PULMONOLOGY TIKI TAKA _______________________

. BRONCHIAL ASTHMA:______________________________________

. SHORTNESS OF BREATH (SOB) + EXPIRATORY WHEEZES. . Severe asthma -> Use of accessory muscles & inability of speaking complete sentence. . SEVERE ASTHMA EXACERBATION manifestations:_____________________________________________ -> ++ RR = Hyperventillation. -> -- in peak flow. -> -- O2 = Hypoxia. -> -- pH = Respiratory acidosis. -> Possible absence of wheezes (To wheeze, one must have air flow!).

. Dx -> Pt with SOB & unclear if the cause is BA:__________________________________________________ -> Do "PULMONARY FUNCTION TESTS" (PFTs) before & after INHALED BRONCHODILATORS: -> ++ in FEV1 > 12 % -> Confirmed BA.

. Dx -> Asymptomatic pt now i.e. H/O of intermittent SOB episodes but now he is normal:________________________________________________________________________________________ -> Do "METACHOLINE STIMULATION TEST": -> -- in FEV1 in response to synthetic acetylcholine (if the pt has BA).

. Tx -> ACUTE ASTHMA:______________________ -> INHALED BRONCHODILATORS (SABA) -> ALBUTEROL. -> BOLUS "Not inhaled" of steroids (Methyl prednisone). -> INHALED IPRATROPIUM. -> OXYGEN. -> Magnesium.

. N.B. Any BA pt. with RESPIRATORY ACIDOSIS & CO2 RETENTION sh'd be placed in the ICU. -> Persistent resp. acidosis is an indication of INTUBATION & MECHANICAL VENTILLATION.

. The following therapies have "NO BENIFIT" in acute asthma exacerbation: -> Theophylline - Cromolyn - Montelukast - INHALED steroids - LABA "Salmeterol".

. NON-ACUTE BA:________________ -> Best initial -> INHALED BRONCHODILATORs (ALBUTEROL). -> Not controlled -> ADD + INHALED STEROIDs. -> Not controlled -> ADD + INHALED LABA (SALMETEROL). . Extrinsic allergies (HAY FEVER) -> Cromolyn or nedocromil. . High Ig E levels not controlled with Cromolyn -> Omalizumab. . Atopic disease -> Montelukast. . COPD -> Ipratropium.

. N.B. VVVVVVVVVVVVVV. imp. GERD can exacerbate airflow obstruction in asthmatics:___________________________________________________________________________________ . Due to ++ vagal tone & micro-aspiration of gastric contents into the upper airway. . Risk factors: Obesity, supine position after meals, laryngitis. . Manifestations: Change in voice & NOCTURNAL COUGH. (ACE Is lead to day & night cough!). . Anti-GERD life style modification. . Give a trial of a proton pump inhibitor (Esomeprazole).

. GERD is present in 75% of asthma pts & may be the trigger of many cases. . Adult onset asthma with GERD (Worsening syms after meals or with lying down). . Obesity, hoarsness, pharyngitis & laryngitis tend towards GERD. . A trial of proton pump inhibitors (Omeprazole) can be both diagnostic & therapeutic.

. N.B. Efficacy of BETA blockers for mortality in cases of MI & CHF is more important than its adverse effects e.g. Asthma & COPD.

. N.B. Exercise induced asthma -> Tx with INHALED BRONCHODILARORS prior to exercise.

. N.B. All pts with SOB sh'd 've -> O2 - pulse oximeter - CXR & ABG.

. TREATMENT OF BRONCHIAL ASTHMA DEPENDS ON ITS SEVERITY:_________________________________________________________ * INTERMITTENT -> CONTINUE CURRENT REGIMEN SABA (B-agonists: ALBUTEROL): _________________________________________________________________________ . Day time syms < 2 /week. . Night time awakenings < 2 / month. . B-agnists < 2 / week. . Normal PFTs. . No limitations on daily activities.

* MILD PERSISTENT -> ADD INHALED CORTICOSTEROIDS:__________________________________________________ . Day time syms > 2 /week. . Night time awakenings 3-4 / month. . Normal PFTs. . MINOR limitations on daily activities.

* MODERATE PERSISTENT -> ADD INHALED LABA (SALMETEROL):________________________________________________________ . Daily symptoms. . Weekly Night time awakenings. . FEV1 <60 - 80 % of predicted. . Moderate limitations on daily activities.

* SEVERE PERSISTENT -> ADD ORAL PREDNISONE:____________________________________________ . Symptoms through out the day. . Frequent night time awakenings. . FEV1 < 60 % of predicted. . Severe limitation on daily activity.

. IMPORTANT DRUG SIDE EFFECTS:____________________________________________________________ . N.B. The most common adverse effect of INHALED CORTICOSTEROIDS is OROPHARYNGEAL THRUSH.

. N.B. The most common adverse effect of "IV" CORTICOSTEROIDS is -- WBCs "NEUTROPHILIA". . Glucocorticoids ++ bone marrow release of of neutrophils. . Glucocorticoids mobilize the marginated neutrophilic pool. . Eosinophils & lymphocytes are decreased.

. N.B. High doses of B2 agonists may develop HYPOKALEMIA ! . Hypokalemia may present as ms weakness, arrhythmia & EKG abnormalities.

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

. INDICATORS OF SEVERE ASTHMATIC ATTACK:________________________________________ . NORMAL or INCREASED CO2 is the worst sign indicating acute severe attack. . CO2 retention is due to severe airway obstruction (air trapping) & respirat. ms fatigue . Speech difficulties. . Diaphoresis. . Altered sensorium. . Cyanosis. . SILENT lungs. . ACUTE EPISODES of SOB MANAGEMENT:___________________________________ -> Oxygen & ABG. -> CXR. -> SABA "ALBUTERL" INHALED. -> IPRATROPIUM INHALED. -> BOLUS of steroids (Methyl prednisone).-------> VVVVVVVVVVV. imp. -> Chest, heart, extremity & nerological exam. -> If fever, sputum & or new infiltrate is present on CXR: ADD CEFTRIAXONE & AZITHROMYCIN for community acquired pneumonia.

. N.B. In pts with acute asthma exacerbation, an ELEVATED or even NORMAL PCO2 = RF. . Respiratory failure due to -- respiratory drive due to respiratory muscle fatigue. . ENDO-TRACEAL INTUBATION & MECHANICAL VENTILLATION is MANDATORY. . Add inhaled SABA (Albeterol) & inhaled ipratropium & systemic corticosteroids.

. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD):______________________________________________________________________________________________ . H/O of long term smoker with ++ SOB & -- exercise tolerance.

. Barrel shaped chest. . Clubbing of fingers. . ++ A-P diameter of the chest. . Loud P2 heart sound (Sign of pulmonary hypertension). . Edema (Sign of -- Rt ventricular out put). . EKG -> Rt. axis deviation - Rt atrial & ventricular hypertrophy. . CXR -> Elongated heart - Flattenning of the diaphragm due to hyperinflated lungs. . N.B. FLATTENING OF THE DIAPHRAGM ++ The WORK OF BREATHING. . CBC -> ++ Hematocrit & reactive microcytic eryhthrocytosis due to chronic hypoxia. . ABG -> ++ pCO2 & -- pO2 & -- pH (Respiratory acidosis). . Chemistry -> ++ serum bicarbonate as metabolic compensation for respiratory acidosis. . N.B. (1): . ABG is critical in acute SOB due to COPD (No other way to assess for CO2 retention !). . N.B. (2): . ABG is important to assess for CO2 retention. . ABG is important to assess for the need for chronic home oxygen based on pO2.

. N.B. (3): . In moderate & severe cases of COPD, pts may become members of the 50/50 club !! . Both pO2 & pCO2 are around 50s ! . Ex -> pH. 7.35 - pCO2 49 - pO2 52 - HCO3 32. . PULMONARY FUNCTION TESTS in COPD -> OBSTRUCTIVE PATTERN:___________________________________________________________ -> -- FEV1. -> -- FVC (Loss of elastic recoil of the lung). -> -- FEV1/FVC ratio. -> ++ Total Lung Capacity (++ TLC due to air trapping .. VVVVVVVVVVVV.imp.). -> ++ Residual Volume. -> -- Diffusion capacity lung CO (-- DLCO due to destruction of lung interstitium).

-> INCOMPLETE IMPROVEMENT WITH ALBUTEROL (# Asthma). -> LITTLE OR NO IMPROVEMENT WITH METACHOLINE (# Asthma).

. N.B. A bronchodilator response test to differentiate COPD from BA:____________________________________________________________________ . Measuring FEV1 before & after adminstration of bronchodilator (B2 agonist). . Significant improvement in FEV1 (> 15%) after bronchodilator -> Reversibility = Asthma. . Little or no improvement in FEV1 after bronchodilator -> Irreversibility = COPD.

. N.B. Chronic hypercapneic respiratory failure due to COPD:____________________________________________________________ . Marked acidosis should be the result of respiratory failure in COPD. . But .. RENAL TUBULAR COMPENSATION occurs. . Kidneys ++ HCO3 retention to compensate for ++ CO2 ! . Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acidosis. . To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !

. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++ bicarbonate retention.

. CHRONIC MEDICAL THERAPY of COPD:___________________________________ . IPRATROPIUM or TIOTROPIUM INHALED (Most effective therapy to reduce syms in COPD). . SABA ALBUTEROL INHALED. . Pneumococcal vaccine -> Hepatavalent vaccine (Pneumovax). . Influenza vaccine yearly. . Long term home oxygen therapy (If pO2 < 55 or SO2 < 88%).

. N.B. Long term O2 therapy in a pulmonary hypertension pt or HCT > 55% -> PaO2 < 60 mmHg.

. N.B. Both smoking cessation & home oxygen therapy & vaccines lower mortality in COPD.

. N.B. SABA (Albuterol), Anticholinergic (Anti-muscarinic ipratropium),LABA & STEROIDS: improve symptoms only without -- mortality rate. . N.B. INHALED ANTI-CHOLINERGICS = INHALED MUSCARINIC ANTAGONISTS - INHALED IPRATROPIUM are the most effective in COPD.

. N.B. Cromolyn & Montelukast have no benefit in COPD.

. ACUTE EXACERBATION OF COPD TTT:_________________________________ . Acute worsening of symptoms in a pt. with COPD. . Caused by upper respiratory tract infection. . May be preceided by cough & fever. . Exam -> Bilateral wheezes. . ABG -> Respiratory acidosis & hypoxia.

. Inhaled bronchodilators (B2 agonists = Albuterol). . Inhaled anti-cholinergics (Ipratropium). . Broad spectrum antibiotics. . INHALED CORTICOSTEROIDS for 2 weeks then tapered gradually. . Smoking cessation. . Oxygen (If pO2 < 55 mmHg or SO2 < 88%).

. N.B. Pts with acute on chronic respiratory failure ttt with high flow supplemental O2, . are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS, . due to a combination of reduced alveolar ventillation & ++ dead space ventillation, . causing ventillation perfusion mis-match & -- Hb affinity for CO2. . The goal oxy-hemoglobin saturation in these pts is 90 - 94 % (Not > 95%)!

. NON INVASIVE POSITIVE PRESSURE VENTILLATION (NIPPV):_______________________________________________________ . Used in acute exacerbations of COPD REFRACTORY to ttt with B-agonist & inhaed steroids. . Used before intubation to avoid its side effects e.g. infection. . Recommended in pt e' respiratory distress with a pH<7.35 or pCO2>45mmHg or RR>25/min. . It is contraindicated in septic, hypotensive or dysrhythmic pts. . NIPPV will provide more O2 & wash out excess CO2.

. If the pt. is refractory to NIPPV -> Intubate with mechanical ventillation !

. SPONTANEOUS PNEUMOTHORAX (A complication of COPD):____________________________________________________ . COPD pt presenting with catastrophic worsening of respiratory symptoms. . Cigarette smoking markedly ++ risk of pneumothorax. . It leads to chronic airway inflammation & respiratory bronchiolitis. . The chronic destruction of the alveolar sacs -> Formation of large alveolar blebs. . which can rupture & leak air into the pleural space. . presents with acute onset of chest pain & shortness of breath. . Breath sounds are markedly reduced & hyperresonance to percussion on affected side.

. VVVVVVVVV. IMP. TWO PRIMARY SUB-TYPES OF COPD: CHRONIC BRONCHITIS & EMPHYSEMA:_________________________________________________________________________________

{A} . COPD with EMPHYSEMA pre-dominance -> (-- DLCO):______________________________________________________ . Thin pts with severe dyspnea, hyperinflated chest. . DECREASED vascular markings. . SEVERE flattening of diaphragm. . DECREASED DLCO -> due to alveolar destruction. {B} . COPD with CHRONIC BRONCHITIS pre-dominance -> (NORMAL DLCO):___________________________________________________________________ . Chronic productive cough for > 3months over 2 consecutive years. . Due to hypersecretion of mucus & structural changes in the tracheo-bronchial tree. . PROMINENT vascular markings. . MILD flattening of diaphragm. . NORMAL DLCO.

. EXACERBATION OF CONGESTIVE HEART FAILURE:___________________________________________ . H/O of coronary artery disease -> Lt ventricular dysfunction -> Heart failure. . Un-controlled hypertension & smoking H/O are risk factors for coronary vascular disease . LVF -> Tachypnea -> fluid pooling in the lungs -> pleural effusion -> Hypoventillation. . Hypoventillation -> Hypoxemia. . Tachypnea -> Hypocapnia & respiratory alkalosis. . Signs of fluid overload - S3 & S4 gallops & cardiomegaly. . Lung exam -> Bi-basilar crackles. . Lung exam -> -- breath sounds at lung bases due to pleural effusion from CHF. . Wheezing can occasionally be present (Cardiac asthma). . ABG -> HYPOXIA - HYPOCAPNIA - RESPIRATORY ALKALOSIS (COPD -> Respiratoy ACIDOSIS). . Dx -> BNP & PCWP.

. ALPHA 1 ANTI-TRYPSIN DEFECIENCY:____________________________________________________________________ . Genetic disorder. . Liver cirrhosis + COPD. . NON-smoker. . Early age < 40 ys NON-smoker having BULLAE at the base of the lungs.

. Dx -> CXR -> Findings of COPD (Bullae - Barrel chest - Flat diaphragm). . Dx -> Blood test -> -- ALBUMIN & ++ PT (Cirrhosis). . Dx -> -- Alpha-1 antitrypsin level. . Tx -> Alpha-1 antitrypsin infusion !

. BRONCHIECTASIS:__________________________________ . Cough - mucopurulent sputum - hemoptysis. . Profound dilatation of the bronchi. . due to anatomic defect in the lungs mostly due to infection in childhood. . Episodes of lung infection with high volume of sputum. . Hemoptysis & fever may occur. . Dx -> CXR -> Dilated bronchi (TRMA TRACKING). . Dx -> CT Chest -> Most accurate test. . Tx -> No curative therapy. . Just ttt the infectious episodes with rotating antibiotics to avoid resistance.

. CYSTIC FIBROSIS:____________________________________ . Young pt. . Mutation in the Chloride transporter protein CFTR. . Abnormally thick secretions. . Affect the respiratory tract - sinuses - pancreas - intestines & reproductive systems. . Respiratory tract -> Chronic cough e' frequent exacerbations & superimposed infections. . Most pts develop BRONCHIECTASIS leading to HEMOPTYSIS. . Pancreas -> Fat malabsorption with bloating & greasy, floating stools. . Dx -> CT -> Atrophic pancreas with calcifications.

. INTERSTITISAL LUNG DISEASES (ILD):________________________________________________________________________

. Pulmonary fibrosis 2ry to environmental or occupational exposure (Pneumoconiosis). . Also caused by medications (NITROFURANTOIN & TMP-SMX "BACTRIM"). . If the etiology is unknown (IDIOPATHIC PULMONARY FIBROSIS).

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

. Shortness of breath. . "DRY" = NON productive cough & chronic hypoxia. . Dry rales - Bi-basilar end-inspiratory crackles. . Loud P2 (Sign of pulmonary hypertension). . Digital clubbing. . NOOOO FEVER - NOOOO systemic findings.

. Dx -> CXR -> Interstitial fibrosis & Honeycombing. . Dx -> CXR -> Pulmonary vascular congestion at the hilum. . Dx -> CT -> PLEURAL PLAQES ARE PATHOGNOMONIC (Pneumoconiosis)! . Dx -> 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 used. . The only form of ILD that responds to steroids is BERYLLIOSIS (Granulomatous disease). . N.B. The most common type of cancer in ASBESTOSIS is LUNG CANCER not mesothelioma. . N.B. ILD may be complicated by COR PULMONALE: -> peripheral edema - Hepatojugular reflex - Jugular venous distension - Rt ventr. heave.

. COMPARISON BETWEEN PFTs in COPD & ILD:________________________________________. COPD -> OBSTRUCTIVE PATTERN & ILD -> RESTRICTIVE PATTERN:___________________________________________________________

. PFTs ___________ COPD __________ ILD

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

. BRONCHILOTIS OBLITERANS ORGANIZING PNEUMONIA BOOP / CRYPTOGENIC ORGANZING PNEUMONIA COP:____________________________________________________________________________________________________________________________________________________________________________________ . Inflammation of the small airways with a chronic alveolitis of an unkown origin ! . Associated with Rheumatoid arthritis. . Resembles ILD but more acute presentation (Over weeks to months). . (SOB - Cough - rales) + FEVER + MALAISE + MYALGIA. . No occupational exposure in history ! . CXR -> Bilateral PATCHY infiltrates. . CT -> Inerstitial disease & alveolitis. . Most accurate -> OPEN LUNG BIOPSY ! . Tx -> Steroids (No response to antibiotics).

. COMPARISON BETWEEN BOOP/COP & ILD:

____________________________________ . BOOP/COP _______________________________ . ILD . Fever- myalgia - malaise _______________ . NO. . Presents over days to weeks ____________ . 6 months or more of symptoms. . PATCHY infiltrates _____________________ . INTERSTITIAL infiltrates. . STEROIDs EFFECTIVE _____________________ . Only BERYLLIOSIS may respond to steroids.

. SARCOIDOSIS:______________ . AFRICAN AMERICAN WOMEN. . Age < 40s. . SOB - Cough & fatigue over a few weeks to months. . Lung - > Rales. . Eye -> ANTERIOR UVEITIS (Sight threatening). . Neural -> Facial palsy (7th cranial nerve). . Skin -> ERYTHEMA NODOSUM. . Joint -> Polyarthralgia. . Heart -> RESTRICTIVE CARDIOMYOPATHY. . HYPERCALCEMIA (2ry to Vit.D production by the granulomas). . Dx -> Best initial test -> CXR. . CXR -> BILATERAL HILAR LYMPHADENOPATHY & diffuse interstitial infiltrates. . Dx -> Most accurate test -> LUNG or LN biopsy -> NON-CASEATING GRANULOMA. . Dx -> ++ Ca & ++ ACE levels . Dx -> BAL -> ++ helper cells.

. Tx -> STEROIDs.

. SYSTEMIC SCLEROSIS:_____________________ . Pulmonary symptoms (Due to interstitial fibrosis). . Dysphagia. . Raynaud's phenomenon. . Hypertension. . Telangiectasia.

. PULMONARY HYPERTENSION:_________________________ . Mean pulmonary arterial blood pressure > 25 mmHg. . Overgrowth & obliteration of pulmonary vasculature -> -- outflow of the Rt ventricle. . SOB more often in young women. . May be 2ry to (MS - COPD - PCV - ILD & chronic pulmonary emboli). . Physical findings (Loud P2 - TR - RV heave). . Dx -> TRANS-THORACIC ECHOCARDIOGRAM (TTE) -> Rt atrial & ventricular hypertrophy. . Dx -> EKG -> Rt axis deviation. . Dx -> CXR -> Pulmonary arteries enlarg. & RVE & tapering of distal vessels (Pruning). . Most accurate -> RIGHT HEART SWAN GANZ CATHETERIZATION -> ++ PULMONARY ARTERY pressure. . Tx -> BOSENTAN -> Endothelial inhibitor. . May be complicated by RVF (Rt ventricular heave - JVD - Tender hepatomegaly - Ascites).

. COR PULMONALE:________________ . Rt sided heart failure due to pulmonary disease. . Jugular venous distension. . Right sided S3 gallop. . Right ventricular heave. . Hepatomegaly. . Ascites. . Dependent LL edema. . Most commonly caused by COPD (Flattened diaphragm - prominent pulmonary vessels on CXR) . CXR -> Prominent right ventricle & pulmonary artery.

. PULMONARY EMBOLISM:__________________________________________ . PERFUSION DEFECT & NO VENTILLATION DEFECT. . ++++++++++++++++++++++++++++ A-a gradient.

. SUDDEN onset SOB + CLEAR LUNGs. . Risk factors of DVT (Immobility - Malignancy - Trauma - Surgery - Thrombophilia). . H/O of recent orthopedic surgery followed by bed rest. . No specific physical finding for PE.

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

. . Clinical assessment for pulmonary embolism .____________________________________________

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

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

. CONFIRMATORY TESTS -> Spiral CT - V/Q scan - LL Doppler - D-Dimer. . MOST ACCURATE TEST -> PULMONARY ANGIOGRAPHY = CHEST CT ANGIOGRAPHY with IV CONTRAST.

. 1 . CXR:___________ . Most common result -> NORMAL. . Most common abnormailty -> Atelectasis. . Wedge shaped infarction & pleural humps are rare. . 2 . EKG:___________ . Most common showing -> SINUS TACHYCARDIA. . Most common abnormality -> NON-SPECIFIC ST-T WAVE CHANGES. . Right axis deviation & Rt BBB are rare.

. 3 . ABG:___________ . HYPOXIA -> ++ A-a gradient. . Mild respiratory alkalosis.

. 4 . SPIRAL CT -> TEST OF CHOICE if the CXR is ABNORMAL:__________________________________________________________ . Standard to confirm the presence of a pulmonary embolus. . Excellent if +ve being specific. . Not specific as it can miss some emboli if they are small & in the periphery. . Chest CT showing a WEDGE SHAPED infarction is PATHOGNOMONIC for pulmonary embolism. . 5 . VENTILLATION PERFUSION V/Q SCAN -> TEST OF CHOICE if the CXR is NORMAL:______________________________________________________________________________ . PERFUSION DEFECT with NO VENTILLATION DEFECT. . NORMAL V/Q scan excludes pulmonary embolism.

. 6 . LOWER EXTREMITY DOPPLER:_______________________________ . If +ve -> No further tests are needed to confirm PE. . The problem is that 30 % of PEs originate in pelvic veins, so the LL Doppler is NORMAL. . So it has low sensitivity i.e. can't exclude PE.

. 7 . D-DIMER TESTING = FIBRIN SPLIT PRODUCTS TESTING:_______________________________________________________ . SINGLE TEST TO EXCLUDE PE. . Very sensitive test with poor specificity. . D-DIMER -> NEGATIVE -> NO PULMONARY EMBOLISM. . D-DIMER -> Not specific -> May be other causes. . The best use of D-DIMER test is in a pt with LOW propability of PE, . & u want a single test to exclude PE !!

. 8 . ANGIOGRAPHY -> SINGLE MOST ACCURATE TEST FOR PE:______________________________________________________ . ANGIOGRAPHY = CHEST CT ANGIOGRAPHY WITH INTRAVENOUS CONTRAST (VVVVVV. imp.). . INVASIVE with risk of death (0.5%).

. MANAGEMENT of PULMONARY EMBOLISM:___________________________________ {1} HEPARIN & OXYGEN -> Standard of care. {2} Warfarin -> Sh'd be used at least for 6 months after Heparin. {3} IVC filter -> in case of contraindication to Anticoagulants (e.g. hematoma)

. {4} Thrombolytics -> used in pts who r hemodynamically UN-stable (e.g. hypotension). {5} Embolectomy is rarely done (High risk of death).

. N.B. When the case so clearly suggests a pulmonary embolism, . i.e. Pt presenting with sudden onset of SOB & clear lungs with H/O of major surgery, . the 1st thing to do is CXR & ABG followed by HEPARIN. . Don't wait the results of V/Q scan or spiral CT to start heparin !!

. When there is a contraindication to anticoagulation e.g. hematoma, . Don't use heparin ! Place an IVC filter.

. For anticoagulation, "Un-fractionated" heparin is preferred in pts with -- GFR ! . LMW heparin (Enoxaparin) can't be given as it causes severe renal insuffeciency.

. Warfarin can be thrombogenic without heparin as a bridge ! . It sh'd be given after initiating heparin with PTT goal 1.5-2 times of normal. . Warfarin takes up to 5-6 days to reach its therapeutic level. . After reaching therapeutic INR level (2-3), heparin can be stopped.

. VVVVVV. imp. N.B. A PROGRESSING CLOT in a pt with sub-therapeutic INR (ex. 1.2), . requires BRIDGING HEPARIN until the INR is therapeutic (2-3), . Example .. A pt recently hospitalized for LL DVT then discharged, . After 5 days, U$ reveals popliteal vein thrombosis extending into the deep femoral vein . So .. U sh'd START INTRAVENOUS UNFRACTIONATED HEPARIN & CONTINUE WARFARIN.

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

. "Factor V Leiden" is the most common genetic disorder causing hypercoagulability & DVT.

. N.B. Acute massive pulmonary embolism can present initially with syncope & shock.. e.g. sudden loss of consciousness at work, BP:80/40 & HR:120/min with cold clammy skin.. Rt heart catheterization -> ++ Right atrial & pulmonary artery pressures.. Normal PCWP Pulmonary artery capillary wedge pressure.

. N.B. Massive pulmonary embolism usually presents with signs of low arterial perfusion,. Hypotension, acute dyspnea, pleuritic chest pain, tachycardia & syncope.. The thrombus ++ pulmonary vascular resistance & Rt ventricular pressure,. causing Rt ventricular hypokinesis -> Rt ventricular dilatation.

. APPROACH TO MANAGEMENT OF PATIENT WITH SUSPECTED PULMONARY EMBOLISM:____________________________________________________________________________________________________________________________________________ . Stabilize the pt with Oxygen & IV fluids

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

. PLEURAL EFFUSION:______________________________________

. Best initial test -> CXR. . Decubitus films (Pt lying on one side) sh'd be done next to assess the fluid mobility. . Most accurate test -> THORAC-CENTESIS. . Un-diagnosed pleural effusion is best evaluated with THORACOCENTESIS, . To detect whether it is a transudate or an exudate. . Except in pts with clear-cut evidence of congestive heart failure, . Associated fluid overgain, pedal edema & bilateral lung base crackles. . Diuretics & echo sh'd be done not thoracocentesis.

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

. EXUDATE PLEURAL EFFUSION ______________________ . TRANSUDATE PLEURAL EFFUSION

. Cancer & infection & Pulmonary embolism _______ . Congestive heart failure & cirrhosis.

. High ptn level > 50 % of serum level __________ . Low ptn level < 50 % of serum level. . High LDH level > 60 % of serum level __________ . Low LDH level < 60 % of serum level. . LDH > 2/3 upper limit of normal serum LDH (250) . < 2/3 !

. pH > 7.3 (Normal 7.6) ______________________ . pH < 7.3 (++ acid prod. by bacteria).

. NO CHANGE IN GLUCOSE OR AMYLASE LEVELS IN BOTH TYPES !

. Tx -> Small pleural effusions don't need therapy ! . Diuretics can be used for those caused by congestive heart failure. . Larger effusions esp. those caused by empyema -> Drain by CHEST TUBE. . Large recurrent effusion from an un-correctable cause -> PLEURODESIS. . If pleurodesis failed -> Decortication.

. N.B. 1 -> EXUDATE -> MALIGNANCY OR INFECTION -> ++ Capillary permeability. . N.B. 2 -> TRANSUDATE -> CONGESTIVE HEART FAILURE -> ++ HYDROSTATIC PRESSURE. . N.B. 3 -> TRANSUDATE -> CIRRHOTIC LIVER FAILURE -> -- PLASMA ONCOTIC PRESSURE.

. COMPLICATED PARA-PNEUMONIC EFFUSION CRITERIA:________________________________________________ . Exudative pleural effusion. . Pleural fluid acidosis. . Low pleural fluid glucose < 60 mg/dl(High metabolic activity of leukocytes or bacteria)

. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION:________________________________________________________________________ 1- pH of the pleural fluid < 7.2. 2- Glucose < 60 mg/dl.

. EMPYEMA = INFECTION OF THE PLEURAL SPACE:___________________________________________ . Due to untreated pneumonia cased by bacterial invasion of a pleural effusion. . or contamination of the pleural space by rupture of a lung abscess. . Others: Bronchopleural fistula - penetrating trauma - thoracotomy or ruptured viscus. . May complicate hemothorax, the residual blood is an excellent medium for bacteria. . A mixed aerobic & anaerobic bacterial infection (Strept. - Staph. - Klebsilella). . Low grade fever. . Dx -> CT scan. . Tx -> Drainage & antibiotics. . Tx -> SURGERY (If localized - complex or having thick rim).

. SLEEP APNEA:______________ . Obese pt complaining of daytime somnolence.

. The pt's partener will report severe snoring. . Hypertension - Headache - Erectile dysfunction & fat neck.

. Obstructive sleep apnea from fatty tissues of the neck blocking breathing. . Central sleep apnea due to -- respiratory drive from the CNS.

. Dx -> NOCTURNAL POLYSOMNOGRAPHY (GOLD STANDARD OF DIAGNOSIS).

. Mild sleep apnea -> 5 - 20 apneic periods per hour. . Severe sleep apnea -> > 30 apneic periods per hour.

. Tx of obstructive sleep apnea -> Weight loss & CPAP:Continous positive airway pressure . If not effective -> Uvulo-palato-pharyngo-plasty.

. Tx of central sleep apnea -> Avoid alcohol & sedatives. . Medroxyprogesterone -> Central respiratory stimulant.

. OBESITY HYPOVENTILLATION $YNDROME (OH$) = PICKWICKIAN $YNDROME:_________________________________________________________________ . Severe obesity (Greater then 150% of ideal body weight -> BMI = 55!). . Thin neck & hypersomnolence. . Obesity -> Distant heart sounds & Low voltage QRS complexes on EKG. . Alveolar hypoventillation during WAKEFULLNESS ! . Polycythemia secondary to alveolar hypoventillation. . ABG -> Hypoxemia & Hypercapnia & Respiratory acidosis. . Due to DECREASED LUNG & CHEST WALL COMPLIANCE ! (Not resp. ms weakness xxx). . Tx -> Weight loss - Ventilator support - Oxygen - Avoid supine posture during sleep. . COMPLICATIONS of long-standing OSA or OH$:____________________________________________ . Pulmonary hypertension with cor pulmonale. . Secondary erythrocytosis. . Hypoxia, chronic hypercapnea & respiratory acidosis (Due to chronic hypoventillation). . N.B. Chronic hypercapneic respiratory failure due to OH$:___________________________________________________________ . Marked acidosis should be the result of respiratory failure in OH$. . But .. RENAL TUBULAR COMPENSATION occurs. . Kidneys ++ HCO3 retention to compensate for ++ CO2 ! . Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acidosis. . To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !

. HOW TO DIFFERENTIATE BETWEEN OBSTRUCTIVE SLEEP APNEA & OBESITY HYPOVENTILLATION $:________________________________________________________________________________________________________________________________________________________________________

.{1}. OBSTRUCTIVE SLEEP APNEA:_______________________________ . Air flow is impeded by AIRWAY OBSTRUCTION, . due to POOR ORO-PHARYNGEAL TONE. . NORMAL ABG ! .{2}. OBESITY HYPOVENTILLATION $:

__________________________________ . Air flow is impeded by diminished expansion of chest & abdominal wall due to obesity. . ABG -> HYPO-ventillation -> Chronic hyoxia & hypercapnia.

. ALLERGIC BRONCHO-PUMONARY ASPERGILLOSIS (ABPA):_________________________________________________ . Asthmatic pt with worsening asthma symptoms. . Coughing of brownish mucous plugs with recurrent infiltrates. . Peripheral eosinophilia. . ++ Ig E levels. . Central bronchiectasis may be seen. . Tx -> ORAL (Not inhaled) corticosteroids. . PULMONARY EDEMA:__________________ . Hypoxia - SOB - Tachypnea. . CXR -> Diffuse alveolar infiltrates. . May be cardiogenic (LVF) or non cardiogenic (ARD$). . Differentiate bet. the two types using pulmonary capillary wedge pressue (PCWP). . PCWP > 18 -> Cardiogenic pulmonary edema. . PCWP < 18 -> Non cardiogenic = ARD$.

. ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$) = NON-CARDIOGENIC PULMONARY EDEMA:_______________________________________________________________________________ . Sudden severe respiratory failure resulting from diffuse lung injury, . secondary to a number of overwheming systemic injuries e.g. . Sepsis - Aspiration of gastric contents - shock - severe infections, . Lung contusion - trauma - toxic inhalation - drowning - pancrestitis - burns. . CXR -> Diffuse patchy infiltrates. . NORMAL wedge pressure -> i.e. < 18. . pO2/FiO2 ratio < 200. . Tx -> Ventilatory support with low tidal volume of 6 ml/kg. . PEEP to keep the alveoli open. (Sh'd reach 15 cm H2O). . ++ FiO2 (Never exceed 60 %). . Prone positioning of the pt's body. . Possible use of diuretics & +ve inotropes such as dobutamine. . Transfer the pt to the ICU if not already there ! . STEROIDS ARE NOTTTTTTT EFFECIVE !

. ARD$ pts on MECHANICAL VENTILLATION:_______________________________________ . Mechanical ventillation includes two components FiO2 & PEEP. . FiO2 = Fraction of inspired oxygen. . PEEP = Positive end expiratory pressure. . ++ FiO2 -> Improves oxygenation. . PEEP -> Prevent alveolar collapse.

. Arterial pO2 is influenced by FiO2 & PEEP. . Arterial pCO2 is influenced by RR & TV.

. When you find a given ABF with pO2 55 mmHg = Low oxygenation. & FiO2 = 70% . So .. You should add PEEP 1st to improve oxygenation. . Don't decrease the FiO2 before adding PEEP or you will worsen the condition !

. When you find a given ABG with pO2 105 mmHg = TOXIC OXYGEN LEVEL. . You should decrease the fractionated oxygen level FiO2 to non toxic value < 6

0% ! . PEEP may be ++ as needed to maintain adequate oxygenation but avoid tension pneumothx.

. When you are given an ABG with respiratory alkalosis (pH > 7.4) & hypocapnia (--CO2), . With appropriate tidal volume < 6 ml/kg (pt. 70 kg -> 420 ml). . With appropriate FiO2 (Ex. 40 %), . With appropriate PEEP (Ex. 5 cm H2O), . Look at the respiratory rate (If it is high e.g. 18), . This respiratory alkalosis will be due to HYPER-ventillation. . So .. Decreasing the respiratory rate is the most appropriate step.

. Ventillation = RR x TV. . Respiratory alkalosis results from hyperventillation. . The RR sh'd be lowered. . -- in TV can trigger ++ in RR -> worsening the condition. . POSITIVE END-EXPIRATORY PRESSURE (PEEP):__________________________________________ . Used in cases of hypoxemic respiratory failue e.g. ARD$ & cardiogenic edema. . Helps to maintain air way pressure above atmospheric pressure at the end of expiration. . Complications -> Alveolar damage - tension pneumothorax & hypotension. . Sudden SOB - --BP & ++ HR - tracheal deviation & unilateral absence of breath sounds.

. SWAN-GANZ (PULMONARY ARTERY) CATHETERIZATION:_______________________________________________ -> Hypovolemic shock -> -- COP & -- CPWP & ++ TPR. -> Cardiogenic shock -> -- COP & ++ CPWP & ++ TPR. -> SEPTIC SHOCK ------> ++ COP & -- CPWP & -- TPR.

. COP -> LOW except in septic shock (High). . PCWP -> LOW except in cardiogenic shock (High). . TPR -> HIGH except in septic shock (Low).

. PCWP is NORMAL in ARD$. (VVVVVVVVVV. imp.). . PCWP is NORMAL in PE. (VVVVVVVVVVVV. imp.).

. PNEUMONIA:____________ . Fever, cough & sputum. . Severe illness -> SOB. . COMMUNITY ACQUIRED PNEUMONIA (CAP) -> PNEUMOCOCCUS. . HOSPITAL ACQUIRED PNEUMONIA (HAP) -> Gram -ve bacilli. . PPI ++ the risk of hospital acquired pneumonia. . Pts > 65ys with chronic dis. of lungs or liver are more prone to respiratory failure. . DM - HIV - Steroid use - Asplenia -> Worse prognosis. . ELDERLY HYPOXIC PT WITH OR WITHOUT FEVER SHOUL BE ADMITTED !

. Dx -> Best initial test -> CXR. . Dx -> Most accurate test -> Sputum gram stain & culture. . N.B. All pts with suspected pneumonia sh'd have a CXR done as the 1st step. . Antibiotics sh'd be adminstered ASAP without waiting for sputum gram stain or

culture.

. Tx -> OUT-PATIENT PNEUMONIA:_______________________________ -> Macrolide (Azithromycin - Doxycycline - Clarithromycin). -> Respiratory fluoroquinolone (Levofloxacin - Moxifloxacin).

. Tx -> IN-PATIENT PNEUMONIA:______________________________ -> Ceftriaxone & Azithromycin. -> Fluoroquinolone as a single agent.

. REASONS TO HOSPITALIZE pts with pneumonia:_____________________________________________ . Hypotension -> SBP < 90 mmHg. . Tachycardia -> HR > 125/min. . Temperature -> T -> 104 F. . Respiratory rate -> RR > 30/min. . PO2 < 60 mmHg. . pH < 7.35 . BUN > 30 mg/dl. . Na < 130. . Glucose > 250. . Confusion. . Age > 65 ys or older. . Co-morbidities eg. cancer, COPD, CHF & RF or liver disease.

. HYPOXIA & HYPOTENSION as single factors are a reason to hospitalize !

. Tx -> VENTILLATOR ASSOCIATED PNEUMONIA (VAP):________________________________________________ . VAP -> Fever - Hypoxia - New infiltrate & ++ secretions. -> Imipenim - Cefepime or Piperacillin/Tazobactam. -> Gentamycin & Vancomycin.

. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION:________________________________________________________________________ 1- pH of the pleural fluid < 7.2. 2- Glucose < 60 mg/dl.

. SPECIFIC ASSOCIATIONS:_________________________ * Recent viral infection -> Staphylococcus. * Alcoholics -> Klebsiella. * GIT syms & confusion -> Legionella. * Young healthy pts -> Mycoplasma. * Animal contact -> Coxiella Burnetii. * Arizona construction workers -> Coccidioidmycosis. * HIV with < 200 CD4 cells -> Pneumocystis carinii PCP.

. MYCOPLASMA PNEUMONIAE:________________________ . Most common cause of atypical pneumonia. . Non productive i.e. dry cough. . Many extra-pulmonary symptoms (Headache - sore throat - skin rash). . ERYTHEMA MULTIFORME -> Dusky red TARGET shaped skin lesions on extremities. . CXR -> Lower lobe interstitial infiltrates. . No cell wall (Only polymorphnuclear cells will appear on gram stain).

. MYCOBACTERIAL PNEUMONIA:

__________________________ . HIV pts have a higher risk of reactivation of tuberculosis. . Non specific symptoms (Cough - Weight loss - Fatigue - Low grade fever & Night sweats). . CXR -> UPPER LOBE INFILTRATES WITH CAVITATION.

. ASPIRATION PNEUMONIA = ANAEROBIC PNEUMONIA:_____________________________________________ . Impaired swallowing due to IMPAIRED EPIGLOTTIC REFLEX is the most imp. predisp. factor. . Aspiration of oro-pharyngeal secretions. . May be a complication of upper GI endoscopy. . Usually caused by ANAEROBES & Streptococcal viridans. . Advanced age, poor dentition, dementia, alcohol addiction are predisposing factors. . Pt presents with systemic syms e.g. fever & malaise & FOUL SMELLING SPUTUM. . Tx -> CLINDAMYCIN.

. KLEBSIELLA PNEUMONIA = FRIEDLANDER's PNEUMONIA:_________________________________________________ . Gram -ve bacilli. . More associated with ALCOHOLICS & immunocomprized pts with neutropenia. . Mechanism -> Colonization in the oropharynx followed by microaspiration of secretions. . Mostly affect the UPPER lobes. . produce CURRANT JELLY sputum. . Sputum culture -> Mucoid colonies.

. PNEUMOCYSTIS CARINII PNEUMONIA (PCP):_______________________________________ . Almost exclusively in AIDS pts with CD4 count < 200. . The HIV pt is usually not on prophylaxis for PCP! . Immunocompromized pt due to chemotherapy. . Dyspnea on exertion, dry cough & fever. . Dx -> Best initial test -> CXR -> Bilateral interstitial infiltrates (CHARACTERISTIC). . Dx -> ABG -> Hypoxia & ++ A-a gradient. (VVVVVVV imp.). . Dx -> ++ LDH level (Normal LDH level excludes PCP). . Dx -> Most accurate test -> BRONCHO-ALVEOLAR LAVAGE. (VVVVVVVVV. imp.). . Dx -> Sputum stain -> if +ve -> Confirm PCP & if -ve -> Bronchoscopy. . Tx -> Best initial therapy for treatment & prophylaxis -> TMP-SMX. . If PCP is severe (pO2 < 70 or A-a gradient > 35) -> Add STEROIDS to -- mortality. . If there is toxicity from TMP-SMX (Rash - BM depression) -> PENTAMIDINE or Primaquine. . If the pt is African American with G6PD (Bite cells on smear) -> Don't give Primaquine. . For PCP prophylaxis -> TMP-SMX .. if there is a rash or neutropenia -> Atovaquone. . If CD4 count is ++ & maintained above 200 for several months -> Stop prophylaxis. . But, NEVER to stop the anti-retroviral medications against HIV !

. LEGIONNAIRE's DISEASE:________________________ . H/O of recent TRAVEL or trip (BAHAMAS). . Linked to cruise ship & hotel water supplies. . HIGH GRADE FEVER > 39 c. . GIT symptoms (Nausea & vomiting & loose stools). . Mild ++ LFTs.

. HYPONATREMIA (PATHOGNOMONIC for LEGIONELLA). . CXR -> Focal lobular consolidation. . Gram -ve stain rod & stains poorly (Intracellular organism). . So.. Gram stain will show many neutrophils but no organisms is chracteristic. . Most accurate test -> Urine antigen test. . Tx -> AZITHROMYCIN or Levofloxacin.

. N.B. ACUTE PNEUMONIA WITH CONSOLIDATION & PHYSILOGIC SHUNT:______________________________________________________________ . -- Breath sounds, ++ Tactile vocal fremitus. . Alveoli of the affected lung become filled with exudative fluid & cellular debris. . These alveoli may have persistent blood flow to areas with impaired ventillation. . Leading to a physiologic intra-pulmonary shunt & arterial hypoxemia. . Positioning of the pt. with the affected lung in dependent position can worsen the case . i.e. his SO2 will drop for example from 94% when lying on one side to 84% on other side

. RECURRENT PNEUMONIA:______________________

. {A} INVOLVING SAME REGION OF THE LUNG:_________________________________________

.1. Local anatomic obstruction:________________________________ .. Bronchial compression (Neoplasm). .. Bronchial obstruction (Bronchiectasis - Retained FB).

.2. Recurrent aspiration:__________________________ .. Seizures. .. Ethanol or drug use. .. GERD.

. {B} INVOLVING DIFFERENT REGION OF THE LUNG:______________________________________________ . Sino-pulmonary disease (Cystic fibrosis). . Non-infectious (BOOP). . Immunodefeciency (HIV - Leukemia - --immunoglobulins).

. BRONCHOGENIC CARCINOMA is the most common cause of recurrent pneumonia in same region.. Associated H/O of old age & prolonged smoking H/O. Dx -> CT chest. (If CT is -ve -> Bronchoscopy).

. HYPERSENSITIVITY PNEUMONITIS (HP):____________________________________ . Inflammation of the lung parenchyma caused by antigen exposure. . Ex: Fancier's lung -> Inhalation of aerosolized bird droppings. . Ex: Farmer's lung -> Inhalation of molds associated with farming. . Acute episodes of cough, breathlessness, fever & malaise within 4-6 hs of Ag exposure. . Chronic exposue may lead to weight loss, clubbing & honey-combing of the lung. . The cornerstone of HP management is AVOIDANCE OF THE RESPONSIBLE ANTIGEN !

. TUBERCULOSIS (T.B):

_____________________ . Immigrants - HIV - Homeless - Prisoners & Alcoholics. . Most important epidemiologic factor is FOREIGN BORN INDIVIDUAL (Not US born: MEXICO!).

. Fever - cough - sputum - weight loss & night sweats. . Dx -> CXR & Sputum acid fast stain & culture to confirm TB. . If culture is +ve -> Start 6 months course of ANTI-TUBERCULOUS THERAPY. . ISONIAZID 6 m - RIFAMPIN 6m - PYRAZINAMIDE & ETHAMBUTOL stop after 2 months. . All of them can lead to liver toxicity. . TB medications sh'd be stopped if the transaminases raised up to 5 times of normal. . Isoniazid -> Peripheral neuropathy (Give Vit.B6). . Rifampin -> Red colored bodily secretions. . Pyrazinamide -> Hyperuricemia. . Ethambutol -> Optic neuritis. . Conditions need ttt > 6ms: Osteomyelitis, Meningitis, Miliary - cavitary TB & pregnancy . LATENT T.B._____________ . PPD -> PURIFIED PROTEIN DERIVATIVE TEST:___________________________________________ . PPD is a screening test for high risk groups. . POSITIVE TEST IF: -> 5 mm -> Close contacts, steroid users, HIV +ve. -> 10 mm -> Homeless - Immigrants - Alcoholics - Health care workers & prisoners. -> 15 mm -> Those without any risks.

. If PPD is +ve -> Proceed as follows:______________________________________ . CXR -> to make sure that occult active disease hasn't been detected. . If CXR is abnormal -> Sputum staining for TB is done. . If sputum staining is +ve -> Give full dose 4 drug therapy.

. ISONIAZID alone is used for 9 months to treat a +ve PPD.

. It -- the risk of developing TB from 99% to 1%.

. Once a PPD is +ve, the test sh'd never be repeated.

. RHINITIS:___________ {A} ALLERGIC RHINITIS:_______________________ . Watery rhinorrhea & sneezing with more prominent eye symptoms. . Early age of onset. . Identifiable trigger (animals - environmental exposure). . Usually seasonal symptoms but can be persistent throughout year. . Nasal mucosa can be normal, pale blue or pale on exam. . Associated with allergic disorders e.g. eczema & asthma. . Tx -> Allergen avoidance. . Tx -> Topical intra-nasal glucocorticoids.

{B} NON-ALLERGIC RHINITIS = VASOMOTOR RHINITIS:________________________________________________ . Nasal congestion - Rhinorrhea - Postnasal discharge (postnasal drip = dry 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 (Loratidine)! . Tx -> TOPICAL INTRANASAL GLUCOCORTICOIDS.

. The 3 most common causes of CHRONIC COUGH (> 8 weeks):________________________________________________________ . UPPER AIRWAY COUGH $YNDROME (Post-nasal drip). . BRONCHIAL ASTHMA. . GERD.

. UPPER AIRWAY COUGH $YNDROME = POST-NASAL DRIP:_________________________________________________ . NON-smoker. . Caused by rhino-sinusitis conditions. . Dry cough is most likely due to post-nasal drip associated with allergic rhinitis. . Dx -> Confirmed by improvement of the nasal discharge & cough with H1 Anti-histaminics. . Chlorpheniramine is an H1 receptor blocker that decreases the allergic response. . Decrease in NASAL SECRETIONS is most likely to significally improve symptoms.

. ANAPHYLAXIS = ANAPHYLACTIC SHOCK:___________________________________ . Type 1 hypersensitivity reaction. . Pts usually have prior exposure to the offending substance. . Pts have preformed Ig E -> Histamine mediated peripheral vasodilatation. . Bee stings - food & medications are the most common allergens. . Acute onset of hypotension & tachycardia. . Dangerous allergic reaction may progress to respiratory failure & circulatory collapse. . Allergen exposure -> Sudden onset of symptoms in more than one system, . Cutaneous (hives - flushing - pruritis). . GIT ( Lip / tongue swelling - vomiting). . Respiratory (Dyspnea - wheezing - stridor - hypoxia). . Cardiovascular (Hypotension). . It is a medical emergency. . Tx -> INTRA-MUSCULAR EPINEPHRINE into the THIGH.

. ASPIRIN SENSITIVITY $YNDROME:_______________________________ . Aspirin ingestion - persistent nasal blockage - Episodes of bronchoconstriction. . Pathogenesis -> Psudo-allergic reaction. . Aspirin -> PGs/LKs imbalance. . Tx -> Avoid NSAIDs & Leukotriene recptor antagonists (Drug of choice).

. MEDIASTINAL TUMORS:__________________________________________ . Dx -> Helical CT CHEST.

. ANTERIOR mediastinum --> THYMOMA & GERM CELL TUMORS. . MIDDLE mediastinum ----> BRONCHOGENIC CYST. . POSTERIOR mediastinum -> Neurogenic tumors e.g. Meningocele.

. GERM CELL TUMORS:___________________ . Affect young adults. . Present as large ANTERIOR mediastinal mass. . Two types of germ cell tumors (Seminomatous & Non-seminomatous). . Both types produce B-HCG (B-Human chorionic gonadotropin). . ONLY "NON"-seminomatous type produces Alpha-feto protein (AFP).

. CHORIOCARCINOMA:__________________ . Metastatic form of gestational trophoblastic disease. . It may occur after molar pregnancy or normal gestation. . The lungs are the most frequent site of metastatic spread. . Any postpartum woman e' pulmonary sympotms & multiple nodules on CXR = CHORIOCARCINOMA. . Dx -> ++++++ B-HCG levels. . INCIDENTALLY DISCOVERED SOLITARY PULMONARY NODULE:____________________________________________________ . May be BENIGN -> Infectious granuloma or hamartoma. . May be MALIGNANT -> Bronchogenic carcinoma & metastasis.

. BIOPSY is the only way to definitively detect whether a nodule is benign or malignant. . Clinical characteristics favoring malignancy: . Age > 50 - H/O of smoking - Weight loss - Previous malignancy.

. Radiographic characteristics of malignancy: . Large size - Low density - Spiculated borders - Absence of calcifications. . Rate of lesion growth is an important parameter: . Malignant nodules tend to double in size bet. one month & one year. . OBTAINING PREVIOUS X-RAY if possible is the FIRST BEST STEP in management. . If a previous x-ray demonstrates that the lesion has been stable in size > 2 ys, . Malignancy is effectively ruled out & no further testing is necessary.

. LOW propability nodules are followed by serial high resolution CT CHEST. . INTERMEDIATE propability nodules are followed by PET SCAN or BIOPSY. . HIGH propability nodules are removed surgically.

. PULMONARY - RENAL ASSOCIATIONS:_________________________________

.1. WEGENER's GRANULOMATOSIS WITH POLYANGIITIS:________________________________________________ . SYSTEMIC VASCULITIS + UPPER & LOWER RESPIRATORY TRACT INFECTION + GLOMERULONEPHRITIS. . Age around 40s. . URT symptoms (Bloody or purulent nasal discharge - oral ulcers - sinusitis). . LRT symptoms (Dyspnea - cough - Hemoptysis). . Renal symptoms (Microscopic hematuria - RBC casts). . Granulomatous inflammation of nasopharynx (Epistaxis - Rhinorrhea - Otitis - sinusitis)

. Saddle nose deformity due to destruction of the nasal cartilage. . Cutaneous manifestations (Painful SC nodules - palpable purpura - pyoderma gangrenosum) . BEST INITIAL TEST -> +ve C-ANCA = serum anti-neutrophilic cytoplasmic antibody. . CXR -> Bilateral multiple nodular opacities. . Urinalysis -> RBCs casts - proteinuria & sterile pyuria. . Tx -> CYCLOPHOSPHAMIDE & High dose corticosteroids.

.2. GOODPASTURE's DISEASE:___________________________ . Due to renal basement membrane antibodies ! . Young male. . Lungs (cough - dyspnes - hemoptysis). . Kidneys (Nephritic proteinuria - ARF - Dysmorphic RBCs & red cell casts on urinalysis). . Systemic symptoms are un common. . Dx -> Renal biopsy -> LINEAR IgG antibodies along the glomerular basement membrane.

. EFFECTS OF ARTERIAL OXYGENATION & VENTILATION IN VARIOUS ENVIRONMENTS:_____________________________________________________________________________________________________ Example ________ A-a gradient ____ Pa CO2 ___ Corrects e' O2

. -- inspired O2 tension = HIGH ALTITUDE:_________________________________________ . A-a gradient -> Normal. . Pa CO2 -> Normal. . Corrects with supplemental O2 -> YES.

. Hypoventillation = CNS DEPRESSION:____________________________________ . A-a gradient -> Normal. . Pa CO2 -> +++++. . Corrects with supplemental O2 -> YES.

. Diffusion limitation = INTERSTITIAL LUNG DISEASES:______________________________________________________ . A-a gradient -> +++++. . Pa CO2 -> Normal. . Corrects with supplemental O2 -> YES.

. Shunt = Intracardiac shunt or extensive ARD$:_______________________________________________ . A-a gradient -> +++++. . Pa CO2 -> Normal. . Corrects with supplemental O2 -> NOOOOOO.

. V/Q mis-match = Obstructive diseases, atelectasis, pulmonary edema & pneumonia:_________________________________________________________________________________ . A-a gradient -> ++++++. . Pa CO2 -> Normal. . Corrects with supplemental O2 -> YES. . Low lung compliance.

. UPPER AIRWAY OBSTRUCTION WITH LARYNGEAL EDEMA:

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

* NORMAL LUNG EXAMINATION:__________________________ . Percussion -> Resonant. . Auscultation -> Vesicular breathing.

* LUNG CONSOLIDATION EXAM:__________________________ . Percussion -> Dullness. . Auscultation -> LOUDER vesicular breathing if airways are patent (Faint if blocked). . Bronchial breathing with full expiratory phase. . ++ TVF. . Bronchophony. . Egophony (Ask the pt to say "E", it will sounds like "A"). . Widespread pectoriloquy.

* PLEURAL EFFUSION EXAM:________________________ . Inspection -> -- movements of ipsilateral chest. . Percussion -> Dullness. . Auscultation -> Decreased breath sounds. . -- TVF. * PNEUMOTHORAX EXAM:____________________ . Percussion -> Hyper-resonance. . Auscultation -> Decreased breath sounds (Will be absent entirely if large pneumothorax) . -- TVF. . JVD, Hypotension & Tracheal deviation to the opposite side. * EMPHYSEMA EXAM:_________________ . Percussion -> bilateral resonance. . Auscultation -> Vesicuar breathing with fine crackles at inspiration.

. N.B. Recurrent bacterial infections in an adult may indicate a HUMORAL IMMUNITY defect.. Recurrent sino-pulmonary & gastro-intestinal infections.. Dx -> Quantitative measurment of serum immunoglobulin "G" levels -> DECREASED.. Cystic fibrosis may have similar presentation BUT (Earlier in life & e'out GIT infects).

. ACE INHIBITORS & DRY COUGH:_____________________________ . Always consider ACE Is as a potential cause of chronic cough. . Pathogenesis -> Accumulation of bradykinins & prostaglandins.

. Simple discontinuation of the drug sh'd precede any diagnostic tests !

. SINGLE PULMONARY NODULE APPROACH:___________________________________ . SOLITARY PULMONARY NODULE = Lesion < 3 cm completely surrounded by pulmonary parenchyma._________________________________________________________________________________________ .| ._______________________________________________ .| .| .| . HIGH MALIGNANCY RISK . INTERMEDIATE RISK . LOW MALIGNANCY RISK ._____________________ .___________________ ._____________________ .| .| .| . Surgical excision. . NODULE SIZE ? . SERIAL CT SCANS . < 1cm: Serial CTs. . > 1cm: PET scan.

* FUNGAL INFECTIONS OF THE LUNG:________________________________

.1. HISTOPLASMOSIS:___________________ . Asymptomatic pulmonary nodule. . Residence in suburban Mississippi or o"H"io river valleys ! . Absence of any complaints. . Absence of significant past H/O. . Absence of any cavitary lesions. . Calcified nodes in the lung may be seen. . It is a dimorphic fungus found in soil with high concentration of bird or bat droppings . Infection through inhalation of the spores of Histoplasma capsulatum fungus.

.2. BLASTOMYCOSIS -> ULCERATED SKIN LESIONS & LYTIC BONE LESIONS:_________________________________________________________________ . Fungal infection of the lung.. . Residence in great lakes, Mississippi, Ohio river & Wisconsin. . Pulmonary symptoms resembling T.B. & Histoplasmosis. . ULCERATED SKIN LESIONS & LYTIC BONE LESIONS (Characteristic!). . Skin lesions -> Multiple well circuscribed verrucus crusted lesions. . Bone lesions -> Lytic lesions in the anterior ribs. . Dx -> Sputum culture -> BROAD BASED BUDDING YEAST. . Tx -> ITRACONAZOLE or Amphotericin B.

.3. COCCIDIOIDOMYCOSIS:_______________________ . Fungal infection of the lung. . Residence in Southwestern US. . Fever, cough & night sweats. . Extra-pulmonary -> skin, meninges & skeleton.

.4. ASPERGILLOSIS = A MOBILE LUNG CAVITARY MASS + INTERMITTENT HEMOPTYSIS:__________________________________________________________________________ . Fungal infection of the lung. . Coarse fragmented septae. . Hyphae are typically seen. . CXR -> Radio-lucency next to a rounded mass.

. Cavitary lesion may form due to destruction of the underlying pulmonary parenchyma. . Debris & hyphae may coalese forming a FUNGUS BALL. . The ball lies freely in the cavity & moves around with position change. . A MOBILE CAVITARY MASS + INTERMITTENT HEMOPTYSIS = ASPERGILLOMA.

. SUPERIOR SULCUS TUMOR:________________________ . Apical lung tumor causing compression effects. . Superior vena cava -> SVC $yndrome. . Sympathetic trunk -> Horner $yndrome. . Brachial plexus -> Pancoast $yndrome (Pain - paresthesia - weakness of arm). . Rt recurrent laryngeal nerve -> Hoarsness of voice.

. PANCOAST $YNDROME:____________________ . Apical lung tumor at the thoracic inlet. . Compress the inferior portion of the brachial plexus. . Shoulder pain radiating in an ulnar distribution.

. SUPERIOR VENA CAVA $YNDROME (SVC):____________________________________ . Obstruction of SVC impedes venous return from the head, neck, face & arms to the heart. . Dyspnea - Venous congestion & swelling of the head, neck & arms. . Malignancy is the most common cause of obstruction (Lung cancer - Hodgkin's lymphoma). . H/O of chronic heavy smoker with recent un-intentional weight loss -> Lung cancer. . Best initial test -> CXR -> If abnormal -> Follow up with Ct chest.

. HYPERTROPHIC OSTEOARTHROPATHY:________________________________ . Development of clubbing & sudden onset joint arthropathy in a chronic smoker. . Bilateral wrist tendrness, thickening of distal fingers & convex nail beds. . Associated with lung cancer. . CXR is mandatory to rule out malignancy.

. FINGER CLUBBING:__________________ . Thickening of the nail bed that causes a devrease in the angle bet the nail bed & fold. . In severe cluccing, the terminal parts of the fingers appear swollen like drumsticks. . It is NOT a feature of simple COPD. . NEW CLUBBING in COPD pts indicates the development of lung cancer or occult malignancy.

. GOLDEN SCHEME:________________________________

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

.| .| . OBSTRUCTIVE DISEASE . RESTRICTIVE DISEASE ._____________________ ._____________________ .| .| . BRONCHO-DILATOR CHALLENGE . DLCO ____________________________ .______ .| .| ._________ .________________ .| .| .| .| . ++ FEV1 . No ++ in FEV1 . NORMAL . -- DLCO ._________ ._______________ ._______ ._________ . ASTHMA. . COPD. . CHEST WALL WEAKNESS . ILD. .| . DLCO ._____________________ .| .| . (--) -> Emphysema . (++) -> Chronic bronchitis.

. N.B. RIGHT MAIN STEM BRONCHUS INTUBATION:___________________________________________ . Relative complication of endotracheal intubation. . It causes asymmetric chest expansion during inspiration. . Markedly decreased or absent breath sounds on the left side on auscultation. . Solve the problem by repositioning of the tube, . Tx -> Pull it back slightly, this will move its tip between the carina & vocal cords.

. N.B. 2ry MALIGNANCY AFTER CHEMOTHERAPY !__________________________________________ . Up to 4% of pts with HODGKIN's disease wil develop a 2ry malignancy (Lung - breast) . After being treated with chemotherapy & radiation !

. N.B. POST-ICTAL STATE ABG:____________________________ . Repiratory ACIDOSIS. . Acisosis (-- pH). . Hypercarbia (++ CO2). . Normal or ++ HCO3 ! . HYPO-ventillation is a major cause of respiratory acidosis.

. N.B. MOST COMMON CAUSE OF HEMOPTYSIS is -> CHRONIC BRONCHITIS:________________________________________________________________. Chronic productive cough for 3 months in 2 successive years with ciagarette smoking.. Other important causes -> BRONCHOGENIC CARCINOMA & BRONCHIECTASIS.. CXR is mandatory to exclude malignancy.

. N.B. Acute bronchitis is a common cause of blood-tinged sputum. . It is usually viral in etiology. . In an "A"FEBRILE pt with NEW-ONSET BLOOD TINGED SPUTUM e'OUT significant serious signs, . OBSERVATION & CLOSE CLINICAL FOLLOW UP is the best ttt strategy.

. MITRAL STENOSIS:__________________ . Most common cause is rheumatic fever.

. Pt. 40 - 50ys. . presents with gradual & progressively worsening dyspnea on exertion. . Orthopnea & hemoptysis due to pulmonary edema. . Auscultation -> Loud S1 & Opening snap after S2 at apex. . Low pitched diastolic rumble at apex (When pt lies on left side with breath holding). . Atrial fibrillation is a common complication. . Af causes rapid decompensation in a previously asymptomatic pt. . Long-standing MS can cause Left atrial enlargement -> Elevation of left main bronchus.

. ACE inhibitors side effect -> Dry cough:__________________________________________ . Pathophysiology -> Accumulation of KININs due to activation of arachidonic acid pathway

. N.B. ACID-BASE BALANCE in two different situations:__________________________________________________________________________________________________________

. 1 . Chronic hypercapneic respiratory failure due to COPD:___________________________________________________________ . Marked acidosis should be the result of respiratory failure in COPD. . But .. RENAL TUBULAR COMPENSATION occurs. . Kidneys ++ HCO3 retention to compensate for ++ CO2 ! . Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acidosis. . To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !

. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++ bicarbonate retention.

. 2 . Mechanically vetillated pt following head trauma:_______________________________________________________ . Hyper-ventillation (Due to ++ TV or RR) -> Excessive CO2 loss & Respiratory Alkalosis. . Hypo-ventillation (Due to -- TV or RR) -> Excess CO2 Retention & Respiratory Acidosis.

. Respiratory alkalosis: -> ++ pH (N = 7.4). -> -- PCO2 (N = 40 mmHg). -> -- HCO3 (N= 24) -> DECREASED due to attempted renal compensation for resp. alkalosis. -> The kidneys retain increased amounts of Hydrogen H (protons) -> & excrete ++ amounts of bicarbonate (HCO3) in attempt to normalize serum pH. -> The ++ amount of HCO3 in urine ALKALIZES the urine.

Dr. Wael Tawfic Mohamed __________________________