RESP: PE, Pleural effusion, Empyema, Pneumothorax, ILD Flashcards
ECG findings in PE?
Sinus tachycardia
“S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign.
—> A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
What is the characteristic finding on high resolution CT thorax with Interstitial Lung disease?
Ground glass appearance
May also be described as honeycombing
What is the prognosis of interstitial lung disease?
Prognosis is poor as damage is irreversible
Management is mainly supportive
How does Idiopathic Pulmonary Fibrosis present?
Insidious onset
dry cough
Shortness of breath
over more than 3 months
Define pulmonary embolism
Where a thrombus forms in the pulmonary arteries.
Usually result of DVT that has developed in legs and embolised (moved from one part of circulation to another) through the venous system
How does pulmonary embolism affect blood flow?
Once in pulmonary arteries, blocks blood flow to lung tissue.
Creates strain on R side of heart
Risk factors for PE?
Immobility / long flights Pregnancy Obesity (>29 kg/m2) Recent surgery (>30min procedures) DVT or previous VTE Contraception - OCP, hormone therapy with oestrogen Tumours Thrombophillia Polycythemia SLE (as SLE is an inflammatory condition). Age (40+)
Booklet has it grouped as follows:
1) Surgery - Abdo, pelvic; Knee, hip replacement, post-op
2) Obstetris - late pregnancy, C section
3) LL - fracture, varicose veins
4) Malignancy - Abdo, pelvic, mets, advanced
5) Reduced mobility
6) Previous VTE.
Presentation of PE?
Give symptoms and signs
Symptoms :
Dyspnoea / SOB - most common.
Pleuritic chest pain
Cough +/- haemoptysis
Signs:
Hypoxia Tachycardia Hypotension - haemodynamic instability Raised RR Low grade fever
Note: may have S+S of a DVT - unilateral leg swelling, tenderness.
What scoring system can be used when patient presents with S+S of PE?
Wells score
What does Wells score predict?
The risk of a patient presenting with symptoms ACTUALLY having a DVT or PE.
Ca
Criteria in Wells score for PE?
Clinical S+S of DVT?
Is PE top differential?
HR >100?
Immobilised for 3 days or surgery in last 4 weeks?
Previous PE or DVT?
Haemoptysis?
Malignancy w/ treatment within 6 months or have palliative care for it?
Next step if Wells score outcome is: Unlikely?
D-dimer. If this is positive - then do CTPA
Conditions that cause raised d-dimer?
DVT, PE Pneumonia Malignancy Heart Failure Surgery Pregnancy
Investigations for suspected PE?
CTPA - IV contrast highlights pulmonary arteries
VQ scan - compare ventilation with perfusion. Used if CTPA is unsuitable. In PE, there will be deficit in perfusion.
D-dimer
Echocardiogram (if pt can not have CTPA)
FBC - thrombocytopenia, or anaemia, polycythaemia.
ECG
U+Es - for renal fuction to assess what drugs to use, and whether contrast can be used in CTPA
Coag screen - baseline before staring anticoagulant
LFTs - help choice of anticoagulant
ABG shows respiratory alkalosis for PE. So does hyperventilation. How to differentiate these two differentials?
PE = resp alkalosis with low pO2.
Hyperventilation = resp alkalosis with high pO2
Methods of thrombolysis for PE?
IV - use peripheral cannula
Catheter-directed thrombolysis = directly into pulmonary arteries using central catheter
Risk of catheter-directed thrombolysis in PE?
Damage to pulmonary arteries
Management of PE
ABCDE
Oxygen if hypoxic
Analgesia if pain
Subcut LMWH (enoxaparin, dalteparin) whilst awaiting CTPA
Confirmed PE on CTPA - long term anticoagulant needed (warfarin, doac, LMWH).
Pt has massive PE. What is management?
ABCDE Oxygen if hypoxic Analgesia Subcut LMWH while waiting for CTPA Thrombolysis with IV alteplase
What is thrombolysis?
Inject fibrinolytic meds that break down clot rapidly.
Examples of thrombolytic agents?
Alteplase
Streptokinase
Tenecteplase
Risk of catheter-directed thrombolysis?
Damage to pulmonary arteries
Absolute contraindications for thrombolysis?
Haemorrhagic stroke or ischaemic stroke within 6 months CNS neoplasia Recent trauma/surgery GI bleed less than 1month ago Bleeding disorder Aortic dissection
Relative contraindications for thrombolysis?
Warfarin/DOAC use
Pregnancy
Advanced liver disease
Infective endocarditis
Presentation of pleural effusion?
SOB - gradual Pleuritic chest pain Non productive cough - not as common (productive cough - only if due to pneumonia) Tachycardia
Investigations for pleural effusion?
Imaging: PA CXR. USS . Contrast CT (good for exudative effusions). ECHO (if suspect HF)
Pleural aspiration: fluid sent for pH, protein, MC&S, glucose.
Bloods: FBC. CRP, blood culture, U+Es, LFTs, bone profile, LDH, clotting
Sputum: sputum gram stain and culture
RF for pleural effusion?
CCF
Malignancy
Pneumonia
Weaker RF:
SLE, RA, recent MI, renal failure, nephrotic syndrome, drug induced - e.g. nitrofurantoin,
Management for pleural effusion?
Ultrasound guided pleural aspiration
Conservative management if small
Chest drain
Examination findings/ signs in pleural effusion?
Reduced chest movement on affected side Stony dull percussion Reduced/absent breath sounds Reduced vocal resonance Tracheal deviation
Define exudate and transudate classification of pleural effusion
Exudate: Pleural protein concentration more than 30g/L
Transudate: less than 30g/L protein.
Transudate causes of pleural effusion?
Transudative = fluid moving across into the pleural space
Heart Failure Hypoalbuminaemia (nephrotic syndrome or peritoneal dialysis) Liver cirrhosis Hypothyroidism Pulmonary embolism Mitral stenosis
Rare:
Meigs’ syndrome (triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor).
Constrictive pericarditis
Superior vena cava obstruction
Exudate causes of pleural effusion?
Exudative = inflammation related - causes protein to leak out of tissue and into pleural space
Infection - pneumonia, TB, subphrenic abscess, TB. HIV (kaposi’s).
Malignancy - lung cancer, mets
Inflammatory causes - Connective tissue disease, RA, SLE, Pancreatitis, lymphatic disorders, PE
Rare: yellow nail syndrome, fungal infections, drugs
Z2F : main ones - lung cancer, pneumonia, RA, Tb
Define empyema
Infected pleural effusion.
Z2F: suspect when pt has improving pneumonia but new or ongoing fever.
Pleural aspiration shows pus, acidic <7.2, low glucose and high LDH
How is empyema managed?
- Chest drain - remove pus.
- antibiotics based on sensitivity - usually for 3 weeks
- supportive care - pain relief, IV fluids, early mobilisation.
bmj bes practice
What is a pneumothorax?
When air gets into the pleural space separating lung from chest wall
Whats the difference between primary and secondary pneumothorax?
Primary- no underlying lung pathology
Secondary- if there is underlying lung disease
Causes of pneumothorax?
Spontaneous
Trauma
Iatrogenic- lung biopsy, mechanical ventilation, central line insertion
Lung pathology- asthma, COPD
What is catamenial pneumothorax?
Due to endometrisosis in the thorax. Occurs during/ after menstruation
Presentation of pneumothorax?
Sudden onset: Dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia
Investigations for pneumothorax?
Erect Cxr
CT thorax for small pneumothorax and can accurately asses the size of the pneumothorax
How do you manage a primary pneumothorax?
rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
How do you manage a secondary pneumothorax?
patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm.
If aspiration fails a chest drain should be inserted.
All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
Where do you insert a chest drain?
Safe triangle: 5th IC space Mid axillary line anterior axillary line within this triangle
What is a tension pneumothorax?
One way valve, not allowing air to escape, leading pressure to rise
Typical pneumothorax pt?
Young, tall and thin man presenting with SOB
Signs of tension pneumothorax?
Tracheal deviation AWAY from side of the pneumothorax Reduced air entry on affected side Increased resonance on affected side Tachycardia Hypotension
Management of tension pneumothorax?
Insert a large bore cannula into the second IC space mid clavicular line
Then use a chest drain for definitive management
What is a Parapneumonic effusion?
Parapneumonic effusions are effusions caused by an underlying pneumonia.
Simple - not infected
Complicated- effusion develops once infection has spread to the pleural space.
How is empyema, a simple parapneumonic effusion and complicated parapneumonic effusion related?
Three conditions = a spectrum of pleural inflammation in response to infection.
From a simple parapneumonic effusion to empyema.
What are RF for empyema ?
recent pneumonia iatrogenic intervention in the pleural space thorax trauma Immunocompromised e.g. diabetes co-morbidities make pneumonia more likely lung disease male sex young or old age alcohol abuse
If empyema or a complicated parapneumonic effusion is diagnosed what must be done urgently?
Insert a chest drain
+ long course of AB
if no improvement with AB and drainage - surgery or fibrinolytics
How do causative pathogens differ from comminity acquired and hospital acquired empyema?
Community: Streptococcus pneumoniae, and staphylococci
Hospital: staphylococci (particularly MRSA)
How would a pt with empyema present?
Constitutional symp:
Malaise, anorexia, weight loss, fatigue
Pyrexia
Rigors
Examination: dullness at the lung base reduced breath sounds reduced vocal resonance signs of sepsis
What investigations for empyema?
Bloods:
Blood cultures - AB choice
FBC - WCC count
CRP
Imaging:
CXR - see effusion, loculated effusion suggests empyema. consolidation due to pneumonia.
Special tests: Thoracentesis : pleaural fluid: appearance; pus diagnostic Odor: putrid - anaerobic PH: <7.2 total protein context > 30 g/l LDH level >2-3 x upper limit of serum Glucose WCC - lymphocytes -TB / malignancy MC&S
What is type 1 respiratory failure?
Pa02<8kPa; PaC02 Normal
Causes of type 1 respiratory failure?
Asthma Congestive HF Pulmonary Embolism Pneumonia Pneumothorax
What is type 2 respiratory failure?
Pa02<8kPa; PaC02 > 6kPa
Causes of type 2 respiratory failure?
Obstructive lung disease e.g. COPD
Restrictive lung disease e.g. IDL
Depression of respiratory centre e.g. opiates
NMJ disease e.g. Guillan barre syndrome, MND
Thoracic wall disease- rib fracture
What are you differentials for Haemoptysis : infection related?
Pneumonia
Tuberculosis
Bronchiectasis / CF
Cavitating lung lesion (often fungal
What are you differentials for Haemoptysis : Malignancy related?
Lung cancer
metastases
What are you differentials for Haemoptysis : Haemorrhage related?
Bronchial artery erosion
Vasculitis
Coagulopathy
What are some differentials for Haemoptysis? Other (resp = clue)
PE!
What is interstitial lung disease?
Umbrella term describing a number of conditions that affect the lung parenchyma in a diffuse manner. an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs.
What are some examples of interstitial lung disease?
Usual Interstitial Pneumonia (UIP)
Non-specific Interstitial Pneumonia (NSIP)
Extrinsic Allergic Alveolitis
Sarcoidosis
Several other conditions
What are important things to cover in hx taking from a pt with ILD? Why?
- comprehensive occupational / environmental history
e. g.
inhalation of dust - Silicosis
Inhalation of asbestos - Asbestosis
Pneumoconioisis (coal workers)
What results to do you get in PFTs for ILD?
Typically restrictive lung diseases on PFT’s
What autoimmune / immunological investigations do you need to do for ILD?
(Looking for conditions associated with developing ILD)
ANA – connective tissue disease OR SLE
ENA – connective tissue disease
Rh F – Rheumatoid Arthritis
ANCA – Vasculitis
Anti-GBM – Pulmonary Renal disease
ACE – Sarcoidosis
Ig G to serum precipitins e.g. pigeon, budgie – Extrinsic Allergic Alveolitis
HIV
What is the most common ILD causing lung fibrosis?
Usual Interstitial Pneumonia (UIP)
often idiopathic
What findings do you see with Usual Interstitial Pneumonia (UIP) and ILD?
`Examination : clubbing, reduced chest expansion
Auscultation: fine inspiratory crepitations (pulling Velcro slowly) – best heard basal / axillary areas
Cardiovascular – features of pulmonary
hypertension
(note L (UIP) is a form of lung disease characterised by progressive scarring of both lungs - interstitial lung disease)
What is Extrinsic Allergic Alevolitis? (ILD)
Also known as Hypersensitivity Pneumonitis
Inhalation of organic antigen to which the individual has been sensitised
How does Extrinsic Allergic Alevolitis? (ILD) present acutely?
short period from exposure - 4-8 hrs.
Usually reversible - spontaneously settle 1-3 days.
Can reocur
How does Extrinsic Allergic Alevolitis? (ILD) present Chronically?
chronic exposure (months – years). Less reversible.
What are some drug causes of ILD? Extrinsic Allergic Alevolitis?
Amiodarone Bleomycin Methotrexate Nitrofurantoin Penicillamin
What is Sarcoidosis ? (ILD)
What do you see on histology?
Multisystem (often resp) inflammatory condition of unknown cause
50% remission, 50% progressive disease
Non-caseating granulomas on Histology
What investigations for Sarcoidosis?
Definitive: tissue biopsy (e.g., lung, lymph nodes), which typically reveals non-caseating granulomas
Bedside: PFTs: restrictive pattern (fibrosis) -(obstructive- an early sign)
Bloods:
* raised ESR
* ACE (not specific or diagnostic)
* U&Es
* raised calcium levels
* lymphocytes may be reduced
Imaging:
* CXR: 4 stages of changes from Sarcoid
Cardiac involvement:
* ECG, 24 tape, ECHO, cardiac MRI
- CT/MRI head: headaches – Neuro sarcoid
What are ILD treatment principals?
Remove trigger exposure e.g. occupational / environment
Stop smoking
MDT approach – Pirfenidone to slow progression
Treatment of infective exacerbations
Oxygen if respiratory failure
Palliative care
Transplantation
How is pleural effusion diagnosed (1st line)?
Do CXR
Ultrasound guided pleural aspiration
What is the only indication for an urgent chest drain in pleural effusion?
If there is an underlying empyema
pH of pleural fluid in empyema plural effusion?
pH <7.2
From a US guided pleural aspiration, what is tested?
Biochemistry —> protein, pH, LDH
Cytology
Microbiology (including acid alkali fast bacteria)
Disadvantage of draining all fluid from pleura without understanding Dx?
Draining all the fluid = prevents opportunity to take pleural biopsies.
Options available to biopsy pleura (e.g. if malignancy is found in cytology from aspiration sample|)?
Thoracoscopy
CT pleural biopsy
How to manage pleural effusion that is found to be transudate?
Treat underlying cause
Pt has transudative pleural effusion. You have treated the underlying cause but pt still has effusion. What is appropriate next step?
Effusion has persisted even after treating underlying cause - so now need to use therapeutic aspiration/drainage
When is Light’s criteria used?
If pleural protein level is between 25-35g/L
Lights criteria to identify exudative pleural effusion?
Pleural fluid/Serum protein >0.5
Pleural fluid/ Serum LDH >0.6
Pleural fluid LDH >2/3rds of the upper limit of normal
What type of shock can PE lead to ?
Mechanical shock
What is pathophysiology of mechanical shock from a massive PE?
Embolus occludes the large pulmonary artery.
Pulmonary artery pressure is high. Occlusion means RV can not empty, and central venous pressure increases.
So, get reduced return of blood to the left side of the heart and there is limited filling of the left heart.
Left atrial pressure is low, so arterial BP is low, leading to shock.
X-ray findings for ILD?
Fluffy appearance- reticulonodular shadowing
Causes of ILD?
Medication e.g. amiodarone, bleomycin, methotrexate, nitrofurantoin Sacroidosis Hypersensitivity pneumonitis coal worker's pneumoconiosis TB
ECG findings for a PE?
Sinus tachycardia
“S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign.
—> A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
Stages of sarcoidosis on CXR?
Stage 1 - Bilateral hilar lymphadenopathy (BHL)
Stage 2 - BHL with peripheral infiltrates
Stage 3 - Peripheral infiltrates alone
Stage 4 - Pulmonary fibrosis
What is sarcoidosis?
Sarcoidosis is a multi-system disease that is characterised by the formation of granulomas, leading to widespread inflammatory changes and complications across multiple body systems.
Signs and symptoms of Acute Sarcoidosis?
Signs and symptoms of acute sarcoidosis, also known as Löfgren syndrome, include:
Fever
Polyarthralgia
Erythema nodosum
Bilateral hilar lymphadenopathy
Common manifestations of Chronic Sarcoidosis?
Involving other organs / systems
- Pulmonary: Dry cough, dyspnoea, reduced exercise tolerance, and crepitations on examination
- Constitutional: Fatigue, weight loss, arthralgia, low-grade fever, lymphadenopathy, and enlarged parotid glands
- Neurological: Meningitis, peripheral neuropathy, bilateral Bell’s palsy
- Ocular: Uveitis, keratoconjunctivitis sicca
- Cardiac: Arrhythmias, restrictive cardiomyopathy
- Abdominal: Hepatomegaly, splenomegaly, renal stones
- Dermatological: Erythema nodosum, lupus pernio
Management of sarcoidosis?
- Bilateral hilar lymphadenopathy alone: Usually self-limiting and often does not require treatment
- Acute sarcoidosis: Bed rest and NSAIDs for symptom control
- Steroid treatment: Oral or intravenous, depending on the severity of the disease
- Immunosuppressants: Used in severe disease.
What is a massive PE?
- causes heart strain due to RV overload
