Respiratory Flashcards
What are some indication for VATS procedure?
wedge resection/segmentectomy
lobectomy
decortication
bullectomy
tx of recurrent pneumothorax
What are the benefits of video-assisted thoracoscopic surgery over open
thoracotomy?
Smaller incision so less:
pain
wound complications
healing time
length of stay
What are the possible indications for a lobectomy?
Lung ca
Aspergilloma
Tuberculosis
Lung abcess
How would you Ix ?lung ca, after CXR?
staging CT TAP
Tissue diagnosis - bronch/EBUS/CT guided biopsy
If curative - PET
How would you work up a patient for lung surgery?
hx and exam
PFTs inc transfer factor
cardiopulmonary exercise testing
When performing a lobectomy, what FEV1 would you want the patient to have?
FEV1 at least 1.5
When performing a pneumonectomy, what FEV1 would you want the patient to have?
FEV1 2
Do you know of a VO2 max threshold which offers a better post- operative
prognosis for the patient?
at least 15mg/kg/min
Tell me about the different histological cell types of lung cancer
- SCLC 20%
- NSCLC (adenocarcinoma, SCC, broncheolar carcinoma, large cell carcinoma, neuro endocrine)
most common: SCC, then adenocarcinoma
What’s the treatment for SCLC?
rarely operable
limited disease - chemo/radio
late disease - palliative chemo
What’s the treatment for Non SCLC?
curative surgery/radical radiotherapy for early disease
chemo/molecular therapies if more advanced
If VATS had been done recently what would you expect?
Tracheal deviation towards side
Reduced air entry
Reasons for bilateral lung surgery
Bilateral apical pleurectomies for recurrent pneumothoraces
Lung volume reduction eg bullectomy
TB
What inhalers can you use for COPD?
short acting beta - salbutamol
short acting mucs - ipratropium
long acting beta - salmeterol
long acting musc - tioptropium
Clinical findings for pneumonectomy vs lobectomy?
Pneumo
- trache deviated
- absent breath sounds
- dull percussion
Lobe
- trache might/not be deviated
- breath sounds normal/reduced
- percussion normal
What are the respiratory causes of clubbing?
ILD
CF
Lung abscess
Bronchiectasis
Lung ca
Whats the difference between primary and secondary pneumothorax?
Primary - spontaenous in otherwise healthy person
Seconday - some form of ILD
What the initial management of breathless primary spontaneous pneumothorax?
ABCDE, rapid escalation, senior help
Try to aspirate up to 2.5l litres
If stops being breathless or residual <2.5cm - home w OP FU
If not drain
<2cm and asx - conservative with early FU
Is there any role for suction in the management of a pneumothorax?
Rarely used due to risk of re-expansion pulmonary edema
High volume, low pressure recommended
Management of patients with on-going air leak or recurrent pneumothoraces
Talc pleuradhesis/pleurectomy
Bullectomy
Surgery/VATS
VATS has 5% chance of recurring pneumothorax vs 1% for open surgery
Differentials for normal chest exam apart from scars
- *Wedge resection** - pulmonary nodule
- *Lung biopsy**
- *Pneumothorax** -Surgical tx/non resolving/recurrent
- *Lobectomy** - long time ago
How would you investigate a patient with asthma?
Baseline obs inc sats
Bloods inc CRP
ABG
Skin prick/RAST
CXR
PF
Spirometry
What would you look for in FBC for asthma?
WCC - infection/steroids
Eosinophilia
IgE also important
Relevance of PF in asthma
Diurnal variation shows not well controlled
Reduction early morning
How might a spirometry in an asthma patient differ than in a patient with chronic
obstructive pulmonary disease?
COPD - obstructive spirometry, reduced FEV1 preserved FEC, reduced FEV1FVC ratio
asthma is reversible obstruction (whereas COPD is fixed), should show improvement following bronchodilator by 200ml PF or 15%
How do you treat asthma?
BTS guidelines
1st - SABA
2nd - inhaled steroid
3rd - LABA
4th - LRA
What are some causes of air flow obstruction?
Bronchiectasis
COPD
Obliterative bronciolitis
What does polyphonic wheeze indicate?
Airflow obstruction
Causes of wheeze?
Asthma
COPD
Pulmonary edema
What is obliterative bronchiolitis?
Fixed airflow obstruction
Secondary to viral infection, polutants or following stem cell transplantations or GvsH
What’s the definition of reversible airflow obstruction?
significant change in either FEV1 or peak expiratory flow rate, in response to a short acting beta-agonist
200ml or 15% change
uncontrolled asthmatics tend to have >400ml change
Differentials of bibasal inspiratory creps?
Bronchiectasis (coarse, clear on coughing)
B/L pneumonias
CCF (elevated JVP, peripheral edema)
Investigations for ILD?
Obs inc sats
FBC - anaemia, infection U+Es, LFTS - MEDS
Autoimmune - RF, dsDNA, ANA, ACNA
RAST/allergens/av avian precipitans
ABG
CXR
HRCT - honeycombing (fibrosis), groundglass - alveolitis
Echo - Right sided heart strain/failure, PHTN
Spirometry
BAL/lung biopsy
What are the typical lung function characteristics associated with pulmonary fibrosis?
spirometry tests - restrictive pattern
reduction in the FEV1 and FEC,a preserved ratio
reduced total lung capacity
reduced transfer factor.
How do you treat ILD?
MDT
Physio, OT, resp nurses
if tx connective tissue disorder DMARD
groundglass might be steroid response
idiopathic pulmonary fibrosis - anti fibrotic agent e.g pirfenidone
Cuases of lower zone fibrosis
SAB IPM
Systemic sclerosis/RA/SLE
Alpha 1 anti tryspin, ABPA
Bronchiectasis
Infection
Medications - bleomycin, nitro, hydralazine, methrotrexate, amiodarone
Clubbing + >50 suggests IPF
Causes of apical fibrosis
(CASH RAT)
Silicosis
Coal workers pneumoconiosis
Histiocytosis
Ank spond
ABPA
Radiation
TB
What’s next line if Ix suggest pulmonary fiborsis?
FVC <80% refer to tertiary care for pirfenidone/nintedanib
Then MDT ax, surgeons ?lung transplant
Substance exposure that can cause ILD
Asbestos
Radiotherapy
Siclia/berylium
Birds
Amiodarone/methotrexate
Examples of idiopathic interstitial pneumoniae
desquamative interstitial pneumonia
respiratory bronchiolitis interstitial lung disease (RB-ILD)
acute interstitial pneumonia (AIP)
nonspecific interstitial pneumonia (NSIP).
Examination findings suggesting CF
Coarse crackles loudest in upper zone - broncheictasis
Portacath scar chest/axilla
Clubbing
PEG
O2
Signs of CF
Whats the cause of cystic fibrosis?
Auto recessive mutaton in CFTR
Increased salt excretion causing thicker mucus
affects rep, disgestive tract, reproductive system
Features of CF
Multi system disease
bronchiectasis
pancreatic insufficiency - Creon + fat soluble vitamins
Liver - cholestasis, gallstones, cirrhosis, liver failure
Kidney stones
Reproductive issues
How you would manage someone with cystic fibrosis?
MDT, speciailist centre
Physio - postural drainage, enhanced breathing techniques to clear mucus from chest
Dieticians - supplements, gastrostomy
Regular nebs - muclotyics, nebulised ABx prophylaxis, recombinant DNAse, hypertonic saline
ABx PO azithromycin, regular IV ABx 2/52 course
Pancreas - Creon, vitamins, high calorie diets
Gene therapies under development
Explain the microbiology of cystic fibrosis lung disease.
most common Pseudomonas aeruginosa
Burkholderia cenocepacia and mycobacterium abscessuspoor prognosisabsolutecontraindicationto lungtransplantation.
Explain the genetics of CFTR
autosomal recessive
genetic mutation chromosome 7 in production of defective CFTR
Lots of different mutations, most common in UK is DeltaF508 now known as Ph508del 508 deletion
50% of UK are homozygous
Describe the nutritional issues in CF
Pancreatic insufficiency
catabolic state due to chornic infection leading to high calorie requirements
often low BMI + signs of supplemental feeding
CF patient can have button PEG tube which lies flush with skin so less detectable
Also CF related diabetes
Non resp features of CF
CF liver disease - PHTN, Hypersplenism
Osteopaenia/porosis, low impact fractures eg coughing
Infertility - absent vas deferns men
Sinus disease/nasal polyps
Constipation/meconium, distal intestinal obstruction
Gallstones, kidney stones
Respiratory complications of CF
ABPA
Pneumothoraces
Bronchiectasis
Haemopytsis - may require bronchial artery embolisation
How is CF diagnosed?
All newborns tested as part of Guithrie
Immunoreactive trypsin levels via heelprick - if raised CF suspected
then screened for most common CTFR mutations +
sweat test - abnormally high chrloide content >60mmol
What does a clam shell scar indicate?
Double lung transplant
Likely accompanied with:
inter costal drain scars
trache scars
centrail line scars
hand tremor - transplant meds
clubbing ?fibrosis ?bronchiectasis
How can you tell from examination if lung transplant is working well?
If not working:
Supplemental O2
Cyanosis
What are the most common indications for lung transplant?
CF
Bronchiectasis
pulmonary vascular disease
pulmonary fibrosis
COPD (single lung)
What would be the usual indications to a double lung transplant, and why would you do a double over a single transplantation?
Double transplant prognosis is better
CF and bronchiectasis usually have double,
plus some pulmonary vascular and PF
medications used in lung transplantation
Usually combo:
tacrolimus + mycophenolate/azothioprine + steroid
cyclosporin was used but now less as causes renal impairment
Can you tell me about complications of lung transplantation?
Acute - hyper acute rejection, opportunistic infection (Causing damage to transplant)
Becomes progressively more susecptible to broncilitis obliterans over time, eventually causes resp failure and death
Do you know of any contraindications to lung transplantation?
- malignancies within the last five years
- v high or low BMIs
- smoking or using illicit drugs
- mental health conditions won’t take medications on a regular basis/ regularly turn up to clinic appointments.
severe atherosclerotic disease, infection, poor functional status, no social support
Scars that indicate lung transplant
Clamshell - double
Median sternotomy and/or lateral thoracotomy - single lung/heart
Drains
Central line
trache
Criteria for lung transplant
- > 50% risk death from lung disease within two years if transplant is not performed
- > 80% likelihood of surviving at least 90 days post-transplant
- > 80% likelihood of a 5-year post-transplant survival from a general medical perspective provided there is adequate graft function.
Median surival is around 6 years, worse in COPD and PF
i.e sick enough to need transplant but well enough for it to work
What’s the main cause of chronic lung transplant rejection?
Bronchilitis obliterans
+ infection, malignancy (lymphoproliferative, skin
Complications of immuno suppresion
Malignancy - lymphoproliferative, skin
Steroids - DM, osteoporosis, skin thinning, cushings
Tarcolimus - tremor
ABx and anti rejection meds - hearing and renal impairment
When to refer for lung transplant
All UIP or fibrotic NSIP
otherwise FVC <80%
transfer factor <40%
CF
Which COPD patients benefit most from lung transplant
BODOE >6 (COPD survival score)
(SOB, FEV, ET, BMI)
Yellow nail syndrome - discolored, hypertrophie, thickened
Possible examination findings of yellow nail syndrome
Creps clear with coughing - bornchiectasis
Dystrophied, thickened discolored nails
Wheeze, productive cough
Long term venous access
Cor pulmonale
Pleural effusion
Lymphedema
Ix for bronchiectasis
Routine bloods
HIV/immunoglobulins
Aspergillous serology
CF if <40
sputum culture
PFTs
CXR
HRCT
Management of bronchiectasis
Physio - postural drainage
Nebs - hypertonic saline, sometimes neds eg psuedomonas
Long term ABx - azithromycin
2 weeks of ABx guided by sputum MCS
PEEP
Flu +pneumococcal vax
carbocisteiene
Surgcial if severe despite max med rx
Causes of bronchiectasis
Immunodeficiency
Connective tissue eg RA
IBD
Lobar pneumonia
pulmonary TB
fungal mould eg ABPA
If you had a patient in whom you suspected bronchiectasis, what sort of questions would you ask in their clinical history?
Chest pain
Cough - ?productive ?volume of sputum ?number of infections/year, SOB/wheeze, haemopytsis
GI sx (IBD)
joint pain/swellings
travel ?TB
prev severe chect infection eg pertusiss, TB
CF - steotorrhae, BMI, fertility (also cilliary dyskinesia, nasal biopsy)
Examination findings to look for ax conditions in bronchiectasis
IBD (abdo scars)
RA joints
Clubbing eg CF
If you had a suspected a patient had lung cancer how would you proceed with investigations?
Bloods:
- FBC - anaemia
- CRP - infection/malignancy
- LFTs - liver mets, future tx
- U+Es - hyponatraemia SLCL, future tx
- clotting ?intervention
Spirometry ?lung function/futness for surgery
Sputum
CXR
staging CT
CT TAP
If you only have a CT scan and that looks like the patient has lung cancer. How would you then proceed?
The next step would be trying to identify a tissue diagnosiS via:
o bronchoscopy
o ultrasound-guided bronchoscopy
o percutaneously via a radiologist.
+ lymph nodes, pleural effusion if curative PET CT
How might someone present if they have lung cancer?
- persistent cough +- haemoptysis
- weight loss
- voice change
- SVCO - face.arm swelling, distended veins
- thirst/bone pain/confusion
- collapse/effusion +-trachea deviated, reduced percussion
- monophonic wheeze from tumour
- Horners if apical
Hypertrophic Pulmonary Osteoarthropathy
HPOA
Cause of hypercalaemia in lung Ca
bone mets
ectopic PTH secretion
Management of lung ca patients with stage 4 disease
Usually palliative
If NSCLC molecular therapies
Hormonal issues ax with SCLC
Lambert Eaton
SIADH
ectopic ACTH
wasting small muscles of hands
Causes of exduative pleural effusion (ie no other signs of overload)
- parapneumonic effusions
- lung infarction eg from PE
- lung malignancy
- connective tissue disorders eg RA
PE, lymphoma, vasculitis
Causes of transudative effusions (ie with overload)
CCF
Liver failure
CKD
Hypoalbuminaemia
PE, myoxedma, periotneal dialysis
How do you tell between a transudative and exudative effusion?
Lights criteria
- Pleural/serum protein is >0.5
- Pleral/serum LDH >0.6
- Pleural LDH greater than 2/3 upper limit of normal serum LDH
What would you want to test for in pleural fluid sample?
- pH
- MCS
- cell count
- cytology
- glucose
- triglyceride
AFB ?TB
(e.g RA or chylous effusion
Indications for drainage of pleural effusion?
If pH >7.2/frank pus/culture positive/large and sx drain
If this patient had a pleural effusion secondary to a primary lung cancer. How would you manage that?
drain and then long term catheter
or pleuradhesis at bedisde or via thoracoscopy
What does low pleural glucose indicate?
Infection
Malignancy
Esophageal rupture
<1.6 RA
Causes of high glucose in pleural fluid
Pancreatits
What kind of lung cancer would require a lobectomy?
NSCLC if caught early
(SCLC is often disseminated and therefore not good for surgery)
Eligibility criteria for surgery for NSCLC?
patient preference, co morbidities etc
lobectomy needs FEV1 of > 1.5 litres
▪ pneumonectomy FEV1 of > 2 litres.
• Cardiopulmonary exercise testing >15 mls/kl/minute confers a better prognosis.
Most common cancer in smokers
Squamous cell
Postero lateral thoractomy scar - pneumonectomy
Reason for pneumonectomy >lobectomy in NSCLC
involves both the upper and lower lobe/
tumour particularly central excision of just one lobe not possible
Anterior mediastinotmy - Chamberlain prodecture scare
to access aortic arch, lymph nodes, mediastinal mass etc
VATS
ports + anterolateral
What questions would you ask to try and find out underlying cause of ILD?
Asbestos
Meds - amiodarone, methotrexate, nitro, chemo eg bleomycin
connective tissue/RA
back probs 0 ank spond
What drug treatments are used for interstitial lung disease?
• IPF:
pirfenidone o nintedanib.
For patients with non-specific interstitial pneumonia: o Steroids o Immunosuppressive therapy.
Signs of PHTN or cor pulmonale on examination
RVH
raised JVP
SOB
edema
loud s2
What tests would you do to Ix SOB with normal examination?
FBC/U+eS/LFTS/TFTS/
CXR/ECG
Auto immune/vasculitic screen
CTPA
hrct
PFTS inc transfer factor
ABG
Sleep studies
Differentials of SOB with normal examination
Anaemia
Ca
Obesity hypoventiliation syndrome
Hyperventiliation
What would you expect the arterial blood gas findings to be in someone with obesity hypoventilation?
T2RF
What are the usual spirometric findings in someone with Chronic Obstructive Pulmonary Disease?
Obstuctive
FEV2/FVC ratio <0.7
How would you classify the severity of Chronic Obstructive Pulmonary Disease via Spirometry?
FEV1 vs predicted
- >80% predicted mild
- 50-80% moderate
- 30-50% severe
- <30% very severe
What is cor pulmonale?
Right sided heart failure secondary to resp disdease
in chronically hypoxic patients
chronic hypoxia causes pulmonary vasocontriction causing PHTN then Right sided heart failure
Rx of cor pulmonale
LTOT (reduces the pulmonary vasoconstriction)
Diuretics
What is LTOT?
• Long term oxygen therapy is classically oxygen which is given for at least 16 hours a day in order to treat patients who are chronically hypoxic, to reduce the risk of Cor Pulmonale.
LTOT Indications
- Non‐smoker
- PaO2 <7.3kPa on air
- PaCO2 that does not rise excessively on O2
7.3-8 if:
• secondary polycythaemia
• pulmonary hypertension
• peripheral oedema
