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Pulmonary Rotation ACNP Cheat Sheet by

ACNP Student Pulmonary Rotation

Asthma (Obstr­uctive Disease)

Infl­amm­atory condition of the airways
hype­rre­spo­nsi­ven­ess leading to airway edema + bronch­­oc­o­n­st­­ric­­tion
• Recurr­ent­/in­ter­mittent episodes of wheezing, shortness of breath, and/or cough
• Usually reve­rsi­ble either sponta­neously or with treatment.
Atopy (IgE mediat­ed) + Enviro­­nm­ental triggers (aller­­gens, irritants, chemicals, respir­­atory infect­­ions, physical stress, and emotional stress).
Reve­rsible bronch­­oc­o­n­st­­ric­tion on own or with bronch­­od­i­lator and a history. Consider challenge test
Interm­­it­tent, mild persis­­tent, moderate persis­­tent, and severe persistent
• GERD, Allergic rhinitis
• Worsened by Allergic bronch­opu­lmonary asperg­illosis (ABPA), Obstru­ctive sleep apnea-­hyp­opnea (OSA), Stress


• Normal if no active disease.
FEV1/FVC < 70%
• Decreased expiratory flow
Sign­­if­­­icant response to beta2-­­­a­g­o­­n­­ist.
• Normal or increased TLC (due to hyperi­­­n­f­l­­a­­tion).
• Normal or reduced VC.
• DLCO is normal.
Exerci­­­se­ induced bronch­­­o­spasm
Decrease in FEV1 of >10% on a treadmill or a stationary bicycle.
Normal in mild cases. Severe asthma shows hyperi­­nf­l­a­ti­­on.
Arterial Blood Gas
• Indicated in respir­­atory distress.
• Hypo­c­ar­bia from hype­r­ve­­nti­­la­t­ion.
• Hypoxemia may be present.
• If CO2 level is normal or high sign that the patient is deco­m­pe­­nsating due to fatigue or severe airway obstru­­ction and intu­bat­ion may be required.
Challenge Test
•Metha­choline challenge, histamine challenge, and thermal (cold air). Principle of nonspe­cific hyperi­rri­tab­ility.
Must both tighten up with the challenge and loosen up with subsequent bronchodilators.
• Response to short-­­acting bronch­­od­i­lator (inc­rease in the FEV1 > 12% and increase of 200 mL).


SABA (albut­­erol)
Quick relief (acute, mild, interm­­ittent disease)
• Short-­­acting beta2-­­ag­o­nists (SABAs)
• Systemic cortic­­os­t­e­roids
• Antich­­ol­i­n­ergics
Long-Term control
Inhaled cortic­­os­t­e­roids (ICS; most potent and most effective)
• Long-a­­cting beta2-­­ag­o­nists (LABAs)
• Mast-cell stabil­­izers (cromolyn sodium +nedoc­­romil)
• Leukot­­riene modifiers
• Methyl­­xa­n­t­hines (theop­­hy­l­line) • Immuno­­mo­d­u­lators (omali­­zumab = anti-IgE)
Acute Exacer­bation
• Inhaled B agonist and ipratr­opium via nebulizer or MDI. Assess response clinically and with peak flow.
• IV or oral cortic­ost­eroids, then taper when improv­ement occurs.
• Third-line agents include IV magnesium, which helps with bronch­ospasm in severe refractory cases.
• Supple­mental oxygen to keep Osat>90%. Antibi­otics if necessary. Intubation for respir­atory failure.
Mild Interm­ittent
• Symptoms <2 times per week, nighttime awakenings <2x per month.
• Normal baseline FEV1 and FEV1/FVC.
• Needs no long-term control medica­tions, just short acting beta agonist (albut­erol).
Mild Persistent
• Symptoms >2 times per week but not every day. 3-4 nighttime awakenings per month, minor limita­tions on activi­ties.
• Normal PFTs.
Low dose inhaled cortic­ost­eroid indicated with PRN albuterol inhaler.
Moderate Persistent
Daily symptoms with frequent exacer­bat­ions.
• FEV1 is 60-80% of expected.
• Daily inhaled low dose cortic­ost­eroid, PRN albuterol inhaler, and LABA inhaler. +/- cromol­yn/­met­hyl­xan­thi­ne/­ant­ile­uko­triene.
Severe Persistent
• Continual symptoms with frequent exacer­bations and limited physical activi­ty.
FEV1 <60% of predic­ted.
• Daily high dose inhaled cortic­ost­eroid, PRN albuterol, and long-a­cting beta agonists. +/- methyl­xan­thine and systemic cortic­ost­eroids.

Treatment and Mainte­nance


Differ­ential Diagnosis of Wheezing

• CHF: due to edema of airways and congestion of bronchial mucosa.
• COPD: inflamed airways may be narrowed or bronch­ospasm may be present.
Asthma: most common cause.
• Cardio­myo­pat­hy/­Per­ica­rditis: can lead to edema around the bronchi.
• Lung Cancer: due to obstru­ction of airways (central tumor or medias­tinal invasion).


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