Pulmonary Board Review 2006

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Pulmonary Board Review 2006

• Wissam Abouzgheib
• Thaddeus Bartter

2

• A 36 year-old woman presents to your office after
  coughing up 5 to 10 ml of bright red blood the
  previous day. Three days earlier she noted the
  onset of coryza and frequent nonproductive cough.
  She denies fever, chest pain, and dyspnea.The
  rest of ROS is negative Denies previous history
  of hemoptysis. She smoked 1 pack /day for 5
  years.
• Physical exam was normal
• Labs were Nl
• UA No erythrocytes, 40 WBC, 4
  bacteria, No proteins, No casts
• CXRay Nl
• The most appropriate diagnostic plan at this time
  is
• -fiberoptic Bronchoscopy
• -HRCT of chest
• -serum ANCA and antiGBM antibody
• -Repeat CXRay at 3 and 6 month

3

• A 36 year-old woman presents to your office after
  coughing up 5 to 10 ml of bright red blood the
  previous day. Three days earlier she noted the
  onset of coryza and frequent nonproductive cough.
  She denies fever, chest pain, and dyspnea.The
  rest of ROS is negative Denies previous history
  of hemoptysis. She smoked 1 pack /day for 5
  years.
• Physical exam was normal
• Labs were Nl
• UA No erythrocytes, 40 WBC, 4
  bacteria, No proteins, No casts
• CXRay Nl
• The most appropriate diagnostic plan at this time
  is
• -fiberoptic Bronchoscopy
• -HRCT of chest
• -serum ANCA and antiGBM antibody
• -Repeat CXRay at 3 and 6 month

4
Key Points

• Most common causes of hemoptysis in smoker and
  non smoker is acute viral bronchitis
• Bacterial infection in HIV
• Even small amounts should be investigated
• History and examination are important in
  diagnosis
• Initial test CXRay , lead the rest
• Bronchoscopy if gt40 pack-year, gt40 years age, gt30
  cc of blood daily or recurrent
• CT scan if bronchoscopy CI
• Massive hemoptysis (gt200 ml / 24 hrs)
• The cause of death is asphyxiation, not
  exsanguination
• protect airway, adequate o2
• bronchial artery embolisation especially
  if bronchiectasis

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What is causing hemoptysis in this 60 year old
with severe emphysema?
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What is causing hemoptysis in this 40 year old
with h/o chronic cough and bronchorrhea?
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For each patient select the most likely flow
volume loop

• 1 A 34 year old woman with dyspnea at rest
  and hoarseness after being intubated for 20 days
  for aspiration pneumonia .
• 2 A 70 year old woman who smoked 2 packs of
  cigarettes daily for 50 years and who had severe
  exertional dyspnea and diminished intensity of
  breath sounds on auscultation .
• 3 A 30 year old female with goiter .

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Intra thoracic
Extra-thoracic
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AIPF B COPD C
Pneumonectomy smoker
10
AIPF B COPD C
Pneumonectomy smoker
11
AIPF B COPD C
Pneumonectomy smoker
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AIPF B COPD C
Pneumonectomy smoker
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AIPF B COPD C
Pneumonectomy smoker
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Empyema

• Chest tube is indicated
• Purulent effusion
• pH lt 7.00
• Glucose lt 40
• LDH gt 1,000
• Positive gram stain

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• Analysis of Pleural Effusion without Phlebotomy
• An Exudate Possesses Any One of the Following
  Characteristics
• Pleural fluid LDH gt 45 of serum upper limit of
  normal, or Pleural fluid cholesterol gt 45 mg/dL,
  or Pleural fluid protein gt 2.9 g/dL

Light Criteria An Exudate Possesses Any One of
theFollowing Characteristics Pleural fluid
proteintoserum protein ratio ³ 0.5, or Pleural
fluid LDHtoserum LDH ratio³ 0.6, or Total
pleural fluid LDH level greater than two-thirds
the upper limit of normal for serum LDH
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A 41-year-old man with a long history of asthma
has increased wheezing over the past 2 months. He
was treated for pneumonia while on vacation a
month ago and still requires prednisone, 7.5
mg/d. His FEV l despite prednisone therapy, has
fallen 9 over the past 2 months. He notices that
his cough is more productive, and at times, forms
"casts" of his airways. He has increased sinus
complaints. His peripheral blood eosinophil
percentage is 11. His CT scan is shown What is
your diagnosis?
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• A-Hypersensitivity pneumonitis
• B-Chronic eosinophilic pneumonia
• C-Allergic bronchopulmonary aspergillosis
• D-Eosinophilic granuloma
• E-Lymphagioleiomyomatosis

19

• A-Hypersensitivity pneumonitis
• B-Chronic eosinophilic pneumonia
• C-Allergic bronchopulmonary aspergillosis
• D-Eosinophilic granuloma
• E-Lymphagioleiomyomatosis

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The Major Diagnostic Features of ABPA include

• History of asthma
• Immediate skin test reactivity to aspergillus
  antigens
• Precipitating serum antibodies to A. Fumigatus
• Serum total IgE concentration greater than 1000
  ng/ml
• Peripheral blood eosinophilia gt 500/mm3
• Lung infiltrates
• Proximal bronchiectasis
• Elevated serum specific IgG and IgA to A.
  Fumigatus

21
A

• A 28 yo HIV women with SOB, Pao2 of 62 and LDH
  of 1000
• Most common Bacteria involved in pulmonary
  superinfection after influenza infection
• Most common organism that infects the lungs of
  patient with PAP

B
C
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• A 28 year-old male smoker has had dyspnea on
  exertion for 6 months. Physical examination is
  unremarkable. PFTs demonstrate a mixed
  obstructive and restrictive ventilatory defect.
  BAL performed

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Pulmonary Langerhans cell histiocytosis
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Pulmonary Langerhans cell histiocytosis-Eosinophil
ic Granuloma

• Young adults 20-40 years old
• Equal gender, Caucasian predominance
• Symptoms non productive cough, dyspnea, chest
  pain
• Physical exam unremarkable
• Recurrent PTX, arteriopathy, Hemoptysis, DI,
  cystic bone lesions
• Radiographic ill defined nodules,
  reticulonodular infiltrates, upper zone cysts,
  costophrenic angle sparing
• PFTs Normal flow or restrictive with reduced
  DLCO

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Pulmonary Langerhans cell histiocytosis-Eosinophil
ic Granuloma

• Diagnosis BAL, TBbiopsy
• Treatment
• Smoking cessation
• Steroids and cytotoxic limited value

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• A 34-year-old woman has progressive dysp- nea
  and severe airflow obstruction (FEV1 34 of
  predicted). One year ago, she had an episode of
  hemoptysis.
• What is your diagnosis?

29
Lymphangioleiomyomatosis

• Women of childbearing age
• Caucasians
• Recurrent pneumothorax
• Chylous effusion
• Hemoptysis
• PFTs obstruction

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Lymphangioleiomyomatosis

• Radiographic normal, interstitiel opacities,
  honeycomb changes, hyperinflation
• TBbiopsy, VATS components of smooth muscle
• Treatment hormonal manipulation, oopherectomy,
  progesterone therapy, Lung transplantation

31

• A 70-year-old male former smoker has had
  progressive dyspnea and a nonproductive cough for
  18 to 24 months. Physical examination reveals
  bibasilar crackles and clubbing.

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• Diagnosis?

34
IPF - UIP

• Sporadic case, 5th or 6th decade
• Men/women 2/1
• Progressive dyspnea and non productive cough
• PFTs restrictive pattern with reduced DLCO

35
IPF - UIP

• Peripheral or subpleural
• Bibasilar reticulonodular opacities
• Architectural distortion with traction
  bronchiectasis
• Honey combing
• In the right clinical setting, radiographic
  findings may be sufficient

36

• A 68 year old retired automative mechanic who
  sandblasted radiators for 20 years. He has
  dyspnea on exertion and a chronic cough. He has
  restrictive lung volumes and abnormal gaz exchange

37
Silicosis

• Inhilation of silica
• Mining, Tunneling, Quarrying, Foundry,
  Sandblasting, Ceramics, Stone work
• Complications
• Progressive Massive Fibrosis
• Tuberculosis superinfection
• ? Increase lung cancer risk
• RA may increase the risk
• Radiographic predominance in the upper lobes
• Clinical diagnosis, open lung biopsy

38

• A 48 year-old bird fancier with 3 weeks of
  dyspnea, cough, and fever.

39

• Diagnosis?

40
Hypersensitivity pneumonitis

• Symptoms start 4-6 hours after exposure
• Fever, chills, sweats, dry cough and dyspnea
• No wheezing
• Resolves in 18-24 hours and recur on re-exposure
• Radiographic Upper or mid lobes, with diffuse
  micronodular and ground glass attenuation

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Hypersensitivity pneumonitis

• Diagnosis
• Exposure history, clinical and radiological
  findings
• Result of removal of the patient from the
  suspected etiologic exposure.
• Treatment
• Reduction of antigenic burden
• Protective devices
• Corticosteroids

42

• A 48 year-old metal machinist who has night
  sweats, chronic cough, and shortness of breath.
  Transbronchial lung biopsy specimen shows
  noncaseating granulomas and patchy interstitial
  fibrosis

43
Berylliosis

• Ceramic worker, beryllium processors, and some
  aerospace worker
• Beryllium lymphocyte transformation test
• Mimic sarcoidosis clinical, radiographic, and
  pathology

44

• A 70 year-old retired construction worker, a
  current smoker with dyspnea on exertion. He has
  bibasilar crackles on respiratory examination.

45
Asbestos

• Interval between exposure and bronchogenic
  carcinoma 15 to 35 years,
• malignant mesothelioma 30 to 40 years
• Pleural plaque is the most common related
  disorder
• Asbestos exposure alone increase the risk of lung
  cancer minimally
• Asbestos and smoking acts synergistically

46

• A 32 year-old woman presents with a 1-week
  history of painful, tender lumps overlying the
  pretibial regions, a low-grade fever, and
  polyarthritis primarily involving her ankles. A
  BAL performed is AFB stain negative.

47
Choose the correct statement

• Cutaneous involvement occurs in 80 of the cases
• Cutaneous sarcoidosis is associated with a good
  prognosis
• EN is associated with a good prognosis
• EN occurs in 30 of the cases with lorgrens
  syndrome

48
Correct statement

• Cutaneous involvement occurs in 80 of the cases
• Cutaneous sarcoidosis is associated with a good
  prognosis
• EN is associated with a good prognosis
• EN occurs in 30 of the cases with lofgrens
  syndrome

49

• A 62 year-old woman presents to the ER with
  cough, dyspnea, and low-grade fever. She is
  nonsmoker and had been healthy until 5 weeks ago,
  when she developed a viral syndrome associated
  with a paroxysmal cough.
• PE reveals inspiratory crackles in the left lower
  lobe. WBC13,000 differential is nl, c7 is nl.
  ESR elevated Sputum gram stain and AFB are
  negative.

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What is your Diagnosis?

• Chronic Aspiration
• Hypersensitivity pneumonitis
• Non Specific interstitiel pneumonia
• Crypotgenic organinzing pneumnia
• Sarcoidosis

52
What is your Diagnosis?

• Chronic Aspiration
• Hypersensitivity pneumonitis
• Non Specific interstitiel pneumonia
• Crypotgenic organinzing pneumonia
• Sarcoidosis

53
Cryptogenic organizing pneumonia or Boop

• 5th or 6th decade, menwomen
• Symptomatic for less than 2 months
• Persitent non productive cough, dyspnea on
  exertion, weight loss, crackles
• Leucocytosis, with elevated ESR
• Radiographic diffuse, bilat alveolar opacities,
  peripheral, migratory or recurrent.
• Diagnosis open lung biopsy
• Treatment steroids for 4 to 8 weeks

54
Distinguishing
Obliterative Bronchiolitis from Bronchiolitis
Obliterans
with Organizing Pneumonia (BOOP)
Manifestations
BOOP
Obliterative Branchiolitis. Focal alveolar
infiltrates
Typical
No Airways obstruction (on pulmonary
No (except function
testing)
in smokers)
Yes Intraluminal polypoid masses within
Typical
No bronchioles Organizing
pneumonia Typical- Response to corticosteroids

Excellent
Rare Prognosis
Excellent
Poor
55

• A 30 year-old man presents with hemoptysis,
  dyspnea, and generalised weakness. He has no
  sinus or upper airway symptoms. PE reveals pallor
  and bibasilar crackles.
• Hemoglobin 7.8 , creatinine 3, microscopic
  hematuria and hypoxemia.

56
Most likely Diagnosis?

• Goodpastures syndrome

57
How would you treat this patient

• Steroids
• Plasmapheresis
• Steroids and Plasmapheresis
• Cyclophosphamide
• Steroids plasmapheresiscyclophosphamide

58
How would you treat this patient

• Steroids
• Plasmapheresis
• Steroids and Plasmapheresis
• Cyclophosphamide
• Steroids plasmapheresiscyclophosphamide

59
A 34-year-old female medical technician is
referred to you with a diagnosis of asthma.
Despite initial Therapy with inhaled
corticosteroids and beta-agonists. she remains
symptomatic with cough and wheeze. The FEV1 is 78
of predicted and improves 13 after
albuterol. The most important next step in the
management of lis patient is A) Increase the
corticosteroid dosage B) Perform a methacholine
challenge C) Perform an inspiratory limb of a
flow-volume loop D) Add theophylline E) Add a
leukotriene receptor antagonist
60
A 34-year-old female medical technician is
referred to you with a diagnosis of asthma.
Despite initial Therapy with inhaled
corticosteroids and beta-agonists. she remains
symptomatic with cough and wheeze. The FEV1 is 78
of predicted and improves 13 after
albuterol. The most important next step in the
management of lis patient is A) Increase the
corticosteroid dosage B) Perform a methacholine
challenge C) Perform an inspiratory limb of a
flow-volume loop D) Add theophylline E) Add a
leukotriene receptor antagonist
61

• All that wheezes is not asthma
• Not all asthmatic wheeze
• Drug-induced bronchospasm
• Vocal cord dysfunction
• GERD
• Provocation inhalation challenge is used to
  detect latent asthma

62

• A 64-year-old man, a 38-pack-year smoker,
  presents with recent onset of pain in both knees
  and shins. Examination reveals clubbing,
  gynecomastia, tenderness of both shins, and mild
  expiratory slowing of lung sounds.

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Most likely diagnosis

• RA with pulmonary involvement
• IPF
• Cryptogenic organizing pneumonia
• Hypertrophic osteoarthropathy
• Acromegaly

65
Most likely diagnosis

• RA with pulmonary involvement
• IPF
• Cryptogenic organizing pneumonia
• Hypertrophic osteoarthropathy
• Acromegaly

66
Hypertrophic Pulmonary Osteoarthropathy

• Common Causes
• adenocarcinoma and large cell carcinoma of
  the lung
• idiopathic
• Radiographs of long bones
• Thickened and raised periostom
• Therapy
• Resection of the tumor
• Somatostatin analog
• Ipsilateral vagotomy

67

• A 65-year-old woman, a 100-pack-year smoker,
  develops progressive weakness.The serum potassium
  level is 2.3

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Paraneoplastic syndrome

• Caused mostly by primary tumor
• Does not indicate metastatic spread

70
Match

• SIADH
• ACTH production
• HPO
• Myasthenic syndrome
• 5. Hypercalcemia
• 6. Cerebellar ataxia

• Small cell carcinoma
• Squamous cell

71

• 19 y.o man presented to ER with SOB and chest
  tightness. Thin, Tall Guy. Current smoker, works
  in Wawa store in Camden
• Test?

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20 PTX
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First episode, What is the correct answer
regarding best management of this patient?

• A. Observation with oxygen supplementation, rate
  of re-absorption 5/ day, rate of recurrence
  similar to general population
• B. Video-assisted thoracoscopy for pleurodesis
  and bullae wedge resection
• C. Tube thoracostomy with talc pleurodesis
• D. Tube thoracostomy with doxycycline pleurodesis
  once air leak resolves
• E. Admit him, Tube thoracostomy without
  pleurodesis till air leak resolves

76
First episode, What is the correct answer
regarding best management of this patient?

• A. Observation with oxygen supplementation, rate
  of re-absorption 5/ day, rate of recurrence
  similar to general population
• B. Video-assisted thoracoscopy for pleurodesis
  and bullae wedge resection
• C. Tube thoracostomy with talc pleurodesis
• D. Tube thoracostomy with doxycycline pleurodesis
  once air leak resolves
• E. Admit him, Tube thoracostomy without
  pleurodesis till air leak resolves

77
While preparing for chest tube insertion, he
informs you that hes planning to be a flight
attendant

• A. Observation with oxygen supplementation, rate
  of re-absorption 5/ day, rate of recurrence
  similar to general population
• B. Video-assisted thoracoscopy for pleurodesis
  and bullae wedge resection
• C. Tube thoracostomy with talc pleurodesis
• D. Tube thoracostomy with doxycycline pleurodesis
  once air leak resolves
• E. Admit him, Tube thoracostomy without
  pleurodesis till air leak resolves

78
While preparing for chest tube insertion, he
informs you that hes planning to be a flight
attendant

• A. Observation with oxygen supplementation, rate
  of re-absorption 5/ day, rate of recurrence
  similar to general population
• B. Video-assisted thoracoscopy for pleurodesis
  and bullae wedge resection
• C. Tube thoracostomy with talc pleurodesis
• D. Tube thoracostomy with doxycycline pleurodesis
  once air leak resolves
• E. Admit him, Tube thoracostomy without
  pleurodesis till air leak resolves

79

• A 59-year-old man is evaluated for snoring,
  abnormal motor behavior during sleep, daytime
  somnolence, systemic hypertension, and morning
  headaches.

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His polysomnography study is shown
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" For each numbered hemodynamic profile, select
the most likely etiology of shock. SBP
RAP PAP
PAOP C1 (mm Hg)
(mm Hg) (mm Hg) (mm Hg)
(L/min/m2) 1 90/68 18
36/24 22
1.8 2 90/46 5
22/8 6
4.7 3 88/40
20 22/16
7 2.2 4 84/60
3 18/6
5 1.8 5 90/68
18 32/18
17 1.8 a. Severe
hemorrhage b. Pneumococcal sepsis c.
Anterolateral myocardial infarction d. Cardiac
tamponade e. Right ventricular myocardial
infarction
85

• A 24 -year-old woman develops sepsis and ARDS
  postpartum. She has been stable with mechanical
  ventilation . The ventilator setting are
  Fio20.6 TV800ml RR24/min PEEP10 cm H2O
• You are consulted by the nurse because the
  patient is suddenly anxious and agitated.
• Measurements during controlled breaths
• Peak airway pressure 55 cm H2O
  (baseline35)
• Plateau airway pressure 50 cm H2O
  (baseline 30)
• Tidal Volume 720 ml (baseline 768 ml)
• What is the most important next step in the
  management of this patient
• Sedation with midazolam and observation of
  patient
• Stat portable chest radiography
• Endotracheal suctioning and reassessment of
  patient
• Stat electrocardiogram
• Increase the ventilatory rate to 28/min and
  rassessment in 30 minutes

86

• A 24 -year-old woman develops sepsis and ARDS
  postpartum. She has been stable with mechanical
  ventilation . The ventilator setting are
  Fio20.6 TV800ml RR24/min PEEP10 cm H2O
• You are consulted by the nurse because the
  patient is suddenly anxious and agitated.
• Measurements during controlled breaths
• Peak airway pressure 55 cm H2O
  (baseline35)
• Plateau airway pressure 50 cm H2O
  (baseline 30)
• Tidal Volume 720 ml (baseline 768 ml)
• What is the most important next step in the
  management of this patient
• Sedation with midazolam and observation of
  patient
• Stat portable chest radiography
• Endotracheal suctioning and reassessment of
  patient
• Stat electrocardiogram
• Increase the ventilatory rate to 28/min and
  rassessment in 30 minutes

87
Ppeak Resistance x Elastance Pplateau
Elastance Ppeak - Pplateau Airflow
Resistance
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• A 68-year-old man, a 56-pack-year smoker,
  undergoes bronchoscopy under topical anesthesia
  for evaluation of streak hemoptysis. One hour
  after he notices bluish discoloration of his
  finger and lips. He has minimal dyspnea and his
  vitals are normal.
• ABGs Pao2 86 Paco2 46 PH 7.38 Sao2 56
• A. Polycythemia from copd
• B. Methemoglobinemia
• C.Right to left anatomical shunt
• D.shock

90

• A 68-year-old man, a 56-pack-year smoker,
  undergoes bronchoscopy under topical anesthesia
  for evaluation of streak hemoptysis. One hour
  after he notices bluish discoloration of his
  finger and lips. He has minimal dyspnea and his
  vitals are normal.
• ABGs Pao2 86 Paco2 46 PH 7.38 Sao2 56
• A. Polycythemia from copd
• B. Methemoglobinemia
• C.Right to left anatomical shunt
• D.shock

91
Pearls

• Sore throat
• Amoxicillin
• Rash
• Infectious mononucleiosis

92
Pearls

• Recurrent sinusitis
• Non responsive to adequate therapy
• Check Immunoglobulins

93
Pearls

• When you suspect tuberculous pleural effusions,
  all pleural fluid workup is non diagnostic, next
• Pleural Biopsy

94
Pearls

• Tuberculosis prophylaxis in an area with less
  than 4 resistance to INH
• INH for 9 months

95
Pearls

• Two simple maneuvers to decrease auto peep
• Decrease TV or RR

96
Pearls

• Vocal cord dysfunction
• Gold standard test
• Fiberoptic laryngoscopy

97
Pearls

• Mild obstructive lung disease
• Colon Cancer
• Next step before OR
• Nothing ! Let him go

98

• GOOD LUCK !