilator effectively rules out COPD.
Severe coughing paroxysms can increase intraalveolar pressure and cause air to leak into subcutaneous tissues (ie, subcutaneous emphysema), resulting in ?
spontaneous pneumomediastinum. The first step in management is chest x-ray to confirm the diagnosis and rule out pneumothorax.
Altered mental status in the setting of an acute exacerbation of chronic obstructive pulmonary disease (COPD) raises suspicion for
symptomatic hypercapnia and should be promptly investigated with arterial blood gas analysis.
This patient who was stabbed in the chest has respiratory distress and right-sided absent breath sounds accompanied by hypotension and distended neck veins. This is concerning for?
tension pneumothorax (TP) TP develops when accumulated air (due to injured lung tissue) causes high intrathoracic pressure that compresses the vena cava and impedes cardiac venous return, resulting in decreased cardiac output and hypotension
"bilateral basilar lucency" refers to:
the panacinar emphysema seen in alpha 1 antitrypsin deficiency
Bronchial carcinoid tumor
they are the leading cause of lung cancer in adolescents and young adults (particularly in those who do not smoke). -->Tumors are typically slow-growing and round and generally form in the proximal airway; they can present with wheezing, dyspnea, cough due to bronchial obstruction or hemoptysis due to tumor bleeding from hypervascularity. note: Compared to gastrointestinal carcinoid tumors, bronchial carcinoid tumors produce far less serotonin/vasoactive amines and do not often cause carcinoid syndrome.
What is the underlying mechanism behind Obesity hypoventilation syndrome?
think: alveolar hypoventilation --> resultant hypercapnia. Obesity reduces chest wall and lung compliance, leading to a decrease in tidal volumes and total lung capacity and an increase in airway resistance. As a result, higher levels of ventilatory drive are required to maintain normocapnia, but there is an inability to exhale excess CO2 during the day (due to persistent restriction). This leads to CO2 accumulation overnight, with subsequent chronic respiratory acidosis. -->Renal bicarbonate excretion is decreased as a compensatory mechanism; this blunts the ventilatory response to the increased CO2 and contributes to hypoventilation.
Findings on chest x-ray (eg, hyperinflation, fluid in interlobar fissures) confirm the diagnosis of
transient tachypnea of the newborn (TTN)
which condition is caused by delayed resorption and clearance of pulmonary fluid?
transient tachypnea of the newborn (TTN) patients born prematurely or by cesarean delivery are at increased risk of TTN
term newborn with increased work of breathing and fluid-filled fissures has?
transient tachypnea of the newborn (TTN), a condition caused by delayed resorption and clearance of pulmonary fluid
Interstitial infiltrates with prominent interlobar fissures is characteristic of ?
transient tachypnea of the newborn, a benign condition due to delayed resorption of alveolar fluid often seen in premature neonates.
chronic pulmonary aspergillosis can be seen in a patient with a history of:
treated or present Tb.
looks like infectious pleural effusion BUT normal glucose?
uncomplicated parapneumonic effusion
COPD + clubbing. suspect?
underlying malignancy COPD alone does not cause digital clubbing, and presence of clubbing in patients with COPD should prompt a search for occult malignancy.
dead space ventilation
volume of air that DOES NOT reach the alveoli per minute note: think PE
