Pulmonary Board Review

Ram Parekh

2/11/09

1. Which of the following statements regarding the epidemiology of COPD is correct?

a. 25% of North Americans older than 55 years have COPD

b. Almost all smokers develop clinically significant COPD

c. Cigarette smoking accounts for up to 50% of the risk of developing COPD

d. COPD is more common in men than in women

e. COPD is the most common cause of death in the US

Answer: D

More common in men than women

a. 25% of North Americans older than 55 years have COPD - 10%

b. Almost all smokers develop clinically significant COPD - 15%

c. Cigarette smoking accounts for up to 50% of the risk of developing COPD - 90%

d. COPD is more common in men than in women

e. COPD is the most common cause of death in the US -4th most common

COPD

• Air flow obstruction resulting from chronic bronchitis or emphysema

• Occurs in 10% of people over 55

• More common in men • 4th most common cause

of death• 15% smokers develop

COPD

2. During midsummer, a 47 year-old construction worker presents complaining of fever, dry cough, headache,

weakness, abdominal cramps, and watery diarrhea. He reports several coworkers with “bad chest colds”. Vitals are

BP 120/70, pulse 104, resp rate 24, temp 104. Patient appears toxic. Chest exam reveals fine scattered rales.

CXR exhibits alveolar infiltrate in the right lower lung field. Which of the following statements regarding this patient’s

illness is correct?

A. direct, person-to-person contact is the mode of

transmission

B. GI symptoms help to narrow the differential

C. IV penicillin is the treatment of choice

D. pulse-temperature dissociation is uncommon in this disease

E. the likely causative organism rarely causes chest pain with this illness

Answer: B

GI symptoms help narrow the differential

A. direct, person-to-person contact is the mode of transmission -no person to person transmission

B. GI symptoms help to narrow the differential

C. IV penicillin is the treatment of choice-macrolides

D. pulse-temperature dissociation is uncommon in this disease

-typically appear toxic (tachy/high fevers)E. the likely causative organism rarely causes chest pain with this illness

–pleuritic chest pain 30%

Legionnaire’s Disease

• Organism, Legionella Pneumophila, is ubiquitous, intracellular, that lives in aquatic environments

• Natural, manmade water systems, mud, heat exchange units, cooling towers, vents, whirlpools, shower stalls

• Construction/excavation sites • No person-to-person

transmission• 19% of CAPs, no seasonality

Legionnaire’s Disease

• Range of illnesses, from benign to multisystem organ failure

• Smokers, elderly, transplant pts, immunosuppressed at risk

• Dry cough, pleuritic chest pain (30%)

• GI – diarrhea, cramping• CXR – unilateral alveolar

infiltrate, hilar adenopathy, pleural effusions

• Tx: Macrolides

Variable patterns of Legionnaire’s Disease

3. A previously healthy 20 year old college student presents with fever, headache, sore throat, earache, and a

dry cough. She reports prior “flu-like” illness for 1 week. Vitals are BP 110/70, pulse 90, resp rate 20, temp 100.4F. Does not appear toxic, but there is a maculopapular rash

on her trunk and pharynx is erythematous. Neck is supple, with few anterior palpable cervical lymph nodes. Chest auscultation reveals scattered rales and rhonchi. CXR

shows bilateral interstitial infiltrate. Which of the following statements regarding etiology is correct?

A. Bullous myringitis occurs frequently

B. fever, headache, and malaise are uncommon

C. Frequently associated with GI symptoms

D. One of the most common CAPs

E. Seen most commonly during winter

Answer: D

One of the most common CAPs

A. Bullous myringitis occurs frequently-sore throat and ear pain common, but not bullous

myringitis

B. fever, headache, and malaise are uncommon-these are the typical prodrome sx’s

C. Frequently associated with GI symptoms-unlike legionella, not a/w GI sx’s

D. One of the most common CAPs

E. Seen most commonly during winter-occurs year round

4. Which of the following statements regarding spontaneous pneumothorax is correct?

A. Chest pain is rarely present

B. may cause ischemic ECG changes

C. More common in females

D. Smoking is not a risk factor

E. Symptoms are not related to the size of the pneumothorax

Answer: B

may cause ischemic ECG changes

A. Chest pain is rarely present-pleuritic chest pain 95%

B. may cause ischemic ECG changes

C. More common in females-males

D. Smoking is not a risk factor-smoking is big risk factor 20:1

E. Symptoms are not related to the size of the pneumothorax

-sx’s related to size and rate of development

Spontaneous Pneumothorax

• Occurs when air enters potential space between visceral and parietal pleura

• Occurs more often in men (6:1 relative risk)

• Smoking a significant risk factor (20:1)

• Sx’s related to size and rate of development

• Acute pleuritic chest pain (95%)• Dyspnea (80%)• Can mimic cardiac ischemia –

ST-T changes

5. A teenaged mother brings in her 7-week old daughter or eval of a cough. The baby had had mild

conjunctivitis 3 weeks earlier. Exam reveals an alert, active infant with a frequent staccato cough, normal temp, resp rate 70, mild retractions, and diffuse inspiratory rales. RA pulse ox reveals O2 sat 89%. CXR shows hyperinflation

and bilateral, diffuse interstitial infiltrates. What is the most likely diagnosis?

A. Chlamydia trachomatis pneumonia

B. Congestive heart failure

C. Laryngotracheobronchitis

D. RSV

E. Strep Pneumo pneumonia

Answer: A

Chlamydia trachomatis pneumonia

A. Chlamydia trachomatis pneumonia

B. Congestive heart failure-diaphoresis during feedings and tachypnea without

retractions

C. Laryngotracheobronchitis-”croup” – typically 2-3d low grade fever, rhinorrhea,

some cough; uncommon in first few months of life

D. RSV-absence of wheezing; conjunctivitis not common

E. Strep Pneumo pneumonia-typically sudden onset fever, cough, elevated WBC

Chlamydia Trachomatis pneumonia

• Chlamydia trachomatis pneumonia can develop when a newborn acquires the organism as it passes through the genital tract of infected mother

• Though contracted at birth, clinical PNA does not develop until 3rd to 19th week of life

• 50% cases preceded by conjunctivitis

• Presentation is afebrile, alert, baby with tachypnea and staccato cough

• Retractions and fine rales on exam; minimal wheezing

• Typically mild hypoxia and normal WBC

• CXR: bilateral diffuse interstitial infiltrates

• “afebrile pneumonia in infancy”

6. Which of the following statements regarding pneumococcal pneumonia is correct?

a. Elderly patients experience a very rapid progression of the disease

b. May be associated with hypernatremia

c. Predominantly affects the elderly population

d. Presents with a bilateral interstitial infiltrate

e. Prevalent at both extremes of age

Answer: E

prevalent at both extremes of age

A. Elderly patients experience a very rapid progression of the disease

-Pts with chronic disease and elderly: slower progression and milder symptoms; Malaise, dehydration, milder cough/sputum

B. May be associated with hypernatremia-hyponatremia

C. Predominantly affects the elderly population-all age groups

D. Presents with a bilateral interstitial infiltrate-lobar infiltrate

E. Prevalent at both extremes of age

Pneumococcal Pneumonia• Occurs in all age groups, but

particularly prevalent at extremes of age

• Classic presentation: sudden onset high fevers, rigors, chest pain, +/- bloody sputum (typical for young adults)

• Lobar infiltrate

• Pts with chronic disease and elderly: slower progression and milder symptoms– Malaise, dehydration, milder

cough/sputum

Pneumococcal Pneumonia

• Leukocytosis common• LFT abnormalities sometimes present• Occasionally associated with hyponatremia

7. Which of the following statements regarding acute bronchitis is correct?

A. Antibiotics do not hasten recovery

B. Chest radiograph is required to make the diagnosis

C. Colored sputum indicates a bacterial etiology

D. Fever and wheezing are the characteristic findings

E. Most cases are caused by Mycoplasma Pneumonia

Answer: A

antibiotics do not hasten recovery

A. Antibiotics do not hasten recovery

B. Chest radiograph is required to make the diagnosis

-hx acute cough, normal O2 sat, no prior hx lung disease, and no ausculatory abnormalities

C. Colored sputum indicates a bacterial etiology-not necessarily; though typically non-productive

cough

D. Fever and wheezing are the characteristic findings

-same answer as B

E. Most cases are caused by Mycoplasma Pneumonia

-typically viruses

Acute Bronchitis

• Infection of the conducting airways

• Produces inflammation, exudate, and sometimes bronchospasm

• Most caused by viruses, though bacteria such as Bordatella pertussis, Mycoplasma Pneumoniae, Chlamydia pneumoniae and possibly Strep pneumo

• Typically non-productive cough, though colored sputum not indicate bacterial etiology

Acute Bronchitis

• Abx not proven to hasten recovery, even if bacterial involvement

• Dx made by hx acute cough, normal O2 sat, no prior hx lung disease, and no ausculatory abnormalities

• CXR not required for dx

8. Which of the following statements regarding aspiration pneumonia is correct?

A. Aspirates with pH near 6 are associated with much higher mortality

B. Aspiration disrupts surfactant and causes an inflammatory response

C. Prophylactic antibiotics should be started within first 36 hours after onset of aspiration

D. Severity of symptoms is unrelated to volume of aspirate

E. Systemic corticosteroids are effective in reversing inflammatory response to aspiration pneumonia

Answer: B

Aspiration disrupts surfactant and causes an inflammatory response

A. Aspirates with pH near 6 are associated with much higher mortality

-pH<2 associated with much higher mortality B. Aspiration disrupts surfactant and causes an inflammatory response

C. Prophylactic antibiotics should be started within first 36 hours after onset of aspiration

-Abx should be started upon start of symptoms

D. Severity of symptoms is unrelated to volume of aspirate -Severity related to volume, amt of bacterial contamination, pH of aspirate

E. Systemic corticosteroids are effective in reversing inflammatory response to aspiration pneumonia -Corticosteroids not indicated

Aspiration pneumonia• Inflammatory process caused by

inhalation of material such as oral secretions, food, FBs, gastric contents

• Inflammatory response is responsible for sx’s of fever and productive cough and CXR findings

• These findings may not be present in immunosuppressed

• Risk factors include AMS, etoh/drug intox, depressed glottic reflexes, seizure activity, tube feedings, anesthesia, advanced age, esoph abnormalities, supine position

• Disrupts surfactant and leads to inflammatory response leading to hypoxia and respiratory failure

Aspiration pneumonia• Severity related to volume, amt of

bacterial contamination, pH of aspirate (pH<2 associated with much higher mortality)

• Acidic gastric contents particularly harmful to lung fever, leukocytosis, purulent sputum, radiographic infiltrates mimicking bacterial PNA

• Can rapidly progress despite initial well appearance

• RLL most common when upright• Any lobe affected when supine,

though predom posterior segments

• Abx should be started upon start of symptoms

• Corticosteroids not indicated

9. Which of the following statements regarding the utility of a spiral CT angiogram of the chest of r the

diagnosis of PE is correct?

A. A completely negative spiral CT lung scan is equivalent to a normal V/Q lung scan

B. A high prob V/Q lung scan and a spiral CT angiogram of the chest have similar specificities for pulmonary embolism

C. A spiral CT lung scan will most likely be nondiagnostic in patients with a history of COPD

D. The sensitivity and specificity of spiral CT for PE in central vessels are similar to those in peripheral vessels

E. When used to diagnose PE, a spiral CT lung scan spares use of contrast material

Answer: B

A high prob V/Q lung scan and a spiral CT angiogram of the chest have similar specificities

for PE

A. A completely negative spiral CT lung scan is equivalent to a normal V/Q lung scan

-a normal V/Q is more sensitive than a negative CTA

B. A high prob V/Q lung scan and a spiral CT angiogram of the chest have similar specificities for pulmonary embolism

C. A spiral CT lung scan will most likely be nondiagnostic in patients with a history of COPD

-V/Q confounded by heavy smoking, chronic pulm disease, parenchymal infiltrate

D. The sensitivity and specificity of spiral CT for PE in central vessels are similar to those in peripheral vessels

-CT has higher sensitivity and specificity for PE in central vs peripheral vessels

E. When used to diagnose PE, a spiral CT lung scan spares use of contrast material - obviously false

CT vs V/Q

• Subsegmental vessels are difficult appreciate on CT• CT has higher sensitivity and specificity for PE in central

vs peripheral vessels• Subsegmental PE’s are common false negatives• CT has similar specificity for PE compared to high prob

V/Q (93% vs 98%)• Similar sensitivity to low prob V/Q (78% vs 82%)• V/Q confounded by heavy smoking, chronic pulm

disease, parenchymal infiltrate

10. Which of the following statements regarding pleural effusions is correct?

A. A common cause of atraumatic hemothorax is SLE

B. A pH of less than 7.3 strongly suggests pleural empyema or esophageal rupture

C. Effusions a/w PE are transudative

D. Management of complicated parapneumonic effusions includes tube thoracostomy

E. The most common cause in developing countries is CHF

Answer: D

Management of complicated parapneumonic effusions includes tube

thoracostomy

A. A common cause of atraumatic hemothorax is SLE -causes exudative effusions, not hemothorax

B. A pH of less than 7.3 strongly suggests pleural empyema or esophageal rupture <7.0

C. Effusions a/w PE are transudative-can be either transudative or exudative

D. Management of complicated parapneumonic effusions includes tube thoracostomy

E. The most common cause in developing countries is CHF -TB

Parapneumonic Effusion

• Pleural effusion a/w bacterial pneumonia, bronchiectasis or lung abscess

• Requires tube thoracostomy

• CHF is most common cause of pleural effusions

• TB most common cause in developing countries

• Inflammatory/neoplastic exudative

• Transudative – low protein, imbalance btwn hydrostatic and oncotic pressures CHF, nephrotic syndrome

Parapneumonic Effusion

• PE/Sarcoid – can be either

• SLE not commonly a/w hemothorax, typically exudative

• pH <7 empyema, esoph rupture

• pH <7.3 parapneumonic effusions, malignancies, rheumatoid effusions, TB

11. A 22 yo college basketball player presents with sudden onset shortness of breath. CXR reveals 10% pneumothorax. Pt has no hx

PTX, is not in acute distress, vitals and O2 sat are wnl. Without intervention, how long would it take for the PTX to resolve on its own?

A. 12 hours

B. 24 hours

C. 36 hours

D. 1 week

E. 3 weeks

Answer: D

One week

Pneumothorax• Observation alone is acceptable

for otherwise young healthy pt with <20% PTX

• Reabsorbtion rate 1-2%/day• 100% increases rate by 3-4x• 100% O2 decreases partial

pressure nitrogenincreases rate at which air diffuses across pleural-alveolar barrier

• F/u should be arranged within 24 hours

• Avoid air travel and underwater diving until resolution

• Pts with underlying lung disease should be managed with tube thoracostomy

12. Which of the following is part of the Wells criteria for the assessment of pretest probability for PE?

A. Heart rate > 90 beats/min

B. Immobilization or surgery in the previous 4 weeks

C. Nonproductive cough

D. PaO2 less than 60 mmHg

E. Pleuritic chest pain

Answer: B

Surgery/immobilization in past 4 weeks

A. Heart rate > 90 beats/min>100bpm

B. Immobilization or surgery in the previous 4 weeks

C. Nonproductive cough-clinical cue to w/u PE, not in Wells

D. PaO2 less than 60 mmHg-not in Wells

E. Pleuritic chest pain-clinical cue to w/u PE, not in Wells

Pulmonary Embolism

• Estimation of pretest probability required

• Wells Criteria:– Suspected DVT = 3 points– Alternative diagnosis less

likely than PE = 3 points– HR > 100bpm = 1.5 points– Immobilization/surgery in

past 4 weeks = 1.5 points– Previous DVT/PE = 1.5

points– Hemoptysis = 1 point– Malignancy = 1 point

13. Which of the following organisms is the most common cause of PNA in a patient with HIV and CD4+

count 850 cells/microliter?

A. Cryptococcus neoformans

B. Mycobacterium tuberculosis

C. Pneumocystis jiroveci

D. Pseudomonas Aeruginosa

E. Streptococcus pneumoniae

Answer: E

Strep Pneumo

A. Cryptococcus neoformans-CD4+ 250-500 TB, Crypto,

Histoplasma

B. Mycobacterium tuberculosis-see above

C. Pneumocystis jiroveci-CD4+ < 200 PCP

D. Pseudomonas Aeruginosa-common but not as common

E. Streptococcus pneumoniae

HIV+ and pneumonia

• Most common cause of bacterial pneumonia in HIV is Strep pneumo

• Incidence of Strep Pneumo PNA in HIV+ 7-10x greater than HIV-

• Incr likelihood of bacteremia

• CD4+ > 800 bacterial infections

• CD4+ 250-500 TB, Crypto, Histoplasma

• CD4+ < 200 PCP

14. In an asthmatic patient who requires intubation:

A. I:E ratio should be kept at 1:2

B. Ketamine is the preferred paralytic agent

C. Nasotracheal intubation is preferred over orotracheal

D. Propofol can be used as a sedating agent

E. Tidal volume should be kept at 10cc/kg

Answer: D

Propofol can be used as a sedating agent

A. I:E ratio should be kept at 1:2-1:4, 1:5 better

B. Ketamine is the preferred paralytic agent-induction agent

C. Nasotracheal intubation is preferred over orotracheal -nasotrach tube too small, increased airway resistance

D. Propofol can be used as a sedating agent

E. Tidal volume should be kept at 10cc/kg-6cc/kg is starting TV

Intubating an asthmatic• Profound hypoxia, depressed

mental status, exhaustion • Orotracheal intubation preferred

(nasotrach tube smaller, therefore increased airway resistance)

• Ketamine preferred induction agent b/c of bronchodilating effects and catecholamine surge

• Propofol also has bronchodilating effects

• Mechanical ventilation frought with difficulties: barotrauma, hypotension

• Decrease minute ventilation• Decrease TV, prolong I:E (1:4,

1:5)• Plateau pressure < 30cm H20

15. Which of the following statements regarding asbestosis is correct?

A. Early radiographic changes occur along the upper lung fields

B. It is a form of localized interstitial fibrosing lung disease

C. Mesotheliomas rarely metastasize

D. Small cell carcinoma is the most common cancer

E. Smoking and asbestos exposure increase the risk of lung cancer

Answer: E

Smoking and asbestos exposure increase the risk of lung cancer

A. Early radiographic changes occur along the upper lung fields -Radiographic changes are bilateral, irregular, or linear opacities along periphery of lungs in lower lobesprogresses to middle and upper lung fields

B. It is a form of localized interstitial fibrosing lung disease -Results in diffuse interstitial fibrosing lung disease, lung CA, mesothelioma

C. Mesotheliomas rarely metastasize-Most mesotheliomas metastasize, but local invasion/extension is

typically responsible for death

D. Small cell carcinoma is the most common cancer -squamous and adenoCA

E. Smoking and asbestos exposure increase the risk of lung cancer

Asbestos• Mineral silicates (chrysolite,

amosite, anthophllite, crocidolite)

• Excellent insulating properties, extensive use in 1930 – 1960’s

• Results in diffuse interstitial fibrosing lung disease, lung CA, mesothelioma

• Duration + intensity of exposure

• Radiographic changes are bilateral, irregular, or linear opacities along periphery of lungs in lower lobesprogresses to middle and upper lung fields

• CA most commonly squamous cell and adenoCA

• Smoking and asbestos combination increase risk of CA

• Mesotheliomas not significantly a/w smoking

• Most mesotheliomas metastasize, but local invasion/extension is typically responsible for death

Things to Know…

• Sputum pearls:“rusty colored” = Pneumococcus

“currant jelly” = Klebsiella

• CXR pearls:pna with bulging fissure = Klebsiella

pna with abscess = Staph, Klebsiella or Pseudomonas

Things to Know…

The pregnant asthmatic:– Elevated progesterone incr sensitivity to mediators of smooth muscle contraction– ¼ of asthmatics worsen during pregnancy– Treat similarly (beta agonists ok, avoid epi in early pregnancy)– Theophylline safe in pregnancy

Intubating a COPD-er:- Vent settings similar to asthmatic

ARDS pathophys:- Complement mediated- Bacterial Endotoxin direct damage- Surfactant function suppressed

Things to Know…Cystic Fibrosis:

- inherited autosomal recessive- most acquired via mutation- pulm disease most common cause of death- few survive into 40’s- Dx: recurrent resp infections, early onset COPD

Sarcoid:- most commonly blacks- wheezing, intrathoracic nodes 80%, fever- eye involvement 25%: blindness- skin changes 25%: erythema nodusum- bone marrow involvement 25%- Biopsy is mandatory to make diagnosis

Things to Know…

Silicosis:- Farming, mining, stone cutting, construction

- After chronic exposure, can develop and become fatal within 2 years

- CXR: miliary infiltration, rounded upper lobe opacities, “egg shell” lymph nodes, hilar adenopathy

- Tx symptomatically with bronchodilator

PCP:- 80% of HIV patients

- diagnosed by sputum immunoflourescent stains

- Tx: Bactrim or Pentamidine, prednisone for PaO2 < 70, A-a > 35

Things to Know…

Inhalational Anthrax:

- Encapsulated Gram positive rod

- Animal/bioterrorism exposure

- Initial flu-like illness

- CXR can be subtle or not hemorragic effusions/mediastinitis,

- progresses to resp distress and sepsis

- hemorrhagic meningitis

- Tx: IV cipro, isolation

Mastitis:- most commonly Staph, think TB if persistent

- post menopausal abscess can be Ecoli, Group D Strep, Anaerobes

Things to Know…

• Most common EKG finding in PE is sinus tach

• CXR in PE: mostly normal, can have elevated hemidiaphragm, Hampton’s hump, and an infiltrate

• Foreign bodies in esophagus appear round on AP

• Gram negatives are most common nosocomial infections

• Most common causes of pneumonia: – Strep pnemo (60-75%)– Legionella (5-15%)– Moraxella (5-18%)