·
The best areas to
listen for right middle lobe findings would be: (1) the right
anterior midclavicular line between the fifth and sixth ribs and (2) the right
midaxillary line between the fourth and sixth ribs. The right middle lobe is
not heard posteriorly, and the lung examination is incomplete if physicians do
not listen anteriorly or medially.
·
The BODE index
is a grading system that consists of four variables. The B stands for body
mass index. The O stands for the degree of airflow obstruction,
measured by the forced expiratory volume in 1 second (FEV1) after a dose of
albuterol. The D stands for dyspnea, which is measured by the modified
medical research council (MMRC) dyspnea scale. The E stands for exercise
capacity, measured by the 6-minute walk test. The BODE index has a score of
0-10; the higher the score, the higher the mortality. It is better than the
FEV1 at predicting the risk of death from any cause and from respiratory causes
among patients with COPD
·
Hamman-Rich
syndrome is also called idiopathic pulmonary fibrosis (IPF).
It is as common as sarcoidosis but is found more in males than females;
the usual age of onset is the fifth or sixth decade of life. Chest
radiograph usually reveals fibrosis.
·
·
Egophony
is characterized by increased intensity of the spoken word upon auscultation
and occurs with lung consolidation. Whispered
pectoriloquy is a whispered voice that can be heard loudly and
clearly through the stethoscope and occurs in areas of pulmonary consolidation.
Bronchophony is increased loudness of
spoken sounds in peripheral areas of consolidation. Bronchial
breath sounds are normally heard over the trachea, bronchovesicular
breath sounds over the main bronchi, and vesicular breath sounds over the
lobes.
·
Chronic cough
is defined as a cough present for >8 weeks. Mycoplasma infection can cause a cough acutely
or a postinfectious cough that persists for as long as 8 weeks. Asthma, postnasal drip, and reflux disease
are the three most common causes of chronic cough in a nonsmoker not taking
angiotensin-converting enzyme (ACE) inhibitors.
·
The typical clinical presentation of IPF/UIP is slowly progressive exertional dyspnea with a
nonproductive cough. Clinical examination reveals dry crackles and
digital clubbing. Patients with IPF are usually >50 years, and more than
two-thirds have a history of current or former tobacco use. A high-resolution
CT scan of the chest can be diagnostic, in the typical clinical situation of an
older individual, and shows subpleural pulmonary fibrosis that is
greatest at the lung bases. As disease progresses, traction bronchiectasis and
honeycombing are characteristic on CT scan.
·
Cryptogenic Organizing Pneumonia (COP), a
known pulmonary manifestation of rheumatoid arthritis. COP (formerly
bronchiolitis obliterans organizing pneumonia, BOOP) usually presents in the
fifth or sixth decades with a flulike illness. Symptoms include
fevers, malaise, weight loss, cough, and dyspnea. Inspiratory crackles are
common, and late inspiratory squeaks may also be heard. Pulmonary function
testing reveals restrictive lung disease. The typical pattern on
high-resolution chest CT is patchy areas of airspace consolidation, nodular
opacities, and ground-glass opacities that occur more frequently in the lower
lung zones. Pathology shows the presence of granulation tissue plugging
airways, alveolar ducts, and alveoli. There is frequently chronic
inflammation in the alveolar interstitium. Treatment with high-dose steroids
is effective in two-thirds of individuals, with most individuals being able to
be tapered
·
Charcot-Leyden
crystals are composed of
lysophospholipase, and their presence in tissue or secretions has been
considered as specific for eosinophil activity. However, lysophospholipase is
also found in basophils.
·
Creola
bodies are clumps of epithelial
cells and suggest a desquamating disease process.
·
Curschmann's
spirals are mucus plugs composed
of mucus, proteinaceous material, and inflammatory cells in a swirling,
spiraling pattern. They usually conform to the configuration of the involved
airways.
·
In WG, Combination treatment with corticosteroids and cyclophosphamide should be
given initially to gain benefits from the rapid anti-inflammatory effects of the
steroid while the cytotoxic actions of the cyclophosphamide are taking effect.
·
A normal PA-aO2
is usually < 10 mmHg in a patient breathing room air. In
conditions that interfere with gas exchange between the alveoli and pulmonary
capillaries, the PA-aO2 increases. In pure hypoventilation, when lung
function is not impaired, the PA-aO2 is normal.
·
Hypoxemia
usually is defined as a partial arterial oxygen tension (PaO2) < 60 mmHg.
·
The diffusing capacity of carbon monoxide (DLCO) estimates the transfer of oxygen from the
alveolus to the red blood cell. The diffusion is determined by the thickness of
the alveolar-capillary membrane, the "driving pressure" or oxygen
tension difference between the alveolus and capillary, and the area of the
alveolar-capillary membrane.
DLCO may be
reduced due to decreased area for diffusion (emphysema, lung resection,
anemia) or increased thickness of the membrane (pulmonary fibrosis, CHF).
·
An exudative pleural effusion meets one or more
of Light's criteria, whereas a transudative meets none:
- Pleural fluid protein/serum protein ratio > 0.5
- Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio > 0.6
- Pleural fluid LDH > two thirds the upper limit of normal for serum
- a pleural cholesterol level greater than 60 mg/dl.
The presence of any of these findings makes the diagnosis
of an exudative effusion more likely. The absence of all four findings points
toward a transudative effusion.
·
Pleural fluid
acidosis has a pH < 7.30 and a glucose level < 60
mg/dL.
Rheumatoid effusion, Lupus
pleuritis, Empyema, Malignancy, Esophageal rupture, TB empyema
·
Hamman's sign:
Mediastinal emphysema or pneumomediastinum
can be detected on auscultation by the presence of a mediastinal
"crunch" coinciding with cardiac systole and diastole.
·
The most common radiologic
manifestation of PCP is bilateral interstitial or alveolar
infiltrates. Other presentations include pneumothorax, cysts, nodules, lobar
infiltrates, or pleural effusion.
·
Before AKT is
started, the following tests should be performed: baseline liver
function tests (INH, rifampin, PZA); CBC with platelets (ethambutol), blood
urea nitrogen, creatinine, and calcium (INH, rifampin); uric acid (PZA,
ethambutol); and visual acuity (retrobulbar optic neuritis, ethambutol).
Patients receiving INH should be questioned monthly about potential symptoms,
including peripheral neuropathy.
·
Nocardiosis
is most commonly associated with underlying disease, such as pulmonary alveolar proteinosis. Most strains
are susceptible to sulfonamides.
·
Unlike MG:
LEMS involves proximal muscle
groups
LEMS has little response to
neostigmine challenge
LEMS demonstrates increased
muscular response/strength to repetitive stimulation
·
Often the interpretation of the chest x-ray of patients with acute PE is
"normal," although subtle nonspecific abnormalities are generally
found. Examples include differences in diameters of vessels that should be
similar in size, abrupt cut-off of a vessel followed distally, increased
radiolucency in some areas, regional oligemia (Westermark's sign), a peripheral wedge-shaped density over the diaphragm (Hampton's
hump), or an enlarged right descending pulmonary artery
(Palla's sign).
·
Although most cases are sporadic, PPH may be associated with: familial factors
(<10%, autosomal dominant with incomplete penetration), anorectic drug use,
chronic illicit drug use (cocaine, amphetamines), portal hypertension, and HIV.
·
ILDs with
pneumothorax: Eosinophilic granuloma,
neurofibromatosis, lymphangioleiomyomatosis, and tuberous sclerosis.
·
Pulmonary syndromes
with rheumatoid arthritis (RA): RA may be associated with ILD. The condition is more common in men, rarely
precedes joint disease, and may be associated with cutaneous nodules. The most
common pulmonary complication is pleural effusion.
Other conditions include pulmonary vasculitis,
parenchymal nodules, and bronchiolitis obliterans.
·
NONCASEATING
GRANULOMAS: Sarcoidosis, Mycobacterial
and fungal disease, Extrinsic allergic alveolitis, , GI diseases (celiac
disease, Crohn's disease, Whipple's disease), Pneumoconiosis, Drug reaction,
Foreign body reaction, Syphilis, Berylliosis
·
Respiratory
Distress Index (RDI): The number of apneas and hypopneas/hour is
termed the respiratory distress index. RDI helps to determine the severity of
OSA.
·
Cardiac asthma
may improve after administration of an inhaled
bronchodilator. Therefore, one should exercise caution in making a
diagnosis of bronchospasm on the basis of bronchodilator responsiveness,
especially in the acute setting. Similarly, corticosteroids
can occasionally relieve symptoms of upper airway
obstruction by decreasing edema.
·
During pregnancy,
approximately one third of patients experience improvement in their symptoms of
asthma, and one third remain stable,
but in one third, symptoms worsen. Those with more severe asthma are at greater
risk of their symptoms worsening.
·
The most effective therapy for exercise-induced asthma is an inhaled beta
agonist. Cromolyn is also effective, and newer leukotriene modifiers may also
have a role. Theophylline, corticosteroids, and
anticholinergics have no role in the treatment of exercise-induced asthma.
·
Aspirin
hypersensitivity can initially present with bronchoconstriction or
other allergic symptoms. Cross-reactivity with other
NSAIDs is almost universal, because the causal mechanism is likely
mediated by COX. Leukotriene modifiers are likely to be
more effective in patients with aspirin hypersensitivity because of their
effect on the COX pathway.
·
Allergic
bronchopulmonary aspergillosis is a hypersensitivity reaction to
colonization of the airways by Aspergillus. Recent studies have shown that the
combination of the antifungal itraconazole and
inhaled steroids may be effective treatment.
·
Only 10% to 15%
of smokers experience clinically significant airway obstruction.
only smoking cessation and long-term administration of
supplemental oxygen to the chronically hypoxemic patient have been definitively
shown to alter the natural history of the disease favorably
·
Clubbing of the digits occurs in the majority of patients with
significant bronchiectasis and is a valuable diagnostic clue, especially since
clubbing of the digits is not a manifestation of CAO.
·
The management of a patient with a solitary lung nodule on chest x-ray can be
challenging. In almost all cases, it should be assumed
that the nodule is malignant. A benign etiology can be assumed if a
chest radiograph taken 2 or more years earlier shows the lesion to have been
the same size as or larger than it is currently.
·
Clinical presentations of patients with alveolar proteinosis can vary greatly. The
condition may progress, remain stable, or resolve spontaneously. Some patients
are asymptomatic; others have severe respiratory insufficiency. Most patients
present with gradually progressive exertional
dyspnea and cough that is usually unproductive. Diagnosis is made with BAL,
which shows grossly turbid exudates in the
airways and PAS-positive material on pathologic examination.
·
A pneumothorax in
the setting of diffuse infiltrative lung disease is a clue to eosinophilic granuloma,
PCP, and lymphangiomatosis.
·
Unlike the hyperventilation associated with
parenchymal lung disease, the hyperventilation that occurs during progesterone stimulation (such as occurs
during pregnancy) and metabolic acidosis is associated with an increase in tidal volume and little increase in
respiratory rate.
·
The apnea-hypopnea
index (AHI) is the total number of apneas and hypopneas that occur
during sleep, divided by the hours of sleep time. 5 IS THRESHOLD FOR NORMALITY.
·
Obese patients
may experience significant dyspnea during exercise, because of the
increased work required to move the heavy chest and abdomen and because of
overall poor conditioning.
·
Kyphoscoliosis
is the most common disorder of the chest wall that produces ventilatory
failure. Approximately 80% of cases are
idiopathic, first manifesting in late childhood and early
adolescence; the other 20% are caused by neuromuscular disorders. Females are four times more likely to develop
this deformity than males. The deformities worsen with age. Immunization with
influenza and pneumococcal vaccines, early treatment of respiratory infections,
avoidance of CNS depressants, and use of nocturnal oxygen therapy can prolong
life and enhance quality of life in these patients. There is no evidence that
yearly pulmonary function testing will affect the disease process or provide
any added information for intervention.
·
Acute hypercapnic
respiratory failure is defined as a
PaCO2 greater than 45 to 50 mm Hg along with respiratory acidosis. Signs
and symptoms of hypercapnia depend not only on the absolute level of PaCO2 but
also on the rate at which the level increases. A PaCO2 above 100 mm Hg may be
well tolerated if the hypercapnia develops slowly and acidemia is minimized by
renal compensatory changes
·
About idiopathic
spontaneous pneumothorax, Common misconceptions
are that strenuous physical activity is frequently a trigger for the
development of pneumothorax and that patients are at increased risk during
airplane travel. In fact, most studies have found that the onset of symptoms of
pneumothorax usually occurs at rest or during light activity.
·
A pleural liquid hematocrit that exceeds half
the simultaneous peripheral blood hematocrit indicates frank bleeding into the
pleural space and is diagnostic of a hemothorax.
In patients who have a pleural effusion associated with bacterial pneumonia
(parapneumonic effusion), a pleural liquid pH of less than 7.0 is suggestive of
an infected pleural space (empyema).
A pH of 6.0 or less suggests esophageal rupture.
·
Mediastinal
tumors are the most common cause of Chylothorax, with lymphomas
exceeding metastatic carcinomas in frequency.
·
In HHT,
there are often numerous arteriovenous malformations (AVMs)
in the lungs and elsewhere in the body. Such patients have an artificially low
pulmonary resistance because a substantial fraction of blood may be shunting
through the AVMs. Although the presence of AVMs generally does not lead
directly to pulmonary hypertension, occasionally pulmonary
hypertension is seen in association with AVM therapy; that is, if AVMs
are resected, one can develop pulmonary hypertension because of vascular
remodeling and an abrupt increase in resistance once the AVMs are no longer
able to shunt blood. Orthopnea is actually unusual
in this disorder; classically, patients have increased dyspnea when standing
up, a symptom called platypnea. Pulmonary
function tests are generally normal except for a
slightly diminished diffusing capacity of
lung for carbon monoxide (DLco). The
long-term risk associated with the disease is largely the possibility that a
clot or organism could embolize through one of these malformations
directly to the brain. This makes treatment of asymptomatic patients
controversial, but some favor it to prevent negative neurologic outcomes.
·
Thoracic
respiration, performed by the upper part of the chest, is seen in normal
women, anxious subjects, patients with ascites, and patients with diaphragmatic
paralysis. In men and young children, respiration is abdominal.
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