The document discusses various types of pneumonia including community acquired pneumonia (CAP), nosocomial pneumonia, and atypical CAP. For CAP, the most common bacterial causes are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Nosocomial pneumonia is most often caused by Staphylococcus aureus or Pseudomonas in the ICU. Atypical CAP is commonly caused by Mycoplasma pneumoniae in young adults presenting with low-grade fever and cough.

1. PULMONOLOGY REVIEW
Breathe. You’re going to be OK.

2. Community Acquired Pneumonia
(CAP)
 Bacterial vs. Viral

3. Community Acquired Pneumonia
(CAP)
 Bacterial vs. Viral
 Top bacterial causes:

4. Community Acquired Pneumonia
(CAP)
 Bacterial vs. Viral
 Top bacterial causes:
 Streptococcus pneumoniae
 Haemophilis influenzae
 Moraxella Catarrhalis

5. Community Acquired Pneumonia
(CAP)
 Bacterial vs. Viral
 Top bacterial causes:
 Streptococcus pneumoniae
 Haemophilis influenzae
 Moraxella Catarrhalis

6. Community Acquired Pneumonia
(CAP)
 Streptococcus pneumoniae –RUST COLORED SPUTUM

7. Community Acquired Pneumonia
(CAP)
 Streptococcus pneumoniae –RUST COLORED SPUTUM
 Haemophilus influenza- COPD, smokers

8. Community Acquired Pneumonia
(CAP)
 Streptococcus pneumoniae –RUST COLORED SPUTUM
 Haemophilus influenza- COPD, smokers
 Klebsiella – alcohol abuse. CURRANT JELLY SPUTUM
 Mycoplasma pneumoniae- *MC ATYPICAL – young adults
 Legionella – air conditioning
 Pseudomonas- cystic fibrosis

9. Community Acquired Pneumonia
(CAP)
 Viral cx:
 Influenza virus
 Respiratory syncytial virus (RSV)
 Adenovirus
 Parainfluenza virus

10. Sample question
 Some dude w/ hx of heavy alcohol use arrives in ER w/
10 day hx of increasing productive cough, fever, sweats.
On physical exam, patient coughs up currant jelly
sputum and crackles heard on left lower lung field. CXR
shows lobar infiltrates in lower left lobe. What is most
likely causative organism of the suspected diagnosis?
 A) Streptococcus pneumoniae
 B) Legionella sp.
 C) Parainfluenza virus
 D) Klebsiella

11. Sample question
 Some dude w/ hx of heavy alcohol use arrives in ER w/
10 day hx of increasing productive cough, fever, sweats.
On physical exam, patient coughs up currant jelly
sputum and crackles heard on left lower lung field. CXR
shows lobar infiltrates in lower left lobe. What is most
likely causative organism of the suspected diagnosis?
 A) Streptococcus pneumoniae
 B) Legionella sp.
 C) Parainfluenza virus
 D) Klebsiella

12. Sample Question
 A 47-year-old man presents with persistent chills following a
recent upper respiratory tract infection. The patient reports
cough with the production of yellowish sputum and myalgia.
The patient is febrile (37.9C), with a HR of 94 bmp and a
respiratory rate of 24/min. Knowing that the patient has had
a prolonged exposure to the air conditioned space in a large
office building, what may be the causative microbial agent in
this case?
 A) Klebsiella
 B) Mycoplasma
 C) Legionella
 D) Staphylococcus aureus

13. Sample Question
 A 47-year-old man presents with persistent chills following a
recent upper respiratory tract infection. The patient reports
cough with the production of yellowish sputum and myalgia.
The patient is febrile (37.9C), with a HR of 94 bmp and a
respiratory rate of 24/min. Knowing that the patient has had
a prolonged exposure to the air conditioned space in a large
office building, what may be the causative microbial agent in
this case?
 A) Klebsiella
 B) Mycoplasma
 C) Legionella
 D) Staphylococcus aureus

14. Sample Question
 A 6-year-old boy presents with fever and cough. He has
history of several episodes of pneumonia. A sweat test reveals
an increased amount of chloride, indicating that he has cystic
fibrosis. He is coughing up thick, greenish sputum.
Temperature is 37.6° C. A Gram stain of the sputum reveals
Gram-negative rods and a culture grows a Gram-negative rod
that is oxidase-positive and produces a blue-green pigment.
What is the most likely cause of the infection?
 A) Legionella
 B) Pseudomonas aeruginosa
 C) Haemophilus influenza
 D) Bordetella pertussis

15. Sample Question
 A 6-year-old boy presents with fever and cough. He has
history of several episodes of pneumonia. A sweat test reveals
an increased amount of chloride, indicating that he has cystic
fibrosis. He is coughing up thick, greenish sputum.
Temperature is 37.6° C. A Gram stain of the sputum reveals
Gram-negative rods and a culture grows a Gram-negative rod
that is oxidase-positive and produces a blue-green pigment.
What is the most likely cause of the infection?
 A) Legionella
 B) Pseudomonas aeruginosa
 C) Haemophilus influenza
 D) Bordetella pertussis

16. To hospitalize or not?
 Hospitalize if…
 LOOKS BAD
 More than 1 lobe involved
 OLD + GOT ISSUES
 >50yo w/ comorbid or AMS
 WEAK
 Neutropenia, hemodynamically unstable, poor host resistance

17. CAP Treatment
 CAN be treated outpatient:
 Doxycycline/ Erythromycin/ Macrolides (Clarithromycin),
fluroquinolone
 IF >60yo, choose 2nd gen cephalosporin / levo + augmentin
 Should be hospitalized:
 Ceftriaxone / cefotaxime + azithromycin (or
fluroquinolone)

18. Nosocomial Pneumonia
Acquired FROM being in the hospital - >48h from admission
2nd most causative hospital acquired infection
Mortality = 20-50%
(try to get them out ASAP while reasonably stable…)

19. Nosocomial Pneumonia
 *MC causative agents:

20. Nosocomial Pneumonia
 *MC causative agents: Staphylococcus aureus & G-neg
bacilli ( Pseudomonas, Klebsiella, E.coli, Enterobacter
sp.,)
 *MC causative agent from ICU:

21. Nosocomial Pneumonia
 *MC causative agents: Staphylococcus aureus & G-neg
bacilli ( Pseudomonas, Klebsiella, E.coli, Enterobacter
sp.,)
 *MC causative agent from ICU: Pseudomonas

22. Nosocomial Pneumonia
 *MC causative agents: Staphylococcus aureus & G-neg
bacilli ( Pseudomonas, Klebsiella, E.coli, Enterobacter
sp.,)
 *MC causative agent from ICU: Pseudomonas
 TX: Empiric tx
 Vanco + pip-taz (or cefepime or meropenum or
tic/clavulanic acid)

23. Sample Question
 A 27-year-old accident victim with a head injury is admitted to
the ICU and kept on mechanical ventilatory support. On the 7th
day after admission, he is clinically diagnosed with pneumonia.
Blood samples and lower respiratory secretions are submitted to
the laboratory for culture, and empiric antimicrobial therapy is
started. What is the most likely etiologic agent of pneumonia in
this patient?
 A) Streptococcus pneumoniae
 B) Klebsiella pneumoniae
 C) Mycoplasma pneumoniae
 D) Moraxella catarrhalis
 E) Haemophilus influenzae

24. Sample Question
 A 27-year-old accident victim with a head injury is admitted to
the ICU and kept on mechanical ventilatory support. On the 7th
day after admission, he is clinically diagnosed with pneumonia.
Blood samples and lower respiratory secretions are submitted to
the laboratory for culture, and empiric antimicrobial therapy is
started. What is the most likely etiologic agent of pneumonia in
this patient?
 A) Streptococcus pneumoniae
 B) Klebsiella pneumoniae
 C) Mycoplasma pneumoniae
 D) Moraxella catarrhalis
 E) Haemophilus influenzae

25. Prophylaxis
 Pneumovax (23 commons strains) – 51-86% effective
 PPV: pneumo polysacc vacc
 Adults >65
 w. chronic illness at risk (sickle cell, liver dz, cardiopulm dz,
splenectomy)
 BOOSTER EVERY 6 YEARS
 PCV: pneumo conjugate vacc
 PEDS 6-15 mos (4 doses)

26. Atypical CAP
 Bacterial vs. viral

27. Atypical CAP
 Bacterial vs. viral
 MC causative organism:

28. Atypical CAP
 Bacterial vs. viral
 MC causative organism: Mycoplasma pneumoniae
 SSX: Weird
 YOUNG adults, low grade fever, non-productive cough
 PE: Decreased breath sounds on a lung field
 Labs: NO SPUTUM STAIN/ CULTURE
 Imaging: CXR: segmental lower lung infiltrate or diffuse
TX:

29. Atypical CAP
 Bacterial vs. viral
 MC causative organism: Mycoplasma pneumoniae
 SSX: Weird
 YOUNG adults, low grade fever, non-productive cough
 PE: Decreased breath sounds on a lung field
 Labs: NO SPUTUM STAIN/ CULTURE
 Imaging: CXR: segmental lower lung infiltrate or diffuse
TX: Erythromycin! OR other macrolide like azithromycin

30. Atypical CAP
 Viral: influenza A/B, adenovirus, chlamydia
 TX: Supportive-
 Neuroaminidase inhibitor
 TAMIFLU (oseltamivir) – only good for 48hour window

31. Sample Question
A 22-year-old man presents with a 1-week history of fever, chills, dry or
mildly productive cough, and chest wall discomfort. He is on no medications,
but he has a history of mild asthma for which he does not need chronic
therapy. He states that he has been under a lot of pressure at work and has
not been sleeping very well. He decided to seek medical attention today
because he has not been improving and is concerned he might have
pneumonia. On examination, vitals include a temperature of 102.6ºF, BP:
126/76 mm Hg, P: 82 beats/min, R: 20/min. Lung exam reveals coarse
rhonchi throughout lung fields with rales in the right lower lobe with
egophony demonstrated over the right lower lobe. The patient is sent for PA
and lateral chest X-ray; he is found to have a right lower lobe infiltration.
Best empiric treatment for his illness?
 A) Amoxicillin 875 mg twice daily for 10 days
 B) Azithromycin 500 mg first dose, then 250mg daily for 4 days
 C) Ciprofloxacin 500 mg twice daily for 10 days
 D) Trimethoprim/sulfamethoxazole DS twice daily for 10 days

32. Sample Question
A 22-year-old man presents with a 1-week history of fever, chills, dry or
mildly productive cough, and chest wall discomfort. He is on no medications,
but he has a history of mild asthma for which he does not need chronic
therapy. He states that he has been under a lot of pressure at work and has
not been sleeping very well. He decided to seek medical attention today
because he has not been improving and is concerned he might have
pneumonia. On examination, vitals include a temperature of 102.6ºF, BP:
126/76 mm Hg, P: 82 beats/min, R: 20/min. Lung exam reveals coarse
rhonchi throughout lung fields with rales in the right lower lobe with
egophony demonstrated over the right lower lobe. The patient is sent for PA
and lateral chest X-ray; he is found to have a right lower lobe infiltration.
Best empiric treatment for his illness?
 A) Amoxicillin 875 mg twice daily for 10 days
 B) Azithromycin 500 mg first dose, then 250mg daily for 4 days
 C) Ciprofloxacin 500 mg twice daily for 10 days
 D) Trimethoprim/sulfamethoxazole DS twice daily for 10 days

33. Pneumonia – HIV related
 Think what organism?

34. Pneumonia – HIV related
 Think Pneumocystis jiroveci
 Opportunistic. Concern for immunocompromised pts.
 Cancer, malnourished, etc.
 TX:

35. Pneumonia – HIV related
 Think Pneumocystis jiroveci
 Opportunistic. Concern for immunocompromised pts.
 Cancer, malnourished, etc.
 TX: Bactrim (TMP/SMX)
 PPX: TMP/SMX- All HIV pts IF:
 CD4 < 200
 Evidence of immocompromise (oral candidiasis)
 Hx of pneumocystis infxn

36. Sample Question
 A 56-year-old man presents for a routine follow-up regarding his
positive HIV status. He is compliant with his medications and has
been feeling well. In addition to his antivirals, he takes daily
trimethoprim/sulfamethoxazole for Pneumocystis jiroveci
pneumonia (PCP) prophylaxis.
 What detail in his history would warrant prophylaxis?
A) CD4 cell count < 400
B) History of previous PCP infection
C) CD4 cell count > 200
D) History of previous pneumonia infection
E) HIV viral load >100,000 copies/mL

37. Sample Question
 A 56-year-old man presents for a routine follow-up regarding his
positive HIV status. He is compliant with his medications and has
been feeling well. In addition to his antivirals, he takes daily
trimethoprim/sulfamethoxazole for Pneumocystis jiroveci
pneumonia (PCP) prophylaxis.
 What detail in his history would warrant prophylaxis?
A) CD4 cell count < 400
B) History of previous PCP infection
C) CD4 cell count > 200
D) History of previous pneumonia infection
E) HIV viral load >100,000 copies/mL

38. Tuberculosis
 What kind of precautions?

39. Tuberculosis
 What kind of precautions? Airborne
 Organism:

40. Tuberculosis
 What kind of precautions? Airborne
 Organism: Mycobacterium tuberculosis
 Background:

41. Tuberculosis
 What kind of precautions? Airborne
 Organism: Mycobacterium tuberculosis
 Background: COUGH. FEVER. NIGHT SWEATS. ANOREXIA/
WEIGHT LOSS.

42. Tuberculosis
 What kind of precautions? Airborne
 Organism: Mycobacterium tuberculosis
 Background: COUGH. FEVER. NIGHT SWEATS. ANOREXIA/
WEIGHT LOSS.
 Review primary vs. latent/reactivated vs. healed
primary
 Highlight: latent/ reactivated/ secondary TB –
 loc: CXR: *APICES of lungs/ upper lobe cavitary dz; reactivated
at immunocompromise
 Highly tested: Tuberculin Skin Test

43. Sample Question
 A 45-year-old man presents with a fever accompanied
by a productive cough. He has had the symptoms for
several weeks. His temperature rises in the evenings,
and he has experienced weight loss. The chest X-ray
shows upper lobe cavitary lesions. What is the most
likely diagnosis?
 A) Secondary tuberculosis
 B) Asbestosis
 C) Pneumocystis carinii pneumonia
 D) Silicosis

44. Sample Question
 A 45-year-old man presents with a fever accompanied
by a productive cough. He has had the symptoms for
several weeks. His temperature rises in the evenings,
and he has experienced weight loss. The chest X-ray
shows upper lobe cavitary lesions. What is the most
likely diagnosis?
 A) Secondary tuberculosis
 B) Asbestosis
 C) Pneumocystis carinii pneumonia
 D) Silicosis

45. PPD
 POSITIVE (induration diameter):
 >5mm = HIV+, recent active TB contact, new transplant
 >10mm = new immigrant, IVDA (HIV-), DM, CKD, close
quarters (college, military, prisons)
 >15mm = no risk factors

46. Sample Questions
 30yo male HIV+ with PPD test showed induration of
7mm. Positive or Negative PPD?

47. Sample Questions
 30yo male HIV+ with PPD test showed induration of
7mm. Positive or Negative PPD?
 70yo female recently immigrated from Cambodia had
PPD test showing induration of 8mm. Positive or
negative PPD?

48. Sample Questions
 30yo male HIV+ with PPD test showed induration of
7mm. Positive or Negative PPD?
 70yo female recently immigrated from Cambodia had
PPD test showing induration of 8mm. Positive or
negative PPD?
 47yo male with DM and CKD going to college for his
second bachelor’s and living at dorms. PPD induration
12mm. Positive or negative?

49. Sample Questions
 30yo male HIV+ with PPD test showed induration of
7mm. Positive or Negative PPD?
 70yo female recently immigrated from Cambodia had
PPD test showing induration of 8mm. Positive or
negative PPD?
 47yo male with DM and CKD going to college for his
second bachelor’s and living at dorms. PPD induration
12mm. Positive or negative?
 28 yo female w/ asthma about to work at hospital. PPD
showed induration of 12mm. Positive or negative?

50. Sample Questions
 30yo male HIV+ with PPD test showed induration of
7mm. Positive or Negative PPD?
 70yo female recently immigrated from Cambodia had
PPD test showing induration of 8mm. Positive or
negative PPD?
 47yo male with DM and CKD going to college for his
second bachelor’s and living at dorms. PPD induration
12mm. Positive or negative?
 28 yo female w/ asthma about to work at hospital. PPD
showed induration of 12mm. Positive or negative?

51. Tuberculosis
 Sputum stain:

52. Tuberculosis
 Sputum stain: acid fast bacilli
 (*supports dx but does not confirm!* )
 Ways to have definite diagnosis that identifies M.
tuberculosis:

53. Tuberculosis
 Sputum stain: acid fast bacilli
 (*supports dx but does not confirm!* )
 Ways to have definite diagnosis that identifies M.
tuberculosis:
 Sputum Culture
 DNA/RNA amplification (PCR)
 Lung Biopsy- histologic hallmark:

54. Tuberculosis
 Sputum stain: acid fast bacilli
 (*supports dx but does not confirm!* )
 Ways to have definite diagnosis that identifies M.
tuberculosis:
 Sputum Culture
 DNA/RNA amplification (PCR)
 Lung Biopsy- histologic hallmark: caseating (necrotizing)
granulomas
 Vs. Sarcoidosis?

55. Acute bronchiolitis
 Who:

56. Acute bronchiolitis
 Who: Infants
 Causative agent:

57. Acute bronchiolitis
 Who: Infants
 Causative agent: RSV
 TX:

58. Acute bronchiolitis
 Who: Infants
 Causative agent: RSV
 TX: premies- hospital & ribavirin
 Otherwise, supportive

59. Acute epiglottitis
(2-7 yo, 45-65yo)
 Which vaccination has decreased incidence?

60. Acute epiglottitis
 Which vaccination has decreased incidence?
 Haemophilus influenzae type B (Hib)
 SSX:

61. Acute epiglottitis
 Which vaccination has decreased incidence?
 Haemophilus influenzae type B (Hib)
 SSX: Tripoding*. Drooling. Sudden high fever, resp
distress.
 Tripoding: ?
What do you do FIRST?

62. Acute epiglottitis
 Which vaccination has decreased incidence?
 Haemophilus influenzae type B (Hib)
 SSX: Tripoding*. Drooling. Sudden high fever, resp
distress.
 Tripoding: sitting upright + neck extended
What do you do FIRST?

63. Acute epiglottitis
 Which vaccination has decreased incidence?
 Haemophilus influenzae type B (Hib)
 SSX: Tripoding*. Drooling. Sudden high fever, resp
distress.
 Tripoding: sitting upright + neck extended
What do you do FIRST? SECURE AIRWAY (intubate)
What do you see on lateral neck XR? :

64. Acute epiglottitis
 Which vaccination has decreased incidence?
 Haemophilus influenzae type B (Hib)
 SSX: Tripoding*. Drooling. Sudden high fever, resp
distress.
 Tripoding: sitting upright + neck extended
What do you do FIRST? SECURE AIRWAY (intubate)
What do you see on lateral neck XR? : THUMBPRINT SIGN

65. Thumbprint sign

66. Sample Question
 3 year old child presents to ER with sudden onset of
fever, difficulty swallowing, drooling, and dyspnea.
Exam reveals febrile child who is sitting, leaning
forward with his neck extended. Chest exam reveals
soft stridor with inspiratory retractions. What is the
next step in management of this patient?
A) Treatment with nebulized albuterol
B) Treatment with nebulized epinephrine
C) Inspection and intubation under controlled conditions
D) IV acetazolamide therapy

67. Sample Question
 3 year old child presents to ER with sudden onset of
fever, difficulty swallowing, drooling, and dyspnea.
Exam reveals febrile child who is sitting, leaning
forward with his neck extended. Chest exam reveals
soft stridor with inspiratory retractions. What is the
next step in management of this patient?
A) Treatment with nebulized albuterol
B) Treatment with nebulized epinephrine
C) Inspection and intubation under controlled conditions
D) IV acetazolamide therapy

68. Croup
 Aka acute laryngotracheobronchitis
 Affects children 6mos to 5yo
 *MC causative agent:

69. Croup
 Aka acute laryngotracheobronchitis
 Affects children 6mos to 5yo
 *MC causative agent: parainfluenzae virus types 1 & 2
 (Note: CAN be caused by RSV, but parainfluenzae is MC)
 Buzz SSX:

70. Croup
 Aka acute laryngotracheobronchitis
 Affects children 6mos to 5yo
 *MC causative agent: parainfluenzae virus types 1 & 2
 (Note: CAN be caused by RSV, but parainfluenzae is MC)
 Buzz SSX: seal-like, barking cough
 Imaging:

71. Croup
 Aka acute laryngotracheobronchitis
 Affects children 6mos to 5yo
 *MC causative agent: parainfluenzae virus types 1 & 2
 (Note: CAN be caused by RSV, but parainfluenzae is MC)
 Buzz SSX: seal-like, barking cough
 Imaging: PA neck film- Steeple sign

72. Steeple sign

73. Croup
 Tx:
 Mild = NO stridor at rest = SUPPORTIVE
 Moderate to Severe = Stridor AT REST =

74. Croup
 Tx:
 Mild = NO stridor at rest = SUPPORTIVE
 Moderate to Severe = Stridor AT REST = Racemic EPI
(nebulized) & hospitalization

75. Sample Question
 A 3-year-old boy presents with difficulty in breathing and a
cough that sounds like a seal. On examination, the child has
fever, a harsh barking cough, a respiratory rate of 38/minute,
and minimal stridor on agitation. On lung auscultation, there
are no rales or wheezing. On cardiac auscultation, there is
tachycardia. Radiological examination reveals the so-called
'steeple sign'. What is the most likely diagnosis?
 A) Bronchiolitis
 B) Croup
 C) Epiglottitis
 D) Foreign body aspiration

76. Sample Question
 A 3-year-old boy presents with difficulty in breathing and a
cough that sounds like a seal. On examination, the child has
fever, a harsh barking cough, a respiratory rate of 38/minute,
and minimal stridor on agitation. On lung auscultation, there
are no rales or wheezing. On cardiac auscultation, there is
tachycardia. Radiological examination reveals the so-called
'steeple sign'. What is the most likely diagnosis?
 A) Bronchiolitis
 B) Croup
 C) Epiglottitis
 D) Foreign body aspiration

77. Sample Question
 4 year old child presents to ER with low-grade fever,
barking cough, respiratory stridor with activity but not
at rest. On exam, you note cough and absence of
drooling. What is the most appropriate treatment for
this child?
 A) Dexamethasone IM
 B) Endotracheal intubation and IV antibiotics
 C) Nebulized racemic epinephrine
 D) Supportive therapy with oral hydration

78. Sample Question
 4 year old child presents to ER with low-grade fever,
barking cough, respiratory stridor with activity but not
at rest. On exam, you note cough and absence of
drooling. What is the most appropriate treatment for
this child?
 A) Dexamethasone IM
 B) Endotracheal intubation and IV antibiotics
 C) Nebulized racemic epinephrine
 D) Supportive therapy with oral hydration

79. Obstructive Lung Dz
 Asthma
 COPD
 Bronchiectasis
 Cystic Fibrosis

80. Obstructive Lung Dz: Asthma
 Classification! & Step Up therapy: What are classes?

81. Obstructive Lung Dz: Asthma
 Classification! & Step Up therapy:
 Intermittent
 Mild persistent
 Moderate persistent
 Severe persistent

82. Asthma
Severity Sx Night Sx Rescue
Use
TX
Intermittent <2 d/wk <2 / mo <2 d/wk
Mild
Persistent
Moderate
Persistent
Severe
Persistent

83. Asthma
Severity Sx Night Sx Rescue
Use
TX
Intermittent <2 d/wk <2 / mo <2 d/wk
Mild
Persistent
Moderate
Persistent
Severe
Persistent
Nightly
(often
7x/wk)

84. Asthma
Severity Sx Night Sx Rescue
Use
TX
Intermittent <2 d/wk <2 / mo <2 d/wk
Mild
Persistent
Moderate
Persistent
Daily
Severe
Persistent
Nightly
(often
7x/wk)

85. Asthma
Severity Sx Night Sx Rescue
Use
TX
Intermittent <2 d/wk <2 / mo <2 d/wk
Mild
Persistent
Not daily.
>2d/wk
Moderate
Persistent
Daily
Severe
Persistent
Nightly
(often
7x/wk)

86. Asthma
Severity Sx Night Sx Rescue
Use
TX
Intermittent <2 d/wk <2 / mo <2 d/wk
Mild
Persistent
Not daily.
>2d/wk
Moderate
Persistent
Daily
Severe
Persistent
Nightly
(often
7x/wk)
More than
once a day

87. Asthma
Severity Sx Night Sx Rescue
Use
TX
Intermittent <2 d/wk <2 / mo <2 d/wk
Mild
Persistent
>2d/wk 3-4 x/mo
(once a
wk)
Not daily.
>2d/wk
Moderate
Persistent
Some
limits ADL
>1 /wk but
not nightly
Daily
Severe
Persistent
Extremely
limited
phys act
Nightly
(often
7x/wk)
More than
once a day

88. Asthma
Severity Sx Night Sx Rescue
Use
TX Lung Fxn
Intermittent <2 d/wk <2 / mo <2 d/wk SABA
Mild
Persistent
>2d/wk 3-4 x/mo
(once a
wk)
Not daily.
>2d/wk
SABA + ICS
Moderate
Persistent
Some
limits ADL
>1 /wk but
not nightly
Daily SABA +ICS +
LABA
Severe
Persistent
Extremely
limited
phys act
Nightly
(often
7x/wk)
More than
once a day
PO
steroids,
hospital if
needed

89. Asthma
Severity Sx Night Sx Rescue
Use
TX Lung Fxn
Intermittent <2 d/wk <2 / mo <2 d/wk SABA FEV1>80%
predicted;
FEV1/FVC
normal
Mild
Persistent
>2d/wk 3-4 x/mo
(once a
wk)
Not daily.
>2d/wk
SABA + ICS “ “
Moderate
Persistent
Some
limits ADL
>1 /wk but
not nightly
Daily SABA +ICS +
LABA
FEV1>60%
but <80%
predict
FEV1/FVC
reduced 5%
Severe
Persistent
Extremely
limited
phys act
Nightly
(often
7x/wk)
More than
once a day
PO
steroids,
hospital if
needed
FEV1<60%
predicted
FEV1/FVC
reduced

90. Asthma
 Spirometry:
 Diagnostic if FEV1 decrease >20%
 Supportive of dx if
 FEV1/FVC = <75%
 FEV1 s/p bronchodilation = >10% decrease

91. Sample Question
 9 year old boy w/ hx of asthma presents with nocturnal
coughing occurring every night along with daily
exacerbations of wheezing and shortness of breath. How
would his asthma be classified?
 A) Intermittent
 B) Mild persistent
 C) Moderate persistent
 D) Severe persistent

92. Sample Question
 9 year old boy w/ hx of asthma presents with nocturnal
coughing occurring every night along with daily
exacerbations of wheezing and shortness of breath. How
would his asthma be classified?
 A) Intermittent
 B) Mild persistent
 C) Moderate persistent
 D) Severe persistent

93. COPD
 Stop smoking
 CXR: emphysema: ___________________?

94. COPD
 Stop smoking
 CXR: emphysema: parenchymal bullae/ subpleural blebs
 PATHOGNOMONIC !
 Vs. chronic bronchitis: nonspecific peribronchial & perivasc
markings
Key medication: anticholinergic: ?

95. COPD
 Stop smoking
 CXR: emphysema: parenchymal bullae/ subpleural blebs
 PATHOGNOMONIC !
 Vs. chronic bronchitis: nonspecific peribronchial & perivasc
markings
Key medication: anticholinergic: ipatropium / tiotropium
(Spiriva = tiotropium bromide)
PPX measures: ?

96. COPD
 Stop smoking
 CXR: emphysema: parenchymal bullae/ subpleural blebs
 PATHOGNOMONIC !
 Vs. chronic bronchitis: nonspecific peribronchial & perivasc
markings
Key medication: anticholinergic: ipatropium / tiotropium
(Spiriva = tiotropium bromide)
PPX measures: pneumococcal vaccine & annual flu

97. COPD
 What is the only therapy known to increase life
expectancy in COPD patients with chronic hypoxemia?
 A) Antibiotics
 B) Bronchodilator therapy
 C) Inhaled corticosteroids
 D) Home Oxygen

98. COPD
 What is the only therapy known to increase life
expectancy in COPD patients with chronic hypoxemia?
 A) Antibiotics
 B) Bronchodilator therapy
 C) Inhaled corticosteroids
 D) Home Oxygen

99. Bronchiectasis
 Think of what disease?

100. Bronchiectasis
 Think CYSTIC FIBROSIS
 50% of cases
SSX: ?

101. Bronchiectasis
 Think CYSTIC FIBROSIS
 50% of cases
SSX: Foul-smelling sputum/ hemoptysis/ recurrent pneumonia
Localized chest crackles/ clubbing
Imaging:
- High resolution CHEST CT: dilated tortuous airways
- CXR: crowded bronchial markings, basal cystic spaces
- *Tram-track lung markings, honeycombing, atelectasis
Tx: chest physio, bronchodilators, abx (10-14d for acute)

102. Cystic Fibrosis
 Autosomal recessive – CFTR gene
 Young, chronic lung dz, pancreatitis. Sputum excess,
steatorrhea, clubbing
 CXR: bronchiectasis
 Dx: sweat chloride test (pilocarpine ionotophoresis)
 Definitive: DNA testing
 TX: multidisciplinary.
 Acetylcysteine = mucolytic. (Mucomyst)

103. Sample Question
 17 year old girl with hx of CF presents with chronic
cough productive of copious, foul smelling, purulent
sputum. Patient is afebrile and lung exam reveals
crackles at lung bases bilaterally. What is the most
likely diagnosis?
 A) Asthma
 B) Bronchiectasis
 C) Bronchiolitis
 D) Croup

104. Sample Question
 17 year old girl with hx of CF presents with chronic
cough productive of copious, foul smelling, purulent
sputum. Patient is afebrile and lung exam reveals
crackles at lung bases bilaterally. What is the most
likely diagnosis?
 A) Asthma
 B) Bronchiectasis
 C) Bronchiolitis
 D) Croup

105. Restrictive Lung Dz
 Pneumoconiosis
 Sarcoidosis

106. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Silicosis
Asbestosis
Berryliosis

107. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Coal mining CXR:
Silicosis
Asbestosis
Berryliosis

108. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Coal mining CXR: small
nodular opac @
UPPER LUNGS
Progressive
fibrosis
Silicosis
Asbestosis
Berryliosis

109. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Coal mining CXR: small
nodular opac @
UPPER LUNGS
Progressive
fibrosis
Silicosis Mining/ sand
blasting/ stone
work
Asbestosis
Berryliosis

110. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Coal mining CXR: small
nodular opac @
UPPER LUNGS
Progressive
fibrosis
Silicosis Mining/ sand
blasting/ stone
work
CXR: nodular
opac @ BASES of
lungs
*EGG SHELL
CALCIFICATIONS*
Calcified hilar
lymph nodes
Progressive
fibrosis, higher
TB risk
Asbestosis
Berryliosis

111. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Coal mining CXR: small
nodular opac @
UPPER LUNGS
Progressive
fibrosis
Silicosis Mining/ sand
blasting/ stone
work
CXR: nodular
opac @ BASES of
lungs
*EGG SHELL
CALCIFICATIONS*
Calcified hilar
lymph nodes
Progressive
fibrosis, higher
TB risk
Asbestosis Construction/
demolition
Berryliosis

112. Pneumoconiosis
Dz Occupation Dx Complications
Coal Worker’s
Pneumoconiosis
Coal mining CXR: small nodular
opac @ UPPER LUNGS
Progressive fibrosis
Silicosis Mining/ sand
blasting/ stone work
CXR: nodular opac @
BASES of lungs
*EGG SHELL
CALCIFICATIONS*
Calcified hilar lymph
nodes
Progressive fibrosis,
higher TB risk
Asbestosis Construction/
demolition
CXR: thickened
pleura / calcified
plaques
BX: asbestos bodies
Mesothelioma, CA
Berryliosis Aerospace/ nuclear/
ceramics
CXR: diffuse
infiltrates/hilar
adenopathy
Progressive fibrosis –
chronic steroids

113. Pneumoconiosis
 Tx:. Corticosteroids. Supportive
 Stop smoking

114. Sample Question
 A 59-year-old man presents with a 3-month history of progressive
exertional dyspnea. He has been experiencing dry cough, but
denies any history of fever, chest pain, or weight loss. On further
questioning, you discover that he works in the ceramic industry
at the outskirts of town. He is a non-smoker and drinks alcohol
very occasionally. Examination reveals bibasilar crackles, and
pulmonary function test indicates FEV1 of 67%, FVC of 73%, and
TLC of 75% with DLCO of 65%. Chest X-ray shows "eggshell
calcification" of hilar lymph nodes.
A) Asbestosis
B) Silicosis
C) Coal Worker’s Pneumoconiosis
D) Berylliosis

115. Sample Question
 A 59-year-old man presents with a 3-month history of progressive
exertional dyspnea. He has been experiencing dry cough, but
denies any history of fever, chest pain, or weight loss. On further
questioning, you discover that he works in the ceramic industry
at the outskirts of town. He is a non-smoker and drinks alcohol
very occasionally. Examination reveals bibasilar crackles, and
pulmonary function test indicates FEV1 of 67%, FVC of 73%, and
TLC of 75% with DLCO of 65%. Chest X-ray shows "eggshell
calcification" of hilar lymph nodes.
A) Asbestosis
B) Silicosis
C) Coal Worker’s Pneumoconiosis
D) Berylliosis

116. Sarcoidosis
 GRUELING mnemonic
 G
 R
 U
 E
 L
 I
 N
 G

117. Sarcoidosis
 GRUELING mnemonic
 Granulomas (what kind? Vs tuberculosis…)
 ARthritis
 Uveitis
 Erythema nodosum
 Lymphadenopathy
 Interstitial fibrosis
 Negative TB
 Gammaglobulinemia

118. Sarcoidosis
 GRUELING mnemonic
 Granulomas (NON-CASEATING)
 ARthritis
 Uveitis
 Erythema nodosum
 Lymphadenopathy
 Interstitial fibrosis
 Negative TB
 Gammaglobulinemia

119. Sarcoidosis
 Confirmatory test for diagnosis:

120. Sarcoidosis
 Confirmatory test for diagnosis: Fine needle node biopsy

121. Sarcoidosis
 Confirmatory test for diagnosis: Fine needle node biopsy
 NONCASEATING GRANULOMAS
TX: 90% responsive to what? Think multi-organ inflammation.

122. Sarcoidosis
 Confirmatory test for diagnosis: Fine needle node biopsy
 NONCASEATING GRANULOMAS
TX: 90% responsive to what? Think multi-organ inflammation.
CORTICOSTEROIDS

123. Sample Question
 A 32-year-old African-American woman, with no significant past medical history, has
been referred to a pulmonologist; she presents with a 2-month history of progressive
dyspnea. She notes associated low-grade fever, malaise, joint pain, and swollen neck
glands. She denies a history of travel, cigarette smoking, drug use, or sexually-
transmitted diseases (she has not been sexually active in the past year). All other
reviews of systems are negative. Her physical exam reveals tender, nodular formations
on her anterior lower extremities, parotid enlargement, hepatosplenomegaly, and
cervical lymphadenopathy. Her vital signs, heart, and lungs are unremarkable.
Diagnostic testing reveals leukopenia, increased ESR, hypercalcemia, hypercalciuria,
elevations of serum ACE levels, and bilateral hilar adenopathy with diffuse reticular
infiltrates. ANCA, ANA, and rheumatoid factor tests are negative. Histological
assessment confirms the presence of noncaseating granulomas.
What is the most likely diagnosis?
 A) Sarcoidosis
 B) Tuberculosis
 C) Pnemocystis jiroveci pneumonia
 D) Idiopathic pulmonary fibrosis

124. Sample Question
 A 32-year-old African-American woman, with no significant past medical history, has
been referred to a pulmonologist; she presents with a 2-month history of progressive
dyspnea. She notes associated low-grade fever, malaise, joint pain, and swollen neck
glands. She denies a history of travel, cigarette smoking, drug use, or sexually-
transmitted diseases (she has not been sexually active in the past year). All other
reviews of systems are negative. Her physical exam reveals tender, nodular formations
on her anterior lower extremities, parotid enlargement, hepatosplenomegaly, and
cervical lymphadenopathy. Her vital signs, heart, and lungs are unremarkable.
Diagnostic testing reveals leukopenia, increased ESR, hypercalcemia, hypercalciuria,
elevations of serum ACE levels, and bilateral hilar adenopathy with diffuse reticular
infiltrates. ANCA, ANA, and rheumatoid factor tests are negative. Histological
assessment confirms the presence of noncaseating granulomas.
What is the most likely diagnosis?
 A) Sarcoidosis
 B) Tuberculosis
 C) Pnemocystis jiroveci pneumonia
 D) Idiopathic pulmonary fibrosis

125. Pleural Dz:
 Pleural effusion
 Pneumothorax
 Pulmonary embolism

126. Pleural Effusion
 *MC cause:

127. Pleural Effusion
 *MC cause: CHF
 Transudate vs. Exudate

128. Pleural Effusion
 *MC cause: CHF
 Transudate vs. Exudate

129. Pleural Effusion
 *MC cause: CHF
 Transudate > Exudate
 Transudate: “intact capillaries” – hold protein in, so
pleural fluid is low protein
 CHF. Atelectasis. Renal/Liver dz (Cirrhosis).
 Exudate: “leaky capillaries” – pleural fluid high protein
 Infection. Malignancy. Trauma. Pulmonary Embolism.

130. Pleural Effusion
 What is the GOLD STANDARD for diagnosis (also
therapeutic) ?

131. Pleural Effusion
 What is the GOLD STANDARD for diagnosis (also
therapeutic) ? Thoracentesis

132. Pleural Effusion
 What is the GOLD STANDARD for diagnosis (also
therapeutic) ? Thoracentesis
 Light’s Criteria !

133. Pleural Effusion: Light’s
Transudate if pleural fluid: Exudate if pleural fluid:
Protein < 3 g/dL
Glucose >60 mg/dl
WBC’s <1,000
LDH <200 IU/L
> 3g/dL
< 60mg/dL
> 1,000
> 200 IU/L
OR
-Fluid protein: serum protein =
<0.5
- Fluid LDH: Serum LDH = <0.6
- Fluid LDH >2/3 of upper limit of
normal serum LDH
= <200 iU/mL
>0.5
>0.6
> 200 iu/mL

134. Sample Question
60 yr old man w/ hx of hypertension and left ventricular
hypertrophy presents with shortness of breath. Exam
reveals dullness to percussion bilaterally with decreased
breath sounds. Pleural fluid is aspirated and analyzed.
Which of the following results is consistent with his most
likely diagnosis?
A) Glucose 40mg/dL
B) LDH 300 iU/L
C) Protein 2.5 mg/dL
D) WBC 2,000

135. Sample Question
60 yr old man w/ hx of hypertension and left ventricular
hypertrophy presents with shortness of breath. Exam
reveals dullness to percussion bilaterally with decreased
breath sounds. Pleural fluid is aspirated and analyzed.
Which of the following results is consistent with his most
likely diagnosis?
A) Glucose 40mg/dL
B) LDH 300 iU/L
C) Protein 2.5 mg/dL
D) WBC 2,000

136. Pneumothorax
 Pt background:

137. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?

138. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?

139. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?
 What happens to mediastinum?

140. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?
 What happens to mediastinum? Shifts contralaterally
 What happens to the trachea? (late sign)

141. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?
 What happens to mediastinum? Shifts contralaterally
 What happens to the trachea? (late sign) Deviates
contralaterally
 What do you do if high suspicion of tension ptx? (this is a
medical emergency!)

142. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?
 What happens to mediastinum? Shifts contralaterally
 What happens to the trachea? (late sign) Deviates
contralaterally
 What do you do if high suspicion of tension ptx? (this is a
medical emergency!) Needle decompression+ chest tube
 *note: thoraCOSTomy vs thoraCOTomy
 What do you see on CXR?

143. Pneumothorax
 Pt background: TALL, THIN MALE (10-30yo)
 Increased or decreased fremitus?
 What happens to mediastinum? Shifts contralaterally
 What happens to the trachea? (late sign) Deviates
contralaterally
 What do you do if high suspicion of tension ptx? (this is a
medical emergency!) Needle decompression+ chest tube
 *note: thoraCOSTomy vs thoraCOTomy
 What do you see on CXR? Pleural line

144. Pneumothorax

145. Sample question
 A 25-year-old male basketball player presents with acute onset shortness of breath
associated with right-sided chest pain. The pain is unaffected by position and is
worse with inspiration. He was grocery shopping when it started. He denies chest
trauma. He had an upper respiratory infection earlier in the month that had
resolved without incident. He smokes 1 pack of cigarettes per day and has no
significant past medical history. On PE he is afebrile; BP is 138/80; P is 124; R is
24; and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is
midline. Lungs are clear to auscultation bilaterally with no wheezing or rhonchi;
tactile fremitus and percussion are equal throughout posterior lung fields. Heart is
tachycardic with normal S1 and S2, no murmur, rubs, or gallops.
What is most likely diagnosis?
A) Pericarditis
B) Pulmonary embolism
C) Spontaneous pneumothorax
D) Community Acquired Pneumonia

146. Sample question
 A 25-year-old male basketball player presents with acute onset shortness of breath
associated with right-sided chest pain. The pain is unaffected by position and is
worse with inspiration. He was grocery shopping when it started. He denies chest
trauma. He had an upper respiratory infection earlier in the month that had
resolved without incident. He smokes 1 pack of cigarettes per day and has no
significant past medical history. On PE he is afebrile; BP is 138/80; P is 124; R is
24; and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is
midline. Lungs are clear to auscultation bilaterally with no wheezing or rhonchi;
tactile fremitus and percussion are equal throughout posterior lung fields. Heart is
tachycardic with normal S1 and S2, no murmur, rubs, or gallops.
What is most likely diagnosis?
A) Pericarditis
B) Pulmonary embolism
C) Spontaneous pneumothorax
D) Community Acquired Pneumonia

147. Pulmonary Embolism
 Majority resulting from ?

148. Pulmonary Embolism
 Majority resulting from DVT
 Virchow’s Triad?
 Other causes:
 Central line  air emboli
 Long bone (femur) fracture  fat emboli
 Active labor  amniotic fluid emboli
What do you see on EKG ?

149. Pulmonary Embolism
 Majority resulting from DVT
 Virchow’s Triad: V (Venous stasis) , I (Increased
coagulability), R (recent injury, reduced activity)
 Other causes:
 Central line  air emboli
 Long bone (femur) fracture  fat emboli
 Active labor  amniotic fluid emboli
What do you see on EKG ?

150. Pulmonary Embolism
 Majority resulting from DVT
 Virchow’s Triad: V (Venous stasis) , I (Increased
coagulability), R (recent injury, reduced activity)
 Other causes:
 Central line  air emboli
 Long bone (femur) fracture  fat emboli
 Active labor  amniotic fluid emboli
What do you see on EKG ? S1Q3T3

151. Normal EKG

152. Normal EKG vs Pulm Embolism

153. Pulmonary Embolism
 What lab can help rule out PE?

154. Pulmonary Embolism
 What lab can help rule out PE? D-Dimer
 Highly SENSITIVE. NOT specific.
 What is the INITIAL imaging test of choice for suspected
PE?

155. Pulmonary Embolism
 What lab can help rule out PE? D-Dimer
 Highly SENSITIVE. NOT specific.
 What is the INITIAL imaging test of choice for suspected
PE?
 SPIRAL CT
 What is DEFINITIVE imaging test for PE?

156. Pulmonary Embolism
 What lab can help rule out PE? D-Dimer
 Highly SENSITIVE. NOT specific.
 What is the INITIAL imaging test of choice for suspected
PE?
 SPIRAL CT
 What is DEFINITIVE imaging test for PE? Pulmonary
angiogram
Anticoagulation! – Heparin & warfarin!
If you can’t anticoagulate, what can you do?

157. Pulmonary Embolism
 What lab can help rule out PE? D-Dimer
 Highly SENSITIVE. NOT specific.
 What is the INITIAL imaging test of choice for suspected
PE?
 SPIRAL CT
 What is DEFINITIVE imaging test for PE? Pulmonary
angiogram
Anticoagulation! – Heparin & warfarin!
If you can’t anticoagulate, what can you do? Vena cava filter

158. Sample Question
A 45-year-old man presents with a 30-minute history of chest
pain; it began while he was on a long airline flight. He denies
any trauma to the chest. On exam, his pulse is 110 BPM;
respirations are 40/min. The chest radiograph reveals a wedge-
shaped opacity.
What is most likely cause of his chest pain?
A) Esophageal reflux
B) Pneumonia
C) Aortic dissection
D) Pulmonary embolism

159. Sample Question
A 45-year-old man presents with a 30-minute history of chest
pain; it began while he was on a long airline flight. He denies
any trauma to the chest. On exam, his pulse is 110 BPM;
respirations are 40/min. The chest radiograph reveals a wedge-
shaped opacity.
What is most likely cause of his chest pain?
A) Esophageal reflux
B) Pneumonia
C) Aortic dissection
D) Pulmonary embolism

160. Acute Resp Distress Syndrome
(ARDS)
 Pt background:

161. Acute Resp Distress Syndrome
(ARDS)
 Pt background:
 Severe multiple trauma
 Aspiration of gastric contents
 SEPSIS
 Shock/ toxic inhalation/ near-DROWNING
SX: tachypnea. FROTHY PINK/ RED SPUTUM.
CXR: Think fluid. Inflammation. Alveolar collapse.
*air bronchograms, patchy bilateral infiltrates that spare the
costophrenic angles.*

162. Normal CXR

163. ARDS

164. ARDS
 TX:

165. ARDS
 TX: Endotracheal intubation-
 POS PRESSURE VENT + low PEEP (Positive End- Expiratory
Pressure)

166. Sample Question
 A 25-year-old man presents at the hospital after a car
accident. He is intubated and placed on a ventilator. He
becomes progressively difficult to oxygenate despite
increasing the PEEP and the oxygen supply to 100%. Patient
remains afebrile. He dies several days later. At autopsy, the
lung shows diffuse hyaline membranes in the alveoli,
thickened alveolar walls, and many alveolar macrophages,
but few neutrophils. What condition did this patient have?
 A) Adult Respiratory Distress Syndrome
 B) Chronic bronchitis
 C) Bronchiectasis
 D) Viral pneumonia

167. Sample Question
 A 25-year-old man presents at the hospital after a car
accident. He is intubated and placed on a ventilator. He
becomes progressively difficult to oxygenate despite
increasing the PEEP and the oxygen supply to 100%. Patient
remains afebrile. He dies several days later. At autopsy, the
lung shows diffuse hyaline membranes in the alveoli,
thickened alveolar walls, and many alveolar macrophages,
but few neutrophils. What condition did this patient have?
 A) Adult Respiratory Distress Syndrome
 B) Chronic bronchitis
 C) Bronchiectasis
 D) Viral pneumonia

168. Foreign Body Aspiration
 What is diagnostic and treatment of choice for removal?

169. Foreign Body Aspiration
 What is diagnostic and treatment of choice for removal?
 Bronchoscopy
Acute aspiration of gastric contents can lead to what?

170. Foreign Body Aspiration
 What is diagnostic and treatment of choice for removal?
 Bronchoscopy
Acute aspiration of gastric contents can lead to what?
ARDS !

171. Sample Question
 5 year old previously healthy presents with acute onset
of respiratory distress following ingestion of a piece of
candy. Which of the following signs is most ominous?
 A) Aphonia
 B) Cough
 C) Drooling
 D) Stridor

172. Sample Question
 5 year old previously healthy presents with acute onset
of respiratory distress following ingestion of a piece of
candy. Which of the following signs is most ominous?
 A) Aphonia
 B) Cough
 C) Drooling
 D) Stridor

173. Hyaline Membrane Dz
 *MC cause of respiratory dz in preterm infant!
 = deficiency of what?

174. Hyaline Membrane Dz
 *MC cause of respiratory dz in preterm infant!
 = deficiency of what? SURFACTANT
 PPX or rescue TX: exogenous surfactant in delivery room
 Synchronized intermittent ventilation
 For high risk premature-antenatal CS given to weeks 24-34
wks

175. Sample Question
 Premature infant born at 32 wks develops rapid shallow
respirations at 60/min, grunting retractions, and
duskiness of skin. CXR shows diffuse bilateral
atelectasis, ground glass appearance, and air
bronchograms. What is the most likely diagnosis?
A) Hyaline membrane disease
B) Acute laryngotracheobronchitis
C) Bronchiolitis
D) Pulmonary embolism

176. Sample Question
 Premature infant born at 32 wks develops rapid shallow
respirations at 60/min, grunting retractions, and
duskiness of skin. CXR shows diffuse bilateral
atelectasis, ground glass appearance, and air
bronchograms. What is the most likely diagnosis?
A) Hyaline membrane disease
B) Acute laryngotracheobronchitis
C) Bronchiolitis
D) Pulmonary embolism

177. Neoplastic Dz
 Bronchogenic Carcinoma
General: #1 leading cause of CA death in men & women
(>colon, breast, & prostate combined)
**Smoking is #1 factor**
 SCLC vs NSCLC
 Pulmonary nodule
 Carcinoid Tumor

178. Small Cell (SCLC)
 Worst. “Small Cell Sucks” (worst prognosis)– use
alliteration to jog memory
 S-Spreads early, Super aggressive, Central bronchi
 Can’t even do Surgery
 TX: *COMBO Radiation & Chemo!*

179. Non small Cell (NSCLC)
 NOT small cell, so NOT as aggressive.
SLOWER growth. & more amenable to Surgery.
Tx: *Surgery
3 Types:
1. Adenocarcinoma (35-50%)
2. Squamous Cell Carcinoma (25-35%)
3. Large Cell Carcinoma

180. Non small Cell (NSCLC)
 NOT small cell, so NOT as aggressive.
SLOWER growth. & more amenable to Surgery.
TX: * Surgery
3 Types:
1. Adenocarcinoma  MC* CA type in NON-SMOKERS
 Appears in lung periphery (“Adeno” – “Away”)
2. Squamous Cell Carcinoma
3. Large Cell Carcinoma

181. Non small Cell (NSCLC)
 NOT small cell, so NOT as aggressive.
SLOWER growth. & more amenable to Surgery.
Tx: *Surgery
3 Types:
1. Adenocarcinoma  MC* CA type in NON-SMOKERS
 Appears in lung periphery (“Adeno” – “Away”)
2. Squamous Cell Carcinoma
 Bronchial & centrally located mass
 Likely present w/ hemoptysis
3. Large Cell Carcinoma

182. Non small Cell (NSCLC)
 NOT small cell, so NOT as aggressive.
SLOWER growth. & more amenable to Surgery.
TX: Surgery*
3 Types:
1. Adenocarcinoma  MC* CA type in NON-SMOKERS
 Appears in lung periphery (“Adeno” – “Away”)
2. Squamous Cell Carcinoma
 Bronchial & centrally located mass
 Likely present w/ hemoptysis
3. Large Cell Carcinoma
 Cytology: large cells
 Central OR peripheral mass

183. Drawing

184. Sample Question
 A 52-year-old man presents to discuss the results of his recent lung
biopsy. You saw him 3 weeks earlier due to his experiencing dyspnea. He
has no other significant past medical history. His chest X-ray reveals a 3-
centimeter (diameter) mass in the right upper lobe near the hilum. A CT
scan of his chest, abdomen, pelvis, and head reveals only the mass seen
on X-ray. His blood counts and blood chemistries are normal. He
underwent bronchoscopic biopsy of the lesion, which reveals small cell
lung cancer. What is the most appropriate course of treatment?
 A) Radiation only
 B) Radiation followed by chemotherapy
 C) Radiation followed by surgical resection
 D) Surgical resection only
 E) Comfort measures only

185. Sample Question
 A 52-year-old man presents to discuss the results of his recent lung
biopsy. You saw him 3 weeks earlier due to his experiencing dyspnea. He
has no other significant past medical history. His chest X-ray reveals a 3-
centimeter (diameter) mass in the right upper lobe near the hilum. A CT
scan of his chest, abdomen, pelvis, and head reveals only the mass seen
on X-ray. His blood counts and blood chemistries are normal. He
underwent bronchoscopic biopsy of the lesion, which reveals small cell
lung cancer. What is the most appropriate course of treatment?
 A) Radiation only
 B) Radiation followed by chemotherapy
 C) Radiation followed by surgical resection
 D) Surgical resection only
 E) Comfort measures only

186. Sample Question
 A 60-year-old woman presents with a history of persistent cough. She is confined
to her bed; walking over 10 paces causes severe breathlessness. She has no energy
to carry out any of her regular activities. She has never smoked, and she drinks
the occasional glass of wine. On physical examination, she is found to have
decreased breath sounds and dullness to percussion over her right lower thorax.
Further evaluation reveals an irregular mass in the periphery of the right lung base
with a right sided pleural effusion. A needle is inserted into the pleural space and
divulges blood stained fluid.
 If results prove to be a malignancy, what is the most likely sub-type considering
she has never smoked?
 A) Small Cell Carcinoma
 B) Large Cell Carcinoma
 C) Squamous Cell Carcinoma
 D) Adenocarcinoma

187. Sample Question
 A 60-year-old woman presents with a history of persistent cough. She is confined
to her bed; walking over 10 paces causes severe breathlessness. She has no energy
to carry out any of her regular activities. She has never smoked, and she drinks
the occasional glass of wine. On physical examination, she is found to have
decreased breath sounds and dullness to percussion over her right lower thorax.
Further evaluation reveals an irregular mass in the periphery of the right lung base
with a right sided pleural effusion. A needle is inserted into the pleural space and
divulges blood stained fluid.
 If results prove to be a malignancy, what is the most likely sub-type considering
she has never smoked?
 A) Small Cell Carcinoma
 B) Large Cell Carcinoma
 C) Squamous Cell Carcinoma
 D) Adenocarcinoma

188. Complications of Lung CA
 SPHERE mnemonic
 S
 P
 H
 E
 R
 E

189. Complications of Lung CA
 SPHERE mnemonic
 SVC Syndrome (compression of SVC excess fluid/blood, HA,
AMS
 Pancoast Tumor (lung apex tumor, horner’s syndrome +
shoulder pain, affects brachial plexus + cervical sympathetic
nerve)
 Horner’s Syndrome ( ?)
 Endocrine (Carcinoid syndrome ?)
 Recurrent laryngeal nerve (hoarseness)
 Effusion ( what kind?)

190. Complications of Lung CA
 SPHERE mnemonic
 SVC Syndrome (compression of SVC excess fluid/blood, HA,
AMS
 Pancoast Tumor (lung apex tumor, horner’s syndrome +
shoulder pain, affects brachial plexus + cervical sympathetic
nerve)
 Horner’s Syndrome (unilat facial ptosis, miosis, anhidrosis)
 Endocrine (Carcinoid syndrome?)
 Recurrent laryngeal nerve (hoarseness)
 Effusion ( what kind?)

191. Complications of Lung CA
 SPHERE mnemonic
 SVC Syndrome (compression of SVC excess fluid/blood, HA,
AMS
 Pancoast Tumor (lung apex tumor, horner’s syndrome + shoulder
pain, affects brachial plexus + cervical sympathetic nerve)
 Horner’s Syndrome (unilat facial ptosis, miosis, anhidrosis)
 Endocrine (Carcinoid syndrome- FDR: flushing/ diarrhea/ R-side
heart fail)
 Recurrent laryngeal nerve (hoarseness)
 Effusion ( what kind?)

192. Complications of Lung CA
 SPHERE mnemonic
 SVC Syndrome (compression of SVC excess fluid/blood, HA,
AMS
 Pancoast Tumor (lung apex tumor, horner’s syndrome + shoulder
pain, affects brachial plexus + cervical sympathetic nerve)
 Horner’s Syndrome (unilat facial ptosis, miosis, anhidrosis)
 Endocrine (Carcinoid syndrome- FDR: flushing/ diarrhea/ R-side
heart fail)
 Recurrent laryngeal nerve (hoarseness)
 Effusion ( exudative)

193. Pulmonary Nodule
Aka coin lesions. >3cm = Mass.
- Most benign solitary nodules are?

194. Pulmonary Nodule
Aka coin lesions. >3cm = Mass.
- Most benign solitary nodules are? Infectious granulomas
(from old/active TB, fungal infxn, FB reaction)
- Benign = No growth >2yrs
- Malignant-> carcinoma/ hamartoma/ bronchial adenoma
Malignant described as :

195. Pulmonary Nodule
Aka coin lesions. >3cm = Mass.
- Most benign solitary nodules are? Infectious granulomas
(from old/active TB, fungal infxn, FB reaction)
- Benign = No growth >2yrs
Malignant described as : INDISTINCT margins. Rapid
progression size. >2cm diameter. Rarely calcified.

196. Pulmonary Nodule
Management:
Low prob malignant: Observe- CT q3mos
Medium prob malig: Biopsy. High rest CT –delineat mass /
detect adenopathy/ presence of mulitple nodes
High prob malig: Resect ASAP. Interim bx not rec’d.

197. Carcinoid Tumor
 General: well differentiated neuroendocrine tumors
 Carcinoid syndrome !
 FDR
 ..also wheezing, hypotension
Labs: Bronchoscopy: pink/purple central lesion well
vascularied, may be pedunculated/sessile (immobile)
- CT/ octreotide scintigraphy  localize dz. CT monitors
growth.
- TX: Surgery! Good prognosis.

198. The End