Pulmonary Board Review

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Pulmonary Board Review

• Dave Brush M.D.
• 3/15/10

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Pulmonary Function Testing

• Lung Volumes
• Normal 80-120
• TLC
• FRC
• RV
• Airflow Spriometry
• Exp/Insp Loop
• DLCO
• Alveolar/Hg surface area of the lung
• Confounders

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Assess Severity
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Asthma Syndromes

• Occupational Asthma
• Worst at work
• Peak flow at work may help diagnose
• Reactive Airways Dysfunction Syndrome
• Acute exposure to chemicals/irritants
• Cough Variant Asthma
• Allergic Bronchopulmonary Aspergillosis
• Bronchiectasis, IgE gt1000, IgE vs Aspergillus or
  skin test
• Exercise Induced Bronchospasm
• How best to test?
• Aspirin Sensitive Asthma
• 20 of asthmatics
• Do you have to stop the ASA?

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Asthma Mimics

• COPD
• Vocal Cord Dysfunction
• CHF
• Bronchiectasis
• Cystic Fibrosis
• Eosinophillic Pulmonary Syndromes
• Mechanical Obstruction

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Vocal Cord Dysfunction
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Fixed Airflow Obstruction
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Inpatient Asthma

• Does this person need intubation?
• 7.39/40/95/98

Depends.make sure to read the whole question!!!
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Therapy at Each Stage of COPD
IV Very Severe
III Severe
II Moderate
I Mild
0 At Risk
New (2003)
FEV1/FVC lt 70 FEV1 lt 30 or FEV1 lt 50
predicted plus chronic respiratory failure
FEV1/FVC lt 70 30 lt FEV1 lt 50 With or
without symptoms
FEV1/FVC lt 70 50 lt FEV1 lt 80 With or
without symptoms
FEV1/FVC lt 70 FEV1 ? 80 With or without
symptoms
Chronic Symptoms Exposure to risk factors Normal
spiro
Characteristics
Avoidance of risk factor(s) influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more
long-acting bronchodilators Add rehabilitation
Add inhaled glucocorticosteroids if repeated
exacerbations
Add long-term oxygen if chronic respiratory
failure Consider surgical treatments
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Oxygen Therapy
COT continuous oxygen therapy NOT nocturnal
oxygen therapy MRC controls no oxygen
therapy MRC domiciliary oxygen therapyFlenley
DC. Chest. 19858799-103. Reproduced with
permission of American College of Chest
Physicians.
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Do not pass GOdo not refer for LVRS if

• FEV1 lt 20
• DLCO lt 20
• Homogenous emphysema on CT
• Gets better after pulmonary rehab

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Idiopathic Pulmonary Fibrosis

• Older adults
• UIP on path
• Characteristic CT
• Honeycombing on CT
• Basilar Predominate
• Edge fibrosis
• Rare/no ground glass
• NO THERAPY except Lung Transplantation

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Sarcoidosis

• Numerous CT appearances
• Apical predominate
• Restrictive/obstructive
• Dx by TBBx and TBNA
• Non-caseating granulomas
• Lofflers syndrome
• E nodosum
• Systemic involvement
• Prednisone/MTX

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Lymphangiomyomatosis

• Woman
• Non-smoker
• Tuberous sclerosis
• Chronic onset
• Obstructed PFTs

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Acute Eosinophillic Pneumonia

• Rapid onset dyspnea
• 4 quadrant airspace filling
• Looks like ARDS
• BAL with gt30 eosinophils

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Diffuse Parenchymal Lung Diseases

• Idiopathic pulmonary fibrosis
• No tx, refer for lung tx if possible, familial
  types occur
• Nonspecific interstitial pneumonia
• Find the underlying cause !
• Collagen vascular related ILD
• Hints at other organs or systems involved
• Vasculitic Pulmonary Syndromes
• Wegners, Goodpastures, etc.
• Cryptogenic organizing pneumonia
• Subacute, non-specific, tx with prednisone
• Acute interstitial pneumonia
• Subacute ARDS-like
• Eosinophillic syndromes
• Churg-Struass, AEP, CEP
• Respiratory bronchiolitis ILD
• Smoker, ground glass, reticular-nodular pattern
• Lymphangiomyomatosis
• Woman, thin walled cysts, Tuberous Sclerosis