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Study guide

High-Yield Pulmonology for the PANCE

Pulmonary is one of the most heavily weighted PANCE organ systems (~10% of the blueprint), with obstructive disease, infections, pulmonary vascular disease, and neoplasms dominating. This guide targets the highest-yield diagnostic thresholds, first-line therapies, and current guideline updates.

Obstructive Disease: Asthma & COPD

  • ◆COPD diagnosis requires a POST-bronchodilator FEV1/FVC < 0.70 on spirometry; classify airflow-limitation severity by FEV1 % predicted (GOLD 1-4), then group by symptoms + exacerbation history (GOLD groups A/B/E).
  • ◆Only smoking cessation and supplemental O2 (for resting hypoxemia, PaO2 <=55 or SpO2 <=88%) reduce COPD mortality; titrate O2 to SpO2 88-92% to avoid CO2 retention.
  • ◆COPD exacerbation: SABA/SAMA nebs + prednisone 40 mg PO x5 days + antibiotic (azithromycin, doxycycline, or augmentin) if increased sputum purulence/volume or need for mechanical ventilation. Per GOLD, blood eosinophils >=300 favor ICS-containing maintenance therapy.
  • ◆Asthma acute exacerbation: albuterol +/- ipratropium, systemic steroids (prednisone 40-60 mg), and O2; add IV magnesium for severe/refractory attacks. Falling/normalizing PCO2 in a distressed asthmatic signals impending respiratory failure.
  • ◆Maintenance asthma per GINA: low-dose ICS-formoterol as combined reliever/controller (SMART, GINA Track 1) is preferred over SABA-alone across steps 1-2 and continues through step 5; step up to daily ICS-LABA maintenance. Long-acting agents (LABA/LAMA) are never used as monotherapy for asthma.

Community-Acquired Pneumonia

  • ◆Diagnosis is clinical + infiltrate on CXR; use CURB-65 (Confusion, Urea >19, RR >=30, BP <90/60, age >=65) or PSI to triage inpatient vs outpatient.
  • ◆Outpatient, no comorbidities (2019 IDSA/ATS): amoxicillin 1 g TID, doxycycline, OR a macrolide only if local pneumococcal resistance <25%.
  • ◆Outpatient WITH comorbidities: beta-lactam (augmentin or cefpodoxime) PLUS macrolide/doxycycline, OR respiratory fluoroquinolone (levofloxacin/moxifloxacin) monotherapy.
  • ◆Inpatient (non-ICU): beta-lactam + macrolide OR respiratory fluoroquinolone; ICU: beta-lactam + macrolide OR beta-lactam + fluoroquinolone. Cover MRSA/Pseudomonas only with validated risk factors.
  • ◆Classic associations: Legionella (hyponatremia, diarrhea, high fever, water exposure), Mycoplasma (young, walking pneumonia, bullous myringitis), Klebsiella (currant-jelly sputum, alcoholism).

Pulmonary Embolism & VTE

  • ◆Risk-stratify with Wells score; PERC rule can exclude PE in low-risk patients without further testing. Low/intermediate probability -> D-dimer; high probability -> straight to CT pulmonary angiography.
  • ◆CTA is the diagnostic gold standard; use V/Q scan when contrast is contraindicated (renal failure, contrast allergy).
  • ◆ECG most commonly shows sinus tachycardia; S1Q3T3 is classic but insensitive. Look for unilateral leg swelling and pleuritic chest pain.
  • ◆First-line treatment for hemodynamically stable PE/DVT is a DOAC (apixaban or rivaroxaban)- no bridging needed for these agents.
  • ◆Massive PE with hypotension/shock -> systemic thrombolytics (tPA/alteplase) unless contraindicated; consider embolectomy if thrombolysis fails or is contraindicated.

Pleural Space & Airway Emergencies

  • ◆Tension pneumothorax is a CLINICAL diagnosis (hypotension, tracheal deviation, absent breath sounds, distended neck veins)- treat with immediate needle decompression (5th ICS anterior/mid axillary line preferred in adults, or 2nd ICS midclavicular) then chest tube; do NOT wait for CXR.
  • ◆Primary spontaneous pneumothorax: tall thin young male smoker. Current guidelines (BTS 2023, ERS/EACTS/ESTS 2024) prioritize symptoms/high-risk features over size- minimally symptomatic, clinically stable patients can be managed conservatively regardless of size; if intervention is needed, needle aspiration is preferred over chest tube, with chest tube for high-risk features (hemodynamic compromise, significant hypoxia, bilateral, underlying lung disease, hemopneumothorax).
  • ◆Light's criteria define EXUDATE if any: pleural/serum protein >0.5, pleural/serum LDH >0.6, or pleural LDH > 2/3 upper normal serum limit. Transudates = CHF, cirrhosis, nephrotic syndrome; exudates = infection, malignancy, PE.
  • ◆Parapneumonic effusion with pH <7.2, glucose <60, or frank pus (empyema) requires chest tube drainage plus antibiotics.

Tuberculosis & Screening

  • ◆Latent TB: positive IGRA or TST with no symptoms and normal/stable CXR; preferred treatment is rifamycin-based short courses- 3HP (isoniazid + rifapentine weekly x12 wks), 3HR (daily INH + rifampin x3 mo), or 4 months daily rifampin.
  • ◆Active TB (RIPE): Rifampin, Isoniazid, Pyrazinamide, Ethambutol x2 months, then rifampin + isoniazid x4 months; always add pyridoxine (B6) with INH to prevent neuropathy.
  • ◆Drug toxicities to know: INH/rifampin/pyrazinamide -> hepatotoxicity; ethambutol -> optic neuritis (red-green color vision); pyrazinamide -> hyperuricemia; rifampin -> orange body fluids + CYP450 induction.
  • ◆Airborne isolation for suspected active pulmonary TB; confirm with sputum acid-fast smear/culture and NAAT. Upper-lobe cavitary disease is classic for reactivation.

Neoplasms, ARDS & Pediatric Pearls

  • ◆Lung cancer screening (USPSTF 2021): annual low-dose CT for adults 50-80 yrs with >=20 pack-year history who currently smoke or quit within 15 years.
  • ◆Small cell lung cancer is central, aggressive, and paraneoplastic (SIADH, ectopic ACTH, Lambert-Eaton)- treated with chemo/radiation, not surgery. Non-small cell (adeno = peripheral, most common; squamous = central + hypercalcemia/PTHrP) may be surgically resectable if early.
  • ◆ARDS (Berlin criteria): acute onset <=1 wk, bilateral infiltrates, not fully explained by cardiac failure/fluid overload, PaO2/FiO2 <=300 with PEEP >=5. Manage with LOW tidal volume 6 mL/kg ideal body weight (lung-protective ventilation) and plateau pressure <30.
  • ◆Bronchiolitis (RSV, <2 yr): wheeze/tachypnea, supportive care (suction, hydration, O2); bronchodilators/steroids NOT routinely recommended.
  • ◆Croup (parainfluenza): barky cough, steeple sign -> dexamethasone (all severities) + nebulized racemic epinephrine if stridor at rest. Epiglottitis (now often nontypeable H. flu): tripod, drooling, thumbprint sign -> secure airway, do not agitate.
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