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194 Cards in this Set
- Front
- Back
Kuszmaul sign |
Neck vein distention during inspiration due to increased right-sided venous pressure due to:
-Right ventricular infarction -Tension pneumothorax -PE -tamponade |
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Stridor
|
Most prominent over the glottis. More distinct upon inspiration.
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PFT for asthma
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FEV1/FVC <70
Normal FEV1 >80% FEV1/FVC < 70 in general indicates airway obstruction |
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When is it necessary to taper steroids |
After 14 days of use
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BOOP
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Idiopathic bronchiolitis obliterans organizing pneumonia
|
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Relationship of ciprofloxacin to Theo
|
Cipro can inhibit the hepatic breakdown of Theo leading to toxic levels
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Spirometry
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It the most widely used pulmonary function test.
Spirometry is obtained by measuring the forced expiratory volume overtime after the patient has taken a deep inspiration. |
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FVC
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Forced vital capacity: the maximum volume exhaled |
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How PET scans work
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PET scanning is based on the principle that cancer cells have a high rate of glycolysis (converting glucose to energy) compared to non-cancer cells. |
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Causes a false positive PET scans
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-TB
-Fungal diseases -Sarcoidosis -Other inflammatory condition |
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Causes of false negative PET scans
|
Low-grade tumor such as:
-Adenocarcinoma in situ -Carcinoid tumor -Malignancies less than 1 cm in diameter |
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Best use of bronchoscopy
|
Effective method for sampling:
-Central airway lesions -Mediastinal nodes -Parenchymal masses Pearls: Peripheral pulmonary nodules < 2 cm in diameter are best sampled with CT guided percutaneous biopsy |
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Use of endobronchial ultrasound
|
It has made endoscopic lung cancer staging similar in yield to mediastinoscopy but without skin incision and general anesthesia
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Asthma remodeling |
It is due to uncontrolled inflammation or repeat exacerbations leading to structural airway changes.
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Age onset of asthma
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Typically in childhood but adult onset is well recognized even in the elderly.
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Incidence of asthma
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5% of the adult population in the US.
More prevalent in western cultures. |
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Allergan testing in asthma
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Between 70 and 90% of patients with asthma have allergies demonstrated with skin testing and confirmed by relevant history
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Typical asthma triggers
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Viral URI
Cold air Stress Exercise |
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FEV1
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The forced expiratory volume exhaled in the first second
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Clubbing is suggestive of what disease?
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Cystic fibrosis
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Confirmatory asthma testing
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FEV1/FVC ratio: <70
Reversibility (12% or greater improvement in FEV1 after administration of bronchodilators) Patients with suspected asthma who have normal spirometry should undergo a bronchial challenge test to assess for airway hyperresponsiveness; a negative test generally excludes asthma |
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Early and late responses of asthma attacks
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Early phase: 30 minutes to 1 hour
Late response: return of asthma symptoms 3 to 8 hours after |
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Reactive airways dysfunction syndrome (RADS)
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It is a distinct type of occupational asthma that results from a single accidental exposure to high levels of irritant vapors, gases, or fumes such as chloride gas, bleach or ammonia.
This exposure leads to significant airway injury with PERSISTENT airway inflammation, dysfunction, and hyperresponsiveness. Symptoms can persist for years afterwards. |
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Cough variant asthma |
It is a type of asthma in patients who have cough as their main symptom.
The cough is typically dry and sometimes the only symptom of asthma. The diagnosis is confirmed with spirometry that demonstrates obstruction with improvement following bronchodilator or with bronchial challenge testing that shows responsiveness. |
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Allergic bronchopulmonary aspergillosis
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This condition should be thought of with patients who have difficult to control asthma or frequent exacerbations requiring systemic steroids.
A chest x-ray should be obtained which often will show: pulmonary infiltrates or bronchiectasis This condition is a result of sensitization Aspergillus fumigatus. DX: Chest x-ray Elevated serum levels of IGE Positive skin test to Aspergillus Eosinophilia Pearls: left untreated BPA can result in progressive pulmonary fibrosis and loss of lung function. |
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Characteristics of exercise-induced bronchospasms
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Triggered by breathing in cold or dry air
Symptoms are at their worst not during exercise but immediately following cessation of exercise. Bronchial obstruction peaks 5 to 10 minutes after cessation and resolves within 30 minutes. Pearls: symptoms should be distinguished from vocal cord dysfunction or exercise-induced Gerd Prevention: treatment with short acting Beta2 agonist 15 minutes before exercise. This protection can last up to 3 hours. |
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Symptoms of vocal cord dysfunction
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Prominent wheezing that is more noticeable during inspiration (stridor).
Abrupt onset of symptoms that are felt in the neck. Abrupt onset is NOT typical of asthma. Pearls: this condition can be difficult to diagnosed in a patient with a history of asthma. DX: laryngoscopy RX: patient education, behavior modification, and speech therapy. |
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Samter Triad
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1. Severe asthma
2. Aspirin sensitivity 3. Nasal polyps Aspirin sensitivity should be considered in patients with difficult to control disease. Asthma patients who must use aspirin should be referred for desensitization. |
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Typical viruses that cause URIs that triggers asthma
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Rhinovirus
Respiratory syncytial virus Influenza |
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Bronchial challenge testing
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Diagnostically positive if FEV1 falls 20% from baseline.
This test is sensitive for asthma but not very specific. |
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A main goal of asthma management
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To reduce the need for rescue albuterol to less than twice weekly
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Types of asthma
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1. Intermittent
2. Persistent: persistent asthma is further classified as: -Mild -Moderate -Severe |
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What does MDI mean?
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Pressurized metered-dose inhalers
Pearls: poor inhaler technique is a common cause of lack of response to asthma therapy |
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Types of long acting Beta2 agonist
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Salmeterol - slower onset of action
Formoterol - rapid onset of action and last for 12 hours Use: typically added with inhaled steroids if symptoms are not adequately controlled after inhaled steroids optimized. Pearls: 1. Provide no anti-inflammatory effects 2. Treatment with long acting Beta two agonist as a single agent therapy in asthma is not appropriate. It can mask worsening of airway inflammation and lead to increased risk of asthma related complications. 3. There is a risk of death with these agents which has led the FDA to require a black box warning. |
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Anticholinergic agents used in asthma and COPD
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Short acting: Ipratropium. Primarily used in COPD but also can be used in as well to enhance the bronchodilator effect of short acting Beta two agonist.
Long acting: Tiotropium |
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Leukotriene modifying drugs
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Monteluast or Singulair
Zafirlukast or Accolate Zileuton or Zyflo These medications block the leukotriene effect of promoting mucus secretion, vasodilatation, and inflammation. They are used primarily as an add-on or alternative to the mainstay medications for asthma. These medications have been reported to cause neuropsychogenic events such as agitation, anxiety, hallucinations, depression and suicidal ideation. As a result the FDA and it a black box warning. Owing to concerns about liver toxicity, Zyflo use has been limited. |
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Theophylline use
|
It is one of the oldest drugs for asthma.
The benefits of using this drug is it's ease-of-use and low cost. Drawbacks of using this drug is that it is a weak bronchodilator and has a very narrow therapeutic margin. It is used primarily as a second line alternative to inhaled corticosteroids. Target therapeutic range is 5-12 ng/mL. Flouroquinolones have been known to increase its circulating levels. Symptoms of toxicity: tremor, headaches, nausea, palpitations, arrhythmia, seizure |
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The mainstay controllers of asthma
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1. Short acting Beta two agonist
2. Inhaled corticosteroids |
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Anti-IGE antibody pulmonary medications
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Omalizumab or Xolair
Only recommended for severe asthma who have evidence of allergies, have elevated IGE between 30 and 700, and remain symptomatic despite optimizing treatment with combination therapy. Serious risk of anaphylactoid reaction; Therefore should be administered by an asthma specialist and the patient should be monitored for two hours after initial three doses and one hour after subsequent treatments. |
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Reduced TLC indicates?
|
TLC: total lung capacity
Reduced TLC indicates chest restriction (<80% of predicted) |
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Diffusing capacity of carbon monoxide (DLco)
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Diffusing capacity of carbon monoxide measures the lung's ability to transfer gas across the alveolar-capillary membrane.
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Six minute walk test
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The six minute walk test is very useful indicator of the patient's functional capacity.
This particular helpful in patients with advanced lung or heart disease. |
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Accuracy of pulse ox
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Accurate within 2% to 3% of arterial oxygen saturation.
Pearls: carboxyhemoglobin can cause falsely elevated oxygen saturation readings because oxyhemoglobin and carboxyhemoglobin waves are not distinguishable by most pulse ox devices. Therefore, pulse ox should not be used in patients who are victims of fire or smoke inhalation. |
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Upper lobe findings on chest x-ray
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Often due to:
-TB -Sarcoidosis -Silicosis -Cystic fibrosis -Languor hands cell histiocytosis |
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Lower lobe findings on chest x-ray
|
Often due to:
-Pulmonary fibrosis -Cryptogenic organizing pneumonia -Asbestosis -Heart failure |
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Effective dose of radiation from CT versus chest x-ray
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Approximately 40 times that of a chest x-ray
|
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Go maintenance of O2 in asthma exacerbation
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92%
|
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How bronchodilators work?
|
Relax the smooth muscles in the airways, resulting in widening of the airways.
|
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Side effects of long-term use of inhaled steroids?
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1. Osteopenia
2. Hyperglycemia 3. Cataracts |
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What is the effective dose of IV steroids in severe COPD exacerbation?
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The effective dose is not known
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Went to use anabiotic's and COPD
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1. In treating infectious exacerbations of COPD.
2. In patients with severe exacerbations of COPD who require mechanical ventilation, whether invasive or noninvasive. A quinolone or third-generation cephalosporin is usually a good choice to cover pulmonary pathogens. |
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Initiation of treatment for COPD
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1. Initiate monotherapy with long-acting bronchodilator or long-acting anticholinergic in patients with FEV1 less than 60% of predicted.
2. Inhaled corticosteroids should not be used alone for maintenance or rescue of COPD. This is different than asthma. |
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Recommendation for oxygen at home
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1. Resting hypoxemia with PaO2 of 55 or lower
2. Resting pulse ox of 88% or lower |
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What is lung volume reduction surgery? |
Involves respecting up to 30% of disease or nonfunctioning parenchyma to reduce hyperinflation and allow the remaining lung to function more efficiently.
It is only recommended in advanced COPD (maximum FEV1 less than or equal to 45%) |
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Indications for pulmonary rehab in COPD
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1. FEV1 less than 50% of predicted
|
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Best test for evaluating diffuse parenchymal lung disease?
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High resolution chest CT
|
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Idiopathic pulmonary fibrosis
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The most common idiopathic interstitial disease.
CT findings: peripheral and basal prominent groundglass, honeycomb and reticular changes. Prognosis, is poor with median survival 3 to 5 years. Treatment: 1. multiple studies have failed to demonstrate any benefit of steroids in IPF. 2. Lung transplantation is the only intervention shown to improve survival. |
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Peak expiratory flow rate (PEFR) in acute asthma exacerbation
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Moderate exacerbation: PEFR 40-69% of predicted personal best
Severe exacerbation: PEFR <40% |
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Characteristics of nonspecific interstitial pneumonia
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Most often associated with underlying connective tissue disease.
Diagnosis: 1. Chest CT showing groundglass without honeycombing 2. requires open lung biopsy showing lymphoplasmacytic interstitial infiltration Treatment: responds to steroids |
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What is cryptogenic organizing pneumonia?
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COP is the idiopathic form of bronchiolitis obliterans organizing pneumonia (Boop). |
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Common connective tissue diseases that cause interstitial lung disease?
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1. Systemic sclerosis: diffuse parenchymal lung disease is the leading cause of mortality |
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What is hypersensitivity pneumonitis?
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Pneumonitis caused by repeat inhalation of finely dispersed antigens; Such as mold, bird feathers and droppings, laboratory animal dander and so on. |
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Types of drugs that cause parenchymal lung disease
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1. Amiodarone: Clarence of drug from pulmonary parenchyma is very slow. Lung disease is one of the leading causes of stopping this medication. |
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Radiation pneumonitis
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Present with cough and/or dyspnea 6 weeks after exposure.
Most parenchymal changes resolve after six months. Treatment: steroids in some cases |
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Sarcoidosis lung manifestation
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Sarcoidosis is a multi organ inflammatory disease characterized by tissue infiltration by: |
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What is Lymphogioleiomyomatosis?
|
It is a rare cystic lung disease seen in young women of childbearing age or in association with tuberous sclerosis.
Consider this diagnosis when spontaneous pneumothorax and chtlothorax in a young woman with chest imaging demonstrating hyperinflation and chest CT showing diffuse, thin-walled, small cyst. |
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Bronchial thermoplasty
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Indicated in severe cases/difficult to manage asthma.
It consist of applying heat to the airway with a catheter that is inserted via bronchoscope connected to radio frequency generator. This treatment should occur three times. It is supposed to reduce smooth muscle hypertrophy which has been reported in patients with asthma. |
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Tests for asthma doing pregnancy that should not be done
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1. Allergen Skin testing
2. Bronchial challenge testing is actually contraindicated |
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Asthma medication safe during pregnancy
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Essentially all of them including theophylline and leukotriene receptor antagonist.
Although systemic steroids have been linked to a small risk of congenital abnormalities, their use is recommended in patients with acute severe asthma. Pearl: asthma is one the most common medical problems that complicates pregnancy. |
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Pathophysiology of COPD
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Slowly progressive inflammatory disease of the airways and lung parenchyma.
It is characterized by gradual loss of lung function with increasing obstruction to EXPIRATORY airflow. |
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Pulmonary complications of COPD
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Pulmonary hypertension
Cor pulmonale Pneumonia Pneumothorax Bronchiectasis Atelectasis Lung cancer |
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Percentage of heavy smokers who develop COPD
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20%
|
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Large global risk factor for COPD other than smoking
|
Exposure to smoke from indoor burning biomass fuels such as wood, charcoal, and vegetable matter.
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Test to diagnose COPD |
Spirometry: a post bronchodilator FEV1/FVC ratio less than 70 is diagnostic.
Note, diagnostic spirometry should be performed AFTER administration of inhaled bronchodilators because this will improve the accuracy of the study results. |
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Asbestosis exposure period in the US
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1940-1979
|
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When to do a thoracentesis due to plural effusion?
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Unexplained effusions >1 cm in thickness
|
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Testing for transudative or exudative plural effusion:
|
Exudative if one criteria met:
1. Pleural total protein to serum total protein ratio > 0.5 2. Pleural fluid lactate dehydrogenase (LDH) level >2/3 the upper limit of normal Transudative if neither of the above criteria met. |
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Conditions associated with bloody pleural effusions?
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-Trauma
-Cancer -Tuberculosis |
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The three types of parapneumonic effusions
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1. Uncomplicated: exudative, White blood cells present but no bacteria. No drainage needed.
2. Complicated: exudative, bacteria present in fluid. May respond to antibiotics but likely require drainage. 3. Empyema: pus in the plural space. Always requires drainage. |
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Low pleural fluid glucose suggest:
|
-TB
-Parapneumonic effusion -Malignant effusion -Rheumatoid disease |
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Pleural fluid analysis of chylothorax
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-TG >110
-Presence of chylomicrons |
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Pleural fluid analysis seen TB
|
Any lymphocytic predominate exudate in the presence of a positive PPD should be considered TB until proven otherwise.
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Latency period of asbestos?
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15 to 35 years
|
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Type of lung disease caused by asbestosis
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Restrictive lung disease
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Pleural effusion seen in asbestosis
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Benign, exudative, often hemorrhagic effusions with eosinophils present 30% of the time.
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Lung cancers associated with asbestos exposure
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-Small cell
-Non-small cell carcinoma -Mesothelioma Smoking in setting of asbestos exposure increases risk of lung cancer 60 fold. |
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What is asbestos made of?
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Hydrated silicate fiber
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What is the actual substance that causes silicosis?
|
Crystalline silicon dioxide (silica)
Any occupation that disturbs the earth's crust or uses or processes silica-containing rock or sand has potential risks of exposure. |
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Silicosis increases the risk of these other diseases:
|
-Tuberculosis
-Autoimmune diseases: systemic sclerosis, rheumatoid arthritis, and Lupus -Lung cancer |
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Treatment of silicosis
|
There is no specific proven therapies.
Treatment of symptomatic silicosis: inhaled bronchodilators, anabiotic's for infection, supplemental oxygen in patients with hypoxemia Pearls:Patients with silicosis should be screened for TB |
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What are the top three causes of pleural effusions?
|
1. CHF
2. Parapneumonic 3. Malignant Effusions |
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Treatment of empyema
|
1. Anabiotic's
2. Drainage 3. Intrapleural tissue plasminogen activator combined with deoxribonuclease to increase pleural drainage, decrease hospital stay, and decreased need for surgery later. |
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Definition of spontaneous pneumothorax
|
Spontaneous pneumothorax is classified as primary if lung disease is absent, and is considered secondary if lung disease is present.
|
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Risk factors for primary spontaneous pneumothorax
|
1. Smoking
2. Family history 3. Marfan syndrome 4. The thoracic endometriosis |
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Definition of small pneumothorax
|
Defined as <2 cm between the lung and the chest wall on CXR
SMALL PRIMARY PNEUMOTHORACES CAN BE MONITORED WITHOUT INTERVENTION. BUT EVEN SMALL SECONDARY PNEUMOTHORACES MUST BE MANAGED IN THE HOSPITAL. |
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The percentage of untreated DVT's which lead to PE
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10% to 30%
|
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Most common signs of PE
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-Tachypnea
-Pleuritic pain -Dyspnea -Anxiety -Cough -Increased intensity of pulmonic component of S2 |
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When is checking a D-dimer indicated in PE
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Only in low pretest probability of PE should you check a d-dimer. Because if negative in moderate to high pretest probability continued workup is indicated.
A negative D dimer in low pretest probability, clinically stable patients virtually excludes PE and eliminates further testing. |
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EKG changes in acute PE
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-Tachycardia
-Right axis deviation -Right bundle branch block -S1Q3T3 pattern |
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Clinical scenarios were VQ scan is less reliable
|
-Abnormal chest x-ray
-Patients with COPD or other conditions were holding breath is difficult |
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Medications approved for treatment of acute PE
|
Heparin IV
Lovenox Arixtra Coumadin |
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How many days should the bridging anticoagulation occur after therapeutic range is reached with Coumadin
|
2 consecutive days. This ensures that all vitamin K dependent factors have declined and physiologic anticoagulation has been reliably achieved.
|
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How many days should the bridging anticoagulation occur after therapeutic range is reached with Coumadin
|
2 consecutive days. This ensures that all vitamin K dependent factors have declined and physiologic anticoagulation has been reliably achieved.
|
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Treatment of acute PE and setting of hypotension
|
1. Judicious IV fluids
2. Vasoconstrictors 3. Thrombolytic therapy in refractory hypotension followed by anticoagulation 4. If thrombolytics contraindicated, surgical or catheter embolectomy should be considered. |
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Duration of anticoagulation in patients with first episode of acute PE
|
3 months, after which the likely cause and the risks and benefits of treatment are reassessed
|
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Definition of pulmonary hypertension
|
Defined as the elevation of main pulmonary artery pressure of 25 or greater during rest.
Diagnoses of PH can only be confirmed by right heart catheterization and direct measurement of me pulmonary artery pressure. A CARDIAC ULTRASOUND SHOWING A SYSTOLIC MEAN PULMONARY ARTERY PRESSURE 40 or GREATER IS HIGHLY SUGGESTIVE BUT NOT DIAGNOSTIC. Echo can be used to monitor progression. |
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Causes of pulmonary hypertension
|
80% of cases of pulmonary hypertension are due to left-sided heart dysfunction or underline chronic lung disease
|
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Treatment of pulmonary hypertension
|
-In most cases treat the underlying cause. Unless 'isolated' pulmonary arterial hypertension.
-The benefits of vasodilator therapy in this population remained unproven. |
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Initial recommend test to evaluate for chronic thromboembolic pulmonary hypertension
|
VQ scan: invariably has mismatching
Treatment: 1. Anticoagulation. 2. Definitive treatment is surgical, involves removing organize clots. |
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The difference in pulmonary hypertension (PH) and pulmonary arterial hypertension (PAH)?
|
PAH is a subset of PH with:
-Elevated mean pulmonary artery pressure -Normal pulmonary capillary wedge pressure less than or equal to 15 -Elevated pulmonary vascular resistance The origin of this condition is not clear but it likely involves intrinsic under expression of vasodilators such as prostaglandin and nitrous oxide and an overexpression vasoconstrictors. Treatment: 1. Diuretics as needed 2. Anticoagulants to prevent in situ clot formation come in many forms of this condition 3. Cardiac glycosides to augment right heart dysfunction 4. Supplemental oxygen 5. Pulmonary artery vasodilators Pearls: Right heart cath should be performed to confirm pulmonary artery hypertension and to assess a vasodilator responsiveness before long term vasodilator therapy is attempted. |
|
Definition of a pulmonary nodule
|
1. A focal, nodule opacity
2. Up to 3 cm in diameter 3. Surrounded by normal lung tissue 4. Not associated with lymphadenopathy Lung lesions over 3 cm are considered lung masses and have a much higher likelihood of malignancy The nodule size it is often the most important feature in predicting malignancy |
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Paraneoplastic Lambert-Eaton syndrome is caused by which lung cancer
|
Small cell
|
|
Staging system of non-small cell lung cancer |
T-tumor, N-node, M-metastasis
|
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Best standard surgical approach to resection of stage I or stage II NSCLC
|
Lobectomy
Patients who have marginal pulmonary reserve, limited resection such as a segmentectomy or wedge resection may be a more appropriate surgical option for these patients. These resections are increasingly being performed by video-assisted thoracic surgery (VATS) versus thoracotomy. Stage III and stage IV lung cancer is treated with chemotherapy alone or in combination with XRT |
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Treatment of small cell lung cancer
|
Limited stage small cell lung cancer is treated primarily with combination of chemotherapy and XRT. |
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Pulmonary nodules benign vs malignant characteristics
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1. 90% of nodules smaller than 8 mm are benign, whereas the majority of nodules larger than 2 cm are malignant. |
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Pulmonary nodules that should not be followed
|
Less than 4 mm in diameter in never smokers or other risk factors for malignancy. |
|
Two-year nodule stability rule
|
Solid nodules that remained stable in size for two years on chest x-ray or CT are considered benign and no further follow-up is indicated
|
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What are the two types in which lung cancer is divided?
|
1. Non-small cell lung cancer (NSCLC). 80% of all lung cancer.
2. Small cell lung cancer (SCLC) |
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Subtypes of non-small cell lung cancer
|
1. Adenocarcinoma - pre-invasive, minimally invasive, or invasive
2. Squamous cell carcinoma 3. Large cell carcinoma |
|
Smoking rates in America
|
20% of men |
|
Risk factors for lung cancer
|
-Tobacco smoke
-Asbestos -Radon -Certain metals-arsenic, chromium, nickel -Ionizing radiation -Polycyclic aromatic hydrocarbons -Pulmonary fibrosis |
|
Paraneoplastic SIADH is caused by which lung cancer |
Small cell |
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Paraneoplastic hypercalcemia is caused by which lung cancer
|
Squamous cell |
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What is mesothelioma
|
A neoplasm that arises from the mesothelial surfaces of the pleural and peritoneal cavities.
80% arise from the pleural cavity. Prognosis: poor with median survival of 6-18 months common symptom: dull, unrelenting pain Treatment: chemo but usually doesn't work |
|
What are carcinoid tumors is of the lung
|
Low-grade malignancy consisting of cells of neuroendocrine origin.
No association with smoking. Typically endobrachial location: therefore patients present with hemoptysis or evidence of obstruction. Two types of carcinoid tumor of the lungs: typical and atypical Treatment: surgical resection in both cases. Carcinoid syndrome (flushing and diarrhea) is rare in carcinoid tumor lung. |
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Location of the mediastinum
|
Lies between the two plural surfaces in the center of the chest and is divided into anterior, middle, and posterior compartments.
|
|
Masses is found in the anterior mediastinum
|
-Lymphoma
-Thyroid or parathyroid tumors -thymoma or thymic carcinoma -Teratoma |
|
Paraneoplastic syndrome associated with thymoma? |
-Myasthenia gravis
-pure red cell aplasia -Hypogammaglobulinemia |
|
Masses found in middle mediastinum
|
-Enlarged lymph nodes from Mets
-Lymphoma -Granulomatous disease (sarcoidosis, fungal infections, TB) -Giant lymph node hyperplasia (Castlemans disease) -Diaphragmatic hernia -Pericardio cyst -Bronchogenic cyst |
|
Masses found and posterior mediastinum
|
-Neurofibroma
-Nuerilemmoma/Schwannoma -leiomyomas |
|
What is mean sleep latency testing (MSLT)
|
This test provides an objective measure of sleepiness and is key to establishing the diagnosis of narcolepsy and Idiopathic hypersomnia.
A mean sleep latency of more than 15 minutes is considered normal and less than 5 minutes is indicative of a pathological sleepiness. |
|
Cheyne-Stokes Breathing |
It is the most common type of central sleep apnea and is also referred to as periodic breathing.
It is characterized by crescendo-decrescendo pattern of ventilation. It is strongly associated with heart failure. |
|
Jet lag
|
Results when the internal circadian clock is out of phase with the local time following air travel across multiple times zones. Usually more than 5 times zones.
It is basically an misalignment between the body's internal clock and the world's external clock. |
|
Apnea
|
Complete cessation of airflow in the upper airways
|
|
Hypoapnea
|
Characterized by reduction in airflow in the upper airways.
|
|
What is the apnea-hypo apnea index (AHI)
|
It is the number of disordered breathing events (apnea and hypoapnea) per hour of sleep.
-An AHI of 5 to 15 indicates mild OSA. -And AHI of more than 30 indicates severe OSA. |
|
Mammalian dive reflex |
In response to hypoxemia there is an acute surg in peripheral vascular resistance along with a slowing of the heart rate.
This is the pathophysiology of obstructive sleep apnea. |
|
The most important risk factor for OSA?
|
Obesity
|
|
Definition of central sleep apnea
|
It is characterized by loss of ventilatory output from the central respiratory generator in the brainstem to the respiratory pump, which manifest on polysomnogram with the absence of respiratory effort associated with loss of airflow for at least 10 seconds.
A key mechanism of central sleep apnea is the tendency to hyperventilate and thus drive down the arterial CO2 to a level near apneic threshold-the point at which respiratory effort ceases. Symptoms: -Frequent awakening from sleep -Insomnia -Non-restorative sleep -EDS -Proximal nocturnal dyspnea Diagnosis: Polysomnogram. Oximetry alone is not adequate to distinguish between OSA and CSA. Treatment: 1. control any underlying comorbidity. 2. Adaptive servoventilation (ASV). Note CPAP can often worsen CSA unless there's underlying OSA. |
|
Sleep breathing drive
|
Breathing while sleeping is primarily driven by blood carbon dioxide tension or arterial CO2 as opposed to arterial oxygen levels.
|
|
Risk factors for central sleep apnea
|
Heart failure
Afibrillation Stroke Brainstem lesions Kidney failure Chronic CPAP use Opiate use High altitude |
|
Confirmation of hypoventilation syndrome
|
<90% O2 saturation for at least five minutes
Or 02 saturation <90% for >30% of total sleep time |
|
Definition of daytime hypercapnia
|
Arterial PaCO2 >45
This can be a cardinal sign of COPD with CO2 retention or obesity hypoventilation syndrome (OHS). |
|
What is high altitude periodic breathing
|
Nearly everyone ascends to elevations greater than 25,000 feet will experience high altitude periodic breathing, which is characterized by cyclic central apneas and hyperapneas associated with repetitive arousals from sleep, often with paroxysms of dyspnea.
This condition is rare and elevations <8200 feet Treatment: -Gradual rather than rapid ascent -Acetazolamide -Oxygen as needed |
|
Symptoms of acute mountain sickness and high altitude cerebral Edema
|
Mountain sickness tends to occur at elevations greater than 6500 feet.
Symptoms of mountain sickness: headache, fatigue, nausea, vomiting, disturbed sleep Symptoms of high altitude cerebral edema: Encephalopathic/altered mental status and ataxia. Both signs of cerebral edema in response to vasogenic brain swelling. Treatment of cerebral edema: -Descent -Dexamethasone -Oxygen -Hyperbaric therapy |
|
High-altitude pulmonary edema
|
Thought to be secondary to elevations and pulmonary arterial pressures in response to hypoxemia.
Treatment: -Oxygen -Descent -If above not available vasodilators such as nifedipine or phosphodiesterase-5 inhibitors (Sildenafil) |
|
Air travel pulmonary disease
|
Commercial airline cabins are pressurize to an equivalent of approximately 5000 to 8200 feet which carries an oxygen tension of 110 and 120 mmHg.
Normal, at sea level, levels are 150 to 160 mmHg of oxygen. A person with the pulse ox <92% indicates a probable need for in-flight supplemental oxygen. Contradictions to airflight: -COPD exacerbation with air trapping -Pneumothorax of any size |
|
Confirmation of hypoventilation syndrome
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<90% O2 saturation for at least five minutes
Or 02 saturation <90% for >30% of total sleep time |
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Definition of daytime hypercapnia
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Arterial PaCO2 >45
This can be a cardinal sign of COPD with CO2 retention or obesity hypoventilation syndrome (OHS). |
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Symptoms of acute mountain sickness and high altitude cerebral Edema
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Mountain sickness tends to occur at elevations greater than 6500 feet.
Symptoms of mountain sickness: headache, fatigue, nausea, vomiting, disturbed sleep Symptoms of high altitude cerebral edema: Encephalopathic/altered mental status and ataxia. Both signs of cerebral edema in response to vasogenic brain swelling. Treatment of cerebral edema: -Descent -Dexamethasone -Oxygen -Hyperbaric therapy |
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High-altitude pulmonary edema |
Thought to be secondary to elevations and pulmonary arterial pressures in response to hypoxemia.
Treatment: -Oxygen -Descent -If above not available vasodilators such as nifedipine or phosphodiesterase-5 inhibitors (Sildenafil) |
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ARDS
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Acute respiratory distress syndrome. It is a non-cardiogenic form of pulmonary edema characterized by acute, persistent, diffuse lung inflammation that is injurious to alveoli and pulmonary capillary vasculature.
ARDS is now graded as mild, moderate, or severe based on pulse ox/arterial oxygen ratio. Pulmonary edema seen in ARDS cannot be from a cardiac source. |
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Confirmation of hypoventilation syndrome
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<90% O2 saturation for at least five minutes
Or 02 saturation <90% for >30% of total sleep time |
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Definition of daytime hypercapnia
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Arterial PaCO2 >45
This can be a cardinal sign of COPD with CO2 retention or obesity hypoventilation syndrome (OHS). |
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What is high altitude periodic breathing
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Nearly everyone ascends to elevations greater than 25,000 feet will experience high altitude periodic breathing, which is characterized by cyclic central apneas and hyperapneas associated with repetitive arousals from sleep, often with paroxysms of dyspnea.
This condition is rare and elevations <8200 feet Treatment: -Gradual rather than rapid ascent -Acetazolamide -Oxygen as needed |
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Mortality with ARDS?
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40%
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Confirmation of hypoventilation syndrome
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<90% O2 saturation for at least five minutes
Or 02 saturation <90% for >30% of total sleep time |
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Signs of diaphragmatic weakness
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Paradoxical inward motion of the abdomen with inspiration
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The nerve that innervates the diaphragm
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The phrenic nerve which arises from cervical spine roots 3, 4, and 5 (C3-5). Complete spinal cord injury above C3 level results in nearly complete loss of ventilatory muscle function.
Such patients require lifelong ventilatory support or diaphragmatic pacing. |
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Kyphoscoliosis causes what kind of lung disease?
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Restrictive.
Restrictive lung disease can be considered extra-pulmonary; in which there is no underlying intrinsic lung disease. |
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How do inhaled anticholinergics work? |
They modestly augment the bronchodilation affect achieved by short acting Beta 2 agonists.
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ICU admission criteria for asthma exacerbation
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No clinical improvement after one hour of aggressive bronchodilator therapy:
-Albuterol neb every 20 minutes x 3 -Ipratropium every 20 minutes times 3 |
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Definition of shock
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It is a state of decreased tissue perfusion, which can result in an adequate oxygen delivery for cellular needs.
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What is the Rapid shallow breathing index. used for?
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For determination of success rate or failure probability on vent weaning.
It is defined as the ratio of respiratory rate to tidal volume. If this ratio is greater than 105 there is a 95% chance of spontaneous breathing trial being unsuccessful. If it is less than 105 there's an 80% chance of success. |
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Definition of ventilator associated pneumonia (VAP)
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It is defined as pneumonia with onset at least 48 hours AFTER endotracheal intubation.
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Meaning of SIRS |
Systemic inflammatory response syndrome. This term was introduced to describe findings:
1. Alter temperature 2. Tachycardia 3. Hyperventilation 4. Abnormal leukocyte count regardless of cause (inflammation or infection) |
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Simple definition of sepsis
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SIRS plus suspected infection
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Definition of daytime hypercapnia
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Arterial PaCO2 >45
This can be a cardinal sign of COPD with CO2 retention or obesity hypoventilation syndrome (OHS). |
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Simple definition of severe sepsis
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Sepsis associate with systemic effects including:
-Hypotension -Decreased urine output -Metabolic acidosis |
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The amount of IV fluid resuscitation likely required in severe sepsis with hypotension?
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4 to 6 L in the first six hours
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When should steroids be given in sepsis?
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Only after blood pressure is found to be poorly responsive to fluid resuscitation and vasopressor therapy.
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Meaning of CRRT
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Continuous renal replacement therapy - a form of dialysis for hemodynamically unstable patients
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Injurious triggers for ARDS?
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Pneumonia
Aspiration Near drowning In elation injury Trauma or lung contusion Sepsis Pancreatitis Multiple blood transfusions |
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How does Naloxone work?
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It is an opioid antagonist; thus an antidote to opioid overdose.
Other alternatives should be thought of after a total naloxone dose of 10 mg has been given and no quick clinical improvement. It is relatively safe to give Naloxone (Narcan) to chronic opioid users but not to give the antidote (Flumazenil) to chronic benzodiazepine users. |
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Treatment of bronchospasms and upper airway edema in burn victims?
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Inhaled racemic epinephrine and other bronchodilators
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What is the antidote to smoke inhalation induced cyanide toxicity?
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Sodium thiosulfate -Should be used rather than nitrates because of the risk of methemoglobin formation with use of nitrates.
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The pathophysiology of anaphylaxis?
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It results from an IgE activation on the surface of basophils and mast cells causing a massive release of histamine and other inflammatory mediators.
Severe symptoms: -Hypotension, it is due to histamine increasing vascular permeability leading to large losses of circulating plasma volume. Treatment: epinephrine IM or IV. Note, high dose or continuous epi may be needed for severe reactions or patients taking beta blockers. Pearls: Radio contrast reaction is a special case in which the contrast agent directly activates mast cells without an IgE intermediary. |
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Definition of angioedema
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Is localized tissue edema. For example affecting the lips, tongue, upper airway, G.I. tract and or extremities.
Angioedema can be due to an agent, particularly ACE I or familial. Familial angioedema is associated with C1 inhibitor deficiency as characterized by episodes of angioedema that occur following trauma or illness and begin early in life. Pearls: - these forms of angioedema do not respond to usual anaphylaxis therapy, although airway management is essential owing to potential laryngeal edema. - Angioedema can occur as a component of anaphylaxis, but it may also occur alone. |
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Treatment of hypertensive urgency versus hypertensive emergency
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Hypertensive emergency should be treated with IV short acting medication generally not reducing blood pressure greater than 25% initially.
Hypertensive urgency generally should be treated with oral medications. |
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Definition of hyperthermia
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Temperature above for 40 Celsius or 104 degrees Fahrenheit
Sources of hypothermia: -Heat stroke -Malignant hyperthermia -Neuroleptic malignant syndrome |
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Heatstroke
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Results from failure of the body's thermoregulatory system; the system may be impaired or overwhelmed.
Thermoregulation may be impaired in the elderly and in patients who have or being treated for conditions that can lead to dehydration or anhidrosis. Treatment: evaporative cooling methods. There is no response to centrally acting antipyretic medications. |
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Malignant hyperthermia |
It is A reaction to certain classes of drugs including anesthetics I feel healthy and in others.
Treatment: - stop the offending agent - Dantrolene (muscle relaxant) 5 to 10 minutes until hyperthermia and rigidity results. |
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What is neuroleptic malignant syndrome?
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Idiosyncratic reaction to neuroleptic antipsychotic agents.
Symptoms: muscle rigidity, hyperthermia, autonomic dysregulation. |
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Definition of hypothermia |
Court temperature below 35°C or 95°F |
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Therapeutic hypothermia
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It is the intentional lowering of the patient's core temperature after cardiac arrest. This has been shown to improve their neurologic outcomes in patients who recover circulation.
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The different types of alcohols?
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1. Ethanol
2. Ethylene glycol or anti-freeze 3. Methanol or wood alcohol 4. Isopropyl alcohol or rubbing alcohol Ethylene glycol is converted to oxalic acid which crystallizes in renal tubules and causes kidney injury. Anion gap metabolic acidosis present. Methanol is converted to formic acid which is a toxin to the retina. Anion gap metabolic acidosis present. Isopropyl alcohol is converted to acetone but has no toxic metabolite. Ketones are elevated in the blood but there is no anion gap metabolic acidosis which is seen in ethylene glycol and methanol toxicities. Pearls: - all of these alcohols have CNS depressant effects. - all three of these toxic alcohols can be rapidly removed with dialysis or reversed with antidote ethanol or fomepizole |
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Carbon monoxide poisoning
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CO binds hemoglobin avidly to produce carboxyhemoglobin. Non-smokers typically have up to 3% of their hemoglobin bound by CO, whereas heavy smokers may have up to 10% to 15% bound.
Diagnosis: -Check co-oximetery. Carboxyhemoglobin levels are typically >20%. Treatment: -100% oxygen -If carboxyhemoglobin levels >20% and patient symptomatic hyperbaric oxygen |
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Acid-base profile of aspirin overdose
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Produces both an anion gap metabolic acidosis as well as a respiratory alkalosis.
Treatment: -Activated charcoal -IV glucose -Bicarbonate infusion |
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Antidote to beta blockers
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Glucagon and calcium chloride
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Antidote to CCB
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Calcium chloride, glucagon
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Antidote to sulfonylureas
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Dextrose, Octreotide; glucagon for short term while dextrose is delayed
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Antidote to tricyclic antidepressants
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Bicarbonate infusion titrated to QT interval improvement on EKG
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Indicator of severe protein and caloric malnutrition
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Pre-albumin level <5
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