Resp Flashcards
Signs of pulmonary fibrosis (6)
Clubbing
Central cyanosis
Tachypnoea
Fine end inspiratory crackles
Signs of autoimmune disease - RA, SLE, systemic sclerosis
Signs of treatment - cushingoid
Discoloured skin - amiodarone
Investigations for pulmonary fibrosis - bloods (3)
ESR
Rheumatoid factor
ANA
What will you see on CXR in pulmonary fibrosis? (3)
Reticulonodular changes
Loss of definition of heart border
Small lungs
Results of lung function tests in pulmonary fibrosis (3)
FEV1/FVC >0.8 (restrictive)
Low TLC
Reduced TLco and Kco
What investigations would you do for pulmonary fibrosis? (7)
Bloods: FBC, CRP, ESR, RhF, ANA
CXR
ABG
Lung function tests
Bronchoalveolar lavage
HRCT
Lung biopsy
Findings on HRCT in pulmonary fibrosis (3)
Bibasal subpleural honeycoming - UIP
Widespread groundglass - NSIP (autoimmune association)
Apical - sarcoidosis, ABPA, old TB, hypersensitivity pneumonitis, langerhans cell histiocytosis
Which diseases cause apical fibrosis ? (8)
Sarcoidosis
Radiation
ABPA
Ankylosing spondylitis
Old TB
Hypersensitivity pneumonitis
Histoplasmosis - fungal infection
Langerhans cell histiocytosis
What are treatment options for pulmonary fibrosis? (4)
Immunosuppression eg NSIP
Pirfenidone - UIP when FEV1 50-80%
NAC
Single lung transplant
Prognosis of pulmonary fibrosis - Highly cellular with ground glass infiltrate with response to immunosuppression
80% 5 year survival
Prognosis of pulmonary fibrosis - honeycombing on CT, no response to immunosuppression
80% 5 year mortality
What are causes of basal pulmonary fibrosis? (4)
UIP
Asbestosis
Connective tissue disease
Aspiration
Signs of bronchiectasis (8)
Cachexia
Tachypnoea
Clubbing
Mixed character crackles that alter with coughing
Occasional squeaks and wheeze
Sputum +++
Cor pulmonale - leg swelling, raised JVP, RV heave, loud P2
Yellow nail syndrome
Investigations for bronchiectasis (8)
Sputum culture and cytology
CXR - tramlines, ring shadows
HRCT - signet ring sign (thickened dilated bronchi larger than adjacent vascular bundle)
Immunoglobulins - hypogammaglobulinaemia
Aspergillus RAST or skin prick
Rheumatoid serology
Saccharine ciliary motility test - kartageners
Genetic screening - cystic fibrosis
Causes of bronchiectasis - congenital (2)
Kartageners
Cystic fibrosis
Causes of bronchiectasis - childhood infection (2)
Measles
TB
Causes of bronchiectasis - immune (2 over active, 2 under active)
ABPA
IBD associated
Hypogammaglobulinaemia
CVID
Causes of bronchiectasis (5)
Congenital - kartageners/CF
Childhood infection - measles/TB
Immune over activity - ABPA/ IBD
Immune under activity - hypogammaglobulinaemia/CVID
Aspiration - alcoholics, GORD, stroke
Treatment for bronchiectasis (5)
Chest physio
Abx for exacerbations
Low dose azithromycin 3 times per week long term
Bronchodilators/ICS if airflow obstruction
Surgery for localised disease
Complications of bronchiectasis (4)
Recurrent infections
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis
Signs of old TB (6)
Chest deformity / absent ribs
Thoracoplasty scar
Tracheal deviation towards fibrosis
Reduced expansion
Dull percussion but present tactile vocal fremitus
Crackles and bronchial breathing
Historical treatment for TB (6)
Plombage - polystyrene balls
Phrenic nerve crush
Thoracoplasty - rib removal, lung not resected
Apical lobectomy
Recurrent medical pneumothoraces
Streptomycin
Side effects of TB drugs (4)
Isoniazid - peripheral neuropathy and hepatitis
Rifampicin - hepatitis and increased contraceptive pill metabolism
Ethambutol - retro bulbar neuritis and hepatitis
Pyrazinamide - hepatitis
What to council TB patients before starting treatment regarding side effects (5)
If jaundice - stop tablets and call nurse
If red becomes less bright - call nurse
If tingling in toes - tell dr at next visit
Secretions will turn orange / red - don’t wear contacts
If on OCP - use barrier contraception
Signs of lobectomy (5)
Reduced expansion and chest wall deformity
Thoracotomy scar
Central trachea
If lower lobectomy - dull percussion note lower zone, absent breath sounds
If upper lobectomy - normal or hyper-resonant percussion upper zone, dull percussion at base - elevated diaphragm
Signs of pneumonectomy (7)
Thoracotomy scar
Reduced expansion on side of op
Trachea deviated to side of op
Dull percussion note through hemi thorax
Absent tactile vocal fremitus beneath scar
Bronchial breathing in upper zone
Reduced breath sounds in rest of hemi thorax
Signs of single lung transplant (3)
Thoracotomy scar
Normal exam on side of scar
Clinical signs on opposite side
Indications for single lung transplant (2)
COPD
Pulmonary fibrosis
(“Dry” lung conditions)
Signs of double lung transplant (1)
Clamshell incision
Indications for double lung transplant (3)
CF
Bronchiectasis
Pulmonary HTN
(“Wet” lung conditions)
Signs of COPD on inspection (4)
Nebuliser or inhalers at bedside
Sputum pot
Dyspnoea
Pursed lips
Signs of COPD in hands (3)
CO2 retention flap
Bounding pulse
Tar stained fingers
Chest signs in COPD (4)
Hyper expanded lungs
Percussion note resonant
Expiratory polyphonic wheeze
Reduced breath sounds at apices
Signs of cor pulmonale (5)
Raised JVP
Ankle oedema
RV heave
Loud P2
Pansystolic murmur of TR
Causes of clubbing - chest (7)
Bronchial carcinoma
Bronchiectasis
Cystic fibrosis
Lung abscess /empyema
Mesothelioma
Idiopathic pulmonary fibrosis
TB
Causes of COPD (3)
Smoking
Industrial dust exposure (apical)
Alpha 1 anti trypsin (basal)
Spirometry result in COPD
Low FEV1
FEV1/FVC ratio <0.7 obstructive
Gas transfer low T CO
GOLD classification of COPD
GOLD 1 - mild: FEV1 ≥80% predicted
GOLD 2 - moderate: 50% ≤ FEV1 <80% predicted
GOLD 3 - severe: 30% ≤ FEV1 <50% predicted
GOLD 4 - very severe: FEV1 <30% predicted
Treatment of COPD (9)
Smoking cessation / NRT
Mild - Beta agonists
Moderate - Tiotropium and beta agonist
Severe - Moderate plus ICS if no pneumonia
Pulmonary rehab
Nutrition
Vaccinations - pneumococcal and influenza
LTOT
Surgical - bullectomy, endobronchial valve replacement, lung reduction surgery, single lung transplant
LTOT inclusion criteria (4)
Non smoker
PaO2 <7.3 on air
PaCO2 does not rise excessively on O2
PaO2 <8 if cor pulmonale
COPD exacerbation prognosis
15% in hospital mortality
Wheezy chest differential (4)
COPD/asthma
Granulomatous polyarteritis
Rheumatoid arthritis (obliterative bronchiolitis)
Post transplant - chronic rejection
Signs of pleural effusion (6)
Asymmetrically reduced expansion
Trachea or mediastinum displaced away from side of effusion
Stony dull percussion note
Absent tactile vocal fremitus
Reduced breath sounds
Bronchial breathing above
Signs to indicate cause of pleural effusion - cancer (3)
Clubbing
Lymphadenopathy
Mastectomy - breast cancer
Signs that indicate cause of pleural effusion - heart failure (2)
Raised JVP
Peripheral oedema
Signs that indicate cause of pleural effusion - chronic liver disease (3)
Leuconychia
Spider naevi
Gynaecomastia
Signs that indicate cause of pleural effusion - renal failure (1)
AV fistula
Causes of chronic pleural effusion (5)
Cancer
Congestive heart failure
Chronic liver disease
Chronic renal failure
Connective tissue disease
Signs of cause of pleural effusion - connective tissue disease (2)
RA hands
Butterfly rash of SLE
Causes of a dull lung base (6)
Effusion
Consolidation - bronchial breathing and crackles
Collapse - tracheal deviation, reduced breath sounds
Lobectomy - reduced lung volume
Pleural thickening - similar to pleural effusion but normal tactile vocal fremitus, scars from VATs pleuradesis
Raised hemidiaphragm - hepatomegaly
Causes of a transudative pleural effusion (3)
CCF
Renal failure
Liver failure
Causes of exudative pleural effusion (4)
Neoplasm
Infection
Infarction
Inflammation - RA/SLE
What pleural effusion aspirate findings suggest exudate? (4)
Protein: >35g/L or lights criteria
Pleural fluid albumin/plasma albumin >0.5
LDH: effusion LDH/plasma LDH >0.6
Or >2/3 normal value
What pleural effusion aspirate findings are suggestive of empyema? (3)
Exudate
Low glucose
pH <7.2
What is an empyema?
Collection of pus in pleural space
Most frequently anaerobes, staph and gram negatives
Associated with bronchial obstruction - carcinoma, recurrent aspiration, poor dentition, alcohol dependence
What is the treatment for empyema? (4)
Pleural drainage
IV abx
Intrapleural DNAse plus TPA
Surgical decortication
Clinical signs of lung cancer (11)
Cachexia
Clubbing
Tar staining
Lymphadenopathy
Tracheal deviation - if collapse or effusion
Reduced expansion
Dull percussion - if collapse or effusion
Absent tactile vocal fremitus - if effusion or increased resonance if consolidation
Auscultation - crackles or reduced breath sounds
Hepatomegaly if mets
Bony tenderness if mets
What signs of lung cancer treatment might you find? (3)
Lobectomy scar
Radiotherapy burn
Radiotherapy tattoo
What are complications of lung cancer? (9)
SVCO
Recurrent laryngeal nerve palsy
Horners sign
Wasted small muscles of hands
Gynaecomastia
Lambert Eaton myasthenia
Dermatomyositis
SIADH
Hypercalcaemia
What are the different types of lung cancer and how common? (5)
Squamous 35%
Small (oat) 24%
Adeno 21%
Large 19%
Alveolar 1%
How do you diagnose lung cancer? (7)
CXR: collapse, mass, hilar lymphadenopathy
CT thorax
Induced sputum cytology
Biopsy by bronchoscopy if central
Percutaneous CT guided needle if peripheral lesion and FEV1 >1L
Staging CT/EBUS/thoracoscopy/PET
Lung function tests for operability assessment
What is important for staging of different lung cancers?
Non small cell - TNM staging to assess operability
Small cell - assess limited or extensive disease
What is ideal FEV1 value for lobectomy and pneumonectomy?
Lobectomy FEV1 >1.5L
Pneumonectomy >2L
What might bloods show in lung cancer that show complications? (6)
Deranged LFTs - mets
Hypercalcaemia - mets or non small cell
Low Hb - mets
Raised PTHrP - non small cell
Raised ACTH - small cell
SIADH - small cell
What are treatment options for lung cancer - non small cell? (4)
Surgery - lobectomy or pneumonectomy
Radiotherapy
Chemo - eGFR positive - erlotinib
MDT approach
What are treatment options for small cell lung cancer? (2)
Chemo
MDT approach
What are palliative treatment options for lung cancer and its complications ? (5)
Dex and radiotherapy for brain mets or SVCO
Stent for SVCO
Radiotherapy for haemoptysis, bone pain, cough
Chemical pleurodesis for effusion
Opiates for pain, cough
What are signs of CF? (8)
Small stature
Clubbed
Tachypnoea
Sputum pot with purulent sputum
Hyperinflated chest with reduced expansion
Coarse crackles and wheeze
Portacath or Hickman lines/scars
PEG
What are the genetics of CF?
1/2500 live births
Autosomal recessive
Chromosome 7q
CFTR gene
Chloride channel
Delta 508 deletion most common
What is the pathophysiology of CF and which organs does it affect?
Secretions thickened and block lumens of various structures:
Bronchioles - bronchiectasis
Pancreatic ducts - loss of endo and exocrine function
Gut - distal intestinal obstruction syndrome in adults
Seminal vesicles - male infertility
Fallopian tubes - reduced female fertility
What are investigations for CF? (3)
Screened at birth- heel prick - low immunoreactive trypsin
Sweat test - Na >60
Genetic screening
What can cause a false positive sweat test for CF?
Hypothyroidism
Addisons
What are treatments for CF? (9)
Physiotherapy - postural drainage and active cycle breathing
Abx for infections
Pancrease
Fat soluble vitamin supplements
Mucolytics- nebulised DNAse
Immunisations
Double lung transplant
Gene therapy under development
Kaftrio for certain mutations
What is the prognosis in CF?
Median survival 35 years but rising
If double lung transplant - 50% survival at 5 years
Poor prognosis if burkholderia cepacia infection
What are signs of pneumonia? (8)
Tachypnoea
Oxygen requirement
Sputum pot with purulent or rusty sputum
Reduced expansion
Dull percussion note
Focal coarse crackles
Increased vocal resonance
Temperatures
What investigations would you do for pneumonia? (6)
CXR: consolidation with air bronchogram, effusion
Bloods: raised WCC, CRP, urea, atypical serology, immunoglobulins
Blood cultures
Sputum culture
Atypical serology in urine - legionella, pneumococcal antigens
Haemoglobulinuria
Which pneumonia causes cold agglutinins leading to haemolysis?
Mycoplasma
What are most common organisms causing CAP? (4)
Strep pneumoniae 50%
Mycoplasma pneumoniae 6%
Haemophilus influenzae - COPD
Chlamydia pneumoniae
What are first line abx for pneumonia? (2)
Penicillin or cephalosporin
+
Macrolide
What bugs might immunosuppressed people be at risk of causing pneumonia and what are treatments? (4)
Fungal - amphotericin
Multi resistant mycobacteria
Pneumocystis carinii- co-trimox or pentamidine
CMV - ganciclovir
What bug commonly causes pneumonia post influenza and what is treatment?
Staph aureus - flucloxacillin
What are complications of pneumonia? (4)
Lung abscess - Staph aureus, klebsiella, anaerobes
Para pneumonic effusion or empyema
Haemoptysis
Septic shock and organ failure
What are risk factors for asthma? (10)
Atopy
FH of asthma or atopy
Inner city environment
Socio-economic deprivation
Obesity
Prematurity and low birth weight
Viral infections in early childhood
Smoking
Maternal smoking
Early exposure to broad-spectrum antibiotics
What are investigations for asthma? (6)
Peak flow diary
Spirometry with reversibility testing
FeNO - elevated levels suggest inflammation
CXR to exclude other causes if atypical
FBC for eosinophilia
Allergen testing IgE
What are steps for managing asthma? (9)
Identify and remove triggers, remember occupational
SABA only if intermittent and mild
Add ICS if frequent symptoms
Add montelukast +/- LABA
Increase steroid dose
Change to MART
Add LABA if not before +/- SR theophylline
Oral steroids
Omalizumab if IgE mediated poorly controlled
What is the most likely underlying pathology of a pancoasts tumour?
Squamous cell carcinoma
What are respiratory indications for VATS? (5)
Lobectomy/Wedge resection/segmentectomy
Bullectomy / volume reduction
Recurrent pneumothorax pleurodesis
Decortication/pleurectomy
Biopsy
What are BTS guidelines for pneumothorax?
If patient is symptomatic, do they have high risk characteristics?
If yes, then drain
If no and pneumothorax large enough (>2cm), patient can choose conservative, ambulatory device or therapeutic aspiration
If aspiration does not resolve it, then drain
What are indications for pleurodesis? (3)
Malignant pleural effusion
Recurrent or persistent pneumothorax
Recurrent pleural effusion
What are causes of airflow obstruction ? (4)
Asthma
COPD
Bronchiectasis
Obliterative bronchiolitis: viral, pollutants, graft vs host
What defines reversible airflow obstruction?
FEV1 200ml or 15% change in response to bronchodilation
Who can have anti fibrotics in IPF?
FVC 50-80% predicted
Which bacteria confers poor prognosis in cystic fibrosis?
Burkholderia cepacia
Rapid decline in lung function, contraindication to transplant
What is the most common cause of chronic lung transplant rejection?
Bronchiolitis obliterans
What are contraindications to lung transplant? (10)
History of malignancy in last 5 years
Untreatable significant other organ dysfunction
Uncorrected atherosclerotic disease
Acute illness
Chronic infection with resistant organisms
Chest wall or spinal deformity
BMI >35
Non adherence to therapies
Poor functional status
Substance abuse: alcohol, smoking
Which condition carries worst prognosis for lung transplant?
ILD
What are signs of hyper inflation on examination? (7)
Prolonged expiration
Tracheal tug
Cricosternal distance less than 3 finger widths
Indrawing of inter and subcostal spaces
Reduced expansion
Quiet breath sounds
Hyper resonance to percussion
What respiratory involvement can occur in rheumatoid arthritis? (8)
ILD - UIP or NSIP
Treatment related ILD
Pulmonary nodules
Pleural effusion
Pleuritis
Obliterative bronchiolitis
Infections related to immunosuppression
Raised hemidiaphragm
What does groundglass appearance on CT suggest?
Inflammation - likely to respond to steroids/immunosuppressants
What does honeycomb appearance on CT mean?
Fibrosis
Not ammenable to steroids /immunosuppressants
