Chapter 2: Pulmonary System

Lung cancer paraneoplastic syndromes

" Small cell: SIADH, ACTH, Lambert Eaton Syndrome
" Squamous cell: PTH-rp
Sarcoidosis:
" Can have lots of extrapulmonary manifestations - anterior uveitis, splenomegaly, hepatomegaly, arthritis (esp
ankles), central
diabetes insipidus, erythema nodosum (inflammation of fat cells, especially on the shins - looks like large red bruises)
Warfarin goals: 6-12 months after PE and Afib - aim for 2-3. With prosthetic heart valves, go higher - 2.5 to 3.5. Over
4 presents a high
risk of bleeding
Pulmonary embolism
- S1Q3T3 pattern indicates right heart strain - present in 10% of PEs. Have S wave in lead I, Q wave and inverted T in
lead III
Pneumonia.
- First step is risk assessment: like CURB-65 algorithm. Give one point for confusion, uremia (BUN > 20), tachypnea
(RR > 30),
Blood pressure < 90/60, and age > 65.
- < 2 points outpatient. If CAP, give doxy or macrolide if otherwise healthy. If unhealthy, give floroquinolone
(levofloxacin or moxifloxacin) or beta lactam + macrolide
- If 2-3 points inpatient. If CAP, treat like an unhealthy outpatient
- If 4 or more poitns inpatient ICU for either IV beta lactam + macrolide or beta lactam + floroquinolone.
- Pneuomcystis jiroveci is an important cause of atypical pneumonia in immune compromised adults.
- Fever, dyspnea, nonproductive cough, diffuse interstitial infiltrate. Basically suspect if an ICed person has hypoxia
and dyspnea. Dx by inducing sputum production with hypertonic saline (best) or by bronchoalveolar lavage (good for
evaluation of malignancy and opportunistic infection)
- Legionella pneumonia - intracellular gram negative rod. Spread by water (e.g., cruise ships). Suspect if patient has
pneumonia with high fever, GI symptoms, and confusion, hyponatremia. Sputum gram stain will show neutrophils, but
no bugs.
Have to use charcoal agar or urinary antigen testing. Treat the same as other atypicals.
- Anaerobes: foul smelling sputum. Use clindamycin.
- Uncomplicated CAP:
- Treat for 5-7 days after fever resolves
Pleural effusion:
1. First step is to determine whether the PE is exudate or transudate - do a thoracentesis. The exception is if the
effusion is
clearly from CHF, then just give diuretics.
a. If any of the following are true, then its exudate: pleural protein/serum protein > 0.5, pleural LDH/serum LDH >
0.6, pleural LDH > the normal upper limit for serum LDH.
i. Shortcut: pleural protein > 3, LDH > 100, cholesterol > 45
b. Exudates are caused by increased capillary permeability, while transudates are from decreased oncotic pressure or
elevated hydrostatic pressure
c. Cirrhosis can cause right sided pleural effusion due to increased permeability of the right hemidiaphragm. Known
as
hepatic hydrothorax.
2. If exudate, then determine if its complicated, uncomplicated, or empyema
a. Empyema is purulent and has bacteria on gram stain
b. Look for glucose < 60, pH < 7.2 suggests bacterial infeection (complicated effusion), rheumatoid pleurisy, drug
induced lupus, tuberculosis, or malignancy. pH < 7.2 means that the fluid almost certainly has to be drained!
i. When the empyema is localized, complex, and has a thick rim, surgery is the only answer. Chest tube wont

do the trick.
c. PE can cause exudate or transudate, but will not affect the pH and glucose
Empyema:
Most often occurs from untreated pneumonia due to bacterial seeding of a pleural effusion. Initially the bugs are the
same as in the
pneumonia, but then a mixed aerobe/anaerboe picture develops - this is one reason why empyema is often
unresponsive to abx
ARDS:
- Oxygenate by increasing PEEP - up to 15 safe.
Drug induced lupus: hydralazine, procainamide, isoniazid. Can cause a picture suggestive of complicated pleural
effusion
COPD exacerbation: Give antibiotics if 2 of 3 of the following - increased dyspnea, cough, and sputum (volume or
color change),
moderate to severe exacerbation, or need for mechanical ventialation. Azithromycin, floroquinolones, or
penicllins/beta lactamases
Digital clubbing - not caused by COPD! Consider lung cancer, bronchiectasis (also seen in cystic fibrosis)
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Acute bronchitis
- Usually no fever - just sore throat, cough, maybe sputum - even bloody. Often viral, so abx arent indicated.
Hypertrophic osteoarthropathy = digital clubbing + sudden onset arthropathy - usually affecting the wrists and hands.
- Hypertrophic pulmonary osteoarthropathy = subset of the condition caused by underlying lung disease - cancer, TB,
bronchiectasis, or emphysema
Mediastinal masses
- Anterior: thymoma, retrosternal thyroid, teratoma. Can cause chest heaviness, discomfort, Horners syndrome,
hoarseness,
and facial and upper extremity edema
- Middle: Bronchogenic cysts, tracheal tumors, pericardial cysts, lymph node enlargement, and aortic aneurysm of the
arch
- Posterior: neurogenic tumors including meningocele, enteric cysts, diaphragmatic hernias, esophageal tumors, and
aortic
aneurysms
- Lymphoma - can be anywhere
Hypoxemia
- Caused by reduced inspired oxygen, hypoventilation, diffusion limitation, shunt, and V/Q mismatch
- Calculate the A-a gradient: Normal is < 15, over 30 is abnormal. Alveolar oxygen is 150-PaCO2/0.8. Then subtract
arterial
oxygen to get the gradient
- Elevated A-a gradient
- V/Q mismatch: pulmonary embolism, atelectasis, pleural effusion, pulmonary edema
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