MKSAP- Pulmonary critical care Exam
questions and answers
A-a gradient
PAO2 - PaO2
PaO2 -> ABG
PAO2 = FiO2 (0.21% on RA) {Patm - Ph20 (760 - 47)} - {PaCO2 / R (ABG/0.8)}
PFTs
Solitary pulmonary nodule
Review previous imaging.
IS < 3 cm and NOT associated w/ LN/atelectasis/pleural effusion
Recommend NON con CT scan
Screening: Fleischner criteria:
> 8 mm + low probability -> Ct scan (3-6, 9-12 and 18-24m)
> 8mm + intermediate probability -> PET scan
> 8mm + high probability -> Excise
If imaging stable > 24 month. No more imaging
Solitary pulmonary nodule follow up
Malignant vs benign features on CT scan
Malignant vs benign
Larger vs smaller
Irregular + Spiculated vs smooth and discrete borders
Less dense (<164 Hounsfield units on CT) vs more dense
Reticular, punctate, amorphous or eccentric pattern vs popcorn (central), laminated and diffuse
Hemoptysis
massive is > 100 ml (1/2 cup -> 120 ml)
Sarcoidosis
,Granulomatous disease primarily involving the lungs
CF: Asymptomatic
Wheezing
Dx: Confirm by bronchoscopic biopsy -> Non caseating granulomas
Lofgren's syndrome
Fevers, EN, acute oligoarthritis + BL hilar LN
Classic clinical presentation of Sarcoid
No immediate need for biopsy
Typically associated with a good prognosis and spontaneous remission
Heerfordt syndrome
uveitis, parotid gland enlargement and fevers
Classic presentation of sarcoid
Lymphangetic carcinomatosis
Interstitial abnormality and hx of malignancy
(adenocarcinoma - breast, GI, melanoma, lymphoma, leukemia)
Acute hypersensitivity pneumonitis
presents within 48 hours after high level exposure to antigen
fever, flu like symptoms, shortness of breath and cough
ground glass on CT and micro nodules in upper/mid upper lobes
Resolves in 24-48 hours.
Recurrence w/ re-exposure
Radiation pneumonitis
Cough/dyspnea 6 weeks after exposure
Usually resolve in 6 months but can progress to fibrosis, volume loss and bronchiectasis
CT - hazy opacities w/ ground glass opacification
Gemcitabine - associated w/ radiation pneumonitis and drug induced pneumonitis
Rx - prednisone for 2 weeks followed by a gradual taper
, Radiation fibrosis
Can occur in patients w or w/o radiation pneumonitis
Usually 6-24m after radiation
Fibrotic process is irreversible
Relapsing polychondritis
Rare immune mediated disease
Episodic inflammation of cartilaginous tissues (ears, nose, joints and upper/lower respiratory tract)
Can cause large airway disease w/ significant airway obsx.
Trouble shooting high pressures
Peak pressure - airway resistance + elastic recoil of lungs + PEEP
Plateau pressure - mid inspiratory pressure during no airflow. related to pressure in small airways OR
static compliance
IF > both peak and plateau pressure (Difference b/w them < 5) -> suggests lung parenchyma/pleura
/diaphragm problem
IF difference b/w peak and plateau > 5 -> more airway obstruction
Viral induced bronchospasm
Usually resolves in 6-8 weeks
Consider asthma if symptoms do not resolve.
Aspirin exacerbated respiratory disease
Samter's triad:
Asthma
Nasal polyps
Aspirin allergy
Pathophysiology: Imbalance b/w pro-inflammatory and anti-inflammatory mediators
Rx: Avoid NSAIDs
Asthma in pregnancy
SABA Inhaled steroids (Budesonide) and leukotriene inhibitor (montelukast) are considered safe in
pregnancy
Curschmann spirals
questions and answers
A-a gradient
PAO2 - PaO2
PaO2 -> ABG
PAO2 = FiO2 (0.21% on RA) {Patm - Ph20 (760 - 47)} - {PaCO2 / R (ABG/0.8)}
PFTs
Solitary pulmonary nodule
Review previous imaging.
IS < 3 cm and NOT associated w/ LN/atelectasis/pleural effusion
Recommend NON con CT scan
Screening: Fleischner criteria:
> 8 mm + low probability -> Ct scan (3-6, 9-12 and 18-24m)
> 8mm + intermediate probability -> PET scan
> 8mm + high probability -> Excise
If imaging stable > 24 month. No more imaging
Solitary pulmonary nodule follow up
Malignant vs benign features on CT scan
Malignant vs benign
Larger vs smaller
Irregular + Spiculated vs smooth and discrete borders
Less dense (<164 Hounsfield units on CT) vs more dense
Reticular, punctate, amorphous or eccentric pattern vs popcorn (central), laminated and diffuse
Hemoptysis
massive is > 100 ml (1/2 cup -> 120 ml)
Sarcoidosis
,Granulomatous disease primarily involving the lungs
CF: Asymptomatic
Wheezing
Dx: Confirm by bronchoscopic biopsy -> Non caseating granulomas
Lofgren's syndrome
Fevers, EN, acute oligoarthritis + BL hilar LN
Classic clinical presentation of Sarcoid
No immediate need for biopsy
Typically associated with a good prognosis and spontaneous remission
Heerfordt syndrome
uveitis, parotid gland enlargement and fevers
Classic presentation of sarcoid
Lymphangetic carcinomatosis
Interstitial abnormality and hx of malignancy
(adenocarcinoma - breast, GI, melanoma, lymphoma, leukemia)
Acute hypersensitivity pneumonitis
presents within 48 hours after high level exposure to antigen
fever, flu like symptoms, shortness of breath and cough
ground glass on CT and micro nodules in upper/mid upper lobes
Resolves in 24-48 hours.
Recurrence w/ re-exposure
Radiation pneumonitis
Cough/dyspnea 6 weeks after exposure
Usually resolve in 6 months but can progress to fibrosis, volume loss and bronchiectasis
CT - hazy opacities w/ ground glass opacification
Gemcitabine - associated w/ radiation pneumonitis and drug induced pneumonitis
Rx - prednisone for 2 weeks followed by a gradual taper
, Radiation fibrosis
Can occur in patients w or w/o radiation pneumonitis
Usually 6-24m after radiation
Fibrotic process is irreversible
Relapsing polychondritis
Rare immune mediated disease
Episodic inflammation of cartilaginous tissues (ears, nose, joints and upper/lower respiratory tract)
Can cause large airway disease w/ significant airway obsx.
Trouble shooting high pressures
Peak pressure - airway resistance + elastic recoil of lungs + PEEP
Plateau pressure - mid inspiratory pressure during no airflow. related to pressure in small airways OR
static compliance
IF > both peak and plateau pressure (Difference b/w them < 5) -> suggests lung parenchyma/pleura
/diaphragm problem
IF difference b/w peak and plateau > 5 -> more airway obstruction
Viral induced bronchospasm
Usually resolves in 6-8 weeks
Consider asthma if symptoms do not resolve.
Aspirin exacerbated respiratory disease
Samter's triad:
Asthma
Nasal polyps
Aspirin allergy
Pathophysiology: Imbalance b/w pro-inflammatory and anti-inflammatory mediators
Rx: Avoid NSAIDs
Asthma in pregnancy
SABA Inhaled steroids (Budesonide) and leukotriene inhibitor (montelukast) are considered safe in
pregnancy
Curschmann spirals
