PANCE Exam: Pulmonary Review Questions & Answers

INFECTIOUS DISORDERS

Question: What are the main symptoms of individuals with acute bronchitis?
Persistent cough for more than 3 weeks, fever, and constitutional symptoms.

Question: What is the main causative agent of acute bronchitis?
Viral pathogen. Most of the time, adenovirus, rhinovirus, and influenza are the agents. In some cases, H. influenza, M. pneumoniae, and C. pneumoniae can be the causative agents.

Question: Name some diseases that can mimic acute bronchitis:
Asthma and allergic bronchospasm can present with the same symptoms of acute bronchitis. Other causes can be congestive heart failure, bronchogenic tumors, and reflux esophagitis can all present with respiratory symptoms similar to that of bronchitis.

Question: Is the use of antibiotics indicated for an acute case of bronchitis?
No.

Question: What are the treatment options for patients with acute bronchitis?
Supportive care. If the patient presents with wheezing on examination, the use of albuterol is supported. If, however, the patient presents only with a cough, bronchodilators are not indicated.

Question: What percentage of cigarette smokers develop chronic bronchitis?
10% to 15%. Chronic bronchitis generally develops after 10 to 12 years of smoking.

Question: What are the signs and symptoms of patients with acute bronchiolitis?
Fever, cough, rhinorrhea, wheezing, tachypnea, and respiratory distress.

Describe the typical findings of a chest X-ray in a patient with acute bronchiolitis:
They are nonspecific but can include increased interstitial marking, peribronchial cuffing, and hyperinflation and in some cases segmental atelectasis.

Question: How do you confirm a case of bronchiolitis?
Most cases can be diagnosed on history and physical examination alone. Nasal washings to look for RSV may be done. Laboratory results are nonspecific and may show mild leukocytosis.

Question: Which is the most common type of pathogen in bronchiolitis?
RSV. It generally affects children younger than 2 years. Bronchiolitis rarely develops in adults. Second most common pathogen is adenovirus.

Question: What is the treatment for severe RSV documented bronchiolitis?
Ribavirin.

Question: A 24-year-old female patient has a high fever, hoarseness, and increased stridor of 3 hours duration. She also has a low fever and sore throat. Examination shows an ill-appearing woman with a temperature of 40°C, inspiratory stridor, drooling, and mild intercostal retractions. She prefers to sit up. What is the most likely diagnosis?
Epiglottitis.

Question: What pathogen is responsible for most cases of epiglottitis?
Group A streptococcus. It is followed by S. pneumoniae, Haemophilus parainfluenzae, and S. aureus. Usually, viruses are not the causative agents.

Question: What is the narrowest part of the adult airway?
The glottic opening.

Question: What is the “thumb print sign”?
A soft tissue inflammation of the epiglottis seen on a lateral X-ray of the neck. The epiglottis, normally long and thin, appears swollen and flat at the base of the hypopharynx in patients with epiglottitis.

Question: What is the treatment of choice for acute epiglottitis?
Maintaining the airway is of paramount importance. If the airway is stable, treatment with a cephalosporin is indicated. Ampicillin/sulbactam is the preferred treatment for 7 to 10 days. Cefuroxime, cefotaxime, or ceftriaxone is appropriate for β-lactam allergic patients.

Question: A 2-year-old child presents with wheezing, rhonchi, inspiratory stridor, and a sudden harsh cough, which worsens at night. What is the diagnosis?
Croup, also known as laryngotracheitis. This condition is usually preceded by a URI and is frequently caused by the parainfluenza virus.

What age group usually contracts croup?
6 months to 3 years. Croup is characterized by cold symptoms; a sudden, barking cough; inspiratory and expiratory stridor; and a slight fever.

Question: What is the difference between the cough of croup and the cough of epiglottitis?
Croup has a seal-like barking cough, while epiglottitis is accompanied by a minimal cough. Children with croup have a hoarse voice, while those with epiglottitis have a muffled voice.

Question: What is the most common pathogen that causes croup?
Parainfluenza type virus. Other pathogens include influenza, RSV, adenovirus, and in some cases Mycoplasma pneumoniae.

Question: What is the “steeple sign”?
Subglottic edema, which creates a symmetrically tapered configuration in the subglottic portion of the trachea when imaged in a frontal soft tissue X-ray of the neck. This is consistent with croup.

Question: A 3-year-old male child is woken in the middle of the night with a barking seal-like cough and signs and symptoms that are consistent with croup. On examination, the child’s respirations are 35/min and oxygen saturation is 95% on room air. There is no evidence of stridor on examination and his lungs are clear. What is the recommended treatment for this patient?
Supportive care, fluids, and observation at home. If oxygen saturation is down, oxygen therapy is indicated. In all cases, inhalable racemic epinephrine by nebulizer is warranted.

Question: What if the child presented with stridor on examination?
Administer dexamethasone 0.6 mg/kg IM one-time dose along with all the other therapies mentioned above.

Question: A 34-year-old woman wakes up with a history of sudden onset of fever, body aches, malaise, chills, cough, and a sore throat. She reports that several other members at home have the same symptoms, as do some of her coworkers. On examination, her temperature is 101°F, pulse 100, respiratory rate 18, and BP 122/86. Her throat appears to be moist without any abnormalities, lungs are clear, and the rest of the examination is unremarkable. What is the most probable cause of this illness?
Influenza.

Question: Which strain of influenza is considered to cause more pandemic outbreaks?
Influenza A.

Question: Which syndrome can be caused by an outbreak of influenza B virus?
Reyes syndrome.

Question: What is the main method of transmission for the influenza virus?
It spreads via aerosol by cough and sneeze and via hand-to-hand contact.

What is the most common type of pneumonia seen in influenza patients?
Viral. A secondary bacterial pneumonia can be caused by Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenza.

Question: What method is used to detect a positive influenza illness?
Throat, nasopharyngeal, or sputum samples with a rapid influenza A or B test.

Question: What is the treatment of choice for a patient with influenza B virus?
Oseltamivir orally or Zanamivir inhaled. However, these medications must be started within 24 to 26 hours of onset of the illness for them to be effective.

Question: Name some other therapies that are helpful in symptomatic relief of an influenza illness:
Supportive care with fluids, analgesics such as acetaminophen for body aches, myalgias, and fever. A cough suppressant with or without codeine may be helpful also.

Question: Which patients should be vaccinated with the influenza vaccine?
Children between the ages of 6 and 59 months, pregnant women (during flu season), children and adults with chronic disorders of the cardiovascular and pulmonary systems, nursing home and chronic care facility patients, any care workers who are at risk of exposure, and health care workers.

Question: What age group is usually afflicted by pertussis?
Infants younger than 2 years of age.

Question: What are some of the hallmark symptoms of a patient with pertussis?
Initially, the patient has the same types of symptoms as in common cold. Within 1 to 2 weeks of the illness progressing, the patient develops a cough that evolves into a paroxysmal phase with more frequent and spasmodic bursts of 5 to 10 at a time. This can also have the sound of a terminal audible whoop. Posttussive vomiting may also occur.

Question: What is the main pathway for infection leading to pneumonia?
Aspiration via the oropharynx.

Question: Describe the different presentations of bacterial and viral pneumonia:
Bacterial pneumonia is typified by a sudden onset of symptoms, including pleurisy, fever, chills, productive cough, tachypnea, and tachycardia. The most common bacterial pneumonia is pneumococcal pneumonia.
Viral pneumonia is characterized by the gradual onset of symptoms, no pleurisy, chills or high fever, general malaise, and a nonproductive cough.

Question: What is the leading identifiable cause of acute community-acquired pneumonia in adults?
Streptococcus pneumoniae.

Name the risk factors for community-acquired pneumonia:
Alcoholism, asthma, immunosuppression, ≥70 years of age.

Question: Name the risk factors for pneumococcal pneumonia:
Dementia, seizure disorder, alcoholism, smoking, COPD, and HIV.

Question: A young infant patient who you suspect has pneumonia is ordered to have a chest X-ray performed. When you view the results, you note the presence of pneumatoceles on the film. What pathogen is likely responsible for this type of finding?
Staphylococcus aureus.

Question: A 24-year-old male patient has had fevers, chills, and a productive cough with dark green sputum for the last week. On physical examination, his temperature is 101.3°F, P 90, R 22, and BP 124/85. There is coryza with moist mucous membranes and a regular rhythm on cardiac examination. Lung sounds reveal an area of crackles with a mild expiratory wheeze at the right lower base of the lung fields. Based on this history and physical examination, what is the treatment of choice for this patient?
A macrolide antibiotic (clarithromycin or azithromycin) for the treatment of community-acquired pneumonia.

Question: If this patient required inpatient treatment of pneumonia but without ICU admission, what is the class of antibiotics that would be indicated? What if the patient needed to be in the ICU?
Fluoroquinolone for non-ICU patients (moxifloxacin, levofloxacin, and gemifloxacin).
For ICU patients, ceftriaxone, ampicillin-sulbactam,
plus azithromycin or fluoroquinolone.

Question: What are some of the more common complications associated with community-acquired pneumonia?
Respiratory failure, shock, worsening of comorbid diseases, especially metastatic infection, lung abscess, and complicated pleural effusion.

Question: Which bacterial pneumonias frequently cause frank hemoptysis?
Pseudomonas aeruginosa, Klebsiella pneumoniae, and Staphylococcus aureus.

Question: What bacteria are associated with pneumonia following influenza?
Streptococcus pneumoniae, Staphylococcus pneumoniae, and Hemophilus influenza.

Question: What two underlying medical conditions are associated with Hemophilus influenzae pneumonia?
Chronic obstructive lung disease and HIV infection.

Question: What is the most common etiologic agent of atypical pneumonia?
Mycoplasma pneumoniae.

Question: What is considered to be the second most common cause of atypical pneumonia?
Chlamydia pneumoniae.

Of the following organisms, which is commonly spread by person-to-person contact: Legionella pneumoniae or Mycoplasma pneumoniae?
Mycoplasma pneumoniae.

Question: What three X-ray findings are associated with a poor outcome in patients with pneumonia?
Multilobar involvement, a cavitary lesion, and pleural effusions.

Question: What is the most common cause of pneumonia in children?
Viral pneumonia. Infecting viruses include influenza, parainfluenza, RSV, and adenoviruses.

Question: Match the pneumonia with the treatment:

(1) c, (2) b, (3) d, (4) c, and (5) a.

Question: Empyema is most often caused by what organism?
Staphylococcus aureus, and in most cases methicillin-resistant S. aureus (MRSA). Gram-negative organisms and anaerobic bacteria may also cause empyema.

Question: What is the chest X-ray finding that suggests a right middle lobe pneumonia?
Loss of the right heart border.

Question: What is the chest X-ray finding of a patient with a left upper lobe consolidation?
Infiltrate seen on the AP to the lower lung field without obstruction of the diaphragm, with confirmation on the lateral film.

Question: What are the most common causes of staphylococcal pneumonias?
Drug use and endocarditis. This pneumonia produces high fever, chills, and a purulent productive cough.

Question: What are the extrapulmonary manifestations of mycoplasma?
Erythema multiforme, pericarditis, and CNS disease.

Question: What is the most frequent etiology of nosocomial pneumonia?
Pseudomonas aeruginosa. There is a high mortality associated with pneumonia caused by Pseudomonas. It most frequently occurs in immunocompromised patients or patients on mechanical ventilation.

A 67-year-old alcoholic man was found in an alley, covered in his own vomit and beer. Upon examination, he is shaking, has a fever of 103.5°F and is coughing up currant jelly sputum. What is the diagnosis?
Pneumonia induced by Klebsiella pneumoniae. This is the most probable etiology in alcoholics, the elderly, the very young, and the immunocompromised patients. Other gram-negative bacteria, such as E. coli and other Enterobacteriaceae, may cause pneumonia in alcoholic patients who have aspirated.

Question: Describe the classic chest X-ray finding associated with Legionella pneumonia:
Dense consolidation and bulging fissures. Expect elevated liver enzymes and hypophosphatemia. The patient with Legionella pneumonia classically presents with a relative bradycardia.

Question: A 43-year-old man presents with pleurisy, sudden onset of fever and chills, and rust-colored sputum. What is the probable diagnosis?
Pneumococcal pneumonia caused by Streptococcus pneumoniae; it is the most common community-acquired pneumonia. It is a consolidating lobar pneumonia and can be treated with penicillin G or erythromycin.

Question: A 20-year-old college student is home for winter break and presents complaining of a 10-day history of a nonproductive dry hacking cough, malaise, a mild fever, and no chills. What is a probable diagnosis?
Mycoplasma pneumoniae, also known as walking pneumonia. Although this is the most common pneumonia that develops in teenagers and young adults, it is an atypical pneumonia and most frequently occurs in close contact populations, i.e., schools and military barracks.

Question: A 56-year-old smoker with COPD presents with chills, fever, green sputum, and extreme shortness of breath. An X-ray shows a right lower lobe pneumonia. What is expected from the sputum culture?
Haemophilus influenza. This organism is generally found in pneumonia and bronchitis patients with underlying COPD. The next most common organism detected in this patient population is Moraxella catarrhalis.
Ampicillin/clavulanate (Augmentin) is the drug of choice, but patients at high risk should have yearly influenza vaccinations.

Question: If a patient has a patchy infiltrate on a chest X-ray and bullous myringitis, what antibiotic should be prescribed?
Erythromycin for mycoplasma.

Question: In what season does Legionella pneumonia most commonly occur?
Summer. Legionella pneumophila thrives in environments such as the water-cooling towers that are used in large buildings and hotels. Staphylococcal pneumonias also occur more frequently in summer.

Question: An older patient with GI symptoms, hyponatremia, and a relative bradycardia probably has which type of pneumonia?
Legionella.

Question: What is the most common cause of pneumonia in sickle cell disease?
Streptococcus pneumoniae.

Which type of pneumonia is often associated with cold agglutinins?
Mycoplasma pneumoniae.

Question: Name four antibiotics known to have in vitro activity against anaerobic bacteria in virtually all cases:

1. Metronidazole

2. Chloramphenicol

3. Imipenem

4. Beta-lactam/beta-lactamase inhibitors

Question: What is the drug of choice for pneumonias acquired in the outpatient setting due to anaerobic bacteria?
Clindamycin.

Question: What is the recommended duration of antibiotic therapy for necrotizing anaerobic pneumonia, lung abscess, or empyema?
4 to 8 weeks.

Question: What anaerobic respiratory infection is associated with slowly enlarging pulmonary infiltrates, pleural effusions, rib destruction, and fistula formation?
Actinomycosis.

Question: What proportion of the patients with pneumonia develop pleural effusions?
40%.

Question: What is the definition of nosocomial pneumonia?
Pneumonia occurring in patients who have been hospitalized for at least 72 hours.

Question: What are the two most important routes of transmission of nosocomial bacterial pneumonia?
Person-to-person transmission via health care workers and contaminated ventilator tubing.

Question: Describe the chest X-ray image of mycoplasma pneumonia:
Patchy densities involving the entire lobe. Pneumatoceles, cavities, abscesses, and pleural effusions can occur but are uncommon. Treat with erythromycin.

Question: Which type of bacterial pneumonia commonly occurs secondary to viral illness?
Staphylococcal infection.

Question: What two types of pneumonia are often contracted during the summer months?
Staphylococcal and Legionella pneumonia.

Describe the chest X-ray image of Legionella pneumonia:
Dense consolidation and bulging fissures. Expect elevated liver enzymes and hypophosphatemia. Relative bradycardia is evident upon physical examination.

Question: What are the potential, often rare, complications of Mycoplasma pneumonia?
- Nonpulmonary: Hemolytic anemia, aseptic meningitis, encephalitis, Guillain-Barré syndrome, pericarditis, and myocarditis.
- Pulmonary: ARDS, atelectasis, mediastinal adenopathy, pneumothorax, pleural effusion, and abscess.

Question: Describe a patient with chlamydial pneumonia:
Chlamydial pneumonia is usually seen in infants 2 to 6 weeks of age. The patient is afebrile and does not appear toxic.

Question: In which type of patients is staphylococcal pneumonia likely?
Patients who are hospitalized, debilitated, or abusing drugs.

Question: What pathogen is suggested by pneumonia with a single rigor?
Pneumococcus.

Question: Where is the most common site of aspiration pneumonitis?
Right lower lobe.

Question: A patient with currant jelly sputum is likely to have which type of pneumonia?
Klebsiella or type 3 pneumococcus.

Question: Under what conditions should staphylococcal pneumonia be considered as a possible diagnosis?
Although staphylococcal pneumonia accounts for only 1% of bacterial pneumonias, it should be considered in patients with sudden chills, hectic fever, pleurisy, and cough (especially following a viral illness, such as measles or influenza).

Question: Where does aspiration generally occur as revealed by chest X-ray?
The lower lobe of the right lung. This is the most direct path for foreign bodies into the lung.

Question: Describe the classic chest X-ray findings in a patient with mycoplasma pneumonia:
Patchy diffuse densities involving the entire lung. Pneumatoceles, cavities, abscesses, and pleural effusions can occur but are uncommon. Treat the patient with erythromycin.

Question: What three findings should be present to consider a sputum sample adequate?

1. >25 PMNs

2. <10 squamous epithelial cells per low-powered field

3. A predominant bacterial organism

What degree of leukocytosis is considered a risk factor for poor outcome among patients with bacterial pneumonia?
Greater than 30,000 cells/mm3.

Question: At what age should the pneumococcal vaccine be administered to healthy adults with no comorbid conditions?
Age 65 or older.

Question: A patient has a staccato cough and a history of conjunctivitis in the first few weeks after birth. What type of pneumonia would this patient have?
Chlamydial pneumonia.

Question: What are the two most common ventilator associated pneumonia?
Pseudomonas aeruginosa and MRSA.

Question: What percentage of people in the Ohio and the Mississippi valleys are infected with histoplasmosis?
100% in endemic areas. However, only 1% of these individuals develop the active disease. The spores of H. capsulatum can remain active for 10 years. For unknown reasons, bird and bat feces promote the growth of the actual fungus. The disease is transmitted when the spores are released and inhaled.

Question: How is the diagnosis of histoplasmosis made?
By bronchoalveolar lavage or by tissue biopsy and blood cultures.

Question: What does the chest X-ray of a patient with histoplasmosis look like?
Interstitial pneumonitis, patchy alveolar infiltrates, and mediastinal adenopathy may be present.

Question: What is the treatment of choice for a histoplasmosis pneumonia?
Itraconazole for 6 to 12 weeks duration.

Question: Where in the United States is coccidioidomycosis most prevalent?
The southwest. If severe, treat the afflicted patient with amphotericin B.

Question: A 46-year-old man with a history of HIV has been diagnosed with coccidioidomycosis pneumonia. His examination and vital signs are stable. What is the initial treatment plan for this patient?
Most of these immunocompromised patients do not require specific therapy. Close follow-up and monitoring of symptoms are enough to ensure that the illness is resolving.

Question: Which type of fungal pneumonia seen in immunocompromised patients, is highly invasive into the lung parenchyma?
Aspergillosis.

What is characteristic of the chest X-ray of aspergillosis pneumonia?
Usually a bilateral upper lobe infiltrate. In some cases, a fungal ball with a cavitary lesion can be seen on CT scan.

Question: What is the primary treatment for aspergillosis pneumonia?
Itraconazole.

Question: What is the best method for detecting adenovirus pneumonia?
Detectiing
adenovirus pneumonia is difficult because it appears quite similar to CAP; but if suspected, the PCR from respiratory secretions, blood, urine, and solid tissues is used.

Question: What is the mortality rate of adenovirus pneumonia?
Around 30%, and up to 50% in immunocompromised patients.

Question: How does a human get infected and develop pneumonia by the hantavirus?
This is by rodent-to-human contact or by cleaning up after a rodent. The virus enters via the respiratory epithelium.

Question: Hantavirus occurs most commonly in what geographic location?
Southwestern United States, especially in areas with deer mice.

Question: Name the antiviral medications that are used for viral pneumonia:
Amantadine and Flumadine for influenza A, and ribavirin for RSV, adenovirus, and hantavirus pneumonia. Oseltamivir and Zanamivir can both be used for influenza A and B pneumonia.

Question: A 67-year-old female patient presents with a 4-day history of fevers, malaise, cough, and a generalized vesicular rash that started on the scalp and then spread to arms and legs. The cough and respiratory symptoms have been correlating to the rash on the legs in timing. The chest X-ray reveals patchy diffuse infiltrates and there is also a small right pleural effusion. What is the etiology of this illness?
Varicella pneumonia. This type of pneumonia can also be at risk for immunocompromised, pregnant, and postpartum patients.

Question: What is the treatment for varicella pneumonia?
Acyclovir for 7 to 10 days.

Question: What secondary bacterial infection often occurs following a viral pneumonia?
Staphylococcal pneumonia.

Question: What is the pathogen that is responsible for HIV-/AIDS-related pneumonia?
Pneumocystis jirovecii.

What is the difference between PCP pneumonia and P. jirovecii pneumonia?
PCP is transmitted through animal contact and does not transmit to humans. P. jeroveci is the human form.

Question: Name five HIV-related pulmonary infections:
PCP, TB, histoplasmosis, Cryptococcus, and CMV.

Question: Describe the chest X-ray of a patient with PCP:
A reticular or miliary pattern ranging from fine to course, ill-defined patchy areas, segmental and subsegmental consolidation; 5% to 10% of PCP pneumonias will have a normal chest X-ray.

Question: What laboratory tests aid in the diagnosis of PCP?
A rising LDH or a LDH > 450 and an ESR > 50. A low albumin implies a poor prognosis.

Question: The initial therapy for PCP includes what antibiotic?
Trimethoprim-sulfamethorazole (Bactrim).

Question: What other medication should be prescribed to a patient with PCP?
Corticosteroids when the Po2 is <70 mm Hg or an oxygen saturation of <90%.

Question: What two drugs are used as prophylactic treatment to prevent PCP in HIV patients?
Aerosolized pentamidine (Pentam) or trimethoprim/sulfamethoxazole (Bactrim).

Question: What is the most common cause of community-acquired bacterial pneumonia among patients infected with HIV?
Streptococcus pneumoniae.

Question: What is the recurrence rate of PCP for those patients who do not receive prophylaxis?
30%.

Question: What is the typical time of year that RSV has an outbreak?
During late winter and early spring.

Question: What are the usual cases that present with an RSV infection?
Pneumonia, tracheobronchitis, and bronchiolitis.

Question: What are some of the common presenting symptoms of RSV?
Fever (low grade), tachypnea, and wheezing are all signs. Apnea is a common symptom. In children, RSV can also cause acute and recurrent otitis media.

What is the treatment of an RSV illness?
Supportive care, which includes hydration, humidified air, and fever reduction with acetaminophen. In very serious cases, ribavirin can be used.

Question: What are the classic signs and symptoms of TB?
Night sweats, fever, weight loss, malaise, cough, and greenish yellow sputum most commonly observed in the mornings.

Question: What are the three stages of TB infections?
Primary, active, and latent.

Question: What is the most common complaint of individuals with TB?
Cough.

Question: What is the main transmission of TB to humans?
Airborne spread through respiratory droplets that are infected with tuberculosis.

Question: Which population is at greatest risk for tuberculosis?
Patients who have had recent infections, fibrotic lesions, and comorbidities such as HIV, silicosis, chronic renal failure, diabetes, IV drug use, immunosuppressive therapy, and gastrectomy, as well as posttransplantation patients.

Question: What age group is most affected by the tuberculosis mycobacterium? And what gender?
Age group: 25 to 34 years; women more than men. As the age becomes older, the gender changes to men. The reasons are unknown.

Question: What do chest X-rays reveal in cases of tuberculosis?
Cavitation of the right upper lobe. Lower lung infiltrates, hilar adenopathy, atelectasis, and pleural effusion are also common.

Question: What is a Gohn lesion?
It is a spontaneously healed TB lesion and presents on chest X-ray as a small calcified lesion.

Question: What is the range of time that results in an immune response to occur?
2 to 10 weeks.

Question: A positive TB test is which type of reaction?
Type 4. Cells are mediated, hypersensitivity is delayed, and neither complements nor antibodies are involved.

Question: What laboratory test is used to detect TB microscopically?
Acid-fast bacillus smear.

What is the best method to yield a positive TB samples?
Needle biopsy, pleural fluid analysis, and needle biopsy of the pleura together gives a 90% diagnosis rate. Individually, each test alone produces a much lower yield.

Question: Right upper lobe cavitation with parenchymal involvement is a classic indicator for what?
TB. Lower lung infiltrates, hilar adenopathy, atelectasis, and pleural effusion are also common.

Question: Does latent TB transmit to other humans?
No, and the disease is not active.

Question: Name the first-line treatment drugs for TB in patients who are HIV negative:
Isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months daily. After the initial 2-month regimen, INH and rifampin can be continued for 4 months.

Question: What is the treatment for HIV-positive patients with TB?
Similar to the non–HIV class with exception to adding an additional 6 months of treatment for a total of 12 months duration. Resistance to isoniazid will cause a longer treatment plan with the other primary medications.

Question: What are the side effects of INH?
Neuropathy, pyridoxine loss, lupus-like syndrome, anion-gap acidosis, and hepatitis.

Question: What percentage of tuberculosis cases are drug resistant?
About 15%. The rate is highly dependent upon geographic location.

Question: Name some common extrapulmonary TB sites:
The lymph nodes, bone, GI tract, GU tract, meninges, liver, and the pericardium.

Question: True/False: Patients younger than 35 years of age with positive TB skin tests should undergo at least 6 months of isoniazid chemoprophylaxis:
True.

Question: What are the typical roentgenographic features of a tuberculous pleural effusion?
They are usually unilateral, small to moderate, and more commonly on the right side. Two-thirds of these can be associated with coexisting parenchymal disease (which may not be apparent on chest radiograph). They are commonly associated with primary disease. The incidence of loculations may be up to 30%.

Question: Is the tuberculin skin test a reliable test for active TB?
No. It has a low sensitivity and specificity to detect active or latent disease.

Question: In which patients should you reserve caution in prescribing INH, rifampin?
Patients with renal failure.

What is the relapse rate for TB?
It is less than 5%; the main cause for this is noncompliance.

Question: Hoarseness can herald far greater problems than viral laryngitis. At what point is a more thorough work-up indicated?
If hoarseness persists for over 6 to 8 weeks or is accompanied by a mass, chest pain, weight loss, aspiration dyspnea, or any other signs of malignancy. Be suspicious of smokers with chronic cough or hoarseness if there is a change in either.

Question: What percent of upper respiratory infectious agents are nonbacterial?
Nonbacterial agents account for more than 90% of pharyngitis, laryngitis, tracheal bronchitis, and bronchitis.

Question: In treating a patient with a common cold, you prescribe an oral decongestant. Is it necessary to also suggest an antitussant?
No. Most coughs, arising from a common cold, are caused by the irritation of the tracheobronchial receptors in the posterior pharynx as a result of postnasal drip. Postnasal drip can be relieved with decongestant therapy, thus eliminating the need for cough suppressant therapy.

Question: What are the most common etiologies of a chronic cough?
Postnasal drip (40%), asthma (25%), and gastroesophageal reflux (20%). Other etiologies include bronchitis, bronchiectasis, bronchogenic carcinoma, esophageal diverticula, sarcoidosis, viruses, and drugs.

Question: What age group is afflicted with the most colds per year?
Kindergartners win the top billing with an average of 12 colds/year. Second place goes to preschoolers with 6 to 10 colds/year. School children contract an average of 7 colds/year. Adolescents and adults average only 2 to 4 colds/year.

Question: What is the duration of a common cold?
3 to 10 days (self-limited).

Question: What antibiotic is the most effective for treating uncomplicated lung abscesses?
Clindamycin.

Question: True/False: Flora of lung abscesses are usually polymicrobial:
True.

Question: Which gram-negative aerobes are known to cause lung abscess?
Pseudomonas and Klebsiella.

Question: What are the two major risk factors for the development of anaerobic lung infection?
Periodontal disease and predisposition to aspiration.

Empyema in the absence of parenchymal lung infiltrate suggests what underlying process?
Subphrenic or other intra-abdominal abscess.

Question: What are the two most important risk factors for the development of anaerobic lung abscess?
Poor oral hygiene and a predisposition toward aspiration.

Question: What organisms are most commonly present in a pulmonary abscess?
Mixed anaerobes.

Question: Which general group of bacteria is most commonly found in lung abscesses?
Anaerobic bacteria.

Question: How do retropharyngeal abscesses arise?
Lymphatic spread of infections in the nasopharynx, oropharynx, or external auditory canal.


NEOPLASTIC DISEASE

Question: What is the most common cancer in the United States?
Lung cancer, which accounts for 29% of all cancer deaths.

Question: What is the average age range for a patient with lung cancer?
55 to 65 years.

Question: What are some of the symptoms that are present in patients with lung cancer?
Cough, hemoptysis, wheeze and stridor, dyspnea, and postobstructive pneumonitis (fever and productive cough) are a few complaints.

Question: Which form of lung cancer is the most common?
Adenocarcinoma followed by squamous cell, then small cell (oat cell) carcinoma.

Question: What percentage of effusions are associated with malignancy?
25%.

Question: What routine program is recommended for screening lung cancer in the adult population?
None. Screening programs for lung cancer have not demonstrated a decrease in morbidity or mortality. Practitioners must be aware of the signs and symptoms associated with lung cancer, including chronic nonproductive cough, increased sputum production, hemoptysis, dyspnea, recurrent pneumonia, hoarseness, pleurisy, weight loss, shoulder pain, SVC syndrome, exercise fatigue, and anemia. Incidental findings on a chest X-ray should also be investigated.

Where do the following cancers most commonly develop within the lung: adenocarcinoma and large cell carcinomas and squamous and small cell carcinomas?
Adenocarcinoma and large cell carcinomas are usually located peripherally, while squamous and small cell carcinomas are located centrally. These four malignancies account for 88% of all lung cancers.

Question: What type of lung cancer is commonly associated with hypercalcemia?
Squamous cell carcinoma. The production of parathormone-related peptide can produce hypercalcemia even without bony metastases.

Question: What type of lung tumors can cause excessive ACTH production and Cushing syndrome?
Small cell carcinoma and carcinoid tumors.

Question: Second-hand cigarette smoke exposure is a risk factor for the development of what two major lung diseases?
Lung cancer and COPD.

Question: The incidence of lung cancer is increasing in the USA among members of which gender?
Women.

Question: What percentage of lung cancers are a result of smoking, either active or former smokers?
85%.

Question: What is the relative risk for first-degree family members getting lung cancer?
Two- to three-fold risk.

Question: What accounts for this increase?
Increased cigarette smoking prevalence.

Question: Which vitamin has been associated with a protective effect against the development of lung cancer?
Vitamin A.

Question: Bilateral periostitis, typically affecting the long bones and associated with lung cancer, is known as what other disease?
Hypertrophic osteoarthropathy (HPO).

Question: What myopathic syndrome is associated with lung cancer?
Eaton-Lambert syndrome.

Question: What is the initial diagnostic test in a clinically stable patient suspected of having lung cancer?
Sputum cytologic examination.

Question: What is the 5-year survival of all patients diagnosed with primary lung cancer?
˜15%.

Which primary lung cancer is most likely to cavitate?
Squamous cell carcinoma.

Question: Which lung cancer is the most prevalent in nonsmoking women?
Adenocarcinoma.

Question: What percentages of patients that have lung cancer are asymptomatic?
5% to 15%.

Question: The increase in death rate from lung cancer among smokers, as opposed to nonsmokers, is how high?
8- to 20-fold.

Question: Do low tar cigarettes decrease the risk of lung cancer?
No.

Question: The risk of lung cancer following smoking cessation approaches that of lifelong nonsmokers after how many years?
15.

Question: The incidence of lung cancer among urban residents is how many times higher than among rural residents?
About 1.5 times higher among urban residents.

Question: The most common malignancy associated with asbestos exposure is which of the following: esophageal carcinoma, primary lung cancer, mesothelioma, or gastric carcinoma?
Primary lung cancer.

Question: What is the incidence of pleural effusion associated with malignancy?
Malignant pleural effusions are the second most common exudative effusions after parapneumonic effusions. The most common malignancies are lung and breast cancer.

Question: What are the conditions associated with malignant transudative effusions?
Lymphatic obstruction, endobronchial obstruction, and hypoalbuminemia due to the primary malignancy.

Question: What type of effusions are suggestive of malignancy?
Massive effusions, large effusions without contralateral mediastinal shift, or bilateral effusions with normal heart size suggest malignancy.

Question: What percentage of lung cancer is related to smoking?
80%.

What other exposures are also factors contributing to the development of bronchogenic carcinoma?
Radon, uranium, nickel, arsenic, bis (chloromethyl) ether, ionizing radiation, vinyl chloride, mustard gas, polycyclic aromatic hydrocarbons, and chromium.

Question: What is the major indication for laser bronchoscopy in the treatment of bronchogenic carcinoma?
Tumor obstruction of large airways.

Question: What is Pancoast syndrome?
Tumor of the apex of the lung that gives rise to Horner syndrome and shoulder pain. The tumor invades the bronchial plexus.

Question: Which primary lung cancer is most frequently associated with paraneoplastic syndromes?
Small cell undifferentiated carcinoma.

Question: What finding indicates emergent radiation therapy for superior vena cava syndrome?
Cerebral edema.

Question: The best 5-year survival for non–small cell carcinoma of the lung is achieved by what therapy modality?
Surgical resection.

Question: Are carcinoid tumors related to smoking?
No.

Question: What are the clinical features of carcinoid syndrome?
Flushing and diarrhea is the most common. Other symptoms include salivation, lacrimation, diaphoresis, diarrhea, and hypotension.

Question: What is the treatment for a nonmetastatic carcinoid tumor?
Surgery is the only option and may improve the symptoms.

Question: What cancers generally metastasize to the lungs?
Breast, colon, prostate, and cervical cancers.

Question: What is the description of a solitary pulmonary nodule?
It is defined as a density that is sharply marginated and surrounded by lung tissue that ranges in size on average of 1 to 6 cm in size.

Question: What percentage of pulmonary nodules is malignant?
35%.

Radiographic stability for what period is assumed to indicate benign origin of a solitary pulmonary nodule?
2 years.

Question: A 27-year-old female nonsmoker is found to have a 2-cm nodule found on a chest X-ray during a preop screening film. The patient is asymptomatic and is otherwise healthy. What is the standard of care in monitoring this nodule?
For patients younger than 35 years of age, 3-month serial CT scans of the chest for 1 year are required. If the patient is older than 35 years of age and is a smoker, an immediate evaluation of the tissue is required.

Question: A solitary pulmonary nodule in an HIV-infected patient may represent which of the following: PCP, histoplasmosis, cryptococcosis, or bronchogenic carcinoma?
All of the above.


OBSTRUCTIVE PULMONARY DISEASE

Question: What is the peak age of asthma?
3 years of age.

Question: What is the gender ratio of asthmatic patients in childhood and adults?
There is a 2:1 male-to-female ratio in childhood, but evens in numbers in adult populations.

Question: What are some categories of risk factors for those with asthma and what are some of those factors?
There are three categories:
- Endogenous: Gender, atopy, hyperresponsiveness, and genetic predisposition.
- Triggers: Allergens, URI viral infections, exercise, cold air, β-blockers, aspirin, stress, and irritants.
- Environmental: Indoor/outdoor allergens, occupational, passive smoking, and respiratory infections.

Question: What blood cell is known to cause the initial inflammatory changes that result in asthma?
Mast cells.

Question: Which blood cell is proliferated during an allergen response?
Eosinophils.

Question: What extrinsic allergens most commonly affect asthmatic children?
Dust and dust mites.

Question: What are the common symptoms that present in asthma?
Cough, shortness of breath, pain between the scapula, itching under the chin (sometimes), and a nonproductive cough especially in children (aka variant asthma cough).

What is the “best” pulmonary function test for the diagnosis of asthma?
FEV1/FVC. This test determines the amount of air exhaled in 1 minute compared to the total amount of air in the lung that can be expressed. A ratio under 80% is diagnostic of asthma. Peak flow monitors are helpful in monitoring asthma at home or during an acute exacerbation.

Question: Is wheezing an integral part of asthma?
No; 33% of children with asthma will only have cough variant asthma with no wheezing.

Question: What X-ray markings may be observed in a patient with a long history of bronchial asthma?
Increased bronchial wall markings and flattening of the diaphragm. The bronchial wall markings are caused by epithelial inflammation and thickening of the bronchial walls.

Question: Patients with exercise-induced asthma will most likely trigger their asthma with what kind of exercise?
High intensity exercise for more than 5 to 6 minutes.

Question: What is the first-line treatment for asthma?
Use of β2-agonist bronchodilators, specifically albuterol in either metered dose inhaler (MDI) or nebulized.

Question: Are anticholinergics medications (i.e., ipratropium bromide) alone effective for the treatment of asthma?
No. They are effective only with use of albuterol as the first-line treatment and if the first-line treatment is not effective on its own.

Question: What is the clinical indication for the use of theophylline?
It is indicated for use in patients with severe asthma who require additional bronchodilators.

Question: What are some of the common side effects of theophylline?
Nausea, vomiting, and headaches.

Question: What is the most effective medication for reduction of inflammation in the treatment of asthma?
Inhalable corticosteroids.

Question: Is there a need to administer a tapering dose of steroids?
No. In cases of steroid regimens of 5 to 10 days duration, a tapering dose is not needed.

Question: Is the sole use of antileukotrienes effective for the suppression of asthma symptoms?
No, they are useful in conjunction with inhalable corticosteroids but are not effective as a stand-alone treatment.

Question: At what point do you need to consider adding more therapy above the normal albuterol regimen so as to control asthma? What is the treatment of choice when you must administer an additional medication?
When rescue inhaler is used three or more times in a week, and inclusion of inhalable corticosteroids will be the next medication added to the regimen.

Which is more effective for relieving an acute exacerbation of bronchial asthma in a conscious patient: nebulized albuterol or albuterol MDI administered via an aerosol chamber?
They are both equally effective.

Question: What are the positive effects of administering β
-agonists in the treatment of asthma?
Relaxation of smooth muscle, inhibition of mast cells, inhibition of airway edema, increase in mucociliary clearance, increase mucus production, and decrease in cough.

Question: What are the chances that a child born to two asthmatic parents will also have asthma?
Up to 50%.

Question: Are there any contraindications to administering a topical β2-blocker for glaucoma (i.e., timolol) to a patient with asthma?
Yes, there is evidence that even a topical β-blocking agent may exacerbate asthma symptoms.

Question: What treatment should be initiated for an acute asthmatic patient who does not improve with humidified O2, albuterol nebulizers, steroids, or anticholinergics?
Subcutaneous epinephrine, 0.3 cm3 administered every 5 minutes.

Question: Asthmatic patients will most likely have a family history of what?
Asthma, allergies, or atopic dermatitis.

Question: What are the recommended therapeutic serum theophylline levels?
10 to 15 mg/L.

Question: What medications should be avoided for an asthmatic patient who is pregnant?
Epinephrine and parenteral β-adrenergic agonists.

Question: A 23-year-old woman who has a history of asthma is 29 weeks pregnant. She is having an asthma attack and is receiving treatment in the emergency room with an albuterol nebulizer. Given this scenario, is this patient a candidate for oral or parenteral steroids?
Yes. If steroids are indicated for this condition, then one should not hold back from giving them.

Question: What is a normal peak expiratory flow rate in adults?
Men: 550 to 600 L/minute. Women: 450 to 500 L/minute. However, this varies somewhat with body size and age.

Question: Which β
-adrenergic receptors primarily control bronchiolar and arterial smooth muscle tone?
β-2-adrenergic receptors.

Question: Terbutaline is administered subcutaneously for asthma in what dose?
0.01 mL/kg of 1 mg/mL terbutaline up to 0.25 mL, i.e., 0.25 mg, which may be repeated once in 20 to 30 minutes.

Is theophylline useful in the emergency management of a severely asthmatic pediatric patient?
No. It has not been shown to affect further bronchodilatation in patients fully treated with β-adrenergic agents. However, theophylline can be used successfully for inpatient management of asthma and may be started in the hospital.

Question: If corticosteroids are prescribed for acute asthma exacerbation, how should prednisone be dosed?
1 to 2 mg/kg/day in two divided doses. Tapering is not necessary if the duration of therapy is 5 days or less.

Question: What is the appropriate parenteral dose of methylprednisolone (Solu-Medrol) to administer to a pediatric patient with status asthmaticus?
1 to 2 mg/kg every 6 hours.

Question: Can beta-adrenergic agonists result in tolerance?
Yes. Repeated administration of beta agonist bronchodilators can result in hyposensitization of the receptors, but this should not preclude their use. Glucocorticoids have been shown to restore the depressed receptor responsiveness.

Question: True/False: Cardioselective beta-blockers avoid precipitation of bronchospasm in asthmatic individuals:
False.

Question: What is the therapeutic drug of choice for beta-blocker–induced bronchospasm?
Inhalable ipratropium bromide. If severe, parenteral glucagon can reverse effects.

Question: How do steroids function in the treatment of asthma?
Steroids increase cAMP, decrease inflammation, and aid in restoring the function of β-adrenergic responsiveness to adrenergic drugs.

Question: What is the most common cause of refractory asthma?
Medical noncompliance.

Question: What is bronchiectasis?
Bronchiectasis is an abnormal dilatation of the proximal medium-sized bronchi greater than 2 mm in diameter. It occurs due to the destruction of the muscular and elastic components of their walls and is usually associated with chronic bacterial infection and foul smelling sputum.

Question: Which gender is more affected by bronchiectasis?
Women.

Question: What are the symptoms of bronchiectasis?
Chronic cough, purulent sputum, fever, weakness, weight loss, dyspnea in some patients, and hemoptysis. Hemoptysis is generally mild, originates from bronchial arteries, and is seen in 50% to 70% of all cases.

What are the main causative agents of bronchiectasis?
Adenovirus and influenza.

Question: What are the most common complications of bronchiectasis?
Recurrent attacks of pneumonia, empyema, pneumothorax, and lung abscess.

Question: A chest X-ray shows honeycombing, atelectasis, and increased bronchial markings. What is the diagnosis?
Bronchiectasis, an irreversible dilation of the bronchi that is generally associated with infection. Bronchography shows dilations of the bronchial tree, but this method of diagnosis is not recommended for routine use.

Question: Bronchiectasis occurs most frequently in patients with what conditions?
Cystic fibrosis, immunodeficiencies, lung infections, or foreign body aspirations.

Question: Which lung segments are most frequently involved in bronchiectasis?
Posterior basal segments of the left or right lower lobes.

Question: What are the most common causes of upper lobe bronchiectasis?
Tuberculous endobronchitis and allergic bronchopulmonary aspergillosis (ABPA).

Question: What is the mainstay of treatment of bronchiectasis?
Antibiotics.

Question: What are the adjunctive treatment measures that may be beneficial in patients with bronchiectasis?
Chest physiotherapy, nutritional support, inhalable indomethacin (shown to decrease bronchial hypersecretion by inhibiting neutrophil recruitment), bronchodilators, supplemental oxygen, immunoglobulin administration for immunoglobulin deficiency, replacement treatment for patients with alpha-1-anti-trypsin deficiency, and recombinant DNAase to reduce sputum viscosity in patients with cystic fibrosis (CF).

Question: What is the definition of chronic bronchitis?
A productive cough for 3 months out of each year for 2 years straight.

Question: What is the definition of emphysema?
Emphysema is a pathologic diagnosis of the destruction of terminal bronchioles with air trapping and enlargement of the air spaces. Coupled with chronic bronchitis, these two diseases make up COPD.

Question: What is the hallmark symptom of COPD?
Exertional dyspnea.

Question: What is a “blue bloater”?
An overweight patient with COPD, bronchitis, and central cyanosis. These individuals have normal lung capacity and are hypoxic.

What is a “pink puffer”?
A patient with COPD and emphysema. These patients are generally thin and noncyanotic. They have an increased total lung capacity and a decreased FEV1.

Question: What percentage of all COPD patients have either smoked or had a significant exposure to cigarette smoke?
80%.

Question: Other than smoking, what are the risk factors for COPD?
Environmental pollutants, recurrent URIs (especially in infancy), eosinophilia or increased serum IgE, bronchial hyperresponsiveness, a family history of COPD, and protease deficiencies.

Question: Is there any hope for patients with COPD who quit smoking?
Yes. Symptomatically speaking, coughing stops in up to 80% of these patients, and 54% of COPD patients find relief from coughing within a month of quitting.

Question: If a patient with chronic bronchitis suffers an acute exacerbation of illness, such as dyspnea, cough, or purulent sputum, what type of O2 therapy should be initiated?
In the case of acute exacerbation of bronchitis, oxygen therapy should be guided by Po2 levels. Adequate oxygen must be maintained at a Po2 above 60 mm Hg. This should be accomplished with the minimal amount of oxygen necessary. The Po2 must be kept above 60 mm Hg even if the patient loses the drive to breathe.

Question: What are the more common pathogens that are found in the sputum of COPD patients?
Streptococcus pneumoniae, H. influenzae, or Moraxella catarrhalis.

Question: Are there any changes to the EKG if the patient has COPD?
Yes, there can be several. Sinus tachycardia can be seen as well as RVH and LVH. Supraventricular arrhythmias (MAT, A-fib/flutter) as well as ventricular irritability can also be present.

Question: Which pulmonary function test shows an increase in COPD?
Residual volume. All other tests (FEV1, FEV1/FVC, and FEV25%–75%) indicate decreases and diffusion capacity.

Question: Which part of the lung is affected by emphysema? By chronic bronchitis?
Emphysema: Terminal bronchi
Chronic bronchitis: Large airways

Question: What is the typical appearance of a chest X-ray in a patient with emphysema?
Increased inflation from cephalo to caudal, with flattening of the diaphragm. In some patients, bullae can develop.

Question: What is the risk of placing a patient with COPD on a high FIO2?
Suppression of the hypoxic ventilatory drive.

What are some potential complications related to COPD?
Pneumonia, cor pulmonale, bronchitis, pulmonary thromboembolism, and left-sided heart failure.

Question: What is the single most important therapy for patients with COPD?
Smoking cessation.

Question: What pharmacologic agents are used for the initial treatment of COPD?
Bronchodilators are the mainstay treatment.

Question: Are there any other therapies in addition to bronchodilators?
Yes, corticosteroids (usually inhaled) are a second-line treatment. This is followed by theophylline as a third-line therapy.

Question: Are there any changes to therapy for COPD patients who require admission to the hospital?
Yes, the addition of ipratropium as well as of broad-spectrum antibiotic and oxygen is indicated. Chest PT is also helpful in clearing secretions for those patients who may be developing mucous plugging.

Question: What parameters should make you consider initiating “home oxygen” therapy for a patient with COPD?
If the patient has a resting Po2 less than 55 mm Hg, or if the patient has a Po2 of less than 60 mm Hg with evidence of tissue hypoxia. O2 desaturation with exercise may also require home O2. Home O2 therapy, 18 h/day, may increase the life span of a patient with COPD by 6 to 7 years.

Question: What nonpharmacologic therapies are indicated for the treatment of COPD?
Aside from smoking cessation, respiratory therapy to increase the clearing of secretions is helpful. Aerobic exercise is also helpful to increase exercise capacity.

Question: What are some late-stage diseases that are caused by COPD?
Cor pulmonale, pulmonary hypertension, pneumonia, and chronic respiratory failure.

Question: What is the most common lethal, inheritable disease among the Caucasian population?
Cystic fibrosis, an autosomal recessive disease that occurs in 1 in 3200 births, and 1 in 25 is a carrier.

Question: A newborn presents with poor weight gain, steatorrhea, and a GI obstruction arising from thick meconium ileus. What test should be performed?
The sweat test, which detects electrolyte concentrations in the sweat. The infant may have cystic fibrosis, an autosomal recessive defect that affects the exocrine glands, producing higher electrolyte concentrations in the sweat glands.

Question: What condition must be ruled out when childhood nasal polyps are found?
Cystic fibrosis (CF).

What is the classic triad of cystic fibrosis?
- COPD
- Pancreatic enzyme deficiency
- Abnormally high concentration of sweat electrolytes

Question: What are the diagnostic criteria for cystic fibrosis?
Primary Criteria:
- Characteristic pulmonary manifestations and/or
- Characteristic gastrointestinal manifestations and/or
- A family history of CF
Plus
- Sweat Cl (concentration >60 mEq/L) [repeat measurement if sweat Cl is 50–60 mEq/L].
Secondary Criteria:
- Documentation of dual CFTR mutations and
- Evidence of one or more characteristic manifestations

Question: What are the immunological defects in cystic fibrosis?
Patients with have low levels of serum IgG in the first decade of life, which increase dramatically once chronic infection is established. T-lymphocyte numbers are adequate. With advancing severity of pulmonary disease, lymphocytes proliferate less briskly in response to P. aeruginosa and other gram-negative organisms. Deficient opsonic activity of alveolar macrophages are seen in patients with established P. aeruginosa infection. Major IgG subclass in serum and lungs in CF patients is IgG.

Question: Pathology in cystic fibrosis is confined predominantly to what part of the lung?
The conducting airways.

Question: What is the most common site of nonpulmonary pathology in cystic fibrosis?
The GI tract, with striking changes seen in the exocrine pancreas. Islets of Langerhans are spared.

Question: What are the reproductive abnormalities in cystic fibrosis?
- In men: The vas deferens, tail and body of the epididymis, and the seminal vesicles are either absent or rudimentary.
- In women: Uterine cervical glands are distended. The mucous and cervical canals are plugged with tenacious mucous secretions. Endocervicitis also seen.

Question: What are the most frequent respiratory pathogens in patients with cystic fibrosis?
Staphylococcus aureus and Pseudomonas aeruginosa.

Question: What are the various radiographic manifestations of cystic fibrosis?
Hyperinflation, peribronchial cuffing, mucous impaction in airways seen as branching fingerlike shadows, bronchiectasis, subpleural blebs, (most prominent along the mediastinal border), and prominent pulmonary artery segments with advanced disease.

What is the immediate mortality with massive hemoptysis?
˜10%.

Question: What are the conditions associated with an elevated sweat chloride?
CF, hypothyroidism, pseudohypoaldosteronism, hypoparathyroidism, nephrogenic diabetes insipidus, type I glycogen storage disease, mucopolysaccharidosis, malnutrition, PGE administration, hypogammaglobulinemia, and pancreatitis.

Question: What are some of the more common pulmonary complications of Cystic Fibrosis How do you manage them?


Question: What two vaccinations should be given to all cystic fibrosis patients?
Pneumococcal and influenza vaccines.

Question: What is the only definitive treatment for advanced cystic fibrosis?
Double lung transplant.

Question: What is the life expectancy of a patient with cystic fibrosis?
The median survival age is over 35 years of age.

Question: Prior steroid administration can precipitate adrenal insufficiency under conditions of stress. How long can these effects last?
Up to 1 year.


PLEURAL DISEASES

Question: Differentiate between transudate and exudate:
- Transudate: Systemic factors that influence the formation and shift of fluid into the pleural space.
Pleural: Serum protein <0.5
Pleural: Serum LDH is <0.6
Most common with heart failure from LV dysfunction (most common), renal disease, and liver disease.
- Exudate: Local factors that influence the formation and absorption of fluid into the pleural space.
Pleural: Serum protein >0.5
Pleural: Serum LDH >0.6
Most common with pneumonia, malignancy, pulmonary embolism, and trauma.

Question: What are the clinical features associated with pleural effusion?
A pleural rub (may be the only finding in the early stages), pleuritic chest pain due to involvement and inflammation of parietal pleura, cough (distortion of lung), dyspnea (mechanical inefficiency of respiratory muscles stretched by outward movement of chest wall and downward movement of diaphragm), diminished chest wall movements, dull percussion, decreased tactile and vocal fremitus, decreased breath sounds, and whispering pectoriloquy. With large amounts, there may be contralateral shift of the mediastinum.

Question: Where does pain from pleurisy radiate?
The shoulder, as a result of diaphragmatic irritation.

Question: What is the minimum amount of pleural liquid that can be detected roentgenographically?
Approximately 250 mL in upright views of the chest. A lateral decubitus film taken with the patient lying on the affected side can detect as little as 50 mL of liquid.

Question: What are the indications for the chest tube placement in parapneumonic effusion?
Presence of a complicated parapneumonic effusion, as evidenced by presence of fever, presence of loculations, gross appearance of fluid purulent (pus), increased WBC count and low glucose (usually <40 mg/dL), a decreased pH (less than 7.0 or 0.15 less than the arterial pH), and elevated LDH (>1000 IU/L) are usually considered indications for placement of chest tube for drainage.

Question: What are the characteristic features of a tuberculous pleural effusion?
Pleural fluid is exudative with a protein content >0.5 g/L, >90% to 95% lymphocytes (in the acute phase, there may be a polymorphonuclear response).

Question: What is the treatment of tuberculous pleural effusion?
A 9-month course of isoniazid 300 mg and rifampin 600 mg, daily. A therapeutic thoracentesis is recommended only to relieve dyspnea. Corticosteroids can decrease the duration of fever and the time required for fluid absorption, but do not decrease the amount of pleural thickening at 12 months after treatment is initiated. They are therefore recommended only for patients who are markedly symptomatic and only after institution of appropriate antimicrobial therapy.

What are the common features of pleural effusions associated with congestive heart failure?
Bilateral effusion, more commonly right-sided, associated with cardiomegaly. Fluid is transudate, serous, <1000 mononuclear cells, pH >7.4, and pleural fluid glucose levels same as serum.

Question: What are the radiological features of pleural effusion associated with cirrhosis?
They are small to massive right-sided effusion in 70%, left-sided effusion in 15%, and bilateral effusions in 15% with normal heart size.

Question: What is the mechanism of pleural effusions associated with atelectasis?
Atelectasis leads to decreased perimicrovascular pressure, resulting in a pressure gradient. Fluid moves from the parietal pleural interstitium into the pleural space due to decreased perimicrovascular pressure.

Question: What is the primary mechanism of pleural effusion in nephritic syndrome?
Decreased plasma oncotic pressure due to hypoalbuminemia.

Question: What factors play a role in the pathogenesis of pleural effusions associated with pulmonary embolism?
Effusions are present in 40% to 50% of cases of pulmonary embolism. Increased capillary permeability, due to ischemia and leak of protein rich fluid into pleural space, are the main factors. Atelectasis may contribute to transudate and lung necrosis can lead to hemorrhage.

Question: What are the characteristics of a pleural effusion associated with chronic pancreatitis?
Pleural effusions associated with chronic pancreatitis are usually large or massive unilateral effusions that occur rapidly after thoracentesis. The pleural fluid can have very high amylase content (>200,000 IU/L). Direct fistulous communications from the pancreatic bed are responsible. Failure of conservative treatment is an indication for the surgical intervention, such as drainage (up to 50%).

Question: What are the characteristic features of pleural fluid in patients with lupus?
LE cells in the pleural fluid. A ratio of pleural fluid/serum ANA of >1.0 is suggestive of lupus.

Question: What are some drugs reported to be associated with pleural effusion?
Procainamide, nitrofurantoin, Dantrolene, Methysergide, procarbazine, methotrexate, Amiodarone, mitomycin, and Bleomycin.

Question: What pathological process is suggested by an air–fluid level in the pleural space?
Bronchopleural fistula.

Question: What is the profile of a classic patient with a spontaneous pneumothorax?
Male, athletic, tall, slim, and 15 to 35 years of age.

Question: What is the recurrence rate of spontaneous pneumothoraces?
50%.

What is the main cause for a patient to develop a pneumothorax?
The most common reason is rupture of a bleb.

Question: A 20-year-old male patient presents with pleuritic chest pain with shortness of breath that has worsened over the last 24 hours after he had a violent cough. In general, the patient is healthy and has no medical problems. On examination, he is afebrile, has a pulse of 100, respirations of 22, and blood pressure is 122/83. Head and neck is normal, and the patient has decreased breath sounds on the right with hyperresononant percussion. What is the likely diagnosis?
Primary spontaneous pneumothorax.

Question: Which types of pneumonia are commonly associated with pneumothorax?
Staphylococcal, TB, Klebsiella, and PCP.

Question: What therapy may increase the body’s absorption of a pneumothorax or pneumomediastinum?
A high Fio2.

Question: Do all pneumothoraces need to have a chest tube or surgical intervention?
No. A small pneumothorax that is <25% with mild to minimal symptoms can be observed as an outpatient with serial chest X-rays to observe reinflation.

Question: A 26-year-old man has been diagnosed with a primary spontaneous pneumothorax, which has been treated and now has a reoccurrence. What is the treatment for this patient?
Surgical pleurodesis. This procedure should completely resolve the condition.

Question: What is the definition of a secondary pneumothorax?
It is a pneumothorax that is caused by COPD, typically by an emphysematous bleb. This tends to be more life-threatening due to the underlying lung disease present.

Question: Is therapy for secondary pneumothorax different from a primary pneumothorax?
Yes, the initial treatment is with a chest tube to re-inflate the lung, then surgical intervention with pleurodesis. If required, a blebectomy or stapling is indicated.

Question: What are some of the more common techniques for pleurodesis?
Mechanical abrasion of the chest wall, chemical application with multiple agents (tetracycline, urea, mechlorethamine, iodoform, and hypertonic glucose), or pleural staple ling are used. Talc has been implemented in the past but is a controversial technique. It is still used in some places.

Question: What is the indication for a chest tube in a patient with a pneumothorax?
Over 20% to 25% pneumothorax or a clinical indication, such as respiratory distress or enlarging pneumothorax.

Question: What are the most common reasons for a traumatic pneumothorax?
Insertion of a transthoracic needle, thoracentesis, and central line placement.

What is the most important cause of hypoxia in a patient with flail chest?
Underlying lung contusion.

Question: Signs of tension pneumothorax on a physical examination include:
Tachypnea, unilateral absent breath sounds, tachycardia, pallor, diaphoresis, cyanosis, hyperresonant percussion on affected side, tracheal deviation, hypotension, and neck vein distention.

Question: What is the most significant finding on a chest X-ray in a patient with a tension pneumothorax?
Shift of the mediastinum away from the effected side.

Question: What is the initial treatment for a tension pneumothorax?
Large bore IV catheter placed in the anterior second intercostal space (not a chest tube).

Question: What are the risk factors of pneumothorax?

Pneumothorax (risk factors):
Tumors


PULMONARY CIRCULATION

Question: What does normal ventilation with decreased lung perfusion suggest?
Pulmonary embolus.

Question: What are the most common signs and symptoms of PE?
In order from most to least common: tachypnea, CP, dyspnea, anxiety tachycardia, fever, DVT, hypotension, and syncope.

Question: What percentage of patients with a symptomatic PE will also have a DVT present in the lower extremities?
50% to 70%.

Question: What is the most common type of substance that forms a pulmonary embolus?
A thrombus.

Question: Are there any other substances that can cause the formation of an embolus?
Yes, there are several which include air from a surgery or a central venous line, amniotic fluid, fat embolus, foreign bodies, parasites, septic emboli, and tumor cells.

Name some risk factors that can predispose a patient to a PE:
Venous stasis (immobility, obesity, stroke), injury to the vascular wall (prior embolus, trauma, and orthopedic surgery), and hypercoagulability (Virchow triad).

Question: What is Virchow triad?
- Injury to the endothelium of the vessels
- Hypercoagulable state
- Stasis
These represent risk factors for pulmonary embolus.

Question: Most pulmonary embolisms arise from what veins?
The iliac and femoral veins.

Question: What is the most common hypercoagulability genetic disorder in white patients?
Factor V Leiden, which is a resistance to protein C.

Question: Name some other hypercoagulable states predisposing individuals to thrombosis and pulmonary embolism:
Deficiencies of protein S and antithrombin III, antiphospholipid syndrome, malignancy particularly adenocarcinoma, nephritic syndrome, protein losing enteropathy, extensive burns, paroxysmal nocturnal hemoglobinuria, and oral contraceptives.

Question: What historical findings suggest an embolus as opposed to a thrombosis in a lower extremity?
- Embolus: Associated with a history of arrhythmia, valvular disease, MI, no skin changes from chronic arterial insufficiency, and no symptoms in the opposite extremity.
- Thrombosis: Opposite extremity shows evidence of chronic arterial occlusive disease with history of rest pain, claudication, etc.

Question: What three syndromes are associated with the various degrees of pulmonary embolism?

1. Acute cor pulmonale: Occurs with massive embolism that obstructs over 60% of the pulmonary circulation.

2. Pulmonary infarction: Occurs with embolization to the distal branches of the pulmonary circulation.

3. Acute dyspnea: Milder obstruction not enough to warrant infarction.

Question: What is the equation for the A–a gradient?
A–a = (713 mm Hg × Fio2) – Pco2 –Po2/0.8)
The normal A–a gradient is 5 to 15 mm Hg (though it increases with age). The A–a gradient increases with PE and diffusion defects (i.e., pulmonary edema and right to left cardiac shunts).

Question: Can a patient with a PE have a PO2 greater than 90 mm Hg?
Yes, but rarely (5%).

Question: What are the most common CXR findings in PE?
Pleural effusions, atelectasis, and pulmonary infiltrates.

What are two relatively specific CXR findings in PE?

1. Hampton hump: Area of lung consolidation with a rounded border facing the hilus.

2. Westermark sign: Dilated pulmonary outflow tract proximal to the emboli with decreased perfusion distal to the lesion.
While both of these findings are specific to PE, they are not seen much.

Question: What test is considered the gold standard for the diagnosis of DVT? For the diagnosis of PE?
- DVT: venography.
- PE: pulmonary angiography.

Question: What changes to an EKG are commonly seen in patients with a PE?
Sinus tachycardia is the most common, followed by nonspecific ST-T changes. These will be seen in about 40% of patients.

Question: When treating DVT/PE, when should warfarin therapy be initiated?
On the first or second day after initiation of heparin therapy. Although heparin should be administered immediately, it can be discontinued when the PTT is 1.5 to 1.8 times normal for at least 3 days.

Question: How long should chronic warfarin therapy, as a prophylaxis for DVT, be given?
Warfarin should be administered for at least 3 to 6 months after a DVT to maintain an INR at two to three times the normal.

Question: What is the anticoagulant treatment schedule for a PE?
IV heparin until PTT is 2 to 2.5 times normal. After 1 day of treatment, warfarin is added until the INR is greater than 2.0. If clots recur, consider a Greenfield filter in the IVC. Pulmonary embolectomy is only necessary in cases of massive embolisms. Lovenox may also be used instead of heparin.

Question: What is the risk factor for PE in a patient with an axillary or subclavian vein thrombus?
About 15%.

Question: What test is most sensitive for evaluating a PE?
Ventilation–perfusion scan is the most sensitive test. However, it is not as specific as a pulmonary angiogram; 5% of normal volunteers will have an abnormal scan and virtually any pulmonary pathology will produce an abnormal scan (i.e., pneumonia).

Question: What is the preferred test to detect a PE in a pregnant patient?
V/Q scan. The IV dye load during pregnancy is not ideal. When performing a V/Q scan, make sure to insert a Foley catheter in the bladder to remove the radioactive material from the bladder so that it does not expose the fetus.

Question: What is the major etiology of pulmonary hypertension?
Chronic hypoxia, most commonly from COPD.

What are the major mechanisms that cause pulmonary hypertension to occur?
- Reduction of the cross section of the pulmonary bed, such as in hypoxemia, emphysema, interstitial lung disease, parasitic infections, and sickle cell disease.
- Increase in pulmonary venous pressure as in LV failure, mitral stenosis, restrictive pericarditis, or left atrial myxoma.
- Increase in pulmonary venous flow such as a congenital left to right shunt.
- Increase in blood viscosity (polycythemia).
- Other conditions such as HIV, and HTN related to cirrhosis, and portal hypertension.

Question: What are the common symptoms related to pulmonary hypertension?
Dyspnea, fatigue, chest pain, and syncope on exertion.

Question: Primary pulmonary hypertension is most common in what population?
Young women. PPH is rapidly fatal within a few years.

Question: What heart sounds accompany pulmonary hypertension?
A splitting of the second heart sound and a louder P2.

Question: What could you expect to see on an ECG in a patient with pulmonary HTN?
Right ventricular strain or hypertrophy, and right atrial enlargement.

Question: What is the most effective method in measuring pulmonary venous pressures in cases of suspected pulmonary hypertension?
Right-sided heart catheterization.

Question: Which noninvasive method can be done to measure pressures?
Echocardiography with Doppler flow.

Question: What is the main treatment plan for patients with secondary pulmonary hypertension?
Treat the underlying disorder that is causing the hypertension.

Question: What is the 2-year survival rate in patients with pulmonary hypertension?
50%.

Question: What is cor pulmonale?
It is the dilation and hypertrophy of the right ventricle in response to changes within the pulmonary vascular and parenchymal system.

Question: What are the two leading conditions that predispose a patient to developing cor pulmonale?
COPD and chronic bronchitis, which leads to pulmonary hypertension.

What is the most common symptom of patients with cor pulmonale?
Dyspnea.

Question: What is the effect of brain natriuretic peptide (BNP) levels in patients with cor pulmonale?
They are usually markedly elevated chronically.

Question: What is the treatment for cor pulmonale?
Treat the underlying cause of the reason for the disease being present.

Question: What are the pulmonary manifestations in Paget disease?
High output cardiac failure with pulmonary edema, impaired respiratory control from bony involvement at base of skull, vertebral fractures leading to kyphosis, and restrictive lung disease.

Question: What are the pulmonary manifestations of polycythemia?
Pulmonary embolism related to hyperviscosity and pulmonary hemorrhage related to an increased bleeding tendency.

Question: What is the classic presentation of venous air embolism?
Sudden hypotension with a mill wheel murmur audible over the precordium.

Question: What is the preferred patient position in suspected venous air embolism?
Left lateral decubitus and Trendelenburg.


RESTRICTIVE PULMONARY DISEASE

Question: What are some of the signs and symptoms of idiopathic pulmonary fibrosis (IPF)?
Exertional dyspnea, nonproductive cough, inspiratory crackles, and digital clubbing on examination.

Question: What are some expected findings on chest X-rays and lung scans in patients with IPF?
Basilar, and subpleural reticular opacities. These are associated with bronchiectasis and honeycombing.

Question: Name some illnesses that can accelerate the disease and overall prognosis of patients with IPF:
Infections (pneumonia, bronchitis), pulmonary embolism, pneumothorax, and heart failure.

Question: What is the survival rate of a patient with IPF who is intubated?
Only 25% of patients make it off the vent and survive.

Question: Is there a recommended therapy for patients with an exacerbation of IPF?
No. There is no one therapy that is recommended. Symptomatic treatment is done. The only other option is lung transplantation for those patients who qualify.

Name the four major groups of pneumoconiosis and the more common types within those groups:

1. Metal dusts: siderosis, stannosis, and baritosis.

2. Coal dusts: coal dust from mining.

3. Inorganic dusts: free silica from mining

4. Silicate dusts: asbestosis, talcosis, kaolin (sands), and Shaver disease (from aluminum production).

Question: What is the major mechanism that these dusts are routed into the lungs?
By inhalation.

Question: How do these products injure the lungs?
They cause an initial inflammatory reaction and then over time create a fibrosis to the lung tissue.

Question: Upper lobe nodules and eggshell hilar node calcification are displayed on X-rays of an individual with what disease?
Silicosis.

Question: What is the average exposure time necessary for the development of silicosis following silicon dioxide inhalation?
20 to 30 years. Employees in mining, pottery, soap production, and granite quarrying are at risk. This population also has a higher chance of acquiring TB.

Question: A 14-year-old adolescent boy was exposed to asbestos for 3 days has a nonproductive cough and chest pain. Does this boy have asbestosis?
No. Although a nonproductive cough and pleurisy are symptoms of asbestosis, other signs, such as exertional dyspnea, malaise, clubbed fingers, crackles, cyanosis, pleural effusion, and pulmonary hypertension, should be displayed before making a diagnosis of asbestosis. In addition, asbestosis does not develop until 10 to 15 years after regular exposure to asbestos.

Question: Asbestosis increases the risk of what two diseases?
Lung cancer and malignant mesothelioma.

Question: Exposure to what mineral, used as insulation, greatly enhances the carcinogenic potential of exposure to cigarette smoke?
Asbestos.

Question: What parts of the pulmonary system are affected by asbestosis?
The pleura and peritoneum. Asbestosis increases the risk of mesotheliomata. It also causes pneumoconioses that invade the lungs.

Question: What age population and race is the most prevalent in the United States for sarcoidosis?
Patients in the age groups of 30 to 40 years, black, women more than men.

What are the usual presenting symptoms in patients with sarcoidosis?
They are usually nonpulmonary. They include symptoms of the skin, eyes, and peripheral nerves. Some patients will have quick onset of malaise, fever, and dyspnea. Erythema nodosum, parotid enlargement, lymphadenopathy, and hepatomegaly are also common findings.

Question: What are the three stages of findings in the chest X-ray of a sarcoidosis patient?
- Stage I: bilateral hilar adenopathy alone
- Stage II: hilar adenopathy and parenchymal involvement
- Stage III: parenchymal involvement alone

Question: What is the best method of test to determine pulmonary sarcoidosis?
Transbronchial biopsy.

Question: What is the treatment for patients with sarcoidosis?
Oral steroids (prednisone) 0.5 to 1.0 mg/kg/day to suppress the symptoms.

Question: What are some advanced pulmonary disease complications related to sarcoidosis?
Advanced fibrosis, bronchiectasis, cavitation, pneumothorax, hemoptysis, and respiratory failure.


OTHER PULMONARY DISEASES AND CONDITIONS

Question: What is ARDS?
Acute respiratory distress syndrome is a syndrome of rapid dyspnea, hypoxia, and pulmonary infiltrates, which lead to respiratory failure. This can be a result of a direct or indirect insult on the lungs.

Question: What are some direct and indirect illnesses that can cause ARDS?
- Direct: Pneumonia, near drowning, toxic inhalation
- Indirect: Sepsis, trauma, drug overdose, pancreatitis

Question: What is the most common cause of ARDS?
Sepsis and pneumonia.

Question: What are the three phases of ARDS progression?
Exudative, proliferative, and fibrotic phase.

Question: What is the goal of management in patients with ARDS?
There is little that can be done for these patients. However, by maintaining a low left atrial filling pressure, higher pressures can be prevented from developing into the pulmonary system, thus reducing the chance of increased permeability of fluid into the extravascular space. Mechanical ventilation is helpful in patients whose respiratory drive is failing and can no longer oxygenate themselves.

Question: What is the mortality range in patients with ARDS?
Anywhere from 41% to 65%.

A preterm infant is breathing rapidly and grunting. Intercostal retractions, nasal flaring, and cyanosis are noted. Auscultation shows decreased breath sounds and crackles. What is the diagnosis?
Newborn respiratory distress syndrome, also known as hyaline membrane disease. X-rays show diffuse atelectasis. Treatment involves artificial surfactant and O2 administration through CPAP.

Question: At what age is the preterm infant more likely to have hyaline membrane disease?
When the infant is around 26 to 28 weeks old.

Question: How is fetal lung maturity assessed?
By measuring the ratio of lecithin to sphingomyelin (L/S). An L/S ratio greater than 2 and the presence of phosphatidyl glycerol confirm that the fetal lungs are mature.

Question: Other than avoiding prematurity, what can be done to prevent newborn respiratory distress syndrome?
If the fetus is older than 32 weeks, administer betamethasone 48 to 72 hours before delivery to augment surfactant production.

Question: If newborn hyaline membrane disease is present, what is the treatment for these patients?
In addition to intravenous surfactant, oxygen with or without nasal CPAP long-term is indicated. This is done until the lung maturity has reached an acceptable level.

Question: What factor determines the magnitude of injury in gastric acid aspiration?
The gastric pH. A pH less than 3 produces the most severe injury.

Question: Under what circumstances is aspiration of vomitus, oral secretions, or foreign material likely?
Anything producing an altered level of consciousness (e.g., alcohol, overdose, general anesthesia, stroke), impaired swallowing or abnormal gastrointestinal motility, or disruption of the esophageal sphincters predisposes to aspiration.

Question: What are the signs of a large obstructing foreign body in the larynx or trachea?
Respiratory distress, stridor, inability to speak, cyanosis, loss of consciousness, and death.

Question: What are the symptoms of a smaller (distally lodged) foreign body?
Cough, dyspnea, wheezing, chest pain, and fever.

Question: What is the procedure of choice for foreign body removal?
Rigid bronchoscopy. Fiberoptic bronchoscopy is an alternate procedure in adults, not in children. If bronchoscopy fails, thoracotomy may be required.

Question: What are the common radiographic findings in foreign body aspiration?
Normal film, atelectasis, pneumonia, contralateral mediastinal shift (more marked during expiration), and visualization of the foreign body.

What are the common directly toxic (noninfected) respiratory tract aspirates?
Gastric contents, alcohol, hydrocarbons, mineral oil, and animal and vegetable fats. All of these produce an inflammatory response and pneumonia. Gastric contents are the most common offender.

Question: What are the consequences of aspirating acid?
The response is rapid, with near-immediate bronchitis, bronchiolitis, atelectasis, shunting, and hypoxemia. Pulmonary edema may occur within 4 hours. The clinical manifestations are dyspnea, wheezing, cough, cyanosis, fever, and shock.

Question: Under what circumstances are antibiotics used in aspiration?
Aspiration of infected material, intestinal obstruction, immune compromised host, and evidence of bacterial superinfection after a noninfected aspirate (new fever, infiltrates, or purulence after the initial 2 to 3 days).

Question: What are the radiographic manifestations of acid aspiration?
Varied, may be bilateral diffuse infiltrates, irregular “patchy” infiltrates, or lobar infiltrates.

Question: What outcomes occur in patients who do not rapidly resolve gastric acid aspiration pneumonitis?
ARDS (adult respiratory distress syndrome), progressive respiratory failure, and death; bacterial superinfection.

Question: At what percentage of an airway obstruction will inspiratory stridor become evident?
70% occlusion.

Question: A foreign body is suspected in the lower airways. What will plain films show?
Air trapping on the affected side. Inspiration and expiration views demonstrate mediastinal shift away from the affected side.

Question: What is the most common cause of death among infants 1 to 12 months old?
Sudden infant death syndrome.

Question: Where in the airway are foreign bodies usually lodged in children older than 1 year?
In the lower airway.

Question: Stridor is observed in what phase of respiration?
Inspiratory.

Question: What is stridor due to?
With extrathoracic airway obstruction, the pressure inside the extrathoracic part of the airway is much more negative relative to atmospheric pressure. This results in further narrowing of the larynx during inspiration and therefore, stridor.

Question: Grunting is observed during what phase of respiration?
Expiratory. Exhalation against a closed glottis.

In the diagnosis of a radiolucent foreign body lodged in the right mainstem bronchus, producing incomplete obstruction, inspiratory and expiratory films will show air-trapping and increased lucency of the lung on the involved side. This phenomenon is due to:
Ball-valve air trapping. Air enters around the foreign body during inspiration, but is trapped as the airway closes around the foreign body during expiration, preventing emptying of that side.

Question: You are at a restaurant and the person at the table next to you begins coughing loudly. She stands up and begins wheezing between coughs, but she is still able to eke out a “Help! I’m choking.” How should you help?
Encourage her to cough deeper and keep breathing. Do not interrupt her spontaneous attempts at expulsion if she still has good air exchange, as evidenced by her state of consciousness and the degree of coughing and wheezing. Should she display severe respiratory difficulty with a weakening cough and the inability to talk, perform the Heimlich maneuver.

Question: What should be done if this patient above is markedly obese and in severe respiratory distress?
The normal Heimlich maneuver will not be as effective. Instead of positioning your fists above the patient’s navel, place your cupped fist on the patient’s chest and deliver swift thrusts. This is also the method of choice for pregnant women.

Question: True/False: Pulse oximetry is a reliable method for estimating oxyhemoglobin saturation in a patient suffering from CO poisoning:
False. COHb has light absorbance that can lead to a falsely elevated pulse oximeter transduced saturation level. The calculated value from a standard ABG may also be falsely elevated. The oxygen saturation should be determined by using a co-oximeter that measures the amounts of unsaturated O2Hb, COHb, and metHb.

Question: What is the indication for long-term tracheostomy?
When intubation is expected to exceed 3 weeks.

Question: What are the potential mechanisms of cardiorespiratory collapse?
Mechanical obstruction of pulmonary vasculature, alveolar capillary leak, pulmonary edema from LV failure, and anaphylaxis.

Question: What are the indications for intubation and ventilation after near drowning?
Apnea, pulselessness, altered mental status, severe hypoxemia, and respiratory acidosis.

Question: Calculate the alveolar–arterial oxygen (A-aO2) gradient given the following arterial blood gas obtained at sea level: pH 7.24, PaCO2 60, PaO2 45:
30 mm Hg.
To calculate the alveolar–arterial oxygen gradient, first calculate the expected alveolar partial pressure of oxygen (PAO2) using the alveolar gas equation: PAO2= Pio2− Paco2/R, where Pio2 is the partial pressure of oxygen in the inspired gas and R is the respiratory exchange ratio, commonly estimated at 0.8. Pio2 is calculated as follows: Pio2= Fio2 (PB − PH2o), where Fio2 is the inspired concentration of oxygen (0.21 at sea level), PB is the atmospheric pressure (760 mm Hg at sea level), and PH2 o is the partial pressure of water (47 mm Hg). At sea level, Pio2 is equal to 150 mm Hg. Thus, for this example, PAO2 = 150 − 60/0.8 or 75 mm Hg.
The A-ao2 gradient is Pao2 − Pao2. Therefore, in this example, the A-ao2 gradient is 75 − 45 or 30 mm Hg.

What is the age-related decline in PaO2?
The Pao2 declines by 2.5 mm Hg per decade. Given that a Pao2 of 95 to 100 mm Hg is normal for a 20-year-old, a Pao2 of 75–80 would be normal for a 80-year-old.

Question: What are the four principal mechanisms that lead to hypoxemia?
Hypoventilation, diffusion limitation, shunt, and ventilation–perfusion inequality. A fifth mechanism, low inspired oxygen concentration, is important only at altitudes above 8000 feet.

Question: Which of the four above mechanisms is the most common?
Ventilation–perfusion inequality.

Question: What are the three major mechanisms of hypoventilation and what clinical conditions are associated with each?

1. Failure of the central nervous system ventilatory centers: drugs (narcotics, barbiturates) and stroke.
2. Failure of the chest bellows: chest wall diseases (kyphoscoliosis), neuromuscular diseases (amyotrophic lateral sclerosis), and diaphragm weakness.
3. Obstruction of the airways: asthma and chronic obstructive pulmonary disease.

Question: How can hypoxemia secondary to hypoventilation alone be distinguished from the other causes of hypoxemia?
If the hypoxemia is from hypoventilation alone, the A-ao2 gradient is normal. It is elevated in all other causes.

Question: What are the most common clinical conditions in which shunt is the primary mechanism for hypoxemia?
Alveolar filling with fluid (pulmonary edema) and pus (pneumonia) are the most commonly seen clinically. Any condition that fills or closes the alveoli preventing gas exchange can lead to shunt.

Question: How can shunt be distinguished from the other causes of hypoxemia?
If given 100% oxygen, the hypoxemic patient with shunt will not have a significant increase in their Pao2. There will be a significant increase in Pao2 when 100% oxygen is given to patients with hypoventilation or ventilation– perfusion inequality.

Question: A leftward shift in the oxyhemoglobin dissociation curve indicates an increased or decreased hemoglobin affinity for oxygen?
Ventilation-increased.

Question: Changes in temperature, PaCO2 or pH, or the level of 2,3-diphosphoglycerate (2,3-DPG) cause a shift in the oxyhemoglobin dissociation curve. To cause a rightward shift, what are the changes that must occur?
Increased temperature, increased Paco2, decreased pH, and increased 2,3-DPG level. An easy way to remember this is that these conditions are often associated with decreased tissue oxygen levels. By right-shifting the curve, more oxygen is released from the hemoglobin to the tissues.

How does the shape of the oxyhemoglobin dissociation curve effect the oxygen content of blood?
Since Sao2 does not increase significantly if the Pao2>60 mm Hg, the oxygen content of blood will increase significantly above this level only by increasing the hemoglobin concentration.

Question: What are the determinants of oxygen delivery to the peripheral tissues?
Oxygen content of the blood (Cao2) and cardiac output. An increase in either will increase oxygen delivery to the tissues.

Question: What is the difference between anatomic and physiologic dead space?
Dead space refers to areas of lung that are ventilated but not perfused. Anatomic dead space refers to the conducting airways (trachea, bronchi, and bronchioles) where there is no gas exchange because there are no alveoli. Physiologic dead space includes the anatomic dead space and any diseased lung in which there is ventilation but no perfusion.

Question: What is the normal dead space in an average 70 kg subject?
150 mL.

Question: Which pulmonary diseases are most associated with an increased physiologic dead space?
Asthma and chronic obstructive pulmonary disease (COPD).

Question: How is the minute ventilation related to alveolar and dead space ventilation?
Minute ventilation (VE) is the product of tidal volume multiplied by breathing frequency
(VE = VT × f). Alveolar ventilation (VA) is that portion of the minute ventilation that contributes to gas exchange, whereas dead space ventilation (VD) is that portion that does not contribute to gas exchange. Thus, VE = VA + VD.

Question: What is the effect of increased alveolar ventilation (VA) on PaCO2?
Paco2 will decrease as VA increases.

Question: Why do asthmatic patients eventually have an increased PaCO2 if untreated?
As the asthma attack continues untreated, the work of breathing will continue to increase. Eventually, the diaphragm fatigues and the patient hypoventilates. The hypoventilation, in association with the increased dead space and increased CO2 production, increases the Paco2.

Question: What is the normal PaCO2 and does it vary with age?
Normal Paco2 is 35 to 45 mm Hg and does not vary with age.

Question: What is the normal expected change in pH if there is an acute change in the PaCO2?
The pH will increase or decrease 0.8 units for every 10 mm Hg decrease or increase (respectively) in Paco2.

What are the consequences of hypercapnia?
Acute hypercapnia has physiologic consequences due to the increased Paco2 itself and the decreased pH. Physiologic effects of the Paco2 increase include:
- increases in cerebral blood flow.
- confusion, headache (Paco2 >60 mm Hg), obtundation and seizures (Paco2 >70 mm Hg).
- depression of diaphragmatic contractility.
The primary consequences of the decreased pH are on the cardiovascular system with changes in cardiac contractility (decreased), the fibrillation threshold (decreased), and vascular tone (predominantly vasodilatation).

Question: What are the consequences of hypocapnia?
Acute hypocapnia has physiologic consequences due to the decreased Paco2 itself and the increased pH. Physiologic effects of the Paco2 decrease include:
- decreases in cerebral blood flow. This reflex is used in the management of neurologic disorders with high intracranial pressures as a short-term measure to decrease the increased intracranial pressure.
- confusion, myoclonus, asterixis, loss of consciousness, and seizures.
The primary consequences of the increased pH are, again, primarily on the cardiovascular system with increased cardiac contractility and vasodilatation.

Question: What is the cause of the hypoxemia?
Hypoventilation is one cause. However, since the A-ao2 gradient is elevated, there is another cause in addition to the hypoventilation. In an obese patient, both ventilation–perfusion inequality and shunt (secondary to atelectasis) can contribute to the development of hypoxemia.

Question: A 50-year-old woman presents with a pneumonia in the right lower and middle lobes. On 50% oxygen by facemask, her PaO2 is 75 mm Hg. Should the patient be positioned right side down or up?
Right side up. Blood flow is gravity dependent. If the patient is positioned right side down, blood flow will preferentially go to the right side. However, because of the pneumonia, this will increase the amount of shunt, lowering the Pao2further.

Question: True/False: If a patient presents with a PaCO2 of 75, he/she should be emergently intubated:
False. There is no Paco2 level at which a patient must be intubated. Intubation is based upon the total clinical condition of a patient, not just upon a blood gas result.

Question: A 45-year-old patient presents to the emergency department after being rescued from a fire. The patient is dyspneic and cyanotic. SaO2 on 50% mask is 84%. The blood gas, however, reveals a PaO2 of 125 mm Hg. Why the discrepancy?
A fire victim is likely to have carbon monoxide poisoning. The carbon monoxide has converted the hemoglobin to carboxyhemoglobin, which decreases the binding of oxygen to hemoglobin and prevents an accurate pulse oximetry reading. However, carbon monoxide does not affect dissolved oxygen, which is what is measured in the arterial blood gas.

Question: What is the treatment for carbon monoxide poisoning?
100% oxygen, which increases carbon monoxide clearance by competing for binding to hemoglobin. If there is no significant response to 100% oxygen, hyperbaric oxygen (oxygen provided at higher than atmospheric pressure) is an alternative therapy.

A 25-year-old woman with a history of mitral valve prolapse presents with “nervousness,” chest tightness, hand numbness, and mild confusion. Arterial blood gas reveals pH 7.52, PaCO225 mm Hg, and PaO2 108 mm Hg. What is the diagnosis?
Acute anxiety attack. She is hyperventilating.

Question: Why is the PaO2elevated?
Because the lower Paco2 means a higher Pao2 (see alveolar gas equation above).

Question: What is the treatment?
The acute hyperventilation can be terminated by having the patient breathe in and out of a bag. Anxiolytics can also be provided.

Question: True/False: Oxygen should never be given to a hypoxemic patient with COPD who has chronic CO2retention:
False. Oxygen should always be given to a patient who is hypoxemic.

Question: Adequacy of alveolar ventilation is reflected by which component of arterial blood gas analysis?
Paco2.

Question: Patients on mechanical ventilation can develop hypoventilation based on what factors?
Increased dead space (including length of ventilator circuit proximal to the “Y” piece separating the inspiratory and expiratory limbs), decreased tidal volume, overdistention of lung, air leaks, and massive pulmonary embolism.

Question: What is the principal mechanism of increased PaCO2 with increased FIO2?
Worsening V/Q mismatch and the Haldane effect.

Question: How does malnutrition contribute to respiratory failure?
Increase in the oxygen cost of breathing and respiratory muscle weakness.

Question: How can the work of breathing with mechanical ventilation associated with intrinsic PEEP be reduced?
Add CPAP, reduce tidal volume, reduce inspiratory time, and increase expiratory time.

Question: Through what mechanism does PEEP decrease cardiac output?
Reduced preload.

Question: Through what mechanism does positive pressure ventilation increase cardiac output?
Decreased afterload.

Question: How can compliance of the lung/chest wall be approximated from airway pressure measurements during mechanical ventilation?
Compliance = tidal volume/(inspiratory plateau pressure − end expiratory pressure).

What are the primary determinants of the work of breathing?
Minute ventilation, lung/chest wall compliance, and presence of intrinsic PEEP.

Question: When may end-tidal carbon dioxide detectors prove inaccurate?
In patients with very low blood flow to the lungs, or in those with a large dead space (i.e., following a pulmonary embolism).

Question: What is the most common complication of endotracheal intubation?
Intubation of a bronchus. Other complications include lacerations of the lip, tongue, pharyngeal or tracheal mucosa resulting in bleeding, hematoma, or abscess. Tracheal rupture, avulsion of an arytenoid cartilage, vocal cord injury, pharyngeal–esophageal perforation, intubation of the pyriform sinus, aspiration of vomitus, hypertension, tachycardia, or arrhythmias can also occur.

Question: What oxygen concentration will be supplied by nasal cannula with a flow rate of 1 L/min?
24%. For each 1 L/min increase in flow, a 4% increase in oxygen concentration will occur; 6 L/min produces a 44% oxygen concentration.

Question: What oxygen flow rate is recommended for face mask ventilation?
At least 5 L/min. Recommended flow is 8 to 10 L/min, which will produce oxygen concentrations as high as 40% to 60%.

Question: What oxygen concentration can be supplied with a face mask and oxygen reservoir?
6 L/min provides approximately 60% oxygen concentration, and each liter increases the concentration by 10%; 10 L/min is almost 100%.

Question: A pulmonary embolism causes which type of cyanosis?
Central cyanosis. However, secondary shock and right-sided heart failure can lead to peripheral cyanosis.

Question: What are the two most common errors made in the intubation of a neonate?

1. Placing the neck in hyperextension; this moves the cords even more anteriorly.
2. Inserting the laryngoscope too far.

Question: Name the two primary causes of peripheral cyanosis with a normal SaO2:
Decreased cardiac output and redistribution (may be secondary to shock, DIC, hypothermia, vascular obstruction).

Question: As PCO2 increases, pH will decrease. How much is the pH expected to decrease for every 10 mm Hg increase in PCO2?
pH decreases by 0.08 U for each 10 mm Hg increase in Pco2.

Question: Describe Kerley A and B lines:
Kerley A lines are straight, nonbranching lines in the upper lung fields. Kerley B lines are horizontal, nonbranching lines at the periphery of the lower lung fields.

A patient presents with cough, lethargy, dyspnea, conjunctivitis, glomerulonephritis, fever, and purulent sinusitis. What is the probable diagnosis?
Wegener granulomatosis. This is a necrotizing vasculitis and pulmonary granulomatosis that attacks the small artery and veins. Treat the patient with corticosteroids and cyclophosphamide.

Question: What serological test is diagnostic for Wegener granulomatosis?
c-ANCA in association with appropriate clinical evidence. A renal, lung, or sinus biopsy may also be helpful in making the diagnosis.

Question: What is the typical time period during which acute radiation pneumonitis develops?
Within the first eight weeks after radiation.

Question: What laboratory finding distinguishes patients with primary SLE and drug-induced lupus?
Drug-induced lupus has a positive ANA, but a negative ds-DN

Question: The chest X-ray reveals no pulmonary parenchymal lesions but does show prominent hila and an enlarged right ventricle. What diagnostic test should be performed?
The patient has no pulmonary parenchymal lesions to cause a shunt; therefore, she most likely has an intracardiac right-to-left shunt (most likely a previously undiagnosed atrial septal defect). An echocardiogram should be performed.

Question: Of the following, which pattern of calcification of a solitary pulmonary nodule is most likely to be associated with a malignant lesion: lamellar (onion skin), popcorn, eccentric, or central?
Eccentric.

Question: What happens to minute ventilation at submaximal work rates in Interstitial lung disease?
It increases due to increased dead space ventilation. As the respiratory rate increases, tidal volume decreases.

Question: What is the incidence of post-operative respiratory complications in patients with COPD?
50% or more.

Question: Which neuromuscular diseases and spinal diseases can lead to ventilatory insufficiency?
Muscular dystrophy, polymyositis, myotonic dystrophy, polyneuritis, Eaton Lambert syndrome, myasthenia gravis, amyotrophic lateral sclerosis, injury, Guillain-Barre syndrome, multiple sclerosis, Parkinson disease, and stroke.

Question: What are some clinical disorders associated with increased capillary permeability causing exudative pleural effusion?
Pleuropulmonary infections, circulating toxins, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, tumor, pulmonary infarction, and viral hepatitis.

What is the incidence of pleural involvement in systemic lupus erythematosus?
50% to 75% of patients with systemic lupus erythematosus develop pleural effusion or pleuritic pain during the course of their disease.

Question: What are the clinical features of lupus pleuritis?
Pleuritic chest pain is the most common presentation. Other features are cough, dyspnea, pleural rub, and fever. An episode of pleuritis usually indicates exacerbation of lupus.

Question: What percentage of elderly have sleep apnea?
40%.

Question: What is the most common cause of sleep apnea in adults?
An upper airway obstruction, generally by the tongue or enlarged tonsils. A medulla that is not responsive to CO2 buildup is the most common cause in children. Obstruction by the tongue or enlarged tonsils also induces sleep apnea.

Question: What is a complication of central sleep apnea in children?
SIDS. Affected children develop morning cyanosis. However, children can be treated with theophylline.

Question: Under what conditions does neurogenic pulmonary edema occur?
Neurogenic pulmonary edema is commonly associated with increased intracranial pressure. It is commonly seen with head trauma, subarachnoid hemorrhage, and even with seizures.

Question: Is a nonsmoker who has lived with a smoker for 25 years at greater risk of lung cancer than a nonsmoker who has not lived with a smoker?
Of course. The risk is 1.34 times as great as a person living in a smoke-free environment.

Question: What percentage of smokers who quit lapse back into their smoking habits?
85%.


REFERENCES
Brunton Laurence L, L. J. (2006). Goodman and Gilman’s the Pharmacological Basis of Therapeutics. 11th ed. New York, NY: McGraw-Hill.
Fauci Anthony S, B. E. (2008, 7 1). Harrisons Online. New York.
Hall JB, Schmidt G, Wood LD. Principles of Critical Care., 3rd ed. New York, NY: McGraw-Hill; 2005.
McPhee Stephen J, PM. Current Medical Diagnosis and Treatment 2009. New York, NY: McGraw-Hill; 2009.
McPhee SJ, Ganong WF. Pathophysiology of Disease—An Introduction to Clinical Medicine. 5th ed. New York, NY: McGraw-Hill; 2006.