303.4 📋 章末速記 Summary

303.4.1 🔑 一句話總結

呼吸系統診斷工具：imaging（CXR first-line、HRCT for ILD、CTPA for PE、V/Q for pregnancy/CKD、PET-CT for cancer、lung ultrasound bedside game-changer）；PFT（spirometry obstructive vs restrictive、lung volumes、DLCO、methacholine challenge for asthma、6MWT、CPET）；bronchoscopy（flexible、rigid、EBUS for mediastinal LN、cryobiopsy for ILD、navigational/robotic for peripheral）；pleural fluid（Light’s criteria exudate）；molecular（NSCLC EGFR/ALK/ROS1/KRAS G12C/MET/BRAF/NTRK/PD-L1）；sleep（PSG gold standard、HSAT for uncomplicated）；2024-2026 趨勢：robotic bronchoscopy (Monarch/Ion) + AI image analysis + organoid culture。

303.4.2 💊 治療精要

• diagnostic workflow：症狀 → CXR → HRCT / CTPA / PFT / bronchoscopy 依需要
• ILD：HRCT 先（UIP pattern = IPF），cryobiopsy 或 surgical 不確定時
• PE：CTPA gold standard；pregnancy / CKD 用 V/Q scan
• NSCLC：tissue biopsy + molecular profiling（liquid biopsy 可補強）
• pleural fluid：thoracentesis + Light’s criteria + cell count + chemistry + culture + cytology + ADA
• sleep apnea：PSG > HSAT；CPAP for OSA

303.4.3 🎯 盧醫師的考前提醒

1. PFT 三大 pattern：obstructive (FEV1/FVC < 0.7)、restrictive (TLC < 80%)、mixed；bronchodilator reversibility > 12% AND > 200 mL FEV1 = asthma
2. methacholine challenge 用於 spirometry 正常但懷疑 asthma；PC20 ≤ 8 mg/mL = positive
3. Light’s criteria for exudate：pleural/serum protein > 0.5 OR pleural/serum LDH > 0.6 OR pleural LDH > 2/3 upper limit serum；ADA > 40 = TB pleurisy
4. BAL 細胞學 patterns：sarcoid（lymphocytic CD4/CD8 > 4）、HP（lymphocytic CD4/CD8 < 1）、eosinophilic pneumonia（> 25%）、bacterial（neutrophilic）、alveolar hemorrhage（hemosiderin macrophages）、PAP（milky + PAS+）
5. NSCLC 分子檢測必做：EGFR (osimertinib)、ALK (alectinib)、ROS1 (crizotinib)、KRAS G12C (sotorasib, adagrasib)、MET exon 14 (capmatinib)、BRAF V600E (dabrafenib + trametinib)、NTRK (larotrectinib)、HER2 (trastuzumab deruxtecan)、PD-L1
6. HRCT 是 ILD diagnosis gold standard：UIP pattern (honeycomb + reticular + sub-pleural basal predominance) → 不必 biopsy 即可診斷 IPF
7. robotic bronchoscopy (Monarch, Ion) 2024-2026 改寫 peripheral pulmonary nodule diagnosis — 比 CT-guided 安全
8. lung ultrasound 床邊 BLUE protocol：A-lines (normal)、B-lines (interstitial fluid/edema)、consolidation、no pleural sliding (pneumothorax)
9. DLCO 解讀：obstruction + ↓ DLCO = emphysema；restriction + ↓ DLCO = ILD；isolated ↓ DLCO = pulmonary HTN 或 anemia；↑ DLCO = alveolar hemorrhage、polycythemia、asthma
10. lung cancer screening USPSTF 2021：50-80 yo + ≥ 20 pack-year + current smoker 或 quit < 15 yr → annual LDCT