Family Medicine EOR (Pulmonology): New for 2026 Topic List (Smarty PANCE)

What is Asthma?

A chronic inflammatory airway disorder characterized by reversible bronchoconstriction, airway hyperresponsiveness, and episodic wheezing, cough, and dyspnea.

What is the classic triad of asthma symptoms?

Wheezing, cough (often nocturnal), and dyspnea — typically episodic and reversible.

What PFT findings confirm asthma?

FEV1/FVC <70% predicted with ≥12% AND ≥200 mL improvement in FEV1 after bronchodilator (reversibility).

What is the GINA stepwise treatment for asthma in adults/adolescents ≥12?

Step 1-2: low-dose ICS-formoterol PRN; Step 3: low-dose ICS-formoterol daily + PRN (MART); Step 4: medium-dose ICS-formoterol MART; Step 5: high-dose ICS-LABA + add-on (tiotropium, biologic).

What defines a severe asthma exacerbation requiring ED management?

Peak flow <50% predicted, inability to speak in full sentences, accessory muscle use, RR >30, HR >120, SpO2 <90%, or silent chest.

What is the first-line treatment for acute asthma exacerbation in the ED?

Oxygen to maintain SpO2 ≥93%, nebulized SABA (albuterol) ± ipratropium, systemic corticosteroids (prednisone 40-60 mg PO or methylprednisolone IV), and IV magnesium sulfate for severe cases.

What does a silent chest indicate in asthma?

Impending respiratory failure — airflow is so poor no wheezing is audible; prepare for intubation.

What ABG finding in an asthma attack signals impending respiratory failure?

Normalizing or rising PaCO2 (>42 mmHg) in a patient who was previously hyperventilating — fatigue is setting in.

What is Samter's triad?

Aspirin sensitivity, nasal polyps, and asthma (also called AERD — aspirin-exacerbated respiratory disease).

What is COPD?

A progressive, partially reversible airflow limitation caused by chronic inflammation from noxious particles (most commonly tobacco smoke), encompassing emphysema and chronic bronchitis.

What spirometry finding confirms COPD?

Post-bronchodilator FEV1/FVC <0.70 (not reversible, unlike asthma).

What are the GOLD stages of COPD based on FEV1?

GOLD 1 (mild): FEV1 ≥80%; GOLD 2 (moderate): 50-79%; GOLD 3 (severe): 30-49%; GOLD 4 (very severe): <30% predicted.

What is the chronic bronchitis vs emphysema "blue bloater vs pink puffer" mnemonic?

Blue bloater (chronic bronchitis): cyanotic, obese, productive cough, cor pulmonale; Pink puffer (emphysema): thin, pursed-lip breathing, barrel chest, minimal cough.

What CXR findings are classic for emphysema?

Hyperinflation, flattened diaphragms, increased AP diameter (barrel chest), bullae, decreased lung markings.

What is the only intervention proven to slow COPD progression and reduce mortality?

Smoking cessation; long-term oxygen therapy (LTOT) reduces mortality in patients with PaO2 ≤55 mmHg or SpO2 ≤88%.

What is the first-line bronchodilator for stable COPD?

Long-acting muscarinic antagonist (LAMA) such as tiotropium, or LABA; combination LAMA/LABA for persistent symptoms.

When are inhaled corticosteroids (ICS) added in COPD?

For frequent exacerbations (≥2/year or ≥1 hospitalization) and elevated blood eosinophils (≥300 cells/µL); add as LABA/LAMA/ICS triple therapy.

What organism most commonly causes acute COPD exacerbations?

Haemophilus influenzae (also S. pneumoniae, Moraxella catarrhalis, viruses); treat with macrolide, doxycycline, or amox-clavulanate.

What should you consider in a young nonsmoker with emphysema and lower-lobe predominance?

Alpha-1 antitrypsin deficiency — check serum A1AT level.

What is Cystic Fibrosis?

An autosomal recessive disorder caused by mutations in the CFTR gene (most commonly ΔF508) leading to thick, viscous secretions affecting lungs, pancreas, GI tract, and reproductive system.

What is the gold standard diagnostic test for cystic fibrosis?

Sweat chloride test ≥60 mmol/L on two occasions; 30-59 mmol/L is intermediate and requires CFTR genetic testing.

What organism colonizes CF lungs in adolescents/young adults and worsens prognosis?

Pseudomonas aeruginosa (Staph aureus more common in young children; Burkholderia cepacia is particularly virulent).

What are the classic clinical features of CF?

Recurrent pulmonary infections, bronchiectasis, pancreatic insufficiency (steatorrhea, failure to thrive), meconium ileus in newborns, infertility in males (congenital absence of vas deferens), salty-tasting skin.

What is the standard pulmonary management of CF?

Airway clearance therapy (chest physiotherapy, vest), inhaled mucolytics (dornase alfa, hypertonic saline), inhaled antibiotics (tobramycin) for chronic Pseudomonas, and CFTR modulators (e.g., elexacaftor/tezacaftor/ivacaftor) for eligible mutations.

What is Foreign Body Aspiration?

Inhalation of an object into the airway, most commonly seen in children 1-3 years, typically lodging in the right mainstem bronchus due to its more vertical anatomy.

What is the classic triad of foreign body aspiration?

Cough, wheezing, and decreased breath sounds (unilateral) — often after a choking episode.

What CXR findings suggest foreign body aspiration?

Often normal (most aspirated objects are radiolucent); look for unilateral hyperinflation on expiratory film, atelectasis, or mediastinal shift away from affected side.

What is the definitive diagnostic and therapeutic procedure for foreign body aspiration?

Rigid bronchoscopy under general anesthesia.

What is the immediate management for a choking conscious child >1 year?

Heimlich maneuver (abdominal thrusts); for infants <1 year: 5 back blows alternating with 5 chest thrusts.

What is Acute Bronchiolitis?

An acute viral lower respiratory tract infection causing inflammation and obstruction of bronchioles, most common in infants <2 years, with RSV as the leading cause.

What is the classic clinical presentation of bronchiolitis?

Infant <2 years with URI prodrome progressing to wheezing, tachypnea, retractions, nasal flaring, and feeding difficulty; peak severity day 3-5.

What is the most common cause of bronchiolitis?

Respiratory syncytial virus (RSV); also rhinovirus, parainfluenza, adenovirus, human metapneumovirus.

How is bronchiolitis diagnosed?

Clinical diagnosis based on history and exam; CXR and viral testing not routinely needed unless atypical presentation.

What is the mainstay of bronchiolitis treatment?

Supportive care — nasal suctioning, hydration, supplemental oxygen if SpO2 <90%; bronchodilators, steroids, and antibiotics are NOT routinely recommended.

What infants qualify for RSV prophylaxis?

Nirsevimab (preferred) for all infants <8 months entering their first RSV season; palivizumab for high-risk infants (premature, chronic lung disease, congenital heart disease).

What is Acute Bronchitis?

Self-limited inflammation of the large airways/bronchi, usually viral, presenting with cough lasting 1-3 weeks following URI symptoms.

What is the most common cause of acute bronchitis?

Viral (>90%) — influenza, RSV, rhinovirus, adenovirus, parainfluenza, coronavirus.

How is acute bronchitis distinguished from pneumonia?

Acute bronchitis: normal vital signs, clear lungs (or scattered wheezing), normal CXR; pneumonia: fever, tachycardia, focal exam findings, infiltrate on CXR.

What is the treatment for acute bronchitis?

Symptomatic care only — antitussives, hydration, rest; antibiotics are NOT indicated (treat with antibiotics only if pertussis suspected or post-influenza bacterial superinfection).

What is Acute Epiglottitis?

A rapidly progressive, life-threatening infection of the epiglottis and supraglottic structures causing airway obstruction, historically caused by Hib but now more common in adults due to widespread Hib vaccination.

What is the classic clinical presentation of epiglottitis?

The "3 D's": Drooling, Dysphagia, Distress — plus high fever, tripod position, muffled "hot potato" voice, stridor; toxic appearance.

What is the most common cause of epiglottitis in the post-Hib vaccine era?

Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and nontypeable H. influenzae; Hib still possible in unvaccinated.

What is the classic radiographic finding in epiglottitis?

"Thumbprint sign" on lateral neck X-ray (swollen epiglottis); however, DO NOT delay airway management for imaging.

What is the management of suspected epiglottitis?

Keep child calm (let parent hold), do NOT examine throat or place IV, secure airway in OR with anesthesia/ENT (controlled intubation or tracheostomy), then IV ceftriaxone + vancomycin.

What is Influenza?

An acute viral respiratory illness caused by Influenza A or B virus, characterized by abrupt onset of fever, myalgias, headache, and respiratory symptoms; seasonal epidemics in winter months.

What is the classic presentation of influenza?

Abrupt onset of high fever, chills, myalgias, headache, malaise, nonproductive cough, sore throat — distinguishes from gradual onset of common cold.

How is influenza diagnosed?

Rapid antigen test (RIDT) — fast but lower sensitivity (~50-70%); RT-PCR is gold standard with high sensitivity and specificity.

Who should receive antiviral therapy for influenza?

Hospitalized patients, severe/progressive illness, high-risk patients (age <2 or ≥65, pregnant, chronic medical conditions, immunocompromised), or anyone presenting within 48 hours of symptom onset.

What is the first-line antiviral for influenza?

Oseltamivir (Tamiflu) 75 mg BID x 5 days; baloxavir is a single-dose alternative; start within 48 hours of symptom onset for best effect.

What is the most feared bacterial superinfection following influenza?

Staphylococcus aureus pneumonia (including MRSA), followed by S. pneumoniae and H. influenzae.

What is Laryngotracheobronchitis (Croup)?

A viral infection causing subglottic inflammation in children 6 months-3 years, most commonly caused by parainfluenza virus, presenting with barking cough, hoarseness, and inspiratory stridor.

What is the classic clinical presentation of croup?

Barking "seal-like" cough, inspiratory stridor, hoarseness, low-grade fever — worse at night; usually preceded by URI symptoms.

What is the most common cause of croup?

Parainfluenza virus type 1 (also types 2, 3; RSV, influenza, adenovirus).

What is the classic radiographic finding in croup?

"Steeple sign" on PA neck X-ray (subglottic narrowing); imaging is not required for diagnosis.

How is croup severity assessed?

Westley croup score: mild (no stridor at rest), moderate (stridor at rest with mild retractions), severe (stridor at rest with marked retractions, agitation, cyanosis).

What is the management of croup?

Mild: cool mist, oral dexamethasone 0.6 mg/kg (single dose); Moderate to severe: dexamethasone + nebulized racemic epinephrine; observe 3-4 hours after epinephrine for rebound.

What is Pertussis?

"Whooping cough" — a highly contagious respiratory infection caused by Bordetella pertussis, characterized by paroxysmal coughing fits often followed by an inspiratory "whoop."

What are the three stages of pertussis?

Catarrhal (1-2 weeks): URI symptoms, low-grade fever; Paroxysmal (2-6 weeks): paroxysmal coughing, inspiratory whoop, post-tussive emesis; Convalescent (weeks to months): gradual resolution.

How is pertussis diagnosed?

Nasopharyngeal PCR (most sensitive in first 3 weeks); culture is specific but slow; serology useful later in illness.

What is the treatment for pertussis?

Azithromycin (preferred), clarithromycin, or erythromycin — antibiotics reduce transmission but only alter clinical course if given in catarrhal phase. Also treat close contacts with prophylaxis.

What vaccine prevents pertussis?

DTaP for children (5 doses by age 6), Tdap booster at age 11-12 and once during each pregnancy (27-36 weeks gestation) for cocooning effect.

What is Bacterial Pneumonia?

An acute lower respiratory tract infection causing inflammation of the lung parenchyma, characterized by fever, productive cough, dyspnea, and infiltrate on chest imaging.

What is the most common cause of community-acquired pneumonia (CAP)?

Streptococcus pneumoniae remains most common typical pathogen; Mycoplasma pneumoniae and viruses also frequent, especially in younger adults.

What are the atypical pneumonia pathogens and their unique features?

Mycoplasma pneumoniae (young adults, "walking pneumonia," bullous myringitis, cold agglutinins); Chlamydophila pneumoniae (mild); Legionella (water source, hyponatremia, diarrhea, high fever, confusion).

What is the CURB-65 score?

Pneumonia severity score: Confusion, Urea >19 mg/dL (BUN >7 mmol/L), Respiratory rate ≥30, Blood pressure (SBP <90 or DBP ≤60), age ≥65 — 0-1: outpatient; 2: admit; ≥3: consider ICU.

What is the outpatient empiric treatment for CAP in healthy adults?

Amoxicillin 1 g TID OR doxycycline OR azithromycin (only if local pneumococcal resistance <25%).

What is the inpatient (non-ICU) empiric treatment for CAP?

Beta-lactam (ceftriaxone or ampicillin-sulbactam) PLUS macrolide (azithromycin), OR respiratory fluoroquinolone monotherapy (levofloxacin, moxifloxacin).

What is the empiric treatment for ICU-level CAP?

Beta-lactam (ceftriaxone) + macrolide OR + respiratory fluoroquinolone; add MRSA coverage (vancomycin/linezolid) and Pseudomonas coverage (piperacillin-tazobactam, cefepime) if risk factors present.

What organism causes "currant jelly" sputum and is associated with alcoholism?

Klebsiella pneumoniae — also causes upper lobe cavitation and the "bulging fissure sign."

What pneumonia is associated with bird/bat exposure (especially Ohio/Mississippi River Valleys)?

Histoplasma capsulatum.

What is Fungal Pneumonia?

Pulmonary infection caused by fungal organisms, often acquired through environmental exposure, with presentations varying from asymptomatic to severe disease, particularly in immunocompromised patients.

What fungal pneumonia is associated with the Ohio and Mississippi River Valleys and bat/bird droppings?

Histoplasmosis (Histoplasma capsulatum) — often subclinical; may cause flu-like illness or chronic cavitary lung disease.

What fungal pneumonia is associated with the southwestern US/California ("Valley Fever")?

Coccidioidomycosis (Coccidioides immitis); presents with fever, cough, erythema nodosum, and arthralgias ("desert rheumatism").

What fungal pneumonia is endemic to the Mississippi/Ohio River Valleys and Great Lakes, causing pulmonary AND skin lesions?

Blastomycosis (Blastomyces dermatitidis); verrucous skin lesions, lytic bone lesions.

What is the treatment for severe systemic fungal pneumonia?

Amphotericin B (severe disease, then step-down to azole); itraconazole for mild-moderate histoplasmosis or blastomycosis; fluconazole for coccidioidomycosis.

What is HIV-Related Pneumonia?

Pulmonary infections occurring in patients with HIV, with risk and pathogen profile correlated to CD4 count; common pathogens include Pneumocystis jirovecii, Mycobacterium tuberculosis, and typical bacterial pathogens.

At what CD4 count does Pneumocystis jirovecii pneumonia (PJP) become a major risk?

CD4 <200 cells/µL.

What is the classic clinical presentation of PJP?

Subacute (weeks) dyspnea on exertion, nonproductive cough, low-grade fever, hypoxia with exertion; LDH often elevated.

What CXR finding is classic for PJP?

Bilateral, diffuse perihilar interstitial ("ground-glass") infiltrates; can be normal in 10-20% of cases — order high-resolution CT if suspicion is high.

What is the treatment for PJP?

TMP-SMX (Bactrim) high-dose for 21 days; add prednisone if PaO2 <70 mmHg or A-a gradient >35 mmHg on room air.

When should PJP prophylaxis be started in HIV patients?

CD4 <200 cells/µL or history of oropharyngeal candidiasis or prior PJP; TMP-SMX is first-line.

What pneumonia should be considered in HIV with CD4 <50 and chronic cough with fever, weight loss?

Mycobacterium avium complex (MAC) — disseminated infection; treat with clarithromycin/azithromycin + ethambutol ± rifabutin.

What is Viral Pneumonia?

Lower respiratory tract infection caused by viruses (influenza, RSV, parainfluenza, adenovirus, coronavirus, human metapneumovirus), often with bilateral interstitial infiltrates and a milder presentation than bacterial pneumonia.

What CXR pattern is more suggestive of viral pneumonia?

Bilateral, diffuse interstitial or ground-glass infiltrates; bacterial typically shows lobar or focal consolidation.

What is the most common cause of viral pneumonia in adults?

Influenza A and B; in children: RSV.

What is the treatment for viral pneumonia?

Supportive care for most viral pneumonias; oseltamivir for influenza if within 48 hours; remdesivir/dexamethasone for severe COVID-19.

What is Tuberculosis (TB)?

A chronic granulomatous infection caused by Mycobacterium tuberculosis, primarily affecting the lungs but capable of disseminating to any organ, transmitted via airborne droplets.

What is the difference between latent TB and active TB?

Latent TB: positive PPD/IGRA, normal CXR, no symptoms, not contagious; Active TB: symptomatic (cough >3 weeks, hemoptysis, weight loss, night sweats), abnormal CXR, contagious.

What is the classic CXR finding in primary TB and reactivation TB?

Primary TB: lower/middle lobe infiltrate with hilar lymphadenopathy (Ghon complex); Reactivation TB: upper lobe cavitation, fibrosis.

How is active TB diagnosed?

Sputum acid-fast bacilli (AFB) smear and culture (gold standard) plus nucleic acid amplification testing (NAAT/Xpert MTB/RIF); 3 sputum samples collected 8-24 hours apart.

What is a positive TST (tuberculin skin test) PPD reading?

≥5 mm: HIV, recent close contact, immunosuppressed, CXR consistent with prior TB; ≥10 mm: high-risk (IVDU, healthcare workers, immigrants from endemic countries, children <4); ≥15 mm: low-risk persons.

What is the treatment for active pulmonary TB?

RIPE therapy x 2 months: Rifampin, Isoniazid, Pyrazinamide, Ethambutol; then 4 months of rifampin + isoniazid (total 6 months); add pyridoxine (B6) with isoniazid.

What is the treatment for latent TB?

Isoniazid 9 months, isoniazid + rifapentine weekly x 12 weeks (3HP), or rifampin 4 months.

What are the major side effects of TB drugs (RIPE mnemonic)?

Rifampin: red-orange body fluids, hepatotoxicity, drug interactions (CYP inducer); Isoniazid: peripheral neuropathy (give B6), hepatotoxicity; Pyrazinamide: hyperuricemia, hepatotoxicity; Ethambutol: optic neuritis (red-green color blindness).

What is Interstitial Lung Disease (ILD)?

A heterogeneous group of disorders causing inflammation and fibrosis of the lung interstitium, leading to progressive dyspnea, dry cough, and restrictive lung physiology.

What are the classic PFT findings in ILD?

Restrictive pattern: decreased FEV1, decreased FVC, NORMAL or INCREASED FEV1/FVC ratio, decreased TLC, decreased DLCO.

What is the most common idiopathic interstitial pneumonia?

Idiopathic pulmonary fibrosis (IPF); usual interstitial pneumonia (UIP) pattern with peripheral, basal honeycombing on HRCT.

What occupational ILDs should you recognize?

Asbestosis (shipyard workers, pleural plaques, lower lobes); Silicosis (mining, sandblasting, upper lobes, eggshell calcifications); Coal worker's pneumoconiosis; Berylliosis (aerospace).

What is the gold standard imaging for ILD?

High-resolution CT (HRCT) of the chest.

What is the treatment for idiopathic pulmonary fibrosis (IPF)?

Antifibrotic therapy: pirfenidone or nintedanib (slow disease progression); supplemental oxygen, pulmonary rehab, lung transplant for advanced disease.