PULMONARY SYSTEM & CRITICAL CARE

1. Appropriate insertion depth for an ETT is 21 cm (8.3 in) for

women and 23 cm (9 in) for men.
2. Pulmonary barotrauma is a risk of mechanical ventilation and
can lead to pneumothorax. Placement of a chest tube is the
preferred initial treatment of a large pneumothorax in a patient
who has not developed tension physiology.
3. Needle decompression is for tension pneumothorax. However,
needle decompression must always be followed by chest tube
placement for definitive management.
4. Prominent horizontal fissure - TTN. Hyperinflation (ie, flattened
diaphragm), mild cardiomegaly, prominent vascular markings,
fluid in the interlobar fissures, and pleural effusions may be
seen on chest x-ray.
5. Respiratory distress syndrome typically affects premature infants
due to deficient pulmonary surfactant, and chest x-ray has a classic
ground-glass appearance with air bronchograms.
6. MAS - CF & HD.
7. Blood tinged sputum in known case of asthma + eosinophilia +
upper/lower lobe infiltrate + prominent bronchial markings - ABPA.
8. Allergic bronchopulmonary aspergillosis should be suspected in
patients with preexisting asthma or cystic fibrosis who develop
recurrent episodes of fever, malaise, cough with brownish mucoid
sputum, wheezing, or symptoms of bronchial obstruction.
9. Bronchiectasis - Prominent bronchial markings. Due to recurrent
infections with mucus plugging, bronchial walls are thickened.
10. Current diagnostic criteria for ABPA include an elevated
Aspergillus-specific IgE with an elevated total IgE, positive
Aspergillus-specific IgG, eosinophilia, and positive skin test
reactivity for Aspergillus.
11. Itraconazole / Voriconazole - For aspergillus. Steroids for acute
exacerbration.
12. Postoperative atelectasis is common 2-5 days following
thoracoabdominal surgery and typically presents with hypoxemia
or respiratory difficulty. Patients without respiratory secretions
can be managed with continuous positive airway pressure, whereas
those with secretions are best managed with aggressive pulmonary
hygiene, including chest physiotherapy and suctioning.
13. Atelectasis - may show linear opacifications in the bilateral
lung bases.
14. Minimal secretions - Rx CPAP; Large secretions - chest
physiotherapy and suctioning.
15. Ceftriaxone with azithromycin is appropriate for community-
acquired pneumonia.
16. Bronchiolitis is a lower respiratory tract infection most
commonly caused by respiratory syncytial virus that presents with
nasal congestion, rhinorrhea, and cough followed by wheezing and
often respiratory distress.
17. Bronchiolitis due to respiratory syncytial virus that requires
hospitalization is associated with recurrent wheezing in early
childhood. Acute complications are apnoea and resp failure.
18. IVC filters are an option for patients with acute venous
thromboembolism and strong/absolute contraindications to
anticoagulation, such as intracranial hemorrhage and active major
bleeding that is not readily controllable.
19. IVC filters pose a long-term trade-off of risk: They lower the
incidence of PEs by half but increase the risk of recurrent DVT by
roughly 2-fold.
20. Bedside ultrasonography is the test of choice for evaluation
of tension pneumothorax in the acute setting (eg, trauma bay,
intensive care unit). A portable supine anteroposterior chest x-ray
can be quickly is an acceptable alternative when relatively rapid
confirmation of pneumothorax is needed and bedside
ultrasonography is unavailable.
21. Ultrasonography allows visualization of the parietal and
visceral pleura; inability to detect lung sliding, the 2 pleural
layers moving against one another during respiration, is consistent
with pneumothorax.
22. Upright posteroanterior chest x-ray is the initial test of choice
when there is suspicion for pneumothorax in the nonacute setting
(low risk of tension physiology).
23. Nocturnal cough - asthma.
24. Causes of prolonged cough - UACS, Asthma and GERD.
25. Symptom improvement following a 2-week trial of a short-
acting beta agonist and inhaled corticosteroid is confirmatory for
asthma.
26. Chest x-ray characteristically shows an irregular, localized lung
opacification - Pulmonary contusion.
27. ARDS, Cardiogenic pulmonary edema - are bilateral.
28. ABPA is characterized by fleeting infiltrates, recurrent asthma
exacerbations, and central bronchiectasis.
29. Relative or absolute cortisol deficiency can manifest as
refractory shock and requires supplementation with stress doses of
corticosteroids. A standard "stress dose steroid" regimen for
septic shock involves 200 mg/day of intravenous hydrocortisone.
30. Plain chest radiograph remains the initial test of choice for
hemoptysis.
31. Acute bronchitis is the most common cause of hemoptysis. A
trial of antibiotic therapy is warranted in COPD patients with
increased dyspnea, increased sputum volume, or increased sputum
purulence.
32. ASD - Echogenic bubble study.
33. Spirometry is performed before and after a challenge such as
exercise; cold, dry air; or voluntary hyperventilation. A fall in FEV1
≥15% from the prechallenge value is considered diagnostic of
Exercise Induced Bronchoconstriction.
34. Lung cancer screening by annual low-dose helical CT scan is
recommended for patients age 50-80 who have a ≥20-pack-year
smoking history and are current smokers or quit within the past 15
years.
35. c/o Irregular pleural thickening and calcifications - Malignant
mesothelioma.
36. Chronic silicosis - Chest x-ray usually shows upper lobe nodules
and lower lobe emphysema.
37. Patient's age >50, male sex, neck circumference >43.2 cm (17
in), elevated BP, BMI >30 kg/m2, chronic headaches, and poor
sleep provide suggestion of OSA.
38. Solitary pulmonary nodule - Rounded opacity, ≤3 cm in diameter
(>3 cm is considered a "mass"), Surrounded by pulmonary
parenchyma, No associated lymph node enlargement. Diagnosis -
Compare with previous X ray or do CT scan now.
39. Nodules >0.8 cm that are intermediate or high probability
for malignancy (ie, ≥5% probability) based on these factors
require tissue diagnosis with biopsy or surgical excision.
40. Fiberoptic bronchoscopy with transbronchial biopsy is typically
useful only for centrally located nodules.
41. Hemodynamic instability after pulmonary embolism is
frequently due to right ventricular dysfunction and is one of the
most important predictors of increased short-term mortality. Other
predictors include advanced age, altered mental status, history of
cancer, tachypnea, tachycardia, hypothermia, marked hypoxemia,
and right ventricular dysfunction.
42. Hemodynamic instability in acute PE is defined as persistent
hypotension (systolic blood pressure <90 mm Hg), hypotension
requiring vasopressors, or hypotension with evidence of end-organ
damage (shock).
43. Low tidal volume ventilation is important for preventing the
risk of barotrauma in acute respiratory distress syndrome.
44. In patients with PE, hemodynamic instability is the most
important indication for thrombolysis, which can be administered
via either systemic infusion or catheter-directed therapy. In
patients who cannot undergo thrombolytic therapy, surgical or
catheter-directed embolectomy should be considered.
45. Death is declared when there is cessation of cardiac activity
(cardiac death) or absence of brain and brainstem function (brain
death). In both cases, apnea is present.
46. Periodic breathing is a physiologic pattern of breathing in
young infants characterized by episodes of alternating pauses (5-10
seconds) in breathing and rapid breathing. This is secondary to
recurrent central apnea due to immaturity of the nervous system in
infants up to age 6 months.
47. Apnea of prematurity is characterized by true apnea and
pauses in breathing lasting ≥20 seconds; it typically resolves by a
corrected gestational age of 37 weeks.
48. To prevent recurrent aspiration, patients with risk factors for
aspiration should undergo a full speech and swallow
evaluation. Modifications to diet (eg, thickened liquids) or position
(eg, chin-tuck) can help prevent recurrence.
49. Recurrent infections and daily cough with mucopurulent
sputum production are suggestive of bronchiectasis. The chronic
airway inflammation and edema can lead to rupture of superficial
blood vessels and cause hemoptysis.
50. Obstructive pattern consisting of a reduced FEV1 and a
reduced FEV1/FVC ratio. A bronchodilator (eg, albuterol) can be
administered and should result in significant improvement in FEV1
(eg, >15% from baseline).
51 Most patients with asthma have a positive methacholine
challenge - The administration of methacholine in these patients
is likely to cause >20% reduction in FEV1, which is diagnostic of
airway hyperresponsiveness. Has high sensitivity and high NPV.
52. Reduced DLCO - Pulmonary HTN.
53. SIADH is associated with normovolemic hyponatremia and can
be caused by small cell carcinoma of the lung.
54. Patients receiving massive fluid resuscitation (eg, patients
with severe burns) are at increased risk for ACS, especially when
coupled with conditions (eg, trauma, burns) that cause a systemic
inflammatory response, increased capillary permeability, and
rapid third spacing of fluids. The increased intraabdominal
pressure of ACS can result in renal impairment (eg, decreased
urine output, increased creatinine), pulmonary dysfunction (high
ventilation pressures (eg, peak inspiratory pressure) and JVD),
and cardiovascular compromise (hypotension). An elevated bladder
pressure (>25mmHg) measured by foley's catheter indicates
ACS. Surgical decompression is the definitive treatment. If
increased IAP is recognized early, nonsurgical measures (eg,
gastrointestinal drainage, sedation) can potentially prevent
progression to ACS.
55. If oropharyngeal erythema, blistering, or soot is present, airway
stabilization with intubation should be strongly
considered. However, bedside fiberoptic laryngoscopy can be
performed in stable patients without strong indicators to guide
airway management and avoid unnecessary intubation.
56. Doctrine of double effect: Interventions that have adverse
effects (eg, respiratory depression) are justified if they promote
patient well-being (eg, allowing for a comfortable death).
57. NIV also is contraindicated in patients with decreased
consciousness and copious secretions (aspiration risk).
58. Laryngeal edema typically presents with post-extubation
stridor (PES) and respiratory failure. Rx - Reintubation and
mechanical ventilation .
59. Croup is a parainfluenza viral infection characterized by a
barking cough and stridor. Mild croup is treated with humidified
air and corticosteroids; moderate/severe croup is treated with
corticosteroids plus nebulized epinephrine.
60. The primary goal of managing a brain-dead organ donor is to
maintain a euvolemic, normotensive, and normothermic (or mildly
hypothermic) state. Patients often receive intravenous fluids,
desmopressin, and pressor support.
61. Acute bronchitis is typically a self-limited bronchial
inflammation characterized by cough lasting >5 days and up to 3
weeks.
62. Popcorn calcification (hamartoma) or concentric, central, or
diffuse homogeneous calcification on radiographic imaging of a
pulmonary nodule is suggestive of a benign etiology. Eccentric,
reticular, or punctate calcification should raise suspicion for
malignancy.
63. CT angiogram of the chest is typically preferred for diagnostic
confirmation of acute PE; however, due to impaired renal function,
intravenous contrast should be avoided. Therefore, ventilation-
perfusion scan is most appropriate.
64. Acute PE can present with fever (15%) due to tissue necrosis in
setting of pulmonary infarction.
65. Patients with obstructive sleep apnea are at increased risk of
perioperative respiratory failure from procedures involving
sedation, neuromuscular blocker, opioids, or anesthesia.
66. Mortality in chronic obstructive pulmonary disease is best
predicted by integrative measures such as global functional
impairment, multidimensional risk indices—such as BODE (low
BMI, very severe Obstruction, disabling Dyspnea, and low Exercise
capacity—and presence of significant nonpulmonary (mainly
cardiovascular) comorbidities.
67. Ventilator-associated pneumonia is associated with fever,
increased secretions, worsening pulmonary infiltrates, and
increased requirements for ventilatory support occurring ≥48
hours after mechanical ventilation.
68. Ketamine facilitates awake intubation by providing dissociation,
amnesia, and analgesia while also maintaining upper airway tone,
protective reflexes, and respiratory drive.
[Link] should be performed in hypoxic, unstable
patients who cannot be oxygenated or ventilated due to an upper
airway obstruction.
70. c/o sepsis and septic shock - Lactated ringer solution and
antibiotics > Norepinephrine > vasopressin and hydrocortisone.
71. c/o interstitial, bilateral infiltrates - Pneumocystic pneumonia.
72. Elevated ADA - TB; pleural biopsy can show pleural
granulomas.
73. Foreign body aspiration should be considered in a young child
with chronic cough and focal wheezing unresponsive to albuterol.
Unilateral hyperinflation on chest x-ray supports the diagnosis, and
bronchoscopy is performed to identify and remove the object.
74. In chronic obstructive pulmonary disease, hypoxemia is
primarily due to ventilation-perfusion (V/Q) mismatch.
Supplemental oxygen improves hypoxemia primarily by delivering a
higher FiO2 to alveoli with low V/Q ratios.
75. Cough-variant asthma - The cough is typically triggered by
exercise (especially in cold temperatures) or forced expiration and
commonly occurs at night.
76. In patients with UACS, accompanying rhinorrhea is expected,
and oropharyngeal cobblestoning is often present on examination.
77. Postoperative pulmonary complications occur most often in
those undergoing thoracic or upper abdominal surgery. Risk is
greatest when patients have a history of COPD, cigarette smoking,
congestive heart failure, or sleep apnea.
78. BMI <20 kg/m2 or weight loss >5% is often used to suggest
pulmonary cachexia syndrome (PCS).
79. In hemodynamically unstable patients with suspected massive
pulmonary embolism, a presumptive diagnosis (sufficient for
empiric thrombolysis) should be made using emergency bedside
echocardiography. Although CT angiography can confirm PE, it is
unsafe in hemodynamically unstable patients given the risk for
circulatory collapse.
80. Relative acidosis (normalization of the PaCO2) during asthma
exacerbation suggests impending respiratory failure and is an
indication for mechanical ventilation.
81. Prednisone 40-60 mg daily for 5-7 days is indicated for
outpatient treatment of patients with mild acute asthma
exacerbations unresponsive to bronchodilator therapy.
82. A normal capnographic waveform with all 4 phases after
intubation indicates proper ETT placement, whereas a flat-line
waveform typically indicates improper esophageal placement.
83. Capnography (measurement of CO2 concentration over time) is
the most reliable method for verification of endotracheal tube (ETT)
placement in the trachea rather than the esophagus.
84. The best diagnostic test for endobronchial obstructive lesions is
flexible bronchoscopy. Next best step after diagnosing
endobronchial lesion is CT scan.
85. Sinus bradycardia in the absence of a pulse represents PEA
rather than symptomatic bradycardia.