Pulmonology

·         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.

·         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.

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·         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:

1. Pleural fluid protein/serum protein ratio > 0.5
2. Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio > 0.6
3. Pleural fluid LDH > two thirds the upper limit of normal for serum
4. 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.

·         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