CHEST Board Review Pulmonology 2024

PE in pregnancy

• lovenox pre partum
• lovenox post partum if breast feeding and DOAC if not
• anticoagulation for 3 months, include 6 weeks post partum

Septic emboli

amnionic fluid embolism

• 36 hours post partum
• postpartum with DIC = think amnionic fluid embolism
• nonspecific image finding
• supportive

air embolism

• central access removal
• chest pain, hypoxia, cough
• CTA: air in vessel
• treatment: fluids, O2, left lateral decubitus position

fat embolism

• post long bone fx
• hypoxia, diffuse petechial rash, fever
• CT: multifocal nodular GGO (like septic emboli without cavity)
• treatment: supportive

pulmonary tumor thrombi

• GI, breast, lung cancers
• interlobular septal thickening
• RV dysfunction but no PE
• treatment: chemo

POCUS

• Blue protocol:
  • A profile
  • B profile
  • PLAPS profile
  • Shred sign: lung consolidations
  • absence of lung slides, can happen in pneumonectomy and bleb: look at lung point
  • sinusoid sign: respiratory variation decreases distance between parietal and visceral pleura
• pleural effusion
  • quad sign
  • sinusoid sign

Pleural Disease

• dura pleural fistula
• pleural fluid glucose is good surrogate for pH
• albumin gradient and protein gradient can be used to confirm transudate in heart failure and cirrhosis
• tips for hepatic hydrothorax
• chylothorax, vs pseudochylothorax
• using pleural elastance to predict pleurodesis, >19 predicts failure
• split pleural sign
• Grawitas and Gravitas: wall suction is safe
• mesothelioma and lung have low cytology sensitivity. In general 40-70%

Lung cancer

• small cell staging: limited (one lung) vs extensive
• use mri for pancoast tumor
• stage 1a: surgery or SBRT
• stage 1b: alk+ or EGFR targeted therapy. Neo adjuvant chemo if negative receptors
• stage 2: surgery and adjuvant chemo
• stage 3: chemoradiation, adjuvant. Immuno for pdl1
• Osimertinib for nsclc
• stage 4: platinum
• small cell: cisplatin and etoposide. radiation for only localized disease
• immunotherapy pneumonitis: 30 days to months
  • asymptomatic: treat through
  • mild symptom: close observation
  • more sx: discontinue therapy, bronch, steroids
  • bronchoscopy only if worry about infections, lymphangietic spread of cancer

Bronchoscopy

• lidocaine 1%: each cc = 10mg lidocaine
• 2%: each cc = 20 mg lidocaine
• topical lidocaine should not exceed 7mg/kg in airway
• Can use 1% instead of 2%
• bleeding: wedge scope, place patient bleeding side down, intubate in non bleeding lung
• use iced saline over epi

Trachebronchomalacia and EDAC

• TBM: softening of trachea cartilages
• EDAC: excessive posterior membrane wall laxity with intact cartinaginous support
• dyspnea, barking cough, secretions, recurrent infections
• CT: inspiratory/expiratory
• PFT: decreased expiratory flow, notching, biphasic flow
• cpap primary treatment
• temporary stent and tracheobronchoplasty

airway obstruction

• lesion must narrow tracheal diameter to less than 8mm to show up on flow volume loop
• hyperinflation can be seen in opposite lung with inhalation of foreign object

Sleep Medicine

• ataxic breathing or biot’s breathing on opioid
• circulation time for cheynne stokes
• ASV for cheynne stokes: serve-hf trial showed increased mortality in HFrEF
• if OSA predominant: CPAP
  • if CSA emerges or persisits: ASV if EF > 45%
• if CSA predominant: CPAP and then ASV if EF > 45%
• avoid autopap for CSA
• transvenous neurostimulation for CSA
• ramelteon and tasimelteon
• mslt: mean sol < 8 min
• mwt: mean sol < 40 min
• actigraphy
• narcolepsy type 1 and 2
• idiopathic hypersomnia: 660 minutes a day
• parasomnia
• RLS: augmentation
• asv vs vaps

TB

• 20-40% active TB have negative smear
• postbronch sputum: 9%
• smear negative does not mean noninfectious
• upper lobe, posterior cavity: reactivation
• effusion, mediastinal necrotic LAD, military, normal CXR more likely primary
• empiric treatment over bronchoscopy
• bronchiectasis, azithromycin: at least a year
• NAAT: both live and dead bacilli. Good sensitivity, high sensitivity. Not good at excluding TB in highest risk patient
• 9 months vs 6 months INH/rifampin
• side effects (drug related lupus)
• HIV and TB: start HAART 2 weeks before TB therapy
• who should be treated for ltbi
• IGRA and T spot
• order CXR after positive IGRA: rules out active TB before treatment
• LTBI treatment
• TB pregnant patient: wait 3 months after delivery

Asthma

• don’t have to stop inhaled steroids for FENO
• stop oral steroids for FENO

Radiology

• IIP
• use thin to differentiate nodule and ggo
• use MIP to assess nodules
• panlobular: paucity of blood vessels. Lower lungs
• LAM vs LCH
• bronchiectasis by locations
• swyer james syndrome
• dipnech
• round atelectasis: comet tail sign
• lung sequestration
• Y sign and bronchial atresia
• AVM
• sickle sign: atelectasis lul
• abscess: air fluid level same size AP and lateral. Always spherical
• empyema: air fluid can be obtuse
• relapsing polychondritis
• thickening of trachea flow chart
• mycetoma
• three density sign

Links to this note

• Pulmonary Diseases

  • CHEST Board Review Pulmonology 2024

• LAM has cysts in normal lungs whereas Langerhan has abnormal lungs

  • [^1]: CHEST Board Review Pulmonology 2024

• acceptability, usability, repeatability of spirometry qualities

  • [^1]: SEEK Questionnaires

• pulmonary hypertension treatment overview

  • [^1]: CHEST Board Review Pulmonology 2024