Pulmonary

Question 1

Difference in lung compromise between smoking-induced COPD and alpha-1 antitrypsin deficiency-related COPD

Answer 1

• Smoking-induced centriacinar (centrilobular) emphysema➡upper lobes
• AAT deficiency panacinar emphysema➡greater destruction of lower lobes

*Chest x-ray AAT deficiency➡bilateral basilar lucency

Question 2

Clues to suspect Alpha-1 antitrypsin

Answer 2

1. COPD at a younger age (<45 years old)
2. COPD with minimal or no smoking history
3. Bibasilar predominant COPD
4. History of unexplained liver disease

Question 3

When do you use bronchoprovocation testing with methacholine?

Answer 3

Patients with typical asthma symptoms but normal spirometry

Question 4

Recommendations for lung cancer screening

Answer 4

• Annual screening→low-dose CT in adults age 55 - 80 who have a 30-pack-year smoking history and currently smoke or have quit within past 15 years
• Discontinue Screening→Once a person has not smoked for 15 years or develops a health problem limiting life expectancy or ability/willingness to have curative lung surgery

Question 5

Difference of the diffusion capacity of the lung for carbon monoxide between emphysema and chronic bronchitis, and why?

Answer 5

• Low in Emphysema→loss of alveolar capillaries

- Normal in Chronic Bronchitis

Question 6

Difference between the pleural exudate of tuberculous effusion and malignancy etiology

Answer 6

• Tuberculous→usually lymphocytosis>70%

- Malignancy→lymphocytosis is uncommon

Question 7

Most common causes of secondary digital clubbing

Answer 7

• Lung malignancies (intrathoracic neoplasms)
• Intrathoracic suppurative diseases (cystic fibrosis, bronchiectasis)
• Right to left cardiac shunts (cyanotic congenital heart disease)

*COPD with or without hypoxemia does not cause digital clubbing

Question 8

Best initial test in acute exacerbation of asthma

Answer 8

• Peak expiratory flow (PEF)→approximation of the FVC

- Arterial blood gas (ABG)→↑ A-a gradient

Question 9

Most accurate test for asthma in an asymptomatic patient

Answer 9

> 20% decrease in FEV1 with use of methacholine or histamine

*Less likely to find an ↑ in FEV1 using a SABA (albuterol)→false negative

Question 10

Findings in the pulmonary function testing in asthma

Answer 10

• ↓ FEV1, FVC and FEV1/FVC
• ↑>12% and 200 mL in FEV1 with albuterol
• ↓>20% in FEV1 with methacholine or histamine
• ↑ Diffusion capacity of the lung for Carbon monoxide (DLCO)

Question 11

When do you use anticholinergics in chronic asthma management?

Answer 11

If SABA, LABA and inhaled corticosteroids at maximum doses are not sufficient

*Iptratropium, Tiotropium

Question 12

Typical presentation in acute asthma exacerbation in arterial blood gas. Which finding suggests the patient is getting worse?

Answer 12

• Hyperventilation→Respiratory alkalosis
• ↑ work of breathing→respiratory muscle fatigue→inability to maintain adequate ventilation (hyper)►normal pH and PaCO2 (normalized or elevated from respiratory alkalosis)►impending respiratory collapse

Question 13

Which are the 3 most common causes of chronic cough? What is chronic cough?

Answer 13

• Chronic cough→lasting >8 weeks
• Upper airway cough syndrome (postnasal drip)
• Asthma
• Gastroesophageal reflux disease (GERD)

Question 14

What is a solitary pulmonary nodule? What is the first step when evaluating it?

Answer 14

• Rounded opacity, <3cm, completely surrounded by pulmonary parenchyma, No associated with lymph node enlargement
• Determine if nodule is low, intermediate or high malignancy risk

Question 15

Which is the management of high, intermediate and low malignancy risk solitary pulmonary nodule?

Answer 15

• High risk→surgical excision
• Intermediate risk→FDG-PET, serial CT scans or Bx depending radiographic findings
• Low risk→serial CT scans

Question 16

First line inpatient non-ICU treatment for community-acquired pneumonia

Answer 16

• Fluoroquinolone: Respiratory→moxifloxacin, levofloxacin

- Beta-lactam + macrolide

Question 17

Best initial and most accurate diagnostic test for COPD?

Answer 17

• Best initial: chest x-ray

- Most accurate: Pulmonary Function Test

Question 18

Which sodium disturbance you may find secondary to a pulmonary pathology and why?

Answer 18

Hypotonic Euvolemic Hyponatremia

• Pulmonary pathology (Pneumocystis pneumonia, Ex)→ SIADH
• Infusion of normal saline - worsen hyponatremia

Question 19

Kartagener syndrome screening test

Answer 19

Decreased nasal nitric oxide

Question 20

COPD patient with acute-on-chronic respiratory acidosis

Answer 20

Hypoventilation→CO2 narcosis

Question 21

Pulmonary variable reflected when doing inspiratory hold maneuver?

Answer 21

Pulmonary compliance

Inspiratory hold maneuver➡measure plateau pressure=elastic pressure + PEEP

*Elastic recoil is inverse related to lung compliance; Elastic pressure=TV/compliance. ⬇Compliance (pulmonary fibrosis)➡stiffer lungs, ⬆elastic pressure

Question 22

Radiologic feature of invasive aspergillosis in the lungs

Answer 22

Chest CT scan: Pulmonary nodules with surrounding ground-glass opacities (“halo sign”)

Question 23

Pulmonary function test results in a patient with amyotrophic lateral sclerosis (ALS)

Answer 23

• Restrictive pattern (normal or ⬆FEV1/FVC, ⬇VC)➡extrinsic limitation of lung expansion
• Diaphragmatic involvement (weakness)➡⬇FVC, ⬇Maximal inspiratory pressure (reflect diaphragmatic strength), DLCO normal (pulmonar parenchyma and alveoli unaffected)

Question 24

Best predictors of postoperative outcomes following lung resection surgery

Answer 24

FEV1 and DLCO

Question 25

First step in evaluating solitary pulmonary nodule (SPN)

Answer 25

Comparison with previous x-ray➡stable lesion in 2-3 years▶malignancy ruled out, no further testing

Question 26

Chest radiograph findings of pulmonary embolism

Answer 26

- Atelectasis (most common) - Infiltrates - Pleural effusions - Westermark's sign➡peripheral hyperlucency due oligemia - Hampton's hump➡peripheral wedge of lung opacity due pulmonary infarction - Fleischner sign➡enlarged pulmonary artery

Question 27

Most likely diagnosis in a nonsmoker young patient with liver disease + emphysema (COPD). Treatment.

Answer 27

- Alpha 1-antitrypsin deficiency | - Replace enzyme

Question 28

Major manifestation of chronic lung transplant rejection

Answer 28

Bronchiolitis obliterans - 50% of recipients after 5 years posttransplant - Obstructive pattern on PFT

Question 29

Most common type of lung cancer in never smokers *Clinical associations

Answer 29

Adenocarcinoma *Lung periphery, clubbing, hypertrophic osteoarthropathy

Question 30

Conditions associated with bronchiectasis

Answer 30

Chronic bronchial obstruction, tobacco use, cystic fibrosis, primary immunodeficiency disorders, Kartagener syndrome, allergic bronchopulmonary aspergillosis

Question 31

Most common lung malignancy in young nonsmokers

Answer 31

Bronchial carcinoid tumor

Question 32

Treatment options that improve mortality and delay the progression of COPD

Answer 32

- Smoking cessation - Oxygen therapy➡benefit directly proportional to the number of hours used - Influenza and pneumococcal vaccine

Question 33

Criteria for oxygen use in COPD

Answer 33

- pO2<55, SatO2≤88% | - If pulmonary hypertension, ⬆hematocrit, right-sided heart disease/failure▶pO2<60, SatO2≤90%

Question 34

Treatment for allergic bronchopulmonary aspergillosis (ABPA)

Answer 34

- Oral steroids | - Oral itraconazole for recurrent episodes

Question 35

Single most common cause of bronchiectasis

Answer 35

Cystic fibrosis *Half of the cases

Question 36

Treatment for specific mutation on cystic fibrosis

Answer 36

- Ivacaftor + lumacaftor➡⬆activity of CFTR in the 5% of patients who have a specific mutation - Tezacaftor is an alternative.

Question 37

Results in the pulmonary function test in a restrictive lung disease

Answer 37

- ⬇of everything proportionately: FEV1, FVC, TLC, and residual volume▶FEV1/FVC ratio will be normal - ⬇DLCO in proportion to the severity of the thickening of the alveolar septum

Question 38

When you may use steroids for interstitial lung disease?

Answer 38

- If the biopsy shows white blood cell or inflammatory infiltrate - Berylliosis is the most likely to respond to treatment with steroids

Question 39

Which treatment could help to decrease the rate of progression of idiopathic pulmonary fibrosis?

Answer 39

- Pirfenidone: antifibrotic➡❌collagen synthesis | - Nintedanib: tyrosine kinase inhibitor➡❌fibrogenic growth factors➡❌fibroblasts

Question 40

Best initial test and finding in sarcoidosis

Answer 40

Chest x-ray: Hilar adenopathy

Question 41

Most accurate test and findings in sarcoidosis

Answer 41

Lymph node biopsy: Noncaseating granulomas

Question 42

Most accurate test for pulmonary hypertension

Answer 42

Right heart or Swanz-Ganz catheter

Question 43

Treatment options for idiopathic pulmonary hypertension

Answer 43

- Prostacyclin analogs (PA vasodilators): epoprostenol, treprostinil, iloprost, beraprost, or selexipag - Endothelin antagonists: bosentan, ambrisentan, macitentan - Phosphodiesterase inhibitors: sildenafil, tadalafil - cGMP stimulators: riociguat - Calcium channel blockers

Question 44

Gastrointestinal manifestation of Sarcoidosis

Answer 44

- Patchy infiltration by noncaseating granulomas in liver (65%)➡mixed cholestatic and hepatocellular changes▶asymptomatic ⬆AST, ALT, AP; Hepatomegaly - Reticuloendothelial granulomatous infiltration▶splenomegaly