Resp Flashcards
What are the features of idiopathic pulmonary fibrosis?
Key characteristics of this condition include: exertion dyspnoea, dry cough, weight loss, bibasal inspiratory crackles on auscultation and finger clubbing.
What would you add first LABA or LTRA?
LTRA
What are the types of lung cancer?
Non-small cell lung cancer (around 80%):
Adenocarcinoma (around 40%)
Squamous cell carcinoma (around 20%)
Large-cell carcinoma (around 10%)
Other types (around 10%)
Small Cell Lung Cancer (SCLC) (around 20%)
Small cell lung cancer cells contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple paraneoplastic syndromes.
Clinical presentation of lung cancer?
Shortness of breath Cough Haemoptysis (coughing up blood) Finger clubbing Recurrent pneumonia Weight loss Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
What are the Ix done for lung cancer?
CXR
Staging VT scan
PET-CT
Bronchoscopy with endobronchial US (EBUS)
Histological diagnosis- can either be by bronchoscopy or percutaneously through skin
What would you be looking for on CXR for lung cancer?
Chest xray is the first line investigation in suspected lung cancer. Findings suggesting cancer include:
Hilar enlargement
“Peripheral opacity” – a visible lesion in the lung field
Pleural effusion – usually unilateral in cancer
Collapse
What are the management options for lung cancer
All treatments are discussed at an MDT meeting involving various consultants and specialists, such as pathologists, surgeons, oncologists and radiologists. This is to make a joint decision about what is the most suitable options for the individual patient.
Surgery is offered first line in non-small cell lung cancer to patients that have disease isolated to a single area with intention to cure the cancer. Lobectomy (removing the lung lobe containing the tumour) is first line. Segmentectomy or wedge resection (taking a segment or wedge of lung to remove the tumour) is also an option.
Radiotherapy can also be curative in non-small cell lung cancer when early enough.
Chemotherapy can be offered in addition to surgery or radiotherapy in certain patients to improve outcomes (“adjuvant chemotherapy”) or as palliative treatment to improve survival and quality of life in later stages of non-small cell lung cancer.
Treatment for small cell lung cancer is usually chemotherapy and radiotherapy. Prognosis is generally worse from small cell lung cancer than non-small cell lung cancer.
Endobronchial treatment with stents or debulking can be used as part of palliative treatment to relieve bronchial obstruction caused by lung cancer.
Extrapulmonary manifestations of lung cancer?
Recurrent laryngeal nerve palsy presents with a hoarse voice. It is caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.
Phrenic nerve palsy due to nerve compression causes diaphragm weakness and presents as shortness of breath.
SVCO
Horners
SIADH (small cell)
Cushings (small cell)
Hypercalcaemia (PTH from squamous cell)
Limbic encephalitis. This is a paraneoplastic syndrome where the small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.
Lambert-Eaton myasthenic syndrome.
What is pembertons sign?
Superior vena cava obstruction is a complication of lung cancer. It is caused by direct compression of the tumour on the superior vena cava. It presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest. “Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.
What is lambert eaton syndrome?
Lambert-Eaton myasthenic syndrome is a result of antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones. This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.
Patients with Lambert-Eaton have reduced tendon reflexes. A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called post-tetanic potentiation.
In older smokers with symptoms of Lambert-Eaton syndrome consider small cell lung cancer.
What is mesothelioma?
Mesothelioma is a lung malignancy affecting the mesothelial cells of the pleura. It is strongly linked to asbestos inhalation. There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years. The prognosis is very poor. Chemotherapy can improve survival but it is essentially palliative.
Presentation of pneumonia?
Presentation
Shortness of breath
Cough productive of sputum
Fever
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain worse on inspiration)
Delirium (acute confusion associated with infection)
Sepsis
Signs
There may be a derangement in basic observations. These can indicate sepsis secondary to the pneumonia:
Tachypnoea (raised respiratory rate) Tachycardia (raised heart rate) Hypoxia (low oxygen) Hypotension (shock) Fever Confusion
What are the characteristic chest signs of pneumonia?
Bronchial breath sounds. These are harsh breath sounds equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.
Focal coarse crackles. These are air passing through sputum in the airways similar to using a straw to blow in to a drink.
Dullness to percussion due to lung tissue collapse and/or consolidation.
Causes of pneumonia?
Common causes
Streptococcus pneumoniae (50%) Haemophilus influenzae (20%)
Other Causes and Associations
Moraxella catarrhalis in immunocompromised patients or those with chronic pulmonary disease
Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
Staphylococcus aureus in patients with cystic fibrosis
Will inflammatory markers always be raised in pneumonia?
Inflammatory markers such as white blood cells and CRP are roughly raised in proportion to the severity of the infection. The trend can be helpful in monitoring the progress of the patient towards recovery. For example, repeating WBC and CRP after 3 days of antibiotics may show a downward trend suggesting the antibiotics are working. CRP commonly shows a delayed response so may be low on first presentation then spike very high a day or two later despite the patient improving on treatment. WBC typically responds faster than CRP and give a more “up to date” picture.
Patients that are immunocompromised may not show an inflammatory response and may not have raised inflammatory markers.
