Resp Flashcards
Fibrotic crackles in upper zones
Fibrotic crackles in upper zones - consider: TB, ankylosing spondylitis, radiation induced fibrosis and possibly extrinsic allergic alveolitis, sarcoidosis, silicosis and coal-workers’ pneumoconiosis.
Fibrotic crackles in lower zones
Consider: cryptogenic fibrosing alveolitis, drugs, connective tissue disease.
Fine end inspiratory crackles
Left ventricular failure, pneumonia and fibrosis (Rheumatoid arthritis, SLE, systemic sclerosis, cryptogenic fibrosing alveolitis, extrinsic allergic alveolitis, drugs (amiodarone, methotrexate, sulphasalazine and cyclophosphamide)) and bronchiectasis.
Extra-articular features of Rheumatoid arthritis
Episcleritis Scleritis Pulmonary fibrosis Pleural effusions Pericarditis Splenomegaly in Felty’s syndrome Glomerulonephritis
Differentials for VATS
Wedge resection of pulmonary nodule Lobectomy Pleurodesis or pleurectomy Bullectomy Lung biopsy
Management of primary pneumothorax (breathless)
ABCDE
Resuscitation with immediate decompression if clinical signs of tensioning
Aspiration can be considered up to 2.5L - if fully resolved / <2cm can be d/c’ed and f/u OP
Chest drain
Surgical if persistant air leak
Treating Idiopathic Pulmonary Fibrosis
MDT approach
Steroids
Pirfenidone
Interstitial lung disease ddx
Peripherial/facial signs of CTD - SS, RA, SLE
Clubbing - IPF more likely (esp if age >50)
AF/PPM - consider drugs such as amiodarone, methotrexate
Basal vs apical fibrosis have slightly different aetiologies
Idiopathic - IPF, sarcoid, COP
Occupational exposure - birds (EAA), asbestos, silicosis, berylosis
Interstitial lung disease spirometry
Reduced TLC
Reduced FEV1 but preserved FEV1/FVC ratio
Reduced fransfer factor
Investigating ILD
Bloods incl FBC, U&E, LFTs, CRP
CXR
ECG / ECHO - pulmonary hypertension
ABG - resting PO2 to guide LTOT
HRCT - honeycombing (fibrosis), ground glass shadowing for alveolitis and therefore response to steroids/immunosupression
Bronchoscopy + BAL +/- endobronchial or transbronchial biopsy
Or lung biopsy in cases of diagnostic difficulty
Dermatomyositis
From top: Heliotrope rash Malar rash and nasolabial folds Shawl sign Gottrons papules and calcinosis Shoulder and pelvic girdle weakness
IPF prognosis
> 5yr 20-30%; median 2-3 years
Poor prognostic criteria - age, dyspnoea, rapid decline in pulmonary function, low ET tolearance, co-existing pulmonary disease, exertional desaturation
Management of CF
MDT in specialist centre
Physiotherapy for mucous clearance (postural drainage, enhanced breathing techniques, exercise)
Mucolytics (like recombinant DNase, hypertonic saline) - nebulised
Nebulised antibiotics
Regular oral azithromycin therapy and may need regular IV Abx
Pancreas - creon and fat solube vitamins, PEG tubes may be required for nutritional support (catabolic state)
Pseudomonas colonisation and burholderia colonisation (burkholderia is absolute CI to lung Tx)
Can get diabetes (usually insulin), liver disease, constipation and obstruction, gallstones, renal stones, osteopenia, infertility, nasal polyps.
B/L lung Tx - FEV1<30%, poor ET, PTH, high exacerbation frequency, NIV, large volume haemoptysis despite embolisation
CF
AR inheritance
Mutation in chr 7 in defective CFTR gene, most common - delta F508,
50% homozygous, 90% heterozygous
Bronchiectasis (classically upper lobes more affected) + clubbing, catabolic state and signs of nutritional deificency.
Long term venous access - e.g. portacath (upper chest, lateral chest)
Can be on LTOT
Median life expectancy into 40s and 50s
CFTR modulating therapies for eligible patients.
All infants in UK - guthrie test, immunoreative trypsin.
Indication for lung transplant
Indications:
>50% risk of death within 2 years
>80% likelihood of surviving 90 days post transplant
>80% likelihood of 5 year post Tx survival
*
Bilateral (Better prognosis, about 7.5 years median), Suppurative lung disease like CF and bronchiectasis usually, pulmonary vascular disease or pulmonary fibrosis less often
Single lung (classic) - COPD/ ILD
Anti-rejection medication in lung transplant
Calcineurin inhibitor: Ciclosoprin (old), Tacrolimus (tremor, diabetes)
Nucleotide blocking agent: Mycophenylate/Azathioprine
Steroids - cushings
Prophylaxis of opportunistic infection
Complication of lung transplants
Hyperacute rejection
Acute rejection
Opportunistic infection - mycobacterial, fungal, viral, bacterial
Chronic rejection - Bronchiolitis obliterans
Post transplant lymphproliferative disease (most common in 1st year post Tx) and skin malignancy
SE from anti-rejection medication
CI to lung Tx
Malignancy within 5 years or previous 2 years if low risk recurrence
Heart liver kidney and brain dysfunction
Uncorrected atherosclerotic disease
Acute illnesses
Chronic infection with highly resisstant organisms - mycobacterium abscesses, burkholderia
Spinal deformities
BMI at extremes
Smoking / drug use
Mental health conditions precluding compliance with medication or follow up
Relative - age >65 (single), BMI <17 / BMI >30, microbiological profiles
COPD on examination
Obstructive lung diseases - ask patient to expire fully
Important to mention signs of respiratory failure, pulmonary hypertension and cor pulmonate
COPD staging
Spirometry, FEV1 Mild - >80% Moderate 50-79 Severe 30-49 Very severe <30
Classifying COPD
FEV1/FVC <0.70 (must for obstructive disease)
GOLD criteria
1. Classifying severity (spirometry, FEV1)
2. Symptoms - Modified British Medical Research Council (mMRC) or COPD assessment test (CAT)
