Pastest - Resp Flashcards
What are the physical signs of interstitial lung disease?
Functional status
-LTOT, sticks etc
Hands
-Clubbing and peripheral cyanosis
-Signs of systemic lung disease (RA, systemic sclerosis, dermatomyositis)
-Important negative finding is lack of tar staining
-Look for steroid bracelet
Neck/chest/ periphery
-Scars from lung biopsy or thoracotomy for transplant
-Lymphadenopathy in sarcoidosis
-Assess cor pulmonale (JVP, displaced apex, left parasternal heave (RVH), ankle swelling)
-Symmetrically reduced expansion, bases dull, reduced VF/TVF over fibrotic areas
Auscultation
-Fine end expiratory creps (no change with coughing)
-Occasional wheeze if obstructive element (sarcoid)
-Split second heart sound or loud P2
What are the differentials for upper and lower zone fibrosis?
Basal creps
-Idiopathic pulmonary fibrosis
-Connective tissue disease
-Asbestosis
-Aspiration
-Drugs
Apical creps
-TB
-Radiation
-Sarcoidosis (mid apical)
-Extrinsic allergic alveolitis/ hypersensitivity pneumonitis,
-Ankylosing spondylosis
-Psoriasis (other rheum conditions cause basal)
-Pneumoconioses (except asbestosis)
What are the investigations for interstitial pulmonary fibrosis?
INITIALLY
Blood tests:
-FBC, Rheumatoid factor, anti-CCP, ANA, ANCA, anti-GBM, CK, serum ACE
Chest radiograph
ABG
KEY DIAGNOSTIC/ PROGNOSTIC TEST
-PFTs (remember sarcoid may show obstructive pattern)
-6MWT for functional status
-HRCT
-BAL (lymphocyte predominant washings = better prognosis because steroid responsive)
-Lung biopsy
-ECHO
What are the physical signs of bronchiectasis?
FUNCTIONAL STATUS
Dyspnoea, cyanosis, sputum pot, cachexia
HANDS
Clubbing
Tar staining
Yellow nails syndrome (yellow thickened, curved nails with lymphoedema on legs - very rare)
NECK/ CHEST/ PERIPHERY
Inspiratory ‘clicks’ from end of bed
Cor pulmonale
May be lymphadenopathy if secondary to local obstruction from lung Ca, sarcoid or TB
AUSCULTATION
Mixed course mid-end inspiratory and expiratory creps (can change with coughing)
May be wheeze if obstructive element
(up to a third of those with COPD will also have bronchiectatic changes. Assess location and extent of the disease. Is a single lobe affected or is it more widespread?
SIGNS OF TREATMENT
There may be a B-agonist induced tremor or signs of surgical resection for severe localised disease
What is the differential diagnosis of bronchiectasis?
Bronchiectasis describes dilatation of the airways resulting from proximal obstruction caused by one of the following:
MECHANICAL
Congenital defects of large airways (yellow nail syndrome)
Bronchial malignancy,
Foreign body,
Traction fibrosis
Lymphadenopathy associated with cancer, sarcoidosis or TB
CHEMICAL
Chronic gastric aspiration or inhalation of toxic chemicals and resultant hypersecretion and obstruction
RECURRENT CHILDHOOD INFECTION: TB, whooping cough, measles
CHRONIC ADULT INFECTION: TB, opportunistic mycobacteria, severe pneumonia
-These may occur in the context of immunosuppression (HIV and hypogammaglobulinaemia)
CILIARY DYSKINESIA: (kartagener’s)
CYSTIC FIBROSIS
AUTOIMMUNE ASSOCIATIONS: Rheumatoid arthritis, Sjogren’s syndrome, IBD
HYPERSENSITIVITY
ABPA
What are the investigations for bronchiectasis?
IN THE FIRST INSTANCE
Blood tests: ESR, CRP, serum ACE, HIV serology
Immunology: aspergillus precipitins, skin tests, RAST, immunoglobulins, ANA, rheumatoid factor
Sputum: MC+S including culture for mycobacterial disease
CXR: ring shadows and tramlines
KEY DIAGNOSTIC/ PROGNOSTIC TESTS
HRCT: diagnostic. Signet ring sign
PFTs: obstructive or restrictive
Ciliary function tests
Bronchoscopy and biopsy
CF investigations if <40
What is the treatment of interstitial lung disease?
PATIENT EDUCATION:
Smoking cessation, avoidance of precipitants and certain medications
PULMONARY REHABILITATION
IMMUNISATION against pneumococcal disease and annual flu
CORTICOSTEROIDS or steroid sparing agents
LTOT
CLINICAL TRIAL
SINGLE/ DOUBLE LUNG TRANSPLANTATION: if <65 and in the context of severe disease
What is the treatment for bronchiectasis?
PATIENT EDUCATION
Smoking cessation, avoid precipitins in ABPA, prompt treatment if infection
PULMONARY REHABILITATION
PHYSIOTHERAPY
Helps with airway clearance
BRONCHODILATORS AND ANTICHOLINERGICS
For those with reversible airflow. No evidence for steroid unless asthma
ANTIBIOTICS
SURGICAL RESECTION
For those with localised disease not controlled with medical management
LTOT
What are the physical signs of lobectomy/ pneumonectomy?
FUNCTIONAL STATUS
Usually not dyspnoeic or cyanosed unless underlying bronchiectasis
HANDS
Clubbing (malignancy, bronchiectasis, lung abscess TB)
Consider malignancy if evidence smoking
NECK/ CHEST/ PERIPHERY
Scars and associated flattening of chest wall
Trachea and apex deviates to side with thoracotomy (less obvious or absent in lower/middle lobectomy)
Use expansion to try determine if upper, lower or full pneumonectomy
Reduced percussion and TVF/VR on side of thoracotomy (determine which lobe/ whole lung)
Beware single lung transplant: thoracotomy scar, normal resp exam that side and possible disease changes remaining on contralateral side
AUSCULTATION
Reduced or missing breath sounds over removed lobe or pneumonectomy
Listen for clues as to underlying lung disease
SIGNS OF TREATMENT
Radiotherapy markings in malignancy
Rib removal (thoracoplasty) historically for TB
Lymphadenopathy and clubbing
What are the differentials in lobectomy/ pneumonectomy?
MALIGNANCY
Clubbing and nicotine staining
Pancoasts syndrome (horners and wasting of small muscles hand)
SVCO or lymphadenopathy
Signs of metastatic disease (jaundice, hepatomegaly)
BRONCHIECTASIS
Indicated for severe local disease or large/ recurrent haemoptysis
Clubbing, coarse inspiratory crackles
Signs of associated diseases (malabsorption in CF)
LUNG ABSCESSES
Clubbing
TB
Thoracoplasty and phrenic nerve crush (supraclavicular scar causing rise in ipsilateral hemidiaphragm, resulting in reduced expansion, dull percussion note and no breath sounds at the base)
What are the physical signs of COPD?
FUNCTIONAL STATUS
Dyspnoea, accessory muscles, prolonged expiratory phase, pursed lips, cyanosis and/or cachexia
HANDS
Staining, flap, bounding pulse, B-agonist tremor
COPD alone does not give clubbing (consider bronchiectasis/ lung Ca)
NECK/ CHEST/ PERIPHERY
Hyperinflated chest with reduced expansion
Hyperresonant percussion
Impalpable or weak apex beat
If pulmonary HTN: raised JVP, parasternal heave, loud P2, ankle swelling
AUSCULTATION
Wheeze and reduced breath sounds throughout. This may be more marked in the bases in alpha1-antitrypsin deficiency
SIGNS OF TREATMENT
Look for signs of steroid use with purpura, striae, cushingoid appearance, proximal myopathy and steroid bracelet/ necklace.
Look for scars
What is the MRC dyspnoea scale?
- Not troubled by breathless except on strenuous exercise
- Short of breath when hurrying or walking up a slight hill
- Walks slower than contemporaries on level ground, or has to stop for breath when walking at own pace
- Stops for breath after walking about 100m or after a few minutes on level ground
- Too breathless to leave the house or breathless when dressing or undressing
What are the investigations for COPD?
PFTs
Bloods: WCC/CRP/ESR in exacerbations, polycythaemia in hypoxia, liver enzymes and alpha1-antitrypsin if deficiency suspected
ABGs
Chest radiograph
ECG (cor pulmonale with RAD, p pulmonale and RBBB)
ECHO
HRCT ?bullous disease or malignancy
Sputum: MC and S
BMI: marker of disease severity and has prognostic value
What is the management of stable COPD?
Smoking cessation
Immunisation against penumococcal disease and annual seasonal influenza immunisation
Optimise inhaled therapy
Mucolytic therapy
LTOT
Surgery
MDT
What are the physical signs in pleural effusion?
FUNCTIONAL STATUS
May be dyspnoeic, coughing (look for sputum pot) and cachectic
HANDS
Look for tar staining and clubbing.
May be swollen, tender wrists if HPOA
Wasting small muscles hand in Pancoast’s tumor
NECK/ CHEST/ PERIPHERY
Horner’s syndrome (test C8-T1 dermatomes)
SVCO
Scars (lobectomy, pneumonectomy, lung or pleural biopsy, or pleuradhesis)
Tattoos or burns from radiotherapy
Lymphadenopathy
Standard signs of effusion
SIGNS OF TREATMENT
Radiotherapy or signs of steroid use
SIGNS OF DISSEMINATED DISEASE
cranial nerves, hepatomegaly, bony tenderness, cord compression legs
PARANEOPLASTIC PHENOMENA
Dermatomyositis
acanthosis nigricans
cerebellar signs
lambert-eaton myasthenic syndrome
gynaecomastia
