CHEST Board Review 2024
PE in pregnancy
- lovenox pre partum
- lovenox post partum if breast feeding and DOAC if not
- anticoagulation for 3 months, include 6 weeks post partum
Septic emboli
amnionic fluid embolism
- 36 hours post partum
- postpartum with DIC = think amnionic fluid embolism
- nonspecific image finding
- supportive
air embolism
- central access removal
- chest pain, hypoxia, cough
- CTA: air in vessel
- treatment: fluids, O2, left lateral decubitus position
fat embolism
- post long bone fx
- hypoxia, diffuse petechial rash, fever
- CT: multifocal nodular GGO (like septic emboli without cavity)
- treatment: supportive
pulmonary tumor thrombi
- GI, breast, lung cancers
- interlobular septal thickening
- RV dysfunction but no PE
- treatment: chemo
POCUS
- Blue protocol:
- A profile
- B profile
- PLAPS profile
- Shred sign: lung consolidations
- absence of lung slides, can happen in pneumonectomy and bleb: look at lung point
- sinusoid sign: respiratory variation decreases distance between parietal and visceral pleura
- pleural effusion
Pleural Disease
- dura pleural fistula
- pleural fluid glucose is good surrogate for pH
- albumin gradient and protein gradient can be used to confirm transudate in heart failure and cirrhosis
- tips for hepatic hydrothorax
- chylothorax, vs pseudochylothorax
- using pleural elastance to predict pleurodesis, >19 predicts failure
- split pleural sign
- Grawitas and Gravitas: wall suction is safe
- mesothelioma and lung have low cytology sensitivity. In general 40-70%
Lung cancer
- small cell staging: limited (one lung) vs extensive
- use mri for pancoast tumor
- stage 1a: surgery or SBRT
- stage 1b: alk+ or EGFR targeted therapy. Neo adjuvant chemo if negative receptors
- stage 2: surgery and adjuvant chemo
- stage 3: chemoradiation, adjuvant. Immuno for pdl1
- Osimertinib for nsclc
- stage 4: platinum
- small cell: cisplatin and etoposide. radiation for only localized disease
- immunotherapy pneumonitis: 30 days to months
- asymptomatic: treat through
- mild symptom: close observation
- more sx: discontinue therapy, bronch, steroids
- bronchoscopy only if worry about infections, lymphangietic spread of cancer
Bronchoscopy
- lidocaine 1%: each cc = 10mg lidocaine
- 2%: each cc = 20 mg lidocaine
- topical lidocaine should not exceed 7mg/kg in airway
- Can use 1% instead of 2%
- bleeding: wedge scope, place patient bleeding side down, intubate in non bleeding lung
- use iced saline over epi
Trachebronchomalacia and EDAC
- TBM: softening of trachea cartilages
- EDAC: excessive posterior membrane wall laxity with intact cartinaginous support
- dyspnea, barking cough, secretions, recurrent infections
- CT: inspiratory/expiratory
- PFT: decreased expiratory flow, notching, biphasic flow
- cpap primary treatment
- temporary stent and tracheobronchoplasty
airway obstruction
- lesion must narrow tracheal diameter to less than 8mm to show up on flow volume loop
- hyperinflation can be seen in opposite lung with inhalation of foreign object
Sleep Medicine
- ataxic breathing or biot's breathing on opioid
- circulation time for cheynne stokes
- ASV for cheynne stokes: serve-hf trial showed increased mortality in HFrEF
- if OSA predominant: CPAP
- if CSA emerges or persisits: ASV if EF > 45%
- if CSA predominant: CPAP and then ASV if EF > 45%
- avoid autopap for CSA
- transvenous neurostimulation for CSA
- ramelteon and tasimelteon
- mslt: mean sol < 8 min
- mwt: mean sol < 40 min
- actigraphy
- narcolepsy type 1 and 2
- idiopathic hypersomnia: 660 minutes a day
- parasomnia
- RLS: augmentation
- asv vs vaps
TB
- 20-40% active TB have negative smear
- postbronch sputum: 9%
- smear negative does not mean noninfectious
- upper lobe, posterior cavity: reactivation
- effusion, mediastinal necrotic LAD, military, normal CXR more likely primary
- empiric treatment over bronchoscopy
- bronchiectasis, azithromycin: at least a year
- NAAT: both live and dead bacilli. Good sensitivity, high sensitivity. Not good at excluding TB in highest risk patient
- 9 months vs 6 months INH/rifampin
- side effects (drug related lupus)
- HIV and TB: start HAART 2 weeks before TB therapy
- who should be treated for ltbi
- IGRA and T spot
- order CXR after positive IGRA: rules out active TB before treatment
- LTBI treatment
- TB pregnant patient: wait 3 months after delivery
Asthma
- don't have to stop inhaled steroids for FENO
- stop oral steroids for FENO
Radiology
- IIP
- use thin to differentiate nodule and ggo
- use MIP to assess nodules
- panlobular: paucity of blood vessels. Lower lungs
- LAM vs LCH
- bronchiectasis by locations
- swyer james syndrome
- dipnech
- round atelectasis: comet tail sign
- lung sequestration
- Y sign and bronchial atresia
- AVM
- sickle sign: atelectasis lul
- abscess: air fluid level same size AP and lateral. Always spherical
- empyema: air fluid can be obtuse
- relapsing polychondritis
- thickening of trachea flow chart
- mycetoma
- three density sign
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