Resp Flashcards
Evidence of specific cause of Pulmonary fibrosis
- RA: Boutonnières, swan neck, nodules
- Systemic sclerosis: sclerodactyly, telangiectasia, microstomia
- SLE: malar rash, discoid rash
- Sarcoidosis: erythema nodosum
- Radiation: tattoos on chest
Causes of pulmonary fibrosis
- Idiopathic
- Rheumatology - RA, SLE, SS, Sjrogren’s
- Sarcoidosis
- EAA: moulds, avian proteins
- Occupational exposure: coal, asbestos, silica
3 drugs which cause pulmonary fibrosis
Methotrexate
Amiodarone
Bleomycin
3 bedside tests for suspected pulmonary fibrosis
PEFR
Spirometry
ECG (RV hypertrophy)
Bloods for suspected pulmonary fibrosis
FBC ABG ESR, CRP ANA (in IPF) RhF and antiCCP (in RA) ACE and Ca (in sarcoid)
Mx of pulmonary fibrosis
If acute exacerbation: Oral prednisolone
Conservative: smoking cessation, pulmonary rehabilitation
Medical:
Antifibrotic therapy: pirfenidone
Steroids for Extrinsic Allergic Alveolitis, sarcoid, Connective Tissue Diseases
Surgical: lung transplant
Signs of pneumonectomy/lobectomy
Tracheal shift towards abnormal side
- Reduced expansion
- Dull percussion
- No BS
Differentials for an oblique scar on lateral/posterior chest wall
- Lobectomy
- Pneumonectomy
- Thoracotomy: biopsy, empyema, abscess
- Transplant
Indications for lobectomy/pneumonectomy
90% bronchogenic carcinoma
- Bronchiectasis
- COPD: lung reduction surgery
- TB: historic, upper lobe
Pathology classification of lung cancer
NSCLC and SCLC
SQCC: bronchogenic, smoking, PTHrP + hypercalcemia
ADENOCARCINOMA: peripheral, late presentation (mets), non-smokers + women
SCLC: poor prognosis, late presentation, smokers (Cushings)
Complications of lung cancer
Local:
- Brachial plexus –> Horner’s syndrome
- SVCO
- Recurrent laryng nerve
- Phrenic nerve
Paraneoplastic:
- PTHrP –> Ca
- SIADH –> hyponatremia
- ACTH –> Cushings
Derm: acanthuses nigricans
Mets:
- Bone pain
- Liver failure
- Confusion, fits, focal neurology
Ix in lung cancer
Bloods: FBC, U+Es (Na), LFTs (mets), bone profile (PTH, Ca)
Imaging:
CXR
Volumetric CT
PET scan - mets
Histology: percutaneous FNA or transbronchial biopsy for grading
Thoracoscopy + LN sampling
Pulmonary function tests (assess fitness for surgery)
Mx of lung cancer
Conservative:
Smoking cessation
Pulmonary rehabilitation
PTOT
Medical:
Chemotherapy + radiotherapy
(Eg SCLC: Cisplatin + Etoposide)
(NSCLC: same, if surgery not viable)
Surgical:
If no metastatic spread!
Palliative care:
- Analgesia
- Radiotherapy - for haemoptysis, bone or CNS mets
- If persistent effusions - pleurodesis
- SVCO: radiotherapy + IV dexamethasone
Old management of TB
- Thoracoplasty (rib removal)
- Plombage (polystyrene balls in thoracic cavity)
- Phrenic nerve crush (diaphragm weakness)
- Apical lobectom
Current Mx of TB - what MUST be done before starting treatment
Rifampacin, Isoniazid, Pyridoxie and Ethambutol
for 2 months
Then just Rifampacin and IsoniazidI for a further 4 months
(- coadminster pyridoxine w isoniazid)
Before treatment, asses:
- LFTs + visual acuity + colour vision testing
Rifampacin
Isoniazid
Pyridoxine
Ethambutol
Side effects of TB treatment
Rifampicin: orange urine, cyp450 induction
Isoniazid: Peripheral neuropathy
Pyrazinamide: hepatitis
Ethambutol: optic neuritis!! (loss of colour)
//// Ethambutol: Eyes affected
Features of latent TB
Pt is infected but no clinical Sx or CXR features
- Non infectious!
Pathophysiology of primary TB infection
TB grows in pleura = Ghon focus
TB spreads to LNs:
Lung lesion + LNs = Ghon complex
Most people’s immune system controls the infection: fibrosis of Ghon focus –> calcified nodule
Diagnosis of latent vs active TB
Latent: tuberculin skin test, if +ve do IGRA
Active: CXR + 3 sputum samples.
- Culture in Lowenstein Jensen media = GOLD STANDARD
- Microscopy w Ziehl-Neelsen stain
What is the initial screening test for latent TB? what are the cons of this?
Tuberculin skin test: inject purified protein + observe induration @ 48-72hours
tests +ve if BCG, other mycobacteria :(
also tests -ve if HIV, sarcoid, lymphoma :(
Causes of a cavitating lung lesion
Infection: TB, Staph, Klebsiella
Rheumatoid nodules
Malignancy: SqCC
pulmonary fibrosis - upper lobe causes?
Lower lobe causes?
Upper: Aspergillus Coal, silica EAA - bird fanciers lung TB
Lower: Sarcoidosis Toxins (methotrexate, bleomycin, amiodarone) Asbestosis Idiopathic Rheum: SLE, SS, RA Silicosis
Drugs which cause pulmonary fibrosis
Bleomycin
Amiodarone
Nitrofurantoin
Methotrexate
Findings O/E of bronchiectasis
DDx
Clubbing
Dull percussion note
Bilateral coarse crackles - may CHANGE W COUGH
Ddx: CHF, Bilateral pleural effusion
Define bronchiectasis
Permanent dilated bronchi secondary to damage of elastic + muscular layers of bronchial wall
Causes of bronchiectasis
1 cause = severe childhood LRTI (due to immunodeficiency)
- Congenital: CF, Kartageners
- Infectious: TB, pertussis
- Associated: RA, UC, ABPA
- OBSTRUCTION = cancer
Ix in ?bronchiectasis
Sputum MC+S + cytology
Bloods: FBC, CRP, autoantibdoes, aspergillus
CXR: tram track opacifications, ring lesions
CT chest: signet ring (thickens bronchus = adjacent vascular bundle)
SPIROMETRY = OBSTRUCTIVE
Mx of bronchiectasis
Conservative:
Smoking cessation
Pulmonary rehab
Chest physio
Medical:
Salbutamol inhaler
Prophylactic abx against pseudomonas (Eg Co-Amox)
Vaccine = pneumococcal, flu
Surgical: lung transplant
Stoma + bilateral coarse crackles
probs UC w bronchiectasis
COPD - findings O/E
Hands: salbutamol tremor CO2 flap Chest: Barrel chest Accessory muscle breathing Cachectic Hyper resonant PN Reduced expansion Auscultation...?
Ix for ?COPD
PEFR Spirometry Basic Obs Sputum MC+S Bloods: FBC, ABG, CRP CXR ECG
Medical Mx of COPD
Depends on severity
- SABA PRN
- LAMA (Tiotropium) or LABA (Salmeterol)
- LABA + LAMA
- LABA + ICS (fluticasone) + LAMA
- Theophylline (Alt Bronchodilator)
Home O2
Follow up every 6 months (6 if mild and stable, 1 if sever)
Mx of COPD exacerbation
Airway: patent? Breathing: oxygen via venturi mask ABG CXR Circulation: bloods (FBC, CRP, U+Es, LFTs, glucose, BCs if pyrexial), give maintenance fluids
Mx of COPD exacerbation
Airway: patent?
Breathing: oxygen via venturi mask. Target Sats: 88-92
ABG
CXR
Circulation: bloods (FBC, CRP, U+Es, LFTs, glucose, BCs if pyrexial), give maintenance fluids
Salbutamol + ipatropium nebs
Oral pred +/- IV hydrocortisone
If no response –> NIV
Useful drug for smoking cessation
Varenicicline
Pneumothorax mx (no underlying lung disease)
-If >2cm/SOB –> aspiration with 16-18G Cannula
-Alternatively consider chest drain (Usually if secondary).
Insertion Seldinger tube into safe triangle.
If no SOB and <2cm –> 10L O2 and observe
//////////////////////////////////////// Safe triangle is within the lateral edge of pectoralis major, lateral edge of latissimus dorsi, base of axilla and 5th intercostal space).
pneumothorax mx in >50yo or underlying lung disease
SOB>2cm –> chest drain
1-2cm –> aspirate
<1cm –> 10L O2 + admit 24 hours
Tension Pneumothorax Mx?
Call the crash team.
Immediate decompression
Insert a 16-18G Cannula into the 2nd intercostal space, mid clavicular line.
Asthma Mx?
Conservative: none
Medical:
SABA (Eg Salbutamol) PRN
Then + Low dose ICS (Eg Beclometasone)
Then + Leukotriene receptor Antagonist (Eg Montelukast)
Then +Consider SAMA (Ipratropium Brimide)
Then + Increase dose of ICS
Then +Consider LAMA (Eg Triotropium)
Pneumonia Mx?
Assess using CURB-65 score Confusion? (+1) Urea >19? (+1) RR >30? (+1) BP <90/60? (+1) 65 or older? (+1)
High severity (3-4):
Urgent Hospital admission and emprical Abx:
IV benzylpenicillin or oral amoxicillin. Oral clarithromycin if penicillin allergy.
Medium Severity (1-2): Hospital admission \+Abx Low severity (0): Didscharge with Empiral Abx: as above.
Cystic Fibrosis Mx?
Conservative:
Counselling on the condition and complications
Chest physiotherapy
Medical:
Inhaled Bronchodilator PRN
Inhaled Mucolytic (Dornase Alfa and Hypertonic Saline)
Tobramycin (Antibiotic for Pseudomonas aeruginosa)
Anti inflammatory (Eg Ibuprofen or macrolide)
Treat co-morbidities (Eg Pneumonia or Acute Asthma)
+Inhaled corticosteroid
+CFTR modulator (ivacaftor)
Surgical:
Lung transplant
Extrinsic Allergic Alveolitis Mx?
Conservative: Avoidance of allergen
Medical:
Short term: Prednisolone
Consider long term low dose corticosteroid (Prednisolone)
Pulmonary Embolism Mx?
Initial
Oxygen, Target sats 94-98%
Fluid resuscitation with Hartmaan’s Solution
Ix: Wells Score + D-Dimer
Acute
Medical
Unfractionated Heparin
(If still haemodynamically unstable )+Thrombolysis
Surgical:
Surgical Embolectomy or percutaneous catheter directed treatment.
Ongoing
Long term anticoagulation (LMWH or DOAC or Warfarin).
//Presentation for (Pulmonary Fibrosis). Differentials? Most likely diagnosis?
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//Presentation for (COPD). Differentials? Most likely diagnosis?
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//Presentation for (Lung cancer X). Differentials? Most likely diagnosis?
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//Presentation for (TB). Differentials? Most likely diagnosis?
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