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Respiratory Flashcards

1
Q

What are some indication for VATS procedure?

A

wedge resection/segmentectomy
lobectomy
decortication
bullectomy
tx of recurrent pneumothorax

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2
Q

What are the benefits of video-assisted thoracoscopic surgery over open
thoracotomy?

A

Smaller incision so less:
pain
wound complications
healing time
length of stay

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3
Q

What are the possible indications for a lobectomy?

A

Lung ca
Aspergilloma
Tuberculosis
Lung abcess

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4
Q

How would you Ix ?lung ca, after CXR?

A

staging CT TAP
Tissue diagnosis - bronch/EBUS/CT guided biopsy
If curative - PET

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5
Q

How would you work up a patient for lung surgery?

A

hx and exam
PFTs inc transfer factor
cardiopulmonary exercise testing

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6
Q

When performing a lobectomy, what FEV1 would you want the patient to have?

A

FEV1 at least 1.5

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7
Q

When performing a pneumonectomy, what FEV1 would you want the patient to have?

A

FEV1 2

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8
Q

Do you know of a VO2 max threshold which offers a better post- operative
prognosis for the patient?

A

at least 15mg/kg/min

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9
Q

Tell me about the different histological cell types of lung cancer

A
  • SCLC 20%
  • NSCLC (adenocarcinoma, SCC, broncheolar carcinoma, large cell carcinoma, neuro endocrine)

most common: SCC, then adenocarcinoma

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10
Q

What’s the treatment for SCLC?

A

rarely operable
limited disease - chemo/radio
late disease - palliative chemo

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11
Q

What’s the treatment for Non SCLC?

A

curative surgery/radical radiotherapy for early disease
chemo/molecular therapies if more advanced

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12
Q

If VATS had been done recently what would you expect?

A

Tracheal deviation towards side
Reduced air entry

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13
Q

Reasons for bilateral lung surgery

A

Bilateral apical pleurectomies for recurrent pneumothoraces
Lung volume reduction eg bullectomy
TB

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14
Q

What inhalers can you use for COPD?

A

short acting beta - salbutamol
short acting mucs - ipratropium
long acting beta - salmeterol
long acting musc - tioptropium

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15
Q

Clinical findings for pneumonectomy vs lobectomy?

A

Pneumo
- trache deviated
- absent breath sounds
- dull percussion
Lobe
- trache might/not be deviated
- breath sounds normal/reduced
- percussion normal

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16
Q

What are the respiratory causes of clubbing?

A

ILD
CF
Lung abscess
Bronchiectasis
Lung ca

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17
Q

Whats the difference between primary and secondary pneumothorax?

A

Primary - spontaenous in otherwise healthy person
Seconday - some form of ILD

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18
Q

What the initial management of breathless primary spontaneous pneumothorax?

A

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

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19
Q

Is there any role for suction in the management of a pneumothorax?

A

Rarely used due to risk of re-expansion pulmonary edema
High volume, low pressure recommended

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20
Q

Management of patients with on-going air leak or recurrent pneumothoraces

A

Talc pleuradhesis/pleurectomy
Bullectomy
Surgery/VATS
VATS has 5% chance of recurring pneumothorax vs 1% for open surgery

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21
Q

Differentials for normal chest exam apart from scars

A
  • *Wedge resection** - pulmonary nodule
  • *Lung biopsy**
  • *Pneumothorax** -Surgical tx/non resolving/recurrent
  • *Lobectomy** - long time ago
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22
Q

How would you investigate a patient with asthma?

A

Baseline obs inc sats
Bloods inc CRP
ABG
Skin prick/RAST
CXR
PF
Spirometry

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23
Q

What would you look for in FBC for asthma?

A

WCC - infection/steroids
Eosinophilia

IgE also important

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24
Q

Relevance of PF in asthma

A

Diurnal variation shows not well controlled
Reduction early morning

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25
Q

How might a spirometry in an asthma patient differ than in a patient with chronic
obstructive pulmonary disease?

A

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%

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26
Q

How do you treat asthma?

A

BTS guidelines
1st - SABA
2nd - inhaled steroid
3rd - LABA
4th - LRA

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27
Q

What are some causes of air flow obstruction?

A

Bronchiectasis

COPD

Obliterative bronciolitis

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28
Q

What does polyphonic wheeze indicate?

A

Airflow obstruction

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29
Q

Causes of wheeze?

A

Asthma

COPD

Pulmonary edema

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30
Q

What is obliterative bronchiolitis?

A

Fixed airflow obstruction

Secondary to viral infection, polutants or following stem cell transplantations or GvsH

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31
Q

What’s the definition of reversible airflow obstruction?

A

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

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32
Q

Differentials of bibasal inspiratory creps?

A

Bronchiectasis (coarse, clear on coughing)

B/L pneumonias

CCF (elevated JVP, peripheral edema)

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33
Q

Investigations for ILD?

A

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

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34
Q

What are the typical lung function characteristics associated with pulmonary fibrosis?

A

spirometry tests - restrictive pattern

reduction in the FEV1 and FEC,a preserved ratio

reduced total lung capacity

reduced transfer factor.

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35
Q

How do you treat ILD?

A

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

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36
Q

Cuases of lower zone fibrosis

SAB IPM

A

Systemic sclerosis/RA/SLE

Alpha 1 anti tryspin, ABPA

Bronchiectasis

Infection

Medications - bleomycin, nitro, hydralazine, methrotrexate, amiodarone

Clubbing + >50 suggests IPF

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37
Q

Causes of apical fibrosis

(CASH RAT)

A

Silicosis

Coal workers pneumoconiosis

Histiocytosis

Ank spond

ABPA

Radiation

TB

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38
Q

What’s next line if Ix suggest pulmonary fiborsis?

A

FVC <80% refer to tertiary care for pirfenidone/nintedanib

Then MDT ax, surgeons ?lung transplant

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39
Q

Substance exposure that can cause ILD

A

Asbestos

Radiotherapy

Siclia/berylium

Birds

Amiodarone/methotrexate

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40
Q

Examples of idiopathic interstitial pneumoniae

A

desquamative interstitial pneumonia

respiratory bronchiolitis interstitial lung disease (RB-ILD)

acute interstitial pneumonia (AIP)

nonspecific interstitial pneumonia (NSIP).

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41
Q

Examination findings suggesting CF

A

Coarse crackles loudest in upper zone - broncheictasis

Portacath scar chest/axilla

Clubbing

PEG

O2

Signs of CF

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42
Q

Whats the cause of cystic fibrosis?

A

Auto recessive mutaton in CFTR

Increased salt excretion causing thicker mucus

affects rep, disgestive tract, reproductive system

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43
Q

Features of CF

A

Multi system disease

bronchiectasis

pancreatic insufficiency - Creon + fat soluble vitamins

Liver - cholestasis, gallstones, cirrhosis, liver failure

Kidney stones

Reproductive issues

44
Q

How you would manage someone with cystic fibrosis?

A

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

45
Q

Explain the microbiology of cystic fibrosis lung disease.

A

most common Pseudomonas aeruginosa

Burkholderia cenocepacia and mycobacterium abscessuspoor prognosisabsolutecontraindicationto lungtransplantation.

46
Q

Explain the genetics of CFTR

A

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

47
Q

Describe the nutritional issues in CF

A

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

48
Q

Non resp features of CF

A

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

49
Q

Respiratory complications of CF

A

ABPA

Pneumothoraces

Bronchiectasis

Haemopytsis - may require bronchial artery embolisation

50
Q

How is CF diagnosed?

A

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

51
Q
A
52
Q

What does a clam shell scar indicate?

A

Double lung transplant

Likely accompanied with:

inter costal drain scars

trache scars

centrail line scars

hand tremor - transplant meds

clubbing ?fibrosis ?bronchiectasis

53
Q

How can you tell from examination if lung transplant is working well?

A

If not working:

Supplemental O2

Cyanosis

54
Q

What are the most common indications for lung transplant?

A

CF

Bronchiectasis

pulmonary vascular disease

pulmonary fibrosis

COPD (single lung)

55
Q

What would be the usual indications to a double lung transplant, and why would you do a double over a single transplantation?

A

Double transplant prognosis is better

CF and bronchiectasis usually have double,

plus some pulmonary vascular and PF

56
Q

medications used in lung transplantation

A

Usually combo:

tacrolimus + mycophenolate/azothioprine + steroid

cyclosporin was used but now less as causes renal impairment

57
Q

Can you tell me about complications of lung transplantation?

A

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

58
Q

Do you know of any contraindications to lung transplantation?

A
  • 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

59
Q

Scars that indicate lung transplant

A

Clamshell - double

Median sternotomy and/or lateral thoracotomy - single lung/heart

Drains

Central line

trache

60
Q

Criteria for lung transplant

A
  1. > 50% risk death from lung disease within two years if transplant is not performed
  2. > 80% likelihood of surviving at least 90 days post-transplant
  3. > 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

61
Q

What’s the main cause of chronic lung transplant rejection?

A

Bronchilitis obliterans

+ infection, malignancy (lymphoproliferative, skin

62
Q

Complications of immuno suppresion

A

Malignancy - lymphoproliferative, skin

Steroids - DM, osteoporosis, skin thinning, cushings

Tarcolimus - tremor

ABx and anti rejection meds - hearing and renal impairment

63
Q

When to refer for lung transplant

A

All UIP or fibrotic NSIP

otherwise FVC <80%

transfer factor <40%

CF

64
Q

Which COPD patients benefit most from lung transplant

A

BODOE >6 (COPD survival score)

(SOB, FEV, ET, BMI)

65
Q
A

Yellow nail syndrome - discolored, hypertrophie, thickened

66
Q

Possible examination findings of yellow nail syndrome

A

Creps clear with coughing - bornchiectasis

Dystrophied, thickened discolored nails

Wheeze, productive cough

Long term venous access

Cor pulmonale

Pleural effusion

Lymphedema

67
Q

Ix for bronchiectasis

A

Routine bloods

HIV/immunoglobulins

Aspergillous serology

CF if <40

sputum culture

PFTs

CXR

HRCT

68
Q

Management of bronchiectasis

A

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

69
Q

Causes of bronchiectasis

A

Immunodeficiency

Connective tissue eg RA

IBD

Lobar pneumonia

pulmonary TB

fungal mould eg ABPA

70
Q

If you had a patient in whom you suspected bronchiectasis, what sort of questions would you ask in their clinical history?

A

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)

71
Q

Examination findings to look for ax conditions in bronchiectasis

A

IBD (abdo scars)

RA joints

Clubbing eg CF

72
Q

If you had a suspected a patient had lung cancer how would you proceed with investigations?

A

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

73
Q

If you only have a CT scan and that looks like the patient has lung cancer. How would you then proceed?

A

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

74
Q

How might someone present if they have lung cancer?

A
  • 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
75
Q
A

Hypertrophic Pulmonary Osteoarthropathy

HPOA

76
Q

Cause of hypercalaemia in lung Ca

A

bone mets

ectopic PTH secretion

77
Q

Management of lung ca patients with stage 4 disease

A

Usually palliative

If NSCLC molecular therapies

78
Q

Hormonal issues ax with SCLC

A

Lambert Eaton

SIADH

ectopic ACTH

79
Q
A

wasting small muscles of hands

80
Q

Causes of exduative pleural effusion (ie no other signs of overload)

A
  • parapneumonic effusions
  • lung infarction eg from PE
  • lung malignancy
  • connective tissue disorders eg RA

PE, lymphoma, vasculitis

81
Q

Causes of transudative effusions (ie with overload)

A

CCF

Liver failure

CKD

Hypoalbuminaemia

PE, myoxedma, periotneal dialysis

82
Q

How do you tell between a transudative and exudative effusion?

A

Lights criteria

  1. Pleural/serum protein is >0.5
  2. Pleral/serum LDH >0.6
  3. Pleural LDH greater than 2/3 upper limit of normal serum LDH
83
Q

What would you want to test for in pleural fluid sample?

A
  • pH
  • MCS
  • cell count
  • cytology
  • glucose
  • triglyceride

AFB ?TB

(e.g RA or chylous effusion

84
Q

Indications for drainage of pleural effusion?

A

If pH >7.2/frank pus/culture positive/large and sx drain

85
Q

If this patient had a pleural effusion secondary to a primary lung cancer. How would you manage that?

A

drain and then long term catheter

or pleuradhesis at bedisde or via thoracoscopy

86
Q

What does low pleural glucose indicate?

A

Infection

Malignancy

Esophageal rupture

<1.6 RA

87
Q

Causes of high glucose in pleural fluid

A

Pancreatits

88
Q

What kind of lung cancer would require a lobectomy?

A

NSCLC if caught early

(SCLC is often disseminated and therefore not good for surgery)

89
Q

Eligibility criteria for surgery for NSCLC?

A

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.

90
Q

Most common cancer in smokers

A

Squamous cell

91
Q
A

Postero lateral thoractomy scar - pneumonectomy

92
Q

Reason for pneumonectomy >lobectomy in NSCLC

A

involves both the upper and lower lobe/

tumour particularly central excision of just one lobe not possible

93
Q
A

Anterior mediastinotmy - Chamberlain prodecture scare

to access aortic arch, lymph nodes, mediastinal mass etc

94
Q
A

VATS

ports + anterolateral

95
Q

What questions would you ask to try and find out underlying cause of ILD?

A

Asbestos

Meds - amiodarone, methotrexate, nitro, chemo eg bleomycin

connective tissue/RA

back probs 0 ank spond

96
Q

What drug treatments are used for interstitial lung disease?

A

• IPF:

pirfenidone o nintedanib.

For patients with non-specific interstitial pneumonia: o Steroids o Immunosuppressive therapy.

97
Q

Signs of PHTN or cor pulmonale on examination

A

RVH

raised JVP

SOB

edema

loud s2

98
Q

What tests would you do to Ix SOB with normal examination?

A

FBC/U+eS/LFTS/TFTS/

CXR/ECG

Auto immune/vasculitic screen

CTPA

hrct

PFTS inc transfer factor

ABG

Sleep studies

99
Q

Differentials of SOB with normal examination

A

Anaemia

Ca

Obesity hypoventiliation syndrome

Hyperventiliation

100
Q

What would you expect the arterial blood gas findings to be in someone with obesity hypoventilation?

A

T2RF

101
Q

What are the usual spirometric findings in someone with Chronic Obstructive Pulmonary Disease?

A

Obstuctive

FEV2/FVC ratio <0.7

102
Q

How would you classify the severity of Chronic Obstructive Pulmonary Disease via Spirometry?

A

FEV1 vs predicted

  1. >80% predicted mild
  2. 50-80% moderate
  3. 30-50% severe
  4. <30% very severe
103
Q

What is cor pulmonale?

A

Right sided heart failure secondary to resp disdease

in chronically hypoxic patients

chronic hypoxia causes pulmonary vasocontriction causing PHTN then Right sided heart failure

104
Q

Rx of cor pulmonale

A

LTOT (reduces the pulmonary vasoconstriction)

Diuretics

105
Q

What is LTOT?

A

• 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.

106
Q

LTOT Indications

A
  • 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

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