2006 pulmonary respiratory secrets

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PULMONARY/
RESPIRATORY
THERAPY


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PULMONARY/

RESPIRATORY
THERAPY

Third Edition
Polly E. Parsons, MD

John E. Heffner, MD

Professor, Department of Medicine
University of Vermont College of Medicine
Chief, Critical Care Service
Fletcher Allen Health Care
Burlington, Vermont

Professor of Medicine
Executive Medical Director
Medical University of South Carolina
Charleston, South Carolina


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1600 John F. Kennedy Boulevard
Suite 1800

Philadelphia, PA 19103-2899
Pulmonary/Respiratory Therapy Secrets
Third Edition

ISBN-13: 978-0-323-03586-6
ISBN-10: 0-323-03586-8

Copyright © 2006 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher.
Permissions may be sought directly from Elsevier’s Health Sciences Rights Department
in Philadelphia, PA, USA: phone: (+1) 215-239-3804, fax: (+1) 215-239-3805, e-mail:
may also complete your request on-line via the
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NOTICE
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy
may become necessary or appropriate. Readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method
and duration of administration, and contraindications. It is the responsibility of the
practitioner, relying on his or her own experience and knowledge of the patient, to make
diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions. To the fullest extent of the law, neither the
Publisher nor the Editor assumes any liability for any injury and/or damage to persons
or property arising out or related to any use of the material contained in this book.
Library of Congress Cataloging-in-Publication Data
Pulmonary/respiratory therapy secrets / [edited by] Polly E. Parsons, John E. Heffner.–3rd ed.

p.; cm. – (The secrets series)
Includes bibliographical references and index.
ISBN-13: 978-0-323-03586-6
ISBN-10: 0-323-03586-8
1. Lungs–Diseases–Examinations, questions, etc. 2. Respiratory therapy–Examinations,
questions, etc. I. Parsons, Polly E., 1954– II. Heffner, John E. III. Series.
[DNLM: 1. Respiratory Tract Diseases–Examination Questions. WF 18.2 P982 2006]
RC756.P84 2006
616.2′0076–dc22
2005057665
Vice President, Medical Student Publishing: Linda Belfus
Developmental Editor: Stan Ward
Senior Project Manager: Cecelia Bayruns
Marketing Manager: Kate Rubin

Printed in China.
Last digit is the print number: 9

8

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6

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DEDICATION
To our spouses, Jim Jacobson and Ann Heffner, for their support and understanding, and to our
children, Alec and Chandler Jacobson and John and Jim Heffner, for their inspiration and patience.


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CONTENTS
Top 100 Secrets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
I. BEDSIDE EVALUATION
1. Taking the Pulmonary History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Karen A. Fagan, MD

2. Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Samer Saleh, MD, and Om P. Sharma, MD, FRCP

3. Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Steven J. Kolpak, MD, and Thomas D. MacKenzie, MD, MSPH

4. Pulmonary Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Bonnie F. Fahy, RN, MN

5. Pulmonary Disability Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Oyebode A. Taiwo, MD, MPH, Carrie A. Redlich, MD, MPH, and Akshay Sood, MD, MPH

6. Preoperative Assessment of the Pulmonary Patient . . . . . . . . . . . . . . . . . . . .38
Katherine Habeeb, MD, FCCP

7. Postoperative Pulmonary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Jeanine P. Wiener-Kronish, MD, and John M. Taylor, MD

II. DIAGNOSTIC IMAGING

8. Chest Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
David L. Levin, MD, PhD, and Jeffrey S. Klein, MD

9. Computed Tomography Scans and Ultrasound . . . . . . . . . . . . . . . . . . . . . . . .65
David A. Lynch, MD

10. Pulmonary Angiography and Magnetic Resonance Imaging of the Chest . . .72
Jonathan Kullnat, MD, and Marc V. Gosselin, MD

III. LABORATORY EVALUATION
11. Arterial Blood Gases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
Dean Hess, PhD, RRT

12. Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
Philip L. Goodman, MS, RRT, and Robert F. Wolken, BS, RRT

13. Pulmonary Function Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Lee K. Brown, MD, and Albert Miller, MD

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14. Clinical Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Alexander S. Niven, MD, Gregory B. Tardie, PhD, and Idelle M. Weisman, MD

IV. PROCEDURES
15. Thoracentesis and Percutaneous Pleural Biopsy . . . . . . . . . . . . . . . . . . . . . .111
Polly E. Parsons, MD, and Yuan-Po Tu, MD

16. Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
Udaya B. S. Prakash, MD

17. Interventional Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
James L. Knepler, Jr., MD, and Praveen N. Mathur, MBBS

18. Chest Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
Thomas Corbridge, MD, and David Ost, MD

19. Flow-Directed Pulmonary Artery Catheters . . . . . . . . . . . . . . . . . . . . . . . . . .135
John E. Heffner, MD

20. Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142
Francis C. Nichols, MD, and James R. Jett, MD

21. Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
Robert J. Karman, MD, and Praveen N. Mathur, MBBS

V. AIRWAY DISEASE

22. Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
Anne E. Dixon, MD

23. Chronic Obstructive Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162
Victor Pinto-Plata, MD, and Bartolome R. Celli, MD

24. Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171
Lori Shah, MD, and Michael C. Iannuzzi, MD

VI. INFECTIOUS DISEASE
25. Community-Acquired Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177
Michael S. Niederman, MD

26. Nosocomial Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
Richard G. Wunderink, MD

27. Aspiration Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198
Rajesh Bhagat, MD, C. Hewitt McCuller, Jr., MD, and G. Douglas Campbell, Jr., MD

28. Fungal Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206
Carol A. Kauffman, MD, and Joseph P. Lynch III, MD

29. Parasitic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213
Samer Saleh, MD, and Om P. Sharma, MD, FRCP

30. Viral Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .218
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31. Pneumonia Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Kala Davis, MD, Ann Weinacker, MD, and Steve Nelson, MD

32. Empyema and Lung Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232
John E. Heffner, MD

33. Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240
Neil W. Schluger, MD

34. Atypical Mycobacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249
Milene T. Saavedra, MD, and Michael E. Hanley, MD

VII. PULMONARY COMPLICATIONS OF AIDS
35. Infectious Pulmonary Complications of HIV Infection . . . . . . . . . . . . . . . . . .255
Mark J. Rosen, MD, and Mangala Narasimhan, DO

36. Noninfectious Pulmonary Complications of HIV Infection . . . . . . . . . . . . . .263
Mangala Narasimhan, DO, and Mark J. Rosen, MD

VIII. PULMONARY VASCULAR DISEASES
37. Thromboembolic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269

Harold I. Palevsky, MD

38. Nonthrombotic Pulmonary Emboli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285
Michael P. Gruber, MD, and Mark W. Geraci, MD

39. Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295
Richard N. Channick, MD

IX. INTERSTITIAL LUNG DISEASES
40. General Approaches to Interstitial Lung Disease . . . . . . . . . . . . . . . . . . . . . .301
Talmadge E. King, Jr., MD

41. Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315
Marc A. Judson, MD

42. Idiopathic Pulmonary Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323
John E. Heffner, MD

43. Collagen Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .328
Marvin I. Schwarz, MD

44. Bronchiolitis, Bronchiolitis Obliterans, and Small Airway Disease . . . . . . . .333
Richard A. Helmers, MD

X. VASCULITIS AND IMMUNOLOGIC DISEASES
45. Small Vessel Vasculitis: Wegener’s Granulomatosis, Microscopic
Polyangiitis, and Churg–Strauss Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . .341
Stephen K. Frankel, MD, and Kevin K. Brown, MD

46. Diffuse Alveolar Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .347

Steve Yang, MBBS, MRCP, FAMS, and Ganesh Raghu, MD, FACP, FCCP

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XI. VENTILATORY DISORDERS
47. Sleep Apnea Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353
Lee K. Brown, MD

48. Alveolar Hypoventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365
Robert D. Ballard, MD

XII. OCCUPATIONAL AND ENVIRONMENTAL LUNG DISEASES
49. Silicosis, Coal Workers’ Pneumoconiosis, and Chronic
Beryllium Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373
Lisa A. Maier, MD, MSPH

50. Asbestos-Related Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .380

E. Brigitte Gottschall, MD, MSPH

51. Hypersensitivity Pneumonitis and Other Disorders
Caused by Organic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .388
Cecile Rose, MD, MPH

52. Occupational Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395
Anne E. Dixon, MD, and Ronald Balkissoon, MD

53. Drug-Induced Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .402
Andrew H. Limper, MD, and Edward C. Rosenow III, MD, MS

54. Radiation Injury to the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .408
Deborah Z. Rubin, MD, and Marie E. Wood, MD

55. Inhalational Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .412
David A. Kaminsky, MD

XIII. LUNG NEOPLASMS
56. Solitary Pulmonary Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .419
Todd M. Bull, MD, and Elizabeth L. Aronsen, MD

57. Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .424
Marc A. Voelkel, MD, Teofilo L. Lee-Chiong, Jr., MD, and Richard A. Matthay, MD

58. Malignant Pleural Effusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .437
Steven A. Sahn, MD

59. Systemic Complications of Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . .443
Peter Mazzone, MD, MPH, FRCPC, FCCP, and Alejandro Arroliga, MD, FCCP

60. Benign Neoplasms of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .448
Karen Wesenberg, MD, and Melvin Morganroth, MD

61. Pulmonary Metastatic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .453
R. Hal Hughes, MD, and Stephanie M. Levine, MD

XIV. RESPIRATORY FAILURE
62. Acute Respiratory Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .459
Hyun Joo Kim, MD, and David H. Ingbar, MD

63. Acute Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469
Ellen L. Burnham, MD, and Marc Moss, MD


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64. Airway Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .476
Mark P. Hamlin, MD, MS, and Mitchell H. Tsai, MD, MS

65. Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .484
John E. Heffner, MD

66. Noninvasive Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .490
Nicholas S. Hill, MD

67. Traditional Invasive Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .501
Gregory Diette, MD, and Roy Brower, MD

68. Alternative Invasive Ventilatory Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . .511
Septimiu D. Murgu, MD, and Catherine S. H. Sassoon, MD

69. Weaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .522
Anthony M. Cosentino, MD, FACP, FACCP

70. Chronic Ventilatory Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .527
Mary Gilmartin, BSN, RRT, AE-C, and Enrique Fernandez, MD

XV. END-STAGE LUNG DISEASE
71. Oxygen Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535
Rebecca L. Meredith, BS, RRT, and James K. Stoller, MD, MS

72. Lung Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .547
Marie M. Budev, DO, MPH, and Janet R. Maurer, MD, MBA

XVI. PLEURAL DISORDERS
73. Pleural Effusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .559
Steven A. Sahn, MD

74. Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .566
Milene T. Saavedra, MD, and Michael E. Hanley, MD

75. Mesothelioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .571
Y. C. Gary Lee, MBChB, PhD, FCCP, FRACP

XVIII. SPECIAL CONSIDERATIONS
76. Pulmonary Manifestations of Systemic Disease . . . . . . . . . . . . . . . . . . . . . .577
Kamel Marzouk, MD, MS, and Om P. Sharma, MD, FRCP

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .585

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CONTRIBUTORS

Elizabeth L. Aronsen, MD
Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center,
Denver, Colorado

Alejandro Arroliga, MD, FCCP
Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland,
Ohio

Ronald Balkissoon, MD
Associate Professor, Department of Medicine, Pulmonary Division, National Jewish Medical and Research
Center; Associate Professor, Department of Medicine, Division of Pulmonary Sciences and Critical Care
Medicine, Department of Preventive Medicine and Biometrics, University of Colorado Health Sciences
Center, Denver, Colorado

Robert D. Ballard, MD
Professor of Medicine, National Jewish Medical and Research Center, University of Colorado Health
Sciences Center, Denver, Colorado

Rajesh Bhagat, MD
Assistant Professor and Staff Physician, Division of Pulmonary, Critical Care, and Sleep Medicine, University
of Mississippi Medical Center, Jackson, Mississippi

Roy Brower, MD
Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Kevin K. Brown, MD
Director, Interstitial Lung Disease Program, National Jewish Medical and Research Center; Division of
Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Denver,
Colorado

Lee K. Brown, MD
Vice Chair, Department of Internal Medicine; Associate Chief, Division of Pulmonary and Critical Care
Medicine; Professor of Medicine and Pediatrics, University of New Mexico School of Medicine; Program in
Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico

Marie M. Budev, DO, MPH
Department of Allergy, Pulmonary, and Critical Care Medicine, Lung Transplantation Program, The Cleveland
Clinic Foundation, Cleveland, Ohio

Todd M. Bull, MD
Assistant Professor of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of
Colorado Health Sciences Center, Denver, Colorado

Ellen L. Burnham, MD
Assistant Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Grady Memorial
Hospital, Atlanta, Georgia

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CONTRIBUTORS

G. Douglas Campbell, Jr., MD
Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson,
Mississippi

Bartolome R. Celli, MD
Chief, Division of Pulmonary/Critical Care Medicine and Sleep Medicine, Caritas St. Elizabeth’s Medical
Center; Assistant Professor, Tufts University School of Medicine, Boston, Massachusetts

Richard N. Channick, MD
Associate Professor of Medicine, Pulmonary and Critical Care Division, University of California at San Diego
Medical Center, La Jolla, California

Thomas Corbridge, MD
Associate Professor of Medicine, Director of Medical Critical Care, Northwestern University Feinberg School
of Medicine, Chicago, Illinois

Anthony M. Cosentino, MD, FACP, FACCP
Chief of Academic Medicine, St. Mary’s Medical Center; Clinical Professor of Medicine, University of
California at San Francisco School of Medicine, San Francisco, California; Associate Clinical Professor of
Medicine, Creighton University School of Medicine, Omaha, Nebraska

Kala Davis, MD
Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, California

Gregory Diette, MD
Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Anne E. Dixon, MD

Assistant Professor, Division of Pulmonary and Critical Care Medicine, University of Vermont College of
Medicine, Burlington, Vermont

Karen A. Fagan, MD
LAC + USC Medical Center, Los Angeles, California

Bonnie F. Fahy, RN, MN
Pulmonary Clinical Nurse Specialist, Pulmonary Rehabilitation Coordinator, St. Joseph’s Hospital and
Medical Center, Phoenix, Arizona

Enrique Fernandez, MD
Professor of Medicine, University of Colorado Health Science Center; National Jewish Medical and Research
Center, Denver, Colorado

Stephen K. Frankel, MD
Assistant Professor, Interstitial Lung Disease Program, National Jewish Medical and Research Center;
Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center,
Denver, Colorado

Mark W. Geraci, MD
Professor of Medicine, Head of Division of Pulmonary Sciences and Critical Care Medicine, University of
Colorado Health Sciences Center, Denver, Colorado

Mary Gilmartin, BSN, RRT, AE-C
Nurse Specialist, Coordinator of the Chronic Obstructive Pulmonary Disease Clinical Research and NETT,
National Jewish Medical and Research Center, Denver, Colorado

Carlos E. Girod, MD
Associate Professor, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern
Medical Center, Dallas, Texas

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CONTRIBUTORS

Philip L. Goodman, MS, RRT
Department of Medicine, Denver Health Medical Center, Denver, Colorado

Marc V. Gosselin, MD
Assistant Professor, Diagnostic Radiology Department, Director of Thoracic Imaging, Oregon Health and
Science University, Portland, Oregon

E. Brigitte Gottschall, MD, MSPH
Assistant Professor, Division of Environmental and Occupational Health Sciences, National Jewish Medical
and Research Center, Denver, Colorado

Michael P. Gruber, MD
Fellow, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences
Center, Denver, Colorado

Katherine Habeeb, MD, FCCP
Clinical Assistant Professor, Division of Pulmonary and Critical Care Medicine, University of Vermont
College of Medicine; Fletcher Allen Health Care, Burlington, Vermont

Mark P. Hamlin, MD, MS
Assistant Professor, Department of Anesthesiology, University of Vermont College of Medicine; Director of
Anesthesia Critical Care, Fletcher Allen Health Care, Burlington, Vermont

Michael E. Hanley, MD
Professor of Medicine, University of Colorado School of Medicine, Denver, Colorado

John E. Heffner, MD
Professor of Medicine, Executive Medical Director, Medical University of South Carolina, Charleston, South
Carolina

Richard A. Helmers, MD
Consultant in Pulmonary and Critical Care Medicine; Vice-Chair, Department of Internal Medicine, Mayo
Clinic Scottsdale, Scottsdale, Arizona

Dean Hess, PhD, RRT
Department of Anesthesiology, Harvard Medical School; Assistant Director of Respiratory Care,
Massachusetts General Hospital, Boston, Massachusetts

Nicholas S. Hill, MD
Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts-New England Medical Center, Boston,
Massachusetts

R. Hal Hughes, MD
East Tennessee Pulmonary Associates, Oak Ridge, Tennessee

Michael C. Iannuzzi, MD
Chief, Division of Pulmonary, Critical Care, and Sleep Medicine, Florette and Ernst Rosenfeld and Joseph
Soloman Professor of Medicine, The Mount Sinai School of Medicine, New York, New York

David H. Ingbar, MD
Professor of Medicine, Physiology, and Pediatrics; Director, Pulmonary Allergy and Critical Care Division,
University of Minnesota School of Medicine, Minneapolis, Minnesota

James R. Jett, MD
Professor of Medicine, Consultant in the Division of Pulmonary and Critical Care Medicine, Mayo Clinic
College of Medicine, Rochester, Minnesota

Marc A. Judson, MD
Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South
Carolina, Charleston, South Carolina

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CONTRIBUTORS

David A. Kaminsky, MD
Associate Professor of Medicine, Pulmonary Disease and Critical Care Medicine, University of Vermont

College of Medicine, Burlington, Vermont

Robert J. Karman, MD
Private Practice, Pulmonary and Critical Care Medicine, Louisville, Kentucky

Carol A. Kauffman, MD
Section of Infectious Diseases, Department of Internal Medicine, Veterans Affairs Medical Center, Ann Arbor,
Michigan

Hyun Joo Kim, MD
Assistant Professor of Medicine, Pulmonary, Allergy, and Critical Care Division, University of Minnesota
School of Medicine, Minneapolis, Minnesota

Talmadge E. King, Jr., MD
Chief, Medical Services, San Francisco General Hospital; The Constance B. Wofsy Distinguished Professor
and Vice-Chairman, Department of Medicine, University of California at San Francisco School of Medicine,
San Francisco, California

Jeffrey S. Klein, MD
Professor, Department of Radiology, University of Vermont College of Medicine; Fletcher Allen Health Care,
Burlington, Vermont

James L. Knepler, Jr., MD
Department of Pulmonary and Critical Care Medicine, University of Cincinnati School of Medicine,
Cincinnati, Ohio

Steven J. Kolpak, MD
Assistant Professor of Medicine, University of Colorado Health Sciences Center; Resident Clinic Director,
Denver Health Ambulatory Care Center, Denver, Colorado

Jonathan Kullnat, MD
Oregon Health and Science University, Portland, Oregon

Y.C. Gary Lee, MBChB, PhD, FCCP, FRACP
Centre for Respiratory Research, University College, London, United Kingdom; Osler Chest Unit, Oxford
Centre of Respiratory Medicine, Oxford, United Kingdom; Asthma and Allergy Research Institute, University
of Western Australia, Perth, Australia

Teofilo L. Lee-Chiong, Jr., MD
Associate Professor, Department of Medicine, University of Colorado Health Sciences Center; National
Jewish Medical and Research Center, Denver, Colorado

David L. Levin, MD, PhD
Department of Radiology, University of California at San Diego School of Medicine, La Jolla, California;
University of California at San Diego Medical Center, San Diego, California

Stephanie M. Levine, MD
Professor, Department of Medicine, Pulmonary and Critical Care, University of Texas Health Science Center,
San Antonio, Texas

Andrew H. Limper, MD
Professor of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota

David A. Lynch, MD
Professor of Radiology and Medicine, Department of Radiology, University of Colorado Health Sciences
Center; University of Colorado Hospital; National Jewish Center for Immunology and Respiratory Medicine,
Denver, Colorado


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CONTRIBUTORS

Joseph P. Lynch III, MD
Division of Pulmonary, Critical Care Medicine, and Hospitalist, Department of Internal Medicine, The David
Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California

Thomas D. MacKenzie, MD, MSPH
Associate Professor of Medicine, University of Colorado Health Sciences Center; Director of General Internal
Medicine, Denver Health Ambulatory Care Center, Denver, Colorado

Lisa A. Maier, MD, MSPH
Assistant Professor, Division of Environmental and Occupational Health Sciences, National Jewish Medical
and Research Center; Assistant Professor, Division of Pulmonary Sciences and Critical Care Medicine,
University of Colorado Health Sciences Center, Denver, Colorado

Kamel Marzouk, MD, MS
Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern
California, Los Angeles, California

Richard A. Matthay, MD
Boehringer Ingleheim Professor of Medicine, Pulmonary and Critical Care Section, Department of
Medicine, Yale University School of Medicine, New Haven, Connecticut

Praveen N. Mathur, MBBS
Professor of Clinical Medicine, Indiana University School of Medicine, Indianapolis, Indiana

Janet R. Maurer, MD, MBA
CIGNA HealthCare, Lifesource/CRU, Cleveland, Ohio

Peter Mazzone, MD, MPH, FRCPC, FCCP
Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio

C. Hewitt McCuller, Jr., MD
Louisiana State University Health Science Center, New Orleans, Louisiana

Rebecca L. Meredith, BS, RRT
Department of Emergency Services, The Cleveland Clinic Foundation, Cleveland, Ohio

Albert Miller, MD
Chief, Division of Pulmonary and Critical Care Medicine, Catholic Medical Center of Brooklyn and Queens,
Jamaica, New York; Professor of Clinical Medicine, New York Medical College, Valhalla, New York

Melvin Morganroth, MD
Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care
Medicine, Oregon Health and Sciences University; Chief of Critical Care, Providence Portland Medical
Center, Portland, Oregon

Marc Moss, MD
Associate Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care, Department of Medicine,
Emory University School of Medicine, Atlanta, Georgia

Septimiu D. Murgu, MD
Fellow, Pulmonary and Critical Care Medicine, Department of Medicine, University of California School of

Medicine, Irvine, California

Mangala Narasimhan, DO
Fellow, Division of Pulmonary and Critical Care Medicine, Beth Israel Medical Center, New York, New York

Steve Nelson, MD
John H. Seabury Professor of Medicine, Louisiana State University Health Services Center, New Orleans,
Louisiana

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CONTRIBUTORS

Francis C. Nichols, MD
Assistant Professor of Surgery, Consultant in the Division of General Thoracic Surgery, Mayo Clinic College
of Medicine, Rochester, Minnesota

Michael S. Niederman, MD
Professor of Medicine, State University of New York at Stony Brook Health Sciences Center; Chairman,

Department of Medicine, Winthrop University Hospital, Mineola, New York

Alexander S. Niven, MD
Director, Respiratory Care Services, Department of Medicine, Pulmonary/CCM Service, Madigan Army
Medical Center, Tacoma, Washington; Clinical Assistant Professor, Department of Medicine, University of
Washington School of Medicine, Seattle, Washington

David Ost, MD
Assistant Professor of Medicine, Department of Pulmonary Medicine, New York University School of
Medicine, New York, New York; North Shore-Long Island Jewish Health System, Manhasset, New York

Harold I. Palevsky, MD
Professor of Medicine, University of Pennsylvania School of Medicine; Chief, Pulmonary, Allergy and Critical
Care, University of Pennsylvania Medical Center–Presbyterian; Director, Pulmonary Vascular Disease
Program, Presbyterian Medical Center, Philadelphia, Pennsylvania

Polly E. Parsons, MD
Professor, Department of Medicine, University of Vermont College of Medicine; Chief, Critical Care Services,
Fletcher Allen Health Care, Burlington, Vermont

Victor Pinto-Plata, MD
Division of Pulmonary/Critical Care Medicine and Sleep Medicine, Caritas St. Elizabeth’s Medical Center,
Boston, Massachusetts

Udaya B. S. Prakash, MD
Scripps Professor of Medicine, Mayo Clinic College of Medicine; Consultant, Pulmonary and Critical Care
Medicine, Mayo Medical Center and Mayo Clinic, Rochester, Minnesota

Ganesh Raghu, MD, FACP, FCCP
Professor of Medicine and Laboratory Medicine, Division of Pulmonary and Critical Care Medicine,

Departments of Medicine and Laboratory Medicine; Chief, Chest Clinic; Director, Lung Transplant Program,
University of Washington Medical Center, Seattle, Washington

Carrie A. Redlich, MD, MPH
Professor of Medicine, Occupational and Environmental Medicine Program and Pulmonary and Critical Care
Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut

Cecile Rose, MD, MPH
National Jewish Medical and Research Center, Denver, Colorado

Mark J. Rosen, MD
Chief, Division of Pulmonary and Critical Care Medicine, Beth Israel Medical Center; Professor of Medicine,
Albert Einstein College of Medicine, New York, New York

Edward C. Rosenow III, MD, MS
Emeritus Professor of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota

Deborah Z. Rubin, MD
Division of Radiation Oncology, University of Vermont College of Medicine; Fletcher Allen Health Care,
Burlington, Vermont


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CONTRIBUTORS

Steven A. Sahn, MD
Professor of Medicine; Director of the Division of Pulmonary/Critical Care Medicine, Allergy, and Clinical
Immunology, Medical University of South Carolina, Charleston, South Carolina

Samer Saleh, MD
Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern
California, Los Angeles, California

Catherine S.H. Sassoon, MD
Pulmonary and Critical Care Section, Veterans Affairs Long Beach Healthcare System, Long Beach,
California; Professor of Medicine, University of California School of Medicine, Irvine, California

Milene T. Saavedra, MD
Assistant Professor of Medicine, University of Colorado Health Sciences Center, Denver, Colorado

Neil W. Schluger, MD
Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and
Surgeons, New York, New York

Marvin I. Schwarz, MD
Department of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences
Center, Denver, Colorado

Lori Shah, MD
Associate Medical Director, Lung Transplantation Program, Division of Pulmonary, Critical Care, and Sleep
Medicine, The Mount Sinai School of Medicine, New York, New York

Om P. Sharma, MD, FRCP

Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Keck School of Medicine,
University of Southern California, Los Angeles, California

Akshay Sood, MD, MPH
Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Southern Illinois
University School of Medicine, Springfield, lllinois

James K. Stoller, MD, MS
Associate Chief of Staff; Vice President of the Division of Medicine, Department of Pulmonary, Allergy, and
Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio

Oyebode A. Taiwo, MD, MPH
Assistant Professor of Medicine, Occupational and Environmental Medicine, Department of Medicine, Yale
University School of Medicine, New Haven, Connecticut

Gregory B. Tardie, PhD
Director, Human Performance Laboratory, Pulmonary Medicine Service, William Beaumont Army Medical
Center, El Paso, Texas

John M. Taylor, MD
Clinical Fellow, Critical Care Medicine, Department of Anesthesia and Perioperative Care, University of
California at San Francisco School of Medicine, San Francisco, California

Mitchell H. Tsai, MD, MS
Clinical Instructor, Department of Anesthesiology, University of Vermont College of Medicine, Burlington,
Vermont

Yuan-Po Tu, MD
Staff Physician, The Everett Clinic, Everett, Washington

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CONTRIBUTORS

Marc A. Voelkel, MD
Pulmonary and Critical Care Section, Department of Medicine, University of Colorado Health Sciences
Center, Denver, Colorado

Ann Weinacker, MD
Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University
Medical Center, Stanford, California

Idelle M. Weisman, MD
Associate Professor of Medicine and Anesthesiology, Texas Tech University Health Sciences Center; Chief,
Department of Clinical Investigations; Director, Human Performance Laboratory and Pulmonary/Critical Care
Services, William Beaumont Army Medical Center, El Paso, Texas

Karen Wesenberg, MD
Pulmonary and Critical Care Medicine, The Oregon Clinic, Portland, Oregon

Jeanine P. Wiener-Kronish, MD
Professor, Departments of Anesthesia and Medicine, Vice-Chairman, Department of Anesthesia,
Cardiovascular Research Institute Investigator, University of California at San Francisco School of Medicine,
San Francisco, California

Robert F. Wolken, BS, RRT
Critical Care Respiratory Specialist, Denver Health Medical Center, Denver, Colorado

Marie E. Wood, MD
Associate Professor of Medicine, Division of Medical Oncology, University of Vermont College of Medicine;
Fletcher Allen Health Care, Burlington, Vermont

Richard G. Wunderink, MD
Professor of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of
Medicine, Chicago, Illinois

Steve Yang, MBBS, MRCP, FAMS
Associate Consultant, Department of Respiratory and Critical Care Medicine, Singapore General Hospital,
Singapore; Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center,
Seattle, Washington


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PREFACE
In this third edition, we have continued our focus on the concept that pulmonary clinicians
and respiratory therapists must first pose proper questions before they can formulate effective
solutions to their patients’ respiratory problems. Perhaps in no field of medicine is this twin challenge of identifying essential questions and deriving appropriate answers more fundamentally
important than in the management of pulmonary disorders. The broad-based nature of pulmonary medicine requires a masterly understanding of diverse immunologic, infectious, traumatic, neoplastic, and inflammatory conditions. Some respiratory conditions arise primarily in
the lungs, whereas others pose as “lung diseases” but actually represent pulmonary manifestations of underlying “occult” systemic disorders. Moreover, effective application of respiratory
therapeutics requires proficiency in diverse pharmacologic and surgical interventions in addition
to a mechanic’s (or in some cases an engineer’s) grasp of ventilator tubes, principles of gas and
fluid flow, and electronic circuitry of ventilatory and monitoring devices. It is no wonder that this
complex field presents clinicians with major challenges in identifying the appropriate questions,
let alone providing corrects answers to patients’ clinical problems.
We have been delighted with the response to the first two editions of Pulmonary/ Respiratory
Therapy Secrets. In this third edition, we have again been fortunate to have many leaders in pulmonary medicine and respiratory therapy contribute chapters in their areas of expertise. These
experts have expanded the Secrets format to include Top Secrets and Key Points. These new features allow readers to note quickly what experienced clinicians consider the most important concepts presented in their chapters. We believe the authors have succeeded in preserving the
“cutting edge” nature of their content while presenting information in a readable and retainable
manner that will benefit a broad readership. We hope that this book will continue to be a valuable
resource to medical students, residents, fellows, and experienced clinicians alike in their efforts
to ask the right questions and discover the best answers.
Polly E. Parsons, MD
John E. Heffner, MD

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TOP 100 SECRETS
These secrets are 100 of the top board alerts. They summarize the concepts,
principles, and most salient details of pulmonary and respiratory therapy.

1. When evaluating complaints of cough or dyspnea, it is important to include onset, precipitants,
exposures, and other associated symptoms in the history of present illness.
2. When evaluating an abnormal chest radiograph, the most important first step is to obtain previous films for comparison.
3. Gynecomastia in a man with cigarette stains on his fingers is a telltale sign of lung cancer. In a
middle-aged man with bibasilar inspiratory rales and clubbing, idiopathic pulmonary fibrosis
should always be suspected.
4. All patients wishing to stop smoking should be offered nicotine replacement, bupropion
sustained-release (SR) therapy, or both. Active physician involvement in attempts at smoking
cessation is vital. Even a discussion about smoking as short as 3 minutes can double a patient’s
chances of quitting successfully.
5. Results from pulmonary function testing should not be used as the sole criterion for referral to
pulmonary rehabilitation. Symptoms and functional limitations direct the need for pulmonary
rehabilitation.
6. Mortality from chronic obstructive pulmonary disease (COPD) often results from secondary

conditions. Pulmonary rehabilitation can change the course of cardiac deconditioning, peripheral muscle dysfunction, decreases in total and lean body mass, anxiety, and poor coping skills.
7. Impairment means loss of physical or physiologic function, whereas disability refers to the
impact of the impairment on the person’s life. Physicians assess impairment, whereas disability
is determined by administrators based on the information provided by physicians and criteria for
eligibility. The commonly accepted legal standard of certainty that a respiratory disease was
caused by an occupational exposure is one of “more probable than not,” or a level of certainty
greater than 50%.
8. The presence of chronic lung disease is the most important patient-related risk factor for the
development of postoperative pulmonary complications and should prompt careful evaluation
and follow-up. A surgical site involving the thorax or upper abdomen carries the highest risk for
the development of postoperative pulmonary complications.
9. Acute respiratory distress syndrome (ARDS) can develop over hours or days. Predisposing factors include sepsis, pneumonia, trauma, the aspiration of gastric contents, and transfusionrelated acute lung injury. Patients with increasing FiO2 requirements, decreased pulmonary
compliance, and chest radiograph findings consistent with pulmonary edema (in the absence of
congestive heart failure) should be ventilated in accordance with the ARDSnet protocol.
10. Atelectasis is the most common cause of postoperative hypoxemia. Profound hypoxemia can be
seen in patients with small regions of atelectasis. Predisposing factors include shallow tidal

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volumes, mechanical compression, mucous plugging, and secretions. The most effective treatment for atelectasis is coughing. Other treatments include incentive spirometry, positive pressure breathing, and tracheal suctioning.
11. When an anterior mediastinal mass is detected in an adult, the most common cause is a thymic
neoplasm or enlarged lymph nodes due to lymphoma.
12. The radiologic features that allow a confident diagnosis of a benign solitary pulmonary nodule
include a smooth margin, a central or complete calcification, and an absence of growth over 2 years.
13. On computed tomography (CT) scanning, intravenous contrast is indicated for the evaluation of
the pulmonary vasculature, the mediastinal veins and arteries, the heart, the pulmonary hila,
suspected lung cancer, and inflammatory pleural disease. High-resolution CT is helpful for the
evaluation of known or suspected interstitial lung disease, bronchiectasis, and lung nodules.
14. Although pulmonary angiography does have some risks, the overall complication rate remains
very low (<3%).
15. The main causes of hypoxemia are decreased inspired oxygen (caused by high altitude),
hypoventilation (caused by respiratory center depression, neuromuscular disease, or respiratory failure), pulmonary or cardiac shunt, ventilation–perfusion (V/Q) mismatch (caused by airway secretions or bronchospasm), and diffusion defect (caused by pulmonary fibrosis,
emphysema, or pulmonary resection).
16. The main types of hypoxia are hypoxemic hypoxia, anemic hypoxia, circulatory hypoxia, affinity
hypoxia (i.e., a decreased release of oxygen from hemoglobin to the tissues), and histotoxic
hypoxia (e.g., cyanide poisoning).
17. Warming cool extremities by placing a glove filled with warm water on the patient’s hand may
improve the ability of the pulse oximeter to detect an adequate signal.
18. Pulmonary function testing can identify patterns of disease such as obstructive impairment with
or without reversibility, restrictive lung disease, restrictive chest wall disease, restrictive neuromuscular disease, and pulmonary vascular disease. Additional information from the patient’s
history, a physical examination, imaging, or a tissue biopsy will usually be required to make a
specific diagnosis.
19. Spirometry is the easiest pulmonary function test to obtain but is often difficult to interpret without information from other pulmonary function studies. Do not hesitate to order tests for static
lung volumes, the single-breath carbon monoxide diffusing capacity of the lungs (DLCOSB), the
maximum inspiratory pressure at residual volume (PImax), and the maximum expiratory pressure (PEmax) when clarification is necessary.
20. Exercise testing is a better estimate of functional capacity and quality of life than resting cardiac
and pulmonary measurements. If you cannot figure out why a patient is short of breath, cardiopulmonary exercise testing can help you determine the primary and contributing diagnoses

and initiate a more timely therapeutic intervention.
21. If the chest x-ray looks weird, think pleural disease.
22. Bronchoalveolar lavage can be safely done in patients with significant bleeding disorders including thrombocytopenia, elevated prothrombin time, and other coagulopathies. Mechanical ventilation is not a contraindication for bronchoscopy.


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23. Fluoroscopic guidance is essential for the biopsy of a solitary lung nodule. Universal infection
prevention precautions are indicated for all patients, regardless of the indication for bronchoscopy.
24. Endobronchial lesions are treated by endobronchial ablation (such as laser therapy, argon
plasma coagulation, or cryotherapy). Extrinsic compression is best treated by stent placement
or brachytherapy. Consider an endobronchial lesion whenever the patient has localized wheezing
or recurrent pneumonia in the same lobe, especially in patients with risk factors such as known
malignancy.
25. Chest tubes are central to the recovery of patients with a sizable pneumothorax, a hemothorax,
complicated parapneumonic effusion, or empyema and also to the palliation of selected patients
with malignant or paramalignant effusions.
26. Complications from chest tubes, including infection, malposition, bleeding, nerve damage, perforation of adjacent structures, and reexpansion pulmonary edema, are minimized by proper
insertion; the regular assessment of function, patency, and location; and timely removal.
27. Only mediastinoscopy allows biopsies of right and left mediastinal lymph nodes through one
small neck incision.
28. Positron emission tomography (PET) scanning does not provide histopathologic confirmation of

metastatic mediastinal disease; therefore, mediastinoscopy remains essential in the evaluation
of patients with lung cancer.
29. Medical thoracoscopy performed with local anesthesia can provide a diagnosis in 90% of cases
of exudative pleural effusion.
30. Beware of the talc particle size before using it for pleurodesis. Small particle size can cause ARDS.
31. Inspiratory stridor in a patient with asthma suggests vocal cord dysfunction, which can be diagnosed by a flow-volume loop followed by fiberoptic laryngoscopy.
32. Frequent use of a rescue inhaler, nocturnal awakenings, and high peak-flow variability suggest
poorly controlled asthma and a need for increased therapy.
33. Consider cystic fibrosis in a patient with chronic cough and sputum production, persistent infection with characteristic organisms, airflow obstruction, chronic chest radiographic abnormalities, or characteristic extrapulmonary manifestations. Pulmonary disease in cystic fibrosis is
characterized by a process of ongoing inflammation, infection, and obstruction. This cycle may
be hindered by a combination of antibiotics, mucolytic agents, bronchodilators, anti-inflammatory agents, and airway clearance devices.
34. All patients with community-acquired pneumonia (CAP) need empirical therapy directed against
pneumococci, atypical pathogens (often as coinfecting pathogens), and other organisms, as
dictated by risk factors. Most patients with CAP show clinical improvement within 3 days of
therapy, and those not responding need a careful evaluation for unusual pathogens, drug-resistant
organisms, pneumonia complications (i.e., empyema, drug-induced colitis, or pulmonary
embolus), and alternate (noninfectious) diagnoses.
35. To avoid inappropriate initial empirical antibiotic therapy for ventilator-associated pneumonia
(VAP), always use a different class of antibiotic from that which the patient received earlier in the
hospitalization. A negative tracheal aspirate Gram stain has a very high negative predictive value

3