Respiratory Flashcards
I would complete my resp examination by checking
Sputum culture
Pulse oximetry
Observation charts
X-rays (recent)
Causes of apical fibrosis
ROAAST:
Radiation
Occupational exposure diseases
Allergic reactions (ABPA, EAA)
Ankylosing spondylitis
Sarcoidosis
Tuberculosis
Causes of lower zone fibrosis
Idiopathic pulmonary fibrosis
Rheumatoid arthritis
Scleroderma, Sjogren, SLE
Asbestosis
Drugs (methotrexate, amiodarone, nitrofurantoin)
Light’s criteria for Exudate pleural effusion?
Pleural fluid to serum protein > 0.5
Pleural fluid to serum LDH > 0.6
Pleural fluid LDH value > 2/3 of the upper limit of the normal serum value
Causes of Exudate pleural effusion
Pneumonia
Pulmonary embolism
Cancer
Tuberculosis
Autoimmune conditions
Causes of Transudate pleural effusion
Liver cirrhosis
Congestive cardiac failure
Nephrotic syndrome
Because they create an increase in the hydrostatic pressure or low plasma oncotic pressure
Alpha-1-antitrypsin deficiency
COPD/Emphysema —> bronchiectasis
Liver cirrhosis
Necrotising panniculitis
Kartagener’s syndrome
Bronchiectasis (from primary ciliary dyskinesia)
Situs inversus / dextrocardia
Sinusitis
Azoospermia
Causes of pulmonary hypertension
Primary
Aortic & Mitral valve pathology
Chronic PEs
ILD
COPD
Treatment of Idiopathic Pulmonary Fibrosis
Nindetanib (tyrosine protein kinase inhibitor)
Pirfenidone
Consider Sildenafil
Indications for VATS
Lung/pleura/LN biopsy
Wedge resection
Lobectomy
Pleurodesis
Management of Resp conditions, to include
Multidisciplinary approach including specialist physicians, OT, PT, patient’s GP
Patient education
Lifestyle modification including smoking
Vaccines
Pulmonary rehab
Indications for pneumonectomy
Malignancy
Bronchiectasis
Tuberculosis
Indications for lobectomy
Non-small cell lung cancer
Bronchiectasis
Tuberculosis or abscess
Lung volume reduction
Indications for thoracoplasty
= removal of ribs
Tuberculosis
Empyema
Types of lung cancer
Small cell carcinoma
Non-small cell includes:
Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma
Typical features of squamous cell lung cancer
Central cavitating lesion
Heavy smoker
Paraneoplastic syndromes:
- Hypercalcaemia (PTHrP)
- Hyperthyroidism (TSH)
Characteristics of adenocarcinoma lung cancer
Most common type of lung cancer 40%
Common in women & non-smokers
Peripheral solid lesion
Metastasises early
Hypertrophic pulmonary osteoarthropathy
Typical features of large cell carcinoma
Start in the bronchial tubes
Early mets
Copious sputum
Characteristics & Complication of small cell lung cancers
Central cavitating lesion
Associated with smoking
Early mets
Paraneoplastic endocrine phenomena:
- Hypercalcaemia from PTHrP release
- Lambert-Eaton myasthenia gravis
Management of non-small cell lung cancer
Surgery
Radical radiotherapy
Platinum-based chemotherapy
Management of small cell lung cancer
Likely to have metastasised and cause endocrine complications
Radiotherapy or chemotherapy may be offered.
No surgery.
Management of tuberculosis
Quadruple therapy for 2 months (including pyrazinamide and ethambutol)
Then continue Rifampicin & Isoniazid
Alongside pyridoxine
Side-effects of TB drugs
Rifampicin - drug interactions, orange fluids
Isoniazid - peripheral neuropathy (treat with Pyridoxine)
Pyrazinamide - gout
Ethambutol - retrobulbar neuritis
All are hepatotoxic
Problems following transplant:
GARLIC T:
Graft dysfunction
Acute or chronic rejection
Recurrence of original disease
Lymphoproliferative disease
Infections
Cancers
Toxicity from immunosuppressant drugs
Causes of clubbing
Idiopathic
Interstitial lung disease
Bronchiectasis
Lung cancer
Cyanotic congenital heart disease
Infective endocarditis
Chronic liver disease
Inflammatory bowel disease
Thyroid acropachy
Causes of Bronchiectasis
CCCCBA:
Cystic fibrosis and Kartagener’s
COPD
Cancer of the bronchus
Congenital immunodeficiency
ABPA
Autoimmune
Management of Bronchiectasis
Regular postural drainage
Antibiotic prophylaxis with pseudomonas cover
Mucolytics
Inhalers with steroids
Cystic fibrosis mutation
CFTR gene on chromosome 7 (delta 508)
Cystic fibrosis extra-pulmonary manifestations
Pancreatic insufficiency (steatorehoea, gallstones)
Méconium ileus
Distal intestinal obstruction syndrome
Infertility
Insulin-dependent diabetes
Respiratory causes of finger clubbing
Lung cancer
Interstitial lung disease
Chronic suppurative lung disease such as CF, Bronchiectasis and lung empyema
Most common type of lung cancer
Adénocarcinoma of the lung
Indications for lung transplant (4)
ILD (single)
COPD (double)
Cystic fibrosis (double)
Primary Pulmonary hypertension (with heart)
Criteria for lung transplant
1) >50% risk of death due to lung disease within 2 years if lung transplantation is not performed;
2) > 80% likelihood of surviving at least 90 days after lung transplantation;
3) >80% likelihood of 5-year post-transplant survival from a general medical perspective
Differentials for bibasal crepitations
Bronchiectasis
ILD
Bilateral pneumonias
Congestive heart failure
Spirometer results for ILD
Restrictive pattern with:
Reduced FEV1
Reduced FVC
Maintained FEV1/FVC ratio
Reduced total lung capacity
Reduced transfer factor
Para pneumonic effusion management
Antibiotics
Chest drain if tap showed:
- pH <7.2
- Frank pus
- Positive cultures
Mutated gene of cystic fibrosis
CFTR gene (chromosome 7) leads to increase sodium excretion causing thicker mucus
Cystic fibrosis manifestations
Bronchiectasis
Chronic pancreatic insufficiency
Liver failure
Gallstones
Constipation and distal intestinal obstruction
Kidney stones
Infertility
Treatment of cystic fibrosis
MDT approach
Prophylactic Azithromycin
Chest physio
Nebulisers and mucolytics
Fat-soluble vitamins
Creon
Nutritional supplements via peg-tubes
Severity grading for COPD
Mild - FEV1 >80%
Moderate - FEV1 50-80%
Severe - FEV1 30-50%
Very severe - FEV1 <30%
Spirometry findings for COPD
Obstructive pattern
FEV1 <80%
FVC normal
FEV1/FVC ratio <0.7
COPD CXR findings
Hyperinflation
Flattened Hemi-diaphragms
Bronchiectasis CT findings
Signed ring sign (bronchi larger than vasculature)
Bronchial wall thickening
Blood tests for Bronchiectasis
Immunoglobulins
Aspergillus IgE
HIV
RF
Alpha-1antitrypsin deficiency
CF genetic mutation analysis
Bronchiectasis examination findings
Clubbing
Inspiration clicks
Coarse inspiration crepitations
Large airway ronchi
Suitability for surgical lung resection
FEV1 >1.5L for lobectomy
FEV1 >2L for pneumonectomy
Complications of Asbestos exposure
Pleural plaques
Diffuse pleural thickening
Pleural effusions
Asbestosis
Increased risk of lung cancer and mesothelioma
Extrinsic allergic alveolitis examples
Bird fanciers lungs
Hot tub lung
Mushroom workers lung
Malt workers lung
Extrinsic allergic alveolitis hypersensitivity type
Acute —> type 3 (immune complex mediated)
Chronic —> type 4 (cell mediated)
Occupational lung disease examples
Silicosis
Berylliosis
Coal worker’s pneumoconiosis
Examples of interstitial lung disease
UIP
NSIP
Cryptogenic organising pneumonia
Management of interstitial lung disease
Lifestyle
Immunisations
Steroid
Oxygen at home
Trials
Types of Bronchiectasis
Cylindrical
Varicose
Cystic
Criteria for LTOT (2)
2 ABGs at least 2 weeks apart with either:
- PaO2 <7.3
- PaO2 <8 and Polycythaemia or nocturnal hypoxaemia or peripheral oedema or pulmonary hypertension
