Resp 7.5 Flashcards
Group 1 pulmonary HTN
(1ry) idiopathic, familial, or persistent pulm HTN of the newborn
- ass in: collagen vast disease, congenital heart disease with systemic->pulm shunts, HIV, drugs & toxins, sickle cell disease
Group 2 pulmonary HTN
= pulm HTN with left heart disease
- left-sided atrial, ventricular or valvular disease e.g. LV systolic & diastolic dysfunction, mitral stenosis & mitral regurgitation
Group 3 pulmonary hypertension?
= pulm HTN 2ry to lung disease/hypoxia
- COPD, ILD, sleep apnoea, high altitude
Group 4 pulmonary hypertension?
= pulm HTN due to thromboembolic disease
Group 5 pulmonary hypertension?
= miscellaneous conditions
- lymphangiomatosis e.g. 2ry to carcinomatosis/sarcoid
Resp manifestations of rheumatoid arthritis?
- pulm fibrosis
- pleural effusion
- pulm nodules
- bronchiolitis obliterans (obstructive)
- complications of drugs e/g/ MTX pneumonitis
- pleurisy
- Caplan’s syndrome - massive fibrotic nodules with occ coal dust exposure
- infection (may be atypical) 2ry to immunosuppression
%pred of FEV1 in copd?
post-bronchodilator FEV1/FVC <0.7
1 mild >80% WITH SYMPTOMS
2 moderate 50-79%
3 severe 30-49%
4 v severe <30%
Rx for low-severity CAP?
1st Amoxicillin 5/7 (/macrolide/tetracycline)
Rx for mod-high severity CAP?
What to consider in high-severity?
- Dual Abx: Amoxicillin + Macrolide 7-10/7
- beta-lactamase stable penicillin e.g. co-amoxiclav/ceftriaxone/tazocin + macolide in high severity
What is transfer factor?
Rate at which a gas will diffuse from alveoli into blood - CO used to test rate of diffusion
- total gas transfer TLCO or corrected for lung volume transfer coefficient KCO
Conditions that can cause increased KCO with a normal/reduced TLCO?
(KCO also tends to increase with age)
- pneumonectomy/lobectomy
- neuromuscular weakness
- scoliosis/kyphosis
- ankylosis of costovertebral joints
Causes of raised TLCO?
- pulmonary haemorrhage
- asthma
- L->R cardiac shunts
- polycythaemia
- hyperkinetic states, exercise, males
Causes of a lower TLCO?
- fibrosis
- pneumonia
- PE
- pulm oedema
- emphysema
- anaemia
- low cardiac output
Causes of predominantly Upper zone fibrosis?
Coal workers pneumoconiosis Histiocytosis/hypersensitivity pneumonitis/EAA Ank spond (rare) Radiation TB Sarcoid/silicosis
Causes of predominantly lower zone fibrosis?
- idiopathic
- most CT disorders except ank spend
- asbestosis
- drugs: amiodarone, bleomycin, MTX, NSAIDs, nitrofurantoin
Gene ass with bronchiectasis?
HLA-DR1
Causes of bronchiectasis?
- post-infective: TB, pneumonia etc
- CF
- obstruction e.g. cancer/FB
- immune deficiency: selective IgA, hypogammaglobulinaemia
- ABPA
- ciliary dyskinetic syndromes: Kartagener’s syndrome, Young syndrome
- yellow nail syndrome
CXR/CT signs in bronchiectasis?
tramlines/tram-track & signet rings
5 features of Churg-Strauss syndrome? (small-medium vessel vasculitis)
- asthma
- blood eosinophilia >10%
- paranasal sinusitis
- monomeuritis multiplex
- pANCA +ive in 60%
What drugs can precipitate Churg-strauss syndrome?
Leukotriene receptor antagonists e.g. montelukast
Sx of acute mountain sickness?
what may if progress to?
prevention?
Rx?
- headache, nausea, fatigue. Develops gradually over 6-12h and can last a number of days. Starts to occur above 2500-3000m
- HAPE/HACE
- prevent with Acetazolamide (carbonic anhydrase inhibitor), gain no more than 500m/day
- Rx = descent…
Features & Rx of HAPE?
- classic pulm oedema features
- Descend, O2 if available, drugs can help by reducing systolic pulmonary artery pressure e.g. nifedipine, dexamethasone, acetazolamide, phosphodiesterase V inhibitors)
Features & Rx of HACE?
- headache, ataxia, papilloedema
- Descent & Dexamethason
Hypersensitivity pneumonitis = EAA
- what is acute presentation?
- CXR? BAL? FBC? CT?
- SOB, dry cough, fever 4-8h post-exposure
- CXR upper/midzone fibrosis
- BAL: lymphocytosis
- FBC: NO eosinophilia
- CT: centrilobular ground glass nodules
Drug Rx in COPD step 1? 2? 3? When to start theophylline? When to consider mucolytics?
- SABA/SAMA
2a. FEV1>50%: LABA/LAMA
2b. FEV1<50%: LABA+ICS/LAMA - Switch LABA to LABA+ICS or Upgrade to a regime of LABA+ICS & LAMA
Theophylline only after trial of above or people who can’t use inhaled therapy - REDUCE DOSE if on macrocode/fluoroquinolone
Mucolytics to consider if chronic productive cough & continued Sx improve
Features of Cor pulmonale?
Rx?
- raised JVP, systolic parasternal heave, peripheral oedema, loud P2
- loop diuretic for oedema, consider LTOT
Factors which may improve survival in stable COPD?
- STOP SMOKING
- LTOT in those who fit criteria
- lung volume reduction surgery in selected pts
Features of ABPA?
5 Ix features?
minor criteria?
Rx?
- bronchiectasis & bronchoconstriction: wheeze, cough, dyspnoea
- eosinophilia
- raised IgE>1000
- CXR e.g. ring shadow/tram track suggestive of bronchiectasis, CT as above or bronchoceles
- positive RAST to Aspergillus Ag
- positive IgG precipitins (less +ve than in aspergilloma
- clinical features of asthma
Rx with Steroids. Itraconazole sometimes added 2nd line
NSCLC - Rx options?
- only 20% suitable for surgery
- mediastinoscopy performed pre-op as CT doesn’t always show mediastinal lymph node involvement
- curative/palliative RT
- poor chemo response
NSCLC - what are the contra-indications to surgery? apart from general health
- stage IIIb/IV (mets)
- FEV1 < 1.5L
- malignant pleural effusion
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
4 indications for NIV?
- COPD with resp acidosis pH 7.25-7.35
- type II resp failure 2ry to: NMD/OSA/chest wall deformity
- cardiogenic pulmonary oedema unresponsive to CPAP
- weaning from tracheal intubation
What are the recommended initial settings for BIPAP in COPD?
- EPAP 4-5cm H20
- IPAP 10-15cm H20
- back up rate 15breaths/min
- backup insp:exp ratio 1:3
Causes of cold?
Smoking
Alpha-1 antitrypsin deficiency
cadmium, coal, cotton, cement, grain
Patients with COPD who should be assessed for LTOT?
How are they assessed?
- v severe i.e. FEV1<30%
- cyanosis
- peripheral oedema
- polycythaemia
- raised JVP
- spO2 <93%
2 ABGs, 3 weeks apart with stable COPD on optimal Rx
When to offer LTOT in COPD patients?
- pO2 < 7.3 or
2. pO2 7.3-8 + 2ry polycythaemia/ nocturnal hypoxaemia/ peripheral oedema/ pulm HTN
What is Silicosis?
What is a particular feature on imaging??
What are pts at risk of?
Fibrosing lung disease (upper zone) caused by silica inhalation
- RF for TB (silica toxic to macrophages)
- Egg-shell calcification of hilar lymph nodes
Factors associated with poor prognosis in sarcoidosis?
- insidious onset, Sx > 6m
- absence of erythema nodosum
- extra-pulm manifestations e.g. splenomegaly, lupus pernio
- CXR: stage III-IV features
- Black people
- HLA B13
Adverse effects of nicotine replacement therapy?
nausea & vomit, headache, flu-like Sx
MoA of Varenicline? When to start? Course of Rx? Adverse effects? When is it cautioned & C/I?
- nicotinic receptor partial agonist
- start 1wk before target stop date
- course c. 12wks
- nausea commonest. also headache, insomnia, abn dreams
- caution in Hx of depression/self-harm
- C/I in pregnancy & breastfeeding
MoA of Bupropion?
when to start?
When is it cautioned & C/I?
- Norepinephrine & dopamine reuptake inhibitor, and nicotinic antagonist
- start 1-2wks before target stop date
- relative C/I if eating disorder
- C/I in epilepsy, pregnancy & breastfeeding
- small risk of seizures 1/1000
What would cause a Leftwards shift of the O2 dissociation curve (lower O2 delivery)?
- Low H+ (alkali)
- Low pCO2
- Low 2,3-dpg
- Low temp
- HbF, metHb, carboxyHb, (lower altitude, less exercise)
Causes of transudate pleural effusion?
<30g/L protein
- heart failure
- hypoalbuminaemia: liver disease, nephrotic syndrome, malabsorption
- hypothyroidism
- Meig’s syndrome
Causes of exudate pleural effusion?
>30g/L protein
- infection: pneumonia, TB, subphrenic abscess
- neoplasia: lung ca, mesothelioma, mets
- CT disease: RA, SLE
- pancreatitis
- PE
- Dressler’s syndrome
- yellow nail syndrome
Major & minor criteria for ABPA?
- clinical features of asthma
- proximal bronchiectasis
- eosinophilia
- immediate skin reactivity to aspergillum Ag
- raised serum IgE >1000
i) fungal elements in sputum
ii) brown flecks in sputum
iii) delayed skin reactivity to fungal Ags
What is alpha1-antitrypsin?
protein inhibitor of neutrophil elastase -> protects lungs against functions of this enzyme
- produced by liver
Genetics of alpha1-antitrypsin:
which chromosome?
inheritance?
how are alleles classified?
- chr 14
- autosomal recessive/co-dominant
- classed by electrophoretic mobility: M normal, S slow, Z v slow
normal = PiMM
homo PiSS 50% normal A1AT levels
homo PiZZ 10% normal A1AT levels - manifest disease
Features of alpha1-antitrypsin deficiency?
Ix?
Lung: panacinar emphysema (esp lower lobes)
Liver: cirrhosis & HCC in adults, cholestasis in children
Ix A1AT concentrations
Rx of alpha1-antitrypsin deficiency?
Cons: no smoking
Med: supportive with bronchodilators, PT; then IV A1AT protein concentrates
Surg: volume reduction surgery, lung Tx
CXR stages of sarcoidosis ?
0 = normal 1 = BHL 2 = BHL + interstitial infiltrates 3 = diffuse interstitial infiltrates only 4 = diffuse fibrosis
Role of ACE in sarcoidosis?
Bloods?
spirometry?
tissue Bx?
- ACE can be used in monitoring disease activity (60% sens 70% spec)
- hypercalcaemia 10%, raised ESR
- may show restrictive defect
- non-caseating granulomas
- also gallium-67 scan, not used routinely
Lung volume inspired/expired with each breath at rest
tidal volume
Maximum lung volume of air that can be inspired at the end of a normal tidal inspiration
inspiratory reserve volume
maximum lung volume of air that can be expired at the end of a normal tidal expiration
expiratory reserve volume
volume of air remaining after maximal expiration
residual volume
- inc with age
expiratory reserve volume + residual volume
functional residual capacity
maximum volume of air that can be expired after a maximal inspiration
vital capacity
- falls with age
tidal volume X (PaCO2 - PeCO2) / PaCO2 = ???
PeCO2 = expired air CO2
physiological deadspace Vd
Asthma Rx in adults steps?
- newly Dx
- uncontrolled or newly Dx with Sx 3+/wk or nighttime waking
- SABA
- SABA + ICS
- SABA + ICS + leukotriene receptor antagonist (LTRA)
- SABA + ICS + LABA
- cont LTRA depending on pt’s response - SABA +/- LTRA
Switch ICS/LABA for a maintenance & reliever therapy (MART), that includes a ICS - SABA +/- LTRA + medium-dose ICS MART
or consider changing back to a fixed-dose of a mod-dose ICS and a separate LABA - SABA +/- LTRA + one of the following:
- increase ICS to high-dose as a part of a fixed-dose regime
- trial of additional drug e.g. LAMA/theophylline
- refer…
What is MART: Maintenance & reliever therapy in asthma?
- form of combined ICS & LABA Rx where a single inhaler containing both is used for both daily maintenance Rx & relief of Sx prn
- only available for ICS & LABA combos in which the LABA has a fast-acting component e.g. formoterol
Doses in adults of low/mod/high doses of ICS in asthma
Low = <=400 mcg budesonide or equivalent Mod = 400-800mcg budesonide High = >800mcg budesonide
Acute Severe Asthma Rx?
IV magnesium sulphate 1.2-2g over 20mins
If no response, consider IV salbutamol
3 imagings in pleural effsuion
PA CXR
US (sensitive for detecting pleural fluid separations)
Contrast CT - Ix underlying cause esp exudative effusions
Pleural aspiration - what to send?
US-guided 21g needle, 50ml syringe
- pH, protein, LDH, cytology, micro
Exudate effusion cutoff?
Transudate effusion cutoff?
Light’s criteria to distinguish transudate & exudate pleural effusion?
Exudate >30g/L protein Transudate < 30 Light's criteria if 25-35 EXUDATE likely if at least 1 of the following: 1. fluid protein/serum protein >0.5 2. fluid LDH/serum LDH >0.6 3. fluid LDH > 2/3 ULN of serum LDH
Pleural fluid with low glucose?
RA, TB
Pleural fluid with raised amylase?
Pancreatitis, oesophageal perforation
Pleural fluid with heavy blood staining?
Mesothelioma, PE, TB
When to put a chest drain in for a pleural effusion?
- if purulent/turbid/cloudy fluid
- if fluid clear but pH<7.2
Rx of recurrent pleural effusion?
- recurrent aspiration
- pleurodesis
- indwelling pleural catheter
- drug to help alleviate Sx e.g. opioids
Significance of nitric oxide in asthma Dx?
Positive FeNO?
NO produced by 3 types of NOSynthase
- iNOS (inducible) levels tend to rise in inflammatory cells esp eosinophils
- therefore NO levels can correlate with levels of inflammation
- FeNO is measured (fractional exhaled nitric oxide): adults 40+ ppb or children 35+ ppb is positive
Asthma Dx in pts < 5yrs
based on clinical judgement
Asthma Dx in 5-16yrs
- spirometry with a bronchodilator reversibility test
- If normal spirometry Or obstructive spirometry with negative BDR -> FeNO test
Asthma Dx if 17+ yrs
- spirometry with BDR test, And FeNO test
- refer if occupational asthma suspected
Positive test in BDR: bronchodilator reversibility testing for asthma?
Children: FEV1 improves 12%+
Adults: above + increase in volume of 200ml+
Features of sarcoidosis: Acute? Insidious? Skin? How does hypercalcaemia occur?
Acute: erythema nodosum, BHL, swinging fever, polyarthralgia
Insidious: dyspnoea, non-productive cough, malaise, weight loss
Skin: lupus pernio
High Ca2+: macrophages inside the granulomas have increased activity of 1alpha-hydroxylase -> increased conversion of vit D -> active form (1,26-dihydroxycholecalciferol)
What is Lofgren’s syndrome?
Acute form of sarcoidosis: BHL, erythema nodosum, fever, polyarthralgia - usually has excellent prognosis
What is Mikulicz syndorome?
Enlargement of parrots & lacrimal glands due to sarcoidosis/TB/lymphoma
(confusing overlap with Sjogren’s)
What is Heerfordt’s syndrome?
= Uveoparotid fever:parotid enlargement, fever & uveitis 2ry to sarcoidosis
Good prognostic features of sarcoidosis?
- erythema nodosum
- Lofgren’s syndrome (BHL, EN, polyartritis, fever, typically in young females)
- HLA-B8
Causes of respiratory acidosis?
- COPD
- sedative drugs: benzos, opiate OD
- decompensation in other resp conditions e.g. life-threatening asthma/pulm oedema
Causes of respiratory alkalosis?
- anxiety -> hyperventilation
- PE
- CNS disorders: stroke, SAH, encephalitis
- salicylate poisoning (early)
- pregnancy, altitude
Causes of a cavitating lung lesion on CXR?
- abscess (staph aureus, klebsiella, pseudomonas)
- squamous lung ca
- TB
- Wegener’s
- PE
- RA
- aspergillosis, histoplasmosis, coccidiodomycosis
What is Loffler’s syndrome?
Cause of pulmonary eosinophilia thought to be caused by parasites causing an alveolar reaction e.g. Ascaris lumbricoides
- fever, cough, night sweats often last < 2 wks
- transient CXR shadowing
- generally self-limiting
Paraneoplastic features of Small cell lung cancer?
- ADH -> hyponatraemia
- ACTH -> Cushing’s syndrome; can cause BL adrenal hyperplasia; high cortisol can lead to hypokalaemic alkalosis
- Lambert-Eaton syndrome: Ab to voltage-gated Ca channels cause myasthenia-like syndrome
Paraneoplastic features of Squamous cell lung cancer?
- hypercalcaemia 2ry to PTH-rp
- clubbing
- HPOA
- hyperthyroidism 2ry to ectopic TSH
Paraneoplastic features of lung adenocarcinoma?
- gynaecomastia
- HPOA
Most common organisms isolated from patients with bronchiectasis?
- Haemophilus infuenzae = most common
- Pseudomonas aeruginosa
- Klebsiella spp
- Streptococcus pneumoniae
After assessing treatable causes, how to manage bronchiectasis?
Cons: - physical training (esp for non-CF) - postural drainage - immunisations Med: - Abx for exacerbations + long-term rotating Abx in severe cases - bronchodilators in selected cases Surgery: - in selected e.g. localised disease
Indications for steroids in sarcoidosis?
- CXR stage 2/3 AND mod-severe/progressive Sx
- hypercalcaemia
- eye, heart, neuro involvement
What is cryptogenic organising pneumonia?
Diffuse interstitial lung disease that affects the distal bronchioles, resp bronchioles, alveolar ducts & alveolar walls
- Unknown aetiology
- presents in 50s/60s, not ass with smoking
- cough, SOB, fever, malaise
- Non-response to Abx
- haemoptysis rare
- clinical exam normal or inspiratory crackles
- bloods: leukocytosis, raised ESR & CRP
- BL patchy/diffuse consolidative or ground glass opacities on imaging
- restrictive lung commonly, but can be obstructive/normal
- reduced transfer factor
- clinical Dx
- Rx watch & wait if mild, oral steroids if severe
What cells does small cell lung ca arise from?
APUD
Amine - high amine content
PU - precursor uptake - high uptake of amine precursors
Decarboxylase - high content
Management of small cell lung ca?
- if v early (T1-2a, N0 M0) can consider surgery
- but usually metastatic at Dx
- most with limited disease receive chemo & RT
- more extensive - palliative chemo
Features of idiopathic pulmonary fibrosis?
clubbing
dry cough
bibasal crackles
progressive exertional dyspnoea
CT scan findings of idiopathic pulmonary fibrosis?
honeycombing
reticular opacities
traction bronchiectasis
architectural distortion
Rx of idiopathic pulmonary fibrosis?
Cons: pulmonary rehabilitation
Med: Pirfenidone (antifibrotic) may be useful in some
Surg: many eventually require O2 & lung Tx
What is Kartagener’s syndrome / 1ry ciliary dyskinesia?
- dyne arm defect results in immotile cilia
- dextrocardia or complete situs inversus
- bronchiectasts
- recurrent sinusitis
- subfertility 2ry to diminished sperm motility & defective ciliary action in fallopian tubes
Causes of pulmonary eosinophilia?
Churg-strauss ABPA Loffler's syndrome eosinophilic pneumonia hypereosinophilic syndrome tropical pulm eosinophilia: Wuchereia bancrofti infection nitrofurantoin, sulphonamides Wegener's less commonly
When to do a 2WW referral for suspected lung cancer?
- Suggestive CXR
- 40+ with inexplained haemoptysis
When to DO a 2ww CXR to assess for lung cancer in people aged 40+?
2+ or 1+ever smoked of the following:
- cough
- fatigue
- SOB
- chest pain
- weight loss
- appetite loss
When to CONSIDER a 2ww CXR to assess for lung cancer in people aged 40+?
Any of:
- persistent/rec chest infection
- clubbing
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- chest signs consistent with lung ca
- thrombocytosis
What is ARDS?
Increased permeability of alveolar capillaries -> fluid accumulation in alveoli
i.e. non-cardiogenic pulmonary oedema
mortality ~40%
Alveolar macrophages release chemotactic cytokines e.g. IL-8 to neutrophils -> neuts transmigrate into alveoli via pulm capillaries -> capillary damage -> leakage of protein-rich fluids -> hyaline membranes
- > damage to type I pneumocytes -> increasing thickness of alveolar-capillary membrane -> impaired gas exchange (pulm shunt)
- > damage to type II pneumocytes -> impaired surfactant production, reduced compliance
Causes of ARDS?
- sepsis, pneumonia
- massive blood transfusion
- trauma
- smoke inh
- pancreatitis
- cardio-pulm bypass
Clinical features of ARDS?
- dyspnoea
- inc RR
- BL lung crackles
- low O2 sats
- usually severe, acute onset
4 criteria for ARDS?i
- Acute onset (within 1wk of a known RF)
- pulm oedema with BL infiltrates on CXR (otherwise not explained) - less sensitive, often delayed
- non-cardiogenic (PA wedgefsarco pressure is <18mmHg in cardiogenic)
- pO2/FiO2 < 40kPa (200mmHg), the lower the ratio the worse the injury i.e. is a continuum; if milder generally termed acute lung injury
Rx of ARDS?
ITU O2/ventilate Organ support e.g. vasopressors Rx underlying cause Prone positioning & muscle relaxation etc may improve outcome
What is GPA/Wegener’s?
AI condition ass with a necrotising granulomatous vasculitis, affecting upper & lower resp tract and kidneys
Features of GPA/Wegener’s?
URT: epistaxis, sinusitis, nasal crusting, saddle-shape nose deformity
LRT: dyspnoea, haemoptysis
Kidney: rapidly progressive glomerulonephritis (‘pauci-immune’, 80%)
Other: rash, eyes affected e.g. proptosis, CN lesions
Ix in GPA/Wegener’s:
ANCA?
CXR?
Renal biopsy?
cANCA +ive in >90%
pANCA +ive 25%
CXR: variety inc cavitating lesions
Renal Bx: Epithelial crescents in Bowman’s capsule
Rx of GPA/Wegener’s?
Steroids
Cyclophosphamide (90% response)
Plasma exchange
Median survival 8-9yrs
Vast majority of bronchial adenomas are Carcinoid tumours, arising from APUD system like small cell tumours Features ? On CXR? Bronchoscopy? Rx?
Age 40-50yrs, smoking NOT a RF
- slow-growing e.g. long Hx of cough, recurrent haemoptysis
- often centrally located/not seen on CXR
- CHERRY RED LESION often seen on bronch
- carcinoid syndrome itself is rare (ass with liver mets)
Rx = surgical resection. 90% 5yr survival if no mets
3 stages of Churg-Strauss?
- Allergy/asthma -> nasal inflammation -> Polyps
- Eosinophilia
- Small & medium vasculitis commonly affecting kidneys, lungs, gut, heart
Predisposing factors to OSA?
2 consequences?
- obesity
- macroglossia: acromegaly hypothyroid, amyloid
- large tonsils
- Marfan’s
- > daytime somnolence, HTN
Assessment of sleepiness in OSA?
Dx tests?
Epworth questionnaire
MLST: multiple sleep latency test - measures time to fall asleep in a dark room using EEG criteria
Dx sleep studies: Can range from noctural pulse oximetry to full polysomnography measuring EEG, resp airflow, thoraco-abdo movement, snoring, etc
Rx of OSA?
- weight loss
- 1st line CPAP
- intra-oral devices e.g. mandibular advancement if mild or CPAP not tolerated
What is mesothelioma?
Where does it metastasis?
Features?
- ca of pleural mesothelial cells: Right lung affected more often than left
- mets to CL lung& peritoneum
- clubbing, weight loss, dyspnoea, chest wall pain
- 30% present as painless pleural effusion
- only 20% with pre-existing asbestosis, 85-90% have Hx of asbestos exposure, latency 30-40yrs
Ix & Dx in mesothelioma:
CXR?
Next Ix?
Single best Ix for sytology negative exudative effusions?
Ix if area of pleural nodularity seen on CT?
- CXR: e.g. pleural effusion or thickening
- > then pleural CT
- send effusion or mcs, biochem, cytology (cytology only helpful in 20-30%)
- To Ix cytology negative exudative effusions = local anaesthetic thoracoscopy (95% Dx yield)
- if nodularity on CT can do image-guided pleural Bx
Rx of mesothelioma?
- Sx
- industrial compensation
- chemo
- surgery is operable
- poor Px, median survival 12m
Over/Rapid aspiration/drainage of pneumothorax i.e. large volume thoracocentesis can result in what?
Re-expansion pulmonary oedema
- uncommon, usually within 1-2h, sometimes 24h later, progresses over 1-2days then resolves
RFs =
- longer duration lung collapse
- larger volume lung collapse
- rapid drainage pleural fluid/air
- suction
- younger age
Types of EAA/hypersensitivity pneumonitis?
bird fanciers lung: avian proteins
famers lung: spores of saccharopolyspora rectivirgula aka micropolyspora faeni
malt workers lung: aspergillus clavatus
mushroom workers lung: thermophilic actinomycetes
Ix of choice for upper airway compression?
Flow-volume loop
Rx of 1ry pneumothorax <2cm or <30% and not SOB?
Discharge
Rx if 1ry pneumothorax <2cm or <30% and SOB?
Aspirate
Rx if 1ry pneumothorax >2cm or 30%?
Aspirate
If after aspirating a 1ry pneumothorax, pt is still SOB or it is still >2cm or 30%?
Chest drain
Rx of 2ry pneumothorax in someone >50yrs who is SOB or >2cm?
Chest drain + admit
Rx of 2ry pneumothorax in someone <50yrs old?
Aspirate if 1-2cm + admit
Rx of 2ry pneumothorax <1cm?
Admit, observe
