Pulm QBANK Questions

__________- is a disease characterized by intermittent dyspnea, cough, and wheezing. The symptoms are variable and recurrent and are the result of airflow obstruction, bronchial hyperresponsiveness, and inflammation, all of which are largely reversible.

Asthma

22-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice tells everyone that he is going to die. An initial survey reveals blood pressure 60/40 mm Hg. Pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyper-resonant to percussion, with no breath sounds. Which of the following is the most appropriate initial step in management?

16 gauge needle inserted in the 2nd right intercostal space (Pt has Tension Pneumo on R and needle decompression is needed. Then formal chest tube should be inserted)

__________- chest radiographs are typically normal, or would only show hyperinflation or increased perihilar markings. Chest x-ray is not indicated in these pts unless presenting with atypical sx, such as: 1. Fever 2. Chronic purulent sputum production 4.Localized wheezing 5. Hemoptysis 6. Weight loss 7. Clubbing 8. Inspiratory crackles 9. Significant hypoxemia

Asthma Exacerbation

Two ways to decrease morbidity and mortality in pts with COPD? (2)

Smoking Cessation and Home Oxygen Use (Smoking cessation decreases the rate at which the FEV1 declines in patients with COPD. Although pulmonary rehabilitation can improve exercise capacity, improve quality of life, decrease dyspnea, and decrease office/ER visits, it does not decrease mortality in patients with COPD)

A 76-year-old man presents to the clinic for his semiannual examination. The patient is well known to the clinic and has been having semiannual examinations for the past 3 years to follow up his chronic obstructive pulmonary disease (COPD). The patient is a long-time smoker, with a 200+ pack year history. He is status post a right upper wedge resection 2 years ago for adenocarcinoma, and at that time had severe obstructive disease. A recent chest CT showed apical bullae and severe emphysematous changes. The patient has moderate dyspnea on exertion and often has shortness of breath with minimal activity. On this visit, the patient relates that he is even more short of breath at rest and is almost unable to perform any physical activity as a result. Which of the following would most strongly suggest the need to initiate home oxygen therapy? -Resting Arterial PaO2 less than _________mmHg

55 (he requirements for utilization of home oxygen therapy have been determined on the basis of placebo-controlled, randomized trials. In patients on a stable medical regimen, an arterial oxygen pressure of less than 55 mm Hg has been determined as the cutoff below which maximal benefit is obtained)

Medicare criteria for home oxygen therapy in patients with chronic lung disease: 1. PaO2 ≤___ mmHg OR arterial oxygen saturation (SaO2) ≤ ____ percent 2. PaO2 ≤ ____ mmHg or SaO2≤ ___ percent, with evidence of *+cor pulmonale, right heart failure, or erythrocytosis* (hematocrit >55 percent)

55, 88, 59, 89

A 35-year-old man comes to the emergency department with shortness of breath, which has worsened over the past 3 days and is associated with a cough productive of yellow sputum. His past medical history is significant for asthma, and his medications include an albuterol inhaler. He has a 20-pack-year history of tobacco use, and currently smokes 2 packs per day. On physical examination his temperature is 37.8°C (100°F), blood pressure 160/87 mm Hg, pulse 69/min, and respirations 24/min. Lung examination is significant for diminished breath sounds, with diffuse wheezing but no evidence of consolidation. Chest radiograph is significant for hyperexpansion. Pulse oximetry shows 90% oxygen saturation on room air. Which of the following is the most appropriate next step in therapy?

Albuterol Nebulizer (patient's hypoxia (on room air) is most likely a result of bronchospasm in the setting of pre-existing reactive airways disease. The appropriate treatment, therefore, is a bronchodilator, and the most appropriate bronchodilator would be albuterol, since it does not have the unwanted associated side effect of promoting the drying of respiratory secretions as with an antimuscarinic, anticholinergic agent.)

No matter the situation, the first step in management of an acute presentation is _________, ___________, ____________

AIRWAY, BREATHING, CIRCULATION.

A 27-year-old pharmacist comes to her health care provider for her annual physical examination. She describes that over the past several months she has awoken from sleep on several occasions with cough, wheezing, and shortness of breath, but denies having these symptoms during the day. The symptoms generally last for up to 2 hours before gradually subsiding. She has no previous history of asthma and exercises regularly without difficulty. She is on no medications, except for the frequent use of over-the-counter histamine-2 receptor antagonists for daily episodes of heartburn. She is afebrile and has normal vital signs. Her lungs are clear to auscultation and percussion. Which of the following is the most likely explanation for her nocturnal symptoms?

Acid Reflux (typical symptoms of the extra-esophageal manifestations of gastroesophageal reflux disease (GERD). At night, while she is supine, acid may reflux across the upper esophageal sphincter and into the upper airway, triggering bronchoconstriction and her asthmatic symptoms. The history of GERD is suggested by her baseline symptoms of heartburn requiring histamine-2 receptor antagonists. The treatment for these patients is acid reduction directed at the underlying GERD process)

________ is the only known proven risk factor for the development of malignant mesothelioma. Just keep in mind that malignant mesothelioma is much LESS common than bronchogenic carcinoma in this patient population!

Asbestos

A 24-year-old tire salesman complains of a low-grade fever and a nonproductive cough for 1 week. His girlfriend had similar symptoms 1 week earlier. He denies any shortness of breath or pleuritic chest pain. On physical examination his temperature is 37.9°C (100.2°F). A lung examination reveals coarse bilateral inspiratory and expiratory crackles. His laboratory results reveal a white blood cell count of 6300/mm3, a hemoglobin of 10.2 g/dL, and a hematocrit of 32%. A cold agglutinin assay of his red blood cells is positive. Which of the following is the most appropriate treatment for this patient?

Azithromycin (Zithromax- patient has the typical findings of an *atypical pneumonia*, with low-grade fevers and a bilateral infiltrate without a productive sputum. The cold agglutinin assay is positive, indicating that the underlying infection is *Mycoplasma pneumonia*. This is also the explanation for his anemia, since he is agglutinating red cells at cold temperatures. The appropriate antibiotic for Mycoplasma is oral azithromycin.)

A 32-year-old man has had asthma for the past 9 years. The symptoms are frequently exacerbated by changes in the weather and household allergens. He has had 2 emergency department visits over the past year, where he was started on oral corticosteroids, but he has not required hospitalization. He uses an albuterol inhaler about 4 times per week for symptom relief and he has symptoms at night about 3 times a month. Which of the following would be the most appropriate therapy to maintain remission between his asthmatic attacks?

Beclomethasone Inhaler (patient has mild persistent asthma. Low-dose inhaled steroids should be the mainstay of therapy to maintain remission between asthmatic episodes in a patient with mild persistent asthma. They effectively reduce airway inflammation, whereas the beta-2 agonist inhalers are more effective for short-term relief of symptoms. The most likely side effect is the development of oral candidiasis, which can be prevented by prompt mouth rinsing after inhaler use)

A 59-year-old construction worker has a history of asbestos exposure. Which of the following malignancies is most likely to occur in this man?

Bronchogenic carcinoma (Malignant mesothelioma is a very rare pleural tumor that is much more common in individuals with a history of asbestos exposure. However, bronchogenic carcinoma is more common than malignant mesothelioma in asbestos-exposed individuals, as well as in the population at large. Asbestos exposure is also associated with pulmonary interstitial fibrosis and pleural reactions. The risk of lung cancer and mesothelioma greatly increase in patients with asbestosis exposure who smoke cigarettes.)

21-year-old college senior comes to the university health clinic complaining of shortness of breath and cough for the past 2 weeks. He has just transferred to this university in Chicago from his hometown in Arizona, where he had studied for the past 3 years. Each evening, on returning from classes to his dormitory room, he develops a dry nonproductive cough that typically lasts for several hours before he falls asleep. He is awakened from sleep with shortness of breath, cough, and wheezing. He denies cigarette smoking, but drinks several beers on weekends and has occasionally smoked marijuana. Symptoms often occur on weekends, when he spends time studying in his dormitory room. On physical examination he denies any respiratory symptoms, and his lung examination is normal. Which of the following is the most likely mechanism for his symptoms?

Bronchospasm (Classic Triad-shortness of breath, nonproductive cough, and wheezing, all of which is consistent with *bronchospasm*. The mechanisms involved in an *asthmatic attack* are bronchospasm and airway obstruction due to reversible inflammation.)

Hyperventilation can be triggered by emotional stress, and the resulting rapid breathing tends to blow off more _____ from the lung than usual. Because ______ is carried in the serum principally as bicarbonate + hydrogen ion, -->blowing off _____ shifts the balance so that less vvbicarbonate and less vvhydrogen ion are present in the blood. Less hydrogen ion translates to higher ^^blood pH, i.e., *alkalosis*, which in this case is of respiratory origin. It is an uncompensated respiratory alkalosis, since renal compensation takes some time to occur. Re-breathing air, which is easily accomplished by breathing into a paper bag, will slow the rate of ____ loss and quickly correct the alkalosis. The manifestations of the type of mild respiratory alkalosis seen in emotional hyperventilation include light-headedness, paresthesias, and sometimes syncope. Severe respiratory alkalosis (not seen in this setting) can also cause cramps, tetany, seizures, and cardiac arrhythmias

CO2

A 14-year-old boy is hit by an automobile while walking across the street and is immediately taken to the emergency department. On arrival, he is conscious and complains of shortness of breath and chest pain. Physical examination reveals an ecchymotic area over his right chest and subcutaneous emphysema. Breath sounds are absent on the right side. His trachea is deviated to the left, and his right hemithorax is tympanic to percussion. Which of the following is the most appropriate initial step in management of this patient?

Chest Tube Thoracostomy (PEx= Tension Pneumothorax. a life-threatening emergency that needs to be managed immediately with either chest tube thoracostomy or needle thoracocentesis to relieve the tension on the affected side of the thorax.)

A 72-year-old woman comes to the emergency department complaining of severe shortness of breath, fevers, chills, and left-sided pleuritic chest pain. She was recently hospitalized for similar symptoms and was just discharged from another hospital 1 week ago. Her temperature is 39.0º C (102.2º F), blood pressure is 100/60 mm Hg, pulse is 133/min, and respirations are 24/min. Her oxygen saturation is 90% on room air. Physical examination reveals an elderly woman in mild respiratory distress. Her heart sounds are tachycardic and regular. Lung examination is significant for decreased breath sounds at the left base. There is no lower extremity edema. Chest radiograph shows a large left-sided pleural effusion. A thoracocentesis is performed which reveals frank pus on aspiration pus & infxn. What is Most Appropriate Management?

Chest Tube placement and antibiotics (This patient has an empyema caused by bacterial pneumonia. An empyema is a severe form of parapneumonic effusion identified by the aspiration of pus or by seeing organisms on Gram stain. A low pH is expected, as is a low glucose and elevated LDH. The pH cutoff for empyema is debatable, but certainly a pH of less than 7.1 is very concerning. Empyema requires chest tube drainage together with a prolonged course of antibiotics)

A 67-year-old man with emphysema comes to his health care provider for a routine checkup. He reports that his symptoms have remained stable, with frequent coughing and dyspnea, despite compliance to his medications, which include oral prednisone, aminophylline, inhaled beta 2 agonists, and rotating courses of antibiotics. On physical examination he has a barrel-chest and distant breath sounds in both lung fields with soft expiratory wheezes. An arterial blood gas reveals an arterial pH of 7.32, a pCO2 of 47 mm Hg, and a pO2 of 53 mm Hg. Which of the following would most likely prolong his survival?

Continuous Home Oxygen Therapy (patient has resting hypoxia and therefore would benefit in terms of survival with the use of continuous, low-flow home oxygen therapy. Care must be taken as to not deliver high concentrations of oxygen, as that would suppress his respiratory drive. Oxygen saturation in these patients should be maintained just above 90%. Continuous home oxygen therapy in this patient will not only improve symptoms, but also prolong survival)

An infant is delivered at full term by a spontaneous vaginal delivery to a 29-year-old primigravida. At delivery, the infant is noted to have subcostal retractions and cyanosis despite good respiratory effort. The abdomen is scaphoid. On bag and mask ventilation, auscultation of the lungs reveals decreased breath sounds on the left, with heart sounds louder on the right. Which of the following is the most likely diagnosis?

Diaphragmatic Hernia (Congenital diaphragmatic hernia is often seen on prenatal ultrasound. A diaphragmatic hernia is a defect in the hemidiaphragm that allows the abdominal contents into the thorax. It has the findings of respiratory distress, cyanosis, and scaphoid abdomen. Auscultation will show decreased breath sounds on the affected side. It occurs more often on the left side than the right.)

Bacterial pneumonia may be complicated by an exudative pleural effusion. ________ is said to exist when +frank pus is aspirated during thoracentesis. Parapneumonia pleural effusions are noted during bacterial pneumonia (especially staph) and drainage in the form of chest tube placement is indicated along with the appropriate antibiotics to treat this infection. Signs of exudative pleural effusion consist of low glucose, high protein, and high LDH levels. Gram stain of the organism will reveal the category of the bacteria and appropriate antibiotic coverage can be instituted.

Empyema

A 57-year-old man comes to his health care provider for a semi-annual visit. He has a medical history significant for long-standing COPD. He has smoked 2-3 packs of cigarettes/day for the past 40 years and drinks a glass of whisky every night. He also has hypertension and diet-controlled type 2 diabetes mellitus. His medications include lisinopril (Prinivil, Zestril) and a thiazide diuretic. He has no allergies. He seems to be compliant with his medications. He walks 1/2 mile every day at a fairly brisk pace but is limited by fatigue and shortness of breath. His home blood glucose log shows a range of values from 108-201 mg/dL. On physical examination he is a fairly obese man with a large barrel chest. He is breathing comfortably. His blood pressure is 152/88 mm Hg, and pulse 82/min and regular. His lungs are hyperresonant to percussion with scant bibasilar crackles. He has an S4 gallop and a grade 1 systolic ejection murmur radiating to the carotids bilaterally. The extremities are without edema or clubbing. Which of the following is the most appropriate preventive measure for this patient?

Encourage Rapid Cessation of Tobacco Use! (here is much discussion among primary care providers and the public in general about preventive measures for health maintenance. A little-discussed related issue, however, is the major impact that lifestyle modification can have on existing conditions. In this case, if the patient's smoking were to stop he would almost immediately receive a tremendous benefit for the COPD. This should be discussed at every health care visit)

___________- likely results from the changes in airway physiology that are caused by the relatively cool, dry air that is inhaled during vigorous activity. Several studies have shown that it improves when the inspired gas is humidified and closer to body temperature, which decreases bronchoconstriction. Dry air increases bronchoconstriction. It is also associated with increased levels of bronchoconstrictive and inflammatory mediators such as leukotrienes, histamine, and interleukins.

Exercise Induced Asthma (EIA-Exercise causes minute ventilation to increase.)

A 26-year-old African American woman comes to the emergency department complaining of severe shortness of breath that began while jogging earlier today and has not improved despite the repeated use of her inhaler, which she has been instructed to always carry with her. Her past medical history is significant for asthma and seasonal allergies. Her medications include oral contraceptive pills and 3 respiratory medications, 2 of which are inhaled and, she says, are closely managed and adjusted by her allergist. Her respiratory rate is 44/min and she is exhibiting supraclavicular retractions. She has difficulty completing her sentences while speaking. On auscultation the lungs have expiratory and inspiratory wheezes. Her nail beds and oral mucosa are pink. In addition to instituting prompt therapy with nebulized beta-agonists, IV steroids, and oxygen, a STAT arterial blood gas (ABG) shows pH 7.46, pO2 86 mm Hg, and pCO2 32 mm Hg. Thirty minutes later the patient's respiratory rate is 25/min. Wheezing is not as audible on auscultation and retractions have diminished. The lips appear blue, however. A second STAT ABG reveals pH 7.38, pO2 84 mm Hg, and pCO2 41 mm Hg. Which of the following is the most appropriate next step in management

Explain the meaning of Respiratory Failure and then INTUBATE! (patient presented to the emergency department in moderate to severe respiratory distress, likely secondary to asthma that was previously diagnosed. The first ABG demonstrates a respiratory alkalosis caused by tachypnea induced by hypoxia. The initial treatment described is correct. Her second ABG may at first glance seem better than the first; however, clinically, the patient is deteriorating. She is cyanotic and her air movement has decreased. Her ABG results may seem better, but in fact, the patient is tiring out and her respiratory alkalosis is now correcting. Her hypoxia is marginally worse. In patients such as this, it is best to explain that intubation is pending and prepare to do so. Note that the bicarbonate value is not given in the vignette. This is because it is in fact calculated and not measured in the laboratory. When a serum bicarbonate value is desired, it is always advised to get one from a chemistry panel where it is actually measured)

A 68-year-old man comes to his health care provider for follow-up. Two weeks ago he was diagnosed with COPD and underwent pulmonary function tests (PFTs) to assess reversibility of his obstruction. He has smoked 3 packs/day for 50 years and has hypercholesterolemia. In the 23 years that he has been a patient in this practice, he has had poor compliance and only sees a health care provider if he is very ill. His PFTs document moderate obstructive lung defects. His quality of life is currently good and he has not had to curtail his daily activities significantly. Which of the following immunizations is most important for this patient?

Flu Vaccine (The morbidity and mortality rate from annual flu epidemics is very high. Even in otherwise healthy elderly patients, influenza can result in a high risk of serious illness. In patients with chronic obstructive pulmonary disease (COPD), this risk is even higher. Every COPD patient should be given an annual flu vaccine unless allergic to the components. It is now even recommended for all healthy adults starting at age 50. Pneumococcal vaccine would also be recommended in this patient.)

Because infections can increase morbidity in patients with COPD, all COPD patients should be routinely vaccinated against _________ & _________. 1. Pneumococcal polysaccharide vaccine should be given to COPD patients age ≥65 or age <65 with a forced expiratory volume in one second (FEV1) less than 40 percent. 2. An annual influenza vaccine should be given to all patients, particularly those with COPD

Flu and Pneumonia (influenza and pneumococcus)

________- is a common problem in patients with asthma and they are likely to experience respiratory symptoms, including those seen in asthma. It is proposed that it can lead to *bronchoconstriction leading to airflow obstruction* in patients with asthma by one of 3 mechanisms: 1. ^Vagal Tone 2. Heightened Bronchial Reactivity 3. Microaspiration of Gastric Contents into upper airways -Lying supine at night= Sx- Nonproductive cough, Wheeze, SOB from Bronchoconstriction

GERD (Gastroesophageal Reflux Dz)

____________- is a gram-negative bacillus. Nontypeable strains may cause pneumonia in elderly patients with chronic respiratory disease.

Haemophilus influenzae

_______ concentration of oxygen can be toxic to lung tissue and therefore the lowest possible fraction of inspired oxygen (FiO2) should be used to maintain adequate oxygenation. In high concentrations, oxygen can lead to absorptive atelectasis, accentuation hypercapnia, airway injury, and lung parenchymal injury. The oxygen toxicity is caused by inflammation which leads to cell death

High (High concentrations of inspired oxygen delivered through a ventilator may lead to irreversible pulmonary fibrosis. In the setting of adult respiratory distress syndrome (ARDS), PEEP (positive end-expiratory pressure) is indicated to prevent the development of oxygen toxicity)

When watching a routine immunization injection being given to her 2-year-old brother, a teenage girl suddenly complains of feeling faint and starts hyperventilating. A nurse has her sit on the floor and gives her a paper bag. What is the rationale for this therapy? -______ CO2 content in Bag will Correct the pts ___________ Respiratory ___________

Higher, Uncompensated Alkalosis (Hyperventilation can be triggered by emotional stress, and the resulting rapid breathing tends to blow off more CO2 from the lung than usual. Because CO2 is carried in the serum principally as bicarbonate plus hydrogen ion, blowing off CO2 shifts the balance so that less bicarbonate and less hydrogen ion are present in the blood. Less hydrogen ion translates to higher blood pH, i.e., alkalosis, which in this case is of respiratory origin. It is an uncompensated respiratory alkalosis, since renal compensation takes some time to occur. Re-breathing air, which is easily accomplished by breathing into a paper bag, will slow the rate of CO2 loss and quickly correct the alkalosis. The manifestations of the type of mild respiratory alkalosis seen in emotional hyperventilation include light-headedness, paresthesias, and sometimes syncope. Severe respiratory alkalosis -not seen in this setting- can also cause cramps, tetany, seizures, and cardiac arrhythmias.)

____________ cancer that only affects one side of the chest and/or within the central lymph nodes is typically treated with chemotherapy combined with radiation therapy. Surgery is rarely indicated and should be reserved for only those patients that have lesions that are amenable to lobectomy (i.e., lesions not located in the central portion of the lung, near the hilum). This CA often causes a paraneoplastic syndrome producing ectopic hormone secretion.

Small cell lung

A 25-year-old man is stabbed in the right chest. He comes into the emergency department fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management?

Insertion of a Chest Tube at the Right Base (Although the patient is hemodynamically stable and thus presumably not "bleeding to death," contaminated blood should not be left in the pleural space, where it could lead to the development of an empyema. A chest tube placed at the base should evacuate it. In doing so, we will also learn whether the amount of blood recovered justifies a more aggressive step to stop the bleeding)

A 63-year-old man is admitted to the hospital for fever and a productive cough. The patient reports that, over the past few days, he has had a worsening cough that has become productive of greenish-crimson sputum. The patient reports temperatures to 39.5° C (103° F) over the past 24 hours. The patient has had nothing to eat or drink for the past 36 hours. On further questioning the man describes a prodromal period 7 days prior to the onset of the cough that was remarkable for rhinorrhea and general malaise. On physical examination the patient appears acutely ill. His blood pressure is 130/80 mm Hg, and his pulse is 110/min and regular. Examination is remarkable for diminished breath sounds on the right lung-base with "a to e" egophony and whispered pectoriloquy. Which of the following is required for the diagnosis of pneumonia?

Infiltrates present on CXR (diagnosis of pneumonia absolutely requires that an infiltrate of some sort -whether interstitial or parenchymal, lobar or diffuse- be present on a chest radiograph. X-ray may need to be repeated if it is obtained too early in the course of pneumonia prior to organized consolidation)

A 12-year-old girl with a history of asthma has been admitted to intensive care units 2 times in the past and has had 3 emergency department visits during the past 12 months. Her only medication is inhaled albuterol as needed, and she uses it 2 to 3 times a day. She has nocturnal symptoms about 2 times a week. She is free of symptoms now but reports that she gets short of breath easily. Which of the following pharmacologic interventions is most appropriate?

Inhaled Corticosteroid (patients with persistent asthma symptoms, inhaled corticosteroid is the treatment of choice. Asthma is one of the most common respiratory diseases in children. It causes significant morbidity and mortality. If not well controlled, asthma can tremendously affect an individual's daily activities and can be life-threatening. Inhaled corticosteroids decrease the degree of inflammation in the airways and reduce airway hyperresponsiveness. Inhaled corticosteroid should be used on a regular daily basis regardless of symptoms of the day. Education for the patient and the patient's family is extremely important so that appropriate treatment can be administered at home.)

Legionella pneumonia- bacteria generally presents with more severe symptoms, as well as with signs of +systemic and GI toxicity such as headache, nausea, vomiting, hepatitis, and diarrhea. And there is no known exposure to Legionnaires' pneumonia

Legionella Pneumonia

A 71-year-old woman is being treated for a severe chronic obstructive pulmonary disease (COPD) flare. She presented to the hospital 3 days ago with cough, fever, and pleuritic chest pain, having been feeling fatigued and, on the day of admission, persistently febrile. She has had more severe shortness of breath, often at rest and with mild exertion, and moderate dyspnea. Chest radiograph revealed a left lower lobe infiltrate and she was started on antibiotics. The patient has a long smoking history with forced expiration in 1 second (FEV1) of 1.1 L (avg FEV1 3.6 L). Which of the following therapies is most beneficial with respect to long-term morbidity and mortality in this patient?

Long Term Oxygen Therapy (There is a clear mortality benefit for hypoxic patients with COPD when they use long-term oxygen therapy (LTOT); it can increase body weight, alleviate cor pulmonale, decrease polycythemia, strengthen cardiac function, and improve exercise tolerance.)

It is extremely important to identify the underlying cause of Interstitial Lung Disease (ILD) as well as the severity of the disease. Laboratory evaluation, radiography, and PFTs are utilized to guide in the decision making process for patients with ILD. Definitive Diagnosis is only by ____________

Lung Biopsy (transbronchoscopic or thoracoscopic or open lung)

A 19-year-old college freshman comes to the university health clinic because of recurrent episodes of wheezing during basketball practices. He has been a starting shooting guard for this team and has typically been hampered by shortness of breath shortly after beginning practice and during games. The symptoms are accompanied by a nonproductive cough and chest tightness. He denies any symptoms at rest. The symptoms occur whether the practices are indoors or outdoors. On physical examination he is comfortable and denies any symptoms. His physical examination is unremarkable. Which of the following cells are most likely to mediate his symptoms?

Mast Cells (patient has symptoms of exercise-induced asthma. Unsurprisingly, he appears normal while in the office. The symptoms of exercise-induced asthma are due to mast cell release of histamines, which degranulate with the initiation of exercise. These symptoms can be prevented with the pre-exercise use of inhaled cromolyn, which will act to stabilize the mast cells. It is less effective once exercise has begun. Once bronchoconstriction has occurred, symptomatic therapy can be provided with a beta-agonist inhaler)

A 33-year-old woman with a history of asthma is being treated for symptoms of hyperthyroidism. Which of the following beta-blockers would be an appropriate therapy?

Metoprolol (Lopressor- Symptoms related to hyperthyroidism include palpitations and tachycardia. If the patient also has asthma, select a drug which blocks beta-1-receptors without affecting the beta-2-receptors found in the respiratory smooth muscle. A selective beta-1-blocker such as metoprolol would be appropriate)

____________- is a common cause of CAP, especially in school-aged children, military recruits, and college students. Most patients with this infection do not develop clinical pneumonia, but rather with *+cough, pharyngitis, rhinorrhea, and otalgia.* If pneumonia does develop, +bilateral interstitial infiltrates may be seen on chest x-ray but there are no clinical or radiographic features that can definitively distinguish this infection from other causes. If this infection is suspected, treatment should be initiated empirically with a macrolide (azithromycin), a respiratory quinolone (levofloxacin), or doxycycline

Mycoplasma Pneumonia

Empiric treatments for probable ____________ infections include macrolides (azithromycin or erythromycin), doxycycline, or respiratory quinolones (levofloxacin or moxifloxacin). *Azithromycin* is most commonly used due to its shorter course and its efficacy in treating it.

Mycoplasma pneumonia (M. pneumonia )

Healthy young man in college/military with pneumonia. What is most likely bacteria causing PNA?

Mycoplasma pneumonia (ealthy young man has a community-acquired "atypical pneumonia." It is atypical in its gradual onset, absence of higher fevers and rigors, and nonproductive cough. The results of the lung examination and the chest x-ray film reveal the typical findings of a bilateral interstitial infiltrate. This clinical pattern can be caused by Mycoplasma pneumoniae. Tx- clarithromycin, azithromycin, quinolones, and doxycycline-> not in kids)

A 27-year-old ski instructor complains of a nonproductive cough for 10 days. He has also developed a low-grade fever and diffuse muscle aches. He has been able to work 6 hours per day but has become increasingly dyspneic on long ski runs. He has no prior medical history and does not smoke or drink. He has a temperature of 38.3°C (100.9°F) and has scattered bilateral crackles. He has a regular heart rhythm. The remainder of his physical examination is normal. A chest x-ray film reveals a faint bilateral interstitial infiltrate. Which of the following is the most likely diagnosis?

Mycoplasma pneumonia (healthy young man has a community-acquired "atypical pneumonia." It is atypical in its gradual onset, absence of higher fevers and rigors, and nonproductive cough. The results of the lung examination and the chest x-ray film reveal the typical findings of a bilateral interstitial infiltrate. This clinical pattern can be caused by Mycoplasma pneumoniae or alternatively by viral agents Common antibacterial agents used to treat M. pneumoniae include clarithromycin, azithromycin, quinolones, and doxycycline-->not in children.)

____________- is a gram-negative diplococcus that is not typically associated with pneumonia.

Neisseria gonorrhoeae

A 24-year-old man with a known history of asthma comes to the emergency department complaining of 5 hours of severe wheezing and shortness of breath. He has used his bronchodilator inhaler 6 times during the past 5 hours but with only minimal relief. On physical examination he appears dyspneic; his temperature is 37.4°C (99.3°F), blood pressure is 118/64 mm Hg, pulse is 106/min, and respirations are 32/min. There is visible use of the sternocleidomastoid muscles with each inspiration. A lung examination reveals bilateral diffuse inspiratory and expiratory wheezing with poor air movement and a prolonged expiratory phase. Which of the following will most likely be found on a chest x-ray film?

Normal CXR (asthmatic attack and is not responding to his usual bronchodilator therapy. Although the findings are consistent with a severe asthmatic attack, i.e., the use of the sternocleidomastoid muscles for inspiration, these patients will generally have a normal chest x-ray film. The patient may have developed a low-grade (probably viral) infection, as suggested by his low-grade fever. However, the infections that are most likely to cause an exacerbation of asthma are usually of the upper respiratory tract; they would consequently be unlikely to produce any findings consistent with pneumonia.)

6-month-old boy is brought to the emergency department because of a 3-day history of cough, congestion and low grade fever. The mother states that the baby has not been feeding well and has only 2 wet diapers over the past 24 hours. Physical examination reveals a pale infant with a temperature of 37.8ºC (100.1ºF), pulse of 170/min, respirations of 60/min and oxygen saturation of 88% on room air. The patient exhibits nasal flaring, subcostal and intercostal retractions. Lung examination reveals diffuse wheezing. Cardiac examination reveals a regular but tachycardic rhythm with no murmur. Central capillary refill is 4 seconds. The remainder of the examination is normal. Which of the following is the most appropriate initial step in management?

Oxygen Therapy (1st ABCs- Saturation of 90% corresponds to an O2 partial pressure of about 60mmHg. Therefore, this patient is hypoxic and needs oxygen to help decrease his work of breathing.)

___________- is a small, hat-shaped fungus that is a common cause of pneumonia in HIV-positive patients.

Pneumocystis carinii

A 56-year-old man is been admitted to the medical intensive care unit (MICU) in respiratory distress. An endotracheal tube is placed for mechanical ventilation at tidal volume 900 mL, rate 12 breaths/min, and fraction of inspired oxygen 50%. The positive end expiratory pressure is 10 cm of water. Medications include subcutaneous heparin and aspirin. Forty-eight hours into his MICU stay he develops tachycardia and a blood pressure 70 mm Hg. Cardiac examination at this time reveals multiple premature contractions. His arterial blood gas reveals PO2 40 mm Hg. Which of the following is the most likely cause of this condition?

Pneumothorax (sudden onset of tachycardia and hypotension indicates an acute process. Since the patient is being mechanically ventilated with positive pressure, he is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax.)

A 49-year-old Vietnamese man is diagnosed with tuberculosis. On physical examination large flocculent masses are noted over the lateral lumbar back, and a similar mass is located in the ipsilateral groin. This pattern of involvement strongly suggests an abscess tracking along which of the following muscles?

Psoas Major (classic presentation of a psoas abscess. This clinical entity was formerly a fairly common complication of vertebral tuberculosis, but is now rare in clinical practice in this country. The psoas muscle is covered by a fibrous sheath known as the psoas fascia. This sheath is open superiorly, permitting an infection involving the soft tissues around the spine to enter the sheath, then track down to the groin.)

__________- can be a result of insults (i.e., oligohydramnios) to the fetus in utero that decrease the lung size. It can also be a result of diaphragmatic hernia, since the lung is displaced by the abdominal contents.

Pulmonary hypoplasia

A 79-year-old man weighing 75 kg with emphysema is intubated in the intensive care unit because of respiratory failure after developing adult respiratory distress syndrome secondary to an Escherichia coli bacteremia. This event followed an untreated urinary tract infection. The ventilator is set to a respiratory rate 20/min, tidal volume 450 mL/breath, and pO2 100%. If these settings are continued for long-term use, the patient has increased risk for developing which of the following complications?

Pulmondary Fibrosis (High concentrations of inspired oxygen delivered through a ventilator may lead to pulmonary fibrosis, which becomes irreversible. In the setting of adult respiratory distress syndrome (ARDS), if the inspired fraction of oxygen cannot be lowered without producing hypoxia, the addition of positive end-expiratory pressure (PEEP) is indicated. Although PEEP does increase the risk of both barotrauma and hypotension by impairing right-sided heart filling, it is indicated to prevent the development of oxygen toxicity, which may result in irreversible pulmonary fibrosis.)

A 33-year-old woman is undergoing a diagnostic work-up because she appears to have Cushing syndrome. She has elevated levels of cortisol, which are not suppressed when she is given high-dose dexamethasone. ACTH levels are greater than 200 pg/ mL. A chest x-ray film shows a central, 3-cm round mass on the hilum of the right lung. Bronchoscopy and biopsies confirm a diagnosis of small cell carcinoma of the lung. Which of the following is the preferred treatment for this woman?

Radiation and Chemotherapy directed at the lung cancer (The endocrine workup is indicative of ectopic ACTH production, and the obvious site is small cell carcinoma of the lung. The lung cancer is what is most lethal, not the endocrine manifestations of the tumor. Although small cell carcinoma of the lung is rarely cured, longer survival can be obtained with radiation and chemotherapy.)

A 71-year-old man comes to the emergency department with fever and cough. He has known hypercholesterolemia and is status post a right hemicolectomy for colon cancer. The patient states that he has had 3 days of fever to 38.9 °C (102 °F), cough productive of green sputum, as well as general malaise and weakness. His physical examination is remarkable for decreased breath sounds at the left base, left basilar egophony and dullness to percussion. A complete blood count reveals a leukocyte count of 15,000/mm3 (normal 5,000-10,000). A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most important part of the history to ascertain prior to initiating therapy?

Recent Hospitalizations (This patient clearly has pneumonia. The absolute requirement for diagnosing pneumonia is an infiltrate on chest radiograph, coupled with clinical findings suggestive of a pneumonia, which this patient has. The next relevant issue is, What is the likely organism? If this man were living at home, the most common organism is the pneumococcus. However, given his recent hemicolectomy and hospitalization, the possibility of a more virulent organism emerges. This is the most critical factor in dictating his course of therapy.)

A 51-year-old man is complaining of shortness of breath. The patient describes a slowly progressive inability to perform physical activities over the past 2 years. He reports being able to start an activity, such as golf or tennis, but within a few minutes he feels like "he has lost his breath." There is no associated chest pain, pressure, or discomfort. More recently, he has had significant shortness of breath even at rest. The clinical picture, with the addition of a restrictive pattern on pulmonary function tests and interstitial infiltrates on the chest x-ray film, suggests the diagnosis of interstitial lung disease. Which of the following is the most appropriate next step in management?

Referral to Pulm for Further Eval and Possible Transbronchial biopsy (pulmonologist may be able to help confirm your diagnosis and is best equipped to recommend confirmatory tests, such as transbronchial biopsy, and help direct treatment options. High resolution CT scan should also be done. *It is extremely important to identify the underlying CAUSE of Interstitial Lung Disease)

___________- is something that health care providers MUST identify as early as possible and one should NOT rely on an ABG to make the decision to intubate. There are 4 simple questions that can help guide the decision about whether to intubate. If the answer is *YES* to any of the following questions, the patient likely needs intubation. 1. Is there failure of airway maintenance or protection? 2. Is there failure of ventilation? 3. Is there failure of oxygenation? 4. Is there an anticipated need for intubation (ie, what is the expected clinical course)?

Respiratory Failure (If a patient is not responding to more conservative treatments and is experiencing continued respiratory distress, intubation and mechanical ventilation should not be delayed.)

____________- bacteria presents in individuals at risk for an invasive pneumonia infections (e.g., IV drug users, major trauma victims, or patients with indwelling IV catheters).

Staphylococcal pneumonia

_____________- occurs as grapelike clusters of large, gram-positive cocci. It may cause pneumonia after surgery or after a viral respiratory infection, such as influenza, and is associated with empyema formation

Staphylococcus aureus

__________- The most common cause of community acquired pneumonia (CAP) is

Strep Pneumonia

A Gram stain of the sputum from a patient with lobar pneumonia involving the left lower lobe demonstrates gram-positive, encapsulated, lancet-shaped diplococci. Which of the following is the most probable causative organism?

Strep pneumonia (classic microscopic description of the pneumococcus Streptococcus pneumoniae, which is a common cause of lobar pneumonia.)

_____________- should be suspected in any patient who presents with worsening dyspnea, hypotension, diminished breath sounds on the affected side, distended neck veins and tracheal deviation away from the affected side. Immediate treatment is required with needle decompression or thoracostomy tube (24 or 28 Fr, 36 Fr for trauma patients). Do NOT delay treatment to obtain a chest-x-ray. If needle thoracostomy is performed, it should be followed by chest tube placement as soon as possible.

Tension pneumothorax

___________- develops when air leaking into the chest increases intrathoracic pressure, completely collapsing the lung on that side.

Tension pneumothorax (results in displacement of the mediastinum and trachea to the opposite side of the chest and impedes venous return)

Inhaled short acting beta-2-adrenergic agonists such as _________ are the treatment of choice for acute exacerbations of asthma.

albuterol

The mechanisms involved in an ______________ are bronchospasm and airway obstruction due to reversible inflammation. The other answer choices produce respiratory problems but vary in their symptomatology -Bronchospasm- SOB< Nonproductive Cough and Wheeze

asthmatic attack

Although some investigators have questioned the causal relationship between asbestosis and bronchogenic carcinoma, most studies have demonstrated a clear association between the 2 entities. Be careful with this type of question as __________ is more likely to occur in a patient with asbestos exposure but *malignant mesothelioma* is directly related to asbestos exposure.

bronchogenic carcinoma

Victims of penetrating chest trauma with dullness to percussion over a lung field should be presumed to have a hemothorax and treated with a __________.

chest tube (Chest tubes for pneumothorax are placed more superiorly as the air collects in non-dependent areas, whereas fluid, such as blood in a hemothorax, settles in the most dependent area, thereby necessitating a chest tube insertion at the lung base.)

Congenital __________- is often seen on prenatal ultrasound and is a defect in the hemidiaphragm that allows the abdominal contents into the thorax. It has the findings of *+respiratory distress, cyanosis, and scaphoid abdomen*. Auscultation will show decreased breath sounds on the affected side. It occurs more often on the L>R

diaphragmatic hernia (a developmental defect of the diaphragm that permits abdominal viscera to herniate into the chest, resulting in pulmonary hypoplasia and pulmonary hypertension, which are often fatal. The abdomen often takes on a scaphoid or concave appearance due to the abdominal contents migrating into the thorax.)

-H. influenzae are small, pleomorphic gram-negative rods. -Neisseria gonorrhoeae are intracellular gram-negative diplococcic. -Pneumocystis jiroveci is a genus of unicellular fungi and requires direct fluorescent antibody staining. -Staphylococcus aureus are gram-positive cocci in clusters. -Streptococcus pneumoniae are gram-positive diplococci (spheres in pairs) - this is pathognomonic for S. pneumonia.

dsfd

Remember the ONLY 2 interventions that will improve survival in patients with COPD are: __________ & ___________

home oxygen therapy and smoking cessation.

COPD patients with severe disease tend to have ______carbia, along with chronic ______xemia; therefore, long-term home oxygen therapy should be initiated as it improves survival and quality of life in these patients.

hyper, hypo

Pneumonia is often diagnosed based on the presence of an ___________ on chest x-ray. Unfortunately, the radiographic findings of it my lag behind the clinical onset of pneumonia, especially if the patient presents for evaluation early on in the infection. The best way to diagnose pneumonia would be to obtain a lower respiratory tract specimen, which is difficult to collect, for culture or microbiologic evaluation

infiltrate

A 21-year-old woman attempts suicide by taking an overdose of barbiturates. On arrival in the emergency department, her blood pressure is 95/65 mm Hg and pulse 105/min. The health care provider orders arterial blood gases. Which of the following values would you expect in this patient? -pO2= _____ -PCO2=_____ -pH=______

low, high, low (Barbiturate overdose causes respiratory depression, resulting in carbon dioxide retention (producing increased PCO2 and decreased pH) and hypoxemia (decreased pO2). In other words, the patient has respiratory acidosis. You should look for *low pO2, high PCO2, and acidotic pH*)

The use of beta-blockers in patients with asthma is not recommended, as it may induce bronchospasm in susceptible patients. (This is most concerning with _____________ beta-blockers.) The use of beta-1 selective beta-blockers such as atenolol (Tenormin) and metoprolol (Lopressor) is usually well-tolerated, but the risk vs. benefit should be considered in those with severe asthma. Patients with COPD who would benefit from beta-blockade (post-MI, heart failure, hypertension, and certain arrhythmias) should not have them withheld. Atenolol or metoprolol, or a combination alpha- and beta-blocker, such as labetalol or carvediol (Coreg), can be used cautiously in these situations. All beta blockades should be avoided in patients with truly severe asthma.

nonselective

The most common type of mechanical ventilation is ________________ ventilation which increases the transalveolar pressure. As a result, the risk of alveolar rupture is always a concern. When alveoli rupture, air can track along the perivascular sheaths toward the mediastinum, leading to: -pneumothorax, -pneumomediastinum, -pneumoperitoneum, and/or -subcutaneous emphysema.

positive pressure

In regions with endemic tuberculosis, mycobacterium tuberculosis is a common cause of _______ abscess. The pathophysiology of the development of a tuberculosis _______ abscess is usually the result of hematogenous or lymphatic spread from distant site. They are usually due to an infection with a single organism.

psoas

Hyperventilation leads to a ______________

respiratory alkalosis (caused by a reduction in arterial PCO2 and an increase in pH. The reduction of PCO2 leads to a loss of a hydrogen ion which essentially functions as an acid, leading to an alkalotic state. Hyperventilation is an acute problem and therefore the kidney's compensatory mechanisms are unable to aid in the correction of the acid-base abnormality, which leads to an uncompensated respiratory alkalosis. Breathing into a brown bag helps to correct the acid-base abnormality by having the patient breathe in higher concentrations of CO2, thereby decreasing the pH and correcting the respiratory alkalosis.)