Pulmonology USMLE WORLD

COPD

The most common bacteria responsible for acute exacerbation of COPD are S.pneumonia, H.inf, and M
catarrhalis
PFTs are the most useful tool to determine if a patient can benefit from the lung resection surgery
Predicted postoperative FEV1 is very helpful for this purpose
can be derived from preoperative value and the fractional function of the lung tissue to be resected
Current ABG do not provide any useful information in this regard
They are more useful in determining the level of respiratory compromise and appropriate ventilator
settings for patients undergoing lung resection surgery
Doubtful benefit of resection after 1- FEV12- split function quantitative lung scans & exercise
testing
A bronchodilator response test is used to demonstrate reversibility of airway obstruction It helps to
differentiate between COPD and asthma, although a subset of patients with COPD may also
demonstrate airway reactivity\

Acute exacerbation
Case:pt with chronic COPD , develop acute exacerbation , failed to respond to steroid and Beta agonist ,
ipratropium and O2what to do ?
DoNIPPV (Noninvasive positive pressure ventilation )>> then intubate if no response. BUT WHY ?
NIPPV :associated with complications that are a hallmark of intubation, which includes infections)
NIPPV is recommended in a patient of respiratory distress with :
o
RR>25 per min.
o
pH<7.35
o PaC02 >45 mmHg
There is better alveolar ventilation and less fatigue of respiratory muscles by using NIPPV
Contraindication to NIPPV:
o septic,
o Hypotensive,
o dysrhythmic patients
The patient is already on oxygen therapy, but she is hypercapnic as well as acidotic
Note: In COPD patients, PCO2 is elevated at baseline and it does not stimulate the respiratory center,
unlike in normal individuals. Their only drive to increase the respiratory rate is hypoxia
If you just provide oxygen, it, in fact, worsens the situation
You should provide NIPPV to provide more oxygen and to wash out the CO2
Caution
It is always better to avoid intubation, if possible, because of various complications associated with
intubation incidence of nosocomial infections, long-term mortality in these patients

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However, if the patient does not respond to NIPPV, then intubation should
be considered
Systemic steroids are the first line therapy of the acute exacerbation of
COPD but are relatively ineffective for chronic maintenance therapy
The only two modalities that can decrease mortality in patients with
COPD are:
o home oxygen therapy
o smoking cessation
This patient has complete left lung collapse (complete opacity), possibly from
mucus plugging and obstruction He also has symptoms of respiratory failure like
confusion and sweating
He needs urgent bronchoscopy and removal of the mucus plugs
The removal of secretions or plugs is associated with rapid improvement in Pa02

Please try to understand the various Tx used for COPD It is a very high yield topic in board exams
Tx of COPD
1st line Anticholinergic drugs (Ipratropium bromide)
2nd lineBeta-2 agonists like albuterol
Inhaled steroids like beclomethasone MDl are not useful
3rd 4th Aminophylline or oral Theophylline the diaphragmatic contraction and help breathing
Systemic steroids are the first line therapy of the acute exacerbation of COPD but are relatively
ineffective for chronic maintenance therapy
Antibiotics therapy should be used empirically for acute exacerbation of COPD and should cover
Streptococcus pneurnonae, Haemophilus influenza, and Moraxella catarrhalis
The only two modalities that can decrease mortality in patients with COPD are:
o home oxygen therapy
o smoking cessation
LTOT( Long-term supplemental oxygen therapy)
Once the patient qualifies for long-term oxygen therapy, it is continued for life
The criteria for initiating long-term oxygen therapy in COPD patients are as follows
1- All COPD patients with PaO2 < 55 mmHg or SaO2 < 88% on room air
2- Patient with cor pulmonale, evidence of pulmonary HTN or hematocrit> 55% should be
started on home oxygen therapy even when PaO 2 is 56-59 mmHg with SaO2 > 89%
3- Home oxygen may also be used in patients who has resting awake PaO2 > 60 mmHg with
Sa02 > 90% if they become hypoxic during exercise or sleep (noctumal hypoxia)
The dose of oxygen should be titrated such that SaO2 is maintained at > 90% during sleep, normal
waking, and at rest.
Survival benefits of home oxygen are significant when it is used for a minimum of 15 hours a day
Note:In any case of COPD the biggest contributor to mortality is Hypoxia pulmonary
vasoconstriction pulmonary artery pressure Pulmonary Arterial Hypertension progressive right
heart enlargement right heart failure death.
After quitting smoking, home oxygen therapy is the only modality known to prolong survival in
COPD

Emphesema
alpha- 1 anti-trypsin deficiency :
Any emphysema in a non-smoker,
emphysema presenting in the 3-rd decade
any emphesematous changes in the lower lobes
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Another diagnostic clue in this patient is the episode of neonatal jaundice, which occurs in 26 % of the patients
Open lung biopsy or video assisted lung biopsy is not needed in this patient, as diagnosis can be made by
Dx serum alpha-I anti-trypsin levels
High resolution CT scan should be considered only after the assessment of alpha-I anti-trypsin levels

ASTHMA

Indicators of sever attack:

o N- PCO2 values indicates CO2 retention because of severe airway obstruction (air trapping)
and or respiratory muscle fatigue
o Speech difficulty,
o Diaphoresis,
o Altered sensorium,
o Cyanosis,
o Silent lungs

Exercise induced asthma

Beta agonists and mast cell stabilizers both play an important role in the management of exerciseinduced asthma
It should be noted that aerobic exercise and cold air are more likely to predispose to exercise induced
asthma
Exercise induced asthma should not be confused with post exercise fatigue and seasonal asthma
Patient with exercise induced asthma experiences chest discomfort, wheezing, cough, breathlessness,
fatigue, and abdominal discomfort in some cases
The symptoms may be underreported in some cases due to fear of loosing position in the team
Treadmill exercise challenges with pre exercise and post exercise PFTs may help in the diagnosis
Acute bronchopulmonary aspergillosis
Characterized by
o worsening asthma;
o fleeting pulmonary infiltrates;
o IgE;
o peripheral eosinophilia;
o immediate skin hypersensitivity reaction to aspergillus antigen;
o precipitating antibodies against aspergillus in serum
o coughing brownish mucous plugs
Oral prednisolone is the Tx of choice for ABPA which is a hypersensitivity reaction to inhaled
aspergillus antigens
Oral itraconazole steroid requirement in patients with ABPA and improves pulmonary function BUT
the mainstay of Tx is oral prednisolone
CXR typically shows a solid mass surrounded by a radiolucent crescent (crescent sign, Monod's sign)
Any case of bronchial asthma + eosinophils >10 %==>should the suspicion for parasitic infestations
or Hypersensitivity to fungal antigens

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Central bronchiectasis
The common diagnostic features of ABPA include
1. Asthma like symptoms
2. IgE
3. HypereosinophiIia
4. Central bronchiectasis
5. Positive Aspergillus Skin test
Whenever a patient with asthma is suspected of having ABPA, skin testing with A antigen is the first
diagnostic step
negative, Dx of ABPA is ruled out
positive, serum precipitins against Aspergillus fumigatus and IgE level are checked
ABPA is excluded if IgE levels are <1OOOng/ml or if serum precipitins against Aspergillus fumigatus are
absent
immediate wheal and flare reaction to Aspergillus fumigatus (type 1 hypersensitivity)
Aspirgilloma
Aspergilloma can grow in the apex of the lung but does not cause
arm pain
hemoptysis, fever, weight loss and a chronic cough
The mass is usually mobile and moves with position
Dx finding of hyphae in the specimen
The occasional aspergilloma can spontaneously regress
CXRcrescent radiolucency next to a rounded mass
Cavitary lesions may form because of destruction of the underlying
pulmonary parenchyma, and debris and hyphae may coalesce and
form a fungus ball, which lies free in the cavity and moves around
with position change
Prophylactic resection is controversial, although some recommend
resection if isolated disease is present in good risk patien

Churg-Strauss syndrome

allergic granulomatosis

multisystem vasculitic disorder

unknown etiology
affects skin, kidney, nervous system, lungs, GI system and heart.
There is usually a history of asthma followed by the development of fever and marked eosinophilia at
which time asthma may have become better.
The disease is severe and requires treatment with glucocorticoids and sometimes with
immunosuppressants
It is characterized by allergic rhinitis, asthma and prominent peripheral blood eosinophilia (Allergic)
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A CSS-like syndrome has been noted in patients who have been successfully treated for chronic steroid
dependent asthma with the leukotriene receptor antagonists (zafirleukast)
Up to 75% of the patients with CSS have evidence of peripheral neuropathy
This patient has evidence of peripheral neuropathy (mononeuritis multiplex)
The disease is severe and requires Tx with glucocorticoids and sometimes with immunosuppressants

Job Syndrome

recurrent bacterial infections

markedly elevated IgE levels
Bacterial infections usually caused by staphlococci and the skin is the most
frequent site of involvement.
Opportunistic infections (LIKE CANDIDA , pcp)
Neutrophils exhibit impaired chemotaxis
Some patients have coarse features while others are fair
Other allergic disorders like eczema, asthma, allergic rhinitis may be present
Txis intermittent or continuous antibiotics

triad of

Wiskott-Aldrich syndrome

eczema,
thrombocytopenic purpura
recurrent pyogenic infections
IgE and IgA levels are high
IgM levels are low
Lymphoreticular malignancies are common in such patients

Chronic Eosinophilic Pneumonia (CEP)

the most common eosinophilic pneumonia in the US

systemic symptoms fever, malaise, anorexia and weight loss for several weeks or months
Pulmonary symptoms cough and breathlessness
Sometimes patients have Hx of bronchial asthma or allergic rhinitis
Chest auscultation shows crackles or wheezing
CXR reveals peripheral infiItrates that are photographic negative of pulmonary edema and this
radiographic finding is pathognomonic of this chronic eosinophilic pneumonia
BAL eosinophils >40% suggestive of chronic eosinophilic pneumonia
Glucocorticoid therapy results in rapid resolution of symptoms and radiographic clearing
CEP who presents with systemic symptoms of fever, malaise, anorexia and weight loss for several
weeks or months you should suspect Cherg Strauce S
Some times the presenting symptom of CCS is CEP
However, CEP usually does not have granulomas on biopsy and generally does not involve organs
other than the lung
Glucocorticoid therapy results in rapid resolution of symptoms and radiographic clearing

Lung CA

A lung mass with cartilage is most likely a hamartoma and can be observed
Most common benign tumor of the lunghamartoma.

SVC syndrome
Today, the most common cause of superior vena cava obstruction is bronchogenic CA.
o Lung abscess and pneumonia Never.
o TB & aspergillosis rarely.
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In the past various surgical procedures were devised to relieve the symptoms of SVC obstruction,
but today, angioplasty with stenting is the standard of care.

Pancoast
Preoperative radiation is administered before resection of this tumor.
Pancoast tumors may be of any histology but the majority are either SCC or adenocarcinomas
When the tumor invades the lower brachial plexus, it can cause severe pain in the arm along the ulnar
nerve
In a smoker with arm pain, cough and weight loss, a mass in the lung apex is a Pancoast tumor untiI
otherwise proven
Note: Carcinoid tumors are slow growing and have the best prognosis of all lung cancers
NoteAny chronic smoker with HPO(Hypertrophic osteoarthropathy) should have a CXR to rule
out malignancy
HPO is associated with chronic proliferative periostitis of the long bones, clubbing, and synovitis
HPOSCC & AdenoCA
Due to high incidence of lung cancer among smokers, it should be suspected in any smoker
presenting with recurrent pneumonia order HRCT

Incidental Lung nodule

ASx + lung mass, the first step is to get previous chest x rays for comparison
The things that you need to remember are
1- Lesions >3 cm are more likely to be malignant
2- Lesions with irregular borders are likely to be malignant where as smooth borders indicate benign
nature
3- Presence of eccentric" calcification indicates malignancy

Pneumonia

Any patient with fever, night sweats and copious foul smelling sputum has anyone of these three
conditions:
1- Bronchiectasis
2- Lung abscess
3- Anaerobic pneumonia
Sputum gram stain a specimen that contains >25 PMN & <10 epithelial cells per low power field
represents a purulent specimen; however, it is very nonspecific, and you often see the oropharyngeal
flora.
Many physicians do not order this test for CAP, since it is often difficult to identify the microbiologic
cause of the pneumonia .Most often the treatment is empirical after the chest x-ray
Obtaining routine sputum cultures is also controversial =1- difficult to interpret 2- fastidious organisms
overgrow the organisms that actually cause pneumonia 3- difficult to interpret if there is a colonizer,
such as MRSA and pseudomonas
Mycoplasma serology rarely performed, (not cost effective) and most of the empirical antibiotics
(azithrornycin, levofloxacin, gatifloxacin) often cover these atypical organisms
Clue In patients with fever and cough after upper GI endoscopy suspect anaerobic lung infection
Clindarnycin and ampicillin plus metronidazole are the commonly used agents for this infection
Doxycycline is a good antibiotic for outpatient community acquired pneumonia were the macrolide
resistance is suspected
Levofloxacin covers atypical organisms also and is often used in the inpatient setting of CAP //HAP
TMP+SMX is the drug of choice pneumocystis carinii pneumonia
Big note Ampicillin and gentarnycin is almost never used for pneumonia
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The combination has good synergism and can be used for abdominal infection in combination
with metronidazole
The new generation quinolones (levofloxacin or gatifloxacin) is being extensively used for the inpatient
Tx of CAP
For the management of out.patient Tx in stable and low-risk patients (no other cardiopulmonary risk
factors, not hypoxic), either azithrornycin or doxycycline can be used
Ampicillin not used for CAP since quite a number of strep pnuemo are resistant, and it does not
cover atypical organisms
Bactrim the drug of choice for uncomplicated cystitis and sinusitis It is not the first line drug for CAP
Noteonly new generation fluoroquinolones have excellent streptococcal coverage
Ciprofloxacin does NOT have good streptococcal coverage and also does NOT cover atypical
organisms
Vancomycin is used for suspected MRSA infection
When pneumonia fails to heal after two weeks of appropriate antibiotics, a CT scan of the chest
followed by bronchoscopy is indicated to ensure that the bronchus is not blocked and there is no lung
abscess
Caution:
Chest tube placed in an acute pneumonia can lead to a bronchopleural fistula.
o This can lead to a significant problem, as these fistulas do not readily close in the presence of
an infection
o Because of the contamination of the pleural space, one risks causing an empyema
o There is no role for a chest tube unless a parapneumonic effusion or empyema is suspected
o

Empyema

The individual will usually present with a low-grade fever, and empyema is best diagnosed
with a CT scan

When the empyema is localized, complex, and has a thick rim, only surgery is the answer
In surgery, the thick pleural peel is removed, the pus is removed, and the chest is drained
All old blood clots are drained and removed
Note:
o Empyema, which is recent in onset, can be removed by fibrinolytic Tx
o Both STK and urokinase have been used
o However, in a patient with a recent motor vehicle trauma, fibrinolytic therapy is
contraindicated
o In addition, the fibrinolytics usually do not have much success when the empyema is loculated
and has a thick rim round it

o
Histoplasmosis

Blastomycosis

Coccidiomycosis
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ASx pulmonary nodule

dimorphic fungus
Mississippi and Ohio River
valleys and Central America
soil with a high
concentration of bird or bat
guano droppings

Triad
LUNG
SKIN
BONE

Primary pulmonary infection

has nonspecific features like
fever, fatigue, dry
cough, weight loss, and
pleuritic chest pain

Wisconsin, Mississippi
river belt or Ohio River
Belt

Arizona, New Mexico,

Texas, Central and South
USA
Cutaneous findings like
erythema multiforme and
erythema nodosum as well
as arthralgias are
immunologically
mediated and may be
present in some cases

Sx self-limiting fever,
chills, and a non-productive
cough

CXRpaten, lobar or
multinodular lobar
Infiltrates.
Chronic cavitary ,
fatalolder COPD patients

CXR50%--> no
abnormality
most common abnormality
unilateral infiltrate with
hilar adenopathy on the
same side
A lung cavity may be
present in some cases
Sometimes there is
evidence for a
parapneumonic effusion

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Histoplasmosis is the most common fungal infection in theUSA

Note:G-negative bacilli accounts for < 2% of CAP, but account for most of the nosocomial infection and have
high mortality rates
GNB pneumonias are rare in healthy individuals and usually occur in infants, the elderly. alcoholics,
and an immunocompromised host, especially with neutropenia
The usual pathophysiological mechanism is colonization of the oropharynx, followed by micro
aspiration of upper airway secretions

TB reactivation in HIV+

chronic cough, weight loss, fever and malaise + bilateral apical consolidation typical for reactivation
tuberculosis
Mycobacterial infection occurs earty in the course of disease with CD4 counts >200/microL
Histoplasma capsulatum on HIV +
Disseminated fungal infection takes place when HIV infection is advanced and radiography usually
shows a miliary pattern
HHV-8 Kaposi us sarcoma, which usually has cutaneous findings and pulmonary involvement, which may
be asymptomatic or mild
CXRusually shows a pulmonary nodule or pleural effusions
PCP

immunocompromised
CD4<200
atypical pneumonia,
Its natural habitat is the lung, and the incubation period ranges from 4-8 weeks (note:after 2nd dose of
chemo)
It is airborne transmitted
Characterized by: dyspnea, fever, and a nonproductive cough
PE tachypnea. tachycardia. and cyanosis with minimal chest findings
CXRBi lateral diffuse interstitial infiItrates beginning in the perihilar region is a characteristic finding
may disseminate outside the lung, and the most common sites of extrapulmonary involvement are the
lymph nodes, spleen, liver, and bone marrow
Klebsiella pneumonia, Friedlers pneumonia
most frequently affect the upper lobe
current jelly-like sputum with tissue necrosis and early abscess formation
fulminant course
Alcoholics
capsulated G - Bacillus
grows as mucoid colonies

Aspiration Pneumonia

Impaired swallowing and epiglottic reflex are frequent abnormalities in pts with advanced dementia
Anaerobic bacteria in combination with some aerobic oral flora (eg ,viridans streptococci) are the
usual etiologic factors of aspiration pneumonia
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Note:Pulmonary congestion due to LVF impairs lymphatic and venous drainage and can
predispose to pneumonia
Advanced GERD can cause aspiration of gastric content, bronchoconstriction, and pneumonia

Legionella

gram-negative bacteria known to cause CAP & HAP

contamination of water sources like air conditioners

Pulmonic + GI Sx
fatigue, malaise, confusion, and fever with chills, productive cough, chest pain, non-bloody
diarrhea and abdominal pain
PEmay show tachypnea. tachycardia. hypotension, breath sounds with dullness on percussion
Labs proteinuria, hyponatremia and hematuria
usually cannot be seen under ordinary gram staining
Sputum analysis will reveal neutrophils
Erythromycin is the treatment of choice
Remember pneumonia, Hyponatremia and diarrhea are almost classic for Legionella
Legionella pneumonia should be suspected in those who have not responded to Beta.actem
antibiotics
5% of CAP and up to 30% of nosocomial pneumonia
More characteristic features suggestive of Legionella pneumonia are the presence of hyponatremia
(sodium of less than 130 mmol/mL)
Gram stain smear of respiratory secretions showing many PMNs but very few visible organisms
CXR paten, interstitial inflammation and unilateral lower lobe involvement, which may progress to
areas of consolidation over a few days
definitive Dx urinary Legionella antigen testing using an ELISA test.
The treatment of choice is high dose erythrornycin or azithrornycin
The most commonly used method of decontamination is periodic superheating and flushing of
water supplies
This method is particularly useful for urgent disinfection during an outbreak
Hyperchlorination is no longer recommended because Legionella species are relatively chlorideresistant
Biocides are also relatively ineffective
it is not an encapsulated organism and does not produce mucoid colonies

Mycoplasma pneumonia also does not usually respond to penicillins or cephalosporins: however, it rarely
gives severe illness
DDx :Streptococcus, Haemophilus and Moraxella usually respond to beta.lactem antibiotics
a common respiratory pathogen in teenagers
mostly It causes pharyngitis or bronchitis only
Pneumonia develops in a few cases
The cough is usually dry Usually ,but it may be productive of white blood-tinged sputum
Many patients with pneumonia have upper respiratory tract signs and symptoms including a sore throat
and rhinorrhea
CXRoften appears worse than symptoms suggest
Extrapulmonary manifestations involving the skin, heart,nervous or hematopoeitic system and they
provide the only clinical clue to the Dx
Page 10 of 22

SJS is one of the extrapulmonary manifestations

Mycoplasma does not have a cell wall and thus does not stain with gram-stain
Dx is inadequate since most laboratories do not process cultures of the organism, serology requires
paired serum specimens, and PCR-based testing is not widely available. Thus, most treatment is
empirically .

Bronchiectesis

The most serious complication of bronchiectasis is hemoptysis

Note Respiratory failure can occur in bronchiectasis, but is a rare entity The majority of patients have
a chronic insidious course
a common finding in CF patients and may be the only finding in adults

Bronchiectasis secondary to

CF is often limited to the upper lobe and sputum generally

grows pseudomonas
Cystic Fibrosis

Sweat chloride test (>60 mEqil) is the gold standard

preferred over direct mutation analysis as more than 1,250 mutations in CFTR can lead to cystic
fibrosis
So gene testing confirmatory.

Lung Abscess

Most cases of primary lung abscess are due to aspiration, periodontal disease or gingivitis
Common causes of altered consciousness are alcoholism, general anesthesia, drug overdose, stroke,
seizures, diabetic coma, shock or other serious illnesses
Secondary lung abscess (obstructive) is most commonly seen in patients with lung malignancy
The location of lung abscess depends on the etiology In case of aspiration, the primary site of
abscess is the posterior segment of right upper lobe or apical segment of right lower lobe
especially in recumbent position
This is because these segments are in direct continuation of right bronchus Same segments on left
side are less likely to develop post aspiration lung abscess because right bronchus has relatively
more straight course than the left one
Note: Basal segment of the right lower lobe abscess might be seen in case of transdiaphragmatic
infection from amebic/pyogenic liver abscess

Pneumothorax
CXRno bronchovascular markings on the half of the right lung
Pleural blebs small, <2 cm, subpleural collections of air contained within the visceral pleura,
resulting from ruptured alveoli.
The blebs are usually found at the apex of the upper lobe or the posterior apex of the lower lobe
These blebs are often accompanied by apical fibrosis
Blebs are well-demarcated from the normal parenchyma and communicate with it, via a narrow neck
The most likely cause of a spontaneous pneumothorax is rupture of small subpleural blebs.
A familial tendency has been described
Blebs are best Dx with a CT scan of the chest
If the PTX is recurrent, then bleb excision is curative
Emphysema
the most common cause of secondary PTX rupture of a bulla
Page 11 of 22

Most patients with emphysema and PTX will present with chest pain, respiratory distress, hypoxia &
hypercarbia.
Because of their limited pulmonary reserve, these patients may not even tolerate a small pneumothorax
Dx CSR and tube drainage is almost always required to reexpand the lung

PTX & CA
PTX may develop as a result of rupture of an ischemic primary tumor or metastases into the pleural
space
PTX is most frequently associated with metastatic sarcoma
Tube drainage is always required to re-expand the lung

Lymphangioleiomyomatosis (LAM)
a diffuse cystic disorder seen in young woman of childbearing-age
It is due to proliferation of atypical smooth muscle through out the lung
present with cough, dyspnea, hemoptysis and PTX
The lung surface is covered with tiny cysts
Although the natural history of the disorder is not known, the majority of patients die with 10 years
Up to 50% of patients develop spontaneous PTX and often this is bilateral, recurrent and may require
pleurodesis
The ongoing smooth muscle proliferation encases the entire lung and pleural space with time

Page 12 of 22

Subcutaneous emphysema

when an individual with asthma presents with subcutaneous emphysema, the

rule out is a
pneumothorax=> CXR
first thing one wants to

commonly seen in severe asthmatics

presents as crepitus over the neck and chest.
It may appear very frightening, but does not produce any respiratory distress
However, a CXR is a must to ensure that there is no pneumothorax
One may also have a tracheobronchial rupture and this may present with subcutaneous
emphysema However, this is more common in trauma and bronchoscopy may be required
Once the CXR is done, and if no pneumothorax is seen, the patient can be observed.
Subcutaneous emphysema does not require any formal treatment , save for

observation
Note:
Endotracheal intubation is not required for SC emphysema
Even though they may appear with significant facial swelling, the majority of these patients are in no
respiratory distress
Criteria for mechanical ventilation is based on physical appearance of the patient, blood gas, acidosis
and oxygen saturation
Hyperparic O2 no role.
CT if suspected bronchial,esophageal tear.
"Extremely high yield question for USMLE
Pulmonary Effusion
Page 13 of 22

the first step is Diagnostic thoracentesis (except in patients with classic signs and symptoms of CHF)
Bronchoscopy is a close alternative when suspect CA ; however, this requires sedation and is
considered to be a relatively invasive procedure
This will be the next step if the pleural fluid cytology is non-diagnostic and the patient has lung mass
If cytology is positive for lung cancer, then the patient does not require a bronchoscopy
Actually.CHF is the most common cause of pleural effusion (right side)
The determination of pH is important in parapneumonic effusions in which

a value of < 7.2 requires a chest tube aspiration to prevent empyema

Normal pleural fluid pH is approximately 7.64 .
Pleural fluid pH < 7.3 indicates pleural inflammation .
pH of 7.35 is consistent with transudative pleural effusion .

SepticEmboli

Drug abuser Tricuspid valve endocarditis S.aureus PC: acute endocarditis +pulmonary infarction
and abscess Sx fever, pleuritic chest pain, hemoptysis and malaise
CXR peripheral well-circumscribed lesions with cavitation
Surgery is required in the majority of these patients( Valve repair or replacement is therapeutic)
Note:Atelectasis may be seen in patients with endocarditis but is a result of the infection and not the
cause of endocarditis.
Note: Pleural effusions in a drug abuser may occur from a parapneumonic effusion
ClueIn a drug abuser, presence of well-circumscribed lung opacity is most likely due to embolism of
infected vegetation causing a pulmonary infarct
' This concept is extremely important for the USMLE exams

Proximal (above knee veins) DVT of lower extremities is the most frequent source of PE.
Proximal veins of lower extremity are iliac, femoral and popliteal

Pulmonary Embolisim

Pulmonary infarction after a pulmonary thromboembolism is very rare.

Death of lung tissue is very rarely seen after embolism because of the copious oxygen supply
The lung receives oxygen from the pulmonary arteries, the bronchial arteries and from the airways
Thus infarction occurs rarely and its appearance usually is associated with compromise of bronchial
arterial blood flow and/or airways to the involved area
Such compromise is promoted by existence of other cardiac or pulmonary pathology, such as left
ventricular failure, mitral stenosis or COPD
When the x-ray is normal and suspicion is still high, the next step is obtain a V/Q scan If the via
scan is of low probability with a normal x-ray, one can exclude the diagnosis of PE
Hampton hump-cone shaped area of opacification
Westermark sign-dilated pulmonary artery with distal oligemia
Factor V Leiden is the most common inherited disorder causing hypercoagulability and
predisposition to thromboses, especially DVT of lower extremities
Therapeutic INR for most clinical indications of warfarin is 2 to 3
These conditions include VTE , VHD, and AFib .
A higher INR of 3.0 to 4.5 is required only in ceratin clinical settings like prosthetic heart valves
Patients with suspected PE should have a CXR and ABG, followed by EKG and V/Q scan.
Note: V/Q scan is the most helpful initial evaluation to rule out PE after CXR, ABG and EKG are
obtained
Page 14 of 22

Spiral CT scan of the Chest is helpful if the emboli are large and in the proximal pulmonary artery
Spiral CT will be the answer (instead of V/Q scan) if the baseline chest-x ray is abnormal (eg destroyed
lung)
Note:Whenever there is Hypoxia, oxygen is ordered as a Tx
o Try noninvasive ventilation such a 100% non-rebreather mask or BiPAP machine
o If the ABG shows sever hypoxia despite being on 100% oxygen the intubation is considered
The most typical findings of a PE on ABG sampling are hypoxemia and hypocarbia
Suspected PE

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Notethe problem with CT angiogram is that it can Dx only large emboli, Small emboli can be easity missed

Suspect choriocarcinoma in any postpartum women who presents with SOB and
hemoptysis The next step chest x-ray, pelvic exam, and beta-hCG

DVT

Patients with DVT in whom anticoagulation is contraindicated require placement of IVC filter for the
prevention of pulmonary embolism
Compression stockings do NOT have any role in the prevention of PE in patients with DVT.
They reduce the incidence of venous thrombosis in postsurgical patients by venous stasis
Once the Dx of DVT is made by diagnostic testing,next step is to start treatment with anticoagulants
unless they are contraindicated.
DVT is not a clinical diagnosis and therefore all suspected cases of DVT should be evaluted with
noninvasive testing and the test of choice for this purpose is compression US.
Dont start Tx till prove Dx(because we have only DVT not PE).
Impedence plethysmography is the study of choice for recurrent DVT(more specific)
o It becomes normal faster than compression US after an episode of DVT that makes it superior
to compression US for recurrent DVT

Nocturnal sleep apnea

Noctunal pulse oximetryis used for diagnosing nocturnal desaturation, especially in patients with
sleep apnea
Patients with sleep apnea will have episodes of apnea with resultant desaturation
Page 15 of 22

These patients wiII benefit from nocturnal oxygen administration in the form of CPAP

ARDS

The earliest sign is often tachypnea followed by dyspnea The physical exam and chest x-ray are
usually normal initially
In ARDS, it is best to keep the patient on the dry side and avoid fluid overload
Therefore, most ARDS patients receive diuretics to help decrease the fluid overload
All patients with ARDS have daily chest x-rays and are weighed daily to monitor the fluid balance
TV beyond the recommended 8-10 ml/kg does not help with oxygenation and may in fact
respiratory compliance
Know the three major complications of too high a PEEP :
o Alveolar damage,
o Tension pneumothorax
o Ventricular failure
Pulmonary HTN is very common in ARDS and it occurs as a result of hypoxemic vasoconstriction
of pulmonary vasculature
PCWP is normal in ARDS and it is the most important differentiating point between ARDS and
cardiogenic pulmonary edema .It is usually <15 mmHg in ARDS while it is >18 mmHg in
cardiogenic pulmonary edema
Criteria for ARDS diagnosis is
1- PCWP< 18 mmHg favors ARDS over cardiogenic pulmonary edema
2- PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the level of PEEP
3- Diffuse, bilateral infiltrates on chest-X ray

This question is based on simple physiology It is expected in USMLE

When PEEP is increased, its major drawback is a decrease in cardiac output
Patients who are maintained on PEEP should be monitored with a Swan-Ganz catheter.
To counteract the effects of PEEP on cardiac output, some physicians may elect to use inotropic
agents or more fluids
Because PEEP increases the intrathoracic pressure, it does slightly increase the central venous pressure
This has no significant affect on the patient
Postoperative patient who presents with dyspnea and tachypnea. one has to exclude:
a. MI,
b. PE,
c. pneumonia
d. ARDS

Goodpasture and hemisiderosis

Both patients with IPH(Idiopathic pulmonary hemosiderosis) and Goodpastures have hemoptysis
(more copious in IPH), iron deficiency anemia and signs of respiratory compromise
In both cases sputum stain may show iron in the form of hemosiderin and CXR may be abnormal
IPH is more common in young children
Serologic assays for measurement of AGBMAbs further help in confirming the Dx and monitoring
treatment

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Wagner

Note:Fiberoptic bronchoscopy with transbronchial biopsy is not useful in the Dx , however a

thoracoscopic lung biopsy will reveal the full range of pathology of the condition but is not favored as a
diagnostic procedure.
Skin biopsy findings are usually non-specific hence not useful in the diagnosis A deep punch or
incisional biopsy demonstrates vasculitis and granulomas

Alveolar proteinosis

characterized by accumulation of phospholipid rich material in the alveoli probably due to

impaired clearance
Its cause is unknown and it presents with dyspnea and dry cough
CXRshows bilateral alveolar infilterates
PFTRLD
Lung Bx wiII confirm the diagnosis by showing PAS positive material
Total lung bronchoalveolar lavage is effective treatment of this disoroer. (suck them up )
Corticosteroids are of no benefit in this disease

Hemoptysis

A case of massive hemoptysis is a medical emergency

Massive hemoptysis is defined as hemoptysis of >600 ml of blood per 24 hrs
Most of the times the volume is not measured; therefore any suspicion of massive hemoptysis based
up on history needs to be treated as an emergency.
RIGID BRONCHOSCOPY is the initial intervention of choice in massive hemoptysis because it
allows for rapid visualization of the bleeding site and it allows for control of bleeding through laser
cautery or other interventions
Flexible bronchoscopy is used in the diagnostic aspects of hemoptysis and it is not a good choice for
emergency management of hemoptysis
Because of its small lumen it cannot provide much scope for interventions
Chest X-ray and CT scan are not ideal choices because of the emergency of the situation

Mediastinal mass

Ant. mediastinal mass + AFP & HCG indicates Nonseminomatous tumor

Txcan be started even without a tissue biopsy.
Non-seminomas can be Tx with cis platinum based multi agent chemotherapy These tumors are
very aggressive and in the majority of patients grow to very large size
Prevention is better than the cure
Always remember the right time when a common vaccine is given whether it is a child or an adult.
This is big in USMLE
People above 65 years of age should receive pneumococcal vaccine

Idiopathic Interstitial Fibrosis

IPF is a Dx of exclusion
best treated with steroids
Most patients will have a positive response in the first six months but they fail to have sustained
response
Bilateral lung transplant is required and it is the rare patient who can get bilateral transplants
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 The shortage of donors has almost eliminated the majority of these patients from transplantation
in diffusing capacity does not relate very well with the severity of disease
Alveolar fibrosis causes elastic recoil and as a result FEV1/FVC ratio may be (fibrosis)
A-a gradient is a useful measure of oxygenation It is increased in interstitial lung diseases due to
poor oxygenation
Systemic sclerosis
Note:diffuse SSc Pulmonary HTN and Lung Fibrosis (they have renal a. involvement)
BUTLimited SSc (crest synd) Pulmonary HTN only. NO Interstitial lung dz. (no renal a.
involvement)
The most common underlying mechanism of pulmonary complications is interstitial
fibrosis
It develops in about 40% patients with diffuse disease Pulmonary vascular lesions can
develop concornitantty with interstitial fibrosis, but isolated pulmonary HTN without
interstitial fibrosis occurs in < 10% of patients
Aspiration of gastric content with resultant pneumonia due to esophageal dysmotility. is
less common than interstitial fibrosis
The risk of bronchogenic carcinoma is in patients with systemic sclerosis, but it is not
the most common cause of pulmonary complications.
Restriction of chest movements due to extensive thoracic skin fibrosis is rare
NoteTx of interstitial lung dz cyclophosphamide.

Pulmonary HTN
It can be classified as follows
1- Pulmonary HTN associated with disorders of the respiratory system, hypoxemia, or both
2- Pulmonary HTN due to pulmonary venous hypertension (left ventricular heart disease, mitral valve
disease, or pulmonary veno-occlusive disease)
3- Pulmonary HTN following chronic thromboembolic disease
4- Pulmonary arterial HTN (primary pulmonary hypertension, pulmonary hypertension associated with
vasculopathy)
5- Pulmonary HTN due to disorders directly affecting the pulmonary vasculature (pulmonary capillary
hemangiomatosis)

Chronic cough : nassar

Cough can be a presenting symptom of GERD

postnasal drip, is the number one cause of chronic cough in nonsmokers
note endoscopy is the most sensitive investigation for establishing the Dx of GERD
The next best step patient is a 24-hour pH recording

Occupational lung Disease

Bird

Fanciers lung
a form of EAA caused by inhalation of birds antigens
initiated and worsened by exposure to organic antigens or haptens.
avoidance of antigen exposure the most effective Tx (sell your pigons jerk)
repeated exposure will cause progressive lung damage
Systemic corticosteroids severe acute symptoms or significant lung dysfunction
o significant improvement clinically and functionally
o Long-term outcome unchanged

Page 18 of 22

Inhaled steroids may prove to be useful for prevention or treatment of recurrent disease, but they
are usually not used for this purpose
Inhaled cromolyn No role in the treatment
o used for prevention of acute bronchoconstriction resulting from an acute challenge like in cases
of exercise-induced asthma, seasonal asthma
o long-term maintenance therapy in patients of asthma
Berylliosis
Granulamtous pulmonary disease
high tech industries like aerospace technology, ceramics, electronics
Asbestosis
DxHx of significant exposure + clinical Sx, + radiographic and physiological findings
A radiographic finding of pleural plaques is the hallmark of asbestos exposure

Obstructive sleep apnea OSA

The treatment of a mild to moderate disorder usually starts with weight reduction, avoidance of
sedatives and alcohol, and avoidance of supine posture during sleep
Other treatment modalities include uvulopalatopharyngoplasty and nasal continuous positive airway
pressure (CPAP) during sleep
Tracheostomy is used in patients with a severe disorder, and when all the other treatment modalities
have failed
The clinical clues for diagnosis of this condition are
1) Habitual nighttime snoring
2) Day time somnolence
3) Hypertension
In severe cases, the patient may develop pulmonary HTN due to chronic hypoxia and 2nd right heart
failure
Once OSA is suspected the investigation of choice is Nocturnal Polysomnography documenting
episodes of apnea
Lateral cephalometry is indicated only.when the patient is scheduled for surgery to relieve the
airway obstruction
Similarly. MRI is used only in the presurgical evaluation of the patient.
Multiple Sleep Latency Test is used only when the diagnosis is not clear after nocturnal
polysomnography.
It is usually done the day after an inconclusive Polysomnography

Drugs

NoteBeta agonist MAT (multifocal atrial tachycardia)

Ipratropium has low potential for toxicity

Know
Theophylline toxicity
manifests as CNS stimulation (headache, insomnia), GI disturbances (nausea,vomiting),
and cardiac toxicity (arrhythmia)
Page 19 of 22

Factors that influence the metabolism of theophylline. (eg , ciprofloxacin and erythromycin
decreases its clearance and raises plasma concentration)
The exact mechanism responsible for the theophylline toxicity is debated, but may include
PDE inhibition, adenosine antagonism, and stimulation of epinephrine release
Beta-agonists
may cause arrhythmia. nervousness, and tremor, but CNS and GI effects are not typical
Patients who are on high doses of beta-2 agonists may develop hypokalemia and patient should be
monitored with daily electrolytes
The other side affects of beta-2 agonists are tachycardia . tremor, and peripheral edema
"Extremely high yield question for USMLE
Steroids
eosinophils
Lymphocyte arrest
neutrophils
o the bone marrow release
o mobilizing the marginated neutrophil pool
Note::Hypersensitivity reaction is a potential cause of leukocytosis due to hypersensitivity-induced
inflammation, but the leukocyte differential neutrophiIia+ eosinophila
Steroids
In adults, the adverse effect of low- dose inhaled corticosteroid are limited to topical problems such as
o dysphonia, which occurs in 50 % of patients
o oral candidiasis; symptomatic in less than 5 percent
High doses of inhaled corticosteroids systemic absorption and can produce
o adrenal suppression,
o cataract formation,
o growth in chiIdren,
o interference with bone metabolism
o purpura
Steroids cause worsening of the GERD symptoms Even if you use steroids in the treatment of
bronchial asthma, inhaled steroids are more efficacious and have less systemic effects
Extremely high yield question for USMLEIII
ACEi
The pathogenesis of the cough is related to an accumulation of the inflammatory or proinflammatory
mediators bradykinin, substance P, thromboxanes, and prostaglandins
If the cough is disturbing, ACE inhibitor therapy should be discontinued.
Only if the cough persists after the discontinuation of ACE inhibitor therapy,CXR
Kinins are degraded by ACE
It is caused by an accumulation of kinins, and possibly by the activation of the arachidonic acid pathway

N-acetylcysteine Anti sitamol

is used to treat patients who have very viscous secretions
The agent reduces the viscosity and prevents airway plugging
N-acetylcysteine is a mucolytic agent, which is no longer used in exacerbation of COPD, as they are
even implicated in worsening bronchospasm
Hyperbaric oxygenation
Page 20 of 22

has a few indications like

o CO poisoning,
o treatment of bends after deep sea diving,
o few chronic infections

ASA
Aspirin Sensitivity Syndrome
High yield Q
Clues to correct DxASA ingestion , Persistant nasal blockage ,and episodes of
bronchoconstriction.
PathogenesisPseudoAllergic Reaction. an exaggerated release of vasoactive and
inflammatory mediators in susceptible individual .
ASA is COX1-2 inhibitor

5-lipoxygenase

leukotrines

pathway

and

change PG/LT balance trigger characteristic reaction ( bronchoconstriction , polyp formation ) in

susceptible individual.

LT inhibitors are gaining popularity in the Tx of this condition . (DOC)

Other commonly used Tx modalities include topical steroid and ASA

desensitization

Tx.

Miscellaneous

Shift of the endotracheal tube or into a main bronchus or mucous plugging could cause a collapsed
lung However, in that case, the main problem is with oxygenation and the circulatory findings are
secondary

BAL is > 90% effective in Dx PCP in HIV positive patients, especially when CD4 count is <200.
non-specific in diagnosing:
sarcoidosis
asbestos industry
37-year-old female with positive RF.
Increased ventilatory rate in patients on mechanical ventilation leads to auto PEEP and it can be
corrected by reducing the ventilatory rate (PEEP intrathoracic pressure venous return CO).
Always consider candida albicans as a cause of infection in a patient with uncontrolled DM do KOH
preparation
o

Pleurocentisis
The aspirated fluid should always be analyzed for
1. the protein content
o does not determine the need for a chest tube
2. gram stain,
3. LDH
o does NOT indicate if an empyema has occurred (MI,cirrhosis,ischemia)
4. cell count,
o PMNchest tube
o lymphoNOT (malignance,TB)
5. cytology (rule out malignancy),
6. glucose levels
o <60chest tube
Page 21 of 22

7. pH
o

Low pH <7.2is almost always indicative of an empyema and indicates chest tube

Note: non-infectious causes generally clear,

infectious,cloudy
Hemorrhagic effusions are bloody in nature,
Ruptured thoracic duct milky white effusion
Which one of the following laboratory tests on the pleural fluid is currently thought to be most helpful in
determining the need for chest tube placement in parapneumonic effusion?

pH

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