Resp Paces Flashcards
Clinical signs of a lobectomy
Posterolateral thoracotomy scar or 3 scars (1 x 10cm in length + 2 port scars)
Reduced expansion and chest wall deformity
Lower lobectomy: dull percussion note over lower zone with absent breath sounds
Upper lobectomy: normal examination or hyperresonant percussion note over upper zone and dull base
CXR: raised hemidiaphragm
Ct chest
Indication for VATS
Lobectomy mainly for malignancy
Wedge resection for benign pathology
Bullectomy for recurrent pneumothoracices
Biopsy
Primary vs secondary spontaneous pneumothorax
Primary: no underlying lung disease, normally occurs in tall, slim men, smoker
Secondary: associated with underlying lung disease
Management of primary spontaneous pneumothorax
If asymptomatic and <2cm: supplementary O2 follow up CXR
If breathless or >2cm:
Supplementary O2, aspiration, if aspiration fails need chest drain
Management of secondary pneumothorax
If < 1cm and no breathlessness: supplementary O2, observe in hospital
If 1-2cm and no breathlessness: O2, aspirate, drain
If >2cm or symptomatic: O2, chest drain
Management of tension pneumothorax
Oxygen
Emergency needle decompression 2nd ICS mid clavicular line or midaxillary line 4th/5th ICS
Management of recurrent pneumothoracices or air leak
Bullectomy if Bullae present
Pleurectomy or talc pleurodesis
Advice to give patient post pneumothorax
Avoid air travel until full resolution
Avoid diving permanently unless has had bilateral surgical pleurectomy and normal lung function tests and Ct chest post- operatively
Risk factors for asthma
Cigarette smoke
Fumes
Work place exposure
Personal/family history of atopy
Resp infection in childhood
Obesity
Triggers for asthma exacerbation
Exercise
Infection
GORD
Drugs- aspirin, NSAIDs, b blockers
Poor medication compliance
Cold weather
Signs of chronic asthma
Tachypnoea
Wheezing
Hyperinflated chest
Nasal polyps
Atopic eczema
Diagnosis of asthma
History
Examination findings
Spirometry
- increased lung volumes
- Reduced FEV1
FEV1:FVC ratio <70%
- reversibility (at least 200ml)
Peak Flow diary
- >20% diurnal variability
- may also identify occupational asthma
- > 15% improvement with bronchodilator
FeNO
- conforms eosinophilic airway inflammation (FeNO level > 40 is positive in steroid naive adults)
Eosinophilia
Skin prick testing
Non pharmacological management of asthma
Education
Inhaler training
Weight loss
Smoking cessation
Peak flow monitoring
Annual follow up
Vaccination
Medical treatment of asthma
- Salbutamol prn + low dose ICS
- LABA + ICS
- Increase ICS dose + LABA + LTRA
- Specialist care
Moderate acute asthma
Sats > 92%
PEFR >50%
No signs of severe
Acute severe asthma
Sats >92
Can’t talk in full sentences
HR >110
RR>25
Peak flow 33-50%
Life threatening asthma
Sats <92
Silent chest
Poor resp effort
Exhaustion
Confusion
Cyanosis
Near fatal asthma
Raised pCO2
Management of asthma exacerbation
Nebs
Steroids
O2
Antibiotics if infection
Magnesium
Aminophylline
Monitor peak flows
Refer to ICU if deteriorating PEFR, worsening hypoxia, rising CO2/acidosis, exhaustion, altered consciousness
Criteria for discharging asthmatic
PEFR at least 75% predicted
Diurnal variation <25%
No nebs for 24 hours
Written asthma action plan
Follow up in next 30 days
Potential triggers for IPF
Acid reflux
Viruses - EBV, herpes, hep C
Dust, textiles, cattle farming
Genetic predisposition
Clinical features of IPF
SOB
Cough
Fatigue
Cyanosis
Finger clubbing
Fine end inspiratory crackles
Signs of steroid use
Look for differential diagnosis:
- joint deformity in RA
- evidence of systemic sclerosis
- skin discolouration if amiodarone
Differential diagnosis for end insp crackles
Acute interstitial pneumonia
RA, IBD, systemic sclerosis
Drug related pulmonary fibrosis
- amiodarone, sulfasalazine, methotrexate, nitrofurantoin
Assessment/ diagnosis of IPF
ABG
ANA - elevated in 10-20%
RA - elevated in 10-20%
Anti CCP - normal
CXR- small lung volumes, interstitial shadowing most marked at bases and peripheries
HRCT
Lung function tests - FEV1/FVC >0.8, low TLC, reduced TLco and Kco
Bronchoalveolar lavage
- exclude infection prior to immunosuppression
- if lymphocytes > neuts likely better response to steroids
Lung biopsy
Management of IPF
Pulmonary rehab
Antifibrotic drugs eg. Pirfenidone
LTOT
Lung transplant
Causes of basal fibrosis
UIP
Asbestosis
Connective tissue diseases
Aspiration
Clinical signs of cystic fibrosis
Clubbing
Wet cough
Hyperinflated lungs reduced chest expansion
Coarse inspiratory crackles and wheeze
Portacath
PEG
What are the genetics of cystic fibrosis
Incidence of 1/2500 live births
Autosomal recessive chromosome 7q
Gene encodes CFTR (Cl- channel)
What is the Pathophysiology of cystic fibrosis
Secretions are thickens and block the lumens of various structures causing:
- bronchiectasis
- diabetes and loss of pancreatic exocrine function
- distal intestinal obstruction syndrome
- absence of vas deferens in males causing infertility
- subfertility in women due to affect of fallopian tubes
How is cystic fibrosis diagnosed
Screening with heel prick test (low immunoreative trypsin)
Sweat test (Na > 60mmol)
Genetic testing
CXR
CT
How is cystic fibrosis managed?
Physiotherapy
Antibiotics - both prophylactic and treatment
Monitor for diabetes
Pancrease and fat- soluble vitamins
Mucolytics
Immunisations
Lung transplant
Gene therapy is an ongoing area of research
Poor prognosis if becomes infected with Burkholderia cepacia
Most common pathogen is cystic fibrosis infection
Staph aureus in young children
Then H.influenza
Then pseudomonas aeruginosa in teenage years
Contra-indications to lung transplant in CF
Burkholderia infection
Sepsis
Multi- organ dysfunction
History of non-adherence to treatment
Morbid obesity
Refractory GORD
Clinical signs of double lung transplant
Scar - clamshell incision, central line, traceostomay
Clubbing which may indicate CF, bronchiectasis, pulmonary hypertension
Indication for lung transplant
Chronic end stage lung disease and meet 3 criteria:
1. > 50% risk of death within 2 years
2. >80% chance of survival 90 days post transplant
3. >80% chance of survival 5 years post transplant
Complications of lung transplant
Primary graft dysfunction (acute rejection) - very common
Chronic rejection usually secondary to bronchiolitis obliterans syndrome (BOS)
Infections
Malignancy
- post transplant lymphoproliferative disease
- skin cancer
Complications of immunosuppressants
Contraindications to lung transplant
Malignancy in the last 5 years or 2 years of low risk of recurrence
Heart/liver/ kidney failure
Atheroscleorotic disease with end organ damage
Chronic infection with resistant organisms
Mycobacterium abscess
Chest wall or spinal deformity
Obesity or low BMI
Non- adherence to therapy
Psychiatric disease
Clinical signs of bronchiectasis
Cachexia
Clubbing
Inspiratory coarse crackles
Wheeze
Sputum
Cor pulmonale
Yellow nail syndrome (yellow nails and lymphoedema
Investigating suspected bronchiectasis
Sputum culture and cytology
CXR: tramlines and ring shadows
CT: signet ring sign
Tests for specific causes
Investigating for specific cause of bronchiectasis
Immunoglobulins
HIV
Aspergillus RAST or skin prick testing
Rheumatoid serology
Saccharine ciliary motility test
Genetic screening for cystic fibrosis
Testing for IBD
Causes of bronchiectasis
Congenital: kartageners and CF
Childhood infection: measles and TB
Immune over activity: allergic bronchopulmonary aspergillosis (ABPA) IBD
Immune under activity: hypogammaglobinaemia, CVID
Aspiration
Treatment of bronchiectasis
Physiotherapy
Antibiotics for acute infection
Low dose azithromycin for prophylaxis
Mucolytics
Complications of bronchiectasis
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis
Resp diseases associated with yellow nail syndrome
Pleural effusions
Bronchiectasis
Chronic sinusitis
Chronic bronchitis
Recurrent pneumonia
Treatment of yellow nail syndrome
Topical vitamin E
Clinical signs of lung cancer
Cachexia
Clubbing and tar staining
Lymphadenopathy
Tracheal deviation - towards collapse or away from effusion
Reduced expansion
Dull percussion note
Increased vocal resonance in collapse or consolidation
Reduced tactile vocal fremitus in effusion
Evidence of mets
Evidence of treatment (lobectomy scar or radiotherapy tattoo
Evidence of complications
- SVCO
- recurrent laryngeal nerve palsy
- horners and wasted small muscles of the hand
- neurological
- dermatomyositis, Gottrons papules or acanthosis nigricans
Types of lung cancer
Small cell
Non small cell
- squamous - typically central, most associated with smoking
- adenocarcinoma
- large cell
- alveolar
Investigation of lung cancer
CXR
CT
Sputum cytology
Bronchoscopy/percutanous needle CT guided/ pleural tap
Staging CT
Lung function tests to aide treatment decisions
Endocrine complications of lung cancer
Non small cell lung ca: increased PTHrP causing hypercalcaemia (typically squamous cell)
SCLC: increased ACTH (cushings) and SIADH
Treatment of lung cancer
NSCLC: lobectomy or pneumonectomy, radiotherapy, chemotherapy
Surgery considered for stage 1 or 2 disease or potentially stage 3 if no mediastinal lymphadenopathy
SCLC: chemotherapy
New targeted treatments
Baseline FEV1 to consider pneumonectomy and lobectomy
> 2L for pneumectomy
1.5L for lobectomy
Indications for pneumonectomy
Large centrally located tumours or those that impinge the proximal bronchial tree
Clinical signs of pneumonectomy
Thoracotomy scar
Reduced expansion on affected side
Tracheal deviation towards pneumonectomy
Dull percussion note
Absent tactile fremitus
Bronchial breathing in the upper zone with reduced breath sounds throughout the rest of the hemi thorax
Natural progression post pneumonectomy
The pneumonectomy space fills with fluid over 3 months and you will see an air fluid level which will then be completely opaque after around 3 months
What are the complications post pneumonectomy?
Bronchopleural fistula: Bronchial stump breaks down and the pneumonectomy space becomes infected with resp organisms
Pneumonectomy empyema: complication of bronchopleural fistula and required drainage
Clinical signs of pleural effusion
Asymmetrically reduced expansion
Trachea pushed away from side of effusion
Stony dull percussion note
Absent tactile vocal fremitus
Reduced breath sounds
Bronchial breathing above
Signs that may indicate cause of pleural effusion
Cancer: clubbing, lymphadenopathy, mastectomy
CCF: raised JVP, peripheral oedema
Chronic liver disease
Chronic renal failure (evidence of RRT)
Connective tissue disease (rheumatoid hands, butterfly rash of SLE)
Causes of dull lung bases
Consolidation
Collapse
Previously lobectomy
Pleural thickening (normal tactile fremitus)
Raised hemidiaphragm
Causes of pleural effusion
Transudate (protein <30)
- CCF, liver or renal failure
Exudate (protein >30)
- cancer
- infection
- infarction
- RA/SLE
Differentiating transudate from exudate
If 25-35g/L of protein, use Lights criteria
An exudate is indicated by:
Effusion protein : plasma protein > 0.5
Effusion LDH : plasma LDH >0.6
Effusion LDH > 2/3 of upper limit of normal serum LDH
Empyema: low glucose and pH <7.2
What is an empyema
Collection of pus in the pleural space
Most frequent organisms are anaerobes, staph, gram -ve
Associated with bronchial obstruction, recurrent aspiration, poor dentition, alcohol dependency
What should pleural fluid be sent for
LDH and protein
Glucose and pH
MC&S
Cytology
If suspicious of Chylothorax send triglycerides
A glucose level <1.6 are seen in effusions due to RA
Clinical signs of COPD
Nebs, inhalers, sputum pot, dyspnoea, central cyanosis, pursed lips
Co2 retention flap, bounding pulse
Tar- stained fingers
Hyper- expanded
Percussion note resonant with loss of cardiac dullness
Expiratory polyphonic wheeze
Cor pulmonale signs (raised JVP, ankle oedema, RV heave, loud P2, tricuspid regurgitation)
Aetiology of COPD
Smoking
Air pollution
Low birthweight and low socioeconomic status
Dust exposure
Alpha- 1 - antitrpsin deficiency
Lung functions tests in COPD
Diagnosis: FEV1:FVC <0.7
Severity (FEV1)
Mild >80%
Moderate 50-79%
Severe 30-49%
Very severe <30%
Patient also have large TLC and reduced diffusion capacity (DLCO)
Investigating COPD
CXR- hyperexpanded, R/O pneumothorax
ABG
Spirometry
Alpha- 1 - antitrypsin if younger, minimal smoking hx or FHx
ECG: p-pulmonale, right axis deviation, RBBB
Sputum culture - most commonly H.influenza, streptococcus
Medical management of COPD
Smoking cessation
Beta agonist
LABA+LAMA
LABA + ICS if evidence of steroid responsivity
Triple therapy (LABA, LAMA, ICS)
Vaccination
Nutrition and exercise
LTOT
Pulmonary rehab
Surgical management of COPD
Bullectomy (if bullae greater than 1L and compressing surrounding lung)
Transplantation if:
FEV1 and DLCO <20%
History of hospitalisation with an exacerbation with T2RF
Pulmonary hypertension/ cor pulmonale
Criteria for LTOT
Non smoker
PaO2 <7.3 on air
PaO2 < 8 on air if cor pulmonale
PaCO2 that does not significantly rise on O2
O2 for at least 16hours a day
Improved average life expectancy by 9 months
DECAF score
Dyspnoea
- too breathless to leave house (1)
- too breathless to wash/dress (2)
Eosinophils <0.05
Consolidation on CXR (1)
Acidaemia (1)
A Fibrillation (1)
Score 3 or me = indicated increased risk of inpatient mortality
Clinical signs of old tuberculosis
Chest deformity and absent ribs, thoracotomy scar
Tracheal deviation towards side of fibrosis
Reduced expansion
Dull percussion but present tactile vocal fremitus
Crackles and bronchial breathing
Side effects of TB drugs
Isoniazid: peripheral neuropathy (co prescribe pyridoxine) and hepatitis
Rifampicin: hepatitis, increased COCP metabolism, orange urine
Ethambutol: retro-bulbar neuritis and hepatitis
Pyrazinamide: hepatitis
Historical management of TB
Plombage: insertion of polystyrene balls into the thoracic cavity
Phrenic nerve crush
Thoracoplasty (rib removal)
What to tell patient before starting TB medication
If yellow sclera- urgent review
If red colour less bright - urgent review
Watch out for peripheral neuropathy
Orange/red secretions will dye contact lenses
Don’t rely on COCP
Investigating suspected TB
FBC
CRP
LFTs
HIV and hepatitis screen
Sputum
Urine AFB
Quantiferon test
CXR
CT (upper lobe fibrosis, traction bronchiectasis)
Bronchoscopy
Biopsy extra pleural site for culture
Causes of upper zone fibrosis
TB
Radiation
Ankylosing spondylitis/ABPA
Sarcoidosis, silicosis
Histoplasmosis
Extrinsic allergic alveolitis
Causes of lower zone fibrosis
RA
Asbestosis
Scleroderma, SLE, sjogrens
IPF
Drugs
When to refer patients for lung transplant
UIP on diagnosis of no CI
ILD with FVC < 80% or transfer factor <40% or O2 requirement
May be listed if FVC drop >10% in 6 months
In CF if FEV1 <30%, poor exercise tolerance, pulmonary arterial hypertension, high exacerbation frequency, recurrent pneumothoracices, haemoptysis
COPD: bode index score >7 (fev1, 6 min walk distance, dyspnoea scale, BMI)
