Ck Pulmonology

PULMONOLOGY TIKI TAKA _______________________ . BRONCHIAL ASTHMA: ___________________ ___________________ . SHORTNESS OF BREATH (SOB) + EXPIRATORY WHEEZES. . Severe asthma -> Use of accessory muscles & inability of speaking complete se ntence. . 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 t he ICU. -> Persistent resp. acidosis is an indication of INTUBATION & MECHANICAL VENTIL LATION. . 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 asthmati cs: ________________________________________________________________________________ ___ . Due to ++ vagal tone & micro-aspiration of gastric contents into the upper ai rway. . Risk factors: Obesity, supine position after meals, laryngitis. . Manifestations: Change in voice & NOCTURNAL COUGH. (ACE Is lead to day & nigh t 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 & thera peutic. . N.B. Efficacy of BETA blockers for mortality in cases of MI & CHF is more imp ortant than its adverse effects e.g. Asthma & COPD. . N.B. Exercise induced asthma -> Tx with INHALED BRONCHODILARORS prior to exer cise. . 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 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 OROPHARYNGE AL THRUSH. . N.B. The most common adverse effect of "IV" CORTICOSTEROIDS is -- WBCs "NEUTR OPHILIA". . 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 fat igue. . 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 lu ngs. . N.B. FLATTENING OF THE DIAPHRAGM ++ The WORK OF BREATHING. . CBC -> ++ Hematocrit & reactive microcytic eryhthrocytosis due to chronic hyp oxia. . ABG -> ++ pCO2 & -- pO2 & -- pH (Respiratory acidosis). . Chemistry -> ++ serum bicarbonate as metabolic compensation for respiratory a cidosis. . N.B. (1): . ABG is critical in acute SOB due to COPD (No other way to assess for CO2 rete ntion !). . 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 interstiti um). -> 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 = CO PD. . 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 acid osis. . 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 C OPD). . 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 i n COPD. . N.B. SABA (Albuterol), Anticholinergic (Anti-muscarinic ipratropium),LABA & ST EROIDS: improve symptoms only without -- mortality rate. . N.B. INHALED ANTI-CHOLINERGICS = INHALED MUSCARINIC ANTAGONISTS - INHALED IPRA TROPIUM 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 supplem ental O2, . are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS, . due to a combination of reduced alveolar ventillation & ++ dead space ventill ation, . 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 pH45mmHg 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 b lebs. . 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 vascul ar disease . LVF -> Tachypnea -> fluid pooling in the lungs -> pleural effusion -> Hypoven tillation. . 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 ACIDO SIS). . 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 Dx Dx Tx

-> -> -> ->

CXR -> Findings of COPD (Bullae - Barrel chest - Flat diaphragm). Blood test -> -- ALBUMIN & ++ PT (Cirrhosis). -- Alpha-1 antitrypsin level. 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 resistanc e. . 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 i nfections. . 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 (Pneumoconio sis). . 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

-> -> -> ->

CXR -> Interstitial fibrosis & Honeycombing. CXR -> Pulmonary vascular congestion at the hilum. CT -> PLEURAL PLAQES ARE PATHOGNOMONIC (Pneumoconiosis)! Lung biopsy.

. Dx -> 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 u sed. . 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 mesothel ioma. . N.B. ILD may be complicated by COR PULMONALE: -> peripheral edema - Hepatojugular reflex - Jugular venous distension - Rt ven tr. heave. . COMPARISON BETWEEN PFTs in COPD & ILD: ________________________________________ . COPD -> OBSTRUCTIVE PATTERN & ILD -> RESTRICTIVE PATTERN: ___________________________________________________________ . PFTs ___________ COPD __________ ILD . . . . . .

FEV1 ___________ FVC ___________ FEV1/FVC _______ TLC ____________ RV _____________ DLCO ___________

-----++ ++ --

__________ __________ __________ __________ __________ __________

--NORMAL ----

. BRONCHILOTIS OBLITERANS ORGANIZING PNEUMONIA BOOP / CRYPTOGENIC ORGANZING PNEU MONIA COP: ________________________________________________________________________________ __________ ________________________________________________________________________________ __________ . Inflammation of the small airways with a chronic alveolitis of an unkown orig in ! . 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 _______________ . Presents over days to weeks ____________ . PATCHY infiltrates _____________________ . STEROIDs EFFECTIVE _____________________ eroids.

. . . .

NO. 6 months or more of symptoms. INTERSTITIAL infiltrates. Only BERYLLIOSIS may respond to st

. 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 ve ntricle. . 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 hypertro phy. . Dx -> EKG -> Rt axis deviation. . Dx -> CXR -> Pulmonary arteries enlarg. & RVE & tapering of distal vessels (P runing). . 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 vesse ls 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 - Thrombophil ia). . 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 3ds) -> Score + 1 point (Hemoptysis - cancer). -> Total score for clinical propability (< 4 -> PE UN-likely .. > 4 -> PE likel y). .

. 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 CONFI

RMED) . 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 CO NTRAST. . 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 emb olism. . 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. hypotens ion). {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 s urgery, . 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 -- GF R ! . LMW heparin (Enoxaparin) can't be given as it causes severe renal insuffecien cy. . 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 fe moral vein . So .. U sh'd START INTRAVENOUS UNFRACTIONATED HEPARIN & CONTINUE WARFARIN. . y . t

The proximal deep leg veins are the most common source of symptomatic pulmonar embolism Less common sources of emboli include calf, pelvic & upper evtremity veins & R heart.

. "Factor V Leiden" is the most common genetic disorder causing hypercoagulabili ty & DVT. . N.B. Acute massive pulmonary embolism can present initially with syncope & sho ck. . e.g. sudden loss of consciousness at work, BP:80/40 & HR:120/min with cold cla mmy 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 pe rfusion, . 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 C RITERIA .__________________________________________ ._______________________ ________ .| .| ._____________________ .______________ _ .| .| .| .| . +ve PE . -ve PE . PE Un-likely . PE likely .________ .________ .______________ .___ ________ .| .| .| .| . IVC FILTER . No further tests .| . START antic oagulation .| .____________ __________ .| .| . D-DIMER TESTING fo r PE .___________________ _____ .| .__________________________________________________________________ ___ .| .| . +ve . -ve . Start or continue anticoagulation, . STOP antico agulation . 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. . um . um .

High ptn level > 50 % of serum level __________ . Low ptn level < 50 % of ser level. High LDH level > 60 % of serum level __________ . Low LDH level < 60 % of ser 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 bac teria). . 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 bact eria. . A mixed aerobic & anaerobic bacterial infection (Strept. - Staph. - Klebsilel la). . 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 hypoventi llation). . 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 acid osis. . To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead ! . HOW TO DIFFERENTIATE BETWEEN OBSTRUCTIVE SLEEP APNEA & OBESITY HYPOVENTILLATIO N $: ________________________________________________________________________________ ____ ________________________________________________________________________________ ____ .{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$). . Differentiate bet. the two types using pulmonary capillary wedge pressue (PCW P). . PCWP > 18 -> Cardiogenic pulmonary edema. . PCWP < 18 -> Non cardiogenic = ARD$. . 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 < 6

0% ! . PEEP may be ++ as needed to maintain adequate oxygenation but avoid tension p neumothx. . 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 e xpiration. . 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 & Nigh t sweats). . CXR -> UPPER LOBE INFILTRATES WITH CAVITATION. . ASPIRATION PNEUMONIA = ANAEROBIC PNEUMONIA: _____________________________________________ . Impaired swallowing due to IMPAIRED EPIGLOTTIC REFLEX is the most imp. predis p. 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 fa ctors. . 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 se cretions. . 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 (CHARACT ERISTIC). . 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 -- mortal ity. . If there is toxicity from TMP-SMX (Rash - BM depression) -> PENTAMIDINE or Pr imaquine. . If the pt is African American with G6PD (Bite cells on smear) -> Don't give P rimaquine. . For PCP prophylaxis -> TMP-SMX .. if there is a rash or neutropenia -> Atovaq uone. . If CD4 count is ++ & maintained above 200 for several months -> Stop prophyla xis. . 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 de bris. . These alveoli may have persistent blood flow to areas with impaired ventillat ion. . Leading to a physiologic intra-pulmonary shunt & arterial hypoxemia. . Positioning of the pt. with the affected lung in dependent position can worse n 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 n ormal. . . . .

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 & prisoner s. -> 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 cou

gh). . 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 (Lo ratidine)! . 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 rhin itis. . Dx -> Confirmed by improvement of the nasal discharge & cough with H1 Anti-hi staminics. . Chlorpheniramine is an H1 receptor blocker that decreases the allergic respon se. . 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 bronchoconstricti on. . 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 = CHORIO CARCINOMA. . 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 m alignant. . 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 + GLOMERULONE PHRITIS. . 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 ga ngrenosum) . BEST INITIAL TEST -> +ve C-ANCA = serum anti-neutrophilic cytoplasmic antibod y. . 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 ur inalysis). . Systemic symptoms are un common. . Dx -> Renal biopsy -> LINEAR IgG antibodies along the glomerular basement mem brane. . EFFECTS OF ARTERIAL OXYGENATION & VENTILATION IN VARIOUS ENVIRONMENTS: ________________________________________________________________________ _____________________________ Example ________ A-a gradient ____ Pa CO2 ___ Corr ects 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 & ex piration. * NORMAL LUNG EXAMINATION: __________________________ . Percussion -> Resonant. . Auscultation -> Vesicular breathing. * LUNG CONSOLIDATION EXAM: __________________________ . Percussion -> Dullness. . Auscultation -> LOUDER vesicular breathing if airways are patent (Faint if bl ocked). . 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 pne umothorax) . -- TVF. . JVD, Hypotension & Tracheal deviation to the opposite side. * EMPHYSEMA EXAM: _________________ . Percussion -> bilateral resonance. . Auscultation -> Vesicuar breathing with fine crackles at inspiration. . Y . . .

N.B. Recurrent bacterial infections in an adult may indicate a HUMORAL IMMUNIT 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 p arenchyma ._______________________________________________________________________________ __________ .| ._______________________________________________ .| .| .| . 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 chyma. . Debris & . The ball . A MOBILE

lesion may form due to destruction of the underlying pulmonary paren hyphae may coalese forming a FUNGUS BALL. lies freely in the cavity & moves around with position change. 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 l ymphoma). . H/O of chronic heavy smoker with recent un-intentional weight loss -> Lung ca ncer. . 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 b ed & fold. . In severe cluccing, the terminal parts of the fingers appear swollen like dru msticks. . It is NOT a feature of simple COPD. . NEW CLUBBING in COPD pts indicates the development of lung cancer or occult m alignancy. . GOLDEN SCHEME: ________________ ________________ .

_

. SPIROMETRY .____________ .| .____________________________________________________ .| .| . LOW FEV1/FVC . NORMAL OR HIGH FEV1/FVC .______________ .________________________

.| . OBSTRUCTIVE DISEASE ._____________________ .| . BRONCHO-DILATOR CHALLENGE ____________________________ .| ._________ .| .| . ++ FEV1 . No ++ in FEV1 ._________ ._______________

.| . RESTRICTIVE DISEASE ._____________________ .| . DLCO .______ .| .________________ .| .| . NORMAL . -- DLCO ._______ .________

_ . ASTHMA.

. COPD. . CHEST WALL WEAKNESS .| . DLCO ._____________________ .| .| . (--) -> Emphysema . (++) -> Chronic bronchitis.

. ILD.

. 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 & voca l cords. . N.B. 2ry MALIGNANCY AFTER CHEMOTHERAPY ! __________________________________________ . Up to 4% of pts with HODGKIN's disease wil develop a 2ry malignancy (Lung - b reast) . 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 sm oking. . 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 seri ous 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 h olding). . 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 ac id 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 acid osis. . 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 A lkalosis. . 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. a lkalosis. -> 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 __________________________