PANCE Blueprint Pulmonary (12%)

Other Pulmonary Disease (PEARLS)

The NCCPA™ PANCE  Pulmonary Content Blueprint classifies five types of pulmonary disease as "other"

Acute respiratory distress syndrome (ARDS) Non-cardiogenic pulmonary edema

Etiology: Sepsis, severe trauma, aspiration of gastric contents, near drowning

Presentation:

  • Rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event.
  • Tachypnea, pink frothy sputum, crackles

Diagnostic studies:

Chest radiograph: air bronchograms and bilaterally fluffy infiltrate

Normal BNP, pulmonary wedge pressure, left ventricle function and echocardiogram

Treatment: Underlying cause and intubation positive pressure oxygen

Asthma (ReelDx) Presentation: Most often young patients present with wheezing and dyspnea often associated with illness, exercise and allergic triggers

Diagnosis and monitor with peak flow. PFT's: Greater than 12% increase in FEV1 after bronchodilator therapy

  • FEV1 to FVC ratio < 80% (You would expect the amount of air exhaled during the first second (FEV1) to be the greatest amount
  • In asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio

Treatment guidelines:

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

Acute treatment:

Oxygen, nebulized SABA, ipratropium bromide, and oral corticosteroids

Making Sense of Forced Vital Capacity

  • 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), second (FEV2), and/or third seconds (FEV3) of the forced breath. Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test
  • You would expect the amount of air exhaled during the first second to be the greatest amount. In asthma, since there is an obstruction (inflammation) you will have a decreased FEV1 and therefore a reduced FEV1 to FVC ratio.

Cystic fibrosis Etiology: Autosomal recessive mutation in CFTR gene

  • Abnormally thick mucus, difficulty clearing mucus

Presentation: Recurrent respiratory infections (especially Pseudomonas), steatorrhea

Diagnosis: Quantitative sweat chloride test

CXR may reveal hyperinflation, mucus plugging, and focal atelectasis

Treatment:

  • Maintenance: Chest physiotherapy, high-fat diet, supplement fat-soluble vitamins (A, D, E, K)
  • Acute exacerbations: Antibiotics
Foreign body aspiration Presentation (depends on the location of obstruction)

  • Inspiratory stridor if high in the airway
  • Wheezing and decreased breath sounds if low in the airway

Complications: Pneumonia, acute respiratory distress syndrome, asphyxia

Treatment: Remove foreign body with a bronchoscope

Hyaline membrane disease Etiology: Insufficient surfactant

  • Population: Preterm newborn
  • Chest radiograph: Ground glass appearance, air bronchograms, bilateral atelectasis

Treatment: Ventilation and steroids

Bronchiectasis Plate-like atelectasis seen with bronchiectasisEtiology: ½ of cases are due to cystic fibrosis

  • Presentation: Copious foul-smelling sputum, frequent respiratory infections, chronic cough
  • Radiograph: Dilated, thickened airways, and scattered opacities. “Tram-tracks”, CXR shows plate-like atelectasis

Treatment: Chest physiotherapy and antibiotics for acute exacerbations

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