Respiratory

Question 1

What are the spirometry changes with Asthma?

Answer 1

FEV1/FVC < 70%
↓ FEV1
normal/↓ FVC,
↑ RV
TLC, normal/
↑ DLCO (diffusing capacity of the lung for carbon monoxide).
Increase in FEV1 ≥ 12% with SABA (albuterol).

Question 2

What is the acute treatment for asthma?

Answer 2

■ O2, SABA (albuterol is first-line), systemic glucocorticoids. SABA/
ipratropium and magnesium can be used in severe exacerbations.
■ Never use ipratropium alone in asthma treatment.
■ Consider intubation in severe cases (cyanosis, inability to maintain respiratory effort, altered mental status) or acutely in patients with a
Paco2 > 50 mmHg or a Pao2 < 50 mmHg

Question 3

Presentation of restrictive lung disease

Answer 3

Presents with shallow, rapid breathing; progressive dyspnea with exertion; and a chronic nonproductive cough.

Patients may have cyanosis, inspiratory squeaks, fine or “velcro-like” crackles, clubbing, or right heart failure.

Question 4

Causes of restrictive lung disease

Answer 4

Alveolar (edema, hemorrhage, pus)
Interstitial lung disease (ILD) (idiopathic
interstitial pneumonias), Inflammatory (sarcoid, cryptogenic organizing pneumonia), Idiopathic pulmonary fibrosis (IPF)
Neuromuscular (myasthenia, phrenic nerve palsy)
Thoracic wall (kyphoscoliosis, obesity, ascites, pregnancy, ankylosing spondylitis

Question 5

Treatment of sarcoid

Answer 5

Asymptomatic: Observation.

Symptomatic: Systemic corticosteroids are indicated for deteriorating
respiratory function, constitutional symptoms, hypercalcemia, or extratho-
racic organ involvement.

Refractory disease: Immunosuppressants (eg, methotrexate, azathioprine,
TNFα inhibitors).
■ Lofgren Syndrome: NSAIDs and supportive therapy

Question 6

Berlin criteria for ARDS

Answer 6

The criteria for ARDS diagnosis (according to the Berlin definition) are as follows:

Acute onset (< 1 week) of respiratory distress.

Ground-glass appearance on CXR: Bilateral alveolar infiltrate consistent
with pulmonary edema.

Pulmonary edema on CXR < 24 hours after insult suggests pulmonary
contusion instead of ARDS.

A Pao2/Fio2 ratio ≤ 300 with positive end-expiratory pressure (PEEP)/
CPAP ≥ 5 cm H2O.

Respiratory failure not completely explained by heart failure.

Question 7

Principles of treatment of ARDS

Answer 7

Low TV
High PEEP
FiO2 <60%

Question 8

What are the clinical findings of cor pulmonale?

Answer 8

Loud, palpable S2 (often split), a flow murmur, an S4, or a parasternal heave. Patient may also be hypoxemic, especially on exertion.

Question 9

Clinical and ECG features of PE

Answer 9

Presents with sudden onset or subacute dyspnea, pleuritic chest pain, low- grade fever, cough, tachypnea, tachycardia, and rarely, hemoptysis (indicates pulmonary infarction).

Exam may reveal a loud P2 and prominent jugular A waves with right
heart failure.

New-onset right bundle branch block. S1Q3T3 is rare (acute right heart strain with an S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III)

Question 10

Lung nodule clues

Answer 10

■ Recent immigrant—think TB.

■ From the southwestern United
States—think coccidioidomycosis.

■ From the Ohio River Valley—think
histoplasmosis or blastomycosis.

Question 11

What is Light’s criteria?

Answer 11

Pleural protein/serum protein
> 0.5

Pleural LDH/serum LDH
> 0.6

Pleural fluid LDH
> 2/3 the upper limit of normal serum LDH > 60 U/Lb