Respiratory Flashcards
What is gold standard for asthma
Spirometry with bronchodilator reversibility
AND
Fractional inhaled nitric oxide
What causes pleural plaques
Asbestos
What do if patient has pleural plaques on CXR
Nothing as do not undergo malignant transformation
What suggests a COPD patient will be steroid responsive
- previous diagnosis of asthma or atopy
- a higher blood eosinophil count
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
MOst common organism found in bronchiectasis
Haemophilus
What do if have lung abscess not responding to IV abx
Arrange CT guided percutaneous drainage
What is included in kartageners syndyome
Dextrocardia
Situs invertus
Bronchiectasis
Recurrent sinusitis
Subfertility
Atelectasis management
Chest physiotherapy with mobilisation and breathing exercise
If have a pleural effusion in pneumonia/sepsis, what are criteria for inserting a chest drain
Must take a fluid sample
- if it is cloudy or purulent
- pH less than 7.2
Then insert chest drain
Resp causes of clubbing
TB
Bronchiectasis
Cancer
Fibrosis
Asbestos
Differeniating between right upper and middle lobe pneumonia
Upper is above the horizontal fissure
Middle is below the horizontal fissure
Picture is of middle lobe pneumonia
Cause of white out lung
Lung collapse
Pneumonectomy
Pleural effusion
Consolidation
Mass
When determining cause of white out in lung, what is useful to look at to help determine cause
Trachea position
Cause of white out lung with trachea central
Consolidation
Pulmonary oedema
Mesothelioma
Cause of white out lung with trachea deviated away from white out
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
Cause of white out lung with trachea pulled towards white out
Pneumonectomy
Complete lung collapse
When have to do an ABG in asthma
If sats less than 92%
Other than alcoholics, who else is klebsiella pneumonia seen in
Diabetics
What pneumonia is red currant jelly sputum seen in
Klebsiella
What is management of a chest infection productive of yellow sputum with rhinosinusitis
Likely viral so self limiting
Patient with unilateral pneumonia develops bilateral crackles, what is cause
ARDS
Causes of ARDS
infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute pancreatitis
Covid-19
cardio-pulmonary bypass
What is a cough worse after taking aspirin
Asthma
What blood result can indicate cancer (nothing to do with paraneoplastic syndromes)
Raised platelets
Gold standard for OSA
polysomnography (PSG)
Prophylactic antibiotic choice in COPD
Azithromycin
Triad for youngs syndrome
Bronchiectasis
Sinusitis
Azoospermia
Immediate atelectasis management
Sit patient upright
Then refer to physio
Who do aspergillomas tend to occur in
People who have hx of TB
Presentation of goodpastures
Haemoptysis
Systemically unwell: fever, nausea
Glomerulonephritis
Exudative causes of pleural effusion
infection (e.g. pneumonia)
inflammation (e.g. rheumatoid arthritis / SLE / pancreatitis)
malignancy
First line management of pleural effusion
Pleural diagnostic aspirate
Do this before any chest drain is inserted
What is a mycetoma/aspergilloma
Fungus ball forming in a pre existing cavity
What is allergic bronchopulmonary aspergillosis
Where get hypersensitivity to aspergillus spores in the airways leading to an eosinophilic asthma
Management of ABPA
Oral prednisolone
2nd line oral itraconazole
Presentation of ABPA
Typically will have previous cystic fibrosis or bronchiectasis
Bronchoconstriction- wheeze, cough, dyspnoea
Mucous plugs
CXR findings of ABPA
Central bronchiectasis
Fleeting changes
Investigations for ABPA
Bloods
- eosinophilia + high IgE
- RAST positive for aspergillus
- positive IgE and IgG preciptins for aspergillus
CXR
- central bronchiectasis
Management of latent TB
6 months of isoniazid with pyridoxine
Management of primary pneumothorax
If less than 2cm and non-dyspnoeic= discharge and review
If over 2cm or dyspnoeic= aspiration
What is the management of recurrent pneumothoraxes
Video assisted thorascopic surgery for pleurodesis (obliterates the pleural space)
Management of alpha 1 antitrypsin
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
Presentation of alpha-1-antitrypsin
Emphysema in a young non-smoker
Jaundice and liver disease
Difference in liver presentation of alpha-1-antitrypsin in children vs adults
Children- cholestasis
Adults- cirrhosis and HCC
Investigations for alpha-1-antitrypsin
A1AT levels
Spirometry shows obstructive picture
Chest imaging shows lower zone fibrosis
Presentation of acute bronchitis
White/clear sputum cough
Fever
Smoker
Differentiating pneumonia from acute bronchitis on CXR
Bronchitis CXR will be clear
Management of acute bronchitis
Doxycycline
CI in children and pregnant women so use amoxicillin
When treat acute bronchitis
CRP over 100
Pre-existing co-morbidities
Systemically unwell
How are most mesotheliomas picked up
CXR showing pleural thickness or effusion
Pleural effusion
Presentation of mesothelioma
Chest pain
SOB
Wt loss
Clubbing
Asbestos- 30 years prior
Investigations for mesothelioma
CT
Confirmed on histology with biopsy from thoracoscopy
Gold standard for mesothelioma
Thoracoscopy for pleural biopsy
What are options for smoking cessation
Nicotine replacement
Varenicline
Bupoprion
Risk of using bupropion
Seizure risk
Bupropion contraindications
Epilepsy
Pregnancy
Breast feeding
Contraindications to varenicline
Pregnancy
Breastfeeding
Management of smoking cessation in pregnancy
CBT first line
NRT might be used
Side effecrs of varenicline
Nausea and vomiting
Suicide
Management of smoking cessation
Motivational interview
Identify target stop date
NRT then use either varenicline or bupropion in lead up to target stop date
Management of small cell lung cancer
If T1 then can consider surgery
If more extensive then radio or chemo
Palliative chemo
How differentiate exudate from transudate
In principal if protein under 30= transudate
If protein over 30 = exudate
If 25-35 use lights criteria
What is in lights criteria
If meets one of these then is exudate
- pleural protein/serum protein >0.5
- pleural LDH/ serum LDH >0.6
- pleural LDH > 2/3 upper limits LDH serum level
LDH=6 to remember
Causes of high amylase in pleural fluid
Oesophageal perforation
Pancreatitis
Causes of very bloody pleural fluid
Mesothelioma
PE
TB
Causes of low glucose in pleural fluid
TB
RA
Empyema
Causes of lower lobe fibrosis
ACID
Asbestosis
Connective tissue diseases- RA, scleroderma
Idiopathic
Drugs- amiodarone, methotrexate, bleomycin, cyclophosphamide, nitrofurantoin
Which drugs cause lower lobe fibrosis
Amiodarone
Methotrexate
Bleomycin
Cyclophosphamide
Nitrofurantoin
Borders of triangle of safety
Base of axilla
Anterior border of latissimus dorsi
5th intercostal space
Lateral edge of pectoralis major
First line for OSA
Weight loss
CPAP if moderate/severe
What is next line for mild OSA after weight loss
Overnight CPAP
In COPD what is main measure to increase survival
Stop smoking
Lung abscess presentation
Subacute presentation over a few weeks
Productive cough of smelly sputum
Haemoptysis
Chest pain
SOB
Systemic upset-fever, weight loss, night sweats
Risk factors/causes of lung abscess
Most commonly from aspiration
- stroke
- LOC
- poor dental hygiene
Empyema
Haematogenous
What bacteria tend to be involved in lung abscesses
Mainly polymicrobial
Monomicrobial
- s.aureus
- klebsiella
- pseudomonas
Investigations for lung abscess
Blood and sputum cultures
CXR
CXR finding in lung abscess
Fluid filled area of consolidation
Air fluid level
Management of lung abscess
IV abx
If these fail then percutaneous draninage
May consider rarely surgical resection
How assess OSA
Assess sleepiness with ESS
Diagnose using PSG
What can be used for OSA if CPAP not tolerated
Intra oral devices like mandibular advancement
Target oxygen saturations if asthmatic
94-98%
What vaccinations should COPD patients recieve
Annual influenza
One off pneumococcal
Difference in tests for asthma in under 16s vs over 16s
Under 16s= spirometry and bronchodilator reversibility test
Over 16s= spirometry with a bronchodilator reversibility test AND FeNO
What happens if overoxygenate a COPD patient
Lose hypoxic drive for O2 therefore hypoventilate, retain CO2 and go into T2RF
Lung cancer with gynaecomastia- what subtype
Adenocarcinoma
If identify cannonball mets on CXR, what is next investigation
CT abdomen
What determines satisfactory NG tube placement on CXR
If subdiaphragmatic position
What effect does OSA have on blood pressure
HTN
CURB65 score
AMTS < 8
RR >30
Raised UREA
Sys <90 or dias <60
What can you not do after a pneumothorax
Fly for 2 weeks
Scuba dive unless surgical pleurodesis
What is most common cause of occupational asthma
Isocyanates from spray paininting
How investigate occupational asthma
Serial peak flow measurements
Is it normal to still have pneumonia sx at 4 weeks
Yes NICE recommends cough and SOB have reduced substantially but still be there
Have CXR at 6weeks
What causes restrictive lung spirometry in ank spond
Kyphoscoliosis
Fibrosis can too but rarer
Management of sarcoidosis
Steroids if
- hypercalcaemia
- lung parenchymal involvement
- eye involvement
- heart involvement
- neuro involvement
What is management of oxygen in all COPD patients acutely
Initially aim for 88-92% with venturi mask at 4L/min
Once do a blood gas aim for 94-98% if know pCO2 is normal
What do if pCO2 is normal on blood gas of COPD patient
Change oxygen to 94-98% target saturations
When do you not give oxygen acutely unless there is evidence of hypoxia
MI
Stroke
Obstetric emergency
Anxiety related hyperventilation
What do oxygen wise if COPD patient comes in acutely unwell
Give high flow 15L as hypoxia kills before hypercapnia
When can acute asthma patients be discharged
Allof
- PEF >75% of best or predicted
- Stable on their discharge medication for 12-24 hours
- Inhaler technique checked and recorded
What would cause a ventilated patient to drastically deteriorate
Tension pneumothorax
Presentation of acute mountain sickness
Headache
Nausea
Fatigue
What causes acute mountain sickness
Fitter you are increases risk
Gain 500m a day
How prevent acute mountain sickness
Acetazolamide
How treat acute mountain sickness
Descent
Presentation of high altitude cerebral oedema
Confusion
Ataxia
Papilloedema
Headache
Presentation of high altitude pulmonary oedema
Normal lung oedema presentation
Management of high altitude pulmonary oedema
Descent
Oxygen
Nifedipine or dexamethasone
Management of high altitude cerebral oedema
Descent
Dexamethasone
What causes egg shell calcification of hilar nodes and upper zone shadowing in a miner
Silicosis
In asymptomatic patient, what does right testicle hanging lower than left suggest
Kartageners due to situs inversus
What does a normal PCO2 classify an asthma attack as
Life threatening
Management of secondary pneumothorax
> 2cm/SOB and over 50 then chest drain
1-2cm aspiration
<1cm then admit and oxygen for 24 hours
Examination findings of idiopathic pulmonary fibrosis
Fine end-inspiratory crepitations
Clubbing
Wedge shaped infarct on CXR
PE
Which lung cancer causes a cavitating lesion
Squamous cell
What is the lingula
Projection of left lung over the where heart is
Homologous with right middle lobe
What is key CXR finding of left lingula consolidation
Cant see left border of heart clearly
Calcified plaques on CXR
Pleural plaques from asbestos
Causes of bullae in the lung
Smoking
COPD
How do bullae appear on CXR
Lucent area
What is diagnosis if in COPD patient do a chest drain on suspected pneumothorax but is no improvement
Bullae
What does high pulmonary capillary wedge pressure suggest about cause of pulmonary oedema
Is cardiac in nature
What use to guide pleural tap
USS
Contraindications to chest drain
INR > 1.3
Platelet count < 75
Pulmonary bullae
Pleural adhesions
Management of tension pneumothorax
Insertion of 14G cannula into 2nd intercostal space
What is normal FEV1/FVC
Above 0.7
Restrictive spirometry findings
Reduced FEV1 and FVC
Maintained or increased FEV1/FVC
Obstructive spirometry findings
Reduced FEV1/FVC ratio
Obstructive spirometry causes
COPD
Asthma
Alpha-1-antitrypsin
Bronchiectasis
Restrictive spirometry causes
Anything that causes fibrosis
Sarcoid
Kyphoscoliosis
ARDS
Neuromuscular conditions
Severe obesity
What is the transfer factor
Rate at which gas will diffuse from alveoli into blood
What is used to measure transfer factor
Carbon monoxide
Causes of increased TLCO
Asthma
Pulmonary haemorrhage
Polycythaemia
Left to right cardiac shunts
Causes of reduced TLCO
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
What would cause a restrictive spirometry with a normal TLCO
Obesity
What is TLCO vs KCO
TLCO is the overall measure of gas transfer
KCO is a coefficient where gas transfer is measured according to total lung volume
What is threshold for asthma diagnosis FENO
Above 40 parts per billion
What are looking for spirometry and reversibility test to diagnose asthma
Spirometry
- FEV1/FVC less than 70%= obstructive
Reversibility
- improvement of 12% or more or increase in volume over 200ml
What is given to newly diagnosed asthma
SABA PRN
OR
Add low dose ICS if with symptoms over 3x a week or night-time waking
Step wised asthma
1=SABA or SABA+ low dose ICS if sx 3x a week or night waking
2= SABA + LD ICS if not already on
3= add LTRA
4= add LABA +/- LTRA depending on response
5= add low dose MART +/- LTRA depending on response
6= change low dose MART to medium
7= cange to high dose MART/trial long acting muscarinic or theophylline/seek advice from expert
What would be a low, medium and high dose steroid inhaler
Low= <400mg budenoside
Medium= 400-800mg budenoside
High= >800mg budenoside
PEFR for classifying asthma attacks
Moderate= >50%
Severe= 33-50%
Life threatening= 33%>
Moderate asthma attack features
PEFR >50%
No features of severe or life threatening
Severe asthma attack features
PEFR 33-50%
Incomplete sentences
RR>25
HR>110
Life threatening asthma attack features
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Normal or high PCO2
What determines a near fatal asthma attack
Raised PCO2
When do a CXR for an asthma attack
Life threatening
Suspected pneumothorax
Failure to respond to treatment
Who admit for an asthma attack
Previous near fatal attack
Pregnant
All life threatening attack
Severe or moderate that are not responding to treatment
How is salbutamol given in asthma attack
Life threatening- nebulised
Severe or better= pressure metred dose inhlaer or oxygen driven
MOA of theophylline
Phosphodiesterase inhibitor
Oxygen therapy in an asthma attack
If acutely unwell start on 15L nonrebreathe
Aim for 94-98%
Acute asthma attack
Salbutamol and oxygen if needed
Oral steroids pred 40mg
Ipatropium if severe or life threatening that is not responding to salbutamol and steroids
IV mag sulp, salbutamol and aminophylline all options then
If trialled all medications what are options for asthma attack
Intubation and ventillation
ECMO
ITU
Options after nebulised medications
IV aminophylline, mag sulphate and salbutamol
What is alternative to salbutamol in acute asthma
Terbutaline
Risk factors for aspiration pneumonia
Recent intubation
Stroke
Neuromuscular deficit
How step down asthma treatment
Not just to go from step 3 to 2 etc
Reduce steroid doses by 25-50%
How often can step down asthma treatment
3 monthly basis
What do with daily asthma medications while in hospital for attack
Keep taking them as per
In seretide 500/50, what does each number suggest
500 is the steroid dose
25 is the laba dose
What does not getting asthma symptoms on holiday or at weekends suggest
Occupational asthma
What should do if asthma patient says they do not get symptoms at weekend or on holiday
Likely occupational asthma so refer to specialist
Patient comes in with suspected asthma attack for last few days, what do
Prescribe prednisolone 40mg for 5 days
What is extrinsic allergic alveolitis/hypersensitivty pneumonitis
Hypersensitivty caused by inhalation of organic spores
Immune response in hypersensitivty pneumonitis
Type III but then can become 4 when chronic
Examples of hypersensitivity pneumonitis
Bird fanciers lung
Farmers lung
Malt workers
Mushroom workers lung
Management of EAA
Avoid triggers
Can use steroids
Investigations for EAA
imaging: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis
Acute EAA presentation
dyspnoea
dry cough
fever
A few hours after exposure
Long term EAA presentation
lethargy
dyspnoea
productive cough
anorexia and weight loss
What determines COPD severity
FEV1 of predicted
COPD severity categories
Stage 1 (mild)- FEV1 >80% with mild symptoms
Stage 2 (moderate)- 50-79%
Stage 3 (severe)- 30-49%
Stage 4 (very severe)- <30%
What must post bronchodilator FEV1/FVC be for COPD diagnosis
<0.7
Investigations for COPD
CXR
FBC to exclude polycythaemia
BMI
Post bronchodilator spirometry
General COPD management for all patients
Smoking cessation
Annual influenza vaccine
One off pneumococcal vaccination
What can be done for COPD patients who are functionally disabled by COPD
Pulmonary rehabilitation- education and exercise programme
First line for COPD
SABA or SAMA
Second line for COPD if steroid responsive
LABA + ICS
Third line for COPD if steroid responsive
SABA as required (must change SAMA to SABA)
Triple therapy
- LABA
- LAMA
- ICS
Use combined inhalers where possible
Second line for COPD if not steroid responisve
Add LABA and LAMA
SABA as required (must change SAMA to SABA)
What do if all inhalers are not working or not feasible in COPD
Oral theophylline
Management of cor pulmonale in COPD
Loop diuretic and consider long term oxygen
What need to do before starting long term azithromycin for COPD
CT thorax to exclude bronchiectasis
Sputum culture to exclude chronic infections
ECG to look for long QT
Baseline LFTs
What is a LABA example
Salmeterol
What is a LAMA example
Tiotropium
How does assessment of COPD patients for long term oxygen work
People are assessed if
- FEV1 <30%
- cyanosis
- polycythaemia
- oedema
- raised JVP
- sats less than 92% on air
Assessment involves having 2 ABGs 3 weeks apart
Who assess for long term oxygen therapy
- FEV1 <30%
- cyanosis
- polycythaemia
- oedema
- raised JVP
- sats less than 92% on air
How assess people for long term oxygen
Take 2 ABGs 3 weeks apart
Based off 2 ABGs who should get long term oxygen
2 measurements pO2 less than 7.3kPa
OR
pO2 7.3-8kPa and 1 of
- polycythaemia
- peripheral oedema
- pulmonary HTN
How would tell if chest drain is in the right place based off the water seal
It would rise on inspiration and fall on expiration
Long term options for COPD (non-inhaler)
Azithromycin
Oxygen therapy
Smoking cessation
Patient is recovering from pneumonia but CRP has risen, why
CRP shows a lag in decreasing in comparison to the white cell count in treatment of acute bacterial infection
Organisms localised in bronchiectasis
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Staph aureus
Long term bronchiectasis management for all patients
Physio
Vaccines
Exacerbation management
What should be given to all COPD exacerbation patients
Prednisolone 30mg for 5 days
When give abx in COPD exacerbations
Purulent sputum
Pneumonia signs like focal area of consolidation or reduced air entry
Reasons for COPD admission
severe breathlessness
acute confusion or impaired consciousness
cyanosis
oxygen saturation less than 90% on pulse oximetry.
social reasons e.g. inability to cope at home (or living alone)
significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
Acute management of COPD exacerbation
Oxygen based off CO2
Nebulised salbutamol and ipratropium
Oral or IV steroids
IV theophylline if needed
What use if acute COPD patients fail to respond to bronchodilators
IV theophylline
What need to do if COPD patient becomes acidotic
pH 7.25-7.35= BiPAP
pH<7.25= BiPAP with more regular monitoring in HDU or consider ventilation
When consider non-invasive ventilation in COPD patients
Failed to respond to all medical treatments
pH<7.35
What can give for patient to take home if frequent COPD exacerbations
Rescue packs- prednisolone and abx
need to contact someone however before taking them
What is required to start long term oxugen therapy in COPD
Must have stopped smoking
What is used to assess risk in PE patients
Pulmonary embolism severity index
PESI score which will determine if outpatient care possible, depends on haem stability, comorbidities and support at home
How treat PE if haem unstable
Thrombolysis
Consider invasive procedures if available at centre
What can do for people with recurrent PEs
Inferior vena cava filters which trap any emboli
Choice of investigation for suspected PE if renal failure
V/Q scan
How interpret wells score
4 or less= d-dimer
More than 4= CTPA or DOAC if delay
What are signs on examination of tension pneumothorax that arent trachea deviation
Absent lung sounds
Hypotension
Elevated JVP
What is blood marker of PE severity
Troponin
What is a patients with asthma predicted PEFR
Above 80% of their best
Management of pneumonia based off CURB 65
0= outpatient with oral amox
1= outpatient with oral amox unless severe comorbidities
2= admit with amox and clari
>3= admit with IV co amox and clari
What must do for patients with CURB65 2 and above
Microbiological testing
- sputum cultures
- legionella etc antigen tests
Which investigation in GP can be done to guide pneumonia management
Point of care CRP which available at some sites and can guide abx
- 20> do not give abx
- 20-100 give delayed
- >100 give abx
What do if strongly suspect legionella in pneumonia management
Add levofloxacin to regime
Low, intermediate and high risk based off CURB65
0/1- LOW
2- INTERMEDIATE
3 and above- HIGH
Hospital acquired pneumonia antibiotics
Non-severe- Co-amox
Severe- tazocin or vancomycin if MRSA
Flu like illness in a farmer
Coxiella
Pancoast tumour extra pulmonary signs
Horners syndrome
Recurrent laryngeal nerve infiltration-> hoarseness
Brachial plexus infiltration
Small cell lung cancer paraneoplastic syndromes
ACTH
SIADH
Lambert-eaton
Limic encephalitis from anti-Hu abs
What is limbic encephalitis
Paraneoplastic syndrome in small cell lung cancer where get anti-hu antibodies produced which target limbic areas leading to confusion, seizures and memory loss
What is pembertons sign
Seen in SVC obstruction
Raising hands above head leads to facial flushing and cyanosis
What is done under NICE 2ww lung cancer referral
CXR within 2 weeks
What need to do if identify supraclavicular nodes or clubbing in an over 40
Urgent CXR in 2 weeks for lung cancer
NICE lung cancer referral guidelines for CXR in 2 weeks
If over 40 and 1 of;
- clubbing
- supraclavicular lymph nodes
- thrombocytosis
- chest signs of cancer
- recurrent chest infections
If over 40 and never smoked with 2 of or smoked and asbestos exposure with 1 of;
- weight loss
- fatigue
- SOB
- cough
- no appetite
What scan do after lung cancer identified on CXR
CT CAP
What non-resp specific symptoms if identified in over 40 require urgent CXR
Clubbing
Supraclavicular lymp nodes
Thrombocytosis
Which cancers do asbestos lead to
Adenocarcinoma of lung most common
Mesothelioma
Idiopathic pulmonary fibrosis management
Prognosis very poor- 3-5 years
Can give 2 drugs to reduce inflammation and fibrosis
- Pirfenidone
- Nintedanib- tyrosine kinase inhibitor
What is cryptogenic organising pneumonia
Where in response to infection, inflammatory disorders, medications, radiation, environmental toxins, or allergens can get area of focal inflammation presenting in similar way to pneumonia
How diagnose and management of cryptogenic organising pneumonia
Lung biopsy
Systemic steroids
General management of lung fibrosis
Stop smoking
Control or avoid trigger
Oxygen therapy
Lung physio and rehab
Can consider lung transplant
What do if CTPA negative
Do duplex USS if suspect DVT
When cant use DOAC for PE
GFR under 15
First and second line for PE
1st- apixaban and rivaroxaban
2nd- LMWH followed by dabigatran or edoxaban OR LMWH followed by warfarin
PE management if antiphospholipid syndrome
LMWH followed by warfarin
What is pneumoconiosis
Where get lung fibrosis in response to inhalation of dust and other particles includes coal workers lung, berryliosis etc
Pneumoconiosis imaging features
Nodules of fibrosis with reticulonodular shadowing- most commonly in upper lobes
Causes of bronchiectasis
CF
TB
Pertussis
PCD syndromes
Yellow nail syndrome
Post pneumonia
Yellow nail syndrome features
Bronchiectasis
yellow nails
Lymphoedema
Signs on examination of bronchiectasis
Clubbing
Cor pulmonale signs- oedema, JVP up
Diffuse coarse crackles which alter with coughing
Scattered wheeze
When consider lung transplant for bronchiectasis
Under 65
FEV1 under 30% or rapid deterioration despite medical tx
How manage a bronchiectasis exacerbation
Sputum culture
14 day course of abx
Consider salbutamol inhaler if wheeze or particularly breathless
When escalate bronchiectasis management
If over 3 exacerbations a year then stepwise approach
1st- physio reassessment and give mucoactive agents
2nd- long term abx
Severe bronchiectasis management
If numerous exacerbations and failure to respond to medical tx then consider
- mucoactive agents
- long term abx
- lung transplant
Imaging findings for bronchiectasis
Tram lines
Proximal dilation of bronchus
Sarcoid features
- cardiac
- neuro
- ENT
- ocular
- skin
- resp
Cardiac- HB, dialted CM, constrictive pericarditis
Neuro- cranial diabetes inspiduus
ENT- parotid (facial nerve palsy, xerostomia)
Ocular- anterior uveitis
Skin- erythema nodosum, lupus pernio
Resp- bilateral hilar lymphadenopathy, fibrosis of upper lobes
Main diagnostic investigation for sarcoid
Bronchoscopy guided biopsy of lymph nodes showing non-caseating granulomas
Diagnostic investigation for COPD
Spirometry showing obstructive picture with no salbutamol reversibility
Features of cor pulmonale on examination
Raised JVP
Parasternal heave
Oedema
Who is eligible for COPD prophylactic azithromycin
Do not smoke
Medical therapy but continue to have continuous exacerbations
Must have CT thorax to exclude bronchiectasis and sputum culture to exclude chronic infections
What must do prior to initiating NIV
CXR to rule out pneumothorax
If spirometry or FeNO is inconclusive for asthma what use to investigate
Serial peak flow measurements for 4 weeks
Measure 4x a day and if variation over 20% then confirms diagnosis
What are serial peak flow measurements
Measure peak flow at various points across day for a month and if over 20% variability then indicates asthma
Transudative causes of pleural effusion
HF, LF, Nephrotic syndrome
Meigs syndrome
Hypothyroidism
Exudative cause of pleural effusion
Pneumonia
Cancer
Pancreatitis
PE
RA
What investigations do for pleural effusion
PA CXR
USS guided pleural aspirate
CT if exudative cause
SOB after insertion of sublcavian line
Pneumothorax
What does FeNO indicate
Eosinophilic inflammation
When refer people under 2WW straight to oncology for lung cancer
Lung cancer like signs on CXR
Over 40 with unexplained haemoptysis
