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