8 - Lung Cancer, Pleural Disease and ILD Flashcards
What are some diseases of the pleura?
- Pneumothorax
- Pleural effusion
- Empyema
- Pleural tumours
- Pleural plaques
- Pleural thickening
What are some of the causes of a pneumothorax?
1. Spontaneous (primary with no lung disease or secondary with lung disease)
2. Traumatic
3. Tension
4. Iatrogenic (post central line or pacemaker insertion)
What are some primary and secondary causes of a spontaneous pneumothorax?
Primary: young thin men with ruptured subpleural bulla
Secondary: asthma, COPD, TB, lung fibrosis, CF, Marfan’s, EDS
What are some iatrogenic causes of a pneumothorax?
- Subclavian CVP line insertion
- Pleural aspiration
- Transbronchial biopsy
- Liver biopsy
- Positive pressure ventilation
What are some risk factors for developing a pneumothorax?
- Pre-existing lung disease
- Height
- Smoking
- Diving
- Trauma/Chest procedure
- Conditions e.g Marfan’s
What are the signs and symptoms of a pneumothorax?
Symptoms: if small asymptomatic, sudden onset dyspnea, pleuritic chest pain
Signs: reduced expansion, hyperresonance to percussion, diminished breath sounds, if tension pneumothorax trachea is deviated to opposite side
How is a pneumothorax managed? (not tension)
Primary
If symptomatic and rim of air >2cm, on CXR give O2 and aspirate. If not working from this insert chest drain
Remove drain after reexpansion of lung
Secondary
If symptomatic and rim of air >2cm then insert chest drain. If persistent air leak >5days refer to thoracic surgeons
NO FLYING OR DIVING UNTIL RESOLVED
How is a tension pneumothorax managed?
Large bore cannula into 2nd ICS MCL then insert a chest drain
Do this BEFORE a CXR
What are the two different types of pleural effusion?
Transudate: protein concentration <25g/L
Exudate: protein concentration >35g/L
What are some of the causes of pleural effusions?
Transudates: heart failure, cirrhosis, constrictive pericarditis, hypoalbuminaemia (peritoneal dialysis or nephrotic syndrome), hypothyroidism, mitral stenosis, PE, Meig’s syndrome
Exudates: infection, inflammation (RA, pancreatitis) malignancy, Yellow nail syndrome, drugs
What is Meig’s sysndrome?
Right pleural effusion and ovarian fibroma
How you do you tell the difference between a transudative and exudative pleural effusion?
Light’s Criteria
if borderline protein use this, only needs one or more of the following to be an exudate
What are the signs and symptoms of a pleural effusion?
Symptoms: asymptomatic, pleuritic chest pain, dyspnea
Signs: decreased expansion, stony dull percussion, diminished breath sounds, decreased vocal resonance, if large may have tracheal deviation away from effusion
Look for stigmata of other disease to try and determine cause
What investigations should you do for a pleural effusion?
- History and exam
- CXR
- Diagnostic apsiration
- Pleural biopsy (CT guided or thoracoscopic)
- ECG
- Bloods: FBC, U+Es, LFTs, CRP, Bone profile, LDH, clotting
- ECHO is supect heart failure
- Staging CT if suspect exudative
What does a pleural effusion look like on CXR?
- Blunting of costophrenic angles
- Shadows with menisci
What should you send a pleural aspiration off for?
Chemistry: protein, glucose, pH, LDH, amylase
Bacteriology: microscopy and culture, TB stain
Cytology
Immunology: rheumatoid factor, ANA, complement
Why should you not put in a chest drain for a pleural effusion?
Only put in if diagnosis is well established. Draining all the fluid off can hinder the opportunity to get pleural biopsies
Urgent chest drain only if underlying empyema (pH<7.2 or visible pus on aspirate)
How do you tmanage a pleural effusion?
- Therapeutic aspiration/drainage via tap or intercostal drain. Repeat as many times as needed. Use chest drain if empyema.
- Pleurodesis
- Surgery if persistent collections and increasing pleural thickness
How do you treat a transudate pleural effusion?
What is interstital lung disease?
Umbrella term for a number of conditions that primarly affect the lung parenchyma in a diffuse manner
Usually have chronic inflammation or progressive interstitial fibrosis
What are some of the underlying diseases causing interstitial lung disease?
- Usual interstitial pneumonia (UIP)
- Non-specific interstitial pneumonia (NSIP)
- Sarcoidosis
- Drug induced
- SLE
What are some clinical features of interstitial lung disease?
- Dyspnea on exertion
- Paroxysmal non-productive cough
- Abnormal CXR
- Restrictive pattern on spirometry
What are some blood tests that should be ordered when a patient is diagnosed with ILD from a lung biopsy?
- ANA
- ENA
- Rheumatoid factor
- Anti-GBM
What is the most common cause of idiopathic pulmonary fibrosis and what are the signs and symptoms of this?
UIP (usual interstitial pneumonia)
Symptoms: dry cough, exertional dyspnea, malaise, arthralgia, weight loss
Signs: cyanosis, finger clubing, reduced chest expansion, fine inspiratory crepitations, may have pulmonary hypertension
What will idiopathic pulmonary fibrosis show on blood tests and CXR?
Bloods: lowered PaO2 on ABG, increased CRP, may have ANA or RhF+
CXR: decreased lung volume, bilateral lower zone shadows, honeycomb lung
What is the management for idiopathic pulmonary fibrosis (UIP)?
- Oxygen
- Pulmonary rehabilitation
- Opiates
- Consider lung transplant
- Consider palliative care
What is extrinsic allergic alveolitis? (a.k.a hypersensitivity pneumonitis)
Repetitive inhalation of allergens (e.g fungal spores or avian proteins) that a patient has already been sensitised to so this provokes a hypersensitivity reaction
In acute phase alveoli are filled with acute inflammatory cells. If diagnosed early and remove allergen can reverse process. If chronic can lead to granuloma formation and obstructive bronchiolitis
What are some causes of extrinsic allergic alveolitis?
Exposure to mould and spores
- Farmers and Mushroom worker’s lung
- Bird/Piegeon Fancier lung
- Malt worker lung
- Sugar worker lung
What are the clinical features of extrinsic allergic alveolitis?
Acute (4-6h post exposure): Fever, rigors, myalgia, dry cough, dyspnea. Reversible and resolves spontaneously after 1-3 days
Chronic (months-years): Finger clubbing, dyspnea, weight loss, Type 1 Respiratory failure, Cor Pulmonale. Less reversible
How do we manage extrinsic allergic alveolitis?
Acute: remove allergen and give O2, PO prednisolone
Chronic: allergen avoidance or wear facemask, long term steroids, seek compensation
What are some causes of fibrotic shadowing on x-ray?
What is sarcoidosis and what is the aetiology of this?
Multisystem inflammatory granulamotous disorder. (Non-caseating granulomas). Usually affects respiratory system but can affect other areas
Associated with HLA-DRB1 and DQB1 alleles
Affects: age 20-40 years, Afro-Caribbeans
What does sarcoidosis do to the respiratory system?
- Pumonary infilitrates of fibrosis
- Dry cough
- Progressive dyspnea
- Chest pain
- Decreased exercise tolerance
What are some extra-thoracic manifestations of sarcoidosis?
- Lymphadenopathy
- Hepatosplenomegaly
- Uveitis
- Conjunctivitis
- Erythema nodosum
- Arrhythmias
- Renal stones
- Spinal syndromes
- Bone cysts
- Hypercalcaemia
What investigations should you do for sarcoidosis?
- Lung function tests (obstructive until fibrosis then restrictive)
- CXR (4 stages)
- Bloods (increased ACE, increased Ca, increased ESR)
- Urinary calcium (increased)
- ECG/ECHO/Cardiac MI (may show arrhythmias)
- CT/MRI head (neurosarcoidosis)
- Tissue biopsy (diagnostic showing NCGs)