Resp Flashcards
What are common indications for a VATS procedure?
Wedge resection (segmentectomy)
Decortication (RA, chronic infection, mesothelioma)
Bullectomy
Lobectomy
Recurrent PTX
What are the benefits of VATS?
Smaller incision
Reduced pain
Reduced wound complications
Redued length of stay
What are the possible indications for a lobectomy?
Lung cancer
Aspergilloma
TB
Lung abscess
Ix for Lung cancer?
Staging CT TAP
Tissue diagnosis
Functional imaging (PET CT)
Working up patient for surgery
How would you assess fitness for surgery?
Full lung function tests including transfer factor assessment
Cardiopulmonary excercise testing
What FEV1 would you want the patient to have if they were having a lobectomy/pneumonectomy?
Lobectomy = 1.5L
Pneumonectomy = 2L
What is the VO2 max threshold that offers a good post-op outcome?
VO2 Max 15ml/kg/min
What are the histological subtypes of lung cancer?
SC (20%)
NSCLC - adenocarcinoma, squamous, large cell, neuroendocrine tumours
What are the treatment options for lung cancer?
SC - chemoradiotherapy, palliative chemotherapy
NSCLC - curative surgical treamtent, adjuvant chemoradiotherapy
What are the clinical signs differences between a pneumonectomy and lobectomy?
Lobectomy
Trachea may not be deviated
Normal/reduced breath sounds
Percussion note normal
Pneumonectomy
Trachea always deviated
towards
Absent breath sounds
Dull percussion note
What are respiratory causes of clubbing?
- ILD
- Chronic suppurative lung disease (CF, abscess, bronchiectasis)
- Lung cancer
What are the indications for surgical management of pneumothorax?
- Persistent air leak
- Inadequate lung expansion
- Recurrent pneumothorax
What is the management of a pneumothorax?
Primary
<2cm and asymptomatic - discharge and repeat CXR
>2cm or symtomatic - aspiration. If aspiration fails, chest drain
Secondary
Chest drain if: >50y, >2cm, SOB
If 1-2cm aspirate followed by chest drain if not resolved.
If <1cm = oxygen and admit for 24 hours
What improvement would you expect when performing peak flow following bronchodilator therapy in asthma?
Improvement in 200ml on peak flow, or an improvement by 15%
How do you treat asthma?
- Step wise approach
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LTRA + LABA
- Switch ICS/LABA For MART that includes a low dose ICS
- Consider introducing theophylline / LAMA
How do you treat COPD?
- SABA or SAMA
- If asthmatic features: LABA + ICS. If no asthmatic features: LABA + LAMA
- LAMA + LABA + ICS (Trimbow)
- Consider theophylline
- Consider carbocisteine
- Consider PDE4 inhibitors (roflumilast)
What causes upper lobe fibrosis?
Coal pneumoconiosis
Hypersensitivity pneumonitis
Ank spond
ABPA
Radiation
TB
Silicosis
Sarcoidosis
What causes lower zone fibrosis
MTX and other drugs
Asbestos
IDiopathic Pulmonary Fibrosis!!!!
Scleroderma and other connective tissue diseases
Differential for bibasal crepitations?
Bronchiectasis (coarse and clear with coughing)
Bilateral pneumonias
Congestive heart failure (elevated JVP)
Fibrosis (fine)
How do you investigate fibrosis?
- Bloods: ESR, RF, ANA
- CXR
- ABG
- Lung function tests (restrictive picture)
- Bronchoalveolar lavage (excludes infection, and Ly/Neu ratio
- HRCT
HRCT findings
Widespread: NSIP - autoimmune > steroids
Bi-basal subpleural honeycombing: UIP > pirfenidone
Apical: Sarcoid, ABPA, TB, Langerhann’s
What are the CT findings of IPF?
Groundglass changes = alveolitis
Honeycombing = fibrosis
What are the spirometry findings of fibrosis?
- Reduced FEV1
- Reduced FVC
- Preserved/high FEV1/FVC ratio
- Reduced TLC
- Reduced transfer factor
Rx for ILD?
- MDT
- Treat underlying connective tissue disorder
- If groundglass = steroids
- IPF: anti-fibrotic agent pirfenidone/ninetanib
- Transplant
CTDs that cause ILD?
RA, SS, SLE, Dermatomyositis
What are the idiopathic causes for ILD?
Sarcoidosis
IPF
Bronchioloitis Obliterans
NSIP (most connective tissue diseases) - reversible groundglass inflammation (steroid responsive)
Usual interstitial pneumonitis (RA) - end stage pulmonary fibrosis and more difficult to treat. Similar pattern to IPF, and ongoing trials looking at anti-fibrotics
Broadly speaking, how can we categorise interstitial lung disease?
- Idiopathic
- Connective tissue disease
- Occupational
- Drug exposure
What specific treatments are available for NSIP?
- Immunosuppression (steroids, Aza, MMF)
What is the life expectancy of ILD?
2-5 years, rate is variable
What is the gene affected in CF?
- AR
- CFTR gene mutation Chr 7 = defective CFTR protein. Commonest delta F508 (PH508del)
- Increased salt excretion
- Thicker mucus affecting respiratory, digestive, reproductive systems
Complications of CF?
- Multi-system disease
- Bronchiectasis
- Pancreatic insufficiency
- Infertility
- Liver failure, gallstones, kidney stones
How do you manage CF?
- MDT
- Regular physiotherapy positional drainage/enhanced breathing techniques
- Nebulised mucolytics (DNAse)
- Nebulised prophylactic abx (tobramycin for pseudomonas)
- Azithromycin
- Pancreatic enzyme replacement
- Nutritional supplementation if unable to meet caloric needs (may have PEG)
- CFTR receptor modulators (ivacaftor)
Microbiology of CF lung disease?
- Different patients have different microbiomes
- Pseudomonas Aeriginosa
- Berkholderia and mycobacterium absceses is an absolute contra-indication in transplant and carries a poor prognosis
Resp comps of CF
ABPA
PTX
Haemoptysis (may be massive or chronic)
Hypoxia
Sinus disease and nasal polyps
Chronic infection - pseudomonas or Burkholderia cenecipacia or mycobacaterium
What are the pre-requisites for lung transplant?
- > 50% risk of death within 2 years if transplant not performed
- > 80% likelihood of surviving 90 days post-transplant
- > 80% 5-year survival from gen med perspective provided adequate graft function
What common conditions are lung transplants performed for?
- ILD (usually single)
- CF (usually double)
- COPD (40% of transplants)
- Pulmonary vascular diseases
What are the complications of lung transplant?
- Hyper-acute rejection
- Hyper-acute graft dysfunction (ischaemic reperfusion)
- Chronic rejection (bronchiolitis obliterans syndrome)
- Infections
- Malignancy - PTLD/skin
Types of immunosupression in lung transplant?
- Steorid
- Calcineurin inhibitor
- Nucleotide blocking agent (MMF/aza)
- Prophylactic antibiotic
What is the COPD BODE index?
FEV1 (% of predicted)
6 minute walk distance
MRC Dyspnoea scale
Estimates 4 year survival
What are the contraindications to lung transplant?
BMI >35
Untreated other organ system
Unstable critical condition
Chest wall deformity
Substance misuse
Poor adherence
Post- lung transplant mortality?
20% at 1 year
50% at 5 years
What is yellow nail syndrome?
- Bronchiectasis
- Pleural effusions
- Lymphoedema
changes with coughing - Dystriphic, discoloured, thickened nails
How would you investigate someone with bronchiectasis?
- Routine bloods
- HIV, Ig, Aspergillus serology, CF, Rheumatoid serology
- Sputum analysis (gen, fungus, mycobacterium)
- CXR
- Spiro
- HRCT
- Saccharine ciliary motility test: Kartagener’s
What are the radiological findings of bronchiectasis?
CXR: tramlines and ring shadows
CT: Signet ring sign (thickened dilated bronchi that are larger than the adjacent vascular bundle)
Management of bronchiectasis?
- MDT
- Postural drainage
- Hypertonic saline
- Long-term antibiotics
- Sputum culture guided IV abx
- Neublised antibiotics in pseudomonas
- Vaccination - pneumococcal and annual influenza
Causes of bronchiectasis?
Congenital: CF, Kartagener’s
Childhood infections: Measles, TB
Immune over-activity: ABPA, IBD
Immune under-activity: HypoG, CVID
Aspiration: GORD, alcohol (RLL)
Amongst patients who dont smoke, what is the most common lung cancer histology?
Adenocarcinoma
What targeted treamtent in NSCLC do you know of?
EGFR (osimertinib)
ALK (repotrectinib)
PD-L1 (nivolumab)
what paraneoplastic syndromes do you know if in small cell lung cancer?
LEMS
ACTH
SIADH
What will you send your pleural sample off for if you have a unilateral pleural effusion?
- pH
- Protein
- LDH
- Cell count and cytology
- Gram stain + AFB staining
- Culture
What is Light’s criteria
<25g/L: transudate
>36g/L: exudate
25-35g/L: apply Light’s criteria
Exudate if:
Pleural:Blood protein ratio >0.5
Pleural:Blood LDH ratio >0.6
Pleural LDH >2/3 the upper limit of normal blood levels
Transudate:
Heart Failure
Liver failure
Nephrotic syndrome
Hypothyroidism
Meig’s syndrome
Exudate:
Infection
Malignancy
CTD
Pancreatitis
Yellow nail syndrome
PE
Dressler’s
What other assays are useful when investigating a pleural effusion?
Low glucose in pleural = infection, malignancy, oeseopheal rupture
Very low glucose = RA
High amylase in pancreatitis
Cell count = higher WCC with neutrophilia in paraneumonic; lymphocytosis in TB
What specific investigations would you conduct for upper zone fibrosis?
Spirometry
Echocardiogram
ABG
Broncheoalveolar lavage (looking for lymphocytosis)
IgG antibodies (precipitins)
What is cor pulmonale?
Right heart failure due to respiratory disease that causes pulmonary vasoconstriction.
What are the causes of pulmonary hypertension?
- LVSD
- Respiratory causes - asthma, COPD, ILD
- PAH
- Thrombo-embolic disease
- MISC - eg. lymphangiomatosis
What is the difference between OSA and OHS?
OSA - Weak airway muscles, most common on obese individuals. Loud snoring in an obese individual. Rx CPAP+/- NIV in overlap syndrome. Diagnosis is made with sleep studies.
OHS - Only affects obese individuals. Impaired diaphragmatic/chest wall movement in sleep - slow/shallow breathing. Importantly, these individuals also experience hypoventilation whilst awake, which differentiates it from OSA. However this is much overlap. Raised pCO2 whilst awake is key to diagnosis.
How do you grade COPD?
FEV1/FVC must be <0.7
FEV1 >80% = mild
FEV1 50-80% = mod
FEV1 30-50% = sev
FEV1 <30% = v sev
DDX for bilateral lower zone creps?
ILD (does not clear with cough)
Heart failure
B/L pneumonia
Bronchiectasis (clear with cough)
How do you differentiate creps in bronchiectasis and ILD?
The characteristics of the creps in bronchiectasis change with coughing
What bronchiectasis syndromes do you know?
- ABPA
- Yellow Nail syndrome
- Primary ciliary dyskinesia
- Young syndrome
- Kartagener’s syndrome
- Chediak-Higashi (AR, chronic granulomatous disease of the lung)
What types of smoking cessation do you know?
- NRT - short courses
- Varinecline - partial nicotinic receptor agonist. CI self-harm/suicide/pregnancy/breastfeeding.
- Buprenorphine - nicotinic receptor antagonist, norepinephrine and dopamine re-uptake inhibitor. CI pregnancy/breastfeeding.
What clinical feature would most likely suggest chronic lung transplant rejection?
Bronchiolitis obliterans producing an obstructive lung defect.
Inclusion criteria for LTOT?
Non-smoker
PaO2<7.3
or PaO2<8 with features of polycythaemia, peripheral oedema, PHTN
What are the features of EGPA?
- Asthma
- Eosinophilia
- Paranasal sinusitis
- Mononeuritis multiplex
- pANCA + in 60%
What are the features of GPA?
Not eosinophilic
Epistaxis, crusting, sinusitis
Haemoptysis
RPGN
Saddle shaped nose deformity
Vasculitic rash, CN lesions
cANCA in 90%
What is the treatment of GPA?
- Steroids
- Cyclophosphamdie (90% response rate)
- Plasma exchange
What are the clinical features of cystic fibrosis?
- Small stature
- Clubbing
- Purulent cough
- Coarse crackles and wheeze (bronchiectatic)
- Pancreatic exocrine dysfunction
- Pancreatic endocrine dysfunction
- Distal intestinal obstruction in adults, meconium ileus in children
- Seminal vesicles - male intertility
- Fallopian tubes - reduced female fertility
What do you know about the genetics of CF?
- AR
- Chromosome 7 - CFTR gene, commonest and most severe is delta F508 (70%)
- Incidence of 1 in 2500
What are the principles of treatment of CF?
- MDT
- Physiotherapy - postural drainage is critical
- Pancrease, fat soluble supplements
- Mucolytics (DNAse)
- Double lung transplant
- Gene therapy
- CFTR potentiators (caftors - lumacaftor, ivacaftor)
