Step 3 Pulmonology II

• Nodules with high malignancy risk typically require surgical resection.Surgical resection may be curative when performed early in high-risk patients.
• Intermediate-risk nodules require serial computed tomography (CT) scans (less than 1 cm) or FDG-positron emission (PET) scan (more than 1 cm).
• Low-malignancy risk nodules can undergo serial CT scans.

• SIADH causes normovolemic hyponatremia.
• In SIADH, the urine is concentrated but the patient is not volume depleted.
• Initially, the symptoms are mild and nonspecific, but as the serum sodium declines (especially less than 120 mEq/L), neurologic symptoms, seizures, and coma may ensue.

• It occurs more often in construction and shipyard workers and generally occurs approximately 20 years after the initial exposure to asbestos.
• The condition is characterized by dyspnea on exertion, cough, chest tightness, and wheezing. Pulmonary fibrosis is evident on CXR or chest CT.

• The hyponatremia that arises in SIADH is secondary to the combination of water retention and the loss of sodium and potassium.
• In chronic SIADH, the loss of sodium is more significant than the amount of water retained.

• Unless there are neurologic symptoms arising from the hyponatremia, it should be corrected slowly with water restriction.
• Once water restriction is initiated, the plasma sodium concentration will slowly begin to normalize. An ideal rate of increase is 0.5 mEq/h.
• Patients must be simultaneously monitored for volume depletion as a sodium deficit may become apparent, requiring concomitant administration of salt.

• They work to blunt the response of the collecting tubule cells to ADH, ultimately increasing the excretion of water.
• These drugs are indicated in patients with persistent severe hyponatremia when water restriction, salt intake, or loop diuretics fail to resolve the condition.

• 1. All patients should be educated regarding the use of lung expansion maneuvers such as deep breathing exercises and incentive spirometry
• 2. All patients should be strongly urged to quit or stop smoking at least eight weeks prior to the planned surgery.
• 3. Patients with COPD should be treated aggressively to optimize their pulmonary function prior to the surgery.
• 4. Routine use of preoperative antibiotics is not indicated in a patient with an underlying stable chronic lung disease.

• Pulmonary artery hypertension often presents with similar symptoms as congestive heart failure.
• A loud S2, enlarged pulmonary arteries on chest imaging, and signs of right heart strain on EKG should all suggest pulmonary hypertension as the diagnosis.
• Echocardiography is the test of choice to confirm this suspicion, although other tests may eventually be necessary to determine the underlying cause.

• The treatment of pulmonary artery hypertension is typically directed towards the underlying cause.
• In patients where pulmonary artery hypertension is idiopathic, a vasoreactivity test can predict which patients will be responsive to calcium channel blockers.
• In patients with a negative vasoreactivity test, treatment is generally started with a prostanoid, endothelin receptor antagonist, or phosphodiesterase-5 inhibitor.

Pulmonary arterial pressure response to a vasodilator is measured with a right heart catheter; patients who respond favorably may be treated with a calcium channel blocker.

• Endothelin-1 is a potent vasoconstrictor, the levels of which are elevated in patients with IPAH.
• Endothelin receptor antagonists can increase exercise capacity, reduce dyspnea and improve cardiopulmonary hemodynamic variables in patients with idiopathic pulmonary arterial hypertension.

• It is the most common cause of hemoptysis.
• The best initial study in patients with hemoptysis is chest x-ray.
• A trial of antibiotic therapy is warranted while the patient is being evaluated for endobronchial lesions with bronchoscopy and CT scan.

• Confidentiality is one of the basic concepts of medical ethics.
• It underscores patient privacy and autonomy.
• Information about a patient's condition, including the information obtained by history taking and chart reviewing, should not be discussed with family and friends unless the patient authorizes you to do so.

• General public health issues (e.g., public officials and people at risk should be informed about cases of reportable infectious diseases)
• Cases wherein a third party can be potentially harmed (e.g., suicidal/homicidal patient or impaired drivers).

• It is a chronic granulomatous disease seen more frequently in young African-American patients.
• It is characterized by the formation of non-caseating granulomas in various involved tissues and organs.
• It usually involves the lungs, but can also involve other organ systems including the skin, lymph nodes, liver, spleen, eyes, exocrine glands (salivary and lacrimal glands), heart, kidneys, and central nervous system.

• Patients with pulmonary sarcoidosis usually present with cough, chest pain, or dyspnea.
• Some other nonspecific features include generalized weakness, lethargy, fever, and weight loss.
• The chest radiograph in patients with pulmonary sarcoidosis classically reveals bilateral hilar adenopathy with or without right paratracheal lymph node enlargement.

• The biopsy of tissues for confirmation of the diagnosis is not required in an asymptomatic patient with the typical history and chest x-ray findings.
• If indicated, the biopsy should be performed in the most easily accessible lesions or organs.
• Some of the potential sites for biopsy include lacrimal glands, salivary glands including parotid glands, skin lesions other than erythema nodosum, and palpable superficial lymph nodes.

• Recurrent bacterial infections in an adult patient may indicate a humoral immunity defect.
• Quantitative measurement of serum immunoglobulin levels helps to establish the diagnosis.
• Selective deficiency of lgG3 alone is more common in adult females and is associated with recurrent sinopulmonary as well as gastrointestinal infections.

• Symptomatic pulmonary disease is usually an indication for corticosteroid therapy in patients with sarcoidosis, especially if it is accompanied by systemic symptoms such as severe fatigue, fever and hypercalcemia.
• Severe extrapulmonary manifestations of sarcoidosis such as cardiac, ocular and neurologic involvement may require high-dose corticosteroid therapy.

• This hypersensitivity reaction to Aspergillus antigens is seen in patients with underlying asthma.
• When the airways of such patients become colonized with Aspergillus, the intense lgE and lgG mediated immune response leads to the characteristic recurrent episodes of fever, malaise, cough with brownish mucoid expectoration, wheezing, and symptoms of bronchial obstruction.

• 1. A history of asthma.
• 2. Immediate skin test reactivity to Aspergillus antigen.
• 3. Precipitating serum antibodies to Aspergillus fumigatus.
• 4. Serum total lgE concentration of greater than 1000 ng/ml.
• 5. Peripheral blood eosinophilia greater than 500 per cubic millimeter.
• 6. Lung infiltrates, usually involving the upper lobes.
• 7. Central bronchiectasis.

• A skin prick test for Aspergillus should be performed initially in all asthmatic patients suspected of having ABPA.
• If the skin prick test is positive, serum total lgE levels and precipitating serum antibodies to Aspergillus fumigatus should be measured.
• If the skin prick test is negative, the diagnosis of ABPA is extremely unlikely.

• Corticosteroids are the mainstay of therapy for patients with ABPA.
• Treatment with corticosteroids is effective in controlling the episodes of acute inflammation and preventing progressive lung fibrosis.
• The clinical response to treatment is measured by the reduction of serum total lgE concentration, clinical improvement and resolution of radiographic findings.

• Patients with diaphragmatic paralysis typically present with shortness of breath that is worse in the supine position, and as a result, it is easy to see how this symptom can erroneously lead to a cardiac workup.
• This difficulty with lying supine can lead to poor sleep, daytime fatigue, and morning headaches.
• Physical examination suggestive of diaphragmatic paralysis is paradoxical abdominal wall retraction during inspiration when the patient is lying supine, which occurs because the diaphragm is not contracting.
• A sniff test using fluoroscopy can be helpful in confirming the diagnosis.

• Current guidelines recommend CT·based screening beginning at age 55 for patients with a significant smoking history (ie, individuals with a 30-pack-year history and who either are current smokers or quit within the last 15 years).
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• Studies have shown that individuals who have not smoked for at least 15 years have an 80%-90% reduction in lung cancer risk when compared to current smokers.
• However, lung cancer risk remains elevated by 10%-80% in former smokers when compared to individuals who have never smoked.
• It reduces the risk of developing chronic obstructive pulmonary disease (COPD) and, in patients with COPD, reduces the risk of experiencing COPD exacerbations

• Current guidelines for the management of acute asthma exacerbation recommend use of supplemental oxygen (to maintain oxygen saturation more than 90%), short-acting bronchodilators (for significant dyspnea), and systemic corticosteroids.
• Similarly, there is no significant difference in the use of oral versus intravenous corticosteroids for asthma exacerbation (unless the patient cannot tolerate oral intake).
• Empiric antibiotics and chest x-ray would be indicated for patients with asthma exacerbation who have signs of concurrent pneumonia (eg, fever, crackles, dullness, egophony)

Patients with asthma exacerbation who are treated with systemic corticosteroids (eg, 3-10 days of a non tapering dose of prednisone with 40-60 mg per day for adults) have shown a decreased risk for relapse of asthma symptoms, future hospitalizations, and use of short-acting beta2-agonists.

• Risk of pulmonary complications is inversely related to the distance of the surgical site from the diaphragm. Studies have shown that smoking cessation at least 4 weeks prior to surgery decreases risk of postoperative pulmonary complications.
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• Popcorn calcifications, concentric or laminated calcifications, central calcifications and diffuse homogenous calcifications.
• Popcorn calcifications are characteristically seen on radiographic imaging in patients with pulmonary hamartoma.

Eccentric calcification (area of asymmetric calcification), as well as reticular or punctate calcifications, should raise the suspicion for a malignant pulmonary nodule.

• This can occur when an intracardiac communication like a patent foramen ovale or atrial septal defect is present and allows a dislodged venous clot to travel into the arterial circulation.
• These so-called paradoxical emboli are often responsible for embolic strokes in younger patients.
• A transthoracic or transesophageal echocardiogram with a bubble study will reveal such an intracardiac shunt.

• Asymptomatic pulmonary sarcoidosis generally does not need treatment.
• Hilar adenopathy associated with erythema nodosum represents a very favorable variant of sarcoidosis that is associated with a high rate of spontaneous remission and good prognosis.
• No treatment, except observation and periodic check ups, is usually necessary.
• Symptomatic patients and patients with decreased pulmonary function or progressive disease are typically treated with corticosteroids.

In the absence of histologic diagnosis, the presence of typical clinical examination (erythema nodosum) and radiographic findings (bilateral hilar adenopathy with or without right paratracheal lymph node enlargement ) is a reliable indicator for the diagnosis of sarcoidosis.

• The prognosis of patients with COPD varies with each individual.
• The two most important predictors of survival are FEV1 and age.
• After adjusting for age, FEV1 remains as the single most important factor in determining the prognosis.

• Asymptomatic patients or patients between episodes frequently have a normal lung function test at the time of their office visits.
• In such patients, one strategy for diagnosing asthma is to attempt to induce airflow obstruction by using a provocative agent.
• It is usually performed in a pulmonary function test lab with the use of methacholine.
• The fall in FEV1 of greater than 20% from the initial baseline value is considered a positive response.
• Bronchial provocative testing is very useful for the diagnosis of asthma in patients who have atypical symptoms of asthma (chronic cough).

Pulmonary function tests in patients with airflow limitation due to asthma typically reveal an obstructive pattern with reduced FEV1/FVC, and normal or elevated TLC and DLCO.