Resp Flashcards
How might lung function change in patient with transplanted lung with IPF?
Lung function could show worsening restrictive pattern suggesting native lung is worsening fibrosis
Or could start to show obstructive pattern if they’re developing bronchiolitis obliterans
Most common type of chronic lung rejection after transplant?
Bronchioloitis obliterans
Spirometry for ILD
Restrictive pattern
Reduced FEV and FVC with preserved ratio
Reduced total lung capacity and transfer factor
Causes of restrictive spirometry
Plural disease, motor neuron disease, obesity, and kyphoscoliosis
Causes of upper zone lung fibrosis
Ankylosing spondylitis
ABPA
TB
radiation
silicosis and sarcoidosis
Causes of lower zone lung fibrosis
IPF, asbestosis, RA, SLE/Sjogren’s
Surgical sieve for long fibrosis
Auto immune
occupational/environmental
drugs
post infective
smoking
other systemic disorders e.g. sarcoid vasculitis IBD
Why don’t we use suction for pneumothorax?
Risk of pulmonary oedema re-expansion
Indication for VATS procedure
Lobectomy or wedge resection, bullectomy, lung reduction, pleurectomy, biopsy
Indications for surgical management of pneumothorax
Recurring pneumothorax or ongoing air leak despite drain
Indications for surgical management of pneumothorax
Recurring pneumothorax or ongoing air leak despite drain
Pros and cons of VAT versus open thoracotomy
That is less invasive, less pain less wound infection
That has slightly higher risk of recurrent pneumothorax
What is ABPA?
Fungal infection in asthmatics/ CF/ immunosuppressed due to sensitivity to aspergillosis antigen
Increased asthma exacerbations, weight loss, sinusitis = ?
APBA
ABPA CT findings
Bronchiectatic changes, centrilobular nodules, tree in bud appearance
Peak flow pattern in asthma
Low peak flow in am and diurnal variation
How does spirometry differ in asthma compared to COPD?
Both obstructive with reduced FEV and preserved FVC
Asthma shows reversibility ie improvement of at least 15%
Gas transfer is reduced in COPD
Common organisms in cystic fibrosis
In children staph aureus
Adults pseudomonas and non tv mycobacterium
burkholderia which is bad prognosis and contraindication to lung transplant
Management of CF
MDT!
1. Daily transfer physio including postural drainage.
2. Nebulisers including mucolytics e.g. hypertonic saline and recombinase
3. Azithromycin and regular courses of antibiotics.
4. Pancreatic enzymes and fat soluble vitamins.
5. Nutritional supplements or NGO peg feeding.
6. CFTR modulator Med is.
7. Insulin therapy
How is cystic fibrosis diagnosed?
Screening with the Guthrie test as newborn and then go onto test for the commonest CFTR mutations and perform a sweat test
Indications for pneumonectomy
Trauma
Cancer
Chronic infections eg TB or fungal
How can you differentiate between an exudate and transudate on a plural tap?
Using lights criteria if protein levels are between 25 and 35
Indications for lung transplant
2 wet 2 dry
Cystic fibrosis bronchiectasis pulmonary hypertension pulmonary fibrosis
COPD single rather than double transplant
Complications of lung transplant
Acute: hyper acute rejection and infection.
Chronic: bronchiolitis obliterans and skin malignancy or lymphoproliferative
What is Churg Strauss
Rare small vessel vasculitis
Unknown aetiology
Features of churg strauss
Late onset asthma, refractory to treatment
Allergic rhinitis
Polyps
Sinusitis
Urticarial rash
Abdo pain
Complications of churg Strauss
Mono neuritis Multiplex, glomerulonephritis, vasculitic rash
Churg Strauss diagnosis
Raised eosinophils and IgE
PANCA
Gold standard is biopsy of affected tissue
Commonest gene mutation for CF
Delta F508
Features of CF
Respiratory: bronchiectasis
Pancreatic insufficiency
Recurrent infections: long-term venous access
Diabetes
Infertility
Gallstones kidney stones constipation
Pulmonary hypertension
Clinical findings differences between pneumonectomy and lobectomy
Trachea - may be deviated in L but will be in P
Breath sounds - reduced or normal in L, absent in P
Percussion - dull in P (normal in L)
Strongest association lung cancer with smoking
Squamous
Main indication for bronchial Alviola lavage in pulmonary fibrosis
Exclude any infection before giving immuno suppressant
Also if lymphocytes > neutrophils then better response to steroids and better prognosis)sarcoid)
Bronchiectasis sign on HRCT
Signet ring sign
Thickened dilated bronchi larger than adjacent vascular bundle
CXR findings in bronchiectasis
Tramlines
Ring shadows
Investigations looking for a specific cause of bronchiectasis
Immunoglobulins for hypo Gamma globin anaemia
Aspergillus RAST or skin print testing for a BPA
Rheumatoid
Nares to taste buds in 30 mins (saccharine ciliary motility test) for kartageners
Genetic screening for CF
Hx f IBD
Causes of bronchiectasis
Congenital: kartageners and CF
Childhood infection: measles and TB
Immune over activity: ABPA, inflammatory bowel disease.
Immune under activity: hypo Gamma global anaemia.
Aspiration: chronic alcoholics and GORD
Complications of bronchiectasis
Core pulmonal
Secondary amyloidosis – tip urine for protein
Massive haemoptysis
Clinical signs of old tuberculosis
Chest deformity and absent ribs – thoracoplasty scar
Tracheal deviation to the fibrosis.
Reduced expansion.
Dull percussion but present tactile vocal fremitus
Crackles and bronchial breathing
Side effects of tuberculosis drugs
Isoniazid - peripheral neuropathy and hepatitis?
Rifampicin - hepatitis
Ethambutol - retrobulbar neuritis and hepatitis
Pyrazinamide - hepatitis.
Indications for single versus double lung transplant
Single lung transplant is for dry lung conditions ICOPD and pulmonary fibrosis.
Double long transplant is for wet lung conditions i.e. CF bronchiectasis or pulmonary hypertension
Clinical features of core pulmonale
Raise JVP
Peripheral oedema
R ventricular heave
Loud P2 with pansystolic murmur of tricuspid regurgitation
LTOT criteria
Non smoker
PaO2 <7.3 on air
PaCO2 that doesn’t rise excessively on O2
Improves average survival by 9 months
Empyema exudate features
Low glucose
PH<7.2
Most common organisms causing empyema
Anaerobes
Staphylococci
Gram neg
Pan coast tumour features
Horners + wasted small muscles of hand (T1)
Rusty sputum
Pneumococcus
Causes of bronchiectasis
Idiopathic
Inflammatory ie RA or IBD
TB
Immunosuppression
Pleural effusion causes
Unilateral and no evidence of fluid overload assume exudate:
Lung malignancy
Infection e.g. para pneumonic effusion
CTD ie sarcoid and rheumatoid arthritis
Transudate effusions: caused by the failures but also hypoalbuminaemia
Lights criteria
You need to perform light criteria on Pleural aspirate
The plural fluid is an exudate if The plural protein divided by the serum protein is greater than 0.5 or the pleural LDH divided by the serum LDH is greater than 0.6 or the pleural LDH is greater than 2/3 the upper limits of normal for the serum LDH
Indications for lobectomy or pneumonectomy
Non-small cell cancer usually peripheral is lobectomy in a central is pneumonectomy
Abscess but could have wedge resection
Localised bronchiectasis
TB
Lung trauma
COPD severity
FEV1
<30% very severe
30-50% severe
50-80% moderate
>80% but still obstructive is mild
Cor pulmonale definition
R Sided cardiac failure secondary to respiratory disease occurs in chronic hypoxia resulting in vasodilation and then pulmonary htn
