Pulmonary Uworld

Goal of FiO2

55-80mmHg (88-95% sat)

Tidal volume on mechanical assist

6mL/kg

Normal pleural fluid pH

7.6 Transudative: 7.4-7.55 Exudative: 7.3-7.45

Solitary pulmonary nodule

>0.8cm bx/excise (might be malignant) based on hx (smoking, age, sex, location of nodule, appearance--regular vs. irregular borders, famhx)

Small cell paraneoplastic

ACTH production (Cushing syndrome) SIADH Lambert-eaton syndrome Central lesion 10-15%

Bronchiectasis

Abnormal bronchial widening in the setting of recurrent infection and inflammation (irreversible dilation and destruction of bronchi) Similar to chronic bronchitis, but sputum production is more prominent Xray reveals dilated airways FVC low (<80%) due to airway destruction Dx: High resolution CT (initial diagnosis, shows bronchial wall thickening), immunoglobin testing, CF/sputum testing, PFT Tx: Chest physiotherapy

Lung abscess imaging

Air-fluid levels, NOT fungus balls

Exercise-induced bronchoconstriction tx

Albuterol 10-20 minutes before exercise Or an anti-leukotriene agent 10-20 minutes before (montelukast, if they cannot tolerate beta agonist)

Epinepherine

Alpha-1 and beta-2, so vasoconstriction and bronchodilation (good for anaphylaxis)

Theophylline

Alternative for ICS + LABA (step 3) of asthma

New pulmonary nodules

Always use CT to test (especially if bigger than 0.8cm with smooth borders -- low risk) and then follow-up if not malignant

Inhaled bronchodilators

Anti-muscarinics (ipratropium, tiatropium) used in COPD and asthma

PE tx

Anticoag should be given prior to CT IF there are no contraindications

Mucus plugging

Atelectasis

Sarcoidosis

Bilateral hilar adenopathy Renal involvement may occur: Interstitial nephritis/nephrolithiasis

Dead space ventilation

Blood isn't getting to a certain area (e.g., PE)

Asbestosis cancer risk

Bronchogenic carcinoma (more common, esp with smokers and has pleural plaques) Pleural mesothelioma (rarer, and presents with unilateral pleural abnormality with large pleural effusion)

Severe renal insufficiency anticoag

CANNOT use enoxaparin, fondaparinux, or rivaroxaban Use unfractionated heparin Bad renal: <30mL GFR

Cor pulmonale etiologies

COPD Interstitial lung disease Pulmonary vascular disease Obstructive sleep apnea

Pulmonary contusion

CT/CXR of patchy, alveolar infiltrate not restricted by anatomical borders Tx: Pain control, pulmonary hygiene, supplemental O2 and ventilatory support Blunt trauma and occurs within <24 hours

TB sxs

Calcified hilar lymph nodes

CREST syndrome

Calcinosis, Raynaud's, esophageal dysmotility with reflux, Sclerodactyly, Telangiectasia Associated with limited cutaneous systemic sclerosis => pulmonary HTN (increases in african americans). Anticentromere antibodies

Mitral stenosis effects

Can cause elevation of left mainstem bronchus (from LA dilation)

Supplemental O2 caution

Can reduce CO2 expiration - Loss of compensatory vasoconstriction and poorly ventilated areas (worsen V/Q mismatch) - Increase in oxyhemoglobin reduces uptake of CO2 due to Haldane effect - Decreased respiratory drive (people don't blow off as much CO2)

Alveolar hypoventilation

Can result from narcotics, anesthetics, sedatives COPD, obstructive sleep apnea, obesity, scoliosis Myasthenia gravis, lambert-eaton, guillan-barre Brainsteam lesion, stroke, infection A-a gradient is normal (is elevated in V/Q mismatch) + respiratory acidosis

Pulmonary TB imaging

Cavitary lesion

Lung abscess xray

Cavity with air/fluid levels

Subcutaneous emphysema next step

Chest xray to rule out pneumothorax

CF pulmonary features

Chronic sinopulmonary infections Nasal polyps Bronchiectasis Digital clubbing Upper lopes (characteristic of bronchiectasis due to CF) Poor growth can be seen as a feature of pancreatic insufficiency

Persistent pulmonary HTN

Clear lungs with decreased pulmonary vascularity (in term/post-term neonates)

Smoking and wrist pain

Concern for hypertrophic osteoarthropathy (may be lung malignancy or TB)

Transient tachypnea of the newborn

Condition of rapid respirations caused by inadequate absorption of fetal lung fluid Risk: Prematurity, c-section Sx: Tachypnea, clear breath sounds, xray: fluid in fissues, hyperinflation Tx: Supportive, resolution in 1-3 days

COPD and sputum

Consider giving abx to COPD (might be what caused acute exacerbation) Also give abx to COPD that requires mechanical ventilation

Refractory anaphylaxis treatment

Continue giving IM epi

Acute exacerbation of COPD

Cough severity or frequency Volume or character of sputum production Level of dyspnea URI may predispose

PEEP with hypovolemic shock

Could collapse the cardiac system by reducing preload (causes increased intrathoracic pressure that squeezes shut the vessels to the right heart)

Nebulized racemic epinephrine

Croup therapy

Pleural effusions sounds

DECREASED tactile fremitus (insulation from lungs) Decreased breath sounds Dullness to percussion

Compensatory metabolic alkalosis process

Decrease Cl- to increase HCO3- (exchanger in kidney)

Bronchiolitis concerns (RSV)

Development of apnea Recurrent wheezing through childhood Use pavilizumab

Cor pulmonale sys

Dilated pulmonary arteries with no congestion Exertional symptoms Loud P2 Tricuspid regurg Elevated JVD Peripheral edema Hepatomegaly Ascites Distant heart sounds (due to hyperinflated lungs)

Empyema tx

Drainage by chesttube and prolonged abx

Consolidation

Dull percussion Increased fremitus and egophony Increased intensity of breath sounds

Tracheobronchial tear sx

Dyspnea Hemoptysis Subcutaneous emphysema Hamman sign (audible crepitus on cardiac auscultation) Sternal tenderness

pneumocystis pneumonia

Dyspnea Nonproductive cough Fever (Usually) Bilateral, diffuse, interstitial infiltrates on chest imaging

CMV pneumonitis

Dyspnea Nonproductive cough Low-grade fever Imaging CT: Patchy or diffuse ground-glass opacities

Nonseminomatous germ cell tumors

Elevated B-HCG and alpha-fetoprotein Usually occur in males and are locally invasive Almost all germ cell tumors in anterior mediastinum are primary rather than metastatic Benign teratomas do not produce markers

Unstable pneumothorax

Emergent needle thorcotomy (do not need to do xray)

Light criteria

Exudative effusion if 1 of following: 1. (Pleural fluid protein) / (serum protein) = >.5 2. (Pleural fluid LDH) / (Serum LDH) = >.6 3. Pleural fluid LDH > 2/3 normal serum LDH

Galactosemia

Failure to thrive in neonatal period Jaundice Vomiting Hepatomegaly Congenital cataracts

Aspiration pneumonia sxs

Fever Leukocytosis Cough Lobar infiltrate May also present with pleuritic chest pain and exudative pleural effusion (but need fever!)

CHF vs COPD

Findings of hypoxia, hypocapnia, and respiratory alkalosis COPD would have respiratory acidosis and hypoxia

Asthma dx

First use PFTs (spirometry) with methacholine challenge

Bleeding in lungs treatment (>600mL/24hr)

First: Bronchoscopy (with treatment, balloon tamponade, cautery) If not: Thoracotomy

Fixed upper airway obstruction

Flattened inspiration and expiration volume loop Could you laryngeal edema (from an allergic reaction to food; use epi, corticosteroids, and antihistamines)

Wells criteria

For pre-test probability of PE 3 points: Clinical signs of DVT, alternate diagnosis less likely than DVT 1.5 points: Previous DVT or PE, heart rate >100, recent surgery or immobilization 1 point: Hemoptysis, cancer >4 PE likely, otherwise unlikely Normal D-dimer but high wells still might mean PE (D-dimer only excludes if low probability)

Histoplasma

Fungi in lung Associated with caves Granulomas Narrow-budding yeast Mid-western US

Acute respiratory distress syndrome (ARDS)

Gas exchange impaired by V/Q mismatch Lung compliance decreased (loss of surfactant and recoil because of edematous lungs) Pulmonary arterial pressure increased (hypoxic vasoconstriction, destruction of lung parenchyma, compression of vascular structures from PEEP)

Drug-induced lupus medications

Hydralazine Procainamide Isoniazid

Squamous cell

Hyperca Central lesion (hilar mass) Smoking history Necrosis and cavitation 20-25%

Hypercapnia on brain

Hypercapnia increases cerebral vasodilation => seizures

Beta-2 agonist side effects

Hypokalemia (drive K+ into cells) => muscle weakness, EKG changes, arrhythmias Tremor, headache, palpitations

Massive PE sxs

Hypotension Acute RH strain

PEEP side effects

Hypotension Alveolar damage Pneumothorax

Atelectasis ABG

Hypoxemia Hypocapnia Respiratory alkalosis

Pulmonary embolism ABG

Hypoxemia Respiratory alkalosis Widened A-a gradient

Severe, persistent asthma tx

IV mag

Hodgkin lymphoma complications

If <30, can develop secondary malignancies due to chemoradiation

Aspirin-exacerbated respiratory disease (AERD)

In patients with asthma and chronic rhinosinitus (sudden worsening of symptoms after ingestion of aspirin) Pseudoallergic reaction (pro-inflammatory leukotrienes and reducation of anti-inflammatory prostaglandins) Tx: Leukotriene antagonists may help (montelukast, zileuton)

Best postoperative prevention of pneumonia

Incentive spirometry

Ventilation

Increase respiratory rate and increase tidal volume Increased tidal volume can cause barotrauma

Consolidation sounds

Increased tactile fremitus Increased breath sounds Dullness to percussion

Pneumointis

Inflammation from gastric acid Presents HOURS after aspiration event (vs. days with pneumonia) Tx: Supportive (no abx)

Restrictive lung disease

Interstitial lung disease (Pneumoconiosis, Pulmonary fibrosis) Sarcoidosis Asbestosis (pleural plaques) HF Low DLCO, normal FEV1/FVC Reduced pulmonary compliance Increased A-a (esp in interstitial lung disease)

Anaphylaxis tx

Intramuscular epi Airway management and volume resuscitation Adjunctive therapy (antihistamines, glucocorticoids)

Obesity hypoventilation syndrome

Just due to alveolar hypoventilation (NOT neuromuscular)

Pulmonary edema markings

Kerley B lines Bilateral infiltrates

Chylothorax

Leak of chyle (from thoracic duct): T-lymphocytes, immunoglobins, lipid-transporting chylomicrons with TGs tx: thoracentesis/chest tube placement, limitation of dietary fat, possible thoracic duct ligation

Survival in COPD

Long term home oxygen (if <88% O2 sat, or <89% O2 sat with cor pulmonale or hematocrit >55%)

Obstructive lung disease

Low DLCO: Emphysema Normal: Chronic bronchitis, asthma High: Asthma

ankylosing spondylitis

Low back pain (<40yo) Hip and buttock pain Limited chest expansion and spinal mobility Enthesitis (inflammation at site of tendon to bone insertion) Systemic symptoms (chills, fever, etc.) Can develop: Acute anterior uveitus, IBD, cardiac, aortic regurg Restrictive lung disease (low FVC, normal FEV/FVC) Improvement of pain with activity Elevated ESR Pain at night HLA-B27

Loculated (complicated paraneumonic) pleural effusion

Low glucose Low pH High protein Tx: Drainage and abx

Transudative pleural effusion

Low protein Normal glucose/pH

Clubbing reasons

Lung malignancies CF Right-to-left cardiac shunts COPD does not cause it

Flail chest treatment

Mechanical positive pressure ventilation (replaces negative with positive, so forces all segments to move outward during inspiration)

Croup tx

Mild: Corticosteroids + humidified air Worse: Corticosteroids + nebulized racemic epi

Nonallergic rhinitis treatment

Mild: intranasal antihistamines or glucocorticoids Moderate - Severe: Combination therapy Boggy, erythematous nasal mucosa but no other atopic sxs Dx: Clinical, do not need any testing

Tuberculous effusion

Moderate lymphocytes Elevated protein Elevated LDH Low pleural pH Low glucose Usually right-sided

Diaphragmatic rupture

More common on the left because right is protected by the liver Xray: May show NG tube in chest cavity

Acetylcysteine

Mucolytic agent Acetaminophen overdose

Panic attack breathing volume loop

Normal

Bad signs for acute asthma exacerbation

Normal PCO2 (usually is decreased in acute because person is breathing so fast, so normalizing means the person can't breathe anymore -- is getting tired) Hypoxemia -- >60mmHg O2 is good for asthma. Anything less is concern for another underlying pathology.

Community acquired pneumonia tx

O/P: Macrolide or doxy (healthy); fluoroquinolone OR beta-lactam + macrolide (comorbidities) Inpatient (non-ICU): IV Fluroquinolone OR IV macrolide + beta-lactam Inaptient (ICU): IV fluoroquinolone + beta-lactam OR IV macrolide + beta-lactam

Alveolar blebs

Occur with smoking (chronic destruction of alveoli) Can rupture and leak air into the pleural space Causes pneumothorax (COPD risk!) Tx: Supportive (with O2) to thoracotomy (dependent on size)

Right-to-left intrapulmonary shunting

Occurs in alveolar consolidation (worsens when lying on the side that is affected) Refers to passage of blood from right side to left side without actually getting oxygenated

Invasive Pulmonary Aspergillosis

Occurs in severe immunosuppression - Prolonged neutropenia - Glucocorticoid therapy - Hematopoietic stem cell transplant - Advanced AIDS (CD4 < 50) - Solid organ transplants - Chronic granulomatous disease Sx: triad of fever, pleuritic chest pain, hemoptysis CT: Nodules and surrounding ground-glass opacities (halo sign) Dx: Biomarkers for cell wall components (galactomannan assay) and sputum stain/culture Tx: 1-2 weeks of voriconazole + echinocandin (caspofungin)

Albuterol

Only beta-2 agonist, relieves airway obstruction

D-dimer testing

Only used in patients with low probability of PE (cannot rule out PE in high-risk--use CT)

Post-natal drip tx

Oral first-generation antihistamines (chlorpheniramine) Combined antihistamine-decongestant (brompheniramine, pseudoephedrine)

Oxygenation

PEEP and FiO2 (use PEEP to keep alveoli open) FiO2 usually wants to be weaned to <60% asap

Small effusions

Paraneumonic effusions that are small without much symptoms can be followed with oral abx and close outpatient follow-up

Meconium aspiration xray

Patchy infiltrates Coarse streaking of both lung fields Flattening of the diaphragm

Mechanical ventilation pressures

Peak airway pressure = Airway resistance + plateau pressure Plateau pressure = Elastic pressure + PEEP Calculated by the end-inspiratory hold maneuver

SIADH

People with HIV are prone to SIADH NS can worsen hyponatremia

Large cell carcinoma

Peripheral Gynecomastia, galactorrhea 5-10%

Adenocarcinoma

Peripheral lesion Hypertrophic pulmonary osteoarthropathy Clubbing Most common (40-50%) In both smokers/nonsmokers, but predominant in nonsmokers

Mesothelioma imaging

Pleural thickening and effusion

Theophylline toxicity

Predisposes if taking a CYP450 deactivator (e.g., fluroquinolones), infection, or diet. Has a narrow therapeutic index. Sx: CNS stimulation (headache, insomnia, seizures) GI disturbances (n/v) Cardiac toxicity (cardiac arrhythmia, multi-focal atrial tachy, supraventricular tachy, ventricular arrythmia) Dx: Serum theophylline levels

Predisposition to respiratory distress syndrome

Prematurity Male sex Perinatal aphysxia Maternal diabetes (delays maturation of surfactant; maternal hyperglycemia => fetal hyperglycemia => fetal hyperinsulinemia => prevent steroids from maturing lungs) C-section without labor Decrease risk: Intrauterine growth restriction, maternal HTN, prolonged rupture of membranes (stress is supposed to help with surfactant maturation)

Alpha-1-antitrypsin deficiency

Presents in 30 for smokers, and 40s in nonsmokers Causes emphysema Basilar-predominant May not have wheezing/other sounds. May have mucoid sputum Dx: Serum AAT and PFTs Tx: IV supplementation with pooled human AAT

Inhaled cromolyn

Prevention of acute bronchoconstriction Long-term management of asthma

Kartagener syndrome

Primary ciliary dyskinesia, bad mucus clearance => recurrent bronchopulmonary infections Triad: Situs inversus, recurrent sinusitis, bronchiectasis CF differences: No dextrocardia, there is pancreatic insufficiency

Chronic bronchitis

Productive cough for >= 3 months over 2 consecutive years Normal DLCO Xray reveals prominent bronchovascular markings and flattened diaphragm May demonstrate more hypoxemia than emphysema

PE risk factors

Prolonged immobilization Central venous catheters Surgery Obesity Advancing age Conditions that increase blood clotting History of thromboembolism

Severe combined immunodeficiency

Recurrent severe infections Poor growth Chronic diarrhea If does not have hematopoietic stem cell transplant, will die by 1 YO

COPD

Reduced inspiratory/expiratory flow rates Increased compliance/distensibility (reduced elasticity) Increased work of breathing (alveoli collapse) Increased TLC, FRC, residual volume, diaphragmatic flattening

Interstitial lung disease sounds

Resonant to percussion Breath sounds are normal/decreased intensity Fine crackles heard at end of inspiration

Congenital Diaphragmatic Hernia (CDH)

Right heart sounds (bowel push heart to right) Polyhydramnios (compression of esophagus) Pulmonary hypoplasia/HTN Bowel may cause concave abdomen/barrel-shaped chest Absent breath sounds on one side (left) of the chest Tx: Endotracheal tube immediately

Chronic pulmonary aspergiollosis

Risk factor: Cavitary TB Sx: Cavitary lesion (fungus ball) Positive asperigillus IgG Tx: Resect, azole meds (Voricanazole), embolize (if severe hemopytsis)

CURB-65

Risk-stratify for pneumonia Confusion Urea > 20 Respirations >30 Blood pressure (<90sys, <60dia) Age >=65 0 = low mortality 1-2 = middle risk 3-5 = high risk (ICU admission if >4) Moxifloxicin is a respiratory fluoroquinolone

Euvolemic hyponatremia

SIADH Tx: Fluid restriction initially, demecylcline (reduces effects of ADH, but nephrotoxic so only use if fluid restriction/salt tablets does not work) Correlated with small cell lung cancer (smoking) Hypertonic solution as tx should only be used if symptomatic hyponatremia, because of risk of overcorrecting

Limited cutaneous systemic sclerosis

Scleroderma on head and distal UE Prominent vascular manifestations - Raynaud phenomenon - Pulmonary HTN (no infiltrates on xray) - Cutaneous telangectasia CREST syndrome Anti-centromere antibodies Better prognosis

Diffuse cutaneous systemic sclerosis

Scleroderma on trunk and UE Prominent internal organ involvement - Scleroderma renal crisis - Myocardial ischemia and fibrosis - Interstitial lung disease Anti-Scl-70 (topoisomerase) Anti-RNA polymerase III antibodies Worse prognosis

Bronchogenic cyst

Seen on AP chest xray, but dx best with CT Located in middle mediastinum Benign Other mediastinal masses: tracheal tumors, pericardial cysts, lymphona, lymph node enlargement, aortic aneurysms of the arch Anterior mediastinum: retrosternal thyroid, teratoma, lymphoma, thymoma. Pts may have chest discomfort and heaviness; hoarseness/Horner's syndrome may occur if tumors invade locally Posterior mediastinum: Neurogenic tumors: meningocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, aortic aneurysms. Use MRI to dx.

Idiopathic pulmonary fibrosis

Slow deterioration of lung function (progressive dyspnea on exertion) Restrictive profile Presents 50-70YO End-inspiratory crackles/squeaks Digital clubbing Abnormal S2 (loud P2, fixed split S2) due to pulmonary HTN Exposure to navy => asbestos => possible fibrosis

Small pneumothorax

Small (<2cm): Supportive with supplemental O2 Large and stable: Needle thoracostomy or chest tube

PE effusions

Small pleural EXUDATIVE effusions (high neutrophil)

Granulomatosis with polyangiitis (Wegener)

Small-medium vasculitis that involves Nose (saddle-nose deformity), lungs, renal, skin (livedo reticularis, nonhealing ulcer) Xray: Tracheal narrowing with ulceration, multiple lung nodules with cavitation with alveolar opacities Dx: ANCA, bx Tx: Corticosteroids, immunomodulators (MTX, cyclophosphamide)

Centracinar emphysema

Smoking-related COPD

GERD

Sore throat Morning hoarseness Worsening cough only at night Increased need for her albuterol inhaler after meals Can exacerbate asthma

Acute pulmonary edema sx

Sudden onset chest pain with rapid progression to orthopnea and dyspnea Bilateral crackles Third heart sound

Pancoast tumor

Superior pulmonary sulcus tumor Tumor compression of brachial plexus - radiating arm pain and parasthesias Horner syndrome due to invasion of sympathetic trunk Hoarseness due to recurrent laryngeal involvement Superior vena cava syndrome Weight loss

COPD exacerbation tx

Supplemental O2 Short-acting bronchodilators (B2 agonist/anticholinergic) Systemic glucocorticoids Abx (in certain pts)

Respiratory distress syndrome

Surfactant deficiency Diffuse reticular (ground-glass) appearance, air bronchograms, low lung volumes Tx: Glucocorticoids, and continuous positive air ventilation

Complement deficiency

Susceptibility to encapsulated organisms

PE findings

Tachypnea, tachycardia, low-grade fever ECG: S1Q3T3 Imaging: Hampton hump, Westermark sign Correlation: Afib, perhaps JVD

Oral corticosteroids side effect

Thrush

Sodium bicarbonate

Treatment for severe acute metabolic acidosis (<7.2)

Hypersensitivity pneumonitis

Tx: Avoidance of antigen causing problem Complications: Pulmonary fibrosis, clubbing, weight loss, honeycombing of lung Imaging: Noncaseating granulomas; xray shows reticular, nodular, or alveolar opacities (NO cavitation)

Moderate or large effusions tx

U/S and drainage (chest tube, video-assisted thorascopic surgery)

Coccidiomycosis

Unilateral infiltrate with ipsilateral hilar LAD Bx has spherules with endospores Western US (including Arizona)

Obstructive sleep apnea

Upper airway collapse

Recurrent pneumonia

Use CT to figure out what's going on (and rule out malignancy) Internal bronchial obstruction (foreign body, bronchiectasis, bronchial stenosis, endobronchial carcinoid) External bronchial compression (lymphadenopathy, tumor, vascular anamoly) Afterwards, may want to do bronchoscopy for bx

COPD exacerbation tx

Use a trial of noninvasive positive-pressure ventilation first. If fails, then intubate.

Pleural effusion

Use thoracentesis to diagnose (need to know if it's malignant or not, exudative vs. transudative) Malignant: Lung and breast carcinomas, lymphoma

Eosinophilic granulomatosis with polyangiitis (Churg- Strauss)

Usually dxed in adulthood Sx: Chronic rhinosinutis (nasal polyps), asthma, eosinophilia

Burn victim

Usually intubate (low threshold) because can be progressively harder with airway edema in the future

PE CT

Wedge-shaped pleural-based opacification Contrast-enhanced CT will show a pulmonary artery filling defect

Esophageal rupture xray

With subcutaneuous crepitus appears as a pneumomediastinum (widened top and air under the heart)

Pneumonia dx

Xray first! Then treat. Need to confirm

Diaphragmatic rupture

Xray may show, but use CT to confirm Children may present without problems in the beginning, but then worsen with time (can take up to months)

Goodpasture's disease

Young adult males Nephritis-range proteinuria Acute renal failure Urinary sediment with dysmorphic RBCs and red cell casts Pulmonary: Shortness of breath, cough, hemoptysis caused by pulmonary hemorrhage Systemic symptoms Patchy bilateral pulmonary infiltrates Path: Antibodies to alpha-3 chain of collagen IV in basement membranes (glomerular and alveolar) Dx: Renal bx shows linear IgG deposition

Panacinar emphysema

alpha 1 antitrypsin deficiency

Fluticasone

inhaled glucocorticoid for asthma (not COPD)

Roflumilast

phosphodiesterase-4 inhibitor with anti-inflammatory properties (can be used in COPD for maintenance and asthma (?))