PANCE Blueprint Pulmonary (12%)

Lessons

1. 2019 PANCE Pulmonary System Content Blueprint
2. 150 Question Pulmonary System Exam (Members Only)

   1. Pulmonology 1: The Audio PANCE and PANRE Podcast Topic Specific Review

      16 mins

      Stephen Pasquini PA-C

3. Pulmonology Flashcards (Members Only)

4. PANCE Pulmonology Review With Joe Gilboy PA-C (Video Lesson)

5. The ABC's of ABG's With Joe Gilboy PA-C (Video Lesson)
6. Pulmonology PANCE and PANRE Content Blueprint Cram Session

   Stephen Pasquini PA-C

7. Obstructive pulmonary disease (PEARLS)

   1. Brian Wallace PA-C Podcast: Obstructive Pulmonary Diseases

      32 mins

      Brian Wallace PA-C

   2. Chronic bronchitis (ReelDx)

      Defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause

      • Chronic Bronchitis = Blue Bloaters (2º to chronic hypoxia)
      • Common in Smokers (80% of COPD patients)
      • Physical exam: Rales, rhonchi
      • Chest radiograph: peribronchial and perivascular markings
        • ↑ HGB and HCT common because of chronic hypoxic state
        • ↑ pulmonary HTN with RVH, distended neck veins, hepatomegaly
      • Short acting bronchodilators for mild disease, long acting bronchodilators +/- inhaled corticosteroids for moderate to severe disease, Ipratropium bromide is inhaler of choice for COPD
        • Smoking cessation and supplemental O2 (O2 is single most important medication in long term)
        • Antibiotics for acute exacerbations
      • Flu and pneumococcal vaccines are a must

   3. Emphysema

      Emphysema is a condition in which air spaces are enlarged as a consequence of destruction of alveolar septae

      • The body's natural response to ↓ lung function is chronic hyperventilation = Pink Puffers! CO2 Retainers - the body must increase ventilation to blow off CO2
      • Minimal cough (compared to chronic bronchitis), quite lungs, thin, barrel chest
      • CXR reveals loss of lung markings and hyperinflation - Parenchymal bullae and blebs are pathognomonic
      • Normal hematocrit (HCT)
      • Management is the same as Chronic Bronchitis

8. Infectious Pulmonary Disorders (PEARLS)

   1. Brian Wallace PA-C Podcast: Pulmonary Infections

      29 mins

      Brian Wallace PA-C

   2. Acute bronchiolitis (ReelDx)

      RSV first episode of wheezing in infants, young children, tachypnea, respiratory distress. Diagnosed with nasal washing for RSV culture and antigen assay. Humidified 02, antipyretics, beta agonists, nebulized racemic epinephrine, corticosteroids if h/o underlying reactive airway disease. Ribavirin if severe lung or heart disease and in immunocompromised patients

   3. Acute bronchitis (ReelDx)

      Cough which persists for more than five days, 95% are viral, usually viral, in chronic lung patients consider H. influenzae, S. pneumoniae, M. catarrhalis, normal vital signs, no rales, no egophony

   4. Acute epiglottitis

      Caused by Hib, unvaccinated child, Thumbprint sign on X-Ray treat with Ceftriaxone (Rocephin)

   5. Croup (ReelDx)

      Caused by Parainfluenza virus in the winter months, patients < 3 years old, Barking cough, stridor at night, AP radiograph shows “Steeple sign” Treatment is supportive (air humidifier), if severe IV fluids and racemic epinephrine

   6. Influenza (ReelDx)

      Fevers, chills, coryza, myalgia diagnose with rapid antigen test can be performed in clinic Zanamivir and Oseltamivir (Tamiflu) treat influenza A and B must be given within 48 hours. Amantadine and Rimantadine treat only influenza A. Annual vaccine for everyone 6 months and older unless contraindicated

   7. Pertussis (Whooping Cough)

      Bordetella pertussis (gram negative capsule), patients < 2 years old, high-pitched "inspiratory whoop", diagnose by nasopharyngeal swab, treat with Macrolide. Children should get 5 doses of DTaP vaccine (2m, 4m, 6m, 15-18m, 4-6y), Tdap booster at 11-12 y/o, DTaP

      • One dose of Tdap is also recommended for adults 19 years of age and older who did not get Tdap as an adolescent
      • Expectant mothers should receive Tdap during each pregnancy, preferably at 27 through 36 weeks

   8. Pneumonias (PEARLS)

      1. Brian Wallace PA-C Podcast: Pneumonia

         18 mins

         Brian Wallace PA-C

      2. Bacterial pneumonia (ReelDx)

         Patients will present with fever, dyspnea, tachycardia, tachypnea, cough +/- sputum

         • S. Pneumoniae: Rust colored sputum, common in patients with splenectomy
         • S. Aureus: Salmon colored sputum, lobar, after influenza, MRSA treat with vancomycin
         • Pseudomonas: Ventilators, Cystic fibrosis, patients become sick fast - treat with 2 antibiotics
         • Legionella: Air conditioning, aerosolized water, low NA+ (hyponatremia), GI symptoms (diarrhea) and high fever
         • Mycoplasma: Young people living in dorms, (+) cold agglutinins, bullous myringitis, walking pneumonia, low temp
         • Klebsiella: Alcohol abuse, currant jelly sputum, aspiration
         • Haemophilus influenzae: COPD, smokers, postsplenectomy
         • Chlamydia pneumoniae: College kids, sore throat, long prodrome
         • Poor dental hygiene is associated with pneumonia caused by anaerobes
         • The indolent course suggests an atypical pneumonia and Mycoplasma is the most common atypical agent
         • Lobar consolidation is seen in community-acquired pneumonia
         • Apical infiltration is seen in tuberculosis

      3. Fungal pneumonia

         • Histoplasma capsulatum: Bird or bat droppings (caves, zoo, bird), Mississippi or Ohio river valley causes mediastinal or hilar lymphadenopathy (looks like sarcoidosis)
         • Coccidioides (valley fever): Caused by fungal inhalation in western states. Look for this in a patient with non-remitting cough/bronchitis non-responsive to conventional treatments.
         • Cryptococcus: Immunocompromised patients usually symptomatic, found in soil can disseminate and can cause meningitis

      4. HIV-related pneumonia

         Pneumocystis jiroveci HIV CD4 < 200, immunosuppressed, CXR is the cornerstone of diagnosis.  The radiograph shows diffuse interstitial or bilateral perihilar infiltrates. Prophylaxis for high risk patients with a CD4 count of less than 200 or with a history of PJP infection.

      5. Viral pneumonia

         • Influenza pneumonia: Most common in adults, characterized by a more precipitous onset and fulminant course
         • Adenovirus: Tends to cause symptoms fast, will present with GI symptoms and lasts about 1 week. May differentiate from bacterial mycoplasma pneumonia as mycoplasma is slow and insidious.
         • RSV: Children <1 year old
         • Parainfluenza: Children 2-5 years old

   9. Respiratory syncytial virus infection (ReelDX)

      Infants, young children, tachypnea, respiratory distress, wheezing. Diagnosed by nasal washing. Supportive measures include, albuterol via nebulizer, antipyretics and humidified oxygen admit if O2 sat < 95% and/or retractions

   10. Tuberculosis (ReelDx)

       Mycobacterium tuberculosis - transmitted by respiratory droplets.

       • Classic findings include fever, night sweats, anorexia and weight loss.
       • PPD Rules: Area of induration = raised area (not the red area).
         • < 5 mm in HIV.
         • < 10 mm in high-risk area (healthcare worker or possible known exposure).
         • < 15 mm for non exposed.
       • Diagnose TB with sputum for AFB smears and cultures.
         • CXR - upper (apical) cavitary lesions.
         • Ghon complex (calcified lymph + lesions).
       • Latent TB - treat with Isoniazid for 9 months.
       • Active treatment: quad therapy (RIPE): Four drugs x 8 weeks then two drugs x 16 weeks. All are Hepatotoxic so you need to get baseline labs.
         • Rifampin (RIF): Orange body fluids, hepatitis - "remember R = red/orange body fluids."
         • Isoniazid (INH): peripheral neuropathy (give with B6- pyridoxine 25 to 50 mg/day).
         • Pyrazinamide (PZA): Hyperuricemia (Gout).
         • Ethambutol (EMB): Optic neuritis, red-green blindness - "remember E = eyes."
       • Patients with active TB will need two negative AFB smears and cultures in a row negative for therapy cessation.
       • Prophylaxis for household members: Isoniazid for 1 year.

9. Pulmonary Neoplasms (PEARLS)

   1. Carcinoid tumors

      Carcinoid tumors are a GI tract cancer that has metastasized to the lungs. Most common type Adenoma - slow growing, rare metastasis

      • Presents with haemoptysis, cough, focal wheezing or recurrent pneumonia, carcinoid syndrome - cutaneous flushing, diarrhea, wheezing and low blood pressure (hallmark sign)
      • Chest X Ray shows low grade CA seen as pedunculated sessile growth in the central bronchi
   2. Lung cancer (ReelDx)

      7 mins

      Small Cell (15% of cases) (central mass) - 99% smokers, does not respond to surgery and mets at presentation

      • Location: Central, very aggressive

      Non Small Cell  (85 percent of lung cancer cases)

      • Squamous cell (central mass) with hemoptysis, 25-35% of lung cancer cases
        • Location: central
        • May cause hemoptysis
        • Paraneoplastic syndrome: hypercalcemia
        • Elevated PTHrp
      • Large cell - fast doubling rates - responds to surgery rare (only 5%)
        • Location: Periphery 60%
        • Paraneoplastic syndrome: Gynecomastia
      • Adenocarcinoma - most common (peripheral mass), 35-40% of cases of lung cancer
        • Most common
        • Associated with smoking and asbestos exposure
        • Location: Periphery
        • Paraneoplastic syndrome: Thrombophlebitis

      Associated manifestations:

      • Superior vena cava syndrome (facial/arm edema and swollen chest wall veins)
      • Pancoast tumor (shoulder pain, Horner’s syndrome, brachial plexus compression)
      • Horner’s syndrome (unilateral miosis, ptosis and anhidrosis)
      • Carcinoid syndrome (flushing, diarrhea and telangiectasia)

   3. Pulmonary nodules

      < 3 cm is a nodule (coin lesion) > 3 cm the lesion is considered  a "mass"

      • Incidental finding on CXR →
      • Send for CT →
      • If suspicious (depending on radiographic findings below) will need biopsy
        • Ill defined, lobular or spiculated suggests cancer
      • If not suspicious < 1 cm it should be monitored at 3 mo, 6 mo, and then yearly for 2 yr
        • Calcification, smooth well-defined edges, suggests benign disease

10. Pleural Diseases (PEARLS)

    1. Brian Wallace PA-C Podcast: Pleural and Restrictive Pulmonary Diseases

       30 mins

       Brian Wallace PA-C

    2. Pleural effusion (ReelDx)

       Dyspnea, and a vague discomfort or sharp pain that worsens during inspiration

       • Differentiate exudate and transudate with pleurocentesis and Light’s Criteria
         • Exudate: (local pleural disease) - protein ratio ↑, LDH ↑, infection, malignancy, trauma
         • Transudate: Congestive heart failure, atelectasis, cirrhosis
       • Decreased tactile fremitus, dullness to percussion and and diminished breath sounds over the effusion
       • Lateral decubitus x-ray and upright films: Blunting of costophrenic angle. Mediastinal shift away from effusion
       • Thoracentesis is the gold standard

    3. Pneumothorax (ReelDx)

       Spontaneous:

       • Population: Tall thin males 10-30 years old
       • Treatment: If > 15%, chest tube insertion with serial radiographs every 24 hours until resolved

       Tension:

       • Etiology: Penetrating injury
       • Physical exam: Hyperresonance to percussion and tracheal shift to contralateral side
       • Treatment: Large bore needle decompression 2nd intercostals space midclavicular line

11. Pulmonary Circulation (PEARLS)

    1. Cor pulmonale

       A 65-year-old man who presents with a chronic productive cough, dyspnea, and wheezing. Examination reveals cyanosis, distended neck veins, and a prominent epigastric pulsation

       • Cor pulmonale is right ventricular enlargement and eventually failure secondary to a lung disorder that causes pulmonary artery hypertension
       • Lung disorders such as PE, vasculitis, ARDS, COPD (most common), Asthma, and ILD causes pulmonary artery hypertension.
       • Findings include peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift
    2. Pulmonary embolism (ReelDx)

       A patient recovering from a recent surgery presents with sudden onset of pleuritic chest pain, dyspnea, apprehension, cough, hemoptysis, and diaphoresis. The cardiac monitor demonstrates a regular rhythm with a rate of 120 bpm. Upon auscultation you notice tachypnea and crackles Virchow’s triad: hypercoagulable state, venous stasis, vascular injury

       • Risk factors: Cancer, surgery, oral contraceptive pills, pregnancy, long bone fracture (fat emboli)
       • Homan’s sign: (Dorsiflexion of foot causes pain in calf) indicative of deep vein thrombosis
       • EKG: Tachycardia (most common), ST changes, S1Q3T3 (Indicates cor pulmonale)
       • Spiral CT: Best initial test
       • Gold Standard is Pulmonary Arteriography
       • Chest radiograph: Westermark's sign and Hampton's Hump (triangular infiltrate secondary to intraparenchymal hemorrhage)
       • Treatment: Heparin to Coumadin bridge, 3-6 mo treatment target INR of 2.5 (INR range, 2.0-3.0)

    3. Pulmonary hypertension

       Pulmonary hypertension is usually caused by an underlying disorder such as constrictive pericarditis, mitral stenosis, LV failure, mediastinal disease compressing the pulmonary veins

       • Pt will present with a history history of underlying disorder (such as COPD) with worsening dyspnea, especially at rest and retrosternal chest pain. On examination, she has narrow splitting of S1, loud P2, systolic ejection click, and parasternal lift
       • Pulmonary artery pressure >25 mmHg - diagnose with right heart catheterization

12. Restrictive Pulmonary Disease (PEARLS)

    15 mins

    1. Idiopathic pulmonary fibrosis

       Chronic progressive lung disorder characterized by increasing scarring, which ultimately reduces the capacity of the lungs; etiology unknown

       • The most common of all interstitial lung diseases
       • In order to be considered "idiopathic", you must be sure to rule out other common causes such as drugs, and environmental or occupational exposures
       • CT chest: diffuse patchy fibrosis with pleural based honeycombing
       • PFTs will demonstrate a restrictive pattern - opposite of what you would see with asthma
       • Decreased lung volume with a normal to increased FEV1/FVC ratio
    2. Pneumoconiosis

       • Asbestosis: ship building, demolition, construction, chest x-ray findings of interstitial fibrosis and pleural thickening, mesothelioma
       • Silicosis: Mining, sandblasting, stone or quarry work, nodular opacities at upper lung fields, "eggshell" calcification of hilar lymph nodes
       • Berylliosis: High-tech fields, nuclear power, ceramics, foundries, diffuse infiltrates and hilar adenopathy
       • Coal Worker's Pneumoconiosis: coal miners, CXR demonstrates nodular opacities

    3. Sarcoidosis

       • Pulmonary manifestations (most common), erythema nodosum, parotid gland enlargement
       • Chest radiograph: Bilateral hilar lymphadenopathy seen on chest radiograph is the hallmark finding in 90% of cases
       • Biopsy: non-caseating granulomas and ↑ ACE levels
       • Treatment: 90% of cases are responsive to steroids and can be controlled with a maintenance note

13. Sleep Apnea and Obesity Hypoventilation Syndrome

14. Other Pulmonary Disease (PEARLS)

    1. Brian Wallace PA-C Podcast: Circulation, Cancer and a Few Other Issues

       36 mins

    2. Acute respiratory distress syndrome (Lecture)

       Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event. Physical exam will show tachypnea, frothy pink or red sputum and diffuse crackles

       • Chest radiograph: air bronchograms and bilaterally fluffy infiltrate
       • Treat with tracheal intubation with lowest level of PEEP

    3. Asthma (ReelDx)

       Greater than 12% increase in FEV1 after bronchodilator therapy monitor with peak flow meter

       • FEV1 to FVC ratio < 80%
         • Forced expiratory volume (FEV) measures how much air a person can exhale during a forced breath.
         • The amount of air exhaled may be measured during the first (FEV1)
         • Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
       • Mild Intermittent: Less than 2 times per week or 3 night symptoms per month
         • Step 1: Short acting beta2 agonist (SABA) PRN
       • Mild Persistent: More than 2 times per week or 3-4 night symptoms per month
         • Step 2: Low-Dose inhaled corticosteroids (ICS) daily
       • Moderate Persistent: Daily symptoms or more than 1 nightly episode per week
         • Step 3: Low-Dose ICS + Long acting beta2 agonist (LABA) daily
         • Step 4: Medium-Dose ICS +LABA daily
       • Severe Persistent: Symptoms several times per day and nightly
         • Step 5: High-Dose ICS +LABA daily
         • Step 6: High-Dose ICS +LABA +oral steroids daily

    4. Cystic fibrosis

       Young patient with a history of chronic lung disease, pancreatitis or infertility

       • Autosomal recessive mutation in CFTR gene
       • Recurrent respiratory infections (especially Pseudomonas)
       • CXR may reveal hyperinflation, mucus plugging and focal atelectasis
       • Labs will reveal an elevated quantitative sweat chloride test (gold standard)
       • Chest physiotherapy, high fat diet, supplement fat soluble vitamins (A, D, E, K), antibiotics for acute exacerbations

    5. Foreign body aspiration

       Presentation (depends on location of obstruction)

       • Inspiratory stridor if high in the airway
       • Wheezing and decreased breath sounds if low in the airway
       • 80% in mainstem or lobar bronchus, 20% in upper airway, right > left
       • Treatment: Remove foreign body with bronchoscope

    6. Hyaline membrane disease

       Affects premature infants. It occurs when infants are born before the lungs are producing adequate amounts of surfactant. Surfactant helps to prevent the lungs from collapsing.  As the airways collapse, infants will struggle more and more to breath until they become acidotic and multisystem organ failure begins

       • CXR will demonstrate diffuse bilateral atelectasis causing a "ground glass appearance" and air bronchograms
       • Antenatal corticosteroids to mother and exogenous surfactant as both treatment and prophylaxis

    7. Bronchiectasis

       Foul breath, purulent sputum, hemoptysis and chronic cough along with a CXR demonstrating dilated and thickened airways with "tram tracks" and “plate-like” atelectasis (scarring)

       • ½ of cases are due to cystic fibrosis
       • Gold standard diagnosis is – CT of the chest
       • Ambulatory oxygen, aggressive antibiotics, CPT (chest physiotherapy = bang on the back) and eventually lung transplant