PCCM MASTER CRASH REVIEW

1. PFTs — know these cold

Spirometry

Obstruction

↓ FEV1/FVC
Asthma
COPD
Bronchiectasis
CF

Restriction

↓ TLC
FEV1/FVC normal/high
ILD
Neuromuscular weakness
Obesity/chest wall disease

Air trapping

↑ RV
↑ RV/TLC

Hyperinflation

↑ TLC

Bronchodilator response

Think significant improvement in FEV1 or FVC after bronchodilator, but remember that absence of reversibility does not exclude asthma.

DLCO

Low DLCO

Emphysema
ILD
Pulmonary vascular disease
Anemia

Normal/high DLCO + obstruction

Asthma
Chronic bronchitis

High DLCO

Asthma
Obesity
Alveolar hemorrhage
Polycythemia

Classic board distinction:

Emphysema → low DLCO
Chronic bronchitis → normal DLCO
Asthma → normal/high DLCO

Neuromuscular disease

Think:

↓ FVC
↓ MIP/MEP
Supine FVC falls with diaphragmatic weakness

2. ASTHMA

Know the progression:

Diagnosis → severity/control → inhaled therapy → phenotype → biologic

Core treatment:

ICS-containing therapy is foundational.
LABA should not be asthma monotherapy.
Escalate ICS/LABA if uncontrolled.
Check adherence, inhaler technique and environmental triggers before calling asthma refractory.

Biologics

Think phenotype.

Omalizumab
→ IgE/allergic asthma

Mepolizumab / benralizumab / reslizumab
→ eosinophilic / IL-5 pathway

Dupilumab
→ IL-4/IL-13; eosinophilic/type-2 disease

Tezepelumab
→ TSLP; broader severe-asthma population

ABPA

Asthma +:

markedly elevated IgE
Aspergillus sensitization
eosinophilia
central bronchiectasis

Think glucocorticoids ± antifungal therapy.

3. COPD

Diagnosis requires persistent airflow obstruction.

Know:

Smoking cessation = enormous intervention

Also:

vaccination
pulmonary rehabilitation
inhalers
oxygen when appropriately indicated

Inhalers

Symptoms predominantly:
→ LABA/LAMA

Frequent exacerbations/eosinophilic phenotype:
→ consider ICS-containing therapy.

ICS benefit increases with higher eosinophils, but carries pneumonia risk.

Long-term oxygen

High yield:

PaO₂ ≤55 or SaO₂ ≤88%

or approximately:

PaO₂ 56–59 with cor pulmonale/polycythemia

COPD exacerbation

Think:

SABA ± SAMA + systemic steroid + selective antibiotics + controlled oxygen

NIV for hypercapnic respiratory failure when appropriate.

4. BRONCHIECTASIS

CT:
airway diameter > accompanying artery

Look for cause:

CF
immunodeficiency
ABPA
NTM
aspiration
autoimmune disease
primary ciliary dyskinesia

Treatment:

airway clearance
treat infection
selected chronic macrolide therapy
address underlying disease

Hemoptysis:
→ bronchial artery embolization when significant.

5. CYSTIC FIBROSIS

Know:

bronchiectasis
Pseudomonas
pancreatic insufficiency
infertility
CF-related diabetes
CFTR modulators

Exacerbations frequently require antipseudomonal therapy guided by prior cultures.

6. INTERSTITIAL LUNG DISEASE

This is a huge pulmonary-board domain.

IPF

Classic HRCT:

UIP

basal
peripheral/subpleural
reticulation
traction bronchiectasis
honeycombing

Treatment:
nintedanib or pirfenidone

Not chronic prednisone/immunosuppression for IPF.

NSIP

ground glass
symmetric
associated with connective-tissue disease

Especially think:
systemic sclerosis

Hypersensitivity pneumonitis

Exposure:

birds
mold
farming

CT:

centrilobular nodules
mosaic attenuation
air trapping

Management:
remove antigen

Sarcoidosis

Classic:

bilateral hilar adenopathy
upper-lobe disease
noncaseating granulomas

Can cause:

hypercalcemia
uveitis
conduction disease
pulmonary hypertension

Don't reflexively treat asymptomatic stage I disease.

7. OCCUPATIONAL LUNG DISEASE

Memorize:

Silica
→ upper lobes
→ TB risk

Coal
→ upper lobes

Asbestos
→ lower lobes
→ pleural plaques
→ mesothelioma
→ bronchogenic carcinoma

Smoking + asbestos dramatically increases lung carcinoma risk.

Beryllium
→ sarcoid-like granulomatous disease

8. PULMONARY HYPERTENSION

Know the WHO groups.

Group 1
PAH

Group 2
Left heart disease

Group 3
Lung disease/hypoxia

Group 4
CTEPH

Group 5
Multifactorial

Hemodynamics

Precapillary PH:

elevated mPAP
PAWP ≤15
increased PVR

PAH is a precapillary phenotype after excluding alternative causes.

CTEPH

Screen:
V/Q scan

Not CTA as the preferred screening test.

Potentially curative:
pulmonary thromboendarterectomy

Selected inoperable disease:

balloon pulmonary angioplasty
riociguat

9. PLEURAL DISEASE

Light criteria

Exudate if any:

Pleural/serum protein >0.5

Pleural/serum LDH >0.6

Pleural LDH >2/3 ULN serum LDH

Parapneumonic effusion

Complicated/empyema clues:

pus
positive culture
low pH, classically <7.20
low glucose
loculations

→ chest tube drainage

Chylothorax

Milky fluid
↑ triglycerides
chylomicrons

Causes:

lymphoma
thoracic duct injury

10. LUNG CANCER

Know:

screening
pulmonary nodule approach
staging principles
mediastinal staging
malignant pleural effusion
paraneoplastic syndromes

Small cell

Think:

SIADH
ectopic ACTH
Lambert-Eaton

Squamous

→ PTHrP hypercalcemia

Adenocarcinoma

→ peripheral
→ common in nonsmokers

11. PULMONARY INFECTIONS

Know imaging + host + exposure.

Aspergillus

Different syndromes:

ABPA
→ asthma/CF

Aspergilloma
→ fungus ball in old cavity
→ hemoptysis

Invasive aspergillosis
→ neutropenia/transplant
→ voriconazole/isavuconazole

Mucor

Think:

DKA
profound immunosuppression

Treatment:
liposomal amphotericin + surgical debridement

Pneumocystis

Diffuse bilateral GGO.

Treatment:
TMP-SMX

Add steroids with substantial hypoxemia, classically:
PaO₂ <70 or A-a gradient ≥35

12. SLEEP MEDICINE

Even if you're not doing sleep fellowship, pulmonary boards require sleep knowledge.

OSA

Diagnosis:
→ polysomnography or appropriate home testing

Treatment:
→ PAP

Know complications:

HTN
AF
cardiovascular disease
daytime somnolence

Obesity hypoventilation

Obesity + awake:

PaCO₂ ≥45

after excluding another cause.

Treat:
→ PAP + weight reduction.

Narcolepsy

Excessive daytime sleepiness ±:

cataplexy
sleep paralysis
hallucinations

MSLT:
→ short sleep latency + multiple sleep-onset REM periods.

NOW THE ICU HALF

The current ABIM CCM certification blueprint places enormous emphasis on management decisions: roughly 50% of the examination is treatment/care decisions. Shock alone is 15%, with renal/endocrine/metabolic 13% and cardiovascular 13% in the updated certification blueprint.

So for CCM, don't study it as a collection of diseases. Study:

patient → physiology → intervention.

13. SHOCK

This needs to become automatic.

Distributive

↓ SVR
usually ↑/normal CO early

Sepsis:
fluids → norepinephrine → vasopressin → selected steroids

Norepinephrine = first-line vasopressor.

Cardiogenic

↓ CO
↑ SVR
↑ filling pressures

Think:

MI
myocarditis
mechanical complication
severe LV/RV failure

Hypovolemic

↓ preload
↓ CO
↑ SVR

Obstructive

Think:

PE
tamponade
tension pneumothorax

14. HEMODYNAMICS

Know:

MAP ≈ DBP + 1/3 pulse pressure

CO = HR × SV

SVR = 80 × (MAP − RAP)/CO

PVR = 80 × (mPAP − PCWP)/CO

Fick

CO relates oxygen consumption to arterial-venous oxygen content difference.

You should be able to look at a PA catheter vignette and identify the shock phenotype.

15. SEPSIS

Core sequence:

Suspected infection + shock:

cultures when feasible without meaningful delay
antibiotics
crystalloids
source control
norepinephrine

Persistent vasopressor requirement:
→ vasopressin

Persistent refractory shock:
→ consider IV hydrocortisone.

Don't chase lactate alone without understanding the clinical perfusion picture.

16. MECHANICAL VENTILATION

Probably the single most important ICU topic.

ARDS

Use lung-protective ventilation.

VT ≈ 6 mL/kg predicted body weight

Not actual body weight.

Keep plateau pressure:
≤30 cm H₂O

Moderate/severe ARDS:
→ appropriate PEEP

Severe ARDS:
→ prone positioning

Selected refractory cases:
→ ECMO evaluation.

Driving pressure

Plateau − PEEP

Lower generally better.

17. VENTILATOR WAVEFORMS

You need to recognize:

Auto-PEEP

Incomplete exhalation.

Seen with:

COPD
asthma
high RR
insufficient expiratory time

Fix:
decrease RR / increase expiratory time ± increase inspiratory flow

Peak pressure ↑, plateau normal

Think airway resistance:

bronchospasm
mucus plug
kinked tube

Peak AND plateau ↑

Think decreased compliance:

ARDS
pulmonary edema
pneumothorax
abdominal hypertension

This distinction is board gold.

18. ACID-BASE

You should be able to do these almost instantly.

Anion gap

Na − (Cl + HCO₃)

Winter formula

Expected PCO₂:

1.5(HCO₃) + 8 ±2

Acute respiratory acidosis

PCO₂ ↑10
→ HCO₃ ↑ ~1

Chronic respiratory acidosis

PCO₂ ↑10
→ HCO₃ ↑ ~3.5–4

Acute respiratory alkalosis

PCO₂ ↓10
→ HCO₃ ↓ ~2

Chronic respiratory alkalosis

PCO₂ ↓10
→ HCO₃ ↓ ~4–5

Delta gap

Useful for finding mixed metabolic disorders.

19. AKI / CRRT

Know:

prerenal
ATN
AIN
obstruction

Dialysis indications = AEIOU

Acidosis
Electrolytes
Ingestions
Overload
Uremia

CRRT is useful when conventional intermittent HD is poorly tolerated because of hemodynamic instability.

20. ELECTROLYTES

Severe symptomatic hyponatremia

→ hypertonic saline

Avoid overly rapid correction because of osmotic demyelination.

Hypernatremia

Calculate free-water deficit and replace gradually.

Hyperkalemia

Order matters:

1. Stabilize heart
→ calcium

2. Shift K intracellularly
→ insulin/glucose ± beta agonist

3. Remove K
→ diuresis/binders/dialysis depending situation

21. ICU CARDIOLOGY

Know:

ACS
AF
VT/VF
bradyarrhythmias
acute RV failure
tamponade
mechanical MI complications

RV failure

Avoid:

hypoxemia
hypercapnia
acidosis
excessive airway pressures

These increase PVR.

Massive PE + shock:
→ reperfusion strategy.

22. ICU NEUROLOGY

Status epilepticus

benzodiazepine → longer-acting antiseizure medication

Persistent:
→ anesthetic infusion + EEG.

Increased ICP

Think:

head elevation
avoid hypoxia/hypotension
hypertonic saline or mannitol when indicated
treat underlying cause

Brain death

Know prerequisites and exam principles.

Delirium

Address:

drugs
infection
sleep
mobility
pain
metabolic problems

Avoid routinely treating ICU delirium with benzodiazepines unless treating something like alcohol/benzodiazepine withdrawal.

23. SEDATION

Propofol

Advantages:

rapid
easily titratable

Problems:

hypotension
hypertriglyceridemia
propofol infusion syndrome

Dexmedetomidine

Advantages:

relatively little respiratory depression
cooperative/light sedation

Problems:

bradycardia
hypotension

Benzodiazepines

Important for:

seizures
alcohol withdrawal

Otherwise generally minimize prolonged exposure when possible because of sedation/delirium issues.

24. ICU INFECTIONS

Know:

CAP
HAP/VAP
CLABSI
CAUTI
meningitis
endocarditis
neutropenic fever
invasive fungal disease
opportunistic infection

VAP

Empiric therapy depends upon:

resistance risk
local antibiogram
prior cultures
MRSA risk
Pseudomonas risk

Then:

DE-ESCALATE

when cultures return.

25. TOXICOLOGY

Memorize antidote pairings:

Poison	Treatment
Acetaminophen	NAC
Opioids	Naloxone
Benzodiazepines	Flumazenil rarely/selected cases
Methanol	Fomepizole
Ethylene glycol	Fomepizole
Organophosphate	Atropine + pralidoxime
Cyanide	Hydroxocobalamin
Digoxin	Digoxin immune Fab
Beta blocker	Glucagon / high-dose insulin strategies
CCB	Calcium + high-dose insulin strategies
TCA	Sodium bicarbonate
Methemoglobinemia	Methylene blue

Know toxidromes as well.

26. TRAUMA

Know:

Massive hemorrhage
→ balanced blood-component resuscitation + hemorrhage control

Tension pneumothorax
→ immediate decompression

Don't wait for imaging in an unstable classic presentation.

Hemothorax
→ tube thoracostomy

Cardiac tamponade
→ urgent intervention

Also:

burns
inhalational injury
rhabdomyolysis
abdominal compartment syndrome

27. ICU GI

Upper GI bleed

Resuscitate → appropriate medications → endoscopy.

Variceal:

vasoactive therapy
antibiotics
urgent endoscopy

Acute liver failure

Think:

encephalopathy
coagulopathy
cerebral edema
hypoglycemia

Early transplant-center involvement.

Pancreatitis

Supportive care, appropriate fluids/nutrition, and treat cause.

Don't prophylactically give antibiotics for sterile pancreatic necrosis.

28. HEMATOLOGY

Know:

DIC

↓ platelets
↑ PT/PTT
↓ fibrinogen
↑ D-dimer

Treat underlying cause.

TTP

MAHA + thrombocytopenia ± neurologic/renal/fever findings.

→ urgent plasma exchange + steroids, with modern adjunctive therapy such as caplacizumab.

Do NOT wait for ADAMTS13 result if clinical suspicion is high.

HIT

4Ts → stop all heparin → start non-heparin anticoagulation when appropriate.

29. ICU ULTRASOUND

This is now explicitly represented on the ABIM CCM blueprint.

You should recognize:

LV
→ hyperdynamic vs depressed

RV dilation
→ think RV strain/PE depending context

Pericardial effusion + chamber collapse
→ tamponade physiology

Lung sliding absent
→ possible pneumothorax

B-lines
→ interstitial fluid pattern

IVC
→ contextual volume/right-sided pressure information; don't use it alone as a magical volume-status measurement.

30. ICU PROCEDURES

Know:

central line complications
arterial lines
chest tubes
thoracentesis
bronchoscopy
intubation
cricothyrotomy
tracheostomy
lumbar puncture
PA catheter interpretation

For central lines, ultrasound guidance is standard when appropriate.

31. WEANING / EXTUBATION

Distinguish:

Ready to wean?

from

Ready to extubate?

Patient may pass SBT but still be unable to protect airway.

Think:

mental status
cough
secretions
airway protection
upper-airway obstruction risk

SBT:
→ low-level support/T-piece approaches depending protocol.

32. ECMO

VV ECMO

Respiratory support

Severe refractory:

ARDS
hypoxemia/hypercapnia

VA ECMO

Cardiac + respiratory support

Think:

cardiogenic shock
selected cardiac arrest scenarios

33. HIGH-YIELD NUMBERS

I'd memorize these early:

VT: ~6 mL/kg PBW in ARDS
Plateau: ≤30
PaO₂ ≤55 / SaO₂ ≤88%: classic LTOT threshold
Pleural pH <7.20: complicated parapneumonic effusion → drainage
OHS: awake PaCO₂ ≥45
PCWP ≤15: component of precapillary PH definition
Winter: 1.5 × HCO₃ + 8 ±2
MAP: DBP + ⅓ pulse pressure
SBT: roughly 30–120 min depending protocol
PJP steroids: PaO₂ <70 or A-a ≥35

The mental framework I'd build during fellowship

Rather than trying to memorize 1,250 SEEK answers, I'd reduce PCCM to about 10 recurring decisions:

Hypoxemic?
→ V/Q mismatch vs shunt vs diffusion vs hypoventilation

Hypercapnic?
→ decreased ventilation / obstruction / neuromuscular

Abnormal PFT?
→ obstruction vs restriction → volumes → DLCO

Diffuse CT?
→ distribution + pattern + exposure/systemic disease

Pulmonary hypertension?
→ determine WHO group before treating

Shock?
→ preload + pump + afterload → distributive/cardiogenic/hypovolemic/obstructive

Ventilator problem?
→ resistance vs compliance vs auto-PEEP vs dyssynchrony

Acid-base?
→ primary disorder → expected compensation → AG → mixed disorder

AKI?
→ perfusion vs intrinsic vs obstruction → dialysis indication

Deteriorating ICU patient?
→ airway → breathing → circulation → ultrasound → source → intervention

Pulmonary board to master

PCCM MASTER CRASH REVIEW

1. PFTs — know these cold

Spirometry

Bronchodilator response

DLCO

Neuromuscular disease

2. ASTHMA

Biologics

ABPA

3. COPD

Inhalers

Long-term oxygen

COPD exacerbation

4. BRONCHIECTASIS

5. CYSTIC FIBROSIS

6. INTERSTITIAL LUNG DISEASE

IPF

NSIP

Hypersensitivity pneumonitis

Sarcoidosis

7. OCCUPATIONAL LUNG DISEASE

8. PULMONARY HYPERTENSION

Hemodynamics

CTEPH

9. PLEURAL DISEASE

Light criteria

Parapneumonic effusion

Chylothorax

10. LUNG CANCER

Small cell

Squamous

Adenocarcinoma

11. PULMONARY INFECTIONS

Aspergillus

Mucor

Pneumocystis

12. SLEEP MEDICINE

OSA

Obesity hypoventilation

Narcolepsy

NOW THE ICU HALF

13. SHOCK

Distributive

Cardiogenic

Hypovolemic

Obstructive

14. HEMODYNAMICS

Fick

15. SEPSIS

16. MECHANICAL VENTILATION

ARDS

Driving pressure

17. VENTILATOR WAVEFORMS

Auto-PEEP

Peak pressure ↑, plateau normal

Peak AND plateau ↑

18. ACID-BASE

Anion gap

Winter formula

Acute respiratory acidosis

Chronic respiratory acidosis

Acute respiratory alkalosis

Chronic respiratory alkalosis

Delta gap

19. AKI / CRRT

20. ELECTROLYTES

Severe symptomatic hyponatremia

Hypernatremia

Hyperkalemia

21. ICU CARDIOLOGY

RV failure

22. ICU NEUROLOGY

Status epilepticus

Increased ICP

Brain death

Delirium

23. SEDATION

Propofol

Dexmedetomidine