PART 2 I PULMONOLOGY

High-Yield Concepts in Pulmonary Physiology

1. Inspiratory Reserve Volume (IRV)
2. Tidal Volume (TV): amount ofair inhaled/exhaled during
the relaxed state (approximately SOOmL)
4 lung volumes 3. Expiratory Reserve Volume (ERV)
4. Residual Volume (RV): remaining air in the lungs after
maximal exhalation; maintains oxygenation of the blood
during breath-holding
1. Vital capacity (VC]: IRV+ TV +ERV;maximum amount of air
that can be inhaled/exhaled
2. lnspiratory Capacity (IC): IRV+ TV
4 lung capacities 3. Functional Residual Capacity (FRC): ERV+ RV; volume of gas
in lungs after normal expiration
4. Total Lung Capacity (TLC): IRV+ TV+ ERV+ RV; Volume of
gas present in lungs after a maximal aspiration
• Zone 1 (no blood flow since Pulmonary Capillary Pressure<
Alveolar Pressure)
• Zone 2 (intermittent blood flow since Pulmonary Capillary
Lung zones Pressure > Alveolar Pressure only during systole but not
diastole)
• Zone 3 (continuous blood flow since Pulmonary Capillary
Pressure> Alveolar Pressure)
V/Q at apex of lung
3 (wasted ventilation)
V for ventilation; 0 for oerfusion

V/Q at base of lung 0.6 (wasted perfusion)

Airway obstruction leading to a shunt
V/Q= 0
100% OYV•endoes not improve Pa02
Blood flow obstruction (physiologic
V/Q=oo dead space]
100% oxygen improves Pao2 (eg, pulmonary embolus)

~y 98%: bound to HgB (oxyhemoglobin)

How Oz is transported in blood
2%: freely-dissolved in plasma
•
70%: converted to HCO,·
How CO2is transported in blood 23%: bound to HgB (carbaminohemoglobin)
7%: freely-dissolved in plasma

Increase in the following factors would cause Mnemonic· CADET face RIGHT:
shift to the right of the 02-Hgb dissociation curve Increased CO2,Acidosis, 2,3-BPG, Exercise, increased
(unloading of02 from Hgb) Temperature

Increase in the following factors would cause Increased Carbon monoxide, Methemoglobin, fetal
shift to the left of the 02-Hgb dissociation curve hemoglobin, decreased temperature, decreased 2,3-BPG,
(increased binding of 02 to Hgb) decreased CO2, alkalosis
Main respiratory center in the medulla; sends
Dorsal respiratory group (DRG) of the medulla
inspiratorv ramp signal to diaphragm
Central control of both inspiration and
expiration (suoolements DRG) during exercise
Ventral respiratory group (VRG) of the medulla
Decreases duration of inspiration and increases
Pneumotaxic center of the pons
resoiratorv rate
Increases duration of inspiration and decreases
respiratory rate Apneustic center of the pons
Pulmonary diseases
High-Yield Concepts in Bronchial Asthma
>12% AND 200 mL increase in FEVi:
15 minutes after an inhaled short-acting 82-agonist;
Reversibility in asthma (spirometry) is demonstrated by or
After a 2 to 4 week trial of oral corticosteroids
[prednisone or prednisolone 30-40 mg daily)
Physiologic abnormality of asthma Airway hyperresponsiveness
Majpr risk factor for asthma Atopy
Imbalance favoring TH2 production over TH1
Pathogenesis behind asthma
IL-5 increased eosinophils
Putative mediators of asthma SRS-A [made up ofleukotrienes C4, D4, E4)
Whorls of shed epithelium in mucus plugs in asthma Curschmann's spirals
Eosinophilic, hexagonal, double-pointed crystals formed
Charcot-Leyden Crystals
from breakdown of eosinophils in sputum
Thickening of the basement membrane due to
Characteristic finding in asthamtic airways
subepithelial collagen deposition
None
Key predominant cell in asthma Many inflammatory cells are involved in asthma
with no key cell that is predominant
Most common allergens that trigger asthma Dermatophagoides (house dust mites)
Most common triggers of acute severe asthma URTI: rhinovirus, respiratory syncytial virus (RSV),
exacerbations coronavirus
Mechanism of exercise-induced asthma (EIA) Hyperventilation
Begins after exercise has ended, and recovers
spontaneously within about 30 min.
Typical presentation of EIA
Worse in cold, dry climates than in hot, humid
conditions.
EIA is best prevented by regular treatment with Inhaled corticosteroids (ICS)
Confirms airflow limitation with a reduced FEY,, FEV,/FVC
Spirometry
ratio, and PEF
Confirms diurnal variations in airflow obstruction Measurements of PEF twice daily
• Relax smooth-muscle cells of all airways, where
they act as functional antagonists
Primary action of 82-agonists
• Has little or no effect on the underlying
inflammatory process

Most common side effects of 82-agonists Muscle tremor and palpitations

• Dry mouth
Most common side effect of anticholinergics • In elderly patients, urinary retention and
glaucoma may also be observed.
Most common side effects of theophylline Nausea, vomiting, headaches
Most effective controllers for asthma ICS
Indicates the need for regular controller therapy Use of a reliever medication >2x a week
Most common reason for poor control of asthma Noncompliance with medications, usuallv ICS
• Short-acting 82-agonists
Drugs that are safe for asthma in pregnancy • ICS
• Theophylline
High-Yield Concepts in COPD
Asthma and COPDare variations of the same basic disease Dutch hypothesis
Asthma (allergic phenomenon) and COPD (smoking-related
British hypothesis
inflammation and damaP-el are fundamentallv different diseases
Imbalance between Protease (Elastase) and Anti·
Pathogenesis behind emphysema
Protease (Alpha• 1 •Anti• Trypsin)

First symptom of emphysema Progressive dyspnea

Ratio of mucus gland layer thickness to the thickness of the wall Reid's Index
between the epithelium and the cartilage orthe trachea and bronchi (>0.4 in Chronic Bronchitis)

Most highly significant predictor ofFEV1 Pack-years of cigarette smoking

Important causes of COPD exacerbations Respiratory infections

Most common form of severe o: 1.AT deficiency PiZ: two Z alleles or one Zand one null allele

Most typical finding in COPD Persistent reduction in forced expiratory flow rates
Accounts for essentially all or the reduction in Pa02 that occurs in
Ventilation-perfusion mismatching
COPD
Major site or increased resistance in COPD Small airways< 2 mm diameter

Centrilobular emphysema: prominent in the upper

Type or emphysema frequently associated with cigarette smoking,
lobes and superior segments of lower lobes and often
characterized by enlarged air spaces found (initially) in association
focal; involves the respiratory bronchiole
with respiratory bronchioles
(Mnemonic: SENTROacinar, Smoking)

Type or emphysema usually observed in patients with al-AT

deficiency, characterized by abnormally large air spaces evenly Panlobular emphysema: predilection for lower lobes
distributed within and across acinar units
Type or emphysema distributed along the pleural margins with
Paraseptal emphysema
relative snarinl!' or the lunl!' core or central rel!'ions
Most typical finding in COPD Persistent reduction in forced expiratory flow rates
'
Major physiologic change in COPD Airflow limitation

Characteristic of COPD,reOecting the heterogeneous nature or the Non-uniform ventilation and ventilation-perfusion
disease process within the airways and lung parenchyma mismatching

Accounts for essentially all of the reduction in Pao2 that occurs in Ventilation-perfusion mismatching
COPD (shunting is minimal)

Most highly significant predictor ofFEVl Pack-years of cigarette smoking

Newly-developed clubbing of-the digits (not a sign ofCOPD) should

Lung Cancer
alert an investigati9n for

Hallmark or COPD Airflow obstruction

The only pharmacologic therapy demonstrated to unequivocally

Supplemental 02
decrease mortality rates

Strong predictor or future COPD exacerbations History of prior exacerbations

• Streptococcus pneumoniae
• Haemophilus injluenzae
Bacteria frequently implicated in COPDexacerbations • Moraxe/la catarrhalis
In addition, Mycoplasma pneumoniae or Chlamydia
pneumoniae are found in 5-10% of exacerbations
• Smoking cessation
The only three interventions shown to inOuence the natural history • Oxygen therapy in chronically hypoxemic patients
ofCOPD • Lung volume reduction surgery in selected patients
with emphysema
High-Yield Concepts in Pneumonia and Other Pulmonary Infections
Most common way microorganisms gain access to the lower
Aspiration from the oropharynx
respiratory tract in pneumonia

Most common etiology of community-acquired pneumonia Streptococcus pneumoniae

Mycoplasma pneumonlae, Chlamydia

pneumoniae, and Legionella species

Common etiologies of atypical pneumonia Respiratory viruses such as influenza

viruses, adenoviruses, human
metapneumovirus, and respiratory syncytial
viruses

Combination or an unprotected airway ( e.g.,

Major risk factor for anaerobic pneumonia in patients with alcohol or drug overdose or a
seizure disorder) and significant gingivitis

Organism well known to complicate influenza infection and has

S. aureus
potentially serious consequences, such as necrotizing pneumonia

Main purpose of the sputum gram stain Ensure suitability of sample for culture

>25 neutrophils; and

To be adequate for culture, a sputum sample must have
<10 squamous cells per low power field

Most frequently isolated pathogen in blood cultures or

Streptococcus pneumoniae
community·acquired pneumonia

High-Yield Concepts in Bronchiectasis

Irreversible airway dilation that involves the lung in either a focal
Bronchiectasis
or a diffuse manner

Most common form of bronchiectasis Cylindrical or tubular

Vicious Cycle Hypothesis - susceptibility to

infection and poor mucociliary clearance
Most widely cited mechanism of infectious bronchiectasis
result in microbial colonization of the bron·
chial tree.

Persistent productive cough with ongoing

Most common clinical presentation of bronchiectasis
production of thick, tenacious sputum

Imaging modality of choice for confirming bronchiectasis Chest CT

High-Yield Concepts in Pleural Effusion and Pneumothorax
Determine whether effusion is a
First step in the diagnostic approach to pleural effusion
transudate or exudate

Leading causes of transudative pleural effusion LV failure and cirrhosis

Pleural fluid N-terminal pro-brain

Virtually diagnostic that the effusion is secondary to congestive heart
natriuretic peptide (NT-proBNP) >1500
failure.
pg/mL

Bacterial pneumonia, malignancy, viral

Leading causes of exudative pleural effusion
inrection, pulmonary embolism

Trauma (most frequently thoracic

Most common cause of chylothorax surgery), but it also may result from
tumors in the mediastinum

• Lung carcinoma
Three tumors that cause ~75% of all malignant pleural effusions • Breast carcinoma
• Lymphoma

Benign ovarian tumors producing ascites and pleural effusion Meigs syndrome

Condition most commonly overlooked in the differential diagnosis of a

Pulmonary embolism
patient with an undiagnosed effusion

Insertion of a chest tube plus

Treatment of choice for most cases of chylothorax
administration of octreotide

Primary spont.aneous pneumothoraxes occur almost exclusively in Smokers

Tracheal deviation in tension pneumothorax Contralateral tracheal deviation

High-Yield Concepts in Obstructive Sleep Apnea/Hypopnea syndrome

(1) Either symptoms of nocturnal breathing disturbances [snoring, snorting, gasping, or
breathing pauses during sleep) or daytime sleepiness or fatigue that occurs despite
Diagnosis of
sufficient opportunities to sleep and is unexplained by other medical problems; and
Obstructive Sleep
Apnea/Hypopnea
(2) Five or more episodes of obstructive apnea or hypopnea per hour of sleep (the
syndrome
apnea-hypopnea index [AHi], calculated as the number of episodes divided by the
number of hours of sleep) documented during a sleep study.

Cessation of airflow for HO s during sleep, accompanied by:

Apnea 0 Persistent respiratory effort (obstructive apneas), or
0 Absence of respiratory effor ( central apneas)

A ~30% reduction in airflow for at least 10 s during sleep that is accompanied by either
Hypopnea
a ~3% desaturation or an arousal
High-Yield Concepts in Mediastinal Masses
First step in evaluating a mediastinal mass Place it in one of the three mediastinal comparbnents
Mnemonic· Remember T!
• Thymomas
Most common lesions in anterior mediastinum • Teratomatous neoplasms
• Thyroid masses
• Terrible Lvmohomas
• Bronchogenic cysts
• Pericardial cysts
Most common masses in the middle mediastinurn • Lymphoma
• Metastatic lymph node enlargement
• Masses of vascular origin
• Neurogenic tumors, meningocele, meningomyelocele,
gastroenteric cysts, esophageal diverticula, hernia
Most common masses in the posterior rnediastinum through foramen of Bochdalek, extramedullary
hematopoiesis

H"1gh -y·1eId Concep ts. m DVT an dP u Imonary Emb o rism

Most common preventable cause of death among
hospitalized patients.
Pulmonary embolism
"
Arterial hypoxemia and an increased alveolar-arterial
Most common gas exchange abnormalities in PE
02 tension gradient,

Hallmarks of massive PE Dyspnea, syncope, hypotension, and cyanosis

Cramp of"'charley horse" in the lower calf that persists

Most common symptom of DVT
and intensifies over several days

Most common symptom of PE Unexplained breathlessness

Useful rule out test: > 95% of patients with normal
Quantitative plasma D-dimer ELISA
levels ( <S00ng/mL) do not have PE
Most frequently cited ECGabnormality in PE St Q3 T3 sign
(in addition to sinus tachycardia) (specific but insensitive)

Most common ECGabnormality in PE T-wave inversion in leads Vt to V4

Principal imaging test for the diagnosis of PE Chest CT Scan with IV contrast

Second-line diagnostic test for PE, used mostly for

Lung Scanning
patients who cannot tolerate IV contrast
McConnell's sign: hypokinesls of the RV free wall with
Best known indirect sign of PE on transthoracic echo
normal motion of the RV apex
Definite diagnostic test for PE which visualizes an
Pulmonary Angiography
intra1uminal filling defect in more than one projection

Foundation for successful treatment of DVTand PE Anticoagulation

Systemic arterial hypotension with usually

Massive pulmonary embolism
anatomically widespread thromboembolism

Moderate to large pulmonary embolism RV hypokinesis with normal systemic arterial pressure

Normal RV function and normal systemic arterial

Small to moderate pulmonary embolism pressure
( excellent prognosis with adequate anticoagulation)
High-Yield Concepts in ARDS
• Severity ofhypoxemia:
• Mild: 200 mmHg < Pao2/Fio2,; 300 mmHg
• Moderate: to0_mmHg < Pao2/Fio2,; 200 mmHg
• Severe: Pao2/Fio2 ,; 100 mmHg

• Acute: Within 1 week of a clinical insult or new or worsening

Diagnostic criteria for ARDS
respiratory symptoms.
• Bilateral opacities consistent with pulmonary edema not fully
explained by effusions, lobar /lung collapse, or nodules
• Absence of left atrial hypertension - Hydrostatic edema is not
the primary cause of respiratory failure. If no ARDSrisk factor
is present. then some objective evaluation is required ( e.g.,
echocardiography) to rule out hydrostatic edema

Pneumonia and sepsis (-40-60%), followed in incidence by

Most cases of ARDSare caused by aspiration of gastric contents, trauma, multiple transfusions,
and drug overdose

3 phases of ARDS Exudative Proliferative Fibrotic phase

Evidence-based recommendation for tidal

Low VT ventilation (6 mL/kg of predicted body weight)
volume to minimize ventilator-inducedlung
The only Grade A recommendation in treatment of ARDS
injury

Mortality in ARDSis Nonpulmonary causes, with sepsis and nonpulmonary organ

largely attributable to failure accounting for >80% of deaths.

High-Yield Concepts in Acute Respiratory Failure

Acute hypoxemic respiratory failure - occurs with alveolar flooding and subsequent
intrapulmonary shunt physiology
• Pulmonary edema
Type 1 • Pneumonia
• Alveolar hemorrhage
• Lung injury

Alveolar hypoventilation and results from the inability to eliminate carbon dioxide
effectively
Type2 • Impaired central nervous system (CNS) drive to breathe
• Impaired strength with failure of neuromuscular function in the respiratory system
• Increased respiratory load

Type3 Respiratory failure due to atelectasis (aka perioperative respiratory failure)

Type4 Hypoperfusion of respiratory muscles usually secondary to shock