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Terms Definitions
What type of disease is mumps? parotitis
Where does the trachea divide into the main bronchi? T4/T5; just below manubriosternal joint
What is the etiology of mumps? caused by a paramyxovirus; spread via respiratory droplets; usually affects children
What is the etiology of mumps? Current p1250
Which main bronchus is more susceptible to foreign body aspiration and why? RT main bronchus
shorter, wider, more vertical than LT main bronchus
What is the clinical presentation of mumps? incubation 2-3 weeks before onset
fatigue and fever → variable
parotid gland enlargement → unilateral or bilateral, usually one enlarges before the other
stenson's duct → erythematous, edematous
parotid tenderness
facial edema
+/- trismus
+/- submaxillary and sublingual gland involvement
What is the clinical presentation of mumps? Current p1250
What are the primary respiratory muscles? diaphram, external intercostals, and internal intercostals
What is the diagnostic work-up of mumps? usually diagnosed clinically; swab parotid duct for confirmation via NAAT (more sensitive), viral culture or serum IgM
What is the diagnostic work-up of mumps? Current p1250
What is the function of the diaphram? moves inferiorly during inspiration to increase intrathoracic pressure
What are the complications of mumps? pancreatitis →affects children; upper abdominal pain, nausea, vomiting
orchitis → affects 25-40% postpubertal men, high fever, testicular swelling and tenderness
oophoritis → affects 5% of postpubertal women, lower abdominal pain, ovarian enlargement
meningitis → high fever, headache, stiff neck, lethargy
What are the complications of mumps? Current p1250
What are the function of the external intercostals? increase AP chest diameter during inspiration
Mumps is the most common cause of what disease in children? pancreatitis
Mumps is the most common cause of what disease in children? Current p1250
What are the function of the internal intercostals? decrease transvere chest diameter during expiration
What is the management of mumps? Symptomatic:
1. topical compresses
2. bed rest until afebrile
3. isolation until swelling subsides (9 days following onset)
What is the management of mumps? Current p1250
What are the accessory respiratory muscles? sternocleidomastoid
trapezius
What is the ddx for parotidis? dehydration → stasis of salivary flow
sialolithiais of stenson's duct
bacterial infection
viral infection
cyst or tumor
etc
What is the ddx for parotidis? Current p1250
Where is the carotid body found? bifurcation of the common carotid arteries
mumps
What is the function of the carotid body? contains chemoreceptors that respond to changes in arterial [O2] and [CO2] → send signal to respiratory center in medulla oblongata → medulla oblongata sends nerve impulses to pons → pons regulates respiratory muscles
mumps
What is the function of the medulla oblongata in respiration? contains chemoreceptors that respond to changes in blood/CSF [H+] → sends signals to respiratory center in medulla oblongata → medulla oblongata sends nerve impulses to pons → pons regulates respiratory muscles
What is the etiology of diphtheria? caused by corynebacterium diphtheriae; spread via respiratory droplets; rare due to TDAP vaccine; infectious disease emergency
What is the etiology of diphtheria? Current p204
What 2 types of chemoreceptors help regulate respiration? medual oblongata chemoreceptors → respond to changes in blood/CSF [H+]
carotid body chemoreceptors → respond to changes in arterial [O2] and [CO2]
What is the clinical presentation of pharyngeal diphtheria? mild fatigue, fever, sore throat; gray tonsillar pseudomembrane covering tonsils and pharynx
What is the clinical presentation of pharyngeal diphtheria? Current p204
Where should you begin counting ribs? 2nd rib
find manubriosternal joint since this is where 2nd rib articulates
Where should you begin counting vertebra? vertebra prominens (C7)
more easily palpated if neck flexed

*but remember the rib you feel in association with a spinous process is that spinous process + 1
What is the diagnostic work-up of diphtheria? diagnosis made clinically but can be confirmed by culture
What is the diagnostic work-up of diphtheria? Current p1302
What are the complications of diphtheria and their associated symptoms? myocarditis → cardiac arrhythmias, heart block, heart failure
neuropathy → initally affects CNs → diplopia, dysphagia, slurred speech
What are the complications of diphtheria and their associated symptoms? Current p1302
What is the management of diphtheria? 1. antitoxin (obtained from CDC)
2. if potential or current airway obstruction → remove pseudomembrane via laryngoscopy or bronchoscopy
3. penicillin 250mg PO 4x daily x 14 days or erythromycin 500mg PO 4x daily x 14 days
4. isolation until 3 consecutive cultures at completion of therapy confirm elimination
5. treat patient contacts → erythromycin 500mg PO 4x daily x 7 days; diphtheria booster
What is the management of diphtheria? Current p1302
Where are the lung apices anteriorly and posteriorly? anteriorly → 4cm above 1st rib
posteriorly → T1
Where are the lung bases anteriorly and posteriorly? anteriorly → 6th rib at midclavicular line
posteriorly → T12 on deep inspiration, T9 on forced expiration
What is the prevention of diphtheria? TDAP vaccination
What is the equipment needed for the respiratory exam? stethoscope
marking pencil
cm ruler
cm measuring tape
List signs of respiratory distress. cyanosis → skin, lips, tongue, nipples, nails
nostril flaring
pursed lip breathing
accessory respiratory muscle use → sternocleidomastoid, trapezius
retractions → visible on inspiration
clutching
tripodding
tachypnea
grunting
stridor
wheezing
anxiety
retractions and tripodding → respiratory distress
Compare and contrast the clinical presentation of the common cold, influenza, and H1N1. common cold → gradual onset, sneezing, nasal congestion, watery rhinorrhea, sore throat, cough

influenza → rapid onset, fatigue, high fever, headache, body aches, chills, nasal congestion, rhinorrhea, sore throat, cough

H1N1 → fatigue, fever, headache, body aches, chills, nasal congestion, rhinorrhea, sore throat, cough, vomiting, diarrhea
Breath that smells like cinnamon may indicate? pulmonary TB
How long does a SPUTC remain positive? possibly several weeks

*do not give additional antituberculous drugs b/c you think the patient is not responding to tx
How long does a SPUTC remain positive? Interpreting Laboratory Data p7
How long does a SPUTC remain positive? possibly several weeks

*do not give additional antituberculous drugs b/c you think the patient is not responding to tx
How long does a SPUTC remain positive? Interpreting Laboratory Data p7
What is another name for pneumococcal pneumonia? strep pneumonia
Breath that smells sweety or fruity may indicate? diabetic ketoacidosis
starvation ketosis
What is the etiology of pneumococcal pneumonia? caused by streptococcus pneumoniae; community-acquired and hospital-acquired pneumonia
pericardial effusion
Current ch10
What is the diagnostic work-up of pneumococcal pneumonia? BC
sputum gram → gram-pos diplococci
sputum culture
CXR → consolidating lobar pneumonia
Breath that smells fishy or stale may indicate? uremia
What is the definition of a good sputum sample? <10 epithelial cells and >25 PMNs per high-power field
What is the definition of a good sputum sample? Current p1252
Breath that smells like ammonia may indicate? uremia
What are the complications of pneumococcal pneumonia? parapneumonic effusion
empyema
pericarditis
endocarditis
What are the complications of pneumococcal pneumonia? Current p1252
Feculant smelling breath may indicate? GI obstruction
What is the clinical presentation of pneumococcal pneumonia? high fever, chills, dyspnea, productive cough, +/- hemoptysis, pleuritic chest pain, bronchial breath sounds
What is the clinical presentation of pneumococcal pneumonia? Current p1252
Breath that smells foul or putrid may indicate? nasal/sinus pathology → foreign body, infection, cancer
respiratory pathology → insistent bronchitis, bronchiectasis, empyema, lung abscess, anaerobic infection
What is the management of pneumococcal pneumonia? 1. empiric treatment until isolation of s. pneumo
2. if uncomplicated → amoxicillin
3. if penicillin-resistant strain → vancomycin
What is the management of pneumococcal pneumonia? Current p1252
Breath that smells fishy or like clover may indicate? portal vein thrombosis, hepatic failure
What is the common name for pertussis? whooping cough
What is the common name for pertussis? Current p1308
Halitosis may indicate? gingivits, necrotizing ulcerative gingivitis, tonsillitis, respiratory infection, GERD
What is the etiology of pertussis? caused by bordetella pertussis; spread via respiratory droplets; 50% before 2y/o
What is the etiology of pertussis? Current p1308
sternal indentation → pectus excavatum
What is the prevention of pertussis? TDAP vaccination
What is the prevention of pertussis? Current p1308
What is the common name for pectus excavatum? funnel chest
What is the management of pertussis? 1. erythromycin 500mg PO 4x daily x 7 days
2. offer erythromycin to contacts if exposed within 3 weeks of onset
What is the management of pertussis? Current p1308
What is the common name for pectus carinatum? pigeon chest
What is the clinical presentation of pertussis? 1. catarrhal stage → fatigue, lacrimation, sneezing, rhinorrhea, hacking night cough, anorexia
2. paroxysmal stage → whooping cough
3. convalescent stage → decrease in severity of whooping cough, 4 weeks after onset

entire illness lasts 6 weeks
What is the clinical presentation of pertussis? Current p1308
sternal protrusion → pectus carinatum
What is the diagnostic work-up of pertussis? collect nasopharyngeal dacron swab
pertussis PCR or pertussis culture with bordet-gengou agar
What is the diagnostic work-up of pertussis? Current p1308
Define pectus carinatum. sternal protrusion
What is the etiology of legionnaire's disease? caused by bacteria legionella pneumophilia; transmitted via contaminated water sources like heating and cooling systems of hospitals; not spread via person-to-person; increased risk in smokers, chronic lung disease, immunocompromised
What is the etiology of legionnaire's disease? Current p1310
Define pectus excavatum. sternal indentation
What is the clinical presentation of legionnaire's disease? fatigue, fever, chills, HA, cough
atypical pneumonia → scant sputum, pleuritic chest pain
What is the clinical presentation of legionnaire's disease? Current p1310
Define lordosis. anterior spinal deviation
What type of pneumonia is legionnaire's disease? community acquired
atypical
What type of pneumonia is legionnaire's disease? Current p1310
Define kyphosis. posterior spinal deviation
What is the diagnostic work-up of legionnaire's disease? sputum GRAM → no bacteria
sputum PCR or culture
CXR → patchy infiltrates or consolidation, often bibasal consolidation
What is the diagnostic work-up of legionnaire's disease? Current p1310
Define gibbus. extreme kyphosis
Where is legionella naturally found? water
Define scoliosis. lateral spinal deviation
What is the management for legionnaire's disease? 1. azithromycin 500mg PO 1x daily x 10-14 days
2. if immunocompromised → extend treatment to 21 days
3. DO NOT prescribe erythromycin
What is the management for legionnaire's disease? Current p1311
anterior spinal deviation → lordosis
Is legionnaire's contagious from person-to-person? no
posterior spinal deviation → kyphosis
What is the etiology of hemophilus influenzae pneumonia? caused by bacteria hemophilus influenzae; community-acquired pneumonia
lateral spinal deviation → scoliosis
What is the diagnostic work-up of hemophilus influenzae pneumonia? sputum GRAM → gram-neg coccobacilli
sputum PCR or culture
CXR
Describe the respiratory exam. 1. introduce self
2. wash hands
3. ask patient to lower gown to waist
4. assess general appearance → gender, age, acutely or chronically ill, signs of respiratory distress, breath odor
5. BP and HR
6. respiratory rate and pattern
7. inspect anterior, lateral, and posterior chest while patient breathing normally, then while breathing deeply → shape, symmetry, AP diameter, deformities
8. inspect for supernumerary nipples (sign of congenital disorders), superficial venous patterns (sign of heart or vascular disease), rib prominence/fat (nutritional deficiencies)
9. inspect nails for cyanosis and clubbing at eye level
10. measure chest wall expansion
11. palpate for tracheal deviation
What is the general presentation of community-acquired pneumonia? acute fever, dyspnea
cough +/- sputum
fatigue, chills, rigors, sweats, HA, hemoptysis, pleuritic chest pain, abdominal pain, myalgia, altered breath sounds, crackles, dullness to percussion if parapneumonic pleural effusion
What is the general presentation of community-acquired pneumonia? Current p246
Define barrel chest. increase in AP chest diameter
ratio of AP and transverse chest diameter is 1:1 instead of 1:2
What are the most common causes of community-acquired pneumonia? 1. pneumococcal pneumoniae
2. mycoplasmal pneumoniae
3. hemophlius influenza
4. legionnairese
5. aspiration
6. respiratory viruses
What are the characteristics of barrel chest? increase in AP chest diameter
manubriosternal joint more prominent
ribs more horizontal
spine more kyphotic
trachea may be posteriorly displaced
What are the most common causes of hospital-acquired pneumonia? 1. streptococcal pneumoniae
2. staph aureus
3. legionnaires
Define flail chest. chest wall fracture with complete detachment
Define diaphragmatic paradox. paradox movement of chest wall
during inspiration, segment of chest wall moves inward instead of expanding
during expiration, segment of chest wall moves outward instead of retracting
Diaphragmatic paradox may indicate? flail chest
What is the cause of flail chest? trauma
Asymmetrical lung expansion may indicate? if unequal or limited → pneumothorax, pleural effusion, mass, collapsed lung
if unilateral bulging → obstruction
if prolonged expiration + bulging on expiration → obstruction, mass, aneurysm, cardiomegaly
What is a common complication of flail chest? pneumothorax
What is the ddx for decreased tactile fremitus? pneumothorax
pleural effusion/empyema

pleural thickening
asthma
emphysema
bronchial obstruction
atelectasis
pulmonary edema
What is egophony? patient says "EEEEE" and you hear "AAAAA" when
ascultating lungs
present in pneumonia
present above area of pleural effusion
absent in pneumothorax
What is the ddx for increased tactile fremitus? consolidation → heavy bronchial secretions, pneumonia, mass
What sound is normal when percussing the lung fields? resonance
Dullness/flatness to percussion of lung fields may indicate? pleural effusion
pneumonia
mass
What are 5 indicators that chest pain probably does not originate in heart? 1. needle-like pain 1-2 seconds long
2. constant achiness
3. pain in shoulders or between shoulder blades
4. pain does not radiate
5. pain worsens when press precordium
What are 5 indicators that chest pain probably does not originate in heart? Mosbys
What is the ddx for diminished breath sounds? splinting (shallow breathing due to pain)
hyperinflated lungs
bronchi obstruction
pleural effusion
What is the ddx for heightened breath sounds? consolidation
mass
Define ventilation. movement in and out of lungs
Define ventilation. Interpreting Laboratory Data p191
Define perfusion. movement of blood through lungs
Define perfusion. Interpreting Laboratory Data p191
What body systems regulate homeostasis? lungs and kidneys
What body systems regulate homeostasis? Lab p179
Define cheyne-stokes respiration. respiratory pattern characterized by alternating periods of crescendo-decrescendo hyperventilation and apnea
What is the ddx for tracheal deviation? Contralateral Deviation:
pneumothorax
pleural effusion
mass
hiatal hernia

Ipsilateral Deviation:
pulmonary fibrosis
atelectasis
lobectomy/pneumonectomy
lung agenesis

Anterior Deviation:
mediastinitis

Other:
kyphoscoliosis (toward compressed lung)
retrosternal thryoid
thoracic aortic aneurysm (usually toward RT side)
malignancy → thyroid, trachea, lungs, mediastinum
Describe the pattern for percussion and auscultation of the lungs.
Define apnea. absence of respirations
Define hypopnea. abnormally slow or shallow respirations
Define hyperpnea AKA hyperventilation. tachypnea + abnormally deep respirations
Define ataxic respirations. disordered respirations characterized by varying rates and depths and may include periods of apnea
Ataxic respirations may indicate? increased ICP, medulla damage, drug overdose
vesicular breath sounds
vesicular breath sounds
Define lingula. tongue-like projection of the LUL
List the fissures of the lungs. LT oblique fissure → divides LUL and LLL
RT horizontal fissure → divides RUL and RML
RT oblique fissure → divides RML and RLL
What is anterior and posterior to the trachea? isthmus of thyroid lies anteriorly
esophagus lies posteriorly
What is another name for the manubriosternal junction? angle of Louis
What is another name for the manubriosternal junction? Current p366
Define platypnea. SOB when sitting upright that is relieved when lying down
Define platypnea. Current p374
Define kussmaul respirations. pattern of respiration characterized by rapid, deep, labored breaths
Kussmaul breathing is associated with? metabolic acidosis
Kussmaul breathing is associated with? Current p375
What is the ddx for Cheyne-Stokes respirations? may affect children and older adults during sleep
otherwise affects seriously ill → cerebral brain damage, drug-induced respiratory compromise
What is the ddx for Cheyne-Stokes respirations? Current p375
Define biot respiration. irregular respirations varying in depth and interspersed with periods of apnea
(less severe that ataxic respiration)
Define biot respiration. Current p375
What is the ddx for biot respiration? severe and persistent increased ICP
medulla brain damage
drug-induced respiratory compromise
What is the ddx for biot respiration? Current p375
Compare signs of airway obstruction above and below glottis. Above glottis:
stridor quieter
hot potato voice
no cough
swallowing more difficult
head may be positioned awkwardly to presevere airway (extended with retropharyngeal abscess; head to affected side with peritonsillar abscess)

Below glottis:
stridor louder
voice is hoarse
barking cough
positioning of head not a factor
Compare signs of airway obstruction above and below glottis. Current p377
Retractions may indicate? respiratory distress
if unilateral + no suprasternal notch involvement → foreign body in bronchi
if lower chest → asthma, bronchiolitis
Retractions may indicate? Mosbys p377
What is normal diaphragmatic excursion? 3-6cm
coarse crackles
bronchovesicular breath sounds
Where are bronchovesicular breath sounds heard? over main bronchi → adjacent to sternum, posterior RT lung field
Where are bronchovesicular breath sounds heard? Mosbys p384
Where are bronchial breath sounds heard? over trachea
Where are bronchial breath sounds heard? Mosbys p385
Where are vesicular breath sounds heard? over lesser bronchi, bronchioles, and lobes
(i.e. everywhere except trachea and main bronchi)
Where are vesicular breath sounds heard? Mosbys p385
Bronchial breath sounds over lung fields that are normally vesicular may indicate? consolidation
Bronchial breath sounds over lung fields that are normally vesicular may indicate? Current p386
Which types of adventitious breath sounds are continuous? wheezes
rhonchi
Which types of adventitious breath sounds are continuous? Current p387
Which types of adventitious breath sounds are discontinous? crackles
Which types of adventitious breath sounds are discontinous? Current p387
Bronchial breath sounds over lung fields that are normally vesicular may indicate? consolidation
Bronchial breath sounds over lung fields that are normally vesicular may indicate? Current p386
Increased vocal resonance (bronchophony, whispered pectoriloquy, egophony) indicates? consolidation
Increased vocal resonance (bronchophony, whispered pectoriloquy, egophony) indicates? Mosbys p388
Decreased vocal resonance (bronchophonoy, whispered pectoriloquy, egophony) indicates? respiratory obstruction → emphysema etc.
Decreased vocal resonance (bronchophonoy, whispered pectoriloquy, egophony) indicates? Mosbys p388
How do you distinguish rhonchi from crackles? rhonchi tend to disappear after coughing whereas crackles do not
How do you distinguish rhonchi from crackles? Mosbys p388
What is bronchiolitis? lower respiratory tract infection
inflammation of the bronchioles
usually d/t viral infection
Define dyspnea. SOB; subjective difficulty in breathing
BRONCHIOLITIS: ETIOLOGY:
lower respiratory tract infection characterized by inflammation of the bronchioles
usually caused by RSV
other causes include Parainfluenza, human metapneumovirus, influenza, adenovirus, Mycoplasma, Chlamydia, Ureaplasma, Bocavirus, and Pneumocystis
usually affects children <2y/o
most common serious acute respiratory illness in young children

CLINICAL PRESENTATION:
irritability, poor feeding, coughing, vomiting
labored breathing, tachypnea, hypoxia
prolonged expiration, wheezing, crackles
usual course → 1-2 days fever, rhinorrhea, and cough followed by respiratory distress (nasal flaring, retractions, cyanosis), tachypnea (shallow and rapid), and wheezing

DIAGNOSTIC WORKUP:
CBC → may be normal or mild lymphocytosis
CXR not indicated in children if temperature not elevated, no significant respiratory distress, or bilateral symmetrical findings on exam

MANAGEMENT:
1. supportive care → fluids, humidifier, rest, no smoking near child
2. hospitalization indicated if:
a. history of apnea
b. marked respiratory distress with retractions
c. moderate tachypnea with feeding difficulties
d. hypoxemia on room air
3. hospital supportive care → frequent suctioning, fluids to maintain hydration, supplemental O2 if hypoxemia present
4. do not prescribe antibiotics unless evidence of associated bacterial pneumonia
5. do not prescribe bronchodilators or corticosteroids (have not been shown to change severity or duration of illness)
6.
PREVENTION:
proper handwashing
reduce exposure to potential environmental risk factors → cigarette smoke, crowded conditions

PATIENT EDUCATION:
cigarette smoke makes a child more susceptible to infection
Define orthopnea. SOB while lying down that is relieved when upright
ASPIRATION OF FOREIGN BODY: ETIOLOGY:
aspiration of foreign body into any part of respiratory tract
history of running with food in mouth (seeds, peanuts, popcorn, hot dogs, hard candy) or playing with small coins or toys
highest risk at 6 months to 4 years

CLINICAL PRESENTATION:
aspiration rarely observed
abrupt onset of coughing, choking, or wheezing
symptoms depend on location of obstruction (laryngospasm if above glottis)
foreign body in upper respiratory tract:
partial upper respiratory tract obstruction → ability to vocalize, drooling, stridor
complete upper respiratory tract obstruction → acute onset of choking, inability to vocalize or cough, cyanosis with marked distress
lower respiratory tract aspiration → abrupt onset of coughing, wheezing, or respiratory distress, asymmetrical decreased breath sounds, localized wheezing, chronic cough, persistent wheezing or recurrent pneumonia

DIAGNOSTIC WORKUP:
CXR → inspiratory and forced expiratory views, asymmetrical findings, 25% normal in setting of aspiration

MANAGEMENT:
if partial upper airway obstruction → initially allow child to use cough reflex to remove foreign body, intervene if does not resolved as brief observation
if complete upper airway obstruction → intervene immediately
1. open airway, if foreign body is visualized carefully remove object, do not perform blind sweeps of mouth
2. if <1 y/o → place infant face down over rescuer’s arm with head positioned below trunk, deliver 5 rapid blows between scapulae with heel of hand, if obstruction persists roll child over and deliver 5 rapid chest compressions, repeat sequence until obstruction relieved
3. if >1 y/o → perform Heimlich maneuver with special care to prevent abdominal organ injury
4. if persistent inadequate ventilation → tracheotomy, cricothyrotomy, or intubation depending on skill and setting
if lower airway aspiration → hosptitalization, bronchoscopy for removal of foreign body, nebulizer treatments and chest physiotherapy to treat bronchospasm and clear mucus

PREVENTION:
teach children not to run with food in mouth or swallow small objects
teach older children not to give certain foods to younger children

PATIENT EDUCATION:
Define paroxysmal nocturnal dyspnea (PND). sudden waking at night with SOB
RESPIRATORY SYNCYTIAL VIRUS: ETIOLOGY:
RSV
causes 70% of bronchiolitis and 40% of pneumonia in young children

CLINICAL PRESENTATION:
epidemics in late fall to early spring (January–February peak)
upper respiratory symptoms (low-grade fever for 2-4 days, cough, difficulty feeding) followed by tachypnea and diffuse wheezing for 3-7 days
hyperinflation, retractions, prolonged expiration, wheezing, crackles
may manifest with apnea
complicated by otitis media, bacterial pneumonia

DIAGNOSTIC WORKUP:
RSV antigen in nasal or pulmonary secretions (fluorescent antibody or ELISA)
CXR → diffuse hyperinflation, peribronchiolar thickening, +/- patchy infiltrates and atelectasis

MANAGEMENT:
outpatient: self-limiting
hospitalization:
1. hospitalize if respiratory distress prevents feeding, hypoxia
2. tube or IV feedings
3. supplemental O2
4. trial of bronchodilator therapy, d/c if no improvement
5. corticosteroids and ribavirin controversial

PREVENTION:
proper handwashing
respiratory isolation during peak season
RSV monoclonal antibody IM monthly during peak season in high-risk children

PATIENT EDUCATION:
90% of children infected by age 2 years
reinfection common but generally only causes upper respiratory symptoms
may increase risk of asthma later in life
Define hemoptysis. coughing up blood
What is Sudden Infant Death Syndrome (SIDS)? sudden death of an infant <1y/o without explanation despite a thorough case investigation (autospy, examination of death scene, review of clinical history)
Define eupnea. normal respiratory rate
12-20 respirations/minute
SUDDEN INFANT DEATH SYNDROME: ETIOLOGY:
sudden death of infant <1y/o without explanation
diagnosis of exclusion after thorough case investigation (autopsy, examination of death scene, review of clinical history)
affects <1:1000 infants, affects male:female 3:2, usually occurs between few weeks and 6 m/o, peak at 2-4 m/o
risk factors include mothers who are racial minorities, teenagers, drug-addicted, low SES, smokers; FH of SIDS; low birth weight; prone sleeping position

CLINICAL PRESENTATION:
history of mild upper respiratory infection symptoms before death
death usually occurs between midnight and 8am while sleeping

DIAGNOSTIC WORKUP:
autopsy
examination of death scene

MANAGEMENT:
counseling and support groups → The National SIDS Resource Center (http://www.sidscenter.org)

PREVENTION & PATIENT EDUCATION:
do not smoke when pregnant
place infant on back to sleep
firm sleep surface
pacifier use during nap or bedtime
avoid overheating
quit smoking
educate family members, friends, and childcare providers on proper sleep position
recent immunizations do not increase risk
Define bradypnea. abnormally slow respiratory rate
<12 respirations/minute
What is the etiology of CF? autosomal recessive genetic disorder → abnormalities in cell membrane chloride channels → causing exocrine glands to produce abnormal mucus → causing obstruction of glands and ducts → causing glandular dilation and tissue damage

abnormalities occur in respiratory, GI, and male reproductive systems

affects 1:3200 (1:25 is carrier)

most common cause of severe lung disease in young adults
most common fatal hereditary disorder in whites in U.S.
Define tachypnea. abnormally fast respiratory rate
>20 respirations/minute
What is the clinical presentation of CF? meconium ileus at birth virtually diagnostic of CF

failure to thrive
chronic or recurrent productive cough
chronic or recurrent respiratory infections (sinusitis, bronchitis, pneumonia)

purulent rhinorrhea, nasal polyps
dyspnea, exercise intolerance
hemoptysis
bulky greasy malodorous stools and steatorrhea (d/t pancreatic insufficiency)

increased AP diameter
hyperresonance
wheezing
apical crackles
clubbing

also consider CF if severe dehydration + hypochloremic alkalosis, unexplained bronchiectasis, cirrhosis, or pancreatitis, rectal prolapse
What is the ddx for hyperresonance? pneumothorax
COPD
acute asthma attack
pleural effusion (if percuss superior to effusion)
What is the diagnostic workup of CF? nutritional deficiencies → hypoproteinemia, anemia, fat-soluble vitamin deficiencies
CXR → hyperinflation, mucus plugging, bronchiectasis, focal atelectasis, pnuemothorax
PFTs → mixed obstruction and restriction; reduced FVC, airflow rates, TLC, air trapping, reduced diffusing capacity
chloride sweat test → >60 mEg/L on two occasions
genotyping → CF gene mutation

positive NBS should be confirmed with chloride sweat test or genotyping
false-negative NBS can occur
Define adventitious breath sounds. abnormal sounds heard over normal breath sounds
What is the management of CF? 1. refer to CF center
2. high calorie, protein, fat, and salt diet
3. daily multivitamin
4. pancreatic enzyme supplement prior to eating
5. clear lower airway secretions via manual chest compressions etc.
6. treat active airway infections via antibiotics
7. inhaled bronchodilators
8. influenza and pneumococcal immunizations
9. lung transplant if end-stage lung disease
10. screen family members
11. genetic counseling and support groups
What are examples of normal breath sounds? bronchial
vesicular
What is the prevention of CF? none → genetic disorder
What are examples of adventitious breath sounds? stridor
wheezes (rhonchi)
crackles (rales)
pleural friction rubs
What is the prognosis for CF? median survival age is >35y/o
death occurs from pulmonary complications (pneumonia, pneumothorax, hemoptysis), chronic respiratory failure, or cor pulmonale
Define digital clubbing. enlargement of terminal phalanges of fingers and/or toes
APNEA: ETIOLOGY:
unexplained breathing cessation for ≥20 seconds or shorter period of breathing cessation associated with bradycardia, pallor, cyanosis, or hypotonia

central apnea:
characterized by respiratory cessation 2° to diminished muscular activation
occurs in newborns (especially preterm infants) d/t infection, metabolic abnormalities, anemia, hypoxia, CNS injury

obstructive apnea:
characterized by cessation of airflow despite respiratory effort (movement of chest wall and abdomen present)
occurs in later infancy and childhood d/t obstructive upper airway conditions (tonsillitis, laryngitis, laryngomalacia, masses)

CLINICAL PRESENTATION:
breathing cessation

DIAGNOSTIC WORKUP:
central apnea → CBCDP, BMP, ionized calcium, magnesium, BC, UAC, URNC, toxicology studies; CT if abnormal mental status, bulging fontanelle, focal neurological sxs; LP if lethargic or toxic-appearing
obstructive apnea → CXR, laternal neck radiograph, sleep study

MANAGEMENT:
hospitalization for observation and full workup
pulse oximeter and apnea monitor
supplemental O2
IV fluids if dehydrated
True or false, asthma and emphysema are associated with clubbing? FALSE
What disorders comprise croup syndrome? laryngotracheal bronchitis
epiglottitis
bacterial tracheitis
What is the ddx for bradypnea? obesity
metabolic alkalosis
cerebrum lesion
narcotic overdose
What is the ddx for acute stridor? laryngeal or esophageal foreign body
croup → laryngotracheobronchitis, epiglottitis, bacterial tracheitis
spasmodic croup
retropharyngeal abscess
angioedema
What is the ddx for tachypnea? hypoxemia
metabolic acidosis
pons lesion
splinting
aspirin overdose
anxiety
What is croup? group of disorders characterized by acute inflammation of the larynx
What is the ddx for PND? RESPIRATORY:
COPD
cor pulmonale

NON-RESPIRATORY:
obesity
snoring
sleep apnea
cardiomyopathy
valvular disease
HF → pulmonary edema
panic disorder
Laryngotracheal Bronchitis (AKA viral croup) usually caused by parainfluenza viruses
also caused by RSV, human metapneumovirus, influenza virus, rubeola virus, adenovirus, and Mycoplasma pneumoniae
usually affects younger children in fall and early winter
edema in subglottic space results in signs of upper airway obstruction, though inflammation of entire airway is usually present
prodrome of upper respiratory tract symptoms
barking cough
stridor
usually no fever
no drooling
lateral neck radiograph
treatment based on symptoms
mild croup = barking cough, no stridor at rest → supportive therapy with oral hydration
severe croup = barking cough, stridor at rest → supplemental O2, nebulized racemic epinephrine, dexamethasone (corticosteroid), recurrent nebulized racemic epinephrine if respiratory distress persists, intubation if impending respiratory failure
most children improve within few days
What is the ddx for orthopnea? RESPIRATORY:
bronchitis
pneumonia
asthma
COPD
pulmonary HTN
cor pulmonale

NON-RESPIRATORY:
obesity
snoring
sleep apnea
GERD
superior vena cava syndrome
cardiomyopathy
valvular disorders
HF → pulmonary edema
polycystic liver disease
panic disorder
EPIGLOTTITIS: usually d/t Haemophilus influenzae in unimmunized children, nontypeable Haemophilus influenza, Neisseria meningitides, or Streptococcus
sudden onset of high fever, dysphagia, drooling, muffled voice
cyanosis, inspiratory retractions, soft stridor
sitting-dog position (provides best airway)
lateral neck radiographs reveal “thumbprint” sign
swollen cherry red epiglottis and swollen arytenoids
management:
1. immediate intubation in children once diagnosis established
2. BC
3. epiglottis culture
4. IV antibiotics covering Haemophilus influenza and Streptococcus → cefriaxone x 2-3 days
5. oral antibiotics x 7 days
6. extubation within 24-48 hours if reduction in swelling
What should you ask a patient who complains of orthopnea? how many pillows do you use to relieve your orthopnea?

can be documented as 1, pillow orthopena, 2, pillow orthopena, 3 pillow orthopnea and so on.
What is the most common cause of cor pulmonale? COPD
What is the ddx for hemoptysis? PULMONARY:
secondary to chronic cough
bronchitis
pneumonia
TB
PE
lung neoplasm

NON-RESPIRATORY:
mitral stenosis
HF
Define cyanosis. blue discoloration of skin or mucous membranes due to deficient oxygenation of blood

*must be 5g of reduced hemoglobin per 100mL of blood for presentation
Define pulsus paradoxus. pulse weaker during inspiration and stronger during expiration
List common signs and symptoms of a pulmonary disorder. dyspnea
orthopnea
paroxysmal nocturnal dyspnea
cough
hemoptysis
pleuritic chest pain
hemoptysis

tachycardia
pulsus paradoxus
hyperpnea
hyperventilation
hyperresonance
adventitious breath sounds
stridor
wheezing
cyanosis
clubbing

hypoxemia
Define hyperpnea. breathing that is faster or deeper than normal

occurs after exercise or in response to low O2
Define hyperventilation. rapid deep breathing that results in abnormal CO2 loss
Define pleuritic chest pain. chest pain that occurs or worsens synchronously with the respiratory cycle
Define hyperresonance. abnormally increased resonance on percussion of the lungs, often lower in pitch
Define hypoxemia. abnormally low pO2
Define hypoxia. either tissue or body deprived of adequate O2
What is the ddx for clubbing? CF
chronic fibrotic changes within the lung
chronic cyanosis of congenital heart disease
What is the ddx for clubbing? Mosbys p377
Define wheezing. adventitious breath sound; whistling, musical, squeaking, or puffing sound that occurs during expiration
Define stridor. adventitious breath sound; high-pitched, noisy respiratory like blowing of the wind; sign of respiratory obstruction
Define empyema. pus accumulation within naturally existing cavity
Define abscess. pus accumulation within newly formed cavity
List signs of upper airway obstruction. nasal flaring
retraction at suprasternal notch
inspiratory stridor
hoarse cough or cry

If severe:
cyanosis
retractions also involving intercostal and subcostal spaces
barking cough
inspiratory and expiratory stridor
List signs of upper airway obstruction. Current p377
mild stridor
severe stridor
What is the ddx for stridor? airway obstruction →
foreign body
aspiration
narrowing due to trauma, allergic reaction, infection or neoplasm
inhalation of caustic agent
What is the ddx for pleuritic chest pain? trauma → blunt or penetrating chest wall trauma, chest wall fracture, thorax or back muscle strain/sprain, pneumothorax
infection → pleural effusion, pleuritis, pneumonia, pulmonary TB
malignancy
spleen injury
What are the differences between chronic OBSTRUCTIVE pulmonary disease and chronic RESTRICTIVE pulmonary disease? chronic obstructive pulmonary disease
-difficulty in getting air out
-caused by:
1. mechanical obstruction → foreign body, mucus plug of chronic bronchitis, tumor
2. increased resistance of airways → inflammation of chronic bronchitis
3. increased tendency for bronchoconstriction → asthma, emphysema

chronic restrictive lung disease
-difficult to get air in
-caused by:
1. stiff lungs → interstitial lung disease
2. stiff chest wall → obesity, kyphoscoliosis, ankylosing spondylitis
3. respiratory muscle weakness → neurological or neuromuscular diseae
List chronic obstructive pulmonary diseases and chronic restrictive pulmonary diseases. Chronic Obstructive Pulmonary Diseases:
1. asthma
2. COPD → chronic bronchitis, emphysema
3. CF
4. bronchiectasis

Chronic Restrictive Pulmonary Diseases:
1. stiff lungs → interstitial fibrosis
-idiopathic
-connective tissue disorder → RA, SLE, scleroderma, myositis
-environmental → pneumoconiosis, asbestosis, silicosis, hypersensitivity pneumonitis
-drugs
2. stiff chest wall
-obesity
-kyphoscoliosis
-ankylosing spondylitis
3. respiratory muscle weakness
-spinal cord injury
-Guillain-Barre
-MS
-ALS
-muscular dystrophies
-myasthenia gravis
What is the pathophysiology of restrictive lung disease? if due to stiff lungs:
alveolar walls become thin and inflexible → alveoli contract more quickly and forcefully and are less likely to collapse → decreases residual volume
What is the Patient Outcome Research Team (PORT) Score? scoring system used to predict severity of adult community acquired pneumonia and thus determine appropriate treatment
What is included in the PORT score? Age? (1 point per year)
Female? (-10)
Nursing home resident? (+10)
History of neoplasm? (+30)
CHF? (+10)
Liver disease? (+20)
Kidney disease? (+10)
Cerebrovascular disease? (+10)
Altered mental status? (+20)
systolic BP <90? (+20)
HR >124? (+10)
RR >29? (+20)
temp <95 or >103.8? (+15)
Hct <30? (+10)
Na+ <130? (+20)
GLUC >249 (+10)
BUN >29? (+20)
pH <7.35? (+30)
PO2 <60 (+10)
pleural effusion on CXR? (+10)
What is the clinical usefulness of the PORT score? can determine mortality rate of adult patient with community acquired pneumonia and if this patient should be admitted or not
Describe the recommendations for the influenza vaccine. 1. includes H1N1
2. get if >6 m/o
3. get yearly during flu season
4. get especially if high risk for developing flu complications or spreading flu:
-children <5y/o
-pregant women
-adults >50y/o
-nursing home residents
-chronic medical conditions
-household contacts of at-risk persons
-caregivers
-healthcare workers
Describe the recommendations for the influenza vaccine. CDC
Describe the recommendations for the pneumococcal vaccine. PVC13 vaccine:
get 4-dose series at 2, 4, 6, and 12 months
get 1 dose if didn't get 4-dose series and 2-5y/o

PPSV vaccine:
get if >65 y/o
get if nursing home resident
if 2-64 y/o → get if chronic medical problem or immunosuppresion
if 19-64 y/o → get if smoke or have asthma
Describe the recommendations for the pneumococcal vaccine. CDC
Describe the recommendations for the haemophilus influenzae type (hib) vaccine. prevents epiglottitis, pneumonia, meningitis,etc.
get 4-dose series at 2, 4, 6, and 12 months
Describe the recommendations for the haemophilus influenzae type (hib) vaccine. CDC
What are the 5 A's of smoking cessation? 1. ask → identify tobacco users
2. advise → urge to quit
3. assess → determine willingness to quit within next 30 days
4. assist → aid in quitting → set quit date, tell family/friends, remove products from environment
5. arrange → follow-up on progress
How much pleural fluid is normally found in the pleural cavity? 5-15mL
Define pleuritis. pain caused by inflammation of the pleura
What does a pleural friction rub indicate? pleuritis
Describe a pleural friction rub. coarse grating sound
usually heard on inspiration
indicative of pleuritis
What is another name for pleuritis? pleurisy
What is the etiology of pleuritis? irritation of the parietal pleura

if young and otherwise healthy → viral respiratory infections, pneumonia

rib fracture
pneumothorax
pleural effusion
What is the etiology of pleuritis? Current ch9
What is the clinical presentation of pleuritis? pain → localized, sharp, fleeting; aggravated by breathing, coughing, sneezing, moving; may refer to ipsilateral shoulder if central portion of diaphragmatic parietal pleura irritated

pleural friction rub
What is the clinical presentation of pleuritis? Current ch9
What is the management of pleuritis? 1. treat underlying disease
2. for pain relief → NSAIDs → indomethacin 25mg PO 2-3x daily
3. for cough relief → codeine 30-60mg PO q8hr (only if retention of airway secretions unlikely to cause complications)
What is the management of pleuritis? Current ch9
Define pleural effusion. abnormal accumulation of fluid in pleural space
Define parapneumonic effusion. pleural effusion associated with pneumonia
Define empyema. pus accumulation within naturally existing cavity
Define hemothorax. blood in pleural space
Define pneumothorax. air in pleural space
What is the pathophysiology of pleural effusion? transudate – ↑ production due to ↑ hydrostatic pressure or ↓ colloid osmotic pressure; due to systemic factors that alter formation and absorption of pleural fluid
exudate – ↑ production due to abnormal capillary permeability or ↓ lymphatic drainage; due to local factors that alter formation and absorption of pleural fluid
Define transudate. any fluid that passes through a membrane wall due to ↑ hydrostatic pressure or ↓ colloid osmotic pressure
Define exudate. any fluid that is exuded out of a tissue or its capillaries due to inflammation, infection, or malignancy
Define pyothorax (pleural empyema). pus in pleural space
What is a tension pneumothorax? pneumothorax where air enters pleural space but cannot exit → can lead to lung collapse and compression of mediastinal structures which can be fatal
What is the etiology of a pneumothorax? air enters pleural space:

1. spontaneous → rupture of an alveolus
○ primary if idiopathic → commonly occurs in 10-30 y/o tall thin males; risk increased if smoker or positive FH
○ secondary if associated with underlying lung disease → occurs as complication of CF, asthma, COPD, interstitial lung disease, Pneumocystis pneumonia, TB
2. trauma → blunt or penetrating chest wound, rib fracture
3. iatrogenic → thoracentesis, lung biopsy, central line placement, mechanical ventilation

*tension pneumothorax often due to penetrating trauma, lung infection, CPR, or mechanical ventilation
What is the clinical presentation of a pneumothorax? • acute onset of dyspnea and chest pain
• symptoms begin during rest and often resolve after 24 hours even if pneumothorax persists
• if pneumothorax small, findings are minimal except for mild tachycardia
• if pneumothorax large, findings include cyanosis, unilateral chest expansion, decreased tactile fremitus, hyperresonance, and diminished breath sounds on affected side
• suspect tension pneumothorax if marked tachycardia, hypotension, tracheal/mediastinal shift, or absent breath sounds on affected side
• if associated with asthma or COPD, may present with life-threatening respiratory failure
What is the diagnostic workup of a pneumothorax? • CXR reveals visceral pleural line; may only be seen on expiratory view
• if tension pneumothorax, CXR reveals large amount of air on affected side and contralateral shift of mediastinum
• if suspected tension pneumothorax, do not delay treatment waiting for CXR results
What is the general management of a pneumothorax? • treatment depends on severity of pneumothorax and underlying disease
• if primary + small + stable pneumothorax – observation; will often resolve spontaneously
• if secondary pneumothorax, large pneumothorax, tension pneumothorax, associated with severe symptoms, or due to mechanical ventilation – place chest tube, order serial CXR every 24 hours, and provide symptomatic relief
• if bilateral pneumothorax, refractory to treatment, or recurrence – surgery
• encourage smoking cessation – 50% risk of recurrence if smoking continued
• avoid exposure to high altitudes, flying in unpressurized aircrafts, scuba diving
• spontaneous pneumothorax has 30% recurrence rate
What is a parapneumonic effusion? exudative pleural effusion associated with pneumonia
What are the different types of parapneumonic effusion? ○ simple parapneumonic effusion = modest-sized exudate, sterile, free-flowing
○ empyema = pus in pleural space
○ complicated parapneumonic effusion = large-sized exudate, inflammatory or loculated
What is the etiology of a parapneumonic effusion? bacterial pneumonia
What is the clinical presentation of a parapneumonic effusion? • fever, cough, dyspnea, pleuritic chest pain
• decreased fremitus, dullness to percussion, decreased breath sounds
What is the diagnostic workup of a parapneumonic effusion? • CXR – order PA and lateral decubitus views
• PA view reveals meniscus-like opacity (though not if large effusion)
• lateral decubitus view reveals flattening of opacity (though not if loculated)
• thoracentesis and pleural fluid analysis – order cell count/diff, glucose, LDH, pH, gram stain, culture
• empyema indicated by positive gram stain or culture
• complicated parapneumonic indicated by frank pus, glucose <20 mg/dL, pH <7.20, LDH >1000 units/mL, positive gram stain or culture, or loculation
What is the general management of a parapneumonic effusion? • if simple effusion – prescribe antibiotics; no drainage needed
• if empyema – prescribe antibiotics; place chest tube and drain
• if complicated effusion – prescribe antibiotics; place chest tube and drain ideally before loculation occurs
• if loculation – place chest tube with VATS or CT guidance; intrapleural injection of fibrinolytic agents may improve drainage but use is controversial
What is the etiology of a hemothorax? most commonly caused by blunt or penetrating chest trauma

non-traumatic and iatrogenic causes uncommon
What is the clinical presentation of a hemothorax? symptoms similar to pleural effusion
dyspnea
chest pain
decreased fremitus
dullness to percussion
decreased breath sounds
What is the diagnostic workup of a hemothorax? CXR → pleural effusion
*<25% of traumatic hemothoraces do not show up on initial CXR → repeat in 3-6 hours and make sure patient is sitting (not supine)
*62-83% have concurrent pneumothorax

thoracentesis/pleural fluid analysis → hct >50% of that of peripheral blood
What is the general management of a hemothorax? 1. place chest tube with large bore tube to minimize clotting within tube → drain blood
2. quantify and monitor bleeding
3. if bleeding >200mL/hr without diminishing → surgical evacuation of blood via VATS
4. timeliness is essential to prevent fibrothorax
What is the etiology of sarcoidosis? unknown
What is sarcoidosis? systemic inflammatory disorder of unknown etiology characterized most often by granulomatous inflammation of the lung
What is the clinical presentation of sarcoidosis? insidious onset of fatigue, fever, and dyspnea
other systems involved include skin, eyes, heart, liver, kidney, and peripheral nerves
erythema nodosum
iritis
arthritis
peripheral neuropathy

may be asymptomatic and found on CXR → bilateral hilar and RT paratracheal lymphadenopathy
What is the diagnostic workup of sarcoidosis? CBC → leukopenia
↑ ESR
hypercalcemia
hypercalciuria
↑ ACE
PFTs → restrictive lung changes with decreased lung volume and diffusing capacity
CXR:
stage 1 → bilateral hilar adenopathy
stage 2 → hilar adenopathy + parenchymal involvement
stage 3 → parenchymal involvement → usually diffuse reticular infiltrates

diagnosis requires biopsy → noncaseating granulomas + exclusion of other granulomatous disorders
What is the general management of sarcoidosis? 1. oral prednisone usually for months to years if:
-disabling constitutional symptoms
-cutaneous lesions
-iritis
-uveitis
-cardiac involvement
-progressive pulmonary lesions
-granulomatous hepatitis
-arthritis
-CNS involvement
-hypercalcemia
What is the pathophysiology of interstitial lung disease? injury to alveoli epithelium or capillary endothelium → obliteration of alveolar capillaries → reorganization of lung parenchyma → fibrosis
What is the clinical presentation of interstitial lung disease? insidious onset of progressive dyspnea
chronic dry cough
tachypnea
bilateral basilar dry crackles
Right HF
clubbing
hypoxemia with exercise
What is the diagnostic workup of interstitial lung disease? PFTs → restrictive changes → reduced lung volumes, diffusing capacity, 6min walk distance
CXR →
reduced lung volumes
patchy distribution of ground glass, reticular, nodular, and cystic opacities
What is the clinical presentation of idiopathic pulmonary fibrosis (usual interstitial pneumonia)? inspiratory crackles
What is the diagnostic workup of idiopathic pulmonary fibrosis (usual interstitial pneumonia)? PFTs → restrictive changes
CXR → diffuse patchy fibrosis; progressive over several years
CT → pleural-based honeycombing
What is the general management of idiopathic pulmonary fibrosis (usual interstitial pneumonia)? Controversial!
Prednisone NOT recommended for UIP
What is the clinical presentation of pulmonary vasculitis (Wegener Granulomatosis)? triad of upper respiratory tract disease + lower respiratory tract disease + glomerulonephritis

vasculitis of small arteries, arterioles, and capillaries
necrotizing granulomatous lesions of upper and lower respiratory tract
glomerulonephritis

suspect if refractory nasal congestion or sinusitus

upper respiratory tract → otitis media, nasal congestion, sinusitis, gingivits, mastoiditis, stridor due to subglottic stenosis

lower respiratory tract → dyspnea, cough, hemoptysis
What is the diagnostic workup of pulmonary vasculitis (Wegener Granulomatosis)? ANCA
biopsy
CXR/CT
What is the general management of pulmonary vasculitis (Wegener Granulomatosis)? prednisone
cyclophosphamide
What is the clinical presentation of pulmonary vasculitis (Churg-Strauss)? vasculitis of small and medium arteries that occurs in asthma patients

often involves skin and lungs
may also involve paranasal sinuses, heart, liver, GI, peripheral nerves
What is the diagnostic workup of pulmonary vasculitis (Churg-Strauss)? CBC → eosinophil count → >1500 cells/mcL or >10% of WBCs
CXR → transient opacities, mutiple nodules
biopsy
What is the general management of pulmonary vasculitis (Churg-Strauss)? prednisone and cyclophosphamide
What is bronchiectasis? permanent abnormal dilation and destruction of bronchial walls
What is the most common cause of bronchiectasis? CF
What is the ddx for barrel chest? CF, asthma, emphysema
What is the normal ratio of AP and tranverse chest diameter? 1:2
What 3 criteria are assessed to determine asthma severity? FEV1/FVC ratio
asthma symptoms
medication use
What 3 criteria are assessed to determine asthma severity? Interpreting Laboratory Data p194
What is status asthmaticus? medical emergency in which asthma symptoms are refractory to bronchodilator therapy
What is the etiology of CF? autosomal recessive genetic disorder → abnormalities in cell membrane chloride channels → causing exocrine glands to produce abnormal mucus → causing obstruction of glands and ducts → causing glandular dilation and tissue damage

affects 1:3200 (1:25 is carrier)

most common cause of severe lung disease in young adults
most common fatal hereditary disorder in whites in U.S.
What is the clinical presentation of CF? history of chronic or recurrent infections, pancreatitis, or infertility
dyspnea
purulent rhinorrhea
chronic or recurrent cough with sputum
recurrent hemoptysis
wheezing
decreased exercise tolerance

increased AP diameter
hyperresonance
apical crackles
clubbing
What is the diagnostic workup of CF? CXR → hyperinflation, mucus plugging, bronchiectasis, focal atelectasis, pnuemothorax
PFTs → mixed obstruction and restriction; reduced FVC, airflow rates, TLC, air trapping, reduced diffusing capacity
chloride sweat test → >60 mEg/L on two occasions
genotyping → CF gene mutation
What is the management of CF? 1. refer to CF center
2. clear lower airway secretions → manual chest percussion etc.
3. antibiotics → treat active airway infections
4. inhaled bronchodilators
5. influenza and pneumococcal immunizations
6. screening of family members
7. genetic counseling
8. lung transplant
What is the prevention of CF? none → genetic disorder
What is the prognosis for CF? median survival age is >35y/o
death occurs from pulmonary complications (pneumonia, pneumothorax, hemoptysis), chronic respiratory failure, or cor pulmonale
What is the etiology of bronchiectasis? congenital or acquired

caused by recurrent inflammation or infection of airways → 50% caused by CF, other causes include abnormal lung defense mechanisms, localized airway obstruction, lung infection
What is the clinical presentation of bronchiectasis? chronic cough with sputum → copious, purulent, foul-smelling
dyspnea
hemoptysis
pleuritic chest pain
wheezing
weight loss
anemia
basilar crackles
if severe → clubbing
What is the diagnostic workup of bronchiectasis? CXR →
dilated thickened bronchi → may appear as "tram-tracks" or ring-like markings
scattered irregular opacities
atelectasis
focal consolidation
CT is preferred diagnostic tool
PFTs → obstructive dysfunction with hypoxemia
What is the etiology of asthma? genetic predisposition
risk factors include obesity and atopy (dust mites, dander, pollen)
other precipitating factors include cold weather, exercise, URTI, GERD, stress
affects 5% of population
more common in male children and female adults
What is the clinical presentation of asthma? chronic or recurrent symptoms of airflow obstruction
airflow obstruction reversible → either sponatneously or with bronchodilator therapy
dyspnea
cough
chest tightness
prolonged expiration
episodic wheezing
symptoms often worse at night
if allergic asthma → enalarged nasal mucosa, nasal secretions, nasal polyps, eczema, atopic dermatitis
What is the diagnostic workup of asthma? PFTs → measure before and after use of bronchodilator
*significant reversibility of airflow obstruction = ≥12% and 200mL in FEV1 and ≥15% and 200mL in FVC after inhaling SABA
bronchoprovacation challenge → if PFTs non-diagnostic
exercise challenge → if exercise-induced asthma suspected
allergy testing
GERD workup
What is the prevention of asthma attacks? 1. develop asthma action plan
2. identify aggravating factors and reduce exposure
3. stop smoking
What is an Asthma Action Plan? plan develped between provider and patient to control asthma
-what medications to take daily
-how to handle asthma long-term → what to avoid
-how to handle asthma attacks → what additional medications to take, when to call provider or go to ER
What is an Asthma Action Plan? http://tiny.cc/AsthmaActionPlan
Does wheezing on forced expiration indicate airflow obstruction? no, wheezing during normal breathing or prolonged expiration indicates obstruction
A reduced FEV1/FVC ratio indicates? airflow obstruction
Describe the stepwise management of asthma.
Describe the classifications of asthma severity.
What is the etiology of COPD? 1. 80% due to smoking
3. 20% due to environmental exposure to tobacco smoke, dusts, chemicals, pollution; allergies, infection; hereditary factors
3. alpha-1-antitripsin deficiency
What is the clinical presentation of COPD? dyspnea
chronic cough with sputum
pursed lip breathing
increased AP diameter
hyperresonance
prolonged expiration
decreased breath sounds
rhonchi

advanced disease → pneumonia, pulmonary HTN, cor pulmonale, chronic respiratory failure
What is the diagnostic workup of COPD? PFTs → non-reversible obstructive changes → decreased FEV1/FVC, decreased FEV1, normal or decreased FVC, normal or increased RV, normal or increased TLC
CXR → hyperinflation, flattening of diaphragm
sputum culture
What is the management and patient education of COPD? 1. encourage smoking cessation
2. supplemental O2
3. bronchodilator for symptomatic relief → 1st-line is anticholinergic, SABA, or LABA, 2nd line is ICS, 4th line is theophylline
4. antibiotics if concomitant infection
5. pullmonary rehabilitation if severe dyspnea, reduced quality of life, or frequent hospitalizations despite medical treatment
4. influenza and pneumococcal immunizations
What is the prevention of COPD? do not smoke!
What is emphysema? abnormal permanent enlargement of air spaces distal to terminal bronchioles
with destruction of their walls but without fibrosis
Prolonged expiration indicates? obstruction
What is COPD? airflow obstruction due to chronic bronchitis or emphysema → usually mixed
What is chronic bronchitis? excessive secretion of bronchial mucus → daily productive cough for ≥3 months in ≥2 consecutive years
What is the prognosis for COPD? poor
degree of pulmonary dysfunction when first seen is important predictor of survivial
FEV1 ≤1L = median survival of 4 years
Which therapy methods reduce rate of decline in COPD? Reduce rate of decline:
smoking cessation
supplemental O2
pulmonary rehabilitation

DO NOT reduce rate of decline:
bronchodilators
Discuss acute bronchitis vs chronic bronchitis. ACUTE:
due to infection
lasts few weeks

CHRONIC:
usually due to chronic smoke exposure
also due to genetics, environmental exposures
chronic cough for at least 3 months in 2 consecutive years
productive cough
What is another name for obesity hypoventilation syndrome? Pickwickian syndrome
What is the etiology of obesity hypoventilation syndrome? obesity → blunted ventilatory drive + increased mechanical load imposed upon chest
What is the clinical presentation of hypoventilation syndrome? obesity
sleep apnea
hypersomnolence

chronic hypercapnea, hypoxemia, polycythemia, pulmonary HTN, RT HF
What is the diagnostic workup of hypoventilation syndrome? sleep studies
What is the management of obesity hypoventilation syndrome? weight loss
smoking cessation
eliminate sleep apnea
NPPV (non-invasive positive pressure ventilation)
respiratory stimulants → theophylline, acetazolamide, progesterone)
What is acute respiratory failure? respiratory dysfunction resulting in abnormalities in oxygenation or ventilation severe enough to threaten the function of vital organs

hypoxemia → dyspnea, restlessness, confusion, anxiety, delirium, HTN, tachycardia or bradycardia, tachypnea, cyanosis, tremor, arrhythmias
hypercapnea → dyspnea, HA, impaired consciousness, HTN, tachycardia, tachypnea, hyperemia, papilledema, asterixis (wrist tremor)

obtain ABG

treat underlying disease
ensure adequate ventilation → supplemental O2, NPPV, intubation, mechanical ventilation
What is acute respiratory distress syndrome? acute hypoxemic respiratory failure following systemic or pulmonary insult without evidence of heart failure
What is the etiology of pulmonary HTN? idiopathic
secondary → lots of causes including any disease that causes chronic hypoxemia
What is the clinical presentation of pulmonary HTN? fatigue
dyspnea
chest pain
exertional syncope
narrow spitting of S2 with loud pulmonic valve closure
if advanced → RT ventricular hypertrophy, HF
What is the diagnostic workup of pulmonary HTN? PFTs → hypoxemia, increased wasted ventilation
EKG → RT ventricular hypertrophy, RT atrial hypertrophy
CXR → enlarged central pulmonary arteries
polycythemia if chronic hypoxemia
What is the initial management of pulmonary HTN? treat underlying disorder
phlebotomy if polycythemia
anticoagulants if primary or secondary + high risk for PE
What is the prognosis of pulmonary HTN? dependent on underlying disease and severity when diagnosed
cor pulmonale = poor prognosis
What is the etiology of cor pulmonale? 1. pulmonary disease + associated hypoxia → most commonly COPD
2. pulmonary HTN

both result in right ventricular systolic and diastoic HF
What is the clinical presentation of cor pulmonale? dependent on underlying disease → often COPD symptoms
parasternal lift
cyanosis
clubbing
elevated JVD
dependent edema
hepatomegaly
ascites
What is the diagnostic workup of cor pulmonale? CXR → enlarged RT ventricle and pulmonary artery
EKG → tall peaked P waves, RT ventricular hypertrophy
polycythemia
What is the initial management of cor pulmonale? 1. treat underlying condition
2. supplemental O2
3. diuretics for edema
4. low salt diet
What is the prognosis for cor pulmonale? same as underlying disease if compensated
if congestive signs → 2-5 years unless uncomplicated emphysema
What is the etiology of PE? embolism → commonly thromboembolism caused by DVT
*PE occurs in 50-60% of DVTs

risk factors:
Virchow triad → venous stasis + injury to vessel wall + hypercoagulability
venous stasis → immobility (bed rest, flying, polycythemia)
injury to vessel wall → trauma, prior thrombosis, surgery
hypercoagulability → oral contraceptives, FVL, protein S deficiency, protein C deficiency, AT3 deficiency, presence of ACL or lupus antibody
What is the clinical presentation of PE? dyspnea
hemoptysis
chest pain
syncope
tachypnea
What is the diagnostic workup of PE? if low risk → DDQ → if positive → helical CT
if high risk → helical CT → if still unsure → venous ultrasonagraphy or pulmonary angiography

VQ scan
What is the initial management of PE? 1. initially heparin or LMWH
2. then warfarin x 6 months
3. warfarin duration dependent on clinical picture
-6 months if reversible risk factor
-12 months if idiopathic
-6 months to indefinitely if non-reversible risk factor or recurrence

thrombolytics may given but shown no difference in outcomes
What is the prognosis of PE? good if PE recognized and appropriately treated

50,000 deaths annually
What is Virchow triad? venous statis + injury to vessel wall + hypercoagulability
What are the clinical features of typical vs atypical pneumonia? TYPICAL:
acute onset
prostration
high fever
cough with sputum
lobar consolidation

ATYPICAL:
insidious onset
little to no fever
cough without sputum
hazy diffuse infiltrates (no signs of consolidation)
What are the CDC guidelines for prevention of active TB in a patient with history of exposure or positive PPD? 1. most people with latent TB never develop active TB
2. certain populations with latent TB are at an increased risk for developing active TB
-infected within last 2 years
-young children
-elderly
-IV drug users
-HIV+
-immunocompromised
-people not correctly treated for TB in past
3. treatment can reduce risk of active TB by 90%
4. treatment consists of isoniazid x 9 months (longer if child or HIV+)
5. directly observed therapy recommended
6. prevention if exposure to active multi-drug resistant TB may not be an option
What are the CDC guidelines for prevention of active TB in a patient with history of exposure or positive PPD? http://tiny.cc/TBprevention
What is diagnostic workup of TB? CXR →
small homogenous infiltrates → often apical
hilar and paratracheal lymph node enlargement
segmental atelectasis
possible pleural effusion, cavitation
miliary TB → diffuse small nodular densities → seen if hematogenous or lymphatic spread
PPD
3 consecutive morning sputum samples
AFB → not diagnostic of TB, may be positive with other mycobacteria
bronchoscopy if suspicion but negative sputum
pleural fluid analysis if associated pleural effusion
biopsy → granulomatous inflammation
Extrapulmonary TB is most common in what population? HIV+ → who display lymphadenitis and miliary TB
PPD distinguises between latent and active TB, true or false? false
How is interpretation of a PPD affected if previous BCG vaccination? interpretation is the same as if no BCG vaccination received
IGRA can distinguish between latent and active TB, true or false? true
What are the advantages of IGRA vs PPD? IGRA
-requires single patient visit
-results in 24 hours
-distinguishes between latent and active TB
-prior BCG does not cause false-pos
-does not cause "boosting"
What are the reporting requirements for TB? report suspected and confirmed cases of TB to local health department within 1 day
What are the reporting requirements for TB? http://www.oregon.gov/DHS/ph/tb/docs/investigativeguide.pdf
What is the clinical presentation of extrapulmonary TB? vague symptoms
fatigue, intermittent fever, night sweats, weight loss, reduced appetite, pain/abscess
most often affects kidneys and lymph nodes
also affects bones, brain, abdominal cavity, pericardium, joints, and reproductive organs
meningitis
pericarditis
Discuss community acquired pneumonia vs hospital acquired pneumonia. CAP:
occurs outside hospital or within 48 hours of admission in patient who is ambulatory and did not reside in long-term care facility


HAP:
occurs in hopsital after 48 hours of admission
excludes infections at time of admission
common in patients requiring mechanical ventilation
What are the risk factors for anaerobic pneumonia? aspiration risk factors → unprotected airway (alcoholics, drug overdose, seizure disorders) + gingivitis
What are the complications of anaerobic pneumonia? parapneumonic effusion
empyema
abscess
What are pneumoconioses? chronic fibrotic lung diseases caused by inhalation of inorganic dusts (coal, silica, asbestos, others)
List diseases that fall under the category of pneumoconiosis. coal miner's pneumoconiosis
silicosis
asbestosis
What is the etiology of coal worker's pneumoconiosis? inhalation of coal dust (which contains silica and carbon)

associated with coal mining
"Black lung" is another name for what disorder? coal worker's pneumoconiosis
What is the pathophysiology of coal worker's pneumoconiosis? inhalation of coal dust → coal dust ingested by alveolar macrophages → formation of coal macules
What is the clinical presentation of coal worker's pneumoconiosis? 1. if simple → asymptomatic, little to no pulmonary dysfunction, coal macules 1-2mm in diameter

2. if complicated → dyspnea, cough, pulmonary dysfunction, possible cor pulmonale, large black necrotic nodules >2 mm in diameter, extensive fibrosis
What is the diagnostic workup of coal worker's pneumoconiosis? PFTs → normal if simple; abnormal if complicated
CXR → diffuse small opacities, 1-2mm if simple, 2-5mm + fibrosis if complicated, more common in upper lung
What is the initial management, patient education, and prevention of coal worker pneumoconiosis? 1. treatment is symptomatic
2. encourage job change within mine to reduce dust exposure
3. encourage smoking cessation (smoking has additive effect)
4. influenza and pneumococcal immunizations
4. serial CXRs to monitor progression
5. O2 as needed
6. consult with pulmonologist
What is the prognosis for coal miner pneumoconiosis? removal from job does not halt progression of disease once it progresses to massive pulmonary fibrosis
What is the etiology of silicosis? inhalation of silica (found in rocks)

associated with:
construction workers
coal miners
glassblowers
sandblasters
stonecutters
quarry workers
What is the pathophysiology of silicosis? inhalation of silica → silica ingested by alveolar macrophages → inflammation → fibrosis
What is the clinical presentation of silicosis? if simple → often asymptomatic, normal pulmonary function, often detected incidentally on CXR
if complicated → fatigue, weight loss, dyspnea, cough with sputum, tachypnea, prolonged expiration, wheezing, rhonchi, crackles, possible cor pulmonale, obstructive and restrictive pulmonary dysfuction, large conglomerate densities in upper lung
What is the diagnostic workup of silicosis? PFTS:
normal if simple
restrictive and obstructive pulmonary dysfunction if complicated
CXR:
silicotic nodules throughout lung → small rounded opacities
eggshell calcification → calcification of periphery of hilar lymph nodes
Eggshell calcification on CXR indicates? silicosis
What is the initial management, patient education, and prevention of silicosis? 1. treat symptoms
2. prevent further exposure
3. encourage smoking cessation
4. influenza and pneumococcal immunizations
5. PPD + current CXR (due to increased susceptibility to TB)
6. lung transplant
7. consult with pulmonologist
What is the etiology of asbestosis? long-term inhalation of asbestos fibers (typically 10-20 years)

associated with:
construction workers
shipyard workers
pipefitters
insulators
What is the clinical presentation of asbestosis? usually presents after 15 years
exertional dyspnea
progressive dyspnea
dry cough
inspiratory crackles
possible cyanosis and clubbing
possible cor pulmonale
What is the diagnostic workup of asbestosis? PFTs
restrictive pulmonary dysfunction
reduced diffusing capacity
CXR:
linear streaking at lung bases
diffuse interstitial fibrosis → opacities of various shapes and sizes
honeycombing if advanced
*pleural calcification

begins in lower lobes and subpleural areas

CT best imaging method for asbestosis

histology required for diagnosis → reveals asbestos bodies, ferruginous bodies
What is the initial management, patient educaiton, and prevention of asbestosis? 1. treat symptoms
2. refer to smoking cessation clinic → risk of bronchogenic carcinoma increases 5-fold for asbestos workers
3. advise on work-related causation and report to state or federal agency
4. influenza and pneumococcal immunizations
5. prescribe O2 if needed
6. frequency of FUVs, PFTs, and CXRs dependent on severity and functional impairment
7. risk of malignant mesothelioma (cancer of pleura or peritoneum) 1000 x greater than general population
What is the etiology of hypersensitivity pneumonitis? inhalation of organic antigens → acute illness

associated with: farmers, pigeon breeders, office workers
farmers lung → moldy hay
humidifier lung → contaminated humidifier, heating systems, air conditioners
pigeon-breeder's disease → bird serum and excrement
moldy sugarcane, redwood sawdust, compost, cork dust
detergent lung → enzyme additives
rotting maple tree
What is the clinical presentation of hypersensitivity pneumonitis? acute onset of fatigue, fever, chills, dyspnea, and cough
nausea after 4-8 hours
tachycardia, tachypnea, bilateral basilar crackles, possible cyanosis
What is the diagnostic workup of hypersensitivity pneumonitis? CBC → leukocytosis, shift to the left, antigens
PFTs → restrictive pulmonary dysfunction, reduced diffusing capacity
CXR → small nodular densities sparing apices and bases
What is the initial management, patient education, and prevention of hypersensitivity pneumonitis? 1. treated by identifying offending agent and avoiding further exposure
2. if severe or long duration → oral corticosteroids x 2 weeks
What is the etiology of psittacosis? recent contact (7-14 days) with bird infected with Chlamydophila psittaci
What is the clinical presentation of psitticosis? exposure 1-2 weeks prior
fever, HA, chills, dry cough, myalgia
atypical pneumonia → dullness to percussion, crackles
possible endocarditis
What is the diagnostic workup of psitticosis? complement-fixing antibodies present after 2 weeks
CXR → interstitial and diffuse
What is the management, patient education, and prevention of psitticosis? tetracycline x 2-3 weeks
What is the most prevalent chronic occuptational lung disease worldwide? silicosis
What is the etiology of histoplasmosis? 1. inhalation of fungal spores of histoplasma capsulatum by disturbing soil contaminated with bird or bat droppings
2. endemic areas include central and eastern U.S. → along river valleys → Ohio River and Mississippi River → 3. common in AIDs or immunocompromised patients
What is the etiology of histoplasmosis? Current ch36
What is the pathophysiology of histoplasmosis? inhalation of fungus spores → spores convert to small budding cells → budding cells ingested by alveolar macrophages → organisms proliferate and spread hematogenously
What is the pathophysiology of histoplasmosis? Current ch36
What is the clinical presentation of histoplasmosis? often asymptomatic and discoved incidentally on CXR
if mild → influenza-like infection x 1-4 days
if severe → fever, cough, sternal chest pain x 5-15 days

acute → prostration, fever, few pulmonary complaints
disseminated → AIDs or immunocompromised patients, prostration, fever, dyspnea, cough, weight loss, oropharynx ulcers, hepatosplenomegaly
What is the clinical presentation of histoplasmosis? Current ch36
What is the diagnostic workup of histoplasmosis? serum or urine antigen
CXR → if acute, CXR usually normal
What is the diagnostic workup of histoplasmosis? Current ch36
What is the initial management, patient education, and prevention of histoplasmosis? 1. if asymptomatic or mild symptoms → no treatment
2. if prolonged symptoms → itraconazole 6-12 weeks
3. if severe symptoms → amphotericin B x 1-2 weeks then itraconazole x 1 year
4. monitor treatment with periodic CXRs
2. if AIDs patient → itraconazole prophylaxis for life
What is the initial management, patient education, and prevention of histoplasmosis? Current ch36
What is another name for a solitary pulmonary nodule? coin lesion
What is the clinical presentation of a solitary pulmonary nodule? usually asymptomatic and detected incidentally on CXR or CT
What is the diagnostic workup of a solitary pulmonary nodule? CXR →
isolated round marginated opacity <3 cm in diameter
not associated with infiltrate, atelectasis, or adenopathy
What is the initial management of a solitary pulmonary nodule? 1. order CT
2. determine if low, medium, or high risk of malignancy
3. if low risk → observe, order serial CXR every 3 months x 2 years, resect if grows
4. if medium risk → biopsy
5. if high risk → resect

*management dependent on risk, contraindications to invasive procedures, and patient preference
What is the etiology of a solitary pulmonary nodule? 95% are:
infectious → granuloma
benign → hamartoma
malignant → primary

•Neoplastic (malignant or benign)
◦Bronchogenic carcinoma
■Adenocarcinoma (including bronchoalveolar carcinoma)
■Squamous cell carcinoma
■Large cell lung carcinoma
■Small cell lung cancer
◦Metastasis
◦Lymphoma
◦Carcinoid
◦Hamartoma
◦Connective-tissue and neural tumors - Fibroma, neurofibroma, blastoma, sarcoma

•Inflammatory (infectious)
◦Granuloma - TB, histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis, nocardiosis
◦Lung abscess
◦Round pneumonia
◦Hydatid cyst

•Inflammatory (noninfectious)
◦Rheumatoid arthritis
◦Wegener granulomatosis
◦Sarcoidosis
◦Lipoid pneumonia
•Congenital
◦Arteriovenous malformation
◦Sequestration
◦Bronchogenic cyst

•Miscellaneous
◦Pulmonary infarct
◦Round atelectasis
◦Mucoid impaction
◦Progressive massive fibrosis
How do you determine if low, medium, or high risk for malignancy for solitary pulmonary nodules? Establish if benign or malignant:
1. risk factors
-risk increases with age if >30y/o
-risk increases with number of cigarettes smoked per day
-risk increases with history of malignancy
2. size
2-5mm = 1% malignancy rate
6-10mm = 24%
11-20mm = 33%
21-45mm = 80%
>80% lesions >5mm are malignant
3. margination
-if smooth and well-defined, most likely benign
-if lobular and ill-defined on CXR, most likely malignant
-if spiculated (spiked) or peripheral halo on CT, most likely malignant
4. calcification pattern
-if dense calcification in diffuse, central, laminated, or popcorn pattern, most likely benign
-if sparse calcification in stippled or eccentric pattern, most likely malignant
5. cavitation
-both benign and malignant lesions cavitate
-if cavitary lesion with thick wall (>16mm), most likely malignant
6. location
-most malignancies located in upper lobes
7. doubling time
-review old radiographs
-if size doubles in <30 days, most likely infection
-if size doubles in >465 days, most likely benign
-most malignancies double in 6 weeks to 16 months
What is the ddx for a mediastinal mass? • masses may be caused by developmental, traumatic, infectious, cardiovascular or neoplastic disorders
• anterior compartment ddx = thymoma, teratoma, thyroid lesions, lymphoma, mesenchymal tumors (lipoma, fibroma)
• middle compartment ddx = lymphadenopathy, pulmonary artery enlargement, aortic aneurysm, developmental cyst (bronchogenic, enteric, pleuropericardial), dilated azygous or hemiazygous vein, foramen of Morgagni hernia
• posterior compartment ddx = hiatus hernia, neurogenic tumor, meningocele, esophageal tumor, foramen of Bochdalek hernia, thoracic spine disease, extramedullary hematopoiesis
What is the clinical presentation of a medistinal mass? • 50% of cases are asymptomatic and detected on routine CXR
• signs/symptoms are nonspecific and usually caused by effects of mass on surrounding structures
• insidious onset of dysphagia, dyspnea, and retrosternal chest pain
• physical exam findings vary depending on type and location of mass
What is the diagnostic workup of a mediastinal mass? • CXR
• barium swallow if suspected esophageal disease
• tissue biopsy if suspected neoplastic disorder
• other possibilities include CT, MRI, ultrasound, and angiography
What is the general management of a mediastinal mass? dependent on underlying cause of mediastinal mass
What is superior vena caval syndrome? clinical manifestation of superior vena caval obstruction → severe reduction in venous return from head, neck, and upper extremities
What is the etiology of superior vena caval syndrome? usually caused by malignant tumors:
lung cancer 85%
lymphoma → suspect if young adult
metastatic cancer → often breast or testicular cancer
other causes include benign tumor, aortic aneurysm, thyromegaly, thrombosis, and fibrosing mediastinitis
What is the clinical presentation of superior vena caval syndrome? facial and neck swelling
dyspnea
cough
other symptoms include pain, lethargy, HA, dizziness, syncopy, nasal congestion, epistaxis, tongue swelling, hoarseness, dysphagia, hemoptysis

symptoms may be aggravated by bending over or lying down

BP higher in upper extremities than lower extremities
cyanosis
edema of face, arms, and chest
dilated neck veins
increased number of collateral veins covering anterior chest wall
What is the diagnostic workup of superior vena caval syndrome? diagnosis made clinically

CXR may reveal superior RT mediastinal widening or RT pleural effusion
other options include CT and bronchoscopy
What is the general management of superior vena caval syndrome? Symptomatic treatment includes:
1. head elevation
2. diuretics
3. supplemental O2
4. low-salt diet

Treatment of underlying cause may include corticosteroids, radiation therapy, chemotherapy, surgery, or stenting
Grey pseudomembrane in posterior orpharynx indictes? diphtheria
Grey pseudomembrane in posterior orpharynx indictes? Mosbys p343
What is the etiology of bronchogenic carcinoma? 90% due to smoking
others include environmental tobacco smoke, radon gas, asbestos, industrial carcinogens

familial predisposition
increased risk with COPD, interstitial lung disease, sarcoidosis
What is the clinical presentation of bronchogenic carcinoma? night sweats
anorexia
weight loss
dyspnea
new cough or change in chronic cough
hemoptysis

clinical presentation depends on type, location, spread, metastasis
grey pseudomembrane → diphtheria
What is the diagnostic workup of bronchogenic carcinoma? CXR → enlarging nodule or mass; persistent opacity, atelectasis, or pleural effusion
pleural fluid
biospy
What is the prognosis of bronchogenic carcinoma? 41% survive first year
17% survive first 5 years
What is the prevention of bronchogenic carcinoma? do not smoke!
avoid environmental exposures!
What is the common name for bronchogenic carcinoma? lung cancer
What is the leading cause of cancer death? lung cancer
What should you order to assess ventilation? PFTs
What should you order to assess oxygenation? pulse oximetry
ABG
What does ABG stand for? arterial blood gas
What are the indications for ordering an ABG? dyspnea, tachypnea
suspected respiratory, renal, metabolic, or acid-base disorder
What are the components of an ABG? 1. arterial pH
2. plasma oxygen (PO2)
3. plasma carbon dioxide (CO2)
4. plasma bicarbonate (HCO3−)
5. base excess/deficit
6. anion gap
What is the procedure for performing an ABG? 1. perform Allen test
2. if patient on O2 → turn off O2 for 20-30 minutes before performing ABG for room air test or document amount of O2 being taken
2. draw blood from radial artery into syringe
3. place syringe on ice
4. deliver to lab immediately
Why must an ABG be transported on ice? to prevent continued in vitro changes in PaO2, PaCO2, and pH
Why must an ABG be transported on ice? Lab Data p.6
What is the normal range for blood pH? 7.34-7.45
If pH is ≤7.35, what is this called? acidemia
If pH is ≤7.35, what is this called? Interpreting Laboratory Data p179
If pH is ≥7.45, what is this called? alkalemia
If pH is ≥7.45, what is this called? Interpreting Laboratory Data p179
Is CO2 an acid or base? acid
True or false, obstructive pulmonary diseases decrease air flow and volume? false, only decrease air flow
True or false, obstructive pulmonary diseases decrease air flow and volume? Interpreting Laboratory Data p192
True or false, restrictive pulmonary diseases decrease air flow and volume? true
True or false, restrictive pulmonary diseases decrease air flow and volume? Interpreting Laboratory Data p192
What is the definition of FVC (forced vital capacity)? total volume of air exhaled as fast as possible after maximal inhalation
What is the definition of FVC (forced vital capacity)? Interpreting Laboratory Data p194
What is the normal FEV1? >80% of predicted normal value (based on gender, age, and height)
What is the normal FEV1? Interpreting Laboratory Data p194
For best results when performing spirometry ... Patient should:
loosen/remove restrictive clothing (ties, belts)
wear nose clip to minimize air loss through nose
sit/stand up straight
completely fill and empty lungs

There should be no:
hesitation/false start
coughing during first second
early termination
evidence of leak (mouth not tightly around mouthpiece)
evidence of obstruction (glottic closure, tongue, false teeth)
Is HCO3 an acid or a base? base
What is the normal range for PCO2? 35-45 torr
How would you describe the results of an ABG? acidosis or alkalosis?
respiratory or metabolic?
compensated or uncompensated?
What patient population should not be given O2? COPD patients
What radiographic views should be ordered for suspected airway obstruction/foreign body? PA view
lateral view
What radiographic views should be ordered for suspected pneumothorax? PA view
expiratory view
What radiographic views should be ordered for suspected pleural effusion? PA view
lateral decubitus view
What radiographic views should be ordered for suspected apical lung tumors? PA view
lordotic view
What are Kerley B lines? small linear opacities in periphery of lung
What are the characteristics of Kerley B lines? 1-2cm
water density
extend to pleura
perpendicular to pleura
represent increased fluid density in interlobar septa
What do Kerley B lines usually indicate? ↑ pulmonary venous pressure + pulmonary edema
What is the ddx for Kerley B lines? pulmonary edema 2° to CHF
pulmonary fibrosis
lymphangitis carinomatosis
What is the silhouette sign? chest imaging sign

characterized by loss of border between structures in thoracic cavity → density of structures is abnormally equal

helps to localize disease → lung, lobe, segment
What is the interpretation of silhouette sign? loss of LT heart border → LUL affected
loss of LT hemi-diaphragm border → LLL affected
loss of RT heart border → RML affected
loss of RT hemi-diaphragm border → RLL affected
silhouette sign

loss of RT heart border indicates RML affected

loss of RT hemi-diaphram border indicates RLL affected

RML/RLL pneumonia
What does PA stand for? posteroanterior
What does AP stand for? anteroposterior
Describe a PA view. film place against anterior (chest) of patient; x-ray beam shot from posterior (back) of patient to anterior (chest) of patient
Describe an AP view. film placed against back of patient; x-ray beam shot from anterior (chest) of patient to posterior (back) of patient
Which is better, AP view or PA view, and why? 1. PA view
2. heart and great vessels are situated more anteriorly
3. the closer the film is to structures, the less magnified and blurry those structures are
What is a portable CXR? AP CXR
film placed against back and x-ray beam shot from anterior to posterior
What are the indications for a portable CXR? patient incapable of standing or sitting for PA view
What are the limitations of a portable CXR? since shot anterior to posterior, film further away from anterior structures (i.e. heart, great vessels)
the further away film is from structures, the more magnified and blurry they become
thus heart is misleadingly magnified and heart borders are blurry
What is a lordotic view? CXR while patient leaning backwards
What is pulse oximetry? noninvasive inexpensive method to monitor O2 saturation of hemoglobin
When is the clinical accuracy of pulse oximetry decreased? 1. severe anemia <5g/dL
2. abnormal hemoglobin moieties → carboxyhemoglobin, methemoglobin, fetal hemoglobin
3. intravascular dyes
4. motion artifact
5. lack of pulsatile arterial flow → hypotension, hypothermia, cardiac arrest, simultaneous use of BP cuff

*pulse oximetry measures percent of bound hemoglobin but cannot distinguish the molecule that is actually bound (i.e. hemoglobin could be bound with carboxyhemoglobin following carbon monoxide poisoning and SaO2 would still be normal)
What are the indications for pulse oximetry? monitor oxygenation
What is polysomnography? sleep study
tracks how often a person stops breathing (apnea) or breathing is blocked (hypopnea)
What is bronchoscopy? bronchoscope inserted into nose or mouth to view airways

bronchoscope may be rigid with light attached or flexible with video equipment
What are the indications for ordering bronchoscopy? FLEXIBLE BRONCHOSCOPY:
1. evaluate airway
2. remove foreign bodies or retained secretions
3. diagnose pulmonary disorders
4. bronchoalveolar lavage
5. diagnose and stage bronchogenic carcinoma
6. lung biopsy
7. evaluate hemoptysis (though not very effective since blood gets everywhere!)

*contraindicated if severe bronchospasm or tendency to bleed

RIGID BRONCHOSCOPY:
1. massive bleeding
2. removal of large obstructing objects → foreign bodies, blood clots, broncholiths, tumors
3. lung biopsy
4. laser therapy
What is a ventilation and perfusion (VQ) scan? radiolabeled albumin injected into vein (to test perfusion) → patient breaths radioactive gas (to test ventilation) → distribution in lungs recorded
What are the VQ scan results for high probability of PE? reduced perfusion + normal ventilation
What are the indications for ordering a VQ scan? medium or high probability of PE
COPD
pre- and post-lobectomy
What are the indications for ordering a DDQ? DVT
PE (only order if low probability of PE, if high probability of PE just order VQ scan)
DIC
What is a DDQ? fibrin degradation product formed after a blood clot is degraded by fibrinolysis
What is a chloride sweat test? induce sweating by placing pilocarpine on skin, placing electrode over it, and applying weak electrical current → clean area → collect sweat for 30 minutes with filter paper → measure chloride
What are the indications for ordering a chloride sweat test? suspected CF
What is the gold standard for diagnosing CF? chloride sweat test
What chloride sweat test results indicate CF? PEDIATRIC:
≤29mmol/L = unlikely
30-59 mmol/L = possible
≥60 mmol/L = CF

ADULT:
≤39 mmol/L = CF
40-59 mmol/L = possible
≥60 mmol/L = CF
What are the indications for ordering polysomnography? suspected sleep apnea
How do you determine if there is appropriate inflation on a CXR? lungs should span 9 ribs
What is the anion gap? anion gap = Na+ - (Cl- + HCO3-)

number of unmeasured anions normally exceeds number of unmeasured cations

*anion = negative charged
*cation = positively charged
What does an increased anion gap indicate? increase in negatively charged weak acids
loss og HCO3- without concurrent increase in Cl-
bicarbonate consumed by unmeasured anion resulting in high anion gap

increased anion gap indicates certain types of metabolic acidosis

anion gap normal if metabolic acidosis caused by HCL production or excessive loss of bicarbonate

anion gap elevated if metabolic acidosis caused by diabetic ketoacidosis, methanol intoxication, etc. (metabolic acidosis that leads to excess anions not in anion gap calculation)
What is the base excess/deficit? base excess = amount of strong acid that must be added to blood to return pH to 7.4
What does an abnormal base excess/deficit indicate? abnormally high base excess = metabolic alkalosis
abnormally low base excess (i.e. base deficit) = metabolic acidosis
What are the indications for ordering PFTs? diagnostic, evaluation and monitoring of respiratory disease

diagnosis of asthma and COPD
monitoring after thoracic radiation, lung transplantation, drugs with potential lung toxicity
How is air flow affected in obstructive diseases? decrease flow of air but not volume
How is air flow affected in restrictive diseases? decrease flow and volume of air
What is forced vital capacity (FVC)? total volume of air exhaled as hard and fast as possible after maximal inhalation
What is forced expiratory volume in 1 second (FEV1)? amount of air exhaled after 1 second
What is the significance of the FEV1/FVC ratio? used to estimate presence and amount of airway obstruction

ratio indicates amount of air mobilized in 1 second as a percentage of total amount of movable air

normal = 50% in 0.5sec, 80% in 1sec, 98% in 3sec
What is FEF(25-75)? measures airflow rate during forced expiration from 25%-75% of vital capacity

25-75% is though to measure airflow in medium and small airways (bronchioles and terminal bronchioles)
What is peak expiratory flow rate (PEFR)? measure of maximum airflow rate (using peak flow meters)
What are the indications for peak flow meters (to measure peak expiratory flow rate)? peak flow meters are useful indications of large airway function → monitor airway obstruction in asthmatics
What is body plethysmography? method used to measure lung volume
patient sits in airtight box → told to inhale and exhale agaisnt a closed shutter → change in pressure measured during respiration → can calculate FRC, IC, RV, TLC
What is residual volume (RV)? volume of air remaining in lungs after forced expiration
What diseases have increased residual volume? COPD
What is inspiratory capacity (IC)? volume of air measured from beginning of inspiration to maximal inspiration
What diseases show increased/decreased functional residual volume (FRC)? INCREASED:
hyperinflation → airway obstruction → obstructive lung diseases

DECREASED:
pneumonia
restrictive lung diseases → pulmonary fibrosis
What is total lung capacity (TLC)? measure of total amount of gas in lungs at maximal inhalation
List 4 types of pharyngitis/tonsillits. 1. viral pharyngitis
2. group A beta-hemolytic streptococcal pharyngitis (GABHS)
3. mononucleosis
4. diphtheria
What are the FEV1/FVC, FEV1, FVC, RV, and TLC results for obstructive and restrictive lung diseases?
What is the air bronchogram sign? normally bronchi are not visible because they are filled with air and surrounded by air

if surrounding alveoli become filled with fluid, bronchi become visible as dark branching markings surrounded by abnormal white lung

may indicate pneumonia, pulmonary edema, or hemorrhage

lesion must be in lung!
What is the ddx for kerley B lines? pulmonary edema → often due to CHF
lymphangitic carcinomatosis
What is cephalization? upper lobe vessels increase in size compared to lower lobe vessels → pulmonary venous hypertension (only if patient erect when CXR taken due to influence of gravity)
"Bat wing" appearance on CXR indicates? pulmonary edema
List drug classes used to treat lung disease. short-acting beta agonists → all asthma, COPD; bronchodilator
inhaled corticosteroids → mild, moderate, severe asthma; anti-inflammatory
long-acting beta agonists → moderate, severe asthma; bronchodilator
systemic corticosteroids → severe asthma; anti-inflammatory
mast cell stabilizer → asthma prophylaxis; inhibitts histamine release
anticholinergics → COPD; inhibits Ach → bronchodilation
phosphodiesterase inhibitors → do not prescribe; bronchodilator
leukotreine modifiers → asthma prophylaxis; inhibits arachidonic acid pathway
List short acting beta agonists. albuterol
pirbutelol
terbutaline
levalbuterol
metaproterenol
What is the MOA of short acting beta agonists? B2 agonists → binding causes relaxation of airway smooth muscle → bronchodilation

effective in 5-30 minutes
last 4-6 hours
What is the MOA of long acting beta agonists? B2 agonists → binding causes relaxation of airway smooth muscle → bronchodilation

*analogs to albuterol but possess lipophilic side chain that increases affinity for B2-adrenoreceptors → increasing duration

last 12 hours
What is are the indications for SABA? prevention or treatment of bronchospasm in asthma
prevention of exericise-induced asthma
List antitubercular drugs. isoniazid
rifampin
pyrazinamide
ethambutol
What is the treatment protocol for TB? 1. if latent TB → treat with isoniazid x 9 months
2. if active TB → treat with isoniazid + rifampin + ethambutol + pyrazinamide x 2 months → then isoniazid + rifampin x 4 months
3. add more drugs if previous TB or suspected resistant TB
What is the treatment protocol for TB? Pharmacology p400
What is the MOA for isoniazid? inhibits enoyl acyl carrier protein reductase (InhA) and B-ketoacyl-ACP synthase (KasA) → inhibiting mycolic acid synthesis → inhibiting mycobacterial cell wall synthesis
What is the MOA for isoniazid? Pharmacology p400
What are the indications for isoniazid? latent TB
active TB
What are the indications for isoniazid? Drug Information Handbook p820
What are the side effects of isoniazid? hypersensitivity
peripheral neuritis (parasthesias of hands and feet)
hepatitis and idiosyncratic hepatotoxicity
inhibits metabolism of phenytoin → potentiating side effects of phenytoin → nystagmus, ataxia
What are the side effects of isoniazid? Pharmacology p401
What is the MOA of rifampin? inhibits mRNA synthesis (transcription)
What is the MOA of rifampin? Pharmacology p402
What are the indications for rifampin? active TB
meningitis prophylaxis

OFF LABEL:
h. flu prophylaxis
legionella pneumonia
leprosy
What are the indications for rifampin? Drug Information Handbook p1315
What are the side effects of rifampin? nausea
vomiting
rash
hepatitis (rare)
liver failure (rare)

*beware if elderly, alcoholic, or chronic liver disease
*make cause flu-like syndrome with fever, chills, myalgias
*sometimes associated with acute renal failure, hemolytic anemia, and shock
What are the side effects of rifampin? Pharmacology p402
What is the MOA of ethambutol? inhibits arabinosyl transferase → inhibiting mycoplasma cell wall
What is the MOA of ethambutol? Pharmacology p403
What are the indications for ethambutol? adjunctive treatment of active TB
other mycobacterial diseases
What are the indications for ethambutol? Drug Information Handbook p573
What are the side effects of ethambutol? optic neuritis → decreased visual acuity and loss of ability to discriminate red and green

decreased uric acid secretion → gout
What are the side effects of ethambutol? Pharmacology p403
What is the MOA of pyrazinamide? unknown
What is the MOA of pyrazinamide? Pharmacology p403
What are the indications for pyrazinamide? adjunctive treatment of active TB
What are the indications for pyrazinamide? Drug Information Handbook p1270
What are the side effects of pyranizamide? fatigue, nausea, vomiting, anorexia, myalgia, arthralgia
liver dysfunction
decreased uric acid secretion → gout
What are the side effects of pyranizamide? Pharmacology p403
What are the symptoms of acute theophylline overdose? MILD INTOXICATION:
nausea
vomiting
tachycardia
tremors

SEVERE INTOXICATION:
hypotension
seizures
supraventricular tachy arrhythmias
ventricular arrhythmias

ACUTE OVERDOSE:
hypokalemia
hyperglycemia
hypercalcemia
hyperphosphatemia
metabolic acidosis
What are the symptoms of acute theophylline overdose? Current ch38
Pharmacology p325
http://emedicine.medscape.com/article/818847-treatment
What is the management of acute theophylline overdose? 1. activated charcoal
2. if large ingestion involving sustained release preparations → whole bowel irrigation in addition to charcoal
3. benzodiazepines for seizures
4. B-blockers for hypotension and tachycardia
What is the management of acute theophylline overdose? Current ch38
http://emedicine.medscape.com/article/818847-treatment
What are the indications for varenicline (Chantix)? aid in smoking cessation
What are the indications for varenicline (Chantix)? Drug Information Handbook p1548
What is the MOA of varenicline? partial neuronal alpha4 beta2 nicotinic cholinergic receptor agonist → preventing nicotine stimulation of meso-limbic dopamine system associated with nicotine addiction

*stimulates dopamine secretion but too much smaller degree than nicotine → resulting in decreased craving and withdrawal symptoms
What is the MOA of varenicline? Drug Information Handbook p1548
What are the contraindications of varenicline? none
What are the contraindications of varenicline? Drug Information Handbook p1548
What are the adverse effects and interactions of varenicline? fatigue
HA
nausea
GI symptoms
insomnia
abnormal dreams/vivid nightmares
mood changes
suicidal thoughts

no interactions
What are the adverse effects and interactions of varenicline? Pharmacology p119
What is the patient education for varenicline? may cause sedation so do not drive or operate heavy machinery

if experience any behavioral or mood changes stop treatment and contact provider immediately
What is the patient education for varenicline? Drug Information Handbook p1548
What are the indications for prescribing buproprion? major depressive disorder
seasonal affective disorder
adjunct in smoking cessation
What are the indications for prescribing buproprion? Drug Information Handbook p223
What is the MOA of buproprion? inhibits reuptake of dopamine and norepinephrine
What is the MOA of buproprion? Pharmacology p145
What are the contraindications for buproprion? children
pregnancy
lactation
hypersensitivity
seizure disorder
anorexia/bulemia
use of MAO inhibitors with 14 days
abrupt discontinuation of alcohol or sedatives
What are the contraindications for buproprion? Drug Information Handbook p224
What are the adverse effects and interactions of buproprion? HA
tachycardia
insomnia
dizziness
weight loss
nausea
pharyngitis
dry mouth
sweating
nervousness
tremor
sexual dysfunction
seizures (increased risk at high doses)
What are the adverse effects and interactions of buproprion? Pharmacology p145
What are the indications for prescribing buproprion? major depressive disorder
seasonal affective disorder
adjunct in smoking cessation
What are the indications for prescribing buproprion? Drug Information Handbook p223
What is the MOA of buproprion? inhibits reuptake of dopamine and norepinephrine
What is the MOA of buproprion? Pharmacology p145
What are the contraindications for buproprion? children
pregnancy
lactation
hypersensitivity
seizure disorder
anorexia/bulemia
use of MAO inhibitors with 14 days
abrupt discontinuation of alcohol or sedatives
What are the contraindications for buproprion? Drug Information Handbook p224
What are the adverse effects and interactions of buproprion? HA
tachycardia
insomnia
dizziness
weight loss
nausea
pharyngitis
dry mouth
sweating
nervousness
tremor
sexual dysfunction
seizures (increased risk at high doses)

avoid concomitant use with MAO inhibitors, alcohol, antidepressants
What are the adverse effects and interactions of buproprion? Pharmacology p145
What type of drug is cromolyn? mast cell stabilizer
What are the indications for cromolyn? inhaled → prophylaxis for allergic disorders including asthma; prevention of exercise-induced bronchospasm

nasal → prevention and treatment of allergic rhinitis
What are the contraindications for cromolyn? hypersensitivity
acute asthma attacks
What is the MOA of cromolyn? inhibits degranulation after contact with antigens → preventing mast cell release of histamine and leukotrienes
What is the adverse effects and interactions of cromolyn? side effects low due to poor absorption
bitter taste
irritation of pharynx and larynx
What is the patient education for cromolyn? only for prophylaxis!
not for acute asthma attacks!
What is the patient education for use of metered dose inhalers? inhale SLOWLY and DEEPLY

if improperly inhaled → 80-90% deposited in mouth, pharynx, or swallowed → systemic absorption → increase in adverse effects

To use an MDI:

Shake the inhaler well before use (3 or 4 shakes)
Remove the cap
Breathe out, away from your inhaler
Bring the inhaler to your mouth. Place it in your mouth between your teeth and close you mouth around it.
Start to breathe in slowly. Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath.
Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.


If you need a second puff, wait 30 seconds, shake your inhaler again, and repeat steps 3-6. After you've used your MDI, rinse out your mouth and record the number of doses taken.
What is the patient education for use of dry powder inhalers? inhale QUICKLY and DEEPLY
"swish and spit" after use to prevent deposition on oral and laryngeal mucosa which can lead to hoarseness and candidiasis
What type of drug is theophylline? phosphodiesterase inhibitor
Describe theophylline. bronchodilator
narrow therapeutic window
lots of side effects and drug interactions
overdose may cause seizures and arrhythmias
List leukotriene modifiers. zarfirlukast
montelukast
zileuton
What are the indications for leukotriene modifiers? prophylaxis of asthma

NOT for acute asthma
What are the adverse effects and drug interactions of leukotriene modifiers? elevated liver enzymes → requires monitoring
Churg-Strauss
HA
dyspepsia
What are the indications for anticholinergics? oral inhalation → anticholinergic bronchodilator used in brochospasm associated with COPD

use in conjunction with SABA!

may cause reflexive bronchospasm
use with caution if myasthenia gravis, narrow-angle glaucoma, prostatic hyperplasia, or bladder neck obstruction
What is the MOA of anticholinergics? inhibits action of Ach at parasympathetic sites in bronchial smooth muscle → bronchodilation
List antiplatelets, anticoagulants, and thrombolytics used in the treatment of thrombotic/embolic cardiopulmonary disorders. ANTIPLATELETS:
aspirin
clopridogrel (Plavix)
ticlodopine (Ticlid)

ANTICOAGULANTS:
heparin
LMWH
warfarin

THROMBOLYTICS:
alteplase (Activase)
What is the clinical use of clopridogrel (Plavix)? MOA → antiplatelet
clinical use → reduces rate of atherothrombotic events
-unstable angina
-NSTEMI
-STEMI
-PAD
-stroke

*risk of bleeding
What is the clinical use of clopridogrel (Plavix)? Drug Handbook p356
What is the clinical use of warfarin? MOA → anticoagulant
clinical use
-thrombosis/embolism → DVT, PE
-reduce risk of embolic complications from atrial fibrillation or valve replacement
-reduce risk of systemic embolism following MI
What is the clinical use of warfarin? Drug Handbook p1570
What is the clinical terminology for lung cancer? adenocarcinoma of the lung
Pertussis

This is a young girl with whooping cough. You can hear her paroxysmal cough first without a whoop. Then you hear two more paroxysms, both followed by the distinctive whooping sound. It is the noise of breathing in, and comes from the larynx (voice box).
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