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65 Cards in this Set
- Front
- Back
These patients are at high risk for vent failure
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VC>20ml/kg; NIF <30 cm H20; declining values
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best method to predict in-flight hypoxemia in COPD patients
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HAST or hypoxia altitude simulation test (patient breathes a hypoxic gas x 20mins)
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how to interpret the HAST?
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PaO2 <50, give in-flight O2; PaO2 >55, no supplemental O2; 50-55 borderling; measure HAST during activity
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mechanism of AAT disease
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AAT is antiproteolytic enzyme; it neutralizes neutrophil elastase, deficiency results in excessive amounts of neutrophil elastase --> destruction of elastin --> early COPD (panacinar emphysema with basilar predominance)
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diagnostic test for CF; hallmarks of CF?
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sweat chloride testing; bronchiectasis, purulent sputum
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Initial treatment of anaphylaxis
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IM or SQ epinephrine + inhaled albuterol
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young woman with dyspnea; CXR shows hyperinflation; comes with spontaneous pneumothorax and/or chylothorax, what diagnosis to consider?
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lymphangioleiomyomatosis
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Pathophysiology of LAM or lymphangioleiomyomatosis
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smooth muscle cells that infiltrate the lung with inactivating tuberous sclerosis complex gene mutations resulting in constitutive activation of the mammalian target of rapamycin (mTOR) signaling pathway.
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characteristic high res CT abnormalities seen in RB-ILD (respiratory bronchiolitis–associated ILD)
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centrilobular nodules with air-trapping and scattered ground-glass attenuation
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Lesions located in the anterior mediastinum
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thyroid tumors, thymic tumors, and lymphomas
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tumors in the middle mediastinum
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bronchogenic cysts, pericardial cysts, LAD
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when is pulmonary rehabilitation indicated?
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symptomatic patients with FEV1 < 50%
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Most patients require a tissue diagnosis, but there are some exceptions that do not warrant histologic confirmation such as
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Löfgren syndrome (fever, erythema nodosum, polyarthralgia, and hilar lymphadenopathy) and Heerfordt syndrome (uveitis, parotid gland enlargement, and fever)
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PDE-4 inhibitor indicated for chronic treatment of severe and very severe COPD with recurrent exacerbations. (not used for acute exacerbations)
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Roflumilast
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The newest National Asthma Education and Prevention Program guidelines - which asthma patients need ICU admission?
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symptomatic, even with mild CO2 retention (PCO2 >= 42) or severely decreased PFTs despite bronchodilator (FEV1 or PEF <40%)
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primary indication for thrombolysis in PE
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persistent hypotension and hemodynamic instability
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confirmatory diagnosis of cystic fibrosis
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measurement of sweat chloride (>60mEq/L)
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flow-volume loop in cystic fibrosis
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flattening of inspiratory and expiratory limbs (fixed airway obstruction)
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The only intervention shown to improve survival in selected patients with IPF
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lung transplantation
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Indications for LTOT
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PaO2 </= 55 mm Hg (7.3 kPa) or O2 sats <= 88% on RA
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What is the Nocturnal Oxygen Therapy Trial (NOTT)?
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continuous O2 better than nocturnal O2 in enhancing survival
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Delirium types
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hyperactive, hypoactive, and mixed
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key feature of AMS
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headache, along with fatigue, nausea, and sleep disturbance (usually due to high-altitude periodic breathing [HAPB], an altitude-associated respiratory change
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most effective therapy to prevent AMS and HAPB when gradual ascnet is not possible
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acetazolamide 24-48 hours before ascent
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when to start treatment with omalizumab in asthma exacerbatoins?
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severe asthma + allergies, elevated IgE + symptomatic despite high-dose inhaled CS and LABA
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young, never smoker, with endobronchial obstruction, recurrent pneumonia, smoothly bordered mass; what is the most likely tumor?
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A carcinoid tumor
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Contraindications to noninvasive ventilation
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resp arrest, CV instability (hypotension, arrhytmias, MI), AMS, high aspiration risk, copious secretions; recent face/GI surgery; craniofacial trauma, fixed nasopharyngeal abnormalities, burns, extreme obesity
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how to interpret allergy skin test in ABPA
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if negative, high NPV; if positive indicates sensitization but not necessarily ABPA, check IgE levels, if >1000 IU/ml, suggests ABPA; if <500, prob not ABPA
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When should LVRS be considered?
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severe COPD, maximal med therapy, completed pulmo rehab + criteria: bilateral emphysema on CT; postbronch TLC >150% and RV >100%; FEV1 max <45%; PaCO2 <60 and PaO2 at least 45 on RA
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treatment for stable but symptomatic COPD and FEV1 <60%
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inhaled bronchodilator
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NOTE: Methylprednisolone and epinephrine are useful in upper airway obstruction from croup and anaphylaxis,
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but they do not have a clear role in the treatment of angioedema associated with ACE inhibitors.
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condition characterized by cyclic central apneas and hyperpneas during sleep upon ascension to high altitude
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HAPB or high-altitude periodic breathing (HAPB)
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best guess for a diagnosis in a former smoker with mediastinal mass and ]probable myasthenic syndrome (Lambert-Eaton syndrome)
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small cell lung cancer
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Lambert-Eaton myasthenic syndrome is a rare neuromuscular junction transmission disorder caused by antibodies directed against
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presynaptic voltage-gated P/Q-type calcium channels
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when to start vasoactive agents in hypotension
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fluid challenge 1L and MAP still <65 or CVP <8-12
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The mean arterial pressure is calculated with the following equation
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(2*DBP + SBP) / 3
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diagnostic criteria for sepsis
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known or suspected infection + 2 of SIRS criteria: T>38 <36; WBC >12 or <4; RR>20; HR>90
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septic patient; central venous O2Sat <70% after fluid challenge, next step?
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transfusion
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normal DLCO
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>/=80% predicted
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indications for chest tube placement
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effusions >1/2 hemithorax; loculation; (+) GS/CS; PF glu <60; PF pH <7.2
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how is asbestosis diagnosed?
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pulmo fibrosis + exposure history + appropriate latency period (10-15 years)
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goal plateau pressure
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<30 cm H20
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in victims of smoke inhalation, which test is sensitive to determine cyanide poisoning?
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lactate >90
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antidote for inhaled cyanide toxicity
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sodium thiosulfate
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NOTe: ARDS + normal BP and normal crea -- when treated with aggressive diuresis
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spent less time on the venilator compared to usual care.
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NOTE: Early use of cisatracurium (to paralyze patients) in severe lung injury
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improves mortality and shortens ventilation
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recommendations for PEEP
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no absolute number, look for PEEP # that achieves FiO2 <0.6 and doesn't cause hypotension
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target BP for hypertensive emergency
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no more than 25% in the first hour; then down to 160/100-110 in next 2-6h
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envelope shaped crystals in urine
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calcium oxalate, ethylene glycol ingestion
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how to identify benign or malignant nodules in the Xray
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borders: smooth benign, spiculated malignant; calcification pattern: popcorn, lamellar, central, diffuse are all benign
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when to start oxygen therapy in COPD?
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PaO2 <55 or O2sats >/= 88% +/- hypercapnea; or PaO2 56-59 or O2 sats <89% + one of the ffg: pulmo HTN, cor pulmonale or edema, Hct >56
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when is alteplase indicated in PE?
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persistent hypotension (SBP <90 or drop in SBP >40)
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changes in the 2012 Berlin consensus definition for ARDS
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Echo or PAWP not necessary; Acuity defined as 1 week; CT chest can be used; classify into mild mod severe based on hypoxemia and ALI term no longer used
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index for assessing severity of COPD; what socre to refer for evaluation for lung transplantation?
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BODE index (BMI, Obstruction, Dyspnea, Exercise) ; score >5 indicates referral for possible lung transplantation
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when is lung transplantation indicated?
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BODE index 7-10 + one of the ffg: hospitalization for hypercapnea / exacerbation; Pulmo HTN, cor pul despite O2 therapy; FEV1 <20% predicted; homogenous emphysema
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radiographic description most consistent with BOOP
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bilateral, diffuse, alveolar opacities in the presence of normal lung volume
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consistent with a transudative process
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serum:PF alb gradient >1.2 or serum:PF total Pr >3.1
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Ideal body weight formula
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50 Kg + (2.3Kg for every inch >60) in MEN; 45.5 Kg + (2.3Kg for every inch >60) in WOMEN
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most common diagnoses for patients with chronic cough and normal CXR
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BA, PND, GERD
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ACCP guidelines for pulmonary nodules follow-up
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repeat CT in 1 year if (former and current) smoker and <4mm nodule; if unchanged, no further CT
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what is a benign / stable nodule
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solid nodule on CXR or CT, stable x 2 years
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what is the apnea-hypopnea index (AHI)?
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apnea + hypopnea per hour of sleep
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how to interpret AIH? An AHI of 5 to 15
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5-15, 16-30, > 30 corresponds to mild, moderate and severe OSA
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idiopathic form of BOOP
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COP
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form of bronchiolitis that occurs in most smokers
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Respiratory bronchiolitis–associated interstitial lung disease (RB-ILD)
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