PANCE Blueprint Pulmonary (9%)

Home PANCE Blueprint Pulmonary (9%)
PANCE Blueprint Pulmonary (9%)
Featured

PANCE Blueprint Pulmonary (9%)

,

60 Lessons

3 hours 3 mins

$19.99 - Purchase Now

Follow along with the NCCPA™ PANCE and PANRE Pulmonology Content Blueprint

Lessons

  4. Pulmonary 149 Question Comprehensive Exam (Members Only)

    Comprehensive PANCE/PANRE Pulmonary System Blueprint Exam

  5. Smarty PANCE Pulmonology Flashcards and Cheat Sheet

    Flashcards covering all Pulmonology PANCE/PANRE NCCPA Content Blueprint topics. Download and print the flashcard cheat sheet and access our premium Quizlet flashcard sets.

    1. Additional Pulmonology Flashcards

  7. Pulmonology PANCE and PANRE Content Blueprint Cram Session

    Stephen Pasquini PA-C

  8. Acute respiratory distress syndrome (Lecture)

    Acute respiratory distress syndrome (ARDS) is acute inflammatory lung injury with increased capillary permeability causing noncardiogenic pulmonary edema and severe hypoxemia
    • Onset within 1 week of a known insult; sepsis is the most common cause (also pneumonia, aspiration, trauma, pancreatitis, transfusion)
    • Severe dyspnea, tachypnea and diffuse crackles; hypoxemia refractory to supplemental oxygen (shunt physiology)
    • Chest X-ray: bilateral infiltrates not fully explained by effusions, collapse or nodules; no cardiomegaly; echocardiography (with BNP) excludes cardiogenic edema
    • Severity by PaO2/FiO2 on PEEP ≥5: mild 201–300, moderate 101–200, severe ≤100
    • Treatment: treat the cause + lung-protective ventilation: low tidal volume 6 mL/kg predicted body weight, plateau pressure ≤30 cm H2O with adequate PEEP
    • Prone positioning ≥16 hours/day for severe ARDS (PaO2/FiO2 <150) also reduces mortality
    • Early corticosteroids are suggested in moderate–severe ARDS; conservative fluids once shock resolves

  9. Foreign body aspiration (ReelDx)

    Foreign body aspiration is airway obstruction from inhaled material, most common in toddlers (1–3 years), leading to partial or complete bronchial blockage.
    • Classic presentation: sudden onset coughing/choking episode followed by persistent unilateral wheeze or decreased breath sounds (key test clue)
    • Most commonly lodges in right mainstem bronchus due to more vertical anatomy
    • Exam findings: asymmetric breath sounds, unilateral wheezing, localized crackles, ± stridor if upper airway obstruction
    • High-yield clue: normal child with abrupt respiratory symptoms and no fever → think aspiration, not infection
    • Diagnosed with chest X-ray (initial) showing air trapping, hyperinflation, or mediastinal shift; bronchoscopy = gold standard (diagnostic + therapeutic)
    • X-ray may be normal (radiolucent objects like peanuts) → expiratory films show air trapping (most tested imaging finding)
    • Complications: recurrent pneumonia, atelectasis, bronchiectasis if delayed diagnosis
    • Treatment involves urgent bronchoscopy for removal (definitive); choking with no effective cough: back blows + chest thrusts if under 1 year; abdominal thrusts (Heimlich) if 1 year or older
      • High-yield = Kids → RIGID bronchoscopy / Adults → Flexible first, rigid if needed
    • Prevention with caregiver education (avoid small foods like nuts, grapes, and hot dogs in young children)

  10. Hyaline membrane disease

    Hyaline membrane disease (neonatal respiratory distress syndrome) is surfactant deficiency in preterm infants → alveolar collapse, poor compliance and hypoxemia
    • Risk rises the more premature the infant; also maternal diabetes, male sex, cesarean delivery without labor
    • Respiratory distress within minutes to hours of birth: tachypnea, grunting, nasal flaring, retractions, cyanosis
    • CXR: diffuse "ground-glass" (reticulogranular) opacities with air bronchograms and low lung volumes
    • Prevention: antenatal corticosteroids to the mother (betamethasone) when preterm delivery is expected
    • Treatment: early nasal CPAP is first-line; surfactant if intubated or oxygen needs rise on CPAP
    • Complication: bronchopulmonary dysplasia (still needing oxygen at 36 weeks postmenstrual age)

  11. Hypersensitivity reactions (allergies and anaphylaxis)

    Hypersensitivity Reactions (Allergies and Anaphylaxis) are exaggerated immune responses classified into four types — anaphylaxis is the acute, potentially fatal type I (IgE-mediated) multisystem reaction, most often to foods, insect stings, and medications.
    • The four types: Type I immediate IgE (anaphylaxis, allergic rhinitis, food/venom allergy); Type II antibody-mediated cytotoxic (AIHA, ITP, transfusion reactions); Type III immune complex (serum sickness, PSGN); Type IV delayed T-cell (contact dermatitis, TB skin test)
    • Anaphylaxis = acute onset of skin/mucosal findings PLUS respiratory compromise or hypotension; biphasic reactions in up to 20%, most within 12 hours
    • Diagnosis is clinical — serum tryptase drawn 15 min–3 h supports it, but a normal level never excludes it
    • TX: IM epinephrine 0.01 mg/kg (max 0.5 mg) of the 1 mg/mL solution into the mid-anterolateral thigh q5–15 min — no absolute contraindication; glucagon for beta-blocked patients; glucocorticoids no longer routine
    • Discharge with TWO epinephrine auto-injectors, an action plan, and allergist referral — venom immunotherapy after sting anaphylaxis
    • Differential diagnoses: isolated urticaria/angioedema, ACE-inhibitor angioedema, vasovagal syncope, asthma exacerbation, other distributive shock, carcinoid syndrome

  12. Infectious Pulmonary Disorders (PEARLS)

    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 areas (healthcare worker or possible known exposure)
      • ≥ 15 mm for non-exposed
    • Diagnose TB with sputum for AFB smears and cultures
    If PPD/IGRA is POSITIVE, order a CXR PPD positive or IGRA + CXR negative = Latent TB ⇒ CDC recommends short-course, rifamycin-based, 3- or 4-month latent TB infection treatment regimens over 6- or 9-month isoniazid monotherapy
      • Three months of once-weekly isoniazid plus rifapentine (3HP)
      • Four months of daily rifampin (4R)
      • Three months of daily isoniazid plus rifampin (3HR)
    PPD positive or IGRA + CXR positive = Active TB ⇒ Several treatment regimens are recommended in the United States for active TB disease. TB treatment can take 4, 6, or 9 months depending on the regimen.
      • 4-month Rifapentine–moxifloxacin TB treatment regimen
        • High-dose daily rifapentine (RPT) with
        • Moxifloxacin (MOX): QT-prolonging agent and has been associated with cardiac arrhythmias, which may be fatal
        • Isoniazid (INH) and
        • Pyrazinamide (PZA)
      • 6- or 9-month quad therapy (RIPE) TB treatment regimen:
        • Rifampin (RIF): Orange body fluids, hepatitis - "remember R = red/orange body fluids"
        • Isoniazid (INH): peripheral neuropathy (given with B6 - pyridoxine 25 to 50 mg/day)
        • Pyrazinamide (PZA): Hyperuricemia (Gout)
        • Ethambutol (EMB): Optic neuritis, red-green blindness - "remember E = eyes"
    Isoniazid, rifampin and pyrazinamide are hepatotoxic, so you need to get baseline labs
    • Treatment continues for the full course (usually 6 months); a patient is no longer considered infectious after 2 weeks of effective therapy, clinical improvement and 3 consecutive negative sputum AFB smears
    • D/C therapy if transaminases > 3-5 × ULN
    • Pts on INH should take supplemental Vitamin B6 (pyridoxine 25-50mg/day) to prevent neuropathy
    • Monitor serum creatinine; take meds on an empty stomach since food can reduce absorption, watch for hepatotoxicity, be aware of drug interactions, especially with HIV meds

    2. Acute bronchiolitis (ReelDx)

      Acute bronchiolitis is a viral lower respiratory infection of infants and children under 2 years, most often caused by RSV
      • URI prodrome (rhinorrhea, cough) → wheezing, crackles, tachypnea and retractions; peaks around days 3–5
      • Apnea may be the first sign in young infants; highest risk under 6 months, preterm, or with heart/lung disease
      • Diagnosis is clinical — routine CXR, labs and viral testing are not needed
      • Treatment is supportive: nasal suctioning, hydration, oxygen if SpO2 below ~90%, high-flow nasal cannula if worsening
      • No routine bronchodilators, steroids, epinephrine or antibiotics; ribavirin only for select severely immunocompromised patients
      • Prevention: nirsevimab for infants (or maternal RSV vaccine at 32–36 weeks)

    3. Acute bronchitis (ReelDx)

      Acute bronchitis is self-limited inflammation of the large airways causing cough, over 90% viral
      • Cough (± sputum) lasting 1–3 weeks after a URI; colored sputum does NOT mean bacterial infection
      • Normal vital signs and lung exam (no fever, tachycardia, tachypnea or focal consolidation)
      • CXR only if vital signs/exam suggest pneumonia; consider pertussis if cough lasts over 2 weeks with paroxysms or whoop
      • Treatment: supportive care — antibiotics are NOT indicated; albuterol may help if wheezing

    4. Acute epiglottitis

      Acute epiglottitis is a rapidly progressive, life-threatening supraglottic airway infection causing edema and obstruction, classically due to Haemophilus influenzae type b in the unvaccinated (now more often Strep and Staph aureus in vaccinated populations, and more common in adults)
      • Bacterial invasion → intense supraglottic inflammation and edema → narrowed airway
      • Abrupt onset high fever, severe sore throat, dysphagia, drooling, muffled "hot potato" voice, toxic appearance; child sits in tripod position (leaning forward, neck extended)
      • Key differentiator: minimal cough but severe distress (vs croup = barking cough, hoarseness, gradual onset, steeple sign)
      • Stridor, respiratory distress, anxiety, cyanosis (late) → rapid progression to complete airway obstruction
      • Diagnosis is clinical + airway priority; confirm with lateral neck X-ray showing "thumbprint sign" (only if stable) or direct visualization in a controlled setting
      • Do NOT attempt a throat exam or agitate an unstable patient → can precipitate airway collapse
      • Treatment involves immediate airway management (endotracheal intubation in OR/ICU) + IV ceftriaxone (or cefotaxime) + vancomycin — all patients are admitted
      • Prevention with Hib vaccination and rifampin prophylaxis for ALL household members when the home includes an under-immunized child younger than 4, an infant without a completed primary series, or an immunocompromised child

    5. Croup (ReelDx)

      Croup (laryngotracheobronchitis) is a viral subglottic airway infection, most often parainfluenza virus, in children 6 months–3 years in fall/winter
      • Barking "seal-like" cough, hoarseness and inspiratory stridor, often worse at night, after a URI prodrome
      • Diagnosis is clinical; AP neck X-ray (not required) shows the "steeple sign" (subglottic narrowing)
      • Treatment: single dose of dexamethasone for ALL severities (oral 0.15–0.6 mg/kg)
      • Moderate–severe (stridor at rest): add nebulized racemic epinephrine and observe 2–4 hours for rebound
      • Contrast epiglottitis: abrupt high fever, drooling, toxic, tripod position, "thumbprint sign"

    6. Influenza (ReelDx)

      Influenza is an acute viral respiratory infection (influenza A/B, Orthomyxovirus) causing abrupt systemic illness with risk of severe complications.
      • Abrupt onset of high fever + myalgias + headache + malaise + dry cough → key distinction from gradual common cold
      • Exam: toxic-appearing, febrile patient with diffuse muscle tenderness; relatively minimal rhinorrhea
      • High-risk: ≥65, <5 (especially <2), pregnant, chronic disease, immunocompromised → treat regardless of symptom duration
      • Most tested complication: secondary bacterial pneumonia (S. aureus) after initial improvement; also primary viral pneumonia (bilateral infiltrates)
      • Reye syndrome: avoid aspirin in children/adolescents with viral illness
      • Diagnosis: clinical in flu season; confirm with RT-PCR (gold standard) if hospitalized or high-risk
      • Treatment involves oseltamivir (Tamiflu) ASAP (best ≤48 hrs; give ANY time if severe/high-risk); alternatives: zanamivir, baloxavir
      • Treatment involves annual vaccination for ALL ≥6 months (inactivated IM for ≥6 months; live intranasal for healthy non-pregnant ages 2–49) + post-exposure prophylaxis with oseltamivir for high-risk contacts

    7. Empyema (Lecture)

      Empyema is the collection of pus in the pleural space, usually resulting from pneumonia, surgery, or trauma
      • Fever, pleuritic chest pain, and dyspnea
      • Decreased breath sounds and dullness to percussion over the affected area
      • Cough with possible purulent sputum
      • Diagnosed with chest X-ray showing pleural effusion; CT scan provides better detail and helps guide drainage
      • Thoracentesis confirms diagnosis by obtaining pleural fluid analysis showing low pH, low glucose, and high LDH
      • Common pathogens include Streptococcus pneumoniae, Staphylococcus aureus, and anaerobes
      • Treated with antibiotics and drainage via chest tube or video-assisted thoracoscopic surgery (VATS); intrapleural fibrinolytics may be used to break down loculations

    8. Pertussis (Whooping Cough)

      Pertussis is a highly contagious respiratory infection caused by Bordetella pertussis (gram-negative coccobacillus), leading to toxin-mediated cough illness.
      • Paroxysmal cough with inspiratory “whoop,” posttussive emesis, apnea in infants, minimal fever
      • Catarrhal (1–2 wk, most infectious, URI-like) → paroxysmal (whooping cough) → convalescent (weeks–months cough)
      • Infants: apnea/cyanosis (often no whoop); adolescents/adults: persistent cough >2 weeks
      • Pertussis toxin → lymphocytosis and ciliary dysfunction → impaired mucociliary clearance
      • Diagnosed with nasopharyngeal PCR (first-line); culture = gold standard early (catarrhal phase)
      • High risk of severe disease in infants <6 months; complications include pneumonia, seizures, apnea
      • Treatment with macrolide → azithromycin (first-line; clarithromycin/erythromycin alternatives, TMP-SMX if intolerance) and droplet isolation until 5 days of therapy completed
      • Treatment involves postexposure prophylaxis with azithromycin for all household contacts and high-risk close contacts (regardless of vaccination status) and prevention with DTaP/Tdap vaccination
      • DTaP: 2, 4, 6 months; 15–18 months; 4–6 years → Tdap at 11–12 years → adults: ONE lifetime Tdap (if not previously given), then Td or Tdap booster every 10 years; Tdap during EVERY pregnancy at 27–36 weeks

      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
        • Outpatient CAP: healthy → amoxicillin (or doxycycline; macrolide only if local resistance is low); comorbidities → amoxicillin-clavulanate or cephalosporin + macrolide/doxycycline, or a respiratory fluoroquinolone
        • Inpatient (non-ICU): beta-lactam (ceftriaxone) + macrolide or respiratory fluoroquinolone alone

      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

        HIV-related pneumonia: the classic opportunistic infection is Pneumocystis jirovecii pneumonia (PJP) when the CD4 count is below 200
        • Subacute dyspnea, dry cough and fever; hypoxemia with exertional desaturation; elevated LDH
        • CXR: bilateral diffuse interstitial / perihilar infiltrates (may be normal) — CT shows ground-glass opacities
        • Diagnosis: induced sputum or bronchoalveolar lavage with stain/PCR
        • Treatment: TMP-SMX; add prednisone if PaO2 <70 mmHg or A-a gradient ≥35
        • Prophylaxis: TMP-SMX when CD4 <200 (or oropharyngeal candidiasis); bacterial pneumonia (S. pneumoniae) is still the most common pneumonia in HIV

      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

    10. Respiratory syncytial virus infection (ReelDX)

      Respiratory syncytial virus infection is a highly contagious RNA paramyxovirus and the most common cause of bronchiolitis in infants (<2 years)
      • Fall/winter presents with tachypnea, wheezing, retractions, and crackles after URI prodrome; highest risk is in infants <6 months, with severe disease also in adults ≥75 or high-risk 50–74
      • Symptoms peak at days 3–5 and typically resolve in 7–10 days
      • Diagnosed clinically (URI → wheeze/crackles + ↑ work of breathing); PCR (nasopharyngeal swab/aspirate) if needed, CXR not routine (may show hyperinflation/peribronchial thickening)
      • Treatment involves supportive care (oxygen if SpO2 <90 to <92 percent, hydration, nasal suctioning) with escalation to HFNC/NIV for worsening distress
      • Hospitalize → SpO₂ <90%, apnea, moderate–severe work of breathing (retractions, nasal flaring, grunting), poor feeding/dehydration, or high-risk infants
      • ⚠️ NO routine bronchodilators, steroids, or antibiotics; ribavirin reserved for severely immunocompromised patients
      • Treatment involves prevention with maternal RSV vaccine (32–36 weeks gestation), adult vaccine for ≥75 or high-risk 50–74, and one infant dose of nirsevimab or clesrovimab (palivizumab has been discontinued in the US)

    11. Tuberculosis (ReelDx + Lecture)

      Tuberculosis is Mycobacterium tuberculosis infection spread by airborne droplet nuclei; classic fever, night sweats, weight loss and chronic cough ± hemoptysis
      • TST (PPD) is read as induration (not redness) at 48–72 h — positive if ≥5 mm (HIV, close contact, fibrotic CXR, immunosuppressed), ≥10 mm (recent immigrants, IV drug use, healthcare/high-risk settings, children under 4), ≥15 mm (no risk factors)
      • IGRA preferred if prior BCG; a positive TST/IGRA → chest X-ray to separate latent from active TB
      • Active TB: CXR upper-lobe cavitary lesions (reactivation); Ghon complex = healed primary; confirm with sputum AFB smear, culture and NAAT ×3
      • Latent TB: rifamycin-based short courses preferred — 3HP (weekly isoniazid + rifapentine ×3 mo), 4R (daily rifampin ×4 mo) or 3HR
      • Active TB: RIPE ×2 months, then isoniazid + rifampin ×4 months (6 months total); airborne isolation
      • Side effects: Rifampin orange body fluids/drug interactions; Isoniazid neuropathy (give B6) and hepatitis; Pyrazinamide hyperuricemia; Ethambutol optic neuritis (red-green color loss)

    2. Carcinoid tumors

      Bronchial carcinoid tumors are well-differentiated neuroendocrine tumors arising in the airways (not GI metastases); usually low-grade and slow growing
      • Typical patient: younger adult, often a nonsmoker; most are central endobronchial lesions
      • Presents with hemoptysis, cough, focal wheeze or recurrent pneumonia in the same lobe (obstruction)
      • Carcinoid syndrome is rare with lung carcinoids (flushing, diarrhea, wheeze) — usually only with liver metastases
      • Bronchoscopy shows a pink-purple, vascular endobronchial mass (biopsy can bleed); CT for staging; somatostatin-receptor imaging
      • Treatment: surgical resection — excellent prognosis for typical carcinoid

    3. Lung cancer (Lecture + ReelDx)

      7 mins

      Lung cancer is the leading cause of cancer death; divided into small cell (~15%) and non-small cell (~85%)
      • Small cell: central, almost always smokers, very aggressive, usually metastatic at diagnosis → chemo-immunotherapy ± radiation (rarely surgery); paraneoplastic SIADH, Cushing (ACTH), Lambert-Eaton
      • Squamous cell: central, smokers, hemoptysis, cavitation; paraneoplastic hypercalcemia (PTHrP)
      • Adenocarcinoma: most common type overall and in nonsmokers/women; peripheral; check targetable mutations (EGFR, ALK)
      • Large cell: peripheral, poorly differentiated, fast growing; gynecomastia/galactorrhea
      • Local spread: Pancoast tumor (shoulder pain, Horner syndrome, brachial plexus), SVC syndrome (facial/arm swelling, dilated chest veins)
      • Screening: annual low-dose CT ages 50–80 with ≥20 pack-years, current smoker or quit within 15 years

    4. Pulmonary nodules

      Solitary pulmonary nodule = round opacity ≤3 cm surrounded by lung; larger than 3 cm is a mass (presumed malignant)
      • Compare with old imaging and get a CT chest; risk depends on size, smoking/age and appearance
      • Suspicious: spiculated or irregular margins, upper lobe, growth, larger size, older smoker
      • Benign clues: popcorn (hamartoma), central, laminated or diffuse calcification; solid nodule stable for 2 years is benign
      • Incidental solid nodule (Fleischner): under 6 mm low risk → no routine follow-up; 6–8 mm → CT at 6–12 months; over 8 mm → CT at 3 months, PET-CT or biopsy
      • Lung cancer screening nodules are followed with Lung-RADS instead

  14. Sleep Apnea and Obesity Hypoventilation Syndrome

    Sleep Apnea & Obesity Hypoventilation Syndrome (OHS) are obesity-related respiratory disorders characterized by nocturnal hypoventilation and daytime hypercapnia due to impaired ventilatory drive and upper airway obstruction.
    • Obstructive Sleep Apnea (OSA) = recurrent upper airway collapse during sleep → apneic/hypopneic episodes
    • OHS = BMI ≥ 30 kg/m² + daytime hypercapnia (PaCO₂ > 45 mmHg) without another cause
    • Symptoms include loud snoring, witnessed apneas, daytime sleepiness, morning headaches, and poor concentration
    • OHS patients often have severe OSA and may show cyanosis, hypoxemia, pulmonary hypertension, and right-sided heart failure (cor pulmonale)
    • Diagnosis
      • OSA: Polysomnography
      • OHS: ABG showing chronic hypercapnia + hypoxemia
      • Pulmonary function testing may show restrictive pattern
    • Risk factors include central obesity, male sex, age > 40, alcohol/sedative use, and structural airway narrowing
    • Management
      • Weight loss is essential
      • CPAP/BiPAP is first-line therapy
      • Avoid respiratory depressants
      • Supplemental oxygen alone is NOT recommended (can worsen CO₂ retention)
    • Complications include systemic & pulmonary hypertension, arrhythmias, heart failure, polycythemia, and sudden cardiac death

    2. Asthma (ReelDx)

      Asthma is a chronic, reversible inflammatory airway disease characterized by episodic bronchoconstriction, airway hyperresponsiveness, and mucus production
      • Common triggers include allergens, exercise, cold air, respiratory infections, and irritants like smoke or pollution
      • Presents with episodic wheezing, cough (especially at night), chest tightness, and dyspnea
      • Physical exam may show prolonged expiration, wheezing, and accessory muscle use during exacerbations
      • Monitor with peak flow
        • PFTs => Greater than 12% increase in FEV1 after bronchodilator therapy
        • FEV1 to FVC ratio <80% (reflects obstruction due to inflammation)
      Stepwise Approach for Youths ≥12 Years and Adults (GINA Track 1)
      • Step 1: As-needed low-dose ICS-formoterol (replaces SABA alone to reduce exacerbation risk)
      • Step 2: Daily low-dose ICS or as-needed low-dose ICS-formoterol
      • Step 3: Low-dose ICS-formoterol maintenance and reliever therapy
      • Step 4: Medium-dose ICS-formoterol maintenance and reliever therapy, or add-on tiotropium
      • Step 5: High-dose ICS-formoterol maintenance and reliever therapy, with add-on tiotropium or biologics if uncontrolled
      Acute exacerbations: Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids
      • GINA Track 2: An alternative option that uses SABA as the reliever, along with a separate preventer inhaler. This track may be used if ICS-formoterol is not available or if patients have no risk factors for exacerbations

    3. Chronic bronchitis (ReelDx)

      Chronic bronchitis is a clinical definition: productive cough for ≥3 months in each of 2 consecutive years; part of COPD, almost always from smoking
      • "Blue bloater": overweight, cyanotic, chronic hypoxemia and CO2 retention, rhonchi/wheeze
      • Hypoxemia → secondary polycythemia and cor pulmonale (JVD, edema, hepatomegaly)
      • COPD diagnosis: post-bronchodilator FEV1/FVC below 0.70 on spirometry
      • Maintenance: long-acting bronchodilators — LAMA or LAMA + LABA; add ICS if frequent exacerbations and eosinophils ≥300
      • Smoking cessation and long-term oxygen (resting PaO2 ≤55 or SpO2 ≤88%) are the only therapies proven to improve survival
      • Exacerbations: SABA ± ipratropium, oral steroids (5 days), antibiotics if increased sputum purulence; vaccines (influenza, pneumococcal, RSV, Tdap, COVID)

    4. Cystic fibrosis

      Cystic fibrosis is an autosomal recessive CFTR mutation (most commonly F508del) causing thick secretions in the lungs, pancreas, GI tract and reproductive tract
      • Think CF in a young patient with recurrent sinopulmonary infections, failure to thrive, steatorrhea or meconium ileus in a newborn
      • Lung infections: early S. aureus, later Pseudomonas aeruginosa; bronchiectasis, nasal polyps, digital clubbing
      • Pancreatic insufficiency (fat-soluble vitamin deficiency), CF-related diabetes, male infertility (absent vas deferens)
      • Diagnosis: newborn screen (IRT) → sweat chloride ≥60 mmol/L (test of choice) ± CFTR genetic testing
      • Treatment: airway clearance, dornase alfa, hypertonic saline, antibiotics; CFTR modulators (elexacaftor-tezacaftor-ivacaftor) for eligible mutations
      • High-calorie, high-fat diet with pancreatic enzymes + vitamins A, D, E, K

    5. Emphysema

      Emphysema is permanent enlargement of air spaces with destruction of alveolar walls → loss of elastic recoil and air trapping
      • "Pink puffer": thin, pursed-lip breathing, tripod position; hyperventilates to keep PaO2 and PaCO2 near normal until late disease
      • Minimal cough/sputum, barrel chest, hyperresonance and distant breath sounds
      • Smoking → centrilobular, upper-lobe disease; panlobular, lower-lobe disease in a young nonsmoker = alpha-1 antitrypsin deficiency
      • CXR: hyperinflation, flattened diaphragms, bullae; PFTs: FEV1/FVC below 0.70, ↑ TLC/RV and ↓ DLCO (vs chronic bronchitis normal DLCO)
      • Management follows COPD (GOLD): smoking cessation, long-acting bronchodilators, vaccines, pulmonary rehab, oxygen if hypoxemic

    2. Pleural effusion (ReelDx)

      Pleural Effusion is the accumulation of excess fluid in the pleural space.
      • Dullness to percussion, decreased breath sounds, and reduced tactile fremitus over the affected area
      • Dyspnea, chest pain, and cough are common symptoms
      • Classified as transudative (due to systemic factors like heart failure, cirrhosis) or exudative (due to local factors like infection, malignancy)
      • Diagnosed with lateral decubitus chest X-ray and upright films (blunting of costophrenic angles), ultrasound, and CT scan for detailed imaging
      • Thoracentesis is performed for diagnostic and therapeutic purposes, with analysis of pleural fluid (e.g., protein, LDH, cell count, pH, glucose) to differentiate between transudative and exudative effusions
      • Light’s criteria help distinguish between transudative and exudative effusions
      • Treatment involves addressing the underlying cause (e.g., diuretics for heart failure, antibiotics for infection) and may include thoracentesis, chest tube placement, or pleurodesis for recurrent effusions

    3. Pneumothorax (ReelDx)

      Pneumothorax is air in the pleural space causing partial or complete lung collapse
      • Primary spontaneous: tall, thin young male smoker (ruptured apical blebs); secondary: underlying lung disease (COPD, CF)
      • Sudden pleuritic chest pain + dyspnea; decreased breath sounds, hyperresonance, decreased fremitus on the affected side
      • Diagnosis: upright CXR (visceral pleural line); bedside ultrasound shows absent lung sliding
      • Treatment is based on symptoms more than size: minimal symptoms → observation (± oxygen); symptomatic → needle aspiration or small-bore chest tube; advise smoking cessation
      • Tension pneumothorax is a clinical diagnosis: hypotension, tachycardia, JVD, tracheal deviation AWAY — do not wait for a CXR
      • Tension treatment: immediate needle decompression (adults 4th/5th intercostal space just anterior to the midaxillary line; 2nd ICS midclavicular is an alternative) → chest tube

    2. Cor pulmonale

      Cor pulmonale is right ventricular enlargement or failure caused by pulmonary hypertension due to lung disease or pulmonary vascular disease
      • Most common cause is COPD; other causes include interstitial lung disease, obstructive sleep apnea, cystic fibrosis, bronchiectasis, and chronic thromboembolic disease
      • Chronic hypoxic pulmonary vasoconstriction → pulmonary hypertension → increased RV afterload → right ventricular hypertrophy/dilation → right-sided heart failure
      • Classic findings include chronic dyspnea, fatigue, cyanosis, loud P2, right ventricular heave, elevated JVP, hepatomegaly, ascites, and peripheral edema
      • Key differentiator: right-sided heart failure signs in a patient with chronic lung disease; unlike left-sided CHF, cor pulmonale is driven by pulmonary disease, not LV dysfunction
      • Acute cor pulmonale can occur with massive pulmonary embolism, ARDS, or severe acute hypoxic lung disease and presents with sudden dyspnea, chest pain, hypotension, syncope, and RV strain
      • Echocardiography is first-line to assess RV size/function and pulmonary pressures; right heart catheterization is the gold standard for pulmonary hypertension
      • Workup identifies the cause: pulse ox/ABG, pulmonary function tests, sleep study for OSA, and CT angiography or V/Q scan if PE/chronic thromboembolic disease is suspected
      • Treatment involves correcting hypoxemia with long-term oxygen therapy when indicated and optimizing the underlying lung disease, especially COPD/OSA/ILD
      • Diuretics for volume overload, smoking cessation, pulmonary rehab, and anticoagulation if PE/chronic thromboembolic disease is present

    3. Pulmonary edema

      Pulmonary Edema is the accumulation of fluid in the alveoli and interstitial spaces of the lungs, leading to impaired gas exchange and respiratory distress
      • Common causes include left-sided heart failure (cardiogenic), acute myocardial infarction, valvular disease, and non-cardiogenic causes such as ARDS, high altitude, or renal failure
      • Symptoms include dyspnea, orthopnea, pink frothy sputum, tachypnea, and crackles/rales on lung exam
      • Physical findings may also include elevated jugular venous pressure, S3 gallop, and peripheral edema in cardiogenic cases
      • Diagnosis is made clinically and supported by chest X-ray (showing bilateral infiltrates, Kerley B lines, and cardiomegaly in cardiogenic edema), elevated BNP, and echocardiography if cardiac origin is suspected
      • ABG may reveal hypoxemia and respiratory alkalosis early on
      • Treatment depends on the cause:
        • Cardiogenic: Oxygen, loop diuretics (e.g., furosemide), nitrates, and noninvasive positive pressure ventilation (e.g., CPAP/BiPAP)
        • Non-cardiogenic (e.g., ARDS): Focus on treating the underlying cause, supportive care, and lung-protective ventilation

    4. Pulmonary embolism (ReelDx)

      Pulmonary embolism is usually a thrombus from the deep veins of the legs lodging in the pulmonary arteries
      • Virchow's triad: venous stasis, endothelial injury, hypercoagulability (surgery, immobilization, cancer, estrogen, pregnancy)
      • Most common symptom dyspnea, most common sign tachypnea; pleuritic pain, hemoptysis; sinus tachycardia is the most common ECG finding (S1Q3T3 is classic but uncommon)
      • Low pretest probability → PERC; low/intermediate → D-dimer (normal rules out); high → imaging
      • CT pulmonary angiography is the test of choice; V/Q scan if contrast allergy or kidney disease; CXR may show Westermark sign or Hampton hump
      • Treatment: anticoagulate — DOACs (apixaban, rivaroxaban) preferred for at least 3 months; LMWH in pregnancy
      • Massive PE (hypotension) → systemic thrombolysis; IVC filter only if anticoagulation is contraindicated

    5. Pulmonary hypertension

      Pulmonary hypertension is mean pulmonary artery pressure >20 mmHg at rest measured by right heart catheterization (gold standard)
      • Five WHO groups: 1 PAH (idiopathic, drugs, connective tissue disease), 2 left heart disease (most common cause), 3 lung disease/hypoxia (COPD, ILD, OSA), 4 chronic thromboembolic (CTEPH), 5 multifactorial
      • Progressive exertional dyspnea, fatigue, exertional syncope or chest pain
      • Exam: loud P2, right ventricular heave, TR murmur, JVD, edema (right heart failure)
      • Echocardiography is the initial screening test; V/Q scan to rule out CTEPH
      • Treatment: treat the underlying cause and give oxygen if hypoxemic; group 1 PAH → vasoreactivity test (calcium channel blocker if positive), otherwise endothelin receptor antagonists, PDE-5 inhibitors, prostacyclins

    2. Idiopathic pulmonary fibrosis

      Idiopathic pulmonary fibrosis is chronic progressive fibrosing lung disease of unknown cause — the most common idiopathic interstitial pneumonia
      • Typical patient: older adult (over 60), often male and a former smoker; exclude drugs, exposures and connective tissue disease first
      • Progressive exertional dyspnea + dry cough; bibasilar "Velcro" crackles and clubbing
      • HRCT: usual interstitial pneumonia (UIP) pattern — subpleural, basal reticulation with honeycombing
      • PFTs: restrictive (↓ TLC, normal/↑ FEV1/FVC) with ↓ DLCO
      • Treatment: antifibrotics — nintedanib or pirfenidone to slow decline; oxygen, pulmonary rehab, lung transplant; steroids are not used

    3. Pneumoconiosis

      Pneumoconioses are occupational lung diseases from inhaled mineral dust → fibrosis; key clue is the job
      • Asbestosis: shipbuilding, insulation, demolition; lower-lobe fibrosis and pleural plaques; ↑ risk of lung cancer (most common malignancy) and mesothelioma
      • Silicosis: mining, sandblasting, quarrying, stone countertops; upper-lobe nodules, eggshell calcification of hilar nodes; ↑ risk of TB
      • Berylliosis: aerospace, electronics, nuclear; granulomas that mimic sarcoidosis (beryllium lymphocyte proliferation test)
      • Coal workers' pneumoconiosis: coal miners; upper-lobe nodules → progressive massive fibrosis
      • Restrictive PFTs with ↓ DLCO; treatment = remove exposure, smoking cessation, supportive care (no cure)

    4. Sarcoidosis

      Sarcoidosis is a multisystem disease of noncaseating granulomas of unknown cause, most often in young adults (more common and severe in Black women)
      • Lungs involved in over 90%: cough, dyspnea; often found incidentally
      • CXR: bilateral hilar lymphadenopathy ± reticular opacities
      • Löfgren syndrome: erythema nodosum + bilateral hilar adenopathy + migratory polyarthritis + fever → good prognosis
      • Extrapulmonary: uveitis, skin, parotid enlargement, heart block, hypercalcemia (granuloma vitamin D activation)
      • Diagnosis: compatible picture + biopsy showing noncaseating granulomas + exclusion of TB/fungi; ACE is elevated but nonspecific
      • Treatment: many resolve without therapy; oral glucocorticoids for symptomatic, progressive or organ-threatening disease

    2. Bronchiectasis

      Bronchiectasis is permanent, abnormal dilation of the bronchi from a cycle of infection, impaired mucus clearance and inflammation
      • Most adult cases are post-infectious or idiopathic; cystic fibrosis is a classic cause (upper-lobe disease), also immune deficiency, ABPA, NTM
      • Daily cough with copious purulent sputum, recurrent infections, hemoptysis, crackles
      • CXR: "tram-track" lines and ring shadows (often nonspecific)
      • Noncontrast high-resolution CT is the test of choice: airway wider than its adjacent artery (signet ring sign), no tapering
      • Treatment: daily airway clearance (cornerstone) + vaccines; exacerbations → 14 days of antibiotics by sputum culture (Pseudomonas → ciprofloxacin)
      • ≥3 exacerbations per year → long-term azithromycin after ruling out nontuberculous mycobacteria; surgery for localized disease, transplant if advanced

Related Courses

🤖 NEW: Smarty PANCE now connects directly to your favorite AI tool. It builds custom exams from your weak areas, and it's included with your membership!

Connect your AI 👉
X