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 methotrexate if not responding
Topical steroids;
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
Detailed history
- Childhood infections, TB, Smoking
Bloods
- FBC and CRP markers of infection
- Functional Abs
- Autoimmune screen, ANA / immunoglobulins
- Consider IgE to aspergilus and Eosinophils
- cystic fibrosis genotyping
Imaging
- Lung fuction tests
- HRCT
Special
- 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 in order of clinical concern?
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
Lower lung fibrosis causes
CABRIOS
Collagen vascular disease / cryptogenic fibrosis alveolitis
Asbestosis
Bleomycin
Rheum arthritis
Idiopathic
Other… (Blah never mind BNM) Bleomycin Nitrofurantoin MTX
Scleroderma
Drugs which cause liver enzyme inhibition? What does this mean?
[Sick more drugs]
- Increased effect of drug
SICKFACES.COM
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Liver enzyme induction
Crap less drugs
CRAP GPs
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
Rule of 10s for phaeo
10%
-Familial
-malignant
-outside adrenals
-Bilateral
Which organisms in asplenia
His Spleen Never Got Sick
Haemophilus influenzae type B
Streptococcus pneumoniae
Neisseria meningitides
Group B streptococcus
Salmonella typhi
Council patient about TB drugs and things to look out for.
Isoniazid
- Peripheral neuropathy (give pyridoxine to prevent)
- hepatitis
Rifampicin
- Increased metabolism of drugs eg COCP
- Orange secretions
- Hepatitis
Ethambutol
- Optic neuritis
Pyrazinamide - Hepatitis
If the whites of your eyes look yellow - stop taking your tablets and contact TB nurse
If red becomes less bright - contact TB nurse that day
New tingling in toes. Continue tablets and tell doctor at clinic visit
Secretions
- may permanently stain contacts -> should not be worn
If on contraceptive - should use barrier protection
CXR of apical lobectomy will show
Likely just raised hemidiaphragm on that side
Pleural effusion signs on exam? Signs to indicate cause?
Inspect
- Asymmetry of chest expansion if large
- Trachea deviated Away from effusion
- If ca and tethered lung with small effuson trachea may deviate towards
Precuss - Stony dull
- Reduced tactile vocal fremitus
- Reduced breath sounds
Cancer - clubbing , lymphadenopathy, mastectomy (Breast Ca V V V common cause of effusion
CCF
CLD
CKD
Connective tissue - Rheum hands, butterfly rash SLE
What are the differentials for a unilateral dull lung base with reduced AE
name all 4.
Pleural effusion
Collapse
Pleural thickening - Esp if VATs scars etc
Raised hemidiaphragm
Eg lobectomy / Hepatomegaly / hepatic abscess
Causes of transudative / exudative pleural effusion?
What on aspirate would make you think exudative? empyema?
Trans
- CCF / CLD / CKD
Ex
- Ca
-Infection
- Infarction
- inflammation RA / SLE
Findings to suggest
Exudative - Lights criteria
- Protein <30<
- effusion albumin / plasma albumin >0.5
- Effusion LDH / Plasma LDH >0.6
- Pleural fluid LDH >2/3 upper limit of normal serum LDH
Empyema
- Low glucose <2.2mmol + pH <7.2
Empyema management
Surgical drainage
IV Abx
Consider DNAse + TPA
Lung Ca signs on exam? Complications
Inspect
Cachexia
Hands
- Clubbing
- Tar staining
Neck
- Cervical lymphadenopathy
- Tracheal deviation towards (collapse) or away (effusion)
Chest
- Collapse / consolidation / effusion
Complications on exam
[Neck down]
- SVCO - Odematous face, dilated veins, stridor
- Horners sign / T1 (small muscles of hand) wasting - pancoast
- Recurrent laryngeal nerve palsy - horse voice, bovine cough
- gynaecomastia - ectopic bHCG
- Lambert eaton myaesthenic syndrome / peripheral neuropathy / proximal myopathy / paraneoplastic cerebellar degeneration
- Derm - dermatomyositis
What are the usual types of lung Ca?
Squamous 35%
small cell 24%
Adenocarinoma 21%
large cell 19%
alveolar 1%
Name 3 ways to get sample for cytology of lung Ca
Sputum cytolocy
BAL
Bronch biopsy
Perc biopsy
Bloods which indicate complications of Lung Ca
Mets - HyperCa, LFTs, Anaemia
Squamous - PTH (releasing protein) - HyperCa
Small cell - ADH -> SIADH + HypoNa
Small cell vs Non small cell lung ca management
Small cell - usually just chemo
NSCLC - surgery / Radiotherapy / chemo
What is this
Portacath
- Used for giving IVs
Attached as below
Key signs on exam for CF
Small
Sputum pot
Possibly O2
Hands
- Clubbed
- Diabetes finger prick marks
Chest
- Hyperinflated
- Coarse crackles / wheeze
- Portacath / hickman
Abdo
PEG
Cause of CF? Pathophysiology and organs affected
Ressessive chromosome 7 CFTR gene
delta 508 mutation
(1/2500 births)
Encodes cloride channels -> thickend secretions
Bronchioles -> Bronchiectasis
Pancreatic ducts - > exocrine / endocrine insufficiency. EG fat soluble vitamines / diabetes
Gut - > delayed transit
Gall bladder -> stones
Seminal vesicles -> infertility
Fallopian tubes -> infertility
When does CF get screened for? other diagnostics
Birth - guthrie heel prick test
Cloride sweat test (>60mmol/L)
Genetic screening
Who may the cloride sweat test be false positive in?
Hypothyroid
Addisons
Management CF
- Patient education
- Regular sputum samples
- Physio - inc postural drainage anbd breathing techniques
- Dietician - vitamins +/- PEG feeding
- Vaccines - esp pneumococcal and flu
- Palliatve care
Medical
- Fat soluble vitamins
- creon
- abx for infections +/- prophylactic
Surgical
- Transplant
Most common bug in CF? Worst prognosis
Pseudomonas aeurginosa
Burkholderia cepacia
When is CAP severe? what does this mean?
CURB 2 or more
Confusion
Urea >7
RR >30
BP less than 90/60
Age >65
IV antibiotics and level 2 care
CAP investigations
Focused a-e
Bloods - inflam
blood cultures
Abg
Sputum cultures
Urine
- Leigonella antigen
- penumococca antigen
- haemoglobinuria - mycoplasma -> haemolysis
Pleural tap bits
pH <7.2 - infection / inflammatory
Protein
LDH
Cytology
BC bottles
glucose
TB
If bloody - worry about cancer
Consider amylase
If milky - cholesterol for cylothroax
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
When might a transudative pleural effusion look exudative on lights
If heart failure and on lots of diuretics
Options for management of recurrent malignant effusions
Indwelling pleural catheter
Talc pleurodesis
Occationally a pleural peritoneal shunt
Pleural biposy options
Can be US / CT guided
Option for VATS -> good as can add talc / indwelling catheter at end if needed
how to manage a pleural effusion
It would depend on
- How symptomatic the patient is
- Size of the effusion (ideally on US)
- Do we have the underlying diagnosis yet
Likely
- CXR to confirm and may give diagnosis
- Then US guided pleural aspirate for diagnosis and symptoms with CT.
- If I am worried about malignancy I would perform a CT CAP
- If an infection is worry for drain + inpatient antibiotics
Present bronchiectasis
- This gentleman has a cough productive of purulent sputum as evidenced by the sputum pot next to the bed
- He is thin with evidence of bilateral finger clubbing
- His respiratory rate is not raised and the trachea is central
- There are coarse crackles at both bases which move with coughing
I would like to know whether these features are long standing and to have a set of basic obervations especially O2 saturation and temperature
these findings are consistent with bibasal bronchiectasis
Differntial of crepetations and clubbing
Bronchiectasis - usually change with coughing
Pulm fibrosis - more fine crackles
Lung Ca
Chroinic lung abscess
Define bronchiectasis
Chornic airway inflammation with abnormal dilation of 1 or more bronchi
It is assosciated with a chronic productive cough and suseptibility of chest infections
What is cystic fibrosis
Autosomal ressessive condition encoded by the d-F508 gene on chromosome 7 with a carrier rate of approx 1/25. Encodes the CFTR protein which is a cloride channel.
Results in abnormal cloride channels
This results in thickened secretions in the
- Lungs -> bronchiectaiss and infections
- Pancreas -> diabetes
- Gall bladder and GI -> lack of ADEK vitamins and delayed transit
- Infertility
Bar bronchiectasis what other respiratory manifestations of CF
Pneumothorax
Allergic bronchopulmonry aspergillosis
Mycobacterial infections
Asthma
What is primary cilliary diskinesia
Autosomal ressesive
All cillia are affected
- Airways -> reduced clearence of secretions which leads to collonisation and infection -> bonchiectasis
- Fallopian tubes
- Impaired fertility in men is secondary to decreased sperm count and motility as the tail is a ciliary hair
30% get situs ivertus with organs appearing on opposite side of chest Eg dextrocardia
- This is kartageners syndrome
Present COPD
This thin elderly woman has a barrel shaped chest and is using her accessory muscles with indrawing of the ribs in inspiration.
She is tachypneic at rest with a resp rate of 24 / minute.
There is a prolonged expiratory phase.
Tar staining is evident at the fingers
There is a bounding pulse without a CO2 retention flap.
The JVP is not raised, there is no right sided parasternal heave, loud p2 or peripheral oedema suggestive of right heart failure.
There is resonant precussion throughout and breath sounds are generally reduced with evidence of scattered expiratory wheeze.
This is consistent with long standing COPD with/without cor pulminale
What murmur common in pulkm hypertension? JVP?
- Loud p2.
- May get 4th heart sound
- Functional TR - pansystolic loudest on inspiration
JVP - large v waves
What is cor pulmonale ? signs?
Development of right sided heart failure secondary to long standing riased right sided heart pressures from pulmonary hypertension
Right sided heart failure
sob
fluid retention
Congestive hepatomegaly
Causes of cor pulmonale
Lungs
Obstructive - Asthma / COPD
Bronchiectasis
Restrictive
- Intinsic - eg pulm fibrosis, lung resection
- Extrinsic - OHS, muscle weakness, thoracic cage abnormalitis
Pulm vasculature
Pulmonary thrombembolic disease
Pulmonary vasculitis
Primary pulm hypertension
What is COPD
Chronic respiratory disease usually caused by smoking
COPD is a progressive, obstructive airway disease that is not fully reversible.
It results from disease of the airways and parenchyma in the form of chronic bronchitis and emphysema
Emphesema is a dilation of the airways distal to the bronchioles. There is a destruction of these airways leading to impaired gas exchange and breathlessness.
Bronchitis is a cough productive of mucoid sputum for at least 3 months/ year
There is mucus gland hyperplasia and loss of cilliary function leading to chronic cough and inflammation of the airways leading to fibrosis.
Differentiate emphysema and chronic bronchitis clinically
Emphesema - pink puffer
- greater hyperinflation with SOB and respiratory drive
- less cyanosed
Bronchitis (blue bloater)
- Commonly cyanosed
- frequently develop cor pulmonale
COPD there is usually a degree of both
COPD aetiology
95% cigarette
Other inhaled substance eg coal dust
If young - A1AT
A1AT gene?
Resessive
Most common alleles
Homozygous ZZ would be most likely to cause COPD
M - normal function
S - reduced
Z - very deficient
Diagnosis COPD? What would you find on pulm function tests? Why is gas transfer reduced?
Spirometry
FEV1 <0.8
FEV1:FVC <0.7
With lack of reversibility
Lung volume and functional residual volume increased due to gas trapping
- Dont exhale fully -> residual air left in lungs
Gas transfer is reduced due to degreased surface area for gas exchange in emphysema
COPD XR findings name 3
Hyperinflated lungs: The lungs appear larger than normal because the lung tissue has lost elasticity and traps air after each breath
Flattened diaphragm: The diaphragm may look lower and flatter than normal
Bullae: Pockets of air that can form near the surface of the lungs. Bullae can grow large and take up space in the lungs, making it difficult to function properly
Narrowed heart: The heart may appear longer or narrower because it changes shape to make room for the expanding lungs
Difficulty seeing ribs: Osteopenic ribs can make it difficult to see the ribs
Common causes of COPD exac name 6
Bacterial
- S pneumo
- H infliuenza
- Moraxella catarrhalis
Viral
- Rhinoviruses
- Influenza
- Parainfluenza
- Coronavirus
- Adenovirus
- Respiratory syncytial virus
Non infective
- Temperature change
- dust
- Air polution
Contraindications for NIV
Absolute
- Unstable cardiac arrhythmia
- Facial burns or severe facial deformity
- Upper-airway obstruction
Relative
- Nausea and vomiting
- reduced GCS / encephalopathy
Present ILD
This elderly man appears breathless and tachypneic at rest.
There is an oxygen tank by the bedspace.
He has a dry cough
There is evidence of finger clubbing and no lymphadenopathy
Chest expansion is reduced and symmetrical
Auscultation demonstrates fine bibasal end inspiratory crackles.
This is consistent with pumonary fibrosis
What is the cause of this persons pulmonary fibrosis ?
nothing bar the pulm fibrosis on exam
Systemic causes
Drugs
Inhaled
There are no features of a systemic inflammatory condition such as Rheumatoid athritis, systemic sclerosis, SLE, Sjrogens syndrome and polymyosistis / dermatomyositit.
Occationally it may be Ankylosing spondylitis if present in the apices with thoracic kyphosis.
Most likely this would be an idiopathic pulmonary fibrosis
It may be drug induced eg Amiodarone, Bleomycin, Nitrofurantoin and Methotrexate.
Inhaled substances may also cause this eg extrinsic allergic alveolitis \ farmers / pigeon fanciers lung
Aspestosis, silicosis can also cause similar signs.
- Rheumatoid arthritis: peripheral symmetrical deforming polyarthropathy (swan neck deformity, Z thumb, ulnar deviation at wrist, may have nodules) NB: the cause of the pulmonary fibrosis may be RA itself or methotrexate use in an RA patient
- Amiodarone: slate grey appearance, pacemaker, may be in AF, photosensitivity
- Connective tissue disease: cutaneous signs of systemic sclerosis, lupus, dermatomyositis (See “station 5” section on website)
- Ankylosing spondylitis: question mark posture, protuberant abdomen
- Radiation: may have radiation tattoo on chest wall, lymphadenopathy
- Sarcoidosis: cutaneous signs of sarcoidosis
If there is evidence of unilateral fibrosis what do you need to ask about
Radiotherapy
Why would you do open lung rather than transbronchial biopsy in some cases of pulm fibrosis
Sometimes peripheral and patchy
Also useful in pulm vasculitis, langerhans histocytosis.
Transbronchial helpful in eg sarcoid and hypersensitivity pneumonitis
Present pleural effusion
This elderly woman is thin.
The JVP is not elevated.
There is a lymphnode palpable in the left supraclavicular fossa.
There is tracheal deviation to the
There is reduced breath sounds and a stony dull precussion note in the left lung base
Tactile vocal phremitus and vocal resonance are also reduced
There is evidece of a previous chest aspiration.
Is lights criteria sensitive or specific?
Very sensitive but not specific
Eg Cardiac effusions if on diuretics
How long do you treat for an empyema
Approx 6 weeks abx
Complications of pleural drain
Infection
pneumothorax
haemothorax
Reexpansion pulmonary oedema. Oten remove approx 500mls then clamp
failure especially blocked tubes
What is the role of CT scanning in effusions
Helpful for differentiating cause.
Also allows look at lung parenchyma
Allows staging of malignancy
What is pleurodesis
inflammatory steril stubstance usually talc is inserted into plerual cavity
-> pleural surfaces adhere to each other
Helps prevent effusion recurrence
What causes a chylothorax
rare complication of lymphoma, nephrotic syndrome, cirrohsis or rheumatoid athritis
Causes of a blood stained effusion
Malignant
Pulmonary embolism
TB
Trauma
Present pneuonectomy
This patient is comfortable at rest without evidence of beathlessness.
There is evidence of tar staining of the hands and no evidence of clubbing.
There is no palpable lyphadenopathy
There is 2 radiotherapy tatoos on the anterior chest wall as well as small scars consisent with chest drain sites
There is reduced expansion and deviation of the trachea towards the right side.
There is reduced air entry and vocal resonance. to the right side.
Why might there be bronchial breathing in the upper zone of a pneumonectomy
Heart over the deviated trachea
What findings on CXR of pneumonectomy
Crowding of ribs
Rised hemidiaphragm
deviated trachea
Appear opaque
indications for heart-lung transplant?
Lung only?
lung-heart transplant
- primary pul hypertension
- eisenmengers
Chronic lung disease
- Pulmonary fibrosis
- COPD usualy A1AT
- CF
- Sarcoid
Most common causes of pneumonia CAP/HAP
CAP
- Strep pneumo
- H influenza
- Mycoplasma pneumonia
HAP
- Staph aureus
- Gram neg eg klebsiella
- Pseudomonas
Aspiration
- Anaerobes
Immunocompromised
- Consider fungi, virus and mycobacteria
Pneumonia investigations
Bedside
- Full set of obervations
- Blood gas
- ECG
- Urine for leigonella / pneumococcal antigen
Imaging
- CXR
- Consider US
Special
- Tap
Stridor differential other than bacterial epiglotitis?
- Bacterial epiglotitis
- Retropharyngeal absess
- bacterial trachietis
Thermal injury
- Smoking drugs
- smoke inhalation
Allergy
Inahled foreign body
Trauma Eg intubation
Bugs in stridor
HIB
Strep pneumo
Strep pyogenes
Staph aureus
Lung transplant failing typically leads to what on PFTs?
Brochiolitis obliterans -> Obstructive patterm
When do you use d dimer for PE screen
Only if low risk wells
yellow nail syndrome triad
- Yellow nails (Can give vit E / antifungals)
- Pulm - bronchiectasis / effusions
- Peripheral oedema
