UWorld Pulmnology
[ARDS]
*Impaired gas exchange* - Alveolar leakage increased O2 diffusion barrier *Decreased lung compliance*: Fluid accumulation destroys surfactant and edema reduce recoil *Pulmonary arterial hypertension*: Hypoxic vasocontriction
[Pleural Effusion]
*Parapneumonic effusions* often occur w/ pneumonia. Can be trans or ex (Light's). *Low glucose* in exudative indicates *high metabolic activity* of leukocytes and/or bacteria in fluid
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*Pulmonary HTN* (>= 25mmHg, prominent pulmonary arteries, enlarged right heart border, right axis deviation) presents w/ exertional dyspnea in young women
[Chronic Cough]
>90% of chronic cough in non-smoking, non-pulmonary pt's are: *GERD, post-nasal drip, and asthma* In post-nasal drip pt's, give oral first-gen antihistamine +/- decongestant
[COPD]
Acute exacerbation of COPD will present with acute worsening of: - Cough - Sputum production - Dyspnea - Accessory muscle use to breathe
[Cor Pulmonale]
Causes: *COPD, interstitial lung dz's, OSA, pulmonary vascualr dz* Signs: Tricuspid regurg, loud P2, JVD, hepatometaly, ascites, elevated pulmonary artery pressure (>25mmHg)
[ARDS]
Causes: Infection, trauma, transfusion, pancreatitis Clinical Signs: Respiratory distress, diffuse crackles, severe hypoxemia, decreased lung compliance, increased pulmonary resistance Imaging: Diffuse alveolar infiltration "white out" CXR
[COPD]
Components of bronchitis and emphysema - Progressive expiratory airflow limitaiton - Increased total capacity from air trapping - Decreased vital capacity due to air trapping causing increased % being residual volume - Increased lung distensibility, compliance - FEV1/FVC ratio < 0.7
[Alpha1 Antitrypsin Deficiency]
Consider AAD in patients with: 1. *COPD at <45yrs* 2. *COPD w/ minimal smoking hx* 3. *Basilar-predominant lucency* - AAD destroys LOWER lobes (smoking causes upper lobes instead) 4. *Unexplained liver disease*
[Chronic Cough]
Dx for chronic cough >8wks; patients should be evaluated using *pulmonary function testing (spirometry w/ bronchodilator)*. give methacholine challenge if not reactive
[Community-aquired Pneumonia]
Empirical therapy for CAP is gonna be: 1. *Flouroquinolone* 2. *Beta-lactam plus macrolide*
[Upper Airway Obstruction] - know these for asthma/COPD (scoop), panic (normal), pneumothorax (mini & right)
Food allergy-induced *laryngeal edema* causes fixed upper airway obstruction *flattening the top/bottom* of the *flow-volume loop*
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For any un-dx'd pleural effusions, *diagnostic thoracentesis* is performed unless they have CHF in which case a *diuretic* is indicated instead
[Pulmonary Embolism]
Highly non-specific symptoms! Acute dyspnea Pleuritic chest pain Tachypnea Tachycardia Fever Hemoptysis Atrial fib Low O2 sat
[Community-acquired Pneumonia]
History of RECURRENT pneumonia in span of only few months in the SAME location in lung raises concerns for *localized airway obstruction* from LAD or neoplasm necessitating *chest CT*
[Interstitial lung disease]
ILD can be caused by: idiopathic, infections, connective tissue diseases. Signs: Include fine crackles, digital clubbing, reticular/nodular opacities; CT scan will show fibrosis, *honeycombing* or *bronchiectasis* EXCESS collagen depo around alveoli causes reduction in *TLC, FRC, and RV* which in turn *INCREASES alveolar-arterial gradient*
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Immigrant w/ prior history of cavitary lung disease (TB) w/ >3mo fever, weight loss, cough, hemoptysis is MOST at risk of *chronic pulmonary aspergillosis*
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In context of COPD w/ reduced FEV/FVC, ONLY *smoking cessation* has shown mortality benefit! SABA, ICS, LABA, O2 only improve symptoms
[Pulmonary Embolism]
In pt's w/ severe renal disease use *unfractionated heparin*! DON'T use *LMWH* (enoxaparin), or *factor Xa inhibitors* (fondaperinux, rivaroxaban)
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MCC of CAP = Strep pneumo Diff: Anaerobic (alcoholics, dementia), Psuedomonas (hospital-acq), Haemophilus influ (more in URIs)
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Mgt of ARDS pt involves: 1. Providing *adequate oxygenation* (w/ PEEP up to 15-20cm H2O to prevent <88& O2 sat) 2. *Avoiding complications* of mechanical ventilation (low tidal volume to prevent overdistension)
[Alpha 1 Antitrypsin Deficiency]
Patient with *COPD symptoms* (progressive exertional dyspnea, productive cough, decreased breath sounds, wheezing) w/ *liver dysfunction* (elevated liver enzymes and family history of cirrhosis) Dx: Alpha 1 Antitrypsin Deficiency
[Pleural Effusion]
Prolonged immobilization, sudden-onset chest pain, dyspnea, tachycardia -> *Pulmonary embolism* -> Hemorrhage/inflammation -> exudate w/ gross blood and pleural irritation -> *Pleural effusion* with pleuritic chest pain NOT aspiration pneumonia due to lack of fever, leukocytosis, cough, and lobar infiltrate on CXR
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Pt w/ COPD being treated w/ theophylline can have side effects of: 1. *CNS stimulation* (headache, insomnia, seizures) 2. *GI disturbances* (N/V) 3. *Cardiac toxicity* (arrhythmia)
[Interstitial lung disease] Know the function tests for asthma, COPD, interstitial lung, and pulm artery HTN
Pt w/ slowly progressive dyspnea, dry cough, fine crackles at bases, no smoking hx Dx = Idiopathic pulmonary fibrosis w/ pulmonary tests showing *decreased TLC, normal FEV1/FVC, decreased DLCO*
[Acute Respiratory Failure]
Pt's w/ pulmonary edema need endotracheal intubation immediately. Because of the right main bronchus's angle, it alone can be preferentially intubated. This then results in hyperinflation of the right hemithorax and deflation of the left, resulting in reduced breath sounds. Fix by *repositioning the ET tube*
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Septic shock (hypotension, tachycardia, hx of pneumonia) will cause: 1. Increased cardiac index (contractility), stroke volume 2. Increased pulse pressure (bounding peripheral pulses) *Early phase of sepsis* will have hyperdynamic phase w/ *bounding peripheral pulses*. Later complication will be *cold extremities* Diff: 1. CHF - Distended neck veins, S3 2. Tamponade - pulsus paradoxus
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Sleep apnea will present w/: *daytime somnolence/fatigue*, morning headaches. Treatment is lifestyle changes (weight loss) and then CPAP
[Asthma]
To differentiate between asthma and COPD: perform *spirometry* before and after an inhaled bronchodilator. *Reversal* of airway obstruction indicates *asthma* Asthma gets inhaled corticosteroid; COPD get long-acting anticholinergic inhaler
