This is dyspnea in a lateral decubitus position, suggesting unilateral lung disease
Trepopnea
This is dyspnea in thee upright position that is relieved with lying down
Platypnea
What can cause platypnea?
Hepatopulmonary syndrone
Right-left shunt
Cardiac abnormality (aortic aneurysm, pericardial effusion)
This is the softening and periungual erythema of the nail beds, increase in the normal 165 degree angle between the nail and the cuticle, enlargement of the distal phalynx, and curvature of the nails
Clubbing
You see a patient with clubbing and subperiosteal formation of new cancellous bone and the end of long bones (hypertrophic osteoarthropathy). What are you concerned about??
Lung carcinoma
There is circulatory bypass of the lung with localized acivation of platelet-endothelial cells and subsequent release of fibroblast growth factors, as well as tumor production and release of VEGF
What is the cause of the cough in the following patient example:
Frequent nasal discharge, sensation of liquid dripping down the back of the throat, frequent throat clearing
Upper airway cough syndrome
What is the cause of the cough in the following patient example:
Nonproductive cough that occurs after meals or worsens after lying down, may be accompanied by heartburn, bitter taste, belching
GERD
What is the cause of the cough in the following patient example:
Nocturnal cough, sputum can be thick and mucoid with casts
Asthma
What is the cause of the cough in the following patient example:
Cough productive of sputum on most days for >3 months for >2 years
Chronic bronchitis
What is the cause of the cough in the following patient example:
Cough with copious foul purulent dishcare, intermittent blood, influenced by posture
Bronchiectasis
What is the cause of the cough in the following patient example:
Sputum eosinophilia >3% of nonsquamous cells induced by nebulized hypertonic saline
Nonasthmatic eosinophilic bronchitis
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
1-2cm narrowing of the trachea at the thoracic inlet
Tracheal stenosis
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
> 50% decrease in cross-sectional area of lumen on dynamic expiratory images
Tracheobronchomalacia
Tracheobronchomalacia
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
Marked decreased in transverse diameter of intrathoracic trachea associated with increase in saggital diameter
Saber-sheather trachea
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
Calcified nodules protruding into the tracheal lumen and sparing of posterior membrane because of absence of cartilage in this area
Tracheobronchpathia osteochrondoplastica
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
Thickening of anterolateral tracheal wall with sparinng of posterior membrane
Relapsing polychondritis
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
With involvement of the tracheobronchial tree, concenntric/nodule thickening of the tracheal submucosa
Amyloidosis
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
Involvement of tracheobronchial tree is rare, usually late in course of disease, with circumfrential thickening, ulceration, and luminal narrowing
Granulomatosis with polyangiitis
Tell me the following tracheobronchial tree abnormality based on the following CT scan findings:
Thin wall trachea with scalloped/corrugated appearance , diameter >3cm, diverticulosis
Mounier-Kuhn syndrome
What is the cutoff value of FDG update to distinguish between benign and malignant tissue?
> 2.5 means likely malignant
knowing that infectious or inflammatory processes can give false positive results
What things can give false negative results on PET scan?
Carcinoid
Adenocarcinoma in situ
Nodules <10mm
What is the process to get a VQ scan done for the patienet?
Breath hold- give radiolabeled gas, ask to take breath and hold it, capture image
Equilibrium- 4 normal VT breaths
Washout- breath room air while radiolabeled gas is exhausted and image is taken (residual = air trapping)
For diseases that have a cystic pattern, which ones are predominant in the upper lobe, predominant in the lower lobe, and diffuse?
Upper lobe: Langerhans cell
histiocytosis
Lower lobe: Lymphocystic
interstitial pneumonia and
Birt-Hogg-Dubé syndrome
Diffuse:
Lymphangioleiomyomatosis
A patient undergoes a difficult central line placement. Ultrasound is used to evaluate the lungs after the procedure. Lung sliding is absent, with an A line- predominant pattern. What is the likely explanation for the ultrasound finding?
Pneumothorax
A decrease in FVC from upright to supine of >30% is an indicator of what?
Inspiratory muscle weakness
5-10% is normal but more than that means diaphragmatic weakness
A decrease in what value in FEV1 is abnormal in exercise challenge testing?
10-15%
A patient is receiving a long-acting anticholinergic and a methacholine test is ordered for further evaluation. How long should the medication be withheld before testing?
Up to 7 days
What happens to the following values in pregnancy:
ERV RV FRC TLC IC VC TV RR Minute ventilation FEV1 DLCO
ERV- ↓ by 8-40% RV - ↓ by 7-22% FRC - ↓ by 10-25% TLC - mild ↓ IC ↑ VC - no change TV- ↑ by 30-50% (progesterone mediated incnrease in central respiratory drive) RR - no change or mild ↑ Minute ventilation ↑ by 20-50% FEV1 - no change DLCO - ↑ then ↓
A 26-year-old woman is evaluated for dyspnea on exertion. PFTs show FEV1 84%, total lung capacity 96%, ERV 50%, FRC 76%, and DLCO 119%. These findings are most consistent with what diagnosis?
Obesity can cause a
reduction in ERV and FRC
and an increase in DLCO.
What happens to the slope in heart rate reserve (HRR) on the graph of HR vs VO2 in heart disease?
Increased slope and shifted to the left
What happens to the line in heart rate reserve (HRR) on the graph of HR vs VO2 in trained individuals?
Shifted to the right
True/False: in lung disease, maximal predicated heart rate is not achieved on CPET
TRUE
This is the relationship between ventilatory demand and ventilatory capacity
Ventilatory reserve (VR)
This is the peak minute ventilation achieived during exercise (VEmax)
Ventilatory demand
How is ventilatory capacity typically measured?
MVV
Which is measured by FEV1x40
What’s a normal VEmax/MVV?
70%
What happens to VE/VO2 and VE/VCO2 in normal subjects?
In those who are hyperventilating?
Normally VE/VO2 increases at AT and VE/VCO2 has a delayed increase
Hyperventilation - the two increase simultaneously
Tell me the disease process given the following CPET interpretation:
VO2max ↓ AT ↓ HRR normal O2 pulse ↓ VE/MVV nomral/↓ VE/VCO2 normal ↑ VD/VT ↑ PaO2 normal PAO2-PaO2 normal
Heart disease
Tell me the disease process given the following CPET interpretation:
VO2max ↓ AT normal/↓/absent HRR ↑ O2 pulse normal/↓ VE/MVV ↑ VE/VCO2 ↑ VD/VT ↑ PaO2 variable PAO2-PaO2 variable
COPD
Tell me the disease process given the following CPET interpretation:
VO2max ↓ AT normal/↓ HRR ↑ O2 pulse normal/↓ VE/MVV normal/↑ VE/VCO2 ↑ VD/VT ↑ PaO2 ↓ PAO2-PaO2 ↑
ILD
Tell me the disease process given the following CPET interpretation:
VO2max ↓ AT ↓ HRR normal O2 pulse ↓ VE/MVV normal VE/VCO2 ↑ VD/VT ↑ PaO2 ↓ PAO2-PaO2 ↑
PVD
Tell me the disease process given the following CPET interpretation:
VO2max ↓ (VO2/kg) AT normal HRR normal O2 pulse normal VE/MVV normal/↑ VE/VCO2 normal VD/VT normal PaO2 normal PAO2-PaO2 normal
Obesity
Tell me the disease process given the following CPET interpretation:
VO2max ↓ AT normal/↓ HRR normal O2 pulse ↓ VE/MVV normal VE/VCO2 normal VD/VT normal PaO2 normal PAO2-PaO2 normal
Deconditioned
Tell me the disease process given the following CPET interpretation:
VO2max ↓ AT normal or absent HRR ↑ O2 pulse ↓ VE/MVV ↓ VE/VCO2 normal VD/VT normal PaO2 normal PAO2-PaO2 normal
Poor effort
A 70-year-old man who is undergoing cardiopulmonary exercise testing for further evaluation of dyspnea on exertion has a reduced O2 pulse and an oscillatory pattern of changes on ventilation. What is the most likely diagnosis?
Congestive heart failure
A 78-year-old man who is undergoing cardiopulmonary exercise testing for evaluation of dyspnea has increased ventilator equivalents, increased VE/MVV ratio, and significant oxygen desaturation. Baseline spirometry results show no obstructive ventilatory impairment. What is the most likely diagnosis?
Interstitial lung disease
FYI, lots of basic IP and PFT stuff, which, at this point is
common sense