Respiratory Flashcards
What are the clinical signs of pulmonary fibrosis?
Clubbing Central cyanosis Fine end inspiratory crackles Signs of associated autoimmune disease Signs of steroid treatment Discoloured skin secondary to amiodarone
How would you investigate a patient with suspected pulmonary fibrosis?
Bloods - ESR, rheumatoid factor, eosinophils
CXR - reticulonodular changes, loss of definition of heart border, small lungs
ABG - type 1 respiratory failure
Lung function tests - FEV1/FVC > 0.8 (restrictive), low total lung capacity, reduced transfer factors
Bronchoalveolar lavage to exclude infection prior to starting treatment
High resolution CT scan
Lung biopsy
What is the treatment of pulmonary fibrosis?
Immunosuppression if inflammatory
Pirfenidone for usual interstitial pneumonia when FEV1 50-80% predicted
N-acetylcysteine
Single lung transplantation
What is the prognosis of pulmonary fibrosis?
Variable as depends on aetiology
Increased risk of bronchogenic carcinoma
Highly cellular with ground glass infiltrates and responds to immunosuppression has 80% 5 year survival
Honeycombing with no response to immunosuppression has 80% 5 year mortality
What are the causes of basal fibrosis?
Usual interstitial pneumonia
Asbestosis
Rheumatoid arthritis
Aspiration
What are the causes of an apical fibrosis?
Substances: Berylliosis, pneumoconiosis, sillicosis, radiation
Infective/immune: Extrinsic allergic alveolitis, Allergic bronchopulmonary aspergillosis, TB
Sarcoidosis
Ankylosing spondylitis
Psoriasis
What are the respiratory causes of clubbing?
Interstitial lung disease Cancer Mesothelioma Bronchiectasis Cystic fibrosis Lung abscess Empyema Tuberculosis
What are the clinical signs of bronchiectasis?
Cachexia Clubbing Crackles that alter with coughing High sputum load Cor pulmonale Yellow nail syndrome
How would you investigate a patient with suspected bronchiectasis?
Sputum culture and cytology
CXR - tramlines and ring shadows
High resolution CT - signet ring sign
Immunoglobulins Aspergillus RAST Rheumatoid serology Saccharine ciliary motility Genetic screening
What are the causes of bronchiectasis?
Congenital - Kartagener’s and cystic fibrosis
Childhood infection - measles and TB
Immune over activity - ABPA, inflammatory bowel disease
Immune under activity - hypogammaglobulinaemia, common variable immunodeficiency
Aspiration
How would you manage a patient with bronchiectasis?
Physiotherapy
Prompt antibiotics for infections
Low dose azithromycin prophylaxis
Bronchodilators and inhaled corticosteroids
Surgery may be used for localised disease
Ensure up to date vaccinations
Long term oxygen therapy in advanced cases
Lung transplantation in cystic fibrosis
What are the possible complications of bronchiectasis?
Sepsis
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis due to mycotic aneurysm
What are the most common pathogens in patients with bronchiectasis?
Staphylococcus aureus Haemophillus influenzae Pseudomonas Streptococcus pneumoniae Klebsiella Aspergillus
Explain the pathophysiology of cystic fibrosis
Autosomal recessive condition that occurs in 1 in 2500
Defect in chromosome 7 that encodes the CFTR gene
Respiratory manifestations - nasal polyps, bronchiectasis
GI - malabsorption, meconium ileus, gallstones
Non-erosive arthropathy and infertility
What are the side effects of tuberculosis medications?
Isoniazid - peripheral neuropathy, hepatitis
Rifampicin - hepatitis, enzyme inducer
Ethambutol - hepatitis, retro-bulbar neuritis
Pyrazinamide - hepatitis
What are the indications for a single lung transplantation?
COPD, pulmonary fibrosis
What are the indications for a double lung transplantation?
Cystic fibrosis
Bronchiectasis
Pulmonary hypertension
What are the clinical signs of COPD?
CO2 retention flap, bounding pulse Hyper- expanded chest Resonant percussion with loss of cardiac dullness Expiratory polyphonic wheeze Cor pulmonale
What are the causes of COPD?
Smoking
Industrial dust exposure
Alpha 1 antitrypsin deficiency
How would you investigate a patient with COPD?
CXR - hyperexpanded, pneumothorax ABG - type 2 respiratory failure Bloods - look for infection, alpha 1 antitrypsin Spirometry - low FEV1, FEV1/FVC <0.7 Reduced gas transfer factor
What is the treatment of COPD?
Smoking cessation is single most beneficial intervention Long term oxygen therapy Pulmonary rehabilitation Beta agonists Tiotropium Inhaled corticosteroids Vaccinations
What are the inclusion criteria for long term oxygen therapy?
Non smoker
PaO2 <7.3 on air (<8 if cor pulmonale)
PaCO2 that does not rise excessively on oxygen
Improves average survival by 9 months
What are the differential diagnoses of a wheezy chest?
COPD
Granulomatous polyangitis
Obliterative bronchiolotis
Rheumatoid arthritis
What are the clinical signs of a pleural effusion?
Asymmetrically reduced expansion Trachea deviated away from effusion Stony dull percussion Absent tactile vocal fremitus Reduced breath sounds
What are the causes of a pleural effusion?
Cancer Heart failure Liver failure Renal failure Connective tissue disease Infection
How would you differentiate between a transudative and an exudative effusion?
Transudate protein count <30
Exudate protein count >30
What would you look for in pleural aspiration?
Protein (compare effusion albumin and plasma albumin)
LDH
Glucose
pH
What is an empyema?
Collection of pus within the pleural space
Anaerobes, staphylococci and gram negative organisms most commonly
Associated with bronchial obstruction (cancer) and recurrent aspiration
How would you classify lung cancer?
Small cell and non-small cell
Squamous is the most common type, associated with smoking
Small cell more common in non-smokers
Small cell usually disseminated at presentation and therefore not amenable to radical surgical treatment
What are the treatment options for non-small cell lung cancer?
Surgery (lobectomy or pneumonectomy)
Radiotherapy
Chemotherapy
What is the definition of COPD?
Progressive and irreversible (or partially reversible) airflow obstruction due to chronic bronchitis and emphysema
What is the definition of chronic bronchitis?
Cough productive of sputum most days for 3 months during two consecutive years
What is the definition of emphysema?
Abnormal and permanent enlargement of air spaces distal to the terminal bronchioles associated with destruction of their walls without obvious fibrosis
What is the appearance and composition of normal pleural fluid?
Clear ultrafiltrate of plasma pH 7.6-7.64 Protein <1.2g/litre WCC <1000 LDH <50% of plasma concentration Glucose similar to plasma concentration
What are Light’s criteria for an exudate?
Pleural fluid protein:serum protein > 0.5
Pleural fluid LDH:serum LDH > 0.6
Pleural fluid LDH >2/3 of the upper limit of the normal serum value
What are the causes of high LDH in pleural fluid?
Empyema
Malignant effusion
Rheumatoid effusion
What are the causes of low glucose in a pleural effusion?
Malignancy Empyema Tuberculosis Oesophageal rupture Rheumatoid arthritis SLE
What are the indications for pleurodesis?
Recurrent malignant pleural effusion
Recurrent pneumothoraces
What agents can be used for chemical pleurodesis?
Talc Doxycycline Bleomycin Zinc sulphate Quinacrine hydrochloride
What is the most common type of non small cell lung cancer?
Adenocarcinoma (50%)
Squamous cell (30%)
Bronchoalveolar
Large cell (least common)
What are the endocrine paraneoplastic manifestations of lung cancer?
SIADH Cushing’s syndrome Hypercalcaemia Hyperthyroidism Hypoglycaemia
What are the neurological paraneoplastic manifestations of lung cancer?
Lambert-Eaton myasthenic syndrome
Sensory neuropathy
Limbic encephalopathy
What are the musculoskeletal paraneoplastic manifestations of lung cancer?
Polymyositis
Dermatomyositis
Clubbing
Hypertrophic pulmonary osteoarthropathy
What are the cutaneous paraneoplastic manifestations of lung cancer?
Acanthosis nigricans
Gynaecomastia
Thrombophlebitis
Herpes zoster
What are the possible indications for a lobectomy?
Bronchiectasis Malignancy Solitary pulmonary nodule Cystic fibrosis Tuberculosis Lung abscess
What are the possible indications for a pneumonectomy?
Bronchiectasis
Malignancy
Tuberculosis
What are the clinical features of old tuberculosis infection?
Apical fibrosis Thoracoplasty Pneumonectomy Lobectomy Phrenic nerve crush (left supraclavicular scar) Recurrent pneumothoraces
What is the prevalence of tuberculosis?
2 billion individuals worldwide, with 8 million new diagnoses every year
What are the risk factors for developing tuberculosis?
Immigrant population Immunocompromised Elderly patients Alcoholics Malnutrition Homeless individuals Occupational exposure
What are the acute complications of tuberculosis?
Respiratory: Pneumothorax, Pleural effusion, Empyema, Collapse, ARDS, respiratory failure
Tubulointerstitial nephritis
Tuberculous meningitis
Miliary TB
What are the chronic complications of tuberculosis?
Pulmonary fibrosis Bronchiectasis Cor pulmonale Aspergilloma Reactivation
How would you investigate a patient with suspected tuberculosis?
Blood tests including HIV serology
CXR: upper lobe cavitating lesion, mediastinal lymphadenopathy
Sputum: three samples, Ziehl-Neilson staining for acid-alcohol fast bacilli
CT scanning
Bronchoscopy
How would you treat pulmonary tuberculosis?
Rifampicin, isoniazid, pyrizinamide and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months
If multi-drug resistant, treatment with at least three different drugs should be continued until the sputum culture becomes negative, and then at least two different drugs should be continued for 12-24 months
What are the causes of a pneumothorax?
Primary
Secondary (respiratory disease, connective tissue disease, lung cysts, iatrogenic, trauma, )
What are the BTS guidelines on the management of a spontaneous primary pneumothorax?
Minimal symptoms and air rim of <2cm can be allowed home with repeat CXR in 7 days
How would you manage a secondary pneumothorax?
Observation alone (<1cm or isolated apical pneumothorax in an asymptomatic patient)
Aspiration if <50, asymptomatic or <2cm
Chest drain if >50, symptomatic or >2cm
