PE	Sx	Heart effect	⤵️ BP	Pt go to	Tx
Asx	ø	ø	ø	HOME	LMWH → Warfarin
Sx	⊕	ø	ø	Ward	LMWH → Warfarin
Submassive	⊕	⊕	ø	ICU	LMWH → Warfarin
Massive	⊕	⊕	⊕	ICU	tPA

Factors ⤴️ Malignant Probability

·       Large size (>2cm = 50% probability) ·       Advanced patient age ·       Female sex ·       Active or previous smoking hx ·       ⊕ FHX / PMHx ·       Upper lobe location ·       Speculated radiographic appearance (irregular borders)

	#	Site	Clx
Adecocarcinoma	40-50%	Peripheral	·       Clubbing ·       Hypertrophic Osteoarthropathy
SqCC	20-25%	Central	Hypercalcemia
Small cell	10-15%	Central	·       Cushing ·       SIADH ·       Lambert-eaton
Large cell	5-10%	Peripheral	Gynecomastia / Galactorrhea

Pancoast Tumor

• Shoulder pain (most common) • Horner syndrome (ipsilateral ptosis, miosis, enophthalmos & anhidrosis) from involvement of paravertebral sympathetic chain & inferior cervical ganglion • C8-T2 neurological involvement   o Weakness &/or atrophy of intrinsic hand muscles   o Pain & paresthesias of 4th & 5th digits, medial arm & forearm • Supraclavicular LN c • Weight loss

	Tumor type	Mechanism	Dx
PTHrP	·       SqCC ·       Renal & bladder cancer ·       Breast & ovarian	Mimics PTH	⤵️ PTH ⤴️ PTHrP
Bone metastasus	·       Breast ·       Multiple myeloma	⤴️ Osteolysis	⤵️ PTH & PTHrP ⤵️ Vit D
1,25 Vit D	·       Lymphoma	⤴️ Calcium Absorption	⤵️ PTH ⤴️ Vit D

Acute Respiratory Distress Syndrome
RF	Infection, trauma, massive transfusion, acute pancreatitis
Path	• Lung injury → fluid/cytokine leakage into alveoli • Impaired gas exchange, decreased lung compliance, PHTN
Dx	·       New/worsening respiratory distress within 1 week of insult ·       ⓑ lung opacities (pulmonary edema) not due to CHF/fluid overload ·       Hypoxemia with PaO2/FiO2 ratio ≤300
Tx	Mechanical ventilation (⤵️ TV, ⤴️ PEEP, permissive hypercapnia)

COPD
Features	·       Both emphysema and chronic bronchitis are manifestations of COPD. ·       Pulmonary function tests show obstructive physiology (reduced FEVI/FVC, increased RV and TLC) ·       DLCO is normal in chronic bronchitis and decreased in emphysema.
S/S	SOB – Productive Cough
Dx	Clx –> PFT
Tx	Stable pt: 1˚ Ipratropium 2˚  Albuterol (may precipitate HF through ⤴️ HF) 3˚ Theophyline –Stop smoking -Home O2 (Start if: PaO2 <55 / O2 <88%) -Vaccine: Pneumococcus q5 ys / Flu q1y Exacerbation 🚨 ·       Get: O2 Saturation + ABG + CXR ·       Give O2 ·       Ipratropium + Albuterol TOGETHER ·       Systemic Corticosteroids (PO = IV) ·       ABx If pt is on theophylline → check levels & DON’T D/C!

Acute Exacerbation of COPD
S/S	·       ⤴️ SOB ·       ⤴️ Cough (more frequent or severe) ·       Sputum (change in color or volume)
Dx	CXR: Hyperinflation ABG: Hypoxia, C02 retention (chronic &/or acute)
Tx	·       Oxygen (target Sp02 of 88%-92%) ·       Inhaled bronchodilators ·       Systemic GCS ·       Abx if? ≥2 cardinal sx ·       oseltamivir if? evidence of influenza ·       Non-invasive positive pressure ventilation if ventilatory failure ·       Tracheal intubation if NPPV failed or contraindicated

Asthma
Features	Reversible AW obstruction
S/S	Acute AW obstruction w/ SOB & Wheezing
Dx	·       Clx → PFT (Gold standard) ·       CXR: ⓝ
Acute Exacerbation Tx	·       1˚ O2 / SABA / ipratropium? ·       2˚ IV methylprednisone ·       3˚ (no improvement w/i 1 h) Mg ·       non-invasive positive pressure ·       If iminent resp failure → ICU + Intubation ·       If pt has ⓝ/⤴️ PaCO2 ·       Muscle fatigue ·       ⤵️  Breath sounds ·       Hypoxia ·       AMS
Chronic Tx

Bronchiectasis
Pathology	·       Recurrent infections + Impaired clearance ·       That leads to bacterial overgrowth & Nø infiltration → tissue damage & AW structural changes
Causes/RF	·       AW obstruction (Cancer) ·       Aotuimmune (RA, Sjögren), ·       Chronic infection (Aspergillosis, mycobacteria) ·       Immunodeficiency (Hypo-Ig) ·       Congenital (Cystic Fibrosis, alpha1-antitrypsin deficiency)
S/S	·       chronic daily cough ·       ⊕ a lot of pus produced ·       Rx Rhinosinusitis, SOB, hemoptysis ·       Crackles, wheezing
Dx	·       High Resolution CT scan of the chest (needed for initial diagnosis) ·       Immunoglobulin quantification ·       CF testing, sputum culture (bacteria, fungi & mycobacteria)

	Interstitial Lung Disease
Causes	• Vasculitis (eg, granulomatosis with polyangiitis) • Infections (eg, fungal, tuberculosis, viral pneumonia) • Occupational & environmental agents (eg, silicosis, Common hypersensitivity pneumonitis) • Connective tissue disease (eg, systemic lupus erythematous, scleroderma) • Idiopathic pulmonary fibrosis, interstitial pneumonia • Cryptogenic organizing pneumonia
S/S	• Progressive exertional dyspnea or persistent dry cough • Pulmonary findings due to other underlying conditions (eg, silicosis, connective tissue disease) • 50% of patients with significant smoking history • Lung examination with fine crackles during mid-late inspiration, possible digital clubbing
Dx	• CXR: reticular or nodular opacities • High-resolution chest CT: fibrosis, honeycombing, or traction bronchiectasis • PFTs: ⓝor ⤴️ FEV1/FVC ratio, ⤵️ DLCO, • Resting arterial blood gas can be normal or show mild hypoxemia • Exertion usually causes significant hypoxemia due to V/Q mismatch

	Sarcoidosis
#	African Americans
S/S	Pulmonary: ⓑ hilar LN I Interstitial infiltrates Skin ·       Papular, nodular, or plaque-like lesions ·       Erythema nodosum Ophtha: ·       Anterior/posterior uveitis ·       Keratoconjunctivitis sicca Hema: Peripheral LN ⊕ I HSM MSK: Acute polyarthritis (especially ankles) CVS: ·       AV block ·       Dilated or restrictive cardiomyopathy CNS: ·       7th CN Palsy ·       Central DI
Imaginc	ⓑ Hilar LN
Labs	·       ⤴️ Ca / ⤴️ Ca in urin ·       ⤴️ ACE level
Bx	Noncaseating granuloma
Tx	Steroids

	Obesity Hypoventilation Syndrome
Dx criteria	·       BMI ≥30 ·       Awake daytime hypercapnia (PaCO2 >45) ·       No altemate cause of hypoventilation
Work-up	·       ABG on room air (hypercapnia, normal A-a gradient) ·       No intrinsic pulmonary disease on chest x-ray ·       Restrictive pattern on PFTs ·       Normal TSH ·       Polysomnography
Tx	·       Noctumal positive-pressure ventilation as first-line therapy ·       Weight loss (bariatric surgery in select cases) ·       Avoidance of sedative medications ·       Respiratory stimulants (Acetazolamide) as last resort

	Asbestosis
RF	·       Prolonged Asbestos exposure (Shipyard, mining) ·       Sx develop ≥20 years after initial exposure
S/S	·       DRY COUGH  ·       Progressive SOB, ·       Basilar fine crackles, ·       Clubbing ·       ⤴️ Risk for Lung cancer & Mesothelioma
Dx	·       Pleural plaques on chest imaging ·       Imaging, PFT & histology consistent w/ pulmonary fibrosis

Sleep Apnea
features	·       Central vs. Obstructive: both when u wake up, no more apnea ·       What’s Central SA? no respiratory effort deriving from decreased CNS drive
PEx	·       In general, the physical examination is normal in patients with OSA, aside from the presence of obesity (body mass index: >30 kg/m2), an enlarged neck circumference (men: >43 cm [17 in]; women: >37 cm [15 in]), and hypertension. ·       ⤴️ Mallampati score:  difficult tracheal intubation ·       Narrowing of the lateral airway walls: Independent predictor of the presence of obstructive sleep apnea in men but not women ·       Enlarged -kissing- tonsils ·       Systemic arterial hypertension ·       CHF ·       pHypertension
S/S	Pt is not sleeping well, thus not refreshed from sleeping. ·       chronic fatigue: similar to narcolepsy ·       morning headache: specific to Central SA ·       loud snoring w/ periods of apnea: specific to OSA ·       PEx: hypertension
Dx	Sleep studies (Polysomnography) ·       ddx b/w Central vs. Obstructive ·       in central: no respiratory drive CBC: polycythemia (2˚ to chronic hypoxia –> ⤴️ EPO)
Tx	Pediatrics: ·       Weight reduction & adenotonsillectomy are the first line of management in appropriately selected children. Adults: ·       Non-medical: weight loss / ⤵️ Alcohol intake / ❌ Smoking ·       OSA: CPAP / Surgery: obstruction correction ·       If central sleep apnea: BiPAP Conservative ·       body positions during sleep (avoid supine position) ·       smoking cessation ·       Avoiding alcohol Pharmacotherapy ·       no much role ·       you can use modafinil as a stimulant Mechanical ·       Nasal CPAP: Standard treatment option ·       BiPAP Surgical ·       Uvulopalatopharyngoplasty ·       Craniofacial reconstruction with advancement of tongue or maxillomandibular bones ·       Tracheostomy
Complications	·       pulmonary HTN → Ⓡ HF ·       Systemic HTN ·       Arrhythmia –> cause of death

Pleural Effusion
Features	Excessive fluid in the pleural space
S/S	·       SOB ·       dullness to percussion ·       decreased breath sounds on the effusion ·       decreased tactile fremitus
DDx	Exudate Transudate Light Criteria P/S protein ratio >0.5 OR P/S LDH ratio >0.6 Not exudative Path Inflammation Hydrostatic or oncotic pressure ? ·       Infection (pneumonia) ·       Malignancy ·       Rheumatologic disease (SLE / RA) ·       CHF ·       Cirrhosis (hepatic hydrothorax) ·       Nephrotic syn
Tx	Depends on the u/c:  If pt has PNA → give ABx Procedural ·       Therapeutic thoracentesis →  if massive effusion and its affecting the patient’s breathing ·       Tube Thoracostomy → in complicated parapneumonic effusions or empyema

Parapneumonic effusions
	Uncomplicated	Complicated
Cause	Sterile exudate in pleural space	Bacterial invasion of pleural space
Fluid Analysis	• pH ≥7.2 • Glucose ≥60 • WBC ≤50,000	• pH <7.2 • Glucose <60 • WBC >50,000
Gram stain & Cx	⊖	⊖
Tx	Abx	Abx + drainage

	Transudate	Exudate
Protein (pleural/serum)	<0.5	>0.5
LDH (pleural/serum)	<0.6	>0.6
OR	Pleural LDH < two-thirds upper limit of normal serum LDH	Pleural LDH > two-thirds upper limit of normal serum LDH
Common causes	• Hypoalbuminemia (cirrhosis, nephrotic syndrome) • Congestive heart failure	• Infection (parapneumonic, TB, fungal, empyema) • Malignancy • PE

Pulmonary auscultation examination findings
	Breath sounds	Tactile Fremitus	Percussion	Mediastinal Shift
Normal Lung	·       Bronchial breathing centrally ·       Vesicular breathing peripherally	ⓝ	Resonance	ø
Consolidation (pneumonia)	⤴️	⤴️	dull	ø
Pleural Effusion	⤵️	⤵️	dull	Away from effusion
Pneumothorax	⤵️	⤵️	hyperresonance	Away from PTX
Emphysema	⤵️	⤵️	hyperresonance	ø
Atelectasis	⤵️	⤵️	dull	Toward atelectasis

#	Measures	🆎 in?
FVC	The difference between the volume of air in the lungs after maximal inspiration and after maximal expiration. (Air in lung: maximal inspiration – maximal expiration)	COPD
FEV1	The maximum volume of air that can be forcefully expired within 1 second after maximal inspiration	COPD
RV	Residual volume in lung	⤴️ COPD
TLC	Total lung capacity	⤴️ COPD
VC	Vital capacity is the maximum amount of air a person can expel from the lungs after a maximum inhalation.	⤵️  ILD + COPD

	COPD	Restrictive
FEV1	⤵️	ⓝ / ⤵️
FVC	⤵️	ⓝ
FEV1/FVC	⤵️	ⓝ / ⤴️
VC	⤵️	⤵️
RV	⤴️	⤵️
TLC	⤴️	⤵️
Compliance	ⓝ	⤵️

	Normal Spirometry	Obstructive	Restrictive
⤵️ DLCO	·       Anemia ·       PE ·       pHTN	Emphysema	·       Interstitial lung disease ·       Sarcoidosis ·       Asbestosis ·       HF
ⓝ DLCO		·        Chronic bronchitis ·       Asthma	·       MSK deformity ·       NM Disoder
⤴️ DLCO	·       Polycythemia ·       Pulmonary hemorrhage	Morbid Obesity	Morbid Obesity