pulmonology

-idiopathic interstitial pneumonias

-environmental/occupational exposures

-systemic ddiseases (sarcoidosis

name the different diffuse parenchymal lung diseases

shipyard, construction

typical exam setting for abestos exposure

mining, sandblasting

typical exam setting for silica exposure

hypersensitivity pneumonitis

birds/mold exposure in the setting of interstitial lung disease indicates

amiodarone, bleomycin, methotrexate, nitrofurantoin

medications causing interstitial lung disease

interstitial ffibrosis

fine "velco" inspiratory crackles is a exam finding of

idiopathic pulmonary ffibrosis, abestosis

digital clubbing indicates these interstitial lungg diseases

Diffuse reticular or ground-glass opacities, honeycombing in fibrosis

imaging findings indicating interstitial lung disease

loud P2, RV heave, JVDD, peripheral edema, tricuspird regurg

physical exam findings indicative of pulmonary vascular disease

ILD: Progressive dyspnea on exertion, chronic nonproductive cough, fatigue

PVD: Dyspnea, fatigue, syncope, chest pain, edema

symptoms of interstitial lung disease vs pulmonary vascular diseases

idiopathic pulmonary fibrosis

Gradual progressive dyspnea, dry cough, age >50, clubbing, Velcro crackles

Poor prognosis, responds poorly to steroids

prognosis associated with idiopathic pulmonary fibrosis

sarcoidosis

Nonproductive cough, dyspnea, systemic symptoms, young adults, African Americans; extrapulmonary: skin, eye

-Noncaseating granulomas; ↑ ACE, hypercalcemia

hypersensitivity pneumonitis

Acute/subacute dyspnea, cough, fever, occurs after antigen exposure (birds, mold, hot tub)

Ground-glass opacities, centrilobular nodules, air-trapping

imaging findings off hypersensitivity pneumonitis

RA, SLE, systemic sclerosis

connective tissue disease-associated interstitial lung diseases

asbestosis

exposure: Shipbuilding, construction, insulation, brake pads

bronchogenic carcinoma, mesothelioma

abestosis increases risk of

sillicosis

exposure: Mining, quarrying, sandblasting, foundry

Silicosis

-Upper lobe nodules, "eggshell" calcification of hilar nodes

-increases risk of TB, lung cancer

coal miner's pneumoconiosis

"black lung"

may cause cor pulmonale

Beryllliosis

exposure: Aerospace, electronics, ceramics

Berylliosis

-Dyspnea, cough, systemic features (like sarcoid)

-Noncaseating granulomas, hilar adenopathy

-↑ Risk of lung cancer; resembles sarcoidosis

Farmer's lung (hypersensitivity pneumonitis subtype)

exposure: moldy hay

Bimodal — 20-40 yrs (most common), smaller peak in >60 yrs

age distribution associated with sarcoidosis

Respiratory: Dyspnea, nonproductive cough, chest pain

Constitutional: Fatigue, fever, weight loss, night sweats

primary clinical presentation of sarcoidosis

-erythema nodosum

-uveitis, conjunctivity

-arthralgias

-CN VII palsy

-caridomyopathy

extrapulmonary manifestations of sarcoidosis

bilateral hilar lymphadenopathy

classic physical exam finding associated with sarcoidosis

Chest X-ray: Bilateral hilar adenopathy (stage I); interstitial infiltrates (stage II/III)

High-resolution CT: Nodules along lymphatic distribution, adenopathy

imaging findings associated with sarcoidosis

↑ ACE levels, hypercalcemia/hypercalciuria (macrophage 1α-hydroxylase ↑ vitamin D activation)

lab findings associated with sarcoidosis

non-caseating granulomas

diagnostic gold standard of sarcoidosis

sarcoidosis

autoimmune disease with fibrous lesions forming in lymph nodes, liver, skin, lungs, spleen, eyes, and small bones of hands and feet

Antifibrotics: pirfenidone, nintedanib; lung transplant if advanced; avoid chronic steroids (harmful in IPF)

standard therapies for idiopathic pulmonary fibrosis

corticosteroids

stanard therapy for sarcoidosis

Supportive (O₂, pulmonary rehab, vaccination); no role for steroids; monitor for malignancy

standard treatment for asbestosis

Stop exposure; supportive; TB surveillance (↑ risk of TB); O₂, lung transplant if advanced

standard treatment for silicosis

Remove exposure; corticosteroids if granulomatous inflammation is symptomatic

standard treatment of berylliosis

Group 1: PAH (idiopathic)

Group 2: PH due to left heart disease

Group 3: PH due to lung disease/hypoxia (COPDD, OSA)

Group 4: chronic thromboembolic PH (chronic PE)

Group 5: PH with unclear/multifactorial mechanisms (sarcoid)

define the different classes of pulmonary hypertension

Progressive exertional dyspnea

Fatigue, syncope, chest pain (angina)

Peripheral edema, ascites (if RV failure develops)

primary symptoms of pulmonary HTN

pulmonary hypertension

exam findings:

Loud P2 (accentuated pulmonic component of S2)

Right ventricular heave

Tricuspid regurgitation murmur

Jugular venous distension, hepatomegaly, edema (late RV failure signs)

right ventricular heave

seen in pulmonary hypertension

right axis deviation, RBBB

ECG findings associated with pulmonary HTN

right heart cath

PCWP >15 mmHg

gold standard diagnostic test for pulmonary HTN

Endothelin receptor antagonists

-PDE 5 inhibitors

-prostacyclin analogs

treatment for group 1 PAH (idiopathic)

Treat underlying HF/valvular disease; PAH drugs not effective

treatment for group 2 PAH (left heart disease)

Treat lung disease, give O₂; avoid routine PAH drugs

treatment for group 3 PAH (COPD/hypoxia)

Lifelong anticoagulation; surgical pulmonary thromboendarterectomy (potentially curative); riociguat if inoperable

treatment for group 4 PAH (thrombotic dx)

bilateral opacities on CXR/CT not fully explained by effusions, collapse, or nodules

imaging indicative of diagnosis off ARDS

TV 6 mL/kg IBW, aim plateau ≤30 cm H₂O, driving pressure as low as possible

PEEP per ARDSNet tables; avoid derecruitment

lung-protective ventilation of ARDS

Tall, thin young men, smoking/vaping, family history

Marfan, Ehlers-Danlos, Birt–Hogg–Dubé

etiologies of primary pneumothorax (no known lung disease)

COPD/emphysema, severe asthma, CF, interstitial lung disease, PJP pneumonia (esp. HIV), TB, necrotizing pneumonia, LAM

etiologies of secondary pneumothorax (underlying lung disease)

Central line, thoracentesis, transbronchial/pleural biopsy, mechanical ventilation (high pressures), CPR, rib fractures, penetrating/blast injury

iatrogenic/trauma etiologies of pneumothorax

-Sudden pleuritic chest pain, acute dyspnea; risk factors above; tension → hemodynamic collapse

-↓/absent breath sounds, hyperresonance, ↓ fremitus; tracheal deviation away if tension

history and exam findings associated with pneumothorax

barcode/stratosphere sign

POCUS finding associated with pneumothorax

tension pneumothorax

a type of pneumothorax in which air that enters the chest cavity is prevented from escaping

Small primary & stable → O₂ + observe/needle aspiration; large/symptomatic or any secondary → chest tube. Tension: immediate needle decompression then tube. Recurrent/air leak → pleurodesis/VATS blebectomy.

first line treatment of pneumothorax

-Progressive dyspnea, orthopnea, pleuritic pain

-↓ breath sounds, dullness to percussion, ↓ fremitus; egophony just above fluid line

history and exam findings associatedd with pleural effusion

pleural effusion on CXR

Blunted costophrenic angle, meniscus sign; large → mediastinal shift

meniscus sign

Curvilinear line seen at the upper end of a pleural effusion

thoracentesis

confirmatory test for pleural effusion

therapeutic thoracentesis if symptomatic. Transudate (CHF, cirrhosis) → diuretics/salt restriction. Exudate → treat underlying (PNA → abx; empyema or pH <7.20 → tube drainage ± tPA/DNase; malignancy → indwelling catheter/pleurodesis).

first line therapy of pleural effusion

platypnea-orthodeoxia

syndrome of dyspnea (and oxygen desaturation) that worsens with sitting upright.

-associated with pulmonary AV fistula

Solitary or multiple round, well-circumscribed nodules with feeding/draining vessels (sometimes subtle)

pulmonary AV fistula CXR

pulmonary AV fistula

an abnormal connection between a pulmonary artery (carrying oxygen-rich blood from the heart to the lungs) and a pulmonary vein (carrying oxygen-poor blood back to the heart)

cirrhosis, malignancy, pneumonia, PE, pancreatitis

Dyspnea, hypoxemia, platypnea–orthodeoxia; HHT (epistaxis, telangiectasias) → paradoxical emboli, stroke/brain abscess

presentation of pulmonary AV fistula

ARDS

acute, bilateral opacities, non-cardiogenic, PaO₂/FiO₂ ≤300 with PEEP ≥5 → low-tidal-volume, high-PEEP, prone.