Show Menu

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).


No comments yet. Add yours below!

Add a Comment

Your Comment

Please enter your name.

    Please enter your email address

      Please enter your Comment.

          Related Cheat Sheets

          PFT ACNP Student Cheat Sheet
          COPD Cheat Sheet

          More Cheat Sheets by kissmekate

          PFT ACNP Student Cheat Sheet
          COPD Cheat Sheet