Pulm 1 Exam Review PDF

1\. What's the definition of **ventilation, perfusion and diffusion** Ventilation: The movement of air in and out of the lungs Perfusion: Movement of blood in and out of the capillary beds, and to the rest of the organs Diffusion: Movement of gases between the air spaces in the lungs and the bloo...

1\. What's the definition of **ventilation, perfusion and diffusion** Ventilation: The movement of air in and out of the lungs Perfusion: Movement of blood in and out of the capillary beds, and to the rest of the organs Diffusion: Movement of gases between the air spaces in the lungs and the bloodstream 2\. What are the lung sounds associated with what conditions? **Wheezing** Whistling musical sound by [narrow or obstructed airway] Asthma COPD chronic bronchitis Sleep apnea CHF and GERD Bronchiectasis, bronchiolitis, lung cancer, sleep apnea, anaphylaxis COPD chronic bronchitis **Crackles** discontinuous high-pitched sounds heard in inspiration COPD chronic bronchitis Asbestosis Idiopathic pulmonary fibrosis **Stridor** monomorphic sound narrowing of larynx Status Asthmaticus Choking/ foreign body/ obstruction of larynx or trachea 3\. Know restrictive vs obstructive diseases +-----------------------------------+-----------------------------------+ | Obstructive Decreased FEV1- FEVC | Restrictive increased or normal | | | FEV1/FEVC | +===================================+===================================+ | - Asthma | - Sarcoidosis | | | | | - COPD | - Pneumoconiosis | | | | | (Emphysema and Chronic | Berylliosis, Byssinosis. | | Bronchitis) | Asbestosis) | | | | | - Cystic Fibrosis | - Idiopathic pulmonary fibrosis | | | | | - Bronchiectasis | | +-----------------------------------+-----------------------------------+ 4\. Know the definition of inconsistent, mild persistent, moderate persistent, severe persistent **Inconsistent** Uses SABA 1-2 times or less in daytime in 1 week, wakes up less than 2 times in a month **Mild persistent** Uses SABA \>2x or more in 1 week, wakes up 3-4 times in one month **Moderate persistence** Daily symptoms, Uses SABA every day, wakes up more than 5 times in 1 month **Severe persistent** Uses SABA 2-3x a day, wakes up every night, has continuous symptoms 5\. Know the Triads of asthma (and all triads) +-----------------------+-----------------------+-----------------------+ | Classic Triad | Atopic Triad | Samster's Triad | +=======================+=======================+=======================+ | - Expiratory | - Asthma | -Asthma | | wheezing | | | | | - Allergic rhinitis | \- Nasal polyps | | - Dyspnea | | | | | - Eczema | \- Aspirin allergy | | - Cough | | | +-----------------------+-----------------------+-----------------------+ 6\. What's the difference between Pulmonary function test, peak flow and incentive spirometry? Pulmonary function tests have Spirometry and Plethysmography Measure the amount and speed of air a person can inhale and exhale. **Plethysmography** An airtight box that patients sit/stand in to conduct the test **Peak** **flow** Monitors the response to treatment (usually used for asthma) The maximum speed at which a person can exhale. 7\. What are the different organisms we suspect when a patient with cystic fibrosis has an infection? **Pseudomonas aeruginosa** Tx: Fluoroquinolone and Aminoglycoside Examples : Levofloxacin and Gentamycin 8\. Cystic fibrosis can cause what other conditions? **Floating stools because of pancreas insufficiency** **Infertility in men and decreased fertility in women** **Meconium ileus in babies** 9\. Some important things to know about cystic fibrosis **autosomal recessive disorder** **Most common lethal genetic disease in the white population** **CFTR gene on chromosome 7 regulates chloride channel ( Na, Cl, HCO3)** How to identify vignette Extra\* Sx: Glands can be inflamed Chronic bacterial infections of lungs/ pulmonary infections which can cause bronchiectasis Pancreatic insufficiency malabsorption of fat, fat soluble vitamins complain oily stools ( steatorrhea) Patients baby can taste salty and have excessive sweating Hyponatremia, elevated lipase levels CXR hyperinflation, bronchial wall thickening, atelectasis, bronchiectasis 10\. What test is confirmatory for cystic fibrosis? Elevated sweat chloride sweat test at **2** separate visit 11\. What test is **definitive** for cystic fibrosis? Genetic screening of Chromosome 7 CFTR 12\. How do you reduce mortality in COPD patients? Oxygen 13\. What's the gold standard test to diagnose sleep apnea Gold Standard Dx: Polysomnography 14\. What is the first line treatment for sleep apnea? What is the best treatment for sleep apnea? First line Tx: Lifestyle modification since the number one risk factor is OBESITY Best treatment/ Gold Standard: Continuous positive airway pressure (CPAP) 15\. Pneumonoconiosis what is each one exposed to? Silicosis working with granite, quartz, slate or sandblaster Increased risk for TB and lung cancer Dyspnea on exertion with a nonproductive cough CXR would show multiple small round nodular opacities in the upper lobe like an eggshell or onion shaped appearance Fix symptomatic treatment can use bronchodilators, O2, and corticosteroids. Definitive : Lung transplant Coal worker pneumoconiosis high carbon coal and or graphite for 20 years Coal workers pneumoconiosis and rheumatoid arthritis Caplan's syndrome CXR: small nodule in upper lobe hyper infiltration Fix symptomatic treatment can use bronchodilators, O2, and corticosteroids. Definitive : Lung transplant Berylliosis aerospace, ceramics, tool, dry, nuclear weapon, fluorescent light bulb Noncaseating granulomas Byssinosis cotton, flax or hemp and got worse while a few days off / vacation Associated chest tightness Methacholine exaggerated in these patients Same tx as asthma Definitive :Biopsy Tx: supportive care 15\. What meds do you give for a COPD exacerbation? Give azithromycin for inflammation with URI exacerbation 16\. What medications would you give for asthma exacerbation? Inhaled bronchodilators + systemic corticosteroids 17\. What is the step-wise approach regarding asthma? 1.Short acting beta agonist (SABA)  Always first line 2\. If patients continue to have symptoms, add on a low dose inhaled corticosteroid 5\. Symptoms persist  Consider use of oral corticosteroids or adjunct medications 18\. Exam finding differences between Emphysema and Chronic Bronchitis +-----------------------------------+-----------------------------------+ | Emphysema | Chronic Bronchitis | +===================================+===================================+ | Dyspnea, | Chronic cough | | | | | prolonged expiration | Increased sputum production | | | | | Thin framed | Wheezing | | | | | Pursed lips | Rhonchi | | | | | Hyperinflation on CXR | Crackles | | | | | Flat diaphragm | Respiratory acidosis on ABG | | | | | Increased AP diameter | | | | | | Hypercapnia | | +-----------------------------------+-----------------------------------+ 19\. What disorders are autosomal recessive/ autosomal dominant? - Autosomal recessive Cystic fibrosis 20\. What is the specific criteria to be considered Chronic Bronchitis - Productive cough for \>3 months or more that occurs multiple times in 2 consecutive years 21\. What lab levels would you expect to see in sarcoidosis? Know all, How do you definitively dx sarcoidosis Hypercalcemia, High ACE levels, High eosinophils CXR: bilateral hilar adenopathy **BIOPSY = Definitive and would show noncaseating granulomas** CT: ground glass opacities, thick bronchovasculature, parenchymal nodules/cysts Will show a maculopapular rash, blurred vision , erythema nodosum, Lupus pernio raised discoloration that looks like frost bite ( specific to only this) Gallium scan - Panda sign (parotid/salivary gland uptake) - Lamda sign (mediastinal/hilar node uptake) 22\. What is the risk factor for developing COPD? SMOKING 23\. What are Exacerbating triggers for COPD? Viral URI, respiratory irritants, acute bacterial bronchitis 24\. What is the difference between Obstructive sleep apnea and obesity hypoventilation syndrome? +-----------------------------------+-----------------------------------+ | Obstructive Sleep Apnea | Obesity Hypoventilation Syndrome | +===================================+===================================+ | Obesity \>35 | Will Have SOB during the day | | | (hypoventilation) | | Constant drowsiness | | | | Obesity \>50 | | | | | | Increased waist circumference | +-----------------------------------+-----------------------------------+ 25\. Know these definitions Tidal volume (VT) Volume of 1 quiet breath (normal breath) Inspiratory Reserve Volume (IRV) Excess volume that can be inspired after a normal breath Expiratory Reserve Volume (ERV) Excess volume that can be expired after a normal breath Residual Volume (RV) Volume remaining in the lung after maximal expiration Total Lung Capacity (TLC) Total volume of gas in lung after a maximal inspiration IRV + VT + ERV + RV = TLC Vital Capacity (VC) Total volume of gas in a maximal expiration after max inspiration IRV + VT + ERV = VC Inspiratory Capacity (IC) Maximal inspiration from the end of a tidal expiration IRV + VT = IC Functional Residual Capacity (FRC) Volume of gas in lungs after a normal breath (tidal) ERV + RV = FRC 26\. Who qualifies for Lung cancer screening in COPD patients? 27: What are Exacerbating triggers for asthma? Cold, dry air, allergens, infections, exercise, emotion, GERD, NSAID use, 28\. Why don't we use corticosteroids all the time for asthma? Has bad side effects and the body can become dependent Adverse effects: weight gain, mood change, Cushing's, dysphonia, oral candidiasis 29\. MOA of beta agonist ( should know really well) Relax bronchial smooth muscle, decrease mast cell and histamine release, inhibit microvascular leakage in airways and increase mucus clearance by increasing ciliary activity 30\. Which patients would be difficult airways? Asthma patients Sleep Apnea 31\. Anatomy on pleura and right and left main stem bronchus Right lobe 3 Left lobe 2 Carina where the trachea bifurcates into right and left bronchi ( right bronchi more straight so things can get stuck there **Cilia** hair like projections that help propel foreign material upward to clear the airway and cilia through coughing along with **goblet** cells ( produce mucus) and structures that produce mucus Pleura serous membrane that attaches to the lungs and fold over and attaches to the chest wall Visceral pleura membrane that covers the lungs Parietal pleura lines the thoracic cavity Pleural space space between the pleural cavities that contain fluid to prevent friction of the structures For pulmonary circulation gas exchange occurs at **alveolocapillary membrane** 32\. What is the cause of patients who have emphysema but are not smokers, how do you test for it? An alpha 1 antitrypsin deficiency, Genetic testing 33\. What are risk factors for sleep apnea? Obesity, men ,Large neck circumference, Narrowed airway, High Mallampati score, HTN, Nasal congestion, DM, Smoking, Family Hx **STOP BANG score** Snore, tired, observed you stop breathing, high blood pressure BMI , Age, Neck circumference, Age 34\. What are the lab values you see on a patient with obesity hypoventilation? Increased bicarb and increased CO2 trying to compensate and normalize pH the bicarb is the compensatory 35\. Definitive treatment for fibrotic lung disease ? Transplant 36\. What are the causes of obesity hypoventilation / aka Pickwickian syndrome BMI over 50, Obstructive sleep apnea , reduced muscle strength, COPD, hypothyroidism are RF causing difficulty breathing during the day leading to low o2 and high CO2 little air movement because of dysregulation of the breathing center from the brain at the medulla oblongata excess lipids affect breathing and put extra weight on the chest making breathing more difficult 37\. How to dx idiopathic pulmonary fibrosis and definitive treatment? Definitive tx lung transplant Sx, diffuse fine crackles and nail clubbing, CXR shows diffuse reticular opacities in lower lungs with honey combing, restrictive, exertional dyspnea 38\. What is the normal o2 therapy for a COPD chronic bronchitis patient? 88-92% 39\. What does each color of sputum mean? Normal clear White/ yellow viral/ allergic Yellow/ green bacteria (can be thick and foul smelling) Bloody/ red TB, cancer, trauma Black/ Dark brown fungal ( usually with patients who are immunocompromised) 40\. V/Q mismatch = a change in ventilation and perfusion in the lungs VQ ratio should be.8 Pathological low response to low Pao2 is vasoconstriction secondary to pulmonary HTN, RAE, Right sided HD, Asthma, chronic bronchitis, acute pulmonary edema Pathological high normal ventilation and no perfusion foreign body, PE, emphysema 41\. What are some risk factors for asthma? Affects boys before puberty and girls after puberty, childhood second hand smoke, Diet ( low vitamin C), obesity, allergen exposure, air pollution exposure, low socioeconomic status, prenatal factors ( lack of breastfeeding, low birth weight) 42\. How do you prevent asthma exaccerbations? Providing less ORAL steroids 43\. Sarcoidosis most commonly in African American women aged 20-40, maculopapular rash