Resp (Imperial Jan Revision Course)

Question 1

scars

Answer 1

thoracotamy; pneumonectomy/lobectomy

mediastinoscopy; lymph nodes

Clambshell scar; bilateral transplant

Question 2

Answer 2

airflow obstruction with pused lip breathing and splinting

CHECK EXPIRATORY PHASE; breath out hard and fast >6s=obstructive airways disease

Question 3

deformities

Answer 3

Question 4

Answer 4

Pedal pitting oedema; Pulmonary hypertension and right heart failure

Question 5

Answer 5

erythema nodosum – Sarcoid, TB

Question 6

Reduced air entry, dull percussion, reduced VF/VR

Answer 6

– = Effusion

Question 7

Bronchial breathing (+/- crackles), dull percussion, increased VF/VR

Answer 7

– = collapse / consolidation

Question 8

Fine crackles, clubbed

Answer 8

– = Fibrosis

Question 9

Coarse crackles, clubbed, sputum

Answer 9

– = Bronchiectasis

Question 10

Asthma station

Ex/complications/Ix/Mx

Answer 10

Asthma

May be normal

Check peak flow

Look for inhalers

Complications:

– Steroid use

– Oral thrush

– Pulm HT???

Investigations:

– Exhaled Nitric Oxide; high=more likely asthma

– Spirometry (obstructive with reversibility / normal)

– Histamine challenge

– Peak flow diary >2wks

– Skin tests / Specific IgE for aeroallergens / Eosinophils

Management

– Inhaled steroid

– Short acting and long acting bronchodilators

– Oral steroids for exacerbations

– Make sure not smoking

– Pulm rehab

– Nurse specialist; asthma action plan

– (Thermoplasty?) – Omalizumab/anti-IgE – Mepolizumab (anti-IL-5; eosinophilic)

Question 11

Bronchiectasis

Examinations/ complications/causes/Ix/Management

Answer 11

• Clubbed?
• Coarse crackles – May change w/ cough
• May have monophonic wheeze
• May have scars (rare)
• Sputum
• Complications: – Pulm HT – Cachexia – Lobar collapse – Massive haemoptysis – Type 2 Resp failure / asterixis – Situs inversus / Kartagener’s

Causes:

Causes: – Idiopathic – Post-infective (Measles, Pertussis, TB) – Immunodeficiency (Hypogammaglobulinaemia / CVID, Specific polysaccharide ab def (test response to pneumo / tet vaccines)) – (CF) – PCD, Young’s, Kartagener’s – ABPA – Obstruction/foreign body / tumour – Rheumatoid, IBD

Ix: – Immunoglobulins – ABPA – CF – Spirometry (obstructive) – HRCT • Ring shadows, tramlines – Cultures

Management – Physio: airway clearance, postural drainage – Prompt anibiotics infection – Correct underlying causes (Intravenous Immunoglobulin, Treat ABPA, CF – DNAse, ??CFTR activators) – Prophylactic antibiotics? – Bronchodilators; not inhaled steroids – Pulm rehab – Smoking cessation – Palliative care?

Question 12

Cancer

Examination, complications, Ix, mx

Answer 12

– relatively unlikely

(Non-small cell – (adenocarcinoma & squamous mainly), Small cell)

• May be clubbed – include in differential
• Look for surgical and radiotherapy scars
• May have signs of COPD
• Complications: SVCO, Horners

Investigations

• CT (Volume) – staging – lower neck, chest, upper abdo – adrenals/liver • Lung function – assess treatment fitness / Resectability
• PET-CT: 18-FDG: labels metabolic uptake – Exclude distant metastases
• Biopsy / Bronchoscopy / EBUS – Sample most accessible, highest stage area

Management

• Non-small cell

– Surgical resection (lobectomy)

– Radiotherapy, including stereotactic/ SABR (“cyberknife”)

– Chemotherapy (Targeted therapies: EGFR-TKi & ALK, Immunotherapy: anti PDL-1)

– Symptomatic / Palliative

• Small cell – Rarely surgical resection; mostly chemo +/- radiation

Question 13

COPD

Examination, causes, complications, Ix, classification, Mx

Answer 13

• Look for signs airflow obstruction

– Prolonged exp phase

– Pursed lip breathing

– May be wheeze

– inhalers

• Hyperexpansion:

– Reduced cricosternal distance

– Loss cardiac dullness

– Displaced liver

• Causes? Nicotine staining?
• Complications: – Bruising / Steroid therapy – Pulmonary hypertension – CO2 retention

Investigations

– FBC: polycythaemia?

– A1AT

– Lung function (Fixed, Obstructive; decreased transfer factor (TLCO) if emphysema)

– Blood gas

– CT to characterise if breathlessness disproportionate

– Echo assess pulm HT

GOLD classification: airflow obstruction (spirometry) & symptoms/ exacerbations

Management

– Bronchodilators (Short / Long acting, Inhaled steroids)

– Pulm rehab

– Dietician

– Smoking cessation

– Steroids/ antibiotics for exacerbation

– Oxygen if pO2 ≤ 7.3 (or 8 if pulm HT)

– Controversy re inhaled steroids: pneumonia

– Pall care?

– LVRS/valves / transplant

Question 14

Effusion

examination, causes, Ix, Mx

Answer 14

• Tracheal shift?
• Reduced expansion unilaterally
• Stony dull
• Reduced air entry
• Decreased vocal fremitus / resonance
• Look for Associated causes: – Transudate: liver, cardiac – Exudate: malignancy, yellow nail, rheumatoid, TB
• Causes: • Light’s criteria: prot>50% serum = exudate; • LDH > 60% serum level or >2/3 x upper lab ref of serum LDH – Transudate (cardiac, liver, nephrotic) – Exudate (Malignant, Infection/parapneumonic/TB, Autoimmune, Trauma/blood, PE)

Investigations – CXR – U/S / CT – Aspiration (MCS, TB, Protein, Glucose, pH, LDH, Cytology) – Pleural biopsy (after CT – image guided)

• Management – Drain: (may include VATS/ LA thoracoscopy / PleurX indwelling drain) – Treat underlying cause

Question 16

Fibrosis

examination, causes, Ix, Mx

Answer 16

Examination

• Clubbing?
• Associated disease: rheumatoid hands
• Fine, late inspiratory crackles
• Erythema Nodosum (Sarcoid)
• JVP/P2/Oedema (Pulm HT)

Causes: – Idiopathic – IPF / CFA – Connective tissue associated (Scleroderma, Rheumatoid, SLE) – Sarcoid – Hypersensitivity pneumonitis (Farmers /Bird-fanciers etc) – Drugs (Amiodarone, Nitrofurantoin, Chemo (Methotrexate, Bleomycin etc))

Investigations: – FBC, Complement, autoimmune screen, precipitins – CXR, HRCT – Lung function, including transfer factor (TLCO) – Echo (PHT) – BAL (Cell diff); TBB / Open lung biopsy – 6 min walk – ABG

Management: – Physio / Pulm rehab – Nurse specialist – LTOT – Cough: anti-tussives – Smoking cessation – Pirfenidone / Ninetadinib: (IPF only) – Immunosupressives / Steroids (esp Sarcoid / CTD associated) – Transplant work up – Palliative care

Question 17

Surgery ; pneumonectomy, lobectomy

• Examination findings*
• Scar, but normal lung?*

Answer 17

• Pneumonectomy: – Scar, chest wall deformity – Shifted trachea / apex • To abnormal side – Reduced expansion on side of scar – PN dull – NO breath sounds (beware transmitted trachea sound)
• Lobectomy – Scar, ribs depressed? – Shifted trachea? • Mainly upper lobectomy – Focally: • Reduced expansion • PN dull • Reduced breath sounds

Scar, but normal lung?

– Thoracotomy

– Transplant (other lung abnormal?)

• Indications: – Cancer, TB, Bronchiectasis

Question 19

Pneumonia / Collapse*

Answer 19

• Unlikely, but possible

– You may however describe the signs:

– Reduced expansion

– Dull

– Reduced / absent air entry (or bronchial breathing if airways patent)

– Increased VR / TVF

Question 20

• Comfortable clubbing • RR: 16 • Expansion equal • PN resonant, equal • Auscultation: Coarse crackles, clubbed, sputum

PRESENT (and Ix and Mx)

Answer 20

I examined this man’s respiratory system. He is clubbed, with bilateral coarse inspiratory crackles which do not fully clear with coughing but do alter. This is consistent with a diagnosis of bronchiectasis. My differential includes pulmonary fibrosis.

HRCT

Airway clearance physiotherapy

Question 21

Comfortable • RR 12 • Expansion equal • PN resonant • Auscultation: ‘normal’

PRESENT (and Ix and Mx)

Answer 21

I examined this lady’s respiratory system. On inspection I noticed she had a salbutamol inhaler. Otherwise there was little to find, with resonant and symmetrical percussion and equal air entry with no added sounds. This is consistent with stable, well controlled asthma • (if no inhaler: normal chest)

Management:: A. Salbutamol inhalerǂ • C. Oral prednisolone • D. Inhaled Steroids • E. Combination long acting beta agonist and inhaled corticosteroid – *depending on severity: talk through the steps – ǂTrue asthma probably never step 1 alone

A. Exhaled nitric oxide • B. Spirometry with reversibility • C. PEFR diary • E. Histamine challenge *spirometry 1 st line; reversibility if obstructive; then FeNO; FeNO if normal then PEFR; or histamine challenge **HRCT useful to exclude other disease

Question 22

Comfortable • RR: 20 • Expansion equal • PN resonant • Auscultation; fine crackles

PRESENT (and Ix and Mx)

Answer 22

I examined this patient’s respiratory system. They were comfortable at rest, but were breathing supplemental oxygen at 2L/min via nasal cannulae with a respiratory rate of 20. I think they have pulmonary fibrosis secondary to rheumatoid arthritis with secondary pulmonary hypertension leading to right heart failure and requiring long term oxygen therapy as evidenced by features of rheumatoid in the hands, without clubbing, characteristic fine end inspiratory crackles on auscultation and peripheral oedema

CXR, full lung function, Restrictive (the FVC is reduced more than the FEV1), HRCT

Question 23

Comfortable • RR 16 • Trachea to right • Reduced expansion R • PN dull R • Auscultation:

PRESENT (and, ‘presenting with new cough and wt loss’, Ix

Answer 23

Right sided pneumonectomy

???

‘presenting with new cough and wt loss’ Ix; CXR, CR chest with contrast; Presuming due to cancer, need to exclude recurrence: should do CXR first, but CT is best

Question 24

• Percussion dull on right • Reduced air entry on right • Resonance reduced • No scar • Trachea central

Dx

Answer 24

Right pleural effusion

Question 25

Comfortable • Reduced cricosternal distance • Loss cardiac dullness • Pursed lip breathing • Expansion equal • PN resonant • Auscultation: ?N

Presentation and Ix

Answer 25

• I examined this man’s respiratory system. On inspection I noticed he had a prolonged expiratory phase and pursed lip breathing. He had signs of hyperinflation, specifically reduced cricosternal distance, loss of cardiac dullness and displaced liver edge. There were no features of pulmonary hypertension and he was not cushingoid. This is consistent with obstructive airways disease with hyperinflation, most likely COPD.

Spirometry, reversibility and gas transfer

Question 26

COPD:

He comes to A&E breathless and the ABG shows pH 7.25, pCO2 8.3, pO2 6.4, HCO3- 34 after 1 hour of nebulisers and controlled oxygen therapy targeting saO2 of 88-92%… what is the best treatment?

• A. reduce FiO2 • B. IV aminophylline • C. IV hydrocortisone • D. Non invasive ventilation • E. ITU and intubation

Answer 26

Non invasive ventilation