2.3 Pulmonary
Key Takeaways
- Pulmonary is the second-largest PANRE category at 10% of scored content, emphasizing obstructive disease, infection, and acute respiratory emergencies.
- Asthma is reversible airflow obstruction managed by stepwise controller therapy centered on inhaled corticosteroids, while COPD is largely fixed obstruction confirmed by post-bronchodilator spirometry and managed with bronchodilators, inhaled steroids in selected patients, and smoking cessation.
- Community-acquired pneumonia management depends on severity and site of care, while suspected pulmonary embolism is risk-stratified before imaging and treated with anticoagulation unless contraindicated.
- Pleural effusions are characterized as transudative or exudative to direct the workup, and a tension pneumothorax is a clinical diagnosis requiring immediate decompression.
- Lung cancer, tuberculosis, interstitial lung disease, and respiratory failure each have characteristic patterns: screening and tissue diagnosis for cancer, isolation and multidrug therapy for active TB, and oxygenation-versus-ventilation reasoning in respiratory failure.
Why Pulmonary Is a High-Yield Block
The Pulmonary System is the second-largest PANRE category at 10% of scored content. The recertification emphasis is on common chronic disease control, recognizing infection severity, and acting fast on respiratory emergencies. Expect vignettes that ask you to interpret spirometry, stratify risk before imaging, choose first-line therapy, and decide level of care.
Asthma and COPD
Asthma is chronic airway inflammation with reversible airflow obstruction, presenting as episodic wheeze, cough, and dyspnea, often with triggers and diurnal variation. Spirometry showing obstruction that improves after a bronchodilator supports the diagnosis. Management is stepwise controller therapy built around inhaled corticosteroids (ICS), with reliever therapy and escalation (adding a long-acting bronchodilator and adjusting ICS intensity) based on symptom control and exacerbations. Acute exacerbations use inhaled bronchodilators, systemic corticosteroids, and oxygen as needed, with disposition based on response.
Chronic obstructive pulmonary disease (COPD) is largely fixed airflow obstruction confirmed by a post-bronchodilator reduced FEV1/FVC ratio on spirometry, typically in a patient with a significant smoking or exposure history. Maintenance therapy uses long-acting bronchodilators, with inhaled corticosteroids added in selected patients (for example, frequent exacerbations or an eosinophilic phenotype).
The single most important intervention is smoking cessation; vaccination and pulmonary rehabilitation reduce morbidity. Exacerbations are treated with bronchodilators, systemic corticosteroids, antibiotics when an infectious pattern is present, and controlled oxygen.
| Condition | Typical Presentation | PA-Level Management Focus |
|---|---|---|
| Asthma | Episodic, reversible wheeze/cough/dyspnea with triggers | Stepwise ICS-based controller therapy; treat exacerbations with bronchodilators and systemic steroids |
| COPD | Chronic dyspnea, smoking history, fixed post-bronchodilator obstruction | Long-acting bronchodilators, selective ICS, smoking cessation, vaccination, rehab |
| Community-acquired pneumonia | Fever, productive cough, focal findings, infiltrate on imaging | Severity-based site-of-care decision and appropriate empiric antibiotics |
| Pulmonary embolism | Acute dyspnea, pleuritic pain, tachycardia, hypoxemia | Risk-stratify, image appropriately, anticoagulate unless contraindicated |
Pneumonia
Community-acquired pneumonia (CAP) presents with fever, productive cough, focal lung findings, and an infiltrate on chest imaging. The key exam decision is severity and site of care (outpatient versus inpatient versus intensive care) using a validated severity assessment, which then drives empiric antibiotic selection appropriate to that setting and to patient-specific risk factors. Reassess clinical response and consider alternative or resistant pathogens when patients fail to improve.
Pulmonary Embolism
Suspect pulmonary embolism (PE) with acute dyspnea, pleuritic chest pain, tachycardia, or unexplained hypoxemia, particularly with venous thromboembolism risk factors. The exam reasoning sequence is pretest probability first, then targeted testing: a sensitive rule-out pathway (clinical decision rule with D-dimer when probability is low) versus definitive imaging such as CT pulmonary angiography when probability is higher. Treat confirmed or high-probability PE with anticoagulation unless contraindicated; hemodynamically unstable (massive) PE prompts consideration of reperfusion therapy and higher-level care.
Pleural Disease
Characterize a pleural effusion as transudative (favoring systemic causes such as heart failure) or exudative (favoring inflammation, infection, or malignancy) using fluid analysis to direct workup; symptomatic large effusions are drained for relief and diagnosis. A pneumothorax presents with sudden pleuritic dyspnea and decreased breath sounds; a tension pneumothorax (hypotension, tracheal deviation, severe distress) is a clinical diagnosis requiring immediate needle or tube decompression without waiting for imaging.
Lung Cancer
Lung cancer is suggested by a persistent cough, hemoptysis, weight loss, or an incidental nodule or mass, especially in patients with a substantial smoking history. Appropriate-population low-dose CT screening detects early disease; a suspicious finding requires tissue diagnosis and staging to guide multidisciplinary treatment. Smoking cessation counseling is part of every encounter.
Tuberculosis
Suspect active tuberculosis (TB) with chronic cough, fever, night sweats, weight loss, and risk factors. Active pulmonary TB requires airborne isolation, sputum testing, and multidrug antimycobacterial therapy with public-health reporting and contact investigation. Latent TB infection is a positive immunologic test (interferon-gamma release assay or tuberculin skin test) without active disease and is treated with an evidence-based latent-infection regimen after excluding active disease.
Interstitial Lung Disease and Respiratory Failure
Interstitial lung disease (ILD) presents with progressive exertional dyspnea, dry cough, fine inspiratory crackles, and a restrictive pattern with reduced diffusing capacity; identify and remove exposures and refer for specialist evaluation and possible antifibrotic or immunomodulatory therapy depending on subtype.
Acute respiratory failure is divided into hypoxemic (oxygenation problem) and hypercapnic (ventilation problem) types. The PANRE skill is matching the pattern to support: supplemental oxygen and treatment of the cause for hypoxemic failure, and ventilatory support (noninvasive or invasive) for hypercapnic or fatiguing patients, always while treating the underlying precipitant such as COPD exacerbation, pneumonia, or pulmonary edema.
A 26-year-old with episodic wheeze and nocturnal cough has spirometry showing airflow obstruction that significantly improves after a bronchodilator. Which describes the most appropriate long-term management approach?
A 65-year-old with a heavy smoking history and progressive dyspnea has post-bronchodilator spirometry showing a persistently reduced FEV1/FVC ratio that does not normalize. Which single intervention most improves the long-term course of this disease?
A patient develops acute pleuritic dyspnea, tachycardia, and unexplained hypoxemia after a long immobilization. Which reasoning sequence best reflects appropriate PANRE-level management of suspected pulmonary embolism?
A trauma patient becomes acutely hypotensive with severe respiratory distress, absent breath sounds on one side, and tracheal deviation away from that side. Which is the most appropriate immediate action?