Extrinsic Restrictive Lung Disease - Kyphoscoliosis, Pleural Effusions, Pneumothorax, Tension Pneumothorax, Neuromuscular Disorders (GBS, MG), OSA

Question 1

How does kyphoscoliosis affect lung function

Answer 1

Deviation of the normal curvature of the spine in the sagittal, coronal plane => restrictive lung problems

Question 2

Pleural effusions

-presentation, examination findings

Answer 2

No hemi diaphragm
Meniscus
Dense white shadowing
Locular effusions
Fluid sinks to the bottom, compresses lung above

Decreased expansion
Mediastinal shift to contralateral side
Stony dull percussion
Bronchial breathing at level of effusion
Decreased VF/TF

Question 3

What is the difference between a chest drain, pleural tap and thorascopy

Answer 3

Chest drain - drainage of air, blood, fluid, pus out of pleural space => reexpansion of lung
-Seldinger kit

Pleural tap - drainage of pleural fluid for sampling

Thorascopy - laproscopic technique to view lung and pleura, take lung biopsies and insert talc

Question 4

What info can you get from a pleural tap

Answer 4

Physical appearance

Protein and LDH often change together
-transudate < 25 LIGHTS CRITERIA 35 < exudate

AFB - TB culture
MCS - microbe culture
Cytology - cells

Glucose and pH often change together

if low, likely
infection/empyema
malignancy
RA, TB, SLE

Question 5

What is the difference between transudate and exudate?

-what are the most common causes

Answer 5

Transudate
due to increased hydrostatic pressure or low oncotic pressure
low in protein and LDH
systemic causes

Exudate
due to inflammation and capillary permeability
high in protien and LDH
infection, inflammation, malignancy

Question 6

What is the Lights Criteria

Answer 6

Exudate if at least 1 of the criteria met

Pleural protein: Serum protein
- ratio > 0.5
Pleural LDH: Serum LDH
- ratio > 0.6
Pleural LDH greater than 2/3 upper limit of normal serum LDH

Question 7

How would you manage a

parapneumonic effusion
empyema
malignant effusion
bilateral effusion

Answer 7

Parapneumonic effusion - secondary to pneumonia
no infection in transudate
manage pneumonia, no need to drain

Empyema - pus from infection in pleural space
-drain if pH low
-drain exudate, identify microbe, ABx

Malignant effusion - cancer cells in exudate increase production of fluid and decrease absorption

lung, breast, lymphoma mets
mesothelioma
pleurodesis with talc to prevent formation of effusions
Bilateral effusion - transudate due to systemic issues
-treat underlying cause

Question 8

Causes of

primary pneumothorax
secondary pneumothorax

Answer 8

No underlying pathology
Tall, thin patients
Presence of bullae on apices of lung
Often smokers

Trauma
Lung disease - asthma, CF, PCP, cancer, sarcoma, COPD
AI affecting lungs
Congenital - CF, Marfans, EDS

Question 9

Pneumothorax

presentation
investigation, diagnosis

Answer 9

Pneumothorax
Sudden onset SOB, pleuritic pain

TP -
Insp => air moves into PS
Exp => valve on lung closes
Increased air in PS => compress heart

Reduced chest expansion, reduce breath sounds on affected side

CXR => loss of lung markings on affected side

Question 10

Management of
-pneumothorax
-recurrent pneumothorax

Answer 10

1. Significant pain, SOB, physiological compromise?
   No => conservative
   -if 2ndary, admit and observe
   Yes => assess for high risks
2. High risk?
   -tension/bilateral/hemothorax/hypoxic
   -underlying lung disease
   -50+ with significant smoking Hx
   Yes => assess safety
   No => choose intervention
3. Safe - 2cm+
   Yes => chest drain
   No => CT and reassess, admit and observe

Conservative
-primary => OP review every 2-4days
-secondary => IP

Ambulatory care
Aspiration
-chest drain if unsuccessful

Once stable => OP in 2-4wks

If recurrent - VATS pleurodesis

Question 11

What neuromuscular conditions may cause a restrictive lung disease
-management

Answer 11

GBS, MG

-IVIG, plasmapheresis

Question 12

Obstructive sleep apnoea
-presentation
-predisposing factors
-diagnostic tests
-management

Answer 12

Daytime sleepiness
Compensated respiratory acidosis
HTN
Excess snoring reported by partner

Hypothyroidism
Obesity

Noctural polysomnography - physiological monitoring at night

Weight loss if caused by obesity
CPAP => mandibular device if CPAP not tolerated
Inform DVLA is causing excessive daytime sleepiness

Question 13

Pneumothorax discharge advice
-smoking
-fit to fly
-scuba diving

Answer 13

Smoking
-avoid smoking to reduce risk of further episodes

Fit to fly
-CAA - 2wks after successful drainage with no residual air
-BTS - 1wk post chest xray

Scuba diving
-permanently avoid