Pulmonary 2
Terms
undefined, object
copy deck
- What is first line therapy in an acute asthma exacerbation?
- beta agonists, usually in the form of albuterol.
- In treating uncomplicated community acquired pneumonia in a 3 week old baby, what bugs should you cover, and what drugs should you use?
- Listeria, E coli, group b strep, and consider herpes. Treat with ampicillin and gentamicin, plus/minus acyclovir.
- If you need to intubate an asthamtic, what is a good choice of agent for induction?
- Ketamine. It is a potent bronchodilator.
- What is the appropriate antibiotic choice for uncomplicated community acquired pneumonia in a 45 year old man that you plan to send home?
- Zithromax
- If you are sending home a 3 year old with community acquired pneumonia, what antibiotic should you choose?
- A beta lactam. The incidence of atypicals is rare in this population, so a macrolide is not appropriate.
- In a patient with suspected PCP, when do you add steroids to bactrim therapy?
- If the patient's sat is less than 90 or the PaO2 is less than 60.
- What EKG findings should make you consider underlying pulmonary disease?
- RVH, RBBB, or, most specifically, wandering atrial pacemaker or multifocal atrial tachycardia.
- Which bacteria accounts for the most total mortality in pneumonia patients?
- strep pneumo
- a patient with pneumonia is a 55 year old smoker. He has altered mental status, hyponatremia, and elevated LFTs. What bug should you consider high on your differential?
- Legionella, treated with macrolides or with macrolide plus rifampin.
- A teenager has pneumonia. He has blisters or bubbles visible on his TMs when you do otoscopy. What is the likely diagnosis?
- Mycoplasma, treated with macrolides.
- An elderly patient has pneumonia. She recently had a lab-proven diagnosis of influenza A. She is hypotensive and toxic. What bug should you cover for?
- Staph aureus.
-
This is an adult who has a fever, but otherwise normal vitals. How should you treat him? - The patient has a RML pneumonia. You can treat him with zithromax or a quinolone
- Does the incidence of pneumonia increase or decrease with age?
- decrease
- what is the most common viral cause of pneumonia in the fall?
- parainfluenza
- what is the most common viral cause of pneumonia in the winter?
- RSV
- what is the most common viral cause of pneumonia in the spring?
- influenza
- Which age group is characterized by bacteria as the leading cause of pneumonia?
- Newborns because of aspiration of maternal genital organisms during labor and delivery
- What is the recommended inpatient treatment for newborns with pneumonia?
- Ampicillin plus cefotaxime or gentamicin
- What is the recommended inpatient treatment for infants 1-24 months with pneumonia?
- Cefuroxime
- What is the most common bacterial cause of pneumonia in children 5-18 years of age? Treatment?
-
Mycoplasma
treat with macrolide - The best physical exam finding for ruling out pneumonia in an infant or child is:
- Absence of tachypnea
- What is the typical prodrome of pertussis?
- 1-2 weeks of coryza, conjunctivitis, and cough
- Is there a male or female predominance in pediatric asthma?
- Male in prepuberty then ratio equalizes during adolescence
- What are the pediatric anatomic differences that put them at a higher risk for respiratory failure?
-
Increased rib cage compliance, immature diaphragm ÿ paradoxical
respiration, increased work of breathing, respiratory muscle fatigue
* Young lung tissue lacks elastic recoil, more prone to atelectasis - What are the typical CXR findings in children with asthma?
-
* hyperinflation
* flattened diaphragm
* increased AP diameter
* peribronchial cuffing
* atelectasis -
When should steroids not be administered in the setting of an acute
asthma exacerbation? -
* PEF > 50%
* immediate response to first nebulizer treatment
* exercise-induced attacks in well child - Is nocturnal asthma associated with a better or worse prognosis?
- Worse
- What is the typical triad of bronchiolitis?
-
* wheezing
* tachypnea
* chest retractions - What is the age group affected by bronchiolitis?
- Less than 2 years old
- What is the peak prevalence of bronchiolitis?
- Late October to May
- What is the most common cause of bronchiolitis?
- RSV (50-70% of cases)
- What is the most notable clinical finding in bronchiolitis?
- Tachypnea (RR > 50-60)
- What is the name of the monthly monoclonal antibody IM injections given as passive immunization against RSV in high-risk children?
- Synergis
- What condition is most likely to be a precipitating factor for pneumothorax?
- Cigarette smoking (>20:1 RR compared to non-smoker)
- Which disease is most commonly associated with pseudocyanosis?
- Hemochromatosis
- Which part of the body most reliably confirms the presence of cyanosis?
- Tongue
- What are the Wells criteria? What are they used to assess?
-
Assess the pretest probability for PE
Wells criteria:
Suspected DVT = 3 points
An alternative dx is less likely than PE = 3 points
HR > 100 bpm = 1.5 points
Immobilization or surgery = 1.5 points
Previous H/O DVT and/or PE = 1.5 points
Hemoptysis = 1 point
Malignancy (on Tx, treated in past 6 months, or palliative) = 1 point
High-risk pts (score>6, 7% of total pts) had a mean probability of 66.7% for PE - Where do large cell lung cancers tend to present?
- In the periphery of the lung
- When are the risks of radiation exposure on the neurologic development of an embryo/fetus the highest?
- 8 to 15 weeks postconception
-
What does this CXR show? -
Emphysema
*hyperinflated lungs
*decreased vascular markings
*increased parenchymal lucency
*small cardiac silhouette
*flattened diaphragm - When are fiberoptic bronchoscopes least helpful?
-
Bleeding in the airway
Excessive oral secretions -
What is abnormal about this CXR of a 3-year old boy? -
Air trapping on right (where a FB has been aspirated)
On exhalation, the FB obstructs outflow, leaving affected side relatively expanded when compared to the unaffected side -
What is abnormal about this CXR? -
Nothing. The linear lucency at the right costophrenic angle is air trapped in between folds of adipose tissue in a
rather corpulent young lady. - How is the clinical presentation of pneumonia different in elderly patients?
-
*Classic signs and symptoms of PNA are often absent in elderly or debilitated patients
*Elderly patients are often sicker and are in advanced stage of illness on initial presentation - Is pneumococcal bacteremia more common in young or elderly patients?
- Pneumococcal bacteremia is 3x more common in elderly patients than in younger patients
- Aspiration pneumonia caused by anaerobes is most common in which patient population?
- Alcoholics
- How well do expectorated sputum cultures identify the causative organism in pneumonia?
- Sputum cultures have low clinical utility due to higher rates of contamination from oropharyngeal colonization
- Which lung lobes are most commonly affected in aspiration pneumonia?
- The posterior segments of the upper lobes and superior segments of the lower lobes are the MC sites if recumbent, basal lower lobes (often RLL) if upright
- Aspergillus fumigatus is commonly found in the sputum of which patient population?
- Cystic fibrosis patients
- The incidence of cystic fibrosis is highest within which ethnic group?
- Highest incidence within white North Americans (1 in 3,000 live births)
- Which organism is most commonly recovered from lung secretions in newly diagnosed CF patients?
- Staph aureus and H.influenzae = MC in newly dx Pseudomonas = MC later on
- What role does lung transplantation play in the treatment of cystic fibrosis?
- It is the only potential treatment
- How are viral and bacterial pneumonias differentiated in children?
- Viral and bacterial pneumonias can seldom be differentiated in children because of overlap in clinical, radiographic, and lab findings
- Is oral dexamethasone recommended in the treatment of mild croup in a previously healthy toddler?
- Yes, it leads to quicker resolution of symptoms when compared with observation
- Is cool mist recommended in the treatment of mild croup in a previously healthy toddler?
- Although historically considered an important component of croup treatment, cool mist is probably clinically ineffective
- What is the most common CXR finding in tuberculosis?
- Lobar pna with hilar adenopathy
- In the United States, the foreign-born patients with TB are most often from _____
- Mexico, India, Vietnam, and the Philippines
- In which patient population is miliary TB most commonly seen?
- Miliary TB is seen in extremes of age and in immunocompromised patients
- Why are Ghon complexes not commonly seen in transplant patients with TB?
- Transplant pts have decreased cell immunity and therefore are less likely to be able to create Ghon complexes
- What are the common physical exam findings in patients with TB?
- There are no reliable physical exam findings in TB
- Which organism is the most common cause of pneumonia in a patient with HIV infection and a CD4+ count of 850 cells/microliter?
-
Streptococcus pneumoniae
*The risk of acquiring opportunistic infections is more likely with lower CD4+ counts
*A CD4+ count < 200 increases the risk of infection with Pneumocystis jiroveci (formerly Pneumocystis carinii) -
TRUE OR FALSE
A cancerous etiology is more likely if the abscess develops in the posterior portion of the lung -
FALSE
A cancerous etiology is more likely if the abscess develops in the anterior portion of the lung -
TRUE OR FALSE
Anaerobic bacteria are more commonly found in immunocompromised patients than in immunocompetent patients -
FALSE
Aerobic bacteria are more commonly found in immunocompromised patients -
TRUE OR FALSE
In most cases, a lung abscess cavity communicates with a bronchiole - TRUE
-
TRUE OR FALSE
Infectious lung abscesses commonly occur in the superior segments of the lower lobes -
FALSE
Infectious lung abscesses commonly occur in the basal segments of the lower lobes -
TRUE OR FALSE
Surgical intervention is commonly necessary for lung abscesses -
FALSE
Surgical intervention is rarely required - What are the early radiographic findings of asbestosis?
- Bilateral, irregular or linear opacities along the periphery of the lungs and in the lower lobes
- What percentage of mesotheliomas metastasize?
- About 50% of mesotheliomas metastasize, however these tumors are locally very invasive and death often occurs from local extension
-
TRUE OR FALSE
Corticosteroids should be administered after completion of bronchodilator therapy in acute severe asthma -
FALSE
Corticosteroids should be used early in treatment -
TRUE OR FALSE
IV beta-agonists are more effective than nebulized beta-agonists in acute severe asthma -
FALSE
IV beta-agonists may produce worse outcomes compared to their nebulized counterparts -
TRUE OR FALSE
Magnesium administration results in an improvement of approximately 10% of predicted FEV1 in the treatment of acute severe asthma - TRUE
-
TRUE OR FALSE
Response to corticosteroids is age related in the treatment of acute severe asthma -
FALSE
There is no age-related response to steroids - A 22-yr old college basketball player presents with sudden-onset SOB. CXR reveals a 10% PTX. The patient has not had a prior episode of PTX. He is in no acute distress and his vital signs are normal. Without any intervention, approximately how long will
-
1 week
The intrinsic absorption rate of intrapleural air is 1-2% of total lung volume per day -
Which of the following drugs is FDA approved for the treatment of intractable hiccups?
a.) Baclofen
b.) Chlorpromazine
c.) Metoclopramide
d.) Nifedipine
e.) Valproic acid -
Chlorpromazine
*Chlorpromazine and Reglan often abolish hiccups within 30 minutes
*Nifedipine, valproic acid, and baclofen exert their effect more gradually -
TRUE OR FALSE
In an asthmatic patient who requires intubation, inspiratory-to-expiratory ratio should be kept at 1:2 - FALSE
-
TRUE OR FALSE
In an asthmatic patient who requires intubation, ketamine is the preferred paralytic agent -
FALSE
*Ketamine is the preferred induction agent bc of its bronchodilating properties
*Neuromuscular blocking agents (succinylcholine, rocuronium) should be used for paralysis -
TRUE OR FALSE
In an asthmatic patient who requires intubation, nasotracheal intubation is preferred over orotracheal -
FALSE
Nasotracheal intubation requires a smaller tube, which creates greater airway resistance -
TRUE OR FALSE
In an asthmatic patient who requires intubation, propofol can be used as a sedating agent - TRUE
-
TRUE OR FALSE
In an asthmatic patient who requires intubation, tidal volume should be kept at 10 cc/kg ideal body weight -
FALSE
Tidal volume should be kept at 6-8 cc/kg ideal body weight (prolongs expiration phase and reduces air trapping) -
TRUE OR FALSE
Regarding arterial blood gas measurements, air bubbles within the syringe lower the pH -
FALSE
Air bubbles elevate the pH and PO2 readings -
TRUE OR FALSE
Regarding arterial blood gas measurements, co-oximetry allows identification of sulfhemoglobin -
FALSE
Co-oximetry cannot differentiate between methemoglobin and sulfhemoglobin, for this reason cyanide is added to the blood sample (cyanide binds only to methemoglobin) -
TRUE OR FALSE
Regarding arterial blood gas measurements, excess heparin within the syringe affects only pH and PCO2 -
FALSE
Excess heparin affects pH, PO2, PCO2, and Hb -
TRUE OR FALSE
Regarding arterial blood gas measurements, the blood gas analyzer warms the blood to 98.6F prior to analysis - TRUE
-
TRUE OR FALSE
Regarding arterial blood gas measurements, the conventional blood gas analyzer directly measures oxygen saturation - FALSE
- What is a common early lab finding in fat embolism?
- Thrombocytopenia
- What is Hamman crunch? In which patient position is it best heard?
-
*Adventitious, crackling sound on auscultation in patient with pneumomediastinum
*Left lateral recumbent position - ARDS might be associated with the use of which antiarrhythmic drug?
- Amiodarone