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Kaplan Pulmonology Video Notes Diagnostic Tests 1. Pulmonary Function Tests a. Differentiate types of lung processes i. Restrictive vs.

Obstructive 1. Obstructive: Asthma, COPD 2. Restrictive: Occupational exposure, pulm. fibrosis 2. Lung Volumes a. Lung volumes measured under static conditions (not dynamic) b. Only allows diagnosis of restrictive lung disease i. Helps confirm volume in restrictive disease ii. Obstructive disease may have lung volumes


i. Expel air out of lung: left w/ RV. ii. > 80% predicted = Normal


i. Measured against time (dynamic conditions) e. FEV1/FVC is the best measure


i. Graph 2: Obstructive disease

1. Slope of curve: 25-75% predicted (part of FVC) ii. Restrictive disease: FEV1 and FVC decrease equally (ratio) g. 2 ways to measure obstructive diseases: i. FEV1/FVC ii. Slope of curve between 25-75

h. 3. DLCO

a. b. Measure of oxygen diffusing capacity

c. d. DLCO with alveolar hemorrhage: Goodpastures, SLE 4. Other Tests a. Methacholine challenge tests i. Use when considering diagnosis of asthma ii. Asthmatic patient will have a mini asthma attack

1. COPD: Chronic bronchitis vs Emphysema a. Airflow obstruction secondary to emphysema &/or chronic bronchitis b. Etiology i. Tobacco smoking (destroys elastin fibers) ii. Alpha-1 antitrypsin deficiency

c. Presentation i. SOB worsened by exertion ii. Intermittent exacerbations w/ cough, sputum, SOB (due to infection) iii. Barrel chest from air trapping iv. Muscle wasting & cachexia d. Diagnosis i. Best initial test: X-ray 1. Increased anterior-posterior diameter (AP) 2. Air trapping and flattened diaphragms ii. Most accurate diagnostic test: PFT 1. FEV1, FVC, FEV1/FVC ration < 70% 2. TLC due to RV 3. DLCO emphysema 4. Incomplete improvement w/ albuterol (unlike asthma) 5. Little or no worsening with methacholine. iii. Arterial blood gas 1. Acute exacerbations of COPD -- Pco2 & HYPOXIA a. Respiratory acidosis (bicarb will be elevated to compensate) iv. EKG 1. Right atrial hypertrophy & right ventricular hypertrophy 2. A-fib or multifocal atrial tachycartia (MAT) v. ECHO 1. Pulm HTN 2. Right atrial & ventricular hypertrophy e. Treatment that improves mortality in COPD i. Smoking cessation ii. O2 therapy for hypoxia

1. Treatment that improves symptoms in COPD i. Short acting beta agonists: Albuterol ii. Inhaled Anticholinergic agents 1. Tiotropium (long acting) 2. Ipratropium (short acting) iii. Long-acting beta agonists: Salmeterol iv. Theophylline 1. PDE4 inhibitor 2. Narrow therapeutic index 3. Interacts w/ cimetidine, phenytoin 4. Toxicity by: erythromycin, cimetidine, fluoroquinolones (Cipro) g. No benefit i. Cromolyn ii. Leukotriene modifiers h. Treatment of Acute exacerbations: Steroids + Antibiotics i. Combo of bronchodilator & systemic steroid ii. Antibiotics (moderate severe) f.

1. Dyspnea, sputum production, change in sputum purulence iii. Most common bugs: 1. Strep pneumo, H. influe, Moraxella cat.



3. Criteria for O2 Use in COPD:

j. 2. Bronchiectasis a. Uncommon disease from chronic destruction, remodeling, and dilation of large bronchi b. Permanent antimonic abnormality c. Etiology i. Cystic fibrosis (MCC) ii. Infections: 1. TB 2. Pneumonia iii. Panhypogammaglobulinemia iv. Foreign body or tumors v. ABPA: Allergic bronchopulmonary vi. Collagen vascular disease (RA) vii. Kartagener syndrome d. Diagnosis: i. Best initial test Chest X-ray ii. Most accurate test High resolution CT

iii. Sputum culture e. Treatment/Management i. Chest physiotherapy (cupping & clapping + postural drainage) ii. Treat each episode of infection 1. Abx same as COPD exacerbation 2. Inhaled antibiotics may be helpful iii. Surgical Resection 3. Allergic Bronchopulmonary Aspergillosis a. Hypersensitivity to fungal Ag that colonizes resp tract b. Found w/ asthma & atopic disorders c. Look for: i. Asthmatic w/ recurrent episodes of brown-flecked sputum & transient infiltrates on X-ray d. Clinical: cough, wheezing, hemoptysis e. Diagnosis: i. Peripheral eosinophilia ii. Skin test reactivity to aspergillus iii. IgE iv. Pulm infiltrate on CXR or chest CT f. Treatment: i. Acute flare prednisone ii. Itraconazole or voriconazole orally 4. Cystic fibrosis a. Autosomal recessive mutation, codes for chloride transport i. CFTR mutation, chromosome 17


c. d. Lungs: i. Damaged mucous clearance decreases ability to get rid of inhaled bacteria

Solitary Pulmonary Nodule & Interstitial Lung disease 1. Solitary Pulm Nodule: a. Benign: < 30 yrs old, no change in size, nonsmoker, smooth border, < 1 cm, no adenopathy, normal PET, dense CENTRAL calcification i. Often represent SCAR from infection ii. Immigrant TB iii. SW US Coocidioidomycosis iv. Ohio, River Valley HISTOPLASMOSIS b. Malignant: i. Remove lesion ii. Sputum cytology, needle biopsy, PET c. Intermediate probability lesion: i. Age 30-40 years ii. Size > 1 cm, < 2 cm iii. Sputum cytology is the best next step iv. Bronchoscopy or Transthoracic needle biopsy (peripheral lesions) d. PET can i. 85-95% sensitivity e. VATS: Video assisted thoracic surgery i. More sensitive & more specific 2. Interstitial Lung disease a. Disease characterized by inflammation of interalveolar septum b. Fibrosis causes i. Impaired gas exchange ii. Increased lung stiffness iii. & iv. Decreased lung compliance & expansion

c. d. Types of Pneumoconioses i. Coal exposure Coal workers pneumoconiosis ii. Sandblasting, rock mining, tunneling Silicosis iii. Shipyard worker, insulator Asbestosis iv. Cotton Byssinosis v. Electronic Berylliosis 1. Biopsy: Granulomas e. Presentation of Pulm Fibrosis i. Dyspnea worsening on exertion ii. Hypoxia worsening on exertion iii. Fine rales or crackles on exam iv. Loud P2 (pulm HTN) v. Clubbed fingers f. Diagnosis i. Best initial test: CXR ii. Most accurate test: Lung biopsy 1. Inflammation, fibrosis iii. PFT: Restrictive lung disease 1. FEV1, FVC, TLC & RV , but FEV1/FV C ration normal iv. DLCO: g. Treatment i. Berylliosis is most likely to respond to steroids. 3. Hypersensitivity Pneumonitis a. Presentation: i. ACUTE: 1. Fever, dyspnea, severe cough 2. 4-6 hours after exposure ii. CHRONIC: 1. Progressive dyspnea 2. Rales b. Most common Antigent: i. Feathers: Bird fanciers lung ii. MAI: hot tub lung iii. Spores of actinomyces: Farmers lung/Air conditioner lung

c. Treatment: i. Corticosteroids ii. Avoid exposure SARCOIDOSIS 1. Most common in African American women 2. Infiltration of NONCASEATING granulomas 3. Presentation: a. SOB on exertion, fine rales, NO wheezing b. Erythema nodosum, Lymphadenopathy i. Bilateral, hilar lymphadenopathy c. Fever, malaise, weight loss d. Arthritis e. Parotid gland enlargement f. Facial palsy g. Heart block h. Iritis, uveitis 4. Diagnosis: a. CXR best initial test i. Hilar lymphadenopathy ii. Parenchymal involvement b. Lymph node biopsy most accurate test c. ACE level (60%) d. Hypercalciuria e. Hypercalcemia i. Granulomas in sarcoidosis make Vitamin D f. PFTs: restrictive lung disease 5. Treatment: a. Prednisone THROMBOEMBOLIC DISEASE 1. Etiology a. Virchows Triad:

i. b. Presentation: i. Sudden onset of SOB, normal CXR ii. Other findings: 1. Tachypnea, tachycardia, cough, hemoptysis 2. Leg pain from DVT

3. Pleuritic chest pain 2/2 lung infarct 4. Fever 2/2 clot or hematoma c. Diagnosis: i. CXR typically normal or atelectasis 1. Hampton hump 2. Westermark sign oligemia of one lobe ii. EKG 1. Nonspecific ST-T wave changes 2. 5% will have new RBBB or RV hypertrophy iii. ABG 1. Hypoxia & respiratory alkalosi a. pH, pCO2