Resp Flashcards
Gottrons papules
Characteristic discrete red areas overlying the knuckles in a patient with dermatomyositis. They may be photosensitive and itchy.
heliotrope rash (dermatomyositis)
Usually purplish colour. It may also be red in certain patients. This is commonly seen around the eyes, but may also be encountered on the upper chest or back.
Crepetations in dermatomyositis ?
Fine
- Pulm fibrosis
First line treatment for dermatomyositis
Steroids
Name 5 symptoms / signs of dematomyositis other than ones given away by the name
Skin rash
Muscle weakness
Muscle tenderness;
Weight loss;
Arthralgia;
Arthritis;
Dyspnea;
Arrhythmia;
Dysphagia;
Dysphonia;
Malignancy (in people >60);
GI ulcers and infections in children;
Tiptoe gait (children);
Joint contractures;
Subcutaneous calcifications
Diagnostic test for dematomyositis
Anti-mi-2
(only found in 30%)
Treatment of dematomyositis
Conservative
- avoiding sun exposure
- physio / nutrition to help reduce atrophy
Medical
Steroids
azathioprine / cyclosporin if not responding
Topical steroids;
Immunomodulatory medications;
Methotrexate;
COPD exam
Hands
- tar staining
- clubbed
- tremor eg salbutamol
- “ can you put hand out to stop traffic” Hand flap
Face
JVP
Trachea
Lympadenopathy
Chest inspection
- front, back and axilla for scar (pneumonectomy)
Chest expansion
Palpate - Heave
Precuss
Auscultate - POLYPHONIC wheeze
Ankle oedema
COPD presentation
Ive examined this 55 year old gentleman with tar staining and a degree of cachxia.
On exam there is a polyphonic wheeze and some hyper-expansion of the chest
They likely have a lung disease such as COPD or asthma
There was no evidence of pulm hypertension as evidenced by lack of JVP, lour second heart stone or peripheral oedema.
Differentials of polyphonic wheeze
COPD
Asthma
Eosinophilic granulomatosis
Rheum -> bronchiolitis obliterans
A1AT deficiency
Investigations in COPD
Bloods including ABG
FBC looking for anaemia / polycythemia and eosinophils
Consder vasculitis screen
IgE to aspergilous
Specific antigens in asthma
Sputum culutres
CXR
Consider Lung function tests
with reversibility testing
- Low TLco
Spirometry with peak flow measurements at morning and night to assess for diurnal variation
Consider echo if evidence of pulm HTN
What are you looking for on CT of COPD
Emphysema - hallmark
Bulous lung disease -> need for surgical treatments
What are you looking for on lung function tests of COPD
Non reversiblity with salbutamol
Obstructive pattern
FEV1/FVC ratio 0.7
<30, 30-50,50-70
FEV less than 80% predicted
- <15% improvement with bronchodilators
Low TLco
How are you going to manage COPD acute
Salbutamol / ipatropium nebs
Prednisolone
ABG - PCO2 / Bicarb
-> Consider NIV if not responding after an hour of treatment
Controlled oxygen therapy
FBC / CRP - consider abx
CXR - Consider abx
How are you going to manage COPD chronic
Conservative
- Stop smoking
- Pulmonary rehabilitation
- Flu / pneumococcal vaccines
- Dietician input - Weight loss if obese, weight gain of low weifght
- LTOT
Medical
inhalers
- If no eosinophils / no reversibility
LABA / LAMA
- If some asthmatic features
-> ICS / LABA
Surgical
- Bullectomy (>1L and compressing surrounding lung)
- Lung reduction surgery if heterogenous distribution
- Single lung transplant
Criteria for LTOT
ABGs with PO2 <7.3
Or Po2 <8 with evidence of polycythaemia, pulm hypertension, or peripheral oedema
Must Stop smoking
Surgical management of COPD
Lung reduction management of areas with lots of deadspace / bullae
-> Allows rest of lung to re expand
Lung transplant -> more usually in A1AT
Bronchiectasis exam? What from end of bed might be a giveaway?
End of bed
- Young
- Sputum pots
- Nebuliser especially if nebulised Abx
Ask patient to cough - big wet productive cough and stable - high risk bronchiectasis
Hands
- Clubbing
- Evidence of autoimmune / crest features
- Yellow nail syndrome
Face
- little to see
Neck
- JVP - unlikely raised
Chest
- Inspect front and back - Eg scars
- Palpation heart - deviated apex and loud p2
- Percussion
- Auscultate - wet coarse crackles at base/s
->Must ask the patient to cough and re-auscultate and see if change (likely to shift secretions in bronchiectasis)
- Small amount of wheeze may be present
Legs
- Pedal oedema if RHF
Bronchiectasis presentation
Signs
Complications
Current evidence of treatment
I examined this patient who had coarse wet crepitation’s which were altered by coughing.
There was no evidence of Right heart failure as evidenced by normal JVP absence of loud P2, displaced apex and absence of peripheral oedema
There was evidence of ongoing treatment with nebulised antibiotics and inhalers.
Mainstay of bronchiectasis management
Antibiotics
NOT steroids
Range of DDs for bronchiectasis aetiology
Idiopathic in many
Young
- Kartagner’s syndrome - bronchiectasis and dextrocardia
- Cystic fibrosis
- Primary cilliary dyskinesia
Post infectious
- TB
- Childhood pneumonia / whooping cough
Autoimmune / connective tissue
- Rheumatoid arthritis
- Lupus
- Sjorgrens
- Allergic bronchopulmonary aspergillus
- Crohns / UC
- Yellow nail
- Marfans
Aspiration
- Usually RLL and alcoholic / GORD
Pulm fibrosis
- Shrunken scar lung -> pulls airways open
Immunodeffiency
- Eg hypogammaglobulinaemia
Bronchiectasis investigate
HRCT is 97% sensitive for diagnosis
CXR may be helpful
Bloods
- FBC and CRP markers of infection
- Autoimmune screen, ANA / immunoglobulins
- Consider IgE to aspergilus and Eosinophils
- Functional Abs
Sputum culture including AFB
Lung function test
If suspicious of particular cause
- cystic fibrosis genotyping
- Bronchoscopy for obstructive lesion
- Ciliary biopsy for dysmotility
What makes an airway bronchiectatic on CXR/ CT
CXR - ring shaddows and tramlines suggest
CT - Signet ring sign - If the airway is bigger than the adjacent blood vessel.
Cystic fibrosis test
Chloride sweat test
Ciliary biopsy (from nose)
Bronchiectasis management
Conservative
- Chest physio - postural drainage
- Flutter valve / acapella to aid exporation
- Nutritional support
- Stop smoking
- Covid / flu / pneumococcus vaccines
Medical
- Treat triggers Eg autoimmune cause
- Carbocystine
- OPAT devices - which help get phlegm off chest
- Targeted antibiotic therapy from regular sputum samples
- often nebulised abx
Surgical
- Lobectomy if localised eg post TB
- Lug transplant if recurrent infections and declining FEV1 in CF
When would you put someone on prophylaxtic abx for bronchiectasis? Choice?
> 2 course of targeted Abx in 1 year
Azithromycin (or cipro)
Or nebulised antibiotics - colistin / gent / tobramycin
bugs in bronchiectasis?
Not too bad
- Haemophylis
- Strep pneumo
Med
- Klebsiella
- Staph
Worse
- pseudomonas
Worst
- Burkholderia
Resp exam with scars
Inspect surroundings
Observe breathing with patient exposed. Are they breathless
Ask patient to exhale fully then inhale fully
Look at position of trachea and check for asymmetry of mastoid muscles (Trails sign)
Hands
- Clubbing
- Tobacco staining
- Flap
- Pulse
Face
- Anaemia
- Horners (apical pancoast tumour)
- JVP
- Check for lymphnodes
- Scars at the back
- ->sacral oedma
- scars at axilla
Palpation
- Chest expansion Must start at end of expiration and involve full inspiration and expiration. Also start near bottom of sterum and complete higher close to axilla
- Apex beat and RV heave
- Precussion - dont forget apex and axilla
Ausculation
- If crepetations -> ask to cough then repeat
Complete vocal tactile phremitus and whispering pectoriloquy.
Temperature, sats and HR
Inspect sputum pot
What is trail sign
Excessive prominence of the clavicular head of the sternomastoid muscle on the side to which the trachea has shifted
Most common resp ddx for clubbing
Bronchiectasis
Cancer
Fibrosis
Lobeectomy / pnemonectomy exam
General inspection
Asymmetry of chest wall movement
Scars
Respiratory distress
Supplemental oxygen
Hands
Clubbing (bronchiectasis / malignancy / pulmonary fibrosis)
Tar staining (underlying malignancy)
Wasting of dorsal interossei (underlying malignancy)
Pulse: bounding +/- CO2 retention flap (COPD)
Face
Conjunctival pallor (anaemia of chronic disease)
Horner’s syndrome (underlying Pancoast tumour)
Central cyanosis
Neck
JVP (complication of pulmonary hypertension)
Cervical lymphadenopathy (underlying malignancy)
Tracheal deviation – usually deviated in upper lobectomy / pneumonectomy, towards the side of the surgery. May be central in lower lobectomy.
Chest
Inspect
Scars: lateral thoracotomy, VATS, chest drain
Ribs: pulled on over affected area
Palpate
Chest expansion:
Lobectomy: reduced anteriorly OR posteriorly
Pneumonectomy: completely reduced anteriorly AND posteriorly
Apex beat (displaced towards side of lobectomy / pneumonectomy)
Right ventricular heave (pulmonary hypertension complicating COPD / bronchiectasis)
Percuss: dull over area of lobectomy / pneumonectomy
Auscultate
Reduced breath sounds over lobectomy site
Normal breath sounds over normal lung
Absent breath sounds over whole hemithorax in pneumonectomy
May sound bronchial if overlying deviated trachea
Vocal resonance reduced over affected area
Listen for underlying aetiology:
Coarse crepitations in bronchiectasis
Prolonged expiratory phase / wheeze in COPD
Sacral oedema / pedal oedema for right heart failure
Complete examination by:
- Looking at vitals chart, specifically temperature and SpO2
- Obtain a chest radiograph
- Inspect sputum mug
Resp exam with this means?
Lung transplant
clamshell throacotomy
Likely VATS scars
Chest drain
Could be just local excision eg skin Ca
With lobectomy scar why might you hear normal breathsounds + no tracheal deviation
The remaining lung has expanded to gap
Differentials for lobe ectomy
pneumonectomy
Lobe
- Most commonly Lung Ca
- Localized bronchiectasis
- Uncontrolled haemoptysis (e.g. following failed bronchial artery embolisation) from bronchiectasis / tuberculosis / underlying pneumonia
-Early non-small cell lung cancer
- Lung volume reduction surgery for COPD
- Lung abscess
- Trauma
- Solitary pulmonary nodule of unknown cause
- Cystic fibrosis
- ILD
What would determine whether a patient could go for a lobeectomy / pneumonectomy in lung cancer
Staging of disease - not if distance mets
CT / PET scan
- Staging EBUS (US scan during bronchoscopy)
Cell type - small cell often inoperable
Lung function tests
- 2L for pneumonectomy
- 1.5L for lobectomy
Others inclde
CPET - cardiopulmonary exercise testing (looking for vo2 max of 15mls/kg)
[Often on bike with mask for measuring gas exchange + ECG and sats probe]
Complications of lung surgery
I would let the patient know about questions to ask thier surgeon.
Immediate post op
- Bleeding
- Mucous plugging
Intermediate
- Infection
Recovery time
Rehab options
Respiratory failure
Posteriolateral thoracotomy
Pneumon/lobectomy
bullectomy
pleurectomy
Anteriolateral thoracotomy
Single side thoracotomy means…
lobectomy
pneumonectomy
open lung biopsy
lung volume reduction or bullectomy
Single lung transplants
Pulmonary fibrosis signs on exam? causes to find on eam?
Inspection
- Cushingoid from steroids
Hands
- Clubbing
- Rheumatoid hands
- Sclerodactyly - CREST
- Irregular pulse - amiodarone
Chest
- Fine end expiratory crackles which do not move with coughing
Possible evidence of RHF
Sclerodactlyly - skin on the fingers or toes to thicken, tighten, and harden, resulting in a claw-like appearance
Investigations for pulm fibrosis (not acute admission)
Bloods
- ESR
- Rheum factor, ANA
- Consider hypersensitivity pneumonitis antigens associated with disease
- Consider HIV
-ABG - type 1 resp failure
CXR
Bibasal Reticulonodular shaddowing
Loss of definition of heart border
Lung funciton tests
- Restricictive (FEV1:FVC >0.8)
- Reduced lung capacity
- Recuded TLco (transfer factor for carbon monoxide) and KCO (diffusion coefficient)
HRCT
- Location of fibrosis helps with differentials
Consider biopsy either transbronchial or open
Management of pulmonary fibrosis
Conservative
- Patient education
- Support groups
- STOP smoking
- Drug induced - stop offending drug
- Hypersensitivity may improve when offending thing removed eg birds at home
- Palliatve care
- Long term oxygen
Inflammatory
- Steroids
- Nintedanib
- Sometimes steroid spairing eg Azathioprine / methotrexate
Idioipathic
- Pirfenidone
- Ninedanib
Surgical
- Single lung transplant
Fine crackles over 1 lung and normal breath sounds on other with a scar?
Single lung transplant pulmonary fibrosis
Dermatomes
T4
T10
L5
S1
T4 - nipple
T10 - Umbilicus (belly butTEN)
L5 - Big toe (Largest of 5)
S1 - Little toe (Smallest 1)
Causes of upper lung fibrosis
BREASTS
Berylliosis
Radiation
Extrinsic alergic alveolitis / eosinophilic pneumonia
Ankylosing spond / allergic bronchopulmonary aspergillosis
Sarcoid
TB
Silicossis
What is this
Portacath
- Used for giving IVs
Attached as below
What is the lights criteria
If protein 25-35 can use lights
For exudate
Pleural fluid protein : serum >0.5
Pleural fluid LDH : Serum LDH >0.6
Pleural fluid LDH >2/3 serum exudate
