Pulmonology Flashcards
(360 cards)
1
Q
What does DLCO measure in pulmonary function tests⁉️
DLCO (diffusing capacity of the lungs for carbon monoxide)
A
- ➡️ Assesses the ability of oxygen to diffuse from the alveoli into pulmonary capillaries and bind to hemoglobin in red blood cells
- ➡️ It assesses alveolar-capillary membrane function
2
Q
What two main components determine the diffusion capacity of carbon monoxide (DLCO)⁉️
A
- 🧪 DLCO is influenced by:
1️⃣ Properties of the alveolar-capillary membrane (thickness, surface area)
2️⃣ Amount of bloodin the pulmonary capillary bed (capillary volume and hemoglobin availability)
💡 This makes DLCO a key marker of gas exchange efficiency in the lungs.
3
Q
What causes low DLCO in restrictive lung diseases⁉️
A
📉 Interstitial lung disease (e.g., pulmonary fibrosis)
➡️ Thickened alveolar-capillary membrane impairs diffusion
4
Q
What conditions cause ↓ DLCO and why⁉️
DLCO (diffusing capacity of the lungs for carbon monoxide)
A
-
Pulmonary fibrosis / ILD:
➡️ Thickened alveolar membrane ➡️ ↓ diffusion -
Emphysema:
➡️ Alveolar destruction ➡️ ↓ surface area for gas exchange -
Pulmonary hypertension / PE:
➡️ Reduced perfusion ➡️ ↓ blood in capillary bed
5
Q
In which conditions is DLCO normal or increased instead of decreased⁉️
DLCO (diffusing capacity of the lungs for carbon monoxide)
A
-
Asthma
➡️ Obstructive, but normal or ↑ DLCO
➡️ Due to increased capillary blood volume -
Polycythemia
🩸 More hemoglobin available for CO binding ➡️ ↑ DLCO -
Congestive heart failure (CHF)
💧 Fluid in alveoli → ↑ membrane thickness, but also ↑ capillary blood
➡️ ↑ DLCO -
Pulmonary hemorrhage (e.g., diffuse alveolar hemorrhage)
🩸 Blood in alveoli binds CO → falsely ↑ DLCO
6
Q
What condition should be suspected when DLCO is decreased but lung volumes and spirometry are normal⁉️
A
- 🚨 Pulmonary vascular disease
(e.g., pulmonary hypertension or pulmonary embolism)
➡️ Due to reduced perfusion, not ventilation or membrane defect
7
Q
What distinguishes myasthenia gravis from interstitial lung disease on PFT ?
Pulmonary Function Tests (PFTs)
A
🧠 Myasthenia gravis: normal DLCO
🧠 Interstitial lung disease: ↓ DLCO + ↓ TLC, FRC, RV, FVC
8
Q
What happens to PFTs in heart failure⁉️
Pulmonary Function Tests (PFTs)
A
Usually normal or nonspecific changes; not diagnostic via spirometry alone
9
Q
A
10
Q
What does spirometry measure and what does it NOT measure?
A
- ✔️ Measures: Dynamic & static lung volumes, airflow rates
- ❌ Does NOT measure: TLC and RV
11
Q
What are the key spirometric and lung volume changes in obstructive pulmonary diseases⁉️
A
- 🫁 Obstructive diseases (e.g. COPD, asthma):
✅ ↓ FEV₁
✅ ↓ FEV₁/FVC
✅ ↑ RV, FRC, TLC (air trapping)
✅ Normal lung compliance (↑ in emphysema)
✅ ↓ DLCO in emphysema, ↑ DLCO in asthma
DLCO = diffusion capacity of carbon monoxide
12
Q
What are the lung volume and diffusion findings in emphysema⁉️ (RV ,FRC ,DLCO )
A
Emphysema causes air trapping ➡️
* 📈 ↑ Residual Volume (RV)
* 📈 ↑ Functional Residual Capacity (FRC)
* 🧪 ↓ DLCO (diffusing capacity of the lungs for carbon monoxide)
➡️ Due to destruction of alveolar-capillary surface area
13
Q
What are the hallmark findings of restrictive pulmonary diseases⁉️
A
🫁 Restrictive diseases (e.g. IPF, obesity, neuromuscular disorders):
✅ ↓ TLC, RV, FRC
✅ Normal or ↑ FEV₁/FVC
✅ ↓ DLCO if parenchymal (e.g. fibrosis)
✅ Normal DLCO if non-parenchymal (e.g. obesity)
✅ ↓ Lung compliance in intrinsic causes (e.g. fibrosis)
DLCO:diffusion capacity of carbon monoxideوidiopathic pulm fibrosis (IPF
14
Q
What is the shape of the flow-volume loop in myasthenia gravis⁉️
A
📉 Smaller, but preserved shape
➡️ Proportional decrease in both FEV₁ and FVC
15
Q
Why is residual volume (RV) increased in restrictive disease due to muscle weakness⁉️
A
💡 Due to incomplete exhalation caused by weak expiratory muscles
16
Q
A
17
Q
How does lung compliance differ in emphysema vs fibrosis?
A
- ✔️ Emphysema: ↑ Compliance (lungs are floppy, easy to expand)
- ✔️ Fibrosis: ↓ Compliance (stiff lungs, hard to expand)
18
Q
Which test is required to confirm a restrictive ventilatory defect⁉️
A
🧪 Body plethysmography
✅ Measures absolute lung volumes including TLC and RV
➡️ Needed to diagnose true restriction (↓ TLC)
19
Q
What is the utility of DLCO in lung function testing⁉️
A
🌬️ DLCO = diffusion capacity of carbon monoxide
* ✅ ↓ in:
* Pulmonary fibrosis
* Emphysema
* Pulmonary hypertension, pulm. embolism
* ✅ ↑ in:
* Asthma
* Polycythemia
* Pulmonary hemorrhage
20
Q
What clinical features and exam findings suggest idiopathic pulmonary fibrosis (IPF)?
A
✅ IPF typically presents with:
* ✔️ Progressive dyspnea over months
* ✔️ Dry cough
* ✔️ End-inspiratory crackles on auscultation
* ✔️ Possible digital clubbing
21
Q
What are the typical high-resolution CT (HRCT) findings in idiopathic pulmonary fibrosis (IPF)?
A
✅ HRCT in IPF often shows:
✔️ Patchy, basilar, subpleural reticular opacities
✔️ Honeycombing
✔️ Traction bronchiectasis
22
Q
What are the hallmark clinical features of idiopathic pulmonary fibrosis⁉️
A
- 🚬 Common in adult smokers
- 🔻 Progressive dyspnea over months
- 🔻 Dry cough
- 🎧 Inspiratory Velcro-like crepitations on auscultation
- Clubbing of fingers
23
Q
What are the classic CT findings in idiopathic pulmonary fibrosis⁉️
A
- 📸 Patchy, basilar, subpleural reticular opacities
- 📸 Honeycombing
- 📸 Traction bronchiectasis
24
Q
Which medications reduce fibrosis progression in IPF⁉️
A
- Nintedanib
-
Pirfenidone
➡️ These are anti-fibrotic agents
25
How does **lung compliance** differ in **emphysema** vs **pulmonary fibrosis**⁉️
* 📉 Compliance curves:
✅**↑ Compliance in emphysema**
✅ **↓ Compliance in fibrosis**
26
What is the **most effective treatment** for idiopathic pulmonary fibrosis (IPF)⁉️
* ✅ **Antifibrotic therapy**:
— **Pirfenidone**
— **Nintedanib**
🧠 Shown to slow lung function decline and improve survival
27
What pulmonary function test (**PFT**) findings are characteristic of **IPF**⁉️
* **↓ TLC, RV, FRC (restrictive pattern)**
📈 **↑ FEV₁/FVC ratio (>80%)**
📉 **↓ DLCO** (due to interstitial thickening
28
Why is **spirometry** **alone** **not** **sufficient** to diagnose **restrictive lung disease**⁉️
* ⚠️ Spirometry **may show normal or ↑ FEV1/FVC**
* ➡️ Restriction is confirmed only by **reduced lung volumes** via **plethysmography**
29
What are the **typical spirometry** and **diffusion findings** in **idiopathic pulmonary fibrosis (IPF)⁉️**
* 🫁 IPF lung function test results:
✅ **Low lung volumes** (↓ TLC, RV, FRC)
✅ **Normal or ↑ FEV1/FVC** ratio > 80% (restrictive pattern)
✅ **↓ DLCO** (impaired diffusion due to parenchymal damage)
30
What is the **most effective treatment** for idiopathic pulmonary fibrosis (IPF)⁉️
* **Antifibrotic therapy**
✅ **Pirfenidone** or **Nintedanib**
➡️ Slows lung function decline
➡️ Improves survival
31
Why are **immunosuppressive agents** like **prednisone** or **azathioprine** (Imuran) **not recommended** in IPF treatment⁉️
* ⛔ Associated with **increased morbidity and mortality in IPF**
* ⛔ **Not effective** and no longer recommended
32
Are **antibiotics effective** in **treating idiopathic pulmonary fibrosis** (IPF)⁉️
* ⛔ **No**
Broad-spectrum antibiotics have no role in treating IPF
33
What were the **historical vs current therapeutic approaches** to IPF⁉️
🔻 **Historical**: Lung transplantation was the only viable option
🔺 **Current**: Antifibrotic drugs (**pirfenidone, nintedanib**) are effective in slowing disease progression
34
What does a **flow-volume loop** with a Concave **(scooped-out) expiratory phase** and preserved inspiration indicate?
* ✔️ **Obstructive lung disease**
✔️ Expiratory airflow is limited due to airway narrowing
✔️ Seen in **COPD**, **asthma**, **bronchiectasis**
✔️ Shape: **Sharp peak** + **concave/“scooped” descent** = **classic obstructive pattern**
35
What does a “**kink**” in the **expiratory phase** of a **flow-volume loop** indicate, and what **spirometry findings** are seen in **obstructive lung disease**⁉️
* 🌀 A “kink” concave in expiration reflects **airflow obstruction**
🧪 Seen in obstructive lung diseases like COPD and asthma
📉 **↓ FEV₁**
📉 **↓ FEV₁/FVC ratio**
➡️ Due to **delayed and reduced expiratory flow**
| kink :sudden bend or dip in the expiratory limb of the flow-volume loop
36
37
What **clinical signs** and **symptoms** are characteristic of idiopathic pulmonary fibrosis (IPF)⁉️
* 🩺 Key features:
✅ **Progressive dyspnea** (over months)
✅**Dry cough**
✅ **Inspiratory "velcro" crackles**
✅ More common in **adult smokers**
38
How is **restriction diagnosed** in pulmonary function testing⁉️
📉 Restriction is confirmed by:
✅ **↓ TLC** on **plethysmography**
➡️ Spirometry alone is **not sufficient** for diagnosing restriction
39
How does **emphysema** differ from **IPF** in lung function tests⁉️
| idiopathic pulmonary fibrosis (IPF)
* **Emphysema**:
✅ **↓ DLCO**
✅ **Obstructive pattern** (↓ FEV1/FVC)
✅ **↑ lung volumes** due to air trapping
* ⛔ Unlike IPF, **FVC is not reduced and lung volumes are increased**
40
What are the **main mechanisms** of **pathogenesis** in **community-acquired pneumonia (CAP)⁉️**
🦠 Mechanisms include:
✅ **Microaspiration (most common**)
✅ Inhalation of pathogens
✅ Direct mucosal dispersion
➡️ **Aspiration pneumonia** accounts for **5–15%** of CAP cases
41
What are key **risk factors** for CAP⁉️
| community-acquired pneumonia (CAP)
⚠️ **Risk factors**:
* Alcoholism
* asthma
* immunosuppression
* institutionalization
age >70
* ➕ **Specific risk associations:**
* **Pneumococcus** → dementia, smoking
* **CA-MRSA** → post-viral, skin colonization
* **Pseudomonas** → structural lung disease (e.g. CF)
* **Legionella** → diabetes, HIV, recent travel/cruise
42
What are the common **clinical features** of CAP⁉️
| community-acquired pneumonia (CAP)
🩺 Symptoms include:
✅ **Fever**, **chills**, **sweats**, **dry or productive cough**
✅ **Dyspnea**, **pleuritic chest pain**, **GI symptoms**, **fatigue**
43
What are the **physical exam findings** in CAP⁉️
📉 Findings include:
✅ **Increased respiratory rate**
✅ **Crackles**, **bronchial breath sounds**
✅ **Increased or decreased fremitus**
✅ **Dullness to percussion** (e.g. pleural fluid)
44
What **pathogens** are common by **site of care in CAP**⁉️
| community-acquired pneumonia (CAP)
1. **Outpatient**:
* Strep pneumo
* Mycoplasma
* H. flu
* Chlamydia pneumo
* viruses
2. **Hospitalized (non-ICU):**
* Add Legionella
* gram negatives
3. **ICU:**
* S. aureus
* Legionella
* gram negatives
* H. flu
* respiratory viruses
45
What is the **empiric outpatient treatment** for **CAP without comorbidities**⁉️
| community-acquired pneumonia (CAP)
💊 **Outpatient, low risk**:
* ✅ **Amoxicillin + macrolide/doxycycline**
* ✅ Or **doxycycline or macrolide alone**
46
What is the empiric outpatient treatment for **CAP with comorbidities or Abx risk**⁉️
| community-acquired pneumonia (CAP)
💊 **Outpatient**, **high** **risk**:
* ✅ **Amoxicillin-clavulanate or cephalosporin**
➕**Macrolide/doxycycline or respiratory fluoroquinolone**
47
What is the empiric **inpatient** treatment for **non-severe CAP**⁉️
| community-acquired pneumonia (CAP)
✅**β-lactam + macrolide**
✅ Or **respiratory fluoroquinolone**
48
What is the empiric **inpatient** treatment for **severe CAP⁉️**
| community-acquired pneumonia (CAP)
* ✅ **β-lactam + macrolide**
✅ Or **β-lactam + respiratory fluoroquinolone**
49
When should **MRSA** or **Pseudomonas coverage** be **added** in CAP⁉️
| community-acquired pneumonia (CAP)
🧪 Add **if risk factors present:**
✅ **MRSA** ➡️ add **vancomycin or linezolid**
✅ **Pseudomonas** ➡️ add **Zosyn, cefepime, meropenem, etc**.
50
How is **site of care** **determined in CAP** (outpatient vs hospitalization vs ICU)⁉️
| community-acquired pneumonia (CAP)
📊 Use **CURB-65** or PSI:
* **C**onfusion
* **U**rea >7
* **RR** ≥30
* **BP** low
* **A**ge ≥65
➡️ **Score ≥2 → consider hospitalization**
➡️ **≥3 → may need ICU**
51
What are warning signs requiring hospitalization in CAP⁉️
| community-acquired pneumonia (CAP)
🚩 Hospitalize if:
✅ **Can’t maintain oral intake**
✅ **Confusion or poor oxygenation**
✅ **Room air O2 saturation <92%**
52
What should be done if a CAP patient **fails to improve after 3 days⁉️**
| community-acquired pneumonia (CAP)
🔍 **Reassess the diagnosis**:
✅ Repeat CXR or CT
✅ Consider **bronchoscopy**
✅ Check for **complications** (abscess, empyema, resistant bug)
53
When should **pneumonia** be **reassessed** for **treatment failure**⁉️
| community-acquired pneumonia (CAP)
🕒 **After 72 hours of antibiotic treatment without improvement**
➡️ Prompt **clinical re-evaluation is necessary**
54
What are common **causes** of **pneumonia treatment failure despite antibiotics⁉️**
| community-acquired pneumonia (CAP)
🚩 Main causes include:
✅ **Antibiotic resistance**
✅ **Incorrect antibiotic choice** (e.g., not covering the pathogen)
✅ **Complications** (e.g., lung abscess, empyema)
✅ **Mimics** (e.g., PE, pulmonary edema, hypersensitivity pneumonitis)
55
What is a **parapneumonic effusion** and **how is it diagnosed**⁉️
🫁 Parapneumonic effusion = **pleural effusion secondary to pneumonia**
✅ Can be associated with:
* **Lung abscess**
* **Bronchiectasis**
✅ Diagnosis: **Chest radiograph (CXR**)
56
What is the recommended step if a **pneumonia patient shows no improvement after 72 hours** of antibiotic therapy⁉️
* 🕒 **Reevaluate the patient**
✅ Consider **complications** (e.g., empyema, abscess)
✅ Order a **chest X-ray to assess for pleural effusion**
57
Is **lobectomy** indicated immediately in pneumonia patients not responding to treatment?
**No**. Lobectomy is not indicated until the cause of treatment failure is identified and conservative options are exhausted. 🚫🔪
58
What is **the most important risk factor** for developing COPD⁉️
🚬 **Smoking**
✅ Risk increases with **intensity and early-life exposure**
59
What **occupational exposures** increase the risk of COPD⁉️
✅ **Coal mining**
✅ **Cotton textile industry**
➡️ Act as **amplifiers** of smoking-related risk
60
Why should beta-blockers be **used cautiously** in COPD patients⁉️
🛑 **Non-selective beta-blockers**(e.g., **carvedilol**) can **worsen bronchoconstriction**
✅ **Cardioselective β1-blockers** (e.g., metoprolol) are **safer in COPD when needed**
61
How does **asthma** contribute to **COPD** development⁉️
🌬️ **Airway hyperresponsiveness in asthma**
✅ In smokers, this leads to **greater airflow obstruction**
➡️ **Asthma** + **smoking** = **higher COPD risk**
62
What **childhood condition** has been linked to **increased COPD risk**⁉️
👶 **Childhood pneumonia**
✅ Associated with **long-term lung function impairment**
63
What **genetic condition** is a known contributor to **early-onset COPD**⁉️
* 🧬 **α1-antitrypsin (α1AT) deficiency**
✅ Leads to **early emphysema**, especially in **non-smokers**
64
Do **adult respiratory infections** cause COPD⁉️
⛔ **No** strong evidence for causing COPD
✅ But they are a **major trigger of COPD exacerbations**
65
What are the **major risk factors** for developing chronic obstructive pulmonary disease (COPD)⁉️
1. 🚬 **Smoking** (most important; risk depends on intensity & timing)
2. 🏭 **Occupational exposures** (e.g. coal mining, cotton textile)
3. 🌬️ **Asthma** (airway hyperresponsiveness + smoking)
4. 👶 **Childhood pneumonia** (linked to long-term lung damage)
5. 🧬 **Genetic predisposition** (e.g. α1-antitrypsin deficiency)
66
Is **adulthood pneumonia** a **risk factor** for **developing COPD⁉️**
* **No**
💡 COPD is primarily caused by smoking, occupational exposures, childhood respiratory infections, and genetic factors (e.g., alpha-1 antitrypsin deficiency).
➡️ **Adulthood pneumonia is not a recognized risk factor for COPD.**
67
Compare treatments that **modify COPD progression** vs. those that **relieve symptoms**.
* **Modify disease course** & **prolong life**:
Smoking cessation
oxygen therapy
lung volume reduction surgery
* **Symptom relief only**: Bronchodilators
inhaled corticosteroids
roflumilast
antibiotics
68
What is the **oxygen saturation threshold** indicating the need for **oxygen therapy in COPD?**
Resting oxygen saturation **below 88%** indicates oxygen therapy is needed. 💨⚠️
69
What is the **diagnostic spirometric criterion** for COPD⁉️
* 📉 **FEV1/FVC < 70%** after bronchodilator use
✅ Confirms persistent airflow limitation
➡️ **Irreversible** with bronchodilators
* ↑ lung volumes (air trapping)
70
What are **typical imaging** and **blood gas findings** in COPD⁉️
* **Chest X-ray: Lung hyperinflation, flat diaphragm**
* **ABG: Hypoxemia, hypercapnia, ↓ pH**
71
What **lung volume changes** are expected in **COPD with emphysema⁉️**
🫁 Due to **hyperinflation** and **loss of elastic recoil:**
✅ ↑ Total lung capacity (TLC) — due to hyperinflation
✅ ↑ Residual volume (RV) — due to air trapping
✅ ↑ Functional Residual Capacity (FRC)
✅ ↓ Diffusing Capacity of the Lungs for CO (DLCO)
72
What **defines a COPD exacerbation** and what is **the most common cause**?
A COPD exacerbation is an **acute worsening of symptoms in a diagnosed COPD patient**.
The most common cause is **lung or airway infections**.
73
What are the **key clinical features** of a **COPD exacerbation**⁉️
* 🧠 **Acute worsening of dyspnea, cough, and/or sputum**
* 🧪 ABG shows:
➡️ Respiratory **acidosis** (↑PaCO₂)
➡️ **Hypoxemia** (↓PaO₂)
➡️ **Metabolic compensation** (↑HCO₃⁻)
74
What is the **indication** for **noninvasive ventilation** in COPD exacerbation⁉️
➡️ **Respiratory acidosis**: PaCO₂ > 45 mmHg
➡️ Signs of **respiratory muscle fatigue** or work of breathing
➡️ **Hypoxemia** **despite oxygen therapy**
🧠 Why: **Improves CO₂ clearance**, **reduces intubation** rates, **shortens hospital stay**
75
How does **ABG** help in **COPD exacerbation** management?
✔️ **Detects hypercapnia** (PaCO2 > 45 mmHg) indicating respiratory failure
✔️ **Guides oxygen and ventilatory support decisions**
✔️ **Assesses acid-base disturbances**
76
How do **arterial blood gases and pulse oximetry** assist in managing **COPD exacerbations**?
They aid in **diagnosis** and help **assess the severity of the exacerbation** by evaluating **oxygenation and ventilation status**.
77
What are **contraindications** for using Non-Invasive Positive Pressure Ventilation (NIPPV) in COPD exacerbation?
✔️ **Cardiovascular instability**
✔️ **Impaired mental status** or inability to cooperate
✔️ **Copious secretions** or inability to clear secretions
✔️ **Respiratory arrest**
Why: These conditions increase risk of failure and aspiration, necessitating invasive mechanical ventilation
78
What is **the full treatment regimen** for an acute COPD **exacerbation**⁉️
* 💊 **Bronchodilators:**
➡️ β₂-agonist (e.g., albuterol)
➡️ Anticholinergic (e.g., ipratropium)
* 💊 **Systemic corticosteroids**
* 💊 **Antibiotics** **(if moderate/severe or signs of infection)**
* 💨 **Supplemental oxygen**
* 💡 Noninvasive ventilation if PaCO₂ > 45 mmHg or signs of failure
79
When are **antibiotics** indicated in a COPD exacerbation⁉️
* ✅ In **moderate to severe exacerbations**
✅ Presence of **increased sputum purulence**, **volume**, or **dyspnea**
80
**In which patients with chronic obstructive pulmonary disease (COPD) is daily azithromycin indicated, and what is its benefit?**
In patients with **severe COPD** who have **frequent exacerbations** and **severe symptoms**,
**daily azithromycin** reduces the frequency of exacerbations.
81
When is **intubation** indicated in a COPD exacerbation patient?
✔️ **Contraindications to NIPPV**
✔️ Severe **hypoxemia** or **hypercarbia** despite NIPPV
✔️ **Respiratory arrest**
82
What are the **hallmark symptoms** and signs of COPD⁉️
* 🩺 Symptoms:
✅ **Chronic cough**, **sputum** production, **exertional dyspnea**
* Exam findings:
✅ **Wheezing**, **prolonged expiration**
83
What are common **ECG findings** in COPD⁉️
📉 Signs of **right heart strain:**
✅ **Right ventricular hypertrophy**
✅ **P-pulmonale** (tall P wave in lead II)
✅ **Right axis deviation**
84
Is **FEV1/FVC** used to determine the **severity** of COPD⁉️
⛔ **No** – it confirms diagnosis, but FEV1 determines severity
85
What is the **GOLD classification** system for COPD severity⁉️
🟨 **Based on FEV1 (% predicted):**
* GOLD 1: >80%
* GOLD 2: 50–80%
* GOLD 3: 30–50%
* GOLD 4: < 30%
86
What determines **GOLD classification** in COPD management⁉️
Based on:
* 1️⃣ **Exacerbation history**
* 2️⃣ **Symptom burden**
💡 No exacerbations + low symptoms → Category A
87
LABA: Long-acting Beta-2 Agonist
LAMA: Long-acting Muscarinic Antagonist
ICS: Inhaled Corticosteroid
SABA: Short-acting Beta-2 Agonist
88
What is the **first-line treatment** for a COPD patient in **GOLD category A⁉️**
* ✅ **Bronchodilator monotherapy**
➡️ Options include:
▪️ Beta-2 agonists (e.g., salbutamol)
▪️ Antimuscarinics (e.g., ipratropium)
▪️ Theophylline
89
Which **interventions** have been shown to **reduce mortality **in COPD⁉️
✅ **Smoking** cessation
✅ Long-term **oxygen** therapy (if resting SpO₂ < 88%)
✅ Lung volume reduction **surgery** (in selected patients)
✅ **Triple inhaled therapy** (LABA + LAMA + ICS) — in selected cases
90
What is the mechanism and role of **roflumilast** in COPD, **does reduce the mortality rate ⁉️**
* 💊 Roflumilast =** PDE4 inhibitor**
➡️ **Reduces exacerbation** frequency
* ⛔ **Does not reduce mortality**
91
What are key **X-ray findings** in COPD⁉️
Radiographic signs include:
* ✅ **Hyperinflated lungs** (>10 posterior ribs)
* ✅ **Flattened diaphragms**
* ✅ **Narrow mediastinum**
92
What is the **first-line pharmacologic** therapy for **stable COPD**⁉️
💊 **Bronchodilators**:
✅ **Antimuscarinics** (**LAMA**)
✅ **Beta-2 agonists** (**LABA/SABA**)
➡️ Add **ICS**, **roflumilast**, or **oxygen** as disease progresses
93
How is **stable** COPD **pharmacologic treatment** grouped⁉️
💊 By symptoms & exacerbations:
* **Group A**: 0–1 exacerbation, few symptoms → **Bronchodilator**
* **Group B**: 0–1 exacerbation, many symptoms → **LABA or LAMA**
* **Group C**: ≥2 exacerbations or ≥1 hospitalization, few symptoms → **LAMA**
* **Group D**: Same exacerbation risk, many symptoms → **LAMA + LABA or ICS + LABA*
LABA: Long-acting Beta-2 Agonist
LAMA: Long-acting Muscarinic Antagonist
ICS: Inhaled Corticosteroid
SABA: Short-acting Beta-2 Agonist
94
What defines a **COPD exacerbation⁉️**
⚠️ Acute worsening of:
✅ **Shortness of breath**
✅ **Sputum production**
✅ **Cough severity**
95
What defines a **life-threatening COPD exacerbation?**
✔️ **Respiratory failure/distress**
✔️ **Altered mental status**
✔️ **Severe hypoxemia** or acidosis
📍 This warrants **immediate intubation and mechanical ventilation**
96
What is the **first-line treatment** for **life-threatening respiratory distress in COPD patients?**
* ✔️ **Intubation and mechanical ventilation**
📌 Especially when patient has altered mental status or failure to protect airway
97
When is **non-invasive ventilation** indicated in COPD and **contraindications**⁉️
🫁 Use NIPPV if:
✅ **Respiratory failure with PaCO₂ > 45 mmHg**
⛔ **Cardiovascular instability** (e.g., hypotension)
⛔ **Impaired mental status** / uncooperative
⛔ **Copious secretions** or **inability to clear**
⛔ **Respiratory arrest** or **failure to protect airway**
98
Why is **theophylline** **not used in acute COPD exacerbation**⁉️
⛔ Theophylline has **no proven benefit** in COPD exacerbation
✅ May be used **in** **severe asthma, not COPD**
99
Why is **triple therapy** (LABA + LAMA + ICS) **not sufficient** in **acute** **COPD exacerbation**⁉️
* ⛔ Triple therapy is for **chronic control**
1. ⚠️ Does **not correct acute ventilatory failure**
* ➡️ This patient needs **urgent ventilatory support (NIPPV or intubation)**
100
Which **interventions improve** COPD prognosis⁉️
Only therapies shown to improve survival:
✅ **Smoking cessation**
✅ Ox**ygen therapy if SaO₂ <88%**
✅ **Lung volume reduction surgery** (emphysema)
✅ **Triple inhaled therapy** in selected patients
101
How is **follow-up pharmacologic** therapy **adjusted in stable COPD**⁉️
📊 Based on **dominant symptom:**
* **Dyspnea**: LAMA or LABA → LAMA+LABA → add ICS
* **Exacerbations**: LAMA or LABA → LAMA+LABA → add ICS
➡️ **Roflumilast** if FEV1<50% + chronic bronchitis
➡️ **Macrolide** if former smoker
102
Is **Carvedilol** preferred for patients with COPD⁉️
🛑**NO**, Carvedilol is a **non-selective beta-blocker**, which can **exacerbate bronchoconstriction**
103
What is **Pneumocystis pneumonia** (PCP), and who is **most at risk⁉️**
🦠 PCP is an **interstitial pneumonia** caused by **Pneumocystis jirovecii**
* Highest risk in **HIV-infected patients with CD4+ < 200/μL**
✅ Especially if not on **ART** or **PCP** prophylaxis
104
What are the **clinical features** of PCP⁉️
| Pneumocystis pneumonia
🩺 Symptoms:
* **Acute/subacutedyspnea**
* **fever**
* **nonproductive cough**
* ➡️ May progress to respiratory failure and death if untreated
105
What are the **typical imaging** **findings** in PCP⁉️
| Pneumocystis pneumonia
🩻 **Chest X-ray**:
✅ Diffuse **bilateral**, **perihilar**, **interstitial infiltrates**
🖥️ **High-resolution CT:**
✅ **Diffuse ground-glass opacities**(in nearly all cases)
106
What is the **first-line antibiotic treatment** for Pneumocystis pneumonia (PCP)⁉️
* 💊 **Trimethoprim-sulfamethoxazole (TMP-SMX)**
✅ Standard of care for both treatment and prophylaxis of PCP
✅ Given IV or PO for **21 days**
107
What are **alternative** antibiotic regimens for PCP in **TMP-SMX intolerance**⁉️
* ✅ **IV pentamidine**
* ✅ **Clindamycin + primaquine**
* ✅ **Atovaquone**
108
When are **adjunctive corticosteroids** indicated in PCP⁉️
🧪 Indicated in **moderate to severe PCP:**
✅ **PaO₂ < 70 mmHg** (on room air)
✅ Or **A–a gradient ≥ 35 mmHg**
➡️ Reduces mortality and respiratory complications
109
What **causes** **pleural effusion** to form⁉️
💧Excess fluid within the **pleural space** accumulates when **fluid formation exceeds absorption**
➡️ Causes: **increased production** or **impaired drainage**
110
What are the **key features** of **malignant pleural effusion** due to cancer⁉️
* 🚩 Common **primary cancers**: **Breast**, **Lung**, **Lymphoma**
* 🚩 Key symptom: **Dyspnea disproportionate to effusion size**
* 🚩 Pleural fluid finding: **Glucose < 60 mg/dL it high tumor burden**
111
Which 3 **cancers** are **most commonly associated** with **malignant pleural effusion⁉️**
* ✅ **Breast** cancer
* ✅ **Lung** cancer
* ✅ **Lymphoma**
112
What **clinical clue** suggests **malignancy** in **pleural effusion** when the **dyspnea seems too severe for the effusion size**⁉️
**Dyspnea out of proportion to effusion size** suggests **malignant etiology**.
113
What pleural fluid **glucose level** suggests high tumor burden in malignant pleural effusion⁉️
**Glucose < 60 mg/dL** indicates high tumor burden in the pleural space.
114
How is pleural effusion **initially detected**?
✔️ **First** detected by **chest X-ray** or **ultrasound**
✔️ **If fluid >10 mm** → perform **diagnostic thoracentesis**
115
What **physical exam findings** suggest pleural effusion⁉️
🩺 Classic findings:
🔴 **Dullness** to percussion
🔵 **Decreased fremitus** on palpation
🔵 **Decreased breath sounds** on auscultation
116
What **imaging modalities** help **confirm** pleural effusion⁉️
🖥️ Diagnosis by:
✅ **Ultrasound** (fluid in pleural space)
✅ **Chest X-ray** (blunting of costophrenic angle)
✅ **CT scan**(more precise localization)
117
What are the **Light's criteria** used to **differentiate** **exudate** from **transudate** in **pleural effusion?**
📊 Fluid is (**exudate** if ≥1 of the following) :
* Effusion protein/serum protein **> 0.5**
* Effusion LDH/serum LDH **> 0.6**
* Effusion LDH **> 2/3** upper normal serum limit
⚠️ If **none** are met → **transudate**
118
What are the common **causes** of **transudative** vs **exudative** effusions⁉️
* 🔹 **Transudates**:
CHF (most common),
cirrhosis,
nephrotic syndrome,
constrictive pericarditis
* 🔸 **Exudates** suggest systemic causes::
Infections
malignancy
PE
autoimmune diseases (SLE, RA)
TB
GI diseases ( (e.g., pancreatitis, esophageal rupture)
119
When is **diagnostic thoracentesis** indicated for **pleural effusion**?
* ✔️ If **pleural fluid is >1 cm** on imaging (X-ray)
* 📌 **Exception**:
No thoracentesis needed in **bilateral CHF cases**
**No chest pain** or **fever** should be present
120
The **most common cause** of **pleural effusion** is?
**Left ventricular failure**
121
What does **lymphocyte-predominant pleural effusion** suggest⁉️
* 🧪 >50% lymphocytes suggests:
🔹 **Cancer**
🔹 **Tuberculosis** (TB)
🔹 **Rheumatologic disease**
* ➡️ Do cytology if malignancy suspected
122
What is **the next step** after identifying an **exudative pleural effusion⁉️**
* 🧪 **Lab analysis of pleural fluid** including:
Glucose
Amylase
Cytology
Gram stain & culture
TB markers
123
When is **pleural biopsy** indicated in pleural effusion workup⁉️
🔍 When **initial fluid investigations and imaging** (e.g., CT scan) are **inconclusive**
➡️ Helps **diagnose TB, malignancy, or other causes**
124
What **imaging** is recommended **before pleural biopsy** in **undiagnosed exudative effusion**⁉️
📸 **Chest CT scan**
➡️ Evaluate for **masses or pulmonary embolism**
125
What conditions cause **neutrophil-predominant pleural effusion⁉️**
📈 Neutrophils seen in:
* 🔹 **Parapneumonic effusion**
* 🔹 **Pulmonary embolism**
* **🔹 Pancreatitis**
126
What is **the best next step** for a **lymphocyte-predominant exudative pleural effusion** with **low glucose** and **high LDH**⁉️
* ✅ **Cytology**
🧪 To evaluate for malignancy, TB, or rheumatologic disease
127
When is **thoracentesis** indicated in a patient with **CHF** in pleural effusion⁉️
* 🔻 **Unilateral**
* 🔻 **Not improving with diuretics**
* 🔻 **Associated with fever** (to rule out infection)
* 🔻 Causing **severe hypoxemia** (therapeutic relief)
128
What is the recommended **management** for a **new unilateral pleural effusion⁉️**
* ✅ Perform **thoracentesis**
➡️ Especially important if **infection or empyema** is suspected
129
Why is **thoracentesis** essential in suspected empyema⁉️
**Empirical antibiotics alone are insufficient**
* ✅ **Empyema requires drainage**: repeated thoracentesis or chest tube
130
What pleural **fluid** characteristics **strongly suggest** a **tuberculous pleural effusion**?
A **lymphocytic pleural effusion** with **increased protein**, **LDH**, and **adenosine deaminase (**ADA) levels is highly suggestive of tuberculosis. 🦠
131
Why do **tuberculous pleural effusions** typically occur?
They are mainly due to a **hypersensitivity reaction to tuberculous protein in the pleural space**, often associated with primary TB. ⚔️🦠
132
What are common **clinical symptoms** of **tuberculous pleuritis**?
* **Fever**
* **weight loss**
* **dyspnea**
* pleuritic **chest pain**.
133
What **diagnostic criteria** confirm **tuberculous** pleural effusion?
* ✔️ Pleural fluid **ADA >40** IU/L or
* ✔️ **Interferon gamma >140 pg/mL**
Alternatively, diagnosis can be confirmed by **pleural fluid culture**, **pleural biopsy,** or **thoracoscopy**. 🧪🔬
| (ADA) Adenosine deaminase
134
Can **lung malignancy** explain increased **ADA in pleural effusion?**
| (ADA) Adenosine deaminase
**No**.
Lung malignancy can cause **pleural effusions with increased protein** and **LDH**, but **not increased ADA. 🎗️🚫**
| (ADA) Adenosine deaminase
135
What are the **key features** and **diagnostic findings** of **chylothorax**⁉️
🩸 Chylothorax = **accumulation of chyle (lymphatic fluid) in pleural space**
🚩 Most common cause: **Trauma or thoracic surgery**
🔬 Thoracentesis findings:
* **Milky fluid**
* **Triglyceride level >110 mg/dL** (1.2 mmol/L)
📸 Chest X-ray: large pleural effusion
⚠️ Often caused by **mediastinal tumors** or ** ** to thoracic duct
136
What is a **chylothorax** ⁉️
🩸 Chylothorax = **pleural effusion** caused by **disruption of the thoracic duct**,
➡️ leading to **accumulation of chyle** (lymphatic fluid) in the **pleural space**
137
What is the **hallmark pleural fluid** finding in **chylothorax**⁉️
* 🍼 **Milky pleural fluid**
* 📈 **Triglyceride level > 110 mg/dL (1.2 mmol/L)**
✅ **Diagnostic of chylothorax**
138
What is the standard **treatment for chylothorax**, and what is the role of **octreotide**?
✔️ **Chest tube** insertion to drain chylous effusion
✔️ **Octreotide**, a somatostatin analog, is used to reduce lymphatic flow and promote resolution 💉🧴
139
What is the **most common cause** of chylothorax⁉️
**Trauma,**
most commonly **due to thoracic surgery,**
➡️ leading to disruption of the thoracic duct and leakage of chyle into the pleural space
140
What is the significance of **eosinophilia** in pleural fluid, and **does it require drainage**?
✔️ High eosinophils in pleural effusion are **not an indication for drainage**
✔️ Possible causes include:
* **Allergic reactions**
* **Churg-Strauss syndrome**
* **Malignancies**
* **Parasitic** infections 🧬🦠
141
What are the classic **physical exam** findings of **pleural effusion**, and how is the **diagnosis confirmed?**
✔️ Physical exam:
* **Dullness to percussion**
* Decreased **tactile fremitus**
* Decreased **breath sounds**
✔️ Diagnosis confirmed by:
* **Chest X-ray**
* **Point-of-care ultrasound** (US)
142
Q: What are **the key components** of the **physical exam** in **respiratory assessment**, and what is **evaluated in each**?
* ✔️ **Inspection**:
* Vital signs
* Signs of respiratory distress 🫤
* ✔️ **Percussion**:
* **Dullness** → Pleural **effusion**
* **Hyper-resonance** → **Pneumothorax** 🥁
* ✔️ **Palpation**:
* **↑ Tactile fremitus** → **Lung consolidation**
* **↓ Tactile fremitus** → **Pleural effusion** ✋
* ✔️ **Auscultation** (most important):
* Breath sounds
* **Wheezes → Asthma**
* Crackles
* Rhonchi
143
What are the **strongest indicators** that a **pleural effusion** is **empyema**⁉️
* 🧪 In decreasing strength:
1. **Visible pus**
2. **Positive Gram stain**/culture
3. **Glucose < 60 mg/dL**
4. **pH < 7.20**
5. **Loculated effusion**
➕ **LDH >1000 U/L** also suggests empyema
144
How is empyema **treated**⁉️
🚨 Requires **complete drainage**
✅ **Chest tube or video-assisted thoracoscopy**
145
When is **thoracostomy** indicated in pleural effusion management⁉️
✔️ **Loculated pleural fluid**
✔️ Pleural fluid **PH < 7.2**
✔️ Pleural fluid **glucose < 60 mg/dL**
✔️ **Positive gram stain** or **culture** of pleural fluid
✔️ Presence of **gross pus** in the pleural space 🩸
146
Does the **amount of pleural fluid alone** indicate thoracostomy?
**No**, fluid volume is not an indication for thoracostomy. 🚫💧
147
What **pleural fluid microbiology** result mandates **thoracostomy**?
A **positive gram stain** or **culture** from pleural fluid aspirate. ✔️🦠
148
What are features of **pleural effusion** due to **malignancy**⁉️
* 🧬 Most common **exudative** cause after infection
* ✅ Diagnosed by **cytology**
* ✅ Features: **Exudate**, **low glucose**
* ➡️ Common malignancies: **Lung**, **breast**, **lymphoma**
149
How is pleural effusion **initially diagnosed** and evaluated⁉️
🩻 Initial detection via **chest X-ray or ultrasound**
✅ If **effusion >1 cm** → perform **thoracentesis**
➡️ **Evaluate fluid via Light's criteria**
150
How does **pleural fluid glucose** help narrow the **differential diagnosis**⁉️
* 🧪 **Glucose < 60 mg/dL:**
✅ Think **malignancy**, **bacterial infection**, **rheumatoid pleuritis**
* 🧪 **Glucose > 60 mg/dL:**
✅ Suggests **pulmonary embolism** or **tuberculosis**
151
What is **the next best step** when **exudate is confirmed** and **glucose is >60 mg/dL⁉️**
🧾 **CT chest scan**
✅ Helps assess for **PE or TB**which are more likely in this context
152
When is **echocardiography** **preferred over CT** in pleural effusion evaluation⁉️
* If **transudate** is confirmed and **CHF** is **suspected** → perform **echocardiography**
153
What **diagnostic procedure** is appropriate for **suspected malignant** pleural disease (e.g. mesothelioma)⁉️
🧬 **Pleural biopsy**
✅ Used when **cytology** **is inconclusive** and suspicion for malignancy is high
154
What is the **definition** of asthma⁉️
* 🫁 Asthma is a **chronic obstructive lung disease**
* characterized by:
✅ **Airway hyperresponsiveness**
✅ **Variable airflow obstruction** (often reversible)
155
What are common **asthma triggers** and **environmental risk factors?**
✔️ **Allergens**
✔️ **Environmental factors** like **animals**, **dust**, **pollens**
✔️ **Smoking**
156
What are the **hallmark features** of **asthma pathophysiology**⁉️
🌀 **Airway hyperresponsiveness**
🌬️ Variable **airflow obstruction (reversible)**
157
What defines **reversible airway obstruction** on spirometry, supporting a diagnosis of asthma?
✔️ An **increase in FEV₁** (forced expiratory volume in 1 second) of
✔️ **≥12%**
✔️ AND **≥200 m**L
**after administration of beta-agonists** (bronchodilators) **indicates reversible obstruction, **
* **characteristic of asthma**
158
What is **the key diagnostic test** for **asthma**⁉️
🩺 **Spirometry with reversibility testing**
159
What spirometry findings confirm a diagnosis of **asthma**⁉️
✅ **Obstruction**: FEV1/FVC < 0.7
✅ **Reversibility**:
➡️ **≥12% increase in FEV1** **AND ≥200 mL increase in FEV1 after SABA** (short-acting beta agonist)
160
What does "**reliever**" therapy for asthma **consist of**, and **when is it used?**
* Reliever therapy is **Short-Acting Beta Agonists (SABA**)
* used as needed to **quickly relieve asthma symptoms**.
161
How does **reliever therapy** differ from **controller therapy** in asthma management?
* **Reliever therapy** (**SABA**) provides **quick symptom relief** on an **as-needed basis.**
* **Controller therapy** aims to **prevent symptoms** by addressing inflammation with regular medication like **ICS**. ✔️
162
What are the **two main types** of asthma **medications**?
✔️ **Controllers**: inhaled corticosteroids, LABA, antileukotrienes, cromolyn sodium, anti-IgE
✔️ **Relievers**: short-acting beta 2 agonists (SABA), anticholinergics
163
Which **medication** class is **most commonly** used as **relievers** for acute asthma symptoms?
**Short-acting beta 2 agonists (SABA)** are the main relievers. Anticholinergics (e.g., ipratropium) can also be used but are less effective.
164
What are the **key criteria** and **treatment steps** in managing **asthma control**?
* **Controlled asthma**: reliever < 2/week + symptoms < 2/week + no activity/nocturnal issues
* **If uncontrolled** → **Stepwise controller therapy starts** → Step 2 : Add ICS → Further steps involve intensifying therapy if needed.
165
Why is a **stepwise approach important** in **asthma treatment?**
It ensures **symptoms are controlled with the least amount of medication necessary**, **minimizing side effects** while **maintaining effectiveness.**
166
What are the typical **arterial blood gas (ABG) findings** in an **acute asthma exacerbation?**
✔️ **Hypoxemia** (low partial pressure of oxygen, PO2)
✔️ **Low** partial pressure of carbon dioxide (**PCO2) initially** due to hyperventilation
✔️ In severe or impending respiratory failure, **PCO2 may become elevated**
167
What is **the first step** in asthma treatment for a **symptomatic patient**⁉️
* ✅ **Use of a reliever**:
— **SABA** (e.g., Ventolin)
— or **ICS+formoterol** (ICS+LABA as needed)
168
Are **antihistamines or beta-blockers** used in asthma management⁉️
⛔ **No** —
* — Beta-blockers can worsen asthma
* — Antihistamines are not effective for asthma control
169
What defines **controlled asthma** in clinical practice?
✔️ Use of **SOS reliever < 2 times/week**
✔️ **Daytime** symptoms **< 2 times/week**
✔️ No **physical activity** limitations
✔️ No **nocturnal symptoms** 😴
NOTE:"SOS reliever" generally refers to a short-acting bronchodilator, also known "reliever" medication
170
How is **asthma diagnosed** using **spirometry**⁉️
📉 **Decreased FEV1/FVC and FEV1**
✅ **Reversibility with SABA: FEV1 ↑ by >12% and >200 mL**
✅ **Methacholine test**: **↓ FEV1 by 20% confirms diagnosis**
171
What is the role of the **methacholine challenge test** in asthma⁉️
✅ Used when **spirometry is normal but asthma is suspected** ( spirometry is inconclusive)
➡️ **Positive test**: **↓ FEV₁ ≥ 20%** **after methacholine** = **airway hyperresponsiveness**
172
Which tests are **not diagnostic** for asthma despite showing changes⁉️
⛔ **Chest X-ray**
⛔ **CT scan**
⛔ **Bronchoscopy**
➡️ These may show findings but are not used for diagnosis
173
What are the signs of an **acute asthma attack⁉️**
* 🚨 Symptoms: **Chest tightness**, **wheezing**, **dyspnea**
* 🩺 Signs: **Tachycardia**, **hyperventilation**
* 🧪 ABG: **Low PaCO₂** due to hyperventilation; later normal/high = BAD
174
What are early **ABG findings** in **acute asthma exacerbation⁉️**
1. ✅ **Hypoxemia**
2. ✅ **↓ PaCO₂ due to hyperventilation**
* ➡️**Normal or rising CO₂ = impending respiratory failure**
175
What **ABG change** in **acute asthma **suggests **impending respiratory failure⁉️**
🚨 **Normal or rising PaCO₂**
➡️ Indicates **exhaustion and hypoventilation**
➡️ Requires **immediate therapy** and possible **intubation**
176
What are **clinical signs** of **severe asthma exacerbation⁉️**
🔹 Inability to **complete sentences**
🔹 **Tachypnea**, **tachycardia**
🔹 **↓ FEV1**
🔹 **Pulsus paradoxus** (>10 mmHg drop in SBP on inspiration)
🔹 **Disappearance of wheezing = danger sign**
177
How is an **acute asthma** **attack treated**⁉️
💊 **Oxygen**(if SpO₂ < 90%)
💊 **High-dose SABA**
💊 **Nebulized anticholinergics**
💊 **Systemic corticosteroids**
⚠️ **Severe**: **Magnesium sulfate, aminophylline**
🛑 **Prophylactic intubation** if PCO₂ normalizes or rises
178
What is the first step in treating an **acute asthma exacerbation** with **hypoxemia**⁉️
* ✅ **Oxygen supplementation**
🧠 To correct hypoxemia and prevent respiratory failure
179
What are the **5 key indicators of poorly controlled asthma**⁉️
⚠️ **Daytime** symptoms **>2/week**
⚠️ Activity **limitation**
⚠️ **Nocturnal** symptoms
⚠️ Need for **reliever >2/week**
⚠️ **FEV1 < 80%**
180
How are **asthma patients classified** and what is the **cornerstone of their treatment**⁉️
* 📊 Asthma patients are classified into “**treatment steps**” based on:
1. Symptom frequency
2. Severity of exacerbations
3. Response to previous treatments
✅ **All patients should receive ICS-LABA inhalers, regardless of step**
➡️ **Inhaled corticosteroid** + **long-acting beta agonist** (ICS-LABA) is the **cornerstone of asthma therapy**
181
What are the **key principles** and structure of asthma controller therapy, and when should t**reatment be adjusted?**
✔️ Follows a stepwise approach aiming to **control symptoms with minimal pharmacologic intervention** 🎯
* ✔️ Controlled asthma is defined by:
* SOS (**reliever) use < 2/week**
* **Daytime symptoms < 2/week**
* **No** activity limitations
* **No** nocturnal symptoms 🌙
* ✔️ If asthma becomes **uncontrolled**, **escalate therapy per step guidelines 🔄**
182
What is the **stepwise treatment** for asthma (Step 1 to Step 6)⁉️
➡️ **Step 1**: As-needed hort-acting beta agonist (SABA) or (ICS)/formoterol
➡️ **Step 2**: **ICS low dose**
➡️ **Step 3**: **ICS medium dose** + **LABA**
➡️ **Step 4**: **ICS high dose** + **LABA**
➡️ **Step 5-6:** High-dose ICS + **Add-on** LAMA / anti-IgE / IL-5 + consider **oral steroids**
* Long-acting muscarinic antagonist (LAMA)
* Low-dose inhaled corticosteroid (ICS)
| Short-acting beta agonist (SABA),long-acting beta-agonist (LABA)
183
What does **GINA recommend** as the preferred reliever **for all steps** of asthma management⁉️
✅ **Low-dose ICS-formoterol(LABA)** is the **preferred reliever at all steps**, even in **mild** or **intermittent** asthma
* 🧠 This strategy reduces:
Exacerbations
Need for systemic steroids
Reliance on SABA alone (which may mask worsening inflammation)
184
Why is **oral corticosteroid (OCS) use inappropriate for long-term asthma control**⁉️
* 🚫 Long-term OCS use is not appropriate **due to significant adverse effects**
* ✅ Reserved for **severe, refractory cases**
* ➡️ **Step down** to** ICS-LABA** if possible and reassess response
185
What makes **ICS** a **critical component of asthma therapy**⁉️
💊 Inhaled corticosteroids (ICS) **reduce**:
✅ **Airway inflammation**
✅ **Asthma exacerbations**
✅ **Mortality risk**
⚠️ LABA must **never** be used without ICS in asthma
186
What is the role of **LABA/LAMA** **combinations** in asthma management⁉️
* 🟡 LABA/LAMA may be added at **Step 5** for persistent symptoms
* ⚠️ Not a replacement for **ICS**
* ➡️ Consider in patients not responsive to ICS-LABA
187
What are **three asthma-associated syndromes** to remember⁉️
1️⃣ **Aspirin-sensitive asthma**: asthma + nasal polyps
2️⃣ **ABPA**: asthma + pulmonary infiltrates + allergic Aspergillus rxn
3️⃣ **Churg-Strauss (EGPA**): asthma + eosinophilia + vasculitis
188
What is **omalizumab**, and in which asthma patients is it **indicated**?
✔️ **Omalizumab** is an **anti-IgE monoclonal antibody** 💉
✔️ Indicated for **asthma patients**:
* **Not controlled by maximal treatment**
* With **circulating IgE levels in a specific qualifying range 📈🧬**
189
Why is omalizumab **not appropriate** for a patient whose **asthma is controlled only with SABA**?
✔️ Omalizumab is **reserved for patients uncontrolled on maximal therapy**
✔️ A patient using **only** short-acting beta agonists (SABA) is **far from meeting this criterion**
190
Which **antibody** therapy **reduces eosinophils** in asthma, and **how does it differ from omalizumab**?
✔️ **Anti-IL-5 antibodies** (e.g., mepolizumab) **reduce tissue eosinophils and exacerbations**
✔️ **Omalizumab does not reduce eosinophils** — it **targets IgE, not IL-5**
191
What is the next step in treatment for **uncontrolled asthma** on **low-dose ICS** with frequent symptoms and reliever use⁉️
⬆️ **Step-up to combination** **therapy**: **ICS + LABA (e.g. formoterol**)
✅ Improves symptom control
✅ Reduces exacerbation risk
🧠 Based on GINA guidelines stepwise approach
192
What is **Allergic Bronchopulmonary Aspergillosis (ABPA)⁉️**
🦠 ABPA is a **hypersensitivity reaction** to **colonization by Aspergillus species** (not invasive infection)
✅ Occurs **mainly in patients with asthma or cystic fibrosis**
✅ Leads to **chronic airway inflammation**, **eosinophilia**, and **bronchiectasis**
193
What are the key **clinical and diagnostic** features of **Allergic Bronchopulmonary Aspergillosis (ABPA)⁉️**
🦠 Aspergillus hypersensitivity in patients with asthma or bronchiectasis
📍 Key features:
✅ **Recurrent pneumonia** + **asthma-like symptoms**
✅ **Eosinophilia**
✅ **Central** **bronchiectasis**
✅ **Brown mucus plugs**
✅ **Positive skin test** / serum precipitins for Aspergillus
194
What **diagnostic tests** **confirm** allergic bronchopulmonary aspergillosis (**ABPA**)?
✔️ **Reactive skin sensitivity test** to Aspergillus
✔️ Positive **serum precipitins** for Aspergillus
✔️ Circulating Aspergillus-specific **IgE** 🧬✅
195
When should ABPA be suspected in an asthma patient⁉️
🧠 Suspect ABPA when:
✅ **Asthma is refractory** to conventional treatment
✅ **High IgE** levels and **eosinophilia** are present
✅ Other signs: **Central bronchiectasis**, **brown mucus plugs**
196
What is the **stepwise treatment approach** for allergic bronchopulmonary aspergillosis (ABPA)⁉️
✔️ Start with **inhaled asthma therapies** 🌬️
✔️ Use **systemic glucocorticoids** if symptoms are **refractory** or during exacerbations 💊
✔️ Consider **antifungal agents** (e.g., fluconazole, voriconazole) in selected patients 🍄
197
is the **first-line treatment** of ABPA⁉️
| allergic bronchopulmonary aspergillosis (ABPA)
✅ **Inhaled therapies for asthma** (e.g., bronchodilators, ICS)
198
What are the **treatment options** for **allergic bronchopulmonary aspergillosis (ABPA),** and **when are each of them used?**
✔️ **Inhaled asthma treatments** (**first-line**) 🌬️
✔️ **Systemic corticosteroids** — used in **refractory** cases or during **exacerbations** 💊
✔️ **Antifungal drug courses** — to reduce fungal burden 🍄🛑
199
What is **bronchiectasis and what causes** it⁉️
* 🫁 **Bronchiectasis** is the **permanent (irreversible ) dilation of bronchi** due to chronic or **recurrent lung infections**, including **recurrent pneumonia**
➡️ Leads to **airway wall damage**, mucus buildup, and persistent inflammation
200
what are the **two major patterns** of **bronchiectasis distribution?**
* ✔️ Can be:
1. **Focal** → often due to **local** obstruction (e.g., tumor, foreign body)
2. **Diffuse** → due to **systemic conditions** such as:
* Recurrent infections
* Immunodeficiency
* Genetic (e.g., cystic fibrosis)
* Autoimmune/rheumatologic diseases
* Idiopathic
201
What are the **common causes** of **bronchiectasis**?
* **Recurrent** lung **infections**
* **hypogammaglobulinemia**
* **connective tissue** diseases
* **alpha-1-antitrypsin** deficiency
* **immotile cilia syndrome**
* **cystic fibrosis**
* **recurrent aspirations**
* allergic bronchopulmonary aspergillosis (**ABPA**)
202
What are the **hallmark clinical findings** of bronchiectasis?
* ✔️ **Most common:**
**Productive cough** with **thick**, **tenacious** sputum
* ✔️ Other findings:
**Crackles**
**Wheezing**
**Digital** **clubbing**
🧪 These signs should raise suspicion for **chronic airway disease**
203
What characterizes **acute exacerbations of bronchiectasis** and which **bacteria are most commonly involved?**
* Acute exacerbations involve **increased sputum production** due to **bacterial infections**
* the most common bacteria are **Pseudomonas aeruginosa and Haemophilus influenzae**.
204
How can **bronchiectasis** be distinguished from **lobar pneumonia** or **pulmonary edema** on **CT**⁉️
* **Lobar pneumonia**: **Homogeneous lobe consolidation**
* **Pulmonary edema**: **Interstitial fluid**, Kerley **B lines**
* **Bronchiectasis**: **Airway dilation** + **thickening**, **not uniform consolidation**
205
What **life-threatening complication** can occur in patients with chronic bronchiectasis⁉️
* 🚨 **Massive hemoptysis**
Due to recurrent infections causing **mucosal blood vessel damage**
206
How is **life-threatening hemoptysis in bronchiectasis** **managed**⁉️
* 🚨 **Initial steps**:
✅ **Intubation** and **stabilization**
✅ Identify the **bleeding source**
✅ Position patient with **bleeding lung down** to protect the other lung
* 🩸 **Definitive treatment**:
✅ **Bronchial artery embolization**
✅ **Surgery** (if embolization fails or not feasible)
207
What are common **causes** of bronchiectasis⁉️
🔁 Chronic and recurrent lung injury from:
✅ **Recurrent pneumonia**
✅ **Cystic fibrosis**
✅ **Alpha-1 antitrypsin deficiency**
✅ **Hypogammaglobulinemia**
✅ **Immotile cilia syndrome**
✅ **ABPA (Allergic bronchopulmonary aspergillosis)**
✅ **Connective tissue diseases**
✅ **Foreign body/tumor (if localized)**
208
What are the **clinical features** of bronchiectasis⁉️
🩺 Key signs/symptoms:
✅ **Chronic productive cough**
✅ **Hemoptysis**
✅ **Dyspnea**
✅ Digital **clubbing**
✅ PFT: **Obstructive pattern**
209
Which **bacteria** are commonly **isolated** during **bronchiectasis exacerbations**⁉️
🦠 Common pathogens:
✅ **Pseudomonas aeruginosa**
✅ **Haemophilus influenzae**
210
What is the **first-line treatment** for **acute exacerbation of bronchiectasis⁉️**
* 💊 **Antibiotics**
* targeting:
➡️ Haemophilus influenzae
➡️ Pseudomonas aeruginosa
✅ Treat infection promptly to reduce airway damage
211
What **supportive treatments** are used in **chronic bronchiectasis**?
✔️ **Mucolytics**
✔️ **Bronchodilators**
✔️ Chest **physiotherapy**
✔️ Prophylactic **antibiotics** in some cases
✔️ Treat **underlying cause** if known
212
Is **dornase alfa** (Pulmozyme) used in **non-CF bronchiectasis**?
❌ **No**.
✔️ **Dornase** is specific for **cystic fibrosis** patients to **reduce mucus viscosity**
213
Should **beta blockers** be used in **bronchiectasis**?
* **Avoid them**
They may worsen bronchospasm and reduce bronchodilation
214
What **imaging** is required in **localized bronchiectasis** to rule out a central cause⁉️
* 📷 **Bronchoscopy**
✅ To rule out foreign body or bronchial tumor if confined to one area
215
What **imaging is used to diagnose bronchiectasis**, and what **does it typically show**?
* ✔️ **CT scan** = diagnostic imaging of choice
* ✔️ Classic signs:
1. **Airway dilation**
▫️ “**Tram track**” sign
▫️ “**Signet ring**” sign
2. **Bronchial wall thickening**
📸 These findings **confirm structural airway changes**
216
What are the key components of bronchiectasis **management**?
* ✔️ **Treat the** **underlying cause**
* ✔️ **Mucolytics** – to thin secretions
* ✔️ **Bronchodilators** – for airway relief
* ✔️ **Antibiotics**:
Used for **prophylaxis**
Used in **acute exacerbations**
💊 Management is tailored to **prevent further lung damage**
217
Why are **corticosteroids not routinely** used in bronchiectasis⁉️
* ⛔ Used only if:
➡️ **Noninfectious cause**
➡️ **Allergic bronchopulmonary aspergillosis (ABPA)**
218
: What are the **clinical features** and **associated conditions** of Obstructive Sleep Apnea (OSA)?
* ✔️ **Recurrent apneas** during **sleep**
🔹 Daytime sleepiness (hypersomnolence)
🔹 Loud snoring, gasping or choking at night
🔹 Morning headaches
🔹 Poor sleep quality
✔️ **Risk factors**:
Obesity
Acromegaly
Hypothyroidism
219
What defines an **apneic event** in the diagnosis of **OSA**⁉️
| Obstructive Sleep Apnea (OSA)
* **Cessation of airflow ≥10 seconds during sleep**
*
✅ Diagnostic if **>5 events/hour** + **hypersomnolence** or **nocturnal symptoms**
220
What is the **gold standard test** for diagnosing **OSA**, and how it diagnose ⁉️
| obstructive sleep apnea (OSA)
**Polysomnography** (sleep study)
* **Diagnosis = >5 apnea events per hour + symptoms** (e.g., sleepiness, snoring)
221
What are the **common complications** associated with OSA?
| Obstructive Sleep Apnea (OSA)
✔️ **Hypertension**
✔️ **Cardiovascular disease**
✔️ **Insulin resistance**
✔️ **Pulmonary hypertension**
222
What is the **overall approach** to **treating** Obstructive Sleep Apnea (OSA)?
| Obstructive Sleep Apnea (OSA)
✔️ **CPAP**: First-line therapy
✔️ **Lifestyle modifications**:
* Weight loss
* Avoiding alcohol
➡️ **These together improve symptoms and reduce complications**
| CPAP (Continuous Positive Airway Pressure)
223
What is **the first-line treatment** for moderate to severe OSA⁉️
| Obstructive Sleep Apnea (OSA)
* **CPAP** (Continuous Positive Airway Pressure)
* Benefits: **improves sleep quality**, **cognition**, **daytime alertness**, and **reduces BP**
224
How is Obstructive Sleep Apnea (OSA) **diagnosed**, and what **criteria confirm** the diagnosis?
| Obstructive Sleep Apnea (OSA)
* ✔️ Diagnosis is made by **polysomnography** (sleep lab study)
* ✔️ Confirmed by:
1. **5 apnea events per hour of sleep**
2. Plus **symptoms like excessive daytime sleepiness** or nocturnal symptoms (e.g., snoring)
225
What **lifestyle modifications** are recommended in OSA⁉️
⚖️ **Weight loss**
🚫 **Alcohol** abstinence
🛌 **Sleep** positioning
226
What is **hemoptysis** and what are its **most common causes**? 🩸
* ✔️ **Hemoptysis** = expectoration of **blood from the respiratory tract**
* ✔️ Common causes include:
**Infections** (pneumonia, TB, aspergilloma)
Bronchogenic **carcinoma**
**Pulmonary embolism**
Airway **trauma** (foreign body, iatrogenic)
**Coagulopathy**
227
How is **massive hemoptysis** defined clinically?
✔️ **> 400 mL/24 hours**
✔️ OR **>150 mL at one time**
228
What is the first step in **assessing hemoptysis severity**?
Determining the **amount or volume** of expectorated blood. 📏
229
What is the **first priority** in **managing massive hemoptysis** and **how is it achieved?**
✔️ **Airway protection**
✔️ Done by:
* **Patient positioning** → bleeding side downward
* **Intubation** if necessary
📌 This helps prevent blood from entering the healthy lung
230
What are the **immediate priorities** in managing a patient with **massive hemoptysis and hypoxemia⁉️**
🚨 **Airway stabilization**
🚨 **Prevent aspiration** into the contralateral lung
🚨 **Maintain oxygenation**
231
Why is **massive hemoptysis** (e.g., 500 mL/24h) **life-threatening⁉️**
⚠️ **Blood** can **aspirate into both lungs**
⚠️ Causes **worsening hypoxemia**
⚠️ May lead to **airway obstruction**
232
Is **hemoglobin level** used to define the severity of hemoptysis?
**No**. Severity is **based on volume of expectorated blood**, not hemoglobin level. 🚫🩸
233
Does the **number of bloody coughs** determine **hemoptysis severity?**
**No**.
Severity depends on the **amount of blood expectorated**, not the number of bloody coughs. ❌
234
What is the **next step** if **bleeding continues** after **airway protection** in **massive hemoptysis?**
* ✔️ **Bronchial artery embolization**
* 📌 If **unsuccessful or unavailable** → **surgical resection** (last resort due to high mortality)
235
When is **invasive ventilation** indicated in **massive hemoptysis⁉️**
* 🚩 Indicated only in:
➡️ **Impending airway compromise**
➡️ **Severe hypoxemia**
⚠️ Otherwise, avoid invasive ventilation as long as possible
236
How can **invasive ventilation** be used **safely** in massive hemoptysis⁉️
* ✅ Use techniques like:
➡️ **Double-lumen endotracheal tube**
➡️ **Selective bronchial intubation**
💡 These allow isolation and ventilation of the unaffected lung
237
What is the **optimal patient position** in massive hemoptysis to **prevent aspiration** into the healthy lung⁉️
➡️ **Lateral decubitus position** with **the bleeding lung down**
* ✅ Prevents blood from entering the nonbleeding lung
238
What **diagnostic or therapeutic procedures** can **follow stabilization** in **massive hemoptysis**⁉️
* **Bronchoscopy** (diagnosis + local control)
* **Embolization** (to stop bleeding)
239
Why is **surgical resection** **not the first-line treatment** in massive hemoptysis?
✔️ It has **high mortality**
✔️ Used only if embolization or other less invasive methods **fail**
240
What is the **general management** flow in massive hemoptysis?
1️⃣ **Assess bleeding volume**
2️⃣ **Protect airway**
3️⃣ **Position patient** (bleeding lung down)
4️⃣ If **bleeding persists** → **embolization**
5️⃣ If **embolization fails** → consider **surgery**
241
What is the role of **bronchoscopy in hemoptysis**, and **when is it not useful?**
✔️ Bronchoscopy helps **locate the source of bleeding**
❌ **Not** used in **massive hemoptysis**, where rapid intervention is required (e.g., embolization)
242
What is the role of **CT angiography** in hemoptysis? When is it **not indicated**?
✔️ CT angiography helps **locate the bleeding site**
❌ **Not useful** during **active massive hemoptysis**, where **urgent treatment is the priority** (e.g., airway protection and embolization)
243
What **arterial blood gas** (ABG) changes occur **at high altitude** (e.g., 4000 meters)⁉️
* 🏔️ **Hypobaric hypoxia** due to **↓ atmospheric pressure** and **↓ oxygen**
🧠 Triggers hyperventilation as a compensatory response
* 📉 **↓ PaO₂** (hypoxemia)
* 📉 **↓ PaCO₂** (due to hyperventilation)
* 📈 **↑ pH** (respiratory alkalosis)
* **HCO₃⁻ normal or slightly ↓** — renal compensation not yet established
* 🧠 Associated symptoms: headache, nausea, dizziness, fatigue (**Acute Mountain Sickness**)
244
What defines **Obesity Hypoventilation Syndrome (OHS)⁉️**
* **BMI > 30 kg/m²**➕ **chronic daytime hypoventilation**
* 📈 **PaCO₂ > 45 mmHg** (hypercapnia)
* ⚠️ **No primary lung disease** & Normal alveolar-arterial (A-a) O₂ gradient
245
What is the typical **ABG finding in OHS**⁉️
* 🧪 **↑ PaCO**₂
* 🧪 **normal alveolar-arterial PO2 gradient** because they don't have lung disease
* ➡️ **Hypoventilation** is due to reduced respiratory drive, not impaired gas exchange
246
What condition is **present in most patients** with OHS⁉️
| obesity hypoventilation syndrome
* 😴 **Obstructive Sleep Apnea (OSA)**
✅ Present in ~90% of OHS cases
➡️ Leads to nocturnal hypoventilation and chronic CO₂ retention
247
What is the **treatment** for OHS⁉️
| obesity hypoventilation syndrome
* ✅ **Weight reduction**
* 💨 **Nocturnal non-invasive positive pressure ventilation** (NIPPV) (e.g., BiPAP)
248
How does **OHS** differ from **panic attack** or **obstructive lung diseases**⁉️
| obesity hypoventilation syndrome (OHS)
**Panic attack** = hyperventilation (**low CO**₂)
**Obstructive lung disease** = **↓ FEV1/FVC**
**OHS** = **hypoventilation** with **normal FEV1/FVC**
249
What **genetic mutation** causes **cystic fibrosis** and **how does it affect the body?**
✔️ Mutation in the **CFTR gene** (Cystic Fibrosis Transmembrane Conductance Regulator)
✔️ CFTR regulates volume and composition of exocrine secretions
✔️ Mutation leads to **thick secretions affecting multiple organs 🧫**
250
What are the **major clinical manifestations** of cystic fibrosis?
✔️ **Pulmonary**: Recurrent lung infections, bronchiectasis, clubbing
✔️ **Gastrointestinal**: Fat-soluble vitamin deficiency, malabsorption, steatorrhea, meconium ileus (newborns)
✔️ **Endocrine**: Diabetes mellitus
✔️ **Reproductive**: Absence of vas deferens → infertility ⛔👶
251
How is cystic fibrosis **diagnosed**?
✔️ **Sweat chloride test** (elevated chloride)
✔️ **Genetic analysis** for CFTR mutation 🧪🧬
252
What are the **main components** of cystic fibrosis **treatment**?
✔️ **Exogenous pancreatic enzymes**
✔️ **Bronchodilators**
✔️ **Nutritional supplementation** (especially fat-soluble vitamins)
✔️ **Anti-inflammatory medications**
✔️ **Antibiotics** for infections
✔️ **Lung transplantation for end-stage pulmonary failure** 🚑💊
253
What key pathophysiologic **features** define **emphysema** and how do they affect lung function?
✔️ **Destruction of alveolar walls** → loss of surface area for gas exchange
✔️ **Loss of elastic recoil** → impaired exhalation
✔️ **Air trapping** → increased residual volume (RV)
✔️ **Airway collapse on exhalation** → obstructive pattern on spirometry
🔍 These changes result in **hyperinflation**, **decreased forced expiratory volume in 1 second (FEV1**), and **decreased diffusing capacity of the lungs for carbon monoxide (DLCO).**
254
In a patient with **emphysema** presenting with dyspnea and a CT showing hyperinflation, which **pulmonary function test value** is most likely **elevated**, and **why**?
✔️ **Residual Volume (RV)** is elevated
→ Due to **air trapping** from alveolar destruction and loss of elastic recoil
✔️ Pulmonary Function Test pattern in emphysema:
▪️ **FEV₁: ↓** (due to obstruction)
▪️ **FVC: Normal or ↓** (air trapping limits full exhalation)
▪️ **FEV₁/FVC ratio**: ↓ (<70%) → hallmark of obstruction
▪️ **RV: ↑ (key distinguishing feature**)
▪️ **DLCO: ↓** (loss of alveolar-capillary surface area)
❌ FEV₁, FVC, and DLCO are not elevated in emphysema
255
How is **life-threatening hemoptysis defined** and **managed**, and what are the **initial signs that suggest it?**
✔️ **Definition**:
* ≥400 mL in 24 hours or
* 100–150 mL expectorated at once
✔️ **Clinical signs:**
* Hypoxemia
* Tachycardia
* Hemodynamic instability
✔️ **Emergency management**:
* Protect airway
* Bronchial artery embolization or surgical resection
256
What **initial laboratory** and **imaging studies** are recommended for all patients presenting with hemoptysis?
✔️ **Complete blood count** (to assess infection, anemia, thrombocytopenia)
✔️ **Coagulation parameters**
✔️ **Electrolytes and renal function tests**
✔️ **Urinalysis** (to exclude pulmonary-renal disease)
✔️ **Chest imaging** (usually chest radiograph first)
257
What is the **first diagnostic test** for a patient with **risk factors for malignancy presenting with non-life-threatening hemoptysis?**
**Chest computed tomography** (CT) **scan**
258
What **flow-volume loop pattern** is characteristic of **fixed upper airway obstruction**, and what are **its common causes?**
* Fixed upper airway obstruction shows **flattening of both inspiratory and expiratory limbs on the flow-volume loop**.
* Common causes include:
✔️ **Malignancies** (e.g., laryngeal or nasopharyngeal carcinoma)
✔️ **Benign tumors** (e.g., papilloma)
✔️ **Lymphadenopathy**
✔️ **Foreign bodies**
✔️ **Subglottic stenosis** (congenital, idiopathic, post-infectious, or syndromic like granulomatosis with polyangiitis)
259
How does the flow-volume loop differ between **fixed upper airway obstruction** and **obstructive lung diseases like COPD, emphysema, and asthma?**
* **Fixed Upper Airway Obstruction**:
✔️ **Flattening of both limbs of the loop** (inspiration + expiration)
* **Obstructive Lung Diseases (COPD, Emphysema, Asthma):**
✔️ "**Dip" after the initial peak in the expiratory limb** — indicates dynamic airway obstruction
✔️ Seen during asthma exacerbations and chronic stages of COPD/emphysema
260
What **clinical features** and **associations** are characteristic of **subglottic stenosis**?
* Subglottic stenosis can present with:
✔️ **Dyspnea**
✔️ **Wheezes**
✔️ **Cough**
* It may be:
✔️ **Congenital**
✔️ **Idiopathic** (e.g., post-infectious)
✔️ Associated with **syndromes** such as **granulomatosis** with **polyangiitis** (**Wegener**’s)
261
Why is **primary pulmonary hypertension not diagnosed with spirometry**, and how does it **differ** from **obstructive or upper airway diseases?**
Primary pulmonary hypertension does not alter spirometry patterns **because it is a vascular disease**, **not an obstructive or restrictive lung disorder.**
✔️ **Spirometry** reflects airflow **dynamics**, **not** pulmonary **arterial pressure**.
✔️ **No flattening or "dip" on the flow-volume loop**
262
What are the **components** and **scoring system** of the **modified Wells criteria** for **pulmonary embolism (PE)?**
* ✅ **Modified Wells Criteria for PE:**
✔️ Clinical signs of deep vein thrombosis** (DVT) = 3 points**
✔️ PE **more likely than other diagnoses = 3 points**
**Previous** PE or DVT = 1.5 points
**Heart rate >100 bpm** = 1.5 points
**Recent surgery/immobilization (past 4 weeks**) = 1.5 points
✔️ **Hemoptysis** = 1 point
✔️**Active malignancy or diagnosed within 6 months** = 1 point
* A total score of **4 or fewer** means that the likelihood of **PE is low**
* A total score **greater than 4 points** means that the likelihood of **PE is high.**
263
How are the **total scores** of the **modified Wells criteria** interpreted for **PE risk stratification**?
✅ Interpretation of Scores:
✔️ **≤4 points** → **Low** probability of PE
✔️ **>4 points** → **High** probability of PE
264
What is the **next diagnostic step** in a patient with a **low pretest probability for pulmonary embolism?**
✅ **Measure D-dimer levels**
* ✔️ If **normal** → **PE ruled out**
* ✔️ If **elevated** → Perform **CT angiography** of pulmonary arteries
* 🧠 **D-dimer: high sensitivity, low specificity**
265
What is the **appropriate next step** in a patient with **high pretest probability of PE** based on **modified Wells criteria?**
* ✅ **Direct imaging**
✔️ Proceed directly to **pulmonary CT angiography**
❌ **Do not check D-dimer first**
266
**Silicosis** defined as?
is a **chronic interstitial lung disease caused by inhalation of silica dust**.
267
What **occupational exposures** are associated with **silicosis**⁉️
🔨 **Foundries**
🔹 **Glass** manufacturing
🔹 **Cement** industries
🔹 **Sandblasting**
🔹 **Marble** work
268
What **pulmonary function pattern** is seen in **silicosis**⁉️
* 🔹 **Restrictive pattern**
* ❗ May become **mixed** (restrictive + obstructive) if **progressive massive fibrosis (PMF) develops**
269
What is a **hallmark symptom** of silicosis?
✔️ **Chronic dyspnea** (persistent difficulty breathing)
270
What **occupational exposure** and **clinical features** support a diagnosis of silicosis?
✅ Silicosis is supported by:
* ✔️ **Occupational history**: Long-term exposure to silica dust (e.g., **marble cutting** 🪨)
* ✔️ Symptom: **Progressive chronic dyspnea** 😮💨
* ✔️ **Smoking**: May **worsen disease progression**
271
Which radiographic findings are characteristic of **silicosis**, and where are they **typically located**?
✅ Silicosis is characterized by:
✔️ **Nodular opacities** predominantly **in the upper lobes**
✔️ "**Eggshell calcifications**" of **hilar lymph nodes** 🥚
272
What **serious complications** can chronic silicosis lead to, and **what is the recommended follow-up**?
✔️ **Progressive massive fibrosis (PMF**)
✔️ Increased risk of **tuberculosis**
* **Regular follow-up is essential**
273
Why are silicosis patients at increased risk for **tuberculosis**⁉️
* ❗ Alveolar **macrophage dysfunction** impairs **immune defense**
Leads to **increased risk for TB and fungal infections**
* 🧪 TB in silicosis may require longer treatment duration
274
Do **silicosis** patients have increased risk for **viral infections** like influenza, measles, or shingles⁉️
**No**
275
What is **Progressive Massive Fibrosis (PMF) in silicosis**⁉️
* **Severe** form of silicosis **with large fibrotic masses**
➡️ Causes **both restrictive and obstructive patterns**
276
How do radiological findings help differentiate **silicosis** from **asthma-COPD overlap syndrome (ACOS)?**
✔️ **Silicosis** shows **nodular opacities**, while ACOS shows **emphysematous changes**
✔️ **ACOS** is a clinical diagnosis involving **airflow limitation** with asthma and COPD features
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Why is **secondary pulmonary hypertension** more plausible than **primary pulmonary hypertension** in a patient with silicosis?
✔️ Primary pulmonary hypertension is rare and usually affects younger individuals
✔️ **Silicosis can cause secondary pulmonary hypertension** due to **lung damage and occupational exposure**
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How do **heart failure** symptoms compare to **silicosis** in a patient with **dyspnea** and typical silicosis **radiological findings**?
✔️ Heart failure can cause dyspnea **but does not cause nodular opacities** or **eggshell calcifications** seen in silicosis
279
What **occupations** are associated with an increased risk of developing **asbestosis** due to **asbestos exposure?**
✔️ **Mining**
✔️ **Construction** (pipe fitters and boilermakers)
✔️ **Ship repair**
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What are the characteristic **chest X-ray findings** in asbestosis?
✔️ **Pleural thickening**
✔️ **Pleural calcification**, especially in the **lower lung fields**
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What **spirometry** pattern is typically seen in **asbestosis**?
* 📉 **Restrictive pattern**
— **↓ Lung volumes**
— **↓ DLCO**
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What **pattern** is seen on **pulmonary function tests (PFTs**) in asbestosis?
✔️ **Restrictive** pattern
* ↓ Total lung capacity (TLC)
* ↓ Forced vital capacity (FVC)
* ↓ Diffusing capacity (DLCO)
* **FEV1/FVC ≥ 80%**
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How does the **FEV1/FVC ratio** differ in **restrictive** vs. **obstructive** lung disease?
* ✔️ **Restrictive** (e.g., asbestosis) → **FEV1/FVC normal or ↑ (>80%)**
* ✔️ **Obstructive** (e.g., COPD, asthma) → **FEV1/FVC ↓ (<70%**)
284
What are the main **complications** resulting from asbestosis?
✔️ Pleural and pulmonary **fibrosis**
✔️ Respiratory tract **cancers** Lung cancer (most common)
✔️ Pleural and peritoneal **mesothelioma**
285
What conditions are linked to **beryllium** exposure?
✔️ Acute **pneumonitis**
✔️ Chronic **granulomatous disease**
✔️ **Lung cancer**
286
What diseases can **talc** exposure cause?
✔️ Pulmonary **fibrosis**
✔️ Lung **cancer**
✔️ **Mesothelioma**
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What is the current **treatment** for asbestosis?
✔️ There is **no specific treatment**; only **supportive** care is available
289
Between **lung cancer** and **mesothelioma**, which is **more common in asbestosis**?
✔️ **Lung cancer** is more common than mesothelioma
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Which **diagnostic test** provides a **definitive diagnosis** for a **mediastinal mass**⁉️
* **Mediastinoscopy**
🧪 Allows **tissue biopsy** of anterior/middle mediastinum → definitive diagnosis
291
What are **the most common causes** of **anterior mediastinal masses⁉️**
🟥 Anterior Mediastinum:
* 🔹 **Teratoma**
* 🔹 **Thymoma**
* 🔹 **Thyroid mass**
* 🔹 **Lymphoma**
292
What are the typical causes of **middle mediastinal masses⁉️**
🟧 Middle Mediastinum:
* 🔸 **Bronchogenic cyst**
* 🔸 **Metastatic lymphadenopathy**
* 🔸 **Vascular masses**
293
What are common causes of **posterior mediastinal masses⁉️**
🟦 Posterior Mediastinum:
* 🔹 **Neurogenic tumors**
* 🔹 **Meningocele**
* 🔹 **Gastroenteric cysts**
294
How is **chronic cough** defined⁉️
* Cough **lasting > 8 weeks**
295
What are **the common causes of chronic cough**⁉️
1. 🔹 **Obstructive lung diseases**:
* — Asthma
* — Chronic bronchitis
2. 🔹 **Non-obstructive causes**:
* — GERD
* — Postnasal drip (upper airway cough syndrome)
296
How long do **acute and subacute coughs last⁉️**
* Acute/Subacute cough **= < 8 weeks**
297
What are **common causes** of **acute or subacute cough⁉️**
* 🦠 **Respiratory infections**:
— **Sinusitis**
— **Bronchitis**
— **Pneumonia**
— **Bronchiectasis**
298
What are the expected **ABG findings** in **acute exposure to high altitude⁉️**
🧪 **pH**: **Elevated** (respiratory alkalosis)
🧪 **PaCO**₂: **Decreased** (due to hyperventilation)
🧪 **PaO**₂: **Decreased** (due to hypobaric hypoxia)
🧪 **HCO₃⁻:** **Normal or slightly decreased** (no time for full renal compensation)
299
What causes **respiratory alkalosis** at **high altitudes⁉️**
🔺 **Hypoxia** → triggers hyperventilation → ↓ PaCO₂ → **↑ pH**
300
What symptoms are seen in **acute mountain sickness (AMS)⁉️**
* 🔹 **Headache**
* 🔹 **Nausea**
* 🔹 **Dizziness**
* 🔹 **Fatigue**
301
Is **hypercarbia** (↑ CO₂) seen in **acute high-altitude illness⁉️**
* **No**
CO₂ levels are **low** due to **hyperventilation**
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What are the **diagnostic criteria for ARDS**⁉️
* **Must meet all of the following**:
1️⃣ **PaO₂/FiO₂** ratio < 300
2️⃣ **Bilateral** alveolar or interstitial infiltrates on chest imaging
3️⃣ **No** signs of **elevated left atrial pressure** (normal PCWP)
4️⃣ **Acute onset**: within 1 week of clinical insult or symptoms
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What are **direct causes** of ARDS⁉️
* 🫁 **Pneumonia**
* 🫁 **Aspiration** of gastric contents
* 🫁 Pulmonary **contusion**
* 🫁 **Near drowning**
* 🫁 **Toxic** inhalation
304
What are **indirect causes** of ARDS⁉️
* 💉 **Sepsis**
* 💥 Severe **trauma**
* 🩸 Multiple **transfusions**
* 💊 **Drug** overdose
* 🫀 **Post-cardiopulmonary bypass**
* 🔥 **Pancreatitis**
305
What are **the phases of ARDS** and their **features**⁉️
* 🔹 **Exudative phase** (0–7 days): dyspnea, tachypnea, **hypoxemia**
* 🔹 **Proliferative phase** (7–21 days): **worsening hypoxemia**, inflammation
🔹 **Fibrotic phase** (21–28 days): fibrosis, **mechanical ventilation often needed**
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What is **the main treatment** approach for ARDS⁉️
* ✅ **Low tidal volume mechanical ventilation**
➕ Treat the **underlying cause**
307
What is **the most common cancer** associated with **asbestosis**⁉️
* ✅ **Lung cancer**
➡️ More common than mesothelioma
308
What **vaccines** are recommended for **COPD patients⁉️**
✅ **Influenza vaccine**
✅ **Pneumococcal vaccine**
309
What is **the most common cause of primary spontaneous pneumothorax⁉️**
* **Rupture of apical pleural blebs**
➡️ Small subpleural cysts located under the visceral pleura
310
What is the **recurrence rate** after an **initial primary spontaneous pneumothorax⁉️**
About **50% of patients** will experience recurrence
311
Which population is most at risk for **primary spontaneous pneumothorax⁉️**
**Smokers**
🧠 Suggests presence of **subclinical lung disease**
312
What is the **initial treatment** for **primary spontaneous pneumothorax⁉️**
✅ **Simple aspiration**
* ➡️ If lung **re-expands** → **observe**
* ➡️ If lung **does not expand** → **further intervention** needed
313
What is the **next step if simple aspiration** **fails** or **pneumothorax recurs**⁉️
🔧 **Thoracoscopy** with:
* — **Stapling of blebs**
* — **Pleural abrasion** to induce pleurodesis
314
Are **TB or pneumonia** common causes of **primary spontaneous pneumothorax⁉️**
* ⛔ **No**
➡️ PSP is not commonly associated with TB, pneumonia, or lung cancer
315
What defines a **tension pneumothorax⁉️**
* Accumulation of **air in the pleural space with increasing intrathoracic pressure**
* ➡️ Leads to **venous return obstruction and decreased cardiac output**
* **➡️ Medical emergency**
316
What are **classic clinical signs** of a **tension pneumothorax⁉️**
* **Unilateral absent breath sounds**
* 🪶 **Hyperresonance** on percussion
* ➡️ **Tracheal/mediastinal shift away from affected side**
* ⬇️ **Hypotension**, **tachycardia**, JVD (late signs)
317
What are the **chest X-ray findings** in **tension pneumothorax⁉️**
* **Sharp** **visceral** **pleural** **line** with **no lung markings beyond it**
* **Contralateral mediastinal shift**
* **Depressed hemidiaphragm**
318
What is the **immediate treatment** for **tension pneumothorax** in an **unstable patient**⁉️
* ✅ **Immediate needle decompression**
➡️ Typically **2nd intercostal space**, **midclavicular** line
Followed by:
* ✅ **Chest tube insertion**
319
What patient **population** is at **highest risk** for **primary spontaneous pneumothorax⁉️**
🚬 **Young**, **thin** **male** **smokers**
320
What does focal inspiratory wheezing (**stridor**) indicate⁉️ AND Common causes?
* 🔊 Stridor = **upper airway obstruction**
* Common cause: **vocal cord paralysis**, fore**ign body**, or **laryngeal/tracheal narrowing**
321
What **respiratory conditions** are associated with **expiratory wheezing**⁉️
* 🫁 **Asthma**
* 🫁 **COPD**
➡️ Both are **lower airway obstructions**
322
What do **rhonchi** suggest on lung auscultation⁉️
🌫️ **Medium-airway obstruction**
🧪 Seen in conditions like bronchiectasis or chronic bronchitis
323
What are common **respiratory exam findings** in **pneumonia**⁉️
* 🔹 **Crackles (rales**)
* 🔹 **Bronchial breath sounds**
* 🔹 Possibly **pleural friction rub**
324
What **physical exam finding** is characteristic of **COPD**⁉️
* 📉 **Prolonged expiration**
* 💨 **Wheezing**
* 📈 Signs of **hyperinflation** (barrel chest, ↓ breath sounds)
325
What are the **five main causes** of **hypoxemia**⁉️
1️⃣ **Hypoventilation** – CNS depression (e.g., overdose, stroke)
2️⃣ **V/Q mismatch** – COPD, asthma, PE
3️⃣ **Right-to-left shunt** – Intracardiac shunts, AVMs, pneumonia, ARDS
4️⃣ **Diffusion limitation** – Pulmonary fibrosis
5️⃣ **Reduced inspired oxygen** – High altitude
326
How does **supplemental oxygen** help **differentiate causes of hypoxemia⁉️**
* 🧪 **V****/Q mismatch**, **diffusion defects, and high altitude** → ✅ **respond to oxygen**
* 🧪 **Right-to-left shunt → ⛔ poor response to oxygen therapy**
327
What are **examples of conditions** causing **V/Q mismatch**⁉️
* **COPD**
* **Pulmonary embolism**
* **Asthma**
328
What **hypoxemia cause** does **not improve** significantly with **oxygen therapy**⁉️
⛔ **Right-to-left shunt** (e.g., **pneumonia**, **ARDS**, **intracardiac shunt**)
329
What is the **hallmark** spirometry feature of **obstructive lung disease** (like emphysema)⁉️
📉 **Reduced FEV₁/FVC ratio (<70%)**
330
What is **the best initial test** when clinical suspicion for **PE is high**⁉️
* ✅ **CT pulmonary angiography (CTPA**)
➡️ Immediate imaging is required **without waiting for D-dimer**
331
What is the **purpose** of the **modified Wells criteria in PE evaluation⁉️**
📊 To **stratify pretest probability** of pulmonary embolism
➡️ Guides the **next diagnostic step** (D-dimer vs CTA)
332
What **test** is used to **classify pleural effusion** as transudate or exudate⁉️
✅ Diagnostic **thoracentesis**
333
Is a pleural fluid **LDH/serum LDH ratio of 0.75** considered exudative⁉️
✅ **Yes** – it exceeds 0.6, meeting Light's criteria
334
What is the **test of choice** to confirm a diagnosis of **interstitial lung disease (ILD)⁉️**
🔍 **Lung biopsy** via **fiber-optic bronchoscopy**
➡️ Allows for **histopathological confirmation before initiating treatment**
335
When is **open thoracotomy** indicated in ILD workup⁉️
🔓 When **diagnosis cannot be established by less invasive methods** (e.g., bronchoscopy)
336
What is the role of **bronchoalveolar lavage** (BAL) in ILD diagnosis⁉️
🧪 BAL may provide **supportive evidence** (e.g., **eosinophils, lymphocytes)**
⛔ But it is **inferior to biopsy** for definitive diagnosis
337
What are the **treatment options** for **latent tuberculosis (LTBI)?**
1. **Rifampin** for 4 months
2. **Isoniazid** (INH) for 9 months
3. **Isoniazid + Rifapentine** for 3 months
📌 Only used after ruling out active TB
338
When is a **PPD test** considered **positive** for healthcare personnel?
✔️ When **induration is ≥ 10 mm**
🧪 **Healthcare personnel** are part of the **intermediate-risk group**
339
What are the **next steps** after a **positive PPD test?**
✔️ **Rule out active TB** (via **history and chest X-ray**)
✔️ If there's **no active disease** → diagnose **latent TB**
✔️ Begin appropriate **LTBI treatment regimen**
340
What is the **purpose** of the **PPD (Mantoux) test**? 🤔
* Used to **detect latent TB infection**
Measures the skin reaction after injecting tuberculin
📌 **Does not confirm active TB**, but guides further evaluation
341
342
What is the cutoff size for a positive PPD in **HIV-infected persons**?
**≥ 5 mm**
343
What is the PPD threshold for persons with **old TB lesions** on chest X-ray?
**≥ 5 mm**
344
345
How does **pulmonary fibrosis** affect residual volume?
Pulmonary fibrosis causes a **decreased RV** due to stiff, non-compliant lungs. ❄️📉
346
Do **obesity** and pneumonia affect residual volume?
**No**, obesity and pneumonia do not significantly affect RV. ⚖️🚫
347
What happens to residual volume (RV) in **emphysema**?
RV is **severely increased** due to **loss of elastic recoil** and airway closure causing pulmonary hyperinflation. 🎈🫁
348
Is **echocardiography** **routinely** used in diagnosing pulmonary embolism (PE)?
**No**, it has **low sensitivity** and most PE patients have normal echocardiograms. 🩺❌
348
When can **echocardiography detect PE?**
It can detect **large emboli** like saddle emboli or emboli in the right/left main pulmonary arteries. ⚡🫀
349
# Pulmonary Embolism (PE)
What is **McConnell’s sign** and what **does it indicate**?
* **Hypokinesis** (reduced movement) of the **right ventricular free wall**,
* a specific **echocardiographic sign of PE**.
350
# Pulmonary Embolism (PE)
What is the **D sign** in **echocardiography related to PE?**
* **Flattening of the interventricular septum** causing a D-shaped left ventricle
* indicating **significant right ventricular overload**.
351
# Pulmonary Embolism (PE)
What is the **initial diagnostic test** for PE if the risk is low?
| Pulmonary Embolism (PE)
**D-DIMER** test to rule out PE. ✅🩸
352
What causes **Hypersensitivity Pneumonitis** (HP)?
* HP is an **alveolar inflammation**
* Caused by exposure to **extrinsic allergens** such as **bird droppings**, **moldy hay**, **grains**, and **coffee beans**. 🐦🌾☕️
353
What **pulmonary function test (PFT)** patterns are seen in HP?
**Both** **obstructive** and **restrictive** patterns may be observed.
353
What are the typical **clinical presentations** of HP?
| Hypersensitivity Pneumonitis (HP)
✔️ **Acute/Subacute**: **fever**, **chills**, **malaise**, worsening dyspnea
✔️ **Chronic**: **gradual cough**, fatigue, **weight loss**, dyspnea, **clubbing of fingers 🩺🔥**
354
What are the **radiological findings** in HP?
| Hypersensitivity Pneumonitis (HP)
* **Acute/subacute**: **micronodular opacities** or **hazy ground-glass on X-ray** 🌫️
* **Chronic**: **fibrotic changes** on imaging 🦴
355
What is the characteristic **histopathology** of HP on lung biopsy?
| Hypersensitivity Pneumonitis (HP)
* **Non-caseating**
* **poorly-defined granulomas** are typical.
356
What is the usual **CD4:CD8 ratio** in HP?
| Hypersensitivity Pneumonitis (HP)
* Typically **less than 1,**
but this is a non-specific finding. ⚖️🔍
357
What is the **primary treatment** for HP?
| Hypersensitivity Pneumonitis (HP)
**Avoidance of the allergen, and corticosteroids in chronic cases.**
358
How does HP differ from **other granulomatous lung diseases?**
## Footnote
Hypersensitivity Pneumonitis (HP)
