PULMONOLOGY RAPID REVISION FOR EXAMINATION

Pulmonology

1. PULMONOLOGY RAPID REVISION

2. ACUTE RESPIRATORY DISTRESS SYNDROME

3. Causes of ARDS:- • MC cause of ARDS overall is ___________ • MC cause of direct lung injury leading to ARDS is ______________. • MC cause of indirect lung injury leading to ARDS is ____________. 3

4. Q)Normal PCWP with pulmonary edema is seen in. Left atrial Myxoma High altitude Pulmonary venous obstruction Pulmonary arterial obstruction 4

5. Non cardiogenic pulmonary edema C ardiogenic pulmonary edema

6. Berlins Criteria - ARDS A cute onset : Symptoms with in 1 week of clinical insult R educed ratio of arterial oxygen tension to fraction of inspired oxygen (Pao2 /FiO2) D iffuse b/l opacities on CXR S wan Ganz wedge pressure < 18mm Hg 6

7. Severity of ARDS Mild: < Pa0/Fi02 Moderate: < Pa0/Fi02 Severe: < Pa0/Fi02 7

8. 8

9. Remember for ARDS • Most common cause of ARDS is Sepsis • Normal pulmonary capillary wedge pressure • Non- cardiogenic pulmonary edema • High protein pulmonary edema • Intrapulmonary shunting • PaO / Fi02 ratio < 200 • CXR shows bilateral white out • Treatment of choice is low volume ventilation using CPAP 9

10. NON CARDIOGENIC PULMONARY EDEMA

11. COPD

12. Gold Criteria for very severe COPD is defined as? a. FEVl /FVC < 0.7 and FEV l < 80% predicted b. FEVl /FVC < 0.7 and FEV l < 70% predicted c. FEVl /FVC < 0. 7 and FEV 1 < 50% predicted d. FEVl /FVC < 0.7 and FEV 1 < 30% predicted

13. Definition of smaller airways:-

14. Examples of Small airway disease:- 15

15. Reid Index : 16

16. Q) Alpha 1-Antitrypsin deficiency is A/W Centriacinar emphysema Panacinar emphysema Irregular emphysema Paraseptal emphysema 17

17. 18

18. Modified Medical Research Council scale for Dysnea 19

19. Diagnosis

20. 21

21. 22

22. GOLD CRITERIA 23

23. Bronchial Asthma

24. Which one of the following values is not a feature of Acute severe asthma? a. Pulsus Paradoxus b. Pa02 of less than 8 kPa c. Heart rate of more than 110/min d. PEF of 60 to 70% of expected

25. 26

26. 27

27. Clinical Features: Curschmann's spirals   Creola bodies Charcot-Leyden crystals 28

28. Status Asthmaticus /Severe Acute Asthma 29

29. Brittle Asthma Some patients show chaotic variations in lung function despite taking appropriate therapy, with diurnal variation in PEFR > 40% Type I brittle asthma:- Type 2 brittle asthma:- 30

30. Q) Asthma diagnosis is by FEV1 Measurement of Tidal volume End expiratory flow rate Total lung capacity 31

31. Diagnosis of Asthma Spirometry : 32

32. FEV1  Classification(FEV 1 is reduced) >70%  40-69%  <40%  <25% 

33. 35

34. A known asthmatic, presented to the emergency with severe exacerbation not relieved by Salbutamol. The patient was given corticosteroids and aminophylline. What is the rationale of giving corticosteroids? a. Corticosteroids facilitate the action of Beta 2 agonists b. Corticosteroids sensitize adenosine receptors to xanthines c. Direct bronchodilator action of corticosteroids d. Increase mucociliary clearance

35. CYSTIC FIBROSIS (CF)

36. Inheritance Gene mutated :-

37. Clinical Features 1. Meconium ileus : 2. Recurrent pneumonia: 39

38. Bronchiectasis :-

39. 3. Secondary biliary cirrhosis : 41

40. 4. Osmotic diarrhea

41. 6. Infertility: 43

42. Sweat chloride concentration  Investigation of choice is 

43. Targeted therapies :-

44. Lung transplantation

45. Bronchiectasis

46. 48

47. Q) Bronchiectasis is MC in which lobe: Rt. UL Rt. Middle lobe Lt. UL Lt. LL 49

48. Types: 50

49. Mid lung field bronchiectasis is seen with? a. M.A.I b. ABPA c. TB d. Post radiation fibrosis

50. Upper lobe Bronchiectasis Mid lung Bronchiectasis Lower lung Bronchiectasis Central Bronchiectasis

51. Investigations Sputum Examination 53

52. Chest X-ray

53. What is the most accurate test?

54. CT Scan 58

55. Bronchography : 59

56. Management Massive hemoptysis :- 60

57. BRONCHOGENIC CARCINOMA

58. Clubbing is least common in: a. Squamous cell carcinoma b. Adenocarcinoma c. Small cell carcinoma of lung d. Mesothelioma

59. MC benign tumor of lung  MC cause of recurrent hemoptysis  MC cause of cancer death  MC risk factor  MC natural risk factor  MC rib destroyed in pancoast tumor  MC nerve roots involved in pancoast tumor  63

60. Most frequent histological type – Most frequent histological type in india - M C histological variety in non smokers – M C histological variety in young patients- M C histological variety in females – M C site for metastasis from ca lung- M C endocrine organ to be involved by MET. CA LUNG – 64

61. Ca lung which metastasises to opp .lung- M C Tumor to metastasise to heart – Histological varieties that cavitate – Histological varieties that are central in distribution – Histological varieties that are peripheral – M C variety associated with para neoplastic syndrome - 65

62. MC associated with hypokalemia – MC variety associated with hypercalcemia – Histological variety most responsive to chemotherapy – Histological variety responds to radio therapy- Histological variety with best prognosis- 66

63. Tumor markers:- CEA (carcinoembryonic antigen): NSE (neuron-specific enolase): 67

64. PULMONARY THROMBOEMBOLISM SYMPTOMS S/O MASSIVE PE SYMPTOMS S/O SMALL EMBOLI 68

65. Q) In acute PE,most frequent ECG finding is: S1Q3T3 pattern P pulmonale Sinus tachycardia Rt. Axis deviation 69

66. 70

67. ECG changes in PE 71

68. 72

69. 73

70. 74 In which clinical condition do you see this sign ?

71. What are the chest X-ray finding s and what is the diagnosis ? 75

72. What are the chest X-ray finding s and what is the diagnosis ? 76

73. Q)D-Dimer values may be increased in all except MI Pneumonia Anticoagulant therapy Pregnancy 77

74. Investigation of choice:-

75. Q) A young ptn. presents to emergency with Acute Pulmonary embolism .Ptn’s BP is normal but ECG reveals Rt.ventricular hypokinesia & compromised CO .The treatment in this ptn. is Thrombolytic therapy Anticoagulant with LMWH Anticoagulant with warfarin Inferiorvenacava filters 79

76. WELLS CRITERIA & MODIFIED WELLS CRITERIA 80

77. MODIFIED WELLS CRITERIA: Scoring is done as follows: • Score >6 = • Score ≥2 but <6 = • Score <2 = 81

78. 82

79. STRATIFY PTN. INTO LOW,INTERMEDIATE,HIGH RISK Low risk (Small PE) Normotension + Rt. Ventricular function Intermediate risk(Submassive PE) NormoTN + RVD High risk (Massive PE) Hypotn +_ RVD IVC filters. Individual risk assessment . Thrombolysis or Embolectomy. 83 Young patient No comorbidities Low risk of bleeding Excellent candidate for thrombolysis Elderly ptn.(>70 yrs) Significant Co-morb High risk of Bleeding Wait n watch with anticoagl.

80. P L E U R A L E F F U S I O N

81. 85

82. 86 Transudate Exudate Protein content Fluid protein serum protein Fluid LDH Sr.LDH

83. 87

84. Therapeutic thoracocentesis should be performed if the free fluid in the lung separates the chest wall by greater than? a. 5 mm b. 10 mm c. 15 mm d. 20 mm

85. A car accident patient complains of breathlessness. On examination BP is 110/70 mmHg with GCS of 15/15. On examination, trachea shows deviation in suprasternal notch, with reduced breath sounds in left infra-axillary area and inframammary areas. SI and S2 are normal in intensity and splitting. CXR is shown below. What is the best step in management of the patient? Needle aspiration Pericardiocentesis c. Chest tube insertion d. Immediate thoracotomy

86. PNEUMOTHORAX

87. Definition of Pneumothorax

88. Tension pneumothorax

89. Tension Pneumothorax

90. Catamenial Lung disorders

91. 95

92. Deep sulcus sign 96

93. Q) which of the following statements about Pneumothorax is true A )Breath sounds are increased B )Percussion note is decreased C )Always need chest tube insertion D)Often needs chest tube insertion 97

94. Respiratory Failure

95. All of the following types of Respiratory Failures are correctly matched, except A. Type I- Hypoxemic B. Type II- Hypercapnic C. Type III- Atelectasis D. Type IV- Perioperative

96. In ICU setting patients suffering from which of the following. respiratory pathology is most predisposed for C02 narcosis? A. Motor Neuron Disease B. Asthma C. Emphysema D. Bronchiectasis

97. What are the chest X-ray findings and what is the diagnosis ? 102

98. Respiratory sounds

99. What are the chest X-ray findings and what is the diagnosis ? 104

100. What are the chest X-ray findings and what is the diagnosis ? 105

101. What are the chest X-ray findings and what is the diagnosis ? 106

102. TB Transmission 1 . Droplets: 107

103. 2. Ingestion : 3. Vertical transmission 4. Direct contact : 108

104. 109

105. Puhl lesion - Assman focus - Weigert focus - Simon focus - Rich focus - Simmond's focus - Poncet's disease - 110

106. 111

107. Snow storm appearance on CXR 112

108. 113

109. 6-10mm is positive in:- 114

110. IOC :-

111. Multi drug resistant tuberculosis is defined as resistance to ? a) INH and Pyrizinamide b) INH and Rifampicin c) Rifampicin and Pyrizinamide d) Resistance to all first line drugs 116

112. Gene mutation responsible for Rifampicin resistance: • Pyrazinamide resistance: • INH Resistance: 117

113. Microscopy – Sputum smear microscopy 118

114. Two stains can be used to demonstrate Acid fast bacilli either the Carbol fuschin (the classic Ziehl - Nelson stain) or the fluorochrome stains (auramine rhodamine and auramine ).

115. New drugs

116. Aspergillosis MCC – Aspergillus fumigatus & usually causes pulmonary aspergillosis . Aspergillus niger – External ear infection(Fungal otis media) Not a highly contagious d/s High risk in severly immunocompromised ptns . 121

117. Pulmonary aspergillosis may take 4 forms: ABPA Saprophytic Aspergillosis/ Aspergilloma Chronic necrotizing aspergillosis Invasive aspergillosis – Severly immunocompromised ptns .

118. ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS Main diagnostic criteria : Clinical history of asthma Pulmonary infilitrates Peripheral esonophilia Immediate skin reactitivty to aspergillous antigen Elevated serum IgE levels Central or proximal bronchiectasis . 123

119. 124

120. Secondary diagnostic criteria : History of brownish plugs in sputum Identification or culture of aspergillus fumigatus from sputum Elevated IgE class antibodies specific for aspergillus fumigatus 125

121. All the following are true about bronchopulmonary aspergillosis except - a) Central bronchiectasis b) Pleural effusion c) Asthma d) Eosinophilia 126

122. Q ) 40 yr old ptn with h/o of prolonged exposure of SOB. CXR – Diffuse pulmonary infiltrates. Skin hypersensitivity - Positive for Aspergillus Antigen Peripheral blood – Normal. Eosinophil count & Sr.IgE  Normal Most likely diagnosis? Allergic BA ABPA Extrinsic Allergic alveolitis Invasive pulmonary Asp. 127

123. Hypersensitivity Reactions to Aspergillus 128

124. Following features suggest extrinsic allergic alveolitis : Normal Ig E levels Absence of peripheral eosinophilia Diffuse pulmonary infiltrates on X Ray 129

125. Radiological - ABPA Fleeting alveolar subsegmental or lobar infiltrates which are usually bilateral (65%) Predominant in upper lobes (50%). 130

126. Rx   Corticosteroid therapy is the mainstay of treatment (for example with  prednisone) 131

127. TROPICAL PULMONARY EOSINOPHILIA 132

128. TROPICAL PULMONARY EOSINOPHILIA It is a distinct syndrome that develops in individuals infected with lymphatic filarial species Features of TPE Male more commonly affected then females History of resistance in filarial endemic region Paroxysmal cough and wheezing that are usually nocturnal Weight loss, low grade fever and adenopathy Eosonophilia more than 3000 eosinophils Chest x ray shows increased broncho vascular markings ,diffuse miliary lesions or mottled opacities Restrictive changes on pulmonary function tests Elevated levels of Ig E and antifilarial antibody 133

129. All the following are features of Tropical pulmonary Eosinophilia except- a) Eosinophilia >3000/mm3 b) Microfilaria in blood c) Paroxysmal cough and wheeze d) Bilateral chest mottling and bronchovascular markings 134

130. Diagnosis :- Treatment :-

131. PULMONARY FUNCTION TESTS

132. 137

133. Spirometry cannot measure

134. PFT in OLD/s FVC  Normal to slightly decreased. FEV in 1 sec.  Decreased out of proportion of FVC FEV 1 /FVC  Decreased can be as low as 20-30% PEFR  Decreased TLC  Increases Residual volume  Increases FRC  Increases 139

135. PFT in RLD/s FVC  Decreased.(more than obstruction) FEV in 1 sec.  Decreased in proportion to FVC FEV 1 /FVC  Near normal or Increased Forced MEFR  Decreased TLC  Decreases Residual volume  Generally decreases FRC  Decreased 140

136. PFT RESULT OBSTRUCTIVE PATTERN RESTRICTIVE PATTERN FEV 1 DECREASED(<80%) DECREASED FVC DECREASED DECREASED FEV1/FVC DECREASED NORMAL /INCREASED FEF 25-75 < 50% PREDICTED DECREASED IN PROPORTION TO LUNG VOLUME TLC NORMAL/ELEVATED DECREASED DLCO NORMAL DECREASED IN EMPHYSEMA Decreased in intrinsic RLD Normal in NM RLD 141

137. 142

138. 143

139. 144

140. 145

141. 147

142. A 65-year-old man is evaluated for progressive dyspnea on exertion that has occurred over the course of the past 3 months. His medical history is significant for an episode of necrotizing pancreatitis that resulted in multiorgan failure and acute respiratory distress syndrome. He required mechanical ventilation for 6 weeks prior to his recovery. He also has a history of 30 pack-years of tobacco, quitting 15 years previously. He is not known to have chronic obstructive pulmonary disease. On physical examination, a low-pitched inspiratory and expiratory wheeze is heard, loudest over the mid-chest area. On pulmonary function testing, the forced expiratory volume in 1 second (FEV1) is 2.5 L (78% predicted), forced vital capacity (FVC) is 4.00 L (94% predicted), and FEV1/FVC ratio is 62.5%. The flow-volume curve is shown in Figure . What is the most likely cause of the patient’s symptoms? A. Aspirated foreign body B. Chronic obstructive pulmonary disease C. Idiopathic pulmonary fibrosis D. Subglottic stenosis E. Unilateral vocal cord paralysis