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Lung conditions with increased A-a gradient

Diffusion limitation: ILD

Shunting: ARDS and intracardiac shunting

V/Q mismatch: COPD, atelectasis, PNA, pulmonary edema


When are breath sounds decreased in a patient with a consolidated lung field?

Normally they are increased, however, when the airway is no longer patent they are decreased.


When is diagnostic thoracentesis not the inital step in management in a patient with pleural effusion?

In patients with classic signs and symptoms of CHF, a trial of diuretic therapy is first indicated.


Tumors that most often cause malignant pleural effusions

Lung, breast and lymphoma


Indications for chest tube in a patient with parapneumonic effusion



Aspiration pneumonia vs. pneumonitis

Pneumonia: aspiration of oral cavity anaerobes, symptoms present days after aspiration and can progress to abscess in the RLL. Treat with clinda or beta-lactam + beta-lactamase inhibitor.

Pneumonitis: aspiration of gastric content, symptoms arise hours after aspiration, CXR shows infiltrates and symptoms resolve with supportive therapy.



S wave in lead I, Q wave in lead III and inverted T-wave in lead III. Seen with acute PE.


Light's criteria

Pleural fluid protein:serum protein > 0.5

Pleural fluid LDH:serum LDH > 0.6

Pleural fluid LDH > 2/3 upper limit of normal serum LDH


Asthma classification and treatment

Intermittent: daytime sx ≤ 2x/week, nighttime sx ≤ 2x/month, normal PFTs. No activity limitations, albuterol PRN only.

Mild persistent: daytime sx > 2x/week (but not daily), nighttime sx 3-4x/month, normal PFTs. No activity limitations, albuterol PRN + ICS.

Moderate persistent: daytime sx daily, nighttime symptoms weekly, FEV1 60-80% predicted. Moderate activity limitation, albuterol PRN + ICS + LABA.

Severe persistent: sx throughout day, frequent nighttime awakenings, FEV1


Treatment of exercise-induced bronchoconstriction

1) albuterol 10-20 minutes before exercise. May also add leukotriene inhibitors and ICS as needed.


Ideal tidal volume for patient on ventilator



How to anticoagulate people with DVT

If there is a reversible risk factor and it is their 1st provoked DVT, continue warfarin for 3 months.

If there is no known risk factor, continue for 6-12 months.


Next test in a patient with hypoxemia and bilateral alveolar infiltrates without risk factors for ARDS.

Echo to rule out cardiac etiology for pulmonary edema.


Main modulators of oxygenation? Ventilation?

Oxygenation = FiO2 (target is below 50-60%) and PEEP.

Ventilation = TV and RR


How does O2 supplementation exacerbate CO2 retention in patients with COPD?

1) You lose the compensatory vasoconstriction in areas of ineffective gas exchange, leading to V/Q mismatch.

2) Reduced CO2 uptake from peripheral tissue due to increased oxyhemoglobin concentration (Haldane effect)

3) Reduced respiratory drive = reduced minute ventilation


Target O2 levels in patients with COPD exacerbation

SaO2 90-93% and PaO2 between 60-70


Definition of chronic bronchitis

3 months of chronic productive cough for at least 2 years


Conditions with increased dead space ventilation

PE (V/Q = infinity because despite adequate ventilation, there is no blood flow)


Conditions with physiologic shunting

PNA (V/Q = 0 because despite adequate blood flow, there is no ventilation)


Risks of undergoing treatment for Hodgkin's lymphoma later down the road

18.5-fold increased risk of developing secondary cancers after chemoradiation (lung, breast, bone, thyroid, GI, acute leukemia and non-Hodgkin lymphoma)


Time when patients may develop radiation fibrosis

4-24 months post-XRT


How to diagnose and treat aspergillosus

Dx: fungus ball on imaging + positive IgG serology.

Tx: itraconazole, surgery or bronchial artery embolization


Most common source of acute PE

Deep veins (iliac, femoral and popliteal)


Differences in COPD due to chronic smoking and patients with alpha-1 antitrypsin deficiency

Alpha-1 antitrypsin deficiency results in panacinar emphysema and lower lobe destruction. Smokers tend to have centriacinar emphysema and upper lobe destruction.


Features of Legionairre's disease that set it apart from CAP

GI symptoms, neurological symptoms, hyponatremia and high grade fever.


Treatment of PNA due to Legionella

Macrolide or fluoroquinolone


Normal pleural fluid pH, transudative pH and exudative pH?

Normal = 7.6

Transudate = 7.4 - 7.55

Exudate = 7.3 - 7.45


3 cardinal symptoms of COPD exacerbation

Increased cough, sputum production and dyspnea.


Treatment for AECOPD

Supplemental O2 with target of 88-92%

Inhaled bronchodilators

Systemic glucocorticoids (oral if mild-moderate)

Macrolide, fluoroquinolone or beta-lactam/beta-lactamase inhibitor if 2+ cardinal symptoms are present, exacerbation is moderate-severe or mechanical ventilation is required.

NPPV if moderate-severe exacerbation

Tracheal intubation if NPPV won't work


When might you see a normal CXR in a patient with pneumonia?

1st 24 hours



Pneumocystis jirovecii


When to anticoagulate a patient with suspected PE?

Modified Wells criteria > 4 = PE likely. You should anticoagulate the patient before getting the CT angio


Symptoms of theophylline toxicity

CNS (HA, insomnia and seizures)

GI (nausea and vomiting)

Cardiac (SVT, atrial tachy and ventricular arrhythmias)


Paraneoplastic effects of lung tumors


Small cell = ACTH, Lambert-Eaton and SIADH

Adenocarcinoma = hypertrophic osteoarthropathy

Large cell = gynecomastia, galactorrhea


Diagnostic criteria for obesity hypoventilation syndrome

Sleep disorder breathing

BMI > 30

Daytime hypercapnea with PaCO2 > 45 and hypoxemia with PaO2


Hypothermia classification and treatment

Mild (32-35C, 90-95F) *increased shivering. Treat with passive external warming (remove wet clothes, give blanket)

Moderate (28-32C, 82-90F) *decreased shivering. Treat with active external warming (warm baths, blankets and IV fluids).

Severe (


Tests to get in patients presenting with AECOPD?

CXR and ABGs.


Treatment algorithm in patients with chronic cough

Treat UACS with 1st generation antihistamine like chlorpheniramine.

If this doesn't work, do a trial of PPI for GERD.

If this doesn't work, get PFTs.


Definition of a solitary pulmonary nodule


Anticoagulants that cannot be used in patients with eGFR

LMWH (fondaparinux) and factor Xa inhibitors (fondaparinux and rivaroxaban)


How to bridge to warfarin. What anticoagulant does not require a heparin bridge?

Anticoagulate the patient until the aPTT is 1.5-2x greater than normal, start warfarin and continue until INR is between 2 and 3 (usually takes 5-7 days).

Rivaroxaban has immediate anticoagulative effects and does not require heparin bridge.


Central lung cancers? Peripheral?

Central: squamous and small cell

Peripheral: adenocarcinoma and large cell


Calculate PAO2 at sea level

150 - PaCO2/0.8


Classification of ARDS severity

Stratified by the PF ratio = PaO2/FiO2

Mild = 200-300mmHg

Moderate = 100-200mmHg

Severe =


Treatment of ARDS

Low TV (6-8mL/kg)
Inspiratory plateau airway pressure


ARDS pathophysiology

Lung injury from trauma, infection, pancreatitis etc. causes release of protein, inflammatory cytokines and PMNs into the alveolar space. Bloody and proteinaceous fluid fill the alveoli, surfactant is lost, the alveoli collapse and are damaged. The end result is impaired gas exchange, decreased compliance and increased pulmonary artery pressure.


Most common causes of secondary digital clubbing

Lung malignancy, cystic fibrosis and LT -> RT cardiac shunting


Pathophysiology of digital clubbing

Megakaryocytes become entrapped in the distal fingertips and release PDGF and VEGF.


Definition of cor pulmonale

Right heart failure secondary to pulmonary hypertension


1st step in management of SIADH from a lung tumor

Limit fluids to less than 800 mL/day to allow serum sodium to rise. If the patient becomes severely symptomatic or resistant, administer hypertonic saline. If this fails, give demeclocycline, which blocks ADH action at the renal collecting ducts.


Indications for oxygen therapy in patients with COPD

PaO2 55%

Cor pulmonale


Features of non-allergic rhinitis vs. allergic rhinitis

Non-allergic: later onset, congestion, no trigger, perennial sx and erythematous nasal mucosa. Treat mild symptoms with intranasal antihistamine or glucocorticoids.

Allergic: watery rhinorrhea, itchy eyes, early onset, identifiable allergen, pale/blue mucosa, treatment is the same.


Why does empyema typically not respond to antibiotics normally used to treat CAP?

These antibiotics cover strep, staph, klebsiella and hemophylus; however, empyema develops due to mixed aerobic and anaerobic bacterial seeding of the pleural space.


Causes of recurrent pneumonia in the same region of the lung

Neoplasms, vascular anomalies, bronchiectasis, retained foreign body, bronchial stenosis, seizures, EtOH/drug use, GERD, dysphagia and achalasia.


Causes of recurrent pneumonia in different lung regions

CF, Kartagener's, vasculitis, bronchiolitis obliterans w/organizing pneumonia and immunodeficiency.


Diagnosing Goodpasture's disease

Hemoptysis and glomerulonephritis tip you off to the diagnosis. Diagnosis is confirmed with renal biopsy showing linear IgG deposition along GBM.


Middle mediastinal masses

Tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement and aortic arch aneurysms.


Anterior mediastinal masses

Thymoma, retrosternal thyroid, teratoma and lymphoma. (4 T's)


Posterior mediastinal masses

Meningocele, enteric cysts, lympohoma, diaphragmatic hernia, esophageal tumors and aortic aneurysms.


Lofgren's syndrome

Erythema nodosum, hilar adenopathy, migratory polyarthralgias and fever associated with sarcoidosis.


CXR seen in patients with pulmonary hypertension

Enlarged pulmonary arteries with rapid tapering of the distal vessels (pruning)


3 setting of empiric CAP treatment

Outpatient: healthy = macrolide or doxycycline. Comorbid conditions = fluoroquinolone or beta-lactam + macrolide.

Inpatient: fluoroquinolone or beta-lactam + macrolide

ICU: beta-lactam + macrolide or beta-lactam + fluoroquinolone.


Clinical tool used to determine if a patient will benefit from admission for CAP



Uremia > 20

RR > 30

BP 65

Patients scoring 2 or better = inpatient.
4 or better = ICU.


Only treatments shown to decrease mortality in patients with COPD

Smoking cessation, home O2 therapy and lung resection.


What's the difference between apnea and hypopnea

Apnea = cessation of breathing x 10s

Hypopnea = SaO2 drop by > 4%


Why do patients with ankylosing spondylosis get restrictive PFT patterns?

Fixation of the rib cage and diminished chest wall mobility


When do patients with AECOPD get intubated

Poor mental status, hemodynamic instability, pH