PACES - Resp Flashcards
Resp causes of clubbing
Cancer
Bronchiectasis
Emphysema
CF
Fibrosis
Wheeze - asthma
Vesicular breath sounds
fine Inspiratory crackles - Fibrosis if not changed by coughing
Coarse crackles
What are the indications for a lobectomy?
Localised cancer
TB
Abscess
Empyema
Emphysema
how does interstitial lung disease present?
Progressive SOB on exertion
Dry cough
Malaise, fatigue
Weight loss
What might you see on examination of a patient with interstitial lung disease?
Clubbing
Scars
Reduced chest expansion
Fine late end-inspiratory crepitations that do not clear with coughing but do quieten/disappear on leaning forwards
What are the underlying causes of interstitial lung disease (and their signs)
Rheumatoid arthritis: peripheral symmetrical deforming polyarthropathy (swan neck deformity, Z thumb, ulnar deviation at wrist, may have nodules) NB: the cause of the pulmonary fibrosis may be RA itself or methotrexate use in an RA patient
Amiodarone: slate grey appearance, pacemaker, may be in AF, photosensitivity
Connective tissue disease: cutaneous signs of systemic sclerosis, lupus, dermatomyositis
Ankylosing spondylitis: question mark posture, protuberant abdomen
Radiation: may have radiation tattoo on chest wall, lymphadenopathy
Sarcoidosis: cutaneous signs of sarcoidosis
What causes upper zone fibrosis
BREAST
Berylliosis
Radiation e.g. for breast cancer
Extringic allergic alveolitis, pneumoconiosis e.g. coal workers
Ankylosing spondylitis, ABPA (Allergic bronchopulmonary aspergillosis)
Silicosis, sarcoidosis psoriasis
Tuberculosis (and histoplasmosis and histiocytosis-X)
What causes lower lobe fibrosis?
RASIO
Rheumatoid arthritis
Asbestosis
Scleroderma, SLE, Sjogrens (and poly/dermatomyositis)
Idiopathic pulmonary fibrosis
Others: Drugs- methotrexate, bleomycin, busulphan, cyclophosphamide, nitrofurantoin, isoniazid, amiodarone, phenytoin, carbamazepine, gold, sulphasalasine.
How would you investigate lung fibrosis?
Bedside: ECG, ABG
Bloods: FBC (eosinophilia, anaemia, polycythaemia), CRP, ESR, Autoimmune screen including antibodies, serum ACE
Imaging: CXR, High resolution CT
Special tests: Lung function tests, Biopsy, Echo (Pulmonary HTN)
What signs might you see on CXR of someone with pulmonary fibrosis?
Bilateral reticulonodular interstitial infiltrates (parenchymal shadowing)
Ground-glass/honeycombing if advanced
Volume loss
Which signs might you see on HRCT of a patient with pulmonary fibrosis?
Reticulation
Ground glass (usually good response to steroid treatment)
Volume loss
Honeycombing
How would you manage Pulmonary Fibrosis?
Conservative: Stop smoking, remove triggers, vaccines, pulmonary physio
Medical: Treat cause. Manage infections. Steroids. Immunosuppressants (Azathioprine)
Surgical: Lung Transplant
How would bronchiectasis present?
Shortness of breath
Chronic productive cough: thick, smelly, purulent sputum
Haemoptysis
Recurrent infections
Pleuritic chest pain
Weight loss
History of childhood infections, sinusitis, subfertility
Which signs might you see in a patient with bronchiectasis?
Clubbing
May have scars
Reduced chest expansion
Early coarse inspiratory crepitations that alter with coughing but do not quieten/disappear on leaning forwards
Wheeze, inspiratory clicks
Which complications of bronchiectasis might you be able to pick up on on examination?
respiratory failure (oxygen, cyanosis, CO2 retention flap)
cor pulmonale (RV heave, loud P2, raised JVP, peripheral oedema)
infection (bronchial breathing, antibiotics at bedside, fever)
What might cause bronchiectasis?
Cystic Fibrosis: young, thin, short, PEG, portacath/Hickmann, signs of chronic liver disease
Kartagener’s Syndrome: Dextrocardia
Connective tissue disease: peripheral symmetrical deforming polyarthropathy, cutaneous signs of lupus
Yellow Nail Syndrome: yellow nails, lymphoedema
COPD, HIV, Post-infective (TB, pertussis, measles)
How might you investigate bronchiectasis?
Bedside: ABG (Resp Failure), ECG (R.Heart Strain)
Bloods: FBC (anaemia, eosinophilia), CRP, Autoimmune screen, HIV test, Aspergiluus percipitins and IgE
Sputum MC&S
Imaging: CXR, HRCT
Lung Function tests, Biopsy, Sweat test
What might you see on CXR of a patient with bronchiectasis?
Tramlines (diseased bronchi side on)
Ring shadows (diseased bronchi end on)
Gloved finger: mucoid impactions in large air ways
Hyperinflation
7% normal CXR
What might you see on HRCT of a patient with bronchiectasis?
Signet ring sign- thickened end-on dilated bronchus >1.5 times larger than adjacent pulmonary artery
Tram tracking
Ring shadows
Volume loss
Flame and blob sign: mucus plugging
How would you manage bronchiectasis?
Conservative: Stop smoking, vaccines, physiotherapy
Medical: Treat cause, steroids, bronchodilators, ABx
Surgical: Lobectomy, Transplant
What are the main complications of bronchiectasis?
infection (Pseudomonas, Haemophilus influenzae), Empyema, Cor Pulmonale, Anaemia, Secondary amyloidosis
How does pleural effusion present?
Dyspnoea
Cough
Pyrexia
Haemoptysis
Pleuritic chest pain
Weight loss, rash, abdominal swelling, peripheral oedema
What might you see on examination of a patient with a pleural effusion?
Reduced expansion
Trachea displaced away from side of the effusion
Apex beat shifted away from the side of the effusion
Stony dull percussion note
Decreased vocal resonance
Reduced air entry/breath sounds
Bronchial breathing may be present above the effusion
Which signs might indicate that malignancy is the underlying cause of a pleural effusion?
clubbing, cachexia, lymphadenopathy, tar staining, radiation burns, Horner’s syndrome, small hand muscle wasting, hypertrophic pulmonary osteoarthropathy (HPOA), evidence of chemo eg. hair loss, resection scars, mastectomy scars
Which signs might indicate that infection is the underlying cause of a pleural effusion?
chest drain scar, iv cannula, iv antibiotics, febrile
What are the main transudate causes of pleural effusion?
CCF
Cirrhosis
Nephrotic Syndrome
What would your differential be for a pt presenting with a likely pleural effusion?
Lower Lobe collapse
Lobectomy (would expect to see a scar)
Raised hemidiaphragm eg. phrenic nerve palsy, hepatomegaly
Basal consolidation
Pleural thickening eg. pleural plaques
Mitotic mass
What are the main exudative causes of pleural effusion?
Malignancy
Infection
PE
Sarcoidosis
Connective Tissue Disorders
How would you investigate a Pleural Effusion?
Bedside: ECG (RH Strain) ABG (Resp Failure), Dipstick (Proteinuria)
Bloods: Routine + CRP/ESR, AI Screen, Lipid profile
Sputum MC&S
Pleural Fluid analysis. Can use USS here
Imaging: CXR, HRCT
How would you manage pleural effusion?
Conservative: O2, analgesia, physio, fluids
Treat the cause
Which drugs can cause pulmonary fibrosis?
BANS ME
Bleomycin
Amiodarone
Nitrofurantoin
Sulfasalazine
Methotrexate
