Long case Flashcards
Lung disease severity measures - history
- Exercise tolerance, up flights stairs
- Ability to be comfortable, speaking in sentences
- Frequency of exacerbations
- Frequency of hospital admissions
- Frequency of respiratory infections
- Frequency of intubations
Lung disease severity measures - exam
- Respiratory rate
- Acute irritability
- Low sats and oxygen requirements
Lung disease severity measures - investigations
- FEV1 and FVC
- DLCO
- Oxygen saturation and concentration on arterial blood gas
- Degree of hypercapnoea and compensation for respiratory acidosis
- Pulmonary pressure on TTE
- VO2 max on exercise testing
Adherence measures/history - cardiorespiratory
- Regular use of inhalers with correct use of spacer and medications
- Smoking cessation
- Peak expiratory flow measures on regular basis
- Use of action plan
- Regular GP and specialist appointments
- Yearly influenza vaccinations, completed pneumococcal vaccinations
- Avoidance of potential triggers
- Involvement in rehabilitation and exercise program
- Involvement of loved ones, community support in care
Bronchiectasis risk factors
recurrent childhood infections
immunodeficiency
abnormal mucociliary drainage – CF, kartager’s syndrome
Complications of bronchiectasis
o Frequency of pneumonia, courses of antibiotics
o Abscess, empyema and thoracic decortication surgery (time of surgery, management, complications)
o Recurrent pleurisy – severity of symptoms, impact on life, management
o Colonisation with resistant organisms – recent cultures, eradication with Abx
o Pulmonary hypertension and right heart failure
o Bronchial haemorrhage requiring bronchoscopy and cautery
o Amyloidosis
o Other systemic infections (infective endocarditis)
Diagnosis of CF
CT, sweat testing, ciliary function testing, bronchoscopy, immunoglobulins, eosinophilia (allergic bronchopulmonary aspergillosis)
Treatment of bronchiectasis
o Sputum clearance o Antibiotics o Bronchodilators o Inhaled steroids o Oral steroids o Twice daily postural drainage o Vaccination o Treatment of HF o IV immunoglobulin o Bronchoscopy of haemoptysis o Lobectomies, wedge resections for localised drainage
Lung carcinoma - local symptoms
o Reduced exercise tolerance
o Pleural and thoracic chest pain (pleural and thoracic wall involvement)
o Dysphagia, hoarseness, stridor (tracheal and oesophageal obstruction)
o Headache and dizziness (superior vena caval obstruction)
o Bony pain, abdominal pain (metastasis)
lung carcinoma - systemic symptoms
o Loss of weight, appetite, night sweats o New paraesthesia, weakness unsteadiness (LEMS, peripheral neuropathy, cerebellar degeneration, polymyositis and dermatomyositis, acute transverse myelitis) o Limb pain, purpura (DVT, DIC) o Polyuria (hypercalcaemia) o Acanthosis nigricans, scleroderma
Lung carcinoma - investigations
o CT scans, biopsy -bronchoscopy or CT guided, VATS pleural, pleural tap
o Staging -CTCAP, PET scan
o PFTs for fitness for surgery FEV1 >1.5L
Lung carcinoma - treatment
o Chemotherapy – weekly/fortnightly course number of courses
Antiemetic therapy, chemotherapy nursing support
In hospital, clinic, home
o Radiotherapy
Brain – prophylactic
Chest –
Complications of lung carcinoma - disease
o Progression of local disease, metastasis – liver, abdominal, bony involvement Cord compression ascites biliary sepsis obstructive pneumonia DVT/PE
Complications of prednisolone treatment
Myopathy Opportunistic infections Mania/psychosis Osteoporotic fractures Dysmorphic cushingoid features BSL derangements, refractory hypertension
Chemotherapy SEs lung cancer
Nausea vomiting Mucositis Typhlitis, neutropaenic sepsis Peripheral neuropathy and pain Ototoxicity
Complications lung Ca - cancer pain
Degree of opioid requirement • Number of rotations • Overdoses Local nerve blocks Functional loss due to pain Degree of sleep loss Degree of emotional distress
Measures of response - lung cancer
Surveillance scans and PET post treatment course
Blood counts, BMT myeloid/lymphoid malignant cell counts
Blood tests – CA199, PSA
Degree of functionality – walking, daily activities, ability to walk, moods
Level of pain
COPD precipitants
o Upper and lower respiratory tract infections o Omission of medications o Heart failure o Sleep apnoea o Pneumothorax o GORD o aspiration
COPD diagnosis
o Initial symptoms, spirometry – bronchodilator responsiveness, CT, arterial blood gases, FVC, FEV1
Complications of COPD
o Number of hospital admissions
o Number of exacerbations
o Number intubations
o Current exercise tolerance, flights of stairs, things unable to do
o FEV1, 6 minute walk test
o Oxygen concentration on arterial blood gas
o Current weight and degree of weight loss
o Pulmonary hypertension and right heart failure
o Lung cancer (separate issue)
o Depression (separate issue)
ECOG
0 Acute without restriction of performance
1 Ambulatory and able to attend light work activity, unable to carry out strenuous activity
2 Can manage self-care but unable to attend any form of work activity, ambulatory for more than 50% of the time while awake
3 Can manage one limited self care, bed bound for more than 50% of the time
4 Disabled, completely bed bound
Smoking - history
Amount smoked
Evidence of nicotine dependence – smokes >10/day, 30mins between smokes, smoking from waking
Smoking - high risk groups
- Pregnancy
- Parents of young children
- Aboriginal and torres strait islanders
- Mental illness
- Other substance abuse
- Lung disease
- CVD risk factors and diabetes
- Low socio-economic status
Smoking - Initial management
brief advice, motivational interviewing, quit date
Follow up - Relapses occur in first few weeks of quitting and require follow up
• Associated with weight gain, stress, and withdrawal symptoms
Smoking - pharmacological therapy
NRT increases quit rates by 60% from placebo, combination therapy oral and patch more effective than one alone CI – pregnancy, arrhthymias, lactation, CVD, angina, stroke
Varenicline – most effective, doubling abstinence rates, nausea; CI neuropsychiatric disease; however no increase in SI
Bupropion – effective with social support- CI in seizures, CNS disease, PD MAOI treatment; caution in DM, CKD, other drugs that may reduce seizure threshold
Current COPD treatment
o Bronchodilators and spacer
o Domociliary oxygen – ABG, desaturation on 6MWT
o Annual influenza vaccinations
o BiPAP
o Number of prednisolone courses
o Pulmonary rehabilitation attendance, number of times, usefulness
o Lung valves, lobectomies
o Transplantation work up (separate issue)
o Antiprotease therapy for alpha1 antitrypsin
o Frusemide for RHF
COPD - asthma ddx
Non smoker Childhood onset Allergy Nocturnal symptoms Rapid response to treatment Eosinophila in sputum Bronchodilator reversibility Atopy
COPD - bronchiectasis ddx
Daily sputum expectoration
Childhood recurrent chest infections, pertussis
Clubbing
COPD examination
- Pursed lip breathin
- Cyanosis/polycythaemia
- Intercostal recession
- Prolonged forced expiration
- Tracheal tug
- Reduced diaphragmatic movements
- Reduced chest wall expansion
- Hoover’s sign
- Reduced breath sounds w/ wheeze
- Sputum
- RHF – parasternal heave, cv JVP, palpable P2, pulsatile liver
- Cachexia
Sleep apnoea - history
- History – symptoms/concern leading to sleep study
- Use of hypnotics
- Evidence of paroxysmal nocturnal dyspnoa, orthopnoea, sensation of choking
- Driving – heavy machinery licence, adherence to driving restrictions
Risk factors OSA
obesity daytime sleepiness alcohol hypertension atrial fibrillation GORD, COPD systolic heart failure deviated nasal septum nasopharyngeal deformity or tonsillar enlargement (if no obvious obesity)
Epworth sleepiness scale
o Reading o TV o Theatre or meeting o Driving as a passenger > 1hr o Lying in afternoon o Sitting and talking o Sitting after lunch o Dozing at traffic lights
Components of sleep study
o Electroencephalogram o Apnoea/hypoapnoea index o Chin myogram o Electro-occular monitoring REM sleep o Sats probe o ECG overnight
Managment OSA
o Use of CPAP Adherence, nose bridge ulcers, uncomfortable mask, dyspnoea/anxiety in mask Improvement in sleepiness o Weightloss o Surgical correction of upper airway
OSA exam
- Malampatti score
- Neck circumference
- BMI
- Hip/waist ratio
- Acanthosis nigricans
- Evidence of nasal bridge ulcers
Interstitial lung disease - symptom history
o Dry cough, worsening dysponea
o History of pneumothorax, young woman
o Systemic/rheumatic symptoms
o History of asthma -> Churg-Strauss syndrome
o Haemoptysis/renal disease – Goodpastures/SLE
Interstitial lung disease - drug/RTx history
Cardiac/anti-arrhythmic – amiodarone, procainamide
Hydralazine
Rheumatologic – MTX, penicillamine
Chemotherapeutics – bleomycin, bisulphin
o Prior radiotherapy
Interstitial lung disease - rheumatic symptoms
Raynauds Polyarthritis Rashes Morning stiffness Generalised malaise, LOW, LOA, sweats Pleural lung disease, pericarditis
Interstitial lung disease - occupational history
Silica, asbestos, coal
Nitrogen, chloride gas, ammonia gas
Brake fluid, vinyl chloride
Interstitial lung disease - Hypersensitivity exposure
Bird, farmers – mouldy hay/grain
Cotton (byssinosis), flax/hemp dust
o History of tuberculosis exposure
Interstitial lung disease - investigations
o CT chest – fibrosis, usual interstitial pneumonia (honey combing, subpleural basal predominance, traction bronchiectasis), Non-specific interstitial fibrosis
o Brochoscopy and lavage w/ biopsy
o ESR, CRP, ANA/ENA ABG
Interstitial lung disease - treatment
o Remove exposure, steroids – hypersensitivity, COP, sarcoidosis, CTD, histiocytosis X
o Nifedipine
o Lung Tx
o Home O2
Investigations for pulmonary HTN
TTE, cardiac catheterisation, PFT, CT chest, V/Q, CTPA, HRCT, 6 minute walk test
Risk factors for Pul HTN
o Prior PE, COPD, heart failure, family history, gene testing (BMPR2), HIV, interstitial lung disease, sleep apnoea, scleroderma/MCTD
Medications for pul HTN
warfarin, bosentin, sildenafil, prostacyclin (SE: flushing)
History for sarcoidosis
o Systemic symptoms o Joint symptoms and rash o Eye involvement – uveitis o Sinusitis, parotiditis o Renal stones o Nerve palsies
Differentials for sarcoidosis
o Connective tissue disease -SLE – joint/rashes, mucosal involvements, RA, seronegative arthritis, sjogrens
o Bechet’s disease – genital and mucosal ulcers, family history
o Vasculitis – Granulomatous polyangiitis, eosinophilic polyangiitis, polyarteritis nodosa, GCA/PMR +/- glomerulonephritis
o Antiphospholipid syndrome
o Lymphoma, paraproteinaemia, POEMS, castleman’s
o Subacute infective endocarditis
o Atrial myxoma
o Cholesterol emboli – recent angiography
o Tick disease
o Hypothyroidism/hyperthyroidism
Symptoms of hypercalcaemia in sarcoid
o Polyuria, polydipsia, confusion
Investigations for sarcoidosis
o ESR, CRP, ANA/ENA/ANCA, dsDNA, SPEP, immunoglobulins, TFTs, FBE, CMP, Vitamin D, CT chest, TTE, blood cultures bone marrow biopsy
Cystic fibrosis - systemic involvement
o Recurrent pneumonia, pleurisy, effusion, empyema and abscess o Bronchiectasis o Nasal polyps o Pancreatic failure - malabsorption, o small bowel obstruction o Focal biliary cirrhosis o Exocrine diabetes mellitus
Cystic fibrosis - investigations
o Sweat/chloride testing
o PCR/DNA gene marker
o Spirometry FEV1, CT scans
o Sputum cultures, colonisation
o FBE for anaemia of chronic disease, IDA, and B12 deficiency
o LFTs, INR, abdominal USS, AFP, gastroscopy for varices
Cystic fibrosis - complications
o Haemoptysis o Pneumonia o Empyema o Pleurisy o Pneumothorax
Management of cystic fibrosis
o Physiotherapy o Exercise tolerance o Pancreatic enzyme supplementation o High fat diet o Recombinant DNAase - Transplantation work up o Regular appointments o Fertility, consideration of IVF
Indications for lung transplant
COPD FER <25%, cystic fibrosis PaCO2 > 55, FER < 30%, ILD DLCO <20%, symptoms, eisenmengers, pulHTN – PAP >55, cardiac index <2L/min?
Contra-indications for lung transplant
Relative - T2DM ,osteoporosis, etOH, smoking, MAC/tuberculosis abscesus colonisation, wt >130% ideal <70% ideal, compliance
Absolute HIV, HBV, HCV, malignancy <5yrs
Transplant history
- Rejection -HLA matching
- Infections – influenza, aspergillosis, CMV, myxomavirus, aspergillosis
- Immunosuppression – renal transplant, hyperlipidaemia, post transplant lymphoproliferative disorders
- Brochiolitis oliterans – chronic rejection,
