Respiratory Flashcards
Causes of ILD
Immune mediated
- hypersensitivity pneumonitis
- connective tissue disease associated
- sarcoid
- occupational exposure
- drug causes: methotrexate, amiodarone, nitrofurantoin
Non-immune mediated
- IPF
Upper zone fibrosis causes
APHAT Aspergillosis Pneumoconiosis e.g. coal / silica Hypersensitivity pneumonitis Ankylosing spondylitis TB
Mid zone fibrosis causes
Sarcoid
Radiotherapy
Lower zone fibrosis causes
DAIR Drugs e.g. methotrexate, nitrofurantoin, amiodarone Asbestosis Idiopathic pulmonary fibrosis Rheumatic
Asthma management (chronic)
1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + montelukast
4) SABA + low dose ICS + LABA (+/- montelukast if it had any effect)
5) SABA (+/- montelukast) & maintenance and reliever LABA/ICS combo
6) Increase steroid dose
7) Increase steroid dose further OR add LAMA OR theophylline
COPD management (chronic)
1) SABA / SAMA (iptrotropium)
2) LABA (salmeterol) + ICS (if asthmatic features)
OR LABA + LAMA (tiotropium) (if no asthmatic features)
3) LABA + LAMA + ICS
4) Roflumilast (>2 exacerbations in a year, despite triple inhaled therapy, where FEV1 is less than 50% of predicted)
Others
- oral theophylline
- mucolytics e.g. carbocysteine
- lung volume reduction surgery
VATS indications
Parenchymal
- lung biopsy
- wedge resection
- lobectomy
- bullectomy
Pleural
- decortication of chronic empyema
- pleurectomy / pleurodesis e.g. recurrent pneumothoraces
Thoracotomy indications
Cancer (CI if malignant pleural effusion / SV obstruction / paralysis vocal cords / tumour near hilum)
- lobectomy (FEV1 >1.5L)
- pneumonectomy (FEV1 >2L)
Lobectomy (non-cancer)
- traumatic lung injury
- vascular malformations
- lung abscess
- bronchiectasis
- aspergilloma
Lung volume reduction surgery (COPD)
Bullectomy
Pleural procedures including pleurectomy for recurrent pleural effusions
Atypical approaches to the thoracic aorta
Lung transplant indications
Aetiologies
- CF
- bronchiectasis
- ILD
- COPD
- pulmonary vascular disease
Prognosis
- > 50% death within 2 years
- otherwise few co-morbidities
Contraindications
- malignancy
- smokers / illicit drug users
- non-compliance with clinic / medications
- poor social support systems
- extremes of BMI
Complications of transplant
Acute
- surgical complications (pain / bleeding / infection / neurovascular injury)
- acute rejection
Chronic
- rejection
- opportunistic infection
- post transplant diabetes (in part related to glucocorticoids)
- malignancy
- > skin cancer (azathioprine / immunosuppression)
- > post transplant lymphoproliferative disorder
- > graft versus host
- disease recurrence
Other complications of immunosuppression
- cushing’s
- calcineurin kidney toxicity
- gum hypertrophy (ciclosporin)
Causes of clubbing
Idiopathic / familial
Respiratory
- ILD e.g. IPF
- chronic suppurative lung disease e.g. CF, bronchiectasis, TB, empyema, abscess
- cancer (non-small cell, mesothelioma)
- part of hypertrophic pulmonary osteoarthropathy
Abdo
- IBD
- cirrhosis of the liver
Cardio
- subacute infective endocarditis
- congenital cyanotic heart disease
Endocrine
- thyroid acropachy of Graves
Management of pneumothorax
Primary
asymptomatic / <2cm - consider discharge
>2cm or symptomatic - aspiration -> chest drain if residual >2cm
Secondary
<1cm: oxygen / admit for observation
1-2cm: aspiration -> chest drain if residual >1cm
>2cm: chest drain
Recurrent
- pleurodesis
- pleurectomy (VATS or thoracotomy)
Causes of pleural effusion
Transudate (protein <25g/dL or -ve Light’s criteria)
- heart failure
- liver failure (including hepatic hydrothorax)
- renal failure
- hypoalbuminaemia (including dietary / severe disease associated)
- Meig’s syndrome - benign ovarian tumour + pleural effusion)
Exudate (protein >35g/dL or +ve Light’s criteria)
- empyema (frank pus, ph <7.2, low glucose,
- parapneumonic
- malignancy
- rheumatological (serositis e.g. SLE, RA)
- pancreatitis
- TB -> low glucose, raised adenosine deaminase
Light’s criteria
Exudative effusion if
- pleural / plasma LDH > 0.6
- pleural LDH > 2/3 upper limit of serum normal range
- pleural / plasma protein > 0.5
Non-small cell lung cancer features
Adenocarcinoma
- 40%
- most common type for non-smokers (but smoking still increases risk)
- peripheral tumours
Squamous
- 25%
- highly smoking associated
- central lesions
- PTHrP secretion -> hypercalcaemia
Large cell
- 10%
- aggressive
- Bhcg secretion
NETs
Non-small cell lung cancer management
Depends on stage at diagnosis
Stage 1/2 (no distant metastases, limited nodal disease)
- curative lobectomy / pneumonectomy +/- adjuvant chemoradiotherapy
- OR radical radiotherapy
Late stage / inoperable
- chemoradiotherapy
Small cell lung cancer features & treatment
Aggressive with early metastases Paraneoplastic syndromes common - SIADH - Lambert Eaton - ACTH secretion (ectopic cushing's)
Surgery: rarely indicated as picked up post mets
Local disease: chemoradiotherapy
Extensive disease: palliative chemotherapy
Causes of bronchiectasis
Recurrent respiratory infections (childhood or adulthood)
Genetic
- CF
- Kartagener’s (situs invertus, primary ciliary dyskinesia)
Chronic lung disease e.g. COPD
Connective tissue disease e.g. RA
Chronic inflammatory disease e.g. IBD
Allergic bronchopulmonary aspergillosis
Immunodeficiency e.g. hypogammaglobulinaemia
Bronchiectasis managment
MDT
- PT / OT
- chest physiotherapy including postural drainage / assisted clearance
- mucolytics
- prompt treatment of infections guided by sputum mcs
- vaccinations
- LTOT if needed
- surgical excision of severely affected lung
- transplant
Causes and definition of pulmonary hypertension
Mean pulmonary artery pressure >20mmHg
Group 1 = pulmonary arterial hypertension - idiopathic - connective disease associated - cirrhosis portopulmonary syndrome Mx - treat cause - CCBs if vasoreactive - PDE5i/ER antagonist if not
Group 2 = left heart disease associated - HFrEF / HFpEP - valvular heart disease (often mitral) Mx - diurese / optimise heart failure medication - treat the cause (e.g. valvular)
Group 3 = lung disease / hypoxia related - e.g. COPD / ILD Mx - supportive - LTOT - treat the cause
Group 4 = pulmonary artery obstructions - e.g. chronic venous thromboembolism Mx - anticoagulation - pulmonary thromboendarterectomy
Group 5 (miscellaneous)
Signs of pulmonary hypertension / cor pulmonale
Loud P2
RV heave (cor pulmonale)
Raised JVP
Peripheral oedema
Asthma severity
Moderate
- peak flow >50-75%
- increasing symptoms
- no greater features
Acute severe
- peak flow 33-50%
- RR >25
- HR >110
- inability to complete sentences in one breath
Life threatening
- peak flow <33%
- spo2 <92%
- pao2 <8
- normal pco2
- exhaustion
- silent chest / poor respiratory effort
- hypotension
- decreased gcs
