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Respiratory System

Acute Asthma Exacerbation

  • Presentation: tachypnea (>20 breaths/min), tachycardia or bradycardia, cyanosis, anxiety; exhausted, fatigued, diaphoretic; uses accessory muscles.

  • Lung exam: often “quiet” lungs with little to no wheeze; cyanosis can be a late sign.

  • Speak: patient may only be able to say 1–2 words due to breath needs.

Acute Carbon Monoxide Poisoning

  • Typical mild-to-moderate symptoms: headache (most common), nausea, malaise, dizziness; can resemble URI.

  • Severe toxicity: seizures, syncope, coma.

  • Physical signs: cherry-red skin/lips may be present but is insensitive.

  • Diagnosis: history + physical; elevated carboxyhemoglobin on co-oximetry of arterial blood gas; venous sample less accurate.

Covid-19

  • Cause: SARS-CoV-2; incubation 2–14 days.

  • Symptoms: fever, chills, headache, myalgia, cough, dyspnea, fatigue, diarrhea, nausea/vomiting; loss of taste/smell in some; sore throat, congestion, rhinitis in others.

  • Risk factors: underlying heart/lung disease or diabetes increase risk of severe disease.

  • Most have mild illness and recover at home; contact primary care for testing instructions and treatment.

  • Isolation: close contacts should self-quarantine up to 14 days.

  • Hospitalization: for serious symptoms (trouble breathing, confusion).

Lung Cancer

  • Presentation: majority present with advanced disease.

  • Warning signs: persistent cough (50%–75% in smokers/former smokers), hemoptysis, dyspnea; chest pain (dull, achy), shoulder/bone pain; weight loss, fatigue, fever.

  • Local obstruction: recurrent pneumonia in same lobe may indicate tumor obstruction.

  • Horner syndrome (ptosis + miosis) may occur; prompts urgent MRI.

  • Histology: Non–small cell lung cancer (NSCLC) is most common (≈85%).

  • Screening: annual LDCT in adults 50–80 with ≥20 pack-year history who currently smoke or quit in past 15 years.

Pulmonary Embolism (PE)

  • Definition: obstruction of the pulmonary artery or branches by thrombus, tumor, air, or fat.

  • Presentation: sudden dyspnea, cough (may be productive of pink-tinged sputum), tachycardia, pallor, sense of impending doom.

  • Risk factors: any condition increasing thrombosis risk (AFib, estrogen therapy, smoking, surgery, cancer, pregnancy, long bone fractures, prolonged inactivity).

Normal Findings (Physical Examination & Basic Tests)

  • Breath sounds

    • Vesicular: soft, low-pitched; heard over most peripheral fields.

    • Bronchial: louder/high-pitched; over lower trachea and manubrium.

    • Bronchovesicular: intermediate; major bronchi mid-chest or between scapula.

    • Tracheal: loudest; over upper trachea/neck.

  • Respiratory rate: normal 12–20 breaths/min in adults; women slightly higher; high PaCO2 >70–80 mmHg can depress respiration and cause headaches, restlessness, unconsciousness, death if untreated.

  • Tips: recognize respiratory failure—tachypnea, loss of wheeze, accessory muscles, diaphoresis, exhaustion.

  • Tachypnea: many causes (increased O2 demand, hypoxia, increased PaCO2); seen in pain, fear, fever, exercise, asthma, pneumonia, PE, hyperthyroidism.

  • Egophony: normal sound “eee”; abnormal when consolidation/fluid present: heard as “bah.”

  • Tactile fremitus: normal stronger at upper lobes, softer at lower lobes; abnormal if consolidation (asymmetric).

  • Whispered pectoriloquy: normal voice distant/muffled; abnormal when consolidation—whispered words heard clearly in lower lobes.

  • Percussion:

    • Normal: resonance.

    • Hyperresonance: COPD/emphysema.

    • Tympanic: drum-like; chest wall abnormal (pneumothorax).

    • Dull: lobar pneumonia, pleural effusion; dull over liver.

  • Pulmonary function testing (PFT): pre- and post-bronchodilator; gold-standard for asthma/COPD; measures include


    • ext{FEV}_1 = ext{forced expiratory volume in 1 second}
      ext{FVC} = ext{forced vital capacity}


    • rac{ ext{FEV}_1}{ ext{FVC}}

    • Obstructive dysfunction: reduced airflow (as in asthma/COPD).

    • Restrictive dysfunction: reduced lung volume (e.g., fibrosis).

  • Asthma: history of symptoms (wheezing, SOB, chest tightness, cough) with variable expiratory limitation; reversible obstruction; atopy/family history common.

Asthma: Core Concepts

  • Definition: chronic airway inflammation; variable symptoms; reversible airway obstruction; airway hyperresponsiveness.

  • Exacerbations can be life-threatening.

  • Trigger assessment: rule out allergic asthma; consider GERD, rhinitis, sinusitis; assess stress.

  • Classic case: exercise/cold air/inhaled allergens trigger worsening; increased albuterol use (>2–3 times/day) indicates poor control.

Asthma Symptoms & Examination (Classic Case)

  • Lungs: wheezing with expiratory prolongation; as obstruction worsens, wheeze may be heard during inspiration and expiration; severe constriction can render breath sounds faint or inaudible.

  • Cardiovascular: tachycardia.

Trigger Factors for Asthma

  • Viral URIs; airborne allergens (dust mites, mold, cockroaches, furry animals, pollens)

  • Food allergies (sulfites, certain dyes, seafood)

  • Irritants (cold air, fumes from chemicals/smoke, smoking, wood-burning stove)

  • Emotional stress; exercise (exercise-induced asthma)

  • GERD; NSAIDs and aspirin; beta-blockers; ACE inhibitors; eye drops

  • Genetics/atopy; past hospitalizations; poor asthma control history

Treatment Goals (All Patients With Asthma)

  • Optimize symptoms to perform usual activities with no limitations.

  • Prevent exacerbations.

  • Minimize need for rescue meds (<2 days/week of albuterol).

  • Avoid ED visits/hospitalization.

  • Maintain near-normal pulmonary function; prevent loss of lung function (children: prevent reduced lung growth).

  • Minimize adverse medication effects.

Treatment Plan & Monitoring

  • Initial visit: assess control; adjust therapy as needed.

  • At each visit: review symptoms, technique, adherence, and patient concerns.

  • PFirst-line: inhaled corticosteroids (ICSs) for lung inflammation.

  • Rescue vs. controller meds:

    • Short-acting beta-agonists (SABA) for acute relief; e.g., albuterol, pirbuterol, levalbuterol.

    • Long-acting beta-agonists (LABA) used with ICS in asthma management (not as rescue alone).

  • Quick-relief meds (SABA) dosing:

    • MDI with or without spacer; nebulizer up to 3 treatments every 20 minutes as needed; could require short course of oral steroids if exacerbation is severe.

  • ICS-LABA combinations: budesonide-formoterol; usual dosing 1–2 inhalations, repeat every 20 minutes for 1 hour for acute relief (use varies by regimen).

  • Long-Term Control Medications:

    • LABAs in asthma should be used in combination with ICS (not as monotherapy).

    • Sustained-release Theophylline (Theo-24) as adjunct; monitor levels (target peak serum 10–20 mg/dL); many drug interactions exist.

  • Inhaler technique aids: spacers or chambers (e.g., AeroChamber) improve delivery and reduce oral thrush from ICS.

  • First-line controller: ICSs; reduce airway inflammation; potential systemic effects with high-dose/long-term use (osteoporosis, growth suppression in children, glaucoma, cataracts, HPA axis suppression).

  • Spacers: recommended to improve delivery and reduce oral adverse effects.

  • Spacers/Chambers tips and cautions included.

Asthma Classification, Stepwise Approach & Guidelines (Age ≥12)

  • Guideline sources: NAEPP 2020 (Expert Panel Report III) and GINA 2020 updates.

  • NAEPP vs GINA: NAEPP uses spirometry/peak flow to determine severity; GINA bases severity on treatment needs to control symptoms/exacerbations.

  • Summary table differences (not reproduced in full here).

Summary: Asthma Treatments by Guideline (Key Points)

  • NAEPP 2020: Intermittent asthma: SABA PRN; Step 2: add low-dose ICS; Step 3: add LABA to low-dose ICS; continue SABA PRN.

  • GINA 2020: Preferred reliever is ICS–formoterol (or ICS–LABA); SABA monotherapy discouraged as sole rescue; ICS–LABA can be maintenance and rescue; budesonide beclomethasone preferred; refer for severe persistent disease as needed.

  • Night awakenings in intermittent asthma: occur 2× or less per month.

  • PEF assessment: HAS mnemonic for predicting PEF from height/age/sex; aim to monitor personal best PEF.

Patient Education & Self-Management

  • Inhaler technique review; rescue vs. controller medications explained.

  • Develop a written asthma action plan; involve patient and family.

  • Allergen avoidance and immunotherapy if allergic asthma; spirometry testing; regular follow-up; manage comorbidities.

  • Spirometry teaching and regular monitoring.

  • Exercise-induced bronchoconstriction (EIB): occurs in up to 90% of asthmatics; prevention with two puffs of SABA 5–20 minutes before exercise; lasts up to 4 hours.

Exercise-Induced Bronchoconstriction (EIB)

  • Mechanism: leukotrienes, histamine, and interleukins increased during exercise.

  • Pre-exercise prophylaxis: two puffs of SABA (albuterol, levalbuterol, pirbuterol) 5–20 minutes prior to exercise; duration up to ~4 hours.

Asthma Exacerbation: Emergency Management

  • Signs of respiratory distress: tachypnea; accessory muscle use; fragmented speech; severe diaphoresis; agitation.

  • Lung exam: minimal to no breath sounds; peak expiratory flow (PEF) <40%; cyanosis; oxygen saturation check; give supplemental oxygen.

  • Acute treatments:

    • Nebulized albuterol 0.5% solution: up to 3 doses every 20–30 minutes.

    • MDI with spacer: 4–8 puffs every 20 minutes for 3 doses.

    • After initial neb/MDI treatments: assess response; wheeze and breath sounds indicate airway opening; no wheeze indicates poor response.

  • Moderate-to-severe exacerbations: oral glucocorticoids (e.g., prednisone 40–60 mg daily for 5–7 days); no taper needed if ICS ongoing and short course (<3 weeks).

  • Consider: inhaled ipratropium with SABA; one-time magnesium sulfate infusion.

  • ED referral: if poor/no response (PEF <40% of predicted) or no improvement after treatment; epinephrine if anaphylaxis suspected.

Peak Expiratory Flow Rate (PEF) & Monitoring

  • Definition: maximal rate of exhalation during a short maximal effort after full inspiration.

  • Use: assesses treatment response, symptom worsening, and exacerbations.

  • Monitoring: record PEF 2–4 times daily for 2 weeks toward personal best; HAS to estimate personal best PEF.

  • Personal best PEF: generally the highest value achieved when asthma is controlled.

  • Zone management (Asthma Action Plan):

    • Green: 80%–100% of personal best; no wheeze; normal sleep; continue controller meds.

    • Yellow: 50%–80% of personal best; mild wheeze; chest tightness; coughing at night; follow plan to regain control.

    • Red: <50% of personal best; warning signs; breathing difficulty; extreme symptoms; administer rescue bronchodilator; call 911 if not improved.

  • Rescue meds: short-acting bronchodilators prescribed to all patients for immediate relief.

  • Ipratropium: short-acting antimuscarinic (SAMA) used as adjunct.

  • Pearls:

    • Pulse oximetry ≤90% during an asthma exacerbation suggests severe hypoxemia; call 911.

    • Near-normal SpO2 may occur in impending respiratory failure due to hypercapnia; bedside capnometry can be useful.

  • Rescue therapy considerations: inhaled anticholinergic, magnesium sulfate, potential avoidance of certain triggers.

Long-Term Control Medications for Asthma

  • Inhaled corticosteroids (ICSs): e.g., budesonide, fluticasone; first-line for inflammation.

  • Long-acting beta-2 agonists (LABAs): should not be used alone; use in combination with ICS (Advair, Symbicort, Dulera).

  • ICS–LABA combos: preferred in many guidelines for both daily maintenance and rescue therapy (e.g., budesonide–formoterol).

  • Methylxanthines: Theophylline (Theo-24); adjunct; monitor trough levels (target 10–20 mg/dL); numerous drug interactions.

  • Leukotriene receptor antagonists/inhibitors: Montelukast, Zafirlukast, Zileuton; monitor for neuropsychiatric effects and liver function (zileuton).

  • Mast cell stabilizers: Cromolyn sodium, Nedocromil; largely discontinued in the U.S.; mild local irritation possible.

  • Anti-IgE antibodies: Dupilumab, Omalizumab; risk of anaphylaxis, urticaria, injection-site reactions; may increase CV events.

  • Systemic corticosteroids: prednisone/prednisolone/methylprednisolone; short courses for exacerbations; taper only if extended therapy (>3 weeks).

  • Spacers or chambers recommended with inhalers to improve delivery and reduce throat infections from ICS.

Asthma Classification, Stepwise Approach, & Guidelines (Summary)

  • NAEPP (2020; ER Report III) vs GINA (2020): both use symptoms, impairment, and risk to guide therapy; categories differ by criteria (spirometry/peak flow vs treatment-based severity).

  • NAEPP steps by age group (adult/older children): Step 1–4/5/6 with ICS and LABA as appropriate.

  • GINA: Preferred reliever is ICS–formoterol or ICS–LABA; SABA monotherapy discouraged; ICS–LABA used for both maintenance and relief in many steps; consider specialist referral for severe persistent asthma.

  • Peak flow guidance: HAS mnemonic for estimating PEF; PEF monitoring important for personal best and home management.

Asthma Self-Management & Education (Continued)

  • Green/Yellow/Red zone descriptions (as above) to guide actions.

  • Ensure access to inhaler spacer devices; teach how to use spirometer; prevent allergen exposures; consider immunotherapy when allergic.

  • Emphasize preventive approach with regular follow-up and comorbidity management.

Exercise-Induced Bronchoconstriction (EIB) – Summary

  • Acute bronchoconstriction during/after exercise; up to 90% of asthmatics affected.

  • Pathophysiology: leukotrienes, histamine, ILs increased during exercise.

  • Prophylaxis: pre-exercise SABA dosing (2 puffs) 5–20 minutes prior; effect up to ~4 hours.

Acute Bronchitis

  • Definition: acute lower respiratory infection of large airways without pneumonia.

  • Etiology: often viral; common agents include adenovirus, influenza, coronavirus, RSV, parainfluenza, hMPV.

  • Presentation: dry cough that can become productive; paroxysms; low-grade fever; sore throat; wheezes/rhonchi.

  • Duration: about 18 days (range 1–3 weeks).

  • Exam: lung findings range from clear to wheezing; chest X-ray normal.

  • Treatment: symptomatic; avoid antibiotics; fluids, rest; antitussives (dextromethorphan, benzonatate), guaifenesin; albuterol for wheezing; short-term oral steroids in severe wheeze.

  • Complications: risk of asthma exacerbation; secondary pneumonia.

Community-Acquired Pneumonia (CAP)

  • Most common bacterial cause: Streptococcus pneumoniae (gram-positive); others include H. influenzae, atypicals (Mycoplasma, Chlamydophila), viruses.

  • Atypical pneumonia: Mycoplasma pneumoniae and Chlamydophila pneumoniae common; Legionella possible in certain settings.

  • Presentation: fever, chills; productive cough with green/rust-colored sputum; pleuritic chest pain; crackles, dullness to percussion; leukocytosis; band forms possible.

  • Diagnosis: CXR is gold standard for CAP; CBC often shows leukocytosis with left shift; sputum culture not always needed.

  • Severity scoring: CURB-65 (0–5) and Pneumonia Severity Index (PSI) help determine site of care.

  • CURB-65 details:

    • C: Confusion

    • U: BUN > 19.6 mg/dL

    • R: Respiratory rate > 30/min

    • B: SBP < 90 mmHg or DBP ≤ 60 mmHg

    • 65: Age ≥ 65

    • Score 0–1 low severity; 2 moderate; 3–5 high risk (death risk ~15–40%).

  • Treatment (outpatient ATS/IDSA guidelines):

    • No comorbidities: Amoxicillin 1 g PO TID x 5–7 days; or Doxycycline 100 mg PO BID x 5–7 days; or Macrolide (if local macrolide resistance <25%): Azithro 500 mg day 1, then 250 mg daily; Clarithro 500 mg BID or 1,000 mg ER daily.

    • With comorbidities or resistance concerns: Amoxicillin–clavulanate 875/125 mg PO BID + Macrolide or Doxycycline; or Cephalosporin + Macrolide/Doxycycline; or Respiratory fluoroquinolone (Levofloxacin 750 mg, Moxifloxacin 400 mg, Gemifloxacin 320 mg).

    • In certain cases: Monotherapy with a respiratory fluoroquinolone if beta-lactam intolerance.

  • Inpatient care: consider if high CURB-65 score, poor oral intake, dehydration, confusion, or hypoxemia; consider IV antibiotics, sooner escalation to hospital.

  • Prevention: influenza vaccination; pneumococcal vaccines PCV13/15/20 and PPSV23 depending on age and risk; PCV15/PCV20 for adults ≥65 or specific conditions; PPSV23 best given after PCV dose; booster decisions based on guidelines.

  • CAP complications: empyema, bacteremia, necrotizing pneumonia; often re-evaluate with follow-up CXR.

Pneumococcal Vaccines & Recommendations

  • PCV13/PCV15/PCV20: recommended for children <2 or certain older children with conditions; adults ≥65 or 19–64 with comorbidities may receive PCV15 or PCV20; PCV13 previously given may be followed by PPSV23; PCV20 can replace PPSV23 in those who have not received PCV13/PPSV23.

  • PPSV23: broad coverage; >80% seroconversion in healthy adults; efficacy ~60–70%; reduced efficacy in chronic illness; given at least 1 year after PCV15; not indicated if PCV20 used.

COVID-19 (Clinical Summary)

  • Global impact; vaccination recommended for all ages; four vaccines approved in the U.S. (including updated boosters).

  • Treatments based on severity and setting:

    • Outpatient: nirmatrelvir–ritonavir within 5 days of symptom onset (alternative: remdesivir).

    • Hospitalized with oxygen: dexamethasone or equivalent; not recommended for non-hospitalized patients not requiring oxygen.

  • Primary prevention: vaccination; updated boosters; follow CDC/WHO guidelines for dosing schedules.

  • Risk factors for progression: age ≥65, comorbidities (asthma, cancer, CF, CV disease, diabetes), immunosuppression, male sex, certain ethnic groups, smoking, corticosteroid or biologic use.

  • Complications: ARDS, thromboembolism, cardiac injury, neurologic events, secondary infections.

Chest X-Ray Interpretation Basics (PA/AP/Lateral)

  • X-ray basics: darker on images indicates air (low density); bones appear white; metals are bright; fluids appear grayish.

  • Common patterns:

    • Emphysema: hyperinflation; lucency in lung fields; flattened diaphragms; reduced vascular markings.

    • Lobar pneumonia: focal consolidation (gray/white region in a lobe).

    • TB: upper lobe cavitations with potential fibrosis and nodularity.

    • LVH/cardiomyopathy: enlarged heart occupying >50% of thoracic width.

    • Silhouette sign: loss of normal cardiomediastinal silhouettes due to adjacent pathology.

  • Reading approach: compare with prior films; PA vs. AP vs. lateral views; systematic approach to interpretation.

Acute Bronchitis (In-depth)

  • Etiology: frequently viral; self-limited.

  • Clinical course: cough often dry at first, may become productive; rhinitis, sore throat, wheeze, low-grade fever.

  • Management: symptomatic care; antibiotics not routinely indicated; bronchodilators for wheeze; short courses of steroids for severe wheeze if indicated.

  • Complications: can trigger or worsen asthma; risk of secondary bacterial pneumonia.

Pertussis (Whooping Cough)

  • Etiology: Bordetella pertussis (gram-negative) highly contagious.

  • Stages: catarrhal (1–2 weeks), paroxysmal (2–4 weeks), convalescent (1–2 weeks).

  • Classic case: long paroxysmal coughing with inspiratory whoop; post-tussive vomiting; worse at night; infants may have apnea instead of whoop.

  • Diagnosis: culture (highest sensitivity in first 2 weeks) and PCR; sensitivity of culture declines after 2 weeks; PCR effective up to ~4 weeks; more than 4 weeks: serology.

  • Treatment: macrolides (e.g., azithromycin, clarithromycin) for adolescents/adults; infants <2 months require careful dosing; alternatives include trimethoprim–sulfamethoxazole for those >2 months.

  • Prevention: Tdap vaccine for adolescents (11–12 years) and pregnant patients (Tdap during each pregnancy, weeks 27–36); adults with no Tdap should receive a dose with boosters every 10 years.

  • Complications: sinusitis, otitis media, pneumonia, rib fractures; precautions for transmission.

Tuberculosis (TB)

  • TB forms:

    • Latent TB infection (LTBI): asymptomatic; not infectious; immune system contains bacteria in granulomas; requires treatment to prevent progression.

    • TB disease: symptomatic; contagious in many cases; active infection with clinical illness.

    • Miliary TB: disseminated hematogenous TB; multi-organ involvement; higher risk in children <5 and older adults.

    • Drug resistance: MDR-TB (isoniazid and rifampin resistance); XDR-TB (additional resistance to fluoroquinolones or second-line injectables).

  • Testing:

    • Mantoux TST (PPD): intradermal 5 TU; result read by induration width; booster phenomenon can occur; two-step TST recommended if last test was long ago.

    • IGRA (QuantiFERON-TB Gold In-Tube, T-SPOT.TB): blood tests; preferred for individuals vaccinated with BCG.

  • Sputum/Imaging/Lab work:

    • Sputum NAAT, culture and susceptibility, AFB smear; NAAT rapid; culture gold standard but slow (up to 8 weeks).

    • CXR findings: upper-lobe cavitations and mediastinal adenopathy in active TB; miliary TB shows mulch-like nodules.

  • LTBI treatment regimens (preferred): rifamycin-based short-course options (3–4 months) using rifapentine + isoniazid or rifampin alone; chosen to minimize hepatotoxicity and adherence burden.

  • Active TB treatment: typically 4-drug regimen (isoniazid, rifampin, ethambutol, pyrazinamide) for 6–9 months, adjusted by susceptibility; Directly Observed Therapy (DOT) recommended for adherence.

  • Drug adverse effects:

    • Isoniazid: neuropathy; give pyridoxine (vitamin B6).

    • Ethambutol: optic neuritis; baseline eye exam.

    • Pyrazinamide: hepatotoxicity; hyperuricemia; arthralgias.

    • Rifampin: hepatotoxicity; orange body fluids; multiple drug interactions.

  • Special notes: TB is reportable; HIV testing recommended for all TB patients; screen for contacts; avoid under-treatment; booster phenomenon can complicate interpretation of TSTs.

Chest X-ray Interpretation: Additional Details

  • PA view vs. AP view; lateral view usefulness; compare with prior films.

  • Anatomic landmarks: trachea, aorta, heart, diaphragms, ribs, etc.

  • Key radiographic patterns to recognize:

    • Upper-lobe cavitation suggests TB.

    • Hyperinflation and flattened diaphragms suggest emphysema.

    • Silhouette sign indicates adjacent pathology.

  • Practical tips: healed TB on PA may show nodules/cavitations in upper lobes; right middle lobe consolidation appears near the level of the right breast.

COPD Overview & Related Conditions

  • Definition: chronic, progressive loss of lung function with airflow limitation; chronic inflammatory response; dyspnea is primary symptom.

  • Common causes: long-term smoking; female sex may increase susceptibility; overlapping asthma (ACOS).

  • Components: emphysema (alveolar destruction, hyperinflation) and chronic bronchitis (productive cough for ≥3 months in ≥2 consecutive years).

  • Classic phenotypes:

    • Emphysema: thin, cachectic; pink puffer; pursed-lip breathing; tachypnea; barrel chest.

    • Chronic bronchitis: blue bloater; cyanotic; chronic productive cough; rhonchi; wheezes.

  • Pathophysiology: decreased elastic recoil; hypoxemia/hypercapnia in later stages; possible cor pulmonale (pulmonary hypertension).

  • GOLD treatment guidelines (2023): classify patients into Groups A, B, or E (with possible C/D used in older versions); initial pharmacologic treatment guided by symptoms and exacerbation risk.

  • Exacerbations: infectious triggers common; management includes SABA/SAMA, long-acting bronchodilators; systemic steroids during exacerbations; antibiotics for suspected bacterial infections; consider ICS in frequent exacerbators.

  • Noninvasive ventilation preferred for COPD exacerbations when required.

  • Long-term management:

    • Smoking cessation; vaccinations (influenza, pneumococcal, COVID-19); pulmonary hygiene; rehab; exercise.

    • Regular inhaler technique evaluation; nutritional support for low BMI; bone health monitoring due to steroid use.

  • Drug options:

    • SABAs: albuterol, levalbuterol, pirbuterol.

    • LABAs: salmeterol, formoterol, vilanterol (not as monotherapy).

    • SAMAs: ipratropium.

    • LAMAs: tiotropium, glycopyrrolate; combinations with LABA available.

    • Phosphodiesterase-4 inhibitors: roflumilast for severe COPD; not bronchodilators.

    • Oxygen therapy for chronic hypoxemia: titrate to SpO2 88–92% to improve survival.

  • Safety cautions:

    • SABAs can cause tachycardia/palpitations; caution with hypertension, angina, hyperthyroidism; avoid caffeine interactions.

    • Anticholinergics: avoid in narrow-angle glaucoma, BPH, bladder outlet obstruction.

Oxygenation & Supportive Therapy for COPD & Acute Illnesses

  • For COPD exacerbations: monitor oxygen saturation; use noninvasive ventilation when indicated.

  • DVT/PE risk increases with COPD; thromboprophylaxis considerations during hospitalization.

  • General COPD management emphasizes vaccination, nutrition, rehab, and daily activity to improve outcomes.

Acute Bronchitis vs Pneumonia: Quick Distinctions

  • Acute bronchitis: usually viral; cough lasting days to weeks; no consolidation on imaging; symptomatic treatment only.

  • CAP: consolidation on CXR; bacterial etiologies common; antibiotic therapy guided by ATS/IDSA guidelines; outpatient regimens vary by comorbidity and resistance patterns.

Common Cold (Viral URI)

  • Self-limited; symptoms include fever, sore throat, nasal congestion, cough; management supportive.

  • Decongestants, analgesics, antihistamines, and antitussives may be used for symptom relief.

  • Antibiotics not indicated unless secondary bacterial infection suspected.

Preventive & Public Health Considerations

  • Vaccinations: influenza annually; pneumococcal vaccines (PCV13/15/20; PPSV23); COVID-19 vaccines per current guidelines; pertussis vaccination with Tdap in adolescence and pregnancy.

  • Screening and testing strategies follow CDC/WHO guidelines; emphasize infection control and vaccination as primary prevention.

  • Directly Observed Therapy (DOT) is recommended for TB treatment adherence.

Quick Reference: Key Numeric Guidelines & Formulas

  • Normal respiratory rate: 12–20 breaths/min.

  • Tachypnea threshold for distress: often >30 breaths/min (context-dependent).

  • CURB-65 scoring (0–5):

    • C Confusion

    • U Urea (BUN) > 19.6 mg/dL

    • R Respiratory rate ≥ 30/min

    • B Blood pressure SBP < 90 mmHg or DBP ≤ 60 mmHg

    • 65 Age ≥ 65 years

    • Interpretation: 0–1 low risk; 2 moderate; 3–5 high risk (death risk ~15%–40%).

  • Peak Expiratory Flow Rate (PEF): best effort; determine personal best;

    • Green zone: 80%–100% of personal best

    • Yellow zone: 50%–80% of personal best

    • Red zone: <50% of personal best

  • HAS mnemonic (PEF estimation): Height (H), Age (A), Sex (S) determine HAS-based estimate of PEF.

  • Asthma pharmacology quick notes:

    • SABA dosing: 2 puffs every 4–6 hours as needed (MDI) or up to 3 neb treatments in acute exacerbation.

    • Budesonide–formoterol (ICS–LABA) as maintenance and rescue in some regimens; standard daily ICS therapy remains first-line for inflammation.

    • Theophylline target trough: 10–20 mg/dL; monitor for interactions and toxicity.

  • COPD therapies (examples):

    • SABAs: albuterol, levalbuterol, pirbuterol

    • LABAs: salmeterol, formoterol, vilanterol

    • SAMAs: ipratropium

    • LAMAs: tiotropium, glycopyrrolate; combinations exist with LABA

    • Oxygen target: SpO2 88%–92%

Notes on Exam-Taking Pearls

  • In a severe asthmatic exacerbation, auscultation may reveal minimal or no wheezing; treat as a potential sign of airway collapse and impending respiratory failure if not responding to bronchodilators.

  • For CAP, even with a negative CXR early on, treat if clinical suspicion remains high (per “Pearls”).

  • If macrolide resistance >25%, avoid macrolide monotherapy for CAP.

  • TB: Do not treat TB with fewer than three drugs; ensure full course per guidelines; ensure HIV testing for TB patients.

  • Always reassess inhaler technique and adherence; provide education on action plans and vaccination status.

  • Smoking cessation remains a cornerstone of COPD management; combine pharmacotherapy with behavioral support when possible.

  • Recognize that asthma management is dynamic and requires regular follow-up, spirometry, and adjustment of therapy to maintain control while minimizing side effects.