PULMONOLOGY TIKI TAKA

_______________________
. BRONCHIAL ASTHMA:
___________________
___________________
. SHORTNESS OF BREATH (SOB) + EXPIRATORY WHEEZES.
. Severe asthma -> Use of accessory muscles & inability of speaking complete
sentence.
. SEVERE ASTHMA EXACERBATION manifestations:
_____________________________________________
-> ++ RR = Hyperventillation.
-> -- in peak flow.
-> -- O2 = Hypoxia.
-> -- pH = Respiratory acidosis.
-> Possible absence of wheezes (To wheeze, one must have air flow!).
. Dx -> Pt with SOB & unclear if the cause is BA:
__________________________________________________
-> Do "PULMONARY FUNCTION TESTS" (PFTs) before & after INHALED
BRONCHODILATORS:
-> ++ in FEV1 > 12 % -> Confirmed BA.
. Dx -> Asymptomatic pt now i.e. H/O of intermittent SOB episodes but now he is
normal:
_____________________________________________________________________________________
___
-> Do "METACHOLINE STIMULATION TEST":
-> -- in FEV1 in response to synthetic acetylcholine (if the pt has BA).
. Tx -> ACUTE ASTHMA:
______________________
-> INHALED BRONCHODILATORS (SABA) -> ALBUTEROL.
-> BOLUS "Not inhaled" of steroids (Methyl prednisone).
-> INHALED IPRATROPIUM.
-> OXYGEN.
-> Magnesium.
. N.B. Any BA pt. with RESPIRATORY ACIDOSIS & CO2 RETENTION sh'd be placed in
the ICU.
-> Persistent resp. acidosis is an indication of INTUBATION & MECHANICAL
VENTILLATION.
. The following therapies have "NO BENIFIT" in acute asthma exacerbation:
-> Theophylline - Cromolyn - Montelukast - INHALED steroids - LABA "Salmeterol".

. NON-ACUTE BA:
________________
-> Best initial -> INHALED BRONCHODILATORs (ALBUTEROL).
-> Not controlled -> ADD + INHALED STEROIDs.
-> Not controlled -> ADD + INHALED LABA (SALMETEROL).
.
.
.
.

Extrinsic allergies (HAY FEVER) -> Cromolyn or nedocromil.

High Ig E levels not controlled with Cromolyn -> Omalizumab.
Atopic disease -> Montelukast.
COPD -> Ipratropium.

. N.B. VVVVVVVVVVVVVV. imp. GERD can exacerbate airflow obstruction in

asthmatics:
___________________________________________________________________________________
. Due to ++ vagal tone & micro-aspiration of gastric contents into the upper airway.
. Risk factors: Obesity, supine position after meals, laryngitis.
. Manifestations: Change in voice & NOCTURNAL COUGH. (ACE Is lead to day &
night cough!).
. Anti-GERD life style modification.
. Give a trial of a proton pump inhibitor (Esomeprazole).
. GERD is present in 75% of asthma pts & may be the trigger of many cases.
. Adult onset asthma with GERD (Worsening syms after meals or with lying down).
. Obesity, hoarsness, pharyngitis & laryngitis tend towards GERD.
. A trial of proton pump inhibitors (Omeprazole) can be both diagnostic &
therapeutic.
. N.B. Efficacy of BETA blockers for mortality in cases of MI & CHF is more important
than its adverse effects e.g. Asthma & COPD.
. N.B. Exercise induced asthma -> Tx with INHALED BRONCHODILARORS prior to
exercise.
. N.B. All pts with SOB sh'd 've -> O2 - pulse oximeter - CXR & ABG.
. TREATMENT OF BRONCHIAL ASTHMA DEPENDS ON ITS SEVERITY:
_________________________________________________________
* INTERMITTENT -> CONTINUE CURRENT REGIMEN SABA (B-agonists: ALBUTEROL):
_________________________________________________________________________
. Day time syms < 2 /week.
. Night time awakenings < 2 / month.
. B-agnists < 2 / week.
. Normal PFTs.
. No limitations on daily activities.
* MILD PERSISTENT -> ADD INHALED CORTICOSTEROIDS:
__________________________________________________

.
.
.
.

Day time syms > 2 /week.

Night time awakenings 3-4 / month.
Normal PFTs.
MINOR limitations on daily activities.

* MODERATE PERSISTENT -> ADD INHALED LABA (SALMETEROL):

________________________________________________________
. Daily symptoms.
. Weekly Night time awakenings.
. FEV1 <60 - 80 % of predicted.
. Moderate limitations on daily activities.
* SEVERE PERSISTENT -> ADD ORAL PREDNISONE:
____________________________________________
. Symptoms through out the day.
. Frequent night time awakenings.
. FEV1 < 60 % of predicted.
. Severe limitation on daily activity.
. IMPORTANT DRUG SIDE EFFECTS:
______________________________
______________________________
. N.B. The most common adverse effect of INHALED CORTICOSTEROIDS is
OROPHARYNGEAL THRUSH.
. N.B. The most common adverse effect of "IV" CORTICOSTEROIDS is -- WBCs
"NEUTROPHILIA".
. Glucocorticoids ++ bone marrow release of of neutrophils.
. Glucocorticoids mobilize the marginated neutrophilic pool.
. Eosinophils & lymphocytes are decreased.
. N.B. High doses of B2 agonists may develop HYPOKALEMIA !
. Hypokalemia may present as ms weakness, arrhythmia & EKG abnormalities.
.
.
.
.
.

N.B. Theophylline toxicity:

CNS stimulation (Headache, insomnia & seizures).
GIT disturbances (Nausea & vomiting).
Cardiac toxicity (Arrhythmia - Multifocal atrial tachycardia & premature beat).
Dx -> Measure serum theophylline levels.

. INDICATORS OF SEVERE ASTHMATIC ATTACK:

________________________________________
. NORMAL or INCREASED CO2 is the worst sign indicating acute severe attack.
. CO2 retention is due to severe airway obstruction (air trapping) & respirat. ms
fatigue
. Speech difficulties.
. Diaphoresis.
. Altered sensorium.
. Cyanosis.
. SILENT lungs.

. ACUTE EPISODES of SOB MANAGEMENT:

___________________________________
-> Oxygen & ABG.
-> CXR.
-> SABA "ALBUTERL" INHALED.
-> IPRATROPIUM INHALED.
-> BOLUS of steroids (Methyl prednisone).-------> VVVVVVVVVVV. imp.
-> Chest, heart, extremity & nerological exam.
-> If fever, sputum & or new infiltrate is present on CXR:
ADD CEFTRIAXONE & AZITHROMYCIN for community acquired pneumonia.
. N.B. In pts with acute asthma exacerbation, an ELEVATED or even NORMAL PCO2
= RF.
. Respiratory failure due to -- respiratory drive due to respiratory muscle fatigue.
. ENDO-TRACEAL INTUBATION & MECHANICAL VENTILLATION is MANDATORY.
. Add inhaled SABA (Albeterol) & inhaled ipratropium & systemic corticosteroids.
. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD):
_______________________________________________
_______________________________________________
. H/O of long term smoker with ++ SOB & -- exercise tolerance.
.
.
.
.
.

Barrel shaped chest.

Clubbing of fingers.
++ A-P diameter of the chest.
Loud P2 heart sound (Sign of pulmonary hypertension).
Edema (Sign of -- Rt ventricular out put).

. EKG -> Rt. axis deviation - Rt atrial & ventricular hypertrophy.

. CXR -> Elongated heart - Flattenning of the diaphragm due to hyperinflated lungs.
. N.B. FLATTENING OF THE DIAPHRAGM ++ The WORK OF BREATHING.
. CBC -> ++ Hematocrit & reactive microcytic eryhthrocytosis due to chronic
hypoxia.
. ABG -> ++ pCO2 & -- pO2 & -- pH (Respiratory acidosis).
. Chemistry -> ++ serum bicarbonate as metabolic compensation for respiratory
acidosis.
. N.B. (1):
. ABG is critical in acute SOB due to COPD (No other way to assess for CO2
retention !).
. N.B. (2):
. ABG is important to assess for CO2 retention.
. ABG is important to assess for the need for chronic home oxygen based on pO2.
. N.B. (3):

. In moderate & severe cases of COPD, pts may become members of the 50/50
club !!
. Both pO2 & pCO2 are around 50s !
. Ex -> pH. 7.35 - pCO2 49 - pO2 52 - HCO3 32.
. PULMONARY FUNCTION TESTS in COPD -> OBSTRUCTIVE PATTERN:
___________________________________________________________
-> -- FEV1.
-> -- FVC (Loss of elastic recoil of the lung).
-> -- FEV1/FVC ratio.
-> ++ Total Lung Capacity (++ TLC due to air trapping .. VVVVVVVVVVVV.imp.).
-> ++ Residual Volume.
-> -- Diffusion capacity lung CO (-- DLCO due to destruction of lung interstitium).
-> INCOMPLETE IMPROVEMENT WITH ALBUTEROL (# Asthma).
-> LITTLE OR NO IMPROVEMENT WITH METACHOLINE (# Asthma).
. N.B. A bronchodilator response test to differentiate COPD from BA:
____________________________________________________________________
. Measuring FEV1 before & after adminstration of bronchodilator (B2 agonist).
. Significant improvement in FEV1 (> 15%) after bronchodilator -> Reversibility =
Asthma.
. Little or no improvement in FEV1 after bronchodilator -> Irreversibility = COPD.
. N.B. Chronic hypercapneic respiratory failure due to COPD:
____________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory
acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !
. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++
bicarbonate retention.
. CHRONIC MEDICAL THERAPY of COPD:
___________________________________
. IPRATROPIUM or TIOTROPIUM INHALED (Most effective therapy to reduce syms in
COPD).
. SABA ALBUTEROL INHALED.
. Pneumococcal vaccine -> Hepatavalent vaccine (Pneumovax).
. Influenza vaccine yearly.
. Long term home oxygen therapy (If pO2 < 55 or SO2 < 88%).
. N.B. Long term O2 therapy in a pulmonary hypertension pt or HCT > 55% -> PaO2
< 60 mmHg.
. N.B. Both smoking cessation & home oxygen therapy & vaccines lower mortality in
COPD.

. N.B. SABA (Albuterol), Anticholinergic (Anti-muscarinic ipratropium),LABA &

STEROIDS:
improve symptoms only without -- mortality rate.
. N.B. INHALED ANTI-CHOLINERGICS = INHALED MUSCARINIC ANTAGONISTS INHALED IPRATROPIUM
are the most effective in COPD.
. N.B. Cromolyn & Montelukast have no benefit in COPD.
. ACUTE EXACERBATION OF COPD TTT:
_________________________________
. Acute worsening of symptoms in a pt. with COPD.
. Caused by upper respiratory tract infection.
. May be preceided by cough & fever.
. Exam -> Bilateral wheezes.
. ABG -> Respiratory acidosis & hypoxia.
.
.
.
.
.
.

Inhaled bronchodilators (B2 agonists = Albuterol).

Inhaled anti-cholinergics (Ipratropium).
Broad spectrum antibiotics.
INHALED CORTICOSTEROIDS for 2 weeks then tapered gradually.
Smoking cessation.
Oxygen (If pO2 < 55 mmHg or SO2 < 88%).

. N.B. Pts with acute on chronic respiratory failure ttt with high flow supplemental
O2,
. are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS,
. due to a combination of reduced alveolar ventillation & ++ dead space
ventillation,
. causing ventillation perfusion mis-match & -- Hb affinity for CO2.
. The goal oxy-hemoglobin saturation in these pts is 90 - 94 % (Not > 95%)!
. NON INVASIVE POSITIVE PRESSURE VENTILLATION (NIPPV):
_______________________________________________________
. Used in acute exacerbations of COPD REFRACTORY to ttt with B-agonist & inhaed
steroids.
. Used before intubation to avoid its side effects e.g. infection.
. Recommended in pt e' respiratory distress with a pH<7.35 or pCO2>45mmHg or
RR>25/min.
. It is contraindicated in septic, hypotensive or dysrhythmic pts.
. NIPPV will provide more O2 & wash out excess CO2.
. If the pt. is refractory to NIPPV -> Intubate with mechanical ventillation !
. SPONTANEOUS PNEUMOTHORAX (A complication of COPD):
____________________________________________________
. COPD pt presenting with catastrophic worsening of respiratory symptoms.
. Cigarette smoking markedly ++ risk of pneumothorax.
. It leads to chronic airway inflammation & respiratory bronchiolitis.

. The chronic destruction of the alveolar sacs -> Formation of large alveolar blebs.
. which can rupture & leak air into the pleural space.
. presents with acute onset of chest pain & shortness of breath.
. Breath sounds are markedly reduced & hyperresonance to percussion on affected
side.
. VVVVVVVVV. IMP. TWO PRIMARY SUB-TYPES OF COPD: CHRONIC BRONCHITIS &
EMPHYSEMA:
_________________________________________________________________________________
{A} . COPD with EMPHYSEMA pre-dominance -> (-- DLCO):
______________________________________________________
. Thin pts with severe dyspnea, hyperinflated chest.
. DECREASED vascular markings.
. SEVERE flattening of diaphragm.
. DECREASED DLCO -> due to alveolar destruction.
{B} . COPD with CHRONIC BRONCHITIS pre-dominance -> (NORMAL DLCO):
___________________________________________________________________
. Chronic productive cough for > 3months over 2 consecutive years.
. Due to hypersecretion of mucus & structural changes in the tracheo-bronchial
tree.
. PROMINENT vascular markings.
. MILD flattening of diaphragm.
. NORMAL DLCO.
. EXACERBATION OF CONGESTIVE HEART FAILURE:
___________________________________________
. H/O of coronary artery disease -> Lt ventricular dysfunction -> Heart failure.
. Un-controlled hypertension & smoking H/O are risk factors for coronary vascular
disease
. LVF -> Tachypnea -> fluid pooling in the lungs -> pleural effusion ->
Hypoventillation.
. Hypoventillation -> Hypoxemia.
. Tachypnea -> Hypocapnia & respiratory alkalosis.
. Signs of fluid overload - S3 & S4 gallops & cardiomegaly.
. Lung exam -> Bi-basilar crackles.
. Lung exam -> -- breath sounds at lung bases due to pleural effusion from CHF.
. Wheezing can occasionally be present (Cardiac asthma).
. ABG -> HYPOXIA - HYPOCAPNIA - RESPIRATORY ALKALOSIS (COPD -> Respiratoy
ACIDOSIS).
. Dx -> BNP & PCWP.
. ALPHA 1 ANTI-TRYPSIN DEFECIENCY:
__________________________________
__________________________________
. Genetic disorder.
. Liver cirrhosis + COPD.
. NON-smoker.

.
.
.
.
.

Early age < 40 ys NON-smoker having BULLAE at the base of the lungs.
Dx -> CXR -> Findings of COPD (Bullae - Barrel chest - Flat diaphragm).
Dx -> Blood test -> -- ALBUMIN & ++ PT (Cirrhosis).
Dx -> -- Alpha-1 antitrypsin level.
Tx -> Alpha-1 antitrypsin infusion !

. BRONCHIECTASIS:
_________________
_________________
. Cough - mucopurulent sputum - hemoptysis.
. Profound dilatation of the bronchi.
. due to anatomic defect in the lungs mostly due to infection in childhood.
. Episodes of lung infection with high volume of sputum.
. Hemoptysis & fever may occur.
. Dx -> CXR -> Dilated bronchi (TRMA TRACKING).
. Dx -> CT Chest -> Most accurate test.
. Tx -> No curative therapy.
. Just ttt the infectious episodes with rotating antibiotics to avoid resistance.
. CYSTIC FIBROSIS:
__________________
__________________
. Young pt.
. Mutation in the Chloride transporter protein CFTR.
. Abnormally thick secretions.
. Affect the respiratory tract - sinuses - pancreas - intestines & reproductive
systems.
. Respiratory tract -> Chronic cough e' frequent exacerbations & superimposed
infections.
. Most pts develop BRONCHIECTASIS leading to HEMOPTYSIS.
. Pancreas -> Fat malabsorption with bloating & greasy, floating stools.
. Dx -> CT -> Atrophic pancreas with calcifications.
. INTERSTITISAL LUNG DISEASES (ILD):
____________________________________
____________________________________
. Pulmonary fibrosis 2ry to environmental or occupational exposure
(Pneumoconiosis).
. Also caused by medications (NITROFURANTOIN & TMP-SMX "BACTRIM").
. If the etiology is unknown (IDIOPATHIC PULMONARY FIBROSIS).
.
.
.
.
.
.

ASBESTOSIS -> Shipyard - Mining - Construction workers - Pipe fitters).

SILICOSIS -> Glass workers - Mining - Sandblasting & Brickyards.
COAL WORKER's PNEUMONIA -> Coal worker !
BYSSINOSIS -> COTTON.
BERYLLIOSIS -> Electronics - Ceramics - Fluorescent & Light bulbs.
PULMONARY FIBROSIS -> Mercury.

. Shortness of breath.

.
.
.
.
.

"DRY" = NON productive cough & chronic hypoxia.

Dry rales - Bi-basilar end-inspiratory crackles.
Loud P2 (Sign of pulmonary hypertension).
Digital clubbing.
NOOOO FEVER - NOOOO systemic findings.

.
.
.
.
.

Dx
Dx
Dx
Dx
Dx

->
->
->
->
->

CXR -> Interstitial fibrosis & Honeycombing.

CXR -> Pulmonary vascular congestion at the hilum.
CT -> PLEURAL PLAQES ARE PATHOGNOMONIC (Pneumoconiosis)!
Lung biopsy.
PFTs -> ALL MEASURES ARE DECREASED but PROPORTIONATELY.

. PULMONARY FUNCTION TESTS in ILD -> RESTRICTIVE PATTERN:

__________________________________________________________
-> -- FEV1.
-> -- FVC.
-> NORMAL FEV1/FVC ratio.
-> -- TLC.
-> -- RV.
-> -- DLCO (VVVVVVVVVV. imp.).
-> VVVVVVVVVV. imp. -> ILF -> +++ A-a gradient !
. Tx -> No specific therapy to reverse any of ILD forms.
. If the lung biopsy shows an inflammatory infiltrate, a trial of steroids is used.
. The only form of ILD that responds to steroids is BERYLLIOSIS (Granulomatous
disease).
. N.B. The most common type of cancer in ASBESTOSIS is LUNG CANCER not
mesothelioma.
. N.B. ILD may be complicated by COR PULMONALE:
-> peripheral edema - Hepatojugular reflex - Jugular venous distension - Rt ventr.
heave.
. COMPARISON BETWEEN PFTs in COPD & ILD:
________________________________________
. COPD -> OBSTRUCTIVE PATTERN & ILD -> RESTRICTIVE PATTERN:
___________________________________________________________
. PFTs ___________ COPD __________ ILD
.
.
.
.
.
.

FEV1 ___________ ---- __________ -FVC ___________ -- __________ -FEV1/FVC _______ -- __________ NORMAL
TLC ____________ ++ __________ -RV _____________ ++ __________ -DLCO ___________ -- __________ --

. BRONCHILOTIS OBLITERANS ORGANIZING PNEUMONIA BOOP / CRYPTOGENIC

ORGANZING PNEUMONIA COP:
_____________________________________________________________________________________
_____
_____________________________________________________________________________________
_____
. Inflammation of the small airways with a chronic alveolitis of an unkown origin !
. Associated with Rheumatoid arthritis.
. Resembles ILD but more acute presentation (Over weeks to months).
. (SOB - Cough - rales) + FEVER + MALAISE + MYALGIA.
. No occupational exposure in history !
. CXR -> Bilateral PATCHY infiltrates.
. CT -> Inerstitial disease & alveolitis.
. Most accurate -> OPEN LUNG BIOPSY !
. Tx -> Steroids (No response to antibiotics).
. COMPARISON BETWEEN BOOP/COP & ILD:
____________________________________
. BOOP/COP _______________________________ . ILD
. Fever- myalgia - malaise _______________ . NO.
. Presents over days to weeks ____________ . 6 months or more of symptoms.
. PATCHY infiltrates _____________________ . INTERSTITIAL infiltrates.
. STEROIDs EFFECTIVE _____________________ . Only BERYLLIOSIS may respond to
steroids.
. SARCOIDOSIS:
______________
. AFRICAN AMERICAN WOMEN.
. Age < 40s.
. SOB - Cough & fatigue over a few weeks to months.
. Lung - > Rales.
. Eye -> ANTERIOR UVEITIS (Sight threatening).
. Neural -> Facial palsy (7th cranial nerve).
. Skin -> ERYTHEMA NODOSUM.
. Joint -> Polyarthralgia.
. Heart -> RESTRICTIVE CARDIOMYOPATHY.
. HYPERCALCEMIA (2ry to Vit.D production by the granulomas).
. Dx -> Best initial test -> CXR.
. CXR -> BILATERAL HILAR LYMPHADENOPATHY & diffuse interstitial infiltrates.
. Dx -> Most accurate test -> LUNG or LN biopsy -> NON-CASEATING GRANULOMA.
. Dx -> ++ Ca & ++ ACE levels
. Dx -> BAL -> ++ helper cells.
. Tx -> STEROIDs.

. SYSTEMIC SCLEROSIS:
_____________________
. Pulmonary symptoms (Due to interstitial fibrosis).
. Dysphagia.
. Raynaud's phenomenon.
. Hypertension.
. Telangiectasia.
. PULMONARY HYPERTENSION:
_________________________
. Mean pulmonary arterial blood pressure > 25 mmHg.
. Overgrowth & obliteration of pulmonary vasculature -> -- outflow of the Rt
ventricle.
. SOB more often in young women.
. May be 2ry to (MS - COPD - PCV - ILD & chronic pulmonary emboli).
. Physical findings (Loud P2 - TR - RV heave).
. Dx -> TRANS-THORACIC ECHOCARDIOGRAM (TTE) -> Rt atrial & ventricular
hypertrophy.
. Dx -> EKG -> Rt axis deviation.
. Dx -> CXR -> Pulmonary arteries enlarg. & RVE & tapering of distal vessels
(Pruning).
. Most accurate -> RIGHT HEART SWAN GANZ CATHETERIZATION -> ++
PULMONARY ARTERY pressure.
. Tx -> BOSENTAN -> Endothelial inhibitor.
. May be complicated by RVF (Rt ventricular heave - JVD - Tender hepatomegaly Ascites).
. COR PULMONALE:
________________
. Rt sided heart failure due to pulmonary disease.
. Jugular venous distension.
. Right sided S3 gallop.
. Right ventricular heave.
. Hepatomegaly.
. Ascites.
. Dependent LL edema.
. Most commonly caused by COPD (Flattened diaphragm - prominent pulmonary
vessels on CXR)
. CXR -> Prominent right ventricle & pulmonary artery.
. PULMONARY EMBOLISM:
_____________________
_____________________
. PERFUSION DEFECT & NO VENTILLATION DEFECT.
. ++++++++++++++++++++++++++++ A-a gradient.
. SUDDEN onset SOB + CLEAR LUNGs.
. Risk factors of DVT (Immobility - Malignancy - Trauma - Surgery - Thrombophilia).
. H/O of recent orthopedic surgery followed by bed rest.

. No specific physical finding for PE.

. MODIFIED WELL'S CRITERIA for PRE-TEST PROPABILITY of PE:
___________________________________________________________
-> Score + 3 points (Clinical signs of DVT).
-> Score + 1.5 points (Prev PE/DVT - HR>100 - Recent surgery <4wks Immobilization>3ds)
-> Score + 1 point (Hemoptysis - cancer).
-> Total score for clinical propability (< 4 -> PE UN-likely .. > 4 -> PE likely).
.

. Clinical assessment for pulmonary embolism

.____________________________________________
.< Modified Well's criteria>
.____________________________
|
.________________________________
.|
.|
. PE UN-likely
. PE likely
.______________
.___________
.|
.|
. D-dimer assay
.|
._______________
.|
.|
.|
.___________________
.|
.|
.|
.(< 500 ng/ml)
.(> 500 ng/ml)-->. CT PULMONARY ANGIOGRAPHY
.|
.____________________________
. PE EXCLUDED
.|
.(-ve = PE EXCLUDED BUT +ve = PE CONFIRMED)

. INITIAL DIAGNOSTIC TESTS -> CXR - EKG - ABG.

. CONFIRMATORY TESTS -> Spiral CT - V/Q scan - LL Doppler - D-Dimer.
. MOST ACCURATE TEST -> PULMONARY ANGIOGRAPHY = CHEST CT ANGIOGRAPHY
with IV CONTRAST.
. 1 . CXR:
___________
. Most common result -> NORMAL.
. Most common abnormailty -> Atelectasis.
. Wedge shaped infarction & pleural humps are rare.
. 2 . EKG:
___________
. Most common showing -> SINUS TACHYCARDIA.
. Most common abnormality -> NON-SPECIFIC ST-T WAVE CHANGES.
. Right axis deviation & Rt BBB are rare.

. 3 . ABG:
___________
. HYPOXIA -> ++ A-a gradient.
. Mild respiratory alkalosis.
. 4 . SPIRAL CT -> TEST OF CHOICE if the CXR is ABNORMAL:
__________________________________________________________
. Standard to confirm the presence of a pulmonary embolus.
. Excellent if +ve being specific.
. Not specific as it can miss some emboli if they are small & in the periphery.
. Chest CT showing a WEDGE SHAPED infarction is PATHOGNOMONIC for pulmonary
embolism.
. 5 . VENTILLATION PERFUSION V/Q SCAN -> TEST OF CHOICE if the CXR is NORMAL:
______________________________________________________________________________
. PERFUSION DEFECT with NO VENTILLATION DEFECT.
. NORMAL V/Q scan excludes pulmonary embolism.
. 6 . LOWER EXTREMITY DOPPLER:
_______________________________
. If +ve -> No further tests are needed to confirm PE.
. The problem is that 30 % of PEs originate in pelvic veins, so the LL Doppler is
NORMAL.
. So it has low sensitivity i.e. can't exclude PE.
. 7 . D-DIMER TESTING = FIBRIN SPLIT PRODUCTS TESTING:
_______________________________________________________
. SINGLE TEST TO EXCLUDE PE.
. Very sensitive test with poor specificity.
. D-DIMER -> NEGATIVE -> NO PULMONARY EMBOLISM.
. D-DIMER -> Not specific -> May be other causes.
. The best use of D-DIMER test is in a pt with LOW propability of PE,
. & u want a single test to exclude PE !!
. 8 . ANGIOGRAPHY -> SINGLE MOST ACCURATE TEST FOR PE:
______________________________________________________
. ANGIOGRAPHY = CHEST CT ANGIOGRAPHY WITH INTRAVENOUS CONTRAST
(VVVVVV. imp.).
. INVASIVE with risk of death (0.5%).
. MANAGEMENT of PULMONARY EMBOLISM:
___________________________________
{1} HEPARIN & OXYGEN -> Standard of care.
{2} Warfarin -> Sh'd be used at least for 6 months after Heparin.
{3} IVC filter -> in case of contraindication to Anticoagulants (e.g. hematoma).
{4} Thrombolytics -> used in pts who r hemodynamically UN-stable (e.g.
hypotension).
{5} Embolectomy is rarely done (High risk of death).
. N.B. When the case so clearly suggests a pulmonary embolism,

. i.e. Pt presenting with sudden onset of SOB & clear lungs with H/O of major
surgery,
. the 1st thing to do is CXR & ABG followed by HEPARIN.
. Don't wait the results of V/Q scan or spiral CT to start heparin !!
. When there is a contraindication to anticoagulation e.g. hematoma,
. Don't use heparin ! Place an IVC filter.
. For anticoagulation, "Un-fractionated" heparin is preferred in pts with -- GFR !
. LMW heparin (Enoxaparin) can't be given as it causes severe renal insuffeciency.
.
.
.
.

Warfarin can be thrombogenic without heparin as a bridge !

It sh'd be given after initiating heparin with PTT goal 1.5-2 times of normal.
Warfarin takes up to 5-6 days to reach its therapeutic level.
After reaching therapeutic INR level (2-3), heparin can be stopped.

. VVVVVV. imp. N.B. A PROGRESSING CLOT in a pt with sub-therapeutic INR (ex.

1.2),
. requires BRIDGING HEPARIN until the INR is therapeutic (2-3),
. Example .. A pt recently hospitalized for LL DVT then discharged,
. After 5 days, U$ reveals popliteal vein thrombosis extending into the deep femoral
vein
. So .. U sh'd START INTRAVENOUS UNFRACTIONATED HEPARIN & CONTINUE
WARFARIN.
. The proximal deep leg veins are the most common source of symptomatic
pulmonary embolism
. Less common sources of emboli include calf, pelvic & upper evtremity veins & Rt
heart.
. "Factor V Leiden" is the most common genetic disorder causing hypercoagulability
& DVT.
. N.B. Acute massive pulmonary embolism can present initially with syncope &
shock.
. e.g. sudden loss of consciousness at work, BP:80/40 & HR:120/min with cold
clammy skin.
. Rt heart catheterization -> ++ Right atrial & pulmonary artery pressures.
. Normal PCWP Pulmonary artery capillary wedge pressure.
. N.B. Massive pulmonary embolism usually presents with signs of low arterial
perfusion,
. Hypotension, acute dyspnea, pleuritic chest pain, tachycardia & syncope.
. The thrombus ++ pulmonary vascular resistance & Rt ventricular pressure,
. causing Rt ventricular hypokinesis -> Rt ventricular dilatation.
. APPROACH TO MANAGEMENT OF PATIENT WITH SUSPECTED PULMONARY
EMBOLISM:
______________________________________________________________________

______________________________________________________________________
. Stabilize the pt with Oxygen & IV fluids
._________________________________________
.|
. CONTRAINDICATIONS to Anticoagulate ?
._____________________________________
.|
._______________________________________________
.|
.|
. YES = Diagnostic tests to evaluate for PE
. NO = MODIFIED WELL's
CRITERIA
.__________________________________________
._______________________________
.|
.|
._____________________
._______________
.|
.|
.|
.|
. +ve PE
. -ve PE
. PE Un-likely . PE likely
.________
.________
.______________ .___________
.|
.|
.|
.|
. IVC FILTER
. No further tests
.| . START anticoagulation
.| .______________________
.|
.|
. D-DIMER TESTING for PE
.________________________
.|
._____________________________________________________________________
.|
.|
. +ve
. -ve
. Start or continue anticoagulation,
. STOP anticoagulation
. consider surgery or thrombolysis if indicated.

. PLEURAL EFFUSION:
___________________
___________________
. Best initial test -> CXR.
. Decubitus films (Pt lying on one side) sh'd be done next to assess the fluid
mobility.
.
.
.
.
.
.

Most accurate test -> THORAC-CENTESIS.

Un-diagnosed pleural effusion is best evaluated with THORACOCENTESIS,
To detect whether it is a transudate or an exudate.
Except in pts with clear-cut evidence of congestive heart failure,
Associated fluid overgain, pedal edema & bilateral lung base crackles.
Diuretics & echo sh'd be done not thoracocentesis.

. COMPARISON BETWEEN EXUDATE & TRANSUDATE (VVVVVVVVVVV. imp.):

_______________________________________________________________

. EXUDATE PLEURAL EFFUSION ______________________ . TRANSUDATE PLEURAL

EFFUSION
. Cancer & infection & Pulmonary embolism _______ . Congestive heart failure &
cirrhosis.
. High ptn level > 50 % of serum level __________ . Low ptn level < 50 % of serum
level.
. High LDH level > 60 % of serum level __________ . Low LDH level < 60 % of serum
level.
. LDH > 2/3 upper limit of normal serum LDH (250) . < 2/3 !
. pH > 7.3 (Normal 7.6) ______________________ . pH < 7.3 (++ acid prod. by
bacteria).
. NO CHANGE IN GLUCOSE OR AMYLASE LEVELS IN BOTH TYPES !
.
.
.
.
.

Tx -> Small pleural effusions don't need therapy !

Diuretics can be used for those caused by congestive heart failure.
Larger effusions esp. those caused by empyema -> Drain by CHEST TUBE.
Large recurrent effusion from an un-correctable cause -> PLEURODESIS.
If pleurodesis failed -> Decortication.

. N.B. 1 -> EXUDATE -> MALIGNANCY OR INFECTION -> ++ Capillary permeability.

. N.B. 2 -> TRANSUDATE -> CONGESTIVE HEART FAILURE -> ++ HYDROSTATIC
PRESSURE.
. N.B. 3 -> TRANSUDATE -> CIRRHOTIC LIVER FAILURE -> -- PLASMA ONCOTIC
PRESSURE.
. COMPLICATED PARA-PNEUMONIC EFFUSION CRITERIA:
________________________________________________
. Exudative pleural effusion.
. Pleural fluid acidosis.
. Low pleural fluid glucose < 60 mg/dl(High metabolic activity of leukocytes or
bacteria)
. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID
ACCUMULATION:
________________________________________________________________________
1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.
. EMPYEMA = INFECTION OF THE PLEURAL SPACE:
___________________________________________
. Due to untreated pneumonia cased by bacterial invasion of a pleural effusion.
. or contamination of the pleural space by rupture of a lung abscess.
. Others: Bronchopleural fistula - penetrating trauma - thoracotomy or ruptured
viscus.

. May complicate hemothorax, the residual blood is an excellent medium for

bacteria.
. A mixed aerobic & anaerobic bacterial infection (Strept. - Staph. - Klebsilella).
. Low grade fever.
. Dx -> CT scan.
. Tx -> Drainage & antibiotics.
. Tx -> SURGERY (If localized - complex or having thick rim).
. SLEEP APNEA:
______________
. Obese pt complaining of daytime somnolence.
. The pt's partener will report severe snoring.
. Hypertension - Headache - Erectile dysfunction & fat neck.
. Obstructive sleep apnea from fatty tissues of the neck blocking breathing.
. Central sleep apnea due to -- respiratory drive from the CNS.
. Dx -> NOCTURNAL POLYSOMNOGRAPHY (GOLD STANDARD OF DIAGNOSIS).
. Mild sleep apnea -> 5 - 20 apneic periods per hour.
. Severe sleep apnea -> > 30 apneic periods per hour.
. Tx of obstructive sleep apnea -> Weight loss & CPAP:Continous positive airway
pressure
. If not effective -> Uvulo-palato-pharyngo-plasty.
. Tx of central sleep apnea -> Avoid alcohol & sedatives.
. Medroxyprogesterone -> Central respiratory stimulant.
. OBESITY HYPOVENTILLATION $YNDROME (OH$) = PICKWICKIAN $YNDROME:
_________________________________________________________________
. Severe obesity (Greater then 150% of ideal body weight -> BMI = 55!).
. Thin neck & hypersomnolence.
. Obesity -> Distant heart sounds & Low voltage QRS complexes on EKG.
. Alveolar hypoventillation during WAKEFULLNESS !
. Polycythemia secondary to alveolar hypoventillation.
. ABG -> Hypoxemia & Hypercapnia & Respiratory acidosis.
. Due to DECREASED LUNG & CHEST WALL COMPLIANCE ! (Not resp. ms weakness
xxx).
. Tx -> Weight loss - Ventilator support - Oxygen - Avoid supine posture during
sleep.
. COMPLICATIONS of long-standing OSA or OH$:
____________________________________________
. Pulmonary hypertension with cor pulmonale.
. Secondary erythrocytosis.
. Hypoxia, chronic hypercapnea & respiratory acidosis (Due to chronic
hypoventillation).
. N.B. Chronic hypercapneic respiratory failure due to OH$:

___________________________________________________________
. Marked acidosis should be the result of respiratory failure in OH$.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory
acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !
. HOW TO DIFFERENTIATE BETWEEN OBSTRUCTIVE SLEEP APNEA & OBESITY
HYPOVENTILLATION $:
____________________________________________________________________________________
____________________________________________________________________________________
.{1}. OBSTRUCTIVE SLEEP APNEA:
_______________________________
. Air flow is impeded by AIRWAY OBSTRUCTION,
. due to POOR ORO-PHARYNGEAL TONE.
. NORMAL ABG !
.{2}. OBESITY HYPOVENTILLATION $:
__________________________________
. Air flow is impeded by diminished expansion of chest & abdominal wall due to
obesity.
. ABG -> HYPO-ventillation -> Chronic hyoxia & hypercapnia.
. ALLERGIC BRONCHO-PUMONARY ASPERGILLOSIS (ABPA):
_________________________________________________
. Asthmatic pt with worsening asthma symptoms.
. Coughing of brownish mucous plugs with recurrent infiltrates.
. Peripheral eosinophilia.
. ++ Ig E levels.
. Central bronchiectasis may be seen.
. Tx -> ORAL (Not inhaled) corticosteroids.
. PULMONARY EDEMA:
__________________
. Hypoxia - SOB - Tachypnea.
. CXR -> Diffuse alveolar infiltrates.
. May be cardiogenic (LVF) or non cardiogenic (ARD$).
. Differentiate bet. the two types using pulmonary capillary wedge pressue (PCWP).
. PCWP > 18 -> Cardiogenic pulmonary edema.
. PCWP < 18 -> Non cardiogenic = ARD$.
. ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$) = NON-CARDIOGENIC
PULMONARY EDEMA:
_______________________________________________________________________________
. Sudden severe respiratory failure resulting from diffuse lung injury,
. secondary to a number of overwheming systemic injuries e.g.
. Sepsis - Aspiration of gastric contents - shock - severe infections,
. Lung contusion - trauma - toxic inhalation - drowning - pancrestitis - burns.

. CXR -> Diffuse patchy infiltrates.

. NORMAL wedge pressure -> i.e. < 18.
. pO2/FiO2 ratio < 200.
.
.
.
.
.
.
.

Tx -> Ventilatory support with low tidal volume of 6 ml/kg.

PEEP to keep the alveoli open. (Sh'd reach 15 cm H2O).
++ FiO2 (Never exceed 60 %).
Prone positioning of the pt's body.
Possible use of diuretics & +ve inotropes such as dobutamine.
Transfer the pt to the ICU if not already there !
STEROIDS ARE NOTTTTTTT EFFECIVE !

. ARD$ pts on MECHANICAL VENTILLATION:

_______________________________________
. Mechanical ventillation includes two components FiO2 & PEEP.
. FiO2 = Fraction of inspired oxygen.
. PEEP = Positive end expiratory pressure.
. ++ FiO2 -> Improves oxygenation.
. PEEP -> Prevent alveolar collapse.
. Arterial pO2 is influenced by FiO2 & PEEP.
. Arterial pCO2 is influenced by RR & TV.
. When you find a given ABF with pO2 55 mmHg = Low oxygenation. & FiO2 = 70%
. So .. You should add PEEP 1st to improve oxygenation.
. Don't decrease the FiO2 before adding PEEP or you will worsen the condition !
. When you find a given ABG with pO2 105 mmHg = TOXIC OXYGEN LEVEL.
. You should decrease the fractionated oxygen level FiO2 to non toxic value < 60% !
. PEEP may be ++ as needed to maintain adequate oxygenation but avoid tension
pneumothx.
. When you are given an ABG with respiratory alkalosis (pH > 7.4) & hypocapnia (-CO2),
. With appropriate tidal volume < 6 ml/kg (pt. 70 kg -> 420 ml).
. With appropriate FiO2 (Ex. 40 %),
. With appropriate PEEP (Ex. 5 cm H2O),
. Look at the respiratory rate (If it is high e.g. 18),
. This respiratory alkalosis will be due to HYPER-ventillation.
. So .. Decreasing the respiratory rate is the most appropriate step.
.
.
.
.

Ventillation = RR x TV.
Respiratory alkalosis results from hyperventillation.
The RR sh'd be lowered.
-- in TV can trigger ++ in RR -> worsening the condition.

. POSITIVE END-EXPIRATORY PRESSURE (PEEP):

__________________________________________
. Used in cases of hypoxemic respiratory failue e.g. ARD$ & cardiogenic edema.

. Helps to maintain air way pressure above atmospheric pressure at the end of
expiration.
. Complications -> Alveolar damage - tension pneumothorax & hypotension.
. Sudden SOB - --BP & ++ HR - tracheal deviation & unilateral absence of breath
sounds.
. SWAN-GANZ (PULMONARY ARTERY) CATHETERIZATION:
_______________________________________________
-> Hypovolemic shock -> -- COP & -- CPWP & ++ TPR.
-> Cardiogenic shock -> -- COP & ++ CPWP & ++ TPR.
-> SEPTIC SHOCK ------> ++ COP & -- CPWP & -- TPR.
. COP -> LOW except in septic shock (High).
. PCWP -> LOW except in cardiogenic shock (High).
. TPR -> HIGH except in septic shock (Low).
. PCWP is NORMAL in ARD$. (VVVVVVVVVV. imp.).
. PCWP is NORMAL in PE. (VVVVVVVVVVVV. imp.).
. PNEUMONIA:
____________
. Fever, cough & sputum.
. Severe illness -> SOB.
. COMMUNITY ACQUIRED PNEUMONIA (CAP) -> PNEUMOCOCCUS.
. HOSPITAL ACQUIRED PNEUMONIA (HAP) -> Gram -ve bacilli.
. PPI ++ the risk of hospital acquired pneumonia.
. Pts > 65ys with chronic dis. of lungs or liver are more prone to respiratory failure.
. DM - HIV - Steroid use - Asplenia -> Worse prognosis.
. ELDERLY HYPOXIC PT WITH OR WITHOUT FEVER SHOUL BE ADMITTED !
. Dx -> Best initial test -> CXR.
. Dx -> Most accurate test -> Sputum gram stain & culture.
. N.B. All pts with suspected pneumonia sh'd have a CXR done as the 1st step.
. Antibiotics sh'd be adminstered ASAP without waiting for sputum gram stain or
culture.
. Tx -> OUT-PATIENT PNEUMONIA:
_______________________________
-> Macrolide (Azithromycin - Doxycycline - Clarithromycin).
-> Respiratory fluoroquinolone (Levofloxacin - Moxifloxacin).
. Tx -> IN-PATIENT PNEUMONIA:
______________________________
-> Ceftriaxone & Azithromycin.
-> Fluoroquinolone as a single agent.

. REASONS TO HOSPITALIZE pts with pneumonia:

_____________________________________________
. Hypotension -> SBP < 90 mmHg.
. Tachycardia -> HR > 125/min.
. Temperature -> T -> 104 F.
. Respiratory rate -> RR > 30/min.
. PO2 < 60 mmHg.
. pH < 7.35
. BUN > 30 mg/dl.
. Na < 130.
. Glucose > 250.
. Confusion.
. Age > 65 ys or older.
. Co-morbidities eg. cancer, COPD, CHF & RF or liver disease.
. HYPOXIA & HYPOTENSION as single factors are a reason to hospitalize !
. Tx -> VENTILLATOR ASSOCIATED PNEUMONIA (VAP):
________________________________________________
. VAP -> Fever - Hypoxia - New infiltrate & ++ secretions.
-> Imipenim - Cefepime or Piperacillin/Tazobactam.
-> Gentamycin & Vancomycin.
. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID
ACCUMULATION:
________________________________________________________________________
1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.
. SPECIFIC ASSOCIATIONS:
_________________________
* Recent viral infection -> Staphylococcus.
* Alcoholics -> Klebsiella.
* GIT syms & confusion -> Legionella.
* Young healthy pts -> Mycoplasma.
* Animal contact -> Coxiella Burnetii.
* Arizona construction workers -> Coccidioidmycosis.
* HIV with < 200 CD4 cells -> Pneumocystis carinii PCP.
. MYCOPLASMA PNEUMONIAE:
________________________
. Most common cause of atypical pneumonia.
. Non productive i.e. dry cough.
. Many extra-pulmonary symptoms (Headache - sore throat - skin rash).
. ERYTHEMA MULTIFORME -> Dusky red TARGET shaped skin lesions on extremities.
. CXR -> Lower lobe interstitial infiltrates.
. No cell wall (Only polymorphnuclear cells will appear on gram stain).
. MYCOBACTERIAL PNEUMONIA:
__________________________

. HIV pts have a higher risk of reactivation of tuberculosis.

. Non specific symptoms (Cough - Weight loss - Fatigue - Low grade fever & Night
sweats).
. CXR -> UPPER LOBE INFILTRATES WITH CAVITATION.
. ASPIRATION PNEUMONIA = ANAEROBIC PNEUMONIA:
_____________________________________________
. Impaired swallowing due to IMPAIRED EPIGLOTTIC REFLEX is the most imp.
predisp. factor.
. Aspiration of oro-pharyngeal secretions.
. May be a complication of upper GI endoscopy.
. Usually caused by ANAEROBES & Streptococcal viridans.
. Advanced age, poor dentition, dementia, alcohol addiction are predisposing
factors.
. Pt presents with systemic syms e.g. fever & malaise & FOUL SMELLING SPUTUM.
. Tx -> CLINDAMYCIN.
. KLEBSIELLA PNEUMONIA = FRIEDLANDER's PNEUMONIA:
_________________________________________________
. Gram -ve bacilli.
. More associated with ALCOHOLICS & immunocomprized pts with neutropenia.
. Mechanism -> Colonization in the oropharynx followed by microaspiration of
secretions.
. Mostly affect the UPPER lobes.
. produce CURRANT JELLY sputum.
. Sputum culture -> Mucoid colonies.
. PNEUMOCYSTIS CARINII PNEUMONIA (PCP):
_______________________________________
. Almost exclusively in AIDS pts with CD4 count < 200.
. The HIV pt is usually not on prophylaxis for PCP!
. Immunocompromized pt due to chemotherapy.
. Dyspnea on exertion, dry cough & fever.
. Dx -> Best initial test -> CXR -> Bilateral interstitial infiltrates (CHARACTERISTIC).
. Dx -> ABG -> Hypoxia & ++ A-a gradient. (VVVVVVV imp.).
. Dx -> ++ LDH level (Normal LDH level excludes PCP).
. Dx -> Most accurate test -> BRONCHO-ALVEOLAR LAVAGE. (VVVVVVVVV. imp.).
. Dx -> Sputum stain -> if +ve -> Confirm PCP & if -ve -> Bronchoscopy.
. Tx -> Best initial therapy for treatment & prophylaxis -> TMP-SMX.
. If PCP is severe (pO2 < 70 or A-a gradient > 35) -> Add STEROIDS to -- mortality.
. If there is toxicity from TMP-SMX (Rash - BM depression) -> PENTAMIDINE or
Primaquine.
. If the pt is African American with G6PD (Bite cells on smear) -> Don't give
Primaquine.
. For PCP prophylaxis -> TMP-SMX .. if there is a rash or neutropenia ->
Atovaquone.
. If CD4 count is ++ & maintained above 200 for several months -> Stop
prophylaxis.
. But, NEVER to stop the anti-retroviral medications against HIV !

. LEGIONNAIRE's DISEASE:
________________________
. H/O of recent TRAVEL or trip (BAHAMAS).
. Linked to cruise ship & hotel water supplies.
. HIGH GRADE FEVER > 39 c.
. GIT symptoms (Nausea & vomiting & loose stools).
. Mild ++ LFTs.
. HYPONATREMIA (PATHOGNOMONIC for LEGIONELLA).
. CXR -> Focal lobular consolidation.
. Gram -ve stain rod & stains poorly (Intracellular organism).
. So.. Gram stain will show many neutrophils but no organisms is chracteristic.
. Most accurate test -> Urine antigen test.
. Tx -> AZITHROMYCIN or Levofloxacin.
. N.B. ACUTE PNEUMONIA WITH CONSOLIDATION & PHYSILOGIC SHUNT:
______________________________________________________________
. -- Breath sounds, ++ Tactile vocal fremitus.
. Alveoli of the affected lung become filled with exudative fluid & cellular debris.
. These alveoli may have persistent blood flow to areas with impaired ventillation.
. Leading to a physiologic intra-pulmonary shunt & arterial hypoxemia.
. Positioning of the pt. with the affected lung in dependent position can worsen the
case
. i.e. his SO2 will drop for example from 94% when lying on one side to 84% on
other side
. RECURRENT PNEUMONIA:
______________________
. {A} INVOLVING SAME REGION OF THE LUNG:
_________________________________________
.1. Local anatomic obstruction:
________________________________
.. Bronchial compression (Neoplasm).
.. Bronchial obstruction (Bronchiectasis - Retained FB).
.2. Recurrent aspiration:
__________________________
.. Seizures.
.. Ethanol or drug use.
.. GERD.
. {B} INVOLVING DIFFERENT REGION OF THE LUNG:
______________________________________________
. Sino-pulmonary disease (Cystic fibrosis).
. Non-infectious (BOOP).
. Immunodefeciency (HIV - Leukemia - --immunoglobulins).
. BRONCHOGENIC CARCINOMA is the most common cause of recurrent pneumonia
in same region.

. Associated H/O of old age & prolonged smoking H/O

. Dx -> CT chest. (If CT is -ve -> Bronchoscopy).
. HYPERSENSITIVITY PNEUMONITIS (HP):
____________________________________
. Inflammation of the lung parenchyma caused by antigen exposure.
. Ex: Fancier's lung -> Inhalation of aerosolized bird droppings.
. Ex: Farmer's lung -> Inhalation of molds associated with farming.
. Acute episodes of cough, breathlessness, fever & malaise within 4-6 hs of Ag
exposure.
. Chronic exposue may lead to weight loss, clubbing & honey-combing of the lung.
. The cornerstone of HP management is AVOIDANCE OF THE RESPONSIBLE ANTIGEN
!
. TUBERCULOSIS (T.B):
_____________________
. Immigrants - HIV - Homeless - Prisoners & Alcoholics.
. Most important epidemiologic factor is FOREIGN BORN INDIVIDUAL (Not US born:
MEXICO!).
. Fever - cough - sputum - weight loss & night sweats.
. Dx -> CXR & Sputum acid fast stain & culture to confirm TB.
. If culture is +ve -> Start 6 months course of ANTI-TUBERCULOUS THERAPY.
. ISONIAZID 6 m - RIFAMPIN 6m - PYRAZINAMIDE & ETHAMBUTOL stop after 2
months.
. All of them can lead to liver toxicity.
. TB medications sh'd be stopped if the transaminases raised up to 5 times of
normal.
.
.
.
.

Isoniazid -> Peripheral neuropathy (Give Vit.B6).

Rifampin -> Red colored bodily secretions.
Pyrazinamide -> Hyperuricemia.
Ethambutol -> Optic neuritis.

. Conditions need ttt > 6ms: Osteomyelitis, Meningitis, Miliary - cavitary TB &
pregnancy
. LATENT T.B.
_____________
. PPD -> PURIFIED PROTEIN DERIVATIVE TEST:
___________________________________________
. PPD is a screening test for high risk groups.
. POSITIVE TEST IF:
-> 5 mm -> Close contacts, steroid users, HIV +ve.
-> 10 mm -> Homeless - Immigrants - Alcoholics - Health care workers & prisoners.
-> 15 mm -> Those without any risks.
. If PPD is +ve -> Proceed as follows:

______________________________________
. CXR -> to make sure that occult active disease hasn't been detected.
. If CXR is abnormal -> Sputum staining for TB is done.
. If sputum staining is +ve -> Give full dose 4 drug therapy.
. ISONIAZID alone is used for 9 months to treat a +ve PPD.
. It -- the risk of developing TB from 99% to 1%.
. Once a PPD is +ve, the test sh'd never be repeated.
. RHINITIS:
___________
{A} ALLERGIC RHINITIS:
_______________________
. Watery rhinorrhea & sneezing with more prominent eye symptoms.
. Early age of onset.
. Identifiable trigger (animals - environmental exposure).
. Usually seasonal symptoms but can be persistent throughout year.
. Nasal mucosa can be normal, pale blue or pale on exam.
. Associated with allergic disorders e.g. eczema & asthma.
. Tx -> Allergen avoidance.
. Tx -> Topical intra-nasal glucocorticoids.
{B} NON-ALLERGIC RHINITIS = VASOMOTOR RHINITIS:
________________________________________________
. Nasal congestion - Rhinorrhea - Postnasal discharge (postnasal drip = dry cough).
. Late age of onset > 20 ys.
. Can't identify clear trigger !
. Symptoms throughout the year but sometimes worse with seasons change.
. Nasal mucosa may be normal or erythematous.
. Less commonly associated with allergic disorders e.g. asthma or eczema.
. Routine allergy testing isn't necessary prior to initiating empiric ttt.
. May respond to 1st generation oral H1 antihistaminics (Chloramphenicol),
. Never ever responds to antihistaminics without anticholinergic properties
(Loratidine)!
. Tx -> TOPICAL INTRANASAL GLUCOCORTICOIDS.
. The 3 most common causes of CHRONIC COUGH (> 8 weeks):
________________________________________________________
. UPPER AIRWAY COUGH $YNDROME (Post-nasal drip).
. BRONCHIAL ASTHMA.
. GERD.
. UPPER AIRWAY COUGH $YNDROME = POST-NASAL DRIP:
_________________________________________________
. NON-smoker.
. Caused by rhino-sinusitis conditions.
. Dry cough is most likely due to post-nasal drip associated with allergic rhinitis.
. Dx -> Confirmed by improvement of the nasal discharge & cough with H1 Antihistaminics.
. Chlorpheniramine is an H1 receptor blocker that decreases the allergic response.

. Decrease in NASAL SECRETIONS is most likely to significally improve symptoms.

. ANAPHYLAXIS = ANAPHYLACTIC SHOCK:
___________________________________
. Type 1 hypersensitivity reaction.
. Pts usually have prior exposure to the offending substance.
. Pts have preformed Ig E -> Histamine mediated peripheral vasodilatation.
. Bee stings - food & medications are the most common allergens.
. Acute onset of hypotension & tachycardia.
. Dangerous allergic reaction may progress to respiratory failure & circulatory
collapse.
. Allergen exposure -> Sudden onset of symptoms in more than one system,
. Cutaneous (hives - flushing - pruritis).
. GIT ( Lip / tongue swelling - vomiting).
. Respiratory (Dyspnea - wheezing - stridor - hypoxia).
. Cardiovascular (Hypotension).
. It is a medical emergency.
. Tx -> INTRA-MUSCULAR EPINEPHRINE into the THIGH.
. ASPIRIN SENSITIVITY $YNDROME:
_______________________________
. Aspirin ingestion - persistent nasal blockage - Episodes of bronchoconstriction.
. Pathogenesis -> Psudo-allergic reaction.
. Aspirin -> PGs/LKs imbalance.
. Tx -> Avoid NSAIDs & Leukotriene recptor antagonists (Drug of choice).
. MEDIASTINAL TUMORS:
_____________________
_____________________
. Dx -> Helical CT CHEST.
. ANTERIOR mediastinum --> THYMOMA & GERM CELL TUMORS.
. MIDDLE mediastinum ----> BRONCHOGENIC CYST.
. POSTERIOR mediastinum -> Neurogenic tumors e.g. Meningocele.
. GERM CELL TUMORS:
___________________
. Affect young adults.
. Present as large ANTERIOR mediastinal mass.
. Two types of germ cell tumors (Seminomatous & Non-seminomatous).
. Both types produce B-HCG (B-Human chorionic gonadotropin).
. ONLY "NON"-seminomatous type produces Alpha-feto protein (AFP).
. CHORIOCARCINOMA:
__________________
. Metastatic form of gestational trophoblastic disease.
. It may occur after molar pregnancy or normal gestation.
. The lungs are the most frequent site of metastatic spread.
. Any postpartum woman e' pulmonary sympotms & multiple nodules on CXR =
CHORIOCARCINOMA.

. Dx -> ++++++ B-HCG levels.

. INCIDENTALLY DISCOVERED SOLITARY PULMONARY NODULE:
____________________________________________________
. May be BENIGN -> Infectious granuloma or hamartoma.
. May be MALIGNANT -> Bronchogenic carcinoma & metastasis.
. BIOPSY is the only way to definitively detect whether a nodule is benign or
malignant.
. Clinical characteristics favoring malignancy:
. Age > 50 - H/O of smoking - Weight loss - Previous malignancy.
. Radiographic characteristics of malignancy:
. Large size - Low density - Spiculated borders - Absence of calcifications.
. Rate of lesion growth is an important parameter:
. Malignant nodules tend to double in size bet. one month & one year.
. OBTAINING PREVIOUS X-RAY if possible is the FIRST BEST STEP in management.
. If a previous x-ray demonstrates that the lesion has been stable in size > 2 ys,
. Malignancy is effectively ruled out & no further testing is necessary.
. LOW propability nodules are followed by serial high resolution CT CHEST.
. INTERMEDIATE propability nodules are followed by PET SCAN or BIOPSY.
. HIGH propability nodules are removed surgically.
. PULMONARY - RENAL ASSOCIATIONS:
_________________________________
.1. WEGENER's GRANULOMATOSIS WITH POLYANGIITIS:
________________________________________________
. SYSTEMIC VASCULITIS + UPPER & LOWER RESPIRATORY TRACT INFECTION +
GLOMERULONEPHRITIS.
. Age around 40s.
. URT symptoms (Bloody or purulent nasal discharge - oral ulcers - sinusitis).
. LRT symptoms (Dyspnea - cough - Hemoptysis).
. Renal symptoms (Microscopic hematuria - RBC casts).
. Granulomatous inflammation of nasopharynx (Epistaxis - Rhinorrhea - Otitis sinusitis)
. Saddle nose deformity due to destruction of the nasal cartilage.
. Cutaneous manifestations (Painful SC nodules - palpable purpura - pyoderma
gangrenosum)
. BEST INITIAL TEST -> +ve C-ANCA = serum anti-neutrophilic cytoplasmic antibody.
. CXR -> Bilateral multiple nodular opacities.
. Urinalysis -> RBCs casts - proteinuria & sterile pyuria.
. Tx -> CYCLOPHOSPHAMIDE & High dose corticosteroids.
.2. GOODPASTURE's DISEASE:
___________________________

. Due to renal basement membrane antibodies !

. Young male.
. Lungs (cough - dyspnes - hemoptysis).
. Kidneys (Nephritic proteinuria - ARF - Dysmorphic RBCs & red cell casts on
urinalysis).
. Systemic symptoms are un common.
. Dx -> Renal biopsy -> LINEAR IgG antibodies along the glomerular basement
membrane.
. EFFECTS OF ARTERIAL OXYGENATION & VENTILATION IN VARIOUS ENVIRONMENTS:
________________________________________________________________________
_____________________________ Example ________ A-a gradient ____ Pa CO2 ___ Corrects
e' O2
. -- inspired O2 tension = HIGH ALTITUDE:
_________________________________________
. A-a gradient -> Normal.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.
. Hypoventillation = CNS DEPRESSION:
____________________________________
. A-a gradient -> Normal.
. Pa CO2 -> +++++.
. Corrects with supplemental O2 -> YES.
. Diffusion limitation = INTERSTITIAL LUNG DISEASES:
______________________________________________________
. A-a gradient -> +++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.
. Shunt = Intracardiac shunt or extensive ARD$:
_______________________________________________
. A-a gradient -> +++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> NOOOOOO.
. V/Q mis-match = Obstructive diseases, atelectasis, pulmonary edema &
pneumonia:
_________________________________________________________________________________
. A-a gradient -> ++++++.
. Pa CO2 -> Normal.
. Corrects with supplemental O2 -> YES.
. Low lung compliance.
. UPPER AIRWAY OBSTRUCTION WITH LARYNGEAL EDEMA:
________________________________________________
. ACUTE ONSET dyspnea & difficulty swallowing.

.
.
.
.
.
.
.
.

Agitation & gasping of breath.

Excessive accessory respiratory muscle use.
Retraction of the subclavicular fossae during inspiration.
H/O of previous food allergy.
Identifiable precipitating event e.g. peanut ingestion.
Physical exam. may reveal stridor & harsh respiratory sounds from trachea.
Wheezing is generally absent on lung auscultation.
A fixed upper airway obstruction will -- air flowrate in all inspiration & expiration.

* NORMAL LUNG EXAMINATION:

__________________________
. Percussion -> Resonant.
. Auscultation -> Vesicular breathing.
* LUNG CONSOLIDATION EXAM:
__________________________
. Percussion -> Dullness.
. Auscultation -> LOUDER vesicular breathing if airways are patent (Faint if
blocked).
. Bronchial breathing with full expiratory phase.
. ++ TVF.
. Bronchophony.
. Egophony (Ask the pt to say "E", it will sounds like "A").
. Widespread pectoriloquy.
* PLEURAL EFFUSION EXAM:
________________________
. Inspection -> -- movements of ipsilateral chest.
. Percussion -> Dullness.
. Auscultation -> Decreased breath sounds.
. -- TVF.
* PNEUMOTHORAX EXAM:
____________________
. Percussion -> Hyper-resonance.
. Auscultation -> Decreased breath sounds (Will be absent entirely if large
pneumothorax)
. -- TVF.
. JVD, Hypotension & Tracheal deviation to the opposite side.
* EMPHYSEMA EXAM:
_________________
. Percussion -> bilateral resonance.
. Auscultation -> Vesicuar breathing with fine crackles at inspiration.
. N.B. Recurrent bacterial infections in an adult may indicate a HUMORAL IMMUNITY
defect.
. Recurrent sino-pulmonary & gastro-intestinal infections.
. Dx -> Quantitative measurment of serum immunoglobulin "G" levels ->
DECREASED.

. Cystic fibrosis may have similar presentation BUT (Earlier in life & e'out GIT
infects).
. ACE INHIBITORS & DRY COUGH:
_____________________________
. Always consider ACE Is as a potential cause of chronic cough.
. Pathogenesis -> Accumulation of bradykinins & prostaglandins.
. Simple discontinuation of the drug sh'd precede any diagnostic tests !
. SINGLE PULMONARY NODULE APPROACH:
___________________________________
. SOLITARY PULMONARY NODULE = Lesion < 3 cm completely surrounded by
pulmonary parenchyma
.
_____________________________________________________________________________________
____
.|
._______________________________________________
.|
.|
.|
. HIGH MALIGNANCY RISK . INTERMEDIATE RISK
. LOW MALIGNANCY RISK
._____________________ .___________________
._____________________
.|
.|
.|
. Surgical excision.
. NODULE SIZE ?
. SERIAL CT SCANS
. < 1cm: Serial CTs.
. > 1cm: PET scan.
* FUNGAL INFECTIONS OF THE LUNG:
________________________________
.1. HISTOPLASMOSIS:
___________________
. Asymptomatic pulmonary nodule.
. Residence in suburban Mississippi or o"H"io river valleys !
. Absence of any complaints.
. Absence of significant past H/O.
. Absence of any cavitary lesions.
. Calcified nodes in the lung may be seen.
. It is a dimorphic fungus found in soil with high concentration of bird or bat
droppings
. Infection through inhalation of the spores of Histoplasma capsulatum fungus.
.2. BLASTOMYCOSIS -> ULCERATED SKIN LESIONS & LYTIC BONE LESIONS:
_________________________________________________________________
. Fungal infection of the lung..
. Residence in great lakes, Mississippi, Ohio river & Wisconsin.
. Pulmonary symptoms resembling T.B. & Histoplasmosis.

.
.
.
.
.

ULCERATED SKIN LESIONS & LYTIC BONE LESIONS (Characteristic!).

Skin lesions -> Multiple well circuscribed verrucus crusted lesions.
Bone lesions -> Lytic lesions in the anterior ribs.
Dx -> Sputum culture -> BROAD BASED BUDDING YEAST.
Tx -> ITRACONAZOLE or Amphotericin B.

.3. COCCIDIOIDOMYCOSIS:
_______________________
. Fungal infection of the lung.
. Residence in Southwestern US.
. Fever, cough & night sweats.
. Extra-pulmonary -> skin, meninges & skeleton.
.4. ASPERGILLOSIS = A MOBILE LUNG CAVITARY MASS + INTERMITTENT
HEMOPTYSIS:
__________________________________________________________________________
. Fungal infection of the lung.
. Coarse fragmented septae.
. Hyphae are typically seen.
. CXR -> Radio-lucency next to a rounded mass.
. Cavitary lesion may form due to destruction of the underlying pulmonary
parenchyma.
. Debris & hyphae may coalese forming a FUNGUS BALL.
. The ball lies freely in the cavity & moves around with position change.
. A MOBILE CAVITARY MASS + INTERMITTENT HEMOPTYSIS = ASPERGILLOMA.
. SUPERIOR SULCUS TUMOR:
________________________
. Apical lung tumor causing compression effects.
. Superior vena cava -> SVC $yndrome.
. Sympathetic trunk -> Horner $yndrome.
. Brachial plexus -> Pancoast $yndrome (Pain - paresthesia - weakness of arm).
. Rt recurrent laryngeal nerve -> Hoarsness of voice.
. PANCOAST $YNDROME:
____________________
. Apical lung tumor at the thoracic inlet.
. Compress the inferior portion of the brachial plexus.
. Shoulder pain radiating in an ulnar distribution.
. SUPERIOR VENA CAVA $YNDROME (SVC):
____________________________________
. Obstruction of SVC impedes venous return from the head, neck, face & arms to
the heart.
. Dyspnea - Venous congestion & swelling of the head, neck & arms.
. Malignancy is the most common cause of obstruction (Lung cancer - Hodgkin's
lymphoma).
. H/O of chronic heavy smoker with recent un-intentional weight loss -> Lung
cancer.
. Best initial test -> CXR -> If abnormal -> Follow up with Ct chest.

. HYPERTROPHIC OSTEOARTHROPATHY:
________________________________
. Development of clubbing & sudden onset joint arthropathy in a chronic smoker.
. Bilateral wrist tendrness, thickening of distal fingers & convex nail beds.
. Associated with lung cancer.
. CXR is mandatory to rule out malignancy.
. FINGER CLUBBING:
__________________
. Thickening of the nail bed that causes a devrease in the angle bet the nail bed &
fold.
. In severe cluccing, the terminal parts of the fingers appear swollen like
drumsticks.
. It is NOT a feature of simple COPD.
. NEW CLUBBING in COPD pts indicates the development of lung cancer or occult
malignancy.
. GOLDEN SCHEME:
________________
________________
.

. SPIROMETRY
.____________
.|
.____________________________________________________
.|
.|
. LOW FEV1/FVC
. NORMAL OR HIGH FEV1/FVC
.______________
._________________________
.|
.|
. OBSTRUCTIVE DISEASE
. RESTRICTIVE DISEASE
._____________________
._____________________
.|
.|
. BRONCHO-DILATOR CHALLENGE
. DLCO
____________________________
.______
.|
.|
._________
.________________
.|
.|
.|
.|
. ++ FEV1
. No ++ in FEV1
. NORMAL
. -- DLCO
._________ ._______________
._______
._________
. ASTHMA.
. COPD.
. CHEST WALL WEAKNESS . ILD.
.|
. DLCO
._____________________
.|
.|
. (--) -> Emphysema . (++) -> Chronic bronchitis.

. N.B. RIGHT MAIN STEM BRONCHUS INTUBATION:

___________________________________________
. Relative complication of endotracheal intubation.
. It causes asymmetric chest expansion during inspiration.
. Markedly decreased or absent breath sounds on the left side on auscultation.
. Solve the problem by repositioning of the tube,
. Tx -> Pull it back slightly, this will move its tip between the carina & vocal cords.
. N.B. 2ry MALIGNANCY AFTER CHEMOTHERAPY !
__________________________________________
. Up to 4% of pts with HODGKIN's disease wil develop a 2ry malignancy (Lung breast)
. After being treated with chemotherapy & radiation !
. N.B. POST-ICTAL STATE ABG:
____________________________
. Repiratory ACIDOSIS.
. Acisosis (-- pH).
. Hypercarbia (++ CO2).
. Normal or ++ HCO3 !
. HYPO-ventillation is a major cause of respiratory acidosis.
. N.B. MOST COMMON CAUSE OF HEMOPTYSIS is -> CHRONIC BRONCHITIS:
________________________________________________________________
. Chronic productive cough for 3 months in 2 successive years with ciagarette
smoking.
. Other important causes -> BRONCHOGENIC CARCINOMA & BRONCHIECTASIS.
. CXR is mandatory to exclude malignancy.
. N.B. Acute bronchitis is a common cause of blood-tinged sputum.
. It is usually viral in etiology.
. In an "A"FEBRILE pt with NEW-ONSET BLOOD TINGED SPUTUM e'OUT significant
serious signs,
. OBSERVATION & CLOSE CLINICAL FOLLOW UP is the best ttt strategy.
. MITRAL STENOSIS:
__________________
. Most common cause is rheumatic fever.
. Pt. 40 - 50ys.
. presents with gradual & progressively worsening dyspnea on exertion.
. Orthopnea & hemoptysis due to pulmonary edema.
. Auscultation -> Loud S1 & Opening snap after S2 at apex.
. Low pitched diastolic rumble at apex (When pt lies on left side with breath
holding).
. Atrial fibrillation is a common complication.
. Af causes rapid decompensation in a previously asymptomatic pt.
. Long-standing MS can cause Left atrial enlargement -> Elevation of left main
bronchus.
. ACE inhibitors side effect -> Dry cough:

__________________________________________
. Pathophysiology -> Accumulation of KININs due to activation of arachidonic acid
pathway
. N.B. ACID-BASE BALANCE in two different situations:
_____________________________________________________
_____________________________________________________
. 1 . Chronic hypercapneic respiratory failure due to COPD:
___________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory
acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !
. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++
bicarbonate retention.
. 2 . Mechanically vetillated pt following head trauma:
_______________________________________________________
. Hyper-ventillation (Due to ++ TV or RR) -> Excessive CO2 loss & Respiratory
Alkalosis.
. Hypo-ventillation (Due to -- TV or RR) -> Excess CO2 Retention & Respiratory
Acidosis.
. Respiratory alkalosis:
-> ++ pH (N = 7.4).
-> -- PCO2 (N = 40 mmHg).
-> -- HCO3 (N= 24) -> DECREASED due to attempted renal compensation for resp.
alkalosis.
-> The kidneys retain increased amounts of Hydrogen H (protons)
-> & excrete ++ amounts of bicarbonate (HCO3) in attempt to normalize serum pH.
-> The ++ amount of HCO3 in urine ALKALIZES the urine.

Dr. Wael Tawfic Mohamed

__________________________