Pulmonary Medicine Review: Respiratory Exam, Diagnostics, and Disease States

These flashcards cover key concepts from the pulmonary lecture notes: physical exam findings (breathing patterns, auscultation, percussion, fremitus), diagnostic tests (PFTs, ABG, imaging), disease states (asthma, COPD, CF, restrictive diseases, pulmonary nodules, infections), pleural diseases (effusions, pneumothorax), sleep disorders (OSA, obesity hypoventilation), pulmonary hypertension and ARDS, critical conditions (anaphylaxis, DVT/PE), and lung cancer (NSCLC, SCLC, carcinoid) with management principles and testing strategies.

What are examples of abnormal breathing patterns that clue you into altered neurologic control of respiration (often in advanced disease or end-of-life states)?

Cheyne-Stokes, Biot, and ataxic breathing patterns.

What signs indicate increased work of breathing in a patient?

Accessory muscle use, restrained sternocleidomastoid (SCM) activity, and intercostal retractions.

Which audible upper airway noises indicate possible upper airway narrowing?

Stridor, snoring, gurgling, and gasping (inspiratory gasp in pertussis).

What is the inspiratory sound associated with whooping cough and why is it called a 'whoop'?

An inspiratory gasp ('whoop') due to vigorous inhalation after coughing fits in pertussis.

What chest deformity is described as an increased AP diameter and is common in emphysema?

Barrel chest.

What are the developmental chest wall deformities called pectus excavatum and pectus carinatum?

Pectus excavatum: depressed sternum; pectus carinatum: protruding sternum; both can impact pulmonary/cardiac function if severe.

What is flail chest and how might it present on exam?

Paradoxical movement of a chest wall segment due to multiple rib fractures; may produce a sucking sound and impaired ventilation.

When is tracheal deviation most likely to be seen?

Late sign typically in severe pneumothorax or cardiac tamponade.

What are vesicular breath sounds?

Normal, low-pitched breath sounds heard in most lung fields.

What are bronchial breath sounds and where are they typically heard?

Higher-pitched, louder breath sounds heard over larger airways; can indicate consolidation or airways disease.

What does dull percussion indicate compared with resonant percussion?

Dullness suggests fluid or inflammation (e.g., effusion or consolidation); resonance is normal air-filled lung; hyperresonance indicates increased air spaces.

What are crackles (rales) and what conditions are they commonly associated with?

Velcro-like high-pitched sounds on inspiration; common with pulmonary edema/CHF and interstitial fluid.

What are wheezes and what do they signify?

High-pitched musical sounds from narrowed airways; common in bronchospasm such as asthma.

What are rhonchi and what causes them?

Low-pitched, snoring-like sounds due to mucus or obstruction; seen with excessive mucus (e.g., CF, pneumonia).

What is a pleural friction rub and when might you hear it?

A fine, scratching sound like walking on snow; occurs when pleural surfaces rub due to irritation.

What does a normal chest percussion note (resonant) indicate?

Normal air-filled chest with intact air movement.

What does dullness on percussion suggest?

Fluid or inflammatory process in the chest (e.g., effusion or consolidation).

What does hyperresonance on percussion indicate?

Increased air spaces (e.g., COPD, emphysema, pneumothorax).

What is tactile fremitus and how is it assessed?

Vibratory sensation felt with palpation when saying words like '99' or 'one-one-one'; increased with consolidation, decreased with air-filled or fluid-filled spaces.

What are the two main spirometry measures and what do they represent?

FVC (forced vital capacity) and FEV1 (forced expiratory volume in 1 second); used with the FEV1/FVC ratio to differentiate obstructive vs restrictive patterns.

What is the normal range interpretation for FEV1/FVC ratio in obstructive vs restrictive disease?

Obstructive disease: reduced FEV1/FVC ratio; restrictive or normal disease: normal or increased FEV1/FVC ratio.

What additional pulmonary function tests accompany spirometry?

DLCO (diffusion capacity), six-minute walk test, bronchoprovocation (e.g., methacholine), and post-bronchodilator spirometry.

What are the three key components of an arterial blood gas (ABG) and their basic meanings?

pH (acid-base status), PaCO2 (respiratory acid), and HCO3- (bicarbonate, metabolic buffer).

How can you distinguish respiratory vs metabolic disturbances using ABG patterns?

Respiratory: pH and PaCO2 move in opposite directions; Metabolic: pH and HCO3- move in the same direction.

What does compensation mean in acid-base disorders?

The body (kidneys and bicarbonate system) adjusts pH to normalize; partial vs full compensation depends on whether pH has returned to normal.

What are the three big obstructive diseases discussed?

Asthma, COPD, and cystic fibrosis (with bronchiectasis often as a related end-stage feature).

How is asthma characterized and why is it often reversible?

Bronchospasm with airway inflammation; episodic wheeze; inflammation and bronchial smooth muscle constriction are often reversible with treatment.

How is asthma classified in the notes (intermittent, persistent, severe) and what guides treatment?

Intermittent: symptoms <2 days/week; nocturnal symptoms <2/mo; preserved FEV1. Persistent and severe categories are defined by symptom frequency, nighttime symptoms, ER/urgent care visits, and steroid use; classification guides stepwise therapy.

What is the asthma action plan traffic light system?

Green: daily routine, takings meds; Yellow: symptoms worsen, may need quick-relief meds; Red: medical emergency requiring urgent care.

What is the initial asthma management approach for 0–4 years old?

PRN albuterol; step up to low-dose ICS; escalate to medium-dose ICS as needed; red stage may require high-dose ICS or oral steroids; montelukast can be considered; environmental control and possible immunotherapy in select cases.

What is the initial asthma management approach for 5–11 year olds?

Low-dose inhaled corticosteroid (ICS) as daily controller; add-on options like formoterol or montelukast; escalate to oral steroids for red; consider other biologics for persistent severe disease.

What is the major distinction for COPD patients in terms of 'pink puffers' vs 'blue bloaters'?

Pink puffers (emphysema): pink appearance, pursed-lip breathing, minimal sputum. Blue bloaters (chronic bronchitis): cyanotic, productive cough with mucus production.

What GOLD criteria are used for COPD staging and what additional classification helps guide treatment?

GOLD stages based on FEV1: mild (>80%), moderate (50–80%), severe (30–50%), very severe (<30%); ABE (exacerbations and hospitalizations) and symptom scales (e.g., MMRC, CAT) guide therapy.

What vaccines are emphasized for COPD patients and why?

Influenza and pneumococcal vaccines to reduce risk of infection and exacerbations; other vaccines (Tdap, SARS vaccines) as appropriate.

What is bronchiectasis and how is it related to COPD?

Chronic airway obstruction with irreversible dilation of bronchi; often due to recurrent infections; commonly associated with COPD as part of a broader obstructive spectrum.

What gene and disease does CFTR mutation cause, and what systems does it affect beyond the lungs?

CFTR gene mutation causes cystic fibrosis; thick secretions affect lungs, pancreas, reproductive tract, and other organs due to abnormal ion transport.

What are key CF treatments and care centers designed to do?

Multidisciplinary CF centers with airway clearance therapies, mucolytics, pancreatic enzyme replacement, vaccines, pulmonary rehab, CFTR modulators; refer to specialized CF centers.

What are sarcoidosis features and how is it diagnosed?

Noncaseating granulomas; commonly affects young individuals (notably Black females in the US); elevated ACE and hypercalcemia; uveitis; hilar lymphadenopathy; diagnosis via tissue biopsy.

What pattern of restrictive disease is described using a sponge analogy and what is its hallmark on PFTs?

Restrictive lung disease; reduced lung expansion with low or normal FEV1/FVC ratio or even normal; decreased total lung capacity (TLC).

What are common causes of restrictive lung disease?

Connective tissue diseases, radiation injury, medications (e.g., amiodarone), hypersensitivity pneumonitis, sarcoidosis; can lead to fibrosis and cor pulmonale.

What are the main non-small cell lung cancer (NSCLC) types and where do they typically arise?

Adenocarcinoma (peripheral, often in COPD/emphysema), squamous cell (central, near larger airways), large cell (peripheral, poorly differentiated).

How is small cell lung cancer different in treatment and prognosis from NSCLC?

Small cell lung cancer (oat cell): highly related to paraneoplastic syndromes; treated mainly with chemotherapy (limited vs extensive disease) with poorer prognosis; rarely resectable.

What is carcinoid tumor and its clinical significance?

Typically younger patients, non-smokers; slow-growing; can have paraneoplastic syndromes (flushing, diarrhea, wheezing); often curable with resection and has good prognosis.

What is the approach to evaluating a solitary pulmonary nodule for malignancy risk?

Assess age and smoking history; spiculated margins increase concern; small, smooth, round nodules in low-risk patients are often benign with serial CT; larger lesions in older or high-risk patients warrant biopsy and PET imaging.

What is paraneoplastic syndrome most commonly associated with small cell lung cancer?

SIADH and Cushing syndrome due to ectopic hormone production.

How do you diagnose and stage lung cancer?

Tissue biopsy for histology, CT/PET for staging, lymph node and distant metastases assessment, and multidisciplinary tumor board discussion.

What is the approach to pleural effusions (transudates vs exudates) and how are they analyzed?

Transudates: due to systemic issues like heart failure; exudates: due to local inflammation or infection; use Light's criteria (protein and LDH) from pleural fluid analysis to differentiate.

What is the management framework for pleural effusions and when is a chest tube indicated?

Treat underlying cause; therapeutic thoracentesis for symptoms in transudates; chest tube or long-term drainage for persistent exudates or empyema; ultrasound-guided tapping and pleural fluid analysis for characterization.

What are the key features and management of pneumothorax (including tension pneumothorax)?

Pneumothorax: sudden pleuritic chest pain and dyspnea with decreased breath sounds and hyperresonance; tension pneumothorax with JVD, tracheal deviation, hypotension requires immediate needle decompression followed by chest tube placement.

What is obstructive sleep apnea (OSA) and how is it diagnosed and treated?

OSA is recurrent upper airway collapse during sleep with apneas/hypopneas; diagnosed by polysomnography; treated with CPAP, dental devices, or Inspire device in select cases; STOP-BANG questionnaire helps risk stratification.

What is obesity hypoventilation syndrome (OHS) and how does it differ from OSA?

Chronic hypoventilation with hypercapnia due to obesity; diurnal hypercapnia; treated with weight loss, noninvasive ventilation; may co-exist with OSA.

How is pulmonary hypertension diagnosed and what is cor pulmonale?

Pulmonary hypertension diagnosed via echocardiography and right heart catheterization (wedge pressure >25 mmHg is concerning); cor pulmonale is right heart failure due to pulmonary hypertension or lung disease.

What is ARDS and its classic radiographic appearance?

Acute respiratory distress syndrome: diffuse bilateral noncardiogenic edema; bat-wing or bird-wing infiltrates on chest imaging; requires supportive care and management of the underlying cause; may require ECMO in severe cases.

How is anaphylaxis managed and what are key considerations?

Immediate epinephrine administration (dose varies by route; epiPen for self-administration; IV dosing in hospital); remove allergen; give antihistamines and corticosteroids; glucagon if on beta-blockers; secure airway and prepare for vasopressors if hypotensive.

What is the Wells score and how is DVT/PE evaluated clinically?

Wells score for DVT risk; D-dimer as an initial screen with imaging (compression ultrasound) to confirm DVT; PE evaluation includes CT angiography or V/Q scan with clinical judgment and Wells criteria.

What are classic EKG and imaging clues for pulmonary embolism?

S1Q3T3 pattern on EKG; Hampton's hump or Westermark sign on radiographs; CTA chest with intraluminal filling defect or V/Q scan mismatch.

What is the standard approach to diagnosing and staging lung cancer metastases?

CT/MRI for staging; PET scan for metabolic activity; biopsy of primary or metastatic site; lymph node involvement and distant metastases determine stage and treatment plan.