Resp Vivas Flashcards
Respiratory indications for midline sternotomy
Anterior mediastinum tumour resection
Lower trachea + main stem bronchus surgery
What is CREST syndrome?
Subtype of limited systemic sclerosis a/w anti-centromere Abs
Calcinosis
Raynaud’s phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
Give a differential for CREST syndrome?
Diffuse cutaneous systemic sclerosis (anti-scl 70 abs)
(most common cause of death is ILD + pulmonary HTN)
Describe management of COPD
- SABA or SAMA
- Is there steroid responsiveness/ asthmatic features?
Y: SAMA/ SABA + LABA + ICS
N: SABA + LAMA + LABA - SABA + LABA + LAMA + ICS
Name a SABA used in COPD
Salbutamol
Name a SAMA used in COPD
Ipratropium
Name a LAMA used in COPD
Tiotropium
Name a LABA used in COPD
Salmeterol
Name a ICS used in COPD
Budesonide
Beclometasone
Conservative Mx of COPD
SMOKING cessation advice: inc. offering NRT: varenicline or bupropion
Annual influenza vaccination
One-off pneumococcal vaccination
Pulmonary rehab to all who view themselves as functionally disabled by COPD
Which 4 features suggest steroid responsiveness in COPD?
Previous dx of Asthma or Atopy
High blood eosinophil count
Substantial variation in FEV1 over time (>,400ml)
Substantial diurnal variation in PEF (>,20%)
When can oral theophylline be used in COPD?
After trials of short + long-acting bronchodilators or to people who can’t used inhaled therapy
When should mucolytics be considered in COPD?
In those with chronic productive cough
Continued if Sx improve
What can be used as prophylactic antibiotic therapy in COPD? When is this indicated?
Azithromycin
Continue to have exacerbations despite not smoking + having optimised standard Tx
What prerequisites are there for Azithromycin prophylaxis in COPD?
CT thorax (to r/o bronchiectasis)
Sputum culture (to r/o atypical infections + TB)
LFTs + ECG to r/o QT prolongation (as azithromycin can prolong QT)
What can be used to reduce risk of COPD exacerbations in those with severe COPD and frequent exacerbations?
PDE-4 inhibitors e.g. Roflumilast
What are the features of cor pulmonale seen in COPD?
Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud P2
Describe management of cor pulmonale in COPD
LTOT
Loop diuretic for oedema e.g. Furosemide
Which factors may improve survival in patients with stable COPD?
Smoking cessation: single most important intervention
LTOT in those who fit criteria
Lung volume reduction surgery in selected patients
What are the types of lung volume reduction?
Lung volume reduction surgery
Endobronchial valves
What is lung volume reduction surgery?
Worst affected part of lung stapled off + removed. Remaining lung re-inflates + can work more effectively.
Laparoscopic
What are endobronchial valves?
Bronchoscopic lung volume reduction (BLVR)
One-way valves stop air from getting into diseased parts of lungs when breathing in but allow air + mucus out when breathing out.
Causes target area of lung to shrink
What are the indications for LTOT?
pO2 of < 7.3 kPa OR pO2 of 7.3-8 kPa + one of the following:
secondary polycythaemia
peripheral oedema
pulmonary HTN
Most common cause of infective exacerbation of COPD
Haemophilus influenzae
Acute exacerbation of COPD Mx
Increase freq. bronchodilator use +/- give via nebuliser
Prednisolone 30mg OD for 5 days
If sputum purulent/ clinical signs of pneumonia: Amoxicillin/ Clarithromycin or doxycycline.
Criteria for admission in acute exacerbation of COPD
Severe breathlessness
Acute confusion/ impaired consciousness
Cyanosis
O2 sats <90% on pulse ox
Inability to cope at home/ living alone
Significant comorbidity (cardiac disease or insulin-dependent diabetes)
Severe acute exacerbation of COPD Mx
28% Venturi mask, 4 L/min
Aim for sats of 88-92% for patients with RFs for hypercapnia + no prior hx of resp. acidosis
Target 94-98% if pCO2 is normal
Nebulised Salbutamol + Ipratropium
Steroids: Pred PO or IV Hydrocortisone
IV theophylline
If not responding to nebs
Describe Mx of T2 respiratory failure in COPD
NIV if resp acidosis pH 7.25-7.35
- BiPaP
Interstitial lung disease pathogenesis
Scarring (pulmonary fibrosis), inflammation or a mix
What are the exposure related causes of ILD?
Hypersensitivity pneumonitis: farmers lung, bird fanciers lung
Pneumoconiosis: Asbestosis, Silicosis, Coal workers lung
Radiation pneumonitis
Drug induced: Amiodarone, Methotrexate, Nitrofurantoin, Bleomycin
What are the causes of ILD secondary to connective tissue disease?
Systemic sclerosis
RhA
Polymyositis
SLE
Sjogrens
Mixed connective tissue disease
Idiopathic causes of ILD
Idiopathic pulmonary fibrosis
Cryptogenic organising pneumonitits
Non specific interstitial pneumonitis
Acute interstitial pneumonitis
5 other causes of ILD
Sarcoidosis
Vasculitis
UC
Renal tubular acidosis
AI thyroid disease
Infections e.g. TB
Ix for ILD
Bedside: ABG (resp failure), ECG (right heart strain)
Lab: FBC (anaemia, polycythaemia), AI screen, serum ACE (sarcoidosis)
Imaging: CXR
HRCT: GS
Ground glass/ honeycombing
Volume loss
Bilateral reticulonodular interstitial infiltrates
Describe lung function tests in ILD
Restrictive pattern with reduced transfer factor
S/S of IPF
Progressive exertion dyspnoea
Bibasal fine end inspiratory crepitations
Dry cough
Clubbing
Ix for IPF
Spirometry: restrictive
Impaired gas exchange: reduced TLCO
CXR: bilateral interstitial shadowing, ground glass, honeycombing
HRCT: required for dx
Mx of IPF
Conservative: pulmonary rehab
Medical: little evidence. Some for Pirfenidone. O2 therapy
Surgical: lung transplant
4 pulmonary manifestations of sarcoidosis
BHL
Dry cough
Progressive dyspnoea
Reduced exercise tolerance
Indications for steroids in sarcoidosis
CXR stage 2/3 + symptomatic
(BHL + interstitial infiltrates)
Ddx for coarse crackles
Bronchiectasis (may partially clear after coughing)
Chronic bronchitis
ddx for fine crackles
Pulmonary fibrosis (interstitial process)
Lateral thoracotomy scar ddx
Lobectomy (Lung malignancy, localised bronchiectasis, Aspergilloma, Large bullectomy (COPD))
Pneumonectomy (malignancy)
Single lung transplant
Lung volume reduction surgery
Describe examination findings in pneumonectomy
Left/ right thoracotomy scar
Dull percussion note
Absent breath sounds
Trachea deviation towards pneumonectomy
Reduced expansion
Describe examination findings in lobectomy
Left/ right thoracotomy scar
May be no other signs due to compensatory hyperexpansion of remaining lobes
May be some reduced expansion, dullness to percussion + reduced air entry
Describe CXR of lobectomy/ pneumonectomy
FLUID fills cavity of removed lung (radio-OPAQUE)
Organs shift into cavity of removed lung (i.e. heart + trachea displaced)
Define bronchiectasis
Permanent dilation of air wards secondary to chronic infection or inflammation
5 causes of bronchiectasis
Post infective: TB, measles, pertussis, pneumonia
CF
Allergic bronchopulmonary aspergillosis
Immune deficiency: selective IgA
Ciliary dyskinetic function: Kartageners syndrome
5 S/S of bronchiectasis
Persistent PRODUCTIVE cough
Dyspnoea
Haemoptysis
Coarse crackles + wheeze
Clubbing
Ix for bronchiectasis
Sputum culture
Spirometry
FBC inc. WCC
CXR: r/o other pathology
HRCT: GS- signet ring sign, tram tracking, ring shadows, volume loss
Mx of bronchiectasis
Physical training: inspiratory muscle training
Postural drainage
Abx for exacerbations
Bronchodilators in some
Immunisations
Surgery in localised disease
Most common organism isolated from those with bronchiectasis
H influenzae
Pathogenesis of CF
Increased viscosity of secretions due to defect in CF transmembrane conductance regular gene
Delta F508 on Chr7
Autosomal recessive
How may CF present?
Neonatal: meconium ileus
Recurrent chest infections
Malabsorption: steatorrhoea, FTT
Liver disease
6 features of CF
Short
DM
Delayed puberty
Rectal prolapse
Nasal polyps
Infertility/ subfertility
Ix for CF
Heel prick test (newborn screening)
Sweat test: abnormally high sweat chloride
Genetic test: blood/ saliva
Mx of CF
MDT approach
BD chest PT + postural drainage
High calorie diet inc. high fat
Minimise contact with other CF
Vitamin supplementation
Pancreatic enzyme supplementation
Lung transplant
CI to lung transplant in CF
Burkholderia cepacia
What drug may be used in CF?
Lumacaftor/ Ivacaftor (Orkambi)
Causes of pulmonary oedema
Cardio: LVF (post MI/ IHD), valvular
ARDS: ?predisposing factors e.g. trauma, sepsis
Fluid overload
Neurogenic: head injury
ddx for pulmonary oedema
Asthma/ COPD
Pneumonia
(may co-exist)
3 Sx of pulmonary oedema
Dyspnoea
Orthopnoea
Pink frothy sputum
Signs of pulmonary oedema
Distressed
Tachycardic
Tachypnoeic
Pulsus alternans
Raised JVP
Fine lung crackles
Wheeze
Ix for pulmonary oedema
BNP: ?HF
U+Es
Troponin: ?MI
ECG: ?MI, dysrrhythmia
CXR: ABCDE
+/- echo
LVF on CXR
Alveolar oedema “bats wing”
kerley B lines
Cardiomegaly
Dilated prominent upper lobe veins/ upper lobe diversion
E pleural Effusion
How would you manage a patient with acute pulmonary oedema?
- Sit upright + high flow O2
- IV access + monitor ECG
- Diamorphine 5mg IV
- Furosemide 40-80mg IV
- GTN spray SL (not if SBP <90)
Consider further furosemide, nitrate infusion, CPAP
