Respiratory Flashcards
Causes of Upper Zone pulmonary fibrosis
SCHART
Silicosis/Sarcoidosis Coal workers pneumoconiosis Histiocytosis X Ank Spond/ABPA Radiation TB
Causes of Lower Zone pulmonary fibrosis
RASID
RA Asbestosis Scleroderma Idiopathic Drugs: Bleomycin, MTx, Nitrofurantoin, Amiodarone, Hydralazine
Resp Schpiel:
Today I examined ___ respiratory system.
Salient features include ___ crepitations/wheeze/dullness/reduced breath sounds in the ____.
This was associated with percussion/vocal resonance/expansion findings of ___ and peripheral findings of ____.
This is consistent with a diagnosis of ____ but tehre are other differentials.
My findings in more detail _____.
Causes of clubbing
Lung cancer
Bronchiectasis
IPF
CF
Infective endocarditis
Cyanotic congenital heart disease
CLD
DDx of non CF bronchiectasis
Recurrent chest infections –> bronchiectasis
Primary ciliary dyskinesia
CVID - recurrent sinopulmonary infections
Bronchial narrowing/obstruction
Pleural effusion -
Transudate causes
Cardiac failure Liver failure Nephrotic syndrome Hypothyroidism Meig's syndrome (Ovarian fibroma and pleural effusion)
Pleural effusion -
Exudate causes
Pneumonia (para-pneumonic) Neoplastic (lung mets/mesothilioma) TB, sarcoidosis Pulmonary infarction RA/SLE
Light’s criteria for exudative effusion
Pleural fluid protein : serum protein > 0.5
Pleural fluid LDH : serum LDH > 0.6
Bronchial breath sounds
Pneumonia
Localised fibrosis/collapse
Above a pleural effusion
Decreased breath sounds
Emphysema Large lung mass Collapse/fibrosis/pneumonia Effusion Pneumothorax
ILD Causes:
Occupational/Environmental (upper zones) - silicosis, asbestosis, extrinsic allergic alveolitis, stone mason/dusts, Birds, Farming
Drugs (lower zones) - bleomycin, MTx, amiodarone
Radiation
CTD/Granulomatous
- RA
- SLE
- Scleroderma
- Sjogren’s syndrome
- Crohn’s disease/UC
- Dermatomyositis/polymyositis
- Sarcoidosis
Idiopathic
- IPF - expect clubbing
- NSIP - extensive ground glass
- UIP
- COP
Fine crackles causes
- Pulmonary fibrosis
- Heart failure (usually coarse)
Coarse crackles causes
- Pneumonia
- Heart failure
- Bronchiectasis
- Atelectasis
Usual Interstitial Pneumonia Findings
- Honeycombing
- Subpleural & Basal Predominance
- Traction bronchiectasis
Rx:
- Pifendidone
- Nintendanib
NSIP Findings
- Ground glass changes
- Subpleural sparing
- Traction bronchiectasis
Rx:
- Steroids
- Mycophenolate/Azathioprine
- Lung Transplant
UIP Causes
- IPF
- Asbestosis
- CTD-related ILD (e.g., RA)
NSIP Causes
- More associated with CTD
- HIV
- Drugs (Amiodarone, MTX, Nitrofurantoin)
Resp additional tests:
- Temperature chart
- Oxygen Saturation
- PEF/FET >3-5 seconds = prolonged/COPD
- Breast examination
Resp Likely cases:
- ILD +/- CREST (39%)
- Bronchiectasis (16%)
- Pneumonectomy/Lobectomy (9%)
- Pleural effusion (7%)
- Lung cancer (4%)
- COPD (4%)
- Lung Tx!
Respiratory causes of clubbing:
- ILD
- Carcinoma of the lung
- Mesothelioma
- Bronchiectasis
- Cystic fibrosis
- Lung abscess
- Empyema
- TB
Complications of ILD:
- Respiratory failure
- Chest infection
- Pulmonary HTN
- Cor pulmonale
- Carcinoma of the lung
Pleural effusion signs:
- reduced chest expansion
- stony dull percussion
- reduced vocal resonance
- reduced breath sounds with area of bronchial breathing above the effusion
Causes of pleural effusion:
- Carcinoma of the lung - nicotine staining, clubbing, lymph nodes, radiation burns, hepatosplenomegaly.
- Lymphoma - LNs, radiation burns, hepatosplenomegaly.
- Carcinoma of the breast - breast lump, nipple changes, lymphadenopathy, previous mastectomy/lumpectomy.
- RA - symmetrical deforming polyarthropathy of the hands, rheumatoid nodules
- SLE - petechial rash, livedo reticularis, purpura, arthopathy, malar rash
- CLD - jaundice, ascites, peripheral oedema, and other stigmata of CLD
- Hypoalmuniamemia - cachexia, poor nutritional status, peripheral oedema
- CCF - raised venous pressure, S3, S4, peripheral oedema.
Exudate (protein >30g/L) causes:
- Neoplasia
- CTD (RA, SLE)
- Infection - CAP, TB
- Pulmonary infarction
- Sub-diaphragmatic: pancreatitis, sub-phrenic abscess, hepatic abscess
- Drugs: MTx, Nitrofurantoin, Bromocriptine
Others: asbestosis, sarcoidosis, Dressler’s syndrome, Trauma, Chylothorax
Transudate (protein <30g/L) causes:
- CCF
- Constrictive pericarditis
- Hypoalbuminaemia
- Nephrotic syndrome
- Cirrhosis
- Peritoneal dialysis
- Uraemia
- Hypothyroidism
Light’s criteria?
Pleural fluid protein : serum protein >0.5
Pleural fluid LDH : serum LDH >0.6
Pleural fluid LDH > 2/3 of the upper limit of normal serum value.
Dullness to percussion of lung base ddx:
- Pleural effusion
- Pleural thickening
- Collapse
- Consolidation
- Raised hemi-diaphragm
- Lower lobe lobectomy (in the presence of thoracotomy scar).
Indications for lobectomy:
- Bronchiectasis (uncontrolled symptoms, i.e., recurrent haemoptysis)
- Malignancy (NSCLC)
- Solitary pulmonary nodule (unknown cause)
- Cystic fibrosis
- TB
- Lung abscess
Indications for pneumonectomy:
- Bronchiectasis
- Malignancy
- TB
Productive cough, clubbing, and coarse crackles ddx:
- Bronchiectasis
- Carcinoma of the lung (nicotine staining, lymphadenopathy)
- Lung abscess
- Pulmonary fibrosis
Causes of bronchiectasis:
1) Respiratory childhood infection - pertussis, measles, TB
2) Bronchial obstruction - foreign body, chronic aspiration, endobronchial tumour, LN (TB, sarcoidosis and malignancy) and granulomata.
3) Fibrosis - long-standing pulmonary fibrosis, TB/sarcoidosis, unresolved or suppurative pneumonia
4) Muco-ciliary clearance defects - CF, immotile cilia syndrome, Kartagener’s syndrome, Young syndrome
5) Immunodeficiency - CVID, AIDS
6) ABPA
7) AI - RA, Sjogren syndrome, IBD (UC > CD)
8) Congenital anatomical defects: Bronchopulmonary sequestration
9) Idiopathic
Cx of bronchiectasis
- Pneumonia
- Pneumothorax
- Empyema
- Collapse
- Metastatic cerebral abscess
- Respiratory failure
- Pulmonary HTN
- Amyloidosis
Consolidation ddx
- pneumonia (pyrexia, purulent sputum, haemoptysis)
- malignancy (cachexia, clubbing, nicotine staining, lymphadenopathy, productive cough)
- infarction (signs of pulmonary HTN, DVT, bruising-suggesting anti-coagulation).
Percussion stony dull (2)
- Fluid/effusion
Percussion resonant (2)
- PTx
- COPD
Vocal resonance increased (clearly audible)
- Consolidation
- Tumour
- Lobar collapse
Vocal resonance decreased (muffled)
- Fluid/effusion
- PTx (air outside lung)
Other (7)
- Pemberton’s - 30 second-1minute
- Legs (oedema)
- Temperature
- Saturations
- Forced expiratory time - 3 seconds or less
- Peak expiratory flow - decreased in COPD (>9 = COPD)
- Spirometry
DECAF
- Extended MRC Dyspnea Scale (2 if can’t leave the house)
- Eosinophils <0.05×10⁹/L (1)
- Consolidation on chest x-ray (1)
- Acidemia, pH <7.30 (1)
- AF (1)
BODE
- BMI - > 21 (1)
- Obstruction - FEV1 <35% (+3)
- Dyspnoea - mMRC Dyspnea Scale (3 if can’t leave the house)
- E - ET: Oxygen - 6MWT
Bronchiectasis management (7)
- Sputum clearance
- Postural drainage
- Chest Physio
- Flu, pneumococcal, covid vax
- Smoking cessation
- Low dose macrolide - MAC/AFB
- IVIG
Daytime sleepiness ddx (6)
- Not enough sleep
- Poor adjustment to shift work
- Use of sedative + stimulant drugs
- Depression w/without early morning waking
- Idiopathic hypersomnolence
- Narcolepsy
Pulmonary Rehab (3)
- Exercise training
- Nutrition
- Counselling
*2x/week, 2hrs at a time, 8 weeks/yr - needs to be done annually
Lung transplant indications (5)
- ILD - IPF and non-IPF
- COPD
- CF
- Pulmonary vascular disease
- Re-Tx for chronic lung allograft dysfunction
Asthma discussion (6)
- Confirm Dx
- Control - previous ICU/ETT
- Inhaler technique/adherence to Rx
- Action plan
- Triggers
*Impact on life/time off work
Asthma biologics (2)
- Allergic - Omalizumab (IgE)
- Eosinophlic - Mepoluzimab - Anti-IL5
*Decreases smooth muscle mass in A, increases QOL, decreases exacerbations
ILD Rx (6)
- Pul rehab
- LTOTx
- Vaccination
- Lung tx
- Anti-fibrotic meds - decrease rate of decline - Nintenadnib - BD, SE GI upset/dLFTs, Pirfinidone - 9-12 tabs/day!, SE photosensitivity rash
- ACP/Pal care
OSA driving:
- CPAP 4-5hrs per night
- AHI <5
OSA management (5)
- LOW
- No ETOH
- CPAP
- Splint
- Surgery
COPD management (7)
- Inhaler, technique
- Vaccination
- Smoking cessation
- Action plan
- Long term Oxygen
- Anxiety Rx
- Pulmonary Rehab
Improve asthma control (3)
- Check inhaler technique and minimise triggers
- R/v previous asthma phenotype and Ax candidacy for biologic Rx
- Ensure non-asthma causes of breathlessness are exluded
In more detail…
COPD general (7)
- Baseline Sx and reliever use
- Lung fn (FEV1 proportional to Sx and prognosis), previous chest imaging
- Exacerbation freq, hospitalisation, ICU admission
- Smoking cessation
- Inhaler technique
- Cx of Rx - Pred
- Preventative measures - vaccination, exercise, pul rehab
COPD basics (5)
- Avoidance of RFs - smoking
- Infection: vaccination, masks, hand hygiene
- Regular physical activity
- Inhalers - LAMA, adherence, technique
- Pul Rehab 8/52 per year
*ICS decreases exacerbations by 25% but SE: CAP
COPD Adv Rx (5)
- Frequent exacerbations, high sputum: ICS, LT Abx - macrolide, doxycycline
- Chronic hypoxia - ABG - home O2 if pO2 <55 or <60 w pul HTN
- Vent failure - ABG is hypercapnic, may be candidate for home NIV
- Hyperinflated? LVRS or bronchoscopic LVR, endobronch valve to shrink lung
- If young, consider LTx
Refractory SOB (3)
- O2
- Opioids, anxiolytics
- Rehab - recondition - pul rehab, breathing techniques to avoid gas trapping
