Pulmonary Board Review

1. Pulmonary Board Review Ram Parekh 2/11/09

2. 1. Which of the following statements regarding the epidemiology of COPD is correct? • 25% of North Americans older than 55 years have COPD • Almost all smokers develop clinically significant COPD • Cigarette smoking accounts for up to 50% of the risk of developing COPD • COPD is more common in men than in women • COPD is the most common cause of death in the US

3. Answer: DMore common in men than women

4. 25% of North Americans older than 55 years have COPD - 10% • Almost all smokers develop clinically significant COPD - 15% • Cigarette smoking accounts for up to 50% of the risk of developing COPD - 90% • COPD is more common in men than in women • COPD is the most common cause of death in the US-4th most common

5. 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

6. 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?

7. A. direct, person-to-personcontact is the mode of transmission B. GI symptoms help to narrow the differentialC. IV penicillin is the treatment of choiceD. pulse-temperature dissociation is uncommon in this diseaseE. the likely causative organism rarely causes chest pain with this illness

8. Answer: BGI symptoms help narrow the differential

9. A. direct, person-to-person contact is the mode of transmission -no person to person transmission B. GI symptoms help to narrow the differentialC. IV penicillin is the treatment of choice-macrolidesD. 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%

10. 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

11. 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

12. Variable patterns of Legionnaire’s Disease

13. 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?

14. A. Bullous myringitis occurs frequentlyB. fever, headache, and malaise are uncommonC. Frequently associated with GI symptomsD. One of the most common CAPsE. Seen most commonly during winter

15. Answer: DOne of the most common CAPs

16. 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

17. 4. Which of the following statements regarding spontaneous pneumothorax is correct? A. Chest pain is rarely presentB. may cause ischemic ECG changesC. More common in femalesD. Smoking is not a risk factorE. Symptoms are not related to the size of the pneumothorax

18. Answer: B may cause ischemic ECG changes

19. A. Chest pain is rarely present-pleuritic chest pain 95%B. may cause ischemic ECG changesC. More common in females-malesD. Smoking is not a risk factor-smoking is big risk factor 20:1E. Symptoms are not related to the size of the pneumothorax-sx’s related to size and rate of development

20. 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

21. 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?

22. Chlamydia trachomatis pneumonia • Congestive heart failure • Laryngotracheobronchitis • RSV • Strep Pneumo pneumonia

23. Answer: A Chlamydia trachomatis pneumonia

24. A. Chlamydia trachomatis pneumoniaB. Congestive heart failure-diaphoresis during feedings and tachypnea without retractionsC. Laryngotracheobronchitis-”croup” – typically 2-3d low grade fever, rhinorrhea, some cough; uncommon in first few months of lifeD. RSV-absence of wheezing; conjunctivitis not commonE. Strep Pneumo pneumonia-typically sudden onset fever, cough, elevated WBC

25. 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” Chlamydia Trachomatis pneumonia

26. 6. Which of the following statements regarding pneumococcal pneumonia is correct? • Elderly patients experience a very rapid progression of the disease • May be associated with hypernatremia • Predominantly affects the elderly population • Presents with a bilateral interstitial infiltrate • Prevalent at both extremes of age

27. Answer: E prevalent at both extremes of age

28. 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/sputumB. May be associated with hypernatremia-hyponatremiaC. Predominantly affects the elderly population-all age groupsD. Presents with a bilateral interstitial infiltrate-lobar infiltrateE. Prevalent at both extremes of age

29. 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

30. Pneumococcal Pneumonia • Leukocytosis common • LFT abnormalities sometimes present • Occasionally associated with hyponatremia

31. 7. Which of the following statements regarding acute bronchitis is correct? • Antibiotics do not hasten recovery • Chest radiograph is required to make the diagnosis • Colored sputum indicates a bacterial etiology • Fever and wheezing are the characteristic findings • Most cases are caused by Mycoplasma Pneumonia

32. Answer: Aantibiotics do not hasten recovery

33. A. Antibiotics do not hasten recoveryB. Chest radiograph is required to make the diagnosis-hx acute cough, normal O2 sat, no prior hx lung disease, and no ausculatory abnormalitiesC. Colored sputum indicates a bacterial etiology-not necessarily;though typically non-productive coughD. Fever and wheezing are the characteristic findings-same answer as BE. Most cases are caused by Mycoplasma Pneumonia-typically viruses

34. 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

35. 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

36. Which of the following statements regarding aspiration pneumonia is correct? • Aspirates with pH near 6 are associated with much higher mortality • Aspiration disrupts surfactant and causes an inflammatory response • Prophylactic antibiotics should be started within first 36 hours after onset of aspiration • Severity of symptoms is unrelated to volume of aspirate • Systemic corticosteroids are effective in reversing inflammatory response to aspiration pneumonia

37. Answer: BAspiration disrupts surfactant and causes an inflammatory response

38. A. Aspirates with pH near 6 are associated with much higher mortality-pH<2 associated with much higher mortalityB. Aspiration disrupts surfactant and causes an inflammatory responseC. Prophylactic antibiotics should be started within first 36 hours after onset of aspiration-Abx should be started upon start of symptomsD. 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

39. 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

40. 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

41. 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 completely negative spiral CT lung scan is equivalent to a normal V/Q lung scan • A high prob V/Q lung scan and a spiral CT angiogram of the chest have similar specificities for pulmonary embolism • A spiral CT lung scan will most likely be nondiagnostic in patients with a history of COPD • The sensitivity and specificity of spiral CT for PE in central vessels are similar to those in peripheral vessels • When used to diagnose PE, a spiral CT lung scan spares use of contrast material

42. Answer: BA high prob V/Q lung scan and a spiral CT angiogram of the chest have similar specificities for PE

43. 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 CTAB. A high prob V/Q lung scan and a spiral CT angiogram of the chest have similar specificities for pulmonary embolismC. 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 infiltrateD. 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 vesselsE. When used to diagnose PE, a spiral CT lung scan spares use of contrast material - obviously false

44. 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

45. 10. Which of the following statements regarding pleural effusions is correct? • A common cause of atraumatic hemothorax is SLE • A pH of less than 7.3 strongly suggests pleural empyema or esophageal rupture • Effusions a/w PE are transudative • Management of complicated parapneumonic effusions includes tube thoracostomy • The most common cause in developing countries is CHF

46. Answer: DManagement of complicated parapneumonic effusions includes tube thoracostomy

47. A. A common cause of atraumatic hemothorax is SLE -causes exudative effusions, not hemothoraxB. A pH of less than 7.3 strongly suggests pleural empyema or esophageal rupture<7.0C. Effusions a/w PE are transudative-can be either transudative or exudativeD. Management of complicated parapneumonic effusions includes tube thoracostomyE. The most common cause in developing countries is CHF -TB

48. 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

49. 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

50. 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? • 12 hours • 24 hours • 36 hours • 1 week • 3 weeks