Resp Flashcards
Benefits of VATS procedure over open thoracotomy
Video-assisted thoracoscopic surgery - small incision, so reduced pain, wound complications, healing time and length of stay
But for Pleurectomy - greater risk of recurrent pneumothorax in VATS (5%) than open (1%)
indications for lobectomy
- Lung cancer resection (main) - most commonly NSCLC, in RUL
- TB
- Aspergilloma (to protect from massive haemorrhage)
- Lung abscess
- Remember pleurectomy for recurrent pneumothox
- and Lung volume reduction surgery i.e. bullectomy
FEV1 for lobectomy to have good outcome
Good outcome if FEV1 > 1.5
> 2 for a full pneumonectomy
provided there is no ILD or disability from SOB
If not clearly operable patients should have Sats at rest and Transfer Factor (TLCO) >50
FEV1 for pneumonectomy to have good outcome
> 2 for a full pneumonectomy
> 1.5 for lobectomy
provided there is no ILD or disability from SOB
If not clearly operable patients should have Sats at rest and Transfer Factor (TLCO) >50
way to measure prognosis in post op lung resection
Stair climbing is practical way
FEV1 and VO2 max < 15ml/kg/min
..VO2max = maximal oxygen utilised during maximal exercise
lung cancer histology
Small Cell
NSCLC (80%)
Majority - Squamous & Adeno
Also - Large cell & Neuro endo
Most common lung cancer in non-smokers
Adenocarcinoma
This is also most common overall, but in smokers squamous is most common
Asbestos causes which cancers
Mesothelioma, but also bronchial carcinoma, laryngeal cancer and ovarian cancer.
Lung cancer with hyponatremia
Small cell… Occurs because of ectopic ADH secretion
Mx of lung cancers
SCLC is rapidly progressive, often presents late…
So early disease - chemoradiotherapy
Late - often palliative chemo
NCLC - could include curative surgical, +/- adjuvant chemoradio
normal examination findings but scar indicating a VATS
Could be
• Wedge resection of solitary pul nodule
• Lung biopsy
• Surgical treatment of non-resolving/recurrent pneumothorax
if RECENT lobectomy, may have deviated trachae and reduced AE
Pneumonectomy will have deviated trachae, absent breath sounds and dull perc
scars on VATS procedure vs open thoracotomy
Open thoracotomy -
• 15-20cm on lat chest wall
• may also be chest drain scar
VATS -
• 3 scars in triangle
• 3-6cm lat chest wall
• Sometimes only 2 or 1 scar apparently
What is Transfer Factor (TLCO) used for related to lung cancer management
If not clearly operable (i.e. FEV1 >2 for pneumonectomy or >1.5 for lobectomy) then TLCO
IF estimated postoperative TLCO and est postop FEV1 is high then low risk
(it measures how your lungs take up oxygen from the air you breathe)
Resp causes of clubbing
- Bronchogenic carcinoma (AKA any type/subtype)
- ILD (particularly IPF)
- Bronchiectasis
- Lung abscess/empyema
- CF
pneumonectomy vs lobectomy examination findings
Pneumonectomy will have deviated trachae, absent breathsounds and dull perc
Lobectomy likely to be normal or possibly reduced
copd inhaler management
FIRST
Short acting
• …beta-2 agonists, like salbutamol
• or …muscarinic antagonists, like ipratropium
SECOND
if no asthmatic/steroid responsive features:
Long acting:
• …beta-2 agonists, like salmeterol
• AND …muscarinic antagonists, like tiotroprium
If that fails, or if asthmatic/steroid responsive features, then trial inhaled corticosteroids
indications for VATS
- Lobectomy
- Wedge resection (i.e. cancer etc)
- Lung biopsy (i.e. ILD, cancer)
- Decortication (i.e. in long-standing empyema, pleural thickening, hemothorax, and pleural tumors)
- Bullectomy (i.e. COPD)
- Pleurectomy (recerrent pneumothoraxes)
Why is suction not be routinely recommended in chest drain pneumothorax?
Rare as risk of re-expansion pulmonary oedema
Consider if persistent air leak…arbitrarily defined as continued bubbling of air through a chest drain after 48 h in situ,,,
Mx of pneumothoraces if no prev history < 50yr and breathless
(Primary pneumothorax)
• As SOB → aspirate up to 2.5L
• if <2cm and breathing improved then consider discharge + OP review in 2-4weeks
• If not → Chest drain
Mx of secondary pneumothorax
- Always admit
- > 2cm OR breathless → chest drain
- 1-2cm → aspirate
- <1cm → admit for 24h with O2
Can you differentiate between a lobectomy and other indication of VATS in otherwise normal exam
- IF normal chest exam, Lobectomy is less likely
- indications for lobectomy are often smoking-related diseases
Lobectomy may have normal chest signs but likely signs related to smoking
Eosinophils in asthma
~ 40% of severe asthmatics are diagnosed with Eosinophilic asthma
Don’t respond to steroids as well so treated with MABs
Diurnal variation in Asthma
Low peak flow in night/morning
spirometry in asthma vs COPD
- both have obstructive picture (<0.7 = reduced FEV1, preserved FVC)
- Asthma would improve with bronchodilator (15% impr of FEV1)
asthma management
1) SABA
2) Add inhaled steroid if: exacerbations in last 2yr; using salbutamol or symp 3/wk; OR waking one night/wk
3) Trial LABA (Salmeterol) +/- increasing steroid
4) Add leukotriene receptor antagonist; theophylline; slow release β2 agonist tablets
5) Oral Steroids
Obstructive respiratory disease
- Asthma
- Bronchiectasis
- COPD
- Rarer…Obliterative bronchiolitis (fixed airflow obstruction, from viral, polutent, Graft vs host (like lung transplant)
causes of polyphonic wheeze
obstructive resp disease
- COPD
- Asthma
- Bronchiectasis
- Rarer…Obliterative bronchiolitis (fixed airflow obstruction, from viral, polutent, Graft vs host (like lung transplant)
bibasal crepitations
• End-inspiratory fine - ILD
• Coarse-inspiratory - Bronchiectasis
with periph oedema and elevated JVP - Congested HF
• Bilat pneumonia
Spirometry findings in ILD
- Restrictive
- Reduction in both FEV1 and FVC with preserved ratio
- Reduced TLC and Transfer Factor
antifibrotic therapies for the treatment of idiopathic pulmonary fibrosis
- Pirfenidone
- and Nintedanib
Considered by tertiary centres if FVC 50-80%
Management of ILD
Conservative
• MDT approach - physio - resp nurses for SOB and QOL
Medical
• Mx underlying connective tissue disorder w DMARD
• May respond to steroids if CT shows ground glass
• if IPF and FVC 50-80% then anti-fibrotic agent
Surgical
• Consideration of lung transplantation
What is HRCT
high resolution CT without contrast that gives definition to pulmonary parenchyma
e.g. in pulmonary fibrosis or bronchiectasis
Upper Vs lower zone fibrosis
ACID causes lower, the rest upper
- Asbestosis
- Connective tissue disorders (except ank spond)
- Idiopathic pulmonary fibrosis / usual Interstitial Pneumonia
- Drugs…… (Amiodarone, bleomycin, methotrexate).
Upper: C -Coal worker's pneumoconiosis H -Histiocytosis/hypersensitivity pneumonitis A -Ankylosing spondylitis R - Radiation T -Tuberculosis S -Silicosis/sarcoidosis
Causes of Interstitial lung disease (ILD)
- Idiopathic – IPF, or sarcoidosis
- Occupational – asbestosis or silicosis
- Hypersensitivity pneumonitis (ABPA, farmer’s)
- Connective tissue disease – RA, SLE, polymyositis
- Drug-induced – Amiodarone, Nitro, Methotrexate, radiotherapy
When would you consider antifibrotic therapies in IPF
Considered by tertiary centres if FVC 50-80% predicted in idiopathic pulmonary fibrosis to slow disease progression
(pirfenidone and nintedanib)
patient over 50yr with SOBOE, persistent cough
OE bilat fine end inspiratory crackles, finger clubbing
Classic hx of idiopathic pulmonary fibrosis
if no signs of connective tissue disease or occupational
Which interstitial lung disease (ILD) carries worst prognosis?
Idiopathic pulmonary fibrosis
- Median survival is 2-3 years from diagnosis
- Only 20-30% survive to 5 years
Poor prognosistic factors for IPF
Basically every bad feature…
- Old age
- Dyspnoea
- Low or declining pulmonary function
- Pulmonary artery HTN
- Co-existing emphysema
- Extensive radiographic involvement
- Low ET
- Exertional desat
- Universal interstitial pneumonia (UIP) on histopath
Pt with coarse inspiratory creps and PEG tube
?CF
May have a Button Gastrostomy instead
Also may have clubbing
Could have previous Portacath
Classically upper lobe creps +/- exp wheeze
what gene transmits CF?
CFTR gene on Chromosome 7
… leads to increase salt excretion
Can you tell me anything about the cause of cystic fibrosis?
- Auto recessive
- Mutation in CFTR chr 7
Leading to increased salt excretion, therefore, thicker mucus which will affect:
• respiratory system → bronchiectasis
• digestive tract → pancreatic insufficiency
• reproductive system → in/subfertility
Drug management for CF
- Regular mucolytics nebs
- Creon and Fat soluable vitamins
- Prophylactic azithro
- Vaccines
• Lumacraftor-ivacaftor (Orkambi) if homogenous ΔF508
(50% of patients are homozygous)
what bacteria in CF is absolute contraindication to lung transplantation?
Burkholderia cenocepacia
non-tuberculous mycobacteria - Mycobacterium abscessus
(carries particularly poor prognosis so is absolute contraindication)
CF life expectancy
~50% will live past the age of 40
as per NHS website
How is CF diagnosed?
All infants in UK are screened using Guthrie’s test for phenylketonuria a few days after birth
Previously, diagnosed following meconium ileus in infancy or failure to thrive
CFTR modulating therapies in CF
Lumacraftor-ivacaftor (Orkambi) can be used if homogenous delta F508
(50% of patients are homozygous)
commonest indications for lung transplant
COPD (most common, likely single lung)
Bronchiectasis (including CF)
Pulmonary fibrosis (likely single)
Pulmonary hypertension (may need heart-lung transplant)
Double lung transplant vs single
Better prognosis (7.5yr median survival vs 4.5) ( most likely in Bronchiectasis e.g. CF )
indications for heart-lung transplant?
severe pulmonary hypertension
Complications of lung transplant
ACUTE PHASE
• acute rejection (most pt will experience at least once in first 6/12)
• opportunistic infections
CHRONIC PHASE
• Bronchiolitis obliterans - usually a terminal event - >50% will develop some degree of BO 5y post-trans
• Cancer - post transplant lymphoproliferative disorder most common in first year/ skin malig
• Steroid SE
• Tacrolimus → diabetes, tremor
• Renal and hearing impairment from anti-rejection agents
contraindications to lung transplant
- Malignancy in last 5yr (or 2yr if low risk of recurrence)
- BMI >35
- Current smokers or substance abuse
- Mental Health conditions that would preclude taking meds or attending clinic
- Untreatable heart liver kidney or brain dysfunction
- Atherosclerotic disease w end organ ischaemia
Criteria to consider lung tranplant in end stage lung disease
> 50% chance of death within 2yr
80% chance of surviving >90 days post transplant
80% 5yr post tranplant survival from gen med perspective
(sick enough to need one, fit enough to survive, with no major comorbs)
When to consider lung transplant in CF
- Poor ET
- Frequent exacerbations
- FEV1 < 30%
- Signif pulmonary artery hypertension
Which lung condition carries the best post-transplant survival
CF
Causes of increased vocal fremitus
- Pneumonia
- hyperinflation like COPD asthma
- Lung abscess
Causes of decreased vocal fremitus:
- Pleural effusion
- Pneumothorax
- Emphysema
yellow nail syndrome triad
- Yellow nail discoloration
- Pulmonary - bronchiectasis, pleural effusion
- Lower limb lymphedema
Chronic sinusitis is frequently associated with the triad.
Causes of bronchiectasis
Bronchiectasis can be idiopathic (40%)
Other causes can include:
• Bronchiectasis can be idiopathic (40%)
• Recurrent infections Alcoholics/asp pneumonia
• childhood infections – , TB, measles
• Hypersensitivity - Allergic bronchopulmonary aspergillosis
• Inherited - CF, primary ciliary dyskinesia
Tell me about Allergic bronchopulmonary aspergillosis (ABPA)
a hypersensitivity response to the fungus Aspergillus (most commonly Asp fumigatus)
causes bronchiectasis
Common in CF and asthma
Dextracardia and chronic productive cough
Primary ciliary dyskinesia
• autosomal recessive genetic ciliary disorder
• Diagnose with ciliary function tests - can they taste saccharin 20m after placed in nose?!
OR if full situs invertus:
Kartagener’s syndrome
• autosomal recessive genetic ciliary disorder
• situs inversus, chronic sinusitis, and bronchiectasis
Diagnosis of Allergic bronchopulmonary aspergillosis (ABPA)
- Aspergillus skin test (AST)
- Elevated IgE (Total, and specific serum to A. fumigatus)
- Baseline CXR
- HRCT
respiratory causes of raised JVP
COPD or ILD
Chronic hypoxia leads to pulmonary vasoconstriction,then
pulmonary hypertension, causing R heart failure
Hypertrophic pulmonary osteoarthropathy
- periostitis
- digital clubbing
- painful arthropathy of the large joints (particularly lower limbs)
How would you do a biopsy for ?Lung cancer
Biopsies may be made via • bronchoscopy • endobronchial ultrasound • percutaneously (under radiology) • mediastinoscopy
LN also biopsied or FNA
Pleural effusions should undergo diagnostic pleural aspiration
Causes of unilateral pleural effusion
Likely exudative • Lung malignancy • Infection (parapneumonic, empyema) • Infarction e.g. due to pulmonary embolus • Inflammation: RA and SLE
Causes of bilat pleural effusion
Likely Transudative
• Cardiac failure
• Liver failure - cirrhosis / hypoalbuminemia
• CKD
How to distinguish between transudative and exudative pleural effusion?
Light’s criteria on a pleural aspirate.
Exudate if one or more of:
• pleural fluid : serum Protein ratio is > 0.5
• pleural fluid : serum LDH ratio is > 0.6
• pleural LDH >2/3 the upper limit of normal for the serum LDH
pH < 7.1 also suggests an exudate
In pleural effusion, when would you drain?
• Symptomatic
Signs it is parapneumonic
• Pleural pH <7.2 is most important (or high LDH and low glucose, but less accurate)
• Purulent or turbid/cloudy
• Positive culture
Most likely diagnosis in pneumonectomy
NSCLC for both pneumonectomy and lobectomy
What drug treatments are used for interstitial lung disease?
For idiopathic pulmonary fibrosis:
• Pirfenidone
• Nintedanib
For patients with non-specific interstitial pneumonia/ground glass shadowing:
• Steroids
• Immunosuppressive therapy
COPD classification of severity
FEV1 compared to predicted • >80% mild • 50-80% moderate • 30-50% severe • <30% very severe
Pt with rheumatoid arthritis who presents with respiratory disease
- ILD
- bronchiectasis directly from RA, or from infections related to immunosuppression
- obliterative bronchiolitis (this is obstructive, and rare)
CXR sarcoidosis
Stage 0 - no abnormalities (5-10%)
Stage 1 - Bilateral hilar lymphad (50%)
Stage 2 - Bilateral hilar lymphad + pulmonary infiltrates (25-30%)
Stage 3 - Diffuse pulmonary infiltrates (10-12%)
Stage 4 - Pulmonary fibrosis 5%
Treatment for sarcoidosis
Mostly supportive only
If severe symptoms or CXR of stage 2 or above, use systemic steroids
Methotrexate or anti TNF therapies can be used
What is sarcoidosis
A granulomatous disorder that affects multiple organs
Cause is not known
Diagnosis of sarcoidosis
transbronchial biopsy +ve in 90%
pulmonary function tests in sarcoidosis
restrictive
decreased TLCO gas transfer
Distinguish between bronchiectasis and ILD
Both have Fine creps , but they shift following a cough with bronchiectasis
ILD -restrictive
Bronch -obstructive
(both can have clubbing)
PE Wells score
4 points (PE likely) • DVT +3 • PE is top diagnosis +3 • Tachy > 100 +1.5 • Immobilisation >3d OR surgery in 4w +1.5 • Previous PE/DVT +1.5 • Hemoptysis +1 • Malignancy +1
DVT Wells score
> = 2 likely
- Malignancy
- Immobilisation >3d OR surgery in 12w
- Calf swelling (>3cm)
- Superficial veins
- Entire leg swollen
- Localised tenderness along the deep venous system
- Unilateral pitting oedema
- Paralysis, paresis, or recent plaster immobilization of the lower extremity
- Previous DVT
- Alternative diagnosis (-2)
Prolonged expiratory phase
Indicates obstructive picture
• COPD
• Asthma
• Bronchiectasis
(ILD is restrictive)
Counselling for Patient with TB
4 antibiotics 6m of treatment SE Liver Avoid alcohol Check HIV etc
Isolation if multidrug-resistant TB until sputum becomes negative
Can force to keep under Public Health Act 1984
Signs of Superior Vena Cava Obstruction
- Dilated veins over the arms, neck and anterior chest wall
- Oedema of the upper body, extremities and face
- Severe respiratory distress
Exacerbated by Pemberton’s sign
Causes of Superior Vena Cava Obstruction
- Bronchiogenic carcinoma
- NSCLC
- SCLC
lymphoma and germ cell tumours responsible for a smaller but significant proportion
Differential causes of obliterative bronchiolitis
- Granulomatous polyarteritis (previously Wegner’s): saddle nose; obliterative bronchiolitis
- Rheumatoid arthritis: wheeze secondary to obliterative bronchiolitis
- Post‐lung transplant: obliterative bronchiolitis as part of chronic rejection spectrum
indications for LTOT
- Non‐smoker
- PaO2 <7.3kPa on air
- PaCO2 that does not rise excessively on O2
7.3-8 if:
• secondary polycythaemia
• pulmonary hypertension
• peripheral oedema
causes of COPD
- Smoking
- industrial dust exposure
- Alpha1 antitrypsin (basal disease)
Obstructive spirometry
FEV1/FVC < 0.7
mechanism behind CO2 retainers
In COPD, pt optimise their gas exchange by hypoxic vasoconstriction leading to altered alveolar VQ ratios
Excessive O2 causes increased blood flow to poorly ventilated alveoli, increasing VQ mismatch
Management of Pulmonary hypertension
- Treat any underlying causes
- Prostacyclin analogues
- Endothelin-A receptor antagonists
- Phosphodiesterase-5 inhibitors
Pulmonary hypertension causes
- Idiopathic
- Drug/toxin-induced
- portal hypertension
- HIV
- Chronic hypoxia
- Congenital HD
- Systemic sclerosis, SLE , RA , Sjogren’s
What is bronchiectasis
long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection
Cor pulmonale
RHF secondary to respiratory disease
(chronic hypoxia -> pul vasoconstriction -> pulmonary hypertension)
Main treatment is oxygen therapy / diuretics
SOB without signs
- Anaemia
- Cancer
- PE
- Obesity hypoventilation
Management for bronchiectasis
- smoking cessation
- vaccines
- postural drainage
- abx / prophylactic
- Bronchodilators
Can consider lung resection
/transplant if FEV1 below 30% of predicted
Treatment of cor pulmonale
LTOT
Cor pulmonale signs
- Raised JVP
- Peripheral oedema
- Loud S2
- RV heave
- S3 gallop
- displaced/thrusting apex
